Lifetime cumulative exposure to waterpipe smoking is associated with coronary artery disease

doi:10.1016/j.atherosclerosis.2014.03.036

Atherosclerosis

Volume 234, Issue 2, June 2014, Pages 454-460

https://doi.org/10.1016/j.atherosclerosis.2014.03.036 Get rights and content

Highlights

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3 fold net increase in odds of severe CAD with lifetime use exceeding 40 WP-years.
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Associations showed a consistent dose–response relationship with increasing exposure.
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CAD Index score increased by 7.8 points with lifetime use exceeding 40 WP-years.
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There is a need to monitor and document WP use among cardiac patients.

Abstract

Objective

Globally, waterpipe (WP) smoking is becoming a more prevalent form of tobacco consumption. Whilst research so far has demonstrated a significant link between WP use and a number of health outcomes, little is known of its association with heart disease. We examine in this study the association of WP smoking with angiographically confirmed coronary artery disease (CAD).

Methods

A total of 1210 patients, aged 40 years and over and free from smoking-associated illnesses or history of cardiovascular procedures, admitted for coronary angiography at four major hospitals in Lebanon, were included. The extent of CAD was summarized in two ways, firstly as diseased (≥50% and ≥70% occlusion in at least one main coronary artery) versus non-diseased (entirely normal coronaries), and secondly, as CAD cumulative score based on Duke CAD Prognostic Index. A score of WP-years, capturing intensity and lifetime duration of exposure, was estimated for each individual.

Results

Lifetime exposure exceeding 40 WP-years was associated with a threefold significant increase in the odds of having severe stenosis (≥70%) compared to non-smokers (OR = 2.94, 95% CI 1.04–8.33) as well as with the CAD Index (β = 7.835, p-value = 0.027), net of the effect of socio-demographic characteristics, health behaviors and co-morbidity. A dose–response relationship between WP-years and percent stenosis was also established. WP smoking status (never, past and current) did not associate with CAD.

Conclusions

Cumulative exposure to WP smoking is significantly associated with severe CAD. There is a need to monitor WP use among cardiac patients and include this information in their medical charts in the same manner cigarettes smoking is documented. This is likely to increase awareness of the hazards of WP smoking and prompt physicians to target WP tobacco control by providing advice to their patients on WP smoking cessation.

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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At this point, we would like to reestablish that tobacco consumption, including waterpipe, is detrimental to health (Kadhum et al., 2015; Kim, Kabir, & Jahan, 2016), particularly cardiovascular (Haddad et al., 2016). In fact, waterpipe smoking has been implicated in the most divesting diseases, including cardiovascular (Islami et al., 2013; Sibai et al., 2014), and respiratory diseases (She et al., 2014; Tageldin et al., 2012), stroke (Farah et al., 2015), and cancer (Etemadi et al., 2017). These diseases are the leading causes of hospitalization, morbidity, and mortality in the globe (McAloon et al., 2016).
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View full text

Lifetime cumulative exposure to waterpipe smoking is associated with coronary artery disease

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Results

Discussion

Funding

Contributors

Competing interests

Acknowledgments

Addict Behav

Toxicol Lett

Chest

Public Health

Cancer Epidemiol

Life Sci

Pharmacol Biochem Behav

WHO report on the global tobacco epidemic; warning about the dangers of tobacco

Change in tobacco use among 13-15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey

Glob Health Promotion

An emerging deadly trend; waterpipe tobacco use

The effects of waterpipe tobacco smoking on health outcomes: a systematic review

Int J Epidemiol

Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses

N Engl J Med

The association of risk factors with arteriographically defined coronary artery disease: what is the appropriate control group?

Am J Epidemiol

Circulation