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

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