the waterpipe: epidemiology
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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. - PowerPoint PPT PresentationTRANSCRIPT
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