Building the evidence base for waterpipe regulation and policy.

Waterpipe (hookah, shisha, narghileh) smoking is emerging as an epidemic, particularly among young people in the USA and globally. Unlike cigarettes, waterpipe smoking involves several components (eg, tobacco, charcoal, device and venues) and is characterised by unique smoking patterns that expose smokers to significant amounts of nicotine and other toxic substances. With the rising prevalence of use among young people and continuing misperceptions about waterpipe's harmful nature, a better understanding of health risks associated with waterpipe smoking is warranted. In response to waterpipe's rising trends, a Deeming Rule that extended the US Food and Drug Administration's (FDA) regulatory authority to all tobacco products was issued in 2016. This rule includes waterpipe tobacco, components and parts. This development created the need for evidence to guide the FDA into best evidence-based strategies to limit waterpipe's spread among young people and harm to public health. This special issue presents some of the studies that were funded under the 'Chemistry, Toxicology, and Addiction Research on Waterpipe Tobacco' programme to inform promising regulatory action on waterpipe products. In this preamble, we briefly summarise findings from these studies and discusses their policy and regulatory implications for different waterpipe products and components.

Epidemiology and Adverse Consequences of Hookah/Waterpipe Use: A Systematic Review.

Hookah smoking is becoming a popular trend globally. Waterpipe smoking is the second most prevalent form of alternate tobacco products. The rapid increase in hookah use is because of the misconception prevalent in society that hookah smoking is less harmful than cigarette smoking. Smoking ban policies had given impetus of switching from cigarette smoking to alternate tobacco products like waterpipe. Hookah users regard hookah to be more socially acceptable, less stigmatizing with flavors and to alleviate cigarette craving symptoms. Newer basic science research on animal models and human cells has shown consistently mutagenic, oxidative, and inflammatory changes that could cause possible health effects of premalignant oral lesion and chronic diseases like atherosclerosis and chronic obstructive pulmonary disease. Studies on the chemistry of waterpipe smoke had shown alarming results with the smoke containing seven carcinogens, 39 central nervous system depressants, and 31 respiratory irritants. Enormous data exist showing waterpipe smoking causing various health effects. Hookah smoking effects on cardiovascular disease is additive with hookah containing a significant amount of nicotine, tar, and heavy metals causing both acute and chronic effects on the cardiovascular system. These effects include increased heart rate, blood pressure, prevalence of coronary heart disease, heart failure, ST-segment elevation myocardial ischemia, recurrent ischemia, and worse outcomes including mortality related to these diseases. The objectives of the review are to assess the factor associated with the increasing use of hookah, its health effects, options for hookah smoking cessation, and public health policy initiatives to mitigate waterpipe use.

Characteristics of Waterpipe Health Warning Labels in the United States.

Objectives: In this paper, we assess characteristics of health warning labels (HWLs) on water-pipe tobacco packages sold in the US and changes after the FDA's minimum required warning statement went into effect in August 2018. Methods: We sampled 16 brands and 45 sub-brands/flavors of the most popular waterpipe tobaccos 6 months before and 4 months after the FDA's compliance deadline. HWL characteristics assessed included type (pictorial or text), message theme, location, and relative size. Results: Before the deadline, all packages had at least one text-only HWL that covered <25% of the surface, with most inconspicuously placed (such as side panel), and focusing on general health risks of tobacco rather than waterpipe-specific risks. After the deadline, only 1 of 10 brands had adopted the new required HWL, adding it to the existing one. Conclusions: HWLs were common on waterpipe tobacco packages in the US prior to the FDA mandate, but did not adhere to recommended standards of being pictorial, large (least 50% of the package), conspicuously placed, and using relevant, rotating message themes. The FDA's required warning has not yet been adopted by most brands. Doing so may improve the efficacy of HWLs to reduce smoking.

Tobacco and waterpipe use among university students in Saudi Arabia: impact of tobacco sales ban.

BACKGROUND: Waterpipe smoking is a method of tobacco consumption that continues to spread globally. In 2002, a ban of tobacco sales was adopted in the Saudi Arabian cites of Mecca and Medina. AIMS: This study aimed to examine prevalence of waterpipe and cigarette smoking among students of Taibah University, the biggest in Medina, where the tobacco sales ban has been implemented. METHODS: A structured questionnaire was distributed between February and April 2015 to examined tobacco use among Taibah University students. RESULTS: The prevalence of current and ever waterpipe use was 24.2% and 36.04%, respectively, compared with 31.9% and 42.7% for current and ever cigarette smoking. This prevalence is similar to that reported in other Saudi cities where tobacco sales are allowed. Multivariate analysis showed that waterpipe use was higher among senior students; those with pocket money spending of > 500 Saudi Arabia riyal (SAR)/month; and if > 5 individuals were living in the household. In addition, waterpipe use was lower among students with monthly household income of 5000-9000 SAR. In contrast, current cigarette smoking was more frequent in those aged > 22 years; among male students; in those with pocket money spending of > 500 SAR/month; and those who lived away from their parents. CONCLUSIONS: Waterpipe and cigarette smoking, despite the ban on tobacco sales, is still common among Taibah University students in Medina, Saudi Arabia.

Acrolein Exposure in Hookah Smokers and Non-Smokers Exposed to Hookah Tobacco Secondhand Smoke: Implications for Regulating Hookah Tobacco Products.

Introduction: Acrolein is a highly ciliatoxic agent, a toxic respiratory irritant, a cardiotoxicant, and a possible carcinogen present in tobacco smoke including hookah tobacco. Methods: 105 hookah smokers and 103 non-smokers attended exclusively hookah smoking social events at either a hookah lounge or private home, and provided urine samples the morning of and the morning after the event. Samples were analyzed for 3-hydroxypropylmercapturic acid (3-HPMA), a metabolite of acrolein. Results: Geometric mean (GM) urinary 3-HPMA levels in hookah smokers and non-smokers exposed to secondhand smoke (SHS) increased significantly, 1.41 times, 95% CI = 1.15 to 1.74 and 1.39 times, 95% CI = 1.16 to 1.67, respectively, following a hookah social event. The highest increase (1.68 times, 95% CI = 1.15 to 2.45; p = 0.007) in 3-HPMA post a hookah social event was among daily hookah smokers (GM, from 1991 pmol/mg to 3348 pmol/mg). Pre-to-post event change in urinary 3-HPMA was significantly positively correlated with pre-to-post event change in urinary cotinine among hookah smokers at either location of hookah event, (ρ = 0.359, p = 0.001), and among non-smokers in hookah lounges (ρ = 0.369, p = 0.012). Conclusions: Hookah tobacco smoke is a source of acrolein exposure. Findings support regulating hookah tobacco products including reducing humectants and sugar additives, which are precursors of acrolein under certain pyrolysis conditions. We suggest posting health warning signs for indoor smoking in hookah lounges, and encouraging voluntary bans of smoking hookah tobacco in private homes. Implications: Our study is the first to quantify the increase in acrolein exposure in hookah smokers and non-smokers exposed to exclusively hookah tobacco SHS at hookah social events in homes or hookah lounges. Our findings provide additional support for regulating hookah tobacco product content, protecting non-smokers' health by posting health warning signs for indoor smoking in hookah lounges, and encouraging home bans on hookah tobacco smoking to safeguard vulnerable residents.