The Waterpipe: Epidemiology

1
The Waterpipe Epidemiology

• Wasim Maziak MD, PhD
• Professor, Chair, Department of Epidemiology
• Florida International University
• Director, Syrian Center for Tobacco Studies

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The Waterpipe (hookah, shisha, narghile,
hubble-bubble)
Centuries old habit with historical roots to the
Middle East
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Definition of Epidemiology
Frequency Quantification of disease
Who? Where? When?

• Study of distribution and determinants of disease
  in human populations

What? Why? How?
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Beginning of waterpipe epidemic268 WP smokers in
cafés (Aleppo)
Rastam, Maziak et al. Estimating the beginning of
the waterpipe epidemic in Syria. BMC Pub Health
2004.
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Factors behind the current waterpipe pandemic

1. Introduction of Maassel in the early 1990s.
2. The internet other social and transnational
   media
3. The reduced-harm perception, the water
   filtering effect
4. The allure of waterpipe and thriving café
   culture.
5. Lack of effective policies (e.g. FCTC).

Maziak W. The Global Epidemic of Waterpipe
Smoking. Addictive Behaviors 2011.
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1. Maassel?

1. Industrialized and commercialized the product,
   increasing availability and variety
2. Appealed to youth through product variety and
   flavors
3. Made the smoke milder and smoother
4. Allowed the mass marketing and sales through the
   internet
5. Simplified the preparation process

Maziak W. The Global Epidemic of Waterpipe
Smoking. Addictive Behaviors 2011.
7
2. The internet other social media
Websites may play a role in enhancing or
propagating misinformation related to hookah
tobacco smoking. The promotional materials
de-emphasize age limits, health warnings, and
even that tobacco is involved in hookah smoking.
Primack et al., 2012.
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3. Reduced harm perception Qualitative study of
15 WP and 15 Cig smokers (Hammal et al, 2008) I
do not worry about narghile. I do not feel it is
harmful. It is not more than entertainment. We
have not heard about anyone who had a health
problem because of the narghile
Hammal F, Mock J, Ward KD, Eissenberg T, Maziak
W. A pleasure among friends. Tobacco Control 2008.
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4. Allure of waterpipe
1. I enjoy the taste, smell, smoothness of
smoke 2. Its a good way to socialize with
friends 3. It helps me to feel relaxed 4.
I like the social ambience 5. It helps me
to feel less stressed 6. Its something to
do when I feel bored 7. I like trying things
that are new, different, or hip 9. It
helps me not smoke cigarettes
Asfar T, Ward KD, Eissenberg T, Maziak W. BMC Pub
Health 20055(1)19. Smith-Simone, Maziak, Ward,
and Eissenberg. Nicotine Tob Research, 2008,
10 393398.
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5. Lack of effective policies
Nakkash et al., 2010 Maziak et al., 2013
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Epidemiology

• Prevalence and use pattern in different parts of
  the world.
• Association with cigarettes.
• Time trends in youth.
• Gateway to cigarette.

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Current cigarette vs. waterpipe smoking among
1315 year olds in several Arab countries
Maziak W et al. Health Policy Plan. 2013
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Most popular tobacco use methods in college
students, US (152 universities n105,012)
Primack B A et al. Nicotine Tob Res 20131529-35
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Time trends Ever waterpipe use for 12th graders
by year (Florida, FYTS)
30
25.3
25
20.2
20
16.2
ever WP use
15
10
5
0
2007
2008
2009
Survey year
Courtesy of Dr. Tracy Barnett via FYTS
(http//www.doh.state.fl.us/disease_ctrl/epi/Chro
nic_Disease/FYTS/Intro.htm)
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(No Transcript)
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Age patterns WP smoking in US college students
Primack B A et al. Nicotine Tob Res 20131529-35
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Age patterns Current WP smoking in Lebanon
Chaaya et al, 2004, 2006
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Age patterns WP adults, Syria
Ward et al. The tobacco epidemic in Syria.
Tobacco Control, 2006
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Gender WP smoking, (13-15 yrs), EMR (n gt 90,000)
Warren CW, et al. Lancet, 2006.
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Gender WP, (11-15 yrs), Estonia, 2006 (N 13826)
Pärna et al. BMC Public Health 2008 8392
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SES WP smoking adults, Syria
Ward et al. The tobacco epidemic in Syria.
Tobacco Control, 2006.
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SES WP quitting, adults, Syria
Ward, Maziak, Eissenberg, et al. The tobacco
epidemic in Syria. Tobacco Control, 2006.
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Frequency of WP use (adults, Syria)
Ward, Maziak, Eissenberg, et al. The tobacco
epidemic in Syria. Tobacco Control, 2006.
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Asfar et al., BMC Public Health 2005
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Association with cigarette smoking
Primack BA et al. NTR, 2013
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McKelvey, Maziak, et al., Eur J PH, 2013
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Age-adjusted smoking rates in men and women, by
country
Khattab A, et al, Respiratory Medicine, 2012
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McKelvey, Maziak, et al., Eur J PH, 2013
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Asfar et al., BMC Public Health 2005
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Smoke narghile mostly at home
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Usually share the same narghile with others
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McKelvey, Maziak, et al., Eur J PH, 2013
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Once addicted on nicotine, young people may go
for Cig because of easier access compared to WP
(gateway hypothesis)
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Main epidemiological trends for WP

• Common among youth all over the world and
  increasing
• More intermittent use than daily
• Educated and affluent (higher SES)
• Male predominance, not consistent across
  populations and age groups.
• Associates with cigarette smoking at early ages
  and can lead to cigarette smoking.

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Summary

• Waterpipe smoking is widespread and increasing
  all over the world.
• It is more widespread among the young, educated
  and affluent
• Gender differences in waterpipe smoking tend to
  vary by region, but girls and women in the EMR
  are increasingly taking up this tobacco use
  method
• Surveillance systems that inquire specifically
  about the waterpipe and are adapted to its use
  patterns are needed to monitor the epidemic and
  groups more at risk of waterpipe smoking

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Acknowledgments

• Our heroes at the Syrian center for Tobacco
  Studies
• Eman Ibrahim
• Fouad Fouad
• Radwan Al Ali
• Samer Rastam
• Taghrid Asfar
• Nizar Al Bache
• Eyad Bashir
• Thomas Eissenberg
• Kenneth Ward
• Fawaz Mzayek
• Our Funders
• U.S. National Institutes of Health (Fogarty,
  NIDA)
• EU