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Objectives. To test a tailored mobile health (i.e., mHealth) intervention for waterpipe tobacco cessation in young adults. Methods. From 2018 to 2020 at 2 US sites, we conducted a randomized trial with 349 waterpipe tobacco smokers aged 18 to 30 years randomized to control (no intervention), untailored, or tailored intervention arms. Intervention arms received a 6-week mHealth intervention conveying risks of waterpipe tobacco through text and images and strategies to enhance motivation and support quitting. The tailored intervention was personalized to baseline measures and intervention text message responses. Risk appraisals, motivation to quit, waterpipe smoking frequency, and cessation were assessed at 6 weeks, 3 months, and 6 months. Results. At 6 months, cessation was higher in the tailored (49%) than the control arm (29%; odds ratio = 2.4; 95% confidence interval = 1.3, 4.2) and smoking frequency was lower in the tailored (mean = 3.5 days) than the control arm (mean = 4.3 days; P = .006). At interim follow-ups, significant differences in other outcomes favored the tailored intervention. Conclusions. Tailored mobile messaging can help young adult waterpipe tobacco smokers quit. This scalable intervention is poised for population implementation.

Chronic tobacco exposure can alter the endocannabinoid (eCB) system, consequently leading to an anxiety state. In this study, we investigated the effects of waterpipe tobacco smoke (WTS) on cannabinoid receptor 1 and 2 (CBR1 and CBR2) gene and protein expression in mesocorticolimbic brain regions. Using elevated plus maze (EPM) and open field (OF) tests, the effects of WTS exposure on withdrawal-induced anxiety-like behavior were examined. The effect of ceftriaxone (CEF), a β-lactam known to upregulate glutamate transporter 1 (GLT-1), on anxiety and the expression of cannabinoid receptors was also determined. Male Sprague-Dawley rats were randomly assigned to four groups: 1) the Control group was exposed only to standard room air; 2) the WTS group was exposed to tobacco smoke and treated with saline vehicle; 3) the WTS-CEF group was exposed to WTS and treated with ceftriaxone; and 4) the CEF group was exposed only to standard room air and treated with ceftriaxone. Rats were exposed to WTS (or room air) for two hours per day, five days per week for a period of four weeks. Behavioral tests (EPM and OF) were conducted weekly during acute withdrawal, 24 h following WTS exposure. Rats were given either saline or ceftriaxone (200 mg/kg i.p.) for five days during Week 4, 30 min prior to WTS exposure. Withdrawal-induced anxiety was induced by WTS exposure but was reduced by ceftriaxone treatment. WTS exposure decreased CBR1 mRNA and protein expression in the NAc and VTA, but not PFC, and ceftriaxone treatment attenuated these effects. WTS exposure did not change CBR2 mRNA expression in the NAc, VTA, or PFC. These findings demonstrate that WTS exposure dysregulated the endocannabinoid system and increased anxiety-like behavior, and these effects were reversed by ceftriaxone treatment, which suggest the involvement of glutamate transporter 1 in these effects.

Dokha is a tobacco product commonly used in Middle Eastern and Northern African regions. It is available in three blends purportedly corresponding to the degree of "buzz" experienced by the user. The "buzz" has been linked in part to nicotine levels, which are higher than those found in cigarettes and is believed to be the reason dokha is abused as a "legal high." There have been reports of seizure activity from dokha users, and elevated concentrations of toxic metals have been measured in dokha tobacco. The purpose of this work was to determine whether we could use dokha's elemental content, measured by inductively coupled plasma-mass spectrometry, to link dokha back to its brand. This could aid investigators in identifying brands and/or distribution routes in the case of adverse effects resulting from dokha use. We measured the concentrations of Mg, K, Mn, Ni, Cu, Rb, Sr, and Ba in Medwakh, Nirvana, Scorpion, Enjoy, Kingdom, and Iconic dokha brands. Analysis of variance revealed statistical differences in concentrations of elements among groups. Discriminant function analysis (using leave-one-out classification) was 58.3% successful at differentiating brands. Enjoy dokha was the most, and Kingdom dokha the least, correctly classified among groups. Attempts to further link dokha blends back to light, medium, and heavy blends were less successful. These results indicate potential for using elemental content to discriminate among dokha brands. Our data may also help to understand the degree of additional processing and/or adulteration of dokha products available to users in the United States.

Introduction Waterpipe tobacco (WPT) smoking has increased among the young population in the United States. This study assessed the extent and predictors of WPT smoking initiation and progression among US adolescents (12–17 years) and young adults (18–24 years) longitudinally. Aims and Methods We analyzed data from 4 waves (2013–2018) of the Population Assessment of Tobacco and Health (PATH) study comprising 10 692 respondents (adolescents = 5428 and young adults = 5264). Kaplan–Meier survival method estimated probabilities of WPT initiation and progression. Cox proportional hazards regression models delineated predictors of the outcomes. Results Between 2013 and 2018, 4.8% of adolescents initiated and 10.6% progressed WPT smoking. Among young adults, 18.5% initiated and 14.1% progressed WPT smoking during the same time interval. Predictors among adolescents included, WPT initiation: Hispanic ethnicity (adjusted odds ratio (aHR) = 1.75, 95% confidence interval (CI) = 1.23–2.49), lower harm perception (aHR = 2.89, 95% CI = 2.10–3.98), and other tobacco products use (aHR = 3.97, 95% CI = 2.73–5.78); WPT progression: illicit drug use (aHR = 4.60, 95% CI = 1.99–10.67). Predictors among young adults included, WPT initiation: non-Hispanic Black (aHR = 2.31, 95% CI = 1.78–3.00), Hispanic (aHR = 1.77, 95% CI = 1.34–2.33), lower harm perception (aHR = 2.77, 95% CI = 2.19–3.50), and other tobacco products use (aHR = 3.14, 95% CI = 2.25–4.38); WPT progression: non-Hispanic Black (aHR = 1.51 95% CI = 1.09–2.10), lower harm perception (aHR = 1.80, 95% CI = 1.41–2.30), and alcohol use (aHR = 1.61, 95% CI = 1.13–2.30). Conclusions Results indicate a high prevalence of WPT initiation and progression among adolescents and young adults over time, with minority racial/ethnic groups being at greater risk for both. WPT-specific risk communication interventions (eg, educational campaigns and health warning labels) are warranted to limit WPT smoking among young people.

Young adults who never engaged in waterpipe tobacco smoking (WTS) yet are open to trying it, that is, are susceptible, is a high-risk group for initiation WTS. Very few interventions dissuade this group from WTS. Thus, we explored how four short videos that varied themes of WTS harms influenced susceptible young adults' risk perceptions, risk beliefs, and susceptibility to future WTS. As part of online cross-sectional study, 208 participants aged 18-34 were randomized to watch or not a short video; each video focused on different themes of WTS risks: physical harms, myths about WTS, addiction, and harms to others. The main outcomes were perceived personal risks, risk beliefs, perceived harm of WTS compared to cigarettes, and susceptibility to future WTS. Watching any video increased beliefs of harm of WTS and lowered susceptibility to future WTS compared to not watching a video. The theme of physical harms was most effective at increasing risk beliefs and lowering susceptibility to future WTS. All four videos were rated as credible, engaging, personally relevant, producing negative affect toward WTS, and effective at dissuading WTS. These promising findings suggest further testing is needed to determine if effects persist and prevent WTS among adults susceptible to WTS.

OBJECTIVE Hookah tobacco use among young adults may be driven by misperceptions of health harms and addictiveness, appealing flavors, and social use. This study examined the effects of hookah prevention messages on participants' cognitive and emotional processing in a lab setting. METHOD One hundred twenty participants (61 susceptible never-users, 59 current users) were exposed to messages representing six categories: health risks only, health risks of social use, health risks of flavors, addiction risks only, addiction risks of social use, and addiction risks of flavors. Guided by the Limited Capacity Model of Motivated Mediated Message Processing, participants' psychophysiological responses (heart rate, skin conductance, facial action coding) were recorded while participants viewed the messages. Recognition memory and counterarguing were measured postexposure. RESULTS The combination of heart rate, skin conductance, both positive and negative facial action coding, and recognition memory indicated that social themed messages were more defensively processed than the other message types. Addiction-social messages, in particular, were least likely to be encoded. Further, defensive processing indicated by the psychophysiological and recognition data did not vary according to user status. Counterarguing was higher for users than for never-users across all message themes and risks. DISCUSSION Messages about health risks and addiction, whether or not they included information on flavors, evoked relatively similar responses. But social themed messages stand out as potentially problematic, especially addiction-social messages. Using psychophysiological and self-report measures extend opportunities to identify optimal hookah tobacco public education message features. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The desire to engage in waterpipe tobacco smoking (WTS) may occur when smokers and nonsmokers conjure positive mental simulations of WTS. However, effects of these simulations on desire to smoke waterpipe tobacco and potential mediators are unexplored. This research addressed these effects among young adult waterpipe tobacco smokers and nonsmokers. Two online studies were conducted with adults ages 18-30. In Study 1, 200 smokers, 190 susceptible nonsmokers, and 182 nonsusceptible nonsmokers were randomized to mentally simulate or not WTS in the future. In Study 2, 234 smokers and 241 susceptible nonsmokers were randomized to four arms: no simulation or simulations that varied valence of experience (positive, negative or no valence provided). Main outcomes were immediate desire to smoke waterpipe tobacco, cognitive and affective attitudes, and perceived harms. In Study 1, mental simulations increased the desire to smoke waterpipe tobacco among smokers. In Study 2, asking participants to simulate WTS positively or with no valence instruction increased desire to smoke relative to negative valence instruction or no simulation. Negative simulations reduced perceived probability of smoking within a month compared to positive simulations. Effects on desire to engage in WTS were mediated by cognitive and affective attitudes among susceptible nonsmokers and by cognitive attitudes among smokers. These findings suggest that exploring when and how often mental simulations about WTS are evoked and their potency for promoting prevention and cessation of WTS merit further attention.

Tobacco consumption, as a worldwide problem, is a risk factor for several types of cancer. In Vietnam, tobacco consumption in the form of waterpipe tobacco smoking is common. This prospective cohort study aimed to study the association between waterpipe tobacco smoking and gastric cancer mortality in Northern Vietnam. A total of 25,619 eligible participants were followed up between 2008 and 2019. Waterpipe tobacco and cigarette smoking data were collected; semi-quantitative food frequency and lifestyle questionnaires were also utilized. Gastric cancer mortality was determined via medical records available at the state health facilities. A Cox proportional hazards model was used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). During 314,992.8 person-years of follow-up, 55 men and 25 women deaths due to gastric cancer were identified. With never-smokers as the reference, the risk of gastric cancer mortality was significantly increased in participants who were ever-smoking (HR = 2.43, 95% CI = 1.35–4.36). The positive risk was also observed in men but was not significantly increased in women. By types of tobacco use, exclusive waterpipe smokers showed a significantly increased risk of gastric cancer mortality (HR = 3.22, 95% CI = 1.67–6.21) but that was not significantly increased in exclusive cigarette smokers (HR = 1.90, 95% CI = 0.88–4.07). There was a significant positive association between tobacco smoking and gastric cancer death for indicators of longer smoking duration, higher frequency per day, and cumulative frequency of both waterpipe and cigarette smoking. Waterpipe tobacco smoking would significantly increase the risk of gastric cancer mortality in the Vietnamese population. Further studies are required to understand the waterpipe tobacco smoking-driven gastric cancer burden and promote necessary interventions.

The aim: The prevalence analysis of three ways of tobacco use among young adults: traditional (smoking of cigarillos or cigars) and alternative (hookah smoking and use of E-cigarettes) as well as the development of ways of tobacco smoking prevention. Materials and methods: Cross-section anonymous survey among young adults 18-44 years of age (n=410) has been conducted. The obtained results were compared with the data of the similar studies from different countries. The statistical methods (analysis of the mean and relative values), structural and logical analysis and systemic approach. Results: Among those who were interviewed, aged 18-44 years, there are 24.15±2.11 % of respondents – hookah smokers, 9.02±1.42 % persons prefer the traditional method of tobacco use (smoking of cigarillos or cigars), while 6.34±1.20 % ones use E-cigarettes. Such forms of smoking are more common among males. The smokers of cigarillos, cigars and hookahs have appreciated their high availability when buying – 9 (7;10) points out of 10 possible. The study has found that 11.54±1.58 % of smokers of E-cigarettes and 8.08±1.35 % of hookah smokers consider them safe types of smoking and harmless to their health. Conclusions: The prevention methods of smoking prevalence among young people must be based on the tougher rules of tobacco market and latest devices for smoking at the legislative level.

Waterpipe tobacco smoking (WTS) is an emerging behavior worldwide, especially among the youth. It continues to spike in the Middle-Eastern region. WTS is associated with many harmful health-related outcomes. Objective: Herein, the attitude, knowledge, and factors affecting the knowledge of university students toward the detrimental effects of WTS were examined. This was a cross-sectional study where university students filled an online questionnaire that was available between October 2019 and May 2020. A total of 966 questionnaires were filled. About 40% of participants were current waterpipe smokers. Around 30% of participants stated that WTS is not addictive, and about third of them indicated that smoking waterpipe is an essential part of social gathering and is socially accepted behavior. Half of participants (55.8%) were knowledgeable about the major harmful consequences of WTS. Older students were more knowledgeable as compared to younger ones. In contrast, students from non-medical colleges and waterpipe smokers were less knowledgeable in comparison to those in medical colleges and non-smokers, respectively. More targeted health campaigns to control the use of WTS among university students should be implemented.

More than 10% of U.S. young adults have smoked waterpipe tobacco in the past month and25% of those who have never smoked are susceptible. We tested messages designed to prevent and reduce waterpipe tobacco smoking (WTS).In 2020, we recruited 830 U.S. young adults (18-30 years) who had never smoked waterpipe tobacco and were susceptible or currently smoked waterpipe tobacco for an online study. We randomized participants to intervention messages about the risks of WTS or control messages unrelated to tobacco. Participants had up to four message exposures over 12 weeks and completed two-, four-, and six-month follow-ups. Outcomes were WTS initiation and curiosity (susceptible never smokers), WTS frequency, cessation, motivation to quit (those who currently smoked), and WTS risk perceptions.Intervention messages increased perceived addictiveness of WTS at two months (β = 0.27; 95% CI: 0.11, 0.43) in susceptible never smokers. There were no significant intervention effects in those who currently smoked. Exploratory analyses among intervention participants showed that higher dose of message exposure decreased WTS initiation at six months in susceptible never smokers (RR = 0.68; 95% CI: 0.48, 0.96) and decreased WTS frequency (IRR = 0.84; 95% CI: 0.73, 0.97) and increased cessation (RR = 1.31; 95% CI: 1.07, 1.59) at six months in those who smoked.Although the WTS intervention messages had few significant effects on outcomes overall, a higher dose of message exposure affected behavioral outcomes in the intervention arm. Findings highlight the need to identify effective message content and optimal message dose, especially for digital media campaigns.

Introduction Waterpipe tobacco (WT) smoking is associated with misperceptions of harm, especially among users. WT packaging contains imagery, flavor descriptors, and text claims that may contribute to misperceptions. The study goal was to characterize visual and text elements of WT packaging. Aims and Methods Using data from the U.S. Population Assessment on Tobacco and Health Study Wave 2 (October 2014–October 2015), we identified the 10 most popular WT brands. For each brand, we identified available flavors, including flavor collections with unique packaging elements. We randomly selected 10 flavors per brand for purchase (March–April 2018). We conducted descriptive content analysis to code all textual and visual design elements of each package. Results Over half (54%) of WT packages had modified risk tobacco product (MRTP) claims prohibited by federal law, including substance-free MRTP claims (43%) and the descriptor “natural” (11%). No MRTP reduced exposure or reduced risk claims were found. Over a quarter (26%) of packaging including one or more of terms that may imply reduced harm including “fresh,” “premium,” “quality,” and “pure.” All packages included a text-only warning, yet none appeared on the primary display panel. Almost all packaging (99%) included imagery, with 72% including flavor imagery. The majority of packages (72%) included a smoking cue. The most popular marketing appeals were “well-made” (57%), “enjoyable” (55%), and “patriotic” (47%). Conclusions Prohibited MRTP claims, other descriptors, and flavor imagery are common on WT packaging, despite federal law. Future research is needed to evaluate if this marketing contributes to misperceptions of reduced harm. Implications Tobacco packaging is used to convey health-related messages, both explicitly and implicitly; however, information about WT packaging is virtually nonexistent. We conducted a content analysis of WT packaging from the 10 most popular US brands. Over half (54%) of packages had prohibited MRTP claims and over a quarter (26%) included one or more descriptors that may be perceived as implying reduced harm. Use of imagery, including smoking cues, was common. The widespread use of prohibited MRTP claims, other descriptors, and imagery on WT packaging may contribute to misperceptions of reduced harm.

Background Impulsivity is a formidable cause of waterpipe tobacco smoking among youth, however, it is understudied among African youth. Using PRIME behavioural theory, this study aimed to develop a model that examines the motivators of impulsivity to smoke waterpipe tobacco in linkage to the moderating role of social media normalisation of waterpipe tobacco, specifically among youth in Nigeria who smoke waterpipe tobacco. Methods Data were drawn from 695 respondents who smoke waterpipe tobacco across six Nigerian universities in the South-West zone using the chain-referral sampling procedure. Descriptive analyses of the obtained data were carried out using the Statistical Package for Social Sciences (SPSS) version 25. The constructs in the developed model were validated through Partial Least Squares Structural Equation Modelling (PLS-SEM) in SmartPLS version 3. Results Among Nigerian youth who smoke waterpipe tobacco, intention (β = 0.442, P P P P Conclusion Intention greatly instigates Nigerian youth’s impulsivity to smoke waterpipe tobacco, and social media normalisation of waterpipe tobacco also considerably increases their impulsivity to smoke waterpipe tobacco. Youth-focused educational waterpipe tobacco cessation-oriented programmes that utilise diverse constructive-based learning approaches like illustrative learning and counselling, can help to enlighten and encourage Nigerian youth on the importance of shunning the desirability to smoke waterpipe tobacco.

ObjectivesTobacco smoking is on the rise in the Eastern Mediterranean region. In light of limited surveillance of smoking in the region, this study sought to understand the prevalence of cigarette and waterpipe smoking among adults and the factors associated with smoking in Lebanon, Jordan and Palestine (West Bank only).Design, setting and participantsHousehold surveys were conducted with participants over the age of 18 in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679) between June and August 2019. A multistage cluster sampling approach with probability-proportional-to-size random selection method was followed in the three countries.Primary and secondary outcome measuresGender-specific prevalence rates for cigarette and waterpipe smoking were estimated. Multivariable logistic regression was used to examine factors associated with current cigarette and waterpipe tobacco smoking.ResultsThe prevalence of cigarette smoking among males and females respectively was 48.6% and 21.5% in Lebanon, 50.4% and 9.1% in Jordan, and 53.4% and 3.1% in Palestine. The prevalence of waterpipe smoking among males and females respectively was 32.7% and 46.2% in Lebanon, 13.4% and 7.8% in Jordan, and 18.0% and 7.9% in Palestine. Cigarette smokers were significantly (pConclusionsThe high prevalence rates of smoking in Lebanon, Jordan and Palestine are concerning. Continued surveillance is key to monitor smoking patterns and inform stronger tobacco control measures.

IntroductionThe 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.MethodsWe 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.ResultsOur 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.ConclusionsOur recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.

Background Hookah tobacco is commonly used among young adults, and use is driven in part by widespread misperceptions about risks. Social media use, particularly Instagram, is prominent in this population and exposure to commercial and user-generated content promoting hookah commonly occurs. Aims This study tested the effects of hookah tobacco risk messaging for delivery via Instagram as a strategy to offset exposure to content promoting hookah use among young adults. Method Young adult hookah smokers were recruited online for a 2 × 3 between-subjects experiment ( n = 601). Participants completed preexposure measures and were randomized to view hookah tobacco Instagram ads (commercial or user generated) with risk messages (none, risk education, or graphic risk). Stimuli were presented as a simulated Instagram feed. After viewing the stimuli, participants completed postexposure outcome measures. Results There was a statistically significant main effect of risk message type but no significant main effect of Instagram ad type or risk message type by ad type interactions. Exposure to the graphic risk and risk education messages were associated with lower intentions to engage with hookah tobacco ads on Instagram. Graphic risk and risk education messages produced greater negative emotional response and the graphic messages increased motivation to quit compared with Instagram ads alone. Discussion Findings provide preliminary evidence that hookah tobacco risk messages delivered via Instagram can offset the influence of content promoting the use of hookah tobacco. Conclusion This study represents an example of risk message testing and the results suggest the messages warrant further testing via social media delivery.

There is a growing evidence for the public health hazards associated with waterpipe tobacco smoking (WTS). While the adverse effects of WTS exposure during pregnancy on the offspring are widely reported, its impact during breastfeeding remains less understood. The effects of WTS exposure during lactation on the reproductive hormones and oxidative stress biomarkers of adult male progeny were examined. Lactating rats received either fresh air (controls) or mainstream WTS for 1 h twice/day from day 4 to day 21 of lactation. The offspring was then followed up until week 20. The data indicated that WTS exposure in the lactating animals reduced the levels of follicle-stimulating hormone (FSH), prolactin (P 0.05), luteinizing hormone (LH) (P = 0.1146), and estradiol (P = 0.0773) in the blood in male progeny. While the activities of testicular superoxide dismutase (SOD), glutathione peroxidase (GPx) and the levels of thiobarbituric acid reactive substances (TBARS) and blood levels of testosterone (P 0.05) remained unaltered, the activity of catalase increased significantly indicating an increased oxidant load in the WTS exposed rats compared to the controls. WTS exposure during lactation impairs male reproductive hormonal profile, augments oxidative damage, and potentially affects male fertility in male offspring rats.

Introduction Waterpipe use remains popular among youth with the availability of flavored shisha tobacco being one of the main drivers of waterpipe use. Although waterpipe mainstream toxicant emissions are well understood, less is known about the carryover of flavorants such as vanillin, benzaldehyde, and eugenol. In this study, flavored waterpipe tobacco was analyzed for flavorants and nicotine, and subsequent carryover to mainstream smoke. Methods Flavorants vanillin, benzaldehyde, and eugenol, and nicotine were quantified in vanilla-, cherry-, and cinnamon-flavored shisha tobacco by gas chromatography/flame ionization detector and subsequently in waterpipe mainstream smoke generated by a smoking machine. The setup allowed for sampling before and after the water-filtration step. Results Flavorant and nicotine content in smoke was reduced 3- to 10-fold and 1.4- to 3.1-fold, respectively, due to water filtration. Per-puff content of filtered waterpipe mainstream smoke ranged from 13 to 46 µg/puff for nicotine and from 6 to 55 µg/puff for flavorants. Conclusions Although water filtration reduced flavor and nicotine content in waterpipe mainstream smoke, the detected flavorant concentrations were similar or higher to those previously reported in e-cigarette aerosol. Therefore, users could be drawn to waterpipes due to similar flavor appeal as popular e-cigarette products. Absolute nicotine content of waterpipe smoke was lower than in e-cigarette aerosol, but the differential use patterns of waterpipe (>100 puffs/session) and e-cigarette (mostly Implications Although waterpipe mainstream smoke is well characterized for toxicants content, little is known about carryover of molecules relevant for appeal and addiction: flavorants and nicotine. This study shows that flavorant content of waterpipe mainstream smoke is comparable or higher than e-cigarette aerosol flavorant content. Regulatory action to address tobacco use behaviors targeting the availability of flavors should also include other tobacco products such as flavored shisha tobacco.

OBJECTIVE: There has been a growth in popularity of hookah (or waterpipes) among American college students, despite the health risks. This study investigated factors that predict hookah susceptibility and whether hookah susceptibility predicts hookah initiation and continued use. METHOD: The study established a cohort of 529 incoming college freshmen (51.6% female) who completed an online survey approximately 1 week before their arrival to a large U.S. university. Students were sent four follow-up surveys throughout the 2016–2017 academic year; 90.5% completed at least one follow-up survey. RESULTS: A total of 13.2% of the sample had used hookah at baseline and 9.9% initiated hookah use over the course of their freshman year. Among the nonusers who had no hookah susceptibility at baseline, 30.0% came to indicate some susceptibility. Multivariable logistic regression indicated that the personality construct conscientiousness was protective against becoming susceptible, whereas coming from a rural part of the state was a risk factor. Susceptibility predicted both continued use among the baseline ever-users and initiation among the baseline never-users. CONCLUSIONS: These findings highlight the role of susceptibility in the trajectory of hookah use among U.S. college students.

Background. Waterpipe tobacco smoking is associated with many negative health outcomes due to toxicants produced by heating the tobacco using charcoal or electrical heaters. Little is known about how young adult waterpipe tobacco smokers perceive harms of these heating sources. Aims. To examine young adult waterpipe tobacco smokers’ perceived harms of electrical heaters and charcoal to heat waterpipe tobacco. Method. This online cross-sectional study enrolled 18- to 32-year-olds who smoked waterpipe tobacco within the past 30 days. Participants completed measures assessing, for each heating source, amount and knowledge of toxicants released (e.g., carbon monoxide, cancer-causing chemicals), perceived safety, worry about inhaling toxicants, perceived health risk, desire to quit, and intention to smoke in the next month. Question order for knowledge of and perceived harms was counterbalanced for each heating source. Results. Analyses were based on responses from 199 participants. Perceived harms for both heating sources were average to low. Despite some question order effects, participants viewed charcoal as more harmful than electrical heaters. Participants knew more about chemicals released from charcoal than electrical heaters. Greater knowledge of chemicals released by both heating sources correlated positively with perceived harms. Perceived harms were associated with a stronger desire to quit, yet unrelated with likelihood of smoking waterpipe during the next month. Discussion. Many young adult waterpipe tobacco smokers view charcoal as more harmful than electrical heaters, although knowledge about harms for each heating source is poor. Conclusion. Interventions are needed to inform the public about harms of waterpipe heating sources in order to curb use.

Little is known about dual use of waterpipe tobacco and cigarettes, especially in countries where both are prevalent.This study aimed to assess demographic correlates, patterns of use and quit behaviours of waterpipe users in Pakistan who also smoke cigarettes.Data were taken from a randomized controlled trial in Pakistan that assessed smoking cessation in 510 adult waterpipe users, stratified on concurrent cigarette use. Logistic regression analysis was done to assess the association between waterpipe tobacco users who also smoke cigarettes (dual use) and their demographic characteristics, smoking history and quit behaviour. Unadjusted odds ratios (OR) and adjusted OR (ORa) and 95% confidence intervals (CI) were determined.Dual use was significantly associated with younger age (ORa = 0.36, 95% CI: 0.19-0.70) and middle-school educational level (11-15 years), versus no formal education, (ORa = 2.01, 95% CI: 1.15-3.50). Dual use was also associated with smoking less than all day versus all day (defined as continuously for several hours) (ORa = 2.71, 95%: CI 1.73-4.25) and younger age at starting smoking (ORa = 0.95, 95% CI: 0.93-0.98). No association was found between dual use and sex, marital status, duration of smoking, nicotine dependence or quit history.Waterpipe tobacco users who also smoke cigarettes differ from waterpipe-only users, particularly in demographic characteristics. More research is needed to explore the interaction between these two smoking behaviours. Health promotion and cessation interventions in Pakistan should consider tailoring their approach to account for the unique characteristics of dual waterpipe and cigarette users.العوامل المرتبطة بالاستخدام المزدوج لتبغ النرجيلة والسجائر بين البالغين في باكستان.محمد جواد، عمارة دوكر،منى كنعان، جاسجيت أهلوواليا، قمران صديقي.لا يُعرف سوى قدر ضئيل من المعلومات عن الاستخدام المزدوج لتبغ النرجيلة والسجائر، خاصة في البلدان التي ينتشر فيها تعاطيهما.هدفت هذه الدراسة إلى تقييم العوامل السكانية، وأنماط الاستخدام، وسلوكيات الإقلاع التي ينتهجها متعاطو النرجيلة في باكستان الذين يدخنون السجائر أيضاً.جُعت البيانات من خلال مجموعة تجارب عشوائية مُضبَّطة في باكستان لتقييم الإقلاع عن التدخين على مستوى 510 أشخاص بالغين يتعاطون النرجيلة، مُقسمين إلى طبقات حسب التدخين المتزامن للسجائر. وقد أُجري تحليل الانحدار اللوجستي لتقييم الارتباط بين متعاطي تبغ النرجيلة الذين يدخنون السجائر أيضاً (الاستخدام المزدوج)، وخصائصهم السكانية، وتاريخهم في تعاطي التبغ وسلوكهم في الإقلاع عنه. وتحددت نسبتا الأرجحية المُصحَّحة وغير المُصحَّحة وفواصل الثقة بنسبة 95٪.ارتبط الاستخدام المزدوج ارتباطاً كبيراً بالسن الأصغر (نسبة الأرجحية المُصحَّحة = 0.36، فاصل الثقة 95٪: 0.19–0.70) والمستوى التعليمي المتوسط (11–15 عاماً) (مقابل عدم الحصول على تعليم رسمي، نسبة الأرجحية المُصحَّحة = 2.01، فاصل الثقة 95٪: 1.15–3.50). كذلك ارتبط الاستخدام المزدوج بالتدخين خلال مدة أقل من يوم كامل (مقابل يوم كامل، نسبة الأرجحية المُصحَّحة = 2.71، فاصل الثقة 95٪: 1.73–4.25) وبالسن الأصغر عند بدء التدخين (نسبة الأرجحية المُصحَّحة = 0.95، فاصل الثقة 95٪: 0.93–0.98). ولم يتبين وجود أي رابط بين الاستخدام المزدوج ونوع الجنس، أو الحالة الزواجية، أو طول مدة التدخين، أو إدمان النيكوتين، أو تاريخ الإقلاع عن التدخين.يختلف متعاطو تبغ النرجيلة الذين يدخنون السجائر أيضاً عن الذين يتعاطون النرجيلة فقط، لا سيما في الخصائص السكانية. ويلزم إجراء مزيدٍ من البحث لاستكشاف التفاعل بين هذين النوعين من سلوكيات التدخين. ويتعين على التدخلات المعنية بتعزيز الصحة والمساعدة في الإقلاع عن التدخين في باكستان النظر في إمكانية مواءمة النهج الذي تسلكه لكي تأخذ بعين الاعتبار الخصائص الفريدة لمتعاطي تبغ النرجيلة بالتزامن مع تدخين السجائر (الاستخدام المزدوج).Facteurs associés au double usage du tabac pour pipe à eau et des cigarettes chez les adultes au Pakistan.Les données sur le double usage du tabac pour pipe à eau et des cigarettes sont rares, notamment dans les pays où les deux sont répandus.La présente étude avait pour objectif d'évaluer les corrélats démographiques, les schémas de consommation et les comportements de sevrage des utilisateurs pakistanais de pipe à eau qui fument également des cigarettes.Les données ont été tirées d'un essai contrôlé randomisé mené au Pakistan qui a évalué le sevrage tabagique chez 510 utilisateurs adultes de pipe à eau, avec stratification sur la consommation simultanée de cigarettes. Une analyse de régression logistique a été réalisée pour évaluer le lien entre les consommateurs de tabac pour pipe à eau qui fument également des cigarettes (double usage) et leurs caractéristiques démographiques, leurs antécédents de tabagisme et leur comportement en matière de sevrage tabagique. Des odds ratios non ajustés (OR) et ajustés (ORa) et des intervalles de confiance à 95 % ont été déterminés.Le double usage était significativement lié à un âge plus jeune (ORa = 0,36, IC à 95 % : 0,19-0,70) et à un niveau d’éducation correspondant au collège (11-15 ans) par rapport à l’absence d'éducation formelle (ORa = 2,01, IC à 95 % : 1,15-3,50). Le double usage était également associé à une consommation qui ne s’étendait pas sur toute la journée par rapport à une consommation sur toute la journée (définie comme continue pendant plusieurs heures) (ORa = 2,71, IC à 95 % : 1,73-4,25) et à un âge plus jeune au début du tabagisme (ORa = 0,95, IC à 95 % : 0,93-0,98). Aucun lien n'a été établi entre le double usage et le sexe, l’état matrimonial, la durée du tabagisme, la dépendance nicotinique ou l'historique des sevrages.Les consommateurs de tabac pour pipe à eau qui fument également des cigarettes se différencient des consommateurs de tabac pour pipe à eau seul, surtout du point de vue des caractéristiques démographiques. Des recherches supplémentaires sont requises pour étudier l'interaction entre ces deux comportements tabagiques. Les approches de promotion de la santé et les interventions en faveur du sevrage tabagique au Pakistan devraient être adaptées en tenant compte des caractéristiques uniques des consommateurs de tabac pour pipe à eau et de cigarettes.

Using waterpipe is the most common method of tobacco consumption among Iranian females and the rate has significantly increased over the past few decades.The purpose of this study was to determine the factors that contribute to the initiation of waterpipe tobacco smoking among females in Gorgan, Islamic Republic of Iran.This cross-sectional study was conducted between March and June 2016 in Gorgan. Two hundred and six females who smoked waterpipe tobacco were recruited as participants using convenience and snowball sampling methods. Data were collected using a questionnaire examining the factors that facilitate initiation of waterpipe smoking among females.Positive attitudes towards waterpipe smoking and its availability were the most frequently reported factors contributing to its initiation among females (87.9%). Curiosity (80.1%) and waterpipe smoking among family members (70.9%) were also significant. The least frequently reported factor was "attracting other's attention and cooperation".A positive opinion, availability, curiosity and presence of waterpipe smoking among family members and relatives were the most signifcant factors that facilitated initiation of waterpipe smoking among females. To reduce its prevalence, it is recommended that intervention strategies be implemented to change attitudes and reduce access to waterpipe tobacco at family and social gatherings.العوامل التي تُسهم في بدء تدخين النرجيلة بين النساء الإيرانيات.شيرين صيقلده، عبد الرحمن جركزي، مهناز أماني، طيبة أستوان، إلميرا منكلي زاده.يُعتبر تدخين النرجيلة أكثر طرق تعاطي التبغ انتشاراً بين النساء الإيرانيات، وقد ارتفع معدل تدخينها ارتفاعاً كبيراً على مدار العقود القليلة الماضية.تمثل الغرض من هذه الدراسة في تحديد العوامل التي تُسهم في بدء تدخين النرجيلة بين النساء في جرجان.أُجريت هذه الدراسة الشاملة لعدة قطاعات في الفترة بين مارس/آذار ويونيو/حزيران 2016 في جرجان. وقد استعنّا بعدد 206 نساء من مدخنات النرجيلة للمشاركة في هذه الدراسة. واُخْتِير هؤلاء النساء بأسلوب أخذ العينات الملائمة وأسلوب كرة الثلج لأخذ العينات. وقد جُعت البيانات عن طريق استبيان لتحديد العوامل التي تُيسر بدء تدخين النرجيلة بين النساء.كانت النظرة الإيجابية تجاه النرجيلة وتوافرها أكثر ما ذُكر من العوامل التي تُسهم في بدء تدخينها بين النساء (87.9٪). ومن ضمن العوامل المهمة أيضاً كان الفضول (80.1٪)، وتدخين النرجيلة بين أفراد الأسرة (70.9٪). أما "جذب انتباه الآخرين والتعاون" فكان من أقل العوامل المذكورة.جاءت النظرة الإيجابية تجاه تدخين النرجيلة، وتوافرها، والفضول إزائها، وتدخينها بين أفراد الأسرة والأقارب ضمن أهم العوامل المذكورة التي تُيسر بدء تدخين النرجيلة بين النساء. ولتقليل معدل انتشار تدخين النرجيلة بين النساء، نوصي ببعض استراتيجيات التدخل التي تُغير النظرة إلى النرجيلة وتقلل إمكانية الوصول إليها في تجمعات الأسرة والأصدقاء.Facteurs contribuant à la mise en place d’un tabagisme par pipe à eau chez les femmes iraniennes.La pipe à eau est la méthode de consommation de tabac la plus répandue parmi les femmes iraniennes et le taux de consommation a considérablement augmenté au cours des dernières décennies.L’objectif de la présente étude était de déterminer les facteurs qui contribuent à la mise en place d’un tabagisme par pipe à eau parmi les habitantes de Gorgan (République islamique d’Iran).La présente étude transversale a été menée entre les mois de mars et de juin 2016 à Gorgan. Nous avons recruté 206 fumeuses de pipe à eau comme participantes. Ces dernières ont été sélectionnées à l’aide des méthodes d’échantillonnage de commodité et boule de neige. Les données ont été collectées au moyen d’un questionnaire portant sur les facteurs qui facilitent l’initiation d’un tabagisme de ce type chez les femmes.Les attitudes positives vis-à-vis de la pipe à eau et de sa disponibilité constituaient les facteurs les plus fréquemment rapportés qui contribuaient à la mise en place d’un tabagisme par pipe à eau chez les femmes (87,9 %). La curiosité (80,1 %) et l’utilisation de la pipe à eau au sein de la famille (70,9 %) étaient également des facteurs importants. Le facteur le moins fréquemment rapporté correspondait à l’énoncé : « attirer l’attention et susciter l’aide de l’autre ».L’attitude positive, la disponibilité, la curiosité et l’existence d’un tabagisme par pipe à eau au sein des membres de la famille et des proches constituaient les facteurs les plus importants qui facilitent la mise en place de ce type de tabagisme chez les femmes. Afin de réduire la prévalence de ce tabagisme chez les femmes, nous recommandons la mise en œuvre de stratégies d’intervention visant à modifier les attitudes et à réduire l’accès au tabac pour pipe à eau lors des réunions en famille et des rencontres sociales.

Cigarette smoking is the most common form of tobacco consumption but other methods have grown in popularity. In the United Arab Emirates and other Gulf countries, smoking dokha, a form of tobacco mixed with herbs and spices in a midwakh pipe, is common.The aim of this study was to determine the prevalence of midwakh use in school students in Lebanon and factors associated with its use.Data on tobacco use from the Lebanon Global School-based Student Health Survey (GSHS), 2017 were analysed, including current midwakh use (defined as midwakh use at least once in the 30 days before the survey). The survey includes school students in grades 7-12 (12-18 years). Current midwakh use was analysed according to sociodemographic and tobacco-related variables using bivariate and logistic regression analyses.Of the 5590 students included in the analysis, 4.6% were current midwakh users. Current midwakh use was significantly more prevalent in students 13 years and older and in male students (P0.01). Current use was also statistically significantly more prevalent in students in public than private schools. Current cigarette smoking (OR = 15.22; 95% CI: 11.08-20.90), ever use of a waterpipe (OR = 9.61; 95% CI: 6.66-13.86) and parental smoking (OR = 1.56; 95% CI: 1.05-2.31) were also significantly associated with current midwakh use.Although midwakh use is low in Lebanon, the patterns of association of midwakh use are similar to those of cigarette and waterpipe smoking in young people. Further research is needed to understand the context of midwakh use and prevent it from spreading.تعاطي التبغ باستخدام المدواخ بين طلاب المدارس في لبنان: تحليل البيانات من المسح العالمي لصحة طلاب المدارس.ريما عفيفي، مونيشا سرافنان، نورا الصليبي، ريما نقاش، أليسار راضي، سكوت شرمان، ليليان غندور.يُعتبر تدخين السجائر من أكثر طرق تعاطي التبغ شيوعاً، ولكن ثمة طرقاً أخرى آخِذة في الانتشار انتشاراً كبيراً. ففي الإمارات العربية المتحدة وبعض بلدان الخليج الأخرى، أصبح شائعاً تدخينُ الدوخة بالمدواخ، وهي نوع من التبغ مخلوطٌ مع أعشاب وتوابل.هدفت هذه الدراسة إلى الوقوف على مدى انتشار استخدام المدواخ بين طلاب المدارس في لبنان والعوامل المرتبطة بذلك.حُللت بيانات بشأن تعاطي التبغ من المسح العالمي لصحة طلاب المدارس في لبنان لعام 2017، وتضمنت الاستخدام الحالي للمدواخ (عُرِّف بأنه استخدام المدواخ مرةً واحدة على الأقل خلال الثلاثين يوماً السابقة للمسح). وشمل المسح طلاب المدارس في الصفوف من 7-12 (12-18 عاماً). وقد حللنا استخدام المدواخ في الوقت الحالي وفقاً للمتغيرات الاجتماعية السكانية وتلك المرتبطة بالتبغ باستخدام تحليل ثنائي المتغير وتحليل الانحدار اللوجستي.تبين أن 4.6٪ من الطلاب الذين شملهم التحليل وعددهم 5590 طالباً من مستخدمي المدواخ في الوقت الحالي. وكانت نسبة مستخدمي المدواخ في الوقت الحالي أعلى كثيراً في الذكور، والطلاب البالغين 13 عاماً فما فوق، وطلاب المدارس العامة. وقد ارتبط ارتباطاً قوياً باستخدام المدواخ في الوقت الحالي: تدخينُ السجائر حالياً (نسبة الأرجحية المُصحَّحة = 15.22؛ فاصل الثقة 95٪: 11.08-20.9)، وأي استخدام للنرجيلة: نسبة الأرجحية المُصحَّحة = 9.61؛ فاصل الثقة 95٪: 6.66-13.86)؛ وتدخين الآباء (نسبة الأرجحية المُصحَّحة = 1.56؛ فاصل الثقة 95٪: 1.05-2.31).على الرغم من انخفاض استخدام المدواخ في لبنان، إلا أن النماذج المرتبطة باستخدامه مشابهة لتلك المرتبطة بتدخين السجائر والنرجيلة في صفوف الشباب. ويلزم إجراء مزيدٍ من البحث لفهم سياق استخدام المدواخ والحيلولة دون انتشاره.Bases factuelles tirées de l'Enquête mondiale en milieu scolaire sur la santé des élèves au Liban sur le tabagisme par midwakh : signe avant-coureur de la prochaine pandémie mondiale de tabagisme ?Le tabagisme par cigarettes est le premier mode de consommation du tabac, mais d'autres méthodes ont gagné en popularité. Aux Émirats arabes unis ainsi que dans d'autres pays du Golfe, il est courant de consommer la dokha, un type de tabac mélangé à des herbes et des épices, au moyen d'une pipe appelée « midwakh ».La présente étude avait pour objectif de déterminer la prévalence de l'utilisation de la midwakh parmi les élèves libanais ainsi que les facteurs qui y sont associés.Les données sur le tabagisme issues de l'Enquête mondiale en milieu scolaire sur la santé des élèves au Liban en 2017 ont été analysées, y compris l’utilisation de la midwakh au moment de l'enquête (définie comme l'utilisation de cette dernière au moins une fois dans les 30 jours ayant précédé l'enquête). L'enquête incluait des collégiens et des lycéens (âge compris entre 12 et 18 ans). En réalisant des analyses bivariées et de régression logistique, nous avons analysé l'utilisation de la midwakh au moment de l’étude en fonction des variables sociodémographiques et liés au tabagisme.Sur les 5 590 élèves inclus dans l'analyse, 4,6 % étaient des utilisateurs de la midwakh au moment de l’étude. L'utilisation de la midwakh était significativement plus fréquente chez les élèves de 13 ans et plus et chez les élèves de sexe masculin (p0,01). L'utilisation de la pipe était statistiquement plus répandue, de façon significative, chez les élèves des écoles publiques par rapport à ceux des écoles privées. Le tabagisme par cigarettes (odds ratio (OR) = 15,22 ; intervalle de confiance à 95 % (IC) : 11,08-20,90), le fait d’avoir déjà fumé le narguilé (OR = 9,61 ; IC à 95 % : 6,66-13,86) et le tabagisme des parents (OR =1,56 ; IC à 95 % : 1,05-2,31) étaient également fortement liés à l'utilisation de la midwakh au moment de l’étude.Bien que l'utilisation de la midwakh soit peu répandue au Liban, les schémas d'association de son utilisation sont analogues à ceux du tabagisme par cigarettes et par narguilé chez les jeunes. Des recherches supplémentaires sont nécessaires pour comprendre le contexte de l’utilisation de la midwakh et pour éviter sa propagation.

Recent data show an increase in the prevalence of waterpipe tobacco smoking (WTS) among university students in the Arab Gulf region alongside an attitude of social acceptability and a perception that WTS is less harmful than traditional cigarette smoking. This study measures the prevalence of WTS among university students and examines the individual, sociocultural, and environmental factors influencing this practice. Participants were selected through stratified random sampling of students in the largest national university in Qatar. Data were collected anonymously using an online questionnaire. Descriptive univariate and bivariate analyses were conducted to examine the association of WTS with participants' sociodemographic characteristics, knowledge, and attitudes. 199 students completed the questionnaire. Among students who reported using tobacco products, waterpipe () was the most common product (70.6%). WTS was significantly associated with having a mother ( = 0.015) or a close friend ( < 0.001) who smoked. Compared to non-users, waterpipe tobacco users were significantly more likely to believe that waterpipe tobacco is less addictive than cigarettes (p = 0.009) and significantly less likely to believe that waterpipe tobacco can lead to cardiovascular diseases (p = 0.003) or dental problems (p = 0.02). More waterpipe tobacco users than non-users disagreed that parents (p = 0.005) or advertisements (p = 0.002) could influence use. More waterpipe tobacco users (70%) than non-users (37%) believed that females were more comfortable using waterpipes than cigarettes. The findings shed light on factors shaping WTS and provide evidence for designing multilevel behavioral interventions to decrease the prevalence of WTS among youth. Open Access funding provided by the Qatar National Library. We acknowledged the support provided by the Institutional Research and Analytic Department at Qatar University in the sampling and data collection process.

Background: Waterpipe (i.e., hookah) tobacco smoking (WTS) is one of the most prevalent types of smoking among young people, yet there is little public education communicating the risks of WTS to the population. Using self-report and psychophysiological measures, this study proposes an innovative message testing and data integration approach to choose optimal content for health communication messaging focusing on WTS. Methods: In a two-part study, we tested 12 WTS risk messages. Using crowdsourcing, participants (N = 713) rated WTS messages based on self-reported receptivity, engagement, attitudes, and negative emotions. In an in-lab study, participants (N = 120) viewed the 12 WTS risk messages while being monitored for heart rate and eye-tracking, and then completed a recognition task. Using a multi-attribute decision-making (MADM) model, we integrated data from these two methods with scenarios assigning different weights to the self-report and laboratory data to identify optimal messages. Results: We identified different optimal messages when differently weighting the importance of specific attributes or data collection method (self-report, laboratory). Across all scenarios, five messages consistently ranked in the top half: four addressed harms content, both alone and with themes regarding social use and flavors and one addiction alone message. Discussion: Results showed that the self-report and psychophysiological data did not always have the same ranking and differed based on weighting of the two methods. These findings highlight the need to formatively test messages using multiple methods and use an integrated approach when selecting content.

Introduction: There are a number of well-established risk factors for multiple sclerosis (MS). Other factors, however, showed conflicting or inconsistent results. Here, we examine some factors that are unique to or more practiced in Saudi Arabia (SA) and the Arab region such as waterpipe tobacco smoking (WTS), face veiling, raw milk (RM) and camel milk (CM) consumption, and tuberculosis (TB) infection in addition to other traditional factors. Methods: This is a sex- and age-matched case-control study in which we used a structured questionnaire to examine the relation between a number of factors and exposures and the risk of MS. Three hundred MS patients and 601 controls were included. Data were analyzed across different statistical models using logistic regression adjusting for age, sex, marital status, duration of breastfeeding, age first joining school, coffee consumption, and face exposure. Results: Cigarette smoking (OR = 1.79, [95% CI: 1.01–3.17], p = 0.047), WTS (OR = 2.25, [95% CI: 1.21–4.15], p = 0.010), and CM consumption (OR = 2.50, [95% CI: 1.20–5.21], p = 0.014) increased the risk of MS, while performing hajj (OR = 0.47, [95% CI: 0.34–0.67], p = 0.001), TB infection (OR = 0.29, [95% CI: 0.11–0.78], p = 0.015), face veiling (OR = 0.32, [95% CI: 0.23–0.47], p = 0.001), and coffee consumption (OR = 0.67, [95% CI: 0.49–0.89], p = 0.008) appeared to be associated with decreased risk. No association was found between fast food, processed meat, soft drinks, animal milk (other than camel), or RM consumption and the risk of MS. Conclusion: The results of this case-control study confirm that different means of tobacco smoking are associated with increased risk of MS. It also sheds more light on the complex association between infections and MS.