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Acute tolerance to the cardiovascular effects of nicotine has long been known to occur105 and this effect has also been demonstrated in waterpipe smokers.63 ,74 That is, during waterpipe use, nicotine levels increase steadily over the first 25 min of a use episode, but heart rate increases are observed during the first 515 min only, and after that stabilise at a level that is higher than before smoking, but without continued increase.63 ,74 However, this acute effect is likely less relevant to dependence assessment than is an increased waterpipe use frequency over time, which has been reported in qualitative research99 as well as survey studies

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