What do we know about treatment for waterpipe addiction? The School of Public Health What do we know about treatment for waterpipe addiction? Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies Taghrid Asfar, MD University of Miami, and Syrian Center for Tobacco Studies 1st International Conference on Waterpipe Research, Oct 20-23rd, 2013, Abu Dhabi

Goals Waterpipe dependence features Are waterpipe smokers interested in quitting? A pilot randomized trial of a behavioral cessation program Recommendations

DSM-IV nicotine dependence criteria Tolerance Nicotine is often taken in larger amounts or over a longer period than was intended Withdrawal Persistent desire or unsuccessful efforts to cut down or control use Great deal of time spent in activities to obtain nicotine Important social, occupational, or recreational activities given up or reduced because of nicotine Use is continued despite knowledge of problems it causes What is ND according to DSM criteria? In DSM, ND is seen as a syndrome; it’s not either theoretically or empirically based 3 or more must occur at the same time within the past year

Tolerance: increased use with time “On holiday . . . I looked at my mum and said ‘Can I try it?’ Then I used to do it with my friends every once in a while, very rarely. When I got to university I started smoking it a little bit more. Then we got one in the flat and we started to do it a lot more.” (Jawad et al., IJTLD, 2013) “Due to the boredom of having free time, I used to go with my friends to a cafe. When they invited me to try narghile, I found it interesting and good. I felt some dizziness, but I enjoyed the taste and the smell. It was fun. And so I became a daily smoker.” (Hammal et al., Tobacco Control, 2008)

Withdrawal “I once tried to quit, but I could not manage without smoking narghile for more than 2 days. I felt the craving, and during those 2 days, I tried to fill my time with something else because as long as I had free time, I thought about the narghile.” Hammal, Mock, Ward, et al., Tobacco Control, 2008

Abstinence-induced withdrawal and craving? 100 Urge Restlessness 40 Craving 30 Score 20 10 M ethods: Sixty-one waterpipe tobacco smokers (56 males; mean age ± SD , 30.9 ± 9.5 years; mean number of weekly waterpipe smoking episodes, 7.8 ± 5.7; mean duration of waterpipe smoking 8.5 ± 6.1 years) abstained from smoking for at least 24 hr and then smoked tobacco from a waterpipe ad libitum in a laboratory. Before and after smoking, expired-air carbon monoxide (CO) and subjective effects were assessed; puff topography was measured during smoking. R esults: The mean waterpipe use episode duration was 33.1 ± 13.1 min. Expired-air CO increased signifi cantly from a mean of 4.0 ± 1.7 before to 35.5 ± 32.7 after smoking. On average, participants took 169 ± 100 puffs, with a mean puff volume of 511 ± 333 ml. Urge to smoke, restlessness, craving, and other tobacco abstinence symptoms were reduced signifi cantly after smoking, while ratings of dizzy, lightheaded, and other direct effects of nicotine increased. Pre Post Time (relative to waterpipe smoking) Maziak, Rastam, Eissenberg et al., NTR, 2009 6

Drug seeking behavior 7

Loss of autonomy, smoking cues “I like to dominate everything, but the narghile has completely dominated me. That bothers me. My happiness is related to the narghile.” (Hammal, et al., 2008) “When I’m walking from the train station to my house, I get a really nice smell of shisha flavors sometimes if the wind is blowing in the right direction” (Jawad et al., 2013) 8

Factors related to level of waterpipe use Monthly OR (95%CI) Weekly Daily ref 1.0 (0.5-2.0) 3.3 (1.1-10.1) Gender (male) 1.9 (0.5-8.3) 6.7 (1.3-33.6) Smoking narghile mainly alone 0.6 (0.3-1.2) 0.3 (0.1-0.8) Share the same narghile 4.3 (0.9-21.5) 30.6 (5.2-179.6) Place of usual smoking (home) 1.8 (0.8-3.9) 6.8 (2.3-19.7) Smoke now more frequently than when started 2.5 (1.6-5.2) 4.1 (0.5-36.2) 3.8 (1.27-11.6) 42.2 (4.2-428.2) Hooked on narghile Not hooked Somehow hooked Very hooked 1.9 (1.0-3.6) 1.5 (0.6-4.2) Narghile is important for selecting cafe/restaurants 2.3 (1.0-5.0) 2.1 (0.7-6.2) Carry narghile with if needed Wasim has already described the research base linking WP to dependence, and here is a table showing how several potential indictors of dependence are related to an important component of dependence, frequency of use. Maziak, Ward, & Eissenberg, Drug and Alc Dep, 2004

Do you think you can quit smoking narghile anytime you want? p<.0001 First, we were interested in users confidence in their ability to quit. To assess this, we asked “Do you think you can quit smoking narghile anytime you want?” Overall, 86.5% thought that they could quit anytime, but this differed according to frequency of use, with the vast majority (96%) of monthly users believing they could quit, compared to only 68% of daily users. Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

Made a quit attempt in past year Of those who expressed interest in quitting, 59% reported making a quit attempt, lasting at least one week, during the previous year. The average quit attempt last 10 weeks. And the likelihood that a quit attempt was made increases as frequency of use increases. Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

Are you interested in quitting narghile smoking? Overall, 28% of users were interested in quitting. Similar to confidence in ability to quit, interest in quitting was related to both the frequency of smoking and perceived dependence. While about 1/3 of monthly users were interested in quitting, only about 20% of daily users expressed interest. Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

Which waterpipe smokers want to quit?

Waterpipe user characteristics: Bahrain and Syria Bahrain (n=380) Syria (n=268) Age (mean, yrs) 29 30 Male (%) 92 60 Years smoked WP (mean) 9 6 Daily users (%) 61 20 “Hooked” on waterpipe Somewhat Very 42 13 40 14 Interested in quitting (%) 28 Believe can quit anytime (%) 82 86 “Protect health” is major reason to quit (%) 85 90 1. The Bahrain study used to same assessment devise as in our study, making comparison easy

Correlates of interest in quitting waterpipe -- Syria Variable Odds Ratio 95% CI p Years smoking 0.92 0.87 - 0.99 .0182 Increased use 0.55 0.30 - 0.99 .0475 Married 2.30 1.24 - 4.24 .0078 Family doesn’t smoke 2.04 1.12 - 3.72 .0196 Family disapproves 2.12 1.15 - 3.91 .0159 We examined which factors were related to interest in quitting narghile use in a logistic regression model. We first examined bivariate correlates, from several categories, including demographics, TU hx and patterns, exposure to others’ smoking, and family’s attitudes and behaviors related to wp smoking. Married smokers were about twice as likely to want to quit, as were Muslims (compared to Christians). Use history was inversely related to desire to quit– those who smoked for a greater number of years, and whose use had increased in frequency since beginning to smoke wp, were less likely to want to quit. In addition, individuals whose family members didn’t smoke and disapproved of wp smoking were more likely to want to quit. Ward, Hammal et al., Nic Tob Research, 2005

Correlates of interest in quitting waterpipe -- Bahrain Variable t p Physician recommended quitting 2.87 .004 Non-Bahraini citizen 3.30 .001 Family hostile toward WP 2.41 .016 Not “hooked” on WP 2.00 .046 We examined which factors were related to interest in quitting narghile use in a logistic regression model. We first examined bivariate correlates, from several categories, including demographics, TU hx and patterns, exposure to others’ smoking, and family’s attitudes and behaviors related to wp smoking. Married smokers were about twice as likely to want to quit, as were Muslims (compared to Christians). Use history was inversely related to desire to quit– those who smoked for a greater number of years, and whose use had increased in frequency since beginning to smoke wp, were less likely to want to quit. In addition, individuals whose family members didn’t smoke and disapproved of wp smoking were more likely to want to quit. Borgan, Marhoon, & Whitford, Nic Tob Research, 2013

Correlates of interest in quitting waterpipe– Aleppo Household Survey Variable Odds Ratio 95% CI p Live in “informal” zone 2.07 1.10-3.90 .0235 Frequency of eating fruit 0.65 0.49-0.86 .0029 Interest in quitting cigarettes Non-Cigarette smoker REF Not interested in quitting cigs 0.23 0.10-0.58 .0016 Interested in quitting cigs 2.03 1.10-3.76 .0247 We examined which factors were related to interest in quitting narghile use in a logistic regression model. We first examined bivariate correlates, from several categories, including demographics, TU hx and patterns, exposure to others’ smoking, and family’s attitudes and behaviors related to wp smoking. Married smokers were about twice as likely to want to quit, as were Muslims (compared to Christians). Use history was inversely related to desire to quit– those who smoked for a greater number of years, and whose use had increased in frequency since beginning to smoke wp, were less likely to want to quit. In addition, individuals whose family members didn’t smoke and disapproved of wp smoking were more likely to want to quit. Ward et al., under review

Variables NOT associated with interest in quitting WP Demographics gender, marital status, religion, education Psychosocial social support, depression Health behaviors vegetable intake, physical activity, sports Health conditions overall self-rated health, cancer, heart disease, respiratory diseases Waterpipe use frequency of use (daily vs. non-daily), perceived difficulty of quitting 1. What might our intervention “hook” be?

If we build it, will they come? So, WP users who seem to be most interested in quitting are those who are less dependent, have more family support (negative social support in the form of family members really not liking WP smoking), possibly more economically disadvantaged users, and those who have been encouraged to quit by their physicians. However, we decided to throw caution to the wind and develop a cessation program for WP smokers who met none of those characteristics Instead, we focused on the most needy: those who were heavily dependent and seemed to lack confidence about their ability to quit

Total amount of contact time Efficacy of Behavioral Counseling is Dose-dependent…at Least Up to a Point Total amount of contact time Number of arms Odds Ratio (95% C.I.) Abstinence Rate (95% C.I.) No minutes 16 1.0 11.0 1-3 minutes 12 1.4 (1.1, 1.8) 14.4 (11.3, 17.5) 4-30 minutes 20 1.9 (1.5, 2.3) 18.8 (15.6, 22.0) 31-90 minutes 3.0 (2.3, 3.8) 26.5 (21.5, 31.4) 91-300 minutes 3.2 (2.3, 4.6) 28.4 (21.3, 35.5) > 300 minutes 15 2.8 (2.0, 3.9) 25.5 (19.2, 31.7) You see the same dose-response relationship for the total # of minutes of tx—up to a point; Beyond 300 minutes there doesn’t seem to be any further gains in efficacy. Source: Fiore et al., 2000

Behavioral cessation treatment of waterpipe smoking: a pilot RCT 50 adult WP users (≥ 3 times/wk), non-cigarette smokers, interested in quitting Randomized to brief (1 session + 3 phone calls) or intensive (3 sessions + 5 phone calls) behavioral treatment Asfar et al., under review

Behavioral treatment strategy Education about health effects/consequences Set specific quit day Stimulus control: quit ritual, social support, coping skills, physical activity Contingency management: self-rewards Problem solving and relapse prevention Asfar et al., under review

Asfar et al., under review

62% (81/131) were not interested in participating

Baseline characteristics Demographics Brief (n=23) Intensive (n=27) Men (%) 96 93 Age (mean, SD) 30 (11) 29 (8) High school grad (%) 71 58 Married (%) 44 Muslim (%) 87 83 1. Age and gender distribution is similar to café studies Asfar et al., under review

Baseline characteristics Tobacco Use Brief (n=23) Intensive (n=27) Age began smoking WP 31 29 Years smoking WP 7 4 Daily WP user (%) 70 85 Carbon monoxide level (ppm) 13 (19) 16 (20) Very confident about quitting (%) 44 41 Past year quit attempt (%) 74 67 Quit for ≥ 1 month 35 30 1. Majority are daily users Asfar et al., under review

Adherence and Retention Brief (n=23) Intensive (n=27) Completed all face-to-face sessions (%) 78 37 Completed all phone calls (%) 39 41 Completed all face-to-face sessions and phone calls (%) 26 35 Completed 3 month f/u (%) 83 Asfar et al., under review

Process evaluation Interventionist was helpful 95 Program helpful 67 % Interventionist was helpful 95 Program helpful 67 Most helpful strategies Getting more active Receiving educational information Following “Rules of relapse” Getting social support 71 58 48 Preference for group counseling 33 Preference for medication 74 While 70% received support from families, only 22% received support from friends Asfar et al., under review

Cessation rates at 3-month f/u (self-report + CO < 10ppm) Brief (n=23) Intensive (n=27) p Continuous 17 18 .61 Prolonged 30 41 .31 7 day point prevalent 31 Absolute effect size: 11% Relative effect size: 37% Power: 12% Sample size needed for 80% power (2-tailed, α=.05) : 466 Asfar et al., under review

Predictors of prolonged abstinence 95% CI Demographics Age 0.98 0.92-1.04 Married 1.76 0.55-5.58 High School grad 0.56 0.17-1.90 SES (Density index) 1.12 0.62-2.02 Employed 0.53 0.16-1.71 Muslim 2.67 0.28-25.84 Tobacco Dependence WPs smoked/wk 0.91 0.43-1.91 Years smoked 1.03 0.92-1.16 Last year quit attempt 0.45 0.14-1.49 Quit confidence 2.74 0.78-9.61 Quit readiness 1.29 0.92-1.82 Baseline withdrawal 1.00 0.96-1.04 Don’t strain your eyes too much

Prolonged Abstinence Ward, Asfar, Al Ali et al., Addiction, 2013

Summary “Low hanging fruit”: brief interventions for less-dependent smokers who have good family support, and dual tobacco users who want to quit all tobacco For heavily dependent smokers, short-term quit rates in our behavioral treatment program were reasonable, but and there was no evidence that a more intensive behavioral program was more helpful than brief treatment Train physicians to deliver brief interventions Test pharmacotherapy

Thank you! www.scts-sy.org Radwan Al Ali, MD Taghrid Asfar, MD Iman Ebrahim Tom Eissenberg, PhD Madonna Elias Fouad Fouad, MD Wasim Maziak, MD, PhD Fawaz Mzayek, MD, PhD Samer Rastam, MD, PhD www.scts-sy.org