The School of Public Health
Social and Psychological
Issues Regarding
Waterpipe Tobacco Use
Kenneth D. Ward, PhD
University of Memphis, and
Syrian Center for Tobacco Studies
1st International Conference on Waterpipe Research, Oct 21-23rd, 2013, Abu Dhabi
Goals
• What psychological and social factors
encourage initiation and maintenance of
waterpipe use?
– Motivational factors
– Perceptions of health effects
– Perceptions of addictiveness
– Social factors, including acceptability and
availability
• Next steps
Publications about psychological and
social aspects of WP use
50
# Medline citations
45
40
35
30
25
20
15
10
5
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Promoting Health: Intervention Strategies from Social and Behavioral Research,
by the National Academy of Sciences.
We have less empirical evidence
about determinants of initiation
than determinants of maintenance.
First use of waterpipe
by university students in Aleppo, Syria
Men (%) Women (%)
Alone
3
0.0
With friends
86
54
With family
members
11
46
Maziak, et al., IJTLD, 2004
Why did you start using waterpipe?
“It’s a pleasure among friends”
Due to the boredom of
having free time, I used to
go with my friends to a
cafe´. When they invited
me to try narghile, I found
it interesting and good. I
felt some dizziness, but I
enjoyed the taste and the
smell. It was fun. And so I
became a daily smoker.
Hammal et al., Tobacco Control, 2008
10th graders in Johannesburg, SA
• 20% smoke waterpipe daily
• Most cited reasons for smoking:
– “Nothing better to do” (46%)
– “Helps to relax” (28%)
– Peer Pressure (14%)
• 39% perceived pressure to smoke waterpipe
– Addicted (6%)
Combrink et al., SAMJ, 2010
Why did you start using waterpipe?
“Everyone does it”
“…I started smoking narghile in public places. I
go out with my friends. They are all [narghile]
smokers. I smoke [narghile] with them to
entertain myself and because I do not want to be
different.”
Hammal et al., Tobacco Control, 2008
Sensory characteristics
• Smell, taste, sight of smoke,
"The strong flavour and strong
sound of bubbling sound
smoke are great. I can do smoke
– Maziak 2004
rings and impress the ladies.
– Nakkash 2011
There would be no point in
– Roskin 2009
smoking if it wasn't flavoured.”
– Smith-Simone 2008
(Roskin & Aveyard, 2009)
“.. I like the smoke when it comes
out as it does…When I wasn’t
smoking the waterpipe, I used to
look at someone who smoked it
and see how the smoke comes
out of it and that made me love
it.” (Nakkash 2011)
Why did you start using waterpipe?
“It’s an affordable novelty”
“...we can order it twice, three
times...Sharing and if it’s for
10,000 L.L. and we are 3 or 4
[people], so approximately 2000
L.L. per person is affordable”
“I think if [the waterpipe was]…
expensive relative to the income,
it would not be that popular (...);
a higher price would deter from
use (Woman non-smoker - urban
area)
Nakkash et al., BMC Public Health, 2011
Social aspects maintain use
• “Time with friends,” “communal aspects,” role
as a “social lubricant,” promotion of “kinship”
and “brotherhood,” relaxation, relief of
boredom
– Guiliani 2010
– Jamil 2010
– Martinasek 2013
– Maziak 2004
– Smith-Simone 2008
- Roskin 2009
- Anjun 2008
- Al Dabbagh 2005
- Labib 2005
- Ghafouri 2011
Family acceptance, or at least
acquiescence
"I have never smoked cigarettes in front of my
parents. They'd be surprised, annoyed and
disappointed. There is something more
acceptable about shisha.”
"When I explained to my parents it was
harmless, they were fine. They've tried it.”
Roskin, et al.,
More family acceptance of WP use for
women than men
Maziak et al., Ann Epidemiol, 2004
A majority of users believe waterpipe
is less harmful than cigarettes
• U.S. samples: Abughosh,
2011; Ajiarrah 2009; Giuliani
2010; Jamil 2011; Smith 2011;
Smith-Simone 2008; Sutfin
2011; Ward 2007
• Middle East samples: (AlDabbagh 2005; Anjum 2008;
Asfar 2005; Chaaya 2004;
Erbaydar 2010; Ghafour 2011;
Hammal 2008; Jawaid 2008;
Labib 2007; Varsano 2003)
“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 et al., 2008)
Perceived addictiveness
• Most users in Middle East and western
countries don’t perceive themselves to be
addicted (Maziak 2005; Primack 2008; Smith-Simone 2008;
Ward 2005, 2007)
• Waterpipe is perceived as less addictive than
cigarettes, by WP smokers, cigarette smokers,
and non-smokers (Abughosh 2011; Azab 2010; Jawaid
2008; Maziak 2004)
Which is more addictive?
WP
users
(%)
90
Nonsmokers
(%)
77
Cigarettes and waterpipe are equally
addictive
8
17
Waterpipe is more addictive
2
5
Cigarettes are more addictive
Maziak et al., Ann Epidemiol, 2004
However, many frequent users do
believe they are addicted
Maziak, et al., Pharm, Biochem, Behav, 2005
Why is waterpipe perceived as less
harmful/addictive?
• “Filtering” means less nicotine and tar get
delivered
– “From what I’ve been told, the water acts as a filter to
get rid of bad stuff.”
– “Water catches the ashes from the charcoal. Not like a
cigarette filter, water is a natural filter.” (Roskin & Aveyard,
2009).
• Flavor/smell indicate it’s safe (Dillon & Chase, 2010)
– “Fruit flavour makes it less harmful. I don’t believe it’s as
harmful as cigarettes.” (Roskin & Aveyard, 2009)
Why is waterpipe perceived as less
harmful/addictive?
• “If it’s so bad,
why haven’t I
heard about it?”
• “Cigarettes are much
more harmful, as the
dangers are publicized. I
don’t really see the
danger [of smoking
waterpipe].” (Nakkash et al.,
2009)
• “There are no warnings
on TV. If there were
warnings, I’d be more
aware.” (Roskin & Aveyard, 2009)
Important to remember that
determinants of waterpipe use are
not invariant across time, population,
and place.
Afifi, et al., Eur J Public Health, 2009
•
•
•
•
•
•
•
•
•
Relief of boredom
Relaxation
Smell
Taste
Look of pipe
Bubbling sound
Availability
Peer influence
Influence of family
members
• Novelty/experimentation
• Affect management
(stress, anxiety,
depression, anger)
• Reduced harm
• Reduced addictiveness
• Exoticness
• Affordability
• Way to quit cigarettes
• Culturally acceptable
alternative to cigarettes
• Way to express cultural
identity
Akl et al., Harm Reduction Journal, 2013
Martinasek, et al., Am J Health Behavior, 2013
Positive attitudes are stronger determinant of
intent to smoke WP than negative attitudes
Hookah seems…
OR
95% CI
Attractive
6.49
4.65-9.05
Romantic
4.56
3.21-6.47
Fun
3.46
2.91-4.10
Relaxing
2.67
2.27-3.14
Overall
9.31
6.77-12.80
Harmful
0.98
0.87-1.10
Addicting
0.71
0.63-0.80
Overall
0.79
0.69-0.90
2.12
1.76-2.54
Positive Perceptions
Negative Perceptions
Socially acceptable
Barnett et al., Am J Health Behavior, 2013
Outcome expectancies are related to intent
to initiate WP use (n=722 never users)
Latent factor
Correlation
with intent to
use WP
.61
<.001
Consistent with values (family,
religious, cultural, intellectual)
.32
<.001
Thrill-seeking
.48
<.001
Acute health effects
-.30
<.001
Long term effects
-.22
<.001
Aids adjustment to college life
p
Martinasek, unpublished data
Many social determinants, but not all,
are “available to awareness” of users…
• Exemptions from clean air laws (Primack 2012)
• Failure to fully enact FCTC: only 7 Arab countries
have enacted comprehensive smoking bans in
public places, while the rest have partial or no
bans and enforcement remains low overall (WHO
2009, reported in Maziak 2013)
• Mismatch of FCTC goals with waterpipe
– E.g., packaging/labeling is more complicated with WP
due to variability compared to cigarettes (Maziak,
Nakkash,et al., 2013)
Summary
• Social nature of WP use (“a pleasure among friends,”
relaxation, peer/family influence) is major determinant of
initiation and maintenance
• Need to “deglamorize and renormalize” WP use (Maziak et al.,
2007)
• More “upstream” determinants are wide availability
promoted by absent/unenforced policies such as clean air
laws, inexpensiveness, lack of knowledge of harms due to
“research to practice” limitations
• Future research should use prospective multilevel approaches
to model how intrapersonal, interpersonal, and
community/societal level factors jointly influence initiation
and maintenance of waterpipe use
• But we shouldn’t wait!
Thank you!
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Radwan Al Ali, MD
Taghrid Asfar, MD
Iman Ebrahim
Tom Eissenberg, PhD
Madonna Elias
Fouad Fouad, MD
Wasim Maziak, MD, PhD
Samer Rastam, MD, PhD
www.scts-sy.org