An Introduction to the Electronic Waterpipe

Restricted (Penn State Only)
Stroup, Andrea Marie
Graduate Program:
Biobehavioral Health
Doctor of Philosophy
Document Type:
Date of Defense:
December 19, 2018
Committee Members:
  • Steven A Branstetter, Dissertation Advisor
  • Steven A Branstetter, Committee Chair
  • Thomas J Gould, Committee Member
  • Stephanie Trea Lanza, Committee Member
  • Marianne Messersmith Hillemeier, Outside Member
  • Electronic waterpipe
  • e-waterpipe
  • hookah
  • e-head
  • waterpipe
  • electronic nicotine delivery systems
With growing popularity in the U.S., it has been estimated that 10 million adults currently smoke traditional waterpipe (TWP) and 1.4 million use every day or some days. Emerging adults aged 18-24 report the highest rates of TWP smoking. In the U.S., approximately 12.2% of young adults and 10% of college students report past-year TWP use. Despite positive perception of use among current and non-users, TWP has been associated with an increased risk of developing cancer, respiratory disease, cardiovascular disease, and addiction. In addition to TWP, there is a new product has emerged in the marketplace within the past five years that provides users with a non-combustible option; the electronic waterpipe (e-waterpipe; EWP). The EWP is a large smoking system that is a combination of two commercially available products including 1) the structure of a TWP (a metal stem, water-filled bowl, and hoses to inhale smoke) and 2) an electronic head (e-head) that electronically heats e-liquid which is then vaporized and inhaled. In an e-head, any flavor and any nicotine content e-liquid can be vaporized using a similar heating mechanism as an electronic cigarette (e-cigarette). Based on the literature comparing e-cigarettes and traditional cigarettes, it can be suggested that the EWP has a similar potential to become a popular, and possibly a safer alternative to TWP. However, to date, there are no known studies investigating EWP use or its comparison to TWP use. Given the gaps in the literature, the purpose of this dissertation was to aid in the development of efforts to identify and evaluate the novel EWP. Specifically, this dissertation included the investigation of the three following aims: 1) define the e-waterpipe and explain how an e-head is used to construct the e-waterpipe, 2) characterize perceptions and intentions of EWP use among first-time users, and 3) compare EWP and TWP total smoke exposure, immediate physiological responses, and future intentions of use. To address these aims, the three-paper dissertation option was utilized. The first manuscript (Chapter 2) included a mini review which highlighted a non-combustible, alternative waterpipe product, the EWP, and gave a brief overview of how it functions as a large smoking system (i.e., a combination of an e-head and a TWP structure). It detailed several models on the market which have varying characteristics and how those characteristics may affect smoking behaviors and vapor/nicotine exposure. Additionally, this review rationalized the need for future research to understand EWP prevalence, perceptions of use, and its associated health risks. In the second manuscript (Chapter 3), pilot data (N=26) from the first known laboratory-based EWP study was analyzed using a descriptive analysis. A factor analysis identified distinct categories among items in a newly-developed EWP questionnaire including 1) perceived health risks, 2) future intentions to use the EWP, and 3) first-time experiences using the EWP. This study’s design and results were used to inform the development and implementation of a larger-scale EWP study, which is discussed in Chapter 4. The findings suggest that EWP use has the potential to become popular similar to e-cigarettes based on positive experiences and perceptions and increased intentions of future use. For the third manuscript (Chapter 4), a laboratory-based study was conducted that allowed smokers (N=36) to attend two experimental sessions, one to smoke the TWP and one to smoke the EWP, where physiological markers were measured pre-and post-smoking. Physiological measurements included change in exhaled carbon monoxide (CO), heart rate (HR), blood pressure (BP), and spirometry parameters (forced expiratory volume (FEV) and estimated lung age). After smoking each device, a questionnaire measured future intentions to use the respective waterpipe. Mixed effect modeling using repeated measures was used to evaluate the association between the type of waterpipe smoked (TWP or EWP) and total smoke exposure on the associated immediate physiological responses and future intentions of use. This study found that for TWP use compared to EWP use, each one second increase in total smoke exposure was associated with 0.006 greater ΔCO from pre- post-smoking. This study alone cannot suggest that the EWP use is a safer alternative to TWP smoking. However, it can imply that the EWP exposes the smoker to significantly less CO compared to TWP smoking. These results highlight a crucial need for more investigation into the use of EWP, as well as the need for comprehensive EWP regulation.