Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Research Article, J Addict Behav Ther Rehabil Vol: 4 Issue: 2

Is Waterpipe Smoking a Gateway to Cigarette Smoking among Youth?

Salameh Pascale1,2*, Zeenny Rony2, Antoun Edwina1, Salamé Joseph3, Waked Mirna4, Barbour Barbour5, Zeidan Nina5 and Baldi Isabelle6
1Clinical & Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Hadath, Lebanon
2Pharmacy Practice department, School of Pharmacy, Lebanese American University, Byblos, Lebanon
3Charité – Universitätsmedizin University Hospital, Berlin, Germany
4Pulmonology department, Saint Georges Hospital & Faculty of Medicine, Balamand University, Beirut, Lebanon
5Faculty of Public Health, Lebanese University, Fanar, Lebanon
6Laboratoire Santé Travail Environnement, Université Bordeaux Segalen, Bordeaux, France
Corresponding author : Pascale Salameh, PharmD, MPH, PhD
Professor of Epidemiology, Jdeidet El Meten, Chalet Suisse street, Ramza Azzam bldg, 5th floor, Beirut, Lebanon
Tel: 009613385542; Fax: 009611696600
E-mail: [email protected]; [email protected]
Received: August 11, 2014 Accepted: March 11, 2015 Published: March 13, 2015
Citation: Pascale S, Rony Z, Edwina A, Joseph S, Mirna W, et al. (2015) Is Waterpipe Smoking a Gateway to Cigarette Smoking among Youth?. J Addict Behav Ther Rehabil 4:2. doi:10.4172/2324-9005.1000136


Is Waterpipe Smoking a Gateway to Cigarette Smoking among Youth?

Introduction: Whether waterpipe smoking is a gateway to cigarette smoking among youth is not known yet. The objective of our study was to assess the profile of dual and single smokers of both, waterpipe and cigarette, and evaluate whether a given type of smoking may be a gateway for the other. Methods: A cross-sectional study was carried out, using a proportionate cluster sample of Lebanese students in the public and private universities. The questionnaire used in this study was composed of several parts, including the sociodemographic part and a detailed active and passive smoking history, in addition to items of the tobacco dependence scales for both waterpipe and cigarette.

Keywords: Cigarette; Waterpipe; Dual smoking; Dependence; Tobacco; Youth


Cigarette; Waterpipe; Dual smoking; Dependence; Tobacco; Youth


Waterpipe smoking is becoming fashionable all over the world. Although it originally started in the Middle East region [1-3], it is now common in the Western world too [4,5]. It has now been declared by the World Health Organization as a threat to public health [6]. This habit is particularly spreading among youth [7-9].
Although wrongly believed to be safe by the general population, including young people [1,2], it has been shown to be as toxic as cigarette, and can equally lead to many diseases [10-12]. Moreover, it can lead to dependence [13]. Although substantial differences may exist between both types of smoking, waterpipe includes a social component that cannot not be found in cigarette smoking and hence the dependence concepts differ [13,14].
Nevertheless, knowledge about the interaction between cigarette and waterpipe is still at its beginnings, and very little information is known about the association between both types of smoking. However, we know that a substantial number of smokers may be dual smokers as shown in several regions of the world, such as Lebanon [15], Jordan [16,17], the United States of America [18] and Denmark [19]. Dual smokers titrate their nicotine levels to suppress abstinence and craving symptoms using interchangeably waterpipe or cigarettes, according to the circumstances and availability of the device [20].
Several studies have started examining the gateway hypothesis, including two prospective studies: Jensen and collaborators found out during an eight months follow-up that among Danish boys, occasional or regular waterpipe smokers were more likely to become regular cigarette smokers [19]; Mzayek et al. found out that Jordanian adolescents, who were exclusive waterpipe smokers at baseline were twice as likely to become current cigarette smokers after two years compared with never smokers [17]. The opposite was also inferred: exclusive cigarette smokers at baseline were twice as likely to become current waterpipe smokers at follow-up [17]. Several cross-sectional studies also have investigated the gateway hypothesis [16,18,21] found out that there were more dual than single smokers among the studied populations.
Whether waterpipe smoking is a gateway to cigarette smoking among Lebanese youth is not known yet. The objective of our study was to assess the profile of dual and single smokers of both waterpipe and cigarette and evaluate whether a given type of smoking may be a gateway for the other among Lebanese youth.


Population and sampling
A cross-sectional study has been carried out using a proportionate cluster sample of Lebanese students in public and private universities. A list of universities in Lebanon, provided by the Center for Pedagogic Researches, was used to adjust the sample size [22]; proportionate numbers of students were taken from every university according to its size. A sample size of at least 3000 individuals was targeted to allow for adequate power for bivariate and multivariate analysis to be carried out.
Although ethical approval was granted by all Internal Review Boards of respective institutions where the study was conducted, most universities’ administrative offices in Lebanon that we approached did not allow drawing a random sample of their enrolled students to participate in the study: they did not provide us with the lists of students and permission was not granted to enter classrooms and search for students nominatively. Thus our research group had to work with a nonrandom sample of students outside their classes. Students were approached on campus during break times between courses by a field worker.
The latter explained the study objectives to the students, and after obtaining oral consent, they were handed the anonymous and selfadministered questionnaire. On average, the questionnaires were completed by participants within approximately 20 minutes. At the end of the process, the completed questionnaires were placed in closed boxes and sent for data entry. During the data collection process, the anonymity of the students was guaranteed. Out of 4900 distributed questionnaires, 3384 (69.1%) were returned to the field worker.
Questionnaires and variables
The questionnaire used in this study is composed of several parts, including the socio-demographic part (age, sex, socioeconomic status, region, and whether the subject is attending a private versus a public university).
A detailed active (waterpipe, cigarette and dual smoking) and passive smoking history was also obtained. Current waterpipe smoking is defined as smoking at least one waterpipe per month (an operational definition commonly used in the absence of a standard definition of a regular waterpipe smoker), while current cigarette smoking is defined as smoking at least one cigarette per day, referring to regular cigarette smoking [23]. Previous smoking is defined as having spent at least one month without smoking cigarette or waterpipe, a definition sometimes used in short term smoking cessation studies [24]. The group of currently non-smokers may include previous smokers, in addition to never smokers and intermittent non regular smokers. Never smokers are subjects who had never smoked, neither previously or currently. The numbers of smoked waterpipes per week and of cigarettes per day were collected for smokers.
Waterpipe dependence was measured using the Lebanese Waterpipe Dependence Scale (LWDS-11), which is a validated scale with adequate psychometric properties in the Lebanese population [13]. This scale includes eleven questions about waterpipe smoking. Cigarette dependence was measured using the Young Adult Cigarette Dependence scale (YACD), a scale including items about cigarette smoking and particularly validated for young adult university students [25]. Due to the absence of common questions between the LWDS and the YACD scale, participants received one single scale to fill out (LWDS/YACD) or both depending whether they were either waterpipe/cigarette smokers or dual smokers, respectively.
Passive smoking is defined as having at least one smoker at home or at work, a surrogate measure of exposure to environmental tobacco smoke. The questionnaire also includes other variables that are not used in this analysis. Further methodological details are presented in more details elsewhere [26].
Statistical analysis
Data was entered and analyzed using SPSS, version 18.0. The chisquare test was used for associations of nominal variables in bivariate analyses. For scale variables, we used the Student test to compare between means of different subgroups. A p-value <0.05 was considered significant; in case p-value was <0.10, it was considered to be a “trend” that needs to be confirmed in future research with higher sample size because of a weak evidence against the null hypothesis [27].
In addition, multivariate analyses were carried out, using backward stepwise logistic regressions. Dependent variables were dichotomous smoking variables of waterpipe, cigarette or dual smoking among different subgroups, while independent variables were age, sex, socioeconomic status, region, attending a private versus a public university, having at least one smoker at home, having at least one smoker at work, and current or previous waterpipe or cigarette smoking (where applicable). Sample adequacy to data was checked by Hosmer Lemeshow test before accepting the final models.


Sample description
The sample included 3384 individuals; among them, 1926 (56.9%) had never smoked cigarettes, 802(23.7%) were previous cigarette smokers, and 349(19.2%) were current cigarette smokers. Moreover, 1639(48.4%) had never tried waterpipe, 949(28.0%) were previous waterpipe smokers, and 779 (23.0%) were current waterpipe smokers.
In other words, 2196(64.9%) of participants were currently nonsmokers (may include previous smokers), 408(12.1%) were currently exclusive cigarette smokers, 545(16.1%) were currently exclusive waterpipe smokers, and 234(6.9%) were currently dual smokers.
Exclusive cigarette smokers had a cigarette dependence score (m=13.62; sd=5.62) statistically similar to that of dual smokers using the YACD scale (m=14.47; sd=6.45) (p=0.558); for waterpipe, exclusive smokers had a LWDS significantly lower (m=9.80; sd=5.86) than that of dual smokers (m=11.24; sd=6.31) (p=0.014).
Socio-demographic characteristics of the university students’ sample
These characteristics are presented in Table 1. Private universities include higher prevalence of cigarette and waterpipe smoking (p<0.001); however, the public university harbors more current waterpipe than cigarette smokers. A clear relationship has been found between cigarette smoking and socioeconomic status, with higher prevalence of current smoking with higher socioeconomic status (p<0.001). For waterpipe, however, the increase is not proportional to that of socioeconomic status, nor statistically significant (p=0.127). There are equal percentages of previous cigarette smokers among males and females, but significantly more current cigarette smokers among males (a fourfold increase; p<0.001). For waterpipe, we found out equal prevalence of previous smoking, compared to 77% more current smokers among males versus females (p<0.001).
Table 1: Socio-demographic characteristics of the university students’ sample.
Moreover, by the age of 20, the likelihood of becoming a current cigarette and waterpipe smoker, particularly for cigarette smoking has almost doubled. A slight but statistically significant increase was also observed for waterpipe smoking (p<0.001). The highest percentage of current cigarette smoking was observed in Mount Lebanon followed by Beirut, the North, the Bekaa plain and finally the South; however, the highest percentage of current waterpipe smoking was observed in Beirut, followed by Mount Lebanon, the Bekaa plain, South Lebanon and then North Lebanon. Finally, having at least one smoker at home significantly increased the prevalence of current smoking, for both cigarette and waterpipe. Similar results were found for smokers at work (p<0.001) (Table 1).
Cigarette smoking among previous and current waterpipe smokers
The great majority of individuals who have never smoked waterpipe were also never smokers of cigarette (76.8%), while 14.7% were current cigarette smokers. Among previous waterpipe smokers, 17.6% were current cigarette smokers. Among current waterpipe smokers, 30% were dual smokers (p<0.001) (Figure 1).
Figure 1: Cigarette smoking among previous and current waterpipe smokers (p<0.001).
Waterpipe smoking among previous and current cigarette smokers
The great majority of individuals, who have never smoked cigarette, have also never smoked a waterpipe (65.3%), while 16.4% are current waterpipe smokers. Among previous cigarette smokers, 28.8% are current waterpipe smokers. Among current cigarette smokers, 36.4% are dual smokers (p<0.001) (Figure 2).
Figure 2: Waterpipe smoking among previous and current cigarette smokers (p<0.001).
Multivariate analyses
Multivariate analyses are presented in Table 2. Previous waterpipe smoking (ORa=1.24; p=0.091) was correlated with current cigarette smoking with a trend towards significance. Current waterpipe smoking (ORa=2.04; p<0.001) is significantly correlated with current cigarette smoking. Moreover, attending a private university, male sex, living in North Lebanon but not in south Lebanon, higher socioeconomic status, older age and having at least one smoker at home or at work are significantly and independently associated with current cigarette smoking. The other way round, previous cigarette smoking and current cigarette smoking are both retained in the model as significant correlates of waterpipe smoking (ORa=2 and ORa=2.39, respectively; p<0.001). Attending a private university, living in Beirut (not in North or South Lebanon), and having at least one smoker at home or at work all are factors associated with current waterpipe smoking.
Table 2: Multivariate analyses of cigarette and waterpipe smoking correlates.
For current dual smoking, male sex, not living in Beirut and having at least one smoker at home or at work are significant and independent correlates to it. Current waterpipe smoking (versus cigarette smoking) is correlated with female sex in addition to living in the South but not in the North, lower socioeconomic status as well as being at younger age. Opposite factors correlated to cigarette smoking, such as male sex, living in the North but not the South, higher socioeconomic status and older age (Table 2).


In this study, we have been able to describe the previous and current smoking habits of university students in Lebanon. We found that current smoking of one type is associated with smoking of the other type, for both cigarette and waterpipe. Current smoking of one type of tobacco interchangeably drives the other. These results can be first explained by tobacco dependence induced by smoking [13,28]: dependence develops during cigarette smoking and may lead to additional waterpipe smoking (while continuing smoking cigarettes in parallel). This is shown among US students, where the majority of waterpipe smokers have used cigarettes or tended to use other forms of tobacco [4]. This result is further supported by the finding that dual smokers are the ones with the highest dependence to both forms of tobacco smoking, as shown in the results section, particularly for waterpipe.
We also found out that previous waterpipe smoking can be a gateway to cigarette smoking, while previous cigarette smoking seems to be a more obvious gateway to current waterpipe smoking. Although dependence to cigarettes and to waterpipe both include nicotine dependence components [28,29], the fact that nicotine dependence is more pronounced among cigarette smokers versus waterpipe smokers can explain a higher switching from cigarette to waterpipe than the other way round [13]. Similar results are found among British university students, where cigarette smoking is a major motive for waterpipe smoking [5]. Moreover, some individuals may think that they would stop smoking cigarette that is toxic, but would switch to waterpipe which they think is less toxic than cigarette [1,2] but still enjoyable and more culturally acceptable [30,31]. Their dependence to nicotine from cigarette smoking might be a silent driver for this behavior. The latter hypothesis remains to be established by adequate measurements.
Conversely, previous smoking of waterpipe may slightly increase the risk of current cigarette smoking since fewer individuals stop waterpipe (thought to be safe) to switch to cigarette that is known to be toxic [1,2]. However, this switch is probably due to the nicotine dependence component during waterpipe smoking [13]. The observed statistical trend (p=0.09) precludes concluding about this point. We recommend future studies with a higher sample size to account for the possible under power of the current analysis.
Furthermore, findings from this paper as well as several other papers [5,17,19] indicate that the “gateway” between smoking types may also be non-specifically related to nicotine but to psychological positive and negative reinforcements that exist in both types of smoking [13,25]. Furthermore, both cigarettes and waterpipe predispose to the use of other substances, such as other forms of tobacco, alcohol, and illicit drugs [32]. The latter idea has also been demonstrated among Lebanese youth: risk taking behavior in general might be affected by risk involvement and perception, attractiveness of risky behaviors, and motives for risk taking, which increases the complexity of toxic substances exposures circumstances [33]. Specific qualitative studies are suggested to depict this aspect.
We also found out that attending a private university is an independent driving factor for both types of smoking, except for the small subgroup of dual smokers that are mainly studying in the public university. Higher socioeconomic status per se is associated with current cigarette smoking and inversely lower socioeconomic status is associated with current waterpipe smoking. A similar discrepancy between public and private universities students regarding health risk behaviors has been reported in other developing countries [34] but not in developed countries [35]. This complex relationship needs to be more thoroughly studied in future research.
Male sex is a predisposing factor for smoking cigarette and dual smoking, while female sex is mainly associated with waterpipe smoking, demonstrating a strong relationship (OR=4.5). These results are similar to those of other researchers showing that females are more prone to smoke waterpipe and depend on it [36], while males smoke more cigarette [37]. These findings are also similar to the results a previous study we undertook among adults of forty years of age and above. In a similar fashion the findings indicated that females were more dependent to waterpipe smoking than males [15]. The cultural aspect of smoking cigarette and waterpipe among males and females deserves to be further studied.
As for age, both types of smoking seemed more common in older age individuals (cigarette smoking in particular), while waterpipe smoking was almost twice more common among younger individuals (in comparison with cigarette smoking). This may show that both types of smoking, cigarettes in particular, may be acquired with time during university life, driven by peer pressure [33], while waterpipe smoking seemed a behavior that is tolerated at younger ages, making more individuals reaching the university while they had already started smoking waterpipe during school years [38]. This finding shows the urgency of health education interventions in schools to promote healthy behaviors.
Finally, having smokers at home and at work are both independent factors consistently associated with all types of smoking, whether exclusive smoking of waterpipe, cigarette or dual smoking. The presence of smokers in the environment of youngsters constitutes a form of pressure and shows that a higher level of tolerance towards smoking within the family or the workplace is a powerful driver or current smoking behavior. We have previously shown this issue in another thorough analysis of the same dataset [39]. The same concept of societal influence is found in other studies [3,40].
Thus, there is a need for health promotion behavior among youth, stressing the relationship between waterpipe and cigarette smoking. The false belief of waterpipe safety should be replaced by the reality that waterpipe is associated to many diseases [12], leads to nicotine dependence [13], and can be a gateway to the well-known toxic cigarette smoking, as shown in this study.
Nevertheless, our study, as with any, has its limitations: the crosssectional design does not allow concluding about the causality of the investigated associations although association temporality was taken into account using “previous” and “current” smoking definitions. A prospective design study is, however, suggested for a better causality judgment. A selection bias could have been possible since the sample was not a random sample and might not be representative of the young adults and students population in Lebanon. This nonrandom sampling could lead to an overrepresentation of students who skip classes and may have higher risky behaviors. However, on the other hand, the length of the questionnaire may also lead to an under representation of this students’ category, leading to compensation of the latter phenomenon.
There can also be a possibility of respondent and information bias since the results of our study are based on a self-administered and completed questionnaire. Despite the fact that we ensured anonymity and confidentiality of all data that have been collected, respondents may have under-reported some of their behaviors that lead to missing values; however, we do not think that this issue may have changed the results we obtained since missing values were infrequent (lower than 5% for all variables). Additional limitations may arise from lack of precision in some questions: for example, having smokers at home or at work does not exactly reflect environmental tobacco smoke, but is just a surrogate marker of this concept.
We suggest further research to be carried out taking into account the above cited limitations. We also suggest thorough investigations to assess the factors that we could not measure, in addition to qualitative research that can explore the knowledge, attitudes, and values of students in order to identify the personal, environmental, social and psychological predictors of smoking and other risky behaviors.


This study findings show that waterpipe may be a gateway for cigarette smoking and vice versa. Although these results need to be further confirmed, there is an urgency of health education interventions among youth to promote healthy behaviors.


The authors have no conflicts of interest to declare. This work was funded by the CEDRE program for French-Lebanese cooperation, grant 118/2009.


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