Hookah smoking and COVID-19: call for action
============================================

* Skand Shekhar
* Fady Hannah-Shmouni

In response to the *CMAJ News* article by Lauren Vogel,1 we would like to highlight a method of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is underrecognized in Canada.

A hookah (shisha or waterpipe) is a single- or multistemmed instrument that has been used for smoking various flavoured 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 US, 2.6 million people smoke hookah, and the number of “hookah bars” has mushroomed, with 100 million hookah users globally.2,3 In Canada, its high prevalence, in particular among young adults, is a matter of growing concern.4

Smoking has emerged as an independent risk not only for transmission but also for severity of coronavirus disease 2019 (COVID-19).5 Similarly, hookahs are ideal 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 transmission of SARS-CoV-2. Furthermore, hookah tobacco smoke contains several hazardous chemicals that injure the respiratory lining and predispose the smoker to viral infections, tuberculosis and other infectious diseases, and the coronavirus is no exception.

Although not formally reported, hookah smoking (like e-cigarettes) could disproportionately increase COVID-19 in youth. Furthermore, Middle East respiratory syndrome coronavirus was also thought to be transmitted by waterpipe smoking.6

Several countries have already placed restrictions on hookah use, given the public health risks of COVID-19 transmission it poses. The cities of Cairo, Egypt, and Abu-Dhabi and Dubai in the United Arab Emirates, recently banned hookah use. In Canada, hookah use per say is legal, but it is illegal in restaurants and bars, enclosed workplaces, and other public and enclosed spaces in Ontario.7,8 Similar provisions exist in Alberta and other provinces.9

Based on recent advice from the World Health Organization10 on COVID-19 and hookah use, we suggest that hookah or waterpipe smoking should be regulated to prevent COVID-19 transmission through hookah smoking.

## Footnotes

*   **Competing interests:** None declared.

## References

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4.  Minaker LM, Shuh A, Burkhalter RJ, et al. Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey. Cancer Causes Control 2015;26:831–8.
    
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5.  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 (Engl) 2020 Feb. 28; [Epub ahead of print]. doi:10.1097/CM9.0000000000000775.
    
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6.  Alagaili AN, Briese T, Amor NMS, et al. Waterpipe smoking as a public health risk: Potential risk for transmission of MERS-CoV. Saudi J Biol Sci 2019;26:938–41.
    
    

7.  Hookahs (waterpipes) & shisha: a summary February 2014 [letter]. Toronto: Ontario Campaign for Action on Tobacco; 2014. Available: [www.ocat.org/pdf/HookahsShishaSummaryFebruary2014.pdf](http://www.ocat.org/pdf/HookahsShishaSummaryFebruary2014.pdf) (accessed 2020 Apr. 9).
    
    

8.  Smoke-Free Ontario Act, 2017. How the Act affects: waterpipe use in enclosed public places, enclosed workplaces, and other places or areas. Toronto: Ontario Ministry of Health; 2017. Available: [https://healthunit.org/wp-content/uploads/SFOA\_Waterpipe.pdf](https://healthunit.org/wp-content/uploads/SFOA_Waterpipe.pdf) (accessed 2020 Apr. 9).
    
    

9.  Waterpipe smoking in Alberta. A report by the Office of the Chief Medical Officer of Health. February 2012. Edmonton: Government of Alberta; 2012. Available: [https://open.alberta.ca/publications/waterpipe-smoking-in-alberta](https://open.alberta.ca/publications/waterpipe-smoking-in-alberta) (accessed 2020 Apr. 9).
    
    

10. Tobacco free initiative: Tobacco and waterpipe use increases the risk of suffering from COVID-19. Cairo: WHO Regional Office for the Eastern Mediterranean; 2020. Available: [www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html](http://www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html) (accessed 2020 Mar. 31).