"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon.

INTRODUCTION: Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. AIMS AND METHODS: We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. RESULTS: Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories. CONCLUSIONS: Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. IMPLICATIONS: Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.

Changes in Attitude to Waterpipe Tobacco Smoking among Youngsters in Eastern Province, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: A growing number of epidemiological evidence suggests a significant increase in waterpipe tobacco smoking, and its potential to become a major public health concern in most Arabic countries, including Saudi Arabia. METHODS: A cross-sectional study was carried out to assess the prevalence of intention to quit among ever users of waterpipe and intention to start among the never users. The study also investigated the barriers that may prevent users from quitting or trigger the nonusers to start waterpipe smoking. The study consisted of 464 university students from Eastern Province, Saudi Arabia. RESULTS: One hundred and sixty-eight (36.2%) participants were responded that they had WTS at least one time in the past. Among the ever users of WTS, 120 (71.4%) participants had made an attempt or more to quit WTS in the past, 64 (38.1%) had made more than one attempt, and nearly two-third expressed the intention to quit WTS in the future. Forty (13.5%) out of 296 never-users expressed their intention to start WTS in the future. The study further showed that peer influence, social acceptance, and risk perception were significant predictors of intention to start or stop WTS among students. CONCLUSION: It is promising that substantial users have the intention to discontinue WTS, though a fraction of never users wish to try WTS in the future.
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Comparison of Water Pipes vs Other Modes of Cannabis Consumption and Subsequent Illicit Drug Use in a Longitudinal Cohort of Young Swiss Men.

Importance: There are concerns that the use of water pipes to consume cannabis is associated with increased risks of engaging in more addictive behaviors. Objective: To examine whether consuming cannabis with a water pipe was associated with later consumption of other illicit drugs compared with not using a water pipe. Design, Setting, and Participants: The Cohort Study on Substance Use Risk Factors (C-SURF) was a population-based study, recruiting 5987 Swiss men aged 18 to 25 years from 3 of 6 Swiss Armed Forces recruitment centers (response rate: 79.2%). The baseline assessment (t0) was done from 2010 to 2012, first follow-up (t1) from 2012 to 2014, and second follow-up (t2) from 2016 to 2018. Our sample included men who participated in both t0 and t2 assessments and used cannabis but no other illicit drugs at t0. Data analysis was performed from July 2020 to January 2021. Exposures: Cannabis use frequency and route of administration from self-administered questionnaires completed at t0 and t2. Main Outcomes and Measures: Outcome measures were initiation of illicit drug use and cannabis use disorder, identified by the Cannabis Use Disorder Identification Test. To examine whether water pipe use at t0 was associated with illicit drug use at t2, multivariable logistic regression analysis was performed. Results: Among 1108 Swiss male cannabis users who did not use other illicit drugs at t0, the mean (SD) age was 20 (1.2) years, 617 (55.7%) were from Switzerland's French-speaking region, and 343 (30%) used water pipes to consume cannabis. Water pipe users at t0 were more likely to use other illicit drugs at t2 compared with water pipe nonusers (adjusted odds ratio [aOR], 1.54; 95% CI, 1.10-2.16). The odds of using middle-stage drugs (including stimulants, hallucinogens, and inhaled drugs) at t2 were increased for water pipe users (aOR, 1.61; 95% CI, 1.13-2.29). Water pipe use at t0 was not associated with cannabis use disorder at t2 after adjusting for cannabis use frequency. Conclusions and Relevance: This cohort study's results suggest that, among Swiss young men, water pipe use is associated with other illicit drug use later in life, particularly middle-stage illicit drugs. Preventive programs must focus on the potential of later harm to cannabis users who use water pipes but have not yet started taking other illicit drugs.

Sociocultural factors contributing to waterpipe tobacco smoking among adolescents and young adult women: a qualitative study in Iran.

Purpose: Waterpipe tobacco smoking (WTS) is currently a serious and growing public health threat in the world, especially in adolescents and young women. The aim of the study was to explore sociocultural factors contributing to WTS among adolescents and young adult women in Iran. Methods: This qualitative study was conducted from August 2017 to January 2019 in Isfahan and Hamadan cities, Iran; it included 13-30-year-old females with experience of WTS. For data collection, in-depth semi-structured personal interviews were conducted at participants' preferred time and place. Concurrent with data collection, data were analysed through conventional content analysis. Results: The study participants described the various sociocultural factors contributing to WTS. These factors were categorized into four following main categories: waterpipe glamorization by its producers and sellers, media advertisement or silence, common sociocultural traditions, and governmental policies and regulations. Conclusion: A wide range of sociocultural factors affects WTS among Iranian adolescents and young adult women. Therefore, interdisciplinary multidimensional strategies are needed for WTS management and prevention among these at-risk groups. Public education, strict supervision of tobacco import, export, and selling, ample employment opportunities for young people and effective leisure time management are essential to reduce WTS.Abbreviation WTS: Waterpipe Tobacco Smoking; MPOWER: Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco.

Waterpipe Nicotine Dependence and Depressive Symptoms among Adolescent Waterpipe and Dual Users.

Background: Waterpipe nicotine dependence and its association with depressive symptoms and dual usage among adolescents are currently not examined in the literature. Adolescents are a vulnerable population that is susceptible to depression and initiation of tobacco use. We aim, in this novel study, to assess the association between depressive symptoms and waterpipe nicotine dependence among adolescents in Jordan, evaluate the association between waterpipe smoking status (waterpipe smoker vs. dual user) and waterpipe nicotine dependence, and assess the internal validity of the Waterpipe Nicotine Dependence Scale (WNDS). Method: A cross-sectional study among adolescents of grade 9th to 12th in Jordan was conducted through multistage cluster random sampling. The self-reported Arabic Youth Tobacco Use Composite Measure Questionnaire (YTUCM) was used to collect the surveys that include demographic information, smoking status, and the WNDS to assess waterpipe nicotine dependence and depressive symptoms. Multiple linear regression and the t-test were used to analyze the data. Findings. One thousand three hundred and three surveys were collected, of which 1082 were included in the study (443 males and 639 females). 64.9% of the sample were nontobacco users, while 20.1% were waterpipe- (WTP-) only smokers, 11.4% were dual users, and 3.7% were cigarettes-only users. After adjusting for weights, 66.6% were nonsmokers, 19.2% were WTP-only smokers, 10.2% were dual users, and 3.9% were cigarettes-only smokers. Using multiple linear regression, depressive symptoms were significantly associated with WTP nicotine dependence (ß 0.618), upon adjusting for confounders. Furthermore, dual users were associated with higher WTP nicotine dependence (ß 12.034) compared to WTP-only smokers after adjusting for confounders. Cronbach's alpha for the WNDS was 0.955. Conclusions: Our study shows that there is a statistically significant association between depressive symptoms and WTP nicotine dependence and higher dependence among dual users compared to WTP-only smokers. The WNDS can be a useful tool to assess WTP nicotine dependence with high internal consistency. However, a longitudinal study is needed to further understand the association and temporality between the depressive symptoms and WTP nicotine dependence. Additionally, research is needed to shorten the WNDS while maintaining high internal consistency and assess the external validity of the WNDS and the short- and long-term consequences of dual usage.

Cigarette and Hookah Smoking in Adolescent Students using World Health Organization Questionnaire Global Youth Tobacco Survey (GYTS): A Pilot Study in Varamin City, Iran in 2016.

BACKGROUND AND OBJECTIVES: Clues show that a large number of toxic agents, including carcinogenic, heavy metals, other particles, and high levels of nicotine, are effectively delivered through cigarette and hookah smoking. A pilot study was carried out in Varamin city, Iran in 2016 aimed to determine status of cigarette and hookah smoking in adolescent students using, Global Youth Tobacco Survey (GYTS) questionnaire. METHODS: It was a cross-sectional study. At the first, of 63 Varamin city schools' using cluster sampling, 48 schools were considered as primary clusters and 4 schools were selected randomly as sample clusters and students with 7, 8 and 9 years of education were studied. The total number of registered students was 1,108 and 1,075 responded to the study questionnaire. The main tool for collecting information used in this study was the GYTS questionnaire developed by the World Health Organization, was completed by subjects. RESULTS: Totally, 479 (44.6%) students were boys and 596 (55.4%) were girls. Of 1,075 subjects the number of students at 7, 8 and 9 years education was 369 (34.3%), 362 (33.7%) and 344 (32.0%) respectively. The cigarette and hookah smoking using experience among the population was 9.2% and 25.5 respectively. Regarding the averages of the total score, although students have a relatively good attitude and specially behavioral intention (72% and 88% of the total score respectively), but only 47% of the total knowledge score by boys and 51% by girls, shows the average level of students' awareness related the undesirable effects of smoking. CONCLUSIONS: Considering that one out of four students experienced cigarette and hookah smoking. Nearly half of the students are exposed to cigarette smoke at home or outdoors. The state of cigarette and hookah smoking in the country is alarming among school students.

Determinants of hookah smoking among men in the coffee houses: an application of socio-ecological approach.

BACKGROUND: Tobacco smoking is the second leading cause of death and is closely linked to fatal diseases. Hookah Smoking (HS) is a traditional way to smoke tobacco, especially in the Eastern Mediterranean region that is constantly rising around the world. This study aimed to evaluate the different levels of personal, interpersonal and social HS in Iranian urban men and determine the most important predictors of the levels through applying the socio-ecological approach (SEA). METHODS: This study was conducted in the coffee houses of Hashtrud and Qarah Aghaj counties in East Azerbaijan, Iran. Data collection was conducted from the entire coffee house (n = 18) from April to June 2017. Systematic sampling was employed to recruit 266 men in the coffee house. A valid and reliable instrument was used to investigate the frequency of HS and its determinants based on SEA. The SEA consists of three levels: personal (age, education, employment, income, and perceived severity and sensitivity), interpersonal (perceived reward), and social level (social support) intended to assess HS determinants. Hierarchical regression was used to determine the predictive value of SEA levels and frequency of HS. RESULTS: The mean age of daily hookah smokers (once per day and more than once per day) were (26.8) significantly lower than those (30.4) smokes weekly (once a week or more than once a week). The hierarchical logistic regression model showed that in the first step individual variables significantly predict 25.1% HS. In the second and third level interpersonal and social levels of SEA explained HS 30.1 and 30.8%, respectively. CONCLUSION: This study found that age, income, education, and perceived reward were all important factors influencing HS among men youth. Application of SEA to determine the factors associated with HS could contribute in the development of a holistic prevention program.

Beliefs Regarding Waterpipe Smoking Among Iranian Men of Turkmen Ethnicity: A qualitative study conducted in Golestan Province.

OBJECTIVES: Waterpipe or hookah smoking has grown considerably in popularity over the past two decades; however, consumers often have misconceptions regarding this practice. This study aimed to determine common beliefs related to waterpipe smoking among Turkmen in Iran. METHODS: This qualitative study was conducted between February and June 2018 in Golestan Province, Iran, utilising data from a previously published study. A total of 26 male Turkmen waterpipe smokers of different ages, occupations and education levels underwent in-depth semi-structured interviews. A content analysis of beliefs regarding waterpipe smoking was performed. RESULTS: Five categories of beliefs were extracted during the content analysis, including beliefs related to addiction, health-related beliefs, preferential beliefs for waterpipe versus cigarette smoking, beliefs related to the social function of waterpipe smoking and beliefs attributed to waterpipe smoking. Several misconceptions were identified, including the idea that waterpipe smoking was not addictive, prevented the use of other more dangerous drugs (i.e. cannabis and opium) and was not as harmful as cigarette smoking. CONCLUSION: The results of this study indicate that Turkmen in Iran hold several misconceptions regarding the use of waterpipe smoking. Educational programmes are essential to correct such misconceptions and to control the prevalence of this habit in Iran.

Intention to quit water pipe smoking among Iranian women: a qualitative directed content analysis.

BACKGROUND: Water-pipe smoking is the most common type of tobacco used among Iranian women. The aim of this study was to explain women's perceptions of their intention for quitting water-pipe smoking based on the theory of planned behavior. METHODS: The study was a qualitative content analysis which was carried out over 4 months in 2016 in Tehran-Iran. The participants were 26 women ages 18 to 45-years-old who smoked water-pipe and were selected through snowball sampling. The study was performed in hookah cafes, parks, and homes. The data were collected through individual interviews. The interviews were open-ended questions based on the theory of planned behavior. Directed content analysis was used to analyze the data. RESULTS: Findings showed that women did not intend to quit water-pipe in that time. Main contributing factors influencing not having intention of cessation were positive attitude and false beliefs toward hookah smoking, as well as having peers and family members who smoked water-pipe or approved its use. Although most females realized the obstacles associated with hookah cessation, they believed that quitting water-pipe smoking was up to them and could control more barriers. CONCLUSION: Social pressure, positive attitude and false beliefs towards hookah smoking, as well as external and internal obstacles diminished women 's intention for cessation. Therefore, it is recommended to apply the theory of planned behavior into behavior change interventions in order to increase the intention to quit water-pipe smoking.

Factors contributing to the initiation of waterpipe tobacco smoking among Iranian women.

BACKGROUND: Using waterpipe is the most common method of tobacco consumption among Iranian females and the rate has significantly increased over the past few decades. AIMS: The purpose of this study was to determine the factors that contribute to the initiation of waterpipe tobacco smoking among females in Gorgan, Islamic Republic of Iran. METHODS: This cross-sectional study was conducted between March and June 2016 in Gorgan. Two hundred and six females who smoked waterpipe tobacco were recruited as participants using convenience and snowball sampling methods. Data were collected using a questionnaire examining the factors that facilitate initiation of waterpipe smoking among females. RESULTS: Positive attitudes towards waterpipe smoking and its availability were the most frequently reported factors contributing to its initiation among females (87.9%). Curiosity (80.1%) and waterpipe smoking among family members (70.9%) were also significant. The least frequently reported factor was "attracting other's attention and cooperation". CONCLUSION: A positive opinion, availability, curiosity and presence of waterpipe smoking among family members and relatives were the most signifcant factors that facilitated initiation of waterpipe smoking among females. To reduce its prevalence, it is recommended that intervention strategies be implemented to change attitudes and reduce access to waterpipe tobacco at family and social gatherings.

Flavor Preference and Systemic Immunoglobulin Responses in E-Cigarette Users and Waterpipe and Tobacco Smokers: A Pilot Study.

Electronic cigarette (e-cigarette) use has had an exponential increase in popularity since the product was released to the public. Currently, there is a lack of human studies that assess different biomarker levels. This pilot study attempts to link e-cigarette and other tobacco product usage with clinical respiratory symptoms and immunoglobulin response. Subjects completed surveys in order to collect self-reported data on tobacco product flavor preferences. Along with this, plasma samples were collected to test for immunoglobulin G (IgG) and E (IgE) levels. Our pilot study's cohort had a 47.9% flavor preference towards fruit flavors and a 63.1% preference to more sweet flavors. E-cigarette and traditional cigarette smokers were the two subject groups to report the most clinical symptoms. E-cigarette users also had a significant increase in plasma IgE levels compared to non-tobacco users 1, and dual users had a significant increase in plasma IgG compared to non-tobacco users 2, cigarette smokers, and waterpipe smokers. Our pilot study showed that users have a preference toward fruit and more sweet flavors and that e-cigarette and dual use resulted in an augmented systemic immune response.

Effectiveness of E-Learning Program in Preventing WP Smoking in Adolescent Females in West of Iran by Applying Prototype-Willingness Model: A Randomized Controlled Trial.

BACKGROUND: Given the increasing trend of Water pipe (WP) smoking in adolescent females, it is necessary to use effective educational strategies in preventing WP smoking in developing countries. We aimed to determine effectiveness of e-learning program in preventing WP smoking in adolescent females west of Iran using prototype-willingness model. STUDY DESIGN: A randomized controlled trial. METHODS: This study was performed on 221 adolescent females in Kermanshah City, Iran during 2019-2020. Multistage random sampling was used. Data collection tool included a researcher-made questionnaire based on prototype-willingness model. E-learning-based intervention program included 5 training sessions. Participants were followed up for 3 months after the intervention. The data were analyzed using SPSS software. RESULTS: The mean scores of attitude, subjective norms, prototype, intention, and behavioral willingness structures were similar in both experimental and control groups before the educational intervention. However, after educational interventions, mean scores of structures of positive attitude towards WP, subjective norms about WP smoking, positive prototype about WP smokers, intention, and behavioral willingness towards WP smoking were decreased in the experimental group. Moreover, frequency of WP smoking was decreased in the experimental group compared to the control group after the educational intervention (P=0.003). CONCLUSION: The use of e-learning-based interventions is an educational strategy for reducing WP smoking in adolescent females.

Effect of flavour manipulation on low and high-frequency waterpipe users' puff topography, toxicant exposures and subjective experiences.

BACKGROUND: Flavoured tobacco is one of the major factors behind the popularity of waterpipe (WP) smoking in the USA and internationally. The current study examined the impact of flavour manipulation on satisfaction, puff topography and toxicant exposure among high-frequency and low-frequency WP users. METHOD: This cross-over study was conducted among 144 current (past month) WP smokers reporting WP smoking less than once a week (low-frequency users; n=69) or at least once a week (high-frequency users; n=75) in the past 6 months. Participants attended two counterbalanced 45 min ad libitum smoking sessions that differed by flavour (preferred flavoured vs unflavoured tobacco), preceded by ≥12 hours of tobacco use abstinence. Outcome measures included puff topography, expired carbon monoxide (eCO), plasma nicotine and subjective measures. RESULTS: Both high-frequency and low-frequency WP users reported an enhanced smoking experience and greater interest in future use after smoking the flavoured compared with unflavoured tobacco (p<0.05 for all). High-frequency users, however, were more keen on smoking the flavoured tobacco in the future, had higher puffing parameters in general compared with low-frequency users (p<0.05 for all) and had no differences in eCO and plasma nicotine concentrations between the flavoured and unflavoured tobacco conditions (p>0.05 for all). On the other hand, low-frequency users had significantly greater eCO and plasma nicotine concentrations following smoking the unflavoured compared with flavoured tobacco condition (p<0.05 for all). CONCLUSIONS: Our results indicate that removing flavours will likely negatively affect WP satisfaction and future use and that such an effect will be more pronounced among high-frequency compared with low-frequency WP smokers.

The effect of flavoured and non-flavoured tobacco on subjective experience, topography and toxicant exposure among waterpipe smokers.

INTRODUCTION: Flavoured waterpipe (WP) tobacco is a major factor in the resurgence of WP smoking and a main attractant of WP use among youth. Yet, evidence of the effects of limiting flavour on WP smoker's experiences and exposures is limited. This study examined the impact of flavour manipulation on WP smokers' toxicant exposure and smoking experiences. METHOD: A total of 144 WP smokers attended two, 45 min ad libitum smoking sessions (flavoured vs non-flavoured tobacco) in a crossover design study. Participants completed a battery of questions assessing subjective smoking experiences. Exhaled carbon monoxide (eCO) and plasma nicotine concentrations were measured before and after the smoking sessions. Puff topography was recorded throughout the smoking sessions. RESULTS: Compared with the non-flavoured WP tobacco, participants reported enhanced subjective smoking measures of satisfaction and enjoyment following smoking flavoured WP tobacco (ps <0.05). Although participants spent a longer time smoking flavoured tobacco, they took on average larger puffs while smoking the non-flavoured tobacco (ps <0.05). Greater levels of eCO were recorded following the non-flavoured tobacco session (p<0.05) compared with flavoured tobacco. No significant differences were observed in plasma nicotine concentrations between the two tobacco conditions. WP harm perception was higher among participants after smoking non-flavoured WP tobacco compared with their preferred flavour (p<0.05). CONCLUSION: Smoking the flavoured tobacco product was associated with enhanced subjective experiences compared with the non-flavoured, suggesting a potential role for flavour regulation in reducing WP use. Mixed results were observed for toxicants exposure in relation to smoking flavoured compared with non-flavoured products suggesting the need for a more comprehensive assessment of the effects of other tobacco constituents and additives on toxicant exposure in WP smokers.

Sex and Polytobacco Use among Spanish and Turkish University Students.

Polytobacco use has become increasingly popular among young adults, particularly males, and can be defined as the concurrent use of regular cigarettes and other tobacco products (e.g., e-cigarettes). The present study investigated the use of legal smoking products (cigarettes, waterpipe and electronic cigarettes) among young adults (n = 355) in Spain and Turkey. The survey measured demographics, lifetime and past month tobacco use, waterpipe and e-cigarette use, whether waterpipes and e-cigarettes contained nicotine and reasons for using these substances. The majority of the Turkish (men = 80% and women = 63.9%) and Spanish sample (men = 61.4% and women = 69.3%) were polytobacco users. The most common reason for using e-cigarettes was "to experiment, to see what is like" (Turkish sample: men 66.7% and women 57.1; Spanish sample: men 72.7% and women 93.8%). The most common reason to use regular cigarettes was "to relax and relieve tension" (Turkish sample: men 88.9% and women 77.6%; Spanish sample: men 78.1% and women 76%), while for waterpipe users, the most common reason was "to experiment, to see what it is like" (Turkish sample: men 93.3% and women 80%; Spanish sample: men 78.9% and women 93.8%). The implications for prevention and future research are discussed.

The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study.

Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.

Respiratory health and quality of life in young exclusive, habitual smokers - a comparison of waterpipe smokers, cigarette smokers and non-smokers.

Purpose: Waterpipe (WP) use has become a global trend in young populations. However, there are few well-controlled studies focusing specifically on the chronic effects of exclusive WP use on young adults' respiratory health. We sought to compare in young adults the burden of respiratory symptoms in regular WP smokers (WPS) relative to regular cigarette smokers (CS, positive controls) and non-smokers (negative controls); and to evaluate differences in health-related quality of life between the three groups. Method: We implemented a cross-sectional survey in college campuses across four countries (Egypt, Jordan, Morocco and Oman). Purposive sampling was employed to identify habitual (regular) healthy WPS (smoked 3 or more WP per week for 3 or more years); CS (smoked 5 or more cigarettes daily for 3 or more years); and non-smokers. Respiratory symptoms were assessed using the European Community Respiratory Health Survey and the American Thoracic Society and the Division of Lung Diseases Questionnaire. Health-related quality of life was measured using the Short-Form 12. Demographic, environmental and lifestyle factors also were measured. Result: The analytic sample included 135 WPS, 303 CS, and 300 non-smokers. Either tobacco group had significantly greater proportions of males than the non-smoker group. A significantly lower proportion of non-smokers (than either tobacco group) was overweight or obese. Average numbers of reported respiratory symptoms were 5.1, 5.8, and 2.9 in WPS, CS, and non-smokers, respectively. In multivariable regressions controlling for environmental exposures, body mass index, and physical activity, WPS and CS exhibited significantly higher rates of respiratory symptoms than non-smokers (1.6 times greater and 1.9 times greater rate of respiratory symptoms than non-smokers, respectively). Non-smokers reported significantly higher scores for general health relative to either WPS or CS. Conclusion: Relative to their young non-smoking counterparts, young habitual WPS exhibit a significant burden of respiratory symptoms that is comparable to that observed with CS. Young WPS (and CS), despite their age, may be well on their way to developing respiratory disease.

Associations between frequency of cigarette and alternative tobacco product use and depressive symptoms: A longitudinal study of young adults.

The association between cigarette use and depression has been documented in many studies. Fewer studies have examined other tobacco products such as electronic cigarettes (e-cigarettes) and hookah that are used by young adults. This study examined whether increased frequency of use of these products was associated with depressive symptoms in a cohort of n = 5236 Texas college students followed from 2014 to 2017. To analyze the longitudinal data, a hierarchical model was used. Model results showed that increased frequency of single product use of cigarettes, refillable e-cigarettes and hookah was associated with depressive symptoms. Refillable and disposable e-cigarettes were examined separately and results did not provide evidence of a different association for each type of e-cigarette when cigarettes were not also used. Dual use of cigarettes with another product was also examined. Dual use was associated with higher depressive symptoms for most product combinations. However, infrequent dual use of disposable e-cigarettes and cigarettes may not be associated with depressive symptoms. Suggestions for further research are included.

Evaluating the predictive value of measures of susceptibility to tobacco and alternative tobacco products.

BACKGROUND: The "cigarette susceptibility index" has been adapted for other products, yet, the validity of these adapted measures-particularly among youth who have used other tobacco products-has not been evaluated. METHODS: We used prospective data from the Southern California Children's Health Study to evaluate the association of questionnaire measures assessing susceptibility to e-cigarette, cigarette, hookah and cigar/cigarillo/little cigar use at wave 1 (W1; 11th/12th grade) with subsequent initiation between W1 and W2 (16 months later, N = 1453). We additionally examined whether each effect estimate differed by use of other tobacco products at W1. RESULTS: Odds ratios, attributable risk%, and risk differences for product initiation among susceptible vs. non-susceptible youth were consistently higher among never users of any tobacco product than among youth with any tobacco use history. For example, susceptible (vs. non-susceptible) youth with no prior tobacco use had 3.64 times the odds of subsequent initiation of e-cigarettes (95%CI:2.61,5.09), while among users of another product, susceptible (vs. non-susceptible) youth had 1.95 times the odds of e-cigarette initiation (95%CI:0.98,3.89; p-interaction = 0.016). 60.4% of e-cigarette initiation among never users of any product could be attributed to susceptibility, compared to 19.8% among users of another product. The e-cigarette absolute risk difference between susceptible and non-susceptible youth was 21.9%(15.2,28.6) for never users, vs. 15.4%(0.2,30.7) for users of another product. CONCLUSION: Tobacco product-specific susceptibility associations with initiation of use at W2 were markedly attenuated among prior users of other products, demonstrating reduced utility for these measures among subjects using other products.

Adolescent Beliefs About Hookah and Hookah Tobacco Use and Implications for Preventing Use.

INTRODUCTION: Hookah tobacco use is popular among youths and there is evidence that perceived risks and normative beliefs are associated with hookah use. The aim of this study was to further examine associations between perceived risks of hookah use, normative beliefs, and lifetime hookah use among youths. METHODS: Participants were adolescents aged 12 to 17 years (n = 257, mean [standard deviation] age, 14.9 [1.6] years, 40% nonwhite, 66% female) attending well-visit checkups at an urban pediatric clinic. Participants completed a survey of measures of cigarette smoking, risk factors for smoking, hookah use, perceived risks, and normative beliefs. Analyses examined associations among lifetime hookah use, beliefs about hookah use, and other smoking risk factors. RESULTS: Overall, 15% of the sample had ever tried hookah smoking and 60% had ever tried cigarette smoking or were susceptible to cigarette smoking. Of those who had tried hookah smoking, 84% had also tried cigarettes or were susceptible to trying cigarettes (P < .001). One-third (33%) indicated that hookah smoking was less harmful than cigarettes, 38% indicated hookah smoking is less addictive than cigarettes, and 48% perceived that hookah smoking is somewhat or very socially acceptable among friends. In multivariable analyses adjusting for demographic and cigarette smoking-related factors, perceiving hookah use to be somewhat or very socially acceptable was associated with a significantly higher odds of ever having tried hookah smoking. CONCLUSION: The study findings indicate that stronger perceived social acceptability of hookah use is associated with a higher likelihood of trying hookah smoking among youths. These normative beliefs may be important targets of interventions aimed at preventing hookah use among youths.