All tobacco together caused an estimated 100 million deaths in the 20th century. According to the World Health Organisation it will cause up to one billion deaths in the 21
st century if the current trend continues. Currently the waterpipe is getting more popular for some major reasons. These include: introduction of a flavoured tobacco mix, the mushrooming of hookah establishments, and aggressive marketing and media hype about this new trend. One of the characteristics of the waterpipe that attracts a lot of people is the aromatic smell [
9‐
11]. This aromatic smell is caused by the slow heating with charcoal of a tobacco that consists for about 30 % of crude cut tobacco and is fermented with about 70 % of honey molasses (syrup) and the pulp of different fruits. This new kind of tobacco called ‘maassel’ was introduced by some Egyptian tobacco companies in the early 1990s. Another reason is the emerging of hookah bars, cafés and restaurants. In 2004 the Smokeshop magazine reported that 200 to 300 hookah bars have been opened in the United States since 1999. These cafés were ‘often near college campuses’ [
12,
13]. Waterpipe hookah bars, cafes, and restaurants lure customers by advertising in college/university, local newspapers and radio stations popular among young people. They emphasise exotic aspects of Middle Eastern culture in their décor, furnishings, music, and displays of a variety of colourful, finely crafted hookahs [
14]. Further, the increasing popularity can be due to the aggressive marketing on hookahs, hookah accessories and maassel of multiple enterprises that have sprung up in the US and the Middle East. To attract customers, these businesses offer a variety of hookahs for sale, e.g. Egyptian Hookahs, Sheik Hookahs, Rotating Hookahs, and Modern Hookahs or give these products exotic names such as ‘Sheherazade,’ ‘Syrian Queen,’ and ‘Queen Nefertiti.’ Some websites promote hookah use as chic and elegant (hookahculture.com), as part of a unique lifestyle (insidehookah.com) or religious worship (sacrednarghile.com) [
14]. The last big contributing factor is the amount of media attention. It can almost be called a media hype. The waterpipe has been given quite a lot of attention, more positive than negative. Some newspapers warn about its potential health risks but most depict it as a new, trendy and safe way of socialising for young people [
15]. Waterpipe tobacco smoking is often associated with Southwest Asia and North Africa. A recent study in Southwest Asia and the United States suggests that children from an Asian background start smoking at a relatively young age. For example, in a survey of 2443 Lebanese students (11 to 17+ years old;
M = 15) from public and private secondary schools in greater Beirut, 64.9 % reported that they had tried waterpipe at some point in their life and 25.6 % reported use in the last past 30 days [
16]. Also, among 388 Israeli schoolchildren aged 12-18 years, 41 % reported current waterpipe tobacco smoking, and 22 % reported that they used a waterpipe to smoke tobacco every weekend [
17]. These data are also about juvenile smoking. All of the data addressing young people are important especially because, at least for cigarette smoking, earlier initiation is associated with longer duration of smoking and increased risk of nicotine dependence and deleterious health effects [
18]. Moreover, waterpipe tobacco smoking may be introducing tobacco to an otherwise tobacco-naive group of adolescents and young adults. In Pittsburgh, 35.4 % of university students who use a waterpipe had never smoked a cigarette. There are several reports stating that the United States and probably also Europa are on the brink of a waterpipe epidemic amongst its college-age population. Most of the reported increasing amounts of waterpipe use (at least 33 states reported waterpipe use) come from cities with a large university [
19‐
26]. Hookahs have become commonplace at fraternity parties at these universities’ [
27]. Young waterpipe users may also be attracted to the aromatic smell of the waterpipe smoke [
10,
28]. Arab Americans describe the waterpipe as cool and as an opportunity for social interaction [
29]. The keyword that comes back in almost every study on the popularity of the waterpipe is socialising. One study resulted in the statistic that 79 % of the 201 tobacco smokers did so, at least partially, because of the social interaction [
7]. A waterpipe is meant to be smoked socially unlike normal cigarettes that can only be smoked outside or in smoking rooms and are thus destroying the social fun. Another surprising outcome of surveys is that girls are more comfortable with a waterpipe than they are with a cigarette.
A worrisome fact is that many waterpipe tobacco smokers are otherwise tobacco naive. Active individuals who enjoy the effects of smoking tobacco with a waterpipe may turn to cigarettes for a more convenient and mobile smoking method. [
30]. Such a prospect is plausible given the fact that waterpipe tobacco smoking is time-consuming and largely site specific. Evidence from a cross-sectional study of Arab American adolescents shows that the odds of experimenting with cigarettes were 8 times greater for those who have ever smoked tobacco using a waterpipe [
31,
32]. Another study among young adult US military recruits shows that waterpipe smokers are more likely to start smoking cigarettes in the following year than non-waterpipe smokers [
32]. Furthermore, there is less to no evidence that waterpipe tobacco smoking is related to marijuana use. A survey under 201 US waterpipe tobacco smokers reported that 64.2 % had not used marijuana in the past 30 days and only 10.4 % reported that they had smoked tobacco and marijuana from the same waterpipe [
7].