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

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. Phoenix, AZ Moscow Tampa, FL Beijing

9. Semiannual Snapshots of State-level SVI (2004- 2013)

10. Map of NYC Hookah Bars Listed on Yelp.com Mapping tool is publicly available on UCLA Geomapping Lecturer Yoh Kawano’s educational website.educational website 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

11. And global suppliers of hookah…

12. Suppliers of waterpipe tobacco

15. Business of hookah – Research questions 1. Producers, suppliers Which countries Small businesses or large multinationals 2. 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 SmokerSpouse/ 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$122 B$ 3 B?? Non-medical$ 83 B$ 72 B$ 8 B$ 3 B  Productivity$115 B$102 B$ 11 B$ 2 B Morbidity$ 30 B ?? Mortality$ 85 B$ 72 B$ 11 B$ 2 B Sloan FA et al. The Price of Smoking. 2004, MIT Press.

19. Grand total SmokerSpouse/ 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$122 B$ 3 B?? Non-medical$ 83 B$ 72 B$ 8 B$ 3 B  Productivity$115 B$102 B$ 11 B$ 2 B Morbidity$ 30 B ?? Mortality$ 85 B$ 72 B$ 11 B$ 2 B Questions 1.Do hookah smokers have increased health care utilization? 2.Do hookah smokers have increased health care costs? 3.What fraction of CVD, CA, etc. is attributable to hookah? Estimated annual US costs of cigarette smoking

20. Estimated annual U.S. costs of cigarette smoking Grand total SmokerSpouse/ 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$122 B$ 3 B?? Non-medical$ 83 B$ 72 B$ 8 B$ 3 B  Productivity$115 B$102 B$ 11 B$ 2 B Morbidity$ 30 B ?? Mortality$ 85 B$ 72 B$ 11 B$ 2 B Questions 1.How much do hookah smokers spend on waterpipe smoking?

21. Estimated annual U.S. costs of cigarette smoking Grand total SmokerSpouse/ 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$122 B$ 3 B?? Non-medical$ 83 B$ 72 B$ 8 B$ 3 B  Productivity$115 B$102 B$ 11 B$ 2 B Morbidity$ 30 B ?? Mortality$ 85 B$ 72 B$ 11 B$ 2 B Questions 1.Do waterpipe smokers have more sick days? 2.Does waterpipe smoking decrease productivity at work? 3.Does waterpipe smoking affect quality of life (short & long term)?

22. Estimated annual U.S. costs of smoking Grand total SmokerSpouse/ 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$122 B$ 3 B?? Non-medical$ 83 B$ 72 B$ 8 B$ 3 B  Productivity$115 B$102 B$ 11 B$ 2 B Morbidity$ 30 B ?? Mortality$ 85 B$ 72 B$ 11 B$ 2 B Questions 1.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 JasieAdekunk Olatunji Tala HaddadPaul Joudrey Susan TierneyLyuboyr Pykalo Scott ShermanMary Beth Woodin

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

29. …the market is changing

30. Research agenda for the next 5 years 1. What fraction of morbidity and mortality is attributable to waterpipe tobacco? 2. What existing national and international surveys include both questions on hookah and economics? Also, need to include hookah questions in future surveys. 3. Understand economics of restaurants/hookah bars Understand supply chain, costs, profitability 4. Understand individual costs/benefits/preferences 5. Price elasticity Compiled data Individual modeling