Behavioral and Environmental Factors of Carbon Monoxide Poisoning and Polycythemia due to Waterpipe Smoking: An Artificial Intelligence-Assisted Systematic Review of Case Reports.

BACKGROUND

We aimed to explore behavioral and environmental factors associated with carbon monoxide (CO) poisoning from waterpipe smoking.

METHODS

We searched the MEDLINE, Web of Science, PubMed, CINAHL, Ichushi-Web, and CiNii databases for case reports or case series on acute CO poisoning and polycythemia related to waterpipe smoking, up to February 2025. Article selection and data extraction were performed with the assistance of generative artificial intelligence (AI) using predefined criteria. All processes performed by AI were verified by the author through careful article review.

RESULTS

A total of 68 cases of acute CO poisoning and 13 cases of polycythemia were identified from 37 case reports and series. Most cases involved individuals aged 20‒29 years. The most common symptoms of acute CO poisoning following waterpipe smoking were syncope, headache, dizziness, and nausea/vomiting, in that order. Symptoms typically occurred shortly after exposure, followed by during exposure, and delayed after exposure. Acute CO poisoning was observed after as little as one hour of waterpipe smoking, in outdoor settings, and from secondhand waterpipe smoking exposure.

CONCLUSIONS

Both active and passive waterpipe smoking can cause acute CO poisoning, depending on the intensity, duration, and environment of exposure. Symptoms may arise not only during or immediately after smoking but also with a delayed onset. The implementation of environmental regulations for closed establishments is necessary to prevent mass CO poisoning and protect workers from it. Further research is needed to better understand the behavioral and environmental factors contributing to CO poisoning from waterpipe smoking.