Recent studies have found the use of waterpipes among adolescents is increasing in popularity in Europe and the USA.1^–5 Additionally, many users do not know that tobacco is the main component of the product smoked in waterpipes. The smoke from a waterpipe contains most of the same compounds present in cigarette smoke (eg, carbon monoxide, carcinogens, nicotine and heavy metals); additionally, studies have found that during a waterpipe session, smokers may inhale a volume of smoke equivalent to that produced by more than 100 cigarettes.1 3 6 Waterpipe users have been found to have increased risk for lung, oral and bladder cancer and heart disease.1 2 In addition, some studies have found that waterpipe smoking may be as addictive as other forms of tobacco.1^–3 Finally, like tobacco smoked in other pipes, smoke from waterpipes can be a significant source of second-hand smoke exposure.7 The tobacco control community needs to be aware of the popularity of waterpipe use among adolescents and prepare prevention efforts to address this emerging problem.

For the first time, nationally representative data on waterpipe use among adolescents is available for two European countries: Latvia and Slovakia. Data from the 2002 and 2007 Global Youth Tobacco Surveys (GYTS) conducted in Latvia and Slovakia highlight the recent spread of waterpipe use among students. The GYTS is a school-based survey of students aged 13–15 years.8 The questionnaire used in each country included a question on smoking tobacco in waterpipes.

Between 2002 and 2007, use of tobacco products other than cigarettes by adolescents increased nearly fourfold in Latvia (10.4% to 37.5%) with much of this increase attributed to a rapid increase in smoking tobacco in waterpipes (29.8% in 2007). In Slovakia, use of other tobacco products did not change between 2003 and 2007 (12.9%); but 4.8% of students reported smoking tobacco in waterpipes in 2007. There was no gender difference in waterpipe use in either Latvia or Slovakia. Most current waterpipe use is less than once a week (76.3% in Latvia and 60.9% in Slovakia); however, 3.0% in Latvia and 6.3% in Slovakia reported daily use.

These findings raise special concerns for tobacco control efforts in these two countries, as well as in other countries in Europe and the rest of the world where smoking tobacco in waterpipes is not historically prevalent; but may be gaining acceptance among adolescents. First, all countries need to be aware of the findings from Latvia and Slovakia and include questions on waterpipe use in future tobacco surveys, especially the GYTS. Second, tobacco control programs in all countries need to be aware that tobacco use among adolescents can increase rapidly, especially when “novelty” products such as smoking tobacco in waterpipes gain the attention of the youth. Ongoing surveillance is necessary to track trends and patterns of youth tobacco use, including boys and girls and all tobacco products. In addition, surveillance data can be one of the primary data sources for evaluating youth tobacco control program efforts. Tobacco control programs thus need to be able to adapt quickly to these changes and include information on these new products in their education and prevention programs and efforts. Third, globally, 5 million tobacco related deaths occur each year, a total estimated to increase to 8 million by 2020.9 This number may be an underestimate if waterpipe use continues to spread to other countries and leads to an overall global increase in tobacco use.