Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 Convention for Tobacco Control. Also our findings from focus group participants indicted that waterpipe ornamented hoses and other innovations in flavouring were designed to draw in consumers. Similarly, innova- tions in cigarette design have been key to the tobacco industry’s success since the 19th century [23] and have long been a strategy followed by multinational tobacco companies to encourage smoking. Research on tobacco industry documents has revealed that the industry has specifically altered cigarette design to target women [24], altering design features such as packaging, length, flavours, among others. Recently, flavoured cigarettes are an innovation of the tobacco industry [25]. More specifically, candy flavoured cigarettes have been manu- factured to attract children [26]. With specific respect to packaging, the industry has made it more attractive “to appeal to women (p. i75)” [27]. Tobacco documents have similarly pointed to sensory characteristics as taste and smell as features manipulated by multinational tobacco companies to continue to attract consumers. For example, menthol cigarettes were introduced specifi- cally for their sensory benefit [28]. Media promotion of waterpipe was stated by partici- pants as attracting and enticing individuals to smoke. Much research on cigarettes has indicated the powerful force of advertising in promoting smoking. Pro-tobacco media has been shown to result in earlier initiation of smoking [29]. A cohort study of adolescents indicated that having a favourite cigarette advertisement in 1993 was positively related to smoking status in 1996 [30]. Understanding reasons behind the rise in waterpipe tobacco use is important if appropriate interventions are to be formulated. As evidence regarding the health effects of WTS increase, it becomes imperative that interventions are developed and tested to prevent initia- tion and promote cessation. Focus group participants referred to the lack of tobacco control policies to con- trol waterpipe smoking as contributing to the waterpipe smoking epidemic. Evidence from cigarette use confirms their statements. Policy change has been documented to be the most effective prevention and control mechanism for tobacco use. Tobacco control policy should therefore be comprehensive and include waterpipe smoking. Ban- ning WTS in public places and increasing taxation on waterpipe tobacco and price of waterpipes served in public places could stem the prevalence of WTS. Coun- tries in Europe that have adopted smoking bans in pub- lic places have faced resistance in its application in waterpipe serving establishments [31] despite all evi- dence pointing to a need to incorporate bans of WTS in indoor public places [9]. Understanding what motivates people to smoke such as the sensory qualities described in our results will help shape anti-smoking messages. Any education campaign Page 7 of 9 should also be coupled with market regulation to pre- vent the production of new flavours and innovations in design. Introduction of plain packaged waterpipe tobacco as well as waterpipe apparatuses with basic unornamented bodies could potentially reduce the allure of this method of smoking. Graphic health warnings on the waterpipe, the tobacco, and all accessories should also be required [32]. Findings from a study evaluating current practices in terms of health labelling on water- pipes and waterpipe products in Lebanon as well as few examples of waterpipe health warning practices in the UAE, South Africa, Canada, and Germany has revealed that health warning are too general, non-informative, very small in size, non-readable, and contain misleading labelling [32]. Such practices could indirectly lead users to believe that WTS is a safe alternative to cigarettes. This research has implications for public health prac- tice, advocacy, and research worldwide. A number of prevalence studies have indicated a rise in waterpipe smoking not only in the EM region but also in other developing and developed countries. For example, rising prevalence of waterpipe smoking among university stu- dents was reported by Jackson and Aveyard in the UK [5]. Findings in surveyed university students found that they had no knowledge regarding the health risks and were lured by its presence and availability within the student culture. In the US, prevalence studies are indi- cating up to 20% prevalence of waterpipe smoking in the last month among young adults [13]. In Syria, water- pipe smoking was regarded more as a pleasurable pass time with no regard for health consequences [14]. In addition, similar themes to those described herein were also observed in the qualitative findings of the larger project in other countries such as Syria, Egypt, and Palestine. Suggested specific themes that have come up from Lebanon that have influenced non smokers to start and encouraged smokers to continue are likely to be similar in other populations due to similarity of human’s response to addiction. Worldwide people smoke cigar- ettes mainly for the same reasons: social norms and pressures that lead them to initiate while their young, curiosity to try leading to addiction; advertising and pro- motion; availability and accessibility; and lack of policy regulations. There are several limitations to the research reported. One possible limitation is the inability to access the var- iation of lived experiences. However, focus groups or interviews were continued until saturation was achieved. Twenty-five focus groups is a large number in qualita- tive research and provide confidence in the breadth of experience achieved. Another main limitation is the potential bias from the researcher during analysis stages. However, this was minimized by having the entire research team construct the coding scheme. Social