Cigarette smoking gained popularity among women decades after that of men and the prevalence rates of the latter increased resulting in a narrower gender gap in some high-income countries [1]. However, global smoking rates have declined in men and women as well as daily cigarette smoking [2]. On the other hand, water pipe tobacco smoking (WTS) is considered as a global epidemic that was not anymore restricted to the Middle East and South East Asia but spread to Western countries [3,4].

In some Arab countries, the prevalence of WTS (shisha or narghile smoking as is called in most Arab countries) among adult females (8.9%) was more than four times that of males (2.0%) in the early eighties, with a lower prevalence among younger females than in earlier decades [5]. This may be explained by the popularity of cigarette smoking among Arab males and its social unacceptability for women. However, the gender gap for WTS narrowed and was almost closed in the early 2000’s [6]. Moreover, it is alarming that WTS by pregnant Arab women ranges between 4.0-8.7% [7,8].

Recent literature shows that WTS has increased among Arab males and females with a wider gender gap. [7,9-12]. This is partly attributed to the prevention and control measures that focused on cigarette rather than tobacco smoking, the belief that shisha smoking is not as harmful as that of cigarettes and in being perceived as an acceptable alternative for those who wish to smoke tobacco or those who want to quit cigarette smoking. This may reflect the deficiency in school curricula and that of health professionals as the emphasis is on the hazards of cigarette smoking rather than all types of tobacco use. Further, the availability of different tobacco flavors and the exotic decorations on the shisha apparatus made it more attractive for the young along with the rise of shisha bars, lounges and café’s. It is noteworthy that the socially and culturally embedded acceptance of Arab women’s shisha smoking helped in making it regain its popularity particularly among the young though at a slower pace than that of men.

Shisha smoking went beyond Arab and other Middle Eastern countries and gained popularity in European and American countries particularly among the young and with a narrower gender gap. The fact that 11.9% of the female university students were WTS compared to 17.9% among males from a recent United Kingdom study of six universities is disturbing [13]. Moreover, a prevalence of WTS reaching 25% and 16% among 11-15 year old school male and female students, respectively in Estonia is worrying [14]. With the success of tobacco control efforts that mainly targeted cigarette smoking and the increase of evidence on the health effects of WTS [15], immediate action should be taken to curb the WTS epidemic globally and from Arab countries in particular. Special attention should be given to Arab women and youth who are the most vulnerable.