1. Using a Waterpipe to Smoke Tobacco: Prevalence, Toxicant Exposure, Effects, and Research Needs. Thomas Eissenberg, Ph.D. Department of Psychology and Institute for Drug and Alcohol Studies VCU

2. Acknowledgments. Dr. Wasim Maziak and Dr. Ken Ward, U of M and SCTS. Dr. Alan Shihadeh, American University of Beirut NIH R01 CA103827 and R01 DA011082.

3. Topics to cover. What is a waterpipe? Who smokes tobacco using a waterpipe? What’s in the smoke? What’s in the smokers? What are the effects of waterpipe tobacco smoking? What do we need to know?

4. What is a waterpipe? Hookah Narghile Arghile Shisha-pipe Hubble-bubble

5. What is a waterpipe? Hookah Narghile Arghile Shisha-pipe Hubble-bubble Figure courtesy Dr. Alan Shihadeh, American University of Beirut

6. What is waterpipe tobacco? Ma’assel Shisha

7. What is waterpipe tobacco? Ma’assel Shisha

8. What is waterpipe tobacco? Ma’assel Shisha

9. What are the flavors of waterpipe tobacco? Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon. Source: Matt Barry at Campaign for Tobacco Free Kids.

10. What are the flavors of waterpipe tobacco? Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon. Candy/Dessert/Spice: Banana split, Bubble gum, Candy, Cappuccino, Caramel, Chocolate mint, Cinnamon, Coffee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla. Source: Matt Barry at Campaign for Tobacco Free Kids.

11. What are the flavors of waterpipe tobacco? Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon. Candy/Dessert/Spice: Banana split, Bubble gum, Candy, Cappuccino, Caramel, Chocolate mint, Cinnamon, Coffee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla. Alcohol: Cocktail, Margarita, Pina colada. Source: Matt Barry at Campaign for Tobacco Free Kids.

12. What are the flavors of waterpipe tobacco? Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon. Candy/Dessert/Spice: Banana split, Bubble gum, Candy, Cappuccino, Caramel, Chocolate mint, Cinnamon, Coffee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla. Alcohol: Cocktail, Margarita, Pina colada. Tangiers F-line (caffeinated): Apple, Cocoa, Kashmir, Root beer. Source: Matt Barry at Campaign for Tobacco Free Kids.

13. Often associated with Indian subcontinent and East. Med. Region. - One history: began in India ~1600 (Chattopadhyay, 2000). - In the EMR, 22% - 69% report “ever use” (Maziak et al., 2004; Memon et al, 2000; Mohamed et al, 2003). Who smokes tobacco using a waterpipe?

14. Particularly popular among EMR university students: - Syria, 45% report ever use (Maziak et al., 2004) - Lebanon, 23-30% report weekly use (Tamim et al, 2003; Chaaya et al., 2004). Global spread suggested by media reports from: Brazil, Canada, Germany, Korea, Ukraine (Daniel, 2004; Gill, 1999 Marchant, 2003; Mirza, 2004; Robbins, 2003; Rudenko, 2002). Converging lines of evidence suggest spread to U.S. Who smokes tobacco using a waterpipe?

15. News media: Waterpipe café/use reported in 33 states. Tobacco industry: 200-300 new U.S. waterpipe cafés since 1999, “often near college campuses” (Smokeshop Magazine, 04/2004). Anecdotal evidence: “In Pittsburgh, 4 hookah bars have opened since 2003, each no more than 5 miles from the campuses of Carnegie Mellon University and the University of Pittsburgh. Hookahs have become commonplace at fraternity parties at these universities.” Primack et al., 2006, p. 1339 (also see Deckers et al, 2006). Waterpipe tobacco smoking in the U.S.

16. Surveys: Past 30-day use in several convenience samples: - 15.3% of 411 JHU freshmen (Smith et al., in press). - 20.3% of 744 VCU Intro Psych students (Smith-Simone, 2007). Re-emerging strain in global tobacco epidemic: U.S. not immune. Waterpipe tobacco smoking in the U.S.

17. What is in the smoke?

19. What is in the smoke: waterpipe topography.

21. Cigarette: 10 puffs * 50 ml = 500 ml (1/4 of a big soda bottle) Waterpipe: 100 puffs * 500 ml = 50,000 ml (25 big soda bottles)

22. What is in the smoke: tar, nicotine, and CO. Mean smoke toxicant content for waterpipe and cigarette. Toxicant (mg) Waterpipe 1 Cigarette 2 Tar80222.3 Nicotine2.961.74 CO14517.3 1 Shihadeh andSaleh, 2005; 2 Djordjevic et al., 2000 Toxicant (mg) Waterpipe 1 Cigarette 2 Tar80222.3 Nicotine2.961.74 CO14517.3 1 Shihadeh and, 2005; 2 Djordjevic et al., 2000

23. What is in the smoke: heavy metals.

24. Shafagoj and Mohammed, 2002; Participants = 14 Jordanian men. Rastam et al. (2006) reported CO increases of ~24 ppm from 26 Syrian smokers (3 women). What is in waterpipe smokers: CO and nicotine Expired air CO

25. Shafagoj and Mohammed, 2002; Shafagoj et al., 2002 Participants = 14 Jordanian men. Rastam et al. (2006) reported CO increases of ~24 ppm from 26 Syrian smokers (3 women). What is in waterpipe smokers: CO and nicotine Expired air CO Plasma nicotine

26. Short-term: cardiovascular effects (Shafagoj et al., 2002). Long-term – associated with: - Tobacco/nicotine dependence (Maziak et al., 2004). - Cardiovascular disease (Jabbour et al., 2003). - Lung disease (e.g., Zakaria et al., 2005). - Cancer (Nafoe et al., 1973; El Hakim and Uthman, 1999). - Fetal tobacco syndrome (Nuwayhid et al., 1998). - Potential for disease transmission with group use. What are the effects of waterpipe tobacco smoking?

27. We are well behind the curve... - Smoke toxicant content under realistic smoking conditions. - Smoker toxicant exposure: co, nicotine, carcinogens, heavy metals, influence of charcoal. - Epidemiological work to understand disease risk. - Large-scale surveys in the U.S. and elsewhere to understand current prevalence and identify targets populations and key messages for prevention and treatment efforts. - Prevention and cessation interventions.... But we have the methods to catch up quickly! What we need to know.

28. Thanks for listening!