Chest
Volume 139, Issue 4, April 2011, Pages 764-774
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Original Research
COPD
Effects of Water-Pipe Smoking on Lung Function: A Systematic Review and Meta-analysis

https://doi.org/10.1378/chest.10-0991Get rights and content

Background

Although common in many Middle Eastern countries, water-pipe tobacco smoking, commonly known as water-pipe smoking (WPS), is increasingly popular in Western cultures. The primary objective of this study was to systematically review the effects of WPS on lung function. The secondary objective was to compare the effects of WPS and cigarette smoking on lung function.

Methods

We conducted a systematic review using the approach of the Cochrane Collaboration to search for, select, and abstract studies. We conducted two separate meta-analyses comparing water-pipe smokers with nonsmokers, and water-pipe smokers with cigarette smokers for each of three spirometric measurements (FEV1, FVC, and FEV1/ FVC). We used the standardized mean difference (SMD) to pool the results.

Results

Six cross-sectional studies were eligible for this review. Compared with no smoking, WPS was associated with a statistically significant reduction in FEV1 (SMD = −0.43; 95% CI, −0.58 to −0.29; equivalent to a 4.04% lower FEV1%), a trend toward lower FVC (SMD = −0.15; 95% CI, −0.34 to 0.04; equivalent to a 1.38% reduction in FVC%), and lower FEV1/ FVC (SMD = −0.46; 95% CI, −0.93 to 0.01; equivalent to a 3.08% lower FEV1/ FVC). Comparing WPS with cigarette smoking, there was no statistically significant difference in FEV1, FVC, and FEV1/ FVC. The six studies suffered from methodologic limitations.

Conclusions

WPS negatively affects lung function and may be as harmful as cigarette smoking. WPS, therefore, is likely to be a cause of COPD.

Section snippets

Eligibility Criteria

We included studies that assessed the association between water-pipe tobacco use and lung function. Eligible studies had to include a group of individuals smoking a water pipe exclusively. They also had to include at least one of the following: (1) a group of nonsmokers, (2) a group of individuals practicing exclusively cigarette smoking. Our outcomes of interest were the following three spirometric measurements: FEV1, FVC, and FEV1/FVC.

Search Strategy

In June 2008, we searched the following electronic

Description of Included Studies

Figure 2 shows the study flow. Of 1,658 identified citations, we included six studies (Table 1)16, 17, 18, 19, 20, 21 One study reported results separately for men and women.18 All studies included a group of nonsmokers, described as passive smokers in two of the studies.19, 21 All but one study included a group of cigarette smokers.19 All studies reported spirometric measurements. Countries in which the studies were conducted were Turkey (n = 3), Kuwait (n = 1), Saudi Arabia (n = 1), and Syria

Discussion

We systematically reviewed the scientific literature for the effects of WPS on lung function. Compared with no smoking, WPS was associated with a statistically significant reduction of FEV1 and a trend toward lower FVC and FEV1/FVC. The quality of evidence is moderate (ie, further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate).15 There were no statistically significant differences in FEV1 and FEV1/FVC between water-pipe

Implications for Public Health Policy

This study adds to the rapidly growing evidence of the association of WPS with deleterious health outcomes,11 which has very important implications for both clinical and public health practice. Spirometry performance might give the clinician an opportunity to convince smokers to quit.26 More importantly, our study supplies the physician with data they might use in counseling patients about the deleterious effect of WPS on lung function. As for the public health practice, this study illustrates

Acknowledgments

Author contributions: Dr Raad: contributed to study selection, data abstraction, data analysis, data interpretation, drafting of the manuscript, revising the article critically for important intellectual content, and approving the final version of this manuscript.

Dr Gaddam: contributed to study data abstraction, revising the article critically for important intellectual content, and approving the final version of this manuscript.

Dr Schunemann: contributed to data interpretation, revising the

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