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
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.”
“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.”
(Jawad et al., IJTLD, 2013)
(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
Craving
Score
40
30
20
10
0
Pre
Post
Time (relative to waterpipe smoking)
Maziak, Rastam, Eissenberg et al., NTR, 2009
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 use
Daily
OR (95%CI)
Weekly
OR (95%CI)
Monthly
OR (95%CI)
Gender (male)
3.3 (1.1-10.1)
1.0 (0.5-2.0)
ref
Smoking narghile mainly alone
6.7 (1.3-33.6)
1.9 (0.5-8.3)
ref
0.3 (0.1-0.8)
0.6 (0.3-1.2)
ref
30.6 (5.2-179.6)
4.3 (0.9-21.5)
ref
6.8 (2.3-19.7)
1.8 (0.8-3.9)
ref
ref
3.8 (1.27-11.6)
42.2 (4.2-428.2)
ref
2.5 (1.6-5.2)
4.1 (0.5-36.2)
ref
ref
ref
Narghile is important for
selecting cafe/restaurants
1.5 (0.6-4.2)
1.9 (1.0-3.6)
ref
Carry narghile with if needed
2.1 (0.7-6.2)
2.3 (1.0-5.0)
ref
Share the same narghile
Place of usual smoking (home)
Smoke now more frequently than
when started
Hooked on narghile
Not hooked
Somehow hooked
Very hooked
Maziak, Ward, & Eissenberg, Drug and Alc Dep, 2004
Do you think you can quit smoking narghile
anytime you want?
p<.0001
100
96
89.9
80
68.2
%
60
40
20
0
Monthly
Weekly
Frequency of narghile use
Daily
Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006
Made a quit attempt in past year
90
76.9
80
70
60
56
55.3
%
50
40
30
20
10
0
Monthly
Weekly
Frequency of narghile use
Daily
Ward, Eissenberg, Rastam, et al., Tobacco Control, 2006
Are you interested in quitting
narghile smoking?
40
35
33.8
29.5
30
%
25
20.3
20
15
10
5
0
Monthly
Weekly
Frequency of narghile use
Daily
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 (%)
40
28
Believe 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), noncigarette 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 characteristics
Demographics
Men (%)
Age (mean, SD)
High school grad (%)
Married (%)
Muslim (%)
Brief
(n=23)
96
Intensive
(n=27)
93
30 (11)
71
44
29 (8)
58
44
87
83
Asfar et al., under review
Baseline characteristics
Tobacco Use
Age began smoking WP
Years smoking WP
Daily WP user (%)
Carbon monoxide level (ppm)
Very confident about quitting (%)
Past year quit attempt (%)
Quit for ≥ 1 month
Brief
(n=23)
31
7
70
13 (19)
44
74
35
Intensive
(n=27)
29
4
85
16 (20)
41
67
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 strategies
Getting more active
Receiving educational information
Following “Rules of relapse”
Getting social support
71
71
58
48
Preference for group counseling
33
Preference for medication
74
Asfar et al., under review
Cessation rates at 3-month f/u
(self-report + CO < 10ppm)
Continuous
Prolonged
7 day point prevalent
Brief
(n=23)
Intensive
(n=27)
p
17
30
30
18
41
41
.61
.31
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
OR
95% CI
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
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
Demographics
Tobacco Dependence
Prolonged Abstinence
35
30
29.3
25
27.3
20
18.6
17.6
15
15.7
15.6
Nicotine
Placebo
10
5
0
EOT
6m
12m
Ward, Asfar, Al Ali et al., Addiction, 2013
Summary
• “Low hanging fruit”: brief interventions for lessdependent 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!
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•
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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