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CAMH Stories Centre for Addiction
and Mental Health

Health concerns identified as hookah and vapour gain popularity among young people

As traditional tobacco smoking continues to decrease, waterpipe (aka hookah) use and e-cigarettes (aka vapour) are gaining traction among young people.

These alternative smoking products are often marketed as benign and still exist in a legal/policy grey zone in many jurisdictions.

Meet three experts who are delivering the hard facts about the health effects related to the use of waterpipe and e-cigarettes.

Man smoking waterpipe

Waterpipe (hookah)

Dr. Roberta Ferrence was principal investigator of an OTRU/CAMH study that went undercover to investigate air quality in 17 waterpipe cafés. The study, titled Enter at your own risk: a multi-method study of air quality and biological measures in Canadian waterpipe cafés, concluded that air quality in indoor waterpipe cafés is hazardous to human health.

Published in the international journal Tobacco Control in 2015, the results support “eliminating waterpipe smoking in hospitality venues, indoors and out,” says Dr. Ferrence, a Senior Scientific Advisor at OTRU (Ontario Tobacco Research Unit). Carbon monoxide exposure and air-nicotine levels in the air often exceeded Ontario’s air-quality guidelines, and particulate matter levels were hazardous according to EPA (Environmental Protection Act) standards, much higher than those reported for smoking rooms in European bars and restaurants.

Dr. Roberta Ferrence
Dr. Roberta Ferrence

“Hookah smoking is on the rise among young people, who often mistakenly believe it is a safe form of smoking,” said Toronto’s Medical Officer of Health Dr. David McKeown at a June Board of Health meeting in which Dr. Ferrence outlined research.

CAMH Scientist Dr. Hayley Hamilton analyzed results of waterpipe use from the Ontario Student Drug Use and Health Survey  (OSDUHS) – which is capturing waterpipe use for the first time.

Her study confirms that waterpipe/hookah use has become popular -- and has equaled or eclipsed tobacco cigarette use -- among Ontario high school students.

  • 12.5% of students report using waterpipe in past year, versus 11% for tobacco.
  • Use is much higher in older students: 19% for grade 12s
  • There is a high awareness of waterpipe – 68%


OSDUHS  included the waterpipe use question for the first time in the latest 2013 survey. Updated results will be available in December of 2015 from this year’s survey.

A similar study in the U.S. shows consistent increases in waterpipe use among U.S. high school students. For example: among grade 12s, waterpipe use increased from 17% in 2010 to 23% in 2014.

Dr. Hamilton notes that waterpipe is marketed as less harmful than cigarettes, and more research is required on student attitudes around this. “Given the health concerns around this product, and increases in use among students, we are worried.”

What’s the real deal on waterpipe? Watch the CAMH video:

e-cigarettes

E-cigarettes have also arrived on the scene over the past few years as traditional tobacco cigarettes come under increasing controls. E-cigarettes use a heating device to deliver a flavoured vapour, which may contain nicotine, inhaled by the smoker. The products come in a range of shapes and sizes – some look almost identical to a standard tobacco cigarette. Some tobacco companies have now entered the e-cigarette business and market.

e-cigarettes
e-cigarette image courtesy of U.S. Food and Drug Administration

Approximately 15 per cent of Ontario high school students now say they have tried e-cigarettes, according to the latest CAMH survey.

Dr. Robert Schwartz, Principal Investigator and Executive Director of OTRU and a Senior Scientist in the Social and Epidemiological Research Department at CAMH, notes that in Canada, legislation prohibits the sale of e-cigarettes containing nicotine; however that ban has not been actively enforced. Meanwhile, provincial governments have been moving to apply existing tobacco controls to e-cigarettes.

Dr. Robert Schwartz
Dr. Robert Schwartz

Ontario recently proposed new regulations in Bill 45 (Making Healthier Choices Act), intended to come into effect January 2016, restricting e-cigarette sales to minors (under 19 years of age) and the point-of-sale promotion of e-cigarette products.

There are several important questions going forward, says Dr. Schwartz, including: What are the long-term effects of e-cigarette vapour, which may contain propylene glycol, various flavourings, and nicotine?

  • How much nicotine do e-cigarette users typically inhale and what are the long-term effects?
  • Are e-cigarettes addictive?
  • If e-cigarettes become normalized, what are the long-term harms for the population as a whole?


“We don’t want to wake up 20 years from now to see a new generation of young adults addicted to nicotine from e-cigarettes and experiencing health consequences.”

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