Energy drinks and waterpipe smoking associated with disordered eating habits among male Palestinian refugees

This cross-sectional study highlights the concerning relationship between stimulants, alcohol use, and weight-related problems among Palestinian refugee men in the West Bank. Self-administered questionnaires were used to gather data on stimulants and alcohol use and eating attitudes and behaviors (EAT-26). The findings revealed that many refugee men were daily cigarette (61.4%) and waterpipe smokers (15.5%), while 30.6% and 2.3% were daily energy drink and alcohol users, respectively. Moreover, most refugee men (67.3%) were obese, and 23.5% were terrified about being obese. They had disordered eating habits, including the impulse to vomit after meals (63.3%). Moreover, 30.7% scored ≥20 using EAT-26 scale, and 44.4% scored at least one positive behavior, including binge eating (40.4%), purging (10.0%), using laxatives or diet pills (8.3%), excessive exercise (30.9%), and losing weight (24.6%). The results of the adjusted binary logistic regression indicated that risk factors associated with self-induced vomiting were daily (OR = 2.71, p-value = 0.004) and weekly energy drink intake (OR = 2.41, p-value = 0.023), weekly alcohol intake (OR = 10.83, p-value = 0.036), and obesity (OR = 2.57, p-value = 0.002), while inversely associated with weekly waterpipe smoking (OR = 0.297, p-value = 0.007). Obesity was inversely associated with daily (OR = 0.146, p-value < 0.01) and weekly waterpipe smoking (OR = 0.259, p-value = 0.002), and weekly cigarette smoking (OR = 0.251, p-value < 0.01). The study underscores the urgent need for community awareness, professional evaluation, and treatment for obesity and disordered eating habits among Palestinian refugee men. It is essential to address the detrimental effects of alcohol and energy drink intake and tobacco smoking to improve the health outcomes of this vulnerable population.

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.

Impact of waterpipe smoking on the salivary microbiome

Background

While oral mirobial dysbiosis due to tobacco smoking has been studied thoroughly, there is limited data on the effect of waterpipe smoking on the oral microbiome. This study aims to compare the salivary microbiome between waterpipe smokers and non-smokers.

Materials and methods

Unstimulated saliva samples were collected from 60 participants, 30 smokers and 30 non-smokers in Kuala Lumpur and Klang Valley, Malaysia. DNA extraction was performed using the Qiagen DNA mini kit, and the 16S rRNA bacterial gene was amplified and sequenced using the Illumina MiSeq platform. Sequencing reads were processed using DADA2, and the alpha and beta diversity of the bacterial community was assessed. Significantly differentiated taxa were identified using LEfSe analysis, while differentially expressed pathways were identified using MaAsLin2.

Results

A significant compositional change (beta diversity) was detected between the two groups (PERMANOVA P < 0.05). Specifically, the levels of phylum Firmicutes and genus Streptococcus were elevated in smokers, whereas phylum Proteobacteria and genus Haemophilus were depleted compared to non-smokers. At the species level, Streptococcus oralis, Streptococcus salivarius, and Streptococcus gingivalis were enriched in smokers. We observed significant differences in the abundance of thirty-seven microbial metabolic pathways between waterpipe smokers and non-smokers. The microbial pathways enriched in smokers were those implicated in polymer degradation and amino acid metabolism.

Conclusion

The taxonomic and metabolic profile of the salivary microbiome in waterpipe smokers compared to healthy controls exhibited a paradigm shift, thus, implying an alteration in the homeostatic balance of the oral cavity posing unique challenges for oral health.

Waterpipe smoke inhalation induces lung injury and aortic endothelial dysfunction in mice

Waterpipe tobacco smoking (WPS) inhalation has been shown to trigger endothelial dysfunction and atherosclerosis. However, the mechanisms underlying these effects are still unknown. Here, we assessed the impact and underlying mechanism of WPS exposure for one month on endothelial dysfunction using aortic tissue of mice. The duration of the session was 30 min/day and 5 days/week. Control mice were exposed to air. Inhalation of WPS induced an increase in the number of macrophages and neutrophils and the concentrations of protein, tumor necrosis factor alpha (TNF alpha), interleukin (IL)-1beta, and glutathione in bronchoalveolar lavage fluid. Moreover, the concentrations of proinflammatory cytokines (TNF alpha, IL-6 and IL-1beta), adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin and P-selectin) and markers of oxidative stress (lipid peroxidation, glutathione, superoxide dismutase and nitric oxide) in aortic homogenates of mice exposed to WPS were significantly augmented compared with air exposed mice. Likewise, the concentration of galectin-3 was significantly increased in the aortic homogenates of mice exposed to WPS compared with control group. WPS inhalation induced vascular DNA damage assessed by comet assay and apoptosis characterized by a significant increase in cleaved caspase-3. While the aortic expression of phosphorylated nuclear factor kappaB (NF-kappaB) was significantly increased following WPS inhalation, the concentration of sirtuin 1 (SIRT1) was significantly decreased in WPS group compared with air-exposed group. In conclusion, our study provided evidence that WPS inhalation triggers lung injury and endothelial inflammation, oxidative stress and apoptosis which were associated with nuclear factor-kappaB activation and SIRT1 down-regulation.

Prevalence of tobacco smoking between 2009 and 2015 among students and the general population in the Kingdom of Saudi Arabia

INTRODUCTION

Tobacco smoking is a major risk factor for morbidity and mortality. Studies on smoking in the Kingdom of Saudi Arabia (KSA) have shown inconsistent results. The purpose of this study was to provide a literature review on the prevalence of tobacco smoking among school students, university students, and the general population of KSA during 2009-2015, before the implementation of new tobacco control measures.

METHODS

We searched PubMed and Google for articles published in English from 2009 to 2015, focused on overall tobacco smoking and/or any form of tobacco smoking (e.g. tobacco, cigarette, and waterpipe) and conducted with a sample of ≥300 participants. Only the prevalence of current smoking was assessed. A narrative synthesis of the prevalence results was conducted.

RESULTS

Of the 360 studies found in the primary search, 91 were selected for further examination for eligibility, and 20 studies were included in the review. Among school students, the prevalence of smoking any form of tobacco (cigarettes, waterpipes, or both) ranged 10.0-21.7%. The prevalence of cigarette smoking ranged 8.9-19.5% and for waterpipe smoking it was 9.5%. Among university students, the prevalence of smoking any form of tobacco ranged 11.1-25.3%, cigarette smoking 7.8-17.5%, and waterpipe 4.3-18.0%. In the general population, the prevalence of cigarette smoking ranged 19.6-23.5% and for waterpipe smoking it was 4.3%.

CONCLUSIONS

Our study shows smoking levels were high in the KSA between 2009 and 2015. Studies utilizing standardized methodology with nationally representative samples are needed to better characterize the prevalence of different types of tobacco smoking. More research on national representative samples is needed, including studies on the same populations/groups/areas over time using standardized tools and definitions.

Prevalence of waterpipe smoking and its associated factors among adolescents aged 12-16 years in 73 countries/territories

Introduction

To describe the recent prevalence of, and trends in, waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years in 73 countries/territories (hereafter "countries").

Methods

Data from 72 countries that had conducted a Global Youth Tobacco Survey (GYTS) in 2010-2019 and from the National Youth Tobacco Survey in the United States in 2019 were used to assess the recent prevalence of waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years. Data from 38 countries that had carried out at least 2 surveys from 2000 to 2019 were used to determine trends in the prevalence of waterpipe smoking among adolescents.

Results

The recent prevalence of current waterpipe smoking (on 1 day during the past 30 days) among adolescents was 6.9% (95%CI 6.4-7.5). The prevalence was highest in the European region (10.9%, 9.9-11.8) and Eastern Mediterranean region (10.7%, 9.5-11.9), but lowest in the Western Pacific region (1.9%, 1.4-2.4). The prevalence of current waterpipe smoking increased or remained unchanged in 19 (50%) of 38 countries, but decreased in the remaining 19 countries (50%). Parental smoking, closest friends' smoking, secondhand smoke exposure, tobacco advertisement exposure, not being taught the dangers of smoking, particularly cigarette smoking, were positively associated with adolescent waterpipe smoking.

Discussion

Waterpipe smoking among adolescents remains a major public health issue worldwide, especially in the regions of Europe and the Eastern Mediterranean. Effective prevention and control strategies and measures are needed to curb the epidemic of adolescent waterpipe smoking.

Impact of COVID-19 lockdown on smoking (waterpipe and cigarette) and participants' BMI across various sociodemographic groups in Arab countries in the Mediterranean Region

INTRODUCTION

Tobacco smokers are at high risk of developing severe COVID-19. Lockdown was a chosen strategy to deal with the spread of infectious diseases; nonetheless, it influenced people's eating and smoking behaviors. The main objective of this study is to determine the impact of the COVID-19 lockdown on smoking (waterpipe and cigarette) behavior and its associations with sociodemographic characteristics and body mass index.

METHODS

The data were derived from a large-scale retrospective cross-sectional study using a validated online international survey from 38 countries (n=37207) conducted between 17 April and 25 June 2020. The Eastern Mediterranean Region (WHO-EMR countries) data related to 10 Arabic countries that participated in this survey have been selected for analysis in this study. A total of 12433 participants were included in the analysis of this study, reporting their smoking behavior and their BMI before and during the COVID-19 lockdown. Descriptive and regression analyses were conducted to examine the association between smoking practices and the participant's country of origin, sociodemographic characteristics, and BMI (kg/m²).

RESULTS

Overall, the prevalence rate of smoking decreased significantly during the lockdown from 29.8% to 23.5% (p<0.05). The percentage of females who smoke was higher than males among the studied population. The highest smoking prevalence was found in Lebanon (33.2%), and the lowest was in Oman (7.9%). In Egypt, Kuwait, Lebanon, and Saudi Arabia, the data showed a significant difference in the education level of smokers before and during the lockdown (p<0.05). Smokers in Lebanon had lower education levels than those in other countries, where the majority of smokers had a Bachelor's degree. The findings show that the BMI rates in Jordan, Lebanon, Oman, and Saudi Arabia significantly increased during the lockdown (p<0.05). The highest percentages of obesity among smokers before the lockdown were in Oman (33.3%), followed by Bahrain (28.4%) and Qatar (26.4%), whereas, during the lockdown, the percentage of obese smokers was highest in Bahrain (32.1%) followed by Qatar (31.3%) and Oman (25%). According to the logistic regression model, the odds ratio of smoking increased during the pandemic, whereas the odds ratio of TV watching decreased. This finding was statistically significant by age, gender, education level, country of residence, and work status.

CONCLUSIONS

Although the overall rates of smoking among the studied countries decreased during the lockdown period, we cannot attribute this change in smoking behavior to the lockdown. Smoking cessation services need to anticipate that unexpected disruptions, such as pandemic lockdowns, may be associated with changes in daily tobacco consumption. Public health authorities should promote the adoption of healthy lifestyles to reduce the long-term negative effects of the lockdown.

Waterpipe Smoking in Pregnant Women of Zahedan City in 2020: Prevalence and Associated Factors

BACKGROUND

Waterpipe smoking is associated with maternal and fetal complications, and valid data contribute to evidence-based planning. This study was conducted to determine the prevalence and factors related with waterpipe smoking among pregnant women of Zahedan city in 2020.

METHODS

This cross-sectional study was conducted in 2020, and 400 pregnant women in the third trimester of pregnancy who lived in Zahedan participated in it by single stage randomized cluster sampling. A questionnaire was used to measure awareness of waterpipe complications, and another one investigated the status of waterpipe smoking to collect data. For data analysis, descriptive statistics and multiple logistic regression were used through SPSS 21.

RESULTS

The findings indicated that the prevalence of waterpipe smoking was 18.8%. In the waterpipe smoking group, 46.6% smoked every day, 89.3% had tried to reduce the smoking, and 64.8% reported fetal death as their main motivation to reduce smoking. Only 5.6% of subjects stated receiving training as the reason for reduction of their waterpipe smoking. The women's level of education, economic status, ethnicity, and awareness of the risks of waterpipe smoking were the predictors for waterpipe smoking (P < 0.05, P = 0.03, P = 0.006, and P < 0.001, respectively).

CONCLUSIONS

The results of this study show the high prevalence of waterpipe smoking in pregnant women of Zahedan. Further investigation and training in this regard are essential for pregnancy as well as pre-pregnancy care. Special attention should be paid to groups with better economic status and level of education, Baluch women, and those with low level of awareness.

Does waterpipe smoking increase the risk of Helicobacter pylori infection?

Background:

In this study, we aimed to evaluate whether waterpipe smoking can be associated with the transmission of Helicobacter pylori infection or not.

Materials and Methods:

Between March 2018 and April 2019, 445 patients aged over 18 years old who were admitted to outpatient clinics with dyspeptic complaints were recruited for the study. Patients are divided into two groups – Group 1 is H. pylori-positive patients and Group 2 is negative. Waterpipe smoking, smoking, age, gender, and educational status were compared among groups.

Results:

Two hundred and sixty-one women (58%) and 184 men (42%), totally 445 patients, tested for H. pylori infection. Seventy-nine of 261 (30%) women and 60 of 184 (32%) men had H. pylori positive. One hundred and sixty-two of 445 (36%) patients were smoking cigarette and 66 of 445 (14%) patients were using waterpipe tobacco. Waterpipe smoking individuals were found to be associated with the H. pylori positivity (P < 0.001); whereas, age, gender, educational level, and smoking were not found to be statistically significant (all P > 0.05). In binary logistic regression analysis, waterpipe tobacco smoking was found to be the only independent predictor of H. pylori infection (P < 0.001, odds ratio = 5.51, confidence interval: 3.158–9.617).

Conclusion:

Waterpipe smoking seems to be an important risk factor for H. pylori infection and may be one of the reasons of high prevalence of H. pylori infection.

Perception and assumptions of young waterpipe smokers in Mumbai, India

Background

Hookah smoking has been on raise all over the world, including India, especially among youngsters. There is growing evidence suggesting the high school children experimenting this form of tobacco.

Objective

The objective of this study was to investigate the characteristics, behavior, and perceptions related to hookah smoking among the hookah smokers in Mumbai.

Materials and Methods

A cross-sectional survey was conducted among 200 randomly selected young adults between the age group of 15-35 years in Mumbai who visited different dental clinics. The questionnaire was distributed as Google Forms online in the month of November and December 2019 and those who submitted completed responses were included in the study.

Results

Only 114 participants returned with the completed forms in the time period of 2 months. The results showed that the majority of participants were between 20 and 24 age, comprising 58% who were having the habit of hookah smoking. Among which 24% females, 76% males had history of hookah habit. Eight percent of males started smoking hookah from very young age. Males (29.89%) shared one hookah pot with four members. Forty percent of the participants stated that they are interested to smoke again because of hookah flavor.

Conclusion

Easy availability of newer forms of smoking at online markets could play a role in promoting the use of hookah among youngsters. Most products are being sold without any warnings, and there is no means to control the selling of the products to minors. Educational intervention is urgently needed to create awareness among youth about the harmful effects of hookah smoking.

Effect of Water-Pipe Smoking on the Normal Development of Zebrafish

Background: Among all types of tobacco consumption, Water-Pipe Smoking (WPS) is the most widely used in the Middle East and second-most in several other countries. The effect of WPS on normal development is not yet fully understood, thus the aim of this study is to explore the acute toxicity effects of WPS extract on zebrafish larvae. Methods: In this study, we compared the effects of WPS smoke condensates at concentrations varying from 50 to 200 µg/mL on developmental, cardiac, and behavioural (neurotoxicity) functions. Gene expression patterns of cardiac biomarkers were also evaluated by RT-qPCR. Results: Exposing zebrafish embryos to 50, 100, 150 and 200 µg/mL WPS for three days did not affect the normal morphology of Zebrafish embryos, as the tail flicking, behavioural and locomotion assays did not show any change. However, WPS deregulated cardiac markers including atrial natriuretic peptide (ANP/NPPA) and brain natriuretic peptide (BNP/NPPB). Furthermore, it induced apoptosis in a dose-dependent manner. Conclusion: Our data demonstrate that WPS can significantly affect specific cardiac parameters during the normal development of zebrafish. Further investigations are necessary to elucidate the pathogenic outcome of WPS on different aspects of human life, including pregnancy.

Estimating the Marginal Causal Effect and Potential Impact of Waterpipe Smoking on Risk of Multiple Sclerosis Using the Targeted Maximum Likelihood Estimation Method: A Large, Population-Based Incident Case-Control Study

There are few if any reports regarding the role of lifetime waterpipe smoking in the etiology of multiple sclerosis (MS). In a population-based incident case-control study conducted in Tehran, Iran, we investigated the association between waterpipe smoking and MS, adjusted for confounders. Cases (n = 547) were patients aged 15-50 years identified from the Iranian Multiple Sclerosis Society between 2013 and 2015. Population-based controls (n = 1,057) were persons aged 15-50 years recruited through random digit telephone dialing. A doubly robust estimation method, the targeted maximum likelihood estimator (TMLE), was used to estimate the marginal risk ratio and odds ratio for the association between waterpipe smoking and MS. The estimated risk ratio and odds ratio were both 1.70 (95% confidence interval: 1.34, 2.17). The population attributable fraction was 21.4% (95% confidence interval: 4.0, 38.8). Subject to the limitations of case-control studies in interpreting associations causally, these results suggest that waterpipe use, or strongly related but undetermined factors, increases the risk of MS. Further epidemiologic studies, including nested case-control studies, are needed to confirm these findings.

Signaling alterations in oral keratinocytes in response to shisha and crude tobacco extract

BACKGROUND

Tobacco consumption in smoking and non-smoking forms has been consequential in the rise of oral cancer cases. Among different forms, epidemiological studies from Middle Eastern countries and rural parts of northern India have reported increasing association of oral cancer with waterpipe (hookah) smoking. However, molecular mechanisms and role played by waterpipe smoking in the onset of oral carcinogenesis remains unexplored.

METHODS

In this study, immortalized normal human oral keratinocytes were chronically treated with extracts of two varieties of waterpipe tobacco-crude tobacco and processed shisha. Phenotypic changes and molecular aberrations were examined using cell culture-based assays and mass spectrometry-based quantitative proteomic analysis, respectively. Bioinformatics analysis was utilized to analyze proteomics data and identify dysregulated pathways.

RESULTS

Our data indicate that chronic treatment with waterpipe tobacco extracts increased proliferation, invasion, migration, and significant dysregulation of protein expression in oral keratinocytes. Altered expression of proteins involved in interferon signaling pathway were observed with both varieties of tobacco. Overexpression of cholesterol metabolism and vesicle-mediated transport proteins were identified exclusively in cells treated with crude tobacco extract. Bioinformatics analyses revealed different oncogenic response in oral cells based on the type of waterpipe tobacco used.

CONCLUSIONS

This study may serve as a useful resource in understanding the early onset of oral cancer attributed to waterpipe smoking.

Determinants of Waterpipe Smoking Among Women: A Systematic Review

Background

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

Methods

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

Results

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

Conclusions

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

One-item susceptibility measure predicts waterpipe and little cigar/cigarillo uptake in a national sample of adolescents and young adults in the United States

INTRODUCTION

Adolescents and young adults in the United States (US) are increasingly using non-cigarette tobacco products such as waterpipe (WP) and little cigars/cigarillos (LCC). One way to predict which non-user adolescents and young adults are most likely to use these products is through measuring their susceptibility or openness to using the products.

METHODS

We conducted a national phone survey (baseline) and an internet survey (follow-up) of adolescents and young adults (ages 13–25 years), who, at baseline, had never used WP (N=1002) or LCC (N=990). At baseline, we measured susceptibility using a single item, asking participants whether they would try WP or LCC if their best friend offered it to them, and subsequently measured uptake at follow-up. We conducted multivariate regression analyses to determine whether product-specific susceptibility was a significant predictor of uptake at follow-up.

RESULTS

Participants who were susceptible and participants who had ever used another tobacco product had higher odds of using WP (AOR=3.5, AOR=4.2) and LCC (AOR=3.2, AOR=5.3) at follow-up than those who were not susceptible to those products, and had not ever used tobacco products respectively, controlling for sociodemographic factors. The one-item measure had adequate sensitivity (WP=51.4%, LCC=40.2%) and specificity (WP=84.9%, LCC=87.9%).

CONCLUSIONS

Our national study of US adolescents and young adults shows that a one-item susceptibility measure at baseline was a significant predictor of WP and LCC uptake at follow-up, even after controlling for other predictors. Future research should assess the predictive validity of the one-item compared to the multi-item scale.

Male students' experiences on predictors of waterpipe smoking reduction: A qualitative study in Iran

INTRODUCTION

In recent years, waterpipe smoking (WPS) has increased among adolescents in Iran. This study aimed to explain the experiences of high school students in Iran on predictors of WPS reduction based on a multi-theory model (MTM) of health behaviour change.

METHODS

This study was a qualitative study of directed content analysis that was conducted in high school male students in Hamadan, Iran, in 2017. In this study, 34 students who had smoked waterpipe (WP) in the last month were recruited through snowball sampling that was continued until data saturation. The data were collected through semi-structured, individual interviews and were then analyzed using directed qualitative content analysis.

RESULTS

The data analysis resulted in the extraction of 104 final codes around the six themes of predetermined MTM constructs consisting of participatory dialogue, behavioural confidence, changes in the physical environment, emotional transformation, practice for change, and changes in the social environment. The findings of this study showed that this model has the potential to explain the behaviour of WPS reduction. The main predictors of reduction in WPS are behavioural confidence, social environment change, and participatory dialogue.

CONCLUSIONS

Findings of the research showed that the belief in an individual’s ability, support from friends and the benefits of WPS reduction are the most important factors in reducing WPS among students. Therefore, it is suggested that comprehensive interventions be developed to improve the individual and social factors that are effective in WPS reduction.

Waterpipe smoking and the risk of myocardial infarction: A hospital-based case-control study

INTRODUCTION

The prevalence of waterpipe smoking is increasing globally. The involvement of waterpipe smoking as an independent risk factor for the development of myocardial infarction is an area in need of further research. Our study examines the possible relationship between waterpipe smoking and myocardial infarction.

METHODS

In this incident case-control study, we enrolled 148 cases with myocardial infarction and 148 participants in the control group. Using logistic regression models, odds ratios and 95% CIs were calculated for the association between waterpipe smoking and myocardial infarction, while adjusting for possible confounders.

RESULTS

Myocardial infarction was associated significantly with current waterpipe smoking (OR=4.08; 95% CI: 1.37–12.10), ever waterpipe smoking (OR=3.6; 95% CI: 1.31–10.19), and exclusive waterpipe smoking (OR=10.26; 95% CI: 2.22–47.29). Exclusive cigarette smoking was also associated significantly with the development of myocardial infarction (OR=4.6; 95% CI: 1.98–11.04).

CONCLUSIONS

Waterpipe smoking is associated with myocardial infarction. Our findings reveal the need for targeted interventions to reduce the prevalence of this globally spreading form of tobacco smoking.

Substance use among high school students in Erbil City, Iraq: prevalence and potential contributing factors

Background

Substance use among adolescents, especially smoking and alcohol consumption, has become a public health concern in the Kurdistan Region, Iraq, in the past 10 years.

Aims

This study aimed to determine the prevalence of substance use and certain associated factors among high school students in Erbil City, Kurdistan Region, Iraq.

Methods

A cross-sectional study was conducted using a multistage cluster sampling technique to collect a sample of 3000 students. A modified version of the School Survey on Drug Use from the United Nations Office on Drugs and Crime was used for data collection. Binary logistic regression models were used to identify risk factors for substance use.

Results

The lifetime prevalence rates of cigarettes smoking, waterpipe smoking and alcohol consumption were 27.6%, 23.6% and 3.7%, respectively. Male gender, age 17-19 years, smoker in the family, and easy accessibility of cigarettes were significantly associated with cigarette smoking. Factors significantly associated with waterpipe smoking were male gender, age 17-19 years, waterpipe smoker in the family, waterpipe smoker friend, and easy accessibility. Male gender, alcohol dependent in the family, alcohol-dependent friend, easy accessibility of alcohol, and low family income were significant predictors of alcohol consumption.

Conclusions

The prevalence of cigarette smoking and waterpipe use was high in the studied sample. Possible explanations for this finding might be the use of flavoured tobacco associated with aromatic smell, and the misconception that waterpipe smoking is less toxic and addictive than cigarette smoking.

Application of Social Cognitive Theory to Prevent Waterpipe Use in Male High-school Students in Kerman, Iran

BACKGROUND

The growing supply and prevalence of waterpipe (WP) smoking among Iranian adolescents have become a concern for both families and policymakers. The aim of this study was to determine the factors underlying WP use and also to design an intervention program based on social cognitive theory (SCT) aimed to reduce the demand for WP smoking among male adolescents.

METHODS

This quasi-experimental study involved 189 high-school students in Kerman, Iran, who were split into two groups, an intervention group and a control group. A validated questionnaire based on SCT constructs was used to collect data. The intervention was performed over four sessions with a focus on preventing WP smoking.

RESULTS

Before intervention, the lifetime and current-use prevalence of WP smoking across both groups was 48.5% and 20.2%, respectively. In the intervention group, the most change was related to knowledge score from 10.70 ± 4.38 to 16.52 ± 3.89 (P < 0.0001) and outcome values score from 12.40 ± 3.81 to 13.53 ± 4.23 (P = 0.007); however, in the control group, no significant changes were seen in posttest scores. The scores for self-efficacy (P = 0.21), outcome expectations (P = 0.09), and environment constructs (P = 0.06) did not show any statistically significant changes after the intervention in both groups. Overall, there was no significant difference in the rate of WP smoking after the intervention.

CONCLUSIONS

Based on the results of this study, although some construct scores showed significant differences after the intervention, there was no significant change in the prevalence of WP smoking. More effective educational interventions based on this theory but with a greater focus on self-efficacy and environmental influences may be warranted.

Multiomic analysis of oral keratinocytes chronically exposed to shisha

BACKGROUND

Tobacco is smoked in different form including cigarettes and water pipes. One popular form of water pipe smoking especially in Middle Eastern countries is shisha smoking. Shisha has been associated with various diseases including oral cancer. However, genomic alterations and gene expression changes associated with chronic shisha exposure have not been previously investigated.

OBJECTIVES

Whole-exome sequencing and gene expression profiling of immortalized human oral keratinocytes (OKF6/TERT1) cells chronically treated with 0.5% shisha extract for a period of 8 months was undertaken to characterize molecular alterations associated with shisha exposure.

METHODS

Genomic DNA and RNA were extracted and preprocessed as per manufacturer's instruction and subjected to whole-exome and transcriptome sequencing using Illumina HiSeq2500 platform. Exome was analyzed using GATK pipeline whereas RNA-Seq data was analyzed using HiSat2 and HTSeq along with DESeq to elucidate differentially expressed genes.

RESULTS

Whole-exome sequence analysis led to identification of 521 somatic missense variants corresponding to 389 genes RNA-Seq data revealed 247 differentially expressed genes (≥2-fold, P-value<0.01) in shisha treated cells compared to parental cells. Pathway analysis of differentially expressed genes revealed that interferon-signaling pathway was significantly affected. We predict activation of MAPK1 pathway which is known to play a key role in oral cancer. We also observed allele specific expression of mutant LIMA1 based on RNA-Seq dataset.

CONCLUSION

Our findings provide insights into genomic alterations and gene expression pattern associated with oral keratinocytes chronically exposed to shisha.

Global Tobacco Use: Old and New Products

Tobacco use and exposure to tobacco smoke remain major but avoidable causes of premature mortality and disease worldwide. Although the age-standardized prevalence of daily smoking has declined for both men and women in many countries, the number of smokers continues to increase because of global population growth. Although cigarettes are the most commonly used tobacco product, the tobacco epidemic has become tremendously complex with the emergence and popularity of alternative products such as waterpipes and electronic cigarettes (also known as e-cigarettes). Exposure sciences play a major role in characterizing the tobacco epidemic as well as in the promotion, enactment, and implementation of tobacco control initiatives including legislation and voluntary measures in countries worldwide. We reviewed several studies in Latin America and other regions, showing how high-quality exposure assessment has contributed to smoke-free policies. Although there are many toxicants in tobacco products, metals could be playing an important role in tobacco-related disease. Tobacco plants accumulate cadmium and lead from soil. In e-cigarettes, a metallic coil heats the e-liquid to produce the aerosol that is inhaled by the vaper, and studies have found high aerosol levels of nickel, chromium, lead, and zinc. Despite many tobacco control successes, including the enactment of the Framework Convention on Tobacco Control, which has been ratified by 181 countries, tobacco control faces many challenges globally. Given the continuing increase in the number of smokers worldwide and the rapid emergence of new tobacco products, additional creative efforts are needed to achieve a smoke-free world, help smokers to quit, and protect youth from initiating tobacco use.

Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco

INTRODUCTION

Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

METHODS

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

RESULTS

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

CONCLUSIONS

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

Characteristics, reasons, behavior and knowledge towards waterpipe smoking in Saudi Arabia

Background The present scenario shows that waterpipe smoking, one of tobacco smoking methods, the practice off which dates back at least 400 year is appealing to the youth. Waterpipe tobacco smoking is frequently linked with nations of the Eastern Mediterranean Region (EMR) comprising Egypt, Kuwait, Lebanon and Syria. The present study shows the socio-demographic characteristics, behavior and knowledge of youth towards waterpipe smoking. Recognizing these features may help emphasize intervention methods. Methods A self-administered questionnaire was used to collect the data about waterpipe smoking comprising sociodemographic, behavior, reasons and knowledge from 230 university students. Results 230 questionnaires were distributed from which only 199 were included in the study as 31 were excluded because of incompleteness of the survey. The mean age for starting smoking was 19.49 ± 3.75 years with 32.5% of family members and the majority of their friends engaged with waterpipe smoking. Pleasure and happiness (76%), helps me to deal with pressure (78%) and acceptance by society (91%), were the major reasons cited for waterpipe smoking. It being less harmful and less addictive (55%) compared to cigarettes and no objection from the parents (58%) were the other cited reasons. Furthermore, less than 50% of the participants had correct knowledge of its harmful effects. Conclusion It is clearly evident from our findings that there is a meagre amount of knowledge regarding the harmful effects of waterpipe smoking. It is essential that programs to impart knowledge regarding the harmful effects of waterpipe smoking and dependence should be of the utmost importance.

Graphic health warnings and their best position on waterpipes: A cross-sectional survey of expert and public opinion

INTRODUCTION

Our aim was to assess the visibility and efficiency of graphic health warnings (GHWs) on waterpipe tobacco packs (WTPs) and to explore other more effective places to display them for better impact. We also evaluated the visibility of GHWs when placed on the waterpipe device.

METHODS

We conducted 3 cross-sectional study phases using face-to-face survey questionnaires in 2014-2015. Phase I surveyed 31 tobacco control experts, while Phase II surveyed 700 participants and Phase III surveyed 348 from the public in Cairo, Egypt.

RESULTS

Approximately half of the experts and participants in Phases II and III thought that GHWs on WTPs are not adequately visible, and 68.9% and 79.6% in Phases II and III, respectively, suggested posting warnings also in other places. About one-third of experts and 69.1% of Phase II participants suggested posting GHWs inside cafés or in public places, while 46.9% of Phase III participants favored placing them on waterpipes. After viewing our suggested positions on a waterpipe, all experts, 80.6% of participants in Phase II, and 81.6% in Phase III acknowledged that GHWs would be more visible there. The mouthpiece was the location selected most often across all phases (31.1% in Phase I, 35.6% in Phase II and 36.3% in Phase III). Lung and throat cancers were similarly effective in raising participants’ concern about waterpipe smoking health risks (24.7%).

CONCLUSIONS

This is the first population-based study to explore the best location to place GHWs on waterpipes. Policymakers should consider enacting a regulatory framework for placing GHWs on waterpipe devices.

Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon

INTRODUCTION

Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated.

METHODS

This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries.

RESULTS

The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children’s participation as ‘positive and active’ in 77.9% of the sessions.

CONCLUSIONS

Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

Effect of waterpipe tobacco smoking on airway inflammation in murine model of asthma

OBJECTIVE

There has been an increase in the popularity of waterpipe tobacco smoking (WTS) worldwide, especially in the younger population, including asthma patients. In this study, we investigated the effects of waterpipe smoking on airway inflammation, cytokine levels and oxidative stress markers in an antigen-driven murine model of asthma.

MATERIALS AND METHODS

Balb/c mice were divided into four groups; (1) control (received fresh air, ovalbumin sensitization and saline challenge), (2) WTS (received WTS, ovalbumin sensitization and saline challenge), (3) Ova S/C (received fresh air, ovalbumin sensitization and ovalbumin challenge) and (4) simultaneous WTS and Ova S/C (received WTS, ovalbumin sensitization and ovalbumin challenge). Airway inflammatory cells were evaluated in the broncho-alveolar lavage fluid. Cytokines [interleukin (IL)-13, 10 and 18] and oxidative stress markers [superoxide dismutase (SOD), catalase and glutathione peroxidase (GPx)] were evaluated in the lung homogenates.

RESULTS

Chronic exposure to WTS significantly increased the number of airway inflammatory cells in mice, specifically: eosinophils, neutrophils, macrophages and lymphocytes. The level of IL-13 in the lungs was increased and the level of IL-10 was reduced (p < 0.05) by WTS. Chronic WTS potentiated the increase in inflammatory cells induced by Ova S/C (p < 0.05). The level of IL-13 in the lungs was increased by simultaneous WTS and Ova S/C (p < 0.05) while, levels of IL-10, IL-18, SOD, catalase and GPx in the lungs were not affected.

CONCLUSIONS

Chronic WTS exposure induced airway inflammation in control mice and enhanced airway inflammation in murine model of asthma.

Waterpipe smoking associated with multiple sclerosis: A population-based incident case-control study

BACKGROUND

While cigarette and passive smoking have been identified as modifiable risk factors for multiple sclerosis (MS), there is no report regarding Waterpipe smoking-MS association.

OBJECTIVE

We examined the association of Waterpipe, tobacco, and passive smoking with MS.

METHODS

Population-based incident case-control study in Iran with 547 incident cases and 1057 general population controls (7 August 2013-17 February 2015). Logistic regression model was used. Multiplicative along with additive interaction was assessed using product term and Synergy Index (SI), respectively, and the population attributable fractions (PAFs) were calculated.

RESULTS

Having ever smoked Waterpipe, tobacco, or being exposed to passive smoking were all significantly associated with MS (odds ratio (OR) = 1.77 (1.36-2.31), OR = 1.69 (1.24-2.31), and OR = 1.85 (1.48-2.32), respectively). Clear dose-response associations were observed with the duration exposed ( p < 0.001 for all three) and the amount smoked ( p < 0.001 for Waterpipe and tobacco). Those who had all three types of smoking had an odds that was 4.1 times higher than those without any type. The three types of smoking jointly contributed to 30.9% of the MS incidence.

CONCLUSION

We identified Waterpipe smoking as a novel risk factor for MS. Given the global increase in Waterpipe smoking, especially among young adults, this finding reinforces the need for public health interventional and educational programs to combat this global increase.

A Systematic Review of Effects of Waterpipe Smoking on Cardiovascular and Respiratory Health Outcomes

BACKGROUND

Waterpipe smoking (WPS) is a social custom common in many Middle Eastern, North African, and Asian countries and has become increasingly popular in the US, especially among youth; however, WPS smoking may be increasing in the US adult population as well. There is a common belief among waterpipe (WP) smokers that WPS is less harmful than smoking cigarettes. Thus, this review aims to systematically explore the literature on the effects of WP tobacco smoking with a particular focus on cardiovascular and respiratory health outcomes as well as on oxidative stress, immunity, and cell cycle interference health outcomes.

METHODOLOGY

We conducted a systematic review, guided by the criteria of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using the following online databases MEDLINE, CINAHL, ScienceDirect, PMC, and Cochrane Library. Results were summarized qualitatively.

RESULTS

Forty studies met the inclusion criteria established for this review. Based on the existing evidence, several cardiovascular and respiratory physiologic health indicators and conditions have been shown to be negatively affected by WPS. In addition to the effects of nicotine and chemical toxicant exposures, WPS was significantly associated with an increase in heart rate, blood pressure, and lower pulmonary function test results, as well as a number of health conditions such as lung cancer, alterations in oxidative stress, immunity, and cell cycle interference.

CONCLUSION

The current literature provides evidence that WPS is associated with a number of negative health indicators and outcomes. There is need for more research related to WPS and its effects on health so that appropriate campaigns and prevention interventions can be implemented to control the epidemic increase of WPS in the US.

Central and peripheral cardiovascular changes immediately after waterpipe smoking

BACKGROUND

Tobacco cigarette smoking is a global health problem that kills millions each year. Recently, tobacco smoking using a waterpipe (WP) has become popular worldwide. However, unlike cigarettes, the cardiovascular (CV) risks associated with WP smoking are uncertain. In this study, the immediate effects of WP smoking on central and peripheral CV indices were evaluated in 53 young healthy smokers.

MATERIALS AND METHODS

Strain-gauge plethysmography was used to measure forearm blood flow (Bf), vascular resistance (Vr), and venous capacitance (Vc) and outflow (Vf) at rest (R) and after occlusion (Oc), whereas heart rate (HR) and blood pressure (BP) were measured using standard automated auscultatory methods immediately before and after a 30-min WP smoking session.

RESULTS

Smoking resulted in HR, diastolic BP, mean arterial BP, rate pressure product and OcVr increases (p < 0.05) 6.6, 3.6, 2.5, 8.0 and 16%, respectively, whereas OcBf and OcVf decreased (p < 0.05) 8.8 and 14.3%, respectively. Additionally, smoking-induced changes in the central CV components correlated (p < 0.05) with changes in the periphery.

CONCLUSION

These results demonstrated changes in the CV central and peripheral components immediately after WP smoking. The correlations between the changes in these components suggest that the periphery is controlled, at least partially, by the same mechanism(s) affecting the central CV components during WP smoking.

The determinants of intention to smoke waterpipe among adolescents in Lebanon: a national household survey

BACKGROUND

The phenomenon of waterpipe smoking (WPS) among adolescents has become eminent, and it is especially prevalent in Lebanon. Unlike cigarette smoking, WPS is parentally and socially acceptable. This study aims at examining the association between intention to smoke waterpipe in the next 6 months, and knowledge, attitudes and parental and social influences.

METHODS

This is a secondary data analysis from a national survey in 2007 on 1028 households. This study addresses 258 non-smoking adolescents and their parents. Consent was sought and the study was approved by the Institutional Review Board at the American University of Beirut. Face-to-face interviews were conducted. Descriptive analysis, crude and adjusted odds ratios (ORs) were generated.

RESULTS

At the bivariate level, late adolescence, mothers without university education, prior adolescents' WPS experiences, best friends' and parents' WPS habits and adolescents' and parents' lower attitude scores were associated with smoking intention. In the adjusted model, adolescents' beliefs about positive effects, best friends' similar habits and prior smoking remained significant (respective ORs [95% confidence interval ]: 1.81 [1.33-2.45], 2.51 [1.24-5.10], 4.91 [2.35-10.36]). Parents' perceived attitude against smoking was protective (OR: 0.57 [0.39-0.83]).

CONCLUSIONS

Adolescents' intention to smoke is highly influenced by parents' permissive attitudes and peer pressure. Interventions targeting these two groups and limiting access to smoking by adolescents should be instigated.

In vitro effects of waterpipe smoke condensate on endothelial cell function: a potential risk factor for vascular disease

AIM

Despite its increasing popularity, little is known about the health effects of waterpipe smoking (WPS), particularly on the cardiovascular system. To investigate the role of WPS as a risk factor for vascular disease, we evaluated its effect on endothelial cell function, which is an early event in vascular disease pathogenesis. We assessed the changes in cell viability, ROS generation, inflammatory and vasodilatory markers and in vitro angiogenesis of human aortic endothelial cells in response to waterpipe smoke condensate exposure.

METHODS AND RESULTS

Mainstream waterpipe smoke condensate (WSC) was generated using a standard laboratory machine protocol. Compared to control, WSC induced cell cycle arrest, apoptosis, and oxidative stress in human primary endothelial cells. In addition, we assayed for impaired endothelium-dependent vasodilation and induced inflammation by studying the effect of WPS on the content and activity of AMPK, eNOS proteins and NF-κB p65 ser536 phosphorylation, respectively. WSC inhibited AMPK/eNOS phosphorylation and induced phosphorylation of p65. Moreover, we evaluated endothelial cells repair mechanism related properties that include migration/invasion and in vitro tube formation upon treatment with WSC. WSC reduced the motility and inhibited angiogenic potential of HAEC cells.

CONCLUSIONS

WPS induced endothelial cell dysfunction as evident by exerting oxidative stress, inflammation, and impaired endothelial vasodilatory function and repair mechanisms. All together these data provide evidence for the potential contribution of WPS to endothelial dysfunction and thus to vascular disease.

Associations of mental health problems with waterpipe tobacco and cigarette smoking among college students

Associations between the emerging trend of waterpipe tobacco smoking and mental health among college students have not been sufficiently explored. This study analyzed data collected from 152 academic institutions that participated in the National College Health Assessment during the 2008-2009 academic year to examine associations between mental health and waterpipe tobacco smoking among college students (N = 100,891). For comparison, cigarette smoking was also examined. Associations with mental health variables were very strong for cigarette smoking but only moderate for waterpipe smoking. Study implications and limitations are noted.

Assessment of tobacco dependence in waterpipe smokers in Egypt

SETTING

Waterpipe smoking is increasing worldwide. Nevertheless, little is known about nicotine dependence in tobacco smokers who use waterpipes.

OBJECTIVE

To assess evidence of dependence among non-cigarette smoking waterpipe smokers in Egypt.

METHODS

A total of 154 male exclusive current waterpipe smokers were enrolled for the present study. We adapted the Fagerström test for nicotine dependence and the Reasons for Smoking (RFS) scales and related these to smoking behavior.

RESULTS

The mean age of the subjects was 47 ± 14 years, the mean age at smoking initiation was 22 ± 9 years, and average daily consumption was 4 ± 8 hagars (tobacco units). The time to the first smoke of the day (P < 0.001), smoking even when ill (P = 0.003), time to tobacco craving (P < 0.001), and hating to give up the first smoke of the day (P = 0.033) were each significantly associated with the number of hagars smoked per day. The RFS subscales of addictive smoking, smoking to relieve negative affect, and smoking for stimulation were also associated with these variables.

CONCLUSION

The overall findings suggest that waterpipe smokers exhibit many of the same features of nicotine dependency attributed to cigarette smokers.

Waterpipe (narghile) smoking among medical and non-medical university students in Turkey

OBJECTIVES

This investigation was performed in order to determine the prevalence rate of waterpipe smoking in students of Erciyes University and the effects of some socio-demographic factors.

METHODS

A total of 645 students who study the first three grades of the medical faculty and the engineering faculty of Erciyes University were enrolled in the study. A questionnaire including 48 questions was applied. Chi-square test and logistic regression method were performed for the statistical analyses.

RESULTS

The total prevalence rate of waterpipe smoking was found to be 32.7%. The prevalence rate of waterpipe smoking was 28.6% in the medical and 37.5% in the non-medical students. It was determined that 41.6% of the males and 20.2% of the females currently smoke waterpipe. Gender, cigarette smoking, and the presence of waterpipe smokers among family members and friends have significant effects on the prevalence of waterpipe smoking. Residence and economical status of the family and with whom the students live have no significant effect on the prevalence rate.

CONCLUSIONS

Approximately one-third of the students currently smoke waterpipe. Smoking of both cigarette and waterpipe was frequently found. The measures against all tobacco products should be combined.

Cigarettes and waterpipe smoking among medical students in Syria: a cross-sectional study

OBJECTIVES

To investigate tobacco use, beliefs and attitudes among medical students in Syria.

METHODS

A cross-sectional study of a random sample of 570 medical students (first and fifth year) registered at the Damascus University Faculty of Medicine in 2006-2007. We used a self-administered questionnaire for demo-graphic information, smoking behaviour (cigarette, waterpipe), family and peer smoking, attitudes and beliefs about smoking and future role in advising patients to quit smoking.

RESULTS

The overall prevalence of tobacco use was 10.9% for cigarettes (15.8% men, 3.3% women), 23.5% for waterpipe (30.3% men, 13.4% women) and 7.3% for both (10.1% men, 3.1% women). Both smoking methods were more popular among the fifth year students (15.4% and 27%) compared to their younger counterparts (6.6% and 19.7%). Regular smoking patterns predominated for cigarettes (62%), while occasional use patterns predominated for waterpipes (83%). More than two thirds of students (69%) thought they might not address or would have difficulty addressing smoking in their future patients.

CONCLUSION

The level of tobacco use among Syrian medical students is alarming and highlights the rapidly changing patterns of waterpipe use, especially among female students. Medical schools should work harder to tackle this phenomenon and address it more efficiently in their curricula.