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Harms associated with the use of smoked tobacco products, including waterpipes, are due to inhalational exposure to toxicants either present in tobacco or formed during the process of combustion. We assessed levels of 37 toxicants in aerosol emissions from conventional waterpipe heated with different charcoals and also with a heat management device (HMD), from the IQOS heated tobacco product (HTP), and the ‘OOKA’ electronic waterpipe. We also utilised literature data on toxicant yields in 3R4F reference cigarette smoke. When taking use patterns into account, toxicant yields were substantially lower in conventional waterpipe aerosol compared with cigarette smoke. Toxicant yields in electronic waterpipe aerosol were substantially lower than those in conventional waterpipe aerosol, both on a per session basis and when taking typical use patterns into account. Numerous toxicants in conventional waterpipe aerosol were absent in electronic waterpipe aerosol. In summary, during typical use conventional waterpipe emits fewer, and lower levels of, a number of toxicants relative to combustible cigarette smoke. In addition, electronically heating shisha further reduces toxicant levels, and many toxicants are absent in OOKA electronic waterpipe aerosol. These findings have important implications concerning toxicant exposure among waterpipe users, and for understanding how to potentially reduce health risks associated with waterpipe use.

Glycerol, flavorings and sweeteners constitute approximately 70% of water-pipe tobacco smoking (WTS) mixtures. Tobacco mixture combustion produces smoke toxins (e.g. carbonyl compounds), of which the type and amount are highly dependable on tobacco mixture formula. While glycerol in tobacco mixture contribute to enhanced smoking experience, its’ combustion produces toxicants such as acrolein. According to WHO, there are no approved international upper limits regulations on WTS ingredients. This study aims to assess toxicant emission levels corresponding to increasing glycerol concentration in WTS mixtures, which may aid in developing tobacco regulations towards harm reduction. Methods Laboratory experimental study. Using laboratory water-pipe smoking machine, levels of toxicant emissions in the smoke from WTS mixture samples containing varying glycerol concentrations were measured using High-performance Liquid Chromatography (HPLC). Smoke from 5 consecutive smoking cycles with 35 puffs each (ISO 22486 standard) was led through a trapping system as described in the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) recommended method No. 74 (Determination of selected carbonyls in mainstream cigarette smoke by HPLC). Trapped carbonyls were then analysed by HPLC with a DAD detector. Results Acrolein emission is associated with glycerol addition in WTS mixture indicated by lab-made samples throughout all glycerol concentrations (10%, 20%, 40% and 60%), and brand samples with glycerol concentrations 10% to 20%. However, brand samples showed no increase in acrolein emission corresponding to the increase in glycerol concentrations from 20% to 60%. Conclusion The effect of glycerol addition in waterpipe tobacco on acrolein emission varies between products. Tobacco fillers, additives and contents quality and other factors may affect toxicant emission levels. Therefore, regulatory recommendations towards defining upper limits of content concentrations require further investigations regarding potential confounders in acrolein emissions and health effects of market-available glycerol concentrations in waterpipe tobacco smoking.

Background: Waterpipe tobacco smoking is increasing in Egypt, although there are several interventions to reduce its use. Aim: To describe the development of a policy brief to reform waterpipe tobacco taxation in Egypt. Methods: During 2019–2022, we synthesized available literature evidence on waterpipe tobacco taxation in Egypt and other countries. We then held a policy dialogue to engage various stakeholders to discuss and finalize a draft policy brief for Egypt. Results: The policy brief proposes 3 elements for improving waterpipe tobacco taxation in Egypt: establishinevidence-informedrm for national data on waterpipe tobacco economics; modelling the economic and public health benefits of an improved waterpipe tobacco taxation system; and raising waterpipe tobacco tax level and reforming the taxation structure. Conclusion: Application of the knowledge-to-policy translation framework was instrumental in bridging the gap between evidence synthesis and political framing for the policy brief. More effort should be made to strengthen evidence informed policymaking, particularly in settings where tobacco control governance is fragmented and tax policies are applied inconsistently.

This study examines the bioaccumulation factor (BAF) of polycyclic aromatic hydrocarbons (PAHs) in Peronia peronii (as the bio-indicator organism) exposed to the leachate resulting from fruit-flavored and traditional burnt tobacco wastes. The ƩPAHs concentrations in the muscle samples of P. Peronii of exposed group I (organisms exposed to the leachate resulting from fruit-flavored waterpipe tobacco wastes) and exposed group II (organisms exposed to the leachate resulting from traditional waterpipe tobacco wastes) and control group (exposed to natural seawater) were 37.49 ± 12.9, 9.32 ± 3.8, and 3.89 ± 1.9 ng/g, respectively. Furthermore, there was a significant difference between the mean values of all ƩPAHs compounds in the three groups (group I, group II, and control). The mean Log BAFs in P. Peronii exposed to fruit-flavored and traditional tobacco waste leachates were ranged from 1.70 to 3.61 and 2.49 to 3.07, respectively. The mean Log BAFs of none of the PAHs compounds did not exceed 3.7 (the limit set as “bio-accumulative”) in none of the leachates (fruit-flavored or traditional). In the organisms exposed to the leachates resulting from fruit-flavored tobacco waste, Log BAFs of Benzo[b] fluoranthene (BbF), benzo(a)anthracene (BaA), and chrysene (Chr) lay within the range of 3.3–3.7 (“potentially bio-accumulative”). However, in the organisms exposed to the leachates resulting from traditional tobacco waste, the mean Log BAFs of all compounds did not reach even 3.3. The findings of our study indicate that leachates from tobacco waste, pose significant environmental and health hazards. Considering the prevalence of tobacco smoking, suitable strategies should be employed for management of these hazardous wastes to protect the environmental health.

Background During the last two decades, waterpipe tobacco smoking (WTS), also known as hookah, witnessed a global increase in use, especially among youth. Little information is known about the burden of WTS among Palestinian youth. A cross-sectional study was conducted to estimate the prevalence of WTS and cigarette smoking and explore the associated factors among a sample of Palestinian university students. Methods 1891 students, from five Palestinian universities in the West Bank and Gaza Strip, completed a self-administered, web-based survey in 2014–2015. The questionnaire, which was based on the Global Adults Tobacco Survey (GATS), had questions on WTS and cigarette smoking patterns and socio-demographic and university-related characteristics. Binary logistic regression analyses were computed to investigate associated factors with WTS and cigarette smoking. Results 50.9% of the sample was women. The mean age was 20.1 ± 2.0. Overall, 30.0% of participants were current tobacco smokers and 33.4% reported ever smoking tobacco through a waterpipe. The prevalence of current WTS (24.4%) surpassed the prevalence of current cigarette smoking (18.0%), with a significantly higher prevalence among men compared to women. The gender gap for WTS (36.4% vs. 12.9%) was smaller than that for cigarette smoking (32.8% vs. 3.6%). Binary logistic regression models for the total sample (men and women) revealed that men were more likely to be current waterpipe and cigarette tobacco smokers compared to women (AOR = 4.20, 95% CI = 3.22–5.48, and AOR = 10.91, 95% CI = 7.25–16.42, respectively). Geographic area of residence, faculty of study and self-reported academic achievement were also associated with the likelihood of being current waterpipe and cigarette tobacco smokers. Conclusion A high prevalence of WTS was reported among our study sample, and it surpassed the prevalence of cigarette smoking. Interventions to curb the practice of tobacco smoking among Palestinian youth should be tailored differently to WTS and cigarette smoking, be gender-sensitive and specific and target the regional variation in the smoking behavior.

Waterpipe tobacco smoking is growing in popularity despite adverse health effects among users. We systematically reviewed the literature, searching MEDLINE, EMBASE and Web of Science, for interventions targeting prevention and cessation of waterpipe tobacco smoking. We assessed the evidence quality using the Cochrane (randomised studies), GRADE (non-randomised studies) and CASP (qualitative studies) frameworks. Data were synthesised narratively due to heterogeneity. We included four individual-level, five group-level and six legislative interventions. Of five randomised controlled studies, two showed significantly higher quit rates in intervention groups (bupropion/behavioural support versus placebo in Pakistan; 6 month abstinence relative risk (RR): 2.3, 95% CI 1.4–3.8); group behavioural support versus no intervention in Egypt, 12 month abstinence RR 3.3, 95% CI 1.4–8.9). Non-randomised studies showed mixed results for cessation, behavioural and knowledge outcomes. One high quality modelling study from Lebanon calculated that a 10% increase in waterpipe tobacco taxation would reduce waterpipe tobacco demand by 14.5% (price elasticity of demand −1.45). In conclusion, there is a lack of evidence of effectiveness for most waterpipe interventions. While few show promising results, higher quality interventions are needed. Meanwhile, tobacco policies should place waterpipe on par with cigarettes.

Mutations in genes encoding proteins necessary for detoxifying oxidative stress products have been predicted to increase susceptibility to lung cancer (LC). Despite this, the association between waterpipe tobacco smoking (WP), genetic polymorphisms, and LC risk remains poorly understood. This is the first study to explore the relationship between WP tobacco smoking and these genetic factors. Previously, we investigated the association of GSTP1 SNPs (rs1695-A/G and rs1138272-C/T) with LC in Iraqi males who smoke WP. Here, we expanded our analysis to include GSTM1 (active/null) and GSTT1 (active/null) genotypes, both individually and in combination with GSTP1 SNPs. Multiplex PCR and RFLP-PCR assays were utilized to determine the genotypes of 123 cases and 129 controls. No significant association was observed between GSTM1-null or GSTT1-null genotypes and LC risk, either separately or in combination with variant genotypes of GSTP1 (rs1695 \"AG+GG\" and rs1138272 \"CT+TT\"). However, smoking WP and carrying null genotypes elevated the risk five-fold for GSTM1-null (OR 5.17, 95 % CI 2.02–13.24, P<0.001) and three-fold for GSTT1-null (OR 3.08, 95 % CI 1.55–6.13, P=0.001) compared to non-smokers carrying active genotypes. Conversely, genotype distribution analysis based on LC histological types did not indicate an increased risk of LC. Lung cancer is a complex multifactorial disease. WP smoking and GSTs genetic polymorphisms might be associated with an increased risk of developing LC. However, our data did not confirm an association between GST polymorphisms alone and the risk of LC. •WP smoking with GSTs null genotypes raises LC risks significantly.•WP smokers with GSTM1 and GSTT1 null genotypes face 5x and 3x higher LC risk.•Combined GSTM1, GSTT1, and GSTP1 genotypes are not associated with increased LC risk.•GSTs polymorphisms alone do not significantly correlate with developing LC risk.•No significant differences observed in GSTs null genotype across histological types.

IntroductionOne possible reason for the rapid proliferation of waterpipe (WP) smoking is the pervasive use of flavoured WP tobacco. To begin to understand the impact of WP tobacco flavours, the current study examined the impact of a preferred WP tobacco flavour compared with a non-preferred tobacco flavoured control on user’s smoking behaviour, toxicant exposure and subjective smoking experience.MethodThirty-six current WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavour vs non-preferred tobacco flavour control) in a randomised cross-over design. Participants completed survey questionnaires assessing subjective smoking experience, exhaled carbon monoxide (eCO) testing, and provided blood samples for monitoring plasma nicotine. WP smoking topography was measured continuously throughout the smoking session.ResultsWhile participants reported an enhanced subjective smoking experience including greater interest in continued use, greater pleasure derived from smoking, increased liking and enjoyment, and willingness to continue use after smoking their preferred WP tobacco flavour (p values <0.05), no significant differences were observed in nicotine and carbon monoxide boost between flavour preparations. Greater average puff volume (p=0.018) was observed during the non-preferred flavour session. While not significant, measures of flow rate, interpuff interval (IPI), and total number of puffs were trending towards significance (p values <0.10), with decreased IPI and greater total number of puffs during the preferred flavour session.DiscussionThe current study is the first to examine flavours in WP smoking by measuring preferred versus control preparations to understand the impact on subjective experience, smoking behaviour and toxicant exposure. The pattern of results suggests that even this relatively minor manipulation resulted in significant changes in subjective experience. These results indicate a possible need for regulations restricting flavours in WP tobacco as with combustible cigarettes.

BackgroundThere is limited information about the hazards of cigarettes, smokeless tobacco and waterpipe in the Middle East. The aim of this study was to determine the association between different types of tobacco use and earlier death in the Golestan Cohort Study.MethodsThe Study includes 50 045 adults (aged 40–75 years) from north eastern Iran. The baseline questionnaire (2004–2008) assessed information about use of cigarettes, chewing tobacco (nass) and waterpipe. To assess the use of each type of tobacco compared with never tobacco users, we used Cox regression models adjusted for age, socioeconomic status, area of residence, education and other tobacco used, and stratified by sex, ethnicity and opium use.Results17% of participants reported a history of cigarette smoking, 7.5% chewing tobacco (nass) and 1.1% smoking waterpipe, and these figures declined in the later birth cohorts. During a median follow-up of 8 years, 4524 deaths occurred (mean age 64.8+9.9 years). Current (HR=1.44; 95% CI 1.28 to 1.61) and former (HR=1.35; 95% CI 1.16 to 1.56) cigarette smokers had higher overall mortality relative to never tobacco users. The highest cigarette-associated risk was for cancer death among current heavy smokers (HR=2.32; 95% CI 1.66 to 3.24). Current nass chewing was associated with overall mortality (HR=1.16; 95% CI 1.01 to 1.34), and there was a 61% higher risk of cancer death in people chewing nass more than five times a day. We observed an association between the cumulative lifetime waterpipe use (waterpipe-years≥28) and both overall (HR=1.66; 95% CI 1.11 to 2.47), and cancer mortality (HR=2.82; 95% CI 1.30 to 6.11).ConclusionsRegular use of cigarettes, smokeless tobacco and waterpipe were associated with the risk of earlier death (particularly from cancer) in our cohort.

Background Waterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq. Methods A cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale. Results When adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit. Conclusion Pictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.