Ziyad Ben Taleb

The global epidemiology of waterpipe smoking

Objectives In the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become a global phenomenon. In this review, we provide an updated picture of the main epidemiological trends in waterpipe smoking globally. Data sources Peer-reviewed publications indexed in major biomedical databases between 2004 and 2014. Search keywords included a combination of: waterpipe, hookah, shisha along with epidemiology, patterns, prevalence and predictors. We also used different spellings of waterpipe terms commonly used. Study selection The focus was on studies with large representative samples, national data or high-quality reports that illuminated aspects of the epidemiology and trends in waterpipe smoking. Data extraction Multiple researchers extracted the data independently and collectively decided on the most important and pertinent studies to include in the review. Data synthesis Waterpipe smoking has become a global phenomenon among youth. The global waterpipe epidemic is likely driven by (1) the introduction of manufactured flavoured tobacco (Maassel); (2) the intersection between waterpipes social dimension and thriving café culture; (3) the evolution of mass communication media; (4) the lack of regulatory/policy framework specific to the waterpipe. Waterpipe smoking is becoming the most popular tobacco use method among youth in the Middle East, and is quickly gaining popularity elsewhere. Important patterns of waterpipe smoking include the predominance among younger, male, high socioeconomic, and urban groups. Intermittent and social use are also noted patterns. Conclusions Waterpipe smoking has become a global public health problem. Developing surveillance, intervention and regulatory/policy frameworks specific to the waterpipe has become a public health priority.

Syria: health in a country undergoing tragic transition

ObjectivesTo document the ongoing destruction as a result of the tragic events in Syria, to understand the changing health care needs and priorities of Syrians.MethodsA directed examination of the scientific literature and reports about Syria before and during the Syrian conflict, in addition to analyzing literature devoted to the relief and rebuilding efforts in crisis situations.ResultsThe ongoing war has had high direct war casualty, but even higher suffering due to the destruction of health system, displacement, and the breakdown of livelihood and social fabric. Millions of Syrians either became refugees or internally displaced, and about half of the population is in urgent need for help. Access to local and international aid organizations for war-affected populations is an urgent and top priority.ConclusionsSyrians continue to endure one of the biggest human tragedies in modern times. The extent of the crisis has affected all aspects of Syrians’ life. Understanding the multi-faceted transition of the Syrian population and how it reflects on their health profile can guide relief and rebuilding efforts’ scope and priorities.

Consensus statement on assessment of waterpipe smoking in epidemiological studies

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipes alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

Predictors of adherence to pharmacological and behavioral treatment in a cessation trial among smokers in Aleppo, Syria

INTRODUCTION The development of evidence-based smoking cessation programs is in its infancy in developing countries, which continue to bear the main brunt of the tobacco epidemic. Adherence to treatment recommendations is an important determinant of the success of smoking cessation programs, but little is known about factors influencing adherence to either pharmacological or behavioral treatment in developing countries settings. Our study represents the first attempt to examine the predictors of adherence to cessation treatment in a low-income developing country. METHODS Predictors of adherence to pharmacological and behavioral treatment were identified by analyzing data from a multi-site, two-group, parallel-arm, double-blind, randomized, placebo-controlled smoking cessation trial in primary care clinics in Aleppo, Syria. Participants received 3 in-person behavioral counseling sessions plus 5 brief follow-up phone counseling sessions, and were randomized to either 6 weeks of nicotine or placebo patch. RESULTS Of the 269 participants, 68% adhered to pharmacological treatment, while 70% adhered to behavioral counseling. In logistic regression modeling, lower adherence to pharmacological and behavioral treatment was associated with higher daily smoking at baseline, greater withdrawal symptoms, and perception of receiving placebo instead of active nicotine patch. Women showed lower adherence than men to behavioral treatment, while being assigned to placebo condition and baseline waterpipe use were associated with lower adherence to pharmacological treatment. CONCLUSION Adherence to cessation treatment for cigarette smokers in low-income countries such as Syria may benefit from integrated cessation components that provide intensive treatment for subjects with higher nicotine dependence, and address concurrent waterpipe use at all stages.

Smoking cessation and changes in body mass index: findings from the first randomized cessation trial in a low-income country setting

Background In high-income countries, quitting cigarette smoking is associated with weight gain, which can reduce motivation to abstain. Whether smoking cessation is associated with weight gain in a low-income country context has never been investigated. We aimed to determine the post-cessation changes in body mass index (BMI) and its predictors among smokers who received a smoking cessation intervention in a low-income country setting. Methods We performed post hoc analyses of data from 269 smokers who participated in a two-group, parallel-arm, double-blind, placebo-controlled randomized trial of combined nicotine replacement therapy (NRT) and behavioral counseling in primary care clinics in Aleppo, Syria. We used generalized estimating equation modeling to identify predictors of changes in BMI at 6 weeks and 6- and 12-month follow-ups after quit date. Results The mean pre-cessation BMI of the sample was 27.9kg/m2 (SD = 5.2). Over 12 months of follow-up, BMI of smoking abstainers averaged 1.8 BMI units (approximately 4.8kg) greater than non-abstainers (p = .012). Throughout the study, greater BMI was associated with being female (p = .048), reporting smoking to control weight (p < .001) and having previously failed to quit due to weight gain (p = .036). Conclusion Similar to findings from high-income countries, smoking cessation in Syria is associated with weight gain, particularly among women and those who have weight concerns prior to quitting. This group of smokers may benefit from tailored cessation interventions with integrated body weight management elements that take into consideration the prevailing local and cultural influences on diet and levels of physical activity. Implications This study provides the first evidence regarding post-cessation changes in BMI among smokers who attempt to quit in a low-income country setting. Our findings advance knowledge regarding post-cessation weight gain and offers insight for researchers and clinicians to identify smokers at higher risk of post-cessation weight gain. This information will help in delivering interventions that take into account the prevailing cultural influence on diet and physical activity and will ultimately help in designing future tailored cessation programs in Syria and other low-income countries with similar cultural background and level of development.

Viewpoint: methanol poisoning outbreak in Libya: a need for policy reforms.

We address the controversies surrounding a 2013 outbreak of methanol poisoning in Tripoli, Libya. We critically examine and systematically analyze the outbreak to highlight the lessons learned from this disaster and how to act properly to prevent similar outbreaks in future. Many health problems have been directly attributed to drinking alcohol; the type and quality of alcohol determines the detrimental effects. An unregulated and flourishing black market in alcohol is among the factors behind the Libyan tragedy, where approximately 90 deaths and about 1000 hospital admissions were reported. We reviewed gaps in local and regional alcohol policy, and highlighted the issue of illegally produced and home-made alcohol. Collaboration between countries in the region plus critical health and policy reforms in Libya, with emphasis on public health preparedness, can dramatically decrease morbidity and mortality associated with such outbreaks.

E-cigarette marketing exposure and combustible tobacco use among adolescents in the United States

E-cigarette advertising has been shown to be associated with use of e-cigarettes, but its association with tobacco use has not been studied. Therefore, we examined the association between e-cigarettes advertisement and tobacco use. Data from nationally representative 22,007 middle and high school students (grades 6-12) were used to conduct the analysis. Logistic regression models estimated the adjusted odds ratios (AOR) of ever and current use of cigarette, hookah, cigar, and polytobacco use. Odds ratios were weighted and adjusted for study design, non-response rates, school level, gender, race/ethnicity, e-cigarette use, and smoking at home. E-cigarette marketing exposure was significantly associated with ever use of cigarettes (AOR: 1.3, 95% CI: 1.1-1.5), hookah (AOR: 1.4, 95% CI: 1.2-1.7), cigars (AOR: 1.5, 95% CI: 1.4-1.6), and polytobacco (AOR: 1.7, 95% CI: 1.5-1.8). Likewise, E-cigarette marketing exposure was significantly associated with current use of cigarettes (AOR: 1.3, 95% CI: 1.1-1.6), hookah (AOR: 1.3, 95% CI: 1.03-1.7), cigars (AOR: 1.3, 95% CI: 1.1-1.6), and polytobacco use (AOR: 1.8, 95% CI: 1.5-2.1). The results suggest that e-cigarette advertisement is associated with use of cigarettes, hookah, cigars, and polytobacco products. These results add to the evidence about the risks of e-cigarette marketing and highlight the need for stricter regulation of e-cigarette advertisements.

Correlates of nicotine dependence among adolescent waterpipe smokers

INTRODUCTION Waterpipe smoking is addictive and its use is increasing globally among youth, yet little is known about the factors associated with nicotine dependence (ND) among waterpipe smokers. We investigated the factors associated with ND symptoms among a sample of Lebanese adolescents who smoke a waterpipe. METHODS We collected data on factors potentially associated with ND (individual, socio-demographic, environmental, smoking patterns) among 160 current (past 30days) waterpipe smokers recruited from 8th and 9th school grades in Lebanon. We assessed the loss of autonomy over tobacco using the Hooked on Nicotine Checklist (HONC), ND using the International Classification of Diseases, 10th revision (ICD-10), and the number of ND symptoms endorsed. RESULTS Depressive symptoms, lower self-esteem, and having at least one sibling who smokes a waterpipe were associated with the presence of ND symptoms, while enrollment in public schools, smoking a waterpipe ≥30min per session, and believing that cigarette smoking is harmful to health were associated with endorsement of a higher number of ND symptoms. Smoking a whole waterpipe head without sharing and being in 9th grade in this study were associated with the presence and endorsement of a higher number of ND symptoms. CONCLUSIONS We identified specific social and psychological characteristics, waterpipe smoking patterns, and beliefs about harmful effects of smoking associated with the presence of ND among adolescent waterpipe smokers. Considering these factors when planning policies to prevent ND among waterpipe smokers is warranted.

Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study

INTRODUCTION Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth. METHODS Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥3 criteria during 12months). RESULTS Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing≥1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥10 vs. <4 waterpipes; Hazard ratio (HR)=2.05, 95% CI: 1.52-2.58, p=0.007), and session length (>60min vs. <30min; HR=2.87, 95% CI: 2.83-2.91, p=0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥10 vs. <4 waterpipes; HR=2.56, 95% CI: 1.89-3.22, p=0.006), and smoking every day/almost every day vs. less than once weekly (HR=2.86, 95% CI: 2.12-3.60, p=0.007). CONCLUSIONS Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers.

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers

Introduction Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers. Methods We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes. Results Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99). Conclusions A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted.