Abstract
WATERPIPE SMOKING is popular among adolescents in the Eastern Mediterranean Region.1,2 Evidence from many countries in the region suggests that the waterpipe is the most common form of tobacco use among youth.1–3 The last Global Youth Tobacco Survey (GYTS 2009) found that 11.5% of adolescents in Jordan were current cigarette smokers compared to 20.7% current waterpipe smokers.4 Both sexes, 27.1% of boys and 15.6% of girls, reported waterpipe smoking in Jordan.4
Waterpipe smoking is widely believed to be less harmful, less addictive and generally safer than cigarette smoking.5 Given the recent spread of waterpipe smoking, evidence of long-term major health effects of waterpipe smoking, such as cancer and cardiovascular disease, is still scarce.6 Available evidence, however, shows that waterpipe smoking exposes smokers to the main carcinogenic and cardiovascular toxic substances present in cigarettes.7 For example, our team has recently reported that waterpipe smokers are exposed to tobacco-specific nitrosamines in comparable amounts to cigarette smokers.8 Moreover, there is strong evidence to suggest that waterpipe smoking is associated with nicotine dependence, including abstinence-induced withdrawal and craving symptoms, which are relieved by subsequent waterpipe smoking.9
Several researchers have recently suggested that waterpipe smoking can lead to cigarette use.10–13 This has major implications for tobacco control, especially in societies with high levels of waterpipe smoking among youth. As evidence for waterpipe use patterns and delivery of the addictive substance, nicotine, has accumulated, the waterpipe-to-cigarette gateway concept was developed further to suggest a possible pathway for this transition.14–16
Compared to cigarettes, waterpipe smoking is a stationary, time-consuming practice, and is not readily accessible. These features led one of our group (WM) to suggest that adolescents who become addicted to nicotine through waterpipe use are likely to resort to the more accessible cigarettes to satisfy their smoking urge.15 The relation between dependence and access is therefore likely to be a major predictor of the transition from waterpipe to cigarette smoking.15,16 On the other hand, the move from ‘less harmful’ tobacco products, such as waterpipes or ecigarettes, to harmful cigarettes represents a unique transition, characterized by the ‘gateway’ hypothesis, beyond the commonalities underlying youthful experimentation with different addictive substances.17,18 The present study examines the potential role played by waterpipe smoking as a gateway to cigarette smoking using a longitudinal study design based on a theoretical framework of behavioral change (attitudes, social influences and self-efficacy),19 as well as evidence of the patterns and determinants of waterpipe use.20,21 We also compared the risk of initiation to cigarette smoking between waterpipe-only smokers and never smokers among schoolchildren (mean age 12.6 years at baseline) in Irbid, Jordan, and examined the dose-related gradient of this risk based on the frequency of waterpipe use as a proxy measure for nicotine dependence.22
