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Saad RK, Maiteh A, Nakkash R, Salloum RG, Chalak A, Abu-Rmeileh NME, Khader Y, Al Nsour M. Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation. JMIR Public Health Surveill 2023; 9:e40177. [PMID: 36951907 PMCID: PMC10132023 DOI: 10.2196/40177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 02/16/2023] Open
Abstract
Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.
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Affiliation(s)
- Randa K Saad
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
| | - Adna Maiteh
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, United States
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Florida, FL, United States
| | - Ali Chalak
- Department of Agriculture, Faculty of Agricultural and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territory
| | - Yousef Khader
- Public Health, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohannad Al Nsour
- Global Health Development | Eastern Mediterranean Public Health Network, Amman, Jordan
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Ebrahimi Kalan M, Bahelah R, Bursac Z, Ward KD, Ben Taleb Z, Tleis M, Jebai R, Asfar T, Eissenberg T, Maziak W. A Group-based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers. Nicotine Tob Res 2021; 23:2056-2064. [PMID: 34125916 DOI: 10.1093/ntr/ntab128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Adolescence represents a critical period in which nicotine dependence(ND) symptoms are developing. Little is known about waterpipe(WP) smoking and developmental trajectories of ND criteria across adolescence. Here, we aimed to identify ND trajectories from early to late adolescence in current(past 30 days) WP smokers and examine baseline correlates of each identified trajectory, using the International Classification of Diseases, 10thVersion(ICD10). METHODS The analytical sample consisted of 278 current WP smokers from 8-waves of an ongoing longitudinal cohort of 8 th-9 th-graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages11-18. RESULTS A group-based modeling approach yielded a four-class solution that best fit the data and reflected differences in the timing of ND onset during adolescence:no-onset of ND(43.9%), early(16.2%), mid(26.6%), and late-onset(13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio[aOR]=4.08, 95%confidence interval:1.01-16.53) and siblings who smoke WP(aOR=3.95:1.08-14.42), exposure to favorite WP-specific advertisements(aOR=3.33:1.03-10.85), and being a novelty seeker(aOR=1.12:1.02-1.23) were associated with early-onset of ND. Daily(aOR=3.48:1.08-11.23) or weekly(aOR=2.20:1.05-4.62) WP smokers (vs. monthly) and having higher stress level (aOR=1.07:1.00-1.14) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR=0.11:0.02-0.82) and spending >60 minutes on a WP smoking session(aOR=5.62:1.20-26.44) were associated with late-onset ND trajectory class. CONCLUSIONS Monitoring the development of ND trajectories among WP smokers may identify an individual as belonging to one of these four groups with distinct individual and socio-environmental factors, and allow the individual and healthcare providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions.
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Affiliation(s)
- Mohammad Ebrahimi Kalan
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St AHC5, 4th Floor, Miami, FL, 33199, USA
| | - Raed Bahelah
- School of Health Sciences, Baldwin Wallace University, Kamm Hall, 191 E Center St, Berea, OH 44017, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St AHC5, 4th Floor, Miami, FL, 33199, USA
| | - Kenneth D Ward
- School of Public Health, University of Memphis, 3720 Alumni Ave, Memphis, TN 38152, USA
| | - Ziyad Ben Taleb
- Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, 411 S. Nedderman Drive Box 19407, Arlington, Texas 76019-0407, USA
| | - Malak Tleis
- Health Promotion and Community Health Department, Faculty of Health Sciences, American University of Beirut, Bliss Street. P.O. Box 11-0236. Beirut, Lebanon. Miami, FL 3313, USA
| | - Rime Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St AHC5, 4th Floor, Miami, FL, 33199, USA
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Thomas Eissenberg
- Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St AHC5, 4th Floor, Miami, FL, 33199, USA
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Soneji S, Knutzen KE, Gravely S, Elton-Marshall T, Sargent J, Lambert E, Hilmi N, Sharma E, Jackson KJ, Wang B, Robinson J, Driezen P, Bover Manderski M, Bansal-Travers M, Hyland A, Travers M, Yang DH, Dang R, Fong GT. Transitions in frequency of hookah smoking among youth and adults: findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study, 2013-15. Addiction 2021; 116:936-948. [PMID: 32896050 DOI: 10.1111/add.15250] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/01/2020] [Accepted: 09/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers. DESIGN Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at wave 1 (2013-14); frequency of hookah smoking and past-year cessation were ascertained at wave 2 (2014-15). Weighted multivariable logistic and ordinal logistic regression models were fitted to predict hookah smoking cessation and frequency of hookah smoking at wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking and frequency of hookah smoking at wave 1. SETTING United States. PARTICIPANTS A total of 693 youth and 4400 adult past-year hookah smokers. MEASUREMENTS Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI). FINDINGS At wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Among all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, the availability of appealing flavors and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors [adjusted odds ratio (aOR) = 0.40; 95% confidence interval (CI) = 0.26-0.62] compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly or more frequent hookah smoking at wave 2, compared with cessation or less than monthly smoking, were higher for adults who liked hookah flavors [adjusted proportional odds ratio (aPOR) = 2.10; 95% CI = 1.48-2.99 and enjoyed socializing while smoking hookah (aPOR = 1.82; 95% CI =1.13-2.94) compared with adults who did not like hookah flavors or socializing. CONCLUSION The availability of appealing flavors, affordability and socialization while smoking hookah in the United States are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.
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Affiliation(s)
- Samir Soneji
- Dartmouth-Hitchcock Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Health Behavior, University of North Carolina, Chapel Hill, NC, USA
| | - Kristin E Knutzen
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Shannon Gravely
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Tara Elton-Marshall
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - James Sargent
- Dartmouth-Hitchcock Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Elizabeth Lambert
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, USA
| | - Nahla Hilmi
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, USA
- Kelly Government Solutions, Rockville, MD, USA
| | | | - Kia J Jackson
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Baoguang Wang
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Joelle Robinson
- Office of Science, Center for Tobacco Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Pete Driezen
- Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
| | - Michelle Bover Manderski
- Center for Tobacco Studies, School of Public Health, Rutgers, State University of New Jersey, Piscataway, NJ, USA
| | - Maansi Bansal-Travers
- Department of Health Behavior, Division of Cancer Prevention and Population Sciences, Roswell Park Comprehensive Cancer Center, Buffalo, New York, NY, USA
| | - Andrew Hyland
- Department of Health Behavior, Division of Cancer Prevention and Population Sciences, Roswell Park Comprehensive Cancer Center, Buffalo, New York, NY, USA
| | - Mark Travers
- Department of Health Behavior, Division of Cancer Prevention and Population Sciences, Roswell Park Comprehensive Cancer Center, Buffalo, New York, NY, USA
| | | | - Rui Dang
- University of Information Science and Technology, Ohrid, North Macedonia
| | - Geoffrey T Fong
- Center for Tobacco Studies, School of Public Health, Rutgers, State University of New Jersey, Piscataway, NJ, USA
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Khani Jeihooni A, Afzali Harsini P. The Effect of an Educational Intervention Based on PRECEDE Model on Oral Cancer Prevention Behaviors in Hookah Users. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:1250-1260. [PMID: 31359373 DOI: 10.1007/s13187-019-01591-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Educational intervention about oral cancer prevention is essential for all people, especially in hookah users. The aim of this study is investigating the effect of an educational intervention based on PRECEDE model on oral cancer prevention in hookah users living in Fasa, Fars Province, Iran, in 2017-2018. In this quasi-experimental study, 360 hookah users were selected and divided into experimental and control groups (180 subjects for each group). Educational intervention was performed for experimental group in 12 sessions. A questionnaire consisting of items evaluating demographic information and PRECEDE model constructs (knowledge, attitude, self-efficacy, enabling factors, and reinforcing factors) was used to measure oral cancer prevention behaviors and nicotine dependency of subjects before and 6 months after intervention. Obtained data were analyzed by SPSS-22 software through paired t test, independent t test, and chi-square test at significance level of P < 0.05. Six months after intervention, experimental group showed significant increase in knowledge, attitude, self-efficacy, enabling factors, reinforcing factors, oral cancer prevention behaviors, and reduction of nicotine dependency compared with control group. This study showed the efficiency of educational intervention based on PRECEDE model in adoption of oral cancer prevention behaviors and reduction of nicotine dependency of hookah users 6 months after intervention.
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Affiliation(s)
- Ali Khani Jeihooni
- Department of Public Health, School of Health, Fasa University of Medical Sciences, Fasa Ibn Sina square, Fasa, 7461686688, Iran.
| | - Pooyan Afzali Harsini
- Department of Public Health, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Bernd K, DeGrood D, Stadtler H, Coats S, Carmack D, Mailig R, Lidsky S, Hauser C. Contributions of charcoal, tobacco, and syrup to the toxicity and particle distribution of waterpipe tobacco smoke. Toxicol Lett 2019; 313:60-65. [PMID: 31226396 DOI: 10.1016/j.toxlet.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 06/05/2019] [Accepted: 06/11/2019] [Indexed: 12/01/2022]
Abstract
The use of waterpipes in the United States is increasing in a largely unregulated market. The shisha smoked in a waterpipe is a complex matrix of tobacco, flavorings, and humectant with smoke generated by an external heat source. This study explored the relationship between shisha components and the particulate matter size distributions and toxicity of smoke generated with heating. Standard waterpipe puff topography of charcoal- or electronic- heated whole shisha and shisha components generated smoke particulate matter that was characterized using a TSI Engine Exhaust Particle Sizer. Relative toxicity of the whole smoke was determined via measurement of lysosomal integrity and measures of membrane integrity following acute exposure of type II alveolar cells at the air-liquid interface. All waterpipe aerosols exhibited a unimodal particle size distribution, the peak and concentration of which varied depending upon the shisha components present. Acute exposure to charcoal-heated whole shisha, flavoring syrup, or humectant smoke, or electronic-heated whole shisha smoke caused significant alveolar cell damage and death, indicating neither tobacco nor charcoal are needed for these cytotoxic effects to occur.
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Affiliation(s)
- Karen Bernd
- Biology Department, Davidson College, Davidson, NC, USA.
| | - David DeGrood
- Chemistry Department, Davidson College, Davidson, NC, USA
| | | | - Sarah Coats
- Chemistry Department, Davidson College, Davidson, NC, USA
| | - Dylan Carmack
- Chemistry Department, Davidson College, Davidson, NC, USA
| | - Ronnae Mailig
- Chemistry Department, Davidson College, Davidson, NC, USA
| | - Samuel Lidsky
- Chemistry Department, Davidson College, Davidson, NC, USA
| | - Cindy Hauser
- Chemistry Department, Davidson College, Davidson, NC, USA
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Kothari S, Berg CJ. Reasons for use, potential use, or discontinued use of hookah among US young adult college students. Tob Prev Cessat 2018; 4. [PMID: 30272038 PMCID: PMC6159938 DOI: 10.18332/tpc/81860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Given the increase in hookah use among young adults, characteristics of hookah use/users, as well as reasons for its use or discontinuation among young adults, are critical to understand. METHODS Data from a study of 18–25 year olds from seven Georgia colleges/universities (n=2865) were analyzed to examined: 1) differences in socio-demographics and other substance use among current (past 4 months), never, and former hookah users; 2) use characteristics among current users (e.g. device types/flavors used, quit intentions); and 3) reasons for use, potential use, and discontinued use among current, never, and former users. RESULTS Of the students, 56.3% were never users, 12.4% were current, and 31.3% former users. Correlates of being a current (vs never) user included being ‘other race’ (vs White), attending a historically black college/university (HBCU vs technical college), and use of other substances. Correlates of being a former (vs never) hookah user included being older (vs younger), being ‘other race’ (vs White), attending an HBCU (vs technical college), and use of other tobacco products, marijuana, or alcohol. Among current users, 73.7% reported no intention to quit; 26.2% attempted to quit in the past year. Two factors were identified regarding reasons for current use (flavors, social reasons): one factor regarding potential use among never users (related to flavors and social factors), and three factors regarding discontinued use (inconvenience, anti-tobacco attitude, social reasons). CONCLUSIONS Findings indicate the risk factors for hookah use and the importance of particular factors (e.g. flavors, social influences) relevant to regulation/policy.
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Affiliation(s)
- Shreya Kothari
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, United States
| | - Carla J Berg
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, United States.,Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, United States.,Winship Cancer Institute, Emory University, Atlanta, United States
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Abstract
Objectives To inform targeted prevention efforts, it is important to understand which tobacco products are used first and associations by demographic characteristics. Methods We conducted a nationally-representative random digit-dial telephone survey of 1125 adolescents ages 13-17. Adolescents reported the first tobacco product they tried, and we analyzed associations with demographic variables. Results Two-hundred nineteen (18.6%) adolescents reported ever using a tobacco product. The most common first product tried was cigarettes (35.4%), followed by electronic nicotine delivery systems (24.3%), smokeless tobacco (17.7%), cigars (11.4%), and waterpipe (11.2%). Weighted multivariable logistic regression analyses showed girls were 2.7 times more likely than boys to report cigarettes as their first product, Hispanic/Latinos were 5.0 times more likely than non-Hispanic/Latinos to report cigarettes, and those whose mothers had at least a 4-year college degree were 6.1 times more likely to report waterpipe compared to those whose mothers had less than a 4-year college degree. Conclusions Nearly one in 5 adolescents had tried a tobacco product. Although cigarettes were the most frequently reported product, most youth initiated with a non-cigarette tobacco product, and demographic differences were found. These findings point towards potential regulatory policies, including targeted campaigns, which might deter adolescents from initiating tobacco use.
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Nasr SZ, Nasrallah AI, Abdulghani M, Sweet SC. The impact of conventional and nonconventional inhalants on children and adolescents. Pediatr Pulmonol 2018; 53:391-399. [PMID: 29084362 DOI: 10.1002/ppul.23836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 01/16/2023]
Abstract
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.
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Affiliation(s)
- Samya Z Nasr
- Division of Pediatric Pulmonology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Stuart C Sweet
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St. Louis, Missouri
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9
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Khabour OF, Alzoubi KH, Al-Sawalha N, Ahmad MB, Shihadeh A, Eissenberg T. The effect of chronic exposure to waterpipe tobacco smoke on airway inflammation in mice. Life Sci 2018; 200:110-114. [PMID: 29555589 DOI: 10.1016/j.lfs.2018.03.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 03/08/2018] [Accepted: 03/16/2018] [Indexed: 12/14/2022]
Abstract
PURPOSE Acute exposure of experimental animals to waterpipe tobacco smoke has been shown to induce lung inflammation and injury. The aim of this study was to investigate the effect of chronic exposure to waterpipe smoke on inflammatory markers and oxidative stress in the mouse lung. METHOD Using a whole-body exposure system, animals were exposed to waterpipe smoke for 6 weeks with a one-hour daily exposure for 5 days a week. RESULTS Exposure to waterpipe tobacco smoke induced the recruitment of inflammatory cells to the airway. Significant elevation in macrophages, lymphocytes and neutrophils was detected in the bronchoalveolar lavage fluid of exposed animals (P < 0.01). Furthermore, levels of catalase, glutathione peroxidase (GPx) and superoxide dismutase (SOD) in the lung homogenates were elevated (P < 0.05). Finally, waterpipe smoking altered the levels of a panel of inflammatory cytokines including TNFα, IL-1 β, IL-6, IL-10 and IL-12 biomarkers in the lung of exposed animals (P < 0.05). CONCLUSION These results support the notion that waterpipe tobacco smoking exerts harmful respiratory health effects.
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Affiliation(s)
- Omar F Khabour
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan.
| | - Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Nour Al-Sawalha
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Mohammad Bani Ahmad
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Alan Shihadeh
- Mechanical Engineering Department, American University of Beirut, Beirut, Lebanon; Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, VA, United States
| | - Thomas Eissenberg
- Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, VA, United States; Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, VA, United States
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10
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Singh N, Jawad M, Darzi A, Lotfi T, Nakkash R, Hawkins B, Akl EA. Features of the waterpipe tobacco industry: A qualitative study of the third International Hookah Fair. F1000Res 2018; 7:247. [PMID: 30728948 PMCID: PMC6347030 DOI: 10.12688/f1000research.13796.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2018] [Indexed: 10/06/2023] Open
Abstract
Background: Little research has been done to uncover the features of the waterpipe tobacco industry, which makes designing effective interventions and policies to counter this growing trend challenging. The objective of this study is to describe the features of the waterpipe industry. Methods: In 2015, we randomly sampled and conducted semi-structured interviews with representatives of waterpipe companies participating in a trade exhibition in Germany. We used an inductive approach to identify emerging themes. Results: We interviewed 20 representatives and four themes emerged: industry growth, cross-industry overlap, customer-product relationship, and attitude towards policy. The industry was described as transnational, generally decentralized, non-cartelized, with ad hoc relationships between suppliers, distributors and retailers. Ties with the cigarette industry were apparent. The waterpipe industry appeared to be in an early growth phase, encroaching on new markets, and comprising of mainly small family-run businesses. Customer loyalty appears stronger towards the waterpipe apparatus than tobacco. There was a notable absence of trade unionism and evidence of deliberate breaches of tobacco control laws. Conclusion: The waterpipe industry appears fragmented but is slowly growing into a mature, globalized, and customer-focused industry with ties to the cigarette industry. Now is an ideal window of opportunity to strengthen public health policy towards the waterpipe industry, which should include a specific legislative waterpipe framework.
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Affiliation(s)
- Neil Singh
- Brighton and Sussex Medical School, Brighton, UK
| | - Mohammed Jawad
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Andrea Darzi
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Tamara Lotfi
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
- Department of Epidemiology and Biostatistics, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
| | - Benjamin Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Elie A. Akl
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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11
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Singh N, Jawad M, Darzi A, Lotfi T, Nakkash R, Hawkins B, Akl EA. Features of the waterpipe tobacco industry: A qualitative study of the third International Hookah Fair. F1000Res 2018; 7:247. [PMID: 30728948 PMCID: PMC6347030 DOI: 10.12688/f1000research.13796.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Little research has been done to uncover the features of the waterpipe tobacco industry, which makes designing effective interventions and policies to counter this growing trend challenging. The objective of this study is to describe the features of the waterpipe industry. Methods: In 2015, we randomly sampled and conducted semi-structured interviews with 20 representatives of waterpipe companies participating in a trade exhibition in Germany. We used an inductive approach to identify emerging themes. Results: We interviewed representatives and four themes emerged: industry globalisation, cross-industry overlap, customer-product relationship, and attitude towards policy. The industry was described as transnational, generally decentralized, non-cartelized, with ad hoc relationships between suppliers, distributors and retailers. Ties with the cigarette industry were apparent. The waterpipe industry appeared to be in an early growth phase, encroaching on new markets, and comprising of mainly small family-run businesses. Customer loyalty appears stronger towards the waterpipe apparatus than tobacco. There was a notable absence of trade unionism and evidence of deliberate breaches of tobacco control laws. Conclusion: The waterpipe industry appears fragmented but is slowly growing into a mature, globalized, and customer-focused industry with ties to the cigarette industry. Now is an ideal window of opportunity to strengthen public health policy towards the waterpipe industry, which should include a specific legislative waterpipe framework.
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Affiliation(s)
- Neil Singh
- Brighton and Sussex Medical School, Brighton, UK
| | - Mohammed Jawad
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Andrea Darzi
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Tamara Lotfi
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
- Department of Epidemiology and Biostatistics, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
| | - Benjamin Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Elie A. Akl
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Joveini H, Dehdari T, Ardebili HE, Mahmoudi M, Firouzian AA, Rohban A. Factors Associated with Hookah Smoking among University Students. Electron Physician 2016; 8:3403-3408. [PMID: 28163855 PMCID: PMC5279973 DOI: 10.19082/3403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/22/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND These days, hookah smoking has gained popularity among people in many communities, especially among youths and students, and more attention to this issue seems necessary. The purpose of this study was to determine the factors affecting hookah smoking among Sabzevar Azad University students. METHODS This cross-sectional study was conducted on university students in Sabzevar, Iran in 2014. The questionnaire was developed and its validity and reliability were assessed. Three hundred six male students of Sabzevar Azad University were selected by simple random sampling and questionnaires were filled out by them. The collected data were analyzed by SPSS software and the Chi-Square and Independent-samples t-test. RESULTS The results showed that 47.7% of the participants had a history of smoking hookah. The main factors affecting hookah smoking from participants' point of view were: filling leisure time, availability of hookah, positive social appearance, friends' invitation and relief from anxieties. Chi-Square tests showed that there was no significant relationship between fathers' level of education (p=0.41), mothers' level of education (p=0.46), fathers' job (p=0.18), mothers' job (p=0.53) and students' current grade (p=0.41) with hookah smoking. The study showed significant relationship between present hookah smoking and awareness about complications of the hookah (p=0.01). CONCLUSION Interventions to reduce and quit hookah smoking among students should include several items, such as teaching problem-solving skills to fill leisure time properly and to deal with the temptation of hookah smoking, as well as teaching refusal skills at the invitation of friends for hookah.
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Affiliation(s)
- Hamid Joveini
- Ph.D. Candidate in Health Education and Promotion, Faculty of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Taherh Dehdari
- Assistant Professor of Health Education, Department of Health Education and Promotion, School of Health, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Eftekhar Ardebili
- Professor, Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Mahmoudi
- Professor, Department of Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran Iran
| | - Ali Asghar Firouzian
- M.Sc. in Nursing, Educator, Esfarayan University of Medical Sciences, Esfarayen, Iran
| | - Alireza Rohban
- M.Sc. in Rehabilitation Management, School of Rehabilitation, Iran University of Medical Sciences, Tehran, Iran
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13
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Islam F, Salloum RG, Nakkash R, Maziak W, Thrasher JF. Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health 2016; 61:709-715. [PMID: 26971508 PMCID: PMC4992403 DOI: 10.1007/s00038-016-0805-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 01/27/2016] [Accepted: 02/25/2016] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Youth have the misperception that waterpipe smoking is less harmful than cigarettes despite the evidence that it is associated with nicotine dependence and many of the diseases caused by cigarettes. There is a pressing need to identify effective health warnings that increase awareness about the harmful effects of waterpipe smoking. Our objective was to test the effectiveness of various health warning messages and their location on waterpipe devices. METHODS Adult waterpipe smokers from a large US university (N = 367) completed an internet-based survey that tested the effect of text-only and pictorial health warning labels and their location on different parts of waterpipe smoking devices. RESULTS Text-only messages and pictorial labels warning about harm to children were the most effective in motivating waterpipe smokers to think about quitting. In terms of warning label location, the base, mouthpiece and stem are all equally noticeable locations. CONCLUSIONS This is the first study to test waterpipe-specific warning labels and location on the waterpipe device. Placing waterpipe-specific labels on waterpipe devices may be an effective policy tool to curb waterpipe smoking.
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Affiliation(s)
- Farahnaz Islam
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Policy, and Institute for Child Health Policy, University of Florida College of Medicine, PO Box 100177, Gainesville, FL, 32610-0177, USA.
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Wasim Maziak
- Department of Epidemiology, Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - James F Thrasher
- Department of Health, Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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[Waterpipe (shisha) smoking among adolescents in Germany: Results of the KiGGS study: first follow-up (KiGGS Wave 1)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 58:467-73. [PMID: 25665891 DOI: 10.1007/s00103-015-2128-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND At the beginning of the 21st century, waterpipe (shisha) smoking has become a new and global youth trend in tobacco consumption. Despite the fact that this type of tobacco use can also lead to serious health problems, there are only a few studies on this topic in Germany. OBJECTIVES The aim of this study was to determine the prevalence of waterpipe smoking among 12- to 17-year-old adolescents. Age- and sex-related differences were analyzed and, for the first time in Germany, the association between parental socioeconomic status and waterpipe use was examined. MATERIALS AND METHODS Data were obtained from the first follow-up of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS Wave 1), which was conducted from 2009 to 2012. Waterpipe smoking was assessed among adolescents aged 12 to 17 years using three items (n = 4,543). We calculated prevalence rates and age-adjusted odds ratios (OR) with 95 % confidence intervals (95 % CI). RESULTS Lifetime prevalence of waterpipe use was 28.9 % (95 % CI: 26.9-31.0). Approximately one fifth (20.6 %; 95 % CI: 18.8-22.6) of the adolescents reported waterpipe use in the past 12 months, one tenth (10.0 %; 95 % CI: 8.6-11.6) reported current use (at least once during the past 30 days). In both sexes, prevalence increased with age. Waterpipe smoking rates were significantly higher among boys than girls, while no significant differences were found regarding parental socioeconomic status. CONCLUSIONS A considerable number of adolescents in Germany are at least occasional waterpipe (shisha) smokers. Because of waterpipe related health and addiction risks that are often underestimated by adolescents, specific health education and prevention measures are necessary.
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Jawad M, Choaie E, Brose L, Dogar O, Grant A, Jenkinson E, McEwen A, Millett C, Shahab L. Waterpipe Tobacco Use in the United Kingdom: A Cross-Sectional Study among University Students and Stop Smoking Practitioners. PLoS One 2016; 11:e0146799. [PMID: 26745806 PMCID: PMC4706414 DOI: 10.1371/journal.pone.0146799] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Despite cigarette-like adverse health outcomes associated with waterpipe tobacco smoking and increase in its use among youth, it is a much underexplored research area. We aimed to measure the prevalence and patterns of waterpipe tobacco use and evaluate tobacco control policy with respect to waterpipe tobacco, in several universities across the UK. We also aimed to measure stop smoking practitioners' encounter of waterpipe tobacco smoking. METHODS We distributed an online survey to six UK universities, asking detailed questions on waterpipe tobacco. Multivariable logistic regression models, adjusted for age, gender, ethnicity, graduate status, university and socioeconomic status (SES) assessed associations between waterpipe tobacco smoking (single use and dual use with cigarettes) and sociodemographic variables. SES was ascertained by average weekly self-spend on non-essentials. We also descriptively analysed data from a 2012 survey of stop smoking practitioners to assess the proportion of clients that used waterpipe regularly. RESULTS f 2217 student responses, 66.0% (95% CI 63.9-68.0%) had tried waterpipe tobacco smoking; 14.3% (95% CI 12.8-15.8%) reported past-30 day use, and 8.7% (95% CI 7.6-9.9%) reported at least monthly users. Past-30 day waterpipe-only use was associated with being younger (AOR 0.95, 95% CI 0.91-0.99), male (AOR 1.44, 95% CI 1.08-1.94), higher SES (AOR 1.16, 95% CI 1.06-1.28) and belonging to non-white ethnicities (vs. white, AOR 2.24, 95% CI 1.66-3.04). Compared to less than monthly users, monthly users were significantly more likely to have urges to smoke waterpipe (28.1% vs. 3.1%, p<0.001) report difficulty in quitting (15.5% vs. 0.8%, p<0.001), report feeling guilty, and annoyed when criticised about waterpipe smoking (19.2% vs. 9.2%, p<0.001). Nearly a third (32.5%) of respondents who had tried waterpipe had violated the UK smokefree law and a quarter (24.5%) reporting seeing health warnings on waterpipe tobacco packaging or apparatuses. Of 1,282 smoking cessation practitioners, a quarter (23.4%, 95% CI 21.5-26.1%) reported having some clients who regularly use waterpipes, but 69.5% (95% CI 67.0-72.0%) never ask clients about waterpipe use. Three quarters (74.8%, 95% CI 72.4-77.1%) want more information about waterpipe tobacco smoking. CONCLUSIONS While two thirds of university students have ever tried waterpipe tobacco, at least monthly use is less common. Regular users display features of waterpipe tobacco dependence, and a substantial minority of SSS practitioners encounter clients who regularly use waterpipe. The lack of training on waterpipe for SSS practitioners and reported violations of smokefree laws for waterpipe highlight the need for regular surveillance of and a coordinated tobacco control strategy for waterpipe use.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, Hammersmith, W6 8RP, United Kingdom
- Academic Unit of Primary Care and Population Sciences, University of Southampton, Hampshire, SO16 6YD, United Kingdom
- * E-mail:
| | - Elham Choaie
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, United Kingdom
| | - Leonie Brose
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8BB, United Kingdom
| | - Omara Dogar
- Department of Health Sciences, University of York, York, YO10 5DD, United Kingdom
| | - Aimee Grant
- Institute of Primary Care and Public Health, Cardiff University School of Medicine, Cardiff, CF14 4YS, United Kingdom
| | - Elizabeth Jenkinson
- Centre for Appearance Research, University of the West of England, Bristol, BS16 1QY, United Kingdom
| | - Andy McEwen
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, United Kingdom
| | - Christopher Millett
- Department of Primary Care and Public Health, Imperial College London, Hammersmith, W6 8RP, United Kingdom
| | - Lion Shahab
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, United Kingdom
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Kassem NOF, Jackson SR, Boman-Davis M, Kassem NO, Liles S, Daffa RM, Yasmin R, Madanat H, Hovell MF. Hookah Smoking and Facilitators/Barriers to Lounge Use among Students at a US University. Am J Health Behav 2015; 39:832-48. [PMID: 26450551 DOI: 10.5993/ajhb.39.6.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine hookah tobacco use, hookah lounge attendance, and facilitators and barriers to hookah lounge attendance. METHODS A cross-sectional Web-based survey of a random sample of 1332 undergraduate students (Mean Age = 21.2 years) attending a United States university. RESULTS The majority of respondents (72.8%) had ever smoked hookah tobacco, and 28% of those had ever smoked during adolescence. The majority of ever hookah smokers (81.5%) and a portion of never hookah smokers (20%) had ever been to a hookah lounge. The adjusted odds of ever visiting a hookah lounge were 2.1 times higher among participants who reported that the closest hookah lounge to the university was < 5 miles away than those who reported that the closest hookah lounge was ≥ 5 miles away. Facilitators of visiting hookah lounges included friends and close proximity of hookah lounges to campus; barriers included cost of smoking hookah, crowded lounges, and having to be 18 years old. CONCLUSION Youth are vulnerable to experimenting with hookah tobacco smoking. Hookah lounges provide patrons the opportunity to smoke hookah tobacco with smoker and non-smoker friends in entertaining settings. Our findings suggest that zoning laws and anti-hookah smoking legislation may help curb hookah uptake by prohibiting hookah lounges from opening in close proximity to universities, reducing the density of hookah lounges in cities, and raising the admission age for hookah lounges to 21 years.
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Affiliation(s)
- Nada O F Kassem
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA.
| | - Sheila R Jackson
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
| | | | - Noura O Kassem
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
| | - Sandy Liles
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
| | - Reem M Daffa
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
| | - Roxana Yasmin
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
| | - Hala Madanat
- Graduate School of Public Health, San Diego State University, San Diego, CA, USA
| | - Melbourne F Hovell
- Center for Behavioral Epidemiology and Community Health (CBEACH), San Diego State University Research Foundation, San Diego, CA, USA
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Jawad M, Power G. Waterpipe tobacco and electronic cigarette use in a southeast London adult sample: a cross-sectional analysis. J Public Health (Oxf) 2015; 38:e114-21. [DOI: 10.1093/pubmed/fdv106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Kassem NOF, Kassem NO, Jackson SR, Liles S, Daffa RM, Zarth AT, Younis MA, Carmella SG, Hofstetter CR, Chatfield DA, Matt GE, Hecht SS, Hovell MF. Benzene uptake in Hookah smokers and non-smokers attending Hookah social events: regulatory implications. Cancer Epidemiol Biomarkers Prev 2015; 23:2793-809. [PMID: 25416714 DOI: 10.1158/1055-9965.epi-14-0576] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Benzene is a human hematotoxicant and a leukemogen that causes lymphohematopoietic cancers, especially acute myelogenous leukemia. We investigated uptake of benzene in hookah smokers and non-smokers attending hookah social events in naturalistic settings where hookah tobacco was smoked exclusively. METHODS We quantified S-phenylmercapturic acid (SPMA), a metabolite of benzene, in the urine of 105 hookah smokers and 103 non-smokers. Participants provided spot urine samples the morning of and the morning after attending an indoor hookah-only smoking social event at a hookah lounge or in a private home. RESULTS Urinary SPMA levels in hookah smokers increased significantly following a hookah social event (P < 0.001). This increase was 4.2 times higher after hookah lounge events (P < 0.001) and 1.9 times higher after home events (P = 0.003). In non-smokers, urinary SPMA levels increased 2.6 times after hookah lounge events (P = 0.055); however, similar urinary SPMA levels were detected before and after home events, possibly indicating chronic exposure to benzene (P = 0.933). CONCLUSIONS Our data provide the first evidence for uptake of benzene in hookah smokers and non-smokers exposed to hookah tobacco secondhand smoke at social events in private homes compared with their counterparts in hookah lounges. Hookah tobacco smoke is a source of benzene exposure, a risk factor for leukemia. IMPACT Because there is no safe level of exposure to benzene, our results call for interventions to reduce or prevent hookah tobacco use, regulatory actions to limit hookah-related exposure to toxicants including benzene, initiate labeling of hookah-related products, and include hookah smoking in clean indoor air legislation.
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Impact of Waterpipe Tobacco Pack Health Warnings on Waterpipe Smoking Attitudes: A Qualitative Analysis among Regular Users in London. BIOMED RESEARCH INTERNATIONAL 2015; 2015:745865. [PMID: 26273642 PMCID: PMC4529913 DOI: 10.1155/2015/745865] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/18/2015] [Accepted: 02/25/2015] [Indexed: 11/22/2022]
Abstract
Background. Despite the rise in prevalence of waterpipe tobacco smoking, it has received little legislative enforcement from governing bodies, especially in the area of health warning labels. Methods. Twenty regular waterpipe tobacco smokers from London took part in five focus groups discussing the impact of waterpipe tobacco pack health warnings on their attitudes towards waterpipe smoking. We presented them with existing and mock waterpipe tobacco products, designed to be compliant with current and future UK/EU legislation. Data were analysed using thematic analysis. Results. Participants felt packs were less attractive and health warnings were more impactful as health warnings increased in size and packaging became less branded. However, participants highlighted their lack of exposure to waterpipe tobacco pack health warnings due to the inherent nature of waterpipe smoking, that is, smoking in a café with the apparatus already prepacked by staff. Health warnings at the point of consumption had more reported impact than health warnings at the point of sale. Conclusions. Waterpipe tobacco pack health warnings are likely to be effective if compliant with existing laws and exposed to end-users. Legislations should be reviewed to extend health warning labels to waterpipe accessories, particularly the apparatus, and to waterpipe-serving premises.
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Jawad M, Nakkash RT, Hawkins B, Akl EA. Gaining Insights Into the Waterpipe Tobacco Industry: Participant Observation and a Cross-Sectional Survey of Products at a Trade Exhibition. Nicotine Tob Res 2015; 18:874-8. [PMID: 26175460 DOI: 10.1093/ntr/ntv155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/07/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The rise in waterpipe tobacco smoking has been accompanied by the emergence of a diverse range of products, such as "herbal" waterpipe tobacco substitutes and electronic waterpipes. The aims of this study were to assess the extent to which emerging waterpipe products are being developed by waterpipe tobacco companies themselves, to understand the key characteristics of the main market players, and to examine the connections between producers of different product categories. METHODS In 2014, one researcher attended an international waterpipe trade exhibition in Germany, conducting a survey of products at exhibition stands, and gathering qualitative data on exhibitors and products using participant observation. Cross-tabulations and chi-square tests identified the association between waterpipe tobacco, waterpipe tobacco substitutes, and electronic waterpipe products. We thematically analyzed field notes into information about exhibitors and products. RESULTS Of 97 exhibitors, 55 displayed waterpipe-related products. Of these, nearly half (45%) displayed electronic waterpipe products, 38% displayed waterpipe tobacco and 23% displayed waterpipe tobacco substitutes. There was an inverse association between the display of waterpipe tobacco and electronic waterpipe products, and a positive association between the display of waterpipe tobacco and waterpipe tobacco substitutes. We found that Japan Tobacco Inc, Philip Morris, and British American Tobacco were partnered or affiliated with exhibitors displaying waterpipe-related products. CONCLUSIONS Electronic waterpipe products were the main feature of this exhibition. Waterpipe tobacco substitutes are likely to be produced by the waterpipe tobacco industry whereas electronic waterpipes are not. There is a developing interest in waterpipe-related products by transnational tobacco corporations. Further industry surveillance is warranted.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, Hammersmith, United Kingdom; Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom;
| | - Rima T Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ben Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Jawad M, Nakkash RT, Hawkins B, Akl EA. Waterpipe industry products and marketing strategies: analysis of an industry trade exhibition. Tob Control 2015; 24:e275-9. [PMID: 26149455 DOI: 10.1136/tobaccocontrol-2015-052254] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 06/20/2015] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Understanding product development and marketing strategies of transnational tobacco companies (TTCs) has been of vital importance in developing an effective tobacco control policy. However, comparatively little is known of the waterpipe tobacco industry, which TTCs have recently entered. This study aimed to gain an understanding of waterpipe tobacco products and marketing strategies by visiting a waterpipe trade exhibition. METHODS In April 2014, the first author attended an international waterpipe trade exhibition, recording descriptions of products and collecting all available marketing items. We described the purpose and function of all products, and performed a thematic analysis of messages in marketing material. RESULTS We classified waterpipe products into four categories and noted product variation within categories. Electronic waterpipe products (which mimic electronic cigarettes) rarely appeared on waterpipe tobacco marketing material, but were displayed just as widely. Claims of reduced harm, safety and quality were paramount on marketing materials, regardless of whether they were promoting consumption products (tobacco, tobacco substitutes), electronic waterpipes or accessories. CONCLUSIONS Waterpipe products are diverse in nature and are marketed as healthy and safe products. Furthermore, the development of electronic waterpipe products appears to be closely connected with the electronic cigarette industry, rather than the waterpipe tobacco manufacturers. Tobacco control policy must evolve to take account of the vast and expanding array of waterpipe products, and potentially also charcoal products developed for waterpipe smokers. We recommend that tobacco substitutes be classified as tobacco products. Continued surveillance of the waterpipe industry is warranted.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, London, UK Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Rima T Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ben Hawkins
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Jawad M, Afifi RA, Mahfoud Z, Bteddini D, Haddad P, Nakkash R. Validation of a simple tool to assess risk of waterpipe tobacco smoking among sixth and seventh graders in Lebanon. J Public Health (Oxf) 2015; 38:403-10. [PMID: 25911620 DOI: 10.1093/pubmed/fdv048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Waterpipe tobacco smoking (WTS) is highly prevalent in the Eastern Mediterranean region. While studies have identified socio-demographic factors differentiating smokers from non-smokers, validated tools predicting WTS are lacking. METHODS Over 1000 (n = 1164) sixth and seventh grade students in Lebanon were randomly assigned to a prediction model group and validation model group. In the prediction model group, backward stepwise logistic regression enabled the identification of socio-demographic and psychosocial factors associated with ever and current WTS. This formed risk scores which were tested on the validation model group. RESULTS The risk score for current WTS was out of four and included reduced religiosity, cigarette use and the perception that WTS was associated with a good time. The risk score for ever WTS was out of seven and included an additional two variables: increased age and the belief that WTS did not cause oral cancer. In the validation model group, the model displayed moderate discrimination [area under the curve: 0.77 (current), 0.68 (ever)], excellent goodness-of-fit (P > 0.05 for both) and optimal sensitivity and specificity of 80.1 and 58.4% (current), and 39.5 and 94.4%, (ever), respectively. CONCLUSIONS WTS use can be predicted using simple validated tools. These can direct health promotion and legislative interventions.
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Affiliation(s)
- Mohammed Jawad
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-2036, Riad El Solh, Beirut 1107 2020, Lebanon Department of Primary Care and Public Health, Imperial College London, London W6 8RH, UK
| | - Rema A Afifi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-2036, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Ziyad Mahfoud
- Department of Global and Public Health, Weill Cornell Medical College, PO Box 24144, Doha, Qatar
| | - Dima Bteddini
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-2036, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Pascale Haddad
- Biostatistics, Epidemiology and Biomathematics Research Core, Weill Cornell Medical College, PO Box 24144, Doha, Qatar
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-2036, Riad El Solh, Beirut 1107 2020, Lebanon
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Experiences of High School Students about the Predictors of Tobacco Use: A Directed Qualitative Content Analysis. JOURNAL OF EDUCATION AND COMMUNITY HEALTH 2015. [DOI: 10.20286/jech-02031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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24
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Jawad M, Nakkash RT, Mahfoud Z, Bteddini D, Haddad P, Afifi RA. Parental smoking and exposure to environmental tobacco smoke are associated with waterpipe smoking among youth: results from a national survey in Lebanon. Public Health 2015; 129:370-6. [PMID: 25749674 DOI: 10.1016/j.puhe.2015.01.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 01/13/2015] [Accepted: 01/16/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Waterpipe tobacco smoking (WTS) is a growing public health concern worldwide yet little is known about the epidemiology of use among young people. The objectives of this study were to examine the prevalence, patterns and correlates of WTS among students across Lebanon. STUDY DESIGN The study design was a cross sectional survey. METHODS 126-item tobacco questionnaire was conducted among 1128 sixth and seventh grade students across Lebanon. Current patterns of use were descriptively analysed, and logistic regression models examined correlates of WTS. RESULTS Ever WTS prevalence was 44.3%, current WTS prevalence was triple that of cigarettes (22.1% vs 7.4%), and 40.0% of current users were at least weekly or daily smokers. Initiation and patterns of use, as well as addiction and cessation attitudes have been reported. Significant correlates of current WTS included older age, reduced religiosity, peer and parent tobacco use, recent waterpipe advertisement exposure, increased pluralistic ignorance and current cigarette use. Significant correlates of ever WTS were similar to current WTS, but included second hand waterpipe tobacco smoke exposure at home and did not include recent waterpipe advertisement exposure. Neither gender nor socio-economic status were significant correlates of current or ever WTS. CONCLUSIONS Waterpipe is the most common form of tobacco smoking, and is used regularly, among sixth and seventh grade Lebanese students. It should be considered a public health priority with increased tobacco surveillance and legislation. Widespread educational and policy interventions might help denormalize the social acceptability of WTS. Meanwhile, more research is needed to understand the changing paradigm of WTS epidemiology and the health outcomes among young smokers.
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Affiliation(s)
- M Jawad
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut, Lebanon; Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - R T Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut, Lebanon
| | - Z Mahfoud
- Department of Global and Public Health, Weill Cornell Medical College, Doha, Qatar
| | - D Bteddini
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut, Lebanon
| | - P Haddad
- Biostatistics, Epidemiology and Biomathematics Research Core, Weill Cornell Medical College, Doha, Qatar
| | - R A Afifi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh, Beirut, Lebanon.
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Akl EA, Ward KD, Bteddini D, Khaliel R, Alexander AC, Lotfi T, Alaouie H, Afifi RA. The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally. Tob Control 2015; 24 Suppl 1:i13-i21. [PMID: 25618895 PMCID: PMC4345979 DOI: 10.1136/tobaccocontrol-2014-051906] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- E A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - K D Ward
- School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - D Bteddini
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - R Khaliel
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - A C Alexander
- School of Public Health, University of Memphis, Memphis, Tennessee, USA
| | - T Lotfi
- Faculty of Medicine, Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - H Alaouie
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - R A Afifi
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Jawad M, El Kadi L, Mugharbil S, Nakkash R. Waterpipe tobacco smoking legislation and policy enactment: a global analysis. Tob Control 2014; 24 Suppl 1:i60-i65. [PMID: 25550418 PMCID: PMC4345984 DOI: 10.1136/tobaccocontrol-2014-051911] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE (1) To review how current global tobacco control policies address regulation of waterpipe tobacco smoking (WTS). (2) To identify features associated with enactment and enforcement of WTS legislation. DATA SOURCES (1) Legislations compiled by Tobacco Control Laws (www.tobaccocontrollaws.org). (2) Weekly news articles by 'Google Alerts' (www.google.com/alerts) from July 2013 to August 2014. STUDY SELECTION (1) Countries containing legislative reviews, written by legal experts, were included. Countries prohibiting tobacco sales were excluded. (2) News articles discussing aspects of the WHO FCTC were included. News articles related to electronic-waterpipe, crime, smuggling, opinion pieces or brief mentions of WTS were excluded. DATA ABSTRACTION (1) Two reviewers independently abstracted the definition of "tobacco product" and/or "smoking". Four tobacco control domains (smokefree law, misleading descriptors, health warning labels and advertising/promotion/sponsorship) were assigned one of four categories based on the degree to which WTS had specific legislation. (2) Two investigators independently assigned at least one theme and associated subtheme to each news article. DATA SYNTHESIS (1) Reviewed legislations of 62 countries showed that most do not address WTS regulation but instead rely on generic tobacco/smoking definitions to cover all tobacco products. Where WTS was specifically addressed, no additional legislative guidance accounted for the unique way it is smoked, except for in one country specifying health warnings on waterpipe apparatuses (2) News articles mainly reported on noncompliance with public smoking bans, especially in India, Pakistan and the UK. CONCLUSIONS A regulatory framework evaluated for effectiveness and tailored for the specificities of WTS needs to be developed.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Lama El Kadi
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sanaa Mugharbil
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Salloum RG, Abbyad CW, Kohler RE, Kratka AK, Oh L, Wood KA. Assessing preferences for a university-based smoking cessation program in Lebanon: a discrete choice experiment. Nicotine Tob Res 2014; 17:580-5. [PMID: 25239962 DOI: 10.1093/ntr/ntu188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 09/03/2014] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Smoking prevalence rates in Lebanon are among the highest in the Eastern Mediterranean region. Few smoking cessation programs are offered in Lebanon and little is known about the preferences of Lebanese smokers for cessation treatment programs. OBJECTIVE To establish which attributes of smoking cessation programs are most important to Lebanese smokers. METHODS Smokers at the American University of Beirut were surveyed to elicit their preferences for, and tradeoffs between the attributes of a hypothetical university-based smoking cessation program. Preferences for medication type/mechanism, risk of benign side effects, availability of support, distance traveled to obtain medication, and price of complete treatment were assessed using the discrete choice experiment method. RESULTS The smokers' responses (N = 191) to changes in attributes were statistically significant. Smokers were willing to make trade-offs between attributes. On average, smokers were willing to pay LBP 103,000 (USD 69) for cessation support. Respondents were willing to give up LBP 105,000 (USD 70) to avoid an additional 10% risk of minor side effects and LBP 18,000 (USD 12) to avoid an addition kilometer of travel to the nearest pharmacy. Heavy smokers were the least responsive group and had the lowest demand elasticities. CONCLUSIONS Student smokers were willing to participate in a relatively complex exercise that weighs the advantages and disadvantages of a hypothetical smoking cessation program. Overall they were less interested in the pill form of smoking cessation treatment, but they were willing to make tradeoffs to be smoke-free.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC;
| | - Christine W Abbyad
- Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Racquel E Kohler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Leighanne Oh
- Department of Biomedical Engineering, Duke University, Durham, NC
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Jawad M. Legislation enforcement of the waterpipe tobacco industry: a qualitative analysis of the London experience. Nicotine Tob Res 2014; 16:1000-8. [PMID: 24642591 DOI: 10.1093/ntr/ntu022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Waterpipe tobacco smoking (WTS) is prevalent worldwide and is legislatively enforceable under many countries' existing tobacco laws. Globally, however, the waterpipe tobacco industry anecdotally appears poorly controlled. This study aimed to gather intelligence from local government (known as local authority [LA]) staff in London, United Kingdom, about their WTS enforcement experiences. METHODS In-depth telephone interviews were conducted among 26 LA staff from 14 London boroughs, exploring industry characteristics and tobacco legislation compliance. Recurrent themes were analyzed and derived deductively. RESULTS Approximately 400 waterpipe premises operate across London, benefiting from high profit margins. LA staff are resource strained, limiting their surveillance of waterpipe premises, some of which are associated with an underground culture. Noise and nuisance are key features of waterpipe premises. Most waterpipe premises were generally noncompliant with most aspects of existing tobacco legislation, mainly due to disproportionately low fines and unclear legislation enforcement guidance. Successful methods for enforcing legislation included a synchronized, multiagency approach; however, this was inconsistently implemented across boroughs. Many LA staff believe licensing waterpipe premises will improve surveillance and control the industry's proliferation. CONCLUSIONS The waterpipe tobacco industry is unregulated and places a significant burden on many LAs in London, mainly due to lack of resources. These problems may also occur in other large cities worldwide. Existing tobacco legislation should be amended to accommodate WTS, including consideration of licensing the industry. More research is needed to gain a full understanding of the waterpipe tobacco industry and its impact on other global cities.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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Jawad M, McEwen A, McNeill A, Shahab L. To what extent should waterpipe tobacco smoking become a public health priority? Addiction 2013; 108:1873-84. [PMID: 23863044 DOI: 10.1111/add.12265] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 04/08/2013] [Accepted: 05/23/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance. AIMS This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority. METHODS Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS. FINDINGS Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users. CONCLUSIONS Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals.
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Affiliation(s)
- Mohammed Jawad
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Abstract
OBJECTIVE YouTube is now the second most visited site on the internet. The authors aimed to compare characteristics of and messages conveyed by cigarette- and hookah-related videos on YouTube. METHODS Systematic search procedures yielded 66 cigarette-related and 61 hookah-related videos. After three trained qualitative researchers used an iterative approach to develop and refine definitions for the coding of variables, two of them independently coded each video for content including positive and negative associations with smoking and major content type. RESULTS Median view counts were 606,884 for cigarettes-related videos and 102,307 for hookah-related videos (p<0.001). However, the number of comments per 1000 views was significantly lower for cigarette-related videos than for hookah-related videos (1.6 vs 2.5, p=0.003). There was no significant difference in the number of 'like' designations per 100 reactions (91 vs 87, p=0.39). Cigarette-related videos were less likely than hookah-related videos to portray tobacco use in a positive light (24% vs 92%, p<0.001). In addition, cigarette-related videos were more likely to be of high production quality (42% vs 5%, p<0.001), to mention short-term consequences (50% vs 18%, p<0.001) and long-term consequences (44% vs 2%, p<0.001) of tobacco use, to contain explicit antismoking messages (39% vs 0%, p<0.001) and to provide specific information on how to quit tobacco use (21% vs 0%, p<0.001). CONCLUSIONS Although internet user-generated videos related to cigarette smoking often acknowledge harmful consequences and provide explicit antismoking messages, hookah-related videos do not. It may be valuable for public health programmes to correct common misconceptions regarding hookah use.
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Affiliation(s)
- Mary V Carroll
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA
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Maziak W, Nakkash R, Bahelah R, Husseini A, Fanous N, Eissenberg T. Tobacco in the Arab world: old and new epidemics amidst policy paralysis. Health Policy Plan 2013; 29:784-94. [PMID: 23958628 DOI: 10.1093/heapol/czt055] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region.
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Affiliation(s)
- Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
| | - Rima Nakkash
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
| | - Raed Bahelah
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
| | - Abdullatif Husseini
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
| | - Nadia Fanous
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
| | - Thomas Eissenberg
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8 St, Miami, 33199 FL, USA, Syrian Center for Tobacco Studies, Sheehan St, Aleppo, Syria, Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El Solh St, 1107 2020 Beirut, Lebanon, Department of Social Medicine and Public Health, Faculty of Medicine and Health Sciences, University of Aden, Aden, Yemen, Institute of Community and Public Health, Birzeit University, PO Box 14 Birzeit, Occupied Palestinian Territory and Department of Psychology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University, 1112 East Clay St, Richmond, 23298 VA, USA
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Khalil J, Afifi R, Fouad FM, Hammal F, Jarallah Y, Mohamed M, Nakkash R. Women and Waterpipe Tobacco Smoking in the Eastern Mediterranean Region: Allure or Offensiveness. Women Health 2013; 53:100-16. [DOI: 10.1080/03630242.2012.753978] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Primack BA, Rice KR, Shensa A, Carroll MV, DePenna EJ, Nakkash R, Barnett TE. U.S. hookah tobacco smoking establishments advertised on the internet. Am J Prev Med 2012; 42:150-6. [PMID: 22261211 PMCID: PMC3391575 DOI: 10.1016/j.amepre.2011.10.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Revised: 07/29/2011] [Accepted: 10/05/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Establishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities. PURPOSE To conduct a comprehensive, qualitative assessment of websites promoting these establishments. METHODS In June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009-2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohen's κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used. RESULTS The search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common. CONCLUSIONS Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.
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Affiliation(s)
- Brian A Primack
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA.
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Nakkash RT, Khalil J, Afifi RA. The rise in narghile (shisha, hookah) waterpipe tobacco smoking: a qualitative study of perceptions of smokers and non smokers. BMC Public Health 2011; 11:315. [PMID: 21569577 PMCID: PMC3112129 DOI: 10.1186/1471-2458-11-315] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 05/14/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of waterpipe tobacco smoking (WTS) in the Middle East region and worldwide is increasing. There is evidence to indicate both short term and long term health effects of WTS, resulting in the issuance of an advisory note by the World Health Organization. METHODS This research aimed at gaining an in-depth understanding of the factors contributing to the rise in WTS in Lebanon. Qualitative focus groups (25) and in-depth interviews (9) were conducted with adults in Lebanon in 2007. Participants were recruited to represent diversity in smoking status, gender, age groups and urban/rural residence. The interviews and focus groups were thematically analyzed, and recurrent themes noted and summarized. RESULTS The main themes identified were availability, affordability, innovation, influence of media, lack of a policy framework, and the sensory characteristics evoked from WTS. Men and women, smokers and non-smokers, and younger and older participants differed in their emphases on the above themes. These themes, though specific to waterpipe, are similar to themes manipulated by the cigarette industry, and eventually controlled through tobacco control policies. CONCLUSIONS Understanding reasons behind the rise in waterpipe tobacco use is important if appropriate prevention, cessation, and policy interventions are to be formulated. Strict adherence to the FCTC is warranted, with careful and vigilant attention that all tobacco products are covered by laws in both high as well as middle to lower income countries.
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Affiliation(s)
- Rima T Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
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Martinasek MP, McDermott RJ, Martini L. Waterpipe (hookah) tobacco smoking among youth. Curr Probl Pediatr Adolesc Health Care 2011; 41:34-57. [PMID: 21232693 DOI: 10.1016/j.cppeds.2010.10.001] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Waterpipe tobacco smoking is a centuries old practice, influenced by cultural tradition in Eastern Mediterranean countries, the Middle East, and parts of Asia. It historically has been an activity enjoyed primarily by men. In the past 2 decades, however, this method of tobacco smoking has increased in popularity in other parts of the world, including the USA. Growing interest in this form of smoking can be traced, in part, to the advent of a flavored tobacco, called maassel. The combination of flavoring agents and the paraphernalia itself used in the smoking process, along with its mystic appeal, novelty, affordability, and the social atmosphere in which smoking often occurs, has made waterpipe smoking attractive to women as well as men, cigarette smokers and nonsmokers alike, and particular groups, including persons of college age and younger adolescents. Although waterpipe smoking is perceived by its new generation of users to be less addictive and hazardous to health than cigarette smoking, researchers draw diametrically opposed conclusions. Research demonstrates that numerous toxic agents, including carcinogens, heavy metals, other particulate matter, and high levels of nicotine, are efficiently delivered through waterpipes. Moreover, sidestream smoke exposes others in the vicinity of waterpipe smokers to the risk of respiratory diseases and other conditions. In addition, persons sharing waterpipe mouthpieces may share infectious agents as well. Waterpipe tobacco smoking has been declared a public health problem by the World Health Organization and other authorities. Recognition of the deleterious effects of waterpipe smoking has led to initial attempts to expand regulatory control. Because waterpipe tobacco is not directly burned in the smoking process, many existing control measures do not apply. Public health authorities should monitor waterpipe tobacco use carefully. Finally, pediatricians and other healthcare providers should discourage experimentation and continued use among their adolescent patients.
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Affiliation(s)
- Mary P Martinasek
- Department of Community and Family Health, University of South Florida, College of Public Health (MDC 056), Tampa, FL, USA
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Maziak W. The global epidemic of waterpipe smoking. Addict Behav 2011; 36:1-5. [PMID: 20888700 PMCID: PMC4135081 DOI: 10.1016/j.addbeh.2010.08.030] [Citation(s) in RCA: 223] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 08/26/2010] [Accepted: 08/26/2010] [Indexed: 10/19/2022]
Abstract
In the past decade waterpipe (WP) smoking (a.k.a. hookah, shisha, and narghile) has been steadily spreading among the youth around the world. The allure of this tobacco use method for the youth can stem from its pleasant smooth smoke, social ambience and the perception of reduced harm. The material in this review is based on detailed Medline search for articles appearing especially in the past two years that are of relevance to WP epidemiology, health and addictive effects, and WP-related tobacco control policies. It shows that WP smoking is continuing to spread among the youth worldwide, and perhaps represents the second global tobacco epidemic since the cigarette. Available evidence suggests that the prevalence of current (past month) WP smoking range from 6 to 34% among Middle Eastern adolescents, 5%-17% among American adolescents, and that WP use is increasing globally. Studies on the health effects of WP smoking are limited by methodological quality, as well as by the novelty of WP epidemic relative to the long latency of important smoking-related health outcomes. Still, research indicates substantial WP harmful effects similar to those of cigarettes, as well as to the potential of providing a bridge to cigarette smoking or relapse. Developing effective interventions to curb WP use among the youth requires a detailed understanding of how dependence develops in WP users, and how it is shaped by WP's unique features such as the following; the predominantly intermittent use with prolonged sessions, preparation time, accessibility, potent sensory cues, and convivial experience of group use. It also requires assessing effective policy options such as factual and visible health warnings on all its parts, as well as youth access and indoor smoking restrictions. WP smoking is currently showing all signs of a burgeoning global epidemic with serious implications for public health and tobacco control worldwide. Investment in research and policy initiatives to understand and curb WP use needs to become a public health priority.
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Affiliation(s)
- Wasim Maziak
- School of Public Health, University of Memphis, Syrian Center for Tobacco Studies, Browning Hall 112, 3820 DeSoto Avenue, Memphis, TN 38152-3340, United States.
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Katurji M, Daher N, Sheheitli H, Saleh R, Shihadeh A. Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique. Inhal Toxicol 2010; 22:1101-9. [PMID: 21062108 DOI: 10.3109/08958378.2010.524265] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
While narghile water pipe smoking has become a global phenomenon, knowledge regarding its toxicant content and delivery, addictive properties, and health consequences is sorely lagging. One challenge in measuring toxicant content of the smoke in the laboratory is the large number of simplifying assumptions that must be made to model a "typical" smoking session using a smoking machine, resulting in uncertainty over the obtained toxicant yields. In this study, we develop an alternative approach in which smoke generated by a human water pipe user is sampled directly during the smoking session. The method, dubbed real-time in situ sampling (RINS), required developing a self-powered portable instrument capable of automatically sampling a fixed fraction of the smoke generated by the user. Instrument performance was validated in the laboratory, and the instrument was deployed in a field study involving 43 ad libitum water pipe use sessions in Beirut area cafés in which we measured inhaled nicotine, carbon monoxide (CO), and water pipe ma'ssel-derived "tar." We found that users drew a mean of 119 L of smoke containing 150 mg of CO, 4 mg of nicotine, and 602 mg of ma'ssel-derived "tar" during a single use session (mean duration = 61 min). These first direct measurements of toxicant delivery demonstrate that ordinary water pipe use involves inhaling large quantities of CO, nicotine, and dry particulate matter. Results are compared with those obtained using the Beirut method smoking machine protocol.
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Affiliation(s)
- M Katurji
- Aerosol Research Laboratory, Mechanical Engineering Department, American University of Beirut, Beirut, Lebanon
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Nakkash R, Khalil J. Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories. Tob Control 2010; 19:235-9. [PMID: 20501497 PMCID: PMC2989164 DOI: 10.1136/tc.2009.031773] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 02/26/2010] [Indexed: 12/02/2022]
Abstract
BACKGROUND Waterpipe tobacco smoking prevalence is increasing around the globe despite current evidence that smoke emissions are toxic and contain carcinogenic compounds. OBJECTIVE To evaluate current health warning labelling practices on waterpipe tobacco products and related accessories. METHODS All waterpipe tobacco products, as well as waterpipe accessories, were purchased from Lebanon and a convenience sample was obtained from Dubai (United Arab Emirates), Palestine, Syria, Jordan, Bahrain, Canada, Germany and South Africa. FINDINGS Of the total number of waterpipe tobacco products collected from Lebanon, the majority had textual health warning labels covering on average only 3.5% of total surface area of the package. Misleading descriptors were commonplace on waterpipe tobacco packages and related accessories. CONCLUSIONS There are no WHO FCTC compliant waterpipe-specific health warning labels on waterpipe tobacco products and related accessories. Introducing health warnings on waterpipe tobacco products and accessories will probably have worldwide public health benefits.
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Affiliation(s)
- Rima Nakkash
- Health Behavior and Education Department, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, PO, Riad El Solh, Beirut 1107 2020, Lebanon.
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Maziak W. Commentary: The waterpipe--a global epidemic or a passing fad. Int J Epidemiol 2010; 39:857-9. [PMID: 20348109 PMCID: PMC2912485 DOI: 10.1093/ije/dyq054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2010] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wasim Maziak
- School of Public Health, University of Memphis, Memphis, TN, USA.
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