Economic Aspects of Waterpipe Tobacco Smoking Scott E. Sherman, MD, MPH Co-Chief, Section on Tobacco, Alcohol and Drug Use Associate Professor of Population Health, Medicine and Psychiatry New York University School of Medicine Staff Physician, VA New York Harbor Healthcare System

Objectives To review scientific knowledge about business and economics aspects of waterpipe tobacco use To outline future research needs

To review scientific knowledge about economics of waterpipe tobacco use

To review scientific knowledge about economics of waterpipe tobacco use

Business and economic aspects - Why do we care? Impact at different levels Society Business Health system Individual Evidence-based policy (Intelligent)

Part 1: The business of hookah

A global market for hookah

A global market for hookah Phoenix, AZ Moscow Beijing Tampa, FL

Semiannual Snapshots of State-level SVI (2004-2013) SVI values have been consistent for the years 2011-2013. Google search use as well as internet penetration have both evolved since 2004. The pattern of increasing SVI might not reflect increase in interest only, but could be a combination of all the mentioned. SVI rates are normalized against density of population and overall Google use in each state.

Map of NYC Hookah Bars Listed on Yelp.com US CDC web site: An estimated 300 hookah cafés operated in the United States in 2006 Yelp: 130 businesses are listed on Yelp with a tag “hookah Bars” within New York City in 2013 Yelp API generates batches of 20-40 businesses per iteration. Mapping tool is publicly available on UCLA Geomapping Lecturer Yoh Kawano’s educational website.

And global suppliers of hookah…

Suppliers of waterpipe tobacco

Suppliers of waterpipe tobacco

Suppliers of waterpipe tobacco

Business of hookah – Research questions Producers, suppliers Which countries Small businesses or large multinationals Sellers Hookah bars vs. sales for home use

Part 2: The economics of hookah

Economics of waterpipe tobacco Internal costs – costs to user (and in some cases to his/her family) External costs – costs to others Businesses Health care system Societal costs = internal + external costs

Estimated annual US costs of cigarette smoking Grand total Smoker Spouse/ Children Outside family Grand Total $323 B $296 B $ 22 B $ 5 B Expenditures $208 B $194 B $ 11 B $ 3 B Medical $125 B $122 B ?? Non-medical $ 83 B $ 72 B $ 8 B  Productivity $115 B $102 B $ 2 B Morbidity $ 30 B Mortality $ 85 B Sloan FA et al. The Price of Smoking. 2004, MIT Press.

Estimated annual US costs of cigarette smoking Grand total Smoker Spouse/ Children Outside family Grand Total $323 B $296 B $ 22 B $ 5 B Expenditures $208 B $194 B $ 11 B $ 3 B Medical $125 B $122 B ?? Non-medical $ 83 B $ 72 B $ 8 B  Productivity $115 B $102 B $ 2 B Morbidity $ 30 B Mortality $ 85 B Questions Do hookah smokers have increased health care utilization? Do hookah smokers have increased health care costs? What fraction of CVD, CA, etc. is attributable to hookah?

Estimated annual U.S. costs of cigarette smoking Grand total Smoker Spouse/ Children Outside family Grand Total $323 B $296 B $ 22 B $ 5 B Expenditures $208 B $194 B $ 11 B $ 3 B Medical $125 B $122 B ?? Non-medical $ 83 B $ 72 B $ 8 B  Productivity $115 B $102 B $ 2 B Morbidity $ 30 B Mortality $ 85 B Questions How much do hookah smokers spend on waterpipe smoking?

Estimated annual U.S. costs of cigarette smoking Grand total Smoker Spouse/ Children Outside family Grand Total $323 B $296 B $ 22 B $ 5 B Expenditures $208 B $194 B $ 11 B $ 3 B Medical $125 B $122 B ?? Non-medical $ 83 B $ 72 B $ 8 B  Productivity $115 B $102 B $ 2 B Morbidity $ 30 B Mortality $ 85 B Questions Do waterpipe smokers have more sick days? Does waterpipe smoking decrease productivity at work? Does waterpipe smoking affect quality of life (short & long term)?

Estimated annual U.S. costs of smoking Grand total Smoker Spouse/ Children Outside family Grand Total $323 B $296 B $ 22 B $ 5 B Expenditures $208 B $194 B $ 11 B $ 3 B Medical $125 B $122 B ?? Non-medical $ 83 B $ 72 B $ 8 B  Productivity $115 B $102 B $ 2 B Morbidity $ 30 B Mortality $ 85 B Questions Does waterpipe smoking increase mortality rates? If so, how many years of life do waterpipe smokers lose?

Modeling Price elasticity Salience – how to make it more relevant Cost-effectiveness of cessation interventions

NYU Global Institute of Public Health Capstone Project Team Survey of hookah bar owners in New York, Abu Dhabi and Dubai – starting in December Karen Jasie Adekunk Olatunji Tala Haddad Paul Joudrey Susan Tierney Lyuboyr Pykalo Scott Sherman Mary Beth Woodin

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market… …the market is changing

Research agenda for the next 5 years What fraction of morbidity and mortality is attributable to waterpipe tobacco? What existing national and international surveys include both questions on hookah and economics? Also, need to include hookah questions in future surveys. Understand economics of restaurants/hookah bars Understand supply chain, costs, profitability Understand individual costs/benefits/preferences Price elasticity Compiled data Individual modeling