Is there a need for a GB shisha cessation service Is there a need for a GB shisha cessation service? Findings from cross-sectional surveys conducted in 2012 and 2013 Dr. Aimee Grant, Public Health Wales NHS Trust, Rory Morrison, ASH Scotland, Martin Dockrell, ASH

Overview How harmful is shisha for health? Existing research: prevalence of shisha use Research design Findings How should we respond? Do we need a shisha cessation service?

How harmful is shisha for health? World Health Organisation (2005) CO poisoning (Clarke et al., 2012) Laboratory study 1 (Eissenberg and Shihadeh, 2009) 45 mins shisha v 1 cigarette High levels of exhaled CO (23.9ppm) High puff volume (50 litres) Similar peak nicotine levels Laboratory Study 2 (Daher et al., 2010) Second hand smoke Ecological validity (Chaouachi, 2011) WHO (2005) – Tobacco Product Regulation study group. First in-depth look at shisha. Many of the same health problems as other conditions, including lung cancer and heart disease. Estimate 1 hour of using shisha equivalent to up to 100 cigarettes CO poisoning has been reported by two sets of physicians in peer reviewed journals. Daher et al, 2010’s laboratory study used an experimental chamber which emulated the characteristics of an indoor environment and found that an hour’s shisha use was equivalent to 4-20 cigarettes being smoked, based on CO and other toxins. Eissenberg and Shihadeh, 2009. 45 minute session. Levels of CO in excess of 2.7ppm for a single cigarette and 1 litre of puff volume.

Estimates of prevalence A ‘Global epidemic’? (Maziak, 2011) Large-population surveys California Tobacco Survey United Arab Emirates International survey evidence Mostly students (5 peer reviewed published studies) Some small samples (Al-Naggar and Saghir, 2011) Opportunity sampling (Rehman et al., 2012) Evidence from the UK? 2 student surveys (Jackson and Aveyard, 2008; Jawad et al., 2012) California – use higher among younger groups UAE – less than 1% of adults used shisha. International survey evidence is mostly surveys of students. In the UK there have been two surveys of students. Jackson and Aveyard, 2008 – surveyed 900 students from Birmingham university and found that 8% were regularly using shisha, and this was prevalent across ethnic groups. The factor most strongly correlated with shisha use was cigarette smoking. Jawad’s study of medical students in London found that 52% had ever smoked shisha, with 11% reporting current use. There was no significant association with gender or ethnicity, but again, smoking status was correlated with shisha use.

Shisha in the news Most articles from the UK focus on breaches of smoke-free legislation Three focus on an apparent rise in users In the last year, (30th May 2012-30th May 2013) there have been 81 articles in UK newspapers about ‘shisha’. From the Observer: A survey soon to be published by the anti-smoking group Ash says an increasing number of people have tried smoking shisha pipes. "Around one in 10 adults have tried shisha but sustained use is very rare," an Ash spokesman said. "Users are typically younger men and from particular ethnic communities." Several of these have focused upon the increase in prevalence in British shisha users or shisha cafes

Research design Research question: What is the prevalence and frequency of shisha use among adults (aged 18+) in Great Britain? Design - repeated cross-sectional surveys: Participants recruited from an online panel maintained by YouGov Plc using targeted quota sampling, surveys conducted online Feb/March 2012 (n=12,436); Feb 2013 (n=12,171) Results weighted to be representative of GB population by sex, age, social class, ethnicity, GB region, newspaper readership, voting intention

Findings: Prevalence & frequency of use, 2012 to 2013 Self-reported shisha use: 'How often, if at all, have you smoked using a “shisha” pipe? (Please note that shisha pipes are also known waterpipes or hookah pipes)' 2012 - % (95% CI) 2013 - % (95% CI) More than 3 to 4 times a month 0.3 (0.2, 0.5) 0.3 (0.1, 0.4) Once or twice a month 0.7 (0.4, 1.0) 0.7 (0.4, 0.9) Once or twice every 2 to 3 months 0.5 (0.3, 0.6) 0.5 (0.3, 0.7) Once every 6 to 12 months 1.5 (1.2, 1.8) Less often 8.2 (7.6, 8.8) 9.0 (8.3, 9.6) Never 68.9 (67.8, 70.0) 70.3 (69.3, 71.3) Don’t know/ can’t remember 1.6 (1.3, 1.9) Not applicable – do not know what a shisha pipe is 18.2 (17.3,19.1) 16.2 (15.4, 17.0) Design-adjusted Chi-sq test for differences in shisha use between years: p-value = 0.13

% ‘ever’ & ‘frequent (at least once or twice a month)’ shisha use - 2012 to 2013 Error bars represent 95% CI. No statistically significant difference between 2012 & 2013 surveys in ever shisha use (p=0.19), or frequent use (p=0.51)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Gender Self- reported ever shisha use differs by gender (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Age group Self- reported ever shisha use differs by age (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Social Grade Self- reported ever shisha use differs by social grade (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Ethnicity Self- reported ever shisha use differs by ethnicity (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: GB country of residence Self- reported ever shisha use differs by GB country of residence (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Smoking status Self- reported ever shisha use differs by smoking status (p<0.001)

Multivariate analysis of predictors of ‘ever shisha use’ (1) Adjusting for covariates in a logistic regression model largely confirmed the results already presented Older adults were less likely to report ever use than younger Women less likely to report ever use than men Lower social grades less likely to report ever shisha use when compared to higher grades Increased odds of use for ‘mixed/multiple’ ethnic groups [OR 2.37 (95% CI 1.64 to 3.41)] and ‘Asian/Asian British’ [OR 1.84 (95% CI 1.39 to 2.45)] compared to white – but no difference detected for other groups

Multivariate analysis of predictors of ‘ever shisha use’ (2) Being a daily, non-daily, or ex-smoker raised odds compared to being a self-reported never smoker Compared to England, residing in Scotland reduced odds of reported ever use [OR 0.75 (95% CI 0.61 to 0.92) – no effect was found for Wales after adjustment for covariates A model based on the outcome of ‘frequent use’ gives similar results, and a range of sensitivity analyses did not materially alter the main conclusions

Strengths & limitations Large, recent survey, providing quite precise estimates of use Limitations: Self-reported shisha use only Survey conducted in English language, perhaps resulting in systematic exclusion of some groups Probably, like many ‘opt-in’ survey methods, under-represents those from most disadvantaged areas who are harder to reach

The UK Public Health response to shisha Healthy Lives, Healthy People (2011) Tower Hamlets and Coventry City Council Information and advice Tobacco Control Action Plan for Wales (2012) SSS to develop a protocol to help users quit Reports of interventions in the media NHS Hull and Hull City Council (Hull Daily Mail, 26.1.13) ‘raise awareness’ Leicester – Horn Concern (Leicester Mercury, 9.2.13) raise awareness in young people Healthy Lives, Healthy People is the Tobacco Control Action Plan for England.

Should the public health response be expanded? Our survey provides little support for the notion of an ‘epidemic’ at the GB population level – but it does not preclude shisha being an issue in specific population sub-groups/local areas There is a need to enforce existing regulations Violation of smokefree regulations Use of illicit (tax free) products Absence of health warnings on shisha Age of users? Lack of clarity regarding tobacco content of shisha Awareness raising activities for high risk groups Cessation support for regular users

Unanswered questions If a person smokes cigarettes every day and shisha once a month, which form of smoking should we be tackling? For ex-smokers, is “shisha prevention” vital relapse prevention? What is the right balance between shisha prevention/cessation and wider tobacco control? In a shisha strategy, what is the right balance between treatment and regulation?

We would like to acknowledge the support of the following organisations in allowing this research to be undertaken