Implications and challenges for implementation of the FDA's final deeming rule for waterpipe tobacco

Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis

INTRODUCTION

Pictorial health warning labels (HWLs) on waterpipe (WP) tobacco packages represent a better strategy for communicating the health risks associated with WP use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown.

AIMS AND METHODS

This study explores how pictorial warnings versus text-only induces higher quit intention among a sample of young adult WP smokers in Lebanon. An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult WP smokers who were exposed to two conditions: pictorial HWLs and text-only warnings on WP tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (eg, attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit.

RESULTS

Using serial mediation, exposure to pictorial warnings versus text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect (β = 0.063; [95% bootstrap CI = 0.004 to 0.149]) and cognitive elaboration (0.047; [0.001 to 0.114]) were statistically significant.

CONCLUSIONS

The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb WP tobacco smoking.

IMPLICATIONS

This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial HWLs on intention to quit in a sample of current WP smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing WP-HWLs regulations in Lebanon and other countries to curb WP tobacco smoking.

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.

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.

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.

Youth Exposure to Warnings on Cigar, E-Cigarette, and Waterpipe Tobacco Packages

INTRODUCTION

Studies of tobacco product warnings have focused primarily on the reach and effectiveness of cigarette warnings for adult smokers, whereas few observational studies have examined noncigarette tobacco product warnings among youth.

METHODS

High school students from the 2019 National Youth Tobacco Survey (n=10,094) reported the frequency of exposure to warnings on cigar, e-cigarette, and waterpipe tobacco packages and the perceived harm of occasionally using e-cigarettes and waterpipe tobacco. In 2020, results were analyzed for the entire sample and among subgroups, including never users, ever users, youth susceptible to using tobacco, and current users.

RESULTS

Reported high exposure to warnings was highest for cigars (22.3%), followed by that for e-cigarettes (20.8%) and that for waterpipe tobacco (7.0%). Youth who were susceptible to using cigars (AOR=1.53, 95% CI=1.29, 1.82), who ever used cigars (AOR=4.32, 95% CI=3.57, 5.22), or who currently used cigars (AOR=8.90, 95% CI=6.95, 11.39) were more likely to report high exposure to cigar warnings than youth who never used cigars. Similar findings were observed for e-cigarette and waterpipe tobacco warnings. For youth who ever used e-cigarettes, high exposure to warnings was associated with higher odds of perceiving e-cigarettes as harmful for occasional product use (AOR=1.50, 95% CI=1.05, 2.15), and high exposure to waterpipe tobacco warnings was associated with higher odds of perceiving waterpipe tobacco as harmful (AOR=1.21, 95% CI=1.00, 1.45).

CONCLUSIONS

Warnings on noncigarette tobacco products reach some youth at risk for using these products, but these warnings may need to be strengthened to further reduce their use.

Health Claims, Marketing Appeals, and Warnings on Popular Brands of Waterpipe Tobacco Packaging Sold in the United States

INTRODUCTION

Waterpipe tobacco (WT) smoking is associated with misperceptions of harm, especially among users. WT packaging contains imagery, flavor descriptors, and text claims that may contribute to misperceptions. The study goal was to characterize visual and text elements of WT packaging.

AIMS AND METHODS

Using data from the U.S. Population Assessment on Tobacco and Health Study Wave 2 (October 2014-October 2015), we identified the 10 most popular WT brands. For each brand, we identified available flavors, including flavor collections with unique packaging elements. We randomly selected 10 flavors per brand for purchase (March-April 2018). We conducted descriptive content analysis to code all textual and visual design elements of each package.

RESULTS

Over half (54%) of WT packages had modified risk tobacco product (MRTP) claims prohibited by federal law, including substance-free MRTP claims (43%) and the descriptor "natural" (11%). No MRTP reduced exposure or reduced risk claims were found. Over a quarter (26%) of packaging including one or more of terms that may imply reduced harm including "fresh," "premium," "quality," and "pure." All packages included a text-only warning, yet none appeared on the primary display panel. Almost all packaging (99%) included imagery, with 72% including flavor imagery. The majority of packages (72%) included a smoking cue. The most popular marketing appeals were "well-made" (57%), "enjoyable" (55%), and "patriotic" (47%).

CONCLUSIONS

Prohibited MRTP claims, other descriptors, and flavor imagery are common on WT packaging, despite federal law. Future research is needed to evaluate if this marketing contributes to misperceptions of reduced harm.

IMPLICATIONS

Tobacco packaging is used to convey health-related messages, both explicitly and implicitly; however, information about WT packaging is virtually nonexistent. We conducted a content analysis of WT packaging from the 10 most popular US brands. Over half (54%) of packages had prohibited MRTP claims and over a quarter (26%) included one or more descriptors that may be perceived as implying reduced harm. Use of imagery, including smoking cues, was common. The widespread use of prohibited MRTP claims, other descriptors, and imagery on WT packaging may contribute to misperceptions of reduced harm.

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.

Options for waterpipe product regulation: A systematic review on product characteristics that affect attractiveness, addictiveness and toxicity of waterpipe use

INTRODUCTION

Despite its known adverse effects on human health, waterpipe smoking is increasing in popularity worldwide. However, compared to cigarettes, regulation of waterpipe product smoking lags behind and presents unique challenges. In search for regulatory options, this systematic review analyzes 36 studies on the differential effects on human health of the waterpipe characteristics including smoking products, heating sources, device components, and packages.

METHODS

A systematic review was performed according to PRISMA guidelines, revealing 443 unique citations. After screening, 36 studies were included in the results. Research articles were selected to inform on differential effects caused by product characteristics on adverse health effects, attractiveness, addictiveness and prevalence of waterpipe use.

RESULTS

Flavors are the key aspect that defines attractiveness of waterpipe product smoking. All waterpipe products, with or without nicotine, produce toxicants in similar quantities as cigarettes. Heating sources for waterpipe tobacco include charcoals and electrical heating. Both heating sources increase toxicant emissions in different ways. Hoses and mouth tips are device components that are often shared in waterpipe smoking. Sharing influences attractiveness by enriching the social experience. At the same time, it influences the transfer of infectious diseases by bacteria and viruses from one smoker to another. Studies showed that more generic and less attractive packages with health warnings are effective in reducing the attractiveness of waterpipe smoking.

CONCLUSIONS

Based on our findings, we advise to include all waterpipe products, tobacco and non-tobacco, with or without nicotine, in tobacco product regulations and smoking bans in order to: ban waterpipe molasses with characterizing flavors or ban the use of flavorings at any level; mandate dissemination of information on all waterpipe tobacco elements to the national regulator; prescribe testing to regulate contents of waterpipe smoking products and heating sources. Moreover, we advise to stimulate research on emissions of waterpipes.

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.

Immune modulation by chronic exposure to waterpipe smoke and immediate-early gene regulation in murine lungs

OBJECTIVE

We investigated the effects of chronic waterpipe (WP) smoke on pulmonary function and immune response in a murine model using a research-grade WP and the effects of acute exposure on the regulation of immediate-early genes (IEGs).

METHODS

WP smoke was generated using three WP smoke puffing regimens based on the Beirut regimen. WP smoke samples generated under these puffing regimens were quantified for nicotine concentration. Mice were chronically exposed for 6 months followed by assessment of pulmonary function and airway inflammation. Transcriptomic analysis using RNAseq was conducted after acute exposure to characterise the IEG response. These biomarkers were then compared with those generated after exposure to dry smoke (without water added to the WP bowl).

RESULTS

We determined that nicotine composition in WP smoke ranged from 0.4 to 2.5 mg per puffing session. The lung immune response was sensitive to the incremental severity of chronic exposure, with modest decreases in airway inflammatory cells and chemokine levels compared with air-exposed controls. Pulmonary function was unmodified by chronic WP exposure. Acute WP exposure was found to activate the immune response and identified known and novel IEG as potential biomarkers of WP exposure.

CONCLUSION

Chronic exposure to WP smoke leads to immune suppression without significant changes to pulmonary function. Transcriptomic analysis of the lung after acute exposure to WP smoke showed activation of the immune response and revealed IEGs that are common to WP and dry smoke, as well as pools of IEGs unique to each exposure, identifying potential biomarkers specific to WP exposure.

Waterpipe tobacco package warning exposure's impact on risk perceptions and use among young adults in the USA: a longitudinal analysis of the population assessment of tobacco and health study

BACKGROUND

Although Food and Drug Administration (FDA)-mandated waterpipe tobacco warnings were not required until August 2018, some waterpipe tobacco packaging (WTP) sold in the USA, contained warnings prior to this date. We examined the prevalence of WTP warning exposure and whether exposure influenced risk perceptions or use among young adult (aged 18-24 years) current waterpipe users.

METHODS

We used data from waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study of US adults and youth. We conducted logistic regression analyses to identify factors associated with wave 1 warning exposure, and whether wave 1 WTP warning exposure predicted wave 2 relative risk perceptions and waterpipe use.

RESULTS

More than one-third of our sample (35.9%, 95% CI 33.5 to 38.4) reported past-month WTP warning exposure. Exposure was higher among males (adjusted OR (AOR)=1.34, 95% CI 1.04 to 1.72), those who usually do not share the waterpipe (AOR=3.10, 95% CI 1.45 to 6.60), those who purchased waterpipe tobacco (AOR=1.73, 95% CI 1.28 to 2.34), and those with a regular brand (AOR=1.84, 95% CI 1.26 to 2.68). Those exposed to WTP warnings at wave 1 were more likely than those not exposed to perceive waterpipe tobacco to be as or more harmful than cigarettes at wave 2 (AOR=1.35, 95% CI 1.02 to 1.78). There was no association between wave 1 WTP exposure and wave 2 waterpipe use.

CONCLUSIONS

More than one-third of US young adult current waterpipe users reported WTP warning exposure prior to FDA-mandated warning implementation. Findings suggest the mandated warning may result in high exposure among users; it will be critical to assess exposure's impact on risk perceptions and behaviour after FDA-mandated warnings are implemented.

Delphi study among international expert panel to develop waterpipe-specific health warning labels

BACKGROUND

Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control.

METHODS

A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median.

RESULTS

Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP's harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes.

CONCLUSION

This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP's harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.

The characterization of flavored hookahs aroma profile and in response to heating as analyzed via headspace solid-phase microextraction (SPME) and chemometrics

Flavors profiling in flavored hookah tobacco is an issue of increasing scrutiny for the health sector owing to its adverse effects on humans, especially being heated to produce smoke. This study aims at tackling the components involved in the flavored hookah tobacco from a chemical and biological point of view. Detecting individual flavor compounds, within a complex hookah tobacco matrix was accomplished using headspace solid phase microextraction (SPME). A total of 114 volatiles were identified in 13 flavored hookah tobacco products, with esters amounting for the major component up to 40%. Whereas oxygenated monoterpenes presented another major volatile class, contributing up to 23%, including (E)-anethole. Superheating flavored hookah tobacco at 190 °C resulted in the release of a mixture of phenol derivatives and polycyclic aromatic compounds that are indicative of coal tar, a major component produced during hookah tobacco usage with potential health hazards. This study provides the first comprehensive volatile profile of hookah tobacco products from different origins identifying chemical components involved in flavors. It is expected to serve as informative grounds for the better understanding of hookah tobacco production and usage. The information presented is also expected to raise awareness on the health risks of hookah tobacco smoking.

Differences in puff topography, toxicant exposure, and subjective response between waterpipe tobacco smoking men and women

Waterpipe tobacco smoking (WTS) exposes users to toxicants in much greater amounts than a cigarette. Little is known about how gender affects WTS toxicant exposure and subjective response. Data from three WTS clinical laboratory studies were combined for analysis. Participants (N = 99; 38 women) completed a 45-min WTS session where they smoked a waterpipe ad libitum. Puff topography was measured throughout, and plasma nicotine concentration, expired air carbon monoxide (CO), and subjective responses were measured pre- and post-WTS. There was a gender effect for total puff volume with men inhaling a greater smoke volume, on average (M = 59.9 L, SD = 40.7), compared with women (M = 38.8 L, SD = 27.8; p < .01). Men had greater post-WTS mean plasma nicotine concentrations (M = 10.0 ng/ml, SD = 7.1) compared with women (M = 6.9 ng/ml, SD = 5.2; p < .05). Post-WTS expired air CO was not associated with gender (men M = 27.6 ppm, SD = 18.9; women M = 22.7 ppm, SD = 17.0, ns). Relative to men, women had higher post-WTS scores for subjective measures of "nauseous," "dizzy," "nervous," "headache," and "heart pounding." Men and women are exposed to toxicants during WTS, and men may achieve higher nicotine exposure than women, likely resulting from differences in smoke inhaled. However, similar post-WTS expired air CO between men and women and higher ratings of negative subjective responses among women may indicate that factors beyond puff topography may impact toxicant exposure and subjective response to WTS. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Comparing harm beliefs and risk perceptions among young adult waterpipe tobacco smokers and nonsmokers: Implications for cessation and prevention

Introduction

Very little is known about how waterpipe tobacco smokers and nonsmokers compare on harm beliefs about waterpipe tobacco smoking (WTS) and how these beliefs are related to risk appraisals and intentions to engage in WTS. We investigated these issues among young adult waterpipe tobacco smokers, susceptible nonsmokers, and non-susceptible nonsmokers.

Methods

Young adults ages 18 to 30 who smoked waterpipe tobacco during the last 30 days or never used waterpipe tobacco were recruited online through Turkprime. Nonsmokers were grouped as susceptible or not. Participants completed measures of harm beliefs, risk appraisals (i.e., perceived risks and worry), and desire to quit among smokers or willingness/curiosity to try waterpipe among nonsmokers.

Results

Analyses were based on 247 smokers and 418 nonsmokers. Smokers endorsed most strongly harm beliefs that portrayed WTS as safe, followed by susceptible and then non-susceptible nonsmokers. Most harm beliefs were significantly related to risk appraisals, yet weakly associated with desire to quit or willingness/curiosity to try waterpipe tobacco, except among susceptible nonsmokers.

Conclusions

Greater efforts are needed to correct maladaptive beliefs about WTS harms, especially among smokers. Among susceptible nonsmokers, harm beliefs may be more influential in predicting willingness to try WTS than risk appraisals.

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Waterpipe tobacco smokers view waterpipe tobacco smoking as safer than nonsmokers.

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Perceived risk correlates with many harm beliefs about waterpipe tobacco smoking.

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Among smokers, desire to quit is related more with perceived risk than harm beliefs.

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Among susceptible nonsmokers, intent to try waterpipe relates to many harm beliefs.

Calls to Poison Centers for hookah smoking exposures

Over the past decade, smoking behaviors have changed in the US. Hookah or waterpipe smoking is increasing, especially among youth and young adults. Social media sites describe the "hookah high" or "buzz", which may be related to nicotine, carbon monoxide, or other inhalants in hookah smoke. Most important is the risk of carbon monoxide poisoning. Case reports include a high number of victims presenting with loss of consciousness from either syncope or seizures. Anaphylaxis and a very rare respiratory hypersensitivity reaction, acute eosinophilic pneumonia, have also been reported from hookah smoking in previously healthy young adults. This article provides background information on hookah smoking, describes hookah-induced acute injuries that could precipitate poison center calls, and offers suggestions for exposure characterization.