1. Hookah Smoking: The Past and Future of Tobacco? Brian Primack, MD, EdM, MS Assistant Professor of Medicine and Pediatrics April 2009

3. Terminology Hookah Waterpipe Shisha-Pipe Narghile Bong Hubble-bubble

5. www.hookah-bars.com

15. Hours Sunday – Thursday: 4 PM – 12:30 AM Friday – Saturday: 4 PM – 2 AM

16. Flavors Fruit –Apple –Banana –Cherry –Melon Candy –Bubble gum –Chocolate mint Alcohol –Margarita –Piña colada

17. Good Quality Regular $7.00 Large $10.00 Arabic Coffee, Apple, Apple Alex, Double Apple, Apricot, Banana, Candy, Cappuccino, Cherry, Carmel, Coconut, Cola, Grape, Jasmine, Lemon, Mint, Mango, Mandarin, Mixed Fruit, Orange, Pistachio, Peach Rose, Salloum, Strawberry, Vanilla, Zaghoul Light, Zaghoul, Licorice

18. Excellent Quality Regular $8.00 Large $11.00 Double apple, Apricot, Banana, Cantaloupe, Cappuccino, Cherry, Coconut, Mint, Melon, Orange, Peach, Pineapple, Rose, Raspberry, Strawberry, Tutti-Frutti, Vanilla Cognac, Margarita, Pina Colada, Strawberry Daiquiri

19. Premiume Quality Regular $8.50 Large $11.50 Apple, Special Apple, Bahrany Apple, Apple Eskandarani, Banana, Cola, Cappuccino, Fruit Cocktail, Honey Melon, Mango, Orange, Peach, Pipe, Rose, Strawberry

20. Superior Quality Regular $9 Large $12 Apple, Strawberry, Grape, Rose

21. * Make your Hookah Cool with adding ice for $1 * Mix & Match Flavors Add $2 * Flavor Your Hookah Water Add $3 * Add 0.25 Per Each Person ** Minimum 1 Order Per Person ** ** Bring your own bottle $2 cork charge ** You Must Be 21 to bring your own alcohol bottle

22. Also Have Fruit Smoothies (e.g. Strawberry, Banana, Mango, Guava) Ice Cream Coffee and Tea Milk Shakes Desserts Games (Mancala, Dominoes)

24. Apple Shaped, $35

25. Silver Crane $120

26. $200 (It rotates!)

27. $600

28. $13 for 250 gm

29. $20 Sampler

30. 16 Coals for $4

31. Smoke Exposure 30-60 minute sessions Each session ~100 inhalations Each inhalation ~500 mL in volume Total volume –Waterpipe session: 50,000 mL –Cigarette: 500-600 mL

32. Smoking Topography Variable Waterpipe 1 (N = 80) Cigarette 2 (N = 87) Puff Number (N)101.111.4 Puff Volume (mL)50349.4 Puff Duration (s)2.71.5 Interpuff Interval (s)22.726.0 1 Shihadeh 2003; Shihadeh 2004 2 Breland 2005; Djordjevic 2000

33. Waterpipe 1 Cigarette 2 Tar (mg)80222 Nicotine (mg)3.01.7 CO (mg)14517 1 Shihadeh, 2005; 2 Djordjevic, 2000

35. Toxin (ng)Waterpipe 1 Cigarette 2 Arsenic16580 Beryllium65300 Chromium134037 Cobalt700.17 Lead687060 Nickel99017 1 Shihadeh, 2003; 2 Hoffman, 2000

36. Blood Nicotine Level = Shafagoj, 2002

37. Known Harm Waterpipe smoke contains... –Carcinogens –Carbon monoxide –Nicotine –Tar –Metals Waterpipe smoking associated with... –Cancer –Cardiovascular disease –Decreased pulmonary function –Nicotine dependence

39. History India, ~1600? EMR = Eastern Mediterranean Region –Syria –Lebanon –Israel –Egypt –Jordan

40. Travel Guide to Syria/Lebanon

41. Prevalence Globally EMR –Syria: 45% report ever use –Lebanon: 30% report weekly use Europe –Germany –Sweden Other –Brazil –Korea –Canada –Ukraine

42. What about the US? 200-300 new waterpipe cafés opened in the U.S. between 1999 and 2004 Particularly in college towns Convenience sample surveys suggest high current use (past 30 days) –411 first-year college students: 15.3% –744 introductory psychology students: 20%

44. Holes in Literature Random sample Associations between waterpipe smoking and –Demographics –Beliefs (e.g., harm, addiction, popularity) Populations outside college

45. STUDY 1: COLLEGE

46. Purpose Determine the 30-day, annual, and lifetime prevalence of waterpipe smoking in a random sample of college students Associations between smoking and predictors?

47. Design Cross-sectional survey Random sample of students at the University of Pittsburgh Collect data via web-based version of the American College Health Association’s (ACHA) National College Health Assessment (NCHA) Added items related to waterpipe use

48. Approvals University of Pittsburgh Institutional Review Board University Vice Provost

49. Procedure April 2007 during a three-week period Avoided the 30-day period following Spring Break Email invitation sent to 3600 randomly selected Pitt students Incentive: lottery to win cash prizes ranging from $25 to $100 Three reminder e-mails sent to students during the three-week period

50. Demographic Measures Age Gender Race Residence (on-vs. off-campus) Undergraduate vs. graduate Membership in a fraternity or sorority Self-reported academic achievement

51. Theory of Reasoned Action Norms Attitudes IntentBehavior

52. Behavior Measures 1.Have you ever smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No) 2.During the past year, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No) 3.During the past 30 days, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No)

53. Attitudes “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more harmful or less harmful than smoking regular cigarettes?” (“waterpipe more harmful” / “waterpipe same harm” / “waterpipe less harmful”) “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more addictive or less addictive than smoking regular cigarettes?” (“waterpipe more addictive” / “waterpipe same addictiveness” / “waterpipe less addictive”)

54. Normative Beliefs “Among your peers, how socially acceptable is it to smoke tobacco from a waterpipe (hookah, shisha, narghile)?” (“not acceptable” / “somewhat/moderately acceptable” / “very acceptable”) “What percentage of college students do you think has ever smoked tobacco from a waterpipe (hookah, shisha, narghile)?” (0- 100%, collapsed into tertiles

55. Response Rate 61 emails undeliverable Response rate 660/3539 = 18.6% 647/660 (98.0%) had outcome data

56. Sample Age (mean, SD)20.9 (2.0) Female (%)65.6 White (%)84.5 On Campus (%)39.9 Undergraduate (%)77.2 Fraternity/Sorority (%)8.5

57. Smoking Data

58. Past-Year Waterpipe Tobacco Smoking

59. Harm, Addictiveness

60. Acceptability, Popularity

61. Other Factors Associated with 1-Year WPTS Younger age Off campus Fraternity membership

62. Major Findings Lifetime use >40%, similar to cigarette lifetime use Current use 9.5% One year use 30.5% Associated with lack of concern for addictiveness (and harm, less so) Associated with sense of acceptability and popularity

63. Cigarettes vs. Waterpipe Many waterpipe smokers had never smoked cigarettes In non-cigarette smokers –Problematic –Introducing nicotine to previously naïve population In cigarette smokers –Substitution? –Augmentation?

64. Rate Differences 30-day rate (9.5%) much lower than annual (30.6%) and ever (40.5%) rates Sampling period: we avoided Spring Break, fraternity rush, etc.

65. Limitations Response rate: 18.6% Cross-sectional design

66. STUDY 2: HIGH SCHOOL

67. Purpose Determine prevalence in statewide sample of high school students Association with waterpipe use in high school

68. No High School National Data Monitoring the Future Youth Risk Behavior Surveillance Survey Others

69. Arizona 2005 Youth tobacco survey Added 2 items dealing with waterpipe tobacco smoking –Ever –Past 30 days

70. Participants Statewide representative sample Grades 6-12 All students enrolled in public and/or charter schools

71. Procedure Schools chose to use active or passive consent forms (89% used passive) Spring semester 2005 45 minute class period

72. Measures Tobacco –30-day waterpipe smoking –Ever waterpipe smoking –Other tobacco smoking Sociodemographic data –Age –Gender –Race –Type of school (charter vs. regular) –Plan to attend college

76. Multivariate Analysis: Ever Use OR Ever Use (95% CI) Grade Level1.6 (1.4, 1.7) Female0.8 (0.6, 1.1) Asian3.2 (1.2, 8.4) Black1.3 (0.5, 3.5) Hispanic1.4 (0.7, 2.9) Hawaiian/PI2.5 (0.7, 9.4) White3.2 (1.6, 6.4) Charter School1.5 (1.2, 1.8) Plans to Attend College0.5 (0.4, 0.6)

77. Multivariate Analysis: 30-Day Use OR 30-Day Use (95% CI) Grade Level1.4 (1.2, 1.5) Female0.6 (0.4, 0.9) Asian2.0 (0.6, 7.0) Black1.0 (0.3, 3.4) Hispanic1.4 (0.6, 3.4) Hawaiian/PI2.5 (0.5, 12.1) White2.1 (0.9, 5.0) Charter School1.4 (1.1, 1.9) Plans to Attend College0.7 (0.5, 0.98)

78. Major Findings History of waterpipe tobacco smoking –6% of all 6 th -12 th graders –15% of 12 th graders More common than 5 other methods of tobacco smoking Associated with age, gender, race, SES

79. Age High school: older College: younger Surrogate for alcohol use?

80. Experimentation vs. Addiction May lead to increased uptake of various types of nicotine Gateway to cigarette smoking?

81. Surveillance National studies (MTF, YRBS) should track this form of tobacco use Likely to increase –Less harsh –Flavored –Educational gaps –Policy issues

82. STUDY 3: NATIONAL PILOT DATA

83. National College Health Assessment Annual American College Health Association Instrument under revision since 2006 (NCHA II) Addition of waterpipe items Pilot Spring 2008 N = 8745 (8 schools)

84. Waterpipe vs. Cigarette

85. Waterpipe tobacco smoking

86. Other Tobacco Types * Includes little cigars, cigarillos

87. By Age

88. By School

89. By Living Arrangement

90. Question—You Be the Judge! Athletes –Varsity –Club –Intramural Tobacco use –Waterpipe –Cigarette

93. Implications College athletes (and others) who would have otherwise been nicotine naïve may be vulnerable to developing lifelong nicotine dependence via waterpipe tobacco smoking Waterpipe perceived as “different”

94. Athlete Types Varsity –Less social time? –Less risk tolerance due to sport commitment? Intramural/Club –Campus leaders –More likely to engage in “trendy” behaviors –Perception as similar to alcohol?

95. Different Tobacco Outcomes Ever waterpipe smoking: 29.5% Current waterpipe smoking: 7.2% –Lower power? –Try once or twice but not at risk for continued use?

96. Limitations Not nationally representative Response rate 28% No biochemical verification

97. Conclusion Waterpipe tobacco smoking represents a major potential threat to public health Threatens to undermine successes from cigarette smoking Surveillance and further research are necessary

98. Thanks! bprimack@pitt.edu