“Waterpipe Is Like a Wife”: Qualitative Assessment of Perspectives on Waterpipe Smoking Dependence

Document Type : Original Article

Authors

1 Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, TN, USA

2 Department of Public Health and Social Work, Slippery Rock University, PA, USA

3 1. School of Public Health, University of Alberta, Edmonton, Canada 2.Syrian Center for Tobacco Studies, Aleppo, Syria

4 1 Syrian Center for Tobacco Studies, Aleppo, Syria 2 Department of Public Health Sciences, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA 3 Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA

5 1 Syrian Center for Tobacco Studies, Aleppo, Syria 2 Center for the Study of Tobacco Products and Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA

6 1. Syrian Center for Tobacco Studies, Aleppo, Syria 2. Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida, USA

7 1 Division of Social and Behavioral Sciences, School of Public Health, University of Memphis, Memphis, TN, USA 2 Syrian Center for Tobacco Studies, Aleppo, Syria

10.34172/ahj.2022.1377

Abstract

Background: Waterpipe (WP) smoking has become a global public health problem in recent decades and growing evidence indicates 
that it can cause nicotine dependence. Most evidence on WP dependence to date has been derived from survey- or laboratorybased studies. This study employed qualitative methods to explore WP users’ perceptions of dependence in Aleppo, Syria.

Methods: A total of 15 focus groups were conducted with 64 adult WP smokers (51 males and 13 females) using a semi-structured 
interview. All focus group discussions were audiotaped, transcribed, and coded using directed content analysis. 

Findings: Several WP dependence features were consistent with those commonly reported by cigarette smokers. These included 
positively reinforced features, such as smoking’s association with social gatherings and cultural connectedness, and negatively 
reinforced features including relief of withdrawal symptoms, stress, and boredom. Although interest in quitting was low, many users 
perceived quitting WP to be difficult and an indicator of loss of control over smoking, a common marker of dependence. Several 
observed dependence features were specific to WP, including transitioning from social smoking to smoking alone, and adapting 
one’s behavior to the considerable effort normally required to engage in WP smoking despite inconvenience or cost, and often at
the expense of other reinforcers such as social interaction.

Conclusion: The general and specific features of WP dependence need to be considered in developing instruments to measure WP 
dependence, in clinical assessment of WP dependence, and in developing cessation programs. 

Keywords