To the Editor:

In response to the interest and criticism by Alexandre Amaral Rodrigues, regarding our article "Noncigarette forms of tobacco use", as for the question about the volume of smoke inhaled in a narghile session, I would like to highlight the fact that Shihadeh et al.(1) was our reference. The aim of using that reference was to provide information that could be used as a guideline in topographic studies on smoking and to obtain the first approximation of the mean parameters related to narghile use, such as volume, duration and frequency of the puffs. Those authors concluded that"results showed that the average water-pipe café smoking session consists of one hundred seventy-one 530 mL puffs of 2.6 s duration at a frequency of 2.8 puffs/min". They also highlight the fact that the volumes of the puffs, during narghile use, are much greater than those during cigarette use, and that even a single puff from narghile might produce a cumulative volume of 335-1,235 mL from a cigarette.

Another study,(2) which analyzed narghile smoke, showed that, in this smoke, there were various chemical substances in abundance, which are believed to be causal factors of the high incidence of cancer, cardiovascular disease and dependence found in cigarette smokers. Radioactive elements similar to those found in cigarettes as well as in the tobacco leaves were also found in the narghile tobacco preparation.(3) In addition to the direct inhalation, the concentrations of CO (a major cause of cardiovascular diseases), measured in some trendy places to smoke narghile and bars, are particularly high. Moreover, the additives present in the charcoal, widely used for burning tobacco in the narghile, and their toxicity are still unknown.(4)

As for the conclusion that the aforementioned critic reaches, in theory, that narghile users should inhale less smoke for it contains more nicotine when compared to cigarette smoke, shows his complete lack of knowledge on chemical dependence, which is to be expected from an economist, even one holding a master's degree in Philosophy from the University of São Paulo, Brazil. I also insist that no datum was altered or manipulated, as stated by that gentleman, but indeed selected from a different viewpoint. We certainly want to convince people that the act of consuming tobacco products is harmful to health, and that there is no question of morality involved, but a question of public health, since 200,000 people die per year in Brazil due to tobacco-related diseases. Another statement made by Rodrigues is that our article is a text for the lay population in a scientific wrapping rather than a scientific article. Here, I suggest that he pose the question directly to the BPJ Editor and Editorial Board, which are responsible for the publication. He also suggests that we are mocking the public. According to the Webster English dictionary, to deceive means "o lead into error; to cause to believe what is false, or disbelieve what is true". I find the statement so absurd that I refuse to make any comments on it.

However, we are also concerned about the accuracy of the information given, and I understand that an important function of health professionals, as well as of communication professionals, is to inform the community of the existence of habits that are harmful to health. On the question of accuracy, it is important to reflect upon the fact that "el hombre más apasionado por la verdad, o al menos por la exactitud, es por lo común el más capaz de darse cuenta, como Pilatos, de que la verdad no es pura. De ahí que las afirmaciones más directas vayan mezcladas con dudas, repliegues, rodeos que un espíritu más convencional no tendría."
(Memoirs of Hadrian - Marguerite Yourcenar). Therefore, I believe that the supposed critic lost focus regarding the objective of our study. Finally, on smoking and ethics, I understand, as a health professional, that not treating and not controlling the use of tobacco products is, indeed, anti-ethical. I only agree that never before has Brazil had such a great need to promote debates on ethics.

Nevertheless, in the specific case, I believe that the most appropriate message to be disseminated is that there is no safe form of tobacco consumption, and that the world needs to be a healthier environment, without tobacco products.(5) Otherwise, approximately 10 million people will die per year worldwide, due to diseases related to the consumption of these products.

Carlos Alberto de Assis Viegas
Associate Professor at the Federal University of Brasília Medical School, Brasília, Brazil.

References

1. Shihadeh A, Azar S, Antonios C, Haddad A. Towards a topographical model of narghile water-pipe café smoking: a pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacol Biochem Behav. 2004;79(1):75-82.

2. Shihadeh A, Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food Chem Toxicol. 2005;43(5):655-61.

3. Khater AE, Abd El-Aziz NS, Al-Sewaidan HA, Chaouachi K. Radiological hazards of Narghile (hookah, shisha, goza) smoking: activity concentrations and dose assessment. J Environ Radioact. 2008;99(12):1808-14.

4. Chaouachi K. The medical consequences of narghile (hookah, shisha) use in the world. Rev Epidemiol Sante Publique. 2007;55(3):165-70.

5. Boyle P, Ariyaratne MA, Barrington R, Bartelink H, Bartsch G, Berns A, et al. Tobacco: deadly in any form or disguise. Lancet. 2006;367(9524):1710-2.