plasma water pipe

Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine


  • 1 Department of Physiology and Biochemistry, Faculty of Medicine, University of Jordan, Amman. [email protected]
  • PMID: 12078938
  • DOI: 10.5414/cpp40249

Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine

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  • 1 Department of Physiology and Biochemistry, Faculty of Medicine, University of Jordan, Amman. [email protected]
  • PMID: 12078938
  • DOI: 10.5414/cpp40249


Objectives: The purpose of the present study was to assess the levels of nicotine and cotinine in biological fluids (plasma, saliva, and urine) following hubble-bubble (HB) smoking.

Methods: Fourteen healthy male volunteers, aged 28 +/- 8 years, body weight of 82.7 +/- 13.53 kg, participated in the study. All volunteers were habitual HB smokers for 3.29 +/- 1.90 years who smoked at least 3 runs per week with an average of 20 g Mua’sel per run. Volunteers were requested to avoid smoking, at least 84 hours prior to the time of the study. After baseline samples were taken, volunteers started smoking 20 g of Mua’sel for a period of 45 minutes. Heparinized blood samples (5 or 10 ml each) were drawn for nicotine and cotinine analysis before, during and after the smoking period. Saliva samples were collected just before smoking (time 0) and at the end of smoking (45 min). Urine also was collected at time 0 and 24-hour urine collection was also taken to measure nicotine and cotinine excretion. Nicotine and cotinine were extracted from samples and assayed by gas chromatography. All data are presented as mean +/- SEM throughout the text, Tables and Figures unless indicated otherwise.

Results: Plasma nicotine levels rose from 1.11 +/- 0.62 ng/ml at baseline to a maximum of 60.31 +/- 7.58 ng/ml (p Conclusion: Following a single run of HB smoking, plasma, saliva and urinary nicotine and cotinine concentration increased to high values. This observation suggests that HB may not be an innocent habit, as people believe.

Following a single run of HB smoking, plasma, saliva and urinary nicotine and cotinine concentration increased to high values. This observation suggests that HB may not be an innocent habit, as people believe.

Waterpipe smoking and nicotine exposure: A review of the current evidence


The waterpipe, also known as shisha, hookah, narghile, goza, and hubble bubble, has long been used for tobacco consumption in the Middle East, India, and parts of Asia, and more recently has been introduced into the smokeless tobacco market in western nations. We reviewed the published literature on waterpipe use to estimate daily nicotine exposure among adult waterpipe smokers. We identified six recent studies that measured the nicotine or cotinine levels associated with waterpipe smoking in four countries (Lebanon, Jordan, Kuwait, and India). Four of these studies directly measured nicotine or cotinine levels in human subjects. The remaining two studies used smoking machines to measure the nicotine yield in smoking condensate produced by the waterpipe. Meta-analysis of the human data indicated that daily use of the waterpipe produced a 24-hr urinary cotinine level of 0.785 μg/ml (95% CI = 0.578–0.991 μg/ml), a nicotine absorption rate equivalent to smoking 10 cigarettes/day (95% CI = 7–13 cigarettes/day). Even among subjects who were not daily waterpipe smokers, a single session of waterpipe use produced a urinary cotinine level that was equivalent to smoking two cigarettes in one day. Estimates of the nicotine produced by waterpipe use can vary because of burn temperature, type of tobacco, waterpipe design, individual smoking pattern, and duration of the waterpipe smoking habit. Our quantitative synthesis of the limited human data from four nations indicates that daily use of waterpipes produces nicotine absorption of a magnitude similar to that produced by daily cigarette use.


According to the World Health Organization (WHO, 2005), tobacco use is responsible for about 5 million deaths per year worldwide. Furthermore, half of the people who smoke today will die prematurely.

In the midst of the present worldwide tobacco epidemic, concern is growing regarding the use of a waterpipe (referred to in various regions as shisha, hookah, narghile, and hubble bubble) to smoke tobacco, a practice dating back at least 400 years. This early form of smoking is experiencing a global revival, particularly in Middle Eastern countries (Maziak, Ward, Soweid, & Eissenberg, 2004). Some of this increase in use has been attributed to the popularity of flavored or sweetened tobaccos for use in the waterpipe (Rastam, Ward, Eissenberg, & Maziak, 2004). Recent reports indicate that waterpipes are commonly used in Egypt, Saudi Arabia, Jordan, Lebanon, Syria, Kuwait, Israel, Africa, India, and certain parts of Asia (Al Mutairi, Shihab-Eldeen, Mojiminiyi, & Anwar, 2006; Maziak, Ward, Soweid, et al., 2004; Singh et al., 2006).

Traditionally, waterpipe smoking has been the habit of older males who, in the Middle East, often gather for waterpipe smoking in street-side cafes where they visit with friends and play table games together. Waterpipe use has recently grown in popularity and present-day waterpipe smokers include trendy youth, university students, and even high-school-aged children (Maziak, Ward, Soweid, et al., 2004). Empirical observations from mainly Middle Eastern countries confirm that new chic cafes for waterpipe smoking are alive with loud music, bright lights, and frequently big screen television sets, and that such establishments are rapidly expanding to shopping malls, expensive hotels, and popular neighborhoods. It is fashionable for young people to socialize around the waterpipe.

Growing evidence indicates that women are increasingly likely to become waterpipe smokers. Some of this trend may be attributable to the introduction of sweetened and flavored waterpipe tobacco during the 1990s (Rastam et al., 2004), which may be attracting female teenagers (Hadidi & Mohammed, 2004). Women in general tend to perceive waterpipe use more positively than cigarette smoking, with women waterpipe users noting its positive attributes of being familiar, looking traditional, and being social (Maziak, Ward, Soweid, et al., 2004). Other studies in the Middle East indicate that women find waterpipe smoking to be attractive (Maziak, Rastam et al., 2004) and an occasion when they can participate with others (Tamim, Terro et al., 2003). Family members’ attitudes toward women using the waterpipe appears to be shifting, with female university students thinking that adult family members would offer no particular opinion, either negative or positive, about their smoking waterpipes (Maziak, Eissenberg et al., 2004).

Much of the emerging public health and medical literature on waterpipe use focuses on its impact on health. A widespread perception exists among users, as well as some physicians (Kandela, 2000), that waterpipe smoking is a far less harmful habit than cigarette smoking. This notion is based on the premise that waterpipe smoke contains less tar, nicotine, and other toxins because of the “purification” (Shihadeh, 2003) that occurs when the smoke passes through water before being inhaled by the user. However, this perception may be changing (Maziak, Eissenberg et al., 2004). Some researchers have speculated that the health consequences are not significantly different from those associated with cigarette smoking and have presented evidence linking waterpipe smoking to cancer, abnormal pulmonary functions, elevated heart rate and blood pressure, high carboxyhemoglobin concentrations, low-birth-weight infants, respiratory ailments from environmental tobacco smoke, and decreased fertility (Knishkowy & Amitai, 2005; Shafagoj, Mohammed, & Hadidi, 2002; Tamim, Musharrafieh, El Roueiheb, Yunis, & Almawi, 2003). Further studies of the morbidity and mortality associated with waterpipe smoking are needed.

In light of the current social trends toward increased waterpipe use, a number of additional questions need to be asked. For example, does waterpipe use promote nicotine addiction with the same strength as more common forms of tobacco such as cigarettes? Also relevant is whether nicotine addiction that is developed through waterpipe use leads to other forms of tobacco use (i.e., cigarette smoking). Much more needs to be learned about waterpipe dependence, but preliminary evidence suggests it has an addictive characteristic (Maziak, Eissenberg, & Ward, 2005). Furthermore, it seems likely that waterpipe dependency has some unique characteristics that differ from those of cigarette dependency (Maziak, Ward, & Eissenberg, 2004)

We reviewed the data on nicotine exposure and waterpipe smoking from six studies that used recent, valid methodologies for measurement and collection of biospecimens (Al Mutairi et al., 2006; Behera, Uppal, & Majumdar, 2003; Macaron, Macaron, Maalouf, Macaron, & Moor, 1997; Shafagoj et al., 2002; Shihadeh, 2003; Shihadeh & Saleh, 2005). This review aimed to (a) ascertain nicotine levels associated with waterpipe usage and (b) compare the nicotine delivery data for waterpipes with comparable data from cigarettes. This analysis will be valuable in ascertaining the public health impact of waterpipe use and its capacity to contribute to nicotine addiction in the population.


The search for articles in this review included computerized databases and references found in published articles. Databases included Medline, EBSCOhost, the Centers for Disease Control and Prevention Office on Smoking and Health, and the WHO’s Tobacco Free Initiative, as well as a general search of the Internet using Google. The waterpipe is also known as shisha, hookah, narghile, arghile, hubble bubble, or goza in various countries and parts of the world. Therefore, the search included all of these terms with their possible alternate spellings (such as sheesha or chicha).

The inclusion criterion for this comprehensive search was that the published work provided an estimate of the nicotine level associated with waterpipe use and was published since 1975. We felt that research done prior to this date would be limited by the technology of its time, raising questions about its comparability with more recent studies. Three identified articles dealing with waterpipe use, but not its nicotine delivery, were published in Hebrew and French. The final search was made in August 2006.

Our review of the literature revealed that two approaches were used to measure nicotine levels from waterpipe use. One method involved analyzing mainstream waterpipe smoke generated by machines designed to mimic human smoking patterns. This method mechanically captured the waterpipe smoke and examined it for nicotine content or other components. The second approach was to collect and analyze a waterpipe smoker’s plasma, urine, or saliva.

Six articles were identified that described studies measuring nicotine levels associated with waterpipe smoking. Two of these studies involved smoking-machine measurements and four were human studies. These studies were conducted between 1997 and 2006 in Lebanon, Jordan, Kuwait, and India. In all of these countries, waterpipe use has been a traditional form of smoking.

Data analyses

The mean urinary cotinine values from k human studies were pooled in a meta-analysis using methods described by Armitage and Berry (1987):

where weight is given by 1/variance of the urinary cotinine value. A 95% confidence interval for the pooled mean is given by

Computing cigarette equivalency from urinary cotinine values

One of the aims of our review was to determine whether the nicotine exposure from daily use of the waterpipe is comparable with the nicotine exposure from daily use of cigarettes. Therefore, we translated our best estimate of the 24-hr urinary cotinine levels among daily waterpipe users into an equivalent number of cigarettes needed to produce the same urinary cotinine level during a 24-hr period. For this analysis we needed accurate data on the relationship between urinary cotinine and number of cigarettes smoked.

Heinrich et al. (2005), in their study of 5,000 German adults aged 18–69 years, confirmed the data from many previous studies indicating that in the range of 1–30 cigarettes/day the relationship is linear and corresponds to urinary cotinine values of 0.075 μg/ml (≤2 cigarettes/day) to 2.1 μg/ml (21–30 cigarettes per day). In a sample of 190 Japanese males, Yang et al. (2001) found similar results, indicating a significant positive correlation between urinary cotinine and number of cigarettes smoked and a regression line indicating that urinary cotinine ranged from 0.08 μg/ml to 2.0 μg/ml for smoking 1–30 cigarettes/day.

Taken together, the slope coefficients from these studies indicated that, in the range of 1–30 cigarettes/day, each cigarette smoked produced 0.078 μg/ml of cotinine in a 24-hr urine sample. In this report, we used this value to compute the “cigarette equivalency” of waterpipe smoking.


In Lebanon, Shihadeh (2003) devised a first-generation smoking machine to determine the chemical profile of the waterpipe’s mainstream smoke ( Table 1 ). For the smoking of 10 g of waterpipe tobacco (maassel-flavored tobacco) using a standard smoking protocol (100 puffs of 3 s/per puff, 300 ml/puff, and 30 s between each puff), he measured a nicotine yield of 2.25 mg of nicotine from the smoke condensate.

Table 1

Smoking machine studies that estimate the nicotine yield from the smoke condensate of a single waterpipe session.

Study Amount of tobacco smoked (per session) Puff frequency (per session) Waterpipe mean nicotine content (per session)
Shihadeh, 2003 10 g 100 puffs at 3 s/puff, 300 ml/puff, 30 s between puffs 2.25 mg
Shihadeh & Saleh, 2005 10 g 171 puffs at 2.6 s/puff, 530 ml/puff, 2.8 puffs/min 2.94 mg

Shihadeh (2003) noted the limitation that the true smoking patterns (i.e., puff frequency, duration, interval between puffs) of waterpipe smokers were unknown. A two-phase follow-up study (Shihadeh, Azar, Antonios, & Haddad, 2004) addressed this concern by studying the smoking patterns of 52 waterpipe smokers in a Beirut cafe. Specifically, the authors studied 38 men and 14 women smokers in a busy Beirut cafe adjacent to a private university. Most of the participants were university students (Mage = 21 years), most likely from higher income strata of Beirut. These volunteers agreed to smoke a waterpipe with an attached smoking topography instrument that measured flow rate against time. The second phase consisted of inconspicuously observing 56 randomly selected waterpipe smokers in the same cafe, recording their smoking patterns. These observations were made without the smoker’s knowledge, and no contact was made before or after the smoking session. The findings from this follow-up study indicated that an “average” waterpipe session involved greater intake of smoke (171 puffs at 530 ml/puff, 2.6 s/puff, and 2.8 puffs/min) than was estimated in the previous smoking-machine study.

Using the new data that indicated a higher-intensity smoking pattern for waterpipe smokers, Shihadeh and Saleh (2005) found that the nicotine yield from a smoking session of 10 g of waterpipe tobacco was 2.94 mg ( Table 1 ). By comparison, the sales-weighted (1,294 brands) machine-measured mean nicotine yield from a single cigarette was 0.88 mg using the standard U.S. Federal Trade Commission (FTC) method that assumes taking 2-s, 35-ml puffs from a U.S. cigarette until a 23-mm butt length remained (FTC, 2000). The higher volume and longer duration of a waterpipe session is noteworthy in this regard.

As a point of interest, we note findings from two early studies that used older smoking machines that are not comparable with the recent studies. Hoffmann, Rathkamp, and Wynder (1963) found that smoking 100 g of waterpipe tobacco produced 38 mg of nicotine in the smoke condensate. The results from smoking 800 mg of waterpipe tobacco showed the nicotine level in the smoke condensate to be 0.43 mg (Galal, Youssef, & Salem, 1973).

Human studies

Table 2 presents the data from recent studies of adults in Lebanon, Jordan, India, and Kuwait that have measured urinary cotinine levels among water-pipe users. These studies are briefly described and summarized below, and pertinent results were included in a meta-analysis.

Table 2

Human studies: Urinary cotinine values measured in waterpipe users.

Waterpipe smoking and nicotine exposure: A review of the current evidence Abstract The waterpipe, also known as shisha, hookah, narghile, goza, and hubble bubble, has long been used for ]]>