The Waterpipe: Epidemiology Wasim Maziak MD, PhD Professor, Chair, Department of Epidemiology Florida International University Director, Syrian Center for Tobacco Studies

(hookah, shisha, narghile, hubble-bubble) The Waterpipe (hookah, shisha, narghile, hubble-bubble) Centuries old habit with historical roots to the Middle East Quick historical note: hookah use was believed to have originated in India during the 16th century and found its way to Persia (Iran), Turkey, and the Eastern Mediterranean. (The origin of hookah www.bbc.co.uk/dna/h2g2/A987825) Narghile smoking is a unique feature of mideastern tobacco use.

Definition of Epidemiology Frequency: Quantification of disease Who? Where? When? Study of distribution and determinants of disease in human populations What? Why? How?

Beginning of waterpipe epidemic 268 WP smokers in cafés (Aleppo) Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

Factors behind the current waterpipe pandemic Introduction of Maassel in the early 1990s. The internet & other social and transnational media The reduced-harm perception, “the water filtering” effect The allure of waterpipe and thriving café culture. Lack of effective policies (e.g. FCTC). Maziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

1. Maassel? Industrialized and commercialized the product, increasing availability and variety Appealed to youth through product variety and flavors Made the smoke milder and smoother Allowed the mass marketing and sales through the internet Simplified the preparation process Maziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

2. The internet & other social media Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. The promotional materials …de-emphasize age limits, health warnings, and even that tobacco is involved in hookah smoking. Primack et al., 2012.

3. Reduced harm perception Qualitative study of 15 WP and 15 Cig smokers; (Hammal et al, 2008) “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 F, Mock J, Ward KD, Eissenberg T, Maziak W. A pleasure among friends. Tobacco Control 2008.

4. Allure of waterpipe 1. I enjoy the taste, smell, smoothness of smoke 2. It’s a good way to socialize with friends 3. It helps me to feel relaxed 4. I like the social ambience 5. It helps me to feel less stressed 6. It’s something to do when I feel bored 7. I like trying things that are new, different, or “hip” 9. It helps me not smoke cigarettes Tell me the top 3 reasons you think college students use hookah My dissertation found that the primary reasons college freshmen used hookah were related to personal image, social aspects of use, and product characteristics Asfar T, Ward KD, Eissenberg T, Maziak W. BMC Pub Health 2005;5(1):19. Smith-Simone, Maziak, Ward, and Eissenberg. Nicotine & Tob Research, 2008, 10: 393–398.

5. Lack of effective policies Nakkash et al., 2010; Maziak et al., 2013

Epidemiology Prevalence and use pattern in different parts of the world. Association with cigarettes. Time trends in youth. Gateway to cigarette. Sales weighted average is derived from the tar/nicotine yield for each cigarette brand weighted by the number of packages of each brand sold annually. Represents a hypothetical “average cigarette” smoked in the US.

Current cigarette vs. waterpipe smoking among 13–15 year olds in several Arab countries Current cigarette vs waterpipe smoking among 13–15 year olds in several Arab countries according to GYTS or surveys of comparable methods (Al-Mulla et al. 2008; Jasim et al. 2009; WHO 2010; Mzayek et al. 2012). *Based on a study in Baghdad city alone. †The estimates for ‘other’ tobacco were mainly for waterpipe. §Based on a study in Irbid city (Jordan). Maziak W et al. Health Policy Plan. 2013

Most popular tobacco use methods in college students, US (152 universities; n=105,012) We studied over 100,000 individuals who participated in the American College Health Association annual survey in the 2008-2009 school year. 30.5% of participants had ever smoked hookah, compared with 34.6% for cigarettes. 8.4% of participants were current (past 30 day) hookah smokers, compared with 16.8% who were current cigarette smokers. Hookah smoking was more common than cigars and smokeless tobacco. It is noteworthy that the cigar category in this survey included “little cigars” or “cigarillos” which are very popular among young people. Primack B A et al. Nicotine Tob Res 2013;15:29-35

Time trends: Ever waterpipe use for 12th graders by year (Florida, FYTS) 30 25.3% 25 20.2% 20 16.2% % ever WP use 15 10 5 2007 2008 2009 Survey year Courtesy of Dr. Tracy Barnett via FYTS (http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/FYTS/Intro.htm) 14

Age patterns: WP smoking in US college students Primack B A et al. Nicotine Tob Res 2013;15:29-35

Age patterns: Current WP smoking in Lebanon Chaaya et al, 2004, 2006

Age patterns: WP adults, Syria Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006

Gender: WP smoking, (13-15 yrs), EMR (n > 90,000) Cigarette and waterpipe use is much higher among men than women Warren CW, et al. Lancet, 2006.

Gender: WP, (11-15 yrs), Estonia, 2006 (N = 13826) Cigarette and waterpipe use is much higher among men than women Pärna et al. BMC Public Health 2008 8:392

SES: WP smoking adults, Syria Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

SES: WP quitting, adults, Syria Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

Frequency of WP use (adults, Syria) Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

Asfar et al., BMC Public Health 2005

Association with cigarette smoking Among 30-day hookah tobacco smokers, more than half are not also current cigarette smokers. Primack BA et al. NTR, 2013

McKelvey, Maziak, et al., Eur J PH, 2013

Age-adjusted smoking rates in men and women, by country Smoking habits in the Middle East and North Africa: Results of the BREATHE study (general population sample of individuals aged ≥ 40 years in ten countries in the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was generated and called. This identified 65,154 eligible subjects, of whom 62,086 agreed to participate. Khattab A, et al, Respiratory Medicine, 2012

McKelvey, Maziak, et al., Eur J PH, 2013

Asfar et al., BMC Public Health 2005

Smoke narghile mostly at home Narghile use is largely a social phenomenon, but we might expect use to become less social in dependent smokers. We found that the % of smokers who reported smoking mostly at home (as opposed to social settings) increased as the frequency of smoking increased.

Usually share the same narghile with others Narghile is often shared both in cafes and at home. And we expected that dependent users would be less likely to share narghile with others. Here, you see that daily users were less likely to report that they usually share the same narghile with others.

McKelvey, Maziak, et al., Eur J PH, 2013

Once addicted on nicotine, young people may go for Cig because of easier access compared to WP (gateway hypothesis)

Main epidemiological trends for WP Common among youth all over the world and increasing More intermittent use than daily Educated and affluent (higher SES) Male predominance, not consistent across populations and age groups. Associates with cigarette smoking at early ages and can lead to cigarette smoking.

Summary Waterpipe smoking is widespread and increasing all over the world. It is more widespread among the young, educated and affluent Gender differences in waterpipe smoking tend to vary by region, but girls and women in the EMR are increasingly taking up this tobacco use method Surveillance systems that inquire specifically about the waterpipe and are adapted to its use patterns are needed to monitor the epidemic and groups more at risk of waterpipe smoking In summary, hookah tobacco smoking in this sample was 8.4% in the past 30 days and 30.5% ever, making it the most common source of tobacco after cigarettes. Although it was associated with certain sociodemographic variables, what is most striking is how common it is among various demographic factors.

Acknowledgments Our heroes at the Syrian center for Tobacco Studies Eman Ibrahim Fouad Fouad Radwan Al Ali Samer Rastam Taghrid Asfar Nizar Al Bache Eyad Bashir Thomas Eissenberg Kenneth Ward Fawaz Mzayek Our Funders U.S. National Institutes of Health (Fogarty, NIDA) EU