Hookah Smoking: The Past and Future of Tobacco

1. Hookah Smoking:The Past and Future of Tobacco? Brian Primack, MD, EdM, MS Assistant Professor of Medicine and Pediatrics May 2008

3. Terminology Hookah Waterpipe Shisha-Pipe Narghile Bong Hubble-bubble

5. www.hookah-bars.com

15. Hours Sunday � Thursday: 4 PM � 12:30 AM Friday � Saturday: 4 PM � 2 AM

16. Flavors Fruit Apple Banana Cherry Melon Candy Bubble gum Chocolate mint Alcohol Margarita Pi�a colada

17. 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

18. 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

19. 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

20. Superior Quality Regular $9Large $12 Apple, Strawberry, Grape, Rose

21. * 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

22. Also Have Fruit Smoothies (e.g. Strawberry, Banana, Mango, Guava) Ice Cream Coffee and Tea Milk Shakes Desserts Games (Mancala, Dominoes)

24. Apple Shaped, $35

25. Silver Crane$120

26. $200(It rotates!)

27. $600

28. $13 for 250 gm

29. $20 Sampler

30. 16 Coals for $4

31. 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

32. Smoking Topography

33. Known Harm Waterpipe smoke contains ... Carcinogens Carbon monoxide Nicotine Waterpipe smoking associated with ... Cancer Cardiovascular disease Decreased pulmonary function Nicotine dependence

34. Waterpipe > Cigarettes Tar Nicotine CO Heavy Metals

36. Growing U.S. Prevalence 200-300 new waterpipe caf�s 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%

37. Holes in Literature Random sample Associations between waterpipe smoking and Demographics Beliefs (e.g., harm, addiction, popularity) Populations outside college

38. STUDY 1: COLLEGE

39. Purpose 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

40. 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

41. Approvals University of Pittsburgh Institutional Review Board University Vice Provost

42. 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

43. Demographic Measures Age Gender Race Residence (on-vs. off-campus) Undergraduate vs. graduate Membership in a fraternity or sorority Self-reported academic achievement

44. Theory of Reasoned Action

45. 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)

46. 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�)

47. 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

48. Analysis 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

49. 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)

50. Sample

51. Smoking Data

52. Past-Year Waterpipe Tobacco Smoking

53. Harm, Addictiveness

54. Acceptability, Popularity

59. Other Factors Associated with1-Year WPTS Younger age Off campus Fraternity membership

60. 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

61. Cigarettes vs. Waterpipe Many waterpipe smokers had never smoked cigarettes In non-cigarette smokers Problematic Introducing nicotine to previously na�ve population In cigarette smokers Substitution? Augmentation?

62. 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.

63. Limitations 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

64. Conclusion 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

65. STUDY 2: HIGH SCHOOL

66. Purpose Determine prevalence in statewide sample of high school students Determine associations with waterpipe use in high school

67. No High School National Data Monitoring the Future Youth Risk Behavior Surveillance Survey Others

68. Arizona 2005 Youth tobacco survey Added 2 items dealing with waterpipe tobacco smoking Ever Past 30 days

69. Participants Statewide representative sample Grades 6-12 All students enrolled in public and/or charter schools

70. Procedure Schools chose to use active or passive consent forms (89% used passive) Spring semester 2005 45 minute class period

71. 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

72. Analysis Sociodemographic trends Multivariate analyses

76. Multivariate Analysis: Ever Use

77. Multivariate Analysis: 30-Day Use

78. 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

79. Age High school: older College: younger Surrogate for alcohol use?

80. Experimentation vs. Addiction May lead to increased uptake of various types of nicotine Gateway to cigarette smoking?

81. Surveillance National studies (MTF, YRBS) should track this form of tobacco use Likely to increase Less harsh Flavored Educational gaps Policy issues

82. Anything National? ACHA including 2 items in NCHA in 2009 Random sample of 7619 college students

83. National Pilot Data

84. 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