Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 students, housewives, employed, unemployed and retired people were all part of the sample. None of the partici- pants who were approached for an interview or to take part in a FGD refused. The interview guide was pretested prior to data collec- tion and covered the following topics: reasons behind WTS, a description of the state of mind of waterpipe smokers, perceived image of women smoking waterpipe and women smoking cigarettes, as well as the enabling and deterring factors behind WTS. Consent was obtained prior to the initiation of data collection. The researcher would read the consent form to all the participants, explaining the purposes of the research, that participation is voluntary, that they may stop the interview at anytime and that confidentiality of records is ensured. Following their approval to join the discussion, their consent to record the discussion was also obtained. Whenever possi- ble, the interviews and focus groups were conducted in natural settings and in Colloquial Arabic. The discussions were recorded and on average took one hour. All inter- views and focus groups were transcribed in their original language in order not to lose meaning in translation. Ethical approval was granted by the American University of Beirut Institutional Review Board. Thematic analysis was the method of choice to exam- ine the transcripts. It is a process of coding qualitative data using a list of themes or patterns found in the tran- scripts, ranging from a simple description of observation to interpretation of phenomenon [17]. A coding scheme was developed following a joint meeting of researchers from all countries after deep immersion and multiple readings of transcripts. This allowed for joint practice in coding and subsequent discussions about the appropri- ateness of each code. Development of codes and themes was inductive and arose from the discussions. The final coding scheme consisted of 11 themes (and 61 sub- themes) (Table 1). All the transcripts were then coded by one researcher in Lebanon. Coding is an essential step in the organization, processing and analysis of qua- litative information and leads the way for the interpreta- tion phase [17]. Following the analysis of each theme, the research team in Lebanon used to meet and review all the sub-themes and related quotes; disagreements were resolved by discussion among the team members or by going back to the original transcripts and consult- ing with the field researcher. This manuscript includes the themes related to sensory characteristics, consumerism, and intervention. To further illustrate themes, we include quotes from the interviews and FGDs. Use of quotes is common in quali- tative research to “support researchers claims, .. illumi- nate experience, evoke emotions ..” [18]. Each quote is followed by the gender of the participant, smoking status and age. The quotes that clearly express the themes were Table 1 List of themes Themes that emerged from the regional study Themes covered in this paper 1. Socio-cultural norms 2. Sensory Characteristics of waterpipe 3. Pros and cons of waterpipe preparation 4. Metaphors 5. Consumerism (Availability, Affordability, Frequency, Cost, Innovation) 6. Indicators of dependence of waterpipe smoking 7. Comparison between cigarettes and waterpipe 8. Health effect of smoking 9. Motivation to smoke (Coping, Entertainment, State of mind, Boredom) 10. Intervention (Media, Awareness, Policy, Regulations, Government role) 11. Tradition Page 3 of 9 ✓ ✓ ✓ selected with variability in the choice of smoking status, gender, and age groups to show discord or unanimity. Results Participants identified the themes of availability, afford- ability, innovations in design, sensory qualities of WTS smoking, media influence, and policy. Availability of the waterpipe in the public sphere Availability of the waterpipe in the public sphere, parti- cularly in cafés and restaurants was thought to have contributed to the increase in its use and to moving the location of smoking from homes to the public sphere. FGD participants stated that availability contributed towards motivating “those who don’t even want to try, to go ahead and try” (female non-smoker - urban area). More women, younger age groups, and smokers noted widespread availability as the reason behind the increase in WTS. An expansion in the availability of waterpipes in food serving establishments was noted across all cate- gories and was described as a recent “trend”. “...an emerging fad... 10 years ago, we were not used to seeing waterpipes. Nowadays... the first thing you [people] ask about [when entering a restaurant]: do you have waterpipes? ... The waterpipe is fundamen- tal for everything. The restaurant is doing well because it has waterpipes. The evening is going well because the waterpipe is available... in every place there is the waterpipe, in every setting...” (Female smoker-urban area) Moreover, FGD participants stated that restaurants and cafés have come to realize that offering waterpipes