1. Which Behaviour Change Techniques may help Waterpipe (WP) smokers to quit? An expert consensus Behaviour change: smokeless tobacco and waterpipes Department of Health Sciences Kamran Siddiqi

2. Acknowledgements 2  Funding: This study was conducted as part of a waterpipe smoking cessation trial funded by Pfizer pharmaceuticals (GRAND 2014)  Collaborators: Nancy O’Neill, Omara Dogar, Mohammed Jawad, Ian Keller, and Mona Kanaan  Experts: Taghrid Asfar, Sena Jawad, Irene Jillson, Isaac Lipkus, Christopher Loffredo Wasim Maziak, Mary Mohlman, James Newell, Sarwat Shah, Heather Thompson and Kenneth Ward  UCL Behaviour Change team – Susan Michie et al

3. Overview  Waterpipe (WP) smoking  WP quit behaviours  The challenge to help WP smokers quit  Interventions for WP smoking cessation  Which behaviour change techniques may help?  Recommendations and conclusions 3

4. WP Tobacco Smoking 4 Unflavoured dry tobacco leaf Flavoured tobacco mixture Tobacco

5.  WP Epidemic  Increasing popularity among youth  Highly Addictive  Progressively increased WP use  Switching to other forms of tobacco  Adversely effects health  Significant toxicant exposure  Lung & oesophageal cancer Scope of the problem 5

6. WP Quit Behaviours  User characteristics  Confident in own ability to quit >80%  Interested in quitting< cigarette smokers  Motivations to Quit  Health, Family disapproval, Physician advice  Quit attempts and challenges  1/4th attempt quit on their own  Challenging to cope with boredom, socializing with smoking friends, and coping with the habit  Broader aspects of cessation  Predominantly social and intermittent behaviour 6

7. The Challenge to help WP smokers Quit  Not being aware of the harms of WP  Diverse WP products  Concomitant, dual and poly-use  Limited expertise 7

8.  Individual level interventions  Group level interventions  Legislative interventions 8

10. Which Behaviour Change Techniques (BCTs) may help WP smokers to Quit? 10  Ranked 55 BCTs categorised into those that promote;  “awareness of harms of WP smoking and advantages of quitting” (14),  “preparation and planning to quit” (29) and  “relapse prevention and sustaining an ex- smoker identity” (12)  Kendall’s W statistics was used to assess agreement

11. Kendall's WAgreementp values Round 1 (n=15) Awareness of harms of WP smoking and advantages of quitting 0.32weak <0.05 Preparation and planning to quit 0.31weak <0.05 Relapse prevention and sustaining an ex-smoker identity 0.53moderate <0.05 Round 2 (n=14) WP smoking - awareness of harms and advantages of quitting 0.60moderate <0.05 Preparation and planning to quit 0.59moderate <0.05 Relapse prevention and sustaining an ex-smoker identity 0.66strong <0.05

12. * Akl, E. A, et al. (2013). Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J, 10, 12. Akl, E. A, et al. (2015). The allure of waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally. Tob Control, 24 Suppl 1, i13-i21. Top 3 ranking BCTs within the categories Awareness of harms of WP smoking and advantages of Quitting 1. Provide information on consequences of WP smoking and consequences of WP cessation 2. Identify reasons for wanting and not wanting to stop smoking WP 3. Salience of consequences Preparation and planning to Quit 1. Assess current readiness and ability to Quit 2. Assess past history of Quit attempts 3. Facilitate barrier identification and problem solving Relapse prevention and sustaining an ex-smoker identity 1. Provide information on withdrawal symptoms 2. Assess withdrawal symptoms 3. Facilitate relapse prevention and coping

13. Conclusion Based on expert consensus, an inventory of BCTs ordered for their potential effectiveness can be useful for health professionals offering cessation support to waterpipe smokers 13

14. Recommendations  Ask and offer cessation support to WP users  Advocate for regulating WP use (graphic warnings, smoke free, taxes, etc.)  Research on WP specific cessation approaches 14

15. 15 Thank you! Contact email: Kamran.siddiqi@york.ac.ukKamran.siddiqi@york.ac.uk Twitter: @kamsid66