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Background: Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey-or laboratorybased studies. This study employed qualitative methods to explore WP users' perceptions of dependence in Aleppo, Syria. Methods: A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis. Findings: Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included positively reinforced features, such as smoking's association with social gatherings and cultural connectedness, and negatively reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting one's behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at the expense of other reinforcers such as social interaction. Conclusion: The general and specific features of WP dependence need to be considered in developing instruments to measure WP dependence, in clinical assessment of WP dependence, and in developing cessation programs. [ABSTRACT FROM AUTHOR]

Aims Effectiveness of nicotine replacement therapy ( NRT) for smoking cessation has not been evaluated in low income countries, such as Syria, where it is expensive and not widely available. We evaluated whether nicotine patch boosts smoking cessation rates when used in conjunction with behavioral support in primary care clinics in Aleppo, Syria. Design Two arm, parallel group, randomized, placebo controlled, double-blinded multi-site trial. Setting Four primary care clinics in Aleppo, Syria. Participants Two hundred and sixty-nine adult primary care patients received behavioral cessation counseling from a trained primary care physician and were randomized to receive six weeks of treatment with nicotine versus placebo patch. Measurements Primary end-points were prolonged abstinence (no smoking after a 2-week grace period) at end of treatment, and 6 and 12 months post-quit day, assessed by self-report and exhaled carbon monoxide levels of <10 p.p.m. Findings Treatment adherence was excellent and nicotine patch produced expected reductions in urges to smoke and withdrawal symptoms, but no treatment effect was observed. The proportion of patients in the nicotine and placebo groups with prolonged abstinence was 21.6% and 20.0%, respectively, at end of treatment, 13.4% and 14.1% at 6 months, and 12.7% and 11.9% at 12 months. Conclusions Nicotine patches may not be effective in helping smokers in low-income countries to stop when given as an adjunct to behavioural support. [ABSTRACT FROM AUTHOR]

Objective: To determine the feasibility of implementing cessation interventions in Syria. Methods: We randomized 50 smokers to either a brief or intensive behavioral cessation intervention. Adherence to treatment and cessation through 3 months postcessation were calculated. Results: Adherence in the intensive group was only moderate and was associated with smoking for more years and higher self-efficacy. Cessation rates in the brief and intensive intervention groups were 16% and 4%, respectively. Nicotine dependence predicted abstinence at 3 months. Conclusion: Important barriers to cessation included perceived dependence, lack of access to pharmacotherapy, poor social support, and water pipe smoking. [ABSTRACT FROM AUTHOR]

Background: To compare patterns of use, beliefs, and attitudes related to waterpipe smoking between university students (beginning smokers) and café customers (established smokers) in Aleppo Syria, in order to explore the evolution of this smoking method. Methods: Two cross-sectional surveys were conducted among representative samples of university students (total 587, 48.4% men, mean age 22 years), and waterpipe users among cafe' customers (total 268, 60% men, mean age 30 years) in Aleppo, Syria. We used interviewer-administered questionnaire inquiring about pattern of waterpipe smoking (initiation, frequency), situational characteristics of use (partner, place, sharing), beliefs related to waterpipe smoking (harmful/addictive properties of waterpipe), attitudes related to waterpipe smoking (confidence in quitting, will to quit, motivation for quitting, past year quit attempt), and cigarette smoking. Results: Daily and regular patterns of smoking become more prevalent with increased duration of smoking, but intermittent smoking remains the predominant pattern of waterpipe use. Women seem to be drawn later to the habit, which seem to escape the usual taboo against women's cigarette smoking. Patterns and context of waterpipe use tend to change with progress of the practice affecting frequency, setting, and sharing of waterpipe. Unlike beginners, established waterpipe smokers seem more smoking-method oriented, more hooked on the habit, less willing to quit, and less likely to foresee challenges to quitting. Conclusion: Use patterns and attitudes related to waterpipe smoking evolve to accommodate the change in dependence and life circumstances of the smoker. Most of use features, beliefs, attitudes, as well as time-course seem unique to this smoking method requiring novel approach to intervention. [ABSTRACT FROM AUTHOR]

Purpose: To assess the beliefs and attitudes related to narghile (waterpipe) smoking that are likely to contribute to its increased popularity among young people in Syria.Methods: In 2003, a cross-sectional survey was administered to university students in Aleppo, using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 ± 2.1; response rate 98.8%).Results: The most common positive perceptions of narghile were related to its smell and taste. Negative perceptions of narghile included the smoke produced, the pollution, and perceived adverse health effects. Students believed the popularity of narghile to be part of a rising regional trend in its use, due to its being an appealing way to spend leisure time socializing with friends. More students (49.7%) believed narghile to be more harmful to health than cigarettes, compared with 30% who believed the opposite. Respiratory disease was the most commonly cited health effect of narghile smoking. Family attitudes regarding tobacco use by younger members were more permissive about narghile compared with cigarettes, and, surprisingly, were more permissive about females smoking narghile than males doing so.Conclusions: The rise in narghile smoking as a trendy social habit appears to be occurring despite considerable appreciation of its potential health risks. Permissiveness of adult family members towards narghile use by young female members, especially in the presence of a strong taboo against female cigarette smoking may contribute to the continuous spread of narghile smoking among women in Syria. [Copyright &y& Elsevier]

Background: Waterpipe smoking is becoming a global public health problem, especially in the Eastern Mediterranean region (EMR). Methods: We try in this study, which is a cross sectional survey among a representative sample of waterpipe smokers in cafes/restaurants in Aleppo-Syria, to assess the time period for the beginning of this new smoking hype. We recruited 268 waterpipe smokers (161 men, 107 women; mean age ± standard deviation (SD) 30.1 ± 10.2, response rate 95.3%). Participants were divided into 4 birth cohorts (= 1960, 1961-1970, 1971-1980, >1980) and year of initiation of waterpipe smoking and daily cigarette smoking were plotted according to these birth cohorts. Results: Data indicate that unlike initiation of cigarette smoking, which shows a clear age-related pattern, the nineties was the starting point for most of waterpipe smoking implicating this time period for the beginning of the waterpipe epidemic in Syria. Conclusion: The introduction of new flavored and aromatic waterpipe tobacco (Maassel), and the proliferation of satellite and electronic media during the nineties may have helped spread the new hype all over the Arab World. [ABSTRACT FROM AUTHOR]

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

This study's objective is to examine the relative effectiveness of cigarettes and waterpipe (WP) in reducing tobacco abstinence symptoms in dual cigarette/WP smokers. Sixty-one dual cigarette/WP smokers participated (mean age±SD 22.0±2.6 year; mean cigarettes/day 22.4±10.1; mean WPs/week 5.2±5.6). After 12-hour abstinence participants completed two smoking sessions (WP or cigarette), while they responded to subjective measures of withdrawal, craving, and nicotine effects administered before smoking and 5, 15, 30 and 45 min thereafter. For both tobacco use methods, scores on measures of withdrawal and craving were high at the beginning of session (i.e., before smoking) and were reduced significantly and comparably during smoking. Analysis of smoking and recovery (post-smoking) phases showed similarity in the way both tobacco use methods suppressed withdrawal and craving, but the recovery of some of these symptoms can be faster with cigarette use. This study is the first to show the ability of WP to suppress abstinence effects comparably to cigarettes, and its potential to thwart cigarette cessation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To examine the prevalence and potential health risks of waterpipe tobacco smoking., Methods: A literature review was performed to compile information relating to waterpipe tobacco smoking., Results: Waterpipe tobacco smoking is increasing in prevalence worldwide; in the United States, 10-20% of some young adult populations are current waterpipe users. Depending on the toxicant measured, a single waterpipe session produces the equivalent of at least 1 and as many as 50 cigarettes. Misconceptions about waterpipe smoke content may lead users to underestimate health risks., Conclusion: Inclusion of waterpipe tobacco smoking in tobacco control activities may help reduce its spread.

Introduction: Waterpipe tobacco smoking is increasing in popularity though the toxicant exposure and effects associated with this tobacco use method are not well understood., Methods: Sixty-one waterpipe tobacco smokers (56 males; mean age +/- SD, 30.9 +/- 9.5 years; mean number of weekly waterpipe smoking episodes, 7.8 +/- 5.7; mean duration of waterpipe smoking 8.5 +/- 6.1 years) abstained from smoking for at least 24 hr and then smoked tobacco from a waterpipe ad libitum in a laboratory. Before and after smoking, expired-air carbon monoxide (CO) and subjective effects were assessed; puff topography was measured during smoking., Results: The mean waterpipe use episode duration was 33.1 +/- 13.1 min. Expired-air CO increased significantly from a mean of 4.0 +/- 1.7 before to 35.5 +/- 32.7 after smoking. On average, participants took 169 +/- 100 puffs, with a mean puff volume of 511 +/- 333 ml. Urge to smoke, restlessness, craving, and other tobacco abstinence symptoms were reduced significantly after smoking, while ratings of dizzy, lightheaded, and other direct effects of nicotine increased., Discussion: Expired-air CO and puff topography data indicate that, relative to a single cigarette, a single waterpipe tobacco smoking episode is associated with greater smoke exposure. Abstinent waterpipe tobacco smokers report symptoms similar to those reported by abstinent cigarette smokers, and these symptoms are reduced by subsequent waterpipe tobacco smoking. Taken together, these data are consistent with the notion that waterpipe tobacco smoking is likely associated with the risk of tobacco/nicotine dependence.

Purpose: Despite the considerable mortality and morbidity associated with cardiovascular disease (CVD), many developing countries lack reliable surveillance of these ailments and their risk factors to guide intervention. This study aims to provide the first population-based estimates of CVD morbidity and mortality among adults in Aleppo, Syria and the distribution of their risk factors., Methods: A cross-sectional survey of adults 18 to 65 years old residing in Aleppo, Syria was carried out in 2004, involving 2038 household representatives (45.2% men; mean age, 35.3 years; response rate, 86%). Main outcomes of interest were physician-diagnosed CVD (infarction, angina, failure, stroke) among survey participants, and past 5-year mortality due to CVD among their household members older than 20 years of age (N = 6252, 49.5% men). Measurement of blood pressure (BP), height and weight, and smoking history were obtained as well., Results: Prevalence of CVD was 4.8% for heart disease and 1.0% for stroke. CVD was responsible for 45.0% of overall mortality reported in the past 5 years, whereby 49% of CVD deaths occurred before the age of 65 years. Mean age of death was 62.6 years (63.6 years for heart disease and 61.4 years for stroke). Annual crude death rate due to CVD was 314 per 100,000 (95% confidence interval [95% CI]: 215-414); of these, 179 were due to heart disease, and 135 due to stroke. More men than women died from heart disease, whereas the opposite was true for stroke. Hypertension was detected in 40.6% (47.7% men, 34.9%women), obesity in 38.2% (28.8% men, 46.4% women), and smoking (cigarettes or waterpipe) in 38.7% (63.6% men, 19.2% women) of participants. Of those surveyed, 39.3% had one CVD risk factor, 27.4% had two risk factors, and 8.3% had 3 risk factors. Main predictors of clustering of risk factors were older age, male gender, and low education., Conclusions: Syria is currently undergoing a stage in which morbidity and mortality from CVD are high but likely to increase based on the population's risk profile. CVD risk distribution in Syrian society highlights the non-generalizability of CVD models from developed societies, and calls for local studies to inform effective interventions and policies.

Aims: To assess exposure to ETS among nonsmokers in the community and examine the relation between various subjective and objective measures of exposure to ETS in a developing country's setting., Methods: An interviewer-administered population-based survey of adults 18-65 years residing in Aleppo, Syria. From a total number of 2038 participants, a sub-sample of 419 nonsmokers (27.2% men, 72.8% women, mean age 34 years) underwent subjective and objective assessment of exposure to ETS (saliva cotinine, breath CO, self-reported measures of exposure combined into ETS exposure scale)., Results: Overall, 97.6% of adults nonsmokers assessed in this study, 72.9% of whom were women, have detectable saliva cotinine levels (mean +/- SD 1.7 +/- 1.5 ng/ml). Correlation between self-reported exposure measures and saliva cotinine was moderate with the strongest observed for number of cigarette smokers in the house, average number of cigarettes smoked daily in the house, house policy regarding smoking, and total ETS score (r 0.3-0.4). These same variables were among the best predictors of saliva cotinine according to stepwise linear regression analysis, but their individual relevance differed between men and women reflecting underlying differences in gender-based behavior-mobility patterns. Generally, subjective measures could explain 22% of the variability in cotinine levels in men and 19% in women., Conclusions: Exposure to ETS is universal among adult nonsmokers in Syria. Saliva cotinine correlated moderately with self-reported measures, whereby selected subjective measures can be as informative as composite scores incorporating multiple measures. Even in this environment of omnipresence of smoking, household restrictions seem to offer protection against ETS exposure.

Background: There is a dearth of standardized studies examining exposure to environmental tobacco smoke (ETS) and its relationship to respiratory health among adults in developing countries., Methods: In 2004, the Syrian Center for Tobacco Studies (SCTS) conducted a population-based survey using stratified cluster sampling to look at issues related to environmental health of adults aged 18-65 years in Aleppo (2,500,000 inhabitants). Exposure to ETS was assessed from multiple self-reported indices combined into a composite score (maximum 22), while outcomes included both self-report (symptoms/diagnosis of asthma, bronchitis, and hay fever), and objective indices (spirometric assessment of FEV1 and FVC). Logistic and linear regression analyses were conducted to study the relation between ETS score and studied outcomes, whereby categorical (tertiles) and continuous scores were used respectively, to evaluate the association between ETS exposure and respiratory health, and explore the dose-response relationship of the association., Results: Of 2038 participants, 1118 were current non-smokers with breath CO levels < or = 10 ppm (27.1% men, mean age 34.7 years) and were included in the current analysis. The vast majority of study participants were exposed to ETS, whereby only 3.6% had ETS score levels < or = 2. In general, there was a significant dose-response pattern in the relationship of ETS score with symptoms of asthma, hay fever, and bronchitis, but not with diagnoses of these outcomes. The magnitude of the effect was in the range of twofold increases in the frequency of symptoms reported in the high exposure group compared to the low exposure group. Severity of specific respiratory problems, as indicated by frequency of symptoms and health care utilization for respiratory problems, was not associated with ETS exposure. Exposure to ETS was associated with impaired lung function, indicative of airflow limitation, among women only., Conclusions: This study provides evidence for the alarming extent of exposure to ETS among adult non-smokers in Syria, and its dose-response relationship with respiratory symptoms of infectious and non-infectious nature. It calls for concerted efforts to increase awareness of this public health problem and to enforce regulations aimed at protecting non-smokers.