Participants identified the themes of availability, affordability, innovations in design, sensory qualities of WTS smoking, media influence, and policy.
Availability of the waterpipe in the public sphere
Availability of the waterpipe in the public sphere, particularly in cafés and restaurants was thought to have contributed to the increase in its use and to moving the location of smoking from homes to the public sphere. FGD participants stated that availability contributed towards motivating "those who don't even want to try, to go ahead and try" (female non-smoker - urban area). More women, younger age groups, and smokers noted widespread availability as the reason behind the increase in WTS. An expansion in the availability of waterpipes in food serving establishments was noted across all categories and was described as a recent "trend".
"...an emerging fad... 10 years ago, we were not used to seeing waterpipes. Nowadays... the first thing you [people] ask about [when entering a restaurant]: do you have waterpipes? ... The waterpipe is fundamental for everything. The restaurant is doing well because it has waterpipes. The evening is going well because the waterpipe is available... in every place there is the waterpipe, in every setting..." (Female smoker-urban area)
Moreover, FGD participants stated that restaurants and cafés have come to realize that offering waterpipes was a flourishing business. Consequently in response to the demand by customers and competition from others, the business of serving the waterpipe became a lucrative one.
"What played a big role in making it a "BOOM" is its commercialization. So maybe it began in a certain occasion where they found that they would benefit from it, so they promoted it pretty well...Our restaurants started to serve waterpipes, while earlier we used to go there to have a beer, there were no waterpipes, but afterwards it was on demand, so they promoted it" (Male smoker - rural area)
Home delivery services have made it accessible at home for people who had otherwise not considered it due to hassles in preparation. WTS requires the purchase of the waterpipe apparatus, the tobacco and all its accessories. It is time consuming and needs a basic level of know-how for preparation - all resolved by the amenities of home delivery. Men more than women, the younger age groups and smokers stated that the advent of waterpipe home delivery services contributed to the increase in use.
Affordability of waterpipe tobacco smoking
The waterpipe also evolved as an affordable way to spend time in cafés or at home, with little incurred cost. Affordability was brought up more by women and the older age categories. Both smokers and non smokers cited affordability almost equally as contributing to the surge in use. The waterpipe is generally offered in a range of prices starting from L.L. 5,000 and reaching L.L.15,000 ($1 = L.L. 1500) depending on the setting (how fancy and in what neighbourhood). Also, the practice of sharing of the waterpipe meant that smokers could share cost. The duration of a WTS session varied, depending on how often the tobacco was replenished, how many smokers were sharing, and how often they puffed.
"...we can order it twice, three times...Sharing and if it's for 10,000L.L. and we are 3 or 4 [people], so approximately 2000L.L. per person is affordable" (Female non smoker - urban area)
For those who smoked at home, it was affordable since, as stated by participants, apart from the tobacco, the accessories can be used repeatedly. Home delivery services were also affordable (L.L. 8,000) [19
]. This affordability at home and in public places was also thought to "encourage young people"
to smoke more (Male smoker - rural area).
Innovations in designs of the waterpipe apparatus and tobacco flavours
Continuous innovations in the design of the waterpipe apparatus increased marketing potential. The waterpipe apparatus could thus be dressed up or down to suit the taste of the smoker and the context. A café for example transformed the traditional looking waterpipe into a modern aluminium design [20
], most likely attractive to trend seeking smokers. Women, the younger age groups, and smokers stated that innovative designs of the apparatus including diverse sizes, colours, and materials have contributed to its popularity, particularly among women.
"Nowadays there are waterpipes especially for women; [they] are small, delicate and golden, with a more beautiful ornamented hose [as opposed to the waterpipe for men]. This is also a motivation [to smoke], maybe this form seduces the woman to smoke it, she might not like it, but it attracts her." (Female smoker - urban area)
The ritual of decorating the waterpipe has become common which also made smoking much more appealing particularly to women who are lured by aesthetics.
"... you put rose petals on the plate, you change its hose, paint it...At the end you'll like the way it looks. If the waterpipe looked nice and clean, then you'd have the desire to smoke it." (Female smoker - rural area)
Innovations such as using cored pineapple and watermelon and shiny ornamentation and crystal bottles were "encouraging use even if it does not taste better at the end, but psychologically [i.e. people feel that it tasted better just because in their view it looks better]" (Male smoker - urban area).
Innovations in tobacco flavours also contributed to the increase in use and motivated initiation. The variety of available flavourings of waterpipe tobacco in the form of Ma'asal attracted smokers in trying them out and also enticed new smokers. More women than men smokers, and younger age category groups (men and women), as well as smokers more than non-smokers mentioned the variety of tobacco flavours of Ma'asal in the market as a reason for the increase in WTS. Ma'asal is fruit-flavoured, typically tobacco mixed with molasses. It gives off an odour of burned sugar when smoked. Ajami is the traditional unflavoured tobacco, with a harsher smell of tobacco. Ma'ssal tobacco is generally favoured by youth and women.
"The companies are making use of it commercially, once they introduce the grape flavour to the market, people would then want to try it out, once they introduce the peach flavour, again people would want to try it out... I mean I think if they had only stopped with the apple flavour, maybe a lot of people would have had gave up waterpipe smoking...." (Male non-smoker - urban area)
Contrasting the experience to that of smoking cigarettes, alluding to the different tastes of flavours, one waterpipe smoker said:
"There is a difference in the taste [between a waterpipe and another] I have never through my entire life found a taste difference between one cigarette and another ... I mean the apple flavour is different than the melon, than the grape, than others... the waterpipe has a taste, and it is a good taste." (Female smoker - urban area)
Sensory qualities of waterpipe tobacco smoking
The sensory qualities of waterpipe smoking were important in encouraging use. The younger age groups and the smokers (regardless of age group) noted the sensory qualities evoked from waterpipe tobacco smoking as reasons that motivated smoking. Men and women equally attributed motivation to the sensory qualities such as taste, smell, sight of smoke, and bubbly sounds of the water in the bowl. Both smokers and non smokers equally cited taste and smell, however smokers more than non-smokers mentioned the sight and bubbly sounds.
In the Shouf [Mountains in Lebanon], when we're sitting together in the evening, drinking something and it's quiet and tranquil... [pauses for a moment] it's sound is very nice... When you inhale it, and the water does this sound [referring to the sound of bubbling water]..." (Male, non-smoker - urban area)
".. I like the smoke when it comes out as it does... When I wasn't smoking the waterpipe, I used to look at someone who smoked it and see how the smoke comes out of it and that made me love it." (Male smoker - rural area)
The taste and smell of Ma'asal tobacco were listed as main reasons for some to try the waterpipe, and eventually become addicted "my parents used to sit and smoke the waterpipe ... Then from its nice smell we got hooked" (Female smoker - rural area). The smell of the waterpipe even in public places was a motivator to initiate WTS:
"When you arrive to a café, you smell the waterpipe from the outside, you say that's it, you want to smoke it" (Male smoker - urban area)
Men and women, smokers and non smokers, and the younger age groups noted the influence of the media - particularly advertisements, movies and TV series broadcast during the month of Ramadan - through its positive depictions of waterpipe tobacco smoking scenes. Much like the cigarette is portrayed as glamorous, sexy, and cool; the media also associated the waterpipe with glamour and lavishness "What do the media do? [They make you] want to try, everything new they advertise... they tempt you with the design etc..." The use of women in the media was common and a strategy used by media to motivate women to take up WTS "... In an advertisement for any café, the first thing they show you is a girl smoking a waterpipe... The Media has a big influence..." (Male smoker - rural area). Other brands were specifically developed and marketed for youth, for example like the new Ma'asal brand produced named "Shabablik "which means in Arabic "that which is youthful."
"When it [Shabablik] was newly released into the market... the media has a big influence. And they seduce you, for example they give you a certain design for the package, they seduce you to try it, or maybe they do it in a cool attractive way ..." (Male smoker - rural area)
The media also made the waterpipe more common and familiar to the people. In the early 1990's, during the month of Ramadan, scenes from cafés and restaurants serving the waterpipe were broadcast live across satellite TV in the middle east region which served to "advertise the waterpipe" and popularize it.
"What really made the waterpipe in vogue over the last 10 years was the cafés, restaurants, Ramadan tents [coffee shops built temporarily during the holy month of Ramadan], these places were aired by TV stations, so... people were encouraged to go to such places. It [the waterpipe] has its own ambiance, they are promoting it."(Male smoker - urban area)
FGD participants noted that tobacco control policies should be set by the government and should regulate all forms of tobacco use, in particular that of waterpipe.
"it's the government's responsibility; the government should tackle such matters, raise awareness, take the necessary steps (Male non-smoker - rural area)
The commonly suggested policies that were brought up by participants were: banning WTS in closed indoor public places such as restaurants, raising price, limiting media influence be it direct or indirect advertising - most notably smokers in TV shows etc, as well as the need for health warning labelling like that required for cigarettes.
With regards to introduction of bans of smoking in public places, most participants viewed it as a measure that will decrease WTS.
"...that would be the only thing that makes us--- if not quit it--- it would at least decrease by 50% or 60%..." (Female smoker - urban area)
Also, the fact that both cigarettes and waterpipe were affordable in Lebanon was stated as one of the reasons why people continue to smoke. FGD participants stated that making WTS more expensive could potentially reduce use, although some were a bit sceptical since waterpipe smokers can prepare it at home as a cheaper alternative.
"I think if [the waterpipe] it is expensive relative to the income, it would not be that popular (...); a higher price would deter from use (Woman non-smoker - urban area)
FGD participants noted ubiquitous advertising of waterpipe tobacco particularly indirectly through propagation of positive images of WTS on TV programs.
"There are loads of advertisements for the Mo'assel tobacco, especially on the radio, more than TV (...). One would be tempted to try new flavors (Woman smoker - rural area)"
"Media and TV have a major impact. In any advertisement for a café they would show a woman smoking waterpipe. It is all about media (...). Media has a major impact on prevalence of waterpipe smoking, like when a new fashionable brand is out, This is the effect of media, you start trying out new trends., advertising has a major impact, they would entice you with a new design, so that you try it, ... (male smoker - rural area)
With regards to the need for HW's on waterpipe tobacco products, one participant compared that to presence of HW on cigarettes:
"Even the ministry of health, although they put a health warning on the cigarette packs, mentions nothing on waterpipe tobacco packs. .. although waterpipe smoking on a daily basis is more harmful than cigarette smoking (Woman non-smoker - urban area)"
Most importantly FGD participants stated that legislating policies and subsequent follow up and enforcement by the government to ensure compliance were essential to controlling WTS.
"[Tobacco control policies] have to be implemented. But such policies about banning waterpipe need to be enforced. There should be proper follow-up and enforcement by the government (male smoker - rural area)"