Comprehensive Tobacco Control Programs Research Articles

Exploring the prevalence, knowledge, attitudes and influencing factors of e-cigarette use among university students in Palestine: a cross-sectional study

ObjectivesE-cigarettes have gained popularity, especially among young adults. This study aims to determine the prevalence of e-cigarette smoking, assess knowledge and attitudes and identify associated factors among Palestinian university students.DesignA...

Factors associated with the implementation of a comprehensive tobacco cessation benefit among California Medicaid managed care plans

AbstractAlthough tobacco control efforts have been successful at reducing the rate of tobacco use in the general population, rates of use among low‐income populations persist. As a leader in tobacco control efforts, the U.S. state of California recently issued regulations regarding comprehensive tobacco cessation service requirements for state Medicaid plans (i.e., Medi‐Cal MCPs) providing health care to low‐income Californians. This research aims to evaluate the potential factors associated with the adoption of a comprehensive tobacco control program among Medi‐Cal's MCPs. In 2018, UC San Diego researchers distributed a survey to a listserv of 25 Medi‐Cal MCP health educators, for a response rate of 96%. The survey was comprised of questions related to All Plan Letter (APL) implementation of tobacco cessation services and policies. Health educators were also recruited to participate in a semi‐structured interview upon survey completion. Two years postrelease of the APL, Medi‐Cal's MCPs demonstrate low implementation of tobacco cessation services and related policies, with only one MCP (5%) fully implementing all 10 core provisions. Five consistent patterns were identified as being associated with implementation: larger MCP enrollment and staffing, lower median household income, noncapitated provider payment, participation in county tobacco control meetings, and high‐quality scores for preventive care and treatment of chronic disease. Small‐sized MCPs have been slow in fully implementing tobacco cessation services. State policymakers and tobacco control stakeholders may consider providing support to small‐sized MCPs to aid in their continued adoption of comprehensive tobacco cessation services. DHCS should also consider releasing guidance on how to engage in activities to ensure APL compliance.

Defining indicators for the scoping stage of health impact assessment to evaluate tobacco control policy in the city of Beijing

IntroductionBeijing initiated the nation’s most comprehensive tobacco control program that adheres to the WHO Framework Convention on Tobacco Control. This study aimed to identify a set of indicators for the scoping of an Health Impact Assessment (HIA) to assess this policy.MethodsThis study used a modified Delphi process. It proposed a tobacco control health impact framework based on the Driving forces- Pressure- State- Exposure- Effect- Action model and the Determinants of Health Theory. After a review of current surveillance system and literature, a working group of 13 experts with multidisciplinary background was established to formulate indicator evaluation criteria and conduct indicator scoring. Each indicator was scored by experts according to four evaluation criteria chosen. Indicators that obtained a total score above 80% and with standard error less than 5 were selected as the final set of indicators. Kendall’s coefficient of concordance was calculated.ResultsTwenty-three out of 36 indicators were selected. Smoking prevalence, mortality rate, hospital admission rate, tobacco consumption and hospital admission fees of smoking related diseases achieved more than 90% of total scores and ranked as the top five. Kendall’s concordance coefficient was 0.218 for all indicators. For all model composition, Kendall’s concordance coefficients were statistically significant.ConclusionThis study identified a set of twenty-three indicators for scoping of HIA of a comprehensive tobacco control policy in Beijing based on a tobacco control health impact conceptual framework. The set of indicators achieved high scores and statistically significant consistency and has great potential to promote the evaluation of tobacco control policy in a global city. Further study might use the set of indicators for HIA on tobacco control policy to analyze empirical data.

Prevalence of Adverse Health Effects of Tobacco Addiction in Different Types of Prakriti – An Observational Study

According to the National Institute on Drug Abuse, tobacco is one of the most widely used addictive items in the United States (NIDA). Addiction is a long-term illness marked by obsessive drug seeking and usage and long-term chemical and molecular alterations in the brain. Tobacco smoking is linked to 5 million fatalities worldwide, making it one of the major causes of mortality. Comprehensive tobacco control programs can significantly lower the frequency of tobacco use. The study was a cross-sectional study. Approval was taken from the institutional ethical committee. Personal interviews were conducted at Mahatma Gandhi Ayurved College, Hospital & Research Centre, Salod (H), Wardha district. All the subjects were personally interviewed based on the questionnaire. The survey elicited 209 replies, and based on the findings, the following observations were made. Individuals who were addicted to tobacco chewing in the Wardha district were included in the study. One hundred percent of participants completed the survey. The evaluation used a question-and-answer format, a typical Prakriti assessment, and tobacco addiction-related questions. The study gathered 209 replies from tobacco-dependent residents in the Wardha district, who were selected based on their comments and observations. Tobacco chewing percentage was more found in males (21%) than females (2.8%). Twenty-five percent were primarily Vata Prakriti, fifty-nine percent were Pitta Prakriti, and eighteen percent were Kapha Prakriti. Compared to Pitta and Kapha Prakriti people, Vata-dominant Prakriti people are more likely to experience the negative effects of tobacco addiction.

Transitions in smoking status in nursing students: A prospective longitudinal study.

To describe transitions in smoking status and their determining factors among nursing students between baseline (2015-2016) and follow-up (2018-2019). Observational prospective longitudinal study of 4381 nursing students in Catalonia (Spain). We examined transitions in smoking status from: (i) current smokers to recent quitters, (ii) never smokers to new smokers and (iii) former smokers to quitters who relapsed. We fitted logistic regression models to assess the predictors of quitting smoking. The proportion of current smokers decreased from 29.7% at baseline to 23.6% at follow-up, with a cumulative incidence rate of quitting of 28.3% during follow-up. Nondaily smokers were more likely to quit than daily smokers. Of those who were never smokers at baseline, 4.6% were smokers at follow-up, and 23.2% of former smokers at baseline had relapsed at follow-up. Nondaily smokers were more likely to have quit smoking at follow-up among this cohort of nursing students. The early implementation of a comprehensive tobacco control program that includes tobacco-free campus policies, tobacco prevention interventions and cessation support during college years may decrease tobacco use among nursing students. Nursing students' tobacco use is concerning, as they are the future workforce of nurses who have a key role in tobacco product use prevention and cessation. During college years, nursing students have a greater likelihood of experimenting with several smoking status changes as well as to consolidate smoking behaviors. This is the first longitudinal study to highlight the factors associated with quitting smoking among a cohort of Spanish nursing students. Being a nondaily smoker at baseline predicted quitting at follow-up. Our findings support the early implementation of a comprehensive tobacco control program that includes tobacco-free campus policies, tobacco prevention interventions and tobacco cessation support during college years to decrease tobacco product use prevalence among nursing students. We have adhered to STROBE guidelines. No Patient or Public Contribution. This observational study has not been registered.

The Impact of a Virtual Tobacco Prevention and Advocacy Training Among Youth in Appalachian Kentucky Communities.

Engaging youth is an important component of comprehensive tobacco control programs. This paper describes the impact of a virtual tobacco prevention training program to encourage and prepare youth in Appalachia to support tobacco prevention policies, to strengthen interpersonal confidence to address tobacco use within their communities and enhance advocacy self-efficacy for tobacco control. A two-part evidence-informed peer-led tobacco prevention and advocacy training was implemented among 16 high school students from Appalachian counties in Kentucky. The initial training (January 2021) included an overview of the e-cigarette landscape, advocacy skills related to policy change, developing messages to decision makers, and media advocacy. A follow-up session (March 2021) included a breakdown of advocacy skills and overcoming barriers. Overall, participants held strong beliefs that tobacco use is an issue that needs to be addressed in their community. There was a statistically significant average difference in student interpersonal confidence between baseline and post-surveys (t = 2.016, P = .062 < .1). Students who participated in at least 1 of the provided advocacy events indicated higher self-reported advocacy. Youth in Appalachia expressed an interest to advocate for stronger tobacco policy in their communities. Youth who participated in the tobacco advocacy policy trainings reported improvements in attitudes, interpersonal confidence, advocacy self-efficacy, and self-reported advocacy. Youth engagement in tobacco policy advocacy is promising and needs to be further supported.

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021.

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021.

Evidence of the impact of a national anti-tobacco prevention campaign across demographic subgroups.

Mass media campaigns are an effective population-level intervention for preventing tobacco use. However, little evidence exists for whether these campaigns similarly influence demographic subgroups. This study examined the effects of the truth® campaign to reduce tobacco use among demographic subgroups. We used data from a national, continuous, cross-sectional tracking survey of 15-24-year-olds (n = 32 331). We used a measure of weekly aggregated campaign exposure to assess whether cigarette smoking intentions and current cigarette use varied by race/ethnicity, financial situation and population density subgroups, controlling for factors known to be associated with tobacco use. Examining estimates across subgroup categories in light of the overall model estimates revealed that the effects of week-level campaign exposure on cigarette smoking intentions and current cigarette use were similar across subgroups. Wald tests of equality across estimates in each subgroup suggested that the estimates did not differ from one another in any given instance. The truth campaign does not differ significantly in its capacity to prompt declines in tobacco use across a broad spectrum of US youth and young adults. Mass media tobacco prevention campaigns can be an effective and critical component of a comprehensive tobacco control program, particularly with respect to reducing tobacco-related disparities among demographic subgroups.

Epidemiology of lung cancer and the gender differences in risk

Background: Lung cancer has progressed from an exceedingly rare disease to the leading cause of all cancer-related deaths, a phenomenon largely attributed to the impact of tobacco smoking and resulting global epidemic. Methods: A thorough literature search was conducted to identify relevant factors in the epidemiology of lung cancer with a focus on recent studies and developments that had the most significant impact on the current understanding of lung cancer. Results: Most recent data suggests the global burden of lung cancer is continuing to rise with 2.2 million new cases in 2020 alone. Although no difference is noted among men, a higher rate of lung cancer deaths among women in the industrialized countries are observed compared to developing nations. Incidence and deaths are closely linked to cigarette smoking. Other risk factors include occupational hazards, increasing air pollution with pulmonary infectious diseases and inflammatory conditions, and genetic factors. Tobacco continues to cause approximately 90% of all lung cancer deaths with a markedly wide variety of incidence rates both geographically and between males and females. Lung cancer incidence has been falling in US and UK since 1990 largely due to comprehensive tobacco control programs. In contrast higher rates of cigarette smoking among emerging nations is a concern. The unprecedented, widespread adoption of electronic-cigarette use among adolescents may pose major obstacles in the prevention and treatment of lung cancer. Conclusions: While the vast majority of current lung cancer cases and deaths continue to be caused by tobacco consumption, shifts in population behaviors, geographical location, and potential new causes may alter this distribution. Further work is crucial in order to better understand the risk factors for lung cancer in the modern world so that a more holistic proactive approach, rather than a reactive approach, can be taken.

Changing pattern of smoking behavior among Mongolian adolescents: Results from the GYTS (2003-2019)

Abstract Background Tobacco use has become a global health concern. Most part of smokers initiate smoking during their adolescence. This study aims to analyze the changing pattern of cigarette smoking among adolescents in Mongolia. Methods The retrospective data analysis is based on four repeated national cross-sectional Global Youth Tobacco Surveys (GYTS) conducted in 2003, 2007, 2014 and 2019. Data were collected by self-administered questionnaires. The sample represented the students aged 12-16 years. Pearson's chi-squared tests and logistic regression analyses were performed by using IBM SPSS version 24 software. Results Altogether, 17,458 students participated in the four surveys. There was an overall decrease in the prevalence of ever smokers (40.4% in 2003, 21.2% in 2019; p &amp;lt; 0.001), current smokers (9.2% in 2003, 4.4% in 2019), and planning of cessation (84.0% in 2003, 62.9% in 2019; p &amp;lt; 0.001). Smoking related knowledge has been changed, e.g., the prevalence of students who thought smoking helps people feel more comfortable decreased from 28.3% to 7.2%. From the point of the media effects the percentage of students who saw anti-tobacco message in the media significantly decreased (from 84.0% to 62.9%, p &amp;lt; 0.001). Additionally, the percentage of participants who were exposed to tobacco smoke at home decreased from 64.1% to 42.6% (p &amp;lt; 0.001) between 2003 and 2019. The multivariate logistic regression analyses by years showed that males, those who were exposed by smoke at home, who thought that smoking makes people more comfortable were more likely to be current smokers; no association was found with anti-tobacco messages. Conclusions Despite of the implementation of tobacco control policies, smoking is a major problem in the Mongolian population. The findings of GYTSs provide information to the development of an adolescent specific national tobacco control program, which will help to combat the tobacco epidemic. Key messages A positive trend of smoking behavior among adolescents has been demonstrated in Mongolia. The findings help to develop a comprehensive adolescent specific school-based tobacco control program.

Regulatory Approaches and Implementation of Minimally Addictive Combusted Products.

A joint meeting was held by the World Health Organization (WHO) and the Convention Secretariat of the WHO Framework Convention on Tobacco Control to examine the potential effects of a regulatory policy to reduce nicotine in cigarettes to minimally addictive levels. This paper reviews the feasibility of and approaches to implementing a nicotine product standard. Prior WHO reports on this topic were consulted and a systematic review of the scientific literature was conducted. The paper was reviewed by the participants at the aforementioned meeting and their feedback was incorporated. The nicotine dose most likely to consistently reduce smoking behavior and dependence is ≤0.4 mg nicotine/g tobacco. An immediate rather than a gradual nicotine reduction approach appears to be more beneficial. Smokers are likely to seek nicotine from alternate sources (e.g., nicotine replacement therapies, e-cigarettes) or potentially, the illegal market. As such, the availability of alternative products, as well as strong policies against illegal markets, can potentially mitigate unintended consequences. An effectively reduced nicotine regulation must be imbedded in a comprehensive and strong tobacco control program that includes public education and surveillance. Barriers and challenges to implementing a nicotine product standard exist, particularly in low-capacity countries. Not all countries will have the capacity to implement a regulation to reduce nicotine in cigarettes (and preferably other combusted tobacco products) to minimally addictive levels. However, for the countries that choose to implement it, such a policy could potentially dramatically reduce the burden of tobacco use. Article 9 of the Framework Convention on Tobacco Control provides signatory governments the authority to implement a product standard for reducing nicotine in tobacco products to minimally addictive levels. This product standard has the potential to result in a dramatic reduction in cigarette and other combusted tobacco use and therefore, smoking-caused mortality and morbidity. This article describes the growing scientific evidence to support nicotine regulation in cigarettes, potential regulatory approaches and describes the infrastructure and tobacco control policies needed to implement a reduced nicotine product standard.

Parental tobacco and indoor secondhand smoking exposure and the risk of offspring under-five mortality in low- and middle-income countries.

Children are vulnerable to exposure of secondhand smoking (SHS) which is a major preventable cause of disease and death. This study aimed to investigate the association between parental tobacco use or SHS exposure, respectively, and under-five mortality. Data were obtained from the nationally representative and population-based Demographic and Health Surveys in low- and middle-income countries (LMICs) between 2000 and 2018. Cox proportional hazard regression models with complex survey design were conducted to examine the adjusted associations between parental smoking and SHS exposure and child under-five mortality. In the pooled analysis of parental smoking, 437322 children were included. Compared with children whose parents are not smoking, those whose father or both parents smoked any form of tobacco had higher risks of mortality (hazard ratio [HR]=1.08, 95% confidence interval [CI]=1.03-1.13; HR=1.18, 95% CI=1.06-1.32, respectively). In addition, parental using smokeless tobacco, smoking tobacco, and using smokeless tobacco and smoking tobacco simultaneously was significantly associated with child under-five mortality (HR=1.07, 95% CI=1.01-1.12; HR=1.12, 95%CI=1.04-1.21; and HR=1.17, 95%CI=1.06-1.30, respectively). In the pooled analysis of SHS exposure, 605442 children were included, and weekly and daily SHS exposure were significantly associated with child under-five mortality (HR=1.11, 95% CI=1.03-1.20, and HR=1.10, 95% CI=1.06-1.15, respectively). The results were robust in most stratification analyses and sensitivity analyses. Parental tobacco use and indoor SHS exposure were associated with increased risk of under-five mortality in LMICs. Comprehensive tobacco control programs should be considered by policymakers in LMICs to promote smoke-free environments for children.

Beyond “Safe and Effective”: The urgent need for high-impact smoking cessation medications

Smoking cessation medications (SCMs) are an evidence-based cornerstone of comprehensive tobacco control programs globally. However, the impact of SCMs on population smoking prevalence is controversial, with inconsistencies between randomized controlled trials (RCTs) and population-based observational studies. We estimated SCM impact on permanent cessation and population smoking prevalence by extrapolating efficacy estimates from meta-analyses of RCTs, using the standard population impact formula: efficacy*reach. We calculated the potential SCM impact under a range of assumptions for permanent cessation (20%,14%), behavioral support (yes/no), reach (40%–2%), and underlying smoking prevalence. Assuming behavioral support for all, depending on reach, 8%–0.3% of smokers are expected to quit permanently. Without behavioral support, permanent cessation is estimated to be 6.4%–0.2%. Assuming an underlying population smoking prevalence of 14%, (current U.S. prevalence), the maximum impact on population smoking prevalence is 1.12%. Impact on prevalence increases with increasing underlying country-specific levels of prevalence. With current U.S. levels of reach, behavioral support and smoking prevalence, we estimate that, based on a single course of treatment, 2.3% of smokers would quit permanently, contributing to a 0.3% decrease in population level smoking prevalence. Even under ideal conditions, the potential of current first-line SCMs to increase cessation in a substantial proportion of smokers, and reduce population smoking prevalence, is limited. In order to avert the predicted billion tobacco-caused deaths in this century, “safe and effective” medications are not sufficient: SCMs with high population impact are urgently needed. Policies to ensure the availability and accessibility of highly efficacious SCMs, with behavioral support, are crucial.

Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network

Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network

A Systematic Review about Educational Campaigns on Smoking Cessation

Background:Health campaigns have been shown effective in the prevention of smoking. These campaigns convey messages about specific behavior to the audience and have a high penetration rate.Objective:This systematic review was conducted to summarize the effect of educational campaigns on smoking.Methods:The PubMed, Web of Science, Scopus, Embase, Google Scholar databases were searched on 16 March, 2019 by using the keywords “Waterpipe, Hookah, Shisha, Cigarette, Smoking” and “Campaign, Antismoking Campaign, Health campaign”.Results:A total of 15 articles related to smoking campaigns entered the review. Campaigns were divided into two broad categories: (1) Campaigns aimed at public education and social change; (2) Campaigns aimed at changing policy or attracting the attention of politicians. The largest campaign was conducted in England. All educational campaigns showed at least one positive effect on preventing and controlling smoking.Conclusion:Anti-smoking campaigns are important investments, and as part of comprehensive tobacco control programs, they can educate people about the harms of smoking, change smoking attitudes and beliefs, increase quitting intentions, promote quitting, and decrease smoking.

Socioeconomic characteristics, paternal smoking and secondhand tobacco smoke exposure among infants in Jakarta, Indonesia.

INTRODUCTIONPrevalence of paternal smoking is high in Asia and babies are vulnerable to secondhand tobacco smoke (SHS) exposure at home. This study assesses socioeconomic characteristics and paternal smoking in households and infants’ exposure to SHS.METHODSA cross-sectional analysis of data collected as part of a prospective cohort study was conducted in Jakarta, Indonesia during 2017–2019. Participants were 156 mother-baby pairs whose babies reached the age of 6 months. Socioeconomic characteristics and smoking behaviour in the household were assessed by questionnaires. Factors related to paternal smoking and infants’ exposure to SHS were assessed using a multivariate logistic regression model.RESULTSAlmost two-thirds of infants lived with fathers who were smokers. Lower levels of paternal education (OR=2.59; 95% CI: 1.19–5.63; p=0.045) and infants with one sibling (OR=2.41; 95% CI: 1.02–5.67; p=0.044) increased the risk of paternal smoking in the household. Moreover, infants with one sibling (OR=3.09; 95% CI: 1.15–8.32; p=0.026), lower level of father education (OR=18.73; 95% CI: 1.54–227.93; p=0.022), and a high number of other household members who smoke (OR=4.54; 95% CI : 1.42–14.48; p=0.011) were the risk factors of SHS exposure among infants at home.CONCLUSIONSThese findings demonstrate the significant influence of educational level, number of children and/or number of other smokers in the household on paternal smoking and SHS exposure among infants at home. Comprehensive tobacco control programmes to increase adoption of smoke-free homes are likely to be an effective way to reduce SHS exposure and promote decreased cigarette smoking in families with children.

School-Based Tobacco Control and Smoking in Adolescents: Evidence from Multilevel Analyses.

Since 2015, universal comprehensive school-based tobacco control programs have been provided in all primary and secondary schools in Korea. This study explored the association of school-level tobacco control with adolescent smoking, and the interactions to investigate whether gender moderates the impact of school tobacco control programs and school-level norms. Both school- and individual-level data were drawn from the 2015 School-Based Tobacco Prevention Program Survey. Multilevel logistic regression analyses were performed using data from 4631 students (ages 10–18 years) who were nested in 62 secondary schools in Seoul, Korea. Students who participated in more prevention programs were less likely to smoke (OR = 0.47, 95% CI 0.30–0.74). The effect of the programs was significantly moderated by gender. For boys, exposure to a greater number of programs decreased the risk of smoking (OR = 0.32, 95% CI 0.18–0.57) but not for girls. At the school level, the school norm regarding tobacco control regulations was negatively associated with smoking (OR = 0.28, 95% CI 0.11–0.76), and its effect was significant for girls only (OR = 0.35, 95% CI 0.17–0.76). This study highlights how the school environment is associated with adolescent smoking behavior, and the effects of programs and norms are different by gender. The findings suggest the need to develop strategies to enhance school-based tobacco control programs and the school norm considering gender differences.

Tobacco use and associated risk factors in Burkina Faso: results from a population-based cross-sectional survey

BackgroundTobacco is a leading preventable cause of non-communicable diseases (NCDs). Studies characterizing the prevalence of tobacco use in low-income countries are lacking. This study describes the prevalence of tobacco use in Burkina Faso and its associated factors.MethodsData from the 2013 Burkina Faso World Health Organization (WHO) Stepwise approach to Surveillance (STEPS) were analyzed. The prevalence of any tobacco product use, cigarette smoking, and other tobacco use was calculated. Logistic regression analyses identified factors associated with tobacco use. Overall, 4691 people were included in this analysis.ResultsThe prevalence of any tobacco use was 19.8% (95% CI: 18.4–21.2). Tobacco use was higher for men (29.2% [27.0–31.5]) than women (11.8% [10.3–13.4]). The prevalence of smoked tobacco was 11.3% (10.3–12.4), with a significantly higher prevalence among men (24.5% [22.1–27.0]) than women (0.1% [0.01–0.3]). The overall prevalence of other tobacco use was 8.9% (7.4–10.7), with lower values for men (5.6% [4.1–7.2]) compared to women (11.7% [9.4–14.1]). Tobacco smoking among men was significantly associated with an increased age and alcohol consumption. The analysis of risk factors for other tobacco use stratified by gender showed that age, education, residence, and alcohol consumption were significantly associated with consumption for women, and age and alcohol consumption for men.ConclusionTobacco use is common in Burkina Faso. To effectively reduce tobacco use in Burkina Faso, a comprehensive tobacco control program should consider associated factors, such as gender, age, and alcohol consumption.

Tobacco Product Use and Associated Factors Among Middle and High School Students - United States, 2019.

Tobacco Product Use and Associated Factors Among Middle and High School Students - United States, 2019.

Determinants of shisha use among secondary school students in Sudan

BackgroundShisha smoking has re-emerged in the Middle East in the last two decades and has spread rapidly in these communities. Information about shisha smoking in adolescents in Sudan is deficient. Hence, the aim of this study is to estimate the prevalence of shisha smoking among adolescents and determine the associated factors.MethodsThis study is a school based cross sectional study among secondary school students in Khartoum State - Sudan that targets both male and female students aged 14–17 years. A total of 3387 students from 29 public and private schools were selected by multi stage random sampling. The participants completed an anonymous self-administered questionnaire which was based on Arabic version of the Global Youth Tobacco Survey (GYTS).ResultsThe response rate was 100% in schools and among participants, 57.3% were females and 51.6% were from public schools. The overall prevalence of those who had ever smoked shisha was 13.4%, and among male students the prevalence was 16.8%, while it was 10.9% in females.The associated factors were poor academic performance OR 2.90 CI 95% (1.21–6.94), friends smoking shisha OR 2.39 CI 95% (1.65–3.45), friends smoking cigarettes OR 2.76 CI 95% (1.90–4.01), peer pressure to smoke shisha OR 13.76 CI 95% (7.86–24.07) and unexpectedly restriction of selling shisha to minors OR 2.21 CI 95% (1.28–3.82).ConclusionThe prevalence of those who had ever smoked shisha is among the lowest in Middle East region; therefore, regular surveillance system is needed. A well-structured peer based comprehensive tobacco control programmes that are supported by strict and rigorous anti-tobacco regulations which control both commercial and social resources of tobacco are needed to contain this issue among adolescents.