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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

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hookah smoking the past and future of tobacco

Hookah Smoking:The Past and Future of Tobacco?

Brian Primack, MD, EdM, MS

Assistant Professor of Medicine and Pediatrics

April 2009

terminology
Terminology
  • Hookah
  • Waterpipe
  • Shisha-Pipe
  • Narghile
  • Bong
  • Hubble-bubble
hours
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

Flavors
slide17
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
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

slide19
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
Superior Quality Regular $9Large $12

Apple, Strawberry, Grape, Rose

slide21
* 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
Also Have
  • Fruit Smoothies (e.g. Strawberry, Banana, Mango, Guava)
  • Ice Cream
  • Coffee and Tea
  • Milk Shakes
  • Desserts
  • Games (Mancala, Dominoes)
smoke exposure
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
Smoking Topography

1Shihadeh 2003; Shihadeh 2004

2Breland 2005; Djordjevic 2000

blood nicotine level
Blood Nicotine Level

=

Shafagoj, 2002

known harm
Known Harm
  • Waterpipe smoke contains ...
    • Carcinogens
    • Carbon monoxide
    • Nicotine
    • Tar
    • Metals
  • Waterpipe smoking associated with ...
    • Cancer
    • Cardiovascular disease
    • Decreased pulmonary function
    • Nicotine dependence
history
History
  • India, ~1600?
  • EMR = Eastern Mediterranean Region
    • Syria
    • Lebanon
    • Israel
    • Egypt
    • Jordan
prevalence globally
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
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
Holes in Literature
  • Random sample
  • Associations between waterpipe smoking and
    • Demographics
    • Beliefs (e.g., harm, addiction, popularity)
  • Populations outside college
purpose
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
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
Approvals
  • University of Pittsburgh Institutional Review Board
  • University Vice Provost
procedure
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
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
Theory of Reasoned Action

Norms

Intent

Behavior

Attitudes

behavior measures
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)
attitudes
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
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
Response Rate
  • 61 emails undeliverable
  • Response rate 660/3539 = 18.6%
  • 647/660 (98.0%) had outcome data
other factors associated with 1 year wpts
Other Factors Associated with1-Year WPTS
  • Younger age
  • Off campus
  • Fraternity membership
major findings
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
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
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
Limitations
  • Response rate: 18.6%
  • Cross-sectional design
purpose1
Purpose
  • Determine prevalence in statewide sample of high school students
  • Association with waterpipe use in high school
no high school national data
No High School National Data
  • Monitoring the Future
  • Youth Risk Behavior Surveillance Survey
  • Others
arizona 2005
Arizona 2005
  • Youth tobacco survey
  • Added 2 items dealing with waterpipe tobacco smoking
    • Ever
    • Past 30 days
participants
Participants
  • Statewide representative sample
  • Grades 6-12
  • All students enrolled in public and/or charter schools
procedure1
Procedure
  • Schools chose to use active or passive consent forms (89% used passive)
  • Spring semester 2005
  • 45 minute class period
measures
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
major findings1
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
slide79
Age
  • High school: older
  • College: younger
  • Surrogate for alcohol use?
experimentation vs addiction
Experimentation vs. Addiction
  • May lead to increased uptake of various types of nicotine
  • Gateway to cigarette smoking?
surveillance
Surveillance
  • National studies (MTF, YRBS) should track this form of tobacco use
  • Likely to increase
    • Less harsh
    • Flavored
    • Educational gaps
    • Policy issues
national college health assessment
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)
other tobacco types
Other Tobacco Types

* Includes little cigars, cigarillos

question you be the judge
Question—You Be the Judge!
  • Athletes
    • Varsity
    • Club
    • Intramural
  • Tobacco use
    • Waterpipe
    • Cigarette
implications
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
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
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?
limitations1
Limitations
  • Not nationally representative
  • Response rate 28%
  • No biochemical verification
conclusion
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

Thanks!

bprimack@pitt.edu