Waterpipe and Cigarette Tobacco Smoking: Effects on Pulmonary and Cardiovascular Functions and Acceptability of Shocking Pictorial Warnings in Lebanon

Background. This dissertation focuses on two major epidemics, Waterpipe (WP) and Cigarette tobacco smoking, as two considerable global public health issues. It consists of three papers that were published in international peer review journals. We aimed at evaluating the acute and chronic effects of WP and cigarette smoking on the cardiovascular and respiratory systems, as well as evaluating the patient's acceptability of shocking pictorial versus actual textual warnings on tobacco packages as an effective control intervention towards smoking cessation".Methods. In the first part of the study, patients were recruited from restaurants in Beirut and Mount Lebanon in order to evaluate the acute (after 45 minutes of waterpipe smoking or immediately following one cigarette smoking) and chronic (before the smoking session) effects on the Forced Expiratory Volume at 1 second (FEV1), Forced Expiratory Volume at 6 seconds (FEV6), FEV1/FEV6, Diastolic Blood Pressure (DBP), Systolic Blood Pressure (SBP) and heart rate (HR). The second part of the study recruited patients from 5 outpatient clinics located in 5 hospitals in Lebanon. The purpose was to evaluate the acceptability of shocking pictorial health warnings versus the actual textual warnings on packages as an effective tobacco control intervention by evaluating their impact on smoking behaviors and motivation.Results. Mean values of FEV1, FEV6, FEV1/FEV6, DBP, SBP in the acute effect of smoking WP and cigarette smokers were very close. There was a trend to significant acute variation between the three groups for DBP (p=0.05) and a significant variation for HR (p˂0.001): DBP increased in WP smokers while it decreased in cigarette smokers. However, the HR increased in both WP and cigarette smokers after the smoking session, but much more with WP. The pulmonary functions (FEV1, FEV6 and FEV1/FEV6) and the cardiovascular values (DBP, SBP and HR) were significantly associated with the following factors: duration of smoking, age at first WP and quantity of smoking. Among the 127 WP smokers, a higher effect of the shocking pictorial warnings was observed in the highly motivated group versus the lower motivated group (OR=4.47, p=0.001); indeed, a higher switching in their favorite tobacco brand was observed in the highly motivated group versus the lower group (OR=2.76, p=0.008). In addition, smokers who had chronic cough were highly motivated to quit waterpipe smoking compared to smokers without chronic cough (OR=7.24, p=0.03).Higher motivation to quit cigarette smoking was seen among male smokers versus females (OR=1.8, p=0.02), among smokers who had stopped smoking for at least 1 month during the last year due the textual warning (OR=2.79, P˂0.001), among smokers who considered very important to report health warning on cigarette packs (OR=1.92, p=0.01), among smokers who had chronic expectorations (OR=1.81, P=0.06) and among smokers who would change their favorite cigarette pack if they put shocking images on the pack (OR=1.95, p=0.004).Conclusions. WP smokers seem as affected as cigarette smokers for the pulmonary values and that acute effect of WP immediately measured after the smoking session increases DBP and SBP; however, acute effect of cigarette decreases DBP and SBP, while both cigarette and WP smoking increase HR. The reduction of most Pulmonary Function Test (PFT) values could be due to the long duration of smoking, younger age of smoking the first WP and quantity of smoking. It differs between cigarette and WP, and between chronic and acute effect of smoking. Moreover, pictorial graphic warnings are more influencing on the behavior of waterpipe smokers than textual warning. On the other hand, low dependent and highly motivated to quit cigarette smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit cigarette smoking was affected by sensitivity to warnings, but not to the presence of all chronic respiratory symptoms. Thus, our study provides further reasons to the policymakers in Lebanon to incorporate more tobacco labeling policies in order to help in reducing the widespread of waterpipe and cigarette tobacco smoking and in increasing the awareness concerning the health symptoms effect of smoking.Doctorat en Sciences de la santé Publiqueinfo:eu-repo/semantics/nonPublishe

Factors associated with smoking cessation success in Lebanon

Objective: The objective is to assess factors associated with the success rate of smoking cessation among Lebanese smokers in a smoking cessation center. Methods: A cross-sectional data study, conducted between March 2014 and March 2016 in an outpatient smoking cessation center with 156 enrolled patients. The patient’s nicotine dependence and motivation to quit smoking were evaluated according to the Fagerstrom Test for Nicotine Dependence and Richmond tests respectively. Results: The number of packs smoked per year decreased the odds of smoking cessation success (p=0.004, ORa=0.982, CI 0.97-0.994), while the compliance with the offered treatment increased the odds of success by 7.68 times (p<0.001, ORa=7.68, CI 3.438-17.187). Highly dependent and highly motivated smokers had more success in the quitting process compared to those with a lower dependence and motivation respectively. Conclusion: Our findings showed that many factors can influence smoking cessation, an experience described as difficult, most significantly the number of packs per year and compliance with the smoking cessation treatment. Moreover, although these outcomes are not representative of the entire Lebanese population, we believe that health authorities could utilize these results when implementing upcoming smoking cessations programs. All attempts at cessation should have a goal of reducing the number of packs smoked per year to improve the chances of ceasing into the future

Factors associated with smoking cessation success in Lebanon

Objective: The objective is to assess factors associated with the success rate of smoking cessation among Lebanese smokers in a smoking cessation center. Methods: A cross-sectional data study, conducted between March 2014 and March 2016 in an outpatient smoking cessation center with 156 enrolled patients. The patient’s nicotine dependence and motivation to quit smoking were evaluated according to the Fagerstrom Test for Nicotine Dependence and Richmond tests respectively. Results: The number of packs smoked per year decreased the odds of smoking cessation success (p=0.004, ORa=0.982, CI 0.97-0.994), while the compliance with the offered treatment increased the odds of success by 7.68 times (p<0.001, ORa=7.68, CI 3.438-17.187). Highly dependent and highly motivated smokers had more success in the quitting process compared to those with a lower dependence and motivation respectively. Conclusion: Our findings showed that many factors can influence smoking cessation, an experience described as difficult, most significantly the number of packs per year and compliance with the smoking cessation treatment. Moreover, although these outcomes are not representative of the entire Lebanese population, we believe that health authorities could utilize these results when implementing upcoming smoking cessations programs. All attempts at cessation should have a goal of reducing the number of packs smoked per year to improve the chances of ceasing into the future.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Community pharmacy in Lebanon: A societal perspective

Objective: To assess patients' attitudes towards the community pharmacist's role and determine their negative and positive reactions towards community pharmacists in Lebanon.Methods: A cross-sectional study, conducted between January and April 2016, was designed to assess the general public satisfaction with the services provided by the community pharmacies. It was carried out, using a proportionate random sampling of Lebanese community pharmacies from each district. Two sided statistical tests were used to compare between group percentages, Wilcoxon test for quantitative variables with non-homogeneous variances or non-normal distribution, and Student’s t-test for quantitative variables of normal distribution and homogeneous variances. The ANOVA test was used to compare between three groups or more, and Pearson correlation coefficient were used to correlate between quantitative variables.Results: a total of 565 participants completely answered the survey questions with a response rate of 94%. The bivariate analysis showed that the patient perception index was positively and significantly correlated with the patient level of expectation index, the overall pharmacy experience and the patient’s reason for visiting the pharmacy (p<0.001 for all 3 variables) but was negatively correlated with the barriers for asking questions significantly (p=0.032). On the other hand, this perception index was significantly and positively associated with the number of pharmacy visits, the age categories, the level of education and the family monthly income (p<0.05 for all variables).Conclusion: Public perception and attitude toward community pharmacist in Lebanon is poor despite highly qualified pharmacists. Aspects of pharmacy services most relevant to patients were respect, empathy, a friendly staff, listening carefully, giving quality time, responding quickly to their needs and respecting their privacy. The ministry of Health in Lebanon, along with the Lebanese Order of Pharmacists should educate the pharmacist about working on the different issues patients are complaining about in order to play a more important role in the society and become the number one trusted health care professional

Predictors of Readiness to Quit Stages and Intention to Quit Cigarette Smoking in 2 and 6 Months in Lebanon

Background: We aimed at examining quitting behaviors among Lebanese cigarette smokers in order to clarify characteristics of adults who were more likely to intend to quit smoking. Study design: A cross-sectional study. Methods: This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder. Results: 40.8% of participants reported having higher stages of readiness to quit while 33% and 7.9% of them intended to quit in 2 and 6 months later, respectively. Higher stages of readiness to quit were associated with high motivation to quit smoking (ORa=1.98; P=0.007), chronic wheezing and real quit attempt duration of ≥ 1 month (ORa=2.35, P=0.020 and ORa=2.15, P=0.003, respectively). Highly motivated smokers (ORa=1.83, P=0.040), who would have changed their favorite pack due to the graphical warnings (ORa=2.11, P=0.010) and who had past quit attempt (ORa=4.39, P<0.001) had more intention to quit in 2 months. Having past quit attempts would increase the intention to quit in 6 months by 7.48 times (ORa=7.48, P=0.007). Conclusions: Significantly higher intentions to quit cigarette smoking were associated with a higher motivation and influenced by shocking images and health related warnings on tobacco boxes. We hope our results will initiate public health educational programs and interventions to surge the intention to quit cigarette smoking as the first step of quitting.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Predictors of past quit attempts and duration of abstinence among cigarette smokers

Objective Despite the widespread awareness of the harms of smoking, millions continue to smoke around the world partly due to the difficulty it takes to quit smoking. Identifying the factors associated with making quit attempts is an essential pillar to reach successful quitting. The purpose of this study is to assess the factors associated with the past quit attempts and their past length of abstinence in a Lebanese sample of cigarette smokers. Methods This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder. Results Smokers who have chronic allergies (ORa = 2.45, p = 0.03), those who have ever stopped smoking for at least one month due to the warnings implemented on the packages (ORa = 4.6, p < 0.0001) and smokers with an intention to quit in 2 months (ORa = 2.49, p < 0.0001) had significantly more past quit attempts. Furthermore, longer quit attempts duration (more than 1 month) were significantly associated with low-nicotine dependent smokers (ORa = 0.56, p = 0.02), higher-motivated smokers (ORa = 1.85, p = 0.01), people with chronic allergies (ORa = 2.07, p = 0.02), smokers who have ever stopped smoking for at least one month due to the warnings (ORa = 3.72, p < 0.0001) and those with an intention to quit in 2 months (ORa = 1.98, p = 0.05). Conclusion The promoters of smoking cessation services should consider these factors when designing comprehensive tobacco control initiatives and in service planning.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon

Introduction: Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation. Methods: A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteris­tics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview. Results: Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004). Conclusion: Low-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Waterpipe effects on pulmonary function and cardiovascular indices: a comparison to cigarette smoking in real life situation

<div><p></p><p><i>Introduction</i>: Smoking is known to have physiological effects on biological systems. The purpose of this study is to evaluate acute and chronic effects on pulmonary functions and cardiovascular indices of waterpipe (WP) smoking in real life circumstances.</p><p><i>Methods</i>: Three groups were included in the study: non-smokers (<i>N</i> = 42), WP smokers (<i>N</i> = 42) and cigarette smokers (<i>N</i> = 48). A questionnaire was completed for each participant, in addition to pulmonary function [forced expiratory volume at 1 s (FEV₁), 6 s (FEV₆), percentage of FEV₁/FEV₆], and cardiovascular [diastolic blood pressure (DBP), systolic blood pressure (SBP) and heart rate (HR)] measures, taken before and after smoking.</p><p><i>Results</i>: Mean values of FEV₁, FEV₆, FEV₁/FEV₆, DBP and SBP in WP and cigarette smokers were very close. However, WP smoking significantly increased HR compared to cigarette smokers (<i>p</i> = 0.007); duration of smoking, age at first WP and quantity of smoking affected pulmonary function and cardiovascular values. In the subgroup of WP smokers, DBP was acutely increased by a larger WP size (<i>p</i> = 0.011), while the FEV₆ was acutely increased by a smaller WP size (<i>p</i> = 0.045).</p><p><i>Conclusion</i>: WP smoking affected the cardiovascular system more than cigarette smoking, while it had similar effects on pulmonary function.</p></div

Validation of the mini pediatric asthma quality of life questionnaire and identification of risk factors affecting quality of life among Lebanese children

BACKGROUND: Few studies used various scales to assess the QOL in Lebanon in general but none was specific to asthma. Our objective was to assess the asthma-related quality of life, using the mini Pediatric Asthma Quality of Life Questionnaire (PAQLQ), in Lebanese asthmatic children, check its validity compared to the original version, and identify clinical and sociodemographic risk factors that might affect these children's QOL. METHODS: This retrospective study included 300 children aged between 7-16 years (51.6% boys and 48.4% girls). To confirm the mini-PAQLQ questionnaire construct validity in the Lebanese population, an exploratory factor analysis was launched for the 13 items of the questionnaire, using the principal component analysis technique. Cronbach's alpha was recorded for reliability analysis. A multivariate analysis linear regression was carried out, taking the QOL score as the dependent variable. RESULTS: The correlation coefficients for factors 1 (symptoms and emotions) and 2 (activities) were similar to that of the original scale. High Cronbach's alphas were found for factor 1 (0.914), factor 2 (0.888), and the full scale (0.921). Uncontrolled asthma, the child's respiratory problems before the age of 2 years, and the presence of pets at home significantly decreased the children's asthma-related quality of life (Beta = -1.541; Beta = -6.846, and Beta = -5.364, respectively). CONCLUSION: We were able to validate the mini-PAQLQ among the Lebanese population. The identification of risk factors, some of which are amenable to intervention, especially uncontrolled asthma, could lead to an improvement in the asthmatic children's QOL