Waterpipe Tobacco Smoking among University Students in Three Eastern Mediterranean Countries: Patterns, Place, and Price.

Background: The objective of this study was to examine waterpipe tobacco smoking patterns, places of smoking, and prices paid among university students in the Eastern Mediterranean Region. Methods: A cross-sectional online survey was administered to a convenience sample of university students in three countries. Participants were young adults (18-29 years) who were ever waterpipe smokers, from Egypt (n = 728), Jordan (n = 790), and Palestine (n = 722). Measures included past-30-day waterpipe smoking, frequency, intensity, place of smoking, and prices paid per waterpipe smoking session and for packaged waterpipe tobacco. Logistic regression models evaluated the factors associated with past-30-day waterpipe smoking. Results: Past-30-day waterpipe smoking (prevalence) was observed among 60.7%, 67.7% and 63.1% of students from Egypt, Jordan, and Palestine, respectively. Among past-30-day smokers, past-5-day waterpipe smoking (frequency) was observed among 28.9%, 51.5%, and 48.6% of participants, respectively. Smoking in a café was highest among participants from Egypt (74.0%), followed by those from Palestine (44.8%), and Jordan (43.0%). Mean price paid per session was USD 0.99 (Egypt), USD 8.07 (Jordan), USD 6.05 (Palestine). The corresponding mean prices per packet were USD 0.86, USD 4.96, and USD 5.55, respectively. Predictors of past-30-day waterpipe smoking included younger age of initiation, male gender, employment, and smoking waterpipe alone. Conclusions: This study contributes to our understanding of waterpipe smoking patterns, places of smoking, and prices paid among young adults in a region with alarmingly high smoking rates. Understanding waterpipe smoking behaviors can inform the design of policy and educational interventions to curb its rising threat.

Tobacco Retail Licensing and Youth Product Use.

BACKGROUND: Restricting youth access to tobacco is a central feature of US tobacco regulatory policy, but impact of local tobacco retail licensing (TRL) regulation on cigarette smoking rates remains uncertain. Effects of TRL on other tobacco product use and use as adolescents reach the age to legally purchase tobacco products has not been investigated. METHODS: Prevalences of ever and past 30-day cigarette, electronic cigarette (e-cigarette), cigar, and hookah use were assessed in a survey of a cohort of 1553 11th- and 12th-grade adolescents (mean age: 17.3 years); rates of initiation were evaluated 1.5 years later. An American Lung Association (2014) youth access grade was assigned to each of 14 political jurisdictions in which participants lived on the basis of the strength of the local TRL ordinance. RESULTS: At baseline, participants living in 4 jurisdictions with "A" grades (ie, with most restrictive ordinances) had lower odds of ever cigarette use (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.41-0.90) and of past 30-day use (OR 0.51; 95% CI 0.29-0.89) than participants in 10 D- to F-grade jurisdictions. At follow-up at legal age of purchase, lower odds of cigarette use initiation (OR 0.67; 95% CI 0.45-0.99) occurred in jurisdictions with stronger TRL policy. Lower odds of e-cigarette initiation at follow-up (OR 0.74; 95% CI 0.55-0.99) and of initiation with past 30-day use (OR 0.45; 95% CI 0.23-0.90) were also associated with better regulation. CONCLUSIONS: Strong local TRL ordinance may lower rates of cigarette and e-cigarette use among youth and young adults.

Tobacco Marketing and Subsequent Use of Cigarettes, E-Cigarettes, and Hookah in Adolescents.

INTRODUCTION: Tobacco marketing has expanded from cigarettes to other tobacco products through many promotional channels. Marketing exposure is associated with use of that tobacco product. However, it is unclear if marketing for one product leads to subsequent use of other tobacco products. METHODS: This prospective cohort study assessed self-reported marketing exposure for six tobacco products across five marketing channels in 11th and 12th grade students in 2014. Approximately 16 months later, a follow-up survey was conducted online (N = 1553) to assess initiation of cigarettes, electronic cigarettes (e-cigarettes), and hookah. RESULTS: Adolescent never-smokers with frequent exposure to cigarette marketing on the Internet and in stores are more than two times as likely to begin smoking as young adults (Internet OR = 2.98 [95% CI = 1.56 to 5.66]; stores OR = 2.83 [95% CI = 1.23 to 6.50]). Never users of e-cigarettes were significantly more likely to initiate use, if exposed to Internet, store, and outdoor e-cigarette marketing. Never users of hookah were more likely to use hookah after seeing it marketed in stores. Youth exposed to marketing of e-cigarettes, hookah, cigars, smokeless tobacco, and pipe tobacco in stores were two to three times more likely to begin smoking cigarettes even though the marketed products were not cigarettes. CONCLUSIONS: Adolescent exposure to marketing of tobacco products is associated with initiation of those products as young adults. Exposure to marketing for non-cigarette tobacco products is associated with subsequent cigarette smoking, even when the promoted products are not cigarettes. Future research and interventions should consider the influence of marketing from multiple tobacco products on adolescent tobacco use. IMPLICATIONS: Adolescents grow up in a rich media environment with exposure to tobacco marketing in both their homes (eg, through the Internet and television) and their communities (eg, stores and billboards). This prospective study provides evidence that adolescents exposed to tobacco marketing for multiple tobacco products are more likely to subsequently begin using those products and to begin smoking cigarettes even when the marketing they recall is for different tobacco products. Adolescent exposure to tobacco marketing can increase likelihood of cigarette smoking, e-cigarette, and hookah use with potential lifelong health effects.