Waterpipe use is growing in popularity in Alberta. Public venues designed for smoking waterpipes are becoming more widespread, exposing many Albertans‐‐including hospitality workers‐‐to secondhand smoke and enticing youth to experiment with alternative forms of smoking. The Alberta Tobacco and Smoking Reduction Act includes provisions to address these health concerns, however these restrictions remain un‐proclaimed more than three years after the Act was passed in the Legislative Assembly. As a result many youth and employees working in these establishments are at risk.

Background and health implications

Waterpipe smoking, also commonly known as ‘hookah’, ‘narghile’ or ‘kalian’, is a form of smoking that typically includes a head piece where tobacco is placed, a body, water bowl, hoses and a mouthpiece. Charcoal is used to heat the tobacco known as shisha or maassel which are the substances typically smoked with a waterpipe. These products are moist, heavily flavoured, contain either honey or molasses and often contain tobacco. A typical session of waterpipe smoking is approximately 45 minutes long, performed in groups, and results in burning and smoking about 20 grams of ‘sisha’.¹

Historically waterpipes have been used to smoke tobacco in the Eastern Mediterranean region, Southeast Asia and in northern Africa. However since the 1990s there has been an increase in prevalence of waterpipe use among youth and young adult populations who reside outside of these traditional geographical regions.² As a result, international public health organizations identify waterpipe use as a growing public health issue with significant negative health effects.^3,4,5,6,7 Both the firsthand and secondhand smoke produced by waterpipe use contain known carcinogens at levels equal to or greater than that of other tobacco products.⁸ People who are around waterpipe smoke are at risk of the same negative health outcomes seen from being exposed to secondhand tobacco smoke even if only herbal waterpipe products are used.⁹ The social nature of waterpipe use has also contributed to the spread of communicable disease. For these reasons, waterpipe use in public places has been banned in countries where use has flourished for centuries such as Turkey¹⁰, Syria¹¹ and Kuwait.¹² The United Arab Emirates also bans cafes and restaurants from serving waterpipe products.¹³ In June 2012, Alberta’s Chief Medical Officer of Health published a report recommending a ban on waterpipe smoking in public places.¹⁴ Unfortunately this recommendation remains unimplemented.

Health misconceptions

Marketed as safer than traditional cigarettes, waterpipe smoking has become a popular alternative to cigarettes in North America.¹⁵ Studies indicate that many waterpipe users incorrectly believe it is less harmful and less addictive than other forms of tobacco use.¹⁶ In reality, depending on the product and smoking pattern of the user, waterpipe use can produce significant levels of nicotine, carbon monoxide, tar and other heavy metals. A waterpipe smoker may inhale as much smoke in an one‐hour session as someone who inhaled 100 or more cigarettes.¹⁷

Youth waterpipe use

Waterpipe use is growing in popularity in Alberta and Canada, particularly among youth.¹⁸ The most recent Canadian Student Tobacco, Alcohol and Drugs Survey revealed that more than 96,600 Canadian youth are waterpipe users.¹⁹ In Alberta, 10,500 young people in grades 6 to 12 used a waterpipe in the past 30 days in 2015.²⁰ The number of Alberta students who had tried waterpipe smoking within 30 days of being surveyed (n=10,500) is now very close to the number of youth who have tried cigarettes in the past 30 days (n=12,780). This illustrates the growing popularity of waterpipe use among Alberta youth. Studies have shown that waterpipe use among youth is strongly associated with the use of other forms of tobacco (along with alcohol and illicit drugs)^21,22,23 and that Canadian waterpipe users are primarily young people.²⁴

Several factors make waterpipe use appealing to youth. Waterpipe products come in an assortment of candy and fruit flavours and are often mixed with honey or molasses to produce an appealing taste and smell. The water in a waterpipe makes the smoke cooler and moist, and considerably less offensive than the harsh, dry smoke of a cigarette for first‐ time or beginner smokers. Waterpipe use at a hookah bar or restaurant is also relatively affordable for youth. A typical session costs between $12 and $15, which can be shared among friends.²⁵ Another contributing factor to youth waterpipe use is the common misconception that it is a safer alternative to other forms of smoking. Waterpipe smoking also provides an opportunity to gather with friends and socialize‐‐an attractive option for youth who are prohibited from entering bars.

Banning flavoured waterpipe tobacco

The vast majority of waterpipe tobacco (shisha) is flavoured and is currently exempted from the flavoured tobacco ban despite high rates of flavoured shisha use among Alberta youth. In Alberta, 9,600 Alberta youth tobacco users in grades 6 to 12 were using flavoured shisha tobacco in 2015.²⁶ In fact, the rate of Alberta youth in grades 6 to 12 using flavoured shisha tobacco in the past 30 days (n=9,600) exceeded the number of Alberta youth who were using menthol cigarettes (n=5,100) and flavoured smokeless tobacco (n=4,500)—making flavoured shisha the most popular flavoured tobacco product among Alberta youth. This disturbing trend provides ample justification for a ban on flavoured shisha tobacco.

Banning waterpipe use in public places

Bars and restaurants that offer waterpipe smoking have been operating in Alberta for over a decade with dozens in Edmonton and Calgary and with several establishments emerging in smaller urban and rural areas.²⁷ Many of these businesses claim to serve only herbal waterpipe products. However shisha products are not currently regulated and studies indicate that product labels cannot always be trusted and the products may contain tobacco.²⁸ Even if the government could effectively monitor waterpipe establishments to ensure they only served tobacco‐free products, such businesses would still be exposing staff and patrons to secondhand smoke and would still be contributing to increased uptake of smoking by youth due to experimentation and possible addiction.

Secondhand smoke exposure is a major preventable contributor to acute and chronic adverse health outcomes that affect all Albertans. There is no safe level of exposure to secondhand tobacco smoke.²⁹ Legislated smoking restrictions protect citizens and workers from the negative health effects of secondhand smoke exposure in public places and workplace. Waterpipe use in hookah bars and restaurants defies the objective of this legislation to protect all Albertans form secondhand smoke, including patrons and staff. Twelve Alberta municipalities have already banned shisha/waterpipe smoking in public establishments.³⁰ Alberta needs a full provincial ban with uniform health protection for all Albertans and a level playing field for all businesses.

Public support for a ban on waterpipe use in public areas

A telephone survey of 1,200 Albertans aged 18 and over conducted in 2016 revealed that 80% of respondents supported a ban on the use of waterpipes in all public places where tobacco use is banned. The 2016 Chronic Disease Prevention Survey was commissioned by the Alberta Policy Coalition for Chronic Disease Prevention.

Policy Recommendations

ASH recommends that the Alberta government:

1. Fully implement the Tobacco and Smoking Reduction Act flavoured tobacco ban by removing the exemption on flavoured shisha tobacco and prohibit the sale of flavoured shisha tobacco which is being used by thousands of Alberta youth. 
2. Proclaim and implement the provisions of the Tobacco and Smoking Reduction Act banning waterpipe use in public establishments and protect all Albertans from exposure to secondhand smoke from waterpipes in these venues. 
3. Develop and implement a public education campaign to coincide with policy enforcement.

References

1. Centers for Disease Control and Prevention (CDC). (2016). CDC – Fact Sheet – Hookah. Accessed June 10, 2016 from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/hookahs/index.htm

2. World Health Organization (WHO). (2015). Waterpipe tobacco smoking: health effects, research needs and recommended actions for regulators – 2nd Edition. Accessed June 12, 2016 from http://apps.who.int/iris/bitstream/10665/161991/1/9789241508469_eng.pdf?ua=1

3. Maziak W, Ward KD, Afifi Soweid RA, et al. Tobacco smoking using a waterpipe: a re‐emerging strain in a global epidemic. Tob Control 2004;13(4):327‐33.

4. Knishkowy B, Amitai Y. Water‐pipe (narghile) smoking: an emerging health risk behavior. Pediatrics 2005;116(1):e113‐9.

5. World Health Organization. Tobacco Free Initiative, WHO Study Group on Tobacco Product Regulation. (2005). Waterpipe tobacco smoking: Health effects, research needs and recommended actions by regulators [online]. Geneva, Switzerland: Author. http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf.

6. Maziak, W., Ward, K. D., & Eissenberg, T. (2004). Factors related to frequency of narghile (waterpipe) use: The first insights on tobacco dependence in narghile users. Drug and Alcohol Dependence, 76, 101–106.

7. Eissenberg, T., & Shihadeh, A. (2009). Waterpipe tobacco and cigarette smoking: Direct comparison of toxicant exposure. American Journal of Preventative Medicine, 37, 18–23

8. Alberta Health Services. Let’s Talk About…Hookah. http://www.albertaquits.ca/files/AB/files/library/HookahFINAL(1).pdf

9. Alberta Health Services. Let’s Talk About…Hookah. http://www.albertaquits.ca/files/AB/files/library/HookahFINAL(1).pdf

10. Turkey's ban on smoking in public places included hookah use and was effective as of July 2009.

11. Syria's ban on Smoking in public spaces included hookah use and took effect in April 2010.

12. As of February 2012

13. The faze‐out of businesses/services was to be finalised as of December 2011.

14. Government of Alberta. Waterpipe Smoking in Alberta. A Report by the Office of the Chief Medical Officer of Health. February 2012. https://open.alberta.ca/dataset/eb8abcdd‐d870‐ 41e6‐ac10‐9702918ef831/resource/53970aab‐d90f‐4045‐91a6‐9dda6810edf3/download/2012‐Waterpipe‐Smoking‐in‐Alberta.pdf

15. Berg, Carla J. et al. Perceived Harm, Addictiveness, and Social Acceptability of Tobacco Products and Marijuana Among Young Adults: Marijuana, Hookah, and Electronic Cigarettes Win. Substance use & misuse 50.1 (2015): 79–89. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302728/

16. Alberta Health Services. Let’s Talk About…Hookah. http://www.albertaquits.ca/files/AB/files/library/HookahFINAL(1).pdf

17. Alberta Health Services. Strategic Brief – Waterpipe Use. 2011 (http://tobaccofreefutures.ca/downloads/pdfs/ahs_waterpipe_aug2_%202011.pdf)

18. Leia M. Minaker et al. Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey. Cancer Causes Control. March 2015.

19. Government of Canada. Summary of results: Canadian Student Tobacco, Alcohol and Drugs Survey 2014/2015. https://www.canada.ca/en/health‐canada/services/canadian‐student‐ tobacco‐alcohol‐drugs‐survey/2014‐2015‐summary.html

20. Cumming, T., Rynard, V. (2017). In Brief: Student Tobacco use in Alberta, 2014/2015 Canadian Student Tobacco, Alcohol and Drugs Survey. Waterloo, Ontario: Propel Centre for Population Health Impact, University of Waterloo. https://uwaterloo.ca/canadian‐student‐tobacco‐alcohol‐drugs‐survey/sites/ca.canadian‐student‐tobacco‐alcohol‐drugs‐ survey/files/uploads/files/cst14_tobacco_use_ab_20170515v5_a.pdf

21. Jackson, D & Aveyard, P. Waterpipe smoking in students: Prevalence, risk factors, symptoms of addiction, and smoke intake. Evidence from one British university. BMC Public Health 2008; 8:174.

22. Smith‐Simone, S et al. Waterpipe tobacco smoking: Knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine & Tobacco Research 2008; 10:393‐398.

23. Cobb, CO et al. Waterpipe tobacco smoking and cigarette smoking: A direct comparison of toxicant exposure and subjective effects. Nicotine & Tobacco Research 2010; doi: 10.1093/ntr/ntq212.

24. Dugas, E. et. al. Water‐Pipe Smoking Among North American Youths. Pediatrics Vol. 125 No. 6 June 1, 2010 pp. 1184 ‐1189

25. Dugas, E. et. al. Water‐Pipe Smoking Among North American Youths. Pediatrics Vol. 125 No. 6 June 1, 2010 pp. 1184 ‐1189

26. Cumming, T., Rynard, V. (2017). In Brief: Student Tobacco use in Alberta, 2014/2015 Canadian Student Tobacco, Alcohol and Drugs Survey. Waterloo, Ontario: Propel Centre for Population Health Impact, University of Waterloo. https://uwaterloo.ca/canadian‐student‐tobacco‐alcohol‐drugs‐survey/sites/ca.canadian‐student‐tobacco‐alcohol‐drugs‐ survey/files/uploads/files/cst14_tobacco_use_ab_20170515v5_a.pdf

27. These facts are based on anecdotal evidence since the government does not register, track, or otherwise monitor such establishments.

28. Testing conducted on behalf of Breathe California. Cited in Tobacco Free U Org, The BACCHUS Network. (2007). Reducing hookah use: A public health challenge for the 21st century [online]. Denver, CO: Author. Retrieved March 7, 2011, from http://www.tobaccofreeu.org/pdf/HookahWhitePaper.pdf.

29. US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Washington: US Department of Health and Human Services, 2006. http://www.surgeongeneral.gov/library/secondhandsmoke/report/index.html.

30. Action on Smoking & Health, Municipal Bylaw Chart October 2015 http://www.ash.ca/municipal_bylaw_chart