Gaining Insights Into the Waterpipe Tobacco Industry: Participant Observation and a Cross-Sectional Survey of Products at a Trade Exhibition

Abstract

Introduction:

The rise in waterpipe tobacco smoking has been accompanied by the emergence of a diverse range of products, such as “herbal” waterpipe tobacco substitutes and electronic waterpipes. The aims of this study were to assess the extent to which emerging waterpipe products are being developed by waterpipe tobacco companies themselves, to understand the key characteristics of the main market players, and to examine the connections between producers of different product categories.

Methods:

In 2014, one researcher attended an international waterpipe trade exhibition in Germany, conducting a survey of products at exhibition stands, and gathering qualitative data on exhibitors and products using participant observation. Cross-tabulations and chi-square tests identified the association between waterpipe tobacco, waterpipe tobacco substitutes, and electronic waterpipe products. We thematically analyzed field notes into information about exhibitors and products.

Results:

Of 97 exhibitors, 55 displayed waterpipe-related products. Of these, nearly half (45%) displayed electronic waterpipe products, 38% displayed waterpipe tobacco and 23% displayed waterpipe tobacco substitutes. There was an inverse association between the display of waterpipe tobacco and electronic waterpipe products, and a positive association between the display of waterpipe tobacco and waterpipe tobacco substitutes. We found that Japan Tobacco Inc, Philip Morris, and British American Tobacco were partnered or affiliated with exhibitors displaying waterpipe-related products.

Conclusions:

Electronic waterpipe products were the main feature of this exhibition. Waterpipe tobacco substitutes are likely to be produced by the waterpipe tobacco industry whereas electronic waterpipes are not. There is a developing interest in waterpipe-related products by transnational tobacco corporations. Further industry surveillance is warranted.

Introduction

Waterpipe smoking is a centuries-old method of tobacco consumption. Historically it was mainly smoked in an unflavored type known as “tumbak” or “ajami” (pure, dark tobacco pastes). ¹ Another type, “jurak”, is mainly confined to India and is either unflavored or flavored with fruit oils. ¹ Since the 1990s we have witnessed an unprecedented rise in waterpipe tobacco use. ² Jordanian trend data suggest an increase in waterpipe use from 13.3% to 18.9% among high school students between 2008 and 2010. ³ Estimates from the Global Youth Tobacco Survey show that current prevalence is highest in Lebanon (36.9%), the West Bank (32.7%), and Latvia (22.7%). ⁴ Countries such as Germany report 10.0% current use among 12-year to 17-year old adolescents. ⁵ This increasing prevalence is disconcerting considering the growing evidence of associations with heart disease, ⁶ cancers ⁷ and respiratory disease. ^{7 , 8} A key component of the recent surge in waterpipe prevalence was the introduction of a new waterpipe tobacco type known as “Mo’assel” ⁹ ; a fruit flavored tobacco mixture laced with honey. Unlike older type of waterpipe tobacco, this form appealed to a younger generation.

We hypothesize that the global increase in waterpipe is likely to have induced the emergence of further types of waterpipe products. These include waterpipe tobacco substitutes: an umbrella term for a range of tobacco-free mixtures. Like Mo’assel, tobacco substitutes are heated by burning charcoal which explains why levels of carbon monoxide and polycyclic aromatic hydrocarbons are found in similar quantities to Mo’assel. ^{10 , 11} The most common subtype of tobacco substitutes (dubbed “herbal”) contains sweeteners and heavy metals, the combustion of which releases non-nicotine particulate matter (ie, tar). ¹⁰ In the acute setting, users of tobacco substitutes were found to have reduced heart rate variability, which is implicated in the development of cardiovascular disease. ¹² Less well-known waterpipe tobacco substitutes include flavored porous rocks known as “steam stones,” although its composition remains largely unknown. ¹³ Approximately 1% of a large US sample of adults had tried steam stones, ¹⁴ but we do not know the prevalence of other waterpipe tobacco substitutes.

Coinciding with the recent invention of electronic cigarettes (e-cigarettes), electronic waterpipe products have emerged onto the waterpipe market. Some electronic waterpipe products replace charcoal with an electric heating element. Most use similar technology to e-cigarettes, where flavored nicotine-containing liquid is heated by an atomizer to produce a “vapor” in various-sized devices. ¹⁵

Little is known about whether the emerging market of waterpipe tobacco substitutes and electronic waterpipe products have been developed by Mo’assel tobacco companies as an extension of their main product categories, by independent producers or by actors in other industries, including the tobacco and e-cigarette industries. We have only limited information about the waterpipe tobacco industry as a whole; who are the main market players, what are their main locations, and what are interactions between companies? We do know that waterpipe tobacco companies are poorly compliant with packaging and labeling regulations, ^{16 , 17} and are prone to deceptive advertising methods that focus on portraying waterpipe as a “healthy” product. ¹⁸ The aims of this study were to understand the extent to which new and emerging waterpipe products are being developed from Mo’assel tobacco companies, and to gain insight into characteristics of the principle market players and the main industry affiliations.

Methods

Setting

In April 2014, one researcher (MJ) attended the most known international waterpipe trade exhibition. Held in the Frankfurt Exhibition Centre in Germany, the “2nd International Hookah Fair” was a 2-day exhibition aiming to promote business-to-business networks and business-to-customer trade. This was the second iteration of the exhibition, which was open to the general public and reportedly attracted over 7000 delegates. It also ran a “Vapor Fair” in parallel, which was an e-cigarette trade exhibition found on the floor above the Hookah Fair.

Study Design and Participants

The study design consisted of a cross-sectional survey of the product range displayed at exhibition stands, and a qualitative component known as participant observation. We had no a priori hypothesis although we posited that the co-display of new and emerging waterpipe products with existing waterpipe tobacco products at exhibition stands may indicate that these products derive from the waterpipe tobacco industry. For the cross-sectional survey, all exhibitors that displayed at least one waterpipe-related product at their stand were surveyed. This included exhibitors that displayed electronic waterpipe products. Exhibitors that did not display waterpipe-related products were excluded from the survey. Products were categorized as follows: waterpipe consumption products (tobacco or tobacco substitutes), waterpipe accessories (apparatuses or charcoals or other), electronic waterpipes, and other products. The display of at least one product was sufficient to code the exhibition stand as displaying that product category.

For the qualitative component participant observation was undertaken, a research method rooted in ethnographic research, which aims to gather an in-depth understanding of groups of individuals by observing and interacting with them. ¹⁹

Data Collection

For the cross-sectional survey, the researcher sequentially attended each exhibition stand and quantitatively collected:

• the company’s country of origin, through discussion with exhibitors;

• the product category on display, by inspecting the exhibition stands; and

• the floor surface area occupied by the exhibitor’s stand, by manual measurement of the exhibition map given to all attendees (proxy measure for the level of promotional investment by exhibitors, as larger floor spaces are more expensive).

The researcher then had informal discussions with exhibitors about the purpose and function of products on display, key product characteristics, and evidence of partnerships and affiliations. He documented all of these observations in a field notebook.

Data Analysis

We ran descriptive statistics on exhibitors’ country of origin and the presence of product categories. We were primarily interested in waterpipe consumption products (tobacco, tobacco substitutes) and electronic waterpipe products. To test the association between these product categories, we cross-tabulated them against one another, conducting chi-square for differences in proportion by groups. We took a significance level of 5% in all analyses.

For the qualitative component, the researcher who attended the exhibition expanded his field notes into thick descriptions soon after the exhibition. ²⁰ He conducted a thematic analysis on these field notes using Braun’s six phases of analysis: data familiarization, initial code generation, theme development, theme recognition, theme analysis, and report writing. ²¹ He structured his findings into two broad areas: exhibitors and products.

Ethical Considerations

The researcher (MJ) introduced himself as a student writing an essay about the waterpipe tobacco industry. However, in order to obtain candid answers from exhibitors and attendees, the researcher did not divulge his academic and advocacy interests in waterpipe tobacco smoking. We did not feel it necessary to gain informed consent from those we observed or spoke to. This deceptive research approach was justified based on the ethical literature supporting such scenarios. ^{22 , 23} The researcher maintained confidentiality by not documenting or reporting identifiable data of people with whom he interacted. This study was approved by the Imperial College Research Ethics Committee.

Results

Characteristics of Sample

There were 97 exhibitors in total. Five companies—Aladin Shisha, Alandalus Flavored Tobacco & Molasses, Blubberhaus, Cocobrico, and Elda Ltd—were identified as the event’s “Premium Partners” (an undefined term present on exhibition materials). Fifty-five exhibitors out of 97 (57%) displayed waterpipe-related products at their stand. The remaining exhibitors displayed e-cigarettes, e-liquid products, or no products, and were not included in our analysis.

The majority of exhibitors ( n = 43, 78%) were found in the Hookah Fair and 12 (22%) were found in the Vapor Fair. Twenty-seven (49%) were German companies, and the remaining 28 (51%) were from the United States ( n = 5), the Netherlands ( n = 4), China ( n = 4), Italy ( n = 3), the United Kingdom ( n = 3), Belgium ( n = 2), Israel ( n = 2) and one from each of Austria, France, Hungary, India, and Jordan.

The median occupied floor area was 1.71 units ² (interquatile range [1.08–3.61]). XEO International, which sold the electronic waterpipe product “Shisha2go,” occupied the largest floor area (10.20 units ² ), which was one and half times larger than the next most occupied floor space (Alandalus Flavored Tobacco, 6.82 units ² ), and larger than the 11 smallest exhibitor floor spaces combined.

Product Categories (Quantitative Component)

Table 1 presents the product categories found among the 55 exhibitors displaying waterpipe-related products, and also shows the proportion of products displayed in the Hookah Fair or Vapor Fair. A detailed breakdown of product brands and categories, as well as exhibitor countries and websites, can be found in Supplementary Appendix 1 . The three most common product categories were electronic waterpipe products ( n = 25, 45%), waterpipe tobacco ( n = 21, 38%, of which all were Mo’assel type) and waterpipe apparatuses ( n = 19, 35%). Each exhibitor displayed a median of one product category (interquatile range 1–2, range 1–6). Around half ( n = 12, 48%) of exhibitors displaying electronic waterpipe products were found in the Vapor Fair, and nearly all exhibitors of all other product types were found in the Hookah Fair.

Table 1.

Product Frequency Among 55 Exhibitors Displaying Waterpipe-Related Products, Stratified by Exhibition Location

Product category	Total n (%) a	Hookah Fair n (%) b	Vapor Fair n (%) b
Electronic waterpipe products	25 (45)	13 (52)	12 (48)
Waterpipe products of consumption: tobacco	21 (38)	25 (100)	0 (0)
Waterpipe accessories: apparatuses	19 (35)	19 (100)	0 (0)
Waterpipe accessories: charcoal	14 (25)	14 (100)	0 (0)
Waterpipe accessories: other	13 (24)	13 (100)	0 (0)
Waterpipe products of consumption: tobacco substitutes	13 (24)	12 (92)	1 (8)
Other products (mainly e-cigarettes and e-liquids)	12 (22)	9 (75)	3 (25)

e-cigarettes = electronic cigarettes.

^a Denominator = number of exhibitors, N = 55.

^b Denominator = total frequency (first column).

Co-displaying of tobacco and tobacco substitutes was seen on 43% (9/21) of all stands displaying tobacco and 69% (9/13) of all stands displaying tobacco substitutes. Co-displaying of tobacco and electronic waterpipes was seen on 19% (4/21) of all stands displaying tobacco and 16% (4/25) of all stands displaying electronic waterpipes. The display of tobacco substitutes was significantly higher at stands displaying tobacco compared with stands not displaying tobacco (69% vs. 28%; P < .05). The display of electronic waterpipes was significantly lower at stands displaying tobacco compared with stands not displaying tobacco (16% vs. 55%; P < .05).

Participant Observation (Qualitative Component)

Exhibitors

The Hookah Fair on the ground floor hosted 44 exhibitors, and was consistently busy throughout the event. Approximately half focused on networking (business-to-business, B2B) and half focused on selling (business-to-customer, B2C). Product samples were tried either at exhibition stands where available, or on the first floor in an area known as the “Shisha Lounge,” which housed approximately 10 waterpipe apparatuses surrounded by couches and other seating. The Vapor Fair on the second floor hosted 53 exhibitors. Nearly all were business-to-business and it was much less crowded than the Hookah Fair. Product samples were tried in a corner of the Vapor Fair (“Vapor Lounge”).

Partnerships and affiliations between waterpipe companies and trans-national tobacco corporations (TTCs) were evident. For example Nakhla Tobacco, owned by the TTC Japan Tobacco Inc, ²⁴ had their logo displayed by the German distributor Aladin Shisha. Moosmayr GmbH, a cigarette distributor for another TTC, British American Tobacco, manufactures and distributes waterpipe apparatuses and electronic waterpipe products. Nicocigs Ltd, owned by Philip Morris, markets a brand of e-cigarettes called Craze E-Shisha. Finally Matmind SRL, the manufacturer of Palmer cigarette filters, was present in its recent capacity as a manufacturing waterpipe mouthpiece filters.

Products

Table 2 presents key product characteristics as identified by exhibitors. Several exhibitors produced products for more than one industry. For example, some manufacturers of waterpipe apparatuses also manufactured bongs, which are used predominantly to smoke cannabis. Some manufacturers of waterpipe charcoal also manufactured BBQ charcoal. There was no clear classification of electronic waterpipe products among exhibitors. Terms such as “e-shisha” and “shisha pens” were used interchangeably to describe a range of electronic waterpipe products.

Table 2.

Key Product Characteristics According to Exhibitors

Product	Key characteristics
Electronic waterpipe products	No liquid leakage, range of flavors, ability to refill
Waterpipe tobacco	Ability to produce thick smoke to create smoke rings
Waterpipe apparatuses	Easy assembly, no smoke leakage, well-decorated
Charcoal	Short ignition time, long burning time, no ash production
Waterpipe tobacco substitutes	Shisha fruits: short heating time, leaves less residue in apparatus

Discussion

By analyzing the co-displaying of products at this trade exhibition, our findings indicate that waterpipe tobacco substitutes are likely to be produced by the waterpipe tobacco industry whereas electronic waterpipes are not. That the majority of exhibitors displayed electronic waterpipes may reflect an evolution in waterpipe smoking from combustible tobacco to electronic. Due to similarities in their underlying technology, the close alignment between electronic waterpipes and the e-cigarette industry means that electronic waterpipe products are potentially symbiotic, contemporaneous and perhaps mutually reinforcing products which allows the same technology to be marketed to different audiences in different ways. Although we could not determine details of TTC involvement in the waterpipe industry, our findings indicate that the waterpipe industry should not be underestimated in its strategic potential for the tobacco industry in its attempts to recruit new nicotine users and ultimately new smokers.

Regulation should classify waterpipe products based on the underlying technology used. All waterpipe use that involves e-cigarette-like technology should be classified as electronic nicotine delivery systems, ²⁵ regardless of its marketed name. This should also include electronic waterpipe products that claim to be nicotine-free. Waterpipe tobacco and tobacco substitutes should be classified as tobacco products, and its accessories should be subject to tobacco control legislation.

Research Implications

It will be important to understand how end users themselves classify and use the wide range of waterpipe products, and to understand whether perception of harmfulness differ between them. Harm reduction debates involving waterpipe tobacco have not yet occurred. Existing studies have shown that waterpipe users underestimate the harmfulness of waterpipe tobacco, ²⁶ and many users are unwilling to quit. ^{27 , 28} It is likely, therefore, that marketing electronic waterpipes as harm reduction products could prove an effective strategy for manufacturers.

Surveillance of the waterpipe tobacco industry should continue, including the extent to which the industry overlaps with cigarette tobacco and e-cigarette industries. This is of great importance given the now extensive penetration of the e-cigarette industry by TTCs, which may use these new products to recruit smokers, and support their core tobacco businesses in other ways (eg, as “bridge products” in smoke free environments). It is not currently known whether electronic waterpipe products represent an acceptable substitute for waterpipe tobacco users. It is also not known whether there is a potential gateway effect of e-cigarette-like products marketed as waterpipes (eg, “hookah pens,” “shisha pens,” “e-shisha”) for either waterpipe tobacco or cigarette use. Significant additional research on usage patterns and dual-use with tobacco products is thus needed.

Limitations

This was the first study to provide insight into the structure of waterpipe tobacco industry. However data were collected by one researcher (possible researcher bias) and they may not be externally valid as they were taken from a single trade exhibition. While some insights have been gained into the cigarette industry via studies of trade exhibitions, ²⁹ the vast majority of our knowledge of this sector come from the release of internal TTC documents into the public domain. ^{30 , 31}

Conclusions

Electronic waterpipe products are being extensively marketed and were a main feature of this exhibition fair. Their display was inversely associated with the display of waterpipe tobacco products. Considering the known harmful effect of waterpipe tobacco and tobacco substitutes, regulation for these two products should be increased. Further surveillance of the waterpipe tobacco industry TTCs is required.

Funding

This study was funded by the Clinical Research Institute at the American University of Beirut. BHs’ research was partially supported by the National Cancer Institute of the National Institutes of Health under award number R01CA091021. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Interests

None declared.