We want to congratulate the authors of the article “Cigarette smoking, environmental tobacco smoke exposure and pancreatic cancer risk in the European Prospective Investigation into Cancer and Nutrition”1 for their contribution to the literature on this very important topic. While, pancreatic cancer is an important health problem. Recognized risk factors for the cancer include cigarette smoking, chronic and hereditary pancreatitis, history of diabetes and familial cancer syndromes.2, 3 This cancer is one of the most difficult conditions to treat, although it only accounts for 3% of all cancers; 5-year survival rate is about 5% in pancreatic cancer patients, and this figure remains largely unchanged over the past 3 decades.3 Therefore, identification of new behavior risk factors as a prevention measure is crucial. On the other hand, water pipe smoking (WPS) is traditional and common especially in the Eastern Mediterranean Region,4, 5 as it is believed that 20% of adult people living in these countries smoke water pipe.5 WPS is now the object of renewed interest, as its use has recently been spreading among young people in the western countries including the United States and Canada.6–8 Though, a precise evaluation of the health effects of WPS is hindered by the small number of published studies.9 Smoke from water pipes contains most of the compounds that are also present in cigarette smoke, although in different proportions. More importantly, the longer duration of a WPS session leads to a much higher yield of tar, nicotine, carbon monoxide, polycyclic aromatic hydrocarbons and heavy metals than cigarette smoking. The water pipe smoker may, therefore, inhale the equivalent of 100 or more cigarettes.8–10 Consequently, we firmly believe that WPS is an important risk factor in the development of several human cancers, especially pancreatic cancer according to the study of Vrieling et al.1 Meanwhile, we propose, to conduct an international epidemiological study, in collaboration with several national Cancer centers, regarding the risk factor of WPS in human pancreatic cancer as well as other human cancers. Moreover, we believe that thorough molecular and cellular biological studies are necessary to determine the real role of WPS in the development of human pancreatic cancer.
The authors thank Mrs. A. Kassab for her critical reading of the manuscript.
Fouad M. Fouad, Samer Rastam, Ala-Eddin Al Moustafa.