Health effects associated with waterpipe smoking

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.

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.

Effects of hookah smoking on indoor air quality in homes

INTRODUCTION

Hookahs (water pipes) are rapidly increasing in popularity worldwide. Evidence suggests that although perceived as safer than cigarette smoke, hookah smoke may be as, or even more, dangerous as cigarette smoke.

METHODS

Air samples from 33 homes-11 where only hookah-smoking occurred, 12 with only cigarettes and 10 with no smoking-were collected to analyse concentrations of particulate matter (PM_2.5), black carbon, elemental and organic carbon and carbon monoxide (CO). Air quality was assessed in rooms where smoking occurred and in an adjacent room.

RESULTS

Hookah and cigarette smoking impaired home air quality. The rooms in which hookahs were smoked showed the highest concentrations for all pollutants. CO was significantly greater in the rooms where hookahs were smoked than in the cigarette-smoking rooms and the non-smoking households (p<0.05). In addition, CO levels in the rooms adjacent to where hookah was smoked were 2.5-fold to 4-fold greater than those in the smoking and non-smoking rooms of the cigarette homes (p<0.05). PM_2.5 levels were also elevated in hookah homes compared to cigarette and non-smoking homes, although not significantly different.

CONCLUSIONS

This study, the first of its kind, demonstrates potentially hazardous levels of home air pollution in rooms where hookahs are being smoked as well as in adjacent rooms. These levels were greater than those in cigarette smoking homes, raising concerns about potential negative health effects on all individuals living in homes where hookahs are smoked.

Waterpipe Tobacco Smoking Among Dental Practitioners: Prevalence and Health Perceptions

BACKGROUND

Waterpipe tobacco smoking prevalence, practice, and the associated health perceptions among dental practitioners have not been previously reported. This study aims to determine the prevalence of waterpipe smoking among dental practitioners and to evaluate their awareness of health hazards of waterpipe smoking, particularly the adverse effects on oral health.

METHODS

This was a cross-sectional questionnaire-based survey among dental practitioners. Surveyed dental practitioners practiced dentistry in the holy city of Al-Madinah Al-Munawarah, a city in the Central-Western Region of Saudi Arabia, and the study was conducted during March 2015. The questionnaire consisted of questions on demographic data, history and practices of tobacco use, and perceptions toward the health hazards of smoking. Dentists were approached at their work places and invited to participate. Descriptive statistics were used to describe the sample’s demographic and smoking characteristics, while cross-tabulation and chi-square test were used to determine the statistical significance of association between the groups (P ≤ 0.05).

RESULTS

One hundred dental practitioners participated in the survey, with 55 males and 45 females. Twenty-six percent indicated that they were waterpipe smokers. Male gender and cigarette smoking were the only factors to be significantly associated with waterpipe smoking (P = 0.008 and P = 0.000, respectively). Most participants stated that waterpipe smoking is harmful to health, and the most commonly reported health hazard was respiratory disease, which was reported by 81% of participants.

CONCLUSIONS

Prevalence of waterpipe smoking among dental practitioners is comparable to adult populations but lower than younger populations of university students. Health awareness of dental practitioners regarding waterpipe smoking was judged to be insufficient.

Nano-based rescue of dysfunctional autophagy in chronic obstructive lung diseases

INTRODUCTION

ΔF508-CFTR (cystic fibrosis transmembrane conductance regulator) is a common CF-mutation that is known to induce oxidative-inflammatory stress through activation of reactive oxygen species (ROS), which induces autophagy-impairment resulting in accumulation of CFTR in aggresome-bodies. Cysteamine, the reduced form of cystamine, is a FDA-approved drug that has anti-oxidant, anti-bacterial, and mucolytic properties. This drug has been shown in a recent clinical trial to decrease lung inflammation and improve lung function in CF patients by potentially restoring autophagy and allowing CFTR to be trafficked to the cell membrane. Areas covered: The delivery of cysteamine to airway epithelia of chronic subjects prerequisite the need for a delivery system to allow rescue of dysfunctional autophagy. Expert opinion: We anticipate based on our ongoing studies that PLGA-PEG- or Dendrimer-mediated cysteamine delivery could allow sustained airway delivery over standard cysteamine tablets or delay release capsules that are currently used for systemic treatment. In addition, proposed nano-based autophagy induction strategy can also allow rescue of cigarette smoke (CS) induced acquired-CFTR dysfunction seen in chronic obstructive pulmonary disease (COPD)-emphysema subjects. The CS induced acquired-CFTR dysfunction involves CFTR-accumulation in aggresome-bodies that can be rescued by an autophagy-inducing antioxidant drug, cysteamine. Moreover, chronic CS-exposure generates ROS that induces overall protein-misfolding and aggregation of ubiquitinated-proteins as aggresome-bodies via autophagy-impairment that can be also be resolved by treatment with autophagy-inducing antioxidant drug, cysteamine.

Electrophysiological mechanisms of biased response to smoking-related cues in young smokers

Cigarette smoking during young adult may result in serious health issues in later life. Hence, it is extremely necessary to study the smoking neurophysiological mechanisms in this critical transitional period. However, few studies revealed the electrophysiological mechanisms of cognitive processing biases in young adult smokers. In present study, nineteen young smokers with 12h abstinent and 19 matched nonsmokers were recruited. By employing event-related potentials (ERP) measurements during a smoking cue induced craving task, electrophysiological brain responses were compared between the young adult smokers and nonsmokers. The Slow Positive Wave (SPW) amplitude of smoking-related cues was enhanced in young adult smokers compared with nonsmokers. In addition, increased P300/SPW component of smoking-related cues relative to neutral cues were found in young adult smokers. Meanwhile, a positive correlation between Cigarette Per Day (CPD) and the amplitude of ERPs wave (P300/SPW) at anterior (Fz), central (Cz) were observed in young adult smokers. Our findings provided direct electrophysiological evidence for the cognitive processing bias of smoking cue and may shed new insights into the smoking behavior in young adult smokers.

Toward a Regulatory Framework for the Waterpipe

Waterpipe smoking has been dramatically increasing among youth worldwide and in the United States. Despite its general association with misperceptions of reduced harm, evidence suggests this is a harmful and dependence-inducing tobacco use method that represents a threat to public health. Waterpipe products continue to be generally unregulated, which likely has contributed to their spread. The Family Smoking Prevention and Tobacco Control Act of 2009 granted the US Food and Drug Administration (FDA) the authority to regulate waterpipe products, and the FDA finalized a rule extending its authority over waterpipe products in May 2016. This critical step in addressing the alarming increase in waterpipe smoking in the United States has created urgency for research to provide the evidence needed for effective regulatory initiatives for waterpipe products. We aim to stimulate such research by providing a framework that addresses the scope of waterpipe products and their unique context and use patterns. The proposed framework identifies regulatory targets for waterpipe product components (i.e., tobacco, charcoal, and device), the waterpipe café setting, and its marketing environment dominated by Internet promotion.

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.

Cancer risk in waterpipe smokers: a meta-analysis

Objectives

To quantify by meta-analysis the relationship between waterpipe smoking and cancer, including cancer of the head and neck, esophagus, stomach, lung and bladder.

Methods

We performed a systematic literature search to identify relevant studies, scored their quality, used fixed and random-effect models to estimate summary relative risks (SRR), evaluated heterogeneity and publication bias.

Results

We retrieved information from 28 published reports. Considering only highquality studies, waterpipe smoking was associated with increased risk of head and neck cancer (SRR 2.97; 95 % CI 2.26–3.90), esophageal cancer (1.84; 1.42–2.38) and lung cancer (2.22; 1.24–3.97), with no evidence of heterogeneity or publication bias. Increased risk was also observed for stomach and bladder cancer but based mainly on poor-quality studies. For colorectum, liver and for all sites combined risk estimates were elevated, but there were insufficient reports to perform a meta-analysis.

Conclusions

Contrary to the perception of the relative safety of waterpipe smoking, this meta-analysis provides quantitative estimates of its association with cancers of the head and neck, esophagus and lung. The scarcity and limited quality of available reports point out the need for larger carefully designed studies in well-defined populations.

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.

Adolescent and Young Adult Perceptions of Hookah and Little Cigars/Cigarillos: Implications for Risk Messages

Use of hookah and little cigars/cigarillos (LCCs) is high among adolescents and young adults. Although these products have health effects similar to cigarettes, adolescents and young adults believe them to be safer. This study examined adolescent and young adult perceptions of hookah and LCCs to develop risk messages aimed at discouraging use among users and at-risk nonusers. Ten focus groups with 77 adolescents and young adults were conducted to explore their perceptions about the perceived risks and benefits of hookah and LCC use. Participants were users of other (non-cigarette) tobacco products (n = 47) and susceptible nonusers (n = 30). Transcripts were coded for emergent themes on participants' perceptions of hookah and LCCs. Participants did not perceive health effects associated with hookah and LCC use to be serious or likely to happen given their infrequency of use and perceptions that they are less harmful than cigarettes. Participants generally had positive associations with smoking hookah and LCCs for several reasons, including that they are used in social gatherings, come in various flavors, and can be used to perform smoke tricks. Because adolescents and young adults underestimate and discount the long-term risks associated with hookah and LCC use, effective messages may be those that focus on the acute/immediate health and cosmetic effects.

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.

Acute Effect of Hookah Smoking on the Human Coronary Microcirculation

Hookah (water pipe) smoking is a major new understudied epidemic affecting youth. Because burning charcoal is used to heat the tobacco product, hookah smoke delivers not only nicotine but also large amounts of charcoal combustion products, including carbon-rich nanoparticles that constitute putative coronary vasoconstrictor stimuli and carbon monoxide, a known coronary vasodilator. We used myocardial contrast echocardiography perfusion imaging with intravenous lipid shelled microbubbles in young adult hookah smokers to determine the net effect of smoking hookah on myocardial blood flow. In 9 hookah smokers (age 27 ± 5 years, mean ± SD), we measured myocardial blood flow velocity (β), myocardial blood volume (A), myocardial blood flow (A × β) as well as myocardial oxygen consumption (MVO2) before and immediately after 30 minutes of ad lib hookah smoking. Myocardial blood flow did not decrease with hookah smoking but rather increased acutely (88 ± 10 to 120 ± 19 a.u./s, mean ± SE, p = 0.02), matching a mild increase in MVO2 (6.5 ± 0.3 to 7.6 ± 0.4 ml·minute(-1), p <0.001). This was manifested primarily by increased myocardial blood flow velocity (0.7 ± 0.1 to 0.9 ± 0.1 second(-1), p = 0.01) with unchanged myocardial blood volume (133 ± 7 to 137 ± 7 a.u., p = ns), the same pattern of coronary microvascular response seen with a low-dose β-adrenergic agonist. Indeed, with hookah, the increased MVO2 was accompanied by decreased heart rate variability, an indirect index of adrenergic overactivity, and eliminated by β-adrenergic blockade (i.v. propranolol). In conclusion, nanoparticle-enriched hookah smoke either is not an acute coronary vasoconstrictor stimulus or its vasoconstrictor effect is too weak to overcome the physiologic dilation of coronary microvessels matching mild cardiac β-adrenergic stimulation.

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.

Hookah and Cigarette Smoking Among African American College Students: Implications for Campus Risk Reduction And Health Promotion Efforts

OBJECTIVE

To identify individual and institutional risks and protections for hookah and cigarette smoking among African American (AA) college students.

PARTICIPANTS

AA college students (N = 1,402; mean age = 20, range = 18-24 years; 75% female) who completed the Fall 2012 American College Health Association-National College Health Assessment II.

METHODS

Respondents were stratified into 4 mutually exclusive groups by last-30-day smoking status: cigarette-only use (5.1%), hookah-only use (5.9%), dual use (2.4%), and nonuse (86.6%). Multinomial logistic regression models identified the relative odds of exclusive and dual hookah and cigarette smoking.

RESULTS

Current hookah and cigarette smoking rates were comparably low. Age, gender identity, current substance use, interest in tobacco use information, and student population prevailed as risks and protections for hookah and cigarette smoking.

CONCLUSIONS

Campus health promotion campaigns may need to tailor messages to AA students, particularly those who use substances, to underscore the health risks of hookah and cigarette smoking.

Waterpipe smoking among secondary school students in Hong Kong

OBJECTIVES

To examine the prevalence of waterpipe smoking and its associated factors among adolescents in Hong Kong.

METHODS

We analyzed data of the School-based Survey on Smoking among Students 2012/2013 from a representative sample of 45,857 secondary school students in Hong Kong (mean age 14.8, SD 1.9). We conducted Chi-square tests and t test to compare current (past 30 days) waterpipe users and nonusers by sociodemographic variables and other covariates. Univariate and multivariable logistic regression models were used to examine the factors associated with current waterpipe smoking.

RESULTS

Overall, 1.2 % of students reported current waterpipe smoking, of whom 43 % reported concurrent use of cigarettes. Waterpipe was the most popular alternative tobacco product (non-cigarette) used by students. Current waterpipe smoking was associated with older age, male sex, higher self-perceived family financial status, poor knowledge about the harm of cigarette smoking, positive attitudes toward smoking, current cigarette smoking, other tobacco use, and alcohol consumption.

CONCLUSIONS

Waterpipe smoking was the most popular alternative tobacco product among Hong Kong adolescents. Despite the low prevalence, it should be routinely monitored. Education programs and cessation interventions need to address waterpipe smoking in addition to cigarette smoking.

Cigarette and waterpipe smoking among adult patients with severe and persistent mental illness in Bahrain: a comparison with the National Non-communicable Diseases Risk Factors Survey

BACKGROUND

Smoking has been associated with several types of mental illness namely schizophrenia, depression, bipolar disorders with a prevalence of smoking twice that of the general population. The study objective was to ascertain whether waterpipe tobacco smoking (WTS), cigarette smoking and all types of tobacco smoking are more common among Bahraini patients with severe and persistent mental illness (SPMI) than the general population.

METHODS

A cross-sectional study was conducted on 222 adult SPMI both in- and out- patients who attended the Psychiatric Hospital in Bahrain. A 29-item questionnaire, which included sociodemographic variables, pattern and history of psychiatric illness and a comprehensive smoking history, was used. Comparative smoking data were obtained from the Bahraini National Non-communicable Diseases Risk Factors Survey.

RESULTS

The prevalence of smoking of tobacco among SPMI patients was 30.2 % compared to 19.9 % in the general population. The corresponding values for cigarette smoking were 25.2, 13.8 %, respectively and for WTS, 11.3, 8.4 %, respectively. SPMI patients were 1.7 (95 % CI 1.3, 2.4 %) times more likely to be smokers, 2.1 (95 % CI 1.5, 2.9 %) times, cigarette smokers and 1.4 (95 % CI 0.9, 1.9 %) times WTS than the general population. SPMI patients smoked at a younger age and consumed more cigarettes than the general population. The mean age started smoking was lower among men than women, similar for cigarettes, and higher for WTS.

CONCLUSIONS

The prevalence of smoking among patients with SPMI in Bahrain is twice that of the general population. The findings of the study have implications on the provision of healthcare to mentally ill patients in the country.

Geographic Proximity of Waterpipe Smoking Establishments to Colleges in the U.S

INTRODUCTION

Waterpipe tobacco smoking is prevalent among college students in the U.S. and increasing in popularity. Waterpipe smoking establishments are almost completely unregulated, and limited information exists documenting the expansion of this industry. The objective of this study was to identify U.S.-based waterpipe establishments and measure their proximity to colleges/universities.

METHODS

Waterpipe establishments and their addresses were compiled using five Internet-based directories during 2014 and analyzed in 2015. Addresses were geocoded and overlaid on a U.S. map of accredited colleges/universities. Proximity of colleges/universities to the nearest waterpipe establishment was measured in 3-mile increments. Multinomial logistic regression was used to model the factors associated with proximity of waterpipe establishments to colleges/universities.

RESULTS

A total of 1,690 waterpipe establishments and 1,454 colleges/universities were included in the study. Overall, 554 colleges/universities (38.1%) were within 3 miles of a waterpipe establishment. Proximity of waterpipe establishments to colleges/universities was associated with higher full-time student enrollment. Public colleges/universities and those with a smoke-free campus policy were at lower odds of having waterpipe establishments within 3 miles of their campuses.

CONCLUSIONS

Waterpipe smoking establishments are more likely to be located near large colleges/universities. This study should inform initiatives aimed at reducing retail tobacco establishment exemptions.

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.

Hookah Smoking and Facilitators/Barriers to Lounge Use among Students at a US University

OBJECTIVE

To examine hookah tobacco use, hookah lounge attendance, and facilitators and barriers to hookah lounge attendance.

METHODS

A cross-sectional Web-based survey of a random sample of 1332 undergraduate students (Mean Age = 21.2 years) attending a United States university.

RESULTS

The majority of respondents (72.8%) had ever smoked hookah tobacco, and 28% of those had ever smoked during adolescence. The majority of ever hookah smokers (81.5%) and a portion of never hookah smokers (20%) had ever been to a hookah lounge. The adjusted odds of ever visiting a hookah lounge were 2.1 times higher among participants who reported that the closest hookah lounge to the university was < 5 miles away than those who reported that the closest hookah lounge was ≥ 5 miles away. Facilitators of visiting hookah lounges included friends and close proximity of hookah lounges to campus; barriers included cost of smoking hookah, crowded lounges, and having to be 18 years old.

CONCLUSION

Youth are vulnerable to experimenting with hookah tobacco smoking. Hookah lounges provide patrons the opportunity to smoke hookah tobacco with smoker and non-smoker friends in entertaining settings. Our findings suggest that zoning laws and anti-hookah smoking legislation may help curb hookah uptake by prohibiting hookah lounges from opening in close proximity to universities, reducing the density of hookah lounges in cities, and raising the admission age for hookah lounges to 21 years.

Changes in the expression and protein level of matrix metalloproteinases after exposure to waterpipe tobacco smoke

Waterpipe smoking has become a worldwide epidemic with health consequences that only now are beginning to be understood fully. Because waterpipe use involves inhaling a large volume of toxicant-laden smoke that can cause inflammation, some health consequences may include inflammation-mediated lung injury. Excess matrix metalloproteinase expression is a key step in the etiology of toxicant exposure-driven inflammation and injury. In this study, changes in the level and mRNA of major matrix metalloproteinases (MMP-1, -9, and -12) in the lungs of mice following exposure to waterpipe smoke were investigated. Balb/c mice were exposed to waterpipe smoke for one hour daily, over a period of 2 or 8 weeks. Control mice were exposed to fresh air only. ELISA and real-time PCR techniques were used to determine the protein and mRNA levels of MMP-1, -9, and -12 in the lungs. Our findings showed that MMP-1, -9, and -12 levels in the lung significantly increased after both 2 (p < 0.05) and 8 weeks (p < 0.01) exposures. Similarly, RT-PCR findings showed that mRNA of those proteinases significantly increased following 2 (p < 0.01) and 8 weeks (p < 0.001) exposures. In conclusion, waterpipe smoking is associated strongly with lung injury as measured by elevation in the expression of MMPs in the lung tissue.

The Effects of Brief Waterpipe Tobacco Use Harm and Addiction Education Messages Among Young Adult Waterpipe Tobacco Users

INTRODUCTION

This study investigated the immediate effects of brief education messages delivered online about harms and addictiveness of waterpipe tobacco use among young adult waterpipe users aged 18 to 30 years.

METHODS

Participants (n = 327, mean age 24.8 years, 62.1% male, 77.6% white, 67.8% used waterpipe monthly, 26.4% weekly, 5.8% daily) were recruited online and randomized to one of three experimental conditions: (1) Control condition viewing no messages; (2) Harms condition viewing messages about harms of waterpipe tobacco; (3) Harms and addiction condition viewing messages about harms and addictiveness of waterpipe tobacco. Outcomes included perceived harm and addictiveness of waterpipe, worry about harm and addiction, and desire to quit.

RESULTS

Compared to the control condition, participants in the harms condition reported significantly greater perceived harm and addictiveness of waterpipe relative to cigarettes, perceived risk of harm and addiction, worry about harm and addiction, and desire to quit. There were few significant differences in these outcomes between participants in the harms condition and the harms and addiction condition. Mediation analyses suggest waterpipe tobacco use harm messages may increase desire to quit by producing greater worry about harm and addiction.

CONCLUSIONS

Brief education messages about waterpipe tobacco use harm increased young adult's perceptions of harm and addictiveness of waterpipe tobacco use and generated stronger desire to quit. The waterpipe tobacco use addiction messages tested had little added impact. Studies should prospectively examine the real-world impact of waterpipe tobacco use harm messages and investigate more effective strategies for designing addiction messages.

IMPLICATIONS

This study demonstrates that brief education messages about waterpipe tobacco use harm can increase young adult waterpipe tobacco user's perceptions of harm and addictiveness of waterpipe tobacco use and generate stronger desire to quit. The findings indicate messages on addictiveness of waterpipe tobacco use have no added impact on these outcomes.

Associations of Adolescents' Cigarette, Waterpipe, and Dual Tobacco Use With Parental Tobacco Use

INTRODUCTION

Previous studies have demonstrated the influence of parental (both mother and father) cigarette smoking on adolescents' cigarette smoking. Little is known, however, about how parental tobacco use is related to waterpipe and dual waterpipe/cigarette use, which is increasing dramatically in the Arab countries.

METHODS

Study data (n = 34 788, N = 6 109 572) were obtained from nationally representative Global Youth Tobacco Surveys in 17 Arab countries. Study outcome was adolescents' tobacco use categorized into none, cigarette smoking only, waterpipe smoking (WPS) only, and dual use. Primary exposure included parental tobacco use categorized into 10 groups-maternal (mother) cigarette smoking only, maternal WPS only, maternal dual use, paternal (father) cigarette smoking only, paternal WPS only, paternal dual use, parental (both mother and father) cigarette smoking only, parental WPS only, parental dual use, and none. Weighted multinomial regression models were conducted to assess the relationships.

RESULTS

Adolescents reported smoking WPS only (5.7%), cigarettes only (2.9%), and dual use (3.5%). Compared to adolescent with no exposure to parental tobacco use, adolescent exposure to parental dual use was associated with significant increase in WPS only (OR = 6.08, 95% CI = 2.38-15.51) and dual use (OR = 3.86, 95% CI = 1.43-10.43). Effect modification of the relationship by adolescents' sex was observed.

CONCLUSIONS

This is the first study to examine adolescent cigarette, waterpipe, and dual use with parental tobacco use. Study findings may help development of cessation interventions targeting parental tobacco use to prevent the rising waterpipe and dual use strain of the global tobacco epidemic.

IMPLICATIONS

(1) Influence of parents' cigarette smoking on adolescents' smoking has been demonstrated in earlier studies, however, little is known about how tobacco use behaviors of mother and father influences an adolescent's cigarette, waterpipe and dual cigarette/waterpipe use. (2) Associations of parental (both mother and father) tobacco use with adolescents' tobacco use differed significantly if the adolescent is a waterpipe smoker or dual user compared to an adolescent cigarette smoker. (3) Adolescents' exposed to their mothers' WPS or dual use were more likely to be a waterpipe smoker or dual user. High likelihood of adolescents' cigarette, waterpipe and dual use is found in homes where parental tobacco use is rampant with both parents smoking either cigarette, waterpipe or both.

Eliciting preferences for waterpipe tobacco smoking using a discrete choice experiment: implications for product regulation

OBJECTIVES

Waterpipe smoking is highly prevalent among university students, and has been increasing in popularity despite mounting evidence showing it is harmful to health. The aim of this study was to measure preferences for waterpipe smoking and determine which product characteristics are most important to smokers.

SETTING

A large university in the Southeastern USA.

PARTICIPANTS

Adult waterpipe smokers attending the university (N=367).

DESIGN

Participants completed an Internet-based discrete choice experiment to reveal their preferences for, and trade-offs between, the attributes of hypothetical waterpipe smoking sessions. Participants were presented with waterpipe lounge menus, each with three fruit-flavoured options and one tobacco flavoured option, in addition to an opt out option. Nicotine content and price were provided for each choice. Participants were randomised to either receive menus with a text-only health-warning message or no message.

OUTCOME MEASURES

Multinomial and nested logit models were used to estimate the impact on consumer choice of attributes and between-subject assignment of health warnings respectively.

RESULTS

On average, participants preferred fruit-flavoured varieties to tobacco flavour. They were averse to options labelled with higher nicotine content. Females and non-smokers of cigarettes were more likely than their counterparts to prefer flavoured and nicotine-free varieties. Participants exposed to a health warning were more likely to opt out.

CONCLUSIONS

Fruit-flavoured tobacco and lower nicotine content labels, two strategies widely used by the industry, increase the demand for waterpipe smoking among young adults. Waterpipe-specific regulation should limit the availability of flavoured waterpipe tobacco and require accurate labelling of constituents. Waterpipe-specific tobacco control regulation, along with research to inform policy, is required to curb this emerging public health threat.

Waterpipe tobacco smoking: The critical need for cessation treatment

BACKGROUND

Waterpipe use has spread globally, and has substantial negative health effects and nicotine dependence potential. A growing literature addresses cessation-related experiences of waterpipe users, but this literature has not been summarized nor is guidance available on developing and testing cessation interventions.

METHOD

Authors gathered key empirical papers on waterpipe cessation-related topics, including observational studies about users' perceived ability to quit, interest in quitting, quit rates, and cessation trials. Based on this review, recommendations are made to guide the development and rigorous evaluation of waterpipe cessation interventions.

RESULTS

Many users want to quit and make quit attempts, but are unsuccessful at doing so on their own; therefore, developing and testing waterpipe cessation interventions should be a priority for global tobacco control efforts. Early efforts have tested waterpipe cessation interventions designed for, or adapted from, cigarette smoking programs.

CONCLUSIONS

Waterpipe-specific cessation programs that address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit are needed. Recommendations are provided to move waterpipe cessation intervention development forward.

Factors associated with smoking frequency among current waterpipe smokers in the United States: Findings from the National College Health Assessment II

BACKGROUND

Some waterpipe smokers exhibit nicotine dependent behaviors such as increased use over time and inability to quit, placing them at high risk of adverse health outcomes. This study examines the determinants of dependence by measuring frequency of use among current waterpipe smokers using a large national U.S.

METHODS

Data were drawn from four waves (Spring/Fall 2009 and Spring/Fall 2010) of the American College Health Association-National College Health Assessment datasets. The sample was restricted to students who smoked a waterpipe at least once in the past 30 days (N=19,323). Ordered logistic regression modeled the factors associated with higher frequency of waterpipe smoking.

RESULTS

Among current waterpipe smokers, 6% used a waterpipe daily or almost daily (20-29 days). Daily cigarette smokers were at higher odds of smoking a waterpipe at higher frequencies compared with non-smokers of cigarettes (OR=1.81; 95% CI=1.61-2.04). There was a strong association between daily cigar smoking and higher frequency of waterpipe smoking (OR=7.77; 95% CI=5.49-11.02). Similarly, students who used marijuana had higher odds of smoking a waterpipe at higher frequencies (OR=1.57; 95% CI=1.37-1.81).

CONCLUSIONS

Daily consumers of other addictive substances are at a higher risk of intensive waterpipe smoking and thus higher risk of waterpipe dependence. Intervention programs must incorporate methods to reduce waterpipe dependence and subsequently prevent its deleterious health effects.

Interventions for waterpipe smoking cessation

BACKGROUND

Waterpipe tobacco smoking is a traditional method of tobacco use, especially in the Eastern Mediterranean Region (EMR), but its use is now spreading worldwide. Recent epidemiological data, for example, show that waterpipe smoking has become the most prevalent tobacco use method among adolescents in the EMR, and the second most prevalent in the US. Waterpipes are used socially, often being shared between friends or family at home, or in dedicated bars and cafes that provide waterpipes to patrons. Because the smoke passes through a reservoir of water, waterpipe tobacco smoking is perceived as being less harmful than other methods of tobacco use. At least in some cultures, women and girls are more likely to use a waterpipe than to use other forms of tobacco, and it is popular among younger smokers. Accumulating evidence suggests that some waterpipe smokers become addicted, have difficulty quitting, and experience similar health risks as cigarette smokers.

OBJECTIVES

To evaluate the effectiveness of tobacco cessation interventions for waterpipe users.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group specialized register in June 2015. We also searched MEDLINE, EMBASE, PsycINFO and CINAHL , using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language, and especially in regions where waterpipe use is widespread.

SELECTION CRITERIA

We sought randomized, quasi-randomized or cluster-randomized controlled trials of smoking cessation interventions for waterpipe smokers of any age or gender. The primary outcome of interest was abstinence from tobacco use, measured at six months post-cessation or longer, regardless of whether abstinence was biochemically verified. We included interventions that were pharmacological (for example, nicotine replacement therapy (NRT) or bupropion) or behavioural, or both, and could be directed at individual waterpipe users or at groups of users. We only included tobacco cessation interventions, and did not consider trials of prevention of uptake.

DATA COLLECTION AND ANALYSIS

Two review authors assessed abstracts of the studies retrieved by the search strategy, for possible inclusion in the review. We retrieved full-text articles for all abstracts that any of the authors believed might be suitable. Two review authors then extracted data and assessed trial quality independently in accordance with standard Cochrane Collaboration methodologies. We aimed to pool groups of studies that we considered to be sufficiently similar, provided there was no evidence of substantial statistical heterogeneity, and aimed to estimate a pooled risk ratio (RR) using the Mantel-Haenszel fixed-effect method. Where meta-analysis was not possible, we presented summary and descriptive statistics.

MAIN RESULTS

Our search retrieved 1311 unique citations, of which 1289 were excluded after title and abstract screening. Of the remaining 22, we excluded 19 because they were empirical studies that were not randomized, quasi-randomized or cluster-randomized controlled trials (n = 12), because they were review articles (n = 3), because they described protocols only (n = 2), they were conducted among cigarette smokers only (n = 1), or they had only a three-month follow-up (n = 1).We identified three controlled trials which tested cessation interventions for waterpipe smokers. Studies were carried out in Egypt (Mohlman 2013), Pakistan (Dogar 2014), and the US (Lipkus 2011). One was a randomized controlled trial and two were cluster-randomized trials. Two studies tested individual-level interventions, and one tested a community-level intervention. Two studies included only behavioural interventions, and one study (Dogar 2014) included two intervention groups: one behavioural, and the other behavioural with bupropion. The Lipkus and Mohlman studies delivered waterpipe-specific interventions, and the Dogar study delivered a non-specific tobacco intervention. Due to study variation we did not pool results, and intervention effects are reported descriptively. Compared to control groups, waterpipe smoking cessation rates were higher in the intervention groups in all three studies, with a significant difference in two studies. For the Dogar study, the RRs for waterpipe smoking abstinence at 25 weeks among waterpipe-only smokers were 2.2 (95% confidence interval (CI) 1.3 to 3.8; 180 participants) in the behavioural group, and 2.5 (95% CI 1.3 to 4.7; 84 participants) in the behavioural plus bupropion group. In our analysis we have combined both groups, to give a RR of 2.28 (95% CI 1.36 to 3.83; 200 participants). The Mohlman study delivered a RR in male waterpipe-smokers at one year in favour of the intervention of 3.25 (95% CI 1.19 to 8.89).

AUTHORS' CONCLUSIONS

Although the literature on waterpipe cessation interventions remains sparse, the reviewed studies provide a basis for developing interventions in this area. The lack of statistically significant effects in one of the three studies is not unexpected, given the small and pilot nature of the studies. The studies highlight important design and content issues that need to be considered for future cessation trials in waterpipe smokers. These include building on the vast experience developed in the study of smoking cessation interventions in cigarette smokers, whilst including components and assessment tools that address the specific aspects of waterpipe smoking, such as its social dimension, unique experiences, and cues.

The Effect of Waterpipe Tobacco Smoke Exposure on Learning and Memory Functions in the Rat Model

Tobacco smoking is a global health hazard that kills about 5 million people annually. Waterpipe smoking is among the most popular methods of tobacco consumption worldwide. In this study, we investigated whether waterpipe smoking impairs learning and memory in the hippocampus, a question of special concern due to the particular popularity of waterpipe use among youth. Additionally, possible molecular targets for expected learning and memory impairment were determined. In this study, rats were exposed to waterpipe smoke (WTS) by whole body exposure 1 h × 5 days/week, for 1 month, and outcomes were compared to a control group exposed only to fresh air. Outcomes included spatial learning and memory using the radial arm water maze (RAWM) and oxidative stress biomarkers (catalase, glutathione peroxidase (GPx), superoxide dismutase (SOD), glutathione (GSH), oxidized glutathione (GSSG), GSH/GSSG ratio). We found that WTS exposure led to impaired short- and long-term memory. This impairment was accompanied by reduced hippocampal activity of catalase, SOD, GPx, GSH, and GSH/GSSG, elevated GSSG, thus marked changes in oxidative stress biomarkers. In conclusion, there is reason for concern that WTS exposure may impair cognitive ability.

Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence?

OBJECTIVE

Waterpipe tobacco smoking (WTS) involves passing tobacco smoke through water prior to inhalation, and has spread worldwide. This spread becomes a public health concern if it is associated with tobacco-caused disease and if WTS supports tobacco/nicotine dependence. A growing literature demonstrates that WTS is associated with disability, disease and death. This narrative review examines if WTS supports nicotine/tobacco dependence, and is intended to help guide tobacco control efforts worldwide.

DATA SOURCES

PUBMED search using: (("waterpipe" or "narghile" or "arghile" or "shisha" or "goza" or "narkeela" or "hookah" or "hubble bubble")) AND ("dependence" or "addiction").

STUDY SELECTION

Excluded were articles not in English, without original data, and that were not topic-related. Thirty-two articles were included with others identified by inspecting reference lists and other sources.

DATA SYNTHESIS

WTS and the delivery of the dependence-producing drug nicotine were examined, and then the extent to which the articles addressed WTS-induced nicotine/dependence explicitly, as well as implicitly with reference to criteria for dependence outlined by the WHO.

CONCLUSIONS

WTS supports nicotine/tobacco dependence because it is associated with nicotine delivery, and because some smokers experience withdrawal when they abstain from waterpipe, alter their behaviour in order to access a waterpipe and have difficulty quitting, even when motivated to do so. There is a strong need to support research investigating measurement of WTS-induced tobacco dependence, to inform the public of the risks of WTS, which include dependence, disability, disease and death, and to include WTS in the same public health policies that address tobacco cigarettes.

Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives

OBJECTIVES

Waterpipe smoking using sweetened, flavoured tobacco products has become a widespread global phenomenon. In this paper, we review chemical, physical and biological properties of waterpipe smoke.

DATA SOURCES

Peer-reviewed publications indexed in major databases between 1991 and 2014. Search keywords included a combination of: waterpipe, narghile, hookah, shisha along with names of chemical compounds and classes of compounds, in addition to terms commonly used in cellular biology and aerosol sizing.

STUDY SELECTION

The search was limited to articles published in English which reported novel data on waterpipe tobacco smoke (WTS) toxicant content, biological activity or particle size and which met various criteria for analytical rigour including: method specificity and selectivity, precision, accuracy and recovery, linearity, range, and stability.

DATA EXTRACTION

Multiple researchers reviewed the reports and collectively agreed on which data were pertinent for inclusion.

DATA SYNTHESIS

Waterpipe smoke contains significant concentrations of toxicants thought to cause dependence, heart disease, lung disease and cancer in cigarette smokers, and includes 27 known or suspected carcinogens. Waterpipe smoke is a respirable aerosol that induces cellular responses associated with pulmonary and arterial diseases. Except nicotine, smoke generated using tobacco-free preparations marketed for 'health conscious' users contains the same or greater doses of toxicants, with the same cellular effects as conventional products. Toxicant yield data from the analytical laboratory are consistent with studies of exposure biomarkers in waterpipe users.

CONCLUSIONS

A sufficient evidence base exists to support public health interventions that highlight the fact that WTS presents a serious inhalation hazard.

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally

Objective

The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review.

Data sources

The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms.

Study selection

Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10–29 years.

Data extraction

Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results.

Data synthesis

The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels.

Conclusions

The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.