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The Burden and Correlates of Waterpipe (Hookah) Smoking among

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The Burden and Correlates of Waterpipe (Hookah)

Smoking among Adolescents and Youth: A
Systematic Review

Stuti Sharad Bhargava, Saibal Das, Harsh Priya, Deepika Mishra, Santhosh
Shivabasappa, Anubhuti Sood, Chaya Rani Hazarika, Prakash Chandra
Gupta, Joy Kumar Chakma, Leimapokpam Swasticharan, Praveen Sinha,
Vineet Gill Munish & Shalini R. Gupta

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Shivabasappa, Anubhuti Sood, Chaya Rani Hazarika, Prakash Chandra Gupta, Joy Kumar
Chakma, Leimapokpam Swasticharan, Praveen Sinha, Vineet Gill Munish & Shalini R. Gupta (31
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Substance Use & Misuse
https://doi.org/10.1080/10826084.2023.2257320

RESEARCH ARTICLE

The Burden and Correlates of Waterpipe (Hookah) Smoking among

Adolescents and Youth: A Systematic Review
Stuti Sharad Bhargavaa*, Saibal Dasb,c*, Harsh Priyad, Deepika Mishrae, Santhosh Shivabasappaf, Anubhuti
Soodg, Chaya Rani Hazarikah, Prakash Chandra Guptai, Joy Kumar Chakmaa, Leimapokpam Swasticharanj,
Praveen Sinhak, Vineet Gill Munishk and Shalini R. Guptal
a
Division of Non Communicable Diseases, Indian Council of Medical Research, New Delhi, India; bIndian Council of Medical Research - Centre for
Ageing and Mental Health, Kolkata, India; cDepartment of Global Public Health, Karolinska Institutet, Stockholm, Sweden; dDepartment of Public
Health Dentistry, Centre for Dental Education and Research, All India institute of Medical Sciences, New Delhi, India; eDepartment of Oral
Pathology and Microbiology, Centre for Dental Education and Research, All India institute of Medical Sciences, New Delhi, India; fDepartment of
Clinical Pharmacology, Jawaharlal Institute of Postgraduate Medical Eductaion and Research, Puducherry, India; gTranslational Health Science and
Technology Institute, Faridabad, India; hSocio-Behavioral Health Systems and Implementation Research Division, Indian Council of Medical
Research, New Delhi, India; iHealis Sekhsaria Institute for Public Health, Navi Mumbai, India; jDirectorate General of Health Services, Ministry of
Health and Family Welfare, Government of India, New Delhi, India; kWorld Health Organization – India, New Delhi, India; lDepartment of Oral
Medicine and Radiology, Centre for Dental Education and Research, All India institute of Medical Sciences, New Delhi, India

ABSTRACT KEYWORDS
Background: This systematic review evaluated the available medical literature on the prevalence and Adolescents; burden; hookah;
trends of waterpipe tobacco smoking among adolescents and youth in jurisdictionally representative waterpipe smoking; youth
populations. Methods: PubMed, Embase, and Scopus were searched for relevant studies from
inception until 31 December 2022 that reported the burden of waterpipe smoking among
adolescents and youth (10–24 years of age). We extracted qualitative data on the demographic
characteristics, burden, and correlates of waterpipe smoking (PROSPERO ID: CRD42022310982).
Results: A total of 2,197 articles were screened and 62 were included in the analysis. The majority
(29) of the studies was from the United States of America and there were no studies from the
south-east Asian region. The prevalence of ever waterpipe smoking among the 10–24 years age
group was noted to be 18.16% (95% CI, 18.03–18.29). The prevalence of current (30-day) waterpipe
smoking was 6.43% (95% CI, 6.34–6.50). The age of initiation of waterpipe smoking was variable.
The prevalence of waterpipe smoking was higher among males, among those who belong to the
high- and middle-income groups, and among university students. The common risk factors of
waterpipe smoking included cigarette smoking, alcohol, and substance use. Waterpipe smoking
resulted in increased susceptibility to the use of conventional forms of tobacco (e.g. smoking)
among those who were never smokers. Conclusion: Waterpipe smoking usage was significantly high
among adolescents and young adults. Developing regulatory guidelines for water-pipe smoking,
surveillance of its use, intervention, and specific policy frameworks may be considered a public
health priority.

Introduction media, lack of waterpipe smoking-specific policy and regula-

Waterpipe smoking is a form of tobacco consumption that uti-
lizes a single or multi-stemmed instrument to smoke flavored
or non-flavored tobacco, where the smoke is designed to pass
through water or other liquid before reaching the smoker.
Although considered to be a traditional practice, the use of
waterpipe smoking is reemerging as a popular trend, especially
among adolescents and young adults across the world. Some
of the distinctive factors that appear to contribute to the grow-
ing popularity of waterpipe tobacco smoking include the intro-
duction of flavored tobacco (muʽassel/maassel), social
acceptability due to the rising café, lounge bars, and restaurant
culture, promotion through mass communication and social
tions, and erroneous perceptions about the relative safety of
waterpipe smoking (Advisory note: waterpipe tobacco smok-
ing: health effects, research needs and recommended actions
by regulators, 2nd edition). Waterpipe smoke is addictive and
toxic, as it emanates from the combustion of tobacco. Waterpipe
smokers absorb toxicants and carcinogens from waterpipe
smoke in appreciable amounts resulting in immediate adverse
physiological effects, as well as multiple long-term adverse
health outcomes (Advisory note: waterpipe tobacco smoking:
health effects, research needs and recommended actions by
regulators, 2nd edition). Evidence suggests that waterpipe
smoking can cause acute lung infection and injury, carbon
monoxide poisoning, oral and systemic genotoxicity, reduced

CONTACT Stuti Sharad Bhargava stuti.bhargava@icmr.gov.in Division of Non Communicable Diseases, Indian Council of Medical Research, V. Ramalingaswami
Bhawan, Ansari Nagar, New Delhi: 110 029, India
*These authors have contributed equally.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/10826084.2023.2257320.
© 2023 Taylor & Francis Group, LLC
2 S. S. BHARGAVA ET AL.
pulmonary function, altered vascular and hemodynamic func-
tions, and adverse psychological effects (Adetona et al., 2021).
Several systematic reviews and meta-analyses have shown
this method of tobacco consumption to be linked to diseases
typically associated with cigarette use, such as lung cancer,
oral cancer, cardiovascular disease, respiratory disease, and
low birth weight (Akl et al., 2010; Waziry et al., 2017).
Despite this, both waterpipe tobacco users and non-users
consider waterpipe tobacco to be less harmful than cigarette
tobacco (Akl et al., 2015). The World Health Organization
Global Action Plan has set a target of a 25% relative reduc-
tion in tobacco use by 2025 (Ward, 2015; Global Action Plan
for the Prevention and Control of NCDs 2013-2020). A sys-
tematic review conducted in 2008 showed that waterpipe
tobacco smoking prevalence was alarmingly high among
school and university students in middle eastern countries as
well as among adolescents of middle eastern descent in west-
ern countries (Akl et al., 2011). A study on the global epide-
miology of waterpipe smoking conducted in 2015 showed
that waterpipe smoking has become a global public health
problem (Akl et al., 2015). A systematic review in 2018 fur-
ther demonstrated that Waterpipe tobacco smoking is most
prevalent in eastern Mediterranean and European countries,
and appears higher among youth than adults (Jawad et al.,
2018). Developing surveillance, intervention, and regulatory/
policy frameworks specific to the waterpipe has become a
public health priority (Maziak et al., 2015),
While these show an exponentially rising number of
prevalence studies, references to these are often unsystematic
and focus on a selective number of studies in a limited
number of countries and typically at a non-jurisdictionally
representative level (e.g., single-center studies among college
students) (Maziak, 2011; Maziak et al., 2015). These
approaches are likely to introduce bias that could under- or
over-estimate the prevalence, and therefore importance, of
waterpipe tobacco use in the discourse, around policy mea-
sures. This is particularly important to address within water-
pipe tobacco research given the relatively high prevalence
among adolescents and youth as compared to other popula-
tion groups (Akl et al., 2011). In this regard, there is a
dearth of summarized evidence on the burden and correlates
of waterpipe smoking among adolescents and youths across
the world. Therefore, we aimed to systematically review the
medical literature on the prevalence and trends of waterpipe
tobacco smoking among adolescents and youth in jurisdic-
tionally representative populations.
Methods
Study design
We included all completed and published studies involving
the general population or demographically defined popula-
tions (e.g. defined by age, gender, or ethnicity) which reported
the burden of waterpipe smoking in the population of age
between 10 and 24 years (adolescents and youth) (Adolescent
and young adult health) including populations within educa-
tional establishments and, at any level of the jurisdiction (as
defined by the authors). We studied any measure of the bur-
den and/or correlates of waterpipe tobacco smoking.
Interventional studies, case reports, case series, commentar-
ies, reviews, viewpoints, editorials, or opinions were excluded.
Studies on waterpipe smoking for non-tobacco products (e.g.
cannabis, opium), studies in which waterpipe tobacco smok-
ing burden and/or correlates were not provided separately
from the data on other forms of tobacco use, and studies
involving other age groups were also excluded.
Search strategy
We searched PubMed, Embase, and Scopus from inception
until 31 December 2022. We used “waterpipe” along with its
synonyms and their spelling variations, e.g., “hookah”, “shisha”,
“narghile”, and other culturally-specific terms. For various bib-
liographic databases, the search terms were adapted along
with database-specific filters. The titles and abstracts of rele-
vant studies in the English language were found using the
search strategy by two independent authors. To determine the
suitability, the authors then retrieved the study abstracts, and
if necessary, the full text of the articles. The web-based Rayyan
software (https://www.rayyan.ai/) was used for this purpose.
For accessing the missing information, the corresponding
authors of the relevant article were contacted by email.
Data analysis
Abstract reviewing and data extraction was carried out inde-
pendently by three authors using a pre-formatted data extraction
spreadsheet. No assumptions or simplifications were made
during data extraction. The included studies were assessed for
risk of bias by three authors using the Newcastle-Ottawa scale
(Table s1) (Ottawa Hospital Research Institute). We extracted
data on the demographic characteristics of the study popula-
tion, burden (proportion for institution-based studies and prev-
alence for community-based studies) for ever use and current
(30-day) use, and correlates of waterpipe smoking. We analyzed
the data based on the geographical region, age of the studied
population, sampling frame, and socio-demographic character-
istics of the study population. The risk factors of waterpipe
smoking were enumerated as reported in the original studies
and classified in the same way. A third author was involved in
disagreement resolution if any. We categorized verbatim preva-
lence measures and trends of current (30-day) and ever water-
pipe smoking. The study protocol can be accessed in
PROSPERO (ID: CRD42022310982).
Results
Description of the included studies
A total of 2,197 articles were screened, and finally, 62
(Varsano et al., 2003; Almerie et al., 2008; Jackson & Aveyard,
2008; Korn & Magnezi, 2008; Primack et al., 2009; Jamil
et al., 2010; Noonan et al., 2011; Smith et al., 2011; Sterling
& Mermelstein, 2011; Abughosh et al., 2012; Fielder et al.,
2012; Jarrett et al., 2012; Mzayek et al., 2012; Heinz et al.,

2013; Jawad et al., 2013, 2016; McKelvey et al., 2013, 2014;
Reveles et al., 2013; Barnett et al., 2014; Goodwin et al.,
2014; Palamar et al., 2014; Wang et al., 2014, 2021;
Cavazos-Rehg et al., 2015; Jaber et al., 2015; Khan et al.,
2015; Kheirallah et al., 2015; Linde et al., 2015; Obaid et al.,
2014; Roohafza et al., 2015; Villanti et al., 2015;
Abbasi-Ghahramanloo et al., 2016; Abdo et al., 2016; Bahelah
et al., 2016; Grinberg & Goodwin, 2016; Jawad & Power,
2016; Kelishadi et al., 2016; Nădăşan et al., 2016; Salloum
et al., 2016; Shepardson & Hustad, 2016; Abdullah et al.,
2017; Kasza et al., 2017; Bashirian et al., 2018; Ghelichkhani
et al., 2018; Kulak et al., 2018; Roods et al., 2018; Ross et al.,
2018; Azagba et al., 2019; Fitzpatrick et al., 2019; Galimov
et al., 2019; Miri-Moghaddam et al., 2019; Abbadi et al.,
2020; Klosterhalfen et al., 2020; Naicker et al., 2020; Roberts
& Ferketich, 2020; Salih et al., 2020; Sharma et al., 2020;
Hanewinkel et al., 2021; Hirpa et al., 2021; Little et al., 2021)
Figure 1. Study flow chart depicting the steps of the synthesis of evidence from the literature.
Substance Use & Misuse 3
were included for the qualitative synthesis (Figure 1). The
characteristics of the included studies are summarized in
Table 1. The 62 studies were conducted in 19 countries. The
majority of the studies were from the United States of
America (USA) (29), followed by Iran (6), Jordan (5), the
United Kingdom (4), and Lebanon (2). There were no studies
from the south-east Asian region. The majority of the studies
were published from 2013-2018 (30), followed by 2018-2023
(15), and 2008-2013 (13). Thirty-three studies were con-
ducted among school-going students, 16 among university
students, two studies included both school-going and univer-
sity students, and 11 studies did not specify the study popu-
lation. Two studies were conducted wholly among female
participants while one included only male participants. The
proportion of female participants in different studies varied
from 43.1 to 63.6. The age of the study participants ranged
from 10 to 24 years.
4 S. S. BHARGAVA ET AL.

Table 1. Summary characteristics of the included studies.

Current
Ever use (30-day)
Sample burden use burden
Author, year Country Study population/setting Study design Study method size (n) (%) (%)
Abbasi-Ghahramanloo Iran University students Cross-sectional study Anonymous structured 1,834 18.16 –
et al., 2016 questionnaires
Varsano et al., 2003 Israel School students Cross-sectional study Self-reported questionnaire 388 40.98 21.91
Primack et al., 2009 USA School students Youth Tobacco Survey Standardized questionnaire 6,594 6.40 3.50
Azagba et al., 2019 USA School students National Youth Tobacco Self-administered, 17,872 7.10 2.50
Survey questionnaires
Hirpa et al., 2021 Ethiopia School students Cross-sectional study Self-reported questionnaire 3,347 2.57 0.60
Korn & Magnezi, 2008 Israel School students Cross-sectional study Self-administered 326 37.12 9.82
anonymous
questionnaire
Bashirian et al., 2018 Iran School students Cross-sectional study Self-administered 730 62.74 26.30
anonymous
questionnaire
Jaber et al., 2015 Jordan School students Longitudinal study Study questionnaire 1,781 16.73 –
Kelishadi et al., 2016 Iran School students Survey of a school-based Self-administered 13,486 5.90 1.83
surveillance system anonymous
questionnaire
Salloum et al., 2016 USA Adults National Adult Tobacco Telephone survey 2,528 15.74 3.80
Survey
McKelvey et al., 2014 Jordan School students Longitudinal Survey Self-administered 1,243 36.85 –
anonymous
questionnaire
Sterling & Mermelstein, USA School students Cross-sectional study Self-administered 951 58.46 29.86
2011 anonymous
questionnaire
Miri-Moghaddam et al., Iran University students Cross-sectional study Self-administered 500 31.20 15.00
2019 anonymous
questionnaire
Ross et al., 2018 USA National Cross-sectional study Telephonic interviews 1,125 2.04 –
population-based
sample of
adolescents
Fielder et al., 2012 USA College students Longitudinal study Monthly online surveys 483 44.93 12.97
Reveles et al., 2013 Brazil School students Cross-sectional study Self-administered 495 19.80 –
anonymous
questionnaire
Jawad et al., 2013 UK Medical students Cross-sectional study Self-administered 489 51.74 6.34
anonymous
questionnaire
Abbadi et al., 2020 Jordan School students Cross-sectional study Self-administered 1,082 – 31.42
anonymous online
questionnaire
Roohafza et al., 2015 Iran School students Cross-sectional study Self-administered 5,336 32.21 11.5
anonymous
questionnaire
McKelvey et al., 2013 Jordan School students Longitudinal study Self-administered 1,781 30.21 14.04
anonymous
questionnaire
Kheirallah et al., 2015 Jordan School students Cross-sectional study Self-administered 1,476 14.16 –
(Global Youth Tobacco anonymous
Survey) questionnaire
Bahelah et al., 2016 Lebanon School students Longitudinal study Interview 498 35.34 32.13
Heinz et al., 2013 USA University students Cross-sectional study Self-administered 143 47.55 22.38
anonymous
questionnaire
Klosterhalfen et al., 2020 Germany Household survey Cross-sectional study Interview 12,220 13.24 1.78
(German Study on
Tobacco Use)
Mzayek et al., 2012 Jordan School students Longitudinal Self-administered 1,701 46.38 18.87
anonymous
questionnaire
Salih et al., 2020 Saudi Arabia University students Cross-sectional study Web-based survey 385 34.03 –
Almerie et al., 2008 Syria University students Cross-sectional study Self-administered 570 23.51 –
anonymous
questionnaire
Ghelichkhani et al., 2018 Iran Community-dwelling Cross-sectional study Interview 2,257 4.25 –
individuals (Iran’s sixth national
Surveillance of Risk
Factors of
Non-Communicable
Diseases)

(Continued)
 Substance Use & Misuse 5

Table 1. Continued.
Current
Ever use (30-day)
Sample burden use burden
Author, year Country Study population/setting Study design Study method size (n) (%) (%)
Abdullah et al., 2017 Canada Community-dwelling Cross-sectional study Telephone-based survey 6,398 19.72 3.36
individuals (Canadian Tobacco Use
Monitoring Survey
2011 and 2012)
Galimov et al., 2019 Russia School students Cross-sectional study Self-administered 716 34.92 9.36
anonymous
questionnaire
Noonan et al., 2011 USA University students Cross-sectional study Web-based survey 223 60.99 13.45
Kulak et al., 2018 USA University students Cross-sectional study Web-based survey 1538 13.85 18.60
Jawad et al., 2016 UK University students Cross-sectional study Online survey 2,213 63.67 13.56
Palamar et al., 2014 USA School students Cross-sectional study Self-administered 5,540 18.74 –
anonymous
questionnaire
Nadasan et al., 2016 Romania School students Cross-sectional study Online questionnaire 1,835 21.09
Fitzpatrick et al., 2019 USA Adolescents visiting an Cross-sectional study Online assessment 257 14.79 –
urban pediatric clinic
Abughosh et al., 2012 USA University students Cross-sectional study Online survey 1,195 50.88 –
Khan et al., 2015 Pakistan Women of reproductive Cross-sectional study Questionnaire 2,554 2.11 –
age group (Pakistan Demographic
and Health Survey)
Jamil et al., 2010 USA Community-dwelling Cross-sectional study Self-administered 89 – 43.82
individuals anonymous
questionnaire
Wang et al., 2021 Hong Kong School students Cross-sectional study Self-administered 33,991 3.60 1.84
anonymous
questionnaire
Shepardson & Hustad, USA University students Cross-sectional study Self-administered 936 22.33 13.10
2016 anonymous
questionnaire
Jawad et al., 2016 UK Community-dwelling Cross-sectional study Self-administered 219 46.58 –
individuals anonymous
questionnaire
Barnett et al., 2014 USA School students Longitudinal (Florida Self-administered 36,439 16.70 7.70
Youth Tobacco Survey) anonymous
questionnaire
Villanti et al., 2015 USA Young adults Cross-sectional study Online questionnaire 1,555 25.02 4.69
(Legacy Young Adult
Cohort Study)
Grinberg & Goodwin, USA Adults Cross-sectional study Telephonic survey 85,545 5.59 1.10
2016 (Tobacco Use
Supplement of the
Current Population
Survey)
Hanewinkel et al., 2021 Germany School students Cross-sectional study Self-administered 2,752 13.84 –
anonymous
questionnaire
Abdo et al., 2016 Lebanon School students Cross-sectional study Self-administered 1,982 31.79 16.90
anonymous
questionnaire
Obaid et al., 2014 Dubai School students Cross-sectional study Self-administered 2,457 2.20 –
anonymous
questionnaire
Roods et al., 2018 USA School students Cross-sectional study Self-administered 4,500 13.00 5.51
(Youth Tobacco Survey) anonymous
questionnaire
Jackson & Aveyard, 2008 UK University students Cross-sectional study Self-administered 937 37.89 8.00
anonymous
questionnaire
Naicker et al., 2020 South Africa School students Cross-sectional study Self-administered 579 26.08 –
anonymous
questionnaire
Cavazos-Rehg et al., 2015 USA Adults Cross-sectional study Online survey 1,217 45.11 –
Sharma et al., 2020 USA Adults and youth Longitudinal (Population Audio computer-assisted 15,647 26.97 –
Assessment of Tobacco self-interviews
and Health Study)
Little et al., 2021 USA USA Air Force military Cross-sectional study Survey 2,411 13.73 –
recruits
Smith et al., 2011 USA School students Cross-sectional study Self-administered 691 26.05 –
anonymous
questionnaire

(Continued)
6 S. S. BHARGAVA ET AL.

Table 1. Continued.
Current
Ever use (30-day)
Sample burden use burden
Author, year Country Study population/setting Study design Study method size (n) (%) (%)
Jarrett et al., 2012 USA University students Cross-sectional study Institution-administered 82,155 30.80 9.56
paper or web-based
questionnaire
Roberts & Ferketich, 2020 USA University students Longitudinal study Online survey 529 13.23 –
Kasza et al., 2017 USA Community-dwelling Longitudinal study Audio computer-assisted 22,761 22.27 9.00
individuals self-interview
Wang et al., 2014 USA School students Cross-sectional study Self-administered 24,658 8.90 0.32
anonymous
questionnaire
Wang et al., 2019 USA School students Cross-sectional study Self-administered 19,018 7.10 2.60
anonymous
questionnaire
Goodwin et al., 2014 USA University students Cross-sectional study Self-administered 1,799 – 14.06
anonymous
questionnaire
Linde et al., 2015 USA USA Air Force military Cross-sectional study Self-administered 5,094 26.15 –
recruits anonymous
questionnaire
UK, United Kingdom; USA, United States of America.

Table 2. Prevalence estimates of waterpipe smoking based on region, country,

reported the current (30-day) prevalence of waterpipe smok-
and study population. ing. The prevalence of current (30-day) waterpipe smoking
Current (30-day) was 6.43% (95% CI, 6.34–6.50). Twenty-eight out of 40
Ever use % (n) use % (n) (70%) studies reported a > 5% prevalence of current (30-day)
WHO regions Africa 6 (3,926) 0.6 (3,347) use of waterpipe, while 11 studies reported such prevalence
America 19.9 (2,76,603) 6.91 (2,60,954) of >15%. The prevalence of ever smoking of waterpipe was
Eastern 17.33 (40,571) 9.35 (27,096)
Mediterranean highest in the European region (22.8%), followed by the
Region Americas (19.9%), and the eastern Mediterranean region
Europe 22.8 (22,095) 4.7 (17,289) (17.3%). The prevalence of current (30-day) use waterpipe
Western Pacific 3.6 (33,991) 1.8 (33,991)
Top seven USA 19.88 (2,69,710) 7 (2,54,556) smoking was highest in the eastern Mediterranean region
countries Iran 14.7 (24,143) 5.6 (20,052) (9.35%), followed by the Americas (6.9%), and Europe
Jordan 28.72 (7,982) 20 (4,564) (4.7%). Table 2 enumerates the prevalence estimates of
Lebanon 32.5 (2,480) 19.96 (2,480)
UK 54.9 (3,858) 11.2 (3,639) waterpipe smoking based on region, country (top seven
Germany 13.35 (14,972) 17.8 (12,220) countries), and study population. Table 3 states the preva-
Israel 39.2 (714) 16.4 (714) lence estimates of waterpipe smoking based on the study
Study population School students 11.8 (2,06,765) 4.3 (1,87,616)
University students 31.4 (94,130) 10.04 (92,433) population. The highest burden of ever use and current use
Not specified 19.09 (76,291) 7.43 (62,628) of hookah was among university students.
The results are represented by percentages (numbers).
WHO, World Health Organization; UK, United Kingdom; USA, United States of
America.
Socio-demographic characteristics of individuals
smoking waterpipe
Table 3. Prevalence estimates of waterpipe smoking according to the
population. The key socio-demographic characteristics of individuals
Study population Ever use % (n) 30-day use % (n) smoking waterpipe are as follows:
School students 11.8 (2,06,765) 4.3 (1,87,616)
University students 31.4 (96,750) 10.3 (94,078) i. Age of initiation: The age of initiation of waterpipe
Young professionals and 16.77 (1,06,809) 5.73 (93,157)
not-specified smoking was variable. Twelve out of 16 studies
reported 14–18 years as the age of initiation of water-
pipe smoking.
ii. Country: The prevalence of ever waterpipe smoking
Prevalence of waterpipe smoking
was highest in the UK followed by Israel, Lebanon,
Fifty-nine studies reported the proportion of participants and Jordan. On the other hand, the prevalence of
who ever smoked a waterpipe. The prevalence of ever water- current (30-day) waterpipe smoking was highest in
pipe smoking among 3,77,186 participants from 19 countries Jordan followed by Lebanon and Germany.
was estimated to be 18.16% (95% CI, 18.03–18.29). iii. Gender: Twenty-six studies reported the gender dis-
Fifty-seven out of 59 (80%) studies reported a prevalence of tribution of waterpipe smoking. Nineteen of these
ever smoking of waterpipe of >10%, while six studies studies reported that the prevalence of waterpipe
reported a prevalence of ever use of >50%. Forty studies smoking was higher among males than females [odds
 Substance Use & Misuse 7

ratio (OR), 1.2–7.46]. The association of male gender iii. Waterpipe smoking in the family: Five studies
with hookah use was reported in school as well as reported waterpipe smoking in the family (parents/
university students. Six studies found no effect of siblings) as a risk factor for waterpipe smoking (OR,
gender on the prevalence of waterpipe smoking. 1.02–13.87). A study among seventh-grader
Contrarily, two studies reported that waterpipe smok- school-going children in Jordan identified that chil-
ing was more common in females. dren were more likely to initiate waterpipe smoking
iv. Socioeconomic status: Seven studies reported a higher if they were exposed to teachers who smoked (OR,
prevalence of waterpipe smoking among high- and 1.12–3.84).
middle-income groups as compared to the low-income iv. Ethnicity: A study from the UK reported that indi-
group. viduals of nonwhite ethnicities had higher odds of
v. Educational status: The prevalence of both ever and waterpipe smoking (OR, 1.66–3.04). Two studies
current (30-day) waterpipe smoking among univer- from the US found higher use of waterpipe among
sity students was higher than those in school-going individuals of Hispanic Latino ethnicities (OR,
children. A majority of the studies conducted among 1.25–1.85).
school children were performed in the USA (12). v. Area of residence: Six studies reported a higher prev-
alence of WPS use among urban-dwelling individuals
as compared to rural-dwelling ones (OR, 1.06–2.05).
Risk factors associated with waterpipe smoking For women in Pakistan, staying in a rural area was a
risk factor for waterpipe smoking.
The risk factors associated with waterpipe smoking are as
vi. Other socio-cultural/perceptual factors: A study
follows (Table 4):
reported curiosity about waterpipes as a strong influ-
encer of waterpipe smoking (OR, 28.28). Another
i. Cigarette smoking: Six studies reported that water-
study reported low self-perception of academic
pipe smoking strongly predisposes to conventional
achievement as the most significant variable leading
tobacco (e.g. cigarette smoking) in later life (OR,
to regularly smoking waterpipe (OR, 25.97). Seven
1.2–3.4). Twenty-three studies reported cigarette
studies reported social acceptability as a risk factor
smoking as a strong predictor of waterpipe smoking
for waterpipe smoking (OR, 1.54–5.77). A study
(OR, 1.26–30.8) among school students, as well as
among school students from Russia identified school
university students. Six studies reported cigarette
troubles and anger coping strategies as risk factors
smoking in the family as a risk factor for waterpipe
for waterpipe use. Nine studies identified considering
smoking (OR, 1.24–19.02). Seven studies reported
waterpipe smoking as a safe and positive attitude as
cigarette smoking among friends influenced water-
a strong risk factor for the initiation of waterpipe
pipe smoking by the individual (OR, 1.18–12.22). A
smoking (OR, 1.64–3.77). Two studies identified low
study from Germany reported an increased risk of
knowledge about tobacco as a risk factor for water-
cigarette and e-cigarette use among those having a
pipe smoking use. Three studies identified the use of
history of prior waterpipe smoking.
flavored tobacco products, receptivity to tobacco
ii. Alcohol and substance use: Marijuana and illicit drug
companies’ marketing, and perception of higher rates
use were identified as risk factors in eight studies
of tobacco use among peers as risk factors for water-
(OR, 1.03–33.81) Ten studies reported a positive
pipe smoking. A study among adolescents in Iran
association between alcohol use and waterpipe smok-
reported students who perceived that their parents
ing (OR, 1.14–14.81).
would punish them or discuss with them if they
smoked were less likely to be waterpipe smokers.
Table 4. Risk factors of waterpipe smoking.
Odds ratio (range as
reported across
Risk factors studies) Discussion
Cigarette smoking By own 1.26–30.8 Based on 62 studies across 19 countries, we found that the
By family members 1.24–19.02
By friends 1.18–12.22 prevalence of ever waterpipe smoking among the 10–24 years
Alcohol and substance Alcohol 1.14–14.81 age group was 18.16% (95% CI, 18.03–18.29). The prevalence
use Substance use 1.03–33.81 of current (30-day) waterpipe smoking was 6.43% (95% CI,
Waterpipe smoking in Waterpipe smoking in the 1.02–13.87
the family family 6.34–6.50). A majority of the studies were conducted among
Ethnicity Nonwhite 1.66–3.04 school-going students in the last decade 2010–2020. Twelve
Latino 1.25–1.85 out of 59 studies reported a prevalence of >40% and 35 stud-
Residence Urban- 1.06–2.05
Knowledge, attitude, Curiosity about waterpipes 28.28 ies reported a prevalence of >20% of ever waterpipe smoking.
and practice Low self-perception of 25.97 Nineteen studies reported a current (30-day) use prevalence
academic achievement of waterpipe smoking of >10%. The prevalence of ever water-
Social acceptability 1.54–5.77
Considering waterpipe 1.64–3.77 pipe smoking was high in Europe (22.8%), the Americas
smoking as a positive (19.9%), and the eastern Mediterranean region (17.33%). The
attitude prevalence of current (30-day) waterpipe users was highest in
8 S. S. BHARGAVA ET AL.
EMR (9.35%) followed by the Americas (6.91%) and Europe.
The age of initiation of waterpipe smoking was variable. The
prevalence of waterpipe smoking was higher among males,
among those who belong to the high- and middle-income
groups, and among university students. The common risk
factors of waterpipe smoking included cigarette smoking,
alcohol and substance use, waterpipe smoking in the family,
nonwhite ethnicity, and urban-dwelling individuals.
Surprisingly, there were no studies from the south-east Asian
region. There is an unmet need to generate evidence on the
burden and determinants of waterpipe use from this geo-
graphical part, especially in India. Longitudinal nationally
representative studies will help in better understanding the
epidemiology of this new epidemic, particularly in terms of
the continued tobacco use habit in later life.
Our results are consistent with another systematic review
on waterpipe tobacco smoking which reported a high prev-
alence of Waterpipe tobacco smoking in eastern Mediterranean
and European countries with Lebanon having the highest
prevalence estimate for current (30-day) use (Jawad et al.,
2018). In our study, the prevalence of current (30-day)
waterpipe smoking was highest in Jordan followed by
Lebanon and Germany. Another study also reported a higher
prevalence among youth than among adults. The prevalence
of current (30-day) waterpipe smoking was highest in Jordan
followed by Lebanon and Germany while past 30-day use
was highest among Lebanese youth as per a recent review
(Jawad et al., 2018). The estimate of current (30-day) water-
pipe smoking (6.18%) is similar to a study among adoles-
cents [prevalence, 6.9% (95% CI, 6.4–7.5)] which was based
on the data from 72 countries that had conducted Global
Youth Tobacco Survey from 2010–2019 (C et al., 2022).
Another systematic review evaluating the prevalence of
waterpipe smoking noted the highest rate among school stu-
dents across countries (Akl et al., 2011).
A previous study has shown that, among school-going
students, the prevalence of waterpipe smoking increases with
each grade throughout high school (Barnett et al., 2017).
Another study has reported the largest increase in waterpipe
smoking between ages 18 and 19 years (Pérez et al., 2021). It
was also reported that the rates of waterpipe smoking initi-
ation were highest during the first two months of schooling
(Fielder et al., 2012). Another study on the prevalence and
attitudes among medical students in London found that
waterpipe smoking was more common than cigarette smok-
ing [current (30-day) 11.0% vs. 6.3%, ever 51.7% vs. 16.8%].
A previous systematic review and meta-analysis showed that
waterpipe use was associated with greater odds of suscepti-
bility to cigarette smoking among adolescents and young
adults who never smoked (Yu et al., 2023). In a study per-
formed in a US university, for more than half (52.9%) of the
ever-users, waterpipe was the first tobacco product ever
tried by the students. This study demonstrated a progression
in waterpipe smoking uptake from non-susceptible, to sus-
ceptible, to first use, and to continued use (Roberts &
Ferketich, 2020).
The analysis of the included studies showed male gender,
cigarette smoking (by self/family/friends), waterpipe smoking
by family/friends, alcohol use, and illicit substance use as
factors associated with waterpipe use. Three studies also
reported that participants who smoked waterpipe used alcohol
and cigarettes at a higher frequency and quantity, and they
reported more severity on measures of problem alcohol and
nicotine use than participants who did not smoke waterpipe
(Heinz et al., 2013). Another study evaluating nicotine depen-
dence among adolescent waterpipe smokers in Lebanon
reported that nicotine dependency developed among adoles-
cent waterpipe smokers at low levels of consumption and fre-
quency of use. Another study reported curiosity about
waterpipes as a strong influence on waterpipe smoking (OR,
28.28; 95% CI, 22.64–35.33) Another study reported low
self-perception of academic achievement as the most signifi-
cant variable that increases the probability of smoking water-
pipe regularly (OR, 25.97) (Korn & Magnezi, 2008).
Participants liked waterpipe smoking because they like its fla-
vor and social environment (46.3% and 29.5% respectively)
(Eshah & Froelicher, 2018). A recent systematic review evalu-
ating the determinants of waterpipe use among women noted
a lack of awareness of the hazardous effects of waterpipe, a
favorable attitude toward use, and the influence of friends and
family as significant risk factors contributing to its use
(Bashirian et al., 2021).
In addition to the findings of our study, tobacco industry
marketing, peer influence, product appeal based on novelty
and flavors, perceived social acceptability, perceptions about
harm relative to conventional tobacco products, and lack of
regulation for e-cigarettes and waterpipe have been cited in
the literature as a predisposing factor for waterpipe smoking
(Wang et al., 2019). The other established factors of use and
initiation, including the availability of flavors, exposure to
tobacco product marketing, curiosity and susceptibility, and
misperceptions about harm from tobacco product use con-
tinue to promote tobacco product use among youths (Wang
et al., 2014). According to the report, there was a connec-
tion between the use of flavored tobacco products, openness
to tobacco company advertising, and the belief that their
peers had a higher prevalence of tobacco usage (Lee et al.,
2015). In a study among Jordanian adults, the majority of
the participants reported that they smoked a waterpipe for
the first time with their friends (66.8%), they usually smoke
in the company of others (63.2%), and believe that quitting
cigarettes smoking is harder than quitting waterpipe smok-
ing (61.6%). More than half (56.7%) of participants have
extremely poor knowledge about the health effects of water-
pipe smoking (Eshah & Froelicher, 2018).
A wide range of sociocultural factors affects waterpipe
smoking among adolescents and young adults. These are
primarily socio-cultural norms, gender differences, motiva-
tion to smoke, sensory characteristics of waterpipe, meta-
phors, consumerism, indicators of dependence, comparison
between cigarettes and waterpipe, health effect of smoking,
and intervention (Afifi et al., 2013; Makvandi et al., 2021).
Therefore, interdisciplinary multidimensional strategies are
needed for waterpipe smoking management and prevention
among these at-risk groups. Public education, strict supervi-
sion of tobacco import, export, and selling, ample employ-
ment opportunities for young people, and effective leisure
time management are essential to reduce waterpipe smoking.

The common barriers to de-addiction treatment among
waterpipe smokers include smoking culture, client resistance,
the lack of resources, staff smoking, and environmental bar-
riers. On the other hand, the facilitators of de-addiction
treatment include financial support, enhanced leadership,
and state mandates against smoking in addiction treatment
programs (Pagano et al., 2016; Farhoudian et al., 2022).
Globally, there is limited attention to waterpipe policies in
various countries because of the inherent complexity. The
various national policies in this regard have been reviewed
comprehensively earlier (Alaouie et al., 2022).
The strengths of our study include the inclusion of a
large number (n = 62) studies, the use of a consistent defini-
tion of ever use and current (30-day) use of waterpipe, and
the inclusion of a wide demographic range of the study pop-
ulation. However, there are certain limitations to this study.
The studies were reported only from selected regions and
countries and there was a paucity of data from a large part
of the world. There was variability in the study population
across the various included studies and not all outcomes of
interest were reported in all studies. Notwithstanding these
limitations, to the best of our knowledge, this is the first
systematic review to summarize the burden and risk factors
of waterpipe smoking among adolescents and young adults
across the globe (WHO., 2015).
Conclusion
To conclude, it was revealed that waterpipe smoking usage
was significantly high among adolescents and young adults.
The prevalence of waterpipe smoking was higher among
males, among those who belong to the high- and
middle-income groups, and among university students. The
common risk factors of waterpipe smoking included ciga-
rette smoking, alcohol, and substance use. Waterpipe smok-
ing resulted in increased susceptibility to the use of
conventional forms of tobacco (e.g. smoking) among those
who were never smokers. There is an unmet need to gener-
ate more global evidence on the burden and determinants of
waterpipe use, especially from south-east Asian countries.
Qualitative studies can help in understanding the miscon-
ceptions about waterpipe smoking and the subsequent initi-
ation of cigarette smoking particularly among the youth. To
protect adolescents and youth from the waterpipe smoking
addiction, tailored awareness programs, public health poli-
cies, and regulations are required. Developing regulatory
guidelines for water-pipe smoking, surveillance of its use,
intervention, and specific policy frameworks may be consid-
ered a public health priority, as Australia is aiming to do in
the near future (Kirby, 2023).
Declaration of interest
The authors declare there is no Complete of Interest at this study.
Disclosure statement
The authors declare no competing interests.
Substance Use & Misuse 9
Acknowledgments
Dr. Roy Daniels, Senior Resident, Centre for Community Medicine,
The All India Institute of Medical Sciences (AIIMS), New Delhi, for
identifying Key words.
Authors’ contributions
SSB conceptualized the review; SSB and HP drafted the study protocol;
HP, DM, SS, and AS were involved in the literature search and study
selection; SSB, SD, HP, DM, SS, and AS extracted data from the included
studies; SD and SS performed the risk of bias analyses; HP, DM, and
AS were involved in disagreement resolutions at all stages; SS and CRH
performed all qualitative synthesis; SSB, SD, and SS interpreted the anal-
yses; SSB, SD, CRH, and SS drafted the review; PCG, JKC, LS, PS,
VGM, and SRG provided guidance, expert inputs, and updated the final
review. All authors had full access to all the data in the study and had
final responsibility for the decision to submit for publication.
Funding
The author(s) reported there is no funding associated with the work
featured in this article.
Data availability statement
The original contributions presented in the study are included in the
main article/supplementary material. Further inquiries can be directed
to the corresponding author.
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