The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally.

OBJECTIVE: The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review. DATA SOURCES: The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms. STUDY SELECTION: Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10-29 years. DATA EXTRACTION: Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results. DATA SYNTHESIS: The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels. CONCLUSIONS: The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria.

BACKGROUND: Throughout the Eastern Mediterranean region (EMR), tobacco is used primarily in two forms: cigarette smoking and waterpipe (called narghile (nar-GIL-eh) in Syria) smoking. OBJECTIVE: To explore whether narghile smokers are different from cigarette smokers in how their smoking habits are embedded in their everyday lives. METHODS: One-to-one interviews with 16 adult narghile smokers and 16 adult cigarette smokers about their feelings, experiences and beliefs regarding their initiation, use patterns, and attempts to quit. FINDINGS: Narghile smokers found that narghile was a pleasurable social experience embedded in cultural rituals. By contrast, cigarette smokers saw their cigarette smoking as a mundane, oppressive, personal addiction. Narghile smokers generally started in their 20s and found that smoking narghile fostered a sense of togetherness and cultural identity, while cigarette smokers started in their early teens, males having started to becoming a "real man". Unlike cigarette smokers who felt stigmatised, narghile smokers generally felt that smoking narghile was socially accepted. Cigarette smokers believed that cigarettes were harmful to their health and harmful to those around them, but narghile smokers believed smoking narghile was relatively harmless to themselves or to others. Unlike cigarette smokers who used cigarettes to manage stress, narghile smokers used narghile for entertainment, leisure, and escape. However, frequent narghile smokers confessed that they felt addicted in much the same way as cigarette smokers. Cigarette smokers and narghile smokers viewed quitting as a matter of will and conviction. Most cigarette smokers had tried to quit. Very few narghile smokers had ever tried to quit, and most were not interested in quitting. Disturbingly, some cigarette smokers had tried to quit cigarettes by switching to smoking narghile, but later relapsed to smoking cigarettes. CONCLUSIONS: This exploratory study suggests that Syrian narghile smokers are different from Syrian cigarette smokers in their perceptions and beliefs about their smoking, and in their smoking patterns and lived experiences with tobacco. Our findings indicate that further in-depth research is need in the EMR to understand both modes of smoking to develop effective mode-specific prevention and cessation approaches. This study also raises concerns about a possible pattern where cigarette smokers are using narghile as a method for quitting cigarettes, and then relapsing.

Exposure to secondhand smoke at home and in public places in Syria: a developing country's perspective.

This study employs sensitive methods to address the issue of exposure to secondhand smoke among children and women in an understudied developing country setting (Syria). The study combines data collected by the Syrian Center for Tobacco Studies as part of two international studies conducted in 2006: the Secondhand Smoke Exposure among Women and Children study (Johns Hopkins) and the Global Air Monitoring Study (Roswell Park Cancer Institute). We employed objective measures (hair nicotine, and ambient household nicotine assessed by passive monitors) to assess children's and mothers' exposure to secondhand smoke at home, and used the TSI SidePak personal aerosol monitor to sample respirable suspended particles less than 2.5 microm diameter (PM(2.5)) in the air in public places (40 restaurants/cafés in Aleppo). In homes, the mean ambient nicotine level (+/- standard deviation, SD) was 2.24 +/- 2.77 microg/m(3). Mean level of hair nicotine was 11.8 ng/mg among children (n = 54), and was higher if the mother was a smoker (19.4 +/- 23.6 ng/mg) than nonsmoker (5.2 +/- 6.9 ng/mg) (p < .05). Mean hair nicotine among nonsmoking mothers (n = 23) was 1.17 +/- 1.56 ng/mg. Children's hair nicotine level was strongly correlated with ambient household nicotine and number of cigarettes smoked daily in the house (r = .54 and r = .50, respectively, p < .001), and also was related to having a father who smoked in the children's presence. In public places, average PM(2.5) in the monitored 40 hospitality venues was 464 microg/m(3) and correlated with smoker density measured as cigarettes-waterpipes/100 m(3) (r = .31, p = 0.049). Thus, children in Syria are exposed to high levels of secondhand smoke at home, in which mothers' smoking plays a major role. Also, levels of respirable hazardous particles are high in public hospitality venues, putting customers and workers at serious health risks. Efforts to limit exposure of children and women at home and to adopt clean air policies should become a public health priority in Syria and the Arab region.

Childhood obesity: are we missing the big picture?

Childhood obesity is increasing worldwide, raising alarm about future trends of cardiovascular disease, diabetes and cancer. This article discusses what may underlie our failure to respond effectively to the obesity epidemic, and presents a wider perspective for future research and public health agendas. So far targeting individual-level determinants and clinical aspects of childhood obesity has produced limited success. There is growing interest in understanding the wider determinants of obesity such as the built environment (e.g. walkability), social interactions, food marketing and prices, but much needs to be learned. Particularly, we need to identify distal modifiable factors with multiple potential that would make them attractive for people and policymakers alike. For example, walking-biking-friendly cities can reduce obesity as well as energy consumption, air pollution and traffic delays. Such agenda needs to be driven by strong evidence from research involving multi-level influences on behaviour, as well as the study of wider politico-economic trends affecting people's choices. This article highlights available evidence and arguments for research and policy needed to curb the obesity epidemic. The upstream approach underlying these arguments aims to make healthy choices not only the most rational, but also the most feasible and affordable.

Interventions for waterpipe smoking cessation.

BACKGROUND: Waterpipe smoking is a traditional method of tobacco use, especially in the Eastern Mediterranean Region, but its use is now spreading throughout Europe and North America. It is smoked socially, often being shared between friends or family at home, or in dedicated bars and cafes that provide waterpipes to patrons. Because the smoke passes through a reservoir of water, waterpipe tobacco smoking is perceived as being less lethal than other methods of tobacco use. At least in some cultures, women and girls are more likely to use a waterpipe than to use other forms of tobacco, and it is popular among younger smokers. Accumulating evidence suggests that waterpipe smoking may be as addictive as other forms of tobacco use, and may carry similar or greater risks to health. OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for waterpipe users. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Review Group specialized register, in June 2007. We also searched MEDLINE, EMBASE, CINAHL and PsycINFO, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language, and especially in regions where waterpipe use is widespread. We have also used our own existing bibliography, compiled from conducting an earlier exhaustive review of the literature on waterpipe smoking. SELECTION CRITERIA: We sought randomized, quasi-randomized or cluster-randomized controlled trials of smoking cessation interventions for waterpipe smokers of any age or gender. The primary outcome of interest was abstinence from tobacco use, preferably sustained and biochemically verified, for at least six months from the start of the intervention. DATA COLLECTION AND ANALYSIS: Each author intended to extract data and assess trial quality independently by standard Cochrane Collaboration methodologies, but no eligible trials were identified. MAIN RESULTS: We found no completed intervention trials targeting waterpipe smokers. A pilot randomized controlled trial by the authors of this review is underway, and will be reported in future updates. AUTHORS' CONCLUSIONS: Epidemiological and observational evidence suggests that waterpipe use is growing in popularity worldwide. It is widely and erroneously perceived to be less lethal than other forms of tobacco use. Women, girls, and young people are more likely to take up waterpipe smoking, especially in the Eastern Mediterranean Region. More research is needed on its addictive properties, and on the associated health risks, both for users and exposed non-smokers. Evidence-based information about waterpipe's addictive and harmful properties should be developed and disseminated in order to deglamourise and denormalise its use. High quality randomized trials are needed to guide treatment of waterpipe smoking.

The tobacco epidemic in Syria.

BACKGROUND: The Syrian Center for Tobacco Studies (SCTS) was established in response to the smoking epidemic in Syria and lack of local knowledge and expertise to confront it. OBJECTIVES: To (1) study tobacco use and local smoking practices using both qualitative and quantitative research methods; (2) develop and test an effective smoking cessation intervention for the Syrian environment; and (3) train Syrian researchers. METHODS AND RESULTS: The Aleppo Household Survey involved a representative sample of adults in Aleppo (2038 subjects, 45.2% men, mean age 35.3 years, response rate 86%). The prevalence of cigarette smoking was 56.9% among men and 17.0% among women, while the prevalence of waterpipe smoking was 20.2% among men and 4.8% among women. Daily use predominated for cigarettes (29.0%), while the opposite was seen in waterpipe use with 10.6% smoking occasionally. Interest in quitting was greater for cigarette than waterpipe smokers (74.0% v 48.6%), while quit rates were higher for waterpipe compared to cigarettes (28.2% v 16.5%). In-depth ethnographic interviews with smokers show that smoking waterpipe is often viewed as an aesthetic enjoyable experience, while smoking cigarettes is viewed as a mundane anxiety-relieving addiction. Clinical laboratory studies reveal that both waterpipe and cigarette smokers in Syria are exposed to smoke toxicants and exhibit dependence symptoms. CONCLUSIONS: All these data have been used iteratively to adapt smoking cessation interventions from developed countries to suit the local Syrian environment. Research conducted in the SCTS to date has provided a fertile training ground for Syrian researchers, as well as for the building of regional collaborations.

Mapping the health and environmental situation in informal zones in Aleppo, Syria: report from the Aleppo household survey.

OBJECTIVES: Despite large communities living in informal zones around major cities in Syria, there is currently no information on the health and environmental situations in these areas. From May to August 2004, the Syrian Center for Tobacco Studies (SCTS) conducted the first household survey aiming to provide a baseline map of main health problems and exposures affecting these communities in Aleppo, the second largest city in Syria (2,500,000 inhabitants). METHODS: Information on 1,021 participants randomly selected using stratified cluster sampling were available (46% males, mean age 34+/-11.7, age range 18-65 years, response rate 86%), including self-reported health/disability, exposures, and saliva cotinine measurement. RESULTS: Some positive findings include better than expected access to electricity, piped water, city sewage, and the use of propane for cooking. Particular areas of concern include high fertility rates, overcrowded housing conditions, and gender inequality in education and work. Household features likely to reflect negatively on residents' health include the use of diesel chimneys for heating and lack of smoking restrictions. Overall, residents of informal zones suffer from substantial physical and mental health problems and are exposed to high levels of indoor air pollution. All seem to affect women and the elderly disproportionately, while men are more affected by smoking, occupational respiratory exposures, and injuries. Both infectious and non-infectious respiratory outcomes were very common among study participants. Chronic and degenerative disease, including CVD and joint problems, were a source of substantial morbidity among the studied communities. CONCLUSIONS: This study highlights major health and environmental specificities of marginalized populations living in Aleppo, where women seem to bear a disproportionate burden of poor health and disability. Smoking and exposure to tobacco smoke seem among the major exposures facing these populations.

Standardizing questionnaire items for the assessment of waterpipe tobacco use in epidemiological studies.

Lessons from surveillance of the smoking epidemic show that the lack of adequate attention to standardizing measures and instruments for epidemiological studies has negatively influenced our ability to assess spatial and secular trends in smoking worldwide. Waterpipe smoking, another hazardous form of tobacco use, is gaining popularity worldwide, with societies in the Eastern Mediterranean region (EMR) being most affected. Several research groups are currently investigating the epidemiology of waterpipe smoking among various populations in the EMR. Initial evidence shows that in contrast to usage patterns observed in adult cigarette smoking, waterpipe smoking is characterized mainly by intermittent and social use. As such, many measures that have been traditionally used for the study of usage patterns and dependence among adult cigarette smokers are uninformative for waterpipe smoking. Thus, the need to develop standardized measures and terminology for assessment of the epidemiology of waterpipe smoking in different populations is of paramount importance. As the monitoring of waterpipe smoking is in its infancy, the development of consensus measures should facilitate the initiation of effective surveillance that can guide public health response to this emerging epidemic.

Patterns of waterpipe use and dependence: implications for intervention development.

Despite the dramatic increase of tobacco smoking via waterpipe in Arab societies, and the apparent potential of waterpipe use to produce tobacco-related disease, little is known about the pharmacological effects of this method of tobacco smoking, particularly its ability to support dependence. This review focuses on recent waterpipe research and current theories of dependence in an attempt to identify patterns of waterpipe use and features likely to reveal dependence. Recent work indicates that, relative to cigarette smoking, this form of tobacco use is characterized by more intermittent use, later age of onset, greater spread among women and lower interest in quitting or appreciation of addictive properties. Waterpipe use is associated with classic features of tobacco/nicotine dependence, as well as features unique to this tobacco use method. However, even shared features of dependence, such as craving and addiction-induced socio-cognitive behavioral changes, can be displayed differently in waterpipe users, indicating the need for waterpipe-specific research approaches. Preliminary evidence suggests that an important step toward dependence involves a transition from social to individual patterns of waterpipe use. Surveillance and research into factors affecting use and cessation of this tobacco use method should pave the way for the development of effective prevention and intervention strategies to curb the burgeoning waterpipe use epidemic.

Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic.

CONTEXT: The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Current research, treatment, and policy efforts focus on cigarettes, while many people in developing regions (Asia, Indian subcontinent, Eastern Mediterranean) smoke tobacco using waterpipes. Waterpipes are increasing in popularity, and more must be learned about them so that we can understand their effects on public health, curtail their spread, and help their users quit. OBJECTIVE: To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy. DATA SOURCES: A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used. STUDY SELECTION: Every identified published study related to waterpipe use was included. DATA SYNTHESIS: Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications. CONCLUSIONS: More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.

Factors related to frequency of narghile (waterpipe) use: the first insights on tobacco dependence in narghile users.

AIMS: To evaluate factors related to level of narghile (waterpipe) use as a first step towards modeling tobacco dependence among narghile users. DESIGN: Cross sectional survey done in 2003 using interviewer-administered anonymous questionnaires. SETTING: Cafes/restaurants serving narghiles in Aleppo, Syria. PARTICIPANTS: Narghile smokers (161 men and 107 women; mean age, 30.1 +/- 10.2, 161; age range, 18-68 years; response rate, 95.3%) randomly selected from the 17 cafes/restaurants sampled. MEASUREMENTS: Frequency of narghile use (daily, weekly, monthly) was assessed as a function of several factors potentially indicative of dependence, including situational characteristics (where, when, and with whom smoking occurs; seasonality of use, and sharing of narghile), attitudes, and experience with quitting narghile use, escalation of use over time, future intentions regarding use, perception of being "hooked" on narghile, and cognitions/behaviors engaged in to support use (carrying one's own narghile; think of narghile when it is not available; considering narghile for selection of cafes/restaurants). FINDINGS: Frequency of narghile use was strongly correlated with participant's subjective judgment of how hooked they are on narghile (coefficient, 0.5). Predictors of narghile use frequency according to multinomial logistic regression were: male gender, smoking mainly alone versus with others; smoking mainly at home versus outside; smoking more frequently since initiation, being hooked on narghile, carrying narghile, and considering it for cafe/restaurant choice. CONCLUSIONS: Our data reveal two main domains of a tobacco dependence syndrome likely to be relevant to narghile; the first reflects the effects of nicotine contained in narghile tobacco, and is not very different from what is seen with other tobacco products, and the second is unique to narghile and is related mainly to its social dimension, with more intensive smokers showing an increasingly individual pattern of narghile smoking.

Prevalence and characteristics of narghile smoking among university students in Syria.

SETTING: Narghile (waterpipe) smoking is increasing in all Arab societies, but little is known about its pattern of use. METHODS: In 2003, a cross-sectional survey was conducted among students at Aleppo University using an interviewer-administered questionnaire. A representative sample of 587 students participated (278 males, 309 females; mean age 21.8 +/- 2.1 years; response rate 98.8%). RESULTS: Ever narghile smoking was seen among 62.6% of men and 29.8% of women, while current smoking was seen among 25.5% of men and 4.9% of women. Only 7.0% of the men used narghile daily. Age of initiation was 19.2 +/- 2.2 and 21.7 +/- 3.2 years for men and women, respectively (P < 0.001). The salient feature of narghile smoking was its social pattern, where most users initiated and currently smoked narghile with friends. Narghile and cigarette smoking were related among students, with narghile smoking most prevalent among daily cigarette smokers. Multivariate correlates of narghile smoking were being older, male, originating from the city, smoking cigarettes, having friends who smoke narghile, and coming from a household where a greater number of narghiles were smoked daily. CONCLUSIONS: Narghile smoking is prevalent among university students in Syria, where it is mainly practiced by men, intermittently, and in the context of social activities with friends.

Characteristics of cigarette smoking and quitting among university students in Syria.

BACKGROUND: No study to date in Syria has documented the smoking and quitting characteristics in a representative sample of university students, and this study aims to fill this void. DESIGN: In 2003, a cross-sectional survey was carried out among students at Aleppo University using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 +/- 2.1 years; response rate, 98.8%). Experiences and attitudes related to smoking and quitting were assessed for two popular forms of tobacco use in Syria-cigarettes and narghile (waterpipe). RESULTS: Current cigarette smoking was reported by 30.9% of male and 7.4% of female students and daily smoking by 24.8% of male and 5.2% of female students. Narghile smoking was seen among 25.5% of men and 4.9% of women, mostly on an occasional basis. More than half of current smokers (56%) believed they could quit cigarettes, 75.2% were interested in quitting, and 78% of those had made a quit attempt in the past year. Important correlates of cigarette smoking among students were being older, male, and smoking narghile, while being older and from a poorer family were associated with increased interest in quitting. Interestingly, peers' smoking was associated with current smoking among students, but inversely with their willingness to quit. CONCLUSIONS: Cigarette smoking is mainly a problem of male students, whose narghile smoking is likely to be dramatically increasing as well, sometimes practiced as a substitute for cigarettes. The findings that most smokers in this sample are interested in quitting smoking and have tried unsuccessfully to do so indicate that cessation support for youths in this country is urgently needed.

Adapting smoking cessation interventions for developing countries: a model for the Middle East.

OBJECTIVE: To describe the rationale and methods for the development of culturally-sensitive smoking cessation interventions for primary care settings in developing countries. RATIONALE: Smokers in the Middle East have great difficulty quitting. Effective smoking cessation programs are currently lacking in the Middle East, and the development of culturally sensitive programs is hindered by the dearth of standardized information regarding tobacco use and dependence in this region. METHODS: Epidemiological and clinical laboratory methods are needed to determine the prevalence and patterns of tobacco use and nicotine dependence. One strategy is to adapt smoking cessation methods widely used in industrialized countries to the Syrian and Middle Eastern environment. In a recently initiated project, the Syrian Center for Tobacco Studies has been established to address these issues. Initial work is focusing on collecting formative data including key informant interviews, focus groups, and epidemiological surveys to assess smokers' use patterns, needs, and resources. Clinical laboratory techniques are also being applied to assess the physiological, behavioral, and subjective effects of local tobacco use methods, such as narghile (water pipe) smoking. These data will be used to help adapt existing smoking cessation interventions from industrialized countries to be evaluated in a randomized controlled trial. CONCLUSION: There is a great need to develop and disseminate effective cessation interventions in low-income countries. Successful interventions will contribute to a culturally sensitive and sustainable regional tobacco control infrastructure. This paper describes one approach to the development of such an infrastructure that is currently underway in the Middle East.

Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria.

BACKGROUND: Narghile (waterpipe) smoking is increasing across the Eastern Mediterranean region (EMR), though little is known about the social attitudes and perceptions related to this method of tobacco use, and how those attitudes and perceptions are influenced by gender. METHODS: Data from two cross-sectional surveys conducted in 2003 in Aleppo, Syria, were used to examine these issues. Overall, 855 participants were included (439 men, 416 women; mean age, 24.4+/-7.1 years; response rate, 97%). The current analysis focuses on responses to four similar nine-item questions tapping perceptions related to narghile smoking by women or men, and cigarette smoking by women or men. Scores on the nine items were summed to yield a total score to gauge participants' perceptions about narghile and cigarette. RESULTS: Generally, participants were less positive about women smoking relative to men smoking, and cigarette smoking relative to narghile smoking. Cigarette smoking by women was the behavior least associated with positive perceptions. Individuals who resided in the city, were economically better-off, and were Christian, had higher perception scores (i.e., more positive attitudes) toward all forms of smoking, whereas older and married participants had higher perception scores for narghile only. Smoking status of participants, especially narghile smoking, was also associated with more positive perceptions toward smoking in general. CONCLUSIONS: We conclude that preliminary analysis shows that views on different forms of smoking in Syria differ by gender and smoking status.

A meta-analysis of the effects of cigarette smoking on bone mineral density.

To determine the magnitude and mediators of the association between cigarette smoking and bone mass in the epidemiologic literature we reviewed articles, published abstracts, and conference proceedings, identified through MEDLINE, psychological abstracts, conference proceedings, and article bibliographies. We studied cross-sectional and prospective human studies that provided a quantitative measure of bone mass (X-ray, absorptiometry, or computed tomography) as a function of cigarette smoking exposure. Effects were expressed as pooled standardized mean differences for categorical comparisons (e.g., bone mass in current versus nonsmokers), and as pooled correlation coefficients for continuous comparisons (e.g., correlation of bone mass and pack-years of smoking). Effects were derived for combined bone sites (all bone sites pooled within each study) and four specific sites (hip, lumbar spine, forearm, and os calcis), and were examined overall and as a function of subject and methodologic characteristics (gender, age, body weight, menopausal status, health status). Data were pooled across 86 studies, enrolling 40,753 subjects. Smokers had significantly reduced bone mass compared with nonsmokers (never and former smokers) at all bone sites, averaging a one-tenth standard deviation (SD) deficit for combined sites. Deficits were especially pronounced at the hip, where the bone mass of current smokers was one-third of a SD less than that of never smokers. Overall, effects were greatest in men and in the elderly, and were dose-dependent. In prospective studies, smokers had greater rates of bone loss over time compared with nonsmokers. Bone mass differences remained significant after controlling for age and body weight differences between the two groups. Absolute effect sizes at most bone sites were greatest for current smokers compared with never smokers, intermediate for current smokers compared with former smokers, and lowest for former smokers compared with never smokers, suggesting that smoking cessation may have a positive influence on bone mass. Based on these data, it is estimated that smoking increases the lifetime risk of developing a vertebral fracture by 13% in women and 32% in men. At the hip, smoking is estimated to increase lifetime fracture risk by 31% in women and 40% in men. It appears that smoking has an independent, dose-dependent effect on bone loss, which increases fracture risk, and may be partially reversed by smoking cessation. Given the public health implications of smoking on bone health, it is important that this information be incorporated into smoking prevention and cessation efforts.

Smoking cessation in pregnant women.

Cigarette smoking is considered the most significant modifiable cause of adverse pregnancy outcomes in US women. Smoking cessation in pregnant patients is one of the most effective ways to reduce negative pregnancy outcomes of fetal growth retardation, preterm delivery, and perinatal mortality. Research evidence documenting the effectiveness of health care provider interventions in smoking cessation has led to the PHS recommendation to screen and counsel every patient. Materials from the PHS and NCI are available to assist health care providers in developing a brief office-based intervention. Patient materials for distribution are also available. Increased use of office-based cessation strategies, of cessation programs in community-based interventions, and of pharmacologic therapies is necessary to remedy the public health burden of fetal exposure to tobacco. Relapse prevention methods using office-based and social support systems are important to improve long-term maintenance of cessation in women who quit smoking during pregnancy.

Food sources of calcium in a sample of African-American an Euro-American collegiate athletes.

Adequate calcium intake is integral to bone health as well as for optimal athletic performance. This study was conducted to investigate: (a) food sources of calcium in a sample of collegiate athletes, (b) gender and/or ethnic differences in food sources of calcium, and (c) whether athletes that derive less of their calcium intake from dairy sources increase their calcium intake from supplements or other food sources. Participants were African-American and Euro-American NCAA Division 1-A athletes. Eighty-five men and 59 women participated. Calcium intake for the previous 7-day period was assessed with a brief calcium screen. Men consumed significantly more calcium than women (1,354 vs. 898 mg/day), with female cross-country runners exhibiting the lowest average intake (605 mg/day). Both men and women obtained the majority of their calcium from dairy products and mixed dishes, while men consumed significantly more calcium-fortified foods. Several gender and ethnic interactions for calcium intake from food groups were found. Mean total dairy calcium intake was found to vary according to total calcium intake in men, and supplemental calcium was not used to augment low dairy intakes of calcium in any group. While African-Americans and Euro-Americans athletes were consuming similar levels of calcium, the female athletes in the sample did not get adequate amounts.

Smoking cessation in hospitalized patients.

The components of readiness to change for smoking cessation that are found in the general population are also applicable to hospitalized smokers. Smoking cessation interventions must be specifically tailored to subgroups among hospitalized patients, with emphasis on smoking-related diagnosis when applicable. Interventions should include key components related to smoking cessation, such as knowledge, self-efficacy, exposure to smoking, and social support. Interventions that include relapse prevention and are conducted in the context of other risk reduction strategies should be developed.

Hostility and the metabolic syndrome in older males: the normative aging study.

OBJECTIVE: Several studies have shown that hostility, as measured by the Minnesota Multiphasic Personality Inventory-derived Cook-Medley Hostility Scale (Ho), is positively associated with several cardiovascular risk factors, possibly accounting for the relationship between Ho scores and cardiovascular mortality. This study was undertaken to examine associations between hostility and cardiovascular risk factors representing the metabolic syndrome in 1,081 older men who participated in the Normative Aging Study. METHODS: Subjects included men who completed the Minnesota Multiphasic Personality Inventory in 1986 and who participated in a subsequent laboratory examination within 1 to 4 years. Total and subscale Ho scores were computed, and associations with anthropometric data, cigarette smoking, dietary information, serum lipids, blood pressure, and fasting glucose and insulin levels were examined. RESULTS: The total Ho score was positively associated with waist/hip ratio, body mass index, total caloric intake, fasting insulin level, and serum triglycerides. The Ho score was inversely related to education and high-density lipoprotein cholesterol concentration. Path analysis also suggested that the effects of hostility on insulin, triglycerides, and high-density lipoprotein cholesterol were mediated by its effects on body mass index and waist/hip ratio, which, in turn, exerted their effects on lipids and blood pressure through insulin. CONCLUSIONS: The results are consistent with those of prior research and also suggest that, in older men, hostility may be associated with a pattern of obesity, central adiposity, and insulin resistance, which can exert effects on blood pressure and serum lipids. Furthermore, effects of hostility on the metabolic syndrome appear to be mediated by body mass index and waist/hip ratio.