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Introduction Relative to non-waterpipe (WP) smokers, WP smokers are more than twice as likely to use alcohol and frequently consume alcohol before or during smoking sessions. Co-use of alcohol and WP may result in greater toxicant exposure compared to WP smoking alone. To date, no study systematically has investigated the impact of acute alcohol intoxication on WP smoking topography, exposure to tobacco-related toxicants, or abuse liability. Methods Dyads of current WP smokers and drinkers (N = 42; age = 21–32 years) completed two in-laboratory ad libitum smoking sessions (≤2 hours) following 12-hour nicotine abstinence in a double-blind, randomized crossover design in which they consumed a placebo versus active drink (sustained breath alcohol concentration = .08). Exhaled carbon monoxide (eCO) and plasma nicotine concentration were assessed. Questionnaires assessed smoking experience and smoking urge. Smoking topography was measured continuously throughout each smoking session. Results The alcohol session was associated with increased inhaled volume, flow rate, and WP session duration compared to placebo. Compared to placebo, participants reported a more positive overall smoking experience following the alcohol session and greater smoking urges pre- and post-smoking session. Although both sessions resulted in significant increases in eCO and plasma nicotine, no significant differences emerged in eCO or nicotine exposure between the active and placebo sessions. Conclusions Co-use of alcohol and WP may contribute to the maintenance of WP smoking through enhanced smoking experiences, increased urge to smoke, and significant exposure to addictive nicotine. Regulations may be necessary to limit the sale of alcohol in WP smoking lounges and reduce exposure to secondhand smoke. Implications The findings suggest co-use of alcohol and WP tobacco likely maintain WP use and dependence by enhancing the smoking experience and increasing urges to smoke. These findings have implications for regulations aimed at limiting co-use of alcohol and WP tobacco in WP lounges and limiting exposure to secondhand smoke. Clinical trials registration NCT03096860

Background: Tobacco is smoked in different form including cigarettes and water pipes. One popular form of water pipe smoking especially in Middle Eastern countries is shisha smoking. Shisha has been associated with various diseases including oral cancer. However, genomic alterations and gene expression changes associated with chronic shisha exposure have not been previously investigated. Objectives: Whole‐exome sequencing and gene expression profiling of immortalized human oral keratinocytes (OKF6/TERT1) cells chronically treated with 0.5% shisha extract for a period of 8 months was undertaken to characterize molecular alterations associated with shisha exposure. Methods: Genomic DNA and RNA were extracted and preprocessed as per manufacturer's instruction and subjected to whole‐exome and transcriptome sequencing using Illumina HiSeq2500 platform. Exome was analyzed using GATK pipeline whereas RNA‐Seq data was analyzed using HiSat2 and HTSeq along with DESeq to elucidate differentially expressed genes. Results: Whole‐exome sequence analysis led to identification of 521 somatic missense variants corresponding to 389 genes RNA‐Seq data revealed 247 differentially expressed genes (≥2‐fold, P‐value

Background and purpose Health warning messages specific to waterpipe smoking (WPS) have not been tested enough in literature. This study evaluated university students' response to such messages. Specifically, this study (1) assessed the extent to which certain warning messages and pictorial signs motivate participants to quit WPS smoking; (2) identified the best location to place the warning signs of waterpipe as perceived by participants; and (3) assessed participants' intention to quit WPS. Methods A descriptive, cross-sectional design was used to collect data from 397 university students in Jordan using an Internet-based survey. The following data were collected: intentions regarding WPS, response to nine warning messages, and responses to four pictorial signs. Results The message that had the highest motivation to quit smoking was " WPS during pregnancy can harm your baby" (79.3%), whereas the highest pictorial sign was regarding "Protect your children" (64.2%). Most (69.5%) participants believed that WPS products and accessories should contain warnings, and the best suggested location was the pipe handle (52.4%). Participants who reported quitting WPS and those who had an intention to quit had significantly higher responses to both types of health warning labels (HWLs). Conclusion Both text-only and pictorial HWLs were found to encourage quitting WPS among university students. Knowing that participants are having an intention to quit mandates extra efforts to make WPS experience less appealing through reminding them regarding its harms. Implications for practice Support is needed by health care providers to put those effective health warning messages in action. Furthermore, providers can use such health warnings in motivating their patients to quit WPS.

Background: How carcinogen exposure varies across users of different, particularly noncigarette, tobacco products remains poorly understood. Methods: We randomly selected 165 participants of the Golestan Cohort Study from northeastern Iran: 60 never users of any tobacco, 35 exclusive cigarette, 40 exclusive (78% daily) waterpipe, and 30 exclusive smokeless tobacco (nass) users. We measured concentrations of 39 biomarkers of exposure in 4 chemical classes in baseline urine samples: tobacco alkaloids, tobacco-specific nitrosamines (TSNA), polycyclic aromatic hydrocarbons (PAH), and volatile organic compounds (VOC). We also quantified the same biomarkers in a second urine sample, obtained 5 years later, among continuing cigarette smokers and never tobacco users. Results: Nass users had the highest concentrations of tobacco alkaloids. All tobacco users had elevated TSNA concentrations, which correlated with nicotine dose. In both cigarette and waterpipe smokers, PAH and VOC biomarkers were higher than never tobacco users and nass users, and highly correlated with nicotine dose. PAH biomarkers of phenanthrene and pyrene and two VOC metabolites (phenylmercapturic acid and phenylglyoxylic acid) were higher in waterpipe smokers than in all other groups. PAH biomarkers among Golestan never tobacco users were comparable to those in U.S. cigarette smokers. All biomarkers had moderate to good correlations over 5 years, particularly in continuing cigarette smokers. Conclusions: We observed two patterns of exposure biomarkers that differentiated the use of the combustible products (cigarettes and waterpipe) from the smokeless product. Environmental exposure from nontobacco sources appeared to contribute to the presence of high levels of PAH metabolites in the Golestan Cohort. Impact: Most of these biomarkers would be useful for exposure assessment in a longitudinal study.

Waterpipe smoking is a method of tobacco consumption that continues to spread globally. In 2002, a ban of tobacco sales was adopted in the Saudi Arabian cites of Mecca and Medina.This study aimed to examine prevalence of waterpipe and cigarette smoking among students of Taibah University, the biggest in Medina, where the tobacco sales ban has been implemented.A structured questionnaire was distributed between February and April 2015 to examined tobacco use among Taibah University students.The prevalence of current and ever waterpipe use was 24.2% and 36.04%, respectively, compared with 31.9% and 42.7% for current and ever cigarette smoking. This prevalence is similar to that reported in other Saudi cities where tobacco sales are allowed. Multivariate analysis showed that waterpipe use was higher among senior students; those with pocket money spending of500 Saudi Arabia riyal (SAR)/month; and if5 individuals were living in the household. In addition, waterpipe use was lower among students with monthly household income of 5000-9000 SAR. In contrast, current cigarette smoking was more frequent in those aged22 years; among male students; in those with pocket money spending of500 SAR/month; and those who lived away from their parents.Waterpipe and cigarette smoking, despite the ban on tobacco sales, is still common among Taibah University students in Medina, Saudi Arabia.تعاطي التبغ والشيشة بين طلاب الجامعة، المملكة العربية السعودية: تأثير حظر مبيعات التبغ.هيثم درادكه، عمر خابور، كارم الزعبي، ريما نقاش، توماس آيسنبيرج.يُعَدُّ تدخين الشيشة إحدى وسائل استهلاك التبغ التي لا تزال منتشرة حول العالم. وفي عام 2002 ، تم إقرار حظر مبيعات التبغ في مكة المكرمة والمدينة المنورة بالمملكة العربية السعودية.هدفت هذه الدراسة إلى فحص معدل انتشار تدخين الشيشة والسجائر بين طلاب جامعة طيبة، التي تُعَد أكبر جامعة في المدينة المنورة حيث طُبِّق حظر مبيعات التبغ.استُخدم استبيان هيكلي لتحقيق أهداف الدراسة.أظهرت الدراسة أن معدل انتشار تدخين الشيشة الحالي والدائم 24.2% و 36.04% على التوالي، بينما تدخين السجائر الحالي والدائم 31.9% و 42.7% على التوالي. ويُعَد معدل الانتشار هذا مشابه لمعدل الانتشار المُبلَّغ عنه بواسطة الدراسات التي أُجريت في المدن السعودية الأخرى المسموح فيها ببيع التبغ. وأوضح التحليل متعدد المتغيرات أن تدخين الشيشة كان أعلى بين طلاب الصفوف العليا، والذين ينتمون لعائلات دخلها الشهري يتراوح بين 5000 و 9000 ريال سعودي، والذين يزيد مصروفهم عن 500 ريال سعودي/شهريًا، وعندما يكون عدد الأفراد الذين يعيشون في نفس المنزل 5 أشخاص أو أكثر. ومن ناحية أخرى، كان معدل التدخين الحالي للسجائر أعلى بين الذين تزيد أعمارهم عن 22 عامًا، وبين الطلاب الذكور، وبين الذين يزيد مصروفهم عن 500 ريال سعودي/شهريًا، والذين يعيشون بعيدًا عن آبائهم.إجمالاً، لا يزال تدخين الشيشة والسجائر، رغم حظر مبيعات التبغ، شائعًا بين طلاب جامعة طيبة في المدينة بالمملكة العربية السعودية.Consommation de tabac et utilisation de la pipe à eau chez les étudiants à l’université en Arabie saoudite : incidence de l’interdiction des ventes de tabac.La consommation de tabac par pipe à eau est une forme de tabagisme qui ne cesse de s’étendre à travers le monde. En 2002, une interdiction sur les ventes de tabac a été adoptée dans les villes saoudiennes de la Mecque et Médine.La présente étude avait pour but d’analyser la prévalence du tabagisme par cigarette et pipe à eau chez les étudiants de l’université Taibah, plus grand établissement universitaire de Médine dans lequel l’interdiction sur les ventes de tabac est appliquée.Un questionnaire structuré a été distribué entre février et avril 2015 pour analyser la consommation de tabac chez les étudiants de l’université Taibah.La prévalence de l’utilisation de la pipe à eau à tout moment dans le passé était de 36,04 % contre 24,2 % au moment de l’étude, alors que les chiffres associés à la consommation de cigarettes sont de 42,7 % et 31,9 % respectivement. Cette prévalence est semblable à celle observée lors d’études menées dans d’autres villes saoudiennes où les ventes de tabac sont autorisées. L’analyse multivariée a montré que l’utilisation de la pipe à eau était plus importante chez les étudiants de cycle supérieur, ceux dont les dépenses d’argent de poche excèdent 500 riyals saoudiens (SAR) par mois, ceux dont le foyer dispose d’un revenu mensuel compris entre SAR 5000 et 9000 et dans les foyers comptant au moins cinq personnes. En comparaison, la consommation actuelle de cigarettes était supérieure chez les plus de 22 ans, les étudiants de sexe masculin, ceux dont les dépenses d’argent de poche dépassent SAR 500/mois et ceux vivant loin de chez leurs parents.Dans l’ensemble, malgré l’interdiction sur les ventes de tabac, la consommation de tabac par pipe à eau et cigarette est toujours courante parmi les étudiants de l’université Taibah à Médine (Arabie saoudite).

The assessment and control of the real losses from water distribution systems require the accurate estimation of the flow rate from an individual leak as a function of the internal pressure. The lack of analytical models able to accurately describe the relationship between the area of the leak and the pressure head is the key problem. This paper utilized the linear-elastic fracture mechanics (LEFM) theory for thin shells to derive models for both longitudinal and circumferential cracks. The models were validated by both finite element (FE) simulations and laboratory experiments under varying crack and pipe parameters. Both fluid-structure interaction (FSI) and traditional FE simulations were performed, and the results were compared to quantify the effect of leakage hydraulics on leak area. In the laboratory experiments, an image analysis technology was utilized to measure the leak area and flow rate simultaneously, so that the effect of the discharge coefficient could be excluded. In addition, the leak area was systematically measured under the effect of different parameters. The results revealed that the values predicted by the derived models were in good agreement with the experimental and FE simulation values for both types of cracks. The LEFM theory and the phenomena observed in this study can improve our understanding of the leak behavior and enable the development of effective pressure management strategies for water distribution systems.

The objective was to assess the prevalence of symptoms of overactive bladder syndrome (OAB) among healthy nulliparous female university students, and to evaluate the correlation of these symptoms with a variety of factors, including waterpipe (WP) smoking. This is a cross-sectional study. A questionnaire was administered to evaluate symptoms of OAB in healthy nulliparous female university students. Variables assessed included body mass index (BMI), cigarette smoking, WP smoking, consumption of alcohol, coffee, and tea with and without artificial sweeteners, soft drinks, and energy drinks. Adjusted odds ratio were calculated to determine the correlation of these variables with OAB symptoms. A total of 767 out of 2,900 females responded to the questionnaire. Bothersome frequency was reported in 32.3%, and nocturia in 47.5% of the women. Urgency and urgency urinary incontinence (UUI) were present in 25.5 and 24.7% of the study participants respectively. Urgency was associated with WP smoking (p value 0.048). Bothersome frequency was associated with artificial sweeteners used with coffee and tea (p value 0.013). UUI was associated with cigarette smoking (p value 0.034) and elevated BMI (p value

Introduction This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. Aims and Methods A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. Results Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. Conclusions The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. Implications The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.

Background For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). Aims The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). Method Participants aged 18 to 24 years ( n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with “warning message” and “nicotine content” as factors. Results Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. Discussion Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. Conclusion The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

The use of high-frequency strain waves to perform examinations and note measurements is referred to as ultrasonic testing (UT). UT is commonly used for the detection or evaluation of flaws and characterization of materials, among other applications. A standard ultrasonic inspection system comprises a pulser/receiver, transducer, and display devices. The pulser/receiver produces electrical pulses of high voltage. The transducer generates high-frequency ultrasonic energy after being driven by the pulser. The reflected wave is then converted into an electrical signal by the transducer and is displayed on a screen. The reflected signal strength versus the time plot helps to glean information regarding the features of a defect. In this paper, we discuss the experiments performed in a laboratory setting to determine ultrasound-based biofilm sensor sensitivity in relation to changes in the surrounding environment of temperature, concentration, turbidity, and conductivity of the liquid passing through the system. The effect of the change in frequency of the sensors was also studied. The sensors being developed are small and compact, portable, can be placed on the outer walls of the desired surface, use digital signal processing techniques, and the biofilm presence on the inner walls of the surface can be monitored.

Introduction Waterpipe tobacco smoking (WTS) often occurs socially, increasing health risks for the smoker and others through secondhand smoke effects. While messages on WTS harms enhance perceived risks for self, whether these messages elevate perceived risks for others, such as one’s romantic partner who engages in WTS, is unclear. We tested this idea by surveying one member of dual-smoking couples who engages in WTS. Aims and Methods As part of an online study, we enrolled adults ages 18–30 who engaged in WTS and were in a committed relationship of at least 6 months whose partner engaged in WTS. Participants were randomized to a control arm or to one of two arms consisting of watching a brief video on health harms or overcoming myths about WTS, respectively. Outcomes were perceived harms and measures of desire and probability of quitting for self and partner. Results Participants (N = 238) who watched either video, compared with participants who did not watch a video, reported greater perceived health risks for self and partner and that their own WTS harmed their partner. Participants who watched either video reported a greater desire to quit for themselves, perceived that their partner had a greater desire to quit, and reported a higher likelihood of quitting together in the next 6 months. Conclusions Brief videos containing risk-based messaging increase young adult waterpipe tobacco smokers’ perceived harms and desire to quit for self and partner. This can be a useful strategy to motivate cessation in couples who engage in WTS. Implications This study shows for the first time that at least among one member of dual-smoking couples who engages in WTS, brief videos on harms of WTS influences perceived harms and motivation to quit for the self and one’s partner. This can be a useful strategy to promote cessation.

Water pipe smoking is highly prevalent in developing countries, especially in Eastern Mediterranean regions. Research finds that more than 100 million people smoke a water pipe. Furthermore, tobacco smoking is one of the leading behavioral factors related to an increased risk of cancer, a leading cause of death globally. We aim to introduce a novel filtration system for water-pipe smoking and evaluate cytotoxic effects of common water pipe condensed smoke in comparison with our novel filtration system on normal (HEK293t) and cancer cell lines (Hep3B and MCF7) by MTS assay, alpha-fetoprotein (aFP), and apoptosis/necrosis effects. More so, the smoke substituents' neurotoxicity effect was evaluated by analyzing the depressive property on AMPA receptors (AMPARs). Our results showed that the silica filtration system was more effective than the water filtration system. The number of toxic compounds was reduced from 145 mg in distilled water extract (DWE) to 57.5 mg in silica solution extract (SSE). The SSE method also showed lower toxicity impacts on normal and cancerous cell lines (HEK293t, Hep3B, and MCF7) with CC50 values 149.9, 10.14, and 8.9 µg/ml, relative to the DWE method (CC50 values 77.1, 3.1, and 5.24 µg/ml, respectively). SSE extraction also reduced the α-FP (tumor marker test) to 2273.3 ng/ml which was closer in value to untreated cells (4066.7 ng/ml) in comparison with DWE which reduced it greatly to 1658.7 ng/ml, and the biophysical properties of AMPAR subunits demonstrate a reduced effect on desensitization rates of GluA2 homomer and GluA1/2 heteromer, using SSE relative to DWE. In conclusion, the condensed smoke of ordinary water pipe (DWE) has cytotoxic and neurotoxic impacts on various cell lines, while our newly developed system (SSE) was less toxic.

Introduction: There is no universal scale for assessing waterpipe tobacco (WT) dependence. We examined the factorial structure and psychometric properties of the Waterpipe Dependence Scale-11 (LWDS-11) among Egyptian WT smokers. Methods: We administered the LWDS-11 during face-interview questionnaires in two cross-sectional surveys among 1490 current WT smokers recruited via purposive quota sampling. Exploratory factor analysis was performed on half of the sample. Confirmatory factor analysis of the resulting model was done using structural equation modelling on the other half. Scale reliability was examined. We assessed convergent construct validity using regression models to examine the association between the adapted dependence scale and factors conceptually expected to be associated with WT dependence. Results: Exploratory factor analysis of the scale yielded eight items (E8-LWDS) supporting a three-factor structure: physical dependence (three items), psychological dependence (three items), and psychological craving (two items). Cronbach’s α were 0.635 for the total scale and 0.823, 0.654, and 0.785 for the three subscales. E8-LWDS was confirmed to have good model fit (comparative fit index = 0.995, root mean squared error of approximation = 0.027). E8-LWDS was independently associated with daily WT smoking, rural residence, being a skilled worker, non-exclusive WTS, smoking ≥ eight WT hagars/day, and measures of perceived behavioral control (self-reported addiction to WT, perceived ability to quit, and previous quit attempts). Conclusion: E8-LWDS showed adequate psychometric properties among this sample of Egyptian current WT smokers, which makes it appropriate for use by researchers and practitioners. Adding items related to perceived behavioral control might enhance the scale robustness.

The present study aimed to explore the perceptions of high school students on Social Unacceptability (Arabic/Persian term = Qabahat) of Hookah Smoking (SUoHS). In this qualitative study, 31 student adolescents in Tabriz, Iran, were invited to participate in semi-structured individual interviews and focus group discussions (FGDs). Data were analyzed using interpretative thematic analysis. The unacceptability of hookah smoking was viewed at the “disreputability of hookah smoking and hookah smokers”. The students also explained SUoHS in the “incivility of hookah smoking and smokers in the society”, “disrespectfulness of hookah smokers and their families”, and “the consequences of hookah smoking”. The SUoHS is rooted from the social values and norms within communities. To decrease hookah smoking levels among adolescents, school health nursing interventions should be tailored to bridge the gap between their recognition of SUoHS and subsequent behavior change through creating group dynamics highlighting the domains of social unacceptability of the behavior., Journal of Preventive Medicine and Hygiene, Vol. 62 No. 1 (2021): 2021621

Waterpipe (WP) smoking is a global phenomenon, with the most consumers in Middle East countries and China. Heavy metals exposure related to WP smoking has been associated with many adverse health effects. However, the association of lifestyle factors and smoking habits with blood heavy metals concentration in WP smokers is unclear yet. Therefore, we aimed to investigate the relationship of lifestyle factors (i.e., diet and physical activity) and smoking habits (i.e., duration of the use of WP and times of smoking WP per week) with blood concentrations of lead (Pb) and cadmium (Cd). This cross-sectional study was based on 86 WP smokers in Khalkhal, Iran (2018). Graphite furnace atomic absorption spectrometry (GFAAS) was used to measure heavy metals. The median (interquartile range (IQR)) of Pb and Cd concentrations were 39 (24) and 1.3 (1.2) μg/L. The blood Pb and Cd levels were significantly higher in participants with lower education level (P-value = 0.049 and 0.041, respectively). An IQR increase in physical activity per week was associated with −0.12 μg/L (95% confidence interval (CI): −0.23, −0.01, P-value = 0.04) decrease in Pb concentration. An increase in the times of consuming fruit per week was negatively associated with the concentration of Cd. Overall, our findings suggested that physical activity and healthy diet have been associated with lower blood heavy metal concentrations in WP smokers; however, further studies are needed to confirm these findings.

Key Points Question Is there an association between consuming cannabis with a water pipe and later consumption of other illicit drugs? Findings In this longitudinal cohort study of 1108 men, both unadjusted and adjusted models showed that consumption of cannabis with a water pipe at baseline was associated with the use of other illicit drugs at follow-up compared with not using a water pipe. Meaning Policy campaigns designed to reduce the prevalence and risks associated with cannabis use should not only target cannabis frequency, but also the water pipe route of administration., This cohort study investigates whether consumption of cannabis with a water pipe is associated with eventually using illicit drugs compared with cannabis consumption without water pipes., 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.

The article's abstract is not available.

Background Electronic hookah (e‐hookah) vaping has increased in popularity among youth, who endorse unsubstantiated claims that flavored aerosol is detoxified as it passes through water. However, e‐hookahs deliver nicotine by creating an aerosol of fine and ultrafine particles and other oxidants that may reduce the bioavailability of nitric oxide and impair endothelial function secondary to formation of oxygen‐derived free radicals. Methods and Results We examined the acute effects of e‐hookah vaping on endothelial function, and the extent to which increased oxidative stress contributes to the vaping‐induced vascular impairment. Twenty‐six healthy young adult habitual hookah smokers were invited to vape a 30‐minute e‐hookah session to evaluate the impact on endothelial function measured by brachial artery flow‐mediated dilation (FMD). To test for oxidative stress mediation, plasma total antioxidant capacity levels were measured and the effect of e‐hookah vaping on FMD was examined before and after intravenous infusion of the antioxidant ascorbic acid (n=11). Plasma nicotine and exhaled carbon monoxide levels were measured before and after the vaping session. Measurements were performed before and after sham‐vaping control experiments (n=10). E‐hookah vaping, which increased plasma nicotine (+4.93±0.92 ng/mL, P P =0.479), increased mean arterial pressure (11±1 mm Hg, P P P P =0.002). All parameters were unchanged during sham studies. Conclusions E‐hookah vaping has adverse effects on vascular function, likely mediated by oxidative stress, which overtime could accelerate development and progression of cardiovascular disease. Registration URL: https://ClinicalTrials.gov . Unique identifier: NCT03690427.

Background Tobacco smoking using a hookah (i.e., waterpipe) is a global epidemic. While evidence suggests that sexual minorities (SM) have higher odds of hookah use compared to heterosexuals, little is known about their hookah use patterns and transitions. We sought to examine transitions between hookah smoking and use of other tobacco and electronic (e-) products among SM adults aged 18 years of age and older versus their heterosexual counterparts. Methods We analyzed nationally representative data of ever and current hookah smokers from Wave 1 (2013–2014; ever use n = 1014 SM and n = 9462 heterosexuals; current use n = 144 SM and n = 910 heterosexuals) and Wave 2 (2014–2015; ever use n = 901 SM and n = 8049 heterosexuals; current use n = 117 SM and n = 602 heterosexuals) of the Population Assessment of Tobacco and Health Study. Comparisons between groups and gender subgroups within SM identity groups were determined with Rao-Scott chi-square tests and multivariable survey-weighted multinomial logistic regression models were estimated for transition patterns and initiation of electronic product use in Wave 2. Results Ever and current hookah smoking among SM adults (ever use Wave 1: 29% and Wave 2: 31%; current use Wave 1: 4% and Wave 2: 3%) was higher than heterosexuals (ever use Wave 1: 16% and Wave 2: 16%; current use Wave 1: 1% and Wave 2: 1%; both p Conclusions Compared to heterosexuals, in addition to higher rates of hookah smoking, higher percentages of SM adults transitioned to hookah plus e-product use between 2013 and 2015. Results have implications for stronger efforts to increase awareness of the harmful effects of hookah as well as vaping, specifically tailored among SM communities.

There are few if any reports regarding the role of lifetime waterpipe smoking in the etiology of multiple sclerosis (MS). In a population-based incident case-control study conducted in Tehran, Iran, we investigated the association between waterpipe smoking and MS, adjusted for confounders. Cases (n = 547) were patients aged 15–50 years identified from the Iranian Multiple Sclerosis Society between 2013 and 2015. Population-based controls (n = 1,057) were persons aged 15–50 years recruited through random digit telephone dialing. A doubly robust estimation method, the targeted maximum likelihood estimator (TMLE), was used to estimate the marginal risk ratio and odds ratio for the association between waterpipe smoking and MS. The estimated risk ratio and odds ratio were both 1.70 (95% confidence interval: 1.34, 2.17). The population attributable fraction was 21.4% (95% confidence interval: 4.0, 38.8). Subject to the limitations of case-control studies in interpreting associations causally, these results suggest that waterpipe use, or strongly related but undetermined factors, increases the risk of MS. Further epidemiologic studies, including nested case-control studies, are needed to confirm these findings.

Background Water pipe smoking (WPS) is re-gaining widespread use and popularity among various groups of people, especially adolescents. Despite different adverse health effects of WPS, many of the WPS interventions have failed to control this type of tobacco smoking. This study was conducted to identify experienced management interventions in preventing and controlling WPS worldwide. Methods A systematic literature review was conducted. Electronic databases were searched for recordes which were published from beginning 1990 to August 2018. Studies aiming at evaluating, at least, one intervention in preventing and controlling WPS were included in this review, followed by performing the quality assessment and data extraction of eligible studies by two independent investigators. Finally, interventions that were identified from the content analysis process were discussed and classified into relevant categories. Results After deleting duplications, 2228 out of 4343 retrieved records remained and 38 studies were selected as the main corpus of the present study. Then, the identified 27 interventions were grouped into four main categories including preventive (5, 18.51%) and control (8, 29.62%) interventions, as well as the enactment and implementation of legislations and policies for controlling WPS at national (7, 25.92%) and international (7, 25.92%) levels. Conclusion The current enforced legislations for preventing and controlling WPS are not supported by rigorous evidence. Informed school-based interventions, especially among adolescents can lead to promising results in preventing and controlling WPS and decreasing the effects of this important social and health crisis in the global arena.

ObjectivesThis study assessed the extent to which the elasticity of cigarette and waterpipe tobacco products differs between men and women. We also explored the levels of substitution and complementarity in tobacco products among men and women.SettingThe study examines tobacco elasticities in three Arab countries: Lebanon, Jordan and the West Bank of Palestine.ParticipantsWe used data from nationally representative surveys of adults aged ≥18 years in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679). The proportion of women was 50.0% of the sample in Lebanon and Palestine, and 44.6% in Jordan.Primary and secondary outcome measuresA zero-inflated Poisson regression model estimated own-price and cross-price elasticities for two variations of cigarettes and five variations of waterpipe tobacco products. Elasticities were measured based on eight scenarios of prices.ResultsDemand for waterpipe tobacco products was elastic for both men and women. The cross-price elasticities in the three countries indicate the existence of substitution between cigarettes and waterpipe products and by different varieties within each of the two tobacco products. Gender differences varied across the three countries whereby higher cross-price elasticities were observed for women in Jordan and Palestine. For example, the price elasticity for discount waterpipe was −1.4 and −0.6 for women and men in Jordan, respectively.ConclusionsResults on the elasticity of demand for tobacco products and the existence of substitution between tobacco products reveal the higher responsiveness of men and women to changes in tobacco prices. This should be taken into consideration in tobacco control strategies particularly when reducing tobacco consumption via taxation policies.

This study aimed to investigate the prevalence and sociodemographic characteristics of smokers in a private medical university in Malaysia and to examine whether there is an association between personality traits and various smoking types. There were 468 participants in this study and the mean age was 20.97 years (±2.743). The prevalence of conventical cigarette users, e-cigarette users, and water pipe users was 4.7%, 6.4%, and 4.0%, respectively. Parents’ annual income (p = 0.001) and ethnicity (p < 0.001) were significantly associated with the current smoker group. Binary logistic regression modelling revealed that study participants with either Malay (OR 4.23, 95% CI 1.73, 10.34) or Chinese (OR 4.16, 95% CI 1.98, 8.73) ethnicity were approximately four times more likely to use tobacco products compared with study participants with Indian and Other ethnicities. Lower parents’ annual income was almost four times more likely to be associated with smoking behaviour (OR 3.82, 95% CI 1.58, 9.27). Significant differences in mean personality traits score of Openness (p = 0.018) and Extraversion (p = 0.004) were observed between never-smoker and current smoker study participants. In addition, cigarette users scored higher in Conscientiousness personality traits compared with non-cigarette whereas e-cigarette users and waterpipe users scored lower in Extraversion (p = 0.02). Post-hoc analysis revealed that the never-smoker group scored higher in Extraversion compared with the dual tobacco user group (p = 0.03). In addition, the single tobacco user group scored higher in Agreeableness personality trait compared with the never-smoker group (p = 0.01). Deeper understanding of the different cognitive dimensions, ethnicities, and educational backgrounds can potentially impact smoking prevention and cessation programs.

Background The present study aimed to investigate the effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adolescents and adults. Methods In this study, two comparable cities in Iran were selected to participate in an intervention program based on a social-ecological model (SEM). In each city, 133 hookah smokers in coffee houses were selected. Environmental changes in coffee houses such as serving light foods and games were conducted. A virtual group named “no hookah” was established on the Telegram application to train participants in the intervention group. Messages, pictures, and short videos were sent to the participants through that virtual network. The frequency and duration of hookah consumption were assessed in both groups at baseline and after the intervention. Results The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group), and the duration of hookah consumption per session decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Conclusions Using multi-level interventions through a social-ecological model can reduce hookah consumption in adults.

Objectives: The purpose of this study was to select a health warning message location on a waterpipe (WP) that both attracted visual attention and conveyed the risks associated with WP smoking. Methods: During June through November 2019, we conducted a within-subjects randomized experiment (N = 74) using eye tracking equipment to examine visual attention to 3 placements of a health warning on the WP (stem, water bowl, hose). We asked young adult ever WP users 3 questions about WP harm perceptions. We used generalized linear mixed models to examine the amount of fixation time spent on the placement locations; we used repeated measures ANOVA to model changes in harm perceptions. Results: There were statistically significant differences across all 3 placement locations; regardless of place, all HWLs attracted a comparable amount of visual attention. Absolute WP harm perceptions significantly increased following the experiment and remained significantly higher at the one-week follow-up, compared to baseline. Conclusions: Warnings on WPs attracted visual attention and increased harm perceptions, and those harm perceptions remained high one week after the experiment. Findings indicate the value of including a warning on the WP device, and underscore the necessity and effectiveness of those health warnings to combat WP harm misperceptions.

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

Background Exposure to carbon monoxide (CO) remains a leading occupational hazard in firefighters, but cigarette and waterpipe smoking likely contributes to the other sources of CO in such workers. The aim of this study was to estimate the contribution of self-reported active cigarette smoking, waterpipe use, and potential job-related sources of CO to the level of exhaled CO in firefighters. Methods We surveyed the personnel of 18 fire stations (N = 842), median age 28 years, who participated at an annual screening not timed to coincide with recent firefighting. We surveyed smoking and waterpipe history, exposure to secondhand smoke (SHS), use of coal for health and biomass for cooking and time since last exposure to firefighting in the workplace. We measured exhaled CO with an instantaneous reading device (piCO Smokerlyzer). We used multivariable regression models to test the association of time since last smoked cigarette (≤12 h) and waterpipe (≤12 h) and time since last fire (≤6 h) with exhaled CO. Results In analysis limited to men (93.5% of all surveyed), 42% were daily cigarette; 1% were waterpipe smokers; 94% were exposed to SHS, 29% used coal for heating and 4% used biomass for cooking. The median CO was 4 (interquartile range 3;8) ppm. Age (beta 0.74 per 10 years, p p = 0.05), cigarette smoked in the last 12 h (beta 8.22, p p p = 0.12). There was a significant interaction between older age and firefighting for exhaled CO (p = 0.03). Conclusions Cigarette and recent waterpipe smoking are associated with increased exhaled CO in firefighters. Firefighting itself was a less potent contributor to exhaled CO when measured at an annual screening, but an age interaction was manifested.

Young adults&rsquo, hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18&ndash, 30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p &lt, 0.001), positive attitudes (p &lt, 0.001), and negative emotional response (p &lt, 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

Background: Waterpipe smoking and Internet addiction may result in a new public health problem globally. This study aimed to explore waterpipe use among a large group of adolescents and its association with Internet use, mental health, primarily depression and their demographic characteristics. Methods: Using a stratified random sampling method, 2054 tertiary school students aged 14-18 years were recruited in 2019. Demographical information and use of tobacco products (eg, waterpipe) were explored and compared with severity of Internet addiction and mental status. Results: A total of 288 (14.0%) adolescents had ever used waterpipe. Multivariate logistic regression analyses suggested that being male (OR = 2.55 and 95% CI = 1.98-3.30; P =.0001), being depressed (OR = 1.62 and 95% CI = 1.24-2.11) and excessive Internet use (OR = 1.94 and 95% CI = 1.50-2.52; P =.0001) were significantly associated with waterpipe use. Family income and parents’ educational status showed no relationship with waterpipe smoking. Conclusions: We suggest that adolescents who are depressed and who use the Internet excessively are at an increased risk for waterpipe use, independent of income and parenteral education. © 2020 John Wiley & Sons Ltd

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 (β 0.618), upon adjusting for confounders. Furthermore, dual users were associated with higher WTP nicotine dependence (β 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.

Background The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region. Hookah users are exposed to an array of chemical compounds and may suffer several chronic diseases as a result. The purpose of this study was to determine the prevalence of hookah use among male high school students in the region and to study different associated factors in order to provide local tobacco control officials with an understanding of this public health problem. Methods A convenient non-probability sampling study was conducted among students in three high schools in Al-Karkh district, Baghdad. The study period was from October 2017 till January 2019 and included 847 male students aged 15–18 years old. Using a simple random technique to select the high schools from a list of schools we chose one school from each directorate. Descriptive, chi-square test of significance, bivariate, and multivariate logistic regression analyses of data were carried out for identifying the risk factors associated with hookah smoking among these high school adolescent males. Results The overall prevalence of hookah smoking in the last 30 days among male high school students was 46.1% while in the past 6 months it was as high as 85.7%. More than two-thirds (70.6%) of the students thought that hookah smoking was more socially acceptable than cigarette smoking. Factors such as having first heard about it from friends, the media, or the presence of a hookah café near their residence were significantly associated (p > 0.05) with hookah smoking among the students. Similarly, being surrounded by friends who used hookah was also found to be significantly associated with hookah smoking, with an odds ratio of 0.18, 95% CI (0.087–0.394). Hookah smokers were less likely than non-hookah smokers to report its use as forbidden in Islam and more likely to say it is allowed in Islam. Conclusions We found an alarmingly high use of hookah smoking among male high school students in this study. Family members and peers had an important role in the prevention of hookah smoking among these students. There is a need for students to be educated about the toxicity of hookah tobacco smoking and its direct effect on their health.

BackgroundThe use of the Asian tobacco waterpipe (TWP) in the Lao People's Democratic Republic represents a potential communal source of infectious disease. This practice of smoking can lead to weakened defences of a smoker's respiratory epithelium, making the smoker vulnerable to respiratory diseases such as coronavirus disease 2019, tuberculosis and others.MethodsThis study evaluated the water quality and hygiene factors among 43 smokers of five villages in rural Luang Namtha Province. Water samples were collected from participant's TWPs and assessed for the presence of Escherichia coli, coliforms and aerobic plate count (APC) bacteria using the 3M Petrifilm.ResultsThe microbial indicator testing results were 95% positive for the APC, 38% positive for coliforms and 17% positive for the E. coli indicator. The concentrations were highest for the APC, with an average of 106 colony forming units (cfu)/ml, followed by coliforms with ConclusionsThe warm, dark and moist internal water container may facilitate microbial survival and growth. The use of a TWP adds several unstudied modes of transmission to a complex and common biobehavioural and environmental pathogen exposure. Future TWP cessation activities should be tailored to consider risks of infectious disease transmission.