Hookah Smoking: Known Health Effects and Associated Substances The Triangulum: Tobacco, Marijuana, and E-Cigarettes Thursday, May 26, 2016 Mary Rezk-Hanna, NP, PhD
Acknowledgments Ronald Victor, MD (Cedars-Sinai Heart Institute) Linda Sarna, RN, PhD (UCLA) Lynn Doering (UCLA) Robert Elashoff, PhD (UCLA) Donald Tashkin, MD (UCLA) Neal Benowitz, MD (UCSF) Wendie Robbins (UCLA) Funding: #22XT-0017, #23DT-0102 Tobacco-Related Disease Research Program
Hookah Smoking > 500 year-old form of tobacco use Unsubstantiated belief “smoke should be first passed through water so that it would be rendered harmless.” i.e. waterpipe, gouza, narghile, or shisha
Head Charcoal Foil Body Tobacco Bowl Hose Schematic showing the major components of a Hookah
From Cultural to Social Then Now
HIGH SCHOOL STUDENTS REPORTING CIGARETTE SMOKING 28% 30 (Past 30 days) 25 Prevalence (%) 20 15 10 7% 5 0 Source: University of Michigan, 2015 Monitoring the Future Study
HIGH SCHOOL STUDENTS REPORTING ALTERNATIVE TOBACCO PRODUCT USE (Past 30 days) 12 10.7% 9.6% 10 Prevalence (%) 8 5.7% 6 3.6% 4 2.2% 2 0 Smokeless/dip/ Cigars/cigarillos/ Cigarettes E-cigarettes Hookah chewing tobacco little cigars Source: Gilreath et al. J Adolescent Health . 2015;58:181-5
YOUNG ADULTS REPORTING HOOKAH SMOKING (Ever use) 30 2005 25 Prevalence (%) 2008 20 15 10 5 0 Men Women Source: California Tobacco Survey 2005, 2008
Global Epidemiology 40 30 Prevalence (%) 20 10 0 Kuwait Jordan Syria West Lebanon Czech Latvia Slovakia Estonia Ukraine Bank Republic Eastern Mediterranean Eastern European
Global Epidemiology 40 Prevalence (%) 30 20 10 0 Kuwait Jordan Syria West Lebanon Czech Latvia Slovakia Estonia Ukraine Bank Sinha et al., Indian J Comm Med , 2003; Narain et al. Indian J Med Res . 2011;133:300-7
Global Epidemiology 40 Prevalence (%) 30 20 10 0 Kuwait Jordan Syria West Lebanon Czech Latvia Slovakia Estonia Ukraine Bank Sinha et al., Indian J Comm Med , 2003; Narain et al. Indian J Med Res . 2011;133:300-7
Polysubstance Use Hookah smoking is associated with polysubstance use especially marijuana, cigarettes and alcohol. Fielder, Carey, Carey. 2013. Addict Behav ;38:2729-35. Brockman et al. 2012. BMJ Open; 2:e001709.
Polysubstance Use Marijuana and cigar use: significant predictors to hookah smoking (Shepardson, Hustad. 2016. Nicotine Tob Res ;18:763-9. Haider et al. 2015. Drug Alcohol Depend ;1:359-63; Villanti et al. 2015. Am J Prev Med ;48:742-6) In 3,418 college students, Hookah/marijuana/ LCC co- users : Past 4 months: 11.3% Past 30 days: 9.1% (Haardorfer et al. 2016. Addict Behav ; 59:58- 64)
Hookah Smoking Epidemic Flavored tobacco product Unregulated (May 5 th , 2016) Accessibility/ affordability Aggressive media and marketing Understudied Reduced harm perception Little is known
Hookah Flavored Tobacco
Media & Marketing
Media & Marketing
“ ehookah just sounds like … we ’ ll just be passing it it ’ s better because if you [ehookah] around & have an ecig, it ’ s still a enjoying the smell that the cigarette in a way. Then vapor leaves in the air you have a hookah pen. because it smells all fruity It ’ s like hookah, it ’ s kind of & candyish & delicious . ” cool . It ’ s better ” Wagoner et al. Nicotine Tob Res . 2016 Mar 30. [Epub ahead of print]
Reduced Harm Perception “ Hookah is harmless “ Hookah will never be because all the smoke passes addicting because it through the water filter first and then through fruits ” does not contain nicotine ” “I hate smoking cigarettes because it has a bad taste to it compared to Hookah which is very flavorful ” Rezk-Hanna, Macabasco- O’Connell, W oo. Nurs Res . 2014;63:300-6
Hookah Smoke Exposure Figure Adapted from: St Helen et al. Cancer Epidemiol Biomarkers Prev . 2014;23:1055-66
Hookah Smoke Exposure Particulate Matter Size and Concentration of Mainstream Smoke Figure Adapted from: Monn et al. Tob Control . 2007;16:390-3.
Hookah Smoke Exposure Particulate matter exposure: modifiable risk factor that contributes to cardiovascular morbidity and mortality Fine Particulate Matter <2.5µm Ultrafine Particulate Matter <0.1µm (PM 2.5 ) (UFP) Hookah a PM 2.5 :1,180 µg/m 3 (real time) Hookah UFP c : 74.4x10 9 µg/m 3 (mainstream) Air pollution b : 150 µg/m 3 Cigarette smoke c : 9.24x10 9 µg/m 3 Figure Adapted from: Araujo et al. Circ Res . 2008;102:589-96; a Zhou et al. Tob Control . 2015;24:193-8; b Brook et al. Circ . 2002;105:1534-6; c Monn et al. Tob Control . 2007;16:390-3
Hookah Smoke Exposure Carbon monoxide (CO) 140 CO * 120 boost:795 100 % (n=166) 1 CO, ppm 80 60 40 20 0 Pre-Hookah Post-Hookah Charcoal is responsible for ~90% of the CO produced in mainstream hookah smoke . 2 1 Martinasek et al. Nicotine Tob Res . 2014;16:1014-9; 2 Monzer et al. Food and Chemical Tox . 2008;46:2991-5
Overview of Hookah Studies Coronary Charcoal Microcirculation (+) CO (+) PM 2.5 , UFP Net Central effect? Aorta (+) Nicotine (+) Other toxins Peripheral Circulation Hookah bowl: tobacco Objective: To determine the net acute effect of hookah smoking on myocardial blood flow, central aorta, and peripheral circulation
Hookah Smoking Chamber Cedars-Sinai Medical Center Hypertension & Vascular Biology Clinical Research Center
Subject Characteristics (n=28)
Hookah Smoking and * Myocardial Oxygen Demand (MVO 2 ) Heart Rate Systolic BP MVO 2 90 130 10 * * mmHg.beats.min -1. 10 -4 * 8 80 beats.min -1 125 mmHg 6 70 4 120 60 2 50 115 0 Pre Post Pre Post Pre Post * Indicates P < 0.05
Hookah Smoking and Myocardial Blood Flow Pre-Hookah Pre Post-Hookah Post Myocardial Blood Rate-Pressure Flow Product * * * Pre-Hookah Pre-Hookah Post-Hookah Post-Hookah Pre Post Pre Post PRE POST PRE POST Unpublished data Nelson et al. Am J Cardiol . 2016;inpress
Hookah Smoking and Central Aorta 8.9 * carotid meter.sec -1 8.4 7.9 femoral 7.4 Pre-Hookah Post-Hookah Baseline Hookah * Indicates P < 0.05
Hookah Smoking and Peripheral Circulation Skin Vascular Resistance Calf Muscle Vascular Resistance P=0.11 P=0.10 55 12 P=0.003 mmHg/%/min 45 mmHg/u 10 35 8 6 25 Baseline Hookah 30 Minutes 60 Minutes Baseline Hookah 30 Minutes 60 Minutes 1 2 3 4 1 2 3 4 Recovery Recovery Recovery Recovery
Acute Effects Chronic Effects - Cardiovascular: - Cardiovascular: - Ischemic heart disease - Increased heart rate - Respiratory: - Increased blood pressure - Respiratory: - Impaired pulmonary function - Impaired pulmonary function - Chronic obstructive lung - Decreased exercise capacity disease - Larynx and voice changes - Larynx and voice changes - Carbon monoxide intoxication - Cancer: - Lung - Esophageal - Gastric - Low birth weight - Periodontal disease - Lower bone density, high fracture risk Figure Adapted from: El-Zaatari et al., Tob Control, 2015
Conclusion • Advocate for more research: extent to which Hookah smoking negatively affects human health is not well known • Policy regulation: flavored hookah tobacco, charcoal and water • Dissemination of findings to the public, particularly to adolescents and young adults
Thank you Mary Rezk-Hanna mrezk@ucla.edu
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