Tobacco Info

From Tobacco Info No. 10 - August 2012
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Waterpipe Forum addresses dangers of hookah use

By Mel Lefebvre

Standing tall and brightly coloured in a restaurant window is a hookah, waiting for someone to walk in off the street to take a puff of its sweet-smelling smoke. But buyer beware! While it may look like an aesthetically appealing and exotic experience, the tobacco it contains can hook users for life. It’s a big enough health concern that over 40 health, enforcement, and tobacco control professionals met in Toronto in February to tackle issues surrounding hookah use.

Waterpipes have been used for centuries, particularly in North Africa, parts of Southeast Asia, and the Mediterranean. The tobacco is consumed by heating a piece of shisha, usually tobacco mixed with flavours, with a piece of charcoal, then cooled by water and inhaled through a long pipe to the mouthpiece and into the lungs of its users. Waterpipe smoking has been spreading among youth in the United States, Canada, Brazil, and Europe since the 1990s, according to the World Health Organization.

Waterpipes go by the names shisha, hookah, and narghile, and are often considered a more exotic and socially acceptable way of consuming tobacco than cigarettes.

When tobacco control professionals from across Canada met in Toronto for the Non-Smokers’ Rights Association’s (NSRA) National Forum on Waterpipe Use (the “Forum”), the room was also filled with RCMP officers and representatives from Health Canada. Plenary presentations and panel discussions addressed the issues of waterpipes and sought possible solutions. The one-and-a-half day workshop resulted in a report that includes a variety of recommendations from enforcement to public education that are designed to curb a deadly trend that is on the rise in Canada.

From the NSRA report: “There was general agreement among participants that in the eyes of decision makers, tobacco (even in shisha form) is already addressed in provincial tobacco legislation and that what is needed to include ‘herbal’ shisha in legislation is evidence regarding its health effects.”

The current lack of evidence regarding the health consequences of herbal shisha makes any further recommendations for controlling waterpipe use challenging. Because it is not readily evident whether or not herbal mixtures contain tobacco, many establishments that offer recreational waterpipes are getting away with allowing the smoking of a  product that contains tobacco, in violation of provincial workplace and public place smoking bans.

In addition, waterpipe tobacco products are sold without graphic health warnings, as not all federal tobacco regulations apply to all tobacco products, according to representatives from Health Canada. Current regulations for graphic health warnings and reporting do not apply to waterpipe tobacco. It is also unregulated and isn’t standardized.

One of the most surprising findings from the Forum is that many users aren’t even aware they’re consuming tobacco. Products are labelled as ‘herbal’ and laden with aromas of fruit and other sweet substances to attract users. Apple, cherry, chocolate, and other flavours mask the harshness of tobacco and give the smoke a pleasant odour. Along with the absence of health warnings on either the shisha or the waterpipe, the sweet flavours allow consumers to believe they are smoking a safe product.

“Much of the misperception about hookah pipes comes from the belief that the water filters nicotine and harmful substances from the smoke,” said Pippa Beck from the NSRA. “A review of half a dozen studies on the filtering capability of hookahs has found that daily waterpipe use results in nicotine absorption of a magnitude similar to that of smoking 10 cigarettes per day.”

In a 2006 report by the Canadian Tobacco Use Monitoring Survey, however, 29 per cent of waterpipe users thought that smoking tobacco in a waterpipe was less harmful than smoking cigarettes, and 34 per cent thought smoking waterpipes reduced the level of tar inhaled compared to a cigarette.

This gives waterpipes some curious allies: medical students taking a study break in the lush interior of a hookah bar with friends, and those holding tight to the ‘culture’ of this addictive pastime. Interestingly, according to presenters at the Forum, many people who won’t touch cigarettes or cigars consume tobacco under more dangerous circumstances than a regular cigarette smoking session.

A shisha session tends to last for 40 to 60 minutes, whereas a cigarette lasts five minutes, meaning all those present during a shisha session have prolonged exposure to high volumes of tobacco smoke—a known carcinogen that disperses carbon monoxide, which is linked to cancer and heart disease.

Another health concern is that there are no standards regarding the method and frequency of cleaning waterpipes. Inadequate sanitation and sharing of mouthpieces leads to an increased risk of non-communicable diseases.

An increase in the number of waterpipe establishments, like bars and restaurants that offer shisha on the side, makes controlling contraband and improperly labelled waterpipe products a nuisance for enforcement officers. An Ontario officer who presented at the Forum described searching one waterpipe location that had hidden a large amount of tobacco in a dirty mop bucket. The tobacco was seized, and the proprietor was given a hefty fine.

Enforcement officers, like the RCMP and other legal branches of local government that seize illicit waterpipe products, have some capacity to test for the presence of tobacco, but the process is expensive and time consuming, so it isn’t often done. Even products that declare the absence of tobacco often contain it anyway.

According to the NSRA’s final report, “The RCMP emphasized that from their perspective, more important than a loss of tax revenue to the government is the concern that profits from contraband tobacco shisha are possibly being used to fund organized crime involving drugs and weapons.”

The report also stated that, “All participants agreed that there are gaps in the Canadian annual current data relating to waterpipe smoking, in terms of prevalence, number of hookah establishments, websites, vendors, charges, shisha importers/manufacturers, public awareness, public opinion, illegal market, etc.” While each province has its own regulations for waterpipe establishments, new hookah bars continue to surface. The trend is on the rise partly due to a growing public malcontent with cigarette smoking.

The Forum had resounding support for more education efforts to teach youths about the dangers of waterpipe smoking. Too many myths, like the idea that shisha is less harmful than cigarettes and that there is a cultural rite to smoking shisha, cloud the truth of waterpipe use, even among health professionals. There is also “An observed lack of awareness among decision makers,” according to the report.

Further, “There is currently no Canadian resource geared for a general audience that addresses the health consequences of waterpipe use, communicable diseases, risk of use becoming a gateway for other drugs, cultural practice versus social activity of youth, occupation health and safety (for workers in waterpipe establishments), and tobacco shisha as contraband,” according to the Forum’s report.

A prevailing sentiment that tobacco is a ‘done’ issue certainly helps waterpipe tobacco slip through legislative cracks, and despite illicit shisha locations popping up across the country, the time and cost of enforcement isn’t enough to curb the growing trend. The NSRA’s Forum report concludes by urging action to halt the rapid spread of waterpipe smoking to protect Canada’s youth.