Background:
Waterpipe tobacco smoking [WPS] is the most prevalent form of smoking among youth. Few studies were reported that tested interventions of WPS cessation among youth, and none employed the use of behavioral counseling. The current study aims to evaluate the effectiveness of a culturally adapted, school-based 5As-guided counseling intervention for waterpipe smoking cessation.

Methods:
A Randomized Clinical Trial [RCT] was conducted to test the effectiveness of a behavioral counseling compared to an information only waterpipe smoking cessation intervention among school students. Eight schools (4 behavioral counseling & 4 information-only group) were randomly selected to participate in the study. School students who reported current waterpipe smoking and accepted to participate were recruited to the study. School counselors served as the study Interventionist. Waterpipe smoking abstinence was assessed at study entry (baseline) and at one month follow-up to assess intervention effect.

Results:
The final sample consisted of 185 participants (48% boys and 51% girls) for the pre-intervention phase and 157 participants for the post-intervention phase. The majority were 10^th or 11^th graders with a small percentage of 12^th grade students. A decrease in number of times for waterpipe smoking is observed between pre- and post- intervention among youth. A significant association was found between study groups for last week and last one day waterpipe smoking (X=12.5, P= 0.006; X=18.5, P= 0.000 respectively). Moreover, students who were in the information group had a higher level of nicotine dependence than students in the behavioral counseling group (t= 2.5, p= 0.01).

Conclusions:
Our study demonstrated that behavioral counseling is effective in decreasing waterpipe smoking habits among youth. Our results also showed that behavioral counseling has an effect on youth nicotine dependence level.