Hookah Smoking:
The Past and Future of Tobacco?
Brian Primack, MD, EdM, MS
Assistant Professor of Medicine and Pediatrics
April 2009
Terminology
•
•
•
•
•
•
Hookah
Waterpipe
Shisha-Pipe
Narghile
Bong
Hubble-bubble
www.hookah-bars.com
Hours
• Sunday – Thursday: 4 PM – 12:30 AM
• Friday – Saturday: 4 PM – 2 AM
Flavors
• Fruit
–Apple
–Banana
–Cherry
–Melon
• Candy
–Bubble gum
–Chocolate mint
• Alcohol
–Margarita
–Piña colada
Good Quality
Regular $7.00
Large $10.00
Arabic Coffee, Apple, Apple Alex,
Double Apple, Apricot, Banana,
Candy, Cappuccino, Cherry, Carmel,
Coconut, Cola, Grape, Jasmine,
Lemon, Mint, Mango, Mandarin, Mixed
Fruit, Orange, Pistachio, Peach Rose,
Salloum, Strawberry, Vanilla, Zaghoul
Light, Zaghoul, Licorice
Excellent Quality
Regular $8.00
Large $11.00
Double apple, Apricot, Banana, Cantaloupe,
Cappuccino, Cherry, Coconut, Mint, Melon,
Orange, Peach, Pineapple, Rose, Raspberry,
Strawberry, Tutti-Frutti, Vanilla
Cognac, Margarita, Pina Colada, Strawberry
Daiquiri
Premiume Quality
Regular $8.50
Large $11.50
Apple, Special Apple, Bahrany Apple,
Apple Eskandarani, Banana, Cola,
Cappuccino, Fruit Cocktail, Honey
Melon, Mango, Orange, Peach, Pipe,
Rose, Strawberry
Superior Quality
Regular $9
Large $12
Apple, Strawberry, Grape, Rose
* Make your Hookah Cool with adding ice for $1
* Mix & Match Flavors Add $2
* Flavor Your Hookah Water Add $3
* Add 0.25 Per Each Person
** Minimum 1 Order Per Person **
** Bring your own bottle $2 cork charge **
You Must Be 21 to bring your own alcohol bottle
Also Have
• Fruit Smoothies (e.g. Strawberry, Banana,
Mango, Guava)
• Ice Cream
• Coffee and Tea
• Milk Shakes
• Desserts
• Games (Mancala, Dominoes)
Apple Shaped, $35
Silver Crane
$120
$200
(It rotates!)
$600
$13 for 250 gm
$20
Sampler
16 Coals for $4
Smoke Exposure
•
•
•
•
30-60 minute sessions
Each session ~100 inhalations
Each inhalation ~500 mL in volume
Total volume
– Waterpipe session: 50,000 mL
– Cigarette: 500-600 mL
Smoking Topography
Waterpipe1
(N = 80)
Cigarette2
(N = 87)
Puff Number (N)
101.1
11.4
Puff Volume (mL)
503
49.4
Puff Duration (s)
2.7
1.5
Interpuff Interval (s)
22.7
26.0
Variable
1Shihadeh
2Breland
2003; Shihadeh 2004
2005; Djordjevic 2000
Waterpipe1
Cigarette2
Tar (mg)
802
22
Nicotine (mg)
3.0
1.7
CO (mg)
145
17
1Shihadeh,
2005; 2Djordjevic, 2000
Toxin (ng)
Waterpipe1
Cigarette2
Arsenic
165
80
Beryllium
65
300
Chromium
1340
37
Cobalt
70
0.17
Lead
6870
60
Nickel
990
17
1Shihadeh,
2003; 2Hoffman, 2000
Blood Nicotine Level
=
Shafagoj, 2002
Known Harm
• Waterpipe smoke contains ...
–
–
–
–
–
Carcinogens
Carbon monoxide
Nicotine
Tar
Metals
• Waterpipe smoking associated with ...
–
–
–
–
Cancer
Cardiovascular disease
Decreased pulmonary function
Nicotine dependence
History
• India, ~1600?
• EMR = Eastern Mediterranean Region
– Syria
– Lebanon
– Israel
– Egypt
– Jordan
Travel Guide to Syria/Lebanon
Prevalence Globally
• EMR
– Syria: 45% report ever use
– Lebanon: 30% report weekly use
• Europe
– Germany
– Sweden
• Other
–
–
–
–
Brazil
Korea
Canada
Ukraine
What about the US?
• 200-300 new waterpipe cafés opened in
the U.S. between 1999 and 2004
• Particularly in college towns
• Convenience sample surveys suggest
high current use (past 30 days)
– 411 first-year college students: 15.3%
– 744 introductory psychology students: 20%
Holes in Literature
• Random sample
• Associations between waterpipe smoking
and
– Demographics
– Beliefs (e.g., harm, addiction, popularity)
• Populations outside college
STUDY 1: COLLEGE
Purpose
• Determine the 30-day, annual, and lifetime
prevalence of waterpipe smoking in a
random sample of college students
• Associations between smoking and
predictors?
Design
• Cross-sectional survey
• Random sample of students at the
University of Pittsburgh
• Collect data via web-based version of the
American College Health Association’s
(ACHA) National College Health
Assessment (NCHA)
• Added items related to waterpipe use
Approvals
• University of Pittsburgh Institutional
Review Board
• University Vice Provost
Procedure
• April 2007 during a three-week period
• Avoided the 30-day period following
Spring Break
• Email invitation sent to 3600 randomly
selected Pitt students
• Incentive: lottery to win cash prizes
ranging from $25 to $100
• Three reminder e-mails sent to students
during the three-week period
Demographic Measures
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Age
Gender
Race
Residence (on-vs. off-campus)
Undergraduate vs. graduate
Membership in a fraternity or sorority
Self-reported academic achievement
Theory of Reasoned Action
Norms
Intent
Attitudes
Behavior
Behavior Measures
1. Have you ever smoked tobacco from a
waterpipe (hookah, shisha, narghile), even one
or two puffs? (Yes/No)
2. During the past year, have you smoked
tobacco from a waterpipe (hookah, shisha,
narghile), even one or two puffs? (Yes/No)
3. During the past 30 days, have you smoked
tobacco from a waterpipe (hookah, shisha,
narghile), even one or two puffs? (Yes/No)
Attitudes
• “Would you say that smoking from a waterpipe
(hookah, shisha, narghile) is more harmful or
less harmful than smoking regular cigarettes?”
(“waterpipe more harmful” / “waterpipe same
harm” / “waterpipe less harmful”)
• “Would you say that smoking from a waterpipe
(hookah, shisha, narghile) is more addictive or
less addictive than smoking regular cigarettes?”
(“waterpipe more addictive” / “waterpipe same
addictiveness” / “waterpipe less addictive”)
Normative Beliefs
• “Among your peers, how socially
acceptable is it to smoke tobacco from a
waterpipe (hookah, shisha, narghile)?”
(“not acceptable” / “somewhat/moderately
acceptable” / “very acceptable”)
• “What percentage of college students do
you think has ever smoked tobacco from a
waterpipe (hookah, shisha, narghile)?” (0100%, collapsed into tertiles
Response Rate
• 61 emails undeliverable
• Response rate 660/3539 = 18.6%
• 647/660 (98.0%) had outcome data
Sample
Age (mean, SD)
20.9 (2.0)
Female (%)
65.6
White (%)
84.5
On Campus (%)
39.9
Undergraduate (%)
77.2
Fraternity/Sorority (%)
8.5
Smoking Data
Percentage
45
40
35
30
25
20
15
Cigarettes
Waterpipe
10
5
0
Ever
Past 30 Days
Past-Year Waterpipe Tobacco
Smoking
Percentage
70
60
50
40
30
20
10
0
Among All
Respondents
Among
Cigarette
Smokers
Among NonSmokers
Percent
Harm, Addictiveness
90
80
70
60
50
40
30
20
10
0
Non-Users
WP Users
WP Less
Harmful
WP Less
Addictive
Acceptability, Popularity
70
60
Percent
50
40
Non-Users
WP Users
30
20
10
0
WP Very
Acceptable
WP Very
Popular
Other Factors Associated with
1-Year WPTS
• Younger age
• Off campus
• Fraternity membership
Major Findings
• Lifetime use >40%, similar to cigarette
lifetime use
• Current use 9.5%
• One year use 30.5%
• Associated with lack of concern for
addictiveness (and harm, less so)
• Associated with sense of acceptability and
popularity
Cigarettes vs. Waterpipe
• Many waterpipe smokers had never
smoked cigarettes
• In non-cigarette smokers
– Problematic
– Introducing nicotine to previously naïve
population
• In cigarette smokers
– Substitution?
– Augmentation?
Rate Differences
• 30-day rate (9.5%) much lower than
annual (30.6%) and ever (40.5%) rates
• Sampling period: we avoided Spring
Break, fraternity rush, etc.
Limitations
• Response rate: 18.6%
• Cross-sectional design
STUDY 2: HIGH SCHOOL
Purpose
• Determine prevalence in statewide sample
of high school students
• Association with waterpipe use in high
school
No High School National Data
• Monitoring the Future
• Youth Risk Behavior Surveillance Survey
• Others
Arizona 2005
• Youth tobacco survey
• Added 2 items dealing with waterpipe
tobacco smoking
– Ever
– Past 30 days
Participants
• Statewide representative sample
• Grades 6-12
• All students enrolled in public and/or
charter schools
Procedure
• Schools chose to use active or passive
consent forms (89% used passive)
• Spring semester 2005
• 45 minute class period
Measures
• Tobacco
– 30-day waterpipe smoking
– Ever waterpipe smoking
– Other tobacco smoking
• Sociodemographic data
– Age
– Gender
– Race
– Type of school (charter vs. regular)
– Plan to attend college
Waterpipe Tobacco Smoking in Arizona Youth
Percent
16
14
Ever
12
Past 30 Days
10
8
6
4
2
0
6th
7th
8th
9th
Grade Level
10th
11th
12th
High School Seniors' Use of Tobacco Products in Arizona
60
50
Ever
Past 30 Days
30
20
10
et
ek
s
Kr
Bi
di
s
Pi
pe
ok
el
es
s
Sm
ill o
s
ig
ar
C
W
at
er
pi
pe
s
ig
ar
C
ig
ar
et
te
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0
C
Percent
40
Waterpipe Smoking by Race
12.0
10.0
Percent
8.0
Ever
Past 30 Days
6.0
4.0
2.0
0.0
AI/AN
Black
Hispanic
Asian
White
H/PI
Multivariate Analysis: Ever Use
OR Ever Use (95% CI)
Grade Level
1.6 (1.4, 1.7)
Female
0.8 (0.6, 1.1)
Asian
3.2 (1.2, 8.4)
Black
1.3 (0.5, 3.5)
Hispanic
1.4 (0.7, 2.9)
Hawaiian/PI
2.5 (0.7, 9.4)
White
3.2 (1.6, 6.4)
Charter School
1.5 (1.2, 1.8)
Plans to Attend College
0.5 (0.4, 0.6)
Multivariate Analysis: 30-Day Use
OR 30-Day Use (95% CI)
Grade Level
1.4 (1.2, 1.5)
Female
0.6 (0.4, 0.9)
Asian
2.0 (0.6, 7.0)
Black
1.0 (0.3, 3.4)
Hispanic
1.4 (0.6, 3.4)
Hawaiian/PI
2.5 (0.5, 12.1)
White
2.1 (0.9, 5.0)
Charter School
1.4 (1.1, 1.9)
Plans to Attend College
0.7 (0.5, 0.98)
Major Findings
• History of waterpipe tobacco smoking
– 6% of all 6th-12th graders
– 15% of 12th graders
• More common than 5 other methods of
tobacco smoking
• Associated with age, gender, race, SES
Age
• High school: older
• College: younger
• Surrogate for alcohol use?
Experimentation vs. Addiction
• May lead to increased uptake of various
types of nicotine
• Gateway to cigarette smoking?
Surveillance
• National studies (MTF, YRBS) should
track this form of tobacco use
• Likely to increase
– Less harsh
– Flavored
– Educational gaps
– Policy issues
STUDY 3: NATIONAL PILOT
DATA
National College Health
Assessment
• Annual
• American College Health Association
• Instrument under revision since 2006
(NCHA II)
• Addition of waterpipe items
• Pilot Spring 2008
• N = 8745 (8 schools)
Waterpipe vs. Cigarette
40
35
30
25
Waterpipe
Cigarette
20
15
10
5
0
Ever
Past 30 Days
Waterpipe tobacco smoking
100
90
80
70
60
50
40
30
20
10
0
Reality
Perception
Ever
Past 30 Days
Other Tobacco Types
40
35
30
25
Ever Used
Past 30 Days
20
15
10
5
0
Cigarettes
Waterpipe
* Includes
little cigars,
cigarillos Cigars*
Smokeless
By Age
40
35
30
25
Ever Used
Past 30 Days
20
15
10
5
0
18
19
20
21
22-25 26-30
31+
By School
40
35
30
25
Ever Used
Past 30 Days
20
15
10
5
0
200
201
202
203
204
205
206
207
By Living Arrangement
60
50
40
Ever Used
Past 30 Days
30
20
10
ll
A
er
O
th
re
nt
Pa
s
am
pu
Fr
at
O
ffC
C
am
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s
0
Question—You Be the Judge!
• Athletes
– Varsity
– Club
– Intramural
• Tobacco use
– Waterpipe
– Cigarette
Adjusted Odds Ratio (95 % CI) for Ever Use
1.4
1.3
Waterpipe
1.2
Cigarettes
1.1
1
0.9
0.8
0.7
0.6
0.5
0.4
Varsity
Club Sports
Intramurals
Adjusted Odds Ratio (95 % CI) for 30-Day Use
1.6
Waterpipe
1.4
Cigarettes
1.2
1
0.8
0.6
0.4
0.2
Varsity
Club Sports
Intramurals
Implications
• College athletes (and others) who would
have otherwise been nicotine naïve may
be vulnerable to developing lifelong
nicotine dependence via waterpipe
tobacco smoking
• Waterpipe perceived as “different”
Athlete Types
• Varsity
– Less social time?
– Less risk tolerance due to sport commitment?
• Intramural/Club
– Campus leaders
– More likely to engage in “trendy” behaviors
– Perception as similar to alcohol?
Different Tobacco Outcomes
• Ever waterpipe smoking: 29.5%
• Current waterpipe smoking: 7.2%
– Lower power?
– Try once or twice but not at risk for continued
use?
Limitations
• Not nationally representative
• Response rate 28%
• No biochemical verification
Conclusion
• Waterpipe tobacco smoking represents a
major potential threat to public health
• Threatens to undermine successes from
cigarette smoking
• Surveillance and further research are
necessary
Thanks!
bprimack@pitt.edu