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The School of Public   Health Kenneth D. Ward, PhD  University of Memphis, and The School of Public   Health Kenneth D. Ward, PhD  University of Memphis, and

The School of Public Health Kenneth D. Ward, PhD University of Memphis, and - PowerPoint Presentation

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The School of Public Health Kenneth D. Ward, PhD University of Memphis, and - PPT Presentation

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 2023 ID: 762631

quit quitting waterpipe ref quitting quit ref waterpipe narghile smoking tobacco review ward time interested behavioral control intensive minutes

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The School of Public Health Kenneth D. Ward, PhD University of Memphis, andSyrian 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 , MD University of Miami, and Syrian Center for Tobacco Studies

Goals Waterpipe dependence featuresAre waterpipe smokers interested in quitting?A pilot randomized trial of a behavioral cessation program Recommendations

DSM-IV nicotine dependence criteria ToleranceNicotine is often taken in larger amounts or over a longer period than was intended WithdrawalPersistent desire or unsuccessful efforts to cut down or control useGreat deal of time spent in activities to obtain nicotineImportant social, occupational, or recreational activities given up or reduced because of nicotineUse 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) Score Urge Restlessness Craving

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 Monthly 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 ref ref ref 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 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? p<.0001Ward, 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? 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)2930Male (%)92 60Years smoked WP (mean)96Daily users (%) 6120“Hooked” on waterpipe Somewhat Very 42134014 Interested in quitting (%)4028Believe can quit anytime (%) 8286 “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 Re search, 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 T ob 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 Demographicsgender, marital status, religion, educationPsychosocial social support, depressionHealth behaviorsvegetable intake, physical activity, sportsHealth conditionsoverall self-rated health, cancer, heart disease, respiratory diseasesWaterpipe usefrequency 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 treatmentAsfar et al., under review

Behavioral treatment strategy Education about health effects/consequencesSet specific quit dayStimulus control: quit ritual, social support, coping skills, physical activityContingency management: self-rewards Problem solving and relapse preventionAsfar et al., under review

Asfar et al., under review

Baseline characteristics Demographics Brief (n=23)Intensive (n=27)Men (%)9693Age (mean, SD)30 (11) 29 (8)High school grad (%)7158Married (%) 4444Muslim (%)87 83Asfar et al., under review

Baseline characteristics Tobacco Use Brief (n=23)Intensive (n=27)Age began smoking WP3129Years smoking WP7 4Daily WP user (%)7085Carbon monoxide level (ppm)13 (19)16 (20)Very confident about quitting (%) 4441Past year quit attempt (%) 7467Quit for ≥ 1 month35 30 Asfar et al., under review

Adherence and Retention Brief (n=23)Intensive (n=27)Completed all face-to-face sessions (%)7837Completed all phone calls (%)3941 Completed all face-to-face sessions and phone calls (%)2635Completed 3 month f/u (%)83 78Asfar et al., under review

Process evaluation % Interventionist was helpful95Program helpful67Most helpful strategies Getting more active Receiving educational information Following “Rules of relapse” Getting social support 71715848Preference for group counseling33Preference for medication 74Asfar et al., under review

Cessation rates at 3-month f/u (self-report + CO < 10ppm) Brief(n=23)Intensive(n=27)pContinuous1718.61Prolonged 3041.317 day point prevalent30 4131Asfar 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 abstinence OR 95% CIDemographics Age0.980.92-1.04 Married1.760.55-5.58 High School grad0.560.17-1.90 SES (Density index)1.12 0.62-2.02 Employed0.530.16-1.71 Muslim2.670.28-25.84Tobacco Dependence WPs smoked/wk0.91 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 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 treatmentTrain physicians to deliver brief interventionsTest pharmacotherapy

www.scts-sy.org Thank you! Radwan Al Ali, MDTaghrid Asfar, MDIman EbrahimTom Eissenberg, PhDMadonna EliasFouad Fouad, MD Wasim Maziak, MD, PhDFawaz Mzayek, MD, PhDSamer Rastam, MD, PhD

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 quitting 69%Boredom/free time is major obstacle16%