Tobacco smoking continues to be the number 1 preventable cause of morbidity and mortality, contributing to millions of deaths every year and wreaking havoc on the welfare of families and communities worldwide. Although smokers are usually aware of smoking risks, they find quitting difficult due to the formidable grip of nicotine dependence (ND). So far, ND research has primarily focused on cigarettes, yet for many youth worldwide, tobacco addiction can be maintained by means other than the cigarette. In particular, over the past decade, water pipe (WP) smoking (a.k.a. hookah, shisha, narwhal) has dramatically become a worldwide phenomenon among youth. WP's worrisome trends have been monitored closely at the Syrian Center for Tobacco Studies (SCTS), where some of the pioneer evidence about its harmful and addictive properties was generated. Despite this, evidence-based solutions to the WP epidemic still lag behind. Obviously, interventions are needed to discourage WP initiation among youth, treat dependent WP smokers, and advance policy and product regulations. Unfortunately, this is hindered in part by the lack of knowledge on how ND develops and manifests in WP smokers. Characterizing ND in WP smokers will help guide the timing and composition of cessation treatments, as well as to counter deceptive product labeling, and drive public health policies to limit WP promotion and youth access. Most studies of ND in WP smokers to date are limited by cross sectional designs, instruments that are geared towards the cigarette, or failure to account for important personal and contextual factors. Thus, an approach that is rooted in common theoretical models of ND, and applies WP- sensitive tools within a longitudinal design has the potential of capturing the full spectrum of ND in young WP smokers. We will adopt this approach to test the following hypotheses: (1) symptoms of ND will appear despite intermittent use patterns in the majority of WP smokers and will predict important clinical outcomes (failed quitting, escalation), (2) the trajectory of ND inWP smokers differs from that of cigarette, and (3) the progression to ND in WP smokers is influenced by personal and contextual factors. For this purpose, we will recruit 250 WP smokers and nonsmokers susceptible to WP, and similar numbers for cigarettes, from 10th graders in Aleppo-Syria (H15 years at baseline) and follow them twice/year for 3 yrs. We plan to test these hypotheses by 1- detecting the first symptoms and diagnosis of ND among WP smokers, 2- comparing common trajectories of ND symptoms among WP smokers, cigarette smokers, and dual smokers, and 3- determining factors that predict ND development in young WP smokers. This project will allow us also to train researchers in Syria and the EMR in tobacco addiction science through a combination of training workshops, seed grants, and extended mentorship. We hope through this project to gain experience about ND in young WP smokers that can guide the development of interventions to reduce WP use and curtail WP-related morbidity and mortality.

Public Health Relevance

This project addresses the knowledge gap about nicotine dependence in young water pipe smokers, in order to guide the development of interventions to reduce water pipe use and curtail WP-related morbidity and mortality.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
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Special Emphasis Panel (ZCA1-SRLB-Y (M1))
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Hartsock, Peter
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Florida International University
Public Health & Prev Medicine
Schools of Public Health
United States
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Bahelah, Raed; DiFranza, Joseph R; Ward, Kenneth D et al. (2016) Correlates of nicotine dependence among adolescent waterpipe smokers. Drug Alcohol Depend 168:230-238
Bahelah, Raed; DiFranza, Joseph R; Fouad, Fouad M et al. (2016) Early symptoms of nicotine dependence among adolescent waterpipe smokers. Tob Control 25:e127-e134
Salloum, Ramzi G; Asfar, Taghrid; Maziak, Wasim (2016) Toward a Regulatory Framework for the Waterpipe. Am J Public Health 106:1773-7
Kates, Frederick R; Salloum, Ramzi G; Thrasher, James F et al. (2016) Geographic Proximity of Waterpipe Smoking Establishments to Colleges in the U.S. Am J Prev Med 50:e9-e14
Jaber, Rana; Mzayek, Fawaz; Madhivanan, Purnima et al. (2016) Predictors of Cigarette Smoking Progression Among a School-Based Sample of Adolescents in Irbid, Jordan: A Longitudinal Study (2008-2011). Nicotine Tob Res 18:403-9
Asfar, Taghrid; Ward, Kenneth D; Al-Ali, Radwan et al. (2016) Building Evidence-Based Tobacco Treatment in the Eastern Mediterranean Region: Lessons Learned by the Syrian Center for Tobacco Studies. J Smok Cessat 11:116-123
Islam, Farahnaz; Salloum, Ramzi G; Nakkash, Rima et al. (2016) Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health 61:709-15
Salloum, Ramzi G; Haider, M Rifat; Barnett, Tracey E et al. (2016) Waterpipe Tobacco Smoking and Susceptibility to Cigarette Smoking Among Young Adults in the United States, 2012-2013. Prev Chronic Dis 13:E24
Maziak, Wasim; Ben Taleb, Ziyad; Jawad, Mohammed et al. (2016) Consensus statement on assessment of waterpipe smoking in epidemiological studies. Tob Control :
Ward, Kenneth D; Ahn, SangNam; Mzayek, Fawaz et al. (2015) The relationship between waterpipe smoking and body weight: population-based findings from Syria. Nicotine Tob Res 17:34-40

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