Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking.

OBJECTIVE: Waterpipe tobacco smoking (WTS) is an emerging trend worldwide. To inform public health policy and educational programming, we systematically reviewed the biomedical literature to compute the inhaled smoke volume, nicotine, tar, and carbon monoxide (CO) associated with a single WTS session and a single cigarette. METHODS: We searched seven biomedical bibliographic databases for controlled laboratory or natural environment studies designed to mimic human tobacco consumption. Included studies quantified the mainstream smoke of a single cigarette and/or single WTS session for smoke volume, nicotine, tar, and/or CO. We conducted meta-analyses to calculate summary estimates for the inhalation of each unique substance for each mode of tobacco consumption. We assessed between-study heterogeneity using chi-squared and I-squared statistics. RESULTS: Sufficient data from 17 studies were available to derive pooled estimates for inhalation of each exposure via each smoking method. Two researchers working independently abstracted measurement of smoke volume in liters, and nicotine, tar, and CO in milligrams. All numbers included in meta-analyses matched precisely between the two researchers (100% agreement, Cohen's k=1.00). Whereas one WTS session was associated with 74.1 liters of smoke inhalation (95% confidence interval [CI] 38.2, 110.0), one cigarette was associated with 0.6 liters of smoke (95% CI 0.5, 0.7). One WTS session was also associated with higher levels of nicotine, tar, and CO. CONCLUSIONS: One WTS session consistently exposed users to larger smoke volumes and higher levels of tobacco toxicants compared with one cigarette. These computed estimates may be valuable to emphasize in prevention programming.

Sex Differences in Hookah-Related Images Posted on Tumblr: A Content Analysis.

Hookah tobacco smoking is prevalent, widespread, and associated with large amounts of toxicants. Hookah tobacco smoking may be viewed differently by males and females. For example, females have been drawn to types of tobacco that are flavored, milder, and marketed as more social and exotic. Individuals often use the growing segment of anonymous social networking sites, such as Tumblr, to learn about potentially dangerous or harmful behaviors. We used a systematic process involving stratification by time of day, day of week, and search term to gather a sample of 140 Tumblr posts related to hookah tobacco smoking. After a structured codebook development process, 2 coders independently assessed all posts in their entirety, and all disagreements were easily adjudicated. When data on poster sex and age were available, we found that 77% of posts were posted by females and 35% were posted by individuals younger than 18. The most prominent features displayed in all posts were references to or images of hookahs themselves, sexuality, socializing, alcohol, hookah smoke, and tricks performed with hookah smoke. Compared with females, males more frequently posted images of hookahs and alcohol-related images or references. This information may help guide future research in this area and the development of targeted interventions to curb this behavior.

Reigniting tobacco ritual: waterpipe tobacco smoking establishment culture in the United States.

INTRODUCTION: Waterpipe tobacco smoking (WTS) is an increasingly prevalent form of tobacco use in the United States. Its appeal may stem from its social, ritualistic, and aesthetic nature. Our aim in this study was to understand WTS as a social ritual with the goal of informing prevention efforts. METHODS: We conducted a covert observational study consisting of 38 observation sessions in 11 WTS establishments in 3 U.S. cities. Data collection was based on an established conceptual framework describing ritualistic elements of tobacco use. Iterative codebook development and qualitative thematic synthesis were used to analyze data. RESULTS: Atmospheres ranged from quiet coffee shop to boisterous bar party environments. While some children and older adults were present, the majority of clientele were young adults. Men and women were evenly represented. However, there were 19 occurrences of a male smoking by himself, but no women smoked alone. The vast majority (94%) of the clientele were actively smoking waterpipes. All 83 observed groups manifested at least 1 of the ritual elements of our conceptual framework, while 41 of the 83 observed groups (49%) demonstrated all 4 ritual elements. CONCLUSIONS: Despite its heterogeneity, WTS is often characterized by 1 or more established elements of a tobacco-related social ritual. It may be valuable for clinical and public health interventions to acknowledge and address the ritualistic elements and social function of WTS.

The LWDS-10J: reliability and validity of the Lebanon Waterpipe Dependence Scale among university students in Jordan.

INTRODUCTION: While the Lebanon Waterpipe Dependence Scale (LWDS-11) has shown promise in assessing dependence on waterpipe tobacco smoking (WTS) in Lebanon among adult users, it would be valuable to identify WTS addiction earlier and to explore reliability and validity of these items in other populations. METHODS: In 2010-2012, we conducted a multiyear survey of 5,853 students from 4 Jordanian universities. We measured WTS, sociodemographic data, and the LWDS-11 items. We conducted exploratory factor analysis with half of the sample and confirmed the resulting model using confirmatory factor analysis with the other half. We examined construct validity with regression models assessing associations between the modified scale and 5 constructs conceptually expected to be associated with dependence. RESULTS: WTS rates were 35% in the past 30 days and 56% ever. Principal-components analysis of LWDS items in the first half of the sample yielded 10 items representing 3 factors labeled physical dependence, relaxation/pleasure, and social aspects. Cronbach's α was .77 for the total scale and was .75, .70, and .67 for each individual subscale. Confirmatory factor analysis in a structural equation modeling framework confirmed good fit (root mean squared error of approximation = 0.068, and comparative fit index = 0.937). Dependence according to the resulting scale (LWDS-10J) was strongly associated with each of the 5 expected constructs, whether the dependent variable was treated as categorical or continuous. CONCLUSIONS: The LWDS-11 items exhibited a different factor structure in our sample. However, the modified scale (LWDS-10J) showed promising reliability and construct validity in this population.

Waterpipe smoking among U.S. university students.

INTRODUCTION: While cigarette use is declining, smoking tobacco with a waterpipe is an emerging trend. We aimed to determine the prevalence of waterpipe use in a large diverse sample of U.S. university students and to assess the association of waterpipe use with individual and institution-related characteristics. METHODS: We assessed students from 152 U.S. universities participating in the National College Health Assessment during 2008-2009. We used multivariable regression models to determine independent associations between individual and institutional characteristics and waterpipe tobacco use in the past 30 days and ever. RESULTS: Of 105,012 respondents included in the analysis, most were female (65.7%), White (71.2%), and attending public (59.7%) nonreligious (83.1%) institutions. Mean age was 22.1 years. A total of 32,013 (30.5%) reported ever using a waterpipe to smoke tobacco. Rates for current tobacco use were 8.4% for waterpipes, 16.8% for cigarettes, 7.4% for cigars (including cigarillos), and 3.5% for smokeless tobacco. Of current waterpipe users, 51.4% were not current cigarette smokers. Although current waterpipe use was reported across all individual and institutional characteristics, fully adjusted multivariable models showed that it was most strongly associated with younger age, male gender, White race, fraternity/sorority membership, and nonreligious institutions in large cities in the western United States. CONCLUSIONS: After cigarettes, waterpipe use was the most common form of tobacco use among university students. Because waterpipe use affects groups with a wide variety of individual and institutional characteristics, it should be included with other forms of tobacco in efforts related to tobacco surveillance and intervention.

A comparison of cigarette- and hookah-related videos on YouTube.

OBJECTIVE: YouTube is now the second most visited site on the internet. The authors aimed to compare characteristics of and messages conveyed by cigarette- and hookah-related videos on YouTube. METHODS: Systematic search procedures yielded 66 cigarette-related and 61 hookah-related videos. After three trained qualitative researchers used an iterative approach to develop and refine definitions for the coding of variables, two of them independently coded each video for content including positive and negative associations with smoking and major content type. RESULTS: Median view counts were 606,884 for cigarettes-related videos and 102,307 for hookah-related videos (p<0.001). However, the number of comments per 1000 views was significantly lower for cigarette-related videos than for hookah-related videos (1.6 vs 2.5, p=0.003). There was no significant difference in the number of 'like' designations per 100 reactions (91 vs 87, p=0.39). Cigarette-related videos were less likely than hookah-related videos to portray tobacco use in a positive light (24% vs 92%, p<0.001). In addition, cigarette-related videos were more likely to be of high production quality (42% vs 5%, p<0.001), to mention short-term consequences (50% vs 18%, p<0.001) and long-term consequences (44% vs 2%, p<0.001) of tobacco use, to contain explicit antismoking messages (39% vs 0%, p<0.001) and to provide specific information on how to quit tobacco use (21% vs 0%, p<0.001). CONCLUSIONS: Although internet user-generated videos related to cigarette smoking often acknowledge harmful consequences and provide explicit antismoking messages, hookah-related videos do not. It may be valuable for public health programmes to correct common misconceptions regarding hookah use.

US health policy related to hookah tobacco smoking.

OBJECTIVES: Although US cigarette smoking is decreasing, hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposure. We assessed how a representative sample of US tobacco control policies may apply to HTS. METHODS: We examined municipal, county, and state legal texts applying to the 100 largest US cities. We developed a summary policy variable that distinguished among cities on the basis of how current tobacco control policies may apply to HTS and used multinomial logistic regression to determine associations between community-level sociodemographic variables and the policy outcome variable. RESULTS: Although 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars, 69 of these cities have exemptions that allow HTS; 4 of the 69 have passed legislation specifically exempting HTS, and 65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation. CONCLUSIONS: Although three fourths of the largest US cities disallow cigarette smoking in bars, nearly 90% of these cities may permit HTS via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.

Role of video games in improving health-related outcomes: a systematic review.

CONTEXT: Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it also may be useful for therapeutic purposes. The goal of this study was to determine whether video games may be useful in improving health outcomes. EVIDENCE ACQUISITION: Literature searches were performed in February 2010 in six databases: the Center on Media and Child Health Database of Research, MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials. Reference lists were hand-searched to identify additional studies. Only RCTs that tested the effect of video games on a positive, clinically relevant health consequence were included. Study selection criteria were strictly defined and applied by two researchers working independently. Study background information (e.g., location, funding source); sample data (e.g., number of study participants, demographics); intervention and control details; outcomes data; and quality measures were abstracted independently by two researchers. EVIDENCE SYNTHESIS: Of 1452 articles retrieved using the current search strategy, 38 met all criteria for inclusion. Eligible studies used video games to provide physical therapy, psychological therapy, improved disease self-management, health education, distraction from discomfort, increased physical activity, and skills training for clinicians. Among the 38 studies, a total of 195 health outcomes were examined. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. Study quality was generally poor; for example, two thirds (66%) of studies had follow-up periods of <12 weeks, and only 11% of studies blinded researchers. CONCLUSIONS: There is potential promise for video games to improve health outcomes, particularly in the areas of psychological therapy and physical therapy. RCTs with appropriate rigor will help build evidence in this emerging area.

U.S. hookah tobacco smoking establishments advertised on the internet.

BACKGROUND: Establishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities. PURPOSE: To conduct a comprehensive, qualitative assessment of websites promoting these establishments. METHODS: In June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009-2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohen's κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used. RESULTS: The search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common. CONCLUSIONS: Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.

Associations between smoking and media literacy in college students.

Organizations recommend media literacy to reduce tobacco use, and higher media literacy has been associated with lower smoking among high school students. The relationship between smoking media literacy and tobacco use, however, has not been systematically studied among college students. The purpose of this study was to determine the association between smoking and smoking media literacy among college students. We conducted the National College Health Assessment (NCHA) at a large, urban university, adding six items measuring smoking media literacy. A total of 657 students responded to this random sample e-mail survey. We used multiple logistic regression to determine independent associations between smoking media literacy items and current smoking. The media literacy scale was internally consistent (alpha = 0.79). Of the respondents, 21.5% reported smoking cigarettes over the past 30 days. In a fully adjusted multivariate model, participants with medium media literacy had an odds ratio (OR) for current smoking of 0.45 (95% CI = 0.29, 0.70), and those with high media literacy had an OR for current smoking of 0.38 (95% CI = 0.20, 0.70). High smoking media literacy is independently associated with lower odds of smoking. Smoking media literacy may be a valuable construct to address in college populations.

Content analysis of tobacco, alcohol, and other drugs in popular music.

OBJECTIVE: To perform a comprehensive content analysis of substance use in contemporary popular music. DESIGN: We analyzed the 279 most popular songs of 2005 according to Billboard magazine. Two coders working independently used a standardized data collection instrument to code portrayals of substance use. OUTCOME MEASURES: Presence and explicit use of substances and motivations for, associations with, and consequences of substance use. RESULTS: Of the 279 songs, 93 (33.3%) portrayed substance use, with an average of 35.2 substance references per song-hour. Portrayal of substance use varied significantly (P < .001) by genre, with 1 or more references in 3 of 35 pop songs (9%), 9 of 66 rock songs (14%), 11 of 55 R & B/hip-hop songs (20%), 22 of 61 country songs (36%), and 48 of 62 rap songs (77%). While only 2.9% of the 279 songs portrayed tobacco use, 23.7% depicted alcohol use, 13.6% depicted marijuana use, and 11.5% depicted other or unspecified substance use. In the 93 songs with substance use, it was most often motivated by peer/social pressure (45 [48%]) or sex (28 [30%]); use was commonly associated with partying (50 [54%]), sex (43 [46%]), violence (27 [29%]), and/or humor (22 [24%]). Only 4 songs (4%) contained explicit antiuse messages, and none portrayed substance refusal. Most songs with substance use (63 [68%]) portrayed more positive than negative consequences; these positive consequences were most commonly social, sexual, financial, or emotional. CONCLUSIONS: The average adolescent is exposed to approximately 84 references to explicit substance use daily in popular songs, and this exposure varies widely by musical genre. The substance use depicted in popular music is frequently motivated by peer acceptance and sex, and it has highly positive associations and consequences.