1. RTI International is a trade name of Research Triangle Institute www.rti.org Addressing Hookah Use Prepared by The Bureau of Tobacco Prevention Program July 2010 Presented by Ron Davis and Jamie Forest

2. Objectives: Provide a description and overview of hookah Convey Florida data regarding hookah prevalence Communicate the Florida BTPP Hookah Plan Explain FCIAA enforcement challenges Describe possible future avenues to address the issue Give recommendations for local action against hookah Hookah Webinar Overview

3. Hookah Description and Overview Hookah is also know as shisha, nargile (pronounced NAH-GEE-LEH), arghile, water-pipe, and hubble- bubble, ( also - sheesha, shishe, nargila, goza, lula, lulava, cachimba, ghalyoon, chillim, huqqa). Shisha is also the name for the type of tobacco smoked in a hookah Originated in India or Persia; increasing world-wide Typically used in a group setting

4. How a hookah works May have single or multiple stems Hose may have interchangeable mouthpieces A lump of sticky tobacco is placed in the bowl Charcoal is placed on top of the bowl (see diagram) Tobacco is heated by charcoal Smoke is drawn down through the water

5. Shisha Tobacco Flavors Most tobacco used in a hookah is flavored tobacco Molasses or honey traditionally used Modern flavors include, fruits, candy, alcohol, coffee “Filtering” liquids include flavored water, fruit juices, alcohol, milk, soft drinks, etc.

6. Hookah costs Hookah bars / lounges Hookah is only one part of the hookah bar experience Food, alcohol, music, belly dancers, elaborate decor, or coffee, ice cream $8-$12 hookah sessions / all night Home use hookahs – less that $20 – thousands Shisha for home use approximately $10

7. Targeting teens and young adults July Issue of Florida Trend Magazine

8. Hookah misperceptions The liquid filters out all the toxins –Cools the smoke – making it less harsh & easier to inhale –Perception that it is less harmful You can not get addicted to hookah smoke –Hookah contains nicotine equivalent to cigarette smoke Hookah smoking is safer than cigarettes –Charcoal creates higher carbon monoxide levels –Longer sessions mean greater exposure to toxins No health risks to occasional hookah use –Cardiovascular risks and communicable disease

9. Hookah smoke risk exposure Cigarette smoker 8-12 puffs, 5-7 minutes,.5-.6 liters of smoke Hookah smoker 20-80 minute session, 50–200 puffs,.15 - 1 liter per puff Typical session equivalent to 100 or more cigarettes Reduced nicotine due to water filtration, may lead to greater consumption to get nicotine fix & therefore exposure to more toxins over the course of the session Greater second hand smoke exposure WHO Advisory Note: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators,”

10. Hookah Health Risks Cancer – lung, oral, bladder, esophagus & stomach Cardiovascular disease Communicable diseases like colds, hepatitis, herpes, & tuberculosis Pregnant women – low birth weight Potential gateway to other tobacco use

11. Current Florida Data Data on prevalence Data on location of hookah establishments

12. Florida BTPP Hookah Plan Assess hookah prevalence –Review current research –Refine data collection instruments Provide technical assistance to community partners Implement local policy strategies Identify state-level strategies –Collaboration with DBPR –Identify hookah establishments statewide Develop a media toolkit

13. Challenges to action against hookah FCIAA challenges –Retail Tobacco Store exemption –FCIAA smoking definition “loophole” "Smoking" means inhaling, exhaling, burning, carrying, or possessing any lighted tobacco product, … Identification of hookah establishments –DBPR Tobacco retailer tracking

14. Future directions for action New law - Chapter 569.0073, F.S –Restricts sale of waterpipes –Legal challenge –Enforcement delayed at least one year – due to “annual gross revenue” portion of bill Tobacco Tax Parity Act of 2010 Creative avenue for local action

15. H.R. 4439. Tobacco Tax Parity Act of 2010 Roll your own tobacco was included in the federal tax increase in 2009 Roll your own tobacco suddenly became labeled as “pipe tobacco” which was not included H.R. 4439 would amend the Internal Revenue Code of 1986 to impose the same rate of tax on pipe tobacco as is imposed on roll-your-own tobacco. Tax would increase 775% This tobacco tax increase would include shisha 100 g increase from 62.5 cents to $4.86

16. Local Action Assist BTPP in identifing hookah establishments in your community Combat misperceptions of hookah risks Include shisha / hookah tobacco in flavored tobacco policy

17. References World Health Organization. WHO Advisory Note: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators,” WHO 2005. Author unknown (2007) An Emerging Deadly Trend: Waterpipe Tobacco Use. American Lung Association: Tobacco Policy Trend Alert The Bacchus Network (May 2007). Reducing Hookah Use: A public health challenge for the 21 st century.