• Slavica Đorđević Academy of Vocational Studies Belgrade, High medical school Belgrade, Serbia
  • Snežana Knežević Dom zdravlja Kraljevo, Kraljevo
  • Katarina Boričić Institute of Public Health of Serbia 'Dr Milan Jovanović-Batut', Belgrade, Serbia
  • Verica Jovanović Institute of Public Health of Serbia 'Dr Milan Jovanović-Batut', Belgrade, Serbia


waterpipe, smoking, dependence, adolescents


Introduction: Smoking waterpipes has become very popular among youth around the world. Among the main reasons for this trend is the misperception that waterpipes are less harmful than cigarettes.

Aim: This paper aims to highlight motives, attitudes, and patterns of waterpipe use among adolescents in Serbia.

Methods: This study was a secondary analysis using data obtained from the study "Health behavior in school-aged children survey in the Republic of Serbia 2017/2018". An international research protocol was used to collect data on the health behavior of 15-year-old students. The questionnaire was designed for adolescents and consists of 74 questions, concerning health and waterpipe smoking habits. The survey was voluntary and anonymous.

Results: The study included 1605 students from 38 high schools, 798 (47.7%) males and 807 (52.3%) females. Waterpipe use is significantly related to smoking experience (β=0.271) and feeling nervous and depressed (β=0.150). Region (p=0.01), communication with friends about problems (p=0.01), and severe problems with family or friends (p=0.01) were all statistically significant in correlation to waterpipe smoking. Smoking habits (β=0.381) and urban regions (β=0.125) had the greatest impact on waterpipe smoking.

Conclusions: This study highlights waterpipe smoking is widespread among fifteen-year-old adolescents in Serbia. Cigarette smoking and anxiety signs like nervousness were risk factors for waterpipe use. Adolescents from Belgrade are considerably more frequently waterpipe smokers than all other regions.


Bou Fakhreddine HM, Kanj AN, Kanj NA. The growing epidemic of water pipe smoking: health effects and future needs. Respir Med. 2014 Sep;108(9):1241–53.

Babaie J, Ahmadi A, Abdollahi G, Doshmangir L. Preventing and controlling water pipe smoking: a systematic review of management interventions. BMC Public Health. 2021 Feb 26;21(1):344.

Qasim H, Alarabi AB, Alzoubi KH, Karim ZA, Alshbool FZ, Khasawneh FT. The effects of hookah/waterpipe smoking on general health and the cardiovascular system. Environmental Health and Preventive Medicine. 2019 Sep 14;24(1):58.

Ramôa CP, Eissenberg T, Sahingur SE. Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare. J Periodontal Res. 2017 Oct;52(5):813–23.

Cobb CO, Blank MD, Morlett A, Shihadeh A, Jaroudi E, Karaoghlanian N, et al. Comparison of puff topography, toxicant exposure, and subjective effects in low- and high-frequency waterpipe users: a double-blind, placebo-control study. Nicotine Tob Res. 2015 Jun;17(6):667–74.

Jukema JB, Bagnasco DE, Jukema RA. Waterpipe smoking: not necessarily less hazardous than cigarette smoking : Possible consequences for (cardiovascular) disease. Neth Heart J. 2014 Mar;22(3):91–9.

Palamar JJ, Zhou S, Sherman S, Weitzman M. Hookah use among U.S. high school seniors. Pediatrics. 2014 Aug;134(2):227–34.

Wong LP, Alias H, Aghamohammadi N, Aghazadeh S, Hoe VCW. Shisha Smoking Practices, Use Reasons, Attitudes, Health Effects and Intentions to Quit among Shisha Smokers in Malaysia. Int J Environ Res Public Health. 2016 Jul 19;13(7):E726.

Health Behaviour in School-aged Children (HBSC) study protocol: Background, methodology and mandatory items for the 2013/14 survey. St Andrews: Child and Adolescent Health Research Unit (CAHRU); 2014.

WHO. WHO report on the global tobacco epidemic, 2013: enforcing bans on tobacco advertising, promotion and sponsorship [Internet]. [cited 2022 Jun 13]. Available from:

Maziak W. The Global Epidemic of Waterpipe Smoking. Addict Behav. 2011;36(0):1–5.

Advisory note: waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators, 2nd edition [Internet]. [cited 2022 May 27]. Available from:

Wang M, Wang H, Fei FR, Xu CX, Du XF, Zhong JM. The associations between cigarette smoking and health-related behaviors among Chinese school-aged adolescents. Tob Induc Dis. 2017;15:27.

Yeom CW, Park YJ, Choi SW, Bhang SY. Association of peripheral BDNF level with cognition, attention and behavior in preschool children. Child Adolesc Psychiatry Ment Health. 2016;10:10.

Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol. 2017 Feb 1;46(1):32–43.

Arrazola RA, Singh T, Corey CG, Husten CG, Neff LJ, Apelberg BJ, et al. Tobacco use among middle and high school students - United States, 2011-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 17;64(14):381–5.

Agaku I, Odani S, Armour B, Glover-Kudon R. Social Aspects of Hookah Smoking Among US Youth. Pediatrics. 2018 Aug;142(2):e20180341.

Ramji R, Arnetz J, Nilsson M, Jamil H, Norström F, Maziak W, et al. Determinants of waterpipe use amongst adolescents in Northern Sweden: a survey of use pattern, risk perception, and environmental factors. BMC Research Notes. 2015 Sep 15;8(1):441.

Maziak W, Fouad FM, Asfar T, Hammal F, Bachir EM, Rastam S, et al. Prevalence and characteristics of narghile smoking among university students in Syria. Int J Tuberc Lung Dis. 2004 Jul;8(7):882–9.

Knishkowy B, Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behavior. Pediatrics. 2005 Jul;116(1):e113-119.






Original Articles