Wasim Maziak MD, PhDProfessor & Chair, Dept. Epidemiology, Florida International University

Director, Syrian Center for Tobacco Studies

The WaterpipeA Cultural Pastime or a Public Health Threat

Syrian Center for Tobacco StudiesSyrian Center for Tobacco Studies

SCTS has been recognized with the Hamdan Award for best Medical/Research Institute in the Arab world for the year 2008

The Waterpipe, origins(hookah, shisha, narghile, hubble-bubble)

Associated with the Indian subcontinent & Middle East

Several records point at an origin that dates back to the 16th century, and probably with substances other than tobacco since tobacco is believed to be introduced to the region at the beginning of 17th century)

The Waterpipe(hookah, shisha, narghile, hubble-bubble)

Beginning of waterpipe epidemic

Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

So what happened? Bonsack machine, 1880

•Hand rolling – 200 cigarettes/day•Bonsack 200/per minute•Current machines – 16,400/minute (984,000/hour)

So what happened?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 processMaziak W. The Global Epidemic of Waterpipe Smoking. Addictive Behaviors 2011.

Social networks, blogs, twitter

And the habit went From this

To this

The culture

“The narghile is good and fun. When we gather to smoke narghile, we know it is a gathering for serenity and joy.”

“My husband smokes [narghile] and I’m waiting for my 4-year-old son to get older so that we can all smoke together”.

Hammal, Maziak, Mock, et al. Tobacco Contol, 2008; Jawad et al., 2013

The social value of waterpipe

“If you vent the smoke in the face of another man or woman, it would mean: I want you. (Woman, smoker, 26–35 yrs., Lebanon)”

Khalil, Afifi, et al., Women Health, 2013

“A woman who smokes waterpipe is more desired. Men are attracted to women who smoke waterpipe because they consider them more liberal. (Man, non-smoker, 18–25 yrs., Syria)”

Emerging social associations of WP

Khalil, Afifi, et al., Women Health, 2013. Jawad et al, IJTLD 2013

Social acceptability “I don't like women to smoke waterpipe in public places … We are an oriental society, we should respect the values. (Man, smoker, 26–35 yrs., Syria)”

“You know that dangerous element, that forbidden element attached to smoking? You get that with shisha, except it’s a halal venue and, perhaps more importantly, socially acceptable”.

The lifestyle

Why should we care?

• Spread.

• Harmful effects

• Addictive properties

• Lack of policy tools to confront it

Current cigarette vs. waterpipe smoking among 13–15 year olds in several Arab countries

Maziak W et al. Health Policy Plan. 2013

Is it harmful and addictive

Reduced harm perception

Jawad M, et al., IJTLD 2013

When I smoke cigarettes I know straight away ‘This is bad for me’, but when I smoke shisha, I don’t feel it’s bad for me and that’s because it’s cold and it’s been through the filter, and you don’t see direct tobacco being burnt—when you’re smoking cigarettes you can see it burning and you can feel the heat.

Machine-generated smoke content using realistic puff parameters for single WP and Cig

Toxicant/mg Waterpipe Cigarette Ratio

Nicotine 2.94 1.74 1.7

CO 145 22.3 6.5

Tar 802 17.3 46.36Cobb C, Maziak W, Ward K, Shihadeh A, Eissenberg T. Am J Health Behavior, 2010.

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

Toxicant exposure of smokers: CO (n=61)

Exposure to carcinogens

Al Ali, Maziak, Shihade, Zataari, et al., Tobacco Control, 2013

Harm to others, particulate matter (PM2.5)

Fromme H et al., Food and Chemical Toxicology, 2009.

- 24-hour (PM2.5) standard 35μg/m3

- Annual PM2.5 standard is 15μg/m3

Is the waterpipe addictive?

• I don’t feel that the narghile fills my need like cigarettes. It is for spending time and entertainment. I don’t feel that I’m addicted to narghile, and I could quit narghile any time

• “I like to dominate everything, but the narghile has completely dominated me. My happiness is related to the narghile. It is essential for having a good time…”

Hammal, Maziak, Mock, et al., Tobacco Control, 2008.

Smokers’ testimonies

Cobb et al., 2011

61 liters of smoke

1 liter of smoke

Waterpipe delivery of nicotine

Time

“If I cannot smoke, I feel restless and tired. When I travel to visit my parents, I do not smoke. Their home environment is not encouraging and I do not feel an urge to smoke. I crave the narghile from 7 till 10 in the evening. (Hammal, Maziak, Mock, et al. Tobacco control, 2008)

“Sometimes it bothers me—if I want it [waterpipe], I don’t just forget about it—I’ll do anything just to have it . . . I don’t know why”. (Jawad M et al., IJTLD 2013)

Withdrawal/craving, qualitative evidence

Once addicted on nicotine, young people may go for cigarettes because of limited access to waterpipe (gateway hypothesis)

“I quit smoking for more than 6 months. Then, I was invited to smoke narghile. After the second puff I asked for a cigarette and I started again”. (Hammal, Maziak, Mock et al. Tobacco Control, 2008)

Thwarting cigarette cessation efforts

Policy implications

Content and packaging regulation information

Blank et al., 2011

Content and packaging regulation

Data from Vansickel et al., 2011.

Policy mismatch

Maziak, Nakkash, Eissenberg, et al., 2013

Ban advertisement

Nakkash et al., 2011

Need for public awareness

•“I don’t see enough advertising to tell me the real effects of shisha, so I don’t really know them. Until then I’m not gonna stop”. (Jawad et al,

2013)

E-Shisha, new unknown in tobacco control policy

Policy implications• Smokefree air laws seem to have had the opposite effect on

hookah establishments, as they are often exempted.

• More must be done to limit minors’ access to waterpipe products.

• Enforce clear warning labels on waterpipe tobacco, and ensure that misleading descriptors such as mild, healthy “0% tar” are removed from packaging.

• Warning labels should be with considerable size and on all parts.

• Enforce advertisement bans to include waterpipe and in involve online advertisement, which is the main promotion for waterpipe.

• Develop novel treatments for waterpipe smoking.

Call received from a 52 year old woman

• “I’ve smoked for thirty years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell. I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.”

Wish you a healthy life away from 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