Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 was a flourishing business. Consequently in response to the demand by customers and competition from others, the business of serving the waterpipe became a lucrative one. “What played a big role in making it a “BOOM” is its commercialization. So maybe it began in a certain occasion where they found that they would benefit from it, so they promoted it pretty well...Our restau- rants started to serve waterpipes, while earlier we used to go there to have a beer, there were no water- pipes, but afterwards it was on demand, so they pro- moted it” (Male smoker - rural area) Home delivery services have made it accessible at home for people who had otherwise not considered it due to hassles in preparation. WTS requires the pur- chase of the waterpipe apparatus, the tobacco and all its accessories. It is time consuming and needs a basic level of know-how for preparation - all resolved by the ame- nities of home delivery. Men more than women, the younger age groups and smokers stated that the advent of waterpipe home delivery services contributed to the increase in use. Affordability of waterpipe tobacco smoking The waterpipe also evolved as an affordable way to spend time in cafés or at home, with little incurred cost. Affordability was brought up more by women and the older age categories. Both smokers and non smokers cited affordability almost equally as contributing to the surge in use. The waterpipe is generally offered in a range of prices starting from L.L. 5,000 and reaching L. L.15,000 ($1 = L.L. 1500) depending on the setting (how fancy and in what neighbourhood). Also, the practice of sharing of the waterpipe meant that smokers could share cost. The duration of a WTS session varied, depending on how often the tobacco was replenished, how many smokers were sharing, and how often they puffed. “...we can order it twice, three times...Sharing and if it’s for 10,000L.L. and we are 3 or 4 [people], so approximately 2000L.L. per person is affordable” (Female non smoker - urban area) For those who smoked at home, it was affordable since, as stated by participants, apart from the tobacco, the accessories can be used repeatedly. Home delivery services were also affordable (L.L. 8,000) [19]. This affordability at home and in public places was also thought to “encourage young people” to smoke more (Male smoker - rural area). Page 4 of 9 Innovations in designs of the waterpipe apparatus and tobacco flavours Continuous innovations in the design of the waterpipe apparatus increased marketing potential. The waterpipe apparatus could thus be dressed up or down to suit the taste of the smoker and the context. A café for example transformed the traditional looking waterpipe into a modern aluminium design [20], most likely attractive to trend seeking smokers. Women, the younger age groups, and smokers stated that innovative designs of the appa- ratus including diverse sizes, colours, and materials have contributed to its popularity, particularly among women. “Nowadays there are waterpipes especially for women; [they] are small, delicate and golden, with a more beautiful ornamented hose [as opposed to the waterpipe for men]. This is also a motivation [to smoke], maybe this form seduces the woman to smoke it, she might not like it, but it attracts her.” (Female smoker - urban area) The ritual of decorating the waterpipe has become common which also made smoking much more appeal- ing particularly to women who are lured by aesthetics. “... you put rose petals on the plate, you change its hose, paint it...At the end you’ll like the way it looks. If the waterpipe looked nice and clean, then you’d have the desire to smoke it.” (Female smoker - rural area) Innovations such as using cored pineapple and water- melon and shiny ornamentation and crystal bottles were “encouraging use even if it does not taste better at the end, but psychologically [i.e. people feel that it tasted better just because in their view it looks better]” (Male smoker - urban area). Innovations in tobacco flavours also contributed to the increase in use and motivated initiation. The variety of available flavourings of waterpipe tobacco in the form of Ma’asal attracted smokers in trying them out and also enticed new smokers. More women than men smokers, and younger age category groups (men and women), as well as smokers more than non-smokers mentioned the variety of tobacco flavours of Ma’asal in the market as a reason for the increase in WTS. Ma’asal is fruit-fla- voured, typically tobacco mixed with molasses. It gives off an odour of burned sugar when smoked. Ajami is the traditional unflavoured tobacco, with a harsher smell of tobacco. Ma’ssal tobacco is generally favoured by youth and women. “The companies are making use of it commercially, once they introduce the grape flavour to the market,