Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 survey of students of Birmingham University, WTS was recognized as an impending public health threat as 37.9% of students had ever tried waterpipe and 8.0% were regular smokers, as compared to 9.4% regular cigarette smokers [6]. WTS is not a safe alternative to cigarettes [7]. Studies using a smoking machine to test toxicant yields in lab environments found that waterpipe tobacco smoke con- tains carbon monoxide, polyhydrocarbons, formalde- hyde, nitrogen, nitric acid, nicotine [7,8] and other toxicants such as arsenic, chromium, lead and volatile aldhehydes [9]. Health risks include [10,11] in the short term developing dependence and acute respiratory dis- eases and lung impairment. Other more serious negative health outcomes include risk of developing cancers, including lung cancer and other chronic diseases such as cardiovascular and respiratory diseases. During preg- nancy, waterpipe smoking can lead to low fetal birth weight [12]. In addition, exposure to second hand smoke from waterpipe smoke poses a serious health risk to non smokers. Other health risks include the spread of infectious diseases, such as Tuberculosis, due to the sharing of the waterpipe among smokers [11]. Despite this knowledge, the health risks of WTS remain largely unrecognized by the lay public [1,13]. For example, a qualitative study in Syria reported people’s views of waterpipe smoking as a pleasurable activity among friends with no regard to health consequences [14]. Understanding the factors contributing to the rise in WTS is important to develop properly tailored preven- tion, cessation, as well as policy interventions. As part of a regional study in Lebanon, Syria, Palestine and Egypt, a qualitative investigation was carried out to understand waterpipe smokers and non smokers’ views of the rea- sons behind the spread of WTS. This manuscript will review the reasons given to explain this increase in WTS in Lebanon. Methods The re-emergence of WTS in the EMR region has been documented [10]. The reasons for this re-emergence and the meaning attributed to WTS have yet to be clearly described. Qualitative methods are uniquely sui- ted to studying phenomena in their naturally occurring setting, and understanding phenomena “in terms of the meanings people bring to them” [15,16]. Focus group discussions (FGD) and in-depth interviews were con- ducted. Men and women, waterpipe smokers and non- smokers were recruited and assigned to different FGDs by gender and waterpipe smoking status, with conscious intent to include women smokers and non-smokers, and men smokers and non-smokers of waterpipe. As for age, participants from four different age groups were recruited: 18-25 yrs, 26-35 yrs, 36-65 yrs, and 65+ years Page 2 of 9 old. Participants were recruited from 2 different areas in Lebanon: Beirut and Bekaa. Participants from Beirut, liv- ing in the capital, were recruited from urban areas; and participants from the Bekaa were mainly recruited from rural areas. Differences in socio-economic status and religion, as well as variability in marital and employment status were monitored throughout the recruitment pro- cess. Thus, if we noted that we were getting too many single participants, we would consciously work on approaching married persons to participate. Similarly, if we noted that many participants were employed, we would then focus on recruiting non-employed participants. Interviews and FGD complemented each other. Dur- ing interviews, participants tended to share insights related to their personal WTS experience; their connec- tion with the apparatus, their unique reasons for smok- ing it; while in FGDs, especially when conducted in natural settings - such as in cafés, restaurant, at the uni- versity, or at home, the researcher was able to observe the social and cultural dynamics of WTS such as water- pipe smokers’ interaction with each other, and with their surrounding environment. Interviews were mainly conducted with persons who were identified to us as heavy waterpipe smokers for a deeper understanding of their experiences. Participants were recruited in cafés, universities, through home visits, and other public places, following a snowballing technique, where one person would put us in contact with his/her friends who either favoured or disfavoured WTS. Interviews and FGDs were con- ducted by a researcher holding a Master of Public Health degree and experienced in qualitative method of research. Data collection was stopped when saturation was reached, i.e. no new themes were being generated during the discussions. A total of 25 FGDs, with 8 to 10 people in each group, and 9 in-depth interviews were conducted in Lebanon, during the summer (July) and the month of Ramadan (mid September - mid October) in 2007. A total of 220 people took part in the interviews and FGDs, with ages ranging between 18 and 74 years old. Few elderly were recruited as they very hard to identify, especially in public places. The majority of the discus- sions (12) were conducted with participants aged between 26 and 35 years old, followed by the age group 36-65 years old, then 18-25 years old. Twenty interviews and FGD were conducted in the Beirut area and 14 in the Bekaa area. Twenty-one discussions were conducted with waterpipe smokers as opposed to 13 discussions with non-smokers. The same number of discussions (17) was conducted with women and men, separately. Participants from different educational levels and eco- nomic statuses were recruited. As for the occupation,