Hookah Smoking: The Past and Future of Tobacco?

1. Hookah Smoking:The Past and Future of Tobacco? Brian Primack, MD, EdM, MS Assistant Professor of Medicine and Pediatrics May 2008

3. Terminology • Hookah • Waterpipe • Shisha-Pipe • Narghile • Bong • Hubble-bubble

5. www.hookah-bars.com

15. Hours • Sunday – Thursday: 4 PM – 12:30 AM • Friday – Saturday: 4 PM – 2 AM

16. Fruit Apple Banana Cherry Melon Candy Bubble gum Chocolate mint Alcohol Margarita Piña colada Flavors

17. Good Quality Regular $7.00Large $10.00 Arabic Coffee, Apple, Apple Alex, Double Apple, Apricot, Banana, Candy, Cappuccino, Cherry, Carmel, Coconut, Cola, Grape, Jasmine, Lemon, Mint, Mango, Mandarin, Mixed Fruit, Orange, Pistachio, Peach Rose, Salloum, Strawberry, Vanilla, Zaghoul Light, Zaghoul, Licorice

18. Excellent QualityRegular $8.00Large $11.00 Double apple, Apricot, Banana, Cantaloupe, Cappuccino, Cherry, Coconut, Mint, Melon, Orange, Peach, Pineapple, Rose, Raspberry, Strawberry, Tutti-Frutti, Vanilla Cognac, Margarita, Pina Colada, Strawberry Daiquiri

19. Premiume Quality Regular $8.50Large $11.50 Apple, Special Apple, Bahrany Apple, Apple Eskandarani, Banana, Cola, Cappuccino, Fruit Cocktail, Honey Melon, Mango, Orange, Peach, Pipe, Rose, Strawberry

20. Superior Quality Regular $9Large $12 Apple, Strawberry, Grape, Rose

21. * Make your Hookah Cool with adding ice for $1 * Mix & Match Flavors Add $2 * Flavor Your Hookah Water Add $3 * Add 0.25 Per Each Person** Minimum 1 Order Per Person ** ** Bring your own bottle $2 cork charge ** You Must Be 21 to bring your own alcohol bottle

22. Also Have • Fruit Smoothies (e.g. Strawberry, Banana, Mango, Guava) • Ice Cream • Coffee and Tea • Milk Shakes • Desserts • Games (Mancala, Dominoes)

24. Apple Shaped, $35

25. Silver Crane$120

26. $200(It rotates!)

27. $600

28. $13 for 250 gm

29. $20 Sampler

30. 16 Coals for $4

31. Smoke Exposure • 30-60 minute sessions • Each session ~100 inhalations • Each inhalation ~500 mL in volume • Total volume • Waterpipe session: 50,000 mL • Cigarette: 500-600 mL

32. Smoking Topography 1Shihadeh 2003; Shihadeh 2004 2Breland 2005; Djordjevic 2000

33. Known Harm • Waterpipe smoke contains ... • Carcinogens • Carbon monoxide • Nicotine • Waterpipe smoking associated with ... • Cancer • Cardiovascular disease • Decreased pulmonary function • Nicotine dependence

34. Waterpipe > Cigarettes • Tar • Nicotine • CO • Heavy Metals Shihadeh 2003; Shihadeh 2004; Djordjevic 2000; Hoffman, 2000

36. Growing U.S. Prevalence • 200-300 new waterpipe cafés opened in the U.S. between 1999 and 2004 • Particularly in college towns • Convenience sample surveys suggest high current use (past 30 days) • 411 first-year college students: 15.3% • 744 introductory psychology students: 20%

37. Holes in Literature • Random sample • Associations between waterpipe smoking and • Demographics • Beliefs (e.g., harm, addiction, popularity) • Populations outside college

38. STUDY 1: COLLEGE

39. Purpose • Determine the 30-day, annual, and lifetime prevalence of waterpipe smoking in a random sample of college students • Determine associations between outcome variables and sociodemographic and predictors

40. Design • Cross-sectional survey • Random sample of students at the University of Pittsburgh • Collect data via web-based version of the American College Health Association’s (ACHA) National College Health Assessment (NCHA) • Added items related to waterpipe use

41. Approvals • University of Pittsburgh Institutional Review Board • University Vice Provost

42. Procedure • April 2007 during a three-week period • Avoided the 30-day period following Spring Break • Email invitation sent to 3600 randomly selected Pitt students • Incentive: lottery to win cash prizes ranging from $25 to $100 • Three reminder e-mails sent to students during the three-week period

43. Demographic Measures • Age • Gender • Race • Residence (on-vs. off-campus) • Undergraduate vs. graduate • Membership in a fraternity or sorority • Self-reported academic achievement

44. Theory of Reasoned Action Norms Intent Behavior Attitudes

45. Behavior Measures • Have you ever smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No) • During the past year, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No) • During the past 30 days, have you smoked tobacco from a waterpipe (hookah, shisha, narghile), even one or two puffs? (Yes/No)

46. Attitudes • “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more harmful or less harmful than smoking regular cigarettes?” (“waterpipe more harmful” / “waterpipe same harm” / “waterpipe less harmful”) • “Would you say that smoking from a waterpipe (hookah, shisha, narghile) is more addictive or less addictive than smoking regular cigarettes?” (“waterpipe more addictive” / “waterpipe same addictiveness” / “waterpipe less addictive”)

47. Normative Beliefs • “Among your peers, how socially acceptable is it to smoke tobacco from a waterpipe (hookah, shisha, narghile)?” (“not acceptable” / “somewhat/moderately acceptable” / “very acceptable”) • “What percentage of college students do you think has ever smoked tobacco from a waterpipe (hookah, shisha, narghile)?” (0-100%, collapsed into tertiles

48. Analysis • Multivariate logistic regression models • Dependent variables • 30-day waterpipe smoking • One year waterpipe smoking • Independent variables • Perception of harm • Perception of addictiveness • Acceptability • Popularity • Covariates • Sensitivity analyses with stepwise regression

49. Response Rate • 61 emails undeliverable • Response rate 660/3539 = 18.6% • 647/660 (98.0%) had outcome data • Compared with non-respondents, respondents were: • Younger (20.9 vs. 21.4, p<0.001) • Female (65.6% vs. 50.5%, p<0.001) • Caucasian (85.4% vs. 80.7%, p=0.004)

50. Sample