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Zarate-Gonzalez G, Brown P, Cameron LD, Song AV. Will tobacco price increases lead more people who smoke to vape? The results from a discrete choice experiment amongst U.S. adults. BMC Public Health 2023; 23:2296. [PMID: 37986072 PMCID: PMC10662298 DOI: 10.1186/s12889-023-17094-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE To understand the extent to which people who smoke, people who vape and nonsmokers would switch between smoking cigarettes and vaping in response to policies (price increases, restrictions on nicotine, places, and information on addictiveness and/or health risks) aimed at decreasing tobacco use by people who smoke and vaping by nonsmokers. DESIGN A total of 525 adults aged 18 to 88 years completed a discrete choice survey of 16 choices between two smoking/vaping alternatives. Analysis was conducted using conditional logistic regression for the entire sample and stratified by nonsmokers, people who smoke, and people who vape. RESULTS The results suggest that most people who vape also smoke. Nonsmokers were more favorable to vaping and were concerned about long-term health risks and cost associated with vaping. Marginal analysis suggests that price increases will have only modest success in moving people who smoke to start vaping or encouraging people who vape to vape rather than use cigarettes. Nonsmokers are not very sensitive to price changes but are sensitive to information about health impacts. CONCLUSIONS Findings indicate that increasing the price of cigarettes would lead to a limited increase in the probability of people who smoke switch to vaping. The study advances our understanding of the views of current nonsmokers toward cigarettes and vaping, suggesting that price increases and increased knowledge of addiction would likely deter nonsmokers from vaping. Changing the amount of nicotine associated with smoking would increase the probability of vaping slightly and have little impact on nonsmokers or vaping preferences, but the most significant change would come from increasing the perceptions of the risk of smoking.
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Affiliation(s)
| | - Paul Brown
- University of California, Merced 5200 North Lake Rd., Merced, CA, 95343, USA
| | - Linda D Cameron
- University of California, Merced 5200 North Lake Rd., Merced, CA, 95343, USA
| | - Anna V Song
- University of California, Merced 5200 North Lake Rd., Merced, CA, 95343, USA
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2
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Khorasani A, Chadi N. The tobacco-free fallacy: What paediatricians should know about herbal smoking products. Paediatr Child Health 2023; 28:141-144. [PMID: 37205137 PMCID: PMC10186095 DOI: 10.1093/pch/pxac096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/16/2022] [Indexed: 09/23/2023] Open
Abstract
While e-cigarette and combustible cigarette use remains more common among youth, herbal smoking products are gaining interest and popularity among children and adolescents. Herbal smoking products are often touted as a safer alternative to tobacco smoking or nicotine vaping; however, research suggests that they emit significant levels of toxicants and carcinogens posing risks to child and adolescent health. The low perceived risk coupled with youth-friendly flavours and easy access may entice youth to use herbal smoking products and increase the risk of subsequent tobacco and substance use. We discuss what is known about the use, health effects, and regulations of herbal smoking products and present strategies for policymakers and paediatric providers to reduce the risks associated with these products for Canadian youth.
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Affiliation(s)
- Arianne Khorasani
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Nicholas Chadi
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
- Division of Adolescent Medicine, Department of Paediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
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Saad RK, Maiteh A, Nakkash R, Salloum RG, Chalak A, Abu-Rmeileh NME, Khader Y, Al Nsour M. Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation. JMIR Public Health Surveill 2023; 9:e40177. [PMID: 36951907 PMCID: PMC10132023 DOI: 10.2196/40177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
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.
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Affiliation(s)
- Randa K Saad
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
| | - Adna Maiteh
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, United States
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Florida, FL, United States
| | - Ali Chalak
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territory
| | - Yousef Khader
- Public Health, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohannad Al Nsour
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
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Fishe JN, Smotherman C, Burcham S, Martin-Gill C, Richards CT, Powell JR, Panchal AR, Salloum RG. Measuring the Implementation Preferences of Emergency Medical Services Clinicians Using Discrete Choice Experiments. PREHOSP EMERG CARE 2023; 28:381-389. [PMID: 36763470 PMCID: PMC10471772 DOI: 10.1080/10903127.2023.2177365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/17/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences. METHODS This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences. RESULTS A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents' preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2%-77.1%) preferred their survey DCE choice to their agency's current implementation practices. In the rank order preferences, most participants selected "knowledge of the underlying evidence behind the change" as the most important component of the process of implementation. CONCLUSIONS In this study of EMS clinicians' implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.
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Affiliation(s)
- Jennifer N Fishe
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Prehospital Guidelines Consortium, Atlanta, Georgia
| | - Carmen Smotherman
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Shannon Burcham
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
| | - Christian Martin-Gill
- Prehospital Guidelines Consortium, Atlanta, Georgia
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher T Richards
- Prehospital Guidelines Consortium, Atlanta, Georgia
- Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Jonathan R Powell
- National Registry of Emergency Medical Technicians, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ashish R Panchal
- Prehospital Guidelines Consortium, Atlanta, Georgia
- National Registry of Emergency Medical Technicians, Columbus, Ohio
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
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Chalak A, Nakkash R, Abu-Rmeileh NME, Khader YS, Jawad M, Mostafa A, Abla R, Louviere J, Salloum RG. Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment. Tob Control 2023; 32:86-92. [PMID: 34193608 PMCID: PMC9763177 DOI: 10.1136/tobaccocontrol-2021-056616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine. METHODS A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption. RESULTS The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers. CONCLUSIONS These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.
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Affiliation(s)
- Ali Chalak
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Yousef S Khader
- Department of Community Medicine, Public Health and Family Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammed Jawad
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ruba Abla
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Ramzi G Salloum
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon,Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
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Discussion of waterpipe tobacco smoking on reddit. Heliyon 2022; 8:e10635. [PMID: 36177232 PMCID: PMC9513777 DOI: 10.1016/j.heliyon.2022.e10635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aimed to examine public discussions of waterpipe tobacco smoking, as well as the potential associations of different waterpipe flavors with health symptoms, using Reddit data. Study design This is an observational infodemiology study. Methods Using keywords such as “waterpipe”, “hookah”, and “shisha”, Reddit posts were extracted from Reddit Archive (pushshift.io) between February 1, 2016, and December 31, 2020. Temporal analysis was used to understand the longitudinal trend of the discussions about waterpipe tobacco smoking. Topic modeling using the Latent Dirichlet Allocation (LDA) model was performed to examine the topics on waterpipe tobacco. We estimated the conditional probability of having each health problem for each given waterpipe flavor. Results The discussion of waterpipe on Reddit was slowly decreasing from 2016 to 2018 and surged until May 2020. The fruit was the most popular waterpipe flavor and the neurological symptom was the most mentioned health category in waterpipe-related Reddit posts. The most popular topics included “Friends spending time together at night with waterpipe smoking”, “Playing games and smoking waterpipe at a hookah bar”, and “Discussing waterpipe flavors and related products”. Some waterpipe flavors were more associated with certain health problems than others. For example, mint/menthol flavor had a high probability to be associated with symptoms related to throat and mouth. Conclusion This study provided longitudinal surveillance of waterpipe tobacco smoking discussed on Reddit. We showed the potential relationship between waterpipe flavors and health symptoms, which provides preliminary evidence about the potential health effects of waterpipe tobacco smoking.
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Kidanu AW, Shi R, Cruz-Cano R, Feldman RH, Butler J, Dyer TV, Fryer CS, Varshney A, Lee E, Clark PI. Visual Attention to Health Warning Labels on Waterpipe Venue Menus in Immersive Virtual Reality. Nicotine Tob Res 2022; 24:1469-1477. [PMID: 35135010 PMCID: PMC9356687 DOI: 10.1093/ntr/ntac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/13/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. AIMS AND METHODS A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. RESULTS Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. CONCLUSIONS The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. IMPLICATIONS The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.
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Affiliation(s)
- Azieb W Kidanu
- Corresponding Author: Azieb W. Kidanu, PhD, CHES, School of Public Health, University of Maryland, College Park, MD 20742, USA. Telephone: 301-405-8740; E-mail:
| | - Rui Shi
- College of Communication and Creative Arts, Rowan University, Glassboro, NJ, USA
| | - Raul Cruz-Cano
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Robert H Feldman
- School of Public Health, University of Maryland, College Park, MD, USA
| | - James Butler
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Typhanye V Dyer
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Craig S Fryer
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Amitabh Varshney
- College of Mathematics and Natural Sciences, University of Maryland, College Park, MD, USA
| | - Eric Lee
- University of Maryland Institute for Advanced Computer Studies, College Park, MD, USA
| | - Pamela I Clark
- School of Public Health, University of Maryland, College Park, MD, USA
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Secondhand smoke exposure from the indoor and outdoor shisha centers located at the perimeter of educational institutions in Malaysia: a cross-sectional study. J Public Health Policy 2022; 43:77-88. [PMID: 35058568 PMCID: PMC8776358 DOI: 10.1057/s41271-021-00329-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 11/21/2022]
Abstract
Shisha is a centuries-old traditional smoking habit rapidly gaining popularity among the students and young adults in Malaysia. The present study evaluated secondhand smoke exposure (SHS) and characteristics of 25 indoor and 25 outdoor shisha centers (SC) operating around the educational institutes such as universities in Petaling Jaya, Malaysia. We observed a significantly higher particulate matter (PM)2.5 concentration in indoor than outdoor SC (3595.28 μg/m3 and 65.12 μg/m3, p < 0.001, respectively). SCs are offering different flavors to attract clients and exposing students and young professionals to a significantly high concentration of SHS. Such exposures may pose a serious health risk. Therefore, policymakers need to strengthen tobacco guidelines and eliminate loopholes in the sale of shisha by enforcing comprehensive and strict smoke-free laws.
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Al-Delaimy AK, Al-Ani WAT. Prevalence of hookah smoking and associated factors among male high school students in Iraq. BMC Public Health 2021; 21:1317. [PMID: 34225683 PMCID: PMC8256481 DOI: 10.1186/s12889-021-11386-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region. Hookah users are exposed to an array of chemical compounds and may suffer several chronic diseases as a result. The purpose of this study was to determine the prevalence of hookah use among male high school students in the region and to study different associated factors in order to provide local tobacco control officials with an understanding of this public health problem. METHODS A convenient non-probability sampling study was conducted among students in three high schools in Al-Karkh district, Baghdad. The study period was from October 2017 till January 2019 and included 847 male students aged 15-18 years old. Using a simple random technique to select the high schools from a list of schools we chose one school from each directorate. Descriptive, chi-square test of significance, bivariate, and multivariate logistic regression analyses of data were carried out for identifying the risk factors associated with hookah smoking among these high school adolescent males. RESULTS The overall prevalence of hookah smoking in the last 30 days among male high school students was 46.1% while in the past 6 months it was as high as 85.7%. More than two-thirds (70.6%) of the students thought that hookah smoking was more socially acceptable than cigarette smoking. Factors such as having first heard about it from friends, the media, or the presence of a hookah café near their residence were significantly associated (p > 0.05) with hookah smoking among the students. Similarly, being surrounded by friends who used hookah was also found to be significantly associated with hookah smoking, with an odds ratio of 0.18, 95% CI (0.087-0.394). Hookah smokers were less likely than non-hookah smokers to report its use as forbidden in Islam and more likely to say it is allowed in Islam. CONCLUSIONS We found an alarmingly high use of hookah smoking among male high school students in this study. Family members and peers had an important role in the prevention of hookah smoking among these students. There is a need for students to be educated about the toxicity of hookah tobacco smoking and its direct effect on their health.
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Affiliation(s)
- Ahmed K Al-Delaimy
- Family & Community Medicine Department / Anbar Medical College, University of Anbar, Ramadi, Iraq.
| | - Waleed A T Al-Ani
- Family & Community Medicine Department Al-Mustansiriya Medical College, University of Al-Mustansiriya, Baghdad, Iraq
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Kidanu AW, Shi R, Cruz-Cano R, Feldman RH, Butler J, Dyer TV, Fryer CS, Clark PI. Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings. HEALTH EDUCATION & BEHAVIOR 2021; 49:618-628. [PMID: 34176309 DOI: 10.1177/10901981211020990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). AIMS The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). METHOD Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors. RESULTS Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. DISCUSSION Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. CONCLUSION The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.
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Affiliation(s)
| | - Rui Shi
- Rowan University, Glassboro, NJ, USA
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Sutfin EL, Lazard AJ, Cornacchione Ross J, Noar SM, Reboussin BA. Waterpipe Tobacco Warnings: An Experimental Study among a Nationally Representative Sample of U.S. Young Adults. Nicotine Tob Res 2021; 23:1855-1860. [PMID: 34077539 DOI: 10.1093/ntr/ntab107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 06/01/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Waterpipe tobacco (WT) smoking by young adults remains high and misperceptions are common. Product warnings can increase knowledge of harms and reduce use. The goal of this study was to test warning statements, including the FDA-required nicotine warning (prior to implementation), on young adults' thinking about harms of and discouragement from WT smoking. METHODS We conducted a between-subjects experiment in a nationally representative telephone survey of 1,152 young adults ages 18-29. Participants were randomly assigned to hear one of five warning statements and reported how much, on a 4-point scale, the warning made them think about the harms and discouraged them from WT smoking. RESULTS The sample was 36.8% female, 57.8% white, 20.2% Black, 24.1% Hispanic, with a mean age of 23.2 (SE=0.25). Under half (43.5%) had ever smoked WT. There were significant differences among the statements on both thinking about harms (p<.0001) and discouragement (p<.0001). The FDA-required 'nicotine' warning led to the lowest thinking about harms (M=2.85, SE=0.08) and was the least discouraging (M=2.86, SE=0.08), while the '100 cigarettes' warning resulted in the greatest thinking about harms (M=3.62, SE=0.05) and was the most discouraging (M=3.56, SE=0.06). CONCLUSION The nicotine warning resulted in the lowest levels of thinking about harms and discouragement from WT smoking, suggesting limited impact. However, a warning focused on comparing smoke inhalation from WT smoking to cigarettes seems promising. Warnings should cover a broad range of WT health effects, and possibly comparisons to cigarettes. Findings also have implications for the content of international waterpipe warnings. IMPLICATIONS This study indicates that the nicotine warning is the least effective at making young adults think about the harms of and discouraging waterpipe tobacco smoking. The FDA and other countries should consider requiring warnings to cover a broader range of health harms, misperceptions, and possibly comparisons to cigarettes.
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Affiliation(s)
- Erin L Sutfin
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Allison J Lazard
- Hussman School of Journalism and Media and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Jennifer Cornacchione Ross
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Seth M Noar
- Hussman School of Journalism and Media and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
| | - Beth A Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC, United States
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Babaie J, Ahmadi A, Abdollahi G, Doshmangir L. Preventing and controlling water pipe smoking: a systematic review of management interventions. BMC Public Health 2021; 21:344. [PMID: 33632181 PMCID: PMC7908788 DOI: 10.1186/s12889-021-10306-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/21/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Javad Babaie
- Department of Health Policy& Management, Tabriz Health Services Management Research Centre, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ayat Ahmadi
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Gholamreza Abdollahi
- Department of Health Policy& Management, Tabriz Health Services Management Research Centre, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Doshmangir
- Department of Health Policy& Management, Tabriz Health Services Management Research Centre, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
- Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Hamadeh RR, Lee J, Abu-Rmeileh NME, Darawad M, Mostafa A, Kheirallah KA, Yusufali A, Thomas J, Salama M, Nakkash R, Salloum RG. Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries. Tob Induc Dis 2020; 18:100. [PMID: 33299390 PMCID: PMC7720794 DOI: 10.18332/tid/129266] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Juhan Lee
- Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, United States
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territories
| | | | - Aya Mostafa
- Department of Community, Environmental and Occupational Medicine, Ain Shams University, Cairo, Egypt
| | - Khalid A Kheirallah
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Justin Thomas
- Department of Psychology, Zayed University, Abu Dhabi, United Arab Emirates
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, The American University in Cairo, New Cairo, Egypt
| | - Rima Nakkash
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, United States
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Chaffee BW, Couch ET, Urata J, Cash D, Werts M, Halpern-Felsher B. Electronic cigarette and moist snuff product characteristics independently associated with youth tobacco product perceptions. Tob Induc Dis 2020; 18:71. [PMID: 32934617 PMCID: PMC7485438 DOI: 10.18332/tid/125513] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Tobacco product characteristics convey product attributes to potential users. This study aimed to assess independent contributions of specific e-cigarette and smokeless tobacco product characteristics to adolescents' perceptions about these products. METHODS In 2019-2020, students (N=1003) attending a convenience sample of 7 high schools in California (USA) were individually randomized to one of two discrete choice experiments, featuring either electronic cigarettes (e-cigarettes) or moist snuff. Participants were presented like-product pairs of randomlygenerated hypothetical tobacco products differing in device type, flavor, vapor cloud, and nicotine amount (for e-cigarettes) or differing in brand, flavor, cut, and price (for moist snuff). Within pairs, participants were asked about which product they were more curious, was more dangerous, would give a greater 'buzz,' and would be easier to use. Conditional logistic regression was used to quantify independent associations of product characteristics to participants' choices. RESULTS Each e-cigarette and moist snuff characteristic was independently associated with multiple product perceptions. All non-tobacco flavors were associated with more curiosity and perceived ease-of-use but lower perceived danger. Tank and pod-type e-cigarettes were viewed as easier to use and garnered more curiosity than 'cigalike' or 'drip-mod' devices. Smaller vapor cloud e-cigarettes and lower-price moist snuff were viewed as less dangerous, less buzz-inducing, and easier to use. Product ever users held stronger perceptions than never users about device type (e-cigarettes) and brands (moist snuff), while product naïve participants more strongly associated flavor with danger and buzz. CONCLUSIONS Tobacco product characteristics convey product attributes to adolescents that may increase appeal. Restricting specific characteristics, including flavors, could reduce positive perceptions of these products among youth.
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Affiliation(s)
- Benjamin W Chaffee
- Division of Oral Epidemiology and Dental Public Health, University of California San Francisco, San Francisco, United States
| | - Elizabeth T Couch
- Division of Oral Epidemiology and Dental Public Health, University of California San Francisco, San Francisco, United States
| | - Janelle Urata
- Division of Oral Epidemiology and Dental Public Health, University of California San Francisco, San Francisco, United States
| | - David Cash
- Division of Adolescent Medicine, Stanford University, Stanford, United States
| | - Miranda Werts
- Division of Oral Epidemiology and Dental Public Health, University of California San Francisco, San Francisco, United States
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Kienhuis AS, Talhout R. Options for waterpipe product regulation: A systematic review on product characteristics that affect attractiveness, addictiveness and toxicity of waterpipe use. Tob Induc Dis 2020; 18:69. [PMID: 32934615 PMCID: PMC7485441 DOI: 10.18332/tid/125079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/05/2020] [Accepted: 07/08/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Despite its known adverse effects on human health, waterpipe smoking is increasing in popularity worldwide. However, compared to cigarettes, regulation of waterpipe product smoking lags behind and presents unique challenges. In search for regulatory options, this systematic review analyzes 36 studies on the differential effects on human health of the waterpipe characteristics including smoking products, heating sources, device components, and packages. METHODS A systematic review was performed according to PRISMA guidelines, revealing 443 unique citations. After screening, 36 studies were included in the results. Research articles were selected to inform on differential effects caused by product characteristics on adverse health effects, attractiveness, addictiveness and prevalence of waterpipe use. RESULTS Flavors are the key aspect that defines attractiveness of waterpipe product smoking. All waterpipe products, with or without nicotine, produce toxicants in similar quantities as cigarettes. Heating sources for waterpipe tobacco include charcoals and electrical heating. Both heating sources increase toxicant emissions in different ways. Hoses and mouth tips are device components that are often shared in waterpipe smoking. Sharing influences attractiveness by enriching the social experience. At the same time, it influences the transfer of infectious diseases by bacteria and viruses from one smoker to another. Studies showed that more generic and less attractive packages with health warnings are effective in reducing the attractiveness of waterpipe smoking. CONCLUSIONS Based on our findings, we advise to include all waterpipe products, tobacco and non-tobacco, with or without nicotine, in tobacco product regulations and smoking bans in order to: ban waterpipe molasses with characterizing flavors or ban the use of flavorings at any level; mandate dissemination of information on all waterpipe tobacco elements to the national regulator; prescribe testing to regulate contents of waterpipe smoking products and heating sources. Moreover, we advise to stimulate research on emissions of waterpipes.
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Affiliation(s)
- Anne S Kienhuis
- Centre for Health Protection, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Reinskje Talhout
- Centre for Health Protection, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Agent-based Modeling in Tobacco Regulatory Science: Exploring 'What if' in Waterpipe Smoking. TOB REGUL SCI 2020; 6:171-178. [PMID: 32582820 DOI: 10.18001/trs.6.3.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives Waterpipe tobacco smoking (WTS) is an emerging public health crisis, particularly among youth and young adults. Different from the use of other tobacco products and e-cigarettes, WTS tends to be a social activity occurring among friends or persons associated with social networks. In this paper, we review a potential strategy for WTS-related research. Methods As a bottom-up computational model, agent-based modeling (ABM) can simulate the actions and interactions of agents, as well as the dynamic interactions between agents and their environments, to gain an understanding of the functioning of a system. ABM is particularly useful for incorporating the influence of social networks in WTS, and capturing people's space-time activity and the spatial distribution of WTS venues. Results Comprehensive knowledge of WTS-related behaviors at the individual level is needed to take advantage of ABM and use it to examine policies such as the interaction between WTS and cigarette smoking and the effect of flavors used in waterpipe tobacco. Longitudinal and WTS-specific surveys and laboratory experiments are particularly helpful to understand WTS basic mechanisms and elicit individual preferences, respectively. Conclusions We argue that the uniqueness of WTS makes ABM a promising tool to be used in WTS-related research, as well as understanding use of other tobacco products.
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Ben Taleb Z, Breland A, Bahelah R, Kalan ME, Vargas-Rivera M, Jaber R, Eissenberg T, Maziak W. Flavored Versus Nonflavored Waterpipe Tobacco: A Comparison of Toxicant Exposure, Puff Topography, Subjective Experiences, and Harm Perceptions. Nicotine Tob Res 2020; 21:1213-1219. [PMID: 29982728 DOI: 10.1093/ntr/nty131] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 07/02/2018] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers' experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers' toxicant exposure, smoking topography, subjective experiences and harm perception. METHODS Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception. RESULTS Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco. CONCLUSIONS Limiting tobacco flavor has a substantial effect on WP smokers' nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth. IMPLICATIONS This study highlights the important role of flavor in shaping WP smokers' experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.
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Affiliation(s)
- Ziyad Ben Taleb
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Alison Breland
- Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, VA
| | - Raed Bahelah
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Mayra Vargas-Rivera
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL
| | - Rana Jaber
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL
| | - Thomas Eissenberg
- Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, VA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL.,Syrian Center for Tobacco Studies, Aleppo, Syria
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Salloum RG, Nakkash R, Abu-Rmeileh NME, Hamadeh RR, Darawad MW, Kheirallah KA, Al-Farsi Y, Yusufali A, Thomas J, Mostafa A, Salama M, El Kadi L, Alzyoud S, Al-Sheyab N, Thrasher JF. Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries. Health Promot Int 2019; 34:1157-1166. [PMID: 30412234 DOI: 10.1093/heapro/day084] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, FL, USA
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020 Beirut, Lebanon
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, PO Box 14, Birzeit, Palestine
| | - Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Road 2904, 293 Manama, Bahrain
| | - Muhammad W Darawad
- School of Nursing, The University of Jordan, Queen Rania Street, 11942 Amman, Jordan
| | - Khalid A Kheirallah
- Department of Public Health, Community Medicine, Jordan University of Science and Technology, PO Box 3030, 22110 Irbid, Jordan
| | - Yahya Al-Farsi
- Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 35, 123, Al Khod, Muscat, Oman
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority and Dubai Medical College, 35th Street, PO Box 2017, Dubai, United Arab Emirates
| | - Justin Thomas
- Department of Psychology, College of Natural and Health Sciences, Zayed University, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Abbassiya, 11566 Cairo, Egypt
| | - Mohamed Salama
- Medical Experimental Research Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Lama El Kadi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, 1107 2020 Beirut, Lebanon
| | - Sukaina Alzyoud
- Department of Community and Mental Health Nursing, Faculty of Nursing, Hashemite University, PO Box 330127, 13133 Zarqa, Jordan
| | - Nihaya Al-Sheyab
- Department of Maternal and Child Nursing, Jordan University of Science and Technology, PO Box 3030, 22110 Irbid, Jordan
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, 29208 Columbia, SC, USA
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Qasim H, Alarabi AB, Alzoubi KH, Karim ZA, Alshbool FZ, Khasawneh FT. The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environ Health Prev Med 2019; 24:58. [PMID: 31521105 PMCID: PMC6745078 DOI: 10.1186/s12199-019-0811-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022] Open
Abstract
Hookah or waterpipe smoking or use is an emerging trend in the US population, especially among the youth. The misperception of hookah being less harmful than cigarettes and the availability of different but "appealing" flavors are considered among the main reasons for this trend. Hookah users however are exposed to many of the same toxic compounds/by-products as cigarette users, but at dramatically higher levels, which might lead to more severe negative health effects. In fact, hookah users are at risks of infections, cancers, lung disease, and other medical conditions. Moreover, because of the overlapping toxicant/chemical profile to conventional cigarettes, hookah smoke effects on the cardiovascular system are thought to be comparable to those of conventional cigarettes. A major source of tobacco addiction is nicotine, whose levels in hookah are extremely variable as they depend on the type of tobacco used. Taken together, in this review of literature, we will provide insights on the negative health effects of hookah in general, with a focus on what is known regarding its impact on the cardiovascular system.
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Affiliation(s)
- Hanan Qasim
- Department of Pharmaceutical Sciences, School of Pharmacy, The University of Texas at El Paso, El Paso, Texas, 79902, USA
| | - Ahmed B Alarabi
- Department of Pharmaceutical Sciences, School of Pharmacy, The University of Texas at El Paso, El Paso, Texas, 79902, USA
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Zubair A Karim
- Department of Pharmaceutical Sciences, School of Pharmacy, The University of Texas at El Paso, El Paso, Texas, 79902, USA
| | - Fatima Z Alshbool
- Department of Pharmaceutical Sciences, School of Pharmacy, The University of Texas at El Paso, El Paso, Texas, 79902, USA.
| | - Fadi T Khasawneh
- Department of Pharmaceutical Sciences, School of Pharmacy, The University of Texas at El Paso, El Paso, Texas, 79902, USA.
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The impacts of potency, warning messages, and price on preferences for Cannabis flower products. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:1-10. [PMID: 31382201 DOI: 10.1016/j.drugpo.2019.07.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Recreational cannabis has been legalized in 11 states and Washington DC in the US. However, little is known about individual preferences for legal cannabis products. This study estimated the impacts of tetrahydrocannabinol (THC), cannabidiol (CBD), warning messages, and price on preferences for cannabis flowers. METHODS A cross-sectional online survey with discrete choice experiments was implemented in October 2017. A sample of 2400 adults aged 21 years or older were recruited from 6 US states with recreational cannabis legalization, consisting of 1200 past-year nonusers and 1200 past-year users. Each respondent was randomly assigned to 12 discrete choice scenarios, each asking them to choose from an opt-out option and 3 cannabis flower products with varying levels in THC, CBD, warning messages, and price. The impacts of product attributes on individual choices were analyzed with nested logit regressions. RESULTS Both cannabis nonusers and users preferred higher CBD and lower price. Users also preferred higher THC. The results on warning messages were mixed: graphic warning on drugged driving and text warning message had positive impacts on nonusers' and users' preferences for cannabis flowers, respectively, whereas FDA disapproval disclaimer had negative impacts on nonusers' preferences. Heterogeneities in preferences were revealed among nonusers by former use status and among users by reason of use. Particularly, medical cannabis users were not as responsive to THC as recreational cannabis users or dual users were. Regarding relative importance of the attributes, all respondents but medical cannabis users perceived price as the most important attribute (relative importance 51-64%), whereas medical cannabis users perceived CBD as the most important attribute (relative importance 47%). CONCLUSION The findings indicated that product characteristics may have influences on US adults' choices of legal cannabis flower products and may deserve consideration for cannabis regulatory framework.
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Maziak W, Ben Taleb Z, Ebrahimi Kalan M, Ward-Peterson M, Bursac Z, Osibogun O, Eissenberg T. Effect of flavour manipulation on low and high-frequency waterpipe users' puff topography, toxicant exposures and subjective experiences. Tob Control 2019; 29:s95-s101. [PMID: 31326956 DOI: 10.1136/tobaccocontrol-2019-055040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Flavoured tobacco is one of the major factors behind the popularity of waterpipe (WP) smoking in the USA and internationally. The current study examined the impact of flavour manipulation on satisfaction, puff topography and toxicant exposure among high-frequency and low-frequency WP users. METHOD This cross-over study was conducted among 144 current (past month) WP smokers reporting WP smoking less than once a week (low-frequency users; n=69) or at least once a week (high-frequency users; n=75) in the past 6 months. Participants attended two counterbalanced 45 min ad libitum smoking sessions that differed by flavour (preferred flavoured vs unflavoured tobacco), preceded by ≥12 hours of tobacco use abstinence. Outcome measures included puff topography, expired carbon monoxide (eCO), plasma nicotine and subjective measures. RESULTS Both high-frequency and low-frequency WP users reported an enhanced smoking experience and greater interest in future use after smoking the flavoured compared with unflavoured tobacco (p<0.05 for all). High-frequency users, however, were more keen on smoking the flavoured tobacco in the future, had higher puffing parameters in general compared with low-frequency users (p<0.05 for all) and had no differences in eCO and plasma nicotine concentrations between the flavoured and unflavoured tobacco conditions (p>0.05 for all). On the other hand, low-frequency users had significantly greater eCO and plasma nicotine concentrations following smoking the unflavoured compared with flavoured tobacco condition (p<0.05 for all). CONCLUSIONS Our results indicate that removing flavours will likely negatively affect WP satisfaction and future use and that such an effect will be more pronounced among high-frequency compared with low-frequency WP smokers.
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Affiliation(s)
- Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
| | - Ziyad Ben Taleb
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, USA
| | - Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
| | - Melissa Ward-Peterson
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
| | - Olatokunbo Osibogun
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
| | - Thomas Eissenberg
- Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
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Stroud L, Werner E, Matteson K, Carey M, Helen GS, Eissenberg T, Scott-Sheldon LAJ. Waterpipe (hookah) tobacco use in pregnancy: use, preferences and perceptions of flavours. Tob Control 2019; 29:s62-s71. [PMID: 31320397 DOI: 10.1136/tobaccocontrol-2019-054984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Waterpipe tobacco (WPT; hookah) use is common in pregnant and reproductive-age women. Sweet flavours contribute to the appeal of WPT and are a potential regulatory target. This study investigated use, preferences and perceptions of WPT flavours in pregnant WPT users, and the impact of flavour preferences on preconception/prenatal WPT use and exposure biomarkers. METHODS 58 pregnant WPT users (mean age=27 years) completed a detailed interview regarding their WPT flavours use, preferences and perceptions. Biomarkers of nicotine and carcinogen exposure (eg, cotinine, benzene, butadiene) were also collected. RESULTS 55% of participants were dual/poly WPT users (ie, reported use of one or more other tobacco products in addition to WPT). Pregnant WPT users reported nearly exclusive use of flavoured WPT, with greater use of menthol/mint (68%) followed by fruit flavours (48%) (p<0.001), and greater preferences for fruit followed by menthol/mint flavours (ps<0.05). Harm perceptions did not differ among flavours. Compared with dual/poly WPT users, WPT-only users reported more total WPT use events, greater use of and preference for menthol/mint flavoured WPT (ps<0.001), and decreased exposure biomarkers (ps≤0.040). Preference for menthol/mint and fruit flavours predicted more flavoured WPT use events during preconception and pregnancy; preference for menthol/mint predicted detectable cotinine and benzene levels but not butadiene. CONCLUSIONS This is the first study of WPT flavour use, preferences and perceptions in pregnant women. Use of and preference for menthol/mint and fruit WPT flavours in this vulnerable population could be considered in regulating WPT flavours to protect the health of women and children.
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Affiliation(s)
- Laura Stroud
- Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA .,Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, USA
| | - Erika Werner
- Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA.,Women & Infants' Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Kristen Matteson
- Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA.,Women & Infants' Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Michael Carey
- Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA.,Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, USA
| | - Gideon St Helen
- Division of Clinical Pharmacology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Thomas Eissenberg
- Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lori A J Scott-Sheldon
- Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA .,Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island, USA
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23
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Cornacchione Ross J, Noar SM, Sutfin EL. Systematic Review of Health Communication for Non-Cigarette Tobacco Products. HEALTH COMMUNICATION 2019; 34:361-369. [PMID: 29236542 PMCID: PMC5999530 DOI: 10.1080/10410236.2017.1407274] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The Food and Drug Administration, which now has regulatory authority over all tobacco products meeting the statutory definition, is tasked with communicating the risks of these products to the public through health warnings and public education. However, there have been no attempts to summarize what is known about non-cigarette tobacco product (NCTP) health messaging. We conducted a systematic review to examine the existing literature on health communication for NCTPs and identify key research gaps. A total of 45 unique studies were retrieved and coded, with the majority focused on messaging for smokeless tobacco (SLT, k = 32, 71.1%), followed by waterpipe tobacco (WT, k = 9, 20%), electronic nicotine delivery systems (ENDS, k = 2, 4.4%), cigars (k = 2, 4.4%), and a potentially reduced exposure product (k = 1, 2.2%). Studies most commonly examined tobacco product warnings (k = 26, 57.8%) and public education (k = 19, 42.2%), which included mass media campaigns. Most studies examined knowledge, attitudes, and beliefs as outcomes (k = 27, 60%), while behavior was an outcome in the minority of studies (k = 8, 17.8%). Pictorial warnings and public education about NCTPs demonstrated positive impact in some studies, although the literature is nascent. Given the increasing use of NCTPs such as ENDS, WT, and cigars, particularly among adolescents and young adults, more research is needed on effective ways to communicate product risk to those audiences most at risk.
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Affiliation(s)
- Jennifer Cornacchione Ross
- Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine
| | - Seth M. Noar
- School of Media and Journalism, University of North Carolina, Chapel Hill
| | - Erin L. Sutfin
- Department of Social Sciences & Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine
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24
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Soekhai V, de Bekker-Grob EW, Ellis AR, Vass CM. Discrete Choice Experiments in Health Economics: Past, Present and Future. PHARMACOECONOMICS 2019; 37:201-226. [PMID: 30392040 PMCID: PMC6386055 DOI: 10.1007/s40273-018-0734-2] [Citation(s) in RCA: 384] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges. METHODS A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated. RESULTS Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels. CONCLUSIONS The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.
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Affiliation(s)
- Vikas Soekhai
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, 3000 CA The Netherlands
| | - Esther W. de Bekker-Grob
- Section of Health Technology Assessment (HTA) and Erasmus Choice Modelling Centre (ECMC), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam (EUR), P.O. Box 1738, Rotterdam, 3000 DR The Netherlands
| | - Alan R. Ellis
- Department of Social Work, North Carolina State University, Raleigh, NC USA
| | - Caroline M. Vass
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK
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25
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Asfar T, Schmidt M, Ebrahimi Kalan M, Wu W, Ward KD, Nakkash RT, Thrasher J, Eissenberg T, Ben Romdhane H, Maziak W. Delphi study among international expert panel to develop waterpipe-specific health warning labels. Tob Control 2019; 29:159-167. [PMID: 30696784 DOI: 10.1136/tobaccocontrol-2018-054718] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/20/2018] [Accepted: 12/20/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control. METHODS A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median. RESULTS Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP's harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes. CONCLUSION This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP's harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.
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Affiliation(s)
- Taghrid Asfar
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA.,Syrian Center for Tobacco Studies, Aleppo, Syria.,Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, Florida, US
| | - Michael Schmidt
- Department of Art, The University of Memphis, Memphis, Tennessee, USA
| | - Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
| | - Wensong Wu
- Department of Mathematics and Statistics, Florida International University, Miami, Florida, USA
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria.,School of Public Health, The University of Memphis, Miami, Florida, USA
| | - Rima T Nakkash
- Health Behaviour and Education Department, American University of Beirut, Beirut, Lebanon
| | - James Thrasher
- Health Promotion, Education, and Behavior, School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Thomas Eissenberg
- Syrian Center for Tobacco Studies, Aleppo, Syria.,USA Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Habiba Ben Romdhane
- Cardiovascular Epidemiology and Prevention Research Laboratory, Faculty of Medicine of Tunis-Tunisia, Tunis, Tunisia
| | - Wasim Maziak
- Syrian Center for Tobacco Studies, Aleppo, Syria.,Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
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26
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Perraud V, Lawler MJ, Malecha KT, Johnson RM, Herman D, Staimer N, Kleinman MT, Nizkorodov SA, Smith JN. Chemical Characterization of Nanoparticles and Volatiles Present in Mainstream Hookah Smoke. AEROSOL SCIENCE AND TECHNOLOGY : THE JOURNAL OF THE AMERICAN ASSOCIATION FOR AEROSOL RESEARCH 2019; 53:1023-1039. [PMID: 33041429 PMCID: PMC7546025 DOI: 10.1080/02786826.2019.1628342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Waterpipe smoking is becoming more popular worldwide and there is a pressing need to better characterize the exposure of smokers to chemical compounds present in the mainstream smoke. We report real-time measurements of mainstream smoke for carbon monoxide, volatile organic compounds and nanoparticle size distribution and chemical composition using a custom dilution flow tube. A conventional tobacco mixture, a dark leaf unwashed tobacco and a nicotine-free herbal tobacco were studied. Results show that carbon monoxide is present in the mainstream smoke and originates primarily from the charcoal used to heat the tobacco. Online measurements of volatile organic compounds in mainstream smoke showed an overwhelming contribution from glycerol. Gas phase analysis also showed that very little filtration of the gas phase products is provided by the percolation of mainstream smoke through water. Waterpipe smoking generated high concentrations of 4-100 nm nanoparticles, which were mainly composed of sugar derivatives and especially abundant in the first 10 min of the smoking session. These measured emissions of volatiles and particles are compared with those from a reference cigarette (3R4F) and represent the equivalent of the emission of one or more entire cigarettes for a single puff of hookah smoke. Considerations related to the health impacts of waterpipe smoking are discussed.
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Affiliation(s)
- Véronique Perraud
- Department of Chemistry, University of California, Irvine, California, USA
| | - Michael J. Lawler
- Department of Chemistry, University of California, Irvine, California, USA
| | - Kurtis T. Malecha
- Department of Chemistry, University of California, Irvine, California, USA
| | | | - David Herman
- School of Medicine, University of California, Irvine, California, USA
| | - Norbert Staimer
- Department of Epidemiology, University of California, Irvine, California, USA
| | | | | | - James N. Smith
- Department of Chemistry, University of California, Irvine, California, USA
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27
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Asfar T, Ben Taleb Z, Osibogun O, Ruano-Herreria EC, Sierra D, Ward KD, Salloum RG, Maziak W. How Do Waterpipe Smoking Establishments Attract Smokers? Implications for Policy. Subst Use Misuse 2018; 54:560-571. [PMID: 30430905 PMCID: PMC6443473 DOI: 10.1080/10826084.2018.1524489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 09/05/2018] [Accepted: 09/12/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Given the unique social nature of waterpipe smoking, an important factor contributing to its popularity is the spread of waterpipe establishments. OBJECTIVES With a focus on implications for regulations, we conducted a qualitative assessment of customers' online reviews on Yelp.com to gain insight into their positive and negative perceptions about waterpipe establishments and products, and identify features that are most important to them. METHODS In June 2016, an online search of Yelp was conducted to identify waterpipe establishments in Miami, Florida. First, we collected information from the websites on establishments' characteristics and their marketing practices. Then we selected customers' waterpipe-related reviews and used an inductive qualitative method to code and identify key themes associated with positive and negative customers' experiences. Thematic analysis was completed upon reaching saturation. The final coding scheme consisted of 32 codes within eight themes. RESULTS The homepage of the establishment was used to promote special discounts and events, while the online waterpipe menu was used to promote the waterpipe products. Our thematic analysis indicated that the variety of flavored tobacco was the most rated positive factor to customers, while the low-quality charcoal and high price were the most negative factors. Conclusions/Importance: Waterpipe online advertisements and promotions should be monitored and restricted. The availability of flavored tobacco, innovative device/accessories, affordable pricing, and charcoal quality are important domains for waterpipe establishments policy/regulation. Regulatory framework for waterpipe establishments should address the complex context of waterpipe including the venue (i.e., physical, website, menu), the tobacco, the device/accessories, and charcoal.
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Affiliation(s)
- Taghrid Asfar
- a Department of Public Health Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA
- b Sylvester Comprehensive Cancer Center , University of Miami Miller School of Medicine , Miami , Florida , USA
- c Syrian Center for Tobacco Studies , Memphis , Tennessee , USA
| | - Ziyad Ben Taleb
- d Department of Epidemiology, Robert Stempel College of Public Health and Social Work , Florida International University , Miami , Florida , USA
| | - Olatokunbo Osibogun
- d Department of Epidemiology, Robert Stempel College of Public Health and Social Work , Florida International University , Miami , Florida , USA
| | - Estefania C Ruano-Herreria
- a Department of Public Health Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Danielle Sierra
- a Department of Public Health Sciences , University of Miami Miller School of Medicine , Miami , Florida , USA
| | - Kenneth D Ward
- c Syrian Center for Tobacco Studies , Memphis , Tennessee , USA
- e Division of Social and Behavioral Sciences, School of Public Health , University of Memphis , Memphis , Tennessee , USA
| | - Ramzi G Salloum
- f Department of Health Outcomes and Policy , University of Florida, College of Medicine , Gainesville , Florida , USA
| | - Wasim Maziak
- c Syrian Center for Tobacco Studies , Memphis , Tennessee , USA
- d Department of Epidemiology, Robert Stempel College of Public Health and Social Work , Florida International University , Miami , Florida , USA
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28
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Regmi K, Kaphle D, Timilsina S, Tuha NAA. Application of Discrete-Choice Experiment Methods in Tobacco Control: A Systematic Review. PHARMACOECONOMICS - OPEN 2018; 2:5-17. [PMID: 29464666 PMCID: PMC5820233 DOI: 10.1007/s41669-017-0025-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND Economic evidence relating to tobacco control is generally derived from the cost effectiveness of smoking-cessation programs or the economic impact of tobacco-induced disease, based on revealed-preference data. However, empirical estimates from stated-preference data on tobacco users' preferences, smoking behaviour and smoking cessation aids using analytical techniques such as discrete-choice experiments (DCEs) could be important for policy decision making in tobacco control. OBJECTIVES Our objective was to review the practice and utility of DCE methodology across nicotine- and tobacco-related issues, particularly smoking and smoking-cessation behaviour, anti-smoking policies and preferences for smoking-cessation aids. METHODS We searched the PubMed, MEDLINE and ECONLIT databases for full-text original research articles on tobacco-related issues published between January 2000 and April 2016 that used a DCE method. We summarised the evidence and methodological characteristics of DCEs according to Lancsar and Louviere, 2008. RESULTS Our review of the 12 eligible studies showed that DCE methodology was used to elicit smoker preferences and to evaluate tobacco-control policies. The majority of the studies were published in the last 5 years. The areas of application were smoking cessation, smoking behaviour, electronic cigarette use, water-pipe smoking and tobacco packaging. Monetary attributes were the most influential attributes in all studies. The design of the DCEs varied. CONCLUSION DCE studies of tobacco-related issues were methodologically consistent with guidelines proposed for conducting health-related DCEs.
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Affiliation(s)
- Kabindra Regmi
- Faculty of Health Science, PAPRSB Institute of Health Science, University Brunei Darussalam, Gadong, BE1410 Brunei Darussalam
- Centre for Innovative Research in Public Health, Pokhara, Nepal
| | - Dinesh Kaphle
- School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sabina Timilsina
- Centre for Innovative Research in Public Health, Pokhara, Nepal
- Faculty of Medicine, Center for Tropical Medicine, Gadjah Mada University, Gedung PAU UGM, Yogyakarta, 55281 Indonesia
| | - Nik Annie Afiqah Tuha
- Faculty of Health Science, PAPRSB Institute of Health Science, University Brunei Darussalam, Gadong, BE1410 Brunei Darussalam
- Department of Primary Care and Public Health, Faculty of Public Health, Imperial College London, London, UK
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29
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Mays D, Tercyak KP, Rehberg K, Crane MK, Lipkus IM. Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco. Tob Prev Cessat 2017; 3:133. [PMID: 32432207 PMCID: PMC7232820 DOI: 10.18332/tpc/80133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/13/2017] [Accepted: 11/11/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content. METHODS Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes. RESULTS Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation. CONCLUSIONS Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.
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Affiliation(s)
- Darren Mays
- Georgetown Lombardi Comprehensive Cancer Center, Washington, United States
| | - Kenneth P Tercyak
- Georgetown Lombardi Comprehensive Cancer Center, Washington, United States
| | - Kathryn Rehberg
- Georgetown Lombardi Comprehensive Cancer Center, Washington, United States
| | - Mary-Kate Crane
- Georgetown Lombardi Comprehensive Cancer Center, Washington, United States
| | - Isaac M Lipkus
- Duke University, School of Nursing, Durham, United States
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30
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Shang C, Huang J, Chaloupka FJ, Emery SL. The impact of flavour, device type and warning messages on youth preferences for electronic nicotine delivery systems: evidence from an online discrete choice experiment. Tob Control 2017; 27:e152-e159. [PMID: 29097588 DOI: 10.1136/tobaccocontrol-2017-053754] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To examine the impact of flavour, device type and health warning messages on youth preference for electronic nicotine delivery systems (ENDS), and to provide evidence and data to inform the Food and Drug Administration's potential regulatory actions on ENDS. DESIGN An online discrete choice experiment was conducted in September 2015. Each participant was given nine choice sets and asked to choose one out of two alternative ENDS products, with varying characteristics in three attributes (flavour, device type and warning message). The impact of the attributes on the probability of choosing ENDS was analysed using conditional and nested logit regressions, controlling for individual sociodemographic characteristics and current smoking status. SETTING AND PARTICIPANTS A general population sample of 515 participants (50 ever-users and 465 never-users of ENDS) aged 14-17 years were recruited to complete the experiment using an online panel. RESULTS Fruit/sweets/beverage flavours significantly increase the probability of choosing ENDS among youth (p<0.01 for never-users and <0.1 for ever-users) and flavour has the most pronounced impact among three attributes. Among never-users, menthol flavour also increases (p<0.05) the probability of choosing ENDS compared with tobacco flavour. Vaping devices that are modifiable, compared with cigarette-like e-cigarettes, increase (p<0.05) the probability of choosing ENDS among adolescent never-users. Warning messages reduce (p<0.01) the probability of choosing ENDS among never-users. CONCLUSIONS AND RELEVANCE Restricting fruit/sweets/beverage flavours in ENDS, regulating modifiable vaping devices and adopting strong health warning messages may reduce the uptake of ENDS among youth.
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Affiliation(s)
- Ce Shang
- Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jidong Huang
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Frank J Chaloupka
- Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, USA.,Department of Economics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sherry L Emery
- Health Media Collaboratory, NORC at the University of Chicago, Chicago, Illinois, USA
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Salloum RG, Abu-Rmeileh N, Hamadeh R, Thomas J, Mostafa A, Yusufali A, Kheirallah KA, Macauda MM, Theis RP, El Kadi L, Johnson EJ, Darawad MW, Nakkash R. Policy-Relevant Context of Waterpipe Tobacco Smoking among University Students in Six Countries Across the Eastern Mediterranean Region: A Qualitative Study. Asian Pac J Cancer Prev 2017; 18:2533-2540. [PMID: 28952296 PMCID: PMC5720662 DOI: 10.22034/apjcp.2017.18.9.2533] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are some of the highest worldwide, especially among young people. This study aimed to improve our knowledge of the policy-relevant context of waterpipe smoking among six countries in the Eastern Mediterranean region. Methods: In-depth interviews were conducted in Bahrain, Egypt, Jordan, Lebanon, Palestine, and the United Arab Emirates. Participants were young adult university students (18-29 years) from both genders who had ever smoked the waterpipe, recruited from universities participating in this study. Directed content analysis was used to analyze the transcripts. Results: A total of 53 in-depth interviews were conducted in Arabic in 2016. Findings were organized around 5 themes: waterpipe product characteristics; patterns of waterpipe smoking; the waterpipe café setting; perceived health consequences; and health warning labels. Waterpipe smoking was commonly perceived as a safe alternative to cigarettes. Waterpipe tobacco was reported to be widely accessible and affordable to young participants. There is a lack of knowledge among waterpipe smokers about the associated health effects. Warning labels are effective at communicating health risks associated with waterpipe smoking. Conclusions: Regulatory frameworks for waterpipe tobacco smoking should be developed and enforced, including waterpipe-specific health warning labels that elucidate the harmful effects of waterpipe smoking.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA.
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32
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Jawad M, McIver C. Waterpipe tobacco smoking prevalence and illegal underage use in waterpipe-serving premises: a cross-sectional analysis among schoolchildren in Stoke-on-Trent. Public Health 2017; 146:32-38. [DOI: 10.1016/j.puhe.2016.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/14/2016] [Accepted: 12/18/2016] [Indexed: 11/30/2022]
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33
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Huang LL, Baker HM, Meernik C, Ranney LM, Richardson A, Goldstein AO. Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review. Tob Control 2016; 26:709-719. [PMID: 27872344 PMCID: PMC5661267 DOI: 10.1136/tobaccocontrol-2016-053196] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 12/05/2022]
Abstract
Objective This systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults. Data sources English-language peer-reviewed publications indexed in 4 databases were searched through April 2016. Study selection A search strategy was developed related to tobacco products and flavours. Of 1688 articles identified, we excluded articles that were not English-language, were not peer-reviewed, were qualitative, assessed menthol-flavoured tobacco products only and did not contain original data on outcomes that assessed the impact of flavours in tobacco products on perceptions and use behaviour. Data extraction Outcome measures were identified and tabulated. 2 researchers extracted the data independently and used a validated quality assessment tool to assess study quality. Data synthesis 40 studies met the inclusion criteria. Data showed that tobacco product packaging with flavour descriptors tended to be rated as more appealing and as less harmful by tobacco users and non-users. Many tobacco product users, especially adolescents, reported experimenting, initiating and continuing to use flavoured products because of the taste and variety of the flavours. Users of many flavoured tobacco products also showed decreased likelihood of intentions to quit compared with non-flavoured tobacco product users. Conclusions Flavours in most tobacco products appear to play a key role in how users and non-users, especially youth, perceive, initiate, progress and continue using tobacco products. Banning non-menthol flavours from tobacco products may ultimately protect public health by reducing tobacco use, particularly among youth.
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Affiliation(s)
- Li-Ling Huang
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Hannah M Baker
- Department of Family Medicine, Tobacco Prevention and Evaluation Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Clare Meernik
- Department of Family Medicine, Tobacco Prevention and Evaluation Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Leah M Ranney
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Family Medicine, Tobacco Prevention and Evaluation Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Amanda Richardson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam O Goldstein
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Family Medicine, Tobacco Prevention and Evaluation Program, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Abstract
Waterpipe smoking has been dramatically increasing among youth worldwide and in the United States. Despite its general association with misperceptions of reduced harm, evidence suggests this is a harmful and dependence-inducing tobacco use method that represents a threat to public health. Waterpipe products continue to be generally unregulated, which likely has contributed to their spread. The Family Smoking Prevention and Tobacco Control Act of 2009 granted the US Food and Drug Administration (FDA) the authority to regulate waterpipe products, and the FDA finalized a rule extending its authority over waterpipe products in May 2016. This critical step in addressing the alarming increase in waterpipe smoking in the United States has created urgency for research to provide the evidence needed for effective regulatory initiatives for waterpipe products. We aim to stimulate such research by providing a framework that addresses the scope of waterpipe products and their unique context and use patterns. The proposed framework identifies regulatory targets for waterpipe product components (i.e., tobacco, charcoal, and device), the waterpipe café setting, and its marketing environment dominated by Internet promotion.
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Affiliation(s)
- Ramzi G Salloum
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
| | - Taghrid Asfar
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
| | - Wasim Maziak
- Ramzi G. Salloum is with the Department of Health Outcomes and Policy and the Institute for Child Health Policy, University of Florida College of Medicine, Gainesville. Taghrid Asfar is with the Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL. Wasim Maziak is with the Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami
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Islam F, Salloum RG, Nakkash R, Maziak W, Thrasher JF. Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health 2016; 61:709-715. [PMID: 26971508 PMCID: PMC4992403 DOI: 10.1007/s00038-016-0805-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 01/27/2016] [Accepted: 02/25/2016] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Youth have the misperception that waterpipe smoking is less harmful than cigarettes despite the evidence that it is associated with nicotine dependence and many of the diseases caused by cigarettes. There is a pressing need to identify effective health warnings that increase awareness about the harmful effects of waterpipe smoking. Our objective was to test the effectiveness of various health warning messages and their location on waterpipe devices. METHODS Adult waterpipe smokers from a large US university (N = 367) completed an internet-based survey that tested the effect of text-only and pictorial health warning labels and their location on different parts of waterpipe smoking devices. RESULTS Text-only messages and pictorial labels warning about harm to children were the most effective in motivating waterpipe smokers to think about quitting. In terms of warning label location, the base, mouthpiece and stem are all equally noticeable locations. CONCLUSIONS This is the first study to test waterpipe-specific warning labels and location on the waterpipe device. Placing waterpipe-specific labels on waterpipe devices may be an effective policy tool to curb waterpipe smoking.
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Affiliation(s)
- Farahnaz Islam
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Policy, and Institute for Child Health Policy, University of Florida College of Medicine, PO Box 100177, Gainesville, FL, 32610-0177, USA.
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Wasim Maziak
- Department of Epidemiology, Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - James F Thrasher
- Department of Health, Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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Maziak W, Ben Taleb Z, Jawad M, Afifi R, Nakkash R, Akl EA, Ward KD, Salloum RG, Barnett TE, Primack BA, Sherman S, Cobb CO, Sutfin EL, Eissenberg T. Consensus statement on assessment of waterpipe smoking in epidemiological studies. Tob Control 2016; 26:338-343. [PMID: 27165995 DOI: 10.1136/tobaccocontrol-2016-052958] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 04/20/2016] [Indexed: 01/03/2023]
Abstract
Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.
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Affiliation(s)
- Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA.,Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Ziyad Ben Taleb
- Department of Epidemiology, Florida International University, Miami, Florida, USA
| | - Mohammed Jawad
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Rima Afifi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria.,Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Policy, and Institute for Child Health Policy, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tracey E Barnett
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Brian A Primack
- Center for Research on Media, Technology, and Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Scott Sherman
- Departments of Population Health, Medicine and Psychiatry, New York University School of Medicine, New York University, New York, New York, USA
| | - Caroline O Cobb
- Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Erin L Sutfin
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Thomas Eissenberg
- Syrian Center for Tobacco Studies, Aleppo, Syria.,Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
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