The prevalence and trends of waterpipe tobacco smoking: A systematic review

Salivary oxidative stress biomarkers in periodontitis-free smokers: a cross sectional study

BACKGROUND

Salivary oxidative stress has been extensively studied with attempts to correlate changes in the oxidative stress markers with local and systemic factors, including smoking. The objective of this study was to evaluate the influence of two forms of smoking, cigarettes and waterpipe smoking (WPS), on selected oxidative stress biomarkers in saliva.

METHODS

Three groups of participants were enrolled into the study, controls (never smokers), cigarette smokers and WPS. Participants were clinically free from periodontitis and systemic conditions known to affect the saliva constituents. Unstimulated whole saliva samples were collected according to a standard protocol and concentrations of 8-hydroxy-2'-deoxyguanosine (8-OHdG), myeloperoxidase (MPO), malondialdehyde (MDA), total antioxidant capacity (TAC), and cortisol. The one-way ANOVA test was used to compare the levels of each oxidative stress biomarker between the three study groups and the hierarchical linear regression analysis was used to test the levels of salivary cortisol for prediction of other oxidative stress biomarkers. Significance levels were set at 95% confidence intervals and probability values ≤0.05.

RESULTS

8-OHdG was highest in WPS group (mean±SE 11,030.35±1829.16 pg/mL) while MDA and cortisol levels were highest in the cigarette smokers group (mean±SE 3.33±0.52 µM and 3.99±0.48 ng/mL, respectively) and MPO was highest in the control group (mean±SE 7.760±1.55 ng/mL). WPS group showed the highest TAC (mean±SE 0.3±0.03 mM). However, none of the tested makers reached a statistically significant difference.

CONCLUSIONS

Despite subtle changes in some biomarkers, the salivary oxidative stress does not appear to be significantly influenced by smoking habits in periodontitis-free smokers.

Identifying the Determinants of Hookah Smoking Among the Youth; A Mixed-Methods Study

Hookahs have been rising in popularity in the United States (U.S.) especially among the youth yet not much research has been carried out to understand the various predictors of hookah use among youth. We have thus conducted a cross-sectional study with a mixed-methods triangulation design to identify the hookah use determinants at different levels of the Social Ecological Model among youth. Participants between the ages of 18-24 years were sampled purposively, between April to November 2023, following a snowballing technique from various communities in Virginia and California, United States. Data were collected via a survey, one-on-one interviews, and focus groups. The study had a total sample size of 20. We found that participants smoked for a median of 5 times in the past 30 days. The main determinants of hookah smoking included the limited knowledge of health effects and addiction, positive attitude, family and peer influence, use as a means to socially connect with others, culture, social acceptability, lack of education at school and work place, access to hookah bars and smoke shops, and lack of strict enforcement of laws to ban smoking of youth. Educational interventions should be implemented by public health authorities to target the youth, their social and communities to provide education on hookah harm and addictiveness and to restrict access to- and the production, distribution, marketing and sales of hookahs.

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.

The association between nicotine stomatitis and waterpipe smoking

INTRODUCTION

Waterpipe smoking (WPS) is gaining popularity worldwide, especially in the Middle East, and significantly affects oral health. Nicotine stomatitis (NS) is an inflammatory response of the palate to the heat and chemical irritation caused by tobacco. The high temperatures of hot beverages have been found to have a synergistic effect. This study investigated the association of NS among waterpipe smokers and hot beverage drinkers.

METHODS

This cross-sectional study was conducted in several public locations in Kuwait. Demographic data, smoking habits, and hot beverage intake were recorded using questionnaires. An oral examination was performed with informed consent, and the occurrence of NS was recorded. Data were analyzed using IBM SPSS statistics version 28.0 (IBM Inc., Chicago, IL, USA).

RESULTS

Of the 211 participants, 55 subjects (26.1%) presented with NS. All the patients with NS drank hot beverages, while 37 (67.3%) patients with NS were waterpipe smokers and hot beverage drinkers. Smokers with NS smoked significantly more tobacco heads (Z= -2.606; p=0.009) and for more hours per day (Z= -2.222; p=0.026).

CONCLUSIONS

This study explored the association between WPS and NS in Kuwait. Waterpipe smokers and males were more likely to present with NS. Also, the number of tobacco heads and the number of hours of WPS were found to correlate with the presence of lesions. Effective strategies to reduce WPS need to be implemented. Further studies are recommended to investigate the cause-andeffect relationships.

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.

Exposure to Waterpipe Smoke Disrupts Erythrocyte Homeostasis of BALB/c Mice

The prevalence of waterpipe tobacco smoking (WPS) is increasing worldwide and is relatively high among youth and young adults. It has been shown, both experimentally and clinically, that WPS exposure adversely affects the cardiovascular and hematological systems through the generation of oxidative stress and inflammation. Our study aimed to evaluate the impact of WPS exposure on erythrocytes, a major component of the hematological system, of BALB/c mice. Here, we assessed the effect of nose-only WPS exposure for four consecutive weeks on erythrocyte inflammation, oxidative stress, and eryptosis. The duration of the session was 30 min/day, 5 days/week. Control mice were exposed to air. Our results showed that the levels of C-reactive protein, lipid peroxidation (LPO), superoxide dismutase, and total nitric oxide (NO) were significantly increased in the plasma of WPS-exposed mice. The number of erythrocytes and the hematocrit were significantly decreased in WPS-exposed mice compared with the control group. Moreover, there was an increase in the erythrocyte fragility in mice exposed to WPS compared with those exposed to air. The levels of lactate dehydrogenase, LPO, reduced glutathione, catalase, and NO were significantly increased in the red blood cells (RBCs) of WPS-exposed mice. In addition, erythrocytes of the WPS-exposed group showed a significant increase in ATPase activity, Ca2+, annexin V binding, and calpain activity. Taken together, our findings suggest that WPS exposure elevated inflammation and oxidative stress in the plasma and induced hemolysis in vivo. It also caused alterations of RBCs oxidative stress and eryptosis in vitro. Our data confirm the detrimental impact of WPS on erythrocyte physiology.

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.

The expression of salivary EGF, VEGF, endothelin, and transferrin in waterpipe and cigarette smokers

The aim of this study was to evaluate the effects of two forms of tobacco smoking, cigarettes and water pipe smoking (WPS), on the expression of a panel of salivary proteins in healthy adults. Three groups of age and gender-matched participants were enrolled in the study: never-smokers, cigarette smokers and WPS (N = 55 per group). Expression of epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), endothelin and transferrin in unstimulated whole saliva was estimated using enzyme-linked immunosorbent assays. Statistical analysis consisted of one-way ANOVA and Tukey's post hoc tests, in addition to bioinformatics analysis. VEGF expression was the least in WPS (51.1 ± 14.5 pg/ml) compared to both controls (150.1 ± 13.8 pg/ml) and cigarette smokers (93 ± 9.9 pg/ml), with a significant difference in WPS (p < 0.001) and cigarette smokers (p < 0.01) compared to controls. Furthermore, transferrin showed the weakest expression in the WPS group (1238 ± 261.4 pg/ml) compared to controls (2205.6 ± 298.6 pg/ml) (p = 0.05) and cigarette smokers (1805.4 ± 244 pg/ml). Neither EGF nor endothelin expression showed any statistical difference between the groups (p > 0.05). Gene-gene interaction network demonstrated that FLT1, TFRC, KDR, VEGFB and PGF genes had the highest potential for interaction with the studied proteins. Further functional annotations on the identified markers in the interaction network were performed to identify HIF-1 pathways among the most relevant pathways. In conclusion, smoking habits alter the expression of salivary VEGF and transferrin, which may correspond to early sub-clinical changes in the oral mucosa. The clinical relevance of these salivary changes requires further research.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Unveiling an Association between Waterpipe Smoking and Bladder Cancer Risk: A Multicenter Case-Control Study in Iran

BACKGROUND

Limited data exist for the association between bladder cancers and waterpipe smoking, an emerging global public health concern.

METHODS

We used the IROPICAN database in Iran and used multivariable logistic regression, adjusting for cigarette smoking, opium use, and other confounding factors. In addition, we studied the association between exclusive waterpipe smoking and bladder cancer.

RESULTS

We analyzed 717 cases and 3,477 controls and a subset of 215 patients and 2,145 controls who did not use opium or cigarettes. Although the OR adjusted for opium, cigarettes, and other tobacco products was 0.92 [95% confidence interval (CI), 0.69-1.20], we observed a statistically significant elevated risk in exclusive waterpipe smokers (OR = 1.78; 95% CI, 1.16-2.72) compared with non-users of opium or any tobacco. Associations were strongest for smoking more than two heads/day (OR = 2.25; 95% CI, 1.21-4.18) and for initiating waterpipe smoking at an age less than 20 (OR = 2.73; 95% CI, 1.11-6.72). The OR for urothelial bladder cancer was higher in ex-smokers (OR = 2.35; 95% CI, 1.24-4.42) than in current smokers (OR = 1.52; 95% CI, 0.72-3.15). All observed associations were consistently higher for urothelial histology.

CONCLUSIONS

Waterpipe smoking may be associated with an increased risk of bladder cancer, notably among individuals who are not exposed to cigarette smoking and opium.

IMPACT

The study provides compelling evidence that waterpipe smoking is a confirmed human carcinogen, demanding action from policymakers. See related In the Spotlight, p. 461.

Impact of waterpipe tobacco taxation on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine: a simulation study

INTRODUCTION

Despite the high prevalence of waterpipe tobacco smoking in the Eastern Mediterranean region, evidence supporting its fiscal measures is limited. We modelled the impact of waterpipe tobacco-specific excise taxes on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine.

METHODS

We developed a simulation model using country-specific and market share-specific price, consumption and price elasticity data from WHO, UN Comtrade and nationally representative surveys. We modelled increases to specific excise taxes to meet a 35.9% tax burden on 20 g of waterpipe tobacco in Lebanon and Jordan, in line with the global average, and to double government revenues from excise duties in Palestine, which has surpassed this average.

RESULTS

Specific excise tax was raised by $1.14 ($0.18-$1.32) in Jordan, $2.41 ($0.03-$2.44) in Lebanon (alongside removal of ad valorem taxes) and $2.39 ($1.72-$4.11) in Palestine per 20 g of waterpipe tobacco. Government revenue increased by $126.3 million in Jordan, $53.8 million in Lebanon and $162.4 million in Palestine while waterpipes smoked decreased by 32.4% in Jordan, 71.0% in Lebanon and 16.3% in Palestine. The corresponding numbers of premature deaths averted annually were approximately 162 000; 1 000 000; and 52 000.

DISCUSSION

Increases in waterpipe tobacco-specific excise taxes substantially reduce smoking and increase government revenue and averted premature deaths in Jordan, Lebanon and Palestine. This has positive implications for both public health and financing and should be considered a policy priority.

Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents

BACKGROUND

Waterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq.

METHODS

A cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale.

RESULTS

When adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit.

CONCLUSION

Pictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Compliance With US Federal Regulations on Waterpipe Tobacco Warnings on Packaging

This cohort study reports the rate and degree of compliance with the Food and Drug Administration–mandated warning labels among waterpipe tobacco brands and products.

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.

Tobacco market trends in 97 countries between 2007 and 2021

INTRODUCTION

Analysis of the tobacco market can provide valuable insights for developing tobacco control strategies. This study examines the market trends of cigarettes, cigars/cigarillos, smoking tobacco, smokeless tobacco, e-cigarettes, heated tobacco products (HTPs), and tobacco-free oral nicotine, across 97 countries between 2007 and 2021.

METHODS

We obtained annual tobacco retail value data from Euromonitor Passport and calculated the market share for each type of tobacco product. The research examined trends in retail value and market share globally, stratified by national income level, as well as in individual countries.

RESULTS

From 2007 to 2015, the growth of the global tobacco market was primarily driven by cigarette sales. However, starting in 2016, emerging products, including e-cigarettes, HTPs, and tobacco-free oral nicotine, as well as non-cigarette combustible products, including cigars/cigarillos and smoking tobacco, have been mostly responsible for the increases in the global tobacco retail value. High-income countries experienced the greatest increase in the retail value of emerging products, while middle- and low-income countries still observed rises in cigarette sales.

CONCLUSIONS

Trends in the retail value of different tobacco products varied widely during the study period, with distinct trends observed in different income levels and within individual countries. These trends can supplement prevalence data and be used to inform local tobacco control policies.

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.

Exposure to Electronic Waterpipes Increases the Risk of Occlusive Cardiovascular Disease in C57BL/6J Mice

INTRODUCTION

It is well documented that cardiovascular disease (CVD) is the leading cause of death in the US and worldwide, with smoking being the most preventable cause. Additionally, most smokers die from thrombotic-based diseases, in which platelets play a major role. To this end, because of the proven harm of smoking, several novel tobacco products such as electronic(e)-waterpipe have been gaining popularity among different sectors of the population, partly due to their "false" safety claims. While many investigators have focused on the negative health effects of traditional cigarettes and e-cigarettes on the cardiovascular system, virtually little or nothing is known about e-waterpipes, which we investigated herein.

METHODS AND MATERIALS

To investigate their occlusive CVD effects, we employed a whole-body mouse exposure model of e-waterpipe vape/smoke and exposed C57BL/6J male mice (starting at 7 weeks of age) for 1 month, with the controls exposed to clean air. Exposures took place seven times a week, according to the well-known Beirut protocol, which has been employed in many studies, as it mimics real-life waterpipe exposure scenarios; specifically, 171 puffs of 530 ml volume of the e-liquid at 2.6 s puff duration and 17 s puff interval.

RESULTS

The e-waterpipe exposed mice had shortened bleeding and occlusion times, when compared to the clean air controls, indicating a prothrombotic phenotype. As for the mechanism underlying this phenotype, we found that e-waterpipe exposed platelets exhibited enhanced agonist-triggered aggregation and dense granule secretion. Also, flow cytometry analysis of surface markers of platelet activation showed that both P-selectin and integrin GPIIb-IIIa activation were enhanced in the e-waterpipe exposed platelets, relative to the controls. Finally, platelet spreading and Akt phosphorylation were also more pronounced in the exposed mice.

CONCLUSION

We document that e-waterpipe exposure does exert untoward effects in the context of thrombosis-based CVD, in part, via promoting platelet hyperreactivity.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Determinants of waterpipe smoking in Iranian adults: results from the IROPICAN study

Introduction

Waterpipe smoking has become increasingly popular in Western countries, particularly among young individuals. This study aims to identify the factors influencing waterpipe smoking by focusing on consumption patterns.

Methods

We utilized data from a multicenter case-control study (IROPICAN) conducted in Iran. Multivariate logistic regression estimated the adjusted odds ratio and 95% confidence intervals as a measure of association between waterpipe smoking and different factors.

Results

Among 3,477 subjects were included, 11.8% were waterpipe smokers. Most of <50 years old smokers were occasional (80%), while daily smokers were often >50 years (85%). Around 59% of occasional users started it before 30 years old. Low education, low SES, alcohol consumption, cigarette smoking, secondhand smoke exposure, and opium use were associated with waterpipe smoking. Stratified analysis by frequency pattern showed an association between occasional smoking with age 0.97 (0.96-0.98), university degree 0.36 (0.17-0.76), urban dwellers 1.40 (1.06-1.86) and between high SES and daily smoking 0.34 (0.17-0.69).

Conclusion

Our results offer valuable information to policymakers for developing waterpipe smoking control measures. The occasional waterpipe smoking results may be generalized to the younger people in Western countries.

Waterpipe and cigarette epigenome analysis reveals markers implicated in addiction and smoking type inference

Waterpipe smoking is frequent in the Middle East and Africa with emerging prevalence worldwide. The epigenome acts as a molecular sensor to exposures and a crucial driver in several diseases. With the widespread use of waterpipe smoking, it is timely to investigate its epigenomic markers and their role in addiction, as a central player in disease prevention and therapeutic strategies. DNA methylome-wide profiling was performed on an exposure-rich population from the Middle East, constituting of 216 blood samples split equally between never, cigarette-only and waterpipe-only smokers. Waterpipe smokers showed predominantly distinct epigenetic markers from cigarette smokers, even though both smoking forms are tobacco-based. Moreover, each smoking form could be accurately (∼90 %) inferred from the DNA methylome using machine learning. Top markers showed dose-response relationship with extent of smoking and were validated using independent technologies and additional samples (total N = 284). Smoking markers were enriched in regulatory regions and several biological pathways, primarily addiction. The epigenetically altered genes were not associated with genetic etiology of tobacco use, and the methylation levels of addiction genes, in particular, were more likely to reverse after smoking cessation. In contrast, other epigenetic markers continued to feature smoking exposure after cessation, which may explain long-term health effects observed in former smokers. This study reports, for the first time, blood epigenome-wide markers of waterpipe smokers and reveals new markers of cigarette smoking, with implications in mechanisms of addiction and the capacity to discriminate between different smoking types. These markers may offer actionable targets to reverse the epigenetic memory of addiction and can guide future prevention strategies for tobacco smoking as the most preventable cause of illnesses worldwide.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between alexithymia, emotional intelligence, smoking addiction, and alcohol use disorder among a sample of Lebanese adults

BACKGROUND

Alexithymia can be associated with worse addictive traits, while emotional intelligence is associated with better addictive outcomes. In Lebanon, the prevalence of cigarette and waterpipe smoking is on the rise, although people are aware of the associated harms. Also, around 11% of Lebanese adults have experienced alcohol use disorder (AUD). This study aimed to assess the association between alexithymia, emotional intelligence, smoking (cigarette and waterpipe), and AUD among a sample of Lebanese adults.

METHODS

A web-based cross-sectional study carried out between February and April 2020, during the lockdown period, enrolled 408 community-dwelling adults. The survey link was shared on social media to reach participants from all Lebanese districts/governorates.

RESULTS

Taking antidepressants (Beta = 4.37) was significantly associated with more cigarette dependence, while female gender (Beta = -1.52) and having a high vs. low monthly income (Beta = 1.02) were significantly associated with less cigarette dependence. None of the variables, including alexithymia, were significantly associated with waterpipe dependence. Female gender (Beta = -0.15) and higher emotional intelligence (Beta = -0.003) were significantly associated with less AUD, whereas higher alexithymia (Beta = 0.003) was significantly associated with more AUD.

CONCLUSION

This study could demonstrate a significant association between alexithymia and cigarette smoking and alexithymia and alcohol consumption. Future research is warranted to investigate the mediating effect of emotional intelligence and how these results may be used to meet the needs of alexithymic individuals with addictions.

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.

Vaping and Hookah Use Among Medical Trainees: A Multinational Survey Study

The increased use of E-cigarettes and hookah among young consumers represents a public health concern. This study aimed to investigate the frequency and patterns of use of E-cigarettes and hookah among medical trainees. This cross-sectional multinational online survey included medical students, residents, and fellows in Brazil, the U.S., and India between October 2020 and November 2021. Information on sociodemographics; mental health; and E-cigarettes, hookah, tobacco, marijuana, and alcohol use were collected. Generalized structural equation models were used in 2022 to explore the factors associated with current vaping and current hookah use (ongoing monthly/weekly/daily use). People reporting previous sporadic/frequent use or those who never used/only tried it once were the reference group. Overall, 7,526 participants were recruited (Brazil=3,093; U.S.=3,067; India=1,366). The frequency of current vaping was 20% (Brazil), 11% (U.S.), and <1% (India), and current hookah use was 10% (Brazil), 6% (U.S.), and 1% (India). Higher family income (OR=6.35, 95% CI=4.42, 9.12), smoking cigarettes (OR=5.88, 95% CI=4.88, 7.09) and marijuana (OR=2.8, 95% CI=2.35, 3.34), and binge drinking (OR=3.03, 95% CI=2.56, 3.59) were associated with current vaping. The same was true for hookah use: higher family income (OR=2.69, 95% CI=1.75, 4.14), smoking cigarettes (OR=3.20, 95% CI=2.53, 4.06), smoking marijuana (OR=4.17, 95% CI=3.35, 4.19), and binge drinking (OR=2.42, 95% CI=1.96, 2.99). In conclusion, E-cigarettes and hookah were frequently used by Brazilian and American trainees, sharply contrasting with data from India. Cultural aspects and public health policies may explain the differences among countries. Addressing the problems of hookah and E-cigarette smoking in this population is relevant to avoid the renormalization of smoking.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of intrapersonal and interpersonal factors in waterpipe cessation: a case-control study

BACKGROUND

The prevalence of waterpipe smoking among women in southern Iran is significantly higher than women in other regions of Iran. We aimed to explore the effect of several demographic factors, knowledge, attitude, self-efficacy and social norms on a successful cessation of waterpipe smoking in the marginalized women of Bandar Abbas city, in the south of Iran.

METHODS

This case-control study was conducted in 2022 among 731 women (246 subjects who successfully quit waterpipe smoking in the case group and 485 who smoked waterpipe in the control group). A cluster sampling method was used to collect the required data through face-to-face interviews and a researcher-made questionnaire. The questionnaire consisted of demographic information, behavioral information about waterpipe smoking and knowledge, attitude, self-efficacy and social norms. The data were analyzed in STATA 14 using univariate and multivariate regression analyses.

RESULTS

The mean and standard deviation of age was 39.24 ± 11.93 and 37.18 ± 13.57 in the control and case groups, respectively. With an increase of one score in social norm (OR: 1.046), the odds of cessation were increased for 4%. With an increase of one score in self-efficacy (OR: 1.152), the odds of cessation were increased for 15%. With an increase of one score in knowledge (OR: 1.064), the odds of cessation were increased for 6%. With an increase of one score in attitude (OR: 1.215) the odds of cessation were increased for 21%.

CONCLUSION

The present findings revealed personal and interpersonal influential factors in successful waterpipe cessation. Women's knowledge can be increased and their attitude can be changed. Important people in women's lives can be influenced to, consequently, affect women positively and improve their self-esteem.

Flavours and flavourings in waterpipe products: a comparison between tobacco, herbal molasses and steam stones

ObjectivesFlavoured products are especially appealing to youth and contribute to the onset of waterpipe smoking and continued use of waterpipe tobacco. The goal of database and chemical analysis was to provide a clear overview of commonly used flavours and flavourings in tobacco and related waterpipe products, that is, herbal molasses and steam stones.

METHODS

In 2019, 249 waterpipe tobacco products were registered in the European Common Entry Gate by manufacturers to be marketed in The Netherlands. Flavour categories were assigned to the registered products based on their brand names and product descriptions. Nicotine and eleven 1111 flavourings were identified and quantified in waterpipe tobacco (n=8), herbal molasses (n=7) and steam stones (n=4) by extraction and gas chromatography-mass spectrometry (GC-MS) analysis.

RESULTS

Flavour categories could be assigned to 237 of 249 registered waterpipe tobacco products. Eight flavour main categories and 48 unique subcategories were identified and presented in a flavour wheel. All registered waterpipe tobacco products were flavoured, and the majority (78%) was fruit flavoured. Herbal molasses contained similar median flavouring levels, and steam stones contained lower median levels compared with waterpipe tobacco. Flavourings in waterpipe products were almost exclusively fruity and sweet, often in combination with menthol/mint flavourings.

CONCLUSIONS

This study is the first to present a waterpipe tobacco flavour wheel, providing a quick overview of waterpipe tobacco flavours and thereby aiding communication among experts around the globe. GC-MS analysis revealed that the most prevalent flavourings are present in similar levels in herbal and tobacco waterpipe products. Banning flavourings in all waterpipe products would be a good strategy to reduce waterpipe smoking among youth.

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.

Socioeconomic and environmental factors associated with waterpipe tobacco smoking among Iranian adults: a PERSIAN cohort-based cross-sectional study

BACKGROUND

Waterpipe tobacco smoking (WTS) is associated with several deleterious health outcomes. We sought to estimate the prevalence of WTS and explore socioeconomic inequalities associated with this culturally-rooted tobacco smoking practice among Iranian adults.

METHODS

A cross-sectional analysis was conducted among 20,460 adults (ages 18 and older) enrolled in the PERSIAN cohort study during 2020. Data were collected on socioeconomic status (SES), lifestyle, alcohol consumption, cigarette smoking, and several risk factors related to non-communicable diseases. The concentration curve and relative concentration index (RCI) were administered to assess and quantify the SES-based inequality in WTS.

RESULTS

Overall age-adjusted prevalence of past-month WTS was 5.1% (95%CI:4.6-5.8), with about 1% for women and 10.6 for men. Age-adjusted prevalence of WTS was higher among younger adults, men, cigarette smokers, obese adults, and those with higher SES. The RCI estimation showed that WTS is more popular among adults with high income and education. WTS was higher among younger adults, cigarette smokers, obese adults, and those with higher SES.

CONCLUSION

There is a clear socioeconomic inequality in WTS, with a higher prevalence among adults with higher income and education. The findings suggest the need for targeted interventions to address this inequality and reduce the prevalence of WTS among high-income communities.

Post-consumption waterpipe tobacco waste as an unrecognized source of toxic metal(loid)s leachates into aquatic environments

Waterpipe is a common form of tobacco smoking, and recently, its use has been increasing globally. Therefore, concern arises regarding the large quantity of post-consumption waterpipe tobacco waste produced and released into the environment and which can contain high levels of dangerous pollutants such as toxic meta(loid)s. This study reports the concentrations of meta(loid)s in waste from fruit-flavoured and traditional tobacco smoking as well as the release rate of these pollutants from waterpipe tobacco waste into three types of water. These include distilled water, tap water, and seawater and contact times ranging from 15 min to 70 days. The mean concentration levels of Ʃmetal(loid)s in waste samples of Al-mahmoud, Al-Fakher, Mazaya, Al-Ayan brands and traditional tobacco brands were 212 ± 92.8, 198 ± 94.4, 197 ± 75.7, 214 ± 85.8 and 40.6 ± 16.1 μg/g, respectively. The concentration levels of Ʃmetal(loid)s in fruit-flavoured tobacco samples were significantly higher than for traditional tobacco samples (p < 0.05). It was found that waterpipe tobacco wastes leached toxic metal(loid)s into different water samples with similar trends. In addition distribution coefficients showed that most metal(loid)s are highly likely to enter the liquid phase. The concentration levels of these pollutants (except Ni and As) in deionized water and tap water exceeded the surface fresh water standards for sustaining aquatic life during long contact time (up to 70 days). In seawater, concentration levels of Cu and Zn exceeded the recommended standards for maintaining aquatic life in the sea. Therefore, due to the possibility of contamination by soluble metal(loid)s through disposal of waterpipe tobacco waste in wastewater, there is concern that these toxic chemicals might enter the human food chain. Appropriate regulatory measures for disposal of waterpipe tobacco waste are necessary to prevent environmental pollution due to discarded wastes into aquatic ecosystems.

Polycyclic aromatic hydrocarbon (PAH) leachates from post-consumption waterpipe tobacco waste (PWTW) into aquatic environment- a primary study

Post-consumption waterpipe tobacco waste (PWTW) is an unrecognized type of hazardous waste that is produced and released in large quantities into the aquatic environment. It may contain high amounts of various pollutants including PAH, and to date, there has been no research on the potential for contamination by PAH from PWTW leaching into aquatic environments. In this study, the concentrations of PAH via PWTW of fruit-flavored and traditional tobacco leachate into three water types, including distilled water (DW), tap water (TW) and sea water (SW) at different contact times were evaluated. There were significantly higher concentration levels of ƩPAH in waters with leachates from fruit-flavored PWTW than traditional tobacco (P-value<0.05). The concentration levels of ƩPAH in DW, TW and SW at a total contact time of two months ranged from 0.13 to 3.51, 0.12 to 3.63 and 0.11-3.64 μg/L, respectively. Lower molecular weight PAH such as naphthalene (Naph), acenaphthylene (Acen) and fluorine (Flu) were detected in leachates immediately after a short contact time of 15 min. Higher molecular weight PAH including benzo [a]anthracene (BaA), benzo [b]fluoranthene (BbF), benzo [k]fluoranthene (BkF), chrysene (Chr), and benzo [a]pyrene (BaP) were detected after one month contact time, while indeno [1,2,3-cd] pyrene (Indp), benzo [ghi]perylene (BghiP) and dibenz [a,h]anthracene (DahA) were only observed at the contact time measurement of two months. By adding sodium azide as an antimicrobial agent and chemical preservative to SW samples, higher concentrations of PAH including IP, DahA and BghiP were observed. The concentration levels of PAH in water samples after two months contact time were higher than water quality standards provided by the World Health Organization (WHO) and other international organizations.

A predictive model of waterpipe smoking cessation among women in southern Iran: application of the theory of planned behavior

BACKGROUND

Today, waterpipe (WT) smoking is a rising issue worldwide, and has taken a significant and growing share of tobacco consumption in the world. Present study aimed to explore the predictors of WT cessation in the light of the theory of planned behavior (TPB).

METHODS

This cross-sectional analytical study was conducted in 2021-2022 using a multi-stratified cluster sampling on 1,764 women in Bandar Abbas, southern Iran. Data were collected through a reliable and valid questionnaire. The three-part questionnaire includes demographic information, behavioral information of WT smoking, and the constructs of the TPB along with an additional habit construct. Multivariate logistic regression analysis was run to model the predictor constructs of WT smoking. The data were analyzed statistically in STATA14.2.

RESULTS

With an increase in one attitude score, the odds of cessation increased by 31% (p < 0.001). Also, with an increase of one score in knowledge, the odds of cessation are increased by 0.05% (0.008). With an increase of one score for intention, the odds of cessation are 26% (0.000). in social norms, the odds of cessation are 0.02% (0.001). With an increase of one score in perceived control, the odds of cessation increased by 16% (0.000) and inhabit score, the odds of cessation decrease by 37% (0.000). In the model where the habit construct was present, the accuracy, sensitivity, and pseudo R2 indices were 95.69%, 77.31%, and 65%, respectively and after removing the habit construct, the so-called indices changed to 90.7%, 50.38% and 0.44%, respectively.

CONCLUSIONS

The present research confirmed the effectiveness of the TPB model in predicting waterpipe cessation behavior. The knowledge obtained from this research can help develop a systematic and effective intervention to facilitate waterpipe cessation. Focusing on the habit variable can play a critical role in waterpipe cessation in women.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

The Intention of Waterpipe Tobacco Smoking by Women in the COVID-19 Pandemic and its Contributing Factors: a Nonparametric Path Analysis

Background

People with waterpipe tobacco smoking (WTS) seem to be more at risk for the serious complications of coronavirus disease 2019 (COVID-19). This study aimed at assessing the behavioral intention (BI) of WTS by women in the COVID-19 pandemic and its contributing factors.

Methods

This cross-sectional descriptive-correlational study was conducted in 2020 (ie, during the COVID-19 pandemic). Participants were 300 women randomly selected through multistage sampling from comprehensive healthcare centers in Khorramabad, Iran. Data collection instrument was a 42-item questionnaire with 4 main subscales, namely knowledge, attitude, differential association, and BI. Data were collected through both online and phone-based methods and were analyzed using non-parametirc path analysis.

Results

The prevalence of WTS among women was 13% (95% CI, 11.06-14.94) and the mean scores of attitude, differential association, and behavioral intention among participants with WTS were significantly higher than participants without WTS (P < 0.001). Moreover, 46.12% (95% CI, 38.12-54.08) of participants with WTS reported intention to quit WTS due to the COVID-19 pandemic and 43.6% (95% CI, 35.66-51.54) of women with WTS and 16.5% (95% CI, 14.20-18.80) of women without WTS believed in the protective effects of WTS against COVID-19. The path analysis model showed that the BI of WTS had a significant inverse relationship with knowledge and a significant direct relationship with attitude and differential association.

Conclusion

This study suggests the need for quality educational and counseling interventions for the general public to correct popular misconceptions about the protective effects of WTS against COVID-19.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Association between waterpipe use and susceptibility to cigarette smoking among adolescents and young adults who never smoked: A systematic review and meta-analysis

INTRODUCTION

Several factors associated with susceptibility to cigarette smoking have been identified, yet there is little evidence on the possible effects of waterpipe use. With this systematic review and meta-analysis, we aimed to investigate the relationship between waterpipe use and cigarette smoking susceptibility among adolescents and young adults who never smoked.

METHODS

Eligible studies were searched in PubMed, Springer Link, ScienceDirect and Cochrane Library up to August 2022. The pooled odds ratio (OR) and 95% confidence intervals (CI) of cigarette smoking susceptibility with waterpipe use were estimated using a random-effects model. Publication bias was assessed by Egger's regression asymmetry test and Begg's rank correlation test with Begg's funnel plot.

RESULTS

A total of 59710 participants, including 3559 waterpipe users from six studies, were identified in this analysis. Results showed that the odds of susceptibility to cigarette smoking were nearly two times (OR=1.90; 95% CI: 1.59-2.26) greater for never smoker adolescents and young adults who used waterpipe tobacco, compared to those who were never users. In subgroup analyses, the pooled OR was 2.19 (95% CI: 1.52-3.14) and 1.70 (95% CI: 1.51-1.92) for current and ever use of waterpipe, while the pooled OR was 1.99 (95% CI: 1.35-2.95) and 1.87 (95% CI: 1.45-2.39) in Arab and non-Arab nations, respectively.

CONCLUSIONS

Our findings suggest that waterpipe use was associated with greater odds of susceptibility to cigarette smoking among adolescents and young adults who never smoked. Tailored public health policies and regulations on waterpipe smoking may help to protect youth never smokers from initiation of cigarette smoking.

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.

Biomonitoring of unmetabolized polycyclic aromatic hydrocarbons (PAHs) in urine of waterpipe/cigarette café workers

Fresh tobacco or the smoke resulting from waterpipe and cigarette contains large amounts of polycyclic aromatic hydrocarbons (PAHs), which consumption can cause releasing of these contaminants into the indoor air of cigarette and waterpipe cafés. This study was conducted to investigate the urinary concentrations of unmetabolized PAH compounds among the employed workers as well as the customers in waterpipe and cigarette cafés along with its association with oxidative stress factors plus kidney injury biomarkers. For this, 35 staffs and 35 customers in these cafés (as an exposed group (EG)), 20 staffs in non-smoking cafés (as 1st control group (CG-1)), and 20 of the public population (as 2nd control group 2 (CG-2)) were chosen and their urine specimens were collected. The results indicated that there is a significant difference between urinary concentration of ƩPAHs in the exposed and control groups (P value < 0.05). Also, "type of tobacco" can be considered as an influential and determining factor for the urinary levels of PAHs among the subjects. Considering the contribution of PAHs to the total toxic equivalents, benzo[a]pyrene (BaP), dibenzo[a,h]anthracene (DahA), and fluoranthene (Flrt) with 32.76%, 27.62%, and 18.65% claimed the largest share in waterpipe/cigarette cafés. The results also indicated a positive and significant relationship between some PAHs and oxidative stress biomarkers as well as uKIM-1 (biomarker for assessing and diagnosing glomerular damage) and TIMP-1 (biomarker of stress in primary steps of injury in tubular cell). Thus, it can be expressed that the workers of these smoking cafés are prone to the detrimental health impacts. Accordingly, proper policies and decisions should be taken to limit the activity of these cafés or proper protective strategies should be adopted to protect the health of exposed individuals.

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.

Price elasticity of demand for cigarettes among youths in high-income countries: a systematic review

Aims: Smoking in youth remains a major public health issue. As increasing tobacco prices is considered one of the most effective prevention strategies, examining youth's responsiveness to price changes on cigarettes will provide crucial knowledge. This study aims systematically to review research examining the price elasticity of demand for cigarettes among youths (<30 years of age) in high-income countries. Methods: Searches were conducted in three databases (Web of Science, Pubmed and Scopus). Inclusion criteria were publications within the past 10 years (2011-2021) written in English and with a population of youths below 30 years of age, concerning price elasticity of demand for cigarettes and from high-income countries. Searches were screened by two independent reviewers and the quality of studies was assessed using a quality assessment tool. Results: Four outcomes related to price elasticity of demand for cigarettes were examined in six studies included in this review; that is, cigarette initiation, consumption, prevalence and cessation. Overall, findings indicate that increasing tobacco prices affect youth tobacco use. The effect was associated with gender and age; young women were more price sensitive concerning smoking initiation, whereas young men were more price sensitive concerning cigarette prevalence and consumption. Moreover, younger age was associated with higher price elasticity. Conclusions: Estimates for price elasticity varied across the included studies. This may be caused by differences in data sources, collection methods used and country of origin. Most included studies were of older date. Therefore, to make reliable predictions of the expected effects of increased tobacco prices, further examinations of up-to-date and locally embedded measures are required.

Cytotoxic and Genotoxic Effects of Waterpipe on Oral Health Status: Systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the cytotoxic and genotoxic impacts of waterpipe smoking on oral health. The databases MEDLINE, Cochrane Library and Dimensions were searched to find studies evaluating whether waterpipe smokers exhibited any cytotoxic or genotoxic effects on their oral cells compared to non-smokers, with regard to mouth neoplasms. Particularly, changes in DNA methylation and p53 expression were assessed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adopted for the systematic review. Review Manager was utilised for statistical analysis with a significance level at P <0.05. To assess the grades of the included articles, a risk of bias analysis was summarised. A forest plot, including some of the included articles included, was created regarding the different grades. A total of 20 studies were included in this review. The results showed that waterpipe smoking has cytotoxic and genotoxic effects on oral cells, with a risk difference of 0.16. Although the published articles are few in number, all confirm the devastating effects of waterpipe smoking related to the carcinogenicity. Waterpipe smoking is harmful to oral health. It causes a series of detrimental cellular and genetic modifications such as acanthosis, epithelial dysplasia and hyperparakeratosis. In addition, waterpipe smoke contains several carcinogenic compounds. As it releases many harmful organic compounds, waterpipe smoking increases the incidence of oral cancer.

The Protective Effects of the Combination of Vitamin E and Swimming Exercise on Memory Impairment Induced by Exposure to Waterpipe Smoke

BACKGROUND

Waterpipe smoking (WP) exposure involves a negative health impact, including memory deficit, which is attributed to the elevation of oxidative stress. Vitamin E (VitE) in combination with swimming exercise exerts protective effects that prevent memory impairment. In the current study, the modulation of WP-induced memory impairment by the combined effect of VitE and swimming exercise (SE) was investigated.

METHODS

Animals were exposed to WP one hour/day, five days per week for four weeks. Simultaneously, VitE (100 mg/kg, six days/week for four weeks) was administered via oral gavage, and the rats were made to swim one hour/day, five days/week for four weeks. Changes in memory were evaluated using radial arm water maze (RAWM), and oxidative stress biomarkers were examined in the hippocampus.

RESULTS

WP exposure induced short-term/long-term memory impairment (p<0.05). This impairment was prevented by a combination of VitE with SE (p<0.05). Additionally, this combination normalized the hippocampal catalase, GPx, and GSH/GSSG ratios that were modulated by WP (p<0.05). The combination further reduced TBARs levels below those of the control group (p<0.05).

CONCLUSION

WP-induced memory impairments were prevented by the combination of VitE with SE. This could be attributed to preserving the hippocampal oxidative mechanism by combining VitE and SE during WP exposure.

Factors Predicting Dependence on Waterpipe Smoking Among Waterpipe Exclusive Smokers

ABSTRACT

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

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

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

Prevalence of waterpipe smoking and its associated factors among adolescents aged 12-16 years in 73 countries/territories

Introduction

To describe the recent prevalence of, and trends in, waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years in 73 countries/territories (hereafter "countries").

Methods

Data from 72 countries that had conducted a Global Youth Tobacco Survey (GYTS) in 2010-2019 and from the National Youth Tobacco Survey in the United States in 2019 were used to assess the recent prevalence of waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years. Data from 38 countries that had carried out at least 2 surveys from 2000 to 2019 were used to determine trends in the prevalence of waterpipe smoking among adolescents.

Results

The recent prevalence of current waterpipe smoking (on 1 day during the past 30 days) among adolescents was 6.9% (95%CI 6.4-7.5). The prevalence was highest in the European region (10.9%, 9.9-11.8) and Eastern Mediterranean region (10.7%, 9.5-11.9), but lowest in the Western Pacific region (1.9%, 1.4-2.4). The prevalence of current waterpipe smoking increased or remained unchanged in 19 (50%) of 38 countries, but decreased in the remaining 19 countries (50%). Parental smoking, closest friends' smoking, secondhand smoke exposure, tobacco advertisement exposure, not being taught the dangers of smoking, particularly cigarette smoking, were positively associated with adolescent waterpipe smoking.

Discussion

Waterpipe smoking among adolescents remains a major public health issue worldwide, especially in the regions of Europe and the Eastern Mediterranean. Effective prevention and control strategies and measures are needed to curb the epidemic of adolescent waterpipe smoking.