Background:
Waterpipe tobacco smoking (WTS) prevalence in the Eastern Mediterranean Region (EMR) is among the highest in the world and it is increasing with time. This paper aims to investigate waterpipe harm believes among university students who smoke waterpipe in five EMR countries.

Methods:
This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Palestine, Oman, and the United Arab Emirates (UAE). Participants were recruited from among young adult students (18-29 years) at selected universities in each country. Data were collected using an Internet-based survey. Participants were included if they were waterpipe tobacco smokers and at least 18 years of age (including users of cigarettes, WTS, and dual users).

Results:
In most countries, participants (70%-80%) had initiated WTS with a friend or several friends with the exception of Palestinians where 31% started smoking with family members and Egyptians where 22% started smoking alone. More than 70% of the participants from Oman, UAE and Egypt started smoking in a café; or restaurants while around 50% of the participants from Jordan and Palestine started smoking at home or someone else's home. Sixty percent had smoked waterpipe and 44.5% had smoked cigarettes in the past 30 days. Most participants from the five countries were aware that WTS can cause harm during pregnancy. Around 30% of participants had misperceptions about waterpipe as a cause of cancer or death. Participants from Egypt seemed to have the least knowledge about WTS harm. Those who smoked cigarettes in the past 30 days had generally good knowledge about WTS harms compared to waterpipe smokers.

Conclusions:
Misperception of waterpipe harm is common among university students in the five EMR countries. Culturally adapted awareness champagnes targeting young adults including university students are needed in all countries