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Maziak W.,Florida International University | Maziak W.,Syrian Center for Tobacco Studies | Nakkash R.,American University of Beirut | Bahelah R.,Florida International University | And 4 more authors.
Health Policy and Planning | Year: 2013

The Arab world is comprised of 22 countries with a combined population of ∼360 million. The region is still at the initial stages of the tobacco epidemic, where it is expected to witness an increase in smoking levels and mounting tobacco-related morbidity and mortality in the future. Still, the bleak outlook of the tobacco epidemic in the Arab world continues to be faced with complacency in the form of underutilization of surveillance systems to monitor the tobacco epidemic and prioritize action, and failure to implement and enforce effective policies to curb the tobacco epidemic. Understandably, the focus on the Arab world carries the risk of trying to generalize to such a diverse group of countries at different level of economic and political development. Yet, tobacco control in the Arab world faces some shared patterns and common challenges that need to be addressed to advance its cause in this region. In addition, forces that promote tobacco use, such as the tobacco industry, and trends in tobacco use, such as the emerging waterpipe epidemic tend to coalesce around some shared cultural and socio-political features of this region. Generally, available data from Arab countries point at three major trends in the tobacco epidemic: (1) high prevalence of cigarette smoking among Arab men compared with women; (2) the re-emergence of waterpipe (also known as hookah, narghile, shisha, arghile) smoking as a major tobacco use method, especially among youth and (3) the failure of policy to provide an adequate response to the tobacco epidemic. In this review, we will discuss these trends, factors contributing to them, and the way forward for tobacco control in this unstable region. © The Author 2013; all rights reserved.


Asfar T.,University of Miami | Al Ali R.,Syrian Center for Tobacco Studies | Rastam S.,Syrian Center for Tobacco Studies | Maziak W.,Florida International University | Ward K.D.,University of Memphis
Addictive Behaviors | Year: 2014

Background: Waterpipe use has increased dramatically in the Middle East and other parts of the world. Many users exhibit signs of dependence, including withdrawal and difficulty quitting, but there is no evidence base to guide cessation efforts. Methods: We developed a behavioral cessation program for willing-to-quit waterpipe users, and evaluated its feasibility and efficacy in a pilot, two arm, parallel group, randomized, open label trial in Aleppo, Syria. Fifty adults who smoked waterpipe ≥. 3 times per week in the last year, did not smoke cigarettes, and were interested in quitting were randomized to receive either brief (1 in-person session and 3 phone calls) or intensive (3 in-person sessions and 5 phone calls) behavioral cessation treatment delivered by a trained physician in a clinical setting. The primary efficacy end point of the developed interventions was prolonged abstinence at three months post-quit day, assessed by self-report and exhaled carbon monoxide levels of <. 10. ppm. Secondary end points were 7. day point-prevalent abstinence and adherence to treatment. Results: Thirty percent of participants were fully adherent to treatment, which did not vary by treatment group. The proportions of participants in the brief and intensive interventions with prolonged abstinence at the 3-month assessment were 30.4% and 44.4%, respectively. Previous success in quitting (OR = 3.57; 95% CI = 1.03-12.43) predicted cessation. Higher baseline readiness to quit, more confidence in quitting, and being unemployed predicted a better adherence to treatment (all p-values <. 0.05). Conclusions: Brief behavioral cessation treatment for waterpipe users appears to be feasible and effective. © 2014 Elsevier Ltd.


Rastam S.,Syrian Center for Tobacco Studies | Eissenberg T.,Virginia Commonwealth University | Ibrahim I.,Syrian Center for Tobacco Studies | Ward K.D.,University of Memphis | And 2 more authors.
Addictive Behaviors | Year: 2011

This study's objective is to examine the relative effectiveness of cigarettes and waterpipe (WP) in reducing tobacco abstinence symptoms in dual cigarette/WP smokers. Sixty-one dual cigarette/WP smokers participated (mean age. ± SD 22.0. ± 2.6. year; mean cigarettes/day 22.4. ± 10.1; mean WPs/week 5.2. ± 5.6). After 12-hour abstinence participants completed two smoking sessions (WP or cigarette), while they responded to subjective measures of withdrawal, craving, and nicotine effects administered before smoking and 5, 15, 30 and 45. min thereafter. For both tobacco use methods, scores on measures of withdrawal and craving were high at the beginning of session (i.e., before smoking) and were reduced significantly and comparably during smoking. Analysis of smoking and recovery (post-smoking) phases showed similarity in the way both tobacco use methods suppressed withdrawal and craving, but the recovery of some of these symptoms can be faster with cigarette use. This study is the first to show the ability of WP to suppress abstinence effects comparably to cigarettes, and its potential to thwart cigarette cessation. © 2011 Elsevier Ltd.


Mzayek F.,University of Memphis | Mzayek F.,Syrian Center for Tobacco Studies | Khader Y.,Jordan University of Science and Technology | Eissenberg T.,Virginia Commonwealth University | And 4 more authors.
Nicotine and Tobacco Research | Year: 2012

Introduction: Tobacco use remains a major public health problem worldwide. Water-pipe smoking is spreading rapidly and threatening to undermine the successes achieved in tobacco control. Methods: A school-based longitudinal study in the city of Irbid, Jordan, was performed from 2008 to 2010. All seventh-grade students in 19 randomly selected schools, out of a total of 60 schools in the city, were enrolled at baseline and surveyed annually. Results: Of the 1781 students enrolled at baseline 1,701 (95.5%) were still in the study at the end of the second year of follow-up (869 boys, median age at baseline 13 years). Ever and current water-pipe smoking were higher than those of cigarette smoking at baseline (ever smoking: 25.9% vs. 17.6% and current smoking: 13.3% vs. 5.3% for water-pipe and cigarette smoking, respectively; p < .01 for both) but cigarette smoking caught up by the second year of follow-up (ever smoking: 46.4% vs. 44.7%; p = .32 and current smoking: 18.9% vs. 14.9%; p < .01). Water pipe-only smokers at baseline were twice as likely to become current cigarette smokers after 2 years compared with never smokers (relative risk (RR) = 2.1; 95% CI = 1.2, 3.4). A similar pattern was observed for cigarette-only smokers at baseline (RR = 2.0; 95% CI = 0.9, 4.8). Conclusions: Prevalence of water-pipe and cigarette smoking increased dramatically over the 2-year follow-up period with similar patterns in boys and girls, although girls had lower prevalence in all categories. Water-pipe smoking at baseline predicted the progress to cigarette smoking in the future and vice versa. © The Author 2011. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.


Maziak W.,Florida International University | Maziak W.,Syrian Center for Tobacco Studies | Taleb Z.B.,Florida International University | Bahelah R.,Florida International University | And 5 more authors.
Tobacco Control | Year: 2015

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 waterpipe’s 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. © 2015, BMJ Publishing Group. All rights reserved.


Salloum R.G.,University of South Carolina | Osman A.,University of South Carolina | Maziak W.,Florida International University | Maziak W.,Syrian Center for Tobacco Studies | Thrasher J.F.,University of South Carolina
Tobacco Control | Year: 2015

Objectives Waterpipe tobacco smoking (WTS), a traditional tobacco consumption practice in the Middle East, is gaining popularity worldwide. Estimates of population-level interest in WTS over time are not documented. We assessed the popularity of WTS using World Wide Web search query results across four English-speaking countries. Methods We analysed trends in Google search queries related to WTS, comparing these trends with those for electronic cigarettes between 2004 and 2013 in Australia, Canada, the UK and the USA. Weekly search volumes were reported as percentages relative to the week with the highest volume of searches. Results Web-based searches for WTS have increased steadily since 2004 in all four countries. Search volume for WTS was higher than for e-cigarettes in three of the four nations, with the highest volume in the USA. Online searches were primarily targeted at WTS products for home use, followed by searches for WTS cafés/lounges. Conclusions Online demand for information on WTSrelated products and venues is large and increasing. Given the rise in WTS popularity, increasing evidence of exposure-related harms, and relatively lax government regulation, WTS is a serious public health concern and could reach epidemic levels in Western societies. © 2015, BMJ Publishing Group. All rights reserved.


Salloum R.G.,University of South Carolina | Thrasher J.F.,University of South Carolina | Kates F.R.,University of South Carolina | Maziak W.,Florida International University | Maziak W.,Syrian Center for Tobacco Studies
Preventive Medicine | Year: 2015

Objective: To report prevalence and correlates of water pipe tobacco smoking (WTS) use among U.S. adults. Methods: Data were from the 2009-2010 National Adult Tobacco Survey, a nationally representative sample of U.S. adults. Estimates of WTS ever and current use were reported overall, and by sex, age, race/ethnicity, educational attainment, annual household income, sexual orientation, and cigarette smoking status. State-level prevalence rates of WTS ever were reported using choropleth thematic maps for the overall population and by sex. Results: The national prevalence of WTS ever was 9.8% and 1.5% for current use. WTS ever was more prevalent among those who are male (13.4%), 18-24. years old (28.4%) compared to older adults, non-Hispanic White (9.8%) compared to non-Hispanic Black, with some college education (12.4%) compared to no high school diploma, and reporting sexual minority status (21.1%) compared to heterosexuals. States with highest prevalence included DC (17.3%), NV (15.8%), and CA (15.5%). Conclusion: WTS is now common among young adults in the US and high in regions where cigarette smoking prevalence is the lowest and smoke-free policies have a longer history. To reduce its use, WTS should be included in smoke-free regulations and state and federal regulators should consider policy development in other areas, including taxes, labeling, and distribution. © 2014 Elsevier Inc.


Ali R.A.,Syrian Center for Tobacco Studies | Rastam S.,Syrian Center for Tobacco Studies | Ibrahim I.,Syrian Center for Tobacco Studies | Bazzi A.,American University of Beirut | And 4 more authors.
Tobacco Control | Year: 2015

Background In the past decade, waterpipe smoking— also known as hookah, shisha, narghileh—has increased among youth. The scarcity of rigorous studies linking waterpipe smoking to smoking-related diseases has hindered policy and regulatory efforts to confront the waterpipe epidemic. This study compares systemic carcinogen exposure between independent groups of exclusive waterpipe smokers, cigarette smokers and nonsmokers. Methods This study was conducted at the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria, between 2010 and 2011. First morning urinary samples were collected from three groups of subjects; exclusive daily waterpipe smokers (n=24), exclusive daily cigarette smokers (n=23), and non-smokers (n=28). These samples were analysed for carcinogenic tobacco-specific nitrosamines 4-(methylnitrosamino)-1-(3-pyridyl)-1- butanol (NNAL) using liquid chromatography—tandem mass spectrometry (LC-MS/MS). Results Our results show that waterpipe smokers are exposed to about 5–10 times greater NNAL than nonsmokers. Mean (95% CI) free and total NNAL was 07 (0 3 to 1. 4) and 3 9 (1 6 to 9.5) pg/mL urine for nonsmokers, 8 4 (4 8 to 14.8) and 33 0 (21 6 to 50.6) pg/ mL urine for waterpipe smokers, and 10 7 (5 0 to 22.6) and 46 8 (27 6 to 79.3) pg/mL urine for cigarette smokers (p<0 001 for all comparisons). Daily waterpipe smokers were less exposed to NNAL than daily cigarette smokers, although the difference did not reach statistical significance for all measurements. Conclusions These results provide the clearest indication to date about systemic exposure to harmful carcinogens associated with long-term waterpipe smoking. Such evidence can support policy and regulatory efforts designed to confront the emerging global waterpipe epidemic, as well as drive interventions aimed at increasing the public awareness about the cancer risk associated with waterpipe smoking. © 2015, BMJ Publishing Group. All rights reserved.


Vansickel A.R.,Virginia Commonwealth University | Shihadeh A.,American University of Beirut | Eissenberg T.,Virginia Commonwealth University | Eissenberg T.,Syrian Center for Tobacco Studies
Tobacco Control | Year: 2012

Background Waterpipe tobacco package labelling typically indicates "0.0% tar" and "0.05% or 0.5% nicotine". Objective To determine the extent to which nicotine labeling is related to nicotine delivery. Methods 110 waterpipe smokers engaged in a 45-minute waterpipe smoking session. Puff topography and plasma nicotine were measured. Three waterpipe tobacco brands were used: Nakhla (0.5% nicotine), Starbuzz (0.05% nicotine), and Al Fakher (0.05% nicotine). Data were analyzed by one-way ANOVA. Results Topography did not differ across brands. Peak plasma nicotine varied significantly across brands. Al Fakher had the highest nicotine delivery (11.4 ng/ml) followed by Nakhla (9.8 ng/ml) and Starbuzz (5.8 ng/ml). Conclusions Nicotine labelling on waterpipe tobacco products does not reflect delivery; smoking a brand with a "0.05% nicotine" label led to greater plasma nicotine levels than smoking a brand with a "0.5% nicotine" label. Waterpipe tobacco products should be labelled in a manner that does not mislead consumers.


Maziak W.,Florida International University | Maziak W.,Syrian Center for Tobacco Studies
American Journal of Preventive Medicine | Year: 2014

The recent popularity of electronic (e)-cigarettes and their rapid uptake by youth has ignited the debate about their role as a harm-reduction strategy. Harm reduction in the context of tobacco control contends that in societies that have achieved considerable success in curbing smoking, leaving the remaining hard-to-quit smokers with an abstinence-only option is unfair, especially when lessharmful choices are available. On one side of the debate are those who call for caution in endorsing such products until critical pieces of evidence about their safety and potential become available, whereas the other side argues that waiting until all questions about e-cigarettes are answered is dogma driven. In this piece, I try to discuss the unresolvable contention between harm-reduction goals of offering safer options to smokers, and those of e-cigarette makers of being commercially viable and profitable. © 2014 American Journal of Preventive Medicine.

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