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Jebai R, Asfar T, Cano MÁ, Nakkash R, Schmidt M, Wu W, Bursac Z, Maziak W. Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis. Nicotine Tob Res 2024; 26:764-770. [PMID: 37952202 DOI: 10.1093/ntr/ntad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
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.
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Affiliation(s)
- Rime Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Miguel Ángel Cano
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
| | - Michael Schmidt
- School of Public Health and Department of Art, University of Memphis, Memphis, TN, USA
| | - Wensong Wu
- Department of Mathematics and Statistics, Florida International University, Miami, FL, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
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Bteddini D, Nakkash RT, Chalak A, Jawad M, Khader Y, Abu-Rmeileh NME, Mostafa A, Abla R, Awawda S, Salloum RG. Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling. Tob Control 2023; 33:116-121. [PMID: 35902224 DOI: 10.1136/tc-2022-057383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.
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Affiliation(s)
- Dima Bteddini
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Rima T Nakkash
- Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, George Mason University College of Health and Human Services, Fairfax, Virginia, USA
| | - Ali Chalak
- Department of Agriculture, American University of Beirut, Beirut, Lebanon
| | - Mohammed Jawad
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Yousef Khader
- Department of Community Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ruba Abla
- Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
| | - Sameera Awawda
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, Florida, USA
- Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
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Jebai R, Asfar T, Nakkash R, Chehab S, Schmidt M, Wu W, Bursac Z, Maziak W. Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study. HEALTH EDUCATION RESEARCH 2023; 38:537-547. [PMID: 37436823 PMCID: PMC10714039 DOI: 10.1093/her/cyad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/09/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
This study compares the impact of pictorial health warning labels (HWLs) and their placements on waterpipe parts (device, tobacco and charcoal packages) on health communication outcomes between waterpipe smokers and nonsmokers in Lebanon. An online randomized crossover experimental study was conducted among young adults (n = 403, August 2021) who observed three conditions of HWLs: pictorial HWLs on the tobacco package, pictorial HWLs on all waterpipe's parts and text-only HWL on the tobacco package in random order. Participants completed post-exposure assessments of health communication outcomes after each image. Using linear mixed models, we examined the differences in the effect of HWL conditions on several outcomes (i.e. warning reactions) between waterpipe smokers and nonsmokers, controlling for confounders (i.e. age, sex). Nonsmokers reported greater attention (β = 0.54 [95% confidence interval: 0.25-0.82]), cognitive elaboration (0.31 [0.05-0.58]) and social interaction (0.41 [0.18-0.65]) for pictorial HWLs on the tobacco packages than text-only compared with smokers. Pictorial HWLs on three parts versus one part elicited higher cognitive reactions and perceived message effectiveness in nonsmokers compared with waterpipe smokers. These findings provide valuable information for policymakers about the potential of implementing HWLs specific to waterpipes to prevent their use among young adults and limit tobacco-related morbidity and mortality in Lebanon.
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Affiliation(s)
- R Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - T Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 919, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 5555 Ponce De Leon Blvd, Miami, FL 33136, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - R Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh 1107 2020, Beirut 11-0236, Lebanon
- Department of Global and Community Health, College of Health and Human Services, George Mason University, 4400 University Drive, MS: 5B7, Fairfax, VA 22030, USA
| | - S Chehab
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh 1107 2020, Beirut 11-0236, Lebanon
| | - M Schmidt
- Department of Art, University of Memphis, 101 Wilder Tower, Memphis, TN 38152, USA
| | - W Wu
- Department of Mathematics and Statistics, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - Z Bursac
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - W Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
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Lang AE, Asfar T. The Path to Prevent the Next Generation From Water-Pipe Smoking. Chest 2023; 164:1345-1347. [PMID: 38070954 DOI: 10.1016/j.chest.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Adam Edward Lang
- Department of Primary Care, McDonald Army Health Center, Fort Eustis, VA; Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond, VA.
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
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Nemati S, Mohebbi E, Toorang F, Hadji M, Hosseini B, Saeedi E, Abdi S, Nahvijou A, Kamangar F, Roshandel G, Ghanbari Motlagh A, Pourshams A, Poustchi H, Haghdoost AA, Najafi F, Sheikh M, Malekzadeh R, Zendehdel K. Population attributable proportion and number of cancer cases attributed to potentially modifiable risk factors in Iran in 2020. Int J Cancer 2023; 153:1758-1765. [PMID: 37548110 DOI: 10.1002/ijc.34659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023]
Abstract
In the current study, we aimed to calculate the fraction of cancer attributable to modifiable risk factors in Iran in 2020. Population attributable fractions (PAFs) were calculated for established cancer risk factors using three data sources: the national cancer incidence reports, relative risks extracted from global and national meta-analyses, and exposure prevalence from national/subnational population-based surveys. In addition to overall cancers, the PAFs were estimated separately for each cancer site among men and women. Overall, 32.6% of cancers in 2020 in Iran were attributable to known risk factors. The PAF in men (40.2%) was twice as high as in women (21.1%). Cigarette smoking (15.4%), being overweight (5.0%), opium use (3.9%) and H. pylori infection (3.8%) were the leading causes of cancers. For men, the highest PAFs belonged to cigarette smoking (26.3%), opium use (6.8%) and being overweight (3.1%), while for women, the highest PAFs belonged to being overweight (7.2%), H. pylori infection (2.7%) and cigarette smoking (2.7%). Among Iranian men and women, the PAFs of waterpipe smoking were 2% and 0.9%, respectively. A third of incident cancers in Iran are due to modifiable exposures, mainly cigarette smoking, being overweight, and H. pylori infection. Opium consumption and waterpipe smoking collectively accounted for 8.8% of cancer occurrence in men and 1.3% in women in Iran. These emerging risk factors should be taken into consideration in future PAF studies.
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Affiliation(s)
- Saeed Nemati
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Mohebbi
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - Fatemeh Toorang
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Hadji
- Department of Public Health, School of Public Health, Tampere University, Tampere, Finland
| | - Bayan Hosseini
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Elnaz Saeedi
- Biostatistics Research Group, Department of Health Science, University of Leicester, Leicester, UK
| | - Sepideh Abdi
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Nahvijou
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical and Natural Sciences, Morgan State University, Baltimore, Maryland, USA
| | - Gholamreza Roshandel
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Ali Ghanbari Motlagh
- Cancer Research Centre, Shahid Beheshti University of Medical Science, Tehran, Iran
- Department of Radiation Oncology, Imam Hossein Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Akram Pourshams
- Digestive Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Poustchi
- Digestive Diseases Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Haghdoost
- Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Farid Najafi
- Department of Epidemiology and Biostatistics, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mahdi Sheikh
- International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Reza Malekzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Asfar T, Livingstone-Banks J, Ward KD, Eissenberg T, Oluwole O, Bursac Z, Ghaddar T, Maziak W. Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev 2023; 6:CD005549. [PMID: 37286509 PMCID: PMC10245833 DOI: 10.1002/14651858.cd005549.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Taghrid Asfar
- Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
- School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Thomas Eissenberg
- Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
- Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Olusanya Oluwole
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Zoran Bursac
- Biostatistics, Florida International University, Miami, FL, USA
| | - Tarek Ghaddar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
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Nemati S, Naji P, Abdi S, Lotfi F, Saeedi E, Mehravar SA, Fattahi P, Sheikh M, Vand Rajabpour M, Eftekharzadeh A, Zendehdel K. National and Regional Fraction of Cancer Incidence and Death Attributable to Current Tobacco and Water-Pipe Smoking in the Eastern Mediterranean Countries in 2020. Nicotine Tob Res 2023; 25:12-18. [PMID: 35895382 DOI: 10.1093/ntr/ntac179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION We aimed to calculate the Population Attributable Fraction (PAF) of cancers due to tobacco use in the Eastern Mediterranean Region (EMRO), where water-pipe smoking is prevalent but its effect was not considered in previous studies. AIMS AND METHODS We applied Levin's formula to estimate PAFs of cancers due to tobacco use (defined as all type tobacco including both cigarette and water-pipe). We also calculated PAF of water-pipe smoking separately. Exposure prevalence data were retrieved from representative national and subnational surveys. Data on cancer incidence and death were also and cancer cases were obtained GLOBOCAN 2020. We also obtained associated relative risks from published meta-analyses. RESULTS Of the total 715 658 incident adult cancer cases that were reported in 2020 in EMRO, 14.6% (n = 104 800) was attributable to tobacco smoking (26.9% [n = 92 753]) in men versus 3.3% (n = 12 048) in women. Further, 1.0% of incident adult cancers were attributable to current water-pipe use (n = 6825) (1.7% [n = 5568]) in men versus 0.4% (n = 1257 in women). CONCLUSIONS PAFs of cancers due to tobacco smoking in EMRO were higher in our study than previous reports. This could be due to the neglected role of water-pipe in previous studies that is a common tobacco smoking method in EMRO. The proportion of cancers attributable to water-pipe smoking in EMRO might be underestimated due to lack of research on the risk of cancers associated with water-pipe smoking and also less developed cancer registries in EMRO. IMPLICATIONS In this study, we found higher PAFs for cancers due to tobacco smoking in the Eastern Mediterranean (EMR) region than previous reports. This difference could be due to ignoring the role of water-pipe smoking in previous studies. In 2020, 1% of incident cancers and 1.3% of cancer-related deaths in EMRO were attributable to water-pipe smoking. We also found a big difference in PAFs of cancers due to tobacco and water-pipe smoking across EMRO countries, with Tunisia, Lebanon, and Jordan having the highest, and Djibouti, Sudan, and Somalia having the lowest proportions of cancers attributable to tobacco and water-pipe smoking.
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Affiliation(s)
- Saeed Nemati
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parnian Naji
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepideh Abdi
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fereshte Lotfi
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Saeedi
- Biostatistics Groups, Health Sciences Department, University of Leicester, Leicester, UK
| | - Sepideh A Mehravar
- Surgical oncology department, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pedram Fattahi
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sheikh
- Genomic Epidemiology Department, International Agency for Research on Cancer (IARC/WHO), Genomic Epidemiology Branch, Lyon, France
| | - Mojtaba Vand Rajabpour
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Anita Eftekharzadeh
- Obesity research department, Obesity Research Center, Research Institute of Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- Cancer Research Center, Cancer Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Asfar T, Chehab S, Schmidt M, Ward KD, Maziak W, Nakkash R. "Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon. Nicotine Tob Res 2022; 24:1458-1468. [PMID: 35196373 PMCID: PMC9356692 DOI: 10.1093/ntr/ntac053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. AIMS AND METHODS We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. RESULTS Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories. CONCLUSIONS Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. IMPLICATIONS Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.
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Affiliation(s)
- Taghrid Asfar
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA,Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA,Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Sara Chehab
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria,School of Public Health, University of Memphis, Memphis, TN, USA
| | - Wasim Maziak
- Syrian Center for Tobacco Studies, Aleppo, Syria,Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International, Miami, FL, USA
| | - Rima Nakkash
- Corresponding Author: Rima Nakkash, DrPH, Department of Health Promotion and Community Health, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Van Dyck Building, PO Box 11-0236, Beirut, Lebanon. Telephone: 961 1 350000 ext. 4667; Fax: 961-1-744470; E-mail:
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Mostafa A, El Houssinie M, Hussein RS. Perceived efficacy of existing waterpipe tobacco warning labels versus novel enhanced generic and waterpipe-specific sets. PLoS One 2021; 16:e0255244. [PMID: 34314460 PMCID: PMC8315518 DOI: 10.1371/journal.pone.0255244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Since 2008, Egypt has four existing generic bi-annually rotating warning labels (WLs) on 50% of the waterpipe tobacco packs (WTPs). The Ministry of Health Tobacco Control Unit proposed increasing WL size to 80%, removing colours and flavour imagery from WTPs, and plain packaging to help curb the rising epidemic of waterpipe tobacco smoking. Therefore, we measured the perceived efficacy of existing against novel enhanced (generic and waterpipe-specific) WTP WLs and the associated factors among Egyptian waterpipe smokers and nonsmokers. METHODS A purposive quota sample of 2014 adults was surveyed in two rounds using face interviews. At each round, participants were randomly shown one of four existing WLs, then one of four novel WLs. Participants rated the perceived efficacy of existing and novel WLs regarding the salience, depth of processing, affective reactions, credibility, relevance, perceived harm and perceived behavioural control. Data were analysed using Generalized Estimating Equations. RESULTS Participants rated novel WTP WLs with higher mean perceived efficacy scores than existing WLs for all measures, although both sets collectively scored modestly (59.7; 95% CI: 58.9-60.5 vs 53.0; 95% CI: 52.1-54.0, respectively; p<0.001). Relative to the existing WTP WLs, novel WLs were particularly able to induce higher salience, affective reactions, and depth of processing. Relative to the generic novel WTP WLs, waterpipe-specific WLs induced higher relevance, perceived harm, and affective reactions. Nonsmokers scored higher than waterpipe tobacco smokers, specifically for perceived behavioral control (65.0±32.5 vs 43.6±19.8, respectively; p<0.001). WTP WLs featuring proximal risks, such as dental effects (β = 9.70; 95% CI: 7.00-12.40), fetal harm (β = 9.42; 95% CI: 6.75-12.10), or toxic contents (β = 9.14; 95% CI: 6.58-11.70) were strongly associated with participants' perceived efficacy scores. Among other independent factors, rural residence (β = 24.09; 95% CI: 22.21-25.97), being a nonsmoker (β = 10.51; 95% CI: 8.92-12.10), survey round 2 (β = 6.96, 95% CI: 5.73-8.19), the novel WTP WL set (β = 6.68; 95% CI: 6.19-7.17), and having higher education (β = 6.31; 95% CI: 4.34-8.27) were highly associated with participants' perceived efficacy scores. CONCLUSIONS Waterpipe-specific WLs on plain WTPs that feature proximal risks and address different population subgroups need to be developed in conjunction with awareness raising campaigns on WTS harms to reinforce the credibility of WTP WLs. Our findings suggest the proposed WTP WL enhancements by the Tobacco Control Unit may support a more effective WTP labelling policy within a comprehensive waterpipe-specific tobacco control framework.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- * E-mail:
| | - Moustafa El Houssinie
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Saad Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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E8-LWDS: Factorial Structure and Psychometric Properties of the Lebanese Waterpipe Dependence Scale-11 in 1490 Egyptian Waterpipe Tobacco Smokers-A Critical Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136741. [PMID: 34201512 PMCID: PMC8269008 DOI: 10.3390/ijerph18136741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/16/2022]
Abstract
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.
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Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design. Contemp Clin Trials Commun 2021; 23:100797. [PMID: 34235290 PMCID: PMC8249778 DOI: 10.1016/j.conctc.2021.100797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/23/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Waterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.
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Kalan ME, Behaleh R, DiFranza JR, Bursac Z, Taleb ZB, Tleis M, Asfar T, Nakkash R, Ward KD, Eissenberg T, Maziak W. Natural Course of Nicotine Dependence Among Adolescent Waterpipe and Cigarette Smokers. J Adolesc Health 2020; 67:859-867. [PMID: 32622925 PMCID: PMC7683372 DOI: 10.1016/j.jadohealth.2020.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/01/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Waterpipe (WP) smoking patterns and setting can result in a unique trajectory of nicotine dependence (ND) compared with cigarette smoking. This longitudinal study compared the development of ND symptoms among adolescent WP and cigarette smokers. METHODS A cohort of 647 eighth and ninth graders in Lebanon were followed over 5 years. This study was based on 283 current exclusive WP and 146 current exclusive cigarette smokers. Kaplan-Meier survival analyses were conducted to evaluate 50% cumulative probability for the development of initial Hooked on Nicotine Checklist symptoms and the International Classification of Diseases, 10th revision (ICD-10) ND. RESULTS An initial Hooked on Nicotine Checklist symptom was endorsed by 59% of WP and 50% of cigarette smokers after smoking onset. Among those, 50% of both WP and cigarette smokers did so within 9.7 and 18.5 months, respectively. Approximately 28% of WP smokers and 22% of cigarette smokers developed ICD-10 ND. Among those, 50% of both WP and cigarette smokers did so within 15 and 22 months, respectively. The most common first to fourth ICD-10 criteria reported by WP smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "neglect of alternative pleasure," and "use despite harm." The most common first to fourth ICD-10 criteria reported by cigarette smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "withdrawal," and "tolerance". CONCLUSIONS Compared with adolescent cigarette smokers, initial ND symptoms and ICD-10 ND can develop sooner after starting to smoke and progress more rapidly among adolescent WP smokers. Developing, implementing, and evaluating intervention programs with adolescent WP smokers should be guided by the WP-specific trajectory of ND.
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Affiliation(s)
- Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
| | - Raed Behaleh
- School of Health Sciences, Baldwin Wallace University, Berea, OH, USA
| | - Joseph R. DiFranza
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
| | - Ziyad Ben Taleb
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, USA
| | - Malak Tleis
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA,Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Rima Nakkash
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria,School of Public Health, University of Memphis, Memphis, TN, USA
| | - Thomas Eissenberg
- Syrian Center for Tobacco Studies, Aleppo, Syria,Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida; Syrian Center for Tobacco Studies, Aleppo, Syria.
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Ebrahimi Kalan M, Bahelah R, Bursac Z, Ben Taleb Z, DiFranza JR, Tleis M, Nakkash R, Jebai R, Alam MM, Cano MÁ, Sutherland MT, Fenni K, Asfar T, Eissenberg T, Ward KD, Maziak W. Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis. Drug Alcohol Depend 2020; 217:108346. [PMID: 33075692 PMCID: PMC7861130 DOI: 10.1016/j.drugalcdep.2020.108346] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8thSt AHC5, 4thFloor, Miami, FL, 33199, USA.
| | - Raed Bahelah
- School of Health Sciences, Baldwin Wallace University, Kamm Hall, 191 E Center St, Berea, OH 44017, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St AHC5, 4th Floor, Miami, FL, 33199, USA
| | - Ziyad Ben Taleb
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, 411 S. Nedderman Drive Box 19407, Arlington, Texas 76019-0407, USA
| | - Joseph R DiFranza
- Reliant Medical Group, 225 New Lancaster Rd, Leominster, MA 01453, USA
| | - Malak Tleis
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Bliss Street. P.O. Box 11-0236. Beirut, Lebanon
| | - Rima Nakkash
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Bliss Street. P.O. Box 11-0236. Beirut, Lebanon
| | - Rime Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8thSt AHC5, 4thFloor, Miami, FL, 33199, USA
| | - Mohammad Masudul Alam
- Center for the Study of Tobacco, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205, USA
| | - Miguel Ángel Cano
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8thSt AHC5, 4thFloor, Miami, FL, 33199, USA
| | - Matthew T Sutherland
- Department of Psychology, Florida International University, 11101 S.W. 13 ST., Miami, FL 33199, USA
| | - Kristopher Fenni
- Division of Natural Sciences, New College of Florida, 5800 Bay Shore Road Sarasota, FL 34243, FL, USA
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 120 NW 14th Street, CRB 919, Miami, FL 3313, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA; Syrian Center for Tobacco Studies, Tishreen Street, SheehanAleppo, P.O.Box: 16542, Syria
| | - Thomas Eissenberg
- Syrian Center for Tobacco Studies, Tishreen Street, SheehanAleppo, P.O.Box: 16542, Syria; Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, 100 W. Franklin St. Suite 200, Richmond, VA 23220, USA
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Tishreen Street, SheehanAleppo, P.O.Box: 16542, Syria; School of Public Health, University of Memphis, 3720 Alumni Ave, Memphis, TN 38152, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8thSt AHC5, 4thFloor, Miami, FL, 33199, USA; Syrian Center for Tobacco Studies, Tishreen Street, SheehanAleppo, P.O.Box: 16542, Syria
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