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

Cigarettes and waterpipe use and risk of colorectal cancer in Iran: the IROPICAN study

We aimed to investigate the association between cigarettes and waterpipe use and colorectal cancer (CRC) in an Iranian population. We analyzed data from a multicenter hospital-based case-control study in Iran (IROPICAN). Data on tobacco smoking, including cigarettes, and waterpipe smoking, were collected in detail. Multivariate logistic regressions estimated the odds ratios (ORs) and 95% confidence intervals (CIs) for the association between cigarette and waterpipe smoking and CRC, accounting for confounders including age, sex, socioeconomic status, opium use, marital status, family history of cancer, red meat, fiber, body shape at age 15 and perceived physical workload, and each other of the two exposures. The study population consisted of 3215 controls and 848 cases, including 455 colon and 393 rectum cancers. We found no association between CRC and cigarette smoking (OR, 0.8; 95% CI, 0.6-1.0) or waterpipe smoking (OR, 1.1; 95% CI, 0.9-1.5). Analysis by categories of cigarette pack-year and frequency of waterpipe smoking (head-year) did not show associations. We observed an inverse association between colon cancer and cigarette smoking (OR, 0.6; 95% CI, 0.5-0.9). There was, however, no significant association by pack-year categories. Cigarette and waterpipe smoking was not associated with CRC in the Iranian population. Further studies are needed to better understand the role of waterpipe on CRC.

Multiple Sclerosis: Economic Burden, Therapeutic Advances, and Future Forecasts in the Middle East and North Africa Region

INTRODUCTION

Multiple sclerosis (MS) is a persistent condition characterized by immune-mediated processes in the central nervous system, affecting around 2.8 million individuals globally. While historically less prevalent in the Middle East and North Africa (MENA) region, recent trends mirror the global rise in MS.

AREA COVERED

The impact of MS is substantial, particularly in the MENA region, with costs per patient surpassing nominal GDP per capita in certain countries. Disease-modifying therapies aim to alleviate MS effects, but challenges persist, especially in managing progressive MS as it shifts from inflammatory to neurodegenerative phases. Limited resources in the MENA region hinder care delivery, though awareness initiatives and multidisciplinary centers are emerging. Contrary to global projections of a decline in the MS market, the MENA region is poised for growth due to increased prevalence, healthcare expenditures, and infrastructure investments.

EXPERT OPINION

This review underscores the urgent necessity for effective treatments, robust disease management, and early diagnosis in tackling MS's repercussions in the MENA region. Bolstering resources tailored to MS patients and elevating the quality of care stand as pivotal strategies for enhancing health outcomes in this context. Taking decisive action holds the key to enhancing the overall well-being of individuals grappling with MS.

Association between waterpipe smoking and lung cancer: a multicentre case-control study in Iran

OBJECTIVES

This study investigated the association between lung cancer and waterpipe smoking, which is an emerging global public health concern.

STUDY DESIGN

Multicentre case-control study.

METHODS

This study included 627 cases and 3477 controls from the Iranian Study of Opium and Cancer (IROPICAN) study, which was conducted between 2017 and 2020. One frequency-matched control for each lung cancer patient was selected by age, gender and residential place; however, this study used controls of four cancer types in the analyses. The multivariable logistic regression model estimated the odds ratio (OR) and 95% confidence intervals (CIs). Additional analyses were performed among 181 lung cancer cases and 2141 controls who were not cigarette smokers or opium or nass/pipe users.

RESULTS

The odds of lung cancer were higher among waterpipe smokers than never-smokers (OR = 1.3, 95% CI: 1.0-1.7). Results showed a higher OR of lung cancer for those who smoked the waterpipe daily (OR = 2.1, 95% CI: 1.4-3.0), smoked more than two heads per day (OR = 2.7, 95% CI: 1.8-4.0), had smoked for >20 years (OR = 1.9, 95% CI: 1.3-2.7), smoked more than 20 head-years (OR = 2.8, 95% CI: 1.9-4.1) and initiated smoking before the age of 30 years (OR = 1.7, 95% CI: 1.1-2.5). The association was only statistically significant for squamous cell carcinomas (OR = 1.8, 95% CI 1.2-2.7). Furthermore, this study observed a higher OR of lung cancer among exclusive waterpipe smokers (OR = 2.3, 95% CI: 1.6, 3.5).

CONCLUSIONS

Waterpipe smoking was associated with an increased risk of lung cancer. The association was stronger with higher frequency, duration and intensity of exposure to waterpipe smoking. The association increases in exclusive waterpipe smokers, which is likely due to controlling for residual confounding by cigarette smoking and opium consumption, and higher exposure levels in this subpopulation.

Arab world's impact on bladder cancer research and opportunities for growth: A bibliometric review study

BACKGROUND

Bladder Cancer (BC) is a widespread form of cancer that affects over 1.6 million people globally. The majority of cases are diagnosed as urothelial carcinoma, with a higher likelihood of diagnosis in men and with increasing age. The Arab world (AW) is one of the regions with the highest incidence and mortality rates of BC, and the average age of diagnosis is between 40 and 49 years in North Africa and the Middle East. This study aims to assess the activity and distribution of BC publications in the AW.

METHODS

A systematic search across MEDLINE and Embase databases spanning 2007 to 2021 identified 1208 English-language articles on bladder cancer with Arab affiliations. The dataset was normalized against the average population and GDP (2007-2020) for 22 Arab countries. Statistical analyses via SPSS and visualizations with VOSviewer unveiled collaboration patterns and thematic trends in Arab bladder cancer research.

RESULTS

A total of 1208 BC publications were published in the AW, representing 0.24% of all biomedical publications. Egypt topped the list with the highest number of publications. The co-authorship analysis generated by VOSviewer revealed that out of 4766 authors, 161 met the minimum threshold of 5 publications.

CONCLUSION

The findings reveal that Egypt and Jordan are at the forefront of BC research in the region, while other Arab countries are lagging behind despite being heavily impacted by the disease. To drive progress in the field, it's important to uncover the obstacles impeding BC research in these countries and implement effective solutions to overcome them.

210Po and 210Pb radioactivity levels in local and imported tobacco used in Palestine and Jordan

This study aimed to assess the concentrations of 210Po and 210Pb in various tobacco samples from Palestine and Jordan. Cigarette smoking is recognized as a significant contributor to the radiation dose received by individuals, primarily due to the elevated levels of 210Pb and 210Po found in tobacco. The analysis revealed that the average concentrations of 210Po in locally sourced tobacco and cigarette samples in Palestine are 16.8 ± 2.3 mBq/g and 18.5 ± 2.0 mBq/g, with a total average of 17.8 ± 7.4 mBq/g (15.5 mBq/cigarette). Similarly, the average concentrations of 210Pb in these samples are 18.5 ± 2.6 mBq/g and 20.3 ± 2.2 mBq/g, with a total average of 19.6 ± 8.1 mBq/g (17.0 mBq/cigarette). In Jordan, the average concentrations of 210Po in cigarette samples and narghile tobacco are 20.1 ± 2.4 mBq/g and 18.3 ± 4.1 mBq/g, with a total average value of 19.6 ± 9.9 mBq/g (18.0 mBq/cigarette), while the average concentrations of 210Pb are 22.2 ± 2.6 mBq/g and 20.2 ± 4.5 mBq/g, with a total average value of 21.6 ± 10.8 mBq/g (19.9 mBq/cigarette). The annual effective doses resulting from inhalation were calculated for smokers of these samples. The findings revealed that the levels of 210Po and 210Pb radioactivity in certain investigated samples exceeded the results of studies in many countries of the world. The associated effective doses per year from smoking for all brands products in Palestine range from 34.7 μSv/y to 186.5 μSv/y with an average of 109.5 μSv/y, while in Jordan 54.5 μSv/y to 289.1 μSv/y with an average of 130.9 μSv/y.

Factors associated with attempting and succeeding in smoking cessation following a National Tobacco Control Plan: Analysis of two nationwide surveys (2010 and 2017)

INTRODUCTION

Lower rates of smoking cessation among disadvantaged groups contribute to widening health-disparities. With this recognition, in 2010 free-of-charge/subsidized smoking cessation services became available to all Israeli residents through the not-for-profit health plans.

METHODS

Based on two cross-sectional National Social Surveys, data on adult ever-smokers were used (n = 2,998 in 2010 and 2,859 in 2017). The outcome variable comprised three categories: no quit attempt, unsuccessful quit attempt and successful quit attempt. Changes over-time and demographic, socioeconomic, health- and smoking-related factors associated with quitting attempts and success were tested in the pooled sample, using multivariable multinomial logistic regression models.

RESULTS

The pooled sample of the two surveys included 2,611 participants (44.2%) who were successful quitters, 1,941 (32.7%) who reported an unsuccessful quit attempt, and 1,305 (23.1%) smokers who did not attempt to quit. Compared to 2010, ever-smokers in 2017 were less likely to report an unsuccessful quit attempt (adjusted OR = 0.81, 95%CI: 0.70-0.94). The likelihood of successfully quitting was similar in both surveys. Older age and self-reported health problem were associated with higher likelihood of quitting attempt. Meeting living expenses, being overweight/obese, engaging in physical activity and heavy smoking were associated with higher likelihood of successful smoking cessation; while environmental tobacco exposure was associated with 43% lower likelihood of successful cessation. Finally, there was an interaction between education and ethnicity. Higher education level was associated with a greater likelihood both to attempt to quit smoking and to succeed among Jewish participants, while the opposite phenomenon was observed among Arab smokers.

CONCLUSIONS

Despite the availability of subsidized smoking cessation services, social disparities in smoking cessation rates persist. Efforts should focus on proactively reaching subpopulations with low cessation rates, using tailored strategies for successful smoking cessation. Promoting smoke free homes and workplaces should be prioritized.

From knowledge production to knowledge translation: Waterpipe tobacco control research in the Eastern Mediterranean Region

Waterpipe tobacco smoking (WTS) rates in the Eastern Mediterranean Region (EMR) are the highest worldwide, particularly among young people. Although fiscal policies to curb tobacco use have been recommended by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), implementation has been suboptimal. The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECON-WTS) was formed in response to this need to produce knowledge on the economics of WTS in the EMR and apply a comprehensive Knowledge translation (KT) framework. The KT framework comprised priority setting, evidence synthesis, knowledge translation, and knowledge uptake. In this article, we discuss the approaches followed in applying the KT framework to WTS control, providing examples and noting challenges and lessons learned where possible.

Factors associated with intentions to quit tobacco use in Lebanon: A cross-sectional survey

Introduction

The prevalence of tobacco smoking in Lebanon is among the highest globally. This study aims to determine past attempts to quit smoking among adults and identify factors associated with intentions to quit.

Methods

A nationally representative telephone survey was conducted between June and August 2022. Eligibility criteria included people aged >=18 years residing in Lebanon. The questionnaire was divided into three components: socio-demographic characteristics, cigarette and waterpipe tobacco use behaviours. Binary logistic regression was used to examine factors associated with intention to quit cigarette and waterpipe tobacco use.

Results

A total of 2003 respondents were included in the study. The prevalence of any tobacco product use was 41%, the prevalence of current cigarette smoking was 41% and the prevalence of current waterpipe tobacco use was 20%. Approximately 24% of adults who smoke cigarettes and 26% of those who use waterpipe tobacco had previous quit attempts mainly due to health concerns. Intentions to quit smoking within the next 6 months were reported among 12% of survey respondents. Among adults who smoke, past quit attempts increased the likelihood of intentions to quit cigarette smoking by 5-fold (OR: 5.11; 95% CI: 1.80-14.47, p = 0.002) and waterpipe tobacco use by 7-fold (OR: 6.98, 95% CI: 2.63-18.51, p = <0.001). Age and income were associated with intentions to quit cigarette but not waterpipe tobacco use.

Conclusion

Intention to quit smoking was strongly associated with past quitting attempts. Understanding factors associated with intentions to quit can help inform the development of context specific smoking cessation interventions.

The association between cultural and social occasions and smoking cessation: The case of Saudi Arabia

INTRODUCTION

Tobacco use remains high in Saudi Arabia, necessitating an understanding of the influence of cultural and social events on smoking cessation. This study examined whether cultural and social events like Ramadan, Eids, and birthdays, motivate Saudi adults to quit smoking.

METHODS

Convenience sampling of 742 Saudi tobacco users was conducted between July 2021 and May 2022. A cross-sectional survey was used to assess self-reported desire to quit (1 = 'least desire' to 10 = 'highest desire') and behaviors in relation to special occasions. Multiple linear regression was performed to examine the association between cultural and social occasions and the desire to quit, while logistic regression was used to assess the relationship between cultural and social occasions and historical quit attempts, medicinal nicotine product use, visiting smoking cessation clinics, and calling the national Quitline. Demographic variables and tobacco types were controlled for in the analyses.

RESULTS

Considering quitting during Ramadan, Eids, and birthdays was associated with a higher desire to quit (Ramadan: B=2.99; 95% CI: 2.51-3.47, Eids: B=2.83; 95% CI: 2.12-3.54, and birthdays: B=2.76; 95% CI: 1.93-3.60, p<0.01) and a greater likelihood of past quit attempts (Ramadan: AOR=8.2; 95% CI: 5.5-12.1, Eids: AOR=5.8; 95% CI: 3.2-10.5, and birthdays: AOR=4.8; 95% CI: 2.4-9.4). Only considering quitting during Ramadan was associated with calling the national Quitline (AOR=2.9; 95% CI: 1.8-4.9).

CONCLUSIONS

Cultural and social events like Ramadan and Eids motivate adults in Saudi Arabia to attempt tobacco cessation. Targeting interventions around meaningful cultural occasions may promote successful quitting. These findings highlight the importance of understanding cultural and religious influences on cessation behaviors in Saudi Arabia and in other countries.

Effect of glycerol concentration on levels of toxicants emissions from water-pipe tobacco smoking (WTS)

Glycerol, flavorings and sweeteners constitute approximately 70% of water-pipe tobacco smoking (WTS) mixtures. Tobacco mixture combustion produces smoke toxins (e.g. carbonyl compounds), of which the type and amount are highly dependable on tobacco mixture formula. While glycerol in tobacco mixture contribute to enhanced smoking experience, its' combustion produces toxicants such as acrolein. According to WHO, there are no approved international upper limits regulations on WTS ingredients. This study aims to assess toxicant emission levels corresponding to increasing glycerol concentration in WTS mixtures, which may aid in developing tobacco regulations towards harm reduction.MethodsLaboratory experimental study. Using laboratory water-pipe smoking machine, levels of toxicant emissions in the smoke from WTS mixture samples containing varying glycerol concentrations were measured using High-performance Liquid Chromatography (HPLC). Smoke from 5 consecutive smoking cycles with 35 puffs each (ISO 22486 standard) was led through a trapping system as described in the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) recommended method No. 74 (Determination of selected carbonyls in mainstream cigarette smoke by HPLC). Trapped carbonyls were then analysed by HPLC with a DAD detector.ResultsAcrolein emission is associated with glycerol addition in WTS mixture indicated by lab-made samples throughout all glycerol concentrations (10%, 20%, 40% and 60%), and brand samples with glycerol concentrations 10% to 20%. However, brand samples showed no increase in acrolein emission corresponding to the increase in glycerol concentrations from 20% to 60%.ConclusionThe effect of glycerol addition in waterpipe tobacco on acrolein emission varies between products. Tobacco fillers, additives and contents quality and other factors may affect toxicant emission levels. Therefore, regulatory recommendations towards defining upper limits of content concentrations require further investigations regarding potential confounders in acrolein emissions and health effects of market-available glycerol concentrations in waterpipe tobacco smoking.

Prevalence, knowledge and factors associated with shisha smoking among university students in Cameroon

BACKGROUND: Young adults consider shisha (water-pipe) less harmful than other smoking methods, but it has been reported to expose its users to excess levels of tobacco. This study sought to determine the prevalence, knowledge and factors associated with shisha use among university students in Buea, Cameroon.METHODS: Consenting participants were included in a cross-sectional study. Knowledge was assessed using a knowledge summary score and logistic regression used to identify factors associated with shisha smoking. P < 0.05 was considered statistically significant.RESULTS: There were 1,008 student participants; 509 (50.9%) were female. The mean age was 22.9 ± 3.1 years. The prevalence of shisha smoking was 26% (95% CI 23.3-28.8). Most respondents had good knowledge about shisha (59.2%). Poor knowledge about shisha (adjusted odds ratio [aOR] 2.37, 95% CI 1.57-3.59)], living in a hostel (aOR 2.00, 95% CI 1.29-3.11), friends' use of shisha (aOR 5.41, 95% CI 3.03-10.43) and alcohol consumption (aOR 1.91, 95% CI 1.24-2.94) were associated with shisha smoking.CONCLUSION: The prevalence of shisha smoking among university students in Buea is high; about one-quarter of the students have poor knowledge about its harmful health effects. There is an increasing need for sensitisation of these young adults to the harmful effects of tobacco smoking.

Telephone versus face-to-face consultation on smoking cessation at primary health care centers in Qatar during COVID-19 pandemic

Smoking cessation leads to a reduction in risks of smoking-related morbidity and mortality. During the coronavirus 2019 (COVID-19) pandemic, smoking cessation services were interrupted. Providing smoking cessation counseling by telephone could be a convenient and safe alternative to traditional face-to-face service. However, the effectiveness of telephone smoking cessation counseling has not yet been thoroughly investigated. This study evaluated telephone smoking cessation counseling compared to face-to-face consultations during the COVID-19 era. In addition, it investigated the association between sociodemographic and health-related factors and cessation rates. A retrospective cohort design was used. Participants were randomly selected from two lists: (1) telephone counseling and (2) face-to-face counseling in smoking cessation clinics in five primary health care centers in Qatar between March 2020 and March 2021. Cessation rates were compared between the two groups at 1, 2, 4, 8, and 12 weeks. A multivariable logistic regression analysis was used to identify the significant associations with smoking cessation. Smokers who underwent telephone consultations had significantly lower quit rates at all follow-ups compared to those who attended face-to-face visits. At the 12-week follow-up, the adjusted odd ratio for quitting through face-to-face consultations was 1.96 (95% CI [1.15-3.35]) times higher than that achieved through telephone consultations. In addition to receiving face-to-face counseling, higher self-efficacy to cease smoking was an independent predictor of successful cessation. Providing smoking cessation counseling by telephone could be a safer but less effective mode of delivery versus traditional face-to-face encounters during the pandemic.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors associated with the desire to quit tobacco smoking in Saudi Arabia: Evidence from the 2019 Global Adult Tobacco Survey

INTRODUCTION

Saudi Arabia is expected to witness a slight reduction in tobacco use. The Saudi government offers free-of-charge smoking cessation services. Yet, factors influencing the desire to quit smoking are not comprehensively investigated in Saudi Arabia. This study examines the factors influencing the desire to quit among smoking adults in Saudi Arabia and investigates whether using alternative tobacco products, such as e-cigarettes, is associated with the desire to quit smoking.

METHODS

Data from the 2019 nationally representative Global Adults Tobacco Survey (GATS) was used. GATS utilized a face-to-face household cross-sectional survey that collected data from adults aged ≥15 years. Several factors including, sociodemographic characteristics, use of alternative tobacco products, attitude toward tobacco control, and awareness of smoking cessation clinics (SCCs), were examined to predict the desire to quit. Logistic regression analysis was conducted.

RESULTS

A total of 11381 individuals completed the survey. Of the total sample, 1667 participants were tobacco smokers. The majority of the tobacco smokers were interested in quitting smoking (82.4%); 58% of cigarette smokers and 17.1% of waterpipe smokers were interested in quitting smoking. The desire to quit smoking was positively associated with the awareness of SCCs (AOR=3; 95% CI: 1.8-5), attitude toward raising tobacco taxes (AOR=2.3; 95% CI: 1.4-3.8), and a strict rule of smoking inside the home (AOR=2; 95% CI: 1.1-3.9). No statistical association was found between the desire to quit smoking and the use of e-cigarettes.

CONCLUSIONS

The desire to quit tobacco smoking among Saudi smokers increased with awareness of SCCs, favoring taxes on tobacco products, and implementing strict rules of smoking inside the home. The study reveals valuable insights into the main factors that could inform the development of more effective policy interventions targeting smokers in Saudi Arabia.

Spirometric Parameters in Waterpipe Smokers, Cigarette Smokers, and Non-smokers of Shahedieh Cohort Study

BACKGROUND

Different kinds of smoking tobacco may affect pulmonary function and reduce some spirometric parameters. This study aimed to assess the relationship between smoking cigarettes and waterpipe and spirometric parameters.

METHODS

This was a cross-sectional study on 1543 middle-aged individuals, as a sub-study of the Shahedieh cohort study in Yazd. The participants were randomly selected from the Shahedieh cohort population and were divided into 6 groups according to their smoking habits: non-smokers (n=455), cigarette smokers (n=139), waterpipe smokers (n=287), ex-cigarette smokers (n=131), concurrent waterpipe and cigarette smokers (n=121), and cigarette or waterpipe passive smokers (n=410). Spirometry was performed on all participants and spirometric parameters were compared between different groups. The data were analyzed by SPSS (version 20) using Kolmogorov-Smirnov, Kruskal-Wallis, and Mann-Whitney U tests.

FINDINGS

FEV1 %, FEV1/FVC, and PEF25-75% were significantly lower in cigarette smokers, compared to waterpipe smokers and non-smokers. The measures were not significantly lower in waterpipe smokers in comparison to non-smokers. The frequency of obstructive pattern and small airway diseases was significantly higher in cigarette smokers compared to waterpipe smokers and non-smokers.

CONCLUSION

The results of this study showed that in the middle-aged population, spirometric parameters related to airway obstruction (FEV1, FEV1/FVC, and FEF25-75%) were significantly lower in cigarette smokers than in non-smokers and waterpipe smokers, but these parameters were not significantly different between waterpipe smokers and non-smokers.

National and Regional Fraction of Cancer Incidence and Death Attributable to Current Tobacco and Water-Pipe Smoking in the Eastern Mediterranean Countries in 2020

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.

National surveillance of cancer survival in Iran (IRANCANSURV): Analysis of data of 15 cancer sites from nine population-based cancer registries

Cancer survival is a key indicator for the national cancer control programs. However, survival data in the East Mediterranean region (EMR) are limited. We designed a national cancer survival study based on population-based cancer registries (PBCRs) from nine provinces in Iran. The current study reports 5-year net survival of 15 cancers in Iranian adults (15-99 years) during 2014 to 2015 in nine provinces of Iran. We used data linkages between the cancer registries and the causes of death registry and vital statistics and active follow-up approaches to ascertain the vital status of the patients. Five-year net survival was estimated through the relative survival analysis. We applied the international cancer survival standard weights for age standardization. Five-year survival was highest for prostate cancer (74.9%, 95% CI 73.0, 76.8), followed by breast (74.4%, 95% CI 72.50, 76.3), bladder (70.4%, 95% CI 69.0, 71.8) and cervix (65.2%, 95% CI 60.5, 69.6). Survival was below 25% for cancers of the pancreas, lung, liver, stomach and esophagus. Iranian cancer patients experience a relatively poor prognosis as compared to those in high-income countries. Implementation of early detection programs and improving the quality of care are required to improve the cancer survival among Iranian patients. Further studies are needed to monitor the outcomes of cancer patients in Iran and other EMR countries.

Prevalence and risk factors of the pregnancy rhinitis at Tikrit General Hospital, Tikrit City, Iraq

Background

Pregnancy rhinitis (PR) is a relatively common condition with a prevalence of 20%. We aimed to identify the prevalence and risk factors of the PR. A prospective cohort study was conducted at the Obstetric and Gyenocology and Otolaryngology Departments in the Tikrit General Hospital, Tikrit City, Iraq. The study covered 12 months (September 2019–September 2020). Pregnant women were divided into two groups; with and without PR. Data regarding the age, body mass index (BMI), occupation, smoking, clinical features, parity, gestational age, and sex of the baby were recorded. Visual analog scale (VAS) and nasal-obstructive-symptom-evaluation (NOSE) scale were used for the evaluation of the nasal obstruction.

Results

The prevalence of the PR was 11.65% (110/944 pregnant women). Rhinorrhea was the commonest associated feature with nasal obstruction of the PR (n = 48, 43.6%). Ninety percent of the patients were in the age group < 35 years. The majority of the subjects were housewives (n = 551, 58.4%), in the second trimester (n = 456, 48.3%), and in the parity group 0–2 (n = 511, 54.1%). The female baby was found in 56.5% of the patients (n = 533). There were statistically significant differences between the two groups: women with and without PR regarding the BMI and gestational age (first trimester) (P value = 0.001). No history of current smoking was found in all women.

Conclusion

The prevalence of PR was 11.65% and was mostly seen in the first trimester. High BMI and pregnant women in the first trimester were considered risk factors for the PR.

The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies

Background

Many countries have started pursuing tobacco ‘endgame’ goals of creating a ‘tobacco-free’ country by a certain date. Researchers have presented models to attain this goal, including shifting the supply of tobacco to a monopoly-oriented endgame model (MOEM), wherein a state-owned entity controls the supply and distribution of tobacco products. Although not designed to end tobacco use, the Regie in Lebanon exhibits some of the key features identified in MOEM and hence can serve as a practical example from which to draw lessons.

Methods

We comprehensively review previous literature exploring tobacco endgame proposals featuring a MOEM. We distil these propositions into core themes shared between them to guide a deductive analysis of the operations and actions of the Regie to investigate how it aligns (or does not) with the features of the MOEM.

Results

Analysing the endgame proposals featuring MOEM, we generated two main themes: the governance of the organisation; and its operational remit. In line with these themes, the investigation of the Regie led to several reflections on the endgame literature itself, including that it: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like Transnational Tobacco Companies (TTC); (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain.

Conclusion

The implementation of tobacco endgame strategies of any type is now closer than ever. Using the Regie as a practical example allows us to effectively revisit both the potential and the pitfalls of endgame strategies aiming to introduce some form of monopoly and requires a focus on: (i) establishing appropriate governance structures for the organisation; and (ii) adjusting the financial incentives to supress any motivation for the organisation to expand its tobacco market.

Youth susceptibility to tobacco use in the Gulf Cooperation Council Countries, 2001–2018

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Analysis of the susceptibility to initiating tobacco use identifies youth at higher risk of initiating tobacco.

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Susceptibility to initiate tobacco use in increased in the United Arab Emirates while decreased in Bahrain and Qatar.

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FCTC may have an independent impact on initiating tobacco use among youth.

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The study helps policymakers identify impactful policies and prioritize resources accordingly.

The Gulf Cooperation Council (GCC) countries – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) – ratified the Framework Convention on Tobacco Control (FCTC) in 2006. Yet, GCC countries predict a slight reduction in tobacco use compared to the Eastern Mediterranean region’s significant downward trend. The purpose of this study was to examine changes in self-reported intention to initiating tobacco use (susceptibility) among youth over time in five GCC countries and the relationship between susceptibility and key FCTC provisions. Complex sample logistic regression analyses were conducted using data from the 2001 to 2018 Global Youth Tobacco Survey (n = 349,878 adolescents). Since the ratification of FCTC in GCC countries, susceptibility to initiate tobacco use significantly decreased in Bahrain and Qatar while it increased in UAE (P < 0.001). Exposure to smoking in public places increased the odds of susceptibility to tobacco use in Bahrain (AOR = 1.6, 95% CI = [1.2–2.2), Kuwait (AOR = 1.6, 95% CI = [1.2–2.0]), Qatar (AOR = 1.9, 95% CI = [1.4–2.6]), and UAE (AOR = 2.1, 95% CI = [1.6–2.7]). Susceptibility to tobacco use was significantly associated with exposure to tobacco imagery in media in the UAE (AOR = 1.7, 95% CI = [1.2–2.3]) and with tobacco industry activities like promotion in Bahrain (AOR = 2.8, 95% CI = [1.9–4.2]) and Kuwait (AOR = 2.2, 95% CI = [1.5–3.1]). In conclusion, the impact of FCTC provisions on tobacco use differs across countries. Findings suggested that the implementation of tobacco control policies may independently influence the initiation of tobacco use.

Prevalence of cigarette and waterpipe tobacco smoking among adults in three Eastern Mediterranean countries: a cross-sectional household survey

OBJECTIVES

Tobacco smoking is on the rise in the Eastern Mediterranean region. In light of limited surveillance of smoking in the region, this study sought to understand the prevalence of cigarette and waterpipe smoking among adults and the factors associated with smoking in Lebanon, Jordan and Palestine (West Bank only).

DESIGN, SETTING AND PARTICIPANTS

Household surveys were conducted with participants over the age of 18 in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679) between June and August 2019. A multistage cluster sampling approach with probability-proportional-to-size random selection method was followed in the three countries.

PRIMARY AND SECONDARY OUTCOME MEASURES

Gender-specific prevalence rates for cigarette and waterpipe smoking were estimated. Multivariable logistic regression was used to examine factors associated with current cigarette and waterpipe tobacco smoking.

RESULTS

The prevalence of cigarette smoking among males and females respectively was 48.6% and 21.5% in Lebanon, 50.4% and 9.1% in Jordan, and 53.4% and 3.1% in Palestine. The prevalence of waterpipe smoking among males and females respectively was 32.7% and 46.2% in Lebanon, 13.4% and 7.8% in Jordan, and 18.0% and 7.9% in Palestine. Cigarette smokers were significantly (p<0.05) more likely to be male, younger and with lower educational attainment across the three countries. Waterpipe smokers were more likely to be young adults across the three countries (p<0.001). They were more likely to be male in Jordan and Palestine, and more likely to be female in Lebanon.

CONCLUSIONS

The high prevalence rates of smoking in Lebanon, Jordan and Palestine are concerning. Continued surveillance is key to monitor smoking patterns and inform stronger tobacco control measures.

Waterpipe tobacco smoking (WTS) control policies: global analysis of available legislation and equity considerations

INTRODUCTION

The Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities.

METHODS

We reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation's Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available.

RESULTS

Our results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal.

CONCLUSIONS

Our recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.

Factors Affecting Waterpipe Tobacco Smoking among University Students in Qatar

Background: Recent data show an increase in the prevalence of waterpipe tobacco smoking (WTS) among university students in the Arab Gulf region alongside an attitude of social acceptability and a perception that WTS is less harmful than traditional cigarette smoking. Objective: This study measures the prevalence of WTS among university students and examines the individual, sociocultural, and environmental factors influencing this practice. Methods: Participants were selected through stratified random sampling of students in the largest national university in Qatar. Data were collected anonymously using an online questionnaire. Descriptive univariate and bivariate analyses were conducted to examine the association of WTS with participants' sociodemographic characteristics, knowledge, and attitudes. Results: 199 students completed the questionnaire. Among students who reported using tobacco products, waterpipe (shisha) was the most common product (70.6%). WTS was significantly associated with having a mother (p = 0.015) or a close friend (p < 0.001) who smoked. Compared to non-users, waterpipe tobacco users were significantly more likely to believe that waterpipe tobacco is less addictive than cigarettes (p = 0.009) and significantly less likely to believe that waterpipe tobacco can lead to cardiovascular diseases (p = 0.003) or dental problems (p = 0.02). More waterpipe tobacco users than non-users disagreed that parents (p = 0.005) or advertisements (p = 0.002) could influence use. More waterpipe tobacco users (70%) than non-users (37%) believed that females were more comfortable using waterpipes than cigarettes. Conclusions and implications: The findings shed light on factors shaping WTS and provide evidence for designing multilevel behavioral interventions to decrease the prevalence of WTS among youth.

Prevalence of tobacco smoking in a sample of general secondary school students in Cairo and its correlation to other psychiatric disorders

Background

Tobacco smoking is considered currently a global public health concern among youth especially school students. There is a scarcity of data about the impact of this global phenomenon in Middle Eastern countries. This study assesses the prevalence of tobacco smoking, including conventional cigarettes, E-cigarettes, and water pipe and its sociodemographic and psychiatric correlates among a sample of general secondary school students in Cairo, Egypt.

Results

A convenient sample of 391 Egyptian general secondary students from different areas of Greater Cairo were assessed using the Socioeconomic scale, Fagerstrom Test For Nicotine Dependence, The Lebanon Water pipe Dependence Scale, questionnaire for electronic cigarette use, Barratt impulsivity scale 11, and The MINI International Neuropsychiatric Interview for Children and Adolescents. 12.8% (n = 50) were smokers. There is a significant relation between family history of smoking and substance use and smoking and significant relation between smoking, impulsivity, and mood symptoms.

Conclusions

Prevalence of tobacco smoking in Egyptian adolescents was 12.8% with significant relation between smoking and impulsivity and mood symptoms.

Withdrawal Symptoms among Cigarette and Waterpipe Smokers: A Study in Natural Setting

Background:

The rates of tobacco use, including cigarette and waterpipe smoking, are surging in the Eastern Mediterranean region. The use of these products causes nicotine dependence that makes even short-term tobacco abstinence difficult due to aversive symptoms. During the daytime fasting of the month of “Ramadan”, people accept significant disruption in regular activities, including tobacco smoking. Thus, daytime during Ramadan (before sunset) is likely associated with abstinence symptoms emerging among tobacco smokers. We assessed this hypothesis by measuring tobacco/nicotine abstinence symptoms and craving among smokers of cigarettes or waterpipes during Ramadan.

Methods:

A cross-sectional survey-based study was conducted on a convenience sample of adults. Participants were assessed for general information about tobacco smoking, dependence, and nicotine desire or craving, and withdrawal symptoms using the Minnesota Nicotine Withdrawal Scale (MNWS) and the Tiffany-Drobes Questionnaire on Smoking Urges.

Results:

The study sample included 632 exclusive cigarette smokers and 161 exclusive waterpipe tobacco smokers. After fasting and abstaining from tobacco during the day, approximately 75% of cigarette smokers and 20% of waterpipe smokers reported smoking within the first 30 minutes. In addition, 10% of cigarette smokers and 30% of waterpipe smokers reported smoking within the first 60 minutes. Regarding smoking urge, no significant difference was found between cigarette and waterpipe smokers. For nicotine craving and withdrawal, significant differences between cigarette and waterpipe smokers were found when comparing mean scores for each of the following items: (i) urge to smoke, (ii) craving nicotine, (iii) hunger, (iv) desire for sweets, and (v) depression/feeling blue (P-values < 0.05).

Conclusion:

This study provided evidence from the month of Ramadan that waterpipe smoking is associated with abstinence-induced smoking urge and withdrawal symptoms that are comparable to cigarette smoking. More interdisciplinary research must be focused on developing interventions to reduce tobacco smoking, including waterpipe.

Epidemiology of type 2 diabetes in the Middle East and North Africa: Challenges and call for action

Type 2 diabetes continues to be a serious and highly prevalent public health problem worldwide. In 2019, the highest prevalence of diabetes in the world at 12.2%, with its associated morbidity and mortality, was found in the Middle East and North Africa region. In addition to a genetic predisposition in its population, evidence suggests that obesity, physical inactivity, urbanization, and poor nutritional habits have contributed to the high prevalence of diabetes and prediabetes in the region. These risk factors have also led to an earlier onset of type 2 diabetes among children and adolescents, negatively affecting the productive years of the youth and their quality of life. Furthermore, efforts to control the rising prevalence of diabetes and its complications have been challenged and complicated by the political instability and armed conflict in some countries of the region and the recent coronavirus disease 2019. Broad strategies, coupled with targeted interventions at the regional, national, and community levels are needed to address and curb the spread of this public health crisis.

Chronic Inflammation and Cancer: The Role of Endothelial Dysfunction and Vascular Inflammation

Long-lasting subclinical inflammation is associated with a wide range of human diseases, particularly at a middle and older age. Recent reports showed that there is a direct causal link between inflammation and cancer development, as several cancers were found to be associated with chronic inflammatory conditions. In patients with cancer, healthy endothelial cells regulate vascular homeostasis, and it is believed that they can limit tumor growth, invasiveness, and metastasis. Conversely, dysfunctional endothelial cells that have been exposed to the inflammatory tumor microenvironment can support cancer progression and metastasis. Dysfunctional endothelial cells can exert these effects via diverse mechanisms, including dysregulated adhesion, permeability, and activation of NF-κB and STAT3 signaling. In this review, we highlight the role of vascular inflammation in predisposition to cancer within the context of two common disease risk factors: obesity and smoking. In addition, we discuss the molecular triggers, pathophysiological mechanisms, and the biological consequences of vascular inflammation during cancer development and metastasis. Finally, we summarize the current therapies and pharmacological agents that target vascular inflammation and endothelial dysfunction.

Trends of maternal waterpipe, cigarettes, and dual tobacco smoking in Jordan. A decade of lost opportunities

Background

Maternal tobacco use is a global public health problem. In the literature, the focus was mainly on cigarette smoking, minimally on waterpipe use, and totally ignored dual use among pregnant women. We estimated the prevalence of current maternal tobacco use by tobacco product (cigarette, waterpipe, and dual use) over a period of ten years (2007 to 2017), and examined the socio-demographic patterning of maternal tobacco use.

Methods

A secondary analysis of Jordan DHS four data waves was conducted for women who reported to be pregnant at the time of the survey. Current cigarette and waterpipe tobacco use were investigated. Prevalence estimates for cigarette-only, waterpipe-only, and dual use, as well as for cigarette, regardless of waterpipe, and waterpipe, regardless of cigarette, were reported. The effect of independent variables on cigarette smoking, waterpipe use, and dual use was assessed. Logistic regression models assessed the adjusted effects of socio-demographic variables on cigarette smoking, waterpipe use, and on dual use. For each outcome variable, a time-adjusted and a time-unadjusted logistic models were conducted.

Results

Over the last decade, the prevalence estimates of current cigarette-only smoking slightly decreased. The prevalence estimates of current waterpipe-only use exceeded those for cigarette-only after 2007 and showed a steady overall increase. Current dual use showed a continuous rise especially after 2009. Gradual increase in cigarette smoking (4.1%, in 2007, and 5.7% in 2017) and in waterpipe use (2.5% to 6.4%) were detected. Education showed an inverse relationship with cigarette and waterpipe smoking. Household wealth demonstrated a positive association with cigarette and waterpipe smoking.

Conclusions

Tobacco use epidemic is expanding its roots among pregnant women in Jordan through not only waterpipe use but also dual cigarette–waterpipe smoking. Maternal and child services should consider tobacco counseling and cessation.

Novel Insights into Young Adults' Perceived Effectiveness of Waterpipe Tobacco-Specific Pictorial Health Warning Labels in Lebanon: Implications for Tobacco Control Policy

This study aims to explore the perceived effectiveness of waterpipe (WP) tobacco specific health warning labels (HWLs) among young adult WP smokers and nonsmokers in Lebanon. Before participating in focus group discussions, participants (n = 66; WP smokers n = 30; nonsmokers n = 36; age 18-33) completed a brief survey to rate the effectiveness of 12 HWLs' and rank them according to four risk themes (WP health effects, WP harm to others, WP-specific harm, and WP harm compared to cigarettes). Differences in HWLs ratings by WP smoking status were examined and the top-ranked HWL in each theme were identified. HWLs depicting mouth cancer and harm to babies were rated as the most effective by both WP smokers and non-smokers. WP smokers rated HWLs which depicted harm to children and infants as more effective than non-smokers. The top-ranked HWLs for perceived overall effectiveness were those depicting "oral cancer", "harm to babies", "orally transmitted diseases" and "mouth cancer". HWLs depicting oral lesions and harm to babies were rated as most effective, while HWLs showing the harmful effects of WP secondhand smoke on infants and children were rated as less effective by nonsmokers compared to smokers. Our study provides evidence on the potential effectiveness of HWLs for further evaluation in Lebanon and the Eastern Mediterranean region. The results will inform and guide the development and implementation of tobacco control policy.

Implementation of tobacco control measures in the Gulf Cooperation Council countries, 2008-2020

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed to assist nations in reducing the demand and supply of tobacco. As of 2020, 182 nations joined the FCTC, agreeing to implement the recommended tobacco control measures. The Gulf Cooperation Council (GCC) countries, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE) ratified the WHO FCTC by August 2006. Given the unique political, cultural, and religious context - and known tobacco industry efforts to influence tobacco use- in these nations, a careful examination of the translation of FCTC measures into policy is needed. This study aimed to assess the implementation of FCTC tobacco control measures at the national level within the six GCC countries.

METHOD

We collected and coded the FCTC measures that were implemented in the GCC countries. We examined trends and variations of the implementation between 2008 and 2020.

RESULTS

GCC countries implemented most FCTC measures targeting the demand for and supply of tobacco, with some variation among countries. Bahrain and Qatar were more comprehensively implementing FCTC measures while Kuwait and Oman implemented the least number of the FCTC measures. Implementing measures related to tobacco prices and eliminating the illicit tobacco trade has slowly progressed in GCC countries. All GCC countries entirely banned smoking in workplaces while three countries implemented a partial ban in restaurants. Only Oman has restrictions on tobacco ads shown in media. There is progress in implementing FCTC measures related to tobacco packaging, cessation, and sale to minors in most GCC countries.

CONCLUSIONS

Given the influence of the tobacco industry in the Gulf region, the findings suggest a need for ongoing surveillance to monitor the proliferation of tobacco control measures and evaluate their effectiveness. Efforts required to address tobacco use should correspond to the unique political and cultural background of the GCC countries.

The association between migration and smoke-free families: how do migrants from different world regions compare?

BACKGROUND

Studies on adolescent secondhand smoke exposure within the family often dichotomously operationalize migration background without paying attention to social and cultural diversity within migrant populations. As a result, little is known about variation within migrant groups in smoke-free family environments (SFFEs). This study analyses the association between SFFEs and parental migration from different world regions.

METHODS

Data from 14- to 16-year-old adolescents (N = 17 144) on SFFEs and parental migration were obtained from cross-sectional repeated SILNE-R surveys. A multivariable multinomial regression was applied, presenting relative risks (RRs) with 95% confidence intervals (CIs) for maternal or paternal tobacco smoking and home smoking bans. Variation in migration background was measured according to parental sex and place of birth.

RESULTS

Approximately 18% of adolescents are exposed to maternal smoking, and 25% are exposed to paternal smoking. Almost half of the respondents do not live in SFFEs but are subject to permissive (5%) or partial (39%) smoking bans at home. We found that adolescents of Eastern European descent are at a higher risk of being exposed to both paternal and maternal smoking. A sex difference in parental smoking was found among Arabic/Islamic migrants, where mothers are less likely to be smokers. Maternal and paternal African origins are associated with prohibitive smoking bans at home. Eastern European mothers show higher odds of permissiveness and freely allowing smoking at home.

CONCLUSION

Notable within-differences according to parental sex and place of birth were found for SFFEs and should be taken into account when implementing equity-sensitive tobacco prevention programs.

Tobacco Research in the Eastern Mediterranean Region: A Scoping Review of Published Studies from Seven Countries

While surveillance on a global scale has been showing a decline in tobacco smoking in the past decade, rates in the Eastern Mediterranean Region (EMR) remained stable with some countries showing rising trends. This study aimed to analyze the landscape of tobacco research in the EMR, present data on publication trends, and identify research gaps and opportunities to guide future tobacco research in the region. We conducted a scoping review of tobacco research in seven countries from January 2000 to December 2013. Three hundred and forty eight studies were identified, the majority of which were published in international journals and in English language. There was an increase in publications over time, with a significant positive linear trend (p = 0.03). Descriptive cross-sectional and case-control studies were the most common study designs (67.0%), and only 8% were longitudinal studies. Papers that reported, in part or solely, on waterpipe tobacco smoking (WTS) constituted 25.6% of the total publication pool. Tobacco consumption was treated as an exposure variable in half of the papers and mostly in relation to cancer and cardiovascular diseases, as an outcome measure in 37.7%, and as a confounding variable in 14.7% of the papers. Studies that examined associations of tobacco with other behaviors (5.3%) were lacking. The scarcity of high-evidence tobacco research in the EMR, together with the relatively deficient data on WTS and associations with other factors warrant the need for discussions on research priority setting and guidance on funding allocations in the region.

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design

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.

Health-Risk Behaviors and Dietary Patterns Among Jordanian College Students: A Pilot Study

Background/Aims: Health promotion and the incorporation of health-protective behaviors in people's lifestyles have a great role in enhancing individuals' overall health and well-being. College students are at increased risk of developing unhealthy dietary and lifestyle behaviors. A cross-sectional pilot study was conducted to assess the health-risk behaviors among undergraduate college students at Jordan University of Science and Technology. Methods: The final sample included 136 students, with a mean age of 21.1 ± 2.37 years, mostly females (69%). A self-reported questionnaire was used for data collection about dietary and lifestyle behaviors among college students. The questionnaire consisted of four parts: sociodemographic characteristics, body weight classifications, lifestyle behaviors, and dietary patterns and intake, and eating behaviors. Results: Most of the students did not meet the daily recommendations for fruit (76%) and vegetable (82%) intake. Males were significantly consuming fast food more frequently (p = 0.019), and smoked cigarettes (p < 0.001) or hookah (p = 0.015) more frequently than did females. Further, the majority met the recommendations for physical activity (81%), but exceeded recommendations for sedentary behavior. Females were more likely to have normal weight or be underweight (OR = 4.865), to have a fear of weight gain (OR = 3.387), and to have the recommended sleeping hours (OR = 7.685) than were males. Conclusion: The results indicate the health-risk behaviors and the gender-related differences among college students.

Child maltreatment and neglect in the United Arab Emirates and relationship with low self-esteem and symptoms of depression

OBJECTIVES

To our knowledge, this study is the first in the United Arab Emirates (UAE) to investigate the prevalence of child maltreatment in relation to depressive symptoms and self-esteem.

STUDY DESIGN

Exposure to physical maltreatment, emotional abuse and neglect was evaluated in 518 adolescents (86% response rate) randomly selected from schools in Al Ain in the Emirate of Abu Dhabi. The Rosenberg self-esteem scale and the Beck Depression Inventory were used to measure self-esteem and depressive symptoms by using multivariate logistic regression analyses.

RESULTS

The mean age of study participants was 14.3 years. Emotional abuse was the most frequent form of maltreatment (33.9%), physical abuse (12.6%) and neglect (12.1%) followed. Male sex was a positive predictor of physical abuse (OR = 2.12; 95% CI 1.18-3.77), whilst higher maternal level of education was protective (OR = 0.40; 95% CI 0.19-0.86). Daily screen time (OR = 2.77; 95% CI 1.17-6.56) and tobacco smoking (OR = 1.86; 95% CI 1.09-3.18) positively predicted emotional abuse. Emotionally maltreated and neglected participants were less likely to report high level of self-esteem and more likely to report symptoms of depression.

CONCLUSIONS

Child maltreatment in the UAE is of a similar magnitude to what reported in other countries around the world and significantly associated with low self-esteem and depressive symptoms.

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework

BACKGROUND

In response to the rising global NCD burden, humanitarian actors have rapidly scaled-up NCD services in crisis-affected low-and-middle income countries. Using the RE-AIM implementation framework, we evaluated a multidisciplinary, primary level model of NCD care for Syrian refugees and vulnerable Jordanians delivered by MSF in Irbid, Jordan. We examined the programme's Reach, Effectiveness, Adoption and acceptance, Implementation and Maintenance over time.

METHODS

This mixed methods retrospective evaluation, undertaken in 2017, comprised secondary analysis of pre-existing cross-sectional household survey data; analysis of routine cohort data from 2014 to 2017; descriptive costing analysis of total annual, per-patient and per-consultation costs for 2015-2017 from the provider-perspective; a clinical audit; a medication adherence survey; and qualitative research involving thematic analysis of individual interviews and focus group discussions.

RESULTS

The programme enrolled 23% of Syrian adult refugees with NCDs in Irbid governorate. The cohort mean age was 54.7 years; 71% had multi-morbidity and 9.9% self-reported a disability. The programme was acceptable to patients, staff and stakeholders. Blood pressure and glycaemic control improved as the programme matured and by 6.6 mmHg and 1.12 mmol/l respectively within 6 months of patient enrolment. Per patient per year cost increased 23% from INT$ 1424 (2015) to 1751 (2016), and by 9% to 1904 (2017). Cost per consultation increased from INT$ 209 to 253 (2015-2017). Staff reported that clinical guidelines were usable and patients' self-reported medication adherence was high. Individual, programmatic and organisational challenges to programme implementation and maintenance included the impact of war and the refugee experience on Syrian refugees' ability to engage; inadequate low-cost referral options; and challenges for MSF to rapidly adapt to operating in a highly regulated and complex health system. Essential programme adaptations included refinement of health education, development of mental health and psychosocial services and addition of essential referral pathways, home visit, physiotherapy and social worker services.

CONCLUSION

RE-AIM proved a valuable tool in evaluating a complex intervention in a protracted humanitarian crisis setting. This multidisciplinary programme was largely acceptable, achieving good clinical outcomes, but for a limited number of patients and at relatively high cost. We propose that model simplification, adapted procurement practices and use of technology could improve cost effectiveness without reducing acceptability, and may facilitate replication.

Epidemiology of tobacco use in Qatar: Prevalence and its associated factors

Tobacco use is a serious public health concern as it causes various deleterious health problems. The aim of this study was to determine the prevalence of tobacco use and various types of tobacco used among a population-based sample of adults 18 years and above in Qatar (residents and expatriates). The study also attempted to assess tobacco use initiation age, tobacco dependency, and to identify factors associated with current tobacco use. This 2019 cross-sectional study was conducted among governmental employees and University students in Qatar using cluster sampling methodology. Study participants completed a self-administered, country-adapted summarized version of the Global Adult Tobacco Survey. 25.2% (n = 1741; N = 6904) of the surveyed sample reported current tobacco use. 21.5% (n = 1481) smoked tobacco (cigarettes, waterpipe, medwakh and cigar) concomitant with other forms of tobacco and only 1.0% (n = 69) were using other forms of tobacco (electronic cigarettes, smokeless tobacco and heat-not-burn tobacco products) and 2.7% (n = 191) did not mention the type of tobacco products used by them. Of the 1550 tobacco users, 42.8% were cigarette smokers, 20.9% waterpipe, 3.2% medwakh (Arabic traditional pipe) and 0.7% cigar. Moreover, 1.9% reported smokeless tobacco use (sweika), 2.0% electronic cigarette use, and 0.3% heat-not-burn tobacco use. The mean age for smoking initiation was 19.7±5.3 (Qataris 18.6±4.8 and non-Qataris 20.3±5.6). Using multivariable logistic regression, significant association was observed between tobacco use and gender, nationality, age, monthly income, living with a smoker, and self-rated health. This large population-based cross-sectional survey provides the first evidence for the prevalence of different types of tobacco use including medwakh smoking among adults (Qataris and non-Qataris) 18 years and above in Qatar. This can serve as a baseline for future research studies on the topic. Based on the review of previous and current tobacco survey findings, it is evident that the prevalence of tobacco use (current) in Qatar has declined suggesting that tobacco control measures implemented by the country have been effective in reducing tobacco consumption.

Preventing and controlling water pipe smoking: a systematic review of management interventions

BACKGROUND

Water pipe smoking (WPS) is re-gaining widespread use and popularity among various groups of people, especially adolescents. Despite different adverse health effects of WPS, many of the WPS interventions have failed to control this type of tobacco smoking. This study was conducted to identify experienced management interventions in preventing and controlling WPS worldwide.

METHODS

A systematic literature review was conducted. Electronic databases were searched for recordes which were published from beginning 1990 to August 2018. Studies aiming at evaluating, at least, one intervention in preventing and controlling WPS were included in this review, followed by performing the quality assessment and data extraction of eligible studies by two independent investigators. Finally, interventions that were identified from the content analysis process were discussed and classified into relevant categories.

RESULTS

After deleting duplications, 2228 out of 4343 retrieved records remained and 38 studies were selected as the main corpus of the present study. Then, the identified 27 interventions were grouped into four main categories including preventive (5, 18.51%) and control (8, 29.62%) interventions, as well as the enactment and implementation of legislations and policies for controlling WPS at national (7, 25.92%) and international (7, 25.92%) levels.

CONCLUSION

The current enforced legislations for preventing and controlling WPS are not supported by rigorous evidence. Informed school-based interventions, especially among adolescents can lead to promising results in preventing and controlling WPS and decreasing the effects of this important social and health crisis in the global arena.

Examining Trends of Cigarette Smoking Amongst Syrian Refugees During Their First Two Years in Canada

This brief report explored trends of cigarette smoking among Syrian newcomers in the first two years of resettlement in Canada. 1794 adult Syrian refugees were surveyed about their physical and mental health, and smoking behaviours. Results were analyzed using descriptive statistics, Wilcoxon signed-rank tests, and logistic regressions. Almost 27% of the sample reported cigarette smoking (50% light smokers and 50% moderate/heavy smokers). Light smokers increased and moderate/heavy smokers decreased in the number of cigarettes smoked from year 1 to year 2. Moderate/heavy smokers were more likely to be male and reported higher post-traumatic stress scores, while light smokers reported higher depression scores. Only 14.3% of smokers recalled receiving advice from health care providers in Canada regarding their smoking habits. Healthcare providers should provide tailored advice to everyone who is an active smoker with a specific emphasis on those who have concurrent health issues.

The impact of smoking different tobacco types on the subgingival microbiome and periodontal health: a pilot study

Smoking is a risk factor for periodontal disease, and a cause of oral microbiome dysbiosis. While this has been evaluated for traditional cigarette smoking, there is limited research on the effect of other tobacco types on the oral microbiome. This study investigates subgingival microbiome composition in smokers of different tobacco types and their effect on periodontal health. Subgingival plaques were collected from 40 individuals, including smokers of either cigarettes, medwakh, or shisha, and non-smokers seeking dental treatment at the University Dental Hospital in Sharjah, United Arab Emirates. The entire (~ 1500 bp) 16S rRNA bacterial gene was fully amplified and sequenced using Oxford Nanopore technology. Subjects were compared for the relative abundance and diversity of subgingival microbiota, considering smoking and periodontal condition. The relative abundances of several pathogens were significantly higher among smokers, such as Prevotella denticola and Treponema sp. OMZ 838 in medwakh smokers, Streptococcus mutans and Veillonella dispar in cigarette smokers, Streptococcus sanguinis and Tannerella forsythia in shisha smokers. Subgingival microbiome of smokers was altered even in subjects with no or mild periodontitis, probably making them more prone to severe periodontal diseases. Microbiome profiling can be a useful tool for periodontal risk assessment. Further studies are recommended to investigate the impact of tobacco cessation on periodontal disease progression and oral microbiome.

Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting

BACKGROUND

Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon.

METHODS

Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs.

RESULTS

Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities.

CONCLUSION

Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tobacco cessation experiences and needs: perspectives from Arabic-speaking communities

Use of tobacco products is higher in Arabic-speaking communities in Australia, compared to other populations. 70 persons identifying as being from Arabic-speaking communities in Western Sydney participated in focus group discussions to explore experiences and needs relating to tobacco, alcohol and other drug treatment. Tobacco was rated as the substance of highest concern in this sample, however a pattern of change was observed. Widespread cigarette use supported by gendered norms that particularly encouraged smoking among men was shifting, with some decline in the social acceptability of cigarette smoking linked to experience of health impacts and the financial cost to families. In contrast, waterpipe tobacco smoking was described as a common and acceptable practice across age and gender cohorts, despite some participants challenging the cultural and health rationales of this practice. Preventing tobacco-related harm among younger populations was highly valued among study participants, drawing on strong support for families as key influencer of health behaviors. Cessation strategies viewed as effective among community members spoken with commonly centered upon the notion of individual willpower, and appreciated the disincentivising impacts of high taxation on cigarettes. This study prioritizes community-informed perspectives for reducing tobacco related harms amongst Arabic-speaking populations in Australia and offers direction to health promoters, public health workers and policymakers. Results indicate opportunities exist to improve tobacco control outcomes through strategies that align prevention and treatment options with relevant community beliefs and norms, and build on existing harm reduction behaviors and support seeking behaviors.

Water-Pipe Smoking Exposure Deregulates a Set of Genes Associated with Human Head and Neck Cancer Development and Prognosis

Water-pipe smoking (WPS) is becoming the most popular form of tobacco use among the youth, especially in the Middle East, replacing cigarettes rapidly and becoming a major risk of tobacco addiction worldwide. Smoke from WPS contains similar toxins as those present in cigarette smoke and is linked directly with different types of cancers including lung and head and neck (HN) carcinomas. However, the underlying molecular pathways and/or target genes responsible for the carcinogenic process are still unknown. In this study, human normal oral epithelial (HNOE) cells, NanoString PanCancer Pathways panel of 770 gene transcripts and quantitative real-time polymerase chain reaction (qRT-PCR) analysis were applied to discover differentially expressed genes (DEG) modulated by WPS. In silico analysis was performed to analyze the impact of these genes in HN cancer patient’s biology and outcome. We found that WPS can induce the epithelial–mesenchymal transition (EMT: hallmark of cancer progression) of HNOE cells. More significantly, our analysis of NanoString revealed 23 genes deregulated under the effect of WPS, responsible for the modulation of cell cycle, proliferation, migration/invasion, apoptosis, signal transduction, and inflammatory response. Further analysis was performed using qRT-PCR of HNOE WPS-exposed and unexposed cells supported the reliability of our NanoString data. Moreover, we demonstrate those DEG to be upregulated in cancer compared with normal tissue. Using the Kaplan–Meier analysis, we observed a significant association between WPS-deregulated genes and relapse-free survival/overall survival in HN cancer patients. Our findings imply that WPS can modulate EMT as well as a set of genes that are directly involved in human HN carcinogenesis, thereby affecting HN cancer patients’ survival.

Trauma exposure, mental health and tobacco use among vulnerable Syrian refugee youth in Jordan

BACKGROUND

Little is known about tobacco use among youth exposed to armed conflicts, or the influence of trauma on tobacco use in this context. This study examined patterns of smoking by tobacco product and gender among Syrian refugee youth living in host communities in Jordan and assessed the associations of post-traumatic stress disorder (PTSD) and depression symptoms, trauma exposure and social support with current smoking status in boys and girls.

METHODS

Syrian refugee students (mean [standard deviation] age = 14.9 [1.33] years) were identified through the public school system. Data were collected using an online Arabic questionnaire that included questions about demographics, trauma exposure, current smoking (cigarette and waterpipe), PTSD, depression and perceived social support. Logistic regression was used to assess the adjusted effects of independent variables on current smoking status.

RESULTS

One in 7 boys and one in 14 girls were current smokers, with boys reporting greater tobacco use than girls. Among boys, current smokers reported significantly higher family member loss and lower perceived family social support than nonsmokers; among girls, current smokers also reported significantly higher family member loss as well as greater PTSD symptoms and lower perceived significant other/special person social support.

CONCLUSIONS

Tobacco use is established among this vulnerable group. The findings highlight the potential role of psychosocial support for tobacco prevention and cessation strategies.