title: Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence?
abstract: OBJECTIVE
  Waterpipe tobacco smoking (WTS) involves passing tobacco smoke through water prior to inhalation, and has spread worldwide. This spread becomes a public health concern if it is associated with tobacco-caused disease and if WTS supports tobacco/nicotine dependence. A growing literature demonstrates that WTS is associated with disability, disease and death. This narrative review examines if WTS supports nicotine/tobacco dependence, and is intended to help guide tobacco control efforts worldwide.
  
  
  METHODS
  PUBMED search using: (("waterpipe" or "narghile" or "arghile" or "shisha" or "goza" or "narkeela" or "hookah" or "hubble bubble")) AND ("dependence" or "addiction").
  
  
  METHODS
  Excluded were articles not in English, without original data, and that were not topic-related. Thirty-two articles were included with others identified by inspecting reference lists and other sources.
  
  
  RESULTS
  WTS and the delivery of the dependence-producing drug nicotine were examined, and then the extent to which the articles addressed WTS-induced nicotine/dependence explicitly, as well as implicitly with reference to criteria for dependence outlined by the WHO.
  
  
  CONCLUSIONS
  WTS supports nicotine/tobacco dependence because it is associated with nicotine delivery, and because some smokers experience withdrawal when they abstain from waterpipe, alter their behaviour in order to access a waterpipe and have difficulty quitting, even when motivated to do so. There is a strong need to support research investigating measurement of WTS-induced tobacco dependence, to inform the public of the risks of WTS, which include dependence, disability, disease and death, and to include WTS in the same public health policies that address tobacco cigarettes.
authors.affiliation: Center for Clinical and Translational Research and Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA.
authors.forename: Eiman
authors.initials: E
authors.lastname: Aboaziza
authors.affiliation: Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Richmond, Virginia, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Eissenberg
mesh_terms: D019317:Evidence-Based Medicine / Q000379:methods; D006801:Humans; D011569:Psychiatric Status Rating Scales; D012907:Smoking / Q000009:adverse effects*; D014029:Tobacco Use Disorder / Q000209:etiology*; D014867:Water
chemical_list: D014867:Water
keywords: Addiction; Global health; Nicotine