Webinar: Waterpipe use from the Middle East to Western Countries
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Webinar: Waterpipe use from the Middle East to Western Countries

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This presentation will discuss the epidemiology, toxicology, and harms of waterpipes, as well as what further research is needed and the challenges in providing treatment for those interested in......

This presentation will discuss the epidemiology, toxicology, and harms of waterpipes, as well as what further research is needed and the challenges in providing treatment for those interested in quitting. Presented as a webinar for Global Bridges on 26 February, 2014.

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  • The fourth row is a part of the results of the study in the third rowInadult WP users, those who ever use WP are much greater in number compared to those who continue to smoke WP (current WP users): e.g. 38%, 40% ever WP users compared to 7-20% current users. It means among adults, many try smoking WP, but few take up the habit.You will see small difference among YOUTH WP users
  • You see here that difference is little between the rate of those who try WP for the first time and the rate of those who take up the habit
  • Introduction of manufactured Maassel, reduced-harm perception, flourishing café culture and mass media, resulted in increased use of WP in EMR
  • We see that the WP use rates are high in the EMR countries among university students
  • Talking about trends in youth WP use in general
  • This is a picture from one of the Ma’assel factories.Ma’assel can be prepared manually by adding the chopped tobacco leaves, along with honey, glycerine, additives, flavors and preservatives and OTHER ADDED SUBSTANCES by the manufacturer that we don’t know what they are, they are all mixed together under non-hygienic situations, and served at cafes and restaurants.
  • In Canada, charcoal is now a restricted product under the Hazardous Products Act. According to the Canadian Department of Justice
  • Polycyclic aromatic hydrocarbons (PAHs) are a group of over 100 different chemicals that are formed during the incomplete burning of coal, oil and gas, garbage, or other organic substances like tobacco or charbroiled meat. PAHs are usually found as a mixture containing two or more of these compounds, such as soot.Exposure to polycyclic aromatic hydrocarbons usually occurs by breathing air contaminated by wild fires or coal tar, or by eating foods that have been grilledThese nitrosamine carcinogens are formed from nicotine and related compounds by a nitrosation reaction that occurs during the curing and processing of tobacco. They are called tobacco-specific nitrosamines because they are found only in tobacco productsThese nitrosamine carcinogens are formed from nicotine and related compounds by a nitrosation reaction that occurs during the curing and processing of tobacco. They are called tobacco-specific nitrosamines because they are found only in tobacco products (and possibly in some other nicotine-containing products). Thus the tobacco-specific nitrosamines are present in both "smokeless" tobacco products such as dipping tobacco and in cigarette smoke
  • nanogram per gram (ng/g) part per billion (109Beryllium is used primarily as a hardening agent in alloys notably beryllium copper In structural applications, high flexural rigidity thermal stability thermal conductivity and low density (1.85 times that of water) make beryllium a quality aerospace material for high-speed aircraft
  • Cigarette smokers typically take 8 – 12, 40-47 ml puffs over 5-7 minutes and inhale 0.5 to 0.6 litres of smoke. In contrast, water pipe smoking sessions typically the last 20-80 minutes, during which the smoker may take 50-200 puffs which range from about 0.15 to 1 litre of smoke each. The water pipe smoker may therefore inhale as much smoke during one session as a cigarette smoker would inhale when smoking a 100 or more cigarettesAccording to Maziak W. et al, 2009:CO in expired-air increased significantly from a mean of 4.0 ppm before to 35.5 ppm after smoking.
  • AbstractThe waterpipe, also known as shisha, hookah, narghile, goza, and hubble bubble, has long been used for tobacco consumption in the Middle East, India, and parts of Asia, and more recently has been introduced into the smokeless tobacco market in western nations. We reviewed the published literature on waterpipe use to estimate daily nicotine exposure among adult waterpipe smokers. We identified six recent studies that measured the nicotine or cotinine levels associated with waterpipe smoking in four countries (Lebanon, Jordan, Kuwait, and India). Four of these studies directly measured nicotine or cotinine levels in human subjects. The remaining two studies used smoking machines to measure the nicotine yield in smoking condensate produced by the waterpipe. Meta-analysis of the human data indicated that daily use of the waterpipe produced a 24-hr urinary cotinine level of 0.785 microg/ml (95% CI = 0.578-0.991 microg/ml), a nicotine absorption rate equivalent to smoking 10 cigarettes/day (95% CI = 7-13 cigarettes/day). Even among subjects who were not daily waterpipe smokers, a single session of waterpipe use produced a urinary cotinine level that was equivalent to smoking two cigarettes in one day. Estimates of the nicotine produced by waterpipe use can vary because of burn temperature, type of tobacco, waterpipe design, individual smoking pattern, and duration of the waterpipe smoking habit. Our quantitative synthesis of the limited human data from four nations indicates that daily use of waterpipes produces nicotine absorption of a magnitude similar to that produced by daily cigarette use.
  • This a study that disagrees with the concept of nicotine dependence in waterpipeAbstractBACKGROUND: Waterpipe tobacco smoking usually involves heating flavored tobacco with charcoal and inhaling the resulting smoke after it has passed through water. Waterpipe tobacco smoking increases heart rate and produces subjective effects similar to those reported by cigarette smokers. These responses are thought to be nicotine-mediated, though no placebo-control studies exist. Accordingly, this double-blind, placebo-control study compared the acute physiological and subjective effects of waterpipe tobacco smoking to those produced when participants used a waterpipe to smoke a flavor-matched, tobacco-free preparation.METHODS: Occasional waterpipe tobacco smokers (n = 37; 2-5 monthly smoking episodes for ≥ 6 months) completed two double-blind, counterbalanced sessions that differed by product: preferred brand/flavor of waterpipe tobacco or flavor-matched, tobacco-free preparation. For each 45-min, ad lib smoking episode blood and expired air CO were sampled, cardiovascular and respiratory response were measured, and subjective response was assessed.RESULTS: Waterpipe tobacco smoking significantly increased mean (± SEM) plasma nicotine concentration (3.6 ± 0.7 ng/ml) and heart rate (8.6 ± 1.4 bpm) while placebo did not (0.1 ± 0.0 ng/ml; 1.3 ± 0.9b pm). For carboxyhemoglobin (COHb) and expired air CO, significant increases were observed for tobacco (3.8 ± 0.4%; 27.9 ± 2.6 ppm) and for placebo (3.9 ± 0.4%; 27.7 ± 3.3 ppm) with no differences across condition. Independent of condition, symptoms of nicotine/tobacco abstinence (e.g., "urges to smoke", "anxious") were reduced and direct effects (e.g., "dizzy", "satisfy") increased.DISCUSSION: These results from the first placebo-control study of waterpipe tobacco smoking demonstrate that waterpipe-induced heart rate increases are almost certainly mediated by nicotine though the subjective effects observed in these occasional smokers were not.During the placebowaterpipe condition, participants smoked a flavor-matched, tobacco-free herbal product(Soex; Soex India Pvt. Ltd; Mumbai, India). According to the manufacturer, Soex is “100%tobacco-free and nicotine-free”, primarily composed of chopped “sugar cane, molasses, andflavor”
  • This scale was suggested and validated to be compatible with the Fagerstrom Scale for cigarette smoking. It is not simple or handy, that is why it is not regularily used. May need to be simplified further.The items of the scale include eleven questions, categorized into:Physiological nicotine dependenceNumber of times you could stop waterpipe for 7 days? Percent of income you would spend on waterpipe smoking?Number of days you could spend without waterpipe? Number of waterpipes you usually smoke per week? Negative reinforcementYou smoke waterpipe to relax your nerves. You smoke waterpipe to improve your moralePsychological craving Do you smoke waterpipe when you are seriously ill? Do you smoke waterpipe alone? Are you ready not to eat in exchange for a waterpipe? Positive reinforcementYou smoke waterpipe for pleasure. You smoke to please others (for conviviality).AbstractWaterpipe smoking is becoming fashionable in Lebanon, but no studies have studied nicotine dependence related to waterpipe smoking. A score was constructed from 21 items and subsequently submitted to two factor analyses, which led to the extraction of four factors. Reliability and test-retest reproducibility were measured. Convergent construct validity and discriminant validity also were assessed for different smokers' samples. The Lebanon Waterpipe Dependence Scale-11 (LWDS-11) was composed of four subscales, the first representing nicotine dependence, the second negative reinforcement, the third psychological craving, and the fourth positive reinforcement. Internal consistency and test-retest reproducibility were adequate, and the subscales correlated adequately with measurements of nicotine metabolites, exhaled carbon monoxide levels, and the frequency of waterpipe smoking. The LWDS-11 discriminated between mild, moderate, and heavy waterpipe smokers, based on a threshold score of 10. Results were biologically and psychologically sound. This is the first scale to characterize waterpipe dependence. With further improvement and confirmation, it could become a useful clinical and epidemiological tool.
  • AbstractWaterpipe smoking has increased dramatically worldwide in recent years, with an estimated 100 million daily users. Research on this traditional Middle Eastern tobacco use method is in its infancy, and little is known about users' cessation-related attitudes and experiences. A random sample of 268 narghile (waterpipe) smokers (40% female; mean age = 30 years; range = 18-68) was obtained from cafes and restaurants in Aleppo, Syria. The majority of users (86.5%) believed they could quit using waterpipes at any time, but that belief was inversely related to perceived dependence, with only 48.7% of those who thought they were "very hooked" believing they could quit. Interest in quitting was expressed by 28.4% of subjects, with the majority (89.2%) reporting health concerns as a primary reason, and 59.2% having made an unsuccessful quit attempt in the past year. In a logistic regression model, independent predictors of interest in quitting included being married, having smoked for fewer years, not increasing the frequency of smoking over time, and having family members who do not smoke a waterpipe and disapprove of its use. Results indicate that a sizable percentage of waterpipe users express interest in quitting and have tried unsuccessfully in the past to quit. Waterpipe use needs to be considered in developing effective tobacco use cessation programs in the Middle East.
  • 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars69 of these cities have exemptions that allow HTS 4 of the 69 have passed legislation specifically exempting HTS65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation.

Transcript

  • 1. WATERPIPE FROM THE MIDDLE EAST TO WESTERN COUNTRIES Feras I. Hawari, M.D Director, Cancer Control Office Chief, Section of Pulmonary and Critical Care King Hussein Cancer Center Director, Global Bridges, EMR 1
  • 2. Disclosures  Sub-award unrestricted educational grant from Global Bridges  American Cancer Society capacity building grant to strengthen tobacco control in Jordan  Virginia Commonwealth University grant to study the acute effect of Hookah exposure on lung function and cardiopulmonary exercise testing 2
  • 3. Outline      Anatomy and epidemiology Toxicology Evidence-based health effects Managing WP dependence Policy on hookah 3
  • 4. ANATOMY AND EPIDEMIOLOGY 4
  • 5. Overview  Invented in India during the 16th century by an Indian physician  Smoke “should be passed through a container of water so that it would be rendered harmless”  Today, WP cafés are gaining popularity around the globe, including Middle East ,Britain, France, Russia and the United States 5
  • 6. Different names, same concept …  Africa, India, US  Egypt, KSA  Jordan, Lebanon, Syria  Iran  Pakistan  China Waterpipe Shisha, Borry, Goza Narghile, Arghile Ghalyoun, Ghalyan Huqqa Shui yan dai Hubble Bubble 6
  • 7. Anatomy of WP 7
  • 8. 8
  • 9. Choose the single best answer: 1) The rate of WTS is highest among young people 2) 30% of college students report ever using WTS 3) 10% of college students report using WP in the past 30 days 4) In the US, WTS is nearly as common as cigarette use 5) All of the above 9
  • 10. Choose the single best answer: 1) The rate of WTS is highest among young people 2) 30% of college students report ever using WTS 3) 10% of college students report using WP in the past 30 days 4) In the US, WTS is nearly as common as cigarette use 5) All of the above 10
  • 11. Prevalence of Adult WP Use in Western Countries Country WP Use Rate Study British university students ever WP use 38% Jackson & Aveyard, 2008 ever WP use French high school students 40% Jackson & Aveyard, 2008 US universities 7 to 20% Cobb et al, 2010 29.5% Primack, Fertman, Rice, Adachi-Mejia, & Fine, 2010 current WP use (a sample of ever WP use 8745 students in eight colleges current WP in the US) use 7.2% 11
  • 12. Prevalence of Adult WP Use in Western Countries Country WP Use Rate Study 12th graders/ Arizona current WP users 7% Barnett et al, 2009 high school students/ Florida ever WP users 11% Barnett et al, 2009 ever WP users 8% Canadian Tobacco Use Monitoring Survey (CTUMS), 2006 United States Canada youth (15–24 years) 12
  • 13. Prevalence of Adult WP Use in the EMR Country WP Use Rate Study university students current WP use 33% 17% school students current WP use Anjum, Ahmed, & Ashfaq, 2008; Jawaid et al, 2008 current WP use 42.7% Pakistan Jordan university students Azab et al., 2010 13
  • 14. WP Use Among Future Healthcare Professionals in EMR Country Current WP Use Study Medical Students Lebanon 20.6% Syria 23.5% Turkey 28.6% Almerie et al, 2008 Nursing Students Jordan 40.5% GHPSS/Jordan2007 14
  • 15. Prevalence of WP Use Among the Youth Globally  GYTS Report: looking at time trends of tobacco use (1999–2008) among youth showed that cigarette smoking is either stable or declining, other forms of tobacco use are showing a rising trend, most notably WP smoking  Report included more than half a million youth ages 13–15 years, involving 209 surveys in 95 countries and 5 areas Warren et al.,2009 15
  • 16. Prevalence of WP Use Among the Youth in EMR  GYTS results from 16 countries and Gaza Strip suggest that current WP smoking ranges between 6-34% among 13–15 year olds Warren et al, 2009 16
  • 17. Waterpipe and Cigarette Smoking Among College Athletes in the United Methods:  Online survey of 8,745 college students at eight institutions as part of the revised National College Health Assessment  Used multivariable regression models to assess the associations between tobacco use (cigarette and waterpipe) and organized sports participation Primack et.al. J Adolesc Health. 2010 17
  • 18. Waterpipe and Cigarette Smoking Among College Athletes in the United Results:  Sports participants of any type had lower odds of having smoked cigarettes.  Participants who played intramural sports (odds ratio=1.15, 95% confidence interval ¼ 1.03, 1.29) or club sports (odds ratio= 1.15, 95% confidence interval= 1.001, 1.33) had significantly higher odds of having smoked waterpipe tobacco. 18
  • 19. Waterpipe and Cigarette Smoking Among College Athletes in the United Conclusions:  College athletes are susceptible to waterpipe tobacco use  Compared with nonathletic counterparts, club sports participants and intramural sports participants generally had higher odds of waterpipe tobacco smoking  Allure for waterpipe tobacco smoking may exist even for individuals who are traditionally considered at low risk for tobacco use 19
  • 20. All statements are correct except: 1) WP smokers are as interested as cigarette smokers in quitting smoking 2) WTS can cause addiction 3) Some of the nicotine is dissolved in the water so smokers compensate by smoking for longer duration and thus expose themselves to more toxins 4) WTS is affordable 20
  • 21. All statements are correct except: 1) WP smokers are as interested as cigarette smokers in quitting smoking 2) WTS can cause addiction 3) Some of the nicotine is dissolved in the water so smokers compensate by smoking for longer duration and thus expose themselves to more toxins 4) WTS is affordable 21
  • 22. Why is WTS spreading so much? Accessibility: Availability Affordability Innovation Influence of media Lack of a policy framework  Sensory characteristics evoked      Nakkash et al, 2011 Amin T et al, 2010 Misperceptions:  Less addictive & less harmful than cigarettes  Users can quit at any time  Primary motives for hookah smoking are outings with friends, company, boredom and wasting time  More socially acceptable than cigarettes  Can relieve stress and tension 22
  • 23.  Social activity  People share hookah  Often mix cigarettes and WP 23
  • 24. 24
  • 25. Ethnicity and Waterpipe Smoking Among US Students  OBJECTIVES: Examine effect of ethnicity on WP smoking among college students.  DESIGN: – A cross-sectional study – Online survey (n = 2334) from March to April 2011. The survey included questions on demographic characteristics (sex, age, race/ ethnicity), tobacco use experience, risk perception, social acceptability and popularity.  We determined predictors of WP use with three outcomes: – ever-use vs. no use – past-year use vs. no use – past-month use vs. no use 25
  • 26. Ethnicity and Waterpipe Smoking Among US Students Results:  Half of the sample had previously smoked tobacco using a WP: – A third in the past year and 12.5% in the past month  Significant predictors of WP use included – Middle Eastern ethnicity – Middle Eastern friend – Past cigarette or cigar use  Perception of harm was associated with less use in the ever-use model  Perceived addictiveness, social acceptability and popularity of WP were predictors in all models 26
  • 27. Ethnicity and Waterpipe Smoking Among US Students Conclusions:  It is important to develop culturally appropriate interventions to control WP smoking among Middle Eastern Americans and those of Indian/Pakistani descent to curb further spread in US society  It is important to develop interventions that target the perceived addictiveness, social acceptability and popularity of WP smoking 27
  • 28. TOXINS IN HOOKAH 28
  • 29. All of the following statements about toxins in WP are correct except: 1) Mu’essel (flavored) tobacco used when smoking WP contains a significant amount of nicotine 2) The use of charcoal increases the health risks from smoking WP 3) The water filters most of the toxins rendering WP smoke harmless 4) Exposure to second hand smoke from WP is harmful 29
  • 30. All of the following statements about toxins in WP are correct except: 1) Mu’essel (flavored) tobacco used when smoking WP contains a significant amount of nicotine 2) The use of charcoal increases the health risks from smoking WP 3) The water filters most of the toxins rendering WP smoke harmless 4) Exposure to second hand smoke from WP is harmful 30
  • 31. Tobacco Used in WP Mu’essel: based on fruits and other artificial flavors (cola, bubble gum, etc…) contains ~30% tobacco & 70% molasses (honey) Jurak: Indian origin, contains fruits or oils, but sometimes could be unflavored Ajami (Tumbak): pure dark paste of tobacco The tobacco used in one hookah smoking session weighs ~10 to 20g 31
  • 32. Tobacco Juices and Variety of Flavors 32
  • 33. Charcoal  Increases the health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals  A restricted product under the Hazardous Products Act. According to the Canadian Department of Justice 33
  • 34. Cigarettes vs. WP Cigarette Smoking – Up to 0.9L in 7 min WP smoking – 7.5-200L in 20-80 min – Equivalent of up to 100-200 times the volume in one cigarette World Health Organization Study Group on Tobacco Product Regulation (TobReg). Advisory Note: Waterpipe Tobacco Smoking: Health Effects,Research Needs and Recommended Actions by Regulators. 2005. Available at: http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20 recommendation_ 34
  • 35. Toxins in WP  Polyaromatic Hydrocarbons (PAH): – 100 chemicals formed  during the incomplete burning of coal, oil and gas, garbage, or other organic substances like tobacco  Nitrosamines (TSNA): – only in tobacco products – formed from nicotine and related compounds by a nitrosation reaction that occurs during the curing and processing of tobacco Heavy metals: – – – – – – Arsenic Beryllium Chromium Cobalt Lead Nickel 35
  • 36. Toxicant Yields Toxin (ng) Waterpipe1 Cigarette2 Arsenic 165 80 Beryllium 65 300 Chromium 1340 37 Cobalt 70 0.17 Lead 6870 60 Nickel 990 17 1Shihadeh, 2003; 2Hoffman, 2000 36
  • 37. Cigarettes vs. WP 37
  • 38. Cigarettes vs. WP (Puff Topography) Cigarettes Waterpipe Puffs 8-12 50-200 Duration/minute 5-7 20-80 Smoke/liters 0.5-0.6 0.15-1 Carbon Monoxide/ ppm 4.0 35.5 WHO Advisory Note: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators, 2005 38
  • 39. CAN WP CAUSE DEPENDENCE? 39
  • 40. WP Dependence  One session of 10 gm WP tobacco produce 4 times the nicotine in one cigarette  Daily use of WP produced a 24-hr urinary cotinine level of 0.785 microg/ml (equivalent to smoking 10 cigarettes/day) Neergaard J. et al. 2007 40
  • 41. WP Dependence (2) 41
  • 42. Nicotine Dependence (3) All were significantly associated with the number of hagars (sessions) smoked per day. (Auf RA. et al. 2012) - Time to the first smoke of the day - Smoking even when ill - Time to tobacco craving - Hating to give up the first smoke of the day 42
  • 43. Nicotine Dependence (4)  Smoking and recovery phases after WTS and Cigarettes showed similarity in the way they both: - Suppressed withdrawal - Suppressed craving  Recovery of some of these symptoms can be faster with cigarette use. (Rastam S. et al. 2011) 43
  • 44. Nicotine Dependence (5) WP smoking vs. placebo  WT smokers completed two double-blind, counterbalanced sessions: tobacco and tobacco-free preparation (sugar cane, molasses, flavor) Drug Alcohol Depen. 2011 Jul 1;116  Independent of condition: – Symptoms of urges to smoke were reduced and direct effects (e.g., “dizzy”, “satisfy”) increased. – Direct effects of nicotine were increased 44
  • 45. Figure 1. Means (±1 SEM) for plasma nicotine (A), HR (B), COHb (C), and systolic BP (D) for active and placebo waterpipe tobacco conditions. The time point “45+” refers to the fact that some participants (n=12) smoked longer than the minimum 45 minute bout. Filled symbols indicate a significant difference from baseline and asterisks (*) indicate a significant difference between active and placebo conditions at that time point (Tukey’s HSD; P<.05). 45
  • 46. Lebanon Waterpipe Dependence Scale (LWDS-11) First scale to characterize WP dependence: Items: - Physiological nicotine dependence Negative reinforcement Psychological craving Positive reinforcement This scale was suggested and validated to be compatible with the Fagerstrom Scale for cigarette smoking. It is not simple or handy and needs to be simplified 46
  • 47. HEALTH EFFECTS OF WP 47
  • 48. 48
  • 49. The Effects of WP Tobacco Smoking on Health Outcomes Methods:  A systematic review using the Cochrane Collaboration methodology for conducting systematic reviews  Rated the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology 49
  • 50. The Effects of WP Tobacco Smoking on Health Outcomes  Included: – Observational studies – case–control studies and cross-sectional studies) assessing the association between WP tobacco smoking and health outcomes  Excluded: – – – – Case reports Case series Outbreak investigations and abstracts Studies assessing physiological outcomes (FEV1) 50
  • 51. 51
  • 52. The Effects of WP Tobacco Smoking on Health Outcomes Conclusions:  WTS was significantly associated: – Low birth-weight – Lung cancer – Periodontal disease – Respiratory illness  WTS was not significantly associated with – Oral dysplasia – Bladder cancer – Infertility – Nasopharyngeal cancer – Hepatitis C. – Esophageal cancer The overall quality of evidence varied from very low to low. 52
  • 53. WP EFFECT ON LUNG FUNCTION AND EXERCISE CAPACITY 53
  • 54. WP Effect on Lung Function 54
  • 55. Effects of WP Tobacco Smoking on Lung Function Methods:  Systematic review using the approach of the Cochrane Collaboration  Conducted two separate meta-analyses comparing: – WP smokers with nonsmokers – WP smokers with cigarette smokers Both comparisons for each of three spirometric measurements (FEV1, FVC, and FEV1/ FVC) 55
  • 56. 56
  • 57. Effects of WP Tobacco Smoking on Lung Function Results: WPS was associated with: – Statistically significant reduction in FEV₁ (SMD= -0.43; 95% CI, -0.58 to -0.29; equivalent to a 4.04% lower FEV₁%) – A trend towards lower FVC (SMD = -0.15; 95% CI, -0.34 to 0.04; equivalent to a 1.38% reduction in FVC%) – A lower FEV₁/ FVC (SMD = -0.46; 95% CI, -0.93 to 0.01; equivalent to a 3.08% lower FEV₁/ FVC). – Comparing WPS with cigarette smoking, there was no statistically significant difference in FEV₁, FVC, and FEV₁/ FVC. 57
  • 58. Effects of WP Tobacco Smoking on Lung Function Conclusions: WPS: – Negatively affects lung function – May be as harmful as cigarette smoking – Likely to be a cause of COPD 58
  • 59. 59
  • 60. Study Design  Objective: – Characterize the acute effects of WTS on lung function and exercise capacity  Methods: – 24 healthy WP male smokers – A pilot single-group pre-test (abstained from WTS for ≥48 hours) post-test (within 0.5 hours of a 45-minute WTS session) design – Performed spirometry, DLCO and timelimited CPET (cycloergometer; 2-min 20Watt warm-up and 25-Watt increase every 2-minutes for 10 minutes) 60
  • 61. 61
  • 62. 62
  • 63. 63
  • 64. Conclusion Acute WTS: -Appears to induce impairment in lung function and exercise capacity. -Larger studies are warranted to further characterize the nature and extent of such impairment. 64
  • 65. Case Study A 35 year old healthy male smokes WP daily. He just got married 2 years ago and recently became a father of a 6 month old baby. He has an 8 to 5 office job. His wife refuses to allow him to smoke at home. He leaves to a coffee shop directly from work daily. He self referred himself after noticing that his marriage is in danger. 65
  • 66. The pharmacological regimen that provides the best abstinence rates results for treating WP dependence is: 1) 2) 3) 4) NRT NRT + Bupropion NRT + Bupropion + Varenicline Non of the above 66
  • 67. The pharmacological regimen that provides the best abstinence rates results for treating WP dependence is: 1) 2) 3) 4) NRT NRT + Bupropion NRT + Bupropion + Varenicline Non of the above 67
  • 68. TDT FOR WP 68
  • 69. Treatment Interventions Cochrane Review No waterpipe cessation interventions The Cochrane Review: Interventions for waterpipe smoking cessation. 2011 69
  • 70. Are WP users interested in quitting?  Interest in quitting was expressed by 28.4% of subjects  The majority (89.2%) reported health concerns as a primary reason  And 59.2% made an unsuccessful quit attempt in the past year Ward KD. et al. 2005 70
  • 71. • A cross-sectional survey-based study in a convenient sample of in Amman, Jordan (n=600) • Effectiveness of educational programs and counseling – 63.85% for cigarette smokers and 60.36% in waterpipe smokers • Effectiveness of smoking cessation medications: – 53.22% for cigarette smokers and 39.46% in waterpipe smokers). 71
  • 72. TDT for WP Smokers  Anecdotal  Detailed patterns of use (regular vs. occasional)  Counseling and motivational interviewing (creating interest to quit)  Avoid comparing cigarettes to WP (both are bad) 72
  • 73. TDT for WP Smokers (2)  Using pharmacotherapy: – NRT: dose and timing – Bupropion – Varenicline  Dealing with relapse 73
  • 74. Most large US cities ban WP smoking in bars: 1) True 2) False 3) Do not know 74
  • 75. Most large US cities ban WP smoking in bars: 1) True 2) False 3) Do not know 75
  • 76. 76
  • 77. US Health Policy Related to HTS  Objective: Assess how a representative sample of US tobacco control policies may apply to HTS  Methods: – Municipal, county, and state legal texts applying to the 100 largest US cities were examined 77
  • 78. 78
  • 79. US Health Policy Related to HTS  Three fourths of the largest US cities disallow cigarette smoking in bars  Nearly 90% of these cities may permit HTS via exemptions  Closing this gap in clean air regulation may significantly reduce exposure to HTS 79
  • 80. Air Quality? Indoor air quality in Virginia waterpipe cafes. Cobb C et al. Tob Control 2012 Mar 24. 80
  • 81.  A revised indoor air quality law has been implemented in Virginia to protect the public from the harmful effects of secondhand smoke exposure.  This legislation contains exemptions that include allowances for smoking in a room that is structurally separated and separately ventilated. 81
  • 82. Indoor Air Quality in Virginia WP cafes Objectives:  Examine the impact of this law on air quality in waterpipe cafés  Compare the air quality in these cafés to restaurants that allow cigarette smoking and those where no smoking is permitted 82
  • 83. Indoor Air Quality in Virginia WP cafes Methods:  Indoor air quality was assessed in 28 venues (17 waterpipe cafés, five cigarette smokingpermitted restaurants and six smoke-free restaurants (five with valid data))  Real-time measurements of particulate matter (PM) with 2.5 μm aerodynamic diameter or smaller (PM(2.5)) were obtained  Occupant behavior and venue characteristics were assessed 83
  • 84. Indoor Air Quality in Virginia WP cafes Results:  Mean PM(2.5) concentration: – WP café smoking rooms (374 μg/m(3), n=17) – WP café non-smoking rooms (123 μg/m(3), n=11) – Cigarette smoking-permitted restaurant smoking rooms (119 μg/m(3), n=5) – Cigarette smoking-permitted restaurant nonsmoking rooms (26 μg/m(3), n=5) – Smoke-free restaurants (9 μg/m(3), n=5) 84
  • 85. Indoor Air Quality in Virginia WP cafes Results (2):  Smoking density positively correlated with PM(2.5) across smoking rooms smoke-free restaurants  PM(2.5) was positively correlated between smoking and non-smoking rooms of venues 85
  • 86. Indoor Air Quality in Virginia WP cafes Conclusions:  Air quality in the WP café smoking rooms was worse than restaurant rooms in which cigarette smoking was permitted  State-required non-smoking rooms in WP cafés may expose patrons and employees to PM(2.5) concentrations above national and international air quality standards  Reducing the health risks of secondhand smoke may require smoke-free establishments in which tobacco smoking sources such as WP are prohibited 86
  • 87. Action Against WP Is Needed! Research: trends, harms, cessation, etc… Subject to same anti-tobacco regulations Health warnings Fight false advertisement about WP’s safety  Cessation interventions  HCP education about risks to vulnerable groups     87
  • 88. Thank You 88