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Tob Control. 2016 Dec;25(e2):e127-e134. doi: 10.1136/tobaccocontrol-2015-052809. Epub 2016 Apr 25.

Early symptoms of nicotine dependence among adolescent waterpipe smokers.

Author information

Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA.
Faculty of Medicine and Health Sciences, Aden University, Yemen.
Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
Syrian Center for Tobacco Studies, Aleppo, Syria.
American University of Beirut, Beirut, Lebanon.
University of Memphis School of Public Health, Memphis, Tennessee, USA.
Department of Psychology and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA.



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.


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.


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.


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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