Lifetime cumulative exposure to waterpipe smoking is associated with coronary artery disease
Introduction
More than 3 billion people worldwide currently smoke tobacco in its various forms, and the majority (80%) live in low and middle-income countries. Tobacco use has already been established as the number one modifiable risk factor for cardiovascular diseases, contributing to an annual mortality rate that exceeds six million individuals [1]. Whist smoking tobacco using waterpipe (WP) has been most commonly associated with the Eastern Mediterranean Region, it is increasingly becoming a popular method of tobacco consumption worldwide [2]. Data from several national and regional studies suggest that the epidemic of WP smoking is on the rise reaching a prevalence of 20–30% among adults and increasing significantly among younger cohorts [3]. With the accumulated evidence of the epidemiology of this behavior and its health consequences, the American Lung Association addresses WP smoking as a ‘growing threat to public health’ and an ‘emerging deadly trend’ [4].
Research has so far demonstrated a significant link between WP smoking and a number of diseases including lung, oral and bladder cancers, respiratory illnesses and adverse pregnancy outcomes [5]. Some studies have also shown associations with surrogate markers of coronary disease such as heart rate variability [6], heart rate and systolic blood pressure [7]. Though anticipated to share the coronary disease hazards of cigarettes smoking [8], epidemiological studies addressing the long-term effect of WP smoking on heart disease remains largely lacking [5]. We examine in this study the association of WP smoking with heart disease as manifested by angiographically determined coronary artery disease (CAD).
Section snippets
Study population
The study sample included consecutive admissions of patients for coronary angiography at four major tertiary hospitals in Beirut, the capital city of Lebanon, and its suburbs, during the period extending from July 2007 until August 2008. Patients were excluded from the study if they: 1) were younger than 40 years old; 2) had undergone a previous coronary angiography, coronary artery bypass surgery, or percutaneous coronary intervention; 3) had a history of heart disease (myocardial infarction,
Results
Of the 1210 study subjects, 235 (19.4%) were ever WP smokers, 765 (63.3%) were ever cigarette smokers, 894 (73.9%) ever smoked either of the two forms of tobacco, and 57(4.7%) were current smokers of both types of tobacco. Also, 140 (11.6%) accumulated a lifetime WP smoking between 1 and 20 WP-years, 49 (4.0%) between 21 and 40 WP-years, and 46 (3.8%) more than 40 WP-years. Further details on smoking habits by case–control status and CAD score are presented in Table 1. Compared to the controls,
Discussion
To date, this study is the first to examine the relationship between WP smoking and CAD as manifested by the extent of angiographically determined stenosis. The study showed that lifetime cumulative WP smoking (frequency and duration of risk exposure) appears to be a more critical risk factor to CAD than the status of WP smoking (never, ex- and current), with individuals accumulating greater than 40 WP-years being almost three times more at risk of having severe stenosis (≥70%) than nonsmokers,
Funding
This work was supported by the International Development Research Centre (IDRC-EDR) [grant number 103436-001] to [AMS]. The funding source had no role in the study design, conduct or analysis; in the writing of the paper or the decision to submit the paper for publication.
Contributors
AMS proposed and designed the study, planned the analyses and contributed significantly to the interpretation of the results and write-up of the manuscript. RAT coordinated and supervised the study conduct and analysis. RAT, TI, SY, EN and MMA contributed to the analysis and helped draft the manuscript. HAI provided critical input on the plan of analysis and contributed significantly to the write-up of the manuscript.
Competing interests
None declared for all authors.
Acknowledgments
We thank all the cardiologists at the American University of Beirut, Makassed General Hospital, Rizk Hospital and Beirut Governmental Hospital for contributing patients for this study, the cardiologists who facilitated conduction of this study (Dr. Samir Alam, American University of Beirut, Dr. George Ghanem, Rizk Hospital, Dr. Shawki Abdallah, Makassed General hospital, Dr. Nabil Shasha, Beirut Governmental hospital, Dr. George Saadeh), and the interviewers at these hospitals (Mireille Azar,
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