The use of substances that contain nicotine has been rampant throughout history in social and ritualistic functions. Hookah smoking is increasingly gaining popularity in Canada due to the belief that it is less harmful compared to cigarette smoking. Known by several names such as water-pipe smoking , shisha smoking, and goza, hookah use presents a serious health concern, given that its use is on the rise worldwide, particularly among the youth. While water-pipe smoking is common among all age groups, it is mainly popular with the youths, who are a more energetic group in society. Consequently, the socio-economic, mental health, and public health impacts of hookah smoking presents a serious burden to the nations affected, given that the youths form the lifeblood of society. Water-pipe smoking often occurs in social settings, including private residences and in lounges that offer ready-to-smoke hookah to customers. Recent public discourse by individuals concerned about the negative impacts of nicotine-laced substances and the effects of smoking, coupled with anti-cancer campaigns, have advocated for severer hookah regulations in an effort to ban and stop the use of hookah in enclosed public spaces. Specifically, the city of Toronto endorsed a law in 2017 that allowed health officials to commence an official crackdown on licenced hookah suppliers (Katawazi, 2020) . In a 2015 article published by PMC, Cancer Causes and Control noted that Canadian youth are increasingly turning to water-pipe smoking due to the strict rules that discourage the use of cigarette. Moreover, there have been numerous public education and awareness creation that sensitize youths on the harmful effects of cigarette smoking (Minaker et al., 2015). Proponents of using the hookah argue that shisha is relatively harmless, and the fact that it has not been flagged as raw tobacco demonstrates that it is safer. Additionally, supporters of shisha use contend that herbal tobacco-free shisha molasses, hookah gels, steam stones, and hookah paste are tobacco and nicotine-free and provide relaxation benefits without the harmful effects of nicotine (Akl et al., 2011). On the contrary, opponents of water-pipe use maintain that there is less control over when nicotine-laced products may be used in a hookah, adding that shisha use poses a great risk in the fight against the popularization of tobacco products ( Fevrier et al., 2018). Overall, the use of hookah poses greater public health concern, especially among the younger Canadian users, and policy recommendations are necessary to address this issue.
Proponents of water-pipe smoking contend that it is safer, arguing that hookah smoking imparts considerably lower nicotine than cigarettes. However, study findings have reported that nicotine exposure is roughly equal between smoking cigarettes and smoking water-pipe ( Sutfin et al., 2014). In fact, in some cases, depending on the smoking habit and the tobacco product, nicotine intake may be greater with hookah smoking. According to Sutfin et al. (2014) , water-pipe smokers are exposed to nicotine, which is highly addictive, along with toxicants and carcinogens including benzene and nitrosamines that put them at increased risk of developing charcoal-related and tobacco-related preventable chronic and acute illnesses. Moreover, hookah smoking has been linked with increased risk of oral cancers, lung cancer, and heart disease. Additionally, following that the substance is often smoked in social settings, the public, including non-users, are exposed to indoor air quality that is harmful to human health because of the carcinogenic and toxic chemicals including carbon monoxide, ultrafine particles, nicotine, and polycyclic aromatic hydrocarbons. Recent research findings have revealed that hookah cafes and bars have been increasing in Canada due to their exemption from certain clean indoor air laws. The increase in the number of such lounges has also been attributed to the absence of public health interventions to create awareness to the youth about the detrimental effects of water-pipe use, and the perception that water-pipe smoking is safer compared to cigarettes.
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Supporters of hookah use also argue that the water pipe’s smooth smoke demonstrates that the substance is less toxic. Nonetheless, opponents of hookah smoking contend that the smoke is smooth as a result of the pipe’s moisture, adding that the smoothness has nothing to do with toxicity. Research findings by Qasim et al. (2019) have also indicated that the smoke appeals to smokers due to the fruity flavors that disguise the product’s real taste, making smokers believe that hookah is not dangerous. Studies have revealed that the smoke contains numerous toxins that can decrease chances of fertility and cause bladder and lung cancers. Importantly, nicotine, a substance found in shisha, has been cited to act as a gateway drug that opens the door to the use and abuse of illicit drugs. According to research findings, nicotine makes the brain to be more vulnerable to cocaine addiction ( Qasim et al., 2019) . The researchers suggested that lowering the rates of smoking among the youths can help minimize abuse of illicit drugs.
Proponents of using the hookah further state that the water in the base of the pipe play a critical role in filtering out toxins. However, opposing views maintain that if the water essentially filters the toxins, it does not lower the health risks associated with using water-pipe. A study by Pratiti & Mukherjee (2019) supported this claim by reporting that even after passing through water, the smoke still contains high volumes of toxic substances. Pratiti & Mukherjee (2019) noted that although the water absorbs some of the toxic agents such as nicotine, hookah smokers can still get exposed to a high dose of the substance to cause addiction. Overall, nicotine intake is a critical regulator of intake of tobacco, as demonstrated by the fact that cigarette smokers often smoke until they consume enough nicotine to satisfy their addiction and urge, but not to a level that can cause nausea. Therefore, there is a likelihood that the reduced nicotine concentration in the hookah smoke can lead to users inhaling higher volumes of smoke, consequently exposing themselves to greater amounts of cancer-causing substances and hazardous gases, including carbon monoxide, compared to when no nicotine was absorbed by the water. The implication is that the absorption of nicotine by the water puts water pipe smokers as well as passive smokers at increased risk of developing respiratory diseases, heart disease, and cancer. A study by Akl et al. (2011) demonstrated that shisha smoke contains numerous chemical substances such as heavy metals, including cobalt, lead, arsenic, chromium, and nickel, in higher concentration than cigarette smoke. Moreover, longer duration of waterpipe smoking sessions have been found to lead to greater nicotine exposure compared to cigarette smoking, with recent research findings adding that the amount of carbon dioxide inhaled during shisha sessions can be ten times higher than those inhaled from cigarette smoking.
Supporters of shisha smoking also maintain that the fruit added to the substance has a health benefit. To counter this argument, opponents of waterpipe smoking contend that fruit flavouring does not contribute to the users’ daily vegetable and fruit quota. Rather, the fruit is just for flavouring. According to Minaker et al. (2015) , advertisements for water pipe mislead viewers by stating that smokers can experience numerous benefits and little or no harmful effects. As a consequence, people tend to underestimate the danger shisha can have on their health. Although the flavors are alluring and the social aspect of hookah smoking enticing, the reality is that smokers still burn tobacco and inhale harmful chemicals that can cause lung disease, heart disease, and cancer. According to Minaker et al. (2015) , an hour of inhaling water pipe smoke exposes users to a correspondent impact of smoking one hundred cigarettes, implying that smoking shisha is not a safer alternative.
Shisha smoking has also been linked to numerous socio-economic impacts on Canadian society. A study by Patel et al. (2019) indicated that hookah smoking leads to addiction, mainly because of the addictive psychoactive substances such as nicotine. This addiction compels poor smokers to engage in criminal activities to raise funds to purchase the product, leading to an increased rate of crime. Moreover, shisha use contributes to adult mortality in Canada, with smokers facing an increased risk of premature deaths compared to non-smokers. The illnesses and deaths caused by shisha-related complications pose a financial burden to the state and to the families of the departed, who have to use financial resources for treatment and funeral arrangements ( Patel et al., 2019) . Water-pipe smoking has also been associated with poverty and poor education, given that addicted teenagers are unlikely to focus on their academics, further leading to a lack of skilled manpower, which translates into joblessness and poverty.
In addition to the public health and socio-economic impacts, shisha use presents mental health burden. Studies have established that water-pipe smokers have self-reported mental dysfunction, although the level of mental health impact is lower than that reported by cigarette smokers ( Katawazi, 2020) . In particular, shisha users exhibit depressive symptoms and higher levels of anxiety. There is evidence that hookah use can increase the risk of depression and that smokers experience regular stress, particularly when they are unable to afford the addictive products. According to Katawazi (2020), understanding the causal connection between shisha use and mental health impacts can help the Canadian government to design an effective intervention for youths. In particular, it can be critical in ensuring that the algorithms for substance use treatment address mental health issues. The authors stress that the associations are mainly relevant to healthcare specialists who are responsible for mental health diagnoses of individuals who fall victims to substance-use related mental complications. Nonetheless, the researchers note that future researchers should exploit the valuable opportunity of considering population-based interventions among such victims.
In conclusion, hookah smoking presents greater public and mental health concerns, with considerable socio-economic impacts on the Canadian government and societies. Consequently, the legal response to ban hookah use was merited, unlike the common view that it was an overblown judicial activist outcome targeting a harmless behaviour. Policy recommendations are, therefore, necessitated to address the increasing use of shisha among Canadian youths. The reason is that the study findings reviewed indicate that there is a high prevalence of water-pipe smoking among teenage and youthful Canadians, implying that the consequences of such behavior among the youthful Canadian population can be far-reaching and disastrous. Notably, there is a lack of awareness programs as well as misconceptions that shisha use is harmless and beneficial. The reality is that the substance is as harmful as cigarette smoking, given that hookah smoke contains high amounts of toxic substances, even after it passes through water. Moreover, the charcoal used to heat the substance emits high amounts of carbon monoxide as well as other disease-causing chemicals. Therefore, there is a need for enactment of preventive programs that comprehensively highlight the detrimental effects of hookah use on public health, mental health, and its socio-economic impacts on society at large. Importantly, the topic should be included into the medical school syllabus so that healthcare professionals can be better prepared to take the responsibility of managing and controlling the social menace effectively. Researchers have also recommended that the Canadian government should introduce more anti-smoking programs in an attempt to minimize the use of tobacco products among the youths. These policies can include the prohibition of promotion and sales of such products to minors, ban of sponsorship, promotion, and advertising of shisha, and compulsory health warnings on the products, television programs, and theatres. Importantly, smoking of shisha in public places should be banned to reduce the usage of the substance in Canada. Additionally, the government should implement a policy of price increase that seeks to discourage the purchase and use of hookah.
References
Akl, E. A., Gunukula, S. K., Aleem, S., Obeid, R., Abou Jaoude, P., Honeine, R., & Irani, J. (2011). The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC public health , 11 (1), 1-12.
Fevrier, B., Vidourek, R. A., & Privitera, P. (2018). Policy implications and research recommendations: A review of hookah use among US college students. Journal of community health , 43 (5), 1012-1018. DOI: 10.1007/s10900-018-0502-4
Katawazi, M. (2020). Toronto proposes harsher hookah rules banning use at all enclosed public spaces, patios. CTV News. https://toronto.ctvnews.ca/toronto-proposes-harsher-hookah-rules-banning-use-at-all-enclosed-public-spaces-patios-1.4807308.
Minaker, L. M., Shuh, A., Burkhalter, R. J., & Manske, S. R. (2015). Hookah use prevalence, predictors, and perceptions among Canadian youth: findings from the 2012/2013 Youth Smoking Survey. Cancer causes & control : CCC , 26 (6), 831–838. https://doi.org/10.1007/s10552-015-0556-x
Patel, M. P., Khangoora, V. S., & Marik, P. E. (2019). A review of the pulmonary and health impacts of Hookah use. Annals of the American Thoracic Society , 16 (10), 1215-1219.
Pratiti, R., & Mukherjee, D. (2019). Epidemiology and adverse consequences of hookah/waterpipe use: A systematic review. Cardiovascular & Hematological Agents in Medicinal Chemistry (Formerly Current Medicinal Chemistry-Cardiovascular & Hematological Agents) , 17 (2), 82-93.DOI: 10.2174/1871525717666190904151856.
Qasim, H., Alarabi, A. B., Alzoubi, K. H., Karim, Z. A., Alshbool, F. Z., & Khasawneh, F. T. (2019). The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environmental health and preventive medicine , 24 (1), 1-17.
Sutfin, E. L., Song, E. Y., Reboussin, B. A., & Wolfson, M. (2014). What are young adults smoking in their hookahs? A latent class analysis of substances smoked. Addictive behaviors , 39 (7), 1191-1196.
