Hookah use among U.S. high school seniors

Prevalence and characteristics of smoking cigarette and narghile among Syrian refugee parents in Ontario, Canada

This study aimed to explore the prevalence and associated sociodemographic, migration, and health-related factors of smoking cigarettes and narghile among Syrian refugee parents resettled in Ontario, Canada since 2015. A total of 540 Syrian refugee parents, with at least one child less than 18 years of age, were interviewed. Multivariate logistic regression analysis was performed to assess the independent relationship between each of the associated sociodemographic, migration, and health-related factors and smoking cigarettes and narghile. The overall prevalence of smoking was 43% (cigarette = 22%, narghile = 25.6%). The average number of cigarettes smoked per day was 15.4 (SD = 10.1). With regard to smoking narghile, 18.2% of the sample smoked daily, while 35.5% and 52.9% smoked at least once weekly and occasionally, respectively. Results from multivariate logistic regression analysis showed that more fathers were at increased odds of smoking cigarettes than mothers OR (95% CI) = 6.6 (3.7-11.9), while no such difference was found for narghile smokers OR (95% CI) = 1.5 (0.9-2.6). Results showed that smoking cigarettes was associated with lower education levels and being Muslim, whereas smoking narghile was associated with younger age and alcohol use. Poor perceived mental health was significant/approached significance for both types of smoking. Greater understanding of smoking patterns of resettled refugees is needed to direct healthcare providers to offer targeted interventions for those who are most at risk.

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

OBJECTIVE

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

DESIGN

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

PATIENTS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Application of inverse weighting analysis to assess the association of youth perceptions with the age of initiation of tobacco products

Introduction

To examine if perceptions of harmfulness and addictiveness of hookah and cigarettes impact the age of initiation of hookah and cigarettes, respectively, among US youth. Youth (12-17 years old) users and never users of hookah and cigarettes during their first wave of PATH participation were analyzed by each tobacco product (TP) independently. The effect of perceptions of (i) harmfulness and (ii) addictiveness at the first wave of PATH participation on the age of initiation of ever use of hookah was estimated using interval-censoring Cox proportional hazards models.

Methods

Users and never users of hookah at their first wave of PATH participation were balanced by multiplying the sampling weight and the 100 balance repeated replicate weights with the inverse probability weight (IPW). The IPW was based on the probability of being a user in their first wave of PATH participation. A Fay's factor of 0.3 was included for variance estimation. Crude hazard ratios (HR) and 95% confidence intervals (CIs) are reported. A similar process was repeated for cigarettes.

Results

Compared to youth who perceived each TP as "a lot of harm", youth who reported perceived "some harm" had younger ages of initiation of these tobacco products, HR: 2.53 (95% CI: 2.87-4.34) for hookah and HR: 2.35 (95% CI: 2.10-2.62) for cigarettes. Similarly, youth who perceived each TP as "no/little harm" had an earlier age of initiation of these TPs compared to those who perceived them as "a lot of harm", with an HR: 2.23 (95% CI: 1.82, 2.71) for hookah and an HR: 1.85 (95% CI: 1.72, 1.98) for cigarettes. Compared to youth who reported each TP as "somewhat/very likely" as their perception of addictiveness, youth who reported "neither likely nor unlikely" and "very/somewhat unlikely" as their perception of addictiveness of hookah had an older age of initiation, with an HR: 0.75 (95% CI: 0.67-0.83) and an HR: 0.55 (95% CI: 0.47, 0.63) respectively.

Discussion

Perceptions of the harmfulness and addictiveness of these tobacco products (TPs) should be addressed in education campaigns for youth to prevent early ages of initiation of cigarettes and hookah.

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.

Quick nic: novel smokeless nicotine products and pediatric trends

PURPOSE OF REVIEW

The development and marketing of smokeless nicotine products in recent years have become increasingly popular among adolescents. In addition to well known conventional inhaled nicotine products, noninhaled products, such as nicotine toothpicks, orbs, lozenges, strips, and more, have dangerously captivated a new youth audience. Although smokeless nicotine products may seem to be less threatening than conventional inhaled nicotine products, there are significant risks associated with the use of these products, including addiction and severe health issues. The purpose of this review is to provide up-to-date information about alternative nicotine products currently on the market that may appeal to youth, and the dangers of nicotine use for pediatric populations.

RECENT FINDINGS

Smokeless nicotine products appeal to minors with their varying flavors and discrete packaging. These products may lead to nicotine toxicity as well as severe health problems, such as cancer, issues with reproduction, and heart attacks. Nicotine is extremely dangerous for young children; in fact, using nicotine products before the age of 18 years can lead to addiction and is linked to an increased likelihood of experimenting with stronger nicotine products or illicit drugs. The development of inconspicuous nicotine packaging has led to increasing concerns for accidental nicotine exposure and overdose in youth.

SUMMARY

Greater knowledge regarding current nicotine products on the market, specifically smokeless nicotine products, will help clinicians be more aware of the dangers associated with these products. Clinicians will be better able to provide their patients and families with proper guidance to avoid nicotine addiction, further drug use, and detrimental health issues. Caregivers and medical professionals must recognize novel and inconspicuous nicotine products commonly used among youth, understand the signs of nicotine abuse and dependence, and take measures to address possible nicotine-related health risks.

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.

Susceptibility to smoking and determinants among never-smoking high school students in Thailand

INTRODUCTION

To prevent youth from becoming smokers, it is essential to understand factors contributing to them becoming susceptible to smoking. The aim of this study was thus to estimate the prevalence of smoking susceptibility among neversmoking youth in Thailand and to identify determinants associated with such behavior.

METHODS

Cross-sectional data for 4572 eighth-grade students (aged 13-15 years) from 120 secondary schools were obtained from a classroom-based survey using a self-administered questionnaire. Using data from never-smoking students (n=3180), simple and multiple logistic regression analyses were performed to identify factors associated with smoking susceptibility. Frequencies and proportions for descriptive statistics are reported along with adjusted odds ratios and 95% confidence intervals for logistic regression models.

RESULTS

A total of 16.4% of Thai never-smoking youth were susceptible to smoking. Several variables of interest were identified in multivariable analysis as significantly associated with increased susceptibility to smoking: being male (AOR=3.16; 95% CI: 25.4-3.92), having a positive attitude toward smoking - agreeing that smoking displays maturity (AOR=1.49; 95% CI: 1.07-2.09), the perception that smoking helps relieve stress (AOR=1.57; 95% CI: 1.14-2.15), the presence of current smoking peers (AOR=2.04; 95% CI: 1.57-2.66), exposure to secondhand smoking in public (AOR=1.51; 95% CI: 1.17-1.94), exposure to online cigarette and smoking-related advertising occasionally (AOR=1.98; 95% CI: 1.49-2.65), attendance at schools where there are sometimes anti-smoking education activities (AOR=1.57; 95% CI: 1.18-2.07); as well as exposure to anti-tobacco messages rarely (AOR=1.40; 95% CI: 1.05-1.87), occasionally (AOR=1.48; 95% CI: 1.12-1.96) and infrequently (AOR=1.41; 95% CI : 1.07-1.87).

CONCLUSIONS

Approximately one in six Thai never-smoking youth was found to be susceptible to smoking. Findings suggest it should be useful to supplement relevant tobacco prevention and control efforts by considering such interpersonal and socio-environmental determinants, among vulnerable people to smoke.

Bacterial communities of hookah tobacco products are diverse and differ across brands and flavors

Abstract

Young adults are increasingly using non-cigarette products, such as hookahs, since they are perceived as healthier alternatives to cigarette smoking. However, hookah users are exposed to not only carcinogenic compounds but also microorganisms that may play an active role in the development of both infectious and chronic diseases among users. Nevertheless, existing hookah research in this area has focused only on microorganisms that may be transferred to users through the smoking apparatus and not on bacterial communities associated with hookah tobacco. To address this knowledge gap, we conducted time-series experiments on commercially available hookah brands (Al Fakher (flavors: two apple, mint, and watermelon) and Fumari (flavors: white gummy bear, ambrosia, and mint chocolate chill)) stored under three different temperature and relative humidity conditions over 14 days. To characterize bacterial communities, the total DNA was extracted on days 0, 5, 9, and 14, PCR-amplified for the V3V4 region of the bacterial 16S rRNA gene, sequenced on the Illumina HiSeq platform, and analyzed using R. Diversity (alpha and beta) analyses revealed that the microbiotas of Fumari and Al Fakher products differed significantly and that flavor had a significant effect on the hookah microbiota. Overall, Pseudomonas, Bacillus, Sphingomonas, and Methylobacterium were the predominant bacterial taxa across all products. Additionally, we observed compositional differences between hookah brands across the 14-day incubation. These data suggest that the bacterial communities of hookah tobacco are diverse and differ across brands and flavors, which may have critical implications regarding exposures to specific bacteria among hookah users.

Key points

• Commercial hookah products harbor diverse bacterial communities.

• Brands and flavors impact the diversity of these communities.

• Research on their viability and transmission to users’ respiratory tracts is needed.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00253-022-12079-7.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Substance use among adolescents and young adults with chronic kidney disease or kidney failure

Substance use, a significant public health issue, is well described in the adult chronic kidney disease (CKD) population. Knowledge about substance use in the adolescent and young adult (AYA) CKD population such as prevalence, impact on kidney function, medication adherence, and psychosocial well-being remain largely unknown. Awareness of and inquiring about substance use is paramount to providing evidence-based care and preparation to transition to adult-focused health services. The authors in this review identify commonly used substances (alcohol, tobacco, marijuana, etc.) and how they impact kidney function and care of the AYA with CKD or kidney failure. Recommendations for screening and intervention strategies are provided.

Comparative Genotoxicity and Mutagenicity of Cigarette, Cigarillo, and Shisha Tobacco Products in Epithelial and Cardiac Cells

Epidemiology studies link cigarillos and shisha tobacco (delivered through a hookah waterpipe) to increased risk for cardiopulmonary diseases. Here we performed a comparative chemical constituent analysis between 3 cigarettes, 3 cigarillos, and 8 shisha tobacco products. The potency for genotoxicity and oxidative stress of each product's generated total particulate matter (TPM) was also assessed using immortalized oral, lung, and cardiac cell lines to represent target tissues. Levels of the carcinogenic carbonyl formaldehyde were 32- to 95-fold greater, while acrolein was similar across the shisha aerosols generated by charcoal heating compared to cigarettes and cigarillos. Electric-mediated aerosol generation dramatically increased acrolein to levels exceeding those in cigarettes and cigarillos by up to 43-fold. Equivalent cytotoxic-mediated cell death and dose response for genotoxicity through induction of mutagenicity and DNA strand breaks was seen between cigarettes and cigarillos, while minimal to no effect was observed with shisha tobacco products. In contrast, increased potency of TPM from cigarillos compared to cigarettes for inducing oxidative stress via reactive oxygen radicals and lipid peroxidation across cell lines was evident, while positivity was seen for shisha tobacco products albeit at much lower levels. Together, these studies provide new insight into the potential harmful effects of cigarillos for causing tobacco-associated diseases. The high level of carbonyls in shisha products, that in turn is impacted by the heating mechanism, reside largely in the gas phase which will distribute throughout the respiratory tract and systemic circulation to likely increase genotoxic stress.

Trends of maternal waterpipe, cigarettes, and dual tobacco smoking in Jordan. A decade of lost opportunities

Background

Maternal tobacco use is a global public health problem. In the literature, the focus was mainly on cigarette smoking, minimally on waterpipe use, and totally ignored dual use among pregnant women. We estimated the prevalence of current maternal tobacco use by tobacco product (cigarette, waterpipe, and dual use) over a period of ten years (2007 to 2017), and examined the socio-demographic patterning of maternal tobacco use.

Methods

A secondary analysis of Jordan DHS four data waves was conducted for women who reported to be pregnant at the time of the survey. Current cigarette and waterpipe tobacco use were investigated. Prevalence estimates for cigarette-only, waterpipe-only, and dual use, as well as for cigarette, regardless of waterpipe, and waterpipe, regardless of cigarette, were reported. The effect of independent variables on cigarette smoking, waterpipe use, and dual use was assessed. Logistic regression models assessed the adjusted effects of socio-demographic variables on cigarette smoking, waterpipe use, and on dual use. For each outcome variable, a time-adjusted and a time-unadjusted logistic models were conducted.

Results

Over the last decade, the prevalence estimates of current cigarette-only smoking slightly decreased. The prevalence estimates of current waterpipe-only use exceeded those for cigarette-only after 2007 and showed a steady overall increase. Current dual use showed a continuous rise especially after 2009. Gradual increase in cigarette smoking (4.1%, in 2007, and 5.7% in 2017) and in waterpipe use (2.5% to 6.4%) were detected. Education showed an inverse relationship with cigarette and waterpipe smoking. Household wealth demonstrated a positive association with cigarette and waterpipe smoking.

Conclusions

Tobacco use epidemic is expanding its roots among pregnant women in Jordan through not only waterpipe use but also dual cigarette–waterpipe smoking. Maternal and child services should consider tobacco counseling and cessation.

Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1-4 (2013-2017)

OBJECTIVE

This study reports the prospectively estimated age of initiation of susceptibility to, ever, past 30-day, and fairly regular hookah use.

DESIGN

Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US youth (ages 12-17).

METHODS

Youth who were never hookah users at their first wave of participation were identified (n = 16,678; N = 31,136,834). Four outcomes were analyzed, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) fairly regular hookah use. The age of hookah initiation of each outcome was estimated. Weighted interval censoring survival analyses and Cox regression models were conducted to estimate the age of initiation of each hookah use outcome, and to estimate differences in age of initiation by sex and by race, respectively.

RESULTS

Around 11% of youth were classified as susceptible to hookah use by 13 years of age, 8% reported initiating ever hookah use by age 17, almost 10% reported initiating past 30-day hookah use by age 19, and 3% reported initiating fairly regular hookah use by age 20. Females and Hispanics were at higher risk of becoming susceptible to and ever hookah use at earlier ages compared to males and Non-Hispanic White youth.

CONCLUSION

Education, communication campaigns, and proven culturally targeted tobacco interventions that reach youth at ages before they first become susceptible or start using hookah use are needed to prevent the onset of hookah use among vulnerable youth.

Shisha Use Is Associated with Deviance among High School Students in Accra, Ghana

A number of studies have established an association between smoking, use of other drugs, and deviance. However, little is known about the association of shisha use or marijuana use, or their interaction, with deviance. We examined the effect of shisha and marijuana use within the past thirty days, including their interaction, on deviance among high school students in Accra, Ghana. In this cross-sectional survey, participants were selected from four senior high schools using quota sampling. The sample comprised 217 males and 112 females (M_age = 17.23, SD_age = 1.33) who completed a self-administered questionnaires. A factorial ANOVA was used in analyzing the data. Main effects of shisha and marijuana use within the past thirty days, including their interaction effect on deviance was established. Although studies of shisha use have often been skewed toward the health problems associated with its use, current findings suggest that using shisha is associated with deviant behavior. Also, the use of marijuana is associated with committing deviant acts. Policy makers should consider a ban on shisha use among adolescents in Ghana.

Factors associated with smoking susceptibility among high school students in western Spain

The Expanded Susceptibility to Smoking Index (ESSI) is based on the combination of susceptibility to smoking and curiosity about smoking. The ESSI can identify young people who are at risk of starting to smoke cigarettes and related products. The objective of this study was to analyse the ESSI results and to examine factors associated with ESSI scores in students between 12 and 16 years of age. Sociodemographic, social/environmental and personal variables were analysed, and the ESSI value was determined for non-smoking students recruited from three schools in western Spain. Regression models were used to examine the factors associated with smoking for the entire sample and the factors associated with ESSI scores in the non-smoking population. Of the 377 participants who were analysed, 20.4% were smokers. Among the non-smokers, 53.5% and 55.3% presented medium-high ESSI scores for cigarettes and e-cigarettes, respectively, and 39.8% presented medium-high ESSI scores for hookah use. A higher ESSI score was associated with greater exposure to people smoking in the home, having more friends who smoke, alcohol consumption, and a higher impulsivity scale score. These findings reinforce the importance of reducing peer pressure and suggest the important role of resolve under conditions of positive affect on reducing impulsivity. Approaches based on self-efficacy could be addressed in preventive programmes developed in educational settings.

Data Visualization Tools of Tobacco Product Use Patterns, Transitions and Sex Differences in the PATH Youth Data

INTRODUCTION

Evaluations of multiple tobacco product use and temporal changes in patterns of use are complicated by a large number of combinations and transitions. Visualization tools could easily identify most common patterns and transitions.

METHODS

Set intersection bar plots describe ever use of five tobacco products among 12-17 years old youth in wave 1 of the Population Assessment of Tobacco and Health (PATH) study (N = 11 497). Heat maps visualize unweighted frequencies of transitions from ever use at wave 1 (2013-2014) to past 12-month use at wave 2 (2014-2015). Weighted calibrated heat maps assess differences in relative frequencies of transitions by pattern at wave 1 and identify differences in transitions by sex.

RESULTS

The most common tobacco product ever use patterns in wave 1 were of cigarettes only, e-cigarettes only or hookah only, followed by ever use of both cigarettes and e-cigarettes. Initiation of use between waves was uncommon. The most frequent transition among those who reported use at wave 2 but not at wave 1 (N = 971) was to e-cigarette use (N = 301). However, among e-cigarette-only ever users at wave 1 (N = 260), about half did not report any product use at wave 2. Use of three or more products remained stable. Adolescent girls compared to boys appeared more likely to report hookah use at both waves.

CONCLUSION

Set intersection bar plots and heat maps are useful for visualizing tobacco product use patterns and transitions, especially for multiple products. Both techniques could identify common problematic tobacco use patterns across and within populations.

IMPLICATIONS

Given the growing complexity of the youth tobacco use landscape, approaches to efficiently communicate patterns of multiple tobacco product use should be used more often. This study introduces set intersection bar plots and modified versions of heat maps to the tobacco product literature and illustrates their use in the PATH youth sample. These techniques are useful for visualizing absolute and relative frequencies of multiple possible patterns and transitions. They also suggest targets for subsequent statistical inference such as sex differences in hookah use. The methods can be applied more generally for data visualization wherever large number of combinations occurs.

Hookah use patterns, social influence and associated other substance use among a sample of New York City public university students

Background

Most hookah use studies have not included racial and ethnic minorities which limits our understanding of its use among these growing populations. This study aimed to investigate the individual characteristics of hookah use patterns and associated risk behaviors among an ethnically diverse sample of college students.

Methods

A cross-sectional survey of 2460 students (aged 18–25) was conducted in 2015, and data was analyzed in 2017. Descriptive statistics were used to present the sociodemographic characteristics, hookah use-related behavior, and binge drinking and marijuana use according to the current hookah use group, including never, exclusive, dual/poly hookah use. Multivariate logistic regression was conducted to examine how hookah related behavior and other risk behaviors varied by sociodemographics and hookah use patterns.

Results

Among current hookah users (n = 312), 70% were exclusive hookah users and 30% were dual/poly hookah users. There were no statistically significant differences in sociodemographic characteristics except for race/ethnicity (p < 0.05). Almost half (44%) of the exclusive hookah users reported having at least five friends who also used hookah, compared to 30% in the dual/poly use group. Exclusive users were less likely to report past year binge drinking (17%) and past year marijuana use (25%) compared to those in the dual/poly use group (44 and 48% respectively); p < 0.001.

Conclusions

The socialization aspects of hookah smoking seem to be associated with its use patterns. Our study calls for multicomponent interventions designed to target poly tobacco use as well as other substance use that appears to be relatively common among hookah users.

PROSPECTIVELY ESTIMATING THE AGE OF INITIATION OF E-CIGARETTES AMONG U.S. YOUTH: FINDINGS FROM THE POPULATION ASSESSMENT OF TOBACCO AND HEALTH (PATH) STUDY, 2013-2017

CONTEXT

There is a lack of research that prospectively estimates the age of initiation of electronic cigarette use in U.S. youth. Younger ages of initiation of tobacco product use are associated with greater exposure to nicotine, and recently e-cigarette use has been associated with subsequent cigarette initiation. This study sought to estimate the distribution of the age of first reporting of e-cigarette use outcomes among youth never e-cigarette users overall, by sex and by race/ethnicity, prospectively.

METHODS

Secondary analysis of the Population Assessment of Tobacco and Health (PATH) youth dataset (ages 12-17) across waves 1 (2013-2014), 2 (2014-2015), 3 (2015-2016), and 4 (2016-2017) were conducted. Four outcomes are presented, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) "fairly regular" e-cigarette use. Each outcome was prospectively estimated using participant age when they entered the study and the number of weeks between the last report of never use and the first report of each outcome across waves. Weighted survival analyses for interval censoring accounting for the complex survey design were implemented.

RESULTS

Among youth non-susceptible to e-cigarettes, 50.2% became susceptible to e-cigarette use by age 18. There were no statistically significant differences in the age of first report of susceptibility to e-cigarette use by sex or by race/ethnicity in this nationally representative sample of U.S. youth. Among never users, 41.7%, 23.5% and 10.3% initiated ever, past 30-day and "fairly regular" e-cigarette use by the age of 18, respectively. Less than 10% initiated ever e-cigarette use between the ages of 18 and 21. Boys had a higher risk of first reporting ever, past 30-day and "fairly regular" e-cigarette use at earlier ages than girls. Non-Hispanic Blacks and Other racial/ethnic groups were less likely than Non-Hispanic Whites to initiate ever e-cigarette use at earlier ages, and there was no difference between Non-Hispanic Whites and Hispanics. Hispanic, Non-Hispanic Black and Other racial/ethnic youth were less likely to first report past 30-day use and "fairly regular" e-cigarette use at earlier ages than Non-Hispanic White youth.

CONCLUSION

This paper provides information on specific ages of the first report of e-cigarette use behaviors by sex and by race/ethnicity that can be used to culturally tailor e-cigarette interventions on specific windows of opportunity before youth begin using e-cigarettes or escalating their use.

Longitudinal pathways of exclusive and polytobacco hookah use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

The goal of this study is to examine cross-sectional rates of use and longitudinal pathways of hookah use among US youth (ages 12-17), young adults (ages 18-24), and adults 25+ (ages 25 and older).

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US adults and youth. Respondents with data at all three waves (youth, n=11 046; young adults, n=6478; adults 25+, n=17 188) were included in longitudinal analyses.

RESULTS

Young adults had higher ever, past 12-month (P12M) and past 30-day cross-sectional prevalence of hookah use at each wave than youth or adults 25+. The majority of Wave 1 (W1) hookah users were P12M users of other tobacco products (youth: 73.9%, young adults: 80.5%, adults 25+: 83.2%). Most youth and adult W1 P12M hookah users discontinued use in Wave 2 or Wave 3 (youth: 58.0%, young adults: 47.5%, adults 25+: 63.4%). Most W1 P12M hookah polytobacco users used cigarettes (youth: 49.4%, young adults: 59.4%, adults 25+: 63.2%) and had lower rates of quitting all tobacco than exclusive hookah users or hookah polytobacco users who did not use cigarettes.

CONCLUSIONS

Hookah use is more common among young adults than among youth or adults 25+. Discontinuing hookah use is the most common pathway among exclusive or polytobacco hookah users. Understanding longitudinal transitions in hookah use is important in understanding behavioural outcomes at the population level.

High Carbon Monoxide Levels from Charcoal Combustion Mask Acute Endothelial Dysfunction Induced by Hookah (Waterpipe) Smoking in Young Adults

BACKGROUND

Hookah smoking is marketed to youth as a harmless alternative to cigarettes. Although cigarette smoking acutely impairs endothelial function, the effect of smoking fruit-flavored hookah tobacco is unknown. Because charcoal traditionally is used to heat the hookah tobacco in the waterpipe, hookah smoke delivers tobacco toxicants and nicotine plus charcoal combustion products: not only carbon-rich nanoparticles, oxidants that may destroy nitric oxide and impair endothelial function, but also large amounts of carbon monoxide (CO), a putative vasodilator molecule.

METHODS

To test the acute effect of hookah smoking on endothelial function, in young adult hookah smokers (n=30, age 26±1 years, mean±SE), we measured plasma nicotine, exhaled CO, and brachial artery flow-mediated dilation (FMD) before and after charcoal-heated hookah smoking. To remove the effect of charcoal combustion, the same measurements were performed when the same flavored hookah tobacco product was heated electrically (n=20). As a positive internal control, we studied age-matched cigarette smokers (n=15) who smoked 1 cigarette. To isolate the effect of the CO boost on FMD, hookah smokers (n=8) inhaled a 0.1% CO gas mixture to approximate their CO boost achieved with charcoal-heated hookah smoking.

RESULTS

Nicotine levels increased similarly with all types of smoking, whereas exhaled CO increased 9- to 10-fold more after charcoal-heated hookah than after either electrically heated hookah or cigarette smoking. FMD did not decrease after smoking charcoal-heated hookah but instead increased by +43±7% ( P<0.001). In contrast, FMD decreased by -27±4% ( P<0.001) after smoking electrically heated hookah, comparable to the decrease after cigarette smoking. FMD increased markedly by 138±71% ( P<0.001) after breathing CO gas, 2.8 times more than the increase induced in the same subjects after smoking charcoal-heated hookah ( P<0.001), despite comparable increases in exhaled CO (24±1 versus 28±3 ppm, hookah versus CO).

CONCLUSIONS

Smoking hookah tobacco, similar to cigarette tobacco, acutely impairs endothelial function. With traditional charcoal-heated hookah smoking, the acute endothelial dysfunction is masked by high levels of carbon monoxide, a potent vasodilator molecule generated by charcoal combustion. With respect to large-artery endothelial function, smoking hookah is not harmless.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifiers: NCT03616002 and NCT03067701.

Using a classification tree modeling approach to predict cigarette use among adolescents in the United States

Objective: The purpose of this study was to screen pertinent variables to identify ordered relations that provide easily interpretable and accurate predictions of the probability of cigarette use among adolescents using a classification tree modeling approach. Methods: This cross-sectional study included a national sample of 3717 U.S. adolescents aged between 12 and 20 years old from the 2016 National Survey on Drug Use and Health. Results: The results indicated that age was the most influential variable, followed by depression, race/ethnicity, family income, gender, and alcohol abuse and dependence. Additionally, several interaction emerged that identified higher and lower cigarette use profiles: youth who were between 18 and 20 years old and self-identified as non-Hispanic White, Native American/Alaska Native, and "Other" racial/ethnic group and African American, Asian, and Latinx adolescents, with depressive symptoms were at higher risk of cigarette use; while youth who reported lower family incomes, were 16-17 years old, who identified as African American, Asian, and Latinx, were also likely to report lower use of cigarettes when they reported lower depressive symptom scores. Discussion: These results are discussed relative to practice implications.

Hookah Use Among US Youth: A Systematic Review of the Literature From 2009 to 2017

INTRODUCTION

Given the US Food and Drug Administration (FDA)'s authority to regulate hookah, more research is needed to inform regulations intended to prevent youth from using hookah. This systematic review summarizes and assesses the literature related to hookah use among adolescents (11 to ≤18 years of age) in the United States from 2009 to 2017.

METHODS

Database searches yielded 867 peer-reviewed articles. After duplicates were removed, authors reviewed 461 articles for inclusion. Included articles (n = 55) were coded for study themes, study quality, and their relevance to FDA's research priorities. A qualitative synthesis is presented.

RESULTS

The following themes were identified: (1) prevalence of hookah use (n = 42), (2) tobacco use transitions (n = 7), (3) sociodemographic correlates (n = 35), (4) psychosocial risk factors (n = 21), (5) concurrent use of other tobacco products (n = 31), (6) concurrent use of other substances (n = 9), and (7) other (n = 15)-which includes low prevalence themes. The qualitative synthesis showed increasing rates of hookah use. Older age, male gender, positive social normative beliefs, higher peer use, as well as lower perceived risk were associated with hookah use. Longitudinal studies of youth hookah use showed bidirectional relationships between use of hookah and other tobacco products. All articles fell within FDA's research priority related to "behavior," and three priorities ("impact analysis," "health effects," and "toxicity") have not been explored for hookah use among US youth since 2009.

CONCLUSIONS

The prevalence of hookah use among youth in the United States is increasing, thus more research is needed to inform policies targeted to protect this vulnerable population.

IMPLICATIONS

This study represents a novel contribution to our understanding of hookah use among youth in the United States from 2009-the year that the Family Smoking Prevention and Tobacco Control Act was passed-to 2017. In recent years, hookah has become a more popular tobacco product among US youth; however, to date, no systematic reviews of hookah use among this population exist. Results highlight implications for future US FDA regulatory policy and identify gaps in research to be addressed in future studies.

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

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

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

Aims and Objectives:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Harm Perceptions of Alternative Tobacco Products among US Adolescents

OBJECTIVES

In this study, we identified groups of adolescents who share similar awareness and perceptions of harm regarding e-cigarettes, cigars, hookah, and smokeless tobacco.

METHODS

We used latent class analyses (LCA) with the data from Wave 1 (2013-14) of the Population Assessment of Tobacco and Health youth and parent survey (PATH; N = 13,650) to address the research goal. Multinomial logistic regression analysis assessed the associations between identified classes with demographic characteristics and tobacco use.

RESULTS

LCA identified 5 classes: (1) perceived harm across all alternative tobacco products (36.6%); (2) perceived harm for e-cigarettes and smokeless tobacco but never heard of cigars and hookah (48.2%); (3) never heard of alternative tobacco products (8.6%); (4) mix of no harm and harm across alternative tobacco products (5.2%); and (5) "don't know" the harm across alternative tobacco products (1.4%). Relative to the class who perceived harm across all alternative tobacco products, classes of adolescents who were unaware of the products or did not know the harms were more likely to be non-white, younger, have lower parental education, and less likely to have tried an alternative tobacco product.

CONCLUSIONS

Tobacco prevention should target vulnerable youth, such as adolescents who are non-white, young, and have low parental education.

Hookah Use among Russian adolescents: Prevalence and correlates

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

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

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

Heated tobacco products likely appeal to adolescents and young adults

BACKGROUND

Beginning in the 1960s in the USA and globally since 1998, tobacco companies have beenaggressively promoting heated tobacco products (HTP). In 2016, Philip Morris International (PMI) applied to the US Food and Drug Administration (FDA) seeking authorisation to market their IQOS HTP system and flavoured 'HeatSticks' in the USA as a modified-risk tobacco product (MRTP).

METHODS

We systematically evaluated the publicly available data PMI submitted to FDA in its MRTP application to determine whether PMI's IQOS product meets the US Tobacco Control Act's standard for MRTP claims. We examined whether PMI provided sufficient data showing tobacco users will not initiate with IQOS, that youth will not misperceive the MRTP-related claims being made concerning IQOS, and how youth perceive health risks associated with IQOS.

RESULTS

PMI's own studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS and will not perceive these products as risk-free. Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.

CONCLUSION

PMI's own data and available evidence from scientific studies conducted independent of the tobacco industry regarding how novel tobacco products are currently being marketed suggest that introduction of IQOS will result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.

Longitudinal associations between youth tobacco and substance use in waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND

While evidence suggests bidirectional associations between cigarette use and substance (alcohol or drug) use, how these associations are reflected across the range of currently available tobacco products is unknown. This study examined whether ever tobacco use predicted subsequent substance use, and ever substance use predicted subsequent tobacco use among 11,996 U.S. youth (12-17 years) from Waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health (PATH) Study.

METHODS

Ever use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, smokeless tobacco excluding snus pouches, dissolvable tobacco, bidis, kreteks, alcohol, marijuana, prescription drugs, and other drugs (cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens) was assessed at Wave 1 followed by past 12-month use assessments at Wave 2. The analyses included covariates (demographics, mental health, sensation seeking, prior use) to mitigate confounding.

RESULTS

Ever tobacco use predicted subsequent substance use. The magnitude of the associations was lowest for alcohol, higher for marijuana, and highest for other drugs. Ever substance use also predicted subsequent tobacco use. Specifically, ever alcohol, marijuana, and non-prescribed Ritalin/Adderall use predicted tobacco-product use. Ever e-cigarette and cigarette use exclusively and concurrently predicted subsequent any drug (including and excluding alcohol) use. E-cigarette and cigarette use associations in the opposite direction were also significant; the strongest associations were observed for exclusive cigarette use.

CONCLUSION

Tobacco and substance use prevention efforts may benefit from comprehensive screening and interventions across tobacco products, alcohol, and drugs, and targeting risk factors shared across substances.

Effect of prenatal waterpipe tobacco smoke on airway inflammation in murine model of asthma of adult offspring mice

OBJECTIVE

Worldwide popularity of waterpipe tobacco smoking has increased, including in pregnant women. This study investigates the effect of prenatal waterpipe tobacco smoke (WTS) exposure on airway inflammation in a murine model of asthma of adult offspring mice.

MATERIALS AND METHODS

Pregnant BALB/c mice were exposed to fresh air or WTS, using a whole-body exposure system that mimics human use during WTS. Adult male offspring mice were divided into; (1) control (prenatal fresh air, postnatal ovalbumin sensitization and saline challenge), (2) postnatal Ova S/C (prenatal fresh air, postnatal ovalbumin sensitization and challenge (Ova S/C)), (3) prenatal WTS (prenatal WTS, postnatal ovalbumin sensitization and saline challenge) and (4) prenatal WTS + postnatal Ova S/C. Cells from the bronchoalveolar lavage fluid, cytokines, and oxidative stress markers (superoxide dismutase (SOD), catalase, glutathione peroxidase (GPx) and thiobarbituric acid reactive substances (TBARS)) from lung homogenates were evaluated.

RESULTS

Prenatal WTS increased recruitment of cells in lungs and levels of SOD and catalase when compared to unexposed offspring's. The levels of cytokines, GPx and TBARS were not affected by prenatal WTS. Prenatal WTS exposure and postnatal Ova S/C increased airway inflammation and activity of SOD compared to control and Ova S/C mice and reduced IL-18 levels compared to Ova S/C mice.

DISCUSSION AND CONCLUSIONS

Prenatal exposure to WTS induced airway inflammation, further enhanced by a murine model of asthma in adult offspring. Prenatal exposure to WTS adversely affects the lung function of the offspring and careful strategies for increasing public awareness regarding the harmful effects of WTS during pregnancy is important.

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

INTRODUCTION

Waterpipe tobacco smoking is harmful to health however its prevalence estimates remain uncertain. We aimed to systematically review the medical literature on waterpipe tobacco prevalence and trends.

METHODS

We searched Medline, Embase and ISI Web of Science for 'waterpipe' and its synonyms, without using language or date restrictions. We included any measure of waterpipe tobacco smoking prevalence in jurisdictionally representative populations. We stratified findings by prevalence measure (past 30 day, ever, regular or occasional, daily, other or unspecified) and age (adults or youth).

RESULTS

We included 129 studies reporting 355 estimates for 68 countries. In general, prevalence estimates among adults were highest in the Eastern Mediterranean, and among youth were about equal between Eastern Mediterranean and European regions. Past 30 day use was highest among Lebanese youth (37.2% in 2008), ever use was highest among Lebanese youth in 2002 and Lebanese university students in 2005 (both 65.3%), regular or occasional use was highest in among Iranian university students (16.3% in 2005), and daily use was highest among Egyptian youth (10.4% in 2005). Trend data were limited but most studies reported increased use over time, ranging from 0.3-1.0% per year among youth in the US to 2.9% per year among youth in Jordan (both for past 30 day use). Results were similar for ever use trends. Turkey (2.3% in 2008 to 0.8% in 2010) and Iraq (6.3% in 2008 and 4.8% in 2012) both witnessed decreased waterpipe use.

CONCLUSION

Waterpipe tobacco smoking is most prevalent in Eastern Mediterranean and European countries, and appears higher among youth than adults. Continued surveillance will be important to assess and inform policy measures to control waterpipe tobacco use.

Co-occurrence of tobacco product use, substance use, and mental health problems among youth: Findings from wave 1 (2013-2014) of the population assessment of tobacco and health (PATH) study

INTRODUCTION

Cigarette use is associated with substance use and mental health problems among youth, but associations are unknown for non-cigarette tobacco product use, as well as the increasingly common poly-tobacco use.

METHODS

The current study examined co-occurrence of substance use and mental health problems across tobacco products among 13,617 youth aged 12-17years from Wave 1 (2013-2014) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study. Participants self-reported ever cigarette, e-cigarette, smokeless tobacco, traditional cigar, cigarillo, filtered cigar, hookah, and other tobacco product use; alcohol, marijuana, and other drugs; and lifetime substance use, internalizing and externalizing problems.

RESULTS

In multivariable regression analyses, use of each tobacco product was associated with substance use, particularly cigarillos and marijuana (AOR=18.9, 95% CI: 15.3-23.4). Cigarette (AOR=14.7, 95% CI: 11.8-18.2) and cigarillo (AOR=8.1, 95% CI: 6.3-10.3) use were strongly associated with substance use problems and tobacco users were more likely to report internalizing (AOR=1.6, 95% CI: 1.4-1.8) and externalizing (AOR=1.4, 95% CI: 1.3-1.6) problems. Female tobacco users were more likely to have internalizing problems than male tobacco users. Poly-tobacco users were more likely than exclusive users to use substances (AOR=3.4, 95% CI: 2.7-4.3) and have mental health (AOR=1.2, 95% CI: 1.0-1.5) and substance use (AOR=4.7, 95% CI: 3.4-6.6) problems.

CONCLUSIONS

Regardless of the tobacco product used, findings reveal high co-occurrence of substance use and mental health problems among youth tobacco users, especially poly-tobacco users. These findings suggest the need to address comorbidities among high risk youth in prevention and treatment settings.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of State-Specific Prevalence, Regional Differences, and Correlates of Hookah Use in U.S. Adults, 2012-2013

OBJECTIVE

To investigate the state-specific prevalence, regional differences, and correlates of hookah use among U.S. adults.

METHODS

We analyzed the most recent nationally representative data of adults from the National Adult Tobacco Survey (NATS) 2012-2013 (n = 60192). State-specific prevalence of lifetime and current hookah use was calculated and mapped. Multivariate logistic regression was performed to determine the association between sociodemographic characteristics, regional differences, and hookah use.

RESULTS

Among U.S. adults (≥18 years), overall prevalence of lifetime hookah use was 12.3%, while current use was 3.9%. Mapping of state-specific prevalence revealed that the West tended to have higher rates of use, while the South tended to have lower ones. In the adjusted model, we observed that current hookah use was positively associated with younger adults, males, non-Hispanic adults, those with higher education and income statuses, being single, those living in the West, and current cigarette use.

CONCLUSION

The prevalence of hookah use varies by state, region, and sociodemographic characteristics among adults. Future research, including longitudinal studies, are needed to identify geographic and sociodemographic characteristics and trends among hookah users, investigate hookah-related health outcomes, and evaluate targeted public health efforts aimed at this emerging threat.

IMPLICATIONS

This study investigates state-level prevalence, regional differences, and sociodemographic characteristics of hookah use among U.S. adults, using the most recent NATS. Hookah use was positively associated with younger adults and those living in the West. This study adds to the understanding of the geographic and sociodemographic factors underlying hookah use, which can be used to develop much needed evidence-based regulations and programs that are responsive to the needs of different risk groups.

Synthetic Cannabinoid Use Among High School Seniors

OBJECTIVES

In this study, we examined the prevalence and correlates of current synthetic cannabinoid (SC) use among high school seniors in the United States.

METHODS

Monitoring the Future, an annual nationally representative survey of high school seniors, began querying current (30-day) SC use in 2014. Data were examined from the 2 most recent cohorts (2014-2015; N = 7805). Prevalence of self-reported use was examined and differences in demographics and recency and frequency of other drug use was compared between current marijuana-only users and current SC (plus marijuana) users using χ² and generalized linear model using Poisson.

RESULTS

We found that 2.9% of students reported current SC use; 1.4% of students (49.7% of users) reported using SCs on ≥3 days in the past month. SC users were more likely to report more recent (and often more frequent) use of lysergic acid diethylamide, cocaine, heroin, and/or nonmedical use of opioids compared with marijuana-only users. Compared with current marijuana-only users, SC users were more likely to report lower parent education (P < .05) and current use of a higher number of illegal drugs other than marijuana (Ps < .001). Students using SCs ≥10 times in the past month were more likely to be boys, frequent marijuana users (Ps < .01), African American, and users of multiple other illegal drugs (Ps < .001).

CONCLUSIONS

SC use is typically part of a repertoire of polydrug use, and polydrug use is less prevalent among marijuana-only users. Current SC users are at risk for poisoning from use of the newest generation of SCs and from concurrent drug use.

Trends and Correlates of Hookah Use Among High School Students in North Carolina

OBJECTIVES Although youth cigarette smoking has declined in the United States, use of alternative tobacco products, such as hookah, has increased. This study assesses changes in prevalence of use from 2011 to 2013, and examines factors associated with current hookah use among North Carolina high school students in 2013.METHODS Data came from the North Carolina Youth Tobacco Survey in 2011 (n = 4,791) and 2013 (n = 4,092). STATA (StataCorp LLC) logistic regression survey procedures account for the complex survey design and sampling weights.RESULTS Prevalence of reported current hookah use significantly increased from 3.6% (95% CI: 2.8-4.5) in 2011 to 6.1% (95% CI: 4.9-7.5) in 2013 while reported lifetime hookah use increased from 9.8% (95% CI: 8.0-12.0) in 2011 to 12.6% (95% CI: 11.0-14.4) in 2013. Correlates of current hookah use included having a weekly disposable income over $50 (adjusted odds ratio (AOR) = 2.05, 95% CI: 1.25-3.35), currently smoking cigarettes (AOR = 4.57, 95% CI: 1.80-11.62), and living with hookah users (AOR = 6.45, 95% CI: 3.21-12.93). Participant self-reports of "liking" or positively commenting on tobacco products on social media were associated with current hookah use (AOR = 1.83, 95% CI: 1.84-4.52). Frequent exposure to online tobacco advertisements (AOR = 1.61, 95% CI: 1.13-2.28) were also associated with current hookah use.CONCLUSIONS Comprehensive product specific communication and policy interventions are needed to educate youth about the dangers of hookah use and reduce social acceptability among youth. To decrease hookah use in North Carolina, policymakers should consider restoring funding for comprehensive tobacco prevention and control programs, and equalizing tobacco tax rates for all tobacco product types.

Youth E-cigarette, Blunt, and Other Tobacco Use Profiles: Does SES Matter?

OBJECTIVE

We examined the associations between socioeconomic status (SES) and adolescent polytobacco use profiles (including e-cigarettes and blunts).

METHODS

Adolescents (N = 1932) completed surveys conducted in 2014 in 3 Connecticut high schools. Within a Latent Class Analysis (LCA) framework, logistic regressions examined associations between SES and polytobacco use profiles comprising never, ever, and current e-cigarette, blunt, cigarette, cigar, cigarillo, hookah, and smokeless tobacco use.

RESULTS

We identified 5 classes: (1) current polytobacco users; (2) ever polytobacco users; (3) current e-cigarette, blunt, and cigarette users; (4) ever e-cigarette and blunt users; and (5) never users. Low SES, relative to high SES, was associated with greater likelihood of being: (1) an ever polytobacco user; (2) a current e-cigarette, blunt, and cigarette user; and (3) an ever e-cigarette and blunt user, relative to a never user.

CONCLUSIONS

Low SES is associated with membership in distinct polytobacco use latent classes. Regulatory initiatives that focus exclusively on cigarette use may miss the opportunity to influence adolescent use of other products, which may be especially relevant to low-income individuals. Future research should examine whether targeting a broader range of products reduces SES-related tobacco use disparities.

The Difference a Decade Makes: Smoking Cessation Counseling and Screening at Pediatric Visits

INTRODUCTION

There has been a sharp decline in adolescents who smoke cigarettes but no national-level study evaluating the impact of smoking cessation counseling by pediatricians or other clinicians who care for children.

METHODS

Combined data from ambulatory portions of the National Hospital Ambulatory Care Survey and National Ambulatory Medical Care Survey from 1997-1999 and 2009-2011 were analyzed to determine changes in the frequency of pediatric visits that included clinician-reported tobacco counseling and how such counseling varied by child, family, and clinician characteristics.

RESULTS

In 1997-1999, 1.5% of all medical visits for children aged below 19 years included tobacco counseling; this increased to 3.8% in 2009-2011 (P < .001). A marked increase from 4.1% to 11.1% was noted at well-child visits (P < .001). There were significant increases in counseling by pediatricians but not mid-level providers or general/family physicians. Provision of counseling did not result in greater visit length during either time point. During 2009-2011, visits with a diagnosis of asthma were four times as likely (OR 4.2, 95% CI 2.8-6.2) and visits for otitis media two times as likely (OR 2.1, 95% CI 1.2-3.7) to include smoking cessation counseling than sick visits for all other diagnoses.

CONCLUSION

These results demonstrate a significant increase in tobacco counseling by pediatric providers within the last decade, especially at well-child visits. However, the American Academy of Pediatrics' recommendation that pediatricians counsel about the harms of tobacco use and secondhand smoke exposure has not yet been exhaustively implemented.

IMPLICATIONS

A significant increase in smoking cessation counseling at pediatric medical appointments, especially at well-child visits, occurred from 2009-2011 compared with 1997-1999, paralleling a large decrease in smoking prevalence. These improvements in counseling rates have been predominantly noted for pediatricians but not mid-level providers or general practitioners. Counseling was not associated with increased visit lengths. Although improved counseling practices by pediatricians have been demonstrated, there is still room for improvement.

Prevalence of and beliefs about electronic cigarettes and hookah among high school students with asthma

PURPOSE

To assess current cigarette, hookah, and electronic cigarette (e-cigarette) use among high school students with and without asthma. Beliefs and use of tobacco products by a household member were also examined.

METHODS

The 2014 Florida Youth Tobacco Survey was administered to high school students to assess current use of cigarettes, hookah, and e-cigarettes (i.e., within past 30 days). Student's home exposure and beliefs about cigarettes, hookah, and e-cigarettes were also assessed. Students were randomly selected using a two-stage cluster probability design.

RESULTS

Adolescents with asthma had a higher prevalence of current hookah (14.0%) and e-cigarette use (12.4%) compared with their peers (10.9%, 10.2%, respectively). Adolescents with asthma were also at increased risk for current use of cigarettes (adjusted odds ratio [AOR]: 1.24), hookah (AOR: 1.32), and e-cigarettes (AOR: 1.34). Adolescents with asthma reported positive beliefs about tobacco products and were more likely to report living with individuals who used cigarettes (31.5%), hookah (12.1%), and e-cigarettes (15.5%) compared with their peers (26.5%, 8.5%, 12.5%, respectively).

CONCLUSIONS

Adolescents with asthma reported tobacco product use, positive beliefs about tobacco products, and high potential home exposure to tobacco products. There is a pressing need for education regarding potential harm of alternative tobacco products among adolescents with asthma.

Prevalence and correlates of hookah use: a nationally representative sample of US adults ages 18-40 years old

BACKGROUND

Hookah use may be increasing among adults in the US. Information on the prevalence and correlates of hookah use in the adult population is relatively limited.

OBJECTIVES

To determine the prevalence of current (past 30-day) and lifetime use of hookah among adults ages 18-40 in the US and to investigate the socio-demographic characteristics associated with lifetime use.

METHODS

Data were drawn from the Tobacco Use Supplement of the Current Population Survey data from May 2010, August 2010, and January 2011 (n = 85,545). Logistic regression was used to examine various demographic correlates of lifetime hookah use.

RESULTS

Among 18-40 year olds, the past month prevalence rate of hookah use was 0.6% and the lifetime prevalence rate of hookah use was 3.9%. Being male, non-Hispanic white, having higher levels of educational attainment, having never been married, not having any children, earning less than $20,000 annually, residing in the Midwest or western US, being a student, and being a cigarette smoker were associated with increased likelihood of lifetime hookah use. The prevalence of hookah use among current, cigarette smokers was 7.9%, more than double that of the general adult population.

CONCLUSIONS

Hookah use is significantly more common among cigarette smokers and among various demographic subgroups among general adult population. Given the risks associated with hookah and poly-tobacco use, targeted public health efforts are recommended. Additionally, health-care providers may consider expanding screening tests to include hookah use.

Waterpipe smoking among secondary school students in Hong Kong

OBJECTIVES

To examine the prevalence of waterpipe smoking and its associated factors among adolescents in Hong Kong.

METHODS

We analyzed data of the School-based Survey on Smoking among Students 2012/2013 from a representative sample of 45,857 secondary school students in Hong Kong (mean age 14.8, SD 1.9). We conducted Chi-square tests and t test to compare current (past 30 days) waterpipe users and nonusers by sociodemographic variables and other covariates. Univariate and multivariable logistic regression models were used to examine the factors associated with current waterpipe smoking.

RESULTS

Overall, 1.2 % of students reported current waterpipe smoking, of whom 43 % reported concurrent use of cigarettes. Waterpipe was the most popular alternative tobacco product (non-cigarette) used by students. Current waterpipe smoking was associated with older age, male sex, higher self-perceived family financial status, poor knowledge about the harm of cigarette smoking, positive attitudes toward smoking, current cigarette smoking, other tobacco use, and alcohol consumption.

CONCLUSIONS

Waterpipe smoking was the most popular alternative tobacco product among Hong Kong adolescents. Despite the low prevalence, it should be routinely monitored. Education programs and cessation interventions need to address waterpipe smoking in addition to cigarette smoking.

Nonmedical opioid use and heroin use in a nationally representative sample of us high school seniors

BACKGROUND

Nonmedical use of opioids has become increasingly problematic in recent years with increases in overdoses, treatment admissions, and deaths. Use also appears to be contributing to heroin initiation, which has increased in recent years. Further research is needed to examine which adolescents are at highest risk for nonmedical use of opioids and heroin and to explore potential links between nonmedical opioid use and heroin use.

METHODS

Data were analyzed from a nationally representative sample of American high school seniors in the Monitoring the Future study (2009-2013, Weighted N=67,822). We examined associations between frequency and recency of nonmedical use of opioids and heroin. Sociodemographic correlates of use of each drug were also examined.

RESULTS

12.4% of students reported lifetime nonmedical opioid use and 1.2% reported lifetime heroin use. As frequency of lifetime nonmedical opioid use increased, so too did the odds for reporting heroin use, with over three-quarters (77.3%) of heroin users reporting lifetime nonmedical opioid use. Recent (30-day) nonmedical opioid use was a robust risk factor for heroin use and almost a quarter (23.2%) of students who reported using opioids ≥40 times reported lifetime heroin use. Black and Hispanic students were less likely to report nonmedical opioid or heroin use than white students, but they were more likely to report heroin use in absence of nonmedical opioid use.

DISCUSSION

Recent and frequent nonmedical opioid use are risk factors for heroin use among adolescents. Prevention needs to be targeted to those at highest risk.

A qualitative assessment of the perceived risks of electronic cigarette and hookah use in pregnancy

BACKGROUND

Studies reveal that electronic cigarette (e-cigarette) and hookah use are increasing among adolescents and young adults. However, the long-term health effects are unknown, especially with regards to pregnancy. Because of the increased use in women of reproductive age, and the unknown long-term health risks, our primary objectives were to determine the perceived risks of e-cigarette and hookah use in pregnancy, and learn common colloquial terms associated with e-cigarettes. Furthermore, we sought to determine if there is a stigma associated with e-cigarette use in pregnancy.

METHODS

Eleven focus groups including 87 participants were conducted immediately following regularly scheduled CenteringPregnancy® prenatal care with women at three different clinics in the greater Houston area. A minimum of two facilitators led the groups, using ten lead-in prompts, with Spanish translation as necessary. Facilitators took notes which were compared immediately following each group discussion and each group was audio recorded and transcribed. Three facilitators utilized NVivo 9.0 software to organize the transcribed data into nodes to identify major themes. To increase rigor, transcripts were further analyzed by two obstetricians who were instructed to find the major themes.

RESULTS

Analyses revealed contradicting themes concerning e-cigarette use. In general, e-cigarettes were perceived as safer alternatives to regular tobacco cigarettes, especially if used as smoking cessation devices. A major theme is that use in pregnancy is harmful to the fetus. However, it was perceived that use for smoking cessation in pregnancy may have fewer side effects. We found that a common term for e-cigarettes is "Blu." In our discussion of hookah use, participants perceived use as popular among teenagers and that use in pregnancy is dangerous for the fetus.

CONCLUSIONS

Although a strong theme emerged against hookah use, we found contradicting themes in our discussions on e-cigarette use in pregnancy. It is possible that e-cigarette use will not carry the same stigma as regular cigarette smoking in pregnancy. In addition, the impression of e-cigarettes as a healthier alternative to smoking may influence use in pregnancy. Clinicians need to be prepared for questions of e-cigarette safety and efficacy as smoking cessation devices from their pregnant patients who smoke, and women who smoke and are planning to become pregnant.

Waterpipe tobacco smoking: A new smoking epidemic among the young?

Waterpipe (hookah, narghile) tobacco smoking (WTS) is becoming prevalent worldwide and is one of the most popular forms of tobacco use among youth. WTS prevalence has increased dramatically among youth in the United States within the past decade. Misperceived as less harmful than cigarette smoking, WTS is associated with many of the same chronic health effects such as lung cancer, chronic obstructive pulmonary disease, cardiovascular disease, bronchitis, and asthma. Much of this risk is due to the fact that a single WTS session exposes users to large volumes of smoke that contain toxic chemicals such as carbon monoxide, cancer-causing polycyclic aromatic hydrocarbons, and volatile aldehydes. Unlike cigarette smoking, WTS poses unique risks of acute negative health outcomes including carbon monoxide poisoning and the spread of communicable diseases such as herpes and tuberculosis. Because waterpipe tobacco smoke contains the addictive chemical nicotine, youth who smoke tobacco from a waterpipe may be at risk for dependence. As a result, many youth may initiate WTS and continue to use despite negative health effects. Considering many of the potential negative health effects associated with WTS affect the pulmonary system, pulmonologists and primary care providers may treat patients who are waterpipe tobacco smokers and should be aware of the risk associated with WTS. The purpose of this review is to describe a waterpipe, the prevalence and correlates of WTS, the toxicants found in waterpipe tobacco smoke, the health effects of WTS, and implications for pulmonologists and other clinicians.

Risk Factors Associated With Hookah Use

BACKGROUND

Potential harms associated with hookah smoking are largely unrecognized and it is emerging as a trendy behavior. To help inform policy and preventive interventions, we used responses from a population survey of US adults to examine risk factors associated with hookah involvement.

METHOD

An online survey of 17 522 US adults was conducted in 2013. The nationally representative sample was drawn from GfK Group's KnowledgePanel plus off-panel recruitment. Multinomial logistic regression was used to examine the relationships between tobacco use patterns across multiple products (cigarettes, cigars, and dissolvables), perceived harms towards regular pipe/hookah use, and demographic characteristics with hookah involvement (never used, ever used with/without reusing intent).

RESULT

Nearly one in five (16%) of the respondents had smoked hookah at least once in their life ("ever users"). Ever users of hookah were at higher risk of having used cigarettes, cigars, and dissolvable tobacco products (all P < .01). Odds for hookah use were greater for those who perceived regular pipe/hookah use as less dangerous (P < .05). Odds for hookah involvement were higher among young adults (P < .001), individuals with higher educational attainment (P < .01), and Hispanics/Latinos (P < .05).

CONCLUSIONS

Information about the public health harms associated with hookah smoking should be delivered to individuals at-risk for hookah smoking. It is likely that misconceptions about the safety of hookah smoking could be driving, at least in-part, its increase in popularity.

Sustained Waterpipe Tobacco Smoking and Trends Over Time

INTRODUCTION

Use of waterpipe tobacco smoking (WTS) is now prevalent among U.S. adolescents. However, the more clinically relevant questions are whether users exhibit sustained patterns of use and whether use is increasing over time relative to other tobacco products. We aimed to examine factors associated with sustained WTS among U.S. adolescents and to compare prevalence trends between WTS and other tobacco products.

METHODS

The Monitoring the Future project began assessing WTS among 12th-grade students in 2010. In 2014, we conducted multivariable regression analyses to examine correlates of sustained WTS, which we defined as use at least six times in the past 12 months. We used trend analysis to compare use of WTS and other types of tobacco.

RESULTS

Of the 8,737 participants queried from 2010 to 2013, 18.8% (1,639) reported past-year WTS, whereas 7.2% (627) reported sustained use. Sustained WTS was inversely associated with female sex (versus male, OR=0.78, 95% CI=0.63, 0.96); African American race (versus Caucasian, OR=0.26, 95% CI=0.14, 0.48); and increased number of parents in the home (p<0.001). Sustained WTS was positively associated with increased school-level parental education (p=0.002); lower grades (p=0.005); truancy (p<0.001); lower religiosity (p<0.001); more evenings out per week (p<0.001); and dating (p=0.03). Visual inspection and non-overlapping CIs suggest that both past-year and sustained WTS are significantly increasing relative to cigarette use but not small cigar use.

CONCLUSIONS

Given the prevalence of sustained WTS and indications of its increase over time, it should be included in efforts related to tobacco surveillance and intervention.

Tracking Hookah Bars in New York: Utilizing Yelp as a Powerful Public Health Tool

BACKGROUND

While cigarette use has seen a steady decline in recent years, hookah (water pipe) use has rapidly increased in popularity. While anecdotal reports have noted a rise in hookah bars, methodological difficulties have prevented researchers from drawing definitive conclusions about the number of hookah bars in any given location. There is no publicly available database that has been shown to reliably provide this information. It is now possible to analyze Internet trends as a measure of population behavior and health-related phenomena.

OBJECTIVE

The objective of the study was to investigate whether Yelp can be used to accurately identify the number of hookah bars in New York State, assess the distribution and characteristics of hookah bars, and monitor temporal trends in their presence.

METHODS

Data were obtained from Yelp that captures a variety of parameters for every business listed in their database as of October 28, 2014, that was tagged as a "hookah bar" and operating in New York State. Two algebraic models were created: one estimated the date of opening of a hookah bar based on the first Yelp review received and the other estimated whether the bar was open or closed based on the date of the most recent Yelp review. These findings were then compared with empirical data obtained by Internet searches.

RESULTS

From 2014 onward, the date of the first Yelp review predicts the opening date of new hookah bars to within 1 month. Yelp data allow the estimate of such venues and demonstrate that new bars are not randomly distributed, but instead are clustered near colleges and in specific racial/ethnic neighborhoods. New York has seen substantially more new hookah bars in 2012-2014 compared with the number that existed prior to 2009.

CONCLUSIONS

Yelp is a powerful public health tool that allows for the investigation of various trends and characteristics of hookah bars. New York is experiencing tremendous growth in hookah bars, a worrying phenomenon that necessitates further investigation.

A literature review on prevalence of gender differences and intersections with other vulnerabilities to tobacco use in the United States, 2004-2014

This report describes results from a systematic literature review examining gender differences in U.S. prevalence rates of current use of tobacco and nicotine delivery products and how they intersect with other vulnerabilities to tobacco use. We searched PubMed on gender differences in tobacco use across the years 2004-2014. For inclusion, reports had to be in English, in a peer-reviewed journal or federal government report, report prevalence rates for current use of a tobacco product in males and females, and use a U.S. nationally representative sample. Prevalence rates were generally higher in males than in females across all products. This pattern remained stable despite changes over time in overall prevalence rates. Gender differences generally were robust when intersecting with other vulnerabilities, although decreases in the magnitude of gender differences were noted among younger and older users, and among educational levels and race/ethnic groups associated with the highest or lowest prevalence rates. Overall, these results document a pervasive association of gender with vulnerability to tobacco use that acts additively with other vulnerabilities. These vulnerabilities should be considered whenever formulating tobacco control and regulatory policies.