Drug and Alcohol Dependence 153 (2015) 14–21
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Review
Waterpipe tobacco smoking: The critical need for cessation treatment Kenneth D. Ward a,b,∗ , Kamran Siddiqi c , Jasjit S. Ahluwalia d , Adam C. Alexander a , Taghrid Asfar b,e a
School of Public Health, University of Memphis, 201 Robison Hall, Memphis, TN 38152-3450, United States Syrian Center for Tobacco Studies, Tishreen Street, Sheehan, PO Box: 16542, Aleppo, Syria Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington York YO10 5DD, England, United Kingdom d Rutgers School of Public Health, The State University of New Jersey, 683 Hoes Lane West, Room 235, Piscataway, NJ 08854, United States e Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Suite 912, Miami, FL 33136, United States b c
a r t i c l e
i n f o
Article history: Received 17 December 2014 Received in revised form 27 April 2015 Accepted 18 May 2015 Available online 27 May 2015 Keywords: Waterpipe Cessation Intervention development Review
a b s t r a c t Background: Waterpipe use has spread globally, and has substantial negative health effects and nicotine dependence potential. A growing literature addresses cessation-related experiences of waterpipe users, but this literature has not been summarized nor is guidance available on developing and testing cessation interventions. Method: Authors gathered key empirical papers on waterpipe cessation-related topics, including observational studies about users’ perceived ability to quit, interest in quitting, quit rates, and cessation trials. Based on this review, recommendations are made to guide the development and rigorous evaluation of waterpipe cessation interventions. Results: Many users want to quit and make quit attempts, but are unsuccessful at doing so on their own; therefore, developing and testing waterpipe cessation interventions should be a priority for global tobacco control efforts. Early efforts have tested waterpipe cessation interventions designed for, or adapted from, cigarette smoking programs. Conclusions: Waterpipe-specific cessation programs that address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit are needed. Recommendations are provided to move waterpipe cessation intervention development forward. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 What we know, and don’t know, about waterpipe cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1. Subjective factors related to cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.1.1. Perceived ability to quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.1.2. Interest in quitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.2. Quit rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.3. Cessation interventions for waterpipe smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.1. Goals for waterpipe cessation should align with the mandates of article 14 of the framework convention on tobacco control (FCTC; http://www.who.int/fctc/guidelines/adopted/article 14/en/). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.2. Existing healthcare delivery systems should serve as a launch pad for implementing waterpipe cessation services. . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3. Waterpipe-specific behavioral and pharmacologic cessation methods should be rigorously tested. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
∗ Corresponding author at: The University of Memphis, School of Public Health, Division of Social and Behavioral Sciences, Memphis, TN 38152, United States. Tel.: +1 901 678 1702; fax: +1 901 678 1715. E-mail address: [email protected] (K.D. Ward). http://dx.doi.org/10.1016/j.drugalcdep.2015.05.029 0376-8716/© 2015 Elsevier Ireland Ltd. All rights reserved.
K.D. Ward et al. / Drug and Alcohol Dependence 153 (2015) 14–21
15
3.4. Identify and target high-risk populations for intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.5. Develop and test psychometrically sound instruments to evaluate dependence in waterpipe smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.6. Standardize the reporting of outcomes in waterpipe cessation trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Author disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1. Introduction Waterpipe (also known as hookah, shisha, and narghile) is a centuries-old method of smoking tobacco with origins in the Middle East and Indian sub-continent (Maziak et al., 2004). Waterpipe use declined throughout most of the twentieth century, but surged in these regions during the 1990s (Rastam et al., 2004; Ray, 2009), driven by the invention of flavored and easier-to-use tobacco, a growing café culture, and expanding internet availability and globalization (Maziak et al., 2015). Waterpipe use has now spread to most of the world, and is particularly popular among young people (Akl et al., 2011; Maziak et al., 2015). For example, among a sample of over 105,000 students from 152 universities in the United States (U.S.), 30.5% had ever used a waterpipe, and 8.4% had done so within the past month (Primack et al., 2012). Among young people, waterpipe use has rapidly become the most popular form of tobacco (second only to cigarettes) in the U.S., and is now more popular than cigarettes in several Middle East countries, including Lebanon and Jordan (Akl et al., 2011; Alzyoud et al., 2013; Mzayek et al., 2012; Tamim et al., 2007; Zoughib et al., 2004). Despite common perceptions that waterpipe is less harmful than cigarettes (Akl et al., 2013), waterpipe delivers large amounts of toxicants, and is associated with many of the same adverse health outcomes as cigarette smoking (Akl et al., 2010). Compared to smoking a single cigarette, a single waterpipe session produces levels of expired carbon monoxide (CO) and blood carboxyhemoglobin that are eight and three times higher, respectively (Eissenberg and Shihadeh, 2009). Similarly, during a waterpipe session, levels of carcinogenic polycyclic aromatic hydrocarbons and lung-damaging aldehydes are 3–200 and 4–27 times higher, respectively, compared to smoking a single cigarette (Gmeiner et al., 1997; Rashidi et al., 2008; Sepetdjian et al., 2008), and waterpipe users have 5–10 times greater urinary concentrations of the carcinogenic tobacco-specific nitrosamines derivative 4-(methylnitrosamino)1-(3-pyridyl)-1-butanol (NNAL) than cigarette smokers (Ali et al., 2013). Consistent with these data, there is growing evidence that waterpipe use is associated with significant lung cancer, respiratory illnesses, coronary heart disease, low birth weight, and periodontal disease (Akl et al., 2010; Sibai et al., 2014). Waterpipe delivers substantial amounts of nicotine, raising concerns about dependence potential. A typical waterpipe smoking session delivers 1.7 times the nicotine dose of a single cigarette (Eissenberg and Shihadeh, 2009), and the nicotine absorption rate in daily waterpipe users is equivalent to smoking 10 cigarettes/day (Neegaard et al., 2007). Such high levels of nicotine exposure raise concerns about nicotine dependency among young people, leading to progressively increased waterpipe use and/or a switch to cigarettes. However, research shows that waterpipe progression varies by country. While most waterpipe users in U.S. colleges maintain low levels of use over time (51% continue to use waterpipe four years later, but only infrequently and/or in social occasions; Dugas et al., 2014), a sizeable proportion of users in other countries such as Syria and Jordan increase their consumption over time. For
example, in Syria, 43% established waterpipe smokers reported that their use had increased over time (Maziak et al., 2004). A similar increase was found among Jordanian students; those who ever smoked waterpipe (non-daily) in 7th grade gained 40% cumulative hazard probability for progression in frequency of use by the time they reached 10th grade (Jaber et al., In Press). Greater frequency of waterpipe use is associated with many signs of dependence. In a study of established waterpipe users (six years or over) in Syria, frequency of use was positively associated with participant’s subjective judgment of their dependency on waterpipe, as well as other related behaviors: smoking alone versus with others, smoking mainly at home versus outside, smoking more frequently since initiation, carrying waterpipe with them in case it is “needed,” and considering access to waterpipe while choosing cafes or restaurants (Maziak et al., 2004, 2005). Furthermore, in a laboratory study, waterpipe users who smoked for at least six months and an average of 5.2 times/week, experienced withdrawal symptoms while abstaining (Rastam et al., 2011), and relief while smoking (Maziak et al., 2009; Rastam et al., 2011). In another lab study, a sample of established waterpipe smokers (had smoked eight years or over) who abstained for 24 hours and then smoked waterpipe ad libitum, reported that their urge to smoke, craving, and restlessness were relieved after smoking, while the effects of nicotine increased, including dizziness, nausea, and lightheadedness (Maziak et al., 2009). Among dual waterpipe/cigarette smokers, waterpipe smoking suppresses abstinence-induced withdrawal and craving comparable to cigarettes (Rastam et al., 2011). In sum, waterpipe use is a growing phenomenon associated with significant toxicant exposure and numerous health risks, leading to dependence and increased use in a sizeable proportion of users. These findings indicate the pressing need to develop a knowledge base about how to assist waterpipe users in quitting.
2. What we know, and don’t know, about waterpipe cessation Despite the rapid rise in waterpipe use globally, and its potential for harm and addiction, there is only a small, but growing, body of literature on whether waterpipe users are confident in their ability to quit, interested in quitting, likely to make a quit attempt, and succeed in doing so. To identify published articles on these topics, we searched several research databases, including PubMed, PsychINFO, CINAHL, and OmniFile Full Text Mega, combining search strings for tobacco use method (waterpipe or shisha or hookah or narghile or arghile or goza or hubble bubble) and topical area (cessation or treatment or intervention or program or quit or quitting or confidence or motivation or interest). We supplemented this with searches of relevant reviews (Akl et al., 2011, 2013, 2015; Maziak et al., 2015) and reference sections of empirical articles. Below, we review the literature on subjective factors related to waterpipe cessation, quit rates, and cessation interventions.
16
K.D. Ward et al. / Drug and Alcohol Dependence 153 (2015) 14–21
2.1. Subjective factors related to cessation 2.1.1. Perceived ability to quit. A consistent finding across populations is that most waterpipe users are very confident about their ability to quit. A recent systematic review (Akl et al., 2013) reports high levels of confidence (79% to 98%) among young waterpipe users in their ability to quit smoking at any time, across five study samples in the U.S. and Middle East. In a population-based study of Syrian adults, 89% of waterpipe users perceive quitting being “not difficult” (Ward et al., 2006). Dual smokers consider waterpipe easier to quit than cigarettes (Ward et al., 2005). Belief in one’s ability to quit, however, is inversely related to frequency of use. Among Syrian waterpipe users, 96% of monthly and 90% of weekly users thought they could quit anytime, compared to 68% of daily users (Maziak et al., 2004).
zones” (OR = 2.07; 95% CI = 1.10–3.90), and eat less fruit (OR = 0.65; CI = 0.49–0.86). Compared to non-cigarette smokers, dual smokers who did not want to quit cigarettes were less likely to want to quit waterpipe (OR = 0.24; CI = 0.10–0.58). Collectively, these data indicate that waterpipe users who are beginners, less nicotine dependent, and from lower socioeconomic backgrounds are more interested in quitting. Family disapproval of waterpipe and physician advice to quit also appears to motivate interest in quitting. Because motivational factors are important determinants of cessation, it is concerning that interest in quitting is considerably lower than what is observed for cigarette smokers. This may reflect knowledge deficits about the health effects and dependence potential of waterpipe, therefore requiring greater health education efforts. 2.2. Quit rates
2.1.2. Interest in quitting. Interest in quitting waterpipe varies considerably across populations, but is consistently lower than the commonly reported 65–75% of cigarette smokers who are interested in quitting (Centers for Disease Control and Prevention (CDC), 2011; Ward et al., 2006; Yong et al., 2014). Akl and colleague’s recent systematic review (2013) indicated that 26–53% of waterpipe users in the U.S. and 21–64% in the Middle East were interested in quitting. Among randomly sampled waterpipe café customers in Aleppo, Syria, 28% were interested in quitting, and 59% made an unsuccessful quit attempt in the previous year (Ward et al., 2005). In a population-based sample of adults in Syria, 56% of waterpipe users were interested in quitting, and 25% made a quit attempt in the past year (Ward et al., 2006). Among Pakistani youths, 32% wanted to quit, and 28% attempted to do so (Anjum et al., 2008). Among those who want to quit, health was the most commonly cited reason. For example, among randomly selected waterpipe users in cafes in Syria, 89% cited protecting their own and their family’s health (14%) as the primary motivator to quit (Ward et al., 2005). Similarly, among Bahraini waterpipe customers, 85% cited personal or family health as the major reason for wanting to quit (Borgan et al., 2013). Consistent with the finding that a majority of waterpipe users believe they can quit at any time; most users do not anticipate any challenges to quitting. Among established waterpipe smokers in Syria, 62% reported having no challenges if they wanted to quit. Among those who anticipated challenges, the main challenges reported were coping with boredom (24%), socializing with smoking friends (21%), and coping with the habit (17%; Ward et al., 2005). Among Arab-American tobacco users in Richmond, Virginia, waterpipe users were less likely to report addiction as a barrier to cessation compared to cigarette smokers (Haddad et al., 2014). Few studies have examined characteristics of waterpipe users who are interested in quitting. Asfar et al. (2005) found that beginners (university students, mean age 22 yrs.) were more likely than established users (adults recruited from cafes, mean age 30 yrs.) to report interest in quitting (41% vs. 28%, respectively). Similarly, in the Syria waterpipe café study discussed above (Ward et al., 2005), interest in quitting was associated with not having increased frequency of use over time, being married, and having family members who did not use waterpipe or disapproved of it. Among randomly sampled Bahraini waterpipe café customers, 40% were interested in quitting; independent correlates of interest in quitting included receiving physician’s advice to quit, being non-Bahraini, having a family with a hostile attitude toward waterpipe smoking, and not considering oneself “hooked” on waterpipe tobacco (Borgan et al., 2013). Among a population-based sample of Syrian adults (Ward, unpublished observations, 2015), those interested in quitting were more likely to live in economically deprived “informal
To our knowledge, only one population-based study has examined quit rates for waterpipe smoking. Among a representative sample of adults in Aleppo, Syria, 28% of ever waterpipe smokers had quit compared to 16% of ever cigarette smokers. Older and lower socioeconomic status waterpipe smokers were more likely to quit (Ward et al., 2006). 2.3. Cessation interventions for waterpipe smokers Cessation interventions for waterpipe smokers are in their infancy. A Cochrane review in 2007 was unable to identify any published waterpipe cessation trials (Maziak et al., 2007). Since then, two relevant trials have been published (Asfar et al., 2014; Dogar et al., 2014; Siddiqi et al., 2013). Asfar et al. (2014) developed a clinic-based behavioral cessation program for waterpipe users, and evaluated its feasibility and efficacy in a pilot, two-arm, parallel group, randomized, open label trial in Aleppo, Syria. Fifty adults who smoked waterpipe ≥3 times per week in the last year, and did not smoke cigarettes, were randomized to receive either brief (1 in-person 45-min educational/counseling session and 3 follow-up phone calls) or intensive (3 in-person 45-min educational/counseling sessions and 5 followup phone calls) behavioral cessation treatment delivered by a trained physician. The behavioral intervention, based on best practice cessation interventions for cigarette smokers (Fiore et al., 2008), was adapted for the Syrian context (Asfar et al., 2008; Ward et al., 2013). The brief arm included one session where participants were educated about the health effects of waterpipe use, encouraged to set a quit date, and taught basic stimulus control and contingency management strategies to quit and prevent relapse. Stimulus control strategies included engaging in a “quitting ritual” involving disposing of smoking cues, such as waterpipe and charcoals, the night before the quit attempt. Contingency management strategies included self-rewards, relaxation, and building social support. In addition to the in-person counseling sessions, participants received 10-min phone calls to review behavioral strategies and quitting ritual, and to problem-solve early relapse. In the “intensive” arm, participants received in addition to the above, five brief (10 min) phone calls counseling in problem solving. This included instruction and practice in anticipating high-risk situations, devising relapse prevention plans, and using cognitive and behavioral coping strategies, self-rewards, and social support. The first call was conducted one day before the quit day and the other calls at 1, 10, 21, and 30 days after the quit day. The primary efficacy outcome was prolonged abstinence at 3month post-quit day, assessed by self-report validated by exhaled carbon monoxide levels of
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
Review
Waterpipe tobacco smoking: The critical need for cessation treatment Kenneth D. Ward a,b,∗ , Kamran Siddiqi c , Jasjit S. Ahluwalia d , Adam C. Alexander a , Taghrid Asfar b,e a
School of Public Health, University of Memphis, 201 Robison Hall, Memphis, TN 38152-3450, United States Syrian Center for Tobacco Studies, Tishreen Street, Sheehan, PO Box: 16542, Aleppo, Syria Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington York YO10 5DD, England, United Kingdom d Rutgers School of Public Health, The State University of New Jersey, 683 Hoes Lane West, Room 235, Piscataway, NJ 08854, United States e Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Suite 912, Miami, FL 33136, United States b c
a r t i c l e
i n f o
Article history: Received 17 December 2014 Received in revised form 27 April 2015 Accepted 18 May 2015 Available online 27 May 2015 Keywords: Waterpipe Cessation Intervention development Review
a b s t r a c t Background: Waterpipe use has spread globally, and has substantial negative health effects and nicotine dependence potential. A growing literature addresses cessation-related experiences of waterpipe users, but this literature has not been summarized nor is guidance available on developing and testing cessation interventions. Method: Authors gathered key empirical papers on waterpipe cessation-related topics, including observational studies about users’ perceived ability to quit, interest in quitting, quit rates, and cessation trials. Based on this review, recommendations are made to guide the development and rigorous evaluation of waterpipe cessation interventions. Results: Many users want to quit and make quit attempts, but are unsuccessful at doing so on their own; therefore, developing and testing waterpipe cessation interventions should be a priority for global tobacco control efforts. Early efforts have tested waterpipe cessation interventions designed for, or adapted from, cigarette smoking programs. Conclusions: Waterpipe-specific cessation programs that address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit are needed. Recommendations are provided to move waterpipe cessation intervention development forward. © 2015 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 What we know, and don’t know, about waterpipe cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1. Subjective factors related to cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.1.1. Perceived ability to quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.1.2. Interest in quitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.2. Quit rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 2.3. Cessation interventions for waterpipe smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.1. Goals for waterpipe cessation should align with the mandates of article 14 of the framework convention on tobacco control (FCTC; http://www.who.int/fctc/guidelines/adopted/article 14/en/). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.2. Existing healthcare delivery systems should serve as a launch pad for implementing waterpipe cessation services. . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3. Waterpipe-specific behavioral and pharmacologic cessation methods should be rigorously tested. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
∗ Corresponding author at: The University of Memphis, School of Public Health, Division of Social and Behavioral Sciences, Memphis, TN 38152, United States. Tel.: +1 901 678 1702; fax: +1 901 678 1715. E-mail address: [email protected] (K.D. Ward). http://dx.doi.org/10.1016/j.drugalcdep.2015.05.029 0376-8716/© 2015 Elsevier Ireland Ltd. All rights reserved.
K.D. Ward et al. / Drug and Alcohol Dependence 153 (2015) 14–21
15
3.4. Identify and target high-risk populations for intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.5. Develop and test psychometrically sound instruments to evaluate dependence in waterpipe smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.6. Standardize the reporting of outcomes in waterpipe cessation trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Author disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1. Introduction Waterpipe (also known as hookah, shisha, and narghile) is a centuries-old method of smoking tobacco with origins in the Middle East and Indian sub-continent (Maziak et al., 2004). Waterpipe use declined throughout most of the twentieth century, but surged in these regions during the 1990s (Rastam et al., 2004; Ray, 2009), driven by the invention of flavored and easier-to-use tobacco, a growing café culture, and expanding internet availability and globalization (Maziak et al., 2015). Waterpipe use has now spread to most of the world, and is particularly popular among young people (Akl et al., 2011; Maziak et al., 2015). For example, among a sample of over 105,000 students from 152 universities in the United States (U.S.), 30.5% had ever used a waterpipe, and 8.4% had done so within the past month (Primack et al., 2012). Among young people, waterpipe use has rapidly become the most popular form of tobacco (second only to cigarettes) in the U.S., and is now more popular than cigarettes in several Middle East countries, including Lebanon and Jordan (Akl et al., 2011; Alzyoud et al., 2013; Mzayek et al., 2012; Tamim et al., 2007; Zoughib et al., 2004). Despite common perceptions that waterpipe is less harmful than cigarettes (Akl et al., 2013), waterpipe delivers large amounts of toxicants, and is associated with many of the same adverse health outcomes as cigarette smoking (Akl et al., 2010). Compared to smoking a single cigarette, a single waterpipe session produces levels of expired carbon monoxide (CO) and blood carboxyhemoglobin that are eight and three times higher, respectively (Eissenberg and Shihadeh, 2009). Similarly, during a waterpipe session, levels of carcinogenic polycyclic aromatic hydrocarbons and lung-damaging aldehydes are 3–200 and 4–27 times higher, respectively, compared to smoking a single cigarette (Gmeiner et al., 1997; Rashidi et al., 2008; Sepetdjian et al., 2008), and waterpipe users have 5–10 times greater urinary concentrations of the carcinogenic tobacco-specific nitrosamines derivative 4-(methylnitrosamino)1-(3-pyridyl)-1-butanol (NNAL) than cigarette smokers (Ali et al., 2013). Consistent with these data, there is growing evidence that waterpipe use is associated with significant lung cancer, respiratory illnesses, coronary heart disease, low birth weight, and periodontal disease (Akl et al., 2010; Sibai et al., 2014). Waterpipe delivers substantial amounts of nicotine, raising concerns about dependence potential. A typical waterpipe smoking session delivers 1.7 times the nicotine dose of a single cigarette (Eissenberg and Shihadeh, 2009), and the nicotine absorption rate in daily waterpipe users is equivalent to smoking 10 cigarettes/day (Neegaard et al., 2007). Such high levels of nicotine exposure raise concerns about nicotine dependency among young people, leading to progressively increased waterpipe use and/or a switch to cigarettes. However, research shows that waterpipe progression varies by country. While most waterpipe users in U.S. colleges maintain low levels of use over time (51% continue to use waterpipe four years later, but only infrequently and/or in social occasions; Dugas et al., 2014), a sizeable proportion of users in other countries such as Syria and Jordan increase their consumption over time. For
example, in Syria, 43% established waterpipe smokers reported that their use had increased over time (Maziak et al., 2004). A similar increase was found among Jordanian students; those who ever smoked waterpipe (non-daily) in 7th grade gained 40% cumulative hazard probability for progression in frequency of use by the time they reached 10th grade (Jaber et al., In Press). Greater frequency of waterpipe use is associated with many signs of dependence. In a study of established waterpipe users (six years or over) in Syria, frequency of use was positively associated with participant’s subjective judgment of their dependency on waterpipe, as well as other related behaviors: smoking alone versus with others, smoking mainly at home versus outside, smoking more frequently since initiation, carrying waterpipe with them in case it is “needed,” and considering access to waterpipe while choosing cafes or restaurants (Maziak et al., 2004, 2005). Furthermore, in a laboratory study, waterpipe users who smoked for at least six months and an average of 5.2 times/week, experienced withdrawal symptoms while abstaining (Rastam et al., 2011), and relief while smoking (Maziak et al., 2009; Rastam et al., 2011). In another lab study, a sample of established waterpipe smokers (had smoked eight years or over) who abstained for 24 hours and then smoked waterpipe ad libitum, reported that their urge to smoke, craving, and restlessness were relieved after smoking, while the effects of nicotine increased, including dizziness, nausea, and lightheadedness (Maziak et al., 2009). Among dual waterpipe/cigarette smokers, waterpipe smoking suppresses abstinence-induced withdrawal and craving comparable to cigarettes (Rastam et al., 2011). In sum, waterpipe use is a growing phenomenon associated with significant toxicant exposure and numerous health risks, leading to dependence and increased use in a sizeable proportion of users. These findings indicate the pressing need to develop a knowledge base about how to assist waterpipe users in quitting.
2. What we know, and don’t know, about waterpipe cessation Despite the rapid rise in waterpipe use globally, and its potential for harm and addiction, there is only a small, but growing, body of literature on whether waterpipe users are confident in their ability to quit, interested in quitting, likely to make a quit attempt, and succeed in doing so. To identify published articles on these topics, we searched several research databases, including PubMed, PsychINFO, CINAHL, and OmniFile Full Text Mega, combining search strings for tobacco use method (waterpipe or shisha or hookah or narghile or arghile or goza or hubble bubble) and topical area (cessation or treatment or intervention or program or quit or quitting or confidence or motivation or interest). We supplemented this with searches of relevant reviews (Akl et al., 2011, 2013, 2015; Maziak et al., 2015) and reference sections of empirical articles. Below, we review the literature on subjective factors related to waterpipe cessation, quit rates, and cessation interventions.
16
K.D. Ward et al. / Drug and Alcohol Dependence 153 (2015) 14–21
2.1. Subjective factors related to cessation 2.1.1. Perceived ability to quit. A consistent finding across populations is that most waterpipe users are very confident about their ability to quit. A recent systematic review (Akl et al., 2013) reports high levels of confidence (79% to 98%) among young waterpipe users in their ability to quit smoking at any time, across five study samples in the U.S. and Middle East. In a population-based study of Syrian adults, 89% of waterpipe users perceive quitting being “not difficult” (Ward et al., 2006). Dual smokers consider waterpipe easier to quit than cigarettes (Ward et al., 2005). Belief in one’s ability to quit, however, is inversely related to frequency of use. Among Syrian waterpipe users, 96% of monthly and 90% of weekly users thought they could quit anytime, compared to 68% of daily users (Maziak et al., 2004).
zones” (OR = 2.07; 95% CI = 1.10–3.90), and eat less fruit (OR = 0.65; CI = 0.49–0.86). Compared to non-cigarette smokers, dual smokers who did not want to quit cigarettes were less likely to want to quit waterpipe (OR = 0.24; CI = 0.10–0.58). Collectively, these data indicate that waterpipe users who are beginners, less nicotine dependent, and from lower socioeconomic backgrounds are more interested in quitting. Family disapproval of waterpipe and physician advice to quit also appears to motivate interest in quitting. Because motivational factors are important determinants of cessation, it is concerning that interest in quitting is considerably lower than what is observed for cigarette smokers. This may reflect knowledge deficits about the health effects and dependence potential of waterpipe, therefore requiring greater health education efforts. 2.2. Quit rates
2.1.2. Interest in quitting. Interest in quitting waterpipe varies considerably across populations, but is consistently lower than the commonly reported 65–75% of cigarette smokers who are interested in quitting (Centers for Disease Control and Prevention (CDC), 2011; Ward et al., 2006; Yong et al., 2014). Akl and colleague’s recent systematic review (2013) indicated that 26–53% of waterpipe users in the U.S. and 21–64% in the Middle East were interested in quitting. Among randomly sampled waterpipe café customers in Aleppo, Syria, 28% were interested in quitting, and 59% made an unsuccessful quit attempt in the previous year (Ward et al., 2005). In a population-based sample of adults in Syria, 56% of waterpipe users were interested in quitting, and 25% made a quit attempt in the past year (Ward et al., 2006). Among Pakistani youths, 32% wanted to quit, and 28% attempted to do so (Anjum et al., 2008). Among those who want to quit, health was the most commonly cited reason. For example, among randomly selected waterpipe users in cafes in Syria, 89% cited protecting their own and their family’s health (14%) as the primary motivator to quit (Ward et al., 2005). Similarly, among Bahraini waterpipe customers, 85% cited personal or family health as the major reason for wanting to quit (Borgan et al., 2013). Consistent with the finding that a majority of waterpipe users believe they can quit at any time; most users do not anticipate any challenges to quitting. Among established waterpipe smokers in Syria, 62% reported having no challenges if they wanted to quit. Among those who anticipated challenges, the main challenges reported were coping with boredom (24%), socializing with smoking friends (21%), and coping with the habit (17%; Ward et al., 2005). Among Arab-American tobacco users in Richmond, Virginia, waterpipe users were less likely to report addiction as a barrier to cessation compared to cigarette smokers (Haddad et al., 2014). Few studies have examined characteristics of waterpipe users who are interested in quitting. Asfar et al. (2005) found that beginners (university students, mean age 22 yrs.) were more likely than established users (adults recruited from cafes, mean age 30 yrs.) to report interest in quitting (41% vs. 28%, respectively). Similarly, in the Syria waterpipe café study discussed above (Ward et al., 2005), interest in quitting was associated with not having increased frequency of use over time, being married, and having family members who did not use waterpipe or disapproved of it. Among randomly sampled Bahraini waterpipe café customers, 40% were interested in quitting; independent correlates of interest in quitting included receiving physician’s advice to quit, being non-Bahraini, having a family with a hostile attitude toward waterpipe smoking, and not considering oneself “hooked” on waterpipe tobacco (Borgan et al., 2013). Among a population-based sample of Syrian adults (Ward, unpublished observations, 2015), those interested in quitting were more likely to live in economically deprived “informal
To our knowledge, only one population-based study has examined quit rates for waterpipe smoking. Among a representative sample of adults in Aleppo, Syria, 28% of ever waterpipe smokers had quit compared to 16% of ever cigarette smokers. Older and lower socioeconomic status waterpipe smokers were more likely to quit (Ward et al., 2006). 2.3. Cessation interventions for waterpipe smokers Cessation interventions for waterpipe smokers are in their infancy. A Cochrane review in 2007 was unable to identify any published waterpipe cessation trials (Maziak et al., 2007). Since then, two relevant trials have been published (Asfar et al., 2014; Dogar et al., 2014; Siddiqi et al., 2013). Asfar et al. (2014) developed a clinic-based behavioral cessation program for waterpipe users, and evaluated its feasibility and efficacy in a pilot, two-arm, parallel group, randomized, open label trial in Aleppo, Syria. Fifty adults who smoked waterpipe ≥3 times per week in the last year, and did not smoke cigarettes, were randomized to receive either brief (1 in-person 45-min educational/counseling session and 3 follow-up phone calls) or intensive (3 in-person 45-min educational/counseling sessions and 5 followup phone calls) behavioral cessation treatment delivered by a trained physician. The behavioral intervention, based on best practice cessation interventions for cigarette smokers (Fiore et al., 2008), was adapted for the Syrian context (Asfar et al., 2008; Ward et al., 2013). The brief arm included one session where participants were educated about the health effects of waterpipe use, encouraged to set a quit date, and taught basic stimulus control and contingency management strategies to quit and prevent relapse. Stimulus control strategies included engaging in a “quitting ritual” involving disposing of smoking cues, such as waterpipe and charcoals, the night before the quit attempt. Contingency management strategies included self-rewards, relaxation, and building social support. In addition to the in-person counseling sessions, participants received 10-min phone calls to review behavioral strategies and quitting ritual, and to problem-solve early relapse. In the “intensive” arm, participants received in addition to the above, five brief (10 min) phone calls counseling in problem solving. This included instruction and practice in anticipating high-risk situations, devising relapse prevention plans, and using cognitive and behavioral coping strategies, self-rewards, and social support. The first call was conducted one day before the quit day and the other calls at 1, 10, 21, and 30 days after the quit day. The primary efficacy outcome was prolonged abstinence at 3month post-quit day, assessed by self-report validated by exhaled carbon monoxide levels of
