Factors associated with dual use of waterpipe tobacco and cigarettes among adults in Pakistan

Background: Little is known about dual use of waterpipe tobacco and cigarettes, especially in countries where both are prevalent. Aims: This study aimed to assess demographic correlates, patterns of use and quit behaviours of waterpipe users in Pakistan who also smoke cigarettes. Methods: Data were taken from a randomized controlled trial in Pakistan that assessed smoking cessation in 510 adult waterpipe users, stratified on concurrent cigarette use. Logistic regression analysis was done to assess the association between waterpipe tobacco users who also smoke cigarettes (dual use) and their demographic characteristics, smoking history and quit behaviour. Unadjusted odds ratios (OR) and adjusted OR (ORa) and 95% confidence intervals (CI) were determined. Results: Dual use was significantly associated with younger age (ORa = 0.36, 95% CI: 0.19-0.70) and middle-school educational level (11-15 years), versus no formal education, (ORa = 2.01, 95% CI: 1.15-3.50). Dual use was also associated with smoking less than all day versus all day (defined as continuously for several hours) (ORa = 2.71, 95%: CI 1.73-4.25) and younger age at starting smoking (ORa = 0.95, 95% CI: 0.93-0.98). No association was found between dual use and sex, marital status, duration of smoking, nicotine dependence or quit history. Conclusion: Waterpipe tobacco users who also smoke cigarettes differ from waterpipe-only users, particularly in demographic characteristics. More research is needed to explore the interaction between these two smoking behaviours. Health promotion and cessation interventions in Pakistan should consider tailoring their approach to account for the unique characteristics of dual waterpipe and cigarette users.