Waterpipe tobacco smoking and its human health impacts

Water pipe smoking and stroke: A systematic review and meta-analysis

OBJECTIVE

Despite the damaging effects of water pipe on physical health, there is little information about the potential harmful effects of this tobacco on stroke. This study aims to investigate the relationship between water pipe smoking and stroke.

METHOD

A systematic review was conducted including Ovid SP, Embase, Pubmed, Web of Science, Scopus, and Google Scholar databases with focus on cohort, case-control, and cross-sectional studies. We reviewed all studies reporting on water pipe smoking and stroke. The funnel plot and the Egger regression test were used to assess publication bias.

RESULTS

In the four eligible studies, there were a total of 2759 participants that 555 patients had at least once experienced stroke. Meta-analysis revealed positive association between water pipe smoking and stroke with pooled adjusted OR 2.79 (95% CI: 1.74-3.84;I 2 = 0 , p = . 741 ${I^2}\; = \;\;0,{\mathrm{\;}}p\;\; = {\mathrm{\;\;}}.741$ ) and the funnel plot shows asymmetry publication bias.

CONCLUSIONS

We found a higher effect of water pipe smoking on stroke compared to cigarette smoking and concluded that water pipe increases the risk of stroke by 2.79. Hence, because most of the water pipe consumer society is young, especially women, policies and decisions need to be taken to control the supply of this tobacco to the market and more provide education on the health problem of water pipe smoking.

IMPLICATIONS

This study provides a higher effect of water pipe smoking on stroke. Physicians and researchers who intend to study in the field of stroke should better examine the effects of water pipe (including time of use, dose-response, long-term effects, and risk factors) on stroke.

"It's nice to just be": A qualitative study on the meaning-imbued reality of waterpipe smoking among young adults in Sweden

Background and aims: Waterpipe smoking is regarded as a burgeoning public health problem due to its popularity among young adults. This study aims to understand the meaning-imbued reality of waterpipe smoking for young adults in Sweden. Method: Data from 18 individual interviews with ethnically diverse Swedish young adults were analysed using inductive latent-level qualitative content analysis. Results: The youth's experience of waterpipe smoking shows different dimensions (time, space, fun, community) that construct the practice of waterpipe smoking as a closed bubble characterised by harmlessness, cosiness and freedom to develop an adult self in the waterpipe group. The bubble provides a breathing space and timeout in everyday life, fuelled by an understanding of the hookah as hazard-free and liberating. A variety of control mechanisms are used to defend the bubble's constructed harmlessness, proving responsibility by applying practice-, communication- and Othering-oriented means. Conclusion: The study enhances the understanding of waterpipe smoking by highlighting its community- and self-forming meaning in a combined focus on ritualistic and symbolic qualities. For young adults, waterpipe smoking combines potentially beneficial and detrimental impacts on health. This complex situation requires a dialogical - rather than a traditional - approach to prevention that negotiates the risk landscape faced by young adults.

Impact of waterpipe and tobacco cigarette smoking on global DNA methylation and nuclear proteins genes transcription in spermatozoa: a comparative investigation

BACKGROUND

Waterpipe smoking is harmful and dangerous, and it is a growing threat to public health.

OBJECTIVES

This study was performed to evaluate the influence of waterpipe smoking on global DNA methylation, DNA fragmentation, and protamine deficiency in spermatozoa compared to cigarette heavy smokers and nonsmokers, and to determine whether the transcription levels of spermatozoa nuclear proteins genes 'PRM1, PRM2, and H2BFWT' in waterpipe smokers are different compared to cigarette heavy smokers and nonsmokers.

METHODS

A total of 900 semen samples were collected from males with a mean age of 32.5 ± 6.3 years (300 waterpipe smokers, 300 cigarette heavy smokers, and 300 nonsmokers). The nucleic acids were isolated from purified spermatozoa, and then the global DNA methylation and transcription levels of the PRM1, PRM2, and H2BFWT genes were assessed using ELISA and qPCR, respectively.

RESULTS

A significant increase was found in the level of global DNA methylation (8.6 ± 0.6 ng/μl vs. 7.1 ± 0.6 ng/μl and 4.7 ± 0.6 ng/μl, p < 0.001), protamine deficiency (72.8 ± 15.3 vs. 51.7 ± 19.2 and 15.3 ± 5.9%, p < 0.001), and DNA fragmentation (73.4 ± 13.4 vs. 50.5 ± 18.9 and 9.3 ± 4.3%, p < 0.001) in waterpipe smokers compared to cigarette heavy smokers and nonsmokers. A significant increase was shown in the transcription levels of PRM1, PRM2, and H2BFWT genes in waterpipe smokers compared to cigarette heavy smokers and nonsmokers (p < 0.001). A down-regulation was found in the transcription level of these genes in different smoker groups compared to nonsmokers (<0.001).

CONCLUSION

This study suggests that waterpipe smoking is more harmful than cigarette smoking on semen parameters, global DNA methylation, and transcription of nuclear protein genes.

Effect of hubble-bubble smoking on global DNA methylation and transcription levels of protamine and histone genes in human spermatozoa

This study was conducted to assess the impact of hubble-bubble smoking on global DNA methylation, DNA fragmentation; protamine deficiency of spermatozoa, and to determine whether the transcription levels of the protamine and histone genes are different in hubble-bubble smokers compared to nonsmokers. Five hundred semen samples were collected from males with an average age of 32.2 ± 6.1 years (300 hubble-bubble smokers "60%" and 200 nonsmokers "40%"). The nucleic acid was isolated from purified sperm, then ELISA and qPCR were used to evaluate the global DNA methylation and transcription level of protamine and histone, respectively. A significant elevation in global DNA methylation, protamine deficiency, and DNA fragmentation was found in hubble-bubble smokers compared to nonsmokers (P < 0.0001). A significant decline was shown in transcription levels of protamine and histone genes in hubble-bubble compared to nonsmokers (P < 0.0001). Additionally, a down-regulation in the transcription levels of protamine and histone was revealed in hubble-bubble compared to nonsmokers with fold change (0.0001 and 0.007, respectively). In conclusion, this study provided proof that hubble-bubble smoking has a negative impact on global DNA methylation, DNA fragmentation, protamine deficiency, and the transcription of protamine and histone genes in spermatozoa, and these findings influence negatively males' fecundity.

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

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

Indoor Exposure and Regional Inhaled Deposited Dose Rate during Smoking and Incense Stick Burning-The Jordanian Case as an Example for Eastern Mediterranean Conditions

Tobacco smoking and incense burning are commonly used in Jordanian microenvironments. While smoking in Jordan is prohibited inside closed spaces, incense burning remains uncontrolled. In this study, particle size distributions (diameter 0.01-25 µm) were measured and inhaled deposited dose rates were calculated during typical smoking and incense stick-burning scenarios inside a closed room, and the exposure was summarized in terms of number and mass concentrations of submicron (PN_Sub) and fine particles (PM_2.5). During cigarette smoking and incense stick-burning scenarios, the particle number concentrations exceeded 3 × 10⁵ cm^-3. They exceeded 5 × 10⁵ cm^-3 during shisha smoking. The emission rates were 1.9 × 10¹⁰, 6.8 × 10¹⁰, and 1.7 × 10¹⁰ particles/s, respectively, for incense, cigarettes, and shisha. That corresponded to about 7, 80, and 120 µg/s, respectively. Males received higher dose rates than females, with about 75% and 55% in the pulmonary/alveolar during walking and standing, respectively. The total dose rates were in the order of 10¹²-10¹³ #/h (10³-10⁴ µg/h), respectively, for PN_Sub and PM_2.5. The above reported concentrations, emissions rates, and dose rates are considered seriously high, recalling the fact that aerosols emitted during such scenarios consist of a vast range of toxicant compounds.

Prevalence, Knowledge, Attitude, and Predictors of Waterpipe Smoking among School Adolescents in Saudi Arabia

This cross-sectional study was designed to investigate the prevalence, knowledge, attitude, and predictors of waterpipe (WP) smoking among intermediate and secondary school adolescents in the Kingdom of Saudi Arabia (KSA). A self-administered anonymous questionnaire was used to collect data on demography, WP smoking status and patterns, the Arabic version of the Global Youth Tobacco Survey tool, and instruments to assess knowledge and attitude towards WP smoking. The Patient Health Questionnaire (PHQ-9) was also used. Descriptive and inferential statistical techniques were used. Modeling of WP smoking behavior was conducted using logistic regression. A total of 639 male students participated in this study. The prevalence of current WP and cigarette smokers were 17.7% and 14.6%, respectively. Out of the total population, 47.8% of students have the misconception that WP smoking is less harmful than cigarettes. A significant association (P < 0.05) of some demographic factors (age, school stage, residence, and parents' educational level) on WP smoking status was observed. Pleasure, socializing, and happiness represented the primary motives for initiating WP smoking. The majority of students had misconceptions about WP's health effects. More than 50% believed that smoking WP could ease anxiety, cause less harm, and has less addictive properties compared to cigarettes. Modeling suggested that the most significant predictors of WP smoking were cigarette smoking, depression, and the attitude index. Current findings warrant further research and official health programs to promote educational initiatives regarding WP smoking.

Biomonitoring of BTEX in primary school children exposed to hookah smoke

Hookah smoking is one of the major indoor sources of benzene, toluene, ethylbenzene, and xylenes (BTEX). This study aimed to investigate the potential exposure to BTEX among primary school children, particularly those exposed to hookah smoke. This cross-sectional study was conducted in Khesht, one of the southwestern cities in Iran, in mid-June 2020. Totally, 50 primary school children exposed to hookah smoke were chosen as the case group and 50 primary school children were selected as the control group. Urinary un-metabolized BTEX was measured by a headspace gas chromatography mass spectrometry (GC-MS). Additionally, a detailed questionnaire was used to gather data and information from the students' parents. The mean levels of urinary benzene, toluene, ethylbenzene, m,p-xylene, and o-xylene were 1.44, 5.87, 2.49, 6.93, and 7.17 μg/L, respectively in the exposed children. Urinary BTEX was 3.93-folds higher in the case group than in the controls (p<0.05). Household cleaning products, the floor on which the house was located, children's sleeping place, and playing outdoors were found to be important factors in predicting urinary BTEX levels. Overall, it was found necessary to avoid indoor smoking to prevent the emission of BTEX compounds via exhaled mainstream smoke and to protect vulnerable non-smokers, especially children, from exposure to second-hand and third-hand smoke.

Secondhand smoke exposure from the indoor and outdoor shisha centers located at the perimeter of educational institutions in Malaysia: a cross-sectional study

Shisha is a centuries-old traditional smoking habit rapidly gaining popularity among the students and young adults in Malaysia. The present study evaluated secondhand smoke exposure (SHS) and characteristics of 25 indoor and 25 outdoor shisha centers (SC) operating around the educational institutes such as universities in Petaling Jaya, Malaysia. We observed a significantly higher particulate matter (PM)_2.5 concentration in indoor than outdoor SC (3595.28 μg/m³ and 65.12 μg/m³, p < 0.001, respectively). SCs are offering different flavors to attract clients and exposing students and young professionals to a significantly high concentration of SHS. Such exposures may pose a serious health risk. Therefore, policymakers need to strengthen tobacco guidelines and eliminate loopholes in the sale of shisha by enforcing comprehensive and strict smoke-free laws.

The adverse health effects of waterpipe smoking in adolescents and young adults: A narrative review

Waterpipe (WP) smoking has rapidly grown in popularity in the United States and other Western countries with the fastest uptake among younger individuals. This growth has been encouraged by the misperception that WP smoke is harmless or less harmful than cigarette smoke. To better understand how WP affects the health of young people, we conducted a narrative review of the literature focusing on the adverse health effects of WP smoking in adolescents and younger adults. We searched scientific literature databases including PubMed, MEDLINE, EMBASE, and ISI Web and selected papers that met the inclusion criteria. Sixty-three papers met the inclusion criteria and were selected for review. Data were abstracted from the selected papers into a standardized table. The evidence demonstrates that WP smoking can cause acute lung infection and injury, and carbon monoxide (CO) poisoning, in adolescents and young adults. It is also associated with adverse subclinical effects in this sub-population, including oral and systemic genotoxicity, lung function decline, and the alteration of vascular and hemodynamic functions. Limited evidence that is available indicates associations with psychological and neurological effects and asthma. No identified publications examined the association between WP use and type 2 diabetes, a condition that is associated with cigarette smoking among young people. WP smoking by younger individuals can result in their hospitalization due to systemic CO poisoning and acute lung disease, and induce subclinical adverse effects in the oral cavity, pulmonary system, and in circulation, that are involved in the pathogenesis of local and systemic chronic diseases.

Prevalence of consumption of psychoactive substances among construction workers

INTRODUCTION

The prevalence of psychoactive substance is constantly increasing in developing countries, and all occupational sectors are concerned. Construction sector is a particular target because of the heavy workload as well as family and social isolation. However, few studies have investigated toxic habits in this population in Morocco. The aim of this study was to determine the prevalence of addictive substances consumption, use, and misuse amongst construction workers and to appreciate the poly-consumption according to socio-demographic and occupational parameters.

METHODS

This cross-sectional study was conducted amongst 1,128 construction workers. The interview with each person took place at occupational health service during his medical examination. The questions were formulated orally in French and /or in Arabic. The questionnaire covered socio-demographic and occupational parameters, toxic habits (tobacco, alcohol, cannabis and others psychotropic substances). The misuse was assessed by specific tests: dependence on smoking tobacco (Fagerstrom), Cannabis Abuse Screening Test (CAST) and Alcohol Use Disorders Identification Test (AUDIT).

RESULTS

The prevalence of consumption was 47.9% for smoking tobacco, 12.7% for cannabis, and 20.1% for alcohol. Amongst consumers, the prevalence of dependence or misuse was 68% for smoking tobacco, 70.6% for cannabis and 63% for alcohol. 42.7% of construction workers had no toxic habit, 36.1% one toxic habit, 16.3% two toxic habits, 4.8% three toxic habits and 0.1% four toxic habits. The most frequent associations were tobacco-alcohol (8.1%) and tobacco-cannabis (3.7%).

CONCLUSIONS

Occupational health physicians have to play a key role in raising awareness and fighting against toxic habits. The prevention approach needs a cooperative spirit. It will be more accepted and applied if all construction workers and their representatives are involved in its elaboration.

Sociocultural factors contributing to waterpipe tobacco smoking among adolescents and young adult women: a qualitative study in Iran

Purpose: Waterpipe tobacco smoking (WTS) is currently a serious and growing public health threat in the world, especially in adolescents and young women. The aim of the study was to explore sociocultural factors contributing to WTS among adolescents and young adult women in Iran.

Methods: This qualitative study was conducted from August 2017 to January 2019 in Isfahan and Hamadan cities, Iran; it included 13–30-year-old females with experience of WTS. For data collection, in-depth semi-structured personal interviews were conducted at participants’ preferred time and place. Concurrent with data collection, data were analysed through conventional content analysis.

Results: The study participants described the various sociocultural factors contributing to WTS. These factors were categorized into four following main categories: waterpipe glamorization by its producers and sellers, media advertisement or silence, common sociocultural traditions, and governmental policies and regulations.

Conclusion: A wide range of sociocultural factors affects WTS among Iranian adolescents and young adult women. Therefore, interdisciplinary multidimensional strategies are needed for WTS management and prevention among these at-risk groups. Public education, strict supervision of tobacco import, export, and selling, ample employment opportunities for young people and effective leisure time management are essential to reduce WTS.Abbreviation WTS: Waterpipe Tobacco Smoking; MPOWER: Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco

Determinants of waterpipe smoking among high school students in Jakarta, Indonesia

Objectives The study aimed to examine factors associated with past 30 days waterpipe use among high school students in Jakarta, Indonesia. Methods We surveyed a multistage cluster random sample of 1,318 students of grade 10th and 11th from 14 schools in Jakarta. Multiple logistic regressions were employed to examine the association between past 30 days waterpipe use with sociodemographic characteristics, cigarettes smoking status, parental and peer use, availability and affordability. Results Of 1,318 participants, 3.3% of female and 8.4% of male currently smoked waterpipe. Multivariate analysis revealed that current waterpipe use was significantly associated with family use (AOR: 4.844, 95% CI: 1.225-19.151), friend use (AOR: 2.554, 95% CI: 1.424-4.582), and availability (AOR: 2.143, 95% CI: 1.127-4.076). Being current smokers were six times more likely (AOR: 6.055, 95% CI: 3.123-11.739) to use waterpipe in the past 30 days. Conclusions The finding suggests that smoking by a family member, friends, use of conventional cigarettes, and availability are significantly associated with increased probability of current waterpipe used among adolescents.

Options for waterpipe product regulation: A systematic review on product characteristics that affect attractiveness, addictiveness and toxicity of waterpipe use

INTRODUCTION

Despite its known adverse effects on human health, waterpipe smoking is increasing in popularity worldwide. However, compared to cigarettes, regulation of waterpipe product smoking lags behind and presents unique challenges. In search for regulatory options, this systematic review analyzes 36 studies on the differential effects on human health of the waterpipe characteristics including smoking products, heating sources, device components, and packages.

METHODS

A systematic review was performed according to PRISMA guidelines, revealing 443 unique citations. After screening, 36 studies were included in the results. Research articles were selected to inform on differential effects caused by product characteristics on adverse health effects, attractiveness, addictiveness and prevalence of waterpipe use.

RESULTS

Flavors are the key aspect that defines attractiveness of waterpipe product smoking. All waterpipe products, with or without nicotine, produce toxicants in similar quantities as cigarettes. Heating sources for waterpipe tobacco include charcoals and electrical heating. Both heating sources increase toxicant emissions in different ways. Hoses and mouth tips are device components that are often shared in waterpipe smoking. Sharing influences attractiveness by enriching the social experience. At the same time, it influences the transfer of infectious diseases by bacteria and viruses from one smoker to another. Studies showed that more generic and less attractive packages with health warnings are effective in reducing the attractiveness of waterpipe smoking.

CONCLUSIONS

Based on our findings, we advise to include all waterpipe products, tobacco and non-tobacco, with or without nicotine, in tobacco product regulations and smoking bans in order to: ban waterpipe molasses with characterizing flavors or ban the use of flavorings at any level; mandate dissemination of information on all waterpipe tobacco elements to the national regulator; prescribe testing to regulate contents of waterpipe smoking products and heating sources. Moreover, we advise to stimulate research on emissions of waterpipes.

Oxidative Stress and Inflammation Induced by Waterpipe Tobacco Smoking Despite Possible Protective Effects of Exercise Training: A Review of the Literature

The prevalence of waterpipe tobacco smoking (WTS), which is also known as ghalyan, shisha or hookah, is increasing rapidly around the world, especially among youth. Growing interest in this form of tobacco smoking can be traced, in part, to the use of flavored tobacco products, social acceptability as a safer option than cigarettes, and its consideration as a relaxation method or entertainment. However, there is a well-established association between WTS and oxidative stress that causes irreversible chronic pathological conditions such as cardiovascular and respiratory problems, as well as different types of cancers, and thus increases the risk of mortality. Clearly, induction of inflammation status through increased reactive oxygen species (ROS), which in turn leads to oxidative stress and harm to lipids, DNA, and proteins, is the most plausible mechanism to explain the potential harmful effects of WTS. Unlike WTS, well-designed exercise training programs increase ROS to the extent that it is beneficial to the body. In this study, we aimed to review available evidence on the impact of exercise training on oxidative stress and inflammation status. We also summarize the effect of acute and chronic WTS on different exercise capacities.

The impacts of waterpipe (hookah, narghile) -use on quality of life: a special report

Introduction While waterpipe-use induced deficiency and incapacity have already been extensively explored, its impacts on quality of life (QoL) was rarely raised. The main aim of this Special Report was to briefly highlight the key results of the studies raising the effects of waterpipe-use on smokers' QoL. Areas covered SCOPUS was consulted on July 3^rd, 2020, using the combination of the following two medical subject headings (MeSH) words: 'Tobacco, Waterpipe' AND 'Quality of Life'. Only English original articles were retained. Merely five studies raised the effects of waterpipe-use on QoL. Studies were performed in Middle East (n = 2), USA (n = 1), Tunisia (n = 1) and 'Egypt, Morocco, Oman and Jordan' (n = 1). Conflicting results were reported related to the effects of waterpipe-use on QoL. While four studies concluded that waterpipe-smokers' have a worse QoL, one study concluded that waterpipe-smokers have a normal QoL. Expert opinion This Special Report is a call to encourage future research to identify the real effects of waterpipe-use on QoL.

Changes at global and site-specific DNA methylation of MLH1 gene promoter induced by waterpipe smoking in blood lymphocytes and oral epithelial cells

Objective: Cigarette tobacco smoking has been shown to cause cancer through different mechanisms that include epigenetic modulation of tumor-suppressor genes. In the present study, the association between global and MLH1 gene promoter methylation and waterpipe tobacco smoking was investigated. Materials and Methods: Blood lymphocytes and oral epithelium were sampled from 150 pure waterpipe smokers and 150 never-smokers from Jordan. Methylation assessment was performed using the methylation-specific PCR technique for MLH1 gene and ELISA for global DNA methylation. Results: Significant increases were shown in global DNA methylation as measured in blood lymphocytes (p < 0.01). In addition, increases in MLH1 gene promoter methylation among waterpipe smokers compared to nonsmokers (p < 0.001) in both oral epithelium and blood lymphocytes was also observed. In addition, strong correlation was found between LWDS-10J dependence score and magnitude of promoter specific methylation of MLH1 (r2 = 0.74-0.78, p < 0.001). Moreover, the percentage of methylated MLH1 promoter was not affected by age or gender (p > 0.05). Discussion and Conclusion: Collectively, the results indicate that waterpipe tobacco use is associated with epigenetic changes that might predispose users to lung and blood cancers. The results highlight the need for actions to discourage waterpipe smoking and can be used in cessation interventions that target this type of smoking.

Microbial contamination and infection risks of narghile besides hazards of tobacco

OBJECTIVE

Water-pipe smoking has become a serious public health threat worldwide. In order to raise awareness of adverse effects and transmission of bacteria via water-pipe smoking, we aimed to identify the bacteria and their antimicrobial resistance profiles that colonize different parts of waterpipes.

METHODS

We examined totally 182 water pipes from 7 lounges (in Turkey) used in public places and we collected 728 culture samples in total by microbiological methods. We used disposable sterile swabs to sample the inside and outside of the mouthpiece, and the handling piece and sterile injectors were used to collect 5 mL of water from the water pipe bowl.

RESULTS

There was a significant (p < 0.05) difference in microbial contamination (growth/presence of bacteria and fungi) among the parts of the water pipes sampled. There was a significant (p < 0.05) difference in the number of bacteria growing (microbial load) among the parts of the water pipes. Only one narghile lounge out of seven, which had 13 water pipes, had a hygiene procedure. The water jars are often contaminated with Gram-negative bacteria.

CONCLUSION

Water pipes, especially the interior and outer part of the mouthpieces and the handle, are colonized by microbes and pose a risk of infection. Procedures for water pipe hygiene should be developed, periods should be defined, and the owners and employees of establishments and water-pipe smokers should be educated in this regard. Water-pipe smoking is a threat to public health and should be regulated by the state.

Waterpipe smoking cessation: knowledge, barriers, and practices of primary care physicians- a questionnaire-based cross-sectional study

BACKGROUND

While cigarette smoking has been considered the most relevant tobacco product worldwide, waterpipe tobacco smoking (WTS) has increased in prevalence globally and calls for more considerable attention now. However, little is known about WTS cessation knowledge and clinical practices among physicians, particularly in Lebanon. This study aims to examine the knowledge, barriers, and cessation practices of primary care practitioners towards WTS.

METHODS

A cross-sectional study where an anonymous self-reported questionnaire was completed by physicians attending the Annual Conference of the Lebanese Society of Family Medicine for family medicine physicians, general practitioners, and internists in Lebanon.

RESULTS

Out of 180 attendees, 105 primary care practitioners (PCPs) responded to the questionnaire. Only 38.1% of the physicians think similar techniques are used for the cessation of smoking of both cigarette and waterpipe. Similarly, 30.5% of the physicians believe that nicotine replacement therapy works in the cessation of waterpipe smoking. There was a statistically significant difference between the percentage of physicians who counsel for cigarette smoking and those who counsel for waterpipe smoking cessation (p = 0.005) where 30% of the physicians tend to counsel against cigarette smoking more than waterpipe smoking.

CONCLUSIONS

This study shows a difference in the attitude and behavior of PCPs towards cigarette and waterpipe smoking cessation. Moreover, there is a lack of knowledge about water pipe smoking cessation techniques. There is a great room for continued medical education to PCPs in their private practice to improve their knowledge.

Substantial Toxic Effect of Water-Pipe Smoking on the Early Stage of Embryonic Development

Background

Water-pipe smoking (WPS) is the most widespread tobacco use in the Middle-East, and is rapidly spreading globally. Smoke from WP contains most of the compounds present in cigarette smoke, although in different proportions. WPS is associated with the risk of several human diseases; however, its impact on the early stage of normal development has not been investigated yet. Thus, in this investigation, we assess the effect of WPS on the embryo at the early stage of development.

Methods

Chicken embryos at 3 days of incubations were used in this study. Meanwhile, we explored the outcome of WPS on angiogenesis using the chorioallantoic membrane (CAM) of the chicken embryos. Finally, quantitative real-time polymerase chain reaction was used to study the regulation of some key control genes of cell proliferation, apoptosis, and migration.

Results

Our data reveal that WPS inhibits angiogenesis of the CAM and in embryos in comparison with their matched controls; in addition, WPS-exposed embryos show slight reduction in their sizes. We also noted that around 80% of WPS-exposed embryos die before 10 days of incubation. More significantly, WPS induces upregulations of BCL-2, Caspase-8, ATF-3, INHIB-A, and Cadherin 6 genes, which are important key regulators of cell apoptosis, proliferation, and migration.

Conclusion

Our data reveal, for the first time, that WPS has very toxic effects during the early stage of embryogenesis. Thus, we believe that further studies are required to elucidate the pathogenic effect of WPS on human health especially on the embryo at the early stage of its development.

Implications

This investigation addresses an important gap on the outcome of WPS during the early stage of embryogenesis. Data of this study point out that WPS can have a very toxic effect on the embryo at this stage. Additionally, results from this report display for the first time that WPS can damage normal angiogenesis of the embryo thus provoking a significant number of embryonic death. Moreover, this study reveals that this effect can occur via the deregulation of several genes related to cell apoptosis, proliferation, and migration.

Chemical Characterization of Nanoparticles and Volatiles Present in Mainstream Hookah Smoke

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

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.

Water-pipe smoking promotes epithelial-mesenchymal transition and invasion of human breast cancer cells via ERK1/ERK2 pathways

Background

With the increasing popularity of water-pipe smoking (WPS), it is critical to comprehend how WPS may affect women's health. The main goal of this study is to identify the potential outcome of WPS on human breast cancer progression.

Methods

Two breast cancer cell lines, MCF7 and BT20, were used in this investigation. We explored the outcome of WPS on cell morphology and cell invasion using inverted microscope and Biocoat Matrigel invasion chambers. On the other hand, Western blot was employed to study the expression patterns of key control genes of cell adhesion and invasion.

Results

Our data reveal that WPS induces epithelial-mesenchymal transition (EMT) of MCF7 and BT20 breast cancer cell lines; thus, WPS enhances cell invasion ability of both cell lines in comparison with their matched controls. More significantly, WPS provokes a down- and up-regulation of E-cadherin and focal adhesion kinase (FAK), respectively, which are important key regulators of cancer progression genes. Finally, our data point out that WPS incites the activation of Erk1/Erk2, which could be behind the stimulation of EMT and invasion as well as the deregulation of E-cadherin and FAK expression.

Conclusion

Our data show, for the first time, that WPS initiates EMT and stimulates cell invasion of breast cancer cells, which could incite metastatic development in breast cancer patients. Thus, we believe that further studies, both in vitro and in vivo, are required to elucidate the pathogenic outcome of WPS on cancer progression of several human carcinomas including breast.

Waterpipe Smoking Is Associated with Changes in Fibrinogen, FVII, and FVIII Levels

Cigarette smoking has been shown to be associated with changes in coagulation factors in the circulation and the subsequent thrombosis development. In this study, the impact of waterpipe smoking on the levels of fibrinogen, factor VII (FVII), and factor VIII (FVIII) was investigated. In addition, the effects of waterpipe smoking were compared to those of cigarette smoking and never smokers. A total of 80 male smokers (40 cigarette smokers and 40 waterpipe smokers) and 40 apparently healthy never smokers were recruited in the study. Both waterpipe smoking and cigarette smoking induced significant increases in the plasma levels of fibrinogen, factor VII, and factor VIII (p < 0.01). The magnitude of the increase in fibrinogen levels induced by waterpipe smoking was higher than that induced by cigarette smoking (p < 0.01), while similar increases were observed in other factors (p > 0.05). In addition, in the waterpipe group, the magnitude of the increase in fibrinogen and factor VIII was higher in the smokers with more than 3 years of use (p < 0.05). In conclusion, similar to cigarette smoking, waterpipe smoking modulates the levels of coagulation factors, suggesting its thrombotic potential.

Isolation and characterization of the cotinine-degrading bacterium Nocardioides sp. Strain JQ2195

Cotinine, the primary nicotine metabolite, not only more stable and more difficult to degrade in the environment but is a potential health risk to human. To date, little is known about the biodegradation process of cotinine. In this study, a bacterial strain JQ2195 was isolated from municipal wastewater and was identified as Nocardioides sp. based on morphological, physiological characteristics, and 16 S rRNA gene phylogenetic analysis. This strain utilized cotinine as a sole carbon source and degraded 0.5 g L^-1 cotinine completely within 32 h. Optimum degradation of cotinine by JQ2195 was at 30 °C and pH 7.0. Two cotinine degradation intermediates were identified as 6-hydroxy-cotinine and 6-hydroxy-3-succinoylpyridine by UV/VIS spectroscopy and liquid chromatography coupled with time-of-flight mass spectrometry. In addition, about half of cotinine was transformed to 6-hydroxy-3-succinoylpyridine which was a value-added compound for biocatalysis. When 2,6-dichlorophenolindophenol was used as an electron acceptor, the cell-free extract containing the inducible cotinine dehydrogenase could convert cotinine into 6-hydroxy-cotinine with the activity 40 ± 6 mUnmg^-1.

Adolescents' perceptions of flavored tobacco products, including E-cigarettes: A qualitative study to inform FDA tobacco education efforts through videogames

INTRODUCTION

Flavored tobacco products have been shown to appeal to youth, however tobacco control strategies have traditionally not focused on these products. To inform the adaptation of an existing videogame to focus on the prevention of flavored tobacco product use, this study explored adolescents' perceptions, beliefs, and social norms surrounding these products, including flavored e-cigarettes.

METHODS

We conducted and analyzed transcripts from seven focus groups with 11-17-year-old adolescents (n = 33) from after-school programs in CT and CA in 2016. Participants discussed flavored tobacco product beliefs and experiences, and how these compared to traditional cigarettes.

RESULTS

Thematic analysis of transcripts revealed that participants could name flavors in tobacco products, even though few discussed first-hand experience with the products. Most groups perceived that flavored tobacco product and flavored e-cigarette use facilitated peer approval and acceptance. All groups discussed how youth could easily access flavored tobacco products, including e-cigarettes. Flavoring was a salient aspect of e-cigarette advertisements; however the groups did not recall exposure to other types of flavored tobacco product counter-marketing.

CONCLUSIONS

These data can help inform the development of tobacco control strategies, novel interventions (such as videogames), and future FDA efforts to prevent adolescent tobacco product use through education and risk communication.

The impact of conventional and nonconventional inhalants on children and adolescents

AIM

Inhalant abuse in the adolescent population is a growing concern for care givers, communities, physicians, and medical providers. The aim of this article is to provide a review of the literature about this new challenge. In addition, it raises awareness about recent health policy rulings.

METHODS

Review of the literature was done.

RESULTS

In this review article, the prevalence of different modes of inhalant use and abuse in children and young adults and their potential health implications will be examined: Cigarettes, ENDS (E Cigarettes), Hookah, Marijuana, and Huffing. Additionally, marketing and advertising tactics will be reviewed to understand how they target this population. A review of current health policy recommendations from the FDA, American Thoracic Society, and the American Academy of Pediatrics will also be discussed.

CONCLUSION

The rapid rise in e-cigarette and hookah use in school aged children should trigger a call to action in the medical and public health communities. Health policy recommendations need to be made to reduce the level of adolescent substance abuse.

Factors associated with waterpipe tobacco smoking among Lebanese women

Waterpipe tobacco smoking (WTS) has become a serious public health threat in the Middle East and beyond. To estimate the prevalence rates of cigarette and WTS among Lebanese women and describe characteristics associated with each behavior. Secondary analysis of women's health data obtained in a national survey in 2010. Of 2,255 selected women, 78 percent reported no or past long-term WTS. Among the 12 percent of regular waterpipe smokers, 40 percent were light users (mean three waterpipe heads weekly), while 60 percent were heavy users (mean of 11 heads per week). About 70 percent were never or past long-term cigarette smokers. Younger age, location within Greater Beirut (GB) and having professional employment were significantly associated with use of WTS. Older age, GB location, lower education, and ever-married were significantly associated with cigarette smoking. WTS is becoming a socially normative behavior among empowered professional women, who can spare the time and expense to engage in this behavior in easily accessible cafés, which prohibit cigarette smoking. Government, media, and NGO campaigns against smoking should target waterpipe use, not only in Lebanon but also across the Arab world and among Arab communities in the Diaspora with messages different from anti-cigarette campaigns.

Oral Health Hazards of Water Pipe Smoking: Current Evidence

Water pipe smoking (WPS) has been a traditional habit in the Middle Eastern Society for hundreds of years. The WPS users have a false sense of safety due to its casual use in social gatherings. It was estimated that about 70% of WPS users believe it to be a safe alternative to cigarette smoking.1 Further, the use of flavored tobacco has led to its growing popularity, especially among youngsters.

Water pipe (Shisha, Hookah, Arghile) Smoking and Secondhand Tobacco Smoke Effects on CYP1A2 and CYP2A6 Phenotypes as Measured by Caffeine Urine Test

Public policies to stop or reduce cigarette smoking and exposure to secondhand smoke and associated diseases have yielded successful results over the past decade. Yet, the growing worldwide popularity of another form of tobacco consumption, water pipe smoking, has received relatively less attention. To the best of our knowledge, no study to date has evaluated the effects of water pipe smoking on cytochrome P450 (CYP450) activities and drug interaction potential in humans, whereas only limited information is available on the impact of secondhand smoke on drug metabolism. In a sample of 99 healthy volunteers (28 water pipe smokers, 30 secondhand tobacco smoke exposed persons, and 41 controls), we systematically compared CYP1A2 and CYP2A6 enzyme activities in vivo using caffeine urine test. The median self-reported duration of water pipe smoking was 7.5 h/week and 3 years of exposure in total. The secondhand smoke group had a median of 14 h of self-reported weekly exposure to tobacco smoke indoor where a minimum of five cigarettes were smoked/hour for a total of 3.5 years (median). Analysis of variance did not find a significant difference in CYP1A2 and CYP2A6 activities among the three study groups (p > 0.05). Nor was there a significant association between the extent of water pipe or secondhand smoke exposure and the CYP1A2 and CYP2A6 activities (p > 0.05). Further analysis in a subsample with smoke exposure more than the median values also did not reveal a significant difference from the controls. Although we do not rule out an appreciable possible impact of water pipe smoke and secondhand smoke on in vivo activities of these two drug metabolism pathways, variability in smoke constituents from different tobacco consumption methods (e.g., water pipe) might affect drug metabolism in ways that might differ from that of cigarette smoke. Further studies in larger prospective samples are recommended to evaluate water pipe and secondhand tobacco smoke effects on CYP450 function, particularly at higher smoke exposure conditions.