1. Rima Nakkash Assistant Professor Health Promotion and Community Health Department WHO Collaborating Center for Health Promotion and Behavioral Sciences Faculty of Health Sciences Coordinator-AUB Tobacco Control Research Group Tobacco Control Research Group 1 st International Conference on Waterpipe Tobacco Smoking Abu Dhabi,U.A.E October 20, 2013

2. 0verview Does the current tobacco control policy regulatory framework address waterpipe tobacco smoking (WTS)? How? Any current policy practices specific to WTS needed.

3. Comprehensive No single measure is sufficient to tackle tobacco – it is important to move on many fronts at once in a comprehensive effort to reduce smoking prevalence. ……hence a FRAMEWORK is needed…..

4. Comprehensive Strategies (FCTC)  Price measures- Taxation measures  Non-price measures  Advertising bans  Warning labels on tobacco products  Ban smoking in public places  Protecting from tobacco industry interference  Other : cessation, prevention and educational campaigns, control smuggling…..

5. Do we need a waterpipe tobacco smoking specific policies? What do we know so far about waterpipe tobacco smoking regulation? Will the same framework be needed for waterpipe tobacco smoking ? Are there additional regulatory parameters that need to be considered that are specific for this smoking phenomenon?

6. Review of the regulatory gaps Flavoring (Family Smoking Prevention and Tobacco Control Act ) Free samples Youth access Use restrictions (tobacco vs. non tobacco products) Point of Sale Warnings, Marketing restrictions, and broad sales prohibitions

7. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings Tobacco industry ?? Cessation Others

8. Taxation Taxing delivery services Taxing serving establishments on sales–prohibitive range of prices (currently 1USD-24 USD) Taxing tobacco packaged products for home preparation of waterpipe or for mass production (by kg) Taxing waterpipe accessories (market size) Research is needed to explore effect of taxation on overall consumption, changes in behaviors such as switching between products, and impact on different population groups especially the vulnerable ones….

9. Current Practice http://www.dutycalculator.com/hs-code-duty-rate- import-restrictions/240311/hookah- tobacco/2403.11.0000/2403.11.0000/3007/ http://www.dutycalculator.com/hs-code-duty-rate- import-restrictions/240311/hookah- tobacco/2403.11.0000/2403.11.0000/3007/ Shows various countries tax structures on hookah tobacco.

10. Waterpipe tobacco smoking specific policies Taxation Advertising /Promotion Indoor smoking bans Health Warnings tobacco industry ?? Cessation Other ?

11. Regulating advertising Waterpipe tobacco product billboard advertising in Lebanon prior to March 2012

12. Banning sponsorship and promotion

13. Misleading … through advertising

14. What is this ?

16. Home Delivery handouts

17. Coal

18. Promoting Innovations http://www.healthy-shisha.com

19. Innovations http://www.healthy-shisha.com/

20. Internet promotion and sales US Hookah Tobacco Smoking Establishments Advertised on the Internet. -unregulated -accessible to the public -Play a role in propagating misinformation Primack, 2012)

21. Social Media Blog, online chats…who monitors? A comparison of cigarette and hookah related video’s on youtube.: portrayed positively, don’t mention short and long term consequences, anti smoking messages, or how to quit tobacco use. Who is in charge of what gets on youtube ? Pimack et. Al, 2013

22. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings Protecting from the tobacco industry ?? Cessation Other ?

23. Indoor smoking bans in public places There should be no exception made for waterpipe tobacco smoking serving establishments Licenses /loopholes/permits Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors. Daher NDaher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A.Saleh RJaroudi ESheheitli HBadr T Sepetdjian EAl Rashidi MSaliba NShihadeh A “ a single waterpipe use session emits in the sidestream smoke approximately four times the carcinogenic PAH, four times the volatile aldehydes, and 30 times the CO of a single cigarette. Accounting for exhaled mainstream smoke, and given a habitual smoker smoking rate of 2 cigarettes per hour, during a typical one-hour waterpipe use session a waterpipe smoker likely generates ambient carcinogens and toxicants equivalent to 2-10 cigarette smokers, depending on the compound in question.” Atmospheric Environment, v. 44, iss. 1, p. 8- 14.2010

24. US-Clean indoor air exemptions 73 of the largest 100 cities disallowed cigarette smoking in bars, nearly all (n = 69) of these cities may allow via exemptions. “poorly defined exemption language resulted in certification that actually assisted” lead to a new niche tobacco market emerging… (Primack et.al, 2012)

25. In London alone showed :500% increase in waterpipe premises in last 5 years (national: 210%) Exact figures unknown Not required to register with local authority Waterpipe premises not exempt from any tobacco legislation Underage purchase (<18 years) Smoke-free law (enforced in 2007) UK-Legislation enforcement of the waterpipe tobacco industry

26. UK-Conclusions Growing concern “One size fits all” legislation approach inappropriate High profit margins? Licensing proposal (at local authority level) (Mohamed, Jawad,Legislation enforcement of the waterpipe tobacco industry, A qualitative analysis of the London experience- October 2013)

27. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings Tobacco industry ?? Cessation Other ?

28. Health warning labels Only one health warning label and not a series of rotating messages Printed in small font Written on the sides of the waterpipe tobacco products alongside other information. Not on unit packs Nakkash and Khalil, 2010

29. Current health warning labels Mentioning an expiry date making waterpipe tobacco products seem misleadingly safe to be consumed prior to expiration In the ingredients, they mainly mentioned natural flavors They also stated that the waterpipe tobacco contains 0.05% Nicotine and 0.0% Tar

30. Misleading information on waterpipe accessories were also found on filters, tips and charcoal:

31. HW Labeling suggested in 2010Egypt 2011

32. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings Tobacco industry? Cessation Other ?

33. Advertisement for Egyptian Waterpipe Tobacco

34. Waterpipe Smoking as an Opportunity for New Profits by the Tobacco Industry? Interest of TNC’s is apparent as early as 1960’s and 1970’s Issue open for exploitation and could be predictive of future interest Flavouring companies interest –global industry too With growing smoking prevalence more concern of growing market for example alternative forms of tobacco use :BAT’s attempt to adapt to local culture as in the case of Kreteks in Indonesia In the case of Lebanon, local monopoly attempting to catch up with global spreading phenomenon. (WCTOH, Nakkash and Lee, 2006)

35. Testing, smoke properties and health effects 1993-META minutes “testing of waterpipe tobacco” -BAT intent to test hubble bubble 1994-Analytical technology department- smoking machine –Hookah experiment

36. Bates:1004867515

37. Opposition from the Industry ? In the US: Opposition on tax hikes :http://www.southsmoke.com/hookahtax.cfm In the US: Opposition on tax hikes :http://www.southsmoke.com/hookahtax.cfm Hookah Industry Association http://www.hookahindustry.org/2010/01/775-hookah-tobacco-tax- increase-rallies-over-2000/ The Hookah Industry Association (HIA) advocates its members’ interests on issues which affect the entire hookah industry. HIA’s mission: -Fight back and push for the repeal of repressive & restrictive legislation -Serve as a mechanism for the sharing of ideas, programs, and skills among the organization’s members -Release research publications & industry news to keep businesses informed -Educate the public on the economic & cultural importance of the industry

38. Tobacco Journal International 1/2013

39. Exports to over 100 countries New customers in remote locations,, Indian ocean, and latin american Since 1913… introduced Maasel in 1980 New competitors

40. http://www.jti.com/media/news-releases/jt- completes-acquisition-leading-water-pipe-tobacco- company/

41. Flavoring

42. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings Protectin g from the tobacco industry ?? Cessation Other ?

43. Cessation Incorporate in national plans Development of waterpipe tobacco smoking tailored cessation services Evaluation of waterpipe tobacco smoking specific cessation protocols Sensitive to dual users and specific to vulnerable populations, youth; pregnant women.

44. Waterpipe tobacco smoking specific policies Taxation Advertising bans Indoor smoking bans Health Warnings the tobacco industry ?? Cessation Other ???

45. Other Product regulation and testing to monitor development Halting sales of WTS products to minors Banning introduction of new products/flavours or altogether Controlling illicit trade Development of prevention messages and campaigns

46. In Conclusion No comprehensive study on challenges to legilsation or policy making for waterpipe Need for building the evidence base for effective waterpipe tobacco control policies Policy influence can be studied in different countries by examining cigarette and waterpipe use prevalence in light of policy that does or does not address each tobacco use method. Identify how policies that do and do not address WTS influence public health outcomes.

47. THANK YOU Email : rn06@aub.edu.lbrn06@aub.edu.lb Website http://www.aub.edu.lb/units/tcrg/Pages/index.aspx