The effect of price on cigarette consumption, distribution, and sale in Tehran: a qualitative study.

BACKGROUND: Appropriate increases in tobacco taxes and prices are an essential component of comprehensive tobacco control strategies. This study investigates factors related to the use, sale, and distribution of cigarettes in Iran, focusing on the relationship between cigarette price and its consumption. METHODS: This interview-based qualitative study was conducted among 20 participants, including cigarette smokers, retail shop owners, large-scale distributors, and an expert in tobacco control research. RESULTS: Seven themes were extracted from participant interviews, including the type and price of cigarette, the best time to sell cigarettes, profits from the sale of cigarette, affordability, rise in cigarette price and smokers' reaction to it, lobbying and black-market sales of cigarettes, and the sale and distribution of cigarettes across the country. Although the price of cigarettes in Iran has shown some increases in the past decade, the timing of these increases are not predictable and the limited amount of these increases has not reduced the use of cigarettes. Following a price increase, consumers are more likely to switch from buying packets to single cigarettes, or buy a less expensive brand, then to quit. Moreover, increases in prices may encourage smokers and sellers to buy a large number of cigarettes and store them for a rainy day. Another adverse effect may be increased smuggling of illicit cigarettes to balance the pressure caused by rising prices. CONCLUSIONS: Our findings highlight two important aspects concerning cigarette pricing in Iran. First is the change in the type of purchase from the whole box of cigarettes to the single stick cigarette or swapping to less expensive cigarettes. Second, increase in cigarette price (either through taxing or regular increases) could be offset by flooding smuggled cigarettes into the market. Therefore, in addition to raising cigarette prices, reducing cigarette consumption rates in Iran requires the development and effective implementation of regulatory policies to control cigarette smuggling, reduce purchasing, and subsequently curb the use of this leading cause of premature morbidity and mortality.

A Group-Based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers.

INTRODUCTION: Adolescence represents a critical period in which nicotine dependence (ND) symptoms are developing. Little is known about waterpipe (WP) smoking and developmental trajectories of ND criteria across adolescence. AIMS AND METHODS: Here, we aimed to identify ND trajectories from early- to late-adolescence in current (past 30 days) WP smokers and examine baseline correlates of each identified trajectory, using the International Classification of Diseases, 10th Revision (ICD-10). The analytical sample consisted of 278 current WP smokers from eight waves of an ongoing longitudinal cohort of eighth to ninth graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages 11-18. RESULTS: A group-based modeling approach yielded a four-class solution that best fit the data and reflected differences in the timing of ND onset during adolescence: no-onset of ND (43.9%), early-onset (16.2%), mid-onset (26.6%), and late-onset (13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio [aOR] = 4.08, 95% confidence interval [95% CI] = 1.01% to 16.53%) and siblings who smoke WP (aOR = 3.95, 95% CI = 1.08% to 14.42%), exposure to favorite WP-specific advertisements (aOR = 3.33, 95% CI = 1.03% to 10.85%), and being a novelty seeker (aOR = 1.12, 95% CI = 1.02% to 1.23%) were associated with early-onset of ND. Daily (aOR = 3.48, 95% CI = 1.08% to 11.23%) or weekly (aOR = 2.20, 95% CI = 1.05% to 4.62%) WP smokers (vs. monthly) and having higher stress level (aOR = 1.07, 95% CI = 1.00% to 1.14%) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR = 0.11, 95% CI = 0.02% to 0.82%) and spending less than 60 minutes on a WP smoking session (aOR = 5.62, 95% CI = 1.20% to 26.44%) were associated with late-onset ND trajectory class. CONCLUSIONS: Monitoring the development of ND trajectories among WP smokers may identify an individual as belonging to one of these four groups with distinct individual and socioenvironmental factors and allow the individual and health care providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions. IMPLICATIONS: The results from this study showed a four-class trajectory of ICD-10-ND criteria and suggested that every ND trajectory class during adolescence could have distinctive characteristics and therefore provides new insights into the process of ND in terms of when and what specific interventions are needed to curb the development of ND and long-term WP smoking among youth.

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.

Vaping while high: Factors associated with vaping marijuana among youth in the United States.

INTRODUCTION: The use of e-cigarette and other vaping devices have become popular among youth in US. In addition to nicotine, vaping devices can be used to vaporize marijuana. However, factors associated with vaping marijuana among youth remain unexplored. This study examined the rates of vaping marijuana and its correlates among youth in the US. METHODS: We conducted a cross-sectional analysis of survey data from the 2018 National Youth Tobacco Survey of middle-and high-schoolers who provided information regarding ever use of vaping devices to vape marijuana (n = 10,680). Multivariable regression model was conducted to assess factors associated with vaping marijuana. RESULTS: Overall, 26.2 % of participants reported ever vaping marijuana. High-schoolers [vs middle-schoolers; aOR = 2.16,95 %CI:1.76-2.67], Hispanics [vs Whites; aOR = 2.30,95 %CI:1.90-2.80], and Blacks [vs Whites; aOR = 1.42,95 %CI:1.04-1.92] were more likely to ever vape marijuana. Those who perceived e-cigarette as equally addictive to cigarettes, were less likely to ever vape marijuana [aOR = 0.79, 95 %CI:0.65-0.97]. In addition, those who reported ever trying cigarettes [aOR = 1.63,95 %CI:1.29-2.06], cigars [aOR = 2.62, 95 %CI:2.08-3.30], or hookah [aOR = 2.88,95 %CI:2.14-3.89] were more likely to ever vape marijuana. Lifetime frequency of e-cigarette use was associated with greater odds of ever vaping marijuana (p-values <0.001). CONCLUSION: Large numbers of youth in the US have ever vaped marijuana. Our findings indicate that sociodemographic characteristics, tobacco product use, frequency of e-cigarette use are important factors associated with vaping marijuana. Tobacco control campaigns targeted at curbing the use of e-cigarette and other vaping devices among youth in the US should be extended to address vaping substances other than nicotine such as marijuana.

The Syrian Center for Tobacco Studies-13 (SCTS-13): Psychometric evaluation of a waterpipe-specific nicotine dependence instrument.

BACKGROUND: Waterpipe tobacco smoking (WTS) has surged globally among young people and causes nicotine dependence (ND). No existing ND instruments are sensitive to waterpipe-specific features of ND and early stages of use. METHODS: We conducted a psychometric scale evaluation among 192 current waterpipe smokers, initially averaging 15 years of age, recruited from schools in Beirut, Lebanon, and assessed 4 times, 6 months apart. Twenty eight self-report items tapping multiple features of ND were submitted to exploratory and confirmatory factor analyses (EFA and CFA) to reduce items and verify factor structure. Convergent validity was assessed with the Lebanese Waterpipe Dependence Scale and the Hooked on Nicotine Checklist, and discriminant validity with the Depressive Symptom Scale and Adolescent Life Events Stress Scale. Concurrent and predictive validity measures included smoking status and intensity (amount, frequency, session duration, and change in frequency), quitting interest and success, perceived addiction, and smoking alone. RESULTS: The EFA yielded a single factor, 13 item solution (named the Syrian Center for Tobacco Studies [SCTS]-13) that explained 91% of variance in responses, was internally consistent (Cronbach's alpha and McDonald's omega = 0.87), and captured several positive reinforcement, negative reinforcement, and social/sensory-related features of ND. The CFA indicated good model fit. The SCTS-13 showed acceptable convergent and discriminant validity. Higher SCTS-13 scores predicted current waterpipe and dual (waterpipe and cigarette) smoking, greater intensity of use, less interest in quitting, shorter duration of abstinence, greater perceived addiction, and smoking alone (vs. socially). CONCLUSION: The SCTS-13 is a promising brief, waterpipe-specific ND instrument.

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers.

INTRODUCTION: Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers. METHODS: We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes. RESULTS: Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99). CONCLUSIONS: A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted.

Flavored Versus Nonflavored Waterpipe Tobacco: A Comparison of Toxicant Exposure, Puff Topography, Subjective Experiences, and Harm Perceptions.

INTRODUCTION: Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers' experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers' toxicant exposure, smoking topography, subjective experiences and harm perception. METHODS: Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception. RESULTS: Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco. CONCLUSIONS: Limiting tobacco flavor has a substantial effect on WP smokers' nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth. IMPLICATIONS: This study highlights the important role of flavor in shaping WP smokers' experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.

Correlates of poly-tobacco use among youth and young adults: Findings from the Population Assessment of Tobacco and Health study, 2013-2014.

INTRODUCTION: Poly-tobacco use is common among youth and young adults. This study examined sociodemographic, tobacco-related, and substance use characteristics of poly-tobacco use compared to mono-tobacco use among youth and young adults (12-34 years) in the United States. METHODS: We conducted a descriptive analysis by age-group of 12898 youth (12-17 years), 8843 younger young adults (18-24 years), and 6081 older young adults (24-34 years) from the 2013-2014 Population Assessment of Tobacco and Health study. Multiple logistic regression modeling was conducted to assess the sociodemographic, tobacco-related, and substance use associations with current (past 30 days) tobacco use on a binary scale (poly- versus mono-tobacco use) among tobacco users. RESULTS: Between 2013 and 2014, 3.6% of youth, 21.7% of younger young adults, and 15.8% of older young adults were current poly-tobacco users in the general population. In the regression analyses, among youth tobacco users, heavy drinking was the only factor associated with higher odds of poly-tobacco use. Factors associated with higher odds of poly-tobacco use among younger young adults included being male, having less than high school diploma or GED, residing in the South, having 2 and ≥3 quit attempts, heavy drinking, and marijuana use. Residing in the South, older ages of exposure to tobacco use, and marijuana use were associated with higher odds of poly-tobacco use among older young adults. CONCLUSIONS: Regardless of tobacco product type, poly-tobacco use was common among youth and young adults. Interventions designed to address factors associated with poly-tobacco use among youth and young adults are warranted.

Does education modify the effect of ethnicity in the expression of ideal cardiovascular health? The Baptist Health South Florida Employee Study.

BACKGROUND: Despite the progress made to decrease risk factors for cardiovascular diseases, disparities still exist. We examined how education and ethnicity interact to determine disparities in cardiovascular health (CVH) as defined by the American Heart Association. HYPOTHESIS: Education modifies the effect of ethnicity on CVH. METHODS: Individual CVH metrics (smoking, physical activity, body mass index, diet, total cholesterol, blood pressure, and blood glucose) were defined as ideal, intermediate, or poor. Combined scores were categorized as inadequate, average, or optimal CVH. Education was categorized as postgraduate, college, some college, and high school or less; ethnicity was categorized as white, Hispanic, black, and other. Main and interactive associations between education, ethnicity, and the measures of CVH were calculated with multinomial logistic regression. RESULTS: Of 9056 study participants, 74% were women, and mean age was 43 (±12) years. Over half were Hispanic, and two-thirds had at least a college education. With postgraduate education category as the reference, participants with less than a college education were less likely to achieve ideal status for most of the individual CVH metrics, and also less likely to achieve 6 to 7 ideal metrics, and optimal CVH scores. In most of the educational categories, Hispanic participants had the highest proportion with optimal CVH scores and 6 to 7 ideal metrics, whereas black participants had the lowest proportion. However, there were no statistically significant interactions of education and ethnicity for ideal CVH measures. CONCLUSIONS: Higher educational attainment had variable associations with achieved levels of ideal CVH across race/ethnic groups. Interventions to improve CVH should be tailored to meet the needs of target communities.

Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study.

INTRODUCTION: Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth. METHODS: Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥3 criteria during 12months). RESULTS: Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing≥1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥10 vs. <4 waterpipes; Hazard ratio (HR)=2.05, 95% CI: 1.52-2.58, p=0.007), and session length (>60min vs. <30min; HR=2.87, 95% CI: 2.83-2.91, p=0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥10 vs. <4 waterpipes; HR=2.56, 95% CI: 1.89-3.22, p=0.006), and smoking every day/almost every day vs. less than once weekly (HR=2.86, 95% CI: 2.12-3.60, p=0.007). CONCLUSIONS: Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers.

Curiosity and susceptibility to cigarette smoking among cigarette-naïve, waterpipe smoking US youth: National Youth Tobacco Survey, 2014.

INTRODUCTION: Waterpipe smoking is harmful and addictive and can be a gateway to cigarette smoking. This study examined the association between curiosity and susceptibility to cigarette smoking among cigarette-naïve US youth who smoke waterpipe using cross-sectional data from the National Youth Tobacco Survey, 2014. METHODS: Susceptibility to cigarettes was assessed using a composite index of three questions: 'Do you think you will smoke a cigarette in the next year?', 'Do you think that you will try a cigarette soon?', and 'If one of your best friends were to offer you a cigarette, would you smoke it?'. Curiosity was assessed by one question: 'Have you ever been curious about smoking a cigarette?'. RESULTS: Among current waterpipe smokers, 48.5% (95% CI: 43.1-53.9) were susceptible to cigarettes and 42.6% (95% CI: 36.5-48.9) were curious about cigarettes. Overall, 45.1% (95% CI: 38.9-51.4) and 46.5% (95% CI: 40.2-52.8) of those living with a waterpipe smoker were susceptible and curious about cigarettes, respectively. Current waterpipe smokers had significantly higher odds of susceptibility to cigarettes (aOR=1.5, 95% CI: 1.1-2.3, p<0.04), but not for curiosity about cigarettes (aOR=1.2, 95% CI: 0.83-1.70, p=0.3). CONCLUSIONS: Initiation of cigarettes among adolescents who smoke waterpipe can be due to increasing susceptibility to cigarette smoking rather than increasing curiosity about cigarettes.

Smoking Cessation and Changes in Body Mass Index: Findings From the First Randomized Cessation Trial in a Low-Income Country Setting.

BACKGROUND: In high-income countries, quitting cigarette smoking is associated with weight gain, which can reduce motivation to abstain. Whether smoking cessation is associated with weight gain in a low-income country context has never been investigated. We aimed to determine the post-cessation changes in body mass index (BMI) and its predictors among smokers who received a smoking cessation intervention in a low-income country setting. METHODS: We performed post hoc analyses of data from 269 smokers who participated in a two-group, parallel-arm, double-blind, placebo-controlled randomized trial of combined nicotine replacement therapy (NRT) and behavioral counseling in primary care clinics in Aleppo, Syria. We used generalized estimating equation modeling to identify predictors of changes in BMI at 6 weeks and 6- and 12-month follow-ups after quit date. RESULTS: The mean pre-cessation BMI of the sample was 27.9kg/m2 (SD = 5.2). Over 12 months of follow-up, BMI of smoking abstainers averaged 1.8 BMI units (approximately 4.8kg) greater than non-abstainers (p = .012). Throughout the study, greater BMI was associated with being female (p = .048), reporting smoking to control weight (p < .001) and having previously failed to quit due to weight gain (p = .036). CONCLUSION: Similar to findings from high-income countries, smoking cessation in Syria is associated with weight gain, particularly among women and those who have weight concerns prior to quitting. This group of smokers may benefit from tailored cessation interventions with integrated body weight management elements that take into consideration the prevailing local and cultural influences on diet and levels of physical activity. IMPLICATIONS: This study provides the first evidence regarding post-cessation changes in BMI among smokers who attempt to quit in a low-income country setting. Our findings advance knowledge regarding post-cessation weight gain and offers insight for researchers and clinicians to identify smokers at higher risk of post-cessation weight gain. This information will help in delivering interventions that take into account the prevailing cultural influence on diet and physical activity and will ultimately help in designing future tailored cessation programs in Syria and other low-income countries with similar cultural background and level of development.

Correlates of nicotine dependence among adolescent waterpipe smokers.

INTRODUCTION: Waterpipe smoking is addictive and its use is increasing globally among youth, yet little is known about the factors associated with nicotine dependence (ND) among waterpipe smokers. We investigated the factors associated with ND symptoms among a sample of Lebanese adolescents who smoke a waterpipe. METHODS: We collected data on factors potentially associated with ND (individual, socio-demographic, environmental, smoking patterns) among 160 current (past 30days) waterpipe smokers recruited from 8th and 9th school grades in Lebanon. We assessed the loss of autonomy over tobacco using the Hooked on Nicotine Checklist (HONC), ND using the International Classification of Diseases, 10th revision (ICD-10), and the number of ND symptoms endorsed. RESULTS: Depressive symptoms, lower self-esteem, and having at least one sibling who smokes a waterpipe were associated with the presence of ND symptoms, while enrollment in public schools, smoking a waterpipe ≥30min per session, and believing that cigarette smoking is harmful to health were associated with endorsement of a higher number of ND symptoms. Smoking a whole waterpipe head without sharing and being in 9th grade in this study were associated with the presence and endorsement of a higher number of ND symptoms. CONCLUSIONS: We identified specific social and psychological characteristics, waterpipe smoking patterns, and beliefs about harmful effects of smoking associated with the presence of ND among adolescent waterpipe smokers. Considering these factors when planning policies to prevent ND among waterpipe smokers is warranted.

Early symptoms of nicotine dependence among adolescent waterpipe smokers.

BACKGROUND: Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon. METHODS: Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon. RESULTS: Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND. CONCLUSIONS: Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review.

Objectives More than 10 % of pregnant women in the United States (U.S.) suffer from depression, which has far-reaching consequences on maternal and fetal well-being. There is conflicting evidence regarding the prevalence of antenatal depression among different race and ethnic groups. This systematic review aimed to summarize the existing literature concerning racial/ethnic disparities in the prevalence and correlates of antenatal depression in the U.S. Methods PubMed, CINAHL and PsycINFO databases were searched online for research studies published in English in peer-reviewed journals until March 2015, using a pre-designed search strategy. Eligibility was determined using pre-specified criteria; and quality was assessed. Results Forty-one (41) articles met the criteria; 13 were cross-sectional, and 21 were longitudinal studies. Overall, the prevalence of antenatal depression was 10-30 %; it was higher among non-Hispanic blacks (NHBs) and Hispanics, compared to non-Hispanic whites (NHWs). Few studies looked at the correlates of depression by race/ethnicity. Among employed women, higher depression scores were observed among NHBs, compared to NHWs; while there was no racial difference among unemployed women. Racial difference and race-employment interaction disappeared once discrimination was accounted for. In another study, higher parity, higher stress, and lower self-esteem were significant correlates of depression among NHBs, while less satisfaction with social support, and higher stress predicted higher depression scores among NHWs and Hispanics respectively. Conclusions The findings of our review suggest that not only is antenatal depression a major public health issue that needs to be addressed, but different racial/ethnic groups seem to differ in their vulnerability and risk factors.

Predictors of adherence to pharmacological and behavioral treatment in a cessation trial among smokers in Aleppo, Syria.

INTRODUCTION: The development of evidence-based smoking cessation programs is in its infancy in developing countries, which continue to bear the main brunt of the tobacco epidemic. Adherence to treatment recommendations is an important determinant of the success of smoking cessation programs, but little is known about factors influencing adherence to either pharmacological or behavioral treatment in developing countries settings. Our study represents the first attempt to examine the predictors of adherence to cessation treatment in a low-income developing country. METHODS: Predictors of adherence to pharmacological and behavioral treatment were identified by analyzing data from a multi-site, two-group, parallel-arm, double-blind, randomized, placebo-controlled smoking cessation trial in primary care clinics in Aleppo, Syria. Participants received 3 in-person behavioral counseling sessions plus 5 brief follow-up phone counseling sessions, and were randomized to either 6 weeks of nicotine or placebo patch. RESULTS: Of the 269 participants, 68% adhered to pharmacological treatment, while 70% adhered to behavioral counseling. In logistic regression modeling, lower adherence to pharmacological and behavioral treatment was associated with higher daily smoking at baseline, greater withdrawal symptoms, and perception of receiving placebo instead of active nicotine patch. Women showed lower adherence than men to behavioral treatment, while being assigned to placebo condition and baseline waterpipe use were associated with lower adherence to pharmacological treatment. CONCLUSION: Adherence to cessation treatment for cigarette smokers in low-income countries such as Syria may benefit from integrated cessation components that provide intensive treatment for subjects with higher nicotine dependence, and address concurrent waterpipe use at all stages.

The global epidemiology of waterpipe smoking.

OBJECTIVES: In the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become a global phenomenon. In this review, we provide an updated picture of the main epidemiological trends in waterpipe smoking globally. DATA SOURCES: Peer-reviewed publications indexed in major biomedical databases between 2004 and 2014. Search keywords included a combination of: waterpipe, hookah, shisha along with epidemiology, patterns, prevalence and predictors. We also used different spellings of waterpipe terms commonly used. STUDY SELECTION: The focus was on studies with large representative samples, national data or high-quality reports that illuminated aspects of the epidemiology and trends in waterpipe smoking. DATA EXTRACTION: Multiple researchers extracted the data independently and collectively decided on the most important and pertinent studies to include in the review. DATA SYNTHESIS: Waterpipe smoking has become a global phenomenon among youth. The global waterpipe epidemic is likely driven by (1) the introduction of manufactured flavoured tobacco (Maassel); (2) the intersection between waterpipe's social dimension and thriving café culture; (3) the evolution of mass communication media; (4) the lack of regulatory/policy framework specific to the waterpipe. Waterpipe smoking is becoming the most popular tobacco use method among youth in the Middle East, and is quickly gaining popularity elsewhere. Important patterns of waterpipe smoking include the predominance among younger, male, high socioeconomic, and urban groups. Intermittent and social use are also noted patterns. CONCLUSIONS: Waterpipe smoking has become a global public health problem. Developing surveillance, intervention and regulatory/policy frameworks specific to the waterpipe has become a public health priority.

Syria: health in a country undergoing tragic transition.

OBJECTIVES: To document the ongoing destruction as a result of the tragic events in Syria, to understand the changing health care needs and priorities of Syrians. METHODS: A directed examination of the scientific literature and reports about Syria before and during the Syrian conflict, in addition to analyzing literature devoted to the relief and rebuilding efforts in crisis situations. RESULTS: The ongoing war has had high direct war casualty, but even higher suffering due to the destruction of health system, displacement, and the breakdown of livelihood and social fabric. Millions of Syrians either became refugees or internally displaced, and about half of the population is in urgent need for help. Access to local and international aid organizations for war-affected populations is an urgent and top priority. CONCLUSIONS: Syrians continue to endure one of the biggest human tragedies in modern times. The extent of the crisis has affected all aspects of Syrians' life. Understanding the multi-faceted transition of the Syrian population and how it reflects on their health profile can guide relief and rebuilding efforts' scope and priorities.

Human papillomavirus vaccine uptake among males 11-26 years in United States: findings from the National Health and Nutrition Examination Survey, 2011-2012.

Anogenital human papillomavirus (HPV) infection is the leading sexually transmitted infection in the United States. In October 2011, the quadrivalent HPV vaccine (HPV4) was recommended for males in the U.S. We analyzed a subsample of 11­26 year old (N = 1012) males, from the National Health and Nutritional Examination Survey 2011­2012 dataset, to examine HPV vaccine uptake. The initiation rates in the 11­17 years and the 18­26 years age-groups were 10.7% (95% confidence interval (CI): 8.09­16.6%) and 5.5% (95%CI: 3.1­9.5%) respectively. The corresponding HPV vaccine completion rates were 39.3% (16.7­67.7%) for the 11­17 year old males and 59.1% (37.2­77.6) for the 18­26-year-old males. Despite a slight increase, HPV vaccine uptake remained low among males. These findings can help in HPV vaccination policy in the United States, with a focus on informational messages directed toward young males and their parents in order to increase uptake of HPV vaccine.