Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Wasim Maziak

First Advisor's Committee Title

Committee chair

Second Advisor's Name

Kristopher Fennie

Second Advisor's Committee Title

Committe member

Third Advisor's Name

Stefany Coxe

Third Advisor's Committee Title

Committe member

Fourth Advisor's Name

Boubakari Ibrahimou

Fourth Advisor's Committee Title

Committe member



Date of Defense



Waterpipe (WP; hookah, shisha, narghile) has re-emerged as a global epidemic of tobacco smoking mainly among young people. Although WP smokers show symptoms of nicotine dependence (ND) and face difficulty quitting, no study has examined the early symptoms and factors associated with ND among young WP smokers. Using baseline data from the Waterpipe Dependence in Lebanese Youth (WDLY) study, this research investigated the appearance and timing of early symptoms, factors, and WP-specific smoking patterns associated with ND symptoms among 160 adolescents (mean age ± SD =14.0 ± 1.1 years at baseline) from 8th and 9th grades who reported WP use in the past 30 days. ND symptoms were assessed using Hooked on Nicotine Checklist (HONC) and the full syndrome of ND was evaluated using the International Classification of Diseases-10th revision (ICD-10 ND).

Our analysis shows that 71.3% of WP smokers endorsed at least one HONC symptom, 38.1% developed ICD-10 ND, with craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%) were the most commonly endorsed early symptoms of ND. The first HONC symptom and full ICD-10 ND were reached 10.9 and 13.9 months, respectively, after the initiation of WP use. Results from multivariable regression models show that depressive symptoms, lower self-esteem, and having at least one sibling who smokes WP were associated with the presence of ND symptoms, while enrollment in public schools, smoking WP ≥30 minutes per session, and believing that cigarette smoking is harmful to health were associated with a higher number of ND symptoms. Smoking a whole WP without sharing and being in 9th grade were associated with the presence and endorsement of a higher number of ND symptoms.

These findings suggest that a large proportion of adolescents experience symptoms of ND within a short time period of initiating WP use. Moreover, we identified specific factors that put adolescents at a higher odds of developing ND symptoms. Therefore, WP prevention and intervention strategies may have greatest impact by educating youth about the harmful and addictive properties of WP, teaching them positive coping skills, targeting those enrolled in public schools, and addressing WP use by family members.



Included in

Epidemiology Commons



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