Table 2.

Study details.

References	Study population and context	Study description/ Aim Method	Intervention type and strategies Mechanisms for change if discussed	Key success factors and barriers to implementation (Lessons learned)	Measured impacts and outcomes	Conclusions
Asfar et al. (12)	Study population: Adult waterpipe smokers (n = 50) who smoked waterpipe > 3 times per week in the last year, did not smoke cigarettes, and were interested in quitting. Context: An outpatient cessation clinic, located in a private general hospital in central Aleppo, Syria.	Aim: To develop and pilot a behavioral intervention for willing-to-quit waterpipe users to: (1) evaluate the feasibility of the intervention (2) test its potential efficacy (3) determine the adequacy of intervention “dose” in terms of contact frequency. Methods: A pilot, two arm, parallel group, randomized, open label trial. Participants were randomized to receive either brief or intensive behavioral cessation treatment. Primary end point was abstinence at 3 months assessed by self-report and exhaled carbon monoxide levels of < 0.10 ppm. Secondary end points were 7 day point-prevalent abstinence and adherence to treatment. Participants completed a semi-structured process evaluation interview.	Brief intervention: Education/counseling sessions by a trained physician and follow up phone calls Brief (1 in-person 45 min session and 3 phone calls) participants educated about health effects and consequences of waterpipe use, encouraged to set a quit date, taught basic stimulus control and contingency management strategies to quit and prevent relapse. or Intensive (3 in-person 45 min sessions and 5 phone calls) behavioral cessation treatment delivered by a trained physician in a clinical setting. The same approach as the brief arm, but provided enhanced counseling in using a problem-solving approach. This included instruction and practice in anticipating high-risk situations, a relapse prevention plan, and using cognitive and behavioral coping strategies, self-rewards, and social support. Both groups: Written educational self-help materials.	The strongest predictor of cessation at the 3-month follow-up was having made a successful quit attempt for at least 1 month during the last year. Could indicate participants developed quitting skills and/or enhanced their self-efficacy that were useful during the current quit attempt. The most helpful strategies: - encouraging physical activity (71.4%) - receiving educational information (71.4%) - rules of relapse prevention (57.6%) - getting social support (47.6%). Suggestions for improvement were more frequent, longer contacts, using medication. Almost half of participants were interested in receiving a group smoking cessation intervention. Participants were interested in receiving more phone calls than in-person sessions.	30% of participants were fully adherent to treatment which did not vary by treatment group. Prolonged abstinence in the brief and intensive interventions at 3-months were 30.4 and 44.4%, respectively. Previous success in quitting (OR = 3.57; 95% CI = 1.03–12.43) predicted cessation. Higher baseline readiness to quit, more confidence in quitting, and being unemployed predicted a better adherence to treatment (all p-values 0.05). The first session in future trials should be provided immediately after randomization to capitalize on smokers' high (but soon-to-dwindle) motivation.	Brief behavioral cessation treatment for waterpipe users appears to be feasible and effective. Cessation rates were not significantly different in the intensive and brief treatment arms. A single in-person session of education and advice from a trained professional, along with brief telephone follow-up, may be as effective as a more intensive intervention for willing-to-quit waterpipe users.
Essa-Hadad et al. (13)	Study population: Arab college/university students aged 18 years of age or older (n = 225; mean age 25; more than 2/3 female) Context: Israel.	Aim: To examine the acceptability and feasibility of a pilot web-based program using tailored feedback to increase smoking knowledge and reduce cigarette and nargila smoking behaviors. Methods: A mixed-methods study using both quantitative (pre/post-test study design) and qualitative tools. A post-test at 1 month following participation in the intervention. Primary outcomes: Self-reporting of cigarette and nargila smoking behavior. Increases in cigarette and nargila smoking knowledge. Focus group sessions assessed acceptability and preferences related to the web-based program. Secondary outcome: intention to quit, reason for wanting to quit, and seeking of professional help to quit.	Health education and skill development: A pilot web-based program providing tailored feedback. Consists of (1) a self-administered online questionnaire on cigarette and nargila smoking behavior and knowledge (2) tailored health education material delivered via text and videos.	Participants preferred tailored feedback. Compared with non-tailored messages, tailored health messages are more likely to be read and remembered, saved and discussed with others, perceived as interesting and personally relevant, and designed especially for the recipient. Primary reason given for trying to quit smoking was to improve health status. The majority (50/56, 89%) of participants, reported preference of the computer program over other traditional means of health education. Participants reported the feedback to be relevant, effective, clear and to the point, and interesting. The majority (49/56, 88%) of participants reported that the feedback regarding nargila smoking was most useful and interesting. Participants agreed there is very little awareness and knowledge regarding nargila. smoking. The majority (40/56, 71%) agreed that nargila smoking was socially and culturally acceptable.	225 participants-response rate of 63.2% (225/356)-completed the intervention at baseline and at 1-month post-study. Statistically significant reductions in nargila smoking (P = 0.001) were found but not for cigarette smoking. The tailored intervention reduced nargila smoking from 58.2% at baseline to 22.2% at the 1-month follow-up. It also resulted in statistically significant increases in the intention to quit cigarette smoking (P = 0.021). No statistically significant increases in knowledge were seen at 1-month post study.	A tailored web-based program may be a promising tool to reduce nargila smoking among Arab university students in Israel. The tailored web intervention was not successful at significantly reducing cigarette smoking or increasing knowledge. However, the intervention did increase participants' intention to quit smoking. Participants considered the Web-based tool to be an interesting, feasible, and highly acceptable strategy.
Lipkus et al. (14)	Study population: College students, aged 18 years or older (mean age 18), who had smoked waterpipe at least once during the last month. Majority Caucasian men. Study 1 (n = 70) Study 2 (n = 110) Context: 6 college and university campuses in central North Carolina.	Aim: To modify perceived risks and worry about waterpipe tobacco smoking. Methods: Two web-based studies providing college waterpipe users with information on (1) spread of and use of flavored tobacco in waterpipe and (2) harms of waterpipe smoking. Study 1 (N = 91) tested the “incremental” effects on perceptions of risk and worry. Study 2 (N = 112) tested the effects on perceptions of risk and worry of reviewing information about harms of waterpipe smoking compared to a no information control group. Outcomes: Between group differences in perceived and factual knowledge of harms and addictive potential of waterpipe use, perceived risk of physical harm and of becoming addicted, and desire to quit. Effects of intervention on self-reported use at 6 months. In Study 1 only the percentage of participants who reported no longer using waterpipe assessed.	Health education: Online Study 1: Experimental group: viewed 20 PowerPoint slides on smoking waterpipe and harms. Control group: shown 8 slides (information on harms excluded). Study 2: Experimental group: viewed 15 slides. Excluded information discussing the spread and popularity of waterpipe and the use of flavored additive in tobacco. Control group: no information. Mechanism: Enhancing accurate knowledge to increase perceived risk and worry about waterpipe tobacco smoking.	Across studies and conditions, participants viewed the information as understandable (mean scores of 5.65–5.95), credible (4.75–5.76), and personally relevant (4.20–5.56). The receipt of harm information produced significant change in each mediator (Perceived risk/Perceived worry of harm and addiction). A change in each mediator produced change in desire to quit, controlling for treatment. The direct effect of treatment (harm information) no longer produced changes in desire to quit when controlling for each mediator separately, suggesting complete mediation.	Pooling data from both studies, participants who received information about the harms of waterpipe smoking (Study 1 only) reported statistically significant greater perceived risk and worry about harm and addiction and expressed a stronger desire to quit. In Study 1, 62% of participants in the experimental group versus 33% in the control group reported having stopped waterpipe use. The experimental condition from Study 1 may be most effective to promote cessation in weekly and monthly users.	These are the first studies to show that perceptions of addiction and harm from waterpipe use can be modified using minimally intensive interventions; such interventions show promise at decreasing waterpipe use.
Pearlstein and Friedman (15)	Study population: 40 adolescent smokers aged 18–24 who were ready to quit. 79% of participants reported using a hookah or water pipe to smoke tobacco in addition to cigarettes. Context: An adolescent ambulatory health centre and internet.	Aim: To evaluate an internet delivered smoking cessation program. Methods: Self-selected enrolment from health centre clients via word of mouth, health centre website, advertising, local health care providers, and the iQUITwebsite. Outcomes: Self report reduction in number of cigarettes per day, reduction in the number of days per month smoking, and reduction in client CO levels.	Health education: Online motivational based smoking cessation counseling delivered by a Nurse Practitioner, certified as a Tobacco Dependence Treatment Specialist using podcasting and text messaging. Key topics on the podcasts were: setting a quit date, avoiding triggers, managing cravings, nicotine replacement, managing stress, and relapse prevention. Daily text messages were offered as additional support for the first 30 days during the program.	Unclear which technology was more helpful, podcasting versus text messaging. Further investigation is needed to determine if this technology could help reduce smoking among young people only using waterpipe.	At commencement, no participants smoked 0 cigarettes per day (CPD); 32% reported 6–10 CPD; 27% reported 11–20 CPD; and 7.5% reported smoking >20 CPD. At 1 month 11% reported 0 CPD; 44% reported 2-5 CPD, 22% reported 6–10 CPD, none reported 11–20 CPD, and 5% reported more than 20 CPD. Carbon monoxide readings still in progress. Six-month follow-up surveys still in progress.	Smoking cessation delivered to adolescents using web-based technology, podcasts, and text messaging support led to a modest reduction in the number of cigarettes used per day and the number of total days of cigarette use per month.
Mohlman (16)	Study population: Six villages of between 10,000 and 20,000 people that had at least one primary, prep and secondary school, a health clinic and a mosque. Context: Egypt.	Aim: To improve knowledge of the hazards of smoking and environmental tobacco smoke and to change attitudes and behaviors at the community and household level. Methods: Randomized controlled trial. Villages that met criteria randomly selected. Interviewer facilitated survey results from before and after the intervention period were analyzed in pair wise comparisons with data from control villages.	Community awareness and action (community campaign): Materials on smoking and passive smoking hazards and training of local people to deliver a multi-prong approach: (1) Primary school students participated in activities aimed at preventing initiation of smoking. (2) Preparatory and secondary school students engaged in an experiential learning program to develop social skills to handle peer pressure to smoke. (3) Engaged mosques and churches in educating their communities about smoking hazards and ETS and in raising smoking as a sinful behavior. (4) Female social change agents provided information to adult women in the home on the negative health effects of tobacco use and ETS. They taught them how to better protect themselves and their children from ETS through a standardized message sensitive to cultural family dynamics.	The intervention group showed greater increase in understanding dangers of smoking cigarettes and waterpipe and became more proactive by limiting exposure to smoke and enacting bans at home. The most significant increase in response to the question why quit among both the intervention and control was cited as children's health.	The intervention increased knowledge of harm; did not lead to a decrease in smokers but modified where smokers smoked and increased non-smokers advocacy for the own and their families' health.	Community interventions that seek to reduce environmental exposure through smoking bans, education and empowering people to ask smokers to stop are effective.
Morris et al. (17)	Study population: Policies related to waterpipe smoking Context: United States	Aim: To identify potential policy interventions to reduce youth hookah use.	Settings and supportive environment: - Increasing price/tax - Health warnings via labels on tobacco products and advertisements. - Extend regulation of flavored tobacco to hookah. - Smoke free environment laws - Restricting internet and mail-order access.	Studies of youth and young adults have found that predictors of smoking hookah are the same as those for cigarettes, including social acceptability, having friends and family members who smoke, and perceiving that smoking a waterpipe is not harmful. Established interventions to reduce youth cigarette smoking should be effective for reducing waterpipe smoking.		Tobacco flavor regulation: Would likely make hookah less appealing, particularly to youth. Smoke free laws: Decreases the perception of smoking as an acceptable behavior, promotes cessation and discourages youth initiation. The presence of hookah lounges creates and reinforces a community norm accepting of waterpipe smoking. Internet purchases: Expanded restrictions on credit processing for Internet purchases and shipping tobacco products would make waterpipe less accessible to youth.
Nakkash and Khalil (18)	Study population: All waterpipe tobacco products, waterpipe accessories. Context: Lebanon and a sample from Dubai (United Arab Emirates), Palestine, Syria, Jordan, Bahrain, Canada, Germany, and South Africa.	Aim: To evaluate current health warning labeling practices on waterpipe tobacco products and related accessories. Methods: Observation study examining health warning messages on waterpipe products.	Settings and supportive environment: Product health warning labeling.		The majority of products from Lebanon had textual health warning labels covering on average only 3.5% of total surface area of the package. Misleading descriptors were commonplace on waterpipe tobacco packages and related accessories.	There are no WHO FCTC compliant waterpipe-specific health warning labels on waterpipe tobacco products and related accessories. Introducing health warnings on waterpipe tobacco products and accessories will probably have worldwide public health benefits.
Islam et al. (19)	Study population: Adult waterpipe smokers (N = 367). Context: Large United States university.	Aim: To test the effectiveness of various text-only and pictorial health warning labels and their location on waterpipe devices. Methods: An internet-based survey.	Settings and supportive environment: Health warning labeling.		Text-only messages and pictorial labels warning about harm to children were the most effective in motivating waterpipe smokers to think about quitting. In terms of warning label location, the base, mouthpiece and stem are all equally noticeable locations.	Placing waterpipe-specific labels on waterpipe devices may be an effective policy tool to curb waterpipe smoking.
Primack et al. (21)	Study population: Municipal, county, and state level tobacco control policies Context: 100 largest cities in the United States.	Aim: To assess whether waterpipe smoking is affected by smoke free laws introduced in the 100 most populous cities in the US in 2011 or whether these laws may have intentionally or unintentionally exempted waterpipe. Methods: Analysis of municipal, county, and state law applying to the 100 largest US cities. A summary policy variable on how current tobacco control policies might apply to HTS was developed and used in a multinomial logistic regression to determine associations between community-level sociodemographic variables and a policy outcome variable.	Settings and supportive environment: Smoke free environments.	Although 3/4 of the largest US cities disallow cigarette smoking in bars, nearly 90% may permit HTS via exemptions.	73 cities had comprehensive anti-tobacco legislation in place on the municipal, county or state level that disallowed cigarette smoking in freestanding bars. However, 69 of these cities may allow HTS via exemption. Only 4 cities had clean air laws with no exemption for HTS.	Closing the gap in clean air regulation may significantly reduce exposure to waterpipe smoking.
Jawad (20)	Study population: Municipal, county, and state level tobacco control policies Context: London, United Kingdon.	Aim: To explore industry characteristics, experiences with enforcement and tobacco legislation compliance in London, UK. Methods: In-depth telephone interviews with 26 local authority (LA) staff from 14 London boroughs.	Settings and supportive environment: Enforcement and tobacco legislation compliance.	Successful methods for enforcing legislation included a synchronized, multiagency approach; however, this was inconsistently implemented across boroughs. Many LA staff believe licensing waterpipe premises would improve surveillance and control the industry's proliferation. Most waterpipe premises were generally noncompliant with most aspects of tobacco legislation, mainly due to disproportionately low fines and unclear legislation enforcement guidance.	The waterpipe industry is unregulated in many London LAs, mainly due to lack of resources. These problems may also occur in other large cities worldwide.	Existing tobacco legislation should be amended to accommodate waterpipe smoking including consideration of licensing the industry. More research is needed to gain a full understanding of the waterpipe tobacco industry and its impact on other global cities.