According to anecdotal evidence, waterpipe smoking may lead to the initiation of cigarette smoking among young people. This hypothesis is yet to be examined using an appropriate study design and a theoretical model for behavioral change.
To compare the risk of cigarette smoking initiation among waterpipe-only smokers and never smokers in a school-based sample of adolescents from Irbid, Jordan. Risk of initiation of cigarette smoking among waterpipe smokers was significantly higher than among never smokers after adjusting for potential confounders aHR 1. The association between waterpipe and cigarette smoking initiation was dose-dependent. Waterpipe smoking led to the initiation of cigarette smoking among this cohort of Jordanian adolescents; the effect was dose-dependent.
Waterpipe smoking is widely believed to be less harmful, less addictive and generally safer than cigarette smoking. Several researchers have recently suggested that waterpipe smoking can lead to cigarette use. As evidence for waterpipe use patterns and delivery of the addictive substance, nicotine, has accumulated, the waterpipe-to-cigarette gateway concept was developed further to suggest a possible pathway for this transition. Compared to cigarettes, waterpipe smoking is a stationary, time-consuming practice, and is not readily accessible.
These features led one of our group WM to suggest that adolescents who become addicted to nicotine through waterpipe use are likely to resort to the more accessible cigarettes to satisfy their smoking urge. A detailed description of the study methods is given elsewhere.
A random sample of 19 schools was selected with probability proportionate to size. Smoking behavior was assessed using a pilot-tested questionnaire developed in accordance with World Health Organization WHO international guidelines, 24 and several instruments validated in Arabic, such as the GYTS. The students completed the questionnaire annually over the 4 years of the study, including baseline, at school with guidance from a study assistant.
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