title: To what extent should waterpipe tobacco smoking become a public health priority?
abstract: BACKGROUND
  Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance.
  
  
  OBJECTIVE
  This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority.
  
  
  METHODS
  Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS.
  
  
  RESULTS
  Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users.
  
  
  CONCLUSIONS
  Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London, UK.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Jawad
authors.forename: Andy
authors.initials: A
authors.lastname: McEwen
authors.forename: Ann
authors.initials: A
authors.lastname: McNeill
authors.forename: Lion
authors.initials: L
authors.lastname: Shahab
mesh_terms: D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008877:Middle East / Q000453:epidemiology; D015995:Prevalence; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology / Q000523:psychology; D016540:Smoking Cessation / Q000379:methods; D014481:United States / Q000453:epidemiology; D014867:Water
chemical_list: D014867:Water
keywords: Health legislation; hookah smoking; preventive medicine; public health; waterpipe