The School of Public H Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies What do we know about treatment for waterpipe addiction? t International Conference on Waterpipe Research, Oct 20-23 rd , 2013, Abu Dhab Taghrid Asfar, MD University of Miami, and Syrian Center for Tobacco Studies
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Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies
The School of Public Health. What do we know about treatment for waterpipe addiction?. Taghrid Asfar , MD University of Miami, and Syrian Center for Tobacco Studies. Kenneth D. Ward, PhD University of Memphis, and Syrian Center for Tobacco Studies. - PowerPoint PPT Presentation
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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)
• 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