Waterpipe a gateway to cigarette smoking initiation among adolescents in Irbid, Jordan: a longitudinal study.

SETTING: According to anecdotal evidence, waterpipe smoking may lead to the initiation of cigarette smoking among young people. This hypothesis is yet to be examined using an appropriate study design and a theoretical model for behavioral change. OBJECTIVE: To compare the risk of cigarette smoking initiation among waterpipe-only smokers and never smokers in a school-based sample of adolescents from Irbid, Jordan. METHODS: A total of 1454 cigarette-naïve participants were drawn from a longitudinal study on smoking behavior conducted in Irbid among 1781 seventh graders who were enrolled at baseline (2008) and completed the study questionnaire on smoking behavior annually until 2011. Grouped time-survival analysis was used to compare the risk of subsequent initiation of cigarette smoking between waterpipe smokers (n = 298) and never smokers (n = 1156) using adjusted hazard ratios (aHRs) and 95% confidence intervals (95%CI). RESULTS: Risk of initiation of cigarette smoking among waterpipe smokers was significantly higher than among never smokers after adjusting for potential confounders (aHR 1.67, 95%CI 1.46-1.92). The association between waterpipe and cigarette smoking initiation was dose-dependent. The risk of initiating cigarette smoking increased with increase in the frequency of waterpipe smoking (P for linear trend < 0.001). CONCLUSIONS: Waterpipe smoking led to the initiation of cigarette smoking among this cohort of Jordanian adolescents; the effect was dose-dependent.

The association of birth weight with arterial stiffness at mid-adulthood: the Bogalusa Heart Study.

BACKGROUND: Birth weight has been found to predict cardiovascular morbidity and mortality. Pulse wave velocity (PWV), a marker of arterial stiffness, has been associated with cardiovascular risk factors. An association between birth weight and blood pressure (BP) has previously been reported. In this study, the association of birth weight with PWV, and the relationship between birth weight, pulse wave velocity and BP in mid-adulthood were investigated. METHODS: The Bogalusa Heart Study (BHS) is a population-based longitudinal study to investigate the natural development of cardiovascular risk factors. In the 2001 survey, brachial-ankle PWV (baPWV) was measured as an indicator of arterial stiffness. Of the 1203 participants in that survey, 707 had complete data on birth weight and PWV, which were utilised for this study. RESULTS: In this study, birth weight was inversely correlated with baPWV, pulse pressure, and systolic and diastolic BP (r = -0.10; r = -0.10; r = -0.13 and r = -0.09, respectively; p< or =0.01 for all). After adjustment, birth weight was inversely associated with baPWV. On average, baPWV decreased by 0.23 m/s (95% CI -0.44 to -0.03 m/s) for each 1 kg increase in birth weight. Birth weight (inversely) and baPWV were independently associated with systolic BP (B = -2.05; 95% CI -3.27 to -0.84 and B = 2.99; 95% CI 2.58 to 3.40 respectively). CONCLUSIONS: Lower birth weight is associated with higher baPWV. The link between birth weight and systolic BP may be partially explained by the association of birth weight with PWV.

The association of birth weight with developmental trends in blood pressure from childhood through mid-adulthood: the Bogalusa Heart study.

Low birth weight has been found to be associated with cardiovascular mortality and morbidity and with an adverse profile of several cardiovascular risk factors. The inverse association between birth weight and blood pressure was consistently reported from many populations. Using longitudinal data from the Bogalusa Heart Study (Louisiana), the authors investigated the association between birth weight and progression of blood pressure through early adulthood, comparing that relation between African Americans and Whites. Birth data of 2,275 participants, screened two or more times in the Bogalusa Heart Study between 1973 and 2001, were retrospectively obtained from birth certificates and were linked to their clinical, laboratory, and socioeconomic and lifestyle data in the Bogalusa Heart Study data sets. Birth weight was inversely associated with systolic blood pressure, diastolic blood pressure, and pulse pressure (p

The tobacco epidemic in Syria.

BACKGROUND: The Syrian Center for Tobacco Studies (SCTS) was established in response to the smoking epidemic in Syria and lack of local knowledge and expertise to confront it. OBJECTIVES: To (1) study tobacco use and local smoking practices using both qualitative and quantitative research methods; (2) develop and test an effective smoking cessation intervention for the Syrian environment; and (3) train Syrian researchers. METHODS AND RESULTS: The Aleppo Household Survey involved a representative sample of adults in Aleppo (2038 subjects, 45.2% men, mean age 35.3 years, response rate 86%). The prevalence of cigarette smoking was 56.9% among men and 17.0% among women, while the prevalence of waterpipe smoking was 20.2% among men and 4.8% among women. Daily use predominated for cigarettes (29.0%), while the opposite was seen in waterpipe use with 10.6% smoking occasionally. Interest in quitting was greater for cigarette than waterpipe smokers (74.0% v 48.6%), while quit rates were higher for waterpipe compared to cigarettes (28.2% v 16.5%). In-depth ethnographic interviews with smokers show that smoking waterpipe is often viewed as an aesthetic enjoyable experience, while smoking cigarettes is viewed as a mundane anxiety-relieving addiction. Clinical laboratory studies reveal that both waterpipe and cigarette smokers in Syria are exposed to smoke toxicants and exhibit dependence symptoms. CONCLUSIONS: All these data have been used iteratively to adapt smoking cessation interventions from developed countries to suit the local Syrian environment. Research conducted in the SCTS to date has provided a fertile training ground for Syrian researchers, as well as for the building of regional collaborations.

Mapping the health and environmental situation in informal zones in Aleppo, Syria: report from the Aleppo household survey.

OBJECTIVES: Despite large communities living in informal zones around major cities in Syria, there is currently no information on the health and environmental situations in these areas. From May to August 2004, the Syrian Center for Tobacco Studies (SCTS) conducted the first household survey aiming to provide a baseline map of main health problems and exposures affecting these communities in Aleppo, the second largest city in Syria (2,500,000 inhabitants). METHODS: Information on 1,021 participants randomly selected using stratified cluster sampling were available (46% males, mean age 34+/-11.7, age range 18-65 years, response rate 86%), including self-reported health/disability, exposures, and saliva cotinine measurement. RESULTS: Some positive findings include better than expected access to electricity, piped water, city sewage, and the use of propane for cooking. Particular areas of concern include high fertility rates, overcrowded housing conditions, and gender inequality in education and work. Household features likely to reflect negatively on residents' health include the use of diesel chimneys for heating and lack of smoking restrictions. Overall, residents of informal zones suffer from substantial physical and mental health problems and are exposed to high levels of indoor air pollution. All seem to affect women and the elderly disproportionately, while men are more affected by smoking, occupational respiratory exposures, and injuries. Both infectious and non-infectious respiratory outcomes were very common among study participants. Chronic and degenerative disease, including CVD and joint problems, were a source of substantial morbidity among the studied communities. CONCLUSIONS: This study highlights major health and environmental specificities of marginalized populations living in Aleppo, where women seem to bear a disproportionate burden of poor health and disability. Smoking and exposure to tobacco smoke seem among the major exposures facing these populations.

Origins of the "black/white" difference in blood pressure: roles of birth weight, postnatal growth, early blood pressure, and adolescent body size: the Bogalusa heart study.

BACKGROUND: The determinants of differences in blood pressure that emerge in adolescence between black Americans of predominantly African descent and white Americans of predominantly European descent are unknown. One hypothesis is related to intrauterine and early childhood growth. The role of early blood pressure itself is also unclear. We tested whether differences in birth weight and in carefully standardized subsequent measures of weight, height, and blood pressure from 0 to 4 or 5 years were related to black/white differences in blood pressure in adolescence. METHODS AND RESULTS: Two Bogalusa cohorts who had complete follow-up data on birth weights and early childhood and adolescent anthropometric and blood pressure measures were pooled. One hundred eighty-five children (48 black and 47 white boys and 41 black and 49 white girls) were followed up and studied after 15 to 17 years. Birth weights were a mean 443 and 282 g lower in black boys and girls, respectively, than in whites (P<0.001). Blood pressures in adolescence were 3.4/1.9 and 1.7/0.6 mm Hg higher, respectively, and tracked from early childhood. In regression analyses, birth weight accounted for the ethnic difference in adolescent blood pressure, which was also independently predicted, in decreasing impact order, by adolescent height, adolescent body mass index, and systolic blood pressure at 4 to 5 years and inversely by growth from 0 to 4 to 5 years. CONCLUSIONS: If these results can be replicated in larger and independent samples, they suggest that efforts to improve intrauterine growth in black infants as well as lessen weight gain in adolescence might substantially reduce excess high blood pressure/hypertension in this ethnic group.

Neoplastic diseases in Aleppo, Syria.

The objective of this study was to determine the pattern of occurrence and distribution of different types of neoplastic diseases in Aleppo, Syria, during one year. The study was set in Aleppo Governorate, Syria with a population of 2.7 million. Information about newly diagnosed cases of cancer was obtained from pathology labs ( =12) and general hospitals ( =5) in the city between August 1998 and August 1999. Pre-piloted charts were distributed to the labs and one of the labs staff was instructed on how to fill them. Information about benign tumours was also gathered. Between August 1998 and August 1999, 1802 new cases of cancer were diagnosed in Aleppo Governorate (970 in men and 832 in women), giving an overall crude incidence rate of 72.8 per 100 000 person-years for this population. The mean age of patients diagnosed with malignant tumours was 51.2 +/- 21.3 and 47.6 +/- 18.5 for males and females, respectively. In males, age-adjusted incidence rates were higher for bladder, leukaemia and lung cancers, in that order. In females age-adjusted incidence rates were higher for breast, uterus (+ cervix) and leukaemia. In conclusion, the presented data represent the first attempt to use standardized methodology to arrive at approximate estimates of the rate of occurrence of different cancers in Aleppo, Syria, and to characterize their patterns and distribution within the population. It calls for the importance of establishing a reliable cancer registry in Syria.

Socio-demographic determinants of smoking among low-income women in Aleppo, Syria.

OBJECTIVES: To determine the spread and sociodemographic correlates of smoking among low-income women in Aleppo, Syria. METHODS: A sample of 412 women was recruited from eight randomly selected primary care centres (total number 22) in Aleppo. The response rate was 97.2%, the mean age of participants was 28 (+/- 8.4) years, and married women constituted 88.3% of those studied. A special questionnaire was prepared for study purposes, and interviews were conducted in an anonymous, one-to-one fashion. RESULTS: Current smoking and daily smoking were found among respectively 16.5% and 7.5% of those investigated. Smokers were older, economically better off and came from smaller households (P < 0.05 for all) than non-smokers. They also were more likely to be non-Arabs, Christians, and city residents than nonsmokers (P < 0.05 for all). Mental morbidity and physical abuse were both associated with smoking among those investigated (P < or = 0.05). Smokers among married women were more likely to marry later, to marry a nonrelative, to be older at the birth of their first child, and were less likely to live with members of their husband's family (P < 0.05 for all). Multivariate predictors of smoking status among married women were race, residence, household, consanguinity, working, mental morbidity and physical abuse. CONCLUSIONS: Our data show that the level of smoking among poor women in this society is still low compared to that of men, but it is higher than that of women in other social strata studied. Women's smoking is found to be associated with a less tradition-oriented social profile.

The dynamics of cigarette smoking during military service in Syria.

SETTING: Understanding the dynamics of smoking in different populations is important to be able to tackle this problem rationally. DESIGN: A cross-sectional survey in a military school near Aleppo. Three groups of recruits were studied (total number of participants 596). The mean age of new draftees (group I) was 19.8 +/- 0.02 years, that of draftees after 6 months of service (group II) was 19.7 +/- 0.02 years, and that of draftees after 2 years of service (group III) was 21 +/- 0.02 years. RESULTS: Current and daily smoking was observed among respectively 46.1% and 34.1% of participants. Daily smokers smoked 17.8 +/- 0.7 cigarettes per day. Within a 2-year interval, current smoking increased from 43.2% to 55.1% (P = 0.01), and daily consumption from 15 to 23.8 cigarettes/day (P < 0.001). Smoking among draftee groups I and II was compared with age-matched male university students (314 first year students aged 19.1 +/- 0.04 years and 262 third year students aged 21.3 +/- 0.05 years). Current smoking among recruits was higher at entry and after 2 years than that of age-matched civilians (P < 0.001), but the 2-year increase was not (P > 0.05). CONCLUSION: Although military service in Syria is a scene of intensive smoking dynamics, it cannot be implicated in creating smokers.

Characterization of the smoking habit among high school students in Syria.

OBJECTIVES: To establish an accurate estimate of the prevalence of smoking among high school students in Aleppo-Syria and to characterize the smoking habit in this age group. DESIGN: A cross-sectional survey was performed, in which a self-administered questionnaire was distributed to 10th, 11th and 12th graders. SUBJECTS: A sample of 1587 students (784 males; mean age 16 years, and 803 females; mean age 15.9 years) was studied. This sample was drawn from 16 schools randomly selected from a total of 73 schools in the city. RESULTS: The prevalence of current smoking was 15.9% for males and 6.6% for females. The prevalence of daily smoking was 2.4% for males and 0.5% for females. Almost all smoking categories increased with age and grade. Forty seven percent of male daily smokers were heavy smokers. Peer influence was evident in all stages of the smoking process, especially for males. Parental smoking was also an important associated factor. The combination of parental and siblings smoking was the strongest predictor of the smoking status of the surveyed (OR: 4.4; 95% CI: 2.7-7). Thirty eight percent of male smokers and 47.2% of female smokers smoke out of boredom. Fifty one percent of male smokers were introduced to smoking by a friend. Forty percent of male smokers buy their cigarettes, while 56.6% of female smokers obtain their cigarettes from home. Logistic regression analyses showed that parental and siblings smoking were the most important predictors of ever trying to smoke or current smoking among male and female students. CONCLUSIONS: Our study shows that smoking is more frequent in male than female students. Parental and sibling smoking are the most important factors associated with smoking in this population, and peer influence is important particularly in the smoking-initiation stage. Pattern of smoking and associated factors differed substantially between males and females in this study.

The dynamics of tobacco smoking among male educated youths in Aleppo-Syria.

Understanding the dynamics of the smoking habit among youths at different stages of their development is crucial for the adoption of effective tobacco control policies. We looked at the smoking habits of 576 male university students and compared it with previously studied 555 male high school students in Aleppo-Syria, stratified into four groups with 2-year interval each. The prevalence of current smoking among 1st and 3rd year university students is 18.2% and 29.4% respectively, compared to 10.5% and 22.6% among 10th and 12th year high school students respectively. This study shows a late onset initiation of regular forms of smoking compared to patterns seen in developed countries.

Smoking behaviour among schoolteachers in the north of the Syrian Arab Republic.

Characterizing the smoking habit in specific populations is important for health planners and policy-makers. We studied the smoking patterns of schoolteachers in Saraqeb, Syrian Arab Republic and found that 52.1% of males and 12.3% of females were current smokers. Male daily smokers smoked 20 +/- 1 cigarettes per day, females 10 +/- 4. Males had smoked for, on average, 16 +/- 1 years, females for 9 +/- 4 years. Daily smokers buying foreign brands spent 22.0% of their monthly income on cigarettes, while those smoking local brands spent 12.2%. Most teachers who smoked did so openly at school. Smoking among teachers should receive attention because it is closely related to the attitudes and practices of young people towards smoking.

Smoking behaviour among schoolteachers in the north of the Syrian Arab Republic

Characterizing the smoking habit in specific populations is important for health planners and policy-makers. We studied the smoking patterns of schoolteachers in Saraqeb, Syrian Arab Republic and found that 52.1% of males and 12.3% of females were current smokers. Male daily smokers smoked 20 +/- 1 cigarettes per day, females 10 +/- 4. Males had smoked for, on average, 16 +/- 1 years, females for 9 +/- 4 years. Daily smokers buying foreign brands spent 22.0% of their monthly income on cigarettes, while those smoking local brands spent 12.2%. Most teachers who smoked did so openly at school. Smoking among teachers should receive attention because it is closely related to the attitudes and practices of young people towards smoking

Effects of environmental tobacco smoke on the health of children in the Syrian Arab Republic.

In the Syrian Arab Republic, studies on the effects of environmental tobacco smoke on children are lacking. We conducted a cross-sectional study on the effect of household environmental tobacco smoke on 1859 children under 12 years from both urban and rural areas. Parental and household smoking were associated with respiratory morbidity in the children. Parental smoking was associated with an increased likelihood of having sudden infant death syndrome in the family and was also associated with the presence of other smokers within households, which adds to children's exposure. To our knowledge this is the first study in the Syrian Arab Republic to report a clear association between environmental tobacco smoke and childhood respiratory morbidity.

Evaluation of mail survey for the assessment of tobacco use among adults.

Full text is available as a scanned copy of the original print version.

Evaluation of mail survey for the assessment of tobacco use among adults.

Full text is available as a scanned copy of the original print version.

Effects of environmental tobacco smoke on the health of children in the Syrian Arab Republic

In the Syrian Arab Republic, studies on the effects of environmental tobacco smoke on children are lacking. We conducted a cross-sectional study on the effect of household environmental tobacco smoke on 1859 children under 12 years from both urban and rural areas. Parental and household smoking were associated with respiratory morbidity in the children. Parental smoking was associated with an increased likelihood of having sudden infant death syndrome in the family and was also associated with the presence of other smokers within households, which adds to children's exposure. To our knowledge this is the first study in the Syrian Arab Republic to report a clear association between environmental tobacco smoke and childhood respiratory morbidity