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

Zoran Bursac

Second Advisor's Committee Title

Committee member

Third Advisor's Name

Miguel Angel Cano

Third Advisor's Committee Title

Committee member

Fourth Advisor's Name

Matthew Sutherland

Fourth Advisor's Committee Title

Committee member

Fifth Advisor's Name

Kristopher Fennie

Fifth Advisor's Committee Title

Committee member


Waterpipe smoking, Cigarette smoking, Nicotine dependence, Adolescents, Lebanon

Date of Defense



Nicotine dependence (ND) is the fundamental reason that people persist in using tobacco products, which kill more than eight million people every year globally. So far, ND research has primarily focused on cigarettes, yet for many youths worldwide, tobacco use, and addiction is maintained by means other than the cigarette including waterpipe (WP) smoking (a.k.a. hookah). It is important to better understand the WP-associated ND trajectories given its unique use features that can influence ND development such as its time-consuming preparation and consumption, intermittent use, and strong sensory and social cues. Hence, using data from 8 waves (2015-2020) of the Waterpipe Dependence in Lebanese Youth (WDLY) study, this pioneer research compared the development of ND symptoms and their predictors among adolescent current (past 30 days) WP (n=283) and cigarette (n=146) smokers. Also, we identified ND trajectories from early to late adolescence in current WP smokers and examine baseline correlates by each identified trajectory. We evaluated the initial ND symptoms using the Hooked on Nicotine Checklist (HONC) and the full syndrome of ND using the International Classification of Diseases-10th revision (ICD-10 ND).

Our findings indicated that compared with adolescent cigarette smokers, initial ND symptoms and full syndrome of ND can develop sooner after starting to smoke and progress more rapidly among adolescent WP smokers. 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. Finally, A mixture modeling approach yielded a four-class solution that best fitted the data varying in the timing of ND onset during adolescence: no-onset of ND (43.9%), early-adolescence onset (16.2%), mid-adolescence (26.6%), and late-adolescence (13.3%) onset of ND symptoms among WP smokers.

In conclusion, our findings suggest that the developing, implementing, and evaluating intervention programs with adolescent WP smokers should be guided by the WP-specific trajectory of ND.




Previously Published In

Ebrahimi Kalan, M., R. Behaleh, J. R. DiFranza, Z. Bursac, Z. Ben Taleb, M. Tleis, T. Asfar, R. Nakkash, K. D. Ward, T. Eissenberg and W. Maziak (2020). "Natural Course of Nicotine Dependence Among Adolescent Waterpipe and Cigarette Smokers." Journal of Adolescent Health 67(6): 859-867.

Ebrahimi Kalan, M., Bahelah, R., Bursac, Z., Ben Taleb, Z., DiFranza, J.R., Tleis, M., Nakkash, R., Jebai, R., Alam, M.M., Cano, M.Á., Sutherland, M.T., Fenni, K., Asfar, T., Eissenberg, T., Ward, K.D., Maziak, W., 2020. Predictors of nicotine dependence among adolescent waterpipe and cigarette smokers: A 6-year longitudinal analysis. Drug and Alcohol Depend, 217, 108346.

Included in

Epidemiology Commons



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