Little and methodologically limited evidence links water pipe smoking to respiratory and cardiovascular disease and does not allow us to draw firm conclusion as to the potential harmful effects of water pipe smoking. We hypothesize that water pipe smoking is associated with increased risk of cardiovascular and respiratory impairment. We propose to conduct an observational study comparing 220 habitual water pipe smokers with 220 never smoker recruited from the community in Beirut and Doha along several biomarkers of cardiovascular and respiratory diseases. Coronary artery calcium score, a non-invasive marker of occult coronary heart disease and a predictor of the risk of cardiac disease, will be the main biomarker of interest. We will also compare vascular stiffness another non-invasive marker of vascular disease and predictor of the risk of hypertension and cardiovascular disease as well as spirometric measures of lung function, respiratory symptoms and serum and urine inflammatory, metabolic and oxidative stress biomarkers. Water pipe smoking will be assessed using a standardized measure that accounts for variability in smoking frequency, session length and type of tobacco

220 daily water pipe smoking individuals and 220 nonsmoking age and sex-matched controls recruited from the community in Beirut, Lebanon and Doha, Qatar.

The study investigators visit cafés that offer water pipe smoking and invite smokers to participate in this study. Controls consists of age and sex-matched never-smokers individuals recruited from patron of smoke free cafes in Beirut and Doha.

Additionally, IRB approved approved posters and flyers were posted at pharmacies and health care centers. Also IRB approved study summary cards were distibuted in waterpipe smonkimg cafes and waterpipe delivery shops. An advertisement was placed in a local newspaper as well to enhance recruitment and reach a wider community.