To the Editor:
We note the Brief Communication “Water pipe smoking-associated carbon monoxide poisoning” from Türkman et al., published in this issue and wish to report that water pipe () smoking is an old tradition in the Middle East that has been considered quite harmless. The use of water pipes is spreading among young people in the Western world,Citation1 but with a different pattern of smoking habits. The tobacco used is most often molasses tobacco mixed with different flavourings, such as apple, cinnamon, or ginger. Drugs such as cannabis and spice are normally not involved. A widespread misconception is that the water is purifying the smoke, thereby making it harmless.Citation2 The Swedish Poisons Information Centre has been consulted on three separate occasions during 2010–2011 regarding serious carbon monoxide (CO) poisoning caused by water pipe smoking. We present these three cases.
Fig. 1. Picture (right) showing a traditional water pipe bought on the Internet. Schematic picture (left) showing the construction of a water pipe and its fundamental function (see colour version of this figure online).
A 15-year-old girl was smoking water pipe during three consecutive days. After the first session, she had no symptoms. Day two, she became dizzy and got a headache after smoking. The third day, she was smoking intensively for 15 min when she became nauseous and stopped. Subsequently, she became dizzy, had a headache, and 1 h after the smoking session she became unconscious. Immediately afterwards she had a short generalised seizure, vomited, and then woke up. The patient presented at the emergency room 1 h and 30 min after smoking. She was then confused, answered questions with delay, and complained of headache. An arterial carboxyhaemoglobin (COHb) sample, taken 2 h and 40 min after smoking, showed 21%. She was treated with 100% normobaric oxygen and the a-COHb had dropped to 1% at 8 h post smoking. At follow-up, she displayed no sequelae.
A 28-year old healthy man was in a habit of smoking waterpipe on his balcony. This time he was smoking outside a friends apartment. After the session he felt dizzy and cold, and soon thereafter he became unconscious. During immediate transport to the hospital, he gradually woke up. At the emergency room, he complained of headache and was unable to lift his arms and legs from the stretcher. An arterial COHb sample taken 1 h after smoking showed 32%. The patient was treated with hyperbaric oxygen and was discharged 2 days later in good condition.
A 16-year old previously healthy boy was smoking water pipe outside in the evening during 45 minutes. After smoking, he went inside and subsequently became dizzy, got a headache and felt shaky in his legs. His mother saw him fainting on three occasions over the next 30 min. The patient presented at the emergency room 1 h and 15 min after smoking. He was then awake but answered questions with delay, and complained of headache and nausea. A neurological examination was unremarkable. Oxygen supply was given and after a poison centre consultation, an arterial COHb sample was taken 2 h after smoking and showed 23.7%. Normobaric 100% oxygen was then delivered through a CPAP device over 6 h. At follow-up two and a half weeks later, he displayed no sequelae.
Two similar cases of CO poisoning associated with water pipe smoking have previously been reported.Citation3,Citation4 Several explanatory factors may contribute to the development of CO poisoning: a higher CO content per smoke volume compared to cigarettes due to incomplete combustion of tobacco and embers;Citation5,Citation6 a much larger volume of each water pipe inhalation because of low and comfortable smoke temperature;Citation6,Citation7 and, probably, a more intense way of smoking water pipe among young people in the Western world compared to traditional users in the Middle East.Citation2 Water pipe smoking involves a risk of serious CO poisoning.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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