ECONOMIC ASPECTS
OF WATERPIPE
TOBACCO SMOKING
Scott E. Sherman, MD, MPH
Co-Chief, Section on Tobacco, Alcohol and Drug Use
Associate Professor of Population Health, Medicine and Psychiatry
New York University School of Medicine
Staff Physician, VA New York Harbor Healthcare System
Objectives
• To review scientific knowledge about business and
economics aspects of waterpipe tobacco use
• To outline future research needs
To review scientific knowledge about
economics of waterpipe tobacco use
To review scientific knowledge about
economics of waterpipe tobacco use
Business and economic aspects - Why do
we care?
• Impact at different levels
• Society
• Business
• Health system
• Individual
• Evidence-based policy (Intelligent)
Part 1: The business of hookah
A global market for hookah
A global market for hookah
Phoenix, AZ
Moscow
Beijing
Tampa, FL
Semiannual Snapshots of State-level SVI (20042013)
Map of NYC Hookah Bars Listed on Yelp.com
US CDC web site: An
estimated 300 hookah
cafés operated in the
United States in 2006
Yelp: 130 businesses
are listed on Yelp with a
tag “hookah Bars” within
New York City in 2013
Mapping tool is publicly available on UCLA Geomapping Lecturer Yoh
Kawano’s educational website.
And global suppliers of hookah…
Suppliers of waterpipe tobacco
Suppliers of waterpipe tobacco
Suppliers of waterpipe tobacco
Business of hookah – Research questions
1. Producers, suppliers
• Which countries
• Small businesses or large multinationals
2. Sellers
• Hookah bars vs. sales for home use
Part 2: The economics of hookah
Economics of waterpipe tobacco
• Internal costs – costs to user (and in some cases
to his/her family)
• External costs – costs to others
• Businesses
• Health care system
• Societal costs = internal + external costs
Estimated annual US costs of cigarette smoking
Grand
total
Smoker
Spouse/
Children
Outside
family
Grand Total
Expenditures
$323 B
$208 B
$296 B
$194 B
$ 22 B
$ 11 B
$
$
Medical
Non-medical
 Productivity
$125 B
$ 83 B
$115 B
$122 B
$ 72 B
$102 B
$ 3B
$ 8B
$ 11 B
??
$ 3B
$ 2B
$ 30 B
$ 85 B
$ 30 B
$ 72 B
??
$ 11 B
??
$ 2B
Morbidity
Mortality
Sloan FA et al. The Price of Smoking. 2004, MIT Press.
5B
3B
Estimated annual US costs of cigarette smoking
Grand
total
Smoker
Spouse/
Children
Outside
family
Grand Total
Expenditures
Medical
$323 B
$208 B
$125 B
$296 B
$194 B
$122 B
$ 22 B
$ 11 B
$ 3B
$
$
5B
3B
??
Non-medical
 Productivity
$ 83 B
$115 B
$ 30 B
$ 72 B
$102 B
$ 30 B
$ 8B
$ 11 B
??
$
$
3B
2B
??
$ 85 B
$ 72 B
$ 11 B
$
2B
Morbidity
Mortality
Questions
1. Do hookah smokers have increased health care utilization?
2. Do hookah smokers have increased health care costs?
3. What fraction of CVD, CA, etc. is attributable to hookah?
Estimated annual U.S. costs of cigarette smoking
Grand
total
Smoker
Spouse/
Children
Outside
family
Grand Total
Expenditures
Medical
$323 B
$208 B
$125 B
$296 B
$194 B
$122 B
$ 22 B
$ 11 B
$ 3B
$
$
5B
3B
??
Non-medical
 Productivity
$ 83 B
$115 B
$ 30 B
$ 72 B
$102 B
$ 30 B
$ 8B
$ 11 B
??
$
$
3B
2B
??
$ 85 B
$ 72 B
$ 11 B
$
2B
Morbidity
Mortality
Questions
1. How much do hookah smokers spend on waterpipe smoking?
Estimated annual U.S. costs of cigarette smoking
Grand
total
Smoker
Spouse/
Children
Outside
family
Grand Total
Expenditures
Medical
$323 B
$208 B
$125 B
$296 B
$194 B
$122 B
$ 22 B
$ 11 B
$ 3B
$
$
5B
3B
??
Non-medical
 Productivity
$ 83 B
$115 B
$ 30 B
$ 72 B
$102 B
$ 30 B
$ 8B
$ 11 B
??
$
$
3B
2B
??
$ 85 B
$ 72 B
$ 11 B
$
2B
Morbidity
Mortality
Questions
1. Do waterpipe smokers have more sick days?
2. Does waterpipe smoking decrease productivity at work?
3. Does waterpipe smoking affect quality of life (short & long term)?
Estimated annual U.S. costs of smoking
Grand
total
Smoker
Spouse/
Children
Outside
family
Grand Total
Expenditures
Medical
$323 B
$208 B
$125 B
$296 B
$194 B
$122 B
$ 22 B
$ 11 B
$ 3B
$
$
5B
3B
??
Non-medical
 Productivity
$ 83 B
$115 B
$ 30 B
$ 72 B
$102 B
$ 30 B
$ 8B
$ 11 B
??
$
$
3B
2B
??
$ 85 B
$ 72 B
$ 11 B
$
2B
Morbidity
Mortality
Questions
1. Does waterpipe smoking increase mortality rates? If so, how
many years of life do waterpipe smokers lose?
Modeling
• Price elasticity
• Salience – how to make it more relevant
• Cost-effectiveness of cessation interventions
NYU Global Institute of Public Health
Capstone Project Team
• Survey of hookah bar owners in New York, Abu
Dhabi and Dubai – starting in December
Karen Jasie
Adekunk Olatunji
Tala Haddad
Paul Joudrey
Susan Tierney
Lyuboyr Pykalo
Scott Sherman
Mary Beth Woodin
And just when we are beginning to study
the market…
And just when we are beginning to study
the market…
And just when we are beginning to study
the market…
And just when we are beginning to study
the market…
And just when we are beginning to study
the market…
…the
market is
changing
Research agenda for the next 5 years
1. What fraction of morbidity and mortality is attributable to
waterpipe tobacco?
2. What existing national and international surveys include
both questions on hookah and economics? Also, need
to include hookah questions in future surveys.
3. Understand economics of restaurants/hookah bars
• Understand supply chain, costs, profitability
4. Understand individual costs/benefits/preferences
5. Price elasticity
• Compiled data
• Individual modeling