The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally

Correlates of susceptibility to waterpipe tobacco smoking in young adults

INTRODUCTION

Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults.

METHODS

Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility.

RESULTS

Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (β = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (β = -0.09, p = 0.04), and greater perceived social acceptability of WTS (β = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (β = 0.53, p<0.01), used cannabis (β = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (β = 0.18, p = 0.03) also had higher WTS susceptibility.

CONCLUSIONS

Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits.

Evaluation of micronuclei, cytomorphometric and cytologic changes of the oral mucosa in hookah and cigarette smokers

OBJECTIVE

To analyze the effect of hookah and cigarettes on the oral mucosa of smokers through the use of exfoliative cytology.

STUDY DESIGN

Smear samples were collected by exfoliative cytology from the tongue of 33 hookah smokers, 22 cigarette smokers, and 30 non-smokers. The selected analyses include micronuclei (MN), metanuclear anomalies, epithelial maturation, and cytomorphology (nuclear area [NA], cytoplasmic area [CA], and NA/CA ratio).

RESULTS

The largest differences observed for MN and metanuclear anomalies were between cigarette smokers and the control group (notably 1 MN P = .04; total cells with MN P = .039; total MN P = .042; karyorrhexis and binucleation, P = .0001). The hookah group, compared with the control group, showed the greatest differences for karyolysis (P = .0023), binucleation (P = .0003), and broken egg (P = .008). Significant differences were found between the smokers and the control groups regarding changes in the superficial cell without nucleus, perinuclear halo, vacuolization, color change, mucus, and keratohyalin granules. There was a significant increase in the NA and NA/CA ratio in the smoker groups.

CONCLUSION

This study showed that a combined analysis of exfoliative cytology associated with other diagnostic methods is a useful tool for studying oral carcinogenesis. Hookah and cigarettes showed similar effects in terms of displaying substantial cytogenetic and cytotoxic damage.

Patterns and associated factors of shisha usage among the undergraduate students of Jouf University, Saudi Arabia: A cross-sectional study

INTRODUCTION

Shisha tobacco use is gaining popularity around the world, especially among young people and college students. Shisha users are exposed to many of the same harmful substances as cigarette smokers but at much higher levels, which could have more serious adverse health impacts. The aims of this study were to: 1) determine the patterns of shisha smoking among university students in the Northern Province of Saudi Arabia; 2) identify the reasons for using shisha tobacco; and 3) ascertain whether usage of shisha smoking differs by their sociodemographic characteristics.

METHODS

A cross-sectional survey was conducted among students of seven different colleges at a public university between October and December 2022. A modified version of the Global Youth Tobacco Survey questionnaire was used to collect information specifically on shisha smoking. After adjusting for confounding variables, a logistic regression analysis was used to determine the related factors.

RESULTS

A total of 418 participants were included in the study. Of the studied population, shisha smoking was seen in 73.7% (n=308). Out of 308 shisha smokers, 208 (67.5%) had their first session of shisha smoking within the past two years; 34.4% of participants had used it in the past 30 days (current users), of which 27.4% had smoked shisha from 1 to 7 days during the past 30 days. The majority of respondents (63.6%) reported having friends that smoke. The most popular flavor among respondents (24.6%) was apple. For quitting attempts, 46.4% reported a 24-hour quit attempt in the previous year. Stress (23.0%) was reported as the main reason for beginning shisha use. Shisha smoking was significantly associated with age (Ref. 18-20 years; 24-26 years, AOR=0.08; 95% CI: 0.02-0.33, p<0.001; ≥27 years, AOR=0.12; 95% CI: 0.02-0.62, p=0.01), living status (Ref. alone; with family, AOR=0.23; 95% CI: 0.11-0.47, p<0.001; with friends, AOR=0.36; 95% CI: 0.18-0.76, p<0.001), with parents having higher education level (Ref. primary school and lower; Bachelor's, AOR=0.33; 95% CI: 0.14-0.76, p<0.001; diploma, AOR=0.33; 95% CI: 0.15-0.73, p<0.001; PhD, AOR=5.15; 95% CI: 1.00-9.65, p=0.05).

CONCLUSIONS

Shisha use was more frequent among Saudi Arabian college students, especially those who were aged 18-20 years, living alone, and having highly educated parents.

Association between history of hookah use and symptoms of postpartum depression: A population-based study

OBJECTIVE

Although several biologic, psychosocial, and behavioral factors have been linked to postpartum depressive symptoms, studies examining the association between non-cigarette tobacco products and symptoms of postpartum depression are currently lacking. This study examined the association between hookah use and postpartum depressive symptoms.

METHODS

A cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System 2016-2020. Self-reported data on hookah use in the last 2 years and maternal mental health were captured using a structured questionnaire. Descriptive and inferential statistics were performed.

RESULTS

The final study sample consisted of 106 894 participants. Approximately 8.2% of the participants reported postpartum depressive symptoms and 4.1% reported hookah use in the past 2 years. Compared with those without postpartum depressive symptoms, participants with postpartum depressive symptoms were more likely to be hookah users (5.5% vs 4.0%, P < 0.001). After adjustment for confounders, the odds of having postpartum depressive symptoms were significantly higher among participants who used a hookah in the past 2 years compared with non-users; adjusted odds ratio (95% confidence interval) 1.20 (1.03-1.40); P = 0.022.

CONCLUSION

In a large, population-based sample of US women, hookah use in the past 2 years significantly increased the odds of having postpartum depressive symptoms, independent of potential confounders. This finding underscores the need for healthcare providers to communicate effectively about the health risks of hookah use.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study

PURPOSE

Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes.

METHODS

We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted.

RESULTS

Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only.

CONCLUSIONS

Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

Correlates of motivation to quit waterpipe tobacco smoking among US young adults: implications for cessation interventions

Waterpipe tobacco smoking is a public health concern that poses many of the same health risks as cigarette smoking, especially among young adults-a subpopulation characterized by the highest prevalence of waterpipe tobacco smoking. Nevertheless, it remains understudied relative to other forms of tobacco use. We examined sociodemographic, behavioral and cognitive factors associated with young adults' motivation to quit waterpipe smoking using a theory-informed approach. We completed a secondary analysis of baseline data on waterpipe tobacco smoking beliefs and behavior collected from 349 US young adults aged 18-30 years. We analyzed sociodemographics, tobacco use and cessation behaviors and perceptions, and theory-related constructs associated with motivation to quit waterpipe tobacco smoking using linear regression. Overall, participants reported low motivation (mean = 2.68, SD = 1.56, scale range 1-7) and high self-efficacy (mean = 5.12, SD = 1.79) to quit waterpipe tobacco smoking. In multivariable analysis, prior quit attempts (β = 1.10, P < 0.01), greater perceived risks of waterpipe tobacco smoking (β = 0.42, P < 0.01) and increasingly negative attitudes toward waterpipe tobacco smoking (β = 0.29, P < 0.01) were associated with higher motivation to quit. These findings highlight the importance of those factors as potential cessation determinants. These findings can help guide the development and refinement of interventions targeting young adult waterpipe tobacco smoking.

Interventions for waterpipe smoking cessation

BACKGROUND

While cigarette smoking has declined globally, waterpipe smoking is rising, especially among youth. The impact of this rise is amplified by mounting evidence of its addictive and harmful nature. Waterpipe smoking is influenced by multiple factors, including appealing flavors, marketing, use in social settings, and misperceptions that waterpipe is less harmful or addictive than cigarettes. People who use waterpipes are interested in quitting, but are often unsuccessful at doing so on their own. Therefore, developing and testing waterpipe cessation interventions to help people quit was identified as a priority for global tobacco control efforts.  OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for people who smoke waterpipes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group Specialized Register from database inception to 29 July 2022, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), quasi-RCTs, or cluster-RCTs of any smoking cessation interventions for people who use waterpipes, of any age or gender. In order to be included, studies had to measure waterpipe abstinence at a three-month follow-up or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from waterpipe use at least three months after baseline. We also collected data on adverse events. Individual study effects and pooled effects were summarized as risk ratios (RR) and 95% confidence intervals (95% CI), using Mantel-Haenszel random-effects models to combine studies, where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarized secondary outcomes narratively. We used the five GRADE considerations (risk of bias, inconsistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for our primary outcome in four categories high, moderate, low, or very low.

MAIN RESULTS

This review included nine studies, involving 2841 participants. All studies were conducted in adults, and were carried out in Iran, Vietnam, Syria, Lebanon, Egypt, Pakistan, and the USA. Studies were conducted in several settings, including colleges/universities, community healthcare centers, tuberculosis hospitals, and cancer treatment centers, while two studies tested e-health interventions (online web-based educational intervention, text message intervention). Overall, we judged three studies to be at low risk of bias, and six studies at high risk of bias. We pooled data from five studies (1030 participants) that tested intensive face-to-face behavioral interventions compared with brief behavioral intervention (e.g. one behavioral counseling session), usual care (e.g. self-help materials), or no intervention. In our meta-analysis, we included people who used waterpipe exclusively, or with another form of tobacco. Overall, we found low-certainty evidence of a benefit of behavioral support for waterpipe abstinence (RR 3.19 95% CI 2.17 to 4.69; I2 = 41%; 5 studies, N = 1030). We downgraded the evidence because of imprecision and risk of bias. We pooled data from two studies (N = 662 participants) that tested varenicline combined with behavioral intervention compared with placebo combined with behavioral intervention. Although the point estimate favored varenicline, 95% CIs were imprecise, and incorporated the potential for no difference and lower quit rates in the varenicline groups, as well as a benefit as large as that found in cigarette smoking cessation (RR 1.24, 95% CI 0.69 to 2.24; I2 = 0%; 2 studies, N = 662; low-certainty evidence). We downgraded the evidence because of imprecision. We found no clear evidence of a difference in the number of participants experiencing adverse events (RR 0.98, 95% CI 0.67 to 1.44; I2 = 31%; 2 studies, N = 662). The studies did not report serious adverse events.   One study tested the efficacy of seven weeks of bupropion therapy combined with behavioral intervention. There was no clear evidence of benefit for waterpipe cessation when compared with behavioral support alone (RR 0.77, 95% CI 0.42 to 1.41; 1 study, N = 121; very low-certainty evidence), or with self-help (RR 1.94, 95% CI 0.94 to 4.00; 1 study, N = 86; very low-certainty evidence).  Two studies tested e-health interventions. One study reported higher waterpipe quit rates among participants randomized to either a tailored mobile phone or untailored mobile phone intervention compared with those randomized to no intervention (RR 1.48, 95% CI 1.07 to 2.05; 2 studies, N = 319; very low-certainty evidence). Another study reported higher waterpipe abstinence rates following an intensive online educational intervention compared with a brief online educational intervention (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70; very low-certainty evidence).  AUTHORS' CONCLUSIONS: We found low-certainty evidence that behavioral waterpipe cessation interventions can increase waterpipe quit rates among waterpipe smokers. We found insufficient evidence to assess whether varenicline or bupropion increased waterpipe abstinence; available evidence is compatible with effect sizes similar to those seen for cigarette smoking cessation.  Given e-health interventions' potential reach and effectiveness for waterpipe cessation, trials with large samples and long follow-up periods are needed. Future studies should use biochemical validation of abstinence to prevent the risk of detection bias. Finally, there has been limited attention given to high-risk groups for waterpipe smoking, such as youth, young adults, pregnant women, and dual or poly tobacco users. These groups would benefit from targeted studies.

Exploring motivation to quit and risk appraisals of hookah tobacco smoking for self and partner among a member of single and dual smoker couples

Negative health effects of waterpipe tobacco smoking (WTS) are likely more pronounced in dual rather than single smoker couples. Data on how smokers' perceived harms for self and partner differ between couple types and how these perceptions are associated with motivation to quit are needed. We examined these associations by surveying one member of dual smoker (i.e., both partners smoke) and single smoker (i.e., one partner smokes) couples who engages in WTS. We enrolled online adults ages 18-32 who engaged in WTS during the last month and were in a committed relationship of at least six months. Participants rated their harm to self and, when relevant, to partner, how much they were harming their partner due to their WTS, and partner's smoke exposure. Participants reported their motivation to quit. Of the 323 participants, 215 (67%) were in dual smoker couples. Participants in dual smoker couples reported lower own perceived risk, which correlated highly with perceived partner risk, than participants in single smoker couples; they also reported harming their partners more even though they downplayed how frequency of smoke exposure was harming the partner. Motivation to quit did not differ by couple type. Across couple types, motivation to quit increased with greater perceived harms. Smokers in dual compared to single smoker couples downplay their risks and perceived harms their smoking causes their partner. Interventions focused on harms to self and partner may be effective to increase motivation to quit and cessation in both couple types.

Knowledge, practices and beliefs of students regarding health effects of shisha use in Ouagadougou, Burkina Faso: A cross‑sectional study

Background

The tobacco epidemic is one of the biggest public health threats the world has ever faced. Shisha use has recently been gaining increased popularity in many developed and developing countries.

Objectives

To determine the prevalence of shisha use among students in Ouagadougou, Burkina Faso, and associated knowledge, smoking practices and beliefs about health effects.

Methods

A total of 443 students were selected for this cross-sectional study, using a stratified sampling method. Data on shisha use, knowledge about shisha, shisha smoking practices, and factors associated with use of shisha were collected via a questionnaire. The association between the independent variables and shisha use was assessed using a χ² test (p<0.05). Binary logistic regression analysis was used to determine variables that were independently associated with shisha smoking.

Results

Of the 421 respondents, 162 (38.5%) indicated that they had smoked shisha; 14.0% were regular smokers. We found that 183 students (43.5%) had poor knowledge about the health effects of shisha. The main reasons for shisha smoking were being in the company of friends who were users (57.4%), the pleasant flavour and fragrance of shisha (25.9%), and fashion (22.2%). Ninety-nine shisha smokers (61.1%) also consumed alcohol. Factors associated with shisha smoking included age <20 years (p<0.001), gender (p=0.034), and educational level of the respondent's father (p=0.0001) and mother (p=0.0004).

Conclusion

We found a relatively high prevalence of shisha smoking among the students, and that 43.5% of them had poor knowledge about its effects on health. Developing surveillance, intervention and regulatory/policy frameworks specific to shisha has become a public health priority.

Study synopsis

What the study adds. The study provides additional data from resource-poor settings such as Burkia Faso, where there is an overall high prevalence of Sisha smoking, and also among students who are poorly informed about the health effects of smoking. Implications of the findings. The data informs advocacy and intervention strategies to combat smoking and decrease overall tobacco use in an African setting.

Predictors of substance use disorder symptoms among women in Katsina State, Nigeria

BACKGROUND

Problems associated with substance use are on the rise among women in northern Nigeria, creating a need to understand factors contributing to this trend.

METHOD

Data on substance use, symptoms of substance use disorder (SUD) using DSM-5 criteria, and risk and protective factors associated with SUD symptoms, including adverse childhood experiences (ACE), were collected in a community-based study of young adult women (M age = 25.76, SD = 4.71 years) from Katsina State.

RESULTS

The analytic sample included 360 women with valid SUD symptom data. SUD symptoms were correlated in expected directions with the majority of risk and protective factors, including ACE. A hierarchical linear regression analysis predicting SUD symptoms revealed that age, ACE, and peer drug use were uniquely associated with higher levels of SUD symptoms; more education and endorsing a positive relationship with parents was associated with fewer SUD symptoms. Notably, ACE remained a unique contributor to SUD symptom totals in the context of protective factors and additional risk factors, although the association of ACE and SUD symptoms was attenuated.

CONCLUSIONS

These data illustrate the enduring impact of ACE on risk for SUD symptoms in women, and the protective role that a positive relationship with parents may play in reducing this risk. Further, these patterns of findings reveal the utility of assessing risk and protective factors across multiple life domains to gain a comprehensive picture of risk for SUD symptoms in women.

Messaging to prevent and reduce young adults' waterpipe tobacco smoking: A randomized trial

INTRODUCTION

More than 10% of U.S. young adults have smoked waterpipe tobacco in the past month and >25% of those who have never smoked are susceptible. We tested messages designed to prevent and reduce waterpipe tobacco smoking (WTS).

METHODS

In 2020, we recruited 830 U.S. young adults (18-30 years) who had never smoked waterpipe tobacco and were susceptible or currently smoked waterpipe tobacco for an online study. We randomized participants to intervention messages about the risks of WTS or control messages unrelated to tobacco. Participants had up to four message exposures over 12 weeks and completed two-, four-, and six-month follow-ups. Outcomes were WTS initiation and curiosity (susceptible never smokers), WTS frequency, cessation, motivation to quit (those who currently smoked), and WTS risk perceptions.

RESULTS

Intervention messages increased perceived addictiveness of WTS at two months (β = 0.27; 95% CI: 0.11, 0.43) in susceptible never smokers. There were no significant intervention effects in those who currently smoked. Exploratory analyses among intervention participants showed that higher dose of message exposure decreased WTS initiation at six months in susceptible never smokers (RR = 0.68; 95% CI: 0.48, 0.96) and decreased WTS frequency (IRR = 0.84; 95% CI: 0.73, 0.97) and increased cessation (RR = 1.31; 95% CI: 1.07, 1.59) at six months in those who smoked.

CONCLUSIONS

Although the WTS intervention messages had few significant effects on outcomes overall, a higher dose of message exposure affected behavioral outcomes in the intervention arm. Findings highlight the need to identify effective message content and optimal message dose, especially for digital media campaigns.

A qualitative analysis of Ethiopian and Eritrean Americans' initiation and continuation of hookah smoking

Hookah smoking is emerging as a popular social practice and health behavior risk among Ethiopian and Eritrean Americans. This qualitative study was the second phase of a sequential exploratory mixed methods study and examined factors that enable the initiation and facilitate the continuation of hookah smoking among Ethiopian and Eritrean Americans. Semi-structured interviews were conducted with twenty-five Ethiopian and Eritrean American hookah smokers residing in the Washington, DC Metropolitan Area of the United States. Interview questions were guided by the Theory of Planned Behavior and addressed: (1) initiation of hookah smoking, (2) past and current patterns of hookah smoking, and (3) behavioral, control and normative beliefs toward hookah smoking. Several themes were identified under the core constructs of 'factors influencing hookah smoking initiation' and 'factors influencing hookah smoking continuation' such as curiosity, lack of health knowledge, socio-cultural acceptance, accessibility, flavor, physical dependence, physiological effects and social connections. Based on these findings, it is recommended that future prevention activities (e.g. health messages) be embedded into a comprehensive tobacco prevention approach to address individual misperceptions of harm and addiction, community social norms and environmental access around hookah smoking, which contribute to both initiation and continuation in the Ethiopian and Eritrean American populations.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment

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.

Hookah Smoking among Brazilian University Students: An Exploratory Survey on the Prevalence and Perceptions of Addiction and its Harmfulness

Background

This study aimed to determine the prevalence, beliefs, attitudes, and perceptions of hookah use in a population of undergraduate students at a large public university in Brazil.

Methods

The sample consisted of 1348 undergraduate students aged over 18-year-old. They completed structured questionnaires on demographic information and close-ended questions on the past and current experiences of smoking hookah. The data underwent descriptive analysis and binary logistic regression.

Findings

Finally, 1298 valid survey forms were obtained from printed and digital questionnaires. More than half (53.9%) of participants reported having tried hookah at least once, however, only 10.8% reported they had experienced it within the last 30 days. The majority of the studied population presented acceptable beliefs about the harmfulness and addictive capacity of hookah smoking. However, when comparing the perceptions of those who had smoked and those who had never smoked hookah, and also, the perceptions of users and non-users, significant differences were observed. Students who were users or had already tried hookah showed a tendency to underestimate the deleterious effects of this type of smoking.

Conclusion

It could be concluded that hookah smoking was common among Brazilian university students. In addition, preoccupying misperceptions of hookah's harmfulness and addictive capacity were found. The results showed that the epidemic of hookah smoking, especially among young people, has spread far beyond the Arab world and the Persians. Accordingly, preventive measures must be taken if this population is to be protected from addiction and other serious health problems.

Water pipe smoking among public versus private university students in Ankara, Turkey: an online survey

Background

Water pipe smoking has become a global public health problem as its popularity increased over time, especially among youth. The objective of our study was to estimate water pipe tobacco smoking prevalence and to assess socioeconomic factors associated with ever water pipe smoking by public and private university students in Ankara, Turkey.

Methods

This descriptive study was based on a survey conducted among public (n=2685) and private (n=2485) university students via an online questionnaire on demographics and water pipe consumption patterns. For every student in the sample, a socioeconomic status index was calculated using principal component analysis. Binary logistic regressions for the outcome variable of ever-using water pipe yielded estimates of adjusted odds ratios (aORs) for the associated factors such as the respondent’s age, gender, university type, and socioeconomic status.

Results

The prevalence of ever use of water pipe was 69.1% (95% CI: 67.2-70.9%) among private and 59.1% (95% CI: 57.2-60.9%) among public university students. A substantial share of ever users were current users (25.5% in private versus 21.6% in public, p=0.008). On average, private university students had higher socioeconomic status than public university students (for example, access to a car (51.7% versus 35.8%, p=0.008), financial support from family (71.5% versus 65.1%, p<0.001)), also demonstrated by a higher socioeconomic status index. Being a private university student (aOR 1.57, 95% CI: 1.38-1.79), older (aORs 1.50 to 2.39, p<0.001), male (aOR 2.36, 95% CI:2.06-2.70), as well as having greater financial resources, such as having access to a car (aOR 1.24, 95% CI:1.07-1.42), or having income support from family (aOR 1.32, 95% CI:1.13-1.54), were associated with ever-using water pipe. A higher SES index was significantly associated with higher odds of ever using water pipe among both private (aOR 1.13, 95% CI:1.06,1.20) and public university (aOR 1.12, 95% CI:1.06,1.19) students.

Conclusions

Water pipe smoking was common in both public and private universities; however, private university students had higher odds of ever using water pipe. There is an urgent need to implement evidence-based interventions, taking into account the socioeconomic status of young adults, to prevent them from water pipe smoking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13616-9.

Motivators of impulsivity to smoke waterpipe tobacco among Nigerian youth who smoke waterpipe tobacco: the moderating role of social media normalisation of waterpipe tobacco

BACKGROUND

Impulsivity is a formidable cause of waterpipe tobacco smoking among youth, however, it is understudied among African youth. Using PRIME behavioural theory, this study aimed to develop a model that examines the motivators of impulsivity to smoke waterpipe tobacco in linkage to the moderating role of social media normalisation of waterpipe tobacco, specifically among youth in Nigeria who smoke waterpipe tobacco.

METHODS

Data were drawn from 695 respondents who smoke waterpipe tobacco across six Nigerian universities in the South-West zone using the chain-referral sampling procedure. Descriptive analyses of the obtained data were carried out using the Statistical Package for Social Sciences (SPSS) version 25. The constructs in the developed model were validated through Partial Least Squares Structural Equation Modelling (PLS-SEM) in SmartPLS version 3.

RESULTS

Among Nigerian youth who smoke waterpipe tobacco, intention (β = 0.442, P < 0.001) was the strongest motivator of impulsivity to smoke waterpipe tobacco as compared to positive evaluations (β = 0.302, P < 0.001). In addition, social media normalisation of waterpipe tobacco acted as a moderator that strengthened the relationship between intention and impulsivity (β = 0.287, P < 0.01), as well as, between positive evaluations and impulsivity (β = 0.186, P < 0.01) among youth.

CONCLUSION

Intention greatly instigates Nigerian youth's impulsivity to smoke waterpipe tobacco, and social media normalisation of waterpipe tobacco also considerably increases their impulsivity to smoke waterpipe tobacco. Youth-focused educational waterpipe tobacco cessation-oriented programmes that utilise diverse constructive-based learning approaches like illustrative learning and counselling, can help to enlighten and encourage Nigerian youth on the importance of shunning the desirability to smoke waterpipe tobacco.

Smoking Behavior among Adolescents: The Lebanese Experience with Cigarette Smoking and Waterpipe Use

(1) Background: The study aims to assess cigarette smoking and waterpipe experimentation among Lebanese adolescent school students with respect to their gender, region, age, and socioeconomic status. (2) Methods: This is a cross-sectional study, where students between 11 to 18 years of age were included from all over Lebanon. (3) Results: A total of 1133 students were interviewed. The total proportion of adolescents who ever experimented with cigarette smoking was 24.5%. Males experimented with cigarette smoking more commonly than females (31.9% vs. 19.1%; p < 0.001). Cigarette smoking experimentation was higher among students from the Beirut area (33.6%; p < 0.001) in comparison to other regions, and among those with poor health perception (29.1% vs. 19.8%; p < 0.001) compared to students with excellent health perception. The total proportion of adolescents who ever used a waterpipe was 33.9%. Waterpipes were significantly more experimented with among males than females (40.3% vs. 29.8%; p < 0.001), and among students with bad perception about their health (39.4% vs. 28.9%; p < 0.001). Adolescents who experimented with both cigarettes and waterpipes constitute 22.2% of the studied sample. (4) Conclusions: The rate of tobacco product use is alarming and constitutes a major public health issue for adolescents that urgently needs intervention. The findings raise important policy implications for the development of cigarette smoking prevention programs for youth.

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

OBJECTIVES

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

DESIGN, SETTING AND PARTICIPANTS

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

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Flavored waterpipe tobacco preferences, perceptions, and use in pregnant women: A latent factor mapping approach

Waterpipe tobacco (WPT) use is increasingly common in young adults including pregnant and reproductive-age women. Sweet flavors contribute to the appeal of WPT and are a promising regulatory target. The present study utilized correspondence analysis of contingency tables, a latent factor mapping technique, to investigate preferences and perceptions of WPT flavors in a sample of racially/ethnically diverse, low-income pregnant women. One hundred pregnant women (mean age = 26 years, 65% racial/ethnic minorities) completed a detailed interview regarding their use, preferences, and perceptions of WPT flavors. Eighty-three percent of participants reported lifetime WPT use; 11% reported prenatal WPT use. Pregnant women reported greatest use of and stronger preferences for sweet (fruit, candy, alcohol) and menthol/mint flavors, and weaker preferences for tobacco flavored WPT. Latent factor mapping revealed clustering of preferred sweet (fruit, candy, alcohol) and menthol/mint flavors versus tobacco flavors, with pungent flavors (coffee, chocolate, spice) clustering between sweet and tobacco flavors. Preferences for sweet and menthol/mint flavors distinguished pregnant women who reported lifetime WPT versus no lifetime WPT use, and prenatal WPT use versus no prenatal WPT use. Harm perceptions did not vary by flavor. Regulations to restrict the availability of WPT flavors may reduce the appeal and use of WPT, especially among pregnant women.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon

INTRODUCTION

Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes.

AIMS AND METHODS

We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis.

RESULTS

Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories.

CONCLUSIONS

Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture.

IMPLICATIONS

Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.

Effects of mental simulation of future waterpipe tobacco smoking on attitudes, perceived harms and intended use among young adults

The desire to engage in waterpipe tobacco smoking (WTS) may occur when smokers and nonsmokers conjure positive mental simulations of WTS. However, effects of these simulations on desire to smoke waterpipe tobacco and potential mediators are unexplored. This research addressed these effects among young adult waterpipe tobacco smokers and nonsmokers. Two online studies were conducted with adults ages 18-30. In Study 1, 200 smokers, 190 susceptible nonsmokers, and 182 nonsusceptible nonsmokers were randomized to mentally simulate or not WTS in the future. In Study 2, 234 smokers and 241 susceptible nonsmokers were randomized to four arms: no simulation or simulations that varied valence of experience (positive, negative or no valence provided). Main outcomes were immediate desire to smoke waterpipe tobacco, cognitive and affective attitudes, and perceived harms. In Study 1, mental simulations increased the desire to smoke waterpipe tobacco among smokers. In Study 2, asking participants to simulate WTS positively or with no valence instruction increased desire to smoke relative to negative valence instruction or no simulation. Negative simulations reduced perceived probability of smoking within a month compared to positive simulations. Effects on desire to engage in WTS were mediated by cognitive and affective attitudes among susceptible nonsmokers and by cognitive attitudes among smokers. These findings suggest that exploring when and how often mental simulations about WTS are evoked and their potency for promoting prevention and cessation of WTS merit further attention.

Factors Affecting Waterpipe Tobacco Smoking among University Students in Qatar

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

Waterpipe Tobacco Smoking among university students in Turkey

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Less than half (38.4%) of the participants smoke waterpipe.

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Female participants tend to smoke more waterpipe than male participants.

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Waterpipe tobacco smokers perceived waterpipe smoking less risky than non-smokers.

Introduction

Waterpipe tobacco smoking is common among adults in numerous Mediterranean countries. Waterpipe cafes where people are allowed to smoke waterpipe tobacco are an increasingly popular venue for socializing among young people. The aim of this study was to assess the frequency and patterns of waterpipe tobacco smoking among university students in Turkey, as well as their perception on the health-risk of smoking the waterpipe.

Method

A total of 411 university students in Turkey participated in this study. Participants completed a set of questionnaires to measure frequency, behaviours, and perceptions of the health risks related to waterpipe tobacco smoking.

Results

Less than half (38.4%) of the participants smoke waterpipe. Female participants tend to smoke more waterpipe than male participants. The mean age of first smoking waterpipe was 17 years. Waterpipe tobacco smokers perceived the health risks of smoking the waterpipe to be less addictive and exaggerated compared to non-users; smokers also regarded smoking waterpipe tobacco to help them to relax.

Conclusion

This study provided support that waterpipe tobacco smoking is common among young people in Turkey. There was poor awareness about the risk of waterpipe tobacco smoking among students. Our findings could inform tobacco control in Turkey, especially among young people.

Influencing Perceptions of Harm of Waterpipe Tobacco Smoking Among One Member of Couples Who Use Waterpipe

INTRODUCTION

Waterpipe tobacco smoking (WTS) often occurs socially, increasing health risks for the smoker and others through secondhand smoke effects. While messages on WTS harms enhance perceived risks for self, whether these messages elevate perceived risks for others, such as one's romantic partner who engages in WTS, is unclear. We tested this idea by surveying one member of dual-smoking couples who engages in WTS.

AIMS AND METHODS

As part of an online study, we enrolled adults ages 18-30 who engaged in WTS and were in a committed relationship of at least 6 months whose partner engaged in WTS. Participants were randomized to a control arm or to one of two arms consisting of watching a brief video on health harms or overcoming myths about WTS, respectively. Outcomes were perceived harms and measures of desire and probability of quitting for self and partner.

RESULTS

Participants (N = 238) who watched either video, compared with participants who did not watch a video, reported greater perceived health risks for self and partner and that their own WTS harmed their partner. Participants who watched either video reported a greater desire to quit for themselves, perceived that their partner had a greater desire to quit, and reported a higher likelihood of quitting together in the next 6 months.

CONCLUSIONS

Brief videos containing risk-based messaging increase young adult waterpipe tobacco smokers' perceived harms and desire to quit for self and partner. This can be a useful strategy to motivate cessation in couples who engage in WTS.

IMPLICATIONS

This study shows for the first time that at least among one member of dual-smoking couples who engages in WTS, brief videos on harms of WTS influences perceived harms and motivation to quit for the self and one's partner. This can be a useful strategy to promote cessation.

Sociocultural factors contributing to waterpipe tobacco smoking among adolescents and young adult women: a qualitative study in Iran

Purpose: Waterpipe tobacco smoking (WTS) is currently a serious and growing public health threat in the world, especially in adolescents and young women. The aim of the study was to explore sociocultural factors contributing to WTS among adolescents and young adult women in Iran. Methods: This qualitative study was conducted from August 2017 to January 2019 in Isfahan and Hamadan cities, Iran; it included 13-30-year-old females with experience of WTS. For data collection, in-depth semi-structured personal interviews were conducted at participants' preferred time and place. Concurrent with data collection, data were analysed through conventional content analysis. Results: The study participants described the various sociocultural factors contributing to WTS. These factors were categorized into four following main categories: waterpipe glamorization by its producers and sellers, media advertisement or silence, common sociocultural traditions, and governmental policies and regulations. Conclusion: A wide range of sociocultural factors affects WTS among Iranian adolescents and young adult women. Therefore, interdisciplinary multidimensional strategies are needed for WTS management and prevention among these at-risk groups. Public education, strict supervision of tobacco import, export, and selling, ample employment opportunities for young people and effective leisure time management are essential to reduce WTS.Abbreviation WTS: Waterpipe Tobacco Smoking; MPOWER: Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco.

Psychophysiological responses to hookah tobacco public education messages among young adults

OBJECTIVE

Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting.

METHOD

One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure.

RESULTS

The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks.

DISCUSSION

Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Integrating Self-Report and Psychophysiological Measures in Waterpipe Tobacco Message Testing: A Novel Application of Multi-Attribute Decision Modeling

BACKGROUND

Waterpipe (i.e., hookah) tobacco smoking (WTS) is one of the most prevalent types of smoking among young people, yet there is little public education communicating the risks of WTS to the population. Using self-report and psychophysiological measures, this study proposes an innovative message testing and data integration approach to choose optimal content for health communication messaging focusing on WTS.

METHODS

In a two-part study, we tested 12 WTS risk messages. Using crowdsourcing, participants (N = 713) rated WTS messages based on self-reported receptivity, engagement, attitudes, and negative emotions. In an in-lab study, participants (N = 120) viewed the 12 WTS risk messages while being monitored for heart rate and eye-tracking, and then completed a recognition task. Using a multi-attribute decision-making (MADM) model, we integrated data from these two methods with scenarios assigning different weights to the self-report and laboratory data to identify optimal messages.

RESULTS

We identified different optimal messages when differently weighting the importance of specific attributes or data collection method (self-report, laboratory). Across all scenarios, five messages consistently ranked in the top half: four addressed harms content, both alone and with themes regarding social use and flavors and one addiction alone message.

DISCUSSION

Results showed that the self-report and psychophysiological data did not always have the same ranking and differed based on weighting of the two methods. These findings highlight the need to formatively test messages using multiple methods and use an integrated approach when selecting content.

A Group-Based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers

INTRODUCTION

Adolescence represents a critical period in which nicotine dependence (ND) symptoms are developing. Little is known about waterpipe (WP) smoking and developmental trajectories of ND criteria across adolescence.

AIMS AND METHODS

Here, we aimed to identify ND trajectories from early- to late-adolescence in current (past 30 days) WP smokers and examine baseline correlates of each identified trajectory, using the International Classification of Diseases, 10th Revision (ICD-10). The analytical sample consisted of 278 current WP smokers from eight waves of an ongoing longitudinal cohort of eighth to ninth graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages 11-18.

RESULTS

A group-based modeling approach yielded a four-class solution that best fit the data and reflected differences in the timing of ND onset during adolescence: no-onset of ND (43.9%), early-onset (16.2%), mid-onset (26.6%), and late-onset (13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio [aOR] = 4.08, 95% confidence interval [95% CI] = 1.01% to 16.53%) and siblings who smoke WP (aOR = 3.95, 95% CI = 1.08% to 14.42%), exposure to favorite WP-specific advertisements (aOR = 3.33, 95% CI = 1.03% to 10.85%), and being a novelty seeker (aOR = 1.12, 95% CI = 1.02% to 1.23%) were associated with early-onset of ND. Daily (aOR = 3.48, 95% CI = 1.08% to 11.23%) or weekly (aOR = 2.20, 95% CI = 1.05% to 4.62%) WP smokers (vs. monthly) and having higher stress level (aOR = 1.07, 95% CI = 1.00% to 1.14%) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR = 0.11, 95% CI = 0.02% to 0.82%) and spending less than 60 minutes on a WP smoking session (aOR = 5.62, 95% CI = 1.20% to 26.44%) were associated with late-onset ND trajectory class.

CONCLUSIONS

Monitoring the development of ND trajectories among WP smokers may identify an individual as belonging to one of these four groups with distinct individual and socioenvironmental factors and allow the individual and health care providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions.

IMPLICATIONS

The results from this study showed a four-class trajectory of ICD-10-ND criteria and suggested that every ND trajectory class during adolescence could have distinctive characteristics and therefore provides new insights into the process of ND in terms of when and what specific interventions are needed to curb the development of ND and long-term WP smoking among youth.

A Pilot Study Assessing Reactions to Educational Videos on Harm of Waterpipe among Young Adults Susceptible to Waterpipe Tobacco Smoking

Young adults who never engaged in waterpipe tobacco smoking (WTS) yet are open to trying it, that is, are susceptible, is a high-risk group for initiation WTS. Very few interventions dissuade this group from WTS. Thus, we explored how four short videos that varied themes of WTS harms influenced susceptible young adults' risk perceptions, risk beliefs, and susceptibility to future WTS. As part of online cross-sectional study, 208 participants aged 18-34 were randomized to watch or not a short video; each video focused on different themes of WTS risks: physical harms, myths about WTS, addiction, and harms to others. The main outcomes were perceived personal risks, risk beliefs, perceived harm of WTS compared to cigarettes, and susceptibility to future WTS. Watching any video increased beliefs of harm of WTS and lowered susceptibility to future WTS compared to not watching a video. The theme of physical harms was most effective at increasing risk beliefs and lowering susceptibility to future WTS. All four videos were rated as credible, engaging, personally relevant, producing negative affect toward WTS, and effective at dissuading WTS. These promising findings suggest further testing is needed to determine if effects persist and prevent WTS among adults susceptible to WTS.

Characteristics of flavored and non-flavored waterpipe tobacco users: a real-world setting study

We aimed to compare sociodemographic characteristics, smoking patterns, beliefs and perceptions, nicotine dependence, and psychological indicators between flavored waterpipe (WP) tobacco (FWT) and non-flavored WP tobacco (non-FWT) smokers in Iran. A cross-sectional study was conducted in 94 WP-serving venues surrounding Tehran and Ardabil metropolitans in Iran. Convenience sampling was applied to select 900 current WP smokers [508 (56%) FWT-only and 392 (44%) non-FWT-only smokers] aged 18 years and older. Multivariable logistic regression was used to examine the independent characteristics of FWT and non-FWT smokers. Compared to non-FWT smokers, FWT smokers were younger (adjusted odds ratio [AOR]=0.88, 95% confidence interval [CI]: 0.87-0.90) and more likely to have ≥ 1 sibling who smoked WP (AOR=1.54, 95% CI: 1.06-2.24), share WP with others (AOR=2.52, 95% CI: 1.68-3.77), report current cigarette smoking (AOR=2.05, 95% CI: 1.23-3.42), and report confidence in quitting at any time (AOR=3.64, 95% CI: 2.45-5.39). FWT smokers were less likely to have seen (AOR=0.40, 95% CI: 0.27-0.60) or read (AOR=0.44, 95% CI: 0.24-0.80) warning messages on WP tobacco packages relative to non-FTW smokers. The most common self-reported reason for smoking WP was entertainment for both groups, followed by stress relief for non-FWT smokers and the escape from loneliness for FWT smokers. FWT-only smokers differ from non-FWT-only smokers in several aspects including being younger, having more positive beliefs and perceptions regarding WP use, and having higher cigarette smoking prevalence. These findings will help in developing more effective and targeted policies and cessation interventions for WP smokers according to flavor type they use, especially in the Middle East.

Key Informant Perspectives on Somali Adolescent Tobacco Use: Contextualizing Influences and Prevention Opportunities

INTRODUCTION

Somali American adolescent tobacco use has increased over the past decade amid a high prevalence of tobacco use among Somali American adults. While established adolescent tobacco use determinants may apply for Somali youth, a deeper understanding of these influences is imperative to the development of effective prevention strategies for this population. This study aimed to identify risk and protective factors influencing Somali American adolescent tobacco use decision making and potential family and community roles in tobacco prevention.

METHOD

We conducted 15 semistructured, in-depth interviews with 12 Somali and 3 non-Somali professionals serving Minnesotan metropolitan Somali communities in clinical, educational, religious, and other community organizations. Grounded Theory informed our data collection and analysis.

RESULTS

Key informants cited three major influences on Somali adolescent tobacco use: evolving norms and increasing exposure to tobacco products in the United States, low risks perception, especially for waterpipes, and conflicting interpretations of faith. Informants highlighted the important roles of families in Somali youth tobacco prevention while acknowledging areas where families would benefit from greater support. Proposed sources of support included faith communities and nonparental, ethnically similar adult mentors. Informants acknowledged challenges to addressing youth tobacco prevention in clinics and underscored the importance of youth involvement in developing prevention strategies.

CONCLUSIONS

Our results indicate Somali adolescent tobacco prevention efforts should address the evolving tobacco use exposures and norms, low risk perceptions, and clarify faith messaging. Effective strategies may include strengthening family-based tobacco prevention approaches that also engage faith and other community leaders along with youth themselves.

Aspects associated with waterpipe smoking in Iranian youths: a qualitative study

BACKGROUND

Waterpipe is one of the oldest methods of tobacco smoking, which has become the public health challenge, especially in the Eastern Mediterranean countries such as Iran. This study aimed to investigate the waterpipe smoking (WPS) in the young people of Kermanshah in 2020, using a qualitative method.

METHODS

This was a qualitative study conducted with the approach of content analysis. Participants were young waterpipe user aged 17 to 25 years selected by purposeful sampling method in Kermanshah city, located in the west of Iran. Data were collected through semi-structured interviews in face-to-face and audio-recorded methods based on an interview guideline during June to August 2020. Then researchers transcribed verbatim and analyzed the content of the interviews thematically.

RESULTS

In this study, 23 young people who were waterpipe users at the time of the study participated. The results showed that social aspects in three sub-categories were involved in WPS including "socio-cultural aspects", "socio-environmental aspects", and "social relations". Individual aspects of waterpipe use as second category also consisted of two sub-categories including "motivational aspects" and "lack of psycho-protective aspects".

CONCLUSIONS

It seems that the implementation of the policy of reducing access to waterpipe in public environments is effective in reducing waterpipe consumption. It is suggested that educational and interventions, based on targeted models and theories be implemented in order to increase young people's belief and perception on dangers of WPS, and to improve their self-efficacy to smoking cessation.

Tailored Mobile Messaging Intervention for Waterpipe Tobacco Cessation in Young Adults: A Randomized Trial

Objectives. To test a tailored mobile health (i.e., mHealth) intervention for waterpipe tobacco cessation in young adults. Methods. From 2018 to 2020 at 2 US sites, we conducted a randomized trial with 349 waterpipe tobacco smokers aged 18 to 30 years randomized to control (no intervention), untailored, or tailored intervention arms. Intervention arms received a 6-week mHealth intervention conveying risks of waterpipe tobacco through text and images and strategies to enhance motivation and support quitting. The tailored intervention was personalized to baseline measures and intervention text message responses. Risk appraisals, motivation to quit, waterpipe smoking frequency, and cessation were assessed at 6 weeks, 3 months, and 6 months. Results. At 6 months, cessation was higher in the tailored (49%) than the control arm (29%; odds ratio = 2.4; 95% confidence interval = 1.3, 4.2) and smoking frequency was lower in the tailored (mean = 3.5 days) than the control arm (mean = 4.3 days; P = .006). At interim follow-ups, significant differences in other outcomes favored the tailored intervention. Conclusions. Tailored mobile messaging can help young adult waterpipe tobacco smokers quit. This scalable intervention is poised for population implementation.

Initial development of the Hookah Smoker Scale: Assessing young adults' mental schemas about hookah "smokers"

Many young adult hookah tobacco users do not consider themselves hookah "smokers," but data on this topic are limited. There are no existing measures of young adults' mental schemas of hookah "smokers." We examined the factor structure and reliability of the Hookah Smoker Scale and examined associations with perceived harm and addictiveness and attitudes toward hookah. Two hundred and forty-six young adult (ages 18-30) hookah smokers participated in a cross-sectional online study. Participants completed items assessing schemas characterizing hookah smokers and valid measures of perceived harm and addictiveness of hookah smoking, risk appraisals, and attitudes toward hookah. Exploratory factor analysis using principal axis factoring with oblique rotation extracted a 12-item scale with three dimensions (Regular Use, Social-Enabled Use, and Self-Enabled Use). The scale explained 69.7% of the variance (eigenvalue = 9.2). Cronbach's α for the scale was .89, with Cronbach's α ≥ .80 for four-item subscales. Higher subscale scores indicate stronger beliefs that the dimension characterizes a hookah smoker. Higher Regular Use scores (score variance = 46.9%; eigenvalue = 5.6) were associated with greater perceived harm and addictiveness (β = 0.21, p = .01), greater risk appraisals (β = 0.20, p = .02), and more negative attitudes toward hookah (β = -0.18, p = .03). The Hookah Smoker Scale is a promising measure that can be used to identify targets for preventing and reducing young adults' hookah tobacco use. Findings also suggest young adults associate health risks of hookah with daily smoking, but not with intermittent social smoking patterns.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Waterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.

Waterpipe Tobacco Warnings: An Experimental Study among a Nationally Representative Sample of U.S. Young Adults

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.

Ceftriaxone Reduces Waterpipe Tobacco Smoke Withdrawal-induced Anxiety in rats via Modulating the Expression of TNF-α/NFĸB, Nrf2, and GLT-1

Tobacco exposure has been linked to neuroinflammation and adaptive/maladaptive changes in neurotransmitter systems, including in glutamatergic systems. We examined the effects of waterpipe tobacco smoke (WTS) on inflammatory mediators and astroglial glutamate transporters in mesocorticolimbic brain regions including the prefrontal cortex (PFC), nucleus accumbens (NAc) and ventral tegmental area (VTA). The behavioral consequences of WTS exposure on withdrawal-induced anxiety-like behavior were assessed using elevated plus maze (EPM) and open field (OF) tests. Male Sprague-Dawley rats were randomly assigned to 3 experimental groups: a control group exposed only to standard room air, a WTS exposed group treated with saline vehicle, and a WTS exposed group treated with ceftriaxone. WTS exposure was performed for 2 h/day, 5 days/week, for 4 weeks. Behavioral tests (EPM and OF) were conducted weekly 24 h after WTS exposure, during acute withdrawal. During week 4, rats were given either saline or ceftriaxone (200 mg/kg i.p.) 30 min before WTS exposure. WTS increased withdrawal-induced anxiety, and ceftriaxone attenuated this effect. WTS exposure increased the relative mRNA levels for nuclear factor ĸB (NFĸB), tumor necrosis factor-α (TNF-α), and brain-derived neurotrophic factor (BDNF) in the PFC, NAc and VTA, and ceftriaxone treatment reversed these effects. In addition, WTS decreased the relative mRNA of nuclear factor erythroid 2 related factor 2 (Nrf2), glutamate transporter 1 (GLT-1) and cystine-glutamate transporter (xCT) in PFC, NAc and VTA, and ceftriaxone treatment normalized their expression. WTS caused neuroinflammation, alteration in relative mRNA glutamate transport expression, and increased anxiety-like behavior, and these effects were attenuated by ceftriaxone treatment.

Hookah venue employees' knowledge and perceptions of hookah tobacco smoking

BACKGROUND

Recent years showed sharp proliferation of hookah bars worldwide with scarcity of workplace safety regulations. Hookah server employees are at high risk for elevated harm. This study reported hookah smoke exposure, assessed acute problems and evaluated factors related to knowledge of hookah-smoking harm and toxicity among high-risk hookah servers.

METHODS

A mixed methods design was employed. A self-reported questionnaire was distributed online, and semistructured in-depth interviews were used. Hookah server employees were recruited using snowball sampling, with 52 participants included in quantitative analyses and 10 participating in semistructured interviews.

RESULTS

Hookah server employees took a median 389 hookah puffs per workday compared with 169-170 per session for customers. Servers were limited in knowledge of potential hookah harms and smoke toxicant exposure. Almost all believed that hookah water bowls filtered out toxicants. Smoking with family members (p=0.012) was associated with lower knowledge scores for hookah harms and exposure. Hookah server employees reported carbon monoxide-poisoning symptoms of dizziness, headaches and fainting during work but believed their bodies would adapt. Home remedies were taken to alleviate symptoms. Work environment and salary attracted hookah server employees to their position and none considered quitting for reasons of harm.

CONCLUSION

Findings demonstrate need for workplace policies and regulations to protect hookah server employees and provide targets for educational interventions for high-risk hookah server employees.

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.

Waterpipe smoking, internet addiction and depression: A public health problem trio?

BACKGROUND

Waterpipe smoking and Internet addiction may result in a new public health problem globally. This study aimed to explore waterpipe use among a large group of adolescents and its association with Internet use, mental health, primarily depression and their demographic characteristics.

METHODS

Using a stratified random sampling method, 2054 tertiary school students aged 14-18 years were recruited in 2019. Demographical information and use of tobacco products (eg, waterpipe) were explored and compared with severity of Internet addiction and mental status.

RESULTS

A total of 288 (14.0%) adolescents had ever used waterpipe. Multivariate logistic regression analyses suggested that being male (OR = 2.55 and 95% CI = 1.98-3.30; P = .0001), being depressed (OR = 1.62 and 95% CI = 1.24-2.11) and excessive Internet use (OR = 1.94 and 95% CI = 1.50-2.52; P = .0001) were significantly associated with waterpipe use. Family income and parents' educational status showed no relationship with waterpipe smoking.

CONCLUSIONS

We suggest that adolescents who are depressed and who use the Internet excessively are at an increased risk for waterpipe use, independent of income and parenteral education.

Transitions in frequency of hookah smoking among youth and adults: findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study, 2013-15

BACKGROUND AND AIMS

The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers.

DESIGN

Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at wave 1 (2013-14); frequency of hookah smoking and past-year cessation were ascertained at wave 2 (2014-15). Weighted multivariable logistic and ordinal logistic regression models were fitted to predict hookah smoking cessation and frequency of hookah smoking at wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking and frequency of hookah smoking at wave 1.

SETTING

United States.

PARTICIPANTS

A total of 693 youth and 4400 adult past-year hookah smokers.

MEASUREMENTS

Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI).

FINDINGS

At wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Among all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, the availability of appealing flavors and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors [adjusted odds ratio (aOR) = 0.40; 95% confidence interval (CI) = 0.26-0.62] compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly or more frequent hookah smoking at wave 2, compared with cessation or less than monthly smoking, were higher for adults who liked hookah flavors [adjusted proportional odds ratio (aPOR) = 2.10; 95% CI = 1.48-2.99 and enjoyed socializing while smoking hookah (aPOR = 1.82; 95% CI =1.13-2.94) compared with adults who did not like hookah flavors or socializing.

CONCLUSION

The availability of appealing flavors, affordability and socialization while smoking hookah in the United States are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Cigarettes versus water-pipes: Differences and similarities in factors predicting the use of cigarettes and water-pipes among young male adults according to the planned-behaviour theory

Cigarette and water-pipe smoking are responsible for substantial harmful health consequences. However, studies have often examined these two types of smoking in separate study samples. Thus, this study examined differences and similarities among factors predicting cigarette and water-pipe smoking according to planned-behaviour theory within the same sample. Two hundred and twenty-one young Arab Israeli male adults (N = 221) completed demographic, self-esteem and planned-behaviour questionnaires. The study findings demonstrated that perceived ability to control one's water-pipe use was significantly higher than perceived ability to control one's use of cigarettes. With regard to attitudes, norms and intentions, no significant differences were found between cigarette and water-pipe use. Hierarchal multiple regressions showed that being Muslim, self-esteem, negative attitudes and negative norms contributed to the explained variance of both cigarette and water-pipe smoking. Self-control contributed to the variance in cigarette smoking, but not water-pipe smoking. The findings make an important contribution to our understanding of the differences and similarities in the factors predicting cigarette and water-pipe use among young male adults. Theoretical and clinical implications are discussed.

[The use of water pipe and its impact on university students' lifestyle and their psychological distress: a cross-sectional study.]

OBJECTIVE

In Spain, water pipe is a common device for substance abuse. It is the second most widespread way of cannabis abuse (11.9%) between young people from 14 to 23 years old. This use has become a public health problem, because of an intensive consumption in young people is considered as a predictor of excessive consumption in adulthood, and it causes health problems and increases the health costs. The aim of this study was to analyze the relationship between water pipe use, lifestyle (diet, physical activity and sleep) and psychological distress, also considering unexpected effects, in university students.

METHODS

An observational and cross-sectional study was carried out, on a sample of 825 students from the University of Huelva, selected by random sampling stratified by conglomerates. The instruments used were extracted from a larger study called "Health Behavior in University". SPSS 26.0 software was used for statistical analysis and statistical analysis was performed on the data collected.

RESULTS

The use of water pipe was associated with less adherence to the Mediterranean diet (t=1.64; p=0.04; d=0.12), a lower number of hours of sleep during weekends (t=2.12; p =0.03; d=0.14) and with intense physical activity (t=-1.80; p=0.07; d=0.13). On the contrary, it was not associated with psychological distress.

CONCLUSIONS

The use of water pipe seems to be inversely related to some aspects of a lifestyle that could be associated with long-term metabolic and respiratory diseases.

Perceptions of Waterpipe Smoking among Young Adults: A Phenomenological Study

BACKGROUND

Waterpipe tobacco smoking is becoming increasingly popular in the West among young people. Given the associated health risks of this behaviour, we aimed to investigate why young adults take up waterpipe tobacco smoking and their attitudes to the associated risks.

METHODS

This was a qualitative study, with a phenomenological perspective. Focus groups and face-to-face semi-structured interviews were conducted among waterpipe smokers aged 20-30 years living in London, UK. Transcripts were analysed using constant comparison and cycling between the data and analysis. Data collection continued until thematic saturation was achieved.

RESULTS

Sixteen smokers attended focus groups and face-to-face interviews. Seven main themes emerged encompassing four main dimensions relating to: lack of knowledge, perceived risk, affordability, and social addiction. Waterpipe was perceived to be safer than cigarette smoking due to the pleasant odour, fruity flavours, and belief that water filtered the toxins. The waterpipe had become a "social addiction" enhancing group atmosphere, was cheap and did not have the dangers of violence or hallucinations associated with other addictions like alcohol and drugs. Because of their intermittent smoking patterns and the lack of statutory warnings, none felt they were not at risk of any adverse side effects.

CONCLUSIONS

Waterpipe smoking is a growing public health problem; the social environment associated with its use is perceived to be a positive outlet by smokers who do not consider it harmful to their health. These perceptions need to be addressed urgently by anti-smoking policies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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