Background:
Waterpipe smoking started as a cultural phenomenon but has become a social phenomenon. Hookah cafes are an increasingly popular venue for socializing. Studies suggest that waterpipe users perceive smoking the waterpipe as less addictive and harmful than cigarette smoking. The aim of this study was to assess the beliefs, and associated behaviours, regarding the health-risk of smoking the waterpipe.

Methods:
A cross-sectional descriptive study was conducted with a sample of first year students at a historically black university in the Western Cape, South Africa. A self-administered questionnaire was constructed from the College Health Behaviour Survey. The final sample was 389 university students, 64% (250) females and 36% (139) males. The sample had a mean age of 22.2 years (SD = 5.04).

Results:
Waterpipe users perceived the health risks of smoking the waterpipe to be exaggerated (48%) and less addictive (58%) than non-users (13% and 17%, p<.001). Additionally, the findings confirm that waterpipe smoking is conducted in a social setting (61%). This social setting included smoking on campus (28%), in the family home (11%), at a party (9%), at a friend’s place (6%) and in a restaurant (1%). Of concern was the majority of users smoked the waterpipe on a daily basis (70%) and that the tobacco mix was easily available (90%). The most common self-reported reason for smoking the waterpipe was for relaxation.

Conclusions:
As with previous studies, the results of this study confirm the false perception that smoking the waterpipe is not a health risk and is socially acceptable. Additionally, the findings of the study raise concerns and an awareness of smoking the waterpipe in the family home and implications for children. The results of this study provide important information for tobacco control and substance abuse policies in South Africa. These findings highlight the need for further research to determine the extent of waterpipe smoking at other universities in South Africa.