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Gathering new evidence on the economics of waterpipe tobacco smoking


Waterpipe tobacco smoking (WTS), also known as “shisha”, is a traditional form of tobacco consumption in the Middle East that passes tobacco through a cooling liquid before reaching the smoker. The introduction of flavoured tobacco products in the early 1990s caused WTS to rapidly gain popularity among young people and women, who are thought to be introduced to it by friends or family. Despite patriarchal attitudes towards women smoking in some countries in this region, it is more acceptable for women to smoke a waterpipe than cigarettes. Evidence shows that the eastern Mediterranean region has the highest prevalence of waterpipe use in the world.

Like cigarettes, WTS is associated with nicotine dependence and life-altering diseases like cancer and lung disease, as well as causing adverse pregnancy outcomes. This creates a catastrophic burden on healthcare systems, individuals, families, and the economy due to loss of productivity. Worryingly, WTS continues to grow in popularity.

In Lebanon, 2008 estimates of the direct and indirect costs for diseases caused by tobacco use among adults over the age of 30 were estimated to be US$13.6 million in environmental costs (fires and collecting smoking-related waste) and US$102.2 million and US$64.6 million in lost productivity due to morbidity and mortality respectively. The global treaty to reduce tobacco consumption, the Framework Convention on Tobacco Control (FCTC), has been poorly implemented in the region and evidence is limited solely to cigarettes. This means the evidence needed to curb WTS is non-existent, and the growing prevalence of WTS has been met with a poor regulatory response globally.

New research is urgently needed to provide detailed knowledge and recommendations to inform governments on the severity of this growing trend and to encourage the implementation of effective policies to curb waterpipe tobacco and cigarette smoking.

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The research

The American University of Beirut (AUB) is leading the project. AUB has made significant investments in knowledge translation infrastructure, culminating with the launch of the Knowledge to Policy Center in 2015. Further to this, AUB was designated as the World Health Organization (WHO) FCTC Knowledge Hub for waterpipe tobacco smoking in 2016. The team spans four countries and is composed of experts and institutions from Lebanon, Jordan, Egypt, and the West Bank and Gaza. They will produce new and critical knowledge on the economics of WTS from the epicentre of the global WTS epidemic.

The team will conduct a range of household surveys in each country to generate much needed up-to-date national data on the prevalence of cigarette and waterpipe smoking in adults (overall and gender-specific). Using these estimates, they will model the impact of fiscal policies on WTS rates and healthcare costs, in addition to estimating impact on government revenues. For example, WHO recommends taxing the individual user (consumer level) and possibly taxing the waterpipe as well as its parts and accessories. The team will disseminate knowledge on the economic impact of waterpipe tobacco control policies to government agencies, policymakers, and advocates. 

New knowledge on the economics of waterpipe tobacco smoking is urgently needed. We’ll be gathering evidence from the epicentre of the global epidemic — the eastern Mediterranean region — to translate it into effective waterpipe control policies. This project allows us to bring a team of world-leading experts together to make real and lasting change in tobacco control.

Rima Nakkash, associate professor in the Faculty of Health Sciences and coordinator of the AUB Tobacco Control Research Group at the American University of Beirut.

The impact

Tobacco control is central to meeting the United Nations 2030 Sustainable Development Goals (SDGs), notably SDG 1 (to end poverty) and SDG 3 (to ensure healthy lives). The consortium will address the health and development challenges posed by WTS in the eastern Mediterranean region, consistent with meeting these SDGs. Research like this gives millions of people a better future, with both immediate and longer-term impact.

Timely estimates of the cost of smoking at the country and regional levels are important for documenting the economic burden of tobacco use, designing effective tobacco control programs, and identifying the healthcare needs of vulnerable populations. Specifically, this research will help women and young people, who are among the fastest growing groups of waterpipe smokers.

Long-term, the team will also focus on building capacity in the field of tobacco economics by developing a research toolkit that guides new researchers on how to conduct studies into the economics of WTS. Through capacity building, researchers as well as citizens, civil society, media, and government counterparts in the four countries will gain the know-how and appreciation for moving evidence to policy.

The ultimate goal is to implement effective legislation that reduces the burden of WTS and improves population health throughout the eastern Mediterranean region. The team will accomplish this with a lasting regional consortium that supports knowledge translation and the dissemination of research on the economics of tobacco control.