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CompletedNCT03253653Updated Apr 9, 2025Results posted

Assessing Toxicity of Waterpipe Tobacco Smoking

An interventional study of Differential effects of waterpipe smoking practices on toxicity of waterpipe tobacco smoke in Waterpipe Smoking, sponsored by San Diego State University. Completed at 1 site in United States. Open to participants aged 21 Years and older, including healthy volunteers. Per ClinicalTrials.gov, last updated 2025-04-09.

Sponsored by San Diego State University · Not applicable, Interventional, and Other

Phase
Not applicable
Study type
Interventional
Enrollment
85
Allocation
Non-randomized
Ages
21 Years and older
Sex
All
01

Where this study stands

Counted across the records on this site · 2026-11-12

Among 15 studies in Water Pipe Smoking with a site in United States — none open to participants now, 1 under way, none of them phase 3. Water Pipe Smoking · United States.

Enrollment
6th of 15
85 · median 50
Started
2017
with 4 others
No phase
13 of 15
none open now
Registered
9th of 15
by date
Lead sponsor
1 of 15
San Diego State University

Among the 15 studies in Water Pipe Smoking with a site in United States, this one is the 6th largest by enrollment, is one of 5 that started in 2017, is one of 13 with no phase, and was the 9th registered.

Water Pipe Smoking

23 studies on the registry are indexed under Water Pipe Smoking; none are open to participants now.

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Open to participants now

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02

Study summary

Waterpipe smoking is a tobacco use method in which smoke passes through a partially-filled water jar. Burning charcoal heats the waterpipe tobacco which produces the smoke that the user inhales. Waterpipe smoking was associated with increased risk for coronary heart and pulmonary diseases. This Waterpipe Study will inform the FDA on regulating waterpipe tobacco products and reduce the harm of it use. This study will be conducted at homes of hookah smokers, in natural settings, aimed to determine the effects of waterpipe smoking practices on physiological injury markers and biomarkers of toxicity of waterpipe tobacco smoking. The investigators will employ a repeated measures design. The investigators will recruit a sample of 50 adult male and female exclusive waterpipe smokers and a control sample of 25 male and female non-smokers via intercept interviews from San Diego County, California communities. Waterpipe smokers will smoke one waterpipe tobacco head (10g) of Starbuzz during 3 separate sessions with a 7-day washout period before each session, as follows: Session 1, Smoking waterpipe tobacco using 1 quick-light charcoal and room temperature water in the waterpipe jar, Session 2, Smoking waterpipe tobacco using 1 quick-light charcoal and adding ice cubes to the water in the waterpipe jar, and Session 3, Smoking waterpipe tobacco without charcoal using a charcoal-free electrically heated waterpipe head to heat the tobacco, and room temperature water in the waterpipe jar. The following data will be collected: a) Tobacco Use History, b) 4-week Tobacco Exposure Diary, c) Waterpipe Use Session Form, d) Carbon monoxide (CO) exposure: Micro+ Smokerlyzer® CO monitor will be used for exhaled CO pre and 2 minutes post each smoking session, e) Pulmonary function testing and measuring blood pressure, heart rate and respiratory rate, and f) 6 first morning urine samples: pre and post the 3 sessions to measure urinary cotinine, a metabolite of nicotine, 4-(methylnitrosamino)-1- (3-pyridyl)-1-butanol (NNAL) and NNAL-glucuronides (total NNAL), metabolites of the lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), 1-hydroxypyrene (1-HOP), a metabolite of the genotoxic carcinogen pyrene, and S-phenylmercapturic acid (SPMA), a metabolite of the human hematotoxicant and leukemogen benzene. The investigators will explore exposure levels to furan, a liver toxicant and carcinogen, among waterpipe smokers via measuring its urinary metabolite, L-2-(acetylamino)-6-(2,5-dihydro-2-oxo-1H-pyrrol-1-yl)-1-hexanoic acid (Furan-BDA-NAL).

Read the detailed description

Globally, 1 in 3 adults or 1.2 billion people smoke. The World Health Organization (WHO) estimated that tobacco is responsible for the death of 1 in 10 adults worldwide, about 6 million premature deaths each year. In the United States (U.S.), cigarette smoking is responsible for more than 480,000 deaths per year, including nearly 42,000 deaths resulting from secondhand smoke exposure. Tobacco use is the single leading most preventable cause of disease, disability, and mortality in the U.S. Tobacco research tends to focus on cigarettes; however, the rise in waterpipe (WP) tobacco use globally warrants studying all aspects of its toxicity. In 2005, the WHO called for a better understanding of WP tobacco smoking. In 2007, the American Lung Association labeled WP smoking as an emerging deadly trend. WP tobacco use was associated with increased risk for Chronic obstructive pulmonary disease (COPD), heart diseases, lung cancers, oral and esophageal cancers.

COPD is a major public health problem leading to airflow obstruction. In the U.S., tobacco smoke is a key factor in the development of COPD, which was the third leading cause of death in the U.S. in 2014. WP smoking decreases respiratory quality of life in adults. Studies found that pulmonary function following WP smoking was impaired as measured by forced expiratory volume (FEV1), forced vital capacity (FVC), FEV1/FVC, and Forced Expiratory Flow (FEF25-75%). Studies investigating acute cardiovascular injury markers due to WP smoking showed significant increases in heart rate, and in systolic and diastolic blood pressure.

In 2014, the U.S. Food and Drug Administration (FDA) initiated regulation WP tobacco. The FDA proposed that the manufacturers of WP tobacco disclose to the FDA their products' ingredients and report harmful and potentially harmful constituents (HPHCs). A review study showed that exposures to HPHCs are 10-100 times higher in WP tobacco smoke than in cigarette smoke. To inform the FDA on the regulation of WP tobacco products, and reduce the harm of it use, the investigators propose a Waterpipe Project in a natural setting to determine the differential effects of WP smoking practices on physiological injury markers, and biomarkers of toxicants and carcinogens.

Worldwide, the WP is used in Africa, Asia, China, India, and the Middle East. Adolescents and young adults in the U.S. are experimenting with WP smoking. The 2014 U.S. National College Health Assessment II found that nearly one third of U.S. undergraduate college students (38.2% of men and 31.4% of women), reported ever using WP tobacco, and 11.6% of men and 8.3% of women reported current use (past 30 days). Among high school students, the 2013 U.S. National Youth Tobacco Survey showed that 15.1% of boys and 13.5% of girls reported ever WP use.

The WP (hookah) consists of a head, a body, a hose, and a water jar. The tobacco is placed in the head and covered with a perforated aluminum foil to allow air-flow. Burning charcoal is placed on top of the aluminum foil. Upon deep inhalation via the WP hose, suction forces hot air through the head, heating and combusting the tobacco to produce the smoke that is forced down the WP body, into and out of the water in the airtight jar, and through the hose into the smoker's mouth and respiratory system. Smokers inhale charcoal toxicant emissions in addition to those from the WP tobacco. Charcoal combustion contributes greatly to benzene, carbon monoxide (CO) and carcinogenic yields. CO is a smoke toxicant that reduces the blood's ability to transport oxygen to various organs, including the brain, and can cause dizziness, headache, syncope and nausea.

A charcoal-free electrically heated WP head is commercially available. Users were satisfied with this device because they did not have to deal with charcoal fire hazardous ambers and ashes, in addition to enjoying the feeling of reduced harm. WP smokers normally use room temperature water in the WP jar. However, other liquid media are gaining in popularity. According to anecdotal evidence, "adding ice cubes in the WP jar has an enjoyable cooling effect to the inhaled smoke". Smokers practice adding ice cubes at home, and for an extra charge hookah lounges provide this option for customers. Toxic chemicals in WP tobacco smoke include cotinine, a metabolite of the addictive drug nicotine; 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and NNAL-glucuronides (total NNAL); metabolites of the lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK); 1-hydroxypyrene (1-HOP), a metabolite of the genotoxic carcinogen pyrene; and S-phenylmercapturic acid (SPMA), a metabolite of the human hematotoxicant and leukemogen benzene; and Furan-BDA-NAL, a metabolite of the carcinogen furan.

METHODS. will compare exhaled CO, pulmonary functions, blood pressure, heart rate and respiratory rate, and urinary levels of cotinine, NNAL, SPMA, and 1-HOP in first void WP smoker urine samples the morning of, and the morning after a WP smoking session across 3 smoking practices. The investigators will recruit a sample of 50 adult male and female exclusive WP smokers and a control sample of 25 male and female non-smokers. Participants will be recruited and qualified via random intercept screen interviews from San Diego County, California communities. Over a 3-week study period, WP smokers will smoke one WP tobacco head (10g) of Starbuzz during 3 separate sessions with a 7-day washout period before each session in their home in a natural setting: Week 1-Session 1, WP smokers will smoke using 1 quick-light charcoal and room temperature water in the WP jar, Week 2-Session 2, WP smokers will smoke using 1 quick-light charcoal but adding ice cubes to the water in the WP jar, Week 3-Session 3, WP smokers will smoke WP tobacco without charcoal using the electric WP head and room temperature water. The investigators will collect the following forms: a) Tobacco Use History; b) 3-week Tobacco Use and Exposure Diaries; c) WP Smoking Session Day and Exposure Form; and will measure d) CO exposure: Micro+ Smokerlyzer® CO monitor will be used for exhaled CO two minutes pre and post each smoking session; e) Pulmonary function testing and measuring blood pressure, heart rate and respiratory rate pre and post each smoking session; and f) 6 first morning urine samples: pre and post the 3 sessions to measure urinary cotinine, NNAL, 1-HOP, SPMA, and Furan-BDA-NAL. Efforts will be made to recruit equal samples of males and females. Flexible scheduling for study activities where applicable. Proration of incentives will apply for completed activities.

The 3-Week Study period: comprised of 3 WP smoking sessions with 7-day wash-out periods

WP Smoking Session 1. Day 1 - Office Visit: The Office Visit is expected to take between 60 and 90 minutes where potential participants will be trained on the study activities. Consent will be obtained, study forms will be completed, and study related materials such as forms and urine cups will be provided. Scheduling will be arranged for the 3 WP smoking sessions and corresponding home visits. Saliva Test: Trained by the PI, the research assistants (RAs) will use NicAlert, an accurate and valid commercial semi-quantitative instant saliva cotinine test, to validate non-smoking status, which the investigators used successfully in their previous studies. The following physiological baseline data will be collected: pulmonary functions, blood pressure, heart rate and respiratory rate. Days 2 - 6: The RAs will contact participants by phone on the 4th day to confirm adherence to the 7-wash-out period and diaries, and on the 6th day to remind participants to collect the first morning urine sample on day 7, and to arrange for a home visit for the first WP smoking session. Day 7: WP smoking session 1. WP smokers will provide one first morning urine sample and store it in their refrigerator (freezer section). WP smokers will smoke WP tobacco (10 grams) as they normally do using charcoal and room temperature water in the water jar. The RAs will collect expired CO levels 2 minutes before and 2 minutes after concluding smoking, and will measure pulmonary functions, blood pressure, heart rate and respiratory rate thereafter. Day 8: Participants will provide a first morning urine sample. The RAs will pick up the 2 urine samples (frozen in a cooler to transfer them to the research center laboratory), and arrange for the 2nd WP smoking session home visit, provide forms, urine cups package for week 2 of the study. WP Smoking Session 2. Days 1 through 7 are similar to session 1 with the exception that the RAs will add one tray of ice cubes and water in the WP jar. The RAs will arrange for a training session to use the charcoal-free electrically heated WP head. WP Smoking Session 3. Days 1 through 7 are similar to session 1 using room temperature water in the WP jar, however using the charcoal-free electrically heated WP head instead of using charcoal. During the last visit, the day after the 3rd smoking session, the RAs will interview participants to complete the Illnesses and Health Care History Form, pick up the final urine samples, and thank the participants.

03

Conditions studied

  • Waterpipe Smoking

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Keywords

  • waterpipe
  • hookah
  • NNAL
  • SPMA
  • 1-HOP
  • Furan-BDA-NAL
  • Carbon monoxide
  • Pulmonary Function
04

Who can participate

Ages eligible
21 Years and older
Sexes eligible
All
Accepts healthy volunteers
Yes

Eligibility criteria

Inclusion Criteria for a Waterpipe Tobacco Smoker

  • Adult male or female exclusive waterpipe tobacco smoker
  • Smokes at least 1 waterpipe tobacco head per month
  • Smokes waterpipe tobacco at home
  • Age 21 years or older

Inclusion Criteria for a Non-Smoker

  • Adult male or female non-smoker
  • Lived in a 'non-smoker home' at least in the last month
  • Age 21 years or older

Inclusion Criteria for a Non-Smoker Home

  • No smokers have lived in in the past month
  • No visitors had smoked indoors/outdoors in the past month

Exclusion Criteria

  • Major physical/psychiatric illnesses
  • Daily waterpipe smokers
  • Pregnant women
05

Study design

Phase
Not applicable
Primary purpose
Other
Allocation
Non-randomized
Intervention model
Parallel assignment
Masking
None (open label)
Enrollment
85 participants (actual)

Study arms

  • Experimental
    Waterpipe smoking

    In a repeated measures design, 50 adult male and female exclusive WP smokers will smoke WP tobacco weekly over a 3-week study period with 3 WP smoking practices.

    Device: Differential effects of waterpipe smoking practices on toxicity of waterpipe tobacco smoke

  • No intervention
    Control

    A total of 25 adult make and female nonsmokers will be recruited as a control.

Interventions

  • DeviceDifferential effects of waterpipe smoking practices on toxicity of waterpipe tobacco smoke

    In a repeated measures design, 50 adult male and female exclusive WP tobacco smokers will smoke WP tobacco weekly over a 3-week study period with 3 WP smoking practices as follows: 1) using room temperature water in the WP jar, 2) adding ice cubes to the water in the WP jar, and 3) using a charcoal-free electronic WP head to heat the tobacco. Six Spot first morning urine samples will be provided by participants. Two urine samples per each of the 3 smoking sessions. Urine samples will be provided on the day of the WP tobacco smoking session and the following day. Physiological measures will be taken at Baseline during the office visit and before and after each of the 3 WP tobacco smoking sessions.

06

What researchers measure

Primary outcomes

  1. Comparing Cotinine Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    Investigators will assess change in creatinine-adjusted urinary levels of cotinine (a metabolite of the addictive drug nicotine) in ng/mL, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.

  2. Comparing S-phenyl-mercapturic Acid (SPMA) Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    Investigators will assess change in creatinine-adjusted urinary levels of SPMA (a metabolite of the human hematotoxicant and leukemogen benzene) in pmol/mL, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.

  3. Comparing 1-hydroxypyrene (1-HOP) But Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    Investigators will assess change in creatinine-adjusted urinary levels of 1-HOP (a metabolite of the genotoxic carcinogen pyrene) in pmol/ML, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.

  4. Comparing Exhaled Carbon Monoxide Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    measuring exhaled CO using a Micro+ Smokerlyzer® carbon monoxide (CO) monitor for exhaled CO before and after each of two waterpipe tobacco smoking sessions, investigators will determine the differential change, pre-to-post waterpipe tobacco smoking, between heating by charcoal vs heating by electric head

    Time frame: Assessment will be taken immediately before starting to smoke, and immediately at conclusion of each of the 2 smoking sessions.

  5. Comparing Systolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    The investigators will determine the differential effects of WP smoking practices on change in systolic blood pressure in mm/Hg after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).

  6. Comparing Diastolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    The investigators will investigate the differential effects of WP smoking practices on change in diastolic blood pressure in mm/Hg after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).

  7. Comparing Heart Rate Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

    The investigators will investigate the differential effects of WP smoking practices on change in heart rate in beats per minute after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).

  8. Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    Investigators will assess change in creatinine-adjusted urinary levels of cotinine (a metabolite of nicotine) in ng/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  9. Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    Investigators will assess change in creatinine-adjusted levels of SPMA (a metabolite of the human hematotoxicant and leukemogen benzene) in pmol/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  10. Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    Investigators will assess change in creatinine-adjusted urinary levels of 1-HOP (metabolite of the genotoxic carcinogen pyrene in pmol/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  11. Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    measuring exhaled CO using a Micro+ Smokerlyzer® CO monitor for exhaled CO before and after the heating by charcoal waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

    Time frame: For the smokers: Assessment will be taken immediately before starting to smoke, and immediately at conclusion of each of the smoking session. For the non-smokers: Assessment will be taken at the home visit.

  12. Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    measuring systolic blood pressure levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.

  13. Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    measuring diastolic blood pressure levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.

  14. Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

    measuring heart rate levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.

  15. Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    Investigators will assess creatinine-adjusted urinary levels of cotinine (a metabolite of nicotine) in ng/mL. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  16. Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    Investigators will assess creatinine-adjusted urinary levels of SPMA (a metabolite of benzene) in pmol/mL. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  17. Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    Investigators will assess creatinine-adjusted urinary levels of 1-HOP (a metabolite of pyrene, a polycyclic aromatic hydrocarbon) pmol/ML. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.

  18. Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    measuring exhaled carbon monoxide levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

    Time frame: For the smokers: Assessment will be taken immediately before starting to smoke, and immediately at conclusion of the smoking session. For the non-smokers: Assessment will be taken at the home visit.

  19. Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    For a smoking session using an electric head to heat the tobacco, investigators will measure systolic blood pressure levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.

  20. Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    For a smoking session using an electric head to heat the tobacco, investigators will measure diastolic blood pressure levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min), or at one point during the non-smoker home visit.

  21. Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

    For a smoking session using an electric head to heat the tobacco, investigators will measure heart rate levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

    Time frame: Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.

Secondary outcomes

  1. Assess Difference in Urinary L-2-(Acetylamino)-6-(2,5-dihydro-2-oxo-1H-pyrrol-1-yl)-1-hexanoic Acid (Furan-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

    The investigators will assess difference in urinary Furan-BDA-NAL levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

    Time frame: For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.

  2. Assess Difference in Urinary Furan-BDA-Lys Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

    The investigators will assess difference in urinary Furan-BDA-Lys levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BDA-Lysis a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

    Time frame: For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.

  3. Assess Difference in Urinary N-acetyl-S-[1-(5-acetylamino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

    The investigators will assess difference in urinary Furan-NAC-BDA-NAL levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-NAC-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

    Time frame: For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.

  4. Assess Difference in Urinary N-acetyl-S-[1-(5-amino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-Lys) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

    The investigators will assess difference in urinary Furan-NAC-BDA-Lys levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BNAC-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

    Time frame: For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.

  5. Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide' Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

    The investigators will assess difference in urinary Furan-NAC-BDA-Lys sulfoxide levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-NAC-BDA-Lys sulfoxide is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

    Time frame: For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.

  6. Assess Difference in Urinary Furan-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.

    Investigators will assess difference between pre-smoking session levels of urinary Furan-BDA-NAL in waterpipe tobacco smokers and post that smoking session. Furan-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

    Time frame: Early morning on day 1 to early morning on day 2.

  7. Assess Difference in Urinary Furan-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.

    Investigators will assess difference between pre-smoking session levels of urinary Furan-BDA-Lys in waterpipe tobacco smokers and post that smoking session. Furan-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

    Time frame: Early morning on day 1 to early morning on day 2

  8. Assess Difference in Urinary Furan-NAC-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

    Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-NAL in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

    Time frame: Early morning on day 1 to early morning on day 2

  9. Assess Difference in Urinary Furan-NAC-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

    Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-Lys in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

    Time frame: Early morning on day 1 to early morning on day 2

  10. Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

    Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-Lys sulfoxide in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-Lys sulfoxide is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session

    Time frame: Early morning on day 1 to early morning on day 2

07

Results

Posted Apr 9, 2025
Limitations and caveats
Smoking duration was shorter for electric head vs charcoal, reducing smoke exposure. WPT smokers smoked alone, not socially, generating less sidestream smoke exposure. Spot urine samples may have underestimated peak levels of benzene and pyrene, due to half-lifes differing among metabolites. Participant use of one type of charcoal, tobacco, WP hoses, and electric heater; convenience sampling; n=50; and participant age 21-35, suggest data may not be representative of WPT smokers in general.

Participant flow

Participant flow — Overall Study
MilestoneWaterpipe Tobacco (WPT) SmokingControl
Started5431
Completed5025
Not completed46
Withdrew: Withdrawal by subject41
Withdrew: Protocol violation05

Outcome measures

PrimaryComparing Cotinine Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

Investigators will assess change in creatinine-adjusted urinary levels of cotinine (a metabolite of the addictive drug nicotine) in ng/mL, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.
Reported as:
Geometric mean · ng/mL
Comparing Cotinine Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
ng/mLCharcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing Cotinine Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head34.9 (24.2 to 50.5)26.4 (18.3 to 38.0)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · Wilcoxon signed-rank test · p = 0.115 · Z score: 1.578
PrimaryComparing S-phenyl-mercapturic Acid (SPMA) Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

Investigators will assess change in creatinine-adjusted urinary levels of SPMA (a metabolite of the human hematotoxicant and leukemogen benzene) in pmol/mL, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.
Reported as:
Geometric mean · pmol/mL
Comparing S-phenyl-mercapturic Acid (SPMA) Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
pmol/mLCharcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing S-phenyl-mercapturic Acid (SPMA) Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head1.35 (0.78 to 2.30)0.34 (0.20 to 0.57)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · z · p = 0.619 · Z: 0.497
PrimaryComparing 1-hydroxypyrene (1-HOP) But Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

Investigators will assess change in creatinine-adjusted urinary levels of 1-HOP (a metabolite of the genotoxic carcinogen pyrene) in pmol/ML, from pre-to post, at each of 2 waterpipe tobacco smoking sessions. For each of the 2 smoking sessions, smokers will provide two first morning spot urine samples--the day of the smoking session and the following morning. The two waterpipe tobacco smoking sessions are as follows: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
On 2 days for each of two smoking sessions, smokers will provide 2 first morning spot urine samples--one urine sample on the morning of the day of the smoking session, and one urine sample on the morning of the following day.
Reported as:
Geometric mean · pmol/ML
Comparing 1-hydroxypyrene (1-HOP) But Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
pmol/MLCharcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing 1-hydroxypyrene (1-HOP) But Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head0.47 (0.34 to 0.65)0.48 (0.35 to 0.66)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · Wilcox and signed rank test · p = 0.085 · Z: 1.720
PrimaryComparing Exhaled Carbon Monoxide Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

measuring exhaled CO using a Micro+ Smokerlyzer® carbon monoxide (CO) monitor for exhaled CO before and after each of two waterpipe tobacco smoking sessions, investigators will determine the differential change, pre-to-post waterpipe tobacco smoking, between heating by charcoal vs heating by electric head

Time frame:
Assessment will be taken immediately before starting to smoke, and immediately at conclusion of each of the 2 smoking sessions.
Reported as:
Geometric mean · Parts per million
Comparing Exhaled Carbon Monoxide Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
Parts per millionCharcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing Exhaled Carbon Monoxide Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head107 (84 to 136)3.5 (2.5 to 4.9)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · Wilcoxon signed rank test · p = <0.001 · Z: 6.154
PrimaryComparing Systolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

The investigators will determine the differential effects of WP smoking practices on change in systolic blood pressure in mm/Hg after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).
Reported as:
Geometric mean · mmHg (Millimeters of mercury)
Comparing Systolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
mmHg (Millimeters of mercury)Waterpipe Smoking - CharcoalWaterpipe Smoking - Electric Head
Comparing Systolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head122 (118 to 125)120 (116 to 124)
Statistical analysis
  • Waterpipe Smoking - Charcoal vs Waterpipe Smoking - Electric Head · Wilcoxon signed rank test · p = 0.253 · Z: -1.144
PrimaryComparing Diastolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

The investigators will investigate the differential effects of WP smoking practices on change in diastolic blood pressure in mm/Hg after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).
Reported as:
Geometric mean · mmHg (Millimeters of mercury)
Comparing Diastolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
mmHg (Millimeters of mercury)Charcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing Diastolic Blood Pressure Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head79 (77 to 81)78 (76 to 80)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · Wilcoxon signed rank test · p = 0.315 · Z: -1.004
PrimaryComparing Heart Rate Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head

The investigators will investigate the differential effects of WP smoking practices on change in heart rate in beats per minute after each of two WP smoking sessions: 1) using charcoal to heat the tobacco, and 2) using a charcoal-free electronic waterpipe head to heat the tobacco.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min).
Reported as:
Geometric mean · Heart beats/minute
Comparing Heart Rate Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head
Heart beats/minuteCharcoal-heated Waterpipe SmokingElectric-head-heated Waterpipe Smoking
Comparing Heart Rate Pre-to-post Change Between 2 Waterpipe Smoking Sessions: Heating Waterpipe Tobacco by (a) Charcoal vs (b) an Electric Head80 (76 to 83)77 (73 to 80)
Statistical analysis
  • Charcoal-heated Waterpipe Smoking vs Electric-head-heated Waterpipe Smoking · Wilcox and signed rank test · p = 0.002 · Z: 3.089
PrimaryAssess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

Investigators will assess change in creatinine-adjusted urinary levels of cotinine (a metabolite of nicotine) in ng/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · ng/mL
Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
ng/mLWaterpipe Smoking - Charcoal HeatedControl
Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal34.9 (24.2 to 50.5)0.02 (0.01 to 0.04)
Statistical analysis
  • Waterpipe Smoking - Charcoal Heated vs Control · Mann-Whitney U rank sum test · p = <0.001 · Z: -7.024
PrimaryAssess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

Investigators will assess change in creatinine-adjusted levels of SPMA (a metabolite of the human hematotoxicant and leukemogen benzene) in pmol/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/mL
Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
pmol/mLWaterpipe SmokingControl
Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal1.35 (0.78 to 2.30)0.17 (0.11 to 0.27)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = <0.001 · Z: -4.541
PrimaryAssess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

Investigators will assess change in creatinine-adjusted urinary levels of 1-HOP (metabolite of the genotoxic carcinogen pyrene in pmol/mL, For a smoking session using charcoal to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will assess difference in urinary cotinine levels between (a) non-smokers vs. (b) waterpipe tobacco smokers after the waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/mL
Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
pmol/mLWaterpipe SmokingControl
Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal0.47 (0.34 to 0.65)0.23 (0.16 to 0.35)
Statistical analysis
  • Waterpipe Smoking · Mann-Whitney U rank sum test · p = .010 · Z: -2.569
PrimaryAssess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

measuring exhaled CO using a Micro+ Smokerlyzer® CO monitor for exhaled CO before and after the heating by charcoal waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

Time frame:
For the smokers: Assessment will be taken immediately before starting to smoke, and immediately at conclusion of each of the smoking session. For the non-smokers: Assessment will be taken at the home visit.
Reported as:
Geometric mean · Parts per million
Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
Parts per millionWaterpipe SmokingControl
Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal107 (84 to 136)2.8 (2.1 to 3.6)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = <0.001 · Z: -7.030
PrimaryAssess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

measuring systolic blood pressure levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · Millimeters of mercury
Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
Millimeters of mercuryWaterpipe SmokingControl
Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal122 (118 to 125)117 (111 to 124)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U test · p = 0.192 · Z: -1.304
PrimaryAssess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

measuring diastolic blood pressure levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · Millimeters of mercury
Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
Millimeters of mercuryWaterpipe SmokingControl
Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal79 (77 to 81)75 (73 to 78)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.033 · Z: -2.136
PrimaryAssess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal

measuring heart rate levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · Beats per minute
Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal
Beats per minuteWaterpipe SmokingControl
Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers Post a Waterpipe Smoking Session, Using Tobacco Heated by Charcoal80 (76 to 83)76 (71 to 81)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.223 · Z: -1.220
PrimaryAssess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

Investigators will assess creatinine-adjusted urinary levels of cotinine (a metabolite of nicotine) in ng/mL. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · ng/mL
Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
ng/mLWaterpipe SmokingControl
Assess Difference in Cotinine Levels Between (a) Non-smokers vs. (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head26.4 (18.3 to 38)0.02 (0.01 to 0.04)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann Whitney U rank sum test · p = <0.001 · Z: -7.024
PrimaryAssess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

Investigators will assess creatinine-adjusted urinary levels of SPMA (a metabolite of benzene) in pmol/mL. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/mL
Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
pmol/mLWaterpipe SmokingControl
Assess Difference in SPMA Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head0.34 (0.20 to 0.57)0.17 (0.11 to 0.27)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.212 · Z: -1.248
PrimaryAssess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

Investigators will assess creatinine-adjusted urinary levels of 1-HOP (a metabolite of pyrene, a polycyclic aromatic hydrocarbon) pmol/ML. For a smoking session using an electric head to heat the tobacco, waterpipe smokers will provide two first morning spot urine samples--the morning of the day of the smoking session and the morning of the following day. The investigators will compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
For smokers: Early morning on the smoking session day to early morning the day after. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/mL
Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
pmol/mLWaterpipe SmokingControl
Assess Difference in 1-HOP Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head0.48 (0.35 to 0.66)0.23 (0.16 to 0.35)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.007 · Z: -2.721
PrimaryAssess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

measuring exhaled carbon monoxide levels before and after the waterpipe tobacco smoking session, investigators will compare the levels between (a) non-smokers and (b) waterpipe tobacco smokers after their smoking session

Time frame:
For the smokers: Assessment will be taken immediately before starting to smoke, and immediately at conclusion of the smoking session. For the non-smokers: Assessment will be taken at the home visit.
Reported as:
Geometric mean · Parts per million
Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
Parts per millionWaterpipe SmokingControl
Assess Difference in Exhaled Carbon Monoxide Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head3.5 (2.5 to 4.9)2.8 (2.1 to 3.6)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.006 · Z: 2.778
PrimaryAssess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

For a smoking session using an electric head to heat the tobacco, investigators will measure systolic blood pressure levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · mmHg
Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
mmHgWaterpipe SmokingControl
Assess Difference in Systolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head120 (116 to 124)117 (111 to 124)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.406 · Z: -0.832
PrimaryAssess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

For a smoking session using an electric head to heat the tobacco, investigators will measure diastolic blood pressure levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration=31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · mmHg
Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
mmHgWaterpipe SmokingControl
Assess Difference in Diastolic Blood Pressure Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head78 (76 to 80)75 (73 to 78)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U ranksum test · p = 0.142 · Z: -1.467
PrimaryAssess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head

For a smoking session using an electric head to heat the tobacco, investigators will measure heart rate levels before and after the waterpipe tobacco smoking session, and compare (a) non-smoker levels with (b) waterpipe tobacco smoker levels after their waterpipe smoking session.

Time frame:
Systolic & diastolic blood pressure and heart rate were assessed multiple times (at intervals>1 min) and averaged. Assessments were at the start and end of each smoking session (mean duration =31 min), or at one point during the non-smoker home visit.
Reported as:
Geometric mean · Beats per minute
Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head
Beats per minuteWaterpipe SmokingControl
Assess Difference in Heart Rate Levels Between (a) Non-smokers and (b) Smokers After a Waterpipe Smoking Session, Using Tobacco Heated by an Electric Head77 (73 to 80)76 (71 to 81)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.551 · Z: -0.596
SecondaryAssess Difference in Urinary L-2-(Acetylamino)-6-(2,5-dihydro-2-oxo-1H-pyrrol-1-yl)-1-hexanoic Acid (Furan-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

The investigators will assess difference in urinary Furan-BDA-NAL levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

Time frame:
For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/ML
Assess Difference in Urinary L-2-(Acetylamino)-6-(2,5-dihydro-2-oxo-1H-pyrrol-1-yl)-1-hexanoic Acid (Furan-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.
pmol/MLWaterpipe SmokingControl
Assess Difference in Urinary L-2-(Acetylamino)-6-(2,5-dihydro-2-oxo-1H-pyrrol-1-yl)-1-hexanoic Acid (Furan-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.131 (111 to 155)112 (91 to 139)
Statistical analysis
  • Waterpipe Smoking · Mann-Whitney U rank sum test · p = 0.431 · Z: -0.787
SecondaryAssess Difference in Urinary Furan-BDA-Lys Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

The investigators will assess difference in urinary Furan-BDA-Lys levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BDA-Lysis a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

Time frame:
For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/ML
Assess Difference in Urinary Furan-BDA-Lys Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.
pmol/MLWaterpipe SmokingControl
Assess Difference in Urinary Furan-BDA-Lys Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.47 (36 to 60)44 (34 to 57)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.515 · Z: -0.652
SecondaryAssess Difference in Urinary N-acetyl-S-[1-(5-acetylamino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

The investigators will assess difference in urinary Furan-NAC-BDA-NAL levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-NAC-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

Time frame:
For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/ML
Assess Difference in Urinary N-acetyl-S-[1-(5-acetylamino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.
pmol/MLWaterpipe SmokingControl
Assess Difference in Urinary N-acetyl-S-[1-(5-acetylamino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-NAL) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.0.05 (0.04 to 0.07)0.01 (0.00 to 0.03)
Statistical analysis
  • Waterpipe Smoking · Mann-Whitney U rank sum test · p = 0. 017 · Z: -2.394
SecondaryAssess Difference in Urinary N-acetyl-S-[1-(5-amino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-Lys) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

The investigators will assess difference in urinary Furan-NAC-BDA-Lys levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-BNAC-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

Time frame:
For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary N-acetyl-S-[1-(5-amino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-Lys) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.
pmol/mLWaterpipe SmokingControl
Assess Difference in Urinary N-acetyl-S-[1-(5-amino-5-carboxylpentyl)-1H-pyrrol-3-yl]-L-cysteine (Furan-NAC-BDA-Lys) Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.4.0 (3.5 to 4.6)2.4 (1.1 to 5.3)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.199 · Z: -1.286
SecondaryAssess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide' Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.

The investigators will assess difference in urinary Furan-NAC-BDA-Lys sulfoxide levels between non-smokers and post a smoking session for waterpipe tobacco smokers. Furan-NAC-BDA-Lys sulfoxide is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples: for smokers, the day of the smoking session and the day following the smoking session; for non-smokers, the day of the home visit.

Time frame:
For smokers: Early morning on day 1 to early morning on day 2. For non-smokers: early in the morning of the home visit.
Reported as:
Geometric mean · pmol/ML
Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide' Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.
pmol/MLWaterpipe SmokingControl
Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide' Between Levels at Post Waterpipe Tobacco Smoking Versus Non-smoker Levels.3.1 (2.6 to 3.6)2.1 (1.8 to 2.5)
Statistical analysis
  • Waterpipe Smoking vs Control · Mann-Whitney U rank sum test · p = 0.002 · Z: -3.091
SecondaryAssess Difference in Urinary Furan-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.

Investigators will assess difference between pre-smoking session levels of urinary Furan-BDA-NAL in waterpipe tobacco smokers and post that smoking session. Furan-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

Time frame:
Early morning on day 1 to early morning on day 2.
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary Furan-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.
pmol/mLWaterpipe Smokers, Pre the Smoking SessionWaterpipe Smokers, Post the Smoking Session
Assess Difference in Urinary Furan-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.128 (111 to 148)131 (111 to 155)
Statistical analysis
  • Waterpipe Smokers, Pre the Smoking Session vs Waterpipe Smokers, Post the Smoking Session · Wilcoxon signed rank test · p = 0.896 · Z: 0.130
SecondaryAssess Difference in Urinary Furan-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.

Investigators will assess difference between pre-smoking session levels of urinary Furan-BDA-Lys in waterpipe tobacco smokers and post that smoking session. Furan-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

Time frame:
Early morning on day 1 to early morning on day 2
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary Furan-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.
pmol/mLWaterpipe Smokers, Pre the Smoking SessionWaterpipe Smokers, Post the Smoking Session
Assess Difference in Urinary Furan-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session.42 (32 to 55)47 (36 to 60)
Statistical analysis
  • Waterpipe Smokers, Pre the Smoking Session vs Waterpipe Smokers, Post the Smoking Session · The Wilcoxon signed rank test · p = 0.717 · Z: -0.362
SecondaryAssess Difference in Urinary Furan-NAC-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-NAL in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-NAL is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

Time frame:
Early morning on day 1 to early morning on day 2
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary Furan-NAC-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session
pmol/mLWaterpipe Smokers, Pre the Smoking SessionWaterpipe Smokers, Post the Smoking Session
Assess Difference in Urinary Furan-NAC-BDA-NAL Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session0.06 (0.04 to 0.09)0.05 (0.04 to 0.07)
Statistical analysis
  • Waterpipe Smokers, Pre the Smoking Session vs Waterpipe Smokers, Post the Smoking Session · Wilcoxon signed rank test · p = 0.026 · Z: 2.233
SecondaryAssess Difference in Urinary Furan-NAC-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-Lys in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-Lys is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session.

Time frame:
Early morning on day 1 to early morning on day 2
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary Furan-NAC-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session
pmol/mLWaterpipe Smokers, Pre the Smoking SessionWaterpipe Smokers, Post the Smoking Session
Assess Difference in Urinary Furan-NAC-BDA-Lys Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session4.0 (3.5 to 4.6)4.0 (3.5 to 4.6)
Statistical analysis
  • Waterpipe Smokers, Pre the Smoking Session vs Waterpipe Smokers, Post the Smoking Session · Wilcoxon signed rank test · p = 0.702 · Z: 0.383
SecondaryAssess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session

Investigators will assess difference between pre-smoking session levels of urinary Furan-NAC-BDA-Lys sulfoxide in waterpipe tobacco smokers and post that smoking session. Furan-NAC-BDA-Lys sulfoxide is a metabolite of furan, a liver toxicant and carcinogen. It will be collected for laboratory assay using two first morning spot urine samples, the day of the smoking session and the day following the smoking session

Time frame:
Early morning on day 1 to early morning on day 2
Reported as:
Geometric mean · pmol/mL
Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session
pmol/mLWaterpipe Smokers, Pre the Smoking SessionWaterpipe Smokers, Post the Smoking Session
Assess Difference in Urinary Furan-NAC-BDA-Lys Sulfoxide Between Levels Pre the Waterpipe Tobacco Smoking Session vs Post the Waterpipe Tobacco Smoking Session3.4 (2.9 to 4.1)3.1 (2.6 to 3.6)
Statistical analysis
  • Waterpipe Smokers, Pre the Smoking Session vs Waterpipe Smokers, Post the Smoking Session · Wilcoxon signed rank test · p = 0.025 · Z: 2.244

Adverse events

Collected over For each of the 50 participants sequentially enrolled as a hookah smoker, the duration of their participation in the study, from enrollment to exit, was three weeks. For each of the 25 participants sequentially enrolled as a non-smoker, the duration of their participation in the study, from enrollment to exit, was one week.. Non-serious events are listed at a 0% frequency threshold.

Adverse event summary by group
GroupDeathsSeriousOther
Waterpipe Smoking0/50 (0%)0/50 (0%)0/50 (0%)
Control0/25 (0%)0/25 (0%)0/25 (0%)

Baseline characteristics

Baseline characteristics were collected only for retained participants (50 smokers; 25 non-smokers) in natural home settings (N=75), who were not disqualified or who were dropouts.

Age, Continuous
Age, Continuous(years)Waterpipe SmokingControlTotal
Mean25.3 ± 3.125.5 ± 4.625.3 ± 3.13
Sex: Female, Male
Sex: Female, Male(Participants)Waterpipe SmokingControlTotal
Female251338
Male251237
Race/Ethnicity, Customized
Race/Ethnicity, Customized(Participants)Waterpipe SmokingControlTotal
White, Caucasian, European11516
Mexican, Hispanic, or Latino16824
Black or African American516
Middle Eastern13013
Asian/Multi-ethnic51116
Highest level of education completed
Highest level of education completed(Participants)Waterpipe SmokingControlTotal
High school718
College, no degree18826
College degree251540
Missing011
Type of natural home setting
Type of natural home setting(Participants)Waterpipe SmokingControlTotal
House301242
Apartment/Townhouse191332
Missing Data101
08

Study locations

1 site
  • Center for Behavioral Epidemiology and Community Health
    San Diego, California 92123, United States
09

References and documents

Publications

  • Kassem NO, Kassem NO, Liles S, Reilly E, Kas-Petrus F, Posis AIB, Hovell MF. Waterpipe device cleaning practices and disposal of waste associated with waterpipe tobacco smoking in homes in the USA. Tob Control. 2020 Feb;29(Suppl 2):s123-s130. doi: 10.1136/tobaccocontrol-2019-054959. Epub 2019 Jul 20. PubMed 31326957 ↗

Study documents

PDFs hosted by the registry, ClinicalTrials.gov.

Individual participant data

Plan to share: No

10

Timeline

Tracking since Sep 25, 2026
ElapsedEstimatedEstimated, not yet reachedSimilar studies: half by the dot; the band is the middle halfHalf of similar studies reached it by the dot; the band is the middle half, from a quarter to three quarters

Ran from Oct 2017 to primary completion in Sep 2018, 11 months.

Results were first posted in Apr 2025, 6 years 6 months after primary completion.

Of 12 interventional studies with no phase under Water Pipe Smoking, half reached primary completion within 9 months of starting (the median), counting those still running; a quarter within 7 and three quarters within 26. This study's 11 months is above that.

How these figures are worked out, and which studies are left out of them.

Registered
Aug 7, 2017
First posted
Aug 18, 2017
StartActual
Oct 20, 2017
Primary completionActual
Sep 25, 2018
CompletionActual
Sep 25, 2018
Results first posted
Apr 9, 2025
Last update
Apr 9, 2025
What these dates mean
Start.
When the first participant enrolled; while estimated, when the study expects to open to recruitment.
Primary completion.
When the last participant was examined or treated to collect data for the study's main question, its primary outcome. A study that stopped early gives the date its data collection stopped.
Completion.
When the last participant's last visit took place, for every outcome, secondary ones and side effects included: the end of the study. Often later than primary completion, sometimes the same day.
Actual and Est.
Actual means the registry says the date has happened. Est. (estimated) is a date the sponsor plans or expects. It can still move, and the sponsor is expected to change it to actual once it has passed.
No changes since tracking began. The registry record was last updated on Apr 9, 2025, before this site started recording changes on Sep 25, 2026. Its history is on ClinicalTrials.gov ↗
11

Registry details

Key details

Study ID
NCT03253653
Responsible party
Nada Kassem (PI, San Diego State University) — Principal investigator
First posted
Aug 18, 2017
Start date
Oct 20, 2017
Primary completion
Sep 25, 2018
Completion
Sep 25, 2018
Results posted
Apr 9, 2025
Last update
Apr 9, 2025

Study contacts

Nada Kassem, DrPH
principal investigator · San Diego State University

Oversight

Data monitoring committee
Yes
FDA-regulated drug
No
FDA-regulated device
Yes
View the source record on ClinicalTrials.gov ↗

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