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!
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