cancer from the middle east mjt (2)

Mark J. Travers, PhD

CANCER FROM THE MIDDLE EAST: COMING SOON TO A

COLLEGE CAMPUS NEAR YOU

EGYPTIAN REVOLUTION 2011

EGYPTIAN REVOLUTION: LEADERS

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

EGYPTIAN REVOLUTION: LEADERS

Ahmad Maher: Cofounded the April 6 Student Movement on Facebook

BEIRUT, LEBANON, WATERPIPE CAFE

DISCLAIMER #1: No researchers were harmed in the making of this presentation

DISCLAIMER #2: I didn’t inhale

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)

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, Coff ee, Cola, Frappucinno, Honey, Jasmine, Licorice, Mint, Molasses, Orange soda, Pistachio, Red tea, Root beer, Rose, Vanilla.

Alcohol: Cocktail, Margarita, Pina colada.Tangiers F-line (caff einated): Apple, Cocoa, Kashmir,

Rootbeer.

Hookah-shisha.com

5 VALENTINES DAY SHISHAS FOR LOVERS

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?

WATERPIPE SMOKING TOPOGRAPHY

Table 1: Mean puff topography for waterpipe users and cigarette smokers.

Topography variable N = 201 N = 522 N = 313 N = 564

Puff number 178 171 10.0 12.7Puff volume (ml) 590 530 51.0 48.6Puff duration (s) 2.8 2.6 1.4 1.5Interpuff interval (s) 15.2 15.5 30.7 21.31Katurji and Shihadeh, 2007; 2Shihadeh et al., 2004; 3Breland, 2005; 4Djordjevic et al., 2000

Waterpipe Cigarette

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)

MACHINE SMOKE CONTENT USING REALISTIC PUFF PARAMETERS FOR SINGLE WATERPIPE AND CIGARETTE

Toxicant/mg Waterpipe Cigarette Ratio

Nicotine 2.94 1.74 1.7

CO 145 22.3 6.5

Tar 802 17.3 46.36

Cobb C, Ward KD, Maziak W, et al. Am J Health Behavior, in press

WP session vs Cig “tar”: Many times the PAH yield

Waterpipe data from Sepetdjian et al., 2008; cigarette data from Gmeiner et al., 1977

Known/suspected carcinogen WP (ng/session)Cig (ng/cig)RatioNaphthalene 2130 236 9.0Acenaphthylene 180 50.4 3.6Acenaphthene 487 25.3 19.2Fluorene 437 119 3.7Phenanthrene 2650 110 24.1Anthracene 493 38.1 12.9Fluoranthene 2380 46.2 51.5Pyrene 2510 33.2 75.6

Chrysene + Benz[a]anthracene 677 35 19.3Benzo fluoranthenes 370 10.1 36.6Benzo[a]pyrene 307 7.9 38.9Benzo[g,h,i]perlyene 140 2.5 56.0Di-benzo[a,h]anthracene 147 0.6 245.0Indeno[1,2,3-cd]pyrene 183 3.5 52.3

Waterpipe Cigarette Ratiomg/episodemg/

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

WP session vs Cig: aldehydes: Many times the yield

Data from Al Rashidi et al., 2008.

Compound

WHAT IS IN THE SMOKE: HEAVY METALS.

Heavy metals in waterpipe and cigarette smoke

Metal (ng) Waterpipe1 Cigarette2 RatioArsenic 165 40-120 1.4Beryllium 65 300 0.2Chromium 1340 4-70 19.1Cobalt 70 0.13-0.2 350.0Lead 6870 34-85 80.8Nickel 990 ND-600 1.71Shihadeh, 2003;

2Hoffman and Hoffman, 2000.

Shafagoj and Mohammed, 2002; Shafagoj et al., 2002Participants = 14 Jordanian men.

Expired air CO Plasma nicotine

WHAT IS IN WATERPIPE SMOKERS: CARBON MONOXIDE AND NICOTINE

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

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

WHAT IS IN WATERPIPE SMOKE? SIDESTREAM SMOKE

0 10 20 30 40 50 60 700

0.5

1

1.5

2

2.5

3

3.5

4

Typical total (5.6-560 nm) particle concentration in chamber versus time

for waterpipe and cigarette

time (min)

N (

10

6/c

c) charcoal added

cigarette

waterpipe

Waterpipe removed

Daher, N., et al. (2010). Atmos Environ, 44(1), 8-14.

EXPOSURE OF NON-SMOKERS

0

100

200

300

400

500

World (932) Syria (40) Smoke free(280)

Ireland (25)

Mea

n PM

2.5

(µg/

m3 )

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. Inhal Toxicol. 2008.

POPULATION SMOKING TRENDS, SYRIA (N=2038, 18-65 YRS, ALEPPO, 2004)

Cigarette Waterpipe0

10

20

30

40

50

32

15.7

47.5

12.1

38.8

6.8

18-29 yrs 30-45 yrs 46-65 yrs

Pre

vale

nce

%

BEGINNING OF THE WATERPIPE EPIDEMIC, SYRIA

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

SMOKING, (13-15 YRS), EMR, GYTS (N > 90,000)

18.8

3.2

9.911.3

15.6

6.7

0

2

4

6

8

10

12

14

16

18

20

Cigarette Other (watepipe) Any

% c

urr

en

t u

se

rs

Boys Girls

Warren CW, et al. Lancet, 2006.

CIG & WATERPIPE SMOKING, 13 YR OLD STUDENTS JORDAN (N=

1781)

Mzayek F, Maziak W, et al., J Adolescent Health (submitted)

SMOKING, MEDICAL STUDENTS (DAMASCUS)

Almerie, Maziak et al. Int J Tuberc Lung Dis 2008.

WATERPIPE, (11-15 YRS), ESTONIA, 2006 (N = 13826)

Pärna et al. BMC Public Health 2008 8:392

WATERPIPE, UNIV OF BIRMINGHAM (AGE 20.2 YRS, N 937)

Jackson and Aveyard. BMC Public Health 2008 8:174

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?

HIGH SCHOOL USE OF TOBACCO (AGE 14, ARIZONA 2005)

Primack, Eissenberg et al., Pediatrics 2009;123:e282-e288

WATERPIPE, ARAB-AMERICAN HIGH SCHOOL STUDENT (N=1313, AGE 15.6)

Weglicki LS et al., Am J Prev Med, 2008

WATERPIPE: COLLEGE STUDENTS IN THE U.S.

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.

20.319.515.3

41.4

-5

5

15

25

35

45

JHU (N=411) VCU (N=744)

% p

reva

len

ce o

f pa

st 3

0 d

ays

use

Waterpipe Cigarettes

WATERPIPE USE IN COLLEGES IN THE U.S.

LifetimePast 30-day

A BNorth America

Baltimore, MDN = 411

Richmond, VAN = 744

Pittsburgh, PAN = 647

Per

cent

(%

)

Southwest Asia

0

20

40

60

80

100

Aleppo, SyriaN = 587

Beirut, LebanonN = 416

LifetimePast 30-day

A BNorth America

Baltimore, MDN = 411

Richmond, VAN = 744

Pittsburgh, PAN = 647

Per

cent

(%

)

Southwest Asia

0

20

40

60

80

100

Aleppo, SyriaN = 587

Beirut, LebanonN = 416

Cobb, Ward, Maziak, & Eissenberg. Waterpipe : An Emerging Health Crisis in the United States: 2009.

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, Port land, Oregon.

Waterpipe use 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

1. I enjoy the taste2. It’s a good way to socialize with friends3. It helps me to feel relaxed4. I enjoy the smell5. It helps me to feel less stressed6. It’s something to do when I feel bored7. Waterpipe smoke is less harsh than cigarette smoke8. I like trying things that are new, diff erent, or “hip”9. It helps me not smoke cigarettes10. 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.

SOCIAL DIMENSION OF WATERPIPE USE

0

10

20

30

40

50

60

70

80

90

Beginners Established

%

AloneWith friendsWith family

Asfar T, Maziak W, et al. BMC Public Health 2005.

• Maassel’s aromatic mild smoke, wide variety and availability,

simplifi cation of the waterpipe preparation process were

perhaps critical for the renewed appeal of the waterpipe

• The internet & other transnational media (e.g. satellite

TV) lead to commercializing & glamorizing waterpipe,

particularly among youths.

• The reduced-harm perception , based on the water fi ltering

myth.

• The thriving café culture.

• All these factors have perhaps created conditions for a

perfect storm that sparked the global waterpipe epidemic.

FACTORS BEHIND THE CURRENT WATERPIPE PANDEMIC

• Particularly popular among young adults and teens in SW Asia:

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

- 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).

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

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

• Global spread suggested by published data from: Brazil, Canada, Germany, Korea, Ukraine, U.S.

WHAT ABOUT WATERPIPE TOBACCO/NICOTINE DEPENDENCE?

Waterpipe users are exposed to nicotine (N = 37).

Data from Blank et al., Drug Alcohol Dep, 2011.

WP-delivered nicotine is physiologically active.

Data from Blank et al., Drug Alcohol Dep, 2011.

A second study: waterpipe relative to a cigarette.

Plasma nicotine (N=31)

0

2

4

6

8

10

12

14

0 5 15 30 45

Time relative to smoking onset

ng

/ml

*

C WP

AUC418 ng/ml

243 ng/ml

Data from Eissenberg & Shihadeh, 2010.

cigarettewaterpipe

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.

• Random sample of 268 Syrian waterpipe smokers.

• 43% reported more frequent use than when they started

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

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

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

• 59% made an unsuccessful quit attempt in the past year (78% of daily smokers).

From Maziak et al., 2004.

EMPIRICAL EVIDENCE: DRUG-SEEKING AND DIFF. QUITTING?

Maziak et al., 2006 (61 Syrian waterpipe smokers, overnight abstinence; CO increased 31.5 ppm)

0

10

20

30

40

100

Pre Post

Time (relative to waterpipe smoking)

Sco

reUrgeRestlessnessCraving

EMPIRICAL EVIDENCE: ABSTINENCE-INDUCED WITHDRAWAL?

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 fi rst

experimentation with tobacco through a waterpipe

precedes that with cigarettes.

IS WATERPIPE USE A “GATEWAY” TO CIGARETTES?

WHERE IS THE BURDEN OF THE TOBACCO EPIDEMIC INCREASING THE FASTEST, 1990-

2020

India+1400%

Middle Eastern Crescent +700%

Latin American and Caribbean+300%

Sub-Saharan Africa+200%

Other Asia and Islands+250%

China+175%

Formerly Socialist Economies of Europe+120%

Established Market Economies+18%

Oral Stomach Colon Rectum Liver Gallbladder Larynx Lung Bladder Prostate Breast Ovary Cervix Thyroid NHL

Leukemia Brain Other

Saudi Arabia

Yemen

Oman

Qatar

Bahrain

Kuwait

Iraq

UAE

Egypt

Palestine

Algeria

Tunisia

Libya

Morocco

Lebanon

Jordan

Syria

Mauritania

Sudan

Saudi Arabia

Yemen

Oman

Qatar

Bahrain

Kuwait

Iraq

UAE

Egypt

Palestine

Algeria

Tunisia

Libya

Morocco

Lebanon

Jordan

Syria

Mauritania

Sudan

Males Females

PERCENTAGE DATA FOR THE FIVE MOST PREVALENT CANCERS IN COUNTRIES OF THE

MIDDLE EAST

4 STAGES OF THE SMOKING EPIDEMIC

REAR VIEW MIRROR- TRENDS IN CIGARETTE CONSUMPTION AND LUNG CANCER MORTALITY IN THE

US

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 20000

1000

2000

3000

4000

5000

0

20

40

60

80

100

Year

Nu

mb

er o

f ci

gar

ette

s p

er c

apit

a

Lu

ng

ca

nc

er

de

ath

ra

te p

er

10

0,0

00

*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.

Per capita cigarette consumption

Lung cancerdeath rates/Men

Lung cancerdeath ratesWomen

1964

CUMULATIVE PUBMED REFERENCES BY YEAR FOR “CIGARETTE”

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

Cigarette

CUMULATIVE PUBMED REFERENCES BY YEAR FOR “WATERPIPE, HOOKAH, SHISHA, NARGHILE, HUBBLE

BUBBLE, ETC.””

2011

2009

2007

2005

2003

2001

1999

1997

1995

1993

1991

1989

1987

1985

1983

1981

1979

1977

1975

1973

1971

1969

1967

1965

1963

1961

1950

-195

90

50

100

150

200

250

300

Waterpipe and related terms

TOBACCO CONTROL POLICY

Framework Convention on Tobacco Control (FCTC)Not clear what the eff ect of FCTC policies will be on

cigarette and in particular waterpipe use in the EMRWaterpipe use generally ignored or given little

attention despite it being as important as cigarettes in EMR

CIGARETTE

Cigarette

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 eff ect 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

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 eff orts.

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. . .

Proposed warning labels for Narghile tobacco and accessories

Courtesy of Rima Nakkash, American University of Beirut

WHAT IS THE PUBLIC HEALTH IMPACT OF INNOVATION? HARM

REDUCTION?


REDUCTION?“All Natural” coconut charcoal


REDUCTION?


REDUCTION?

Typical Lebanese, no vent Typical Egyptian, vented


REDUCTION?

AIRBORNE POLLUTION EXPOSURE RESEARCH LABORATORY

Gratwick Basic Science Building 4936

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 eff ects of exposure to tobacco smoke or other airborne pollutants

Need IRB protocols.


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.


Some available equipment:

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

TRAINING COURSE AT:WWW.TOBACCOFREEAIR.ORG

HTTP: / /VIMEO.COM/CHANNELS/84864

http://www.tobaccofreeair.org/

http://www.tobaccofreeair.org/

http://vimeo.com/channels/84864

http://vimeo.com/channels/84864

U.S.A.

U.S.A.Jan 22,2011

Wasim Maziak, MD, PhD, Syrian Center for Tobacco Studies and University of Memphis

Alan Shihadeh, PhD, American University of BeirutTom Eissenberg, PhD, Virginia Commonwealth

UniversityRima Nakkash, PhD, American University of Beirut

ACKNOWLEDGMENTS

cancer from the middle east mjt (2)

Documents

alfayez et

alsafi et

alkutabi et

waterpipe smokers

waterpipe epidemic

single waterpipe

waterpipe users

waterpipe cafedisclaimer