Ghada Radwan

Comparison of Cigarette and Water Pipe Smoking Among Female University Students in Egypt

This study investigated behavioral and sociodemographic factors associated with tobacco use among female university students patronizing water pipe cafes in Cairo, Egypt. We interviewed two groups of female university student smokers (100 and 96 students from a public and a private university, respectively). The interviews took place in nine water pipe cafes near the two universities. A logistic regression model was developed to analyze the relationship between tobacco-related knowledge and beliefs and the choice between smoking water pipe or cigarettes. Among these smokers, 27% smoked cigarettes only, 37.8% smoked water pipe only, and 35.2% smoked both types of tobacco. Most of the water pipe smokers (74.1%) preferred this method because they believe it to be less harmful than smoking cigarettes. More than half of the subjects were encouraged to start smoking by other females (56.6%). Curiosity was a significant factor for initiation (OR = 2.8, 95% CI = 1.3-6.2, p<.01). We found no significant differences between water pipe and cigarette smokers regarding current age, age at initiation, quit attempts, knowledge about the hazards of smoking, wanting to be fashionable, or smoking with friends. About one in four (23.7%) attempted to quit, with health cited as a major reason. An urgent need exists for correction of the misperception among this study population that water pipe smoking is safe and less harmful than cigarette smoking.

Genotoxic effects of waterpipe smoking on the buccal mucosa cells

Waterpipe smoking is popular in many parts of the world. Micronuclei (MN) evaluation in the exfoliated oral cells of smokers is a non-invasive technique for evaluation of possible tobacco harm. We aimed to assess whether MN levels are higher in waterpipe smokers than in never smokers. We examined oral smears of 128 adult male waterpipe smokers and 78 males who never smoked tobacco in rural Egypt. The total number of MN per 1000 cells per subject, and the number of MN-containing cells per individual were compared. We observed a higher level of total MN in waterpipe smokers (10 +/- 4) than in never smokers (4 +/- 2, p < 0.001). A similar difference was found for the mean number of affected cells per individual (8 +/- 3 vs. 4 +/- 1.62, p < 0.001). MN levels were not significantly dose related. This study is among the first to assess the association between waterpipe smoking and a cytogenetic measure of tobacco harm. The twofold increase in MN level is consistent with previous reports of MN in cigarette smokers. More research is needed to determine if such MN levels are predictive of future health consequences.

Tobacco-Specific Nitrosamine Exposures in Smokers and Nonsmokers Exposed to Cigarette or Waterpipe Tobacco Smoke

INTRODUCTION The causal relationship between tobacco smoking and a variety of cancers is attributable to the carcinogens that smokers inhale, including tobacco-specific nitrosamines (TSNAs). We aimed to assess the exposure to TSNAs in waterpipe smokers (WPS), cigarette smokers (CS), and nonsmoking females exposed to tobacco smoke. METHODS We measured 2 metabolites, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronides (NNAl-Gluc) in the urine of males who were either current CS or WPS, and their wives exposed to either cigarette or waterpipe smoke in a sample of 46 subjects from rural Egypt. RESULTS Of the 24 current male smokers, 54.2% were exclusive CS and 45.8% were exclusive WPS. Among wives, 59.1% reported exposure to cigarette smoke and 40.9% to waterpipe smoke. The geometric mean of urinary NNAL was 0.19 ± 0.60 pmol/ml urine (range 0.005-2.58) in the total sample. Significantly higher levels of NNAL were observed among male smokers of either cigarettes or waterpipe (0.89 ± 0.53 pmol/ml, range 0.78-2.58 in CS and 0.21-1.71 in WPS) compared with nonsmoking wives (0.04 ± 0.18 pmol/ml, range 0.01-0.60 in CS wives, 0.05-0.23 in WPS wives, p = .000). Among males, CS had significantly higher levels of NNAL compared with WPS (1.22 vs. 0.62; p = .007). However, no significant difference was detected in NNAL levels between wives exposed to cigarette smoke or waterpipe smoke. CONCLUSIONS Cigarette smokers levels of NNAL were higher than WPS levels in males. Exposure to tobacco smoke was evident in wives of both CS and WPS. Among WPS, NNAL tended to increase with increasing numbers of hagars smoked/day.

Assessment of tobacco dependence in waterpipe smokers in Egypt.

SETTING Waterpipe smoking is increasing worldwide. Nevertheless, little is known about nicotine dependence in tobacco smokers who use waterpipes. OBJECTIVE To assess evidence of dependence among non-cigarette smoking waterpipe smokers in Egypt. METHODS A total of 154 male exclusive current waterpipe smokers were enrolled for the present study. We adapted the Fagerström test for nicotine dependence and the Reasons for Smoking (RFS) scales and related these to smoking behavior. RESULTS The mean age of the subjects was 47 ± 14 years, the mean age at smoking initiation was 22 ± 9 years, and average daily consumption was 4 ± 8 hagars (tobacco units). The time to the first smoke of the day (P < 0.001), smoking even when ill (P = 0.003), time to tobacco craving (P < 0.001), and hating to give up the first smoke of the day (P = 0.033) were each significantly associated with the number of hagars smoked per day. The RFS subscales of addictive smoking, smoking to relieve negative affect, and smoking for stimulation were also associated with these variables. CONCLUSION The overall findings suggest that waterpipe smokers exhibit many of the same features of nicotine dependency attributed to cigarette smokers.

DRD2/ANKK1 TaqI polymorphism and smoking behavior of Egyptian male cigarette smokers.

Little is known about the genetic contribution to cigarette smoking and nicotine addiction in Egypt. The dopamine D2 receptor gene contains a TaqI repeat fragment length polymorphism creating two alleles with functional significance, DRD2*A1 and DRD2*A2. We investigated the relationship between these alleles and tobacco use in a study of 389 Egyptian male current smokers (mean age = 40 years; SD = 12). Participants were interviewed in 2004 on their smoking behaviors and quit attempts, and were given the Fagerström Test for Nicotine Dependence (FTND). Blood samples were obtained and genotyped for DRD2 A1and A2 alleles. The frequencies of A1/A2, A1/A2, and A2/A2 genotypes were 6%, 29%, and 65%, respectively. We found no statistically significant association between genotype and age at onset of smoking, years of smoking, FTND score, or average number of cigarettes smoked per day. DRD2 genotype was associated with the number of cigarettes smoked in the past 48 hr (42.2 in A1 carriers vs. 37.6 in A2, p = .03), the previous quit duration (28% in A1 vs. 40% in A2 quit for more than 1 month, p = .05), and the depth of inhalation (82% in A1 vs. 72% in A2 inhaled the smoke deeply, p = .03). Logistic regression analysis including DRD2 genotype, FTND score, age at smoking initiation, marital status, and education as predictors showed that maximum duration of quit time was associated with FTND score (p = .003), DRD2 genotype (p = .01), marital status (p = .03), and age at smoking initiation (p = .04). These findings suggest a modest association between DRD2 genotype and quitting behavior in male cigarette smokers in Egypt.

Implementation, barriers and challenges of smoke-free policies in hospitals in Egypt

BackgroundTobacco use is a serious public health challenge in North Africa, and health professionals play a vital role in tobacco control. In Egypt, limited data are available on the knowledge and attitudes of health care providers regarding tobacco control policies. Such data are especially relevant due to Egypt’s tobacco control laws, adopted in 2007, prohibiting smoking in hospitals and other public places. This study surveyed 49 senior administrative staff, 267 physicians, 254 nurses, and 109 administrative employees working in El-Kasr El-Aini Hospital in Cairo, assessing their knowledge and attitudes regarding Egypt’s tobacco control laws and barriers to their effective implementation in health care facilities. We also investigated the hospital’s compliance with smoke-free policies.ResultsThe majority (>90%) of the hospital workers knew that exposure to second-hand smoke is harmful to health. Physicians and nurses had a more favorable attitude towards the smoking ban when compared to administrative employees. Hospital staff identified the following barriers to successfully implementing the smoking ban: lax enforcement of tobacco control laws, the lack of penalties for violators, the lack of cessation programs, and the prevalence of smoking among physicians.ConclusionsOverall, smoke-free policies were poorly enforced in this large teaching hospital in Cairo, Egypt. Interventions to address the identified barriers to their implementation could include the provision of cessation training and services as well as effective communication programs to educate health care workers at all levels regarding the dangers of second-hand smoke exposure and effective measures for protection.

Secondhand smoke in waterpipe tobacco venues in Istanbul, Moscow, and Cairo

OBJECTIVE The prevalence of waterpipe tobacco smoking has risen in recent decades. Controlled studies suggest that waterpipe secondhand smoke (SHS) contains similar or greater quantities of toxicants than cigarette SHS, which causes significant morbidity and mortality. Few studies have examined SHS from waterpipe tobacco in real-world settings. The purpose of this study was to quantify SHS exposure levels and describe the characteristics of waterpipe tobacco venues. METHODS In 2012-2014, we conducted cross-sectional surveys of 46 waterpipe tobacco venues (9 in Istanbul, 17 in Moscow, and 20 in Cairo). We administered venue questionnaires, conducted venue observations, and sampled indoor air particulate matter (PM2.5) (N=35), carbon monoxide (CO) (N=23), particle-bound polycyclic aromatic hydrocarbons (p-PAHs) (N=31), 4-methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (N=43), and air nicotine (N=46). RESULTS Venue characteristics and SHS concentrations were highly variable within and between cities. Overall, we observed a mean (standard deviation (SD)) of 5 (5) waterpipe smokers and 5 (3) cigarette smokers per venue. The overall median (25th percentile, 75th percentile) of venue mean air concentrations was 136 (82, 213) µg/m(3) for PM2.5, 3.9 (1.7, 22) ppm for CO, 68 (33, 121) ng/m(3) for p-PAHs, 1.0 (0.5, 1.9) ng/m(3) for NNK, and 5.3 (0.7, 14) µg/m(3) for nicotine. PM2.5, CO, and p-PAHs concentrations were generally higher in venues with more waterpipe smokers and cigarette smokers, although associations were not statistically significant. CONCLUSION High concentrations of SHS constituents known to cause health effects indicate that indoor air quality in waterpipe tobacco venues may adversely affect the health of employees and customers.

PM2.5 as a marker of exposure to tobacco smoke and other sources of particulate matter in Cairo, Egypt.

SETTING Cairo and Giza governorates of Egypt. BACKGROUND Particulate matter under 2.5 μm in diameter (PM2.5) arises from diverse sources, including tobacco smoke from cigarettes and waterpipes, and is recognized as a cause of acute and chronic morbidity and mortality. OBJECTIVE To measure PM2.5 in workplaces with different intensities of smoking and varying levels of smoking restrictions. DESIGN We conducted an air sampling study to measure PM2.5 levels in a convenience sample of indoor and outdoor venues in 2005-2006. RESULTS Using a calibrated SidePak instrument, 3295 individual measurements were collected at 96 venues. Compared to indoor venues where tobacco smoking was banned (PM2.5 levels 72-81 μg/m(3)), places offering waterpipes to patrons of cafes (478 μg/m(3)) and Ramadan tents (612 μg/m(3)) had much higher concentrations, as did venues such as public buildings with poor enforcement of smoking restrictions (range 171-704 μg/m(3)). Both the number of waterpipe smokers and the number of cigarette smokers observed at each venue contributed significantly to the overall burden of PM2.5. CONCLUSION Such data will support smoke-free policies and programs aimed specifically at reducing environmental tobacco exposure and improving air quality in general, and will provide a baseline for monitoring the impact of tobacco control policies.

Associations of depression and neuroticism with smoking behavior and motives among men in rural Qalyubia (Egypt).

PURPOSE Smoking addiction is influenced by cultural and environmental factors and personality traits. We assessed the associations between neuroticism and depression and smoking behavior and motives among Egyptian adult men in rural Qalyubia Governorate. PATIENTS AND METHODS Using a cross-sectional design, we administered questionnaires to randomly selected 201, 278, and 120 adult men aged 18 years or above who were never, current, and former smokers, respectively. We used Center for Epidemiologic Studies Short Depression (CES-D) scale, Eysenck Personality Inventory (EPI), Fagerström Test for Nicotine Dependence (FTND), and Wisconsin Inventory of Smoking Dependence Motives scales to assess the associations between neuroticism, depression, and smoking risk. RESULTS The mean CES-D and EPI scores were significantly higher among current smokers as compared with never smokers (P=0.02 and 0.006, respectively). The greatest risk for ever smoking was observed among those with both neuroticism and depression [adjusted odds ratio (95% confidence interval) were 1.98 (1.23-3.19); 2.56 (1.34-4.88); and 1.82 (1.10-3.03) for ever, former, and current smokers, respectively]. Both CES-D and EPI scores were associated with a variety of smoking motives and with the level of severity or intensity of nicotine dependence on FTND. CONCLUSION AND RECOMMENDATIONS Neuroticism and depression were associated with smoking behavior and motives among Egyptians, and thus attention should be given to individual needs in designing and implementing smoking cessation interventions.

Biomarkers of Secondhand Smoke Exposure in Waterpipe Tobacco Venue Employees in Istanbul, Moscow, and Cairo

Background Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees. Methods We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul, Moscow, and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO), hair nicotine, saliva cotinine, urine cotinine, urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures. Results There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers, the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2, 40.9) µg/g creatinine urine cotinine, 5.5 (2, 15) ng/mL saliva cotinine, 0.95 (0.36, 5.02) ng/mg hair nicotine, 1.48 (0.98, 3.97) pg/mg creatinine urine NNAL, 0.54 (0.25, 0.97) pmol/mg creatinine urine 1-OHPG, and 1.67 (1.33, 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68, 95% CI: 1.20, 2.37) and hair nicotine (GMR: 1.22, 95% CI: 1.05, 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83, 95% CI: 1.05, 7.62). Conclusions Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS, including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs). Implications Smoke-free regulation should be extended to waterpipe venues to protect nonsmoking employees and patrons from the adverse health effects of SHS.