Rima Nakkash
Assistant Professor
Health Promotion and Community Health Department
WHO Collaborating Center for Health Promotion
and Behavioral Sciences
Faculty of Health Sciences
Coordinator-AUB Tobacco Control Research Group
1st International Conference on
Waterpipe Tobacco Smoking
Abu Dhabi,U.A.E
October 20, 2013
Tobacco Control
Research Group
0verview
 Does the current tobacco control policy
regulatory framework address waterpipe
tobacco smoking (WTS)? How?
 Any current policy practices specific to WTS
needed.
Comprehensive
No single measure is sufficient to tackle tobacco – it is
important to move on many fronts at once in a
comprehensive effort to reduce smoking prevalence.
……hence a FRAMEWORK is needed…..
Comprehensive Strategies (FCTC)
 Price measures- Taxation measures
 Non-price measures
 Advertising bans
 Warning labels on tobacco products
 Ban smoking in public places
 Protecting from tobacco industry
interference
 Other : cessation, prevention and
educational campaigns, control
smuggling…..
Do we need a waterpipe tobacco
smoking specific policies?
 What do we know so far about waterpipe tobacco
smoking regulation?
 Will the same framework be needed for waterpipe
tobacco smoking ?
 Are there additional regulatory parameters that need
to be considered that are specific for this smoking
phenomenon?
Review of the regulatory gaps
Flavoring (Family Smoking Prevention and Tobacco
Control Act )
•Free samples
•Youth access
•Use restrictions (tobacco vs. non tobacco products)
•Point of Sale Warnings, Marketing restrictions, and
broad sales prohibitions
Waterpipe tobacco smoking
specific policies
Others
Taxation
Advertising
bans
Cessation
Tobacco
industry
??
Indoor
smoking
bans
Health
Warnings
Taxation
 Taxing delivery services
 Taxing serving establishments on sales–prohibitive range of prices
(currently 1USD-24 USD)
 Taxing tobacco packaged products for home preparation of
waterpipe or for mass production (by kg)
 Taxing waterpipe accessories (market size)
Research is needed to explore effect of taxation on overall consumption,
changes in behaviors such as switching between products, and impact
on different population groups especially the vulnerable ones….
Current Practice
 http://www.dutycalculator.com/hs-code-duty-rate-
import-restrictions/240311/hookahtobacco/2403.11.0000/2403.11.0000/3007/
Shows various countries tax structures on hookah
tobacco .
Waterpipe tobacco smoking
specific policies
Other ?
Taxation
Advertising
/Promotion
Cessation
tobacco
industry
??
Indoor
smoking
bans
Health
Warnings
Regulating advertising
Waterpipe tobacco product billboard advertising in Lebanon prior to March 2012
Banning sponsorship and
promotion
Misleading … through advertising
What
is
this ?
Home
Delivery
handouts
Coal
Promoting Innovations
http://www.healthy-shisha.com
Innovations
http://www.healthy-shisha.com/
Internet promotion and sales
US Hookah Tobacco Smoking
Establishments Advertised on
the Internet.
-unregulated
-accessible to the public
-Play a role in propagating
misinformation
Primack,
2012)
Social Media
 Blog , online chats…who monitors?
 A comparison of cigarette and hookah related video’s on
youtube.:
 portrayed positively, don’t mention short and long term
consequences, anti smoking messages, or how to quit
tobacco use.
 Who is in charge of what gets on youtube ?
Pimack et. Al, 2013
Waterpipe tobacco smoking
specific policies
Other ?
Taxation
Advertising
bans
Cessation
Indoor
smoking
bans
Protecting
from the
tobacco
industry ??
Health
Warnings
Indoor smoking bans in public places
 There should be no
exception made for
waterpipe tobacco
smoking serving
establishments
 Licenses
/loopholes/permits
Comparison of carcinogen, carbon monoxide,
and ultrafine particle emissions from narghile
waterpipe and cigarette smoking: Sidestream
smoke measurements and assessment of
second-hand smoke emission factors.
Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T,
Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A.
“ a single waterpipe use session emits in the
sidestream smoke approximately four times the
carcinogenic PAH, four times the volatile
aldehydes, and 30 times the CO of a single
cigarette. Accounting for exhaled mainstream
smoke, and given a habitual smoker smoking rate
of 2 cigarettes per hour, during a typical one-hour
waterpipe use session a waterpipe smoker likely
generates ambient carcinogens and toxicants
equivalent to 2-10 cigarette smokers, depending
on the compound in question.”
Atmospheric Environment, v. 44, iss. 1, p. 814.2010
US-Clean indoor air exemptions
 73 of the largest 100 cities disallowed cigarette smoking
in bars, nearly all (n = 69) of these cities may allow via
exemptions.
 “poorly defined exemption language resulted in
certification that actually assisted” lead to a new niche
tobacco market emerging…
(Primack et.al, 2012)
UK-Legislation enforcement of the
waterpipe tobacco industry
 In London alone showed :500% increase in waterpipe
premises in last 5 years (national: 210%)
 Exact figures unknown
 Not required to register with local authority
 Waterpipe premises not exempt from any tobacco
legislation
 Underage purchase (<18 years)
 Smoke-free law (enforced in 2007)
UK-Conclusions
 Growing concern
 “One size fits all” legislation approach inappropriate
 High profit margins?
 Licensing proposal (at local authority level)
(Mohamed, Jawad,Legislation enforcement of the waterpipe tobacco industry, A qualitative analysis of the
London experience- October 2013)
Waterpipe tobacco smoking
specific policies
Other ?
Taxation
Advertising
bans
Cessation
Indoor
smoking
bans
Tobacco
industry
??
Health
Warnings
Health warning labels
 Only one health warning label and not a
series of rotating messages
 Printed in small font
 Written on the sides of the waterpipe
tobacco products alongside other
information.
 Not on unit packs
Nakkash and Khalil, 2010
Current health warning labels
 Mentioning an expiry date
making waterpipe tobacco
products seem misleadingly
safe to be consumed prior
to expiration
• In the ingredients, they mainly
mentioned natural flavors
• They also stated that the
waterpipe tobacco contains
0.05% Nicotine and 0.0% Tar
Misleading information on waterpipe accessories were also
found on filters, tips and charcoal:
HW Labeling suggested in 2010
Egypt 2011
Waterpipe tobacco smoking
specific policies
Other ?
Taxation
Advertising
bans
Cessation
Indoor
smoking
bans
Tobacco
industry?
Health
Warnings
Advertisement for Egyptian Waterpipe Tobacco
Waterpipe Smoking as an Opportunity for New
Profits by the Tobacco Industry?
• Interest of TNC’s is apparent as early as 1960’s and 1970’s
• Issue open for exploitation and could be predictive of
future interest
• Flavouring companies interest –global industry too
• With growing smoking prevalence more concern of
growing market for example alternative forms of tobacco
use :BAT’s attempt to adapt to local culture as in the case
of Kreteks in Indonesia
• In the case of Lebanon, local monopoly attempting to
catch up with global spreading phenomenon.
(WCTOH, Nakkash and Lee, 2006)
Testing, smoke properties and health effects
1993
-META minutes “testing
of waterpipe tobacco”
-BAT intent to test
hubble bubble
1994
-Analytical technology
department- smoking
machine –Hookah
experiment
Bates:1004867515
Opposition from the Industry ?
 In the US: Opposition on tax hikes
:http://www.southsmoke.com/hookahtax.cfm
 Hookah Industry Association
http://www.hookahindustry.org/2010/01/775-hookah-tobacco-taxincrease-rallies-over-2000/
The Hookah Industry Association (HIA) advocates its members’
interests on issues which affect the entire hookah industry. HIA’s
mission:
-Fight back and push for the repeal of repressive & restrictive
legislation
-Serve as a mechanism for the sharing of ideas, programs, and skills
among the organization’s members
-Release research publications & industry news to keep businesses
informed
-Educate the public on the economic & cultural importance of the
industry
Tobacco Journal International 1/2013
 Exports to over 100 countries
 New customers in remote locations, , Indian ocean,
and latin american
 Since 1913… introduced Maasel in 1980
 New competitors
http://www.jti.com/media/news-releases/jtcompletes-acquisition-leading-water-pipe-tobaccocompany/
Flavoring
Waterpipe tobacco smoking
specific policies
Other ?
Taxation
Advertising
bans
Cessation
Protectin
g from
the
tobacco
industry
??
Indoor
smoking
bans
Health
Warnings
Cessation
 Incorporate in national plans
 Development of waterpipe tobacco smoking tailored
cessation services
 Evaluation of waterpipe tobacco smoking specific
cessation protocols
 Sensitive to dual users and specific to vulnerable
populations, youth; pregnant women.
Waterpipe tobacco smoking
specific policies
Other
???
Taxation
Advertising
bans
Cessation
Indoor
smoking
bans
the
tobacco
industry ??
Health
Warnings
Other
 Product regulation and testing to monitor development
 Halting sales of WTS products to minors
 Banning introduction of new products/flavours or
altogether
 Controlling illicit trade
 Development of prevention messages and campaigns
In Conclusion
• No comprehensive study on challenges to legilsation
or policy making for waterpipe
• Need for building the evidence base for effective
waterpipe tobacco control policies
• Policy influence can be studied in different
countries by examining cigarette and waterpipe use
prevalence in light of policy that does or does not
address each tobacco use method.
• Identify how policies that do and do not address
WTS influence public health outcomes.
THANK YOU
Email : rn06@aub.edu.lb
Website
http://www.aub.edu.lb/units/tcrg/Pages/index.aspx