Implementing pictorial health warning labels on waterpipe tobacco products in Lebanon: A policy framework analysis of content, actors, context, and process.

INTRODUCTION: Lebanon has one of the world's highest waterpipe (WP) consumption rates. Research has documented the effectiveness of implementing pictorial health warning labels (PHWLs) on WP products at encouraging smoking cessation and discouraging youth uptake of smoking. This study aims to gain insight into key informants' (KIs) views on the issuance, implementation, and compliance of a decree for PHWLs on WP products. METHODS: Thirteen KIs (policymakers, media, and international/local non-government organization representatives) were interviewed online and asked about potential barriers and facilitators they saw to issuing and implementing a PHWL decree. They were shown examples of PHWLs and asked about processes needed for implementation and compliance. The policy triangle framework (content, actors, context, and process) was used to interpret findings. RESULTS: Although there was clear discrepancy and ambiguousness among the KIs' views regarding process and actors, there was more consensus and clarity around context and content. Challenges to implementation were: (1) multiple sources of production and supply of WP (2) uncertainty regarding the responsible actors for each step, (3) prioritization of a tobacco control decree amidst a political and economic crisis, and (4) challenges to practicality of applying PHWL on the WP given its multi-component nature. CONCLUSION: This research provides an in-depth understanding of KI's views regarding content, actors, context, and process in relation to the issuance, implementation, and compliance to PHWLs on WP products. Noted challenges require careful consideration if progress is to be made to introduce PHWLs. IMPLICATIONS OF THE STUDY: A growing research base has documented the potential effectiveness of PHWLs on reducing WP consumption.Findings of this study show that implementing PHWLs on WP products requires a distinct understanding of the policy environment and context, as well as content, actors, and processes.Implementing PHWLs on waterpipe tobacco products needs to address the complex nature of waterpipe smoking as a multi-component tobacco use method.

Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis.

INTRODUCTION: Pictorial health warning labels on waterpipe tobacco packages represent a better strategy for communicating the health risks associated with waterpipe use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown. This study explores how pictorial warnings vs. text-only induce higher quit intention among a sample of young adult waterpipe smokers in Lebanon. METHODS: An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult waterpipe smokers who were exposed to two conditions: pictorial health warning label and text-only warning on waterpipe tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (e.g., attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit. RESULTS: Using serial mediation, exposure to pictorial warnings vs. text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect [ß= 0.063; (95% bootstrap CI=0.004, 0.149)] and cognitive elaboration [0.047; (0.001, 0.114)] were statistically significant. CONCLUSIONS: The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb waterpipe tobacco smoking. IMPLICATIONS: This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial health warning labels on intention to quit in a sample of current waterpipe smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing waterpipe health warning labels regulations in Lebanon and other countries to curb waterpipe tobacco smoking.

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study.

PURPOSE: Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes. METHODS: We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted. RESULTS: Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only. CONCLUSIONS: Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment.

BACKGROUND: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine. METHODS: A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption. RESULTS: The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers. CONCLUSIONS: These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

"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.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health.

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

Waterpipe tobacco smoking (WTS) control policies: global analysis of available legislation and equity considerations.

INTRODUCTION: The Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities. METHODS: We reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation's Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available. RESULTS: Our results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal. CONCLUSIONS: Our recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling.

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Impact of waterpipe tobacco taxation on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine: a simulation study.

INTRODUCTION: Despite the high prevalence of waterpipe tobacco smoking in the Eastern Mediterranean region, evidence supporting its fiscal measures is limited. We modelled the impact of waterpipe tobacco-specific excise taxes on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine. METHODS: We developed a simulation model using country-specific and market share-specific price, consumption and price elasticity data from WHO, UN Comtrade and nationally representative surveys. We modelled increases to specific excise taxes to meet a 35.9% tax burden on 20 g of waterpipe tobacco in Lebanon and Jordan, in line with the global average, and to double government revenues from excise duties in Palestine, which has surpassed this average. RESULTS: Specific excise tax was raised by $1.14 ($0.18-$1.32) in Jordan, $2.41 ($0.03-$2.44) in Lebanon (alongside removal of ad valorem taxes) and $2.39 ($1.72-$4.11) in Palestine per 20 g of waterpipe tobacco. Government revenue increased by $126.3 million in Jordan, $53.8 million in Lebanon and $162.4 million in Palestine while waterpipes smoked decreased by 32.4% in Jordan, 71.0% in Lebanon and 16.3% in Palestine. The corresponding numbers of premature deaths averted annually were approximately 162 000; 1 000 000; and 52 000. DISCUSSION: Increases in waterpipe tobacco-specific excise taxes substantially reduce smoking and increase government revenue and averted premature deaths in Jordan, Lebanon and Palestine. This has positive implications for both public health and financing and should be considered a policy priority.

'When I smoked it, it was like a slap in the face but it felt really good': exploring determinants of midwakh use among young adults in Lebanon.

BACKGROUND: Dokha ('dizziness' in English) is a type of alternative tobacco product (ATP) increasing in popularity in the Arab world; and smoked in a pipe called a midwakh. Midwakh use is common among nationals in the United Arab Emirates (UAE); yet, evidence indicates its spread among expats in the UAE as well as beyond the UAE. Research on midwakh use is nascent, and no qualitative research has been published. This paper explored the context and determinants of midwakh use among young adults in Lebanon using qualitative methods. METHODS: We conducted four focus group discussions with 18 midwakh ever smokers aged 18-25 years in Lebanon. Discussions were recorded, transcribed and thematically analysed using the Pragmatics, Attraction, Communication, Expectations framework. RESULTS: 'Pragmatics' was evident in participants' comments about availability of a supply of dokha. For 'attraction', participants described why they prefer midwakh smoking and compared it to other ATPs. Regarding communication, participants shared terms used to describe their use of midwakh (eg, 'buzz'/taking a hit). Participants also described expectations from smoking midwakh, including stress relief. CONCLUSION: Midwakh smoking is appealing to young adults due to factors such as the 'buzz', perceived harm reduction, stress relief and its ability to satisfy nicotine craving with small amounts of tobacco. As a result, despite experiencing negative effects on first use, young adults choose to continue to use midwakh, and find it hard to quit. These results have implications for prevention and control of midwakh smoking among young adults. Framework Convention on Tobacco Control guidance documents to address ATPs are critically needed to prevent the global spread of yet another tobacco product.

A call to advance and translate research into policy on governance, ethics, and conflicts of interest in public health: the GECI-PH network.

Efforts to adopt public health policies that would limit the consumption of unhealthy commodities, such as tobacco, alcohol and ultra-processed food products, are often undermined by private sector actors whose profits depend on the sales of such products. There is ample evidence showing that these corporations not only try to influence public health policy; they also shape research, practice and public opinion. Globalization, trade and investment agreements, and privatization, amongst other factors, have facilitated the growing influence of private sector actors on public health at both national and global levels. Protecting and promoting public health from the undue influence of private sector actors is thus an urgent task. With this backdrop in mind, we launched the "Governance, Ethics, and Conflicts of Interest in Public Health" Network (GECI-PH Network) in 2018. Our network seeks to share, collate, promote and foster knowledge on governance, ethical, and conflicts of interest that arise in the interactions between private sectors actors and those in public health, and within multi-stakeholder mechanisms where dividing lines between different actors are often blurred. We call for strong guidance to address and manage the influence of private sector actors on public health policy, research and practice, and for dialogue on this important topic. Our network recently reached 119 members. Membership is diverse in composition and expertise, location, and institutions. We invite colleagues with a common interest to join our network.

Delphi study among international expert panel to develop waterpipe-specific health warning labels.

BACKGROUND: Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control. METHODS: A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median. RESULTS: Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP's harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes. CONCLUSION: This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP's harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.

Building Emotional Resilience in Youth in Lebanon: a School-Based Randomized Controlled Trial of the FRIENDS Intervention.

In Lebanon, approximately one in four adolescents suffers from a psychiatric disorder. Alarmingly, 94% of adolescents with a mental disorder have not sought any treatment. This study assessed the effectiveness of an evidence-based school-based universal mental health intervention (the FRIENDS program) in reducing depression and anxiety symptoms in middle school students in Lebanon. A total of 280 6th graders aged 11-13 years were recruited from 10 schools in Beirut. Schools were matched on size and tuition and randomly assigned to intervention or control groups. The FRIENDS program was translated into Arabic, adapted, and then implemented by trained mental health professionals during 10 classroom sessions over 3 months. We assessed sociodemographic and relevant psychological symptoms by self-report, using the Scale for Childhood Anxiety and Related Disorders (SCARED), Mood and Feelings Questionnaire (MFQ), and Strengths and Difficulties Questionnaire (SDQ), at baseline. We re-administered these scales at 3 months post-intervention. There was a significant time × group interaction for the SDQ emotional score (p = 0.011) and total MFQ score (p = 0.039) indicating significant improvement in depressive and emotional symptoms in the intervention group. Subgroup analysis by gender showed a significant time × group interaction for the total SCARED score (p = 0.025) in females but not in males (p = 0.137), consistent with a reduction of anxiety symptoms in this stratum of the intervention group as compared with the control group. The FRIENDS program was effective in reducing general emotional and depressive symptoms among middle school students in this Lebanese study population. This intervention provides an opportunity for promoting mental health in Lebanese schools and reducing the treatment gap in mental health care.

Poly-Tobacco Use among Young Adult Waterpipe Smokers: Insights from University Students in Three Eastern Mediterranean Countries.

INTRODUCTION: There is a tendency of waterpipe smokers to advance their practice toward concurrent use (poly-tobacco use) of other tobacco products and nicotine delivery systems. This study investigated poly-tobacco use among waterpipe smokers, and its effect on their quit intention. METHODS: Descriptive cross-sectional design was utilized to recruit a convenience sample of university students who used waterpipe in three East Mediterranean countries. Using an internet-based survey, data were collected regarding participants' demographics, use of alternative tobacco products and nicotine delivery systems, and waterpipe quitting profile. Results: A total of 2290 students agreed to participate, among which 1116 (45.3%) reported using at least one tobacco product beside waterpipe. Poly-tobacco use was highest (61.1%) in Egypt, followed by Jordan (45.1%) and Palestine (33.1%). Across countries, cigarettes were the most common product (45.2%, n = 924) followed by cigar (18.6%, n = 374) and e-shisha (17.5%, n = 353). Conversely, the least reported product was smokeless tobacco (7.5%, n = 151) preceded by regular pipe (9.5%, n = 193). Participants who were males (OR = 2.83, 95% CI: 2.18-3.65), older (22-29 years) (OR = 1.15, 95% CI: 1.09-1.22), unemployed (OR = 1.58, 95% CI: 1.22-2.04), and those who initiated waterpipe at a younger age (OR = 0.87, 95% CI: 0.87-0.91) had higher odds of being poly-smokers. Poly-tobacco users were significantly more resistant to quit waterpipe. Conclusion: This study demonstrates poly-tobacco use as a rising phenomenon among waterpipe smokers and highlights the necessity for initiating advanced interventions to help waterpipe poly-tobacco users quit this dangerous type of addiction. Various country-specific programs are needed considering the various products used by the users.

Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts.

Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.

Individual-level determinants of waterpipe smoking demand in four Eastern-Mediterranean countries.

The prevalence of waterpipe tobacco smoking in the Eastern Mediterranean Region is at alarmingly high levels, especially among young people. The objective of this research was to evaluate the preferences of young adult waterpipe smokers with respect to potential individual-level determinants of waterpipe smoking using discrete choice experiment methodology. Participants were young adult university students (18-29 years) who were ever waterpipe smokers, recruited from universities across four Eastern Mediterranean countries: Jordan, Oman, Palestine and the United Arab Emirates. The Internet-based discrete choice experiment, with 6 × 3 × 2 block design, evaluated preferences for choices of waterpipe smoking sessions, presented on hypothetical waterpipe café menus. Participants evaluated nine choice sets, each with five fruit-flavored options, a tobacco flavored option (non-flavored), and an opt-out option. Choices also varied based on nicotine content (0.0% vs. 0.05% vs. 0.5%) and price (low vs. high). Participants were randomized to receive menus with either a pictorial + text health-warning message or no message (between-subjects attribute). Multinomial logit regression models evaluated the influence of these attributes on waterpipe smoking choices. Across all four samples (n = 1859), participants preferred fruit-flavored varieties to tobacco flavor, lower nicotine content and lower prices. Exposure to the health warning did not significantly predict likelihood to opt-out. Flavor accounted for 81.4% of waterpipe smoking decisions. Limiting the use of fruit flavors in waterpipe tobacco, in addition to accurate nicotine content labeling and higher pricing may be effective at curbing the demand for waterpipe smoking among young adults.

Waterpipe Tobacco Smoking among University Students in Three Eastern Mediterranean Countries: Patterns, Place, and Price.

Background: The objective of this study was to examine waterpipe tobacco smoking patterns, places of smoking, and prices paid among university students in the Eastern Mediterranean Region. Methods: A cross-sectional online survey was administered to a convenience sample of university students in three countries. Participants were young adults (18-29 years) who were ever waterpipe smokers, from Egypt (n = 728), Jordan (n = 790), and Palestine (n = 722). Measures included past-30-day waterpipe smoking, frequency, intensity, place of smoking, and prices paid per waterpipe smoking session and for packaged waterpipe tobacco. Logistic regression models evaluated the factors associated with past-30-day waterpipe smoking. Results: Past-30-day waterpipe smoking (prevalence) was observed among 60.7%, 67.7% and 63.1% of students from Egypt, Jordan, and Palestine, respectively. Among past-30-day smokers, past-5-day waterpipe smoking (frequency) was observed among 28.9%, 51.5%, and 48.6% of participants, respectively. Smoking in a café was highest among participants from Egypt (74.0%), followed by those from Palestine (44.8%), and Jordan (43.0%). Mean price paid per session was USD 0.99 (Egypt), USD 8.07 (Jordan), USD 6.05 (Palestine). The corresponding mean prices per packet were USD 0.86, USD 4.96, and USD 5.55, respectively. Predictors of past-30-day waterpipe smoking included younger age of initiation, male gender, employment, and smoking waterpipe alone. Conclusions: This study contributes to our understanding of waterpipe smoking patterns, places of smoking, and prices paid among young adults in a region with alarmingly high smoking rates. Understanding waterpipe smoking behaviors can inform the design of policy and educational interventions to curb its rising threat.

Nicotine and Carbonyl Emissions From Popular Electronic Cigarette Products: Correlation to Liquid Composition and Design Characteristics.

Introduction: Available in hundreds of device designs and thousands of flavors, electronic cigarette (ECIG) may have differing toxicant emission characteristics. This study assesses nicotine and carbonyl yields in the most popular brands in the U.S. market. These products included disposable, prefilled cartridge, and tank-based ECIGs. Methods: Twenty-seven ECIG products of 10 brands were procured and their power outputs were measured. The e-liquids were characterized for pH, nicotine concentration, propylene glycol/vegetable glycerin (PG/VG) ratio, and water content. Aerosols were generated using a puffing machine and nicotine and carbonyls were, respectively, quantified using gas chromatograph and high-performance liquid chromatography. A multiregression model was used to interpret the data. Results: Nicotine yields varied from 0.27 to 2.91 mg/15 puffs, a range corresponding to the nicotine yield of less than 1 to more than 3 combustible cigarettes. Nicotine yield was highly correlated with ECIG type and brand, liquid nicotine concentration, and PG/VG ratio, and to a lower significance with electrical power, but not with pH and water content. Carbonyls, including the carcinogen formaldehyde, were detected in all ECIG aerosols, with total carbonyl concentrations ranging from 3.72 to 48.85 µg/15 puffs. Unlike nicotine, carbonyl concentrations were mainly correlated with power. Conclusion: In 15 puffs, some ECIG devices emit nicotine quantities that exceed those of tobacco cigarettes. Nicotine emissions vary widely across products but carbonyl emissions showed little variations. In spite of that ECIG users are exposed to toxicologically significant levels of carbonyl compounds, especially formaldehyde. Regression analysis showed the importance of design and e-liquid characteristics as determinants of nicotine and carbonyl emissions. Implications: Periodic surveying of characteristics of ECIG products available in the marketplace is valuable for understanding population-wide changes in ECIG use patterns over time.

Consensus statement on assessment of waterpipe smoking in epidemiological studies.

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.