Markers of oxidative stress and toxicant exposure among young waterpipe smokers in the USA


Waterpipe (aka hookah) tobacco smokers are exposed to toxicants that can lead to oxidative DNA and RNA damage, a precursor to chronic disease formation. This study assessed toxicant exposure and biomarkers of DNA [8-oxo-7, 8-dihydro-2′-deoxyguanosine (8-oxodG)] and RNA [8-oxo-7,8-dihydroguanosine (8-oxoGuo)] oxidative damage during smoking of flavored and non-flavored waterpipe tobacco. Thirty waterpipe smokers completed two counterbalanced 2-h lab waterpipe smoking sessions (flavored vs. non-flavored waterpipe tobacco). Urinary concentrations of 8-oxodG and 8-oxoGuo and expired carbon monoxide (eCO) were measured before and after the smoking sessions. A significant increase in the urinary concentrations of 8-oxodG (from 2.12 ± 0.83 to 2.35 ± 0.91 ng/mg creatinine, p = 0.024) and 8-oxoGuo (from 2.96 ± 0.84 to 3.45 ± 0.76 ng/mg creatinine, p = 0.003) were observed after smoking the non-flavored and flavored waterpipe tobacco, respectively. Our results also showed that the mean ± SD of eCO increased significantly after smoking the flavored (from 1.3 ± 1.1 to 20.3 ± 23.6 ppm, p < 0.001) and non-flavored waterpipe tobacco (from 1.8 ± 1.2 to 24.5 ± 26.1 ppm, p < 0.001). There were no significant differences in the means of 8-oxodG (p = 0.576), 8-oxoGuo (p = 0.108), and eCO (p = 0.170) between the flavored and non-flavored tobacco sessions. Smoking non-flavored and flavored waterpipe tobacco leads to oxidative stress and toxicant exposure. Our findings add to the existing evidence about the adverse effects of waterpipe tobacco smoking (WTS) and the need for strong policies to inform and protect young people from the risks of WTS.

This is a preview of subscription content, access via your institution.

Data availability

The datasets analyzed during the current study are available from the corresponding author on reasonable request.


  1. Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J (2013) Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J 10(1):12.

    Article  Google Scholar 

  2. Alsaad AM, Al-Arifi MN, Maayah ZH, Attafi IM, Alanazi FE, Belali OM et al (2019) Genotoxic impact of long-term cigarette and waterpipe smoking on DNA damage and oxidative stress in healthy subjects. Toxicol Mech Methods 29(2):119–127.

    CAS  Article  Google Scholar 

  3. American College Health Association-National College Health Assessment (2019) Accessed 16 June 2020

  4. Andreoli R, Mutti A, Goldoni M, Manini P, Apostoli P, De Palma G (2011) Reference ranges of urinary biomarkers of oxidized guanine in (2′-deoxy) ribonucleotides and nucleic acids. Free Radic Biol Med 50(2):254–261

    CAS  Article  Google Scholar 

  5. Badran M, Laher I (2020) Waterpipe (shisha, hookah) smoking, oxidative stress and hidden disease potential. Redox Biol 34:101455.

    CAS  Article  Google Scholar 

  6. Ben Taleb Z, Vargas M, Ebrahimi Kalan M, Breland A, Eissenberg T, Brown D, Maziak W (2019) The effect of flavoured and non-flavoured tobacco on subjective experience, topography and toxicant exposure among waterpipe smokers. Tob Control 29(Suppl 2):s72–s79.

    Article  Google Scholar 

  7. Benowitz NL, Jacob P, Ahijevych K et al (2002) Biochemical verification of tobacco use and cessation. Nicotine Tob Res (2):149–159.

  8. Bhatnagar A, Maziak W, Eissenberg T, Ward KD, Thurston G, King BA et al (2019) Water pipe (Hookah) smoking and cardiovascular disease risk: a scientific statement from the American Heart Association. Circulation 139(19):E917–E936.

    Article  Google Scholar 

  9. Centers for Disease Control and Prevention (2020) Hookahs. Accessed 5 June 2020

  10. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T (2011) Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects. Nicotine Tob Res 13(2):78–87

    CAS  Article  Google Scholar 

  11. Cooke MS, Olinski R, Loft S (2008) Measurement and meaning of oxidatively modified DNA lesions in urine. Cancer Epidemiol Biomarkers Prev 17:3–14.

    CAS  Article  Google Scholar 

  12. Delfino RJ, Staimer N, Vaziri ND (2011) Air pollution and circulating biomarkers of oxidative stress. Air Qual Atmos Health 4(1):37–52.

    CAS  Article  Google Scholar 

  13. Eichhorn L, Michaelis D, Kemmerer M, Jüttner B, Tetzlaff K (2018) Carbon monoxide poisoning from waterpipe smoking: a retrospective cohort study. Clin Toxicol 56(4):264–272

    CAS  Article  Google Scholar 

  14. Eissenberg T, Shihadeh A (2009) Waterpipe tobacco and cigarette smoking. Direct Comparison of Toxicant Exposure. Am J Prev Med 37(6):518–523.

    Article  Google Scholar 

  15. Ellegaard PK, Poulsen HE (2016) Tobacco smoking and oxidative stress to DNA: a meta-analysis of studies using chromatographic and immunological methods. Scand J Clin Lab Invest 76(2):151–158.

    CAS  Article  Google Scholar 

  16. FDA (2016) Hookah Tobacco (Shisha or Waterpipe Tobacco) FDA finalized a,and distribution of hookah tobacco. Accessed 23 Dec 2020

  17. Inyang NA, Chang JT, Wang B (2020) National estimates of hospital emergency department visits due to acute injuries associated with hookah smoking, United States, 2011–2019. Inj Epidemiol 7(1):1–6

    Article  Google Scholar 

  18. Li Z, Yao Y, Zhang Y, Zhang Y, Shao Y, Tang C et al (2019) Classification and temporal variability in urinary 8-oxodG and 8-oxoGuo: analysis by UHPLC-MS/MS. Sci Rep 9(1):1–9

    Article  Google Scholar 

  19. Melikian AA, Djordjevic MV, Chen S, Richie J, Stellman SD (2007) Effect of delivered dosage of cigarette smoke toxins on the levels of urinary biomarkers of exposure. Cancer Epidemiol Biomark Prev 16(7):1408–1415

    CAS  Article  Google Scholar 

  20. Mesaros C, Arora JS, Wholer A, Vachani A, Blair IA (2012) 8-Oxo-2′-deoxyguanosine as a biomarker of tobacco-smoking-induced oxidative stress. Free Radic Biol Med 53:610–617.

    CAS  Article  Google Scholar 

  21. Naddafi K, Nabizadeh R, Rostamy R, Ebrahimi Kalan M, Hassanvand MS, Fazlzadeh M (2019a) Indoor air quality in waterpipe cafés: exposure level to particulate matter. Environ Sci Pollut Res 26(26):26605–26616.

    CAS  Article  Google Scholar 

  22. Naddafi K, Nabizadeh R, Rostami R, Ghaffari HR, Fazlzadeh M (2019b) Formaldehyde and acetaldehyde in the indoor air of waterpipe cafés: measuring exposures and assessing health effects. Build Environ 165:106392.

    Article  Google Scholar 

  23. Perraud V, Lawler MJ, Malecha KT, Johnson RM, Herman DA, Staimer N, Kleinman MT, Nizkorodov SA, Smith JN (2019) Chemical characterization of nanoparticles and volatiles present in mainstream hookah smoke. Aerosol Sci Technol 53(9):1023–1039.

    CAS  Article  Google Scholar 

  24. Poulsen HE, Weimann A, Henriksen T, Kjær LK, Larsen EL, Carlsson ER, Christensen CK, Brandslund I, Fenger M (2019) Oxidatively generated modifications to nucleic acids in vivo: measurement in urine and plasma. Free Radic Biol Med 145:336–341

    CAS  Article  Google Scholar 

  25. Primack BA, Carroll MV, Weiss PM, Shihadeh AL, Shensa A, Farley ST, Fine MJ, Eissenberg T, Nayak S (2016) Systematic review and meta-analysis of inhaled toxicants from waterpipe and cigarette smoking. Public Health Rep 131(1):76–85.

    Article  Google Scholar 

  26. Salloum RG, Thrasher JF, Kates FR, Maziak W (2015) Water pipe tobacco smoking in the United States: findings from the National Adult Tobacco Survey. Prev Med 71:88–93.

    Article  Google Scholar 

  27. Shih YM, Cooke MS, Pan CH, Chao MR, Hu CW (2019) Clinical relevance of guanine-derived urinary biomarkers of oxidative stress, determined by LC-MS/MS. Redox Biol 20:556–565.

    CAS  Article  Google Scholar 

  28. Shihadeh A (2003) Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 41(1):143–152.

    CAS  Article  Google Scholar 

  29. Shihadeh A, Schubert J, Klaiany J, El Sabban M, Luch A, Saliba NA (2015) Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives. Tob Control 24(Suppl 1):i22–i30.

    Article  Google Scholar 

  30. Sørensen AS, Kjær LK, Petersen KM, Henriksen T, Cejvanovic V, Pedersen O, Hansen T, Christensen CK, Brandslund I, Poulsen HE (2017) The effect of smoking on the urinary excretion of 8-oxodG and 8-oxoGuo in patients with type 2 diabetes. Scand J Clin Lab Invest 77(4):253–258.

    CAS  Article  Google Scholar 

  31. Tranfo G, Paci E, Carrieri M, Marchetti E, Sisto R, Gherardi M, Costabile F, Bauleo L, Ancona C, Pigini D (2019) Levels of urinary biomarkers of oxidatively generated damage to DNA and RNA in different groups of workers compared to general population. Int J Environ Res Public Health 16(16):2995.

    CAS  Article  Google Scholar 

  32. Wagener TL, Leavens ELS, Mehta T, Hale J, Shihadeh A, Eissenberg T et al (2020) Impact of flavors and humectants on waterpipe tobacco smoking topography, subjective effects, toxicant exposure and intentions for continued use. Tob Control:1–7.

  33. Yue-dong Y (1998) Simultaneous determination of creatine, uric acid, creatinine and hippuric acid in urine by high performance liquid chromatography. Biomed Chromatogr 12(2):47–49.<47::AID-BMC717>3.0.CO;2-Y

    Article  Google Scholar 

  34. Zalba G, Beaumont J, San José G, Fortuño A, Fortuño MA, Díez J (2000) Vascular oxidant stress: molecular mechanisms and pathophysiological implications. J Physiol Biochem 56(1):57–64.

    CAS  Article  Google Scholar 

  35. Zhao G, Fu Y, Yu J, Wang S, Duan K, Xie F, Liu H (2017) A simple method for the determination of 8-oxoguanosine, 8-Oxo-2′-deoxyguanosine and 8-Iso-prostaglandin F2α in human urine by UHPLC–MS/MS. Chromatographia 80(3):401–408

    CAS  Article  Google Scholar 

Download references


We would like to thank all participants who contributed their time and completed laboratory study sessions.


This work was supported by the National Institute on Drug Abuse at National Institutes of Health (NIDA NIH) [R01 DA042477]; and Fogarty International Center (FIC) [R01TW010654-01]. RJ is supported by NIH FIC [R01TW010654]. MEK is supported by the NIDA NIH [R01DA042477]; and NIH FIC [R01TW010654]. MVR is supported by NIH FIC [R01TW010654]. OO is supported by the NIDA [T32DA043449]. ZB is supported by the FIU-Research Center in Minority Institution [U54MD012393-01]. WM is supported by NIH [R01-DA035160, R01-TW010654, R01-DA042477] and the NIDA [T32DA043449]. This study was approved by the Florida International University (FIU) Institutional Review Board.

Author information




RJ and WM conceptualized and designed the study and drafted the initial manuscript. RJ, MEK, and ZB conducted data analysis. MEK, MVR, OO, WL, PG, MC, CH, and ZB contributed to the interpretation of data and critically revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted.

Corresponding author

Correspondence to Wasim Maziak.

Ethics declarations

Competing interest

The authors declare that they have no competing interest.

Ethics approval and consent to participate

The Florida International University Institutional Review Board has approved the study protocol based on the fact that it protects patients’ anonymity and confidentiality. A written informed consent was obtained from those who approved to participate in the study.

Consent for publication

Not applicable.


The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Responsible Editor: Lotfi Aleya



Table 1 Baseline characteristics for the overall sample (n=30)
Table 2 Concentrations (ng/mg creatinine) of 8-oxodG and 8-oxoGuo by time (pre vs. post) and flavor session (flavored vs. non-flavored)
Table 3 Concentrations (ppm) of eCO by time (pre vs. post) and flavor session (flavored vs. non-flavored)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Jebai, R., Ebrahimi Kalan, M., Vargas-Rivera, M. et al. Markers of oxidative stress and toxicant exposure among young waterpipe smokers in the USA. Environ Sci Pollut Res (2021).

Download citation


  • DNA
  • RNA
  • 8-oxo-7,8-dihydro-2′-deoxyguanosine
  • 8-oxo-7,8-dihydroguanosine
  • Oxidative damage
  • Carbon monoxide
  • Waterpipe