Harmful effects of shisha: literature review

Waterpipe vs non-Waterpipe carbon monoxide poisoning: Comparison of patient characteristics, clinical presentation and outcomes

OBJECTIVE

The aim of this study is to describe the difference between carboxyhemoglobin (CO-Hb) acute poisoning caused by waterpipe vs non-waterpipe exposures as they relate to demographics, clinical presentations and outcome of patients.

DESIGN

Retrospective cohort study conducted in the Emergency Department (ED) at the Lebanon.

PATIENTS

All adult patients presenting with a CO-Hb level ≥ 10 between January 2019 and August 2023 with exposure types stratified as waterpipe or non-waterpipe.

MEASUREMENTS AND MAIN RESULTS

111 ED visits were identified. Among these, 73.9% were attributed to waterpipe exposure, while 26.1% were non-waterpipe sources. These included cigarette smoking (17.2%), burning coal (24.1%), fire incidents (3.6%), gas leaks (6.9%), heating device use (10.3%), and undocumented sources (37.9%). Patients with waterpipe-related carbon monoxide exposure were younger (41 vs 50 years, p = 0.015) women (63.4 vs 41.4%, p = 0.039) with less comorbidities compared to non-waterpipe exposures (22.2 vs 41.4%, p = 0.047). Waterpipe smokers were more likely to present during the summer (42.7 vs 13.8%, p = 0.002) and have shorter ED length of stays (3.9 vs 4.5 h, p = 0.03). A higher percentage of waterpipe smokers presented with syncope (52.4 vs 17.2%, p = 0.001) whereas cough/dyspnea were more common in non-waterpipe exposures (31 vs 9.8%, p = 0.006). The initial CO-Hb level was found to be significantly higher in waterpipe exposure as compared to non-waterpipe (19.7 vs 13.7, p = 0.004). Non-waterpipe exposures were more likely to be admitted to the hospital (24.1 vs 4.9%, p = 0.015). Waterpipe smokers had significantly higher odds of experiencing syncope, with a 5.74-fold increase in risk compared to those exposed to non-waterpipe sources (p = 0.004) irrespective of their CO-Hb level. Furthermore, males had significantly lower odds of syncope as compared to females, following carbon monoxide exposure (aOR 0.31, 95% CI 0.13-0.74).

CONCLUSION

CO-Hb poisoning related to waterpipe smoking has distinctive features. Syncope is a commonly associated presentation that should solicit a focused social history in communities where waterpipe smoking is common. Furthermore, CO-Hb poisoning should remain on the differential in patients presenting with headache, syncope, dizziness, vomiting or shortness of breath, even outside of the non-waterpipe exposure peaks of winter season.

Reasons for shisha smoking: Findings from a mixed methods study among adult shisha smokers in Nigeria

Shisha smoking has increased significantly worldwide over the past decade including in developing countries such as Nigeria. We aimed to understand the reasons for shisha smoking in Nigeria in order to address the lack of context-specific evidence to inform the national response to the growing threat posed by shisha smoking. We adopted the Theory of Planned Behaviour to conduct in-depth interviews among 78 purposely sampled current shisha smokers in 13 states (six in each state), and a quantitative survey including a random sample of 611 current shisha smokers in 12 states, across the six geopolitical zones in Nigeria. The in-depth interview data was analysed using thematic analysis whilst the quantitative survey data was analysed descriptively. We triangulated the key findings from the two datasets using a triangulation matrix organised by the three meta-themes: attitude, subjective norms, perceived behavioural control. Positive attitudes towards shisha smoking stem from shisha flavours, perceived pleasure from shisha smoking, curiosity about product attributes, beliefs about health benefits, limited knowledge on the health effects, and weak regulation. Having friends and family members who smoke shisha and the need to belong, particularly during social events, also promote shisha smoking. Negative societal views towards shisha smoking are potentially a protective factor. The availability of and ability to smoke shisha in many places makes shisha more accessible, whilst the high costs of shisha are potentially prohibitive. The findings also indicate that quitting shisha smoking without support is difficult. Restrictions on flavours, strengthening compliance monitoring and enforcement of the tobacco control laws in relation to shisha (e.g., smoke-free environments in indoor and outdoor public places; health warnings in English on shisha products including the pots; and tax and price measures) have the potential to minimise initiation and use, and to protect the health and wellbeing of Nigeria's general public.

Carbon monoxide intoxication with a CO-Hb of 30% while smoking waterpipe: a case report

Carbon monoxide (CO) poisoning is a significant public health issue and a considerable economic burden in developed countries. While the majority of non-fire-related CO poisonings are attributed to gas heating, there are several other less recognized sources that should be considered in the initial differential diagnosis.The patient in this case was a 21-year-old who experienced a brief episode of loss of consciousness and was subsequently admitted to the Emergency department. Upon evaluation, the patient was diagnosed with CO poisoning, which necessitated hyperbaric oxygen therapy to mitigate the effects of this toxic exposure.Despite exhibiting harmful symptoms initially, the patient stated in a phone interview two and a half years post-incident that they have not experienced any enduring effects such as cardiac arrhythmia or concentration deficits. While their understanding of the risks associated with waterpipe smoking has increased, it has not influenced any major changes in their waterpipe smoking habits.

Shared Lifestyle-Related Risk Factors of Cardiovascular Disease and Cancer: Evidence for Joint Prevention

Cardiovascular disease (CVD) and cancer are leading causes of mortality and morbidity worldwide and are the major focus of the World Health Organization's joint prevention programs. While, diverse diseases, CVD and cancer, have many similarities. These include common lifestyle-related risk factors and shared environmental, metabolic, cellular, inflammatory, and genetic pathways. In this review, we will discuss the shared lifestyle-related and environmental risk factors central to both diseases and how the strategies commonly used to prevent atherosclerotic vascular disease can be applied to cancer prevention.

Longitudinal associations between exclusive, dual, and polytobacco use and asthma among US youth

Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each follow-up (Waves 2-5). We classified past 30-day tobacco use as 1) no products (never/former use), 2) exclusive cigarettes, 3) exclusive electronic nicotine delivery systems (ENDS), 4) exclusive other combustible (OC) tobacco products (cigars, hookah, pipe), 5) dual cigarettes/OC and ENDS, 6) dual cigarettes and OCs, and 7) polytobacco use (cigarettes, OCs, and ENDS). Using discrete time survival models, we analyzed the incidence of asthma across Waves 2-5, predicted by time-varying tobacco use lagged by one wave, and adjusted for potential baseline confounders. Asthma was reported by 574 of the 9141 respondents, with an average annual incidence of 1.44% (range 0.35% to 2.02%, Waves 2-5). In adjusted models, exclusive cigarette use (HR: 1.71, 95% CI: 1.11-2.64) and dual cigarette and OC use (HR: 2.78, 95% CI: 1.65-4.70) were associated with incident asthma compared to never/former use, while exclusive ENDS use (HR: 1.50, 95% CI: 0.92-2.44) and polytobacco use (HR: 1.95, 95% CI: 0.86-4.44) were not. To conclude, youth who use cigarettes with or without OCs had higher risk of incident asthma. Further longitudinal studies on the respiratory health effects of ENDS and dual/polytobacco use are needed as products continue to evolve.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Study synopsis

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

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.

Spirometric Parameters in Waterpipe Smokers, Cigarette Smokers, and Non-smokers of Shahedieh Cohort Study

BACKGROUND

Different kinds of smoking tobacco may affect pulmonary function and reduce some spirometric parameters. This study aimed to assess the relationship between smoking cigarettes and waterpipe and spirometric parameters.

METHODS

This was a cross-sectional study on 1543 middle-aged individuals, as a sub-study of the Shahedieh cohort study in Yazd. The participants were randomly selected from the Shahedieh cohort population and were divided into 6 groups according to their smoking habits: non-smokers (n=455), cigarette smokers (n=139), waterpipe smokers (n=287), ex-cigarette smokers (n=131), concurrent waterpipe and cigarette smokers (n=121), and cigarette or waterpipe passive smokers (n=410). Spirometry was performed on all participants and spirometric parameters were compared between different groups. The data were analyzed by SPSS (version 20) using Kolmogorov-Smirnov, Kruskal-Wallis, and Mann-Whitney U tests.

FINDINGS

FEV1 %, FEV1/FVC, and PEF25-75% were significantly lower in cigarette smokers, compared to waterpipe smokers and non-smokers. The measures were not significantly lower in waterpipe smokers in comparison to non-smokers. The frequency of obstructive pattern and small airway diseases was significantly higher in cigarette smokers compared to waterpipe smokers and non-smokers.

CONCLUSION

The results of this study showed that in the middle-aged population, spirometric parameters related to airway obstruction (FEV1, FEV1/FVC, and FEF25-75%) were significantly lower in cigarette smokers than in non-smokers and waterpipe smokers, but these parameters were not significantly different between waterpipe smokers and non-smokers.

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.

The Effect of Water-Pipe and Cigarette Smoking on Exhaled Nitric Oxide

CONTEXT

Fractional exhaled nitric oxide can be used as a biomarker of some respiratory diseases.

AIMS

This study was conducted to compare exhaled nitric oxide in cigarette and water-pipe smokers with nonsmokers.

METHODS

This cross-sectional study was conducted on 549 adult subjects as a sub-study of Shahedieh cohort in Yazd. Participants were divided into 5 groups according to their smoking habits: non-smokers (n = 202), cigarette smokers (n = 121), water-pipe smokers (n = 129), cigarette ex-smokers (n = 58), water-pipe and cigarette smokers (n = 39). The smokers were also categorized into heavy and light smokers. Fractional exhaled nitric oxide was compared between the groups.

STATISTICAL ANALYSIS USED

The data were analyzed by SPSS (ver. 20) using Kolmogorov-Smirnov, Kruskal-Wallis, and Mann-Whitney U tests.

RESULTS

Fractional exhaled NO was lower in all smokers than nonsmokers, but cigarette smokers showed the least level of NO than other groups. Fractional exhaled NO was not significantly lower in water-pipe smokers than nonsmokers.

CONCLUSIONS

Cigarette smoking significantly affect fractional exhaled NO, but water-pipe smoking did not significantly affect exhaled NO level.

Mumps virus outbreak related to a water pipe (narghile) shared smoking

INTRODUCTION

This study describes a mumps outbreak among a group of young people who shared a same narghile to smoking. Saliva and blood samples were obtained from 3 cases for RT-PCR and serology respectively.

METHODS

The notification of a mumps case started an epidemiological investigation. Information of other 6 additional symptomatic persons who had gathered with the case in a discotheque where they smoking in a same narghile was achieved. RT-PCR positive samples were genotyped by sequencing.

RESULTS

The 7 patients resided in 3 different municipalities, and they do not have get together for more than a month until the meeting in the discotheque. Four cases were confirmed by RT-PCR and/or IgM determinations. The genomic investigation showed identical nucleic sequences.

CONCLUSIONS

This outbreak is consequence of the common use of a narghile to smoking. The public usage of these water pipes should be regulated.

Association between anxiety, alcohol, poly-tobacco use and waterpipe smoking: A cross-sectional study in Lagos, Nigeria

Background

Waterpipe smoking (WPS) has been reported to have a wide range of damaging health effects on pulmonary and cardiovascular systems. Studies suggest that waterpipe tobacco smoking is associated with reduced harm perceptions, mental health problems and the use of psychoactive substances. We investigate the patterns of use and the association of WPS with anxiety, poly-tobacco and alcohol use in Lagos, Nigeria.

Materials and Methods

A cross-sectional study design was used to assess the data from 818 adolescents and adults in Lagos State, Nigeria. An online questionnaire obtained demographic information, waterpipe, e-cigarette, alcohol and other tobacco product use from respondents. Anxiety was assessed using the validated Generalised Anxiety Disorder 7-point scale. Bivariate and multivariate logistic regression analysis was used to identify the factors associated with waterpipe ever-use. P < 0.05 was considered statistically significant.

Results

The mean (standard deviation) age of respondents was 23.43 (±3.96), over half were female (55.2%) and a majority had a college diploma or more (88.59%). Among study participants, 18.58% reported waterpipe ever-use. Among ever waterpipe users, 17.33% reported current use (past 30-days), with a majority having smoked waterpipe in a bar or pub. Alcohol use (P < 0.001), e-cigarette ever-use (P: 0.010) and poly-tobacco ever-use (P: 0.030) were significantly associated with higher odds of waterpipe use in the multivariate regression model. Further, there was a lower likelihood of waterpipe ever-use in the bivariate regression model among respondents with mild and moderate to severe anxiety levels than those with normal anxiety levels (P: 0.030); however, this association was no longer significant in the adjusted model.

Conclusions

Our findings suggest a relatively high prevalence of WPS in Lagos, Nigeria. Concurrent alcohol consumption, e-cigarette and poly-tobacco use are associated with WPS, and most waterpipe smokers have normal anxiety levels. The Nigerian Government should consider surveillance measures for WPS and a more comprehensive smoke-free policy.

Geographic distribution and time trends of water-pipe use among Iranian youth and teenage students: A meta-analysis and systematic review

Water-pipe tobacco smoking is harmful to health, yet its rate of prevalence remains uncertain. Recent evidence has shown that the prevalence of water-pipe smoking among students is higher than in the general population. In this study, a systematic review of related literature on water-pipe use was conducted, and for this purpose, 76 articles were examined in the study. In this vein, geographic distribution and time trends of water-pipe consumption in Iran were considered. The results of this study showed that lifetime, last-year, and last-month prevalence of water-pipe smoking use among Iranian students were 28.78 (25.07-32.49), 20.84 (16.01-25.66), and 16.36 (11.86-20.85), respectively. The results also showed a wide variation by the region and sex in Iran. This study has shown the importance of addressing public prevention and alerting programs in schools and universities.

Prevalence of hookah smoking and associated factors among male high school students in Iraq

BACKGROUND

The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region. Hookah users are exposed to an array of chemical compounds and may suffer several chronic diseases as a result. The purpose of this study was to determine the prevalence of hookah use among male high school students in the region and to study different associated factors in order to provide local tobacco control officials with an understanding of this public health problem.

METHODS

A convenient non-probability sampling study was conducted among students in three high schools in Al-Karkh district, Baghdad. The study period was from October 2017 till January 2019 and included 847 male students aged 15-18 years old. Using a simple random technique to select the high schools from a list of schools we chose one school from each directorate. Descriptive, chi-square test of significance, bivariate, and multivariate logistic regression analyses of data were carried out for identifying the risk factors associated with hookah smoking among these high school adolescent males.

RESULTS

The overall prevalence of hookah smoking in the last 30 days among male high school students was 46.1% while in the past 6 months it was as high as 85.7%. More than two-thirds (70.6%) of the students thought that hookah smoking was more socially acceptable than cigarette smoking. Factors such as having first heard about it from friends, the media, or the presence of a hookah café near their residence were significantly associated (p > 0.05) with hookah smoking among the students. Similarly, being surrounded by friends who used hookah was also found to be significantly associated with hookah smoking, with an odds ratio of 0.18, 95% CI (0.087-0.394). Hookah smokers were less likely than non-hookah smokers to report its use as forbidden in Islam and more likely to say it is allowed in Islam.

CONCLUSIONS

We found an alarmingly high use of hookah smoking among male high school students in this study. Family members and peers had an important role in the prevention of hookah smoking among these students. There is a need for students to be educated about the toxicity of hookah tobacco smoking and its direct effect on their health.

The impact of filtered water-pipe smoke on healthy versus cancer cells and their neurodegenerative role on AMPA receptor

Water pipe smoking is highly prevalent in developing countries, especially in Eastern Mediterranean regions. Research finds that more than 100 million people smoke a water pipe. Furthermore, tobacco smoking is one of the leading behavioral factors related to an increased risk of cancer, a leading cause of death globally. We aim to introduce a novel filtration system for water-pipe smoking and evaluate cytotoxic effects of common water pipe condensed smoke in comparison with our novel filtration system on normal (HEK293t) and cancer cell lines (Hep3B and MCF7) by MTS assay, alpha-fetoprotein (aFP), and apoptosis/necrosis effects. More so, the smoke substituents' neurotoxicity effect was evaluated by analyzing the depressive property on AMPA receptors (AMPARs). Our results showed that the silica filtration system was more effective than the water filtration system. The number of toxic compounds was reduced from 145 mg in distilled water extract (DWE) to 57.5 mg in silica solution extract (SSE). The SSE method also showed lower toxicity impacts on normal and cancerous cell lines (HEK293t, Hep3B, and MCF7) with CC₅₀ values 149.9, 10.14, and 8.9 µg/ml, relative to the DWE method (CC₅₀ values 77.1, 3.1, and 5.24 µg/ml, respectively). SSE extraction also reduced the α-FP (tumor marker test) to 2273.3 ng/ml which was closer in value to untreated cells (4066.7 ng/ml) in comparison with DWE which reduced it greatly to 1658.7 ng/ml, and the biophysical properties of AMPAR subunits demonstrate a reduced effect on desensitization rates of GluA2 homomer and GluA1/2 heteromer, using SSE relative to DWE. In conclusion, the condensed smoke of ordinary water pipe (DWE) has cytotoxic and neurotoxic impacts on various cell lines, while our newly developed system (SSE) was less toxic.

The Chronic Effects of Narghile Use on Males' Cardiovascular Response During Exercise: A Systematic Review

Narghile use has regained popularity throughout the world. Public opinion misjudges its chronic harmful effects on health, especially on the cardiovascular system. This systematic review aimed to evaluate the chronic effects of narghile use on cardiovascular response during exercise. It followed the preferred reporting items for systematic reviews guidelines. Original articles from PubMed and Scopus published until January 31, 2020, written in English, and tackling the chronic effects of narghile use on human cardiovascular response during exercise were considered. Five studies met the inclusion criteria. Only males were included in these studies. They were published between 2014 and 2017 by teams from Tunisia (n = 4) and Jordan (n = 1). One study applied the 6-min walk test, and four studies opted for the cardiopulmonary exercise test. Narghile use was associated with reduced submaximal (e.g., lower 6-min walk distance) and maximal aerobic capacities (e.g., lower maximal oxygen uptake) with abnormal cardiovascular status at rest (e.g., increase in heart rate and blood pressures), at the end of the exercise (e.g., lower heart rate, tendency to chronotropic insufficiency) and during the recovery period (e.g., lower recovery index). To conclude, chronic narghile use has negative effects on cardiovascular response to exercise with reduced submaximal and maximal exercise capacities.

Metabolic Syndrome Associated with Tobacco and Caffeine Products Use Among Refugee Adolescents: Risk of Dyslipidemia

INTRODUCTION

Due to their stressful lives, Palestinian refugees are prone to use cognitive enhancers (CE) and psychostimulant substances (PS). Recognising health problems associated with CE/PS use can indicate how preventive programs should be directed towards adolescents. Unfortunately, research has not thoroughly investigated the health problems related to tobacco and caffeine products, the most socially acceptable CE/PS among Palestinian refugee adolescents.

METHODOLOGY

In 2021, schoolchildren from five Palestinian refugee camps (N=271) aged 12-<16 years agreed to give blood samples and to be interviewed to address the association between metabolic syndrome (MetS) and tobacco smoking, coffee, energy drinks (ED), black tea, and chocolate consumption. MetS was diagnosed based on International Diabetic Federation Criteria. To address the association, we used binary logistic regression models adjusted to age, gender, BMI, and central obesity.

RESULTS

The prevalence of MetS was [17 (6.3%)]; (7.4%) in males, (5.1%) in females. The prevalence of substance use was as follows: ED [163 (48.9%)], coffee [255 (76.6%)], black tea [295 (89.1%)], cigarette [35 (10.5%)], waterpipe [59 (17.7%)], and chocolate [309 (93.6%)], with male predominance. Cigarette smokers have increased central obesity (p-value=0.024), and decreased HDL-cholesterol (p-value=0.015) than non-smokers. Similar results were observed for waterpipe smokers besides the increased levels of triglycerides (p-value=0.01). ED consumers have increased central obesity (p-value=0.03) and fast blood sugar (p-value=0.003) than non-consumers. Chocolate consumers have decreased central obesity (p-value=0.008) and increased HDL levels (p-value=0.04) than non-consumers. ED consumers were significantly at higher risk of MetS (OR=9.97, p-value=0.019) than non-consumers and chocolate consumers were at lower risk of MetS (OR=0.14, p-value=0.046) than non-consumers. Waterpipe smokers were at a higher risk of having increased plasma triglycerides than non-consumers (OR=3.4, p-value=0.03).

CONCLUSION

The high prevalence of ED consumption and waterpipe smoking in Palestinian refugee adolescents is problematic. Their use was associated with higher odds of MetS, dyslipidemia, and central obesity, which justifies greater attention.

Is there a relation between vitamin D, interleukin-17, and bone mineral density in patients with inflammatory bowel disease?

INTRODUCTION

In inflammatory bowel diseases (IBD), osteopenia and osteoporosis constitute a significant medical problem. Cytokines, especially IL-17, play an important role in the pathogenesis of IBD and osteoporosis. Vitamin D is a regulator of bone metabolism, and helps maintain immune system homeostasis.

MATERIAL AND METHODS

The research sample consisted of 208 persons: 83 patients (age 35 ±11.99 years) with Crohn's disease (CD); 86 patients (age 39.58 ±14.74 years) with ulcerative colitis (UC); and 39 persons (age 30.74 ±8.63 years) in the control group (CG). Clinical data on bone mineral density of the lumbar spine (L2-L4), bone mineral density of the femoral neck (FN), and body mass index (BMI) were collected. 25OHD and IL-17 serum concentrations were also measured.

RESULTS

Body mass index (kg/m²) results: in CD, 21.51 ±3.68; in UC, 23.31 ±4.38; and in CG, 24.57 ±3.45 (p < 0.01). Densitometry results for L2-L4 T-score SD: in CD -0.83 ±1.45; in UC -0.47 ±1.15; in CG 0.09 ±0.70. Densitometry results for FN T-score SD: in CD -0.62 ±1.26; in UC -0.29±1.17; in CG 0.41 ±1.03 25OHD (ng/ml) serum concentrations: in CD, 21.33±12.50; in UC, 22.04±9.56; in CG, 21.56±9.11 (ns). IL-17 (pg/ml) serum concentrations: in CD, 8.55±10.99; in UC, 11.67±12.97; in CG, 5.16±9.11 (ns).

CONCLUSIONS

Inflammatory bowel diseases patients and persons from the CG did not differ in vitamin D or IL-17 levels. Patients with a mild course of the disease had a higher vitamin D concentration and bone mineral density. In UC, higher vitamin D concentrations were associated with lower IL-17 concentrations. The IBD patients with a severe course of the disease had a lower body mass than those in the CG and the patients with a mild course of the disease.

Mumps virus outbreak related to a water pipe (narghile) shared smoking

INTRODUCTION

This study describes a mumps outbreak among a group of young people who shared a same narghile to smoking. Saliva and blood samples were obtained from 3cases for RT-PCR and serology respectively.

METHODS

The notification of a mumps case started an epidemiological investigation. Information of other 6additional symptomatic persons who had gathered with the case in a discotheque where they smoking in a same narghile was achieved. RT-PCR positive samples were genotyped by sequencing.

RESULTS

The 7patients resided in 3different municipalities, and they do not have get together for more than a month until the meeting in the discotheque. Four cases were confirmed by RT-PCR and/or IgM determinations. The genomic investigation showed identical nucleic sequences.

CONCLUSIONS

This outbreak is consequence of the common use of a narghile to smoking. The public usage of these water pipes should be regulated.

The ongoing challenge of Pulmonary Tuberculosis in Southern Tunisia: A review of a 22-year period

BACKGROUND

Despite the wide use of anti-tuberculosis drugs, pulmonary tuberculosis (PTB) remains one of the most important causes of mortality and morbidity, particularly in developing countries. Therefore, combining clinical and epidemiological approach would be of a great benefit. Our study aimed to describe the epidemiological and clinical specificities of PTB and its recent chronological trends.

METHODS

We conducted a retrospective study of all PTB new cases of any age diagnosed between 1995 and 2016 in Southern Tunisia. We applied the direct method of age-standardization using the World Standard Population to compute the age standardized incidence rate (ASIR) and the age standardized mortality rate (ASMR) per 100 000 inhabitants.

RESULTS

We recorded 1121 new cases with PTB among 2771 new cases of tuberculosis (40.5%). The ASIR of PTB was 5.3/100 000 inhabitants/year and didn't change over the study period (rho=0.3; P=0.2). Patients with PTB were mainly aged between 15 and 59 years (n=861; 76.8%) and came from urban areas (n=600; 55%). The median duration of treatment was 7.6 months (IQR=[6-8 months]). Successful outcome was notified in 1075 cases (95.9%). Forty-one patients died yielding an ASMR of 0.18/100 000 inhabitants/year. Factors statistically associated with unsuccessful outcome included age≥60 years (OR=5; P<0.001) and shorter treatment duration (6.15 months vs 7.76 months; P<0.001).

CONCLUSION

In contrast to the decline in the global PTB incidence reported worldwide and in the neighboring countries, our study revealed no significant change in the PTB rates from 1995 to 2016. Therefore, tools and strategies used to manage PTB should be strengthened by a substantial effort in both basic science and epidemiology to have better incidence curves.

Association between cigarette & shisha smoking and the severity of polycythemia: A cross sectional study

Tobacco cigarette smoking is assumed to be a key reason of death all over the world. Smoking had both severe as well long-lasting effects on hematological constraints. As per the data available from World Health Organization, every year nearly 5 million individuals die around the world due to the diseases triggered by smoking. Cigarette smoking is linked with an elevated risk of cardiovascular diseases. To examine the association between shisha or cigarette smoking and the severity of polycythemia, present study is a cross-sectional organized at King Saud University Medical City during the period from October 2017 to April 2018. Participants were patients who have hemoglobin level above 160 g/L on multiple reading in KSUMC between May 2015-February 2018. The sample size (227 patients) was computed on single proportion formula, Data were collected through questionnaires and from medical record of the patients. A pilot study was conducted to evaluate the validity of the questionnaire. A statistical analysis was performed using SPSS 21.0 version. A p-value of ≤ 0.05 considered as statistically significant. Out of 227 study subjects, 86 (37.8%) were smokers, (61.6%) were cigarette smokers while (29%), shisha smokers. Total (9.3%) were smoking both cigarette and Shisha. 29% patients had high normal hemoglobin between the ranges of (160-168 g/L), 17.6% patients had pre-polycythemic hemoglobin between the range of (169-171 g/L) and 53% patients were having polycythemic hemoglobin (>172 g/L). The hemoglobin level in non-smokers was 168.74 g/L, hemoglobin level in cigarette smokers was170.7 g/L, hemoglobin level in shisha smokers was 171.4 g/L while hemoglobin level in those who smokes both cigarette and shisha was 175 g/L. Smoking has adverse effects on hemoglobin. Shisha or cigarette Smoking is associated with increase in the hemoglobin levels and the severity of polycythemia. The findings may help in raising the awareness of tobacco smokers.

A Call for Effective Interventions to Curb Shisha Tobacco Smoking among University Students in Eastern Province, Saudi Arabia: Findings from a Cross-Sectional Study

BACKGROUND

Although the number of cigarettes smoked has been declining due to major public health initiatives, shisha tobacco smoking is gaining popularity around the world, particularly among youth and university students.

METHODS

A cross-sectional study was conducted among 464 university students in Eastern Province of Saudi Arabia using a structured questionnaire (i) to assess the prevalence of shisha smoking; (ii) to evaluate risk-perception, knowledge and normative belief about shisha smoking, and to compare these among users and non-users of shisha.

RESULTS

The study reported a high prevalence (22.8%) of the current use of shisha among the university students with a narrow gender gap and found that STS is getting more popular than other forms of tobacco. A quarter of participants had low risk perception and 30.2% had low knowledge of shisha smoking harm. Importantly, more than two-fifth of them were current users of shisha. Low risk-perception about shisha and social acceptability were significantly contributed to the high prevalence of shisha smoking among the youth.

CONCLUSION

It is important to provide exposure to education related to shisha hazards and increase the awareness of students and the public about the health effects of shisha smoking.

Development of an instrument based on the theory of planned behavior variables to measure factors influencing Iranian adults' intention to quit waterpipe tobacco smoking

Background

Theory of planned behavior (TPB) is one of the most widely used theoretical frameworks to explain addictive behaviors, such as tobacco smoking. The aim of this study is to develop and validate an instrument based on TPB variables to measure factors influencing Iranian rural adults’ intention to quit waterpipe tobacco smoking.

Methods

This study was performed on a sample of rural adult waterpipe consumers living in two villages in Shiraz, Southern Iran. In the beginning, the initial items of instrument were extracted from the literature review and interviews with 20 waterpipe consumers. After that, face validity and qualitative content validity of the items were appraised. To measure quantitative content validity index (CVI) and the content validity ratio (CVR), a panel of experts reviewed the items. In addition, the exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were applied to characterize the construct validity of the instrument. Finally, Cronbach’s alpha coefficient and intraclass correlation coefficient (ICC) were computed.

Results

CVI and CVR of items were within the ranges of 0.89–0.95 and 0.85–0.96, respectively. EFA indicated the Kaiser-Meyer-Olkin (=0.71) and Bartlett’s test of sphericity was significant (=912.36, df=105, p<0.0001). Principal component analysis revealed that 15 items could be grouped into four subscales that accounted for 64.97% of the variance. Based on CFA, two items were deleted. CFA results showed that the remained data were fit to the model. The Cronbach’s alpha and ICC of subscales were, respectively, in the ranges of 0.72–0.87 and 0.64–0.82. Finally, a 13-item instrument with four subscales was confirmed.

Conclusions

The findings reveal that the developed TPB instrument is a reliable and valid scale to identify the determinants of the intention to quit waterpipe smoking among Iranian rural adults.

Newer Forms of Tobacco Products: Characteristics of Poly Users Among Adults Living in Colorado-A Secondary Data Analysis of the Attitudes and Behaviors Survey on Health 2015

Aims:

Data from The Attitudes and Behaviors Survey (TABS) conducted in 2015 were used to investigate the prevalence of different forms of tobacco use and marijuana use among adults in Colorado.

Methods:

A secondary analysis of TABS on health data was conducted. A representative sample of 8616 adults 18 years and older participated in the survey, with sample weights used to adjust for oversampling.

Results:

Lifetime prevalence of cigarette-only use was 25.8%, compared with 10.6% for hookah use, 7.0% for both hookah and cigarettes, 12.6% for anything except cigarettes, and 43.0% for marijuana. The typical hookah user was a single/living alone (15.9%), English-speaking (11.6%), male (16.7%), age < 30 years (24.2%), with some college education (13.0%), and income less than 35 000 per year (14.3%). Hookah users, whether or not they also used cigarettes, were similar to those who used any other noncigarette tobacco products. The typical marijuana user was a single/living alone (50.2%), white (46.0%), English-speaking (46.7%), male (48.5%), age < 30 years (50.1%), with a graduate degree (40.8%) and salary of at least 50 000 per year (43.4%).

Implications:

In Colorado, in 2015, cigarette use was still highest among all forms of tobacco, but the use of other tobacco products such as vaping and hookah is on the rise, especially among young adults. Marijuana and hookah users were demographically similar to each other, and different from the typical cigarette user. These results indicate the need for further study of alternative tobacco product use, especially among young adults.

News media coverage of shisha in Nigeria from 2014 to 2018

INTRODUCTION

Shisha which was formally popular mostly in the Eastern Mediterranean region is now gaining popularity globally and has become a trending tobacco product in Nigeria. The increasing popularity of shisha is possibly driven by the attractive flavours and the misperception that it is safer than traditional cigarettes. Since the media plays a significant influence on public awareness, perception and understanding of various issues, this study sought to explore the coverage of shisha use by five national newspapers in Nigeria.

METHODS

Five newspapers were selected based on their website traffic (online readership). The software NVIVO 12 was used to organise the content of the articles into themes.

RESULTS

Between 2014 and 2018, we found 30 relevant publications about shisha. Some newspaper articles reported that shisha smoking was gaining popularity among youths, especially in tertiary institutions across the country. Similarly, some misconceptions about the safety of smoking shisha among shisha users was reported. Addiction to shisha was also reported as being so common that many shisha users were no longer satisfied with just visiting nightclubs and shisha cafes but now own the shisha paraphernalia. There were also reports that the tobacco in shisha was in some instances being replaced or mixed with other hard drugs like marijuana. Subtle advertisement of shisha lounges, which is a violation of the Nigeria National Tobacco Control Act, was also observed.

CONCLUSIONS

There is a need for increased sensitization of the public through the media on the dangers of shisha smoking and other tobacco product use. There is also a need for a national survey to determine the prevalence of shisha use in Nigeria.

The effects of hookah/waterpipe smoking on general health and the cardiovascular system

Hookah or waterpipe smoking or use is an emerging trend in the US population, especially among the youth. The misperception of hookah being less harmful than cigarettes and the availability of different but "appealing" flavors are considered among the main reasons for this trend. Hookah users however are exposed to many of the same toxic compounds/by-products as cigarette users, but at dramatically higher levels, which might lead to more severe negative health effects. In fact, hookah users are at risks of infections, cancers, lung disease, and other medical conditions. Moreover, because of the overlapping toxicant/chemical profile to conventional cigarettes, hookah smoke effects on the cardiovascular system are thought to be comparable to those of conventional cigarettes. A major source of tobacco addiction is nicotine, whose levels in hookah are extremely variable as they depend on the type of tobacco used. Taken together, in this review of literature, we will provide insights on the negative health effects of hookah in general, with a focus on what is known regarding its impact on the cardiovascular system.

Lifetime prevalence and correlates of smoking behavior in Iranian adults' population; a cross-sectional study

ABSTACT

BACKGROUND: There are few if any reports concerning the joint use of waterpipe, cigarette and exposure to second-hand smoking in Tehran, Iran. Here, we simultaneously investigated the prevalence and predictors of smoking habits in Iranian adults.

METHODS

In this population-based cross-sectional study, we recruited 1057 Iranian adults between August 2013 and February 2015, in Tehran, a multi-ethnic city. Participants were selected using random digit dialing. Three separate logistic regression models were applied to estimate the adjusted odds ratios (95% CI).

RESULTS

Exposure to second-hand smoking was the most prevalent smoking type (37, 95% CI: 35-41%) followed by cigarette (23.9% (95% CI: 21-27%)) and water-pipe smoking (20.25% (95% CI: 18-23%)) in adults in Tehran. Almost 3.3 and 4.5% of adults reported three and two types of lifetime smoking behaviors, respectively. Age, sex, history of depression along with lifetime alcohol intake was the important predictors of all three types of smoking. Lifetime alcohol consumption was associated with increased prevalence of all three types of smoking (p for trend < 0.009). Lifetime drug abuse was also associated with increased prevalence of cigarette smoking (OR = 2.04, 95% CI: 1.61-2.59, p < 0.001).

CONCLUSIONS

Lifetime prevalence of waterpipe, cigarette and exposure to second-hand smoking is moderately high. Dual smoking behaviors are increasing in Iranian adults. An apparent age-related difference in pattern of waterpipe and cigarette smoking was observed. These findings highlight the need for further educational and preventive programs especially for dual smoking in Iranian young adults. This could provide practical information for evaluating and reforming the tobacco control programs and policies in Iran.

Hookah products and online retail marketing strategies in India: A content analysis

INTRODUCTION

Hookah smoking is becoming increasingly popular among the youth. Evidence shows that exposure to marketing of the unhealthy products through social media platforms may impact adolescent health behaviors. The aim of the study was to perform a content analysis of online portals selling hookah products.

MATERIALS AND METHODS

A content analysis of online retail market was conducted on Google India using three keywords hookah, hookah products, and shisha. Retail websites popular in India that were selling hookah products were randomly selected and explored. A total of 15 themes were developed and used to describe various promotional strategies for hookah products.

RESULTS

In all, 41 (19.2%) products claimed to be tobacco/nicotine-free and only 14 products (6.5%) displayed age/health-specific warnings. About 86% of products were available at discounted rates; glamorizing words for describing products in form of superior, premium, and legendary were found on 189 (88.3%) products. Phrases such as "ultimate way to celebrate," "perfect excuse to chill with your friends," and "now enjoy the world of smoking without any doubt of harm" are commonly used to promote hookah products.

CONCLUSION

Easy availability of newer forms of smoking at online markets could play a role in promoting the use of hookah among the youth. Most products are being sold without any warnings and there is no means to control the selling of the products to minors. There is a need to raise the issue of hookah products in the same tune as done for other forms of tobacco.

Shisha smoking in selected nightclubs in Nigeria

Introduction

Shisha consumption is a growing public health issue all over the globe and public health awareness about its deleterious health consequences is still not sufficiently raised.

Methods

In this location-based study of nightclubs in Ibadan, Nigeria, 633 patrons of selected nightclubs were interviewed in order to obtain information on prevalence, correlates and predictors of shisha smoking.

Results

The overall prevalence of shisha smoking was 7.1%. The age of initiation into shisha smoking was lower among women, p = 0.03, but men were significantly more likely to be more frequent users, daily or weekly users, p < 0.001 and also to be current cigarette smokers, p = 0.03. There was no significant gender variability in the stage of readiness to quit. Regression analysis showed that after adjusting for age, the predictors of shisha smoking were: cigarette smoking, OR = 4.83, 95% CI (1.49-15.70) and more than 12 years of education, OR = 7.55, 95% CI (1.88 - 30.37), while being a rural dweller was a protective factor, OR = 0.05, 95% CI (0.01-0.20).

Conclusion

Shisha smoking has emerged as a prevalent public health issue in Nigeria. There is a need for an immediate response from policy providers towards shisha smoking intervention in Nigeria.

Association Between Smoking Hookahs (Shishas) and Higher Risk of Obesity: A Systematic Review of Population-Based Studies

The American Heart Association has published a scientific statement on the effect of hookah smoking on health outcomes; nevertheless, hookah smoking continues to be popular worldwide, especially among the young. Recent reports mention a potential link between hookah smoking and obesity; however, uncertainties still surround this issue. The aim of the current study was to conduct a systematic review to clarify whether hookah smoking is associated with a higher risk of obesity among the general population. This study was conducted in compliance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, and data were collated by means of a meta-analysis and a narrative synthesis. Of the 818 articles retrieved, five large-population and low-bias studies comprising a total of 16,779 participants met the inclusion criteria and were reviewed. All included studies reported that, regardless of gender, hookah smoking increases the risk of obesity among all ages and observed an association between the two after a correction for several confounders or reported a higher prevalence of obesity among hookah smokers. This was confirmed by the meta-analysis. Therefore, hookah smoking seems to be associated with a higher risk of obesity. Public health policymakers should be aware of this for the better management of obesity and weight-related comorbidities.

Prevalence and Perception of Shisha Smoking among University Students: A Cross-sectional Study

Aims and Objectives:

Understanding perceptions and factors behind the rise in the prevalence of shisha smoking is important for the development of prevention strategies and policies. The aim of this descriptive study was to assess the prevalence and perception of shisha smoking among university students.

Materials and Methods:

The anonymous, self-structured 12-item questionnaire was administered to 450 male university students, with an overall response rate of 82.44% (n = 371). Prevalence, knowledge, and other associated factors regarding shisha smoking were compared between dental and other specialty students using SPSS software for descriptive statistical analysis.

Results:

Among 371 university students, 40.43% (n = 150) were nonsmokers, 32.88% (n = 122) were shisha smokers, 12.94% (n = 48) were cigarette smokers, and 13.75% (n = 51) smoked both shisha and cigarette. The overall prevalence of shisha smoking (46.63%, n = 173) was higher than that of cigarette smoking (26.68%, n = 99). The percentage of those knowledgeable about the ill effects of shisha smoking was 44.2% with lesser knowledge among shisha smokers than cigarette smokers. There was no statistically significant difference in the mean total knowledge score between dental (5.65 ± 2.08) and other specialty (5.21 ± 2.3) students.

Conclusions:

A high prevalence of shisha use among university students is reported in this study as well as a general lack of understanding of the dangers involved with this behavior. Study authors recommend the development of policies targeted at preventing further rise in the prevalence of shisha smoking through the implementation of preventive strategies such as incorporating this topic into the school syllabus and encouraging research on shisha smoking.

Tobacco hookah smoking-induced carbon monoxide poisoning: A case report of non-ambient exposure

Carbon monoxide (CO) toxicity should be considered in patients presenting to the emergency department with any acute vague manifestations after hookah smoking; furthermore, smoking in an open space does not eliminate the risk of CO toxicity. High-flow supplemental oxygen should be provided immediately while further investigations and management options are considered.

Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review

BACKGROUND

Despite evidence for the harms of waterpipe tobacco smoking (WTS), its use is increasing amongst college and university students worldwide. This systematic review aims to assess the knowledge of, attitudes towards and perceptions of WTS among college or university students.

METHODS

We electronically searched MEDLINE, EMBASE, CINAHL, PSYCHINFO and ISI the Web of Science in October 2018, restricting our search to studies published since January 1990. We included studies among university or college students that used qualitative or quantitative methods, and addressed either knowledge, attitudes, or perceptions towards WTS. We excluded studies where WTS could not be distinguished from other forms of tobacco use and studies reported as abstracts where the full text could not be identified. Data were synthesised qualitatively and analysed data by region (global north/ south), and by reasons for use, knowledge of health hazards, how knowledge influences use, perceptions towards dependence, and policy knowledge.

RESULTS

Eighty-six studies were included; 45 from the global north and 41 from the global south. Socio-cultural and peer influences were major contributing factors that encouraged students to initiate WTS. Furthermore, WTS dependence had two components: psychological and social. This was compounded by the general perception that WTS is a less harmful, less addictive and more sociable alternative to cigarette smoking. Knowledge of WTS harms failed to correlate with a reduced risk of WTS use, and some students reported symptoms of WTS addiction. A large proportion of students believed that quitting WTS was easy, yet few were able to do so successfully. Finally, students believed current public health campaigns to educate on WTS harms were inadequate and, particularly in the global north, were not required.

CONCLUSION

Reasons for WTS amongst university students are multi-faceted. Overall, interventions at both the individual and community level, but also policy measures to portray a message of increased harm amongst students, are required. Additional studies are necessitated to understand temporal changes in students' beliefs, thus allowing for better targeted interventions.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Comparison of Periodontal Status Between Male Exclusive Narghile Smokers and Male Exclusive Cigarette Smokers

Studies evaluating the effects of narghile use on the periodontium present conflicting conclusions. This study aimed to compare the periodontal status of exclusive narghile smokers (ENSs, n = 74) to that of exclusive cigarette smokers (ECSs, n = 74). Males aged 20-40 years were recruited to participate in this comparative study. Information concerning oral health habits (number of yearly visits to the dentist, daily toothbrushing frequency) and tobacco exposure were obtained. Clinical measurements were performed on all the existing teeth, except the third molars. The number of remaining teeth and decayed/missing/filled teeth (DMFT) were noted. The plaque levels were recorded using the plaque index of Löe and Silness. The gingival index modified by Löe was used to evaluate gingival inflammation. Teeth mobility was measured using bidigital mobility. The probing pocket depth was measured using a periodontal probe. Periodontal disease was defined as the presence of at least 10 sites with a probing depth ≥5 mm. Student's t and chi-square tests were used to compare, respectively, the two groups' quantitative and qualitative data. The two groups were matched for quantities of used tobacco, age, daily toothbrushing frequency, teeth mobility, number of remaining teeth, plaque index, and DMFT. Compared to the ECS group, the ENS group had a significantly lower number of yearly visits to the dentist (mean ± SD: 0.2 ± 0.5 vs. 0.1 ± 0.2), lower probing pocket depth (mean ± SD: 2.33 ± 0.63 vs. 2.02 ± 0.80 mm), and gingival index (median [interquartile]: 0.46 [0.10-0.89] vs. 0.00 [0.00-0.50]), and it included significantly lower percentages of smokers with periodontal disease (24.3% vs. 9.5%). In conclusion, chronic exclusive narghile smoking has fewer adverse effects on the periodontium than chronic exclusive cigarette smoking.

Hookah Use among Russian adolescents: Prevalence and correlates

Hookah use among adolescents is increasing globally. No prior studies in the published literature have examined hookah use among youth in the Russian Federation. We assessed demographic, psychological and behavioral factors associated with lifetime and past 30-day hookah use among Russian youth. This cross-sectional study was conducted in three areas of Bashkortostan, Russia. In 2015, we surveyed Russian high school students (n = 716) on socio-demographic characteristics, tobacco (cigarettes, e-cigarettes, hookah) and drug use (alcohol, marijuana, and other illicit drugs), coping strategies, and getting in trouble (self and/or family). We estimated hookah use prevalence and performed bivariate analyses prior to fitting two multilevel models evaluating lifetime and past 30-day hookah use. Within this sample, 34.92% and 9.36% were lifetime and last 30-day hookah users, respectively. Lifetime hookah use was associated with older age (OR = 1.29), higher anger coping (OR = 1.41), school troubles (OR = 2.30), lifetime cigarette (OR = 1.59), e-cigarette (OR = 4.62), alcohol (OR = 5.61), and marijuana use (OR = 8.05). Additionally, past 30-day hookah use was associated with older age (OR = 1.71), lifetime use of alcohol (OR = 5.39), school troubles (OR = 5.82), and anger coping strategies (OR = 1.40). Hookah use is currently high among Russian youth in Bashkortostan and is associated with other risky behaviors. Effective interventions targeting multiple substances and coping strategies are needed. Social media campaigns encouraging cessation and advocating against its use at home may be beneficial in curbing hookah use among youth.

Chemical Characterization of Nanoparticles and Volatiles Present in Mainstream Hookah Smoke

Waterpipe smoking is becoming more popular worldwide and there is a pressing need to better characterize the exposure of smokers to chemical compounds present in the mainstream smoke. We report real-time measurements of mainstream smoke for carbon monoxide, volatile organic compounds and nanoparticle size distribution and chemical composition using a custom dilution flow tube. A conventional tobacco mixture, a dark leaf unwashed tobacco and a nicotine-free herbal tobacco were studied. Results show that carbon monoxide is present in the mainstream smoke and originates primarily from the charcoal used to heat the tobacco. Online measurements of volatile organic compounds in mainstream smoke showed an overwhelming contribution from glycerol. Gas phase analysis also showed that very little filtration of the gas phase products is provided by the percolation of mainstream smoke through water. Waterpipe smoking generated high concentrations of 4-100 nm nanoparticles, which were mainly composed of sugar derivatives and especially abundant in the first 10 min of the smoking session. These measured emissions of volatiles and particles are compared with those from a reference cigarette (3R4F) and represent the equivalent of the emission of one or more entire cigarettes for a single puff of hookah smoke. Considerations related to the health impacts of waterpipe smoking are discussed.

Biochemical Data and Metabolic Profiles of Male Exclusive Narghile Smokers (ENSs) Compared With Apparently Healthy Nonsmokers (AHNSs)

Studies evaluating the metabolic profiles of ENSs are scarce and presented controversial conclusions. This study aimed to compare the metabolic profiles of ENSs' and AHNSs' groups. Males aged 25-45 years and free from a known history of metabolic and/or cardiovascular diseases were included. According to the smoking status, two groups of ENSs and AHNSs were identified. Body mass index (BMI, kg/m2), waist circumference (WC, cm), systolic and diastolic blood pressures (SBP, DBP, mmHg), fasting blood data in mmol/L (blood glycemia [FBG], triglycerides [TG], total cholesterol [TC], high- and low- density lipoprotein cholesterol [HDL-C, LDL-C]) and obesity status were evaluated. The metabolic syndrome (MetS) was defined according to the 2006 International Diabetes Federation (IDF) recommendations. Data were expressed as mean ± standard deviation ( SD) or percentages. Compared to the AHNSs' group ( n = 29), the ENSs' one ( n = 29) had (a) higher values of BMI (26.5 ± 2.3 vs. 28.2 ± 3.6), WC (95 ± 7 vs. 100 ± 10), and TG (1.22 ± 0.40 vs. 1.87 ± 0.85); and (b) included a lower percentage of males having low HDL-C (82.7% vs. 62.0%), and higher percentages of males having obesity (6.9% vs. 37.9%) or hypertriglyceridemia (10.7% vs. 51.7%). Both the ENSs' and AHNSs' groups: (a) had similar values of FBG (5.38 ± 0.58 vs. 5.60 ± 0.37), TC (4.87 ± 1.16 vs. 4.36 ± 0.74), HDL-C (0.92 ± 0.30 vs. 0.82 ± 0.21), LDL-C (3.09 ± 0.98 vs. 2.92 ± 0.77), SBP (117 ± 9 vs. 115 ± 8), and DBP (76 ± 6 vs. 73 ± 7); and (b) included similar percentages of males having normal weight (17.2% vs. 31.0%); overweight (44.8% vs. 62.1%); android obesity (79.3% vs. 59.6%), hypertension (10.3% vs. 10.3%), hyperglycemia (37.9% vs. 48.2%), and MetS (51.7% vs. 34.5%). There is a need to monitor narghile use among male metabolic patients since it alters some components of the MetS.

p53 Overexpression in Oral Mucosa in Relation to Shisha Smoking in Syria and Lebanon

Introduction

Shisha (waterpipe) smoking is becoming a very prevalent form of tobacco consumption in the Middle east and use is growing over the world. Smoking-related malignancies have a high genome-wide burden of mutations, including examples in the gene encoding p53.

Aims

To investigate alterations in p53 immunohistochemical expression in the normal, pre-malignant, malignant oral mucosa in relation to Shisha smoking habits.

Materials and Methods

A total of 105 paraffin embedded tissue sections of OSCCs (52 smokers,53 non-smokers), 96 of premalignant lesions (48 smokers,48 non-smokers) and 60 normal oral mucosa. Some 30 patients with a history of Shisha smoking daily for more than 5 years were also investigated for mutant expression of p53. Tissue samples were considered positive for p53 staining when any positive cells of epithelial origin could be detected.

Results

The majority (74.3%) of oral squamous cell carcinomas showed positive staining for p53 expression (83.1% and 65.5% with Shisha smokers and non-smokers, respectively). In the 96 premalignant lesions, about 23% from non-smokers and 41.7% from smokers showed p53 positivity. In normal epithelium, P53 positive cells were noted in 6.6% of non-smokers and 16.6% of smokers. Positive correlations with Shisha smoking were evident for the following groups: WDOSCC, MDOSCC, mild dysplasia G1, moderate dysplasia G2 and in normal mucosa using Student’s t- test, P value<0.05.

Conclusion

These results strongly suggest that p53 mutations are associated with Shisha smoking in OSCC, pre-malignant lesions and normal mucosa of the oral cavity.

Shisha microbiota: the good, the bad and the not so ugly

OBJECTIVE

Over the last decade, there has been a rapid expansion of the trendy water pipe smoking around the world especially among younger adults. The initial objective of this study was to identify the microbiota of the shisha, which may either be of no harm for the smoker or enhance the threat on his well-being. The total DNA for the metagenomics study was conducted on three different shishas from three different delivery shops in Jounieh, Lebanon. The microbiota in two solid parts of the shisha, shaft and hose, were analysed including the fresh tobacco and the water in the bowl. All samples were analysed using high-throughput sequencing of 16S rRNA gene amplicons.

RESULTS

Overall, more than 40 bacterial genera were found in the three investigated shishas, some are commensal others are pathogenic. All three shishas showed similar microbial content regarding the bacteria inhabiting in water, shaft, or hose. From the results of this study it appears that a very large quantity of bacteria was found in the water pipes, some are harmful and others beneficial. We assume that the presence of gut dependent microbiota is related to the loose hygienic conditions in which the shisha is prepared.

Cytological multimarker screening using BMCyt test in waterpipe smokers: an integrative study of cell damage, toxicological and cancer risk

Waterpipe smoking is an ancient method of tobacco smoking practiced worldwide. There is a common belief that waterpipe smoking is a safer alternative to cigarette, but many studies showed that some toxicants were associated with cancer risk, significantly higher in waterpipe smoking. Thus, this study aimed to evaluate the status of waterpipe smoker's buccal cells and its cancer risk using the buccal micronucleus cytome test. Forty waterpipe smokers (noncigarette smokers) were recruited and paired by gender, age and alcoholic habits with 40 control subjects. One-thousand cells from each individual were analysed and the number of pyknotic cells (PYC), karyolitic cells (KYL), karyorrhetic cells (KHC), condensed chromatin (CC), binucleated cells (BN), basal cells (BC), nuclear buds (NBUD) and differentiated cells (DIFF) were counted. Additionally, 2000 differentiated cells were analysed counting micronucleated cells (MNi) and nuclear buds. We observed an increasing P< 0.05 in all waterpipe smoker's cell parameters, except DIFF (fold-decrease). Only CC showed no differences between groups. The interference in the cell cycle plus DNA damage observed in this study could be responsible for the high number of damaged cells and in death process, showing the importance of our study and the high risk in waterpipe smoking.

Do Clinicians Ask Pregnant Women about Exposures to Tobacco and Cannabis Smoking, Second-Hand-Smoke and E-Cigarettes? An Australian National Cross-Sectional Survey

Clinicians often ask pregnant women about tobacco smoking, but their practices of asking about other smoking and nicotine exposures are unknown. This study analysed how often clinicians ask pregnant women about their use of e-cigarettes, cannabis, chewing tobacco, and second-hand smoke (SHS) exposure. Two cross-sectional surveys were undertaken. A random sample of 500 General Practitioner (GP) members were invited from the National Faculty of Aboriginal and Torres Strait Islander Health (NFATSIH) to complete an on-line survey, and 5571 GP and Obstetrician (OBS) members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were sent a paper survey by mail. Questions on frequency of asking about the exposures used Likert Scales, later dichotomized to "often-always" and "never-sometimes". Logistic regressions estimated associations between clinician type and asking about cannabis, e-cigarettes, chewing tobacco, and SHS. An adjusted model reduced potential confounders of location, guidelines, gender and population. n = 378 GPs and OBS participated (6.2% response). In total, 13-14% asked "often-always" about e-cigarettes; 58% cannabis; 38% cannabis with tobacco; 27% SHS, and 10% chewing tobacco-compared to 95% of the sample asking about cigarette smoking. After adjustment, the odds of RANZCOG GPs (OR 0.34) and OBS (OR 0.63) asking about cannabis were lower compared to NFATSIH GPs. Clinician type was non-significant for asking about e-cigarettes, chewing tobacco and SHS. Surveyed Australian GPs and obstetricians asked less frequently about e-cigarettes, chewing, SHS exposure, and cannabis, potentially missing important exposures for mother and child.

The Prevalence, Attitudes, and Correlates of Waterpipe Smoking Among High School Students in Iran: a Cross-Sectional Study

PURPOSE

The purpose of the present study was to determine the correlates of waterpipe (WP) smoking among 15-17-year-old high school students in Iran.

METHOD

Data were collected using the Global Youth Tobacco Survey (GYTS), a self-administrated questionnaire distributed to a representative sample of high school students aged 15-17 in the city of Tabriz. Current WP smoking was defined as past 30-day use, and ever WP smoking was defined as at least one or two lifetime puffs. Differences in WP use, knowledge, and attitudes were analyzed using chi-square and Fisher exact tests. Binary logistic regression estimated the association between relevant independent variables (e.g., age) and the dependent variables (current/ever WP smoking).

RESULTS

Of 1517 students, 21.6 % (95 % confidence interval [CI] = 19.5, 23.8) were ever WP smokers, and 9.7 % (95 % CI = 8.2, 11.2) were current WP smokers. Of current WP smokers, 40.3 % have stated that they want to stop smoking now. Moreover, 14.1 % of non-WP smokers reported that they might enjoy smoking WP. Of current WP smokers, 49.0 % have smoked at cafés. Additionally, 95.3 % of current WP smokers reported that their age did not prevent them from being served a WP. Studying in high school third grade (adjusted odds ratios (AORs) = 1.70; 95 % CI [1.10, 2.63]), experience of cigarette smoking (AORs = 1.57; 95 % CI [1.12, 2.20]), and being prepared to accept a WP offered by close friends (AORs = 3.31; 95 % CI [2.17, 5.04]) were independently associated with ever WP smoking, and accepting a WP offered by close friends (AORs = 4.36; 95 % CI [2.69, 7.07]) and gender (female) (AORs = 0.45; 95 % CI [0.30, 0.70] were independently associated with current WP smoking.

CONCLUSION

Prevalence of current and ever WP smoking is high in Tabriz. There is an urgent need to design interventions in order to increase students' and their parents' awareness regarding the harmfulness of WP, and to establish legal measures to restrict adolescents' access to WPs and tobacco in society.

Pulmonary Abnormalities in Young, Light-Use Waterpipe (Hookah) Smokers

RATIONALE

Waterpipes, also called hookahs, are currently used by millions of people worldwide. Despite the increasing use of waterpipe smoking, there is limited data on the health effects of waterpipe smoking and there are no federal regulations regarding its use.

OBJECTIVES

To assess the effects of waterpipe smoking on the human lung using clinical and biological parameters in young, light-use waterpipe smokers.

METHODS

We assessed young, light-use, waterpipe-only smokers in comparison with lifelong nonsmokers using clinical parameters of cough and sputum scores, lung function, and chest high-resolution computed tomography as well as biological parameters of lung epithelial lining fluid metabolome, small airway epithelial (SAE) cell differential and transcriptome, alveolar macrophage transcriptome, and plasma apoptotic endothelial cell microparticles.

MEASUREMENTS AND MAIN RESULTS

Compared with nonsmokers, waterpipe smokers had more cough and sputum as well as a lower lung diffusing capacity, abnormal epithelial lining fluid metabolome profile, increased proportions of SAE secretory and intermediate cells, reduced proportions of SAE ciliated and basal cells, markedly abnormal SAE and alveolar macrophage transcriptomes, and elevated levels of apoptotic endothelial cell microparticles.

CONCLUSIONS

Young, light-use, waterpipe-only smokers have a variety of abnormalities in multiple lung-related biological and clinical parameters, suggesting that even limited waterpipe use has broad consequences on human lung biology and health. We suggest that large epidemiological studies should be initiated to investigate the harmful effects of waterpipe smoking.

[Nutrition, physical activity and substance use in children and adolescents : Representative results of the federal state module Thuringia in KiGGS wave 1]

The term health behaviour combines both health-promoting and health-risk components. In this study, the health behaviour of children and adolescents in Thuringia is analysed. The database was a representative subsample of the federal state module Thuringia, which was conducted by the Robert Koch Institute as part of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) wave 1 (2010-2012; n = 4,096; 3-17 years). Health behaviour was described based on nine indicators: fruit and vegetable consumption, soft drink consumption, breakfast at home, physical activity, sport, swimming ability, alcohol consumption, smoking and water pipe consumption (shisha smoking). Prevalence and mean values with 95 % confidence intervals were reported, and based on logistic or linear regression, the significance of the group differences was examined. The results show that 43.4 % of children and adolescents in Thuringia ate fruits and vegetables daily, 44.5 % consumed soft drinks less than once a week, and 67.9 % had breakfast at home every weekday. In addition, 31.0 % of children and adolescents in Thuringia were physically active at least 60 min a day, 69.8 % did sports for at least 2 h a week, and 81.5 % can swim. Additionally, 15.9 % of adolescents in Thuringia had hazardous alcohol consumption, 14.4 % currently smoked, and 20.0 % smoked a water pipe. Differences existed with regard to gender, age, socio-economic status (SES) of the family and residence (urban/rural). In summary, many of the children and adolescents in Thuringia demonstrate relatively positive health behaviour. However, the results also indicate groups at higher risk of unhealthy behaviour, such as children and adolescents from families with low SES.

Correlates of Hookah Pipe Awareness and Perceived Harmfulness Among U.S. Adults

INTRODUCTION

Hookah smoking has recently become a common form of smoking, and its prevalence has increased worldwide. This study determined the prevalence and correlates of hookah awareness and perceived harmfulness among U.S. adults.

METHODS

Weighted multivariable logistic regression analyses were performed on 6,711 adults aged ≥18 years collected from the 2013-2014 Health Information National Trends Survey (Cycles 3 and 4). Analysis was conducted in 2016.

RESULTS

Overall, 74.3% were aware of hookah. Of these, 73.4% believed hookah pipes were equally harmful as cigarettes whereas 15.7% believed otherwise. Older (OR=0.13, 95% CI=0.09, 0.18), black (OR=0.51, 95% CI=0.38, 0.71), Hispanic (OR=0.52, 95% CI=0.37, 0.71), and less-educated (OR=0.42, 95% CI=0.27, 0.65) respondents had lower odds of being aware of hookah. Compared with non-smokers, former smokers had 83% (95% CI=1.44, 2.33) higher odds of hookah awareness. Among those aware of hookah, older (OR=0.44, 95% CI=0.31, 0.62), black (OR=0.64, 95% CI=0.43, 0.96), and less-educated (OR=0.55, 95% CI=0.33, 0.92) respondents had lower odds of perceiving hookah as less harmful than cigarettes.

CONCLUSIONS

Most adults in U.S. are aware of hookah, but only 15.7% believe it is less harmful than cigarettes. This small proportion are mostly young, white, and college graduates. Targeted behavioral interventions will be necessary to increase individuals' perceived risk, knowledge, and perceived harmfulness of hookah smoking.