Confronting the Emerging Threat of Hookah Bars

1. Confronting the Emerging Threat of Hookah Bars Access: Building A Tobacco-Free Future Seattle, Washington March 26, 2008

2. Presenter Michael F. Strande, J.D. Deputy Director Legal Resource Center for Tobacco Regulation, Litigation, & Advocacy University of Maryland School of Law 500 W. Baltimore St. Baltimore, Md 21201 mstrande@law.umaryland.edu 410-706-1129 · 410-706-1128 (fax)

3. What Is Hookah? • Way to smoke specially made tobacco • Involves heating the tobacco, usually with burning embers or charcoal. • Resulting smoke is filtered through a bowl of water (sometimes mixed with other liquids such as wine) and then drawn through a rubber hose to a mouthpiece.

4. What Is Hookah? Waterpipes generally consist of 4 main parts: 1. Head – where tobacco heated 2. Bowl – filled with liquid 3. Pipe – connects the bowl to the base 4. Hose / mouthpiece – through which smoke is inhaled.

5. History of Hookah • Originated in ancient Persia and India • Shisha created by mixing shredded tobacco and honey, molasses or dried fruit • Several U.S. companies manufacture and sell their own • Widely used in Mid East and imagery in pop culture Alice’s Adventures in Wonderland (1865)

6. Health Consequences of Hookah • General Perception is that Hookah is Safer • Research limited compared to cigarettes • Links made to same adverse health effects, including lung cancer and heart disease • October 2007 issue of Nicotine and Tobacco Research indicates that daily usage produces nicotine absorption levels similar to that produced by daily cigarette use

7. Health Consequences of Hookah The Facts • water cools the smoke so it feels less harsh • smoke for longer durations and inhale more deeply The Myth • water acts as a filter removing impurities • smell, taste and smoothness of sweetened tobacco provide less-irritation

8. Health Consequences of Hookah • Hookah sessions often last 40 to 45 minutes, vs. the 5 to 10 minutes it takes to smoke a cigarette. • Water does absorb some nicotine, BUT studies suggest MORE smoke is inhaled to satisfy their nicotine addiction. • Studies show double the carbon monoxide and triple the nicotine exposure when comparing one 45 minute session vs. one cigarette. • Due to the longer, deeper, more sustained period of inhalation and exposure, hookah smokers may inhale as much as 20 cigarettes during a single session.

9. Health Consequences of Hookah The Facts • Still contains tobacco • commonly used heat sources (wood cinders or charcoal), also release high levels of potentially dangerous chemicals, including carbon monoxide and metals. The Myth • less tobacco = less impurities

10. Chemicals found in hookah vs. cigarette smoke Shahadeh, A. and Saleh, R. (2005). Polycyclic aromatic hydrocarbons, carbon monoxide, “tar”, and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food & Chemical Toxicology, 43:655-661.

11. Health Consequences of Hookah • Increases the Risk of Exposure to Infectious Diseases • Shared mouthpieces and the heated, moist smoke enhance the spread of diseases, such as tuberculosis, and viruses, such as hepatitis and herpes

12. What Is A Hookah Bar? • The hookah bars market themselves as hip smoking lounges. • emphasize the “experience” of smoking a hookah and equate this with experiencing Middle Eastern culture. • Arabic décor and music are often present and in some cases belly dancers present to help create the “experience.” • Increasingly marketed to college students. • intellectually stimulating and relaxing environments where individuals can play games or socialize.

13. What Is A Hookah Bar? • The hookah bars are open late (in Md, usually until 4 a.m. on the weekends) • market themselves as the “place to be after hours.” • Those that do not serve alcohol are not regulated by any of the last call rules for alcohol establishments.

14. Web Page of ICE HOOKAH LOUNGETowson, Md Step 1: Choose Your Hookah Step 2: Choose Your Shisha Step 3: Choose Your Drink Bottled Water Soda Juice Tea

15. Regulation Via Common Law • Individual Nuisance suit • Case by Case Basis • Smoke drift into home or store • A private nuisance exists when one person unreasonably interferes with another's interest in real property. • "continuousness or recurrence of the things, facts, or acts, which constitute the nuisance." • One act, though causes injury, not enough

16. Regulation Via Legislation • Clean Indoor Air Law • Be aware of Exemptions: • Retail tobacco shops • selling primarily tobacco products and tobacco related accessories; and the sale of other items is incidental • bright line prohibitions on selling specific items (alcohol) • Cigar Bar • Private Club • Vague definition of smoking • Smoking defined as the “burning of a lighted cigarette, cigar, … or any other substance containing tobacco.” • One hookah bar in Md. attempting to switch to a leaf other than tobacco.

17. Regulation Via Legislation • Local Regulation • Legislative authority or Local Board of Health regulations • based on elimination of Nuisance or control any “cause of disease”/ spread of contagious disease” • Business Licensure Requirements • License to sell tobacco • Limit hours of operation • Limit sale of other items (alcohol; food) • Limit age of patrons • Prohibit live music and dancing (including belly dancing) unless obtain a permit.

18. Violation of Current Law? • Violation of Current Non-Smoking Restrictions • Absence of non-smoking sections? • Health Code Violation • Powers to control spread of infectious disease • Sanitary Laws • Mirage Hookah Lounge; Frederick, Md. • Not cleaning mouth piece; Going from food to shisha without handwashing • Sale of Tobacco to Minors

19. Zoning Regulations • Power to zone/control land “undoubtedly broad” • w/in police power to promote public health + safety • Late night crowds / communicable disease / preserve character of neighborhood • Limit #’s / Disperse / Concentrate in certain zone • In purely commercial / industrial zones • away from colleges and residential areas • Variances/Conditional Use Permits (CUP) – in addition, a city could require hookah bars to obtain use permits. A planning commission could be specifically directed to consider proximity to colleges/parks when issuing permits

20. Zoning Regulations • Standard of Review determined by nature of right asserted • Smoking NOT First Amendment right • use Rational Basis test • Rationally related to a legitimate state interest • Minimal burden of proof

21. Recommendations If possible enact strong Clean Indoor Air laws without exemptions If not possible to eliminate … • Regulate through current health code, youth access laws

22. Recommendations • Through permitting: • limit the hours of operation • require employees and customers to be over 18 Preventing hookah bars from being “the place to be after hours” will reduce customers’ and employees’ exposure to the dangers of hookah smoke.

23. Recommendations • Curtail the spread of infectious diseases: • require hookah bars provide individually packaged disposable mouthpieces. • While reducing spread of disease, individual mouthpieces will probably not overcome the problem entirely because respiratory droplets can still be deposited within the mouthpiece tubing and diseases can still be transferred in part due to the moist smoke. • Mandate warning sign • Limit Locations • Zone away from colleges and residential areas • Seek voluntary advertisement bans • Have colleges prohibit advertisements in college papers or on campus

24. The End Michael F. Strande, J.D. Legal Resource Center for Tobacco Regulation, Litigation & Advocacy University of Maryland School of Law 500 West Baltimore Street Baltimore, Md 21201 mstrande@law.umaryland.edu 410-706-1129 • 410-706-1128 (fax)