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  • Tell me the top 3 reasons you think college students use hookahthe primary reasons college freshmen used hookah were related to personal image, social aspects of use, and product characteristics
  • Cancer from the middle east mjt (2)

    1. 1. Cancer from the Middle East: Coming soon to a college campus near you<br />Mark J. Travers, PhD<br />
    2. 2. Egyptian Revolution 2011<br />
    3. 3. Egyptian Revolution: leaders<br />Karim El-Beheiry: Egyptian activist and blogger, has been tortured and imprisoned for his work<br />
    4. 4. Egyptian Revolution: leaders<br />Ahmad Maher: Cofounded the April 6 Student Movement on Facebook<br />
    5. 5. Beirut, lEbanon, waterpipe cafe<br />DISCLAIMER #1: No researchers were harmed in the making of this presentation <br />DISCLAIMER #2: I didn’t inhale<br />
    6. 6. Origin associated with Indian subcontinent & Eastern Mediterranean Region (EMR).<br />One history: began in India ~1600 (Chattopadhyay, 2000)<br />A different type of waterpipe found in China as well<br />The Waterpipe(hookah, shisha, narghile, arghile, hubble-bubble)<br />
    7. 7. Beirut, lEbanon, waterpipe cafe<br />
    8. 8. Drink menu for today<br />Fruit: Apple (caramel, double, green, red, or sour), Apricot, Banana, Blueberry, Cantaloupe, Cherry, Cherry banana, Coconut, Grape, Guava, Kiwi, Lemon, Lemon-lime, Mandarin, Mango, Melon, Mixed fruit, Orange, Passion fruit, Peach, Pear, Pineapple, Pomegranate, Raspberry, Strawberry, Strawberry kiwi, Watermelon<br />Candy/Dessert/Spice: Banana split, Bubble gum, Candy, Cappuccino, Caramel, Chocolate mint, Cinnamon, Coffee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla.<br />Alcohol: Cocktail, Margarita, Pina colada.<br />Tangiers F-line (caffeinated): Apple, Cocoa, Kashmir, Rootbeer.<br />
    9. 9. Beirut, lEbanon, waterpipe cafe<br />
    10. 10. Beirut, lEbanon, waterpipe cafe<br />
    11. 11.<br />5 Valentines day shishas for lovers<br />
    12. 12. Most popular type in the U.S. and in the Middle East is maassel or shisha<br />A wet mixture of tobacco, sweetener, and flavorings.<br />What is Waterpipe Tobacco?<br />
    13. 13. waterpipe smoking topography<br />Cigarette: 10 puffs * 50 ml = 500 ml (1/4 of a big soda bottle)<br />Waterpipe: 175 puffs * 550 ml = 96,250 (about 48 big soda bottles)<br />
    14. 14. Machine smoke content using realistic puff parameters for single Waterpipe and Cigarette<br />Cobb C, Ward KD, MaziakW, et al. Am J Health Behavior, in press<br />
    15. 15. WP session vs Cig “tar”: Many times the PAH yield<br />Known/suspected carcinogen<br />WP (ng/session)<br />Cig (ng/cig)<br />Ratio<br />Naphthalene<br />2130<br />236<br />9.0<br />Acenaphthylene<br />180<br />50.4<br />3.6<br />Acenaphthene<br />487<br />25.3<br />19.2<br />Fluorene<br />437<br />119<br />3.7<br />Phenanthrene<br />2650<br />110<br />24.1<br />Anthracene<br />493<br />38.1<br />12.9<br />Fluoranthene<br />2380<br />46.2<br />51.5<br />Pyrene<br />2510<br />33.2<br />75.6<br />Chrysene + Benz[a]anthracene<br />677<br />35<br />19.3<br />Benzofluoranthenes<br />370<br />10.1<br />36.6<br />Benzo[a]pyrene<br />307<br />7.9<br />38.9<br />Benzo[g,h,i]perlyene<br />140<br />2.5<br />56.0<br />Di-benzo[a,h]anthracene<br />147<br />0.6<br />245.0<br />Indeno[1,2,3-cd]pyrene<br />183<br />3.5<br />52.3<br />Waterpipe data from Sepetdjian et al., 2008; cigarette data from Gmeiner et al., 1977<br />
    16. 16. WP session vs Cig: aldehydes: Many times the yield<br />Waterpipe Cigarette Ratio mg/episode mg/cigarette<br />Formaldehyde 630 23 27.4<br />Acetaldehyde 2520 619 4.1<br />Acrolein 892 47 19.0<br />Propionaldehyde 403 46.5 8.7<br />Methacrolein 106 24 4.4<br />Compound<br />Data from Al Rashidi et al., 2008.<br />
    17. 17. What is in the smoke: heavy metals.<br />Heavy metals in waterpipe and cigarette smoke<br />1<br />2<br />Waterpipe<br />Cigarette<br />Metal (ng)<br />Ratio<br />Arsenic<br />165<br />40-120<br />1.4<br />Beryllium<br />65<br />300<br />0.2<br />Chromium<br />1340<br />4-70<br />19.1<br />Cobalt<br />70<br />0.13-0.2<br />350.0<br />Lead<br />6870<br />34-85<br />80.8<br />Nickel<br />990<br />ND-600<br />1.7<br />1<br />2<br />Shihadeh, 2003; <br />Hoffman and Hoffman, 2000.<br />
    18. 18. Expired air CO<br />Plasma nicotine<br />Shafagoj and Mohammed, 2002; Shafagoj et al., 2002<br />Participants = 14 Jordanian men. <br />What is in waterpipe smokers: Carbon mOnoxideand nicotine<br />
    19. 19. Toxicant exposure of smokers: CO (n=61)<br />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<br />
    20. 20. Lung cancer: (Nafae et al, 1973: Qiao et al, 1989), increased risk (dose-response) of lung cancer among waterpipe users.<br />Oesophageal SCC: Nasrollahzadeh et al., BJC 2008.<br />Pregnancy outcomes: (Nuwayhid et al,1997) waterpipe use in pregnancy leads to low birth weight & Apgar Score.<br />Cardiovascular, respiratory: (Al-Fayez et al, 1988; Kiter et al 2000, Mutairi et al, 2006, Shafagoj, Ward et al, 2006; Al-Kutabi et al, 2006; Al-Safi et al, 2008; Ben Saad H et al, 2009) waterpipe use is associated with decreased function and accelerated aging of lungs, chronic respiratory sym, acute & chronic increase BP and heart rate.<br />Dental disease: (Baljoon, Netto, 2005; Dar-Odeh 2009) periodontal disease, potentially malignant lesions& oral cancer<br />Infectious contamination: (Steentoft et al, 2006), TB.<br />Health Effects<br />
    21. 21. What is in Waterpipe smoke? Sidestream smoke<br />Daher, N., et al. (2010). Atmos Environ, 44(1), 8-14.<br />
    22. 22. Exposure of Non-smokers<br />Hyland, Travers, et al. A 32-country comparison of tobacco smoke derived particle…. Tob Control. 2008.<br />Maziak, Travers, et al. Exposure to secondhand smoke at home and in public places in Syria. InhalToxicol. 2008. <br />
    23. 23. Population smoking trends, Syria (n=2038, 18-65 yrs, Aleppo, 2004)<br />
    24. 24. Beginning of the Waterpipe epidemic, Syria<br />Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.<br />
    25. 25. Smoking, (13-15 yrs), EMR, GYTS (n > 90,000)<br />Warren CW, et al. Lancet, 2006.<br />
    26. 26. Cig & Waterpipesmoking, 13 yr old students Jordan (n= 1781)<br />Mzayek F, Maziak W, et al., J Adolescent Health (submitted)<br />
    27. 27. Smoking, Medical Students (Damascus)<br />Almerie, Maziak et al. Int J Tuberc Lung Dis 2008.<br />
    28. 28. Waterpipe, (11-15 yrs), Estonia, 2006 (N = 13826)<br />Pärna et al. BMC Public Health 2008 8:392<br />
    29. 29. Waterpipe, Univ of Birmingham (age 20.2 yrs, N 937)<br />Jackson and Aveyard. BMC Public Health 2008 8:174<br />
    30. 30. Waterpipe use has been reported in 33 states. <br />200-300 waterpipe cafes have opened in the U.S. since 1999 (Smokeshop Magazine, 2004) “often near college campuses”. <br />Waterpipe cafes now exist near many large universities including Virginia Commonwealth (Richmond), Arizona State (Tempe); Colorado State (Fort Collins); Iowa (Iowa City); Nebraska (Lincoln); Kent State (Kent, OH), Weber State (Ogden, UT), University of Memphis.<br />Is the U.S. in an early stage of a waterpipe epidemic among college students?<br />
    31. 31. High school use of tobacco (age 14, Arizona 2005)<br />Primack, Eissenberg et al., Pediatrics 2009;123:e282-e288<br />
    32. 32. Waterpipe, Arab-American high school student (n=1313, age 15.6)<br />Weglicki LS et al., Am J Prev Med, 2008<br />
    33. 33. Waterpipe: College Students in the U.S.<br />
    34. 34. Johns Hopkins University<br />- 411 freshmen (100% < age 23, 48% women, 58% white, 93% US citizens)<br />Virginia Commonwealth University<br />- 744 students (93% < age 23, 65% women, 43% non-white, 92% US citizens), spring semester 2006<br />Waterpipe use in colleges in the US<br />Smith-Simone, Maziak, Ward, Eissenberg. Nicotine & Tobacco Research 2008 Feb;10(2):393-8.<br />Eissenberg, Ward, Smith-Simone, Maziak. J Adolescent Health 2008;42(5):526-9.<br />
    35. 35. Waterpipe use in colleges in the U.S.<br />Cobb, Ward, Maziak, & Eissenberg. Waterpipe : An Emerging Health Crisis in the United States: 2009.<br /> <br />
    36. 36. Is waterpipe use increasing in U.S.?<br />Web-based survey administered to Intro Psychology students at VCU during March ’06 (n=744) and ’07 (n=339)<br />Cobb, Ward, Maziak, & Eissenberg. Presented at SRNT annual meeting, February, 2008, Portland, Oregon.<br />
    37. 37. Waterpipeuse more common on weekend.<br />Majority purchased their waterpipe on the internet.<br />Majority use flavored tobacco, fruit flavor most popular.<br />Majority smoke intermittently.<br />Majority are confident they could quit, most of whom have no intention of quitting.<br />Majority believe that cigarettes are more harmful and addictive.<br />Use patterns among US college youths<br />Smith-Simone, Maziak, Ward, and Eissenberg. 2008<br />
    38. 38. I enjoy the taste<br />It’s a good way to socialize with friends<br />It helps me to feel relaxed<br />I enjoy the smell<br />It helps me to feel less stressed<br />It’s something to do when I feel bored<br />Waterpipesmoke is less harsh than cigarette smoke<br />I like trying things that are new, different, or “hip”<br />It helps me not smoke cigarettes<br /> It helps me not use other tobacco products besides cigarettes (e.g., cigars or chew)<br />Why youths smoke waterpipe<br />Smith-Simone, Maziak, et al, 2008.<br />Maziak et. at, 2004.<br />
    39. 39. Social dimension of waterpipeuse<br />Asfar T, Maziak W, et al. BMC Public Health 2005.<br />
    40. 40. <ul><li>Maassel’s aromatic mild smoke, wide variety and availability, simplification of the waterpipe preparation process were perhaps critical for the renewed appeal of the waterpipe
    41. 41. The internet & other transnational media (e.g. satellite TV) lead to commercializing & glamorizing waterpipe, particularly among youths.
    42. 42. The reduced-harm perception, based on the water filtering myth.
    43. 43. The thriving café culture.
    44. 44. All these factors have perhaps created conditions for a perfect storm that sparked the global waterpipe epidemic.</li></ul>Factors behind the current waterpipe pandemic<br />
    45. 45. What about waterpipe tobacco/nicotine dependence?<br /><ul><li>Particularly popular among young adults and teens in SW Asia:
    46. 46. Syria, 45% of college students at Aleppo University report ever use (29.8% women; Maziak et al., 2004)
    47. 47. Jordan, 61% of university students reported ever use; 43% reported past 30-day use (random sample of 548 students across four universities; Azab et al., 2010).
    48. 48. Lebanon, 23-30% of Beirut university students report current use (Tamim et al, 2003; Chaaya et al., 2004).
    49. 49. Lebanon, 25.6% of 11-17 year olds in Beirut reported past 30-day use (Tamim et al., 2007).
    50. 50. Global spread suggested by published data from: Brazil, Canada, Germany, Korea, Ukraine, U.S.</li></li></ul><li>Waterpipe users are exposed to nicotine (N = 37).<br />Data from Blank et al., Drug Alcohol Dep, 2011.<br />
    51. 51. WP-delivered nicotine is physiologically active.<br />Data from Blank et al., Drug Alcohol Dep, 2011.<br />
    52. 52. A second study: waterpipe relative to a cigarette.<br />14<br />Plasma nicotine (N=31)<br />AUC<br />418 ng/ml<br />cigarette<br />12<br />waterpipe<br />*<br />10<br />8<br />ng/ml<br />6<br />243 ng/ml<br />4<br />C<br />2<br />WP<br />0<br />0<br />5<br />15<br />30<br />45<br />Time relative to smoking onset<br />Data from Eissenberg & Shihadeh, 2010.<br />
    53. 53. Thread title: “Why is hookah not addictive?”<br />“It is addictive. Period. End of story. Maybe not as easily habit forming as cigarettes because hookah is not a convenient as a pack of smokes. But rest assured, it is addictive. . .” (Lukasa)<br />“I'd say I'm pretty hooked. I smoke anywhere from 1-3 times per day, virtually every day of the week. It's pretty rare that I'll miss a day. . .” (Yashman19)<br />“. . . Lets not kid ourselves, when I smoked hookah lots I started to get hooked and craved tobacco, then I realized this and quit for a while and don't smoke as much anymore. The nicotine in the tobacco for hookahs and the nicotine in cigarettes is identical, so it is equally addictive.” (Joseph) <br />Anecdotal evidence for waterpipe dependence.<br />
    54. 54. Empirical evidence: drug-seeking and diff. quitting?<br /><ul><li>Random sample of 268 Syrian waterpipe smokers.
    55. 55. 43% reported more frequent use than when they started
    56. 56. 55% reported being “somehow” or “very” hooked on waterpipe (83% of daily smokers).
    57. 57. 63% choose café/restaurant based on waterpipe availability (77% of daily smokers)
    58. 58. 42% carry waterpipe with them (69% of daily smokers).
    59. 59. 59% made an unsuccessful quit attempt in the past year (78% of daily smokers). </li></ul>From Maziak et al., 2004.<br />
    60. 60. 100<br />Urge<br />Restlessness<br />40<br />Craving<br />30<br />Score<br />20<br />10<br />0<br />Pre<br />Post<br />Time (relative to waterpipe smoking)<br />Maziak et al., 2006 (61 Syrian waterpipe smokers, overnight abstinence; CO increased 31.5 ppm)<br />Empirical evidence: abstinence-induced withdrawal?<br />
    61. 61. Among Arab-American adolescents, odds of experimenting with cigarettes were 8 times greater among ever waterpipe smokers (Rice et al., 2006).<br />In a population-based study of young military recruits (US), waterpipe users were more likely than non-users to plan to initiate cigarette smoking in the next year (Ward et al., 2006).<br />Youth studies in the EMR show that first experimentation with tobacco through a waterpipe precedes that with cigarettes.<br /> Is waterpipe use a “gateway” to cigarettes?<br />
    62. 62. Where is the burden of the tobacco epidemic increasing the fastest, 1990-2020<br />Formerly Socialist Economies of Europe<br />+120%<br />Established Market Economies<br />+18%<br />China<br />+175%<br />Middle Eastern Crescent +700%<br />Other Asia and Islands<br />+250%<br />India<br />+1400%<br />Latin American and Caribbean<br />+300%<br />Sub-Saharan Africa<br />+200%<br />
    63. 63. Percentage Data for the Five Most Prevalent Cancers in Countries of the Middle East<br />Oral Stomach Colon Rectum Liver Gallbladder Larynx Lung Bladder Prostate Breast Ovary Cervix Thyroid NHL Leukemia Brain Other<br />
    64. 64. 4 Stages of the smoking epidemic<br />
    65. 65. Rear View Mirror- Trends in Cigarette Consumption and Lung Cancer Mortality in the US<br />Lung cancerdeath rates/Men<br />1964<br />Per capita cigarette consumption<br />Lung cancerdeath ratesWomen<br />*Per 100,000, age-adjusted to 2000 U.S. standard population.<br />Data Source: Death rates: US Mortality Public Use Tapes, 1960-2002, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. <br />Cigarette consumption: US Department of Agriculture, 1900-1987, 1988, 1989-2003.<br />
    66. 66. Cumulative Pubmed references by year for “cigarette”<br />
    67. 67. Cumulative Pubmed references by year for “waterpipe, hookah, shisha, narghilE, hubble bubble, etc.””<br />
    68. 68. Tobacco control Policy<br />Framework Convention on Tobacco Control (FCTC)<br />Not clear what the effect of FCTC policies will be on cigarette and in particular waterpipe use in the EMR<br />Waterpipe use generally ignored or given little attention despite it being as important as cigarettes in EMR<br />cigarette<br />Cigarette<br />
    69. 69. Addition of waterpipe in assessments of tobacco use may help counteract the perception that it is benign to use.<br />Smokefree air laws seem to have had the opposite effect on hookah establishments, bolstering them as they are often unaddressed or exempted from many laws (ALA, 2007).<br />More must be done to limit minors’ access to waterpipe products.<br />Enforce clear warning labels on waterpipe tobacco, and ensure that common but misleading descriptors such as “0% tar” are removed from packaging.<br />Enforce advertisement bans to include waterpipe.<br />Waterpipe Policy<br />
    70. 70. Smoker toxicant exposure: co, nicotine, carcinogens.<br />Large-scale surveys in the U.S. and elsewhere to understand current prevalence and identify targets populations and key messages for prevention and treatment efforts.<br />Epidemiological work to understand disease risk.<br />Develop and test policy initiatives to curb the spread of waterpipe.<br />. . . But we have the science to catch up quickly!<br />We are well behind the curve. . . <br />
    71. 71. Proposed warning labels for Narghile tobacco and accessories<br />Courtesy of Rima Nakkash, American University of Beirut<br />
    72. 72. What is the public health impact of Innovation? Harm reduction?<br />
    73. 73. What is the public health impact of Innovation? Harm reduction?<br />
    74. 74. What is the public health impact of Innovation? Harm reduction?<br />“All Natural” coconut charcoal<br />
    75. 75. What is the public health impact of Innovation? Harm reduction?<br />
    76. 76. What is the public health impact of Innovation? Harm reduction?<br />
    77. 77. What is the public health impact of Innovation? Harm reduction?<br />
    78. 78. What is the public health impact of Innovation? Harm reduction?<br />Typical Lebanese, no vent<br />Typical Egyptian, vented<br />
    79. 79. What is the public health impact of Innovation? Harm reduction?<br />
    80. 80. Airborne Pollution Exposure Research Laboratory<br />Gratwick Basic Science Building 4936<br />
    81. 81. Airborne Pollution Exposure Research Laboratory<br />
    82. 82. Airborne Pollution Exposure Research Laboratory<br />
    83. 83. Testing emissions of various smoked tobacco and alternative products<br />Validating methods and equipment to measure airborne pollutants <br />Human studies on smoking behavior, topography, product switching<br />Possible human exposure studies looking at effects of exposure to tobacco smoke or other airborne pollutants<br />Need IRB protocols.<br />Airborne Pollution Exposure Research Laboratory<br />
    84. 84. Continuous particle monitors for measuring particulate matter concentration, particle counts, ultrafine particle counts, polycyclic aromatic hydrocarbons, active particle surface area.<br />Continuous monitors for temperature, humidity, carbon monoxide, carbon dioxide, volatile organic compounds. <br />Sampling pumps.<br />Various other compounds can be measured in conjunction with a commercial laboratory.<br />LifeShirt noninvasive, ambulatory, physiological monitoring system for measuring cardiac and respiratory parameters.<br />Airborne Pollution Exposure Research Laboratory<br />Some available equipment:<br />
    85. 85. Measuring Exposure to Tobacco Smoke Pollution<br />Cigarettes, cigars and pipes are major emitters of respirable suspended particles less than 2.5 microns (PM2.5) in diameter that are easily inhaled deep into the lungs<br />TSI SidePak AM510 Personal Aerosol Monitor (weight: ~1 lb)<br />This device is a real-time laser photometer with a built-in sampling pump that measures airborne particle mass-concentration<br />
    86. 86. Training course at:www.tobaccofreeair.org<br />
    87. 87. U.S.A.<br />
    88. 88. U.S.A.<br />Jan 22,2011<br />
    89. 89. India<br />
    90. 90. WasimMaziak, MD, PhD, Syrian Center for Tobacco Studies and University of Memphis<br />Alan Shihadeh, PhD, American University of Beirut<br />Tom Eissenberg, PhD, Virginia Commonwealth University<br />Rima Nakkash, PhD, American University of Beirut<br />Acknowledgments<br />