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Would placing pictorial health warnings on waterpipe devices reduce waterpipe tobacco smoking? A qualitative exploration of Egyptian waterpipe smokers’ and non-smokers’ responses
  1. Aya Mostafa1,
  2. Heba Tallah Mohammed1,2,
  3. Wafaa Mohamed Hussein1,
  4. Mahmoud Elhabiby3,
  5. Wael Safwat4,5,
  6. Sahar Labib6,
  7. Aisha Aboul Fotouh1,
  8. Janet Hoek7
  1. 1 Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
  2. 2 School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
  3. 3 Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
  4. 4 Egyptian Tobacco Control Coalition, Cairo, Egypt
  5. 5 Egypt Health Foundation, Cairo, Egypt
  6. 6 Tobacco Control Unit, Ministry of Health, Cairo, Egypt
  7. 7 Departments of Public Health and Marketing, University of Otago, New Zealand
  1. Correspondence to Dr. Aya Mostafa, Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, 11566, Egypt; aya.kamaleldin{at}


Background Although Egypt places four generic pictorial health warnings (PHWs) on the front and back half of waterpipe tobacco packs (WTPs), waterpipe tobacco smoking (WTS) rates have continued to rise. It has been suggested that PHWs would be more salient if placed on the waterpipe device itself. This qualitative study explored how participants perceived the effects placing PHWs on waterpipe devices would have on warning salience and uptake or quitting of WTS.

Methods We conducted 10 focus groups and 10 in-depth interviews with 90 adult waterpipe smokers and non-smokers, men and women, who lived in rural, semi-urban and urban regions of Egypt. We presented participants with four novel PHWs of different sizes positioned randomly at four locations on a waterpipe device (the glass body, metal holder, mouthpiece or hose), one at a time. At each session, participants viewed a PHW on all four locations. Novel warnings were shown on plain labels with a dark uniform background and featured pictures, text and the quitline number. Transcripts were analysed using thematic analysis.

Results Participants thought placing PHWs on waterpipe devices might increase salience, prevent WTS initiation or trigger quit attempts; they favoured placing PHWs on the glass body, mouthpiece or waterpipe hose. Both waterpipe smoker and non-smoker participants thought these potential effects would affect non-smokers or non-established smokers more than established waterpipe users.

Conclusions Our exploratory study suggests that PHWs featured prominently on waterpipe devices could potentially deter experimentation with waterpipe tobacco products and promote cessation, especially among non-established users.

  • packaging and labelling
  • public policy
  • non-cigarette tobacco products
  • prevention
  • cessation

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors AM: conceived and designed the study and developed its tools. AM, ME, WS, WMH: carried out the study. SL and AM: sought necessary approvals for using the PHWs. WMH and HM: transcribed the data. AA, HM, AM and JH: analysed the data. AM, HM, AA and JH: drafted the paper. All authors critically revised contents and provided final approval on the submitted manuscript.

  • Funding This work was carried out with the aid of a grant from the International Development Research Centre, Ottawa, Canada (Grant 106981-001) through the American University of Beirut, the Tobacco Control Research Group, to study waterpipe tobacco smoking prevention and intervention programs in the region, as part of the project “Shaping Research for Health in the Arab World: A Systems and Network Approach to Advance Knowledge, Inform Policy, and Promote Public Health”.

  • Competing interests None declared.

  • Ethics approval This study was approved by the Research Ethics Committee of Faculty of Medicine, Ain Shams University (FMASU R 10/2015).

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Author note Checklist for reporting guidelines: the authors used SRQR guidelines for reporting qualitative research.

  • Presented at The abstract of this study has been presented at the World Conference on Tobacco or Health, 2018 in South Africa:

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