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Waterpipe tobacco package warning exposure’s impact on risk perceptions and use among young adults in the USA: a longitudinal analysis of the population assessment of tobacco and health study
  1. Jessica L King1,
  2. Beth A Reboussin2,
  3. Jennifer Cornacchione Ross1,
  4. Erin L Sutfin1
  1. 1 Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  2. 2 Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Jessica L King, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; jlking{at}


Background Although Food and Drug Administration (FDA)-mandated waterpipe tobacco warnings were not required until August 2018, some waterpipe tobacco packaging (WTP) sold in the USA, contained warnings prior to this date. We examined the prevalence of WTP warning exposure and whether exposure influenced risk perceptions or use among young adult (aged 18–24 years) current waterpipe users.

Methods We used data from waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study of US adults and youth. We conducted logistic regression analyses to identify factors associated with wave 1 warning exposure, and whether wave 1 WTP warning exposure predicted wave 2 relative risk perceptions and waterpipe use.

Results More than one-third of our sample (35.9%, 95% CI 33.5 to 38.4) reported past-month WTP warning exposure. Exposure was higher among males (adjusted OR (AOR)=1.34, 95% CI 1.04 to 1.72), those who usually do not share the waterpipe (AOR=3.10, 95% CI 1.45 to 6.60), those who purchased waterpipe tobacco (AOR=1.73, 95% CI 1.28 to 2.34), and those with a regular brand (AOR=1.84, 95% CI 1.26 to 2.68). Those exposed to WTP warnings at wave 1 were more likely than those not exposed to perceive waterpipe tobacco to be as or more harmful than cigarettes at wave 2 (AOR=1.35, 95% CI 1.02 to 1.78). There was no association between wave 1 WTP exposure and wave 2 waterpipe use.

Conclusions More than one-third of US young adult current waterpipe users reported WTP warning exposure prior to FDA-mandated warning implementation. Findings suggest the mandated warning may result in high exposure among users; it will be critical to assess exposure’s impact on risk perceptions and behaviour after FDA-mandated warnings are implemented.

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

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  • Contributors JLK, BAR, JCR, and ELS contributed to the conceptual design of the study. JLK conducted statistical analyses. BAR provided statistical support. JLK led the first draft of the manuscript, and all coauthors contributed to and approved the final version prior to submission.

  • Funding Grant number P50CA180907 from the National Cancer Institute and the FDA Center for Tobacco Products (CTP) supported JLK’s time spent writing the paper.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Westat.

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