cancer from the middle east mjt (2)
TRANSCRIPT
Mark J. Travers, PhD
CANCER FROM THE MIDDLE EAST: COMING SOON TO A
COLLEGE CAMPUS NEAR YOU
EGYPTIAN REVOLUTION 2011
EGYPTIAN REVOLUTION: LEADERS
Karim El-Beheiry: Egyptian activist and blogger, has been tortured and imprisoned for his work
EGYPTIAN REVOLUTION: LEADERS
Ahmad Maher: Cofounded the April 6 Student Movement on Facebook
BEIRUT, LEBANON, WATERPIPE CAFE
DISCLAIMER #1: No researchers were harmed in the making of this presentation
DISCLAIMER #2: I didn’t inhale
Origin associated with Indian subcontinent & Eastern Mediterranean Region (EMR). One history: began
in India ~1600 (Chattopadhyay, 2000)
A different type of waterpipe found in China as well
THE WATERPIPE(HOOKAH, SHISHA, NARGHILE, ARGHILE,
HUBBLE-BUBBLE)
BEIRUT, LEBANON, WATERPIPE CAFE
DRINK MENU FOR TODAY
Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon
Candy/Dessert/Spice: Banana split, Bubble gum, Candy, Cappuccino, Caramel, Chocolate mint, Cinnamon, Coff ee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla.
Alcohol: Cocktail, Margarita, Pina colada.Tangiers F-line (caff einated): Apple, Cocoa, Kashmir,
Rootbeer.
BEIRUT, LEBANON, WATERPIPE CAFE
BEIRUT, LEBANON, WATERPIPE CAFE
Hookah-shisha.com
5 VALENTINES DAY SHISHAS FOR LOVERS
Most popular type in the U.S. and in the Middle East is maassel or shisha
A wet mixture of tobacco, sweetener, and flavorings.
WHAT IS WATERPIPE TOBACCO?
WATERPIPE SMOKING TOPOGRAPHY
Table 1: Mean puff topography for waterpipe users and cigarette smokers.
Topography variable N = 201 N = 522 N = 313 N = 564
Puff number 178 171 10.0 12.7Puff volume (ml) 590 530 51.0 48.6Puff duration (s) 2.8 2.6 1.4 1.5Interpuff interval (s) 15.2 15.5 30.7 21.31Katurji and Shihadeh, 2007; 2Shihadeh et al., 2004; 3Breland, 2005; 4Djordjevic et al., 2000
Waterpipe Cigarette
Cigarette: 10 puffs * 50 ml = 500 ml (1/4 of a big soda bottle)Waterpipe: 175 puffs * 550 ml = 96,250 (about 48 big soda bottles)
MACHINE SMOKE CONTENT USING REALISTIC PUFF PARAMETERS FOR SINGLE WATERPIPE AND CIGARETTE
Toxicant/mg Waterpipe Cigarette Ratio
Nicotine 2.94 1.74 1.7
CO 145 22.3 6.5
Tar 802 17.3 46.36
Cobb C, Ward KD, Maziak W, et al. Am J Health Behavior, in press
WP session vs Cig “tar”: Many times the PAH yield
Waterpipe data from Sepetdjian et al., 2008; cigarette data from Gmeiner et al., 1977
Known/suspected carcinogen WP (ng/session)Cig (ng/cig)RatioNaphthalene 2130 236 9.0Acenaphthylene 180 50.4 3.6Acenaphthene 487 25.3 19.2Fluorene 437 119 3.7Phenanthrene 2650 110 24.1Anthracene 493 38.1 12.9Fluoranthene 2380 46.2 51.5Pyrene 2510 33.2 75.6
Chrysene + Benz[a]anthracene 677 35 19.3Benzo fluoranthenes 370 10.1 36.6Benzo[a]pyrene 307 7.9 38.9Benzo[g,h,i]perlyene 140 2.5 56.0Di-benzo[a,h]anthracene 147 0.6 245.0Indeno[1,2,3-cd]pyrene 183 3.5 52.3
Waterpipe Cigarette Ratiomg/episodemg/
cigarette
Formaldehyde 630 23 27.4
Acetaldehyde 2520 619 4.1
Acrolein 892 47 19.0
Propionaldehyde 403 46.5 8.7
Methacrolein 106 24 4.4
WP session vs Cig: aldehydes: Many times the yield
Data from Al Rashidi et al., 2008.
Compound
WHAT IS IN THE SMOKE: HEAVY METALS.
Heavy metals in waterpipe and cigarette smoke
Metal (ng) Waterpipe1 Cigarette2 RatioArsenic 165 40-120 1.4Beryllium 65 300 0.2Chromium 1340 4-70 19.1Cobalt 70 0.13-0.2 350.0Lead 6870 34-85 80.8Nickel 990 ND-600 1.71Shihadeh, 2003;
2Hoffman and Hoffman, 2000.
Shafagoj and Mohammed, 2002; Shafagoj et al., 2002Participants = 14 Jordanian men.
Expired air CO Plasma nicotine
WHAT IS IN WATERPIPE SMOKERS: CARBON MONOXIDE AND NICOTINE
TOXICANT EXPOSURE OF SMOKERS: CO (N=61)
Maziak W, et al. Tobacco Abstinence Symptoms, CO exposure, and Puff Topography in Waterpipe Tobacco Smokers. N &TR 2009; 11(7): 806-11.. Cigarette data from Kleykamp et al 2008
Lung cancer: (Nafae et al, 1973: Qiao et al, 1989), increased risk (dose-response) of lung cancer among waterpipe users.
Oesophageal SCC: Nasrollahzadeh et al., BJC 2008. Pregnancy outcomes : (Nuwayhid et al,1997) waterpipe use
in pregnancy leads to low birth weight & Apgar Score. Cardiovascular, respiratory: (Al-Fayez et al, 1988; Kiter et
al 2000, Mutairi et al, 2006, Shafagoj, Ward et al, 2006; Al-Kutabi et al, 2006; Al-Safi et al, 2008; Ben Saad H et al, 2009) waterpipe use is associated with decreased function and accelerated aging of lungs, chronic respiratory sym, acute & chronic increase BP and heart rate.
Dental disease: (Baljoon, Netto, 2005; Dar-Odeh 2009) periodontal disease, potentially malignant lesions& oral cancer
Infectious contamination: (Steentoft et al, 2006), TB.
HEALTH EFFECTS
WHAT IS IN WATERPIPE SMOKE? SIDESTREAM SMOKE
0 10 20 30 40 50 60 700
0.5
1
1.5
2
2.5
3
3.5
4
Typical total (5.6-560 nm) particle concentration in chamber versus time
for waterpipe and cigarette
time (min)
N (
10
6/c
c) charcoal added
cigarette
waterpipe
Waterpipe removed
Daher, N., et al. (2010). Atmos Environ, 44(1), 8-14.
EXPOSURE OF NON-SMOKERS
0
100
200
300
400
500
World (932) Syria (40) Smoke free(280)
Ireland (25)
Mea
n PM
2.5
(µg/
m3 )
Hyland, Travers, et al. A 32-country comparison of tobacco smoke derived particle…. Tob Control. 2008.Maziak, Travers, et al. Exposure to secondhand smoke at home and in public places in Syria. Inhal Toxicol. 2008.
POPULATION SMOKING TRENDS, SYRIA (N=2038, 18-65 YRS, ALEPPO, 2004)
Cigarette Waterpipe0
10
20
30
40
50
32
15.7
47.5
12.1
38.8
6.8
18-29 yrs 30-45 yrs 46-65 yrs
Pre
vale
nce
%
BEGINNING OF THE WATERPIPE EPIDEMIC, SYRIA
Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.
SMOKING, (13-15 YRS), EMR, GYTS (N > 90,000)
18.8
3.2
9.911.3
15.6
6.7
0
2
4
6
8
10
12
14
16
18
20
Cigarette Other (watepipe) Any
% c
urr
en
t u
se
rs
Boys Girls
Warren CW, et al. Lancet, 2006.
CIG & WATERPIPE SMOKING, 13 YR OLD STUDENTS JORDAN (N=
1781)
Mzayek F, Maziak W, et al., J Adolescent Health (submitted)
SMOKING, MEDICAL STUDENTS (DAMASCUS)
Almerie, Maziak et al. Int J Tuberc Lung Dis 2008.
WATERPIPE, (11-15 YRS), ESTONIA, 2006 (N = 13826)
Pärna et al. BMC Public Health 2008 8:392
WATERPIPE, UNIV OF BIRMINGHAM (AGE 20.2 YRS, N 937)
Jackson and Aveyard. BMC Public Health 2008 8:174
Waterpipe use has been reported in 33 states.
200-300 waterpipe cafes have opened in the U.S. since 1999 (Smokeshop Magazine, 2004) “often near college campuses”.
Waterpipe cafes now exist near many large universities including Virginia Commonwealth (Richmond), Arizona State (Tempe); Colorado State (Fort Collins); Iowa (Iowa City); Nebraska (Lincoln); Kent State (Kent, OH), Weber State (Ogden, UT), University of Memphis.
IS THE U.S. IN AN EARLY STAGE OF A WATERPIPE EPIDEMIC AMONG COLLEGE
STUDENTS?
HIGH SCHOOL USE OF TOBACCO (AGE 14, ARIZONA 2005)
Primack, Eissenberg et al., Pediatrics 2009;123:e282-e288
WATERPIPE, ARAB-AMERICAN HIGH SCHOOL STUDENT (N=1313, AGE 15.6)
Weglicki LS et al., Am J Prev Med, 2008
WATERPIPE: COLLEGE STUDENTS IN THE U.S.
Johns Hopkins University
- 411 freshmen (100% < age 23, 48% women, 58% white, 93% US citizens)
Virginia Commonwealth University
- 744 students (93% < age 23, 65% women, 43% non-white, 92% US citizens), spring semester 2006
WATERPIPE USE IN COLLEGES IN THE US
Smith-Simone, Maziak, Ward, Eissenberg. Nicotine & Tobacco Research 2008 Feb;10(2):393-8.Eissenberg, Ward, Smith-Simone, Maziak. J Adolescent Health 2008;42(5):526-9.
20.319.515.3
41.4
-5
5
15
25
35
45
JHU (N=411) VCU (N=744)
% p
reva
len
ce o
f pa
st 3
0 d
ays
use
Waterpipe Cigarettes
WATERPIPE USE IN COLLEGES IN THE U.S.
LifetimePast 30-day
A BNorth America
Baltimore, MDN = 411
Richmond, VAN = 744
Pittsburgh, PAN = 647
Per
cent
(%
)
Southwest Asia
0
20
40
60
80
100
Aleppo, SyriaN = 587
Beirut, LebanonN = 416
LifetimePast 30-day
A BNorth America
Baltimore, MDN = 411
Richmond, VAN = 744
Pittsburgh, PAN = 647
Per
cent
(%
)
Southwest Asia
0
20
40
60
80
100
Aleppo, SyriaN = 587
Beirut, LebanonN = 416
Cobb, Ward, Maziak, & Eissenberg. Waterpipe : An Emerging Health Crisis in the United States: 2009.
IS WATERPIPE USE INCREASING IN U.S.?
Web-based survey administered to Intro Psychology students at VCU during March ’06 (n=744) and ’07 (n=339)
Cobb, Ward, Maziak, & Eissenberg. Presented at SRNT annual meeting, February, 2008, Port land, Oregon.
Waterpipe use more common on weekend.Majority purchased their waterpipe on the
internet.Majority use flavored tobacco, fruit flavor
most popular.Majority smoke intermittently.Majority are confident they could quit, most
of whom have no intention of quitting.Majority believe that cigarettes are more
harmful and addictive.
USE PATTERNS AMONG US COLLEGE YOUTHS
Smith-Simone, Maziak, Ward, and Eissenberg. 2008
1. I enjoy the taste2. It’s a good way to socialize with friends3. It helps me to feel relaxed4. I enjoy the smell5. It helps me to feel less stressed6. It’s something to do when I feel bored7. Waterpipe smoke is less harsh than cigarette smoke8. I like trying things that are new, diff erent, or “hip”9. It helps me not smoke cigarettes10. It helps me not use other tobacco products besides
cigarettes (e.g., cigars or chew)
WHY YOUTHS SMOKE WATERPIPE
Smith-Simone, Maziak, et al, 2008.Maziak et. at, 2004.
SOCIAL DIMENSION OF WATERPIPE USE
0
10
20
30
40
50
60
70
80
90
Beginners Established
%
AloneWith friendsWith family
Asfar T, Maziak W, et al. BMC Public Health 2005.
• Maassel’s aromatic mild smoke, wide variety and availability,
simplifi cation of the waterpipe preparation process were
perhaps critical for the renewed appeal of the waterpipe
• The internet & other transnational media (e.g. satellite
TV) lead to commercializing & glamorizing waterpipe,
particularly among youths.
• The reduced-harm perception , based on the water fi ltering
myth.
• The thriving café culture.
• All these factors have perhaps created conditions for a
perfect storm that sparked the global waterpipe epidemic.
FACTORS BEHIND THE CURRENT WATERPIPE PANDEMIC
• Particularly popular among young adults and teens in SW Asia:
- Syria, 45% of college students at Aleppo University report ever use (29.8% women; Maziak et al., 2004)
- Jordan, 61% of university students reported ever use; 43% reported past 30-day use (random sample of 548 students across four universities; Azab et al., 2010).
- Lebanon, 23-30% of Beirut university students report current use (Tamim et al, 2003; Chaaya et al., 2004).
- Lebanon, 25.6% of 11-17 year olds in Beirut reported past 30-day use (Tamim et al., 2007).
• Global spread suggested by published data from: Brazil, Canada, Germany, Korea, Ukraine, U.S.
WHAT ABOUT WATERPIPE TOBACCO/NICOTINE DEPENDENCE?
Waterpipe users are exposed to nicotine (N = 37).
Data from Blank et al., Drug Alcohol Dep, 2011.
WP-delivered nicotine is physiologically active.
Data from Blank et al., Drug Alcohol Dep, 2011.
A second study: waterpipe relative to a cigarette.
Plasma nicotine (N=31)
0
2
4
6
8
10
12
14
0 5 15 30 45
Time relative to smoking onset
ng
/ml
*
C WP
AUC418 ng/ml
243 ng/ml
Data from Eissenberg & Shihadeh, 2010.
cigarettewaterpipe
Thread title: “Why is hookah not addictive?”
“It is addictive. Period. End of story. Maybe not as easily habit forming as cigarettes because hookah is not a convenient as a pack of smokes. But rest assured, it is addictive. . .” (Lukasa)
“I'd say I'm pretty hooked. I smoke anywhere from 1-3 times per day, virtually every day of the week. It's pretty rare that I'll miss a day. . .” (Yashman19)
“. . . Lets not kid ourselves, when I smoked hookah lots I started to get hooked and craved tobacco, then I realized this and quit for a while and don't smoke as much anymore. The nicotine in the tobacco for hookahs and the nicotine in cigarettes is identical, so it is equally addictive.” (Joseph)
ANECDOTAL EVIDENCE FOR WATERPIPE DEPENDENCE.
• Random sample of 268 Syrian waterpipe smokers.
• 43% reported more frequent use than when they started
• 55% reported being “somehow” or “very” hooked on waterpipe (83% of daily smokers).
• 63% choose café/restaurant based on waterpipe availability (77% of daily smokers)
• 42% carry waterpipe with them (69% of daily smokers).
• 59% made an unsuccessful quit attempt in the past year (78% of daily smokers).
From Maziak et al., 2004.
EMPIRICAL EVIDENCE: DRUG-SEEKING AND DIFF. QUITTING?
Maziak et al., 2006 (61 Syrian waterpipe smokers, overnight abstinence; CO increased 31.5 ppm)
0
10
20
30
40
100
Pre Post
Time (relative to waterpipe smoking)
Sco
reUrgeRestlessnessCraving
EMPIRICAL EVIDENCE: ABSTINENCE-INDUCED WITHDRAWAL?
Among Arab-American adolescents, odds of
experimenting with cigarettes were 8 times greater
among ever waterpipe smokers (Rice et al., 2006).
In a population-based study of young military recruits
(US), waterpipe users were more likely than non-users
to plan to initiate cigarette smoking in the next year
(Ward et al., 2006).
Youth studies in the EMR show that fi rst
experimentation with tobacco through a waterpipe
precedes that with cigarettes.
IS WATERPIPE USE A “GATEWAY” TO CIGARETTES?
WHERE IS THE BURDEN OF THE TOBACCO EPIDEMIC INCREASING THE FASTEST, 1990-
2020
India+1400%
Middle Eastern Crescent +700%
Latin American and Caribbean+300%
Sub-Saharan Africa+200%
Other Asia and Islands+250%
China+175%
Formerly Socialist Economies of Europe+120%
Established Market Economies+18%
Oral Stomach Colon Rectum Liver Gallbladder Larynx Lung Bladder Prostate Breast Ovary Cervix Thyroid NHL
Leukemia Brain Other
Saudi Arabia
Yemen
Oman
Qatar
Bahrain
Kuwait
Iraq
UAE
Egypt
Palestine
Algeria
Tunisia
Libya
Morocco
Lebanon
Jordan
Syria
Mauritania
Sudan
Saudi Arabia
Yemen
Oman
Qatar
Bahrain
Kuwait
Iraq
UAE
Egypt
Palestine
Algeria
Tunisia
Libya
Morocco
Lebanon
Jordan
Syria
Mauritania
Sudan
Males Females
PERCENTAGE DATA FOR THE FIVE MOST PREVALENT CANCERS IN COUNTRIES OF THE
MIDDLE EAST
4 STAGES OF THE SMOKING EPIDEMIC
REAR VIEW MIRROR- TRENDS IN CIGARETTE CONSUMPTION AND LUNG CANCER MORTALITY IN THE
US
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 20000
1000
2000
3000
4000
5000
0
20
40
60
80
100
Year
Nu
mb
er o
f ci
gar
ette
s p
er c
apit
a
Lu
ng
ca
nc
er
de
ath
ra
te p
er
10
0,0
00
*Per 100,000, age-adjusted to 2000 U.S. standard population.Data Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. Cigarette consumption: US Department of Agriculture, 1900-1987, 1988, 1989-2003.
Per capita cigarette consumption
Lung cancerdeath rates/Men
Lung cancerdeath ratesWomen
1964
CUMULATIVE PUBMED REFERENCES BY YEAR FOR “CIGARETTE”
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
Cigarette
CUMULATIVE PUBMED REFERENCES BY YEAR FOR “WATERPIPE, HOOKAH, SHISHA, NARGHILE, HUBBLE
BUBBLE, ETC.””
2011
2009
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
1971
1969
1967
1965
1963
1961
1950
-195
90
50
100
150
200
250
300
Waterpipe and related terms
TOBACCO CONTROL POLICY
Framework Convention on Tobacco Control (FCTC)Not clear what the eff ect of FCTC policies will be on
cigarette and in particular waterpipe use in the EMRWaterpipe use generally ignored or given little
attention despite it being as important as cigarettes in EMR
CIGARETTE
Cigarette
Addition of waterpipe in assessments of tobacco use may help counteract the perception that it is benign to use.
Smokefree air laws seem to have had the opposite eff ect on hookah establishments, bolstering them as they are often unaddressed or exempted from many laws (ALA, 2007).
More must be done to limit minors’ access to waterpipe products.
Enforce clear warning labels on waterpipe tobacco, and ensure that common but misleading descriptors such as “0% tar” are removed from packaging.
Enforce advertisement bans to include waterpipe.
WATERPIPE POLICY
Smoker toxicant exposure: co, nicotine, carcinogens.Large-scale surveys in the U.S. and elsewhere to
understand current prevalence and identify targets populations and key messages for prevention and treatment eff orts.
Epidemiological work to understand disease risk.Develop and test policy initiatives to curb the spread
of waterpipe. . . . But we have the science to catch up quickly!
WE ARE WELL BEHIND THE CURVE. . .
Proposed warning labels for Narghile tobacco and accessories
Courtesy of Rima Nakkash, American University of Beirut
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?“All Natural” coconut charcoal
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
Typical Lebanese, no vent Typical Egyptian, vented
WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM
REDUCTION?
AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY
Gratwick Basic Science Building 4936
AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY
AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY
Testing emissions of various smoked tobacco and alternative products
Validating methods and equipment to measure airborne pollutants
Human studies on smoking behavior, topography, product switching
Possible human exposure studies looking at eff ects of exposure to tobacco smoke or other airborne pollutants
Need IRB protocols.
AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY
Continuous particle monitors for measuring particulate matter concentration, particle counts, ultrafine particle counts, polycyclic aromatic hydrocarbons, active particle surface area.
Continuous monitors for temperature, humidity, carbon monoxide, carbon dioxide, volatile organic compounds.
Sampling pumps.Various other compounds can be measured in
conjunction with a commercial laboratory.LifeShirt noninvasive, ambulatory, physiological
monitoring system for measuring cardiac and respiratory parameters.
AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY
Some available equipment:
MEASURING EXPOSURE TO TOBACCO SMOKE POLLUTION
Cigarettes, cigars and pipes are major emitters of respirable suspended particles less than 2.5 microns (PM2.5) in diameter that are easily inhaled deep into the lungs
TSI SidePak AM510 Personal Aerosol Monitor (weight: ~1 lb)
This device is a real-time laser photometer with a built-in sampling pump that measures airborne particle mass-concentration
TRAINING COURSE AT:WWW.TOBACCOFREEAIR.ORG
HTTP: / /VIMEO.COM/CHANNELS/84864
U.S.A.
U.S.A.Jan 22,2011
India
Wasim Maziak, MD, PhD, Syrian Center for Tobacco Studies and University of Memphis
Alan Shihadeh, PhD, American University of BeirutTom Eissenberg, PhD, Virginia Commonwealth
UniversityRima Nakkash, PhD, American University of Beirut
ACKNOWLEDGMENTS