Waterpipe Tobacco Smoking: A Global Epidemic

Waterpipe Tobacco Smoking: A Global Epidemic
Source: Tobacco Control

The story has been told many times: waterpipe, a centuries-old tobacco use method in which smoke is passed through water before being inhaled, probably originated on the Indian subcontinent and southeast Asia. Over the years, it spread and became popular in the Middle East. During most of the 20th century, it seemed that waterpipe’s heyday had passed, in favour of easy-to-use types of tobacco such as cigarettes. Its use was not even registered in the expanding body of global tobacco surveillance systems. The medical and public health literatures made little note of it: Rakower and Fatal’s examination of lung cancer mortality rates by ethnic groups in Jerusalem that differed in their use of waterpipe, appearing in the British Journal of Cancer, was the first notice of waterpipe in Medline in 1962, and almost 20 years were to pass before any additional studies were to appear. But things suddenly changed in the 1990s: upticks in use were observed in the Middle East, especially among teenagers and young adults. This was mostly fuelled by the invention of flavoured and easier-to-use tobacco, a growing café culture in the Middle East, and expanding internet availability and globalisation. As a result, waterpipe use has snowballed globally at the start of the 21st century.

Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis

Cigarette graphic warning labels and smoking prevalence in Canada: a critical examination and reformulation of the FDA regulatory impact analysis
Source: Tobacco Control

Background
The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration’s (FDA) regulatory impact analysis (RIA), required by law as part of its rule-making process. However, evidence on the impact of GWLs on smoking prevalence is scarce.

Objective
The goal of this paper is to critically analyse FDA’s approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence.

Methods
A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control.

Findings
We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87–4.68 percentage points, a relative reduction of 12.1–19.6%; 33–53 times larger than FDA’s estimates of a 0.088 percentage point reduction. We also demonstrated that FDA’s estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed.

Conclusions
Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3–8.6 million in 2013. Our analysis demonstrates that FDA’s approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA’s effective regulation of tobacco products.