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The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally
  1. E A Akl1,
  2. K D Ward2,
  3. D Bteddini3,
  4. R Khaliel3,
  5. A C Alexander2,
  6. T Lotfi4,
  7. H Alaouie3,
  8. R A Afifi3
  1. 1Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
  2. 2School of Public Health, University of Memphis, Memphis, Tennessee, USA
  3. 3Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
  4. 4Faculty of Medicine, Clinical Research Institute, American University of Beirut, Beirut, Lebanon
  1. Correspondence to Dr Rema A Afifi, Faculty of Health Sciences, Department of Health Promotion and Community Health, American University of Beirut, PO Box 11-0236 Riad El Solh, Beirut 1107 2020, Lebanon; ra15{at}


Objective The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review.

Data sources The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms.

Study selection Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10–29 years.

Data extraction Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results.

Data synthesis The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels.

Conclusions The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

  • Non-cigarette tobacco products
  • Global health
  • Media
  • Packaging and Labelling
  • Prevention

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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