Tobacco control expert. Public health specialist. Self-proclaimed epidemiologist. Stop smoking connoisseur

Transcription

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2 Tobacco control expert Public health specialist Self-proclaimed epidemiologist Stop smoking connoisseur

3 IMPERIAL COLLEGE SCHOOL OF MEDICINE Final year medical student BSc (Hons) Health Sciences with Business Management Academic foundation programme ELSEWHERE Brent PCT/Brent Council (Audit Lead) Imperial College School of Public Health

4 Jawad M, Khaki H, Hamilton F. Shisha guidance for GPs. Eliciting the hidden history. Br J Gen Pract 2012;595(62):66-67 Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J. Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J (in press) Jawad M, Abbas J, Hariri A, Akl EA. Using social media for public health campaigning: the case of waterpipe tobacco smoking. (in press) Jawad M, Abbas J, Hariri A, Rajasooriar KG, Salmasi H, Millet C, Hamilton FL. Waterpipe smoking prevalence and attitudes amongst medical students in London. (in press)

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6 1) Recent News 2) History 3) Functionality 4) Cigarettes 5) Health affects 6) Popularity 7) Attitudes 8) Legislation 9) Potential for escalation 10) Tying it all up

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13 Synonyms: waterpipe, hookah, nargile, hubble-bubble, goza, qalyan, etc 600 year old practice Indian/Middle Eastern origin [By and large] tobacco smoking

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15 1. Coal: Heated and placed on a pierced aluminium foil 2. Head: This is where the tobacco goes 3. Body: The smoke travels down here 5. Hose: This is where you inhale the cooled smoke Water 4. Water bowl: The smoke is cooled down here (not filtered!)

16 30% tobacco 70% honey-based, fruit flavoured mixture NB Unregulated and contents vary significantly

17 Different types of coal - Lump charcoal - Quick lighters - Coconut-based healthier options

18 - Elaborate design - Increasing popularity amongst women

19 - Large plumes of smoke - Lots of fun!!

20 Which is worse?

21 Smoked 10x longer than a cigarette Each puff is 10x deeper than a cigarette Amount of smoke is 100x more than a cigarette

22 Study Smoking time Number of puffs Total volume of smoke drawn Puff duration Puff volume Katurji mins 220 puffs 130 L 2.8 secs 626 ml Shihadeh mins 171 puffs 91 L 2.6 secs 530 ml Maziak mins 169 puffs 86 L 3.2 secs 511 ml Monn mins 100 puffs 100 L 5.0 secs 1000 ml Shihadeh mins 101 puffs 2.8 secs Cobb puffs 62 L 834 ml Eissenberg mins 72 puffs 49 L 818 ml

23 Study Smoking time Number of puffs Total volume of smoke drawn Puff duration Puff volume Katurji Shihadeh Maziak Monn Shihadeh Cobb Eissenberg

24 Shisha has approximately: 30 cigarettes worth of tar 10 cigarettes worth of carbon monoxide 2 cigarettes worth of nicotine In one 45 minute session

25 Study Tar CO Nicotine NO Katurji mg 150mg 4.82mg Shihadeh mg 143mg 2.96mg Shihadeh mg 2.25mg Shihadeh mg 155mg 1.04mg 437mg Shihadeh 2012 (non-tobacco herbal shisha) 513mg 159mg <0.01mg 386mg

26 Study Tar CO Nicotine NO Katurji Shihadeh Shihadeh Shihadeh Shihadeh 2012 (non-tobacco herbal shisha)

27 IARC Classification Description 1 Carcinogenic to humans 2A 2B Probably carcinogenic to humans Possibly carcinogenic to humans 3 Probably not carcinogenic to humans

28 Toxin (ng) IARC Classification Waterpipe (Shihadeh 2003) Cigarette (Hoffman 2000) Shisha s magnitude of difference Arsenic Beryllium Nickel 1/2B Cobalt 2B Chromium Lead 2B

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30 1. Coal: Three types 2. Aluminium foil Normal coal Quick-light coal Natural coals No. & density of piercings Size of piercings Foil thickness Different temperatures Shiny-side up or down 5. The hose 3. Tobacco Leather or plastic Sharing with friends Disposable mouth tips Brand differences Herbal shisha Amount/ cocktails Length of hose Currently unregulated in UK 6. The smoker 4. Apparatus and water Number of puffs Depth of each puff Total time smoking Water Shisha pipe sizes Water levels Cleaning habits Smoking indoors Replacing water with?

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32 Plain tobacco packaging? Hah!

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34 SHISHA S HEALTH EFFECTS Cigarette-like health effects Shisha-specific health effects

35 atio] % CI.44] ] ] ] Odds Ratio Odds Ratio SE IV, Random, Weight 95% IV, CI Random, 95% CI 28.1% 3.50 [0.97, 12.60] 40.2% 2.17 [0.74, 6.33] 31.8% 1.32 [0.40, 4.40] Odds Ratio IV, Random, 95% CI 100.0% 2.12 [1.08, 4.18].42].19, df = 2 (P = 0.55); I² = 0% ) Protective effect Harmful effect Lung cancer Protective effect Harmful effect Low birth weight Oesophageal cancer For those of you more academicallyminded Lung function Akl EA, Gaddam S, Gunukula SK, Honeine R, Abou Jaoude P, Irani J. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol 2010;39(3):

36 NICOTINE-BASED Cravings Withdrawal symptoms Drug-seeking behaviour SOCIALLY-BASED Shisha centrepiece Associated with a good time Ornate instrument

37 SHISHA S HEALTH EFFECTS Cigarette-like health effects Lung cancer Oesophageal cancer Low birth weight Lung function Addiction Shisha-specific health effects?

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39 12 A&E admissions in one day from one café Neurological symptoms Dizziness Light-headedness Vomiting Passing out Seizures Smoker s feelings Headrush Buzz Getting high

40 TOBACCO Recreational drugs Painkillers WATER Vodka Stimulant drinks e.g. RedBull Milk

41 Ease of self-assembling

42 Cleanliness?

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44 SHISHA S HEALTH EFFECTS Cigarette-like health effects Lung cancer Oesophageal cancer Low birth weight Lung function Addiction Shisha-specific health effects CO poisoning Cocktailing Infection transmission

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46 Country No. of studies Country No. of studies USA 23 Bahrain 1 Iran 13 Czech 1 Saudi Arabia 10 Denmark 1 Jordan 7 Estonia 1 Lebanon 7 Germany 1 Pakistan 4 Iraq 1 Egypt 3 Malaysia 1 Israel 3 Oman 1 Syria 3 Poland 1 Canada 2 Tunisia 1 Kuwait 2 UAE 1 South Africa 2 UK 1

47 13-17yrs 18-24yrs >24yrs Number of studies

48 75% Cigarette (current) 50% Shisha (current) 25% USA Iran Jordan

49 75% Cigarette (current) 50% Shisha (current) 25% Sutfin 2011 Noonan 2011 Primack 2010 Eissenberg 2008 Smith 2007 Primack 2008

50 75% 50% Cigarette (current) Shisha (current) 25% Estonia (Parna 2008) Iraq (CDC 2009) Israel (Korn 2008) Jordan (Mzayek 2011) Lebanon (El Roueiheb 2008) USA (Weglicki 2008) UK (Jawad 2012* - unpublished)

51 Very poorly understood (esp in UK) Barely any national surveys conducted Shisha may be more popular, but it is smoked less frequently Monthly Weekly Daily smokers? The tobacco alcopops

52 Behavioural mimicry from a young age

53 Glamorisation like cigarettes 50 years ago

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55 Styles, shapes, sizes

56 rative, ornate normalisation

57 Marketing Techniques

58 Multiculturalist spread

59 Fun and games!

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64 Social acceptance Even amongst family Socialising Entertainment Fashion Expression of cultural identity Lack of a realistic alternative Cool, safe, cheap, long hours too good to be true?

65 Disneyworld Florida

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67 Smokefree law Paradoxical rise in cafes Underage smoking Precursor to cigarette smoking Unregulated tobacco and coal packaging Deceptive marketing Cleaning practices Infection transmission

68 Shisha cafes huge profit margins 6/kg in UAE 10/10g ( 1,000/kg) Budget fines into yearly accounts Tobacco not duty paid Perceived as a socially acceptable alternative to cigarettes No health warnings Online domain e.g. 4% of shisha websites used the word tobacco The perfect business for society Good profit margins Popular, cheap, long hours, safe, fashionable, fun

69 Shisha smokers: Do not consider themselves tobacco smokers Do not believe in addiction Will probably not use the service Stop smoking advisors: Find it hard to gauge level of addiction May not be adequately equipped to deal with shisha Will traditional interventions work?

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71 1) As bad as cigarettes 2) Popular amongst young people 3) Socially acceptable 4) Unique smoking method/environment 5) Lack of legislation 6) Media hindrance 7) Barely any research with a weak infrastructure