Young adult waterpipe smokers: Smoking behaviors and associated subjective and physiological effects
Introduction
Nearly all adults who smoke cigarettes started smoking before the age of 26 (U.S. Department of Health and Human Services, 2012). One in every four senior high school students uses tobacco (Arrazola, Dube, & Engstrom, 2012). As youth transition to adulthood, tobacco use becomes more prevalent (U.S. Department of Health and Human Services, 2012). In fact, young adults (18–25 years old) currently have the highest prevalence of cigarette smoking of all age groups (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011).
In recent years, waterpipe smoking has become increasingly popular. Waterpipe smoking is becoming the most common type of tobacco smoking after cigarettes among U.S. young adults (Cobb et al., 2012, Primack et al., 2008, Primack et al., 2013). Reports have shown a 40% increase from 2005 to 2008 (Smith et al., 2011). This rise is a major concern in the U.S. and globally (Maziak, 2011, Waterpipe Tobacco Research Conference Declaration, 2013, U.S. Department of Health and Human Services, 2012, World Health Organization, 2005).
Typically, waterpipe smoking in the young adult population is non-daily, with the majority smoking only on weekends (Ahmed, Jacob, Allen, & Benowitz, 2011). Additionally, substantial proportions (6–41%) of current waterpipe smokers do not report the use of other tobacco products (Cobb et al., 2012, Primack et al., 2013). As such, waterpipe smoking is affecting a population of otherwise nicotine-naïve individuals who might not have initiated tobacco use without waterpipes. This raises the concern that waterpipe smoking may serve as a portal to nicotine dependence (Maziak et al., 2009, Ward et al., 2007). Thus, understanding waterpipe smoking behaviors and the consequences of waterpipe smoking in young adult occasional smokers who do not smoke cigarettes or use other tobacco products is imperative.
Exposure to waterpipe tobacco smoke poses a serious health risk (Akl et al., 2010, Al Mutairi et al., 2006, Al-Kubati et al., 2006, Aydin et al., 2004, Boskabady et al., 2012, El-Nachef and Hammond, 2008, El-Setouhy et al., 2008, Sajid et al., 2008, Sepetdjian et al., 2008). Waterpipe smoke delivers the same or larger quantities of harmful gases and cancer-causing toxins as cigarettes (Al Rashidi et al., 2008, Jacob et al., 2011, Jacob et al., 2013, Saleh and Shihadeh, 2008, Sepetdjian et al., 2008, Shihadeh et al., 2012). The American Cancer Society warns that waterpipe tobacco smoking is linked to heart disease and cancers in a manner similar to cigarette smoking (American Cancer Society, 2012). However, current knowledge of waterpipe tobacco smoking is based largely on samples of dual users of both waterpipes and cigarettes (Blank et al., 2011, Eissenberg and Shihadeh, 2009, Rastam et al., 2011).
Using puff topography (puff numbers, volume, duration, and intermittent puff intervals [IPI]) measures, studies demonstrated that waterpipe smokers adjusted puffing during each smoking session by controlling the number of puffs and the volume of inhaled tobacco smoke in each puff (Eissenberg and Shihadeh, 2009, Maziak et al., 2009). Self-regulation is well demonstrated in cigarette smokers where the dose of nicotine obtained from tobacco products is regulated by the number of puffs, the duration of individual puffs, and the volume of inhaled tobacco smoke (Husten, 2009). This is further evidenced by waterpipe smoking studies. A study of dependent dual users found that plasma nicotine levels increased with an increase in total inhaled tobacco smoke volume, while puff number and total smoke volume decreased over the course of a waterpipe smoking session (Maziak et al., 2011). Similarly, a study of occasional dual users of waterpipe and cigarettes, ages 18–50, found that puff number and total smoke volume decreased over time (Blank et al., 2011). Smoking behaviors among younger naïve waterpipe smokers have not been studied. Therefore, a comparison of the nicotine and non-nicotine conditions will help in better understanding the effects of nicotine on waterpipe smoking behaviors in the young adult population.
Evidence suggests that non-daily cigarette smokers seek immediate positive reinforcement from cigarette smoking (Glautier, 2004), while daily smokers seek drug maintenance to avoid withdrawal symptoms when smoking—negative reinforcement (Shiffman, Dunbar, Scholl, & Tindle, 2012). A survey of occasional waterpipe smokers indicated that the most commonly reported subjective effect was lightheadedness (Ahmed et al., 2011). In a laboratory-based study examining the effectiveness of waterpipe and cigarette smoking in reducing tobacco abstinence symptoms experienced by dependent dual users of waterpipe and cigarettes, participants experienced lightheadedness, nausea, and dizziness (Maziak et al., 2009, Rastam et al., 2011). However, in a laboratory-based study comparing the subjective effects of waterpipe tobacco by occasional dual users of waterpipe and cigarettes compared to a placebo, subjective effects observed were not related to the nicotine condition (Blank et al., 2011). The subjective effects of nicotine on occasional waterpipe smokers who do not use other tobacco products need to be examined.
The purpose of this study was to inform our limited knowledge of the effects of waterpipe smoking on young adults in the U.S. who do not smoke cigarettes or use tobacco products other than occasional waterpipe smoking. The primary aim of this study was to examine smoking behaviors (puff topography) and the associated subjective and physiological effects of nicotine throughout waterpipe smoking session by comparing these parameters during a nicotine and a non-nicotine condition. The research hypotheses tested whether smoking behaviors differ by nicotine condition and can be associated with the direct effect of nicotine.
Section snippets
Participants
Twenty-two participants were recruited. Inclusion criteria were: (a) 18–30 years of age, (b) smoked a waterpipe at least 10 times in the past year, and (c) had not smoked a waterpipe more than two times per week in the past 3 months. Exclusion criteria were: (a) smoked cigarettes or used any other tobacco product, (b) the use of illicit drugs, including marijuana and prescribed opioids, in the past 14 days, and (c) pregnancy. Participants were recruited from the community through postings on
Statistical analysis
All analyses were conducted in SPSS version.20.0, and our alpha threshold for determining statistical significance was set at 0.05. Descriptive analyses of sample characteristics included the calculation of percentages for categorical variables and a mean (M)/standard deviation (SD) for continuous variables. To compare puff topography outcomes for participants during the nicotine condition to the same participants during the non-nicotine condition, paired t-tests were performed. To examine the
Descriptive characteristics
The study included 22 participants. The participants were young adults (23 years of age ± 3.1 years) of several ethnicities: Caucasian (82%), African American (4.5%), Asian (4.5%), Hispanic (4.5%), and Middle Eastern (4.5%). The sample was predominantly male (59%), and less than half of the participants were employed part-time (45.5%), while more than one fourth (27%) were unemployed or students (18%). Less than one third (29%) smoked a waterpipe 1–2 times per week, and the majority (71%) did not
Discussion
This study demonstrates that changes in smoking behaviors (i.e. puff topography measures) occur as a result of the nicotine condition. In the current study, the target total tobacco smoke volume was pre-determined. The nicotine condition, compared to the non-nicotine condition, was associated with longer smoking visits, shorter puffs, less volume inhaled per puff, and more overall puffs during waterpipe smoking. Participants in the nicotine condition took a longer time (45 min) to reach the
Role of funding sources
This investigation was supported by funds provided for medical and biological research by the State of Washington Initiative Measure No. 171 (WSU Alcohol and Drug Abuse Research Program).
Contributors
Dr. Shishani reviewed the literature, interpreted the data, and prepared the manuscript.
Dr. Howell designed the study.
Dr. Sterling conducted the statistical analysis.
Dr. Roll provided the consultation on all aspects of the project.
Conflict of interest
All authors declare no competing interests.
Acknowledgments
The authors would like to acknowledge:
Dr. Tamara Odom-Maryon for editing the manuscript.
Dr. Alan Shihadeh for his technical expertise, and Arlana Byers, Amanda Lamp, Rebecca Shorr, Sandy Henley, Jennifer Cameron, Carolyn Herrity, and Laura Hoeg for their assistance in executing the study.
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