Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 R E S E A R C H A R T I C L E Open Access The rise in narghile (shisha, hookah) waterpipe tobacco smoking: A qualitative study of perceptions of smokers and non smokers Rima T Nakkash, Joanna Khalil and Rema A Afifi* Abstract Background: The prevalence of waterpipe tobacco smoking (WTS) in the Middle East region and worldwide is increasing. There is evidence to indicate both short term and long term health effects of WTS, resulting in the issuance of an advisory note by the World Health Organization. Methods: This research aimed at gaining an in-depth understanding of the factors contributing to the rise in WTS in Lebanon. Qualitative focus groups (25) and in-depth interviews (9) were conducted with adults in Lebanon in 2007. Participants were recruited to represent diversity in smoking status, gender, age groups and urban/rural residence. The interviews and focus groups were thematically analyzed, and recurrent themes noted and summarized. Results: The main themes identified were availability, affordability, innovation, influence of media, lack of a policy framework, and the sensory characteristics evoked from WTS. Men and women, smokers and non-smokers, and younger and older participants differed in their emphases on the above themes. These themes, though specific to waterpipe, are similar to themes manipulated by the cigarette industry, and eventually controlled through tobacco control policies. Conclusions: Understanding reasons behind the rise in waterpipe tobacco use is important if appropriate prevention, cessation, and policy interventions are to be formulated. Strict adherence to the FCTC is warranted, with careful and vigilant attention that all tobacco products are covered by laws in both high as well as middle to lower income countries. Keywords: Waterpipe tobacco smoking Lebanon, Qualitative Research, FCTC Background The prevalence of waterpipe (aka narghile, shisha, hoo- kah) tobacco smoking (WTS) in the Middle East region and worldwide is increasing [1]. Youth WTS is on the rise as compared to cigarette smoking [2,3]. In Lebanon, the Global Youth Tobacco Survey (GYTS), administered to 13-15 year olds in 2005, indicated that 59.8% smoked other forms of tobacco (most likely waterpipe) at least once in the past month as opposed to 10% cigarettes. Compared to 2001, cigarette use among 13-15 year olds in Lebanon has decreased while use of other tobacco products has increased [2]. A cross sectional study of * Correspondence: ra15@aub.edu.lb Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon 1964 university students, conducted in Beirut, Lebanon, in 2001, reported use of waterpipe exclusively to be 21.1%, 7.6% only cigarettes, and 11.3% both [3]. In other countries in the region, similar trends are observed. GYTS results evaluating the trends of tobacco use among 13-15 year olds between 1999 and 2008 indi- cated that in all countries of the Arab region, use of tobacco products other than cigarettes (most likely waterpipe) was more common than use of cigarettes [4]. Although not as widespread in the West, WTS remains an impending threat. In a study in Arizona, USA of 6594 middle and high school students during the 2004- 2005 school year, WTS was the third most common source of tobacco consumption after cigarettes and cigars [5]. Similarly in the UK, in a cross-sectional © 2011 Nakkash et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.