Water-Pipe Among North American Youths

WHAT’S KNOWN ON THIS SUBJECT: Water-pipe smoking has AUTHORS: Erika Dugas, MSc,a Miche`le Tremblay, MD,b increased recently in North America and . Because of its Nancy C. P. Low, MD, MSc,c Daniel Cournoyer, MSc,a and potential impact on life-threatening conditions and Jennifer O’Loughlin, PhDa,b,d dependence and because of the lack of knowledge about its aUniversity of Montreal Hospital Research Center, Montreal, health effects, water-pipe smoking may represent a public health Quebec, Canada; bNational Institute of Public Health of Quebec, c threat. Montreal, Quebec, Canada; Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, Quebec, Canada; and dDepartment of Social and Preventive Medicine, Faculty of WHAT THIS STUDY ADDS: This study describes the Medicine, University of Montreal, Montreal, Quebec, Canada sociodemographic characteristics of water-pipe users and KEY WORDS compares the use of other psychoactive substances between water-pipe, , smoking, youth, correlates, substance use users and nonusers. Evidence-based public health policies may ABBREVIATION be required to equip the public to make informed decisions about NDIT—Nicotine Dependence in Teens water-pipe use. www.pediatrics.org/cgi/doi/10.1542/peds.2009-2335 doi:10.1542/peds.2009-2335 Accepted for publication Feb 5, 2010 Address correspondence to Jennifer O’Loughlin, PhD, University of Montreal, Department of Social and Preventive Medicine, 3875 abstract St Urbain, Montreal, Quebec H2W 1V1, Canada. E-mail: OBJECTIVES: The objectives of this analysis were to identify the socio- [email protected] demographic characteristics of water-pipe users in a North American PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). context and to describe concurrent psychoactive substance use. Copyright © 2010 by the American Academy of Pediatrics METHODS: Data on sociodemographic characteristics, water-pipe FINANCIAL DISCLOSURE: The authors have indicated they have smoking, and use of other psychoactive substances were collected in no financial relationships relevant to this article to disclose. 2007 through mailed self-report questionnaires completed by 871 young adults, 18 to 24 years of age, who were participating in the Nicotine Dependence in Teens Study, a longitudinal investigation of the natural history of nicotine dependence among adolescents in Mon- treal, Canada. Independent sociodemographic correlates of water-pipe use were identified in multivariate logistic regression analyses. RESULTS: Previous-year water-pipe use was reported by 23% of par- ticipants. Younger age, male gender, speaking English, not living with parents, and higher household income independently increased the odds of water-pipe use. Water-pipe use was markedly higher among participants who had smoked , had used other tobacco prod- ucts, had drunk alcohol, had engaged in binge drinking, had smoked marijuana, or had used other illicit drugs in the previous year. CONCLUSIONS: Water-pipe users may represent an advantaged group of young people with the leisure time, resources, and opportunity to use water-pipes. Evidence-based public health and policy interventions are required to equip the public to make informed decisions about water-pipe use. Pediatrics 2010;125:1184–1189

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As the prevalence of smoking is equivalent to smoking 100 cigarettes home (French, English, or other), cur- decreases in North America, water- in a 200-puff session.18 rently in school, living with parents, pipe smoking is becoming increasingly There are few studies on the frequency annual household income (below popular, especially among youths.1–5 and determinants of water-pipe use $30 000, $30 000–99 000, $100 000 or Also known as , shisha, goza, outside the Middle East.1 In the United above, or missing data), white race, narghile, and hubble bubble,6 water- States, previous-month use propor- and currently employed. Frequency of pipe smoking is a centuries-old tradi- tions ranged between 9% and 20% previous-year water-pipe use was tion in Arabic societies6,7 that involves among college students.2,3,19 In the measured with the following question: smoking tobacco by using an upright 2006 Canadian Youth Smoking Sur- “In the past 12 months, how often did device with a small platform where to- vey,20 7% of adolescents in grades 7 to you use a water-pipe (hubble bubble, bacco is burned, a metal body, a base 12 reported ever use and 3% reported nargile´, or shisha)?” Response choices half-filled with water, and a hose with a use in the previous 30 days. In the 2006 included never, less than once per mouthpiece for inhaling.3,6,8 The con- Canadian Tobacco Use Monitoring Sur- month, 1 to 3 times per month, 1 to 6 tent and packaging of water-pipe to- vey,21 5% of male participants and 2% times per week, and every day. For Ն bacco sold on the market are not cur- of female participants 15 years of multivariate analyses, participants rently regulated by the Canadian Food age, and 8% of participants 15 to 24 were grouped according to whether or Inspection Agency or the US Food and years of age had ever used a water- not they had used a water-pipe in the pipe. Several US studies report that Drug Administration.8–10 previous year. rates of concurrent psychoactive sub- Little is known about the addictive na- Previous-year cigarette smoking was stance use are high among water-pipe measured as follows: “Check the one ture or health risks of water-pipe 1,22 users. The aims of the current anal- box that describes you best . . . I have smoking, but it may be at least as ysis were to identify the sociodemo- smoked cigarettes but not at all in the harmful as cigarette smoking. Similar graphic characteristics of water-pipe past 12 months; I smoked cigarettes to cigarette smoke, water-pipe smoke users in a North American context and once or a couple of times in the past 12 contains harmful constituents, includ- to describe concurrent psychoactive months; I smoke cigarettes once or a ing nicotine,11 carbon monoxide,12,13 substance use. couple of times each month; I smoke and carcinogens.14 In fact, water-pipe cigarettes once or a couple of times smoke may contain greater amounts METHODS each week; or I smoke cigarettes every of tar and heavy metals, including co- Data Source day.”24 Use of other psychoactive sub- balt, chromium, and lead, than ciga- Data were drawn from the Nicotine De- stances was measured with the fol- rette smoke.15 Water-pipe use has pendence in Teens (NDIT) Study, a pro- lowing question: “In the past 12 been linked to , heart spective cohort investigation of 1293 months, how often did you . . . (1) disease, infectious diseases, and students recruited in 1999–2000 from smoke cigars, (2) smoke a pipe, (3) pregnancy-related complications,6,8 al- all grade 7 classes in a convenience use bidis (a tobacco product from In- though the health risks are likely influ- sample of 10 secondary schools in dia), (4) use chewing tobacco, (5) enced by the quantity and type of Montreal, Canada.23 The present analy- use snuff, (6) drink alcoholic bever- tobacco used, the duration and fre- sis uses data collected through ages (beer, wine, or liquor), (7) drink quency of water-pipe use by the mailed, self-report questionnaires in 5 or more alcoholic beverages on smoker, the volume of smoke inhaled, 2007–2008, when participants were 18 one occasion (ie, binge drinking), (8) and the burn temperature.16 Estimates to 24 years of age. Participants pro- use marijuana, , or hashish, of the equivalence between cigarette vided written informed consent in this (9) use cocaine, (10) use speed (am- and water-pipe smoking are highly most recent follow-up evaluation. The phetamines), (11) use ecstasy (3,4- variable and depend on how equiva- study was approved by the research methylenedioxymethamphetamine) lence is measured. Neergaard et al17 ethics committee of the University of or other similar drugs, (12) use hallu- reported that a single water-pipe ses- Montreal Hospital Research Center cinogens (, lysergic acid sion might be equivalent to smoking 2 (CRCHUM). diethylamide [acid], or mushrooms), cigarettes for a nondaily water-pipe (13) use inhalants (glue or gasoline), user or 10 cigarettes for a daily water- Study Variables (14) use heroin (smack or junk), and pipe user. A World Health Organization Sociodemographic data included data (15) use another illicit drug (use of il- report suggested that water-pipe use on age, gender, language spoken at licit drugs)?” Response choices in-

PEDIATRICS Volume 125, Number 6, June 2010 1185 Downloaded from www.aappublications.org/news by guest on September 24, 2021 cluded never, less than once per TABLE 1 Previous-Year Water-pipe Use According to Selected Sociodemographic Characteristics month, 1 to 3 times per month, 1 to 6 na Previous-Year Adjusted Odds Ratio (95% times per week, and every day. Be- Water-pipe Use, % Confidence Interval)b cause of low frequency, we grouped ci- Age 0.8 (0.6–1.0)c 18–19 y 245 24.9 gars, pipe, bidis, chewing tobacco, and 20 y 483 24.0 snuff into a single variable termed 21–24 y 143 18.9 “other tobacco products.” Participants Gender Female 471 21.2 Reference were categorized as answering either Male 400 26.0 1.3 (1.0–1.9) yes (ie, used Ն1 of these tobacco prod- Language ucts in the previous year) or no (ie, did French 279 18.6 Reference not use any of these tobacco products English 460 27.0 1.7 (1.1–2.4) Other 129 20.9 1.2 (0.7–2.1) in the previous year). Similarly, co- Lives with parents caine, speed, ecstasy, hallucinogens, Yes 667 22.5 Reference inhalants, heroin, and other illicit No 200 27.0 1.8 (1.2–2.6) White drugs were grouped into a single vari- No 157 19.1 Reference able termed “other illicit drugs.” Yes 712 24.3 1.4 (0.9–2.2) Annual household income, CAN$ We created the indicator of number Ͻ30 000 272 18.4 Reference of other substances as the arith- 30 000–99 000 236 21.6 1.3 (0.8–2.0) metic sum of positive responses for Ն100 000 167 29.9 1.8 (1.1–2.9) Missing data 196 27.0 1.7 (1.1–2.6) previous-year use of cigarettes, other Currently in school tobacco products, marijuana, other il- No 278 19.8 Reference licit drugs, and binge drinking. Use of Yes 593 25.1 1.2 (0.8–1.8) alcohol was excluded because of its Employed No 191 27.2 Reference high prevalence and overlap with Yes 680 22.4 0.8 (0.6–1.2) binge drinking. Values for the number a Totals differ because of missing data. of other substances ranged between 0 b Odds ratios were adjusted for all other variables in the table. c Age was used as a continuous variable in the multivariate regression analysis. and 5 (mean Ϯ SD: 2.2 Ϯ 1.5; median: 2.0). pipe use were missing for 7 partici- water-pipe users, compared with Data Analysis pants; therefore, the analytic sample 1.9 Ϯ 1.4 among nonusers. Compared Descriptive statistics were computed included 871 participants. Participants with nonusers, markedly higher pro- to describe water-pipe use according were 18 to 24 years of age (mean Ϯ SD: portions of water-pipe users reported to sociodemographic characteristics 20 Ϯ 1 years), and 46% were male. using each of the psychoactive sub- and concurrent psychoactive sub- A total of 204 participants (23%) re- stances investigated (Table 2). Virtu- stance use. Adjusted odds ratios and ported previous-year water-pipe use. ally all water-pipe users drank alcohol 95% confidence intervals for potential Among water-pipe users, 78% smoked and 92% reported binge drinking. The sociodemographic correlates of water-pipes less than once per month, largest difference between groups water-pipe use were obtained in multi- 19% smoked 1 to 3 times per month, was in marijuana use; 74% of water- variate logistic regression analyses. 3% smoked 1 to 6 times per week, and pipe users reported marijuana use, All analyses were conducted by using 0% smoked every day. Younger age, compared with 35% of nonusers. Table SAS/STAT 9.1 (SAS Institute, Cary, NC). male gender, speaking English, not liv- 3 shows that participants who had ing with parents, and higher house- used other psychoactive substances in RESULTS hold income each independently in- the previous year were markedly more Eighty-five of the original 1293 NDIT creased the odds of water-pipe use likely to report previous-year water- Study participants were either lost to (Table 1). pipe use. follow-up monitoring or refused to Use of other psychoactive substances participate after secondary school. investigated were relatively high in DISCUSSION Among 1208 participants available for this sample (Table 2). The mean Ϯ SD In this study, 23% of young adults had follow-up evaluation, 878 (73%) com- number of other substances used in used a water-pipe in the previous year, pleted questionnaires. Data on water- the previous year was 3.2 Ϯ 1.3 among a prevalence estimate almost 3 times

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TABLE 2 Use of Other Psychoactive Substances in Previous Year According to Previous-Year Water-pipe Use Previous-Year n Use of Other Psychoactive Substances in Previous Year, % Water-pipe Use Cigarettes Other Tobacco Alcohol Binge Drinking Marijuana, Cannabis, Other Illicit Productsa or Hashish Drugsb Total 871 47 36 91 77 44 16 No 667 41 30 89 72 35 11 Yes 204 67 55 98 92 74 33 P for differencec Ͻ.0001 Ͻ.0001 Ͻ.0001 Ͻ.0001 Ͻ.0001 Ͻ.0001 a Includes cigars, pipe, bidis, chewing tobacco, and snuff. b Includes cocaine, speed, ecstasy, hallucinogens, inhalants, heroin, and other. c P values were obtained from Pearson ␹2 tests.

TABLE 3 Previous-Year Water-pipe Use According to Use of Other Psychoactive Substances in sorbed in the “filtration” process, the Previous Year concentrations of toxic substances are a b Use of Other Psychoactive n Previous-Year Water-pipe P for Difference not reduced sufficiently to reduce neg- Substances in Previous Year Use, % ative health effects.10 (4) Fruits added Cigarettes Yes 409 33.5 Ͻ.0001 to flavored tobacco makes water-pipe No 461 14.5 a healthy choice. In c Other tobacco products fact, fruit flavors mask the tobacco Yes 312 35.9 Ͻ.0001 No 559 16.5 taste and cannot be viewed as a Alcohol healthy food intake/choice. Yes 790 25.3 Ͻ.0001 No 80 5.0 Our results on the sociodemographic Binge drinking correlates of water-pipe use mirror Yes 668 28.1 Ͻ.0001 findings in other Western coun- No 201 8.0 5,21,29 Marijuana, cannabis, or hashish tries indicating that water-pipes Yes 382 39.5 Ͻ.0001 are used primarily by younger persons No 488 10.9 and by male individuals. Water-pipe us- Other illicit drugsd Yes 141 47.5 Ͻ.0001 ers in the NDIT Study were more likely No 730 18.8 to be male and, even with the re- a Totals differ because of missing data. stricted age range in the NDIT Study, b P values were obtained from Pearson ␹2 tests. c Includes cigars, pipe, bidis, chewing tobacco, and snuff. younger participants were more likely d Includes cocaine, speed, ecstasy, hallucinogens, inhalants, heroin, and other. to use water-pipes. This may reflect the experimentation with new sub- stances that typically occurs during higher than the 8% reported in the tive than cigarette smoking.2,3,22 In fact, later adolescence,30,31 although prefer- 2006 Canadian Tobacco Use Monitor- Knishkowy and Amitai8 described 4 ences for specific substances often do ing Survey for a similar age group.21 myths about water-pipe use that seem not solidify until the early 20s.32 In- Numerous factors may underlie the common across cultures, as follows. creased exposure to psychoactive sub- growing popularity of water-pipes in- (1) Water-pipes are safer than ciga- stances may coincide with the end of cluding low cost,8,25 easy access,8 ap- rettes because of lower nicotine con- secondary schooling and a shift to ei- peal of the social interaction that tent. In reality, different water-pipe ther working or further schooling in accompanies use,9,17,26,27 commercial- products and smoking patterns could less-structured settings characterized ization by the media,16,18 availability of result in higher nicotine intake. (2) Be- sweetened, flavored, and aromatic to- cause the texture of water-pipe smoke by decreased parental control and in- bacco or maassel, which can mask the is smoother, it is less toxic. In fact, the creased socialization with new friends. taste of tobacco,1,22,28 perceptions of lack of irritation has been associated Consistent with previous reports,29 low risk to health,1,2,22,26 linked to the with the moisture in the pipe, which water-pipe use was not restricted to belief that the water filters the toxins makes its use more palatable but not any single racial, ethnic, or cultural from the smoke,1,18 the lack of public less toxic. (3) Toxins are filtered group, which supports the idea that health warnings about the dangers of through water before the smoke is in- water-pipe smoking has spread to water-pipe use,10,26 and the perception haled. Although it is plausible that many groups within Western cultures. that water-pipe smoking is less addic- some water-soluble toxins may be ab- Finally, not living with parents and

PEDIATRICS Volume 125, Number 6, June 2010 1187 Downloaded from www.aappublications.org/news by guest on September 24, 2021 higher annual household income were service utilization attributable to ently increasing use is required. Re- associated with water-pipe use. This alcohol and illicit substance use prob- search is needed to increase under- supports the previous finding that lems,41 and decreased work productiv- standing of the health effects, natural higher weekly disposable income was ity.42 Interestingly, one-third of water- history, and determinants of water- associated with water-pipe use.5 pipe users did not smoke cigarettes. pipe smoking, as well as the reasons Water-pipe users may represent a Although cigarette smokers may for the high levels of concurrent psy- more-privileged group of young people switch intermittently to water-pipes to choactive substance use. The constitu- with the leisure time, resources, and reduce their cigarette-related risk, in- ents of water-pipe smoke should be opportunities to use water-pipes. dividuals who do not smoke cigarettes better delineated and, if water-pipe Although findings were similar to may try smoking tobacco with a water- use is associated with impairment or prevalences reported among young pipe because of the perception that increased health service utilization, adults in Canada,33 Europe,30 Austra- water-pipe smoking is less harmful then research on treatment for misuse lia,34 and the ,35–38 there than cigarette smoking.43 may be justified. Evidence-based pub- was a high level of psychoactive sub- Limitations of this analysis include the lic health interventions may be re- stance use among NDIT Study partici- fact that self-report data may be sub- quired to facilitate the public making pants irrespective of water-pipe use. ject to recall bias. Use of a convenience informed decisions about water-pipe Relatively more users than nonusers sample may limit generalizability of use. of other psychoactive substances re- the findings. The NDIT Study sample ported water-pipe use. Individuals who had low power to study water-pipe use ACKNOWLEDGMENTS use multiple substances concurrently in ethnic groups other than the white This work was supported by the Cana- are potentially exposed to higher group. Finally, use of cross-sectional dian Cancer Society (grants 010271 doses of noxious substances and ele- data limits the causal inferences about and 017435). Dr O’Loughlin holds a vated risks of dependence and dis- the determinants of water-pipe use Canada Research Chair in the Early De- ease,3 and water-pipe users may be that can be made. terminants of Adult Chronic Disease. among those at highest risk. Use of Dr Low holds a Clinical Research multiple substances concurrently in CONCLUSIONS Scholar Career Award from the Health this young age group is also associ- Although the public health burden of Research Foundation of Quebec. ated with increased likelihood of men- water-pipe smoking is not known, We thank the NDIT Study participants tal health problems,39–40 greater health more in-depth surveillance of appar- and their parents. REFERENCES

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