Background:
The worldwide popularity of water pipe usage has sharply increased in recent years, especially among young adults and youths.

Methods:
In this study, we conducted a secondary analysis of the school-based Global Youth Tobacco Survey (GYTS). GYTS included questions about waterpipe tobacco use in a total of 60 countries between 2007 and 2015. We analysed data of 182,154 students aged 13 to 15 years from these 60 countries (sample sizes ranging from 1,221 to 8,789), to estimate the prevalence of ever and current (within the last 30 days) waterpipe smoking. We also used logistic regression to assess the association of sex and amount of weekly allowance money (proxy for family finances) with waterpipe use.

Results:
The prevalence of current waterpipe use among youths varied significantly between countries, from 2.7% in Gabon to 35.2% in West Bank and 37.0% in Lebanon. The percentage of youths who have ever tried waterpipe was highest in Lebanon (55.1%). In 39 out of 54 countries that had data on current waterpipe use, males were significantly more likely to smoke waterpipe than females, with adjusted Odds Ratios (AOR) ranging from 1.29 to 9.51. In contrast, female students were significantly more likely to use waterpipe in Djibouti and Maldives. Students receiving the largest amount of weekly allowance were more likely to be current users of waterpipe in the majority, but not all, of the countries assessed, compared to those in the category of the lowest amount. However, AOR varied widely, ranging from 0.58 to 12.55.

Conclusions:
Waterpipe use among youths is high in many regions, in particular within Eastern Mediterranean and Eastern European countries. Sex and socioeconomic equalities were identified in most countries. Systematic surveillance of waterpipe use would allow closer monitoring of the trends in use over time.