Open Access Highly Accessed Open Badges Research

Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review

Elie A Akl123*, Mohammed Jawad4, Wai Yim Lam5, Christopher N Co1, Rawad Obeid6 and Jihad Irani7

Author Affiliations

1 Department of Medicine, State University of New York at Buffalo ECMC-DKM C216, 462 Grider St, Buffalo, NY 14215, USA

2 Department of Internal Medicine, American University of Beirut, Beirut, Lebanon

3 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada

4 Imperial College London, South Kensington, London, UK

5 North Shore-Long Island Jewish Health Systems, Great Neck, NY, USA

6 Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, USA

7 Faculty of Health Sciences, University of Balamand, Beirut, Lebanon

For all author emails, please log on.

Harm Reduction Journal 2013, 10:12  doi:10.1186/1477-7517-10-12

Published: 2 July 2013



In spite of the negative health effects of waterpipe tobacco smoking, its use is becoming more common. The objective of this study is to systematically review the medical literature for motives, beliefs and attitudes towards waterpipe tobacco smoking.


We electronically searched MEDLINE, EMBASE, and the ISI the Web of Science in January 2012. We included both quantitative and qualitative studies. We selected studies and abstracted data using standard systematic review methodology. We synthesized data qualitatively.


We included 58 papers reporting on 56 studies. The main motives for waterpipe tobacco smoking were socializing, relaxation, pleasure and entertainment. Peer pressure, fashion, and curiosity were additional motives for university and school students while expression of cultural identity was an additional motive for people in the Middle East and for people of Middle Eastern descent in Western countries. Awareness of the potential health hazards of waterpipe smoking was common across settings. Most but not all studies found that the majority of people perceived waterpipe smoking as less harmful than cigarette smoking. Waterpipe smoking was generally socially acceptable and more acceptable than cigarette smoking in general. In Middle Eastern societies, it was particularly more acceptable for women’s use compared to cigarette use. A majority perceived waterpipe smoking as less addictive than cigarette smoking. While users were confident in their ability to quit waterpipe smoking at any time, willingness to quit varied across settings.


Socializing, relaxation, pleasure and entertainment were the main motives for waterpipe use. While waterpipe users were aware of the health hazards of waterpipe smoking, they perceived it as less harmful, less addictive and more socially acceptable than cigarette smoking and were confident about their ability to quit.

Tobacco; Waterpipe; Addiction; Motives; Beliefs; Attitudes