1. The Waterpipe: Epidemiology Wasim Maziak MD, PhD Professor, Chair, Department of Epidemiology Florida International University Director, Syrian Center for Tobacco Studies

2. The Waterpipe (hookah, shisha, narghile, hubble-bubble) Centuries old habit with historical roots to the Middle East

3.  Study of distribution and determinants of disease in human populations Frequency: Quantification of disease Definition of Epidemiology Who? Where? When? What? Why? How?

4. Beginning of waterpipe epidemic 268 WP smokers in cafés (Aleppo) Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

5. Factors behind the current waterpipe pandemic 1. Introduction of Maassel in the early 1990s. 2.The internet & other social and transnational media 3.The reduced-harm perception, “the water filtering” effect 4. The allure of waterpipe and thriving café culture. 5. Lack of effective policies (e.g. FCTC). Maziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

6. 1. Maassel? 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.

7. 2. The internet & other social media Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. The promotional materials …de-emphasize age limits, health warnings, and even that tobacco is involved in hookah smoking. Primack et al., 2012.

8. 3. Reduced harm perception Qualitative study of 15 WP and 15 Cig smokers; (Hammal et al, 2008) “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 F, Mock J, Ward KD, Eissenberg T, Maziak W. A pleasure among friends. Tobacco Control 2008.

9. 4. Allure of waterpipe Asfar T, Ward KD, Eissenberg T, Maziak W. BMC Pub Health 2005;5(1):19. Smith-Simone, Maziak, Ward, and Eissenberg. Nicotine & Tob Research, 2008, 10: 393–398. 1. I enjoy the taste, smell, smoothness of smoke 2. It’s a good way to socialize with friends 3. It helps me to feel relaxed 4. I like the social ambience 5. It helps me to feel less stressed 6. It’s something to do when I feel bored 7. I like trying things that are new, different, or “hip” 9. It helps me not smoke cigarettes

10. 5. Lack of effective policies Nakkash et al., 2010; Maziak et al., 2013

11. Prevalence and use pattern in different parts of the world. Association with cigarettes. Time trends in youth. Gateway to cigarette. Epidemiology

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

13. Most popular tobacco use methods in college students, US (152 universities; n=105,012) Primack B A et al. Nicotine Tob Res 2013;15:29-35

14. 0 5 10 15 20 25 30 200720082009 Survey year % ever WP use 16.2% 20.2% 25.3% Courtesy of Dr. Tracy Barnett via FYTS (http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/FYTS/Intro.htm) Time trends: Ever waterpipe use for 12 th graders by year (Florida, FYTS)

16. Age patterns: WP smoking in US college students Primack B A et al. Nicotine Tob Res 2013;15:29-35

17. Age patterns: Current WP smoking in Lebanon Chaaya et al, 2004, 2006

18. Age patterns: WP adults, Syria Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006

19. Gender: WP smoking, (13-15 yrs), EMR (n > 90,000) Warren CW, et al. Lancet, 2006.

20. Gender: WP, (11-15 yrs), Estonia, 2006 (N = 13826) Pärna et al. BMC Public Health 2008 8:392

21. SES: WP smoking adults, Syria Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

22. SES: WP quitting, adults, Syria Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

23. Frequency of WP use (adults, Syria) Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

24. Asfar et al., BMC Public Health 2005

25. Association with cigarette smoking Primack BA et al. NTR, 2013

26. McKelvey, Maziak, et al., Eur J PH, 2013

27. Age-adjusted smoking rates in men and women, by country Khattab A, et al, Respiratory Medicine, 2012

28. McKelvey, Maziak, et al., Eur J PH, 2013

29. Asfar et al., BMC Public Health 2005

30. Smoke narghile mostly at home

31. Usually share the same narghile with others

32. McKelvey, Maziak, et al., Eur J PH, 2013

33. Once addicted on nicotine, young people may go for Cig because of easier access compared to WP (gateway hypothesis)

34. Main epidemiological trends for WP Common among youth all over the world and increasing More intermittent use than daily Educated and affluent (higher SES) Male predominance, not consistent across populations and age groups. Associates with cigarette smoking at early ages and can lead to cigarette smoking.

35. Summary Waterpipe smoking is widespread and increasing all over the world. It is more widespread among the young, educated and affluent Gender differences in waterpipe smoking tend to vary by region, but girls and women in the EMR are increasingly taking up this tobacco use method Surveillance systems that inquire specifically about the waterpipe and are adapted to its use patterns are needed to monitor the epidemic and groups more at risk of waterpipe smoking

36. Acknowledgments Our heroes at the Syrian center for Tobacco Studies Eman Ibrahim 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