Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies

1. The School of PublicHealth What do we know about treatment for waterpipe addiction? TaghridAsfar, MD University of Miami, andSyrian Center for Tobacco Studies Kenneth D. Ward, PhD University of Memphis, andSyrian 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

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 narghilefor 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 0 Pre Post Time (relative to waterpipe smoking) Maziak, Rastam, Eissenberg et al., NTR, 2009

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”(Jawadet al., 2013)

9. Factors related to level of waterpipe use Maziak, Ward, & Eissenberg, Drug and AlcDep, 2004

10. Do you think you can quit smoking narghileanytime 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

15. Correlates of interest in quitting waterpipe -- Syria Ward, Hammal et al., NicTob Research, 2005

16. Correlates of interest in quitting waterpipe -- Bahrain Borgan, Marhoon, & Whitford, NicTob Research, 2013

17. Correlates of interest in quitting waterpipe– Aleppo Household Survey 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 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

25. Baseline characteristicsDemographics Asfar et al., under review

26. Baseline characteristicsTobacco Use Asfar et al., under review

27. Adherence and Retention Asfar et al., under review

28. Process evaluation Asfar et al., under review

29. Cessation rates at 3-month f/u(self-report + CO < 10ppm) 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

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! • Radwan Al Ali, MD • TaghridAsfar, MD • ImanEbrahim • Tom Eissenberg, PhD • Madonna Elias • FouadFouad, MD • Wasim Maziak, MD, PhD • FawazMzayek, MD, PhD • SamerRastam, MD, PhD www.scts-sy.org