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ORIGINAL RESEARCH
Systemic Inflammatory Markers Among Waterpipe
Smokers, Cigarette Smokers, and Nonsmokers
Bhavita Kumari, MPH, MBBS, Syeda Kanwal Aslam, MSc, MBBS, Sidra Zaheer, MSc,
Syed Omair Adil, MS, and Kashif Shafique, PhD, MPH, MBBS
Downloaded from https://journals.lww.com/journaladdictionmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3mH5nK33R3QgM5C+F6MSjRBdhsJWzrJhQPRbLfg9hr00= on 09/26/2018
Objective: To determine the levels of neutrophil to lymphocyte ratio
(NLR) and platelet to lymphocyte ratio (PLR) among exclusive
groups of waterpipe (WP) smokers, cigarette smokers, and non-
smokers.
Methods: This cross-sectional study was conducted among adults,
apparently healthy individuals, aged between 18 and 40 years of
either gender. NLR and PLR as measures of systemic inflammation
were studied in association with individuals’ sociodemographic,
health, and tobacco use related characteristics. The results of linear
and logistic regression models were reported as crude and adjusted
beta coefficients and odds ratios with 95% confidence intervals (CIs).
Results: Out of 190 participants, 34.2% (n ¼ 65) exclusively smoked
WP, 32.6% (n ¼ 62) smoked cigarettes, and 33.2% (n ¼ 63) were
nonsmokers. The mean NLR and PLR were significantly higher
among WP smokers when compared with nonsmokers; however, the
comparison between WP smokers and cigarette smokers for both
NLR and PLR was not statistically significant. The odds of raised
NLR was 4.40 times higher (AOR ¼ 4.40, 95% CI ¼ 1.97, 9.85), and
the odds of raised PLR was 3.48 times higher (AOR ¼ 3.48, 95%
CI ¼ 1.60, 7.57) for WP smokers compared to nonsmokers.
Conclusions: WP smoking has a significant association with sys-
temic inflammation as measured by NLR and PLR. The study and
existing evidence implicate an urging need to regulate WP industry
and its policies.
From the School of Public Health, Dow University of Health Sciences (BK,
SKA, SZ, KS); Department of Research, Dow University of Health
Sciences, Karachi Pakistan (SOA); Institute of Health and Wellbeing,
Public Health, University of Glasgow, Glasgow, UK (KS).
Received for publication November 10, 2017; accepted June 10, 2018.
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
Informed consent: Informed consent was obtained from all individual par-
ticipants included in the study.
The authors declare that they have no conflict of interest.
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions
of this article on the journal’s Web site (www.journaladdictionmedici-
ne.com).
Send correspondence to Kashif Shafique, PhD, MPH, MBBS, Institute of
Health and Wellbeing, Public Health, University of Glasgow, 1-Lilybank
Gardens, Glasgow, UK. E-mail: kashif.shafique@glasgow.ac.uk
Copyright ß 2018 American Society of Addiction Medicine
ISSN: 1932-0620/16/0000-0001
DOI: 10.1097/ADM.0000000000000446
J Addict Med  Volume 00, Number 00, Month/Month 2018
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
Key Words: inflammatory markers, tobacco, waterpipe smoking
(J Addict Med 2018;xx: xxx–xxx)
W aterpipe smoking is on the rise in many countries and is
replacing cigarettes. Numerous efforts have been
directed toward examining the adverse health effects of
waterpipe (WP) smoking. The smoke inhaled during a single
session of WP smoking is said to have several folds higher
dose of tobacco-related toxicants in comparison to cigarette
smoke. It is justly speculated that WP-related health effects
can be similar to those of cigarette smoking and even worse
(Eissenberg and Shihadeh, 2009; Shihadeh et al., 2015).
However, there is a dearth of evidence related to long-term
effects of WP smoking (Maziak et al., 2014).
One of the several explanations given for the biological
plausibility of the etiological link between cigarette smoking
and chronic diseases is tobacco smoke-mediated systemic
inflammation (Krüger et al., 2015; Shiels et al., 2014). Several
studies have reported that systemic inflammation may be one
of the precursors for several chronic diseases, including
diabetes mellitus, cardiovascular disorders, and cancers (Fol-
som et al., 1999, 2002; Nakanishi et al., 2002; Pitsavos et al.,
2007). Thus, it can be speculated that WP smoking may also
be associated with these chronic diseases plausibly mediated
through its systemic inflammatory effects.
Varieties of biochemical and haematological markers
are available to measure the systemic inflammation.
Although, novel disease-specific biomarkers have been iden-
tified, most of which are time consuming and expensive.
Neutrophil to lymphocyte ratio (NLR) and platelet to lym-
phocyte ratio (PLR) could be an important measure of sys-
temic inflammation as it is cost-effective, readily available
and easily calculated. Recent studies have reported that higher
NLR and PLR are not only associated with different malig-
nancies and cardiovascular diseases but also influenced by
demographic, lifestyle and environmental factors as well
(Durmus et al., 2015; Lin et al., 2016; Yodying et al.,
2016). It has been reported that WP smoking affects leukocyte
and platelet count, coagulation, and lipid profile (Al-Dahr,
2010). However, studies on the prognostic significance of the
relationship between elevated NLR and PLR with WP smok-
ing are scarce; we thus aim to examine the association of WP
smoking with systemic inflammation. Further the specific
objective of the study was to measure and compare levels of
neutrophil to lymphocyte ratio and platelet to lymphocyte
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Kumari et al.
ratio among exclusive groups of WP smokers, cigarette
smokers, and nonsmokers.
METHODS
Study Setting and Participants
This cross-sectional study was conducted among adults
in Karachi, the largest metropolitan city of Pakistan, with a
population of more than 20 million people. Waterpipe smok-
ing is gaining popularity as a trendy social substance abuse
among the metropolis dwellers and is being readily accepted
as a norm, as roots of WP origin lie in the Indian subcontinent
(Maziak et al., 2004). A recent study reported almost quarter
of university students regularly smoke WP (Jawaid et al.,
2008).
Ethical Considerations
The study was approved by the institutional review
board (IRB No: IRB-536/DUHS/-14). The participants were
detailed about the study objectives, data collection, sample
collection procedures, and possible side effects. The partic-
ipants were assured of their autonomy, confidentiality, and
right to withdraw from the study at any time. They were
recruited after signing an informed consent form.
Sampling Technique
The current WP smoking university students were used
as starting point for the snowball sampling to reach potential
participants. A comparison group was also recruited as a
control group, which was apparently similar to those in
WP smoking group but did not smoke any form of tobacco.
Furthermore, a comparison group of cigarette smokers was
also included who were currently exclusive cigarette smokers.
Inclusion/Exclusion Criteria
Apparently healthy individuals, aged between 18 and
40 years, who were eligible to be in one of the 3 groups, that is,
WP smokers, cigarette smokers, or nontobacco smokers group
criteria (operational definitions provided below), were
included in this study. Pregnant or lactating women and
individuals with any self-reported noncommunicable disease,
namely, diabetes, hypertension, cardiac disease, blood disor-
ders, liver or kidney disease, recent infection, fever, or
ingestion of medications (within past 14 days); were
excluded.
Data Collection
A structured questionnaire using standardized Global
Tobacco Surveillance System (GTSS) was used to collect
sociodemographic, and tobacco use related information
(CDC). Furthermore, a trained qualified nurse from public
sector university hospital carried out a physical examination
and collected blood samples. A blood sample was collected
from the ante-cubital vein with a 3-mL syringe without using a
tourniquet. Blood was collected in an ethylene diamine tetra
acetic acid tube and shaken properly, inverting the tube 3 to
4 times, as to avoid coagulation. Samples were stored at room
temperature and tested for complete cell blood count in an
automated Abbott—Cell Dyne Ruby analyzer.
2 ß
Copyright © 2018 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.
J Addict Med  Volume 00, Number 00, Month/Month 2018
Operational Definitions
Exposure
Waterpipe smoker was defined as a person who had at
least one WP session per month in the last 6 months. Non-
smoker was defined as a person who has not smoked WP or
cigarette in the last 6 months. Whereas, a cigarette smoker
was defined as a person who has smoked >100 cigarettes, and
is currently smoking every day or >3 days per week.
To avoid duplication, only those participants were
considered who reported the exclusive use of WP or cigarette
smoking, and those participants using both types of tobacco
were excluded from the study.
Outcome
NLR and PLR have been calculated as follows:
Total number of neutrophil
NLR ¼
Total number of lymphocyte
Total number of platelet
PLR ¼
Total number of lymphocyte
The values were read on a continuous scale, dividing it
in 2 groups using median cutoff.
Study Variables
The 2 diagnostic ratios, NLR and PLR, were taken as
outcome variables. The outcome variables were studied in
association with individuals’ sociodemographic, health, and
tobacco use related characteristics (independent variables).
Statistical Analysis
Descriptive characteristics were reported as frequencies
and percentages (categorical variables); and means and stan-
dard deviations (continuous variables). Nonparametric anal-
yses including Kruskal-Wallis and Chi-square test were used
to assess the associations between 3 groups and all other study
variables. Kruskal-Wallis test (P < 0.001) suggested very
strong evidence of a difference between mean ranks of at least
one pair of groups. As multiple tests are being carried out,
Dunn’s Bonferroni corrections used to correct for inflated
type 1 error rates associated with multiple comparisons
applying for continuous outcomes NLR and PLR both
(Kao and Green, 2008).
Associations of tobacco smoking status and systemic
inflammatory markers were further assessed using univariate
and multivariate linear regression models; the NLR and PLR
were taken as the outcome. In multivariate linear regression
analyses, results were adjusted for age, sex, marital status,
education level, income level, physical activity, blood pres-
sure, heart rate, and waist circumference, and were reported as
beta coefficients, standard errors with 95% confidence inter-
vals (CIs) and P values.
Furthermore, the diagnostic ratios were also divided
into 2 categories, using the median as the cutoff. NLR of
1.47 was coded as low, and >1.47 as high; PLR of >107.35
as low, and >107.35 as high. Univariate and multivariate
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J Addict Med  Volume 00, Number 00, Month/Month 2018 Waterpipe Smoking and Its Association With Systemic Inflammation

binary logistic regression analyses were then conducted,
and results were reported as crude and adjusted odds
ratio, with 95% CI and their corresponding P values. In
multivariate logistic regression analyses, results were also
adjusted for age, sex, marital status, education level, income
level, physical activity, blood pressure, heart rate, and
waist circumference.
RESULTS
A total of 250 individuals were invited for participation in
the study, 200 consented to participate (response rate ¼ 80%).
Ten individuals were excluded due to ineligibility, and final
analysis was based on 190 participants. Among participants,
34.2% (n ¼ 65) exclusively smoked WP, 32.6% (n ¼ 62%)
smoked cigarettes, and 33.2% (n ¼ 63) were nonsmokers.
Basic Health Characteristics
Furthermore, regarding basic health characteristics of
participants, 77.4% (n ¼ 147) of them were not involved in
any physical activity; participants had a mean heart rate of
91.03 beats/min; 119.39 mm Hg mean systolic blood pressure,
and 77.84 mm Hg mean diastolic blood pressure; and mean
waist circumference of 30.65 in. No statistically significant
differences in baseline characteristics were observed between
the 3 groups of WP smokers, cigarette smokers, and non-
smokers (Table 1).
Social Characteristics of Waterpipe Smokers
Mean age of starting WP among WP smokers was
18.74 years, and mean frequency of WP use was 6.89 times
per month, with mean puff frequency in one session being
23.88. The mean duration of a single session was 2.2 hours. A
majority (72.3%) of participants smoked it in the company of
friends, while 15.4% took it mostly with family, and 12.3%
smokers reported smoking WP alone. Most of the participants
(70.8%) smoked WP at cafes or restaurants and considered the
availability of WP smoking facility while choosing a restau-
rant (data not shown).
NLR and Tobacco Smoking Status
The mean NLR varied significantly according to
tobacco smoking status among participants (P < 0.01). The
mean NLR was highest among WP smokers as compared to
cigarette smokers (P ¼ 0.124, adjusted using the Bonferroni
correction), and nonsmokers (P < 0.001, adjusted using the
Bonferroni correction) (Table 1, Table S1, http://links.
lww.com/JAM/A91). Results of univariate linear regression
analysis (Model 0) indicate that WP smoking status was
positively associated with increased NLR (Beta ¼ 0.58,
95% CI 0.23, 0.93, P < 0.01) as compared to nonsmoking,
and this association remained the same after the adjustment of
all other factors in Model 1 (Beta ¼ 0.61, 95% CI 0.25, 0.96,
P < 0.01). It is also noted that the positive unit change of NLR

TABLE 1. Descriptive Characteristic of Respondents According to Smoking Status (n ¼ 190)

Waterpipe Smokers (n ¼ 65) Cigarette Smokers (n ¼ 62) Nonsmokers (n ¼ 63)
Characteristics Mean  SD Mean  SD Mean  SD P
Inflammatory markers
NLR 1.73  0.79 1.48  0.61 1.15  0.58 <0.01
PLR 117.38  42.62 108.66  31.89 98.27  43.81 <0.01
Blood pressure
Systolic 120.46  16.83 121.69  17.10 116.03  15.50 0.13
Diastolic 78.62  10.84 78.63  11.02 76.27  8.56 0.47
Heart rate 90.69  15.38 91.58  16.95 90.84  16.01 0.98
Waist circumference 31.02  3.46 31.18  3.10 29.76  3.15 0.08
Moderate physical activity, min/wk
138.57  70.88 157.50  45.10 185.59  60.97 0.10

n (%) n (%) n (%) P

Age
<25 years 41 (31.8) 42 (32.6) 46 (35.7) 0.48
25 years 24 (39.3) 20 (32.3) 17 (27.9)
Gender
Male 54 (34.8) 54 (34.8) 47 (30.3) 0.18
Female 11 (31.4) 08 (22.9) 16 (45.7)
Marital status
Single 55 (33.7) 53 (32.5) 55 (33.7) 0.90
Married 10 (37.0) 09 (33.3) 08 (29.6)
Education level
School (12 years) 17 (39.5) 12 (27.9) 14 (32.6) 0.85
Graduate (13–16 years) 44 (33.6) 44 (33.6) 43 (32.8)
Postgraduate (>16 years) 04 (25.0) 06 (37.5) 06 (37.5)
Monthly income (in PKR)
10,000–50,000 25 (35.2) 26 (36.6) 20 (28.2) 0.63
50,001–80,000 23 (35.4) 17 (26.2) 25 (38.5)
80,001 R 17 (31.5) 19 (35.2) 18 (33.3)
NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio.

P value calculate by using Kruskal-Wallis test.

P value calculate by using Chi-square test.

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Kumari et al. J Addict Med  Volume 00, Number 00, Month/Month 2018

TABLE 2. Association of Tobacco Smoking Status and Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0 Model 1
Beta SE 95% CI P Beta SE 95% CI P
Neutrophil to lymphocyte ratio
Smoking status
Nonsmokers Reference Reference
Cigarette smokers 0.33 0.178 0.01, 0.68 0.06 0.38 0.185 0.02, 0.74 0.03
Waterpipe smokers 0.58 0.176 0.23, 0.93 <0.01 0.61 0.182 0.25, 0.96 <0.01
Platelet to lymphocyte ratio
Smoking status
Nonsmokers Reference Reference
Cigarette smokers 10.39 0.178 10.03, 10.74 <0.01 12.43 0.185 12.07, 12.79 <0.01
Waterpipe smokers 19.11 0.178 18.76, 19.45 <0.01 20.86 0.182 20.51, 21.21 <0.01
Model 0 ¼ univariate analysis.
Model 1 ¼ Model 0 þ age, gender, marital status, education level, income, physical activity, systolic blood pressure, diastolic blood pressure, heart rate, waist circumference.
CI, confidence interval; NLR, neutrophil to lymphocyte ratio; PLR, platelet to lymphocyte ratio; SE, standard error.

was higher among WP smokers as compared to cigarette
smokers in Models 0 and 1 (Table 2). Furthermore, logistic
regression analysis also indicated that the odds of raised NLR
was significantly higher for WP smokers compared to non-
smokers (Model 0, OR ¼ 3.40, 95% CI 1.64, 7.03, P < 0.01;
Model 1, OR ¼ 4.40, 95% CI 1.97, 9.85, P < 0.01), even after
adjustment with all study variables (Table 3).
PLR and Tobacco Smoking Status
The mean PLR was significantly higher among WP
smokers (mean 117.39, S.D  42.62) as compared to non-
smokers (P-value 0.003, adjusted using the Bonferroni cor-
rection) (see Table 1, Table S1, http://links.lww.com/JAM/
A91). Furthermore, Model 0 indicates that WP smoking status
was positively associated with PLR as compared to nonsmok-
ing. Even after adjusting for all important physical health, and
socio-demographic covariates (Model 1), WP smoking
remained positively associated with PLR as compared to
nonsmoking (Beta ¼ 20.86, 95% CI 20.51, 21.21, P < 0.01)
(Table 2). Furthermore, adjusted logistic regression analysis
also indicates that the odds of raised PLR were 3.48 times
higher for WP smokers compared to nonsmokers (OR ¼ 3.48,
95% CI 1.60, 7.57, P < 0.01) (see Table 3).
Furthermore, linear associations between systemic
inflammatory markers among WP and cigarette smokers
indicated that WP smoking remained positively associated
with NLR (Beta ¼ 0.27, 95% CI 0.08, 0.62, P ¼ 0.13) and
PLR (Beta ¼ 9.23, 95% CI 8.87, 9.58, P < 0.01) as compared
to cigarette smoking (Table 4).
DISCUSSION
The findings of this study indicate that WP smoking is
significantly associated with raised systemic inflammatory
markers, particularly NLR and PLR. Although, the NLR and
PLR values were in normal range among WP smokers,
cigarette smokers, and nonsmokers, the average NLR and
PLR values were significantly higher among WP smokers
compared with nonsmokers. Comparing the inflammatory
effects of the different forms of smoked tobacco, WP smokers
had higher odds of raised NLR and PLR as compared to
cigarette smokers. Furthermore, study also adds evidence
related to the social and behavioral characteristics of the
WP smoking, indicating that majority of them initiated
use in late teens; were having at least 7 to 8, 1-hourly
smoking sessions in a month; and were using it as a social
drug in company of friends, preferring the cafes and

TABLE 3. Logistic Regression Odds Ratio of Higher Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0 Model 1
Characteristics OR (95% CI) P OR (95% CI) P
NLR (compared to NLR < 1.47)
Smoking status
Nonsmokers 1 1
Cigarette smokers 1.86 (0.90–3.82) 0.08 2.40 (1.09–5.30) 0.03
Waterpipe smokers 3.40 (1.64–7.03) <0.01 4.40 (1.97–9.85) < 0.01
PLR (compared to PLR < 107.36)
Smoking status
Nonsmokers 1 1
Cigarette smokers 1.73 (0.85–3.55) 0.12 2.06 (0.95–4.45) 0.06
Waterpipe smokers 2.97 (1.44–6.09) <0.01 3.48 (1.60–7.57) < 0.01
Model 0 ¼ univariate analysis.
Model 1 ¼ Model 0 þ age, gender, marital status, education level, income, physical activity, systolic blood pressure, diastolic blood pressure, heart rate, waist circumference.
CI, confidence interval; NLR, neutrophil to lymphocyte ratio; OR, odds ratio; PLR, platelet to lymphocyte ratio.

4 ß 2018 American Society of Addiction Medicine

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J Addict Med  Volume 00, Number 00, Month/Month 2018 Waterpipe Smoking and Its Association With Systemic Inflammation
TABLE 4. Association of Tobacco Smoking Status and Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio
Model 0
Beta SE
Neutrophil to lymphocyte ratio
Smoking status
Cigarette smokers Reference
Waterpipe smokers 0.25 0.177
Platelet to lymphocyte ratio
Smoking status
Cigarette smokers Reference
Waterpipe smokers 8.72 0.177
Model 0 ¼ univariate analysis
Model 1 ¼ Model 0 þ age, gender, marital status, education level, income, physical activity, systolic blood pressure, diastolic blood pressure, heart rate, waist circumference.
CI, confidence intervals; SE, standard error.
restaurants which offered WP smoking facility at the venue
(data not shown).
In light of existing literature, various mediators have
been linked with onset of systemic inflammation, including
obesity, lack of physical activity, stress, and even cigarette
smoking (Bell and O’Keefe, 2007; Brooks et al., 2010;
Copeland et al., 2014; Nakanishi et al., 2002; Pirkola et al.,
2010; Pitsavos et al., 2007; Yasue et al., 2006). Comparing
study results with existing evidence available in this regard,
raised total leukocyte count among WP smokers had been
reported in several studies (Bentur et al., 2014; Khabour
et al., 2012), and the results are also comparable with studies
that have reported raised total leukocyte count among cigarette
smokers (Shenwai and Aundhakar, 2012; Tell et al., 1985;
Whitehead et al., 1995). Our study adds to the limited evidence
available. Even after adjusting for several important health-
related parameters including blood pressure, body mass index,
physical activity, NLR, and PLR remained significantly asso-
ciated with WP smoking as evident from study results where
WP smokers were found to have higher odds of raised inflam-
matory markers as compared to cigarette smokers.
As far as use of NLR and PLR as inflammatory markers
in the present study is concerned, they have been used in
several studies to assess the presence of low-grade systemic
inflammation, in association with cardiovascular diseases,
cancer survival, and chronic diseases (Bovill et al., 1996;
Freedman et al., 1996; Imtiaz et al., 2012; Yasue et al., 2006).
However, to the best of our knowledge, this is the first study to
report the association of the NLR and PLR with WP smoking,
and thus the results warrant further investigations to confirm
the finding. In case the findings related to use of NLR and
PLR as a valid measure of low-grade systemic inflammation is
confirmed, these can be used as a simple, cost-effective
measure of low-grade systemic inflammation in resource-
limited scenarios.
Regarding the implications of raised inflammatory
markers among WP smokers, a chronic systemic inflamma-
tory effect may lead to several diseases like cardiovascular
diseases, diabetes mellitus, hypertension. For instance, leu-
kocytosis caused by cigarette smoking has been found to be
associated with low-grade inflammation in atherosclerosis
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Model 1
95% CI P Beta SE 95% CI P
Reference
0.09, 0.59 0.16 0.27 0.18 0.08, 0.62 0.13
Reference
8.37, 9.06 <0.01 9.23 0.18 8.87, 9.58 <0.01
(Flouris et al., 2012). Although the biological plausibility
of the association has not been studied much, it may be
explained by the cellular response of blood components to
inflammation which is mediated by endothelial dysfunction
(Marsland et al., 2010). Similarly, a relation between chronic,
low-grade, subclinical inflammation, and insulin resistance
leading to clinically over diabetes mellitus has also been
reported (Pitsavos et al., 2007). In case of establishing the
association between WP use and systemic inflammation, it
may then also be well justified to state that, WP smoking, in
the long run, maybe a potential risk factor for developing
chronic diseases like metabolic syndrome, diabetes, and
cardiovascular disease. However, present evidence in this
regard is limited and calls for further investigations.
The findings of the study may also be used for effective
advocacy against the use of WP smoking, which at the
moment is emerging as a popular, relatively less harmful
form of smoked tobacco, among users (Maziak et al., 2004).
As discussed earlier, though, NLR and PLR were at a higher
level among WP smokers as compared to cigarette smokers
and nonsmokers in our study, these values were in normal
ranges among all 3 groups. It may take several years before we
have large-scale, multiyear epidemiological studies to vali-
date the chronic health effects of WP smoking. In such
circumstances, evidence from studies like this may hold
importance with regard to the advocacy to prevent the use
of WP usage at the population level. Previous findings related
to the characteristics of WP smokers are also important, as
they clearly indicate that majority of the users unaware of the
harmful effects of WP smoking, consider it relatively safe as
compared to cigarette smoking (Maziak et al., 2004).
Although cigarette use may have declined in several devel-
oped countries, it is currently a big dilemma for the antito-
bacco efforts, that the newer products like e-cigarettes and re-
emerging popular forms like WP have gained ground as
relatively safe social drugs (Maziak et al., 2004, 2014).
Our study had various limitations; first, as an observa-
tional study, it cannot outline a causal association between
WP smoking and inflammatory effect. However, supporting
evidence points in the same direction, and it may be well
justified to speculate causative role of WP smoking in
5
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Kumari et al.
systemic inflammation. Nevertheless, the results call for a
further understanding of the phenomenon through longitudi-
nal studies. Secondly, we used nonprobability sampling tech-
nique, because of a hindrance to reaching the target
population. It is also important to note here, that the partic-
ipants were selected on basis of their exclusive smoking
habits. However, in reality, users may use WP along with
cigarettes. Therefore, there are fair chances that participants
who might have been exposed to higher doses of toxicants due
to synergistic effects of combined WP and cigarette use may
have been completely missed. Nevertheless, a study of exclu-
sive WP and cigarette smoking groups enabled us to compare
the inflammatory effects caused by the 2 different forms of
smoked tobacco. Furthermore, any results can also be masked
by environmental air pollution, as well as any underlying
health conditions, which were not studied in the present study.
CONCLUSIONS
Waterpipe smoking has a significant association with
systemic inflammation as measured by NLR and PLR. The
study and existing evidence implicate the need to regulate the
WP industry and its policies. Public awareness policies are
required to correct the perception regarding the safety of WP.
ACKNOWLEDGMENTS
We would like to thank all personnel who provided
support for logistic support. We would also like to thank
all study participants and organizations involved in this study.
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