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Early symptoms of nicotine dependence among adolescent waterpipe smokers
  1. Raed Bahelah1,2,
  2. Joseph R DiFranza3,
  3. Fouad M Fouad4,5,
  4. Kenneth D Ward4,6,
  5. Thomas Eissenberg7,
  6. Wasim Maziak1,4
  1. 1Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA
  2. 2Faculty of Medicine and Health Sciences, Aden University, Yemen
  3. 3Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  4. 4Syrian Center for Tobacco Studies, Aleppo, Syria
  5. 5American University of Beirut, Beirut, Lebanon
  6. 6University of Memphis School of Public Health, Memphis, Tennessee, USA
  7. 7Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
  1. Correspondence to Dr Wasim Maziak, Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th Street, AHC5 489, Miami, FL 33199, USA; wmaziak{at}


Background Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon.

Methods Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon.

Results Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND.

Conclusions Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

  • Addiction
  • Low/Middle income country
  • Nicotine
  • Non-cigarette tobacco products

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  • Contributors RB and WM conceptualised and designed the study. FMF obtained the data. RB analysed the data. RB and JRD wrote the first draft of the manuscript. FMF, KDW, TE, WM provided critical intellectual feedback to the manuscript. All authors read and approved the final manuscript.

  • Funding This study is supported by the National Institute on Drug Abuse (NIDA) (grant R01 DA035160 awarded to Wasim Maziak) and Fogarty International Center (grant R03 TW07233 awarded to Kenneth Ward) of the National Institutes of Health. Dr Eissenberg's work is supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number P50DA036105 and the Center for Tobacco Products of the U.S. Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIDA, NIH or the FDA.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Florida International University and the American University of Beirut.

  • Provenance and peer review Not commissioned; externally peer reviewed.