Waterpipe smoking is associated with presence and severity of coronary artery disease: a propensity score-matched study.

BACKGROUND: The prevalence of waterpipe smoking (WPS) has been increasing worldwide. This trend is alarming as WPS can negatively impact cardiovascular health. In the present study, we explored the association between WPS and the presence and severity of CAD. METHODS: This study was a retrospective analysis of patients who underwent diagnostic coronary angiography at Tehran Heart Center between April 2021 and May 2022. Patients with a previous history of percutaneous coronary intervention and coronary surgery were excluded. Waterpipe smokers were matched with non-smokers based on age, gender, and cigarette smoking using a 1:4 propensity score matching model. Stenosis ≥ 50% in any coronary artery was considered a CAD diagnosis. Gensini score was also calculated to measure the severity of the CAD. RESULTS: We reviewed the medical records of 8699 patients, including 380 waterpipe smokers. After matching, 1520 non-smokers with similar propensity scores to the waterpipe smokers were selected. Waterpipe smokers were more likely to have CAD than non-smokers (OR: 1.29; 95% CI: 1.04-1.60, P = 0.021). In addition, WPS increased the natural logarithm of the Gensini score by 1.24 (95% CI: 1.04-1.48, P = 0.014) in patients with atherosclerotic coronary disease. CONCLUSION: WPS may increase the risk of CAD independent of age, gender, and cigarette smoking. In addition, among patients with any degree of atherosclerosis in coronary arteries (GS > 0), WPS may lead to higher average GS, suggesting more severe atherosclerosis.

Prevalence and Incidence of Metabolic Syndrome and Its Components Among Waterpipe Users.

Objectives: To determine the associations between waterpipe use, duration, and intensity of use with prevalence and incidence of metabolic syndrome and its components (increased waist circumference, triglycerides, fasting glucose, blood pressure and decreased high-density lipoprotein cholesterol). Methods: We conducted cross-sectional and prospective analyses using data from the Pars Cohort Study in southern Iran, encompassing 9,264 participants at the baseline, and 5,002 randomly selected in a repeated follow-up. We used multivariate logistic regression models adjusted for age, sex, education, wealth score, physical activity and cigarette pack-years to report odds ratios (OR) and 95% confidence intervals (CI). Results: Among 9,264 participants, 3,119 (33.7%) had metabolic syndrome, and 3,482 (37.6%) had ever smoked waterpipe, with both more common in women than in men. In adjusted models, former waterpipe use was significantly associated with prevalence (OR = 1.43, 95% CI: 1.23-1.68) and incidence (OR = 1.57, 95% CI: 1.19-2.06) of the metabolic syndrome while current waterpipe use was not. Past use was associated with increased risk in all components of metabolic syndrome; current use was associated with increases in all except high blood glucose and hypertension. Past waterpipe users had higher waterpipe use intensity (before quitting) in comparison with current users (2.3 vs. 2.0 waterpipes per day, p < 0.01) and had started waterpipe smoking at a younger age (27.2 vs. 30.1 years, p < 0.01). Conclusion: Waterpipe use was associated with metabolic syndrome and its components, especially among former users potentially due to higher intensity and earlier initiation of use.

Salivary oxidative stress biomarkers in periodontitis-free smokers: a cross sectional study.

BACKGROUND: Salivary oxidative stress has been extensively studied with attempts to correlate changes in the oxidative stress markers with local and systemic factors, including smoking. The objective of this study was to evaluate the influence of two forms of smoking, cigarettes and waterpipe smoking (WPS), on selected oxidative stress biomarkers in saliva. METHODS: Three groups of participants were enrolled into the study, controls (never smokers), cigarette smokers and WPS. Participants were clinically free from periodontitis and systemic conditions known to affect the saliva constituents. Unstimulated whole saliva samples were collected according to a standard protocol and concentrations of 8-hydroxy-2'-deoxyguanosine (8-OHdG), myeloperoxidase (MPO), malondialdehyde (MDA), total antioxidant capacity (TAC), and cortisol. The one-way ANOVA test was used to compare the levels of each oxidative stress biomarker between the three study groups and the hierarchical linear regression analysis was used to test the levels of salivary cortisol for prediction of other oxidative stress biomarkers. Significance levels were set at 95% confidence intervals and probability values ≤0.05. RESULTS: 8-OHdG was highest in WPS group (mean±SE 11,030.35±1829.16 pg/mL) while MDA and cortisol levels were highest in the cigarette smokers group (mean±SE 3.33±0.52 µM and 3.99±0.48 ng/mL, respectively) and MPO was highest in the control group (mean±SE 7.760±1.55 ng/mL). WPS group showed the highest TAC (mean±SE 0.3±0.03 mM). However, none of the tested makers reached a statistically significant difference. CONCLUSIONS: Despite subtle changes in some biomarkers, the salivary oxidative stress does not appear to be significantly influenced by smoking habits in periodontitis-free smokers.

Evaluation of Periodontal Clinicoradiographic Status and Whol Salivary Prostaglandin E2 Levels among Users of Water Pipe and Cigarettes.

PURPOSE: The objective was to evaluate the periodontal clinicoradiographic status and whole salivary prostaglandin E2 (PgE2) levels among users of water pipe and cigarettes. MATERIALS AND METHODS: Demographic data, duration of smoking (pack years), and familial history of smoking were recorded using a questionnaire. Participants were allocated into three groups based on their smoking status: group 1: self-reported cigarette smokers (CS); group 2: self-reported water-pipe-users; and group 3: non-smokers. The assessment included measurements of full-mouth plaque and gingival indices (PI and GI), as well as probing depth (PD), clinical attachment loss (CAL), and marginal bone loss (MBL). Unstimulated whole saliva samples were collected and PgE2 levels were measured. Group comparisons were done and p<0.05 was considered statistically significant. RESULTS: Thirty-three, 34 and 33 individuals were included in groups 1, 2 and 3, respectively. Full mouth PI (p<0.05), GI (p<0.05), PD (p<0.05) and mesial (p<0.05) and distal (p<0.05) MBL were statistically significantly higher among patients in groups 1 and 2 than group 3. The scores of CAL in groups 1 and 2 were 3.45 ± 0.97 and 3.62 ± 1.2 mm, respectively. None of the individuals in the control group displayed CAL. PgE2 levels were statistically significantly higher among patients in groups 1 (231.5 ± 66.3 pg/ml) (p<0.05) and 2 (231.5 ± 66.3 pg/ml) (p<0.05) compared with group 3 (76.6 ± 10.6 pg/ml). In groups 1 and 2, a statistically significant relationship was observed between pack-years, the duration of water-pipe smoking, and the levels of PgE2 and PD. CONCLUSION: There is no difference in periodontal clinicoradiographic status and whole salivary PgE2 levels between CS and waterpipe-users; however, these parameters are worse in CS and water-pipe users than in non-smokers.

Correlates of susceptibility to waterpipe tobacco smoking in young adults.

INTRODUCTION: Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults. METHODS: Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility. RESULTS: Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (ß = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (ß = -0.09, p = 0.04), and greater perceived social acceptability of WTS (ß = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (ß = 0.53, p<0.01), used cannabis (ß = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (ß = 0.18, p = 0.03) also had higher WTS susceptibility. CONCLUSIONS: Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits.

A qualitative exploration of experts' views about multi-dimensional aspects of hookah smoking control in Iran.

BACKGROUND: The related literature has primarily addressed cigarette smoking control. It seems that researchers have failed to explore the determinants of hookah smoking (HS) control. In an attempt to fill this gap, the present study explores experts' views about aspects of HS control in Bandar Abbas, a city in the south of Iran. METHODS: The present qualitative study, conducted in 2022 and 2023, used a content analysis. To this aim, 30 experts in tobacco prevention and control were invited to participate in the research. Twenty seven accepted the invitation. In-depth, semi-structured, and face-to-face interviews were held with the experts. A purposive sampling was used and the data collection continued until data saturation. The interviews lasted between 18 and 65 min. MAXQDA 10.0 was used for data management and analysis. RESULTS: The expert interviewees had a mean age of 44.77 ± 6.57 years and a mean work experience of 18.6 ± 6.8 years. A total number of six main categories were extracted from the data, including usin influential figures to control HS, controlling HS by alternative activities, changing beliefs and attitudes toward HS, taking administrative and regulatory measures, and facilitating HS cessation. CONCLUSION: This qualitative study explored the multifaceted ways people adopt to quit HS. Using influential figures to control hookah smoking, promoting alternative activities as a means of control, changing beliefs and attitudes, enforcing administrative regulations, and facilitating quit attempts all play an important role in tackling the prevalence of hookah smoking. These findings emphasize the importance of a comprehensive and multifaceted approach to integrate various interventions to effectively address hookah smoking behavior.

Association between waterpipe smoking and lung cancer: a multicentre case-control study in Iran.

OBJECTIVES: This study investigated the association between lung cancer and waterpipe smoking, which is an emerging global public health concern. STUDY DESIGN: Multicentre case-control study. METHODS: This study included 627 cases and 3477 controls from the Iranian Study of Opium and Cancer (IROPICAN) study, which was conducted between 2017 and 2020. One frequency-matched control for each lung cancer patient was selected by age, gender and residential place; however, this study used controls of four cancer types in the analyses. The multivariable logistic regression model estimated the odds ratio (OR) and 95% confidence intervals (CIs). Additional analyses were performed among 181 lung cancer cases and 2141 controls who were not cigarette smokers or opium or nass/pipe users. RESULTS: The odds of lung cancer were higher among waterpipe smokers than never-smokers (OR = 1.3, 95% CI: 1.0-1.7). Results showed a higher OR of lung cancer for those who smoked the waterpipe daily (OR = 2.1, 95% CI: 1.4-3.0), smoked more than two heads per day (OR = 2.7, 95% CI: 1.8-4.0), had smoked for >20 years (OR = 1.9, 95% CI: 1.3-2.7), smoked more than 20 head-years (OR = 2.8, 95% CI: 1.9-4.1) and initiated smoking before the age of 30 years (OR = 1.7, 95% CI: 1.1-2.5). The association was only statistically significant for squamous cell carcinomas (OR = 1.8, 95% CI 1.2-2.7). Furthermore, this study observed a higher OR of lung cancer among exclusive waterpipe smokers (OR = 2.3, 95% CI: 1.6, 3.5). CONCLUSIONS: Waterpipe smoking was associated with an increased risk of lung cancer. The association was stronger with higher frequency, duration and intensity of exposure to waterpipe smoking. The association increases in exclusive waterpipe smokers, which is likely due to controlling for residual confounding by cigarette smoking and opium consumption, and higher exposure levels in this subpopulation.

Exposure to Electronic Waterpipes Increases the Risk of Occlusive Cardiovascular Disease in C57BL/6J Mice.

INTRODUCTION: It is well documented that cardiovascular disease (CVD) is the leading cause of death in the US and worldwide, with smoking being the most preventable cause. Additionally, most smokers die from thrombotic-based diseases, in which platelets play a major role. To this end, because of the proven harm of smoking, several novel tobacco products such as electronic(e)-waterpipe have been gaining popularity among different sectors of the population, partly due to their "false" safety claims. While many investigators have focused on the negative health effects of traditional cigarettes and e-cigarettes on the cardiovascular system, virtually little or nothing is known about e-waterpipes, which we investigated herein. METHODS AND MATERIALS: To investigate their occlusive CVD effects, we employed a whole-body mouse exposure model of e-waterpipe vape/smoke and exposed C57BL/6J male mice (starting at 7 weeks of age) for 1 month, with the controls exposed to clean air. Exposures took place seven times a week, according to the well-known Beirut protocol, which has been employed in many studies, as it mimics real-life waterpipe exposure scenarios; specifically, 171 puffs of 530 ml volume of the e-liquid at 2.6 s puff duration and 17 s puff interval. RESULTS: The e-waterpipe exposed mice had shortened bleeding and occlusion times, when compared to the clean air controls, indicating a prothrombotic phenotype. As for the mechanism underlying this phenotype, we found that e-waterpipe exposed platelets exhibited enhanced agonist-triggered aggregation and dense granule secretion. Also, flow cytometry analysis of surface markers of platelet activation showed that both P-selectin and integrin GPIIb-IIIa activation were enhanced in the e-waterpipe exposed platelets, relative to the controls. Finally, platelet spreading and Akt phosphorylation were also more pronounced in the exposed mice. CONCLUSION: We document that e-waterpipe exposure does exert untoward effects in the context of thrombosis-based CVD, in part, via promoting platelet hyperreactivity.

Assessing the Causal Relationship between Waterpipe Smoking and Bladder Cancer.

Rates of waterpipe use increase with very little data reporting any potential health consequences. The current study, a large case-control study, of 4,194 patients from Iran denotes an elevated risk of bladder cancer in exclusive waterpipe smokers compared with non-users. Additional studies are needed to further understand the risk waterpipe smoking has on bladder cancer. See related article by Hadji et al., p. 509.

Consumption of hookahs, e-cigarettes, and classic cigarettes and the impact on medically assisted reproduction treatment.

Smoking of classic cigarettes has been well-established as a health risk factor, including cardiovascular, neurological, and pulmonary diseases. Adverse effects on human reproduction have also been shown. Smokers are assumed to have a significantly lower chance of pregnancy, however, the impact of smoking on medically assisted reproduction (MAR) treatment outcomes is controversial. Moreover, smoking habits have changed during the last decades since e-cigarettes and hookahs, or water pipes, have become very popular, yet little is known regarding vaping or hookah-smoking patients undergoing MAR treatments. This prospective study aimed to examine the presence of benzo[a]pyrene, nicotine, and its main metabolite, cotinine, in human follicular fluid (FF) in non-smoking, smoking, and vaping/hookah-smoking patients and to evaluate the impact on female fertility. Human FF samples were collected from 320 women subjected to intracytoplasmic sperm injection (ICSI) cycles due to male subfertility. Gas chromatography combined with mass spectrometry was used to analyse the presence of benzo[a]pyrene, nicotine, and cotinine. A questionnaire was provided to assess patient consumption behaviour and to identify (1) non-smoking patients, (2) patients who consumed cigarettes, and (3) patients with exclusive consumption of e-cigarettes or hookahs. Data were analysed using linear and logistic regression, Fisher's exact test, and the Mann-Whitney U Test. Nicotine was present in 22 (6.8%) and cotinine in 65 (20.3%) of the 320 samples. The nicotine and cotinine concentrations per sample ranged from 0 to 26.3 ng/ml and 0-363.0 ng/ml, respectively. Benzo[a]pyrene was not detectable in any of the samples analysed. Nicotine and cotinine were also present in the FF of patients with exclusive consumption of e-cigarettes or hookahs. The clinical pregnancy rate, fertilization and maturation rates, and number of oocytes per oocyte pick-up were not statistically significantly different between non-smoking, smoking, or vaping/hookah-smoking patients. Smoking and the accumulation of smoking toxins in the FF have no impact on the outcome of MAR treatments-neither the clinical pregnancy rate, maturation and fertilization rates, nor the number of retrieved oocytes were affected. For the first time, nicotine and cotinine were quantified in the FF of patients exclusively vaping e-cigarettes or smoking hookahs. Since vaping liquids and hookah tobaccos contain potentially harmful substances, other adverse effects cannot be excluded.Trial registration ClinicalTrials.gov Identifier: NCT03414567.

Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents.

BACKGROUND: Waterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq. METHODS: A cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale. RESULTS: When adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit. CONCLUSION: Pictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.

The effectiveness of a theory -based health education program on waterpipe smoking cessation in Iran: one year follow-up of a quasi-experimental research.

BACKGROUND: The present research aimed to determine the effect of an educational intervention based on the extended theory of planned behavior (ETPB) on waterpipe (WT) smoking cessation in women. METHODS: The present quasi-experimental had a pre-test, post-test design with 3, 6 and 12 months follow-ups was conducted in Bandar Abbas city, south of Iran in December 2021-March 2023. A total of 448 women over the age of 15 (224 in the intervention group (IG), 224 in the control group (CG)), using a two-stage cluster sampling method participated. The educational intervention focused on WT smoking cessation implemented in 14 sessions. The educational methods in the training sessions were lectures, collaborative discussions, Q&As, brainstorming, role plays, and peer education. The main outcome was WT cessation behavior. Repeated measures ANOVA tests and post hoc were run to compare the IG and CG at baseline in terms of demographic variables, t-test and chi square test, and in the four points of time of data collection. The data were analyzed in Stata14. A p-value < 0.05 was considered as statistically significant. RESULTS: The mean and standard deviation of WT cessation behavior and all ETPB constructs in the IG was significantly higher than the CG. After the educational intervention, in the IG, the perceived behavioral control, attitude, subjective norm, intention and knowledge increased, and the weekly smoking and WT smoking habit decreased (P < 0.001). The CG did not have any significant change in other variables except for the increased knowledge score. During the 12-month follow-up, the cessation rate was 43.81% (P = 0.645) in the IG and 7.45% in the CG (P = 0.081). CONCLUSIONS: The educational intervention positively affected WT smoking reduction and cessation in women through influencing the ETPB constructs. It is strongly recommended to design theory-based interventions beyond the individual level with an emphasis on interpersonal relationships to facilitate WT cessation as far as possible.

Water pipe smoking and stroke: A systematic review and meta-analysis.

OBJECTIVE: Despite the damaging effects of water pipe on physical health, there is little information about the potential harmful effects of this tobacco on stroke. This study aims to investigate the relationship between water pipe smoking and stroke. METHOD: A systematic review was conducted including Ovid SP, Embase, Pubmed, Web of Science, Scopus, and Google Scholar databases with focus on cohort, case-control, and cross-sectional studies. We reviewed all studies reporting on water pipe smoking and stroke. The funnel plot and the Egger regression test were used to assess publication bias. RESULTS: In the four eligible studies, there were a total of 2759 participants that 555 patients had at least once experienced stroke. Meta-analysis revealed positive association between water pipe smoking and stroke with pooled adjusted OR 2.79 (95% CI: 1.74-3.84; I 2 = 0 , p = . 741 ${I^2}\; = \;\;0,{\mathrm{\;}}p\;\; = {\mathrm{\;\;}}.741$ ) and the funnel plot shows asymmetry publication bias. CONCLUSIONS: We found a higher effect of water pipe smoking on stroke compared to cigarette smoking and concluded that water pipe increases the risk of stroke by 2.79. Hence, because most of the water pipe consumer society is young, especially women, policies and decisions need to be taken to control the supply of this tobacco to the market and more provide education on the health problem of water pipe smoking. IMPLICATIONS: This study provides a higher effect of water pipe smoking on stroke. Physicians and researchers who intend to study in the field of stroke should better examine the effects of water pipe (including time of use, dose-response, long-term effects, and risk factors) on stroke.

Waterpipe vs non-Waterpipe carbon monoxide poisoning: Comparison of patient characteristics, clinical presentation and outcomes.

OBJECTIVE: The aim of this study is to describe the difference between carboxyhemoglobin (CO-Hb) acute poisoning caused by waterpipe vs non-waterpipe exposures as they relate to demographics, clinical presentations and outcome of patients. DESIGN: Retrospective cohort study conducted in the Emergency Department (ED) at the Lebanon. PATIENTS: All adult patients presenting with a CO-Hb level ≥ 10 between January 2019 and August 2023 with exposure types stratified as waterpipe or non-waterpipe. MEASUREMENTS AND MAIN RESULTS: 111 ED visits were identified. Among these, 73.9% were attributed to waterpipe exposure, while 26.1% were non-waterpipe sources. These included cigarette smoking (17.2%), burning coal (24.1%), fire incidents (3.6%), gas leaks (6.9%), heating device use (10.3%), and undocumented sources (37.9%). Patients with waterpipe-related carbon monoxide exposure were younger (41 vs 50 years, p = 0.015) women (63.4 vs 41.4%, p = 0.039) with less comorbidities compared to non-waterpipe exposures (22.2 vs 41.4%, p = 0.047). Waterpipe smokers were more likely to present during the summer (42.7 vs 13.8%, p = 0.002) and have shorter ED length of stays (3.9 vs 4.5 h, p = 0.03). A higher percentage of waterpipe smokers presented with syncope (52.4 vs 17.2%, p = 0.001) whereas cough/dyspnea were more common in non-waterpipe exposures (31 vs 9.8%, p = 0.006). The initial CO-Hb level was found to be significantly higher in waterpipe exposure as compared to non-waterpipe (19.7 vs 13.7, p = 0.004). Non-waterpipe exposures were more likely to be admitted to the hospital (24.1 vs 4.9%, p = 0.015). Waterpipe smokers had significantly higher odds of experiencing syncope, with a 5.74-fold increase in risk compared to those exposed to non-waterpipe sources (p = 0.004) irrespective of their CO-Hb level. Furthermore, males had significantly lower odds of syncope as compared to females, following carbon monoxide exposure (aOR 0.31, 95% CI 0.13-0.74). CONCLUSION: CO-Hb poisoning related to waterpipe smoking has distinctive features. Syncope is a commonly associated presentation that should solicit a focused social history in communities where waterpipe smoking is common. Furthermore, CO-Hb poisoning should remain on the differential in patients presenting with headache, syncope, dizziness, vomiting or shortness of breath, even outside of the non-waterpipe exposure peaks of winter season.

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.

The Diversity in Tobacco Use Among Women of Reproductive Age (15-49 Years) in Pakistan: A Secondary Analysis of a Multiple Indicator Cluster Survey 2016-2018.

INTRODUCTION: Tobacco use in women of reproductive age group (15-9 years) may contribute to poor maternal and child health outcomes. We estimated the prevalence of smokeless tobacco (ST), cigarette, and waterpipe use among these women in Pakistan and explored associations with socio-economic differences and birth weights after recent childbirths (past 2 years). AIMS AND METHODS: We used the Multiple Indicator Cluster Surveys datasets from three provinces in Pakistan. Prevalence was generated for current use of tobacco among women with recent childbirth (WWRC) and without recent childbirth (WWoRC). We further compared socio-economic status and birth weights between tobacco users and non-users. RESULTS: The prevalence of current ST use was 1.4% and 2.5%, and waterpipe smoking was 1.2% and 1.8%, in WWRC and WWoRC, respectively. ST use varied across Pakistan's provinces by 13 percentage points in WWRC and WWoRC while waterpipe smoking by 10 and 15 percentage points, respectively. The odds of using any form of tobacco were significantly lower with higher levels of education or wealth index. Compared to children born to mothers who did not use tobacco, the birth weight of children born to mothers who smoked waterpipe was on average 0.83 kg (95% CI -1.6 to -0.1) lower whereas it was 0.33 kg (95% CI -0.9 to 0.3) higher for ST users. CONCLUSIONS: Tobacco use among women of reproductive age in Pakistan varied significantly based on province and tobacco type. Waterpipe smoking was associated with a reduction in birth weight. Raising awareness of the harms of tobacco use among women of reproductive age and targeting interventions in high-burden regions of Pakistan should be prioritized. IMPLICATIONS: The prevalence of current smokeless tobacco use and waterpipe smoking varied significantly in Pakistan (~13 and ~15 percentage points, respectively) among women of reproductive age, and there seems to be little change in tobacco use behavior around pregnancy and early motherhood. The study highlights a need to better understand the prevalence of tobacco use in Pakistan, and further contextual research is warranted to understand the reasons for such high tobacco use in certain areas. This information highlights the need for improving current tobacco control interventions and policies, including measures that could help reduce its use and prevent its uptake. Furthermore, compared to children born to mothers who did not use any form of tobacco, we found a statistically significant difference (830 g) in birth weight for babies born to mothers who at the time of the interview smoked waterpipe and a non-statistically significant difference of about 330 g for children born to mothers who at the time of the interview used smokeless tobacco. In addition to our findings, some literature suggests the association of waterpipe smoking with low birth weight. A possible explanation could be the exposure to smoke that contains toxicants from the tobacco product itself in addition to the burning of charcoal, which is required when using waterpipe. Waterpipe smoking also results in high exposures to carbon monoxide and polycyclic aromatic hydrocarbons, which are known to be carcinogenic and teratogenic. In terms of smokeless tobacco use, further research is warranted to understand its impact on birth outcomes through longitudinal studies accounting for diverse products, its constituents and the amount of consumption.

Study of waterpipe smoking topography in Fars province of Iran.

Despite a sharp increase in the use of the waterpipe (WP) has been noted recently in Iran, no information is available for the smoking behavior and topography parameters. The present study is intended to obtain the inhalation and smoking topography parameters for the Iranian WP smokers. The smoking data collected from 122 smoking sessions, including 192 WP smokers in the Iranian Fars province have been used to perform smoking topography assessments. The influence of demographic and smoking parameters on puffing data is obtained. Results have indicated that gender and tobacco type strongly affect puff volume and duration. Women smokers inhale smaller volume of smoke than men and puff duration is significantly increased for regular smokers than occasional smokers. However, the results of the present study have not revealed a major effect of age, residence and setting on the puffing behavior.

Effects of Waterpipe Smoke Exposure on Experimentally Induced Chronic Kidney Disease in Mice.

Tobacco smoking is an independent risk factor in the onset of kidney disease. To date, there have been no reports on the influence of waterpipe smoke (WPS) in experimentally induced chronic kidney disease (CKD) models. We studied the effects and mechanisms of actions of WPS on a mouse model of adenine-induced CKD. Mice fed either a normal diet, or an adenine-added diet and were exposed to either air or WPS (30 min/day and 5 days/week) for four consecutive weeks. Plasma creatinine, urea and indoxyl sulfate increased and creatinine clearance decreased in adenine + WPS versus either WPS or adenine + saline groups. The urinary concentrations of kidney injury molecule-1 and adiponectin and the activities of neutrophil gelatinase-associated lipocalin and N-acetyl-ß-D-glucosaminidase were augmented in adenine + WPS compared with either adenine + air or WPS groups. In the kidney tissue, several markers of oxidative stress and inflammation were higher in adenine + WPS than in either adenine + air or WPS groups. Compared with the controls, WPS inhalation in mice with CKD increased DNA damage, and urinary concentration of 8-hydroxy-2-deoxyguanosine. Furthermore, the expressions of nuclear factor κB (NF-κB) and mitogen-activated protein kinases (MAPKs) (ERK and p38) were elevated in the kidneys of adenine + WPS group, compared with the controls. Likewise, the kidneys of adenine + WPS group revealed more marked histological tubular injury, chronic inflammation and interstitial fibrosis. In conclusion, WPS inhalation aggravates kidney injury, oxidative stress, inflammation, DNA damage and fibrosis in mice with adenine-induced CKD, indicating that WPS exposure intensifies CKD. These effects were associated with a mechanism involving NF-κB, ERK and p38 activations.

Copper ion affects oxidant decay and combined aspartic acid transformation during chlorination in water pipes: Differentiated action on the yield of trihalomethanes and haloacetonitriles.

The chlorination of extracellular polymeric substances (EPS) secreted by biofilm often induces the formation of high-toxic disinfection byproducts (DBPs) in drinking water distribution systems. The protein components in EPS are the main precursors of DBPs, which mostly exist in the form of combined amino acids. The paper aimed to study the action of a pipe corrosion product (Cu2+) on the formation of DBPs (trihalomethanes, THMs; haloacetonitriles, HANs) with aspartic acid tetrapeptide (TAsp) as a precursor. Cu2+ mainly promoted the reaction of oxidants with TAsp (i.e., TAsp-induced decay) to produce DBPs, rather than self-decay of oxidants to generate BrO3‒ and ClO3‒. Cu2+ increased THMs yield, but decreased HANs yield due to the catalytic hydrolysis. Cu2+ was more prone to promote the reaction of TAsp with HOCl than with HOBr, leading to a DBPs shift from brominated to chlorinated species. The chemical characterizations of Cu2+-TAsp complexations demonstrate that Cu2+ combined with TAsp at the N and O sites in both amine and amide groups, and the intermediate identification suggests that Cu2+ enhanced the stepwise chlorination process by promoting the substitution of chlorine and the breakage of CC bonds. The effect of Cu2+ on THMs yield changed from promoting to inhibiting with the increase of pH, while that on HANs yield was inhibiting regardless of pH variation. Additionally, the impact of Cu2+ on the formation of DBPs was also affected by Cu2+ dose, Cl2/C ratio and Br- concentration. This study helps to understand the formation of EPS-derived DBPs in water pipes, and provides reference for formulating control strategies during biofilm outbreaks.

Unveiling an Association between Waterpipe Smoking and Bladder Cancer Risk: A Multicenter Case-Control Study in Iran.

BACKGROUND: Limited data exist for the association between bladder cancers and waterpipe smoking, an emerging global public health concern. METHODS: We used the IROPICAN database in Iran and used multivariable logistic regression, adjusting for cigarette smoking, opium use, and other confounding factors. In addition, we studied the association between exclusive waterpipe smoking and bladder cancer. RESULTS: We analyzed 717 cases and 3,477 controls and a subset of 215 patients and 2,145 controls who did not use opium or cigarettes. Although the OR adjusted for opium, cigarettes, and other tobacco products was 0.92 [95% confidence interval (CI), 0.69-1.20], we observed a statistically significant elevated risk in exclusive waterpipe smokers (OR = 1.78; 95% CI, 1.16-2.72) compared with non-users of opium or any tobacco. Associations were strongest for smoking more than two heads/day (OR = 2.25; 95% CI, 1.21-4.18) and for initiating waterpipe smoking at an age less than 20 (OR = 2.73; 95% CI, 1.11-6.72). The OR for urothelial bladder cancer was higher in ex-smokers (OR = 2.35; 95% CI, 1.24-4.42) than in current smokers (OR = 1.52; 95% CI, 0.72-3.15). All observed associations were consistently higher for urothelial histology. CONCLUSIONS: Waterpipe smoking may be associated with an increased risk of bladder cancer, notably among individuals who are not exposed to cigarette smoking and opium. IMPACT: The study provides compelling evidence that waterpipe smoking is a confirmed human carcinogen, demanding action from policymakers. See related In the Spotlight, p. 461.