Prevalence of water pipe smoking in the city of Mashhad (North East of Iran) and its effect on respiratory symptoms and pulmonary function tests

Standards for the care of people with cystic fibrosis; establishing and maintaining health

This is the second in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on establishing and maintaining health. The guidance is produced using an evidence-based framework and with wide stakeholder engagement, including people from the CF community. Authors provided a narrative description of their topic and statements, which were more directive. These statements were reviewed by a Delphi exercise, achieving good levels of agreement from a wide group for all statements. This guidance reinforces the importance of a multi-disciplinary CF team, but also describes developing models of care including virtual consultations. The framework for health is reinforced, including the need for a physically active lifestyle and the strict avoidance of all recreational inhalations, including e-cigarettes. Progress with cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy is reviewed, including emerging adverse events and advice for dose reduction and interruption. This paper contains guidance that is pertinent to all people with CF regardless of age and eligibility for and access to modulator therapy.

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.

Trend of Smuggled Cigarette Consumption in Tehran in the Last Two Decades

Background: Illicit tobacco trade is focused on Iran as a main target in the WHO’s eastern Mediterranean region. Serial studies of Cigarette Packs Survey with same method were conducted in Tehran between 2003 and 2015 to evaluate consumed smuggled cigarettes. This study as the fourth Cigarette Packs Survey is designed to indicate the trends of illicit cigarette trade in Tehran in the last two decades. Methods: A cross-sectional household study was carried out in early 2021 in Tehran on 3042 persons who smoked at least one daily cigarette for a year. The sampling method was like the sampling method used in three previous studies. Participants aged≥15 years were asked to reveal their current cigarette pack, which was either legal cigarettes (having governmental label); or illegal cigarettes (without governmental label). Results: The subjects included 2536 males (83.4%) and the mean age was 39.9±12.1 years; 1854 subjects (60.9%) showed foreign cigarettes and 1188 (39.1%) showed domestic cigarettes; 2705 (88.9%) consumed legal cigarettes and 337 (11.1%) consumed illegal cigarettes. Consumption of illegal cigarettes by gender showed greater use of smuggled cigarettes in males (11.7%vs 8.1%). No significant differences were seen based on the marital and educational status in terms of illegal cigarettes prevalence. Conclusion: Compare with previous studies, the trend of consumption of illicit cigarettes was decreasing in past two decades. This could be due to new regulation on monitoring cigarette distribution and changing illegal brands to legal as joint production.

Analysis of heavy metals and PAHs in the waste resulting from hookah consumption: Ahvaz City, Iran

Hookah, a popular form of smoking tobacco, has been commonly used in Asia and Africa. However, the widespread consumption of hookah has a major impact on human health being. In addition to health risks, discarding the waste products of hookah would be a serious potential danger for environmental resources. In this study, the waste materials of hookah consumption (water, tobacco, and charcoal) were analyzed for the determination of the metals and PAHs using inductively coupled plasma mass spectrometry (ICP-MS) and gas chromatography-mass spectrometry (GC-MS), respectively. Results showed that the average concentration of iron in different flavors of tobacco had the highest amount (3654.2 ppb). Iron had the maximum concentration among the heavy metals, particularly in the mint flavor (10,863.3 ± 4.1). The highest ƩPAHs were related to the mint flavor (47.48 ± 15.21 ppb). Results showed that the aromatic tobacco available in the Ahvaz-Iran market is polluted by heavy metals. The high consumption of hookah in Ahvaz city and the presence of pollutants in hookah waste materials, apart from health risk aspects, can be potentially regarded as sources of environmental contamination. Therefore, education and preventive measures are necessary for this concern.

Comparison of Urinary Heavy Metals and Pulmonary Function Test in Cafe Workers Based on Exposure to Secondhand Tobacco Smoke, Tehran 2021

Background

Secondhand tobacco smoke exposure is one of the morbidity causes but it is ignored occasionally. Various studies have shown that hookah and cigarette smoke contain significant volume of heavy metals. This study was designed aiming biological monitoring of the level of heavy metals in the urine samples of workers in smoking cafés and its association with their lung function and respiratory symptoms in Tehran City.

Methods

The list of cafés in Tehran was provided, and they were divided into water pipe cafés (WPC), cigarette smoking cafés (CSC), and non-smoking cafés (NSC); and then, 10 cafés were randomly selected from each group. Sampling was performed after explaining the study and obtaining the consent of the manager and staff. A check list of demographic data and smoking history was completed and analyzed.

Results

A total of 96 individuals were studied; there were 32 subjects in each group. All subjects were male. Six days a week, they worked about 10 h a day in café. The concentration of heavy metals in the groups of hookah and cigarettes was significantly higher and respiratory indices in these groups were significantly lower than non-smoking group.

Conclusions

Exposure to secondhand smoke increases the urinary level of heavy metals and reduces the respiratory capacity of people and this can be highly pathogenic in the future. Comprehensive informing on human rights should be provided in this regard and smoking bans in public places must be properly enforced.

Waterpipe smoking: a review of pulmonary and health effects

Waterpipe smoking is an old form of tobacco smoking, originating in Persia and the Middle East. The popularity of the waterpipe is increasing worldwide, particularly among young adults, and there are widespread misconceptions regarding its negative health effects. The inhaled smoke of the waterpipe contain several toxic and hazardous materials including nicotine, tar, polyaromatic hydrocarbons and heavy metals, all of which are proven to be related to lung diseases and cancer. Regular waterpipe smoking is associated with respiratory symptoms, a decrease in pulmonary function and increased risk for lung disease such as COPD. Additional negative health effects include increased risk for arterial stiffness, ischaemic heart disease and several cancer types including lung cancer. This review summarises the negative health effects of waterpipe smoking, with emphasis on cardiorespiratory complications. Increased awareness and knowledge amongst healthcare professionals will hopefully help identify waterpipe smokers and promote patient education. Applying World Health Organization (WHO) regulations will provide a synergistic effect in reducing waterpipe use and associated disease.

Steps toward community health promotion: Application of transtheoretical model to predict stage transition regarding smoking

BACKGROUND

Recently, the Iranian Ministry of Health estimated about 750,000 deaths are attributed smoking complications. The aim of this study was to apply the transtheoretical model (TTM) on general population of Mashhad city to evaluate the stages of change and possible cultural factors regarding smoking cessation.

METHODS

This descriptive, cross-sectional population-based study was conducted in Mashhad, Iran. A total number of 562 participants selected by multistage sampling. They were asked about stages of change for smoking cessation for both hookah and cigarette smoking. Stages of change refer to an orderly sequence of changes in smoking behavior that people progress through according to the TTM. Its six stages are as follows: precontemplation (PC) (no intention to quit smoking within 6 months), contemplation (planning to quit smoking in the following 6 months), preparation (planning to stop smoking within 1 month), action (quit smoking for <6 months), maintenance (stopped smoking for 6 months or more), and termination (will never smoke again). Data were analyzed using tests such as Chi-square, Kruskal-Wallis, and logistic regression by SPSS 11.5.

RESULTS

About 18% and 19% of people in this study were regular hookah and cigarette smokers, respectively. There was significant difference between cigarette smoking and sex (P < 0.001) and marital status (P = 0.01). There was a statistically significant difference between stages of change in men and women from the point of cigarette smoking (P < 0.001). Male sex, hookah smoking, and alcohol abuse were predictors of PC, and age was the only predictor of termination stage for cigarette smoking. Sex did not have any role in hookah smoking.

CONCLUSION

Targeted education based on gender and marital status warrant attention. Community-wide education and interventions such as increasing the price of cigarettes are desired.

Effects of Waterpipe Tobacco Smoking on the Spirometric Profile of University Students in Palestine: A Cross-Sectional Study

Background

Waterpipe smoking in young individuals is increasing with limited studies addressing its respiratory health effects. The aim of the study was to determine the effect of waterpipe smoking on young adults' lung functions. Spirometric parameters were compared between waterpipe smokers and nonsmokers.

Methods

A comparative cross-sectional study of university students, including males and females, was conducted. An interviewer-administered questionnaire was used to record students' characteristics. The spirometry test was performed to assess students' lung functions; we recorded the forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow (PEF), and forced expiratory flow between 25 and 75% of FVC (FEF_25–75%).

Results

A total of 300 apparently healthy students (150 waterpipe smokers and 150 nonsmokers) were included in the study. Waterpipe smokers showed significantly lower values in FEV₁, FEV₁/FVC ratio, PEF, and FEF_25–75% compared to the nonsmoker group (P < 0.05 to P < 0.001). The subgroup analysis on female students (50 WP smokers and 50 nonsmokers) showed a significant decrease in FEV₁/FVC ratio, PEF, and FEF_25–75% parameters (P < 0.001).

Conclusion

Waterpipe smoking is associated with reduced spirometric parameters in healthy young adults with relatively limited smoking years.

The effect of Zataria multiflora on inflammatory cytokine and respiratory symptoms in veterans exposed to sulfur mustard

The effect of Zataria multiflora (Z. multiflora) on serum cytokine, chemokines, and respiratory symptoms in the veterans exposed to sulfur mustard (SM) more than two decades (27-30 years) ago was conducted in 2018. Thirty-four patients were randomly assigned to the placebo group (P, mean age (54.40 ± 5.51)) and two treated groups with Z. multiflora extract 5 and 10 mg/kg/day (Z5 and 10; mean age, 58.50 ± 3.60 and 55.18 ± 4.11, respectively). Serum levels of tumor necrosis factor (TNF-α), monocyte chemotactic protein 1 (MCP-1), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), forced expiratory volume-one second (FEV₁), and respiratory symptoms including chest wheeze (CW), night wheeze (NW), night cough (NC), and cough and wheeze during exercise (ECW) were assessed at the baseline (phase 0), 1 and 2 months after starting treatment (phase I and II, respectively). The value of FEV₁ was significantly increased in Z10 in phase I and II compared with that in phase 0 (p < 0.01 for both) and in Z5 in phase II compared with phase I and 0 (p < 0.001for both). All respiratory symptoms significantly decreased in Z5 and 10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). Serum levels of TNF-α and VEGF were decreased in Z5 and 10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). Serum levels of MCP-1 and EGF were decreased in Z10 in phase I and II compared with those in phase 0 (p < 0.05 to p < 0.001). The percent change of respiratory symptoms, serum levels of cytokines during the treatment period, was significantly improved in the treated groups compared with that in the placebo group. Two months' of treatment with Z. multiflora improved cytokine levels, respiratory symptom, and FEV₁ values in SM-exposed patients.

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.

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

RATIONALE

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

OBJECTIVES

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

METHODS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Waterpipe Tobacco Smoking Prevalence and Associated Factors in the Southeast of Iran

BACKGROUND

Waterpipe smoking is a growing public health threat worldwide. The aim of this study was to assess waterpipe smoking prevalence and its associated factors among Iranian adults.

METHODS

This cross-sectional study was conducted in Kerman, Iran, recruiting 1090 adult participants using multistage sampling in 2016. A self-reported researcher-designed questionnaire was used. The socio-demographic characteristics and waterpipe smoking behaviors such as pattern, duration, and the most common place of waterpipe use, the type of tobacco, and the concurrent use of alcohol and substances were assessed. Data analyses were performed using chi-square, independent t-test, and multiple logistic regression.

FINDINGS

The prevalence of ever, current and daily waterpipe smoking were 43.8%, 28.8%, and 7.2%, respectively. Men initiated to use waterpipe in more early ages than women (P < 0.001). Café or restaurant (34.4%) and friends' house (36.8%) were the most frequent places for waterpipe using by men and women, respectively. Men used waterpipe 2.8 times more frequently than women. Waterpipe smoking was 4.9 times more likely in the 18-24 years age range compared to the 45 years or older. Waterpipe use was 2.4 times greater in the unemployed than in housewives. People with a university education were 1.4 and 1.7 times more likely to use waterpipe compared to people with high school diploma and illiterates, respectively.

CONCLUSION

The present study revealed that men, high level of education, younger age and unemployment were associated with waterpipe smoking. Therefore, we need to design and implement more effective interventions, especially for vulnerable target groups.

Waterpipe tobacco smoking and its human health impacts

Waterpipe tobacco smoking (WTS, also known as hookah, shisha, narghile, and many other names) involves passing tobacco smoke through water prior to inhalation by the consumer. As the number of waterpipe smokers is rising rapidly, there is growing concern over the use of WTS, particularly as there has been a widely held misconception that WTS is free from health hazards. In reality, it is associated with a variety of adverse health outcomes on both a short- and long-term basis. Hence, it is desirable to develop advanced techniques for surveillance, intervention, and regulatory/policy frameworks specific to the production and use of waterpipe tobacco. This review is written to survey the types and extent of pollutants released from its use and their potential health risks. A review of the present regulation guidelines is also included.

A Systematic Review of Effects of Waterpipe Smoking on Cardiovascular and Respiratory Health Outcomes

BACKGROUND

Waterpipe smoking (WPS) is a social custom common in many Middle Eastern, North African, and Asian countries and has become increasingly popular in the US, especially among youth; however, WPS smoking may be increasing in the US adult population as well. There is a common belief among waterpipe (WP) smokers that WPS is less harmful than smoking cigarettes. Thus, this review aims to systematically explore the literature on the effects of WP tobacco smoking with a particular focus on cardiovascular and respiratory health outcomes as well as on oxidative stress, immunity, and cell cycle interference health outcomes.

METHODOLOGY

We conducted a systematic review, guided by the criteria of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the following online databases MEDLINE, CINAHL, ScienceDirect, PMC, and Cochrane Library. Results were summarized qualitatively.

RESULTS

Forty studies met the inclusion criteria established for this review. Based on the existing evidence, several cardiovascular and respiratory physiologic health indicators and conditions have been shown to be negatively affected by WPS. In addition to the effects of nicotine and chemical toxicant exposures, WPS was significantly associated with an increase in heart rate, blood pressure, and lower pulmonary function test results, as well as a number of health conditions such as lung cancer, alterations in oxidative stress, immunity, and cell cycle interference.

CONCLUSION

The current literature provides evidence that WPS is associated with a number of negative health indicators and outcomes. There is need for more research related to WPS and its effects on health so that appropriate campaigns and prevention interventions can be implemented to control the epidemic increase of WPS in the US.

Structural characterization of rat ventricular tissue exposed to the smoke of two types of waterpipe

OBJECTIVES

this study focused on the effect of waterpipe smoke exposure toxicity on the structure of albino rat's ventricular tissue and their recovery.

MATERIALS AND METHODS

Albino rats were divided into three groups: control, flavored, and unflavored. The control group was exposed to normal air while the flavored and unflavored groups were exposed to waterpipe smoke for a period of 90 days. Each group was followed by a period of 90 days of fresh air exposure. Following each period, the ventricular tissue was removed for biochemical and histopathological studies.

RESULTS

The ventricular tissues of waterpipe exposed rats showed some degree of separation between cardiac muscle fibers, infiltration of lymphocytes, and congestion of blood vessel. Also, thin cross sections of ventricular cells revealed pleomorphic mitochondria with partially disrupted cristae, partial disruption of the myofibrils, and deposited toxic materials. The unflavored waterpipe has more deleterious effects on heart ventricular tissues than the flavored one. Waterpipe smoke didn't induce apoptosis in the ventricular tissue. We also found very high levels of plasma thiocyanate after exposure to smoke in the flavored and unflavored groups, while the control group showed no increase. After the recovery period, those tissues showed partial recovery.

CONCLUSION

Waterpipe smoke induces structural changes in the heart ventricle tissues, causing a negative impact on the capacity of the cardiac muscle for pumping blood and may lead to heart attack due to accumulation of free radicals and tissue inflammation. Cessation of smoking is important in returning most of these changes to their normal structure.

BTEX in indoor air of waterpipe cafés: Levels and factors influencing their concentrations

BTEX (benzene, toluene, ethylbenzene and xylene) concentrations, factors affecting their levels, and the exposure risks related to these compounds were studied in waterpipe (Ghalyun/Hookah) cafés of Ardabil city in Islamic Republic of Iran. 81 waterpipe cafés from different districts of Ardabil city were selected and their ambient air was monitored for BTEX compounds. Air samples were taken from standing breathing zone of employees, ~150 cm above the ground level, and were analyzed using GC-FID. In each case, the types of smoked tobacco (regular, fruit flavored), types of ventilation systems (natural/artificial), and the floor level at which the café was located were investigated. A high mean concentration of 4.96±2.63 mg/m(3) corresponding to long term exposure to benzene-related cancer risk of 4314×10(-6) was estimated. The levels of the remaining compounds were lower than the national guideline limits, but their hazard quotients (HQ) for long term exposure to ethylbenzene (1.15) and xylene (17.32) exceeded the HQ unit value. Total hazard indices (HI) of 63.23 were obtained for non-cancer risks. Type of the smoked tobacco was the most important factor influencing BTEX concentrations in the cafés. BTEX concentrations in indoor ambient air of Ardabil waterpipe cafés were noticeably high, and therefore may pose important risks for human health on both short and long term exposures.

Health effects associated with waterpipe smoking

OBJECTIVE

It is widely held that waterpipe smoking (WPS) is not associated with health hazards. However, several studies have documented the uptake of several toxicants and carcinogens during WPS that is strongly associated with harmful health effects. This paper reviews the literature on the health effects of WPS.

DATA SOURCES

Three databases-PubMed, MEDLINE and EMBASE-were searched until August 2014 for the acute and long-term health effects of WPS using the terms 'waterpipe' and its synonyms (hookah, shisha, goza, narghileh, arghileh and hubble-bubble) in various spellings.

STUDY SELECTION

We included original clinical studies, case reports and systematic reviews and focused on clinical human studies. ∼10% of the identified studies met the selection criteria.

DATA EXTRACTION

Data were abstracted by all three authors and summarised into tables. Abstracted data included study type, results and methodological limitations and were analysed jointly by all three authors.

DATA SYNTHESIS

WPS acutely leads to increased heart rate, blood pressure, impaired pulmonary function and carbon monoxide intoxication. Chronic bronchitis, emphysema and coronary artery disease are serious complications of long-term use. Lung, gastric and oesophageal cancer are associated with WPS as well as periodontal disease, obstetrical complications, osteoporosis and mental health problems.

CONCLUSIONS

Contrary to the widely held misconception, WPS is associated with a variety of adverse short-term and long-term health effects that should reinforce the need for stronger regulation. In addition, this review highlights the limitations of the published work, which is mostly cross-sectional or retrospective. Prospective studies should be undertaken to assess the full spectrum of health effects of WPS, particularly in view of its growing popularity and attractiveness to youth.

Approach to Patients with Severe Asthma: a Consensus Statement from the Respiratory Care Experts' Input Forum (RC-EIF), Iran

Challenges in the assessment, diagnosis and management of severe, difficult-to-control asthma are increasingly regarded as clinical needs yet unmet. The assessments required to determine asthma severity, comorbidities and confounding factors, disease phenotypes and optimal treatment are among the controversial issues in the field. The respiratory care experts' input forum (RC-EIF), comprised of an Iranian panel of experts, reviewed the definition, appraised the available guidelines and provided a consensus for evaluation and treatment of severe asthma in adults. A systematic literature review followed by discussions during and after the forum, yielded the present consensus. The expert panel used the appraisal of guidelines for research and evaluation-II (AGREE-II) protocol to define an initial locally-adapted strategy for the management of severe asthma. Severe asthma is considered a heterogeneous condition with various phenotypes. Issues such as assessment of difficult-to-control asthma, phenotyping, the use of blood and sputum eosinophil count, exhaled nitric oxide to guide therapy, the position of anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty as well as the use of established, recently-developed and evolving treatment approaches were discussed and unanimously agreed upon in the panel. A systematic approach is required to ensure proper diagnosis, evaluate compliance, and to identify comorbidities and triggering factors in severe asthma. Phenotyping helps select optimized treatment. The treatment approach laid down by the Global Initiative for Asthma (GINA) needs to be followed, while the benefit of using biological therapies should be weighed against the cost and safety concerns.