Young adult waterpipe tobacco users’ perceived addictiveness of waterpipe tobacco
More details
Hide details
Georgetown Lombardi Comprehensive Cancer Center, Washington, United States
Duke University, School of Nursing, Durham, United States
Darren Mays   

Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street NW, Suite 4100, 20007 Washington, United States
Publication date: 2017-12-05
Submission date: 2017-08-02
Final revision date: 2017-10-13
Acceptance date: 2017-11-11
Tob. Prev. Cessation 2017;3(December):133
Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

Hu SS, Neff L, Agaku IT, Cox S, Day HR, Holder-Hayes E, King BA: Tobacco product use among adults - United States, 2013-2014. MMWR Morb Mortal Wkly Rep 2016, 65(27): 685-691. doi:10.15585/mmwr.mm6527a1.
Maziak W: The waterpipe: Time for action. Addiction 2008, 103(11): 1763-1767. doi:10.1111/j.1360-0443.2008.02327.x.
Sepetdjian E, Shihadeh A, Saliba NA: Measurement of 16 polycyclic aromatic hydrocarbons in narghile waterpipe tobacco smoke. Food Chem Toxicol 2008, 46(5): 1582-1590. doi:10.1016/j.fct.2007.12.028.
Al Rashidi M, Shihadeh A, Saliba NA: Volatile aldehydes in the mainstream smoke of the narghile waterpipe. Food Chem Toxicol 2008, 46(11): 3546-3549. doi:10.1016/j.fct.2008.09.007.
Monzer B, Sepetdjian E, Saliba N, Shihadeh A: Charcoal emissions as a source of CO and carcinogenic PAH in mainstream narghile waterpipe smoke. Food Chem Toxicol 2008, 46(9): 2991-2995. doi:10.1016/j.fct.2008.05.031.
Primack BA, Carroll MV, Weiss PM, Shihadeh AL, Shensa A, Farley ST, Fine MJ, Eissenberg T, Nayak S: Systematic review and meta-analysis of inhaled toxicants from waterpipe and cigarette smoking. Public Health Rep 2016, 131(1): 76-85. doi:10.1177/003335491613100114.
Shihadeh A: Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 2003, 41(1): 143-152. doi:S027869150200220X.
Neergaard J, Singh P, Job J, Montgomery S: Waterpipe smoking and nicotine exposure: A review of the current evidence. Nicotine Tob Res. 2007, 9(10): 987-994. doi:783052859.
Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T: Waterpipe tobacco smoking: An emerging health crisis in the United States. Am J Health Behav 2010, 34(3): 275-285]. doi:10.5555/ajhb.2010.34.3.275.
Montazeri Z, Nyiraneza C, El-Katerji H, Little J: Waterpipe smoking and cancer: Systematic review and meta-analysis. Tob Control 2017, 26(1): 92-97. doi:10.1136/tobaccocontrol-2015-052758.
Raad D, Gaddam S, Schunemann HJ, Irani J, Abou JP, Honeine R, Akl EA: Effects of water-pipe smoking on lung function: A systematic review and meta-analysis. Chest 2011, 139(4): 764-774. doi:S0012-3692(11)60175-X.
Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA: The effects of waterpipe tobacco smoking on health outcomes: An updated systematic review and meta-analysis. Int J Epidemiol 2017, 46(1): 32-43. doi:10.1093/ije/dyw021.
Aboaziza E, Eissenberg T: Waterpipe tobacco smoking: What is the evidence that it supports nicotine/tobacco dependence? Tob Control 2015, 24 Suppl 1: i44-i53. doi:10.1136/tobaccocontrol-2014-051910.
Bahelah R, DiFranza JR, Fouad FM, Ward KD, Eissenberg T, Maziak W: Early symptoms of nicotine dependence among adolescent waterpipe smokers. Tob Control 2016, 25(e2): e127-e134. doi:10.1136/tobaccocontrol-2015-052809.
Maziak W, Ward KD, Afifi Soweid RA, Eissenberg T: Tobacco smoking using a waterpipe: A re-emerging strain in a global epidemic. Tob Control 2004, 13(4): 327-333. doi:13/4/327.
Watkins SS, Koob GF, Markou A: Neural mechanisms underlying nicotine addiction: Acute positive reinforcement and withdrawal. Nicotine Tob Res 2000, 2(1): 19-37.
Ward KD, Hammal F, VanderWeg MW, Eissenberg T, Asfar T, Rastam S, Maziak W: Are waterpipe users interested in quitting? Nicotine Tob Res 2005, 7(1): 149-156. doi:U03T810711538J26.
Hammal F, Mock J, Ward KD, Eissenberg T, Maziak W: A pleasure among friends: How narghile (waterpipe) smoking differs from cigarette smoking in Syria. Tob Control 2008, 17(2): e3. doi:10.1136/tc.2007.020529.
Rastam S, Eissenberg T, Ibrahim I, Ward KD, Khalil R, Maziak W: Comparative analysis of waterpipe and cigarette suppression of abstinence and craving symptoms. Addict Behav 2011, 36(5): 555-559. doi:10.1016/j.addbeh.2011.01.021.
Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J: Motives, beliefs and attitudes towards waterpipe tobacco smoking: A systematic review. Harm Reduct J 2013, 10(12). doi:10.1186/1477-7517-10-12.
Akl EA, Ward KD, Bteddini D, Khaliel R, Alexander AC, Lofti T, Alaouie H, Afifi RA: The allure of the waterpipe: A narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally. Tob Control 2015, 24 Suppl 1: i13-i21. doi:10.1136/tobaccocontrol-2014-051906.
Cornacchione J, Wagoner KG, Wiseman KD, Kelley D, Noar SM, Smith MH, Sutfin EL: Adolescent and young adult perceptions of hookah and little cigars/cigarillos: Implications for risk messages. J Health Commun 2016, 21(7): 818-825. doi:10.1080/10810730.2016.117714.
Aljarrah K, Ababneh ZQ, Al-Delaimy WK: Perceptions of hookah smoking harmfulness: Predictors and characteristics among current hookah users. Tob Induc Dis 2009, 5(1): 16-9625-5-16. doi:10.1186/1617-9625-5-16.
Majeed BA, Sterling KL, Weaver SR, Pechacek TF, Eriksen MP: Prevalence and harm perceptions of hookah smoking among U.S. adults, 2014-2015. Addict Behav 2017, 69: 78-86: doi:S0306-4603(17)30059-X.
Maziak W, Jawad M, Jawad S, Ward KD, Eissenberg T, Asfar T: Interventions for waterpipe smoking cessation. Cochrane Database Syst Rev 2015, 7(CD005549): doi:10.1002/14651858.CD005549.pub3.
Food and Drug Administration. Deeming tobacco products to be subject to the Federal Food, Drug, and Cosmetic Act, as amended by the family smoking prevention and tobacco control act; regulations on the sale and distribution of tobacco products and required warning statements for tobacco products. Final Rule. Federal Register 2016, 81(90), 28973-29106.
Husten CG, Deyton LR: Understanding the tobacco control act: Efforts by the US food and drug administration to make tobacco-related morbidity and mortality part of the USA's past, not its future. Lancet 2013, 381(9877): 1570-1580. doi:10.1016/S0140-6736(13)60735-7.
Duke JC, Alexander TN, Zhao X, Delahanty JC, Allen JA, MacMonegle AJ, Farrelly M: Youth's awareness of and reactions to the real cost national tobacco public education campaign. PLoS One 2015, 10(12): e0144827. doi:10.1371/journal.pone.0144827.
Lipkus IM, Eissenberg T, Schwartz-Bloom RD, Prokhorov AV, Levy J: Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine Tob Res 2011, 13(7): 599-610. doi:10.1093/ntr/ntr049.
Mays D, Tercyak KP, Lipkus IM. The effects of brief waterpipe tobacco use harm and addiction education messages among young adult waterpipe tobacco users. Nicotine Tob Res 2016, 18(5): 777-784. doi:10.1093/ntr/ntv223.
Hall MG, Ribisl KM, Brewer NT: Smokers' and nonsmokers' beliefs about harmful tobacco constituents: Implications for FDA communication efforts. Nicotine Tob Res 2014, 16(3): 343-350. doi:10.1093/ntr/ntt158.
Leas EC, Pierce JP, Dimofte CV, Villasenor A, Strong DR: US adult smokers' perceptions of Australia's cigarette warning labels: Variance by warning content and consistency across socio-demographic sub-segments. Tob Control 2016, 26(4): 485-486. doi:tobaccocontrol-2016-053006.
Magnan RE, Cameron LD: Do young adults perceive that cigarette graphic warnings provide new knowledge about the harms of smoking? Ann Behav Med 2015, 49(4): 594-604:. doi:10.1007/s12160-015-9691-6.
Mays D, Moran MB, Levy DT, Niaura RS: The impact of health warning labels for Swedish snus advertisements on young adults' snus perceptions and behavioral intentions. Nicotine Tob Res 2016, 18(5): 1371-1375. doi:10.1093/ntr/ntv140.
Mays D, Smith C, Johnson AC, Tercyak KP, Niaura RS: An experimental study of the effects of electronic cigarette warnings on young adult nonsmokers' perceptions and behavioral intentions. Tob Induc Dis 2016, 14: 17-016-0083-x. eCollection 2016. doi:10.1186/s12971-016-0083-x.
Pearson JL, Richardson A, Feirman SP, Villanti AC, Cantrell J, Cohn A, Tacelosky M, Kirchner TR: American spirit pack descriptors and perceptions of harm: A crowdsourced comparison of modified packs. Nicotine Tob Res 2016, 18(8): 1749-1756. doi:10.1093/ntr/ntw097.
Kraemer JD, Strasser AA, Lindblom EN, Niaura RS, Mays D. Crowdsourced data collection for public health: A comparison with nationally representative, population tobacco use data. Prev Med 2017, 102: 93-99. doi:S0091-7435(17)30252-9.
Sussman S, Arnett JJ. Emerging adulthood: Developmental period facilitative of the addictions. Eval Health Prof 2014, 37(2): 147-155: doi:10.1177/0163278714521812.
Shepardson RL, Hustad JT. Hookah tobacco smoking during the transition to college: Prevalence of other substance use and predictors of initiation. Nicotine Tob Res 2016, 18(5): 763-769. doi:10.1093/ntr/ntv170.
Primack BA, Freedman-Doan P, Sidani JE, et al. Sustained waterpipe tobacco smoking and trends over time. Am J Prev Med 2015, 49(6): 859-867. doi:10.1016/j.amepre.2015.06.030.
Sidani JE, Shensa A, Naidu MR, Yabes JG, Primack BA. Initiation, progression, and sustained waterpipe use: A nationally representative longitudinal study of U.S. young adults. Cancer Epidemiol Biomarkers Prev 2017, 26(5): 748-755. doi:10.1158/1055-9965.EPI-16-0687-T.
Ferrer R, Klein WM: Risk perceptions and health behavior. Curr Opin Psychol 2015, 5: 85-89. doi:10.1016/j.copsyc.2015.03.012.
Portnoy DB, Ferrer RA, Bergman HE, Klein WM: Changing deliberative and affective responses to health risk: A meta-analysis. Health Psychol Rev 2014, 8(3): 296-318: doi:10.1080/17437199.2013.798829.
Sheeran P, Harris PR, Epton T: Does heightening risk appraisals change people's intentions and behavior? A meta-analysis of experimental studies. Psychol Bull 2014, 140(2): 511-543. doi:10.1037/a0033065.
Agaku IT, King BA, Husten CG, Bunnell R, Ambrose BK, Hu SS, Holder-Hayes E, Day HR: Tobacco product use among adults--United States, 2012-2013. MMWR Morb Mortal Wkly Rep 2014, 63(25): 542-547. doi:mm6325a3.
Lipkus IM, Mays D, P Tercyak K: Characterizing young adults' susceptibility to waterpipe tobacco use and their reactions to messages about product harms and addictiveness. Nicotine Tob Res 2016.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006, 3(2): 77-101. doi: 10.1191/1478088706qp063oa.
Pope C, Ziebland S, Mays N: Qualitative research in health care. analysing qualitative data. BMJ 2000, 320(7227): 114-116. doi: 10.1136/bmj.320.7227.114.
Choi K, Fabian L, Mottey N, Corbett A, Forster J: Young adults' favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: Findings from a focus group study. Am J Public Health 2012, 102(11): 2088-2093: doi:10.2105/AJPH.2011.300525.
Johnson AC, Mays D, Hawkins KB, Denzel M, Tercyak KP: A qualitative study of adolescent perceptions of electronic cigarettes and their marketing: Implications for prevention policy. Children's Health Care 2016. doi:10.1080/02739615.2016.1227937.
McQueen A, Tower S, Sumner W: Interviews with "vapers": Implications for future research with electronic cigarettes. Nicotine Tob Res 2011, 13(9): 860-867: doi:10.1093/ntr/ntr088.
Roditis ML, Halpern-Felsher B: Adolescents' perceptions of risks and benefits of conventional cigarettes, E-cigarettes, and marijuana: A qualitative analysis. J Adolesc Health 2015, 57(2), 179-185. doi: 10.1016/j.jadohealth.2015.04.002.
Giovino GA, Henningfield JE, Tomar SL, Escobedo LG, Slade J: Epidemiology of tobacco use and dependence. Epidemiol Rev 1995, 17(1): 48-65. doi: 10.1093/oxfordjournals.epirev.a036185.
Eissenberg T, Ward KD, Smith-Simone S, Maziak W: Waterpipe tobacco smoking on a U.S. college campus: Prevalence and correlates. J Adolesc Health 2008, 42(5): 526-529. doi:10.1016/j.jadohealth.2007.10.004.
Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE: Prevalence of and associations with waterpipe tobacco smoking among U.S. university students. Ann Behav Med 2008, 36(1): 81-86. doi:10.1007/s12160-008-9047-6.
Soneji S, Sargent JD, Tanski SE, Primack BA: Associations between initial water pipe tobacco smoking and snus use and subsequent cigarette smoking: Results from a longitudinal study of US adolescents and young adults. JAMA Pediatr 2015, 169(2):129-136. doi:10.1001/jamapediatrics.2014.2697.
Sutfin EL, McCoy TP, Reboussin BA, Wagoner KG, Spangler J, Wolfson M: Prevalence and correlates of waterpipe tobacco smoking by college students in North Carolina. Drug Alcohol Depend 2011, 115(1-2): 131-136. doi:10.1016/j.drugalcdep.2011.01.018.
Villanti AC, Cobb CO, Cohn AM, Williams VF, Rath JM: Correlates of hookah use and predictors of hookah trial in U.S. young adults. Am J Prev Med 2015, 48(6): 742-746. doi:10.1016/j.amepre.2015.01.010.
Ward KD, Eissenberg T, Gray JN, Srinivas V, Wilson N, Maziak W: Characteristics of U.S. waterpipe users: A preliminary report. Nicotine Tob Res 2007, 9(12): 1339-1346. doi:10.1080/14622200701705019.
Hiilamo H, Crosbie E, Glantz SA: The evolution of health warning labels on cigarette packs: The role of precedents, and tobacco industry strategies to block diffusion. Tob Control 2014, 23(1): e2. doi:10.1136/tobaccocontrol-2012-050541.
Huang LL, Thrasher JF, Abad EN, Cummings KM, Bansal-Travers M, Brown A, Nagelhout GE: The U.S. national tips from former smokers antismoking campaign: Promoting awareness of smoking-related risks, cessation resources, and cessation behaviors. Health Educ Behav 2015, 42(4): 480-486. doi:10.1177/1090198114564503.
Noar SM, Hall MG, Francis DB, Ribisl KM, Pepper JK, Brewer NT: Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob Control 2016, 25(3): 341-354. doi:10.1136/tobaccocontrol-2014-051978.
Salloum RG, Maziak W, Hammond D, Nakkash R, Islam F, Cheng X, Thrasher JF: Eliciting preferences for waterpipe tobacco smoking using a discrete choice experiment: Implications for product regulation. BMJ Open 2015, 5(9): e009497. doi:10.1136/bmjopen-2015-009497.
Smith A. U.S. smartphone use in 2015. Pew Research Center Web site, 2015. Available at: (accessed May 2, 2016).
Scott-Sheldon LA, Lantini R, Jennings EG, Thind H, Rosen RK, Salmoirago-Blotcher E, Bock BC: Text messaging-based interventions for smoking cessation: A systematic review and meta-analysis. JMIR Mhealth Uhealth 2016, 4(2): e49. doi:10.2196/mhealth.5436.
Spohr SA, Nandy R, Gandhiraj D, Vemulapalli A, Anne S, Walters ST: Efficacy of SMS text message interventions for smoking cessation: A meta-analysis. J Subst Abuse Treat 2015, 56: 1-10. doi:10.1016/j.jsat.2015.01.011.
Development and Pretesting of Risk-Based Mobile Multimedia Message Content for Young Adult Hookah Use
Andrea Johnson, Isaac Lipkus, Kenneth Tercyak, George Luta, Kathryn Rehberg, Lilianna Phan, Lorien Abroms, Darren Mays
Health Education & Behavior