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Background of study Hookah smoking is a major concern worldwide, especially in Eastern Mediterranean countries. In this study, we aimed to develop and psychometrically test the factors underlying hookah smoking among women. Methods We conducted both qualitative and quantitative phases between 2019 and 2022. The study sample comprised women who smoked hookah and were visiting health centers in Bandar Abbas. The primary questionnaire items were developed based on the findings from the qualitative phase of the study. The validity of the questionnaire was tested using the item impact, content validity ratio (CVR), content validity index (CVI), and face validity. A total of 485 subjects completed the questionnaire for an exploratory factor analysis (EFA) and 485 subjects did so for a confirmatory factor analysis (CFA). Results In the qualitative phase, 97 items were generated to enter the psychometric phase. Twelve items were removed based on the content validity results and six were removed in the face validity phase. In the EFA, 16 items were removed with factor loadings less than 0.3, and 81 items were loaded on 16 factors. CFA results of the 16-factor structure of the questionnaire included socio-economic deficiencies, role of advertisement and education, availability, fun and entertainment, hookah smoking in family and relatives, search for peace, others’ attention and approval, physical/mental dependence, color, flavor and sound of hookah, happy environment of coffee shops, pleasant experience of the first puff of hookah smoking, more acceptability of hookah smoking in society (vs. cigarettes), false beliefs, low self-efficacy, peer pressure, and family tendencies. Conclusion This study provides a robust, reliable, and valid tool to identify the complex social, psychological, and environmental factors driving hookah smoking among women in Iran. The findings underscore the urgent need for tailored, multi-pronged public health interventions to curb this emerging global health threat.

To prospectively estimate the age of initiation of ever, past 30-day, and fairly regular hookah use among young adults (ages 18-24) overall, by sex, by race/ethnicity, and to explore the association of prior use of other tobacco products with these hookah use behaviors. Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US young adults. Young adult never hookah users at the first wave of adult participation in PATH waves 1-3 (2013-2016) were followed-up into waves 2-4 (2014-2017) to estimate the age of initiation of three outcomes: (i) ever use, (ii) past 30-day use, and (iii) fairly regular hookah use. Weighted interval-censoring Cox proportional hazards regression models were used to examine the differences in the estimated age of initiation by sex and by race/ethnicity while controlling for the total number of other tobacco products ever used at participants' first wave of PATH participation. In addition, to examine if prior use of other tobacco products was associated with the age of hookah initiation behaviors, six additional Cox models are reported for each hookah initiation behaviors. The largest increase in hookah use occurred between ages 18 and 19: 5.8% for ever use and 2.7% for past 30-day hookah use. By age 21, 10.5%, 4.7% and 1.2% reported initiation of ever, past 30-day and fairly regular hookah use, respectively. There were statistically significance differences in the age of initiation of hookah use behaviors by race/ethnicity. Educational interventions should target young adults before the age of 21, focusing efforts specifically on males, non-Hispanic Blacks and Hispanics, to stall initiation and progression of hookah use behaviors.

Introduction The clustering of high-risk behaviors among different populations is growing. The current research aims to determine profiles of risk-taking behaviors among hookah smokers and associations with life satisfaction. Methods This cross-sectional study was performed on 424 hookah smokers. The sample was selected through multistage random sampling from five municipal districts in Ardabil city. All participants completed three sets of checklists and questionnaires. Data analysis was conducted using chi-square and latent class analysis. Results Four latent classes were identified; namely, “low-risk” (27.3%), “moderate risk” (27.2%), “high-risk” (26.2%), and “very high-risk” (19.3%). After adjusting for other studied covariates, higher age significantly decreased the odds of being in the high-risk class (OR = 0.87, 95% CI: 0.82–0.92) compared to the low-risk class. Similarly, having a higher life satisfaction score significantly decreased the odds of membership in high-risk (OR = 0.43, 95% CI: 0.24–0.76) and very high-risk (OR = 0.40, 95% CI: 0.23–0.69) classes in comparison to the low-risk class. On the other hand, being male, compared to being female, increased the odds of membership in moderate risk (OR = 2.27, 95% CI: 1.16–4.44) and very high-risk (OR = 6.53, 95% CI: 2.56–16.60) classes compared to the low-risk class. Also, existing substance users among family members increased the odds of belonging to moderate risk (OR = 4.45, 95% CI: 3.17–9.36), high-risk (OR = 2.30, 95% CI: 1.28–4.11), and very high-risk (OR = 5.25, 95% CI: 3.01–9.17) classes in comparison to the low-risk class. Conclusion Results showed that 45.5% of the participants fell under high- risk or very high-risk classes. Consequently, higher life satisfaction is often associated with lower levels of risk-taking behaviors in hookah smokers.

As if it were raw garlic, they bit into the layers of gossip till her name smoked out on their breaths...

Objective To analyze the consumption frequency and factors associated with hookah usage. Methods This cross-sectional study involved adults, hookah users, residing in the city of Curitiba. Hookah groups were contacted on social networking sites via an invitation that contained a link to the questionnaire, which comprised 21 questions covering demographic and socioeconomic characteristics, user profiles, use of cigarettes and alcohol, symptoms, and perceptions of the risks of hookah use. The dependent variables were low and high consumption frequency. Multivariate analysis was performed using the backward method with p  ≤ 0.20 in the chi-square test, and variables with p  ≤ 0.05 were included in the final model. Results Two hundred and seven questionnaires were included, and most hookah users were aged 22 years or older, resident in the south region, male, higher education, single, with high income, and categorized as low-consumption users. They started using hookah at up to 17 years old, discovered it through friends, purchased hookah essence from a tobacconist, and used it in groups, with 3 sessions or more per day, and the session duration was 50 min or more. They did not smoke conventional cigarettes, either during the hookah session or otherwise, and consumed alcohol during the hookah session, felt dizzy while using the device, and most believed that hookahs could harm their health. Higher values for high consumption compared to low consumption were observed in individuals aged up to 22 years, those with high school education, and those who purchase hookah essence from a distributor. High consumption was associated with individual use and the absence of symptoms when using hookah. Smoking conventional cigarettes during hookah session, experiencing dizziness, and reporting that symptoms disappeared after cessation of use were higher in the low-consumption group. Among high-consumption users, the majority resided in the northern region (Prevalence Ratio 6.736), were under 22 years of age (1.445) and bought essence from the distributor (1.463). Those who experienced dizziness (0.671) consumed hookah less frequently. Conclusion High consumption was associated with region, age, and place of purchase of essence, indicating that effective public policies necessitate formulating. Categories: Behavioral, Epidemiologic, and Health Services Research.

Young adults are increasingly using non-cigarette products, such as hookahs, since they are perceived as healthier alternatives to cigarette smoking. However, hookah users are exposed to not only carcinogenic compounds but also microorganisms that may play an active role in the development of both infectious and chronic diseases among users. Nevertheless, existing hookah research in this area has focused only on microorganisms that may be transferred to users through the smoking apparatus and not on bacterial communities associated with hookah tobacco. To address this knowledge gap, we conducted time-series experiments on commercially available hookah brands (Al Fakher (flavors: two apple, mint, and watermelon) and Fumari (flavors: white gummy bear, ambrosia, and mint chocolate chill)) stored under three different temperature and relative humidity conditions over 14 days. To characterize bacterial communities, the total DNA was extracted on days 0, 5, 9, and 14, PCR-amplified for the V3V4 region of the bacterial 16S rRNA gene, sequenced on the Illumina HiSeq platform, and analyzed using R. Diversity (alpha and beta) analyses revealed that the microbiotas of Fumari and Al Fakher products differed significantly and that flavor had a significant effect on the hookah microbiota. Overall, Pseudomonas , Bacillus , Sphingomonas , and Methylobacterium were the predominant bacterial taxa across all products . Additionally, we observed compositional differences between hookah brands across the 14-day incubation . These data suggest that the bacterial communities of hookah tobacco are diverse and differ across brands and flavors, which may have critical implications regarding exposures to specific bacteria among hookah users. Key points • Commercial hookah products harbor diverse bacterial communities . • Brands and flavors impact the diversity of these communities . • Research on their viability and transmission to users’ respiratory tracts is needed . Graphical abstract

Background The prevalence of hookah smoking among females, including university students, is increasing and is considered a high-risk behavior; therefore, designing and implementing effective interventions is crucial. This study aimed to determine the effect of an educational program based on an integrated model of the Theory of Planned Behavior (TPB) and the Prototype Willingness Model (PWM) on hookah smoking among female university students. Methods A quasi-experimental study was conducted on 100 female university students residing in dormitories from October 2024 to January 2025. Four dormitories were randomly assigned to intervention and control groups. Students were recruited through convenience sampling, proportionate to the population of each dormitory. Based on the integrated model, the educational program was delivered to the intervention group in four sessions. Data were collected using a demographic information form and a self-developed questionnaire to assess the integrated model constructs at baseline and three months post-intervention. Data were analyzed using t-tests, chi-square tests, and the Mann–Whitney U test (SPSS v26). Results Scores for positive attitude towards hookah smoking ( P  = 0.01), subjective norms ( P  = 0.04), behavioral willingness ( P  = 0.02), prototype favorability ( P  = 0.03), and perceived behavioral control ( P  = 0.02) significantly decreased in the intervention group. Behavioral intention, however, significantly increased ( P  = 0.03). No significant differences were observed in prototype similarity ( P  = 0.81). Although the prevalence of hookah users after the intervention did not differ significantly between the two groups ( P  = 0.41), the frequency of hookah use ( P  = 0.02) and the duration of each smoking session ( p  = 0.03) were significantly different between the groups. Conclusion The integrated model-based educational intervention led to significant reductions in both the frequency of hookah use and the duration of each smoking session. This model can be employed as an innovative and practical approach to modify students’ behavior.

Our purpose was to quantify 36 inorganic chemical elements in aerosols from disposable electronic cigarettes (ECs) and electronic hookahs (EHs), examine the effect of puffing topography on elements in aerosols, and identify the source of the elements. Thirty-six inorganic chemical elements and their concentrations in EC/EH aerosols were determined using inductively coupled plasma optical emission spectroscopy, and their source was identified by analyzing disassembled atomizers using scanning electron microscopy and energy dispersive X-ray spectroscopy. Of 36 elements screened, 35 were detected in EC/EH aerosols, while only 15 were detected in conventional tobacco smoke. Some elements/metals were present in significantly higher concentrations in EC/EH aerosol than in cigarette smoke. Concentrations of particular elements/metals within EC/EH brands were sometimes variable. Aerosols generated at low and high air-flow rates produced the same pattern of elements, although the total element concentration decreased at the higher air flow rate. The relative amount of elements in the first and last 60 puffs was generally different. Silicon was the dominant element in aerosols from all EC/EH brands and in cigarette smoke. The elements appeared to come from the filament (nickel, chromium), thick wire (copper coated with silver), brass clamp (copper, zinc), solder joints (tin, lead), and wick and sheath (silicon, oxygen, calcium, magnesium, aluminum). Lead was identified in the solder and aerosol of two brands of EHs (up to 0.165 μg/10 puffs). These data show that EC/EH aerosols contain a mixture of elements, including heavy metals, with concentrations often significantly higher than in conventional cigarette smoke. While the health effects of inhaling mixtures of heated metals is currently not known, these data will be valuable in future risk assessments involving EC/EH elements/metals.

Negative health effects of waterpipe tobacco smoking (WTS) are likely more pronounced in dual rather than single smoker couples. Data on how smokers’ perceived harms for self and partner differ between couple types and how these perceptions are associated with motivation to quit are needed. We examined these associations by surveying one member of dual smoker (i.e., both partners smoke) and single smoker (i.e., one partner smokes) couples who engages in WTS. We enrolled online adults ages 18–32 who engaged in WTS during the last month and were in a committed relationship of at least six months. Participants rated their harm to self and, when relevant, to partner, how much they were harming their partner due to their WTS, and partner’s smoke exposure. Participants reported their motivation to quit. Of the 323 participants, 215 (67%) were in dual smoker couples. Participants in dual smoker couples reported lower own perceived risk, which correlated highly with perceived partner risk, than participants in single smoker couples; they also reported harming their partners more even though they downplayed how frequency of smoke exposure was harming the partner. Motivation to quit did not differ by couple type. Across couple types, motivation to quit increased with greater perceived harms. Smokers in dual compared to single smoker couples downplay their risks and perceived harms their smoking causes their partner. Interventions focused on harms to self and partner may be effective to increase motivation to quit and cessation in both couple types.

Background The use of the hookah-smoking device is increasing at a large scale in the Eastern Mediterranean region. Hookah users are exposed to an array of chemical compounds and may suffer several chronic diseases as a result. The purpose of this study was to determine the prevalence of hookah use among male high school students in the region and to study different associated factors in order to provide local tobacco control officials with an understanding of this public health problem. Methods A convenient non-probability sampling study was conducted among students in three high schools in Al-Karkh district, Baghdad. The study period was from October 2017 till January 2019 and included 847 male students aged 15–18 years old. Using a simple random technique to select the high schools from a list of schools we chose one school from each directorate. Descriptive, chi-square test of significance, bivariate, and multivariate logistic regression analyses of data were carried out for identifying the risk factors associated with hookah smoking among these high school adolescent males. Results The overall prevalence of hookah smoking in the last 30 days among male high school students was 46.1% while in the past 6 months it was as high as 85.7%. More than two-thirds (70.6%) of the students thought that hookah smoking was more socially acceptable than cigarette smoking. Factors such as having first heard about it from friends, the media, or the presence of a hookah café near their residence were significantly associated ( p  > 0.05) with hookah smoking among the students. Similarly, being surrounded by friends who used hookah was also found to be significantly associated with hookah smoking, with an odds ratio of 0.18, 95% CI (0.087–0.394). Hookah smokers were less likely than non-hookah smokers to report its use as forbidden in Islam and more likely to say it is allowed in Islam. Conclusions We found an alarmingly high use of hookah smoking among male high school students in this study. Family members and peers had an important role in the prevention of hookah smoking among these students. There is a need for students to be educated about the toxicity of hookah tobacco smoking and its direct effect on their health.