1. Cancer from the Middle East: Coming soon to a college campus near you Mark J. Travers, PhD

2. Egyptian Revolution 2011

3. Egyptian Revolution: leaders Karim El-Beheiry: Egyptian activist and blogger, has been tortured and imprisoned for his work

4. Egyptian Revolution: leaders Ahmad Maher: Cofounded the April 6 Student Movement on Facebook

5. Beirut, lEbanon, waterpipe cafe DISCLAIMER #1: No researchers were harmed in the making of this presentation DISCLAIMER #2: I didn’t inhale

6. Origin associated with Indian subcontinent & Eastern Mediterranean Region (EMR). One history: began in India ~1600 (Chattopadhyay, 2000) A different type of waterpipe found in China as well The Waterpipe(hookah, shisha, narghile, arghile, hubble-bubble)

7. Beirut, lEbanon, waterpipe cafe

8. Drink menu for today 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 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. Alcohol: Cocktail, Margarita, Pina colada. Tangiers F-line (caffeinated): Apple, Cocoa, Kashmir, Rootbeer.

9. Beirut, lEbanon, waterpipe cafe

10. Beirut, lEbanon, waterpipe cafe

11. Hookah-shisha.com 5 Valentines day shishas for lovers

12. Most popular type in the U.S. and in the Middle East is maassel or shisha A wet mixture of tobacco, sweetener, and flavorings. What is Waterpipe Tobacco?

13. waterpipe smoking topography Cigarette: 10 puffs * 50 ml = 500 ml (1/4 of a big soda bottle) Waterpipe: 175 puffs * 550 ml = 96,250 (about 48 big soda bottles)

14. Machine smoke content using realistic puff parameters for single Waterpipe and Cigarette Cobb C, Ward KD, MaziakW, et al. Am J Health Behavior, in press

15. WP session vs Cig “tar”: Many times the PAH yield Known/suspected carcinogen WP (ng/session) Cig (ng/cig) Ratio Naphthalene 2130 236 9.0 Acenaphthylene 180 50.4 3.6 Acenaphthene 487 25.3 19.2 Fluorene 437 119 3.7 Phenanthrene 2650 110 24.1 Anthracene 493 38.1 12.9 Fluoranthene 2380 46.2 51.5 Pyrene 2510 33.2 75.6 Chrysene + Benz[a]anthracene 677 35 19.3 Benzofluoranthenes 370 10.1 36.6 Benzo[a]pyrene 307 7.9 38.9 Benzo[g,h,i]perlyene 140 2.5 56.0 Di-benzo[a,h]anthracene 147 0.6 245.0 Indeno[1,2,3-cd]pyrene 183 3.5 52.3 Waterpipe data from Sepetdjian et al., 2008; cigarette data from Gmeiner et al., 1977

16. WP session vs Cig: aldehydes: Many times the yield Waterpipe Cigarette Ratio mg/episode mg/cigarette Formaldehyde 630 23 27.4 Acetaldehyde 2520 619 4.1 Acrolein 892 47 19.0 Propionaldehyde 403 46.5 8.7 Methacrolein 106 24 4.4 Compound Data from Al Rashidi et al., 2008.

17. What is in the smoke: heavy metals. Heavy metals in waterpipe and cigarette smoke 1 2 Waterpipe Cigarette Metal (ng) Ratio Arsenic 165 40-120 1.4 Beryllium 65 300 0.2 Chromium 1340 4-70 19.1 Cobalt 70 0.13-0.2 350.0 Lead 6870 34-85 80.8 Nickel 990 ND-600 1.7 1 2 Shihadeh, 2003; Hoffman and Hoffman, 2000.

18. Expired air CO Plasma nicotine Shafagoj and Mohammed, 2002; Shafagoj et al., 2002 Participants = 14 Jordanian men. What is in waterpipe smokers: Carbon mOnoxideand nicotine

19. Toxicant exposure of smokers: CO (n=61) 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

20. Lung cancer: (Nafae et al, 1973: Qiao et al, 1989), increased risk (dose-response) of lung cancer among waterpipe users. Oesophageal SCC: Nasrollahzadeh et al., BJC 2008. Pregnancy outcomes: (Nuwayhid et al,1997) waterpipe use in pregnancy leads to low birth weight & Apgar Score. 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. Dental disease: (Baljoon, Netto, 2005; Dar-Odeh 2009) periodontal disease, potentially malignant lesions& oral cancer Infectious contamination: (Steentoft et al, 2006), TB. Health Effects

21. What is in Waterpipe smoke? Sidestream smoke Daher, N., et al. (2010). Atmos Environ, 44(1), 8-14.

22. Exposure of Non-smokers Hyland, Travers, et al. A 32-country comparison of tobacco smoke derived particle…. Tob Control. 2008. Maziak, Travers, et al. Exposure to secondhand smoke at home and in public places in Syria. InhalToxicol. 2008.

23. Population smoking trends, Syria (n=2038, 18-65 yrs, Aleppo, 2004)

24. Beginning of the Waterpipe epidemic, Syria Rastam, Maziak et al. Estimating the beginning of the waterpipe epidemic in Syria. BMC Pub Health 2004.

25. Smoking, (13-15 yrs), EMR, GYTS (n > 90,000) Warren CW, et al. Lancet, 2006.

26. Cig & Waterpipesmoking, 13 yr old students Jordan (n= 1781) Mzayek F, Maziak W, et al., J Adolescent Health (submitted)

27. Smoking, Medical Students (Damascus) Almerie, Maziak et al. Int J Tuberc Lung Dis 2008.

28. Waterpipe, (11-15 yrs), Estonia, 2006 (N = 13826) Pärna et al. BMC Public Health 2008 8:392

29. Waterpipe, Univ of Birmingham (age 20.2 yrs, N 937) Jackson and Aveyard. BMC Public Health 2008 8:174

30. Waterpipe use has been reported in 33 states. 200-300 waterpipe cafes have opened in the U.S. since 1999 (Smokeshop Magazine, 2004) “often near college campuses”. 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. Is the U.S. in an early stage of a waterpipe epidemic among college students?

31. High school use of tobacco (age 14, Arizona 2005) Primack, Eissenberg et al., Pediatrics 2009;123:e282-e288

32. Waterpipe, Arab-American high school student (n=1313, age 15.6) Weglicki LS et al., Am J Prev Med, 2008

33. Waterpipe: College Students in the U.S.

34. Johns Hopkins University - 411 freshmen (100% < age 23, 48% women, 58% white, 93% US citizens) Virginia Commonwealth University - 744 students (93% < age 23, 65% women, 43% non-white, 92% US citizens), spring semester 2006 Waterpipe use in colleges in the US Smith-Simone, Maziak, Ward, Eissenberg. Nicotine & Tobacco Research 2008 Feb;10(2):393-8. Eissenberg, Ward, Smith-Simone, Maziak. J Adolescent Health 2008;42(5):526-9.

35. Waterpipe use in colleges in the U.S. Cobb, Ward, Maziak, & Eissenberg. Waterpipe : An Emerging Health Crisis in the United States: 2009.

36. Is waterpipe use increasing in U.S.? Web-based survey administered to Intro Psychology students at VCU during March ’06 (n=744) and ’07 (n=339) Cobb, Ward, Maziak, & Eissenberg. Presented at SRNT annual meeting, February, 2008, Portland, Oregon.

37. Waterpipeuse more common on weekend. Majority purchased their waterpipe on the internet. Majority use flavored tobacco, fruit flavor most popular. Majority smoke intermittently. Majority are confident they could quit, most of whom have no intention of quitting. Majority believe that cigarettes are more harmful and addictive. Use patterns among US college youths Smith-Simone, Maziak, Ward, and Eissenberg. 2008

38. I enjoy the taste It’s a good way to socialize with friends It helps me to feel relaxed I enjoy the smell It helps me to feel less stressed It’s something to do when I feel bored Waterpipesmoke is less harsh than cigarette smoke I like trying things that are new, different, or “hip” It helps me not smoke cigarettes It helps me not use other tobacco products besides cigarettes (e.g., cigars or chew) Why youths smoke waterpipe Smith-Simone, Maziak, et al, 2008. Maziak et. at, 2004.

39. Social dimension of waterpipeuse Asfar T, Maziak W, et al. BMC Public Health 2005.

41. The internet & other transnational media (e.g. satellite TV) lead to commercializing & glamorizing waterpipe, particularly among youths.

42. The reduced-harm perception, based on the water filtering myth.

43. The thriving café culture.

44. All these factors have perhaps created conditions for a perfect storm that sparked the global waterpipe epidemic.Factors behind the current waterpipe pandemic

46. Syria, 45% of college students at Aleppo University report ever use (29.8% women; Maziak et al., 2004)

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. Lebanon, 23-30% of Beirut university students report current use (Tamim et al, 2003; Chaaya et al., 2004).

49. Lebanon, 25.6% of 11-17 year olds in Beirut reported past 30-day use (Tamim et al., 2007).

51. WP-delivered nicotine is physiologically active. Data from Blank et al., Drug Alcohol Dep, 2011.

52. A second study: waterpipe relative to a cigarette. 14 Plasma nicotine (N=31) AUC 418 ng/ml cigarette 12 waterpipe * 10 8 ng/ml 6 243 ng/ml 4 C 2 WP 0 0 5 15 30 45 Time relative to smoking onset Data from Eissenberg & Shihadeh, 2010.

53. Thread title: “Why is hookah not addictive?” “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) “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) “. . . 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) Anecdotal evidence for waterpipe dependence.

55. 43% reported more frequent use than when they started

56. 55% reported being “somehow” or “very” hooked on waterpipe (83% of daily smokers).

57. 63% choose café/restaurant based on waterpipe availability (77% of daily smokers)

58. 42% carry waterpipe with them (69% of daily smokers).

59. 59% made an unsuccessful quit attempt in the past year (78% of daily smokers). From Maziak et al., 2004.

60. 100 Urge Restlessness 40 Craving 30 Score 20 10 0 Pre Post Time (relative to waterpipe smoking) Maziak et al., 2006 (61 Syrian waterpipe smokers, overnight abstinence; CO increased 31.5 ppm) Empirical evidence: abstinence-induced withdrawal?

61. Among Arab-American adolescents, odds of experimenting with cigarettes were 8 times greater among ever waterpipe smokers (Rice et al., 2006). 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). Youth studies in the EMR show that first experimentation with tobacco through a waterpipe precedes that with cigarettes. Is waterpipe use a “gateway” to cigarettes?

62. Where is the burden of the tobacco epidemic increasing the fastest, 1990-2020 Formerly Socialist Economies of Europe +120% Established Market Economies +18% China +175% Middle Eastern Crescent +700% Other Asia and Islands +250% India +1400% Latin American and Caribbean +300% Sub-Saharan Africa +200%

63. Percentage Data for the Five Most Prevalent Cancers in Countries of the Middle East Oral Stomach Colon Rectum Liver Gallbladder Larynx Lung Bladder Prostate Breast Ovary Cervix Thyroid NHL Leukemia Brain Other

64. 4 Stages of the smoking epidemic

65. Rear View Mirror- Trends in Cigarette Consumption and Lung Cancer Mortality in the US Lung cancerdeath rates/Men 1964 Per capita cigarette consumption Lung cancerdeath ratesWomen *Per 100,000, age-adjusted to 2000 U.S. standard population. 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. Cigarette consumption: US Department of Agriculture, 1900-1987, 1988, 1989-2003.

66. Cumulative Pubmed references by year for “cigarette”

67. Cumulative Pubmed references by year for “waterpipe, hookah, shisha, narghilE, hubble bubble, etc.””

68. Tobacco control Policy Framework Convention on Tobacco Control (FCTC) Not clear what the effect of FCTC policies will be on cigarette and in particular waterpipe use in the EMR Waterpipe use generally ignored or given little attention despite it being as important as cigarettes in EMR cigarette Cigarette

69. Addition of waterpipe in assessments of tobacco use may help counteract the perception that it is benign to use. 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). More must be done to limit minors’ access to waterpipe products. Enforce clear warning labels on waterpipe tobacco, and ensure that common but misleading descriptors such as “0% tar” are removed from packaging. Enforce advertisement bans to include waterpipe. Waterpipe Policy

70. Smoker toxicant exposure: co, nicotine, carcinogens. 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. Epidemiological work to understand disease risk. Develop and test policy initiatives to curb the spread of waterpipe. . . . But we have the science to catch up quickly! We are well behind the curve. . .

71. Proposed warning labels for Narghile tobacco and accessories Courtesy of Rima Nakkash, American University of Beirut

72. What is the public health impact of Innovation? Harm reduction?

73. What is the public health impact of Innovation? Harm reduction?

74. What is the public health impact of Innovation? Harm reduction? “All Natural” coconut charcoal

75. What is the public health impact of Innovation? Harm reduction?

76. What is the public health impact of Innovation? Harm reduction?

77. What is the public health impact of Innovation? Harm reduction?

78. What is the public health impact of Innovation? Harm reduction? Typical Lebanese, no vent Typical Egyptian, vented

79. What is the public health impact of Innovation? Harm reduction?

80. Airborne Pollution Exposure Research Laboratory Gratwick Basic Science Building 4936

81. Airborne Pollution Exposure Research Laboratory

82. Airborne Pollution Exposure Research Laboratory

83. Testing emissions of various smoked tobacco and alternative products Validating methods and equipment to measure airborne pollutants Human studies on smoking behavior, topography, product switching Possible human exposure studies looking at effects of exposure to tobacco smoke or other airborne pollutants Need IRB protocols. Airborne Pollution Exposure Research Laboratory

84. Continuous particle monitors for measuring particulate matter concentration, particle counts, ultrafine particle counts, polycyclic aromatic hydrocarbons, active particle surface area. Continuous monitors for temperature, humidity, carbon monoxide, carbon dioxide, volatile organic compounds. Sampling pumps. Various other compounds can be measured in conjunction with a commercial laboratory. LifeShirt noninvasive, ambulatory, physiological monitoring system for measuring cardiac and respiratory parameters. Airborne Pollution Exposure Research Laboratory Some available equipment:

85. Measuring Exposure to Tobacco Smoke Pollution 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 TSI SidePak AM510 Personal Aerosol Monitor (weight: ~1 lb) This device is a real-time laser photometer with a built-in sampling pump that measures airborne particle mass-concentration

86. Training course at:www.tobaccofreeair.orghttp://vimeo.com/channels/84864

87. U.S.A.

88. U.S.A. Jan 22,2011

89. India

90. WasimMaziak, MD, PhD, Syrian Center for Tobacco Studies and University of Memphis Alan Shihadeh, PhD, American University of Beirut Tom Eissenberg, PhD, Virginia Commonwealth University Rima Nakkash, PhD, American University of Beirut Acknowledgments