The Waterpipe: EpidemiologyWasim Maziak MD, PhD

Professor, Chair, Department of EpidemiologyFlorida 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

Study of distribution and determinants of disease in human populations

Frequency: Quantification of disease

Definition of EpidemiologyDefinition of Epidemiology

Who? Where? When?

What? Why? How?

Beginning of waterpipe epidemic268 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

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.

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

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.

Epidemiology

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

05

1015202530

2007 2008 2009Survey year

%ev

er W

P us

e

16.2%20.2%

25.3%

Courtesy of Dr. Tracy Barnett via FYTS (http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/FYTS/Intro.htm)

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

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

39.8

21.2

4

26.7

8.9

36

0

5

10

15

20

25

30

35

40

45

Cigarette Waterpipe

% c

urre

nt u

sers

Low SESMiddle SESHigh SES

SES: WP smoking adults, Syria

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

13.9

19.4

37.3

13.7

30.3

16.1

0

5

10

15

20

25

30

35

40

Cigarettes Waterpipe

% c

urre

nt u

sers

LowMiddleHigh

SES: WP quitting, adults, Syria

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

Frequency of WP use (adults, Syria)

51.4

5.51.4

18.8

11.55.5

0.64.2

0

10

20

30

40

50

60

Daily Occasional Daily Occasional

Cigarette Waterpipe

Pre

vela

nece

%

Men Women

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

McKelvey, Maziak, et al., Eur J PH, 2013

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

Khattab A, et al, Respiratory Medicine, 2012

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

McKelvey, Maziak, et al., Eur J PH, 2013

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 MzayekOur Funders• U.S. National Institutes of Health (Fogarty, NIDA)• EU