Waterpipe tobacco smoking among college students in South Carolina. 13 August 2014 SC TRIG Medical University of South Carolina

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1 Waterpipe tobacco smoking among college students in South Carolina 13 August 2014 SC TRIG Medical University of South Carolina

2 Acknowledgments Frederick Kates, MBA PhD Candidate Dept. of Health Services Policy and Management University of South Carolina James Thrasher, PhD Associate Professor Dept. of Health Promotion, Education and Behavior University of South Carolina Farahnaz Islam, BSc MSPH Candidate Dept. of Epidemiology and Biostatistics University of South Carolina Wasim Maziak, MD, PhD Professor and Chair Dept. of Epidemiology Florida International University This work is supported by the Office of the Vice President for Research at the University of South Carolina (ASPIRE Program)

3 Waterpipe tobacco smoking (WTS) Also known as hookah, shisha, narghileh, arguileh Centuries old form of tobacco consumption native to Middle East and South Asia 1990s commercialization and worldwide spread with introduction of flavoring and mass media

various derivations of tobacco, among other things.

4 WTS in the United States During the 1960s and 1970s, hookah became a popular tool for the consumption of various derivations of tobacco, among other things. A Tale of Two Cities. Mad Men. AMC. 18 Jun Television

WTS among college students 2nd most common form of tobacco use after cigarettes Roughly 1/2 have never smoked cigarettes, suggesting WTS delivers tobacco to millions

5 WTS among college students 2nd most common form of tobacco use after cigarettes Roughly 1/2 have never smoked cigarettes, suggesting WTS delivers tobacco to millions of young adults May facilitate the uptake of cigarettes by increasing the appeal of smoking to young people because of flavoring Shared mouthpieces: TB, hepatitis, herpes

6 Evidence on WTS

7 Regulatory strategies Health warning labels and misleading health claims Internet sales and sales to minors Smoke-free laws Flavoring

8 How popular is waterpipe tobacco smoking? Analyzed trends in Google search queries related to WTS vs. electronic cigarettes Between 2004 and 2013 Australia, Canada, UK, and USA Weekly search volumes were reported as percentages relative to the week with the highest volume of searches

9 National search trends of waterpipe tobacco smoking relative to electronic cigarettes Salloum, Osman, Maziak, & Thrasher, Tobacco Control 2014

10 Online searches were primarily targeted at WTS products for home use, followed by searches for WTS cafés/lounges. Salloum, Osman, Maziak, & Thrasher, Tobacco Control 2014

11 Estimates of ever and current waterpipe tobacco smoking among U.S. adults aged 18 years: National Adult Tobacco Survey Salloum, Thrasher, Kates, & Maziak, under review

12 Adjusted models of factors associated with waterpipe tobacco smoking (ever and current) among U.S. adults aged 18 years Salloum, Thrasher, Kates, & Maziak, under review

13 Percent of U.S. adults who have ever smoked tobacco from a waterpipe by state: National Adult Tobacco Survey, Salloum, Thrasher, Kates, & Maziak, under review

14 Proximity of colleges and universities to commercial WTS establishments in the United States Two maps commercial WTS establishments and colleges/ universities with dorm capacity > 250 students combined using joins and relation function in ArcGIS ArcMap 10.2 used to run proximity analysis for distance from colleges and universities to nearest commercial WTS establishment Colleges and universities color-coded in 2-mile increments based on the distance to the nearest WTS establishment

Commercial WTS establishments in the US List of commercial WTS establishments compiled from: Yellow Pages Hookah-Hookah directory Better Business Bureau (BBB) Hoovers Street addresses

15 Commercial WTS establishments in the US List of commercial WTS establishments compiled from: Yellow Pages Hookah-Hookah directory Better Business Bureau (BBB) Hoovers Street addresses geocoded in ArcGIS with 93% match rate (N = 1,210 locations) Comparison: In 2007, the ALA reported WTS establishments operating in the US using 3 hookah directories, BBB and Hoovers

16 WTS establishments in the US (Count = 1210)

17 Proximity of colleges and universities to WTS establishments ArcGIS 10.2 proximity analysis 1,458 colleges and universities 1,210 WTS establishments 0-2 miles = 369 schools (25%) 2-4 miles =182 schools (12%) 4-6 miles = 81 schools (6%) > 6 miles = 826 schools (57%)

18 Proximity of colleges and universities to WTS establishments

19 Student Survey

20 Participants Ongoing, target enrollment: 350 Total number of waterpipe ever users: 98 Number of waterpipe only users: 65 Dual users of waterpipe and cigarettes: 33 Results from 06/23/14 08/01/14 Inclusion Criteria: Over 18 years Student currently attending/will be attending college in South Carolina Has smoked a waterpipe, even one or two puffs

21 Demographics Gender: female, 39.8%; male 60.2% Age range, y, mean, 24.9 y Distribution by Race: White non-hispanic, 56.1% Black or African American, 16.3% Asian or Pacific Islander, 16.3% Other race, 11.3% 1/3 spend >$500/month excluding room and board expenses Undergraduate, 48.0%; graduate, 49.0%

22 First WTS experience Average age at first experience is 20 years 45.9% first tried it at home or someone else s home and 35.7% first tried it at a café/restaurant/bar 75.5% first tried it with several friends

23 Last WTS experience 52.0% last smoked waterpipe at home or someone else s home, 46.9% at a commercial establishment If last WTS session was at commercial establishment: Average price paid (session): $16.93 (SD, $9.55) 19.6% saw a health warning on building/menu If last WTS session was at home: Average price paid (packet): $5.47 (SD, $6.86) 39.2% saw a health warning label on packet

24 Beliefs about WTS 62.2%, cigarettes are more harmful than waterpipe 86.7%, cigarettes are more addictive than waterpipe 52.0%, cigarettes contain more nicotine than waterpipe

25 Text-based warnings To what extent do the following messages motivate you to think about quitting hookah smoking? Messages Not at All (%) Somewhat (%) Very much (%) WARNING: Hookah smoking is addictive WARNING: Hookah smoke can harm your children WARNING: Hookah smoking causes fatal lung disease WARNING: Hookah smoking causes cancer WARNING: Hookah smoking causes stroke and heart disease WARNING: Hookah smoking during pregnancy can harm your baby WARNING: Hookah smoking can kill you WARNING: Hookah smoke causes fatal lung disease in nonsmokers WARNING: Quitting hookah smoking now greatly reduces serious risks to your health

26 Pictorial warning labels Proportion who reported that the warning label very much motivates them to think about stopping or reducing WTS Images: Nakkash & Khalil, Tobacco Control, 2010

27 Pictorial warning labels Images: Nakkash & Khalil, Tobacco Control, 2010 C is the most popular with 60.2% reporting that it would be very effective to motivate them to stop or reduce WTS D is the least popular with 44.9% reporting that it would not be at all effective to motivate them to stop or reduce WTS

28 Health warning placement The majority of respondents felt that a warning label on the mouthpiece would be most noticeable

29 Discrete choice experiment Basic premise a good or service can be defined by a set of attributes Participants are given various sets of hypothetical situations in which they must choose among various sets of alternatives In theory, they should choose the alternative they find most preferable Choices may also demonstrate which attributes they deem most important A monetary component may be added in order to determine an individual s willingness to pay

30 Waterpipe Lounge Menu Full factorial design 1 x 4-level attribute: flavor 2 x 3-level attributes: price, nicotine content Fractional factorial design (SAS 9.3) 18 distinct choice sets (2 blocks of 9) Respondents randomly assigned to 1 block either with or w/o HWL

31 Thank you! Ramzi G. Salloum, PhD Assistant Professor Department of Health Services Policy & Management Arnold School of Public Health University of South Carolina (803)

Final Frequencies (n=1,002) NATIONAL ONLINE SURVEY The Mellman Group, Inc. June 19, 2013

Final Frequencies (n=1,002) NATIONAL ONLINE SURVEY The Mellman Group, Inc. June 19, 2013 Are you female or male? male... 48 female... 52 In which state are you registered to vote? [PROVIDE LIST OF STATES