Waterpipe Tobacco Smoking among Arab Youth; a Cross-Country Study

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.

National and Regional Fraction of Cancer Incidence and Death Attributable to Current Tobacco and Water-Pipe Smoking in the Eastern Mediterranean Countries in 2020

INTRODUCTION

We aimed to calculate the Population Attributable Fraction (PAF) of cancers due to tobacco use in the Eastern Mediterranean Region (EMRO), where water-pipe smoking is prevalent but its effect was not considered in previous studies.

AIMS AND METHODS

We applied Levin's formula to estimate PAFs of cancers due to tobacco use (defined as all type tobacco including both cigarette and water-pipe). We also calculated PAF of water-pipe smoking separately. Exposure prevalence data were retrieved from representative national and subnational surveys. Data on cancer incidence and death were also and cancer cases were obtained GLOBOCAN 2020. We also obtained associated relative risks from published meta-analyses.

RESULTS

Of the total 715 658 incident adult cancer cases that were reported in 2020 in EMRO, 14.6% (n = 104 800) was attributable to tobacco smoking (26.9% [n = 92 753]) in men versus 3.3% (n = 12 048) in women. Further, 1.0% of incident adult cancers were attributable to current water-pipe use (n = 6825) (1.7% [n = 5568]) in men versus 0.4% (n = 1257 in women).

CONCLUSIONS

PAFs of cancers due to tobacco smoking in EMRO were higher in our study than previous reports. This could be due to the neglected role of water-pipe in previous studies that is a common tobacco smoking method in EMRO. The proportion of cancers attributable to water-pipe smoking in EMRO might be underestimated due to lack of research on the risk of cancers associated with water-pipe smoking and also less developed cancer registries in EMRO.

IMPLICATIONS

In this study, we found higher PAFs for cancers due to tobacco smoking in the Eastern Mediterranean (EMR) region than previous reports. This difference could be due to ignoring the role of water-pipe smoking in previous studies. In 2020, 1% of incident cancers and 1.3% of cancer-related deaths in EMRO were attributable to water-pipe smoking. We also found a big difference in PAFs of cancers due to tobacco and water-pipe smoking across EMRO countries, with Tunisia, Lebanon, and Jordan having the highest, and Djibouti, Sudan, and Somalia having the lowest proportions of cancers attributable to tobacco and water-pipe smoking.

Impact of COVID-19 lockdown on smoking (waterpipe and cigarette) and participants' BMI across various sociodemographic groups in Arab countries in the Mediterranean Region

INTRODUCTION

Tobacco smokers are at high risk of developing severe COVID-19. Lockdown was a chosen strategy to deal with the spread of infectious diseases; nonetheless, it influenced people's eating and smoking behaviors. The main objective of this study is to determine the impact of the COVID-19 lockdown on smoking (waterpipe and cigarette) behavior and its associations with sociodemographic characteristics and body mass index.

METHODS

The data were derived from a large-scale retrospective cross-sectional study using a validated online international survey from 38 countries (n=37207) conducted between 17 April and 25 June 2020. The Eastern Mediterranean Region (WHO-EMR countries) data related to 10 Arabic countries that participated in this survey have been selected for analysis in this study. A total of 12433 participants were included in the analysis of this study, reporting their smoking behavior and their BMI before and during the COVID-19 lockdown. Descriptive and regression analyses were conducted to examine the association between smoking practices and the participant's country of origin, sociodemographic characteristics, and BMI (kg/m²).

RESULTS

Overall, the prevalence rate of smoking decreased significantly during the lockdown from 29.8% to 23.5% (p<0.05). The percentage of females who smoke was higher than males among the studied population. The highest smoking prevalence was found in Lebanon (33.2%), and the lowest was in Oman (7.9%). In Egypt, Kuwait, Lebanon, and Saudi Arabia, the data showed a significant difference in the education level of smokers before and during the lockdown (p<0.05). Smokers in Lebanon had lower education levels than those in other countries, where the majority of smokers had a Bachelor's degree. The findings show that the BMI rates in Jordan, Lebanon, Oman, and Saudi Arabia significantly increased during the lockdown (p<0.05). The highest percentages of obesity among smokers before the lockdown were in Oman (33.3%), followed by Bahrain (28.4%) and Qatar (26.4%), whereas, during the lockdown, the percentage of obese smokers was highest in Bahrain (32.1%) followed by Qatar (31.3%) and Oman (25%). According to the logistic regression model, the odds ratio of smoking increased during the pandemic, whereas the odds ratio of TV watching decreased. This finding was statistically significant by age, gender, education level, country of residence, and work status.

CONCLUSIONS

Although the overall rates of smoking among the studied countries decreased during the lockdown period, we cannot attribute this change in smoking behavior to the lockdown. Smoking cessation services need to anticipate that unexpected disruptions, such as pandemic lockdowns, may be associated with changes in daily tobacco consumption. Public health authorities should promote the adoption of healthy lifestyles to reduce the long-term negative effects of the lockdown.

"Waterpipe Is Like a Wife": Qualitative Assessment of Perspectives on Waterpipe Smoking Dependence

BACKGROUND

Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey- or laboratory-based studies. This study employed qualitative methods to explore WP users' perceptions of dependence in Aleppo, Syria.

METHODS

A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis.

FINDINGS

Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included positively reinforced features, such as smoking's association with social gatherings and cultural connectedness, and negatively reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting one's behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at the expense of other reinforcers such as social interaction.

CONCLUSION

The general and specific features of WP dependence need to be considered in developing instruments to measure WP dependence, in clinical assessment of WP dependence, and in developing cessation programs.

Factors associated with the onset of smoking and alcohol consumption: A cross-sectional study among Lebanese adolescents in schools

OBJECTIVES

This study aimed to evaluate factors and profiles associated with the earlier onset of cigarette/waterpipe smoking and alcohol consumption among Lebanese adolescents in schools.

METHODS

A total of 4000 adolescents (mean age = 15.31 ± 2.01 years) participated in this cross-sectional study. The standardized questionnaire was taken from the Health Behavior in School Children (HBSC) study in different countries (France, Belgium, and the USA) and adjusted to the Lebanese population. K-means clustering analysis was conducted to classify participants into three clusters according to their patterns (surrounded by smokers, surrounded by drinkers, and ease of talking to family members and friends) and Cox regression analyzes were conducted.

RESULTS

Participants were divided into three clusters. Cluster 1 (16.75% of participants) included adolescents with the lowest ease of talking to a family member or friend, with the latter smoking and drinking a lot (worst cluster). Cluster 2 (54.95%) included adolescents with moderate ease of talking to a family member and more to friends, surrounded by low-to-moderate smoking and alcohol consumption, particularly for a best friend (positive influence cluster). Finally, cluster 3 (28.30%) included adolescents with low ease of talking to friends, moderate ease of talking to a family member, and low-to-moderate smoking and alcohol consumption (low influence cluster). The results of the Cox regressions (taking the age at onset of smoking cigarettes and waterpipes as the dependent variables) showed that older age at onset of cigarette and waterpipe smoking was significantly associated with female participants and those belonging to clusters 2 and 3 compared to cluster 1. Moreover, a younger age at first alcohol use and getting drunk was significantly associated with living outside Beirut, whereas female gender and belonging to clusters 2 or 3 compared to cluster 1 were significantly associated with older age at first alcohol use and getting drunk.

CONCLUSION

This study identified risk factors (ease of talking as well as smoking and alcohol-drinking status of parents, siblings, and friends) and profiles related to early alcohol and cigarette/waterpipe use. These risk factors and profiles could help implement prevention campaigns to reduce substance use and improve adolescent health.

Association between preventable risk factors and metabolic syndrome

The risk factors associated with metabolic syndrome (Met-S) including hypertension, hyperglycemia, central obesity, and dyslipidemia are preventable, particularly at their early stage. There are limited data available on the association between Met-S and preventable risk factors in young adults. We randomly selected 2,010 Saudis aged 18-30 years, who applied to be recruited in military colleges. All the procedures followed the guidelines of International Diabetes Federation. The results showed that out of 2,010 subjects, 4088 were affected with Met-S. The commonest risk factors were high blood sugar (63.6%), high systolic and diastolic blood pressures (63.3 and 37.3%), and high body mass index (57.5%). The prevalence of prediabetes and diabetes were 55.2 and 8.4%, respectively. Obesity, diabetes, hypertension, and hypertriglyceridemia were significantly associated with Met-S. The frequency of smoking was significantly linked with the development of Met-S. The prevalence of Met-S was found to be significantly higher in individuals with sedentary lifestyle. In conclusion, the results of this study clearly indicate that military recruits, who represent healthy young adults, are also prone to Met-S. The findings of this study will help in designing preventive measures as well as public awareness programs for controlling the high prevalence of Met-S in young adults.

What factors are associated with waterpipe smoking cessation? A secondary data analysis

INTRODUCTION

Waterpipe smoking is gaining popularity and becoming a major global public health concern. An understanding of factors that predict waterpipe smoking cessation is necessary for targeting tobacco control efforts.

METHODS

This is a secondary data analysis of a randomised controlled-trial comparing the efficacy of varenicline against placebo in helping waterpipe smokers to quit. A total of 510 adult daily waterpipe smokers were recruited to the trial in 2016. Logistic regression models were applied to assess factors (i.e., demographic, environmental, behavioural, and physiological) associated with primary outcome (waterpipe smoking cessation) and secondary outcomes (waterpipe cessation alongside abstinence from cigarette and short-term and long-term waterpipe smoking cessation). Cessation was defined as 7-day point prevalence abstinence from smoking reported at 5,12, and/or 25 weeks follow ups.

RESULTS

Over a period of six months, 189 (39.2%) participants abstained from waterpipe smoking for at least one week. Being male (adjusted odds ratio (aOR):2.99 (95%CI:1.47-6.08)), dual smoker (waterpipe and cigarettes) (aOR:2.98 (95%CI:1.87-4.74)), more withdrawal symptoms measured by the Mood and Physical Symptoms Scale (aOR:1.08 (95%CI:1.02-1.13)), less nicotine dependency measured by Lebanon Waterpipe Dependency Scale (aOR:0.90 (95%CI:0.85-0.96)), having history of quit attempt (aOR:2.14 (95%CI:1.16-3.96)), smoking restriction in the house (aOR:2.69 (95%CI:1.01-7.14)), and not sharing waterpipe with others (aOR:2.72 (95%CI:1.31-5.66)) predicted waterpipe smoking cessation.

CONCLUSIONS

In addition to nicotine dependency, social factors such as home restrictions on smoking, and not sharing waterpipe were identified as predictors of waterpipe smoking cessation. To help waterpipe smokers quit, social environment may be just as or even more important than well-known physical and psychological factors.

IMPLICATIONS

A range of factors, predominantly social factors play a significant role in facilitating or deterring waterpipe smokers from quitting smoking. Our findings suggest that interventions that focus on social as well as physical/psychological factors may encourage waterpipe smokers in achieving abstinence.

Attitudes and Knowledge of the Harmful Effects of Waterpipe Tobacco Smoking among university students: A study from Jordan

Waterpipe tobacco smoking (WTS) is an emerging behavior worldwide, especially among the youth. It continues to spike in the Middle-Eastern region. WTS is associated with many harmful health-related outcomes.Objective: Herein, the attitude, knowledge, and factors affecting the knowledge of university students toward the detrimental effects of WTS were examined. This was a cross-sectional study where university students filled an online questionnaire that was available between October 2019 and May 2020. A total of 966 questionnaires were filled. About 40% of participants were current waterpipe smokers. Around 30% of participants stated that WTS is not addictive, and about third of them indicated that smoking waterpipe is an essential part of social gathering and is socially accepted behavior. Half of participants (55.8%) were knowledgeable about the major harmful consequences of WTS. Older students were more knowledgeable as compared to younger ones. In contrast, students from non-medical colleges and waterpipe smokers were less knowledgeable in comparison to those in medical colleges and non-smokers, respectively. More targeted health campaigns to control the use of WTS among university students should be implemented.

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.

Novel Insights into Young Adults' Perceived Effectiveness of Waterpipe Tobacco-Specific Pictorial Health Warning Labels in Lebanon: Implications for Tobacco Control Policy

This study aims to explore the perceived effectiveness of waterpipe (WP) tobacco specific health warning labels (HWLs) among young adult WP smokers and nonsmokers in Lebanon. Before participating in focus group discussions, participants (n = 66; WP smokers n = 30; nonsmokers n = 36; age 18-33) completed a brief survey to rate the effectiveness of 12 HWLs' and rank them according to four risk themes (WP health effects, WP harm to others, WP-specific harm, and WP harm compared to cigarettes). Differences in HWLs ratings by WP smoking status were examined and the top-ranked HWL in each theme were identified. HWLs depicting mouth cancer and harm to babies were rated as the most effective by both WP smokers and non-smokers. WP smokers rated HWLs which depicted harm to children and infants as more effective than non-smokers. The top-ranked HWLs for perceived overall effectiveness were those depicting "oral cancer", "harm to babies", "orally transmitted diseases" and "mouth cancer". HWLs depicting oral lesions and harm to babies were rated as most effective, while HWLs showing the harmful effects of WP secondhand smoke on infants and children were rated as less effective by nonsmokers compared to smokers. Our study provides evidence on the potential effectiveness of HWLs for further evaluation in Lebanon and the Eastern Mediterranean region. The results will inform and guide the development and implementation of tobacco control policy.

Tobacco Research in the Eastern Mediterranean Region: A Scoping Review of Published Studies from Seven Countries

While surveillance on a global scale has been showing a decline in tobacco smoking in the past decade, rates in the Eastern Mediterranean Region (EMR) remained stable with some countries showing rising trends. This study aimed to analyze the landscape of tobacco research in the EMR, present data on publication trends, and identify research gaps and opportunities to guide future tobacco research in the region. We conducted a scoping review of tobacco research in seven countries from January 2000 to December 2013. Three hundred and forty eight studies were identified, the majority of which were published in international journals and in English language. There was an increase in publications over time, with a significant positive linear trend (p = 0.03). Descriptive cross-sectional and case-control studies were the most common study designs (67.0%), and only 8% were longitudinal studies. Papers that reported, in part or solely, on waterpipe tobacco smoking (WTS) constituted 25.6% of the total publication pool. Tobacco consumption was treated as an exposure variable in half of the papers and mostly in relation to cancer and cardiovascular diseases, as an outcome measure in 37.7%, and as a confounding variable in 14.7% of the papers. Studies that examined associations of tobacco with other behaviors (5.3%) were lacking. The scarcity of high-evidence tobacco research in the EMR, together with the relatively deficient data on WTS and associations with other factors warrant the need for discussions on research priority setting and guidance on funding allocations in the region.

Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries

INTRODUCTION

Males have a higher prevalence of waterpipe tobacco smoking (WTS) than females in most Eastern Mediterranean Region (EMR) countries, with a smaller gender gap than that of cigarette smoking. The objective of this study was to determine gender differences among university students with respect to WTS initiation, smoking behavior, tobacco flavors, and expenditure on WTS, in four EMR countries.

METHODS

A cross-sectional online survey was conducted based on convenient samples of ever waterpipe smokers among university students in four EMR countries (Egypt, Jordan, Occupied Palestinian Territories, and the United Arab Emirates) in 2016. The total samples included 2470 participants. Study participants were invited through flyers, university portals, emails and Facebook, followed by emails with links to the internet survey.

RESULTS

Females (80.4%) were more likely than males (66.4%, p<0.001) to be in the younger age group (18–22 years) and they were less likely to be current waterpipe smokers (females, 60.0%; males 69.5%, p<0.001). Two-thirds of students across both genders smoked their first waterpipe at the age of 15–19 years, with more females starting with family members. Over one-third of males and 14.9% of the females usually smoked ≥10 heads (p<0.001). About half (46.6%) of females smoked for less than half an hour compared to 30.5% of males (p<0.001). Only 1% of females smoked non-flavored tobacco compared to 11% of males (p<0.001). There was a significant (p=0.05) positive correlation (r=0.808) with respect to tobacco flavor usually smoked between males and females with apple/double apple being the most popular.

CONCLUSIONS

There were gender differences in WTS in several aspects. The study has implications for educational establishments, tobacco control and women civil society groups, as well as policymakers.

Exploration of Lifestyle Choices, Reproductive Health Knowledge, and Polycystic Ovary Syndrome (PCOS) Awareness Among Female Emirati University Students

Objective

Healthy lifestyle and adequate reproductive health knowledge are prerequisites for maintenance of physical and mental well-being of women across the world. With increasing prevalence of metabolic disorders such as polycystic ovary syndrome (PCOS), it is important that sufficient awareness of these issues is generated, especially in conservative communities in Arab regions. The main objective of this study is to assess reproductive health (RH) knowledge and awareness of PCOS among female Emirati students and also to explore their lifestyle choices.

Materials and Methods

A total of 493 Emirati students were recruited based on convenience sampling and completed a survey containing questions related to demography, lifestyle preferences, RH knowledge, and PCOS awareness.

Results

Of the students, 13% self-reported being diagnosed with PCOS, with 3.5% also taking medication for the same, 6% reported having high androgen levels, 30.7% reported polymenorrhea, and 3.5% reported oligomenorrhea for frequency of menstrual cycle. Also, 12.4% students experienced abnormal bleeding (heavy/none) during menstruation and 24% reported excessive body hair. It was found that 4.3% of students were taking medication for hyperglycemia and 75% of students reported a family history of diabetes. Students displayed low reproductive health knowledge and poor awareness of PCOS. Lifestyle preferences indicated low physical activity and high indulgence in fast food.

Conclusion

Lifestyle choices adopted by Emirati University students may predispose them to disorders such as PCOS. Early detection and management of PCOS coupled with a dynamic awareness campaign for RH can help in improving fertility rates of Emirati women. The study identifies major gaps in knowledge and awareness of RH and PCOS in Emirati women that need to be addressed by creating a culturally congruent heathcare policy with emphasis on education and health promotion. Mandatory PA programs and increasing availability of healthy eating options in campus should be considered by all universities, particularly in Arab regions, for improving lifestyle and preventing metabolic disorders in young students.

Trauma exposure, mental health and tobacco use among vulnerable Syrian refugee youth in Jordan

BACKGROUND

Little is known about tobacco use among youth exposed to armed conflicts, or the influence of trauma on tobacco use in this context. This study examined patterns of smoking by tobacco product and gender among Syrian refugee youth living in host communities in Jordan and assessed the associations of post-traumatic stress disorder (PTSD) and depression symptoms, trauma exposure and social support with current smoking status in boys and girls.

METHODS

Syrian refugee students (mean [standard deviation] age = 14.9 [1.33] years) were identified through the public school system. Data were collected using an online Arabic questionnaire that included questions about demographics, trauma exposure, current smoking (cigarette and waterpipe), PTSD, depression and perceived social support. Logistic regression was used to assess the adjusted effects of independent variables on current smoking status.

RESULTS

One in 7 boys and one in 14 girls were current smokers, with boys reporting greater tobacco use than girls. Among boys, current smokers reported significantly higher family member loss and lower perceived family social support than nonsmokers; among girls, current smokers also reported significantly higher family member loss as well as greater PTSD symptoms and lower perceived significant other/special person social support.

CONCLUSIONS

Tobacco use is established among this vulnerable group. The findings highlight the potential role of psychosocial support for tobacco prevention and cessation strategies.

Waterpipe and cigarette tobacco smoking and depressive symptoms among public school students in central Jordan

Purpose

Tobacco is the most widely used substance in the world that has been linked to several psychological problems. Few studies have assessed the relationship between dual (waterpipe and cigarette) tobacco smoking. This study aims to examine the relationship between dual tobacco use and symptoms of depression amongst its users.

Design/methodology/approach

A cross-sectional study using a random sample of school students was conducted to assess youth tobacco smoking in the central region of Jordan. A self-reported questionnaire including biographical information, smoking status and experience of depression symptoms was used with a sample of 9th to 12th-grade students. χ2 and regression test were used to analyze the data.

Findings

The final sample comprised 576 school students, of whom 60% were males. The age range was between 16 and 18 years (mean = 15.84 years, SD ± 0.97). 30% of the participants were dual tobacco smokers. A significant difference was found between males and females, with males being more likely to be dual tobacco smokers compared to females. Two depressive symptoms (“feeling sad” and “having crying spells”) had a significant likelihood amongst the youth who were dual smokers.

Originality/value

To the best of the authors' knowledge, this is the first study that aims to report the relationship between dual tobacco smoking and depressive symptoms. Prevention programs are crucial for raising awareness of the harmful effects of dual tobacco smoking and smoking cessation amongst the youth

Addictions Causing Head-and-Neck Cancers

Head-and-neck cancers pose a serious economic burden, with most countries investing significant resources to reduce the incidence, primarily focusing on understanding addictive etiologies. The traditional literature focused on tobacco and alcohol use, with few studies on contemporary factors such as e-cigarette, waterpipe smoking, and human papillomavirus. This article attempts to collate and present an update on the globally identified etiologic factors.

The aim of this study was to identify and review the addictive etiologic factors causing head-and-neck cancers.

An electronic search was performed on Medline, Embase, and Google Scholar to identify the etiologies causing head-and-neck cancers and narrowed down on those driven by addiction. Further, we identified their constituents, mechanism of action, and the risks attributable to various forms of products.

Substances identified included smoked and chewed tobacco, alcohol, mate, marijuana, areca nut and betel quid, and viruses. An alarming majority of youth are now utilizing these substances. Furthermore, migrant movements have led to the spread of traditional practices across the regions, especially from the Asian subcontinent.

Ironically, despite modern advances and technology, we still see that a large proportion of population succumb to these cancers, emphasizing the need for more effective and targeted policies to combat this menace at the grassroots level.

Waterpipe use among the youth in Ghana: Lessons from the Global Youth Tobacco Survey (GYTS) 2017

INTRODUCTION

The Global Youth Tobacco Survey’s findings have been used to support Ghana’s tobacco control legislation, monitor tobacco use among the youth and also used in meeting various Articles of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). These Articles include: Article 8 (Protection for exposure to tobacco smoke); Article 12 (Education, communication, training and public awareness); Article 13 (Tobacco advertising, promotion, and sponsorship); Article 14 (Demand reduction measures concerning tobacco dependence and cessation); and Article 16 (Sales to and by minors). Among the four waves of GYTS in Ghana, the 2017 GYTS was the first to assess waterpipe smoking, through optional questions included in the GYTS questionnaire. We assessed sex, age and regional differentials in waterpipe smoking among the youth in Ghana, and also explored the association between the use of other tobacco products and waterpipe use.

METHODS

The GYTS employs a standardized methodology with self-administered questionnaires, consisting of core, optional, and country specific questions. Fourteen questions, out of the seventy-four (74) questions administered for the entire GYTS, assessed waterpipe tobacco smoking (WTS). Chi-squared test was used to assess sex, age, grade/form and regional differentials in waterpipe use. Furthermore, the association between smoking cigarettes, smokeless tobacco, electronic cigarettes and waterpipe smoking, was explored by employing a chi-squared test with a 5% significance level.

RESULTS

Of a total of 5664 students who participated in the study, 90.9% were aged 13–15 years. The respondents were almost equally distributed among males and females. Overall, 3.1% of the respondents had ever smoked waterpipe. The overall prevalence of current waterpipe use was 1.7%; with 2.1% in girls (95% CI: 0.9–4.7%) and 0.9% in boys (95% CI: 0.5–1.6%), p=0.033. Additionally, more than half (55.0%) of the current waterpipe users smoked three or more sessions per day. Surprisingly, close to half (46.9%) of the current waterpipe users smoked at home.

CONCLUSIONS

Waterpipe use, particularly among the female student population, represents an emerging tobacco epidemic and hence deserves immediate attention from authorities. This study revealed that waterpipe is being used among Junior High students in Ghana. Education on the health implications of waterpipe use should be intensified among the youth, to help minimize its use and to prevent its associated health harms.

The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study

Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.

Epidemiology and Adverse Consequences of Hookah/Waterpipe Use: A Systematic Review

Hookah smoking is becoming a popular trend globally. Waterpipe smoking is the second most prevalent form of alternate tobacco products. The rapid increase in hookah use is because of the misconception prevalent in society that hookah smoking is less harmful than cigarette smoking. Smoking ban policies had given impetus of switching from cigarette smoking to alternate tobacco products like waterpipe. Hookah users regard hookah to be more socially acceptable, less stigmatizing with flavors and to alleviate cigarette craving symptoms. Newer basic science research on animal models and human cells has shown consistently mutagenic, oxidative, and inflammatory changes that could cause possible health effects of premalignant oral lesion and chronic diseases like atherosclerosis and chronic obstructive pulmonary disease. Studies on the chemistry of waterpipe smoke had shown alarming results with the smoke containing seven carcinogens, 39 central nervous system depressants, and 31 respiratory irritants. Enormous data exist showing waterpipe smoking causing various health effects. Hookah smoking effects on cardiovascular disease is additive with hookah containing a significant amount of nicotine, tar, and heavy metals causing both acute and chronic effects on the cardiovascular system. These effects include increased heart rate, blood pressure, prevalence of coronary heart disease, heart failure, ST-segment elevation myocardial ischemia, recurrent ischemia, and worse outcomes including mortality related to these diseases. The objectives of the review are to assess the factor associated with the increasing use of hookah, its health effects, options for hookah smoking cessation, and public health policy initiatives to mitigate waterpipe use.

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon

Waterpipe tobacco smoking (WTS) is spreading worldwide. Research has indicated health consequences of WTS similar to cigarettes. Prevalence of WTS is high among young people. In Lebanon, current use rates of 35% have been documented among 13⁻15 year olds. We evaluated a school-based intervention. Method: We conducted a randomized-controlled-trial of a theory-informed WTS intervention. The intervention consisted of ten sessions based on social cognitive theory and the social influences approach. Thirty-one schools participated: 14 intervention and 17 control; a total of 1279 students completed pre and post assessments. We measured knowledge, attitudes and self-reported behaviors related to WTS using Chi-square tests and regression analyses to compare results between the two study arms. Results: The intervention increased knowledge of intervention group compared to control group participants-about WTS constituents and health consequences; and shifted attitudes of intervention group participants to be even more unfavorable towards WTS. We found no impact of the intervention on WTS behaviors. Discussion: The effectiveness of the intervention on knowledge and attitudes supports previous research. The lack of intervention effect on behavior is not surprising given the timing of the post assessment immediately after the intervention, and the social context that was supportive of waterpipe use.

Harm perceptions of waterpipe tobacco smoking among university students in five Eastern Mediterranean Region countries: A cross-sectional study

INTRODUCTION

Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries.

METHODS

This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries.

RESULTS

A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe.

CONCLUSIONS

Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.

Policy-Relevant Context of Waterpipe Tobacco Smoking among University Students in Six Countries Across the Eastern Mediterranean Region: A Qualitative Study

Background:

Waterpipe tobacco smoking rates in the Eastern Mediterranean region are some of the highest worldwide, especially among young people. This study aimed to improve our knowledge of the policy-relevant context of waterpipe smoking among six countries in the Eastern Mediterranean region.

Methods:

In-depth interviews were conducted in Bahrain, Egypt, Jordan, Lebanon, Palestine, and the United Arab Emirates. Participants were young adult university students (18-29 years) from both genders who had ever smoked the waterpipe, recruited from universities participating in this study. Directed content analysis was used to analyze the transcripts.

Results:

A total of 53 in-depth interviews were conducted in Arabic in 2016. Findings were organized around 5 themes: waterpipe product characteristics; patterns of waterpipe smoking; the waterpipe café setting; perceived health consequences; and health warning labels. Waterpipe smoking was commonly perceived as a safe alternative to cigarettes. Waterpipe tobacco was reported to be widely accessible and affordable to young participants. There is a lack of knowledge among waterpipe smokers about the associated health effects. Warning labels are effective at communicating health risks associated with waterpipe smoking.

Conclusions:

Regulatory frameworks for waterpipe tobacco smoking should be developed and enforced, including waterpipe-specific health warning labels that elucidate the harmful effects of waterpipe smoking.

Waterpipe and cigarette tobacco smoking among Palestinian university students: a cross-sectional study

BACKGROUND

During the last two decades, waterpipe tobacco smoking (WTS), also known as hookah, witnessed a global increase in use, especially among youth. Little information is known about the burden of WTS among Palestinian youth. A cross-sectional study was conducted to estimate the prevalence of WTS and cigarette smoking and explore the associated factors among a sample of Palestinian university students.

METHODS

1891 students, from five Palestinian universities in the West Bank and Gaza Strip, completed a self-administered, web-based survey in 2014-2015. The questionnaire, which was based on the Global Adults Tobacco Survey (GATS), had questions on WTS and cigarette smoking patterns and socio-demographic and university-related characteristics. Binary logistic regression analyses were computed to investigate associated factors with WTS and cigarette smoking.

RESULTS

50.9% of the sample was women. The mean age was 20.1 ± 2.0. Overall, 30.0% of participants were current tobacco smokers and 33.4% reported ever smoking tobacco through a waterpipe. The prevalence of current WTS (24.4%) surpassed the prevalence of current cigarette smoking (18.0%), with a significantly higher prevalence among men compared to women. The gender gap for WTS (36.4% vs. 12.9%) was smaller than that for cigarette smoking (32.8% vs. 3.6%). Binary logistic regression models for the total sample (men and women) revealed that men were more likely to be current waterpipe and cigarette tobacco smokers compared to women (AOR = 4.20, 95% CI = 3.22-5.48, and AOR = 10.91, 95% CI = 7.25-16.42, respectively). Geographic area of residence, faculty of study and self-reported academic achievement were also associated with the likelihood of being current waterpipe and cigarette tobacco smokers.

CONCLUSION

A high prevalence of WTS was reported among our study sample, and it surpassed the prevalence of cigarette smoking. Interventions to curb the practice of tobacco smoking among Palestinian youth should be tailored differently to WTS and cigarette smoking, be gender-sensitive and specific and target the regional variation in the smoking behavior.