Women and Waterpipe Tobacco Smoking in the Eastern Mediterranean Region: Allure or Offensiveness

Electronic nicotine delivery system use and its relation to waterpipe smoking among youth in seven Arab countries

OBJECTIVES

Electronic Nicotine Delivery System (ENDS) use and Waterpipe Tobacco Smoking (WTS) are reported to be a growing strain of tobacco epidemic among youth in the Arab world. Therefore, we aimed to: (1) estimate the regional prevalence of ENDS use among youth in 7 Arab countries and, (2) to explore the bidirectional relationship between ENDS use and WTS among Arab adolescents.

METHODS

We analyzed data from the World Health Organization Global Youth Tobacco Survey (GYTS 2014-2018) of 18,536 schoolchildren aged 12-16 from Iraq, Mauritania, Morocco, Oman, Qatar, Tunisia, and Yemen. The weighted prevalence was calculated to generate nationally representative estimates. Adjusted multilevel logistic regression models were conducted to assess the association between ENDS use and WTS.

RESULTS

The pooled weighted prevalence of ENDS use was 9.5%. Higher odds of ENDS use were significantly associated with WTS (AOR: 5.26, 95%CI: 4.28-6.46), smoking conventional cigarettes (AOR: 1.54, 95%CI: 1.23-1.94) and first tobacco use prior to the age of 12 (AOR: 1.40, 95%CI: 1.14-1.72). Females and children who were taught in school the dangers of tobacco had less odds of using ENDS.

CONCLUSION

WTS was associated with increased odds of ENDS use by >5 folds, and vice versa. Tobacco consumption at age younger than 12 years was associated with higher odds of ENDS use, but less odds of WTS. Females and those who were taught in school the dangers of tobacco were less likely to report ENDS use.

Smoking behaviors among Middle Eastern college women in the United States

Objective: to examine factors associated with cigarette and hookah smoking among Middle Eastern (ME) Arab college women. Participants: 406 adult women of ME Arabic background, currently enrolled in or recently graduated from a US college. Methods: a cross-sectional design, using an anonymous online survey of demographic characteristics, sociocultural factors, and access to health care factors. Data analysis included regression model to identify predictors of smoking behaviors. Results: Smoking rates were 21% and 19% for cigarette and hookah smoking. Cigarette smoking was higher with having liberal attitudes toward sexuality and lower among those having a healthcare provider. Hookah smoking was higher among students who are Muslim, involved in student organizations, have higher acculturation-heritage levels, and have more liberal attitudes toward women. Hookah smoking was lower among students born in the US, attending college part-time, and having higher religiosity levels. Conclusions: The study findings have several implications for interventions to address smoking behaviors among ME Arab college women through community organizations and within college campuses.

Prevalence and factors associated with second hand smoke exposure among a sample of pregnant women in Cairo, Egypt

PURPOSE

This study estimated the prevalence of and factors associated with secondhand smoke (SHS) exposure, and assessed attitudes and knowledge about SHS among pregnant women in Cairo, Egypt.

METHODS

Pregnant women in the third trimester were recruited to participate in a survey assessing tobacco smoking and SHS exposure during their current pregnancy. Participants were recruited from three antenatal clinics in Cairo, Egypt, from June 2015 to May 2016. We examined differences in sociodemographic characteristics and SHS exposure, attitudes, and knowledge by smoking/SHS status. We used multivariable ordinary least squares regression to examine the association between husbands' smoking and pregnant women's mean daily hours of SHS exposure, adjusting for women's smoking status, age group, education, and urban (vs. suburban/rural) residence.

RESULTS

Of two hundred pregnant women aged 16-37 years, about two-thirds (69%) had a husband who smoked tobacco. During their current pregnancy, most women reported being non-smokers (71%), and 38% of non-smokers reported being SHS-exposed. Non-smokers exposed to SHS tended to live in more rural areas and have husbands who smoked in the home. In adjusted analyses, having a husband who smoked was significantly associated with a greater mean number of hours of SHS exposure per day exposed, and this difference was driven by husbands who smoked in the home (p < 0.001). Women in the SHS-exposed group were less likely than other groups to agree that SHS exposure was harmful to their own or their future child's health; however, all groups agreed that SHS was harmful to newborn health.

CONCLUSION

Among our sample of pregnant women in Cairo, Egypt, there was a high rate of SHS exposure as well as misconceptions about the safety of SHS exposure to a developing fetus. Our findings suggest a need for targeted education and gender-sensitive messaging about SHS exposure, along with improved enforcement of existing tobacco control policies.

Healthcare Professionals' Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Gender differences in the price elasticity of demand for waterpipe and cigarette smoking in Lebanon, Jordan and Palestine: a volumetric choice experiment

OBJECTIVES

This study assessed the extent to which the elasticity of cigarette and waterpipe tobacco products differs between men and women. We also explored the levels of substitution and complementarity in tobacco products among men and women.

SETTING

The study examines tobacco elasticities in three Arab countries: Lebanon, Jordan and the West Bank of Palestine.

PARTICIPANTS

We used data from nationally representative surveys of adults aged ≥18 years in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679). The proportion of women was 50.0% of the sample in Lebanon and Palestine, and 44.6% in Jordan.

PRIMARY AND SECONDARY OUTCOME MEASURES

A zero-inflated Poisson regression model estimated own-price and cross-price elasticities for two variations of cigarettes and five variations of waterpipe tobacco products. Elasticities were measured based on eight scenarios of prices.

RESULTS

Demand for waterpipe tobacco products was elastic for both men and women. The cross-price elasticities in the three countries indicate the existence of substitution between cigarettes and waterpipe products and by different varieties within each of the two tobacco products. Gender differences varied across the three countries whereby higher cross-price elasticities were observed for women in Jordan and Palestine. For example, the price elasticity for discount waterpipe was -1.4 and -0.6 for women and men in Jordan, respectively.

CONCLUSIONS

Results on the elasticity of demand for tobacco products and the existence of substitution between tobacco products reveal the higher responsiveness of men and women to changes in tobacco prices. This should be taken into consideration in tobacco control strategies particularly when reducing tobacco consumption via taxation policies.

Water pipe smoking among public versus private university students in Ankara, Turkey: an online survey

Background

Water pipe smoking has become a global public health problem as its popularity increased over time, especially among youth. The objective of our study was to estimate water pipe tobacco smoking prevalence and to assess socioeconomic factors associated with ever water pipe smoking by public and private university students in Ankara, Turkey.

Methods

This descriptive study was based on a survey conducted among public (n=2685) and private (n=2485) university students via an online questionnaire on demographics and water pipe consumption patterns. For every student in the sample, a socioeconomic status index was calculated using principal component analysis. Binary logistic regressions for the outcome variable of ever-using water pipe yielded estimates of adjusted odds ratios (aORs) for the associated factors such as the respondent’s age, gender, university type, and socioeconomic status.

Results

The prevalence of ever use of water pipe was 69.1% (95% CI: 67.2-70.9%) among private and 59.1% (95% CI: 57.2-60.9%) among public university students. A substantial share of ever users were current users (25.5% in private versus 21.6% in public, p=0.008). On average, private university students had higher socioeconomic status than public university students (for example, access to a car (51.7% versus 35.8%, p=0.008), financial support from family (71.5% versus 65.1%, p<0.001)), also demonstrated by a higher socioeconomic status index. Being a private university student (aOR 1.57, 95% CI: 1.38-1.79), older (aORs 1.50 to 2.39, p<0.001), male (aOR 2.36, 95% CI:2.06-2.70), as well as having greater financial resources, such as having access to a car (aOR 1.24, 95% CI:1.07-1.42), or having income support from family (aOR 1.32, 95% CI:1.13-1.54), were associated with ever-using water pipe. A higher SES index was significantly associated with higher odds of ever using water pipe among both private (aOR 1.13, 95% CI:1.06,1.20) and public university (aOR 1.12, 95% CI:1.06,1.19) students.

Conclusions

Water pipe smoking was common in both public and private universities; however, private university students had higher odds of ever using water pipe. There is an urgent need to implement evidence-based interventions, taking into account the socioeconomic status of young adults, to prevent them from water pipe smoking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13616-9.

Factors Affecting Waterpipe Tobacco Smoking among University Students in Qatar

Background: Recent data show an increase in the prevalence of waterpipe tobacco smoking (WTS) among university students in the Arab Gulf region alongside an attitude of social acceptability and a perception that WTS is less harmful than traditional cigarette smoking. Objective: This study measures the prevalence of WTS among university students and examines the individual, sociocultural, and environmental factors influencing this practice. Methods: Participants were selected through stratified random sampling of students in the largest national university in Qatar. Data were collected anonymously using an online questionnaire. Descriptive univariate and bivariate analyses were conducted to examine the association of WTS with participants' sociodemographic characteristics, knowledge, and attitudes. Results: 199 students completed the questionnaire. Among students who reported using tobacco products, waterpipe (shisha) was the most common product (70.6%). WTS was significantly associated with having a mother (p = 0.015) or a close friend (p < 0.001) who smoked. Compared to non-users, waterpipe tobacco users were significantly more likely to believe that waterpipe tobacco is less addictive than cigarettes (p = 0.009) and significantly less likely to believe that waterpipe tobacco can lead to cardiovascular diseases (p = 0.003) or dental problems (p = 0.02). More waterpipe tobacco users than non-users disagreed that parents (p = 0.005) or advertisements (p = 0.002) could influence use. More waterpipe tobacco users (70%) than non-users (37%) believed that females were more comfortable using waterpipes than cigarettes. Conclusions and implications: The findings shed light on factors shaping WTS and provide evidence for designing multilevel behavioral interventions to decrease the prevalence of WTS among youth.

Exclusive and Dual Cigarette and Hookah Smoking Is Associated with Adverse Perinatal Outcomes among Pregnant Women in Cairo, Egypt

This study assessed the prevalence of prenatal smoking, factors associated with prenatal smoking, and its association with birth outcomes in a sample of pregnant women in Egypt. Pregnant women were recruited during their last trimester from antenatal clinics in Cairo from June 2015 to May 2016. Participants completed an interviewer-administered survey that assessed tobacco use and attitudes, and exhaled carbon monoxide (CO) was measured. Gestational age at delivery and offspring birth weight were collected via a postnatal phone interview. Two hundred pregnant women ages 16–37 years participated. More than a quarter (29.0%) of women reported smoking (cigarettes, hookah, or both) during their current pregnancy, and hookah was more popular than cigarettes. Most women who smoked prior to their current pregnancy either maintained their current smoking habits (46.6%) or switched from dual to hookah-only smoking (46.6%). Current smokers during pregnancy had a higher mean (±SD) exhaled CO level (2.97 ± 1.45 vs. 0.25 ± 0.60 ppm, p < 0.001) and had babies with a lower mean birth weight (2583 ± 300 vs. 2991 ± 478 g, p < 0.001) than non-smokers. Smokers during pregnancy had greater odds of premature birth and/or low birth weight babies compared to non-smokers. Dual cigarette-hookah smokers had the highest risk. Additional focused programs are required to prevent women of childbearing age from initiating tobacco use and empower women to stop tobacco use during the preconception and gestational periods.

Characteristics of flavored and non-flavored waterpipe tobacco users: a real-world setting study

We aimed to compare sociodemographic characteristics, smoking patterns, beliefs and perceptions, nicotine dependence, and psychological indicators between flavored waterpipe (WP) tobacco (FWT) and non-flavored WP tobacco (non-FWT) smokers in Iran. A cross-sectional study was conducted in 94 WP-serving venues surrounding Tehran and Ardabil metropolitans in Iran. Convenience sampling was applied to select 900 current WP smokers [508 (56%) FWT-only and 392 (44%) non-FWT-only smokers] aged 18 years and older. Multivariable logistic regression was used to examine the independent characteristics of FWT and non-FWT smokers. Compared to non-FWT smokers, FWT smokers were younger (adjusted odds ratio [AOR]=0.88, 95% confidence interval [CI]: 0.87-0.90) and more likely to have ≥ 1 sibling who smoked WP (AOR=1.54, 95% CI: 1.06-2.24), share WP with others (AOR=2.52, 95% CI: 1.68-3.77), report current cigarette smoking (AOR=2.05, 95% CI: 1.23-3.42), and report confidence in quitting at any time (AOR=3.64, 95% CI: 2.45-5.39). FWT smokers were less likely to have seen (AOR=0.40, 95% CI: 0.27-0.60) or read (AOR=0.44, 95% CI: 0.24-0.80) warning messages on WP tobacco packages relative to non-FTW smokers. The most common self-reported reason for smoking WP was entertainment for both groups, followed by stress relief for non-FWT smokers and the escape from loneliness for FWT smokers. FWT-only smokers differ from non-FWT-only smokers in several aspects including being younger, having more positive beliefs and perceptions regarding WP use, and having higher cigarette smoking prevalence. These findings will help in developing more effective and targeted policies and cessation interventions for WP smokers according to flavor type they use, especially in the Middle East.

"It's beyond the pale to smoke hookah": perceptions of Iranian adolescents on social unacceptability of hookah smoking

Introduction

Globally, the popularity of hookah smoking, as a social and entertaining behavior, is increasing among adolescents and youths. The present study aimed to explore the perceptions of high school students on Social Unacceptability (Arabic/Persian term = Qabahat) of Hookah Smoking (SUoHS) in an Iranian context.

Methods

In this qualitative study, 31 student adolescents in Tabriz, Iran, were invited to participate in semi-structured individual interviews and focus group discussions (FGDs). Data were analyzed using interpretative thematic analysis.

Results

The unacceptability of hookah smoking was viewed at the “disreputability of hookah smoking and hookah smokers”. The students also explained SUoHS in the “incivility of hookah smoking and smokers in the society”, “disrespectfulness of hookah smokers and their families”, and “the consequences of hookah smoking”.

Conclusions

The SUoHS is rooted in the social values and norms within communities. To decrease hookah smoking levels among adolescents, school health nursing interventions should be tailored to bridge the gap between their recognition of SUoHS and subsequent behavior change through creating group dynamics highlighting the domains of social unacceptability of the behavior.

Determinants of Waterpipe Smoking Among Women: A Systematic Review

Background

The present study aimed to assess the determinants of waterpipe smoking among women based on a systematic review regarding the increasing prevalence of waterpipe smoking in women and the tendency of them to this type of tobacco.

Methods

The present study was a systematic review. The search strategies were based on using a combination of MeSH and free-text terms. Searches were performed inIranian databasesand PubMed, ScienceDirect, Web of Science, EMBASE, Scopus and Medline. Databases inclusion criteria included articles and gray literature in English or Persian, published between January 2000 and December 2018. The keywords were related to women and waterpipe and related terms. The quality of the articles was assessed using the EPHPP tool.

Results

In the initial search, out of 1027 articles, 15 articles were studied. Inclusion criteria in this study were the target population of women and girl and descriptive and qualitative studies on waterpipe use among women. The mean prevalence of waterpipe smoking in quantitative studies was 13.980/0. Studies have shown that waterpipe smoking in women is influenced by several individual (awareness, favorable attitudes, and positive prototype), interpersonal (role of family and friends), and socio-political factors.

Conclusions

Due to the influence of various determinants on women's inclination to waterpipe smoking, there is a necessity to act and impose interventions such as lessening women's favorable attitude toward waterpipe, increasing women's awareness, encouraging negative prototype about waterpipe smoking, and restricting access to tobacco products that can be useful. Interpersonal factors such as the role of family and friends are one of the major determinants in waterpipe smoking. It seems that developing the skill of saying "no" to the pressure of friends can help prevent waterpipe use. Furthermore, educating the family about the risks of waterpipe use is an effective strategy in this respect.

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

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.

Effectiveness of E-Learning Program in Preventing WP Smoking in Adolescent Females in West of Iran by Applying Prototype-Willingness Model: A Randomized Controlled Trial

Background: Given the increasing trend of Water pipe (WP) smoking in adolescent females, it is necessary to use effective educational strategies in preventing WP smoking in developing countries. We aimed to determine effectiveness of e-learning program in preventing WP smoking in adolescent females west of Iran using prototype-willingness model.

Study Design: A randomized controlled trial.

Methods: This study was performed on 221 adolescent females in Kermanshah City, Iran during 2019-2020. Multistage random sampling was used. Data collection tool included a researcher-made questionnaire based on prototype-willingness model. E-learning-based intervention program included 5 training sessions. Participants were followed up for 3 months after the intervention. The data were analyzed using SPSS software.

Results: The mean scores of attitude, subjective norms, prototype, intention, and behavioral willingness structures were similar in both experimental and control groups before the educational intervention. However, after educational interventions, mean scores of structures of positive attitude towards WP, subjective norms about WP smoking, positive prototype about WP smokers, intention, and behavioral willingness towards WP smoking were decreased in the experimental group. Moreover, frequency of WP smoking was decreased in the experimental group compared to the control group after the educational intervention (P=0.003).

Conclusion: The use of e-learning-based interventions is an educational strategy for reducing WP smoking in adolescent females.

A Qualitative Study of Factors Influencing the Onset of Hookah Smoking among Iranian Men with Turkmen Ethnicity

Introduction: Hookah smoking has grown considerably among Iranian Turkmen in the past two decades. The reasons for this increase in the consumption of hookah are unclear. Therefore, this study was conducted with the aim of determining the factors related to the start of hookah smoking in men with Turkmen ethnicity.

Methods: This qualitative study was conducted between February 2018 and June 2018 in Turkmen cities of Golestan provinces in Iran. The study participants included 26 male Turkmen water pipe smokers with various ages, occupation, and education level. Study data were collected through semi-structured individual interview and the results were analyzed in August 2018 by content analysis. Data management was done by software, MAXQDA version 10.

Results: In this study, 26 hookah smoker men with the age range of 20–45 years were interviewed. The age of the participants at the time of starting hookah consumption varied from 14 to 25 years. On the basis of qualitative data, the reasons for the start of hookah smoking in male Turkmen were classified into three main categories: (1) individual (curiosity and sense of adulthood, fewer perceived risks compared with other substances and hookah’s sensory attractions); (2) interpersonal (hookah-smoking friends and consumption of hookah by family members); and (3) societal (blaming unemployed people in small neighborhoods, cultural influence, more social acceptance compared with other substances, and easy access to hookah).

Conclusion: Individual, interpersonal, and societal factors play important role in the start of hookah smoking among male Turkmens. Developing health policies based on the above factors can be effective in adopting hookah prevention and control strategies. Moreover, future studies could be developed with the goal of discovering ways to solve the problem of unemployment and plan for developing recreational activities in this area to prevent initiation of hookah smoking especially among youth.

Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers' and non-smokers' responses to enhanced versus existing pictorial health warnings in Egypt

OBJECTIVE

Despite the global increase in waterpipe tobacco smoking (WTS) including in Egypt, few studies have assessed the effectiveness of waterpipe tobacco (WT) health warnings. Egypt has used pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) and has rotated these every two years since 2008. We explored in this qualitative study how participants perceived existing PHWs on WTPs, assessed how they interpreted novel plain packaging of WT featuring enhanced PHWs, and probed perceptions of how existing and novel sets would affect uptake or cessation of WTS.

DESIGN

We conducted ten qualitative focus groups and ten in-depth interviews. We explored participants' views of the four existing PHWs (occupied 50% of the front and back of WTPs, displayed cancers, and featured colourful fruits and flavors) and four novel PHWs (occupied 80% of the front and back of WTPs, displayed different topical content, with plain packaging). Transcripts were analyzed using thematic analysis.

SETTING

Rural Menoufia, urban and semi-urban Cairo, Egypt.

PARTICIPANTS

90 waterpipe smokers and non-smokers, men and women, aged 18 years or older.

OUTCOMES

Perceived potential effect on WTS uptake or cessation, probing factors related to PHW content and WTP design.

RESULTS

Participants in focus groups and in-depth interviews thought existing WT PHWs elicited affective responses, but found them unclear or unrealistic and thought the colourful packaging detracted from the warnings. In contrast, they thought novel and larger WT PHWs presented in plain packaging might prevent WTS initiation or trigger quit attempts. Participants regarded warnings featuring proximal health risks as most likely to be acceptable.

CONCLUSIONS

Our exploratory study suggests larger WT PHWs featuring proximal risks and presented on plain WTPs could potentially deter experimentation with WT products among non-users and promote cessation among existing users.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

Smoking Behaviors in Arab Americans: Acculturation and Health Beliefs

INTRODUCTION

Arab Americans are a growing population in the United States. In the 2011 American Community Survey, the U.S. Census Bureau reported there were close to 1.8 million Arab Americans living within the United States, a 47% increase in population size from 2000. According to the Arab American Institute, currently, that estimate has grown to approximately 3.7 million. They have high rates of smoking and low rates of smoking cessation. In this study, the researchers investigated factors influencing desire to quit smoking among Arab Americans, and their association with acculturation and health beliefs.

METHODOLOGY

Cross-sectional descriptive study investigating smoking behaviors and factors influencing the desire to quit smoking among adult Arab American. Data were collected to measure tobacco use, nicotine dependence, desire to quit smoking, acculturation, and health beliefs.

RESULTS

The sample ( N = 96) was 55% female, mean age of 44 years (±14.79). The desire to quit smoking was positively associated with perceived severity (p < .05) and susceptibility to cancer (p < .05), perceived benefits of quitting smoking ( p < .01); and negatively associated with smoking barriers (addiction barriers p < .05, external barriers p = .27, internal barriers p < .05), and nicotine dependence (p < .05). Being female, having a lower level of nicotine dependence, and a higher perception of cancer severity predicted higher desire to quit smoking ( p < .01).

DISCUSSION

Smoking cessation intervention studies need to target appropriate health beliefs, especially the high risk of cancer caused by smoking among Arab Americans.

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.

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.

Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking

Waterpipe tobacco usage is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world, waterpipe usage surpasses cigarette smoking. Waterpipes and cigarettes are both mechanisms for inhalation of tobacco smoke and therefore have serious health consequences. However, because of the many differences between the two products, prevention and control strategies that have proven effective for cigarettes may not transfer readily to waterpipe. This report highlights the differences between waterpipes and cigarettes in toxicant exposure and physiologic effects, patterns of use, social norms, the extent of evidence, and the policy environment. There is little evidence to date around effective interventions for waterpipe prevention and control. The current state of evidence for intervention to curb or control waterpipe is at ground zero and critically needs attention from both scientists and policy makers. National and global efforts aimed at cigarette prevention have succeeded, particularly in developed countries. We suggest the time has come to harness what we know works for cigarette prevention and control and adapt it to tackle the growing epidemic of waterpipe tobacco use.

Sex Differences in Hookah-Related Images Posted on Tumblr: A Content Analysis

Hookah tobacco smoking is prevalent, widespread, and associated with large amounts of toxicants. Hookah tobacco smoking may be viewed differently by males and females. For example, females have been drawn to types of tobacco that are flavored, milder, and marketed as more social and exotic. Individuals often use the growing segment of anonymous social networking sites, such as Tumblr, to learn about potentially dangerous or harmful behaviors. We used a systematic process involving stratification by time of day, day of week, and search term to gather a sample of 140 Tumblr posts related to hookah tobacco smoking. After a structured codebook development process, 2 coders independently assessed all posts in their entirety, and all disagreements were easily adjudicated. When data on poster sex and age were available, we found that 77% of posts were posted by females and 35% were posted by individuals younger than 18. The most prominent features displayed in all posts were references to or images of hookahs themselves, sexuality, socializing, alcohol, hookah smoke, and tricks performed with hookah smoke. Compared with females, males more frequently posted images of hookahs and alcohol-related images or references. This information may help guide future research in this area and the development of targeted interventions to curb this behavior.

Burden of waterpipe smoking and chewing tobacco use among women of reproductive age group using data from the 2012-13 Pakistan Demographic and Health Survey

BACKGROUND

Despite the general decline in cigarette smoking, use of alternative forms of tobacco has increased particularly in developing countries. Waterpipe (WP) and Chewing Tobacco (CT) are two such alternative forms, finding their way into many populations. However, the burden of these alternative forms of tobacco and their socio demographic determinants are still unclear. We assessed the prevalence of WP and CT use among women of reproductive age group in Pakistan.

METHODS

Data from the most recent Pakistan Demographic and Health Survey 2012-13 (n = 13,558) was used for this analysis. Information obtained from ever married women, aged between 15 and 49 years were analyzed using two separate data subgroups; exclusive WP smokers (total n = 12,995) and exclusive CT users (total n = 12,771). Univariate and Multivariate logistic regression analyses were conducted and results were reported as crude and adjusted Odds Ratio with 95% confidence intervals.

RESULTS

Prevalence of WP smoking and CT were 4% and 2%, respectively. After multivariate adjustments, ever married women who were: older than 35 years (OR; 4.68 95% CI, 2.62-8.37), were poorest (OR = 4.03, 95% CI 2.08-7.81), and had no education (OR = 9.19, 95% CI 5.10-16.54), were more likely to be WP smokers. Similarly, ever married women who were: older than 35 years (OR = 3.19, 95% CI 1.69-6.00), had no education (OR = 4.94, 95% CI 2.62-9.33), were poor (OR = 1.64, 95% CI 1.07-2.48) and had visited health facility in last 12 months (OR = 1.81, 95% CI 1.22-2.70) were more likely to be CT users as well.

CONCLUSION

Older women with lower socio-economic profile were more likely to use WP and CT. Focused policies aiming towards reducing the burden of alternate forms of tobacco use among women is urgently needed to control the tobacco epidemic in the country.

Waterpipe Use and Susceptibility to Cigarette Smoking Among Never-Smoking Youth

INTRODUCTION

Susceptibility to cigarette smoking, defined as the lack of a firm decision against smoking, is a strong predictor of regular smoking and addiction. Several modifiable risk factors have been identified among never cigarette smokers, and one potential factor of interest is waterpipe use. The purpose of this study is to determine the association of waterpipe use with susceptibility to cigarette smoking among never-smoking youth.

METHODS

In a pooled analysis of 17 Arab nations with nationally representative Global Youth Tobacco Surveys conducted during 2002-2011, tobacco-related information was obtained from 30,711 never-smoking adolescents representing 4,962,872 youth. Study outcome was susceptibility to cigarette smoking, and primary exposure was waterpipe use. Data were analyzed in 2014 using weighted logistic regression models, including stratified models by gender, to determine the odds of susceptibility to cigarette smoking with waterpipe use, adjusting for confounders.

RESULTS

Overall, 20% of never-smoking youth were susceptible to cigarette smoking, ranging from 13.1% in Oman to 32.6% in Somalia; 5.2% currently used waterpipe, ranging from 0.3% in Morocco to 23.5% in Kuwait. The estimated odds of susceptibility to cigarette smoking were 2.5 (95% CI=1.9, 3.4) times higher for adolescents who used waterpipe in the past month compared with those who did not, controlling for confounders. Estimates were similar when stratified by gender.

CONCLUSIONS

Waterpipe use is associated with susceptibility to cigarette smoking. Study findings identify a novel risk factor for never smokers to initiate smoking and will help the public health community develop and implement policies around waterpipe use prevention.

Predictors of waterpipe smoking progression among youth in Irbid, Jordan: A longitudinal study (2008-2011)

BACKGROUND

The predictors of waterpipe smoking progression are yet to be examined using a longitudinal study that is guided by a theoretical model of behavioral change. This study identifies the gender-specific predictors of waterpipe smoking progression among adolescents in Irbid, Jordan.

METHODS

This study uses data from a school longitudinal study of smoking behavior in Irbid, Jordan. A random sample of 19 schools was selected by probability proportionate to size. A total of 1781 seventh graders were enrolled at baseline, and completed a questionnaire annually from 2008 through 2011. Students who reported ever smoking waterpipe (N=864) at any time point were assessed for progression (escalation in the frequency of waterpipe smoking) in the subsequent follow-up. Grouped-time survival analysis was used to identify the risk of progression.

RESULTS

During the three years of follow-up, 29.6% of students progressed in waterpipe smoking. Predictors of waterpipe smoking progression were higher mother's education, enrollment in public school, frequent physical activity, and low refusal self-efficacy among boys, having ever smoked cigarettes, and having friends and siblings who smoke waterpipe among girls. Awareness of harms of waterpipe was protective among boys and seeing warning labels on the tobacco packs was protective among girls.

CONCLUSIONS

Even at this early stage, about a third of waterpipe smokers progressed in their habit during the 3 year follow up. Factors predicting progression of use differed by gender, which calls for gender-specific approaches to waterpipe interventions among Jordanian youth.

Waterpipe (Hookah) Smoking Among Youth and Women in Canada is New, not Traditional

INTRODUCTION

When asserting the right of individuals to be free to smoke a hookah (waterpipe [WP]) in public places, the "cultural" importance of the practice is often cited. The purpose of this study was to explore the cultural significance of WP smoking.

METHODS

Qualitative methods were used to elicit the views of groups of WP smokers from different cultural backgrounds.

RESULTS

Sixteen group discussion sessions with a total of 75 WP smokers aged between 18 and 30 were conducted. A few participants saw culture as a factor supporting WP smoking initiation and maintenance. The vast majority indicated that WPs being perceived as "healthier" than cigarettes, and the availability of flavored shisha as important factors in their initiation and ongoing use. Most started smoking before the age of 18 calling it a "high school thing" and admitted that they had easy access to WP cafés. Many indicated that they did not know if they were smoking tobacco or a "herbal" substance.

CONCLUSION

Peer influence, availability of flavored products and facile access to WP cafés are major factors in WP initiation. Ethno-cultural traditions play only a minor role. The assertion that cultural traditions and practice are inherent in WP smoking as implied by media and marketing was not supported by our findings. Contemporary use of WP is spreading among new non-traditional users. Lack of knowledge about the harms of WP smoking indicates a need for education and regulation to require packaging and health warning labels and restrictions on access, especially to minors.

A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040

The time has come for the world to acknowledge the unacceptability of the damage being done by the tobacco industry and work towards a world essentially free from the sale (legal and illegal) of tobacco products. A tobacco-free world by 2040, where less than 5% of the world's adult population use tobacco, is socially desirable, technically feasible, and could become politically practical. Three possible ways forward exist: so-called business-as-usual, with most countries steadily implementing the WHO Framework Convention on Tobacco Control (FCTC) provisions; accelerated implementation of the FCTC by all countries; and a so-called turbo-charged approach that complements FCTC actions with strengthened UN leadership, full engagement of all sectors, and increased investment in tobacco control. Only the turbo-charged approach will achieve a tobacco-free world by 2040 where tobacco is out of sight, out of mind, and out of fashion--yet not prohibited. The first and most urgent priority is the inclusion of an ambitious tobacco target in the post-2015 sustainable development health goal. The second priority is accelerated implementation of the FCTC policies in all countries, with full engagement from all sectors including the private sector--from workplaces to pharmacies--and with increased national and global investment. The third priority is an amendment of the FCTC to include an ambitious global tobacco reduction goal. The fourth priority is a UN high-level meeting on tobacco use to galvanise global action towards the 2040 tobacco-free world goal on the basis of new strategies, new resources, and new players. Decisive and strategic action on this bold vision will prevent hundreds of millions of unnecessary deaths during the remainder of this century and safeguard future generations from the ravages of tobacco use.

Promotion of waterpipe tobacco use, its variants and accessories in young adult newspapers: a content analysis of message portrayal

The objective of our study was to identify waterpipe tobacco smoking advertisements and those that promoted a range of products and accessories used to smoke waterpipe tobacco. The content of these advertisements was analyzed to understand the messages portrayed about waterpipe tobacco smoking in young adult (aged 18-30) newspapers. The study methods include monitoring of six newspapers targeting young adults from four major cities in the Southeastern United States over a 6-month period. A total of 87 advertisements were found; 73.5% (64) were distinct and content analyzed. The study results showed that of the advertisements analyzed, 25% advertised waterpipe tobacco smoking, 54.7% featured waterpipe tobacco smoking and other tobacco use, 14.1% featured non-tobacco waterpipe variants (i.e. vaporizers), and 6.3% featured waterpipe apparatus accessories (e.g. charcoal, hoses). The sociability (34%) and sensuality (29.7%) of waterpipe smoking were promoted themes. Alternative to cigarette use messages (3.1%), and harm-reduction messages (17.1%) emphasized that smoking waterpipe tobacco using the featured accessory or waterpipe variant was a healthier experience than cigarette smoking. The study concluded that the messages that promoted waterpipe tobacco smoking to young adults are parallel to those used to promote cigarette use. Tobacco control professionals should continue to monitor young adult newspapers as a source of waterpipe-related advertising.

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally

Objective

The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review.

Data sources

The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms.

Study selection

Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10–29 years.

Data extraction

Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results.

Data synthesis

The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels.

Conclusions

The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

Social norms and attitudes linked to waterpipe use in the Eastern Mediterranean Region

Waterpipe tobacco smoking (WTS) is on the rise globally, particularly among vulnerable populations such as youth and women. Increasing knowledge about toxicant yield from waterpipe tobacco and deleterious health effects points to the potential for a health epidemic. WTS is often viewed as a safe alternative to cigarette smoking. Though the original objective of the research was to explore the social norms and attitudes that lead to waterpipe being a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean Region, the use of a qualitative research methodology resulted in rich data that helped to understand more generally the phenomenon of waterpipe smoking. Both focus group discussions (FGDs) and key informant interviews were used. Participants were recruited to represent genders, various age groups, socioeconomic status, waterpipe smoking status, and residents of urban and rural areas. A total of 81 FGDs and 38 in-depth interviews were conducted in 2007. Thematic analysis was used to analyze the transcripts. A total of ten themes emerged: socio-cultural norms, gender differences, motivation to smoke, sensory characteristics of waterpipe, metaphors, consumerism, indicators of dependence, comparison between cigarettes and waterpipe, health effect of smoking, and intervention. Results indicated that WTS has socio-cultural dynamics associated with it that are far more pronounced than health considerations. An increased socio-cultural acceptability, the perceived reduced harm and the advent of the fruity Moassel tobacco are among the many reasons for WTS acceptability. Findings point to the need for a unified strategy to address this health issue at all levels of the ecological framework and have important implications for future policy and practice.