Sustained Waterpipe Tobacco Smoking and Trends Over Time

Prevalence and predictors of waterpipe smoking initiation and progression among adolescents and young adults in waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study

BACKGROUND

Waterpipe tobacco (WPT) smoking has increased among the young population in the United States (US). This study assessed the extent and predictors of WPT smoking initiation and progression among US adolescents (12-17 years) and young adults (18-24 years) longitudinally.

METHODS

We analyzed data from 4 waves (2013-2018) of the Population Assessment of Tobacco and Health (PATH) study comprising 10,692 respondents (adolescents=5,428 and young adults=5,264). Kaplan-Meier survival method estimated probabilities of WPT initiation and progression. Cox proportional hazards regression models delineated predictors of the outcomes.

RESULTS

Between 2013 to 2018, 4.8% of adolescents initiated and 10.6% progressed WPT smoking. Among young adults, 18.5% initiated and 14.1% progressed WPT smoking during the same time interval. Predictors among adolescents included, WPT initiation: Hispanic ethnicity (adjusted odds ratio (aHR)=1.75, 95% confidence interval (CI)=1.23-2.49), lower harm perception (aHR=2.89, 95% CI=2.10-3.98), and other tobacco products use (aHR=3.97, 95% CI=2.73-5.78); WPT progression: illicit drug use (aHR=4.60, 95% CI=1.99-10.67). Predictors among young adults included, WPT initiation: non-Hispanic Black (aHR=2.31, 95% CI=1.78-3.00), Hispanic (aHR=1.77, 95% CI=1.34-2.33), lower harm perception (aHR=2.77, 95% CI=2.19-3.50), and other tobacco products use (aHR=3.14, 95% CI=2.25-4.38); WPT progression: non-Hispanic Black (aHR=1.51 95% CI=1.09-2.10), lower harm perception (aHR=1.80, 95% CI=1.41-2.30), and alcohol use (aHR=1.61, 95% CI=1.13-2.30).

CONCLUSIONS

Results indicate a high prevalence of WPT initiation and progression among adolescents and young adults over time, with minority racial/ethnic groups being at greater risk for both. WPT-specific risk communication interventions (e.g., educational campaigns and health warning labels) are warranted to limit WPT smoking among young people.

Psychophysiological responses to hookah tobacco public education messages among young adults

OBJECTIVE

Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting.

METHOD

One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure.

RESULTS

The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks.

DISCUSSION

Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1-4 (2013-2017)

OBJECTIVE

This study reports the prospectively estimated age of initiation of susceptibility to, ever, past 30-day, and fairly regular hookah use.

DESIGN

Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US youth (ages 12-17).

METHODS

Youth who were never hookah users at their first wave of participation were identified (n = 16,678; N = 31,136,834). Four outcomes were analyzed, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) fairly regular hookah use. The age of hookah initiation of each outcome was estimated. Weighted interval censoring survival analyses and Cox regression models were conducted to estimate the age of initiation of each hookah use outcome, and to estimate differences in age of initiation by sex and by race, respectively.

RESULTS

Around 11% of youth were classified as susceptible to hookah use by 13 years of age, 8% reported initiating ever hookah use by age 17, almost 10% reported initiating past 30-day hookah use by age 19, and 3% reported initiating fairly regular hookah use by age 20. Females and Hispanics were at higher risk of becoming susceptible to and ever hookah use at earlier ages compared to males and Non-Hispanic White youth.

CONCLUSION

Education, communication campaigns, and proven culturally targeted tobacco interventions that reach youth at ages before they first become susceptible or start using hookah use are needed to prevent the onset of hookah use among vulnerable youth.

Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults

Young adults’ hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18–30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p < 0.001), positive attitudes (p < 0.001), and negative emotional response (p < 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

Data Visualization Tools of Tobacco Product Use Patterns, Transitions and Sex Differences in the PATH Youth Data

INTRODUCTION

Evaluations of multiple tobacco product use and temporal changes in patterns of use are complicated by a large number of combinations and transitions. Visualization tools could easily identify most common patterns and transitions.

METHODS

Set intersection bar plots describe ever use of five tobacco products among 12-17 years old youth in wave 1 of the Population Assessment of Tobacco and Health (PATH) study (N = 11 497). Heat maps visualize unweighted frequencies of transitions from ever use at wave 1 (2013-2014) to past 12-month use at wave 2 (2014-2015). Weighted calibrated heat maps assess differences in relative frequencies of transitions by pattern at wave 1 and identify differences in transitions by sex.

RESULTS

The most common tobacco product ever use patterns in wave 1 were of cigarettes only, e-cigarettes only or hookah only, followed by ever use of both cigarettes and e-cigarettes. Initiation of use between waves was uncommon. The most frequent transition among those who reported use at wave 2 but not at wave 1 (N = 971) was to e-cigarette use (N = 301). However, among e-cigarette-only ever users at wave 1 (N = 260), about half did not report any product use at wave 2. Use of three or more products remained stable. Adolescent girls compared to boys appeared more likely to report hookah use at both waves.

CONCLUSION

Set intersection bar plots and heat maps are useful for visualizing tobacco product use patterns and transitions, especially for multiple products. Both techniques could identify common problematic tobacco use patterns across and within populations.

IMPLICATIONS

Given the growing complexity of the youth tobacco use landscape, approaches to efficiently communicate patterns of multiple tobacco product use should be used more often. This study introduces set intersection bar plots and modified versions of heat maps to the tobacco product literature and illustrates their use in the PATH youth sample. These techniques are useful for visualizing absolute and relative frequencies of multiple possible patterns and transitions. They also suggest targets for subsequent statistical inference such as sex differences in hookah use. The methods can be applied more generally for data visualization wherever large number of combinations occurs.

Results of a Single Arm Pilot Study of a Mobile Messaging Intervention for Hookah Tobacco Cessation in Young Adults

Background

Hookah tobacco use is common among young adults. Unlike cigarette smoking, there is limited evidence on mobile (ie, mHealth) interventions to promote cessation.

Objectives

This pilot study tested the preliminary effects of mobile messaging for cessation in young adult hookah smokers.

Methods

Young adults (N = 20) aged 18 to 30 years who smoke hookah at least monthly and have done so at least once in the past 30 days received a 6-week mHealth multimedia messaging (text and images) intervention. Message scheduling (2 days/week × 6 weeks) was based on the literature. Content was developed iteratively by the study team and focused on health harms and addictiveness of hookah. Content was individually tailored by baseline hookah use frequency, risk beliefs, and responses to interactive text messages assessing participants' hookah tobacco use behavior and beliefs to maximize impact. Engagement was assessed during the intervention, and we examined effects on risk perceptions, risk beliefs, and risk appraisals, motivation to quit, and behavior change immediately post-intervention.

Results

Participants responded to 11.5 (SD = 0.69) of 12 text message prompts on average, endorsed high message receptivity (M = 6.1, SD = 0.93, range = 1-7), and reported the messages were helpful (M = 8.5, SD = 1.5, range = 1-10). There were significant (P < .05) increases in risk perceptions (d's = 0.22-0.88), risk appraisals (d = 0.49), risk beliefs (d = 1.11), and motivation to quit (d = 0.97) post-intervention. Half of participants reported reducing frequency of hookah use (20%) or quitting completely (30%) by end of treatment.

Conclusions

These pilot results provide preliminary support for an mHealth messaging intervention about risks of hookah tobacco for promoting cessation. Rigorously examining the efficacy of this promising intervention is warranted.

Effect of risk messages on risk appraisals, attitudes, ambivalence, and willingness to smoke hookah in young adults

Objective: We examined effects of hookah tobacco risk messages on risk appraisals, attitudes towards hookah, ambivalence about hookah use, and willingness to smoke in young adults aged 18–30 years (n = 234).

Design: In an online experiment, participants completed pre-exposure measures and were randomized to hookah tobacco risk messages or to a no message control condition.

Main Outcome Measures: Risk appraisals, attitudes, ambivalence, and willingness to smoke hookah.

Results: Those who viewed risk messages reported greater risk appraisals (M 4.50, SD 1.17 vs. M 3.87, SD 1.16, p < .001), less positive attitudes (M −0.56, SD 1.24, vs. M 0.39, SD 1.35, p < .001), greater ambivalence (M 3.86, SD 1.26, vs. M 3.08, SD 1.32, p < .001), and less willingness to smoke than controls (M 4.48, SD 1.27, vs. M 4.85, SD 1.37, p = .034). Structural equation modeling demonstrated messages reduced willingness to smoke by evoking less positive attitudes (b = −0.15, 95% CI −0.32, −0.05) and by the effect of heightened risk appraisals on less positive attitudes (b = −0.14, 95% CI −0.30, −0.07).

Conclusions: Honing messages and understanding their mechanisms of action are necessary to produce more effective interventions to address hookah and other tobacco use in young adults.

Short-Term Exposure to Waterpipe/Hookah Smoke Triggers a Hyperactive Platelet Activation State and Increases the Risk of Thrombogenesis

OBJECTIVE

Cardiovascular disease is a major public health problem. Among cardiovascular disease's risk factors, tobacco smoking is considered the single most preventable cause of death, with thrombosis being the main mechanism of cardiovascular disease mortality in smokers. While tobacco smoking has been on the decline, the use of waterpipes/hookah has been rising, mainly due to the perception that they are less harmful than regular cigarettes. Strikingly, there are few studies on the negative effects of waterpipes on the cardiovascular system, and none regarding their direct contribution to thrombus formation. Approach and Results: We used a waterpipe whole-body exposure protocol that mimics real-life human exposure scenarios and investigated its effects, relative to clean air, on platelet function, hemostasis, and thrombogenesis. We found that waterpipe smoke (WPS)-exposed mice exhibited both shortened thrombus occlusion and bleeding times. Further, our results show that platelets from WPS-exposed mice are hyperactive, with enhanced agonist-induced aggregation, dense and α-granule secretion, αIIbβ3 integrin activation, phosphatidylserine expression, and platelet spreading, when compared with clean air-exposed platelets. Finally, at the molecular level, it was found that Akt (protein kinase B) and ERK (extracellular signal-regulated kinases) phosphorylation are enhanced in the WPS and in nicotine-treated platelets.

CONCLUSIONS

Our findings demonstrate that WPS exposure directly modulates hemostasis and increases the risk of thrombosis and that this is mediated, in part, via a state of platelet hyperactivity. The negative health impact of WPS/hookah, therefore, should not be underestimated. Moreover, this study should also help in raising public awareness of the toxic effects of waterpipe/hookah.

The Relationship between School Absenteeism and Substance Use: An Integrative Literature Review

Background: Chronic school absenteeism is prevalent among high school students in the United States. Its impacts on academic success and health are cause for concern. One specific area of concern is its relationship to youth substance use; chronic absenteeism is associated with using alcohol, marijuana, tobacco, and other drugs. Despite important findings, absent from the literature is a recent and systematic synthesis of related research. Objective: We aimed to examine the literature to provide a better understanding of the relationship between chronic school absenteeism and the use of alcohol, tobacco, marijuana and other drugs among U.S. high school students. Methods: We conducted an integrative review of existing peer-reviewed literature using key terms in five databases from the education and health sectors. We included English-language, quantitative and qualitative studies published between 1992 and October 2017 and focused on U.S. students in grades 9 through 12 and between ages 13 and 21. We extracted data and study quality measures for included studies. Results: After screening 3,130 articles using titles and abstracts and reviewing 99 full-text articles, 37 met inclusion criteria. Most were cross-sectional, used local-level data, widely varied in sampling, were of limited generalizability, and simultaneously considered school absenteeism and the use of multiple substances. Due to methodological issues, the relationship between chronic absenteeism and substance use is difficult to fully understand. Conclusions: We confirm the connection between school absenteeism and substance use among U.S. youth, highlight a limited understanding of how and why this relationship manifests, and call for absenteeism research that uses longitudinal methods, national data, and clearly articulated methodologies and self-appraised limitations.

Development and Pretesting of Risk-Based Mobile Multimedia Message Content for Young Adult Hookah Use

Background. Hookah is one of the most commonly used tobacco products among U.S. young adults due in part to widespread misperceptions that it is not harmful or addictive. There is growing evidence that hookah tobacco is associated with health harms and can lead to addiction. Research on interventions to address these misperceptions by communicating the harms and addictiveness of hookah use is needed. Aims. This study developed and pretested mobile multimedia message service (MMS) message content communicating the risks of hookah tobacco use to young adult hookah smokers. Method. Message content, delivery, and pretesting were tailored to participants' risk beliefs, hookah use frequency, and responses to simulated text message prompts. Participants viewed 4 of 12 core MMS messages randomized within-subjects and completed postexposure measures of message receptivity and emotional response (e.g., worry). Results. The sample included 156 young adult (age 18-30 years) hookah smokers; 31% smoked hookah monthly and 69% weekly/daily. Prior to viewing messages, a majority endorsed beliefs reflecting misperceptions about the risks of hookah tobacco. Postexposure measures showed participants were receptive to the messages and the messages evoked emotional response. As anticipated, messages produced similar receptivity and there were few differences in emotional response between the messages tested. Discussion. Young adult hookah tobacco smokers were receptive to tailored mobile MMS messages and messages evoked emotional response, two critical precursors to behavior change. Conclusion. Findings indicate that research testing the efficacy of tailored MMS messaging as a strategy for reducing hookah tobacco use in young adults is warranted.

Hookah Use Among US Youth: A Systematic Review of the Literature From 2009 to 2017

INTRODUCTION

Given the US Food and Drug Administration (FDA)'s authority to regulate hookah, more research is needed to inform regulations intended to prevent youth from using hookah. This systematic review summarizes and assesses the literature related to hookah use among adolescents (11 to ≤18 years of age) in the United States from 2009 to 2017.

METHODS

Database searches yielded 867 peer-reviewed articles. After duplicates were removed, authors reviewed 461 articles for inclusion. Included articles (n = 55) were coded for study themes, study quality, and their relevance to FDA's research priorities. A qualitative synthesis is presented.

RESULTS

The following themes were identified: (1) prevalence of hookah use (n = 42), (2) tobacco use transitions (n = 7), (3) sociodemographic correlates (n = 35), (4) psychosocial risk factors (n = 21), (5) concurrent use of other tobacco products (n = 31), (6) concurrent use of other substances (n = 9), and (7) other (n = 15)-which includes low prevalence themes. The qualitative synthesis showed increasing rates of hookah use. Older age, male gender, positive social normative beliefs, higher peer use, as well as lower perceived risk were associated with hookah use. Longitudinal studies of youth hookah use showed bidirectional relationships between use of hookah and other tobacco products. All articles fell within FDA's research priority related to "behavior," and three priorities ("impact analysis," "health effects," and "toxicity") have not been explored for hookah use among US youth since 2009.

CONCLUSIONS

The prevalence of hookah use among youth in the United States is increasing, thus more research is needed to inform policies targeted to protect this vulnerable population.

IMPLICATIONS

This study represents a novel contribution to our understanding of hookah use among youth in the United States from 2009-the year that the Family Smoking Prevention and Tobacco Control Act was passed-to 2017. In recent years, hookah has become a more popular tobacco product among US youth; however, to date, no systematic reviews of hookah use among this population exist. Results highlight implications for future US FDA regulatory policy and identify gaps in research to be addressed in future studies.

Obscenity of Cigarette and Hookah Smoking in Iranian Adolescents: A Longitudinal School-based Study

Background:

There is a very limited information on the obscenity of cigarette and hookah smoking among adolescents. Using a large and representative longitudinal sample of adolescents (n = 4820) aged 14–19 years from Tabriz (a metropolitan city in northwestern Iran), this study aimed at comparing the obscenity of cigarette and hookah smoking and assessing factors associated with obscenity of smoking. Moreover, we examined how the obscenity of cigarette and hookah smoking affected by the progress in the stages of cigarette and hookah smoking.

Methods:

In this longitudinal study, a random sample of high-school students was selected in Tabriz in 2010. Using a valid and reliable self-administered questionnaire, the data from the sampled students were collected twice at two points in time, 12 months apart. Multivariate backward logistic regression was used to determine the effect of the transition in cigarette (or hookah) smoking stages on the obscenity of cigarette (or hookah) smoking.

Results:

While 3,079 (63.9%) students expressed that obscenity of cigarette smoking is higher than obscenity of hookah smoking, 1,741 (36.1%) students expressed that obscenity of hookah smoking is higher than obscenity of cigarette smoking. The results of multivariate backward logistic regression indicated that the transition in cigarette (hookah) smoking stages was not related to the obscenity of cigarette (hookah) smoking.

Conclusions:

The results showed that obscenity of hookah smoking was less than obscenity of cigarette smoking, especially among females. Further study is required to understand the effect of obscenity on smoking and transition to different stages of cigarette and hookah smoking.

Investigating gateway effects using the PATH study

BACKGROUND

A recent meta-analysis of nine cohort studies in youths reported that baseline ever e-cigarette use strongly predicted cigarette smoking initiation in the next 6-18 months, with an adjusted odds ratio of 3.62 (95% confidence interval 2.42-5.41).  A recent review of e-cigarettes agreed there was substantial evidence for this "gateway effect".  However, the number of confounders considered in the studies was limited, so we investigated whether the effect might have resulted from inadequate adjustment, using Waves 1 and 2 of the Population Assessment of Tobacco and Health study.

METHODS

Our main analyses considered Wave 1 never cigarette smokers who, at Wave 2, had information available on smoking initiation.  We constructed a propensity score for ever e-cigarette use from Wave 1 variables, using this to predict ever cigarette smoking.  Sensitivity analyses accounted for use of other tobacco products, linked current e-cigarette use to subsequent current smoking, or used propensity scores for ever smoking or ever tobacco product use as predictors.  We also considered predictors using data from both waves to attempt to control for residual confounding from misclassified responses.

RESULTS

Adjustment for propensity dramatically reduced the unadjusted odds ratio (OR) of 5.70 (4.33-7.50) to 2.48 (1.85-3.31), 2.47 (1.79-3.42) or 1.85 (1.35-2.53), whether adjustment was made as quintiles, as a continuous variable or for the individual variables.  Additional adjustment for other tobacco products reduced this last OR to 1.59 (1.14-2.20).  Sensitivity analyses confirmed adjustment removed most of the gateway effect.  Control for residual confounding also reduced the association.

CONCLUSIONS

We found that confounding is a major factor, explaining most of the observed gateway effect.  However, our analyses are limited by small numbers of new smokers considered and the possibility of over-adjustment if taking up e-cigarettes affects some predictor variables.  Further analyses are intended using Wave 3 data which should avoid these problems.

Investigating gateway effects using the PATH study

BACKGROUND

A recent meta-analysis of nine cohort studies in youths reported that baseline ever e-cigarette use strongly predicted cigarette smoking initiation in the next 6-18 months, with an adjusted odds ratio of 3.62 (95% confidence interval 2.42-5.41).  A recent review of e-cigarettes agreed there was substantial evidence for this "gateway effect".  However, the number of confounders considered in the studies was limited, so we investigated whether the effect might have resulted from inadequate adjustment, using Waves 1 and 2 of the Population Assessment of Tobacco and Health study.

METHODS

Our main analyses considered Wave 1 never cigarette smokers who, at Wave 2, had information available on smoking initiation.  We constructed a propensity score for ever e-cigarette use from Wave 1 variables, using this to predict ever cigarette smoking.  Sensitivity analyses accounted for use of other tobacco products, linked current e-cigarette use to subsequent current smoking, or used propensity scores for ever smoking or ever tobacco product use as predictors.  We also considered predictors using data from both waves to attempt to control for residual confounding from misclassified responses.

RESULTS

Adjustment for propensity dramatically reduced the unadjusted odds ratio (OR) of 5.70 (4.33-7.50) to 2.48 (1.85-3.31), 2.47 (1.79-3.42) or 1.85 (1.35-2.53), whether adjustment was made as quintiles, as a continuous variable or for the individual variables.  Additional adjustment for other tobacco products reduced this last OR to 1.59 (1.14-2.20).  Sensitivity analyses confirmed adjustment removed most of the gateway effect.  Control for residual confounding also reduced the association.

CONCLUSIONS

We found that confounding is a major factor, explaining most of the observed gateway effect.  However, our analyses are limited by small numbers of new smokers considered and the possibility of over-adjustment if taking up e-cigarettes affects some predictor variables.  Further analyses are intended using Wave 3 data which should avoid these problems.

Intra-Ethnic Racial Differences in Waterpipe Tobacco Smoking among Latinos?

BACKGROUND AND OBJECTIVES

This study examined differences in waterpipe smoking (both lifetime and current) by race and ethnicity. More specifically, we evaluated intra-ethnic racial differences among Latinos using a nationally representative sample.

METHODS

Pooled data from the National Adult Tobacco Survey (NATS) [2012-2014] was used, in which Log-Poisson multivariable regression models were deployed to determine the prevalence of waterpipe smoking behavior. Models were stratified by gender and we further investigated acculturation, controlling for relevant sociodemographic characteristics.

RESULTS

In fully-adjusted models assessing lifetime WTS, Black Latinos and White Latinos exhibited an increase prevalence of lifetime WTS compared to their non-Hispanic white counterparts. Once stratifying by gender, Black Latino men (PR = 1.49; 95% CI = 1.16, 1.90) exhibited increased prevalence of lifetime WTS compared to their non-Hispanic white men counterparts; although white Latino men (PR = 0.88; 95% CI = 0.80, 0.98) exhibited decreased prevalence compared to their non-Hispanic white male counterparts. Similar trends were found for current WTS among men. In fully adjusted models assessing lifetime WTS, among women, only white Latina's (PR = 1.23; 95% CI = 1.04, 1.46) exhibited increased prevalence compared to their non-Hispanic white women counterparts. When evaluating current WTS, Black Latina's (PR = 2.19; 95% CI = 1.32, 3.65) and white Latinas (PR = 1.28; 95% CI = 1.00, 1.63) exhibited increased prevalence of WTS compared to their non-Hispanic white women counterparts. Conclusions/Importance: Among the U.S. general adult population, intra-ethnic racial differences in WTS behaviors exist among Latinos; and is shaped by gender. Future efforts to eliminate racial disparities in WTS should be attentive intra-ethnic racial differences among Latinos.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pennsylvania policymakers' knowledge, attitudes and likelihood for action regarding waterpipe tobacco smoking and electronic nicotine delivery systems

INTRODUCTION

Use of waterpipe tobacco smoking (WTS, or hookah smoking) and electronic nicotine delivery systems (ENDS, such as e-cigarettes) is rapidly increasing. However, legislatures have been slow to update policy measures related to them. Therefore, we aimed to assess knowledge, attitudes and likelihood to take future action regarding WTS and ENDS among Pennsylvania legislators.

METHODS

We approached all Standing Members of key Pennsylvania House and Senate health and welfare committees to complete a survey about substances of abuse, including WTS and ENDS. Closed-ended knowledge, attitude and action items used a 100-point scale. Responses to open-ended items were assessed using thematic analysis by three independently working researchers.

RESULTS

We received responses from 13 of 27 eligible policymakers (48%). Participants answered a mean of only 27% (SD=20%) of knowledge items correctly. When asked to rank by priority eight issues in substance abuse, WTS ranked eighth (least urgent) and ENDS ranked fifth. Participants reported low likelihood to introduce legislation on WTS (mean=29, median=25) and/or ENDS (mean=28, median=10). Thematic analysis revealed that participants readily acknowledged lack of understanding of WTS and ENDS, and were eager for additional information.

CONCLUSIONS

Policymakers exhibit a lack of knowledge concerning newer forms of tobacco and nicotine delivery systems and consider them to be relatively low legislative priorities. However, respondents expressed a desire for more information, suggesting the potential for public health entities to promote effective policy development via improved dissemination of information.

The prevalence and trends of waterpipe tobacco smoking: A systematic review

INTRODUCTION

Waterpipe tobacco smoking is harmful to health however its prevalence estimates remain uncertain. We aimed to systematically review the medical literature on waterpipe tobacco prevalence and trends.

METHODS

We searched Medline, Embase and ISI Web of Science for 'waterpipe' and its synonyms, without using language or date restrictions. We included any measure of waterpipe tobacco smoking prevalence in jurisdictionally representative populations. We stratified findings by prevalence measure (past 30 day, ever, regular or occasional, daily, other or unspecified) and age (adults or youth).

RESULTS

We included 129 studies reporting 355 estimates for 68 countries. In general, prevalence estimates among adults were highest in the Eastern Mediterranean, and among youth were about equal between Eastern Mediterranean and European regions. Past 30 day use was highest among Lebanese youth (37.2% in 2008), ever use was highest among Lebanese youth in 2002 and Lebanese university students in 2005 (both 65.3%), regular or occasional use was highest in among Iranian university students (16.3% in 2005), and daily use was highest among Egyptian youth (10.4% in 2005). Trend data were limited but most studies reported increased use over time, ranging from 0.3-1.0% per year among youth in the US to 2.9% per year among youth in Jordan (both for past 30 day use). Results were similar for ever use trends. Turkey (2.3% in 2008 to 0.8% in 2010) and Iraq (6.3% in 2008 and 4.8% in 2012) both witnessed decreased waterpipe use.

CONCLUSION

Waterpipe tobacco smoking is most prevalent in Eastern Mediterranean and European countries, and appears higher among youth than adults. Continued surveillance will be important to assess and inform policy measures to control waterpipe tobacco use.

Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco

INTRODUCTION

Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

METHODS

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

RESULTS

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

CONCLUSIONS

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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