1. 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

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

3. 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

4. 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)

5. 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

6. 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

7. Drug seeking behavior 7

8. 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

9. Factors related to level of waterpipe use
Monthly
OR (95%CI)
Weekly
Daily
ref
1.0 ( )
3.3 ( )
Gender (male)
1.9 ( )
6.7 ( )
Smoking narghile mainly alone
0.6 ( )
0.3 ( )
Share the same narghile
4.3 ( )
30.6 ( )
Place of usual smoking (home)
1.8 ( )
6.8 ( )
Smoke now more frequently than when started
2.5 ( )
4.1 ( )
3.8 ( )
42.2 ( )
Hooked on narghile
Not hooked
Somehow hooked
Very hooked
1.9 ( )
1.5 ( )
Narghile is important for selecting cafe/restaurants
2.3 ( )
2.1 ( )
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

10. 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

11. 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

12. 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

13. Which waterpipe smokers want to quit?

14. 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

15. Correlates of interest in quitting waterpipe -- Syria
Variable
Odds Ratio
95% CI p
Years smoking
0.92
.0182
Increased use
0.55
.0475
Married
2.30
.0078
Family doesn’t smoke
2.04
.0196
Family disapproves
2.12
.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

16. 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

17. Correlates of interest in quitting waterpipe– Aleppo Household Survey
Variable
Odds Ratio
95% CI p
Live in “informal” zone
2.07
.0235
Frequency of eating fruit
0.65
.0029
Interest in quitting cigarettes
Non-Cigarette smoker
REF
Not interested in quitting cigs
0.23
.0016
Interested in quitting cigs
2.03
.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

18. 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?

19. 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

20. 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)
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

21. 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

22. 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

23. Asfar et al., under review

24. 62% (81/131) were not interested in participating

25. 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

26. 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

27. 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

28. 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

29. 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

30. Predictors of prolonged abstinence
95% CI
Demographics
Age
0.98
Married
1.76
High School grad
0.56
SES (Density index)
1.12
Employed
0.53
Muslim
2.67
Tobacco Dependence
WPs smoked/wk
0.91
Years smoked
1.03
Last year quit attempt
0.45
Quit confidence
2.74
Quit readiness
1.29
Baseline withdrawal
1.00
Don’t strain your eyes too much

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

32. 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

33. 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