1. 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

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

3. To review scientific knowledge about economics of waterpipe tobacco use

4. To review scientific knowledge about economics of waterpipe tobacco use

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

6. Part 1: The business of hookah

7. A global market for hookah

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

9. Semiannual Snapshots of State-level SVI (2004-2013)
SVI values have been consistent for the years
Google search use as well as internet penetration have both evolved since 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.

10. 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 businesses per iteration.
Mapping tool is publicly available on UCLA Geomapping Lecturer Yoh Kawano’s educational website.

11. And global suppliers of hookah…

12. Suppliers of waterpipe tobacco

13. Suppliers of waterpipe tobacco

14. Suppliers of waterpipe tobacco

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

16. Part 2: The economics of hookah

17. 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

18. 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.

19. 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?

20. 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?

21. 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)?

22. 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?

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

24. 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

25. And just when we are beginning to study the market…

26. And just when we are beginning to study the market…

27. And just when we are beginning to study the market…

28. And just when we are beginning to study the market…

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

30. 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