Patterns of waterpipe use and dependence: implications for intervention development

https://doi.org/10.1016/j.pbb.2004.10.026Get rights and content

Abstract

Despite the dramatic increase of tobacco smoking via waterpipe in Arab societies, and the apparent potential of waterpipe use to produce tobacco-related disease, little is known about the pharmacological effects of this method of tobacco smoking, particularly its ability to support dependence. This review focuses on recent waterpipe research and current theories of dependence in an attempt to identify patterns of waterpipe use and features likely to reveal dependence. Recent work indicates that, relative to cigarette smoking, this form of tobacco use is characterized by more intermittent use, later age of onset, greater spread among women and lower interest in quitting or appreciation of addictive properties. Waterpipe use is associated with classic features of tobacco/nicotine dependence, as well as features unique to this tobacco use method. However, even shared features of dependence, such as craving and addiction-induced socio-cognitive behavioral changes, can be displayed differently in waterpipe users, indicating the need for waterpipe-specific research approaches. Preliminary evidence suggests that an important step toward dependence involves a transition from social to individual patterns of waterpipe use. Surveillance and research into factors affecting use and cessation of this tobacco use method should pave the way for the development of effective prevention and intervention strategies to curb the burgeoning waterpipe use epidemic.

Introduction

Waterpipe is a generic name for a device in which tobacco smoke passes through water prior to inhalation. The term incorporates centuries-old tobacco use methods usually associated with the orient, and encompasses different names and shapes from different cultures and regions (e.g., shisha, narghile, hookah, hubble-bubble; see Fig. 1). There is an alarming global revival of waterpipe use. This revival is particularly apparent in Arab societies (e.g., Maziak et al., 2004a), where recent surveys show that up to quarter of some populations currently use waterpipe (Chaaya et al., 2003, Chaaya et al., 2004, Gadalla et al., 2003, Maziak et al., 2004b, Tamim et al., 2003, Varsano et al., 2003). Waterpipe use once involved unflavored raw tobacco, but, in the Arab region today, waterpipe use and spread is facilitated by tobacco that is sweetened and flavored (Maassel), introduced in the 1990s (Rastam et al., 2004). Popular claims about the filtering power of the water, as well as intermittent use patterns, may produce a false perception of minimal risk of tobacco-related dependence and disease (Kandela, 2000, Asfar et al., under review). In addition, the permissive attitude towards waterpipe use by women in Arab societies, as opposed to a taboo against their cigarette smoking (Asfar et al., under review), may lead to an escalation of waterpipe-related addiction and disease among Arab women.

Understanding the influence of waterpipe use on dependence and disease is challenging, because the upsurge in waterpipe use is relatively recent, and because many waterpipe users also use cigarettes. However, preliminary evidence suggests that waterpipe use can be addictive, is associated with negative health outcomes and may replace cigarettes when smokers quit (Maziak et al., 2004b, Shihadeh, 2003, Shafagoj et al., 2002, Nuwayhid et al., 1998). For example, cross-study comparisons suggest that, relative to a single cigarette, smoked in about 5 min, a single waterpipe use that occurs in approximately 45 min nearly doubles CO and triples nicotine exposure, with near equivalent effects on cardiovascular response (heart rate) (Maziak et al., 2004a). Further, recent results are consistent with the notion that dependence can develop among waterpipe users (Maziak et al., 2004c). Unfortunately, despite the potential public health magnitude of this emerging smoking method, currently, there are no effective prevention or intervention strategies to curb its spread. Preventing initiation and intervening with current users of this appealing and social form of tobacco use is likely be challenging, and requires continuous surveillance using standardized tools and careful research into issues of waterpipe-associated tobacco dependence and disease.

Section snippets

Initiating standardized waterpipe surveillance

An important early step in dealing with an emerging public health threat is to initiate active surveillance in order to assess its spread, predict its course and design control strategies. The success of active surveillance is contingent upon standard definitions and assessment tools. Lessons learned from decades of surveillance for cigarette smoking show that if we do not pay proper attention to standardizing assessment definitions and tools, interpreting and comparing data across different

Patterns of waterpipe use and quitting

Most of what we know currently about patterns of waterpipe use in Syria comes from two surveys done in 2003 in the city of Aleppo. These surveys were conducted among representative samples of university students (total 587, 52.6% women, mean age 22 years), and waterpipe users among café customers (total 268, 40% women, mean age 30 years) (Maziak et al., 2004b, Maziak et al., 2004c). Briefly, the student survey was carried out at Aleppo University's dormitories (total 19), where four women's and

The study of dependence among waterpipe users

Cigarette smoking involves self-administration of nicotine, a dependence producing psychomotor stimulant (APA, DSM-IV, 1994). Dependence is a chronic condition involving repeated drug self-administration despite known health risks, high financial costs and multiple quit attempts (APA, DSM-IV, 1994). The compulsive self-administration characteristic of the dependent user is thought to be a behavioral manifestation of neuropharmacological changes in the brain reward pathways (Koob and LeMoal, 1997

What is likely to be unique about dependence in waterpipe users?

Many of the dependence features mentioned above are modulated by nicotine, and thus are likely to be shared by other tobacco use methods. Waterpipe users, however, may experience dependence in some ways that differ from other tobacco use methods. First, the waterpipe use pattern is predominantly intermittent. An intermittent use pattern may decrease the likelihood of physical dependence on nicotine (Shiffman, 1989), but may support conditional tolerance and/or withdrawal (Eissenberg, 2004). An

Developing smoking cessation interventions for waterpipe users

Information about patterns of use, beliefs/attitudes, as well as dependence features of waterpipe can help guide intervention development in terms of format, timing, intensity, and target groups. One strategy for intervention development in the Arab region focuses on collecting information about regional patterns of tobacco consumption, as well as on local health care systems, in order to modify existing effective cessation interventions to suit local tobacco users and local health systems (

Conclusions

Waterpipe use is becoming a global phenomenon, and we are only beginning to learn about its spread and health and addictive effects. Controlling this public health threat requires the initiation of effective surveillance as well as the development of prevention and intervention strategies. These goals are contingent on the initiation of multi-disciplinary research into the harmful and addictive properties of waterpipe and factors influencing its spread. Knowledge obtained from such research can

Acknowledgements

This work was supported by USPHS grants R01 TW05962, R21 TW006545, and IC Health Proposal Development Grant.

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