Waterpipe Tobacco Smoking: A Potential Conduit of COVID-19

Mohammad Ebrahimi Kalan, Ziyad Ben Taleb, Mehdi Fazlzadeh, Kenneth D Ward, Wasim Maziak

On New Year’s Eve 2019, the outbreak of a novel infectious respiratory disease (known as Coronavirus disease 2019; COVID-19) was reported in several patients with a history of exposure to the Huanan seafood market, in multiple hospitals in the city of Wuhan, Hubei Province, China. It soon spread to other parts of the globe, spurring scientists to rapidly sequence the virus genome and develop diagnostic tests as well as initiating vaccine development and therapeutics trials. According to Johns Hopkins Coronavirus Resource Center, as of March 22th, 2020, more than 300,000 cases were reported globally with > 13,000 deaths. COVID-19 cases have been reported in several countries in the Middle Eastern region (Iran, Saudi Arabia, United Arab Emirates, Lebanon, Bahrain, Kuwait, Oman, Jordan, Qatar, Pakistan, Afghanistan, Iraq) with Iran declaring the highest number of cases and deaths in the region. The majority of these low- and middle-income countries have under-developed healthcare infrastructure and lack transparent systems capable of assessing and responding to this epidemic.

Some of the important features enabling the spread of COVID-19 infection are its long incubation period, when the asymptomatic person can transmit the virus to healthy individuals, and the virus’s ability to survive on surfaces made from a variety of materials for hours to days. These features facilitate the social transmission of the virus during daily activities and interactions of people. Given these characteristics, the potential of waterpipe tobacco smoking (also known as hookah, shisha, narghile), to facilitate the transmission and spread is a particular concern. Waterpipe tobacco smoking is widespread globally, but particularly popular in the Middle East. Estimates from different countries in the Middle East put waterpipe smoking ahead of cigarettes as the most common tobacco use method among youth, with prevalence of more than 35% in some countries. Studies from the UK and US indicate that waterpipe tobacco smoking is gaining popularity among young people amid growing evidence of health risks.

The reason why this method of smoking can pose a specific concern for the COVID-19 epidemic is that unlike cigarettes and other tobacco use, waterpipe smoking is commonly practiced in groups and special establishments, known as waterpipe cafés or lounges. Within these venues, it is not unusual for the same waterpipe to be shared by a group of friends. For example, in a study of 970 college-aged waterpipe smokers in the US, about 60% reported sharing their waterpipes with friends in cafés or lounges. Moreover, apart from the disposable mouth tip that is provided for every new customer, all other parts of the device (e.g. tubing, hose, bowl) are commonly re-used for different customers without any guidelines of necessary cleaning and sanitation measures needed to prevent the spread of infections through this route.

Features that promote the spread of COVID-19 infection and those of the social practice of waterpipe  tobacco smoking, can collide to provide a perfect storm for spreading infection among young people and in wider society. As we try to deal with the COVID-19 pandemic, attention needs to be devoted to waterpipe cafes as a potential vector for the spread of COVID-19 and other infectious agents. As a first step, waterpipe tobacco smoking needs to discouraged by all means, both for improving general health and reducing susceptibility to COVID-19. Where waterpipe use does continue, sharing needs to be prevented wherever possible, and guidelines for sanitation of reusable waterpipe components need to be developed and enforced to prevent the spread of infectious diseases such as COVID-19 through these venues.

Mohammad Ebrahimi Kalan and Wasim Maziak are with the Robert Stempel College of Public Health, Florida International University, USA. Ziyad Ben Taleb is with the College of Nursing and Health Innovation, University of Texas at Arlington. Mehdi Fazlzadeh is with the School of Public Health, Tehran University of Medical Sciences and Ardabil University of Medical Sciences, Iran. Kenneth D Ward is with the School of Public Health at the University of Memphis, USA. All authors declare no competing interests.

Corresponding Author: Mohammad Ebrahimi Kalan: mebra006@fiu.edu

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