Rima NakkashAssistant Professor

Health Promotion and Community Health DepartmentWHO Collaborating Center for Health Promotion  

    and Behavioral Sciences

Faculty of Health Sciences

Coordinator-AUB Tobacco Control Research Group

Tobacco Control Research Group

1st International Conference on Waterpipe Tobacco Smoking

Abu Dhabi,U.A.EOctober 20, 2013

0verviewDoes the current tobacco control

policy regulatory framework address waterpipe tobacco smoking (WTS)? How?

Any current policy practices specific to WTS needed.

Comprehensive

No single measure is sufficient to tackle tobacco – it is important to move on many fronts at once in a comprehensive effort to reduce smoking prevalence.

……hence a FRAMEWORK is needed…..

Comprehensive Strategies (FCTC) Price measures- Taxation measures Non-price measures

Advertising bans Warning labels on tobacco products Ban smoking in public places Protecting from tobacco industry

interference Other : cessation, prevention and

educational campaigns, control smuggling…..

Do we need a waterpipe tobacco smoking specific policies?

What do we know so far about waterpipe tobacco smoking regulation?

Will the same framework be needed for waterpipe tobacco smoking ?

Are there additional regulatory parameters that need to be considered that are specific for this smoking phenomenon?

Review of the regulatory gaps Flavoring (Family Smoking Prevention and Tobacco Control Act )•Free samples•Youth access•Use restrictions (tobacco vs. non tobacco products)•Point of Sale Warnings, Marketing restrictions, and broad sales prohibitions

Waterpipe tobacco smoking specific policies

Taxation Taxing delivery services Taxing serving establishments on sales–prohibitive range of prices

(currently 1USD-24 USD)Taxing tobacco packaged products for home preparation of

waterpipe or for mass production (by kg)Taxing waterpipe accessories (market size)

Research is needed to explore effect of taxation on overall consumption, changes in behaviors such as switching between products, and impact on different population groups especially the vulnerable ones….

Current Practicehttp://www.dutycalculator.com/hs-code-duty-r

ate-import-restrictions/240311/hookah-tobacco/2403.11.0000/2403.11.0000/3007/

Shows various countries tax structures on hookah tobacco .

Waterpipe tobacco smoking specific policies

Regulating advertising

Waterpipe tobacco product billboard advertising in Lebanon prior to March 2012

Banning sponsorship and promotion

What is this ?

Home Delivery handouts

Coal

Promoting Innovations

http://www.healthy-shisha.com

Innovations

http://www.healthy-shisha.com/

Internet promotion and sales

US Hookah Tobacco Smoking Establishments Advertised on the Internet.

-unregulated-accessible to the public-Play a role in propagating misinformation

Primack, 2012)

Social MediaBlog , online chats…who monitors?A comparison of cigarette and hookah related video’s on

youtube.:portrayed positively, don’t mention short and long term

consequences, anti smoking messages, or how to quit tobacco use.

Who is in charge of what gets on youtube ?

Pimack et. Al, 2013

Waterpipe tobacco smoking specific policies

Indoor smoking bans in public places

There should be no exception made for waterpipe tobacco smoking serving establishments

Licenses /loopholes/permits

Comparison of carcinogen, carbon monoxide, and ultrafine particle emissions from narghile waterpipe and cigarette smoking: Sidestream smoke measurements and assessment of second-hand smoke emission factors.Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, Al Rashidi M, Saliba N, Shihadeh A.

“ a single waterpipe use session emits in the sidestream smoke approximately four times the carcinogenic PAH, four times the volatile aldehydes, and 30 times the CO of a single cigarette. Accounting for exhaled mainstream smoke, and given a habitual smoker smoking rate of 2 cigarettes per hour, during a typical one-hour waterpipe use session a waterpipe smoker likely generates ambient carcinogens and toxicants equivalent to 2-10 cigarette smokers, depending on the compound in question.”

Atmospheric Environment, v. 44, iss. 1, p. 8-14.2010

US-Clean indoor air exemptions73 of the largest 100 cities disallowed

cigarette smoking in bars, nearly all (n = 69) of these cities may allow via exemptions.

“poorly defined exemption language resulted in certification that actually assisted” lead to a new niche tobacco market emerging…

(Primack et.al, 2012)

In London alone showed :500% increase in waterpipe premises in last 5 years (national: 210%)Exact figures unknownNot required to register with local authority

Waterpipe premises not exempt from any tobacco legislationUnderage purchase (<18 years)Smoke-free law (enforced in 2007)

UK-Legislation enforcement of the waterpipe tobacco industry

UK-ConclusionsGrowing concern

“One size fits all” legislation approach inappropriate

High profit margins?

Licensing proposal (at local authority level)

(Mohamed, Jawad,Legislation enforcement of the waterpipe tobacco industry, A qualitative analysis of the London experience- October 2013)

Waterpipe tobacco smoking specific policies

Health warning labels

Only one health warning label and not a series of rotating messages

Printed in small font Written on the sides of the

waterpipe tobacco products alongside other information.

Not on unit packs

Nakkash and Khalil, 2010

Current health warning labelsMentioning an

expiry date making waterpipe tobacco products seem misleadingly safe to be consumed prior to expiration

• In the ingredients, they mainly mentioned natural flavors

• They also stated that the waterpipe tobacco contains 0.05% Nicotine and 0.0% Tar

Misleading information on waterpipe accessories were also found on filters, tips and charcoal:

HW Labeling suggested in 2010 Egypt 2011

Waterpipe tobacco smoking specific policies

Advertisement for Egyptian Waterpipe Tobacco

Waterpipe Smoking as an Opportunity for New Profits by the Tobacco Industry?

• Interest of TNC’s is apparent as early as 1960’s and 1970’s

• Issue open for exploitation and could be predictive of future interest

• Flavouring companies interest –global industry too• With growing smoking prevalence more concern

of growing market for example alternative forms of tobacco use :BAT’s attempt to adapt to local culture as in the case of Kreteks in Indonesia

• In the case of Lebanon, local monopoly attempting to catch up with global spreading phenomenon.

(WCTOH, Nakkash and Lee, 2006)

Testing, smoke properties and health effects

1993 -META minutes “testing of waterpipe tobacco”

-BAT intent to test hubble bubble

1994 -Analytical technology department- smoking machine –Hookah experiment

Bates:1004867515

Opposition from the Industry ?In the US: Opposition on tax hikes

:http://www.southsmoke.com/hookahtax.cfmHookah Industry Associationhttp://www.hookahindustry.org/2010/01/775-hookah-

tobacco-tax-increase-rallies-over-2000/

The Hookah Industry Association (HIA) advocates its members’ interests on issues which affect the entire hookah industry. HIA’s mission:

-Fight back and push for the repeal of repressive & restrictive legislation

-Serve as a mechanism for the sharing of ideas, programs, and skills among the organization’s members

-Release research publications & industry news to keep businesses informed

-Educate the public on the economic & cultural importance of the industry

Tobacco Journal International 1/2013

Exports to over 100 countriesNew customers in remote locations, , Indian

ocean, and latin americanSince 1913… introduced Maasel in 1980New competitors

http://www.jti.com/media/news-releases/jt-completes-acquisition-leading-water-pipe-tobacco-company/

Flavoring

Waterpipe tobacco smoking specific policies

Cessation Incorporate in national plans

Development of waterpipe tobacco smoking tailored cessation services

Evaluation of waterpipe tobacco smoking specific cessation protocols

Sensitive to dual users and specific to vulnerable populations, youth; pregnant women.

Waterpipe tobacco smoking specific policies

OtherProduct regulation and testing to monitor

developmentHalting sales of WTS products to minorsBanning introduction of new products/flavours

or altogetherControlling illicit tradeDevelopment of prevention messages and

campaigns

In Conclusion • No comprehensive study on challenges to

legilsation or policy making for waterpipe• Need for building the evidence base for

effective waterpipe tobacco control policies• Policy influence can be studied in different

countries by examining cigarette and waterpipe use prevalence in light of policy that does or does not address each tobacco use method.

• Identify how policies that do and do not address WTS influence public health outcomes.

THANK YOU

Email : rn06@aub.edu.lb

Website http://www.aub.edu.lb/units/tcrg/Pages/index.aspx