Objective Waterpipe tobacco (WPT; hookah) use is common in pregnant and reproductive-age women. Sweet flavours contribute to the appeal of WPT and are a potential regulatory target. This study investigated use, preferences and perceptions of WPT flavours in pregnant WPT users, and the impact of flavour preferences on preconception/prenatal WPT use and exposure biomarkers.
Methods 58 pregnant WPT users (mean age=27 years) completed a detailed interview regarding their WPT flavours use, preferences and perceptions. Biomarkers of nicotine and carcinogen exposure (eg, cotinine, benzene, butadiene) were also collected.
Results 55% of participants were dual/poly WPT users (ie, reported use of one or more other tobacco products in addition to WPT). Pregnant WPT users reported nearly exclusive use of flavoured WPT, with greater use of menthol/mint (68%) followed by fruit flavours (48%) (p<0.001), and greater preferences for fruit followed by menthol/mint flavours (ps<0.05). Harm perceptions did not differ among flavours. Compared with dual/poly WPT users, WPT-only users reported more total WPT use events, greater use of and preference for menthol/mint flavoured WPT (ps<0.001), and decreased exposure biomarkers (ps≤0.040). Preference for menthol/mint and fruit flavours predicted more flavoured WPT use events during preconception and pregnancy; preference for menthol/mint predicted detectable cotinine and benzene levels but not butadiene.
Conclusions This is the first study of WPT flavour use, preferences and perceptions in pregnant women. Use of and preference for menthol/mint and fruit WPT flavours in this vulnerable population could be considered in regulating WPT flavours to protect the health of women and children.
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Contributors LS designed and conceptualised the study, coordinated the acquisition of data, drafted the initial manuscript, contributed to the interpretation of results and revised the manuscript critically for important intellectual content. EW provided substantial contribution to recruitment and data collection, and in revising the manuscript critically for intellectual content. KM provided substantial contribution to recruitment and data collection, and in revising the manuscript critically for intellectual content. MC provided input into the study design, and in revising the manuscript critically for intellectual content. GSH provided input into study design and in revising the manuscript critically for intellectual content. TE provided input into study design and in revising the manuscript critically for intellectual content. LAJS-S designed and conceptualised the study, conducted statistical analyses and drafted the results, and revised the manuscript critically for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Funding Funding for this study and manuscript preparation was supported by the National Institute on Drug Abuse (NIDA) of the National Institutes of Health and the Center for Tobacco Products of the US Food and Drug Administration (FDA) under grant 5R01 DA042484 to LS and LAJS-S. TE is also supported by NIDA under Award Number U54 DA036105 and the Center for Tobacco Products of the FDA.
Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration. NIDA, CTP and FDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Competing interests TE is a paid consultant in litigation against the tobacco industry and is named on a patent for a device that measures the puffing behaviour of electronic cigarette users.
Patient consent for publication Not required.
Ethics approval All study procedures were approved by local institutional review boards.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request.
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