INTRODUCTION: Waterpipe use amongst adolescents is on the rise globally. Thus, there is a need to understand adolescents 'attitudes towards and perceptions of waterpipe use in order to develop specific interventions against this form of tobacco use.

METHODS: Focus group interviews were conducted among 37 Swedish adolescents (14 boys and 23 girls) from grades 10 to 12. Waterpipe users and nonusers were interviewed separately, with two groups each for users and nonusers. Interviews were audiotaped, transcribed, and thematically analyzed using content analysis.

RESULTS: Six themes emerged including taking a stand, weighing the risks, Lack of knowledge, Social context, Waterpipe new and unknown, and Family influence. Taking a stand was about being able to stand up for one's owns views rather than giving in to peer pressure to smoke waterpipe. Participants feared harming others via secondhand smoke and expressed criticism of the tobacco industry. Participants considered the health consequences and feared addiction. Lack of knowledge concerning health effects of waterpipe smoking due to the unavailability of credible information was also reported. Waterpipe smoking was considered a social event carried out in the company of friends. Perceived as novel and fun, waterpipe was smoked out of curiosity. Parents' and siblings' smoking behaviors influenced adolescent waterpipe use.

CONCLUSION: Adolescents reported lacking information about the possible health effects of waterpipe smoking and that gaining such knowledge would make it easier for them to take a stand and refuse smoking waterpipe. Prevention strategies should focus on providing adolescents with factual information about the dangers of waterpipe use.