Nakkash et al. BMC Public Health 2011, 11:315 http://www.biomedcentral.com/1471-2458/11/315 “it’s the government’s responsibility; the government should tackle such matters, raise awareness, take the necessary steps (Male non-smoker - rural area) The commonly suggested policies that were brought up by participants were: banning WTS in closed indoor public places such as restaurants, raising price, limiting media influence be it direct or indirect advertising - most notably smokers in TV shows etc, as well as the need for health warning labelling like that required for cigarettes. With regards to introduction of bans of smoking in public places, most participants viewed it as a measure that will decrease WTS. “...that would be the only thing that makes us— if not quit it— it would at least decrease by 50% or 60%...” (Female smoker - urban area) Also, the fact that both cigarettes and waterpipe were affordable in Lebanon was stated as one of the reasons why people continue to smoke. FGD participants stated that making WTS more expensive could potentially reduce use, although some were a bit sceptical since waterpipe smokers can prepare it at home as a cheaper alternative. “I think if [the waterpipe] it is expensive relative to the income, it would not be that popular (...); a higher price would deter from use (Woman non-smo- ker - urban area) FGD participants noted ubiquitous advertising of waterpipe tobacco particularly indirectly through propa- gation of positive images of WTS on TV programs. “There are loads of advertisements for the Mo’assel tobacco, especially on the radio, more than TV (...). One would be tempted to try new flavors (Woman smoker - rural area)” “Media and TV have a major impact. In any adver- tisement for a café they would show a woman smok- ing waterpipe. It is all about media (...). Media has a major impact on prevalence of waterpipe smoking, like when a new fashionable brand is out, This is the effect of media, you start trying out new trends., advertising has a major impact, they would entice you with a new design, so that you try it, ... (male smoker - rural area) With regards to the need for HW’s on waterpipe tobacco products, one participant compared that to pre- sence of HW on cigarettes: Page 6 of 9 “Even the ministry of health, although they put a health warning on the cigarette packs, mentions nothing on waterpipe tobacco packs. .. although waterpipe smoking on a daily basis is more harmful than cigarette smoking (Woman non-smoker - urban area)” Most importantly FGD participants stated that legis- lating policies and subsequent follow up and enforce- ment by the government to ensure compliance were essential to controlling WTS. “[Tobacco control policies] have to be implemented. But such policies about banning waterpipe need to be enforced. There should be proper follow-up and enforcement by the government (male smoker - rural area)” Discussion This manuscript has documented waterpipe smokers’ and non smokers’ perceptions about the rise in water- pipe tobacco smoking using qualitative methods. Quali- tative methods are intended to show the variation in opinions, feelings, and experiences within a target popu- lation [18]. Despite not aiming for representativeness in the same sense as epidemiologic surveys, qualitative results are considered valid representations of a phe- nomenon of interest. The results described herein have suggested specific themes that have influence non-smokers to start, and encouraged smokers to continue. There is a dearth of qualitative research exploring the meaning attributed to WTS and possible reasons for its spread in the Arab region and beyond. Quantitative research in Syria has specifically asked participants to describe why they think there was an increase in waterpipe smoking. They pro- vided similar reasons as those of participants in this study such as availability, media, the social atmosphere, among others [21]. However, interestingly, although specific to waterpipe smoking, many of the themes described above are com- parable to those manipulated by the cigarette industry to increase cigarette smoking, suggesting that the water- pipe industry has learned its lessons well from its prede- cessor. Finding from FGD’s and interviews indicate that factors that are used to encourage WTS are similar to those that have been successful in enticing people to smoke cigarettes. For example, with regards to afford- ability, much research on the cost of cigarettes has indi- cated that “Price is one of the strongest influences on tobacco consumption (p.760)” [22]. This has led to pri- cing measures being included in the Framework