1. Ali Al-Bakri, ali.albakri777@gmail.com Mohammed Jawad, mohammed.jawad06@imperial.ac.uk Mustafa al’Absi, malabsi@umn.edu Pascal Salameh, pascalesalameh1@hotmail.com Saba Kassim, s.kassim@qmul.ac.uk Opportunistic insights into occupational health hazards associated with the waterpipe tobacco industry in the United Kingdom

2. Introduction  Waterpipe tobacco smoking (WP) is getting popular in Europe with negative health effects and occupational health hazards (1)  200% increase in WP premises between 2007 and 2012 in the UK (over 400 in London) (2,3)  WP under Smoke free laws in the UK but poor compliance (3)  No study in occupational health hazard of employees in WP premises !

3. Methodology  Primary study about investigating WP dependency in customers in 7 WP premises (6)  During data collection, researcher (AA) observed and interacted culturally with premises staff  Another researcher (MJ) interviewed the data collector (AA) to explore the participant observation experience (4-5).  Exhaled Carbon Monoxide (CO) taken from 9 staff members  Study approved by QMUL ethics committee

4. WP premisesEmployee types CO (ppm)COHb (%) 1Serving WP 24 27 4.5 5.0 Serving food 6 1.5 2Serving WP 55 42 9.4 7.4 Serving food 2 0.8 3Serving WP 28 21 5.1 4.0 Serving food 41.2 CO: carbon monoxide, ppm: part per million, COHb (%): percentage of Carboxyhemoglobin

5.  Arabic culture embodiment in WP premises  Smoke free laws were perceived as an attack to the Middle Eastern Culture  Occupational health hazards noticed (i.e. igniting and cleaning WP, walking and moving holder)  Self reported deteriorating physical health since working in WP premises  Self reported mental health problems of staff (i.e. stress, long working hours, lack of educational and professional development)

6. “Dr, if you want to do research, please do research on us [WP premise employees]. We have lots of difficulties, mainly financial ones because our payment is not good, and we always work with smoke. I sometimes feel scared when I think about my future in 20 years and how this smoke will affect my health”.

7. Discussion  First study to investigate occupational health hazards in WP premises in the UK.  Previous Studies measured CO in WP premises (7-9)  Comparable results in studies measuring exhaled CO in patrons of WP premises (10)  Igniting WP and greatest increase in COHb in first 5 mins of smoking (11)  First 5 minutes of WP session produce different size of particles (12)

8. Future research  Investigating occupational health hazards of WP premises in a larger scale  Investigating the exhaled CO of the staff during different time in their shifts

9. Conclusion  High level of CO identified in WP-serving staff  Occupational, physical and mental problems associated with working in WP premises  Future research to investigate the occupational risks including second-hand smoking in WP premises.

10. References 1- MAZIAK, W. 2011. The global epidemic of waterpipe smoking. Addict Behav, 36, 1-5 2- British Heart Foundation (BHF). (2012). Rise in ‘shisha bars’ prompts warning on dangers of waterpipe smoking [online]. Available at: http://www.bhf.org.uk/default.aspx?page=14417. [Date of access 29 June 2013]. from http://www.bhf.org.uk/default.aspx?page=14417 http://www.bhf.org.uk/default.aspx?page=14417 3- Jawad, M. (2014). Legislation Enforcement of the Waterpipe Tobacco Industry: A Qualitative Analysis of the London Experience. Nicotine & Tobacco Research. doi: 10.1093/ntr/ntu022 4- Kawulich, Barbara B. (2005). Participant Observation as a Data Collection Method [81 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 6(2), Art. 43, http://nbn-resolving.de/urn:nbn:de:0114-fqs0502430.http://nbn-resolving.de/urn:nbn:de:0114-fqs0502430 5- Pearson Educaton (1995-2005). Participant Observation [online]. Available at http://wps.pearsoned.co.uk/ema_uk_he_plummer_sociology_3/40/10342/2647687.cw/content/ Date of access 25 May 2014 http://wps.pearsoned.co.uk/ema_uk_he_plummer_sociology_3/40/10342/2647687.cw/content/ 6- Kassim, S., Al-Bakri, A., al’Absi, M., & Croucher, R. (2014). Waterpipe Tobacco Dependence in U.K. Male Adult Residents: A Cross-Sectional Study. Nicotine & Tobacco Research, 16(3), 316-325. doi: 10.1093/ntr/ntt148 7- Cobb, C. O. ;Vansickel, A. R. ;Blank, M. D. ;Jentink, K. ;Travers, M. J. ;Eissenberg, T. Indoor air quality in Virginia waterpipe cafes. 2013. Tob Control. 2013; 22: 338-43 8- Zhang, B. ;Haji, F. ;Kaufman, P. ;Muir, S. ;Ferrence, R. 'Enter at your own risk': a multimethod study of air quality and biological measures in Canadian waterpipe cafes. 2013. Tob Control 9- Torrey, C. M. ;Moon, K. A. ;Williams, D. A. ;Green, T. ;Cohen, J. E. ;Navas-Acien, A. ;Breysse, P. N. Waterpipe cafes in Baltimore, Maryland: Carbon monoxide, particulate matter, and nicotine exposure. 2014. J Expo Sci Environ Epidemiol 10- Barnett TE, Curbow BA, Soule EK, et al. Carbon monoxide levels among patrons of hookah cafes. Am J Prev Med. 2011;40:324-8 11-. Monn C, Kindler P, Meile A, et al. Ultrafine particle emissions from waterpipes. Tob Control. 2007;16:390-3. 12-Chaouachi K. Hookah (shisha, narghile, "water pipe") indoor air contamination in German unrealistic experiment. Serious methodological biases and ethical concern. Food Chem Toxicol. 2010;48:992-5; author reply 6-7.

11.  Special thanks for Peninsula Dental School for funding my participation  The contribution of the owners and staff of the WP premises in the study is appreciated

12. Thank you for listening