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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 48-52

Does hookah smoking carry less cardiovascular risks than cigarette smoking in patients presenting with myocardial infarction?


1 King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Al-Babtain Cardiac Center, Dammam, Saudi Arabia

Date of Submission28-Jun-2019
Date of Decision02-Sep-2019
Date of Acceptance09-Oct-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Turki B Albacker
King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JNSM.JNSM_26_19

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  Abstract 


Introduction: Smoking is an important risk factor for cardiovascular diseases. There is an increase in the prevalence of hookah smoking in both genders and among all age groups in Saudi Arabia with the misconception that hookah smoking carries less risk than cigarette smoking.Objective: Our aim in this study was to compare the outcomes of hookah versus cigarette smoking in patients presenting with myocardial infarction (MI). Methodology: In this retrospective study, we included 246 patients who presented with MI between May 2014 and October 2016. The prevalence of smoking was 56.5% in this group. The smokers were divided into two groups: hookah smokers and cigarette smokers. Propensity matching was performed to control for differences in patients' characteristics. The outcomes of in-hospital mortality, number of diseased vessels, type of intervention, and recurrence of ischemia were compared between the two groups. Results: Among the 139 smokers, 35 were hookah smokers (25%) and 104 were cigarette smokers (75%). The median number of cigarettes or cigarette equivalent per day was similar between the two groups (20). Both groups had similar outcomes in the number of diseased vessels, type of intervention, recurrence of symptoms, and mortality (hookah = 4.9% and cigarettes = 2.9%, P = 1). Conclusion: These findings support the fact that hookah smoking carries the same harmful effect as cigarette smoking on patients with MI and that the risk might be related to the number of cigarettes smoked per day rather than the type of smoking.

Keywords: Cigarettes, hookah, myocardial infarction, outcomes, smoking


How to cite this article:
Albacker TB, Barghouthi R, Al Fawaz I, Al Saadan Y, Tokhta M, Alkorbi A, Almakarem SA, Refaie M, Eskandar K. Does hookah smoking carry less cardiovascular risks than cigarette smoking in patients presenting with myocardial infarction?. J Nat Sci Med 2020;3:48-52

How to cite this URL:
Albacker TB, Barghouthi R, Al Fawaz I, Al Saadan Y, Tokhta M, Alkorbi A, Almakarem SA, Refaie M, Eskandar K. Does hookah smoking carry less cardiovascular risks than cigarette smoking in patients presenting with myocardial infarction?. J Nat Sci Med [serial online] 2020 [cited 2020 Jan 21];3:48-52. Available from: http://www.jnsmonline.org/text.asp?2020/3/1/48/272325




  Introduction Top


Cardiovascular diseases are the leading cause of death globally, with ischemic heart diseases representing the major proportion of these diseases.[1] Several studies have shown that smoking is one of the major modifiable risk factors for cardiovascular diseases.[2] Hookah (also called waterpipe, hubble-bubble, narghile, or shisha) consists of a head into which tobacco is placed, a body that is half-filled with water, and a hose through which the user inhales. The tobacco is often flavored (e.g., apple, coffee, and mint) and sweetened. When the user inhales, smoke passes through the water and hose into the lungs. Smoke inhalation can be substantial: a single waterpipe episode can last 30–60 min and can involve more than 100 inhalations, each approximately 500 ml in volume.[3] Recent studies have shown that hookah smoking is related to the same diseases associated with other forms of tobacco use, especially the cardiovascular and respiratory systems.[4] In addition, cigarettes and hookah have common toxicants in their contents, therefore having some mutual risk despite the misconception that hookah precipitate is less harmful among the vast majority of hookah smokers.[5],[6],[7],[8] This notion dates back to the time when hookah was invented four centuries ago as an alternative and a less harmful method of smoking. This claim comes from the conception that when the smoke is drawn downward to the water bowl of hookah, the harmful components are filtered.[9]

Statistics have shown a marked increase in the prevalence of both hookah and cigarette smoking in both genders in all ages, contrary to the decline in the United States.[10],[11] Hookah smoking has been markedly noticed as a new major emerging tobacco smoking trend.[12] With the suggestion that more than a hundred million people smoke daily, many concerns are directed to the younger age group.[13] For example, in the Western societies, several studies show that the prevalence of hookah smoking exceeded cigarette smoking among youngsters, keeping in mind that there is evidence that smoke emerging from water pipe contains numerous toxicants known to cause cancer, heart, and other diseases.[4],[14]

A study from the UK revealed that the prevalence of hookah smoking among 2399 secondary school students was more than two times compared to cigarette smoking (7.6% vs. 3.4%). Furthermore, in the United States, another study on 1203 students of Florida University showed that hookah smokers outnumbered cigarette smokers (46.4% vs. 42.1%).[15],[16] Similarly, looking upon the neighboring countries, a multicountry study of 13–15-year-old schoolchildren in multiple countries (Kuwait, Bahrain, Qatar, Oman, the United Arab Emirates, and Yemen) showed the prevalence of hookah smoking to be 9%–15% of students, which nearly exceed the prevalence of cigarette smoking.[17] In a study of 1272 high school students in Saudi Arabia, the prevalence of hookah smoking was 10.2%, which is consistent with the findings of a previous study.[18] Unfortunately, the sweet flavors and aroma of the hookah, the conception that the smoke is filtered through water, and the scarcity of studies are all thought to be contributing factors that make hookah more appealing.[3]

Many studies were conducted on tobacco smoking as a risk factor for myocardial infarction (MI). However, few studies discussed hookah as a specific risk factor for MI.[14],[19] Several researches revealed that hookah smokers had a higher mortality rate than nonsmokers. Nonetheless, only a single study had emphasized the prevalence and outcome of cigarette and hookah smoking among patients with acute coronary syndrome in different countries.[3]

Given the facts that there is an increase in the prevalence of smoking in both genders and among all age groups in Saudi Arabia, the misbelief that hookah carries less risk than cigarettes, and the ambiguity in the differences of their risk of MI, our aim is to look at the differences in cardiac outcomes in patients who present with MI comparing those who smoke hookah versus cigarettes, ultimately raising awareness in the society and building a foundation for further research in this subject.


  Methodology Top


This study is a retrospective study that included all patients who presented to two tertiary cardiac centers between May 2014 and October 2016. A total of 701 patients presented with a final diagnosis of ST-segment elevation MI (STEMI) or non-STEMI (NSTEMI) during this period, of whom 427 patients were excluded due to either missing/incorrect contact number or language barrier(s).

All the data were collected from electronic medical records including demographic characteristics, risk factors and family history of cardiovascular diseases, final diagnosis (STEMI and NSTEMI), in-hospital therapy (revascularization, coronary angiogram, thrombolytic therapy, percutaneous coronary intervention, and coronary artery bypass graft), number of diseased coronaries (single-, double-, or triple-vessel disease), recurrent chest pain, and in-hospital mortality. Information about smoking habits was obtained directly from the patients through a phone call including the type of smoking and the number of cigarettes (or cigarette equivalent for hookah smokers) per day. Cigarette equivalent was measured per one session of hookah smoking as seventy cigarettes.[20]

The ethics committee in both centers approved the study, and an informed consent was obtained from the patients.

Comparative analysis was performed using the Chi-square and Fisher's exact tests for categorical variables and t-test for continuous variables. Propensity matching was performed to control for differences in patients' characteristics if found. P < 0.05 was considered statistically significant. All data analyses were carried out using the all statistical data analysis were performed using SPSS version 21.0 (IBM Corp., 2012, Armonk, NY).


  Results Top


The study included 246 patients, of whom 139 (56.5%) were smokers and 107 (43.5%) were nonsmokers. The smokers' group was significantly younger than nonsmokers (53.83 ± 11.16 vs. 59.29 ± 12.42, respectively, P < 0.001) and included more males (135 [97.1%] vs. 71 [66.4%], respectively, P < 0.001). Diabetes was higher in smokers (54.29%) than nonsmokers (74.77%) (P < 0.001). In addition, hypercholesterolemia was higher in smokers (33.57%) than in nonsmokers (18.69%) (P = 0.009). Smokers were more likely to present with a previous history of MI than nonsmokers (52.14% vs. 24.30%, P < 0.001). The rest of patients' characteristics are shown in [Table 1].
Table 1: Clinical characteristics of patients with myocardial infarction according to their smoking status

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The number of double- and triple-diseased coronaries was higher among smokers than that of nonsmokers, P = 0.026. Death was higher among nonsmokers [Table 2]. After propensity [Table 3], the number of major diseased coronaries remained statistically significantly higher in smokers, P = 0.049. Furthermore, recurrent chest pain after MI was higher in smokers (40.7%) than nonsmokers (25.37%), P = 0.028 [Table 4].
Table 2: Clinical outcomes of patients with myocardial infarction according to their smoking status

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Table 3: Clinical characteristics of patients with myocardial infarction according to their smoking status after propensity matching

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Table 4: Clinical outcomes of patients with myocardial infarction according to their smoking status after propensity matching

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Among the 139 smokers, 35 were hookah smokers (25.18%) and 104 were cigarette smokers (74.82%). The median number of cigarettes per day was similar (20 vs. 20, respectively) between the two groups. There was no statistical difference in the characteristics of both groups [Table 5]. Hookah group had 71% of patients with double- or triple-vessel disease compared to 60.5% in the cigarette smoking group (P = 0.81). There were no differences in the Clinical Outcomes between the two groups [Table 6] including recurrence of symptoms after treatment in both the groups (5.9% in hookah versus 2.9% in cigarettes, P = 0.48) in hospital mortality (hookah = 4.9% and cigarettes = 2.9%, P = 1).
Table 5: Clinical characteristics of patients with myocardial infarction according to their smoking habits

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Table 6: Clinical outcomes of patients with myocardial infarction according to their smoking habits

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  Discussion Top


This is the first study on comparing cigarette versus hookah smoking among MI patients in Saudi Arabia, and it draws attention to the high risk of hookah smoking that is perceived otherwise.

Consistent with the literature, we found in our study that smokers presented at a younger age than nonsmokers. The prevalence of smoking among MI patients was 56.68%, of which 75% were cigarette smokers and 25% were hookah smokers. These two findings support the huge impact of smoking on developing coronary atherosclerosis and its rapid progression to cause MI at a younger age. In addition, smokers tend to develop more diffuse disease in the form of triple-vessel disease rather than single- or double-vessel disease, as shown in [Table 2]. After controlling for confounders by propensity matching, the smokers' group continued to have more patients with triple-vessel disease and more patients with recurrent chest pain after treatment. However, the hospital mortality was similar in both groups.

The hookah smokers had similar demographic characteristics to cigarette smokers. There was no statistical difference among both groups in the presenting diagnosis of STEMI versus NSTEMI. This is not consistent with the findings of Al Suwaidi et al. who reported STEMI to be more common among hookah smokers and NSTEMI among cigarette smokers in a cross-sectional study that involved 6691 patients.[3] This difference could be explained by the similar cigarette consumption in our patients between the two groups. In addition, there was no difference in the number of disease coronaries, recurrent symptoms after treatment, or death. All these similarities in the outcomes of patients presenting with MI point to the risk of hookah smoking and its similar harmful effects on the cardiovascular system.

Study limitations

Firm conclusion about these observations cannot be made because of the retrospective nature of the study and its small sample size. In addition, due to the open legibility in the cardiac centers where the study was conducted, there was a significant number of expatriate patients who left the country and were unreachable at the start time of the study. This explains the 61% of MI patients who were not included in the study. However, we still consider the patients included in the study as a representative sample of the population of interest. Further, large-scale studies are required to confirm our findings.


  Conclusion Top


Despite the perception that hookah smoking is safer than cigarette smoking and despite that hookah smoking could only be done in specific dedicated places which leads to less frequency of smoking sessions, it appears that it still carries the same risk as cigarette smoking in patients with known or at risk of coronary artery disease, as evidenced by the similar impact on cardiovascular outcomes shown in our study and that risk might be related to the number of cigarettes or cigarette equivalent smoked per day rather than the type of smoking.

Summary

The authors in this article hope to correct the misconception of most hookah smokers that it is safer given the lower frequency of smoking sessions and the presence of the water filter that filters all the toxins. Our article shows that hookah smoking leads to similar nondesired cardiac outcomes to cigarette smoking in patients presenting with acute coronary syndromes. This is especially an important health message because hookah smoking is becoming a wide-spreading health hazard, especially among younger adults, and is associated with youth social gatherings.

Acknowledgment

We would like to acknowledge the support of the College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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