Interventions for waterpipe smoking cessation

Taghrid Asfar; Jonathan Livingstone-Banks; Kenneth D Ward; Thomas Eissenberg; Olusanya Oluwole; Zoran Bursac; Tarek Ghaddar; Wasim Maziak

doi:10.1002/14651858.CD005549.pub4

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Figure 1

Study selection PRISMA flow chart

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Figure 2

Risk of bias summary: review authors’ judgments about each risk of bias item for each included study

+ Low risk, ‐ High risk and? Unclear risk

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Figure 3

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Figure 4

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Analysis 1.1

Comparison 1: Face‐to‐face behavioral interventions versus control, Outcome 1: Waterpipe abstinence

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Analysis 1.2

Comparison 1: Face‐to‐face behavioral interventions versus control, Outcome 2: Waterpipe abstinence: subgrouped by exclusive waterpipe use vs dual tobacco use

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Analysis 1.3

Comparison 1: Face‐to‐face behavioral interventions versus control, Outcome 3: Waterpipe abstinence: subgrouped by baseline motivation to quit

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Analysis 2.1

Comparison 2: Varenicline versus placebo, Outcome 1: Waterpipe abstinence

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Analysis 2.2

Comparison 2: Varenicline versus placebo, Outcome 2: Adverse events

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Analysis 2.3

Comparison 2: Varenicline versus placebo, Outcome 3: Serious adverse events

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Analysis 3.1

Comparison 3: Bupropion + behavioral support versus behavioral support alone, Outcome 1: Waterpipe abstinence

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Analysis 4.1

Comparison 4: Bupropion + behavioral support versus self‐help, Outcome 1: Waterpipe abstinence

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Analysis 5.1

Comparison 5: E‐health interventions for waterpipe smoking cessation, Outcome 1: Waterpipe abstinence

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Summary of findings 1. Interventions for waterpipe smoking cessation

Patients or population: people who use waterpipe

Settings: clinics/communities/college campuses

Intervention: behavioral support and pharmacotherapy

Comparison: usual care/brief intervention/placebo

Outcome

Anticipated absolute effects (95% CI)

Relative effect (Random effect)

Number of participants

(number of studies)

Certainty of the evidence

(GRADE)

Risk without intervention, usual care

Risk with Interventions

Face‐to‐face behavioral intervention vs minimal or no support

(Measured 3 to 6 months with CO‐validated prolonged and continuous abstinence, and self‐reported abstinence)

112 per 1000

297 per 1000

(187 to 472)

RR 2.64

(1.66 to 4.20)

851

(5 cluster‐RCTs)

⨁⨁⊝⊝
Low ^{a, b}

Varenicline plus behavioral intervention vs placebo plus behavioral intervention ‐ (repeated point prevalence abstinence (not even a puff/chew/session in the last 7 days) at each of weeks 5, 12, and 25 (combined), verified by CO cutoff < 10 ppm)

56 per 1000

70 per 1000

(39 to 126)

RR 1.24

(0.69 to 2.24)

662

(2 RCT)

⨁⨁⊝⊝
Low^c

Bupropion therapy plus behavioral intervention vs behavioral intervention alone

(continuous waterpipe smoking abstinence, defined as an expired CO of 9 ppm or less at the 6‐month postintervention follow‐up visits)

449 per 1000

364 per 1000

(189 to 633)

RR 0.77

(0.42 to 1.41)

121

(1 cluster‐RCT)

⨁⊝⊝⊝
Very low ^{a, c}

Bupropion therapy plus behavioral support versus self‐help

(continuous waterpipe smoking abstinence, defined as an expired CO of 9 ppm or less at the 6‐month postintervention follow‐up visits)

194 per 1000

375 per 1000

(182 to 774)

RR 1.94

(0.94 to 4.00)

(1 cluster‐RCT)

⨁⊝⊝⊝
Very low ^{a, c}

Impact

Number of participants

(number of studies)

Certainty of the evidence

(GRADE)

E‐health interventions

Due to the variation in the studies, we did not pool the results.

Quit rates were higher among participants randomized to receive either the tailored or untailored intervention groups compared with those in the no intervention control group (RR 1.48, 95% CI 1.07 to 2.05; 1 study, N = 319).

Smoking abstinence rates were higher among those randomized to receive a 20‐slide presentation compared with those randomized to receive an 8‐slide presentation (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70).

389

(2 RCTs)

⨁⊝⊝⊝
Very low ^{a, c}

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect

CI: confidence interval; CO: carbon monoxide; ppm: parts per million; RCT: randomized controlled trial; RR: risk ratio

^aDowngraded one level for risk of bias: no studies were at low risk of bias
^b Downgraded one level because of imprecision: fewer than 300 events
^c Downgraded two levels because of imprecision: fewer than 150 events

Summary of findings 1. Interventions for waterpipe smoking cessation

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Comparison 1. Face‐to‐face behavioral interventions versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Waterpipe abstinence Show forest plot	5	851	Risk Ratio (M‐H, Random, 95% CI)	2.64 [1.66, 4.20]

1.2 Waterpipe abstinence: subgrouped by exclusive waterpipe use vs dual tobacco use Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.2.1 People who exclusively use waterpipe	5	482	Risk Ratio (M‐H, Random, 95% CI)	2.36 [1.62, 3.43]
1.2.2 People who use both waterpipe and combustible cigarettes (dual use)	2	485	Risk Ratio (M‐H, Random, 95% CI)	3.62 [1.57, 8.36]
1.3 Waterpipe abstinence: subgrouped by baseline motivation to quit Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.3.1 Participants motivated to quit	2	218	Risk Ratio (M‐H, Random, 95% CI)	1.72 [0.96, 3.08]
1.3.2 Participants not selected based on motivation to quit	3	264	Risk Ratio (M‐H, Random, 95% CI)	2.94 [1.81, 4.77]

Comparison 1. Face‐to‐face behavioral interventions versus control

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Comparison 2. Varenicline versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Waterpipe abstinence Show forest plot	2	662	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.69, 2.24]

2.2 Adverse events Show forest plot	2	662	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.67, 1.44]

2.3 Serious adverse events Show forest plot	2	0	Risk Ratio (M‐H, Random, 95% CI)	Not estimable

Comparison 2. Varenicline versus placebo

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Comparison 3. Bupropion + behavioral support versus behavioral support alone

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Waterpipe abstinence Show forest plot	1	121	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.42, 1.41]

Comparison 3. Bupropion + behavioral support versus behavioral support alone

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Comparison 4. Bupropion + behavioral support versus self‐help

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Waterpipe abstinence Show forest plot	1	86	Risk Ratio (M‐H, Random, 95% CI)	1.94 [0.94, 4.00]

Comparison 4. Bupropion + behavioral support versus self‐help

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Comparison 5. E‐health interventions for waterpipe smoking cessation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Waterpipe abstinence Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1.1 Text messages vs no intervention	1	349	Risk Ratio (M‐H, Random, 95% CI)	1.41 [1.01, 1.97]
5.1.2 Tailored vs untailored text messages	1	230	Risk Ratio (M‐H, Random, 95% CI)	1.24 [0.89, 1.71]
5.1.3 20‐slide vs 8‐slide presentation	1	88	Risk Ratio (M‐H, Random, 95% CI)	1.91 [1.06, 3.42]

Comparison 5. E‐health interventions for waterpipe smoking cessation

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