TOBACCO, VAPING & CANNABIS - Alberta Health Services
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TOBACCO, VAPING & CANNABIS
INFORMATION SERIES
citing “relaxation after a stressful day at
Waterpipes school” (Cloud 9 Hookah Lounge & Bar,
Calgary) or hosting themed nights with onsite
Background DJs and karaoke. Such promotion of
Waterpipes, also called hookah or narghile, waterpipe establishments demonstrate the
involves smoking products known as “shisha”. increasing commercialization of shisha in
It dates back several centuries with its origin Alberta over the past two decades, with both
traced to India and also to South Africa, Persia tobacco and purported non-tobacco-
and Ethiopia.1 Traditional tobacco shisha is a containing products readily available.
mixture of tobacco and water, and sometimes
In fact, an increase in prevalence and spread
mixed with glycerin and/or honey. Tobacco-
of use of waterpipes has been observed
containing shisha is sometimes marketed as
globally. The World Health Organization
“washed” or “unwashed.” Washing tobacco
(WHO) reports that contributing factors to this
does not affect nicotine levels and tobacco still
increase include: the introduction of flavoured
contains dangerous chemicals after being
tobacco, social acceptability, developments in
washed.
mass communications and social media, and
Shisha is also available without tobacco and a lack of waterpipe-specific policy and
such products are often described as “herbal.” regulations.3
Flavouring has been added to most products
to make them more appealing including many
Prevalence
non-traditional flavours (such as those In 2017, past-30-day use of a waterpipe to
inspired by cocktails and energy drinks). smoke tobacco was reported by 1% (208,000)
Overtly flavoured shisha is not traditional, nor of Canadians aged 15 years and older.4 A
are venues that have recently opened in closer look at age groups demonstrated the
Alberta.2 past 30-day prevalence among youth aged 15
Venues offering public waterpipe use promote to 19 was one percent (1% or 30,000) and
among young adults aged 20 to 24, the rate
a range of casual to luxury atmospheres,
increased to 3% (75,000).5
Tobacco, Vaping and Cannabis Program/June 2021WATERPIPES | 2
The 2018-19 Canadian Student Tobacco, Alberta Health Services (AHS) supports these
Alcohol and Drug Survey (CSTADS) reported recommendations and continues to advocate
6.9% of Grade 7-12 students had ever tried for clean air legislation to protect against
waterpipe, down from 8.6% in 2016-2017.6 exposure to waterpipe smoke.
An aspect of concern surrounding the spread Indoor public use of waterpipes in Alberta
of waterpipe use is the potential for it to exposes Albertans to carcinogens and other
impede quit attempts by those who smoke contaminants in public venues. This
cigarettes or serve as a bridge to cigarette undermines the fundamental objective of
smoking among young people.7 This worry provincial legislation which is to protect
has been echoed in a recent systematic Albertans from exposure to carcinogens and
review which concluded that waterpipe other contaminants in public venues.
tobacco smoking is associated with more than
Cities/municipalities in Alberta including Red
doubling of the odds of later initiation of
Deer, Cold Lake and Spruce Grove have
cigarette smoking.8
made strides by enacting bylaws to prevent
In order to maintain a downward trend in indoor waterpipe use. On July 1st, 2020 a ban
prevalence rates, prevention and policy on all waterpipe smoking in public places
measures for waterpipe must remain a comes into effect in the city of Edmonton.
priority.
As public waterpipe venues do not require a
The trend of banning public waterpipe unique business license, accurate information
use on the number of venues in Alberta is not
readily available. A scan of waterpipe lounges
Over the last decade, public waterpipe use in Alberta indicates at least 30 in operation in
was banned in Syria, Lebanon, Turkey, and cities/towns where bylaws do not exist.
Jordan.9,10,11,12 As of March 31, 2018 New
Brunswick, Newfoundland/Labrador, Nova Despite a ban on other flavored tobacco
Scotia, Prince Edward Island and Quebec products since 2015, a subsequent review of
have all banned waterpipe in public spaces.13 the Tobacco and Smoking Reduction Act in
A growing number of cities and communities 2019 and the introduction of Bill 19 - The
in British Columbia and Ontario have also Tobacco, Smoking and Vaping Amendment
implemented waterpipe bans.14 Alberta’s Act in June 2020, flavoured waterpipe and
Tobacco and Smoking Reduction Act vaping products continue to be available in
continues to provide an exemption that Alberta.
permits the use of waterpipes in public Tobacco product labelling
establishments.
In the past, testing conducted by public health
Alberta Health’s Office of the Chief Medical officials in Ottawa, Toronto and New York City
Officer of Health recommended in 2012 that has determined that tobacco was present
waterpipe use should be prohibited in within products sold at lounges, although
enclosed public places and work-places, and customers were told that the items were
within five metres of entrances, windows and tobacco free.16 Testing is logistically difficult
air intakes in public venues and workplaces.15
Tobacco, Vaping and Cannabis Program/June 2021WATERPIPES | 3
and capacity to comprehensively test shisha than that of tobacco products.20 The same
products for tobacco content is insufficient. research study also found toxic trace metals
Some waterpipe venues in Alberta prepare and carcinogens – at levels equal to or
their own “mixes” of shisha, using Red Bull or greater than those in cigarettes – in three raw
Monster Juice, which adds to the complexity herbal shisha products tested.21
of monitoring these products. However, it
Air quality in shisha venues affects not only
does not change the health risks associated
owners/operators of waterpipe venues, but
with the products.
also employees. If the waterpipe venue is part
In order to increase awareness of health risks of a multi-unit building, people in adjacent
and effects associated with tobacco use, units may also be adversely affected.
Health Canada has proposed to make Ventilation is not an option because a
changes to health-related labelling of tobacco ventilation system with the technology to
products.17 The Forward Regulatory Plan eliminate the carcinogens in tobacco smoke
2019-2021: Tobacco Products Labelling does not exist.22
Regulations also proposes new requirements
The recent outbreak of the 2019 novel
for labelling on products such as waterpipe
coronavirus (a.k.a. COVID-19), has prompted
tobacco, which are not currently subject to
considerations of public health policies and
any labelling requirements.
the risks of smoking and vaping in the
Waterpipe smoking and disease transmission, trajectory and outcomes of
infectious diseases. Studies of infectious
Tobacco smoke from waterpipes has been viruses, including the novel coronavirus,
linked to diseases also known to be indicate they can remain viable and infectious
associated with cigarette use. Such diseases in aerosols and on surfaces, for long periods
include malignancies, cardiovascular disease, of time.23,24 The risk of disease transmission
lung diseases, pregnancy complications, oral through frequent hand to mouth contact is
or dental complications, hematologic well-established. Waterpipes are also said to
disturbances and genetic abnormalities.18 increase a person’s exposure to harmful
The charcoal used to heat waterpipes adds microorganisms due to moisture conditions
additional health risks as it produces high that encourage their development and device
levels of CO, metals and cancer-causing structures that make proper cleaning and
chemicals.19 sanitization difficult.25
Alberta's own research has found that even The communal nature of waterpipe smoking
the non-tobacco, or “herbal” shisha products within social settings includes using a single
used in waterpipes produce toxic air mouthpiece and hose, shared between users,
pollutants – including carbon monoxide, often in restaurant and/or lounge settings.26,27
volatile aldehydes and polyaromatic Waterpipe users are therefore also at an
hydrocarbons. In fact, both the main-stream increased risk of communicable diseases like
and second-hand smoke produced by herbal herpes and meningococcal disease that are
shisha contained these known cancer- transmitted through sharing waterpipe
causing agents at levels equal to or greater mouthpieces.28
Tobacco, Vaping and Cannabis Program/June 2021WATERPIPES | 4
With regard to tobacco and nicotine The findings of the review amidst public
dependence, a review examining whether health concerns regarding the growing
waterpipe smoking supports dependence in popularity of waterpipe smoking demonstrates
its users is aptly summarized by the the importance of public health action on
following:29 waterpipe use. Informing the public of the
risks of waterpipe use (including nicotine
• waterpipe smoking delivers active
dependence) and ensuring waterpipe
doses of dependence-producing
smoking is included in the same public health
nicotine
policies as cigarette smoking is a vital
• waterpipe tobacco smokers may
component of current tobacco control
engage in waterpipe use on a daily
interventions.30
basis
• waterpipe tobacco smokers do For more information, please contact Alberta
experience withdrawal, alter their Health Services Tobacco, Vaping and
behaviours to access waterpipes, and Cannabis Program at
have difficulty quitting. tru@albertahealthservices.ca.
References
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http://www.ncbi.nlm.nih.gov/pubmed/15995011 The National World. (2014)Tougher enforcement of Jordan
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Vanderhoek, A., Huynh, C., Plateel, G., Finegan, B. (2013).
Respiratory Medicine. 108(5), 661-667.
‘Herbal’ but potentially hazardous: An analysis of the constituents 26
P. Koul, M. Hajni, M. Sheikh, U. Khan, A. Shah, Y. Khan, A.
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21 Journal of Cancer Prevention, vol. 12, no. 2, pp. 519-24, 2011.
Ibid
22
27
C. Tan and S. Glantz, “Association between smoke-free
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28
Prevention, Coordinating Center for Health Promotion, National Supra, note 12.
29
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Ibid
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