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Background: Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees. Methods: We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul Moscow and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO) hair nicotine saliva cotinine urine cotinine urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures. Results: There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2 40.9) mu g/g creatinine urine cotinine 5.5 (2 15) ng/mL saliva cotinine 0.95 (0.36 5.02) ng/mg hair nicotine 1.48 (0.98 3.97) pg/mg creatinine urine NNAL 0.54 (0.25 0.97) pmol/mg creatinine urine 1-OHPG and 1.67 (1.33 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68 95% CI: 1.20 2.37) and hair nicotine (GMR: 1.22 95% CI: 1.05 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83 95% CI: 1.05 7.62). Conclusions: Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs).

Fine particulate air pollution <2.5 μm in diameter (PM(2.5)) is a major environmental threat to global public health. Multiple national and international medical and governmental organizations have recognized PM(2.5) as a risk factor for cardiopulmonary diseases. A growing body of evidence indicates that several personal-level approaches that reduce exposures to PM(2.5) can lead to improvements in health endpoints. Novel and forward-thinking strategies including randomized clinical trials are important to validate key aspects (e.g., feasibility, efficacy, health benefits, risks, burden, costs) of the various protective interventions, in particular among real-world susceptible and vulnerable populations. This paper summarizes the discussions and conclusions from an expert workshop, Reducing the Cardiopulmonary Impact of Particulate Matter Air Pollution in High Risk Populations, held on May 29 to 30, 2019, and convened by the National Institutes of Health, the U.S. Environmental Protection Agency, and the U.S. Centers for Disease Control and Prevention.