Hookah in Toronto

This infographic is based on the findings of a study by OTRU researchers that assessed air quality using multiple ambient air measures and a biomarker for exposure in both indoor and outdoor waterpipe cafes in Toronto, Canada.

Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe cafes. Tobacco Control 2015: 24; 175-181.

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Poster References

Why Study Hookah?

1. Misinformation about safety: Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. American Journal of Preventive Medicine 2009; 37:518e23; Minaker LM1, Shuh A, Burkhalter RJ, Manske SR. Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey. Cancer Causes and Control 2015 Mar 18. [Epub ahead of print]
2. Regulation and enforcement issues: Ontario Campaign for Action on Tobacco. Hookahs (Waterpipes) and Shisha: A Summary. Toronto, ON: OCAT, February 2014; Non-Smokers’ Rights Association/ Smoking and Health Action Foundation. Smoke-Free Laws Database. Available at: https://www.nsra-adnf.ca/cms/smoke-free-laws-database.html; Jawad M, El Kadi L, Mugharbil S, Nakkash R. Waterpipe tobacco smoking legislation and policy enactment: a global analysis. Tobacco Control 2015;24:i60-i65.
3. New science on exposure and hazards: Kumar SR, Davies S, Weitzman M, Sherman S. A review of air quality, biological indicators and health effects of second-hand waterpipe smoke exposure. Tobacco Control 2015;24:i54-i59.
4. More Young Canadians Are Using Hookah (%) graph: Canadian Tobacco Use Monitoring Survey data for 2006, 2011, 2012, Canadian Tobacco, Alcohol and Drugs Survey data for 2013.

What Was Measured?

1. Nicotine in tobacco smoke: US Centers for Disease Control and Prevention. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Office on Smoking and Health Atlanta, GA: Centers for Disease Control and Prevention (US); 2006.
2. Carbon monoxide (CO) A poisonous gas that you can’t see, smell or taste: Ontario Ministry of the Environment and Climate Change. Carbon Monoxide (CO). Available at http://www.airqualityontario.com/science/pollutants/carbon.php
3. Fine particulate matter (PM_2.5) Very tiny particles inhaled deep into the lungs. Particles are 30-40 times smaller than a grain of sand: Ontario Ministry of the Environment and Climate Change. Fine Particulate Matter. Available at http://www.airqualityontario.com/science/pollutants/particulates.php
4. Compare these diameters. A human hair, a grain of sand, a particle PM_2.5: United States Environmental Protection Agency. Particulate Matter.  Available at http://www.epa.gov/airscience/air-particulatematter.htm
5. According to Ontario’s Air Quality Index, a level of fine particulate matter over 91µg/m³ is very poor, with possible serious respiratory effects: Ontario Ministry of the Environment and Climate Change. Fine Particulate Matter. Available at http://www.airqualityontario.com/science/pollutants/particulates.php

What Did the Study Find?

1. Average air nicotine in ‘tobacco-free’ hookah cafés is similar to levels of nicotine in smoky bars (average of 3.27µg/m³ compared to 3.69µg/m³ in a study of European smoking venues): Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181; Lopez MJ, Fernandez E, Gorini G. et al. Exposure to secondhand smoke in terraces and other outdoor hospitality venues in eight European countries. PloS ONE 2012;7:e42130
2. 2 hours exposure in a Toronto hookah café = 10 cigarettes smoked (based on CO levels): Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181.
3. Compared to outdoor air, hookah cafes had 4 times higher PM_2.5 on patios/69 times higher PM_2.5 inside cafes/89 times higher CO inside cafes: Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181.
4. Fine Particulate Matter Exposure (PM_2.5) in µg/m³ (graph):
   • Outdoor Air – 21µg/m³: Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181; Environment Canada.  Ambient levels of fine particulates. Available at https://www.ec.gc.ca/indicateurs-indicators/default.asp?lang=en&n=029BB000-
   • Toronto Hookah café – patio average, 80.5µg/m³: Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181.
   • Hazardous level – 91µg/m³: Ontario Ministry of the Environment and Climate Change: Fine Particulate Matter. Available at http://www.airqualityontario.com/science/pollutants/particulates.php
   • Forest Fire – 250µg/m³ (short-term peak background): McKendry I. Background Concentrations of PM_2.5 and Ozone in British Columbia, Canada. British Columbia Ministry of Environment, March 2006. Available at http://www.bcairquality.ca/reports/pdfs/background_pm25_ozone.pdf
   • Toronto hookah café – inside average, 1400µg/m³: Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181.

What About Legislation?

1. 10+ Ontario municipalities ban or restrict hookah: Non-Smokers’ Rights Association/ Smoking and Health Action Foundation. Smoke-Free Laws Database. Available at: https://www.nsra-adnf.ca/cms/smoke-free-laws-database.html.
2. 3 Provinces legislate hookah use: AB, QC, NS: Non-Smokers’ Rights Association/ Smoking and Health Action Foundation. Smoke-Free Laws Database. Available at: https://www.nsra-adnf.ca/cms/smoke-free-laws-database.html.
3. Many Middle Eastern countries ban or restrict hookah, including Jordan, Syria, Lebanon, Dubai, Saudi Arabia, and Turkey: Ontario Campaign for Action on Tobacco. Hookahs (Waterpipes) and Shisha: A Summary.  Toronto, ON: OCAT, February 2014.

The Bottom Line

1. Particulates and CO found in Toronto hookah cafes are hazardous to the health of smokers, nonsmokers and particularly to café staff who are exposed regularly for longer periods: Zhang B, Haji F, Kaufman P, Muir S, Ferrence R. ‘Enter at your own risk’: a multimethod study of air quality and biological measures in Canadian waterpipe Cafes. Tobacco Control 2015: 24; 175-181.