Health effects associated with waterpipe smoking

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers

INTRODUCTION

Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers.

METHODS

We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes.

RESULTS

Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99).

CONCLUSIONS

A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted.

The role of sociodemographic factors associated with waterpipe smoking among male adolescents in western Iran: A cross-sectional study

INTRODUCTION

Waterpipe smoking (WPS) is an increasingly popular leisure activity among young people in Iran. The purpose of this study was to identify the role of sociodemographic factors associated with WPS among male adolescents in Iran.

METHODS

The study used a cross-sectional design. It included 730 high school male students (Grades 10–12) recruited through multistage random sampling conducted in 2017 in Hamadan city, western Iran. The self-administered questionnaires included information on demographic variables and behavioral risk factors related to WPS. Descriptive statistics and multinomial logistic regression modeling were conducted using SPSS.

RESULTS

The student mean age, and standard deviation (SD), and age at WPS initiation were 16.41 (0.84) and 13.31 (2.43) years, respectively. The percentages of never, former and current WPS were 37.3%, 36.4% and 26.3%, respectively. We found that ever cigarette smoking (OR=5.14, 95% CI: 2.56–10.32) and WPS family (OR=2.55, 95% CI: 1.40–4.64) were significantly associated with former WPS. Furthermore, being 18 years, studying in technical fields, reporting ever and current smoking of cigarettes and family usage of WP were significantly associated with current WPS. Friends with WPS (OR= 0.50, 95% CI: 0.34–0.72) however played a protective role on former WPS.

CONCLUSIONS

The results indicate that the prevalence of former and current WPS was high in Hamadan city. Thus, designing and implementing interventions for increasing students’, friends’ and family’s awareness regarding the harms of WPS and cigarette smoking are necessary to facilitate behavior change.

[Old and new tobacco products]

Tobacco use is not just about manufactured cigarettes. Rolling tobacco, highly prized in the wake of price increases, is estimated to carry more toxic agents than its counterpart. This study shows that the use of cigar, pipe, cigarillos and narghile also leads to a cohort of pathologies similar to or more than what is known for smoking single cigarettes. Exotic, liquid or heated forms do just as much. The non-smoked tobacco, often fallen into disuse in France is very used in the United States and especially in Scandinavia. Denuded of inhaled products, it is often pointed as a form of reduction of smoking risks. Its use by athletes in all countries as a doping attitude, especially in ski disciplines, required a campaign of prevention within the federations concerned.

Comparison of toxicant load from waterpipe and cigarette tobacco smoking among young adults in the USA

OBJECTIVES

To form population-level comparisons of total smoke volume, tar, carbon monoxide and nicotine consumed from waterpipe tobacco smoking (WTS) and cigarette smoking using data from a nationally representative sample of smokers and non-smokers aged 18-30 years.

METHODS

In March and April 2013, we surveyed a nationally representative sample of 3254 US young adults to assess the frequency and volume of WTS and cigarette smoking. We used Monte Carlo analyses with 5000 repetitions to estimate the proportions of toxicants originating from WTS and cigarette smoking. Analyses incorporated survey weights and used recent meta-analytic data to estimate toxicant exposures associated with WTS and cigarette smoking.

RESULTS

Compared with the additive estimates of WTS and cigarette smoking combined, 54.9% (95% CI 37.5% to 72.2%) of smoke volume was attributed to WTS. The proportions of tar attributable to WTS was 20.8% (95% CI 6.5% to 35.2%), carbon monoxide 10.3% (95% CI 3.3% to 17.3%) and nicotine 2.4% (95% CI 0.9% to 3.8%).

CONCLUSIONS

WTS accounted for over half of the tobacco smoke volume consumed among young US adult waterpipe and cigarette smokers. Toxicant exposures to tar, carbon monoxide and nicotine were lower, but still substantial, for WTS alone compared with WTS and cigarette smoking. Public health and policy interventions to reduce harm from tobacco smoking in young US adults should explicitly address WTS toxicant exposures.

Comparison of a preferred versus non-preferred waterpipe tobacco flavour: subjective experience, smoking behaviour and toxicant exposure

INTRODUCTION

One possible reason for the rapid proliferation of waterpipe (WP) smoking is the pervasive use of flavoured WP tobacco. To begin to understand the impact of WP tobacco flavours, the current study examined the impact of a preferred WP tobacco flavour compared with a non-preferred tobacco flavoured control on user's smoking behaviour, toxicant exposure and subjective smoking experience.

METHOD

Thirty-six current WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavour vs non-preferred tobacco flavour control) in a randomised cross-over design. Participants completed survey questionnaires assessing subjective smoking experience, exhaled carbon monoxide (eCO) testing, and provided blood samples for monitoring plasma nicotine. WP smoking topography was measured continuously throughout the smoking session.

RESULTS

While participants reported an enhanced subjective smoking experience including greater interest in continued use, greater pleasure derived from smoking, increased liking and enjoyment, and willingness to continue use after smoking their preferred WP tobacco flavour (p values <0.05), no significant differences were observed in nicotine and carbon monoxide boost between flavour preparations. Greater average puff volume (p=0.018) was observed during the non-preferred flavour session. While not significant, measures of flow rate, interpuff interval (IPI), and total number of puffs were trending towards significance (p values <0.10), with decreased IPI and greater total number of puffs during the preferred flavour session.

DISCUSSION

The current study is the first to examine flavours in WP smoking by measuring preferred versus control preparations to understand the impact on subjective experience, smoking behaviour and toxicant exposure. The pattern of results suggests that even this relatively minor manipulation resulted in significant changes in subjective experience. These results indicate a possible need for regulations restricting flavours in WP tobacco as with combustible cigarettes.

Hookah Use Among College Students: Recent Use, Knowledge of Health Risks, Attitude and Reasons for Use

Notwithstanding the efforts of health educators and other health professionals regarding tobacco and smoking cessation, research indicates that hookah smoking among college students remains a health concern. Research shows an upward trend in college students' hookah use. The purpose of this study was to identify and describe potential patterns/differences in college students' hookah use, and the relations among attitudes toward and knowledge about hookah use and use of this drug. A four-page, 20-item survey was used to collect data from participants (N = 403) and to measure participants 'recent use, knowledge of health risks, attitudes and reasons for hookah use among college students. Results indicated increased prevalence rates (53.8%) among participants of this study. Participants' recent hookah use was consistent with that of current research. Study findings supports current research, which found that college students have low negative perceptions of the health risks (addictive and detrimental properties) of hookah use. Analyses also determined that college students' attitudes toward hookah was associated with use of this drug. Regarding reasons why students may use hookah, data analysis indicated statistical significance in lifetime hookah use based on reasons for use. Study provide information for health educators creating hookah risk awareness educational programs aimed at reducing rates of hookah smoking among college students.

The impact of conventional and nonconventional inhalants on children and adolescents

AIM

Inhalant abuse in the adolescent population is a growing concern for care givers, communities, physicians, and medical providers. The aim of this article is to provide a review of the literature about this new challenge. In addition, it raises awareness about recent health policy rulings.

METHODS

Review of the literature was done.

RESULTS

In this review article, the prevalence of different modes of inhalant use and abuse in children and young adults and their potential health implications will be examined: Cigarettes, ENDS (E Cigarettes), Hookah, Marijuana, and Huffing. Additionally, marketing and advertising tactics will be reviewed to understand how they target this population. A review of current health policy recommendations from the FDA, American Thoracic Society, and the American Academy of Pediatrics will also be discussed.

CONCLUSION

The rapid rise in e-cigarette and hookah use in school aged children should trigger a call to action in the medical and public health communities. Health policy recommendations need to be made to reduce the level of adolescent substance abuse.

Comparing harm beliefs and risk perceptions among young adult waterpipe tobacco smokers and nonsmokers: Implications for cessation and prevention

Introduction

Very little is known about how waterpipe tobacco smokers and nonsmokers compare on harm beliefs about waterpipe tobacco smoking (WTS) and how these beliefs are related to risk appraisals and intentions to engage in WTS. We investigated these issues among young adult waterpipe tobacco smokers, susceptible nonsmokers, and non-susceptible nonsmokers.

Methods

Young adults ages 18 to 30 who smoked waterpipe tobacco during the last 30 days or never used waterpipe tobacco were recruited online through Turkprime. Nonsmokers were grouped as susceptible or not. Participants completed measures of harm beliefs, risk appraisals (i.e., perceived risks and worry), and desire to quit among smokers or willingness/curiosity to try waterpipe among nonsmokers.

Results

Analyses were based on 247 smokers and 418 nonsmokers. Smokers endorsed most strongly harm beliefs that portrayed WTS as safe, followed by susceptible and then non-susceptible nonsmokers. Most harm beliefs were significantly related to risk appraisals, yet weakly associated with desire to quit or willingness/curiosity to try waterpipe tobacco, except among susceptible nonsmokers.

Conclusions

Greater efforts are needed to correct maladaptive beliefs about WTS harms, especially among smokers. Among susceptible nonsmokers, harm beliefs may be more influential in predicting willingness to try WTS than risk appraisals.

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Waterpipe tobacco smokers view waterpipe tobacco smoking as safer than nonsmokers.

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Perceived risk correlates with many harm beliefs about waterpipe tobacco smoking.

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Among smokers, desire to quit is related more with perceived risk than harm beliefs.

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Among susceptible nonsmokers, intent to try waterpipe relates to many harm beliefs.

Acrolein Exposure in Hookah Smokers and Non-Smokers Exposed to Hookah Tobacco Secondhand Smoke: Implications for Regulating Hookah Tobacco Products

Introduction

Acrolein is a highly ciliatoxic agent, a toxic respiratory irritant, a cardiotoxicant, and a possible carcinogen present in tobacco smoke including hookah tobacco.

Methods

105 hookah smokers and 103 non-smokers attended exclusively hookah smoking social events at either a hookah lounge or private home, and provided urine samples the morning of and the morning after the event. Samples were analyzed for 3-hydroxypropylmercapturic acid (3-HPMA), a metabolite of acrolein.

Results

Geometric mean (GM) urinary 3-HPMA levels in hookah smokers and non-smokers exposed to secondhand smoke (SHS) increased significantly, 1.41 times, 95% CI = 1.15 to 1.74 and 1.39 times, 95% CI = 1.16 to 1.67, respectively, following a hookah social event. The highest increase (1.68 times, 95% CI = 1.15 to 2.45; p = 0.007) in 3-HPMA post a hookah social event was among daily hookah smokers (GM, from 1991 pmol/mg to 3348 pmol/mg). Pre-to-post event change in urinary 3-HPMA was significantly positively correlated with pre-to-post event change in urinary cotinine among hookah smokers at either location of hookah event, (ρ = 0.359, p = 0.001), and among non-smokers in hookah lounges (ρ = 0.369, p = 0.012).

Conclusions

Hookah tobacco smoke is a source of acrolein exposure. Findings support regulating hookah tobacco products including reducing humectants and sugar additives, which are precursors of acrolein under certain pyrolysis conditions. We suggest posting health warning signs for indoor smoking in hookah lounges, and encouraging voluntary bans of smoking hookah tobacco in private homes.

Implications

Our study is the first to quantify the increase in acrolein exposure in hookah smokers and non-smokers exposed to exclusively hookah tobacco SHS at hookah social events in homes or hookah lounges. Our findings provide additional support for regulating hookah tobacco product content, protecting non-smokers' health by posting health warning signs for indoor smoking in hookah lounges, and encouraging home bans on hookah tobacco smoking to safeguard vulnerable residents.

Hookah smoking impairs nasal mucociliary clearance

INTRODUCTION

Active tobacco smoking has been causally associated with nasal mucociliary clearance (MCC). Smoking through a hookah as an alternative to tobacco smoking has been shown in some scientific studies to have several toxic effects on human health. However, no study has been conducted on the effects on nasal MCC of the hookah as an alternative way of smoking tobacco. The aim of this study is to research whether or not hookah affects nasal MCC.

METHODS

The study included 40 subjects in the control group and 38 subjects in the hookah group. The hookah group was divided into two subgroups: those who used hookahs regularly, once every week (N1 group), and those who used hookahs more than once a week (N2 group, of 2 to 5 sessions/week). The N1 group had 20 subjects, while the N2 group had 18 subjects. The MCC test was performed on each subject and results were recorded in minutes.

RESULTS

The nasal MCC value in the total hookah group was found to be significantly higher than in the control group (p<0.05). The nasal MCC value of the N2 group that used hookahs more than once a week was significantly higher than those of the control group and N1 group that used hookahs once every week (p<0.05).

CONCLUSIONS

Our study has shown that, especially when a hookah was used more than once a week, there was MCC impairment that may put the participant at risk of respiratory tract diseases.

Levels of Urine Cotinine from Hookah Smoking and Exposure to Hookah Tobacco Secondhand Smoke in Hookah Lounges and Homes

Background

Nicotine, an addictive drug, is present in all forms of tobacco products, including hookah tobacco, which is not yet regulated in the United States.

Objectives

This study aimed to investigate the uptake of nicotine in hookah smokers and non-smokers exposed to secondhand smoke (SHS) at indoor hookah social events in natural settings where hookah tobacco was smoked exclusively.

Patients and Methods

We quantified cotinine, a metabolite of nicotine, in the urine of 105 hookah smokers and 103 non-smokers. Participants provided spot urine samples the morning of and the morning after attending an indoor hookah-only smoking social event at a hookah lounge or in a private home.

Results

Following a social event where exclusively hookah tobacco was smoked, urinary cotinine levels increased significantly 8.5 times (geometric mean (GM): 16.0 ng/mg to 136.1 ng/mg) among hookah smokers, and 2.5 times (GM: 0.4 ng/mg to 1.0 ng/mg) among non-smokers exposed exclusively to hookah tobacco SHS. Among hookah smokers, the highest increase in urinary cotinine levels post a hookah event was found in occasional hookah smokers in which GM levels increased significantly 31.2 times post smoking (from 2.0 ng/mg to 62.3 ng/mg). Reported reasons for preference to smoke hookah at home by hookah smokers who attended a hookah social event in a private home included recreational purposes, socializing with friends and family, ‘Me’ time and relaxing at home, more comfortable to smoke hookah at home, owning a hookah and hookah tobacco, eating and drinking while smoking hookah, and saving money by smoking at home and not going to hookah lounges.

Conclusions

Hookah tobacco smoke is a source of substantial nicotine exposure. Our results call for protecting hookah smokers’ and non-smokers’ health by requiring accurate hookah tobacco labels, raising taxes on hookah tobacco, reducing the spread of hookah lounges, and encouraging voluntary bans on smoking hookah tobacco in private homes.

Online data to contextualize waterpipe tobacco smoking establishments surrounding large US universities

Waterpipe tobacco smoking has grown in popularity among US college students and is associated with serious health risks. Much of the waterpipe tobacco smoking takes place in establishments such as "hookah bars" or in lounge settings. Web-based data platforms such as Yelp have demonstrated utility in locating these establishments but are prone to over- and underestimation. The purpose of this study was to optimize strategies for algorithmically estimating the prevalence of waterpipe tobacco smoking establishments. We conducted searches for potential waterpipe tobacco smoking establishments near highly residential US universities (N = 41). Of 521 potential establishments, independent coders confirmed 257 as permitting waterpipe tobacco smoking. We compared four strategies for using Yelp metadata to estimate the number of confirmed waterpipe tobacco smoking establishments by location. An accuracy-weighted approach generated estimates that closely matched confirmed data without significant over- or underestimation. The use of algorithms such as these may dramatically improve the feasibility and efficacy of future research linking environmental data and health outcomes.

Descriptive and injunctive norms of waterpipe smoking among college students

INTRODUCTION

Smoking tobacco via a waterpipe (WP) is on the rise, particularly among college students. One reason for this may be normative perceptions of WP tobacco smoking (WTS) among this population. The current study examined the perceived and actual descriptive and injunctive norms of WTS among a college student sample.

METHODS

Participants were 894 college students enrolled at a large, Midwestern university. Participants completed measures of WTS frequency and quantity and perceived/actual descriptive and injunctive norms of WTS.

RESULTS

Over one-third of the sample reported ever trying WTS, while only 2% reported current (past month) use. When comparing ever and never WP smokers, ever smokers reported greater perceived peer approval of WTS. Both males and females overestimated WTS frequency of same-sex students at their university.

DISCUSSION

The current study is one of the first to investigate descriptive and injunctive norms of WTS among college students. Students who report WTS are more likely to overestimate descriptive norms of WTS among their peers, suggesting corrective normative feedback regarding actual use by peers may be an important target for WTS intervention among college students. Future research should investigate the temporal association between normative perceptions and WTS behaviors among college students.

Water Pipe (shisha) Use and Legislation Awareness Against Shisha Smoking Among Medical Students: A study from Karachi, Pakistan

The aim of the study was to determine the prevalence of shisha smoking; its associated factors and awareness among medical students of Karachi, Pakistan following the imposition of nationwide shisha ban. A cross sectional study was conducted among medical students of two medical universities, namely Sindh Medical College and Aga Khan University Karachi, Pakistan from October till December 2014. A total of 422 participants were included. Data was collected via a self-administered questionnaire. The mean age was 21 ± 1.6 years and 229 (54.26 %) were females. Shisha smoking was found to be relatively common among medical students; the prevalence being 21.5 % out of which 73.62 % were males and belonged to a private medical college p value < 0.001. Majority of those who smoked shisha were aware that it contains tobacco (59.34 %), it has no filtration system (42.85 %), it is harmful (91.20 %) and 47.25 % held the opinion that shisha was not any better than cigarettes. It was alarming that majority students were aware of its harmful effects. However, a significant lack of awareness of the legislation against shisha was found among students.

American pediatric society's 2017 John Howland award acceptance lecture: a tale of two toxicants: childhood exposure to lead and tobacco

This article summarizes the presentation of the 2017 Howland Award to Michael Weitzman, MD, at the Annual Pediatric Academic Society Meetings. It summarizes the remarkable advances in understanding the effects and pathways of exposure of the two most common and pernicious of our nation's child environmental exposures, namely lead and tobacco. It also summarizes the profound effect of the translation of these findings into prudent and effective clinical and public health policies such that exposure to both has dramatically decreased over the past 40 years due to the tenacious activities of pediatricians, other child-related professionals, government agencies at all levels, and the American Academy of Pediatrics. Research and clinical activities, although essential, were not sufficient to produce these successes, but required extensive mentoring to produce a generation of academic pediatricians capable of conducting the requisite research, and extensive advocacy by pediatricians and others to overcome the formidable inertia and outright opposition to efforts to protect our children from these exposures. Moreover, the article highlights that both of these environmental exposures have roots in social and environmental injustice and neither is solved, and that there is no safe level of exposure to either of these toxicants.

Waterpipe use in adolescents in Northern Sweden: Association with mental well-being and risk and health behaviours

AIMS

There is a lack of studies examining the association between waterpipe smoking and mental well-being among adolescents. This study sought to determine whether waterpipe smoking is associated with mental well-being and other risk and health behaviours in adolescents.

METHODS

A questionnaire was distributed to 1006 adolescents in grades 9-12 (with a response rate of >95%), containing questions on measures of stress, mental energy and sleep. In addition, the questionnaire assessed risk and health behaviours, including use of a waterpipe, cigarettes, e-cigarettes, snus, alcohol, narcotics, gambling and exercise. Logistic regression was used to assess factors associated with waterpipe use.

RESULTS

Thirty-seven per cent ( n=371) of the participants had used a waterpipe at some point. Waterpipe use was associated with lower mental energy (odds ratio [OR] = 0.90, 95% confidence interval [CI] 0.81-0.99), higher stress (OR = 1.10, 95% CI 1.02-1.20) and use of cigarettes (OR = 3.82, 95% CI 2.33-6.03), e-cigarettes (OR = 3.26, 95% CI 2.12-4.99), snus (OR = 2.29, 95% CI 2.12-4.99), alcohol (OR = 1.92, 95% CI 1.07-3.44) and narcotics (OR = 3.64, 95% CI 1.75-7.58). Waterpipe use was not significantly associated with gambling, exercise or sleep quality.

CONCLUSIONS

Waterpipe use in adolescents is associated with worse mental well-being, as well as use of other nicotine products, alcohol and narcotics. Prospective studies are needed to delineate causal and temporal relationships further between waterpipe use and mental well-being and its relationship to other risky behaviours in order to design effective prevention programs.

Hazards of cigarettes, smokeless tobacco and waterpipe in a Middle Eastern Population: a Cohort Study of 50 000 individuals from Iran

BACKGROUND

There is limited information about the hazards of cigarettes, smokeless tobacco and waterpipe in the Middle East. The aim of this study was to determine the association between different types of tobacco use and earlier death in the Golestan Cohort Study.

METHODS

The Study includes 50 045 adults (aged 40-75 years) from north eastern Iran. The baseline questionnaire (2004-2008) assessed information about use of cigarettes, chewing tobacco (nass) and waterpipe. To assess the use of each type of tobacco compared with never tobacco users, we used Cox regression models adjusted for age, socioeconomic status, area of residence, education and other tobacco used, and stratified by sex, ethnicity and opium use.

RESULTS

17% of participants reported a history of cigarette smoking, 7.5% chewing tobacco (nass) and 1.1% smoking waterpipe, and these figures declined in the later birth cohorts. During a median follow-up of 8 years, 4524 deaths occurred (mean age 64.8+9.9 years). Current (HR=1.44; 95% CI 1.28 to 1.61) and former (HR=1.35; 95% CI 1.16 to 1.56) cigarette smokers had higher overall mortality relative to never tobacco users. The highest cigarette-associated risk was for cancer death among current heavy smokers (HR=2.32; 95% CI 1.66 to 3.24). Current nass chewing was associated with overall mortality (HR=1.16; 95% CI 1.01 to 1.34), and there was a 61% higher risk of cancer death in people chewing nass more than five times a day. We observed an association between the cumulative lifetime waterpipe use (waterpipe-years≥28) and both overall (HR=1.66; 95% CI 1.11 to 2.47), and cancer mortality (HR=2.82; 95% CI 1.30 to 6.11).

CONCLUSIONS

Regular use of cigarettes, smokeless tobacco and waterpipe were associated with the risk of earlier death (particularly from cancer) in our cohort.

Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study

INTRODUCTION

Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth.

METHODS

Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥3 criteria during 12months).

RESULTS

Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing≥1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥10 vs. <4 waterpipes; Hazard ratio (HR)=2.05, 95% CI: 1.52-2.58, p=0.007), and session length (>60min vs. <30min; HR=2.87, 95% CI: 2.83-2.91, p=0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥10 vs. <4 waterpipes; HR=2.56, 95% CI: 1.89-3.22, p=0.006), and smoking every day/almost every day vs. less than once weekly (HR=2.86, 95% CI: 2.12-3.60, p=0.007).

CONCLUSIONS

Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers.

Identifying Sentiment of Hookah-Related Posts on Twitter

BACKGROUND

The increasing popularity of hookah (or waterpipe) use in the United States and elsewhere has consequences for public health because it has similar health risks to that of combustible cigarettes. While hookah use rapidly increases in popularity, social media data (Twitter, Instagram) can be used to capture and describe the social and environmental contexts in which individuals use, perceive, discuss, and are marketed this tobacco product. These data may allow people to organically report on their sentiment toward tobacco products like hookah unprimed by a researcher, without instrument bias, and at low costs.

OBJECTIVE

This study describes the sentiment of hookah-related posts on Twitter and describes the importance of debiasing Twitter data when attempting to understand attitudes.

METHODS

Hookah-related posts on Twitter (N=986,320) were collected from March 24, 2015, to December 2, 2016. Machine learning models were used to describe sentiment on 20 different emotions and to debias the data so that Twitter posts reflected sentiment of legitimate human users and not of social bots or marketing-oriented accounts that would possibly provide overly positive or overly negative sentiment of hookah.

RESULTS

From the analytical sample, 352,116 tweets (59.50%) were classified as positive while 177,537 (30.00%) were classified as negative, and 62,139 (10.50%) neutral. Among all positive tweets, 218,312 (62.00%) were classified as highly positive emotions (eg, active, alert, excited, elated, happy, and pleasant), while 133,804 (38.00%) positive tweets were classified as passive positive emotions (eg, contented, serene, calm, relaxed, and subdued). Among all negative tweets, 95,870 (54.00%) were classified as subdued negative emotions (eg, sad, unhappy, depressed, and bored) while the remaining 81,667 (46.00%) negative tweets were classified as highly negative emotions (eg, tense, nervous, stressed, upset, and unpleasant). Sentiment changed drastically when comparing a corpus of tweets with social bots to one without. For example, the probability of any one tweet reflecting joy was 61.30% from the debiased (or bot free) corpus of tweets. In contrast, the probability of any one tweet reflecting joy was 16.40% from the biased corpus.

CONCLUSIONS

Social media data provide researchers the ability to understand public sentiment and attitudes by listening to what people are saying in their own words. Tobacco control programmers in charge of risk communication may consider targeting individuals posting positive messages about hookah on Twitter or designing messages that amplify the negative sentiments. Posts on Twitter communicating positive sentiment toward hookah could add to the normalization of hookah use and is an area of future research. Findings from this study demonstrated the importance of debiasing data when attempting to understand attitudes from Twitter data.

Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare

Cigarette smoking increases the risk of developing several systemic conditions including cancer, cardiovascular and pulmonary diseases. Cigarette smoking is also detrimental to oral health as it increases the incidence and severity of oral cancer, periodontal diseases and peri-implantitis, as well as impacting negatively on the dental patients' response to therapy. Therefore, consideration of smoking behavior and recommendation of smoking cessation are important parts of dental treatment planning. However, cigarettes are no longer the most popular form of tobacco use among adolescents in the United States and globally. In recent years, tobacco smoking using a waterpipe ("hookah," "shisha") and use of electronic cigarettes (ECIGs) has increased significantly. Thus, dental clinicians likely will treat more patients who are waterpipe and/or ECIG users. Yet, the literature on the health effects of waterpipe and ECIGs use is sparse. Both waterpipe and ECIGs deliver the dependence-producing drug nicotine. Waterpipe tobacco smoking has been associated with periodontitis, dry socket, premalignant lesions, and oral and esophageal cancer. The health effects of long-term ECIG use are unknown. The purpose of this review is to inform healthcare professionals about waterpipes and ECIGs, highlight emerging evidence on the biological effects of these increasingly popular tobacco products, and introduce perspectives for dental patient management and future research.

Urinary NNAL in hookah smokers and non-smokers after attending a hookah social event in a hookah lounge or a private home

Tobacco smoking and exposure to tobacco secondhand smoke (SHS) can cause lung cancer. We determined uptake of NNK (4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone), a tobacco specific potent pulmonary carcinogen, in hookah smokers and non-smokers exposed to hookah tobacco SHS. We analyzed data from a community-based convenience sample of 201 of adult (aged ≥18 years) exclusive hookah smokers (n = 99) and non-smokers (n = 102) residing in San Diego County, California. Participants spent an average of three consecutive hours indoors, in hookah lounges or private homes, where hookah tobacco was smoked exclusively. Total NNAL [the sum of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronides], the major metabolites of NNK, were quantified in spot urine samples provided the morning of and the morning after attending a hookah event. Among hookah smokers urinary NNAL increased significantly (p<0.001) following a hookah social event; the geometric mean doubled, from 1.97 to 4.16 pg/mg. Among non-smokers the increase was not significant (p = 0.059). Post hookah event urinary NNAL levels were highest in daily hookah smokers, and significantly higher than in non-daily smokers or non-smokers (GM: 14.96 pg/mg vs. 3.13 pg/mg and 0.67 pg/mg, respectively). For both hookah smokers and non-smokers, pre-to-post event change in urinary NNAL was not significantly different between hookah lounges and homes. We suggest posting health warning signs inside hookah lounges, and encouraging voluntary bans of smoking hookah tobacco in private homes.

Policy-Relevant Context of Waterpipe Tobacco Smoking among University Students in Six Countries Across the Eastern Mediterranean Region: A Qualitative Study

Background:

Waterpipe tobacco smoking rates in the Eastern Mediterranean region are some of the highest worldwide, especially among young people. This study aimed to improve our knowledge of the policy-relevant context of waterpipe smoking among six countries in the Eastern Mediterranean region.

Methods:

In-depth interviews were conducted in Bahrain, Egypt, Jordan, Lebanon, Palestine, and the United Arab Emirates. Participants were young adult university students (18-29 years) from both genders who had ever smoked the waterpipe, recruited from universities participating in this study. Directed content analysis was used to analyze the transcripts.

Results:

A total of 53 in-depth interviews were conducted in Arabic in 2016. Findings were organized around 5 themes: waterpipe product characteristics; patterns of waterpipe smoking; the waterpipe café setting; perceived health consequences; and health warning labels. Waterpipe smoking was commonly perceived as a safe alternative to cigarettes. Waterpipe tobacco was reported to be widely accessible and affordable to young participants. There is a lack of knowledge among waterpipe smokers about the associated health effects. Warning labels are effective at communicating health risks associated with waterpipe smoking.

Conclusions:

Regulatory frameworks for waterpipe tobacco smoking should be developed and enforced, including waterpipe-specific health warning labels that elucidate the harmful effects of waterpipe smoking.

Carbon monoxide poisoning from waterpipe smoking: a retrospective cohort study

OBJECTIVE

Waterpipe smoking may increasingly account for unintentional carbon monoxide poisoning, a serious health hazard with high morbidity and mortality. We aimed at identifying waterpipe smoking as a cause for carbon monoxide poisoning in a large critical care database of a specialty care referral center.

METHODS

This retrospective cohort study included patients with a history of exposure to waterpipe smoking and carbon monoxide blood gas levels >10% or presence of clinical symptoms compatible with CO poisoning admitted between January 2013 and December 2016. Patients' initial symptoms and carbon monoxide blood levels were retrieved from records and neurologic status was assessed before and after hyperbaric oxygen treatment.

RESULTS

Sixty-one subjects with carbon monoxide poisoning were included [41 males, 20 females; mean age 23 (SD ± 6) years; range 13-45] with an initial mean carboxyhemoglobin of 26.93% (SD ± 9.72). Most common symptoms included syncope, dizziness, headache, and nausea; 75% had temporary syncope. Symptoms were not closely associated with blood COHb levels.

CONCLUSION

CO poisoning after waterpipe smoking may present in young adults with a wide variability of symptoms from none to unconsciousness. Therefore diagnosis should be suspected even in the absence of symptoms.

Ethnic differences in smoking intensity and COPD risk: an observational study in primary care

Chronic obstructive pulmonary disease risk is lower in black and south Asian people than white people, when adjusting for age, sex, deprivation and smoking status. The role of smoking intensity was assessed for its contribution to ethnic differences in chronic obstructive pulmonary disease risk, a relationship not previously investigated. This cross-sectional study included routinely collected primary care data from four multi-ethnic London boroughs. Smoking intensity (estimated by cigarettes per day) was compared between ethnic groups. Chronic obstructive pulmonary disease risk was compared between ethnic groups using multiple logistic regression, controlling for age, sex, deprivation, asthma and both smoking status and smoking intensity, examined independently. In all, 1,000,388 adults were included. Smoking prevalence and intensity were significantly higher in the white British/Irish groups than other ethnic groups. Higher smoking intensity was associated with higher chronic obstructive pulmonary disease risk. Chronic obstructive pulmonary disease risk was significantly lower in all ethnic groups compared with white British/Irish after adjustment for either smoking status or smoking intensity, with lowest risk in black Africans (odds ratio 0.33; confidence interval 0.28-0.38). Ethnic differences in chronic obstructive pulmonary disease risk were not explained in this study by ethnic differences in smoking prevalence or smoking intensity. Other causes of ethnic differences in chronic obstructive pulmonary disease risk should be sought, including ethnic differences in smoking behaviour, environmental factors, repeated respiratory infections, immigrant status, metabolism and addictiveness of nicotine and differential susceptibility to the noxious effects of cigarette smoke.COPD: SMOKING INTENSITY NOT BEHIND ETHNIC DIFFERENCES IN DISEASE RISK: Lower smoking intensity among blacks and south Asians does not explain their lower risk for chronic obstructive pulmonary disease (COPD). A UK team led by Alexander Gilkes from Kings College London analysed primary care data from more than a million people living in four multi-ethnic boroughs of the British capital. The researchers found that smoking status and intensity (as measured by number of cigarettes smoked per day) were both significantly higher in white British or Irish groups than in other ethnic populations. Even after statistically adjusting for smoking status or smoking intensity, however, the researchers couldn't account for the fact that people of south Asian or African descent had much lower prevalence rates of COPD, a lung disease linked to smoking. The findings suggest that other explanations of ethnic differences are still needed.

Smoking and Lung Cancer: A Geo-Regional Perspective

Lung cancer is the leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) represents the most frequently diagnosed subtype of this morbid malignancy. NSCLC is causally linked to tobacco consumption with more than 500 million smokers worldwide at high risk for this fatal malignancy. We are currently lagging in our knowledge of the early molecular (e.g., genomic) effects of smoking in NSCLC pathogenesis that would constitute ideal markers for early detection. This limitation is further amplified when considering the variable etiologic factors in NSCLC pathogenesis among different regions around the globe. In this review, we present our current knowledge of genomic alterations arising during early stages of smoking-induced lung cancer initiation and progression, including discussing the premalignant airway field of injury induced by smoking. The review also underscores the wider spectra and higher age-adjusted rates of tobacco (e.g., water-pipe smoke) consumption, along with elevated environmental carcinogenic exposures and relatively poorer socioeconomic status, in low-middle income countries (LMICs), with Lebanon as an exemplar. This “cocktail” of carcinogenic exposures warrants the pressing need to understand the complex etiology of lung malignancies developing in LMICs such as Lebanon.

Pulmonary Abnormalities in Young, Light-Use Waterpipe (Hookah) Smokers

RATIONALE

Waterpipes, also called hookahs, are currently used by millions of people worldwide. Despite the increasing use of waterpipe smoking, there is limited data on the health effects of waterpipe smoking and there are no federal regulations regarding its use.

OBJECTIVES

To assess the effects of waterpipe smoking on the human lung using clinical and biological parameters in young, light-use waterpipe smokers.

METHODS

We assessed young, light-use, waterpipe-only smokers in comparison with lifelong nonsmokers using clinical parameters of cough and sputum scores, lung function, and chest high-resolution computed tomography as well as biological parameters of lung epithelial lining fluid metabolome, small airway epithelial (SAE) cell differential and transcriptome, alveolar macrophage transcriptome, and plasma apoptotic endothelial cell microparticles.

MEASUREMENTS AND MAIN RESULTS

Compared with nonsmokers, waterpipe smokers had more cough and sputum as well as a lower lung diffusing capacity, abnormal epithelial lining fluid metabolome profile, increased proportions of SAE secretory and intermediate cells, reduced proportions of SAE ciliated and basal cells, markedly abnormal SAE and alveolar macrophage transcriptomes, and elevated levels of apoptotic endothelial cell microparticles.

CONCLUSIONS

Young, light-use, waterpipe-only smokers have a variety of abnormalities in multiple lung-related biological and clinical parameters, suggesting that even limited waterpipe use has broad consequences on human lung biology and health. We suggest that large epidemiological studies should be initiated to investigate the harmful effects of waterpipe smoking.

Waterpipe and cigarette tobacco smoking among Palestinian university students: a cross-sectional study

BACKGROUND

During the last two decades, waterpipe tobacco smoking (WTS), also known as hookah, witnessed a global increase in use, especially among youth. Little information is known about the burden of WTS among Palestinian youth. A cross-sectional study was conducted to estimate the prevalence of WTS and cigarette smoking and explore the associated factors among a sample of Palestinian university students.

METHODS

1891 students, from five Palestinian universities in the West Bank and Gaza Strip, completed a self-administered, web-based survey in 2014-2015. The questionnaire, which was based on the Global Adults Tobacco Survey (GATS), had questions on WTS and cigarette smoking patterns and socio-demographic and university-related characteristics. Binary logistic regression analyses were computed to investigate associated factors with WTS and cigarette smoking.

RESULTS

50.9% of the sample was women. The mean age was 20.1 ± 2.0. Overall, 30.0% of participants were current tobacco smokers and 33.4% reported ever smoking tobacco through a waterpipe. The prevalence of current WTS (24.4%) surpassed the prevalence of current cigarette smoking (18.0%), with a significantly higher prevalence among men compared to women. The gender gap for WTS (36.4% vs. 12.9%) was smaller than that for cigarette smoking (32.8% vs. 3.6%). Binary logistic regression models for the total sample (men and women) revealed that men were more likely to be current waterpipe and cigarette tobacco smokers compared to women (AOR = 4.20, 95% CI = 3.22-5.48, and AOR = 10.91, 95% CI = 7.25-16.42, respectively). Geographic area of residence, faculty of study and self-reported academic achievement were also associated with the likelihood of being current waterpipe and cigarette tobacco smokers.

CONCLUSION

A high prevalence of WTS was reported among our study sample, and it surpassed the prevalence of cigarette smoking. Interventions to curb the practice of tobacco smoking among Palestinian youth should be tailored differently to WTS and cigarette smoking, be gender-sensitive and specific and target the regional variation in the smoking behavior.

Tobacco use among Kyrgyzstan medical students: an 11-year follow-up cross-sectional study

BACKGROUND

Medical students are the first line active force to combat tobacco epidemic, but they may suffer from high smoking prevalence and wrong attitude themselves. The aim of the study was to assess the effect of current curriculum on smoking behavior of medical students in Kyrgyzstan.

METHODS

20% random sample of all 6 years of the School of Medicine in Kyrgyz State Medical Academy were interviewed in spring 2016. The questionnaire included sections on tobacco products consumption and knowledge and attitude to counseling. We verified smoking status with exhaled CO measurement using Bedfont Smokelyzer.

RESULTS

In 618 students (48% female), the overall daily cigarette smoking prevalence was 21% (34% in males and 6% in females), being highest in years 1 and 3 and least in year 5 (prevalence difference 14%). With very low smokeless products and electronic cigarettes use prevalence, ever-smoking prevalence of waterpipe use was very high, reaching 85% in 6-year male students with alarmingly high prevalence in female students also. Only 74% students responded there was 100% evidence of harmful effects of tobacco, unchanged throughout the course of study.

CONCLUSIONS

The use of tobacco products, especially smoking waterpipe, in Kyrgyzstan medical students remains very high. Coupled with poor knowledge and high demand for more information, this demonstrates urgent need for more active and advanced training on tobacco control in medical school.

Review on the Implementation of the Islamic Republic of Iran about Tobacco Control, Based on MPOWER, in the Framework Convention on Tobacco Control by the World Health Organization

BACKGROUND

Smoking is the largest preventable cause of death in the world, killing nearly 6 million people annually. This article is an investigation of measures implemented laws in the Iran to study the proposed strategy of control and reduce tobacco use based on the monitor, protect, offer, warn, enforce and raise (MPOWER) policy.

METHODS

All laws approved by the Parliament along with the instructions on tobacco control prepared by the Ministry of Health and Medical Education, Ministry of Industry, Mine and Trade were collected and studied. Moreover, practical steps of Ministry of Health and other organizations were examined in this regard.

FINDINGS

Iranian Parliament after the adoption of the Framework Convention on Tobacco Control (FCTC) acts to create a comprehensive and systematic program for tobacco control legislation as a first step towards comprehensive national tobacco control and combat. In this law and its implementing guidelines and based on the strategy of MPOWER, specific implement is done to monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship and raise taxes on tobacco. However, the full objectives of the legislation have not achieved yet.

CONCLUSION

According to Iran's membership in the FCTC and executive producer of tobacco control laws and regulations, necessary infrastructure is ready for a serious fight with tobacco use. In Iran, in comparison with developed countries, there is a huge gap between ratified laws and performing of laws.

Graphic health warnings and their best position on waterpipes: A cross-sectional survey of expert and public opinion

INTRODUCTION

Our aim was to assess the visibility and efficiency of graphic health warnings (GHWs) on waterpipe tobacco packs (WTPs) and to explore other more effective places to display them for better impact. We also evaluated the visibility of GHWs when placed on the waterpipe device.

METHODS

We conducted 3 cross-sectional study phases using face-to-face survey questionnaires in 2014-2015. Phase I surveyed 31 tobacco control experts, while Phase II surveyed 700 participants and Phase III surveyed 348 from the public in Cairo, Egypt.

RESULTS

Approximately half of the experts and participants in Phases II and III thought that GHWs on WTPs are not adequately visible, and 68.9% and 79.6% in Phases II and III, respectively, suggested posting warnings also in other places. About one-third of experts and 69.1% of Phase II participants suggested posting GHWs inside cafés or in public places, while 46.9% of Phase III participants favored placing them on waterpipes. After viewing our suggested positions on a waterpipe, all experts, 80.6% of participants in Phase II, and 81.6% in Phase III acknowledged that GHWs would be more visible there. The mouthpiece was the location selected most often across all phases (31.1% in Phase I, 35.6% in Phase II and 36.3% in Phase III). Lung and throat cancers were similarly effective in raising participants’ concern about waterpipe smoking health risks (24.7%).

CONCLUSIONS

This is the first population-based study to explore the best location to place GHWs on waterpipes. Policymakers should consider enacting a regulatory framework for placing GHWs on waterpipe devices.

A Man in His 20s With Diffuse Lung Opacities and Acute Respiratory Failure After Hookah Smoking

A man in his 20s with no medical history presented with 2 days of progressively worsening shortness of breath accompanied by subjective fevers, chills, body aches, decreased appetite, night sweats, and cough producing nonbloody sputum. He denied childhood lung diseases, allergies, or a family history of lung disease. He did not smoke cigarettes but had smoked hookah in Saudi Arabia before moving to the United States 1 month before presentation and had restarted 2 days before the start of symptoms. He denied travel outside of the northeastern United States. He did not take medications, use illicit drugs, or engage in high-risk behavior.

Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon

INTRODUCTION

Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated.

METHODS

This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries.

RESULTS

The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children's participation as 'positive and active' in 77.9% of the sessions.

CONCLUSIONS

Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

Patterns of Waterpipe Tobacco Smoking Among U.S. Young Adults, 2013-2014

INTRODUCTION

Patterns of waterpipe smoking and associated other tobacco use were assessed among U.S. young adults (aged 18-24 years).

METHODS

A descriptive analysis of baseline data (2013-2014) from the Population Assessment of Tobacco and Health Study was conducted in 2016.

RESULTS

The study included 9,119 young adults-44% ever and 11% past-30 day waterpipe smokers (12% of men and 9% of women were past-30 day smokers). Among past-30 day smokers, waterpipe smoking frequency was distributed as follows: 4% daily, 23% weekly, 36% monthly, and 37% less than monthly. The average session exceeded 30 minutes for 79% of respondents. In this age group, 29% were exclusive waterpipe smokers, 16% were dual (waterpipe/cigarette) smokers, 8% were dual (waterpipe/e-cigarette) users, 19% were waterpipe/cigarette/e-cigarette users, and 28% presented with other combinations of poly use.

CONCLUSIONS

Waterpipe smoking is widespread among U.S. young adults. Although waterpipe patterns are predominantly intermittent, the average smoking session provides prolonged exposure. Waterpipe smoking among young adults is primarily characterized by the use of flavored tobacco, the café culture, and poly tobacco use. Rising trends in waterpipe smoking among U.S. youth warrant a strong regulatory response to prevent future waterpipe-related morbidity and mortality.

Prevalence and characteristics of flavoured tobacco use among students in grades 10 through 12: a national cross-sectional study in Canada, 2012-2013

BACKGROUND

Tobacco use is the leading cause of preventable death in Canada and the world. Despite documented decreases in the prevalence of smoking in Canada, increases in flavoured tobacco use by its youth poses a serious public health concern. This study examined the prevalence and characteristics of flavoured tobacco use among a national sample of Canadian students in grades 10 through 12.

METHODS

This study used a cross-sectional design on a nationally generalizable, school-based, Youth Smoking Survey (YSS), 2012-2013. It incorporated data from a representative sample of 19,979 students in grades 10-12 from across Canada. Univariate and multivariate logistic regression models were used to examine differences in flavoured tobacco use (menthol cigarettes, flavoured little cigar or cigarillo, flavoured cigar, flavoured tobacco in water pipe [hookah]) by demographic (sex, grade and ethnicity) and social characteristics (friends, siblings, parents/guardians who are smokers and weekly personal spending money).

RESULTS

This study found that 14.8% of the participating students used flavoured tobacco in the past 30-days. Results of the logistic regression analysis show that flavoured tobacco use was significantly higher among male students [(OR = 1.63; 95% CI = 1.36-1.95)], who had at least one friend or sibling who smoke [(OR = 2.20; CI = 1.62 to 2.99) and (OR = 1.51; CI = 1.22 to 1.88), respectively] and who received greater than $20/week in personal spending money [(OR = 1.76; CI = 1.26 to 2.45)].

CONCLUSIONS

The results of our study indicate that flavoured tobacco use is a growing public health concern and has a strong appeal among youth in Canada. This is a particularly troubling finding, especially in light of the fact that there is a national ban on certain flavoured tobacco products. To be effective, strategies specifically tailored for youth using flavoured tobacco would require appropriate educational/prevention initiatives, more comprehensive legislation and better regulatory mechanisms.

Shisha (waterpipe) smoking initiation among youth in Malaysia and global perspective: a scoping review (2006-2015)

OBJECTIVE

To explore the initiating factors of waterpipe tobacco smoking (WTS) among youth.

STUDY DESIGN

The analytic framework for this scoping review was performed using the methodology outlined by Arksey and O'Malley, which includes identification of the research question, study selection, charting the data, collating, summarizing and reporting the results that were primarily guided by the research question; 'what is known about the initiation of shisha smoking among youth?'

METHODS

Electronic databases such as Cochrane, MEDLINE and PsycINFO were used to search for relevant articles. Articles included were all in English and published within the year of 2006 to 2015. Inclusion criteria; i) age range of 10 to 29 years; ii) examined the reasons why youth started or tried WTS; iii) in full text. Therefore, 26 articles were included in this scoping review.

RESULTS

This review has identified and classified the initiating factors of WTS among youth in four subtopics: individual factors, interpersonal influences, cigarettes and alcohol use, and media influences. Individual factors and interpersonal influences played an important role in initiation factors of WTS among youth.

CONCLUSION

This study concludes that public health professionals within the Southeast Asia region need to promote innovative preventive measures through peer-to-peer led interventions that are also easily assessable on social media platforms. The public health messages need to address the misconceptions of risk associated to WTS use.

Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking

Waterpipe tobacco usage is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world, waterpipe usage surpasses cigarette smoking. Waterpipes and cigarettes are both mechanisms for inhalation of tobacco smoke and therefore have serious health consequences. However, because of the many differences between the two products, prevention and control strategies that have proven effective for cigarettes may not transfer readily to waterpipe. This report highlights the differences between waterpipes and cigarettes in toxicant exposure and physiologic effects, patterns of use, social norms, the extent of evidence, and the policy environment. There is little evidence to date around effective interventions for waterpipe prevention and control. The current state of evidence for intervention to curb or control waterpipe is at ground zero and critically needs attention from both scientists and policy makers. National and global efforts aimed at cigarette prevention have succeeded, particularly in developed countries. We suggest the time has come to harness what we know works for cigarette prevention and control and adapt it to tackle the growing epidemic of waterpipe tobacco use.

Two SNPs in the promoter region of Toll-like receptor 4 gene are not associated with smoking in Saudi Arabia

Defects in the innate immune system, particularly in Toll-like receptors (TLRs), have been reported in several cigarette smoke-promoted diseases. The aim of this study was to examine the impact of tobacco smoke on allelic frequencies of TLR4 single-nucleotide polymorphisms (SNPs) and to compare the genotypic distribution of these SNPs in a Saudi Arabian population with that in previously studied populations. DNA was extracted from 303 saliva samples collected from smokers and nonsmokers. Two transitional SNPs in the promoter region of TLR4 were selected, rs2770150 (T/C) and rs10759931 (G/A). Genotype frequencies were determined using quantitative polymerase chain reaction. Our results showed a slight effect of smoking on the distribution of rs2770150 and rs10759931. However, the differences were not significant. Thus, we conclude that the SNPs selected for this study were independent of smoking and may not be related to smoking-induced diseases.

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.

Chronic exposure to water-pipe smoke induces cardiovascular dysfunction in mice

Water-pipe tobacco smoking is becoming prevalent in all over the world including Western countries. There are limited data on the cardiovascular effects of water-pipe smoke (WPS), in particular following chronic exposure. Here, we assessed the chronic cardiovascular effects of nose-only WPS exposure in C57BL/6 mice. The duration of the session was 30 minutes/day, 5 days/week for 6 consecutive months. Control mice were exposed to air. WPS significantly increased systolic blood pressure. The relative heart weight and plasma concentrations of troponin-I and B-type natriuretic peptide were increased in mice exposed to WPS. Arterial blood gas analysis showed that WPS caused a significant decrease in [Formula: see text] and an increase in [Formula: see text] WPS significantly shortened the thrombotic occlusion time in pial arterioles and venules and increased the number of circulating platelet. Cardiac lipid peroxidation, measured as thiobarbituric acid-reactive substances, was significantly increased, while superoxide dismutase activity, total nitric oxide activity, and glutathione concentration were reduced by WPS exposure. Likewise, immunohistochemical analysis of the heart revealed an increase in the expression of inducible nitric oxide synthase and cytochrome c by cardiomyocytes of WPS-exposed mice. Moreover, hearts of WPS-exposed mice showed the presence of focal interstitial fibrosis. WPS exposure significantly increased heart DNA damage assessed by Comet assay. We conclude that chronic nose-only exposure to WPS impairs cardiovascular homeostasis. Our findings provide evidence that long-term exposure to WPS is harmful to the cardiovascular system and supports interventions to control the spread of WPS, particularly amid youths.NEW & NOTEWORTHY No data are available on the chronic cardiovascular effects of water-pipe smoke (WPS). Our findings provide experimental evidence that chronic exposure to WPS increased blood pressure, relative heart weight, troponin I, and B-type natriuretic peptide in plasma and induced hypoxemia, hypercapnia, and thrombosis. Moreover, WPS caused cardiac oxidative stress, DNA damage, and fibrosis.

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.

Reflections on 15 Years in the Global Tobacco Trenches

This paper is based on my 2017 Research Laureate Presentation at the Annual Scientific Meeting of the American Academy of Health Behavior in Tucson, Arizona. It provides a brief overview of the history of the smoking epidemic, and describes my work in global tobacco control, focusing on my experiences over the last 15 years as a co-founder and intervention director of the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria. The SCTS is an NIH-funded research center that draws on a broad range of complementary expertise and resources from developed and developing nations to address the tobacco epidemic in the Arab World. The SCTS strives to serve as a model of scientific excellence and commitment to the health of people in the Middle East and beyond. Major research streams using qualitative, epidemiological, clinical lab, and intervention methodologies are reviewed, along with some of the successes and challenges encountered since the SCTS's founding.

The relationship of waterpipe use with cigarette smoking susceptibility and nicotine dependence: A cross-sectional study among Hong Kong adolescents

INTRODUCTION

Waterpipe smoking has become increasingly popular in adolescents. We examined the association of waterpipe smoking with cigarette smoking susceptibility and nicotine dependence among adolescents in Hong Kong.

METHODS

We analyzed the data of School-based Survey on Smoking among Students 2012/13 from a representative sample of 45,857 secondary school students (US grades 7-12) in Hong Kong. Among never cigarette smokers (n=37,740), we conducted chi-square test to compare cigarette smoking susceptibility by current (past 30-day) waterpipe smoking status, and used multivariate logistic regression to examine the association between current waterpipe smoking and cigarette smoking susceptibility controlling for age, sex, peer cigarette smoking, and living with a cigarette smoker. Then we conducted chi-square test and multivariate logistic regression among current cigarette smokers (n=1694) to examine the relationship of current waterpipe smoking with two nicotine dependence outcomes, including heavier smoking (≥5 cigarettes/day) and first cigarette within 30min of waking, controlling for demographics and the number of smoking days in the past 30days.

RESULTS

Among never cigarette smokers, current waterpipe use was associated with cigarette smoking susceptibility (adjusted odds ratio [AOR]=3.58, 95% confidence interval [CI]: 1.61-7.97). Of current cigarette smokers, waterpipe use was associated with heavier smoking (AOR=1.56, 95% CI: 1.00-2.43) and first cigarette within 30min of waking (AOR=2.08, 95% CI: 1.35-3.19).

CONCLUSIONS

Surveillance, prevention, and intervention programs should address waterpipe use in addition to cigarette smoking. Educational programs need to inform youth about the harmful and addictive effects of waterpipe smoking. Public health campaigns deglamourizing waterpipe use may help reduce waterpipe smoking among youth.

The effect of habitual waterpipe tobacco smoking on pulmonary function and exercise capacity in young healthy males: A pilot study

BACKGROUND

Evidence regarding the health effects of habitual waterpipe smoking is limited, particularly in young smokers. Respiratory health and cardiopulmonary exercise tests were compared in young male habitual waterpipe smokers (WPS) versus non-smokers.

METHODS

69 WPS (≥3 times/week for three years) and 69 non-smokers were studied. Respiratory health was assessed through the American Thoracic Society and the Division of Lung Diseases (ATS-DLD-78) adult questionnaire. Pulmonary function and cardiopulmonary exercise tests were performed. Self-reported respiratory symptoms, forced expiratory volume in first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, forced expiratory flow between 25 and 75% of FVC (FEF25-75%), peak expiratory flow (PEF), exercise time, peak end-tidal CO2 tension (PetCO2), subject-reported leg fatigue and dyspnea; peak O2 uptake (VO2 max), and end-expiratory lung volume (EELV) change from baseline (at peak exercise) were measured.

RESULTS

WPS were more likely than non-smokers to report respiratory symptoms. WPS also demonstrated: shorter exercise time; lower peak VO2; higher perceived dyspnea at mid-exercise; lower values of the following: FEV1, FVC, PEF, and EELV change.

CONCLUSION

Habitual waterpipe tobacco smoking in young seemingly healthy individuals is associated with a greater burden of respiratory symptoms and impaired exercise capacity.