Transcript Patterns of use and dependence of narghile smokers

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
Who? Where?
When?
Frequency: Quantification
of disease
 Study of distribution and determinants of
disease in human populations
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 12th graders
by year (Florida, FYTS)
% ever WP use
30
25.3%
25
20
20.2%
16.2%
15
10
5
0
2007
2008
2009
Survey year
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 200811
80
70
60
50
40
30
20
10
0
Boys
Girls
2008
McKelvey, Maziak, et al., Eur J PH, 2013
Boys
Girls
Boys
2009
Girls
2010
Ever
Current
Boys
Girls
2011
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
39.8
40
36
% current users
35
30
26.7
25
21.2
20
15
8.9
10
4
5
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
37.3
40
35
30.3
% current users
30
25
19.4
20
15
16.1
13.7
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
60
Women
51.4
Prevelanece %
50
40
30
20
18.8
11.5
5.5
10
5.5
1.4
0.6
4.2
0
Daily
Occasional
Cigarette
Daily
Waterpipe
Ward, Maziak, Eissenberg, et al. The tobacco epidemic in Syria. Tobacco Control, 2006.
Occasional
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
% Prevalence
10
8
6
4
2
0
2008
McKelvey, Maziak, et al., Eur J PH, 2013
2009
cig only
2010
wp only
Total Cig+WP
2011
Age-adjusted smoking rates in men and
women, by country
Khattab A, et al, Respiratory Medicine, 2012
Age of initiation by smoking method among a cohort of
school children in Irbid, Jordan, 2008-11
35
*
% Prevalence
30
25
20
Cigarette
15
*
10
5
0
≤8
McKelvey, Maziak, et al., Eur J PH, 2013
9-10
11-12
Age (years)
13-14
≥15
Waterpipe
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
% Prevalence
10
8
6
4
2
0
2008
McKelvey, Maziak, et al., Eur J PH, 2013
2009
cig only
2010
wp only
Total Cig+WP
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