Hookah Smoking:The Past and Future of Tobacco?

Brian Primack, MD, EdM, MS

Assistant Professor of Medicine and Pediatrics

April 2009

Terminology

• Hookah

• Waterpipe

• Shisha-Pipe

• Narghile

• Bong

• Hubble-bubble

www.hookah-bars.com

Hours

• Sunday – Thursday: 4 PM – 12:30 AM

• Friday – Saturday: 4 PM – 2 AM

Flavors

• Fruit

–Apple

–Banana

–Cherry

–Melon

• Candy

–Bubble gum

–Chocolate mint

• Alcohol

–Margarita

–Piña colada

Good Quality Regular $7.00Large $10.00

Arabic Coffee, Apple, Apple Alex, Double Apple, Apricot, Banana,

Candy, Cappuccino, Cherry, Carmel, Coconut, Cola, Grape, Jasmine, Lemon, Mint, Mango, Mandarin, Mixed Fruit, Orange, Pistachio, Peach Rose, Salloum,

Strawberry, Vanilla, Zaghoul Light, Zaghoul, Licorice

Excellent QualityRegular $8.00Large $11.00

Double apple, Apricot, Banana, Cantaloupe, Cappuccino, Cherry,

Coconut, Mint, Melon, Orange, Peach, Pineapple, Rose, Raspberry,

Strawberry, Tutti-Frutti, Vanilla

Cognac, Margarita, Pina Colada, Strawberry

Daiquiri

Premiume Quality Regular $8.50Large $11.50

Apple, Special Apple, Bahrany Apple, Apple Eskandarani,

Banana, Cola, Cappuccino, Fruit Cocktail, Honey Melon, Mango,

Orange, Peach, Pipe, Rose, Strawberry

Superior Quality Regular $9Large $12

Apple, Strawberry, Grape, Rose

* Make your Hookah Cool with adding ice for $1

* Mix & Match Flavors Add $2

* Flavor Your Hookah Water Add $3

* Add 0.25 Per Each Person

** Minimum 1 Order Per Person **

** Bring your own bottle $2 cork charge **

You Must Be 21 to bring your own alcohol bottle

Also Have

• Fruit Smoothies (e.g. Strawberry, Banana, Mango, Guava)

• Ice Cream

• Coffee and Tea

• Milk Shakes

• Desserts

• Games (Mancala, Dominoes)

Apple Shaped, $35

Silver Crane$120

$200(It rotates!)

$600

$13 for 250 gm

$20 Sampler

16 Coals for $4

Smoke Exposure

• 30-60 minute sessions

• Each session ~100 inhalations

• Each inhalation ~500 mL in volume

• Total volume– Waterpipe session: 50,000 mL– Cigarette: 500-600 mL

Smoking Topography

VariableWaterpipe1

(N = 80)

Cigarette2

(N = 87)

Puff Number (N) 101.1 11.4

Puff Volume (mL) 503 49.4

Puff Duration (s) 2.7 1.5

Interpuff Interval (s) 22.7 26.0

1Shihadeh 2003; Shihadeh 2004

2Breland 2005; Djordjevic 2000

Waterpipe1 Cigarette2

Tar (mg) 802 22

Nicotine (mg) 3.0 1.7

CO (mg) 145 17

1Shihadeh, 2005; 2Djordjevic, 2000

Toxin (ng) Waterpipe1 Cigarette2

Arsenic 165 80

Beryllium 65 300

Chromium 1340 37

Cobalt 70 0.17

Lead 6870 60

Nickel 990 17

1Shihadeh, 2003; 2Hoffman, 2000

Blood Nicotine Level

=

Shafagoj, 2002

Known Harm

• Waterpipe smoke contains ...– Carcinogens– Carbon monoxide– Nicotine– Tar– Metals

• Waterpipe smoking associated with ...– Cancer– Cardiovascular disease– Decreased pulmonary function– Nicotine dependence

History

• India, ~1600?

• EMR = Eastern Mediterranean Region– Syria– Lebanon– Israel– Egypt– Jordan

Travel Guide to Syria/Lebanon

Prevalence Globally

• EMR– Syria: 45% report ever use– Lebanon: 30% report weekly use

• Europe– Germany– Sweden

• Other– Brazil– Korea– Canada– Ukraine

What about the US?

• 200-300 new waterpipe cafés opened in the U.S. between 1999 and 2004

• Particularly in college towns

• Convenience sample surveys suggest high current use (past 30 days)– 411 first-year college students: 15.3%– 744 introductory psychology students: 20%

Holes in Literature

• Random sample

• Associations between waterpipe smoking and– Demographics– Beliefs (e.g., harm, addiction, popularity)

• Populations outside college

STUDY 1: COLLEGE

Purpose

• Determine the 30-day, annual, and lifetime prevalence of waterpipe smoking in a random sample of college students

• Associations between smoking and predictors?

Design

• Cross-sectional survey

• Random sample of students at the University of Pittsburgh

• Collect data via web-based version of the American College Health Association’s (ACHA) National College Health Assessment (NCHA)

• Added items related to waterpipe use

Approvals

• University of Pittsburgh Institutional Review Board

• University Vice Provost

Procedure

• April 2007 during a three-week period• Avoided the 30-day period following

Spring Break• Email invitation sent to 3600 randomly

selected Pitt students• Incentive: lottery to win cash prizes

ranging from $25 to $100• Three reminder e-mails sent to students

during the three-week period

Demographic Measures

• Age

• Gender

• Race

• Residence (on-vs. off-campus)

• Undergraduate vs. graduate

• Membership in a fraternity or sorority

• Self-reported academic achievement

Theory of Reasoned Action

Norms

Attitudes

Intent Behavior

Behavior Measures

1. Have you ever smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No)

2. During the past year, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No)

3. During the past 30 days, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No)

Attitudes

• “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more harmful or less harmful than smoking regular cigarettes?” (“waterpipe more harmful” / “waterpipe same harm” / “waterpipe less harmful”)

• “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more addictive or less addictive than smoking regular cigarettes?” (“waterpipe more addictive” / “waterpipe same addictiveness” / “waterpipe less addictive”)

Normative Beliefs

• “Among your peers, how socially acceptable is it to smoke tobacco from a waterpipe (hookah, shisha, narghile)?” (“not acceptable” / “somewhat/moderately acceptable” / “very acceptable”)

• “What percentage of college students do you think has ever smoked tobacco from a waterpipe (hookah, shisha, narghile)?” (0-100%, collapsed into tertiles

Response Rate

• 61 emails undeliverable

• Response rate 660/3539 = 18.6%

• 647/660 (98.0%) had outcome data

Sample

Age (mean, SD) 20.9 (2.0)

Female (%) 65.6

White (%) 84.5

On Campus (%) 39.9

Undergraduate (%) 77.2

Fraternity/Sorority (%) 8.5

Smoking Data

0

5

10

15

20

25

30

35

40

45

Ever Past 30 Days

Per

cen

tag

e

Cigarettes

Waterpipe

Past-Year Waterpipe Tobacco Smoking

0

10

20

30

40

50

60

70

Among AllRespondents

AmongCigaretteSmokers

Among Non-Smokers

Per

cen

tag

e

Harm, Addictiveness

0102030405060708090

WP LessHarmful

WP LessAddictive

Per

cen

t

Non-Users

WP Users

Acceptability, Popularity

0

10

20

30

40

50

60

70

WP VeryAcceptable

WP VeryPopular

Per

cen

t

Non-Users

WP Users

Other Factors Associated with1-Year WPTS

• Younger age

• Off campus

• Fraternity membership

Major Findings

• Lifetime use >40%, similar to cigarette lifetime use

• Current use 9.5%

• One year use 30.5%

• Associated with lack of concern for addictiveness (and harm, less so)

• Associated with sense of acceptability and popularity

Cigarettes vs. Waterpipe

• Many waterpipe smokers had never smoked cigarettes

• In non-cigarette smokers– Problematic– Introducing nicotine to previously naïve

population

• In cigarette smokers– Substitution?– Augmentation?

Rate Differences

• 30-day rate (9.5%) much lower than annual (30.6%) and ever (40.5%) rates

• Sampling period: we avoided Spring Break, fraternity rush, etc.

Limitations

• Response rate: 18.6%

• Cross-sectional design

STUDY 2: HIGH SCHOOL

Purpose

• Determine prevalence in statewide sample of high school students

• Association with waterpipe use in high school

No High School National Data

• Monitoring the Future

• Youth Risk Behavior Surveillance Survey

• Others

Arizona 2005

• Youth tobacco survey

• Added 2 items dealing with waterpipe tobacco smoking– Ever– Past 30 days

Participants

• Statewide representative sample

• Grades 6-12

• All students enrolled in public and/or charter schools

Procedure

• Schools chose to use active or passive consent forms (89% used passive)

• Spring semester 2005

• 45 minute class period

Measures• Tobacco

– 30-day waterpipe smoking– Ever waterpipe smoking– Other tobacco smoking

• Sociodemographic data– Age– Gender– Race– Type of school (charter vs. regular)– Plan to attend college

Waterpipe Tobacco Smoking in Arizona Youth

0

2

4

6

8

10

12

14

16

6th 7th 8th 9th 10th 11th 12th

Grade Level

Per

cen

t

Ever

Past 30 Days

High School Seniors' Use of Tobacco Products in Arizona

0

10

20

30

40

50

60

Cigare

ttes

Cigars

Wate

rpip

e

Cigarill

os

Smok

eless

Pipe

Bidis

Krete

ks

Per

cen

t

Ever

Past 30 Days

Waterpipe Smoking by Race

0.0

2.0

4.0

6.0

8.0

10.0

12.0

AI/AN Black Hispanic Asian White H/PI

Per

cen

t

Ever

Past 30 Days

Multivariate Analysis: Ever UseOR Ever Use (95% CI)

Grade Level 1.6 (1.4, 1.7)

Female 0.8 (0.6, 1.1)

Asian 3.2 (1.2, 8.4)

Black 1.3 (0.5, 3.5)

Hispanic 1.4 (0.7, 2.9)

Hawaiian/PI 2.5 (0.7, 9.4)

White 3.2 (1.6, 6.4)

Charter School 1.5 (1.2, 1.8)

Plans to Attend College 0.5 (0.4, 0.6)

Multivariate Analysis: 30-Day UseOR 30-Day Use (95% CI)

Grade Level 1.4 (1.2, 1.5)

Female 0.6 (0.4, 0.9)

Asian 2.0 (0.6, 7.0)

Black 1.0 (0.3, 3.4)

Hispanic 1.4 (0.6, 3.4)

Hawaiian/PI 2.5 (0.5, 12.1)

White 2.1 (0.9, 5.0)

Charter School 1.4 (1.1, 1.9)

Plans to Attend College 0.7 (0.5, 0.98)

Major Findings

• History of waterpipe tobacco smoking– 6% of all 6th-12th graders– 15% of 12th graders

• More common than 5 other methods of tobacco smoking

• Associated with age, gender, race, SES

Age

• High school: older

• College: younger

• Surrogate for alcohol use?

Experimentation vs. Addiction

• May lead to increased uptake of various types of nicotine

• Gateway to cigarette smoking?

Surveillance

• National studies (MTF, YRBS) should track this form of tobacco use

• Likely to increase– Less harsh– Flavored– Educational gaps– Policy issues

STUDY 3: NATIONAL PILOT DATA

National College Health Assessment

• Annual

• American College Health Association

• Instrument under revision since 2006 (NCHA II)

• Addition of waterpipe items

• Pilot Spring 2008

• N = 8745 (8 schools)

Waterpipe vs. Cigarette

0

5

10

15

20

25

30

35

40

Ever Past 30 Days

Waterpipe

Cigarette

Waterpipe tobacco smoking

0102030405060708090

100

Ever Past 30 Days

Reality

Perception

Other Tobacco Types

0

5

10

15

20

25

30

35

40

Cigarettes Waterpipe Cigars* Smokeless

Ever Used

Past 30 Days

* Includes little cigars, cigarillos

By Age

0

5

10

15

20

25

30

35

40

18 19 20 21 22-25 26-30 31+

Ever Used

Past 30 Days

By School

0

5

10

15

20

25

30

35

40

200 201 202 203 204 205 206 207

Ever Used

Past 30 Days

By Living Arrangement

0

10

20

30

40

50

60

Campu

sFra

t

Off-Cam

pus

Paren

t

Other All

Ever Used

Past 30 Days

Question—You Be the Judge!

• Athletes– Varsity– Club– Intramural

• Tobacco use– Waterpipe– Cigarette

0.4

0.5

0.6

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

Varsity Club Sports Intramurals

Cigarettes

WaterpipeA

djus

ted

Odd

s R

atio

(95

% C

I) fo

r E

ver

Use

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Varsity Club Sports Intramurals

Cigarettes

WaterpipeA

djus

ted

Odd

s R

atio

(95

% C

I) fo

r 30

-Day

Use

Implications

• College athletes (and others) who would have otherwise been nicotine naïve may be vulnerable to developing lifelong nicotine dependence via waterpipe tobacco smoking

• Waterpipe perceived as “different”

Athlete Types

• Varsity– Less social time?– Less risk tolerance due to sport commitment?

• Intramural/Club– Campus leaders– More likely to engage in “trendy” behaviors– Perception as similar to alcohol?

Different Tobacco Outcomes

• Ever waterpipe smoking: 29.5%

• Current waterpipe smoking: 7.2%– Lower power?– Try once or twice but not at risk for continued

use?

Limitations

• Not nationally representative

• Response rate 28%

• No biochemical verification

Conclusion

• Waterpipe tobacco smoking represents a major potential threat to public health

• Threatens to undermine successes from cigarette smoking

• Surveillance and further research are necessary

Thanks!

bprimack@pitt.edu