Hookah Smoking: Known Health Effects and Associated Substances The - - PowerPoint PPT Presentation

The Triangulum: Tobacco, Marijuana, and E-Cigarettes Thursday, May 26, 2016

Mary Rezk-Hanna, NP, PhD

Hookah Smoking:

Known Health Effects and Associated Substances

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

• > 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

Hookah Smoking

Schematic showing the major components of a Hookah

Head Body Bowl Charcoal Foil Tobacco Hose

Then Now

From Cultural to Social

Prevalence (%)

Source: University of Michigan, 2015 Monitoring the Future Study

HIGH SCHOOL STUDENTS REPORTING CIGARETTE SMOKING

7% 28%

5 10 15 20 25 30

(Past 30 days)

Prevalence (%)

Source: Gilreath et al. J Adolescent Health. 2015;58:181-5

HIGH SCHOOL STUDENTS REPORTING ALTERNATIVE TOBACCO PRODUCT USE

5.7% 9.6% 2.2% 3.6% 10.7%

2 4 6 8 10 12

Smokeless/dip/ chewing tobacco Cigars/cigarillos/ little cigars Cigarettes E-cigarettes Hookah

(Past 30 days)

Source: California Tobacco Survey 2005, 2008

Prevalence (%)

2005 2008

YOUNG ADULTS REPORTING HOOKAH SMOKING

5 10 15 20 25 30

Men Women

(Ever use)

Global Epidemiology

Prevalence (%)

10 20 30 40

Kuwait Jordan Syria West Bank Lebanon Czech Latvia Slovakia Estonia Ukraine Republic Eastern Mediterranean Eastern European

10 20 30 40

Kuwait Jordan Syria West Bank Lebanon Czech Latvia Slovakia Estonia Ukraine

Global Epidemiology

Prevalence (%)

Sinha et al., Indian J Comm Med, 2003; Narain et al. Indian J Med Res. 2011;133:300-7

10 20 30 40

Kuwait Jordan Syria West Bank Lebanon Czech Latvia Slovakia Estonia Ukraine

Global Epidemiology

Prevalence (%)

Sinha et al., Indian J Comm Med, 2003; Narain et al. Indian J Med Res. 2011;133:300-7

Hookah smoking is associated with polysubstance use especially marijuana, cigarettes and alcohol.

Polysubstance Use

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)

• Flavored tobacco product
• Unregulated (May 5th, 2016)
• Accessibility/ affordability
• Aggressive media and marketing
• Understudied
• Reduced harm perception
• Little is known

Hookah Smoking Epidemic

Hookah Flavored Tobacco

Media & Marketing

Media & Marketing

…we’ll just be passing it [ehookah] around & enjoying the smell that the vapor leaves in the air because it smells all fruity & candyish & delicious.”

Wagoner et al. Nicotine Tob Res. 2016 Mar 30. [Epub ahead of print]

“ehookah just sounds like it’s better because if you have an ecig, it’s still a cigarette in a way. Then you have a hookah pen. It’s like hookah, it’s kind of

• cool. It’s better”

Reduced Harm Perception

Rezk-Hanna, Macabasco-O’Connell, Woo. Nurs Res. 2014;63:300-6

“I hate smoking cigarettes because it has a bad taste to it compared to Hookah which is very flavorful” “Hookah is harmless because all the smoke passes through the water filter first and then through fruits” “Hookah will never be addicting because it does not contain nicotine”

Hookah Smoke Exposure

Figure Adapted from: St Helen et al. Cancer Epidemiol Biomarkers Prev. 2014;23:1055-66

Figure Adapted from: Monn et al. Tob Control. 2007;16:390-3.

Particulate Matter Size and Concentration

• f Mainstream Smoke

Hookah Smoke Exposure

Figure Adapted from: Araujo et al. Circ Res. 2008;102:589-96; aZhou et al. Tob Control. 2015;24:193-8; bBrook et al. Circ. 2002;105:1534-6; cMonn 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 (PM2.5) Ultrafine Particulate Matter <0.1µm (UFP)

Hookaha PM2.5:1,180 µg/m3 (real time) Air pollutionb: 150 µg/m3 Hookah UFPc: 74.4x109 µg/m3(mainstream) Cigarette smokec: 9.24x109 µg/m3

1Martinasek et al. Nicotine Tob Res. 2014;16:1014-9; 2Monzer et al. Food and Chemical Tox. 2008;46:2991-5

Hookah Smoke Exposure

Carbon monoxide (CO) Charcoal is responsible for ~90% of the CO produced in mainstream hookah smoke.2

20 40 60 80 100 120 140

Pre-Hookah Post-Hookah CO, ppm

*

CO boost:795 % (n=166)1

Overview of Hookah Studies

(+) CO (+) PM2.5, UFP (+) Nicotine (+) Other toxins Hookah bowl: tobacco Charcoal

Central Aorta Coronary Microcirculation Peripheral Circulation Objective: To determine the net acute effect of hookah smoking on myocardial blood flow, central aorta, and peripheral circulation

Net effect?

Hookah Smoking Chamber

Cedars-Sinai Medical Center Hypertension & Vascular Biology Clinical Research Center

Subject Characteristics (n=28)

115 120 125 130

Pre Post

Hookah Smoking and Myocardial Oxygen Demand (MVO2)

* Indicates P < 0.05

Systolic BP

beats.min-1

Heart Rate

*

MVO2

50 60 70 80 90

Pre Post

*

mmHg

*

2 4 6 8 10

Pre Post

mmHg.beats.min-1.10-4

*

Pre-Hookah

Hookah Smoking and Myocardial Blood Flow

PRE POST

Pre-Hookah Post-Hookah

Post-Hookah

*

PRE POST

*

Unpublished data

Post Pre

Post-Hookah Pre-Hookah

Pre Post Pre Post

Myocardial Blood Flow

*

Rate-Pressure Product

Nelson et al. Am J Cardiol. 2016;inpress

carotid femoral 7.4 7.9 8.4 8.9

Baseline Hookah

*

meter.sec-1

* Indicates P < 0.05

Pre-Hookah Post-Hookah

Hookah Smoking and Central Aorta

Hookah Smoking and Peripheral Circulation

6 8 10 12

1 2 3 4

25 35 45 55

1 2 3 4

Calf Muscle Vascular Resistance

Baseline Hookah 30 Minutes Recovery 60 Minutes Recovery

Skin Vascular Resistance

Baseline Hookah 30 Minutes Recovery 60 Minutes Recovery mmHg/%/min

P=0.11 P=0.10 P=0.003

mmHg/u

Acute Effects Chronic Effects

• Cardiovascular:
• Increased heart rate
• Increased blood pressure
• Respiratory:
• Impaired pulmonary function
• Decreased exercise capacity
• Larynx and voice changes
• Carbon monoxide intoxication
• Cardiovascular:
• Ischemic heart disease
• Respiratory:
• Impaired pulmonary function
• Chronic obstructive lung

disease

• Larynx and voice changes
• 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

• 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

Conclusion

Mary Rezk-Hanna mrezk@ucla.edu

Thank you