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Hookah smoking and COVID-19: Call for Action

  • Skand Shekhar, Section on Endocrinology & Genetics (SEGEN), National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland
  • Other Contributors:
    • Fady Hannah-Shmouni, Section on Endocrinology & Genetics (SEGEN), National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland
6 April 2020

A hookah (shisha or waterpipe) is a single or multi- stemmed instrument used for smoking various flavored substances such as cannabis, tobacco and opium for centuries and is popular in the Indian subcontinent, the Arabian peninsula, Kenya, South Africa, Turkey, United States and Canada.  Across the United States, 2.6 million people smoke hookah with a recent mushrooming of ‘hookah bars’ with 100 million hookah-ers globally.1,2 Comparably, in Canada its high prevalence particularly among young adults is a matter of growing concern.3 

Smoking has emerged as an independent risk not only for transmission but also COVID-19 severity.4 Similarly hookahs are an ideal mode for transmission and may exacerbate the risk for severe COVID-19 through shared use. They have difficult-to-clean, long pipes and a cold water reservoir, ideal for coronavirus transmission. Further, hookah smoke contains several hazardous chemicals in addition to  tobacco that injure the respiratory lining predisposing the smoker to viral infections, tuberculosis and other infectious diseases and the coronavirus is not exception. Though not formally reported, hookah smoking (like e-cigarettes) poses a threat of disproportionately increasing COVID-19 in the youth. Furthermore, MERS-CoV, another coronavirus infection, was also thought to be transmitted by waterpipe smoking.

Several countries have already placed restrictions on hookah use given the public health risks of COVID-19 transmission it poses. In Cario, Egypt a recent ban on hookahs was imposed with the cities of Abu-Dhabi and Dubai in UAE, also banning hookah use. In Canada, the legality of hookah varies by province - it is illegal in Ottawa and parts of Alberta but it remains legal in other provinces.

Noting the recent WHO advice5 on COVID-19 and hookah use, we suggest that hookah or waterpipe smoking should be regulated to ensure restriction of COVID-19 transmission through hookah smoking.

Competing Interests: None declared.
References 
1. Prevention CfDCa. Tobacco Product Use Among Adults — United States. November 9, 2018 2017.
2. Akl EA, Gunukula SK, Aleem S, et al. The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health. 2011;11(1):244.
3. Minaker LM, 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 Control. 2015;26(6):831-838.
4. Liu W, Tao Z-W, Lei W, et al. Analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease. Chin Med J. 9000;Publish Ahead of Print.
5. Mediterranean WHOROftE. Tobacco and waterpipe use increases the risk of suffering from COVID-19. Tobacco Free initiative. 2020. http://www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html. Acc
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