***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: INTRODUCTION While cross-sectional studies have shown that hookah tobacco smoking ( HTS ) is an increasingly popular behavior among university students , little is known about factors associated with initiation . This study sought to determine associations between knowledge , attitudes , and normative beliefs and initiation of  HTS  among university students . METHODS Data were from a prospect i ve longitudinal cohort study of 569 r and omly selected first- and second-year university students .  Online question naires that were developed in accordance with our composite theoretical model were completed in September 2010 and April 2011 . RESULTS About one-seventh ( 13 % ) of participants initiated HTS by follow-up . Positive attitudes and favorable normative beliefs were associated with increased adjusted odds of initiation ( AOR = 4.12 , 95 % CI = 2.56 , 6.59 ; and AOR = 2.01 , 95 % CI = 1.35 , 2.99 , respectively ) , while negative attitudes were associated with decreased adjusted odds ( AOR = 0.62 , 95 % CI = 0.48 , 0.80 ) . Correct knowledge regarding toxicants associated with HTS was not significantly associated with initiation . CONCLUSIONS While positive attitudes and favorable normative beliefs are associated with initiation of  HTS  in a cohort of never-users , increased knowledge about toxins is not associated with lower initiation . It may be particularly valuable for educational interventions to attempt to alter positive attitudes and normative beliefs related to HTS Background Although waterpipe tobacco smoking seems to be increasing on U.S. university campuses , these data have come from convenience sample s. Purpose We aim ed to determine the prevalence of and associations with waterpipe tobacco smoking among a r and om sample of students . Methods We surveyed a r and om sample of graduate and undergraduate students at a large , urban university . We used multivariate modeling to determine independent associations between belief-related predictors and waterpipe tobacco smoking . Results Of the 647 respondents ,  waterpipe smoking was reported in 40.5 % , over the past year in 30.6 % , and over the past 30 days in 9.5 % . Over half of the sample ( 52.1 % ) perceived that tobacco smoking from a waterpipe was less addictive than cigarette smoking . In fully adjusted multivariate models , 1-year waterpipe smoking was associated with low perceived harm ( OR = 2.54 , 95 % CI = 1.68 , 3.83 ) , low perceived addictiveness ( OR = 4.64 , 95 % CI = 3.03 , 7.10 ) , perception of high social acceptability ( OR = 20.00 , 95 % CI = 6.03 , 66.30 ) , and high perception of popularity ( OR = 4.72 , 95 % CI = 2.85 , 7.82 ) . Conclusions In this sample , lifetime waterpipe use was as common as lifetime cigarette use . Perception of harm , perception of addictiveness , social acceptability , and popularity were all strongly related to waterpipe smoking INTRODUCTION Tobacco use in low- to middle-income countries is a major public health concern for both smokers and those exposed to environmental tobacco smoke ( ETS ) . Egypt has made important strides in controlling tobacco use , but smoking and ETS remain highly prevalent . This r and omized intervention sought to improve the target population 's knowledge regarding the hazards of smoking and ETS and to change attitudes and smoking behaviors within the community and the household . METHODS In this 2005 - 2006 study in Egypt 's Qalyubia governorate , trained professionals visited schools , households , mosques , and health care centers in rural villages r and omly selected for the intervention to discuss the adverse effects of smoking and ETS exposure and ways to reduce one 's ETS exposure . Data collected in interviewer-facilitated surveys before and after the intervention period were analyzed in pairwise comparisons with data from control villages to assess the effectiveness of the intervention in achieving its aims . RESULTS The intervention group showed a greater increase in underst and ing the dangers associated with smoking cigarettes and waterpipes  and became more proactive in limiting ETS exposure by asking smokers to stop , avoiding areas with ETS , and enacting smoking bans in the home . However , the intervention had little to no impact on the number of smokers and the amount of tobacco smoked . CONCLUSIONS Results are consistent with previous studies showing that changing smokers ' behavior can be difficult , but community-wide efforts to reduce ETS exposure through smoking bans , education , and empowering people to ask smokers to stop are effective . The method can be generalized to other setting INTRODUCTION Although water pipe tobacco smoking is common in Lebanon and Syria , prevalence in neighboring Jordan is uncertain . The purpose s of this study were ( a ) to assess the prevalence of  water pipe tobacco smoking among university students in Jordan and ( b ) to determine associations between sociodemographic variables and water pipe tobacco smoking in this population . METHODS A trained interviewer administered a question naire among r and omly selected students at four prominent universities in Jordan . The question naire assessed sociodemographic data , personal history of water pipe tobacco use , and attitudes regarding water pipe tobacco smoking . We used logistic regression to determine independent associations between sociodemographic and attitudinal factors and each of two dependent variables : ever use of water pipe and use at least monthly . RESULTS Of the 548 participants , 51.8 % were male and mean age was 21.7 years . More than half ( 61.1 % ) had ever smoked tobacco from a water pipe , and use at least monthly was reported by 42.7 % . Multivariable analyses controlling for all relevant factors demonstrated significant associations between ever use and only two sociodemographic factors : ( a ) gender ( for women compared with men , odds ratio [ OR ] = 0.11 , 95 % CI = 0.07 - 0.17 ) and ( b ) income ( for those earning 500 - 999 Jordanian dinar ( JD ) monthly vs. < 250 JD monthly , OR = 2.37 , 95 % CI = 1.31 - 4.31 ) . There were also significant associations between perception of harm and addictiveness and each outcome . DISCUSSION Water pipe tobacco smoking is highly prevalent in Jordan . Although use is associated with male gender and upper middle income levels , use is widespread across other sociodemographic variables . Continued surveillance and educational interventions emphasizing the harm and addictiveness of water pipe tobacco smoking may be valuable in Jordan INTRODUCTION In Egypt , each faculty has it own students ' union , which represents the students and collaborates in organizing all educational , sporting and social activities . The objectives of the current study were to evaluate the knowledge of members of students ' unions about cigarette and Shisha smoking together with assessing their attitudes towards smoking in public places in general and in the university . METHODOLOGY A r and om sample of members of Ain Shams University Students ' Unions was subjected to an interview question naire . All participants were individually interviewed face-to-face by a trained interviewer from March 1 , 2005 to April 30 , 2005 . RESULTS Our study showed that 34 ( 31.5 % ) students were smokers . The mean knowledge score percentage was 79.4 + /- 20.7 . Regarding knowledge about Shisha smoking hazards , the majority of the students ( 84.3 % ) knew that Shisha smoking is hazardous . The mean attitude score percentage was 56.8 + /- 22.2 . Smokers had less mean knowledge as regard smoking hazards compared to non-smokers ( p < 0.01 ) . Also , smokers had a lower mean attitude compared to non-smokers ( p < 0.001 ) . More than one-third ( 38.9 % ) of the interviewed students did n't know if the students ' union has a policy for prevention of smoking or not . CONCLUSION Our findings point that although our students had a moderately high mean knowledge score yet this did n't increase their attitude about the smoking problem in the university and in the community . This supports the notion that , in addition to knowledge about smoking hazards , efforts are needed to change beliefs that allow this offensive habit to continue SETTING Waterpipe smoking is becoming a global health crisis among youth . OBJECTIVE To identify the prevalence of waterpipe use among Iranian university students and to explore perceived reasons for use . METHODS A r and om sample of 1024 university students at two major universities in South Iran was enrolled in the study . A three-part question naire ( baseline data , tobacco smoking status and perceived reasons for waterpipe use ) was used . Students filled out the self-administered question naire in their classrooms . RESULTS The prevalence of waterpipe smoking in the respondents ' lifetime and in the last 30 days was 42.5 % and 18.7 % , respectively . The mean age at initiation of waterpipe smoking was 16.3 ± 3.2 years . Ever smoking was positively associated with age and male sex , whereas no association was found regarding marital status . The highest odds of lifetime waterpipe smoking were observed in students with close friends who smoked the waterpipe ( 5.94 , 95%CI 4.26 - 8.30 ) . The most important perceived reason for waterpipe smoking as stated by students was enjoyment ( 55.8 % ) . CONCLUSION Given the alarming prevalence of waterpipe smoking , preventive measures should be adopted among university students taking into account the influence of peers , siblings and parents in the lessening social tolerance of waterpipe smoking Background and objectives Narghile is becoming the favorite form of tobacco use by youth globally . This problem has received more attention in recent years . The aim of this study was to investigate the prevalence and pattern of narghile use among students in three public Jordanian universities ; to assess their beliefs about narghile 's adverse health consequences ; and to evaluate their awareness of oral health and oral hygiene . Methods The study was a cross-sectional survey of university students . A self-administered , anonymous question naire was distributed r and omly to university students in three public Jordanian universities during December , 2008 . The question naire was design ed to ask specific questions that are related to smoking in general , and to narghile smoking in specific . There were also questions about oral health awareness and oral hygiene practice s. Results 36.8 % of the surveyed sample indicated they were smokers comprising 61.9 % of the male students and 10.7 % of the female students in the study sample .  Cigarettes and narghile  were the preferred smoking methods among male students ( 42 % ) . On the other h and , female students preferred narghile only ( 53 % ) . Parental smoking status but not their educational level was associated with the students smoking status . Smokers had also significantly poor dental attendance and poor oral hygiene habits . Conclusion This study confirmed the spreading narghile epidemic among young people in Jordan like the neighboring countries of the Eastern Mediterranean region . Alarming signs were the poor oral health awareness among students particularly smokers National data indicate nearly a quarter of college students smoked from a hookah at some point in their lifetime regardless of gender . To address this issue , research ers assessed the perceptions , knowledge , beliefs of  hookah users at a large Midwestern University and also determined what other drug related high-risk behaviors were associated with this behavior . An anonymous , online survey was sent to 2,000 r and omly selected undergraduate students from a large Midwestern University . Research ers used a cross sectional research design to determine the prevalence and motivating factors associated with hookah use . Respondents included 438 individuals ( 60 % female ) with an average age of 23.1 ( SD = 12.32 ) , yielding a response rate of 22 % . Approximately 15.4 % of the sample had previously smoked hookah , while 6 % used hookah within the past 30 days . Common motivating factors associated with smoking hookah included socializing/partying ( 29 % ) , peer influence ( 27 % ) , and for relaxation ( 25 % ) . Correlations were calculated comparing hookah use to other high risk behaviors with the two highest correlations consisted of 30-day tobacco use ( r = 0.67 ) and marijuana ( r = 0.39 ) . The results from this study suggest hookah use is limited to a small percentage of students . Students appear to smoke hookah for social reasons and underestimate the addictive properties associated with the product . Research ers and practitioners need to develop and evaluate specific interventions to educate college students about the health hazards associated with hookah use Introduction Hookah smoking is becoming increasingly popular among young adults and is often perceived as less harmful than cigarette use . Prior studies show that it is common for youth and young adults to network about substance use behaviors on social media . Social media messages about hookah could influence its use among young people . We explored normalization or discouragement of hookah smoking , and other common messages about hookah on Twitter . Methods From the full stream of tweets posted on Twitter from April 12 , 2014 , to May 10 , 2014 ( approximately 14.5 billion tweets ) , all tweets containing the terms hookah , hooka , shisha , or sheesha were collected ( n = 358,523 ) . The hookah tweets from Twitter users ( tweeters ) with high influence and followers were identified ( n = 39,824 ) and a r and om sample of 5,000 tweets was taken ( 13 % of tweets with high influence and followers ) . The sample of tweets was qualitatively coded for normalization ( ie , makes hookah smoking seem common and normal or port 
    Output:
    
Socio-cultural and peer influences were major contributing factors that encouraged students to initiate WTS .
Furthermore , WTS dependence had two components : psychological and social .
This was compounded by the general perception that WTS is a less harmful , less addictive and more sociable alternative to cigarette smoking .
Knowledge of WTS harms failed to correlate with a reduced risk of WTS use , and some students reported symptoms of WTS addiction .
A large proportion of students believed that quitting WTS was easy , yet few were able to do so successfully .
Finally , students believed current public health campaigns to educate on WTS harms were inadequate and , particularly in the global north , were not required .
Conclusion Reasons for WTS amongst university students are multi-faceted .