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?

1st International Conference on Waterpipe Research, Oct 20-23rd, 2013, Abu Dhabi

Taghrid Asfar, MDUniversity of Miami, and

Syrian Center for Tobacco Studies

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

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?

Maziak, Rastam, Eissenberg et al., NTR, 2009

0

10

20

30

40

100

Pre Post

Time (relative to waterpipe smoking)

Scor

eUrgeRestlessnessCraving

Drug seeking behavior

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)

Factors related to level of waterpipe useMonthly

OR (95%CI)Weekly

OR (95%CI) Daily

OR (95%CI)

ref 1.0 (0.5-2.0) 3.3 (1.1-10.1) Gender (male)

ref 1.9 (0.5-8.3) 6.7 (1.3-33.6) Smoking narghile mainly alone

ref 0.6 (0.3-1.2) 0.3 (0.1-0.8) Share the same narghile

ref 4.3 (0.9-21.5) 30.6 (5.2-179.6) Place of usual smoking (home)

ref 1.8 (0.8-3.9) 6.8 (2.3-19.7) Smoke now more frequently than when started

refrefref

ref2.5 (1.6-5.2)

4.1 (0.5-36.2)

ref3.8 (1.27-11.6)

42.2 (4.2-428.2)

Hooked on narghileNot hookedSomehow hookedVery hooked

ref 1.9 (1.0-3.6) 1.5 (0.6-4.2) Narghile is important for selecting cafe/restaurants

ref 2.3 (1.0-5.0) 2.1 (0.7-6.2) Carry narghile with if needed

Maziak, Ward, & Eissenberg, Drug and Alc Dep, 2004

Do you think you can quit smoking narghile

anytime you want?

96 89.9

68.2

0

20

40

60

80

100

Monthly Weekly DailyFrequency of narghile use

%

p<.0001

Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

Made a quit attempt in past year

Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006

Are you interested in quitting narghile smoking?

33.8

29.5

20.3

0

5

10

15

20

25

30

35

40

Monthly Weekly DailyFrequency of narghile use

%

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 60Years smoked WP (mean) 9 6Daily users (%) 61 20“Hooked” on waterpipe

SomewhatVery

4213

4014

Interested in quitting (%) 40 28Believe can quit anytime (%) 82 86“Protect health” is major reason to quit (%) 85 90

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

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

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

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

If we build it, will they come?

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 16 3.0 (2.3, 3.8) 26.5 (21.5, 31.4)

91-300 minutes 16 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)

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

Baseline characteristicsDemographics

Brief (n=23)

Intensive (n=27)

Men (%) 96 93Age (mean, SD) 30 (11) 29 (8)High school grad (%) 71 58Married (%) 44 44Muslim (%) 87 83

Asfar et al., under review

Baseline characteristicsTobacco Use

Brief (n=23)

Intensive (n=27)

Age began smoking WP 31 29Years smoking WP 7 4Daily WP user (%) 70 85Carbon monoxide level (ppm) 13 (19) 16 (20)Very confident about quitting (%) 44 41Past year quit attempt (%) 74 67Quit for ≥ 1 month 35 30

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 78

Asfar et al., under review

Process evaluation%

Interventionist was helpful 95

Program helpful 67

Most helpful strategiesGetting more activeReceiving educational informationFollowing “Rules of relapse”Getting social support

71715848

Preference for group counseling 33

Preference for medication 74Asfar 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 .61Prolonged 30 41 .317 day point prevalent 30 41 31

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

Predictors of prolonged abstinenceOR 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

Prolonged Abstinence

EOT 6m 12m0

5

10

15

20

25

30

35

29.3

17.615.6

27.3

18.615.7 Nicotine

Placebo

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

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