Understanding the Discrepancy in Addiction Awareness

Clinicians frequently encounter patients who minimize their tobacco use or deny having an addiction. A recent cross-sectional study in Lebanon highlights a significant gap regarding tobacco dependence self-perception among cigarette and waterpipe users. This phenomenon is particularly critical in culturally sensitive regions where social desirability heavily influences self-reported health behaviors. Consequently, many individuals who score high on clinical dependence scales still view themselves as non-dependent smokers.

The study, which enrolled 377 participants in early 2025, revealed that 10.6% of cigarette smokers and nearly 28.6% of waterpipe smokers did not perceive themselves as dependent. This underestimation was significantly more prominent among waterpipe users. Furthermore, researchers found that higher actual dependence levels were Paradoxically associated with a greater likelihood of underestimating that very addiction. Importantly, factors such as having more smokers at home and experiencing depression were strong predictors of this cognitive gap.

The Role of Social Desirability and Mental Health

Social desirability components, specifically reversed independent thinking, played a major role in how participants reported their habits. Specifically, individuals who prioritize social conformity may struggle to acknowledge their tobacco dependence self-perception accurately. Moreover, the study linked lower virtuous perfectionism in both genders to a higher likelihood of underestimating nicotine addiction. In female participants, the presence of depression was a specific marker for underestimating waterpipe dependence, while for males, living outside major urban centers like Beirut was a contributing factor.

Therefore, medical professionals should look beyond physical health metrics when discussing cessation. Psychological factors and cultural context are equally important. Addressing these social and psychological barriers can help patients develop the self-awareness necessary to seek help. Targeted public health campaigns should focus on challenging social conformity and encouraging patients to embrace the reality of their addiction without stigma.

Frequently Asked Questions

Why is waterpipe dependence underestimated more than cigarette dependence?

Waterpipe smoking is often perceived as a social activity rather than a chemical addiction. This cultural view, combined with social desirability, leads users to believe they can quit easily, even when clinical scales show high levels of dependence.

How does depression affect tobacco dependence self-perception?

Depression can complicate a patient's insight into their smoking habits. The study showed that individuals with depression were significantly more likely to underestimate their level of dependence, potentially using tobacco as a maladaptive coping mechanism while denying its addictive hold.

What should clinicians do to address this gap?

Healthcare providers should use validated dependence scales rather than relying solely on patient self-reports. Additionally, they should integrate mental health screenings and discuss the social influences of smoking to improve the patient's self-awareness during cessation counseling.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Refer to the latest local and national guidelines for clinical practice.

References

Karam D et al. Perceived vs. actual cigarette and waterpipe dependence in Lebanon: a cross-sectional study of social desirability across demographic subgroups. Arch Public Health. 2026 May 15. doi: 10.1186/s13690-026-01934-y. PMID: 42141494.

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2023. Geneva: World Health Organization; 2023.

Bainter T et al. A key indicator of nicotine dependence is associated with greater depression symptoms, after accounting for smoking behavior. PLoS ONE. 2020;15(5):e0233656. doi:10.1371/journal.pone.0233656.