Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis

doi:10.31083/j.rcm.2020.03.135

Reviews in Cardiovascular Medicine

2020, Vol. 21

Issue (3): 453-468 DOI: 10.31083/j.rcm.2020.03.135

Systematic Review

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Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis

Radwan Al Ali^1,^*(

), Davor Vukadinović¹, Wasim Maziak², Lama Katmeh¹, Viktoria Schwarz¹, Felix Mahfoud¹, Ulrich Laufs³, Michael Böhm¹

¹Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 100, 66421 Homburg/Saar, Germany
²Robert Stempel College of Public Health, Florida International University, Miami, Florida 33174, USA
³Klinik und Poliklinik für Kardiologie, Universitätsklinikum, Liebigstr. 20, 04103 Leipzig, Germany

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Abstract:

Waterpipe smoking has developed into a major and rapidly growing global tobacco epidemic affecting more than 100 million people worldwide. This study identifies and analyzes comprehensively all available data on the cardiovascular effects of waterpipe smoking. Databases PubMed, EMBASE, Web of Science, and the Cochrane Library were searched for studies published until December 2019 assessing cardiovascular effects of waterpipe smoking. We included experimental, cohort, cross-sectional and case-control studies and excluded systematic reviews, case reports/series and qualitative studies. Studies not conducted in humans or not distinguishing waterpipe smoking from other forms of smoking were also excluded. A total of 42 studies with 46 cardiovascular parameters were eligible for analysis. The meta-analysis included 31 studies with 38,037 individuals. Results showed that one waterpipe smoking session leads to immediate increases in heart rate and blood pressure (P $<$ 0.001). Compared to non-smokers, waterpipe smokers had significantly lower high-density lipoprotein levels (P $<$ 0.001), higher levels of low-density lipoprotein (P = 0.04), triglyceride (P $<$ 0.001) and fasting blood glucose (P = 0.03) and higher heart rate (P = 0.04) with a tendency to have higher blood pressure. Mean heart rate, blood pressure and lipids levels did not differ between waterpipe and cigarette smokers, except for total cholesterol, being higher among waterpipe smokers (P $<$ 0.001). Current level of evidence suggests that waterpipe smoking is associated with substantial adverse effects on cardiovascular system, which seem to be similar to those of cigarette smoking. Longitudinal studies are required to scrutinize the magnitude of these effects.

Key words: Waterpipe smoking cardiovascular disease cardiovascular risk factors

Submitted: 14 July 2020 Revised: 09 September 2020 Accepted: 12 September 2020 Published: 30 September 2020

^*Corresponding Author(s): Radwan Al Ali E-mail: radwan.al-ali@uks.eu

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Cite this article:

Radwan Al Ali, Davor Vukadinović, Wasim Maziak, Lama Katmeh, Viktoria Schwarz, Felix Mahfoud, Ulrich Laufs, Michael Böhm. Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis. Reviews in Cardiovascular Medicine, 2020, 21(3): 453-468.

URL:

https://rcm.imrpress.com/EN/10.31083/j.rcm.2020.03.135 OR https://rcm.imrpress.com/EN/Y2020/V21/I3/453

Fig. 1. PRISMA Flow diagram showing the process of the sytematic search and study selection including eligibility against the inclusion and exclusion criteria. The number of studies is the bottom of the flowchart represents that of the selected studies that were considered eligible for inclusion in this meta-analysis.

Fig. 2. Forest plots demonstrating individual (squares) and pooled (rhombus) acute changes (mean difference) in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP), with corresponding 95% confidence intervals (horizontal lines), obtained after one waterpipe smoking session. WPS: Waterpipe smoking

Table 1. Study Characteristics.

Study	Study design	Sampling	Participants	N	Male	Age, years Mean $\pm$ SD (range)	WPS			CS	NS	Pre-session abstinence	WPS session, min.	Smoking setting	Tobacco used
Study	Study design	Sampling	Participants	N	Male	Age, years Mean $\pm$ SD (range)	Total	Exclusive	Frequency	CS	NS	Pre-session abstinence	WPS session, min.	Smoking setting	Tobacco used
Experimental studies
Al-Kubati et al., 2006	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	20	20	27.2 $\pm$ 6.4 (20-40)	20	n.s.	n.s.	-	-	12 h	45	Laboratory	5 g moassal
Alomari et al., 2014	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	53	34	22.7 $\pm$ 4.8 (18-35)	53	n.s.	$\geq$ 3 WP/week	-	-	n.s.	30	A well-ventilated room	10 g flavoured tobacco
Azar et al., 2016	Three-Group Pretest-Posttest	Convenience sampling	Healthy subjects	194	112	35.6 (> 18)	101	n.s.	n.s.	-	42	12 h	15	Restaurants	n.s.
Bentur et al.,2014	Two-Group Pretest-Posttest	Convenience sampling	Healthy subjects	62	33	24.9 $\pm$ 6.2 ( $\geq$ 18)	47	n.s.	n.s.	-	-	24 h	30	Indoor environment	10 g moassal
Blank et al.,2011	One-Group Pretest-Posttest, Two-condition crossover	Convenience sampling	Healthy subjects	37	29	20.5 $\pm$ 2.1 (18-50)	37	≤ 5 cig/month	2-5 WP/month	-	-	Overnight	45	Laboratory	10 g flavoured tobacco
Cobb et al.,2011	One-Group Pretest-Posttest, Two-condition crossover	Convenience sampling	Healthy subjects	54	36	21.2 $\pm$ 2.3 (18-50)	54	$\geq$ 5 cig/day	$\geq$ 2 WP/month	54	-	12 h	43.3 (CS 6.1)	Laboratory	n.s.
Cobb et al.,2012	One-Group Pretest-Posttest, Two-condition crossover	Convenience sampling	Healthy subjects	32	16	21.6 $\pm$ 2.7 (18-50)	32	≤ 5 cig/month	$\geq$ 4 WP/month	32	-	12 h	45	Laboratory	10 g flavoured tobacco
Eissenberg and Shihadeh,2009	One-Group Pretest-Posttest, Two-condition crossover	Voluntary response sampling	Healthy subjects	31	21	21.4 $\pm$ 2.3 (18-50)	31	$\geq$ 1 cig/week	$\geq$ 1 WP/month	31	-	$\geq$ 12 h	45 (CS 5)	Laboratory	15 g flavoured tobacco
Elias et al.,2012	Two-Group Pretest-Posttest	Convenience sampling	Healthy subjects	100	n.s.	29.5 $\pm$ 10.4 (18-60)	70	70	weekly WPS, (6.9 $\pm$ 3.7)	-	30	n.s.	30	n.s.	n.s.
Hakim et al.,2011	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	45	30	32.3 $\pm$ 23.4 (18.3-65.1)	45	37	Regularly	-	-	24 h	30	An outdoor environment.	10 g moassal
Hawari et al.,2013	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	24	24	20.4 (18-25)	24	n.s.	4 (0.5-14) WP/week	-	-	$\geq$ 48 h	45	Laboratory	n.s.
Kadhum et al.,2014	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	61	49	(18-25)	61	61	n.s.	-	-	$\geq$ 24 h	45-90	Cafes	n.s.
Layoun et al.,2014	Three-Group Pretest-Posttest	Convenience sampling	n.s.	132	87	33.4 ( $\geq$ 18)	42	42	$\geq$ 1WP/week	48	42	n.s.	45	Restaurants	20 g moassal
Nelson et al.,2016	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	28	20	27 $\pm$ 5 (17-39)	28	28	¿ 12 times in the past year	-	-	72 h	30 (102 $\pm$ 60)	Laboratory	n.s.
Rezk-Hanna et al.,2019	Two-Group Pretest-Posttest	Voluntary response sampling	Healthy subjects	55	10	26 $\pm$ 1 (18-34)	40	40	$\geq$ 12 times in the past year	15	-	Overnight	96 $\pm$ 40 (60-120)	Laboratory	n.s.
Shafagoj and Mohammed,2002	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	18	18	27 $\pm$ 8 (20-45)	18	18	$\geq$ 3 times/week	-	-	84 h	45	Laboratory	20 g moassal
Shaikh et al.,2008	One-Group Pretest-Posttest	Cluster sampling	Healthy subjects	202	202	33.2 (¿ 17)	202	202	n.s.	-	-	20 min	30-45	Café	n.s.
Shishani et al.,2014	One-Group Pretest-Posttest Two-condition crossover	Voluntary response sampling	Healthy subjects	22	n.s.	23 $\pm$ 3.1 (18-30)	22	22	$\geq$ 10 times in the past year, and ≤ 2 times/week in the past 3 months	-	-	24 h	45–60	Outdoor laboratory	n.s.
Wolfram et al.,2003	One-Group Pretest-Posttest	Convenience sampling	Healthy subjects	7	7	$\geq$ 18	7	7	occasionally	-	-	3 months	55 (45-70)	Laboratory	15 g of tobacco
Case-control studies
Al-Amri et al.,2019	Case-control hospital-based	Convenience sampling	Cases are myocardial infarction, controls from dermatology and surgery departments	296	203	47.8 $\pm$ 14.6 ( $\geq$ 18)	35	35	Daily	89	261	n.s.	-	-	n.s.
Al-Numair et al.,2007	Case-control	Convenience sampling	Healthy subjects	200	200	(19-50)	100	100	Daily	-	100	n.s.	-	-	ma’ssel
Chami et al.,2019	Case-control community-based	Convenience and voluntary response sampling	Healthy subjects	345	233	53.7 $\pm$ 9.1 ( $\geq$ 35)	175	98%	Daily	-	170	n.s.	-	-	n.s.
Chwyeed,2018	Case-control	Randomly selection	Healthy subjects	75	75	(30-60)	20	20	n.s.	20	35	n.s.	-	-	n.s.
Diab et al.,2015	Case-control	Convenience sampling	Healthy subjects	77	77	35.1 $\pm$ 1.05 (≤ 60)	30	30	Daily	30	17	n.s.	-	-	n.s.
Ghasemi et al.,2010	Case-control community-based	Convenience sampling	Healthy subjects	54	54	33.3 $\pm$ 2.94	27	27	Daily	-	27	n.s.	-	-	mostly of moassal
Hashem Sezavar et al.,2004	Case-control community-based	Convenience sampling	n.s.	450	450	(20-75)	150	150	Daily	150	150	n.s.	-	-	n.s.
Jabbour et al.,2003	Case-control hospital-based	Convenience sampling	Cases are CHD patients, controls recruited from 3 hospitals	525	n.s.	n.s.	49	n.s.	¿ 4/week	-	299	n.s.	-	-	n.s.
Koubaa et al.,2015a	Case-control community-based	Convenience sampling	Healthy subjects	43	43	43.6 $\pm$ 2.2	14	14	$\geq$ 5 WP-year	15	14	n.s.	-	-	10 and 25 g
Koubaa et al.,2015b	Case-control community-based	Convenience sampling	Healthy subjects	43	43	43.6 $\pm$ 2.2	14	14	$\geq$ 5 WP-year	15	14	n.s.	-	-	10 and 25 g
Muddathir et al.,2018	Case-control	Convenience sampling	Healthy subjects	120	80	29.2 (18-51)	40	40	Daily	40	40	n.s.	-	-	n.s.
Selim et al.,2013a	Case-control community-based	Convenience sampling	Healthy subjects	70	63	28.7 (25-35)	30	30	Daily	30	10	n.s.	-	-	n.s.
Cross-sectional/cohort studies
Al Suwaidi et al.,2012	Cross-sectional prospective hospital-based cohort	Convenience sampling	ACS patients	7930	6253	59.6	130	130	Regular	3605	3742	-	-	-	n.s.
Al-Safi et al.,2009	Cross-sectional population-based	Stratified cluster random sampling	Healthy subjects	14310	7400	31.4 ( $\geq$ 18)	2272	1132	$\geq$ 1 WP/week	2691	9347	n.s.	-	-	n.s.
Islami et al.,2013	Cross-sectional prospective population-based cohort	Systematic clustering random sampling	Cases: participants with heart disease history, Controls: participants with no heart disease history	50045	21234	(40-75)	525	n.s.	Ever	-	49489	n.s.	-	-	n.s.
Khan et al.,2020	Cross-sectional community-based	Voluntary response sampling	Healthy subjects	73	41	39.8 (21-65)	12	12	Daily	26	25	n.s.	-	-	n.s.
	Cross-sectional community-based	Voluntary response sampling	Healthy subjects	57	27	25.4	33	33	$\geq$ 1 WP/month		24	n.s.	-	-	n.s.
Platt et al.,2017	Cross-sectional hospital-based	Convenience sampling	Coronary angiography patients	7705	5188	61.2 $\pm$ 11.4	574	574	Regularly	2625	4506	n.s.	-	-	n.s.
Saffar Soflaei et al.,2018	Cross-sectional population-based	Stratified cluster random sampling	-	9690	n.s.	(35-65)	1067	1067	n.s.	864	6742	n.s.	-	-	n.s.
Selim et al.,2013b	Cross-sectional hospital-based	Convenience sampling	Coronary angiography patients	287	n.s.	n.s.	63	63	Regularly	100	109	n.s.	-	-	n.s.
Shafique et al.,2012	Cross-sectional population-based cohort	Voluntary response sampling	Healthy subjects	2032	1039	(30-75)	325	325	$\geq$ 1 WP/week	-	1707	n.s.	-	-	n.s.
Sibai et al.,2014	Cross-sectional hospital-based	Convenience sampling	Coronary angiography patients	1754	n.s.	( $\geq$ 40)	235	n.s.	Ever $\geq$ 1 WP-year	544	975	n.s.	-	-	n.s.
Ward et al.,2015	Cross-sectional population-based	Stratified cluster random sampling	-	2536	1220	25-65	286	n.s.	Regularly	-	2134	n.s.	-	-	n.s.
Wu et al.,2013	Cross-sectional prospective population-based cohort	Convenience sampling	n.s.	20033	1971	(18-75)	n.s.	n.s.	Ever regularly	n.s.	n.s.	n.s.	-	-	n.s.
WP: Waterpipe, WPS: Waterpipe smoking, CS: Cigarette smoking, ACS: Acute coronary syndrome. CHD: Coronary heart disease. n.s.: Not specified.

Fig. 3. Forest plots demonstrating individual (squares) and pooled (rhombus) mean differences in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP), with corresponding 95% confidence intervals (horizontal lines), obtained in waterpipe smokers compared to non-smokers. WPS: Waterpipe smoking. NS: Non-smoking.

Fig. 4. Forest plots demonstrating individual (squares) and pooled (rhombus) mean differences in blood levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) and triglyceride (TG), with corresponding 95% confidence intervals (horizontal lines), obtained in waterpipe smokers compared to non-smokers. WPS: Waterpipe smoking. NS: Non-smoking.

Fig. 5. Forest plots demonstrating individual (squares) and pooled (rhombus) mean differences in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP), with corresponding 95% confidence intervals (horizontal lines), obtained in waterpipe smokers compared to cigarette smokers. WPS: Waterpipe smoking. CS: Cigarette smoking.

Fig. 6. Forest plots demonstrating individual (squares) and pooled (rhombus) mean differences in blood levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) and triglyceride (TG), with corresponding 95% confidence intervals (horizontal lines), obtained in waterpipe smokers compared to cigarette smokers. WPS: Waterpipe smoking. CS: Cigarette smoking.

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