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Hookah Smoking: The Past and Future of Tobacco? Brian Primack, MD, EdM, MS Assistant Professor of Medicine and Pediatrics May 2008 Terminology Hookah Waterpipe Shisha-Pipe Narghile Bong Hubble-bubble www.hookah-bars.com Hours Sunday – Thursday: 4 PM – 12:30 AM

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Hookah smoking the past and future of tobacco l.jpg

Hookah Smoking:The Past and Future of Tobacco?

Brian Primack, MD, EdM, MS

Assistant Professor of Medicine and Pediatrics

May 2008

Terminology l.jpg


  • Hookah

  • Waterpipe

  • Shisha-Pipe

  • Narghile

  • Bong

  • Hubble-bubble

Www hookah bars com l.jpg


Hours l.jpg


  • Sunday – Thursday: 4 PM – 12:30 AM

  • Friday – Saturday: 4 PM – 2 AM

Flavors l.jpg







Bubble gum

Chocolate mint



Piña colada


Slide17 l.jpg

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

Slide18 l.jpg

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


Slide19 l.jpg

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

Slide20 l.jpg

Superior Quality Regular $9Large $12

Apple, Strawberry, Grape, Rose

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* 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

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Also Have

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

  • Ice Cream

  • Coffee and Tea

  • Milk Shakes

  • Desserts

  • Games (Mancala, Dominoes)

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Apple Shaped, $35

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Silver Crane$120

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$200(It rotates!)

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13 for 250 gm l.jpg

$13 for 250 gm

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$20 Sampler

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16 Coals for $4

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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

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Smoking Topography

1Shihadeh 2003; Shihadeh 2004

2Breland 2005; Djordjevic 2000

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Known Harm

  • Waterpipe smoke contains ...

    • Carcinogens

    • Carbon monoxide

    • Nicotine

  • Waterpipe smoking associated with ...

    • Cancer

    • Cardiovascular disease

    • Decreased pulmonary function

    • Nicotine dependence

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Waterpipe > Cigarettes

  • Tar

  • Nicotine

  • CO

  • Heavy Metals

Shihadeh 2003; Shihadeh 2004; Djordjevic 2000; Hoffman, 2000

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Growing U.S. Prevalence

  • 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%

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Holes in Literature

  • Random sample

  • Associations between waterpipe smoking and

    • Demographics

    • Beliefs (e.g., harm, addiction, popularity)

  • Populations outside college

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Purpose l.jpg


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

  • Determine associations between outcome variables and sociodemographic and predictors

Design l.jpg


  • 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

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  • University of Pittsburgh Institutional Review Board

  • University Vice Provost

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  • 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

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Demographic Measures

  • Age

  • Gender

  • Race

  • Residence (on-vs. off-campus)

  • Undergraduate vs. graduate

  • Membership in a fraternity or sorority

  • Self-reported academic achievement

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Theory of Reasoned Action





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Behavior Measures

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

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

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

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  • “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 l.jpg

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

Analysis l.jpg


  • Multivariate logistic regression models

    • Dependent variables

      • 30-day waterpipe smoking

      • One year waterpipe smoking

    • Independent variables

      • Perception of harm

      • Perception of addictiveness

      • Acceptability

      • Popularity

    • Covariates

  • Sensitivity analyses with stepwise regression

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Response Rate

  • 61 emails undeliverable

  • Response rate 660/3539 = 18.6%

  • 647/660 (98.0%) had outcome data

  • Compared with non-respondents, respondents were:

    • Younger (20.9 vs. 21.4, p<0.001)

    • Female (65.6% vs. 50.5%, p<0.001)

    • Caucasian (85.4% vs. 80.7%, p=0.004)

Sample l.jpg


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Smoking Data

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Past-Year Waterpipe Tobacco Smoking

Harm addictiveness l.jpg

Harm, Addictiveness

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Acceptability, Popularity

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Other Factors Associated with1-Year WPTS

  • Younger age

  • Off campus

  • Fraternity membership

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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

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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?

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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 l.jpg


  • Response rate: 18.6%

  • Demographic differences between respondents and non-respondents

  • May have inflated our results since younger population more likely to smoke waterpipe

  • Cross-sectional design

Conclusion l.jpg


  • First random sample

  • Ever use common in this sample

  • Further research

    • Longitudinal designs

    • National samples (NCHA)

  • Educational/interventional efforts

    • Major educational gaps

    • Worthwhile to start now

    • Focus on addictiveness, acceptability, popularity

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Purpose66 l.jpg


  • Determine prevalence in statewide sample of high school students

  • Determine associations with waterpipe use in high school

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No High School National Data

  • Monitoring the Future

  • Youth Risk Behavior Surveillance Survey

  • Others

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Arizona 2005

  • Youth tobacco survey

  • Added 2 items dealing with waterpipe tobacco smoking

    • Ever

    • Past 30 days

Participants l.jpg


  • Statewide representative sample

  • Grades 6-12

  • All students enrolled in public and/or charter schools

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

  • Spring semester 2005

  • 45 minute class period

Measures l.jpg


  • 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

Analysis72 l.jpg


  • Sociodemographic trends

  • Multivariate analyses

Multivariate analysis ever use l.jpg

Multivariate Analysis: Ever Use

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Multivariate Analysis: 30-Day Use

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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

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  • High school: older

  • College: younger

  • Surrogate for alcohol use?

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Experimentation vs. Addiction

  • May lead to increased uptake of various types of nicotine

  • Gateway to cigarette smoking?

Surveillance l.jpg


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

  • Likely to increase

    • Less harsh

    • Flavored

    • Educational gaps

    • Policy issues

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Anything National?

  • ACHA including 2 items in NCHA in 2009

  • Random sample of 7619 college students

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National Pilot Data

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

  • Threatens to undermine successes from cigarette smoking

  • Surveillance and further research are necessary

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