1. Wasim Maziak MD, PhD Professor & Chair, Dept. Epidemiology, Florida International University Director, Syrian Center for Tobacco Studies The Waterpipe A Cultural Pastime or a Public Health Threat

2. Syrian Center for Tobacco Studies SCTS has been recognized with the Hamdan Award for best Medical/Research Institute in the Arab world for the year 2008

3. The Waterpipe, origins (hookah, shisha, narghile, hubble-bubble) Associated with the Indian subcontinent & Middle East Several records point at an origin that dates back to the 16 th century, and probably with substances other than tobacco since tobacco is believed to be introduced to the region at the beginning of 17 th century)

4. The Waterpipe (hookah, shisha, narghile, hubble-bubble)

5. Beginning of waterpipe epidemic Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

6. So what happened? Bonsack machine, 1880 Hand rolling – 200 cigarettes/day Bonsack 200/per minute Current machines – 16,400/minute (984,000/hour)

7. So what happened? 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.

8. Social networks, blogs, twitter

9. And the habit went From this To this

10. The culture

11. “The narghile is good and fun. When we gather to smoke narghile, we know it is a gathering for serenity and joy.” “My husband smokes [narghile] and I’m waiting for my 4-year-old son to get older so that we can all smoke together”. Hammal, Maziak, Mock, et al. Tobacco Contol, 2008; Jawad et al., 2013 The social value of waterpipe

12. “If you vent the smoke in the face of another man or woman, it would mean: I want you. (Woman, smoker, 26–35 yrs., Lebanon)” Khalil, Afifi, et al., Women Health, 2013 “A woman who smokes waterpipe is more desired. Men are attracted to women who smoke waterpipe because they consider them more liberal. (Man, non- smoker, 18–25 yrs., Syria)” Emerging social associations of WP

13. Khalil, Afifi, et al., Women Health, 2013. Jawad et al, IJTLD 2013 Social acceptability “I don't like women to smoke waterpipe in public places … We are an oriental society, we should respect the values. (Man, smoker, 26–35 yrs., Syria)” “You know that dangerous element, that forbidden element attached to smoking? You get that with shisha, except it’s a halal venue and, perhaps more importantly, socially acceptable”.

14. The lifestyle

15. Why should we care? Spread. Harmful effects Addictive properties Lack of policy tools to confront it

16. Current cigarette vs. waterpipe smoking among 13–15 year olds in several Arab countries Maziak W et al. Health Policy Plan. 2013

17. Is it harmful and addictive

18. Reduced harm perception Jawad M, et al., IJTLD 2013 When I smoke cigarettes I know straight away ‘This is bad for me’, but when I smoke shisha, I don’t feel it’s bad for me and that’s because it’s cold and it’s been through the filter, and you don’t see direct tobacco being burnt—when you’re smoking cigarettes you can see it burning and you can feel the heat.

19. Machine-generated smoke content using realistic puff parameters for single WP and Cig Toxicant/mgWaterpipeCigaretteRatio Nicotine2.941.741.7 CO14522.36.5 Tar80217.346.36 Cobb C, Maziak W, Ward K, Shihadeh A, Eissenberg T. Am J Health Behavior, 2010.

20. Maziak W, et al. Tobacco Abstinence Symptoms, CO exposure, and Puff Topography in Waterpipe Tobacco Smokers. N &TR 2009; 11(7): 806-11.. Cigarette data from Kleykamp et al 2008 Toxicant exposure of smokers: CO (n=61)

21. Exposure to carcinogens Al Ali, Maziak, Shihade, Zataari, et al., Tobacco Control, 2013

22. Harm to others, particulate matter (PM2.5) Fromme H et al., Food and Chemical Toxicology, 2009. -24-hour (PM2.5) standard 35μg/m3 - Annual PM2.5 standard is 15μg/m3

23. Is the waterpipe addictive?

24. I don’t feel that the narghile fills my need like cigarettes. It is for spending time and entertainment. I don’t feel that I’m addicted to narghile, and I could quit narghile any time “I like to dominate everything, but the narghile has completely dominated me. My happiness is related to the narghile. It is essential for having a good time…” Hammal, Maziak, Mock, et al., Tobacco Control, 2008. Smokers’ testimonies

25. Cobb et al., 2011 61 liters of smoke 1 liter of smoke Waterpipe delivery of nicotine Time

26. “ If I cannot smoke, I feel restless and tired. When I travel to visit my parents, I do not smoke. Their home environment is not encouraging and I do not feel an urge to smoke. I crave the narghile from 7 till 10 in the evening. ( Hammal, Maziak, Mock, et al. Tobacco control, 2008) “Sometimes it bothers me—if I want it [waterpipe], I don’t just forget about it—I’ll do anything just to have it... I don’t know why”. ( Jawad M et al., IJTLD 2013 ) Withdrawal/craving, qualitative evidence

27. Once addicted on nicotine, young people may go for cigarettes because of limited access to waterpipe (gateway hypothesis)

28. “I quit smoking for more than 6 months. Then, I was invited to smoke narghile. After the second puff I asked for a cigarette and I started again”. ( Hammal, Maziak, Mock et al. Tobacco Control, 2008 ) Thwarting cigarette cessation efforts

29. Policy implications

30. Content and packaging regulation information Blank et al., 2011

31. Content and packaging regulation Data from Vansickel et al., 2011.

32. Policy mismatch Maziak, Nakkash, Eissenberg, et al., 2013

33. Ban advertisement Nakkash et al., 2011

34. Need for public awareness “I don’t see enough advertising to tell me the real effects of shisha, so I don’t really know them. Until then I’m not gonna stop”. (Jawad et al, 2013)

35. E-Shisha, new unknown in tobacco control policy

36. Policy implications Smokefree air laws seem to have had the opposite effect on hookah establishments, as they are often exempted. More must be done to limit minors’ access to waterpipe products. Enforce clear warning labels on waterpipe tobacco, and ensure that misleading descriptors such as mild, healthy “0% tar” are removed from packaging. Warning labels should be with considerable size and on all parts. Enforce advertisement bans to include waterpipe and in involve online advertisement, which is the main promotion for waterpipe. Develop novel treatments for waterpipe smoking.

38. Call received from a 52 year old woman “I’ve smoked for thirty years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell. I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.”

39. Wish you a healthy life away from smoking

40. 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