Interventions for waterpipe tobacco smoking prevention and cessation: a systematic review

Waterpipe tobacco smoking is growing in popularity despite adverse health effects among users. We systematically reviewed the literature, searching MEDLINE, EMBASE and Web of Science, for interventions targeting prevention and cessation of waterpipe tobacco smoking. We assessed the evidence quality using the Cochrane (randomised studies), GRADE (non-randomised studies) and CASP (qualitative studies) frameworks. Data were synthesised narratively due to heterogeneity. We included four individual-level, five group-level, and six legislative interventions. Of five randomised controlled studies, two showed significantly higher quit rates in intervention groups (bupropion/behavioural support versus placebo in Pakistan; 6 month abstinence relative risk (RR): 2.3, 95% CI 1.4–3.8); group behavioural support versus no intervention in Egypt, 12 month abstinence RR 3.3, 95% CI 1.4–8.9). Non-randomised studies showed mixed results for cessation, behavioural, and knowledge outcomes. One high quality modelling study from Lebanon calculated that a 10% increase in waterpipe tobacco taxation would reduce waterpipe tobacco demand by 14.5% (price elasticity of demand −1.45). In conclusion, there is a lack of evidence of effectiveness for most waterpipe interventions. While few show promising results, higher quality interventions are needed. Meanwhile, tobacco policies should place waterpipe on par with cigarettes.

Year of study: [2011][2012] Eligibility criteria: -Adults aged over 18 years -Suspected tuberculosis (cough >=3 weeks of unknown cause) -Regular smokers (>= 1 cigarette or waterpipe per day) -Excluded those requiring hospitalization or urgent medical attention 1) Two brief behavioural support cessations (first visit 30min, second on quit day 10min) (BSS) 2) Two brief behavioural support cessations (as above) plus bupropion for seven weeks (75mg/d for first week, 150mg/d for next six weeks) (BSS+) Participants in the experimental group were shown 20 MS PowerPoint slides that covered 1) what is a waterpipe and how it works (e.g., names it goes by, schematic of a waterpipe), 2) what is in waterpipe, focusing on the flavorings added to the tobacco, 3) who smokes waterpipe, concentrating on origins, spread, and use by subgroups, 4) amount of smoke inhaled by waterpipe in laboratory studies and in relation to smoking cigarettes, 5) production of tar, CO, and nicotine in waterpipe tobacco compared to cigarettes, 6) exposure levels of toxic compounds (e.g., aldehyde), and 7) health effects associated with waterpipe tobacco smoking (e.g., cancer, heart disease, infections). The average length of time reviewing these materials online was 7.5 min for the experimental condition. Setting: Villages Egypt that had between 10,000-20,000 inhabitants, at least one primary, preparatory, and secondary school, a public health clinic, a youth club, a mosque Country: Egypt Region: Qalyubia governorate Health promotion over a 12 month period simultaneously in all six villages 1) Primary school students participated in traditional and nontraditional activities aimed at preventing the initiation of smoking by deglamorizing tobacco use and teaching about its health hazards.
2) Preparatory and secondary school students engaged in an experiential learning program to develop social skills among teenagers to handle peer pressure to smoke.
3) Engaging mosques and churches in educating their communities about the hazards of smoking and ETS and in raising the issue of smoking as a sinful behaviour 4) Female social change agents (raedat refeyat) provided information to adult women in the home on the negative health effects of tobacco use and ETS. 5) They also taught these women how to better protect themselves and their children from ETS through a standardized message sensitive to cultural family dynamics. Ten sessions over ten weeks: four knowledgefocused, six skill-building (media literacy (1), decision making (2), refusal skills and social promise (3)) No intervention

Waterpipe cessation
Past-30 day waterpipe use Waterpipe knowledge, attitudes and beliefs -Starts with a 2-way conversation with a physician, informing the reasons for smoking, the mechanisms and risks of smoking with emphasis on health consequences and the role of advertising -Followed by an interview with a patient suffering from a tobacco-related illness. Emphasis was on the consequences of the patients usually long-term smoking habit -2/3 students from each class had a lung function test and finger pulse oximetry -A concluding group discussion about the test results (point above) and the students questions were answered Control group who did not receive the interventi on, but details not describe d

Abstinence from waterpipe smoking initiation
Post-test at six months after intervention  Supplementary Table S3: Risk of bias assessments using Cochrane (randomised studies) and GRADE (non-randomised studies) and CASP (qualitative studies) frameworks Authors report using a computer random number generator.
Low risk of selection bias.
Insufficient information to permit judgement of 'Low risk' or 'High risk'..

Unclear risk of selection bias.
No blinding and outcome likely to be influenced by lack of blinding.
High risk of performance bias.
No blinding but outcome biochemically verified and unlikely to be affected by lack of blinding.
Low risk of detection bias.
Missing outcome data balanced across intervention groups, with similar reasons for missing data across groups.
Low risk of attrition bias.
The study protocol is available and all of the study's pre-specified (primary and secondary) outcomes that are of interest in the review have been reported in the pre-specified way Low risk of reporting bias. Dogar 2014 Authors report using a computer random number generator.
Low risk of selection bias.
Central allocation.
Low risk of selection bias.
No blinding and outcome likely to be influenced by lack of blinding.
High risk of performance bias.
No blinding but outcome biochemically verified and unlikely to be affected by lack of blinding.
Low risk of detection bias.
Missing outcome data balanced across intervention groups, with similar reasons for missing data across groups Low risk of attrition bias.
Not all of the study's pre-specified primary outcomes have been reported (point abstinence at 4 weeks) High risk of reporting bias.

Lipkus 2011
Authors report using a computer random number generator. Missing outcome data balanced in numbers across intervention groups Low risk of attrition bias.
One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta-analysis Unclear risk of attrition bias.
(point abstinence at 4 weeks) High risk of reporting bias. Multistage sampling of participants, although no details given (unclear risk).

High risk
Authors do not report using a validated tool.

Unclear risk
Authors report using a pretested questionnaire but no adequate evidence of validation provided.

High risk
Authors do not report controlling for relevant confounders.
High risk Authors provide no information about missing data, which appear apparent from the results tables.

Deshpande 2010 High risk
Mixture of random, convenience and purposive sampling.

Low risk
All venues are subject to the smokefree law and are hence 'exposed' to this health policy.

Low risk
Validated instrument for PM2.5 measurement. Standardised protocol for taking measurements (i.e. in centre of venue, for 60 mins).

Unclear risk
Authors report controlling for confounders but without adequate details.

Low risk
Data are complete.

Low risk
Authors report using a previously validated tool.

High risk
Authors do not report using a validated tool. Data are complete.

Stamm-Balderjahn 2012 High risk
Non-random, convenience sample with no eligibility criteria.

High risk
Authors do not report using a validated tool.

High risk
Authors do not report using a validated tool.

High risk
No controlling for confounding, but they assessed for interaction.

Low risk
Authors provide specific figures for missing data, suggesting low rates.    Perceptions regarding water pipe smoking changed significantly after intervention and the opinion regarding addiction associated with water pipe smoking improved. Highly significant difference was observed with regards to shisha being more addictive and harmful than cigarette smoking.
Social perceptions related to water pipe that it is more socially acceptable and part of our cultural heritage remain deep rooted and no significant difference was observed.
Majority of the students were of the opinion that shisha cafes play an important role in promoting shisha smoking. Most students said that shisha smoking is influenced by other people in close family circle smoking water pipe. Perceptions regarding health hazards associated with shisha smoking changed significantly after the health awareness sessions. The students attributed shisha smoking to all forms of cancers specifically those of lips, bladder and lung. Strong positive association was also observed with infertility, high blood pressure and cardiovascular problems.

Conclusion
The knowledge of the participating students regarding water pipe smoking improved to some extent after the health awareness sessions especially in terms of health hazards associated with water pipe. This study helped in changing their perceptions regarding health hazards associated with shisha smoking.
Deshpande 2010  PM2.5 measurements of indoor air quality before SidePak AM510 Personal Aerosol  PM2.5 decreased in all premises except hookah venues (mean 973 ug/m 3 pre ban to 1267 ug/m 3 post ban -30% This is possibly due to an exodus of smokers from their customary venues to hookah parlors, since these parlors were and after  Active smoker density before and after the ban using the number of people smoking and room volume Monitor increase)  Active smoker density decreased to zero in all premises except hookah venues, where it increased to 3.08 burning cigarettes per 100 cubic meters volume clearly violating the law under the excuse that the flavored hookah's being served did not contain any nicotine.
Hookah parlors remained uniquely insulated from the ban's effect. It was apparent that cigarette smoking was not discouraged in the hookah enclosures. Essa-Hadad 2015  Primary: past-7 day waterpipe use  Secondary: feasibility outcomes Pre-and postintervention survey Past-7 day waterpipe use: 58.2% to 22.2% (p=0.01) Satisfied or very satisfied with intervention: 97.8% Recommend the intervention to a friend: 93.8% The findings from the study suggest that a tailored Web intervention was found interesting and acceptable among Arab university students and seems promising in reducing nargila smoking. Quadri 2014 Knowledge that waterpipe causes oral cancer Pre-and postintervention survey Knowledge increased from 0.80 (SD 0.34) to 0.98 (SD 0.13).
The post intervention results showed a significant improvement in the knowledge of the respondents as the mean value obtained was fairly high.
The study effectively increased the knowledge and awareness among the youth about oral cancer per se and its prevention measures. Hence, giving a direction for further public health initiatives in this prone oral cancer region. Many educational programs should be conducted on a regular basis targeting a larger sector of the community. The expenditure data do not provide information on tobacco products consumed at other commercial establishments such as restaurants and cafes. Our measures of spending on shisha tobacco are therefore likely an underestimate the total spending on shisha tobacco by households.

Stamm-Balderjahn 2012
Abstinence from waterpipe smoking initiation Pre-and postintervention survey Altogether, 23 students had taken up waterpipe smoking during the 6-month observation period: 5 in the intervention group, 18 in the control group. The difference was statistically significant (P<0,01). Compared to the control group, the nonsmokers (with respect to the waterpipe-only smokers) in the intervention group had a three and a half times likelihood of staying abstinent (OR: 3,64; SE: 0,52; 95% CI: 1,32 -10,03). Qualitative interview "I also use shisha as a substitute for coming off cigarettes, some people use nicotine patches and all that, I find shisha more effective . . . with shisha, a whole"

N/A as this was additional information outside of the manuscript
Watepripe use increased after the smokefree law for one participant -no waterpipe use for anyone else These accounts suggest that smokers were using these products prior to, and after, the implementation of smoke-free legislation. Some regarded these practices as less harmful than smoking, while others framed them as an alternative way of weaning themselves off cigarettes: However, some Bangladeshi smokers, old and young, appear to have increased their use of other forms of tobacco, such as shisha and paan, despite the former being included in smokefree restrictions and the provision of specific guidance to this effect. Prior to the implementation of the legislation, there was widespread concurrent use of traditional cigarettes and indigenous tobacco products among Bangladeshi smokers.
Since implementation, some smokers may be using such products as a substitute for smoking cigarettes and as an aid to smoking cessation, in the mistaken belief that these products are harmless. Thus, a modest reduction in cigarette consumption by some of our participants was counterbalanced by an increase in the use of other forms of tobacco. Jawad 2013 Waterpipe smoking behavior after English smokefree law Qualitative interviews post legislation "Regarding the impact on waterpipe smoking of the 2007 smokefree law in England, opinions were divided into two broad categories: either there was no effect, or there was increased use as a result of the ban. Some participants adapted by smoking at home instead of at cafes, and subsequently increased their waterpipe consumption as it was more readily available and notably cheaper. Five years after the ban, participants described frequenting UK waterpipe cafes that flouted the smokefree law" Of primary importance is the enforcement of waterpipe smoking legislation as directed by the World Health Organization Framework Convention on Tobacco Control. Other legislative issues that merit attention include appropriate taxation of waterpipe tobacco, enforcing the smokefree law to avoid carbon monoxide poisoning, and regulating the content of waterpipe tobacco Jawad 2014 Waterpipe premise compliance with English smokefree law Qualitative interviews post legislation "Our enforcement policy basically says to give guidance, then send them a warning letter, then enforce. So they all know what they're doing is wrong and illegal, but they carry on doing it because a) they think they're going to get away with it or b) they'd rather take the fine and carry on with their business. I mean, I have one business which is right across the road, who says "What Compliance with smoke-free law is generally poor, but unlike health warning labels or underage sales, is transiently compliant. Factors such as the cold weather, lack of regular monitoring from LA staff, peak times of trade, and low prosecution fines all encourage waterpipe premises to be noncompliant with smoke-free law. In one borough, fines ranged between £300 and £1,500. "A premises has forty people in there, if twenty of those are smoking and they paid fifteen pounds per waterpipe pipe -if they then get a fine of a hundred and fifty pounds, there's no deterrent for the premises because they can cover that in half a day.
fines are not designed for intentional and recurrent flouting of smoke-free law. Additionally, the prosecution process is labor and resource intensive.

Lock 2010
Change in smoking behavior, changes in the geographical location of smoking and its social impacts, and smoking illegally Qualitative interviews pre-and post-smokefree law "Some Somali respondents felt that smoking cessation services would not help as they focussed on cigarette use and did not address shisha smoking." ""For those who smoke Shisha they have to be home..... the gathering that used to take place in a restaurant takes place home a lot now." (Middle-aged Somali woman)" "Somali women appeared to experience the greatest social impact of SFL. All Somali respondents discussed the traditional importance of shisha, with all but one of the Somali women currently or previously smoking shisha, while few smoked cigarettes. Despite an estimated 17% of Somali women in this community who admit to smoke, it is considered culturally unacceptable for Somali women to smoke, especially in public. Respondents said this was the custom rather than because of specific religious beliefs." "Both Somali men and women agreed that the legislation has had a greater impact on women because of increased social restrictions. Before, SFL Somali women smokers could hire separate indoor smoking rooms in public shisha venues where they could socialise in private with friends. Women who continue to It is important to understand the differences found between ethnic groups after SFL. Overall, the social impacts appeared most restrictive for young Somali women who, due to cultural sensitivity around female smoking, were often now unable to smoke in public where they might be seen and were thus taking measures to hide their smoking (including visiting illegal venues). Somali respondents also perceived that smoking cessation services were not culturally sensitive, focussing on cigarette, and this may have contributed to some of the ethnic differences seen in the lack of willingness to use cessation services.
The perceived stigma for some women associated with smoking outside in public since SFL may make already disadvantaged groups even more difficult to target or engage in future smoking cessation strategies smoke shisha say they feel that they now can only smoke in private homes or, if continuing to smoke publicly, by taking measures to conceal themselves, travelling away from their local community or smoking in illegal venues (box 5).
"For girls, they cannot sit outside. They feel a bit embarrassed. A friend -a family friend, like, someone might see them and tell the family. So what happened was, they put hoods on, a bit clothing on. Now they face on the wall, and they're just smoking. but they cannot sit there for a long time. And when they're, like, smoking the Shisha, they're not feeling comfortable.... I did it a couple of times, but it was at night time anyway. So I'm sure that my family aren't around. It was far away from where I live and I went out with a couple of friends, and even though it does matter, the way you dress up I just put my hood on like this, and.nobody's gonna see your face. ...I was not feeling comfortable. you know, before it was really okay, not anymore. It's the shame." (Young Somali woman) ""I think I told you, that these people will go underground. and, yes, they did. There were restaurants that had a lower floor and I think they will let only their regulars in...I sat there and I could easily say that the space occupied about 50 to 60 people and I wouldn't be able to see the person at the far corner." (Young Somali woman about shisha smoking)" ""..one place.it was a normal restaurant upstairs, which used to be a normal Shisha bar.and you'd have to go downstairs and there was a room in the basement, that was for Shisha smokers. And you can still find places that are the same as before, like, inside, but it's just the fact that you have to pay more for them just cause it's inside and that's not allowed." (Young Somali woman)"