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Waterpipe and Hookah Smoking - A Dangerous New Trend

What is waterpipe smoking?

Waterpipes or hookahs, as they are often called, are devices used to smoke moist tobacco or other herbal products. These products, usually sweetened and flavoured, are heated by charcoal, or other heat sources, to create smoke. The smoke is then cooled as it passes through a water-filled chamber before being inhaled through a hose fitted with a mouthpiece.

Some waterpipes have a single hose that is shared among a group of users. Other pipes have multiple hoses allowing a group of people to smoke from the same pipe at the same time.

Alarming growth in popularity

An alarming increase in waterpipe use over the past decade in North America has promoted groups like the American Lung Association to issue an alert calling waterpipe tobacco use an emerging deadly trend.

In Canada in 2013, the Canadian Tobacco, Alcohol, and Drugs Survey (CTADS) found ever use of a waterpipe included:

  • 10 per cent (or 2.8 million) of people 15 years and older.
  • 14 per cent (or 296,000) of youth 15 to 19 years.
  • 29 per cent (or 694,000) of young adults 20 to 24 years.

In Ontario, data on the prevalence of smoking and of hookah establishments is limited but it has been identified as an emerging issue that needs to be addressed.

Health risks

  • Secondhand smoke - The smoke from a waterpipe has carbon monoxide and other particulate matter. As well, when tobacco is burned, it contains the same cancer-causing chemicals as cigarettes. Smoking a waterpipe or breathing the secondhand smoke can cause lung cancer, respiratory illness, decreased lung function, gum disease, heart disease, and low birth weight.
  • Burning charcoal - The charcoal used to heat the tobacco in a waterpipe can also expose the user to metals and cancer-causing chemicals. There have been case reports of carbon monoxide poisoning after waterpipe smoking.
  • Exposure prolonged - Waterpipe smoking is usually carried out for long periods at each use. A typical one hour session of waterpipe smoking exposes the user to 100 to 200 times the volume of smoke inhaled from a single cigarette. Repeated exposure to the tobacco can lead to addiction.
  • Infectious diseases - The use of publicly shared waterpipes increases the risk of contracting viruses and infectious diseases such as tuberculosis, hepatitis or herpes. Using a disposable tip while sharing a waterpipe does not prevent the transmission of contagious diseases.
  • Reintroduces indoor smoking - Another unfortunate consequence of waterpipe use in public settings is that it involuntarily exposes workers and patrons to secondhand smoke. It also undermines the work being done to portray smoking as an unacceptable behaviour.
  • Undermines prevention/cessation - With smoking responsible for the death of one of every two long-term tobacco users, it is important that smoking in public settings continues to be an unacceptable behaviour to encourage youth to choose a smoke-free lifestyle. Keeping tobacco out of public areas also supports people trying to quit and stay smoke free.

Myths and Facts about waterpipe use

  • MYTH: Since the smoke passes through water before being inhaled, it is healthier and less dangerous than cigarette smoking.
    • FACT: Wrong. The water cools the smoke making it less irritating for the user, but it does not remove the cancer-causing chemicals, hard metals or toxins present when tobacco or herbal products are smoked.[1]
  • MYTH: If waterpipes can legally be used indoors at a restaurant and at other public places, the smoke that is released must be safe.
    • FACT: The fact that waterpipe use indoors is allowed in many places in Ontario does not make it safe. The Smoke-Free Ontario Act (SFOA) was written specifically to protect people from secondhand smoke. At present, if the product being smoked in a waterpipe is herbal or otherwise labelled as tobacco free, it is not prohibited under the law. Research continues on waterpipe smoking of non-tobacco products. Studies looking at the use of charcoal to heat the products have shown it gives off gases and particulate matter that causes health issues.[2] Ongoing research will determine the extent of the damage to health from smoking or breathing herbal and other products. In an effort to protect workers and patrons from the secondhand smoke of waterpipe use, some local municipalities now are moving to ban the use of waterpipes in enclosed public places as a health protection measure.
  • MYTH: Smoking herbal products in a waterpipe is a safe alternative to smoking tobacco.
    • FACT: The charcoal used to heat tobacco in the waterpipe poses health risks by producing high levels of carbon monoxide, metals, and cancer-causing chemicals.[2] Group waterpipe use can also mean group sharing of communicable diseases.[3]
  • MYTH: Occasional waterpipe use is harmless.
    • FACT: Due to the mode of smoking - including frequency of puffing, depth of inhalation, and length of the smoking session - waterpipe smokers may absorb higher concentrations of the toxins found in cigarette smoke.[4]
  • MYTH: Using a disposable tip for the waterpipe hose provides protection from the transmission of communicable diseases like TB or herpes.
    • FACT: Improper cleaning of any part of the waterpipe can leave users at risk for diseases that can be passed from user to user via the hose or mouthpiece whether or not a new tip is used.[5]

Where to get more information


[1] World Health Organization. WHO Advisory Note: “Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators” WHO 2005.

[2] American Lung Association. An Emerging Deadly Trend: Waterpipe Tobacco Use. (PDF–222 KB) Washington: American Lung Association, 2007

[3] Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: An emerging health crisis in the United States. American Journal of Health Behavior 2010; 34(3): 275-285.

[4] World Health Organization. Tobacco Regulation Advisory Note. Water Pipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. (PDF–550 KB) Geneva: World Health Organization, Tobacco Free Initiative, 2005

[5] Knishkowy, B., Amtai, Y. (2005). Water-Pipe (Narghile) Smoking: An Emerging Health Risk Behavior. Pediatrics 116:113-119

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