Comparison of puff topography, toxicant exposure, and subjective effects in low- and high-frequency waterpipe users: a double-blind, placebo-control study

Nicotine Tob Res. 2015 Jun;17(6):667-74. doi: 10.1093/ntr/ntu196. Epub 2014 Sep 25.


Introduction: Clinical laboratory work among intermittent and daily waterpipe tobacco smokers has revealed significant risks for tobacco dependence and disease associated with waterpipe tobacco smoking (WTS). No studies have compared these groups directly. This study examined whether WTS frequency was associated with differential puff topography, toxicant exposure, and subjective response using a placebo-control design.

Methods: Eighty participants reporting WTS of 2-5 episodes (LOW; n = 63) or ≥20 episodes (HIGH; n = 17) per month for ≥6 months completed 2 double-blind, counterbalanced 2-hr sessions that were preceded by ≥12hr of tobacco abstinence. Sessions differed by product smoked ad libitum for 45+ min: preferred brand/flavor of waterpipe tobacco (active) or a flavor-matched tobacco-free waterpipe product (placebo). Outcomes included puff topography, plasma nicotine, carboxyhemoglobin (COHb), and subjective response.

Results: HIGH users had more puffs, shorter inter-puff-intervals, and a higher total puff volume for placebo relative to active, as well as relative to LOW users during placebo. Plasma nicotine concentrations increased when smoking active (but not placebo) with no significant differences between groups at 25min post-product administration. COHb increased significantly during all conditions; the largest increase was for HIGH users when smoking placebo. There was some evidence of higher baseline scores for nicotine/tobacco nicotine abstinence symptomology.

Conclusions: Higher frequency waterpipe users may be more sensitive to the effects of waterpipe smoke nicotine content. Among HIGH users, higher baseline nicotine/tobacco abstinence symptoms may indicate greater nicotine dependence. These data support continued surveillance of WTS and development of dependence measures specific to this product.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Arterial Pressure
  • Carbon Monoxide / analysis
  • Carboxyhemoglobin / metabolism*
  • Double-Blind Method
  • Female
  • Flavoring Agents
  • Hazardous Substances
  • Heart Rate
  • Humans
  • Inhalation Exposure / analysis
  • Male
  • Nicotine / administration & dosage
  • Nicotine / blood*
  • Smoking / blood*
  • Smoking / epidemiology
  • Smoking / physiopathology
  • Tobacco Products / statistics & numerical data*
  • Tobacco Use Disorder / blood*
  • Tobacco Use Disorder / epidemiology
  • Tobacco Use Disorder / physiopathology
  • Young Adult


  • Flavoring Agents
  • Hazardous Substances
  • Nicotine
  • Carbon Monoxide
  • Carboxyhemoglobin