Waterpipe Use and Susceptibility to Cigarette Smoking Among Never-Smoking Youth

      Introduction

      Susceptibility to cigarette smoking, defined as the lack of a firm decision against smoking, is a strong predictor of regular smoking and addiction. Several modifiable risk factors have been identified among never cigarette smokers, and one potential factor of interest is waterpipe use. The purpose of this study is to determine the association of waterpipe use with susceptibility to cigarette smoking among never-smoking youth.

      Methods

      In a pooled analysis of 17 Arab nations with nationally representative Global Youth Tobacco Surveys conducted during 2002–2011, tobacco-related information was obtained from 30,711 never-smoking adolescents representing 4,962,872 youth. Study outcome was susceptibility to cigarette smoking, and primary exposure was waterpipe use. Data were analyzed in 2014 using weighted logistic regression models, including stratified models by gender, to determine the odds of susceptibility to cigarette smoking with waterpipe use, adjusting for confounders.

      Results

      Overall, 20% of never-smoking youth were susceptible to cigarette smoking, ranging from 13.1% in Oman to 32.6% in Somalia; 5.2% currently used waterpipe, ranging from 0.3% in Morocco to 23.5% in Kuwait. The estimated odds of susceptibility to cigarette smoking were 2.5 (95% CI=1.9, 3.4) times higher for adolescents who used waterpipe in the past month compared with those who did not, controlling for confounders. Estimates were similar when stratified by gender.

      Conclusions

      Waterpipe use is associated with susceptibility to cigarette smoking. Study findings identify a novel risk factor for never smokers to initiate smoking and will help the public health community develop and implement policies around waterpipe use prevention.

      Introduction

      Tobacco dependence typically begins during or prior to adolescence and develops quickly in youth.
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      Therefore, it is important to identify risk factors that promote a never cigarette–smoking adolescent into smoking his or her first cigarette. Susceptibility to cigarette smoking, defined as the lack of a firm decision against cigarette smoking, is a strong predictor of regular or established smoking, with adolescents more likely to participate in tobacco industry activities and less likely to respond to tobacco prevention programs.
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      thereby encouraging an adolescent to smoke his or her first cigarette. In addition, waterpipe use is a social phenomenon, and a minimal gender gap exists because of its increased use and acceptability in social gatherings.
      • Maziak W.
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      Therefore, understanding its role in cigarette learning behavior of adolescents will help predict the magnitude of future regular smokers. Using data from multiple Arab nations, we aimed to determine the relationship between waterpipe use and susceptibility to cigarette smoking among never cigarette–smoking youth.
      Waterpipe use (hookah, shisha, narghile, arghila, goza, and hubble-bubble) is an old tobacco smoking practice culturally predominant in Eastern Mediterranean countries, the Middle East, and parts of South Asia.
      • Martinasek M.P.
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      Recently, it has garnered significant attention by public health researchers and healthcare practitioners owing to its increasing consumption in Western countries.
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      Although it is predominantly smoked by men, the advent of flavoring agents, paraphernalia, accessibility, novelty, and the social atmosphere has made it more attractive for women and youth.
      • Maziak W.
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      Waterpipe smoking and dependence are associated with chronic bronchitis: a case-control study in Lebanon.
      Several chronic diseases have been attributed to waterpipe use, including respiratory tract infections, lung cancer, and periodontal infections.
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      With widespread public perception that waterpipe use is less harmful and less toxic than traditional cigarettes, it has become a socially acceptable practice, resulting in increased consumption in youth.
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      However, studies
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      have found that waterpipe smoke contains the same toxicants as cigarette smoke, including polycyclic aromatic hydrocarbons, tar, nicotine, and carbon monoxide. Studies have compared nicotine levels between waterpipe use and cigarette smoking and found higher plasma nicotine concentrations with either a single puff
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      or one session
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      per day of waterpipe use compared with that of a single puff or one session of cigarette smoking per day. Previous studies
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      have reported that youth have become increasingly attracted to waterpipe use and might become regular smokers in the future. In addition, studies
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      Determinants of waterpipe smoking initiation among school children in Irbid, Jordan: a 4-year longitudinal analysis.
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      Waterpipe smoking among middle and high school Jordanian students: patterns and predictors.
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      Beliefs and norms associated with smoking tobacco using a waterpipe among college students.
      have reported the prevalence estimates and identified predictors of waterpipe smoking in different populations; however, no study has been conducted to estimate the odds of susceptibility to cigarette smoking among waterpipe users. With increasing evidence of a global waterpipe use pandemic and high level of nicotine dependence among waterpipe users,
      • Maziak W.
      The global epidemic of waterpipe smoking.
      • Neergaard J.
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      • Job J.
      • Montgomery S.
      Waterpipe smoking and nicotine exposure: a review of the current evidence.
      using a pooled analysis of multiple Global Youth Tobacco Surveys (GYTSs) conducted in the Arab nations where waterpipe use is more common,
      • Akl E.A.
      • Gunukula S.K.
      • Aleem S.
      • et al.
      The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review.
      we investigated the association of waterpipe use with susceptibility to cigarette smoking among 30,711 adolescents representing 4.97 million youth who have never tried or experimented with cigarette smoking in their lifetime.

      Methods

      Study Population and Global Youth Tobacco Survey

      The Global Youth Tobacco Surveys (GYTS) conducted during 2002–2011 were used to obtain information on youth tobacco use in 19 of 22 Arab nations (Table 1). Only surveys in which samples represented the youth nationwide in respective countries were included; therefore, those conducted in Algeria and Iraq were not included. Moreover, the survey was administered separately for Gaza Strip province of the Palestine, and hence was included separately, similar to other countries’ national surveys. Consistent with earlier studies,
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Koh H.K.
      • Alpert H.R.
      • Judge C.M.
      • et al.
      Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey.
      • Veeranki S.P.
      • Mamudu H.M.
      • Zheng S.
      • et al.
      Secondhand smoke exposure among never-smoking youth in 168 countries.
      • Warren C.W.
      • Jones N.R.
      • Eriksen M.P.
      • Asma S.
      Patterns of global tobacco use in young people and implications for future chronic disease burden in adults.
      data from the most recent survey were used for countries that had administered the survey more than once. The survey questionnaire, sampling frame, and design have been described in earlier studies.
      • Warren C.W.
      • Jones N.R.
      • Eriksen M.P.
      • Asma S.
      Patterns of global tobacco use in young people and implications for future chronic disease burden in adults.
      Global Youth Tobacco Survey Collaborative Group
      Tobacco use among youth: a cross country comparison.
      The GYTS employs a standard methodology in questionnaire preparation and administration and in collection and processing of data.
      • Warren C.W.
      • Jones N.R.
      • Eriksen M.P.
      • Asma S.
      Patterns of global tobacco use in young people and implications for future chronic disease burden in adults.
      • Warren C.W.
      • Jones N.R.
      • Peruga A.
      • et al.
      Global youth tobacco surveillance, 2000-2007.
      The IRB at the East Tennessee State University provided study approval.
      Table 1Study Measures, Survey Items With Responses, Global Youth Tobacco Survey (GYTS)
      Study measureGYTS survey itemsGYTS item responsesDichotomized measure
      GYTS question used to obtain never-smoking youth
       Smoking statusHave you ever tried or experimented with cigarette smoking, even one or two puffs?
      • Yes
      • No
      • Yes=Ever cigarette smoker
      • No=Never cigarette smoker
      Outcome
       Susceptibility to cigarette  smoking
      • If one of your friends offered you a cigarette, would you smoke it?
      • At any time during the next 12 months do you think you will smoke a cigarette?
      • Do you think you will be smoking cigarettes 5 years from now?
      • Definitely not
      • Probably not
      • Probably yes
      • Definitely yes
      • No=“Definitely not” for all three items
      • Yes=any other responses for any of the three items
      Exposure
       Current waterpipe useDuring the past 30 days (one month), on how many days did you smoke shisha, hookah, narghile, arghila, or waterpipe?
      • 0 days
      • 1 or 2 days
      • 3 to 5 days
      • 6 to 9 days
      • 10 to 19 days
      • 20 to 29 days
      • All 30 days
      • No=0 days
      • Yes=>0 days
      Covariates
       Exposure to secondhand smoke (SHS) inside homeDuring the past week, on how many days have people smoked in your home, in your presence?
      • 0
      • 1 to 2
      • 3 to 4
      • 5 to 6
      • 7
      • No=0 days for both items
      • Yes=≥1 day for both items
       Exposure to SHS outside homeDuring the past 7 days, on how many days have people smoked in your presence, in places other than in your home?
      • 0
      • 1 to 2
      • 3 to 4
      • 5 to 6
      • 7
      • No=0 days for both items
      • Yes=≥1 day for both items
       Parental smokingDo your parents smoke?
      • None Both
      • Father only
      • Mother only
      • No=none
      • Yes=any other response
       Peer smokingDo any of your closest friends smoke cigarettes?
      • None of them
      • Some of them
      • Most of them
      • All of them
      • No=none of them
      • Yes=any other response
       Support for smoking banAre you in favor of banning smoking in public places (such as in restaurants, in buses, streetcars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)?
      • No
      • Yes
      • No
      • Yes
       Knowledge about harmful effects of smoking and SHS exposureDo you think cigarette smoking is harmful to your health? Do you think the smoke from other people’s cigarettes is harmful to you?
      • Definitely not
      • Probably not
      • Probably yes
      • Definitely yes
      • No=“Definitely not” for both items
      • Yes=any other responses for either item
       Exposure to anti-smoking messages in media
      • During the past 30 days (one month), how many anti-smoking media messages (e.g. television, radio, billboards, posters, newspapers, magazines, movies) have you seen?
      • When you go to sports events, fairs, concerts, community events, or social gatherings, how often do you see anti-smoking messages?
      • None
      • A few
      • A lot
      • No=“none/never” response for both items
      • Yes=any other response for either item
       Tobacco industry promotion
      • Do you have something (T-shirt, pen, backpack, etc.) with a cigarette brand logo on it?
      • Has a (cigarette representative) ever offered you a free cigarette?
      • No
      • Yes
      • No
      • Yes
       Anti-smoking education in schools
      • During this school year, were you taught in any of your classes about the dangers of smoking?
      • During this school year, did you discuss in any of your classes the reasons why people your age smoke?
      • During this school year, were you taught in any of your classes about the effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad?
      • No
      • Not sure
      • Yes
      • No=“No” for all three items
      • Yes=Yes for any of the three items
       AgeHow old are you?
      • 13 years
      • 14 years
      • 15 years
       SexWhat is your sex?
      • Female
      • Male
      • No=Female
      • Yes=Male
      Note: Dichotomization of GYTS survey responses were conducted using previously described methods.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Alzyoud S.
      • Weglicki L.S.
      • Kheirallah K.A.
      • Haddad L.
      • Alhawamdeh K.A.
      Waterpipe smoking among middle and high school Jordanian students: patterns and predictors.
      “No” responses were coded as 0 and “Yes” responses as 1 for multivariable logistic regression model.

      Measures

      The outcome variable was susceptibility to cigarette smoking among never cigarette smokers. A never cigarette smoker was defined as a participant who responded no to the question Have you ever tried or experimented with cigarette smoking, even one or two puffs? Similar to earlier studies and using a validated definition for susceptibility to cigarette smoking developed by Pierce et al.,
      • Pierce J.P.
      • Choi W.S.
      • Gilpin E.A.
      • Farkas A.J.
      • Merritt R.K.
      Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      an adolescent was defined as being susceptible to cigarette smoking based on his or her response on a 5-point ordinal scale ranging from definitely not to definitely yes to the three following questions:
      • 1.
        If one of your friends offered you a cigarette, would you smoke it?
      • 2.
        At any time during the next 12 months, do you think you will smoke a cigarette?
      • 3.
        Do you think you will be smoking cigarettes 5 years from now?
      An adolescent who responded definitely not to all three questions was defined as not susceptible, and who reported any other response to the three questions was defined as being susceptible to cigarette smoking.
      The main predictor variable was waterpipe use among never-smoking youth. Information on waterpipe use among youth was obtained by supplemental questions in the “core” questionnaires of the GYTS. We defined an adolescent currently using waterpipe when he or she responded >0 days to the question During the past 30 days (one month), on how many days did you smoke shisha, hookah, narghile, arghila, or waterpipe? Waterpipe use–specific questions were not administered for Bahrain, Comoros, Mauritania, and Somalia, and hence were not included in the regression analysis.
      Specific adolescent characteristics were included as covariates in the regression models based on the existing literature and plausible associations with both waterpipe use and susceptibility to smoking.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • McKelvey K.
      • Attonito J.
      • Madhivanan P.
      • et al.
      Determinants of waterpipe smoking initiation among school children in Irbid, Jordan: a 4-year longitudinal analysis.
      • Alzyoud S.
      • Weglicki L.S.
      • Kheirallah K.A.
      • Haddad L.
      • Alhawamdeh K.A.
      Waterpipe smoking among middle and high school Jordanian students: patterns and predictors.
      • Noonan D.
      • Kulbok P.A.
      Beliefs and norms associated with smoking tobacco using a waterpipe among college students.
      Bandura’s social cognitive theory
      • Bandura A.
      Human agency in social cognitive theory.
      was employed as a theoretic framework to select the covariates, which included parental or peer smoking, exposure to SHS inside or outside the home, knowledge about harmful effects of smoking and SHS exposure, exposure to anti-smoking media messages or tobacco industry promotions, receptivity of anti-smoking education in schools, support for smoking ban in public places, age, sex, and year of GYTS administration. All variables were categorical in nature, and dichotomized using previously described methods.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Koh H.K.
      • Alpert H.R.
      • Judge C.M.
      • et al.
      Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey.
      • Veeranki S.P.
      • Mamudu H.M.
      • Zheng S.
      • et al.
      Secondhand smoke exposure among never-smoking youth in 168 countries.
      • Warren C.W.
      • Jones N.R.
      • Eriksen M.P.
      • Asma S.
      Patterns of global tobacco use in young people and implications for future chronic disease burden in adults.
      Information on GYTS questions, participant responses, and coding for data analysis is presented in Table 1.

      Statistical Analysis

      Data were analyzed for descriptive and inferential statistics. During assembly of data records, it was found that adolescents aged <13 and >15 years also participated in the surveys. The GYTS is a school-based survey designed to collect tobacco information among school-attending adolescents. Because all students in selected classes are eligible for participation, it is possible that adolescents aged <13 and >15 years might have participated in the survey. Therefore, to avoid data inconsistencies across multiple countries and to remain consistent with the sampling frame and previous literature,
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Koh H.K.
      • Alpert H.R.
      • Judge C.M.
      • et al.
      Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey.
      • Veeranki S.P.
      • Mamudu H.M.
      • Zheng S.
      • et al.
      Secondhand smoke exposure among never-smoking youth in 168 countries.
      only adolescents aged 13–15 years were included. Descriptive characteristics were reported using unweighted sample counts and weighted population percentages. Bivariate analyses were conducted to assess differences in waterpipe use by adolescent characteristics using chi-square tests. To predict the population estimates, GYTS sample data were adjusted for sampling design effect, nonresponses, and post-stratification of the sample relative to grade and sex distribution of the population.
      • Koh H.K.
      • Alpert H.R.
      • Judge C.M.
      • et al.
      Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey.
      Global Youth Tobacco Survey Collaborative Group
      Tobacco use among youth: a cross country comparison.
      A final adjustment summed the weights by grade and sex to the population of schoolchildren in the selected grades in each sample site. A multivariable logistic regression model was conducted to estimate the odds of susceptibility to cigarette smoking with waterpipe use, adjusting for covariates including parental or peer smoking, SHS exposure inside or outside the home, knowledge about harmful effects of smoking and SHS, exposure to tobacco industry promotions, receptivity of anti-smoking education in schools, and country and year the GYTS was administered. Because earlier studies have reported significant differences in waterpipe use between female and male participants,
      • Maziak W.
      • Rastam S.
      • Eissenberg T.
      • et al.
      Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria.
      • Salameh P.
      • Khayat G.
      • Waked M.
      Lower prevalence of cigarette and waterpipe smoking, but a higher risk of waterpipe dependence in Lebanese adult women than in men.
      • Khalil J.
      • Afifi R.
      • Fouad F.M.
      • et al.
      Women and waterpipe tobacco smoking in the eastern mediterranean region: allure or offensiveness.
      weighted multivariable logistic regression models stratified by sex were conducted to estimate the relationships among male and female adolescents separately. As information on support for smoking bans in public places was not available in all surveys, it was not adjusted for in the regression models. Regression diagnostics were conducted and no correlations among covariates were observed to warrant omission of variables for multicollinearity issues. Hosmer–Lemeshow tests were performed to assess the goodness of fit for regression models, and identified p-values >0.05 indicating a good model fit. All parameter estimates with p-values <0.001 were considered significant for statistical inferences. Data were managed and analyzed in 2014 using SAS, version 9.2, with “survey” syntaxes to accommodate for final weights in the models.

      Results

      A total of 39,710 school-attending adolescents aged 13–15 years representing 6,270,302 youth participated in the survey. Among them, 30,711 representing 4,962,872 youth had never smoked cigarettes, with prevalence estimates ranging from 54% in the West Bank to 91% in Morocco, and were included in the study (Table 2). Information on current waterpipe use was not available for Bahrain, Comoros, Mauritania, and Somalia, resulting in the final data of 27,012, representing 4,920,729 never-smoking youth. The majority of never-smoking youth was female (54.0%) and aged 14 years (37.1%). More than one third (33.7%) had parents who smoke, were exposed to SHS inside (34.5%) or outside the home (38.0%), and around one fourth (25.5%) had peers who smoke. Approximately 98% were knowledgeable about the harmful effects of smoking and SHS exposure, and 76% supported smoking bans in public places (Table 3).
      Table 2Susceptibility to Cigarette Smoking Among Never–Cigarette Smoking Youth in Arab Nations
      Arab nationYear GYTS administeredGYTS participants aged 13--15 yearsNever-smoking youthSusceptibility to smoking (19.7%)
      Sample (n=39,710)Population (N=6,270,302)Unweighted count (n=30,711)Weighted count (N=4,962,872)Weighted percentage (%)
      Bahrain20021,44525,2641,07818,75724.8
      Comoros200781111,4695738,05714.7
      Djibouti20091,09612,0028739,55923.6
      Egypt20093,4721,105,8432,863883,50014.1
      Gaza strip20051,39590,5071,06468,36721.4
      Jordan20091,523255,2491,075182,03024.1
      Kuwait20092,21352,7361,58837,44226.2
      Lebanon20111,651141,6451,17399,71921.7
      Libya20101,361234,0291,155199,14327.9
      Mauritania20091,76912,4291,2909,01123.3
      Morocco20102,106906,6731,913822,19316.3
      Oman201090580,16879870,44313.1
      Qatar20079438,1117226,21717.0
      Saudi Arabia20101,797816,9261,336604,10221.1
      Somalia20078977,5137586,31732.6
      Sudan2009950505,265827439,18818.9
      Syria20101,210953,223924715,84621.5
      Tunisia20101,294356,8221,034284,64424.0
      United Arab Emirates200510,821111,7198,41685,24317.5
      West Bank20091,401149,73974480,73026.4
      Yemen2008650432,970507332,36324.1
      GYTS, Global Youth Tobacco Survey.
      Table 3Bivariate Analysis of Factors Associated With Waterpipe Use Among Never Cigarette Smoking Youth in Arab Nations
      Waterpipe use information was not available for Bahrain, Comoros, Mauritania, and Somalia.
      CharacteristicsPercentage yes
      Waterpipe use information was not available for Bahrain, Comoros, Mauritania, and Somalia.
      VariableUnweighted countWeighted countPercentage used waterpipep-value
      Used waterpipeDid not use waterpipeUsed waterpipeDid not use waterpipe
      Parental smoking33.7
      • No
      • Yes
      • 681
      • 737
      • 17,213
      • 7,664
      • 105,651
      • 132,280
      • 3,047,732
      • 1,510,235
      • 3.3
      • 8.0
      <0.001
      Peer smoking25.5
      • No
      • Yes
      • 657
      • 791
      • 18,833
      • 6,346
      • 118,221
      • 133,259
      • 3,500,502
      • 1,103,750
      • 3.3
      • 10.6
      <0.001
      Exposure to SHS inside home34.5
      • No
      • Yes
      • 569
      • 876
      • 17,320
      • 7,877
      • 94,887
      • 152,657
      • 3,070,286
      • 1,528,070
      • 3.0
      • 9.0
      <0.001
      Exposure to SHS outside home38.0
      • No
      • Yes
      • 560
      • 876
      • 16,200
      • 8,926
      • 83,951
      • 163,330
      • 2,889,641
      • 1,690,476
      • 2.8
      • 8.7
      <0.001
      Support for smoking ban
      • 75.9
      • 36.8
      • No
      • Yes
      • 294
      • 799
      • 4,840
      • 17,422
      • 61,444
      • 158,462
      • 926,068
      • 3,550,528
      • 6.2
      • 4.2
      0.1
      Age
      • 37.1
      • 26.1
      • 54.0
      • 13 years
      • 14 years
      • 15 years
      • 491
      • 531
      • 449
      • 9,610
      • 8,838
      • 6,923
      • 77,988
      • 98,764
      • 76,866
      • 1,719,746
      • 1,715,092
      • 1,196,015
      • 4.3
      • 5.4
      • 6.0
      0.1
      Sex
      • 44.2
      • 1.7
      • Female
      • Male
      • 758
      • 674
      • 14,908
      • 10,151
      • 111,522
      • 136,706
      • 2,534,596
      • 2,015,489
      • 4.2
      • 6.3
      0.03
      Knowledge about the harmful effects of smoking and SHS exposure97.9
      • No
      • Yes
      • 37
      • 1,423
      • 691
      • 24,608
      • 2,063
      • 250,006
      • 81,202
      • 4,532,823
      • 2.5
      • 5.2
      0.02
      Exposure to anti-smoking media messages86.7
      • No
      • Yes
      • 210
      • 1,239
      • 3,696
      • 21,501
      • 30,931
      • 220,866
      • 583,940
      • 4,013,773
      • 5.0
      • 5.2
      0.8
      Exposure to tobacco industry promotions15.3
      • No
      • Yes
      • 1,026
      • 365
      • 20,699
      • 3,709
      • 177,290
      • 64,970
      • 3,735,569
      • 681,540
      • 4.5
      • 8.6
      <0.001
      Receptivity of anti-smoking education in school56.3
      • No
      • Yes
      • 287
      • 890
      • 5,627
      • 15,124
      • 50,134
      • 152,899
      • 1,261,228
      • 2,603,885
      • 3.8
      • 5.5
      0.003
      Year GYTS was administered
      • 3.1
      • 0.1
      • 6.8
      • 33.2
      • 54.8
      • 2.0
      • 2005
      • 2007
      • 2008
      • 2009
      • 2010
      • 2011
      • 422
      • 47
      • 6
      • 456
      • 267
      • 273
      • 8,972
      • 658
      • 465
      • 7,499
      • 6,880
      • 897
      • 8,375
      • 401
      • 4,704
      • 67,761
      • 148,960
      • 23,416
      • 143,337
      • 5,673
      • 302,435
      • 1,560,932
      • 2,542,556
      • 75,921
      • 5.5
      • 6.4
      • 1.4
      • 4.2
      • 5.5
      • 23.5
      <0.001
      Country GYTS was administered
      • 0.2
      • 18.0
      • 1.4
      • 3.7
      • 0.8
      • 2.0
      • 4.0
      • 16.7
      • 1.4
      • 0.1
      • 12.3
      • 8.9
      • 14.5
      • 5.8
      • 1.7
      • 1.6
      • 6.8
      • Djibouti
      • Egypt
      • Gaza strip
      • Jordan
      • Kuwait
      • Lebanon
      • Libya
      • Morocco
      • Oman
      • Qatar
      • Saudi Arabia
      • Sudan
      • Syria
      • Tunisia
      • United Arab Emirates
      • West Bank
      • Yemen
      • 34
      • 61
      • 77
      • 133
      • 69
      • 273
      • 24
      • 37
      • 3
      • 47
      • 37
      • 27
      • 136
      • 30
      • 345
      • 132
      • 6
      • 839
      • 2,796
      • 966
      • 936
      • 1,519
      • 897
      • 1,131
      • 1,874
      • 794
      • 658
      • 1,295
      • 798
      • 787
      • 999
      • 8,006
      • 611
      • 465
      • 386
      • 14,478
      • 4,979
      • 21,799
      • 1,680
      • 23,416
      • 3,981
      • 16,989
      • 237
      • 401
      • 15,606
      • 14,876
      • 103,653
      • 8,494
      • 3,396
      • 14,542
      • 4,704
      • 9,173
      • 867,737
      • 62,087
      • 159,141
      • 35,762
      • 75,921
      • 195,162
      • 804,291
      • 70,130
      • 5,673
      • 586,521
      • 423,056
      • 611,652
      • 274,800
      • 81,250
      • 66,063
      • 302,435
      • 4.0
      • 1.6
      • 7.3
      • 12.0
      • 4.5
      • 23.5
      • 2.0
      • 2.1
      • 0.3
      • 6.4
      • 2.6
      • 3.4
      • 14.5
      • 3.0
      • 4.0
      • 18.0
      • 1.4
      <0.001
      Note: Boldface indicates statistical significance (p<0.001).
      SHS, secondhand smoke; GYTS, Global Youth Tobacco Survey.
      a Waterpipe use information was not available for Bahrain, Comoros, Mauritania, and Somalia.
      Overall, 5.2% of never-smoking youth in Arab nations currently used waterpipe, with prevalence estimates ranging from 0.3% in Morocco to 23.5% in Kuwait. The prevalence estimate of waterpipe use was significantly higher among male (6.3%) compared with female (4.2%) adolescents (p=0.03). By contrast, there was no significant difference identified across the three age categories (p=0.10). When studying never-smoking adolescent characteristics by the waterpipe use groups, 8% and 10.6% of waterpipe users had smoking parents or peers, 9% and 8.7% were exposed to SHS inside or outside the home, respectively, and 8.6% of waterpipe users were exposed to tobacco industry promotions. By contrast, 5.2% and 5.5% of youth who were knowledgeable about harmful effects of smoking and SHS exposure or who received anti-smoking education in schools, respectively, used waterpipe. Overall, significant differences in waterpipe use were identified by most adolescent characteristics, except among those who supported smoking bans in public places (p=0.10) and those who were exposed to anti-smoking messages in the media (p=0.80) (Table 3).
      Overall, 19.7% of never cigarette–smoking youth were susceptible to cigarette smoking, with prevalence estimates ranging from 13.1% in Oman to 32.6% in Somalia. In addition, never-smoking male adolescents (22.6%) were more susceptible to cigarette smoking than female adolescents (17.1%) (p<0.001). Approximately 44% of youth who used waterpipe were susceptible to cigarette smoking, compared with 18% who did not (p<0.001). Table 4 presents the odds of susceptibility to cigarette smoking with waterpipe use among never-smoking youth in the Arab nations. The estimated odds of being susceptible to cigarette smoking were 2.5 times (AOR=2.5, 95% CI=1.9, 3.3) higher for adolescents who used waterpipe compared with adolescents who did not, controlling for confounders. Sensitivity analysis that involved maximum likelihood estimation and multiple imputation methods for missing values had results consistent with our primary analysis. As it was planned a priori to assess the relationships among male and female adolescents separately, weighted logistic regression models stratified by sex were conducted, and similar estimates were identified for cigarette smoking susceptibility among never-smoking male (AOR=2.4, 95% CI=1.6, 3.3) and female (AOR=2.7, 95% CI=1.8, 4.0) adolescents, respectively.
      Table 4Association of Waterpipe Use With Susceptibility to Cigarette Smoking Among Never–Cigarette Smoking Youth
      Waterpipe useUnweighted countWeighted percentageSusceptibility to cigarette smoking
      Unweighted countWeighted percentageOR
      OR is adjusted for parental or peer smoking, secondhand smoke exposure inside or outside home, knowledge about harmful effects of smoking and secondhand smoke, exposure to tobacco industry promotions, receptivity of anti-smoking education in schools, country, year of survey administration.
      (95% CI)
      Total
        Yes1,4715.264743.92.5 (1.9, 3.3)
       No
      Never–cigarette smoking youth who did not smoke waterpipe (referent group).
      25,37194.14,66018.2
      Males
        Yes6746.331043.82.4 (1.6, 3.3)
       No
      Never–cigarette smoking youth who did not smoke waterpipe (referent group).
      10,15192.72,22621.1
      Females
        Yes7584.231642.12.7 (1.8, 4.0)
       No
      Never–cigarette smoking youth who did not smoke waterpipe (referent group).
      14,90895.42,36215.9
      Note: Boldface indicates statistical significance (p<0.001).
      a OR is adjusted for parental or peer smoking, secondhand smoke exposure inside or outside home, knowledge about harmful effects of smoking and secondhand smoke, exposure to tobacco industry promotions, receptivity of anti-smoking education in schools, country, year of survey administration.
      b Never–cigarette smoking youth who did not smoke waterpipe (referent group).

      Discussion

      In a pooled analysis of 30,711 never cigarette–smoking adolescents representing 4,962,872 youth, approximately 44% of youth who used waterpipe were found to be susceptible to cigarette smoking compared with 18% who did not. In addition, never-smoking youth who used waterpipe had 2.5 times increased odds of susceptibility to cigarette smoking. Similar point estimates were identified among male and female adolescents.
      Tobacco use continues to be a global public health issue, with more than 1 billion smokers worldwide, a majority of whom reside in low- and middle-income countries (LMICs).
      • Ossip D.J.
      The global tobacco epidemic: public health crisis and public health opportunity.
      Several tobacco control interventions have been developed to address the issue, including smoke-free policies, cessation support, advertising bans, mass media campaigns, school- and community-based interventions, tobacco excise taxes, and restricting youth access to tobacco products
      • Myers M.L.
      The FCTC’s evidence-based policies remain a key to ending the tobacco epidemic.
      • Hill S.
      • Amos A.
      • Clifford D.
      • Platt S.
      Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence.
      • Lantz P.M.
      • Jacobson P.D.
      • Warner K.E.
      • et al.
      Investing in youth tobacco control: a review of smoking prevention and control strategies.
      ; however, it remains the leading cause of preventable death worldwide. Therefore, it is important to curb the global tobacco pandemic by developing interventions and policies that target the initiation of cigarette smoking. In order to develop such control efforts, it is important to identify factors that promote a never-smoking adolescent to initiate smoking his or her first cigarette. Such factors include parental and peer smoking, media messages, and promotions and have been identified in early studies, but these have been conducted primarily in high-income countries,
      • Pierce J.P.
      • Choi W.S.
      • Gilpin E.A.
      • Farkas A.J.
      • Merritt R.K.
      Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.
      • Evans N.
      • Farkas A.
      • Gilpin E.
      • Berry C.
      • Pierce J.P.
      Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking.
      with only few studies in LMICs.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Lim K.H.
      • Chong Z.
      • Khoo Y.Y.
      • Kaur J.
      Parental smoking status, stress, anxiety, and depression are associated with susceptibility to smoking among nonsmoker school adolescents in Malaysia.
      • Aslam S.K.
      • Zaheer S.
      • Rao S.
      • Shafique K.
      Prevalence and determinants of susceptibility to cigarette smoking among school students in Pakistan: secondary analysis of Global Youth Tobacco Survey.
      A novel potential risk factor is waterpipe use, proposed but with scientific evidence yet to be established.
      Given that waterpipe use is predominant in the Arab nations,
      • Akl E.A.
      • Gunukula S.K.
      • Aleem S.
      • et al.
      The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review.
      the GYTSs conducted in the Arab nations were used to determine the relationship between its use and cigarette smoking susceptibility. It was found that approximately 20% of never-smoking youth were susceptible to cigarette smoking, with prevalence estimates higher than those reported in previous studies.
      • Veeranki S.P.
      • Mamudu H.M.
      • Anderson J.L.
      • Zheng S.
      Worldwide never-smoking youth susceptibility to smoking.
      • Lim K.H.
      • Chong Z.
      • Khoo Y.Y.
      • Kaur J.
      Parental smoking status, stress, anxiety, and depression are associated with susceptibility to smoking among nonsmoker school adolescents in Malaysia.
      • Aslam S.K.
      • Zaheer S.
      • Rao S.
      • Shafique K.
      Prevalence and determinants of susceptibility to cigarette smoking among school students in Pakistan: secondary analysis of Global Youth Tobacco Survey.
      Compared with studies by Lim et al.
      • Lim K.H.
      • Chong Z.
      • Khoo Y.Y.
      • Kaur J.
      Parental smoking status, stress, anxiety, and depression are associated with susceptibility to smoking among nonsmoker school adolescents in Malaysia.
      and Aslam and colleagues
      • Aslam S.K.
      • Zaheer S.
      • Rao S.
      • Shafique K.
      Prevalence and determinants of susceptibility to cigarette smoking among school students in Pakistan: secondary analysis of Global Youth Tobacco Survey.
      that investigated susceptibility to cigarette smoking in Malaysia and Pakistan, respectively, our study utilized data from multiple Arab nations to determine this relationship. Approximately 5% of never-smoking youth reported currently using waterpipe, similar to earlier studies.
      • Maziak W.
      The global epidemic of waterpipe smoking.
      • Alzyoud S.
      • Weglicki L.S.
      • Kheirallah K.A.
      • Haddad L.
      • Alhawamdeh K.A.
      Waterpipe smoking among middle and high school Jordanian students: patterns and predictors.
      With the perception that waterpipe use is less harmful and less toxic than cigarette smoking,
      • Akl E.A.
      • Jawad M.
      • Lam W.Y.
      • Co C.N.
      • Obeid R.
      • Irani J.
      Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review.
      it has been gaining importance as an alternate tobacco product in Western nations.
      • Abughosh S.
      • Wu I.H.
      • Peters R.J.
      • Hawari F.
      • Essien E.J.
      Ethnicity and waterpipe smoking among U.S. students.
      • Eissenberg T.
      • Ward K.D.
      • Smith-Simone S.
      • Maziak W.
      Waterpipe tobacco smoking on a U.S. college campus: prevalence and correlates.
      • Primack B.A.
      • Sidani J.
      • Agarwal A.A.
      • Shadel W.G.
      • Donny E.C.
      • Eissenberg T.E.
      Prevalence of and associations with waterpipe tobacco smoking among U.S. university students.
      • Smith-Simone S.
      • Maziak W.
      • Ward K.D.
      • Eissenberg T.
      Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples.
      However, it has been reported that the daily use of waterpipe produces high levels of urine cotinine levels with a nicotine absorption rate equivalent to smoking ten cigarettes per day.
      • Neergaard J.
      • Singh P.
      • Job J.
      • Montgomery S.
      Waterpipe smoking and nicotine exposure: a review of the current evidence.
      In addition, studies have reported that motivation to engage in waterpipe use exceeded users’ health-risk perception,
      • Kelishadi R.
      • Mokhtari M.R.
      • Tavasoli A.A.
      • et al.
      Determinants of tobacco use among youths in Isfahan, Iran.
      and that families encouraged children to use waterpipe at home in social gatherings.
      • Makhoul J.
      • Nakkash R.
      Understanding youth: using qualitative methods to verify quantitative community indicators.
      These factors call for attention when designing tobacco control intervention efforts for youth and should reflect a holistic approach focusing on the family, youth social networks, cultural background, psychosocial aspects, and subsequent impacts of waterpipe smoking.
      Although evidence that waterpipe smoking might be a gateway for initiating cigarettes is not yet established, it is plausible that waterpipe use creates high nicotine dependence,
      • Maziak W.
      The global epidemic of waterpipe smoking.
      • Neergaard J.
      • Singh P.
      • Job J.
      • Montgomery S.
      Waterpipe smoking and nicotine exposure: a review of the current evidence.
      and its use could subsequently result in cigarette smoking initiation. Initial support for this theory is the present study finding that waterpipe use among never cigarette smoking youth is associated with increased odds of cigarette smoking susceptibility. Earlier studies have demonstrated the association between waterpipe use and cigarette smoking behaviors in LMICs,
      • Jensen P.D.
      • Cortes R.
      • Engholm G.
      • Kremers S.
      • Gislum M.
      Waterpipe use predicts progression to regular cigarette smoking among Danish youth.
      • Jawad M.
      • Lee J.T.
      • Millett C.
      The relationship between waterpipe and cigarette smoking in low and middle income countries: cross-sectional analysis of the Global Adult Tobacco Survey.
      but this is the first study to estimate the relationship with cigarette smoking susceptibility among never cigarette smokers. Given that waterpipe use is unique in its characteristics and emergence as a new strain of global tobacco pandemic, it is important to develop policy initiatives and interventions to curb waterpipe use and prevent a never-smoking adolescent from initiating his or her first cigarette. Specific tobacco-cessation and education programs should be developed targeting adolescents who are never cigarette smokers but are waterpipe users because of their misperception that waterpipe use is not harmful. Similarly, policies should be developed to prevent youth access to waterpipe coffee shops or social gatherings where it is used. Moreover, familial education and intervention programs should be implemented where parents should be informed about the possible gateway effect of waterpipe use for future cigarette smoking.

      Limitations

      The study has limitations to consider. The GYTS is a cross-sectional school-based survey and includes adolescents who attend school on the day the survey is administered. The study’s cross-sectional design limits establishment of causal inferences; hence, longitudinal studies should be conducted to investigate the relationship between waterpipe use and subsequent initiation of cigarette smoking. Multiple country-level data sets across different populations were used and might be subject to measurement bias; however, these populations are culturally similar and share similar demographic characteristics. Previous studies
      • Primack B.A.
      • Mah J.
      • Shensa A.
      • Rosen D.
      • Yonas M.A.
      • Fine M.J.
      Associations between race, ethnicity, religion, and waterpipe tobacco smoking.

      Klassen BJ, Smith KZ, Grekin ER. Differential relationships between religiosity, cigarette smoking, and waterpipe use: implications for college student health. J Am Coll Health. 2013;61(7):381–385. 10.1080/07448481.2013.819806.

      • Alzyoud S.
      • Kheirallah K.A.
      • Ward K.D.
      • Al-Shdayfat N.M.
      • Alzyoud A.A.
      Association of religious commitment and tobacco use among Muslim adolescents.
      have demonstrated the association of waterpipe use with religiosity or religious commitment; however, information on religious commitment was not collected from the GYTSs, and future studies should be conducted to include such information. Only individual-level characteristics were obtained from the GYTSs, and future studies should include country-level characteristics, including national tobacco control plans, policy, and intervention efforts. In addition, although the outcome variable was assessed using a validated measure,
      • Pierce J.P.
      • Choi W.S.
      • Gilpin E.A.
      • Farkas A.J.
      • Merritt R.K.
      Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.
      the primary exposure variable, self-reported waterpipe use, has not been previously validated and future studies should be conducted in this direction. Nevertheless, waterpipe use is a new strain of global tobacco pandemic and a potential gateway for cigarette smoking, and this study is the first investigation that demonstrates that waterpipe use among never cigarette–smoking youth is associated with increased susceptibility to cigarette smoking.

      Conclusions

      In a pooled analysis of 30,711 never cigarette–smoking adolescents representing 4.9 million youth in Arab nations, waterpipe use was associated with increased susceptibility to cigarette smoking. With increasing waterpipe use among youth and emergence of a new waterpipe strain of global tobacco pandemic, the study findings will help public health professionals, policy advocates, and healthcare practitioners develop policies and intervention efforts around waterpipe use prevention to prevent never smokers from initiating cigarette smoking.

      Acknowledgments

      Dr. Veeranki would like to thank the Department of Preventive Medicine and Community Health at the University of Texas Medical Branch for providing the logistic support. In addition, the authors would like to thank all personnel, including study participants, study coordinators, and organizations involved with the Global Youth Tobacco Survey. In particular, the authors would like to acknowledge the U.S. CDC for making the data publicly available through the Global Tobacco Surveillance System data portal.
      No financial disclosures were reported by the authors of this paper.

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