Introduction Tobacco is a preventable cause of morbidity and mortality across the globe. Low and middle-income countries are most severely affected. Estimates show that tobacco- related deaths are expected to rise from 5.4 million in 2005 to 6.4 million in 2015 and 8.3 million in 2030. 1 This prediction highlights the need to study the trends and patterns of tobacco usage in different forms as well as to come up with effective control and prevention strategies for these developing countries. 2 Water pipe smoking commonly known as shisha, narghile, hookah, hubble bubble in different countries and cultures, is a form of tobacco intake in which the smoke passes through water before inhalation. Though this practice is centuries old, it has recently increased in popularity among many Arab countries and generally across the world. 3,4 It is now commonly practiced in commercial cafés, restaurants and even at homes. The most common users are university and college students. Even though several health hazards have been associated with water pipe smoking; the general population has not yet fully understood the associated risks. 5,6 The prevalence of tobacco intake in Pakistan is high, reaching up to 33% among middle aged males. 7 It is used in different forms such as cigarettes, chewable tobacco, tobacco snuff and water-pipe. According to a survey, one in every five Pakistani males has consumed more than 100 cigarettes or used a water pipe in his life time. 8 Furthermore a recently conducted study showed a high smoking index among male smokers in one of the cities in Pakistan. 9 These alarming figures can be controlled with interventions targeting youth. One such study showed that graphic pictorial/multi-media health warnings that depict cosmetic and functional distortions were perceived as effective anti-smoking messages. 10 Tobacco is used in different forms and among these shisha smoking is gaining immense popularity mainly because of youth appeal. 3,4,6 The increasing trend of water pipe smoking can be attributed to several misconceptions. These include the popular beliefs that the nicotine content in water pipes is lower as compared to cigarettes and that the water used in this form of tobacco intake filters out all the hazardous chemicals such as carbon monoxide, nicotine and tar. 3 These common misconceptions lead the public to believe that water pipe smoking is not a significant health hazard. Research however has proved otherwise, suggesting three additional risks of water pipe smoking over cigarette smoking. 11 First of all water-pipe is smoked over coal adding additional harmful toxins to the smoke. Secondly, a water- Vol. 62, No. 2, February 2012 192 Cross-sectional study identifying forms of tobacco used by Shisha smokers in Pakistan Sameer-ur-Rehman, 1 Mohammed Ali Sadiq, 2 Maria Adnan Parekh, 3 Ali Bin Sarwar Zubairi, 4 Philippe M. Frossard, 5 Javaid Ahmed Khan 6 Medical Students, 1-3 Section of Pulmonology and Critical Care, 4,6 Aga Khan University Medical College, Center for Non-Communicable Diseases, 5 Karachi, Pakistan. Abstract Objectives: To estimate the frequency of different forms of tobacco intake such as smoker's tobacco, chewable tobacco and snuff tobacco among shisha smoker's and to study the patterns and predictors of shisha smoking affecting youth from different cities of Pakistan. Methods: A cross-sectional study was conducted including youth from four cities. Participants were asked to fill out a data collection tool at shisha cafes, shopping malls and restaurants. Data was analyzed using SPSSv.18. Results: A total of 406 participants, 296 (73%) males and 110 (27%) females were included in the study. There were 163 (40%) cigarette smokers; 65(16%) chewed tobacco and 33 (8%) snuffed it.The median age at initiation of Shisha smoking was 20 years. 280 (69%) considered Shisha smoking to be less deleterious to health than cigarettes. Respiratory disease was the most commonly cited health effect reported. Most 248 (61%) of the participants were infrequent shisha smokers. Conclusion: There is high frequency of tobacco usage in the form of cigarettes, chewable tobacco and snuff tobacco among shisha smokers of Pakistan. The highest frequency is for cigarette smoking. The rise in Shisha smoking as a trendy social habit appears to be occurring despite emerging scientific evidence of its potential health risks. Keywords: Smoking, Shisha, Tobacco, Cigarette smoking, Pakistan (JPMA 62:192; 2012). Students’ Corner Original Article