Cessation of Waterpipe Smoking

Abstract

Tobacco smoking using a waterpipe (known regionally by such names as “hookah,” “shisha,” “goza,” and “narghile”) is a centuries-old tradition in the Middle East in which tobacco is heated, usually with charcoal, and its smoke is passed through water before inhalation. Its use has increased dramatically over the last 20 years and has spread to much of the rest of the world, despite growing evidence that waterpipe smoking damages health and causes dependence. Most users smoke only occasionally and believe they can quit anytime but are not motivated to do so. A sizeable number of users, however, smoke regularly, exhibit withdrawal symptoms when they abstain, and have difficulty quitting.

Unfortunately, little evidence is currently available to guide healthcare practitioners on how to best help waterpipe smokers to quit. Brief educational and motivational interventions may boost quit rates in younger, non-dependent smokers. For dependent smokers, behavioral strategies that have proven effective for cigarette cessation may be useful when adapted for waterpipe cessation, including educating the smoker about the health consequences of waterpipe use, increasing motivation to quit by reviewing the pros and cons of smoking and quitting, setting and preparing for the quit day, and providing coping assistance to prevent relapse. Contingency management, providing financial rewards for abstinence, also may be useful. Pharmacologic agents have not been widely tested yet, but there is preliminary evidence that bupropion may be helpful, while a randomized trial found that varenicline did not boost quit rates beyond placebo. Interventions need to be rigorously tested in adequately powered, randomized, controlled trials using standardized outcome criteria, including follow-up durations of at least 6 months, biochemical verification of abstinence, intention-to-treat analysis to maintain prognostic balance when a loss to follow-up occurs, and blinded follow-up assessment.