Waterpipe Tobacco Research Articles

Chemical Constituents and Particle Size Distribution of Mainstream Emission from Electronic Waterpipe.

An electronic waterpipe (electronic hookah) uses an electronic heating element to promote the vaporization and aerosolization of an e-liquid in a waterpipe. There is little or no published information characterizing the toxicant levels or particle size distributions of electronic waterpipe mainstream emission. Controlled laboratory experiments were performed to evaluate electronic waterpipe mainstream emission for 40 test conditions: 10 e-liquid products × 2 power settings × 2 puffing topographies. Data were collected for amounts of three volatile toxicants and selected semi-volatile compounds, mass of total particulate matter, and particle size distribution within the size range of 5-1000nm. Amounts of the volatile toxicants acetaldehyde, acrolein, and benzene measured in mainstream emission were 33-505 µg/session, 27-415 µg/session, and 0.69-2.44 µg/session, respectively. The amounts of acetaldehyde and acrolein, when reported in units of µg/puff, are generally similar to some literature-reported amounts in e-cigarette mainstream emission and tobacco waterpipe smoke. A bimodal or trimodal particle size distribution was typically observed, and substantial concentrations of nanoparticles were detected. The amounts (in µg/puff) of the volatile toxicants and several quantitative measures of particle size distribution were significantly affected by power setting and puffing topography. Given the hazards of acetaldehyde and acrolein and the distinctive toxicological profile of nanoparticles, electronic waterpipe use may present significant toxicity concerns. Operation of an electronic waterpipe is a complex process in which physics, fluid dynamics, and chemistry interact to yield mainstream emission for which the composition is sensitive to changes from various sources. This publication, to our knowledge, is the first to report the amounts of toxicants and particle size distributions in electronic waterpipe mainstream emission. The results reported herein suggest that there may be significant toxicity concerns associated with electronic waterpipe use as indicated by the levels of volatile toxicants and the presence of nanoparticles in electronic waterpipe mainstream emission. This knowledge is valuable to support the research community and tobacco regulatory agencies in understanding the impact that electronic waterpipe use may have on public health.

Digital Marketing Strategies Used to Promote Waterpipe Tobacco Among Retailers and Manufacturers

Introduction Waterpipe tobacco (WT) is unique compared to other tobacco products. Retailers and manufacturers may promote WT products using different marketing appeals and sales propositions on popular digital marketing media. This study examined WT digital marketing content in the United States (U.S.). Methods In 2020, a census of WT manufacturers that sold WT products in the U.S. was created and 33 WT manufacturers and 30 WT retailers across the U.S. were identified. Business websites and the 20 most recent Facebook and Instagram posts from identified manufacturers and retailers were recorded. Marketing appeals were coded for themes including sexuality and romance, U.S. patriotism, Middle Eastern culture, WT smoking cues, health or safety, and enjoyable experiences. Sale proposition content was also coded and included price promotions, scarcity, and free products. Results Digital marketing content posts (n = 1,520) were recorded, including 70 webpages (primary and secondary pages), 770 Instagram posts, and 680 Facebook posts. Most content (91.0%) included at least one examined marketing appeal, including smoking cues (54.3% of all marketing content), Middle Eastern culture (29.1%), enjoyable experiences (22.4%), and sexuality and romance (19.7%). At least one sales proposition was used in 28.6% of all marketing content. The most commonly used sales proposition was a financial incentive, which was included in 11.8% marketing content. Conclusions Manufacturers and retailers in the U.S. use a variety of digital marketing strategies to promote WT products. Research is needed examine the impact of WT digital marketing on consumer perceptions, particularly among youth and young adults who are at greatest risk for WT smoking.

Development of a policy brief to reform waterpipe tobacco taxation in Egypt.

Waterpipe tobacco smoking is increasing in Egypt, although there are several interventions to reduce its use. To describe the development of a policy brief to reform waterpipe tobacco taxation in Egypt. During 2019-2022, we synthesized available literature evidence on waterpipe tobacco taxation in Egypt and other countries. We then held a policy dialogue to engage various stakeholders to discuss and finalize a draft policy brief for Egypt. The policy brief proposes 3 elements for improving waterpipe tobacco taxation in Egypt: establishing a public platform for national data on waterpipe tobacco economics; modelling the economic and public health benefits of an improved waterpipe tobacco taxation system; and raising waterpipe tobacco tax level and reforming the taxation structure. Application of the knowledge-to-policy translation framework was instrumental in bridging the gap between evidence synthesis and political framing for the policy brief. More effort should be made to strengthen evidence-informed policymaking, particularly in settings where tobacco control governance is fragmented and tax policies are applied inconsistently.

The association of combined GSTM1, GSTT1, and GSTP1 genetic polymorphisms with lung cancer risk in male Iraqi Waterpipe Tobacco (Nargila) smokers

Mutations in genes encoding proteins necessary for detoxifying oxidative stress products have been predicted to increase susceptibility to lung cancer (LC). Despite this, the association between waterpipe tobacco smoking (WP), genetic polymorphisms, and LC risk remains poorly understood. This is the first study to explore the relationship between WP tobacco smoking and these genetic factors. Previously, we investigated the association of GSTP1 SNPs (rs1695-A/G and rs1138272-C/T) with LC in Iraqi males who smoke WP. Here, we expanded our analysis to include GSTM1 (active/null) and GSTT1 (active/null) genotypes, both individually and in combination with GSTP1 SNPs. Multiplex PCR and RFLP-PCR assays were utilized to determine the genotypes of 123 cases and 129 controls. No significant association was observed between GSTM1-null or GSTT1-null genotypes and LC risk, either separately or in combination with variant genotypes of GSTP1 (rs1695 "AG+GG" and rs1138272 "CT+TT"). However, smoking WP and carrying null genotypes elevated the risk five-fold for GSTM1-null (OR 5.17, 95 % CI 2.02–13.24, P<0.001) and three-fold for GSTT1-null (OR 3.08, 95 % CI 1.55–6.13, P=0.001) compared to non-smokers carrying active genotypes. Conversely, genotype distribution analysis based on LC histological types did not indicate an increased risk of LC. Lung cancer is a complex multifactorial disease. WP smoking and GSTs genetic polymorphisms might be associated with an increased risk of developing LC. However, our data did not confirm an association between GST polymorphisms alone and the risk of LC.

Temporal and Thematic Analysis of Promotional Waterpipe-Related Posts on Twitter/X in the US.

Waterpipe tobacco smoking (WTS), also known as hookah, shisha, or narghile, is particularly popular among young people in the United States (US). WTS poses serious health risks similar to those of cigarette smoking. Using the Twitter/X streaming API (Application Programming Interface), we collected 4,853,562 tweets between March 9, 2021, and March 14, 2023, using waterpipe-related keywords, such as "hookah" and "waterpipe". After geographical filtering to identify tweets from the US and keyword filtering for the promotional content, we identified 23,803 promotional waterpipe-related tweets. We examined trends in the posting time of these promotional waterpipe-related tweets and identified prevalent topics from these tweets using the BERTopic (Bidirectional Encoder Representations from Transformers) modeling. The number of promotional waterpipe-related tweets showed an overall decreasing trend during the study period. The posting of promotional waterpipe-related tweets was more active later in the day. Major topics in the promotional tweets included "Promotion from hookah lounges and online hookah business" (63.97%, 15,227/23,803), "promoting hookah parties and events" (32.26%, 7,679/23,803), and "promoting engineered and durable hookah products" (3.77%, 897/23,803). Twitter/X accounts posting waterpipe-related promotional content have substantial variations in the number of relevant tweets (mean = 2.28, SD = 12.22) and followers (mean = 5,937, SD = 76,770). This study demonstrates a significant social media activity in promoting waterpipe tobacco smoking. Our findings underscore the urgent need to regulate the promotional content of WTS on social media and promote public health education messages on social media to counteract the promotion of WTS.

Waterpipe size matters: the effect of waterpipe size on toxicant exposures and subjective experiences.

Waterpipe (WP) tobacco smoking remains popular among US young adults, yet specific regulations for WP devices are lacking. This study examines how WP device size (base volume and height) affects smoking behavior, toxicant exposures, and subjective experiences. Thirty-eight individuals who smoke WP aged 21 to 39 participated in a randomized crossover study. Each completed three 45-minute ad libitum smoking sessions using small, medium, and large WP sizes. Saliva nicotine and exhaled carbon monoxide (eCO) were measured before and after smoking. Puff topography was recorded during sessions, and subjective smoking experiences were collected afterward. Significant differences were observed in saliva nicotine between the three WP sizes, with higher concentrations for the small WP relative to larger sizes (Ps<0.05). Exhaled CO was significantly higher after smoking the large WP compared to smaller sizes (Ps<0.05). Puff topography revealed significant differences and followed a dose-response pattern, with larger size associated with longer puff duration, greater smoke volume inhaled, and larger puff volume (Ps<0.05). The large WP was associated with enhanced subjective experiences for satisfaction and concentration compared to the small WP (Ps<0.05). WP size substantially impacts smoking experiences and exposures. Regulation of WP size should be essential in comprehensive tobacco control policies aimed at curbing WP use among young adults. These findings will aid in developing of WP size-specific standards to regulate the marketing and sales of WP devices. Such regulations should aim to minimize toxicant exposure by controlling the dimensions and design of WP components, which can significantly influence smoking behavior and toxicant intake. This study underscores the critical role of waterpipe (WP) size in shaping smoking behavior, experiences, and exposures among young adults.

Biological monitoring of exposure to benzene in water pipe smokers of rural Western Uttar Pradesh (India)

Aim: Present study was performed to investigate the possible human exposure to benzene through water pipe smoking, if any, in the selected rural population of Western Uttar Pradesh. Methodology: Urine samples from water pipe smokers of both the sexes were collected and analyzed for urinary concentration of phenol, creatinine and malondialdehyde employing standard methods. Results: The results showed that tobacco used by selected rural population contained traces of benzene in the range of 2.75 to 9.682µl ml-1. Analysis of urine samples for phenol, a major metabolite of benzene, showed its increased concentrations in water pipe smokers than non smokers. Further, the effects of age and gender differences on the excretion of phenol were also recorded. Female water pipe smokers were found to be more vulnerable to benzene exposure than male smokers. Intriguingly, alcoholic water pipe smokers were less vulnerable than the non-alcoholic smokers. Interpretation: It is concluded that respiratory, cardiac and haematological disorders caused by water pipe smoking might be attributed to long term benzene exposure amongst water pipe smokers. Large scale epidemiological studies are warranted in Indian rural population considering WHO (Framework Convention on Tobacco Control) regulations of water pipe smoking and tobacco products. Key words: Biological monitoring, Benzene, Oxidative stress, Phenol, Tobacco, Waterpipe smoking

Sociodemographic inequalities in cigarette, smokeless tobacco, waterpipe tobacco, and electronic cigarette use among adolescents aged 12-16 years in 114 countries: A cross-sectional analysis.

The majority of users of tobacco and nicotine products start using them in adolescence. In order to keep equity considerations at the forefront of tobacco control, it is crucial to assess whether inequalities in prevalence of tobacco and nicotine use exist among adolescents globally. We conducted a secondary analysis of Global Youth Tobacco Survey (GYTS) data from 538644 school-based adolescents (79.3% aged 13-15 years) in 114 countries (2013-2019). Data were collected on current (past 30-day) use of cigarettes, smokeless tobacco, waterpipe tobacco and electronic cigarettes. We used weighted Poisson regression models adjusted for sex, pocket money, and age to assess differences in prevalence of current use between boys and girls, and between students with high versus low pocket money. Although there was substantial regional variation, in most countries boys were statistically significantly more likely to report current use of all assessed products (ranging from 50.0% of countries for waterpipe tobacco to 73.3% of countries for electronic cigarettes). Inequalities by sex were less pronounced in Europe compared to other regions. Inequalities by pocket money were less consistent; students with more pocket money were more likely to report current use of cigarettes (vs those with less pocket money) in 61.8% of the countries, but more likely to report current use of smokeless tobacco in only 18.3% of countries. Globally, boys and adolescents with more pocket money are generally more likely to use a range of tobacco and nicotine products. However, these patterns are not universal and local variations should be taken into consideration to design effective and equitable tobacco control policies.

Water-pipe Tobacco Components and their Association with Oxidative Stress.

Oxidative stress (OS) results from an imbalance between the formation and detoxification of reactive species. Although reactive species at low or moderate levels play numerous physiological roles, high concentrations can lead to disturbances in signaling and metabolic pathways and cause different metabolic, chronic, and age-related disorders. Several endogenous and exogenous processes may lead to the formation of reactive species. The severity of OS can be reduced with the help of antioxidants. Tobacco is one of the most important environmental factors contributing to reactive species production. After cigarette smoking, water-pipe tobacco (WPT) smoking is ranked as the second most popular tobacco product. Its popularity is proliferating due to flavored products, social acceptability, etc. However, studies have shown that WPT smoking is associated with an increased risk of arterial stiffness, ischemic heart disease, and several cancer types. In this study, we aimed to review the most recent evidence on WPT smoking constituents and their association with OS.

Waterpipe Tobacco Smoking and Multiple Sclerosis: A Systematic Review and Meta-Analysis.

Multiple sclerosis (MS), as an autoimmune disease of the central nervous system, has a significant burden among people worldwide. Tobacco smoking is one of the most prevalent habits of patients with different diseases including those with MS, and among the methods of use, waterpipe tobacco smoking is gaining popularity. Herein, we aimed to systematically evaluate the association between waterpipe smoking and MS. Relevant studies were identified to be included in this systematic review and meta-analysis through a systematic search in PubMed, Scopus, Web of Science, and Embase. Studies were screened by the title/abstract and then by their full text. Extraction of data was performed for relevant studies. Odds ratios (ORs) and their 95% confidence intervals (CIs) of the association between waterpipe smoking and MS were used to pool the results observed in each study. After the screening, a total of five studies were included in our systematic review, comprised of 3,087 individuals, among which there were 1,135 cases with MS. Random-effect meta-analysis revealed that ever-smoking waterpipe had a significant association with MS (OR: 1.73, 95% CI: 1.38-2.17, p value &lt;0.0001). Similarly, past waterpipe smoking was significantly higher in those with MS, compared with controls (OR: 2.17, 95% CI: 1.61-2.92, p value &lt;0.0001). Based on the reported results, smoking both tobacco and waterpipe had an additive association with MS. Finally, no association was found between the Expanded Disability Status Scale (EDSS) and waterpipe smoking. Waterpipe as one of the common ways of tobacco smoking becoming popular has an association with MS, and even the use of waterpipe for a certain period in the lifetime has a significant correlation with MS. Further large-scale studies are needed to confirm these findings. These results could help clinicians in risk-stratifying the patients and to provide better care for the MS population.

Toxicity of waterpipe tobacco smoking: the role of flavors, sweeteners, humectants, and charcoal.

Waterpipe tobacco (WPT) smoking is a public health concern, particularly among youth and young adults. The global spread of WPT use has surged because the introduction of pre-packaged flavored and sweetened WPT, which is widely marketed as a safer tobacco alternative. Besides flavorants and sugars, WPT additives include humectants, which enhance the moisture and sweetness of WPT, act as solvents for flavors, and impart smoothness to the smoke, thus increasing appeal to users. In the United States, unlike cigarette tobacco flavoring (with the exception of menthol), there is no FDA product standard or policy in place prohibiting sales of flavored WPT. Research has shown that the numerous fruit, candy, and alcohol flavors added to WPT entice individuals to experience those flavors, putting them at an increased risk of exposure to WPT smoke-related toxicants. Additionally, burning charcoal briquettes-used as a heating source for WPT-contributes to the harmful health effects of WPT smoking. This review presents existing evidence on the potential toxicity resulting from humectants, sugars, and flavorants in WPT, and from the charcoal used to heat WPT. The review discusses relevant studies of inhalation toxicity in animal models and of biomarkers of exposure in humans. Current evidence suggests that more data are needed on toxicant emissions in WPT smoke to inform effective tobacco regulation to mitigate the adverse impact of WPT use on human health.

Correlates of susceptibility to waterpipe tobacco smoking in young adults.

Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults. Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility. Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (β = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (β = -0.09, p = 0.04), and greater perceived social acceptability of WTS (β = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (β = 0.53, p<0.01), used cannabis (β = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (β = 0.18, p = 0.03) also had higher WTS susceptibility. Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits.

Peronia peronii as a bio-indicator to assess the toxicity of waterpipe tobacco leachates in aquatic and sediment media.

This study was aimed to survey toxicity of waterpipe wastes leachates on Peronia peronii in aquatic and sediment environments as two exposure media. For this, leachates of four tobacco types including burnt traditional tobacco (BTT), fresh traditional tobacco (FTT), burnt fruit-flavored tobacco (BFT) and fresh fruit-flavored tobacco (FFT)) were prepared and used to assess their toxic effects on P. peronei in two aquatic and sediment media. The in-vivo toxic effects of five different concentrations of waterpipe tobacco waste leachates on P. peronii were evaluated. The LC50 values of BTTs leachates to P. peronii were 17.50, 16.05, 11.31 and 9.38g/L at exposure times of 24, 48, 72 and 96h, respectively in aquatic media. These values for BFTs leachates were 14.86, 12.38, 9.53 and 7.46g/L at exposure times of 24, 48, 72 and 96h, respectively. In the case of sediment media, the LC50 values of BTTs leachates were 15.33, 13.70, 9.09 and 6.70g/L at exposure times of 24, 48, 72 and 96h, respectively while these values for BFTs leachates were 12.00, 10.32, 8.20 and 5.65g/L. Fruit-flavored tobacco leachates had significantly higher toxicity than traditional tobacco leachates for P. peronii. The findings also showed significant differences between the LC50 values of different leachates in different media of water and sediment. The results demonstrated that even small amount of tobacco waste (~ 5 to 6g/L) can lead to P. peronii mortality and may also pose a hazard to other aquatic and benthic organisms. The results obtained from the present study can be used as a baseline data to assess local effects causing from unsafe disposal of post-consumption tobacco waste in beach areas. In addition, these findings can lead to encouraging decision-makers to focus more on the types of tobacco waste in the municipal solid waste management system and to implement a source separation process for these wastes.

Waterpipe Tobacco Smoking and Risk of Cancer Mortality

There has been an increasing trend of using noncigarette products, including waterpipe tobacco (WTP), worldwide. While cigarette smoking is a well-established risk factor for numerous cancers, little is known about the association between WTP smoking and cancer mortality. To assess the association between WTP smoking and risk of cancer mortality in Vietnam. This cohort study was based on data from the Hanoi Prospective Cohort Study, an ongoing study with a median (range) follow-up of 11.0 (0.1-11.6) years for participants aged 15 years or older in Northern Vietnam from 2007 through 2019. Data were analyzed from June 1 to September 1, 2023. Tobacco smoking and WTP smoking statuses. Overall and site-specific cancer mortality. Cox proportional regression models were used to calculate the hazard ratio (HR) and 95% CIs for the associations between WTP smoking alone, cigarette smoking alone, and dual WTP and cigarette smoking and the risk of cancer death. A total of 554 cancer deaths were identified among the 39 401 study participants (mean [SD] age, 40.4 [18.8] years; 20 616 females [52.3%]). In multivariable models, compared with never smokers, ever smokers had a significantly increased risk of cancer mortality (HR, 1.87; 95% CI, 1.48-2.35). Exclusive WTP smokers had the highest risk of cancer mortality compared with never smokers (HR, 2.66; 95% CI, 2.07-3.43). Risk of cancer mortality was higher for dual smokers of WTP and cigarettes (HR, 2.06; 95% CI, 1.53-2.76) than for exclusive cigarette smokers (HR, 1.86; 95% CI, 1.41-2.45). As most smokers (95.6% [8897 of 9312]) were male, these patterns were more apparent in male participants. Compared with never smokers, exclusive WTP smoking among males was associated with an elevated risk of death from liver cancer (HR, 3.92; 95% CI, 2.25-6.85), lung cancer (HR, 3.49; 95% CI, 2.08-5.88), nasopharyngeal carcinoma (HR, 2.79; 95% CI, 1.27-6.12), and stomach cancer (HR, 4.11; 95% CI, 2.04-8.27). For exclusive WTP smokers, the risk of cancer mortality was highest among those who smoked 11 to 15 sessions per day (HR, 3.42; 95% CI, 2.03-5.75), started smoking at age 26 to 30 years (HR, 4.01; 95% CI, 2.63-6.11), smoked for 9 to 20 years (HR, 4.04; 95% CI, 2.16-7.56), and smoked 61 to 160 sessions annually (HR, 3.68; 95% CI, 2.38-5.71). For males, the risk of cancer death was lower for those who had quit smoking for more than 10 years, compared with those who quit smoking within 1 year (HR, 0.27; 95% CI, 0.11-0.66; P for trend < .001). In this cohort study in Vietnam, WTP smoking alone or in combination with cigarette smoking was associated with an increased risk of cancer death due to liver cancer, lung cancer, nasopharyngeal carcinoma, and stomach cancer. A tailored program to control WTP smoking is warranted in Vietnam and low- and middle-income countries with a high prevalence of smoking and modest resources to address smoking-related issues.

Exposure to Waterpipe Smoke Disrupts Erythrocyte Homeostasis of BALB/c Mice

The prevalence of waterpipe tobacco smoking (WPS) is increasing worldwide and is relatively high among youth and young adults. It has been shown, both experimentally and clinically, that WPS exposure adversely affects the cardiovascular and hematological systems through the generation of oxidative stress and inflammation. Our study aimed to evaluate the impact of WPS exposure on erythrocytes, a major component of the hematological system, of BALB/c mice. Here, we assessed the effect of nose-only WPS exposure for four consecutive weeks on erythrocyte inflammation, oxidative stress, and eryptosis. The duration of the session was 30 min/day, 5 days/week. Control mice were exposed to air. Our results showed that the levels of C-reactive protein, lipid peroxidation (LPO), superoxide dismutase, and total nitric oxide (NO) were significantly increased in the plasma of WPS-exposed mice. The number of erythrocytes and the hematocrit were significantly decreased in WPS-exposed mice compared with the control group. Moreover, there was an increase in the erythrocyte fragility in mice exposed to WPS compared with those exposed to air. The levels of lactate dehydrogenase, LPO, reduced glutathione, catalase, and NO were significantly increased in the red blood cells (RBCs) of WPS-exposed mice. In addition, erythrocytes of the WPS-exposed group showed a significant increase in ATPase activity, Ca2+, annexin V binding, and calpain activity. Taken together, our findings suggest that WPS exposure elevated inflammation and oxidative stress in the plasma and induced hemolysis in vivo. It also caused alterations of RBCs oxidative stress and eryptosis in vitro. Our data confirm the detrimental impact of WPS on erythrocyte physiology.

Prevalence of, and perceptions regarding water pipe smoking amongst college students in Johannesburg, South Africa

Background: Water pipe tobacco smoking has similar health risks as other forms of tobacco use, such as increased risk of cardiovascular disease and lung cancer, decreased pulmonary function, as well as various other oral diseases. Because there are perceptions among young people that its health effects are less harmful, its use in this group is reportedly high, though its prevalence is not known. This study purposed to determine the prevalence and perceptions of water pipe smoking amongst Technical and Vocational Education and Training (TVET) college students in Johannesburg, South Africa.Methods: A cross-sectional quantitative survey was conducted among the students. Using the STATA statistical software, bivariate analysis was used to calculate the prevalence of water pipe smoking, and the chi square test was used to explore associations between socio-demographic variables and water pipe smoking. The quantitative questions on perceptions were analysed using summary statistics.Results: A total of 479 TVET students, 57.8% females and 42.2% males, with a mean age of 22 participated in the study. The prevalence of water pipe smoking was 61.6%, with more males compared to female students (70.8% vs 54.9%) using the pipe. More than half (62.2%) have a false perception regarding the health risks of water pipe smoking.Conclusion: There is a high prevalence of water pipe smoking and false perceptions about the health risks of water pipe smoking amongst TVET college students. Thus, the current Tobacco policy should be amended to include the regulation of water pipe smoking as well as increased health education about the dangers of smoking water pipe.

Waterpipe Tobacco Brands and Flavors Sold Online in the USA

Introduction Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies. Methods We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder. Results We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2953 flavors, including 1871 unique flavors. Brands averaged 45 flavors (range: 1–183). Almost three quarters (73.5%, n = 2171) used explicit flavor names and 26.5% (n = 782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%). Conclusions WT is available in 1871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Implementing Pictorial Health Warning Labels on Waterpipe Tobacco Products in Lebanon: A Policy Framework Analysis of Content, Actors, Context, and Process.

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

Electronic nicotine delivery system use and its relation to waterpipe smoking among youth in seven Arab countries

ObjectivesElectronic Nicotine Delivery System (ENDS) use and Waterpipe Tobacco Smoking (WTS) are reported to be a growing strain of tobacco epidemic among youth in the Arab world. Therefore, we aimed to: (1) estimate the regional prevalence of ENDS use among youth in 7 Arab countries and, (2) to explore the bidirectional relationship between ENDS use and WTS among Arab adolescents. MethodsWe analyzed data from the World Health Organization Global Youth Tobacco Survey (GYTS 2014–2018) of 18,536 schoolchildren aged 12–16 from Iraq, Mauritania, Morocco, Oman, Qatar, Tunisia, and Yemen. The weighted prevalence was calculated to generate nationally representative estimates. Adjusted multilevel logistic regression models were conducted to assess the association between ENDS use and WTS. ResultsThe pooled weighted prevalence of ENDS use was 9.5%. Higher odds of ENDS use were significantly associated with WTS (AOR: 5.26, 95%CI: 4.28–6.46), smoking conventional cigarettes (AOR: 1.54, 95%CI: 1.23–1.94) and first tobacco use prior to the age of 12 (AOR: 1.40, 95%CI: 1.14–1.72). Females and children who were taught in school the dangers of tobacco had less odds of using ENDS. ConclusionWTS was associated with increased odds of ENDS use by >5 folds, and vice versa. Tobacco consumption at age younger than 12 years was associated with higher odds of ENDS use, but less odds of WTS. Females and those who were taught in school the dangers of tobacco were less likely to report ENDS use.

Waterpipe Tobaccos, Part I. Composition of Forty Brand-Styles of Contemporary Waterpipe Tobacco Available on the US Market in 2020–2022

Summary The compositions of waterpipe tobaccos available for retail sale on the US market are relatively unknown compared with more popular products such as cigarettes. Indeed, the phrase “waterpipe tobaccos” is used only in some governmental regulations and in journal articles dealing with regulatory aspects of those products. Commercially, the terms “shisha”, “hookah tobaccos”, and “flavored tobaccos” are used. In addition to the differences in commercial terminology, there is also confusion about the composition of such tobaccos, with the term “waterpipe tobacco” also being applied to products on the market that do not contain enough glycerol to prevent combustion during use. Therefore, during the past several years, 40 samples of shisha products on the US market were sent to an ISO 17025 accredited laboratory for the determination of glycerol, propylene glycol, fructose, glucose, and sucrose, in addition to the usual tobacco analytes and water using the Karl Fischer method. Moreover, two surrogate samples of shisha tobacco, one based on flue-cured tobacco and the other based on dark air-cured tobacco, were analyzed by the same laboratory along with samples of the starting tobaccos. The main finding from these analyses was that there were two very different types of shisha tobaccos on the market. One type was based on dark air-cured tobacco and the other type was based on flue-cured tobacco. Among the brand-styles based on flue-cured tobacco, some had higher levels of glycerol and lower levels of added sugars than others that had higher added sugars and lower levels of glycerol. Another important point of differentiation was that the products based on dark air-cured tobacco had much smaller tobacco particle sizes than did those based on flue-cured tobacco. The results of this research as well as other research that will be presented in two subsequent reports showed that waterpipe tobaccos cannot be considered as a single product category. This is particularly true for the determination of emissions using the instrumentation specified in ISO 22486:2019 (Water pipe tobacco smoking machine — Definitions and standard conditions).