A global prison?
This interview is also available in German, thanks to FORCES Germany. Click here.
In this exclusive interview, expert tobacco researcher Dr Kamal Chaouachi talks to Chris Snowdon about hookah smoking and the anti-smoking movement, and explains why the World Health Organisation has lost its scientific credibility in the field of tobacco.
The World Health Organisation is increasingly turning its attention to the use of water-pipes as a method of tobacco-smoking. For many years, water-pipes ('hookahs', shishas' or 'narghiles') have fallen under the radar of anti-smoking organisations as they battled against cigarettes. This is partly because they are not so widely used in the Western world, and partly because of the long-accepted knowledge that - like pipes, cigars and chewing tobacco - they are significantly less harmful to health.
Dr Kamal Chaouachi (pronounced Sha-wa-shi) is a Paris-based tobacco researcher who is arguably the world's leading expert on the science of hookah smoking. He is a scientific collaborator of various excellence research centres in Asia, Africa and Europe. He also works as a consultant, though he has never been contracted by the pharmaceutical industry or tobacco industry.
Dr Chaouachi has authored or co-authored two comprehensive transdisciplinary books and dozens of biomedical publications including:
-a critique of the WHO expert report on hookah smoking (2006);
-the first world aetiological studies on hookah smoking and cancer (2007, 2008);
-a study on its radiological hazards (2008);
-a 60 page Tetralogy on Hookah and Health (2005, 2006);
-an in-depth critical review of its ETS (Environmental Tobacco Smoke), i.e. passive smoking (2009)
A list of Dr Chaouachi's many articles can be viewed at:
CS: Dr Chaouachi, would you tell me a little about yourself and your work?
KC: I studied physics, chemistry and social science at Paris VII and Paris X Universities. I hold a post-graduate diploma in tobacco science from the University of Paris XI where I also teach French doctors what science says about hookah smoking. I early on specialised in hookah smoking, not cigarette smoking. I have been doing research on tobacco issues, mainly from a medical anthropology perspective.
I was born in Tunisia. I was raised there, in France and the Middle East. Tunisia is an interesting country because this is where I first noticed the hookah scene. In the late 1980s, something unusual happened there: outdoor hookah smoking was banned while indoor puffing remained permitted, not to say encouraged. Perhaps some ministers by that time thought that the sight of grown-ups smoking the hookah in public (particularly on cafe terraces) did not convey a "positive" image to the crowds of tourists who visit this country every year. Little by little, they realised that the latter were actually enjoying hookah smoking so they later forgot about the ban.
CS: Today, countries like Britain and France include hookah bars in their far-reaching indoor smoking bans. Judging by a press release released by the WHO in 2006, one could be forgiven for thinking that cigarettes now play only a minor role in tobacco's mounting death toll. Today, the WHO explicitly declares that all forms of tobacco are equally hazardous. It claims that 5 million people die worldwide from tobacco-related diseases, and predicts that this will double to 10 million by 2020. But the WHO warns that even this estimate may be too low because of an 'epidemic' of water-pipe use, saying:
"Forms of non-cigarette smoking, such as water-pipes, also known as "shishas", "narghiles" or "hubble-bubbles", are gaining wider acceptance around the world, especially among young people in cafes and on college campuses".
According to Dr Charles Warren of the WHO's Global Tobacco Control Program:
"Given the high rates of non-cigarette tobacco use among the young, especially girls, previous estimates of 10 million deaths a year by 2020 could be conservative."
Dr Chaouachi, how seriously do you take these warnings about smokeless tobacco and water-pipes?
KC: As far as tobacco is concerned, WHO is not anymore the independent or objective UN agency bound by a strict ethical mandate. WHO has been recently criticised by independent researchers for having repeatedly issued inadequate expert recommendations (Oxman et al., Lancet, 2007). Leaving aside the question of its recent non-smoking employment policy, it exclusively hires anti-tobacco experts who, most of the time, are affiliated to organisations federated under the umbrella of Globalink, the UICC and Pfizer-sponsored anti-smoking organisations.
Unsurprisingly, this situation is also reflected in the geographic, linguistic and ideological diversity of the WHO Study Group for the regulation of Tobacco Products (TobReg). Until recently, a majority of its members (6 out of 11) belonged to the US anti-tobacco camp. The few non-US members are either in ideological (anti-tobacco) sympathy with their US counterparts or openly follow their line. The Lebanese one is actually affiliated to the US-American University of Beirut. The South African, Dutch and Brazilian seats are in fact very recent and were only created as a direct result of my critiques (about this very lack of diversity)*. Two independent experts there (from India and the United Kingdom) serve as a sort of alibi. However, in the end, decisions are taken by absolute majority.
What the world actually needs is a democratic and independent (from both the pharmaceutical and tobacco industries) scientific council that will be representative of all trends in tobacco research.
CS: And these are the people who dictate WHO tobacco control policy?
KC: These are the individuals who bring the "scientific evidence" for decisions that affect the daily life of hundreds of millions of people around the world. These TobReg members can be found among the speakers in each of the World Conferences on Tobacco or Health held every three years. The last one took place in Bombay in March 2009. There, Gregory Connolly, from the Harvard School of Public Health, a member of Globalink and of course a close colleague of these people, warned there that "qualifying SLT [smokeless tobacco] as reduced harm agent may [...] drive the pharmaceutical industry out of the cessation market and send the wrong message to hundreds of millions of SLT users in developing countries" (Connolly, 2009).
In the field of tobacco, WHO is not doing science anymore but mere propaganda. For instance, you can read on its site, phrases like: "Rigorous research leaves no doubt". Obviously, the function of this narrative style is to let the reader not question the "science" offered to him/her on a golden tray by official experts. Like Connolly, WHO states in one of its reports that all forms of tobacco are equally hazardous, "deadly" to be more accurate. This is nonsense. A moist snuff like the Swedish Snus, is, in the view of prominent international experts, highly recommendable all the more that it is also very low in carcinogenic substances. In a broad harm reduction perspective, its use should be encouraged, particularly in Asia and Africa. This is what we did in our study on hookah smoking and cancer.
CS: So how dangerous are water-pipes to the user?
KC: I have been at odds with WHO experts because they have published two (yes, two) reports on hookah smoking which contain very serious scientific errors. The most famous was prepared by the "waterpipe" experts of the US funded Syrian Centre for Tobacco Studies whose logo is a hookah and whose studies almost all focus on "waterpipe". The WHO report was also prepared by the US-American University of Beirut with direct inputs ("several layers of peer-review") from the TobReg experts.
All these experts showed to the world that they were ignorant of the fact that the smoking mixture in a modern hookah (as it is used in Europe or the USA) is not burnt but heated to a great extent. This "detail" has tremendous chemical consequences because, in the end, the smoke is much less complex than that generated by a cigarette. Indeed, I had to emphasise that only a few hundred compounds vs. a few thousand were found in both cases.
The WHO report ("Advisory Note" in their jargon) is stained with errors of the same size, quotations from erroneous and biased studies, after they were all carefully "cherry picked". They not only blacklisted my early comprehensive publications (among them a 420 page 850 footnote transdisciplinary doctoral thesis on the very subject) but also hookah studies led by international prestigious tobacco (cancer) specialists of the past decades (Hoffmann, Wynder, and many others).
Furthermore, for two years, the head of the US-Syrian Centre had not declared his actual co-authorship of the report. I have nothing against funding by US institutions. However, I have seen how the staff in charge of selecting tobacco projects in the "developing world" and channelling the related funding always have a prohibitionist objective**.
CS: How flawed was that WHO report, and what effect did it have?
KC: Can you imagine a WHO report in which the first two sentences contain a misquotation and a huge error? Yet, I early warned Dr Lee, the former Director General of WHO, that the situation was going to worsen should they not allow a democratic exchange of views on this burning issue (Letters 15 Dec 2005 and 31 Mar 2006).
Indeed, I did not want to publish my critique of the WHO report, which was my first substantial biomedical publication on this issue. The dates and the contents of my letters to Dr Lee show I was compelled to do it. Notably, I concluded with these words:
"Finally, if no action were quickly taken, I am afraid this widely advertised erroneous report will have tremendous counter-effects. On the one hand, it will disrepute the work of a United Nations agency. On the other, it will make hookah smoking even more fashionable."
Sadly enough, this is what happened. I sometimes receive calls from public health officials around the world who are scared by the growing use of hookah in their country. Some of them now ask me: what solution do you see? I answer that censorship does not work and they are harvesting the rotten fruits of "waterpipe" experts' stubbornness for eight years now. Hookah users, and particularly teenagers, have seen how these experts have made huge mistakes and many of them felt they have been deceived. Fear-mongering proved, once again, to be counter-productive.
A whole system is responsible for this situation: WHO, Globalink, journals like Tobacco Control, Nicotine and Tobacco Research, Addiction, The Cochrane Review, and many others in direct or indirect connection with these people.
You began the interview by citing Charles Warren. For your information, he has himself co-authored an article published in the International Journal of Public Health ("As if cigarettes were not enough, here comes narghile"), an officially peer-reviewed journal. His paper gives a rosy picture of a previous publication in the same journal in which, among numerous serious errors, the authors (Yunis et al.) take one smoking product for the other and, more picturesquely, consider Tunisia as a country of the Middle East.
In view of what I said, I can only answer your question "How dangerous are water pipes to the user?" by: What the "waterpipe" experts have actually demonstrated is that they, themselves, are the problem, much more than the "waterpipe" itself. How can a device in which the smoking mixture is only heated (to a great extent) be equivalent to 400 or 200 cigarettes as these well-regarded scientists have claimed? It's time for accountability in this field.
CS: What about the issue of secondhand smoke? There is a growing belief that all forms of tobacco are equally dangerous and the smoking bans of places like France and Britain are based - in part - on Surgeon General Carmona's famous claim that "there is no safe level of secondhand smoke".
The bans have, of course, been disastrous for the shisha bars, even more so than for the pubs. Do you think these bans are scientifically justified?
KC: For a long time, I did not pay attention to Environmental Tobacco Smoke because I was too naive or too busy or both. In the UK, the ban on hookah smoking was scientifically touted by doctors who published a tribune in the British Medical Journal (Gatrad et al., 2007).
Once again, I was slow to realise why they did it. I first focussed on the "evidence" about health effects and found numerous serious errors in their review. Then, in my recent call to lift the UK ban, I showed that they have literally invented the hazards of hookah "passive smoking", together with WHO experts who say that "second-hand smoke from waterpipes [...] poses a serious risk for non-smokers."
The American Lung Association and the French INPES (Institut National pour la Prevention et l'Education a la Sante) resorted to faking (photo-montages) posters and images showing hookahs emitting passive smoke [see right and below]. Of course, they do not.
Just imagine that tomorrow the American Lung Association publishes in the mainstream media a poster showing smoke stemming from a mysterious hole in the middle of a cigarette rod and that it raises fears about Fourth Hand Smoke. How would you react? This is what they actually did with hookah.
CS: So what is hookah ETS made up of?
KC: Firstly, most of hookah ETS is made up of Exhaled Mainstream Smoke (i.e. the smoke that comes out the smoker's mouth). Secondly, it is much less complex than cigarette smoke because the tobacco-molasses based mixture is only heated (the temperature inside the bowl of the hookah does not go in excess of 200 degrees C) while at the tip of a cigarette, the tobacco is burnt at about 900 degrees C. This has tremendous chemical consequences, as I said before. Furthermore, the smoke is mainly made up of water and glycerol (80-90%) which are biologically inactive. These hard facts have always been glossed over by anti-smoking researchers.
As for ETS from cigarettes themselves, I recently stressed in a call to lift the UK smoking ban that:
"it appears that the epidemiologic sources on which some corresponding European laws relied, were either manipulated or unscientific. Enstrom and Kabat have carried out a study whose conclusions do not apparently support any similar law in the USA or elsewhere. In these conditions, it is amazing to hear of ETS (Environmental Tobacco Smoke) hazards caused by a device known to produce NO side-stream smoke, unlike cigarettes".
Fortunately, I have recently published a comprehensive critical review of what sound science says about hookah and cigarette Environmental Tobacco Smoke. It was not easy to publish it. External "pressures", so to speak, (likely by a peer-reviewer) tried to block the publication of my article by warning the Editors (who are independent scientists, I insist) that:
"It would be very injurious for the scientific community to give a larger audience to Chaouachi by accepting his manuscript for publication in the Int J Environ Res Public Health: such publications are indeed frequently used by the tobacco industry to entertain the controversy about the health effects of the various forms of tobacco use."
CS: It seems the peer-review process is not what it was.
KC: The whole system of peer-review is perverted, much more in the field of tobacco research than in others because of huge global commercial interests (mainly, these days, from the pharmaceutical industries). In a few words, because many things have been written on this issue, most of the time, the so-called "peer-reviewers" do not play their role of assessing a manuscript for its mere scientific merit but rather take the decision to bash it only because its author(s), title, abstract or conclusions do not conform with "their standard", i.e. their prohibitionist ideology.
No need to say that the market of tobacco research is dominated by three main journals (Tobacco Control, Nicotine and Tobacco Research, Addiction) which absolutely do not deserve the "aura" or "prestige" they enjoy (among antismoking researchers only).
They have published papers (at least I can say this in my field of specialisation, hookah smoking) with very huge serious errors. The WHO flawed report (which was based on some of them) is only the tip of the iceberg of this destructive underground trend.
Interestingly, a recent paper published in the Journal of Biology (Virginia Walbot: "Are we training pit bulls to review our manuscripts?") sounds very relevant. It would show that there has been a qualitative evolution in this field: from watchdogs to pitbulls...
CS: Although you are a leading tobacco researcher, you began to fall out with the anti-smoking movement when you were kicked off Globalink on three occasions. I believe that you were twice 'rehabilitated'.
For the benefit of those who are not familiar with it, can you tell us what Globalink is and what you said to annoy some of the people on there?
KC: Globalink is a network of some 6,000 antismoking experts/organisations across the world mainly formed of discussion lists broken down according to language, countries, regions of the world, sub-regions, topics (general, ETS, harm reduction, etc.). When a public health officer in, let's say Ukraine or Kuala-Lumpur, wishes to implement a ban on smoking, he posts a message in Globalink to request help for providing the "scientific basis" (from their jargon) to her/his Ministry of Health. He generally receives quick and documented responses (e.g. from US or European counterparts) on how to proceed.
I was expelled from it three times mainly because I naively and openly criticised the poor science on which the smoking bans in the US, UK and Thailand relied.
When a decision is taken to expel or rehabilitate a "dissident" there, no reason is given. This is a completely irrational process and people there are simply afraid to voice any dissent. So, you never know and they themselves do not know.
CS: Dr Michael Siegel has also been removed from the group in much the same way.
KC: I had never heard of Dr Siegel until I finally quit this organisation of intolerant people. I stumbled one day on his blog and realised that he had also been expelled for the same kind of non-reason.
Similarly, I had never paid attention to organisations defending the victims of the anti-smoking propaganda. Little by little, I discovered Forces, heard of what anti-smoking researchers did to Enstrom and Kabat and so on. The fact is that I focused on other things and I did not know that passive smoking was so "important". As I told you, I was so isolated - and still am- in my research and I was kept busy by trying in vain to clarify things and clear up confusion in an asymmetric showdown. I later understood (perhaps I am wrong) that Dr Siegel was ousted from Globalink for his position on this very issue (ETS).
CS: Dr Siegel has said several times that he believes that the tobacco control movement today has become intolerant of any opinion that does not fit the rigid aims of a movement that has become largely prohibitionist. Is this fair?
KC: Like him, I have used the "tobacco control" phrase and even naively used it to describe my activity as a researcher. I realised only later how this phrase hurts the victims of the hygienists.
Of course, I do not use the "Tobacco Control" phrase with the meaning of "Tobacco Kontrol" ("controlling smokers and their suppliers" according to Pierre Lemieux' cogent critiques). Instead, I use it with a diametrical point of view: that of the broad traditional meaning of "drug control." In my daily practice, this non-prohibitionist notion means the control over the quality of products (cigarettes, cigars, etc.) that also implies a systematic decriminalisation of harm reduction solutions (Eclipse cigarette, Swedish Snus, No-Carbon Monoxide hookah, etc.) and, not the least, a rejection of the growing related junk science that stained the credibility of science and public health.
However, the position of Dr Siegel, with whom I have never had any special direct contact, is somewhat different. I have noted that he emphasises the original meaning of "tobacco control" and relevantly raises the question of accountability. He still believes that what he calls the "tobacco control movement" can be rectified. But unless the groups who have got the power over the crowds are forced to leave their positions, I see it as impossible. A totalitarian system has been put in place and, should it hopefully collapse, we could not go on using the "tobacco control" phrase as if nothing had happened.
CS: How would you describe the prevailing mindset of Globalink and the people, like Simon Chapman, who run it?
KC: Simon Chapman has been for ages the Editor-in-Chief of the Tobacco Control journal and simultaneously policy officer (an euphemism for "Big Boss") of Globalink. This shows that there is no independence between each other. Chapman should acknowledge this undeclared "private" conflict of interest: that he is the iron fist in the velvet glove of the "respectable" Globalink and "well regarded" "peer-reviewed" "good science" produced by his own journal. This is also true for other journals working towards the same objective: Nicotine and Tobacco Research (David Balfour) or Addiction (Robert West). Most of the latter's staff, and of many other powerful structures (WHO TobReg, WHO TFI, etc.), are members of Globalink. This has a great importance because the world tobacco policy, that affects hundreds of millions of people, is, as I said, drafted by WHO TobReg but also discussed inside Globalink.
I concluded a recent paper with the following statement:
"it is [time] for all independent scientists in all fields of cigarette and hookah research (smoke chemistry, ETS, addiction, smokeless products, harm reduction, etc.) to think over the feasibility of setting up an international parallel network, similar in its structure to Globalink. This should bring back the necessary balance and avoid tragic drifts in science, ethics and politics."
CS: Two recent papers have accused scientists who criticise the more outlandish studies to have come out about passive smoking of being 'dissidents' and 'denialists'. Some of these 'dissidents' have found themselves the victims of ad hominem attacks and personal abuse. Have you experienced any of that?
KC: When responding to objections, one of the classic arguments of anti-smoking researchers is to accuse proponents of heterodox views of holding "conflicts of interest" with the tobacco industry. The other argument is repetition so that "almost always, the side that responds to challenges is telling the truth, while the side that just repeats themselves and talks around the argument is not." (Carl Phillips, Tobacco Harm Reduction).
As for the recent publication on "denialism" you refer to, failure to acknowledge the "overwhelming consensus on the evidence" about the huge hazards of ETS on non-smokers now qualifies for "denialism" (Diethem and McKee, European Journal of Public Health, 2009). Paradoxically, the chief author of the last paper, which also stresses the need to "test the strengths and weaknesses of the differing views," did not realise that he himself published a document on hookah ETS in which he took a study on active smoking for one on passive smoking! He also went so far as declaring, among other numerous errors, that hookah ETS is even more dangerous than cigarette ETS (Diethelm, 'Narguile, attention danger', 2007).
CS: What do you think the priorities for the anti-smoking movement should be in 2009? Can it re-establish its scientific credibility, and if so how?
KC: I don't care for their "anti-smoking" priorities. I know that tobacco is not an innocent product, that it is dangerous and can become very dangerous too, so I am interested only in real hazards, diseases and facts. Just have a look at the agenda of the FCTC (Framework Convention for Tobacco Control). Their "priorities" mean more and more prohibitive measures (bans on smoking in homes, streets, cars, etc.) that, if not clearly stated in order not to scare people, will always be "in agreement" with the FCTC ratified by most of the States of the world.
In sum, I was slow to understand another poster advertised by WHO ["Smoke-free inside", see above]. At first, I did not react because I believed it represented a bubble (of oxygen, of course). Then, one day, I realised that it clearly shows the Earth with not a single spot left on it for smoking. I wondered: Is this what they are eventually aiming for, a global prison?
8 April 2009.
- Chaouachi K. Hookah (Shisha, Narghile) Smoking and Environmental Tobacco Smoke (ETS). A Critical Review of the Relevant Literature and the Public Health Consequences. International Journal of Environmental Research and Public Health. 2009; 6(2):798-843.
- Chaouachi K. Letter to Dr Lee, former DG, WHO. 31 Mar 2006.
- Connolly G. World Conference on Tobacco or Health (Bombay, 9 March 2009):
- Diethelm, P, McKee, M. Denialism: what is it and how should scientists respond? Eur J Public Health. 2009; 19:2-4.
Relevant comment: http://eurpub.oxfordjournals.org/cgi/eletters/19/1/2#114
- Gatrad R, Gatrad A, Sheikh A. Hookah smoking. BMJ 2007 Jul 7;335(7609):20.
- Lemieux P. Tobacco Kontrol. Laissez Faire Electronic Times 2002 (17 Oct)
- Mokdad AH, Warren CW (2007). As if cigarettes were not enough, here comes narghile. Int J Public Health 52 (5):263-4.
- Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9. Comment: Chaouachi K. Pessimism about a Possible Change in WHO Expert Recommendations. The Lancet Early Online Publication 2007 (14 May). Comment on: Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. The Lancet Early Online Publication 2007 (9 May). DOI:10.1016/S0140-6736(07)60675-8
- WHO (World Health Organisation)/TobReg. New Composition 2009:
- World Health Organisation/TobReg. Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Advisory Note, 2005.
* KC: "Of course, no biomedical journal, even the most progressive, would dare take issue when it comes to such a political critique. Keep in my mind that having the critique of the WHO report published remains in itself a miracle. When TobReg members sent comments to the journal in which it appeared (Journal of Negative Results in Biomedicine), I felt that the Editor-in-Chief was very concerned and disturbed. For instance, he has not accepted to publish a response by independent researchers who supported my position. I understood that he wished to quickly put an end to the comments. Please also note that my critique proved to be very popular since it is the most viewed article there. Therefore, I understand that the recent changes in the geographical distribution (only geographical because no new independent expert was included) are a result of my written interventions: my Letter to Dr Director-Gal WHO to demand the dissolution (winding up) of WHO TobReg (7 Sep 2007) for instance."
** KC: "A recent paper based on a survey in "post-occupation" Iraq is, once again, a good example of the kind of financial and "scientific support" a US institution such as the Centers for Disease Control (together with WHO) can bring. The paper is full of errors and cite seriously erroneous papers (references 2, 5, 6, 7: Maziak (Time for action); Prignot, Sasco et al. (citing itself a plagiarised material); etc.)]
I invite readers to go to
and check by themselves."
Centers for Disease Control and Prevention (CDC). 'Tobacco use among students aged 13-15 years--Baghdad, Iraq, 2008'. MMWR Morb Mortal Wkly Rep. 2009 Apr 3;58(12):305-8.