Correlates of nicotine dependence among adolescent waterpipe smokers

The association of individual cognition and social environment of smoking with autonomy over tobacco: A survey from rural China

INTRODUCTION

This study explores the association of individual cognition and social environment of smoking with autonomy over tobacco, providing evidence and insights to help smokers effectively prevent and reduce tobacco dependence.

METHODS

Data were collected from 1389 participants, aged ≥15 years, by face-to-face interviews from June 2018 to November 2019 in central China. We assessed autonomy over tobacco using the Autonomy Over Smoking Scale (AUTOS), including Withdrawal Symptoms (WS), Psychological Dependence (PD) and Cue-induced Cravings (CC), and examined factors of individual cognition and social environment, as well as covariates, including demographic characteristics, health status, and smoking behavior.

RESULTS

AUTOS total score was 16.92 ± 9.05, WS score was the lowest (4.40 ± 3.36) in the three subscales, and CC score was the highest (6.88 ± 3.2). After adjustment, WS score of having a greater awareness of smoking hazards to one's own health was lower than those who had no awareness (β=0.14; 95% CI: -0.31-0.00), and the total score of AUTOS, the score of PD and CC for those who thought smoking was 'more helpful (high)' to interpersonal communication were higher than 'not helpful (not at all)' (β=0.14; 95% CI: 0.01-0.28 with β=0.16; 95% CI: 0.02-0.29; and β=0.14; 95% CI: 0.00-0.28; respectively). Having a greater difficulty in smoking cessation was associated with higher AUTOS total and subscale scores (p<0.001). Notably, none of the social-environmental factors included had a significant association with AUTOS scores.

CONCLUSIONS

Interventions targeting individual cognitive factors of tobacco dependence seem to be more effective in smoking cessation. Future research may explore the influence of family and workplace among social environmental factors, which may reveal the effect of a binding force.

Factors Predicting Dependence on Waterpipe Smoking Among Waterpipe Exclusive Smokers

ABSTRACT

The current study targeted a sample of waterpipe (WP) exclusive smokers to identify the levels and predictors of dependence on this smoking pattern and to examine the relationship between WP smoking (WPS) dependence and depressive symptoms. A cross-sectional research design was employed with a community sample of 270 subjects who are currently WP exclusive smokers. Assessment of WPS dependence and depressive symptoms was performed using self-report measures. About 62.6% of the subjects were WPS dependent. The unique significant predictors of WPS dependence were age, depression levels, age of starting WPS, duration of WPS, income, smoking WP daily, the belief of being attracted to WPS, and the desire to stop WPS. These predictors explained 35% of the variance in WPS dependence. WPS dependence was associated with increased depressive symptoms. Although few studies have been conducted, the WPS dependence prevalence appears to be alarmingly high among WP exclusive smokers. Factors associated with WPS dependence provide useful information that can be used to tailor WP prevention interventions.

Motivators of impulsivity to smoke waterpipe tobacco among Nigerian youth who smoke waterpipe tobacco: the moderating role of social media normalisation of waterpipe tobacco

Background

Impulsivity is a formidable cause of waterpipe tobacco smoking among youth, however, it is understudied among African youth. Using PRIME behavioural theory, this study aimed to develop a model that examines the motivators of impulsivity to smoke waterpipe tobacco in linkage to the moderating role of social media normalisation of waterpipe tobacco, specifically among youth in Nigeria who smoke waterpipe tobacco.

Methods

Data were drawn from 695 respondents who smoke waterpipe tobacco across six Nigerian universities in the South-West zone using the chain-referral sampling procedure. Descriptive analyses of the obtained data were carried out using the Statistical Package for Social Sciences (SPSS) version 25. The constructs in the developed model were validated through Partial Least Squares Structural Equation Modelling (PLS-SEM) in SmartPLS version 3.

Results

Among Nigerian youth who smoke waterpipe tobacco, intention (β = 0.442, P < 0.001) was the strongest motivator of impulsivity to smoke waterpipe tobacco as compared to positive evaluations (β = 0.302, P < 0.001). In addition, social media normalisation of waterpipe tobacco acted as a moderator that strengthened the relationship between intention and impulsivity (β = 0.287, P < 0.01), as well as, between positive evaluations and impulsivity (β = 0.186, P < 0.01) among youth.

Conclusion

Intention greatly instigates Nigerian youth’s impulsivity to smoke waterpipe tobacco, and social media normalisation of waterpipe tobacco also considerably increases their impulsivity to smoke waterpipe tobacco. Youth-focused educational waterpipe tobacco cessation-oriented programmes that utilise diverse constructive-based learning approaches like illustrative learning and counselling, can help to enlighten and encourage Nigerian youth on the importance of shunning the desirability to smoke waterpipe tobacco.

Exploring the degree of nicotine dependence and willingness to quit smoking in Chinese smoking patients with stroke: A cross-sectional survey

Smoking is closely related to the occurrence of stroke. The degree of nicotine dependence and willingness to quit smoking are key factors that determine whether a smoker can successfully quit smoking. Few studies have been conducted on factors affecting the willingness to quit smoking among smokers who suffered from stroke.Although the smoking rate has declined, it is still the main changeable risk factor for cerebrovascular diseases. We aimed to investigate the current status of nicotine dependence and willingness to quit smoking among patients who suffered from stroke. We also clarified factors that affect the willingness to quit smoking among stroke patients and provide evidence for quitting smoking.Convenience sampling methods were used to conduct cross-sectional studies. A questionnaire survey was administered to 215 stroke patients who smoked. A general information questionnaire as well as patient smoking and cessation status questionnaire were used. Nicotine dependence test scale, smoking attitude factor score, and tobacco harm perception scale were applied for investigation. Logistic regression was used to analyze factors related to patients' willingness to quit smoking.Statistically significant differences in willingness to quit smoking were found among stroke patients with different ages, household registration status, education levels, marital status, occupation, smoking attitude, and nicotine dependence (P < .05). About 34.4%, 39.1%, and 26.5% of smoking patients had low, moderate, and severe nicotine dependence, respectively. Logistic analysis showed that compared with other occupations, workers, retirees, farmers, and freelancers compared with other people (0.050, 0.081, 0.053, 0.048) had a negative impact on the willingness to quit smoking among stroke patients. Compared with positive attitudes, negative and neutral smoking attitudes (0.190, 0.048) had a negative impact on the willingness to quit smoking among stroke patients. Compared with high nicotine dependence, low and moderate nicotine dependence (4.628, 2.596) had a positive impact on willingness to quit smoking.Smoking patients in neurology department are more willing to quit smoking (67.9%). Factors such as occupation, smoking attitude, and nicotine dependence should be considered when establishing smoking cessation interventions for stroke smokers.

E8-LWDS: Factorial Structure and Psychometric Properties of the Lebanese Waterpipe Dependence Scale-11 in 1490 Egyptian Waterpipe Tobacco Smokers-A Critical Approach

INTRODUCTION

There is no universal scale for assessing waterpipe tobacco (WT) dependence. We examined the factorial structure and psychometric properties of the Waterpipe Dependence Scale-11 (LWDS-11) among Egyptian WT smokers.

METHODS

We administered the LWDS-11 during face-interview questionnaires in two cross-sectional surveys among 1490 current WT smokers recruited via purposive quota sampling. Exploratory factor analysis was performed on half of the sample. Confirmatory factor analysis of the resulting model was done using structural equation modelling on the other half. Scale reliability was examined. We assessed convergent construct validity using regression models to examine the association between the adapted dependence scale and factors conceptually expected to be associated with WT dependence.

RESULTS

Exploratory factor analysis of the scale yielded eight items (E8-LWDS) supporting a three-factor structure: physical dependence (three items); psychological dependence (three items); and psychological craving (two items). Cronbach's α were 0.635 for the total scale and 0.823, 0.654, and 0.785 for the three subscales. E8-LWDS was confirmed to have good model fit (comparative fit index = 0.995; root mean squared error of approximation = 0.027). E8-LWDS was independently associated with daily WT smoking, rural residence, being a skilled worker, non-exclusive WTS, smoking ≥ eight WT hagars/day, and measures of perceived behavioral control (self-reported addiction to WT, perceived ability to quit, and previous quit attempts).

CONCLUSION

E8-LWDS showed adequate psychometric properties among this sample of Egyptian current WT smokers, which makes it appropriate for use by researchers and practitioners. Adding items related to perceived behavioral control might enhance the scale robustness.

A Group-based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers

INTRODUCTION

Adolescence represents a critical period in which nicotine dependence(ND) symptoms are developing. Little is known about waterpipe(WP) smoking and developmental trajectories of ND criteria across adolescence. Here, we aimed to identify ND trajectories from early to late adolescence in current(past 30 days) WP smokers and examine baseline correlates of each identified trajectory, using the International Classification of Diseases, 10thVersion(ICD10).

METHODS

The analytical sample consisted of 278 current WP smokers from 8-waves of an ongoing longitudinal cohort of 8 th-9 th-graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages11-18.

RESULTS

A group-based modeling approach yielded a four-class solution that best fit the data and reflected differences in the timing of ND onset during adolescence:no-onset of ND(43.9%), early(16.2%), mid(26.6%), and late-onset(13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio[aOR]=4.08, 95%confidence interval:1.01-16.53) and siblings who smoke WP(aOR=3.95:1.08-14.42), exposure to favorite WP-specific advertisements(aOR=3.33:1.03-10.85), and being a novelty seeker(aOR=1.12:1.02-1.23) were associated with early-onset of ND. Daily(aOR=3.48:1.08-11.23) or weekly(aOR=2.20:1.05-4.62) WP smokers (vs. monthly) and having higher stress level (aOR=1.07:1.00-1.14) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR=0.11:0.02-0.82) and spending >60 minutes on a WP smoking session(aOR=5.62:1.20-26.44) were associated with late-onset ND trajectory class.

CONCLUSIONS

Monitoring the development of ND trajectories among WP smokers may identify an individual as belonging to one of these four groups with distinct individual and socio-environmental factors, and allow the individual and healthcare providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions.

Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis

OBJECTIVE

Identifying the factors associated with nicotine dependence (ND) is essential to prevent initiation and continued use, and to promote cessation among youth. This study aims to document the predictors of the appearance of initial ND symptoms and full ND syndrome among adolescent waterpipe (WP) and cigarette smokers.

METHODS

A 6-year longitudinal study was conducted among 8th and 9th graders from 38 schools in Lebanon. The analysis sample included exclusive-WP (n = 228) and exclusive-cigarette smokers (n = 139). Weighted Cox proportional hazards models were used to characterizing predictors of initial ND symptoms and full ND syndrome.

RESULTS

Predictors of experiencing initial ND symptoms among WP smokers included low maternal educational level, having a sibling who smoked WP, low physical activity, high body mass index (BMI), smoking initiation at a younger age. For cigarette smokers these were being male, younger, having lower BMI, having a sibling who smoked cigarettes, living in a crowded household, and smoking daily. Among WP smokers, predictors of developing full ND syndrome include being younger, believing that WP smokers have more friends, depression, high levels of impulsivity, and initiating smoking at a younger age. For cigarette smokers, predictors of full ND syndrome were being younger and initiating smoking at a younger age.

CONCLUSION

Smoking cessation and prevention interventions targeting youth should address modifiable, and tobacco use-specific factors that influence the development of ND among young WP and cigarette smokers. They also need to start at a younger age to target those most vulnerable to developing life-long addiction to tobacco products.

The Syrian Center for Tobacco Studies-13 (SCTS-13): Psychometric evaluation of a waterpipe-specific nicotine dependence instrument

BACKGROUND

Waterpipe tobacco smoking (WTS) has surged globally among young people and causes nicotine dependence (ND). No existing ND instruments are sensitive to waterpipe-specific features of ND and early stages of use.

METHODS

We conducted a psychometric scale evaluation among 192 current waterpipe smokers, initially averaging 15 years of age, recruited from schools in Beirut, Lebanon, and assessed 4 times, 6 months apart. Twenty eight self-report items tapping multiple features of ND were submitted to exploratory and confirmatory factor analyses (EFA and CFA) to reduce items and verify factor structure. Convergent validity was assessed with the Lebanese Waterpipe Dependence Scale and the Hooked on Nicotine Checklist, and discriminant validity with the Depressive Symptom Scale and Adolescent Life Events Stress Scale. Concurrent and predictive validity measures included smoking status and intensity (amount, frequency, session duration, and change in frequency), quitting interest and success, perceived addiction, and smoking alone.

RESULTS

The EFA yielded a single factor, 13 item solution (named the Syrian Center for Tobacco Studies [SCTS]-13) that explained 91% of variance in responses, was internally consistent (Cronbach's alpha and McDonald's omega = 0.87), and captured several positive reinforcement, negative reinforcement, and social/sensory-related features of ND. The CFA indicated good model fit. The SCTS-13 showed acceptable convergent and discriminant validity. Higher SCTS-13 scores predicted current waterpipe and dual (waterpipe and cigarette) smoking, greater intensity of use, less interest in quitting, shorter duration of abstinence, greater perceived addiction, and smoking alone (vs. socially).

CONCLUSION

The SCTS-13 is a promising brief, waterpipe-specific ND instrument.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

Validation of the AUDIT scale and factors associated with alcohol use disorder in adolescents: results of a National Lebanese Study

BACKGROUND

This study objective was to evaluate the prevalence of alcohol use disorder (AUD) and related factors (smoking, internet addiction, social anxiety, child abuse, and bullying) among a representative sample of Lebanese adolescents, and to validate and confirm psychometric properties of the Alcohol Use Disorders Identification Test (AUDIT).

METHODS

A cross-sectional study, conducted between January and May 2019, enrolled 1810 adolescents aged between 14 and 17 from schools of all Lebanese districts. From the total number of schools, a proportionate number was selected in each district. AUD was defined as a high AUDIT score (≥8; score range 0-40). A principal component analysis technique to confirm the validity of the construct of the AUDIT scale score was done and a confirmatory analysis to assess the structure of the instrument was conducted. Spearman correlation was used for linear correlation between continuous variables. The Mann-Whitney test was used to compare the means of two groups, while the Kruskal-Wallis test was used to compare three groups or more. A stepwise linear regression was conducted, taking the AUDIT total score as the dependent variable and taking child abuse (psychological, sexual, physical and verbal), cigarette and waterpipe smoking dependence, bullying, social phobia, and internet addiction as independent variables.

RESULTS

The mean AUDIT score was 6.46 ± 8.44 and high risk of AUD was found in 507 (28.0%) adolescents [95% CI 0.259-0.301]. One factor solution of the AUDIT scale was found after running the factor analysis (αCronbach = 0.978). Higher AUDIT scores were significantly associated with higher cigarette (Beta = 0.527; p < 0.001) and waterpipe (Beta = 0.299; p < 0.001) dependence, higher childhood sexual abuse (Beta = 0.656; p < 0.001) and neglect (Beta = 0.126; p < 0.001), higher bullying victimization (Beta = 0.236; p < 0.001).

CONCLUSION

Alcohol use disorder among Lebanese adolescents seems to be associated with several factors, such as cigarette and waterpipe dependence, parents' divorce, higher internet addiction, bullying victimization, and childhood sexual abuse and neglect. Parents and healthcare professionals could use this data for early interventions.

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reflections on 15 Years in the Global Tobacco Trenches

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