Flavored Versus Nonflavored Waterpipe Tobacco: A Comparison of Toxicant Exposure, Puff Topography, Subjective Experiences, and Harm Perceptions

Abstract

Introduction Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers’ experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers’ toxicant exposure, smoking topography, subjective experiences and harm perception. Methods Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception. Results Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco. Conclusions Limiting tobacco flavor has a substantial effect on WP smokers’ nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth. Implications This study highlights the important role of flavor in shaping WP smokers’ experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.

The effect of flavoured and non-flavoured tobacco on subjective experience, topography and toxicant exposure among waterpipe smokers

“…In line with our pilot study, 15 the results show that subjective positive and negative smoking experiences were dependent on the flavour condition, where smoking flavoured WP tobacco enhanced positive experiences and reduced negative responses. For example, participants found the flavoured tobacco to be more satisfying, calming, good tasting, well-liked and experienced less dizziness and nausea compared with the nonflavoured tobacco.…”

“…14 As a proof of concept of the effect of eliminating flavour on WP smokers' experience, we conducted a pilot study involving 32 WP smokers, who were compared when smoking their preferred flavour versus non-flavoured tobacco. 15 Our preliminary findings indicated that compared with nonflavoured tobacco, study participants reported an enhanced smoking experience while using flavoured WP tobacco with no changes in puffing…”

“…These findings validate our pilot work that showed a trend towards larger puffs and greater eCO levels among participants following smoking non-flavoured tobacco. 15 Accordingly, merely eliminating flavour may lead to compensating smoking behaviour, which in turn can increase exposure to some toxicants.…”

“…Puff topography was assessed using a validated instrument 15 with software that converted pressure signals to air flow (mL/s) data, producing measures of total time spent smoking, cumulative puffing time, puff duration, interpuff interval, number of puffs, total volume inhaled, average puff volume and maximum puff volume.…”

“…Means were calculated for all subjective measures and compared by tobacco condition using two-tailed paired samples t-tests. Similar to previous studies, 15 27 plasma nicotine concentration values below LOQ were replaced with the LOQ (1 ng/mL), which is more conservative than assuming values below the LOQ were zero. Consumed tobacco for each condition was calculated by subtracting the remaining tobacco weight after each smoking session from the baseline tobacco weight (15 g).…”