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Waterpipe Smoking
Waterpipe Smoking
ORIGINAL RESEARCH
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
CE: A.M.; JAM-D-17-00182; Total nos of Pages: 6;
JAM-D-17-00182
Kumari et al. J Addict Med Volume 00, Number 00, Month/Month 2018
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
CE: A.M.; JAM-D-17-00182; Total nos of Pages: 6;
JAM-D-17-00182
J Addict Med Volume 00, Number 00, Month/Month 2018 Waterpipe Smoking and Its Association With Systemic Inflammation
binary logistic regression analyses were then conducted, Social Characteristics of Waterpipe Smokers
and results were reported as crude and adjusted odds Mean age of starting WP among WP smokers was
ratio, with 95% CI and their corresponding P values. In 18.74 years, and mean frequency of WP use was 6.89 times
multivariate logistic regression analyses, results were also per month, with mean puff frequency in one session being
adjusted for age, sex, marital status, education level, income 23.88. The mean duration of a single session was 2.2 hours. A
level, physical activity, blood pressure, heart rate, and majority (72.3%) of participants smoked it in the company of
waist circumference. friends, while 15.4% took it mostly with family, and 12.3%
smokers reported smoking WP alone. Most of the participants
RESULTS (70.8%) smoked WP at cafes or restaurants and considered the
A total of 250 individuals were invited for participation in availability of WP smoking facility while choosing a restau-
the study, 200 consented to participate (response rate ¼ 80%). rant (data not shown).
Ten individuals were excluded due to ineligibility, and final
analysis was based on 190 participants. Among participants, NLR and Tobacco Smoking Status
34.2% (n ¼ 65) exclusively smoked WP, 32.6% (n ¼ 62%) The mean NLR varied significantly according to
smoked cigarettes, and 33.2% (n ¼ 63) were nonsmokers. tobacco smoking status among participants (P < 0.01). The
mean NLR was highest among WP smokers as compared to
Basic Health Characteristics cigarette smokers (P ¼ 0.124, adjusted using the Bonferroni
Furthermore, regarding basic health characteristics of correction), and nonsmokers (P < 0.001, adjusted using the
participants, 77.4% (n ¼ 147) of them were not involved in Bonferroni correction) (Table 1, Table S1, http://links.
any physical activity; participants had a mean heart rate of lww.com/JAM/A91). Results of univariate linear regression
91.03 beats/min; 119.39 mm Hg mean systolic blood pressure, analysis (Model 0) indicate that WP smoking status was
and 77.84 mm Hg mean diastolic blood pressure; and mean positively associated with increased NLR (Beta ¼ 0.58,
waist circumference of 30.65 in. No statistically significant 95% CI 0.23, 0.93, P < 0.01) as compared to nonsmoking,
differences in baseline characteristics were observed between and this association remained the same after the adjustment of
the 3 groups of WP smokers, cigarette smokers, and non- all other factors in Model 1 (Beta ¼ 0.61, 95% CI 0.25, 0.96,
smokers (Table 1). P < 0.01). It is also noted that the positive unit change of NLR
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
CE: A.M.; JAM-D-17-00182; Total nos of Pages: 6;
JAM-D-17-00182
Kumari et al. J Addict Med Volume 00, Number 00, Month/Month 2018
TABLE 2. Association of Tobacco Smoking Status and Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0 Model 1
Beta SE 95% CI P Beta SE 95% CI P
Neutrophil to lymphocyte ratio
Smoking status
Nonsmokers Reference Reference
Cigarette smokers 0.33 0.178 0.01, 0.68 0.06 0.38 0.185 0.02, 0.74 0.03
Waterpipe smokers 0.58 0.176 0.23, 0.93 <0.01 0.61 0.182 0.25, 0.96 <0.01
Platelet to lymphocyte ratio
Smoking status
Nonsmokers Reference Reference
Cigarette smokers 10.39 0.178 10.03, 10.74 <0.01 12.43 0.185 12.07, 12.79 <0.01
Waterpipe smokers 19.11 0.178 18.76, 19.45 <0.01 20.86 0.182 20.51, 21.21 <0.01
Model 0 ¼ univariate analysis.
Model 1 ¼ Model 0 þ age, gender, marital status, education level, income, physical activity, systolic blood pressure, diastolic blood pressure, heart rate, waist circumference.
CI, confidence interval; NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; SE, standard error.
was higher among WP smokers as compared to cigarette Furthermore, linear associations between systemic
smokers in Models 0 and 1 (Table 2). Furthermore, logistic inflammatory markers among WP and cigarette smokers
regression analysis also indicated that the odds of raised NLR indicated that WP smoking remained positively associated
was significantly higher for WP smokers compared to non- with NLR (Beta ¼ 0.27, 95% CI 0.08, 0.62, P ¼ 0.13) and
smokers (Model 0, OR ¼ 3.40, 95% CI 1.64, 7.03, P < 0.01; PLR (Beta ¼ 9.23, 95% CI 8.87, 9.58, P < 0.01) as compared
Model 1, OR ¼ 4.40, 95% CI 1.97, 9.85, P < 0.01), even after to cigarette smoking (Table 4).
adjustment with all study variables (Table 3).
DISCUSSION
PLR and Tobacco Smoking Status The findings of this study indicate that WP smoking is
The mean PLR was significantly higher among WP significantly associated with raised systemic inflammatory
smokers (mean 117.39, S.D 42.62) as compared to non- markers, particularly NLR and PLR. Although, the NLR and
smokers (P-value 0.003, adjusted using the Bonferroni cor- PLR values were in normal range among WP smokers,
rection) (see Table 1, Table S1, http://links.lww.com/JAM/ cigarette smokers, and nonsmokers, the average NLR and
A91). Furthermore, Model 0 indicates that WP smoking status PLR values were significantly higher among WP smokers
was positively associated with PLR as compared to nonsmok- compared with nonsmokers. Comparing the inflammatory
ing. Even after adjusting for all important physical health, and effects of the different forms of smoked tobacco, WP smokers
socio-demographic covariates (Model 1), WP smoking had higher odds of raised NLR and PLR as compared to
remained positively associated with PLR as compared to cigarette smokers. Furthermore, study also adds evidence
nonsmoking (Beta ¼ 20.86, 95% CI 20.51, 21.21, P < 0.01) related to the social and behavioral characteristics of the
(Table 2). Furthermore, adjusted logistic regression analysis WP smoking, indicating that majority of them initiated
also indicates that the odds of raised PLR were 3.48 times use in late teens; were having at least 7 to 8, 1-hourly
higher for WP smokers compared to nonsmokers (OR ¼ 3.48, smoking sessions in a month; and were using it as a social
95% CI 1.60, 7.57, P < 0.01) (see Table 3). drug in company of friends, preferring the cafes and
TABLE 3. Logistic Regression Odds Ratio of Higher Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0 Model 1
Characteristics OR (95% CI) P OR (95% CI) P
NLR (compared to NLR < 1.47)
Smoking status
Nonsmokers 1 1
Cigarette smokers 1.86 (0.90–3.82) 0.08 2.40 (1.09–5.30) 0.03
Waterpipe smokers 3.40 (1.64–7.03) <0.01 4.40 (1.97–9.85) < 0.01
PLR (compared to PLR < 107.36)
Smoking status
Nonsmokers 1 1
Cigarette smokers 1.73 (0.85–3.55) 0.12 2.06 (0.95–4.45) 0.06
Waterpipe smokers 2.97 (1.44–6.09) <0.01 3.48 (1.60–7.57) < 0.01
Model 0 ¼ univariate analysis.
Model 1 ¼ Model 0 þ age, gender, marital status, education level, income, physical activity, systolic blood pressure, diastolic blood pressure, heart rate, waist circumference.
CI, confidence interval; NLR, neutrophil to lymphocyte ratio; OR, odds ratio; PLR, platelet to lymphocyte ratio.
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
CE: A.M.; JAM-D-17-00182; Total nos of Pages: 6;
JAM-D-17-00182
J Addict Med Volume 00, Number 00, Month/Month 2018 Waterpipe Smoking and Its Association With Systemic Inflammation
TABLE 4. Association of Tobacco Smoking Status and Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0 Model 1
Beta SE 95% CI P Beta SE 95% CI P
restaurants which offered WP smoking facility at the venue (Flouris et al., 2012). Although the biological plausibility
(data not shown). of the association has not been studied much, it may be
In light of existing literature, various mediators have explained by the cellular response of blood components to
been linked with onset of systemic inflammation, including inflammation which is mediated by endothelial dysfunction
obesity, lack of physical activity, stress, and even cigarette (Marsland et al., 2010). Similarly, a relation between chronic,
smoking (Bell and O’Keefe, 2007; Brooks et al., 2010; low-grade, subclinical inflammation, and insulin resistance
Copeland et al., 2014; Nakanishi et al., 2002; Pirkola et al., leading to clinically over diabetes mellitus has also been
2010; Pitsavos et al., 2007; Yasue et al., 2006). Comparing reported (Pitsavos et al., 2007). In case of establishing the
study results with existing evidence available in this regard, association between WP use and systemic inflammation, it
raised total leukocyte count among WP smokers had been may then also be well justified to state that, WP smoking, in
reported in several studies (Bentur et al., 2014; Khabour the long run, maybe a potential risk factor for developing
et al., 2012), and the results are also comparable with studies chronic diseases like metabolic syndrome, diabetes, and
that have reported raised total leukocyte count among cigarette cardiovascular disease. However, present evidence in this
smokers (Shenwai and Aundhakar, 2012; Tell et al., 1985; regard is limited and calls for further investigations.
Whitehead et al., 1995). Our study adds to the limited evidence The findings of the study may also be used for effective
available. Even after adjusting for several important health- advocacy against the use of WP smoking, which at the
related parameters including blood pressure, body mass index, moment is emerging as a popular, relatively less harmful
physical activity, NLR, and PLR remained significantly asso- form of smoked tobacco, among users (Maziak et al., 2004).
ciated with WP smoking as evident from study results where As discussed earlier, though, NLR and PLR were at a higher
WP smokers were found to have higher odds of raised inflam- level among WP smokers as compared to cigarette smokers
matory markers as compared to cigarette smokers. and nonsmokers in our study, these values were in normal
As far as use of NLR and PLR as inflammatory markers ranges among all 3 groups. It may take several years before we
in the present study is concerned, they have been used in have large-scale, multiyear epidemiological studies to vali-
several studies to assess the presence of low-grade systemic date the chronic health effects of WP smoking. In such
inflammation, in association with cardiovascular diseases, circumstances, evidence from studies like this may hold
cancer survival, and chronic diseases (Bovill et al., 1996; importance with regard to the advocacy to prevent the use
Freedman et al., 1996; Imtiaz et al., 2012; Yasue et al., 2006). of WP usage at the population level. Previous findings related
However, to the best of our knowledge, this is the first study to to the characteristics of WP smokers are also important, as
report the association of the NLR and PLR with WP smoking, they clearly indicate that majority of the users unaware of the
and thus the results warrant further investigations to confirm harmful effects of WP smoking, consider it relatively safe as
the finding. In case the findings related to use of NLR and compared to cigarette smoking (Maziak et al., 2004).
PLR as a valid measure of low-grade systemic inflammation is Although cigarette use may have declined in several devel-
confirmed, these can be used as a simple, cost-effective oped countries, it is currently a big dilemma for the antito-
measure of low-grade systemic inflammation in resource- bacco efforts, that the newer products like e-cigarettes and re-
limited scenarios. emerging popular forms like WP have gained ground as
Regarding the implications of raised inflammatory relatively safe social drugs (Maziak et al., 2004, 2014).
markers among WP smokers, a chronic systemic inflamma- Our study had various limitations; first, as an observa-
tory effect may lead to several diseases like cardiovascular tional study, it cannot outline a causal association between
diseases, diabetes mellitus, hypertension. For instance, leu- WP smoking and inflammatory effect. However, supporting
kocytosis caused by cigarette smoking has been found to be evidence points in the same direction, and it may be well
associated with low-grade inflammation in atherosclerosis justified to speculate causative role of WP smoking in
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
CE: A.M.; JAM-D-17-00182; Total nos of Pages: 6;
JAM-D-17-00182
Kumari et al. J Addict Med Volume 00, Number 00, Month/Month 2018
systemic inflammation. Nevertheless, the results call for a Folsom AR, Rosamond WD, Shahar E, et al. Prospective study of markers of
further understanding of the phenomenon through longitudi- hemostatic function with risk of ischemic stroke. Circulation
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in men. Ann Epidemiol 1996;6:74–82.
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cigarettes. Therefore, there are fair chances that participants measure of systemic inflammation in prevalent chronic diseases in Asian
who might have been exposed to higher doses of toxicants due population. Int Arch Med 2012;5:2.
to synergistic effects of combined WP and cigarette use may Jawaid A, Zafar A, Rehman T, et al. Knowledge, attitudes and practice of
have been completely missed. Nevertheless, a study of exclu- university students regarding waterpipe smoking in Pakistan. Int J Tuberc
Lung Dis 2008;12:1077–1084.
sive WP and cigarette smoking groups enabled us to compare Kao LS, Green CE. Analysis of variance: is there a difference in means and
the inflammatory effects caused by the 2 different forms of what does it mean? J Surg Res 2008;144:158–170.
smoked tobacco. Furthermore, any results can also be masked Khabour OF, Alzoubi KH, Bani-Ahmad M, et al. Acute exposure to waterpipe
by environmental air pollution, as well as any underlying tobacco smoke induces changes in the oxidative and inflammatory markers
in mouse lung. Inhal Toxicol 2012;24:667–675.
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CONCLUSIONS Physiol Lung Cell Mol Physiol 2015;309:L119–L128.
Waterpipe smoking has a significant association with Lin BD, Hottenga JJ, Abdellaoui A, et al. Causes of variation in the
neutrophil–lymphocyte and platelet–lymphocyte ratios: a twin-family
systemic inflammation as measured by NLR and PLR. The
study. Biomark Med 2016;10:1061–1072.
study and existing evidence implicate the need to regulate the Marsland AL, McCaffery JM, Muldoon MF, et al. Systemic inflammation and
WP industry and its policies. Public awareness policies are the metabolic syndrome among middle-aged community volunteers.
required to correct the perception regarding the safety of WP. Metabolism 2010;59:1801–1808.
Maziak W, Ward K, Soweid RA, et al. Tobacco smoking using a waterpipe:
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ACKNOWLEDGMENTS 327–333.
We would like to thank all personnel who provided Maziak W, Taleb ZB, Bahelah R, et al. The global epidemiology of waterpipe
support for logistic support. We would also like to thank smoking. Tob Control 2014;24(suppl 1):i3–i12.
all study participants and organizations involved in this study. Nakanishi N, Sato M, Shirai K, et al. White blood cell count as a risk factor for
hypertension; a study of Japanese male office workers. J Hypertens
2002;20:851–857.
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