Assessment of prevalence, predictors, reasons and regulations of substance smoking among children in Ghana.

BACKGROUND: In Ghana, it is against the law for children to smoke. Nevertheless, a portion of children in the country do smoke. However, there is a paucity of research on young smokers in Ghana and other sub-Saharan African nations. This study, therefore, investigated the prevalence of smoking, the kinds of substances children smoke, predictors of smoking, reasons for and factors that lead children to smoke, and regulation of smoking among children in Ghana. METHODS: In total, 5024 children aged 8-17 were studied using a cross-sectional convergent parallel mixed method. Descriptive statistics, Person's Chi-square test, Fisher Exact test, and binary logistic regression were used to analyse the quantitative data. In contrast, thematic analysis was used to analyse the qualitative data. RESULTS: The results showed that 3.2% of children had ever smoked. Male children smoked more often than female children. The prevalence of cigarette, marijuana, and shisha smoking was 78.3%, 18%, and 3.7%, respectively. While more male children than female children smoked cigarettes and marijuana, more female children than male children used shisha. Children mainly smoked for fun and due to group culture. In addition, children were influenced by friends; parents, family members, and neighbours who smoke; curiosity; and advertisements and videos to initiate smoking. Despite the availability of regulations and laws regulating tobacco products in public places, tobacco advertisement, promotion, and sale to persons under 18, children are still smoking. CONCLUSIONS: Children who have ever engaged in smoking reported using cigarettes, marijuana, and shisha. Policymakers urgently need to strategise and strengthen their policies, programmes, and interventions to address smoking among children.

Water pipe smoking among public versus private university students in Ankara, Turkey: an online survey.

BACKGROUND: Water pipe smoking has become a global public health problem as its popularity increased over time, especially among youth. The objective of our study was to estimate water pipe tobacco smoking prevalence and to assess socioeconomic factors associated with ever water pipe smoking by public and private university students in Ankara, Turkey. METHODS: This descriptive study was based on a survey conducted among public (n=2685) and private (n=2485) university students via an online questionnaire on demographics and water pipe consumption patterns. For every student in the sample, a socioeconomic status index was calculated using principal component analysis. Binary logistic regressions for the outcome variable of ever-using water pipe yielded estimates of adjusted odds ratios (aORs) for the associated factors such as the respondent's age, gender, university type, and socioeconomic status. RESULTS: The prevalence of ever use of water pipe was 69.1% (95% CI: 67.2-70.9%) among private and 59.1% (95% CI: 57.2-60.9%) among public university students. A substantial share of ever users were current users (25.5% in private versus 21.6% in public, p=0.008). On average, private university students had higher socioeconomic status than public university students (for example, access to a car (51.7% versus 35.8%, p=0.008), financial support from family (71.5% versus 65.1%, p<0.001)), also demonstrated by a higher socioeconomic status index. Being a private university student (aOR 1.57, 95% CI: 1.38-1.79), older (aORs 1.50 to 2.39, p<0.001), male (aOR 2.36, 95% CI:2.06-2.70), as well as having greater financial resources, such as having access to a car (aOR 1.24, 95% CI:1.07-1.42), or having income support from family (aOR 1.32, 95% CI:1.13-1.54), were associated with ever-using water pipe. A higher SES index was significantly associated with higher odds of ever using water pipe among both private (aOR 1.13, 95% CI:1.06,1.20) and public university (aOR 1.12, 95% CI:1.06,1.19) students. CONCLUSIONS: Water pipe smoking was common in both public and private universities; however, private university students had higher odds of ever using water pipe. There is an urgent need to implement evidence-based interventions, taking into account the socioeconomic status of young adults, to prevent them from water pipe smoking.

The Effect of Perceptions of Hookah Harmfulness and Addictiveness on the Age of Initiation of Hookah Use among Population Assessment of Tobacco and Health (PATH) Youth.

Despite the negative health consequence of hookah, hookah risk perceptions are misguided among youth. Secondary data analysis of 12-17-year-old never hookah users at their first wave of PATH participation (2013-2019) was performed. The effect of perceptions of hookah harmfulness and addictiveness on the age of initiation ever, past 30-day, and fairly regular hookah use were estimated using interval-censored Cox proportional hazards models. The distribution of the age of initiation of hookah outcomes by perception levels of harmfulness and addictiveness are reported as cumulative incidence and 95% CI. Youth who perceived hookah to be neither harmful nor addictive were 173% more likely to initiate ever, 166% more likely to first report past 30-day use, and 142% more likely to first report fairly regular hookah use at earlier ages compared to youth who considered hookah to be both harmful and addictive. By age 18, 25.5% of youth who perceived hookah as neither harmful nor addictive were estimated to initiate ever hookah use while 9.3% of youth who perceived hookah as harmful and addictive were estimated to initiate ever hookah use. These findings indicate the need to provide prevention and education campaigns to change perceptions of the harmfulness and addictiveness of hookah to delay the age of initiation of hookah use.

Prospective estimation of the age of initiation of hookah use among youth: Findings from the Population Assessment of Tobacco and Health (PATH) study waves 1-4 (2013-2017).

OBJECTIVE: This study reports the prospectively estimated age of initiation of susceptibility to, ever, past 30-day, and fairly regular hookah use. DESIGN: Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US youth (ages 12-17). METHODS: Youth who were never hookah users at their first wave of participation were identified (n = 16,678; N = 31,136,834). Four outcomes were analyzed, age of first report of: (i) susceptibility to use, (ii) ever use, (iii) past 30-day use, and (iv) fairly regular hookah use. The age of hookah initiation of each outcome was estimated. Weighted interval censoring survival analyses and Cox regression models were conducted to estimate the age of initiation of each hookah use outcome, and to estimate differences in age of initiation by sex and by race, respectively. RESULTS: Around 11% of youth were classified as susceptible to hookah use by 13 years of age, 8% reported initiating ever hookah use by age 17, almost 10% reported initiating past 30-day hookah use by age 19, and 3% reported initiating fairly regular hookah use by age 20. Females and Hispanics were at higher risk of becoming susceptible to and ever hookah use at earlier ages compared to males and Non-Hispanic White youth. CONCLUSION: Education, communication campaigns, and proven culturally targeted tobacco interventions that reach youth at ages before they first become susceptible or start using hookah use are needed to prevent the onset of hookah use among vulnerable youth.

Transitions in frequency of hookah smoking among youth and adults: findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study, 2013-15.

BACKGROUND AND AIMS: The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers. DESIGN: Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at wave 1 (2013-14); frequency of hookah smoking and past-year cessation were ascertained at wave 2 (2014-15). Weighted multivariable logistic and ordinal logistic regression models were fitted to predict hookah smoking cessation and frequency of hookah smoking at wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking and frequency of hookah smoking at wave 1. SETTING: United States. PARTICIPANTS: A total of 693 youth and 4400 adult past-year hookah smokers. MEASUREMENTS: Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI). FINDINGS: At wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Among all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, the availability of appealing flavors and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors [adjusted odds ratio (aOR) = 0.40; 95% confidence interval (CI) = 0.26-0.62] compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly or more frequent hookah smoking at wave 2, compared with cessation or less than monthly smoking, were higher for adults who liked hookah flavors [adjusted proportional odds ratio (aPOR) = 2.10; 95% CI = 1.48-2.99 and enjoyed socializing while smoking hookah (aPOR = 1.82; 95% CI =1.13-2.94) compared with adults who did not like hookah flavors or socializing. CONCLUSION: The availability of appealing flavors, affordability and socialization while smoking hookah in the United States are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Waterpipe Tobacco Smoking among University Students in Three Eastern Mediterranean Countries: Patterns, Place, and Price.

Background: The objective of this study was to examine waterpipe tobacco smoking patterns, places of smoking, and prices paid among university students in the Eastern Mediterranean Region. Methods: A cross-sectional online survey was administered to a convenience sample of university students in three countries. Participants were young adults (18-29 years) who were ever waterpipe smokers, from Egypt (n = 728), Jordan (n = 790), and Palestine (n = 722). Measures included past-30-day waterpipe smoking, frequency, intensity, place of smoking, and prices paid per waterpipe smoking session and for packaged waterpipe tobacco. Logistic regression models evaluated the factors associated with past-30-day waterpipe smoking. Results: Past-30-day waterpipe smoking (prevalence) was observed among 60.7%, 67.7% and 63.1% of students from Egypt, Jordan, and Palestine, respectively. Among past-30-day smokers, past-5-day waterpipe smoking (frequency) was observed among 28.9%, 51.5%, and 48.6% of participants, respectively. Smoking in a café was highest among participants from Egypt (74.0%), followed by those from Palestine (44.8%), and Jordan (43.0%). Mean price paid per session was USD 0.99 (Egypt), USD 8.07 (Jordan), USD 6.05 (Palestine). The corresponding mean prices per packet were USD 0.86, USD 4.96, and USD 5.55, respectively. Predictors of past-30-day waterpipe smoking included younger age of initiation, male gender, employment, and smoking waterpipe alone. Conclusions: This study contributes to our understanding of waterpipe smoking patterns, places of smoking, and prices paid among young adults in a region with alarmingly high smoking rates. Understanding waterpipe smoking behaviors can inform the design of policy and educational interventions to curb its rising threat.

Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries.

The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.

Shisha use among students in a private university in Kigali city, Rwanda: prevalence and associated factors.

BACKGROUND: All over the globe shisha smoking is fast growing among different age brackets. Shisha use has been reported to be increasing among youths in African major cities. Its use is documented to result in health effects such as lung cancer, cardiovascular and respiratory conditions, periodontal diseases, keratoacanthoma which are also associated with cigarette smoking. In Kigali, Rwanda's capital, reports indicate that shisha use is increasing among the youths, particularly the university students. The study aimed at determining the prevalence, and establishing factors associated with shisha use among students in a university in Kigali Rwanda, which will be a significant step in stemming shisha fame among youths in Rwanda as there was no previously documented evidence-based study. METHODS: A total of 427 students were selected for this cross-sectional study using stratified sampling method. A questionnaire was used to collect data on shisha use, knowledge about shisha, attitude towards shisha, and factors associated with use of shisha. The association between the independent variables and shisha use was assessed using chi-square p value < 0.05. Binary logistic regression was used to determine variables that were independently associated with shisha smoking. RESULTS: Prevalence of ever smoking shisha among the university students was 26.1% and that of those that smoked in the last month (30 days) was 20.8%. About 40 % (39.9%) of the participants that had heard about shisha before demonstrated low level of knowledge, and 41.6% of these reported shisha use in the last 30 days. Logistic regression revealed that the followings were independently associated with shisha smoking: always drink alcohol (p = 0.003); drink alcohol occasionally (p = 0.045); having friend(s) who smoke shisha (p = 0.001); being aware of shisha's availability in cafes, bars and restaurants in Kigali (p = 0.022); positive attitude towards shisha smoking (p < 0.001) and participants with age < 20 years (p = 0.039). CONCLUSIONS: There is a relative high prevalence of shisha smoking and a poor knowledge about its impact on health among these university students. Regular medical education and health promotion targeting the youths could improve knowledge and practices about shisha use. Shisha laws and regulations should be enacted, and fines imposed on individuals or group who flout them.

Policy Implications and Research Recommendations: A Review of Hookah Use Among US College Students.

The rate of Hookah use among college students during the last decade is about 30%. Although college students perceive hookah use as a safer alternative to conventional cigarettes, hookah use increases the risk of disease and nicotine dependence, and therefore remains an area of concern. Presently, the US Food and Drug Administration (FDA) has little regulation for the manufacture, distribution, or sale of hookah. This review attempts to assess empirical literature relating to hookah use while focusing on the consequences for regulatory policy. PubMed (including MEDLINE 2010-2017), PsycINFO, EBSCO, Scopus (Elsevier) databases were examined to pinpoint articles published in English. The following terms were used in the searches: Hookah or Waterpipe or nargile or "arghile" or "shisha" or "hubble bubble" or "alternative tobacco product" or "flavored tobacco". Hookah use may initiate smoking among tobacconaïve college students. College students who use hookah are generally not aware of the increased risks for tobacco related diseases as it relates to their behavior. In addition, few public health messages target college-age adults with anti-hookah messages. A lack of information regarding the dangers and potential harms of hookah use may be misinterpreted as a sign of "safety" which inadvertently may imply a suggestion of no need for safety measures. Hence, a research agenda that would inform about health policy actions has been proposed.

Banning shisha smoking in public places in Iran: an advocacy coalition framework perspective on policy process and change.

INTRODUCTION: Shisha smoking is a widespread custom in Iran with a rapidly growing prevalence especially among the youth. In this article, we analyze the policy process of enforcing a federal/state ban on shisha smoking in all public places in Kerman Province, Iran. Guided by the Advocacy Coalition Framework (ACF), we investigate how a shisha smoking ban reached the political agenda in 2011, how it was framed by different policy actors, and why no significant breakthrough took place despite its inclusion on the agenda. METHODS: We conducted a qualitative study using a case study approach. Two main sources of data were employed: face-to-face in-depth interviews and document analysis of key policy texts. We interviewed 24 policy actors from diverse sectors. A qualitative thematic framework, incorporating both inductive and deductive analyses, was employed to analyze our data. RESULTS: We found that the health sector was the main actor pushing the issue of shisha smoking onto the political agenda by framing it as a public health risk. The health sector and its allies advocated enforcement of a federal law to ban shisha smoking in all public places including teahouses and traditional restaurants whereas another group of actors opposed the ban. The pro-ban group was unable to neutralize the strategies of the anti-ban group and to steer the debate towards the health harms of shisha smoking. Our analysis uncovers three main reasons behind the policy stasis: lack of policy learning due to lack of agreement over evidence and related analytical conflicts between the two groups linked to differences in core and policy beliefs; the inability of the pro-ban group to exploit opportunities in the external policy subsystem through generating stronger public support for enforcement of the shisha smoking ban; and the nature of the institutional setting, in particular the autocratic governance of CHFS which contributed to a lack of policy learning within the policy subsystem. CONCLUSIONS: Our research demonstrated the utility of ACF as a theoretical framework for analyzing the policy process and policy change to promote tobacco control. It shows the importance of accounting for policy actors' belief systems and issue-framing in understanding how some issues get more prominence in the policy-making process than others. Our findings further indicate a need for significant resources employed by the state through public awareness campaigns to change public perceptions of shisha smoking in Iran which is a deeply anchored cultural practice.

Shisha Smoking Practices, Use Reasons, Attitudes, Health Effects and Intentions to Quit among Shisha Smokers in Malaysia.

Despite its popularity, shisha smoking practices, reasons for its use, attitudes, detrimental health effects and intention to quit among shisha users in Malaysia have never been investigated. A total of 503 shisha users responded to a cross-sectional study conducted between July 2015 and March 2016. The majority of users were young people aged 21-30; a small minority were underage. The reasons for shisha use were its growing popularity as a favourite pastime activity and the perception of shisha use as cool and trendy. Just over half (57.3%) agree that shisha use exposes the smoker to large amounts of smoke and the majority were unsure about the health risks of shisha smoking compared to tobacco smoking. The three most common detrimental health effects reported by the study respondents were dry throat, headache and nausea. Regular shisha users have significantly higher detrimental health effects compared to no-regular shisha users. Shisha users with a duration of smoking of 6-12 months (odds ratio (OR) 3.212; 95% confidence interval (CI) 1.651-6.248) and 6 months and below (OR 2.601; 95% CI 1.475-4.584) were significantly more likely to have a higher proportion who intend quitting smoking than shisha users of more than 12 months duration.

Prevalence of tobacco use among adults in Egypt, 2009.

INTRODUCTION: We assessed the differences in overall use of tobacco and in the use of various tobacco products, by sex and by frequency of use across various demographic groups. METHODS: We used data from the Global Adult Tobacco Survey (GATS), conducted in 2009 in Egypt. The data consist of answers to GATS by 20,924 respondents from a nationally representative, multistage probability sample of adults aged 15 years or older from all regions of Egypt. Current tobacco use was defined as current smoking or use of smokeless tobacco products, either daily or occasionally. We analyzed the differences in current cigarette, shisha, and smokeless tobacco use by sex and frequency of use (daily or occasional); and by demographic characteristics that included age, region, education level and employment status. RESULTS: Overall, 19.7% of the Egyptian population currently use some form of tobacco. Men (38.1% [95% confidence interval (CI) 36.8-39.4]) are much more likely than women (0.6% [95% CI 0.4-0.9]) to use tobacco. Almost 96% of men who use tobacco, do so daily. Men are more likely to use manufactured cigarettes (31.8% [95% CI 30.6-33.1]) than shisha (6.2% [95% CI 5.6-6.9]) or smokeless tobacco (4.1% [95% CI 3.4-4.8]). Few women use tobacco (cigarettes (0.2%), shisha (0.3%) and smokeless tobacco (0.3%)); however, all women who currently smoke shisha, do so daily. Lower educational status, being between ages 25-64 and being employed predicted a higher use of tobacco. CONCLUSION: Egypt has implemented several initiatives to reduce tobacco use. The World Health Organization (WHO) MPOWER technical package, which aims to reverse the tobacco epidemic, is implemented at various levels throughout the country. Our findings show that there is significant variation in the prevalence of tobacco use and types of tobacco used by adult men and women in Egypt. GATS data can be used to better understand comparative patterns of tobacco use by adults, which in turn can be used to develop interventions.

Waterpipe Tobacco Smoking in Turkey: Policy Implications and Trends from the Global Adult Tobacco Survey (GATS).

Waterpipe tobacco smoking (WTS) is an emerging tobacco product globally, especially among adolescents and young adults who may perceive WTS as a safe alternative to smoking cigarettes. Monitoring the use of WTS in Turkey in relation to the tobacco control policy context is important to ensure that WTS does not become a major public health issue in Turkey. The Global Adult Tobacco Survey (GATS) was conducted in Turkey in 2008 and was repeated in 2012. GATS provided prevalence estimates on current WTS and change over time. Other indicators of WTS were also obtained, such as age of initiation and location of use. Among persons aged 15 and older in Turkey, the current prevalence of WTS decreased from 2.3% in 2008 to 0.8% in 2012, representing a 65% relative decline. Among males, WTS decreased from 4.0% to 1.1% (72% relative decline). While the overall smoking prevalence decreased among females, there was no change in the rate of WTS (0.7% in 2008 vs. 0.5% in 2012), though the WTS prevalence rate was already low in 2008. Comprehensive tobacco control efforts have been successful in reducing the overall smoking prevalence in Turkey, which includes the reduction of cigarette smoking and WTS. However, it is important to continue monitoring the use of waterpipes in Turkey and targeting tobacco control efforts to certain groups that may be vulnerable to future WTS marketing (e.g., youth, women).

Potential harmful health effects of inhaling nicotine-free shisha-pen vapor: a chemical risk assessment of the main components propylene glycol and glycerol.

BACKGROUND: A shisha-pen is an electronic cigarette variant that is advertised to mimic the taste of a water pipe, or shisha. The aim of this study was to assess the potential harmful health effects caused by inhaling the vapor of a nicotine-free shisha-pen. METHODS: Gas chromatography analysis was performed to determine the major components in shisha-pen vapor. Risk assessment was performed using puff volumes of e-cigarettes and "normal" cigarettes and a 1-puff scenario (one-time exposure). The concentrations that reached the airways and lungs after using a shisha-pen were calculated and compared to data from published toxicity studies. RESULTS: The main components in shisha-pen vapor are propylene glycol and glycerol (54%/46%). One puff (50 to 70 mL) results in exposure of propylene glycol and glycerol of 430 to 603 mg/m(3) and 348 to 495 mg/m(3), respectively. These exposure concentrations were higher than the points of departure for airway irritation based on a human study (propylene glycol, mean concentration of 309 mg/m(3)) and a rat study (glycerol, no-observed adverse effect level of 165 mg/m(3)). CONCLUSIONS: Already after one puff of the shisha-pen, the concentrations of propylene glycol and glycerol are sufficiently high to potentially cause irritation of the airways. New products such as the shisha-pen should be detected and risks should be assessed to inform regulatory actions aimed at limiting potential harm that may be caused to consumers and protecting young people to take up smoking.

Assessment of narghile (shisha, hookah) smokers' actual exposure to toxic chemicals requires further sound studies.

Tobacco smoking is hazardous for health. However, not all forms of tobacco use entail the same risks and the latter should be studied and compared in a sound realistic way. Smoking machines for cigarettes (which are consumed in a few minutes) were early designed as a tool to evaluate the actual intake of toxic substances ('toxicants') by smokers. However, the yields (tar, nicotine, CO, etc.) provided by such machines poorly reflect the actual human smoking behaviour known to depend on numerous factors (anxiety, emotions, anthropological situation, etc.). In the case of narghile smoking, the problems are even more complex, particularly because of the much longer duration of a session. A recent study from the US-American University of Beirut was based on a field smoking topography and claimed consistency with a laboratory smoking machine. We offer a point by point critical analysis of such methods on which most of the 'waterpipe' antismoking literature since 2002 is based.