Early symptoms of nicotine dependence among adolescent waterpipe smokers

Psychometric evaluation of a new instrument to hookah tobacco smoking-related factors in the Iranian female university students based on the Extended Parallel Process Model

BACKGROUND

The higher prevalence of hookah tobacco smoking (HTS) has become worrisome in women. Thus, it is essential to identify and measure the perceptions associated with this unhealthy behavior as well as the type of response to risk messages to design the effective programs. This study aimed to psychometric evaluation of a new instrument, named the Extended Parallel Process Model-Hookah Tobacco Smoking Questionnaire (EPPM-HTSQ), for female university students.

MATERIAL AND METHODS

This methodological study was conducted in 2019-2020 in central and western Iran. The first version of the instrument was developed with 97 items. Face, Content, and construct validity methods were used to assess the EPPM-HTSQ validity. The data viability for factorability was guided through Kaiser-Meyer-Olkin (KMO) measure of sample adequacy (Values >0.7) and Bartlett's test of Sphericity (P < 0.05). The Exploratory Factor Analysis (EFA) method with varimax rotation and SPSS software was performed to identify the main factors of the questionnaire and interpretable factors. The internal consistency and external reliability were determined. The test-retest was used for evaluating the stability of tools.

RESULTS

During the assessment of the face and content validity 71 items remained in the questionnaire. EFA led to the extraction of nine dimensions: "Focusing on superior rewards," "Response Efficacy," "Perceived physical threat," "Perceived social threat," "Self-efficacy," "Fear control," "Attitude," "Fear," and "Intention" Kaiser-Meyer-Olkin (KMO) test (0.957) and Bartlett's test (P < 0.001). Cronbach's alpha (0.871-0.951) and ICC (0.985-0.998) were approved for scale dimensions.

CONCLUSION

Important findings of the present study were the development and validation of the EPPM-HTSQ for measuring EPPM variables in relation to HTS; introducing a new variable "focusing on superior rewards"; as well as, the new classification of the concept of "perceived threat." The final version of the EPPM-HTSQ is a valid and reliable tool, but it is suggested to be re-evaluated in other studies with different populations and sample sizes.

Factors contributing to the rising prevalence of waterpipe smoking dependence among university students: a cross-sectional study

INTRODUCTION

Waterpipe smoking (WPS) has been associated with a variety of adverse health effects, consequences, and symptoms of nicotine dependence. This study aims to determine the prevalence of WPS dependence among Palestinian university waterpipe smoking students, their normative beliefs about WPS, and their relationship to dependence.

METHODS

A cross-sectional study of current WPS university students at five major Palestinian universities was conducted from September to December 2022. Participants were recruited using convenient sampling, and data collection was carried out via an interviewer-administered questionnaire. We assessed students' WPS dependence using the Lebanese Waterpipe Dependence Scale. We used the Poisson regression model with robust variance to analyze factors independently associated with high WPS dependence.

RESULTS

The study included 746 current WPS university students. Results revealed a high prevalence of WPS dependence, with 69.4% (95%CI: 66.0-72.7%) exhibiting high dependence. Factors contributing to high WPS dependence included dual cigarette smoking (aPR: 1.18; 95%CI: 1.12-1.25), studying medical sciences (aPR: 1.13; 95%CI: 1.10-1.18), friends' approval of WPS (aPR: 1.25; 95%CI: 1.17-1.34), daily WPS frequency (aPR: 1.98; 95%CI: 1.39-2.23), spending more than 50% of daily allowance on WPS (aPR: 1.37; 95%CI: 1.10-1.64), and morning WPS sessions (aPR: 1.97; 95%CI: 1.31-2.27). The study highlighted the influence of social factors, such as peers' approval and perceived prevalence, on WPS dependence.

CONCLUSIONS

WPS dependence is prevalent among university students, and it is associated with morning WPS, dual smoking, and increased WPS frequency. Notably, peer and cultural factors are essential primary motivators. As a result, it is critical to incorporate WPS considerations into Palestine's antismoking health promotion program. Therefore, it is vital to incorporate WPS into the Palestinian antismoking health promotion policy, and the health education of adolescents regarding the dangers of WPS should coincide with antismoking initiatives.

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.

Genotoxicity of waterpipe smoking in young adults from Sarajevo, Bosnia & Herzegovina

Background

Waterpipe, also known as a hookah or narghile, is a type of tobacco products consumption device. Recently it has been increasingly popular in Bosnia and Herzegovina and the region. Waterpipe consumers are predominantly adolescents and young adults. Many of them believe in slighter harmful effects of waterpipes, compared to cigarettes. We aimed to determine the DNA damage in oral leukocytes and buccal cells of young individuals who have smoked a waterpipe for more than one year.

Methods

The study group consisted of 40 cigarette non-smokers who regularly smoked a waterpipe on average of once per week. As a control, 40 non-smoking individuals were selected to match smokers for age. All participants in the study were healthy male and female adults from Bosnia and Herzegovina, 18-30 years of age. Before sampling, detailed survey and informed consent have been provided by each participant. Comet assay in oral leukocytes and buccal micronucleus cytome (BMCyt) assay in exfoliated buccal cells were applied.

Results

Almost half of waterpipe smokers (WPS) tasted waterpipe at 15-16 years of age. Comet assay analysis showed increased tail intensity, tail length, and tail moment values among WPS compared to non-smokers (NS) (p = 0.0001, p = 0.0067, and p = 0.0001, respectively). Frequencies of the micronucleated (p = 0.0004), binucleated (p = 0.01), karyorrhectic, (p = 0.0036), and pycnotic cells (p = 0.03) were significantly higher in WPS compared to NS group.

Conclusions

Genotoxicity and DNA damage biomarkers were increased in oral leukocytes and exfoliated buccal cells of young waterpipe smokers from Bosnia and Herzegovina, compared to NS group.

Factors Predicting Dependence on Waterpipe Smoking Among Waterpipe Exclusive Smokers

ABSTRACT

The current study targeted a sample of waterpipe (WP) exclusive smokers to identify the levels and predictors of dependence on this smoking pattern and to examine the relationship between WP smoking (WPS) dependence and depressive symptoms. A cross-sectional research design was employed with a community sample of 270 subjects who are currently WP exclusive smokers. Assessment of WPS dependence and depressive symptoms was performed using self-report measures. About 62.6% of the subjects were WPS dependent. The unique significant predictors of WPS dependence were age, depression levels, age of starting WPS, duration of WPS, income, smoking WP daily, the belief of being attracted to WPS, and the desire to stop WPS. These predictors explained 35% of the variance in WPS dependence. WPS dependence was associated with increased depressive symptoms. Although few studies have been conducted, the WPS dependence prevalence appears to be alarmingly high among WP exclusive smokers. Factors associated with WPS dependence provide useful information that can be used to tailor WP prevention interventions.

"Waterpipe Is Like a Wife": Qualitative Assessment of Perspectives on Waterpipe Smoking Dependence

BACKGROUND

Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey- or laboratory-based studies. This study employed qualitative methods to explore WP users' perceptions of dependence in Aleppo, Syria.

METHODS

A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis.

FINDINGS

Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included positively reinforced features, such as smoking's association with social gatherings and cultural connectedness, and negatively reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting one's behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at the expense of other reinforcers such as social interaction.

CONCLUSION

The general and specific features of WP dependence need to be considered in developing instruments to measure WP dependence, in clinical assessment of WP dependence, and in developing cessation programs.

Nicotine Dependence from Different E-Cigarette Devices and Combustible Cigarettes among US Adolescent and Young Adult Users

E-cigarettes, the most popular tobacco product among adolescents, vary widely in design and nicotine composition; thus, different devices may have different addictive potential. However, few studies examine levels of nicotine dependence across devices among adolescent and young adult (AYA) e-cigarette users. To assess the extent of nicotine dependence among US AYA (ages 13-24) by e-cigarette device type, we conducted a large, national, cross-sectional survey (n = 4351) and used the Hooked on Nicotine Checklist (HONC) to assess levels of nicotine dependence among those who had used disposable, pod-based, and/or mods/other e-cigarette devices in the past 30 days. We also examined HONC scores among those who had used combustible cigarettes in the past 30 days, whether with or without using e-cigarettes. Patterns of nicotine dependence were comparable across those who had used a combustible cigarette and/or e-cigarette in the past 30 days, with 91.4% of combustible cigarette users, 80.7% of disposable e-cigarette users, 83.1% of pod-based e-cigarette users, and 82.5% of mods/other e-cigarette users showing signs of nicotine dependence, as measured by endorsing at least one HONC symptom. This pattern persisted when analyses were restricted to e-cigarette only users, with more than 70% of all e-cigarette only past-30-day users endorsing at least one HONC symptom, across all types of devices. A thorough understanding of the extent and presentation of nicotine dependence among AYA will help researchers, public health officials, and clinicians recognize and manage AYA nicotine dependence.

Biomarkers of nicotine exposure correlate with the Hooked on Nicotine Checklist among adolescents in California, United States

BACKGROUND

The Hooked on Nicotine Checklist (HONC) has been used to assess nicotine dependence (loss of autonomy over tobacco) among adolescents. Existing HONC validation studies for non-cigarette products, such as electronic cigarettes (e-cigarettes), have generally not considered biomarkers of nicotine exposure.

METHODS

Within a cross-sectional sample of California (USA) high school students (total N = 1396; mean age 15.2 years; 56% female; 54% Hispanic/Latinx), self-reported past 30-day users of any tobacco (including e-cigarettes) completed a modified 10-item HONC questionnaire and provided saliva samples (N = 318 samples, including N = 234 exclusive past 30-day e-cigarette users). Samples were analyzed for cotinine using liquid chromatography-tandem mass spectrometry (lower limit of quantification: 1.0 ng/mL).

RESULTS

Across four categories of HONC score corresponding to an increasing number of reported dependence symptoms (scores: 0, 1, 2-4, 5-10), the prevalence of quantifiable salivary cotinine increased among past 30-day tobacco users (20%, 21%, 38%, 55%, respectively, P-for-trend < 0.001) and among past 30-day exclusive e-cigarette users (15%, 22%, 31%, 42%, respectively, P-for-trend = 0.001). Among participants with quantifiable cotinine levels, HONC total score and cotinine were positively correlated among past 30-day tobacco users (n = 89; Spearman rho = 0.449; P < 0.001) and past 30-day exclusive e-cigarette users (n = 49; Spearman rho = 0.520; P < 0.001). HONC score was also associated with past 30-day frequency of tobacco product use and reported use of tobacco within 30 min of waking.

CONCLUSIONS

These results support the validity of HONC to assess nicotine dependence among adolescents. Dependence symptoms may be experienced at low levels of nicotine exposure.

Latent class analysis of initial nicotine dependence among adult waterpipe smokers

Waterpipe (WP) tobacco smoking increases the risk of smoking-related health problems. In this study, we sought to identify the unobserved class memberships of WP-associated initial nicotine dependence (ND) symptoms and assess the predictors of each latent class. This cross-sectional study was conducted among a convenience sample of 900 current (past 30-day) WP smokers who were recruited from 94 WP-serving venues surrounding Tehran and Ardebil metropolitans in Iran. All participants completed a self-administrated questionnaire. We performed latent class analysis using PROC LCA in SAS to identify class memberships of initial ND symptoms using 10-item Hooked on Nicotine Checklist. Five latent classes were identified as non-dependent (25.4 %), low dependent (7.1 %), low-moderate dependent (19.6 %), moderate dependent (15.6 %), and high dependent (32.2 %). Using flavored WP tobacco significantly increased the odds of belonging to low-moderate dependent class [adjusted OR (aOR) = 1.89; 95 % confidence interval (CI): 1.07-3.34] compared to non-dependent class. Also, having academic education decreased the odds of belonging to low-moderate dependent (aOR = 0.43; 95 %CI: 0.26-0.67) and moderate dependent (aOR = 0.39; 95 %CI: 0.23-0.67) class in comparison to non-dependent class. Also, WP smoking initiation at an older age was associated with belonging to high dependent (OR = 2.05; 95 %CI: 1.39-3.03) class compared to non-dependent. This study revealed that nearly half of WP smokers fell under moderate and high-dependent classes. Our findings showed that some items of HONC had more role in the clustering of participants based on ND symptoms. The WP-specific cessation programs and targeted clinical trials should consider the diversity of ND levels among smokers to achieve successful quit rates among these smokers. Additionally, limiting flavors would be a strong strategy to limit the rate of ND, especially among young people who are eager to smoke flavored WP 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).

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.

Lebanese Waterpipe Dependence Scale (LWDS-11) validation in a sample of Lebanese adolescents

Background

Salameh et al. developed the Lebanese Waterpipe Dependence Scale (LWDS-11) that assesses nicotine dependence among adult waterpipe smokers. In view of the high waterpipe use among Lebanese youth and other neighboring countries, it was deemed necessary to check the psychometric properties of the LWDS-11, originally adapted to the Lebanese population, to measure nicotine dependence among adolescents.

Methods

Two cross-sectional investigations were conducted; Study 1 (January and May 2019) enrolled a total of 449 students who were exclusive waterpipe smokers; this sample was used to conduct the exploratory factor analysis. Study 2 enrolled another sample composed of 243 waterpipe smoking adolescents. This sample was independent from the first one and was used to conduct the confirmatory analysis.

Results

The results also showed that 312 (69.5%) [95% CI 0.652–0.738] had high waterpipe dependence (scores of ≥10). Results of the factor analysis in sample 1 showed that all LWDS-11 items were extracted following the factor analysis. Items converged over a solution of one factor; total variance explained = 70.45%, α_Cronbach = 0.96). The results of the confirmatory factor analysis were as follows: the Maximum Likelihood Chi-Square = 129.58 and Degrees of Freedom = 45, which gave a χ²/df = 2.88. For non-centrality fit indices, the Steiger-Lind Root Mean Square Error of Approximation (RMSEA) was 0.08 [0.071–0.106]. Moreover, the Comparative Fit Index (CFI) value was 0.77.

Conclusion

The preliminary results suggest that the LWDS-11 has good psychometric properties to measure waterpipe dependence among adolescents. We hope this tool would serve the benefit of research and epidemiology.

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.

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. 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, 10thVersion(ICD10).

METHODS

The analytical sample consisted of 278 current WP smokers from 8-waves of an ongoing longitudinal cohort of 8 th-9 th-graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages11-18.

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(16.2%), mid(26.6%), and late-onset(13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio[aOR]=4.08, 95%confidence interval:1.01-16.53) and siblings who smoke WP(aOR=3.95:1.08-14.42), exposure to favorite WP-specific advertisements(aOR=3.33:1.03-10.85), and being a novelty seeker(aOR=1.12:1.02-1.23) were associated with early-onset of ND. Daily(aOR=3.48:1.08-11.23) or weekly(aOR=2.20:1.05-4.62) WP smokers (vs. monthly) and having higher stress level (aOR=1.07:1.00-1.14) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR=0.11:0.02-0.82) and spending >60 minutes on a WP smoking session(aOR=5.62:1.20-26.44) 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 socio-environmental factors, and allow the individual and healthcare providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions.

Adaptation of the Young Adults' Cigarette Dependence (YACD) Scale for the development and validation of the Adolescent Cigarette Dependence Scale (ACDS)

Vulnerable adolescents may lose control over cigarette use within a day or two after smoking their first cigarette, as nicotine dependence (ND) symptoms may appear before actual daily smoking and usually occur at low levels of daily smoking. Moreover, smoking can cause illnesses and promote other types of substance abuse. Therefore, it was deemed essential to adapt the Young Adults' Cigarette Dependence (YACD) Scale to develop and validate the Adolescent Cigarette Dependence Scale (ACDS) in Lebanese adolescents and evaluate whether cumulative cigarette smoking is associated with nicotine dependence and symptoms of dependence. A cross-sectional study was carried out between August and September 2020, during the partial sanitary lockdown imposed by the government to limit COVID-19, coinciding with the summer holidays for most Lebanese. The total sample consisted of 564 community-dwelling adolescents aged 13 to 18. A factor analysis was performed using a varimax rotation. The Kaiser-Meyer-Olkin (KMO) measurement of sampling adequacy and Bartlett's sphericity test were appropriate. The factors retained corresponded to Eigenvalues > 1. Cronbach's alpha value represented the internal consistency of the scale. The Hooked on Nicotine Checklist (HONC) was used to screen for dependence symptoms. All items of the YACD were extracted, except for items 4 (smoking to concentrate at work) and 18 (smoking as a habit), which yielded a three-factor solution (factor 1 = smoking patterns; factor 2 = positive and negative reinforcements; factor 3 = smoking cessation) with Eigenvalues > 1 (variance explained = 56.18%; KMO = 0.784; Bartlett's sphericity test p < 0.001; α_Cronbach = 0.875). The newly generated scale was termed Adolescent Cigarette Dependence Scale (ACDS) and consisted of 19 items. Higher ACDS scores (higher cigarette dependence) were significantly associated with higher HONC scores (higher symptoms of dependence) (rho = 0.647; p < 0.001). Having deceased (B = 8.54) or divorced (B = 4.26) parents and higher cumulative cigarette smoking (B = 0.29) were significantly associated with higher ACDS scores. Higher cumulative cigarette smoking (B = 0.05) was significantly associated with higher HONC scores due to cigarettes. This study could validate a new tool to evaluate nicotine dependence among Lebanese adolescents, the Adolescent Cigarette Dependence Scale (ACDS). This version adapted from the Young Adults' Cigarette Dependence (YACD) Scale is reliable and valuable and correlates well with other scales, such as the HONC. However, further studies are necessary to improve this instrument, adding new questions useful for the diagnosis and evaluation of cigarette dependence.

Evaluation of the Psychometric Properties of the Lebanon Waterpipe Dependence Scale in a Sample of Iranian Waterpipe Smokers

Background

Waterpipe tobacco smoking (WTS) has recently increased in Iran. There is no valid instrument to measure the level of nicotine dependence among its consumers. This study was aimed to investigate the validity and reliability of the Lebanon Waterpipe Dependence Scale-11 (LWDS-11).

Methods

A cross-sectional study was conducted in the year 2017 whereby 367 waterpipe smokers were recruited from Golestan Province of Iran. LWDS-11 scale is composed of 4 subscales: 1) nicotine dependence, 2) negative reinforcement, 3) psychological craving, and 4) positive reinforcement. The validity of the questionnaire was examined using construct validity. Reliability of this scale was examined using test-retest reliability and internal consistency.

Findings

The four-factor model for LWDS [comparative fit index (CFI) = 0.985, Tucker-Lewis index (TLI) = 0.979, standardised root mean residual (SRMR) = 0.059, root mean square error of approximation (RMSEA) = 0.049 (0.031, 0.061)] demonstrated good fit to this data. Cronbach’s α was 0.825 for total scale and it was 0.818, 0.746, 0.624, and 0.670 for each individual subscale. The test-retest reliability of the scale was 0.925.

Conclusion

All goodness of fit indices (GFIs) represented a good fit of model. The LWDS-11 scale had an appropriate remarkable validity and reliability for waterpipe consumers to measure the level of nicotine dependence and it appeared to be likely useful for utilizing in the clinical and epidemiological studies.

Natural Course of Nicotine Dependence Among Adolescent Waterpipe and Cigarette Smokers

PURPOSE

Waterpipe (WP) smoking patterns and setting can result in a unique trajectory of nicotine dependence (ND) compared with cigarette smoking. This longitudinal study compared the development of ND symptoms among adolescent WP and cigarette smokers.

METHODS

A cohort of 647 eighth and ninth graders in Lebanon were followed over 5 years. This study was based on 283 current exclusive WP and 146 current exclusive cigarette smokers. Kaplan-Meier survival analyses were conducted to evaluate 50% cumulative probability for the development of initial Hooked on Nicotine Checklist symptoms and the International Classification of Diseases, 10th revision (ICD-10) ND.

RESULTS

An initial Hooked on Nicotine Checklist symptom was endorsed by 59% of WP and 50% of cigarette smokers after smoking onset. Among those, 50% of both WP and cigarette smokers did so within 9.7 and 18.5 months, respectively. Approximately 28% of WP smokers and 22% of cigarette smokers developed ICD-10 ND. Among those, 50% of both WP and cigarette smokers did so within 15 and 22 months, respectively. The most common first to fourth ICD-10 criteria reported by WP smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "neglect of alternative pleasure," and "use despite harm." The most common first to fourth ICD-10 criteria reported by cigarette smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "withdrawal," and "tolerance".

CONCLUSIONS

Compared with adolescent cigarette smokers, initial ND symptoms and ICD-10 ND can develop sooner after starting to smoke and progress more rapidly among adolescent WP smokers. Developing, implementing, and evaluating intervention programs with adolescent WP smokers should be guided by the WP-specific trajectory of ND.

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.

Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults

Young adults’ hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18–30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p < 0.001), positive attitudes (p < 0.001), and negative emotional response (p < 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

Nicotine Dependence and Loss of Autonomy among Greek Adolescent Smokers: A Countrywide Cross-Sectional Study

Nicotine dependence is one of the main reasons for the continuation of smoking among adolescents. Loss of autonomy (LOA) is a measure of dependence. This study is the first to investigate LOA and its determinants among Greek adolescents. In 2013, 13-to-15-year-old middle-school students were selected by multi-stage clustered sampling. LOA was evaluated with the Hooked-on-Nicotine Checklist (HONC). Multiple univariate analysis was used to assess the association between adolescent demographics, smoking habits, and loss of autonomy. Three-hundred thirty-nine current smokers responded to the questionnaire (response rate: 82.3%). Of these respondents, 51.2% were male and 88.8% reported at least one LOA symptom. The mean HONC score was 4.13/10 (95% CI: 3.82–4.45). Higher scores were negatively associated with lower smoking frequency (cumulative odds ratio (cOR): 0.240, 95% CI: 0.144–0.400) and positively associated with lower age at first cigarette (cOR: 2.29, 95% CI: 1.38–3.82). Female gender was significantly associated with the prevalence but not the degree of LOA. Overall, the prevalence and the degree of nicotine dependence among adolescent smokers in Greece is similar to other countries. Frequent smoking and initiation of smoking at a younger age are linked to nicotine dependence, although it was not possible to make causal inferences. The relationship between nicotine dependence and gender remains unclear.

Testing the Effects of Hookah Tobacco Social Media Risk Communication Messages Among Young Adults

BACKGROUND

Hookah tobacco is commonly used among young adults, and use is driven in part by widespread misperceptions about risks. Social media use, particularly Instagram, is prominent in this population and exposure to commercial and user-generated content promoting hookah commonly occurs.

AIMS

This study tested the effects of hookah tobacco risk messaging for delivery via Instagram as a strategy to offset exposure to content promoting hookah use among young adults.

METHOD

Young adult hookah smokers were recruited online for a 2 × 3 between-subjects experiment (n = 601). Participants completed preexposure measures and were randomized to view hookah tobacco Instagram ads (commercial or user generated) with risk messages (none, risk education, or graphic risk). Stimuli were presented as a simulated Instagram feed. After viewing the stimuli, participants completed postexposure outcome measures.

RESULTS

There was a statistically significant main effect of risk message type but no significant main effect of Instagram ad type or risk message type by ad type interactions. Exposure to the graphic risk and risk education messages were associated with lower intentions to engage with hookah tobacco ads on Instagram. Graphic risk and risk education messages produced greater negative emotional response and the graphic messages increased motivation to quit compared with Instagram ads alone.

DISCUSSION

Findings provide preliminary evidence that hookah tobacco risk messages delivered via Instagram can offset the influence of content promoting the use of hookah tobacco.

CONCLUSION

This study represents an example of risk message testing and the results suggest the messages warrant further testing via social media delivery.

The Syrian Center for Tobacco Studies-13 (SCTS-13): Psychometric evaluation of a waterpipe-specific nicotine dependence instrument

BACKGROUND

Waterpipe tobacco smoking (WTS) has surged globally among young people and causes nicotine dependence (ND). No existing ND instruments are sensitive to waterpipe-specific features of ND and early stages of use.

METHODS

We conducted a psychometric scale evaluation among 192 current waterpipe smokers, initially averaging 15 years of age, recruited from schools in Beirut, Lebanon, and assessed 4 times, 6 months apart. Twenty eight self-report items tapping multiple features of ND were submitted to exploratory and confirmatory factor analyses (EFA and CFA) to reduce items and verify factor structure. Convergent validity was assessed with the Lebanese Waterpipe Dependence Scale and the Hooked on Nicotine Checklist, and discriminant validity with the Depressive Symptom Scale and Adolescent Life Events Stress Scale. Concurrent and predictive validity measures included smoking status and intensity (amount, frequency, session duration, and change in frequency), quitting interest and success, perceived addiction, and smoking alone.

RESULTS

The EFA yielded a single factor, 13 item solution (named the Syrian Center for Tobacco Studies [SCTS]-13) that explained 91% of variance in responses, was internally consistent (Cronbach's alpha and McDonald's omega = 0.87), and captured several positive reinforcement, negative reinforcement, and social/sensory-related features of ND. The CFA indicated good model fit. The SCTS-13 showed acceptable convergent and discriminant validity. Higher SCTS-13 scores predicted current waterpipe and dual (waterpipe and cigarette) smoking, greater intensity of use, less interest in quitting, shorter duration of abstinence, greater perceived addiction, and smoking alone (vs. socially).

CONCLUSION

The SCTS-13 is a promising brief, waterpipe-specific ND instrument.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

Flavored Versus Nonflavored Waterpipe Tobacco: A Comparison of Toxicant Exposure, Puff Topography, Subjective Experiences, and Harm Perceptions

INTRODUCTION

Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers' experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers' toxicant exposure, smoking topography, subjective experiences and harm perception.

METHODS

Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception.

RESULTS

Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco.

CONCLUSIONS

Limiting tobacco flavor has a substantial effect on WP smokers' nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth.

IMPLICATIONS

This study highlights the important role of flavor in shaping WP smokers' experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.

Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Effect of risk messages on risk appraisals, attitudes, ambivalence, and willingness to smoke hookah in young adults

Objective: We examined effects of hookah tobacco risk messages on risk appraisals, attitudes towards hookah, ambivalence about hookah use, and willingness to smoke in young adults aged 18–30 years (n = 234).

Design: In an online experiment, participants completed pre-exposure measures and were randomized to hookah tobacco risk messages or to a no message control condition.

Main Outcome Measures: Risk appraisals, attitudes, ambivalence, and willingness to smoke hookah.

Results: Those who viewed risk messages reported greater risk appraisals (M 4.50, SD 1.17 vs. M 3.87, SD 1.16, p < .001), less positive attitudes (M −0.56, SD 1.24, vs. M 0.39, SD 1.35, p < .001), greater ambivalence (M 3.86, SD 1.26, vs. M 3.08, SD 1.32, p < .001), and less willingness to smoke than controls (M 4.48, SD 1.27, vs. M 4.85, SD 1.37, p = .034). Structural equation modeling demonstrated messages reduced willingness to smoke by evoking less positive attitudes (b = −0.15, 95% CI −0.32, −0.05) and by the effect of heightened risk appraisals on less positive attitudes (b = −0.14, 95% CI −0.30, −0.07).

Conclusions: Honing messages and understanding their mechanisms of action are necessary to produce more effective interventions to address hookah and other tobacco use in young adults.

Evidence of compensation among waterpipe smokers using harm reduction components

OBJECTIVES

We examined two waterpipe tobacco smoking components advertised to reduce harm to determine if they result in lower levels of biomarkers of acute exposure.

METHODS

We conducted a crossover study of 34 experienced waterpipe smokers smoking a research-grade waterpipe in three configurations ad libitum in a controlled chamber: control (quick-light charcoal), electric (electric heating) and bubble diffuser (quick-light charcoal and bubble diffuser). We collected data on smoking topography, environmental carbon monoxide (CO), subjective effects, heart rate, plasma nicotine and exhaled CO and benzene.

RESULTS

Smokers' mean plasma nicotine, heart rate, and exhaled benzene and CO boost were all significantly lower for electric compared with control. However, smokers puffed more intensely and took significantly more and larger volume puffs for a larger total puffing volume (2.0 times larger, p<0.0001) when smoking electric; machine yields indicate this was likely due to lower mainstream nicotine. Smokers rated electric smoking experience less satisfying and less pleasant. For charcoal heating, the mean mass of CO emitted into the chamber was ~1 g when participants smoked for a mean of 32 minutes at a typical residential ventilation rate (2.3 hr-1).

CONCLUSION

Waterpipe smokers engaged in compensation (i.e., increased and more intense puffing) to make up for decreased mainstream nicotine delivery from the same tobacco heated two ways. Waterpipe components can affect human puffing behaviours, exposures and subjective effects. Evidence reported here supports regulation of waterpipe components, smoking bans in multifamily housing and the use of human studies to evaluate modified or reduced risk claims.

Development and Pretesting of Risk-Based Mobile Multimedia Message Content for Young Adult Hookah Use

Background. Hookah is one of the most commonly used tobacco products among U.S. young adults due in part to widespread misperceptions that it is not harmful or addictive. There is growing evidence that hookah tobacco is associated with health harms and can lead to addiction. Research on interventions to address these misperceptions by communicating the harms and addictiveness of hookah use is needed. Aims. This study developed and pretested mobile multimedia message service (MMS) message content communicating the risks of hookah tobacco use to young adult hookah smokers. Method. Message content, delivery, and pretesting were tailored to participants' risk beliefs, hookah use frequency, and responses to simulated text message prompts. Participants viewed 4 of 12 core MMS messages randomized within-subjects and completed postexposure measures of message receptivity and emotional response (e.g., worry). Results. The sample included 156 young adult (age 18-30 years) hookah smokers; 31% smoked hookah monthly and 69% weekly/daily. Prior to viewing messages, a majority endorsed beliefs reflecting misperceptions about the risks of hookah tobacco. Postexposure measures showed participants were receptive to the messages and the messages evoked emotional response. As anticipated, messages produced similar receptivity and there were few differences in emotional response between the messages tested. Discussion. Young adult hookah tobacco smokers were receptive to tailored mobile MMS messages and messages evoked emotional response, two critical precursors to behavior change. Conclusion. Findings indicate that research testing the efficacy of tailored MMS messaging as a strategy for reducing hookah tobacco use in young adults is warranted.

The effect of flavoured and non-flavoured tobacco on subjective experience, topography and toxicant exposure among waterpipe smokers

INTRODUCTION

Flavoured waterpipe (WP) tobacco is a major factor in the resurgence of WP smoking and a main attractant of WP use among youth. Yet, evidence of the effects of limiting flavour on WP smoker's experiences and exposures is limited. This study examined the impact of flavour manipulation on WP smokers' toxicant exposure and smoking experiences.

METHOD

A total of 144 WP smokers attended two, 45 min ad libitum smoking sessions (flavoured vs non-flavoured tobacco) in a crossover design study. Participants completed a battery of questions assessing subjective smoking experiences. Exhaled carbon monoxide (eCO) and plasma nicotine concentrations were measured before and after the smoking sessions. Puff topography was recorded throughout the smoking sessions.

RESULTS

Compared with the non-flavoured WP tobacco, participants reported enhanced subjective smoking measures of satisfaction and enjoyment following smoking flavoured WP tobacco (ps <0.05). Although participants spent a longer time smoking flavoured tobacco, they took on average larger puffs while smoking the non-flavoured tobacco (ps <0.05). Greater levels of eCO were recorded following the non-flavoured tobacco session (p<0.05) compared with flavoured tobacco. No significant differences were observed in plasma nicotine concentrations between the two tobacco conditions. WP harm perception was higher among participants after smoking non-flavoured WP tobacco compared with their preferred flavour (p<0.05).

CONCLUSION

Smoking the flavoured tobacco product was associated with enhanced subjective experiences compared with the non-flavoured, suggesting a potential role for flavour regulation in reducing WP use. Mixed results were observed for toxicants exposure in relation to smoking flavoured compared with non-flavoured products suggesting the need for a more comprehensive assessment of the effects of other tobacco constituents and additives on toxicant exposure in WP smokers.

Characteristics of Hookah Tobacco Smoking Sessions and Correlates of Use Frequency Among US Adults: Findings From Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study

Introduction

Hookah tobacco smoking has increased in the United States. However, information on hookah use frequency and other characteristics of hookah use is limited.

Methods

Investigators analyzed data from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of US youth and adults. Our analysis draws on baseline data from adult (ages ≥18 years) ever (N = 10 624) and past year (n = 3947) hookah users. Bivariate and regression analyses were conducted to identify associations between demographics, use characteristics, and hookah use frequency.

Results

Overall, 16.4% of adults reported ever smoking tobacco from a hookah. Of those, 31.9% reported smoking hookah within the past year. Among 3947 past-year hookah tobacco smokers, 10.7% were daily/weekly users, 13.7% were monthly users, 42.1% smoked every couple of months, and 33.5% smoked about once a year. Among daily/weekly hookah users, 66% were young adults (ages 18-24 years). When comparing daily/weekly hookah users to those who smoked every couple of months, more frequent hookah use was associated with younger age, male gender, a greater number of times the hookah is refilled during a session, fewer people sharing, and hookah ownership.

Conclusion

Although there were few demographic differences between daily/weekly users and less frequent hookah tobacco smokers, some notable differences in use behaviors exist among use frequency groups. Unlike other tobacco products, hookah is often smoked communally, over an extended time period. A detailed understanding of hookah user characteristics and experiences could inform hookah-specific measures, messaging, and regulations.

Implications

To our knowledge, this is one of the first studies to characterize hookah use frequency, session length, and other hookah use experiences using a nationally representative sample of US adult hookah smokers. Understanding characteristics of hookah tobacco smokers, their use experiences, and patterns of hookah use frequency would be useful in assessing risks for hookah tobacco dependence at the population level. Additionally, identifying variation in use behaviors of hookah tobacco smokers could be used to inform the development of strategies to reduce and prevent hookah tobacco use, such as tobacco regulations or public education efforts, particularly among young adults.

New and Emerging Tobacco Products and the Nicotine Endgame: The Role of Robust Regulation and Comprehensive Tobacco Control and Prevention: A Presidential Advisory From the American Heart Association

The advent of new tobacco products such as electronic cigarettes and the dramatic rise in their use, especially by adolescents and young adults, are significant public health concerns. Electronic cigarettes have become the most popular tobacco products for youth and adolescents in the United States and are attracting youth to new avenues for nicotine addiction. Although these products may have benefit by helping some smokers quit or to move to a less harmful product, the long-term health effects of these products and the net public health effect associated with their use remain unclear and widely debated. There is increasing concern that the use of newer tobacco products may catalyze transition to the use of other tobacco products or recreational drugs, particularly in young adults. Therefore, there is urgent need for robust US Food and Drug Administration regulation of all tobacco products to avoid the significant economic and population health consequences of continued tobacco use. Although the American Heart Association acknowledges that the ultimate endgame would be an end to all tobacco and nicotine addiction in the United States, it supports first minimizing the use of all combustible tobacco products while ensuring that other products do not addict the next generation of youth and adolescents. The endgame strategy needs to be coordinated with the long-standing, evidence-based tobacco control strategies that have significantly reduced tobacco use and initiation in the United States.

A Cross Sectional Study on Knowledge, Beliefs and Psychosocial Predictors of Shisha Smoking among University Students in Sharjah, United Arab Emirates

Background:

Smoking is now prohibited in all educational institutions and other public places in the United Arab Emirates (UAE), but shisha smoking is considered as one of the major problems among the students population. This study aimed to identify the (a) prevalence of ever shisha, current shisha and shisha dependency smokers among university students in the University of Sharjah (UOS), (b) knowledge and belief differences among ever shisha, current shisha as well as shisha dependency smoking students, (c) relationship between precipitating factors and shisha dependency and (d) precipitating factors (stimulation, handling, pleasure, tension reduction, addiction (dependency), automatism (habit) and social interaction, parents smoking behavior, knowledge and beliefs about smoking predict shisha dependency among students in UOS.

Materials and Methods:

In this cross sectional study, 633 students participated from UOS, UAE. Knowledge and Belief scale, Modified Reason for Smoking Scale and Fagerstrom Test for Nicotine Dependence (FTND) were used to measure knowledge, beliefs, shisha dependency and predictive factors of smoking behavior among undergraduate students in UOS.

Results:

Nearly103 (16.3%) of students were addictive to shisha smoking based on FTND. Students had adequate knowledge that smoking led to cardiac problems; however, their knowledge about the other consequences of smoking was inadequate and believed that smoking was not harmful. There was a significant positive relationship between addiction, pleasure, social interaction, habit, parental smoking behavior and shisha dependency behavior among current shisha dependency students. Habit, addiction, pleasure, social interaction and parental smoking were the predictors of shisha smoking dependency among this population. Step wise multiple regressions showed that social interaction was the highest significant predictor for shisha dependency behavior.

Conclusions:

Hence, there is a need to enhance the knowledge and modify irrational beliefs about shisha smoking as these students possess inadequate knowledge about consequences of shisha smoking.

Epidemiology and Adverse Consequences of Hookah/Waterpipe Use: A Systematic Review

Hookah smoking is becoming a popular trend globally. Waterpipe smoking is the second most prevalent form of alternate tobacco products. The rapid increase in hookah use is because of the misconception prevalent in society that hookah smoking is less harmful than cigarette smoking. Smoking ban policies had given impetus of switching from cigarette smoking to alternate tobacco products like waterpipe. Hookah users regard hookah to be more socially acceptable, less stigmatizing with flavors and to alleviate cigarette craving symptoms. Newer basic science research on animal models and human cells has shown consistently mutagenic, oxidative, and inflammatory changes that could cause possible health effects of premalignant oral lesion and chronic diseases like atherosclerosis and chronic obstructive pulmonary disease. Studies on the chemistry of waterpipe smoke had shown alarming results with the smoke containing seven carcinogens, 39 central nervous system depressants, and 31 respiratory irritants. Enormous data exist showing waterpipe smoking causing various health effects. Hookah smoking effects on cardiovascular disease is additive with hookah containing a significant amount of nicotine, tar, and heavy metals causing both acute and chronic effects on the cardiovascular system. These effects include increased heart rate, blood pressure, prevalence of coronary heart disease, heart failure, ST-segment elevation myocardial ischemia, recurrent ischemia, and worse outcomes including mortality related to these diseases. The objectives of the review are to assess the factor associated with the increasing use of hookah, its health effects, options for hookah smoking cessation, and public health policy initiatives to mitigate waterpipe use.

Varenicline versus placebo for waterpipe smoking cessation: a double-blind randomized controlled trial

BACKGROUND AND AIMS

Waterpipe tobacco smoking is a growing public health concern. There is limited research using pharmacotherapy and no research using varenicline (established treatment for smoking cessation) in waterpipe smokers. We tested the efficacy of varenicline in achieving abstinence from all tobacco use among waterpipe smokers.

DESIGN

Two-arm, parallel group, placebo-controlled, double-blind, multi-centre (n = 4), individually randomized trial with follow-up to 25 weeks.

SETTINGS

District general hospitals and catchment communities within four districts of Punjab, Pakistan.

PARTICIPANTS

Adult daily waterpipe smokers (n = 510; 253 in varenicline and 257 in placebo arms), who were interested in quitting, were recruited and analysed between March and November 2016. Of these, 220 (87%) in the varenicline and 239 (93%) in the placebo arms completed all follow-ups. Participants were on average aged 49 [standard deviation (SD) = 15.2] years, daily smokers and smoked for the last 27 (SD = 15.9) years. More than half (261, 51.2%) also smoked cigarettes.

INTERVENTION AND COMPARATOR

All trial participants received two structured sessions of behavioural support (of 30 and 10 minutes) one at the time of registration and the other 1 week later. Participants were randomized to varenicline (active arm) and placebo (control arm) stratified on district, sex and concomitant cigarette smoking. Varenicline and placebo were dispensed as identical unlabelled tablets for 12 weeks: 0.5 mg for 1 week (once on days 1-3, twice on days 4-7) and 1 mg for the subsequent 11 weeks (twice daily).

MEASUREMENTS

The trial participants were followed-up for a period of 25 weeks post-randomization. The primary outcome was 7-day repeated point prevalence abstinence from all forms of tobacco, self-reported at each of weeks 5, 12 and 25, verified by carbon-monoxide cut-off < 10 parts per million.

FINDINGS

No evidence of statistically significant difference in repeated point prevalence abstinence between the varenicline (12 of 253; 4.7%) and placebo (11 of 257; 4.3%) arms (relative risk = 1.11, 95% confidence interval = 0.50-2.47, P = 0.80) was observed (Bayes factor = 0.048). Adverse events reported in 27 participants were 34 (15 in varenicline and 19 in placebo); none was serious.

CONCLUSIONS

Varenicline was not more effective than placebo in aiding cessation of tobacco use in long-term daily waterpipe smokers.

Reasons for use, potential use, or discontinued use of hookah among US young adult college students

INTRODUCTION

Given the increase in hookah use among young adults, characteristics of hookah use/users, as well as reasons for its use or discontinuation among young adults, are critical to understand.

METHODS

Data from a study of 18–25 year olds from seven Georgia colleges/universities (n=2865) were analyzed to examined: 1) differences in socio-demographics and other substance use among current (past 4 months), never, and former hookah users; 2) use characteristics among current users (e.g. device types/flavors used, quit intentions); and 3) reasons for use, potential use, and discontinued use among current, never, and former users.

RESULTS

Of the students, 56.3% were never users, 12.4% were current, and 31.3% former users. Correlates of being a current (vs never) user included being ‘other race’ (vs White), attending a historically black college/university (HBCU vs technical college), and use of other substances. Correlates of being a former (vs never) hookah user included being older (vs younger), being ‘other race’ (vs White), attending an HBCU (vs technical college), and use of other tobacco products, marijuana, or alcohol. Among current users, 73.7% reported no intention to quit; 26.2% attempted to quit in the past year. Two factors were identified regarding reasons for current use (flavors, social reasons): one factor regarding potential use among never users (related to flavors and social factors), and three factors regarding discontinued use (inconvenience, anti-tobacco attitude, social reasons).

CONCLUSIONS

Findings indicate the risk factors for hookah use and the importance of particular factors (e.g. flavors, social influences) relevant to regulation/policy.

#Hookahlife: The Rise of Waterpipe Promotion on Instagram

Introduction. Hookah smoking is becoming increasingly popular worldwide, especially among young adults. The growth of social media has also enabled sharing of opinions, experiences, and marketing related to hookah via user-generated content. Aim. To evaluate the portrayal and promotion of hookah on Instagram and to highlight public health challenges created by this content. Method. A qualitative content analysis was performed on a sample of 301 Instagram posts made with the hashtags #hookah or #shisha in October 2016. Results. Of the 301 coded posts, 279 were relevant to hookah. These posts were most commonly made by hookah lounges/bars (29.2%) and individual users (27.6%). Posters were most commonly from Russia (38.5%), the United States (18.6%), and Germany (10.7%). A total of 63.8% of the posts were promotional in nature; 19.7% of posts contained hashtags that expressed hookah identity or community (e.g., #hookahlife); 35.5% of posts associated nightlife activities with hookah smoking and 33.0% portrayed hookah smoking as a social activity. Only one post (0.4%) mentioned that hookah might have negative health effects. Likes were more common on posts depicting novel rather than traditional hookah designs ( p = .027). Conclusions. Images from Instagram may help in understanding health behaviors such as hookah smoking. Our results suggest that domestic and international hookah promotion is common on Instagram. Instagram posts cast hookah in an overwhelmingly positive light and may normalize hookah use through associations with nightlife, community, and hookah identity. Policy makers and researchers should explore approaches for reducing the volume of promotional posts and tailoring counter-marketing to the specific themes presented on social media.

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers

INTRODUCTION

Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers.

METHODS

We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes.

RESULTS

Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99).

CONCLUSIONS

A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted.

Comparison of toxicant load from waterpipe and cigarette tobacco smoking among young adults in the USA

OBJECTIVES

To form population-level comparisons of total smoke volume, tar, carbon monoxide and nicotine consumed from waterpipe tobacco smoking (WTS) and cigarette smoking using data from a nationally representative sample of smokers and non-smokers aged 18-30 years.

METHODS

In March and April 2013, we surveyed a nationally representative sample of 3254 US young adults to assess the frequency and volume of WTS and cigarette smoking. We used Monte Carlo analyses with 5000 repetitions to estimate the proportions of toxicants originating from WTS and cigarette smoking. Analyses incorporated survey weights and used recent meta-analytic data to estimate toxicant exposures associated with WTS and cigarette smoking.

RESULTS

Compared with the additive estimates of WTS and cigarette smoking combined, 54.9% (95% CI 37.5% to 72.2%) of smoke volume was attributed to WTS. The proportions of tar attributable to WTS was 20.8% (95% CI 6.5% to 35.2%), carbon monoxide 10.3% (95% CI 3.3% to 17.3%) and nicotine 2.4% (95% CI 0.9% to 3.8%).

CONCLUSIONS

WTS accounted for over half of the tobacco smoke volume consumed among young US adult waterpipe and cigarette smokers. Toxicant exposures to tar, carbon monoxide and nicotine were lower, but still substantial, for WTS alone compared with WTS and cigarette smoking. Public health and policy interventions to reduce harm from tobacco smoking in young US adults should explicitly address WTS toxicant exposures.

Cigarette, waterpipe and e-cigarette use among an international sample of medical students. Cross-sectional multicenter study in Germany and Hungary

Background

Tobacco use is the leading preventable cause of death worldwide. Besides cigarette smoking, waterpipe and e-cigarettes are gaining popularity among young adults. Medical students’ smoking behavior is of particular interest because of their impending role in health promotion as future physicians. Aim of our study is to examine the prevalence and predictors of cigarette, waterpipe and e-cigarette use and the association of tobacco use with self-reported health status in an international sample of medical students.

Methods

In a multicenter cross-sectional study data on different aspects of health behavior were collected from medical students of 65 nationalities using a self-administered questionnaire in Germany (Dresden, Munich) and Hungary (Budapest, Pécs). The survey was conducted among 1st, 3rd and 5th year students. To explore associations between smoking behavior and socio-cultural factors Pearson’s chi²-tests and multivariate binary logistic regression analyses were performed.

Results

The largest subpopulations were formed by German (n = 1289), Hungarian (n = 1055) and Norwegian (n = 147) students. Mean age was 22.5 ± 3.3 years. Females represented 61.6% of the sample. In the whole sample prevalence of cigarette smoking was 18.0% (95% CI 16.6–19.4%), prevalence of waterpipe use was 4.8% (95% CI 4.0–5.7%), that of e-cigarette 0.9% (95% CI 0.5–1.2%). More males (22.0%) than females (15.5%) reported cigarette smoking. The lowest prevalence of cigarette smoking was found among Norwegian students (6.2%). Cigarette smokers were older, waterpipe users were younger than non-users. E-cigarette use was not associated with age of the students. Religious involvement was protective only against cigarette smoking. Financial situation showed no association with any kind of tobacco consumption. Cigarette smokers and e-cigarette users were less likely to report very good or excellent health status.

Conclusions

Cigarette smoking is still the most popular way of consuming tobacco, although alternative tobacco use is also prevalent among medical students. To further health consciousness, medical schools should pay more attention to students’ health behavior, especially their smoking habits. Tobacco prevention and cessation programs for medical students should consider not only the health risks of cigarette smoking but the need to discourage other forms of tobacco use, such as waterpipe.

A randomized clinical trial to evaluate the efficacy of contingency management for treatment of waterpipe tobacco addiction

BACKGROUND AND OBJECTIVES

Unlike cigarette smoking cessation, waterpipe tobacco smoking cessation is relatively understudied. The objective of this randomized clinical trial was to examine the efficacy of contingency management (CM) for promoting initial waterpipe smoking abstinence.

METHODS

The study used a two-group, repeated measures design. Participants attended 10 visits (two visits per week, on Mondays and Thursdays) across 5 weeks. Thirty-nine adult waterpipe tobacco users who did not smoke cigarettes and were not planning on quitting waterpipe tobacco smoking were randomly assigned to either the contingent (n = 19) or non-contingent (n = 20) groups. Contingent group received monetary rewards based on negative salivary cotinine results. Earning rewards started at $14 and increased by $.50 with each subsequent negative sample for a maximum $192.50. Non-contingent group earned rewards independent of salivary cotinine results. Prolonged abstinence was defined as having negative salivary cotinine results for eight or more visits (two lapses were allowed); and 7-day point prevalence was defined as having negative salivary cotinine results at visit 9 and 10 (final week).

RESULTS

The prolonged abstinence rate in the contingent and non-contingent groups were 42.1% and 5.0%, respectively, (p = .008). The 7-day point prevalence in the contingent and non-contingent were 47.4% and 5.0%, respectively, (p = .003).

DISCUSSION AND CONCLUSIONS

Rewards contingent on biochemically verified abstinence promote initial waterpipe tobacco cessation. This is useful information for consideration in future cessation programs for waterpipe smokers.

SCIENTIFIC SIGNIFICANCE

CM strategy may have potential benefit in addressing waterpipe tobacco smoking in non-treatment seeking adults. (Am J Addict 2018;27:202-209).

Waterpipe use in adolescents in Northern Sweden: Association with mental well-being and risk and health behaviours

AIMS

There is a lack of studies examining the association between waterpipe smoking and mental well-being among adolescents. This study sought to determine whether waterpipe smoking is associated with mental well-being and other risk and health behaviours in adolescents.

METHODS

A questionnaire was distributed to 1006 adolescents in grades 9-12 (with a response rate of >95%), containing questions on measures of stress, mental energy and sleep. In addition, the questionnaire assessed risk and health behaviours, including use of a waterpipe, cigarettes, e-cigarettes, snus, alcohol, narcotics, gambling and exercise. Logistic regression was used to assess factors associated with waterpipe use.

RESULTS

Thirty-seven per cent ( n=371) of the participants had used a waterpipe at some point. Waterpipe use was associated with lower mental energy (odds ratio [OR] = 0.90, 95% confidence interval [CI] 0.81-0.99), higher stress (OR = 1.10, 95% CI 1.02-1.20) and use of cigarettes (OR = 3.82, 95% CI 2.33-6.03), e-cigarettes (OR = 3.26, 95% CI 2.12-4.99), snus (OR = 2.29, 95% CI 2.12-4.99), alcohol (OR = 1.92, 95% CI 1.07-3.44) and narcotics (OR = 3.64, 95% CI 1.75-7.58). Waterpipe use was not significantly associated with gambling, exercise or sleep quality.

CONCLUSIONS

Waterpipe use in adolescents is associated with worse mental well-being, as well as use of other nicotine products, alcohol and narcotics. Prospective studies are needed to delineate causal and temporal relationships further between waterpipe use and mental well-being and its relationship to other risky behaviours in order to design effective prevention programs.

Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco

INTRODUCTION

Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

METHODS

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

RESULTS

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

CONCLUSIONS

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study

INTRODUCTION

Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth.

METHODS

Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥3 criteria during 12months).

RESULTS

Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing≥1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥10 vs. <4 waterpipes; Hazard ratio (HR)=2.05, 95% CI: 1.52-2.58, p=0.007), and session length (>60min vs. <30min; HR=2.87, 95% CI: 2.83-2.91, p=0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥10 vs. <4 waterpipes; HR=2.56, 95% CI: 1.89-3.22, p=0.006), and smoking every day/almost every day vs. less than once weekly (HR=2.86, 95% CI: 2.12-3.60, p=0.007).

CONCLUSIONS

Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers.

Reflections on 15 Years in the Global Tobacco Trenches

This paper is based on my 2017 Research Laureate Presentation at the Annual Scientific Meeting of the American Academy of Health Behavior in Tucson, Arizona. It provides a brief overview of the history of the smoking epidemic, and describes my work in global tobacco control, focusing on my experiences over the last 15 years as a co-founder and intervention director of the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria. The SCTS is an NIH-funded research center that draws on a broad range of complementary expertise and resources from developed and developing nations to address the tobacco epidemic in the Arab World. The SCTS strives to serve as a model of scientific excellence and commitment to the health of people in the Middle East and beyond. Major research streams using qualitative, epidemiological, clinical lab, and intervention methodologies are reviewed, along with some of the successes and challenges encountered since the SCTS's founding.

The relationship of waterpipe use with cigarette smoking susceptibility and nicotine dependence: A cross-sectional study among Hong Kong adolescents

INTRODUCTION

Waterpipe smoking has become increasingly popular in adolescents. We examined the association of waterpipe smoking with cigarette smoking susceptibility and nicotine dependence among adolescents in Hong Kong.

METHODS

We analyzed the data of School-based Survey on Smoking among Students 2012/13 from a representative sample of 45,857 secondary school students (US grades 7-12) in Hong Kong. Among never cigarette smokers (n=37,740), we conducted chi-square test to compare cigarette smoking susceptibility by current (past 30-day) waterpipe smoking status, and used multivariate logistic regression to examine the association between current waterpipe smoking and cigarette smoking susceptibility controlling for age, sex, peer cigarette smoking, and living with a cigarette smoker. Then we conducted chi-square test and multivariate logistic regression among current cigarette smokers (n=1694) to examine the relationship of current waterpipe smoking with two nicotine dependence outcomes, including heavier smoking (≥5 cigarettes/day) and first cigarette within 30min of waking, controlling for demographics and the number of smoking days in the past 30days.

RESULTS

Among never cigarette smokers, current waterpipe use was associated with cigarette smoking susceptibility (adjusted odds ratio [AOR]=3.58, 95% confidence interval [CI]: 1.61-7.97). Of current cigarette smokers, waterpipe use was associated with heavier smoking (AOR=1.56, 95% CI: 1.00-2.43) and first cigarette within 30min of waking (AOR=2.08, 95% CI: 1.35-3.19).

CONCLUSIONS

Surveillance, prevention, and intervention programs should address waterpipe use in addition to cigarette smoking. Educational programs need to inform youth about the harmful and addictive effects of waterpipe smoking. Public health campaigns deglamourizing waterpipe use may help reduce waterpipe smoking among youth.

Stages of physical dependence in New Zealand smokers: Prevalence and correlates

BACKGROUND

Physically dependent smokers experience symptoms of wanting, craving or needing to smoke when too much time has passed since the last cigarette. There is interest in whether wanting, craving and needing represent variations in the intensity of a single physiological parameter or whether multiple physiological processes may be involved in the developmental progression of physical dependence.

AIM

Our aim was to determine how a population of cigarette smokers is distributed across the wanting, craving and needing stages of physical dependence.

METHODS

A nationwide survey of 2594 New Zealanders aged 15years and over was conducted in 2014. The stage of physical dependence was assessed using the Levels of Physical Dependence measure. Ordinal logistic regression analysis was used to assess relations between physical dependence and other variables.

RESULTS

Among 590 current smokers (weighted 16.2% of the sample), 22.3% had no physical dependence, 23.5% were in the Wanting stage, 14.4% in the Craving stage, and 39.8% in the Needing stage. The stage of physical dependence was predicted by daily cigarette consumption, and the time to first cigarette, but not by age, gender, ethnicity or socioeconomic status.

CONCLUSION

Fewer individuals were in the craving stage than either the wanting or needing stages. The resulting inverted U-shaped curve with concentrations at either extreme is difficult to explain as a variation of a single biological parameter. The data support an interpretation that progression through the stages of wanting, craving and needing may involve more than one physiological process.

WHAT THIS RESEARCH ADDS

Physical dependence to tobacco develops through a characteristic sequence of wanting, craving and needing which correspond to changes in addiction pathways in the brain. It is important to neuroscience research to determine if the development of physical dependence involves changes in a single brain process, or multiple processes. Our data suggests that more than one physiologic process is involved in the progression of physical dependence.

Correlates of nicotine dependence among adolescent waterpipe smokers

INTRODUCTION

Waterpipe smoking is addictive and its use is increasing globally among youth, yet little is known about the factors associated with nicotine dependence (ND) among waterpipe smokers. We investigated the factors associated with ND symptoms among a sample of Lebanese adolescents who smoke a waterpipe.

METHODS

We collected data on factors potentially associated with ND (individual, socio-demographic, environmental, smoking patterns) among 160 current (past 30days) waterpipe smokers recruited from 8th and 9th school grades in Lebanon. We assessed the loss of autonomy over tobacco using the Hooked on Nicotine Checklist (HONC), ND using the International Classification of Diseases, 10th revision (ICD-10), and the number of ND symptoms endorsed.

RESULTS

Depressive symptoms, lower self-esteem, and having at least one sibling who smokes a waterpipe were associated with the presence of ND symptoms, while enrollment in public schools, smoking a waterpipe ≥30min per session, and believing that cigarette smoking is harmful to health were associated with endorsement of a higher number of ND symptoms. Smoking a whole waterpipe head without sharing and being in 9th grade in this study were associated with the presence and endorsement of a higher number of ND symptoms.

CONCLUSIONS

We identified specific social and psychological characteristics, waterpipe smoking patterns, and beliefs about harmful effects of smoking associated with the presence of ND among adolescent waterpipe smokers. Considering these factors when planning policies to prevent ND among waterpipe smokers is warranted.