Symptoms of Nicotine Dependence in Adolescent Waterpipe Smokers


In this study by Bahelah and colleagues, they found that symptoms of nicotine dependence develop among adolescent waterpipe smokers at low levels of consumption and frequency of use.

The researchers found that the early symptoms of nicotine dependence present among adolescent waterpipe smokers in Lebanon were craving and feeling addicted. Their findings extend those of previous research by demonstrating that infrequent use of a non-cigarette tobacco product can produce dependence, as measured by the International Classification of Diseases (ICD-10), in adolescents. This study showed that nicotine dependence can appear within a relatively short time period after the initiation of waterpipe smoking among adolescents, and at a lower frequency of waterpipe use compared to cigarette smokers. They found that frequency and intensity of nicotine dependence symptoms did not differ between waterpipe and cigarette smokers, but did find that waterpipe smoking involves different use behaviours, social context and sensory experiences than cigarette smoking. They conclude by suggesting that their findings indicate that waterpipe-specific prevention and intervention programmes targeting youth are needed.


Article Title: 

Early symptoms of nicotine dependence among adolescent waterpipe smokers (Paywall)




Raed Bahelah, Joseph R DiFranza, Fouad M Fouad, Kenneth D Ward, Thomas Eissenberg, and Wasim Maziak




Florida International University, Aden University, University of Massachusetts Medical School, Syrian Center for Tobacco Studies, American University of Beirut, University of Memphis School of Public Health, and Virginia Commonwealth University




The researchers aimed to determine if waterpipe smokers could develop nicotine dependence with non-daily use and how symptoms of nicotine dependence experienced by waterpipe smokers compared to those of cigarette smokers. They also aimed to determine at what age nicotine dependence begins among waterpipe smokers. Using baseline data, they described symptoms of nicotine dependence among adolescent waterpipe smokers in relation to the duration, quantity, and frequency of waterpipe use.




The researchers noted that Lebanon is among the countries most affected by the waterpipe epidemic, with the highest prevalence of current waterpipe smoking among 13–15-year olds globally (36.9%). They also noted previous work that shows a single waterpipe session exposes smokers to 1.7 times the amount of nicotine, and about 50 times the volume of smoke inhaled compared to a single cigarette (48.6 vs 1 L). They suggested that while waterpipes may be less accessible and used less frequently, larger amounts of inhaled smoke/nicotine, length of smoking session and its strong social cues may facilitate nicotine dependence in a specific way for waterpipe smokers. Finally, they noted no studies had documented the natural history of the development of symptoms of nicotine dependence among adolescent waterpipe smokers.Therefore, they were interested in examining the timing and characteristics of nicotine dependence in waterpipe smokers in order to guide the development of waterpipe-specific prevention and intervention strategies.




The researchers conducted individual confidential interviews to evaluate nicotine dependence in 160 waterpipe smokers and 24 cigarette smokers from a sample of students enrolled in 8th and 9th grades in Lebanon. They used a multiple measures, including the Stages of Physical Dependence measure, the Hooked on Nicotine Checklist, tThe Lebanon Waterpipe Dependence Scale, and the Syrian Center for Tobacco Studies-28 test battery.


ScientiFix tip: The researchers acknowledged that their study had some limitations. Here I will just highlight a couple. The researchers state that the small number of cigarette smokers provided limited statistical power to detect significant differences between waterpipe and cigarette smokers. The issue with poor power, as we have mentioned before, is that the researchers have not tested enough people to have a strong chance of detecting a true effect between the two groups. But poor power also reduces the likelihood that a statistically significant result reflects a true effect (rather than an effect occurring by chance). They also noted that their sample of cigarette smokers was almost all male, which would limit the generalisability of their findings (whether their findings are only representative of their sample or a larger population). For a recent Guardian blog on the topic of waterpipes, click here (featured on ScientiFix Weekly).


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