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

1. 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

2. 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?

3. 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)

4. 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)

5. Shisha in the news • Most articles from the UK focus on breaches of smoke-free legislation • Three focus on an apparent rise in users

6. 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

7. Findings: Prevalence & frequency of use, 2012 to 2013 • Design-adjusted Chi-sq test for differences in shisha use between years:p-value = 0.13

8. % ‘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)

9. % ‘ever’ shisha use, 2012 & 2013 combined, by: Gender • Self- reported ever shisha use differs by gender (p<0.001)

10. % ‘ever’ shisha use, 2012 & 2013 combined, by: Age group • Self- reported ever shisha use differs by age (p<0.001)

11. % ‘ever’ shisha use, 2012 & 2013 combined, by: Social Grade • Self- reported ever shisha use differs by social grade (p<0.001)

12. % ‘ever’ shisha use, 2012 & 2013 combined, by: Ethnicity • Self- reported ever shisha use differs by ethnicity (p<0.001)

13. % ‘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)

14. % ‘ever’ shisha use, 2012 & 2013 combined, by: Smoking status • Self- reported ever shisha use differs by smoking status (p<0.001)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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?