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Effect of flavour manipulation on low and high-frequency waterpipe users’ puff topography, toxicant exposures and subjective experiences
  1. Wasim Maziak1,
  2. Ziyad Ben Taleb2,
  3. Mohammad Ebrahimi Kalan1,
  4. Melissa Ward-Peterson1,
  5. Zoran Bursac3,
  6. Olatokunbo Osibogun1,
  7. Thomas Eissenberg4
  1. 1Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
  2. 2Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, USA
  3. 3Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA
  4. 4Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA
  1. Correspondence to Dr Wasim Maziak, College of Public Health, Florida International University, Miami, FL 33199, USA; wmaziak{at}


Background Flavoured tobacco is one of the major factors behind the popularity of waterpipe (WP) smoking in the USA and internationally. The current study examined the impact of flavour manipulation on satisfaction, puff topography and toxicant exposure among high-frequency and low-frequency WP users.

Method This cross-over study was conducted among 144 current (past month) WP smokers reporting WP smoking less than once a week (low-frequency users; n=69) or at least once a week (high-frequency users; n=75) in the past 6 months. Participants attended two counterbalanced 45 min ad libitum smoking sessions that differed by flavour (preferred flavoured vs unflavoured tobacco), preceded by ≥12 hours of tobacco use abstinence. Outcome measures included puff topography, expired carbon monoxide (eCO), plasma nicotine and subjective measures.

Results Both high-frequency and low-frequency WP users reported an enhanced smoking experience and greater interest in future use after smoking the flavoured compared with unflavoured tobacco (p<0.05 for all). High-frequency users, however, were more keen on smoking the flavoured tobacco in the future, had higher puffing parameters in general compared with low-frequency users (p<0.05 for all) and had no differences in eCO and plasma nicotine concentrations between the flavoured and unflavoured tobacco conditions (p>0.05 for all). On the other hand, low-frequency users had significantly greater eCO and plasma nicotine concentrations following smoking the unflavoured compared with flavoured tobacco condition (p<0.05 for all).

Conclusions Our results indicate that removing flavours will likely negatively affect WP satisfaction and future use and that such an effect will be more pronounced among high-frequency compared with low-frequency WP smokers.

  • smoking topography
  • nicotine
  • prevention
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  • Contributors WM and MEK conceptualised and designed the study, and drafted the initial manuscript. MEK, ZBT and ZB conducted data analysis. ZBT, MW-P, OO and TE contributed to the interpretation of data and critically revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted.

  • Funding This study was funded by the National Institute on Drug Abuse at National Institutes of Health (NIH) under award R01 DA042477 and Fogarty International Center (FIC) under award R01TW010654-01. MW-P is currently supported by the National Institute of Minority Health and Health Disparities grant (U54MD012393-01) for FIU-RCMI. TE is supported by the NIH under Award U54DA036105 and the FDA CTP. TE is a paid consultant in litigation against the tobacco industry and is named on a patent for a device that measures the puffing behaviour of electronic cigarette users.

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

  • Competing interests No, there are no competing interests.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Institutional Review Board at Florida International University.

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

  • Data availability statement No data are available.

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