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Effects of flavourants and humectants on waterpipe tobacco puffing behaviour, biomarkers of exposure and subjective effects among adults with high versus low nicotine dependence
  1. Brittney Keller-Hamilton1,
  2. Toral Mehta1,
  3. Jessica J Hale1,
  4. Eleanor L S Leavens2,
  5. Alan Shihadeh3,4,
  6. Thomas Eissenberg4,
  7. Marielle C Brinkman1,5,
  8. Theodore L Wagener1,6
  1. 1 Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
  2. 2 Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas, USA
  3. 3 Mechanical Engineering, American University of Beirut, Beirut, Lebanon
  4. 4 Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
  5. 5 College of Public Health, The Ohio State University, Columbus, Ohio, USA
  6. 6 Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
  1. Correspondence to Dr Brittney Keller-Hamilton, Center for Tobacco Research, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio 43214, USA; keller-hamilton.1{at}


Introduction Flavourants and humectants in waterpipe tobacco (WT) increase product appeal. Removal of these constituents, however, is associated with increased intensity of WT puffing, likely due to reduced nicotine delivery efficiency. To clarify the potential public health outcomes of restrictions on flavourants or humectants in WT, we evaluated the effects of these constituents on puffing behaviours, biomarkers of exposure and subjective effects among adults with high versus low WT dependence.

Methods N=39 high dependence and N=49 low dependence WT smokers (Lebanese Waterpipe Dependence Scale scores >10 = high dependence) completed four smoking sessions in a cross-over experiment. Conditions were preferred flavour with humectant (+F+H), preferred flavour without humectant (+F-H), unflavoured with humectant (−F+H) and unflavoured without humectant (−F−H). Measures of puff topography, plasma nicotine and expired carbon monoxide (eCO) boost, and subjective effects were assessed.

Results Level of WT dependence modified the effect of WT condition on average flow rate, average puff volume and eCO boost. Although, overall, participants puffed the +F+H WT least intensely and −F−H WT most intensely, this association was strongest among WT smokers with high dependence. Participants preferred smoking the +F+H WT and achieved the largest plasma nicotine boost in that condition.

Discussion Findings underscore the complexity of setting product standards related to flavourants and humectants in WT. Future research evaluating whether WT smokers with high dependence would quit or reduce their WT smoking in response to removal of flavourants or humectants from WT is necessary to appreciate the full public health effects of such policies.

  • non-cigarette tobacco products
  • smoking topography
  • addiction

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  • Contributors BK-H completed data analyses and drafted and revised the manuscript. She is guarantor. TM collected data and reviewed the manuscript. JH oversaw study procedures and performed data management. ELSL, AS, TE and MCB assisted with study design and reviewed the manuscript. TLW designed the study, assisted with interpretation of results and critically reviewed the manuscript.

  • Funding This study was funded by National Institute on Drug Abuse and Center for Tobacco Products (CTP) of the US Food and Drug Administration (Grant: R03 DA041928, R03 DA041928 02S1, PI: TLW). MCB and TLW’s effort is also supported by R01CA255563 from the National Cancer Institute and the CTP of the US Food and Drug Administration). TS’s effort is supported, in part, by grant number U54DA036105 from the National Institute on Drug Abuse of the National Institutes of Health and the CTP of the US Food and Drug Administration. ELSL’s effort is supported by an NIH CTSA award to the University of Kansas Medical Center (TL1TR002368).

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

  • Competing interests TE and AS are paid consultants in litigation against the tobacco industry and also the electronic cigarette industry and are named on a patent for a device that measures the puffing behaviour of electronic cigarette smokers. The other authors have no interests to disclose.

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