Multiple tobacco use among young adult waterpipe smokers in Egypt.

Background: The use of multiple tobacco products is an emerging trend. Studies on multiple use among waterpipe smokers are limited.

Objectives: We aimed to estimate the proportion of other tobacco products used by current adult waterpipe smokers in Egypt and identify the determinants of multiple tobacco product use.

Methods: Population-based surveys were conducted using interview questionnaires during 2015-2017 in urban Cairo and rural Menoufia. Participants aged 18 years and older were selected using purposive quota non-random sampling. The total sample included 2 014 participants. We analysed the data on 1 490 current waterpipe smokers. Variables recorded included: tobacco use, health beliefs, waterpipe smoking behaviour, sociodemographic characteristics, and perceived effectiveness of pictorial health warnings on waterpipe tobacco packs. Current waterpipe smokers were classified as waterpipe-only users and multiple tobacco product users.

Results: Almost half (47.9%) of the current waterpipe smokers used multiple tobacco products; 93.4% were dual users and 6.6% poly-users. The other tobacco products used were cigarettes (86.4%), electronic nicotine delivery systems (ENDS) (7.0%) or both (6.6%). Multiple users were more likely to be younger than waterpipe-only users. Young adult female waterpipe smokers used ENDS 12 times more than young adult males (48.8% versus 4.1% respectively). Non-daily waterpipe smoking, usually smoking at cafes, higher education and knowledge of pictorial health warnings were independent predictors of multiple tobacco product use.

Conclusion: Multiple tobacco product use was common among current waterpipe smokers in our study. Interventions to tackle non-cigarette and multiple tobacco use, especially in young adults, are urgently needed.