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72 Furthermore, long-term WP smokers had a shorter 6?min-walk-test BGJ398 datasheet distance compared to healthy non-smokers.73 Table?3 Long-term effect of waterpipe smoking on pulmonary function Studies that evaluated the associations between the total number of WPs,61 71 total weight of tobacco smoked62 or WP-years66 and PF parameters reported a significant moderate negative correlation with FEV1 r??0.35.61 62 66 71 Other negative correlates of the amount of WP smoked include FVC r??0.39,61 71 FEF25-75,61 62 71 peak expiratory flow61 62 71 and FEV1/FVC.62 A significant positive correlation between the amount of WPS and functional residual capacity and residual volume was also reported.62 COPD, chronic bronchitis, emphysema, asthma and others While studies on PF parameters provide preliminary evidence that WPS causes respiratory disease, a few studies have shown an association with frank clinical syndromes. The GOLD guidelines define COPD by the presence of FEV1/FVC Unoprostone community-based studies69 75�C77 and one hospital-based study67 evaluated the association of WPS with COPD. These studies were conducted in Syria,67 Lebanon,75 the UAE,77 China69 and several Middle Eastern and North African Countries.76 Two studies, using the GOLD spirometry-based definition of COPD, found an association between COPD and smoking the traditional75 (OR=2.53, 95% CI 1.83 to 3.50) or Chinese WP (OR=10.61, 95% CI 6.89 to 16.34).69 (The Chinese WP is similar to the regular traditional Middle Eastern WP, but the tobacco is lit directly without charcoal.) Both analyses adjusted for possible confounders such as age and cigarette smoking. The association of WP with COPD was also ascertained using an epidemiological questionnaire-based definition (pProtease Inhibitor Library were methodologically limited.67 77 One included women only and did not account for the total quantity of WP smoked;67 thus, women may have been exposed to less WP smoke than participants in other studies, accounting for the lack of association. In addition, this study included women as young as 20?years and did not pilot test its survey, report on randomisation methods or calculate the sample size.67 The second study had a low COPD prevalence and inadequate power.77 WPS was also associated with chronic bronchitis and emphysema in cross-sectional studies from Lebanon,45 78 79 Iran,61 China69 and a combination of Middle Eastern and North African countries.76 Overall, the studies were robust in design including randomisation,69 76 78 good survey designs,61 79 adequate power61 78 79 and controlling for cigarette smoking61 69 76 and other confounders.78 79 The associations between WPS and chronic bronchitis, using the standard definition (chronic cough with sputum production for 3 consecutive months for 2?years), were: adjusted OR=1.42, 95% CI 1.12 to 1.