Determinants of Tobacco and Hookah Smoking in a Nationally Representative Sample of Iranian Children and Adolescents: The CASPIAN-IV Study

Prevalence and Determinants of Hookah Smoking Among the Youth: A Scoping Review

Hookah smoking is highly prevalent and has been rising in popularity among young people worldwide. Yet, no recent and comprehensive reviews have been published to assess the prevalence and identify the main predictors of hookah use. We have thus carried out a comprehensive scoping review to consolidate and review the existing evidence for the prevalence and main determinants of hookah smoking among youth. A comprehensive literature search was thus conducted utilizing various databases including ScienceDirect, Scopus, Embase, and MEDLINE to identify relevant studies. To be incorporated in this review, studies had to include individuals below the age of 25, measure the prevalence of hookah smoking, or examine the determinants of hookah smoking. The review showed that hookah is mostly prevalent among youth from the Middle Eastern region, USA, South Asia, and various European countries. It also identified the main determinants of hookah smoking, which include age, the male gender, socioeconomic status, geographic region, other forms of substance use, knowledge, beliefs, and attitudes toward hookah smoking, sensation seeking, having friends and/or family members who smoke hookah, social acceptability, intention, accessibility, and lack of enforcement of prohibiting laws. The main determinants of hookah use include having friends and/or family members who smoke hookah, social acceptability, attitude, accessibility, and lack of enforcement of prohibiting laws. Public health authorities, educators, and other stakeholders should implement educational interventions to enhance the knowledge level on hookah smoking's harm and addiction and should target not only the individuals but also the family and the social environment.

The Burden and Correlates of Waterpipe (Hookah) Smoking among Adolescents and Youth: A Systematic Review

BACKGROUND

This systematic review evaluated the available medical literature on the prevalence and trends of waterpipe tobacco smoking among adolescents and youth in jurisdictionally representative populations.

METHODS

PubMed, Embase, and Scopus were searched for relevant studies from inception until 31 December 2022 that reported the burden of waterpipe smoking among adolescents and youth (10-24 years of age). We extracted qualitative data on the demographic characteristics, burden, and correlates of waterpipe smoking (PROSPERO ID: CRD42022310982).

RESULTS

A total of 2,197 articles were screened and 62 were included in the analysis. The majority (29) of the studies was from the United States of America and there were no studies from the south-east Asian region. The prevalence of ever waterpipe smoking among the 10-24 years age group was noted to be 18.16% (95% CI, 18.03-18.29). The prevalence of current (30-day) waterpipe smoking was 6.43% (95% CI, 6.34-6.50). The age of initiation of waterpipe smoking was variable. The prevalence of waterpipe smoking was higher among males, among those who belong to the high- and middle-income groups, and among university students. The common risk factors of waterpipe smoking included cigarette smoking, alcohol, and substance use. Waterpipe smoking resulted in increased susceptibility to the use of conventional forms of tobacco (e.g. smoking) among those who were never smokers.

CONCLUSION

Waterpipe smoking usage was significantly high among adolescents and young adults. Developing regulatory guidelines for water-pipe smoking, surveillance of its use, intervention, and specific policy frameworks may be considered a public health priority.

Aspects associated with waterpipe smoking in Iranian youths: a qualitative study

BACKGROUND

Waterpipe is one of the oldest methods of tobacco smoking, which has become the public health challenge, especially in the Eastern Mediterranean countries such as Iran. This study aimed to investigate the waterpipe smoking (WPS) in the young people of Kermanshah in 2020, using a qualitative method.

METHODS

This was a qualitative study conducted with the approach of content analysis. Participants were young waterpipe user aged 17 to 25 years selected by purposeful sampling method in Kermanshah city, located in the west of Iran. Data were collected through semi-structured interviews in face-to-face and audio-recorded methods based on an interview guideline during June to August 2020. Then researchers transcribed verbatim and analyzed the content of the interviews thematically.

RESULTS

In this study, 23 young people who were waterpipe users at the time of the study participated. The results showed that social aspects in three sub-categories were involved in WPS including "socio-cultural aspects", "socio-environmental aspects", and "social relations". Individual aspects of waterpipe use as second category also consisted of two sub-categories including "motivational aspects" and "lack of psycho-protective aspects".

CONCLUSIONS

It seems that the implementation of the policy of reducing access to waterpipe in public environments is effective in reducing waterpipe consumption. It is suggested that educational and interventions, based on targeted models and theories be implemented in order to increase young people's belief and perception on dangers of WPS, and to improve their self-efficacy to smoking cessation.

Geographic distribution and time trends of water-pipe use among Iranian youth and teenage students: A meta-analysis and systematic review

Water-pipe tobacco smoking is harmful to health, yet its rate of prevalence remains uncertain. Recent evidence has shown that the prevalence of water-pipe smoking among students is higher than in the general population. In this study, a systematic review of related literature on water-pipe use was conducted, and for this purpose, 76 articles were examined in the study. In this vein, geographic distribution and time trends of water-pipe consumption in Iran were considered. The results of this study showed that lifetime, last-year, and last-month prevalence of water-pipe smoking use among Iranian students were 28.78 (25.07-32.49), 20.84 (16.01-25.66), and 16.36 (11.86-20.85), respectively. The results also showed a wide variation by the region and sex in Iran. This study has shown the importance of addressing public prevention and alerting programs in schools and universities.

Smoking among High School Students in Iran: A Meta-Analysis Study

Objective: Cigarette smoking is an important and preventable risk factor, especially for adolescents and high school students. This issue has become one of the challenges for health system. Thus, the present study aimed to investigate the prevalence of smoking among Iranian high school students.

Method: This systematic review and meta-analysis study was done by searching PubMed, Scopus, Web Science (WOS), Science Direct, SID, and Google Scholar using the following keywords: “student” and “smoking” from 2000 to March 2018. After initial and critical appraisal, data were entered into a checklist and analyzed by a comprehensive meta-analysis software.

Results: The prevalence of smoking was 7.9% by combining the results of 49 articles. Males and females had 10.6% and 4.5% smoking prevalence, respectively. The overall prevalence of smoking was higher in northern areas in Iran (22.4%). Males in the northern (22.4%) and females in western regions (5.3%) were more smokers. There was a significant relationship between the prevalence of smoking with the year of publication, sample size, and age (P < 0.001).

Conclusion: In this study, Students' tendency to smoke was different in various regions of Iran, and had a high rate (7.9%). This figure indicates the necessity for planning some coherent educational programs for the public.

Development of a Hookah Smoking Obscenity Measurement Scale for Adolescents

Background

The worldwide trend of hookah use among adolescents is increasing, and literature shows a relationship between obscenity and adolescents’ tendency toward hookah smoking. As there is a lack of appropriate instruments to measure the obscenity of hookah smoking, in the present study, we aimed to develop an instrument to measure hookah smoking obscenity among adolescents.

Methods

In this methodological study, a sequential exploratory design was used to conduct the study from February 2017 to July 2018 on adolescents in Tabriz, Iran. In the qualitative phase, we conducted semi-structured individual interviews (with 18 students) and a focus group discussion (FGD) (with 13 students) to explain the concept of obscenity and develop the items of hookah smoking obscenity scale (HSOS). We then examined the psychometric properties of the HSOS based on face, content, construct and predictive validities as well as internal consistency and repeatability.

Findings

The HSOS was developed with 21 items based on the results of qualitative data analysis. Applying confirmatory factor analysis (CFA), the χ²/degree of freedom (df) ratio was found to be 3.792 for the four-factor structure of the questionnaire and the fit indices of this structural model were satisfactory. The values of Cronbach’s alpha and the intraclass correlation coefficient (ICC) for the constructs in the HSOS ranged 0.81-0.93 and 0.79-0.92, respectively.

Conclusion

We found the HSOS with a good level of fit indices, validity, and reliability. The HSOS may be applied by school healthcare providers and health practitioners to find valid and reliable data on the obscenity of hookah smoking when developing hookah smoking prevention/cessation interventions among adolescents.

Use of Tobacco Products in Turkish Children and Young People: Is there an Alarm for Hookah Use?

OBJECTIVES

In the recent years, it has been observed that the use of hookah, a tobacco product, has increased in children and young people in Turkey. This study was conducted to determine the prevalence of cigarette and hookah use in children and young people specific to age and gender and to define the factors relevant to the use of hookah.

MATERIALS AND METHODS

The study was conducted with secondary/high school students between 11 and 17 years of age (Survey 1, n=4718) and with university students between 18 and 23 years of age (Survey 2, n=1588) as two groups, which made a total of 6306 students. The students were asked to fill in a questionnaire which consisted of questions about socio-demographic data and the use of tobacco and tobacco products.

RESULTS

It was determined that the use of cigarette and hookah was high in males, and it increased as the age increased in both genders (p<0.05). It was also determined that parents and friends using cigarette and hookah affected the use of cigarette and hookah in the study groups in both surveys (p<0.05). Additionally, it was determined that the educational level of the parents and being of a high social class were the social determiners of hookah use (p<0.05).

CONCLUSION

It is important that we fight against the use of all tobacco products, especially in young people. Education about the damages of tobacco and applying tobacco products should start at an early age, and accurate tobacco control models may provide support in this field.

The First Cigarette Smoking Experience and Future Smoking Behaviors Among Adolescents with Different Parental Risk: a Longitudinal Analysis in an Urban Iranian Population

BACKGROUND

Longitudinal research among Iranian adolescent smoking is limited. The current study aimed to investigate (1) the first smoking experience (FSE) and future smoking behaviors of adolescents with different parental risk factors and (2) the association between age of the FSE and future smoking behaviors over a 12-year follow-up.

METHOD

Based on Tehran Lipid and Glucose Study (TLGS) database, 1487 adolescents (12-18 years) with complete baseline parental data were recruited. Using two-step cluster analysis, families were classified as either high or low risk; these were based on parental risk factors including age, education, employment, and smoking status. Participants were examined four times in 12 years and their data were used for survival analysis. After exclusion of 24 cases who were smokers at baseline, Cox proportional hazard modeling was used to evaluate the effect of parental clusters on the FSE in 1463 nonsmoking adolescents who completed all prospective follow-ups. Logistic regression analysis was used to examine the effect of the age of FSE on future smoking behaviors.

RESULTS

The mean age of adolescents was 14.63 ± 2.07 years at baseline. Adolescents in the high-risk cluster group were 49% more likely to try smoking for their first time, and 55% more likely to smoke in the future. Compared with girls, boys had 83% higher chance of trying their first cigarette. Moreover, 1-year delay in the FSE resulted in 25% reduction in the probability of smoking in the future.

CONCLUSION

The findings show that compared with adolescents living in low-risk families, teenagers living in high-risk families are at greater risk of smoking at an earlier age; therefore, this group could benefit from gender- and culture specific preventive interventions.

Determinants of shisha use among secondary school students in Sudan

BACKGROUND

Shisha smoking has re-emerged in the Middle East in the last two decades and has spread rapidly in these communities. Information about shisha smoking in adolescents in Sudan is deficient. Hence, the aim of this study is to estimate the prevalence of shisha smoking among adolescents and determine the associated factors.

METHODS

This study is a school based cross sectional study among secondary school students in Khartoum State - Sudan that targets both male and female students aged 14-17 years. A total of 3387 students from 29 public and private schools were selected by multi stage random sampling. The participants completed an anonymous self-administered questionnaire which was based on Arabic version of the Global Youth Tobacco Survey (GYTS).

RESULTS

The response rate was 100% in schools and among participants, 57.3% were females and 51.6% were from public schools. The overall prevalence of those who had ever smoked shisha was 13.4%, and among male students the prevalence was 16.8%, while it was 10.9% in females. The associated factors were poor academic performance OR 2.90 CI 95% (1.21-6.94), friends smoking shisha OR 2.39 CI 95% (1.65-3.45), friends smoking cigarettes OR 2.76 CI 95% (1.90-4.01), peer pressure to smoke shisha OR 13.76 CI 95% (7.86-24.07) and unexpectedly restriction of selling shisha to minors OR 2.21 CI 95% (1.28-3.82).

CONCLUSION

The prevalence of those who had ever smoked shisha is among the lowest in Middle East region; therefore, regular surveillance system is needed. A well-structured peer based comprehensive tobacco control programmes that are supported by strict and rigorous anti-tobacco regulations which control both commercial and social resources of tobacco are needed to contain this issue among adolescents.

Decomposition of passive smoking inequality in Iranian children and adolescents: the CASPIAN-V Study

To investigate the socioeconomic inequality in passive smoking in Iranian children and adolescents. Through a multistage random cluster sampling method, a representative sample of 14,400 school students, aged 6-18 years, were enrolled from urban and rural areas of 30 provinces of Iran. Using a non-linear principal component analysis (NLPCA), the correlated variables were summarized as socioeconomic status (SES). Normalized concentration index (NCI) was used to measure inequality in passive smoking at national and regional SES levels. We decomposed total socioeconomic inequality in passive smoking into explanatory variables to identify the main contributors of inequality in passive smoking in the population studied. Data of 12,327 students and parents were complete for the current study. The response rate was 85.6% (50.9% boys, 71.2% urban residents). About 44% of Iranian students were exposed to passive smoking. The NCI for passive smoking at a national level was - 0.043 (95% confidence interval - 0.035, - 0.012), indicating that passive smoking was more concentrated among poorer children and adolescents. This inequality was statistically significant at a national level and in all regions except for regions with lower middle- and lowest SES levels. Considering the decomposition analysis, the household SES (63%), mothers' educational level (37%), fathers' educational level (29%), and school type (18%) made the largest positive contribution to inequality in passive smoking of children and adolescents. Passive smoking was distributed unequally among Iranian children and adolescents; it was more concentrated among socioeconomically disadvantaged families. Public health policies attentions should be given to reduce passive smoking among low SES children and adolescents living with illiterate or low-educated parents.

Obscenity of Cigarette and Hookah Smoking in Iranian Adolescents: A Longitudinal School-based Study

Background:

There is a very limited information on the obscenity of cigarette and hookah smoking among adolescents. Using a large and representative longitudinal sample of adolescents (n = 4820) aged 14–19 years from Tabriz (a metropolitan city in northwestern Iran), this study aimed at comparing the obscenity of cigarette and hookah smoking and assessing factors associated with obscenity of smoking. Moreover, we examined how the obscenity of cigarette and hookah smoking affected by the progress in the stages of cigarette and hookah smoking.

Methods:

In this longitudinal study, a random sample of high-school students was selected in Tabriz in 2010. Using a valid and reliable self-administered questionnaire, the data from the sampled students were collected twice at two points in time, 12 months apart. Multivariate backward logistic regression was used to determine the effect of the transition in cigarette (or hookah) smoking stages on the obscenity of cigarette (or hookah) smoking.

Results:

While 3,079 (63.9%) students expressed that obscenity of cigarette smoking is higher than obscenity of hookah smoking, 1,741 (36.1%) students expressed that obscenity of hookah smoking is higher than obscenity of cigarette smoking. The results of multivariate backward logistic regression indicated that the transition in cigarette (hookah) smoking stages was not related to the obscenity of cigarette (hookah) smoking.

Conclusions:

The results showed that obscenity of hookah smoking was less than obscenity of cigarette smoking, especially among females. Further study is required to understand the effect of obscenity on smoking and transition to different stages of cigarette and hookah smoking.

Factors Associated with Tobacco Use among Iranian Adolescents: An Application of Protection Motivation Theory

BACKGROUND

Tobacco use is a significant predisposing factor to many diseases. Protection motivation theory is a well-suited theory, since fear can motivate individuals to change their unhealthy behaviors.

OBJECTIVE

This study was conducted to examine the associations between the constructs of this theory with intention and tobacco use behavior.

METHOD

The present cross-sectional study was conducted in Noshahr, Iran. The participants were 440 high school boys selected using a stratified random sampling in 2016. A questionnaire about tobacco use based on protection motivation theory was developed and its validity and reliability were assessed. The questionnaire included the demographic information, the constructs of theory, and tobacco use behavior. Structural equation modeling was used to test the associations between the constructs with intention and tobacco use.

RESULTS

The variables of perceived vulnerability (β = 0/137, P < 0.001), fear (β = 0/149, P < 0.001), self-efficacy (β = 0/249, P < 0.001), perceived intrinsic reward (β = -0.285, P < 0.001), threat appraisal (β = -0.25, P < 0.001), and coping appraisal (β = 0.358, P < 0.001) had direct effect and are significant with intention. Moreover, perceived vulnerability (β = -0.158, P < 0.001), fear (β = -0.172, P < 0.001), self-efficacy (β = -0.288, P < 0.001), perceived intrinsic reward (β = 0.329, P < 0.001), threat appraisal (β = 0.265, P < 0.001), and coping appraisal (β = -0.379, P < 0.001) affected tobacco use indirectly through intention and were significantly associated with behavior. Also, intention had direct effect and is significant with tobacco use (β = -1.156, P < 0.001).

CONCLUSIONS

The protection motivation theory provides a useful framework for investigating factors of tobacco use among male students. Future tobacco prevention interventions should focus on increasing the vulnerability and fear, decreasing intrinsic reward, and improving self-efficacy to reduce tobacco use.

The role of sociodemographic factors associated with waterpipe smoking among male adolescents in western Iran: A cross-sectional study

INTRODUCTION

Waterpipe smoking (WPS) is an increasingly popular leisure activity among young people in Iran. The purpose of this study was to identify the role of sociodemographic factors associated with WPS among male adolescents in Iran.

METHODS

The study used a cross-sectional design. It included 730 high school male students (Grades 10–12) recruited through multistage random sampling conducted in 2017 in Hamadan city, western Iran. The self-administered questionnaires included information on demographic variables and behavioral risk factors related to WPS. Descriptive statistics and multinomial logistic regression modeling were conducted using SPSS.

RESULTS

The student mean age, and standard deviation (SD), and age at WPS initiation were 16.41 (0.84) and 13.31 (2.43) years, respectively. The percentages of never, former and current WPS were 37.3%, 36.4% and 26.3%, respectively. We found that ever cigarette smoking (OR=5.14, 95% CI: 2.56–10.32) and WPS family (OR=2.55, 95% CI: 1.40–4.64) were significantly associated with former WPS. Furthermore, being 18 years, studying in technical fields, reporting ever and current smoking of cigarettes and family usage of WP were significantly associated with current WPS. Friends with WPS (OR= 0.50, 95% CI: 0.34–0.72) however played a protective role on former WPS.

CONCLUSIONS

The results indicate that the prevalence of former and current WPS was high in Hamadan city. Thus, designing and implementing interventions for increasing students’, friends’ and family’s awareness regarding the harms of WPS and cigarette smoking are necessary to facilitate behavior change.

Is single-child family associated with cardio-metabolic risk factors: the CASPIAN-V study

BACKGROUND

In the present study, the association of the cardio-metabolic risk factors and the status of single-child family were studied in a national representative sample of Iranian children and adolescents.

METHODS

This cross sectional study was conducted as the fifth round of "Childhood and Adolescence Surveillance and PreventIon of Adult Non- communicable disease" surveys. The students' questionnaire was derived from the World Health Organization-Global School Student Health Survey. Using survey data analysis methods, data from questionnaires'; anthropometric measures and biochemical information analyzed by logistic regression analysis.

RESULTS

Overall, 14,274 students completed the survey (participation rate: 99%); the participation rate for blood sampling from students was 91.5%. Although in univariate logistic regression model, single child students had an increased risk of abdominal obesity [OR: 1.37; 95% CI: 1.19-1.58)], high SBP [OR: 1.58; 95% CI:1.17-2.14)], high BP [OR: 1.21; 95% CI:1.01-1.45)] and generalized obesity [OR: 1.27; 95% CI:1.06-1.52)], in multiple logistic regression model, only association of single child family with abdominal obesity remained statistically significant [OR: 1.28; 95% CI:1.1-1.50)]. Also in multivariate logistic regression model, for each increase of a child in the family the risk of abdominal obesity [OR: 0.95; 95% CI: 0.91-0.97), high SBP [OR: 0.88; 95% CI: 0.81-0.95)] and generalized obesity [OR: 0.95; 95% CI: 0.91-0.99)] decreased significantly.

CONCLUSION

The findings of this study serve as confirmatory evidence on the association of cardio-metabolic risk factors with single-child family in children and adolescents. The findings of study could be used for better health planning and more complementary research.

The prevalence and trends of waterpipe tobacco smoking: A systematic review

INTRODUCTION

Waterpipe tobacco smoking is harmful to health however its prevalence estimates remain uncertain. We aimed to systematically review the medical literature on waterpipe tobacco prevalence and trends.

METHODS

We searched Medline, Embase and ISI Web of Science for 'waterpipe' and its synonyms, without using language or date restrictions. We included any measure of waterpipe tobacco smoking prevalence in jurisdictionally representative populations. We stratified findings by prevalence measure (past 30 day, ever, regular or occasional, daily, other or unspecified) and age (adults or youth).

RESULTS

We included 129 studies reporting 355 estimates for 68 countries. In general, prevalence estimates among adults were highest in the Eastern Mediterranean, and among youth were about equal between Eastern Mediterranean and European regions. Past 30 day use was highest among Lebanese youth (37.2% in 2008), ever use was highest among Lebanese youth in 2002 and Lebanese university students in 2005 (both 65.3%), regular or occasional use was highest in among Iranian university students (16.3% in 2005), and daily use was highest among Egyptian youth (10.4% in 2005). Trend data were limited but most studies reported increased use over time, ranging from 0.3-1.0% per year among youth in the US to 2.9% per year among youth in Jordan (both for past 30 day use). Results were similar for ever use trends. Turkey (2.3% in 2008 to 0.8% in 2010) and Iraq (6.3% in 2008 and 4.8% in 2012) both witnessed decreased waterpipe use.

CONCLUSION

Waterpipe tobacco smoking is most prevalent in Eastern Mediterranean and European countries, and appears higher among youth than adults. Continued surveillance will be important to assess and inform policy measures to control waterpipe tobacco use.

Factors Associated with Hookah Use among Male High School Students: The Role of Demographic Characteristics and Hookah User and Non-User Prototypes

BACKGROUND

As students' hookah use has become a widespread problem in the developing countries, it is time to understand the cognitive determinants of students' decisions to do so. This study aimed to investigate the roles of psychological and demographic factors associated with hookah use among male high school students.

METHODS

This descriptive-analytical study was performed among 601 high school male students, recruited through multistage sampling method in the Kermanshah City, west of Iran in 2016. The data-gathering tool consisted of a self-administered questionnaire with questions about hookah use behavior and demographic, behavioral and psychological variables. Data were analyzed using SPSS-18 software using chi-square and logistic regression.

RESULTS

36.1% of the participants reported ever hookah use and 17.1% mentioned using hookah in the past month. Pleasure (28.1%) and sensation seeking (22.5%) were common reasons of hookah use. In comparison to non-users, hookah users evaluated a typical hookah user as more clever, less immature, more popular, more attractive, more self-confident, more independent, and less selfish (P<0.001).

CONCLUSIONS

The results revealed the importance of psychological factors when examining students' hookah use status. Thus, design and implementation of interventions might be effective in prevention of hookah use among students.