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The School of Public Health. Social and Psychological Issues Regarding Waterpipe Tobacco Use. Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies. 1 st International Conference on Waterpipe Research, Oct 21-23 rd , 2013, Abu Dhabi . Goals.

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Kenneth d ward phd university of memphis and syrian center for tobacco studies

The School of PublicHealth

Social and Psychological

Issues Regarding

Waterpipe Tobacco Use

Kenneth D. Ward, PhD University of Memphis, andSyrian Center for Tobacco Studies

1st International Conference on Waterpipe Research, Oct 21-23rd, 2013, Abu Dhabi


Goals
Goals

  • What psychological and social factors encourage initiation and maintenance of waterpipe use?

    • Motivational factors

    • Perceptions of health effects

    • Perceptions of addictiveness

    • Social factors, including acceptability and availability

  • Next steps



Kenneth d ward phd university of memphis and syrian center for tobacco studies

Promoting Health: Intervention Strategies from Social and Behavioral Research, by the National Academy of Sciences.


Kenneth d ward phd university of memphis and syrian center for tobacco studies

We have less empirical evidence about determinants of Behavioral Researchinitiation than determinants of maintenance.


First use of waterpipe by university students in aleppo syria
First use of waterpipe Behavioral Research by university students in Aleppo, Syria

Maziak, et al., IJTLD, 2004


Why did you start using waterpipe it s a pleasure among friends
Why did you start using waterpipe? Behavioral Research“It’s a pleasure among friends”

Due to the boredom of having free time, I used to go with my friends to a cafe´. When they invited me to try narghile, I found it interesting and good. I felt some dizziness, but I enjoyed the taste and the smell. It was fun. And so I became a daily smoker.

Hammal et al., Tobacco Control, 2008


10 th graders in johannesburg sa
10 Behavioral Researchth graders in Johannesburg, SA

  • 20% smoke waterpipe daily

  • Most cited reasons for smoking:

    • “Nothing better to do” (46%)

    • “Helps to relax” (28%)

    • Peer Pressure (14%)

      • 39% perceived pressure to smoke waterpipe

    • Addicted (6%)

Combrink et al., SAMJ, 2010


Why did you start using waterpipe everyone does it
Why did you start using waterpipe Behavioral Research?“Everyone does it”

“…I started smoking narghile in public places. I go out with my friends. They are all [narghile] smokers. I smoke [narghile] with them to entertain myself and because I do not want to be different.”

Hammalet al., Tobacco Control, 2008


Sensory characteristics
Sensory characteristics Behavioral Research

  • Smell, taste, sight of smoke, sound of bubbling sound

    • Maziak 2004

    • Nakkash 2011

    • Roskin 2009

    • Smith-Simone 2008

"The strong flavour and strong smoke are great. I can do smoke rings and impress the ladies. There would be no point in smoking if it wasn't flavoured.” (Roskin & Aveyard, 2009)

“.. I like the smoke when it comes out as it does…When I wasn’t smoking the waterpipe, I used to look at someone who smoked it and see how the smoke comes out of it and that made me love it.”(Nakkash 2011)


Why did you start using waterpipe it s an affordable novelty
Why did you start using waterpipe? Behavioral Research“It’s an affordable novelty”

“...we can order it twice, three times...Sharing and if it’s for 10,000 L.L. and we are 3 or 4 [people], so approximately 2000 L.L. per person is affordable”

“I think if [the waterpipe was]… expensive relative to the income, it would not be that popular (...); a higher price would deter from use (Woman non-smoker - urban area)

Nakkash et al., BMC Public Health, 2011


Social aspects maintain use
Social aspects maintain use Behavioral Research

  • “Time with friends,” “communal aspects,” role as a “social lubricant,” promotion of “kinship” and “brotherhood,” relaxation, relief of boredom

    • Guiliani2010 - Roskin 2009

    • Jamil 2010 - Anjun 2008

    • Martinasek 2013 - Al Dabbagh 2005

    • Maziak 2004 - Labib 2005

    • Smith-Simone 2008 - Ghafouri 2011


Family acceptance or at least acquiescence
Family acceptance, or at least acquiescence Behavioral Research

"I have never smoked cigarettes in front of my parents. They'd be surprised, annoyed and disappointed. There is something more acceptable about shisha.”

"When I explained to my parents it was harmless, they were fine. They've tried it.”

Roskin, et al.,


More family acceptance of wp use for women than men
More family acceptance of WP use for women than men Behavioral Research

Maziak et al., Ann Epidemiol, 2004


A majority of users believe waterpipe is less harmful than cigarettes
A majority of users believe waterpipe is less harmful than cigarettes

  • U.S. samples: Abughosh, 2011; Ajiarrah 2009; Giuliani 2010; Jamil 2011; Smith 2011; Smith-Simone 2008; Sutfin 2011; Ward 2007

  • Middle East samples: (Al-Dabbagh 2005; Anjum 2008; Asfar 2005; Chaaya 2004; Erbaydar 2010; Ghafour 2011; Hammal 2008; Jawaid 2008; Labib 2007; Varsano 2003)

“I do not worry about narghile. I do not feel it is harmful. It is not more than entertainment. We have not heard about anyone who had a health problem because of the narghile.” (Hammal et al., 2008)


Perceived addictiveness
Perceived addictiveness cigarettes

  • Most users in Middle East and western countries don’t perceive themselves to be addicted (Maziak 2005; Primack 2008; Smith-Simone 2008; Ward 2005, 2007)

  • Waterpipe is perceived as less addictive than cigarettes,by WP smokers, cigarette smokers, and non-smokers (Abughosh 2011; Azab 2010; Jawaid 2008; Maziak 2004)


Which is more addictive
Which is more addictive? cigarettes

Maziak et al., Ann Epidemiol, 2004


However many frequent users do believe they are addicted
However, many frequent users do believe they are addicted cigarettes

Maziak, et al., Pharm, Biochem, Behav, 2005


Why is waterpipe perceived as less harmful addictive
Why is waterpipe perceived as less harmful/addictive? cigarettes

  • “Filtering” means less nicotine and tar get delivered

    • “From what I’ve been told, the water acts as a filter to get rid of bad stuff.”

    • “Water catches the ashes from the charcoal. Not like a cigarette filter, water is a natural filter.” (Roskin & Aveyard, 2009).

  • Flavor/smell indicate it’s safe (Dillon & Chase, 2010)

    • “Fruit flavour makes it less harmful. I don’t believe it’s as harmful as cigarettes.” (Roskin & Aveyard, 2009)


Why is waterpipe perceived as less harmful addictive1
Why is waterpipe perceived as less harmful/addictive? cigarettes

  • “If it’s so bad, why haven’t I heard about it?”

  • “Cigarettes are much more harmful, as the dangers are publicized. I don’t really see the danger [of smoking waterpipe].” (Nakkash et al., 2009)

  • “There are no warnings on TV. If there were warnings, I’d be more aware.” (Roskin & Aveyard, 2009)


Kenneth d ward phd university of memphis and syrian center for tobacco studies

Important to remember that determinants of waterpipe use are not invariant across time, population, and place.


Kenneth d ward phd university of memphis and syrian center for tobacco studies

Afifi not invariant across time, population, and place, et al., Eur J Public Health, 2009


Kenneth d ward phd university of memphis and syrian center for tobacco studies

  • Relief of boredom not invariant across time, population, and place

  • Relaxation

  • Smell

  • Taste

  • Look of pipe

  • Bubbling sound

  • Availability

  • Peer influence

  • Influence of family members

  • Novelty/experimentation

  • Affect management (stress, anxiety, depression, anger)

  • Reduced harm

  • Reduced addictiveness

  • Exoticness

  • Affordability

  • Way to quit cigarettes

  • Culturally acceptable alternative to cigarettes

  • Way to express cultural identity

Akl et al., Harm Reduction Journal, 2013


Kenneth d ward phd university of memphis and syrian center for tobacco studies

Martinasek not invariant across time, population, and place, et al., Am J Health Behavior, 2013


Positive attitudes are stronger determinant of intent to smoke wp than negative attitudes
Positive attitudes are stronger determinant of intent to smoke WP than negative attitudes

Barnett et al., Am J Health Behavior, 2013


Outcome expectancies are related to intent to initiate wp use n 722 never users
Outcome expectancies are related to intent to initiate WP use (n=722 never users)

Martinasek, unpublished data


Many social determinants but not all are available to awareness of users
Many social determinants, but not all, are “available to awareness” of users…

  • Exemptions from clean air laws (Primack 2012)

  • Failure to fully enact FCTC: only 7 Arab countries have enacted comprehensive smoking bans in public places, while the rest have partial or no bans and enforcement remains low overall (WHO 2009, reported in Maziak 2013)

  • Mismatch of FCTC goals with waterpipe

    • E.g., packaging/labeling is more complicated with WP due to variability compared to cigarettes (Maziak, Nakkash,et al., 2013)


Summary
Summary awareness” of users…

  • Social nature of WP use (“a pleasure among friends,” relaxation, peer/family influence) is major determinant of initiation and maintenance

  • Need to “deglamorize and renormalize” WP use (Maziak et al., 2007)

  • More “upstream” determinants are wide availability promoted by absent/unenforced policies such as clean air laws, inexpensiveness, lack of knowledge of harms due to “research to practice” limitations

  • Future research should use prospective multilevel approaches to model how intrapersonal, interpersonal, and community/societal level factors jointly influence initiation and maintenance of waterpipe use

  • But we shouldn’t wait!


Thank you
Thank you! awareness” of users…

www.scts-sy.org

Radwan Al Ali, MD

TaghridAsfar, MD

ImanEbrahim

Tom Eissenberg, PhD

Madonna Elias

FouadFouad, MD

Wasim Maziak, MD, PhD

SamerRastam, MD, PhD