I read with interest the research letter by Carroll and colleagues.1 They make the case that the concern about waterpipe use among Arabic-speaking Australians is perhaps not warranted given its low prevalence among them (11% compared to 26 for cigarette/cigar/pipe, CCP), the fact that most waterpipe users are CCP smokers as well (CCP is the strongest predictor for waterpipe use), and the low likelihood of switching between smoking methods as only one ex-CCP smoker is currently a daily waterpipe user.1
I think that neither the data they present nor the arguments they used justify their conclusion. First, being concerned about a new public health threat does not mean to take away the focus from a bigger one. Concern about waterpipe use is based mainly on how fast it is spreading, and its potential harmful effects. Other factors that argue in favor of further spread of waterpipe use include increased availability, trendiness (allure), dependence potential, misperception about harmful/addictive effects, slow public health response and replacement potential because of the concerns about cigarette smoking. Although time trend studies about waterpipe use have been lacking, the evidence that this tobacco use method is witnessing a boom all over the world is overwhelming. Barely witnessed among older males in societies in the Middle East about two decades ago, waterpipe use is now been documented worldwide, particularly among youths.2 Second, I do not understand how in a cross-sectional analysis one can make confident assumptions about the actual relation between two risk factors (i.e. CCP smoking and waterpipe use). The time sequence is lacking and any inference about such an analysis, other than the actual association is poorly justified.1 The waterpipe epidemic moreover, is still in the making, so whatever patterns we observe currently may well change in the near future as the epidemic follows a more defined course. Finally, the waterpipe is mainly an intermittent tobacco use method,3 so arguing that because only one ex-CCP smoker is currently a daily waterpipe user as an evidence for the low-level of switching between different tobacco use methods is premature to say the least. Our, as well as other's, data demonstrate that waterpipe use can be a vehicle for cigarette smoking either among tobacco naive or cigarette-quitters.4
We need to keep an eye on the main public health threat of cigarette smoking, but as the history of the cigarette epidemic clearly demonstrates, failing to react timely to an emerging threat can be very costly.