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This effect may well occur, and one prospective study that investigated it in Jordanian youth (age 1316 years) suggests that tolerance may manifest itself not as increased waterpipe use but rather initiation and increasing use of tobacco cigarettes.106 If this form of cross-tolerance from waterpipe toward cigarettes is reliable and generalises to other populations, it further supports the idea that WTS is a grave and immediate public health threat

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While overall youth tobacco and nicotine use is declining, many of those who do use are showing troubling signs of dependence as illegal flavored, high-nicotine products surge, said Kathy Crosby, CEO and President of Truth Initiative