Lessons from surveillance of the smoking epidemic show that the lack of adequate attention to standardizing measures and instruments for epidemiological studies has negatively influenced our ability to assess spatial and secular trends in smoking worldwide. Waterpipe smoking, another hazardous form of tobacco use, is gaining popularity worldwide, with societies in the Eastern Mediterranean region (EMR) being most affected. Several research groups are currently investigating the epidemiology of waterpipe smoking among various populations in the EMR. Initial evidence shows that in contrast to usage patterns observed in adult cigarette smoking, waterpipe smoking is characterized mainly by intermittent and social use. As such, many measures that have been traditionally used for the study of usage patterns and dependence among adult cigarette smokers are uninformative for waterpipe smoking. Thus, the need to develop standardized measures and terminology for assessment of the epidemiology of waterpipe smoking in different populations is of paramount importance. As the monitoring of waterpipe smoking is in its infancy, the development of consensus measures should facilitate the initiation of effective surveillance that can guide public health response to this emerging epidemic.