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https://docs.google.com/spreadsheets/d/1EhyLTJyZfrINZ2R94HKE92Uq32d6dmC3BokMx1C4KZ4/edit?usp=sharing

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1. Which method helped you most in combating your addiction
a. Motivations to quit
b. How to fight your cravings
c. Foods that help you quit nicotine
d. Understanding withdrawal symptoms

2. Did you actively engage in the whatsapp group, if no, why not?

3. Did our challenge help you understand the social aspects of addiction?

4. Did out page help you understand your nicotine addictions (stages, withdrawal, symptom management) ?

5. Were you able to quit nicotine during the ramadan challenge, if not, why?

6. Did having a smoker communtiy trying to quit motivate you to participate in the challenge and overcome your addiction, if not, why?

6. Are you able to identify social situations that may trigger your cravings?

7. Are you able to manage your symptoms when you get a craving?

8. What was the hardest part about the challenge and the easiest part?

9. After the challenge, were you able to continue with quitting nicotine, if not, why?

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1st: https://docs.google.com/spreadsheets/d/1Ed6GX2Sbf9jU9dAziczsZRJE_U7PZrJnT-ZTUkWMUms/edit?usp=sharing

2nd:
https://docs.google.com/spreadsheets/d/11OuFacSm1L6AMI66vdsNlPQkehZkM1b9iU8yYFbBIwc/edit?usp=sharing

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1. Did your cigarette consumption change since you've started the challenge? [Yes/No]
2. How much did you smoke per day before vs after joining the challenge? [Text Entry]
3. How do you feel now compared to before starting the challenge? (health-wise; mentally/physically) [Text Entry]
4. Do you have any tips or suggestions that you'd like to share with the others participating in this challenge? [Text Entry]
5-7. University, Age, Gender [Text Entry]

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4 respondents: ages 20-23 (1 male, 3 female), all auc students.
Participation: two didn't participate the first day because of stress and not being ready to commit.
The challenges they faced: inability to sleep, mood swings, agitation, being around smokers, stress, and anxiety.
Feedback on the posts/challenge: helpful, informative, elicits reflection on nicotine intake.
Suggestions: bonus challenges, people sharing how they feel

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1. What university are you enrolled in? [Text Entry]
2. Have you been participating from day 1? [Yes/No]
3. Did you skip any days or hours in the past week? [Yes/No]
4. If yes, which days or how many hours did you skip? [Text Entry]
5. And can you elaborate on why? [Text Entry]
6. What are some challenges that you faced? (i.e withdrawal, keeping up with the hours, etc.) [Text Entry]
7. In general, what do you think of our challenge and instagram posts so far? [Text Entry]
8. Do you have any suggestions for the challenge or instagram page? [Text Entry]
9. Age: [Text Entry]
10. Gender: [Text Entry]

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Stop the habit before it's too late. (1)

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Hey guys, things are looking good. Where are you now that Ramadan already started? Your insta only has one post up. How do people join the whatsapp? Will you be posting more social psychology content on insta as the month goes on?

There are several typos in your infographics both the bluish ones and the ones with the darker background. Be sure to proofread everything carefully before you circulate them and make your sources clear and easy to access on Instagram (link in the caption in addition to being in the photo).  You should also make it clear on your page and your infographics/flyers who you are so people know who is running this.

Let me know if you have questions.

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Cigo.Auc

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1. Focus on Health Benefits during ramadan as people begin to feel more healthy by smoking less
2. Use different types of formats to share posts on Instagram (Gif, Meme, Story)

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Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12–16 years from 1999 to 2018: an analysis of repeated cross-sectional surveys

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Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12–16 years from 1999 to 2018: an analysis of repeated cross-sectional surveys

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This article was used for its statistics on second hand smoke death annually world-wide.
Ma, C. et al. (2021) “Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12–16 years from 1999 to 2018: An analysis of repeated cross-sectional surveys,” The Lancet Global Health, 9(12). Available at: https://doi.org/10.1016/s2214-109x(21)00365-x.

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Introduction

Secondhand smoke exposure has been considered a key modifiable risk factor for morbidity and mortality among both children and adults. The adverse effects of secondhand smoke exposure on several preclinical markers of cardiovascular disease have also been shown in young children.

According to reports from WHO, exposure to secondhand smoke causes about 1·2 million deaths every year. Nearly half of all children worldwide are exposed to secondhand smoke and 65 000 children die from illnesses related to secondhand smoke exposure every year, according to WHO. Globally, in 2004, secondhand smoke caused an estimated 165 000 deaths due to lower respiratory infections in children younger than 5 years, and 1150 deaths due to asthma in children younger than 15 years. Additionally, secondhand smoke exposure in childhood substantially increases the risk of respiratory infections, worsens asthma, and slows lung growth in the short term, and is associated with subclinical cardiovascular disease markers in adulthood, including carotid atherosclerotic plaques, increased carotid intima-media thickness, and reduced flow-mediated dilation.

To protect people from secondhand smoke exposure, WHO has recommended that each country should pass legislation that defines and categorises smoke-free environments in public places and all indoor spaces. Unfortunately, despite comprehensive smoke-free laws in many countries, more than 80% of people worldwide remain unprotected from secondhand smoke exposure. Based on data from the 1999-2005 Global Youth Tobacco Survey (GYTS), Warren and colleagues found that 54·2% (95% CI 51·6-56·8) of adolescents aged 13-15 years in 131 countries and territories were exposed to secondhand smoke on at least 1 day during the past 7 days in public places, and 44·1% (41·6-46·6) were exposed to secondhand smoke on at least 1 day during the past 7 days at home. Based on data from the 2006-13 Global School-based Student Health Survey (GSHS), Xi and colleagues found that 55·9% (95% CI 52·7-59·1) of adolescents aged 12-15 years in 68 low-income and middle-income countries were exposed to secondhand smoke on at least 1 day during the past 7 days. More recent data from the GYTS (2010-18) have been made available to calculate the most up-to-date prevalence estimates of secondhand smoke exposure among adolescents and also to examine trends in prevalence. These data can provide greater understanding of the effectiveness of existing smoke-free policies and help policy makers identify whether new strategies are required to reduce secondhand smoke exposure.

We used recent data collected in the GYTS from 2010 to 2018 to assess the prevalence of secondhand smoke exposure in adolescents aged 12-16 years in 142 countries and territories. We also aimed to analyse trends in the prevalence of secondhand smoke exposure among adolescents in 131 countries and territories from 1999 to 2018.

Study design and participants

The GYTS is a nationally representative, self-administered, school-based cross-sectional survey mainly focusing on tobacco use and related factors among adolescents aged 12-16 years worldwide. A two-stage sampling strategy is applied to select a random sample, which is representative of each country. A standardised questionnaire is distributed in each participating country, to enable comparisons between countries. In the first stage, schools are randomly selected with the probability proportion method according to enrolment size. In the second stage, classes within selected schools are randomly chosen. All students within the selected classes are eligible to participate voluntarily in the survey. The standardised questionnaire is translated into the local language by investigators in each country and back-translated to ensure accuracy. The research protocol of GYTS is approved by WHO and the US Centers for Disease Control and Prevention. All GYTS surveys are approved by the ethical boards at the country level. Further details of the GYTS are available online.

The GYTS is an ongoing survey, with data collection repeated every 4 years. We used the most recent data from 142 countries and territories that had done at least one survey between 2010 and 2018 to assess the prevalence of secondhand smoke exposure. We also used data from countries and territories that had done two or more surveys between 1999 and 2018 to assess trends in the prevalence of secondhand smoke exposure over time. The criteria for inclusion and exclusion of participating countries are summarised in appendix 2 (p 1). Participants with complete data on sex, age, and secondhand smoke exposure (at home or in public places) were included. The sample size was based on the feasibility of secondary use of the GYTS data; data on participants from 142 countries (2010-18) were used to assess the recent prevalence of secondhand smoke exposure, and data on participants from 131 countries were used to assess the secular trends from 1999 to 2018.

Definition of secondhand smoke exposure

Exposure to secondhand smoke at home was defined as students who responded "1 or more days" to the question: "During the past 7 days, on how many days have people smoked in your presence, in your home?" Exposure to secondhand smoke in public places was defined as students who responded "1 or more days" to the question: "During the past 7 days, on how many days have people smoked in your presence, in places other than in your home?" Based on the responses to the two questions above, exposure to secondhand smoke in any place was further defined as students who were exposed to secondhand smoke in public places or at home on at least 1 day during the past 7 days. The frequency of secondhand smoke exposure at home, in public places, or in any place was defined as 1 or more days, 3 or more days, 5 or more days, and daily during the past 7 days, based on students' responses. We unified heterogeneous information by combining school property, markets, stores, and transportation vehicles together as one variable (public places).

The year when the WHO Framework Convention on Tobacco Control (FCTC) was ratified by each country was obtained from the UN website.

Each country's income level was obtained from the World Bank classification according to the survey year of the GYTS in our study.

Statistical analysis

Prevalence estimates and 95% CIs of secondhand smoke exposure were calculated by taking into consideration sampling weights, strata, and primary sampling units based on the GYTS with the "Complex Samples" module in SPSS (version 16.0). The weighted prevalence of secondhand smoke exposure at the country level was calculated according to the original sampling weights, and the overall, regional, and other subgroup estimates were calculated by the rescaled weights, taking into consideration the sample size of each country. A detailed description of the sampling weights is given in appendix 2 (p 2). Modified Poisson regression analyses with robust error variance (with the SAS PROC GENMOD procedure), assuming data in each country to be linear, were used to examine trends in the prevalence of secondhand smoke exposure, considering all available surveys in each country over time. Furthermore, trends in prevalence based on non-linear data over time in some countries (ie, in any place for 23 countries, at home for 14 countries, and in public places for 19 countries) were re-assessed by calculating the derivative of the fitting equation during the survey period. Secular trends in the prevalence of secondhand smoke exposure were calculated per 5 calendar years. Two-sided p values less than 0·05 were considered statistically significant. We also used the objective cutoff of a 5% change to indicate no change (<5%), an increase (≥5%) and a decrease (≥5%) over time.

Role of the funding source

The funder of the study had no role in study design, data collection, data analyses, data interpretation, or writing of the report.

Details of the surveys and characteristics of participants in the 142 participating countries from 2010 to 2018 are provided in appendix 2 (pp 3-6). Countries from six WHO regions (22 in the African region, 29 in the region of the Americas, 24 in the Eastern Mediterranean region, 33 in the European region, nine in the Southeast Asia region, and 25 in the Western Pacific region) were included, and data were analysed for 711 366 adolescents (348 404 [51·3%] boys) aged 12-16 years.

Based on the most recent surveys done between Jan 1, 2010, and Dec 31, 2018, in 142 countries, 62·9% (95% CI 61·7-64·1) of adolescents aged 12-16 years were exposed to secondhand smoke (on ≥1 day during the past 7 days) in any place, 33·1% (32·1-34·1) at home, and 57·6% (56·4-58·8) in public places ( table 1). The prevalence of secondhand smoke exposure was high in any place, at home, and in public places in all countries, although it varied substantially across countries; the prevalence of secondhand smoke exposure in public places was much higher than that at home across almost all countries for both boys and girls ( figure 1, appendix 2 pp 7-20). The prevalence of secondhand smoke exposure also varied by frequency and location, such that the prevalence of secondhand smoke exposure for 3 or more days was 51·0% (95% CI 49·8-52·1) in any place, 20·1% (19·3-20·9) at home, and 43·4% (42·2-44·6) in public places; the prevalence of secondhand smoke exposure for 5 or more days was 40·1% (38·9-41·2) in any place, 14·9% (14·2-15·7) at home, and 30·3% (29·2-31·5) in public places; and the prevalence of daily secondhand smoke exposure was 32·5% (31·5-33·6) in any place, 12·3% (11·7-13·0) at home, and 23·5% (22·5-24·5) in public places ( table 1). The prevalence of secondhand smoke exposure based on different frequency categories (ie, ≥1 day, ≥3 days, ≥5 days, or daily during the past 7 days) increased with age regardless of location (ie, both at home and in public places). The prevalence of secondhand smoke exposure was highest in the Western Pacific and European regions and lowest in the African region and the region of the Americas ( table 1; appendix 2 p 21). Prevalence was highest in high-income countries and lowest in upper-middle-income countries. There were no significant differences between sexes. The prevalence of secondhand smoke exposure tended to be higher in countries that had not ratified the FCTC than in those that had ( table 1).

Table 1 Prevalence of secondhand smoke exposure in any place, at home, and in public places among adolescents aged 12-16 years according to sex, exposure frequency, age group, WHO region, World Bank income status, and FCTC ratification status

131 countries and territories had carried out two or more surveys between Jan 1, 1999, and Dec 31, 2018. Data from 1 405 458 adolescents aged 12-16 years were obtained from these countries to assess trends in the prevalence of secondhand smoke exposure in any place, and specifically at home and in public places over time ( appendix 2 pp 22-38). Between 1999 and 2018, 47 countries had done two surveys, 48 had done three surveys, 30 had done four surveys, four had done five surveys, one had done six surveys, and one had done seven surveys. 16 countries had done the surveys at the subnational level (based on data from one or more cities), which were used to estimate the prevalence of secondhand smoke exposure at the national level ( appendix 2 pp 22-38).

Although there were large differences in secular trends in secondhand smoke exposure (≥1 day during the past 7 days) in any place between 1999 and 2018 in each country ( appendix 2 pp 22-27), the prevalence of secondhand smoke exposure in any place generally decreased in most regions, except for the Eastern Mediterranean and African regions ( figure 2). There were also larger decreases in upper-middle-income countries compared with low-income, lower-middle-income, and high-income countries, and in ratified FCTC countries versus non-ratified countries ( table 2). Similar results were found in both sexes ( appendix 2 pp 39-40). Although the decrease in prevalence was mainly observed at home and occurred in 86 (65·6%) of 131 countries, the prevalence of secondhand smoke exposure in public places increased or remained unchanged in countries (65·6% overall; increased prevalence in 40 [30·5%] of 131 countries and no change in 46 [35·1%]) between 1999 and 2018 ( table 2; figure 2; appendix 2 pp 41-42). When using the objective cutoff of a 5% change to indicate unchanged, increased, and decreased prevalence of secondhand smoke exposure, our results showed similar trends as indicated by the p values based on the Poisson regression analysis for trends ( table 2; appendix 2 pp 39-40).

Table 2 Proportion of countries with upward, downward, and unchanged trends in secondhand smoke exposure (on ≥1 day during the past 7 days) among adolescents aged 12-16 years between 1999 and 2018 by WHO region, World Bank income group, and FCTC ratification status

We assumed that the prevalence of exposure to secondhand smoke changed linearly with the survey years in each of the 131 countries. Overall, the global prevalence of secondhand smoke exposure (on ≥1 day during the past 7 days) in any place decreased markedly between 1999 and 2018 (calculated as per 5 calendar-years; table 3). The rate of the decrease tended to be higher in boys than among girls, in adolescents aged 12-14 years than in those aged 15-16 years, in the Americas than in other WHO regions, and in upper-middle-income countries than in low-income, lower-middle-income, and high-income countries (defined as a decrease of more than 2·4% per 5 calendar-years; table 3). Additionally, we found that the prevalence of secondhand smoke exposure at home decreased in nearly each frequency category (ie, ≥1 day, ≥3 days, ≥5 days, or daily during the past 7 days), whereas exposure in public places generally increased in certain frequency categories (≥3 days, ≥5 days, or every day), especially for the Eastern Mediterranean, European, South-East Asia, and Western Pacific regions, for low-income, lower-middle-income, and high-income countries, and for countries that did not ratify the FCTC ( table 3). However, the change in prevalence in some countries (ie, in any place for 23 countries, at home for 14 countries, and in public places for 19 countries) was non-linear with survey years, and the sensitivity analyses for re-testing the trends based on non-linear data in these countries showed similar results to the primary analyses ( appendix 2 pp 22-38).

Table 3 Trends (per 5 calendar-years) in the prevalence of secondhand smoke exposure among adolescents aged 12-16 years between 1999 and 2018 according to location, sex, exposure frequency, age group, WHO region, World Bank income group, and FCTC ratification status

Discussion

Based on GYTS data from 142 countries, 62·9% of adolescents aged 12-16 years were exposed to secondhand smoke since 2010, most of which occurred in public places. Yet, there was substantial variation by country. Differences were also predominantly visible between FCTC-ratified and non-ratified countries. Results from 131 countries examining trends from 1999 to 2018 revealed an overall decrease in secondhand smoke exposure among adolescents, but not in all locations; although there was a decrease in secondhand smoke exposure at home in most countries, there was also an increase or no change in secondhand smoke exposure in public places in most countries. The decreases tended to be more noticeable among younger adolescents and in upper-middle-income countries. Notably, the prevalence of tobacco use among adolescents aged 13-15 years in 143 of these countries was substantial in both boys (11·3% [95% CI 10·3-12·3]) and girls (6·1% [5·6-6·6]), highlighting the double burden of both active smoking and secondhand smoke exposure in adolescents globally.

Compared to our results on the prevalence of secondhand smoke exposure in 142 countries and territories in 2010-18 (33·1% at home and 57·6% in public places), in a previous study by Warren and colleagues, based on data from the GYTS from 1999 to 2005, the prevalence of secondhand smoke exposure in adolescents aged 13-15 years in 131 countries and regions was higher at home (44·1%) but slightly lower in public places (54·2%). Additionally, data from the 2006-13 GSHS in 68 low-income and middle-income countries showed a lower prevalence of secondhand smoke exposure among adolescents aged 12-15 years in any place (55·9%) than the present study (64·0%). Our results show that the prevalence of secondhand smoke exposure (in any place, at home, and in public places) remains high across all WHO regions, particularly in public places. These findings suggest that although considerable tobacco control efforts have been made during the past two decades, secondhand smoke exposure, especially in public places, remains a major public health issue worldwide.

To our knowledge, this is the first study to assess the global prevalence of secondhand smoke exposure with the most recently available data and according to different frequencies (≥1 day, ≥3 days, ≥5 days, or daily during the past 7 days). Notably, daily exposure during the past 7 days was high in all locations (32·5% in any place, 12·3% at home, and 23·5% in public places). Children and adolescents are psychologically and biologically the most vulnerable to secondhand smoke exposure. Thus, bans on tobacco advertising and implementation of smoke-free policies to protect young people should be at the forefront of political agendas in all countries.

Although some progress has been made in several countries since the implementation of these recommendations, extensive work is still required to reduce secondhand smoke exposure among young people. Family-based, school-based, and community-based interventions are needed to create a smoke-free society. Previous studies have shown that school-based interventions (eg, the Tobacco Education Group, Tobacco Awareness Program, Not On Tobacco, and Botvin Training Program) could substantially decrease the prevalence of secondhand smoke exposure.

, , Furthermore, parents should set good examples for their children by not smoking at home or in public places, or by quitting smoking altogether.,

The prevalence of secondhand smoke exposure increases with age, which might be partly explained by the increasing prevalence of tobacco use with age.,

Older adolescents might have a more tolerant attitude towards tobacco use and are, therefore, also more likely to be exposed to secondhand smoke. We also found that the prevalence of secondhand smoke exposure was lowest in the WHO region of the Americas, which might be due to more effective adoption of tobacco control policies among a growing number of countries in this region.

Inadequate technical support and funding to advance smoke-free legislation might be another possible cause of the varied prevalence of secondhand smoke exposure across WHO regions.

Greater efforts are required in the Western Pacific, Eastern Mediterranean, and South-East Asia regions to fully implement the WHO FCTC, including establishing and enforcing the legislations, building greater capacity, and garnering support for tobacco control initiatives from the public.

Indeed, we found that the prevalence of secondhand smoke exposure was lower in countries that had ratified the WHO FCTC than in those that did not. This observation further emphasises the effectiveness of implementing the WHO FCTC, although ratification does not fully reflect the implementation status.

Another important finding of this study is that the prevalence of secondhand smoke exposure in any place decreased in 57 (43·5%) of 131 countries over time. To reduce exposure to secondhand smoke, many countries have established policies and passed legislation to ban smoking in public places (eg, on public transportation, in restaurants, and in hospitals) and hospitality-related workplaces (eg, bars and restaurants).

However, despite the implementation of these smoking bans, the level of compliance varies within countries, particularly in low-income and middle-income countries, as a result of various political or economic factors.

Although the prevalence of secondhand smoke exposure at home decreased between 1999 and 2018 in most countries, it is worrying that during the same period the prevalence of secondhand smoke exposure in public places increased or did not change in most countries. The underlying reasons for the rise in smoking prevalence in public places might include poorly enforced smoking bans in enclosed places, weak implementation of the FCTC, and the continued social tolerance towards tobacco use. Furthermore, the low cost of tobacco products due to low excise tax and easy accessibility to such products increases the probability of tobacco use and thus secondhand smoke exposure. Although the decreasing prevalence of secondhand smoke exposure at home was observed in most countries, the reasons for this trend are unclear and this might be partly explained by improved health education among populations and the establishment of smoke-free laws or policies at home in most countries.

However, as smoking prevalence remains high at home, stricter legislations and educational interventions showing the benefits of comprehensive smoke-free policies are still necessary. Targeted interventions and programmes to reduce secondhand smoke exposure in homes could increase the proportion of smoke-free homes worldwide. Compliance with rules to promote and maintain a smoke-free home environment can substantially reduce secondhand smoke exposure at home. These findings call for stricter laws and policies promoting zero tolerance for secondhand smoke exposure among adolescents.

This study had several strengths. First, the most recent GYTS data (2010-18) of 711 366 participants from 142 countries were used to assess the prevalence of secondhand smoke exposure, and data on 1 405 458 participants from 131 countries were used to assess the secular trends from 1999 to 2018. Second, the same standard questionnaire was used in all countries, thus allowing comparisons across countries. Third, we assessed the frequency of secondhand smoke exposure in 142 countries to observe the density of exposure and to inform policies. However, several limitations of this study should be noted. First, the GYTS is based on self-reported responses, thus responses might have been over-reported or under-reported because of recall bias. However, a good test-retest reliability of the questionnaire has been reported. Additionally, self-reported secondhand smoke exposure among adolescents has been shown to have adequate validity. Second, we only included adolescents aged 12-16 years, thus limiting the generalisability of our findings to adolescents of other ages. Third, 16 (12·2%) of 131 countries only included data from one or more cities; therefore, the results might not be representative of the whole country. Fourth, only 142 countries were included in our study, as no GYTS data were available for many countries. Fifth, only 131 (92·3%) of 142 countries were included in the trend analysis because in 11 countries the survey was only done once between 1999 and 2018. Sixth, our estimates are conservative as the GYTS was a school-based survey, and students out of school might be more likely to engage in risky behaviour than those in school. Seventh, although the FCTC ratification status of countries was considered in our study, smoke-free policies at a national level will be more informative. However, there are no related comparable data that are publicly available to assess smoke-free policies in all countries. This limitation should be addressed in future studies. Eighth, prevalence varied largely across countries, even within the same WHO region. However, we provided pooled estimates according to WHO region to allow comparison of our findings with previous similar studies,, as well as to guide the development of specific strategies and measures at the regional level. Ninth, other information (eg, the number of, and specific information about, selected schools and classes) was unavailable from the GYTS datasets. Thus, we could not estimate intraclass correlation. Additionally, there was heterogeneity between countries, such as differences in population characteristics. These confounding factors might have influenced the availability of information and affected the representativeness of estimates.

In conclusion, secondhand smoke exposure remains a serious public health challenge among adolescents worldwide. Although the prevalence of secondhand smoke exposure at home decreased in most countries, prevalence in public places increased or remained unchanged in most countries during the past two decades. These findings emphasise the need to strengthen smoke-free policies worldwide, especially in public places.

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Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12-16 years from 1999 to 2018: an analysis of repeated cross-sectional surveys

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Secondhand smoke exposure among adolescents remains a serious public health challenge worldwide. Although the prevalence of secondhand smoke exposure at home decreased in most countries, the prevalence in public places increased or remained unchanged in most countries between 1999 and 2018. These findings emphasise the need to strengthen smoke-free policies, especially in public places.

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Moderators of Peer Social influence in adolescent smoking

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Moderators of Peer Social influence in adolescent smoking

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This article tests 6 moderators to adolescent smoking to determine the efficiency in enabling smoking. The moderators were social influence, self-efficacy, self--esteem, latchkey-status (adult supervision), stress, and smoking tendency.

stacy, A.W. et al. (1992) “Moderators of peer social influence in adolescent smoking,” Personality and Social Psychology Bulletin, 18(2), pp. 163–172. Available at: https://doi.org/10.1177/0146167292182007.

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You all have collected some interesting scholarly sources so far, but I think you should work on some more primary research. In reading your empathy investigations I noted two common occurrences. First, the interviews were a bit too structured so there were not enough follow-up questions to get people to elaborate on why they feel the way they do or why they do what they do. Motivation is extremely important in understanding addiction, so this is an area that needs more investigation for you to be able to really empathize with your target group. Second, there were several assumptions baked into the observations and interview interpretations that I didn't really see any evidence to support in the actual interview or observation notes. It might be helpful to take a step back and think about your own perceptions of smokers and why you think they smoke. Are you suffering from confirmation bias in your research process and only paying attention to the information that supports your original opinions?

As for your project, I don't think an instagram awareness campaign will do much to improve the lives of college age smokers since they probably already know a lot of the information you are going to post and they can easily choose to just ignore your posts in their feed if they don't want to think about their addiction. Try to brainstorm a bit more on this to see what other ideas you guys can come up with. Don't limit yourself to the insta campaign idea yet.

Let me know if you need help with anything.

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instagram account
posts:
social aspects of smoking (& avoiding their influence)
quitting tips/dealing with withdrawal
persona - based on people observed/interviewed
challenge to stop smoking (ramadan)
+ posters in smoking areas

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"Smoking cessation for university students. (Raising awareness on social causes that enable addiction and how to avoid them)"

1. What is the problem or concern your target group is facing?
Quitting smoking
2. How can your project improve these people's lives in some way?
By helping and possibly guiding them through their quitting journey. By helping them understand the causes of their addiction and guiding them to quitting.
3. What challenges do you think you will face in creating your project or getting information to the target audience?
Integrating the most useful information; making the target audience actually listen/try quitting (especially if they've already tried before and it didn't work out)
4. What format should your project take to best reach your audience?
Instagram account, since most university students use the app a lot of the time.

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Findings:
Most started smoking from around 14-18 years because of some kind of emotional distress. They have friends/family that are also smokers. Some of them tried to quit but failed. Smoking is a kind of social activity; especially in smoking areas.
Themes:
Adolescent/Social/Emotional smoking

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For my first investigation, I chose to observe two male family members. One of them only consumes one source of nicotine, which is cigarettes, and the other consumes several sources of nicotine, including cigars and cigarettes. I wanted to see whether it makes a difference in their behavior that they're addicted to one or several sources. Through observing them at different family events, I noticed similar behaviors from both individuals. They both have designated times in which they excuse themselves from the gathering to go smoke. Surprisingly, I have seen the individual who smokes only cigarettes excuse himself to smoke more than the individual who consumes multiple sources of nicotine. In addition, even though the family member who only smokes cigarettes tries to keep it from other family members that he does, he would still have to go smoke after every meal, so he tries to do it subtly.

thoughts: I was expecting to find out that the individual who consumes several sources of nicotine is more addicted to them, but from my observation, I saw that the other family member who only smokes cigarettes does so more (at least in family events where I was able to observe them).

For my second investigation, I observed some of the students in the AUC smoking area. I noticed that they would always be sitting or standing together in groups, and they would be mostly smoking cigarettes or vape. In general at uni, I would sometimes see a group of girls smoking together in the bathroom, or people subtly vaping on campus instead of going outside to the smoking area. Some of the people I saw in the smoking area I also see smoking on campus too.

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subject: male 24 years old,
observed his behavior through many social situations . He started smoking since he was 19, smokes a minimum of a pack per day. His behavior towards cigarettes change depending on his surroundings. If there are adults around he walks away to finish his cigarette but if he is with younger people he smokes 2 or 3 cigarettes in a row shamelessly. The subject's sleeping schedule is upside down.  He has anger issues but sometimes is in a good mood and jokes around with people.
Recently his father got paralyzed and started smoking too . This incident did not trigger his addiction but definitely had a negative impact on it.
He once stated that he smokes, since his friends are smoking and his mother thinks badly of him already.

thoughts: cigarettes are not necessarily used because of bad events or peer pressure but maybe simply out of carelessness and normalisations. I also believe his addiction is a source of stress for him

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participant : male 19 years old
He has been smoking for only 2 weeks. He says he has been through a rough life event recently and cigarettes help him relax. He doesn’t feel the need or a craving for them yet.
He has been around his smoker friends for the past few years but was never compelled  to try them till now. He tried shisha and weed once or twice. However he did not develop a physical or psychological dependence for any of them.
Participant said he sometimes suffers from fluctuations in his blood pressure and is highly aware of the risks of smoking.

thoughts : He seems to like exploring different substances but do not get attached to them. However the situation  here is different since he is turning to cigarettes out of sadness and stress and this treats the symptom not the cause.
His interview opened my eye to the fact that cigarettes have a calming effect and are not just for pleasure or out of peer pressure

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The interviewee is a stakeholder (the smoker's mother). She found out about her son's smoking 1 year ago, when she found out she felt shocked, disappointment which then lead to trust issues with her son. She had assumptions about why he started smoking, she believed it was so he can fit in, seem "cool" and due to peer pressure. She says the biggest impact of her son's smoking on her stress due to her constantly being nervous for him.

Thoughts:
This interview shows how other stakeholders can be effected by addiction. It does not only shows differences in the addict's behaviour from another perspective but it also shows how stakeholders like family members can develop issues of their own like stress and trust issues.

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The interviewee is a 19 year old male who started smoking 2 years ago. He says that what had him start smoking was trying from his friends and liking it and liking how it felt to him. In addition he admits that most of his friends are smokers. Despite the aforementioned information, he says that peer pressure was not an influence. This individual tried quitting but failed due to him not being able to feed his impulses which are strongest when he is bored or after he's had a meal. This individual has a negative view on smoking.

Thoughts:
I believe us having the assumption or stereotype about smokers mainly being male in the beginning of this research project is mainly due to the fact that smoking is very normalised within groups of male friends where it shows how social pressure or peer pressure can consciously or unconsciously influence these males to start smoking. This has been showed to be the case with my interviewee where he says that he started due to his friends and due to him trying from them and where he admitted that a lot of his friends are smokers. It is interesting how the interviewee says that he was not influenced by peer pressure as it could be true or it could be that he does not know that he is affected by it. He enjoyed the feeling at first but as he started to get addicted he wanted to quit but quitting was harder that he thought. His main difficulty was dealing with boredom.

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https://docs.google.com/document/d/1peo86bzA7YQT9QuwpEChpf-GSu3dftJJAUxcVuoWClQ/edit?usp=sharing

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Create a new document and edit with others at the same time -- from your computer, phone or tablet. Get stuff done with or without an internet connection. Use Docs to edit Word files. Free from Google.

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Participant #1 (23 y/o female) tried smoking for the first time when she was 14 and started regularly smoking when she was 18, because she was feeling sad. She smokes around 3 cigarettes a day, starting around 3 hours after waking up. Her father used to smoke and quit after 20 years. She usually smokes around other people and finds it difficult if she's in a place where smoking isn't allowed.

Participant #2 (19 y/o male) started smoking when he was 13 and currently smokes around one pack every day starting around 30 minutes after waking up. He tried quitting at some point but only stopped for around two months. Multiple people around him also smoke - some of them due to stress or anxiety. He gets anxious if he isn't able to smoke for a while.

Participant #3 (22 y/o female) started smoking when she was 18 because of university. All of her friends and some family members also smoke. She usually smokes between half and a full pack of cigarettes starting around 20 minutes after waking up. She finds it an inconvenience if she's somewhere where she can't smoke.

All three of them say that smoking was an individual choice, not influenced by friends or family.

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I conducted two observations in the smoking areas at AUC. The first one was in bus gate smoking area at 1:30pm on a thursday. I observed multiple friend groups and a social setting. I'd say most people that were there were there because they were passing around a vape or iqos. People who stood alone smoked iqos or cigarettes but vape was more common between groups. Disposable vapes specifically were the most common. Regardless people still shared all three items between each other. Some people who smokes vapes also smoke cigarettes and would borrow from their friends. There was little seating and if any uncomfortable. The other smoking area I observed was gardens in assembly at a Wednesday. I observed that it was quiet and less people were there. Groups of 2-3 and more individuals. More iqos and cig than vapes and very little vapes even between groups. Charging station, counter, and shade available.

Final Thoughts:
I think the social aspect of smoking is very obvious is bus gate than it is in gardens smoking area. Vapes are passed around a lot easier than iqos and cig. I saw a pattern than vapes appear between groups and almost never appear with individuals standing by themselves.

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Name: Person A
Name: Person A

Age: 20

Date: 23/02/2023

*Disclosure of purpose of interview and research paper, interviewee wanted to keep identity hidden.

In this interview I asked Person A about their smoking journey. They used to smoke vape and now cigarettes and occasionally smokes cannabis. They started smoking vape at 16 and introduced to smoking by friends but never family. They were first a social smoker then it shifted to smoking while alone when things got difficult in their life. They are surrounded by smokers and have a thorough education on the harms and risks of smoking. They have tried to quit but have problems with withdrawal symptoms. They do have close friends that have successfully quit. They only quit vape when it broke and they didn't have access to another one. In their university, there are designated smoking areas that enable the smoking community. Smokers go there to hangout first and smoke second. Their view on smokers is a negative view yet they do not identify with that view, despite acknowledging that they are a smoker/addict.

Final Thoughts:
Person A was not educated about cannabis used but was educated about nicotine addiction. They began smoking socially and addiction creeped up on them. They enjoy the social aspect but aim to quit at some time. They feel that they are surrounded by social smoking that it is difficult to quit.

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program that supports smokers to control their dependance on nicotine

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World Health Organization - Regional Office for the Eastern Mediterranean

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Tobacco control is a major challenge in Egypt, with 24.4% of the adults currently using tobacco products and 50% of Egyptian people exposed to secondhand smoke in their own homes. There are also increasing trends of young female uptake of tobacco, and an overall rise in shisha use. Tobacco is a driv…

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UntitledAdolescent (Mis)Perceptions About Nicotine Addiction: Results From a Mixed-Methods Study Document

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Adolescent perception on nicotine addiction

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Adolescent perception on nicotine addiction

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This paper aims to tackle the problem of adolescents lack of information about nicotine addiction. This allows their use of nicotine frequently over their developing years with the idea that they can quit easily. They examined adolescents’ understanding of the definition and process of nicotine addiction using a mixed-methods approach. They conducted a survey to test the level of understand of teenagers about nicotine addiction. Their results proved that further education about addiction is needed for teenagers as their perceived risk is very low. This article can be used to establish the reason nicotine addiction rates are increased in university students (lack of education or awareness of addiction).

Citation:
Roditis M, Lee J, Halpern-Felsher BL. Adolescent (Mis)Perceptions About Nicotine Addiction: Results From a Mixed-Methods Study. Health Education & Behavior. 2016;43(2):156-164. doi:10.1177/1090198115598985

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Note: Access to electronic resources is limited to current students, faculty and staff due to license restrictions with the vendors. Please visit our Access Online Resources page for more information.

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This study looked at the habits, locations, and costs associated with smoking waterpipe tobacco among college students in the Eastern Mediterranean. Methods: A convenience sample of university students from three nations was subjected to a cross-sectional online survey. Participants were young adults (18–29) from Egypt (n = 728), Jordan (n = 790), and Palestine (n = 722) who had ever smoked a waterpipe. Measurements included the number of waterpipe sessions smoked during the previous 30 days, their frequency and intensity, where they were smoked, and the costs associated with buying packaged waterpipe tobacco. The parameters related to recent 30-day waterpipe use were assessed using logistic regression models. Results: Students from Egypt, Jordan, and Palestine, respectively, made up 60.7%, 67.7%, and 63.1% of those who had smoked a waterpipe within the previous 30 days. Results: Students from Egypt, Jordan, and Palestine, respectively, made up 60.7%, 67.7%, and 63.1% of those who had smoked a waterpipe within the previous 30 days.

Past-5-day waterpipe smoking (frequency) was seen among 28.9%, 51.5%, and 48.6% of persons who had smoked during the previous 30 days. Those from Egypt smoked in cafes the most (74.0%), followed by those from Palestine (44.8%) and Jordan (43.0%). The average amount paid per session was $0.99 in Egypt, $8.07 in Jordan, and $6.05 everywhere (Palestine). The respective mean prices for each packet were $0.86, $4.96, and $5.55. Younger age of initiation, male gender, job, and waterpipe use alone were predictors of prior 30-day waterpipe use. Conclusions: This study advances our knowledge of young adults' waterpipe smoking habits, locations where they smoke, and costs associated with doing so in an area with disturbingly high smoking rates.

Studying waterpipe smoking practices can help in the creation of legislative and educational initiatives to reduce the threat that it poses.

Salloum, R. G., Lee, J., Mostafa, A., Abu-Rmeileh, N. M. E., Hamadeh, R. R., Darawad, M. W., Kheirallah, K. A., Salama, M., Maziak, W., & Nakkash, R. (2019). Waterpipe Tobacco Smoking among University Students in Three Eastern Mediterranean Countries: Patterns, Place, and Price. Substance Use & Misuse, 54(14), 2275–2283. https://doi-org.libproxy.aucegypt.edu/10.1080/10826084.2019.1645177

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Note: Access to electronic resources is limited to current students, faculty and staff due to license restrictions with the vendors. Please visit our Access Online Resources page for more information.

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cannabis use among collage students in Egypt 

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cannabis use among collage students in Egypt 

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The goal of this study is to determine the prevalence of cannabis usage among Egyptian university students and to investigate the risk factors that go along with it. 2380 students participated in a cross-sectional study that lasted three months. A pre-designed, self-administered questionnaire that comprised demographic information, the Addiction Severity Index, and the Depression Anxiety Stress Scale was given to participants. The prevalence of substance abuse was also highly correlated with gender and socioeconomic status; the majority of illegal drug users (93.1%) were men and had poor (41.3%) or moderate (50.8%) socioeconomic status. Positive family conflict history, peer encouragement, male gender, positive child abuse history, being a male, having a stay-at-home mother, residing in an urban region, and positive family history of substance use were the most important risk variables linked to substance use.

The WHO claimed in 2012 that 0.5% of people worldwide abuse opioids, compared to 2.5 to 5% of those who abuse cannabinoids. Cultural norms that view cannabinoids as less dangerous than other narcotics and having less obvious withdrawal symptoms may help to explain this . Yet, there is little scientific support for these cultural presumptions.

According to the research, prolonged lockdowns have a negative impact on substance usage because of the tension and worry they cause. Government initiatives should concentrate on lowering the prevalence of cannabis usage among college students. Programs for student and family therapy should address the problem of substance abuse concurrently. The use of orientation efforts that dispel myths about cannabis and emphasize their harmful effects is necessary to change societal attitudes about illegal drugs.

Naguib, .M., Sherif, H.A., Elbalshy, A.T. et al. Prevalence and associated risk factors of cannabinoid abuse among Egyptian university students: a cross-sectional study. Environ Sci Pollut Res 28, 68706–68716 (2021). https://doi-org.libproxy.aucegypt.edu/10.1007/s11356-021-15412-1

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Introduction

The Cannabis sativa plant is the most commonly abused illicit drug worldwide (Hermanns-Clausen et al. 2013). Cannabis contains over 90 different cannabinoids, with delta9-Tetrahydrocannabinol (THC) being the primary psychoactive ingredient (Bramness et al. 2010). The natural cannabinoids extracted from dried leaves, fruits, and flowers are used to produce hashish and a form of marijuana known as Bhang, both of which can be smoked, inhaled, or ingested with other substances (Sharma et al. 2012). Synthetic cannabinoids (SCs) are artificial, mind-altering chemicals. Although SCs produce similar effects to cannabis, however, their effects are more potent as they acquire higher cannabinoid receptor affinity(Clayton et al. 2017). On the other hand, SCs do not contain cannabidiol or cannabinol (naturally occurring substances in cannabis), which produce different side effects form cannabis (Davidson et al. 2017).

THC produces transient and dose-related psychotic symptoms, as well as memory impairment (D'Souza et al. 2004). Cannabis use has also been reported to cause an increase in susceptibility to schizophrenia, hallucinations, violence, and self-injuring behavior (Davidson et al. 2017). SC users could suffer from serious side effects as SCs could affect many bodily systems including the cardiovascular system. SCs can also affect the respiratory system causing coughing, pneumothorax, and other respiratory diseases. They can also lead to acute tubular necrosis which devastates the renal system. Cannabinoids have also been linked to several cases of death (Davidson et al. 2017). Despite these hazardous side effects, SCs are spreading rapidly in different societies.

Global surveys have documented the increase in the consumption of cannabinoids among different populations in both developed and developing countries. According to a 2015 survey conducted in Western Australia, 12.1% of 472 Western Australians aged between 18 and 35 years reported using cannabinoids (Goggin et al. 2015). A report that gathered data from 130 public and private schools throughout the 48 contiguous states of the United States found that 2.9% of high school seniors reported using SCs (Palamar et al. 2017). Studies carried out in Egypt in 2013 revealed cannabinoids to be the most commonly used illicit drug among Egyptians (Hamdi et al. 2013). It was estimated that 10.4% of the Egyptian population is estimated to abuse drugs, which is nearly double the world average. Unfortunately, an even higher prevalence of drug abuse was reported among high school students and teenagers (Rabie et al. 2020).

A strong association has been established between cannabinoid use and other illicit substance abuse. Alcohol and nicotine are some of the most common substances ingested with cannabis, especially among young adults (Swift et al. 2012). Considering the lack of research in this field and under-reporting of such cases despite high prevalence, especially among young adults, the current study aims to clarify the prevalence of cannabinoid abuse among a sample of Egyptian university students and explore the associated risk factors.

Subjects and methods

Ethical considerations

This study obtained ethical approval from the Institutional Review Board of Menoufia University, Faculty of Medicine (ID: 191219COM). The data were collected in accordance with the "Declaration of Helsinki." Informed consent was obtained from each study participant and each participant was informed about all aspects of the study and granted the right quit the study without any negative repercussions. All responses were kept anonymous to maintain the confidentiality of respondents.

Study design and setting

A cross-sectional study was carried out over 3 months starting from the 1st of July until the 1st of October2020. This study was performed at a randomly chosen Egyptian university, where 4 colleges, and 2 practical and 2 theoretical ones, were chosen randomly.

Sampling and sample size

After calculating the required sample number from each selected college based on the proportionate allocation method, a systematic random sampling technique was adopted for student's selection. All students were informed of their right to refuse to share information or withdraw from the study at any time. Based on previous estimation of the prevalence of cannabinoid use to be 7.4% (Hamdi et al. 2013), the sample size was calculated using the following equation: n = (z ²×p × q)/ D ² at CI 95%,which resulted in a necessary sample size of 2327 participants. If the non-response rate were 15%, 2585 subjects would be recruited. With a response rate of 92.1%, this study collected 2380 complete questionnaires; 205 students either refused to participate or delivered incomplete questionnaires.

Inclusion and exclusion criteria

Egyptian students who were attending on-campus programs at the specified colleges and consented to participate in the study were considered eligible and included in the present study. Non-Egyptian and non-attending students, those who refused or hesitated to participate in the study even after signing a consent form, and those who submitted incomplete questionnaires were excluded.

Data collection tool

Participants were subjected to a pre-designed, self-administered questionnaire composed of three sections. The first section reported demographic data such as age, sex, education level, occupation, socioeconomic status (SES), smoking, and drug abuse. The second section included the Addiction Severity Index (5th Edition) (Mclellan et al. 1998). The last section included the Depression Anxiety Stress Scale (DASS), a quantitative measure of distress along the three axes of depression, anxiety, and stress. It is not a categorical measure that can clinically diagnose patients. DASS scores ranged from normal passing to mild, moderate, severe, and extremely severe. These ranges correspond to the numerical ranges of0-4, 5-6, 7-10, 11-13, and ≥14, respectively, for depression; 0-3, 4-5, 6-7,8-9, and ≥10, respectively, for anxiety; and 0-7,8-9, 10-12, 13-16, ≥17, respectively, for stress (Parkitny and McAuley 2010).

Two weeks before the actual study commenced, the survey was piloted on 80 randomly selected participants of the same population to ascertain if the questions were well defined, easy to understand, and presented in a consistent manner. This pilot survey allowed the researchers to test the comprehensiveness and appropriateness of the questionnaire. The questionnaire was modified according to the pilot study results. To assess the validity of the questionnaire, two independent public health and community medicine specialists reviewed the survey. All participants were interviewed, and the survey was explained for participants thoroughly.

To clarify the risk factors associated with substance use, students who abuse drugs (116 students) were first identified. Subsequently, a random selection of students was chosen from among the non-substance-abusing students to compare with substance-abusing students. The ratio of substance-abusing students to non-substance-abusing students was 1:4, with a total of 116 substance-abusing students and 464 non-substance-abusing students.

Statistical analysis

Analyses were conducted using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were expressed in number (No), percentage (%) mean (x̅), and standard deviation (SD). The significance of associations between the two groups according to qualitative variables was determined using Chi-squared (χ2) test. Fisher's exact test was used when the number of an expected cell was less than 5. An unpaired t-test ( t) was used to compare between two means for normally distributed quantitative variables. Binary logistic regression was carried out to ascertain the predictors of substance abuse among participants. Z test was used to compare between proportions. A p value of <0.05 and a 95% confidence interval were considered significant.

Results

The mean age of the studied students was 20.5±1.35 (range: 18-24 years old). 66.1% of the participants were males and 33.9% were females. Practical college students represented 65.6% of all respondents; 26.7% of whom were sophomores and 35.5% of whom were juniors. Of the participating students 46.8% had a moderate SES. Among the participants, 39.3% reported studying for more than 15 h per week. Working students constituted 38.3% of all the participants; 11% of them were working on full-time basis, while 73.2% were working only during vacations. 59.3% of the study participants reported good academic performance. The need for private courses was reported by 34.3% of students (Table 1).

Concerning substance use, 41% of students reported smoking cigarettes and4.9% reported abusing illicit substances. Among substance-abusing students, 51.7% reported using illicit substances regularly, 41.3% of whom reported the abuse of more than one substance. The most used substances were Hashish (96.5%), Strox (41.3%), Bhang (34.4%), Voodoo (34.4%), and Tramadol (31.1%). Regarding the illicit drugs which students reported abusing regularly, the most common were hashish (25%), Bhang (30%), voodoo (30%), Strox (33.3%), Heroin (28.6%), and Tramadol (22.2%). Among illicit substance abusers, 50% reported drinking alcohol. During the COVID-19 quarantine, substance abuse increased by 79.3% among illicit substance users. Health problems were reported among 17.2% of drug users, while only 20.7 % received addiction therapy (Table 2).

History of child abuse and family conflict were reported by 47.9% and 28.4% of students, respectively. A family history of substance abuse was reported by 2.5% of students. 18.2% of illicit substance abusers reported being encouraged by peers. Regarding mental health among those who reported substance abuse, 33.1% suffered from depression, while 25% suffered from anxiety, and 14.8 % suffered from stress (Table 3).

There was no significant difference regarding age, type of college, the education level of one's father or mother, or family income between substance users and non-users. However, there were significant differences regarding gender (93.1% of substance users were males), residency (51.7% of substance users lived in rural areas), occupation of a respondent's mother (65.5% of substance users had stay-at-home mothers), and SES (41.3% of substance users were of low SES and 50.8% were of moderate SES (Table 4).

Poor academic performance may be considered either a cause or a result of substance use (OR=2.40; CI95%: 1.34-4.33). Substance use was significantly associated with a tendency to study more than 10 h per day (OR= 2.40; CI95%: 1.34-4.33), having more than 10 h per day of spare time (OR=1.61; CI95%: 1.01-2.56), being a self-funded student (OR = 2.92; CI95%: 1.67-5.11), history of child abuse (OR=1.60; CI95%: 1.06-2.40), family history of conflicts whether financial or legal (OR=2.02; CI95%: 1.29-3.14), family history of substance use (OR=5.83; CI95%: 2.40-14.21), and encouragement by peers (OR=4.41; CI95%: 2.85-6.82) (Table 5).

Binary logistic regression revealed that the most significant risk factors associated with substance use were positive history of family conflict (OR=6.48; CI95%: 5.08-8.64, p<0.001), encouragement by peers (OR=2.95; CI95%: 1.73-5.05, p<0.001), male gender (OR=5.46; CI95%: 2.40-12.44, p=0.001), positive history of child abuse (OR=2.85; CI95%: 1.96-3.04, p=0.001), having a stay-at-home mother (OR= 1.56, CI95%: 1.19-2.04, p=0.001), living in an urban area (OR=2.22; CI95%: 1.53-5.0, p=0.002), and positive family history of substance use (OR=1.98; CI95%: 1.48-2.08, p=0.045) (Table 6).

Discussion

The current study revealed that 4.9% of interviewed university students between 18 and 24 years old are illicit substance users, and 41% are current cigarette smokers. Hashish was the most used substance, followed by marijuana (commonly referred to as Bhang), and SCs, such as Strox and Voodoo. Hashish is made by drying the resin secreted from the flowing buds of the cannabis sativa plant(Sharma et al. 2012). The popularity of hashish reported in the current study agrees with previous studies conducted in Egypt and elsewhere (in the US, Khiabani et al. 2006 and Palamar et al. 2017; In Egypt, Hamdi et al. 2016). Smokable marijuana is usually obtained from the stems, leaves, and dried flowers of the plant and constitutes one of the most commonly smoked forms of cannabinoids, especially among young adults (Sharma et al. 2012). Since Hashish is an extracted resin, it is more potent and hence more frequently used compared to marijuana and other cannabinoids.

Strox is a novel SCs that is synthesized from other ingredients, including the Atropa belladonna plant. Existing studies show that in the last decade, the use of Strox has increased among Egyptian populations. Similarly, voodoo abuse has also increased rapidly in Egypt, and the drug is currently listed as prohibited substance by the Egyptian government (Sobh and Sobh 2020).

The high prevalence of cannabinoids abuse resembles the estimated rates of abuse of opioids such as Tramadol, alcohol, and other substances that have been reported by the World Health Organization (WHO). In 2012, The WHO has reported that 2.5 to 5% of the global population abuses cannabinoids, compared to 0.5% for opioid abuse This might be explained by cultural norms that consider cannabinoids to be less harmful than other substances and to have less apparent withdrawal symptoms (Kleczkowska et al. 2016). However, these cultural assumptions lack scientific evidence. Craving and abstinence-associated symptoms of different severities related to cannabinoid abuse have been reported in the literature(Coffey et al. 2002).

The current study revealed that students consumed alcohol and opioids (Tramadol and heroin) less frequently than cannabinoids. Approximately 34.40% of substance abusers were dependent on alcohol, and 31.1% were also Tramadol abusers. In contrast with other substances, alcohol was the only substance that was more likely to be regularly abused (50%) than used just once or more than once. Our findings agreed with (Coffey et al. 2002), and it could be explained by the physical and psychological tolerance of alcohol abuse.

In contrast to our study, a systematic review carried out in Saudi Arabia found a high prevalence of alcohol abuse (9-70.3%) among populations compared to a lower prevalence of cannabinoid abuse (1-60%). This discrepancy could be explained by the difference in the study designs and settings. Unlike our study, that review included only patients reported in a treatment setting; therefore, the study may not reflect rates of substance abuse among the actual population (Bassiony 2013).

Among substance abusers, 41.3% reported using more than one type of substance. These findings are in line with those of Australian and Turkish studies (Swift et al. 2012; Besli et al. 2015). Moreover, controlling cannabinoid consumption was reported to be associated with higher rates of cessation for other drugs, which strengthens these findings (Swift et al. 2012). Gateway theory justifies this relationship and identifies nicotine and alcohol abusers as more susceptible than non-users to becoming illicit drug abusers (Haug et al. 2014).

This study found a high prevalence of cannabis exposure among male adolescents, a finding which agrees with other studies in developing countries, including Egypt (Faeh et al. 2006; Hamdi et al. 2016) and developed countries such as Australia and Switzerland (Hayatbakhsh et al. 2013; Haug et al. 2014). The predominance of male abusers could be explained by their relatively higher vulnerability to externalizing disorders, including substance abuse and aggression, compared their female counterparts, who are more vulnerable to internalizing disorders, such as depression and anxiety (Eaton et al. 2012). The high prevalence of cannabinoid use among males is also influenced by cultural norms and where substance abusers live. For example, the overrepresentation of male drug users in rural residents might be attributed to social stigma surrounding drug use in rural areas, and rural women's apprehensive to disclose their substance abuse habits(Hamdi et al. 2016). Surprisingly, previous cohort studies reported a narrowing gap between male and female cannabis users; the female: male cannabis use ratio increased from 1: 2 to 1: 1.3. Indeed, a greater increase in cannabis consumption has been reported among young females compared to males (Chapman et al. 2017).

Although 61.8% of study participants lived in rural areas, those living in urban areas reported higher rates of cannabis abuse. In support to our data, it was reported previously that substance abusers were primarily urban residents and he explained this by that strong social and family bonds in rural areas function to discourage substance abuse (Hamdi et al. 2016). This also could be explained by a more excepting attitude toward cannabis use and legalization in urban areas (Winhusen et al. 2020).

Although the current study shows significant differences between abusers and non-abusers regarding SES and maternal occupation (being a housewife), the association between these factors and their relationship to susceptibility of drug abuse is not fully elucidated. These findings partially agree with previous studies, which found that SES and paternal education status were risk factors for drug abuse (Hamdi et al. 2013, 2016; Haug et al. 2014). More highly educated parents are more likely to monitor their children, which reduces involvement in illicit drug abuse. The high prevalence of cannabis abuse among Egyptian students working in semiskilled or skilled work agrees with an earlier Egyptian study (Hamdi et al. 2013).

The current study demonstrated that dysfunctional social relationships are predictors of cannabis and other substance abuse. More than one-third of adolescent abusers reported suffering from legal or financial family conflicts. This agrees with previous studies in Australia and Switzerland that describe early paternal divorce and unstable marital relationships as predictors of cannabis abuse among adolescents (Hayatbakhsh et al. 2013; Haug et al. 2014). This association is not limited to cannabinoid abuse, but also extends to the other substance. Indeed, an intact family structure is crucial for maintaining the wellness of young adolescents and protecting them from substance abuse (Van Ryzin et al. 2012). The association between adolescent substance abuse and family conflict can be explained in reference to multiple theories, such as family system theory, strain theory, as well as social and cognitive theories (Vakalahi 2001). Such an investigation, however, is outside the scope of this study.

In order to further explore the impact of social relationships on substance abuse, this study noted that being encouraged to engage in substance use by a friend was a predictor of substance abuse. ﻿The relationship between having friends engaged in delinquency as a risk factor for cannabinoid abuse was identified previously (Van Ryzin et al. 2012). Peer pressure and having friends who abuse cannabinoids were reported as cannabinoid abuse predictors among young adolescents (Pérez et al. 2010; Haug et al. 2014). Moreover, the current study found a strong association between being a victim of child abuse and becoming a cannabinoid abuser. Previous studies have identified a comorbid association between child abuse and illicit drug use (Cross et al. 2015). The association between child abuse and becoming an illicit drug abuser might be attributable to abuse-induced stress and depression, which showed a significant interpersonal variability (Agrawal et al. 2012).

The current study reveals that approximately 79.3% of substance abusers reported increased drug use during the COVID-19 pandemic, and 1% of substance abusers started abusing an illicit substance during the pandemic. The increased consumption of illicit drugs during the current pandemic agrees with previous studies carried out within Egypt and worldwide (Vanderbruggen et al. 2020; Fayed and Sharif 2021). These findings may be related to the reported higher prevalence of substance abuse (72.4%) among students who reported psychological problems. Pandemic lockdowns and social distancing can exacerbate levels of anxiety, stress, and depression, which can lead to substance abuse (Martinotti et al. 2020).

Moreover, the current study reports that patients suffering from depression, anxiety, hallucinations, stress, and suicidal thoughts are vulnerable to becoming substance abusers. This association agrees with previous studies and is relevant to both cannabinoid abuse and the abuse of other illicit drugs (Krebs et al. 2019). Studies have also documented that, compared to cannabinoids, the abuse of SCs (Strox and voodoo) is associated with more serious and long-lasting psychiatric illnesses (Cohen et al. 2019). Furthermore, amphetamine was reported to be associated with violence, aggression, schizophrenia, obsession, and paranoid thinking (Zweben et al. 2004). Alcohol abuse is a common finding among psychotic patients, those suffering from stress and anxiety disorders, and suicidal individuals (Pompili et al. 2010). Similarly, a significant proportion of opioid abusers report suffering from depression and anxiety (Sullivan et al. 2005).

Studies clarifying the association between psychiatric illness and substance abuse, especially cannabinoids, display ambiguous results. A wealth of studies suggests that cannabinoids can induce psychiatric illness. These studies refer to dose-dependent psychiatric symptoms and the reported regression of symptoms after substance withdrawal to support their conclusions (Krebs et al. 2019). Conversely, some studies claim that cannabinoid abuse is a consequence of psychiatric illness or is merely associated with psychiatric illness. Such studies propose a shared genetic predisposition to both psychiatric illness and cannabis use (Christopher 2016).

This theory of shared genetic predisposition might explain the findings reported in the current study and other studies, in which significant abuse was reported among the students of families with a positive history of cannabis abuse (Krebs et al. 2019). An association between reported hypersensitivity to the psychotomimetic properties of cannabis, early drug abuse, and psychosis strengthens this theory (Goldberger et al. 2010). However, complex environmental interactions reduce the reliability of different theories in different contexts. Nevertheless, experimental studies have hypothesized common links between the endocannabinoid system and chronic stress. The complex role of the endocannabinoid system in coping with chronic stress might explain the higher prevalence of substance abuse among students who study for more than 10 h per week and low achievers in this study (Agrawal et al. 2012).

Apart from cannabinoids-associated psychiatric illnesses, the injurious effects of cannabinoids include other health disorders. Airway disease, lung cancer, increased cardiovascular activity, acute myocardial infarction, sudden arrest, and cardiomyopathy are all associated with cannabinoid use (Cohen et al. 2019). In addition to lung cancer, in vitro studies have mentioned that cannabinoids modulate the immune system and disturb the T helper cell and cytokines expression, which might induce carcinogenesis in the head and neck as well as other organs (Tanasescu and Constantinescu 2010). Despite lacking strong evidence from studies on humans, disturbance of reproductive system function has been reported in experimental studies on chronic cannabis exposure (Smith et al. 2004).

Strength and limitations

The variations in affiliations between the study participants strengthen the current study and enhance the rigor of its methodology. However, including more participants from different geographical regions would increase the reliability of the study. Given the sensitivity of the study topic, the conservative values of Egyptian society, and students' apprehensiveness to share details of their personal lives, the response rate of the study (92.1%) was acceptable. The study recruited 2380 students, which provided a high statistical power and reduced the Type 2 error probability (Cohen 1988).

Conclusion

The current study highlighted a potential high prevalence of substance abuse among Egyptian university students. The most used substances, in order of prevalence, were Hashish, followed by Strox, Bhang, voodoo, and Tramadol. Prolonged lockdown has unfavorable effect on substance use, apparently due to the associated stress and anxiety. Governmental efforts should be focused on reducing the prevalence of cannabinoid use among university students. Simultaneously, student and family counseling programs should deal with the issue of substance abuse. Orientation campaigns that correct misconceptions about cannabinoids and highlight their adverse effect should be employed to modify social norms regarding illicit substances.

Acknowledgements

All authors would like to acknowledge all students who participate in this study. Also, all authors would like to acknowledge the Faculty of Medicine, Menoufia University.

Author information

Authors and Affiliations

1. Physiology Department, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain

Yahya M. Naguib

2. Department of Medical Physiology, Faculty of Medicine, Menoufia University, Shibin El Kom, Menoufia, Egypt

Yahya M. Naguib

3. Medical Student at Faculty of Medicine, Menoufia University, Shibin El Kom, Menoufia, Egypt

Huda A. Sherif, Eslam A. Edrees & Ahmed E. Sabry

4. Medical Student at Faculty of Medicine, KasrAlainy, Cairo University, Giza, Egypt

Amr T. Elbalshy

5. Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt

Asmaa F. Sharif

6. Department of Clinical Medical Sciences, College of Medicine, Dar Al Uloom University, Riyadh, Kingdom of Saudi Arabia

Asmaa F. Sharif

7. Department of Public Health and Community Medicine Faculty of Medicine, Taiz University, Taiz, Yemen

Samar H. A. Aloshari

8. Department of Public Health and Community Medicine Faculty of Medicine, Menoufia University, Shibin El Kom, Menoufia, Egypt

Zeinab A. Kasemy

Contributions

All those who met the authorship criteria were listed as authors. Yahya M. Naguib conceptualized the idea, set the protocol, supervised data collection, discussed the results, and edited and approved the final version of the manuscript.HudaA. Sherif, Amr T. Elbalshy, EslamA, Edrees and Ahmed E. Sabry participated in conceptualizing the idea, and collected the data. Asmaa F. Sharif wrote the discussion and methods sections and revised the entire manuscript. Samar H. A. Aloshari performed the statistical analysis and participated in writing the manuscript. Zeinab A. Kasemy participated in conceptualizing the idea, took part in the statistical analysis, wrote the methodology and results sections, participated in the final revision of the manuscript, and coordinated publishing the manuscript.

Corresponding author

Correspondence to Zeinab A. Kasemy.

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Ethics approval and consent to participate

The current study received Research Ethical Committee approval (ID:191219COM).

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Not applicable.

Competing interests

The authors declare no competing interests.

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Naguib, .M., Sherif, H.A., Elbalshy, A.T. et al. Prevalence and associated risk factors of cannabinoid abuse among Egyptian university students: a cross-sectional study. Environ Sci Pollut Res 28, 68706-68716 (2021). https://doi.org/10.1007/s11356-021-15412-1
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Keywords

Cannabis,

Synthetic cannabinoids,

Substance abuse,

Addiction,

Hashish,

Strox,

Alcohol,

University students

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Prevalence and associated risk factors of cannabinoid abuse among Egyptian university students: a cross-sectional study - Environmental Science and Pollution Research

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Global surveys have highlighted rise in consumption of cannabinoids among residents of both developed and developing countries. Cannabinoids cause severe damage to the cardiovascular, nervous, respiratory, and renal systems, and have been linked with several deaths. Despite these adverse health effects, the use of cannabinoids has rapidly increased.

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Examining College Students’ Social Environment, Normative Beliefs, and Attitudes in Subsequent Initiation of Electronic Nicotine Delivery Systems

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Examining College Students’ Social Environment, Normative Beliefs, and Attitudes in Subsequent Initiation of Electronic Nicotine Delivery Systems

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This paper discusses the effects of environment, beliefs and attitudes in the probability of initiating use of nicotine delivery systems. They gathered a group of college students and had them fill in a 3 wave online survey in which they made sure the students weren't initially smokers. They would then assess whether their environment, beliefs and attitudes led them to start using nicotine or not during a 1 year period. The results showed that 16% of the participants started using nicotine, which shows that colleges should stress on preventing its initiation from the beginning.

Agarwal, D., Loukas, A., & Perry, C. L. (2017). Examining college students’ social environment . Health education and behavior. Retrieved February 19, 2023, from https://journals.sagepub.com/doi/10.1177/1090198117739672

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This article talks about the increase of using multiple tobacco products/ sources among college students. They conducted an experiment in which a group of college students, including all those who smoke, were asked to fill a survey that assess tobacco uses and attitudes. They found that most students who smoked used several sources of tobacco, and that gender and ethnicity can play a role in these results.

Butler, K. M., Ickes, M. J., Rayens, M. K., Wiggins, A. T., & Hahn, E. J. (2015, March 13). Polytobacco use among college students. OUP Academic. Retrieved February 19, 2023, from https://academic.oup.com/ntr/article/18/2/163/2583959

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Abstract

Introduction

Polytobacco use is increasing in popularity, particularly as new forms of tobacco products are emerging. Polytobacco use is the concurrent use of cigarettes and other tobacco products such as electronic cigarettes (e-cigarettes), smokeless tobacco, waterpipe (hookah) and cigars, or more simply stated, the use of more than one tobacco product at a time. The CDC reports that the use of cigarettes with any other form of tobacco is highest among certain subgroups, such as those between the ages of 18-24. College students predominantly fall into this age group, and often exhibit high levels of substance use and progression to regular tobacco use. Approximately 14.1% of college students are current cigarette smokers and 16.1% have smoked cigarettes in their lifetime. Little is known about the full extent of tobacco use among college students, especially as the use of new noncombustible tobacco products gain popularity. Given the tendency for college students to be drawn to emerging tobacco products (ie, hookah, e-cigarettes), research is warranted.

College-aged young adults are at increased risk for using non-cigarette tobacco products including cigars, cigarillos, smokeless tobacco, hookah, and e-cigarettes. Consequently, young adults aged 18-24 are more likely to report polytobacco use than adults 25 years or older, with rates varying from 30% to 45%. A Canadian study reported a slightly lower prevalence of lifetime polytobacco use among young adults ages 20-24 at 26.2%.

Whereas past research has focused mainly on cigarette use with its inherent health risks and societal costs, the introduction of new, emerging tobacco products has created a need to examine polytobacco use. Unfortunately, research is limited in this area. However, a nationally representative survey of college students in 2000 indicated that 51.3% of tobacco-using American college students used more than one product. At that time, however, fewer products were available, not accurately reflecting current polytobacco use patterns. Latimer, Batanova, and Louka found that 10.3% of college students were polytobacco users, with hookah use most common. Others reported that 9.3% of undergraduates reported dual use of cigarettes and hookah. Current hookah use is associated with daily and nondaily cigarette smoking while lifetime use is associated with heavy cigarette smoking and problem tobacco use. E-cigarette use is also associated with conventional cigarette smoking. Young men who use smokeless tobacco are also more likely to smoke cigarettes than those who do not use smokeless. The results of these studies are concerning when one considers the potential individual and public health outcomes.

Polytobacco use is associated with increased physical and psychological health risks compared to single tobacco product use. Polytobacco users report more dependence symptoms than those who smoke cigarettes or use smokeless tobacco alone. In addition, polytobacco use increases nicotine exposure and risk for dependence, which may in turn increase risk of tobacco-related disease or death compared to single product use. This is especially important for population health and policy regulations. Polytobacco users typically have a more difficult quitting and tobacco dependence treatment programs have historically been focused on cigarette smoking cessation, and not toward the newer emerging tobacco products. Currently there are few regulations associated with the marketing, sale, and use of emerging tobacco products even though the Food and Drug Administration has tobacco regulatory authority under the 2009 Tobacco Control Act. As a result, these emerging products are more easily available and are heavily promoted and marketed, perhaps, contributing to polytobacco use.

Research is needed to identify those at risk and patterns of polytobacco use in order to plan and test targeted interventions and guide product regulation. This study examined: (1) polytobacco use patterns among college students who had ever used tobacco; and (2) sociodemographic and personal factors associated with current polytobacco use, compared to current single tobacco product use and former tobacco use among college students.

Methods

The analysis reported here was part of a larger study to evaluate the impact of the CDC Tips television campaign conducted at a large public university in the Southeastern United States. Two randomly-selected cohorts of students were surveyed 2 months apart. The analysis is based on the combined sample of those who had ever used one of five tobacco products (ie, cigarettes, e-cigarettes, hookah, smokeless tobacco, and the combined category of cigars, little cigars, and clove cigarettes). Approval for the study was obtained from the university's Institutional Review Board.

Participants

Two cohorts of randomly-selected students (5000 each), all aged 18 or older, were provided by the University Registrar. Each was representative (in terms of gender and academic status) of the population of 26 139 students enrolled in Spring 2013; pre-professional (eg, medicine, nursing, dentistry, pharmacy, physical therapy, etc.) students were not included in the sample. The two separate samples were sent surveys in February and April 2013, respectively. The combined sample of 10 000 randomly-selected students who were sent surveys included 4134 female undergraduates; 1065 female graduate students; 3968 male undergraduates; and 833 male graduate students. These samples reflected the ratio of undergraduates (81%) to graduate students (19%), as well as the percentage of females (52%) to males (48%) in the university population of eligible students. With combined cohorts, a total of 1593 students responded to the survey (15.9% overall response rate). Only those who had ever used tobacco were included in this analysis ( n = 662; 41.6% of survey completers). Of the remaining 931 participants, 847 were not included because they had never used any of the five forms of tobacco, and an additional 84 were omitted due to incomplete tobacco use history.

Procedures

Students were invited via their university email to participate in an online survey through Qualtrics software, which assigned potential participants a unique code to protect confidentiality. Reminder emails from survey codes not returned were sent a follow-up email 1 and 2 weeks after the initial email. Those who did not return the survey after 3 weeks were considered nonresponders and further follow-up was not attempted. All survey completers were provided a separate link to enter a drawing to win a $25 gift card.

Measures

Tobacco Use

Tobacco use related to conventional cigarettes, e-cigarettes, hookah, smokeless tobacco, and the combined category of cigars, little cigars, and clove cigarettes was assessed using a series of questions. Current and former cigarette use was determined by assessing whether respondents had smoked at least 100 cigarettes and how recently they had used them. Among those who met the 100-cigarette threshold, current smokers had used in the last 30 days and former smokers used less recently. Current and former use of the four emerging products was assessed by asking: "Within the last 30 days, on how many days did you use:" "never," "have used, but not in the last 30 days," "1-2 days," "3-5 days," "6-9 days," "10-19," "20-29," and "used daily." Based on responses to these questions, participants were categorized as former, single, or polytobacco product users. Former users had not used any tobacco product in the past 30 days, but had used at least one of the five products prior to that time. Current single tobacco users had used exactly one of the five tobacco products in the past 30 days, though they may have used others previously. For example, a former cigarette smoker (who most recently smoked more than a month ago) currently using only hookah would be defined as a single tobacco product user. Current polytobacco users had used at least two of the five products in the last 30 days, regardless of type or number.

Sociodemographic and Personal Variables

Three questions comprised the cigarette social norms subscale including acceptance of peer smoking and personal beliefs about smoking. Five-point Likert items included, "How would your best friend react if you smoked cigarettes?" ("very upset," "somewhat upset," "no opinion," "somewhat approving," "very approving"); "People who are important to me think I should not smoke cigarettes" ("strongly agree" to "strongly disagree"); and "It is OK for someone like you to smoke cigarettes" ("strongly agree" to "strongly disagree"). The three items were summed to form the total score, ranging from 3-15; higher scores indicated greater perceived acceptance of cigarette smoking. Cronbach's alpha was 0.62. Age, gender, race/ethnicity, academic level (ie, lower undergraduate, upper undergraduate, graduate student), type of residence (on- or off-campus), and involvement in a Greek organization were assessed.

Data Analysis

Descriptive statistics were used to summarize study variables. One-way analysis of variance assessed differences in cigarette social norms among the three tobacco use groups; post-hoc pairwise testing was accomplished with Fisher's least significant difference procedure. Prevalence of use was calculated for each tobacco product among single and polytobacco users.

To evaluate overall model fit of the multinomial regression, Hosmer-Lemeshow goodness-of-fit tests were used for each binary comparison (polytobacco vs. former use; polytobacco vs. single use), as suggested by Hosmer and Lemeshow. Variance inflation factors assessed for multicollinearity. All analyses were conducted using SAS v. 9.3; an alpha level of 0.05 was used throughout.

Multivariate multinomial logistic regression was used to evaluate sociodemographic and personal characteristics associated with tobacco use group membership (former, single, and polytobacco users). Potential predictors included age, gender, race, academic status, residence, member of fraternity/sorority, cohort, and cigarette social norms. The model simultaneously tested for predictors of former and single tobacco use relative to the reference category of polytobacco use. The multinomial regression model yielded two series of estimates: former users versus polytobacco users, and single tobacco product users versus polytobacco users. To identify possible risk factors for polytobacco use relative to single and former use, corresponding odds ratios from the multinomial model were inverted to reflect group comparisons of interest: polytobacco users versus former users, and polytobacco users versus single tobacco product users, each with accompanying 95% confidence intervals.

Results

Mean age of the 662 study participants was 22.4 years ( SD = 6.1; Table 1 ). Most participants were female, and over three-quarters were white, non-Hispanic. Approximately half were lower level undergraduates (freshman or sophomore). Fewer than one-third lived on-campus, and one in five students were in a fraternity/sorority. The combined sample included slightly more participants from the February cohort (54%). Compared to the full cohort of students who were sent surveys, this sample included an over-representation of both females (52% vs. 65%, respectively) and graduate students (19% vs. 27%, respectively), but it is unknown how these characteristics compared to the demographics of the population of current and former tobacco users at the university.

Among respondents using exactly one of the five tobacco products (ie, "single" users), the most commonly used product was conventional cigarettes (37%), followed by hookah (33%) and cigars, little cigars, or clove cigarettes (20%; Figure 1 ). Less than 10% of students in the single tobacco product user group currently used smokeless tobacco or e-cigarettes as their sole tobacco product. Over half of the ever-using students were former tobacco users.

The frequency of use for each of the five products among polytobacco users are also shown in Figure 1 . Since everyone in this group of participants used at least two of these products, the sum of percentages across the five products exceeds 100. The most commonly used product among polytobacco users was the combined category of cigars, little cigars, or clove cigarettes ( Figure 1 ) and almost three-quarters used them in combination with one or more other tobacco products. The second most commonly used combination product was conventional cigarettes; over 60% of polytobacco users smoked conventional cigarettes. Nearly half of the polytobacco group used hookah in combination with one or more other tobacco product(s). Smokeless tobacco and e-cigarettes were the least commonly used by polytobacco users.

Among polytobacco users, nearly two-thirds used two products (64%). Nearly one-fourth of polytobacco users used three products in the last 30 days (23%), while fewer indicated using four (11%) or five products (2%) during this time period. For the 60 polytobacco users who indicated they had used exactly two products, the most frequent pairing was cigarettes with cigars, little cigars, or clove cigarettes (25%). Among the 22 polytobacco users who indicated they had used exactly three products in the past month, the most common combination was cigarettes and hookah with cigars, little cigars or clove cigarettes (41%). For the 10 tobacco users who used exactly four products, the only product indicated by all 10 was the combined category of cigars, little cigars and clove cigarettes. There were also two participants in this polytobacco group who indicated they had used all five products in the last month.

The average cigarette social norms score was 6.07 ( SD = 2.31; range 2-13). There was a significant difference among the three tobacco use groups ( F = 60.1, P < .0001): former tobacco users had the lowest average score ( M = 5.35; SD = 2.02), followed by single tobacco users ( M = 6.54; SD = 2.25), and polytobacco users ( M = 7.89; SD = 2.26). All three groups differed from each other on cigarette social norms ( P < .0001).

The overall multinomial model was significant (χ ² = 142.0; P < .001; Table 2 ). Gender, academic status, and cigarette social norms were significant predictors of tobacco use group. Males were at 63% higher risk of polytobacco use compared to single use and 53% more likely to be polytobacco users than former users. Relative to graduate students, freshmen and sophomores were at 76% greater risk of polytobacco use compared to single use and 84% more likely to be polytobacco users than former users. Juniors and seniors were 38% less likely to be polytobacco users compared to single tobacco product users. For every 1-unit increase in cigarette social norms, the likelihood of being a polytobacco user relative to a single tobacco product user increased by 26%; odds of polytobacco use relative to a former use increased by 64%. Tobacco user group was not related to race/ethnicity, residence, Greek status, or cohort. Academic status, not age, was used in the multivariate analysis to avoid parameter distortion due to multicollinearity. Both Hosmer-Lemeshow goodness-of-fits tests for the binary logistic models were not significant ( P = .30 and P = .29, respectively), suggesting the overall multinomial model fit the data well. All variance inflation factors were less than 1.6, indicating multicollinearity did not influence the model.

Discussion

Nearly 15% of college students were current polytobacco users, lower than an estimated 30% dual use rate among young adult tobacco users. Over a third of polytobacco users reported use of three or more tobacco products. This is consistent with previous findings that most college students who use tobacco consume more than one product. It is concerning that polytobacco use is increasing in popularity. In our study, polytobacco users were more likely than single tobacco users to consume emerging tobacco products, namely hookah and e-cigarettes. These young polytobacco users are particularly prone to nicotine addiction, resulting in subsequent negative health risks, prompting the need to identify those most at risk and design effective interventions.

While each of the five tobacco products had been used by at least one-quarter of the polytobacco user group in the last month, the most frequently used products were the combined category of cigars, little cigars or clove cigarettes and conventional cigarettes, followed by hookah, smokeless tobacco and e-cigarettes. Although research is limited in this area, our findings are similar to other studies in that use of these products is common in college students who are polytobacco users. Nearly three-fourths of polytobacco users used cigars, little cigars or clove cigarettes, but relatively few single tobacco product users reported using them. However, hookah and conventional cigarettes were used by at least one-third of both user groups.

E-cigarettes have been available in the United States since at least 2006 and are gaining popularity among young adults. While the rate of e-cigarette use was fairly low in our sample, e-cigarettes were just beginning to gain popularity in the Southeast during this time period. A large study of college students reported current use of e-cigarettes at 1.5% in the past 30 days, however, this study did not differentiate between single product and polytobacco users. Interestingly, the prevalence of both smokeless tobacco and e-cigarettes was higher in the polytobacco user group than in the single tobacco user group. It is possible that smokeless tobacco and e-cigarettes are promoted and viewed as products to be used in addition to cigarettes or when conventional smoking is not allowed, and not as a replacement for cigarettes. E-cigarette manufacturers are using aggressive marketing messages similar to those used by the tobacco industry to promote cigarette smoking in the 1950s and 1960s (eg, product placement in movies). Advertising occurs in venues where cigarette advertising has been prohibited. Population health implications are that promotion and use of these products may contribute to tobacco dependence by providing a nicotine delivery system that can be used when and where smoking is prohibited. In addition, these products may be more easily obtainable by young people as they are not presently regulated by the Food and Drug Administration, which may contribute to a new generation of tobacco users using one or more products at a young age.

Males were more likely to be polytobacco users, as were lower level undergraduates, while upper class undergraduates, graduate students and females were more likely to be single tobacco users. Similarly, Rigotti et al. found that college men are more likely to smoke and also use another tobacco product than women. More recent evidence related to demographics of college student polytobacco users is limited. In a study examining the combined use of cigarettes and smokeless tobacco by college students, men were more likely than women to use these two products. While tobacco use seemed to increase with progression from freshman to junior years, dual use was less prevalent among seniors compared to all other classes. Dual users also reported smoking initiation at significantly younger ages than either sole cigarette smokers or sole smokeless tobacco users. Our findings are consistent with the literature in terms of gender, and partially consistent in terms of decreasing polytobacco use from freshman to senior years of college. It is possible that our results were influenced by various use trajectories, such as experimentation with emerging products or as a substitute for cigarette smoking. However, it is unlikely that participants were using emerging products as a substitute since e-cigarette use was so low in the entire group of former and current tobacco users. There is a critical need to further understand sociodemographic factors, such gender, age, academic class, residence on- or off-campus, membership in a fraternity/sorority, and ethnicity impacting polytobacco use among college student sub-groups.

Polytobacco users were more likely to report a greater acceptance of cigarette smoking. Similarly, Miller et al. found that dual users of cigarettes and smokeless tobacco viewed cigarette smoking as more socially acceptable than single tobacco product users. There are alarming future health implications as social acceptability supports continued smoking and polytobacco use, increasing the risk of associated health consequences. Polytobacco use is associated with higher nicotine addiction, greater difficulty quitting tobacco and increased incidence of smoking-related cancers compared to cigarette smoking alone. College students reporting dual use (only two products) in one study were more likely than single tobacco product users to perceive themselves as regular tobacco users, but also had greater confidence in their ability to quit than single tobacco product users and were more likely to have received assistance from a health care provider in their most recent quit attempt. There is a need for tobacco treatment strategies on college campuses directed at both single product tobacco users and polytobacco users. More research is needed on the ability of polytobacco users to quit and the best ways to motivate these subgroups of college students to participate in tobacco treatment and achieve abstinence.

We found an association between race and likelihood of being a polytobacco user, but only when comparing single tobacco product users and polytobacco users. Students who identified as "white" were less likely to be a polytobacco user, compared to the combined group of students who reported a different race. This is in contrast to an earlier study by Rigotti and colleagues reporting that dual tobacco users were more likely to be "white." Since 2000, emerging tobacco products may have had more appeal to minority groups. The tobacco industry has a history of targeting ethnic groups in their marketing strategies, potentially putting these groups at higher risk for polytobacco use. However, Miller and colleagues did not report an association between ethnicity and dual tobacco use. More research is needed to investigate the role of race/ethnicity in college student polytobacco use.

The implications of the study findings are of concern. Although rates of cigarette smoking among college students are well documented, the patterns of reported polytobacco use are alarming, and support our premise that college students are both attracted to and using emerging tobacco products in combination with other products. One supposition is that these emerging products are marketed by the tobacco industry specifically to the college-aged population. For example, hookah bars have opened in areas around college campuses, increasing the likelihood of hookah use by college students. In many communities, hookah bars are exempt from comprehensive smoke-free legislation meaning they can open in neighborhoods and locations where young people are likely to visit. In addition, e-cigarettes are marketed by manufacturers through youth-oriented events, national television and radio programming with young audiences, and through the use of social media. These marketing strategies are similar to those used by the tobacco industry in the past to market cigarettes to youth and young adults, and are likely to continue until there is federal regulation to restrict the marketing, labeling and sale of e-cigarettes.

This study was conducted in a tobacco-growing state which consistently reports higher rates of tobacco use than the national average. It is not known how many of the participants were in-state students and if so, whether they were impacted by the pro-tobacco culture. However, the majority of students enrolled at the university are in-state students. Interestingly, the campus is tobacco-free, and the city in which the study was conducted has a comprehensive smoke-free workplace law. College students comprise a unique population whose patterns and motives for tobacco use may differ from those of adolescents or adults. More research is needed to determine the impact of social and environmental influences on polytobacco use, including the pro-tobacco culture and surrounding smoke- and tobacco-free policies.

One study limitation was the lack of information regarding frequency of lifetime use of certain tobacco products. For cigarettes, we were able to accurately classify participants as former or current tobacco users using both past 30 day smoking and whether they had smoked at least 100 cigarettes in their lifetime. For the other four tobacco product categories, we knew whether students had ever used the product, but no "100 cigarette" analog has been developed to assess lifetime or established use. We may have over-estimated the number of current or former e-cigarette, hookah, smokeless and cigar/little cigar/clove cigarette users by including those who had used a given product fewer than 100 times in their life. This may be particularly true of certain emerging products that may be more linked to experimentation. However, this study is consistent with similar research that has measured current consumption solely as past 30 day use. Given the ordinal nature of the tobacco user group (former, single, polytobacco user), it would have been preferable to fit a proportional odds model to determine predictors of level of use. However, the proportional odds assumption was violated, requiring the use of the more general multinomial model. An additional limitation is that it was not possible to make demographic comparisons between those who completed the survey and those who did not, and it is not known whether the sample of current and former tobacco users in this study is representative of all tobacco-using students at this institution, as the demographic profile of that group is not available. This concern is lessened by the fact that the combined sample had somewhat similar gender and academic status distributions compared to the accessible population, which includes both tobacco users and nonusers. More research is needed with this at-risk population to understand the degree to which these results are generalizable to all tobacco-using college students. Finally, there is a small chance that a student was invited to participate in the study at both time points and was part of both cohorts, which would result in lack of independence among all observations. The likelihood that this occurred is small, both due to the overall response rate of 16% coupled with use of only a portion of the full sample (ie, ever tobacco users) from among those who responded; the study sample represented less than 3% of the eligible students. In conclusion, polytobacco users were more likely to use emerging tobacco products, an issue of grave concern for college and population health. Men, underclassmen, and non-whites were at higher risk for polytobacco use. As college students are particularly prone to nicotine addiction, which can prolong tobacco use and lead to acute and chronic negative health risks, there is a need to further investigate polytobacco use, particularly among the subgroups identified to be at greater risk. Future research is needed to identify risk factors among college students and develop and test strategies to prevent and treat polytobacco use.

Funding

The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR000117. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Declaration of Interests
None declared.
Acknowledgments

The authors would like to thank University of Kentucky Department of Kinesiology and Health Promotion for providing the incentives for participation.

References

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Polytobacco use is increasing in popularity, particularly as new forms of tobacco products are emerging. Polytobacco use is the concurrent use of cigarettes and other tobacco products such as electronic cigarettes (e-cigarettes), smokeless tobacco, waterpipe (hookah) and cigars, or more simply stated, the use of more than one tobacco product at a time.

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Smokefree60+ is designed to help older adults overcome the challenges they face when quitting smoking. Find the information and tools you need to help you quit tobacco for good.

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Van Den Putte, B., Yzer, M. C., & Brunsting, S. (2005). Social influences on smoking cessation: a comparison of the effect of six social influence variables. Preventive medicine, 41(1), 186-193.

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Van Den Putte, B., Yzer, M. C., & Brunsting, S. (2005). Social influences on smoking cessation: a comparison of the effect of six social influence variables. Preventive medicine, 41(1), 186-193.

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This is a research study done to compare the social influences that lead someone to quit smoking. The researchers used six social influences that they found in several previous studies. These influences were split into two categories: explicit and implicit influences. The two explicit influences are 'verbal norm' and 'behavioral norm'. The first one is verbal stimulation to quit smoking, and the second one is offering help and giving information on quitting. The implicit influences are 'descriptive smoking norm', 'descriptive quitting norm', injunctive norm', and subjective norm. These influences are based on perceptions of smoking. In the listed order, the influences are perceptions of: how many people smoke, how many quit, acceptability within society, and whether others think that the person should quit smoking. The results showed that implicit social influences are more effective. This means that smokers would stop or continue smoking based on what they perceive as the norm of the society they are in.

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Our target group is college students/ adolescents so I chose an instagram account, that campaigns for smoking/vaping  prevention, as an online resource because instagram is one of the most used social media platforms. This makes their access for information or help much more easier and bearable for our target group. In addition to that it will help us better understand the target audience and their needs through their online feedbacks which for example can be in the form of comments or shares of posts on the account.

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Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors 

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Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors 

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This article talks about how multiple of research was made to identify prevention methods for addiction but how there is a gap between what research has shown to be effective and the methods generally used in most schools. The article tells us in order to have promising prevention methods we should start off by targeting adolescents, especially the ones in the beginning of their adolescence, and teaching them drug resistance skills with personal and social skills. The aforementioned approach was shown to be effective in reducing adolescent tobacco, alcohol, and marijuana use.

Citation: Author links open overlay panelGilbert J Botvin, AbstractDrug abuse continues to be an important public health problem throughout the world. Although considerable progress has been made in identifying effective prevention approaches, Evans, R. I., Ennett, S. T., Clayton, R. R., Botvin, G. J., Arkin, R. M., Bandura, A., Bangert-Drowns, R. L., Caplan, M., Donaldson, S. I., Dukes, R. L., Ellickson, P. L., Flay, B. R., & Hansen, W. B. (2000, September 22). Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors. Addictive Behaviors. Retrieved February 19, 2023, from https://www.sciencedirect.com/science/article/pii/S0306460300001192

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Preventing drug abuse in schools: Social and competence enhancement approaches targeting individual-level etiologic factors

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Drug abuse continues to be an important public health problem throughout the world. Although considerable progress has been made in identifying effect…

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Social influences on nicotine related behaviors

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Social influences on nicotine related behaviors

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This article highlights the fact that the number of nicotine smokers are rapidly rising, especially among adolescents, thus highlighting the importance of discussing the social influences on that matter. This article discusses and investigates studies that explore the patterns or connections nicotine and tobacco have with social influences. Not only do these studies examine the susceptibility of smoking due to the impact of social relationships such as family and friends but they also examine the how drug intake, acquisition, maintenance, and relapse is impacted by social influences or relationships. They also mention the impact of environmental enrichment (EE).

Citation: Social influences on nicotine-related behaviors - sciencedirect. (n.d.). Retrieved February 19, 2023, from https://www.sciencedirect.com/science/article/pii/S0074774218300308

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Social Influences on Nicotine-Related Behaviors

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Cigarette smoking is the leading preventable cause of death in the United States. The number of new smokers, specifically among adolescents, has risen...

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https://www.facebook.com/groups/449741115485419/?ref=share&mibextid=S66gvF

This is a facebook auc students group. Since our target audience are AUC students, we can use this group to put out surveys or ask questions to the AUC student community. This will provide us with accurate pathway for our research to able to impact our audience. It will also help us keep our information and guidelines for addiction accurate and relatable to university students.

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Cannabis Addiction and the Brain: a Review

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This article talks about the increased used of marijuanna and the decreased perceived risk of its addiction. They attempt to evaluate the process of marijuanna addiction using the neurobiologicalmodel of Koob and Volkow. It states that repeated use of the substance causes neurobiological changes than is separated into three stages (three stages of addiction). They found that the three stage framework model is applicable with marijuana addiction and urges the field to conduct more research specific to neurobiological changes of cannabis addiction. This article can be used to referenced to when discussing stages of addiction to marijuanna.

Citation: Zehra, A., Burns, J., Liu, C.K. et al. Cannabis Addiction and the Brain: a Review. J Neuroimmune Pharmacol 13, 438–452 (2018). https://doi-org.libproxy.aucegypt.edu/10.1007/s11481-018-9782-9

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