Hookah Middle East

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Hookahs on stand Hookahs on stand

Develop and test culturally sensitive pictorial health warning labels to young adults in Lebanon and Tunis

This international project will help Tunisia and Lebanon develop effective health warning labels for the waterpipe and equip them with the means to implement them successfully.


Hookah Smoking in the Middle East

The past decade has seen unprecedented increases in the usage of hookah smoking among young adults in the Eastern Mediterranean Region. Hookah smoking originated in ancient Persia, Iran, and India around 500 years ago. Spreading through Middle Eastern and Asian countries, hookah smoking has become embedded in their cultures of these areas and has become a prominent component in social gatherings. 1 The Middle East has an increased prevalence of smoking, Jordan (35.0%), Saudi Arabia (30.4%), and Lebanon (26.3%), respectively. 2

Lebanon and Tunisia suffer from considerable hookah smoking among youth. For example, a new study of 3384 students from 17 universities in Lebanon, showed that 23% were current hookah smokers compared to 19.2% for cigarettes. 3 Among 13–15-year-old, current hookah smoking in Lebanon according to the Global Youth Tobacco Survey 4 was 34.8% compared to 11.3% for cigarettes. 5 Tunisia, in particular, has weak tobacco control research, 6 but earlier results from the GYTS show an increasing trend in non-cigarette use; an indicator of hookah smoking (7.2% in 2001 to 13.9% in 2007). 7 Both countries have ratified the FCTC but are struggling with implementation. In a recent analysis of FCTC policy implementation in the EMR, Tunisia ranked 17 and Lebanon 15 out of 22 countries. 8 This demonstrates the need for translational research to help Tunisia and Lebanon respond to the hookah epidemic, and strengthen their national tobacco control capacity.


Resources
  1. Montazeri Z, Nyiraneza C, El-Katerji H, Little J. Waterpipe smoking and cancer: systematic review and meta-analysis. Tob Control. 2017 Jan;26(1):92-97. doi: 10.1136/tobaccocontrol-2015-052758. Epub 2016 May 10. PMID: 27165994.
  2. Nasser AMA, Geng Y, Al-Wesabi SA. The Prevalence of Smoking (Cigarette and Waterpipe) among University Students in Some Arab Countries: A Systematic Review. Asian Pac J Cancer Prev. 2020 Mar 1;21(3):583-591. doi: 10.31557/APJCP.2020.21.3.583. PMID: 32212782; PMCID: PMC7437327.
  3. Salameh P, Salamé J, Waked M, Barbour B, Zeidan N, Baldi I. Waterpipe dependence in university students and effect of normative beliefs: a cross-sectional study. BMJ Open. 2014 Feb 14;4(2):e004378. doi: 10.1136/bmjopen-2013-004378. PMID: 24531452; PMCID: PMC3927928.
  4. Centers for Disease Control and Prevention. (2011). Global tobacco surveillance system data (GTSSData).  Saudi Arabia GYTS Factsheet. Received from: http://nccd. cdc. gov/GTSSData/default/CountryResults. aspx.
  5. Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R, Salloum RG. The global epidemiology of waterpipe smoking. Tob Control. 2015 Mar;24 Suppl 1(Suppl 1):i3-i12. doi: 10.1136/tobaccocontrol-2014-051903. Epub 2014 Oct 8. PMID: 25298368; PMCID: PMC4345835.
  6. Zyoud SH, Al-Jabi SW, Sweileh WM, Awang R. A Scopus-based examination of tobacco use publications in Middle Eastern Arab countries during the period 2003-2012. Harm Reduct J. 2014 May 1;11:14. doi: 10.1186/1477-7517-11-14. PMID: 24885706; PMCID: PMC4012166.
  7. El-Awa F, Warren CW, Jones NR. Changes in tobacco use among 13-15-year-olds between 1999 and 2007: findings from the Eastern Mediterranean Region. East Mediterr Health J. 2010 Mar;16(3):266-73. PMID: 20795439.
  8. Heydari G, Talischi F, Algouhmani H, Lando HA, Ahmady AE. WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report. East Mediterr Health J. 2013 Apr;19(4):314-9. PMID: 23882955.

This study is funded by the Fogarty International Center of the National Institutes of Health, R01 TW010654.

Collaborators

Taghrid Asfar, M.D., M.S.P.H.

Dr. Asfar has extensive experience in tobacco control research nationally and internationally. Since 2001, her tobacco control work has been funded continuously by the NIH and conducted both in the United States and the Eastern Mediterranean Region, including Syria, Lebanon, and Tunisia. This work involves epidemiological and qualitative studies of tobacco use, randomized clinical trials of smoking cessation interventions, and tobacco regulatory research in health communication approaches targeting emerging tobacco products such as e-cigarettes and hookahs. She has two overarching aims in her research: (1) improving smoking cessation treatment among socially disadvantaged and high-risk populations (i.e., low-income adults, ethnic minorities, HIV patients, cancer survivors); and (2) preventing tobacco use among youth and young adults by advancing health communication strategies, such as health warning labels. She has more than 60 peer-reviewed publications (Asfar T - Search Results - PubMed) and many of these are in leading, high impact journals in this field (i.e., Tobacco Control; Nicotine and Tobacco Research; Addiction; and the Cochrane Tobacco Addiction Group). Dr. Asfar has currently five active grants as PI including:

  • 1R01DA051836: Developing and testing health warning labels on the ENDS (electronic cigarette) device
  • 20K10 James and Esther King Biomedical Research Program: Developing and testing waterpipe-specific health warning labels targeting young people in Florida
  • R01TW010654-01: Translating Evidence and Building Capacity to Support Waterpipe Control in the Eastern Mediterranean
  • CFAR Pilot Award P30AI07396: “Mind2Quit” Developing A Mindfulness Smartphone App for Smoking Cessation for People Living with HIV
  • Sylvester Cancer Center Pilot Award P30CA240139: Smartphone Application versus In-Person Mindfulness-Based Smoking Cessation Intervention for Young Cancer Survivors: Reach versus Effectiveness

Rima Nakkash, Ph.D.

Rima Nakkash is a distinguished Professor in the Global and Community Health Department, renowned for her international leadership in tobacco control research, prevention, and policy evaluation. Her expertise extends to community-based participatory research, with a focus on mental health promotion among youth and disadvantaged populations. Nakkash is deeply engaged in civic and citizen involvement in health policy making, translating evidence-based public health for interventions and policy, and advocating for health. Notably, she played a pivotal role in the passage of Lebanon's comprehensive tobacco control law in 2011 and received the WHO World No Tobacco Day Award in 2013.


Michael Schmidt, Ph.D., M.G.D.

Dr. Michael Schmidt is a social and behavioral research scientist in the field of public health, graphic designer, associate professor of design in the Department of Art, and affiliate faculty member in the School of Public Health at the University of Memphis. Dr. Schmidt's research areas include substance use disorders, intimate partner violence, and child and family wellbeing.


Wu Wensong, Ph.D.

Wensong Wu attained her Bachelor's degree in Computational Mathematics from Nanjing University, China in 2004 and her Master's degree in Mathematics from the University of South Carolina in 2007. In 2011, under the guidance of Dr. Edsel Pena, she completed her PhD in Statistics at the University of South Carolina, subsequently joining Florida International University as an assistant professor. Her research focuses on Bayesian methodologies for multiple hypothesis testing and classification, model selection and averaging for high- dimensional data, as well as statistical learning theory and its applications.


Wasim Maziak, M.D., Ph.D.

Dr. Wasim Maziak is a professor of Epidemiology, Director of the Clinical Research Lab for Tobacco Smoking at Florida International University, and Founder of the Syrian Center for Tobacco Studies. Dr. Maziak has extensive experience in tobacco control research and has published over 200 peer-reviewed scientific reports, including contributions in Science, Nature, Lancet, and British Medical Journal. His focus has been on emerging tobacco products such as e-cigarettes and hookah (Waterpipe), especially risk communication strategies targeting young users. He has been continuously funded by NIH since 2001 for tobacco control research.

Dr. Maziak’s Clinical Research Laboratory is located at the Academic Health Center 4 at FIU MMC campus. This state-of-the-art facility is fully equipped with five computer stations, blood drawing and specimen processing areas, fully furnished physical examination station, real-time monitoring equipment for vital signs, subjective measures assessment capability, and the latest in smoking topography technology (i.e., puff count, puff volume, average flow, puff duration, interpuff interval). This laboratory is devoted to assessing the impact of emerging tobacco products among young people such as waterpipe (hookah) and electronic nicotine delivery systems (i.e., ENDS, e-cigarettes). The research team is the first to evaluate this highly addictive and misperceived tobacco use method in a clinical lab setting, as its popularity grows statewide and nationally—especially among youth


Kenneth D. Ward, Ph.D.

Kenneth D. Ward, PhD is a Professor and Director of the Division of Social and Behavioral Sciences at the University of Memphis as well as Adjunct Professor of Preventive Medicine at the University of Tennessee College of Medicine. Dr. Ward’s research focuses on community, healthcare system, and population level approaches to reduce the burden of tobacco use. He is particularly interested in improving methods to help smokers quit and is a Certified Tobacco Treatment Specialist and holds a National Certificate in Tobacco Treatment Practice. Currently, Dr. Ward’s research projects include: (1) Epidemiology, prevention, and treatment of waterpipe ("hookah") and cigarette smoking in the U.S. and Middle East; (2) effects of stress and tobacco use on birth outcomes; and (3) use of tobacco and other substances in the aftermath of a disaster. He is also a Research Laureate the American Academy of Health Behavior and a fellow of AAHB, the Society for Research on Nicotine and Tobacco, and Society of Behavioral Medicine.


Habiba Zehi Ben Romdhane

Habiba Zehi Ben Romdhane attained a public health degree from the Faculty of Medicine at the University of Tunis in 1978. She furthered her training in public health at Laval University in 1979, the University of Chicago in 1981, and the University of Tokyo in 1988. Currently serving Formatted: Font color: Text 1 Formatted: Line spacing: single Commented [AC5]: Newly added, no need to include a picture as a professor of preventive medicine within the Faculty of Medicine at the University of Tunis, she also leads the Laboratory for Research on the Epidemiology and Prevention of Cardiovascular Diseases. Additionally, she has collaborated with the World Health Organization and was Tunisia’s health minister.

  • Asfar T, Ward K D, Oluwole O J, Ghaddar T M, Eissenberg T, Maziak W. Smoking Cessation Interventions for Waterpipe Smoking. (2023). The Cochrane database of systematic reviews, 6(6), CD005549. https://doi.org/10.1002/14651858.CD005549.pub4
  • Ben Mansour N, Rejaibi S, Sassi Mahfoudh A, Ben Youssef S, Ben Romdhane H, Schmidt M, Ward K D, Maziak W, & Asfar T.* (2023). Adapting waterpipe-specific pictorial health warning labels to the Tunisian context using a mixed method approach. PloS one, 18(3), e0279014. https://doi.org/10.1371/journal.pone.0279014 (*Senior and Corresponding Author).
  • Jebai, R., Asfar, T., Cano, M. A., Nakkash, R., Schmidt, M., Wu, W., Bursac, Z., & Maziak, W. (2023). Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, ntad223. Advance online publication. https://doi.org/10.1093/ntr/ntad223
  • Jebai, R., Asfar, T., Nakkash, R., Chehab, S., Schmidt, M., Wu, W., Bursac, Z., & Maziak, W. (2023). Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study. Health education research, 38(6), 537–547. https://doi.org/10.1093/her/cyad027
  • Lang A E, & Asfar T. (2023). The Path to Prevent the Next Generation from Water-Pipe Smoking. Chest, 164(6), 1345–1347. https://doi.org/10.1016/j.chest.2023.08.027
  • Asfar, T., Chehab, S., Schmidt, M., Ward, K. D., Maziak, W., & Nakkash, R. (2022). "Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 24(9), 1458–1468. https://doi.org/10.1093/ntr/ntac053
  • Jebai R, Asfar T, Nakkash R, Cano M, Chehab S, Wu W, Bursac Z, Maziak W. (2022). Impact of Pictorial Health Warning Labels on Smoking Beliefs and Perceptions Among Waterpipe Smokers: An Online Randomized Cross-over Experimental Study. Tobacco control, 32(6), 715–722. https://doi.org/10.1136/tobaccocontrol-2021-057202
  • Kedia S, Ahuja N, Hammal F, Asfar T, Eissenberg T, Maziak W, & Ward K D. (2022). “Waterpipe Is Like a Wife”: Qualitative Assessment of Perspectives on Waterpipe Smoking Dependence. Addiction & health, 14(4), 268–278. https://doi.org/10.34172/ahj.2022.1377
  • Ebrahimi Kalan, M., Bahelah, R., Bursac, Z., Ward, K. D., Ben Taleb, Z., Tleis, M., Jebai, R., Asfar, T., Eissenberg, T., & Maziak, W. (2021). A Group-based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers. Nicotine & tobacco research: official journal of the Society for Research on Nicotine and Tobacco, ntab128. Advance online publication. https://doi.org/10.1093/ntr/ntab128
  • Jebai, R., Asfar, T., Nakkash, R., Chehab, S., Ben Romdhane, H., & Maziak, W. (2021). Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design. Contemporary clinical trials communications, 23, 100797. https://doi.org/10.1016/j.conctc.2021.100797
  • Nakkash R, Tleis M, Chehab S, Wensong W, Schmidt M, Ward K D, Maziak W, Asfar T*. (2021). Novel Insights into Young Adults' Perceived Effectiveness of Waterpipe Tobacco-Specific Pictorial Health Warning Labels in Lebanon: Implications for Tobacco Control Policy. International journal of environmental research and public health, 18(13), 7189. https://doi.org/10.3390/ijerph18137189 (*Senior and Corresponding Author).
  • Alam, M. M., Ward, K. D., Bahelah, R., Kalan, M. E., Asfar, T., Eissenberg, T., & Maziak, W. (2020). The Syrian Center for Tobacco Studies-13 (SCTS-13): Psychometric evaluation of a waterpipe-specific nicotine dependence instrument. Drug and alcohol dependence, 215, 108192. https://doi.org/10.1016/j.drugalcdep.2020.108192
  • Asfar, T., Ward, K. D., Al-Ali, R., & Maziak, W. (2016). Building Evidence-Based Tobacco Treatment in the Eastern Mediterranean Region: Lessons Learned by the Syrian Center for Tobacco Studies. Journal of smoking cessation, 11(2), 116– 123. https://doi.org/10.1017/jsc.2016.5

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