Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence?

The expression of salivary EGF, VEGF, endothelin, and transferrin in waterpipe and cigarette smokers

The aim of this study was to evaluate the effects of two forms of tobacco smoking, cigarettes and water pipe smoking (WPS), on the expression of a panel of salivary proteins in healthy adults. Three groups of age and gender-matched participants were enrolled in the study: never-smokers, cigarette smokers and WPS (N = 55 per group). Expression of epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), endothelin and transferrin in unstimulated whole saliva was estimated using enzyme-linked immunosorbent assays. Statistical analysis consisted of one-way ANOVA and Tukey's post hoc tests, in addition to bioinformatics analysis. VEGF expression was the least in WPS (51.1 ± 14.5 pg/ml) compared to both controls (150.1 ± 13.8 pg/ml) and cigarette smokers (93 ± 9.9 pg/ml), with a significant difference in WPS (p < 0.001) and cigarette smokers (p < 0.01) compared to controls. Furthermore, transferrin showed the weakest expression in the WPS group (1238 ± 261.4 pg/ml) compared to controls (2205.6 ± 298.6 pg/ml) (p = 0.05) and cigarette smokers (1805.4 ± 244 pg/ml). Neither EGF nor endothelin expression showed any statistical difference between the groups (p > 0.05). Gene-gene interaction network demonstrated that FLT1, TFRC, KDR, VEGFB and PGF genes had the highest potential for interaction with the studied proteins. Further functional annotations on the identified markers in the interaction network were performed to identify HIF-1 pathways among the most relevant pathways. In conclusion, smoking habits alter the expression of salivary VEGF and transferrin, which may correspond to early sub-clinical changes in the oral mucosa. The clinical relevance of these salivary changes requires further research.

A decade of tobacco control efforts: Implications for tobacco smoking prevalence in Eastern Mediterranean countries

BACKGROUND AND OBJECTIVES

This study aimed to assess the association between the 10-year implementation of tobacco control policies, cigarette affordability index and changes in tobacco smoking prevalence across Eastern Mediterranean (EMR) countries.

MATERIALS AND METHODS

An ecologic study was conducted using EMR countries as the analytical unit. Data from three sources were utilized: the MPOWER scale to measure tobacco control policy implementation (2010-2020), the tobacco affordability index (expressed as a percentage of GDP per capita required to purchase 2000 cigarettes, from 2010 to 2020), and national tobacco smoking prevalence data for EMR countries (2010-2023). Linear Fixed-effect regression was employed to investigate associations between changes in MPOWER scores, the cigarette affordability index, and alterations in tobacco prevalence over a decade.

RESULTS

Statistically significant inverse associations were observed between changes in MPOWER scores and tobacco smoking prevalence among both men and women in EMR countries (P-value<0.05). Each unit increase in MPOWER score corresponded to a 0.26% reduction in tobacco prevalence among men and a 0.12% reduction among women. The regression model revealed that each unit increase in the cigarette affordability index was linked to a 0.9% decrease in tobacco smoking prevalence across EMR countries (P-value<0.05). Furthermore, even after adjusting for multiple confounders, significant inverse associations were noted between tobacco monitoring (β = -0.41), health warning (β = -0.45), and changes in tobacco smoking prevalence (P-value<0.05).

CONCLUSION

This study underscored the effectiveness of enhancing the implementation of tobacco control policies and increasing the cigarette affordability index as preventive measures to reduce tobacco smoking prevalence in EMR countries over the past decade.

Factors contributing to the rising prevalence of waterpipe smoking dependence among university students: a cross-sectional study

INTRODUCTION

Waterpipe smoking (WPS) has been associated with a variety of adverse health effects, consequences, and symptoms of nicotine dependence. This study aims to determine the prevalence of WPS dependence among Palestinian university waterpipe smoking students, their normative beliefs about WPS, and their relationship to dependence.

METHODS

A cross-sectional study of current WPS university students at five major Palestinian universities was conducted from September to December 2022. Participants were recruited using convenient sampling, and data collection was carried out via an interviewer-administered questionnaire. We assessed students' WPS dependence using the Lebanese Waterpipe Dependence Scale. We used the Poisson regression model with robust variance to analyze factors independently associated with high WPS dependence.

RESULTS

The study included 746 current WPS university students. Results revealed a high prevalence of WPS dependence, with 69.4% (95%CI: 66.0-72.7%) exhibiting high dependence. Factors contributing to high WPS dependence included dual cigarette smoking (aPR: 1.18; 95%CI: 1.12-1.25), studying medical sciences (aPR: 1.13; 95%CI: 1.10-1.18), friends' approval of WPS (aPR: 1.25; 95%CI: 1.17-1.34), daily WPS frequency (aPR: 1.98; 95%CI: 1.39-2.23), spending more than 50% of daily allowance on WPS (aPR: 1.37; 95%CI: 1.10-1.64), and morning WPS sessions (aPR: 1.97; 95%CI: 1.31-2.27). The study highlighted the influence of social factors, such as peers' approval and perceived prevalence, on WPS dependence.

CONCLUSIONS

WPS dependence is prevalent among university students, and it is associated with morning WPS, dual smoking, and increased WPS frequency. Notably, peer and cultural factors are essential primary motivators. As a result, it is critical to incorporate WPS considerations into Palestine's antismoking health promotion program. Therefore, it is vital to incorporate WPS into the Palestinian antismoking health promotion policy, and the health education of adolescents regarding the dangers of WPS should coincide with antismoking initiatives.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

Correlates of motivation to quit waterpipe tobacco smoking among US young adults: implications for cessation interventions

Waterpipe tobacco smoking is a public health concern that poses many of the same health risks as cigarette smoking, especially among young adults-a subpopulation characterized by the highest prevalence of waterpipe tobacco smoking. Nevertheless, it remains understudied relative to other forms of tobacco use. We examined sociodemographic, behavioral and cognitive factors associated with young adults' motivation to quit waterpipe smoking using a theory-informed approach. We completed a secondary analysis of baseline data on waterpipe tobacco smoking beliefs and behavior collected from 349 US young adults aged 18-30 years. We analyzed sociodemographics, tobacco use and cessation behaviors and perceptions, and theory-related constructs associated with motivation to quit waterpipe tobacco smoking using linear regression. Overall, participants reported low motivation (mean = 2.68, SD = 1.56, scale range 1-7) and high self-efficacy (mean = 5.12, SD = 1.79) to quit waterpipe tobacco smoking. In multivariable analysis, prior quit attempts (β = 1.10, P < 0.01), greater perceived risks of waterpipe tobacco smoking (β = 0.42, P < 0.01) and increasingly negative attitudes toward waterpipe tobacco smoking (β = 0.29, P < 0.01) were associated with higher motivation to quit. These findings highlight the importance of those factors as potential cessation determinants. These findings can help guide the development and refinement of interventions targeting young adult waterpipe tobacco smoking.

Interventions for waterpipe smoking cessation

BACKGROUND

While cigarette smoking has declined globally, waterpipe smoking is rising, especially among youth. The impact of this rise is amplified by mounting evidence of its addictive and harmful nature. Waterpipe smoking is influenced by multiple factors, including appealing flavors, marketing, use in social settings, and misperceptions that waterpipe is less harmful or addictive than cigarettes. People who use waterpipes are interested in quitting, but are often unsuccessful at doing so on their own. Therefore, developing and testing waterpipe cessation interventions to help people quit was identified as a priority for global tobacco control efforts.  OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for people who smoke waterpipes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group Specialized Register from database inception to 29 July 2022, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), quasi-RCTs, or cluster-RCTs of any smoking cessation interventions for people who use waterpipes, of any age or gender. In order to be included, studies had to measure waterpipe abstinence at a three-month follow-up or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from waterpipe use at least three months after baseline. We also collected data on adverse events. Individual study effects and pooled effects were summarized as risk ratios (RR) and 95% confidence intervals (95% CI), using Mantel-Haenszel random-effects models to combine studies, where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarized secondary outcomes narratively. We used the five GRADE considerations (risk of bias, inconsistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for our primary outcome in four categories high, moderate, low, or very low.

MAIN RESULTS

This review included nine studies, involving 2841 participants. All studies were conducted in adults, and were carried out in Iran, Vietnam, Syria, Lebanon, Egypt, Pakistan, and the USA. Studies were conducted in several settings, including colleges/universities, community healthcare centers, tuberculosis hospitals, and cancer treatment centers, while two studies tested e-health interventions (online web-based educational intervention, text message intervention). Overall, we judged three studies to be at low risk of bias, and six studies at high risk of bias. We pooled data from five studies (1030 participants) that tested intensive face-to-face behavioral interventions compared with brief behavioral intervention (e.g. one behavioral counseling session), usual care (e.g. self-help materials), or no intervention. In our meta-analysis, we included people who used waterpipe exclusively, or with another form of tobacco. Overall, we found low-certainty evidence of a benefit of behavioral support for waterpipe abstinence (RR 3.19 95% CI 2.17 to 4.69; I2 = 41%; 5 studies, N = 1030). We downgraded the evidence because of imprecision and risk of bias. We pooled data from two studies (N = 662 participants) that tested varenicline combined with behavioral intervention compared with placebo combined with behavioral intervention. Although the point estimate favored varenicline, 95% CIs were imprecise, and incorporated the potential for no difference and lower quit rates in the varenicline groups, as well as a benefit as large as that found in cigarette smoking cessation (RR 1.24, 95% CI 0.69 to 2.24; I2 = 0%; 2 studies, N = 662; low-certainty evidence). We downgraded the evidence because of imprecision. We found no clear evidence of a difference in the number of participants experiencing adverse events (RR 0.98, 95% CI 0.67 to 1.44; I2 = 31%; 2 studies, N = 662). The studies did not report serious adverse events.   One study tested the efficacy of seven weeks of bupropion therapy combined with behavioral intervention. There was no clear evidence of benefit for waterpipe cessation when compared with behavioral support alone (RR 0.77, 95% CI 0.42 to 1.41; 1 study, N = 121; very low-certainty evidence), or with self-help (RR 1.94, 95% CI 0.94 to 4.00; 1 study, N = 86; very low-certainty evidence).  Two studies tested e-health interventions. One study reported higher waterpipe quit rates among participants randomized to either a tailored mobile phone or untailored mobile phone intervention compared with those randomized to no intervention (RR 1.48, 95% CI 1.07 to 2.05; 2 studies, N = 319; very low-certainty evidence). Another study reported higher waterpipe abstinence rates following an intensive online educational intervention compared with a brief online educational intervention (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70; very low-certainty evidence).  AUTHORS' CONCLUSIONS: We found low-certainty evidence that behavioral waterpipe cessation interventions can increase waterpipe quit rates among waterpipe smokers. We found insufficient evidence to assess whether varenicline or bupropion increased waterpipe abstinence; available evidence is compatible with effect sizes similar to those seen for cigarette smoking cessation.  Given e-health interventions' potential reach and effectiveness for waterpipe cessation, trials with large samples and long follow-up periods are needed. Future studies should use biochemical validation of abstinence to prevent the risk of detection bias. Finally, there has been limited attention given to high-risk groups for waterpipe smoking, such as youth, young adults, pregnant women, and dual or poly tobacco users. These groups would benefit from targeted studies.

Factors Predicting Dependence on Waterpipe Smoking Among Waterpipe Exclusive Smokers

ABSTRACT

The current study targeted a sample of waterpipe (WP) exclusive smokers to identify the levels and predictors of dependence on this smoking pattern and to examine the relationship between WP smoking (WPS) dependence and depressive symptoms. A cross-sectional research design was employed with a community sample of 270 subjects who are currently WP exclusive smokers. Assessment of WPS dependence and depressive symptoms was performed using self-report measures. About 62.6% of the subjects were WPS dependent. The unique significant predictors of WPS dependence were age, depression levels, age of starting WPS, duration of WPS, income, smoking WP daily, the belief of being attracted to WPS, and the desire to stop WPS. These predictors explained 35% of the variance in WPS dependence. WPS dependence was associated with increased depressive symptoms. Although few studies have been conducted, the WPS dependence prevalence appears to be alarmingly high among WP exclusive smokers. Factors associated with WPS dependence provide useful information that can be used to tailor WP prevention interventions.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSION

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

The prevalence and associated factors of shisha use among smokers attending three primary healthcare centers in Qatar, 2020

INTRODUCTION

Smoking is one of the most serious health issues. One form of tobacco use, shisha, is prevalent in the Eastern Mediterranean Region. There is a misconception among smokers that waterpipe use poses no harm to human health. In Qatar, the Global Adult Tobacco Survey in 2013 has shown that 3.4% of adults in the country were current waterpipe users. Nevertheless, there remains a scarcity of data on the knowledge and practice of shisha smokers in Qatar.

METHODS

This was a cross-sectional study across three primary healthcare (PHC) centers in Qatar between September and December 2020. A convenient sampling technique was employed to enroll participants. Upon consent, an interview was conducted to collect data from adult smokers (aged ≥18 years). Descriptive and analytic statistics were used when appropriate.

RESULTS

A total of 281 individuals participated in this study. Nearly half (48.8%) were current shisha users and almost three-quarters (72.9%) had inadequate knowledge in this regard. In addition, only one-fifth (19.5%) of participants attended smoking cessation clinics at the primary healthcare centers and a quarter (25%) of the respondents managed to quit smoking before relapsing. A significant association was found between the shisha knowledge of participants and their nationality (Qatari), employment status (unemployed), smoking status (current smoker), and duration of smoking.

CONCLUSIONS

The study results convey a high prevalence of shisha use (47.8%), inadequate shisha knowledge (72.9%), and lack of awareness about available smoking cessation services (46.6%) among the participants. Further research is recommended to generate evidence on the determinants of shisha use and knowledge among the attendees of primary healthcare centers in Qatar.

Changes in the Use of Tobacco, Alternative Tobacco Products, and Tobacco Alternatives in Germany

BACKGROUND

Due to the increasing use of alternative tobacco products (waterpipes, heat-not-burn) and tobacco alternatives (e-cigarettes), we studied recent changes in the prevalence of conventional tobacco use and alternative products.

METHODS

Data come from ten waves of the Epidemiological Survey of Substance Abuse (ESA) from 1995 to 2021, with representative samples collected via paperpencil questionnaires, telephone interviews, or online. We compared the prevalence of conventional tobacco use and alternative products by gender and age (18-24, 25-39, 40-59 years).

RESULTS

In all age groups, the use of conventional tobacco products decreased. The prevalence of the exclusive use of one of the three alternative products differed statistically significantly between age groups and in 2021 was higher for ages 18-24 (females: 11.1%, males: 12.4%) compared to ages 25-39 (females: 2.9%; males: 4.9%) and ages 40-59 (females: 1.4%; males: 2.0%). The use of alternative products was mainly due to the exclusive use of waterpipes among individuals aged 18 to 24 and 25 to 39 and the exclusive use of e-cigarettes among individuals aged 40 to 59.

CONCLUSION

The higher prevalence of alternative product use among young adults implies a turning point that needs to be considered in prevention. Because of the addictive potential of these products, young adults can be expected to maintain their use into middle and older adulthood. There is a need to monitor the use of alternative products, identify the risks associated with them, and develop effective prevention and cessation interventions for adults.

Re: Effects of Abstinence Self-Efficacy and Outcome Expectancies of Tobacco Smoking on the Desire to Quit Among Saudi Women: A Cross-Sectional Mediation Analysis

This letter offers commentary on Alanazi and colleagues recent analysis of desire to quit tobacco use among Saudi women, and suggestions for future studies.

Waterpipe smoking: Results from a population-based study in Qatar

INTRODUCTION

Waterpipe smoking is common in the Eastern Mediterranean Region and is becoming more prevalent in Qatar. To better plan waterpipe smoking control strategies we aimed to: 1) determine the prevalence of waterpipe smoking and explore its patterns in Qatar; 2) describe the knowledge, attitudes, and practices related to smoking behaviors; 3) recognize locations of waterpipe smoking and symptoms experienced during waterpipe sessions; and 4) evaluate the frequency of waterpipe smoking and the initiation age.

METHODS

We analyzed the data of a 7921 population-based survey of adults aged ≥18 years (nationals and expatriates), conducted in Qatar between March and December 2019. Out of 7105 surveys collected, 6904 were complete and included in the analysis.

RESULTS

Of the 6904, 570 (8.3%; 95% CI: 7.7–9.0) were waterpipe tobacco smokers, 425 (10.6%) males and 145 (5.1%) females. The highest prevalence of waterpipe smoking was reported among people aged 18–24 years (10.6%). Of the 575 waterpipe smokers, 56.3% (n=324) were exclusive waterpipe smokers. Use of other tobacco products among waterpipe smokers was higher among Qataris (52.3%) than expatriates (37.7%). Waterpipe cafés were the most common location for waterpipe smoking, however, females preferred restaurants; 83.3% reported that waterpipe smoking is harmful, while 39.3% considered that it is less harmful than cigarette smoking.

CONCLUSIONS

Waterpipe smoking prevalence is considerably high in Qatar, the second form of tobacco used. The formulation of new policies and enforcement of regulatory restrictions on waterpipe smoking are essential to reduce its uptake. Expansion in tobacco cessation services for women and poly-tobacco users is needed.

Simple HPLC method for simultaneous quantification of nicotine and cotinine levels in rat plasma after exposure to two different tobacco products

Purpose

Development and validation of a selective analytical method to accurately and precisely quantify nicotine and cotinine levels in rat's plasma after exposure to tobacco cigarettes and tobacco water-pipe.

Methods

An easy HPLC-Photodiode-Array Detection (PDA) method was developed and validated for simultaneous determination of nicotine and cotinine levels in plasma of 15 rats (10 rats after tobacco products exposure and 5 control rats). Nicotine and cotinine were extracted in one step from plasma using acetonitrile and concentrated to lowest volume using nitrogen stream.

Results

The developed method offered a rapid analysis time of 14 min with single step of analytes extraction from rat's plasma with recovery percentage range between 93 and 95% and excellent linearity with correlation factor more than 0.994 with analytical range between 50 and 1000 ng mL−1 and LOD of 25 ng mL−1 and 23 ng mL−1 for nicotine and cotinine, respectively. The analysis of rat's plasma after 28 days of exposure to tobacco cigarettes and tobacco water-pipe revealed that the average concentrations of 376 ng mL−1 for cotinine and 223 ng mL−1 for nicotine were obtained after tobacco cigarettes exposure, and 220 ng mL−1 for cotinine and 192 ng mL−1 for nicotine after tobacco water-pipe exposure.

Conclusion

Higher nicotine and cotinine levels were found in plasma after tobacco cigarettes exposure than water-pipe exposure which may have potential undesirable effects on passive smokers in both cases.

Waterpipe Tobacco Smoking among university students in Turkey

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Less than half (38.4%) of the participants smoke waterpipe.

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Female participants tend to smoke more waterpipe than male participants.

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Waterpipe tobacco smokers perceived waterpipe smoking less risky than non-smokers.

Introduction

Waterpipe tobacco smoking is common among adults in numerous Mediterranean countries. Waterpipe cafes where people are allowed to smoke waterpipe tobacco are an increasingly popular venue for socializing among young people. The aim of this study was to assess the frequency and patterns of waterpipe tobacco smoking among university students in Turkey, as well as their perception on the health-risk of smoking the waterpipe.

Method

A total of 411 university students in Turkey participated in this study. Participants completed a set of questionnaires to measure frequency, behaviours, and perceptions of the health risks related to waterpipe tobacco smoking.

Results

Less than half (38.4%) of the participants smoke waterpipe. Female participants tend to smoke more waterpipe than male participants. The mean age of first smoking waterpipe was 17 years. Waterpipe tobacco smokers perceived the health risks of smoking the waterpipe to be less addictive and exaggerated compared to non-users; smokers also regarded smoking waterpipe tobacco to help them to relax.

Conclusion

This study provided support that waterpipe tobacco smoking is common among young people in Turkey. There was poor awareness about the risk of waterpipe tobacco smoking among students. Our findings could inform tobacco control in Turkey, especially among young people.

Latent class analysis of initial nicotine dependence among adult waterpipe smokers

Waterpipe (WP) tobacco smoking increases the risk of smoking-related health problems. In this study, we sought to identify the unobserved class memberships of WP-associated initial nicotine dependence (ND) symptoms and assess the predictors of each latent class. This cross-sectional study was conducted among a convenience sample of 900 current (past 30-day) WP smokers who were recruited from 94 WP-serving venues surrounding Tehran and Ardebil metropolitans in Iran. All participants completed a self-administrated questionnaire. We performed latent class analysis using PROC LCA in SAS to identify class memberships of initial ND symptoms using 10-item Hooked on Nicotine Checklist. Five latent classes were identified as non-dependent (25.4 %), low dependent (7.1 %), low-moderate dependent (19.6 %), moderate dependent (15.6 %), and high dependent (32.2 %). Using flavored WP tobacco significantly increased the odds of belonging to low-moderate dependent class [adjusted OR (aOR) = 1.89; 95 % confidence interval (CI): 1.07-3.34] compared to non-dependent class. Also, having academic education decreased the odds of belonging to low-moderate dependent (aOR = 0.43; 95 %CI: 0.26-0.67) and moderate dependent (aOR = 0.39; 95 %CI: 0.23-0.67) class in comparison to non-dependent class. Also, WP smoking initiation at an older age was associated with belonging to high dependent (OR = 2.05; 95 %CI: 1.39-3.03) class compared to non-dependent. This study revealed that nearly half of WP smokers fell under moderate and high-dependent classes. Our findings showed that some items of HONC had more role in the clustering of participants based on ND symptoms. The WP-specific cessation programs and targeted clinical trials should consider the diversity of ND levels among smokers to achieve successful quit rates among these smokers. Additionally, limiting flavors would be a strong strategy to limit the rate of ND, especially among young people who are eager to smoke flavored WP tobacco.

Psychophysiological responses to hookah tobacco public education messages among young adults

OBJECTIVE

Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting.

METHOD

One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure.

RESULTS

The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks.

DISCUSSION

Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Pilot Study Assessing Reactions to Educational Videos on Harm of Waterpipe among Young Adults Susceptible to Waterpipe Tobacco Smoking

Young adults who never engaged in waterpipe tobacco smoking (WTS) yet are open to trying it, that is, are susceptible, is a high-risk group for initiation WTS. Very few interventions dissuade this group from WTS. Thus, we explored how four short videos that varied themes of WTS harms influenced susceptible young adults' risk perceptions, risk beliefs, and susceptibility to future WTS. As part of online cross-sectional study, 208 participants aged 18-34 were randomized to watch or not a short video; each video focused on different themes of WTS risks: physical harms, myths about WTS, addiction, and harms to others. The main outcomes were perceived personal risks, risk beliefs, perceived harm of WTS compared to cigarettes, and susceptibility to future WTS. Watching any video increased beliefs of harm of WTS and lowered susceptibility to future WTS compared to not watching a video. The theme of physical harms was most effective at increasing risk beliefs and lowering susceptibility to future WTS. All four videos were rated as credible, engaging, personally relevant, producing negative affect toward WTS, and effective at dissuading WTS. These promising findings suggest further testing is needed to determine if effects persist and prevent WTS among adults susceptible to WTS.

Lebanese Waterpipe Dependence Scale (LWDS-11) validation in a sample of Lebanese adolescents

Background

Salameh et al. developed the Lebanese Waterpipe Dependence Scale (LWDS-11) that assesses nicotine dependence among adult waterpipe smokers. In view of the high waterpipe use among Lebanese youth and other neighboring countries, it was deemed necessary to check the psychometric properties of the LWDS-11, originally adapted to the Lebanese population, to measure nicotine dependence among adolescents.

Methods

Two cross-sectional investigations were conducted; Study 1 (January and May 2019) enrolled a total of 449 students who were exclusive waterpipe smokers; this sample was used to conduct the exploratory factor analysis. Study 2 enrolled another sample composed of 243 waterpipe smoking adolescents. This sample was independent from the first one and was used to conduct the confirmatory analysis.

Results

The results also showed that 312 (69.5%) [95% CI 0.652–0.738] had high waterpipe dependence (scores of ≥10). Results of the factor analysis in sample 1 showed that all LWDS-11 items were extracted following the factor analysis. Items converged over a solution of one factor; total variance explained = 70.45%, α_Cronbach = 0.96). The results of the confirmatory factor analysis were as follows: the Maximum Likelihood Chi-Square = 129.58 and Degrees of Freedom = 45, which gave a χ²/df = 2.88. For non-centrality fit indices, the Steiger-Lind Root Mean Square Error of Approximation (RMSEA) was 0.08 [0.071–0.106]. Moreover, the Comparative Fit Index (CFI) value was 0.77.

Conclusion

The preliminary results suggest that the LWDS-11 has good psychometric properties to measure waterpipe dependence among adolescents. We hope this tool would serve the benefit of research and epidemiology.

Tailored Mobile Messaging Intervention for Waterpipe Tobacco Cessation in Young Adults: A Randomized Trial

Objectives. To test a tailored mobile health (i.e., mHealth) intervention for waterpipe tobacco cessation in young adults. Methods. From 2018 to 2020 at 2 US sites, we conducted a randomized trial with 349 waterpipe tobacco smokers aged 18 to 30 years randomized to control (no intervention), untailored, or tailored intervention arms. Intervention arms received a 6-week mHealth intervention conveying risks of waterpipe tobacco through text and images and strategies to enhance motivation and support quitting. The tailored intervention was personalized to baseline measures and intervention text message responses. Risk appraisals, motivation to quit, waterpipe smoking frequency, and cessation were assessed at 6 weeks, 3 months, and 6 months. Results. At 6 months, cessation was higher in the tailored (49%) than the control arm (29%; odds ratio = 2.4; 95% confidence interval = 1.3, 4.2) and smoking frequency was lower in the tailored (mean = 3.5 days) than the control arm (mean = 4.3 days; P = .006). At interim follow-ups, significant differences in other outcomes favored the tailored intervention. Conclusions. Tailored mobile messaging can help young adult waterpipe tobacco smokers quit. This scalable intervention is poised for population implementation.

Initial development of the Hookah Smoker Scale: Assessing young adults' mental schemas about hookah "smokers"

Many young adult hookah tobacco users do not consider themselves hookah "smokers," but data on this topic are limited. There are no existing measures of young adults' mental schemas of hookah "smokers." We examined the factor structure and reliability of the Hookah Smoker Scale and examined associations with perceived harm and addictiveness and attitudes toward hookah. Two hundred and forty-six young adult (ages 18-30) hookah smokers participated in a cross-sectional online study. Participants completed items assessing schemas characterizing hookah smokers and valid measures of perceived harm and addictiveness of hookah smoking, risk appraisals, and attitudes toward hookah. Exploratory factor analysis using principal axis factoring with oblique rotation extracted a 12-item scale with three dimensions (Regular Use, Social-Enabled Use, and Self-Enabled Use). The scale explained 69.7% of the variance (eigenvalue = 9.2). Cronbach's α for the scale was .89, with Cronbach's α ≥ .80 for four-item subscales. Higher subscale scores indicate stronger beliefs that the dimension characterizes a hookah smoker. Higher Regular Use scores (score variance = 46.9%; eigenvalue = 5.6) were associated with greater perceived harm and addictiveness (β = 0.21, p = .01), greater risk appraisals (β = 0.20, p = .02), and more negative attitudes toward hookah (β = -0.18, p = .03). The Hookah Smoker Scale is a promising measure that can be used to identify targets for preventing and reducing young adults' hookah tobacco use. Findings also suggest young adults associate health risks of hookah with daily smoking, but not with intermittent social smoking patterns.

Use of waterpipes and other substances in adolescents: Prevalence and potential associations with mental and behavioral well-being, a cross-sectional study

INTRODUCTION

This study assess the prevalence and potential determinants (attitudes, behavioral and emotional conditions) associated with waterpipe tobacco smoking (WTS) and cigarette smoking in adolescents in public compulsory secondary schools.

METHODS

This was a cross-sectional study conducted in October 2017 in three secondary schools from Seville, Spain, among adolescents aged 12-18 years. We administered an ad hoc questionnaire to explore the demographic and clinical characteristics of students; in addition, it included questions on consumption of tobacco (waterpipe and/or cigarette), alcohol (usual consumption and/or drunkenness) and/or cannabis, and attitudes towards waterpipe tobacco smoking. We also administered a validated version of the Strengths and Difficulties Questionnaire (SDQ), which is used to screen children and adolescents with emotional and behavioral problems. An established usage of a substance was defined as weekly or daily use. A multivariate analysis was performed using binary logistic regression methods to determine the probability of established usage.

RESULTS

Of the 1135 adolescents, 72.1% lived with at least one smoker; the established usage was 13.4% for waterpipe; 9.2% for cigarettes and 3.2% for dual use. Of those with established usage of waterpipe, 38.2% had established alcohol usage, 12.7% were drunk weekly or daily, and 27.4% used cannabis. Students consolidating the consumption of waterpipes were three times more likely to have established cigarette use than those not having an established usage (OR=3.7; p=0.0005). The overall SDQ score increased the likelihood of established usage of both waterpipes and cigarettes (p=0.0005).

CONCLUSIONS

The probability of established usage of cigarettes (multivariate analysis) is associated with increasing age (course), cohabitation with smokers, established usage of waterpipe, established use of alcohol and a borderline score in the behavioral dimension (SDQ). Addiction to waterpipes among teens is significantly associated with their behavioral and emotional difficulties.

Waterpipe smoking: a review of pulmonary and health effects

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

E8-LWDS: Factorial Structure and Psychometric Properties of the Lebanese Waterpipe Dependence Scale-11 in 1490 Egyptian Waterpipe Tobacco Smokers-A Critical Approach

INTRODUCTION

There is no universal scale for assessing waterpipe tobacco (WT) dependence. We examined the factorial structure and psychometric properties of the Waterpipe Dependence Scale-11 (LWDS-11) among Egyptian WT smokers.

METHODS

We administered the LWDS-11 during face-interview questionnaires in two cross-sectional surveys among 1490 current WT smokers recruited via purposive quota sampling. Exploratory factor analysis was performed on half of the sample. Confirmatory factor analysis of the resulting model was done using structural equation modelling on the other half. Scale reliability was examined. We assessed convergent construct validity using regression models to examine the association between the adapted dependence scale and factors conceptually expected to be associated with WT dependence.

RESULTS

Exploratory factor analysis of the scale yielded eight items (E8-LWDS) supporting a three-factor structure: physical dependence (three items); psychological dependence (three items); and psychological craving (two items). Cronbach's α were 0.635 for the total scale and 0.823, 0.654, and 0.785 for the three subscales. E8-LWDS was confirmed to have good model fit (comparative fit index = 0.995; root mean squared error of approximation = 0.027). E8-LWDS was independently associated with daily WT smoking, rural residence, being a skilled worker, non-exclusive WTS, smoking ≥ eight WT hagars/day, and measures of perceived behavioral control (self-reported addiction to WT, perceived ability to quit, and previous quit attempts).

CONCLUSION

E8-LWDS showed adequate psychometric properties among this sample of Egyptian current WT smokers, which makes it appropriate for use by researchers and practitioners. Adding items related to perceived behavioral control might enhance the scale robustness.

A Group-based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers

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.

Anti-Inflammatory and Antioxidant Effects of Dietary Supplementation and Lifestyle Factors

Trends relating to specific diets and lifestyle factors like physical (in) activity have formed in recent times [...].

Effects of hookah and cigarette smoking on the recovery after septoplasty

BACKGROUND

Hookah is a tobacco product of Middle Eastern origin; however, its popularity increases in Europe and the US. Despite its frequent use, hookah's potentially detrimental effects are underestimated as a result of the scarcity of the relevant research. Since septoplasty is one of the most commonly performed procedures of otolaryngology practice, we aimed to investigate the impact of hookah consumption on recovery after septoplasty.

METHODS

Patients who underwent septoplasty in Sanliurfa Training and Research Hospital Department of Otolaryngology between January 2017 and December 2019 were divided into four groups based on their history of hookah and cigarette smoking. The patients' prospectively collected data, including demographic features, healing time, and presence or absence of septal perforation during follow-up, were compared between these four groups.

RESULTS

The entire cohort included 270 patients. The mean patient age was 29.2 ± 5.8 years. One hundred and thirty-two (48.9%) patients were non-smokers, 96 (35.5%) were cigarette smokers, 27 (10%) were hookah smokers and 15 (5.6%) consumed both tobacco products regularly. Mean healing time was 10 days, and septal perforation was encountered in 10 patients (3.7%). A comparison of the groups revealed that cigarette smoking did not impact septal perforation rates (P = .326) but prolonged the healing time. However, hookah smoking with or without cigarette smoking significantly influenced septal perforation rates and healing times.

CONCLUSION

Patients should be questioned about hookah smoking in addition to cigarette smoking before the septoplasty procedure. Patients with a positive history of hookah smoking should be followed closely in terms of delayed healing and increased septal perforation rates.

Preventing and controlling water pipe smoking: a systematic review of management interventions

BACKGROUND

Water pipe smoking (WPS) is re-gaining widespread use and popularity among various groups of people, especially adolescents. Despite different adverse health effects of WPS, many of the WPS interventions have failed to control this type of tobacco smoking. This study was conducted to identify experienced management interventions in preventing and controlling WPS worldwide.

METHODS

A systematic literature review was conducted. Electronic databases were searched for recordes which were published from beginning 1990 to August 2018. Studies aiming at evaluating, at least, one intervention in preventing and controlling WPS were included in this review, followed by performing the quality assessment and data extraction of eligible studies by two independent investigators. Finally, interventions that were identified from the content analysis process were discussed and classified into relevant categories.

RESULTS

After deleting duplications, 2228 out of 4343 retrieved records remained and 38 studies were selected as the main corpus of the present study. Then, the identified 27 interventions were grouped into four main categories including preventive (5, 18.51%) and control (8, 29.62%) interventions, as well as the enactment and implementation of legislations and policies for controlling WPS at national (7, 25.92%) and international (7, 25.92%) levels.

CONCLUSION

The current enforced legislations for preventing and controlling WPS are not supported by rigorous evidence. Informed school-based interventions, especially among adolescents can lead to promising results in preventing and controlling WPS and decreasing the effects of this important social and health crisis in the global arena.

Association of characters and temperaments with cigarette and waterpipe dependence among a sample of Lebanese adults

It was discovered that the relation between certain personality traits and nicotine dependence differs among ethnicities and cultures; therefore, this study was conducted to determine which temperaments and personality traits are associated with smoking dependence in order to contribute to the development of effective and targeted interventions for smoking dependence within the Lebanese population. A cross-sectional study was carried out between March and April 2020 among a sample of Lebanese adults from all Lebanese governorates. The sample included (N = 501) divided as follows: 62 (12.4%) nonsmokers, 37 (7.4%) cigarette smokers, 266 (53.1%) waterpipe smokers, and 136 (27.1%) mixed smokers. Higher cooperativeness (B = - 0.03) was significantly associated with lower waterpipe dependence. High vs. low education level (B = - 0.97), female gender compared to males (B = - 1.07), higher cooperativeness (B = - 0.01), and higher self-transcendence (B = - 0.01) were significantly associated with lower cigarette dependence, whereas higher age (B = 0.03) was significantly associated with higher cigarette dependence. A multinomial regression analysis, taking the smoking group as the dependent variable, showed that higher harm avoidance (aOR = 0.97) and novelty seeking (aOR = 0.97) were significantly associated with lower cigarette smoking. A high level of education vs. a low one (aOR = 8.85) was significantly associated with higher cigarette smoking. Higher self-transcendence was significantly associated with lower mixed smoking. Being married vs. single (aOR = 2.46) was significantly associated with higher odds of being a mixed smoker, whereas female gender compared to males (aOR = 0.41) was significantly associated with lower odds of being a mixed smoker. These results are pivotal in understanding the relationship between personality and smoking dependence.

Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adolescents and adults: an application of socio-ecological model

Background

The present study aimed to investigate the effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adolescents and adults.

Methods

In this study, two comparable cities in Iran were selected to participate in an intervention program based on a social-ecological model (SEM). In each city, 133 hookah smokers in coffee houses were selected. Environmental changes in coffee houses such as serving light foods and games were conducted. A virtual group named “no hookah” was established on the Telegram application to train participants in the intervention group. Messages, pictures, and short videos were sent to the participants through that virtual network. The frequency and duration of hookah consumption were assessed in both groups at baseline and after the intervention.

Results

The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group), and the duration of hookah consumption per session decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group).

Conclusions

Using multi-level interventions through a social-ecological model can reduce hookah consumption in adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10219-8.

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

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

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

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

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

Effects of flavourants and humectants on waterpipe tobacco puffing behaviour, biomarkers of exposure and subjective effects among adults with high versus low nicotine dependence

INTRODUCTION

Flavourants and humectants in waterpipe tobacco (WT) increase product appeal. Removal of these constituents, however, is associated with increased intensity of WT puffing, likely due to reduced nicotine delivery efficiency. To clarify the potential public health outcomes of restrictions on flavourants or humectants in WT, we evaluated the effects of these constituents on puffing behaviours, biomarkers of exposure and subjective effects among adults with high versus low WT dependence.

METHODS

N=39 high dependence and N=49 low dependence WT smokers (Lebanese Waterpipe Dependence Scale scores >10 = high dependence) completed four smoking sessions in a cross-over experiment. Conditions were preferred flavour with humectant (+F+H), preferred flavour without humectant (+F-H), unflavoured with humectant (-F+H) and unflavoured without humectant (-F-H). Measures of puff topography, plasma nicotine and expired carbon monoxide (eCO) boost, and subjective effects were assessed.

RESULTS

Level of WT dependence modified the effect of WT condition on average flow rate, average puff volume and eCO boost. Although, overall, participants puffed the +F+H WT least intensely and -F-H WT most intensely, this association was strongest among WT smokers with high dependence. Participants preferred smoking the +F+H WT and achieved the largest plasma nicotine boost in that condition.

DISCUSSION

Findings underscore the complexity of setting product standards related to flavourants and humectants in WT. Future research evaluating whether WT smokers with high dependence would quit or reduce their WT smoking in response to removal of flavourants or humectants from WT is necessary to appreciate the full public health effects of such policies.

Is there a relation between vitamin D, interleukin-17, and bone mineral density in patients with inflammatory bowel disease?

INTRODUCTION

In inflammatory bowel diseases (IBD), osteopenia and osteoporosis constitute a significant medical problem. Cytokines, especially IL-17, play an important role in the pathogenesis of IBD and osteoporosis. Vitamin D is a regulator of bone metabolism, and helps maintain immune system homeostasis.

MATERIAL AND METHODS

The research sample consisted of 208 persons: 83 patients (age 35 ±11.99 years) with Crohn's disease (CD); 86 patients (age 39.58 ±14.74 years) with ulcerative colitis (UC); and 39 persons (age 30.74 ±8.63 years) in the control group (CG). Clinical data on bone mineral density of the lumbar spine (L2-L4), bone mineral density of the femoral neck (FN), and body mass index (BMI) were collected. 25OHD and IL-17 serum concentrations were also measured.

RESULTS

Body mass index (kg/m²) results: in CD, 21.51 ±3.68; in UC, 23.31 ±4.38; and in CG, 24.57 ±3.45 (p < 0.01). Densitometry results for L2-L4 T-score SD: in CD -0.83 ±1.45; in UC -0.47 ±1.15; in CG 0.09 ±0.70. Densitometry results for FN T-score SD: in CD -0.62 ±1.26; in UC -0.29±1.17; in CG 0.41 ±1.03 25OHD (ng/ml) serum concentrations: in CD, 21.33±12.50; in UC, 22.04±9.56; in CG, 21.56±9.11 (ns). IL-17 (pg/ml) serum concentrations: in CD, 8.55±10.99; in UC, 11.67±12.97; in CG, 5.16±9.11 (ns).

CONCLUSIONS

Inflammatory bowel diseases patients and persons from the CG did not differ in vitamin D or IL-17 levels. Patients with a mild course of the disease had a higher vitamin D concentration and bone mineral density. In UC, higher vitamin D concentrations were associated with lower IL-17 concentrations. The IBD patients with a severe course of the disease had a lower body mass than those in the CG and the patients with a mild course of the disease.

Natural Course of Nicotine Dependence Among Adolescent Waterpipe and Cigarette Smokers

PURPOSE

Waterpipe (WP) smoking patterns and setting can result in a unique trajectory of nicotine dependence (ND) compared with cigarette smoking. This longitudinal study compared the development of ND symptoms among adolescent WP and cigarette smokers.

METHODS

A cohort of 647 eighth and ninth graders in Lebanon were followed over 5 years. This study was based on 283 current exclusive WP and 146 current exclusive cigarette smokers. Kaplan-Meier survival analyses were conducted to evaluate 50% cumulative probability for the development of initial Hooked on Nicotine Checklist symptoms and the International Classification of Diseases, 10th revision (ICD-10) ND.

RESULTS

An initial Hooked on Nicotine Checklist symptom was endorsed by 59% of WP and 50% of cigarette smokers after smoking onset. Among those, 50% of both WP and cigarette smokers did so within 9.7 and 18.5 months, respectively. Approximately 28% of WP smokers and 22% of cigarette smokers developed ICD-10 ND. Among those, 50% of both WP and cigarette smokers did so within 15 and 22 months, respectively. The most common first to fourth ICD-10 criteria reported by WP smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "neglect of alternative pleasure," and "use despite harm." The most common first to fourth ICD-10 criteria reported by cigarette smokers were "a strong desire to use tobacco," "difficulties in controlling tobacco taking behavior," "withdrawal," and "tolerance".

CONCLUSIONS

Compared with adolescent cigarette smokers, initial ND symptoms and ICD-10 ND can develop sooner after starting to smoke and progress more rapidly among adolescent WP smokers. Developing, implementing, and evaluating intervention programs with adolescent WP smokers should be guided by the WP-specific trajectory of ND.

Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis

OBJECTIVE

Identifying the factors associated with nicotine dependence (ND) is essential to prevent initiation and continued use, and to promote cessation among youth. This study aims to document the predictors of the appearance of initial ND symptoms and full ND syndrome among adolescent waterpipe (WP) and cigarette smokers.

METHODS

A 6-year longitudinal study was conducted among 8th and 9th graders from 38 schools in Lebanon. The analysis sample included exclusive-WP (n = 228) and exclusive-cigarette smokers (n = 139). Weighted Cox proportional hazards models were used to characterizing predictors of initial ND symptoms and full ND syndrome.

RESULTS

Predictors of experiencing initial ND symptoms among WP smokers included low maternal educational level, having a sibling who smoked WP, low physical activity, high body mass index (BMI), smoking initiation at a younger age. For cigarette smokers these were being male, younger, having lower BMI, having a sibling who smoked cigarettes, living in a crowded household, and smoking daily. Among WP smokers, predictors of developing full ND syndrome include being younger, believing that WP smokers have more friends, depression, high levels of impulsivity, and initiating smoking at a younger age. For cigarette smokers, predictors of full ND syndrome were being younger and initiating smoking at a younger age.

CONCLUSION

Smoking cessation and prevention interventions targeting youth should address modifiable, and tobacco use-specific factors that influence the development of ND among young WP and cigarette smokers. They also need to start at a younger age to target those most vulnerable to developing life-long addiction to tobacco products.

Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults

Young adults’ hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18–30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p < 0.001), positive attitudes (p < 0.001), and negative emotional response (p < 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

Waterpipe use and associated consumer characteristics in the German population: Data from a national representative survey (DEBRA study)

BACKGROUND

Waterpipes (WP) have a long tradition in certain regions of the world, and their use has been increasing worldwide. Current data on the use of WP in different subgroups of the German population are missing.

OBJECTIVE

To estimate the current prevalence of WP use and associated socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour in the German population aged ≥14 years; to describe the frequency of use and starting age in current WP users.

METHODS

We analysed data from waves 13-18 (June/July 2018-April/May 2019; N = 12,220) of the German Study on Tobacco Use (DEBRA) - a representative, computer-assisted national household survey. Associations of socio-demographic characteristics, tobacco smoking status and e-cigarette usage behaviour were assessed with multivariable logistic regression models.

RESULTS

A total of 1.8% (n = 217) (95% confidence interval (CI) = 1.5%-2.0%) of the population were current WP users, 13% (n = 1618) (95% CI = 12.3%-13.5%) were ever users. Adjusted multivariable logistic models showed that people with migration background, male sex, younger age, and those who were smokers or used e-cigarettes, were more likely to use a WP. Among current WP users, 15.2% (n = 33) (95% CI = 10.7%-20.7%) had started to use WP at the age of 26 or older, and 23.0% (n = 50) (95%CI = 17.6%-29.2%) had used WP at least once a week or almost daily in the last month.

CONCLUSIONS

In Germany, the use of WP is popular and most strongly associated with migration background and use of tobacco and e-cigarettes. These aspects should be considered when designing future target group-specific prevention strategies.

Testing the Effects of Hookah Tobacco Social Media Risk Communication Messages Among Young Adults

BACKGROUND

Hookah tobacco is commonly used among young adults, and use is driven in part by widespread misperceptions about risks. Social media use, particularly Instagram, is prominent in this population and exposure to commercial and user-generated content promoting hookah commonly occurs.

AIMS

This study tested the effects of hookah tobacco risk messaging for delivery via Instagram as a strategy to offset exposure to content promoting hookah use among young adults.

METHOD

Young adult hookah smokers were recruited online for a 2 × 3 between-subjects experiment (n = 601). Participants completed preexposure measures and were randomized to view hookah tobacco Instagram ads (commercial or user generated) with risk messages (none, risk education, or graphic risk). Stimuli were presented as a simulated Instagram feed. After viewing the stimuli, participants completed postexposure outcome measures.

RESULTS

There was a statistically significant main effect of risk message type but no significant main effect of Instagram ad type or risk message type by ad type interactions. Exposure to the graphic risk and risk education messages were associated with lower intentions to engage with hookah tobacco ads on Instagram. Graphic risk and risk education messages produced greater negative emotional response and the graphic messages increased motivation to quit compared with Instagram ads alone.

DISCUSSION

Findings provide preliminary evidence that hookah tobacco risk messages delivered via Instagram can offset the influence of content promoting the use of hookah tobacco.

CONCLUSION

This study represents an example of risk message testing and the results suggest the messages warrant further testing via social media delivery.

The Syrian Center for Tobacco Studies-13 (SCTS-13): Psychometric evaluation of a waterpipe-specific nicotine dependence instrument

BACKGROUND

Waterpipe tobacco smoking (WTS) has surged globally among young people and causes nicotine dependence (ND). No existing ND instruments are sensitive to waterpipe-specific features of ND and early stages of use.

METHODS

We conducted a psychometric scale evaluation among 192 current waterpipe smokers, initially averaging 15 years of age, recruited from schools in Beirut, Lebanon, and assessed 4 times, 6 months apart. Twenty eight self-report items tapping multiple features of ND were submitted to exploratory and confirmatory factor analyses (EFA and CFA) to reduce items and verify factor structure. Convergent validity was assessed with the Lebanese Waterpipe Dependence Scale and the Hooked on Nicotine Checklist, and discriminant validity with the Depressive Symptom Scale and Adolescent Life Events Stress Scale. Concurrent and predictive validity measures included smoking status and intensity (amount, frequency, session duration, and change in frequency), quitting interest and success, perceived addiction, and smoking alone.

RESULTS

The EFA yielded a single factor, 13 item solution (named the Syrian Center for Tobacco Studies [SCTS]-13) that explained 91% of variance in responses, was internally consistent (Cronbach's alpha and McDonald's omega = 0.87), and captured several positive reinforcement, negative reinforcement, and social/sensory-related features of ND. The CFA indicated good model fit. The SCTS-13 showed acceptable convergent and discriminant validity. Higher SCTS-13 scores predicted current waterpipe and dual (waterpipe and cigarette) smoking, greater intensity of use, less interest in quitting, shorter duration of abstinence, greater perceived addiction, and smoking alone (vs. socially).

CONCLUSION

The SCTS-13 is a promising brief, waterpipe-specific ND instrument.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of hookah (water pipe) smoking on semen parameters

Hookah (water pipe) smoking, an old method of tobacco smoking, is regaining widespread popularity all over the world. Although the research in this field is still deficient, it has been proven for its harmful effect on human's health by increasing the risk of cardiovascular disease, infection and lung, oral and bladder cancer (Al-Numair et al., J Food Agric Environ, 5: 17, 2007; Bou Fakhreddine et al., Respir Med, 108: 1241-1253, 2014; Chaouachi, J Negat Results Biomed, 5: 17, 2006). However, no research was found to address its effect on human fertility or reproductive outcome. In this cross-sectional study, we aim to explore the effect of smoking hookah on human semen parameters among men attending In Vitro Fertilization LABs for seminal fluid analysis testing. 104 patients aged between 25 and 45, who are noncigarette smokers and have no chronic medical illness, were enrolled in the study: 50 hookah nonsmokers and 54 hookah smokers. Their semen parameters were compared. Semen volume, normal morphology and progressive motility were slightly lower in the hookah smoker (3.21 ml; 10.2%; 29.56%) versus (3.45 ml; 11.5%; 33.20%), respectively, in nonhookah smokers; however, the difference was not statistically significant. The effect of hookah smoking on semen observed in our study was not statistically significant. Further studies are needed to explore more and confirm any unfavourable effect.

Waterpipe Tobacco Warnings Need to Inform Users of Harm

Objectives

Health warning messages could be an effective means of communicating the health risks associated with waterpipe (WP) smoking. The objective of this study was to select a message that conveyed the risks associated with WP smoking.

Methods

A mixed-methods approach was used to explore the effectiveness of the Food and Drug Administration's (FDA's) mandated message, and others, among young adults using focus groups and surveys. Two focus group studies and one convenience survey were conducted to examine the FDA's mandated message and 11 other WP warning messages. The final study, conducted with a random sample of first-year university students, examined the effectiveness and reactance of the chosen message using previously validated items (scored on a 1-5 scale).

Results

The FDA's mandated message did not resonate well with focus group participants. In the random sample of students, the top message (WARNING: Hookah smoke contains poisons that cause lung and oral cancers) had high effectiveness (M = 4.49) and a low reactance (M = 2.12).

Conclusions

Our studies suggest that other messages are more effective for communicating the risks associated with WP smoking than the FDA's message for WP tobacco.

Agent-based Modeling in Tobacco Regulatory Science: Exploring 'What if' in Waterpipe Smoking

Objectives

Waterpipe tobacco smoking (WTS) is an emerging public health crisis, particularly among youth and young adults. Different from the use of other tobacco products and e-cigarettes, WTS tends to be a social activity occurring among friends or persons associated with social networks. In this paper, we review a potential strategy for WTS-related research.

Methods

As a bottom-up computational model, agent-based modeling (ABM) can simulate the actions and interactions of agents, as well as the dynamic interactions between agents and their environments, to gain an understanding of the functioning of a system. ABM is particularly useful for incorporating the influence of social networks in WTS, and capturing people's space-time activity and the spatial distribution of WTS venues.

Results

Comprehensive knowledge of WTS-related behaviors at the individual level is needed to take advantage of ABM and use it to examine policies such as the interaction between WTS and cigarette smoking and the effect of flavors used in waterpipe tobacco. Longitudinal and WTS-specific surveys and laboratory experiments are particularly helpful to understand WTS basic mechanisms and elicit individual preferences, respectively.

Conclusions

We argue that the uniqueness of WTS makes ABM a promising tool to be used in WTS-related research, as well as understanding use of other tobacco products.

Smoking Water-Pipe, Opium Use and Prevalence of Heart Disease: A Cross-sectional Analysis of Baseline Data from the Pars Cohort Study, Southern Iran

BACKGROUND

Associations between hookah and opium use and an increased risk of ischemic heart disease (IHD) have been suggested in a few studies, but more research is needed on the nature of these associations. We aimed to investigate the association between hookah and opium use and the prevalence of IHD in a population with relatively high prevalence of these exposures in Iran.

METHODS

Using baseline data from the Pars Cohort Study (PCS), a prospective study of individuals aged 40-75 years in Fars province, southern Iran, we calculated adjusted and crude odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for the independent association of hookah and opium use with prevalence of IHD.

RESULTS

Of 9248 participants, 10.2% (95% CI: 9.5, 10.9) had self-reported IHD. Prevalence of ever use of hookah and opium was 48.9% (95% CI: 44.6, 53.6) and 10.2% (95% CI: 8.3, 12.5) among those with IHD, and 37.0% (95% CI: 35.7, 38.3) and 8.1% (95% CI: 7.5, 8.7) among those without IHD, respectively. Adjusted OR for the association with prevalence of IHD was 1.26 (95% CI: 1.08, 1.46) for hookah use and 1.71 (95% CI: 1.30, 2.24) for opium abuse. No dose-response association was found between hookah and prevalence of IHD.

CONCLUSION

Hookah and opium abuse were associated with prevalent IHD in this study. Although more research is needed on these associations, particularly in prospective settings, reducing hookah and opium use could potentially reduce IHD risk.

Flavored Versus Nonflavored Waterpipe Tobacco: A Comparison of Toxicant Exposure, Puff Topography, Subjective Experiences, and Harm Perceptions

INTRODUCTION

Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers' experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers' toxicant exposure, smoking topography, subjective experiences and harm perception.

METHODS

Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception.

RESULTS

Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco.

CONCLUSIONS

Limiting tobacco flavor has a substantial effect on WP smokers' nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth.

IMPLICATIONS

This study highlights the important role of flavor in shaping WP smokers' experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.

Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Effect of risk messages on risk appraisals, attitudes, ambivalence, and willingness to smoke hookah in young adults

Objective: We examined effects of hookah tobacco risk messages on risk appraisals, attitudes towards hookah, ambivalence about hookah use, and willingness to smoke in young adults aged 18–30 years (n = 234).

Design: In an online experiment, participants completed pre-exposure measures and were randomized to hookah tobacco risk messages or to a no message control condition.

Main Outcome Measures: Risk appraisals, attitudes, ambivalence, and willingness to smoke hookah.

Results: Those who viewed risk messages reported greater risk appraisals (M 4.50, SD 1.17 vs. M 3.87, SD 1.16, p < .001), less positive attitudes (M −0.56, SD 1.24, vs. M 0.39, SD 1.35, p < .001), greater ambivalence (M 3.86, SD 1.26, vs. M 3.08, SD 1.32, p < .001), and less willingness to smoke than controls (M 4.48, SD 1.27, vs. M 4.85, SD 1.37, p = .034). Structural equation modeling demonstrated messages reduced willingness to smoke by evoking less positive attitudes (b = −0.15, 95% CI −0.32, −0.05) and by the effect of heightened risk appraisals on less positive attitudes (b = −0.14, 95% CI −0.30, −0.07).

Conclusions: Honing messages and understanding their mechanisms of action are necessary to produce more effective interventions to address hookah and other tobacco use in young adults.