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Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis |
Radwan Al Ali1, *( ), 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.
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Submitted: 14 July 2020
Revised: 09 September 2020
Accepted: 12 September 2020
Published: 30 September 2020
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*Corresponding Author(s):
Radwan Al Ali
E-mail: radwan.al-ali@uks.eu
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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 SD (range) | WPS | CS | NS | Pre-session abstinence | WPS session, min. | Smoking setting | Tobacco used | Total | Exclusive | Frequency | Experimental studies | Al-Kubati et al., 2006 | One-Group Pretest-Posttest | Convenience sampling | Healthy subjects | 20 | 20 | 27.2 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 4.8 (18-35) | 53 | n.s. | 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 6.2 ( 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 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 2.3 (18-50) | 54 | 5 cig/day | 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 2.7 (18-50) | 32 | ≤ 5 cig/month | 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 2.3 (18-50) | 31 | 1 cig/week | 1 WP/month | 31 | - | 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 10.4 (18-60) | 70 | 70 | weekly WPS, (6.9 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 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 | - | - | 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. | - | - | 24 h | 45-90 | Cafes | n.s. | Layoun et al.,2014 | Three-Group Pretest-Posttest | Convenience sampling | n.s. | 132 | 87 | 33.4 ( 18) | 42 | 42 | 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 5 (17-39) | 28 | 28 | ¿ 12 times in the past year | - | - | 72 h | 30 (102 60) | Laboratory | n.s. | Rezk-Hanna et al.,2019 | Two-Group Pretest-Posttest | Voluntary response sampling | Healthy subjects | 55 | 10 | 26 1 (18-34) | 40 | 40 | 12 times in the past year | 15 | - | Overnight | 96 40 (60-120) | Laboratory | n.s. | Shafagoj and Mohammed,2002 | One-Group Pretest-Posttest | Convenience sampling | Healthy subjects | 18 | 18 | 27 8 (20-45) | 18 | 18 | 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 3.1 (18-30) | 22 | 22 | 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 | 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 14.6 ( 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 9.1 ( 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 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 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 2.2 | 14 | 14 | 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 2.2 | 14 | 14 | 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 ( 18) | 2272 | 1132 | 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. | | 57 | 27 | 25.4 | 33 | 33 | 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 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 | 1 WP/week | - | 1707 | n.s. | - | - | n.s. | Sibai et al.,2014 | Cross-sectional hospital-based | Convenience sampling | Coronary angiography patients | 1754 | n.s. | ( 40) | 235 | n.s. | Ever 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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