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Calls for hookah ban backed by OTRU/CAMH research

When the Toronto Board of Health called on the city and province in June to ban hookahs/waterpipes in restaurants and bars, it drew upon research of the UofT/CAMH-affiliated Ontario Tobacco Research Unit (OTRU).

“Waterpipe smoke is toxic,” Dr. Roberta Ferrence told the Board of Health at a hearing on the issue June 1st. “It contains high levels of carbon monoxide, fine particulates, benzene, heavy metals and other contaminants.” In addition, research shows that “most waterpipe cafés serve at least some tobacco products in contravention of the Smoke-Free Ontario Act.” She noted that waterpipe use among Ontario students is now at least as high as their cigarette use.

A hookah, also known as a waterpipe, is used to smoke moist tobacco or herbal products, known as shisha.

Dr. Ferrence, Senior Scientific Advisor at OTRU, was principal investigator of an OTRU/CAMH study that went undercover to investigate air quality in 17 waterpipe cafés (12 indoors and 5 outdoors) in Toronto. On average, there were 25 patrons and 10 active waterpipes in each indoor café.

The study, titled Enter at your own risk: a multi-method study of air quality and biological measures in Canadian waterpipe cafés, concluded that air quality in indoor waterpipe cafés is hazardous to human health. Some of the study’s key points:

  • Employees and patrons face serious health risks from carbon monoxide exposure alone, the study found. CO exposure approached or exceeded Ontario’s guidelines for residential indoor air quality.
  • The average air-nicotine level in indoor waterpipe cafés was similar to that of cigarette smoking venues such as restaurants and bars in Europe (or in Canada before smoking was banned in those venues)
  • Particulate matter levels were much higher than those reported for smoking rooms in European bars/restaurants. Employees who work an 8-hour shift in a waterpipe café are being exposed to hazardous levels of particulates according to Environmental Protection Act standards.
  • Air quality was better in outdoor cafés but still presented harms to patrons and staff.

Short-term health effects of waterpipe use include increased heart rate, blood pressure and headaches. Long-term health effects include lung and heart disease, cancers, as well as infection risk (from sharing pipe equipment).

“We also found that for our non-smoking field staff, by the end of a two-hour session at each café, their breath carbon monoxide levels were equivalent to those of a regular smoker,” said Dr. Ferrence. Levels were measured by a breath test.

The results of the study, published in the international journal Tobacco Control in 2015, supported “eliminating waterpipe smoking in hospitality venues indoors and out.”

“Hookah smoking is on the rise among young people, who often mistakenly believe it is a safe form of smoking,” said Toronto’s Medical Officer of Health Dr. David McKeown at the June meeting. His report cited key results from the OTRU study, among other findings.

The latest CAMH survey showed that 9.7 per cent of Ontario students in grades 7 through 12 had used a waterpipe in the past year, compared to 8.5 per cent who said they had used tobacco cigarettes in the past year. Nationally, waterpipe use by youth aged 15 to 19 increased from 6 per cent in 2006 to 14 per cent in 2013.

The popularity of waterpipe/hookah smoking could undermine tobacco control laws, says Dr. Ferrence. She notes that youth are targeted with flavored herbal hookah products, and there are no health warnings. Waterpipe use is marketed as a way to relax and socialize using an herbal product. “Patrons don’t know what they are smoking.”

Some proponents of waterpipe use cite culture and tradition. As a counterpoint, Dr. Ferrence notes that several countries where waterpipes have been used traditionally, including Jordan, Syria, Lebanon and Turkey, have banned indoor use, and that use has been in a small minority of the population.

Three Canadian provinces – Nova Scotia, Quebec and Alberta – have enacted laws on waterpipes. Ontario is considering the issue in emerging legislation.

In 2015, Dr. Ferrence continues to present these research findings to public health units, universities and governments as policies and legislation evolve.

The Toronto Board of Health voted to ask city council to ban the use of hookah in licensed businesses in Toronto effective October 1, 2015. In addition, the Board asked council to request the province to ban hookah/waterpipes in all restaurants, bars and entertainment venues, regardless of whether the substance being smoked is or is not tobacco-based.

The OTRU/CAMH research team that undertook the waterpipe study included:

  • Principal Investigator: Roberta Ferrence
  • First author and Co-Investigator: Bo Zhang
  • Co-investigators: Farzana Haji, Pamela Kaufman, Sara Muir.