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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. [ABSTRACT FROM AUTHOR]

Background: To compare patterns of use, beliefs, and attitudes related to waterpipe smoking between university students (beginning smokers) and café customers (established smokers) in Aleppo Syria, in order to explore the evolution of this smoking method. Methods: Two cross-sectional surveys were conducted among representative samples of university students (total 587, 48.4% men, mean age 22 years), and waterpipe users among cafe' customers (total 268, 60% men, mean age 30 years) in Aleppo, Syria. We used interviewer-administered questionnaire inquiring about pattern of waterpipe smoking (initiation, frequency), situational characteristics of use (partner, place, sharing), beliefs related to waterpipe smoking (harmful/addictive properties of waterpipe), attitudes related to waterpipe smoking (confidence in quitting, will to quit, motivation for quitting, past year quit attempt), and cigarette smoking. Results: Daily and regular patterns of smoking become more prevalent with increased duration of smoking, but intermittent smoking remains the predominant pattern of waterpipe use. Women seem to be drawn later to the habit, which seem to escape the usual taboo against women's cigarette smoking. Patterns and context of waterpipe use tend to change with progress of the practice affecting frequency, setting, and sharing of waterpipe. Unlike beginners, established waterpipe smokers seem more smoking-method oriented, more hooked on the habit, less willing to quit, and less likely to foresee challenges to quitting. Conclusion: Use patterns and attitudes related to waterpipe smoking evolve to accommodate the change in dependence and life circumstances of the smoker. Most of use features, beliefs, attitudes, as well as time-course seem unique to this smoking method requiring novel approach to intervention. [ABSTRACT FROM AUTHOR]