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
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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)
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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)
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)
Shisha in the news
• Most articles from
the UK focus on
breaches of smokefree legislation
• Three focus on an
apparent rise in users
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:
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)
1.5 (1.2, 1.8)
Less often
8.2 (7.6, 8.8)
9.0 (8.3, 9.6)
68.9 (67.8, 70.0)
70.3 (69.3, 71.3)
1.6 (1.3, 1.9)
1.6 (1.3, 1.9)
18.2 (17.3,19.1)
16.2 (15.4, 17.0)
'How often, if at all, have you smoked using a
“shisha” pipe? (Please note that shisha pipes are
also known waterpipes or hookah pipes)'
Never
Don’t know/ can’t remember
Not applicable – do not know what a
shisha pipe is
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
• Strengths:
– 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
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 subgroups/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?