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

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

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? Maziak, Rastam, Eissenberg et al., NTR, 2009 0 10 20 30 40 100 PrePost Time (relative to waterpipe smoking) Score Urge Restlessness Craving

7. Drug seeking behavior

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)

9. Factors related to level of waterpipe use Monthly OR (95%CI) Weekly OR (95%CI) Daily OR (95%CI) ref1.0 (0.5-2.0)3.3 (1.1-10.1) Gender (male) ref1.9 (0.5-8.3)6.7 (1.3-33.6) Smoking narghile mainly alone ref0.6 (0.3-1.2)0.3 (0.1-0.8) Share the same narghile ref4.3 (0.9-21.5)30.6 (5.2-179.6) Place of usual smoking (home) ref1.8 (0.8-3.9)6.8 (2.3-19.7) Smoke now more frequently than when started ref 2.5 (1.6-5.2) 4.1 (0.5-36.2) ref 3.8 (1.27-11.6) 42.2 (4.2-428.2) Hooked on narghile Not hooked Somehow hooked Very hooked ref1.9 (1.0-3.6)1.5 (0.6-4.2) Narghile is important for selecting cafe/restaurants ref2.3 (1.0-5.0)2.1 (0.7-6.2) Carry narghile with if needed Maziak, Ward, & Eissenberg, Drug and Alc Dep, 2004

10. Do you think you can quit smoking narghile anytime you want? p<.0001 Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

11. Made a quit attempt in past year Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

12. Are you interested in quitting narghile smoking? 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)2930 Male (%)9260 Years smoked WP (mean)96 Daily users (%)6120 “Hooked” on waterpipe Somewhat Very 42 13 40 14 Interested in quitting (%)4028 Believe can quit anytime (%)8286 “Protect health” is major reason to quit (%)8590

15. Correlates of interest in quitting waterpipe -- Syria VariableOdds Ratio95% CIp Years smoking0.920.87 - 0.99.0182 Increased use0.550.30 - 0.99.0475 Married2.301.24 - 4.24.0078 Family doesn ’ t smoke 2.041.12 - 3.72.0196 Family disapproves2.121.15 - 3.91.0159 Ward, Hammal et al., Nic Tob Research, 2005

16. Correlates of interest in quitting waterpipe -- Bahrain Variabletp Physician recommended quitting2.87.004 Non-Bahraini citizen3.30.001 Family hostile toward WP2.41.016 Not “hooked” on WP2.00.046 Borgan, Marhoon, & Whitford, Nic Tob Research, 2013

17. Correlates of interest in quitting waterpipe– Aleppo Household Survey VariableOdds Ratio 95% CIp Live in “informal” zone2.071.10-3.90.0235 Frequency of eating fruit0.650.49-0.86.0029 Interest in quitting cigarettes Non-Cigarette smokerREF Not interested in quitting cigs0.230.10-0.58.0016 Interested in quitting cigs2.031.10-3.76.0247 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

19. If we build it, will they come?

20. 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 minutes161.011.0 1-3 minutes121.4 (1.1, 1.8)14.4 (11.3, 17.5) 4-30 minutes201.9 (1.5, 2.3)18.8 (15.6, 22.0) 31-90 minutes163.0 (2.3, 3.8)26.5 (21.5, 31.4) 91-300 minutes163.2 (2.3, 4.6)28.4 (21.3, 35.5) > 300 minutes152.8 (2.0, 3.9)25.5 (19.2, 31.7) 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

25. Baseline characteristics Demographics Brief (n=23) Intensive (n=27) Men (%)9693 Age (mean, SD)30 (11)29 (8) High school grad (%)7158 Married (%)44 Muslim (%)8783 Asfar et al., under review

26. Baseline characteristics Tobacco Use Brief (n=23) Intensive (n=27) Age began smoking WP3129 Years smoking WP74 Daily WP user (%)7085 Carbon monoxide level (ppm)13 (19)16 (20) Very confident about quitting (%)4441 Past year quit attempt (%)7467 Quit for ≥ 1 month3530 Asfar et al., under review

27. Adherence and Retention Brief (n=23) Intensive (n=27) Completed all face-to-face sessions (%)7837 Completed all phone calls (%)3941 Completed all face-to-face sessions and phone calls (%) 2635 Completed 3 month f/u (%)8378 Asfar et al., under review

28. Process evaluation % Interventionist was helpful95 Program helpful67 Most helpful strategies Getting more active Receiving educational information Following “Rules of relapse” Getting social support 71 58 48 Preference for group counseling33 Preference for medication74 Asfar et al., under review

29. Cessation rates at 3-month f/u (self-report + CO < 10ppm) Brief (n=23) Intensive (n=27) p Continuous1718.61 Prolonged3041.31 7 day point prevalent304131 Asfar et al., under review Absolute effect size: 11% Relative effect size: 37% Power: 12% Sample size needed for 80% power (2-tailed, α=.05) : 466

30. Predictors of prolonged abstinence OR95% CI Demographics Age0.980.92-1.04 Married1.760.55-5.58 High School grad0.560.17-1.90 SES (Density index)1.120.62-2.02 Employed0.530.16-1.71 Muslim2.670.28-25.84 Tobacco Dependence WPs smoked/wk0.910.43-1.91 Years smoked1.030.92-1.16 Last year quit attempt0.450.14-1.49 Quit confidence2.740.78-9.61 Quit readiness1.290.92-1.82 Baseline withdrawal1.000.96-1.04

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. www.scts-sy.org Thank you! 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

34. Population-based data from Syria on interest in quitting WP Cross-sectional, population-based survey of 2038 adults in Aleppo, including 248 (12%) WP smokers Interested in quitting56% Made quit attempt in past year25% Perceiving quitting to be “not difficult”89% Friends/socializing is major obstacle to quitting69% Boredom/free time is major obstacle16%