Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Dr. Wasim Maziak

First Advisor's Committee Title

Committee Chair

Second Advisor's Name

Dr. Miguel Angel Cano

Second Advisor's Committee Title

Committee Member

Third Advisor's Name

Dr. Tan Li

Third Advisor's Committee Title

Committee Member

Fourth Advisor's Name

Dr. Matthew T. Sutherland

Fourth Advisor's Committee Title

Committee Member


Predictors, Waterpipe Smoking, Trajectories, Adolescents, Young Adults, Pictorial Health Warning Label

Date of Defense



In recent years waterpipe tobacco (WPT) smoking has increased among young people in the United States (US). Adequate characterization of the WPT smoking trajectories (initiation, progression, and cessation), their predictors, and examination of the effects of a pictorial health warning label (PHWL) on WPT smokers is essential to guide interventions and policies to curb WPT smoking among young people in the US. Using the Population Assessment of Tobacco and Health Study (PATH) and clinical lab data, this dissertation assessed: 1) prevalence and predictors of WPT smoking initiation and progression among adolescents and young adults; 2) magnitude and predictors of WPT cessation among young adults, and 3) the effects of PHWL on low- and high-frequency WPT smokers’ experiences, toxicant exposures, and puffing behavior.

In the first study, between 2013-2018, 4.8% of the adolescents and 18.5% of young adults initiated WPT smoking. During the same period, 10.6% of adolescent WPT smokers and 14.1% of young adult-WPT smokers progressed in WPT smoking (increase in the frequency of smoking at any subsequent wave). Predictors of WPT initiation among adolescents include lower harm perception (adjusted odds ratio (aHR)=2.89, 95% confidence interval (CI)=2.10-3.98), and other tobacco products use (aHR=3.97, 95% CI=2.73-5.78), while predictors of WPT progression include illicit drug use (aHR=4.60, 95% CI=1.99-10.67). Among young adults, predictors of WPT initiation include lower harm perception (aHR=2.77, 95% CI=2.19-3.50), and other tobacco products use (aHR=3.14, 95% CI=2.25-4.38); while predictors of WPT progression were lower harm perception (aHR=1.80, 95% CI=1.41-2.30), and alcohol use (aHR=1.61, 95% CI=1.13-2.30).

In the second study, 25.13% of the young adult WPT smokers quit smoking between waves 1-5 (2015-2019). The major predictor of WPT smoking cessation was regretting smoking (aHR= 2.33, 95% CI=1.29-4.21) whereas barriers to cessation were the lack of smoking restriction at home (aHR=0.35, 95% CI=0.18-0.70) and alcohol use (aHR=0.62, 95% CI=0.41-0.93) among young adults WPT smokers. A moderate correlation between regret smoking WPT and quit attempts (ρ=0.3, p-value

In the third study, both low- and high-frequency smoking groups showed no effect of PHWL on exposure to nicotine and other toxicants. However, there was a reduction in acute subjective experiences of smoking among high-frequency smokers compared to low-frequency smokers after smoking WPT with PHWL compared to the no-PHWL (e.g., puff liking -1.2 vs. -0.5; puff satisfaction -1.0 vs. -0.3) (p

Overall, we found a high rate of WPT smoking initiation and progression. Several modifiable risk factors including lower harm perception towards WPT and the loopholes in regulating WPT establishments were the drivers of WPT initiation, progression, and continuation. The PHWL on the WPT device showed differential effectiveness among low- and high-frequency smokers. The FDA should mandate PHWL on the WPT device and WPT establishments should not be exempted from smoke-free air legislation and not allowed indirect promotion in social media.





Previously Published In

Gautam P, Sharma E, Ebrahimi Kalan M, et al. Prevalence and predictors of waterpipe smoking initiation and progression among adolescents and young adults in waves 1-4 (2013-18) of the Population Assessment of Tobacco and Health (PATH) study [published online ahead of print, 2022 Feb 23]. Nicotine Tob Res. 2022;ntac051. doi:10.1093/ntr/ntac051

Gautam, P., Kalan, M.E., Li, W. et al. The Effects of Pictorial Health Warning Label on Waterpipe (Low- and High-Frequency) Smokers’ Experiences, Toxicant Exposures, and Puffing Behavior. Int.J. Behav. Med. (2022).

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