Waterpipe Smoking and Breast Cancer Risk: The Emerging Need for Research and Prevention

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Mojgan Karbakhsh


Breast cancer, waterpipe, smoking



Breast cancer has now overrun lung cancer as the world's most commonly diagnosed cancer, based on the latest estimates released by the International Agency for Research on Cancer. 1 To prevent an estimated 2.5 million deaths per annum, it is crucial to focus on increasing public awareness for risk reduction and early diagnosis, especially in the regions with increasing rates and unequitable resources. 2 Tobacco smoke is the most important human carcinogen and passive and active smoking is among the known risk factors of breast cancer. 3 Although much evidence exists for a moderate increase in the risk of breast cancer in tobacco smoking women, 45 much less is known about potential association between waterpipe smoking and breast cancer risk. Waterpipe (also known as hookah, hubble-bubble, narghile, shisha, borry or goza) is a form of tobacco consumption where the smoke bubbles through water before reaching the smoker.

The highest rates of waterpipe use have been reported from the Middle East, Asia and Africa, but it has rapidly become an emerging problem in the United States as well as Europe. 6 The reasons for increasing popularity include misconceptions about safety (in comparison to cigarette smoking, as the smoke passes through water,) introduction of flavoured tobacco, social acceptability and lack of waterpipe-specific control policy and regulations. 78 Women and young people seem more likely to be choosing waterpipe over cigarettes, with the prevalence surpassing cigarette smoking in some areas. 8 A typical waterpipe smoking session lasts about 45 minutes to one hour, exposing the active and passive smokers to tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, volatile aldehydes, nitric oxide and heavy metals. 3 A naturalistic study (in a bar setting) among 55 water pipe smokers (43.6% female) demonstrated 73-fold increase in urine nicotine and 2-fold increase in tobacco-specific nitrosamine (NNAL) immediately following waterpipe smoking. 9 Although the impact of these alarming trends are not yet reflected in breast cancer risk, there are some in vitro studies supporting this association. Waterpipe smoke has been shown to induce epithelialmesenchymal transition (EMT) of MCF7 and BT20 breast cancer cell lines, increasing their cell invasion ability in comparison with their matched controls. Also, waterpipe smoke causes a down-and upregulation of E-cadherin and focal adhesion kinase (FAK), respectively, which are considered as vital regulators of cancer progression genes. Waterpipe smoke also activates Erk1/Erk2, which could be the major factor for stimulating epithelial-mesenchymal transition, increasing invasion and the deregulation of E-cadherin and FAK expression. 10 These studies are alarming and call for an urgent need for increasing awareness among women and promoting research in this area.


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