Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure

Effect of waterpipe tobacco smoking on airway inflammation in murine model of asthma

OBJECTIVE

There has been an increase in the popularity of waterpipe tobacco smoking (WTS) worldwide, especially in the younger population, including asthma patients. In this study, we investigated the effects of waterpipe smoking on airway inflammation, cytokine levels and oxidative stress markers in an antigen-driven murine model of asthma.

MATERIALS AND METHODS

Balb/c mice were divided into four groups; (1) control (received fresh air, ovalbumin sensitization and saline challenge), (2) WTS (received WTS, ovalbumin sensitization and saline challenge), (3) Ova S/C (received fresh air, ovalbumin sensitization and ovalbumin challenge) and (4) simultaneous WTS and Ova S/C (received WTS, ovalbumin sensitization and ovalbumin challenge). Airway inflammatory cells were evaluated in the broncho-alveolar lavage fluid. Cytokines [interleukin (IL)-13, 10 and 18] and oxidative stress markers [superoxide dismutase (SOD), catalase and glutathione peroxidase (GPx)] were evaluated in the lung homogenates.

RESULTS

Chronic exposure to WTS significantly increased the number of airway inflammatory cells in mice, specifically: eosinophils, neutrophils, macrophages and lymphocytes. The level of IL-13 in the lungs was increased and the level of IL-10 was reduced (p < 0.05) by WTS. Chronic WTS potentiated the increase in inflammatory cells induced by Ova S/C (p < 0.05). The level of IL-13 in the lungs was increased by simultaneous WTS and Ova S/C (p < 0.05) while, levels of IL-10, IL-18, SOD, catalase and GPx in the lungs were not affected.

CONCLUSIONS

Chronic WTS exposure induced airway inflammation in control mice and enhanced airway inflammation in murine model of asthma.

Kinetics of Exhaled Carbon Monoxide After Water-pipe Smoking Indoors and Outdoors

BACKGROUND

Despite accumulating evidence about its adverse health effects, water-pipe tobacco smoking has become very popular among youth. The aim of this study was to compare smoke exposure and the kinetics of exhaled carbon monoxide (eCO) between water-pipe and cigarette smokers under different conditions.

METHODS

Using a cross-over study design, changes in eCO and urinary cotinine levels were measured in a cohort of 32 healthy university students after sessions of water-pipe smoking indoors and outdoors. An indoor cigarette smoking session with equal amounts of tobacco was conducted for reference purposes. Both active and passive smokers participated in all sessions.

RESULTS

In indoor sessions, we found that among active participants, eCO levels were approximately 7.5-fold higher in water-pipe users than cigarette smokers. eCO levels remained significantly elevated even 10 h after discontinuing water-pipe smoking. Notably, eCO levels in passive water-pipe smokers were in the same range as in active cigarette smokers. Compared with indoor sessions, eCO levels in active water-pipe users were reduced in outdoor environments. Nonetheless, levels were still higher in these subjects than those in active cigarette smokers measured in indoor sessions. Urinary cotinine levels were comparable in active water-pipe and cigarette smokers.

CONCLUSIONS

Our results suggest that water-pipe smoking is associated with significantly higher toxicant exposure than cigarette smoking even in outdoor environments. Furthermore, even passive, indoor water-pipe smoke exposure may have significant health hazards compared with those of active cigarette smoking.

Assessing the Effect of Waterpipe Smoking on Cancer Outcome - a Systematic Review of Current Evidence

Background: Waterpipe smoking (WPS) is widely believed to be a safe and hazard-free tobacco habit. However, a number of studies have indicated that exposure to several toxicants and carcinogens through WPS is strongly related to serious health hazards. The current paper presents a narrative review on the effects of WPS on cancer outcome. Methods: The addressed focused question was “Is there an association between waterpipe smoking and cancer outcome?” PubMed, Medline, EMBASE, ISI Web of Science and the Cochrane databases were searched until June 2015 using the key words “Waterpipe”, “Hookah”, “Narghileh”, “Shisha”, “Hubbly Bubbly” “cancer” in various combinations. Letters to the Editor, review articles, case-reports and unpublished articles were excluded. Results: A total of 16 studies were included: six on lung cancer, three on oesophageal cancer, two on gastric cancer, two on bladder cancer, and one each on nasopharyngeal, pancreatic and prostate cancers. Our search did not yield any study that evaluated the risk of oral cancer in WPS users. The available evidence showed a significant association of WPS with lung cancer (UOR 6.0, 95% CI 1.78–20.26); however, no association was observed with bladder, nasopharyngeal, pancreatic and prostate cancers. Gastric (OR 3.4, 95% CI 1.7-7.1) and oesophageal cancers (OR 1.85, 95% CI 1.41-2.44) were observed to have weak associations with WPS. Conclusion: Regardless of the limitations, there is sufficient evidence to suggest associations of WPS with cancer, particularly in the lung. Future well-designed studies are required to identify and quantify with confidence all the health effects of this form of smoking.

Initiation, Progression, and Sustained Waterpipe Use: A Nationally Representative Longitudinal Study of U.S. Young Adults

Background: Waterpipe tobacco smoking (WTS) is increasing in popularity despite evidence of harm and potential for dependence. Intervention development has been hampered by a lack of longitudinal, nationally representative data on usage patterns and factors independently associated with WTS initiation. Therefore, we aimed to characterize key transitions between WTS states in a nationally representative group of young adults, with particular attention to factors independently associated with initiation.Methods: Participants were randomly selected from a national probability-based panel representing 97% of the United States. A total of 1,785 adults ages 18 to 30 at baseline completed two Web-based surveys 18 months apart in 2013 and 2014. Assessments included knowledge of waterpipe tobacco smoke composition, positive and negative attitudes toward WTS, normative beliefs, intention to use waterpipe, and WTS behavior. We used multivariable logistic regression to assess the association between predictive factors and subsequent WTS initiation.Results: In fully adjusted models, overall knowledge about toxicants associated with WTS was not associated with subsequent WTS initiation. Similarly, negative attitudes and normative beliefs were not associated with WTS uptake. However, baseline positive attitudes were strongly and significantly associated with WTS initiation [adjusted OR (AOR) = 1.7; 95% confidence interval (CI), 1.2-2.3]. Similarly, baseline intention to use WTS was strongly associated with subsequent initiation (AOR = 7.0; 95% CI, 3.5-13.7).Conclusions: Prevention efforts may be most successful if they target individuals with clear intentions to use WTS and challenge positive attitudes surrounding WTS.Impact: Surveillance of WTS trajectories will help inform health care and policy surrounding this emerging risk behavior among U.S. young adults. Cancer Epidemiol Biomarkers Prev; 26(5); 748-55. ©2017 AACR.

Hookah tobacco use and stressful life events in a sample of young non-daily cigarette smokers

INTRODUCTION

Understanding factors that influence hookah use among young adults is important given its increasing popularity and health risks. The purpose of this study was to examine whether young adult non-daily cigarette smokers use hookah for stress regulation. We hypothesized that greater perceived stress and greater stressful life events would predict probability and frequency of recent hookah use.

METHODS

Participants (n=598, 50.7% male) were non-daily smokers aged 18-24years (M=20.5, SD=1.8), who completed a baseline assessment online or via mobile phone as part of a longitudinal study. Participants had been non-daily smokers for at least six months but had never been daily smokers.

RESULTS

Thirty-one percent of participants reported using hookah over the past 14days. Full-time students were more likely to have used hookah recently. More stressful life events and more frequent alcohol use predicted likelihood and frequency of hookah use (ps<0.05). Perceived stress was not associated with hookah use.

CONCLUSIONS

Findings suggest that hookah tobacco use is related to frequency of stressful life events but not perceived stress among non-daily cigarette smokers. Tobacco prevention and intervention programs should address hookah use and should include adaptive strategies for coping with stressful events.

Comparison of pharmacy students' knowledge and self-efficacy to provide cessation counseling for hookah and cigarette use

OBJECTIVES

We aimed to assess pharmacy students' self-efficacy to provide cessation counseling for commercial cigarette and hookah tobacco use.

METHODS

A cross-sectional study including PharmD students at a College of Pharmacy was conducted in Spring 2014. Confidence in counseling and perception of knowledge were self-rated and based on the Ask-Advise-Assess-Assist-Arrange follow-up (5A's) model and general tobacco cessation counseling skills. Comparisons were made between cigarettes and hookahs and by program level using t-tests, Wilcoxon signed-rank test, analyses of variance, and Tukey-Kramer tests.

RESULTS

Overall, 82% and 16% of the students, respectively, reported receiving training on cigarette smoking and hookah tobacco use cessation. Students were moderately confident in their ability to counsel. Compared to hookah tobacco use cessation counseling, students were more confident in their general counseling skills and ability to counsel on cigarette smoking cessation using the 5A's (p < 0.001 in each case). Students perceived themselves to be more knowledgeable about cigarette smoking cessation than about hookah tobacco use cessation. Almost half of the students (42.0%) thought hookah tobacco was less harmful than traditional cigarettes.

CONCLUSIONS

Pharmacy students need further training to address hookah and other alternative tobacco products to support patients' cessation needs, decrease risks for tobacco-related morbidity and mortality, and increase medication effectiveness.

Early symptoms of nicotine dependence among adolescent waterpipe smokers

BACKGROUND

Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon.

METHODS

Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon.

RESULTS

Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND.

CONCLUSIONS

Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

The Protective Effect of Selenium on Oxidative Stress Induced by Waterpipe (Narghile) Smoke in Lungs and Liver of Mice

Waterpipe smoking is common in the Middle East populations and results in health problems. In this study, we investigated the effects of exposure of mice to waterpipe smoke on oxidative stress in lungs and liver and the effects of selenium administration before smoke exposure on the oxidative stress. Twenty-four mice were divided equally into four groups: (i) the control mice received no exposure or treatment; (ii) mice exposed to waterpipe smoke; (iii) mice received intraperitoneal injection of 0.59 μg selenium/kg body weight as sodium selenite 15 min before the exposure to waterpipe smoke; and (iv) mice received intraperitoneal injection of 1.78 μg selenium/kg body weight as sodium selenite 15 min before the exposure to waterpipe smoke. Mice were exposed to waterpipe smoke every other day for four times within 8 successive days. Malondialdehyde and nitric oxide levels were significantly higher in the lungs and liver, while the activities of superoxide dismutase, glutathione peroxidase-1, and catalase were significantly lower in the waterpipe smoke group when compared to control mice. Treating mice with 1.78 μg selenium/kg body weight significantly restored the normal levels of these parameters. Histological examinations of lungs and liver confirmed the protective actions of selenium against the effects of exposure to waterpipe smoke. In conclusion, exposure of mice to waterpipe smoke-induced oxidative stress in lungs and liver. Administration of low level of selenium, 1.78 μg selenium/kg body weight as sodium selenite, exerted protective effects against oxidative stress induced by exposure to waterpipe smoke.

Determination of Genotoxic Effects of Hookah Smoking by Micronucleus and Chromosome Aberration Methods

BACKGROUND Use of a hookah (a type of water pipe) is a traditional way of smoking tobacco, particularly in the Middle East. In Turkey, its popularity has been growing in recent years, especially among young people. It is known that cigarette smoking has genotoxic effects and causes mutations, but no comprehensive study has been done on the genotoxic effects of hookah usage, particularly in Turkey. MATERIAL AND METHODS We collected peripheral blood/buccal smear samples from 30 subjects who did not smoke cigarettes but who regularly smoke a hookah an average of 2 times per week, and from 30 control subjects who had never smoked cigarettes or a hookah. Chromosome analyses were performed on the samples obtained from peripheral blood of each individual, 25 metaphase plaques were counted for each, and chromosome/chromatid breakage/gap parameters were evaluated. Micronucleus analysis was done on buccal smear samples and micronucleus/binucleus parameters were investigated by counting 2000 cells of each individual. RESULTS Chromosome breakage ratios were found to be 0.64±0.86 and 0.46±0.71 in the study and control groups, respectively, while chromatid breakage ratios were 0.53±0.83 and 0.53±0.71; fragment ratios were 0.82±1.24 and 0.21±0.49 (p<0.05); and gap ratios were 0.57±0.83 and 0.18±0.53 (p<0.05), respectively. Micronucleus ratio was 6.03±2.06 and 4.43±2.27 (p<0.05) in the study and control groups, respectively, and binucleus ratios were 8.53±3.23 and 12.15±5.18, respectively (p<0.05). CONCLUSIONS Results of our study reveal significant statistical differences between the individuals who smoked hookah and those who did not in terms of fragment, gap, micronucleus, and binucleus parameters, suggesting that smoking a hookah may cause genotoxic effects.

Waterpipe smoking associated with multiple sclerosis: A population-based incident case-control study

BACKGROUND

While cigarette and passive smoking have been identified as modifiable risk factors for multiple sclerosis (MS), there is no report regarding Waterpipe smoking-MS association.

OBJECTIVE

We examined the association of Waterpipe, tobacco, and passive smoking with MS.

METHODS

Population-based incident case-control study in Iran with 547 incident cases and 1057 general population controls (7 August 2013-17 February 2015). Logistic regression model was used. Multiplicative along with additive interaction was assessed using product term and Synergy Index (SI), respectively, and the population attributable fractions (PAFs) were calculated.

RESULTS

Having ever smoked Waterpipe, tobacco, or being exposed to passive smoking were all significantly associated with MS (odds ratio (OR) = 1.77 (1.36-2.31), OR = 1.69 (1.24-2.31), and OR = 1.85 (1.48-2.32), respectively). Clear dose-response associations were observed with the duration exposed ( p < 0.001 for all three) and the amount smoked ( p < 0.001 for Waterpipe and tobacco). Those who had all three types of smoking had an odds that was 4.1 times higher than those without any type. The three types of smoking jointly contributed to 30.9% of the MS incidence.

CONCLUSION

We identified Waterpipe smoking as a novel risk factor for MS. Given the global increase in Waterpipe smoking, especially among young adults, this finding reinforces the need for public health interventional and educational programs to combat this global increase.

Waterpipe tobacco smoking and its human health impacts

Waterpipe tobacco smoking (WTS, also known as hookah, shisha, narghile, and many other names) involves passing tobacco smoke through water prior to inhalation by the consumer. As the number of waterpipe smokers is rising rapidly, there is growing concern over the use of WTS, particularly as there has been a widely held misconception that WTS is free from health hazards. In reality, it is associated with a variety of adverse health outcomes on both a short- and long-term basis. Hence, it is desirable to develop advanced techniques for surveillance, intervention, and regulatory/policy frameworks specific to the production and use of waterpipe tobacco. This review is written to survey the types and extent of pollutants released from its use and their potential health risks. A review of the present regulation guidelines is also included.

College students' perceptions and knowledge of hookah use

PURPOSE

Hookah is an increasingly popular tobacco product among college students. The purpose of this study was to determine if college students are aware of tobacco and nicotine content in hookah, and examine associations between college students' knowledge and perceptions of hookah and their past 30-day hookah use.

METHODS

Participants were 5451 young adults attending one of 24 2- and 4-year colleges. Analyses examined if hookah knowledge was uniquely associated with current hookah use, over and above perceptions of harm and addictiveness, number of other tobacco products currently used, and socio-demographic factors. Analyses were first conducted for the entire sample and then only for current hookah users.

RESULTS

26.9% of all students believed hookah did not contain tobacco and 38% believed that hookah did not contain nicotine. Students who believed that hookah contained tobacco were at increased odds of hookah use, and those with increased perceptions of harm were at decreased odds of hookah use. However, hookah knowledge was not associated with hookah users' intensity of use. Moreover, although increased perceptions of harm were associated with lower intensity of use among current users, increased perceptions of addictiveness were associated with higher intensity of use.

CONCLUSIONS

This study shows gaps in knowledge of hookah contents, and adds to the body of literature, which provides evidence for mandating warning labels as well as tobacco interventions for college students.

Correlates of nicotine dependence among adolescent waterpipe smokers

INTRODUCTION

Waterpipe smoking is addictive and its use is increasing globally among youth, yet little is known about the factors associated with nicotine dependence (ND) among waterpipe smokers. We investigated the factors associated with ND symptoms among a sample of Lebanese adolescents who smoke a waterpipe.

METHODS

We collected data on factors potentially associated with ND (individual, socio-demographic, environmental, smoking patterns) among 160 current (past 30days) waterpipe smokers recruited from 8th and 9th school grades in Lebanon. We assessed the loss of autonomy over tobacco using the Hooked on Nicotine Checklist (HONC), ND using the International Classification of Diseases, 10th revision (ICD-10), and the number of ND symptoms endorsed.

RESULTS

Depressive symptoms, lower self-esteem, and having at least one sibling who smokes a waterpipe were associated with the presence of ND symptoms, while enrollment in public schools, smoking a waterpipe ≥30min per session, and believing that cigarette smoking is harmful to health were associated with endorsement of a higher number of ND symptoms. Smoking a whole waterpipe head without sharing and being in 9th grade in this study were associated with the presence and endorsement of a higher number of ND symptoms.

CONCLUSIONS

We identified specific social and psychological characteristics, waterpipe smoking patterns, and beliefs about harmful effects of smoking associated with the presence of ND among adolescent waterpipe smokers. Considering these factors when planning policies to prevent ND among waterpipe smokers is warranted.

Chemical analysis and potential health risks of hookah charcoal

Hookah (waterpipe) smoking is a very common practice that has spread globally. There is growing evidence on the hazardous consequences of smoking hookah, with studies indicating that its harmful effects are comparable to cigarette smoking if not worse. Charcoal is commonly used as a heating source for hookah smoke. Although charcoal briquettes are thought to be one of the major contributors to toxicity, their composition and impact on the smoke generated remains largely unidentified. This study aims to analyze the elemental composition of five different raw synthetic and natural charcoals by using Carbon-Hydrogen-Nitrogen (CHN) analysis, inductively coupled plasma (ICP), and scanning electron microscopy coupled with energy dispersive X-Ray spectrometry (SEM-EDS). Elemental analysis showed that the raw charcoals contain heavy metals such as zinc, iron, cadmium, vanadium, aluminum, lead, chromium, manganese and cobalt at concentrations similar, if not higher than, cigarettes. In addition, thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS) was used to analyze the chemical composition of the smoke produced from burning the charcoal samples. The smoke emitted from charcoal was found to be the source of numerous compounds which could be hazardous to health. A total of seven carcinogens, 39 central nervous system depressants and 31 respiratory irritants were identified.

Waterpipe Tobacco Smoking and Gastric Cancer Risk among Vietnamese Men

BACKGROUND

The association of waterpipe tobacco (WPT) smoking with gastric cancer (GC) risk was suggested.

METHODS

A hospital-based case-control study was conducted to examine the association of WPT with GC risk among Vietnamese men, in Hanoi city, during the period of 2003-2011. Newly-diagnosed GC cases (n = 454) and control patients (n = 628) were matched by age (+/- 5 years) and the year of hospitalization. Information on smoking and alcohol drinking habits and diet including salty food intake and fruits/vegetables consumption were obtained by the interview. Maximum likelihood estimates of odds ratios (ORs) and corresponding 95% confidence intervals (Cis) were obtained using conditional logistic regression models.

RESULTS

The group with the highest consumption of citrus fruits showed a significantly low GC risk (OR = 0.6, 95%CI = 0.4-0.8, P for trend = 0.002). However, there was no association of raw vegetable consumption with GC risk. Referring to never smokers, GC risk was significantly higher in current WPT smokers (OR = 1.8, 95%CI = 1.3-2.4), and it was more evident in exclusively WPT smokers (OR = 2.7, 95%CI = 1.2-6.5). GC risk tended to be higher with daily frequency and longer duration of WPT smoking but these trends were not statistically significant (P for trend: 0.144 and 0.154, respectively). GC risk of those who started smoking WPT before the age of 25 was also significantly high (OR = 3.7, 95%CI = 1.2-11.3). Neither cigarette smoking nor alcohol drinking was related to GC risk.

CONCLUSION

The present findings revealed that WPT smoking was positively associated with GC risk in Vietnamese men.

Variability in Puff Topography and Exhaled CO in Waterpipe Tobacco Smoking

OBJECTIVES

We examined intra-individual variability in puff topography and CO measures collected during laboratory waterpipe (WP) tobacco smoking using a research-grade waterpipe (RWP).

METHODS

WP smoking topography and exhaled CO measures were obtained from 10 established WP smokers in a single-blind, crossover design. Using a previously validated RWP, each participant smoked "Two Apples" WP tobacco ad libitum with a single quick-light charcoal to satiation in 3 laboratory sessions spaced at least one week apart. To examine the intra-individual variability, the intraclass correlation coefficient (ρ) for topography and CO measures were estimated. Results: The majority of the topography and CO measures were stable. Most stable were puff frequency (ρ = 0.88), number of puffs (ρ = 0.86), and puff duration (ρ = 0.80). Less stable were peak flow (ρ = 0.57) and total puff volume (ρ = 0.52).

CONCLUSIONS

The results provide the first set of empirical evidence that most topography and CO measurements collected using the RWP from a single laboratory smoking session are stable such that they can be representative of a smoker's puffing behaviors and reproducible among 3 sessions spread equally across 3 weeks.

Waterpipe smoking among health sciences university students: Knowledge, attitude and patterns of use

INTRODUCTION

Although waterpipe smoking is common in Gulf counties, its prevalence in Saudi Arabia is uncertain. The purposes of this study were (a) to assess the prevalence of waterpipe smoking among healthcare university students in Saudi Arabia and (b) to determine their attitudes and practices of waterpipe smoking.

MATERIALS AND METHODS

A cross-sectional survey was conducted among university students of three different health sciences colleges, namely medical, dental, and pharmacy, of a public university, through random cluster sampling. The questionnaire was designed to ask specific questions related to smoking in general and to waterpipe smoking specifically. The study was approved by the institutional research & ethics committees.

RESULTS

A total of 535 participants were included in the study. More than one-third of the participants that reported having ever smoked a waterpipe (n = 198, 37%), and the majority of these were current smokers (62.1%, n = 123); dental students were the most common (45.5%, n = 90). Curiosity and pleasure-seeking were the main factors associated with starting waterpipe smoking. About one-sixth (14.9%, n = 80) of the participants failed to identify a single harmful effect, while a vast majority of participants considered waterpipe smoking to be less unhealthy than cigarette smoking.

CONCLUSION

Waterpipe smoking is very popular among Saudi university students, and knowledge among university students about the dangers of waterpipe smoking is alarmingly low.

Evaluating ECG and carboxyhemoglobin changes due to smoking narghile

PURPOSE

This study aimed to investigate whether increased carboxyhemoglobin (COHB) levels and ECG changes, which associated with fatal ventricular dysrhythmias, including increased QT, P-wave and T peak (Tp)-Tend (Te) dispersion, can be detected after smoking narghile, which is a traditional method of smoking tobacco that is smoked from hookah device.

MATERIALS AND METHODS

After local ethics committee approval, this prospective study was conducted using healthy volunteer subjects at a "narghile café," which is used by people smoking narghile in an open area. Before beginning to smoke narghile, all subjects' 12-lead electrocardiographs (ECG), measurements of COHB levels, and vital signs were recorded. After smoking narghile for 30 min, the recording of the 12-lead ECGs and the measurements of COHB level and all vital signs were repeated.

RESULTS

The mean age of subjects was 26.8 ± 6.2 years (min-max: 18-40), and 28 subjects (84.8%) were male. Before smoking narghile, the median value of subjects' COHB levels was 1.3% (min-max: 0-6), whereas after smoking, the median value of COHB was 23.7% (min-max: 6-44), a statistically significant increase (p < 0.001). Analysis of the subjects' ECG changes after smoking narghile showed that dispersions of QT, QTc, P-wave and Tp-Te were increased, and all changes were statistically significant (p < 0.001 for all parameters).

CONCLUSION

Although, especially among young people, it is commonly thought that smoking narghile has less harmful or toxic effects than other tobacco products. The results of this study and past studies clearly demonstrated that smoking narghile can cause several ECG changes - including increased QT, P-wave and Tp-Te dispersion - which can be associated with ventricular dysrhythmias.

Waterpipe smoking and risk of coronary artery disease

PURPOSE OF REVIEW

Smoking tobacco using a water pipe is becoming more prevalent globally, particularly amongst younger populations. In addition to its growing popularity, more evidence is emerging regarding associated harm, and several misconceptions exist concerning the likely adverse health effects of waterpipe smoking (WPS). It is timely, therefore, to examine the body of evidence linking WPS to coronary artery disease (CAD). Here, we review the direct evidence linking WPS to CAD and examine additional, indirect evidence of associated harm. We discuss the clinical and public health implications of the current evidence and provide suggestions for further research.

RECENT FINDINGS

A multicentre case-control study in Lebanon has recently demonstrated an association between WPS and CAD. There are few prior studies making this direct link. However, a large body of evidence has emerged showing close similarities between WPS and cigarette smoking with regard to the toxicity of smoke and acute inflammatory and haemodynamic effects following exposure to it.

SUMMARY

There are consistent similarities between WPS and cigarette smoking in regard to association with CAD, the nature of the smoke produced, and the acute haemodynamic effects and inflammatory responses that follow exposure. These findings justify both public health and clinical interventions to reduce WPS. Further studies are warranted to confirm a causal association between WPS and CAD.

Hookah addiction among adolescents of five major cities in Central India

INTRODUCTION

Hookah use among the Indian adolescents is on the rise without them being aware of its tobacco content. This prevalence study highlights the issues associated with hookah use among high school students of five cities of Central India.

METHODS

A study among 3500 students of high schools was undertaken to estimate the prevalence of hookah users and its associated factors including initiation/cessation, patterns, perceptions and behavior. Responses were received from 225 hookah users.

RESULTS

The prevalence of hookah users in the present study was found to be 6.4% (225). Most of the subjects first learned about hookah use from friends (64.5%) and smoked hookah in hookah lounges (90.7%). Generally, the adolescents were aware of various lounges in their locality.

CONCLUSION

This study suggests that the use of hookahs is attracting adolescents at a very early age and is attributed to the presence of hookah lounges in various cities of Central India. Hence, the legality of hookah lounges in India should be reconsidered.

Nicotine exposure induces bronchial epithelial cell apoptosis and senescence via ROS mediated autophagy-impairment

Waterpipe smoking and e-cigarette vaping, the non-combustible sources of inhaled nicotine exposure are increasingly becoming popular and marketed as safer alternative to cigarette smoking. Hence, this study was designed to investigate the impact of inhaled nicotine exposure on disease causing COPD-emphysema mechanisms. For in vitro studies, human bronchial epithelial cells (Beas2b) were treated with waterpipe smoke extract (WPSE, 5%), nicotine (5mM), and/or cysteamine (250μM, an autophagy inducer and anti-oxidant drug), for 6hrs. We observed significantly (p<0.05) increased ubiquitinated protein-accumulation in the insoluble protein fractions of Beas2b cells treated with WPSE or nicotine that could be rescued by cysteamine treatment, suggesting aggresome-formation and autophagy-impairment. Moreover, our data also demonstrate that both WPSE and nicotine exposure significantly (p<0.05) elevates Ub-LC3β co-localization to aggresome-bodies while inducing Ub-p62 co-expression/accumulation, verifying autophagy-impairment. We also found that WPSE and nicotine exposure impacts Beas2b cell viability by significantly (p<0.05) inducing cellular apoptosis/senescence via ROS-activation, as it could be controlled by cysteamine, which is known to have an anti-oxidant property. For murine studies, C57BL/6 mice were administered with inhaled nicotine (intranasal, 500μg/mouse/day for 5 days), as an experimental model of non-combustible nicotine exposure. The inhaled nicotine exposure mediated oxidative-stress induces autophagy-impairment in the murine lungs as seen by significant (p<0.05, n=4) increase in the expression levels of nitrotyrosine protein-adduct (oxidative-stress marker, soluble-fraction) and Ub/p62/VCP (impaired-autophagy marker, insoluble-fraction). Overall, our data shows that nicotine, a common component of WPS, e-cigarette vapor and cigarette smoke, induces bronchial epithelial cell apoptosis and senescence via ROS mediated autophagy-impairment as a potential mechanism for COPD-emphysema pathogenesis.

Correlates of waterpipe smoking among Iranian university students and the role of religiosity

Waterpipe smoking among youth and adolescents in Iran has gained in popularity. The aim of this study was to investigate the relationship between waterpipe smoking and different dimensions of religiosity in a sample of students attending two major universities in South East Iran. A total of 682 students completed a waterpipe and cigarette smoking questionnaire along with the Duke University Religion Index. The lifetime prevalence of dual cigarette and waterpipe use was 48.3%, with prevalence of current use (within the last 30 days) of 24.9%. The proportions of lifetime and current waterpipe-only users were 27.0% and 18.8%, respectively. Students who participated more often in private religious activities were less likely to report engaging in waterpipe smoking (odds ratio: 0.82; 95% confidence interval: 0.71-0.98). A higher level of attendance of religious services was negatively associated with dual cigarette and waterpipe smoking (odds ratio: 0.71; 95% confidence interval: 0.54-0.93). Waterpipe-only use was significantly higher among males, students who had lower grade point averages, those who reported having a close friend or a family member who was a waterpipe smoker. To conclude, it is possible that religious observance may have a protective role in lowering waterpipe usage among Iranian university students.

A Systematic Review of Effects of Waterpipe Smoking on Cardiovascular and Respiratory Health Outcomes

BACKGROUND

Waterpipe smoking (WPS) is a social custom common in many Middle Eastern, North African, and Asian countries and has become increasingly popular in the US, especially among youth; however, WPS smoking may be increasing in the US adult population as well. There is a common belief among waterpipe (WP) smokers that WPS is less harmful than smoking cigarettes. Thus, this review aims to systematically explore the literature on the effects of WP tobacco smoking with a particular focus on cardiovascular and respiratory health outcomes as well as on oxidative stress, immunity, and cell cycle interference health outcomes.

METHODOLOGY

We conducted a systematic review, guided by the criteria of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the following online databases MEDLINE, CINAHL, ScienceDirect, PMC, and Cochrane Library. Results were summarized qualitatively.

RESULTS

Forty studies met the inclusion criteria established for this review. Based on the existing evidence, several cardiovascular and respiratory physiologic health indicators and conditions have been shown to be negatively affected by WPS. In addition to the effects of nicotine and chemical toxicant exposures, WPS was significantly associated with an increase in heart rate, blood pressure, and lower pulmonary function test results, as well as a number of health conditions such as lung cancer, alterations in oxidative stress, immunity, and cell cycle interference.

CONCLUSION

The current literature provides evidence that WPS is associated with a number of negative health indicators and outcomes. There is need for more research related to WPS and its effects on health so that appropriate campaigns and prevention interventions can be implemented to control the epidemic increase of WPS in the US.

Tobacco Use Disorders

Tobacco use is a pervasive public health problem and the leading cause of preventable morbidity and mortality in the United States. This article reviews the epidemiology of tobacco use in youth, with a description of cigarettes, alternative tobacco product, and polytobacco use patterns among the general population and among adolescents with psychiatric and/or substance use disorders. The article also provides an update on the diagnosis and assessment of tobacco use disorder in adolescents, with a particular focus on the clinical management of tobacco use in adolescents with co-occurring disorders.

Periodontal bone height of exclusive narghile smokers compared with exclusive cigarette smokers

OBJECTIVE

To compare the periodontal bone height (PBH) of exclusive narghile smokers (ENS) with that of exclusive cigarette smokers (ECS).

METHODS

Tunisian males aged 20-35 years who have been ENS for more than five narghile-years or ECS for more than five pack-years were recruited to participate in this comparative cross-sectional study. Information about oral health habits and tobacco consumption were gathered using a predetermined questionnaire. Plaque levels were recorded in four sites using the plaque index of Loe and Silness. The PBH was measured mesially and distally from digital panoramic radiographs of each tooth and expressed as a percentage of the root length. A PBH level ≤ 0.70 was applied as a cutoff reference value signifying bone loss. Student t-test and Chi(2) test were used to compare quantitative and qualitative data of both groups.

RESULTS

There were no significant differences between the ENS (n=60) and ECS (n=60) groups regarding age and the consumed quantities of tobacco (28 ± 4 vs. 27 ± 5 years, 7 ± 3 narghile-years vs. 8 ± 3 pack-years, respectively). Compared with the ECS group, the ENS group had a significantly higher plaque index (mean ± SD values were 1.54 ± 0.70 vs. 1.84 ± 0.73, respectively). However, the two groups had similar means of PBH (0.85 ± 0.03 vs. 0.86 ± 0.04) and tooth brushing frequencies (1.1 ± 0.8 vs. 0.9 ± 0.6 a day, respectively) and had similar bone loss frequencies (15% vs. 12%, respectively).

CONCLUSIONS

Both ENS and ECS exhibited the same PBH reduction, which means that both types of tobacco smoking are associated with periodontal bone loss.

Consensus statement on assessment of waterpipe smoking in epidemiological studies

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

DECOY: Documenting Experiences with Cigarettes and Other Tobacco in Young Adults

OBJECTIVES

We examined psychographic characteristics associated with tobacco use among Project DECOY participants.

METHODS

Project DECOY is a 2-year longitudinal mixed-methods study examining risk for tobacco use among 3418 young adults across 7 Georgia colleges/universities. Baseline measures included sociodemographics, tobacco use, and psychographics using the Values, Attitudes, and Lifestyle Scale. Bivariate and multivariable analyses were conducted to identify correlates of tobacco use.

RESULTS

Past 30-day use prevalence was: 13.3% cigarettes; 11.3% little cigars/cigarillos (LCCs); 3.6% smokeless tobacco; 10.9% e-cigarettes; and 12.2% hookah. Controlling for sociodemographics, correlates of cigarette use included greater novelty seeking (p < .001) and intellectual curiosity (p = .010) and less interest in tangible creation (p = .002) and social conservatism (p < .001). Correlates of LCC use included greater novelty seeking (p < .001) and greater fashion orientation (p = .007). Correlates of smokeless tobacco use included greater novelty seeking (p = .006) and less intellectual curiosity (p < .001). Correlates of e-cigarette use included greater novelty seeking (p < .001) and less social conservatism (p = .002). Correlates of hookah use included greater novelty seeking (p < .001), fashion orientation (p = .044), and self-focused thinking (p = .002), and less social conservatism (p < .001).

CONCLUSIONS

Psychographic characteristics distinguish users of different tobacco products.

Group Waterpipe Tobacco Smoking Increases Smoke Toxicant Concentration

INTRODUCTION

Waterpipe tobacco smoking is a global health concern. Laboratory research has focused on individual waterpipe users while group use is common. This study examined user toxicant exposure and smoke toxicant yield associated with individual and group waterpipe smoking.

METHODS

Twenty-two pairs of waterpipe smokers used a waterpipe individually and as a dyad. Before and after smoking, blood was sampled and expired carbon monoxide (CO) measured; puff topography was recorded throughout. One participant from each pair was selected randomly and their plasma nicotine and expired air CO concentrations were compared when smoking alone to when smoking as part of a dyad. Recorded puff topography was used to machine-produce smoke that was analyzed for toxicant content.

RESULTS

There was no difference in mean plasma nicotine concentration when an individual smoked as part of a dyad (mean = 14.9 ng/ml; standard error of the mean [SEM] = 3.0) compared to when smoking alone (mean = 10.0 ng/ml; SEM = 1.5). An individual smoking as part of as a dyad had, on average, lower CO (mean = 15.8 ppm; SEM = 2.0) compared to when smoking alone (mean= 21.3 ppm; SEM = 2.7). When two participants smoked as a dyad they took, on average, more puffs (mean = 109.8; SEM = 7.6) than a singleton smoker (mean = 77.7; SEM = 8.1) and a shorter interpuff interval (IPI; dyad mean = 23.8 seconds; SEM = 1.9; singleton mean = 40.8 seconds; SEM = 4.8). Higher concentrations of several toxicants were observed in dyad-produced smoke.

DISCUSSION

Dyad smoking may increase smoke toxicant content, likely due to the dyad's shorter IPIs and greater puff number. More work is needed to understand if group waterpipe smoking alters the health risks of waterpipe tobacco smoking.

IMPLICATIONS

This study is the first to measure toxicants in smoke generated from a waterpipe when used by a dyad. Relative to smoke generated by a singleton, dyad smoke had higher concentration of some toxicants. These differences may be attributed to differences in puffing behavior, specifically the shorter IPI and greater puff number observed in the dyad condition. Relative to singleton smokers, dyad smokers were exposed to less CO, but nicotine exposure did not differ. More work is needed to assess the health effects of inhalation of more toxicant-laden smoke during group waterpipe use.

Update on Smoking Cessation: E-Cigarettes, Emerging Tobacco Products Trends, and New Technology-Based Interventions

Tobacco use disorders (TUDs) continue to be overly represented in patients treated in mental health and addiction treatment settings. It is the most common substance use disorder (SUD) and the leading cause of health disparities and increased morbidity/mortality amongst individuals with a psychiatric disorder. There are seven Food and Drug Administration (FDA) approved medications and excellent evidence-based psychosocial treatment interventions to use in TUD treatment. In the past few years, access to and use of other tobacco or nicotine emerging products are on the rise, including the highly publicized electronic cigarette (e-cigarette). There has also been a proliferation of technology-based interventions to support standard TUD treatment, including mobile apps and web-based interventions. These tools are easily accessed 24/7 to support outpatient treatment. This update will review the emerging products and counter-measure intervention technologies, including how clinicians can integrate these tools and other community-based resources into their practice.

Hookah smoking behavior initiation in the context of Millennials

OBJECTIVES

This study aims to examine current hookah users' perceptions, attitudes, and normative beliefs regarding hookah smoking to further elucidate the rise in hookah smoking prevalence among young adults (aged 18-24 years) and reveal why hookah smoking is perceived as less harmful than other forms of tobacco consumption.

STUDY DESIGN

Qualitative.

METHODS

Data from six focus group interviews with hookah smokers aged between 18 and 24 years were analyzed using a grounded theory approach. Focus groups were evenly split between frequent and infrequent hookah users, and were predominantly composed of college students, with two groups of hookah users consisting of 18-24 year olds of non-student status.

RESULTS

Hookah users shared a much larger set of positive hookah smoking behavioral beliefs as opposed to negative behavioral beliefs. Generational traits served as the overarching commonality among the behavior performance initiation determinants observed. The most notable generational trends observed were within the cultural category, which included the following millennial characteristics: autonomy, personalization, novelty appeal, convenience, globally oriented, entertainment, collaboration, health conscious, and valuing their social network.

CONCLUSIONS

Millennial hookah users revealed mindfulness regarding both potential negative and positive reasons stemming from continued hookah use; however, behavioral beliefs were primarily fixated on the perception that hookah smoking was a healthier alternative to cigarette smoking. Future implications for this study's findings include generating more positive ways to express these traits for young adults; policy implications include raising hookah bar age limits, implementing indoor smoking restrictions, and limiting the ease of accessibility for purchasing hookah supplies.

Building Evidence-Based Tobacco Treatment in the Eastern Mediterranean Region: Lessons Learned by the Syrian Center for Tobacco Studies

The tobacco epidemic in Syria is characterized by high rates of cigarettes smoking in men and dramatic reemergence of waterpipe smoking, especially among youths and women. The Syrian Center for Tobacco Studies (SCTS), an NIH-funded pioneer research and capacity building institution, has developed a research infrastructure and conducted three randomized clinical trials to develop and rigorously test culturally-appropriate tobacco treatment programs integrated into primary healthcare (PHC) centers. This review aimed to discuss challenges and lessons learned from the Syrian experience. Addressing these challenges may inform future cessation research activities in Syria and other developing countries. To develop a research infrastructure, the SCTS has established Syria's first IRB and trained physicians/medical students in both tobacco treatment and research methods. Main challenges to conduct the cessation trials were difficulties of coordination between the local and international collaborators; high Smoking Rates among PHC providers; lack of pharmacological agents used in tobacco treatment; and difficulties of conducting research in a politically volatile region. Strategies to overcome these challenges were ensuring an active and regular involvement of all investigator; and advocating for a national smoking-cessation plan that involves training health care providers in smoking cessation treatment and make pharmacological agents used in smoking cessation available.

Sex Differences in Hookah-Related Images Posted on Tumblr: A Content Analysis

Hookah tobacco smoking is prevalent, widespread, and associated with large amounts of toxicants. Hookah tobacco smoking may be viewed differently by males and females. For example, females have been drawn to types of tobacco that are flavored, milder, and marketed as more social and exotic. Individuals often use the growing segment of anonymous social networking sites, such as Tumblr, to learn about potentially dangerous or harmful behaviors. We used a systematic process involving stratification by time of day, day of week, and search term to gather a sample of 140 Tumblr posts related to hookah tobacco smoking. After a structured codebook development process, 2 coders independently assessed all posts in their entirety, and all disagreements were easily adjudicated. When data on poster sex and age were available, we found that 77% of posts were posted by females and 35% were posted by individuals younger than 18. The most prominent features displayed in all posts were references to or images of hookahs themselves, sexuality, socializing, alcohol, hookah smoke, and tricks performed with hookah smoke. Compared with females, males more frequently posted images of hookahs and alcohol-related images or references. This information may help guide future research in this area and the development of targeted interventions to curb this behavior.

Patterns of Alternative Tobacco Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst Youth

PURPOSE

There is a growing public health concern related to the rapid increase in the use of multiple tobacco products among adolescents. This study examined patterns of adolescent use of cigarettes, e-cigarettes, cigars/cigarillo, hookah/waterpipe, and smokeless/dip/chewing tobacco in a population of southern California adolescents.

METHODS

Data from 2,097 11th- and 12th-grade participants in the Southern California Children's Health Study were collected via self-report in 2014. Study participants were asked about lifetime and current (past 30 days) use of cigarettes, cigars/cigarillos/little cigars, e-cigarettes, hookah/waterpipe, and smokeless/dip/chewing tobacco. Latent class analysis (LCA) was used to identify patterns of tobacco use.

RESULTS

Hookah/waterpipe tobacco use had the highest current prevalence (10.7%) followed by e-cigarettes (9.6%). The prevalence of use of smokeless/dip/chewing tobacco was lowest, with 2.2% of adolescents reporting current use. The LCA suggested four distinct classes, comprising nonusers (72.3% of the sample), polytobacco experimenters (13.9%), e-cigarette/hookah users (8.2%), and polytobacco users (5.6%). Multinomial logistic regression based on these four classes found that males had double the odds to be polytobacco users relative to nonusers compared to females (odds ratio, 2.3; 95% confidence interval, 1.26-4.25).

CONCLUSIONS

By identifying naturally occurring configurations of tobacco product use in teens, these findings may be useful to practitioners and policymakers to identify the need for tobacco control interventions that address specific tobacco products and particular combinations of polytobacco use. LCA can be used to identify segments of the population overrepresented among certain tobacco use classes (e.g., boys) that may benefit most from targeted polyproduct intervention approaches.

Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking

OBJECTIVE

Waterpipe tobacco smoking (WTS) is an emerging trend worldwide. To inform public health policy and educational programming, we systematically reviewed the biomedical literature to compute the inhaled smoke volume, nicotine, tar, and carbon monoxide (CO) associated with a single WTS session and a single cigarette.

METHODS

We searched seven biomedical bibliographic databases for controlled laboratory or natural environment studies designed to mimic human tobacco consumption. Included studies quantified the mainstream smoke of a single cigarette and/or single WTS session for smoke volume, nicotine, tar, and/or CO. We conducted meta-analyses to calculate summary estimates for the inhalation of each unique substance for each mode of tobacco consumption. We assessed between-study heterogeneity using chi-squared and I-squared statistics.

RESULTS

Sufficient data from 17 studies were available to derive pooled estimates for inhalation of each exposure via each smoking method. Two researchers working independently abstracted measurement of smoke volume in liters, and nicotine, tar, and CO in milligrams. All numbers included in meta-analyses matched precisely between the two researchers (100% agreement, Cohen's k=1.00). Whereas one WTS session was associated with 74.1 liters of smoke inhalation (95% confidence interval [CI] 38.2, 110.0), one cigarette was associated with 0.6 liters of smoke (95% CI 0.5, 0.7). One WTS session was also associated with higher levels of nicotine, tar, and CO.

CONCLUSIONS

One WTS session consistently exposed users to larger smoke volumes and higher levels of tobacco toxicants compared with one cigarette. These computed estimates may be valuable to emphasize in prevention programming.

Opportunistic insights into occupational health hazards associated with waterpipe tobacco smoking premises in the United Kingdom

BACKGROUND

Smokefree laws aim to protect employees and the public from the dangers of secondhand smoke. Waterpipe premises have significantly increased in number in the last decade, with anecdotal reports of poor compliance with the smokefree law. The literature is bereft of information pertaining to waterpipe premise employees. This study aimed to opportunistically gather knowledge about the occupational health hazards associated with working in waterpipe premises in London, England.

MATERIALS AND METHODS

Employees from seven convenience-sampled, smokefree-compliant waterpipe premises in London were observed for occupational activities. Opportunistic carbon monoxide (CO) measurements were made among those with whom a rapport had developed. Observations were thematically coded and analysed.

RESULTS

Occupational hazards mainly included environmental smoke exposure. Waterpipe-serving employees were required to draw several puffs soon after igniting the coals, thereby providing quality assurance of the product. Median CO levels were 27.5 ppm (range 21-55 ppm) among these employees. Self-reported employee health was poor, with some suggestion that working patterns and smoke exposure was a contributory factor.

CONCLUSIONS

The smokefree law in England does not appear to protect waterpipe premise employees from high levels of CO. Continued concerns surrounding chronic smoke exposure may contribute to poor self-reported physical and mental wellbeing.

Waterpipe tobacco smoking: A new smoking epidemic among the young?

Waterpipe (hookah, narghile) tobacco smoking (WTS) is becoming prevalent worldwide and is one of the most popular forms of tobacco use among youth. WTS prevalence has increased dramatically among youth in the United States within the past decade. Misperceived as less harmful than cigarette smoking, WTS is associated with many of the same chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, bronchitis, and asthma. Much of this risk is due to the fact that a single WTS session exposes users to large volumes of smoke that contain toxic chemicals such as carbon monoxide, cancer-causing polycyclic aromatic hydrocarbons, and volatile aldehydes. Unlike cigarette smoking, WTS poses unique risks of acute negative health outcomes including carbon monoxide poisoning and the spread of communicable diseases such as herpes and tuberculosis. Because waterpipe tobacco smoke contains the addictive chemical nicotine, youth who smoke tobacco from a waterpipe may be at risk for dependence. As a result, many youth may initiate WTS and continue to use despite negative health effects. Considering many of the potential negative health effects associated with WTS affect the pulmonary system, pulmonologists and primary care providers may treat patients who are waterpipe tobacco smokers and should be aware of the risk associated with WTS. The purpose of this review is to describe a waterpipe, the prevalence and correlates of WTS, the toxicants found in waterpipe tobacco smoke, the health effects of WTS, and implications for pulmonologists and other clinicians.

A Study of the Use, Knowledge, and Beliefs About Cigarettes and Alternative Tobacco Products Among Students at One U.S. Medical School

PURPOSE

In the United States, the prevalence of the use of alternative tobacco products (ATPs) (e.g., hookahs, e-cigarettes, cigars/cigarillos) has increased sharply. As future health care providers, medical students will play a critical role in health promotion and disease prevention. This study investigated medical students' use, knowledge, and beliefs about cigarettes and ATPs.

METHOD

In 2014, the authors surveyed all students enrolled at one medical school in New York City. The survey included questions about personal use of tobacco products, perceptions about the harms of ATPs and their role in disease causation, education about ATPs, and cessation training and practices related to ATPs and cigarettes. The authors compared results across medical school classes.

RESULTS

Of 720 students, 431 (59.9%) completed the survey. Of those, 64 (14.7%) were current users of tobacco or smoking products, including cigarettes (17; 3.9%), ATPs (21; 4.8%), or marijuana (39; 8.9%). Many believed that ATPs contributed less than cigarettes to various diseases. Respondents received less cessation training regarding ATPs than cigarettes (P < .0001). They felt less confident providing ATP cessation counseling than cigarette cessation counseling (P < .0001) and were less likely to report counseling patients on ATP cessation than cigarette cessation (46 [10.7%] versus 280 [64.8%], P < .0001).

CONCLUSIONS

A concerning percentage of surveyed medical students use tobacco products, including ATPs, and lack the knowledge, education, and cessation counseling skills to provide accurate information about them to patients. ATP education should be added to medical school curricula to address this gap.

Risk Factors Associated With Hookah Use

BACKGROUND

Potential harms associated with hookah smoking are largely unrecognized and it is emerging as a trendy behavior. To help inform policy and preventive interventions, we used responses from a population survey of US adults to examine risk factors associated with hookah involvement.

METHOD

An online survey of 17 522 US adults was conducted in 2013. The nationally representative sample was drawn from GfK Group's KnowledgePanel plus off-panel recruitment. Multinomial logistic regression was used to examine the relationships between tobacco use patterns across multiple products (cigarettes, cigars, and dissolvables), perceived harms towards regular pipe/hookah use, and demographic characteristics with hookah involvement (never used, ever used with/without reusing intent).

RESULT

Nearly one in five (16%) of the respondents had smoked hookah at least once in their life ("ever users"). Ever users of hookah were at higher risk of having used cigarettes, cigars, and dissolvable tobacco products (all P < .01). Odds for hookah use were greater for those who perceived regular pipe/hookah use as less dangerous (P < .05). Odds for hookah involvement were higher among young adults (P < .001), individuals with higher educational attainment (P < .01), and Hispanics/Latinos (P < .05).

CONCLUSIONS

Information about the public health harms associated with hookah smoking should be delivered to individuals at-risk for hookah smoking. It is likely that misconceptions about the safety of hookah smoking could be driving, at least in-part, its increase in popularity.

Tracking Hookah Bars in New York: Utilizing Yelp as a Powerful Public Health Tool

BACKGROUND

While cigarette use has seen a steady decline in recent years, hookah (water pipe) use has rapidly increased in popularity. While anecdotal reports have noted a rise in hookah bars, methodological difficulties have prevented researchers from drawing definitive conclusions about the number of hookah bars in any given location. There is no publicly available database that has been shown to reliably provide this information. It is now possible to analyze Internet trends as a measure of population behavior and health-related phenomena.

OBJECTIVE

The objective of the study was to investigate whether Yelp can be used to accurately identify the number of hookah bars in New York State, assess the distribution and characteristics of hookah bars, and monitor temporal trends in their presence.

METHODS

Data were obtained from Yelp that captures a variety of parameters for every business listed in their database as of October 28, 2014, that was tagged as a "hookah bar" and operating in New York State. Two algebraic models were created: one estimated the date of opening of a hookah bar based on the first Yelp review received and the other estimated whether the bar was open or closed based on the date of the most recent Yelp review. These findings were then compared with empirical data obtained by Internet searches.

RESULTS

From 2014 onward, the date of the first Yelp review predicts the opening date of new hookah bars to within 1 month. Yelp data allow the estimate of such venues and demonstrate that new bars are not randomly distributed, but instead are clustered near colleges and in specific racial/ethnic neighborhoods. New York has seen substantially more new hookah bars in 2012-2014 compared with the number that existed prior to 2009.

CONCLUSIONS

Yelp is a powerful public health tool that allows for the investigation of various trends and characteristics of hookah bars. New York is experiencing tremendous growth in hookah bars, a worrying phenomenon that necessitates further investigation.

Adverse Effects of Electronic Cigarette Use: A Concept Mapping Approach

INTRODUCTION

Electronic cigarette (ECIG) use has grown rapidly in popularity within a short period of time. As ECIG products continue to evolve and more individuals begin using ECIGs, it is important to understand the potential adverse effects that are associated with ECIG use. The purpose of this study was to examine and describe the acute adverse effects associated with ECIG use.

METHODS

This study used an integrated, mixed-method participatory approach called concept mapping (CM). Experienced ECIG users (n = 85) provided statements that answered the focus prompt "A specific negative or unpleasant effect (ie, physical or psychological) that I have experienced either during or immediately after using an electronic cigarette device is…" in an online program. Participants sorted these statements into piles of common themes and rated each statement. Using multidimensional scaling and hierarchical cluster analysis, a concept map of the adverse effects statements was created.

RESULTS

Participants generated 79 statements that completed the focus prompt and were retained by researchers. Analysis generated a map containing five clusters that characterized perceived adverse effects of ECIG use: Stigma, Worry/Guilt, Addiction Signs, Physical Effects, and Device/Vapor Problems.

CONCLUSIONS

ECIG use is associated with adverse effects that should be monitored as ECIGs continue to grow in popularity. If ECIGs are to be regulated, policies should be created that minimize the likelihood of user identified adverse effects.

IMPLICATIONS

This article provides a list of adverse effects reported by experienced ECIG users. This article organizes these effects into a conceptual model that may be useful for better understanding the adverse outcomes associated with ECIG use. These identified adverse effects may be useful for health professionals and policy makers. Health professionals should be aware of potential negative health effects that may be associated with ECIG use and policy makers could design ECIG regulations that minimize the risk of the adverse effects reported by ECIG users in this study.

How Health Risks Are Pinpointed (or Not) on Social Media: The Portrayal of Waterpipe Smoking on Pinterest

Waterpipe tobacco is among the most rapidly growing trends in tobacco smoking, the growing use and acceptance of which are taking place at a time when cigarette smoking is regarded in an increasingly negative manner (Martinasek, McDermott, & Martini, 2011). Given the health risks and the misperceptions associated with waterpipe smoking, this study focuses on how waterpipe smoking is portrayed and represented on the social media platform Pinterest. In total, 800 Pinterest pins were content analyzed. The vast majority of the sampled pins were primarily image based. More than half of the pins linked to a website external to Pinterest that often redirected the pinner to a commercial website. Waterpipe-focused pins portrayed waterpipe smoking more in a positive light than in a negative light, and conveyed a sense of pleasure, aesthetic, and relaxation, which tended to trigger more repins, likes, and higher levels of engagement. Overall, the risks of waterpipe smoking were not represented on Pinterest, indicating that the social media portrayal of waterpipe smoking needs improvement and could benefit from a public health perspective.

Air quality in New York City hookah bars

BACKGROUND

Hookahs are increasingly being used in the USA and elsewhere. Despite the popularity of hookah bars, there is a paucity of research assessing the health effects of hookah smoke, and although New York City (NYC) bans indoor tobacco smoking, hookah lounges claim that they only use herbal products without tobacco. This study investigated levels of multiple indices of indoor air pollution in hookah bars in NYC.

METHODS

Air samples were collected in 8 hookah bars in NYC. Along with venue characteristics, real-time measurements of fine particulate matter (PM2.5), black carbon (BC), and carbon monoxide (CO), and total gravimetric PM, elemental carbon (EC), organic carbon (OC), and nicotine were collected in 1-2 hour sessions.

RESULTS

Overall, levels of indoor air pollution increased with increasing numbers of active hookahs smoked. The mean (SD) real time PM2.5 level was 1179.9 (939.4) µg/m(3), whereas the filter-based total PM mean was 691.3 (592.6) µg/m(3). The mean real time BC level was 4.1 (2.3) µg/m(3), OC was 237.9 (112.3) µg/m(3), and CO was 32 (16) ppm. Airborne nicotine was present in all studied hookah bars (4.2 (1.5) µg/m(3)).

CONCLUSIONS

These results demonstrate that despite the ban on smoking tobacco products, at the very least, some NYC hookah bars are serving tobacco-based hookahs, and have elevated concentrations of indoor air pollutants that may present a health threat to visitors and employees. Therefore, there is an urgent need for better air quality monitoring in such establishments and policies to combat this emerging public health threat.

Secondhand smoke emission levels in waterpipe cafes in Doha, Qatar

BACKGROUND

Exposure to the emissions of a tobacco waterpipe is associated with increased health risks among its users as well as those exposed to its secondhand smoke. Waterpipe use is an emerging concern to the tobacco control community, particularly among countries of the Eastern Mediterranean Region. In 2002, Qatar adopted legislation that prohibited cigarette smoking inside public venues, but exempted tobacco waterpipe smoking. To inform the development and enforcement of effective policy, the impact of cigarette and waterpipe use on indoor air quality was monitored in waterpipe cafes in Doha, Qatar.

METHODS

Particulate matter (PM2.5) levels were measured inside and outside of a sample of 40 waterpipe cafes and 16 smoke-free venues in Doha, Qatar between July and October 2012. In addition, the number of waterpipes being smoked and the number of cigarette smokers were counted within each venue. Non-paired and paired sample t tests were used to assess differences in mean PM2.5 measurements between venue type (waterpipe vs smoke-free) and environment (indoor vs outdoor).

RESULTS

The mean PM2.5 level inside waterpipe venues (476 μg/m(3)) was significantly higher than the mean PM2.5 level inside smoke-free venues (17 μg/m(3); p<0.001), and significantly higher than the mean PM2.5 level found immediately outside waterpipe venues (35 μg/m(3); p<0.001). In smoke-free venues, the outside mean PM2.5 level (30 μg/m(3)) did not differ significantly from the mean PM2.5 inside levels inside these venues (p=0.121).

CONCLUSIONS

Elevated levels of particulate pollution were found in waterpipe cafes in Doha, Qatar, potentially endangering the health of employees and patrons. To protect the public from the dangers of secondhand tobacco smoke, and to change social norms around tobacco use, smoke-free policies that apply to all forms of combusted tobacco products, including the waterpipe, are needed.

Predictors of cessation in smokers suspected of TB: Secondary analysis of data from a cluster randomized controlled trial

BACKGROUND

Smoking cessation services are rarely found within health services in low income countries. Given the interactions between Tuberculosis (TB) and tobacco, including cessation support within TB programs offers a promising cost-effective solution. We conducted secondary analysis of data from a cluster randomized controlled trial of smoking cessation in health centers in Pakistan to identify predictors of continuous and short-term abstinence in smokers suspected of TB using cigarettes or hookah.

METHODS

Predictor variables of those continuously abstinent at 5 and 25 weeks post quit-date (continuous abstinence) and those abstinent only at 5 weeks (short-term abstinence) were compared with those who continued smoking and with each other. Self-reported abstinence at both time points was confirmed biochemically.

RESULTS

Data obtained from 1955 trial participants were analyzed. The factors that predicted continued smoking when compared to continuous abstinence were: being older RR 0.97 (0.95 to 0.98), smoking higher quantities of tobacco RR 0.975 (0.97 to 0.98) and sharing a workplace with other smokers RR 0.88 (0.77 to 0.99). Those with a confirmed TB diagnosis were more likely to remain continuously abstinent than those without RR 1.27 (1.10-1.47).

CONCLUSIONS

Those diagnosed with TB are more likely to be abstinent than those diagnosed with other respiratory conditions. Beyond this, predictors of continued smoking in Pakistan are similar to those in high income contexts. Taking advantage of the 'teachable moment' that a TB diagnosis provides is an efficient means for resource-poor TB programs in low income settings to increase tobacco cessation and improve health outcomes.

Design and Validation of a Research-Grade Waterpipe Equipped With Puff Topography Analyzer

INTRODUCTION

Worldwide, commercially available waterpipes vary widely in design and durability, including differences in fabrication materials, degree of leak-tight fit, and flow path diameter. Little is known about how the components of the waterpipe may influence puffing behavior and user's exposure to toxins. To systematically evaluate exposure, it is necessary to use a standardized research-grade waterpipe (RWP) when conducting clinical and laboratory-based trials.

METHODS

We developed a RWP that is configured with an in-line topography system which allows real-time measurement and recording of the smoke volume drawn through the RWP. The RWP was calibrated across the flow rate range expected for waterpipe tobacco smoking and the calibration was verified for known puff volumes using a smoking machine. Operation of the RWP was qualified in a cohort of experienced waterpipe smokers, each smoker using the RWP ad libitum in a laboratory setting while smoker topography and subjective effects data were collected.

RESULTS

RWP machine smoking was highly reproducible and yielded puff volumes that agreed well with true values. User acceptance was comparable, and puffing behavior was similar in pattern, with more frequent puffing in the beginning of the session, but significantly different in intensity from that used to estimate the majority of toxicant exposure reported in the literature.

CONCLUSIONS

The RWP operates with known precision and accuracy and is well accepted by experienced smokers. This tool can be used to determine the extent to which puffing behaviors are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings and/or additives known to increase addictiveness.

IMPLICATIONS

This study describes a standardized RWP, equipped with a puffing topography analyzer, which can operate with known precision and accuracy, and is well-accepted by experienced smokers in terms of satisfaction and reward. The RWP is an important tool for determining if puffing behaviors, and thus estimated toxin exposures, are affected by the waterpipe design, components, and/or accessories, tobacco nicotine content, sweet flavorings, and/or additives that are known to increase addictiveness.

Risk factors for hookah smoking among arabs and chaldeans

Hookah smoking is more prevalent among individuals of Middle Eastern descent. This study examined general and ethnic-specific risk factors for hookah smoking among Arabs and Chaldeans. A self-administered anonymous questionnaire was conducted among 801 adults residing in Southeast Michigan. Binary logistic regression modeling was used to predict risk factors for hookah smoking. Hookah smoking was significantly more prevalent among Arabs (32%) than Chaldeans (26%, p < 0.01) and being Arab was a risk factor for lifetime hookah use. Younger age (<25 years), being male, higher annual income, and having health insurance were significant risk factors for hookah use. Chaldeans believed to a greater extent than Arabs that smoking hookah is less harmful than cigarette smoking (75 vs. 52%, p < 0.001). Hookah smoking is prevalent in both ethnic groups, but significantly higher among Arabs. Results indicate that prevention efforts should target younger males with higher incomes.