Qat chewing and water pipe (mada’a) smoking in Yemen: a necessary clarification when studying health effects on oral mucosa
2007; Elsevier BV; Volume: 104; Issue: 6 Linguagem: Inglês
10.1016/j.tripleo.2007.08.030
ISSN1528-395X
Autores Tópico(s)Respiratory and Cough-Related Research
ResumoThanks to his analysis of histopathologic changes in some Yemenis’ oral mucosa, Ali has recently provided the scientific community with the first results on the possible relation between Qat chewing and Mada’a smoking.1Ali A. Histopathologic changes in oral mucosa of Yemenis addicted to water-pipe and cigarette smoking in addition to takhzeen al-qat.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: e55-e99Google Scholar The present commentary is based on a critical review and discussion of the findings by the above researcher in this field. The mada’a is a kind of tall narghile (water pipe) particularly used in Yemen. It is similar to the hookah or narghile in other countries. However, it is different from the fashionable shisha, now found in all parts of the world, because the kind of tobacco-based smoking mixture is different in both cases: pure dampened shredded tobacco leaves (called “tutun” in Yemen and “tumbak” or “tumbeki” in other countries) in one case, tobacco-molasses (called tobamel or mu’assel, i.e., “honeyed” in Arabic) in the other. There are other forms of water pipes in Yemen, such as the “rushba” (a coconut-based artefact similar to the Egyptian gûza) of the Hadramawt (northeastern region of Yemen) and the belly-shaped “kûz” of the Tihama region (on the Red Sea), particularly appreciated by the fishermen there. These two objects, as well as others, including the national mada’a, and not to forget the recently arrived shisha, have been described in detail in our research.2Chaouachi K. Le narguilé au Yémen.in: Naim S. D’un itinéraire à l’autre. Maisonneuve et Larose, Paris2001: 130-147Google Scholar In these conditions, citing Wolfram et al. for the ethnographic aspects of narghile (hookah, shisha) use in the world is certainly not relevant, all the more so because their sources were not given.3Wolfram R.M. Chehne F. Oguogho A. Sinzinger H Narghile (water pipe) smoking influences platelet function and (iso)eicosanoids.Life Sci. 2003; 74: 47-53Google Scholar In the same vein, water pipe smoking is not common “only” “in the “Arabic and in some Asian countries.” Ali cites in this respect Kandela4Kandela P. Nargile smoking keeps Arabs in Wonderland. Lancet 2000;356(9236):1175.Google Scholar who is, in fact, the author of a 1-page paper based on personal anecdotes, not on scientific observation.5Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators.”.J Neg Results Biomed. 2006; 5 (Available at: http://www.jnrbm.com/content/5/1/17): 17Google Scholar “Takhzeen-al-qat provides psychostimulant effects in the form of moderate euphoria and mild excitement.” This would be the reason why “millions of Yemenis practice the habit.”1Ali A. Histopathologic changes in oral mucosa of Yemenis addicted to water-pipe and cigarette smoking in addition to takhzeen al-qat.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: e55-e99Google Scholar This is actually a quick and rather reductionist analysis of a complex situation. Yemenis also use qat for sociologic and anthropologic reasons described in detail in early works.6Weir S. Qât in Yemen: consumption and social change. British Museum, London1985Google Scholar, 7Lambert J. Le qât au Yémen: imaginaire d’une drogue imaginaire. In: Psychotropes, vol. VIII. Outremont (Québec); 1992. p. 91-102.Google Scholar, 8Chaouachi K. Le narguilé Anthropologie d’un mode d’usage de drogues douces. Ed. L’Harmattan, Paris1997Google Scholar One of the major findings of these studies in the field of social sciences shows that the use of the mada’a is a chief element of the ritual qat parties that take place during the long afternoons in Yemen. During these (often daily) events, qat is chewed and stocked in the mouth (takhzeen-al-qat), and the national water pipe, the madâ’a, is a necessary element of the whole mise-en-scène or staging. The situation would be clear if the male participants in the qat parties were not also (heavy) cigarette smokers. In these conditions, a good attitude is to remain cautious as far as the causes of histopathologic changes of the oral mucosa are concerned,1Ali A. Histopathologic changes in oral mucosa of Yemenis addicted to water-pipe and cigarette smoking in addition to takhzeen al-qat.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: e55-e99Google Scholar because of the confusion factors: simultaneous cigarette and mada’a smoking. However, we think that they could have been partly raised if the results in the tables on histopathologic differences in biopsies had also been presented according to gender. As a matter of fact, the 6 qat-chewing women analyzed by Ali, and supposed to be noncigarette smokers, were probably madâ’a smokers and, unlike men, exclusive users of this tobacco use mode. Sexual Differentiation. Ali points out that “cigarette smoking is stigmatized and not acceptable among women in Yemeni society.” For these reasons, the male:female ratio and mean age varied among the 3 groups in his study. These finding are supported by many other studies.”1 This question of cigarette smoking had not been soundly analyzed in the 2 publications cited to support his statement.4Kandela P. Nargile smoking keeps Arabs in Wonderland. Lancet 2000;356(9236):1175.Google Scholar, 9Maziak M. Eissenberg T. Rastam S. Hammal F. Asfar T. Bachir M.E. et al.Beliefs and attitudes related to narghile (water-pipe) smoking among university students in syria.Ann Epidemiol. 2004; (14): 646-654Google Scholar Indeed, narghile use by women is a very complex issue.8Chaouachi K. Le narguilé Anthropologie d’un mode d’usage de drogues douces. Ed. L’Harmattan, Paris1997Google Scholar Unfortunately, it has been simplified and sometimes caricaturized. The same paper4 has been cited over and over again in many publications, and this situation has led to great international confusion.5Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators.”.J Neg Results Biomed. 2006; 5 (Available at: http://www.jnrbm.com/content/5/1/17): 17Google Scholar Al-Fayez et al. are cited about pulmonary diseases in connection with mada’a use.10Al-Fayez S. Salleh M. Ardawi M. Zahran F. Effects of sheesha and cigarette smoking on pulmonary function of Saudi males and females.Tropic Geogr Med. 1988; 40: 115-123Google Scholar As in many other fields related to the potential pathologic aspects of narghile use, it is not easy to draw conclusions, because, as in Ali’s study about qat chewing and in-mouth stocking (takhzeen-al-qat),1Ali A. Histopathologic changes in oral mucosa of Yemenis addicted to water-pipe and cigarette smoking in addition to takhzeen al-qat.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 103: e55-e99Google Scholar the remote and recent career of the volunteers were not detailed.5Chaouachi K. A Critique of the WHO’s TobReg “Advisory Note” entitled: “Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators.”.J Neg Results Biomed. 2006; 5 (Available at: http://www.jnrbm.com/content/5/1/17): 17Google Scholar In these conditions, only 1, almost bias-free, recently published study is beginning to shed some light on the practice of narghile smoking and its medical consequences.11Al-Mutairi S.S. Shihab-Eldeen A.A. Mojiminiyi O.A. Anwar A.A. Comparative analysis of the effects of hubble-bubble (sheesha) and cigarette smoking on respiratory and metabolic parameters in hubble-bubble and cigarette smokers.Respirology. 2006; 11: 449-455Google Scholar However, caution is still needed, because each time the smoked product and the device used, among other variables, are different. Finally, stating that few studies have “reported the effect of water pipe on the oral cavity” is not exact. Unfortunately the 2 publications cited by Ali in this respect pose a certain number of problems.12Chaouachi K. Periodontal health and hookah narghile smoking [Letter to the Editor].J Periodontol. 2006; 77 (Critical analysis of: Natto S, Baljoon M, Bergstrom J. Tobacco smoking and periodontal health in a Saudi Arabian population. J Periodontol 2005;76:1919-26. Available at: http://www.joponline.org/toc/jop/77/5;jsessionid=nr4HkR8kSFX70r-xBT): 929-930Google Scholar, 13Chaouachi K. Post-publication peer review: errors in this new review.Pediatrics. 2005; 116 (Available at: http://pediatrics.aappublications.org/cgi/eletters/116/1/e113. Critical analysis of: Knishkowy B, Amitai A. Water-pipe (narghile) smoking: an emerging health risk behavior.): e113-e119Google Scholar Besides, one of them was only a review of the existing literature. Conclusion. Only a transdisciplinary approach, bridging between biomedical and social sciences, can help enhance research in this complex field where the confusion factors are many. No competing commercial interests, but co-inventor on patent applicatin for a no-carbon monoxide harm reduction hookah project (novagraaf/France). IMPORTANT NOTE: I signed away my past and future rights (total relinquishment) on this harm reduction patent by June 15, 2005, i.e. before its commercial exploitation. From that date, I no longer have any relation of any sort with the patent, even if the US patent (Young & Thompson/USA) may still mention my name on the internet. A legal document was signed on the same date in presence of a State Attorney in Paris (France). When leaving, I was paid a lump sum, not for the patent itself but, for my participation in the project.
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