1. The School of Public Health Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies Social and Psychological Issues Regarding Waterpipe Tobacco Use 1 st International Conference on Waterpipe Research, Oct 21-23 rd, 2013, Abu Dhabi

2. Goals What psychological and social factors encourage initiation and maintenance of waterpipe use? – Motivational factors – Perceptions of health effects – Perceptions of addictiveness – Social factors, including acceptability and availability Next steps

4. Publications about psychological and social aspects of WP use # Medline citations

5. Promoting Health: Intervention Strategies from Social and Behavioral Research, by the National Academy of Sciences.

6. We have less empirical evidence about determinants of initiation than determinants of maintenance.

7. First use of waterpipe by university students in Aleppo, Syria Men (%)Women (%) Alone30.0 With friends8654 With family members 1146 Maziak, et al., IJTLD, 2004

8. Why did you start using waterpipe?Its a pleasure among friends Due to the boredom of having free time, I used to go with my friends to a cafe´. When they invited me to try narghile, I found it interesting and good. I felt some dizziness, but I enjoyed the taste and the smell. It was fun. And so I became a daily smoker. Hammal et al., Tobacco Control, 2008

9. 10 th graders in Johannesburg, SA 20% smoke waterpipe daily Most cited reasons for smoking: – Nothing better to do (46%) – Helps to relax (28%) – Peer Pressure (14%) 39% perceived pressure to smoke waterpipe – Addicted (6%) Combrink et al., SAMJ, 2010

10. Why did you start using waterpipe?Everyone does it …I started smoking narghile in public places. I go out with my friends. They are all [narghile] smokers. I smoke [narghile] with them to entertain myself and because I do not want to be different. Hammal et al., Tobacco Control, 2008

12. Sensory characteristics Smell, taste, sight of smoke, sound of bubbling sound – Maziak 2004 – Nakkash 2011 – Roskin 2009 – Smith-Simone 2008 "The strong flavour and strong smoke are great. I can do smoke rings and impress the ladies. There would be no point in smoking if it wasn't flavoured. (Roskin & Aveyard, 2009).. I like the smoke when it comes out as it does…When I wasnt smoking the waterpipe, I used to look at someone who smoked it and see how the smoke comes out of it and that made me love it. (Nakkash 2011)

13. Why did you start using waterpipe? Its an affordable novelty...we can order it twice, three times...Sharing and if its for 10,000 L.L. and we are 3 or 4 [people], so approximately 2000 L.L. per person is affordable I think if [the waterpipe was]… expensive relative to the income, it would not be that popular (...); a higher price would deter from use (Woman non-smoker - urban area) Nakkash et al., BMC Public Health, 2011

14. Social aspects maintain use Time with friends, communal aspects, role as a social lubricant, promotion of kinship and brotherhood, relaxation, relief of boredom – Guiliani 2010- Roskin 2009 – Jamil 2010- Anjun 2008 – Martinasek 2013- Al Dabbagh 2005 – Maziak 2004- Labib 2005 – Smith-Simone 2008 - Ghafouri 2011

15. Family acceptance, or at least acquiescence "I have never smoked cigarettes in front of my parents. They'd be surprised, annoyed and disappointed. There is something more acceptable about shisha. "When I explained to my parents it was harmless, they were fine. They've tried it. Roskin, et al.,

16. More family acceptance of WP use for women than men Maziak et al., Ann Epidemiol, 2004

17. A majority of users believe waterpipe is less harmful than cigarettes U.S. samples: Abughosh, 2011; Ajiarrah 2009; Giuliani 2010; Jamil 2011; Smith 2011; Smith-Simone 2008; Sutfin 2011; Ward 2007 Middle East samples: (Al- Dabbagh 2005; Anjum 2008; Asfar 2005; Chaaya 2004; Erbaydar 2010; Ghafour 2011; Hammal 2008; Jawaid 2008; Labib 2007; Varsano 2003) 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 et al., 2008)

18. Perceived addictiveness Most users in Middle East and western countries dont perceive themselves to be addicted (Maziak 2005; Primack 2008; Smith-Simone 2008; Ward 2005, 2007) Waterpipe is perceived as less addictive than cigarettes, by WP smokers, cigarette smokers, and non-smokers (Abughosh 2011; Azab 2010; Jawaid 2008; Maziak 2004)

19. Which is more addictive? WP users (%) Non- smokers (%) Cigarettes are more addictive9077 Cigarettes and waterpipe are equally addictive 817 Waterpipe is more addictive25 Maziak et al., Ann Epidemiol, 2004

20. However, many frequent users do believe they are addicted Maziak, et al., Pharm, Biochem, Behav, 2005

21. Why is waterpipe perceived as less harmful/addictive? Filtering means less nicotine and tar get delivered – From what Ive been told, the water acts as a filter to get rid of bad stuff. – Water catches the ashes from the charcoal. Not like a cigarette filter, water is a natural filter. (Roskin & Aveyard, 2009). Flavor/smell indicate its safe (Dillon & Chase, 2010) – Fruit flavour makes it less harmful. I dont believe its as harmful as cigarettes. (Roskin & Aveyard, 2009)

22. Why is waterpipe perceived as less harmful/addictive? If its so bad, why havent I heard about it? Cigarettes are much more harmful, as the dangers are publicized. I dont really see the danger [of smoking waterpipe]. (Nakkash et al., 2009) There are no warnings on TV. If there were warnings, Id be more aware. (Roskin & Aveyard, 2009)

23. Important to remember that determinants of waterpipe use are not invariant across time, population, and place.

24. Afifi, et al., Eur J Public Health, 2009

25. Relief of boredom Relaxation Smell Taste Look of pipe Bubbling sound Availability Peer influence Influence of family members Novelty/experimentation Affect management (stress, anxiety, depression, anger) Reduced harm Reduced addictiveness Exoticness Affordability Way to quit cigarettes Culturally acceptable alternative to cigarettes Way to express cultural identity Akl et al., Harm Reduction Journal, 2013

26. Martinasek, et al., Am J Health Behavior, 2013

27. Positive attitudes are stronger determinant of intent to smoke WP than negative attitudes Hookah seems…OR95% CI Positive Perceptions Attractive6.494.65-9.05 Romantic4.563.21-6.47 Fun3.462.91-4.10 Relaxing2.672.27-3.14 Overall9.316.77-12.80 Negative Perceptions Harmful0.980.87-1.10 Addicting0.710.63-0.80 Overall0.790.69-0.90 Socially acceptable2.121.76-2.54 Barnett et al., Am J Health Behavior, 2013

28. Outcome expectancies are related to intent to initiate WP use (n=722 never users) Latent factorCorrelation with intent to use WP p Aids adjustment to college life.61<.001 Consistent with values (family, religious, cultural, intellectual).32<.001 Thrill-seeking.48<.001 Acute health effects-.30<.001 Long term effects-.22<.001 Martinasek, unpublished data

29. Many social determinants, but not all, are available to awareness of users… Exemptions from clean air laws (Primack 2012) Failure to fully enact FCTC: only 7 Arab countries have enacted comprehensive smoking bans in public places, while the rest have partial or no bans and enforcement remains low overall (WHO 2009, reported in Maziak 2013) Mismatch of FCTC goals with waterpipe – E.g., packaging/labeling is more complicated with WP due to variability compared to cigarettes (Maziak, Nakkash,et al., 2013)

30. Summary Social nature of WP use (a pleasure among friends, relaxation, peer/family influence) is major determinant of initiation and maintenance Need to deglamorize and renormalize WP use (Maziak et al., 2007) More upstream determinants are wide availability promoted by absent/unenforced policies such as clean air laws, inexpensiveness, lack of knowledge of harms due to research to practice limitations Future research should use prospective multilevel approaches to model how intrapersonal, interpersonal, and community/societal level factors jointly influence initiation and maintenance of waterpipe use But we shouldnt wait!

31. www.scts-sy.org Thank you! Radwan Al Ali, MD Taghrid Asfar, MD Iman Ebrahim Tom Eissenberg, PhD Madonna Elias Fouad Fouad, MD Wasim Maziak, MD, PhD Samer Rastam, MD, PhD

32. Correlates of interest in quitting waterpipe VariableOdds Ratio95% CIp Married2.301.24 - 4.24.0078 Muslim1.980.96 - 4.05.0630 Years smoking0.920.87 - 0.99.0182 Increased use0.550.30 - 0.99.0475 Family doesn t smoke 2.041.12 - 3.72.0196 Family disapproves2.121.15 - 3.91.0159

33. Correlates of interest in quitting waterpipe – Abughosh study JACH 12 VariableOdds Ratio95% CI Race White, non-Mid East White, Mid East Indian/Pakistani Hispanic/Latino Black/Mix/Other REF 1.27 4.74 1.72 1.23 0.45-3.59 1.61-13.93 0.65-4.56 0.46-3.30 Believes WP is harmful to health 2.381.05-5.36 How long do you smoke WP? 0-30 minutes 30-60 minutes > 60 minutes REF 0.72 0.29 0.33-1.60 0.12-0.73

34. Population-based data from Syria on interest in quitting WP 12% of adults (n=248) used WP 56% were interested in quitting 25% had made quit attempt in last year 89% perceived quitting not to be very difficult Major obstacles to quitting: – Friends/socializing (69%) – Boredom/free time (16%) Correlates of desire to quit: – Living in poorer neighborhoods – Wanting to quit cigarettes – Desire to quit not correlated with frequency of use, exposure to others WP use, or health status

35. Users are not very aware of health hazards StudentsEstablished users Cardiovascular610 Respiratory4837 Cancer2936 Other135 None, dont know513 Asfar et al., BMC Public Health, 2005

36. Cigarette smokers are at increased risk of initiating WP 8.4% currently use WP 34% of WP smokers use cigars 50% of WP users smoke cigarettes Primack et al., Nic & Tob Research, 2012

37. Cigarette smokers are at increased risk of initiating WP Irbid Longitudinal Smoking Study (n=1781 7 th graders followed for 3 years) – Baseline cigarette smokers twice as likely to initiate WP use over two years as never-smokers (RR=2.0; CI 0.9-4.8) – Baseline WP smokers were twice as likely to initiate cigarette smoking over 2 years as never- smokers (RR=2.1; CI=1.2-3.4)

38. Does greater knowledge and worry of WP risks increase desire to quit? Web-based survey of 316 college WP users in US rp Perceived knowledge of WP harms.10<.09 Factual knowledge.10<.09 Perceived risk.30<.0001 Worried about harm.49<.0001 Perceived risk of addiction.27<.0001 Worried about becoming addicted.45<.0001