Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure

Evaluation of micronuclei, cytomorphometric and cytologic changes of the oral mucosa in hookah and cigarette smokers

OBJECTIVE

To analyze the effect of hookah and cigarettes on the oral mucosa of smokers through the use of exfoliative cytology.

STUDY DESIGN

Smear samples were collected by exfoliative cytology from the tongue of 33 hookah smokers, 22 cigarette smokers, and 30 non-smokers. The selected analyses include micronuclei (MN), metanuclear anomalies, epithelial maturation, and cytomorphology (nuclear area [NA], cytoplasmic area [CA], and NA/CA ratio).

RESULTS

The largest differences observed for MN and metanuclear anomalies were between cigarette smokers and the control group (notably 1 MN P = .04; total cells with MN P = .039; total MN P = .042; karyorrhexis and binucleation, P = .0001). The hookah group, compared with the control group, showed the greatest differences for karyolysis (P = .0023), binucleation (P = .0003), and broken egg (P = .008). Significant differences were found between the smokers and the control groups regarding changes in the superficial cell without nucleus, perinuclear halo, vacuolization, color change, mucus, and keratohyalin granules. There was a significant increase in the NA and NA/CA ratio in the smoker groups.

CONCLUSION

This study showed that a combined analysis of exfoliative cytology associated with other diagnostic methods is a useful tool for studying oral carcinogenesis. Hookah and cigarettes showed similar effects in terms of displaying substantial cytogenetic and cytotoxic damage.

Patterns and associated factors of shisha usage among the undergraduate students of Jouf University, Saudi Arabia: A cross-sectional study

INTRODUCTION

Shisha tobacco use is gaining popularity around the world, especially among young people and college students. Shisha users are exposed to many of the same harmful substances as cigarette smokers but at much higher levels, which could have more serious adverse health impacts. The aims of this study were to: 1) determine the patterns of shisha smoking among university students in the Northern Province of Saudi Arabia; 2) identify the reasons for using shisha tobacco; and 3) ascertain whether usage of shisha smoking differs by their sociodemographic characteristics.

METHODS

A cross-sectional survey was conducted among students of seven different colleges at a public university between October and December 2022. A modified version of the Global Youth Tobacco Survey questionnaire was used to collect information specifically on shisha smoking. After adjusting for confounding variables, a logistic regression analysis was used to determine the related factors.

RESULTS

A total of 418 participants were included in the study. Of the studied population, shisha smoking was seen in 73.7% (n=308). Out of 308 shisha smokers, 208 (67.5%) had their first session of shisha smoking within the past two years; 34.4% of participants had used it in the past 30 days (current users), of which 27.4% had smoked shisha from 1 to 7 days during the past 30 days. The majority of respondents (63.6%) reported having friends that smoke. The most popular flavor among respondents (24.6%) was apple. For quitting attempts, 46.4% reported a 24-hour quit attempt in the previous year. Stress (23.0%) was reported as the main reason for beginning shisha use. Shisha smoking was significantly associated with age (Ref. 18-20 years; 24-26 years, AOR=0.08; 95% CI: 0.02-0.33, p<0.001; ≥27 years, AOR=0.12; 95% CI: 0.02-0.62, p=0.01), living status (Ref. alone; with family, AOR=0.23; 95% CI: 0.11-0.47, p<0.001; with friends, AOR=0.36; 95% CI: 0.18-0.76, p<0.001), with parents having higher education level (Ref. primary school and lower; Bachelor's, AOR=0.33; 95% CI: 0.14-0.76, p<0.001; diploma, AOR=0.33; 95% CI: 0.15-0.73, p<0.001; PhD, AOR=5.15; 95% CI: 1.00-9.65, p=0.05).

CONCLUSIONS

Shisha use was more frequent among Saudi Arabian college students, especially those who were aged 18-20 years, living alone, and having highly educated parents.

Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis

INTRODUCTION

Pictorial health warning labels (HWLs) on waterpipe (WP) tobacco packages represent a better strategy for communicating the health risks associated with WP use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown.

AIMS AND METHODS

This study explores how pictorial warnings versus text-only induces higher quit intention among a sample of young adult WP smokers in Lebanon. An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult WP smokers who were exposed to two conditions: pictorial HWLs and text-only warnings on WP tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (eg, attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit.

RESULTS

Using serial mediation, exposure to pictorial warnings versus text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect (β = 0.063; [95% bootstrap CI = 0.004 to 0.149]) and cognitive elaboration (0.047; [0.001 to 0.114]) were statistically significant.

CONCLUSIONS

The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb WP tobacco smoking.

IMPLICATIONS

This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial HWLs on intention to quit in a sample of current WP smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing WP-HWLs regulations in Lebanon and other countries to curb WP tobacco smoking.

Biomarkers of Waterpipe Tobacco Smoke Exposure: A Systematic Review and Meta-Analysis

INTRODUCTION

The prevalence of waterpipe tobacco smoking is increasing globally. Biomarkers of waterpipe tobacco smoke (WTS) exposure are less studied.

AIMS AND METHODS

To identify the types of biomarkers of WTS exposure and estimate changes in biomarker concentrations pre- to post-WTS exposure. PubMed, Embase, Web of Science, CINAHL Plus, PsycINFO, and Cochrane Library were searched for studies up to April 24, 2023. The types of biomarkers were identified. Random-effects models were used to estimate changes in biomarker concentrations pre- to post-WTS exposure.

RESULTS

Seventy-three studies involving 3755 participants exposed to WTS (49% male, mean age: 24.8 years) and 11 types of biomarkers of WTS exposure were identified. The biomarkers included tobacco alkaloids, expired carbon monoxide (eCO), carboxyhemoglobin (COHb), tobacco-specific nitrosamines, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), heavy metals, unmetabolized VOCs, unmetabolized PAHs, furan metabolites, and heterocyclic aromatic amines. Compared with pre-WTS exposure, eCO (breath; mean difference [MD] 27.00 ppm; 95% confidence interval [CI]: 20.91 to 33.08), COHb (blood; MD 4.30%; 95%CI: 2.57 to 6.03), COHb (breath; MD 7.14%; 95%CI: 4.96 to 9.31), nicotine (blood; MD 8.23 ng/mL; 95%CI: 6.27 to 10.19), and cotinine (urine; MD 110.40 ng/mL; 95%CI: 46.26 to 174.54) significantly increased post-WTS exposure.

CONCLUSIONS

Biomarkers of WTS exposure were systematically identified. The similarity between the biomarkers of WTS exposure and those of cigarette smoke and higher concentrations of some biomarkers post-WTS exposure underscore the need for further research on applying biomarkers in surveillance, interventions, and regulations to mitigate the harms of waterpipe tobacco smoking.

IMPLICATIONS

This study provides the first comprehensive overview of biomarkers investigated and available for assessing WTS exposure and their concentration changes in the human body. Researchers can use biomarkers such as eCO, COHb, nicotine, and cotinine to measure the health risks associated with WTS exposure and objectively evaluate the effectiveness of public health interventions aimed at reducing waterpipe tobacco smoking. Public health policymaking can also be informed through increased biomarker concentrations following WTS exposure, to implement regulations and public health education campaigns on limiting or preventing waterpipe tobacco smoking.

Effects of Waterpipe Smoke Exposure on Experimentally Induced Chronic Kidney Disease in Mice

Tobacco smoking is an independent risk factor in the onset of kidney disease. To date, there have been no reports on the influence of waterpipe smoke (WPS) in experimentally induced chronic kidney disease (CKD) models. We studied the effects and mechanisms of actions of WPS on a mouse model of adenine-induced CKD. Mice fed either a normal diet, or an adenine-added diet and were exposed to either air or WPS (30 min/day and 5 days/week) for four consecutive weeks. Plasma creatinine, urea and indoxyl sulfate increased and creatinine clearance decreased in adenine + WPS versus either WPS or adenine + saline groups. The urinary concentrations of kidney injury molecule-1 and adiponectin and the activities of neutrophil gelatinase-associated lipocalin and N-acetyl-β-D-glucosaminidase were augmented in adenine + WPS compared with either adenine + air or WPS groups. In the kidney tissue, several markers of oxidative stress and inflammation were higher in adenine + WPS than in either adenine + air or WPS groups. Compared with the controls, WPS inhalation in mice with CKD increased DNA damage, and urinary concentration of 8-hydroxy-2-deoxyguanosine. Furthermore, the expressions of nuclear factor κB (NF-κB) and mitogen-activated protein kinases (MAPKs) (ERK and p38) were elevated in the kidneys of adenine + WPS group, compared with the controls. Likewise, the kidneys of adenine + WPS group revealed more marked histological tubular injury, chronic inflammation and interstitial fibrosis. In conclusion, WPS inhalation aggravates kidney injury, oxidative stress, inflammation, DNA damage and fibrosis in mice with adenine-induced CKD, indicating that WPS exposure intensifies CKD. These effects were associated with a mechanism involving NF-κB, ERK and p38 activations.

Waterpipe and cigarette epigenome analysis reveals markers implicated in addiction and smoking type inference

Waterpipe smoking is frequent in the Middle East and Africa with emerging prevalence worldwide. The epigenome acts as a molecular sensor to exposures and a crucial driver in several diseases. With the widespread use of waterpipe smoking, it is timely to investigate its epigenomic markers and their role in addiction, as a central player in disease prevention and therapeutic strategies. DNA methylome-wide profiling was performed on an exposure-rich population from the Middle East, constituting of 216 blood samples split equally between never, cigarette-only and waterpipe-only smokers. Waterpipe smokers showed predominantly distinct epigenetic markers from cigarette smokers, even though both smoking forms are tobacco-based. Moreover, each smoking form could be accurately (∼90 %) inferred from the DNA methylome using machine learning. Top markers showed dose-response relationship with extent of smoking and were validated using independent technologies and additional samples (total N = 284). Smoking markers were enriched in regulatory regions and several biological pathways, primarily addiction. The epigenetically altered genes were not associated with genetic etiology of tobacco use, and the methylation levels of addiction genes, in particular, were more likely to reverse after smoking cessation. In contrast, other epigenetic markers continued to feature smoking exposure after cessation, which may explain long-term health effects observed in former smokers. This study reports, for the first time, blood epigenome-wide markers of waterpipe smokers and reveals new markers of cigarette smoking, with implications in mechanisms of addiction and the capacity to discriminate between different smoking types. These markers may offer actionable targets to reverse the epigenetic memory of addiction and can guide future prevention strategies for tobacco smoking as the most preventable cause of illnesses worldwide.

Central and Peripheral Hemodynamics in Young Adults Who Use Water Pipes and the Acute Effects of Water-Pipe Use

BACKGROUND

Tobacco use via water pipe (commonly referred to as water-pipe smoking [WPS]) is popular among young adults globally and exposes those who smoke to toxicants.

RESEARCH QUESTION

Is WPS associated with impaired measures of arterial function and does WPS acutely impair these measures in young adults?

STUDY DESIGN AND METHODS

We assessed heart rate (HR), brachial and aortic BP, HR-adjusted augmentation index (AI), and carotid-femoral pulse wave velocity (CFPWV) in 62 individuals who use water pipes and 34 individuals who have never used a water pipe recruited from the community (mean age, 22.5 ± 3.0 years; 48% female). Measurements were obtained before and after an outdoor session of WPS among participants who use water pipes and among the control group of participants who have never used a water pipe. Measurements were compared after vs before exposure and between those who use and those who do not use water pipes, adjusting for possible confounders using linear regression.

RESULTS

Participants who use water pipes and control participants had similar demographic characteristics. BP and HR increased acutely after WPS (brachial systolic BP by 4.13 mm Hg [95% CI, 1.91-6.36 mm Hg]; aortic systolic BP by 2.31 mm Hg [95% CI, 0.28-4.33 mm Hg]; brachial diastolic BP by 3.69 mm Hg [95% CI, 1.62-5.77 mm Hg]; aortic diastolic BP by 3.03 mm Hg [95% CI, 0.74-5.33 mm Hg]; and HR by 7.75 beats/min [95% CI, 5.46-10.04 beats/min]), but not in the control group. AI was significantly higher in participants who use water pipes compared with those who do not (9.02% vs 3.06%; P = .03), including after adjusting for BMI and family history of cardiovascular disease (β = 6.12; 95% CI, 0.55-11.69; P = .03) and when assessing habitual tobacco use via water-pipe extent (water pipes used/day × water-pipe use duration) in water-pipe-years (β = 2.51/water-pipe-year; 95% CI, 0.10-4.92/water-pipe-year; P = .04). However, CFPWV was similar in those who use water pipes and those who do not, and AI and CFPWV did not change acutely after WPS.

INTERPRETATION

In apparently healthy young individuals from the community, habitual WPS was associated with increased AI, a predictor of cardiovascular risk, and one WPS session acutely increased HR and brachial and aortic BP.

Flavours and flavourings in waterpipe products: a comparison between tobacco, herbal molasses and steam stones

ObjectivesFlavoured products are especially appealing to youth and contribute to the onset of waterpipe smoking and continued use of waterpipe tobacco. The goal of database and chemical analysis was to provide a clear overview of commonly used flavours and flavourings in tobacco and related waterpipe products, that is, herbal molasses and steam stones.

METHODS

In 2019, 249 waterpipe tobacco products were registered in the European Common Entry Gate by manufacturers to be marketed in The Netherlands. Flavour categories were assigned to the registered products based on their brand names and product descriptions. Nicotine and eleven 1111 flavourings were identified and quantified in waterpipe tobacco (n=8), herbal molasses (n=7) and steam stones (n=4) by extraction and gas chromatography-mass spectrometry (GC-MS) analysis.

RESULTS

Flavour categories could be assigned to 237 of 249 registered waterpipe tobacco products. Eight flavour main categories and 48 unique subcategories were identified and presented in a flavour wheel. All registered waterpipe tobacco products were flavoured, and the majority (78%) was fruit flavoured. Herbal molasses contained similar median flavouring levels, and steam stones contained lower median levels compared with waterpipe tobacco. Flavourings in waterpipe products were almost exclusively fruity and sweet, often in combination with menthol/mint flavourings.

CONCLUSIONS

This study is the first to present a waterpipe tobacco flavour wheel, providing a quick overview of waterpipe tobacco flavours and thereby aiding communication among experts around the globe. GC-MS analysis revealed that the most prevalent flavourings are present in similar levels in herbal and tobacco waterpipe products. Banning flavourings in all waterpipe products would be a good strategy to reduce waterpipe smoking among youth.

Interventions for waterpipe smoking cessation

BACKGROUND

While cigarette smoking has declined globally, waterpipe smoking is rising, especially among youth. The impact of this rise is amplified by mounting evidence of its addictive and harmful nature. Waterpipe smoking is influenced by multiple factors, including appealing flavors, marketing, use in social settings, and misperceptions that waterpipe is less harmful or addictive than cigarettes. People who use waterpipes are interested in quitting, but are often unsuccessful at doing so on their own. Therefore, developing and testing waterpipe cessation interventions to help people quit was identified as a priority for global tobacco control efforts.  OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for people who smoke waterpipes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group Specialized Register from database inception to 29 July 2022, 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.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), quasi-RCTs, or cluster-RCTs of any smoking cessation interventions for people who use waterpipes, of any age or gender. In order to be included, studies had to measure waterpipe abstinence at a three-month follow-up or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from waterpipe use at least three months after baseline. We also collected data on adverse events. Individual study effects and pooled effects were summarized as risk ratios (RR) and 95% confidence intervals (95% CI), using Mantel-Haenszel random-effects models to combine studies, where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarized secondary outcomes narratively. We used the five GRADE considerations (risk of bias, inconsistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for our primary outcome in four categories high, moderate, low, or very low.

MAIN RESULTS

This review included nine studies, involving 2841 participants. All studies were conducted in adults, and were carried out in Iran, Vietnam, Syria, Lebanon, Egypt, Pakistan, and the USA. Studies were conducted in several settings, including colleges/universities, community healthcare centers, tuberculosis hospitals, and cancer treatment centers, while two studies tested e-health interventions (online web-based educational intervention, text message intervention). Overall, we judged three studies to be at low risk of bias, and six studies at high risk of bias. We pooled data from five studies (1030 participants) that tested intensive face-to-face behavioral interventions compared with brief behavioral intervention (e.g. one behavioral counseling session), usual care (e.g. self-help materials), or no intervention. In our meta-analysis, we included people who used waterpipe exclusively, or with another form of tobacco. Overall, we found low-certainty evidence of a benefit of behavioral support for waterpipe abstinence (RR 3.19 95% CI 2.17 to 4.69; I2 = 41%; 5 studies, N = 1030). We downgraded the evidence because of imprecision and risk of bias. We pooled data from two studies (N = 662 participants) that tested varenicline combined with behavioral intervention compared with placebo combined with behavioral intervention. Although the point estimate favored varenicline, 95% CIs were imprecise, and incorporated the potential for no difference and lower quit rates in the varenicline groups, as well as a benefit as large as that found in cigarette smoking cessation (RR 1.24, 95% CI 0.69 to 2.24; I2 = 0%; 2 studies, N = 662; low-certainty evidence). We downgraded the evidence because of imprecision. We found no clear evidence of a difference in the number of participants experiencing adverse events (RR 0.98, 95% CI 0.67 to 1.44; I2 = 31%; 2 studies, N = 662). The studies did not report serious adverse events.   One study tested the efficacy of seven weeks of bupropion therapy combined with behavioral intervention. There was no clear evidence of benefit for waterpipe cessation when compared with behavioral support alone (RR 0.77, 95% CI 0.42 to 1.41; 1 study, N = 121; very low-certainty evidence), or with self-help (RR 1.94, 95% CI 0.94 to 4.00; 1 study, N = 86; very low-certainty evidence).  Two studies tested e-health interventions. One study reported higher waterpipe quit rates among participants randomized to either a tailored mobile phone or untailored mobile phone intervention compared with those randomized to no intervention (RR 1.48, 95% CI 1.07 to 2.05; 2 studies, N = 319; very low-certainty evidence). Another study reported higher waterpipe abstinence rates following an intensive online educational intervention compared with a brief online educational intervention (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70; very low-certainty evidence).  AUTHORS' CONCLUSIONS: We found low-certainty evidence that behavioral waterpipe cessation interventions can increase waterpipe quit rates among waterpipe smokers. We found insufficient evidence to assess whether varenicline or bupropion increased waterpipe abstinence; available evidence is compatible with effect sizes similar to those seen for cigarette smoking cessation.  Given e-health interventions' potential reach and effectiveness for waterpipe cessation, trials with large samples and long follow-up periods are needed. Future studies should use biochemical validation of abstinence to prevent the risk of detection bias. Finally, there has been limited attention given to high-risk groups for waterpipe smoking, such as youth, young adults, pregnant women, and dual or poly tobacco users. These groups would benefit from targeted studies.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Varenicline Treatment for Waterpipe Smoking Cessation

BACKGROUND

Waterpipe smoking is increasing worldwide with no proven interventions for cessation. We compared abstinence rates with 12-week varenicline therapy versus placebo among habitual waterpipe smokers willing to quit.

METHODS

This double-blind placebo-controlled single-center trial, randomized waterpipe smokers from Lebanon who did not smoke other tobacco products to receive varenicline or placebo for 12 weeks. All participants also received three structured 30-minute individual behavioral intervention sessions. The primary outcome was repeated point prevalence abstinence assessed by self-report and verified by exhaled carbon monoxide three times during 12 weeks and analyzed with the intention to treat. End of treatment urine cotinine, weight, blood pressure, anxiety, depression, withdrawal, and adverse symptoms were also assessed.

RESULTS

In total, 152 waterpipe smokers (mean age 38 years [SD = 13], 39% females) willing to quit, who smoked waterpipe exclusively (average 2.3 per day [SD = 1.6] for 16.8 years [SD = 10.8]) were randomized. Seventy-nine participants (52%) with any missing abstinence assessment were considered to have relapsed. Repeat point prevalence abstinence rate was numerically higher among the varenicline group compared to placebo, but the difference did not reach statistical significance when assessed by self-report (16.9 vs. 13.6%, respectively, p = .6) and when further verified by exhaled carbon monoxide (14.1% vs. 9.9%, respectively, p = .4). Abstinence rates were similar in both groups when further verified by urine cotinine at end of treatment. No serious adverse events were reported, adverse symptoms and other outcomes were similar in the varenicline and placebo arms.

CONCLUSIONS

Varenicline for 12 weeks was not more effective than placebo to achieve abstinence among daily waterpipe smokers.

IMPLICATIONS

Varenicline in combination with a behavioral intervention did not significantly enhance the quit rate among exclusive waterpipe smokers compared to behavioral intervention plus placebo. We experienced difficulty enrolling exclusive waterpipe smokers willing to quit and observed high dropout rates among participants demonstrating the difficulties of waterpipe smoking cessation.

The Protective Effects of the Combination of Vitamin E and Swimming Exercise on Memory Impairment Induced by Exposure to Waterpipe Smoke

BACKGROUND

Waterpipe smoking (WP) exposure involves a negative health impact, including memory deficit, which is attributed to the elevation of oxidative stress. Vitamin E (VitE) in combination with swimming exercise exerts protective effects that prevent memory impairment. In the current study, the modulation of WP-induced memory impairment by the combined effect of VitE and swimming exercise (SE) was investigated.

METHODS

Animals were exposed to WP one hour/day, five days per week for four weeks. Simultaneously, VitE (100 mg/kg, six days/week for four weeks) was administered via oral gavage, and the rats were made to swim one hour/day, five days/week for four weeks. Changes in memory were evaluated using radial arm water maze (RAWM), and oxidative stress biomarkers were examined in the hippocampus.

RESULTS

WP exposure induced short-term/long-term memory impairment (p<0.05). This impairment was prevented by a combination of VitE with SE (p<0.05). Additionally, this combination normalized the hippocampal catalase, GPx, and GSH/GSSG ratios that were modulated by WP (p<0.05). The combination further reduced TBARs levels below those of the control group (p<0.05).

CONCLUSION

WP-induced memory impairments were prevented by the combination of VitE with SE. This could be attributed to preserving the hippocampal oxidative mechanism by combining VitE and SE during WP exposure.

Effects of electronic cigarettes and hookah (waterpipe) use on home air quality

INTRODUCTION

A major site of secondhand smoke exposure for children and adults is the home. Few studies have evaluated the impact of e-cigarette or hookah use on home air quality, despite evidence finding toxic chemicals in secondhand e-cigarette aerosols and hookah smoke. We assessed the effect of e-cigarette and hookah use on home air quality and compared it with air quality in homes where cigarettes were smoked and where no smoking or e-cigarette use occurred.

METHODS

Non-smoking homes and homes where e-cigarettes, hookah or cigarettes were used were recruited in the New York City area (n=57) from 2015 to 2019. Particulate matter with diameter less than 2.5 µm (PM2.5), black carbon and carbon monoxide (CO) were measured during a smoking or vaping session, both in a 'primary' smoking room and in an adjacent 'secondary' room where no smoking or vaping occurred. Log transformed data were compared with postanalysis of variance Tukey simultaneous tests.

RESULTS

Use of hookah significantly increased PM2.5 levels compared with non-smoking homes, in both the primary and secondary rooms, while use of e-cigarettes increased PM2.5 levels only in primary rooms. Additionally, in-home use of hookah resulted in greater CO concentrations than the use of cigarettes in primary rooms.

CONCLUSIONS

Use of e-cigarettes or hookah increases air pollution in homes. For hookah, increases in PM2.5 penetrated even into rooms adjacent to where smoking occurs. Extending smoke-free rules inside homes to include e-cigarette and hookah products is needed to protect household members and visitors from passive exposure to harmful aerosols and gases.

Indoor Exposure and Regional Inhaled Deposited Dose Rate during Smoking and Incense Stick Burning-The Jordanian Case as an Example for Eastern Mediterranean Conditions

Tobacco smoking and incense burning are commonly used in Jordanian microenvironments. While smoking in Jordan is prohibited inside closed spaces, incense burning remains uncontrolled. In this study, particle size distributions (diameter 0.01-25 µm) were measured and inhaled deposited dose rates were calculated during typical smoking and incense stick-burning scenarios inside a closed room, and the exposure was summarized in terms of number and mass concentrations of submicron (PN_Sub) and fine particles (PM_2.5). During cigarette smoking and incense stick-burning scenarios, the particle number concentrations exceeded 3 × 10⁵ cm^-3. They exceeded 5 × 10⁵ cm^-3 during shisha smoking. The emission rates were 1.9 × 10¹⁰, 6.8 × 10¹⁰, and 1.7 × 10¹⁰ particles/s, respectively, for incense, cigarettes, and shisha. That corresponded to about 7, 80, and 120 µg/s, respectively. Males received higher dose rates than females, with about 75% and 55% in the pulmonary/alveolar during walking and standing, respectively. The total dose rates were in the order of 10¹²-10¹³ #/h (10³-10⁴ µg/h), respectively, for PN_Sub and PM_2.5. The above reported concentrations, emissions rates, and dose rates are considered seriously high, recalling the fact that aerosols emitted during such scenarios consist of a vast range of toxicant compounds.

Indoor partitioning and potential thirdhand exposure to carbonyl flavoring agents added in e-cigarettes and hookah tobacco

Flavoring agents added to the e-cigarettes and hookah tobacco have increased the attractiveness of novel nicotine products. Many widely used flavorings are carbonyls, which are toxic to humans. In an indoor environment, residents can be exposed to such harmful flavorings previously emitted to the surrounding environment, through a process termed thirdhand exposure. The recent discovery of a large volume of indoor reservoirs emphasizes the importance of indoor partitioning, which is responsible for thirdhand exposure. Indoor partitioning can be expressed with partitioning coefficients, such as Henry's law solubility constant (H). However, reliable H values for many key flavorings are currently lacking. To better understand their environmental behavior, this study experimentally determined the effective Henry's law constant (Hcps,eff) using the inert gas stripping (IGS) method. Further, the influence of the hydration process for target flavorings was quantified using proton nuclear magnetic resonance (¹H NMR) spectroscopy. We found that hydration of α-dicarbonyls (diacetyl and 2,3-pentanedione) enhanced their Hcps,eff from their intrinsic Henry's law constant (Hcps) by a factor of 3.52 and 2.88, respectively. The two-dimensional partitioning plots were employed to simulate the indoor phase distribution and evaluate the pathways of human exposure. Our findings show that the indoor partitioning of many harmful flavorings is highly sensitive to temperature and the size of indoor reservoirs, indicating that residents are likely to experience third-hand exposure.

"Waterpipe Is Like a Wife": Qualitative Assessment of Perspectives on Waterpipe Smoking Dependence

BACKGROUND

Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey- or laboratory-based studies. This study employed qualitative methods to explore WP users' perceptions of dependence in Aleppo, Syria.

METHODS

A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis.

FINDINGS

Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included positively reinforced features, such as smoking's association with social gatherings and cultural connectedness, and negatively reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting one's behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at the expense of other reinforcers such as social interaction.

CONCLUSION

The general and specific features of WP dependence need to be considered in developing instruments to measure WP dependence, in clinical assessment of WP dependence, and in developing cessation programs.

Changes in the Use of Tobacco, Alternative Tobacco Products, and Tobacco Alternatives in Germany

BACKGROUND

Due to the increasing use of alternative tobacco products (waterpipes, heat-not-burn) and tobacco alternatives (e-cigarettes), we studied recent changes in the prevalence of conventional tobacco use and alternative products.

METHODS

Data come from ten waves of the Epidemiological Survey of Substance Abuse (ESA) from 1995 to 2021, with representative samples collected via paperpencil questionnaires, telephone interviews, or online. We compared the prevalence of conventional tobacco use and alternative products by gender and age (18-24, 25-39, 40-59 years).

RESULTS

In all age groups, the use of conventional tobacco products decreased. The prevalence of the exclusive use of one of the three alternative products differed statistically significantly between age groups and in 2021 was higher for ages 18-24 (females: 11.1%, males: 12.4%) compared to ages 25-39 (females: 2.9%; males: 4.9%) and ages 40-59 (females: 1.4%; males: 2.0%). The use of alternative products was mainly due to the exclusive use of waterpipes among individuals aged 18 to 24 and 25 to 39 and the exclusive use of e-cigarettes among individuals aged 40 to 59.

CONCLUSION

The higher prevalence of alternative product use among young adults implies a turning point that needs to be considered in prevention. Because of the addictive potential of these products, young adults can be expected to maintain their use into middle and older adulthood. There is a need to monitor the use of alternative products, identify the risks associated with them, and develop effective prevention and cessation interventions for adults.

Urinary concentrations of BTEX in waterpipe smokers and nonsmokers: Investigating the influence of conventional activities and multiple factors

The aim of this study was to compare the concentrations of the benzene, toluene, ethylbenzene, and xylene (BTEX) compounds in the urine of smokers and the control group considering the role of age, weight, job, history of waterpipe and cigarette smoking, and driving time. The chemicals in the urine of 99 smokers and 31 nonsmokers were extracted by liquid-liquid extraction method and their concentrations were measured by liquid injection GC/MS. The mean concentration of benzene, toluene, ethylbenzene, m-xylene, o-xylene, p-xylene, and total BTEX in waterpipe smokers were found to be 471.40, 670.90, 127.91, 167.64, 90.62, 46.04, and 1574.50 ng/g. creatinine, respectively. For the waterpipe&cigarette smokers, the concentration of the compounds were 708.00, 959.00, 146.40, 192.50, 93.30, 53.07, and 2152.00 ng/g.creatinine, respectively. For nonsmokers the concentrations of these compounds were 88.12, 140.40, 36.68, 57.29, 31.53, 26.21, and 380.30 ng/g.creatinine, respectively. Driving time, waterpipe smoking and cigarette smoking were positively associated with BTEX concentration (p < 0.05). Fruity tobacco showed higher concentrations of BTEX compared to the regular tobacco, and athlete persons had les urinary BTEX than the non-athletes. There was not significant correlation between the BTEX and age, height, weight, and BMI. High concentrations of BTEX compounds in the urine of waterpipe and cigarette smokers compared to nonsmokers indicate that waterpipe and cigarette can be an important source of exposure to these compounds and the known adverse effects of these compounds, especially carcinogenicity, threaten the health of smokers.

Hookah Smoking among Brazilian University Students: An Exploratory Survey on the Prevalence and Perceptions of Addiction and its Harmfulness

Background

This study aimed to determine the prevalence, beliefs, attitudes, and perceptions of hookah use in a population of undergraduate students at a large public university in Brazil.

Methods

The sample consisted of 1348 undergraduate students aged over 18-year-old. They completed structured questionnaires on demographic information and close-ended questions on the past and current experiences of smoking hookah. The data underwent descriptive analysis and binary logistic regression.

Findings

Finally, 1298 valid survey forms were obtained from printed and digital questionnaires. More than half (53.9%) of participants reported having tried hookah at least once, however, only 10.8% reported they had experienced it within the last 30 days. The majority of the studied population presented acceptable beliefs about the harmfulness and addictive capacity of hookah smoking. However, when comparing the perceptions of those who had smoked and those who had never smoked hookah, and also, the perceptions of users and non-users, significant differences were observed. Students who were users or had already tried hookah showed a tendency to underestimate the deleterious effects of this type of smoking.

Conclusion

It could be concluded that hookah smoking was common among Brazilian university students. In addition, preoccupying misperceptions of hookah's harmfulness and addictive capacity were found. The results showed that the epidemic of hookah smoking, especially among young people, has spread far beyond the Arab world and the Persians. Accordingly, preventive measures must be taken if this population is to be protected from addiction and other serious health problems.

Nicotine and cotinine quantification after a 4-week inhalation of electronic cigarette vapors in male and female mice using UPLC-MS/MS

OBJECTIVES

To detect the cotinine and nicotine serum concentrations of female and male C57BL/6J mice after a 4-week exposure to electronic (e)-cigarette vapors using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS).

METHODS

This experimental study was carried out at an animal facility and laboratories, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia, between January and August 2020. A 4-week exposure to e-cigarettes was carried out using male and female mice and serum samples were obtained for cotinine and nicotine quantification using UPLC-MS/MS. The chromatographic procedures involved the use of a BEH HSS T3 C18 column (100 mm x 2.1 mm, 1.7 μm) with acetonitrile as a mobile phase and 0.1% formic acid (2:98 v/v).

RESULTS

The applied methodology has highly efficient properties of detection, estimation, and extraction, where the limit of quantification (LOQ) for nicotine was 0.57 ng/mL and limit of detection (LOD) for nicotine was 0.19 ng/mL, while the LOQ for cotinine was 1.11 ng/mL and LOD for cotinine was 0.38 ng/mL. The correlation coefficient was r²>0.99 for both compounds. The average recovery rate was 101.6±1.33 for nicotine and 100.4±0.54 for cotinine, while the precision and accuracy for cotinine and nicotine were less than 6.1. The serum cotinine level was higher in males (433.7±19.55) than females (362.3±16.27).

CONCLUSION

This study showed that the gender factor might play a crucial role in nicotine metabolism.

Waterpipe smoking: Results from a population-based study in Qatar

INTRODUCTION

Waterpipe smoking is common in the Eastern Mediterranean Region and is becoming more prevalent in Qatar. To better plan waterpipe smoking control strategies we aimed to: 1) determine the prevalence of waterpipe smoking and explore its patterns in Qatar; 2) describe the knowledge, attitudes, and practices related to smoking behaviors; 3) recognize locations of waterpipe smoking and symptoms experienced during waterpipe sessions; and 4) evaluate the frequency of waterpipe smoking and the initiation age.

METHODS

We analyzed the data of a 7921 population-based survey of adults aged ≥18 years (nationals and expatriates), conducted in Qatar between March and December 2019. Out of 7105 surveys collected, 6904 were complete and included in the analysis.

RESULTS

Of the 6904, 570 (8.3%; 95% CI: 7.7–9.0) were waterpipe tobacco smokers, 425 (10.6%) males and 145 (5.1%) females. The highest prevalence of waterpipe smoking was reported among people aged 18–24 years (10.6%). Of the 575 waterpipe smokers, 56.3% (n=324) were exclusive waterpipe smokers. Use of other tobacco products among waterpipe smokers was higher among Qataris (52.3%) than expatriates (37.7%). Waterpipe cafés were the most common location for waterpipe smoking, however, females preferred restaurants; 83.3% reported that waterpipe smoking is harmful, while 39.3% considered that it is less harmful than cigarette smoking.

CONCLUSIONS

Waterpipe smoking prevalence is considerably high in Qatar, the second form of tobacco used. The formulation of new policies and enforcement of regulatory restrictions on waterpipe smoking are essential to reduce its uptake. Expansion in tobacco cessation services for women and poly-tobacco users is needed.

Hypertension in the Middle East: current state, human factors, and barriers to control

Hypertension is the leading source of morbidity and death. In the 21st century, there still is a major gap between high and low to middle-income countries in awareness, management, and control; countries in the Middle East represent an example of such disparities. In this review of the literature, light is shed on the prevalence and modifiable risk factors of hypertension specific to the region, as well as regional disparities in diagnosis and management. The crude prevalence rate is estimated to be around 29.5% with wide variability between countries. Various modifiable factors affect the prevalence of hypertension in this region such as excessively high rates of smoking, obesity, a sedentary lifestyle, some gender gap, and a suboptimal healthcare system; socio-economic factors and disparities in education, literacy, and urbanization play a significant role. Patient adherence to treatment is a determining factor of blood pressure control and nonadherence adversely affect outcomes. In addition, physician adherence to international guidelines is poor. Recognizing these barriers to hypertension management, this review serves as a call for increased national and regional efforts to implement favorable healthcare policies and improve clinical outcomes.

Waterpipe Tobacco Smoking and Risk of Stomach Cancer: A Case-Control Study in Vietnamese Men

OBJECTIVE

This study investigated the impacts of waterpipe tobacco (WTP) and cigarette smoking on stomach cancer development in Vietnamese men.

METHODS

A total of 80 stomach cancer cases and 146 controls were recruited in a hospital-based case-control study. Data on sociodemographic, anthropometric characteristics, tobacco smoking, and the dietary pattern was obtained based on a semi-quantitative food frequency and demographic lifestyle questionnaire; and venous anti-Helicobacter pylori IgG antibodies were tested by ELISA. Unconditional logistic regression analysis with adjustments for potential confounding was performed to estimate the association between target exposures and stomach cancer.

RESULTS

Compared to the never tobacco smokers, the risk of stomach cancer significantly increased among tobacco smokers (OR 2.95, 95%CI 1.26-6.90, p=0.013). Those who early started tobacco smoking before 26 years old had a high risk of SC (OR 3.04, 95%CI 1.29-7.20, p for trend=0.011). For types of tobacco, It was increased risk in exclusively cigarette smokers (OR 2.85, 95%CI 1.19-6.85, p=0.019) and in WPT smokers (OR 3.09, 95%CI 1.24-7.68, p=0.015). The daily frequency and longer duration of exclusively WPT or cigarette smoking tended to be significantly higher SC risk.

CONCLUSIONS

The findings suggest that tobacco smoking, particularly water pipe tobacco smoking, dramatically and independently increased the risk of stomach cancer.

Clinical and cytological findings in oral cavity of young shisha smokers and non-smokers – a comparative study

Introduction: Shisha, a form of smoking tobacco is known to be detrimental to oral health. Yet, the effects of shisha on oral health is not well documented. Hence, this study was undertaken to compare the clinical and cytological findings in oral cavity of young shisha smokers as compared to non-smokers. Materials and methods: A cross-sectional analytical study was undertaken among 60 subjects including 30 young shisha smokers and 30 non-smokers. Clinical examination was carried out to record gingival status, periodontal status, oral hygiene and dental caries experience. Exfoliative cytology was used to study the cytological changes of buccal mucosal cells. Data was analysed using SPSS version 22. Student’s t-test, Fisher’s exact test and odd’s ration was used for comparison. p < 0.05 was considered statistically significant. Results: No significant differences were found between the groups with respect to proportion of subjects with gingivitis (p = 0.071), erosion (p = 0.085) and dental caries experience (p = 0.329). However, shisha smokers had poorer oral hygiene and more severe gingival inflammation as compared to non-smokers with p = 0.026 and p = 0.007 respectively. The odds of having atypical cells in oral mucosa among shisha smokers was 3.76 times higher than the non-smokers. Conclusion: The findings of our study showed that young shisha smokers had more atypical cells in oral mucosa as compared to their non-smoking counterparts. However, longitudinal studies are needed to affirm the findings of this study.

Exercise Training Attenuates Cardiac Vulnerability and Promotes Cardiac Resistance to Isoproterenol-Induced Injury Following Hookah Smoke Inhalation in Male Rats: Role of Klotho and Sirtuins

Hookah smoking is on the rise around the world. Present study investigated the heart resistance to harmful stress following long-term waterpipe tobacco smoking (WTS) and moderate-intensity exercise training intervention in male Wistar rats. Animals were randomly divided into a non-ischemic heart control group and four ischemic heart groups including ISO (isoproterenol-treated), Ex + ISO (subjected to exercise plus ISO), S + ISO (exposed to hookah smoke plus ISO), and Ex + S + ISO (subjected to exercise along with hookah smoke plus ISO). After eight weeks of training and WTS, heart ischemia induced by isoproterenol injections. Then, cardiac functional indices and some biochemical and histopathological parameters were assessed. WTS + ISO reduced systolic pressure, ± dP/dt max, and contractility indices (P < 0.001 vs. ISO group) and increased end diastolic pressure and Tau index (P < 0.001 vs. ISO) of the left ventricle. Also, WTS + ISO was associated with an increase in Bax protein level and Bax/Bcl-2 ratio (P < 0.05 and P < 001, respectively, vs. ISO group) as apoptotic markers of heart tissue. Hookah smoke significantly decreased SIRT1 (P < 0.05 and P < 0.001, respectively, vs. ISO) and klotho (P < 0.01 and P < 0.001, respectively, vs. ISO) in serum and heart, and SIRT3 and pS9-GSK-3β (P < 001 and P < 0.05, respectively, vs. ISO) in heart tissue. Combination of exercise with WTS prevented the hookah smoke-induced alterations in apoptotic markers, cardiac functional indices, and SIRT1, SIRT3, klotho, and pS9-GSK-3β proteins. The findings demonstrated that hookah smoke inhalation intensifies ventricular dysfunction and decreases heart resistance to harmful stresses. Moderate-intensity exercise training attenuated these complications partly through recovering the klotho and sirtuins levels and apoptosis-survival balancing.

Flavored waterpipe tobacco preferences, perceptions, and use in pregnant women: A latent factor mapping approach

Waterpipe tobacco (WPT) use is increasingly common in young adults including pregnant and reproductive-age women. Sweet flavors contribute to the appeal of WPT and are a promising regulatory target. The present study utilized correspondence analysis of contingency tables, a latent factor mapping technique, to investigate preferences and perceptions of WPT flavors in a sample of racially/ethnically diverse, low-income pregnant women. One hundred pregnant women (mean age = 26 years, 65% racial/ethnic minorities) completed a detailed interview regarding their use, preferences, and perceptions of WPT flavors. Eighty-three percent of participants reported lifetime WPT use; 11% reported prenatal WPT use. Pregnant women reported greatest use of and stronger preferences for sweet (fruit, candy, alcohol) and menthol/mint flavors, and weaker preferences for tobacco flavored WPT. Latent factor mapping revealed clustering of preferred sweet (fruit, candy, alcohol) and menthol/mint flavors versus tobacco flavors, with pungent flavors (coffee, chocolate, spice) clustering between sweet and tobacco flavors. Preferences for sweet and menthol/mint flavors distinguished pregnant women who reported lifetime WPT versus no lifetime WPT use, and prenatal WPT use versus no prenatal WPT use. Harm perceptions did not vary by flavor. Regulations to restrict the availability of WPT flavors may reduce the appeal and use of WPT, especially among pregnant women.

Comparison of Repair Index in Cigarette and Waterpipe Smokers: A Bio-Monitoring Assessment Using Human Exfoliated Buccal Mucosa Cells

BACKGROUND

Repair index (RI) using DNA changes reveals the activity of carcinogenesis. Cigarette and waterpipe smoking are important contributors to oral cavity malignancy. The RI in cigarette and waterpipe smokers has not been compared so far. The aim of this study was to compare the RI in cigarette and waterpipe smokers using the human exfoliated buccal mucosa cells.

METHODS

The exfoliated buccal mucosa cells of 60 cigarette and waterpipe smokers and 20 nonsmokers were evaluated in a case-control study. The number of micronuclei (MN), broken egg (BE), karyorrhexis (KR), and karyolysis (KL) were counted in 1000 cells from randomly selected fields. The RI = (KL + KR)/(MN + BE) was calculated and compared between subjects and controls. Data were analyzed by one-way analysis of variance (ANOVA), Tukey's Honest Significant Difference (HSD), and Spearman's correlation coefficient test at P < 0.05 probability level.

RESULTS

The difference of MN (P < 0.0001), BE (P < 0.0001), KR (P < 0.0001), and KL (P < 0.0001) count was significant between cigarette smokers, waterpipe smokers, and nonsmokers. The RI was significantly different between groups (P = 0.007). The RI was significantly higher in cigarette smokers compared to waterpipe smokers (P = 0.04) and nonsmokers (P = 0.009).

CONCLUSIONS

The RI was significantly higher in cigarette smokers compared to waterpipe smokers. The finding suggests that due to higher interrupted cellular hemostasis, the risk of carcinoma in waterpipe smokers can be greater than that in cigarette smokers.

Severe chronic Carboxyhemoglobinemia and polycythemia due to smoking hookah

Acute carbon monoxide (CO) poisoning due to smoking hookah has been reported and may present similarly to other causes of acute carbon monoxide poisoning with nausea, headache, and loss of consciousness [1]. In the acute poisoned patient, immediate removal from the carbon monoxide source is paramount in addition to administration of oxygen and possible hyperbaric oxygen therapy (HBO) in certain situations. However, cases of chronic CO poisoning, treatment options, and long-term adverse health effects are far less reported but may include atherosclerosis and vague neurologic symptoms [2]. We present a case of a patient who chronically smoked hookah creating a condition of chronic carboxyhemoglobinemia which was discovered during work up for unexplained polycythemia. While being seen in the hematology clinic, he was found to have a blood carboxyhemoglobin of level 33.6% despite being asymptomatic. This is the highest recorded hookah-related carboxyhemoglobin concentration in the medical literature; and the significant chronic carboxyhemoglobinemia explained his polycythemia. This case illustrates that a social history is crucial when assessing the patient with severe carboxyhemoglobinemia as HBO is not indicated in chronic CO poisoning in an asymptomatic patient.

Latent class analysis of initial nicotine dependence among adult waterpipe smokers

Waterpipe (WP) tobacco smoking increases the risk of smoking-related health problems. In this study, we sought to identify the unobserved class memberships of WP-associated initial nicotine dependence (ND) symptoms and assess the predictors of each latent class. This cross-sectional study was conducted among a convenience sample of 900 current (past 30-day) WP smokers who were recruited from 94 WP-serving venues surrounding Tehran and Ardebil metropolitans in Iran. All participants completed a self-administrated questionnaire. We performed latent class analysis using PROC LCA in SAS to identify class memberships of initial ND symptoms using 10-item Hooked on Nicotine Checklist. Five latent classes were identified as non-dependent (25.4 %), low dependent (7.1 %), low-moderate dependent (19.6 %), moderate dependent (15.6 %), and high dependent (32.2 %). Using flavored WP tobacco significantly increased the odds of belonging to low-moderate dependent class [adjusted OR (aOR) = 1.89; 95 % confidence interval (CI): 1.07-3.34] compared to non-dependent class. Also, having academic education decreased the odds of belonging to low-moderate dependent (aOR = 0.43; 95 %CI: 0.26-0.67) and moderate dependent (aOR = 0.39; 95 %CI: 0.23-0.67) class in comparison to non-dependent class. Also, WP smoking initiation at an older age was associated with belonging to high dependent (OR = 2.05; 95 %CI: 1.39-3.03) class compared to non-dependent. This study revealed that nearly half of WP smokers fell under moderate and high-dependent classes. Our findings showed that some items of HONC had more role in the clustering of participants based on ND symptoms. The WP-specific cessation programs and targeted clinical trials should consider the diversity of ND levels among smokers to achieve successful quit rates among these smokers. Additionally, limiting flavors would be a strong strategy to limit the rate of ND, especially among young people who are eager to smoke flavored WP tobacco.

Overactive bladder syndrome in nulliparous female university students: prevalence and risk factors including waterpipe smoking

INTRODUCTION AND HYPOTHESIS

The objective was to assess the prevalence of symptoms of overactive bladder syndrome (OAB) among healthy nulliparous female university students, and to evaluate the correlation of these symptoms with a variety of factors, including waterpipe (WP) smoking.

METHODS

This is a cross-sectional study. A questionnaire was administered to evaluate symptoms of OAB in healthy nulliparous female university students. Variables assessed included body mass index (BMI), cigarette smoking, WP smoking, consumption of alcohol, coffee, and tea with and without artificial sweeteners, soft drinks, and energy drinks. Adjusted odds ratio were calculated to determine the correlation of these variables with OAB symptoms.

RESULTS

A total of 767 out of 2,900 females responded to the questionnaire. Bothersome frequency was reported in 32.3%, and nocturia in 47.5% of the women. Urgency and urgency urinary incontinence (UUI) were present in 25.5 and 24.7% of the study participants respectively. Urgency was associated with WP smoking (p value 0.048). Bothersome frequency was associated with artificial sweeteners used with coffee and tea (p value 0.013). UUI was associated with cigarette smoking (p value 0.034) and elevated BMI (p value < 0.001). OAB symptoms were not found to be significantly associated with soft drink and energy drink consumption. A lower prevalence of nocturia (p value 0.009) and urgency was associated with alcohol consumption (p value 0.017). More than two-thirds (69.2%) of WP smokers expressed readiness to decrease WP smoking if this would improve their lower urinary tract symptoms (LUTS).

CONCLUSION

Overactive bladder is common in healthy young nulliparous women and is associated with multiple risk factors, including WP smoking.

Waterpipe tobacco smoke and health: What we have learned from rodent models?

AIMS

Waterpipe smoking (WPS) is a popular form of tobacco smoking. This is due to the misperception that WPS is less detrimental than cigarette smoking. This review aimed to present the adverse effects of WPS on health outcomes through utilizing animal models.

MAIN METHODS

The design of the current study is systematic review. PubMed, HINARI, Google, and SCOPUS databases were searched for the adverse effects of WPS on general health in rodents. Certain key information was extracted and collected from the included studies.

KEY FINDINGS

After screening different databases and removal of duplicates, 43 papers were included in this review. It was found that WPS was able to negatively affect the oxidative stress and inflammatory biomarkers in mice. Furthermore, WPS increased the levels of Tumor necrosis factor-α and 8-isoprostane, and DNA damage in mice lung homogenates. Additionally, chronic exposure to WPS increased the serum levels of creatinine and blood urea nitrogen in mice; indicating injury to renal tissues. The negative effect of WPS extends to affect offspring rats following prenatal WPS, in which WPS in utero lead to remarkable increase in the levels of testosterone, estrogen and follicle-stimulating hormones in WPS exposed animals.

SIGNIFICANCE

This systematic review highlighted the adverse effects of WPS on health outcomes at cellular and biochemical levels in different tissues and organs of rodents. The current reviews' findings highlighted the great hazards presented by WPS in the selected rodents' model and the essential necessity for future improved management of WPS indoor consumption.

Cannabis and Lung Health: Does the Bad Outweigh the Good?

Cannabis use is growing, with multiple medical ‘indications’ and approval for recreational use in many countries. This article will review some of the respiratory complications to cannabis use, which include lung function changes, lung destruction, increased risk of lung and head and neck cancer, and others. These are mostly related to smoking, and the co-administration of nicotine makes the risks a bit difficult to measure. However, with many reports of EVALI, electronic vaping-associated lung injury, being related to cannabis coadministration, it appears that the safest administration of cannabis, as far as lung health, is orally.

Predictors of waterpipe smoking among university students in the Qassim region, Saudi Arabia

INTRODUCTION

Waterpipe smoking has gained global popularity among adolescents and young adults. This study aimed to identify the predictors of waterpipe smoking among university students in the Qassim region of Saudi Arabia.

METHODS

A cross-sectional study was conducted using a pre-tested, validated, and self-administered questionnaire to identify the predictors of waterpipe smoking among university students aged >18 years in the Qassim region.

RESULTS

Of the 1158 questionnaires distributed, 928 were returned with complete responses. Of these 928 participants, 820 were men (88.7%) and the majority were unmarried (95.6%). The risk of waterpipe smoking was significantly higher in students aged >26 years (OR=3.39; 95% CI: 1.30– 8.80), those who had a brother who smoked (OR=1.78; 95% CI: 1.13–2.79), and those who were married (OR=3.21; 95% CI: 1.36–7.59). Furthermore, participants who had smoked cigarettes (OR=3.18; 95% CI: 1.89–5.34) or other tobacco products (OR=6.39; 95% CI: 3.69–11.07) within the past 30 days, and students who believed that waterpipe smoking was less harmful than cigarette smoking (OR=2.61; 95% CI: 1.54–4.41) had a higher risk of engaging in waterpipe smoking. However, the risk was lower among students receiving a monthly financial aid of more than US$264 (OR=0.34; 95% CI: 0.13–0.89).

CONCLUSIONS

This study revealed that higher age, being male, being married, low student financial aid, waterpipe smoker sibling, cigarette and other types of tobacco smoking in the past 30 days, and believing waterpipe smoking to be less harmful than cigarette smoking, were significant predictors of waterpipe smoking. Educational programs targeted at improving awareness of the adverse effects of waterpipe smoking should be considered for early prevention in young adults.

Association between cumulative cigarette and Waterpipe smoking and symptoms of dependence in Lebanese adults

BACKGROUND

Waterpipe and cigarette smoking dependence are becoming increasingly prevalent forms of addiction globally. This study examined whether cumulative cigarette smoking and cumulative waterpipe smoking are associated with higher dependence on both cigarettes and waterpipe.

METHODS

This cross-sectional study conducted between February and April 2020, enrolled 363 participants drawn from all Lebanese districts. The mean age was 29.51 years, 64.8% were females, and 124 (34.2%) exclusive cigarette smokers, 189 (52.1%) exclusive waterpipe smokers, and 50 (13.8%) dual smokers (waterpipe and cigarette). We used the Hooked on Nicotine Checklist (HONC) as an indicator of decreased autonomy towards nicotine, in addition to the Lebanon Waterpipe Dependence Scale-11 (LWDS11) and the Lebanese Cigarette Dependence scale (LCD). A stepwise linear regression was performed taking the HONC scores due to cigarette and waterpipe smoking, LCD and LWDS-11 scores as dependent variables.

RESULTS

The results showed that in the total sample, higher cumulative cigarette smoking (B = 0.005 with a confidence interval of 0.004, 0.006) was significantly associated with higher HONC cigarette scores, whereas higher cumulative waterpipe smoking (B = -0.006 with a confidence interval of - 0.009, - 0.002) was significantly associated with lower HONC cigarette scores. Moreover, higher cumulative waterpipe smoking (B = 0.012 with a confidence interval of 0.009,0.015) was significantly associated with higher HONC waterpipe scores. The results showed that, in both sexes, higher cumulative cigarette smoking was associated with higher HONC cigarette scores and lower HONC waterpipe scores. Furthermore, higher cumulative waterpipe smoking was significantly associated with higher HONC waterpipe scores in both sexes.

CONCLUSION

Our study supports the fact that heavy nicotine consumption, related to both the increased frequency and smoking duration, can increase the risk of dependence. It raises the need for strategic plans to minimize and discourage the use of nicotine products in Lebanese community settings.

Differential Effects of Electronic Hookah Vaping and Traditional Combustible Hookah Smoking on Oxidation, Inflammation and Arterial Stiffness

BACKGROUND

Traditional hookah smoking has quickly grown to become a global tobacco epidemic. More recently, electronic (e-) hookahs-vaped through traditional waterpipes-were introduced as healthier alternatives to combustible hookah. With combustible tobacco smoking, oxidative stress, inflammation and vascular stiffness are key components in the development and progression of atherosclerosis. The comparable effects of hookah are unknown.

RESEARCH QUESTION

What is the differential acute effect of e-hookah vaping vs combustible hookah smoking on oxidation, inflammation and arterial stiffness?

STUDY DESIGN AND METHODS

In a randomized crossover design study-among a cohort of 17 healthy young adult chronic hookah smokers-we investigated the effect of e-hookah vaping and hookah smoking on measures of conduit arterial stiffness, including carotid-femoral pulse wave velocity (PWV), augmentation index corrected for heart rate before and after a 30-minute exposure session. We assessed a panel of circulating biomarkers indicative of inflammation and oxidants and measured plasma nicotine and exhaled carbon monoxide (CO) levels before and after the sessions.

RESULTS

E-hookah vaping tended to lead to a larger acute increase in PWV than hookah smoking (e-hookah: +0.74±0.12m/s^-1; combustible hookah: +0.57±0.14m/s^-1, both p<0.05, mean ± SE), indicative of large artery stiffening. Compared to baseline, only e-hookah vaping induced an acute increase in augmentation index (e-hookah: +5.58±1.54%, p=0.004; combustible hookah: +2.87±2.12%, p=ns). These vascular changes were accompanied by elevation of pro-inflammatory biomarkers high sensitivity C-reactive protein, fibrinogen, and TNFα after vaping (all p<0.05). No changes in biomarkers of inflammation and oxidants were observed after smoking. Compared to baseline, exhaled CO levels were higher after smoking than after vaping (+36.81±6.70 versus -0.38±0.22 ppm, p<0.001), whereas plasma nicotine concentrations were comparable (+6.14±1.03 versus +5.24±0.96 ng/mL, p=0.478).

INTERPRETATION

While advertised to be "safe", flavored e-hookah vaping exerts injurious effects on the vasculature which are, at least in part, mediated by inflammation.

The association of waterpipe smoking with arterial stiffness and wave reflection in a community-based sample

PURPOSE

The evidence linking waterpipe smoking to cardiovascular disease is limited. We evaluated the association of waterpipe smoking (WPS) with arterial stiffness and wave reflection measured by augmentation pressure (AP), augmentation index (AIx), and carotid-femoral pulse wave velocity (CFPWV), which are validated predictors of cardiovascular disease.

MATERIALS AND METHODS

Community-based, cross-sectional study including 205 exclusive waterpipe smokers and 199 matched never-smokers aged 35 years or older (mean age 51.7 ± 8.9 years, 36% females). Smoking and its extent were assessed using a validated questionnaire and urine cotinine levels. CFPWV, AP, AIx (AP/aortic pulse pressure) and heart rate adjusted AIx (AIx@75) were determined using tonometry and compared between smokers and non-smokers, and the association of WPS with tonometry measures was assessed using linear regression adjusting for possible confounders.

RESULTS

Waterpipe smokers and non-smokers had similar mean age and sex distribution. Compared to non-smokers, waterpipe smokers had significantly higher adjusted AP (10.5 ± 3.9 vs. 9.4 ± 3.9 mmHg respectively; p = 0.01), AIx (28.1 ± 8.4 vs. 25.7 ± 8.5% respectively; p = 0.01) and AIx@75 (24.2 ± 8.7 vs. 21.8 ± 8.9% respectively; p = 0.01). AIx was significantly associated with WPS extent, measured by a number of waterpipe smoked/day (β = 1.04/waterpipe, 95%CI:[0.50-1.58]), duration of waterpipe smoking (β = 0.77/10-years, 95%CI:[0.16-1.38]), their products in waterpipe-years (β = 0.30/10-waterpipe-year, 95%CI:[0.12-0.47]) and plasma cotinine (β = 0.56/100 ng/ml, 95%CI:[0.14-0.98]), adjusting for possible confounders, and so were AP and AIx@75. CFPWV however, was not associated with waterpipe smoking.

CONCLUSION

In a community-based sample, exclusive WPS and its extent were associated with a dose-dependent increase in AIx and AP, accounting for other risk factors, suggesting that waterpipe smokers are at increased risk of cardiovascular disease.

Prevalence of hookah smoking and associated factors among male high school students in Iraq

BACKGROUND

The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region. Hookah users are exposed to an array of chemical compounds and may suffer several chronic diseases as a result. The purpose of this study was to determine the prevalence of hookah use among male high school students in the region and to study different associated factors in order to provide local tobacco control officials with an understanding of this public health problem.

METHODS

A convenient non-probability sampling study was conducted among students in three high schools in Al-Karkh district, Baghdad. The study period was from October 2017 till January 2019 and included 847 male students aged 15-18 years old. Using a simple random technique to select the high schools from a list of schools we chose one school from each directorate. Descriptive, chi-square test of significance, bivariate, and multivariate logistic regression analyses of data were carried out for identifying the risk factors associated with hookah smoking among these high school adolescent males.

RESULTS

The overall prevalence of hookah smoking in the last 30 days among male high school students was 46.1% while in the past 6 months it was as high as 85.7%. More than two-thirds (70.6%) of the students thought that hookah smoking was more socially acceptable than cigarette smoking. Factors such as having first heard about it from friends, the media, or the presence of a hookah café near their residence were significantly associated (p > 0.05) with hookah smoking among the students. Similarly, being surrounded by friends who used hookah was also found to be significantly associated with hookah smoking, with an odds ratio of 0.18, 95% CI (0.087-0.394). Hookah smokers were less likely than non-hookah smokers to report its use as forbidden in Islam and more likely to say it is allowed in Islam.

CONCLUSIONS

We found an alarmingly high use of hookah smoking among male high school students in this study. Family members and peers had an important role in the prevention of hookah smoking among these students. There is a need for students to be educated about the toxicity of hookah tobacco smoking and its direct effect on their health.

Cigarette, waterpipe, and electronic cigarette use among college fraternity and sorority members and athletes in the United States

To examine the association between fraternity/sorority membership and athlete status with tobacco use by tobacco product type. Participants: Undergraduate college students who participated in the Spring 2017 National College Health Assessment-II Survey (n = 47,821). Methods: Prevalence of current (past-30 day) cigarette smoking, waterpipe tobacco smoking (WTS), and e-cigarette (ECIG) use was examined. Logistic regressions examined associations between fraternity/sorority membership and participation in collegiate athletics with tobacco use. Results: Fraternity/sorority members had the highest current use rates for cigarettes, waterpipe tobacco, and ECIGs and were nearly twice as likely to report cigarette smoking, WTS, and ECIG use relative to non-fraternity/sorority members. Relative to non-varsity athletes, varsity athletes were less likely to report cigarette smoking and WTS, but not ECIG use. Conclusions: Fraternity/sorority members appear to be at risk for use of multiple tobacco products. Varsity athlete status may be protective for some tobacco products, but does not appear no for ECIG use. ECIGs may appeal to groups typically at low risk for other tobacco products.

An Emerging Problem of Shisha Smoking among High School Students in Ethiopia

Shisha smoking is also known as hookah, water pipe, goza, and nargile. Shisha use among the young is increasing globally. Shisha smoke results in a high concentration of carbon monoxide, tar, nicotine, and heavy metals which can be toxic to humans, especially with chronic exposure. This study aims to determine the prevalence and risk factors of shisha smoking among in-school adolescents in Ethiopia. Four regional states in Ethiopia (Oromia, Amhara, Southern Nations, Nationalities, and Peoples' Region, Tigray) and the capital city (Addis Ababa) were the study areas. A two-stage cluster sampling approach was employed to produce a representative sample. From the sampling frames in the study areas, 36 high schools were selected randomly. A multi-level logistic regression analysis was used to account for cluster-specific random effects, the effect of individuals', and school-level variables for ever-use of shisha. A total of 3355 secondary school grade 9 and 10 students aged between 13 and 22 years took part in this study. A total of 86 (2.6%) and 20 (0.6%) of the study participants, reported that they had ever smoked or were current smokers of shisha, respectively. Of all study participants, 38.6% perceived shisha as less harmful than cigarettes and 48.5% reported that they do not know which was more harmful to health. Students were more likely to ever use shisha if they had friend/s who smoke shisha (AOR = 16.8, 95% CI: 6.4-44.3), ever smoked cigarettes (AOR = 8.2, 95% CI: 3.4-19.8), ever used khat (AOR = 4.2, 95% CI: 1.9-10.4), ever used marijuana (AOR = 3.9, 95% CI: 1.4-11.1), ever used smokeless tobacco (AOR = 3.1 95% CI: 1.1-8.4), and students had received income from their parents (AOR = 3.1 CI: 1.1-8.8). Prevalence of ever and current use of shisha among high school students is low in Ethiopia compared to many countries in Africa. The majority of adolescents perceived shisha as less harmful to health than cigarette smoking. Health education about the harmful effects of shisha should be delivered to adolescents, along with information on other substances like khat, cigarettes, marijuana, and smokeless tobacco to prevent initiation of substance use.

Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings

BACKGROUND

For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS).

AIMS

The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS).

METHOD

Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors.

RESULTS

Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS.

DISCUSSION

Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences.

CONCLUSION

The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

Waterpipe Tobacco Warnings: An Experimental Study among a Nationally Representative Sample of U.S. Young Adults

BACKGROUND

Waterpipe tobacco (WT) smoking by young adults remains high and misperceptions are common. Product warnings can increase knowledge of harms and reduce use. The goal of this study was to test warning statements, including the FDA-required nicotine warning (prior to implementation), on young adults' thinking about harms of and discouragement from WT smoking.

METHODS

We conducted a between-subjects experiment in a nationally representative telephone survey of 1,152 young adults ages 18-29. Participants were randomly assigned to hear one of five warning statements and reported how much, on a 4-point scale, the warning made them think about the harms and discouraged them from WT smoking.

RESULTS

The sample was 36.8% female, 57.8% white, 20.2% Black, 24.1% Hispanic, with a mean age of 23.2 (SE=0.25). Under half (43.5%) had ever smoked WT. There were significant differences among the statements on both thinking about harms (p<.0001) and discouragement (p<.0001). The FDA-required 'nicotine' warning led to the lowest thinking about harms (M=2.85, SE=0.08) and was the least discouraging (M=2.86, SE=0.08), while the '100 cigarettes' warning resulted in the greatest thinking about harms (M=3.62, SE=0.05) and was the most discouraging (M=3.56, SE=0.06).

CONCLUSION

The nicotine warning resulted in the lowest levels of thinking about harms and discouragement from WT smoking, suggesting limited impact. However, a warning focused on comparing smoke inhalation from WT smoking to cigarettes seems promising. Warnings should cover a broad range of WT health effects, and possibly comparisons to cigarettes. Findings also have implications for the content of international waterpipe warnings.

IMPLICATIONS

This study indicates that the nicotine warning is the least effective at making young adults think about the harms of and discouraging waterpipe tobacco smoking. The FDA and other countries should consider requiring warnings to cover a broader range of health harms, misperceptions, and possibly comparisons to cigarettes.

Markers of oxidative stress and toxicant exposure among young waterpipe smokers in the USA

Waterpipe (aka hookah) tobacco smokers are exposed to toxicants that can lead to oxidative DNA and RNA damage, a precursor to chronic disease formation. This study assessed toxicant exposure and biomarkers of DNA [8-oxo-7, 8-dihydro-2'-deoxyguanosine (8-oxodG)] and RNA [8-oxo-7,8-dihydroguanosine (8-oxoGuo)] oxidative damage during smoking of flavored and non-flavored waterpipe tobacco. Thirty waterpipe smokers completed two counterbalanced 2-h lab waterpipe smoking sessions (flavored vs. non-flavored waterpipe tobacco). Urinary concentrations of 8-oxodG and 8-oxoGuo and expired carbon monoxide (eCO) were measured before and after the smoking sessions. A significant increase in the urinary concentrations of 8-oxodG (from 2.12 ± 0.83 to 2.35 ± 0.91 ng/mg creatinine, p = 0.024) and 8-oxoGuo (from 2.96 ± 0.84 to 3.45 ± 0.76 ng/mg creatinine, p = 0.003) were observed after smoking the non-flavored and flavored waterpipe tobacco, respectively. Our results also showed that the mean ± SD of eCO increased significantly after smoking the flavored (from 1.3 ± 1.1 to 20.3 ± 23.6 ppm, p < 0.001) and non-flavored waterpipe tobacco (from 1.8 ± 1.2 to 24.5 ± 26.1 ppm, p < 0.001). There were no significant differences in the means of 8-oxodG (p = 0.576), 8-oxoGuo (p = 0.108), and eCO (p = 0.170) between the flavored and non-flavored tobacco sessions. Smoking non-flavored and flavored waterpipe tobacco leads to oxidative stress and toxicant exposure. Our findings add to the existing evidence about the adverse effects of waterpipe tobacco smoking (WTS) and the need for strong policies to inform and protect young people from the risks of WTS.

Semi-outdoor filterless air purifier for smog and microbial protection with water purifier system

PURPOSE

Air pollution and COVID-19 problems are being increasingly scrutinized. This article discusses the optimum design of an indoor and semi-outdoor air purifier, using a water-based filtration system.

METHODS

An air purifier was fabricated, then comparison of purifying efficacy of the system between untreated air and using an air pump was done. Incense smoke was generated within a room for 10 seconds. The number of particle sizes of PM0.3, PM0.5, PM1.0, PM3.0, PM5.0, and PM10 μm (particle/ m3) as well as the detection of mass concentration of PM1.0, PM2.5, PM5.0, and PM10 (mg/m3) at 0 and 5 min were recorded. Each experiment was repeated 10 times.

RESULTS

Particles in untreated air, except PM10, showed the maximum increase rate of the number of particle sizes greater than the air pump experiment. The highest differentiation between two methods was that PM1.0 and PM0.5 of untreated air increased to 113.647 and 61.539 % whereas the air pump method showed 4.720 and 2.533 %, respectively. The PM mass concentration of untreated air increased from 50.217 to 51.167 % while the increased rate of PM using an air pump was 2.784 to 2.902 %.

CONCLUSION

This study proposed a water-based air filtration technique, which can reduce the level of particulate matter, and also is a low-cost prototype. For the next experiment, the study should extend test length, clarify an optimum ratio of disinfectant technologies, connect with the internet of things, compare the efficiency with a HEPA filter air purifier, and then also measure some particles which are smaller than 0.2 μm.

Hookah venue employees' knowledge and perceptions of hookah tobacco smoking

BACKGROUND

Recent years showed sharp proliferation of hookah bars worldwide with scarcity of workplace safety regulations. Hookah server employees are at high risk for elevated harm. This study reported hookah smoke exposure, assessed acute problems and evaluated factors related to knowledge of hookah-smoking harm and toxicity among high-risk hookah servers.

METHODS

A mixed methods design was employed. A self-reported questionnaire was distributed online, and semistructured in-depth interviews were used. Hookah server employees were recruited using snowball sampling, with 52 participants included in quantitative analyses and 10 participating in semistructured interviews.

RESULTS

Hookah server employees took a median 389 hookah puffs per workday compared with 169-170 per session for customers. Servers were limited in knowledge of potential hookah harms and smoke toxicant exposure. Almost all believed that hookah water bowls filtered out toxicants. Smoking with family members (p=0.012) was associated with lower knowledge scores for hookah harms and exposure. Hookah server employees reported carbon monoxide-poisoning symptoms of dizziness, headaches and fainting during work but believed their bodies would adapt. Home remedies were taken to alleviate symptoms. Work environment and salary attracted hookah server employees to their position and none considered quitting for reasons of harm.

CONCLUSION

Findings demonstrate need for workplace policies and regulations to protect hookah server employees and provide targets for educational interventions for high-risk hookah server employees.

Is there a relation between vitamin D, interleukin-17, and bone mineral density in patients with inflammatory bowel disease?

INTRODUCTION

In inflammatory bowel diseases (IBD), osteopenia and osteoporosis constitute a significant medical problem. Cytokines, especially IL-17, play an important role in the pathogenesis of IBD and osteoporosis. Vitamin D is a regulator of bone metabolism, and helps maintain immune system homeostasis.

MATERIAL AND METHODS

The research sample consisted of 208 persons: 83 patients (age 35 ±11.99 years) with Crohn's disease (CD); 86 patients (age 39.58 ±14.74 years) with ulcerative colitis (UC); and 39 persons (age 30.74 ±8.63 years) in the control group (CG). Clinical data on bone mineral density of the lumbar spine (L2-L4), bone mineral density of the femoral neck (FN), and body mass index (BMI) were collected. 25OHD and IL-17 serum concentrations were also measured.

RESULTS

Body mass index (kg/m²) results: in CD, 21.51 ±3.68; in UC, 23.31 ±4.38; and in CG, 24.57 ±3.45 (p < 0.01). Densitometry results for L2-L4 T-score SD: in CD -0.83 ±1.45; in UC -0.47 ±1.15; in CG 0.09 ±0.70. Densitometry results for FN T-score SD: in CD -0.62 ±1.26; in UC -0.29±1.17; in CG 0.41 ±1.03 25OHD (ng/ml) serum concentrations: in CD, 21.33±12.50; in UC, 22.04±9.56; in CG, 21.56±9.11 (ns). IL-17 (pg/ml) serum concentrations: in CD, 8.55±10.99; in UC, 11.67±12.97; in CG, 5.16±9.11 (ns).

CONCLUSIONS

Inflammatory bowel diseases patients and persons from the CG did not differ in vitamin D or IL-17 levels. Patients with a mild course of the disease had a higher vitamin D concentration and bone mineral density. In UC, higher vitamin D concentrations were associated with lower IL-17 concentrations. The IBD patients with a severe course of the disease had a lower body mass than those in the CG and the patients with a mild course of the disease.