Wasim Maziak MD, PhD
Professor, Chair, Department of Epidemiology
Florida International University
Director, Syrian Center for Tobacco Studies

(hookah, shisha, narghile, hubble-bubble)
Centuries old habit with historical roots to the Middle East

Frequency: Quantification of disease
Who? Where?
When?
 Study of distribution and determinants of disease in human populations
What? Why? How?

268 WP smokers in cafés (Aleppo)
Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

Factors behind the current waterpipe pandemic
1.
Introduction of Maassel in the early 1990s.
2. The internet & other social and transnational media
3. The reduced-harm perception, “ the water filtering ” effect
4.
The allure of waterpipe and thriving café culture.
5.
Lack of effective policies (e.g. FCTC).
Maziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

1. Maassel?
1. Industrialized and commercialized the product, increasing availability and variety
2. Appealed to youth through product variety and flavors
3. Made the smoke milder and smoother
4. Allowed the mass marketing and sales through the internet
5. Simplified the preparation process
Maziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

2. The internet & other social media
Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. The promotional materials …de-emphasize age limits, health warnings, and even that tobacco is involved in hookah smoking. Primack et al., 2012 .

3. Reduced harm perception
Qualitative study of 15 WP and 15 Cig smokers;
(Hammal et al, 2008) “ 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 F, Mock J, Ward KD, Eissenberg T, Maziak W. A pleasure among friends. Tobacco Control 2008.

1. I enjoy the taste, smell, smoothness of smoke
2. It ’ s a good way to socialize with friends
3. It helps me to feel relaxed
4. I like the social ambience
5. It helps me to feel less stressed
6. It ’ s something to do when I feel bored
7. I like trying things that are new, different, or “ hip ”
9. It helps me not smoke cigarettes
Asfar T, Ward KD, Eissenberg T, Maziak W. BMC Pub Health 2005;5(1):19.
Smith-Simone, Maziak, Ward, and Eissenberg. Nicotine & Tob Research, 2008, 10: 393–398.

5. Lack of effective policies
Nakkash et al., 2010; Maziak et al., 2013

•
Prevalence and use pattern in different parts of the world.
•
Association with cigarettes.
•
Time trends in youth.
•
Gateway to cigarette.

Current cigarette vs. waterpipe smoking among
13 –15 year olds in several Arab countries
Maziak W et al. Health Policy Plan. 2013

Primack B A et al. Nicotine Tob Res 2013;15:29-35

Time trends: Ever waterpipe use for 12 th graders by year (Florida, FYTS)
30
25
20
15
10
5
0
16.2%
20.2%
25.3%
2007 2008
Survey year
2009
Courtesy of Dr. Tracy Barnett via FYTS
(http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/FYTS/Intro.htm)

Time trends: Ever and current waterpipe smokers among school children in Jordan 2008-
11
80
70
60
50
40
30
20
10
0
Boys
2008
Girls
McKelvey, Maziak, et al., Eur J PH, 2013
Boys Girls
2009
Boys
Ever Current
2010
Girls Boys Girls
2011

Age patterns: WP smoking in US college students
Primack B A et al. Nicotine Tob Res 2013;15:29-35

Chaaya et al, 2004, 2006

Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006

Gender: WP smoking, (13-15 yrs), EMR (n >
90,000)
Warren CW, et al. Lancet, 2006.

Gender: WP, (11-15 yrs), Estonia, 2006 (N = 13826)
Pärna et al. BMC Public Health 2008 8:392

45
40
35
36
39.8
30
25
26.7
21.2
20
15
8.9
10
5
4
0
Cigarette Waterpipe
Ward et al. The tobacco epidemic in Syria. Tobacco Control, 2006.
Low SES
Middle SES
High SES

40
35
30
25
37.3
30.3
19.4
20
15 13.7
16.1
13.9
10
5
0
Cigarettes Waterpipe
Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.
Low
Middle
High

Men Wom en
60
50
40
10
0
30
20
51.4
11.5
5.5
5.5
1.4
0.6
18.8
4.2
Daily Occasional Daily
Cigarette Waterpipe
Occasional
Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.

Asfar et al., BMC Public Health 2005

Primack BA et al. NTR, 2013

Current cigarette, waterpipe, and dual smoking among school children in Jordan, 2008-11
16
14
12
10
8
6
4
2
0
2008
McKelvey, Maziak, et al., Eur J PH, 2013
2009 cig only wp only Total Cig+WP
2010 2011

Khattab A, et al, Respiratory Medicine, 2012

15
10
5
35
Age of initiation by smoking method among a cohort of school children in Irbid, Jordan, 2008-11
*
30
25
20
Cigarette
Waterpipe
*
0
≤8 9-10 11-12
Age (years)
13-14 ≥15
McKelvey, Maziak, et al., Eur J PH, 2013

Asfar et al., BMC Public Health 2005

Current cigarette, waterpipe, and dual smoking among school children in Jordan, 2008-11
16
14
12
10
8
6
4
2
0
2008
McKelvey, Maziak, et al., Eur J PH, 2013
2009 cig only wp only Total Cig+WP
2010 2011

Once addicted on nicotine, young people may go for Cig because of easier access compared to WP (gateway hypothesis)

• Common among youth all over the world and increasing
• More intermittent use than daily
• Educated and affluent (higher SES)
• Male predominance, not consistent across populations and age groups.
• Associates with cigarette smoking at early ages and can lead to cigarette smoking.

• Waterpipe smoking is widespread and increasing all over the world.
• It is more widespread among the young, educated and affluent
• Gender differences in waterpipe smoking tend to vary by region, but girls and women in the EMR are increasingly taking up this tobacco use method
• Surveillance systems that inquire specifically about the waterpipe and are adapted to its use patterns are needed to monitor the epidemic and groups more at risk of waterpipe smoking

Acknowledgments
• Our heroes at the Syrian center for Tobacco Studies
• Eman Ibrahim
• Fouad Fouad
• Radwan Al Ali
• Samer Rastam
• Taghrid Asfar
• Nizar Al Bache
• Eyad Bashir
• Thomas Eissenberg
• Kenneth Ward
• Fawaz Mzayek
Our Funders
• U.S. National Institutes of Health (Fogarty, NIDA)
• EU