ARTICLE AVAILABLE ONLINE Journal of Smoking Cessation 18 Watad, W., Sukhera, J., Shushan, S., Kazlak, M., Skinner, H.A., Alnueirat, A.A., & Roth, Y. (2009). Water pipe smoking: Effects, attitudes and directions. Journal of Smoking Cessation, 4(1), 18–25. DOI 10.1375/jsc.4.1.18 Address for correspondence:Yehudah Roth, MD, Department of Otolaryngology — Head & Neck Surgery, Edith Wolfson Medical Center, P.O.B. 5, Holon 58100, Israel. E-mail: orl@wolfson.health.gov.il While cigarettes account for the largest share of manu- factured tobacco products (MacKay & Eriksen, 2002), smokeless tobacco and water pipe (WP) are extremely popular in several countries (World Health Organization, 1997). For example, 600 million individuals use tobacco and areca nut mixtures in India (Gupta & Ray, 2003), and WP is familiar to approximately 1 billion people across the globe (Wolfram, Chehne, Oguoghu, & Sinzinger, 2003). The water pipe is also known as nargile, hookah, shisha, hubbly bubbly (Kandela, 2000), hubble bubble (Kandela, 1997), boory, oriental pipe, goza (Radwan, Mohamed, El-Sethouhy, & Israel, 2003), argileh (Shafagoj, Mohammed, & Hadidi, 2002), mada’a (Yemen; Gunaid, Sumairi, Shidrawi, Al-Hanaki, Al- Haimi et al., 1995) and qalyoun (Iran) (‘Iran to ban water pipe in public’, 2004). It is used daily by approxi- mately 100 million men and women in countries across Africa, Asia and the Mediterranean (Wolfram, Chehne, Oguoghu, & Sinzinger, 2003), and is gaining popularity both in the Middle East (Kandela, 2000) and across the world (Israel, El-Sethouhy, Gadalla, Ali Aouin, Mikhail et al., 2003; Kandela, 1997; Rastam, Ward, Eissenberg, & Maziak, 2004). Most WP users believe that WP smoking is less harmful and addictive than cigarette smoking (Kandela, 2000; Kinshkowy & Amitai, 2005; Shafagoj, Mohammed, & Hadidi, 2002). A standard WP consists of a large glass bottle partly filled with water and placed on the ground. There is tubing fixed to the neck of the bottle, a mouthpiece at the end of the tubing, and a small container that rests on top of the bottle containing the tobacco and heated pieces of charcoal (Israel et al., 2003; Kandela, 2000; Radwan, Mohamed, El-Sethouhy, & Israel, 2003). The heat from the coals lights the tobacco, the emitted smoke enters the water-filled bottle and is inhaled through the tube. The tobacco used in WP comes in several forms Water Pipe Smoking: Effects, Attitudes and Directions Waseem Watad, 1 Javeed Sukhera, 2 Sagit Shushan, 1 Mazen Kazlak, 1,3 Harvey A. Skinner, 4 Arafat A. Alnueirat 5 and Yehudah Roth 1,6 1 Department of Otolaryngology—Head & Neck Surgery, Edith Wolfson Medical Center,Tel Aviv University Sackler School of Medicine, Holon, Israel 2 Department of Psychiatry, University of Rochester Medical Center, Rochester, United States of America 3 New Dawn Society, Nablus, Palestinian Authority 4 Faculty of Health, York University, Toronto, Canada 5 Department of ENT, Royal Medical Services, Amman, Jordan 6 Dalla Lana School of Public Health, University of Toronto, Canada W ater pipe (WP) smoking is prevalent in several countries and is emerging as a major international public health issue. This article reviews the literature on WP smoking practices and its health effects. Water pipe smoking in the Middle East is more common in women compared to cigarette smoking. WP smoking has harmful effects similar to cigarette smoking, and the nicotine and tar content of WP smoke is higher than that of cigarettes. Still, many users believe that WP is less harmful than cigarettes and are unaware of the damage that WP can cause to their health. There is limited lit- erature on WP smoking, highlighting the need for research in several areas including: epidemiology of WP smoking, sociological dimensions and tobacco control. The unique social and traditional role of WP smoking renders forgiving, culture-sensitive and patient approach. Keywords: prevention, cessation