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

2024 Guidelines of the Taiwan Society of Cardiology on the Primary Prevention of Atherosclerotic Cardiovascular Disease --- Part I

Atherosclerotic cardiovascular disease (ASCVD) is one of the leading causes of death worldwide and in Taiwan. It is highly prevalent and has a tremendous impact on global health. Therefore, the Taiwan Society of Cardiology developed these best-evidence preventive guidelines for decision-making in clinical practice involving aspects of primordial prevention including national policies, promotion of health education, primary prevention of clinical risk factors, and management and control of clinical risk factors. These guidelines cover the full spectrum of ASCVD, including chronic coronary syndrome, acute coronary syndrome, cerebrovascular disease, peripheral artery disease, and aortic aneurysm. In order to enhance medical education and health promotion not only for physicians but also for the general public, we propose a slogan (2H2L) for the primary prevention of ASCVD on the basis of the essential role of healthy dietary pattern and lifestyles: "Healthy Diet and Healthy Lifestyles to Help Your Life and Save Your Lives". We also propose an acronym of the modifiable risk factors/enhancers and relevant strategies to facilitate memory: " ABC2D2EFG-I'M2 ACE": Adiposity, Blood pressure, Cholesterol and Cigarette smoking, Diabetes mellitus and Dietary pattern, Exercise, Frailty, Gout/hyperuricemia, Inflammation/infection, Metabolic syndrome and Metabolic dysfunction-associated fatty liver disease, Atmosphere (environment), Chronic kidney disease, and Easy life (sleep well and no stress). Some imaging studies can be risk enhancers. Some risk factors/clinical conditions are deemed to be preventable, and healthy dietary pattern, physical activity, and body weight control remain the cornerstone of the preventive strategy.

Waterpipe Tobacco Smoking and Risk of Cancer Mortality

Importance

There has been an increasing trend of using noncigarette products, including waterpipe tobacco (WTP), worldwide. While cigarette smoking is a well-established risk factor for numerous cancers, little is known about the association between WTP smoking and cancer mortality.

Objective

To assess the association between WTP smoking and risk of cancer mortality in Vietnam.

Design, Setting, and Participants

This cohort study was based on data from the Hanoi Prospective Cohort Study, an ongoing study with a median (range) follow-up of 11.0 (0.1-11.6) years for participants aged 15 years or older in Northern Vietnam from 2007 through 2019. Data were analyzed from June 1 to September 1, 2023.

Exposures

Tobacco smoking and WTP smoking statuses.

Main Outcomes and Measures

Overall and site-specific cancer mortality. Cox proportional regression models were used to calculate the hazard ratio (HR) and 95% CIs for the associations between WTP smoking alone, cigarette smoking alone, and dual WTP and cigarette smoking and the risk of cancer death.

Results

A total of 554 cancer deaths were identified among the 39 401 study participants (mean [SD] age, 40.4 [18.8] years; 20 616 females [52.3%]). In multivariable models, compared with never smokers, ever smokers had a significantly increased risk of cancer mortality (HR, 1.87; 95% CI, 1.48-2.35). Exclusive WTP smokers had the highest risk of cancer mortality compared with never smokers (HR, 2.66; 95% CI, 2.07-3.43). Risk of cancer mortality was higher for dual smokers of WTP and cigarettes (HR, 2.06; 95% CI, 1.53-2.76) than for exclusive cigarette smokers (HR, 1.86; 95% CI, 1.41-2.45). As most smokers (95.6% [8897 of 9312]) were male, these patterns were more apparent in male participants. Compared with never smokers, exclusive WTP smoking among males was associated with an elevated risk of death from liver cancer (HR, 3.92; 95% CI, 2.25-6.85), lung cancer (HR, 3.49; 95% CI, 2.08-5.88), nasopharyngeal carcinoma (HR, 2.79; 95% CI, 1.27-6.12), and stomach cancer (HR, 4.11; 95% CI, 2.04-8.27). For exclusive WTP smokers, the risk of cancer mortality was highest among those who smoked 11 to 15 sessions per day (HR, 3.42; 95% CI, 2.03-5.75), started smoking at age 26 to 30 years (HR, 4.01; 95% CI, 2.63-6.11), smoked for 9 to 20 years (HR, 4.04; 95% CI, 2.16-7.56), and smoked 61 to 160 sessions annually (HR, 3.68; 95% CI, 2.38-5.71). For males, the risk of cancer death was lower for those who had quit smoking for more than 10 years, compared with those who quit smoking within 1 year (HR, 0.27; 95% CI, 0.11-0.66; P for trend < .001).

Conclusion and Relevance

In this cohort study in Vietnam, WTP smoking alone or in combination with cigarette smoking was associated with an increased risk of cancer death due to liver cancer, lung cancer, nasopharyngeal carcinoma, and stomach cancer. A tailored program to control WTP smoking is warranted in Vietnam and low- and middle-income countries with a high prevalence of smoking and modest resources to address smoking-related issues.

From smoke to stroke: quantifying the impact of smoking on stroke prevalence

PURPOSE

The objective of this study is to assess the impact of smoking on stroke prevalence and to delineate the relationship between smoking-related factors and the risk of stroke, incorporating an analysis of demographic variations influencing this association.

METHODS

Our analysis encompassed 9,176 participants, evaluating clinical attributes alongside smoking-related characteristics such as duration of cigarette consumption, and levels of nicotine, tar, and carbon monoxide. We employed weighted univariate logistic regression and restricted cubic splines to examine the association between smoking indicators and stroke risk, complemented by subgroup analyses for demographic differentiation.

RESULTS

The overall prevalence of stroke in our cohort was 3.4%. Statistically significant associations were found between stroke incidence and factors such as age, gender, education, and marital status (p < 0.05). Adjusted logistic regression models showed increased odds ratios (ORs) for stroke with higher nicotine and carbon monoxide levels across progressively adjusted models: Model 1 (unadjusted), Model 2 (adjusted for age, gender), Model 3 (further adjusted for education, marital status, BMI, PIR), and Model 4 (fully adjusted for additional factors including hypertension, hyperlipidemia, diabetes, and drinking). Specifically, ORs for nicotine increased from 2.39 in Model 1 to 2.64 in Model 4; for carbon monoxide, from 1.10 to 1.11 over the same models.​The threshold analysis using restricted cubic splines revealed critical points for stroke risk increase at smoke exposure levels of 410 units, tar 12 mg, nicotine 1.1 mg, and carbon monoxide 12 ppm. Above these thresholds, stroke risk escalates significantly. Additionally, the presence of family smoking history was associated with higher stroke risks compared to those without such history.

CONCLUSION

This study confirms that smoking significantly contributes to increased stroke risk, particularly through exposure to nicotine and carbon monoxide. The findings emphasize the necessity for tailored stroke prevention strategies that specifically address smoking behaviors and consider demographic susceptibilities. Incorporating smoking-related indicators into risk assessment models could enhance the precision of stroke prevention efforts.

Waterpipe smoking is associated with presence and severity of coronary artery disease: a propensity score-matched study

BACKGROUND

The prevalence of waterpipe smoking (WPS) has been increasing worldwide. This trend is alarming as WPS can negatively impact cardiovascular health. In the present study, we explored the association between WPS and the presence and severity of CAD.

METHODS

This study was a retrospective analysis of patients who underwent diagnostic coronary angiography at Tehran Heart Center between April 2021 and May 2022. Patients with a previous history of percutaneous coronary intervention and coronary surgery were excluded. Waterpipe smokers were matched with non-smokers based on age, gender, and cigarette smoking using a 1:4 propensity score matching model. Stenosis ≥ 50% in any coronary artery was considered a CAD diagnosis. Gensini score was also calculated to measure the severity of the CAD.

RESULTS

We reviewed the medical records of 8699 patients, including 380 waterpipe smokers. After matching, 1520 non-smokers with similar propensity scores to the waterpipe smokers were selected. Waterpipe smokers were more likely to have CAD than non-smokers (OR: 1.29; 95% CI: 1.04-1.60, P = 0.021). In addition, WPS increased the natural logarithm of the Gensini score by 1.24 (95% CI: 1.04-1.48, P = 0.014) in patients with atherosclerotic coronary disease.

CONCLUSION

WPS may increase the risk of CAD independent of age, gender, and cigarette smoking. In addition, among patients with any degree of atherosclerosis in coronary arteries (GS > 0), WPS may lead to higher average GS, suggesting more severe atherosclerosis.

Prevalence and Incidence of Metabolic Syndrome and Its Components Among Waterpipe Users

Objectives

To determine the associations between waterpipe use, duration, and intensity of use with prevalence and incidence of metabolic syndrome and its components (increased waist circumference, triglycerides, fasting glucose, blood pressure and decreased high-density lipoprotein cholesterol).

Methods

We conducted cross-sectional and prospective analyses using data from the Pars Cohort Study in southern Iran, encompassing 9,264 participants at the baseline, and 5,002 randomly selected in a repeated follow-up. We used multivariate logistic regression models adjusted for age, sex, education, wealth score, physical activity and cigarette pack-years to report odds ratios (OR) and 95% confidence intervals (CI).

Results

Among 9,264 participants, 3,119 (33.7%) had metabolic syndrome, and 3,482 (37.6%) had ever smoked waterpipe, with both more common in women than in men. In adjusted models, former waterpipe use was significantly associated with prevalence (OR = 1.43, 95% CI: 1.23-1.68) and incidence (OR = 1.57, 95% CI: 1.19-2.06) of the metabolic syndrome while current waterpipe use was not. Past use was associated with increased risk in all components of metabolic syndrome; current use was associated with increases in all except high blood glucose and hypertension. Past waterpipe users had higher waterpipe use intensity (before quitting) in comparison with current users (2.3 vs. 2.0 waterpipes per day, p < 0.01) and had started waterpipe smoking at a younger age (27.2 vs. 30.1 years, p < 0.01).

Conclusion

Waterpipe use was associated with metabolic syndrome and its components, especially among former users potentially due to higher intensity and earlier initiation of use.

Risk of acute coronary syndrome and relationship with the use of khat and tobacco products in the Jazan region, Saudi Arabia: A prospective case-control study

INTRODUCTION

Previous studies have identified several risk factors for acute coronary syndrome (ACS). This study was intended to examine the potential risk of ACS associated with khat and tobacco use.

METHODS

A case-control study of 344 people (172 cases and 172 controls) was conducted at Prince Mohammed Bin Nasser Hospital in Jazan, Saudi Arabia, from April to September 2019. The cases and controls were matched for age (±5 years) and gender. Data were analyzed using descriptive, inferential, and modeling analyses. We utilized the adjusted odds ratio (AOR) to express the results.

RESULTS

The prevalence of ever khat chewing among all study participants was 29.1%, significantly higher for the cases with ACS than for the control group (43.6% vs 14.5%, p<0.001). Cigarette smokers accounted for 33.4% of the study participants, and 22.1% were ACS cases, which is a significantly higher percentage than the control group. The prevalence of smokeless tobacco was 20.3% among ACS cases and 14.5% among controls, with no statistically significant differences (p>0.05). In the final model, tobacco use was more likely to be reported among cases with myocardial infarction (MI) (AOR=4.58; 95% CI: 1.01-4.73, p<0.05) as was khat chewing (AOR=3.4; 95% CI: 1.55-7.46, p<0.05), after controlling for other traditional risk factors.

CONCLUSIONS

Khat chewing was reported more by those who reported ACS. ACS cases were more likely to be frequent khat users with chewing sessions of five or more days per week. Regular tobacco use was also reported in those who reported ACS, and this increases with the amount of tobacco used. Implementing early intervention strategies can help mitigate the impact of khat chewing and smoking on the development of ACS.

N-acetyltransferase metabolism and DNA damage following exposure to 4,4'-oxydianiline in human bronchial epithelial cells

Waterpipe smoking is increasingly popular and understanding how chemicals found in hookah smoke may be harmful to human bronchial epithelial cells is of great importance. 4,4'-Oxydianiline (ODA), is an aromatic amine which is present at comparatively high levels in hookah smoke. The metabolism and the subsequent toxicity of ODA in human bronchial epithelial cells remains unknown. Given that ODA is an aromatic amine, we hypothesized that ODA is N-acetylated and induces DNA damage following exposure to immortalized human bronchial epithelial cells (BEP2D cells). We measured the N-acetylation of ODA to mono-acetyl-ODA and the N-acetylation of mono-acetyl-ODA to diacetyl-ODA by BEP2D cells following separation and quantitation by high performance liquid chromatography. For ODA, the apparent KM in cells was 12.4 ± 3.7 µM with a Vmax of 0.69 ± 0.03 nmol/min/106 cells, while for mono-acetyl-ODA, the apparent KM was 111.2 ± 48.3 µM with a Vmax of 17.8 ± 5.7 nmol/min/106 cells ODA exposure for 24 h resulted in DNA damage to BEP2D cells following concentrations as low as 0.1 µM as measured by yH2Ax protein expression These results demonstrate that ODA, the most prevalent aromatic amine identified in hookah smoke, is N-acetylated and induces DNA damage in human bronchial epithelial cells.

A qualitative exploration of experts' views about multi-dimensional aspects of hookah smoking control in Iran

BACKGROUND

The related literature has primarily addressed cigarette smoking control. It seems that researchers have failed to explore the determinants of hookah smoking (HS) control. In an attempt to fill this gap, the present study explores experts' views about aspects of HS control in Bandar Abbas, a city in the south of Iran.

METHODS

The present qualitative study, conducted in 2022 and 2023, used a content analysis. To this aim, 30 experts in tobacco prevention and control were invited to participate in the research. Twenty seven accepted the invitation. In-depth, semi-structured, and face-to-face interviews were held with the experts. A purposive sampling was used and the data collection continued until data saturation. The interviews lasted between 18 and 65 min. MAXQDA 10.0 was used for data management and analysis.

RESULTS

The expert interviewees had a mean age of 44.77 ± 6.57 years and a mean work experience of 18.6 ± 6.8 years. A total number of six main categories were extracted from the data, including usin influential figures to control HS, controlling HS by alternative activities, changing beliefs and attitudes toward HS, taking administrative and regulatory measures, and facilitating HS cessation.

CONCLUSION

This qualitative study explored the multifaceted ways people adopt to quit HS. Using influential figures to control hookah smoking, promoting alternative activities as a means of control, changing beliefs and attitudes, enforcing administrative regulations, and facilitating quit attempts all play an important role in tackling the prevalence of hookah smoking. These findings emphasize the importance of a comprehensive and multifaceted approach to integrate various interventions to effectively address hookah smoking behavior.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

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.

Biomarkers of Waterpipe Tobacco Smoke Exposure: A Systematic Review and Meta-Analysis

INTRODUCTION

The prevalence of waterpipe tobacco smoking is increasing globally. Biomarkers of waterpipe tobacco smoke (WTS) exposure are less studied.

AIMS AND METHODS

To identify the types of biomarkers of WTS exposure and estimate changes in biomarker concentrations pre- to post-WTS exposure. PubMed, Embase, Web of Science, CINAHL Plus, PsycINFO, and Cochrane Library were searched for studies up to April 24, 2023. The types of biomarkers were identified. Random-effects models were used to estimate changes in biomarker concentrations pre- to post-WTS exposure.

RESULTS

Seventy-three studies involving 3755 participants exposed to WTS (49% male, mean age: 24.8 years) and 11 types of biomarkers of WTS exposure were identified. The biomarkers included tobacco alkaloids, expired carbon monoxide (eCO), carboxyhemoglobin (COHb), tobacco-specific nitrosamines, volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), heavy metals, unmetabolized VOCs, unmetabolized PAHs, furan metabolites, and heterocyclic aromatic amines. Compared with pre-WTS exposure, eCO (breath; mean difference [MD] 27.00 ppm; 95% confidence interval [CI]: 20.91 to 33.08), COHb (blood; MD 4.30%; 95%CI: 2.57 to 6.03), COHb (breath; MD 7.14%; 95%CI: 4.96 to 9.31), nicotine (blood; MD 8.23 ng/mL; 95%CI: 6.27 to 10.19), and cotinine (urine; MD 110.40 ng/mL; 95%CI: 46.26 to 174.54) significantly increased post-WTS exposure.

CONCLUSIONS

Biomarkers of WTS exposure were systematically identified. The similarity between the biomarkers of WTS exposure and those of cigarette smoke and higher concentrations of some biomarkers post-WTS exposure underscore the need for further research on applying biomarkers in surveillance, interventions, and regulations to mitigate the harms of waterpipe tobacco smoking.

IMPLICATIONS

This study provides the first comprehensive overview of biomarkers investigated and available for assessing WTS exposure and their concentration changes in the human body. Researchers can use biomarkers such as eCO, COHb, nicotine, and cotinine to measure the health risks associated with WTS exposure and objectively evaluate the effectiveness of public health interventions aimed at reducing waterpipe tobacco smoking. Public health policymaking can also be informed through increased biomarker concentrations following WTS exposure, to implement regulations and public health education campaigns on limiting or preventing waterpipe tobacco smoking.

Smoking behaviors among Middle Eastern college women in the United States

Objective: to examine factors associated with cigarette and hookah smoking among Middle Eastern (ME) Arab college women. Participants: 406 adult women of ME Arabic background, currently enrolled in or recently graduated from a US college. Methods: a cross-sectional design, using an anonymous online survey of demographic characteristics, sociocultural factors, and access to health care factors. Data analysis included regression model to identify predictors of smoking behaviors. Results: Smoking rates were 21% and 19% for cigarette and hookah smoking. Cigarette smoking was higher with having liberal attitudes toward sexuality and lower among those having a healthcare provider. Hookah smoking was higher among students who are Muslim, involved in student organizations, have higher acculturation-heritage levels, and have more liberal attitudes toward women. Hookah smoking was lower among students born in the US, attending college part-time, and having higher religiosity levels. Conclusions: The study findings have several implications for interventions to address smoking behaviors among ME Arab college women through community organizations and within college campuses.

Assessing the risk of metabolic syndrome and diabetes in relation to Hookah smoking: Evidence from a cohort study in Southern Iran

Background

Hookah smoking has pointedly increased worldwide and could have different harmful health effects. However, long term hookah smoking effects on chronic diseases has not been well studied. This study was aimed to investigate the relationship between hookah smoking with metabolic syndrome and diabetes.

Methods

In this prospective study, the baseline data from 3695 participant (35-70 years old) of Bandar-e-Kong cohort study in Hormozgan province, Iran were used. In this study, data were collected through the questionnaires designed in the Kong cohort study and 25 mm of blood sample. All analyses were performed using SPSS version 27.0 and the ggplot2 package in RStudio version 2023.06.1 + 524. p < 0.05 was considered a significant difference.

Results

The prevalence of hookah smoking was 17.3% in total. Also, the prevalence of metabolic syndrome, diabetes, hypertension, and dyslipidemia were 35.6, 15.2, 31.2, and 78.0%, respectively. Our results showed that there were statistically significant relationship between hookah smoking and metabolic syndrome, hypertension and diabetes (p < 0.05). In the case of dyslipidemia, hookah smoking was also associated with increase in dyslipidemia (p < 0.05).

Conclusions

More evidence is needed to understand the mechanism of hookah smoking and these health effects. As well as, health education and increasing public awareness about the health effects of hookah smoking and implementation of smoking prohibition policies are highly recommended.

Electronic hookah (waterpipe) vaping reduces vascular endothelial function: the role of nicotine

Vaping has risen substantially in recent years, particularly among young adults. Electronic (e-) hookahs are a newer category of vaping devices touted as safer tobacco alternatives. Although e-hookah vaping acutely reduces endothelial function, the role of nicotine and the mechanisms by which it may impair endothelial function remain understudied. In a randomized crossover study, we investigated the acute effects of vaping e-hookah, with and without nicotine, as compared with sham on endothelial function assessed by brachial artery flow-mediated dilation (FMD), among 18 overtly healthy young adults. To determine the role of changes in circulating factors in plasma on endothelial cell function, human umbilical vein endothelial cells (HUVECs) were cultured with participants' plasma, and acetylcholine-stimulated nitric oxide (NO) production and basal reactive oxygen species (ROS) bioactivity were assessed. Plasma nicotine was measured before and after the sessions. E-hookah vaping with nicotine, which acutely increased heart rate (HR) by 8 ± 3 beats/min and mean arterial pressure (MAP) by 7 ± 2 mmHg (means ± SE; P < 0.05), decreased endothelial-dependent FMD by 1.57 ± 0.19%Δ (P = 0.001), indicating impairment in endothelial function. Vaping e-hookah without nicotine, which mildly increased hemodynamics (HR, 2 ± 2 beats/min and MAP 1 ± 1 mmHg; P = ns), did not significantly impair endothelial function. No changes were observed after sham vaping. HUVECs cultured with participants' plasma after versus before e-hookah vaping with nicotine, but not without nicotine or sham vaping, exhibited reductions in endothelial cell NO bioavailability and increases in ROS bioactivity (P < 0.05). Plasma nicotine concentrations increased after vaping e-hookah with nicotine (6.7 ± 1.8 ng/mL; P = 0.002), whereas no changes were observed after vaping e-hookah without nicotine or sham (P = ns). Acute e-hookah vaping induces endothelial dysfunction by impairing NO bioavailability associated with increased ROS production, and these effects are attributable to nicotine, not to nonnicotine constituents, present in the flavored e-liquid.NEW & NOTEWORTHY Despite safety claims heavily advertised by the hookah tobacco industry, acute e-hookah vaping induces in vivo endothelial dysfunction by impairing ex vivo NO bioavailability associated with increased ROS production. These effects are attributable to nicotine, not to nonnicotine constituents, present in the flavored e-liquid.

The effectiveness of a theory -based health education program on waterpipe smoking cessation in Iran: one year follow-up of a quasi-experimental research

BACKGROUND

The present research aimed to determine the effect of an educational intervention based on the extended theory of planned behavior (ETPB) on waterpipe (WT) smoking cessation in women.

METHODS

The present quasi-experimental had a pre-test, post-test design with 3, 6 and 12 months follow-ups was conducted in Bandar Abbas city, south of Iran in December 2021-March 2023. A total of 448 women over the age of 15 (224 in the intervention group (IG), 224 in the control group (CG)), using a two-stage cluster sampling method participated. The educational intervention focused on WT smoking cessation implemented in 14 sessions. The educational methods in the training sessions were lectures, collaborative discussions, Q&As, brainstorming, role plays, and peer education. The main outcome was WT cessation behavior. Repeated measures ANOVA tests and post hoc were run to compare the IG and CG at baseline in terms of demographic variables, t-test and chi square test, and in the four points of time of data collection. The data were analyzed in Stata14. A p-value < 0.05 was considered as statistically significant.

RESULTS

The mean and standard deviation of WT cessation behavior and all ETPB constructs in the IG was significantly higher than the CG. After the educational intervention, in the IG, the perceived behavioral control, attitude, subjective norm, intention and knowledge increased, and the weekly smoking and WT smoking habit decreased (P < 0.001). The CG did not have any significant change in other variables except for the increased knowledge score. During the 12-month follow-up, the cessation rate was 43.81% (P = 0.645) in the IG and 7.45% in the CG (P = 0.081).

CONCLUSIONS

The educational intervention positively affected WT smoking reduction and cessation in women through influencing the ETPB constructs. It is strongly recommended to design theory-based interventions beyond the individual level with an emphasis on interpersonal relationships to facilitate WT cessation as far as possible.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Effects of Waterpipe Smoke Exposure on Experimentally Induced Chronic Kidney Disease in Mice

Tobacco smoking is an independent risk factor in the onset of kidney disease. To date, there have been no reports on the influence of waterpipe smoke (WPS) in experimentally induced chronic kidney disease (CKD) models. We studied the effects and mechanisms of actions of WPS on a mouse model of adenine-induced CKD. Mice fed either a normal diet, or an adenine-added diet and were exposed to either air or WPS (30 min/day and 5 days/week) for four consecutive weeks. Plasma creatinine, urea and indoxyl sulfate increased and creatinine clearance decreased in adenine + WPS versus either WPS or adenine + saline groups. The urinary concentrations of kidney injury molecule-1 and adiponectin and the activities of neutrophil gelatinase-associated lipocalin and N-acetyl-β-D-glucosaminidase were augmented in adenine + WPS compared with either adenine + air or WPS groups. In the kidney tissue, several markers of oxidative stress and inflammation were higher in adenine + WPS than in either adenine + air or WPS groups. Compared with the controls, WPS inhalation in mice with CKD increased DNA damage, and urinary concentration of 8-hydroxy-2-deoxyguanosine. Furthermore, the expressions of nuclear factor κB (NF-κB) and mitogen-activated protein kinases (MAPKs) (ERK and p38) were elevated in the kidneys of adenine + WPS group, compared with the controls. Likewise, the kidneys of adenine + WPS group revealed more marked histological tubular injury, chronic inflammation and interstitial fibrosis. In conclusion, WPS inhalation aggravates kidney injury, oxidative stress, inflammation, DNA damage and fibrosis in mice with adenine-induced CKD, indicating that WPS exposure intensifies CKD. These effects were associated with a mechanism involving NF-κB, ERK and p38 activations.

Pathophysiologic effects of waterpipe (shisha) smoke inhalation on liver morphology and function in mice

AIMS

The global prevalence of waterpipe tobacco smoking is increasing. Although the cardiorespiratory, renal, and reproductive effects of waterpipe smoking (WPS) are well-documented, there is limited knowledge regarding its adverse impact on the liver. Therefore, our study aimed to assess the effects and potential mechanisms of WPS inhalation for one or four weeks on the liver.

MAIN METHODS

Mice were exposed to WPS for 30 min per day, five days per week, while control mice were exposed to clean air.

KEY FINDINGS

Analysis using light microscopy revealed the infiltration of immune cells (neutrophils and lymphocytes) accompanied by vacuolar hepatic degeneration upon WPS inhalation. At the four-week timepoint, electron microscopy analysis demonstrated an increased number of mitochondria with a concomitant pinching-off of hepatocyte plasma membranes. WPS exposure led to a significant rise in the activities of liver enzymes alanine aminotransferase and aspartate aminotransferase in the bloodstream. Additionally, WPS inhalation elevated lipid peroxidation and reactive oxygen species levels and disrupted the levels of the antioxidant glutathione in liver tissue homogenates. The concentration of proinflammatory cytokines, including tumor necrosis factor α, interleukin (IL)-6, and IL-1β, was significantly increased in the WPS-exposed group. Furthermore, WPS inhalation induced DNA damage and a significant increase in the levels of cleaved caspase-3, cytochrome C and hypoxia-inducible factor 1α along with alterations in the activity of mitochondrial complexes I, II, III and IV.

SIGNIFICANCE

Our findings provide evidence that WPS inhalation triggers changes in liver morphology, oxidative stress, inflammation, DNA damage, apoptosis, and alterations in mitochondrial activity.

A method for cancer elemental risk assessments in hookah: An example in two common types of traditional and flavored tobaccos in Iran

AIM

This study aimed to compare the elemental composition of traditional and flavored hookah tobacco, with a focus on heavy metals.

METHODS

We used inductively coupled plasma mass spectrometry (ICP-MS) to analyze the concentrations of 29 elements in the raw tobacco, tobacco ash, hookah water after smoking, and tobacco smoke.

RESULTS

The results showed that the traditional tobacco had significantly higher metal concentrations than the flavored tobacco in all samples. Most of the toxic metals (more than 98 %) remained in the smoke of both types of tobacco. The tobacco and hookah smoke contained high levels of harmful metals that can pose health risks to hookah users.•ICP-MS provides a comprehensive analysis of multiple elements simultaneously and it allows for precise quantification of metal concentrations in different samples.•ICP-MS requires specialized equipment and trained personnel and it may not detect elements present in extremely low concentrations.

Association of non-daily hookah tobacco smoking and cardiovascular disease-related exposure biomarkers among U.S. users: The Population Assessment of Tobacco and Health Study

Hookah smoking has grown to become a global tobacco epidemic. While cigarette smoking is a well-established cardiovascular disease (CVD) risk factor, the CVD risks of hookah smoking are unknown, particularly among regular U.S. adult hookah users who are predominantly non-daily users. Herein, we examined the association between hookah smoking and biomarkers of CVD risk among regular exclusive hookah smokers (n = 75), compared to regular exclusive cigarette smokers (n = 1773), dual hookah and cigarette smokers (n = 43) and never tobacco users (n = 757), using data from a nationally representative sample of adults from the Population Assessment of Tobacco and Health Study (2013-2014). Whereas 84% of cigarette smokers reported daily use, only 8% of hookah smokers reported daily use, with more than a third reporting monthly use. Adjusting for age and sex and as compared to exclusive cigarette smokers, exclusive hookah smokers had significantly lower geometric mean concentrations in serum sICAM-1 and urinary F2-isoprostane (p < 0.05). Although not statistically significant, a signal of increased oxidative stress was observed among hookah smokers as compared to never tobacco users (urinary F2-isoprostane). CVD-related harm biomarkers appear to be lower among hookah smokers than cigarette smokers. These findings represent patterns of hookah smoking predominantly shared among adult U.S. users who report non-daily occasional use and do not reflect solitary, daily use as is common in the Middle East. Future studies with longer exposure and longitudinal hookah use are warranted to explore the association between hookah smoking and CVD risk.

Endurance Exercise Training Attenuates the Waterpipe Smoke Inhaling-Induced Learning and Memory Impairment in Rats: Role of Neurotrophic Factors and Apoptotic System

INTRODUCTION

The increasing prevalence of waterpipe tobacco smoking (WTS) and its detrimental effects on memory function have been reported. This study was conducted to investigate the effect of moderate-intensity endurance exercise on the detrimental effects of WTS on learning and spatial memory in rats.

AIMS AND METHODS

Animals were divided into the Control group (CTL), the exercise group (Ex) which trained for 8 weeks, the WTS group (Wp) exposed to smoke inhalation (30 minutes per day, 5 days each week, and for 8 weeks), and the group that did exercise training and received waterpipe smoke together (Ex + Wp). Thereafter, learning and spatial memory were assessed by the Morris water maze test and hippocampal molecular measurements were done.

RESULTS

Waterpipe smoke significantly impaired learning and spatial memory, decreased expression of neurotrophic factors IGF-1 and BDNF (p < .01 and p < .05 vs. CTL group, respectively), increased BAX to BCL-2 ratio (p < .001 vs. CTL group) in hippocampal tissue, and increased the percent of damaged neurons in the hippocampal CA1 area (p < .05 vs. CTL group). Combination of exercise training with WTS prevented learning and spatial memory disturbances and recovered expression of neurotrophic factors IGF-1 (p < .05 vs. Wp group), decreased BAX to BCL-2 ratio (p < .001 vs. Wp group), and reduced percentage of damaged neurons (p < .05 vs. Wp group).

CONCLUSIONS

Findings suggest that moderate-intensity endurance exercise training can ameliorate learning and memory impairment caused by waterpipe smoke in rats. This effect partly results from increasing the expression of neurotrophic factors BDNF and IGF-1 and correcting pro/anti-apoptotic proteins balance in the hippocampal tissue.

IMPLICATIONS

The popularity of WTS especially among youth is increasing. We assessed the effect of hookah smoke with/without exercise on learning and memory. Hookah smoke leads to CA1-neural injury and impairs learning and memory in rats. A combination of exercise training with hookah smoke attenuates these complications. This positive effect of exercise is partially mediated by the balancing of brain-derived neurotrophic factor (BDNF) and Insulin-like growth factor-1 (IGF-1) and also the BAX to BCL-2 ratio, a significant predictor of cell susceptibility to apoptosis. Extrapolation of these positive findings to humans needs complementary studies.

Seeing Beyond the Smoke: Selecting Waterpipe Wastewater Chemicals for Risk Assessments

Background

Increasing use prevalence of waterpipe tobacco smoking raises concerns about environmental impacts from waterpipe waste disposal. The U.S. Food and Drug Administration (FDA) is required to assess the environmental impact of its tobacco regulatory actions per the National Environmental Policy Act. This study builds on FDA's efforts characterizing the aquatic toxicity of waterpipe wastewater chemicals.

Methods

We compiled a comprehensive list of waterpipe wastewater chemical concentrations from literature. We then selected chemicals for risk assessment by estimating persistence, bioaccumulation, and aquatic toxicity characteristics (PBT; U.S. Environmental Protection Agency), and hazardous concentration values (concentration affecting specific proportion of species).

Results

Of 38 chemicals in waterpipe wastewater with concentration data, 20 are listed as harmful or potentially harmful constituents (HPHCs) in tobacco smoke and tobacco products by FDA, and 15 are hazardous waste per U. S. Environmental Protection Agency. Among metals, six (cadmium, chromium, lead, mercury, nickel and selenium) are included in both HPHC and hazardous waste lists and were selected for future risk assessments. Among non-metals, nicotine, and 4-methylnitrosamino-1-(3-pyridyl)-1-butanone (NNK) were shortlisted, as they are classified as persistent and toxic. Further, N-nitrosonornicotine (NNN), with a low HC50 value for chronic aquatic toxicity, had high aquatic toxicity concern and is selected.

Conclusions

The presence of multiple hazardous compounds in waterpipe wastewater highlights the importance of awareness on the proper disposal of waterpipe wastewater in residential and retail settings. Future studies can build on the hazard characterization provided in this study through fate and transport modeling, exposure characterization and risk assessments of waterpipe wastewater chemicals.

Smoking waterpipe, cigarette, and heart disease: a cross-sectional analysis of baseline data from the Kong Cohort Study in the South of Iran

Previous studies have shown the association between smoking and increased risk of cardiovascular diseases, but long-term effects of waterpipe use are unknown and more research is needed. The present study explored the relationship between cigarette and waterpipe smoking and heart disease in southern Iran. This cross-sectional study used the basic data of Bandar Kong Cohort Study (KCS) to test the relationship between waterpipe and cigarette smoking and heart disease in 4009 participants. A multivariate binary logistic regression was run to estimate adjusted odds ratios (ORs) in SPSS 16. The prevalence of tobacco use was 27.7%. The frequency of heart disease was 7.8% percent (n = 314). There was a statistically significant relationship between cigarette smoking and heart disease (OR = 2.11; 95% CI:1.41-3.16). In individuals who only smoked waterpipes, the odds of heart disease were higher than non-smokers. This relationship was not statistically significant (OR = 1.25, 95% CI:0.88-1.78). In those who smoked cigarettes and waterpipe at the same time, the odds of heart disease were higher than non-smokers (OR = 1.42; 95% C.I: 0.83-2.59). In general, cigarette smoking increases the risk of heart disease. As well as waterpipe smoking was associated with heart disease. However, this association was not statistically significant. More studies are required to validate the association between waterpipe smoking and heart disease. Also, waterpipe use was more common at younger ages, and on the other hand, heart diseases have a long latent period, so in this age group, high incidence of heart disease is likely in the future.

Waterpipe smoke inhalation induces lung injury and aortic endothelial dysfunction in mice

Waterpipe tobacco smoking (WPS) inhalation has been shown to trigger endothelial dysfunction and atherosclerosis. However, the mechanisms underlying these effects are still unknown. Here, we assessed the impact and underlying mechanism of WPS exposure for one month on endothelial dysfunction using aortic tissue of mice. The duration of the session was 30 min/day and 5 days/week. Control mice were exposed to air. Inhalation of WPS induced an increase in the number of macrophages and neutrophils and the concentrations of protein, tumor necrosis factor alpha (TNF alpha), interleukin (IL)-1beta, and glutathione in bronchoalveolar lavage fluid. Moreover, the concentrations of proinflammatory cytokines (TNF alpha, IL-6 and IL-1beta), adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin and P-selectin) and markers of oxidative stress (lipid peroxidation, glutathione, superoxide dismutase and nitric oxide) in aortic homogenates of mice exposed to WPS were significantly augmented compared with air exposed mice. Likewise, the concentration of galectin-3 was significantly increased in the aortic homogenates of mice exposed to WPS compared with control group. WPS inhalation induced vascular DNA damage assessed by comet assay and apoptosis characterized by a significant increase in cleaved caspase-3. While the aortic expression of phosphorylated nuclear factor kappaB (NF-kappaB) was significantly increased following WPS inhalation, the concentration of sirtuin 1 (SIRT1) was significantly decreased in WPS group compared with air-exposed group. In conclusion, our study provided evidence that WPS inhalation triggers lung injury and endothelial inflammation, oxidative stress and apoptosis which were associated with nuclear factor-kappaB activation and SIRT1 down-regulation.

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.

Epidemiology and prevalence of tobacco use in Tehran; a report from the recruitment phase of Tehran cohort study

INTRODUCTION

Tobacco use is a major health concern worldwide, especially in low/middle-income countries. We aimed to assess the prevalence of cigarette smoking, waterpipe, and pipe use in Tehran, Iran.

METHODS

We used data from 8272 participants of the Tehran Cohort Study recruitment phase. Tobacco use was defined as a positive answer to using cigarettes, waterpipes, or pipes. Participants who did not report tobacco use during the interview but had a previous smoking history were categorized as former users. Age- and sex-weighted prevalence rates were calculated based on the national census data, and characteristics of current and former tobacco users were analyzed.

RESULTS

Age- and sex-weighted prevalence of current tobacco users, cigarette smokers, waterpipe, and pipe users in Tehran was 19.8%, 14.9%, 6.1%, and 0.5%, respectively. Current tobacco use was higher in younger individuals (35-45 years: 23.4% vs. ≥ 75 years: 10.4%, P < 0.001) and men compared to women (32.9% vs. 7.7% P < 0.001). The prevalence of tobacco use increased with more years of education (> 12 years: 19.3% vs. illiterate: 9.7%, P < 0.001), lower body mass index (< 20 kg/m2: 31.3% vs. ≥ 35 kg/m2: 13.8%, P < 0.001), higher physical activity (high: 23.0% vs. low: 16.4%, P < 0.001), opium (user: 66.6% vs. non-user: 16.5%, P < 0.001), and alcohol use (drinker: 57.5% vs. non-drinker: 15.4%, P < 0.001). Waterpipe users were younger (46.1 vs. 53.2 years) and had a narrower gender gap in prevalence than cigarette smokers (male/female ratio in waterpipe users: 2.39 vs. cigarette smokers: 5.47). Opium (OR = 5.557, P < 0.001) and alcohol consumption (OR = 4.737, P < 0.001) were strongly associated with tobacco use. Hypertension was negatively associated with tobacco use (OR = 0.774, P = 0.005).

CONCLUSION

The concerning prevalence of tobacco use in Tehran and its large gender gap for cigarette and waterpipe use warrant tailored preventive policies.

Predictive Factors of Stages of Change in Hookah Smoking Cessation Among Iranian Adults Based on the Transtheoretical Model

BACKGROUND

Hookah, as a traditional method of smoking, is widely used in Iran, especially in Bushehr province. It is essential to identify the most important determinants of modifying hookah smoking behavior. This study aimed to investigate the predictors of the stages of change in quitting hookah smoking in 15-60-year-old individuals in Bushehr province, southern Iran, based on the transtheoretical model (TTM).

METHODS

This descriptive-analytical study was conducted on 1173 Hookah smokers in Bushehr province. The samples were selected by two-stage random sampling from 10 cities. Data were collected using a valid and reliable questionnaire consisting of 5 sections (demographic characteristics, stages of change, processes of change, decisional balance, and self-efficacy). Data were analyzed by R version.3.3.1 using analysis of variance and ordinal logistic regression at a significant level of 0.05.

FINDINGS

The data revealed 82% of the participants were in the preparatory phase (55.3% in pre-contemplation and 26.7% in contemplation stages). Marital status, family members smoking hookah, cigarette smoking, level of education, number of family members, number of quitting attempts, self-efficacy, self-reevaluation, counter-conditioning, reinforcement management, and stimulus control were predictors of quitting hookah smoking.

CONCLUSION

Given that most study participants were in the inactive stages of quitting hookah smoking, it seems necessary to design and implement behavioral interventions based on the predictive TTM constructs in this population.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Assessing the risk of cardiovascular diseases in relation to shisha smoking among adults in Qatar: An analytical cross-sectional study

INTRODUCTION

Tobacco smoking is a preventable cause of disease and death worldwide. Shisha has become a popular method of smoking tobacco. In Qatar, the prevalence of smoking in 2019 was 25.2%, of which 20.9% was smoking shisha. Shisha smoking is thought to have a harmful effect on the cardiovascular system. The main objective of this study was to understand the relationship between shisha smoking and cardiovascular disease risks.

METHODS

All data were obtained from the Qatar Biobank (QBB). The study population consisted of 1045 individuals, which included cases defined as participants who had a history of angina, heart attack and/or stroke and their matched healthy controls for age and gender. The measurement of both the exposure and the outcome was done through the survey provided by QBB. A conditional logistic regression model was used to assess the association between smoking and cardiovascular disease (CVD), and adjusted odds ratio (AOR) and 95% confidence intervals (CI) were calculated after adjusting for covariates.

RESULTS

After adjusting for hypertension diagnosis, diabetes diagnosis, dyslipidemia diagnosis, abdominal obesity, and sedentary lifestyle, exclusive shisha smokers had 1.65 times higher odds of reporting cardiovascular disease diagnoses compared to non-smokers (95% CI: 0.71-1.91). Dual shisha and cigarette smokers also had 1.47 times higher odds of reporting cardiovascular disease diagnoses compared to non-smokers (95% CI: 0.88-2.45). CVD cases had a younger median age of initial shisha smoking compared to controls (20 years vs 25 years, p=0.003).

CONCLUSIONS

Shisha smoking was associated with an increased risk of developing cardiovascular disease. However, this association did not reach the level of statistical significance within this study. A finding to consider that showed strong evidence is the younger age of initial shisha smoking in cases. Further studies are needed to demonstrate the true relationship between shisha smoking and cardiovascular disease.

Waterpipe smoke inhalation potentiates cardiac oxidative stress, inflammation, mitochondrial dysfunction, apoptosis and autophagy in experimental hypertension

Cigarette smoking worsens the health of hypertensive patients. However, less is known about the actions and underlying mechanisms of waterpipe smoke (WPS) in hypertension. Therefore, we evaluated the effects of WPS inhalation in mice made hypertensive (HT) by infusing angiotensin II for six weeks. On day 14 of the infusion of angiotensin II or vehicle (normotensive; NT), mice were exposed either to air or WPS for four consecutive weeks. Each session was 30 min/day and 5 days/week. In NT mice, WPS increased systolic blood pressure (SBP) compared with NT air-exposed group. SBP increase was elevated in HT+WPS group versus either HT+air or NT+WPS. Similarly, the plasma levels of brain natriuretic peptide, C-reactive protein, 8-isoprostane and superoxide dismutase were increased in HT+WPS compared with either HT+air or NT+WPS. In the heart tissue, several markers of oxidative stress and inflammation were increased in HT+WPS group vs the controls. Furthermore, mitochondrial dysfunction in HT+WPS group was more affected than in the HT+air or HT+WPS groups. WPS inhalation in HT mice significantly increased cardiac DNA damage, cleaved caspase 3, expression of the autophagy proteins beclin 1 and microtubule-associated protein light chain 3B, and phosphorylated nuclear factor κ B, compared with the controls. Compared with HT+air mice, heart histology of WPS-exposed HT mice showed increased cardiomyocyte damage, neutrophilic and lymphocytic infiltration and focal fibrosis. We conclude that, in HT mice, WPS inhalation worsened hypertension, cardiac oxidative stress, inflammation, mitochondrial dysfunction, DNA damage, apoptosis and autophagy. The latter effects were associated with a mechanism involving NF-κB activation.

The Effects of Pictorial Health Warning Label on Waterpipe (Low- and High-Frequency) Smokers' Experiences, Toxicant Exposures, and Puffing Behavior

BACKGROUND

Pictorial health warning label (PHWL) is an effective risk communication measure among cigarette smokers. However, there is a lack of knowledge regarding the effect of PHWL on low- and high-frequency waterpipe (WP) smokers. This study examined the effects of PHWL on puffing behavior, subjective experiences, and toxicant exposures among low- and high-frequency WP smokers in the United States (US).

METHODS

Sixty current (past-month) WP smokers (low-frequency; n = 30 and high-frequency; n = 30) completed two 45-min ad libitum WP smoking sessions in a cross-over design study (WP with no-PHWL vs. WP with PHWL). We compared the mean differences of puff topography, expired carbon monoxide (eCO), plasma nicotine concentration, and subjective experiences between the two smoking groups.

RESULTS

Mean age of low-frequency smokers was 21.5 years and high-frequency smokers was 21.3 years. Compared to high-frequency, low-frequency smokers had significant reduction in average total smoking time [mean difference (SD) =  -7.6 (10.2) min vs. -2.6 (6.7) min, p = 0.03] and number of puffs [mean difference (SD) =  -33.37 (70.7) vs. -0.70 (29.2), p = 0.02] following exposure to PHWL compared to no-PHWL condition. Post-session subjective experiences were lower among high-frequency smokers compared to low-frequency smokers following smoking WP with PHWL compared to the no-PHWL session (puff liking -1.2 vs. -0.5; puff satisfaction -1.0 vs. -0.3; craving reduction -0.5 vs. 1.2) (p < 0.05 for all).

CONCLUSION

Our findings indicate that placing PHWL on the WP device may be a promising strategy with differential effectiveness among WP smokers: low-frequency (reduce puffing behaviors) and high-frequency (reduce smoking experience).

Analysis of the incidence and influencing factors associated with binary restenosis of target lesions after drug-coated balloon angioplasty for patients with in-stent restenosis

BACKGROUND

Drug-coated balloon (DCB) is a novel and effective device for coronary artery disease patients with in-stent restenosis (ISR). However, the incidence and possible influencing factors associated with binary restenosis have not yet been adequately assessed.

METHODS

The data are extracted from a prospective, multicenter, randomized controlled trial. A total of 211 patients with ISR were enrolled at 13 centers from August 2017 to October 2018 and treated with DCB. At the 9-month coronary angiographic follow-up, patients were divided into restenosis and non-restenosis groups, and demographic data, lesion features, and laboratory tests were retrospectively reviewed. Furthermore, logistic regression analysis was used to identify possible influencing factors.

RESULTS

All patients successfully underwent treatment, and 166 patients with 190 lesions took part in angiography follow-ups at 9 months. Of these, 41 patients with 44 target lesions developed restenosis following treatment, and the incidence of ISR was 24.7%. There were significant differences in the average length of target lesions and the number of multivessel lesions and fasting plasma glucose (FBG) between the two groups (p < 0.05). Demographic data, cardiac risk factors, left ventricular ejection fractions (LVEF), blood routine tests, biochemical tests, and other features of devices and lesions showed no difference. Logistic regression analyses showed that FBG > 6.1 mmol/L (OR: 7.185 95% CI: 2.939-17.567 P < 0.001) and length of lesion (OR:1.046 95% CI: 1.001-1.093 P = 0.046) were associated risk factors.

CONCLUSIONS

The longer length of lesions, more target lesions and FBG > 6.1 mmol/L per individual may be characteristics of patients showing ISR following treatment. Studies with larger sample size, and more complete follow-up data are needed in the future to expend on these findings.

TRIAL REGISTRATION

No.: NCT04213378, first posted date (30/12/2019).

Attitudes towards the 'Shisha No Thanks' campaign video: Content analysis of Facebook comments

INTRODUCTION

While social media are commonly used in public health campaigns, there is a gap in our understanding of what happens after the campaign is seen by the target audience. This study aims to understand how the Shisha No Thanks campaign video was received by the Facebook audience by analyzing Facebook comments posted to it. Specifically, this study aims to determine whether the Facebook audience accepted or rejected the campaign’s message.

METHODS

A sample of the Facebook comments was extracted, and the study team, which included cultural support workers, developed content categories consistent with the research question. Each comment was then coded by three team members, and only assigned a category if there was agreement by at least two members.

RESULTS

Of the 4990 comments that were sampled, 9.1% (456) accepted the campaign message, 22.9% (1144) rejected the message, 21.8% (1089) were unclear, and 46.1% (2301) contained only tagged names. Of the sample, 2.8% (138) indicated the commenter took on board the campaign message by expressing an intention to stop smoking shisha, or asking a friend to stop smoking shisha. Of the comments that showed rejection of the campaign, the majority were people dismissing the campaign by laughing at it or expressing pro-shisha sentiments.

CONCLUSIONS

This study demonstrates that conducting content analyses of social media comments can provide important insight into how a campaign message is received by a social media audience.

Tobacco product use and the risks of SARS-CoV-2 infection and COVID-19: current understanding and recommendations for future research

Heterogeneity in the clinical presentation of SARS-CoV-2 infection and COVID-19 progression underscores the urgent need to identify individual-level susceptibility factors that affect infection vulnerability and disease severity. Tobacco product use is a potential susceptibility factor. In this Personal View, we provide an overview of the findings of peer-reviewed, published studies relating tobacco product use to SARS-CoV-2 infection and COVID-19 outcomes, with most studies focusing on cigarette smoking in adults. Findings pertaining to the effects of tobacco product use on the incidence of SARS-CoV-2 infection are inconsistent. However, evidence supports a role for cigarette smoking in increasing the risk of poor COVID-19 outcomes, including hospital admission, progression in disease severity, and COVID-19-related mortality. We discuss the potential effects of tobacco use behaviour on SARS-CoV-2 transmission and infection, and highlight the pathophysiological changes associated with cigarette smoking that could promote SARS-CoV-2 infection and increased disease severity. We consider the biological mechanisms by which nicotine and other tobacco product constituents might affect immune and inflammatory responses to SARS-CoV-2 infection. Finally, we identify current knowledge gaps and suggest priorities for research to address acute and post-acute health outcomes of COVID-19 during and after the pandemic.

Prevalence and predictors of waterpipe smoking cessation among young adults in the US: Findings from a population-based study

BACKGROUND

The prevalence of waterpipe tobacco (WPT) smoking is 9.2 % among young adults aged 18-24 years in the United State (US). Adequate understanding of the factors predicting WPT smoking cessation among the young population is essential to tobacco control efforts. This study assessed the prevalence and predictors of WPT smoking cessation among young adults.

METHODS

The population assessment of tobacco and health (PATH) study data (waves 1-5) was used for the study. A total sample of 561 young adults exclusively using WPT (past 30-days) was used for the analysis. The probability of WPT smoking cessation (no use in the past 12 months) was estimated using the Kaplan-Meier survival method, and the predictors were assessed using the Cox proportional hazards regression model.

RESULTS

During the five waves, 25.1 % of the young adult WPT smokers quit smoking. Among them, 58.2 % were females and the remaining 41.8 % were males. The Hispanics (40.2 %) had the highest rate of cessation among the ethnic groups. Regret smoking (adjusted hazard ratio (aHR) = 2.33, 95 % confidence interval (CI) = 1.24-4.36), smoking restriction at home (aHR = 2.86, 95 % CI = 1.41-5.88), and living in Midwest geographical region (aHR = 2.11, 95 % CI = 1.16-3.84) increased the likelihood whereas alcohol use (aHR = 0.62, 95 % CI = 0.41-0.93) decreased the likelihood of cessation among the young adult WPT smokers.

CONCLUSIONS

Communicating the health and economic consequences associated with WPT smoking (e.g., pictorial health warning labels), involving smoker's household members in WPT awareness campaigns, and closing regulatory loopholes related to WPT venues will increase the WPT smoking cessation rate among the young population in the US.

Effects of smoking shisha, cancer risk, and strategies for prevention of shisha habit

Smoking tobacco through a water pipe, also referred to as Shisha, is prevalent in Middle Eastern countries but has gained popularity worldwide, especially among youth. The increasing global trend of shisha use is mainly led by misleading information about it being safe. The shisha smoke has potentially harmful chemicals, including several human carcinogens and other toxic products. There are recognised adverse effects on passive smokers exposed to second-hand smoke. It is a potential risk factor for several cancers and risks pregnant women and the foetus. A session of shisha smoking for 40 minutes is equivalent to smoking 100 or more cigarettes. There should be awareness about Shisha's harmful effects to reduce the risk to health through a coordinated global effort.

Tobacco use disorder and cardiovascular health

This narrative review examines the impact of cigarette smoking and the use of other tobacco and nicotine products on cardiovascular disease. Smoking increases the incidence of both acute and chronic cardiovascular diseases, and the harmful effects are substantially and relatively quickly reversible after quitting. Recommended cessation treatment includes offering pharmacotherapy, counseling which should emphasize the rapid risk reduction that occurs after quitting and adequate follow-up contacts. Although most research on cardiovascular disease in relation to tobacco use has focused upon cigarette smoking, we also review available data related to other combustible tobacco products, smokeless tobacco, electronic nicotine delivery systems and second-hand smoke. We discuss the implications of smoking on clinical management of patients with heart disease and newer developments with potential relevance to treatment of such patients.

Exercise Training Attenuates Cardiac Vulnerability and Promotes Cardiac Resistance to Isoproterenol-Induced Injury Following Hookah Smoke Inhalation in Male Rats: Role of Klotho and Sirtuins

Hookah smoking is on the rise around the world. Present study investigated the heart resistance to harmful stress following long-term waterpipe tobacco smoking (WTS) and moderate-intensity exercise training intervention in male Wistar rats. Animals were randomly divided into a non-ischemic heart control group and four ischemic heart groups including ISO (isoproterenol-treated), Ex + ISO (subjected to exercise plus ISO), S + ISO (exposed to hookah smoke plus ISO), and Ex + S + ISO (subjected to exercise along with hookah smoke plus ISO). After eight weeks of training and WTS, heart ischemia induced by isoproterenol injections. Then, cardiac functional indices and some biochemical and histopathological parameters were assessed. WTS + ISO reduced systolic pressure, ± dP/dt max, and contractility indices (P < 0.001 vs. ISO group) and increased end diastolic pressure and Tau index (P < 0.001 vs. ISO) of the left ventricle. Also, WTS + ISO was associated with an increase in Bax protein level and Bax/Bcl-2 ratio (P < 0.05 and P < 001, respectively, vs. ISO group) as apoptotic markers of heart tissue. Hookah smoke significantly decreased SIRT1 (P < 0.05 and P < 0.001, respectively, vs. ISO) and klotho (P < 0.01 and P < 0.001, respectively, vs. ISO) in serum and heart, and SIRT3 and pS9-GSK-3β (P < 001 and P < 0.05, respectively, vs. ISO) in heart tissue. Combination of exercise with WTS prevented the hookah smoke-induced alterations in apoptotic markers, cardiac functional indices, and SIRT1, SIRT3, klotho, and pS9-GSK-3β proteins. The findings demonstrated that hookah smoke inhalation intensifies ventricular dysfunction and decreases heart resistance to harmful stresses. Moderate-intensity exercise training attenuated these complications partly through recovering the klotho and sirtuins levels and apoptosis-survival balancing.

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.

Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention

Tobacco products present a deadly combination of nicotine addiction and carcinogen exposure resulting in millions of cancer deaths per year worldwide. A plethora of smokeless tobacco products lead to unacceptable exposure to multiple carcinogens, including the tobacco-specific nitrosamine N'-nitrosonornicotine, a likely cause of the commonly occurring oral cavity cancers observed particularly in South-East Asian countries. Cigarettes continue to deliver a large number of carcinogens, including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons and volatile organic compounds. The multiple carcinogens in cigarette smoke are responsible for the complex mutations observed in critical cancer genes. The exposure of smokeless tobacco users and smokers to carcinogens and toxicants can now be monitored by urinary and DNA adduct biomarkers that may be able to identify those individuals at highest risk of cancer so that effective cancer prevention interventions can be initiated. Regulation of the levels of carcinogens, toxicants and nicotine in tobacco products and evidence-based tobacco control efforts are now recognized as established pathways to preventing tobacco related cancer.

Evaluation of 'Shisha No Thanks' - a co-design social marketing campaign on the harms of waterpipe smoking

BACKGROUND

Waterpipe (shisha) is becoming increasingly popular worldwide, particularly among young people; and in some countries, it is one of the few forms of tobacco use that is increasing. While there is a growing body of evidence of the harms of waterpipe smoke, there is a scarcity of research of interventions to address this form of tobacco consumption.

METHODS

The Shisha No Thanks project was a co-design social marketing campaign that aimed to raise awareness of the harms of waterpipe smoking among young people from an Arabic speaking background in Sydney, Australia. The campaign distributed material through social media and community events. We evaluated the project through an SMS community panel using a longitudinal study design. The cohort were sent questions before and after the project asking about their awareness of messages of harms, attitudes, intention to reduce waterpipe smoking, and awareness of support services. Data was analysed as matched pre- post- data.

RESULTS

The evaluation recruited 133 people to the panel. There was a significantly greater proportion of people who reported seeing, hearing or reading something about the harms of waterpipe smoking after the campaign (67.5%) compared with before (45.0%) (p=0.003). Post-campaign, there were higher proportions of people who strongly agreed that waterpipe smoking causes damage, and that it contains cancer-causing substances, but these increases were not statistically significant. There was low awareness of waterpipe cessation services at baseline and post campaign (22.5%).

CONCLUSIONS

The Shisha No Thanks project increased awareness of messages about the harms of waterpipe smoking. Although this is a small study, the longitudinal evaluation findings have international relevance and make a useful contribution to the understanding of the impact such interventions can have in addressing one of the few forms of tobacco use that is growing in both developed and developing countries.

Prevalence and predictors of waterpipe smoking initiation and progression among adolescents and young adults in waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study

BACKGROUND

Waterpipe tobacco (WPT) smoking has increased among the young population in the United States (US). This study assessed the extent and predictors of WPT smoking initiation and progression among US adolescents (12-17 years) and young adults (18-24 years) longitudinally.

METHODS

We analyzed data from 4 waves (2013-2018) of the Population Assessment of Tobacco and Health (PATH) study comprising 10,692 respondents (adolescents=5,428 and young adults=5,264). Kaplan-Meier survival method estimated probabilities of WPT initiation and progression. Cox proportional hazards regression models delineated predictors of the outcomes.

RESULTS

Between 2013 to 2018, 4.8% of adolescents initiated and 10.6% progressed WPT smoking. Among young adults, 18.5% initiated and 14.1% progressed WPT smoking during the same time interval. Predictors among adolescents included, WPT initiation: Hispanic ethnicity (adjusted odds ratio (aHR)=1.75, 95% confidence interval (CI)=1.23-2.49), lower harm perception (aHR=2.89, 95% CI=2.10-3.98), and other tobacco products use (aHR=3.97, 95% CI=2.73-5.78); WPT progression: illicit drug use (aHR=4.60, 95% CI=1.99-10.67). Predictors among young adults included, WPT initiation: non-Hispanic Black (aHR=2.31, 95% CI=1.78-3.00), Hispanic (aHR=1.77, 95% CI=1.34-2.33), lower harm perception (aHR=2.77, 95% CI=2.19-3.50), and other tobacco products use (aHR=3.14, 95% CI=2.25-4.38); WPT progression: non-Hispanic Black (aHR=1.51 95% CI=1.09-2.10), lower harm perception (aHR=1.80, 95% CI=1.41-2.30), and alcohol use (aHR=1.61, 95% CI=1.13-2.30).

CONCLUSIONS

Results indicate a high prevalence of WPT initiation and progression among adolescents and young adults over time, with minority racial/ethnic groups being at greater risk for both. WPT-specific risk communication interventions (e.g., educational campaigns and health warning labels) are warranted to limit WPT smoking among young people.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Waterpipe smoke-induced hypercoagulability and cardiac injury in mice: Influence of cessation of exposure

Waterpipe tobacco smoking has gained worldwide popularity, particularly among youths. Several clinical and experimental studies have reported that waterpipe smoking (WPS) injures the cardiovascular system. However, the impact of smoking cessation (CS) on the cardiovascular toxicity induced by WPS received scant attention. Hence, we assessed, in C57BL/6 mice, the cardiovascular effects of WPS exposure for 3 months followed by 3 months of SC, as compared with mice exposed for either 3 months to WPS or air (control). WPS exposure induced hypertension, prothrombotic events both in vivo and in vitro and increased the plasma concentrations of tissue factor, fibrinogen and plasminogen activator inhibitor-1. These effects were significantly alleviated by SC. In heart tissue, the levels of troponin I, creatine kinase, lipid peroxidation, 8-isoprostane, tumor necrosis factor α, inteleukin 6, DNA damage and cleaved caspase-3 were significantly increased by WPS exposure. These actions were significantly reduced in the group of mice exposed to WPS followed by SC. Similarly, the increase in the level of nuclear factor κ-β induced by WPS exposure was significantly mitigated by SC. Immunohistochemical analysis of the hearts showed that WPS exposure increased the expression of nuclear factor erythroid-derived 2-like 2 by cardiomyocytes. The latter effect was significantly reduced by SC. Taken together, our data show that SC is associated with amelioration of WPS induced hypertension, prothrombotic events and cardiac oxidative stress, inflammation, DNA damage and apoptosis.

Does a Course of Aerobic Training Affect the Inflammatory Status and Cardiometabolic Risk Factors of Hookah-smoker Women? Results of a Cross-sectional Study

Background

Hookah consumption is a major risk factor for inflammation and cardiovascular diseases (CVDs). The aim of this study was to evaluate the effects of two-month aerobic training on metabolic profile and serum C-reactive protein (CRP) levels in hookah-smoker women.

Methods

In this quasi-experimental study with a pretest-posttest design, 22 hookah-smoker women (at least twice a week) matched in terms of age (27.82 ± 3.81 years) and body mass index (BMI) (26.66 ± 5.92 kg/m²) were recruited and randomly divided into two groups of smokers + aerobic exercise (n = 11) and smokers (n = 11). A matched control group of non-smoker women (n = 10, age: 27.11 ± 2.71 years, BMI: 26.20 ± 2.39 kg/m²) were also recruited for baseline comparison. The aerobic exercise program was performed three days a week, 35-50 minutes a day for 8 weeks. The smokers' group were asked to continue their normal lives. Serum levels of CRP and metabolic risk factors were measured before and after the intervention. Data were analyzed using repeated measures analysis of variance (ANOVA).

Findings

At baseline, non-smoker participants had significantly better CRP level (P = 0.001) and maximal oxygen consumption (VO2max) (P = 0.020) than hookah-smoker women. After 8 weeks of aerobic exercise, no significant change was observed in the lipid profile of hookah-smoker women (P > 0.050). Simultaneously, body weight (P = 0.030), VO2max (P = 0.001), and CRP levels (P = 0.010) improved significantly in response to aerobic exercise.

Conclusion

These findings suggest that a course of aerobic exercise program improves the aerobic fitness of hookah-smoker women. This improvement is associated with reduction of CRP without significant changes in plasma lipid profile.

Differential Effects of Electronic Hookah Vaping and Traditional Combustible Hookah Smoking on Oxidation, Inflammation, and Arterial Stiffness

BACKGROUND

Traditional hookah smoking has grown quickly to become a global tobacco epidemic. More recently, electronic hookahs (e-hookahs)-vaped through traditional water pipes-were introduced as healthier alternatives to combustible hookah. With combustible tobacco smoking, oxidative stress, inflammation, and vascular stiffness are key components in the development and progression of atherosclerosis. The comparable effects of hookah are unknown.

RESEARCH QUESTION

What is the differential acute effect of e-hookah vaping vs combustible hookah smoking on oxidation, inflammation, and arterial stiffness?

STUDY DESIGN AND METHODS

In a randomized crossover design study, among a cohort of 17 healthy young adult chronic hookah smokers, we investigated the effect of e-hookah vaping and hookah smoking on measures of conduit arterial stiffness, including carotid-femoral pulse wave velocity (PWV), augmentation index-corrected for heart rate before and after a 30-min exposure session. We assessed a panel of circulating biomarkers indicative of inflammation and oxidants and measured plasma nicotine and exhaled carbon monoxide (CO) levels before and after the sessions.

RESULTS

e-Hookah vaping tended to lead to a larger acute increase in PWV than hookah smoking (mean ± SE: e-hookah, +0.74 ± 0.12 m/s; combustible hookah, +0.57 ± 0.14 m/s [P < .05 for both]), indicative of large artery stiffening. Compared with baseline, only e-hookah vaping induced an acute increase in augmentation index (e-hookah, +5.58 ± 1.54% [P = .004]; combustible hookah, +2.87 ± 2.12% [P = not significant]). These vascular changes were accompanied by elevation of the proinflammatory biomarkers high-sensitivity C-reactive protein, fibrinogen, and tumor necrosis factor α after vaping (all P < .05). No changes in biomarkers of inflammation and oxidants were observed after smoking. Compared with baseline, exhaled CO levels were higher after smoking than after vaping (+36.81 ± 6.70 parts per million vs -0.38 ± 0.22 parts per million; P < .001), whereas plasma nicotine concentrations were comparable (+6.14 ± 1.03 ng/mL vs +5.24 ± 0.96 ng/mL; P = .478).

INTERPRETATION

Although advertised to be "safe," flavored e-hookah vaping exerts injurious effects on the vasculature that are, at least in part, mediated by inflammation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03690427; URL: www.clinicaltrials.gov.