Age of initiation of hookah use among young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017.

OBJECTIVE: To prospectively estimate the age of initiation of ever, past 30-day, and fairly regular hookah use among young adults (ages 18-24) overall, by sex, by race/ethnicity, and to explore the association of prior use of other tobacco products with these hookah use behaviors. METHODS: Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US young adults. Young adult never hookah users at the first wave of adult participation in PATH waves 1-3 (2013-2016) were followed-up into waves 2-4 (2014-2017) to estimate the age of initiation of three outcomes: (i) ever use, (ii) past 30-day use, and (iii) fairly regular hookah use. Weighted interval-censoring Cox proportional hazards regression models were used to examine the differences in the estimated age of initiation by sex and by race/ethnicity while controlling for the total number of other tobacco products ever used at participants' first wave of PATH participation. In addition, to examine if prior use of other tobacco products was associated with the age of hookah initiation behaviors, six additional Cox models are reported for each hookah initiation behaviors. RESULTS: The largest increase in hookah use occurred between ages 18 and 19: 5.8% for ever use and 2.7% for past 30-day hookah use. By age 21, 10.5%, 4.7% and 1.2% reported initiation of ever, past 30-day and fairly regular hookah use, respectively. There were statistically significance differences in the age of initiation of hookah use behaviors by race/ethnicity. CONCLUSION: Educational interventions should target young adults before the age of 21, focusing efforts specifically on males, non-Hispanic Blacks and Hispanics, to stall initiation and progression of hookah use behaviors.

Characterization and Validation of the Second-generation wPUM Topography Monitors.

INTRODUCTION: Little is known about the natural use behavior of new and emerging tobacco products due to the limited availability of reliable puff topography monitors suitable for ambulatory deployment. An understanding of use behavior is needed to assess the health impact of emerging tobacco products and inform realistic standardized topography profiles for emissions studies. The purpose of this study is to validate four monitors: the wPUM cigalike, vapepen, hookah, and cigarette monitors. AIMS AND METHODS: Each wPUM monitor was characterized and validated for range, accuracy, and resolution for puff flow rate, duration, volume, and interpuff gap in a controlled laboratory environment. Monitor repeatability was assessed for each wPUM monitor using four separate week-long natural environment monitoring studies including cigalike, vapepen, hookah, and cigarette users. RESULTS: The valid flow rate range was 10 to 100 mL/s for cigalike and cigarette monitors, 10 to 95 mL/s for vapepen monitors, and 50 to 400 mL/s hookah monitors. Flow rate accuracy was within ±2 mL/s for cigalike, vapepen, and cigarette monitors and ±6 mL/s for the hookah monitor. Durations and interpuff gaps as small as 0.2 s were measured to within ±0.07 s. Monitor calibrations changed by 4.7% (vapepen), 1.5% (cigarette), 0.5% (cigalike), and 0.1% (hookah) after 1 week of natural environment use. CONCLUSIONS: The wPUM topography monitors were demonstrated to be reliable when deployed in the natural environment for a range of emerging tobacco products. IMPLICATIONS: The current study addresses the lack of available techniques to reliably monitor topography in the natural environment, across multiple emerging tobacco products. Natural environment topography data will inform standardized puffing protocols for premarket tobacco product applications. The ability to quantify topography over extended periods of time will lead to a better understanding of use behavior and better-informed regulations to protect public health.

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

OBJECTIVE: Identifying the factors associated with nicotine dependence (ND) is essential to prevent initiation and continued use, and to promote cessation among youth. This study aims to document the predictors of the appearance of initial ND symptoms and full ND syndrome among adolescent waterpipe (WP) and cigarette smokers. METHODS: A 6-year longitudinal study was conducted among 8th and 9th graders from 38 schools in Lebanon. The analysis sample included exclusive-WP (n = 228) and exclusive-cigarette smokers (n = 139). Weighted Cox proportional hazards models were used to characterizing predictors of initial ND symptoms and full ND syndrome. RESULTS: Predictors of experiencing initial ND symptoms among WP smokers included low maternal educational level, having a sibling who smoked WP, low physical activity, high body mass index (BMI), smoking initiation at a younger age. For cigarette smokers these were being male, younger, having lower BMI, having a sibling who smoked cigarettes, living in a crowded household, and smoking daily. Among WP smokers, predictors of developing full ND syndrome include being younger, believing that WP smokers have more friends, depression, high levels of impulsivity, and initiating smoking at a younger age. For cigarette smokers, predictors of full ND syndrome were being younger and initiating smoking at a younger age. CONCLUSION: Smoking cessation and prevention interventions targeting youth should address modifiable, and tobacco use-specific factors that influence the development of ND among young WP and cigarette smokers. They also need to start at a younger age to target those most vulnerable to developing life-long addiction to tobacco products.

Prevalence of hookah pipe smoking in high-school learners in Johannesburg, South Africa.

BACKGROUND: Hookah pipe (HP) smoking has become popular globally, especially among young adults and adolescents. There are misperceptions regarding the safety of HP smoking, relative to cigarettes. OBJECTIVES: To assess the prevalence of HP use in grade 8 and 12 students and the factors associated with use in the different age groups. METHODS: A cross-sectional study was conducted in grade 8 and 12 high-school students from six randomly selected public schools in Johannesburg, South Africa. A self-administered structured questionnaire was completed by students after consent had been obtained from parents and students. The questionnaire focused on knowledge and awareness of HP smoking. Data were analysed using Stata/SE version 15. A p-value <0.05 was considered significant. RESULTS: A total of 347 grade 8 and 232 grade 12 students participated in the study. Of the sample, 26% in grade 8 and 70% in grade 12 had ever smoked an HP. In both grades a higher proportion of males smoked. Eleven percent of students in grade 8 and 37% in grade 12 were currently smoking the HP. Approximately 47% and 51% of grade 8 and grade 12 students, respectively, first started smoking at parties. The mean age of initiation was 8 and 12 years in grade 8 and 12, respectively. Grade 12 students had greater awareness of the risks of HP smoking. Having a family member who smoked an HP was significantly related to HP use in grade 8 students. Overall, factors associated with increased odds of smoking the HP were being in grade 12, not being aware of health effects, and seeing the health warnings on hookah tobacco package labels. CONCLUSIONS: HP smoking increased significantly between grades 8 and 12. Increasing knowledge and awareness of the risks involved in HP smoking in children at an early age is recommended. One of the factors influencing uptake of HP smoking in young students was having a family member smoking it; adult anti-smoking and anti-HP campaigns are therefore also important.

[Carbon monoxide poisoning in active or passive shisha smokers]. / Intoxication au monoxyde de carbone chez les fumeurs actifs ou passifs de chicha.

In France, shisha (narghile) smoking is increasingly popular among adolescents and young adults and is generally thought to be less harmful and addictive than cigarettes. This systematic review of data on carbon monoxide (CO) poisoning in active or passive shisha tobacco smokers selected 17 studies. Sixteen case reports, including 39 patients (mean age: 22.3 years; males: 51.3%), described acute carbon monoxide poisoning in active shisha smokers. The most common symptoms were dizziness, headache, and nausea. Loss of consciousness occurred in 43.6% of patients. Two patients had an epileptic seizure. The mean carboxy-haemoglobin (HbCO) blood level was 17.3%. Electrocardiographic changes were present in five patients. Most patients were treated with normobaric oxygen therapy while only four received hyperbaric oxygen therapy; two of whom were non tobacco smokers exposed to shisha smoke during their work. The outcome was favourable in all patients. Shisha use must be suspected in cases of CO poisoning, especially in adolescents and young adults. Practitioners must help shisha users to stop their consumption.

Association of energy drink consumption with substance-use initiation among adolescents: A 12-month longitudinal study.

BACKGROUND: Aggressive marketing has resulted in exponential growth of energy drink sales in recent years. Despite growing concerns about the negative health effects of energy drinks, they are increasingly popular among young people. Little is known about temporal associations between energy drink consumption and other drug use, though some researchers have suggested that energy drink consumption reflects an entry into a drug-using lifestyle. AIMS: The purpose of this study was to evaluate whether energy drink use among adolescents who have never tried substances is associated with a risk of initiating tobacco (i.e. cigarettes, e-cigarettes, and hookah) and alcohol use. METHODS: A school-based longitudinal study of 3071 adolescents ages 9-17 years was conducted in six federal states of Germany. Data analyses involved two assessment waves that took place approximately 12 months apart: baseline (fall-winter of school year 2016-2017), and 12-month follow-up (fall-winter of school year 2017-2018). RESULTS: Multilevel models revealed that energy drink use at baseline was associated with cigarette (odds ratio for energy drink ever use, 3.15 (95% confidence interval, 2.07-4.78 )), e-cigarette (odds ratio, 4.32 (95% confidence interval, 2.87-6.51)), hookah smoking (odds ratio, 3.15 (95% confidence interval, 2.06-4.82)), and alcohol use (odds ratio, 2.26 (95% confidence interval, 1.75-2.93)) initiation within 12 months. CONCLUSIONS: These results raise the possibility that energy drinks may potentially act as a gateway drug to other substances. However, inferences regarding whether this association is or is not causal cannot yet be made.

The effect of college attendance on young adult cigarette, e-cigarette, cigarillo, hookah and smokeless tobacco use and its potential for addressing tobacco-related health disparities.

The goal of this study was to assess the effect of college attendance on tobacco use among young adults and across subpopulations with disparities in tobacco use. Using a cohort of US youth (<18 years) who aged into young adulthood (18-24 years) in the Population Assessment of Tobacco and Health (2013-14, 2015-16, n = 3619) and propensity score matching we estimated the effect of college attendance on past 30-day use of cigarettes, e-cigarettes, cigarillos, hookah and smokeless tobacco. In unmatched analysis, college attenders (vs. nonattenders) had lower risk of using any form of tobacco (Risk Difference (RD): -10.0; 95% CI: -13.2, -7.0), cigarettes (RD: -13.0; 95% CI: -15.4, -10.5), e-cigarettes (RD: -4.1; 95% CI: -6.8, -1.7), cigarillos (RD: -5.7; 95% CI: -7.6, -3.8), and smokeless tobacco (RD: -2.0; 95% CI: -3.4, -0.6), but not hookah (RD: -0.2; 95% CI: -2.1, 1.6). In matched analysis, these associations were all near-null, with the exception of cigarettes (matched RD: -7.1; 95% CI: -10.3, -3.9). The effect of college attendance on cigarette smoking was stable for all subpopulations we assessed including among those identifying as non-Hispanic Black or Lesbian, Gay or Bisexual as well as among those living in the South, Midwest or whose parents did not attend college. The results suggest that college attendance may reduce young adults' risk of cigarette smoking but may not reduce the risk of using other tobacco products.

The Effect of an Educational Intervention Based on PRECEDE Model on Oral Cancer Prevention Behaviors in Hookah Users.

Educational intervention about oral cancer prevention is essential for all people, especially in hookah users. The aim of this study is investigating the effect of an educational intervention based on PRECEDE model on oral cancer prevention in hookah users living in Fasa, Fars Province, Iran, in 2017-2018. In this quasi-experimental study, 360 hookah users were selected and divided into experimental and control groups (180 subjects for each group). Educational intervention was performed for experimental group in 12 sessions. A questionnaire consisting of items evaluating demographic information and PRECEDE model constructs (knowledge, attitude, self-efficacy, enabling factors, and reinforcing factors) was used to measure oral cancer prevention behaviors and nicotine dependency of subjects before and 6 months after intervention. Obtained data were analyzed by SPSS-22 software through paired t test, independent t test, and chi-square test at significance level of P < 0.05. Six months after intervention, experimental group showed significant increase in knowledge, attitude, self-efficacy, enabling factors, reinforcing factors, oral cancer prevention behaviors, and reduction of nicotine dependency compared with control group. This study showed the efficiency of educational intervention based on PRECEDE model in adoption of oral cancer prevention behaviors and reduction of nicotine dependency of hookah users 6 months after intervention.

Stress, stressors, and substance use: Differential risk for hookah use among African American college students.

Using differential, multivariable risk models, we assessed the contribution of substance use and stress/traumatic events to hookah use among African American college students (n = 1,402) using data from the Fall 2012 American College Health Association-National College Health Assessment (ACHA-NCHA) II. Lifetime hookah use was 24.8%, with 34.2% of lifetime users having done so in the past 30 days. Compared to nonusers, hookah users had significantly higher use rates of alcohol, marijuana, other tobacco, and other drugs. Furthermore, hookah use was more likely among those with cumulative stress, yet less likely among older students. An implication is that prevention messages may need to be tailored for African American college students and particularly target younger students, substance users, and those with cumulative stress. These findings also inform policy discussions regarding hookah use on college campuses.

Adoption of electronic-cigarette-free, hookah-free and American College Health Association recommended tobacco-free policies among a national sample of postsecondary educational institutions.

Objective: To examine the prevalence of various types of tobacco-free policies among a US national sample of postsecondary educational institutions (PEIs). Participants: A national sample of US PEIs (N = 605) attended by the participants of the NEXT Generation Health Study. Methods: Tobacco policies of these PEIs were reviewed to determine if they were e-cigarette-free (yes/no), hookah-free (yes/no), and ACHA-recommended tobacco-free (yes/no) in June-December 2017. Logistic regression models were used to examine the relationships between institutional characteristics and tobacco policies. Results: Overall, 39.2, 26.0, and 20.0% of the sample adopted e-cigarette-free, hookah-free, and ACHA-recommended tobacco-free policies, respectively. Proprietary PEIs (vs. public) were less likely to have ACHA-recommended tobacco-free policies, while PEIs in the South and Midwest (vs. West) were more likely to have ACHA-recommended tobacco-free policies (p < 0.05). Conclusions: Most sampled PEIs did not have ACHA-recommended tobacco-free polices. Subsequent research needs to investigate how ACHA-recommended tobacco policies influence tobacco use.

Vapes, E-cigs, and Mods: What Do Young Adults Call E-cigarettes?

INTRODUCTION: A diverse class of products, "e-cigarettes" present surveillance and regulatory challenges because of nonstandard terminology used to describe subtypes, especially among young adults, where occasional e-cig use is most prevalent. METHODS: Young adults (n = 3364) in wave 9 (Spring 2016) of the Truth Initiative Young Adult Cohort were randomized to see two of five photos of common e-cig products (three varieties of first-generation e-cigs and one variety each of second- and third-generation e-cigs). Qualitative responses were coded into nine classifications: "e-cigarette, e-hookah, vape-related, mod, other or more than one kind of e-cig, marijuana-related, non-e-cig tobacco product, misidentified, and don't know." We characterized the sample and survey responses and conducted multivariable logistic regression to identify participant characteristics associated with correctly identifying the devices as e-cigs. Data were weighted to represent the young adult population in the United States in 2016. RESULTS: The majority of participants identified the pictured devices as some type of e-cig (57.7%-83.6%). The white first-generation e-cig, as well as the second- and third-generation e-cigs caused the greatest confusion, with a large proportion of individuals responding "don't know" (12.2%-25.1%, depending on device) or misidentifying the e-cig as a non-nicotine product (3.4%-16.1%, depending on device) or non-e-cig tobacco product (1.4%-14.6%, depending on device). CONCLUSIONS: Accurate surveillance and analyses of the effect of e-cigs on health behavior and outcomes depend on accurate data collection on users' subtype of e-cig. Carefully chosen images in surveys may improve reporting of e-cig use in population studies. IMPLICATIONS: Survey researchers using images to cue respondents, especially young adult respondents, should consider avoiding use of white or colorful first-generation e-cigs, which were commonly misidentified in this research, in preference for black or dark colored first-generation e-cigs, such as the blu brand e-cig. Given the sizable proportion of respondents who classified second- and third-generation e-cigs with terminology related to vaping, surveys specifically aimed at assessing use of these types of e-cigs should include the term "vape" when describing this subclass of devices.

A Proposed Waterpipe Emissions Topography Protocol Reflecting Natural Environment User Behaviour.

Usage of waterpipes is growing in popularity around the world. Limited waterpipe natural environment topography data reduces the ability of the research community to accurately assess emissions and user exposure to toxicants. A portable ergonomic waterpipe monitor was provided to study participants to use every time they smoked their own waterpipe during a one-week monitoring period in conjunction with their own choice shisha tobacco. Users provided demographic information and logged their product use to supplement electronic monitor data. A total of 44 prospective study participants were invited to an intake appointment following an on-line pre-screening survey. Of these, 34 individuals were invited to participate in the study and data for 24 individuals who completed all aspects of the 1-week monitoring protocol is presented. 7493 puffs were observed during 74 waterpipe sessions accumulating over 48 h of waterpipe usage. The 95% CI on mean puff flow rate, duration, volume and interval are presented, yielding grand means of 243 [mL/s], 3.5 [s], 850 [mL], and 28 [s] respectively. The middle 95% of puff flow rates ranged between 62 to 408 [mL/s], durations from 0.8 to 6.8 [s], and puff volumes from 87 to 1762 [mL]. A waterpipe emissions topography protocol consisting of 13 flow conditions is proposed to reflect 93% of the observed range of puff flow rate, puff duration and puff volume with representative inter-puff interval, cumulative session time and aerosol volumes.

[Use of electronic cigarette in France among adolescents aged 17: Results from the ESCAPAD 2017 survey]. / Usages de la cigarette électronique en France à 17 ans : résultats de l'enquête nationale ESCAPAD 2017.

INTRODUCTION: The use of electronic cigarettes has become relatively popular in France since 2010, including among adolescents. However, its use in relation to smoking and other factors is not well understood today. METHODS: The data come from the ESCAPAD 2017 survey, a nationally representative cross-sectional survey taking place at a 1-day session of civic and military information compulsory for all French nationals around 17 (39,115 respondents). Descriptive analyses and multivariate regressions were undertaken to describe the recent use of e-cigarette at 17 and its associated factors. RESULTS: e-cigarettes were experimented by 52.4 % of 17 year-olds, and used by 16.8 % in the preceding month, 1.9 % daily. Most recent users were also daily smokers (62.5 %), and only 7.6 % had never experimented cigarettes before. Among those who experimented with both products, only 13.3 % tried e-cigarettes before cigarettes. The associated uses of other products were the most striking factors: daily smoking (relative risk [RR]=2.73), ever use of hookah (RR=2.31), cannabis use in the last year (RR=1.60), regular alcohol drinking (RR=1.20) and ever use of another illicit drug (RR=1.11). Recent vapers that were also daily smokers had a more pronounced sociodemographic profile and a higher level of other drugs consumptions than recent vapers only. DISCUSSION: Although a majority of French adolescents experiment with vaping, they are fewer to use it regularly and its current use is frequently associated with daily smoking. Future trends and the relationship between smoking and vaping among adolescents will have to be further investigated, including the motivations of its use.

A Call for Effective Interventions to Curb Shisha Tobacco Smoking among University Students in Eastern Province, Saudi Arabia: Findings from a Cross-Sectional Study.

BACKGROUND: Although the number of cigarettes smoked has been declining due to major public health initiatives, shisha tobacco smoking is gaining popularity around the world, particularly among youth and university students. METHODS: A cross-sectional study was conducted among 464 university students in Eastern Province of Saudi Arabia using a structured questionnaire (i) to assess the prevalence of shisha smoking; (ii) to evaluate risk-perception, knowledge and normative belief about shisha smoking, and to compare these among users and non-users of shisha. RESULTS: The study reported a high prevalence (22.8%) of the current use of shisha among the university students with a narrow gender gap and found that STS is getting more popular than other forms of tobacco. A quarter of participants had low risk perception and 30.2% had low knowledge of shisha smoking harm. Importantly, more than two-fifth of them were current users of shisha. Low risk-perception about shisha and social acceptability were significantly contributed to the high prevalence of shisha smoking among the youth. CONCLUSION: It is important to provide exposure to education related to shisha hazards and increase the awareness of students and the public about the health effects of shisha smoking.

Shisha smoking in selected nightclubs in Nigeria.

INTRODUCTION: Shisha consumption is a growing public health issue all over the globe and public health awareness about its deleterious health consequences is still not sufficiently raised. METHODS: In this location-based study of nightclubs in Ibadan, Nigeria, 633 patrons of selected nightclubs were interviewed in order to obtain information on prevalence, correlates and predictors of shisha smoking. RESULTS: The overall prevalence of shisha smoking was 7.1%. The age of initiation into shisha smoking was lower among women, p = 0.03, but men were significantly more likely to be more frequent users, daily or weekly users, p < 0.001 and also to be current cigarette smokers, p = 0.03. There was no significant gender variability in the stage of readiness to quit. Regression analysis showed that after adjusting for age, the predictors of shisha smoking were: cigarette smoking, OR = 4.83, 95% CI (1.49-15.70) and more than 12 years of education, OR = 7.55, 95% CI (1.88 - 30.37), while being a rural dweller was a protective factor, OR = 0.05, 95% CI (0.01-0.20). CONCLUSION: Shisha smoking has emerged as a prevalent public health issue in Nigeria. There is a need for an immediate response from policy providers towards shisha smoking intervention in Nigeria.

Determinants of shisha use among secondary school students in Sudan.

BACKGROUND: Shisha smoking has re-emerged in the Middle East in the last two decades and has spread rapidly in these communities. Information about shisha smoking in adolescents in Sudan is deficient. Hence, the aim of this study is to estimate the prevalence of shisha smoking among adolescents and determine the associated factors. METHODS: This study is a school based cross sectional study among secondary school students in Khartoum State - Sudan that targets both male and female students aged 14-17 years. A total of 3387 students from 29 public and private schools were selected by multi stage random sampling. The participants completed an anonymous self-administered questionnaire which was based on Arabic version of the Global Youth Tobacco Survey (GYTS). RESULTS: The response rate was 100% in schools and among participants, 57.3% were females and 51.6% were from public schools. The overall prevalence of those who had ever smoked shisha was 13.4%, and among male students the prevalence was 16.8%, while it was 10.9% in females. The associated factors were poor academic performance OR 2.90 CI 95% (1.21-6.94), friends smoking shisha OR 2.39 CI 95% (1.65-3.45), friends smoking cigarettes OR 2.76 CI 95% (1.90-4.01), peer pressure to smoke shisha OR 13.76 CI 95% (7.86-24.07) and unexpectedly restriction of selling shisha to minors OR 2.21 CI 95% (1.28-3.82). CONCLUSION: The prevalence of those who had ever smoked shisha is among the lowest in Middle East region; therefore, regular surveillance system is needed. A well-structured peer based comprehensive tobacco control programmes that are supported by strict and rigorous anti-tobacco regulations which control both commercial and social resources of tobacco are needed to contain this issue among adolescents.

Prevalence, knowledge and practices of shisha smoking among youth in Kampala City, Uganda.

INTRODUCTION: globally tobacco use kills more than seven million people annually, a figure expected to rise to 8 million deaths every year by 2030. Though perceived as safe, shisha smoking is reported to have the same or worse health effects as cigarette smoking yet, this practice has gained popularity especially among youths globally. We assessed shisha smoking and factors associated with shisha smoking to support public health interventions. METHODS: a cross-sectional study was conducted among 663 systematically selected youths aged between 18-30 years attending bars in two divisions of Kampala city Uganda. Data was analyzed using Stata version 12 and logistic regression model run to establish factors independently associated with shisha smoking. RESULTS: we found that 458 (86.4%) youths had low knowledge of the health effects of shisha and 193 (36.4%) smoked shisha. Majority of the respondents, 184 (97.4%) smoked flavoured and sweetened tobacco, 69 (36.5%) smoked on a weekly basis, 163 (86.2%) smoked in the company of friends, 162 (85.7%) shared shisha pipes. Factors associated with shisha smoking include smoking cigarettes adjusted odds ratio [aOR]: 5.91, 95% Confidence Interval (CI): 3.86-9.05); positive attitude (aOR: 3.89, 95% CI: 2.50-6.05); urban residence (aOR: 3.98, 95% CI: 1.99-8.00) and older age [25-30 years] (aOR: 2.13, 95% CI: 1.37-3.22). CONCLUSION: the prevalence of shisha smoking is high with three in ten youths smoking shisha yet their knowledge about the health effects associated with shisha smoking was low. Shisha smoking ban should be implemented in all bars in Kampala as stated by the newly enacted tobacco law.

The Effect of Hookah Use on Buccal Mucosa: Evaluation of Repair Index

Background and aim: Cigarettes, hookah, and tobacco are the most important etiologic factors for oral cancers and dysplastic lesions. This study was undertaken to determine the correlation between hookah use and the percentage of cells with micronucleus, karyorrhexis, karyolysis, and broken egg in the buccal mucosa; and secondly to compare hookah user and non-user in terms of repair index. Materials and methods: The present historical cohort study was carried out on 72 samples taken from 36 hookah users and 36 control subjects. Smear samples were obtained from participants' buccal mucosa for cytological evaluation using Papanicolaou technique. Then, the percentages of cells with micronucleus, karyorrhexis, karyolysis, and broken egg were recorded and the repair index was calculated. Data were analyzed using Mann-Whitney U test. Results: A total of 72 samples taken from 36 hookah users and 36 control subjects were evaluated. The means of micronucleus scores in the buccal mucosa cells of hookah users and controls were 10.7±2.6 and 5.8±2.0, the karyorrhexis scores in the hookah users and controls were 0.1±0.06 and 0.04±0.06, and the karyolysis scores in hookah users and controls were 0.16±0.05 and 0.08±0.06, respectively. These differences were statistically significant between hookah users and controls (P<0.001). The broken egg score was 0.66±0.07 for the hookah users and 0.03±0.04 for the control group, revealing a statistically significant difference (P<0.036). Finally, the repair index values were 0.03±0.01 and 0.05±0.13 in hookah users and controls, respectively. This difference was also significant (P<0.026). Conclusion: The percentages of cells with micronucleus, karyorrhexis, karyolysis, and broken egg in the buccal mucosa of hookah users were significantly higher than those in control group; in addition, the repair index of the buccal mucosa cells in hookah users was significantly lower than that in the control group.

A Cross Sectional Study on Knowledge, Beliefs and Psychosocial Predictors of Shisha Smoking among University Students in Sharjah, United Arab Emirates

Background: Smoking is now prohibited in all educational institutions and other public places in the United Arab Emirates (UAE), but shisha smoking is considered as one of the major problems among the students population. This study aimed to identify the (a) prevalence of ever shisha, current shisha and shisha dependency smokers among university students in the University of Sharjah (UOS), (b) knowledge and belief differences among ever shisha, current shisha as well as shisha dependency smoking students, (c) relationship between precipitating factors and shisha dependency and (d) precipitating factors (stimulation, handling, pleasure, tension reduction, addiction (dependency), automatism (habit) and social interaction, parents smoking behavior, knowledge and beliefs about smoking predict shisha dependency among students in UOS. Materials and Methods: In this cross sectional study, 633 students participated from UOS, UAE. Knowledge and Belief scale, Modified Reason for Smoking Scale and Fagerstrom Test for Nicotine Dependence (FTND) were used to measure knowledge, beliefs, shisha dependency and predictive factors of smoking behavior among undergraduate students in UOS. Results: Nearly103 (16.3%) of students were addictive to shisha smoking based on FTND. Students had adequate knowledge that smoking led to cardiac problems; however, their knowledge about the other consequences of smoking was inadequate and believed that smoking was not harmful. There was a significant positive relationship between addiction, pleasure, social interaction, habit, parental smoking behavior and shisha dependency behavior among current shisha dependency students. Habit, addiction, pleasure, social interaction and parental smoking were the predictors of shisha smoking dependency among this population. Step wise multiple regressions showed that social interaction was the highest significant predictor for shisha dependency behavior. Conclusions: Hence, there is a need to enhance the knowledge and modify irrational beliefs about shisha smoking as these students possess inadequate knowledge about consequences of shisha smoking.

Impact of Question Type and Question Order on Tobacco Prevalence Estimates in US Young Adults: A Randomized Experiment.

The purpose of this study was to identify the effects of question type, order, and inclusion of product images on tobacco use estimates in a national sample of young adults. Participants aged 18-34 years (N = 4,100) in the Truth Initiative Young Adult Cohort Study (2016) were randomized to one of five question types assessing ever and past 30-day use of tobacco products: (1) "select all that apply" list (checklist, CL); (2) breakout items for each product (B); (3) breakout + images (B + I); (4) CL and B; and (5) CL and B + I. The order of question type was randomly assigned in groups 4 and 5. Bivariate analyses estimated product-specific prevalence by question type/order. Ever cigarette and cigar use prevalence was higher and ever e-cigarette use was lower in B and B + I than in CL. Ever hookah use was higher in B + I than in CL. Past 30-day e-cigarette use was 8.3% higher and past 30-day smokeless use was 13.0% higher in B + I than in CL. In groups 4 and 5, higher prevalence of ever cigarette, cigar, hookah, and past 30-day smokeless use was observed when B was presented first. Question type, order, and inclusion of images affect prevalence estimates of tobacco use. IMPLICATIONS: This study identifies the effects of question type, order, and inclusion of product images on tobacco use estimates in a national sample of young adults. Ever use and past 30-day use prevalence estimates of specific products were affected by respondents answering breakout items or breakout items with images compared with respondents answering a checklist of items in the survey. Current surveys that include a "select all that apply" list format may be underestimating ever and past 30-day prevalence estimates of tobacco products.