Waterpipe (hookah, narghile, shisha, etc.) use is long-standing and has been used for almost five centuries in Egypt, Turkey, Persia and India. Introduction of flavored tobacco in 1990s significantly increased the use of waterpipes among youth, first in the Middle East and later in other countries and continents, mostly at universities and schools. The popularity of cafés and restaurants, which often included waterpipes in their service, contributed to this development. Waterpipe is used mostly by young educated persons, and the increase in number of waterpipe bars indicates that an increase in waterpipe use can also be expected.

Waterpipe consists of a head where specially prepared tobacco is placed. On the top of it a perforated aluminum foil sheet is placed containing charcoal which is lit. The air, which is first heated by passing from the region of heated charcoal through tobacco and then cooled by passing through the water, finally reaches the mouth of the smoker through the hose.

There is a myth that waterpipe smoke is less harmful than cigarettes because it is filtered through water, which contributes to the increased popularity and social acceptability of waterpipe use. This is not true; waterpipe smoke contains combustion products from both tobacco and charcoal. Tobacco burning generates toxic agents, such as nitrous oxides, arsenic, nickel and lead, and carcinogens, including tobacco specific nitrosamines, polycyclic aromatic hydrocarbons (PAHs), formaldehydes and benzene. Additionally, the burning charcoal also generates PAHs, 15 times more carbon monoxide and 36 times more tar then smoking a single cigarette. Therefore, smoking tobacco-free waterpipe with herbal mixtures is just as harmful to health.

Smoking the waterpipe for an hour causes the smoker to inhale 100 to 200 times more smoke than smoking a single cigarette does.

Health consequences are similar to those for smoking cigarettes. Waterpipe smoking results immediately in elevated heart rate and blood pressure, as well as in acute carbon monoxide poisoning, and syncope. Long-term effects include chronic nasal inflammation, gastro-oesophageal reflux, reduced physical capacity, male infertility, impaired mental health and reduced birth weight for children born from mothers who smoked waterpipe during pregnancy. Toxic and carcinogenic agents are associated with lung, heart and blood disorders and increased risk of stroke, lung cancer and other cancers such as oral, oesophageal, gastric and bladders cancers. As tobacco contains nicotine, waterpipe smoking is also addictive.

Secondhand smoke from waterpipe tobacco smoke poses a serious health threat for nonsmokers, particularly because its smoke does not come only from the combustion of tobacco, but also from charcoal. Smoke generated from tobacco-free waterpipe products is equally dangerous, and, except for the nicotine, contains the same toxic and biologically active substances as the tobacco-based products.

Sharing the mouthpieces can pose the serious risk for infectious diseases, such as cold, influenza, oral herper, hepatitis, tiberculosis, etc.

Precise data on waterpipe use in Serbia are not available yet. However, it is evident that there is a significant increase in the number of cafés and restaurants offering waterpipe to their customers. Specific legislation that covers the use of waterpipe does not exist. Since this is the case of the tobacco burning product, the following legislation related to cultivation, production, trade and use of tobacco can be applied: Law on Tobacco, Law on Advertising and Law on Protection of the Citizens from Exposure to Tobacco Smoke. Special emphasis should be placed on banning the sale of waterpipes to minors.