Time trends of cigarette and waterpipe smoking among a cohort of school children in Irbid, Jordan, 2008-11

The Burden and Correlates of Waterpipe (Hookah) Smoking among Adolescents and Youth: A Systematic Review

BACKGROUND

This systematic review evaluated the available medical literature on the prevalence and trends of waterpipe tobacco smoking among adolescents and youth in jurisdictionally representative populations.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies from inception until 31 December 2022 that reported the burden of waterpipe smoking among adolescents and youth (10-24 years of age). We extracted qualitative data on the demographic characteristics, burden, and correlates of waterpipe smoking (PROSPERO ID: CRD42022310982).

RESULTS

A total of 2,197 articles were screened and 62 were included in the analysis. The majority (29) of the studies was from the United States of America and there were no studies from the south-east Asian region. The prevalence of ever waterpipe smoking among the 10-24 years age group was noted to be 18.16% (95% CI, 18.03-18.29). The prevalence of current (30-day) waterpipe smoking was 6.43% (95% CI, 6.34-6.50). The age of initiation of waterpipe smoking was variable. The prevalence of waterpipe smoking was higher among males, among those who belong to the high- and middle-income groups, and among university students. The common risk factors of waterpipe smoking included cigarette smoking, alcohol, and substance use. Waterpipe smoking resulted in increased susceptibility to the use of conventional forms of tobacco (e.g. smoking) among those who were never smokers.

CONCLUSION

Waterpipe smoking usage was significantly high among adolescents and young adults. Developing regulatory guidelines for water-pipe smoking, surveillance of its use, intervention, and specific policy frameworks may be considered a public health priority.

Association between waterpipe use and susceptibility to cigarette smoking among adolescents and young adults who never smoked: A systematic review and meta-analysis

INTRODUCTION

Several factors associated with susceptibility to cigarette smoking have been identified, yet there is little evidence on the possible effects of waterpipe use. With this systematic review and meta-analysis, we aimed to investigate the relationship between waterpipe use and cigarette smoking susceptibility among adolescents and young adults who never smoked.

METHODS

Eligible studies were searched in PubMed, Springer Link, ScienceDirect and Cochrane Library up to August 2022. The pooled odds ratio (OR) and 95% confidence intervals (CI) of cigarette smoking susceptibility with waterpipe use were estimated using a random-effects model. Publication bias was assessed by Egger's regression asymmetry test and Begg's rank correlation test with Begg's funnel plot.

RESULTS

A total of 59710 participants, including 3559 waterpipe users from six studies, were identified in this analysis. Results showed that the odds of susceptibility to cigarette smoking were nearly two times (OR=1.90; 95% CI: 1.59-2.26) greater for never smoker adolescents and young adults who used waterpipe tobacco, compared to those who were never users. In subgroup analyses, the pooled OR was 2.19 (95% CI: 1.52-3.14) and 1.70 (95% CI: 1.51-1.92) for current and ever use of waterpipe, while the pooled OR was 1.99 (95% CI: 1.35-2.95) and 1.87 (95% CI: 1.45-2.39) in Arab and non-Arab nations, respectively.

CONCLUSIONS

Our findings suggest that waterpipe use was associated with greater odds of susceptibility to cigarette smoking among adolescents and young adults who never smoked. Tailored public health policies and regulations on waterpipe smoking may help to protect youth never smokers from initiation of cigarette smoking.

The effect of exposure to tobacco smoking-related media messages on youths' smoking behavior in Jordan: A longitudinal, school-based study

Only a few studies investigated the link between tobacco smoking-related media and youth smoking in the Eastern Mediterranean Region (EMR). This study aimed to assess the influence of both promotional and control messages on cigarette smoking behavior among young Jordanian students. Generalized Linear Mixed Models were analyzed using data from the Irbid Longitudinal Smoking Study that followed a random sample of 2174 students (2008-2011). We examined the associations of media messaging with smoking behavior, as well as intention-to-quit smoking, and intention-to-start smoking, among young adolescents. At baseline, 12.2% and 43.7% of students were exposed to only pro-smoking or only anti-smoking messages, while 41.8% were equally exposed to both. Exposure to anti-smoking messages was associated with lower odds of ever smoking at baseline among girls (AOR = 0.4; 95% CI: 0.2, 0.8). Boys who were exposed to anti-smoking messages were more likely to report an intention to quit, with borderline significance (AOR = 2.0; 95% CI: 0.9, 4.1). The cumulative exposure to anti-smoking messages over time was associated with lower odds of intention to smoke among girls (AOR = 0.5; 95% CI: 0.3, 0.9) but with higher odds among boys (AOR = 1.8; 95% CI: 1.0, 3.1). In both sexes, media messaging was not associated with progression of the smoking habit. In conclusion, this comprehensive analysis of both pro- and anti-smoking messages advances our understanding of their role in influencing youths' smoking behaviors, and could guide the development of evidence-based interventions to address adolescent tobacco smoking in Jordan and the EMR.

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.

Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries

INTRODUCTION

Males have a higher prevalence of waterpipe tobacco smoking (WTS) than females in most Eastern Mediterranean Region (EMR) countries, with a smaller gender gap than that of cigarette smoking. The objective of this study was to determine gender differences among university students with respect to WTS initiation, smoking behavior, tobacco flavors, and expenditure on WTS, in four EMR countries.

METHODS

A cross-sectional online survey was conducted based on convenient samples of ever waterpipe smokers among university students in four EMR countries (Egypt, Jordan, Occupied Palestinian Territories, and the United Arab Emirates) in 2016. The total samples included 2470 participants. Study participants were invited through flyers, university portals, emails and Facebook, followed by emails with links to the internet survey.

RESULTS

Females (80.4%) were more likely than males (66.4%, p<0.001) to be in the younger age group (18–22 years) and they were less likely to be current waterpipe smokers (females, 60.0%; males 69.5%, p<0.001). Two-thirds of students across both genders smoked their first waterpipe at the age of 15–19 years, with more females starting with family members. Over one-third of males and 14.9% of the females usually smoked ≥10 heads (p<0.001). About half (46.6%) of females smoked for less than half an hour compared to 30.5% of males (p<0.001). Only 1% of females smoked non-flavored tobacco compared to 11% of males (p<0.001). There was a significant (p=0.05) positive correlation (r=0.808) with respect to tobacco flavor usually smoked between males and females with apple/double apple being the most popular.

CONCLUSIONS

There were gender differences in WTS in several aspects. The study has implications for educational establishments, tobacco control and women civil society groups, as well as policymakers.

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.

Determinants of shisha use among secondary school students in Sudan

BACKGROUND

Shisha smoking has re-emerged in the Middle East in the last two decades and has spread rapidly in these communities. Information about shisha smoking in adolescents in Sudan is deficient. Hence, the aim of this study is to estimate the prevalence of shisha smoking among adolescents and determine the associated factors.

METHODS

This study is a school based cross sectional study among secondary school students in Khartoum State - Sudan that targets both male and female students aged 14-17 years. A total of 3387 students from 29 public and private schools were selected by multi stage random sampling. The participants completed an anonymous self-administered questionnaire which was based on Arabic version of the Global Youth Tobacco Survey (GYTS).

RESULTS

The response rate was 100% in schools and among participants, 57.3% were females and 51.6% were from public schools. The overall prevalence of those who had ever smoked shisha was 13.4%, and among male students the prevalence was 16.8%, while it was 10.9% in females. The associated factors were poor academic performance OR 2.90 CI 95% (1.21-6.94), friends smoking shisha OR 2.39 CI 95% (1.65-3.45), friends smoking cigarettes OR 2.76 CI 95% (1.90-4.01), peer pressure to smoke shisha OR 13.76 CI 95% (7.86-24.07) and unexpectedly restriction of selling shisha to minors OR 2.21 CI 95% (1.28-3.82).

CONCLUSION

The prevalence of those who had ever smoked shisha is among the lowest in Middle East region; therefore, regular surveillance system is needed. A well-structured peer based comprehensive tobacco control programmes that are supported by strict and rigorous anti-tobacco regulations which control both commercial and social resources of tobacco are needed to contain this issue among adolescents.

Waterpipe Smoking Is Associated with Changes in Fibrinogen, FVII, and FVIII Levels

Cigarette smoking has been shown to be associated with changes in coagulation factors in the circulation and the subsequent thrombosis development. In this study, the impact of waterpipe smoking on the levels of fibrinogen, factor VII (FVII), and factor VIII (FVIII) was investigated. In addition, the effects of waterpipe smoking were compared to those of cigarette smoking and never smokers. A total of 80 male smokers (40 cigarette smokers and 40 waterpipe smokers) and 40 apparently healthy never smokers were recruited in the study. Both waterpipe smoking and cigarette smoking induced significant increases in the plasma levels of fibrinogen, factor VII, and factor VIII (p < 0.01). The magnitude of the increase in fibrinogen levels induced by waterpipe smoking was higher than that induced by cigarette smoking (p < 0.01), while similar increases were observed in other factors (p > 0.05). In addition, in the waterpipe group, the magnitude of the increase in fibrinogen and factor VIII was higher in the smokers with more than 3 years of use (p < 0.05). In conclusion, similar to cigarette smoking, waterpipe smoking modulates the levels of coagulation factors, suggesting its thrombotic potential.

Features of the waterpipe tobacco industry: A qualitative study of the third International Hookah Fair

Background: Little research has been done to uncover the features of the waterpipe tobacco industry, which makes designing effective interventions and policies to counter this growing trend challenging. The objective of this study is to describe the features of the waterpipe industry. Methods: In 2015, we randomly sampled and conducted semi-structured interviews with 20 representatives of waterpipe companies participating in a trade exhibition in Germany. We used an inductive approach to identify emerging themes. Results: We interviewed representatives and four themes emerged: industry globalisation, cross-industry overlap, customer-product relationship, and attitude towards policy. The industry was described as transnational, generally decentralized, non-cartelized, with ad hoc relationships between suppliers, distributors and retailers. Ties with the cigarette industry were apparent. The waterpipe industry appeared to be in an early growth phase, encroaching on new markets, and comprising of mainly small family-run businesses. Customer loyalty appears stronger towards the waterpipe apparatus than tobacco. There was a notable absence of trade unionism and evidence of deliberate breaches of tobacco control laws. Conclusion: The waterpipe industry appears fragmented but is slowly growing into a mature, globalized, and customer-focused industry with ties to the cigarette industry. Now is an ideal window of opportunity to strengthen public health policy towards the waterpipe industry, which should include a specific legislative waterpipe framework.

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.

Knowledge, attitudes, beliefs and patterns of waterpipe use among Jordanian adults who exclusively smoke waterpipes

BACKGROUND

Widespread waterpipe smoking (WPS) is reported worldwide. Although remarkable numbers of waterpipe smokers do not smoke cigarettes, very few studies have explored the phenomenon of WPS in people who smoke water pipes exclusively. The aim of this study was to assess levels of knowledge, attitudes, beliefs and patterns of WPS among Jordanian waterpipe-only smokers.

METHODS

A cross-sectional descriptive design was used; with 247 participants who were recruited through convenience sampling from 23 cafés offering waterpipes. An interview and self-reported questionnaire was used to collect data.

RESULTS

The average age for starting WPS was 19.4 ± 5.6 years, of whom 71% started as teenagers. Participants like WPS because they like its flavor and social environment (46.3% and 29.5% respectively). The majority of participants reported that they smoked a waterpipe for the first time with their friends (66.8%), they usually smoke in the company of others (63.2%), and believe that quitting cigarettes smoking is harder than quitting WPS (61.6%). More than half (56.7%) of participants have extremely poor knowledge about the health effects of WPS. Participants who had smoked cigarettes in the past, were more knowledgeable than those who had never smoked cigarettes. The majority of participants, and specifically women, have high positive feelings and emotions (attitude) toward WPS, and 88.3% of them reported that it is a socially acceptable behavior.

CONCLUSIONS

Waterpipe smoking participants started WPS at an early age, and are attracted to the social environment that accompanies WPS. Participants have high positive attitude about WPS however they lack knowledge about harmful health effects of WPS.

Prevalence and characteristics of water-pipe smoking in Canada: results from the Canadian Tobacco Use Monitoring Survey

OBJECTIVES

To investigate the prevalence and characteristics of water-pipe smoking (WPS) nationally in Canada.

STUDY DESIGN

This study was a cross-sectional study.

METHODS

Data from the Canadian Tobacco Use Monitoring Survey 2011 and 2012 was used. Outcomes investigated were ever and current WPS. Demographic, socio-economic and smoking-related variables were included in a multivariable logistic regression model to determine associations with the outcomes.

RESULTS

Prevalence of WPS was 8.9% for ever and 0.8% for current WPS (1.8% among <18 years old and 4.0% among 18-24 years old). The highest prevalence of ever WPS was in Quebec (11.3%) and of current WPS in Alberta (1.2%). Age was the strongest predictor for WPS with an odds ratio = 47.86, 95% confidence interval: 37.97-60.33 for current WPS for those aged <18 years compared to 35 + years. Male gender, urban residence, being single, speaking another language at home (not English/French), higher education, cigarette smoking and marijuana use were also significantly associated with increased WPS.

CONCLUSIONS

Multiple factors impact WPS, with the younger population having the highest prevalence. This necessitates further research into the attitudes of this age group to better focus health promotion efforts.

Health Effects of Waterpipe Tobacco Use: Getting the Public Health Message Just Right

Many public health messages benchmark the harms of waterpipe tobacco against those of cigarettes, usually using numerical magnitudes of risk. This approach, although well intentioned, could be perceived as alarmist, damaging scientific credibility, and giving an unintended impression that one tobacco product is less harmful than the other. This commentary makes clear the harm waterpipe tobacco smoking poses to public health by describing its mechanism of use, consumption uptake, toxicologic profile, and documented health outcomes, as well as challenge existing thinking that toxicologic assessments are the most appropriate way to frame waterpipe tobacco health promotion messages. How can we describe the health effects of waterpipe tobacco without undermining its toxicity nor falling into the temptation of alarmist messaging? Several recommendations are provided.

Waterpipe Smoking among University Students in Sulaimaniyah, Iraqi Kurdistan: Prevalence, Attitudes, and Associated Factors

BACKGROUND

Waterpipe smoking is increasingly becoming the most common method of tobacco use among adolescents in the Eastern Mediterranean Region. This study was undertaken in Iraqi Kurdistan to estimate its prevalence among students and investigate attitudes and factors associated with it.

MATERIALS AND METHODS

In a cross-sectional survey at Sulaimani Polytechnic University, 1160 students were approached in a two-stage design using a self-administered questionnaire. Data was entered into Epidata and analysis was done in Stata.

RESULTS

Prevalence of cigarette smoking was 10% and waterpipe smoking was 28% (male 49%, female 10%). Waterpipe smoking was initiated prior to joining the university in 74% of the cases and 22% of waterpipe smokers smoked every day. The most common place for smoking was coffee shops (52%) and 71% of smokers shared the pipe. The significant risk factors were smoking cigarettes (OR 10.3, 95% CI 7.0-15.0), male gender (OR 5.7, 95% CI 3.9-8.2), non-Kurdish ethnicity (OR 3.0, 95% CI 1.6-15.9), city residence (OR 1.5, 95% CI 1.0-2.1), and use of alcohol and other substances (OR 2.8 95% CI 1.4-5.6).

CONCLUSION

Waterpipe smoking is highly prevalent among students in Iraqi Kurdistan, especially among males, and is becoming a public health problem. Tobacco control interventions should be designed specifically to address this problem among adolescents and the youth.

Waterpipe tobacco smoking and its human health impacts

Waterpipe tobacco smoking (WTS, also known as hookah, shisha, narghile, and many other names) involves passing tobacco smoke through water prior to inhalation by the consumer. As the number of waterpipe smokers is rising rapidly, there is growing concern over the use of WTS, particularly as there has been a widely held misconception that WTS is free from health hazards. In reality, it is associated with a variety of adverse health outcomes on both a short- and long-term basis. Hence, it is desirable to develop advanced techniques for surveillance, intervention, and regulatory/policy frameworks specific to the production and use of waterpipe tobacco. This review is written to survey the types and extent of pollutants released from its use and their potential health risks. A review of the present regulation guidelines is also included.

Waterpipe Tobacco Smoking among Arab Youth; a Cross-Country Study

OBJECTIVE

Waterpipe tobacco smoking (WTS) is considered a global epidemic that is spreading among youth. Our analysis was conducted to compare the national baseline prevalence rate estimates of WTS among Arab boys and girls.

DESIGN SETTING AND PARTICIPANTS

The Global Youth Tobacco Survey (GYTS) is a school-based survey using standardized self-administered questionnaires; it employs a two-stage cluster sampling technique to obtain a representative sample of youth (13-15 years of age). We conducted a secondary data analysis of nationally representative GYTSs available from 16 Arab countries.

MAIN MEASURES

Youth who self-reported smoking waterpipe at least once in the past 30 days were considered to be current waterpipe tobacco smokers. National weighted WTS prevalence rate estimates along with respective 95% confidence intervals were reported for boys and girls.

RESULTS

Pooled GYTS data from 16 Arab countries yielded a total of 31,359 youth. Overall, 10.6% of the respondents were current waterpipe tobacco smokers, with boys (13.7%) having significantly higher estimates than girls (7.2%). Overall, current WTS prevalence rate estimates ranged from .9% in Oman to 34.2%, in Lebanon. The WTS epidemic was more predominant among boys and girls, respectively, in the West Bank (42.8% and 24.2%), Lebanon (38.6% and 30.5%) and Jordan (25.7% and 14.5%).

CONCLUSION

Among Arab boys and girls, WTS represents a growing strain of the tobacco epidemic that requires immediate attention.

Evaluation of Dual Tobacco Smoking (Water Pipe and Cigarettes) and Associated Factors in Adults in Tehran

BACKGROUND

Concurrent use of tobacco products such as cigarettes and water pipes may be associated with increased risk of nicotine dependence and smoking-related complications. Accurate statistics are not available regarding the prevalence of water pipe use or concurrent use of cigarettes and water pipe in the Iranian population. Thus, this study sought to assess the prevalence of concurrent use of cigarettes and water pipes and their related factors in Iran.

MATERIALS AND METHODS

This cross-sectional study was conducted on Tehran residents over 15 years of age, who were selected via cluster, multi-stage randomized sampling, from different geographical districts of Tehran between November and December 2014. The data were collected using the water pipe section of the Global Adult Tobacco Survey (GATS) questionnaire.

RESULTS

A total of 1,830 individuals participated in this study, 243 (13.3%) of which exclusively used water pipes, 76 (4.2%) used both cigarettes and water pipes, and 120 (6.6%) exclusive smoked cigarettes. Of those who used both cigarettes and water pipes, 86.8% were men and 13.2% were women (P < 0.001). The mean age of those who only used water pipes was 28.01 ± 8.7 years while the mean age of those who used both water pipes and cigarettes was 33.1 ± 1.1 (P < 0.001). Male sex (adj. OR: 3.8) and older age (adj. OR: 1.06) increased the odds of using both tobacco products.

CONCLUSION

The prevalence of concurrent use of cigarettes and water pipes and that of exclusive water pipe use were 4.2% and 13.3%, respectively. The prevalence of exclusive cigarette smoking was 6.1%. Those who smoked both cigarettes and water pipes had a higher mean age than those who exclusively used water pipes and they were mostly men. Among those who used cigarettes and water pipes, the mean age at which they began using water pipes was lower than the mean age at which they began smoking cigarettes. In other words, dual smokers started water pipe smoking sooner than cigarette smoking. Future studies with different methodologies are required to further scrutinize the relationship between water pipe and cigarette smoking. Smoking cessation programs must specifically target dual smokers.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Waterpipe Use and Susceptibility to Cigarette Smoking Among Never-Smoking Youth

INTRODUCTION

Susceptibility to cigarette smoking, defined as the lack of a firm decision against smoking, is a strong predictor of regular smoking and addiction. Several modifiable risk factors have been identified among never cigarette smokers, and one potential factor of interest is waterpipe use. The purpose of this study is to determine the association of waterpipe use with susceptibility to cigarette smoking among never-smoking youth.

METHODS

In a pooled analysis of 17 Arab nations with nationally representative Global Youth Tobacco Surveys conducted during 2002-2011, tobacco-related information was obtained from 30,711 never-smoking adolescents representing 4,962,872 youth. Study outcome was susceptibility to cigarette smoking, and primary exposure was waterpipe use. Data were analyzed in 2014 using weighted logistic regression models, including stratified models by gender, to determine the odds of susceptibility to cigarette smoking with waterpipe use, adjusting for confounders.

RESULTS

Overall, 20% of never-smoking youth were susceptible to cigarette smoking, ranging from 13.1% in Oman to 32.6% in Somalia; 5.2% currently used waterpipe, ranging from 0.3% in Morocco to 23.5% in Kuwait. The estimated odds of susceptibility to cigarette smoking were 2.5 (95% CI=1.9, 3.4) times higher for adolescents who used waterpipe in the past month compared with those who did not, controlling for confounders. Estimates were similar when stratified by gender.

CONCLUSIONS

Waterpipe use is associated with susceptibility to cigarette smoking. Study findings identify a novel risk factor for never smokers to initiate smoking and will help the public health community develop and implement policies around waterpipe use prevention.

How popular is waterpipe tobacco smoking? Findings from internet search queries

OBJECTIVES

Waterpipe tobacco smoking (WTS), a traditional tobacco consumption practice in the Middle East, is gaining popularity worldwide. Estimates of population-level interest in WTS over time are not documented. We assessed the popularity of WTS using World Wide Web search query results across four English-speaking countries.

METHODS

We analysed trends in Google search queries related to WTS, comparing these trends with those for electronic cigarettes between 2004 and 2013 in Australia, Canada, the UK and the USA. Weekly search volumes were reported as percentages relative to the week with the highest volume of searches.

RESULTS

Web-based searches for WTS have increased steadily since 2004 in all four countries. Search volume for WTS was higher than for e-cigarettes in three of the four nations, with the highest volume in the USA. Online searches were primarily targeted at WTS products for home use, followed by searches for WTS cafés/lounges.

CONCLUSIONS

Online demand for information on WTS-related products and venues is large and increasing. Given the rise in WTS popularity, increasing evidence of exposure-related harms, and relatively lax government regulation, WTS is a serious public health concern and could reach epidemic levels in Western societies.

BTEX in indoor air of waterpipe cafés: Levels and factors influencing their concentrations

BTEX (benzene, toluene, ethylbenzene and xylene) concentrations, factors affecting their levels, and the exposure risks related to these compounds were studied in waterpipe (Ghalyun/Hookah) cafés of Ardabil city in Islamic Republic of Iran. 81 waterpipe cafés from different districts of Ardabil city were selected and their ambient air was monitored for BTEX compounds. Air samples were taken from standing breathing zone of employees, ~150 cm above the ground level, and were analyzed using GC-FID. In each case, the types of smoked tobacco (regular, fruit flavored), types of ventilation systems (natural/artificial), and the floor level at which the café was located were investigated. A high mean concentration of 4.96±2.63 mg/m(3) corresponding to long term exposure to benzene-related cancer risk of 4314×10(-6) was estimated. The levels of the remaining compounds were lower than the national guideline limits, but their hazard quotients (HQ) for long term exposure to ethylbenzene (1.15) and xylene (17.32) exceeded the HQ unit value. Total hazard indices (HI) of 63.23 were obtained for non-cancer risks. Type of the smoked tobacco was the most important factor influencing BTEX concentrations in the cafés. BTEX concentrations in indoor ambient air of Ardabil waterpipe cafés were noticeably high, and therefore may pose important risks for human health on both short and long term exposures.

Determinants of cigarette smoking initiation in Jordanian schoolchildren: longitudinal analysis

OBJECTIVE

To identify determinants of cigarette smoking initiation, by gender, among schoolchildren in Irbid, Jordan.

METHODS

Between 2008 and 2011, data were collected annually using self-reported questionnaires over 4-years in a prospective cohort of 1,781 students recruited from all 7th grade classes in 19 secondary schools, selected out of a total 60, using probability-proportionate-to-size method. Independent predictors of smoking initiation were identified among the cigarette naïve participants (N = 1,454) with mixed-effect multivariable logistic regression.

RESULTS

Participants were 12.6 years of age on average at baseline. 29.8% of the 1,454 students (37.2% of boys and 23.7% of girls) initiated cigarette smoking by 10th grade. Of those who initiated (n = 498), 47.2% of boys and 37.2% of girls initiated smoking in the 8th grade. Determinants of cigarette smoking initiation included ever smoking a waterpipe, low cigarette refusal self-efficacy, intention to start smoking cigarettes, and having friends who smoked. For girls, familial smoking was also predictive of cigarette initiation.

CONCLUSION

This study shows that many Jordanian youth have an intention to initiate cigarette smoking and are susceptible to cigarette smoking modeled by peers and that girls are influenced as well by familial cigarette smoking. Prevention efforts should be tailored to address culturally relevant gender norms, help strengthen adolescents' self-efficacy to refuse cigarettes, and foster strong non-smoking social norms.

Waterpipe use and cognitive susceptibility to cigarette smoking among never-cigarette smoking Jordanian youth: analysis of the 2009 Global Youth Tobacco Survey

INTRODUCTION

Susceptibility to cigarette smoking, defined as lack of a firm decision to not initiate smoking, predicts youth smoking initiation and experimentation and is a first step in the transition to regular smoking. This study investigated whether waterpipe (WP) smoking, an increasingly prevalent form of tobacco use among Arab adolescents, was associated with increased susceptibility to cigarette smoking.

METHODS

A secondary analysis of the 2009 Jordan Global Youth Tobacco Survey was conducted to assess the association between WP use and cigarette susceptibility, after adjusting for important confounders.

RESULTS

A total of 1,476 youth aged 13-15 years old who had never smoked cigarettes were identified and represented 166,593 never-cigarette smoking Jordanian youth. We found 40% of boys and 29% of girls were susceptible to cigarette smoking, and both boys (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [CI] = 1.41-1.54) and girls (AOR = 1.95, 95% CI = 1.83-2.04) who had ever smoked WP were more susceptible to cigarette smoking than those who never smoked WP.

CONCLUSION

This is the first study to report that WP use may increase youth's susceptibility to initiate cigarette smoking.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

The determinants of intention to smoke waterpipe among adolescents in Lebanon: a national household survey

BACKGROUND

The phenomenon of waterpipe smoking (WPS) among adolescents has become eminent, and it is especially prevalent in Lebanon. Unlike cigarette smoking, WPS is parentally and socially acceptable. This study aims at examining the association between intention to smoke waterpipe in the next 6 months, and knowledge, attitudes and parental and social influences.

METHODS

This is a secondary data analysis from a national survey in 2007 on 1028 households. This study addresses 258 non-smoking adolescents and their parents. Consent was sought and the study was approved by the Institutional Review Board at the American University of Beirut. Face-to-face interviews were conducted. Descriptive analysis, crude and adjusted odds ratios (ORs) were generated.

RESULTS

At the bivariate level, late adolescence, mothers without university education, prior adolescents' WPS experiences, best friends' and parents' WPS habits and adolescents' and parents' lower attitude scores were associated with smoking intention. In the adjusted model, adolescents' beliefs about positive effects, best friends' similar habits and prior smoking remained significant (respective ORs [95% confidence interval ]: 1.81 [1.33-2.45], 2.51 [1.24-5.10], 4.91 [2.35-10.36]). Parents' perceived attitude against smoking was protective (OR: 0.57 [0.39-0.83]).

CONCLUSIONS

Adolescents' intention to smoke is highly influenced by parents' permissive attitudes and peer pressure. Interventions targeting these two groups and limiting access to smoking by adolescents should be instigated.

Agreement between exhaled breath carbon monoxide threshold levels and self-reported cigarette smoking in a sample of male adolescents in Jordan

This study aimed to measure the percent agreement between Exhaled Breath Carbon Monoxide (eBCO) measure using a piCO+ smokerlyzer® and self-reported cigarette smoking status and to determine the optimal thresholds for definite identification of cigarette smokers of male school students in Jordan. A descriptive, cross sectional, study of a random sample of male adolescents in grades 7 and 8 from four public high schools in Irbid, completed an adaptation of a standardized Arabic-language tobacco smoking questionnaire and an eBCO measure. Sensitivity and specificity of the eBCO were calculated against self-reported cigarette smoking. Participants (n = 439) had a mean age of 12.5 years (SD = 0.50) and 174 (39.9%) reported being an ever smoker of whom 59 (33.9%) reported being a recent (30-day) smoker. The optimal eBCO cut-off point for recent smoking was 4.5 ppm with a sensitivity of 84.7% and specificity of 65.5%. Overall, eBCO can accurately identify recent smokers and distinguish them from non-smokers. The eBCO use enables healthcare professionals and researchers to assess efficacy of smoking cessation and prevention programs without necessarily relying on self-report. Further research is indicated to validate our findings and should be expanded to include females, detailed characteristics of cigarette and waterpipe smoking.

Double trouble: Exploring the association between waterpipe tobacco smoking and the nonmedical use of psychoactive prescription drugs among adolescents

BACKGROUND

In youth, both waterpipe tobacco smoking (WTS) and nonmedical use of prescription drugs (NMUPD) are globally growing concerns. This study assesses for the first time the lifetime and past-year associations between WTS and four classes of psychoactive prescription drugs.

METHODS

Cross-sectional data (2011) on 986 high school students attending public and private high schools in Beirut (Lebanon) was analyzed. Schools were selected using proportionate random cluster sampling from a comprehensive list of schools provided by the Ministry of Education.

RESULTS

Almost half (46%) had tried WTS compared to 25% who had ever tried cigarettes. Lifetime prevalence estimates of NMUPD were: pain relievers (8.2%), sedatives/tranquilizers (5.6%), stimulants (3.5%), antidepressants (2.5%), and sleeping pills (2.3%). WTS was associated with increased odds of sedatives/tranquilizer use (OR = 3.22, 95% CI: 1.25, 8.25), pain reliever use (OR = 4.31, 95% CI: 2.02, 9.17), and sleeping medication use (OR = 8.31, 95% CI: 2.37, 29.20), controlling for sex, age, school type, and other substance use. For cigarettes, the associations were consistently either weaker or non-existent, except with stimulant use (OR = 5.29, 95% CI: 1.55, 18.05).

CONCLUSIONS

While public health professionals have watched with caution the global prevalence of youth cigarette use-worldwide, an insidious alternative form of tobacco use has grown. Further research is needed to understand the unique risk factors and motives associated with WTS and how these relate to NMUPD in order to inform the development of effective intervention programs and policies that support youth positive health decisions.

The global epidemiology of waterpipe smoking

OBJECTIVES

In the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become a global phenomenon. In this review, we provide an updated picture of the main epidemiological trends in waterpipe smoking globally.

DATA SOURCES

Peer-reviewed publications indexed in major biomedical databases between 2004 and 2014. Search keywords included a combination of: waterpipe, hookah, shisha along with epidemiology, patterns, prevalence and predictors. We also used different spellings of waterpipe terms commonly used.

STUDY SELECTION

The focus was on studies with large representative samples, national data or high-quality reports that illuminated aspects of the epidemiology and trends in waterpipe smoking.

DATA EXTRACTION

Multiple researchers extracted the data independently and collectively decided on the most important and pertinent studies to include in the review.

DATA SYNTHESIS

Waterpipe smoking has become a global phenomenon among youth. The global waterpipe epidemic is likely driven by (1) the introduction of manufactured flavoured tobacco (Maassel); (2) the intersection between waterpipe's social dimension and thriving café culture; (3) the evolution of mass communication media; (4) the lack of regulatory/policy framework specific to the waterpipe. Waterpipe smoking is becoming the most popular tobacco use method among youth in the Middle East, and is quickly gaining popularity elsewhere. Important patterns of waterpipe smoking include the predominance among younger, male, high socioeconomic, and urban groups. Intermittent and social use are also noted patterns.

CONCLUSIONS

Waterpipe smoking has become a global public health problem. Developing surveillance, intervention and regulatory/policy frameworks specific to the waterpipe has become a public health priority.

Determinants of waterpipe smoking initiation among school children in Irbid, Jordan: a 4-year longitudinal analysis

OBJECTIVE

Guided by the Attitude-Social influence-self Efficacy (ASE) theory, this study identified predictors of waterpipe (WP) smoking initiation in a WP naïve cohort of Jordanian school children.

METHODS

A school-based cohort of all 7th grade students (N=1781) in 19 of 60 schools in Irbid, Jordan, was followed from 2008 to 2011. Generalized linear mixed modeling was used to examine predictors of WP initiation among WP-naïve students (N=1243).

RESULTS

During the 3-year study, WP initiation was documented in 39% of boys and 28% of girls. Prior cigarette smoking (boys: odds ratio 7.41; 95% confidence interval 4.05-12.92 and girls: 8.48; 4.34-16.56) and low WP refusal self-efficacy (boys: 26.67; 13.80-51.53 and girls: 11.49; 6.42-20.55) were strongly predictive of initiating WP. Boys were also more likely to initiate WP smoking if they had siblings (2.30; 1.14-4.64) or teachers (2.07; 1.12-3.84) who smoked and girls if they had friends (2.96; 1.59-5.54) who smoked.

CONCLUSION

There is a sizeable incidence of WP initiation among students of both sexes. These findings will help in designing culturally responsive prevention interventions against WP smoking. Gender-specific factors, refusal skills, and cigarette smoking need to be important components of such initiatives.

Prevalence, patterns and correlates of cigarette smoking in male adolescents in northern Jordan, and the influence of waterpipe use and asthma diagnosis: a descriptive cross-sectional study

Our study investigates the prevalence, patterns and predictors of tobacco smoking among early adolescent males in Northern Jordan and whether asthma diagnosis affects smoking patterns. A descriptive cross sectional design was used. Males in grades 7 and 8 from four randomly selected high schools in the city of Irbid were enrolled. Data on waterpipe (WP) use and cigarette smoking patterns were obtained (n = 815) using a survey in Arabic language. The overall prevalence of ever having smoked a cigarette was 35.6%, with 86.2% of this group smoking currently. Almost half of the sample reported WP use. The most common age in which adolescents started to experiment with cigarettes was 11–12 years old (49.1%), although 10 years was also common (25.3%). Significant predictors of male cigarette smoking were WP use (OR = 4.15, 95% CI = 2.99–5.76), asthma diagnosis (OR = 2.35, 95% CI = 1.46–3.78), grade 8 (OR = 1.52, 95% CI = 1.10–2.11), and having a sibling who smokes (OR = 2.23, 95% CI = 1.53–3.24). However, this cross-sectional study cannot establish causality, thus longitudinal studies are needed. Public health programs and school-based anti-tobacco smoking interventions that target children in early years at high schools are warranted to prevent the uptake of tobacco use among this vulnerable age group. High school students with asthma should be specifically targeted.

Tobacco smoking status and perception of health among a sample of Jordanian students

Limited data are available from Jordan examining patterns of tobacco use among adolescents, or how use is related to health perceptions. This study aims to estimate the prevalence of tobacco use and to assess the relationship between use and health-related perceptions. A cross-sectional survey was conducted among a sample of 11–18 year old school students from a major governorate in Jordan. Using a multistage random sampling 1050 students were selected. Students were categorized as non-smokers, cigarette-only smokers, waterpipe-only smokers, or dual smokers. Rates of waterpipe-only and cigarette-only smoking were 7% and 3%, respectively, and were similar for boys and girls. In contrast, the rate of dual use was much higher than for single product use and was double in girls compared to boys (34% vs. 17%). Dual-smokers were significantly more likely to think that it is safe to smoke as long as the person intends to quit within two years compared to non-smokers, and had lower self-rated health status than other groups. This is the first study among Arab adolescents to document high rates of dual tobacco use, especially pronounced among girls. The study findings have significant implications for designing tobacco smoking prevention programs for school health settings.

Waterpipe smoking among middle and high school Jordanian students: patterns and predictors

Despite the increase in attention to waterpipe tobacco smoking, the patterns and predictors of this method of tobacco use among Jordanian youth are not well known. The current study was conducted to assess the patterns and the predictors of waterpipe tobacco smoking among school aged students in one of Jordan's Central Governorates. A cross-sectional survey was conducted to investigate the patterns and predictors of waterpipe tobacco smoking among youth (grades 6, 8, 10 and 12). Using a multistage random sampling more than 1,000 students was selected. Data were collected using the Arabic Youth Tobacco Use Composite Measure (YTUCM). Waterpipe smoking was assessed for "past 12 months", "past month" and "past week". Students' ages ranged from 11 to 18 years, (mean age ± 14.7; SD ± 1.9 years). The percentage of girls who smoked waterpipe was greater for all frequencies of use than it was for boys. Age, gender, and belief that smoking makes more friends were predictors of smoking among study participants. This is the first known study to examine waterpipe smoking among youth aged 11 and 12. Our findings illustrate the need for public health campaigns to reach and educate youth, their families, teachers and school systems regarding the growing recognized health risks of waterpipe smoking.

Tobacco in the Arab world: old and new epidemics amidst policy paralysis

The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region.