Early symptoms of nicotine dependence among adolescent waterpipe smokers

Background 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. Methods 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. Results 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. Conclusions 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

Determinants of progression of nicotine dependence symptoms in adolescent waterpipe smokers

Introduction Waterpipe smoking continues to pose significant challenges to tobacco control efforts and many adolescent waterpipe smokers experience symptoms of nicotine dependence (ND). This study examined the predictors of progression of ND symptoms in adolescent waterpipe smokers. Methods We assembled a cohort of Lebanese adolescents enrolled in eighth and ninth grades at baseline, and surveyed them every 6 months over the next 24 months. Progression of ND symptoms was defined as an increase over time in the number of items endorsed on the Hooked on Nicotine Checklist. Predictors included individual (eg, psychological factors, attitudes towards waterpipe, school performance, physical activity) and socioenvironmental (eg, smoking among parents, siblings and close friends; the café environment) attributes. Results Among 264 adolescent waterpipe smokers (baseline mean age=14.6 years, 50.4% females), 105 (39.7%) progressed on ND symptoms during follow-up. Predictors of progression were higher baseline stress (OR 1.11, 95% CI 1.03 to 1.19) and higher self-esteem (OR 1.14, 95% CI 1.05 to 1.24). Reporting difficulty refraining from smoking waterpipe while in a restaurant was the strongest predictor of progression (OR 4.04, 95% CI 1.44 to 11.34). Having a mother with ≥12 years of education protected against progression of ND (OR 0.46, 95% CI 0.21 to 0.99). Conclusions A significant proportion of adolescent waterpipe smokers progressed on ND. Venue-based policies such as limiting youth access to waterpipe cafés are warranted

Waterpipe smoking patterns and symptoms of nicotine dependence: The Waterpipe Dependence in Lebanese Youth Study

Introduction Waterpipe typically is smoked intermittently over long smoking sessions. Waterpipe is addictive and its users show symptoms of nicotine dependence (ND). This study examined the risk of developing ND symptoms across waterpipe use patterns among Lebanese youth. Methods Waterpipe use patterns (length of smoking session, smoking a whole waterpipe without sharing, past-30 day use frequency, number of waterpipes smoked) were assessed. Symptoms of ND were assessed using the 10-item Hooked on Nicotine Checklist (HONC; endorsement of ≥ 1 symptom) and the 6 criteria of the International Classification of Diseases-10th revision (ICD-10 ND; presence of ≥ 3 criteria during 12 months). Results Both the proportion of participants endorsing ND symptoms and the average number of endorsed ND symptoms increased with increasing waterpipe use frequency, number of waterpipes smoked, and length of smoking session. The risk of endorsing ≥ 1 HONC symptom increased with increasing number of waterpipes smoked in the past 30-days (≥ 10 vs. \u3c 4 waterpipes; Hazard ratio (HR) = 2.05, 95% CI: 1.52–2.58, p = 0.007), and session length (\u3e 60 min vs. \u3c 30 min; HR = 2.87, 95% CI: 2.83–2.91, p = 0.001). The risk of attaining ICD-10 ND increased with increasing number of waterpipes used in the past 30-days (≥ 10 vs. \u3c 4 waterpipes; HR = 2.56, 95% CI: 1.89–3.22, p = 0.006), and smoking every day/almost every day vs. less than once weekly (HR = 2.86, 95% CI: 2.12–3.60, p = 0.007). Conclusions Increasing use frequency, number of waterpipes smoked, and longer smoking sessions were associated with higher risk of ND. The length of smoking session emerged as a novel indicator of ND among waterpipe smokers

The effect of price on cigarette consumption, distribution, and sale in Tehran: a qualitative study

Background: Appropriate increases in tobacco taxes and prices are an essential component of comprehensive tobacco control strategies. This study investigates factors related to the use, sale, and distribution of cigarettes in Iran, focusing on the relationship between cigarette price and its consumption. Methods: This interview-based qualitative study was conducted among 20 participants, including cigarette smokers, retail shop owners, large-scale distributors, and an expert in tobacco control research. Results: Seven themes were extracted from participant interviews, including the type and price of cigarette, the best time to sell cigarettes, profits from the sale of cigarette, affordability, rise in cigarette price and smokers� reaction to it, lobbying and black-market sales of cigarettes, and the sale and distribution of cigarettes across the country. Although the price of cigarettes in Iran has shown some increases in the past decade, the timing of these increases are not predictable and the limited amount of these increases has not reduced the use of cigarettes. Following a price increase, consumers are more likely to switch from buying packets to single cigarettes, or buy a less expensive brand, then to quit. Moreover, increases in prices may encourage smokers and sellers to buy a large number of cigarettes and store them for a rainy day. Another adverse effect may be increased smuggling of illicit cigarettes to balance the pressure caused by rising prices. Conclusions: Our findings highlight two important aspects concerning cigarette pricing in Iran. First is the change in the type of purchase from the whole box of cigarettes to the single stick cigarette or swapping to less expensive cigarettes. Second, increase in cigarette price (either through taxing or regular increases) could be offset by flooding smuggled cigarettes into the market. Therefore, in addition to raising cigarette prices, reducing cigarette consumption rates in Iran requires the development and effective implementation of regulatory policies to control cigarette smuggling, reduce purchasing, and subsequently curb the use of this leading cause of premature morbidity and mortality. © 2021, The Author(s)

Correlates of nicotine dependence among adolescent waterpipe smokers

Introduction Waterpipe smoking is addictive and its use is increasing globally among youth, yet little is known about the factors associated with nicotine dependence (ND) among waterpipe smokers. We investigated the factors associated with ND symptoms among a sample of Lebanese adolescents who smoke a waterpipe. Methods We collected data on factors potentially associated with ND (individual, socio-demographic, environmental, smoking patterns) among 160 current (past 30 days) waterpipe smokers recruited from 8th and 9th school grades in Lebanon. We assessed the loss of autonomy over tobacco using the Hooked on Nicotine Checklist (HONC), ND using the International Classification of Diseases, 10th revision (ICD-10), and the number of ND symptoms endorsed. Results Depressive symptoms, lower self-esteem, and having at least one sibling who smokes a waterpipe were associated with the presence of ND symptoms, while enrollment in public schools, smoking a waterpipe ≥30 min per session, and believing that cigarette smoking is harmful to health were associated with endorsement of a higher number of ND symptoms. Smoking a whole waterpipe head without sharing and being in 9th grade in this study were associated with the presence and endorsement of a higher number of ND symptoms. Conclusions We identified specific social and psychological characteristics, waterpipe smoking patterns, and beliefs about harmful effects of smoking associated with the presence of ND among adolescent waterpipe smokers. Considering these factors when planning policies to prevent ND among waterpipe smokers is warranted

Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis

Objective: Identifying the factors associated with nicotine dependence (ND) is essential to prevent initiation and continued use, and to promote cessation among youth. This study aims to document the predictors of the appearance of initial ND symptoms and full ND syndrome among adolescent waterpipe (WP) and cigarette smokers. Methods: A 6-year longitudinal study was conducted among 8th and 9th graders from 38 schools in Lebanon. The analysis sample included exclusive-WP (n = 228) and exclusive-cigarette smokers (n = 139). Weighted Cox proportional hazards models were used to characterizing predictors of initial ND symptoms and full ND syndrome. Results: Predictors of experiencing initial ND symptoms among WP smokers included low maternal educational level, having a sibling who smoked WP, low physical activity, high body mass index (BMI), smoking initiation at a younger age. For cigarette smokers these were being male, younger, having lower BMI, having a sibling who smoked cigarettes, living in a crowded household, and smoking daily. Among WP smokers, predictors of developing full ND syndrome include being younger, believing that WP smokers have more friends, depression, high levels of impulsivity, and initiating smoking at a younger age. For cigarette smokers, predictors of full ND syndrome were being younger and initiating smoking at a younger age. Conclusion: Smoking cessation and prevention interventions targeting youth should address modifiable, and tobacco use-specific factors that influence the development of ND among young WP and cigarette smokers. They also need to start at a younger age to target those most vulnerable to developing life-long addiction to tobacco products