CHEST
Original Research TOBACCO CESSATION AND PREVENTION
Laboratory and Clinical Acute Effects of Active and Passive Indoor Group Water-Pipe (Narghile) Smoking Lea Bentur, MD; Elias Hellou, BSc; Aviv Goldbart, MD; Giora Pillar, MD; Einat Monovich, BSc; Maram Salameh, PharmD; Inna Scherb, MSc; and Yedidia Bentur, MD
Background: Indoor group water-pipe tobacco smoking, commonly referred to as water-pipe smoking (WPS), especially in coffee shops, has gained worldwide popularity. We performed a comprehensive laboratory and clinical evaluation of the acute effects of active and passive indoor group WPS. Methods: This comparative study evaluated pre- and post-30-min active and passive indoor group WPS. The outcome parameters were carboxyhemoglobin (COHb), nicotine, and cotinine levels; CBC count; and cardiorespiratory parameters. Exhaled breath condensate (EBC) cytokines and endothelial function (using the EndoPat device [Itamar Medical Ltd]) were measured only in active smokers. Statistical methods used were Student t test, Wilcoxon signed rank test, Fisher exact test, analysis of variance, and Newman-Keuls post hoc test where relevant. Results: Sixty-two volunteers aged 24.9 ⫾ 6.2 years were included; 47 were active smokers, and 15 were passive smokers. COHb level increased postactive WPS (active smokers, 2.0% ⫾ 2.9% vs 17.6% ⫾ 8.8%; P , .00001); six subjects (12.7%) had a . 25% increase, and two subjects (4.2%) had a . 40% increase. Plasma nicotine level increased postactive WPS (active smokers, 1.2 ⫾ 4.3 ng/mL vs 18.8 ⫾ 13.9 ng/mL; P , .0001); plasma cotinine and urinary nicotine and cotinine levels also increased significantly. EBC IL-4, IL-5, IL-10, IL-17, and g-interferon decreased significantly with postactive smoking; endothelial function did not change. WPS was associated with adverse cardiorespiratory changes. In passive smokers, COHb level increased (0.8% ⫾ 0.25% vs 1.2% ⫾ 0.8%, respectively, P 5 .003) as did respiratory rate. Conclusions: One session of active indoor group WPS resulted in significant increases in COHb and serum nicotine levels (eightfold and 18-fold, respectively) and was associated with adverse cardiorespiratory health effects. The minor effects found in passive smokers suggest that they too may be affected adversely by exposure to WPS. The results call for action to limit the continuing global spread of WPS in coffee shops. Trial registry: ClinicalTrials.gov; No.: NCT1237548; URL: www.clinicaltrials.gov CHEST 2014; 145(4):803–809 Abbreviations: CO 5 carbon monoxide; COHb 5 carboxyhemoglobin; EBC 5 exhaled breath condensate; FEF25%-75% 5 forced expiratory flow, midexpiratory phase; PEFR 5 peak expiratory flow rate; WPS 5 water-pipe smoking
tobacco smoking, commonly referred Water-pipe to as water-pipe smoking (WPS), has been prac-
ticed extensively for about 400 years by . 100 million people worldwide.1 Over the past decades, WPS has been spreading steadily from eastern to western countries. It has been estimated that 38% of British and 20% to 40% of American students have engaged in WPS.2-4 A flourishing café culture is among the factors creating optimal conditions for the thriving global journal.publications.chestnet.org
epidemic of water-pipe use. In such cafés, active and passive water-pipe smokers may spend hours together. Water-pipe use can provide a gateway for cigarette smoking in otherwise nonsmokers. Therefore, WPS may have worldwide implications for public health and tobacco control.5 We reported the adverse effects of one session of WPS on an open-air balcony.6 The present study hypothesis was that indoor WPS even more than open-air CHEST / 145 / 4 / APRIL 2014
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exposure could adversely affect multiple laboratory and cardiorespiratory parameters and passive smokers. Thus, the aim of this study was to evaluate comprehensively the effect of a single session of both active and passive indoor group WPS on multiple laboratory and clinical parameters.
ing and postsmoking assessments and a 30-min smoking session. Each smoking session included a group of four to five active and one to two passive smokers. Water pipes were prepared as previously described, including the same water pipes, tobacco brand, and charcoal disk.6 Study parameters were evaluated before and after the 30-min session of WPS. Parameters
Materials and Methods Subjects The study was approved by the local Institutional Review Board (number 0284-10). Each subject signed an informed consent form. Eligible subjects were healthy individuals aged . 18 years who had previously smoked water pipes. Exclusion criteria were a history of any acute or chronic cardiorespiratory disease (acute or chronic symptoms and use of medications), abnormal physical examination, and abnormal pulmonary function test or laboratory results. Healthy subjects could be enrolled in the study if BP values measured at the research facility were compatible with stage I or low-grade stage II hypertension. To be included in the analysis, repeated ambulatory follow-up BP measurements had to be ⱕ 120/80 mm Hg. Pregnant or lactating women were excluded. The abstinence time from smoking we used was the same as in our previous open-air study, allowing us to better assess the effect of indoor WPS.6 Inconsistency among researchers should be noted regarding the abstinence time used for assessing the acute effects of WPS or cigarette smoking, ranging from hours to days.7-10 The time frame for detecting the effects of WPS on BP, pulmonary function tests, exhaled breath condensate (EBC), and endothelial function is unclear. In addition, 24-h abstinence from cigarette smoking is a difficult task, which may result in low compliance, unlike the case for WPS. Setting and Procedure The study was conducted in the waiting room of the Pediatric Pulmonology Unit, a 54-m2 space with one open window. Research sessions lasted several hours and comprised presmokManuscript received April 22, 2013; revision accepted October 1, 2013. Affiliations: From the Pediatric Pulmonology Unit (Drs L. Bentur and Salameh), Meyer Children’s Hospital, Rambam Health Care Campus, Haifa; Rappaport Faculty of Medicine (Drs L. Bentur, Pillar, and Y. Bentur; Mr Hellou; and Ms Monovich), Technion– Israel Institute of Technology, Haifa; Department of Pediatrics (Dr Goldbart), Faculty of Health Sciences, Ben Gurion University, Soroka University Medical Center, Beer-Sheva; Department of Pediatrics (Dr Pillar), Carmel Medical Center, Haifa; School of Pharmacy (Dr Salameh), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem; and Clinical Toxicology and Pharmacology Laboratory (Ms Scherb) and Israel Poison Information Center (Ms Scherb and Dr Y. Bentur), Rambam Health Care Campus, Haifa, Israel. Funding/Support: The study was supported by the Israel Cancer Association, Israel Lung Association, and Israel Science Foundation [Grant 753/2011]. Correspondence to: Lea Bentur, MD, Pediatric Pulmonology Unit, Meyer Children’s Hospital, Rambam Health Care Campus, PO Box 9602, Haifa 31096, Israel; e-mail: l_bentur@rambam. health.gov.il © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0960 804
Spirometry was performed in accordance with American Thoracic Society/European Respiratory Society criteria with a KoKo spirometer (KoKo system; nSpire Health, Inc).11 Each maneuver was repeated to obtain at least three technically acceptable forced expiratory flow volume curves; the best results were used for analysis. Results are expressed as percent predicted.12 Carboxyhemoglobin (COHb) level was measured in venous blood samples by an Illex co-oximeter (IL-682; Instrumentation Laboratory). CBC was analyzed with an automated hematology flow cytometer (Coulter STKS; Beckman Coulter, Inc). EBC samples were collected in RTubes (Respiratory Research) as previously described.6,13,14 High-sensitivity enzyme-linked immunosorbent assay kits were used to analyze samples for IL-4, IL-5, IL-10, IL-17 (R&D Systems, Inc), and g-interferon (eBioscience, Inc). All samples were assayed in duplicate at two dilutions and a plate reader absorbance of 450 nm. Results were analyzed with a four-parameter logistic curve fit. The intraassay and interassay variability was , 10%; specificity ranged from 94% to 98%. The limit of detection of the assays was 0.06 pg/mL, 15 pg/mL, 0.11 pg/mL, and 0.09 pg/mL for IL-5, IL-17, IL-4, and IL-10, respectively, and 0.15 pg/mL for g-interferon. Plasma and urine nicotine and cotinine concentrations were determined by liquid chromatography-tandem mass spectrometry, with a lower limit of quantitation of 1 ng/mL (Quattro micro API equipped with Waters 2795 HPLC; Waters Corp).15 Endothelial function was quantitatively determined as the ratio between the average arterial pulse wave amplitude after a 5-min arterial occlusion in the forearm to the preocclusion value using the EndoPat device (Itamar Medical Ltd). A value of ⱕ 1.67 is considered to indicate endothelial dysfunction. This methodology has been validated and shown to characterize endothelial function more accurately than other technologies.16-18 Adverse symptoms or unusual sensations were voluntarily reported by the subjects and recorded. Statistical Analysis Sample size was determined by Win Episcope 2 (CLIVE [Computer-Aided Learning in Veterinary Education], The University of Edinburgh) for paired tests. For the primary outcome of an increase in COHb concentration from 2% to 3.5% with 95% confidence and 80% power, seven subjects were required. Pulmonary function tests, vital signs, nicotine and cotinine levels, EBC cytokine levels, and endothelial function as assessed by EndoPAT were considered secondary outcome parameters. The sample size was increased to a minimum of 20 subjects to allow detection of a 10% increase in respiratory rate and systolic and diastolic BP. Power analyses for the other parameters were not predetermined. Analysis was performed by paired Student t test for parametric values and Wilcoxon signed rank test for nonparametric values. Repeated-measures analyses were performed to find categorical (sex) predictors related to the dependent variables. For EBC, analysis of variance was used followed by NewmanKeuls post hoc test whenever appropriate. Results are expressed as mean ⫾ SD, median, and range. P , .05 was considered statistically significant. Because multiple outcome parameters were evaluated, the P value was also adjusted by Bonferroni correction. In active smokers, 25 parameters were evaluated; therefore, the
Original Research
corrected P value was .002. In passive smokers, 17 parameters were evaluated; therefore, the corrected P value was .003.
Results Sixty-two subjects were included in the study (aged 24.9 ⫾ 6.2 years; 47 [33 male] active smokers; 15 [six male] passive smokers). The vital signs and results of endothelial function assessed by EndoPat and pulmonary function tests before and after one session of WPS are shown in Table 1. Four healthy subjects with no history of hypertension were found to have elevated BP values at the research facility. Repeated follow-up BP measurements outside the research facility and the hospital were normal. The changes in blood and urine laboratory parameters before and after WPS are presented in Table 2. Post-WPS COHb concentration increased eightfold in active smokers (P , .0001), by . 25% in six subjects (12.7%), and by .40% in two subjects (4.2%) (41.6% and 44%). In passive smokers, post-WPS COHb levels increased by 50% (P 5 .003). Post-WPS plasma nicotine levels increased 18-fold (P , .0001) in active smokers. Sex analysis showed significant differences only in post-WPS plasma nicotine concentrations in active smokers (22.80 ⫾ 13.71 ng/mL and 8.65 ⫾ 8.15 ng/mL in men and women, respectively; P 5 .002).
EBC was analyzed only in active smokers; the results are shown in Table 3. After WPS, the levels of IL-4, IL-5, IL-10, IL-17, and g-interferon decreased significantly. Self-reported symptoms are shown in Table 4. Discussion Cafés and restaurants offering WPS as a form of entertainment have mushroomed in recent years. A paucity of data is available on the effects of indoor WPS and the possible biologic effects of passive exposure to WPS in such cafés.19 The present study comprehensively assessed acute changes in multiple laboratory and clinical parameters in indoor group WPS and in passive smokers. This study shows that a single 30-min session of indoor group WPS resulted in a significant and alarming increase in COHb level, significant elevations in plasma and urine nicotine and cotinine concentrations, increased BP and heart and respiratory rates, significant decreases in EBC cytokine levels, and no change in endothelial function. Significant increases in COHb concentration and respiratory rate were found in passive water-pipe smokers. Both active and passive WPS were associated with adverse symptoms. The following is a discussion of the outcome parameters, beginning with the most important findings.
Table 1—Vital Signs and Results of Endothelial Function Assessed by EndoPat and Pulmonary Function Tests Before and After Indoor Group Active and Passive WPS Active WPS (n 5 47) Parameter Heart rate, beats/min Median (range) Systolic BP, mm Hg Median (range) Diastolic BP, mm Hg Median (range) Respiratory rate, breaths/min Median (range) EndoPat score Median (range) FVC, L % predicted FEV1, L/s % predicted FEV1/FVC % predicted FEF25%-75%, L % predicted PEFR, L % predicted
Passive WPS (n 5 15)
Before
After
P Value
Before
After
P Value
77.3 ⫾ 12.2 75 (51-105) 124.0 ⫾ 13.6 122 (99-162) 72.6 ⫾ 10.1 72 (53-100) 16.2 ⫾ 2.6 16 (12-24) 1.85 ⫾ 0.52 1.69 (1.0-4.0) 4.7 ⫾ 0.9 99.1 ⫾ 10.5 4.0 ⫾ 0.8 99.9 ⫾ 9.5 86 ⫾ 0.6 104.4 ⫾ 7.2 4.5 ⫾ 0.9 95.7 ⫾ 18.6 8.4 ⫾ 1.7 93 ⫾ 13
92.8 ⫾ 16.3 91 (56-128) 132.8 ⫾ 14.97 132 (99-170) 77.6 ⫾ 12.2 78 (51-110) 19.7 ⫾ 3.3 20 (12-30) 1.86 ⫾ 0.55 1.78 (1.0-4.0) 4.6 ⫾ 0.9 98.4 ⫾ 10.5 4.0 ⫾ 0.7 100.0 ⫾ 9.2 87 ⫾ 0.6 105 ⫾ 7.3 4.5 ⫾ 0.9 95.8 ⫾ 18.1 8.1 ⫾ 1.6 89.4 ⫾ 13.3
.0001 … .0001 … .001 … .0001 … NS … NS … NS … NS … NS … .015 .026b
81.1 ⫾ 13.2 78.5 (68-112) 117.3 ⫾ 9.9 118 (95-130) 78.0 ⫾ 8.2 79 (62-90) 16.25 ⫾ 1.91 16 (12-20) NA NA 3.8 ⫾ 0.6 97.5 ⫾ 6.6 3.3 ⫾ 0.5 97.8 ⫾ 7.1 86.8 ⫾ 0.68 104.5 ⫾ 7.1 3.7 ⫾ 8.7 89.9 ⫾ 17.1 8.4 ⫾ 1.7 90.1 ⫾ 13.1
80.1 ⫾ 15.2 79 (56-108) 120.5 ⫾ 10.4 120 (102-139) 80.27 ⫾ 7.41 81 (68-91) 20.5 ⫾ 2.9 20 (16-24) NA NA 3.8 ⫾ 0.7 97 ⫾ 6.4 3.3 ⫾ 0.5 98.4 ⫾ 7.6 87.7 ⫾ 0.65 105.7 ⫾ 7.3 3.9 ⫾ 8.4 94.7 ⫾ 17.1 8.3 ⫾ 1.6 89.5 ⫾ 13.4
.35 … .6 … .38 … .009a … NA … NS … NS … NS … NS … NS …
Data are presented as mean ⫾ SD unless otherwise indicated. FEF25%-75% 5 forced expiratory flow, midexpiratory phase; NA 5 not applicable; NS 5 not significant; PEFR 5 peak expiratory flow rate; WPS 5 water-pipe smoking. aInsignificant after applying Bonferroni correction (corrected P value for passive smokers 5 .003). bInsignificant after applying Bonferroni correction (corrected P value for active smokers 5 .002). journal.publications.chestnet.org
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Table 2—Blood and Urine Laboratory Parameters Before and After Indoor Group Active and Passive WPS Active WPS (n 5 47) Parameter Hemoglobin, g/dL WBC, /mL Eosinophils, /mL Eosinophils, % COHb, % Plasma nicotine, ng/mL Plasma cotinine, ng/mL Urine nicotine, ng/mLb Urine cotinine, ng/mLb
Passive WPS (n 5 15)
Before
After
P Value
Before
After
P Value
14.5 ⫾ 1.3 7.8 ⫾ 1.8 144 ⫾ 104 1.92 ⫾ 1.30 2.02 ⫾ 2.89 1.1 ⫾ 4.1 61.2 ⫾ 96.7 70.4 ⫾ 232.2 146.2 ⫾ 232.2
14.8 ⫾ 1.4 8.7 ⫾ 2.0 149 ⫾ 119 1.76 ⫾ 1.29 17.57 ⫾ 8.79 19.1 ⫾ 13.9 78.2 ⫾ 93.7 290.8 ⫾ 319.6 165.3 ⫾ 243.6
.0001 .001 NS .02a , .00001 , .0001 , .0001 , .0001 .033a
13.4 ⫾ 1.9 8.1 ⫾ 1.8 100 ⫾ 114 1.25 ⫾ 1.48 0.8 ⫾ 0.2 0.44 ⫾ 1.7 9.2 ⫾ 25.0 NA NA
13.4 ⫾ 1.9 8.1 ⫾ 1.8 102 ⫾ 105 1.28 ⫾ 1.36 1.2 ⫾ 0.8 0.4 ⫾ 1.4 13.9 ⫾ 46.0 NA NA
NS NS NS NS .003 NS NS NA NA
Data are presented as mean ⫾ SD. COHb 5 carboxyhemoglobin. See Table 1 legend for expansion of other abbreviations. aInsignificant after applying Bonferroni correction (corrected P value for active smokers 5 .002). bUrine nicotine and cotinine concentrations were analyzed only in active smokers.
COHb Concentration The results show an eightfold increase in COHb levels post-WPS, with a . 25% increase in six subjects (12.7%) and . 40% in two subjects (4.2%). Such levels may require hospital admission and normobaric or hyperbaric oxygen therapy. High levels of COHb necessitating hospital admission and oxygen treatment have been reported in a few patients after WPS.20 The COHb levels measured in the present study are much higher than those previously reported by us and others.6,20,21 In our previous open-air study, post-WPS COHb levels rose to 9.49% ⫾ 5.52% and to . 25% (26%) in one subject (2.2%). The only difference between our studies is the indoor vs open-air smoking design, suggesting higher ambient carbon monoxide (CO) levels in a closed space than in an outdoor setting. In passive smokers, COHb level was significantly elevated (by 50%). This increase is similar to that observed in healthy volunteers of a similar age who were exposed in a model room to the smoke of five cigarettes smoked by a machine during a series of five 30-min sessions (overall exposure, 2.5 h).22 Coffee shops usually are smaller, less ventilated, and more crowded than the setting we used in the present study, suggesting that real-life exposure to CO in WPS can be higher than we found. This is supported Table 3—Level of Cytokines in Exhaled Breath Condensate Before and After Indoor Group Active WPS Active WPS Parameter IL-4 IL-5 IL-10 IL-17 g-Interferon
No. Subjects Before, pg/mL After, pg/mL 46 46 45 45 46
7.98 ⫾ 3.26 2.20 ⫾ 0.72 12.2 ⫾ 4.64 31.97 ⫾ 6.02 29.19 ⫾ 4.11
P Value
.001 5.52 ⫾ 1.83 .00003 1.62 ⫾ 0.27 9.28 ⫾ 1.62 , .0001 .006 28.46 ⫾ 5.73 23.05 ⫾ 3.89 , .001
Data are presented as mean ⫾ SD. See Table 1 legend for expansion of abbreviation. 806
by a study demonstrating a 300% increase in exhaled CO after 1 h of WPS smoking, whereas in cigarette smokers, exhaled CO increased by only 60%.23 Plasma and Urine Nicotine and Cotinine Concentrations We found significant increases in plasma and urinary nicotine and, to a lesser extent, cotinine concentrations after active WPS. Compared with the present findings (19.1 ⫾ 13.9 ng/mL), various plasma nicotine concentrations have been reported in the literature (lower, 3.6 ⫾ 0.7 ng/mL24 and 10.2 ⫾ 7.0 ng/mL25; similar, 15.7 ⫾ 8.7 ng/mL26; higher, 60.3 ng/mL27). This variability may be explained by the burning temperature, type and amount of tobacco, smoking topography, subject selection, study design, and method of nicotine concentration determination.1 High levels of 24-h urinary nicotine and cotinine were reported in long-term WPS.28 A meta-analysis indicated that variable daily use (one to 10 water pipes) produced a 24-h urinary cotinine level of 0.785 mg/mL (equivalent to smoking 10 cigarettes/d).1 In the present study, passive exposure to WPS resulted in an insignificant increase in plasma cotinine. Similarly, 1 h of secondhand cigarette smoke exposure has been shown to result in a mild increase of serum cotinine.29 The substantial exposure of water-pipe smokers to nicotine found in the present study suggests that it may contribute to cardiovascular morbidity similarly to cigarette smokers. Vital Signs The significant increases in BP and heart and respiratory rates described in the present study are similar to those previously reported by us and others.6,7,30 The causative role of nicotine in these hemodynamic changes was suggested in a double-blind study that showed an increased heart rate only in smokers of nicotine-containing water pipes.7,9 Original Research
Table 4—Self-Reported Symptoms After 30 Min of Active and Passive WPS Symptom Dizziness Fatigue Headache Palpitations Nausea Dry throat Chest discomfort Dyspnea Drowsiness Blurred vision
Active Smokers (n 5 47) Passive Smokers (n 5 15) 31 (66) 27 (57.4) 22 (46.8) 10 (21.3) 8 (17) 8 (17) 7 (4.9) 3 (6.4) 2 (4.3) 2 (4.3)
5 (33.3) 8 (53.3) 11 (73.3) 0 (0) 1 (6.7) 1 (6.7) 3 (20) 2 (13.3) 0 (0) 0 (0)
Data are presented as No. (%). The main symptoms reported by both active and passive water-pipe smokers were dizziness, fatigue, headache, nausea, dry throat, chest discomfort, and dyspnea. See Table 1 legend for expansion of abbreviation.
Pulmonary Function Tests No change was found in FVC, FEV1, FEV1/FVC, and forced expiratory flow, midexpiratory phase (FEF25%-75%) after active indoor group WPS. We found a minor decrease in peak expiratory flow rate (PEFR), which became insignificant after applying Bonferroni correction. No change was found in pulmonary function tests after passive WPS. In our earlier open-air study,6 we found decreases in PEFR (P 5 .0043) and FEF25%-75% (P 5 .045); both became insignificant after applying Bonferroni correction. The more pronounced decrease in PEFR in both studies is unclear because PEFR is effort dependent and less sensitive than FEV1 or FEF25%-75%. The minor decrease in PEFR may represent poor performance after WPS or type I error. Hence, the significance of the finding is questionable. Conflicting results were found in the acute effect of active and passive cigarette smoking on pulmonary function tests.8,10 A meta-analysis of six cross-sectional studies compared pulmonary function in long-term WPS and long-term cigarette smokers. Most of the six studies had methodological limitations and inconsistent results. The conclusions derived from the pooled data were that WPS decreases lung function.31 Although other studies31 as well as the present study suggest that WPS may be associated with changes in pulmonary function, more research is required to elucidate this issue. It is unclear what amount of passive WPS is required to adversely affect lung function, if at all. CBC Hemoglobin concentration and WBC count increased significantly, and the percent decrease of eosinophils was small but significant. Short-term cigarette smoking was also reported to increase hemoglobin concentration and WBC count and to decrease the number of eosinophils.10,32 Increased circulating WBCs in journal.publications.chestnet.org
cigarette smokers was implicated in low-grade inflammation related to atherosclerosis.32 The suggested mechanisms for the decrease in the number of eosinophils associated with cigarette smoking are direct (apoptotic) effect by toxic substances33 and antiinflammatory substances, such as CO.34 The similarity between the effects of WPS on CBC and those reported after cigarette smoking suggests that WPS may also be involved in smoking-induced atherosclerosis. This hypothesis requires further evaluation in long-term active and passive WPS. Exhaled Breath Condensate We found significant decreases in all EBC cytokine (IL-4, IL-5, IL-17, IL-10, and g-interferon) levels after active WPS. These results are in accordance with the decrease in 8-isoprostane in EBC found in our previous study.6 To our knowledge, the effect of acute WPS or cigarette smoking on these parameters has not been previously studied. Given the role of inflammation in the development of impaired respiratory function, understanding the effect of short-term WPS on the response of EBC cytokines is important.35 Airway inflammation together with oxidative stress form a vicious cycle that leads to disease progression in patients with COPD.36 The cytokines IL-4, IL-5, and IL-17 are T helper-cell 2 derived, whereas IL-10 and g-interferon are T helper-cell 1 derived. These cytokines are associated with chronic lung inflammation and structural changes in chronic pulmonary diseases.36 It is unclear whether the reduced concentrations of EBC cytokines after WPS found in the present study reflect a decreased production or reduced delivery. Decreased cytokine production may be explained by the high levels of CO, a potent antiinflammatory agent.37 Alternatively, smoke that elicits endoplasmic reticulum stress may activate the unfolded protein response, resulting in inhibition of global protein synthesis and degradation through the ubiquitin system.38 Decreased cytokine delivery may be due to mechanical factors (eg, decreased ciliary function, particle trapping that prevents the delivery of EBC cytokines). The possible clinical implications of the post-WPS decrease in EBC cytokine levels requires further study. Endothelial Dysfunction Assessed by EndoPat The data show that short-term WPS does not alter endothelial function as measured by EndoPat. Cigarette smoking is associated with endothelial dysfunction and an increased risk of atherosclerosis. Endothelial nitric oxide production is reduced in reaction to tobacco smoke39 and may affect brachial artery dilation. The lack of endothelial dysfunction assessed by EndoPat may be explained by the different effects of CHEST / 145 / 4 / APRIL 2014
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nicotine and COHb on the vascular system. Nicotine accounts for endothelial dysfunction, whereas a COHb concentration . 7% (as found in the present study) increases cyclic guanosine monophosphate, resulting in vascular relaxation.40 Endothelial function should be evaluated in long-term WPS. Limitations The main limitations of this study are the small number of passive smokers and active WPS in women, no assessment of smoking topography, lack of evaluation of EBC cytokines and endothelial function in passive smokers, and no determination of ambient CO and toxic smoke constituents (eg, aldehydes, polycyclic aromatic hydrocarbons). Multiple parameters were evaluated; therefore, statistical analysis was done with and without Bonferroni correction. After applying this correction, the marginally significant changes in PEFR, percentage of eosinophils, urinary cotinine levels in active smokers, and respiratory rate in passive smokers were insignificant. Although Bonferroni correction controls the probability of type I error, it comes at the cost of increasing the probability of type II error. The present results call for further studies evaluating real-life WPS exposure in coffee shops. These studies should include a larger number of passive and female smokers and assessment of the health consequences of long-term indoor WPS. In summary, one session of indoor active group WPS resulted in an eightfold and 18-fold increase in COHb and plasma nicotine concentrations, respectively. These increases were associated with significant changes in cardiorespiratory parameters to a greater extent than in our previous open-air group WPS study.6 The minor, but significant increase (50%) in COHb concentration in passive smokers suggests that passive smokers may also be adversely affected by WPS. These results call for actions aimed at limiting the global spread of WPS in coffee shops. Acknowledgments Author contributions: Dr L. Bentur had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr L. Bentur: contributed to the study design, institutional review board application, supervision of the experiments, data analysis, and writing of the manuscript. Mr Hellou: contributed to the institutional review board application, patient recruitment, the performance of all tests, data analysis, literature survey, and revision of the manuscript. Dr Goldbart: contributed to the cytokine analysis and discussion of exhaled breath condensate parameters and revision of the manuscript. Dr Pillar: contributed to the design of the EndoPat study, analysis of the results, and revision of the manuscript. Ms Monovich: contributed to the performance and analysis of the EndoPat tests and revision of the manuscript. 808
Dr Salameh: contributed to the patient recruitment, performance of all tests, data analysis, literature survey, and revision of the manuscript. Ms Scherb: contributed to the nicotine and cotinine analysis and revision of the manuscript Dr Y. Bentur: contributed to the study design, supervision of the experiments, data analysis, and writing of the manuscript. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Role of sponsors: The sponsors had no role in the study design, data analysis, writing of the manuscript, or its submission.
References 1. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;9(10):987-994. 2. Warren CW, Lea V, Lee J, Jones NR, Asma S, McKenna M. Change in tobacco use among 13-15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey. Glob Health Promot. 2009;16(suppl 2):38-90. 3. Chaouachi K. More rigor needed in systematic reviews on “waterpipe” (hookah, narghile, shisha) smoking. Chest. 2011; 139(5):1250-1251. 4. Jackson D, Aveyard P. Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health. 2008;8:174. 5. Mzayek F, Khader Y, Eissenberg T, Al Ali R, Ward KD, Maziak W. Patterns of water-pipe and cigarette smoking initiation in schoolchildren: Irbid longitudinal smoking study. Nicotine Tob Res. 2012;14(4):448-454. 6. Hakim F, Hellou E, Goldbart A, Katz R, Bentur Y, Bentur L. The acute effects of water-pipe smoking on the cardiorespiratory system. Chest. 2011;139(4):775-781. 7. Al-Kubati M, Al-Kubati AS, al’Absi M, Fiser B. The shortterm effect of water-pipe smoking on the baroreflex control of heart rate in normotensives. Auton Neurosci. 2006;126-127: 146-149. 8. Flouris AD, Metsios GS, Carrillo AE, et al. Acute and shortterm effects of secondhand smoke on lung function and cytokine production. Am J Respir Crit Care Med. 2009;179(11): 1029-1033. 9. Shihadeh A, Salman R, Jaroudi E, et al. Does switching to a tobacco-free waterpipe product reduce toxicant intake? A crossover study comparing CO, NO, PAH, volatile aldehydes, “tar” and nicotine yields. Food Chem Toxicol. 2012;50(5): 1494-1498. 10. van der Vaart H, Postma DS, Timens W, ten Hacken NH. Acute effects of cigarette smoke on inflammation and oxidative stress: a review. Thorax. 2004;59(8):713-721. 11. Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26(2): 319-338. 12. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official statement of the European Respiratory Society. Eur Respir J Suppl. 1993;16: 5-40. 13. Rosias PP, Robroeks CM, Kester A, et al. Biomarker reproducibility in exhaled breath condensate collected with different condensers. Eur Respir J. 2008;31(5):934-942. 14. Mutlu GM, Garey KW, Robbins RA, Danziger LH, Rubinstein I. Collection and analysis of exhaled breath condensate in humans. Am J Respir Crit Care Med. 2001;164(5):731-737. Original Research
15. Yue B, Kushnir MM, Urry FM, Rockwood AL. Quantitation of nicotine, its metabolites, and other related alkaloids in urine, serum, and plasma using LC-MS-MS. Methods Mol Biol. 2010; 603:389-398. 16. Kuvin JT, Patel AR, Sliney KA, et al. Assessment of peripheral vascular endothelial function with finger arterial pulse wave amplitude. Am Heart J. 2003;146(1):168-174. 17. Yinon D, Lowenstein L, Suraya S, et al. Pre-eclampsia is associated with sleep-disordered breathing and endothelial dysfunction. Eur Respir J. 2006;27(2):328-333. 18. Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G. The effects of 1-year treatment with a Herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest. 2007;131(3):740-749. 19. Moritsugu KP. The 2006 report of the Surgeon General: the health consequences of involuntary exposure to tobacco smoke. Am J Prev Med. 2007;32(6):542-543. 20. La Fauci G, Weiser G, Steiner IP, Shavit I. Carbon monoxide poisoning in narghile (water pipe) tobacco smokers. CJEM. 2012;14(1):57-59. 21. Zahran FM, Ardawi MS, Al-Fayez SF. Carboxyhemoglobin concentrations in smokers of sheesha and cigarettes in Saudi Arabia. Br Med J (Clin Res Ed). 1985;291(6511):1768-1770. 22. Czogala J, Goniewicz ML. The complex analytical method for assessment of passive smokers’ exposure to carbon monoxide. J Anal Toxicol. 2005;29(8):830-834. 23. Bacha ZA, Salameh P, Waked M. Saliva cotinine and exhaled carbon monoxide levels in natural environment waterpipe smokers. Inhal Toxicol. 2007;19(9):771-777. 24. Blank MD, Cobb CO, Kilgalen B, et al. Acute effects of waterpipe tobacco smoking: a double-blind, placebo-control study. Drug Alcohol Depend. 2011;116(1-3):102-109. 25. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. Am J Prev Med. 2009;37(6):518-523. 26. Maziak W, Rastam S, Shihadeh AL, et al. Nicotine exposure in daily waterpipe smokers and its relation to puff topography. Addict Behav. 2011;36(4):397-399. 27. Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther. 2002;40(6): 249-255.
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28. Behera D, Uppal R, Majumdar S. Urinary levels of nicotine & cotinine in tobacco users. Indian J Med Res. 2003;118: 129-133. 29. Baltar VT, Xun WW, Chuang SC, et al. Smoking, secondhand smoke, and cotinine levels in a subset of EPIC cohort. Cancer Epidemiol Biomarkers Prev. 2011;20(5):869-875. 30. Shaikh RB, Vijayaraghavan N, Sulaiman AS, Kazi S, Shafi MS. The acute effects of waterpipe smoking on the cardiovascular and respiratory systems. J Prev Med Hyg. 2008;49(3): 101-107. 31. Raad D, Gaddam S, Schunemann HJ, et al. Effects of waterpipe smoking on lung function: a systematic review and metaanalysis. Chest. 2011;139(4):764-774. 32. Flouris AD, Poulianiti KP, Chorti MS, et al. Acute effects of electronic and tobacco cigarette smoking on complete blood count. Food Chem Toxicol. 2012;50(10):3600-3603. 33. Aoshiba K, Tamaoki J, Nagai A. Acute cigarette smoke exposure induces apoptosis of alveolar macrophages. Am J Physiol Lung Cell Mol Physiol. 2001;281(6):L1392-L1401. 34. Chapman JT, Otterbein LE, Elias JA, Choi AM. Carbon monoxide attenuates aeroallergen-induced inflammation in mice. Am J Physiol Lung Cell Mol Physiol. 2001;281(1):L209-L216. 35. Papaioannou AI, Koutsokera A, Tanou K, et al. The acute effect of smoking in healthy and asthmatic smokers. Eur J Clin Invest. 2010;40(2):103-109. 36. Litonjua AA, Sparrow D, Guevarra L, O’Connor GT, Weiss ST, Tollerud DJ. Serum interferon-gamma is associated with longitudinal decline in lung function among asthmatic patients: the Normative Aging Study. Ann Allergy Asthma Immunol. 2003;90(4):422-428. 37. Otterbein LE, Bach FH, Alam J, et al. Carbon monoxide has anti-inflammatory effects involving the mitogen-activated protein kinase pathway. Nat Med. 2000;6(4):422-428. 38. Kelsen SG. Respiratory epithelial cell responses to cigarette smoke: the unfolded protein response. Pulm Pharmacol Ther. 2012;25(6):447-452. 39. Yufu K, Takahashi N, Okada N, et al. Influence of systolic blood pressure and cigarette smoking on endothelial function in young healthy people. Circ J. 2009;73(1):174-178. 40. Kanten WE, Penney DG, Francisco K, Thill JE. Hemodynamic responses to acute carboxyhemoglobinemia in the rat. Am J Physiol. 1983;244(3):H320-H327.
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Original Research TOBACCO CESSATION AND PREVENTION
Laboratory and Clinical Acute Effects of Active and Passive Indoor Group Water-Pipe (Narghile) Smoking Lea Bentur, MD; Elias Hellou, BSc; Aviv Goldbart, MD; Giora Pillar, MD; Einat Monovich, BSc; Maram Salameh, PharmD; Inna Scherb, MSc; and Yedidia Bentur, MD
Background: Indoor group water-pipe tobacco smoking, commonly referred to as water-pipe smoking (WPS), especially in coffee shops, has gained worldwide popularity. We performed a comprehensive laboratory and clinical evaluation of the acute effects of active and passive indoor group WPS. Methods: This comparative study evaluated pre- and post-30-min active and passive indoor group WPS. The outcome parameters were carboxyhemoglobin (COHb), nicotine, and cotinine levels; CBC count; and cardiorespiratory parameters. Exhaled breath condensate (EBC) cytokines and endothelial function (using the EndoPat device [Itamar Medical Ltd]) were measured only in active smokers. Statistical methods used were Student t test, Wilcoxon signed rank test, Fisher exact test, analysis of variance, and Newman-Keuls post hoc test where relevant. Results: Sixty-two volunteers aged 24.9 ⫾ 6.2 years were included; 47 were active smokers, and 15 were passive smokers. COHb level increased postactive WPS (active smokers, 2.0% ⫾ 2.9% vs 17.6% ⫾ 8.8%; P , .00001); six subjects (12.7%) had a . 25% increase, and two subjects (4.2%) had a . 40% increase. Plasma nicotine level increased postactive WPS (active smokers, 1.2 ⫾ 4.3 ng/mL vs 18.8 ⫾ 13.9 ng/mL; P , .0001); plasma cotinine and urinary nicotine and cotinine levels also increased significantly. EBC IL-4, IL-5, IL-10, IL-17, and g-interferon decreased significantly with postactive smoking; endothelial function did not change. WPS was associated with adverse cardiorespiratory changes. In passive smokers, COHb level increased (0.8% ⫾ 0.25% vs 1.2% ⫾ 0.8%, respectively, P 5 .003) as did respiratory rate. Conclusions: One session of active indoor group WPS resulted in significant increases in COHb and serum nicotine levels (eightfold and 18-fold, respectively) and was associated with adverse cardiorespiratory health effects. The minor effects found in passive smokers suggest that they too may be affected adversely by exposure to WPS. The results call for action to limit the continuing global spread of WPS in coffee shops. Trial registry: ClinicalTrials.gov; No.: NCT1237548; URL: www.clinicaltrials.gov CHEST 2014; 145(4):803–809 Abbreviations: CO 5 carbon monoxide; COHb 5 carboxyhemoglobin; EBC 5 exhaled breath condensate; FEF25%-75% 5 forced expiratory flow, midexpiratory phase; PEFR 5 peak expiratory flow rate; WPS 5 water-pipe smoking
tobacco smoking, commonly referred Water-pipe to as water-pipe smoking (WPS), has been prac-
ticed extensively for about 400 years by . 100 million people worldwide.1 Over the past decades, WPS has been spreading steadily from eastern to western countries. It has been estimated that 38% of British and 20% to 40% of American students have engaged in WPS.2-4 A flourishing café culture is among the factors creating optimal conditions for the thriving global journal.publications.chestnet.org
epidemic of water-pipe use. In such cafés, active and passive water-pipe smokers may spend hours together. Water-pipe use can provide a gateway for cigarette smoking in otherwise nonsmokers. Therefore, WPS may have worldwide implications for public health and tobacco control.5 We reported the adverse effects of one session of WPS on an open-air balcony.6 The present study hypothesis was that indoor WPS even more than open-air CHEST / 145 / 4 / APRIL 2014
803
exposure could adversely affect multiple laboratory and cardiorespiratory parameters and passive smokers. Thus, the aim of this study was to evaluate comprehensively the effect of a single session of both active and passive indoor group WPS on multiple laboratory and clinical parameters.
ing and postsmoking assessments and a 30-min smoking session. Each smoking session included a group of four to five active and one to two passive smokers. Water pipes were prepared as previously described, including the same water pipes, tobacco brand, and charcoal disk.6 Study parameters were evaluated before and after the 30-min session of WPS. Parameters
Materials and Methods Subjects The study was approved by the local Institutional Review Board (number 0284-10). Each subject signed an informed consent form. Eligible subjects were healthy individuals aged . 18 years who had previously smoked water pipes. Exclusion criteria were a history of any acute or chronic cardiorespiratory disease (acute or chronic symptoms and use of medications), abnormal physical examination, and abnormal pulmonary function test or laboratory results. Healthy subjects could be enrolled in the study if BP values measured at the research facility were compatible with stage I or low-grade stage II hypertension. To be included in the analysis, repeated ambulatory follow-up BP measurements had to be ⱕ 120/80 mm Hg. Pregnant or lactating women were excluded. The abstinence time from smoking we used was the same as in our previous open-air study, allowing us to better assess the effect of indoor WPS.6 Inconsistency among researchers should be noted regarding the abstinence time used for assessing the acute effects of WPS or cigarette smoking, ranging from hours to days.7-10 The time frame for detecting the effects of WPS on BP, pulmonary function tests, exhaled breath condensate (EBC), and endothelial function is unclear. In addition, 24-h abstinence from cigarette smoking is a difficult task, which may result in low compliance, unlike the case for WPS. Setting and Procedure The study was conducted in the waiting room of the Pediatric Pulmonology Unit, a 54-m2 space with one open window. Research sessions lasted several hours and comprised presmokManuscript received April 22, 2013; revision accepted October 1, 2013. Affiliations: From the Pediatric Pulmonology Unit (Drs L. Bentur and Salameh), Meyer Children’s Hospital, Rambam Health Care Campus, Haifa; Rappaport Faculty of Medicine (Drs L. Bentur, Pillar, and Y. Bentur; Mr Hellou; and Ms Monovich), Technion– Israel Institute of Technology, Haifa; Department of Pediatrics (Dr Goldbart), Faculty of Health Sciences, Ben Gurion University, Soroka University Medical Center, Beer-Sheva; Department of Pediatrics (Dr Pillar), Carmel Medical Center, Haifa; School of Pharmacy (Dr Salameh), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem; and Clinical Toxicology and Pharmacology Laboratory (Ms Scherb) and Israel Poison Information Center (Ms Scherb and Dr Y. Bentur), Rambam Health Care Campus, Haifa, Israel. Funding/Support: The study was supported by the Israel Cancer Association, Israel Lung Association, and Israel Science Foundation [Grant 753/2011]. Correspondence to: Lea Bentur, MD, Pediatric Pulmonology Unit, Meyer Children’s Hospital, Rambam Health Care Campus, PO Box 9602, Haifa 31096, Israel; e-mail: l_bentur@rambam. health.gov.il © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0960 804
Spirometry was performed in accordance with American Thoracic Society/European Respiratory Society criteria with a KoKo spirometer (KoKo system; nSpire Health, Inc).11 Each maneuver was repeated to obtain at least three technically acceptable forced expiratory flow volume curves; the best results were used for analysis. Results are expressed as percent predicted.12 Carboxyhemoglobin (COHb) level was measured in venous blood samples by an Illex co-oximeter (IL-682; Instrumentation Laboratory). CBC was analyzed with an automated hematology flow cytometer (Coulter STKS; Beckman Coulter, Inc). EBC samples were collected in RTubes (Respiratory Research) as previously described.6,13,14 High-sensitivity enzyme-linked immunosorbent assay kits were used to analyze samples for IL-4, IL-5, IL-10, IL-17 (R&D Systems, Inc), and g-interferon (eBioscience, Inc). All samples were assayed in duplicate at two dilutions and a plate reader absorbance of 450 nm. Results were analyzed with a four-parameter logistic curve fit. The intraassay and interassay variability was , 10%; specificity ranged from 94% to 98%. The limit of detection of the assays was 0.06 pg/mL, 15 pg/mL, 0.11 pg/mL, and 0.09 pg/mL for IL-5, IL-17, IL-4, and IL-10, respectively, and 0.15 pg/mL for g-interferon. Plasma and urine nicotine and cotinine concentrations were determined by liquid chromatography-tandem mass spectrometry, with a lower limit of quantitation of 1 ng/mL (Quattro micro API equipped with Waters 2795 HPLC; Waters Corp).15 Endothelial function was quantitatively determined as the ratio between the average arterial pulse wave amplitude after a 5-min arterial occlusion in the forearm to the preocclusion value using the EndoPat device (Itamar Medical Ltd). A value of ⱕ 1.67 is considered to indicate endothelial dysfunction. This methodology has been validated and shown to characterize endothelial function more accurately than other technologies.16-18 Adverse symptoms or unusual sensations were voluntarily reported by the subjects and recorded. Statistical Analysis Sample size was determined by Win Episcope 2 (CLIVE [Computer-Aided Learning in Veterinary Education], The University of Edinburgh) for paired tests. For the primary outcome of an increase in COHb concentration from 2% to 3.5% with 95% confidence and 80% power, seven subjects were required. Pulmonary function tests, vital signs, nicotine and cotinine levels, EBC cytokine levels, and endothelial function as assessed by EndoPAT were considered secondary outcome parameters. The sample size was increased to a minimum of 20 subjects to allow detection of a 10% increase in respiratory rate and systolic and diastolic BP. Power analyses for the other parameters were not predetermined. Analysis was performed by paired Student t test for parametric values and Wilcoxon signed rank test for nonparametric values. Repeated-measures analyses were performed to find categorical (sex) predictors related to the dependent variables. For EBC, analysis of variance was used followed by NewmanKeuls post hoc test whenever appropriate. Results are expressed as mean ⫾ SD, median, and range. P , .05 was considered statistically significant. Because multiple outcome parameters were evaluated, the P value was also adjusted by Bonferroni correction. In active smokers, 25 parameters were evaluated; therefore, the
Original Research
corrected P value was .002. In passive smokers, 17 parameters were evaluated; therefore, the corrected P value was .003.
Results Sixty-two subjects were included in the study (aged 24.9 ⫾ 6.2 years; 47 [33 male] active smokers; 15 [six male] passive smokers). The vital signs and results of endothelial function assessed by EndoPat and pulmonary function tests before and after one session of WPS are shown in Table 1. Four healthy subjects with no history of hypertension were found to have elevated BP values at the research facility. Repeated follow-up BP measurements outside the research facility and the hospital were normal. The changes in blood and urine laboratory parameters before and after WPS are presented in Table 2. Post-WPS COHb concentration increased eightfold in active smokers (P , .0001), by . 25% in six subjects (12.7%), and by .40% in two subjects (4.2%) (41.6% and 44%). In passive smokers, post-WPS COHb levels increased by 50% (P 5 .003). Post-WPS plasma nicotine levels increased 18-fold (P , .0001) in active smokers. Sex analysis showed significant differences only in post-WPS plasma nicotine concentrations in active smokers (22.80 ⫾ 13.71 ng/mL and 8.65 ⫾ 8.15 ng/mL in men and women, respectively; P 5 .002).
EBC was analyzed only in active smokers; the results are shown in Table 3. After WPS, the levels of IL-4, IL-5, IL-10, IL-17, and g-interferon decreased significantly. Self-reported symptoms are shown in Table 4. Discussion Cafés and restaurants offering WPS as a form of entertainment have mushroomed in recent years. A paucity of data is available on the effects of indoor WPS and the possible biologic effects of passive exposure to WPS in such cafés.19 The present study comprehensively assessed acute changes in multiple laboratory and clinical parameters in indoor group WPS and in passive smokers. This study shows that a single 30-min session of indoor group WPS resulted in a significant and alarming increase in COHb level, significant elevations in plasma and urine nicotine and cotinine concentrations, increased BP and heart and respiratory rates, significant decreases in EBC cytokine levels, and no change in endothelial function. Significant increases in COHb concentration and respiratory rate were found in passive water-pipe smokers. Both active and passive WPS were associated with adverse symptoms. The following is a discussion of the outcome parameters, beginning with the most important findings.
Table 1—Vital Signs and Results of Endothelial Function Assessed by EndoPat and Pulmonary Function Tests Before and After Indoor Group Active and Passive WPS Active WPS (n 5 47) Parameter Heart rate, beats/min Median (range) Systolic BP, mm Hg Median (range) Diastolic BP, mm Hg Median (range) Respiratory rate, breaths/min Median (range) EndoPat score Median (range) FVC, L % predicted FEV1, L/s % predicted FEV1/FVC % predicted FEF25%-75%, L % predicted PEFR, L % predicted
Passive WPS (n 5 15)
Before
After
P Value
Before
After
P Value
77.3 ⫾ 12.2 75 (51-105) 124.0 ⫾ 13.6 122 (99-162) 72.6 ⫾ 10.1 72 (53-100) 16.2 ⫾ 2.6 16 (12-24) 1.85 ⫾ 0.52 1.69 (1.0-4.0) 4.7 ⫾ 0.9 99.1 ⫾ 10.5 4.0 ⫾ 0.8 99.9 ⫾ 9.5 86 ⫾ 0.6 104.4 ⫾ 7.2 4.5 ⫾ 0.9 95.7 ⫾ 18.6 8.4 ⫾ 1.7 93 ⫾ 13
92.8 ⫾ 16.3 91 (56-128) 132.8 ⫾ 14.97 132 (99-170) 77.6 ⫾ 12.2 78 (51-110) 19.7 ⫾ 3.3 20 (12-30) 1.86 ⫾ 0.55 1.78 (1.0-4.0) 4.6 ⫾ 0.9 98.4 ⫾ 10.5 4.0 ⫾ 0.7 100.0 ⫾ 9.2 87 ⫾ 0.6 105 ⫾ 7.3 4.5 ⫾ 0.9 95.8 ⫾ 18.1 8.1 ⫾ 1.6 89.4 ⫾ 13.3
.0001 … .0001 … .001 … .0001 … NS … NS … NS … NS … NS … .015 .026b
81.1 ⫾ 13.2 78.5 (68-112) 117.3 ⫾ 9.9 118 (95-130) 78.0 ⫾ 8.2 79 (62-90) 16.25 ⫾ 1.91 16 (12-20) NA NA 3.8 ⫾ 0.6 97.5 ⫾ 6.6 3.3 ⫾ 0.5 97.8 ⫾ 7.1 86.8 ⫾ 0.68 104.5 ⫾ 7.1 3.7 ⫾ 8.7 89.9 ⫾ 17.1 8.4 ⫾ 1.7 90.1 ⫾ 13.1
80.1 ⫾ 15.2 79 (56-108) 120.5 ⫾ 10.4 120 (102-139) 80.27 ⫾ 7.41 81 (68-91) 20.5 ⫾ 2.9 20 (16-24) NA NA 3.8 ⫾ 0.7 97 ⫾ 6.4 3.3 ⫾ 0.5 98.4 ⫾ 7.6 87.7 ⫾ 0.65 105.7 ⫾ 7.3 3.9 ⫾ 8.4 94.7 ⫾ 17.1 8.3 ⫾ 1.6 89.5 ⫾ 13.4
.35 … .6 … .38 … .009a … NA … NS … NS … NS … NS … NS …
Data are presented as mean ⫾ SD unless otherwise indicated. FEF25%-75% 5 forced expiratory flow, midexpiratory phase; NA 5 not applicable; NS 5 not significant; PEFR 5 peak expiratory flow rate; WPS 5 water-pipe smoking. aInsignificant after applying Bonferroni correction (corrected P value for passive smokers 5 .003). bInsignificant after applying Bonferroni correction (corrected P value for active smokers 5 .002). journal.publications.chestnet.org
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Table 2—Blood and Urine Laboratory Parameters Before and After Indoor Group Active and Passive WPS Active WPS (n 5 47) Parameter Hemoglobin, g/dL WBC, /mL Eosinophils, /mL Eosinophils, % COHb, % Plasma nicotine, ng/mL Plasma cotinine, ng/mL Urine nicotine, ng/mLb Urine cotinine, ng/mLb
Passive WPS (n 5 15)
Before
After
P Value
Before
After
P Value
14.5 ⫾ 1.3 7.8 ⫾ 1.8 144 ⫾ 104 1.92 ⫾ 1.30 2.02 ⫾ 2.89 1.1 ⫾ 4.1 61.2 ⫾ 96.7 70.4 ⫾ 232.2 146.2 ⫾ 232.2
14.8 ⫾ 1.4 8.7 ⫾ 2.0 149 ⫾ 119 1.76 ⫾ 1.29 17.57 ⫾ 8.79 19.1 ⫾ 13.9 78.2 ⫾ 93.7 290.8 ⫾ 319.6 165.3 ⫾ 243.6
.0001 .001 NS .02a , .00001 , .0001 , .0001 , .0001 .033a
13.4 ⫾ 1.9 8.1 ⫾ 1.8 100 ⫾ 114 1.25 ⫾ 1.48 0.8 ⫾ 0.2 0.44 ⫾ 1.7 9.2 ⫾ 25.0 NA NA
13.4 ⫾ 1.9 8.1 ⫾ 1.8 102 ⫾ 105 1.28 ⫾ 1.36 1.2 ⫾ 0.8 0.4 ⫾ 1.4 13.9 ⫾ 46.0 NA NA
NS NS NS NS .003 NS NS NA NA
Data are presented as mean ⫾ SD. COHb 5 carboxyhemoglobin. See Table 1 legend for expansion of other abbreviations. aInsignificant after applying Bonferroni correction (corrected P value for active smokers 5 .002). bUrine nicotine and cotinine concentrations were analyzed only in active smokers.
COHb Concentration The results show an eightfold increase in COHb levels post-WPS, with a . 25% increase in six subjects (12.7%) and . 40% in two subjects (4.2%). Such levels may require hospital admission and normobaric or hyperbaric oxygen therapy. High levels of COHb necessitating hospital admission and oxygen treatment have been reported in a few patients after WPS.20 The COHb levels measured in the present study are much higher than those previously reported by us and others.6,20,21 In our previous open-air study, post-WPS COHb levels rose to 9.49% ⫾ 5.52% and to . 25% (26%) in one subject (2.2%). The only difference between our studies is the indoor vs open-air smoking design, suggesting higher ambient carbon monoxide (CO) levels in a closed space than in an outdoor setting. In passive smokers, COHb level was significantly elevated (by 50%). This increase is similar to that observed in healthy volunteers of a similar age who were exposed in a model room to the smoke of five cigarettes smoked by a machine during a series of five 30-min sessions (overall exposure, 2.5 h).22 Coffee shops usually are smaller, less ventilated, and more crowded than the setting we used in the present study, suggesting that real-life exposure to CO in WPS can be higher than we found. This is supported Table 3—Level of Cytokines in Exhaled Breath Condensate Before and After Indoor Group Active WPS Active WPS Parameter IL-4 IL-5 IL-10 IL-17 g-Interferon
No. Subjects Before, pg/mL After, pg/mL 46 46 45 45 46
7.98 ⫾ 3.26 2.20 ⫾ 0.72 12.2 ⫾ 4.64 31.97 ⫾ 6.02 29.19 ⫾ 4.11
P Value
.001 5.52 ⫾ 1.83 .00003 1.62 ⫾ 0.27 9.28 ⫾ 1.62 , .0001 .006 28.46 ⫾ 5.73 23.05 ⫾ 3.89 , .001
Data are presented as mean ⫾ SD. See Table 1 legend for expansion of abbreviation. 806
by a study demonstrating a 300% increase in exhaled CO after 1 h of WPS smoking, whereas in cigarette smokers, exhaled CO increased by only 60%.23 Plasma and Urine Nicotine and Cotinine Concentrations We found significant increases in plasma and urinary nicotine and, to a lesser extent, cotinine concentrations after active WPS. Compared with the present findings (19.1 ⫾ 13.9 ng/mL), various plasma nicotine concentrations have been reported in the literature (lower, 3.6 ⫾ 0.7 ng/mL24 and 10.2 ⫾ 7.0 ng/mL25; similar, 15.7 ⫾ 8.7 ng/mL26; higher, 60.3 ng/mL27). This variability may be explained by the burning temperature, type and amount of tobacco, smoking topography, subject selection, study design, and method of nicotine concentration determination.1 High levels of 24-h urinary nicotine and cotinine were reported in long-term WPS.28 A meta-analysis indicated that variable daily use (one to 10 water pipes) produced a 24-h urinary cotinine level of 0.785 mg/mL (equivalent to smoking 10 cigarettes/d).1 In the present study, passive exposure to WPS resulted in an insignificant increase in plasma cotinine. Similarly, 1 h of secondhand cigarette smoke exposure has been shown to result in a mild increase of serum cotinine.29 The substantial exposure of water-pipe smokers to nicotine found in the present study suggests that it may contribute to cardiovascular morbidity similarly to cigarette smokers. Vital Signs The significant increases in BP and heart and respiratory rates described in the present study are similar to those previously reported by us and others.6,7,30 The causative role of nicotine in these hemodynamic changes was suggested in a double-blind study that showed an increased heart rate only in smokers of nicotine-containing water pipes.7,9 Original Research
Table 4—Self-Reported Symptoms After 30 Min of Active and Passive WPS Symptom Dizziness Fatigue Headache Palpitations Nausea Dry throat Chest discomfort Dyspnea Drowsiness Blurred vision
Active Smokers (n 5 47) Passive Smokers (n 5 15) 31 (66) 27 (57.4) 22 (46.8) 10 (21.3) 8 (17) 8 (17) 7 (4.9) 3 (6.4) 2 (4.3) 2 (4.3)
5 (33.3) 8 (53.3) 11 (73.3) 0 (0) 1 (6.7) 1 (6.7) 3 (20) 2 (13.3) 0 (0) 0 (0)
Data are presented as No. (%). The main symptoms reported by both active and passive water-pipe smokers were dizziness, fatigue, headache, nausea, dry throat, chest discomfort, and dyspnea. See Table 1 legend for expansion of abbreviation.
Pulmonary Function Tests No change was found in FVC, FEV1, FEV1/FVC, and forced expiratory flow, midexpiratory phase (FEF25%-75%) after active indoor group WPS. We found a minor decrease in peak expiratory flow rate (PEFR), which became insignificant after applying Bonferroni correction. No change was found in pulmonary function tests after passive WPS. In our earlier open-air study,6 we found decreases in PEFR (P 5 .0043) and FEF25%-75% (P 5 .045); both became insignificant after applying Bonferroni correction. The more pronounced decrease in PEFR in both studies is unclear because PEFR is effort dependent and less sensitive than FEV1 or FEF25%-75%. The minor decrease in PEFR may represent poor performance after WPS or type I error. Hence, the significance of the finding is questionable. Conflicting results were found in the acute effect of active and passive cigarette smoking on pulmonary function tests.8,10 A meta-analysis of six cross-sectional studies compared pulmonary function in long-term WPS and long-term cigarette smokers. Most of the six studies had methodological limitations and inconsistent results. The conclusions derived from the pooled data were that WPS decreases lung function.31 Although other studies31 as well as the present study suggest that WPS may be associated with changes in pulmonary function, more research is required to elucidate this issue. It is unclear what amount of passive WPS is required to adversely affect lung function, if at all. CBC Hemoglobin concentration and WBC count increased significantly, and the percent decrease of eosinophils was small but significant. Short-term cigarette smoking was also reported to increase hemoglobin concentration and WBC count and to decrease the number of eosinophils.10,32 Increased circulating WBCs in journal.publications.chestnet.org
cigarette smokers was implicated in low-grade inflammation related to atherosclerosis.32 The suggested mechanisms for the decrease in the number of eosinophils associated with cigarette smoking are direct (apoptotic) effect by toxic substances33 and antiinflammatory substances, such as CO.34 The similarity between the effects of WPS on CBC and those reported after cigarette smoking suggests that WPS may also be involved in smoking-induced atherosclerosis. This hypothesis requires further evaluation in long-term active and passive WPS. Exhaled Breath Condensate We found significant decreases in all EBC cytokine (IL-4, IL-5, IL-17, IL-10, and g-interferon) levels after active WPS. These results are in accordance with the decrease in 8-isoprostane in EBC found in our previous study.6 To our knowledge, the effect of acute WPS or cigarette smoking on these parameters has not been previously studied. Given the role of inflammation in the development of impaired respiratory function, understanding the effect of short-term WPS on the response of EBC cytokines is important.35 Airway inflammation together with oxidative stress form a vicious cycle that leads to disease progression in patients with COPD.36 The cytokines IL-4, IL-5, and IL-17 are T helper-cell 2 derived, whereas IL-10 and g-interferon are T helper-cell 1 derived. These cytokines are associated with chronic lung inflammation and structural changes in chronic pulmonary diseases.36 It is unclear whether the reduced concentrations of EBC cytokines after WPS found in the present study reflect a decreased production or reduced delivery. Decreased cytokine production may be explained by the high levels of CO, a potent antiinflammatory agent.37 Alternatively, smoke that elicits endoplasmic reticulum stress may activate the unfolded protein response, resulting in inhibition of global protein synthesis and degradation through the ubiquitin system.38 Decreased cytokine delivery may be due to mechanical factors (eg, decreased ciliary function, particle trapping that prevents the delivery of EBC cytokines). The possible clinical implications of the post-WPS decrease in EBC cytokine levels requires further study. Endothelial Dysfunction Assessed by EndoPat The data show that short-term WPS does not alter endothelial function as measured by EndoPat. Cigarette smoking is associated with endothelial dysfunction and an increased risk of atherosclerosis. Endothelial nitric oxide production is reduced in reaction to tobacco smoke39 and may affect brachial artery dilation. The lack of endothelial dysfunction assessed by EndoPat may be explained by the different effects of CHEST / 145 / 4 / APRIL 2014
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nicotine and COHb on the vascular system. Nicotine accounts for endothelial dysfunction, whereas a COHb concentration . 7% (as found in the present study) increases cyclic guanosine monophosphate, resulting in vascular relaxation.40 Endothelial function should be evaluated in long-term WPS. Limitations The main limitations of this study are the small number of passive smokers and active WPS in women, no assessment of smoking topography, lack of evaluation of EBC cytokines and endothelial function in passive smokers, and no determination of ambient CO and toxic smoke constituents (eg, aldehydes, polycyclic aromatic hydrocarbons). Multiple parameters were evaluated; therefore, statistical analysis was done with and without Bonferroni correction. After applying this correction, the marginally significant changes in PEFR, percentage of eosinophils, urinary cotinine levels in active smokers, and respiratory rate in passive smokers were insignificant. Although Bonferroni correction controls the probability of type I error, it comes at the cost of increasing the probability of type II error. The present results call for further studies evaluating real-life WPS exposure in coffee shops. These studies should include a larger number of passive and female smokers and assessment of the health consequences of long-term indoor WPS. In summary, one session of indoor active group WPS resulted in an eightfold and 18-fold increase in COHb and plasma nicotine concentrations, respectively. These increases were associated with significant changes in cardiorespiratory parameters to a greater extent than in our previous open-air group WPS study.6 The minor, but significant increase (50%) in COHb concentration in passive smokers suggests that passive smokers may also be adversely affected by WPS. These results call for actions aimed at limiting the global spread of WPS in coffee shops. Acknowledgments Author contributions: Dr L. Bentur had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr L. Bentur: contributed to the study design, institutional review board application, supervision of the experiments, data analysis, and writing of the manuscript. Mr Hellou: contributed to the institutional review board application, patient recruitment, the performance of all tests, data analysis, literature survey, and revision of the manuscript. Dr Goldbart: contributed to the cytokine analysis and discussion of exhaled breath condensate parameters and revision of the manuscript. Dr Pillar: contributed to the design of the EndoPat study, analysis of the results, and revision of the manuscript. Ms Monovich: contributed to the performance and analysis of the EndoPat tests and revision of the manuscript. 808
Dr Salameh: contributed to the patient recruitment, performance of all tests, data analysis, literature survey, and revision of the manuscript. Ms Scherb: contributed to the nicotine and cotinine analysis and revision of the manuscript Dr Y. Bentur: contributed to the study design, supervision of the experiments, data analysis, and writing of the manuscript. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Role of sponsors: The sponsors had no role in the study design, data analysis, writing of the manuscript, or its submission.
References 1. Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007;9(10):987-994. 2. Warren CW, Lea V, Lee J, Jones NR, Asma S, McKenna M. Change in tobacco use among 13-15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey. Glob Health Promot. 2009;16(suppl 2):38-90. 3. Chaouachi K. More rigor needed in systematic reviews on “waterpipe” (hookah, narghile, shisha) smoking. Chest. 2011; 139(5):1250-1251. 4. Jackson D, Aveyard P. Waterpipe smoking in students: prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health. 2008;8:174. 5. Mzayek F, Khader Y, Eissenberg T, Al Ali R, Ward KD, Maziak W. Patterns of water-pipe and cigarette smoking initiation in schoolchildren: Irbid longitudinal smoking study. Nicotine Tob Res. 2012;14(4):448-454. 6. Hakim F, Hellou E, Goldbart A, Katz R, Bentur Y, Bentur L. The acute effects of water-pipe smoking on the cardiorespiratory system. Chest. 2011;139(4):775-781. 7. Al-Kubati M, Al-Kubati AS, al’Absi M, Fiser B. The shortterm effect of water-pipe smoking on the baroreflex control of heart rate in normotensives. Auton Neurosci. 2006;126-127: 146-149. 8. Flouris AD, Metsios GS, Carrillo AE, et al. Acute and shortterm effects of secondhand smoke on lung function and cytokine production. Am J Respir Crit Care Med. 2009;179(11): 1029-1033. 9. Shihadeh A, Salman R, Jaroudi E, et al. Does switching to a tobacco-free waterpipe product reduce toxicant intake? A crossover study comparing CO, NO, PAH, volatile aldehydes, “tar” and nicotine yields. Food Chem Toxicol. 2012;50(5): 1494-1498. 10. van der Vaart H, Postma DS, Timens W, ten Hacken NH. Acute effects of cigarette smoke on inflammation and oxidative stress: a review. Thorax. 2004;59(8):713-721. 11. Miller MR, Hankinson J, Brusasco V, et al; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J. 2005;26(2): 319-338. 12. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official statement of the European Respiratory Society. Eur Respir J Suppl. 1993;16: 5-40. 13. Rosias PP, Robroeks CM, Kester A, et al. Biomarker reproducibility in exhaled breath condensate collected with different condensers. Eur Respir J. 2008;31(5):934-942. 14. Mutlu GM, Garey KW, Robbins RA, Danziger LH, Rubinstein I. Collection and analysis of exhaled breath condensate in humans. Am J Respir Crit Care Med. 2001;164(5):731-737. Original Research
15. Yue B, Kushnir MM, Urry FM, Rockwood AL. Quantitation of nicotine, its metabolites, and other related alkaloids in urine, serum, and plasma using LC-MS-MS. Methods Mol Biol. 2010; 603:389-398. 16. Kuvin JT, Patel AR, Sliney KA, et al. Assessment of peripheral vascular endothelial function with finger arterial pulse wave amplitude. Am Heart J. 2003;146(1):168-174. 17. Yinon D, Lowenstein L, Suraya S, et al. Pre-eclampsia is associated with sleep-disordered breathing and endothelial dysfunction. Eur Respir J. 2006;27(2):328-333. 18. Itzhaki S, Dorchin H, Clark G, Lavie L, Lavie P, Pillar G. The effects of 1-year treatment with a Herbst mandibular advancement splint on obstructive sleep apnea, oxidative stress, and endothelial function. Chest. 2007;131(3):740-749. 19. Moritsugu KP. The 2006 report of the Surgeon General: the health consequences of involuntary exposure to tobacco smoke. Am J Prev Med. 2007;32(6):542-543. 20. La Fauci G, Weiser G, Steiner IP, Shavit I. Carbon monoxide poisoning in narghile (water pipe) tobacco smokers. CJEM. 2012;14(1):57-59. 21. Zahran FM, Ardawi MS, Al-Fayez SF. Carboxyhemoglobin concentrations in smokers of sheesha and cigarettes in Saudi Arabia. Br Med J (Clin Res Ed). 1985;291(6511):1768-1770. 22. Czogala J, Goniewicz ML. The complex analytical method for assessment of passive smokers’ exposure to carbon monoxide. J Anal Toxicol. 2005;29(8):830-834. 23. Bacha ZA, Salameh P, Waked M. Saliva cotinine and exhaled carbon monoxide levels in natural environment waterpipe smokers. Inhal Toxicol. 2007;19(9):771-777. 24. Blank MD, Cobb CO, Kilgalen B, et al. Acute effects of waterpipe tobacco smoking: a double-blind, placebo-control study. Drug Alcohol Depend. 2011;116(1-3):102-109. 25. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. Am J Prev Med. 2009;37(6):518-523. 26. Maziak W, Rastam S, Shihadeh AL, et al. Nicotine exposure in daily waterpipe smokers and its relation to puff topography. Addict Behav. 2011;36(4):397-399. 27. Shafagoj YA, Mohammed FI, Hadidi KA. Hubble-bubble (water pipe) smoking: levels of nicotine and cotinine in plasma, saliva and urine. Int J Clin Pharmacol Ther. 2002;40(6): 249-255.
journal.publications.chestnet.org
28. Behera D, Uppal R, Majumdar S. Urinary levels of nicotine & cotinine in tobacco users. Indian J Med Res. 2003;118: 129-133. 29. Baltar VT, Xun WW, Chuang SC, et al. Smoking, secondhand smoke, and cotinine levels in a subset of EPIC cohort. Cancer Epidemiol Biomarkers Prev. 2011;20(5):869-875. 30. Shaikh RB, Vijayaraghavan N, Sulaiman AS, Kazi S, Shafi MS. The acute effects of waterpipe smoking on the cardiovascular and respiratory systems. J Prev Med Hyg. 2008;49(3): 101-107. 31. Raad D, Gaddam S, Schunemann HJ, et al. Effects of waterpipe smoking on lung function: a systematic review and metaanalysis. Chest. 2011;139(4):764-774. 32. Flouris AD, Poulianiti KP, Chorti MS, et al. Acute effects of electronic and tobacco cigarette smoking on complete blood count. Food Chem Toxicol. 2012;50(10):3600-3603. 33. Aoshiba K, Tamaoki J, Nagai A. Acute cigarette smoke exposure induces apoptosis of alveolar macrophages. Am J Physiol Lung Cell Mol Physiol. 2001;281(6):L1392-L1401. 34. Chapman JT, Otterbein LE, Elias JA, Choi AM. Carbon monoxide attenuates aeroallergen-induced inflammation in mice. Am J Physiol Lung Cell Mol Physiol. 2001;281(1):L209-L216. 35. Papaioannou AI, Koutsokera A, Tanou K, et al. The acute effect of smoking in healthy and asthmatic smokers. Eur J Clin Invest. 2010;40(2):103-109. 36. Litonjua AA, Sparrow D, Guevarra L, O’Connor GT, Weiss ST, Tollerud DJ. Serum interferon-gamma is associated with longitudinal decline in lung function among asthmatic patients: the Normative Aging Study. Ann Allergy Asthma Immunol. 2003;90(4):422-428. 37. Otterbein LE, Bach FH, Alam J, et al. Carbon monoxide has anti-inflammatory effects involving the mitogen-activated protein kinase pathway. Nat Med. 2000;6(4):422-428. 38. Kelsen SG. Respiratory epithelial cell responses to cigarette smoke: the unfolded protein response. Pulm Pharmacol Ther. 2012;25(6):447-452. 39. Yufu K, Takahashi N, Okada N, et al. Influence of systolic blood pressure and cigarette smoking on endothelial function in young healthy people. Circ J. 2009;73(1):174-178. 40. Kanten WE, Penney DG, Francisco K, Thill JE. Hemodynamic responses to acute carboxyhemoglobinemia in the rat. Am J Physiol. 1983;244(3):H320-H327.
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