Fadi Hammal

A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria

Background: Throughout the Eastern Mediterranean region (EMR), tobacco is used primarily in two forms: cigarette smoking and waterpipe (called narghile (nar-GIL-eh) in Syria) smoking. Objective: To explore whether narghile smokers are different from cigarette smokers in how their smoking habits are embedded in their everyday lives. Methods: One-to-one interviews with 16 adult narghile smokers and 16 adult cigarette smokers about their feelings, experiences and beliefs regarding their initiation, use patterns, and attempts to quit. Findings: Narghile smokers found that narghile was a pleasurable social experience embedded in cultural rituals. By contrast, cigarette smokers saw their cigarette smoking as a mundane, oppressive, personal addiction. Narghile smokers generally started in their 20s and found that smoking narghile fostered a sense of togetherness and cultural identity, while cigarette smokers started in their early teens, males having started to becoming a “real man”. Unlike cigarette smokers who felt stigmatised, narghile smokers generally felt that smoking narghile was socially accepted. Cigarette smokers believed that cigarettes were harmful to their health and harmful to those around them, but narghile smokers believed smoking narghile was relatively harmless to themselves or to others. Unlike cigarette smokers who used cigarettes to manage stress, narghile smokers used narghile for entertainment, leisure, and escape. However, frequent narghile smokers confessed that they felt addicted in much the same way as cigarette smokers. Cigarette smokers and narghile smokers viewed quitting as a matter of will and conviction. Most cigarette smokers had tried to quit. Very few narghile smokers had ever tried to quit, and most were not interested in quitting. Disturbingly, some cigarette smokers had tried to quit cigarettes by switching to smoking narghile, but later relapsed to smoking cigarettes. Conclusions: This exploratory study suggests that Syrian narghile smokers are different from Syrian cigarette smokers in their perceptions and beliefs about their smoking, and in their smoking patterns and lived experiences with tobacco. Our findings indicate that further in-depth research is need in the EMR to understand both modes of smoking to develop effective mode-specific prevention and cessation approaches. This study also raises concerns about a possible pattern where cigarette smokers are using narghile as a method for quitting cigarettes, and then relapsing.

The tobacco epidemic in Syria

Background: The Syrian Center for Tobacco Studies (SCTS) was established in response to the smoking epidemic in Syria and lack of local knowledge and expertise to confront it. Objectives: To (1) study tobacco use and local smoking practices using both qualitative and quantitative research methods; (2) develop and test an effective smoking cessation intervention for the Syrian environment; and (3) train Syrian researchers. Methods and results: The Aleppo Household Survey involved a representative sample of adults in Aleppo (2038 subjects, 45.2% men, mean age 35.3 years, response rate 86%). The prevalence of cigarette smoking was 56.9% among men and 17.0% among women, while the prevalence of waterpipe smoking was 20.2% among men and 4.8% among women. Daily use predominated for cigarettes (29.0%), while the opposite was seen in waterpipe use with 10.6% smoking occasionally. Interest in quitting was greater for cigarette than waterpipe smokers (74.0% v 48.6%), while quit rates were higher for waterpipe compared to cigarettes (28.2% v 16.5%). In-depth ethnographic interviews with smokers show that smoking waterpipe is often viewed as an aesthetic enjoyable experience, while smoking cigarettes is viewed as a mundane anxiety-relieving addiction. Clinical laboratory studies reveal that both waterpipe and cigarette smokers in Syria are exposed to smoke toxicants and exhibit dependence symptoms. Conclusions: All these data have been used iteratively to adapt smoking cessation interventions from developed countries to suit the local Syrian environment. Research conducted in the SCTS to date has provided a fertile training ground for Syrian researchers, as well as for the building of regional collaborations.

‘Herbal’ but potentially hazardous: an analysis of the constituents and smoke emissions of tobacco-free waterpipe products and the air quality in the cafés where they are served

Background There are limited data on the composition and smoke emissions of ‘herbal’ shisha products and the air quality of establishments where they are smoked. Methods Three studies of ‘herbal’ shisha were conducted: (1) samples of ‘herbal’ shisha products were chemically analysed; (2) ‘herbal’ and tobacco shisha were burned in a waterpipe smoking machine and main and sidestream smoke analysed by standard methods and (3) the air quality of six waterpipe cafés was assessed by measurement of CO, particulate and nicotine vapour content. Results We found considerable variation in heavy metal content between the three products sampled, one being particularly high in lead, chromium, nickel and arsenic. A similar pattern emerged for polycyclic aromatic hydrocarbons. Smoke emission analyses indicated that toxic byproducts produced by the combustion of ‘herbal’ shisha were equivalent or greater than those produced by tobacco shisha. The results of our air quality assessment demonstrated that mean PM2.5 levels and CO content were significantly higher in waterpipe establishments compared to a casino where cigarette smoking was permitted. Nicotine vapour was detected in one of the waterpipe cafés. Conclusions ‘Herbal’ shisha products tested contained toxic trace metals and PAHs levels equivalent to, or in excess of, that found in cigarettes. Their mainstream and sidestream smoke emissions contained carcinogens equivalent to, or in excess of, those of tobacco products. The content of the air in the waterpipe cafés tested was potentially hazardous. These data, in aggregate, suggest that smoking ‘herbal’ shisha may well be dangerous to health.

Social norms and attitudes linked to waterpipe use in the Eastern Mediterranean Region.

Waterpipe tobacco smoking (WTS) is on the rise globally, particularly among vulnerable populations such as youth and women. Increasing knowledge about toxicant yield from waterpipe tobacco and deleterious health effects points to the potential for a health epidemic. WTS is often viewed as a safe alternative to cigarette smoking. Though the original objective of the research was to explore the social norms and attitudes that lead to waterpipe being a more acceptable form of tobacco smoking for women than cigarettes in the Eastern Mediterranean Region, the use of a qualitative research methodology resulted in rich data that helped to understand more generally the phenomenon of waterpipe smoking. Both focus group discussions (FGDs) and key informant interviews were used. Participants were recruited to represent genders, various age groups, socioeconomic status, waterpipe smoking status, and residents of urban and rural areas. A total of 81 FGDs and 38 in-depth interviews were conducted in 2007. Thematic analysis was used to analyze the transcripts. A total of ten themes emerged: socio-cultural norms, gender differences, motivation to smoke, sensory characteristics of waterpipe, metaphors, consumerism, indicators of dependence, comparison between cigarettes and waterpipe, health effect of smoking, and intervention. Results indicated that WTS has socio-cultural dynamics associated with it that are far more pronounced than health considerations. An increased socio-cultural acceptability, the perceived reduced harm and the advent of the fruity Moassel tobacco are among the many reasons for WTS acceptability. Findings point to the need for a unified strategy to address this health issue at all levels of the ecological framework and have important implications for future policy and practice.

Women and Waterpipe Tobacco Smoking in the Eastern Mediterranean Region: Allure or Offensiveness

The prevalence of waterpipe tobacco smoking is increasing worldwide, despite evidence indicating its adverse health effects. Women and young people seem more likely to be choosing waterpipe tobacco smoking over cigarettes. The objective of this qualitative study was to understand better whether and why waterpipe smoking is a more acceptable form of tobacco use than cigarettes for women in the Eastern Mediterranean Region, and to understand whether the strategies used by multi-national corporations to attract women to cigarette smoking were perceived to be relevant in the context of waterpipe tobacco use. Focus groups (n = 81) and in-depth interviews (n = 38) were conducted with adults in Lebanon, Egypt, Palestine, and Syria. Discussions were thematically analyzed and recurrent themes identified. One of the themes which emerged was the negative image of women smoking waterpipes. Moreover, the sexual allure conveyed through waterpipe smoking as well as waterpipe tobacco smoking as a symbol of emancipation was illustrated. The latter was mainly expressed in Lebanon, in contrast with Egypt where traditional gender roles depict women smoking waterpipes as disrespectful to society. Understanding the social aspects of waterpipe tobacco smoking is crucial to planning future interventions to control waterpipe tobacco smoking among women and in society at large.

Settling with danger: conditions and health problems in peri-urban neighbourhoods in Aleppo, Syria

In the Eastern Mediterranean region, mass rural-to-urban migration and uncontrolled population growth in low-income countries such as Syria have given rise to sprawling unplanned peri-urban development. Virtually no data are available on the environmental conditions and health status of residents of such communities. This paper describes formative qualitative research in eight settlements in informal zones around Aleppo, Syria’s second-largest city, to assess environmental problems and health hazards. Several common themes emerged regarding community-level conditions that placed residents at substantial health risk, including sub-standard housing, limited access to high-quality health care, an absence of adequate essential services, problems with toxins and pollutants, poor educational and employment opportunities, and crime. Further research is being conducted to understand the distribution of these problems and the associations between environmental conditions and health status. Urgent action is needed to eliminate dangerous living conditions in these settlements.

Smoking status and survival: impact on mortality of continuing to smoke one year after the angiographic diagnosis of coronary artery disease, a prospective cohort study

BackgroundSmoking is an undertreated risk factor for coronary artery disease (CAD) and is associated with adverse outcomes after myocardial infarction. Aims of our study were to determine if management of CAD by medical therapy (MT) alone or with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) influence smoking status at one year following angiography and if a change in smoking status at one year influences long term survival.MethodsProspective cohort study using the APPROACH registry. Two cohorts were examined: (1) 11,334 patients who returned a one year follow-up questionnaire; (2) 4,246 patients propensity-matched based on their post-angiography treatment - MT or revascularization (RV). Multivariate modeling and survival analysis were used.ResultsIn the propensity-matched cohort, quit rates at one year were greater among CABG patients (68%) than PCI (37%) or MT patients (47%). Smokers in the RV group, who self-reported quitting at one year, had a significantly reduced mortality compared to those who continued to smoke.ConclusionsCABG patients were more likely to quit smoking than those treated with MT alone or PCI. Quitting smoking was associated with improved long-term survival; smoking remains a key risk factor for mortality in patients with CAD. These data underscore the importance of nicotine addiction management in patients with CAD and the need to emphasize cessation particularly in those patients undergoing MT or PCI.

Exploring Attitudes of Children 12–17 Years of Age Toward Electronic Cigarettes

The purpose of this study is to explore electronic cigarettes (EC) use among youth. Focus group sessions with youth (aged 12–17) were held to explore their knowledge and attitudes about EC use. Content analysis techniques were used. There has been an increase in the visibility and accessibility of EC in the past few years among youth. Compared with conventional cigarettes (CC), youth indicated that they would be more willing to use EC under their peer influence. This was motivated by the perception that EC were less harmful. Among youth EC are perceived as less harmful, easier to access and use than CC. Youth do not appear to have received much education about EC. However, they were not convinced that EC were risk free. Clear and unambiguous education about the risk of engaging in any form of smoking/vaping and enforcement of access restrictions appear to be required.

Knowledge About the Waterpipe (Hookah), a Qualitative Assessment Among Community Workers in a Major Urban Center in Canada

Waterpipe (WP) use has surged in popularity since the introduction of flavoured shisha. It is now an increasingly popular form of smoking among youth in North America. Health professionals/educators knowledge about the WP may well be inadequate. This study, using qualitative methods, sought to explore the knowledge and attitude of leaders in the community toward the WP. Family physicians, pharmacists, tobacco counsellors, social workers and educators were invited to participate in a one–one interview using open-ended questions. A total of 27 interviews were conducted. Individuals from Eastern Mediterranean backgrounds raised doubt about the overemphasised cultural significance of the WP and perceived this as a marketing strategy by industry. Most felt that WP smokers believed the WP to be less harmful than cigarettes and that the use of flavoured tobacco was motivating people to smoke. Participants believed that education should be directed at the general public and healthcare professionals, suggesting school programs and the use of social media to inform young smokers. Most thought that the current practices regarding packaging and second hand smoke exposure are confusing. They identified the lack of knowledge, poor enforcement procedures, “so called cultural aspects” and the economic impact of banning the WP on small businesses as barriers to change. Despite the awareness of an increase in WP use, our participants recognized that little has been done to curb this problem. Our findings emphasize the need for further education and better legislation to regulate WP use and availability.

Nicotine addiction management following surgery: a quality improvement approach in the post anesthesia care unit

Quality problem For smokers, hospital admission is accompanied by forced involuntary nicotine abstinence due to smoke-free site/grounds policies. An audit of patients admitted to our surgical wards revealed that identification of smoking status was inadequate and that nicotine addiction management (NAM) was infrequently offered. The project aimed to enhance both these metrics by initiating NAM in the post anesthesia care unit (PACU). Initial assessment Out of 744 patients admitted to our PACU in August 2015, 54% had their smoking status documented. The 200 patients (27%) out of the 744 were smokers and only 50% were offered NAM before discharge. Choice of solution PACU unit staff to determine the smoking status of every patient before discharge from the PACU (later changed to OR nursing staff) and, if a patient was identified as a smoker, to offer NRT (patch and mouth spray only) and initiate therapy prior to transfer of the patient to the ward. Implementation Data about number of patients admitted, presence of documented smoking status, number of identified smokers, and number offered/accepted nicotine replacement therapy (NRT) were collected at baseline and thereafter quarterly. Engaging video education sessions addressed the education gaps highlighted in a needs assessment. Identification of smoking status was made part of preoperative checklist and NRT was made available in post-operative recovery room. Results These interventions resulted in an increase in screening for tobacco use from 54% at baseline to 95% and the offer of NRT to smokers from 50 to 89%.