Patterns of use and dependence of narghile smokers

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The Waterpipe: Epidemiology

Wasim Maziak MD, PhD

Professor, Chair, Department of Epidemiology

Florida International University

Director, Syrian Center for Tobacco Studies

The Waterpipe

(hookah, shisha, narghile, hubble-bubble)

Centuries old habit with historical roots to the Middle East

Definition of Epidemiology

Frequency: Quantification of disease

Who? Where?

When?

Study of

distribution

and determinants disease in human populations of

What? Why? How?

Beginning of waterpipe epidemic

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.

4. Allure of waterpipe

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

Epidemiology

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

Most popular tobacco use methods in college students, US (152 universities; n=105,012)

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

Time trends: Ever waterpipe use for 12 th by year (Florida, FYTS) graders

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

2009

Girls

Ever

Boys

2010

Girls

Current

Boys

2011

Girls

Age patterns: WP smoking in US college students

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

Age patterns: Current WP smoking in Lebanon

Chaaya et al, 2004, 2006

Age patterns: WP adults, Syria

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

SES: WP smoking adults, Syria

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

SES: WP quitting, adults, Syria

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

Frequency of WP use (adults, Syria)

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

Association with cigarette smoking

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

Age-adjusted smoking rates in men and women, by country

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

Smoke narghile mostly at home

Usually share the same narghile with others

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)

Main epidemiological trends for WP

• 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.

Summary

• 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

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