Hookah Smoking: The Past and Future of Tobacco

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Hookah SmokingThe Past and Future of Tobacco?

• Brian Primack, MD, EdM, MS
• Assistant Professor of Medicine and Pediatrics
• May 2008

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Terminology

• Hookah
• Waterpipe
• Shisha-Pipe
• Narghile
• Bong
• Hubble-bubble

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www.hookah-bars.com
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Hours

• Sunday Thursday 4 PM 1230 AM
• Friday Saturday 4 PM 2 AM

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Flavors

• Fruit
• Apple
• Banana
• Cherry
• Melon

• Candy
• Bubble gum
• Chocolate mint
• Alcohol
• Margarita
• Piña colada

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• Good Quality
• Regular 7.00Large 10.00
• Arabic Coffee, Apple, Apple Alex, Double Apple,
  Apricot, Banana, Candy, Cappuccino, Cherry,
  Carmel, Coconut, Cola, Grape, Jasmine, Lemon,
  Mint, Mango, Mandarin, Mixed Fruit, Orange,
  Pistachio, Peach Rose, Salloum, Strawberry,
  Vanilla, Zaghoul Light, Zaghoul, Licorice

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• Excellent QualityRegular 8.00Large 11.00
• Double apple, Apricot, Banana, Cantaloupe,
  Cappuccino, Cherry, Coconut, Mint, Melon, Orange,
  Peach, Pineapple, Rose, Raspberry, Strawberry,
  Tutti-Frutti, Vanilla
• Cognac, Margarita, Pina Colada, Strawberry
• Daiquiri

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• Premiume Quality Regular 8.50Large 11.50
• Apple, Special Apple, Bahrany Apple, Apple
  Eskandarani, Banana, Cola, Cappuccino, Fruit
  Cocktail, Honey Melon, Mango, Orange, Peach,
  Pipe, Rose, Strawberry

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• Superior Quality Regular 9Large 12
• Apple, Strawberry, Grape, Rose

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• Make your Hookah Cool with adding ice for 1
• Mix Match Flavors Add 2
• Flavor Your Hookah Water Add 3
• Add 0.25 Per Each Person Minimum 1 Order
  Per Person
• Bring your own bottle 2 cork charge
• You Must Be 21 to bring your own alcohol bottle

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Also Have

• Fruit Smoothies (e.g. Strawberry, Banana, Mango,
  Guava)
• Ice Cream
• Coffee and Tea
• Milk Shakes
• Desserts
• Games (Mancala, Dominoes)

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Apple Shaped, 35
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Silver Crane120
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200(It rotates!)
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600
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13 for 250 gm
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20 Sampler
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16 Coals for 4
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Smoke Exposure

• 30-60 minute sessions
• Each session 100 inhalations
• Each inhalation 500 mL in volume
• Total volume
• Waterpipe session 50,000 mL
• Cigarette 500-600 mL

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Smoking Topography
1Shihadeh 2003 Shihadeh 2004 2Breland 2005
Djordjevic 2000
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Known Harm

• Waterpipe smoke contains ...
• Carcinogens
• Carbon monoxide
• Nicotine
• Waterpipe smoking associated with ...
• Cancer
• Cardiovascular disease
• Decreased pulmonary function
• Nicotine dependence

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Waterpipe Cigarettes

• Tar
• Nicotine
• CO
• Heavy Metals

Shihadeh 2003 Shihadeh 2004 Djordjevic 2000
Hoffman, 2000
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Growing U.S. Prevalence

• 200-300 new waterpipe cafés opened in the U.S.
  between 1999 and 2004
• Particularly in college towns
• Convenience sample surveys suggest high current
  use (past 30 days)
• 411 first-year college students 15.3
• 744 introductory psychology students 20

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Holes in Literature

• Random sample
• Associations between waterpipe smoking and
• Demographics
• Beliefs (e.g., harm, addiction, popularity)
• Populations outside college

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STUDY 1 COLLEGE
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Purpose

• Determine the 30-day, annual, and lifetime
  prevalence of waterpipe smoking in a random
  sample of college students
• Determine associations between outcome variables
  and sociodemographic and predictors

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Design

• Cross-sectional survey
• Random sample of students at the University of
  Pittsburgh
• Collect data via web-based version of the
  American College Health Associations (ACHA)
  National College Health Assessment (NCHA)
• Added items related to waterpipe use

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Approvals

• University of Pittsburgh Institutional Review
  Board
• University Vice Provost

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Procedure

• April 2007 during a three-week period
• Avoided the 30-day period following Spring Break
• Email invitation sent to 3600 randomly selected
  Pitt students
• Incentive lottery to win cash prizes ranging
  from 25 to 100
• Three reminder e-mails sent to students during
  the three-week period

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Demographic Measures

• Age
• Gender
• Race
• Residence (on-vs. off-campus)
• Undergraduate vs. graduate
• Membership in a fraternity or sorority
• Self-reported academic achievement

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Theory of Reasoned Action
Norms
Intent
Behavior
Attitudes
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Behavior Measures

• Have you ever smoked tobacco from a waterpipe
  (hookah, shisha, narghile), even one or two
  puffs? (Yes/No)
• During the past year, have you smoked tobacco
  from a waterpipe (hookah, shisha, narghile), even
  one or two puffs? (Yes/No)
• During the past 30 days, have you smoked tobacco
  from a waterpipe (hookah, shisha, narghile), even
  one or two puffs? (Yes/No)

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Attitudes

• Would you say that smoking from a waterpipe
  (hookah, shisha, narghile) is more harmful or
  less harmful than smoking regular cigarettes?
  (waterpipe more harmful / waterpipe same harm
  / waterpipe less harmful)
• Would you say that smoking from a waterpipe
  (hookah, shisha, narghile) is more addictive or
  less addictive than smoking regular cigarettes?
  (waterpipe more addictive / waterpipe same
  addictiveness / waterpipe less addictive)

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Normative Beliefs

• Among your peers, how socially acceptable is it
  to smoke tobacco from a waterpipe (hookah,
  shisha, narghile)? (not acceptable /
  somewhat/moderately acceptable / very
  acceptable)
• What percentage of college students do you think
  has ever smoked tobacco from a waterpipe (hookah,
  shisha, narghile)? (0-100, collapsed into
  tertiles

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Analysis

• Multivariate logistic regression models
• Dependent variables
• 30-day waterpipe smoking
• One year waterpipe smoking
• Independent variables
• Perception of harm
• Perception of addictiveness
• Acceptability
• Popularity
• Covariates
• Sensitivity analyses with stepwise regression

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Response Rate

• 61 emails undeliverable
• Response rate 660/3539 18.6
• 647/660 (98.0) had outcome data
• Compared with non-respondents, respondents were
• Younger (20.9 vs. 21.4, p
• Female (65.6 vs. 50.5, p
• Caucasian (85.4 vs. 80.7, p0.004)

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Sample
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Smoking Data
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Past-Year Waterpipe Tobacco Smoking
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Harm, Addictiveness
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Acceptability, Popularity
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Other Factors Associated with1-Year WPTS

• Younger age
• Off campus
• Fraternity membership

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Major Findings

• Lifetime use 40, similar to cigarette lifetime
  use
• Current use 9.5
• One year use 30.5
• Associated with lack of concern for addictiveness
  (and harm, less so)
• Associated with sense of acceptability and
  popularity

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Cigarettes vs. Waterpipe

• Many waterpipe smokers had never smoked
  cigarettes
• In non-cigarette smokers
• Problematic
• Introducing nicotine to previously naïve
  population
• In cigarette smokers
• Substitution?
• Augmentation?

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Rate Differences

• 30-day rate (9.5) much lower than annual (30.6)
  and ever (40.5) rates
• Sampling period we avoided Spring Break,
  fraternity rush, etc.

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Limitations

• Response rate 18.6
• Demographic differences between respondents and
  non-respondents
• May have inflated our results since younger
  population more likely to smoke waterpipe
• Cross-sectional design

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Conclusion

• First random sample
• Ever use common in this sample
• Further research
• Longitudinal designs
• National samples (NCHA)
• Educational/interventional efforts
• Major educational gaps
• Worthwhile to start now
• Focus on addictiveness, acceptability, popularity

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STUDY 2 HIGH SCHOOL
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Purpose

• Determine prevalence in statewide sample of high
  school students
• Determine associations with waterpipe use in high
  school

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No High School National Data

• Monitoring the Future
• Youth Risk Behavior Surveillance Survey
• Others

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Arizona 2005

• Youth tobacco survey
• Added 2 items dealing with waterpipe tobacco
  smoking
• Ever
• Past 30 days

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Participants

• Statewide representative sample
• Grades 6-12
• All students enrolled in public and/or charter
  schools

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Procedure

• Schools chose to use active or passive consent
  forms (89 used passive)
• Spring semester 2005
• 45 minute class period

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Measures

• Tobacco
• 30-day waterpipe smoking
• Ever waterpipe smoking
• Other tobacco smoking
• Sociodemographic data
• Age
• Gender
• Race
• Type of school (charter vs. regular)
• Plan to attend college

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Analysis

• Sociodemographic trends
• Multivariate analyses

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Multivariate Analysis Ever Use
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Multivariate Analysis 30-Day Use
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Major Findings

• History of waterpipe tobacco smoking
• 6 of all 6th-12th graders
• 15 of 12th graders
• More common than 5 other methods of tobacco
  smoking
• Associated with age, gender, race, SES

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Age

• High school older
• College younger
• Surrogate for alcohol use?

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Experimentation vs. Addiction

• May lead to increased uptake of various types of
  nicotine
• Gateway to cigarette smoking?

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Surveillance

• National studies (MTF, YRBS) should track this
  form of tobacco use
• Likely to increase
• Less harsh
• Flavored
• Educational gaps
• Policy issues

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Anything National?

• ACHA including 2 items in NCHA in 2009
• Random sample of 7619 college students

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National Pilot Data
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Conclusion

• Waterpipe tobacco smoking represents a major
  potential threat to public health
• Threatens to undermine successes from cigarette
  smoking
• Surveillance and further research are necessary