Withdrawal Symptoms among Cigarette and Waterpipe Smokers: A Study in Natural Setting

Samah F. Al-Shatnawi1, Karem H. Alzoubi1, 2, *, Omar F. Khabour3
1 Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
2 Department of Pharmacy Practice and Pharmacotherapeutics, University of Sharjah, Sharjah, UAE
3 Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan

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© 2021 Al-Shatnawi et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Department of Clinical Pharmacy Faculty of Pharmacy Jordan University of Science and Technology Irbid, Jordan; E-mail:



The rates of tobacco use, including cigarette and waterpipe smoking, are surging in the Eastern Mediterranean region. The use of these products causes nicotine dependence that makes even short-term tobacco abstinence difficult due to aversive symptoms. During the daytime fasting of the month of “Ramadan”, people accept significant disruption in regular activities, including tobacco smoking. Thus, daytime during Ramadan (before sunset) is likely associated with abstinence symptoms emerging among tobacco smokers. We assessed this hypothesis by measuring tobacco/nicotine abstinence symptoms and craving among smokers of cigarettes or waterpipes during Ramadan.


A cross-sectional survey-based study was conducted on a convenience sample of adults. Participants were assessed for general information about tobacco smoking, dependence, and nicotine desire or craving, and withdrawal symptoms using the Minnesota Nicotine Withdrawal Scale (MNWS) and the Tiffany-Drobes Questionnaire on Smoking Urges.


The study sample included 632 exclusive cigarette smokers and 161 exclusive waterpipe tobacco smokers. After fasting and abstaining from tobacco during the day, approximately 75% of cigarette smokers and 20% of waterpipe smokers reported smoking within the first 30 minutes. In addition, 10% of cigarette smokers and 30% of waterpipe smokers reported smoking within the first 60 minutes. Regarding smoking urge, no significant difference was found between cigarette and waterpipe smokers. For nicotine craving and withdrawal, significant differences between cigarette and waterpipe smokers were found when comparing mean scores for each of the following items: (i) urge to smoke, (ii) craving nicotine, (iii) hunger, (iv) desire for sweets, and (v) depression/feeling blue (P-values < 0.05).


This study provided evidence from the month of Ramadan that waterpipe smoking is associated with abstinence-induced smoking urge and withdrawal symptoms that are comparable to cigarette smoking. More interdisciplinary research must be focused on developing interventions to reduce tobacco smoking, including waterpipe.

Keywords: Smoking, Waterpipe, Cigarettes, Withdrawal symptoms, Ramadan, Natural environment.