title: Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives.
abstract: OBJECTIVE
  Waterpipe smoking using sweetened, flavoured tobacco products has become a widespread global phenomenon. In this paper, we review chemical, physical and biological properties of waterpipe smoke.
  
  
  METHODS
  Peer-reviewed publications indexed in major databases between 1991 and 2014. Search keywords included a combination of: waterpipe, narghile, hookah, shisha along with names of chemical compounds and classes of compounds, in addition to terms commonly used in cellular biology and aerosol sizing.
  
  
  METHODS
  The search was limited to articles published in English which reported novel data on waterpipe tobacco smoke (WTS) toxicant content, biological activity or particle size and which met various criteria for analytical rigour including: method specificity and selectivity, precision, accuracy and recovery, linearity, range, and stability.
  
  
  METHODS
  Multiple researchers reviewed the reports and collectively agreed on which data were pertinent for inclusion.
  
  
  RESULTS
  Waterpipe smoke contains significant concentrations of toxicants thought to cause dependence, heart disease, lung disease and cancer in cigarette smokers, and includes 27 known or suspected carcinogens. Waterpipe smoke is a respirable aerosol that induces cellular responses associated with pulmonary and arterial diseases. Except nicotine, smoke generated using tobacco-free preparations marketed for 'health conscious' users contains the same or greater doses of toxicants, with the same cellular effects as conventional products. Toxicant yield data from the analytical laboratory are consistent with studies of exposure biomarkers in waterpipe users.
  
  
  CONCLUSIONS
  A sufficient evidence base exists to support public health interventions that highlight the fact that WTS presents a serious inhalation hazard.
authors: Department of Mechanical Engineering, American University of Beirut, Beirut, Lebanon Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA.
authors: Alan
authors: A
authors: Shihadeh
authors: Department of Safety of Pesticides, German Federal Institute for Risk Assessment, Berlin, Germany.
authors: Jens
authors: J
authors: Schubert
authors: Department of Chemistry, American University of Beirut, Beirut, Lebanon.
authors: Joanne
authors: J
authors: Klaiany
authors: Department of Human Morphology, American University of Beirut, Beirut, Lebanon.
authors: Marwan
authors: M
authors: El Sabban
authors: Department of Chemicals and Product Safety, German Federal Institute for Risk Assessment, Berlin, Germany.
authors: Andreas
authors: A
authors: Luch
authors: Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA Department of Chemistry, American University of Beirut, Beirut, Lebanon.
authors: Najat A
authors: NA
authors: Saliba
mesh_terms: D015386:Hazardous Substances / Q000032:analysis* / Q000633:toxicity; D006801:Humans; D010316:Particle Size; D012906:Smoke / Q000009:adverse effects / Q000032:analysis*; D014028:Tobacco Smoke Pollution / Q000009:adverse effects / Q000032:analysis*; D014867:Water; D014026:Nicotiana
chemical_list: D015386:Hazardous Substances; D012906:Smoke; D014028:Tobacco Smoke Pollution; D014867:Water
keywords: Carcinogens; Non-cigarette tobacco products; Toxicology