ECONOMIC ASPECTS OF WATERPIPE TOBACCO SMOKINGScott E. Sherman, MD, MPHCo-Chief, Section on Tobacco, Alcohol and Drug Use

Associate Professor of Population Health, Medicine and Psychiatry

New York University School of Medicine

Staff Physician, VA New York Harbor Healthcare System

Objectives• To review scientific knowledge about business and

economics aspects of waterpipe tobacco use• To outline future research needs

To review scientific knowledge about economics of waterpipe tobacco use

To review scientific knowledge about economics of waterpipe tobacco use

Business and economic aspects - Why do we care?

• Impact at different levels• Society• Business• Health system• Individual

• Evidence-based policy (Intelligent)

Part 1: The business of hookah

A global market for hookah

A global market for hookah

Phoenix, AZ

Moscow

Tampa, FLBeijing

Semiannual Snapshots of State-level SVI (2004-2013)

Map of NYC Hookah Bars Listed on Yelp.com

Mapping tool is publicly available on UCLA Geomapping Lecturer Yoh Kawano’s educational website.

US CDC web site: An estimated 300 hookah cafés operated in the United States in 2006

Yelp: 130 businesses are listed on Yelp with a tag “hookah Bars” within New York City in 2013

And global suppliers of hookah…

Suppliers of waterpipe tobacco

Suppliers of waterpipe tobacco

Suppliers of waterpipe tobacco

Business of hookah – Research questions

1. Producers, suppliers• Which countries• Small businesses or large multinationals

2. Sellers• Hookah bars vs. sales for home use

Part 2: The economics of hookah

Economics of waterpipe tobacco

• Internal costs – costs to user (and in some cases to his/her family)

• External costs – costs to others• Businesses• Health care system

• Societal costs = internal + external costs

Estimated annual US costs of cigarette smoking

Grand total

Smoker Spouse/Children

Outside family

Grand Total $323 B $296 B $ 22 B $ 5 B

Expenditures $208 B $194 B $ 11 B $ 3 B

Medical $125 B $122 B $ 3 B ??

Non-medical $ 83 B $ 72 B $ 8 B $ 3 B

Productivity $115 B $102 B $ 11 B $ 2 B

Morbidity $ 30 B $ 30 B ?? ??

Mortality $ 85 B $ 72 B $ 11 B $ 2 B

Sloan FA et al. The Price of Smoking. 2004, MIT Press.

Grand total

Smoker Spouse/Children

Outside family

Grand Total $323 B $296 B $ 22 B $ 5 B

Expenditures $208 B $194 B $ 11 B $ 3 B

Medical $125 B $122 B $ 3 B ??

Non-medical $ 83 B $ 72 B $ 8 B $ 3 B

Productivity $115 B $102 B $ 11 B $ 2 B

Morbidity $ 30 B $ 30 B ?? ??

Mortality $ 85 B $ 72 B $ 11 B $ 2 B

Questions1. Do hookah smokers have increased health care utilization?2. Do hookah smokers have increased health care costs?3. What fraction of CVD, CA, etc. is attributable to hookah?

Estimated annual US costs of cigarette smoking

Estimated annual U.S. costs of cigarette smokingGrand total

Smoker Spouse/Children

Outside family

Grand Total $323 B $296 B $ 22 B $ 5 B

Expenditures $208 B $194 B $ 11 B $ 3 B

Medical $125 B $122 B $ 3 B ??

Non-medical $ 83 B $ 72 B $ 8 B $ 3 B

Productivity $115 B $102 B $ 11 B $ 2 B

Morbidity $ 30 B $ 30 B ?? ??

Mortality $ 85 B $ 72 B $ 11 B $ 2 B

Questions1. How much do hookah smokers spend on waterpipe smoking?

Estimated annual U.S. costs of cigarette smokingGrand total

Smoker Spouse/Children

Outside family

Grand Total $323 B $296 B $ 22 B $ 5 B

Expenditures $208 B $194 B $ 11 B $ 3 B

Medical $125 B $122 B $ 3 B ??

Non-medical $ 83 B $ 72 B $ 8 B $ 3 B

Productivity $115 B $102 B $ 11 B $ 2 B

Morbidity $ 30 B $ 30 B ?? ??

Mortality $ 85 B $ 72 B $ 11 B $ 2 B

Questions1. Do waterpipe smokers have more sick days?2. Does waterpipe smoking decrease productivity at work?3. Does waterpipe smoking affect quality of life (short & long term)?

Estimated annual U.S. costs of smokingGrand total

Smoker Spouse/Children

Outside family

Grand Total $323 B $296 B $ 22 B $ 5 B

Expenditures $208 B $194 B $ 11 B $ 3 B

Medical $125 B $122 B $ 3 B ??

Non-medical $ 83 B $ 72 B $ 8 B $ 3 B

Productivity $115 B $102 B $ 11 B $ 2 B

Morbidity $ 30 B $ 30 B ?? ??

Mortality $ 85 B $ 72 B $ 11 B $ 2 B

Questions1. Does waterpipe smoking increase mortality rates? If so, how

many years of life do waterpipe smokers lose?

Modeling• Price elasticity• Salience – how to make it more relevant• Cost-effectiveness of cessation interventions

NYU Global Institute of Public Health Capstone Project Team

• Survey of hookah bar owners in New York, Abu Dhabi and Dubai – starting in December

Karen Jasie Adekunk Olatunji

Tala Haddad Paul Joudrey

Susan Tierney Lyuboyr Pykalo

Scott Sherman Mary Beth Woodin

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market…

And just when we are beginning to study the market…

…the market is changing

Research agenda for the next 5 years

1. What fraction of morbidity and mortality is attributable to waterpipe tobacco?

2. What existing national and international surveys include both questions on hookah and economics? Also, need to include hookah questions in future surveys.

3. Understand economics of restaurants/hookah bars• Understand supply chain, costs, profitability

4. Understand individual costs/benefits/preferences

5. Price elasticity• Compiled data• Individual modeling