Midwakh/dokha tobacco use in the Middle East: much to learn

University students' and staff attitudes toward the implementation of a "tobacco-free" policy: A view from Qatar

Objectives

Tobacco-free campus policies are needed to create environments conducive to prevention or quitting in the Eastern Mediterranean Region (EMR), where the use of various tobacco products is on the rise among university students. The objectives of this study were to assess overall support for a 100% tobacco-free campus policy and its predictors among different stakeholder groups at the largest national university in Qatar and to understand attitudes towards specific policy components.

Study design

A cross-sectional online survey of faculty and students.

Methods

We measured sociodemographic variables, tobacco use, and support for components of a 100% tobacco-free campus policy. A total score for support was calculated, and associations with selected predictors were assessed using multivariable linear regression.

Results

413 respondents participated in the survey. A majority of faculty/staff and students (76.6% and 75.5%, respectively) supported the implementation of a 100% tobacco-free campus policy, with a majority supporting extension of the policy beyond cigarettes. Support for other components of the policy varied. Among students, overall support was lower among males and tobacco users and higher among the married. Among faculty and staff, support was lower among Qatari nationals and tobacco users.

Conclusion

In the context of a growing tobacco crisis in the EMR, implementing and understanding the impact of tobacco-free campus policies is essential. This paper underscores the importance of addressing diverse stakeholder attitudes and providing empirical evidence to guide policy implementation and evaluation.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

A literature review addressing midwakh and e-cigarette use in the Gulf region

A notable decrease in conventional cigarette smoking has been witnessed on a global scale. However, this decrease has been accompanied by an equally striking global increase in the consumption of alternative tobacco products (ATPs), namely e-cigarettes and midwakh in the Arabian Gulf region. A literature review was used to outline the chemical composition of these two ATPs and review their impacts on health. The study was conducted using databases like PubMed, Google Scholar, MDPI, and WorldCat. The literature search included terms such as "e-cigarettes," "midwakh," "dokha," "heath impacts," "psychological effects," "social influences," and "cigarette smoking" with emphasis on literature from the Arabian Gulf region. Data shows that midwakh contains markedly high levels of tar, nicotine, and various compounds of notable effects on the human body. Similarly, it was found that e-cigarettes contain non-negligible amounts of nicotine and other chemical compounds that may not have been extensively investigated. Alarming reports of system-specific effects brought about by midwakh, and e-cigarette consumption, have been reported, although further research is needed to deduce the mechanism. We also discussed some of the social and psychological factors leading to their consumption within this population. Hence, this review raises questions around the safety of these two types of ATPs and encourages comprehensive studies globally and regionally.

Do Current Lung Cancer Clinical Trials Represent All Patient Populations Including Minorities?

The under-representation of racial, sexual, and gender minorities in cancer clinical trials has long been a deficit in clinical cancer research. This review aims to survey current literature to determine the participation of minorities in the United States in lung cancer clinical trials and to find educational methods that have been studied and researched in order to improve patient clinical trial enrollment. A literature search of relevant articles published since 2015 was conducted using PubMed and Google Scholar. Clinical trials conducted in the United States from Clinicaltrials.gov were also collected to determine minority patient enrollment in lung cancer clinical trials. The results of the literature search yielded 6 relevant articles about racial minority representation in lung cancer clinical trials and one relevant article about LGBTQ+ minority representation in cancer clinical trials. Collectively, the literature highlighted the under-representation of racial minorities (such as Black, Hispanic, and American Indian) in clinical trials. Many articles showed that disparities in enrollment were less significant for Asian patients with lung cancer. However, many articles did not mention minorities like Middle Eastern/North Africans and failed to mention the lack of distinguishment of South Asian minorities from Pacific Asian minorities. The findings of this literature review support the idea that current lung cancer clinical trials lack representation of minority patient populations in the United States. The inclusion of racial, sexual, and gender diversity in clinical trial patient populations will aid providers in determining appropriate therapeutics and could potentially improve lung cancer outcomes. Future directions for improving diversity in lung cancer clinical trial enrollment include the utilization of various educational tools to increase minority patient participation in trials, the inclusion of detailed demographic data in cancer clinical trial analysis, and the recruitment of providers and research staff from various minorities to conduct cancer clinical trials.

Effects of medwakh smoking on salivary metabolomics and its association with altered oral redox homeostasis among youth

The use of alternative tobacco products, particularly medwakh, has expanded among youth in the Middle East and around the world. The present study is conducted to investigate the biochemical and pathophysiological changes caused by medwakh smoking, and to examine the salivary metabolomics profile of medwakh smokers. Saliva samples were collected from 30 non-smokers and 30 medwakh smokers and subjected to metabolomic analysis by UHPLC-ESI-QTOF-MS. The CRP and Glutathione Peroxidase 1 activity levels in the study samples were quantified by ELISA and the total antioxidant capacity (TAC) by TAC assay kits. Statistical measurements and thorough validation of data obtained from untargeted metabolomics identified 37 uniquely and differentially abundant metabolites in saliva of medwakh smokers. The levels of phthalate, L-sorbose, cytosine, uridine, alpha-hydroxy hippurate, and L-nicotine were noticeably high in medwakh smokers. Likewise, 20 metabolic pathways were differentially altered in medwakh smokers. This study identified a distinctive saliva metabolomics profile in medwakh smokers associated with altered redox homeostasis, metabolic pathways, antioxidant system, and CRP levels. The impact of the altered metabolites in medwakh smokers and their diagnostic utility require further research in large cohorts.

Dentists' perception of health-risk associated with cigarettes and alternative tobacco products: A descriptive study

Cigarettes and alternative tobacco products cause various oral health issues ranging from minor tooth decay/gum-diseases to oral cancer. According to the Centre for Disease Control (CDC), over 40% of adult cigarette smokers have untreated tooth decay which later leads to severe oral health problems. The present study intended to assess the impact of dentists' perceived risk of smoking tobacco products on their attitude and practice toward tobacco cessation advice. It was a cross-sectional study to collect data on the perception of dentists who are smokers, regarding smoking-related health risks. Dentists' attitude was measured using a questionnaire with a 5-point rating scale and a practice list of items with a 3-point rating scale. Descriptive/inferential techniques were applied, and a significance level was fixed at 5%. Among the 31 tobacco users, 80.6% of dentists perceived severe risk with cigarette use as compared to alternative tobacco products (71%). Positive attitude and good practice were observed among those who perceived severe risk; however, no statistical significance was observed (p-value >0.05). Young dentists, males, Arab nationals, highly educated and specialists had a positive attitude toward smoking cessation activities. Among the smokers, dentists recognize their role and responsibility very seriously in building a smoke-free community, but their risk perception and good attitude did not positively reflect on their clinical practice in smoking cessation programs. Though the dentists had a better perception and attitude towards smoking cessation, their clinical practice in offering advising sessions is inversely related to their perception/attitude.

Midwakh: Assessment of Levels of Carcinogenic Polycyclic Aromatic Hydrocarbons and Nicotine in Dokha Tobacco Smoke

Midwakh, which originated in the Middle East, has started to spread globally with different brands commercialized online and in local stores across Europe and the USA. Dokha is the tobacco used in midwakh. To this day, risk of midwakh smoking is poorly understood. Three different types of dokha were evaluated in this study, classified as cold, medium, and hot using gas chromatography-mass spectrometry (GC-MS). The concentrations of nicotine and polycyclic aromatic hydrocarbons (PAHs) in raw and smoked dokha samples were measured, and the results were compared to data in the literature on different types of tobacco products. PAH concentrations were used to estimate the toxic equivalency quotient, daily exposures, incremental lifetime cancer risk, and hazard quotient. The level of nicotine in raw dokha exceeded by far the levels reported in cigarettes, cigar, waterpipe, and chewing tobacco. Although only a portion of the nicotine is released into the smoke, the amount of nicotine in dokha smoke exceeded those reported for cigarettes. Two PAHs were found in raw dokha at trace amounts and 12 PAHs were detected in dokha smoke in amounts that exceeded those reported for cigarette smoke. The PAHs distribution showed a specific pattern in the smoke and a higher risk factor than that obtained for cigarettes and other tobacco products. Dokha products present a potential higher risk and immediate action should be taken to avoid its global consumption.

Patterns of Tobacco Smoking and Nicotine Vaping among University Students in the United Arab Emirates: A Cross-Sectional Study

Various forms of tobacco smoking and nicotine vaping tools are available on the market. This study quantified the prevalence of and identified factors associated with patterns of smoking and nicotine vaping among university students in the United Arab Emirates (UAE). A cross-sectional sample of students enrolled in three public universities was surveyed. Self-reported current smoking and nicotine vaping were recorded. Of 1123 students, 81.7% completed the online survey (mean age, 20.7 ± 3.4 (SD) years; 70.7% females). The prevalence of current smoking was 15.1% while the prevalence of current nicotine vaping was nearly 4.0%. Among current smokers, 54.7% reported conventional smoking only, 15.1% reported nicotine vaping only, and 28.8% were poly-users. Conventional midwakh (47.5%), followed by conventional shisha/waterpipe (36.7%), conventional cigarettes (36.7%), electronic shisha/waterpipe (25.2%), and electronic cigarettes (24.5%), were most commonly reported by students. Students aged 20–25 years (adjusted odds ratios (aOR): 2.08, 95% confidence interval (CI): 1.18–3.67) or >25 years (aOR: 4.24, 95% CI: 1.41–12.80) had higher odds of being current smokers compared to those aged 17–19 years. The male gender was also independently associated with higher odds of being a current smoker (aOR: 5.45, 95% CI: 3.31–8.97) as well as higher odds of smoking cigarettes, shisha, and midwakh, or nicotine vaping compared to being female. Of nicotine vaping users, 36.1% reported using nicotine vaping because they enjoyed the flavor and vaporizing experience and 34.4% used it to help them to quit smoking. A relatively high prevalence of self-reported smoking was reported among university students in the UAE. The findings also suggest that nicotine vaping use is relatively widespread, but still less common than traditional smoking. Vigilant and tailored university-based smoking control and preventive measures are warranted.

Choice and Variety-Seeking of E-liquids and Flavor Categories by New Zealand Smokers Using an Electronic Cigarette: A Longitudinal Study

BACKGROUND

Little is currently known about how e-liquid flavor use evolves among electronic cigarette users. We describe patterns of e-liquid and flavor category use, and variety-seeking, among New Zealand adult smokers attempting to transition from smoking to e-cigarettes.

METHODS

Data were collected in 2018-19, using a longitudinal design comprising up to five in-depth interviews over a 12-20 week period. Participants (n = 32) were current smokers aged ≥18 years, who were not currently using an e-cigarette once a week or more often, and were willing to use an e-cigarette in an attempt to stop smoking. We purchased participants a starter e-cigarette of their choice; they supplied their own e-liquids throughout the study. We extracted e-liquid use data from the verbatim interview transcripts, categorized these into flavor categories, and then explored these data for the whole sample, and by flavor category purchased at intake.

RESULTS

Most participants (n = 12) selected a tobacco flavored e-liquid at intake; fruit (n = 7), mint/menthol (n = 6), and dessert/sweets and non-alcoholic beverage (both n = 5) were also popular. Most participants were still using their initially chosen flavor category at study exit, however, many described variety-seeking behaviors, which typically occurred during the first 12 weeks of enrolment.

CONCLUSION

Most participants did not follow a straightforward e-liquid or flavor category pathway. Evidence of a variety-seeking continuum, typically occurring within the first 12 weeks, suggests possible opportunities at specialist e-cigarette stores to couple e-liquid purchasing occasions with cessation advice.

IMPLICATIONS

Variety-seeking behavior was common and typically reported within the first 12 weeks of participants' e-cigarette-assisted attempt to transition away from smoking. Policies allowing diverse e-liquid flavors at specialist stores only could support users' variety-seeking and potentially create opportunities to couple e-liquid purchasing occasions with cessation advice during the first months of a transition attempt.

'When I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon

BACKGROUND

Dokha ('dizziness' in English) is a type of alternative tobacco product (ATP) increasing in popularity in the Arab world; and smoked in a pipe called a midwakh. Midwakh use is common among nationals in the United Arab Emirates (UAE); yet, evidence indicates its spread among expats in the UAE as well as beyond the UAE. Research on midwakh use is nascent, and no qualitative research has been published. This paper explored the context and determinants of midwakh use among young adults in Lebanon using qualitative methods.

METHODS

We conducted four focus group discussions with 18 midwakh ever smokers aged 18-25 years in Lebanon. Discussions were recorded, transcribed and thematically analysed using the Pragmatics, Attraction, Communication, Expectations framework.

RESULTS

'Pragmatics' was evident in participants' comments about availability of a supply of dokha. For 'attraction', participants described why they prefer midwakh smoking and compared it to other ATPs. Regarding communication, participants shared terms used to describe their use of midwakh (eg, 'buzz'/taking a hit). Participants also described expectations from smoking midwakh, including stress relief.

CONCLUSION

Midwakh smoking is appealing to young adults due to factors such as the 'buzz', perceived harm reduction, stress relief and its ability to satisfy nicotine craving with small amounts of tobacco. As a result, despite experiencing negative effects on first use, young adults choose to continue to use midwakh, and find it hard to quit. These results have implications for prevention and control of midwakh smoking among young adults. Framework Convention on Tobacco Control guidance documents to address ATPs are critically needed to prevent the global spread of yet another tobacco product.

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

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

The Emerging Global Tobacco Treatment Workforce: Characteristics of Tobacco Treatment Specialists Trained in Council-Accredited Training Programs from 2017 to 2019

Tobacco use is projected to kill 1 billion people in the 21st century. Tobacco Use Disorder (TUD) is one of the most common substance use disorders in the world. Evidence-based treatment of TUD is effective, but treatment accessibility remains very low. A dearth of specially trained clinicians is a significant barrier to treatment accessibility, even within systems of care that implement brief intervention models. The treatment of TUD is becoming more complex and tailoring treatment to address new and traditional tobacco products is needed. The Council for Tobacco Treatment Training Programs (Council) is the accrediting body for Tobacco Treatment Specialist (TTS) training programs. Between 2016 and 2019, n = 7761 trainees completed Council-accredited TTS training programs. Trainees were primarily from North America (92.6%) and the Eastern Mediterranean (6.1%) and were trained via in-person group workshops in medical and academic settings. From 2016 to 2019, the number of Council-accredited training programs increased from 14 to 22 and annual number of trainees increased by 28.5%. Trainees have diverse professional backgrounds and work in diverse settings but were primarily White (69.1%) and female (78.7%) located in North America. Nearly two-thirds intended to implement tobacco treatment services in their setting; two-thirds had been providing tobacco treatment for 1 year or less; and 20% were sent to training by their employers. These findings suggest that the training programs are contributing to the development of a new workforce of TTSs as well as the development of new programmatic tobacco treatment services in diverse settings. Developing strategies to support attendance from demographically and geographically diverse professionals might increase the proportion of trainees from marginalized groups and regions of the world with significant tobacco-related inequities.

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

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

Prevalence and predictors of midwakh smoking among male students of Qassim University, Al-Qassim, Saudi Arabia

INTRODUCTION

Novel tobacco products are becoming more popular in the Middle East and especially in Saudi Arabia. We studied the prevalence of midwakh pipe (tobacco smoking pipe) use among students at Qassim University and evaluated factors associated with midwakh pipe usage.

METHODS

A cross-sectional study was conducted using a self-administered questionnaire to collect the data. The participants were male students from Qassim University, Al-Qassim, Saudi Arabia. Data were collected over the period from May to June 2018. A multivariable logistic regression model was used to identify sociodemographic factors and smoking history related to midwakh smoking.

RESULTS

A total of 316 responses were collected; 7.9% (n=25) were midwakh smokers at some point, and 3.8% (n=12) were current midwakh smokers. Multivariable logistic regression indicated that the significant predictors of midwakh smoking among male university students were having a friend who is a tobacco or midwakh smoker, and consuming other forms of tobacco other than midwakh.

CONCLUSIONS

Having midwakh smoking friends, having friends smoking any other form of tobacco, and being a smoker could predict the use of midwakh among university male students in Saudi Arabia. Interventions are required to control this behavior to prevent smoking-related health consequences.

Oral and Oropharyngeal Cancers and Possible Risk Factors Across Gulf Cooperation Council Countries: A Systematic Review

Background

In recent years, there is an emerging increase in the prevalence of oral and oropharyngeal cancers (O-OPCs) across the Arabian Gulf Cooperation Council (GCC) countries. Consequently, this review aimed to explore the epidemiology and possible risk factors of O-OPCs in GCC countries.

Methods

Data published after 2008 related to O-OPCs in GCC countries were obtained through electronic searches in Medline/PubMed, Scopus, Web of Science, EMBASE and Google Scholar. Keywords related to the association between O-OPCs metrics (epidemiology and risk factors) and GCC countries were used for electronic searches.

Results

The overall prevalence of OPCs increased significantly over time (40-51%) in some countries (Saudi Arabia and Arab Emigrated) of the Gulf regions. The pooled risk factor was 3.4 (2.5 - 4.7). Among the risk factors, human papillomavirus and the use of smoke and smokeless tobacco revealed odds ratio (OR) 3.31 (3.13 - 4.5) and 0.60 (0.45 - 0.80) at 95% confidence interval (CI).

Conclusion

A positive correlation between factors like age, diet, hygiene, genetics, viral and bacterial infection, consumption of alcohol and tobacco products with OPC-MFC is suggested.

Knowledge and attitudes towards E-cigarette use in Lebanon and their associated factors

BACKGROUND

Despite the misconceptions regarding E-cigarettes (ECs), only a few studies have been conducted in the Middle East that focused on this topic. This study assesses the knowledge of and attitudes towards ECs in Lebanon, determines how these two measures are associated, and identifies the variables that explain each of these measures.

METHODS

A cross sectional study was conducted on a convenience sample of Lebanese pedestrians aged between 18 and 64 inclusive. A structured self-administered questionnaire comprising of knowledge and attitude scales, and questions on demographical, health and smoking characteristics was used.

RESULTS

Scores for attitudes and knowledge of ECs were summed and dichotomized using a 75% cutoff, above which the participant was considered to have a positive attitude and good knowledge. Among the 352 participants (56.6% males, 43.3% females, mean age 30.3, 46.2% smokers), 63.3% exhibited a lower level of EC knowledge. More than 50% erroneously thought that ECs are not associated with lung and bladder cancer or impair lung and heart function. 65% falsely thought that it is harmless and not addictive. As for attitude, 43.3, 53.9, and 44.3% thought that it is socially acceptable, helps in smoking cessation, and is a good replacement for cigarettes and an enjoyable recreational device respectively. Our results revealed an inverse correlation between attitude and knowledge scores (Spearman's correlation = -.30, p < .001). Predictors of knowledge included health-related occupation (p = .010), regular exercise (p = .016), healthy diet (p = .026), EC use (p = .026), perception that ECs are not harmful (p = .001), and help in smoking cessation (p = .017). Predictors of attitude included EC use (p = .008), sex (p = .010), and knowledge that most ECs are addictive (p = .006), harmful (p = .014), and impair heart and lung function (p = .047).

CONCLUSIONS

Our study revealed a gap in EC knowledge, especially among participants who displayed a positive attitude towards ECs. Hence, measures should be undertaken to regulate its use by instituting more stringent laws and holding nationwide awareness campaigns.

"Stages of change, smoking behavior and acceptability of a textmessaging intervention for tobacco cessation among cigarette, dokha and shishasmokers: A qualitative research study."

OBJECTIVES

To explore: (A) the underlying motivators and barriers to smoking cessation among young Arabic speaking smokers and (B) to examine the suitability and preferences for tobacco cessation interventions (specifically text messages) and study the possibility of enrollment methods for a randomised controlled study using text messages as an intervention for tobacco cessation.

DESIGN

Qualitative research using focus group discussions and content analysis.

SETTINGS

Two universities, one of them is the first and foremost comprehensive national university in the United Arab Emirates (UAE). The third setting is the largest hospital in the UAE and the flagship institution for the public health system in the emirate of Abu Dhabi.

PARTICIPANTS

Six focus group discussions with a total of 57 participants. Forty-seven men and 10 women. Fifty-three of them were current smokers.

RESULTS

The analysis of six focus groups was carried out. Main themes arose from the data included: preferences for tobacco cessation interventions and acceptability and feasibility of text messaging as tobacco cessation intervention. Different motives and barriers for quitting smoking including shisha and dokha were explored.

CONCLUSION

Interventions using text messaging for smoking cessation have not been used in the Middle East and they could potentially be effective; however, tailoring and closely examining the content and acceptability of text messages to be used is important before the conduction of trials involving their use. Social media is perceived to be more effective and influential, with a higher level of penetration into communities of young smokers.

Smokeless tobacco and oral cancer in the Middle East and North Africa: A systematic review and meta-analysis

INTRODUCTION

Cancer of the oral cavity is regarded lethal with a fairly low mean 5-year survival rate. The current systematic review and meta-analysis is the first of its kind to examine, if the evidence from the Middle East and North African region indicates an association between oral cancer and tobacco; and evaluates the quality of the evidence that portrays this relationship.

METHODS

A search for articles was carried out in October 2017 and then cross-checked at the end of June 2018 using Medline, Web of Science, CINAHL, and Cochrane databases. Retrieved articles were later subjected to eligibility criteria. The search was not limited to any particular research design adopted by the investigators. However, dissertations, theses and opinion-based reviews generated from the search were excluded during the screening of titles and abstracts. Quality of included studies was determined objectively (Newcastle Ottawa Scale) and subjectively. Revman (Version 5.3) was used for conducting the meta-analysis.

RESULTS

Six studies satisfied the selection criteria of the current review. The New Castle Ottawa evaluation scale suggested that the three cross-sectional studies and the three case-control studies included in the current review were of relatively low to moderate quality. All included studies explored the association of only one form of smokeless tobacco, i.e. shammah. Three case-control studies revealed a pooled estimate odds ratio of 38.74 (95% CI: 19.50–76.96), indicating that the odds for the occurrence of oral cancer among shammah users were nearly 39 times higher compared to the non-users.

CONCLUSIONS

Shammah is a potential risk factor for oral cancer; thus, it is necessary that public health practitioners design and implement effective strategies to prevent the abuse of shammah.

Prevalence, attitudes, behaviours and policy evaluation of midwakh smoking among young people in the United Arab Emirates: Cross-sectional analysis of the Global Youth Tobacco Survey

INTRODUCTION

Non-cigarette tobacco products are an increasing public health concern globally. Little is known about midwakh, a pipe indigenous to the United Arab Emirates (UAE). This study aimed to assess the prevalence, attitudes, behaviours and policy evaluation of midwakh smoking among 13 to 15 year olds in the UAE.

METHODS

We conducted secondary analyses of the 2013 UAE Global Youth Tobacco Survey. The main three outcomes were ever use, current use (past-30 days), and the number of midwakhs smoked per day. We assessed cessation, attitude, and policy measures. Regression models identified the association between each outcome measure and sex, school grade, nationality, weekly spending money, cigarette use, and parent and peer tobacco use.

RESULTS

The prevalence of ever and current midwakh use were 18.5% and 9.0%, respectively. Daily midwakh users smoked a median of 8.0 per day while non-daily users smoked 3.8 per month. Higher midwakh prevalence was reported among wealthier males, older age groups, concurrent cigarette users and among participants having peers or parents who use tobacco. There was also variation by nationality. Reduced harm perception was greater among midwakh users than non-users. About 39.6% reported being declined a midwakh purchase due to age, and 35.5% reported noticing health warnings on packages.

CONCLUSIONS

Midwakh use is prevalent among 13 to 15 year olds in the UAE, and burden lies mainly with daily users. Further needed research should not delay implementation and evaluation of policies known to curb tobacco use among youth, including taxation, media campaigns, and provision of cessation services.

Types of tobacco consumption and the oral microbiome in the United Arab Emirates Healthy Future (UAEHFS) Pilot Study

Cigarette smoking alters the oral microbiome; however, the effect of alternative tobacco products remains unclear. Middle Eastern tobacco products like dokha and shisha, are becoming globally widespread. We tested for the first time in a Middle Eastern population the hypothesis that different tobacco products impact the oral microbiome. The oral microbiome of 330 subjects from the United Arab Emirates Healthy Future Study was assessed by amplifying the bacterial 16S rRNA gene from mouthwash samples. Tobacco consumption was assessed using a structured questionnaire and further validated by urine cotinine levels. Oral microbiome overall structure and specific taxon abundances were compared, using PERMANOVA and DESeq analyses respectively. Our results show that overall microbial composition differs between smokers and nonsmokers (p = 0.0001). Use of cigarettes (p = 0.001) and dokha (p = 0.042) were associated with overall microbiome structure, while shisha use was not (p = 0.62). The abundance of multiple genera were significantly altered (enriched/depleted) in cigarette smokers; however, only Actinobacillus, Porphyromonas, Lautropia and Bifidobacterium abundances were significantly changed in dokha users whereas no genera were significantly altered in shisha smokers. For the first time, we show that smoking dokha is associated to oral microbiome dysbiosis, suggesting that it could have similar effects as smoking cigarettes on oral health.

Salivary cotinine concentration and carbon monoxide levels in young adults smoking midwakh in comparison with cigarette smokers

Objectives

To estimate and compare the salivary cotinine levels using a semiquantitative method, called NicAlert, between three groups: non-smokers, daily smokers of cigarettes and daily smokers of midwakh, and to compare the carbon monoxide (CO) levels among these groups.

Materials and methods

A total of 159 adult male volunteers aged 20 and above were included, with 54 current cigarette smokers, 52 current midwakh smokers and 53 non-smokers. Estimate of breath carbon monoxide and salivary cotinine were collected, as well as sociodemographic characteristics and details of smoking habits and second-hand smoke exposure among participants. Institutional review board approval was obtained and data were analysed using SPSS V.21 with the Kruskal-Wallis test used to obtain differences in the distribution.

Results

There was no significant difference in the median breath CO and salivary cotinine levels between cigarette and midwakh smokers. Levels of breath CO were significantly higher in cigarette and midwakh smokers as compared with non-smokers (19.5, 17.5 and 6.0, respectively, p<0.05); the same relationship was observed for cotinine levels among cigarette and midwakh smokers as compared with non-smokers (4.0, 3.0 and 0.0, respectively, p≤0.05). Additionally, the values of both salivary cotinine and breath CO increased with the frequency of tobacco use.

Conclusion

These are the first data that we are aware of that demonstrate that in terms of at least two key biomarkers of tobacco use, there are comparable levels of exposure between cigarettes and midwakh users, demonstrating a need for intensified attention to the use of midwakh.

Patterns of tobacco use in the United Arab Emirates Healthy Future (UAEHFS) pilot study

INTRODUCTION

Self-reported tobacco use in the United Arab Emirates is among the highest in the region. Use of tobacco products other than cigarettes is widespread, but little is known about specific behavior use patterns. There have been no studies that have biochemically verified smoking status.

METHODS

The UAE Healthy Future Study (UAEHFS) seeks to understand the causes of non-communicable diseases through a 20,000-person cohort study. During the study pilot, 517 Emirati nationals were recruited to complete a questionnaire, provide clinical measurements and biological samples. Complete smoking data were available for 428 participants. Validation of smoking status via cotinine testing was conducted based on complete questionnaire data and matching urine samples for 399 participants, using a cut-off of 200ng/ml to indicate active smoking status.

RESULTS

Self-reported tobacco use was 36% among men and 3% among women in the sample. However, biochemical verification of smoking status revealed that 42% men and 9% of women were positive for cotinine indicating possible recent tobacco use. Dual and poly-use of tobacco products was fairly common with 32% and 6% of the sample reporting respectively.

CONCLUSIONS

This is the first study in the region to biochemically verify tobacco use self-report data. Tobacco use in this study population was found to be higher than previously thought, especially among women. Misclassification of smoking status was more common than expected. Poly-tobacco use was also very common. Additional studies are needed to understand tobacco use behaviors and the extent to which people may be exposed to passive tobacco smoke.

IMPLICATIONS

This study is the first in the region to biochemically verify self-reported smoking status.

Chemical characterization and safety assessment of dokha: An emerging alternative tobacco product

Dokha is known to be one of the most rapidly spreading alternative tobacco products (ATPs) in the Middle East and North Africa (MENA) region. It is smoked using a pipe known as Midwakh. There is no scientific research published on the chemical composition of dokha and only very little was done to investigate its impact on human health. Three different types of dokha were included in this study. The trace metals content in the dokha samples were analyzed using inductively-coupled plasma-optical emission spectroscopy and energy-dispersive X-ray spectroscopy-scanning electron microscope. Dokha smoke was generated using a device that simulates human smoking/puffing. The smoke samples were collected on Tenax and activated carbon adsorbent tubes followed by chemical analysis using thermal desorption-gas chromatography-mass spectrometry. The results showed the presence of toxic metals in dokha samples such as cobalt, cadmium, chromium, and lead in amounts classified as harmful to human health. In addition, the presence of several potentially harmful and even toxic organic compounds in dokha smoke was identified based on the available clinical data. These included 22 irritants, 3 known carcinogens, and 5 central nervous system (CNS) depressants in addition to several other compounds with miscellaneous effects. The findings of this work demonstrate evidence for the presence of potentially harmful and toxic metals and compounds in dokha tobacco as well as dokha smoke. More research is required to further investigate the clinical impact of dokha on human health.

Coronary Heart Disease in the Middle East and North Africa: Current Status and Future Goals

PURPOSE OF REVIEW

The Middle East and North Africa has witnessed a dramatic transformation over the last 30 years caused by rapid urbanization and modernization and significant changes to diet and lifestyle. This review attempts to highlight recent data in regards to ischemic heart disease and its risk factors from the region.

RECENT FINDINGS

Ischemic heart disease is now the leading cause of death in the region. Age at presentation with myocardial infarction and acute coronary syndrome appears to be significantly younger than global averages. Increased rates of all major risk factors including diabetes, hypertension, hyperlipidemia, smoking, obesity, and sedentary lifestyle have been noted. Specifically, significant changes to dietary habits and growing epidemic of use of alternative tobacco products are noted. This review article highlights the growing epidemic of ischemic heart disease in the region led by dramatic increases in incidence of its risk factors. This epidemic will require a multipronged approach to address the varied issues and mitigate the growing prevalence of the disease.