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PubMedDate not supplied

Etiology of exudative pleural effusions in adults in North Lebanon.

OBJECTIVE: To establish the clinical pattern and etiology of exudative pleural effusions in adults in North Lebanon. MATERIALS AND METHODS: All patients aged 21 years and older who were admitted with exudative pleural effusions to the Husseini Hospital, Tripoli, North Lebanon, between 1997 and 1999 were studied prospectively. RESULTS: Of 165 patients with exudative pleural effusions, 114 (69.1%) were men and 51 (30.9%) were women. The most frequent cause of exudative pleural effusions was tuberculosis (43.7%), followed by malignancy (32.1%). The majority (88.7%) of malignant pleural effusions were due to lung cancer. Tuberculous effusions were more frequent in the first five decades of life (66.7%) and were the most common type of pleural effusion, accounting for 68.6% of patients younger than 50 years of age. Malignant effusions were more frequent among the older age groups, with 73.6% of patients with malignant effusions being older than 50 years of age. Most types of exudative pleural effusions showed a preference for the right side of the thorax. Of the diagnostic procedures used in the present study, the most useful were histological examination and culture of pleural biopsies. CONCLUSIONS: In North Lebanon, the clinical pattern and etiology of exudative pleural effusions are similar to those in the developing countries; the most frequent cause of pleural exudates is tuberculosis, followed by malignancy, particularly malignancy due to lung cancer.

Adult↗
PubMed1997

National surveillance of poultry diseases in Lebanon.

From 1992 to mid-1996, a national survey of poultry diseases in Lebanon was conducted. This surveillance included meat breeder, layer breeder, commercial layer and chicken broiler flocks. The history, signs, lesions and laboratory tests of poultry were used in the diagnosis of prevalent poultry diseases. Culture techniques were used to screen for bacterial diseases; serological techniques and, to a lesser extent, culture techniques were used to diagnose viral diseases; and both serological and culture techniques were used to diagnose Mycoplasma infections. The outbreaks of diseases detected in broiler breeder flocks and the number of such flocks experiencing these diseases were as follows: femoral head necrosis (6), egg-drop syndrome (3), reovirus-associated malabsorption syndrome (3), synovitis (Mycoplasma synoviae infection) (7), swollen head syndrome (SHS) (3), tenosynovitis (viral arthritis) (1), lymphoid leukosis (3), avian encephalomyelitis (1), fowl pox (1) and aortic rupture (1). The disease outbreaks detected in layer breeders were as follows: SHS (2), bumble foot (2), egg-drop syndrome (3) and avian infectious bronchitis (IB) (1). The disease outbreaks detected in commercial layer flocks were as follows: egg-drop syndrome (5), avian infectious laryngotracheitis (2), avian IB (nephrogenic strain) (1), malabsorption (1), avian tuberculosis (Mycobacterium avium) (1), Marek's disease (1), fowl pox (1), Salmonella enterica subsp. enterica Enteritidis infection (1), salpingitis (1) and Heterakis gallinae infestation (1). The disease outbreaks detected in broiler flocks were as follows: colibacillosis (40), infectious bursal disease (Gumboro disease) (15), malabsorption syndrome (8), avian infectious laryngotracheitis (8), paratyphoids (salmonellosis) (7), femoral head necrosis (8), SHS (6), avian mycoplasmosis (Mycoplasma gallisepticum infection) (6), synovitis (7), avian IB (6), botulism (1), avian encephalomyelitis (1) and gangrenous dermatitis (1). Diseases which occurred and which were reported for the first time in Lebanon were as follows: bumble foot, femoral head necrosis, avian IB (nephrogenic strain), malabsorption syndrome and SHS. This surveillance helped to establish baseline data concerning the predominant poultry diseases in Lebanon. Such information is a prerequisite for future regional and international collaboration to identify the source of the aetiological agents and to control their spread to neighbouring countries.

Adenoviridae Infections↗
PubMedDate not supplied

In-hospital mortality after acute myocardial infarction in Lebanon: incidence, associations, and influence of newer treatment regimens.

PURPOSE: To study the incidence of in-hospital mortality following acute myocardial infarction in Lebanon, and its relationship to demographic, clinical variables, and therapeutic strategies. PATIENTS & METHODS: Consecutive admissions due to myocardial infarction to 18 medical centers in various regions of Lebanon were entered into the Lebanese Myocardial Infarction Study, conducted between January and July 1996. Information was obtained on age, gender, time of onset of symptoms, delay to hospital arrival, mode of transport, and coronary risk factor analysis. The patients were followed up in hospital for analysis of modes of therapy, complications and mortality. RESULTS: There were 44 in-hospital deaths among the 433 admissions (10.2%), which is a rate lower than those previously reported from Lebanon. Less than half the patients presented within 6 hours of onset of symptoms and only 28% received thrombolytic therapy. The mortality rate was higher in older age groups, those presenting with cardiogenic shock or pulmonary edema, those with a history of angina, infarction or heart failure, and those who developed recurrent ischemia or infarction during their hospital stay. Furthermore, occurrence of ventricular arrhythmias, mechanical complications, congestive heart failure and left bundle branch block was associated with a higher mortality rate. Treatment with angiotensin converting enzyme inhibitors, beta-blockers, aspirin, heparin, nitrates and thrombolytics significantly reduced mortality rates. CONCLUSIONS: The results reveal improvement in the survival of patients after acute myocardial infarction to values similar to those reported from Western countries. Further effort should be expended to enhance early arrival to the hospital, increased thrombolytic therapy and to implement treatment strategies supported by large clinical trials such as use of aspirin, ACE inhibitors and beta-blockers.

Adult↗
PubMed2001

[Human brucellosis. Retrospective studies of 63 cases in Lebanon].

OBJECTIVES: We performed an epidemiological survey to ascertain the clinical features of brucellosis in Lebanon. PATIENTS AND METHODS: Between 1994 and 1998, 63 patients were seen at the Hôtel-Dieu de France Hospital in Beirut Lebanon. Diagnostic criteria were brucellar agglutinins at a titer > or = 1/160 with symptoms suggestive of brucellosis in the absence of another diagnosis. We also conducted a survey in 1138 cases registered by the Ministry of Health during the same period. RESULTS: Among the 1137 cases, 40% of the patients were over 60 and only 16% were under 14. The overall male to female ratio was 1.01 and 69% of the patients were seen in spring and summer. Among the 63 patients, 10 were pediatric cases. The disease was acute in 41 (65%), subacute in 21 (33%) and chronic in 1. The main presenting symptoms were fever, sweating, easy fatigability and joint pain. Osteoarticular involvement was the most prevalent complication (25%), predominantly spondylitis. Among the blood tests, relative lymphocytosis was significantly more frequent in children than adults (80% versus 13%, p < 0.001). CONCLUSION: Brucellosis is still an endemic disease in Lebanon and should be considered notably in patients presenting with prolonged fever, and articular and neurological manifestations.

Adolescent↗
PubMed2003

Cost of work-related injuries in insured workplaces in Lebanon.

OBJECTIVE: To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics. METHODS: A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims. FINDINGS: The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers. CONCLUSION: The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.

Accidents, Occupational↗
PubMedDate not supplied

Glycopeptide and oxacillin activity against Staphylococcus aureus isolates at a tertiary care center in Lebanon.

BACKGROUND: Worldwide reports have noted the emergence of glycopeptide-intermediate Staphylococcus aureus (GISA). However, data from Lebanon is lacking. METHODS: We conducted a study to determine the minimum inhibitory concentrations (MICs) for oxacillin (OXA), vancomycin (VAN) and teicoplanin (TEC) against consecutive clinical isolates of S. aureus at a tertiary care center in Lebanon. The categorization of isolates as susceptible, intermediately-resistant, or resistant was based on the OXA agar screen plate (OS) and the 1 microg OXA disk diffusion (OD) according to the National Committee for Clinical Laboratory Standards (NCCLS) guidelines. The MICs of OXA, VAN and TEC against these isolates were determined using the E-test. RESULTS: We tested 147 S. aureus isolates, 108 of which were methicillin-resistant (MRSA) and 39 methicillin-susceptible (MSSA). The rar ges of MICs (microg/ml) among MRSA and MSSA isolates respectively were : OXA 1.5- > or = 256 and 0.19-3; VAN 1-3 and 1.5-3; TEC 0.094-3 and 0.19-2. The MIC50/90 (microg/ml) for MRSA versus MSSA isolates were, respectively: 24/ > or = 256 vs. 1/2 for OXA; 2/3 vs. 2/2 for VAN; 1/1.5 vs. 0.75/1.5 for TEC. CONCLUSION: This data indicates that despite the presence of high rates of MRSA (around 38%), these strains remain fully susceptible to VAN and TEC. We did not detect any GISA at this tertiary care referral medical center in Lebanon.

Adolescent↗
PubMedDate not supplied

Planning dental manpower in Lebanon: scenarios for the year 2015.

The requirements for dentists in Lebanon for the year 2015 were estimated using the World Health Organization/World Dental Federation planning model. The aim was to help decision- and policy-makers in Lebanon to plan strategically for the supply of dental personnel in line with the recommendations of the Oral Health National Plan guidelines from 1995. Assumptions based on previous research in selected populations were taken to support the simulation. The number of dentists required for Lebanon in the year 2015 was estimated to be 2715 while the projected supply will be 6176. Urgent measures are needed to reduce the potential oversupply of dentists in this country.

Adolescent↗
PubMedDate not supplied

Epidemiology of HIV infection in Lebanon. Data from 1985-2005.

Lebanon is considered among the countries where the HIV epidemic is still in its early phase of spread. Little information is available on the magnitude of the problem due to the lack of an efficient surveillance system. In this review, we report on the epidemiology of HIV infection in Lebanon, based on limited data generated by the Lebanese National AIDS Control Program (NAP). By May 2005, a cumulative number of 813 cases had been diagnosed. The most prevalent mode of HIV transmission in Lebanon is heterosexual exposure accounting for around 50% of the cases. Two hundred ninety-six patients (36.4%) fulfilled the AIDS case definition. Despite the availability of highly active antiretroviral therapy (HAART) provided by the Ministry of Health, the disease burden of HIV infection remains unknown in this country.

Adolescent↗
PubMed1984

Causes of diarrheal disease in soldiers stationed in Lebanon and in northern Israel.

A study of acute gastroenteritis in soldiers was carried out during a 1-year period. Causes of diarrhea were compared between 33 soldiers stationed in southern Lebanon and 174 soldiers stationed in northern Israel. Shigella sp. caused 42.4% of diarrheal disease in Lebanon, compared with only 19.0% of cases in Israel. Sh. flexneri was a more common cause of bacillary dysentery in Lebanon than in Israel (71.4 vs. 18.2%, respectively), and caused a more severe illness.

Diarrhea↗
PubMedDate not supplied

Cancer in Lebanon: analysis of 10,220 cases from the American University of Beirut Medical Center.

Cancers seen and recorded between 1983 and 1995 in the Hospital Tumor Registry at the American University of Beirut Medical Center (AUBMC), one of the largest primary and tertiary care hospitals in Lebanon, were retrospectively reviewed and analyzed. There was a total of 10,220 cases, excluding 916 skin cancers other than skin melanoma, averaging 786 cases per year. There were 5086 cancer cases in males with the five most common cancers being: lung cancer (915 cases: 17.9%) followed by bladder cancer (503 cases: 9.8%), larynx (438 cases: 8.6%), lymphoma (393 cases: 7.7%) and leukemia (336 cases: 6.6%). As for female cancer cases, a total of 5134 cases were observed with the five most common cancers being: breast cancer (1821 cases), followed by cervical cancer (535 cases), colo-rectal cancer (256 cases: 4.9%), lymphoma (232 cases: 4.5%), and brain cancer (213 cases: 4.1%). The average age for all cancer cases was 50.5 years with a standard deviation (SD) of 18.8 years. The average age of females (48.8 yrs; SD 17.4) was relatively lower than that of males (52.2 yrs; SD 19.9) and the difference was statistically significant. 40.6% of the patients were under the age of 50 years. 49% of breast cancer patients were below 50 years of age. In children less than 15 years of age, there were 555 cases, with leukemia being the commonest (185 cases: 33.3% of childhood cases) followed by brain cancer (112 cases: 20.1%), lymphoma (63 cases: 11.3%), bone cancer (41 cases: 7.3%), soft tissue sarcoma (35 cases: 6.3%) and kidney cancer (28 cases: 5.0%). Lung cancer in males and breast cancer in females are the most common cancers in Lebanon. These cancers are amenable to prevention (cigarette cessation and anti-smoking campaigns for lung cancer) and early detection (screening, regular breast examination and mammography for breast cancer). Our paper emphasizes the importance of addressing those and other issues including bladder cancer and age at diagnosis of breast cancer. It also presents important epidemiological and historical reference data on cancer in Lebanon during the civil war and immediately after it.

Adolescent↗
PubMed1973

Microbiology of Lebanon bologna.

Various aspects of the microbiology of the Lebanon bologna process were studied. Manufacture of Lebanon bologna appeared to be similar to that of summer sausage and other fermented sausages and consisted of a lactic acid fermentation by lactobacilli accompanied by the production of cured meat color from the reduction of nitrate by micrococci. The traditional process consists of aging coarse ground beef at 5 C for several days. Aging the beef for about 10 days was necessary to allow development of lactic acid bacteria; for successful fermentation, the concentration of lactic acid producers must be 10(4)/g or more. At least 3% NaCl was necessary to suppress the development of pseudomonads during the aging period; higher concentrations of salt suppress the development of the lactic acid-producing flora. During aging, in the presence of salt, the predominant flora developing on the meat consisted of catalase-positive, gram-positive rods and cocci; during fermentation at 35 C, the predominant flora became catalase-negative, gram-positive rods with characteristics of lactobacilli. Lebanon bologna could be made from frozen beef if the meat was thawed, salted, and aged. However, bolognas could not be made from unaged beef unless a lactic acid starter culture was used. The microflora of several commercial bolognas is reported also.

Animals↗
PubMed2001

Survival of Escherichia coli O157:H7, Salmonella typhimurium and Listeria monocytogenes in and on vacuum packaged Lebanon bologna stored at 3.6 and 13.0 degrees C.

Escherichia coli O157:H7, Salmonella Typhimurium, or Listeria monocytogenes was spread onto the surface of Lebanon bologna luncheon slices using sterile glass rods. The inoculated slices were stacked and vacuum packaged. The packages were stored at 3.6 or 13 degrees C. The foodborne pathogens. E. coli O157:H7, Salmonella Typhimurium, or L. monocytogenes were reduced in Lebanon bologna during storage at 3.6 or 13 degrees C. The higher storage temperature (13.0 degrees C) resulted in significantly faster destruction of E. coli O157:H7 and L. monocytogenes, compared to storage at refrigeration temperature (3.6 degrees C) (P < 0.005). E. coli O157:H7 was the most resistant to destruction among the three foodborne pathogens. A linear destruction of E. coli O157:H7 occurred only after an initial lag period. Storage temperature did not have a significant effect on the rate of destruction of Salmonella Typhimurium. Foodborne pathogens inoculated prior to fermentation did not show any enhanced survival compared to control cells (inoculated after fermentation) during storage of the Lebanon bologna at 3.6 degrees C.

Animals↗
PubMed2006

Distinct association of factor V-Leiden and prothrombin G20210A mutations with deep venous thrombosis in Tunisia and Lebanon.

Factor V G1691A (FV-Leiden) and prothrombin (PRT) G20210A single nucleotide polymorphisms (SNPs) were associated with venous thrombosis among Caucasians. We assessed the contribution of both SNPs to the genetic susceptibility of deep venous thrombosis (DVT) among Lebanese and Tunisian patients. Subjects comprised 198 DVT patients and 540 healthy controls from Lebanon and 126 Tunisian DVT patients and 197 control subjects; FV-Leiden (MnlI) and PRT G20210A (HindIII) genotyping was done by PCR-RFLP. While the prevalence of FV-Leiden mutant A allele and the G/A and A/A genotypes were significantly higher among DVT patients from Lebanon and Tunisia, the association of PRT G20210A with DVT was pronounced among Lebanese but not Tunisian patients. The prevalence of PRT G20210A mutant A allele (P < 0.001 vs. P = 181) and G/A genotype (P < 0.001 vs. P = 0.994) was significantly higher among Lebanese but not Tunisians, respectively. While FV-Leiden was a common genetic risk factor for DVT in both communities, the contribution of PRT G20210A to the genetic susceptibility of DVT differed among Lebanese and Tunisians, which underscores the need to determine prothrombotic gene polymorphisms associated with DVT among Arab and Mediterranean basin communities.

Alleles↗
PubMed2003

Work-related injuries in Lebanon: does nationality make a difference?

BACKGROUND: To compare the type, severity, cause, and cost of work-related injuries between Lebanese and non-Lebanese workers in insured workplaces in Lebanon. METHODS: A total of 4,186 claims and medical reports for 3,748 work-related injuries filed in 1998 at five major insurance companies were reviewed. RESULTS: Non-Lebanese workers (46%) were younger (29 vs. 31 years), belonged mainly to the construction sector (62% vs. 29%), and were paid less (365 dollars vs. 438 dollars/month) than Lebanese workers. Non-Lebanese construction workers reported more feet and eye injuries. Falls were more common among Lebanese workers while non-Lebanese workers commonly reported being struck by an object. No differences were noted in the severity of injuries (workdays lost; hospitalization) between the two groups, but, overall cost per injury was higher among the Lebanese workers. CONCLUSIONS: There were no salient differences between Lebanese and non-Lebanese workers regarding severity of work injuries, which may reflect the disparity in access to the Lebanese heath care system by nationality. Syrian migrant workers appear to represent a special group in Lebanon. Additional, in-depth analysis of the social, political, and workplace mechanisms leading to work injuries is recommended.

Accidental Falls↗
PubMed2003

Postgraduate educational program for primary care physicians in remote areas in Lebanon.

INTRODUCTION: Continuing medical education (CME) is a requirement in many developed countries. Lebanon lacks such a rule; hence, the dictum "once a doctor always a doctor" holds. This article describes a pioneering postgraduate educational program for primary care physicians in remote areas of Lebanon. METHOD: The Lebanese Society of Family Medicine introduced a 2-year structured CME program to four remote Lebanese areas. Thirteen family physicians provided 33 activities to 1,073 primary care physicians tackling 22 subjects chosen from a list of 53 common clinical problems approved by community medical leaders. Each attendee was requested to complete an evaluation form at the end of each session. RESULTS: The activities were attended by 1,073 physicians, 914 of whom filled out the evaluation forms (85.2% response rate). The analysis of the response of the attendees revealed that 65% of the attendees completely agreed that they benefited from the activities, 68% completely agreed that the presentations were clear, 86% thought that the methods used were adequate, 57% agreed completely that the presenters were prepared, and 69% replied that enough time was available for interaction. DISCUSSION: The CME programs were conducted with minimal costs. They were well received by attendees. It is recommended that the Lebanese health authorities make CME a requirement to promote the knowledge and behavior of primary care physicians and improve health.

Education, Medical, Continuing↗
PubMed2007

Clinical epidemiology of inflammatory bowel disease in Lebanon.

BACKGROUND: The objectives of this study were to determine the prevalence and incidence of inflammatory bowel disease (IBD) in a representative Lebanese cohort and to describe practice prevalence trends, disease characteristics, and impact on quality of life (QoL) of IBD patients in Lebanon. METHODS: All of a university-based health program's 2000-2004 computerized records that listed a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were reviewed. In addition, data on patients seen in the gastroenterology clinics and data from the IBD registry at the American University of Beirut Medical Center (AUBMC) from the same period were analyzed. RESULTS: Of 15,073 insured individuals, 8 had a diagnosis of CD and 16 of UC, giving an age-adjusted prevalence of 53.1 per 100,000 people for CD and 106.2 per 100,000 people for UC. The mean age at diagnosis for patients with CD and UC was 28.8 +/- 11.1 and 32.0 +/- 13.4 years, respectively, and there was a slight female predominance. The mean annual incidence was 4.1 per 100,000 people for UC and 1.4 per 100,000 people for CD (range, 0-6.9/100,000 for both). Of the 10,383 patients seen in the gastroenterology clinic from 2000 to 2004, 251 (2.4%) had IBD (142 UC, 100 CD, and 9 indeterminate), a ratio that trended upward over time (range, 1.8%-2.7%). The median IBD Quality-of-Life (IBDQ) questionnaire score was 124.9 +/- 30.5, indicating that the disease had a moderately severe impact on QoL. CONCLUSIONS: The prevalence of IBD in this representative Lebanese cohort falls in the intermediate range of that reported for white populations in Europe and North America. Future studies are needed to examine local risk factors, disease genotypes and phenotypes, and epidemiologic time trends. The psychosocial burden of IBD in Lebanon appears significant.

Adolescent↗
PubMed1994

Antimicrobial susceptibility patterns of bacterial isolates at the American University Medical Center in Lebanon.

In Lebanon, knowledge of the prevailing pattern of bacterial resistance to antimicrobial agents has been limited, particularly because of 15 years of civil strife. Thus, the current study was conducted to determine the antimicrobial susceptibility patterns of nonselected bacterial isolates recovered from recent clinical specimens, using the standardized disk agar diffusion technique. A total of 5216 isolates (1443 Gram positive and 3773 Gram negative) were examined. Over 92% of Staphylococcus aureus and coagulase-negative staphylococci (CNS) were resistant to penicillins. Methicillin resistance was more frequently noted among CNS (28%) compared with S. aureus (18%). For the pneumococci, 27% of the isolates were resistant to penicillin G. High but variable rates of multidrug resistance were encountered among Acinetobacter spp., Pseudomonas spp., Serratia spp., Citrobacter spp., and Enterobacter spp. Ampicillin resistance was detected in 65% of Escherichia coli and in 20% of Haemophilus influenzae isolates. Although one resistant Salmonella typhi strain was observed, 17% of other Salmonella spp. and 60% of Shigella spp. proved to be resistant to ampicillin, chloramphenicol, and cotrimoxazole. Among Vibrio cholerae isolates, high resistance to tetracycline (71%) and trimethoprim-sulfamethoxazole (94%) was observed. The overall antimicrobial resistance rates in Lebanon seem to fall between figures reported from the Arabian Gulf countries (higher) and those from medical centers in the United States (lower).

Drug Resistance, Microbial↗
PubMed2004

Knowledge, attitudes, and practices of argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in Lebanon.

BACKGROUND: Currently, little is known about argileh (water pipe or hubble-bubble) and cigarette smoking among pregnant women in the Arab world, despite emerging evidence on the adverse health effects of argileh smoking and well-established knowledge about the health risks of cigarette smoking during pregnancy. OBJECTIVES: The present study assesses pregnant Arab women's knowledge of chemical contents and related harmful effects of argileh and cigarettes, their attitudes towards smoking argileh and cigarettes, and their actual smoking of argileh and cigarettes, both before and during pregnancy. METHODS: A stratified sample of 864 women from 23 health care centers in Lebanon completed a structured, interviewer-administered questionnaire. Information was collected on basic demographic variables, women's knowledge, attitudes, and cigarette and argileh smoking. RESULTS: Women were partially knowledgeable about the health risks of cigarette smoking, knew little about the harmful ingredients of argileh smoking, and had many misconceptions regarding how argileh worked or how it can produce harm. Attitudes were permissive towards all forms of smoking. Almost one quarter (23%) of participants reported smoking during pregnancy, with 17% smoking only cigarettes, 4% smoking only argileh, and 1.5% smoking both cigarette and argileh. CONCLUSION: A significant and growing percentage of pregnant Arab women are smoking in Lebanon, with four cigarette smokers for every argileh smoker. Smoking behaviors are empirically linked with important gaps in knowledge and with permissive attitudes. These data may be used to design more effective prevention programs targeting this vulnerable population.

Adult↗