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Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina
  1. Andrew B Seidenberg1,
  2. Elizabeth N Orlan1,
  3. Mark J Travers2,
  4. Erin L Sutfin3
  1. 1 Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2 Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
  3. 3 Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Andrew B Seidenberg, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; aseiden{at}


Background After North Carolina (NC) fire inspectors detected unsafe carbon monoxide (CO) levels inside several waterpipe cafés, the state fire code was amended to include provisions regulating waterpipe cafés, adding a requirement for air ventilation. These regulations apply to new buildings constructed after 1 January 2016, but can be enforced for older buildings where there exists a distinct hazard to life. We measured air quality at a sample of waterpipe cafés before and after the starting date of this regulation and collected information on presence of air ventilation.

Methods Air quality (CO, fine particulate matter (PM2.5)) monitoring was conducted inside and outside of six waterpipe cafés in NC in September of 2015 (time 1) and September of 2016 (time 2). In addition, questionnaires were administered to managers from each waterpipe café at time 2 to determine the presence of air ventilation systems.

Results Elevated levels of CO and PM2.5 were found inside waterpipe cafés at time 1 (median CO=42 ppm; median PM2.5=379.3 µg/m3) and time 2 (median CO=65 ppm; median PM2.5=484.0 µg/m3), with no significant differences between time periods (p>0.05). Indoor levels were significantly higher than levels outside cafés at both time periods (p<0.05). All waterpipe cafés reported having an air ventilation system that was installed prior to time 1 air monitoring.

Conclusions Unsafe levels of CO and PM2.5 were observed in waterpipe cafés in NC, despite reported use of air ventilation systems. Prohibiting indoor waterpipe smoking may be necessary to ensure clean air for employees and patrons.

  • secondhand smoke
  • non-cigarette tobacco products
  • public policy

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  • Contributors ABS conceptualised the study, conducted statistical analyses and led the writing of the manuscript’s draft. ENO, ELS and MJT helped draft and revise the manuscript.

  • Funding ABS was supported by the UNC Lineberger Cancer Control Education Program (R25 CA57726). MJT was supported by the Roswell Park Comprehensive Cancer Center and National Cancer Institute (NCI) grant P30CA016056

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval UNC and Wake Forest School of Medicine IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.