Impact of COVID-19 pandemic on patterns of cigarette, hookah and marijuana consumption among undergraduate students of University of Sarajevo Bosnia and Herzegovina: a repeated cross-sectional study.

Aim: The aim of the study was to assess the impact of COVID-19 pandemic on patterns of cigarette, hookah and marijuana consumption among undergraduate students of Bosnia and Herzegovina. Methods: The first part of the double cross-sectional study was conducted among undergraduate students of the University of Sarajevo from 22nd to 26th January 2020, prior to the first COVID-19 case in the country (study period 1), and the second part from March 25th to August 26th 2021, during the third wave of COVID- 19 outbreak (study period 2). Results: The majority of the 1,230 respondents were women (N1 70.9%, N2 70.1%), pursuing medical sciences (N1 60.0%, N2 55.0%), in their 3rd year of study (N1 26.3%, N2 26.7%), and living in urban environment (N1 84.9%, N2 86.4%). Similar proportion of cigarette smokers (N1 38.5%, N2 39.2%), and smaller, similar portions of hookah smokers (N1 19.3%, N2 21.1%) were classified in both study periods, while the smallest portion of marijuana smokers (N2 8.0%) was classified during COVID-19. Similar number of cigarettes per day, types of cigarettes consumed and consumption frequency in the last 30 days, with the similar independent predictors of cigarette consumption (being woman and living in rural environment associated with decreased risk, and age older than 22 associated with increased risk) were identified both before and during COVID-19 pandemic. Compared to before COVID-19 pandemic, increased trends in intentions (73.6% vs. 81.2%) and attempts (51.9% vs. 75.1%) to smoking cessation among cigarette smokers, but decreased determination not to smoke in the coming year among cigarette non-smokers (N1 72.2%, N2 51.6%) and decreased awareness of smoking harmfulness among both cigarette smokers (N1 68.0%, N2 46.5%) and especially cigarette nonsmokers (N1 60.9%, N2 22.9%) were seen during COVID-19 pandemic. Also, risky behavior among hookah smokers was evident during COVID-19 pandemic. Conclusions: COVID-19 pandemic seemed to positively affect intentions and attempts to smoking cessation among cigarette smokers while negatively affecting attitudes towards cigarette smoking among cigarette non-smokers.

Investigating the factors of hookah smoking before and during the COVID-19 pandemic: Application of Protection Motivation Theory

INTRODUCTION In recent decades, hookah use has been considered a common method of smoking. Since hookah use is one of the factors exacerbating the coronavirus disease, COVID-19, the present study aimed to determine the factors affecting hookah smoking during the COVID-19 pandemic using protection motivation theory (PMT). METHODS This is a cross-sectional study and conducted on 560 people aged ≥13 years living in Hamedan. Data were collected electronically using a researcher-made questionnaire consisting of three parts. The first, second, and third parts included demographic information, questions about hookah use, and information about the constructs of PMT, respectively. Data were analyzed using SPSS 22 software. RESULTS The mean age of the participants was 28.8 ± 9.6 years. In the regression analysis of perceived reward structures (β=0.378), perception sensitivity (β=0.208), self-efficacy (β=0.0166) were respectively the important predictors for the intention of hookah use behavior. Overall, the constructs of the PMT explain 71% of the variance of the changes in the behavioral intention construct in the participants. No significant relationship was observed between self-efficacy constructs (r=0.039) and perceived cost. The prevalence of hookah use before the COVID-19 pandemic in participants was 41.8%, which decreased to 35% during the COVID-19 pandemic. CONCLUSIONS A greater correlation between the constructs of the PMT concerning protective behaviors against COVID-19 emphasizes designing educational programs based on this theory and the role of media to increase people’s knowledge in preventive behaviors.

Chronic exposure to waterpipe smoke elicits immunomodulatory and carcinogenic effects in the lung

Effects of waterpipe smoking on lung pathobiology and carcinogenesis remain sparse despite the worldwide emergence of this tobacco vector as a socially acceptable form of smoking, particularly among the youth. To address this gap, we investigated the effects of chronic waterpipe smoke (WPS) exposure on lung pathobiology, host immunity, and tumorigenesis using both an experimental animal model and an exploratory observational analysis of human waterpipe smokers and non-smokers. Mice exposed to increasing doses of WPS (once or five times per week for 20 weeks), through an exclusively devised exposure system for this study, were more prone to develop lung tumors compared to control-air exposed littermates. This effect was accompanied by various pro-tumor immune phenotypes, including increased IL-17A+ levels in T/B cells as well as elevated expression of the immune checkpoint PD-L1 and the pro-inflammatory cytokine IL-1β in myeloid cells. While flow cytometry analysis revealed increased CD4 and CD8 T cell infiltration in WPSexposed mice, gene signatures of cytotoxic and expanded immune response were, conversely, decreased in animals exposed to heavy WPS relative to control air. Interestingly, mice heavily exposed to WPS exhibited increased expression of Tmprss4, Cd55, and Ace2, cell receptors and mediators of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entry and, thus, COVID-19 pathogenesis. We also perform RNA-sequencing analysis of bronchial airway epithelial brushings of cancer-free waterpipe smokers and non-smokers undergoing diagnostic bronchoscopy. Transcriptomes of normal airway cells in waterpipe smokers, relative to waterpipe non-smokers, harbored gene programs that were associated with poor clinical outcomes in lung adenocarcinoma (LUAD) patients, alluding to a WPS-associated molecular injury, like that established in response to cigarette smoking. Overall, our analyses demonstrate immunomodulatory and carcinogenic effects of WPS on the murine and human lung. Our study also shows that WPS exposure leads to a field of injury that may be associated with increased risk for lung cancer. This study is unique for interrogating carcinogenic effects of chronic exposure to WPS with the longest, to our knowledge, follow-up time in vivo. Our findings accentuate the need for additional studies that can guide evidence-based policies to counteract shortfalls in public health control of waterpipe smoking.

COVID-19 and hookah smoking cessation among women in Southern Iran: A cross-sectional study.

Hookah smoking does not only transmit COVID-19 but also intensifies the symptoms of the disease. Thus, the present research aimed to explore the association between COVID-19 and hookah cessation among female smokers. The institutional-based cross-sectional study was conducted nine months after the onset of the COVID-19 pandemic. Face-to-face interviews were held between November 2020 and January 2021 to explore the pattern of hookah smoking among 561 female hookah smokers in Bandar Abbas in the south of Iran. The daily, weekly and monthly rates of hookah smoking showed a statistically significant decrease in the during COVID-19 era (p < .001). Thirteen percent of women managed to cease hookah smoking successfully during the pandemic. The odds ratio of hookah cessation was higher in single women (95% CI 1.09-5.23) as well as women with a high socioeconomic status (SES) (95% CI 4.28-24.01). It was also higher among women who initiated hookah smoking at an older age (95% CI 29-68) and among those with no hookah smoking family member (95% CI 301- 943). Fear of COVID-19 infection was the leading factor involved in hookah cessation or reduction. Entertainment was the leading barrier to successful hookah cessation behavior. It is believed that COVID-19 has directly and indirectly contributed to the reduced or ceased hookah smoking behavior. One of the reasons for the reduction of hookah smoking was the fear of aggravated symptoms and reasons for cessation included closure of coffee shops and removal of all hookahs from the city.

From vaping and smoking: Risk assessment of new tobacco and nicotine releasing systems

90% of all e-cigarette users use tobacco cigarettes instead of quitting smoking and, due to sweet-flavored liquids and advertising as a lifestyle product, young never-smokers are increasingly using these new products. Even though e-cigarettes may also contain lower levels of harmful substances, no e-cigarette was free from potentially toxic and carcinogenic substances, and there is also evidence that e-cigarettes contain new toxic substances;in 2019, they led to EVALI in the USA with 68 deaths. In the steam from tobacco heaters, 295% increased amounts of carcinogenic acenaphthene compared to tobacco cigarettes were found. The use of nicotine-containing e-cigarettes and tobacco heaters did not reduce tobacco-related diseases. Shisha lead to a similar nicotine addiction potential, a considerably higher pollution, and carbon monoxide exposure. Shiazzo steam stones have a significantly lower health risk than shishas with the same risk of carbon monoxide poisoning. The consumption of e-cigarettes by adolescents and young adults led to a 5-fold increased risk of contracting COVID-19, in combination with tobacco cigarettes even to a 7-fold increased risk. The new tobacco or nicotine-releasing substances are neither harmless to health nor suitable for smoking cessation.

The effect of hookah use on COVID-19 related adverse outcomes: Lessons learned from integrating STEPs 2016 and national COVID-19 registration databases.

INTRODUCTION: Amidst the COVID-19 pandemic, an international effort has been concerted to identify the factors associated with more adverse outcomes to better allocate resources and perform more effective targeted preventive measures. This study aims to describe the risk of COVID-19 adverse outcomes among individuals with a history of being ever cigarette smokers and being ever hookah users. METHODS: We combined two databases, including the Iran national registry of COVID-19 patients, including 2020 with 656258 hospitalized patients and STEPs survey 2016 with 30541 participants. After merging the two databases using the national ID, the association was investigated between being ever smoker or hookah user and the adverse outcomes of COVID-19 including death, need for a ventilation therapy, and admission in the intensive care unit (ICU), among 474 severe acute respiratory infections (SARI) cases and 211 PCR-positive patients. RESULTS: Among 211 PCR-positive patients, 40 (19%) patients were ever hookah users and 28 (13.3%) were ever cigarette smokers. Death occurred in 27 (12.8%) patients and severe COVID-19 in 17 (11.6%). Among 211 PCR-positive patients, ever cigarette smokers had 4.2 times (95% CI: 1.1-15.4, p=0.03) higher odds of ICU admission and 4.2 times (95% CI: 1.1-15.4, p=0.03) increased odds for need of ventilation, compared with non-smokers. Besides, ever hookah users had 3.9 times (95% CI: 1.1-13.6, p=0.03) higher odds for need of ventilation therapy, compared with non-hookah users. CONCLUSIONS: Tobacco use and hookah smoking were associated with adverse outcomes among COVID-19 patients in Iran.

Patterns of cigarette, hookah and other tobacco product consumption habits among undergraduate students of the University of Sarajevo before the COVID-19 outbreak in Bosnia and Hercegovina, a cross-sectional study.

Background: Tobacco products represent a major health risk factor and a potent way to help transmission of COVID-19. Current data regarding consumption of these products in the region are scarce. The aim of this study was to evaluate patterns of cigarette, hookah and other tobacco products consumption among undergraduate students from the University of Sarajevo before the COVID-19 outbreak in the country. Methods: This cross-sectional study based on a National Youth Tobacco Survey (NYTS) was conducted among undergraduate students from the University of Sarajevo in Bosnia and Hercegovina via an online questionnaire from 22nd to 26th of January 2020. Results: Out of 605 students involved in the study, most of them were female (N=429, 70.9%); 363 (60.0%) were enrolled in medical sciences; 159 (26.3%) were attending the 3rd year of their curriculum; 224 (37%) were original from Canton Sarajevo and 514 (84.9%) were living in urban environment. Two hundred thirty five students out of 605 (38.8%) were current smokers and 117 (19.3%) hookah smokers. Being female (OR=0.539, 95% CI 0.368-0.790, p=0.002), in the 1st or 2nd year of study (OR=0.805, 95% CI 0.667-0.972, p=0.024) and living in a rural environment (OR=0.335, 95% CI 0.191-0.585, p<0.001) were associated with reduced risk of cigarette consumption, while older age (22+ years) (OR=1.287, 95% CI 1.122-1.476, p<0.001) increased the same risk. On the other side, being female (OR=0.595, 95% CI 0.380-0.930, p=0.023), of younger age (18-21 years) (OR=0.832, 95% CI 0.743-0.932, p=0.001) and medical science student (OR=0.567, 95% CI 0.328-0.978, p=0.041) were associated with decreased risk of consuming hookah. Conclusions: This study provides an insight in prevalence of smoking among students at the University of Sarajevo. More antismoking efforts are needed, especially in urban environments; and a follow-up study, to be planned in the near future, should determine whether COVID-19 pandemic (and all the modifications of lifestyles connected with it) have eventually changed tobacco consumption patterns among undergraduate students.

Feasibility of Using the Hexoskin Smart Garment for Natural Environment Observation of Respiration Topography.

Background: Limited research has been done to measure ambulatory respiratory behavior, in particular those associated with tobacco use, in the natural environment due to a lack of monitoring techniques. Respiratory topography parameters provide useful information for modeling particle deposition in the lung and assessing exposure risk and health effects associated with tobacco use. Commercially available Wearable Respiratory Monitors (WRM), such as the Hexoskin Smart Garment, have embedded sensors that measure chest motion and may be adapted for measuring ambulatory lung volume. Methods: Self-reported "everyday" and "some days" Hookah and Cigarette smokers were recruited for a 3-day natural environment observation study. Participants wore the Hexoskin shirt while using their preferred tobacco product. The shirt was calibrated on them prior to, during, and after the observation period. A novel method for calculating the calibration parameters is presented. Results: NH = 5 Hookah and NC = 3 Cigarette participants were enrolled. Calibration parameters were obtained and applied to the observed chest motion waveform from each participant to obtain their lung volume waveform. Respiratory topography parameters were derived from the lung volume waveform. Conclusion: The feasibility of using the Hexoskin for measuring ambulatory respiratory topography parameters in the natural environment is demonstrated.