Is there a need for a GB shisha cessation service? Findings from

cross-sectional surveys conducted in 2012 and 2013

Dr. Aimee Grant, Public Health Wales NHS Trust,Rory Morrison, ASH Scotland,

Martin Dockrell, ASH

Overview

• How harmful is shisha for health?• Existing research: prevalence of shisha use• Research design• Findings• How should we respond?• Do we need a shisha cessation service?

How harmful is shisha for health?• World Health Organisation (2005)• CO poisoning (Clarke et al., 2012)

• Laboratory study 1 (Eissenberg and Shihadeh, 2009)

– 45 mins shisha v 1 cigarette– High levels of exhaled CO (23.9ppm)– High puff volume (50 litres)– Similar peak nicotine levels

• Laboratory Study 2 (Daher et al., 2010)

– Second hand smoke• Ecological validity (Chaouachi, 2011)

Estimates of prevalence• A ‘Global epidemic’? (Maziak, 2011)

• Large-population surveys– California Tobacco Survey– United Arab Emirates

• International survey evidence– Mostly students (5 peer reviewed published studies)

– Some small samples (Al-Naggar and Saghir, 2011)

– Opportunity sampling (Rehman et al., 2012)

• Evidence from the UK?– 2 student surveys (Jackson and Aveyard, 2008; Jawad et

al., 2012)

• Most articles from the UK focus on breaches of smoke-free legislation • Three focus on an

apparent rise in users

Shisha in the news

Research design• Research question:– What is the prevalence and frequency of shisha

use among adults (aged 18+) in Great Britain?• Design - repeated cross-sectional surveys:– Participants recruited from an online panel

maintained by YouGov Plc using targeted quota sampling, surveys conducted online

– Feb/March 2012 (n=12,436); Feb 2013 (n=12,171)– Results weighted to be representative of GB

population by sex, age, social class, ethnicity, GB region, newspaper readership, voting intention

Findings: Prevalence & frequency of use, 2012 to 2013

Self-reported shisha use:'How often, if at all, have you smoked using a “shisha” pipe? (Please note that shisha pipes are also known waterpipes or hookah pipes)'

2012 - % (95% CI) 2013 - % (95% CI)

More than 3 to 4 times a month 0.3 (0.2, 0.5) 0.3 (0.1, 0.4)

Once or twice a month 0.7 (0.4, 1.0) 0.7 (0.4, 0.9)

Once or twice every 2 to 3 months 0.5 (0.3, 0.6) 0.5 (0.3, 0.7)

Once every 6 to 12 months 1.5 (1.2, 1.8) 1.5 (1.2, 1.8)

Less often 8.2 (7.6, 8.8) 9.0 (8.3, 9.6)

Never 68.9 (67.8, 70.0) 70.3 (69.3, 71.3)

Don’t know/ can’t remember 1.6 (1.3, 1.9) 1.6 (1.3, 1.9)

Not applicable – do not know what a shisha pipe is

18.2 (17.3,19.1) 16.2 (15.4, 17.0)

Design-adjusted Chi-sq test for differences in shisha use between years:p-value = 0.13

% ‘ever’ & ‘frequent (at least once or twice a month)’ shisha use - 2012 to 2013

Error bars represent 95% CI. No statistically significant difference between 2012 & 2013 surveys in ever shisha use (p=0.19), or frequent use (p=0.51)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Gender

Self- reported ever shisha use differs by gender (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Age group

Self- reported ever shisha use differs by age (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Social Grade

Self- reported ever shisha use differs by social grade (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Ethnicity

Self- reported ever shisha use differs by ethnicity (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: GB country of residence

Self- reported ever shisha use differs by GB country of residence (p<0.001)

% ‘ever’ shisha use, 2012 & 2013 combined, by: Smoking status

Self- reported ever shisha use differs by smoking status (p<0.001)

Multivariate analysis of predictors of ‘ever shisha use’ (1)

• Adjusting for covariates in a logistic regression model largely confirmed the results already presented

• Older adults were less likely to report ever use than younger

• Women less likely to report ever use than men• Lower social grades less likely to report ever shisha use

when compared to higher grades• Increased odds of use for ‘mixed/multiple’ ethnic groups

[OR 2.37 (95% CI 1.64 to 3.41)] and ‘Asian/Asian British’ [OR 1.84 (95% CI 1.39 to 2.45)] compared to white – but no difference detected for other groups

Multivariate analysis of predictors of ‘ever shisha use’ (2)

• Being a daily, non-daily, or ex-smoker raised odds compared to being a self-reported never smoker

• Compared to England, residing in Scotland reduced odds of reported ever use [OR 0.75 (95% CI 0.61 to 0.92) – no effect was found for Wales after adjustment for covariates

• A model based on the outcome of ‘frequent use’ gives similar results, and a range of sensitivity analyses did not materially alter the main conclusions

Strengths & limitations

• Strengths:– Large, recent survey, providing quite precise

estimates of use • Limitations:– Self-reported shisha use only– Survey conducted in English language, perhaps

resulting in systematic exclusion of some groups– Probably, like many ‘opt-in’ survey methods,

under-represents those from most disadvantaged areas who are harder to reach

The UK Public Health response to shisha

• Healthy Lives, Healthy People (2011)– Tower Hamlets and Coventry City Council• Information and advice

• Tobacco Control Action Plan for Wales (2012)– SSS to develop a protocol to help users quit

• Reports of interventions in the media– NHS Hull and Hull City Council (Hull Daily Mail, 26.1.13)

• ‘raise awareness’– Leicester – Horn Concern (Leicester Mercury, 9.2.13)

• raise awareness in young people

Should the public health response be expanded?

• Our survey provides little support for the notion of an ‘epidemic’ at the GB population level – but it does not preclude shisha being an issue in specific population sub-groups/local areas

• There is a need to enforce existing regulations– Violation of smokefree regulations– Use of illicit (tax free) products– Absence of health warnings on shisha– Age of users?– Lack of clarity regarding tobacco content of shisha

• Awareness raising activities for high risk groups• Cessation support for regular users

Unanswered questions• If a person smokes cigarettes every day and

shisha once a month, which form of smoking should we be tackling?

• For ex-smokers, is “shisha prevention” vital relapse prevention?

• What is the right balance between shisha prevention/cessation and wider tobacco control?

• In a shisha strategy, what is the right balance between treatment and regulation?