{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,20]],"date-time":"2026-08-20T10:46:48Z","timestamp":1787222808599,"version":"build-2736575974"},"reference-count":40,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"19","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circulation"],"published-print":{"date-parts":[[2019,5,7]]},"abstract":"<jats:sec>\n            <jats:title>Background:<\/jats:title>\n            <jats:p>Hookah smoking is marketed to youth as a harmless alternative to cigarettes. Although cigarette smoking acutely impairs endothelial function, the effect of smoking fruit-flavored hookah tobacco is unknown. Because charcoal traditionally is used to heat the hookah tobacco in the waterpipe, hookah smoke delivers tobacco toxicants and nicotine plus charcoal combustion products: not only carbon-rich nanoparticles, oxidants that may destroy nitric oxide and impair endothelial function, but also large amounts of carbon monoxide (CO), a putative vasodilator molecule.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods:<\/jats:title>\n            <jats:p>To test the acute effect of hookah smoking on endothelial function, in young adult hookah smokers (n=30, age 26\u00b11 years, mean\u00b1SE), we measured plasma nicotine, exhaled CO, and brachial artery flow-mediated dilation (FMD) before and after charcoal-heated hookah smoking. To remove the effect of charcoal combustion, the same measurements were performed when the same flavored hookah tobacco product was heated electrically (n=20). As a positive internal control, we studied age-matched cigarette smokers (n=15) who smoked 1 cigarette. To isolate the effect of the CO boost on FMD, hookah smokers (n=8) inhaled a 0.1% CO gas mixture to approximate their CO boost achieved with charcoal-heated hookah smoking.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results:<\/jats:title>\n            <jats:p>\n              Nicotine levels increased similarly with all types of smoking, whereas exhaled CO increased 9- to 10-fold more after charcoal-heated hookah than after either electrically heated hookah or cigarette smoking. FMD did not decrease after smoking charcoal-heated hookah but instead increased by +43\u00b17% (\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001). In contrast, FMD decreased by \u201327\u00b14% (\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001) after smoking electrically heated hookah, comparable to the decrease after cigarette smoking. FMD increased markedly by 138\u00b171% (\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001) after breathing CO gas, 2.8 times more than the increase induced in the same subjects after smoking charcoal-heated hookah (\n              <jats:italic>P<\/jats:italic>\n              &lt;0.001), despite comparable increases in exhaled CO (24\u00b11 versus 28\u00b13 ppm, hookah versus CO).\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions:<\/jats:title>\n            <jats:p>Smoking hookah tobacco, similar to cigarette tobacco, acutely impairs endothelial function. With traditional charcoal-heated hookah smoking, the acute endothelial dysfunction is masked by high levels of carbon monoxide, a potent vasodilator molecule generated by charcoal combustion. With respect to large-artery endothelial function, smoking hookah is not harmless.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Clinical Trial Registration:<\/jats:title>\n            <jats:p>\n              URL:\n              <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/www.clinicaltrials.gov\">https:\/\/www.clinicaltrials.gov<\/jats:ext-link>\n              . Unique identifiers: NCT 03616002 and NCT 03067701.\n            <\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/circulationaha.118.037375","type":"journal-article","created":{"date-parts":[[2019,2,15]],"date-time":"2019-02-15T10:00:13Z","timestamp":1550224813000},"page":"2215-2224","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":31,"title":["High Carbon Monoxide Levels from Charcoal Combustion Mask Acute Endothelial Dysfunction Induced by Hookah (Waterpipe) Smoking in Young Adults"],"prefix":"10.1161","volume":"139","author":[{"given":"Mary","family":"Rezk-Hanna","sequence":"first","affiliation":[{"name":"Smidt Heart Institute (M.R.-H., F.R., M.R., K.D., N.B.M., R.G.V.), Cedars-Sinai Medical Center, Los Angeles, CA."},{"name":"School of Nursing (M.R.-H., L.D., W.R., L.S.), University of California, Los Angeles."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zab","family":"Mosenifar","sequence":"additional","affiliation":[{"name":"Division of Pulmonary and Critical Care Medicine (Z.M.), Cedars-Sinai Medical Center, Los Angeles, CA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neal L.","family":"Benowitz","sequence":"additional","affiliation":[{"name":"Division of Clinical Pharmacology &amp; Experimental Therapeutics, Departments of Medicine and Bioengineering &amp; Therapeutic Sciences, University of California, San Francisco (N.L.B.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florian","family":"Rader","sequence":"additional","affiliation":[{"name":"Smidt Heart Institute (M.R.-H., F.R., M.R., K.D., N.B.M., R.G.V.), Cedars-Sinai Medical Center, Los Angeles, CA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamad","family":"Rashid","sequence":"additional","affiliation":[{"name":"Smidt Heart Institute (M.R.-H., F.R., M.R., K.D., N.B.M., R.G.V.), Cedars-Sinai Medical Center, Los Angeles, CA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine","family":"Davoren","sequence":"additional","affiliation":[{"name":"Smidt Heart Institute (M.R.-H., F.R., M.R., K.D., N.B.M., R.G.V.), Cedars-Sinai Medical Center, Los Angeles, CA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Norma B.","family":"Moy","sequence":"additional","affiliation":[{"name":"Smidt Heart Institute (M.R.-H., F.R., M.R., K.D., N.B.M., R.G.V.), Cedars-Sinai Medical Center, Los Angeles, CA."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynn","family":"Doering","sequence":"additional","affiliation":[{"name":"School of Nursing (M.R.-H., L.D., W.R., L.S.), University of California, Los Angeles."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendie","family":"Robbins","sequence":"additional","affiliation":[{"name":"School of Nursing (M.R.-H., L.D., W.R., L.S.), University of California, Los Angeles."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda","family":"Sarna","sequence":"additional","affiliation":[{"name":"School of Nursing (M.R.-H., L.D., W.R., L.S.), University of California, Los Angeles."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ning","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Biomathematics, David Geffen School of Medicine (N.L., L.C.C., R.M.E.), University of California, Los Angeles."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L. 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