Elsevier

Drug and Alcohol Dependence

Volume 76, Issue 1, 5 October 2004, Pages 101-106
Drug and Alcohol Dependence

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Factors related to frequency of narghile (waterpipe) use: the first insights on tobacco dependence in narghile users

https://doi.org/10.1016/j.drugalcdep.2004.04.007Get rights and content

Abstract

Aims: To evaluate factors related to level of narghile (waterpipe) use as a first step towards modeling tobacco dependence among narghile users. Design: Cross sectional survey done in 2003 using interviewer-administered anonymous questionnaires. Setting: Cafes/restaurants serving narghiles in Aleppo, Syria. Participants: Narghile smokers (161 men and 107 women; mean age, 30.1 ± 10.2, 161; age range, 18–68 years; response rate, 95.3%) randomly selected from the 17 cafes/restaurants sampled. Measurements: Frequency of narghile use (daily, weekly, monthly) was assessed as a function of several factors potentially indicative of dependence, including situational characteristics (where, when, and with whom smoking occurs; seasonality of use, and sharing of narghile), attitudes, and experience with quitting narghile use, escalation of use over time, future intentions regarding use, perception of being “hooked” on narghile, and cognitions/behaviors engaged in to support use (carrying one’s own narghile; think of narghile when it is not available; considering narghile for selection of cafes/restaurants). Findings: Frequency of narghile use was strongly correlated with participant’s subjective judgment of how hooked they are on narghile (coefficient, 0.5). Predictors of narghile use frequency according to multinomial logistic regression were: male gender, smoking mainly alone versus with others; smoking mainly at home versus outside; smoking more frequently since initiation, being hooked on narghile, carrying narghile, and considering it for cafe/restaurant choice. Conclusions: Our data reveal two main domains of a tobacco dependence syndrome likely to be relevant to narghile; the first reflects the effects of nicotine contained in narghile tobacco, and is not very different from what is seen with other tobacco products, and the second is unique to narghile and is related mainly to its social dimension, with more intensive smokers showing an increasingly individual pattern of narghile smoking.

Introduction

A narghile, or waterpipe, is a centuries old method of using tobacco. Generally, a narghile consists of head, body, water bowl, and hose (see Fig. 1). Charcoal heats the tobacco which produces the smoke that the user inhales once it has passed through the partially filled waterbowl. In the past decade, narghile use has become a worldwide phenomenon (McNicoll, 2002). In the Eastern Mediterranean region (EMR), long accustomed to waterpipes, the behavior is reaching alarming proportions, and may affect a quarter of some populations (Tamim et al., 2003, Chaaya et al., 2003). Observations from around the world suggest that narghile smoking is becoming an urban social phenomenon (Frey, 2002, McNicoll, 2002). This popularity likely involves several factors, including the introduction of Maassel (a specially prepared tobacco with sweetened fruit flavors and mild aromatic smoke), media attention, and social trends (Kandela, 2000, Maziak et al., 2004a). Anthropological work suggests that narghile use is an important ingredient of a “laid back” oriental culture that contrasts favorably with the fast, nervous, lifestyle of the west, symbolized by cigarettes (Chaouachi, 2000).

Understanding narghile use and its effects is important because it involves inhaling tobacco smoke, which is associated with well-known risks to individual and public health. Of particular interest for individuals interested in decreasing narghile use is the understanding to what extent the concept of dependence, extensively studied in cigarette smokers, applies to narghile users. According to American Psychiatric Association (DSM-IV, 1994), nicotine dependence encompasses most of the salient physiological, psychological, and behavioral features of substance dependence, including tolerance, withdrawal, and compulsive drug taking despite problems arising from use. Narghile smoke contains considerable amount of nicotine, and narghile smoking has been shown to produce high levels of nicotine metabolites in the blood of smokers (Shihadeh, 2003, Shafagoj et al., 2002). Furthermore, narghile smokers have been shown to continue use despite knowledge of potential harmful effects and to be unable to quit despite wanting to (Maziak et al., 2004a). Thus, dependence in narghile users likely shares many features with dependence in cigarette smokers.

In addition to these common features, narghile users may experience dependence in ways that are unique to this method of tobacco use. First, tobacco use patterns are likely to be narghile-specific (Maziak et al., 2004, Maziak et al., 2004a). For example, a survey of university students suggests that narghile use has a predominantly intermittent and social pattern. An intermittent use pattern may decrease the likelihood of physical dependence on nicotine (e.g., Shiffman, 1989) and render uninformative self-report items traditionally used to assess dependence in cigarette smokers (e.g., number of cigarettes smoked daily, time of first cigarette). Second, the social aspects of narghile use suggest that narghile-specific factors such as number of friends smoking narghile and family attitude towards narghile smoking may influence narghile use and cessation (Maziak et al., 2004). Third, narghile smokers may value highly some unique features of this tobacco use method, including its smell, taste, and social ambience (Maziak et al., 2004a). Even shared features of dependence of tobacco use such as craving and addiction-induced socio-cognitive behavioral changes can be displayed differently in narghile smokers due to its specific makeup (e.g., its size makes it inconvenient for anything other than seated use, preparation and use demands time, and use is frequently in a social context). Therefore, any examination of dependence in narghile users may require measures that are narghile-specific. However, these measures presuppose an accurate description of patterns of narghile use and an understanding of such fundamental issues as users’ perception of dependence and ease of cessation.

To date, there have been no studies related to tobacco dependence in narghile. Advancing our understanding of this issue is of major importance for the design of intervention strategies to curb narghile’s spread (Maziak et al., 2004b). Guided by the data collected in our initial study among university students (Maziak et al., 2004), the current study of adult narghile smokers in Aleppo (Syria) cafes/restaurants examines more closely the factors likely to be important in defining use patterns and dependence related to narghile smoking. We hope that this work, in conjunction with that being carried out elsewhere (Shihadeh, 2003, Shafagoj et al., 2002), will form the foundation of a psychometrically sound approach to assessing tobacco dependence related to narghile smoking in Arab societies.

Section snippets

Methods

This study is a cross sectional study conducted in 2003 among narghile smokers (in restaurants and cafes), 18 years of age and older, using interviewer-administered anonymous questionnaires. A list of all cafes/restaurants in Aleppo (population of about 2,500,000) serving narghile was obtained from Aleppo Department of Tourism, totaling 112 cafes/restaurants. In the first stage, two cafes/restaurants were randomly selected to pilot survey procedures (obtaining the cooperation of restaurant

Statistical analysis

Frequency analysis of main study indices was tabulated according to frequency of narghile smoking, and compared using the chi-square test for linear trend (Table 1). Means were calculated for continuous variables (age, education, age of initiation, DI) and were compared using one-way analysis of variance (ANOVA; α < 0.05 considered significant). Spearman rank correlation coefficient was calculated for frequency of narghile use and responses to the hooked on narghile, and future expectation

Results

Overall, 268 narghile users participated in the study (161 males and 107 females; mean age, 30.1 ± 10.2 (range, 18–68 years); 12 individuals refused to participate, yielding a response rate of 95.3%. Means for age of participants, age at initiation of narghile (24.2 ± 8.1 years), duration of narghile smoking, DI, and years of education did not differ according to smoking level of participants (P > 0.05 for all). The results of univariate analysis of main studied factors with frequency of

Discussion

In a previous study, we showed that narghile users among university students in Aleppo tend to be in the initial experimental phase of use, characterized by occasional and social use, whereby students begin their narghile use history, currently smoke narghile, and share the same narghile with their peers (Maziak et al., 2004). This information, together with students’ beliefs and attitude about narghile use (Maziak et al., 2004a), formed the basis of item selection for the current assessment of

Acknowledgements

This work is supported by USPHS grants R01 TW05962, R21 TW006545, and R01 DA11082.

References (30)

  • Chaouachi, K., 2000. Le narguilé: analyse socio-anthropologique. Culture, convivialité, histoire et tabacologie d’un...
  • J.R. DiFranza et al.

    Measuring the loss of autonomy over nicotine use in adolescents: the development and assessment of nicotine dependence in youths (DANDY) study

    Arch. Pediatr. Adolesc. Med

    (2002)
  • DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), 1994. Fourth ed. American Psychiatric Association,...
  • J.F. Etter et al.

    Validity of the Fagerstrom test for nicotine dependence and of the heaviness of smoking index among relatively light smokers

    Addiction

    (1999)
  • J.F. Etter et al.

    A self-administered questionnaire to measure dependence on cigarettes: the cigarette dependence scale

    Neuropsychopharmacology

    (2003)
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