Water-Pipe Smoking Among North American Youths

Transcription

1 Wter-Pipe Smoking Among North Americn Youths WHAT S KNOWN ON THIS SUBJECT: Wter-pipe smoking hs incresed recently in North Americ nd Europe. Becuse of its potentil impct on life-thretening conditions nd nicotine dependence nd becuse of the lck of knowledge bout its helth effects, wter-pipe smoking my represent public helth thret. WHAT THIS STUDY ADDS: This study describes the sociodemogrphic chrcteristics of wter-pipe users nd compres the use of other psychoctive substnces between users nd nonusers. Evidence-bsed public helth policies my be required to equip the public to mke informed decisions bout wter-pipe use. bstrct OBJECTIVES: The objectives of this nlysis were to identify the sociodemogrphic chrcteristics of wter-pipe users in North Americn context nd to describe concurrent psychoctive substnce use. METHODS: Dt on sociodemogrphic chrcteristics, wter-pipe smoking, nd use of other psychoctive substnces were collected in 2007 through miled self-report questionnires completed by 871 young dults, 18 to 24 yers of ge, who were prticipting in the Nicotine Dependence in Teens Study, longitudinl investigtion of the nturl history of nicotine dependence mong dolescents in Montrel, Cnd. Independent sociodemogrphic correltes of wter-pipe use were identified in multivrite logistic regression nlyses. RESULTS: Previous-yer wter-pipe use ws reported by 23% of prticipnts. Younger ge, mle gender, speking English, not living with prents, nd higher household income independently incresed the odds of wter-pipe use. Wter-pipe use ws mrkedly higher mong prticipnts who hd smoked cigrettes, hd used other tobcco products, hd drunk lcohol, hd engged in binge drinking, hd smoked mrijun, or hd used other illicit drugs in the previous yer. CONCLUSIONS: Wter-pipe users my represent n dvntged group of young people with the leisure time, resources, nd opportunity to use wter-pipes. Evidence-bsed public helth nd policy interventions re required to equip the public to mke informed decisions bout wter-pipe use. Peditrics 2010;125: AUTHORS: Erik Dugs, MSc, Michèle Trembly, MD, b Nncy C. P. Low, MD, MSc, c Dniel Cournoyer, MSc, nd Jennifer O Loughlin, PhD,b,d University of Montrel Hospitl Reserch Center, Montrel, Quebec, Cnd; b Ntionl Institute of Public Helth of Quebec, Montrel, Quebec, Cnd; c Deprtment of Psychitry, Fculty of Medicine, McGill University, Montrel, Quebec, Cnd; nd d Deprtment of Socil nd Preventive Medicine, Fculty of Medicine, University of Montrel, Montrel, Quebec, Cnd KEY WORDS wter-pipe, tobcco, smoking, youth, correltes, substnce use ABBREVIATION NDIT Nicotine Dependence in Teens doi: /peds Accepted for publiction Feb 5, 2010 Address correspondence to Jennifer O Loughlin, PhD, University of Montrel, Deprtment of Socil nd Preventive Medicine, 3875 St Urbin, Montrel, Quebec H2W 1V1, Cnd. E-mil: jennifer.oloughlin@umontrel.c PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2010 by the Americn Acdemy of Peditrics FINANCIAL DISCLOSURE: The uthors hve indicted they hve no finncil reltionships relevnt to this rticle to disclose DUGAS et l

2 ARTICLES As the prevlence of cigrette smoking decreses in North Americ, wterpipe smoking is becoming incresingly populr, especilly mong youths. 1 5 Also known s hookh, shish, goz, nrghile, nd hubble bubble, 6 wterpipe smoking is centuries-old trdition in Arbic societies 6,7 tht involves smoking tobcco by using n upright device with smll pltform where tobcco is burned, metl body, bse hlf-filled with wter, nd hose with mouthpiece for inhling. 3,6,8 The content nd pckging of wter-pipe tobcco sold on the mrket re not currently regulted by the Cndin Food Inspection Agency or the US Food nd Drug Administrtion Little is known bout the ddictive nture or helth risks of wter-pipe smoking, but it my be t lest s hrmful s cigrette smoking. Similr to cigrette smoke, wter-pipe smoke contins hrmful constituents, including nicotine, 11 crbon monoxide, 12,13 nd crcinogens. 14 In fct, wter-pipe smoke my contin greter mounts of tr nd hevy metls, including coblt, chromium, nd led, thn cigrette smoke. 15 Wter-pipe use hs been linked to lung cncer, hert disese, infectious diseses, nd pregnncy-relted complictions, 6,8 lthough the helth risks re likely influenced by the quntity nd type of tobcco used, the durtion nd frequency of wter-pipe use by the smoker, the volume of smoke inhled, nd the burn temperture. 16 Estimtes of the equivlence between cigrette nd wter-pipe smoking re highly vrible nd depend on how equivlence is mesured. Neergrd et l 17 reported tht single wter-pipe session might be equivlent to smoking 2 cigrettes for nondily wter-pipe user or 10 cigrettes for dily wterpipe user. A World Helth Orgniztion report suggested tht wter-pipe use is equivlent to smoking 100 cigrettes in 200-puff session. 18 There re few studies on the frequency nd determinnts of wter-pipe use outside the Middle Est. 1 In the United Sttes, previous-month use proportions rnged between 9% nd 20% mong college students. 2,3,19 In the 2006 Cndin Youth Smoking Survey, 20 7% of dolescents in grdes 7 to 12 reported ever use nd 3% reported use in the previous 30 dys. In the 2006 Cndin Tobcco Use Monitoring Survey, 21 5% of mle prticipnts nd 2% of femle prticipnts 15 yers of ge, nd 8% of prticipnts 15 to 24 yers of ge hd ever used wterpipe. Severl US studies report tht rtes of concurrent psychoctive substnce use re high mong wter-pipe users. 1,22 The ims of the current nlysis were to identify the sociodemogrphic chrcteristics of wter-pipe users in North Americn context nd to describe concurrent psychoctive substnce use. METHODS Dt Source Dt were drwn from the Nicotine Dependence in Teens (NDIT) Study, prospective cohort investigtion of 1293 students recruited in from ll grde 7 clsses in convenience smple of 10 secondry schools in Montrel, Cnd. 23 The present nlysis uses dt collected through miled, self-report questionnires in , when prticipnts were 18 to 24 yers of ge. Prticipnts provided written informed consent in this most recent follow-up evlution. The study ws pproved by the reserch ethics committee of the University of Montrel Hospitl Reserch Center (CRCHUM). Study Vribles Sociodemogrphic dt included dt on ge, gender, lnguge spoken t home (French, English, or other), currently in school, living with prents, nnul household income (below $30 000, $ , $ or bove, or missing dt), white rce, nd currently employed. Frequency of previous-yer wter-pipe use ws mesured with the following question: In the pst 12 months, how often did you use wter-pipe (hubble bubble, nrgilé, or shish)? Response choices included never, less thn once per month, 1 to 3 times per month, 1 to 6 times per week, nd every dy. For multivrite nlyses, prticipnts were grouped ccording to whether or not they hd used wter-pipe in the previous yer. Previous-yer cigrette smoking ws mesured s follows: Check the one box tht describes you best... I hve smoked cigrettes but not t ll in the pst 12 months; I smoked cigrettes once or couple of times in the pst 12 months; I smoke cigrettes once or couple of times ech month; I smoke cigrettes once or couple of times ech week; or I smoke cigrettes every dy. 24 Use of other psychoctive substnces ws mesured with the following question: In the pst 12 months, how often did you... (1) smoke cigrs, (2) smoke pipe, (3) use bidis ( tobcco product from Indi), (4) use chewing tobcco, (5) use snuff, (6) drink lcoholic beverges (beer, wine, or liquor), (7) drink 5 or more lcoholic beverges on one occsion (ie, binge drinking), (8) use mrijun, cnnbis, or hshish, (9) use cocine, (10) use speed (mphetmines), (11) use ecstsy (3,4- methylenedioxymethmphetmine) or other similr drugs, (12) use hllucinogens (phencyclidine, lysergic cid diethylmide [cid], or mushrooms), (13) use inhlnts (glue or gsoline), (14) use heroin (smck or junk), nd (15) use nother illicit drug (use of illicit drugs)? Response choices in- PEDIATRICS Volume 125, Number 6, June

3 cluded never, less thn once per month, 1 to 3 times per month, 1 to 6 times per week, nd every dy. Becuse of low frequency, we grouped cigrs, pipe, bidis, chewing tobcco, nd snuff into single vrible termed other tobcco products. Prticipnts were ctegorized s nswering either yes (ie, used 1 of these tobcco products in the previous yer) or no (ie, did not use ny of these tobcco products in the previous yer). Similrly, cocine, speed, ecstsy, hllucinogens, inhlnts, heroin, nd other illicit drugs were grouped into single vrible termed other illicit drugs. We creted the indictor of number of other substnces s the rithmetic sum of positive responses for previous-yer use of cigrettes, other tobcco products, mrijun, other illicit drugs, nd binge drinking. Use of lcohol ws excluded becuse of its high prevlence nd overlp with binge drinking. Vlues for the number of other substnces rnged between 0 nd 5 (men SD: ; medin: 2.0). Dt Anlysis Descriptive sttistics were computed to describe wter-pipe use ccording to sociodemogrphic chrcteristics nd concurrent psychoctive substnce use. Adjusted odds rtios nd 95% confidence intervls for potentil sociodemogrphic correltes of wter-pipe use were obtined in multivrite logistic regression nlyses. All nlyses were conducted by using SAS/STAT 9.1 (SAS Institute, Cry, NC). TABLE 1 Previous-Yer Wter-pipe Use According to Selected Sociodemogrphic Chrcteristics RESULTS Eighty-five of the originl 1293 NDIT Study prticipnts were either lost to follow-up monitoring or refused to prticipte fter secondry school. Among 1208 prticipnts vilble for follow-up evlution, 878 (73%) completed questionnires. Dt on wterpipe use were missing for 7 prticipnts; therefore, the nlytic smple included 871 prticipnts. Prticipnts were 18 to 24 yers of ge (men SD: 20 1 yers), nd 46% were mle. A totl of 204 prticipnts (23%) reported previous-yer wter-pipe use. Among wter-pipe users, 78% smoked wter-pipes less thn once per month, 19% smoked 1 to 3 times per month, 3% smoked 1 to 6 times per week, nd 0% smoked every dy. Younger ge, mle gender, speking English, not living with prents, nd higher household income ech independently incresed the odds of wter-pipe use (Tble 1). Use of other psychoctive substnces investigted were reltively high in this smple (Tble 2). The men SD number of other substnces used in the previous yer ws mong n Previous-Yer Wter-pipe Use, % Adjusted Odds Rtio (95% Confidence Intervl) b 0.8 ( ) c Age y y y Gender Femle Reference Mle ( ) Lnguge French Reference English ( ) Other ( ) Lives with prents Yes Reference No ( ) White No Reference Yes ( ) Annul household income, CAN$ Reference ( ) ( ) Missing dt ( ) Currently in school No Reference Yes ( ) Employed No Reference Yes ( ) Totls differ becuse of missing dt. b Odds rtios were djusted for ll other vribles in the tble. c Age ws used s continuous vrible in the multivrite regression nlysis. wter-pipe users, compred with mong nonusers. Compred with nonusers, mrkedly higher proportions of wter-pipe users reported using ech of the psychoctive substnces investigted (Tble 2). Virtully ll wter-pipe users drnk lcohol nd 92% reported binge drinking. The lrgest difference between groups ws in mrijun use; 74% of wterpipe users reported mrijun use, compred with 35% of nonusers. Tble 3 shows tht prticipnts who hd used other psychoctive substnces in the previous yer were mrkedly more likely to report previous-yer wterpipe use. DISCUSSION In this study, 23% of young dults hd used wter-pipe in the previous yer, prevlence estimte lmost 3 times 1186 DUGAS et l

4 ARTICLES TABLE 2 Use of Other Psychoctive Substnces in Previous Yer According to Previous-Yer Wter-pipe Use Previous-Yer Wter-pipe Use n Use of Other Psychoctive Substnces in Previous Yer, % Cigrettes Other Tobcco Alcohol Binge Drinking Mrijun, Cnnbis, Products or Hshish Other Illicit Drugs b Totl No Yes P for difference c Includes cigrs, pipe, bidis, chewing tobcco, nd snuff. b Includes cocine, speed, ecstsy, hllucinogens, inhlnts, heroin, nd other. c P vlues were obtined from Person 2 tests. TABLE 3 Previous-Yer Wter-pipe Use According to Use of Other Psychoctive Substnces in Previous Yer Use of Other Psychoctive Substnces in Previous Yer n Previous-Yer Wter-pipe Use, % P for Difference b Cigrettes Yes No Other tobcco products c Yes No Alcohol Yes No Binge drinking Yes No Mrijun, cnnbis, or hshish Yes No Other illicit drugs d Yes No Totls differ becuse of missing dt. b P vlues were obtined from Person 2 tests. c Includes cigrs, pipe, bidis, chewing tobcco, nd snuff. d Includes cocine, speed, ecstsy, hllucinogens, inhlnts, heroin, nd other. higher thn the 8% reported in the 2006 Cndin Tobcco Use Monitoring Survey for similr ge group. 21 Numerous fctors my underlie the growing populrity of wter-pipes including low cost, 8,25 esy ccess, 8 ppel of the socil interction tht ccompnies use, 9,17,26,27 commerciliztion by the medi, 16,18 vilbility of sweetened, flvored, nd romtic tobcco or mssel, which cn msk the tste of tobcco, 1,22,28 perceptions of low risk to helth, 1,2,22,26 linked to the belief tht the wter filters the toxins from the smoke, 1,18 the lck of public helth wrnings bout the dngers of wter-pipe use, 10,26 nd the perception tht wter-pipe smoking is less ddictive thn cigrette smoking. 2,3,22 In fct, Knishkowy nd Amiti 8 described 4 myths bout wter-pipe use tht seem common cross cultures, s follows. (1) Wter-pipes re sfer thn cigrettes becuse of lower nicotine content. In relity, different wter-pipe products nd smoking ptterns could result in higher nicotine intke. (2) Becuse the texture of wter-pipe smoke is smoother, it is less toxic. In fct, the lck of irrittion hs been ssocited with the moisture in the pipe, which mkes its use more pltble but not less toxic. (3) Toxins re filtered through wter before the smoke is inhled. Although it is plusible tht some wter-soluble toxins my be bsorbed in the filtrtion process, the concentrtions of toxic substnces re not reduced sufficiently to reduce negtive helth effects. 10 (4) Fruits dded to flvored tobcco mkes wter-pipe tobcco smoking helthy choice. In fct, fruit flvors msk the tobcco tste nd cnnot be viewed s helthy food intke/choice. Our results on the sociodemogrphic correltes of wter-pipe use mirror findings in other Western countries 5,21,29 indicting tht wter-pipes re used primrily by younger persons nd by mle individuls. Wter-pipe users in the NDIT Study were more likely to be mle nd, even with the restricted ge rnge in the NDIT Study, younger prticipnts were more likely to use wter-pipes. This my reflect the experimenttion with new substnces tht typiclly occurs during lter dolescence, 30,31 lthough preferences for specific substnces often do not solidify until the erly 20s. 32 Incresed exposure to psychoctive substnces my coincide with the end of secondry schooling nd shift to either working or further schooling in less-structured settings chrcterized by decresed prentl control nd incresed sociliztion with new friends. Consistent with previous reports, 29 wter-pipe use ws not restricted to ny single rcil, ethnic, or culturl group, which supports the ide tht wter-pipe smoking hs spred to mny groups within Western cultures. Finlly, not living with prents nd PEDIATRICS Volume 125, Number 6, June

5 higher nnul household income were ssocited with wter-pipe use. This supports the previous finding tht higher weekly disposble income ws ssocited with wter-pipe use. 5 Wter-pipe users my represent more-privileged group of young people with the leisure time, resources, nd opportunities to use wter-pipes. Although findings were similr to prevlences reported mong young dults in Cnd, 33 Europe, 30 Austrli, 34 nd the United Sttes, there ws high level of psychoctive substnce use mong NDIT Study prticipnts irrespective of wter-pipe use. Reltively more users thn nonusers of other psychoctive substnces reported wter-pipe use. Individuls who use multiple substnces concurrently re potentilly exposed to higher doses of noxious substnces nd elevted risks of dependence nd disese, 3 nd wter-pipe users my be mong those t highest risk. Use of multiple substnces concurrently in this young ge group is lso ssocited with incresed likelihood of mentl helth problems, greter helth REFERENCES service utiliztion ttributble to lcohol nd illicit substnce use problems, 41 nd decresed work productivity. 42 Interestingly, one-third of wterpipe users did not smoke cigrettes. Although cigrette smokers my switch intermittently to wter-pipes to reduce their cigrette-relted risk, individuls who do not smoke cigrettes my try smoking tobcco with wterpipe becuse of the perception tht wter-pipe smoking is less hrmful thn cigrette smoking. 43 Limittions of this nlysis include the fct tht self-report dt my be subject to recll bis. Use of convenience smple my limit generlizbility of the findings. The NDIT Study smple hd low power to study wter-pipe use in ethnic groups other thn the white group. Finlly, use of cross-sectionl dt limits the cusl inferences bout the determinnts of wter-pipe use tht cn be mde. 1. Wrd KD, Eissenberg T, Gry JN, Srinivs V, Wilson N, Mzik W. Chrcteristics of US wterpipe users: preliminry report. Nicotine Tob Res. 2007;9(12): Eissenberg T, Wrd KD, Smith-Simone S, Mzik W. Wterpipe tobcco smoking on US college cmpus: prevlence nd correltes. J Adolesc Helth. 2008;42(5): Primck BA, Sidni J, Agrwl AA, Shdel WG, Donny EC, Eissenberg TE. Prevlence of nd ssocitions with wterpipe tobcco smoking mong US university students. Ann Behv Med. 2008;36(1): Primck BA, Wlsh M, Bryce C, Eissenberg T. Wter-pipe tobcco smoking mong middle nd high school students in Arizon. Peditrics. 2009;123(2). Avilble t: 2/e Smith-Simone SY, Curbow BA, Stillmn FA. Differing psychosocil risk profiles of college freshmen wterpipe, cigr, nd cigrette smokers. Addict Behv. 2008;33(12): Mzik W, Wrd KD, Afifi Soweid RA, Eissenberg T. Tobcco smoking using wterpipe: re-emerging strin in globl epidemic. Tob Control. 2004;13(4): Primck BA, Aronson JD, Agrwl AA. An old custom, new thret to tobcco control. Am J Public Helth. 2006;96(8): Knishkowy B, Amiti Y. Wter-pipe (nrghile) smoking: n emerging helth risk behvior. Peditrics. 2005;116(1). Avilble t: full/116/1/e Gtrd R, Gtrd A, Sheikh A. Hookh smoking. BMJ. 2007;335(7609): World Helth Orgniztion. Tobcco: Dedly in Any Form or Disguise: World No Tobcco Dy Genev, Switzerlnd: World Helth Orgniztion; Shihdeh A. Investigtion of the minstrem smoke erosol of the rgileh wter CONCLUSIONS Although the public helth burden of wter-pipe smoking is not known, more in-depth surveillnce of pprently incresing use is required. Reserch is needed to increse understnding of the helth effects, nturl history, nd determinnts of wterpipe smoking, s well s the resons for the high levels of concurrent psychoctive substnce use. The constituents of wter-pipe smoke should be better delineted nd, if wter-pipe use is ssocited with impirment or incresed helth service utiliztion, then reserch on tretment for misuse my be justified. Evidence-bsed public helth interventions my be required to fcilitte the public mking informed decisions bout wter-pipe use. ACKNOWLEDGMENTS This work ws supported by the Cndin Cncer Society (grnts nd ). Dr O Loughlin holds Cnd Reserch Chir in the Erly Determinnts of Adult Chronic Disese. Dr Low holds Clinicl Reserch Scholr Creer Awrd from the Helth Reserch Foundtion of Quebec. We thnk the NDIT Study prticipnts nd their prents. pipe. Food Chem Toxicol. 2003;41(1): El-Nchef WN, Hmmond SK. Exhled crbon monoxide with wterpipe use in US students. JAMA. 2008;299(1): Fromme H, Dietrich S, Heitmnn D, et l. Indoor ir contmintion during wterpipe (nrghile) smoking session. Food Chem Toxicol. 2009;47(7): Shihdeh A, Sleh R. Polycyclic romtic hydrocrbons, crbon monoxide, tr, nd nicotine in the minstrem smoke erosol of the nrghile wter pipe. Food Chem Toxicol. 2005;43(5): Mzik W, Wrd KD, Eissenberg T. Interventions for wterpipe smoking cesstion. Cochrne Dtbse Syst Rev. 2007;(4): CD Mzik W. The wterpipe: time for ction. Addiction. 2008;103(11): Neergrd J, Singh P, Job J, Montgomery S. Wterpipe smoking nd nicotine exposure: 1188 DUGAS et l

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