Introduction Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers.
Methods We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes.
Results Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99).
Conclusions A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted.
- non-cigarette tobacco products
- public policy
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Contributors RB and WM conceptualised and designed the study, supervised data collection, performed the initial analyses, contributed to interpretation of the data and drafted the initial manuscript, and critically revised the manuscript for important intellectual content. KDW, ZBT, JRD, TE and RJ contributed to interpretation of the data and critically revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.
Funding The WDLY study is funded by grants R01DA035160 and R01TW010654 from the National Institute of Health Fogarty International Center (NIH FIC) and National Institute on Drug Abuse (NIDA) of the National Institute of Health (PI: WM). TE is supported, in part, 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 US Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA. RJ was supported by the American Heart Association Tobacco Regulation and Addiction Center under National Heart, Lung and Blood Institute of the National Institutes of Health and Center for Tobacco Products Award Number P50HL120163.
Competing interests TE is a paid consultant in litigation against the tobacco industry and is named on a patent application for a device that measures the puffing behaviour of electronic cigarette users.
Patient consent Not required.
Ethics approval The institutional review boards of Florida International University and the American University of Beirut approved Waterpipe Dependence in Lebanese Youth study (WDLY).
Provenance and peer review Not commissioned; externally peer reviewed.