Waterpipe smoking and health outcomes: review of evidence and road map for an international consortium

The prevalence of waterpipe smoking (WPS) is increasingly recognised as a growing global public health concern. Available studies show that WPS exposes users to toxicants at levels similar to or higher than those in cigarette smoke, contributing to respiratory disease, cardiovascular damage and cancer. The WHO has flagged WPS as a growing threat, especially among adolescents and young adults, where use is rapidly increasing. Yet research progress is constrained by small samples, inconsistent exposure measures and inadequate adjustment for confounders. These limitations highlight the need for more rigorous epidemiological, clinical and toxicological studies. Importantly, the persistence and expansion of WPS cannot be explained solely by individual behaviours or perceptions of health risk. A range of socioeconomic, political and commercial forces-including industry marketing, weak regulatory oversight, cultural acceptance, low cost and the spread of waterpipe cafés-continues to drive WPS and shape patterns of use. These structural factors are likely to undermine the impact of current public health measures but remain under-researched. Expanding the evidence based on these upstream determinants is crucial for developing more effective and context-appropriate policies. In response to these challenges, experts from multiple disciplines convened in June 2024 to examine the evolving WPS epidemic. Participants emphasised the need for comprehensive, multisectoral strategies that integrate robust research, strengthen surveillance systems and target public awareness initiatives. The meeting concluded with a set of recommendations outlining priority research areas and a strategic roadmap aimed at addressing the complex and escalating public health threat posed by WPS.