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Are waterpipe users tobacco-dependent?

Jawad and colleagues (1) argue that waterpipe tobacco smoking has the potential to become the next public health priority, as the global prevalence of waterpipe smoking is increasing, especially among younger users. They note that, across a number of geographical regions, users typically lack knowledge about the health risks of waterpipe tobacco smoking. A number of misbeliefs appear to be common, such as that the water in the waterpipe bowl acts as a filter for harmful chemicals, that waterpipe tobacco has fewer toxic chemicals than cigarettes, and that the aromatic flavour and smell of waterpipe tobacco (something that is regulated for cigarettes in many countries) implies safety. Although these misbeliefs are worrying, there is also a lack of reliable evidence on the health effects of waterpipe tobacco smoking. There have been relatively few studies investigating the effect of waterpipe tobacco smoking on health, and those that have been conducted are typically of limited quality. Similarly, research on the relative level of toxicant exposure resulting from waterpipe tobacco smoking (compared with cigarette smoking) is misleading, due to the differing patterns of use between the two. In many groups, particularly those where it is a recent phenomenon, waterpipe is often infrequent and more social in nature. It may therefore not be associated with the same pattern of dependence seen in regular, habitual cigarette smokers.