Faculty Bibliography

OBJECTIVE: To investigate the state-specific prevalence, regional differences and correlates of hookah use among US adults. METHODS: We analyzed the most recent nationally representative data of adults from the National Adult Tobacco Survey (NATS) 2012-2013 (n=60,192). State-specific prevalence of lifetime and current hookah use were calculated and mapped. Multivariate logistic regression was performed to determine the association between socio-demographic characteristics, regional differences, and hookah use. RESULTS: Among US adults (>/= 18 years), overall prevalence of lifetime hookah use was 12.3%, while current use was 3.9%. Mapping of state-specific prevalence revealed that the West tended to have higher rates of use, while the South tended to have lower ones. In the adjusted model, we observed that current hookah use was positively associated with younger adults, males, non-Hispanic adults, those with higher education and income statuses, being single, those living in the West, and current cigarette use. CONCLUSION: The prevalence of hookah use varies by state, region, and socio-demographic characteristics among adults. Future research, including longitudinal studies, are needed to identify geographic and socio-demographic characteristics and trends among hookah users, investigate hookah-related health outcomes, and evaluate targeted public health efforts aimed at this emerging threat. IMPLICATIONS: This study investigates state-level prevalence, regional differences and socio-demographic characteristics of hookah use among US adults, using the most recent National Adult Tobacco Survey (NATS). Hookah use was positively associated with younger adults, and those living in the West. This study adds to the understanding of the geographic and socio-demographic factors underlying hookah use, which can be used to develop much needed evidence-based regulations and programs that are responsive to the needs of different risk groups.

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

INTRODUCTION: Hookahs (water pipes) are rapidly increasing in popularity worldwide. Evidence suggests that although perceived as safer than cigarette smoke, hookah smoke may be as, or even more, dangerous as cigarette smoke. METHODS: Air samples from 33 homes-11 where only hookah-smoking occurred, 12 with only cigarettes and 10 with no smoking-were collected to analyse concentrations of particulate matter (PM2.5), black carbon, elemental and organic carbon and carbon monoxide (CO). Air quality was assessed in rooms where smoking occurred and in an adjacent room. RESULTS: Hookah and cigarette smoking impaired home air quality. The rooms in which hookahs were smoked showed the highest concentrations for all pollutants. CO was significantly greater in the rooms where hookahs were smoked than in the cigarette-smoking rooms and the non-smoking households (p<0.05). In addition, CO levels in the rooms adjacent to where hookah was smoked were 2.5-fold to 4-fold greater than those in the smoking and non-smoking rooms of the cigarette homes (p<0.05). PM2.5 levels were also elevated in hookah homes compared to cigarette and non-smoking homes, although not significantly different. CONCLUSIONS: This study, the first of its kind, demonstrates potentially hazardous levels of home air pollution in rooms where hookahs are being smoked as well as in adjacent rooms. These levels were greater than those in cigarette smoking homes, raising concerns about potential negative health effects on all individuals living in homes where hookahs are smoked.

Importance: Shift-to-shift transitions in care among house staff are associated with adverse events. However, the association between end-of-rotation transition (in which care of the patient is transferred) and adverse events is uncertain. Objective: To examine the association of end-of-rotation house staff transitions with mortality among hospitalized patients. Design, Setting, and Participants: Retrospective multicenter cohort study of patients admitted to internal medicine services (N = 230701) at 10 university-affiliated US Veterans Health Administration hospitals (2008-2014). Exposures: Transition patients (defined as those admitted prior to an end-of-rotation transition who died or were discharged within 7 days following transition) were stratified by type of transition (intern only, resident only, or intern + resident) and compared with all other discharges (control). An alternative analysis comparing admissions within 2 days before transition with admissions on the same 2 days 2 weeks later was also conducted. Main Outcomes and Measures: The primary outcome was in-hospital mortality. Secondary outcomes included 30-day and 90-day mortality and readmission rates. A difference-in-difference analysis assessed whether outcomes changed after the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations. Adjustments included age, sex, race/ethnicity, month, year, length of stay, comorbidities, and hospital. Results: Among 230701 patient discharges (mean age, 65.6 years; men, 95.8%; median length of stay, 3.0 days), 25938 intern-only, 26456 resident-only, and 11517 intern + resident end-of-rotation transitions occurred. Overall mortality was 2.18% in-hospital, 9.45% at 30 days, and 14.43% at 90 days. Adjusted hospital mortality was significantly greater in transition vs control patients for the intern-only group (3.5% vs 2.0%; odds ratio [OR], 1.12 [95% CI, 1.03-1.21]) and the intern + resident group (4.0% vs 2.1%; OR, 1.18 [95% CI, 1.06-1.33]), but not for the resident-only group (3.3% vs 2.0%; OR, 1.07 [95% CI, 0.99-1.16]). Adjusted 30-day and 90-day mortality rates were greater in all transition vs control comparisons (30-day mortality: intern-only group, 14.5% vs 8.8%, OR, 1.17 [95% CI, 1.13-1.22]; resident-only group, 13.8% vs 8.9%, OR, 1.11 [95% CI, 1.04-1.18]; intern + resident group, 15.5% vs 9.1%, OR, 1.21 [95% CI, 1.12-1.31]; 90-day mortality: intern-only group, 21.5% vs 13.5%, OR, 1.14 [95% CI, 1.10-1.19]; resident-only group, 20.9% vs 13.6%, OR, 1.10 [95% CI, 1.05-1.16]; intern + resident group, 22.8% vs 14.0%, OR, 1.17 [95% CI, 1.11-1.23]). Duty hour changes were associated with greater adjusted hospital mortality for transition patients in the intern-only group and intern + resident group than for controls (intern-only: OR, 1.11 [95% CI, 1.02-1.21]; intern + resident: OR, 1.17 [95% CI, 1.02-1.34]). The alternative analyses did not demonstrate any significant differences in mortality between transition and control groups. Conclusions and Relevance: Among patients admitted to internal medicine services in 10 Veterans Affairs hospitals, end-of-rotation transition in care was associated with significantly higher in-hospital mortality in an unrestricted analysis that included most patients, but not in an alternative restricted analysis. The association was stronger following institution of ACGME duty hour regulations.