1. Is there a need for a GB shisha cessation service
Is there a need for a GB shisha cessation service? Findings from cross-sectional surveys conducted in 2012 and 2013
Dr. Aimee Grant, Public Health Wales NHS Trust,
Rory Morrison, ASH Scotland,
Martin Dockrell, ASH

2. Overview How harmful is shisha for health?
Existing research: prevalence of shisha use
Research design
Findings
How should we respond?
Do we need a shisha cessation service?

3. How harmful is shisha for health?
World Health Organisation (2005)
CO poisoning (Clarke et al., 2012)
Laboratory study 1 (Eissenberg and Shihadeh, 2009)
45 mins shisha v 1 cigarette
High levels of exhaled CO (23.9ppm)
High puff volume (50 litres)
Similar peak nicotine levels
Laboratory Study 2 (Daher et al., 2010)
Second hand smoke
Ecological validity (Chaouachi, 2011)
WHO (2005) – Tobacco Product Regulation study group. First in-depth look at shisha. Many of the same health problems as other conditions, including lung cancer and heart disease.
Estimate 1 hour of using shisha equivalent to up to 100 cigarettes
CO poisoning has been reported by two sets of physicians in peer reviewed journals.
Daher et al, 2010’s laboratory study used an experimental chamber which emulated the characteristics of an indoor environment and found that an hour’s shisha use was equivalent to 4-20 cigarettes being smoked, based on CO and other toxins.
Eissenberg and Shihadeh, minute session. Levels of CO in excess of 2.7ppm for a single cigarette and 1 litre of puff volume.

4. Estimates of prevalence
A ‘Global epidemic’? (Maziak, 2011)
Large-population surveys
California Tobacco Survey
United Arab Emirates
International survey evidence
Mostly students (5 peer reviewed published studies)
Some small samples (Al-Naggar and Saghir, 2011)
Opportunity sampling (Rehman et al., 2012)
Evidence from the UK?
2 student surveys (Jackson and Aveyard, 2008; Jawad et al., 2012)
California – use higher among younger groups
UAE – less than 1% of adults used shisha.
International survey evidence is mostly surveys of students.
In the UK there have been two surveys of students.
Jackson and Aveyard, 2008 – surveyed 900 students from Birmingham university and found that 8% were regularly using shisha, and this was prevalent across ethnic groups. The factor most strongly correlated with shisha use was cigarette smoking.
Jawad’s study of medical students in London found that 52% had ever smoked shisha, with 11% reporting current use. There was no significant association with gender or ethnicity, but again, smoking status was correlated with shisha use.

5. Shisha in the news
Most articles from the UK focus on breaches of smoke-free legislation
Three focus on an apparent rise in users
In the last year, (30th May th May 2013) there have been 81 articles in UK newspapers about ‘shisha’.
From the Observer:
A survey soon to be published by the anti-smoking group Ash says an increasing number of people have tried smoking shisha pipes. "Around one in 10 adults have tried shisha but sustained use is very rare," an Ash spokesman said. "Users are typically younger men and from particular ethnic communities."
Several of these have focused upon the increase in prevalence in British shisha users or shisha cafes

6. Research design Research question:
What is the prevalence and frequency of shisha use among adults (aged 18+) in Great Britain?
Design - repeated cross-sectional surveys:
Participants recruited from an online panel maintained by YouGov Plc using targeted quota sampling, surveys conducted online
Feb/March 2012 (n=12,436); Feb 2013 (n=12,171)
Results weighted to be representative of GB population by sex, age, social class, ethnicity, GB region, newspaper readership, voting intention

7. Findings: Prevalence & frequency of use, 2012 to 2013
Self-reported shisha use: 'How often, if at all, have you smoked using a “shisha” pipe? (Please note that shisha pipes are also known waterpipes or hookah pipes)'
% (95% CI)
% (95% CI)
More than 3 to 4 times a month
0.3 (0.2, 0.5)
0.3 (0.1, 0.4)
Once or twice a month
0.7 (0.4, 1.0)
0.7 (0.4, 0.9)
Once or twice every 2 to 3 months
0.5 (0.3, 0.6)
0.5 (0.3, 0.7)
Once every 6 to 12 months
1.5 (1.2, 1.8)
Less often
8.2 (7.6, 8.8)
9.0 (8.3, 9.6)
Never
68.9 (67.8, 70.0)
70.3 (69.3, 71.3)
Don’t know/ can’t remember
1.6 (1.3, 1.9)
Not applicable – do not know what a shisha pipe is
18.2 (17.3,19.1)
16.2 (15.4, 17.0)
Design-adjusted Chi-sq test for differences in shisha use between years: p-value = 0.13

8. % ‘ever’ & ‘frequent (at least once or twice a month)’ shisha use - 2012 to 2013
Error bars represent 95% CI. No statistically significant difference between 2012 & 2013 surveys in ever shisha use (p=0.19), or frequent use (p=0.51)

9. % ‘ever’ shisha use, 2012 & 2013 combined, by: Gender
Self- reported ever shisha use differs by gender (p<0.001)

10. % ‘ever’ shisha use, 2012 & 2013 combined, by: Age group
Self- reported ever shisha use differs by age (p<0.001)

11. % ‘ever’ shisha use, 2012 & 2013 combined, by: Social Grade
Self- reported ever shisha use differs by social grade (p<0.001)

12. % ‘ever’ shisha use, 2012 & 2013 combined, by: Ethnicity
Self- reported ever shisha use differs by ethnicity (p<0.001)

13. % ‘ever’ shisha use, 2012 & 2013 combined, by: GB country of residence
Self- reported ever shisha use differs by GB country of residence (p<0.001)

14. % ‘ever’ shisha use, 2012 & 2013 combined, by: Smoking status
Self- reported ever shisha use differs by smoking status (p<0.001)

15. Multivariate analysis of predictors of ‘ever shisha use’ (1)
Adjusting for covariates in a logistic regression model largely confirmed the results already presented
Older adults were less likely to report ever use than younger
Women less likely to report ever use than men
Lower social grades less likely to report ever shisha use when compared to higher grades
Increased odds of use for ‘mixed/multiple’ ethnic groups [OR 2.37 (95% CI 1.64 to 3.41)] and ‘Asian/Asian British’ [OR 1.84 (95% CI 1.39 to 2.45)] compared to white – but no difference detected for other groups

16. Multivariate analysis of predictors of ‘ever shisha use’ (2)
Being a daily, non-daily, or ex-smoker raised odds compared to being a self-reported never smoker
Compared to England, residing in Scotland reduced odds of reported ever use [OR 0.75 (95% CI 0.61 to 0.92) – no effect was found for Wales after adjustment for covariates
A model based on the outcome of ‘frequent use’ gives similar results, and a range of sensitivity analyses did not materially alter the main conclusions

17. Strengths & limitations
Large, recent survey, providing quite precise estimates of use
Limitations:
Self-reported shisha use only
Survey conducted in English language, perhaps resulting in systematic exclusion of some groups
Probably, like many ‘opt-in’ survey methods, under-represents those from most disadvantaged areas who are harder to reach

18. The UK Public Health response to shisha
Healthy Lives, Healthy People (2011)
Tower Hamlets and Coventry City Council
Information and advice
Tobacco Control Action Plan for Wales (2012)
SSS to develop a protocol to help users quit
Reports of interventions in the media
NHS Hull and Hull City Council (Hull Daily Mail, )
‘raise awareness’
Leicester – Horn Concern (Leicester Mercury, )
raise awareness in young people
Healthy Lives, Healthy People is the Tobacco Control Action Plan for England.

19. Should the public health response be expanded?
Our survey provides little support for the notion of an ‘epidemic’ at the GB population level – but it does not preclude shisha being an issue in specific population sub-groups/local areas
There is a need to enforce existing regulations
Violation of smokefree regulations
Use of illicit (tax free) products
Absence of health warnings on shisha
Age of users?
Lack of clarity regarding tobacco content of shisha
Awareness raising activities for high risk groups
Cessation support for regular users

20. Unanswered questions
If a person smokes cigarettes every day and shisha once a month, which form of smoking should we be tackling?
For ex-smokers, is “shisha prevention” vital relapse prevention?
What is the right balance between shisha prevention/cessation and wider tobacco control?
In a shisha strategy, what is the right balance between treatment and regulation?

21. We would like to acknowledge the support of the following organisations in allowing this research to be undertaken