Article Text

Download PDFPDF
Pictorial health warning labels on the waterpipe device are effective in reducing smoking satisfaction, puffing behaviour and exposure to CO: first evidence from a crossover clinical laboratory study
  1. Wasim Maziak1,2,
  2. Ziyad Ben Taleb1,
  3. Mohammad Ebrahimi Kalan1,
  4. Thomas Eissenberg3,
  5. James Thrasher4,
  6. Alan Shihadeh5,
  7. Taghrid Asfar2,6,7
  1. 1 Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
  2. 2 Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
  3. 3 Department of Psychology, Center for the Study of Tobacco Products, Virginia Commonwealth University, Miami, Florida, USA
  4. 4 Health Promotion, Education, and Behavior, Arnold School of Public Health, Columbia, South Carolina, USA
  5. 5 College of Engeenering, American University of Beirut, Beirut, Lebanon
  6. 6 Miller School of Medicine, University of Miami, Miami, Florida, USA
  7. 7 Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, Florida, USA
  1. Correspondence to Dr Wasim Maziak, Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami FL 33174, USA; wmaziak{at}


Objectives This study examined the effect of pictorial health warning labels (HWLs) on the waterpipe (WP) device on smokers’ experience, puffing behaviour, harm perception and exposure to respiratory toxicants.

Methods Thirty WP smokers completed two 45 min ad libitum smoking sessions (WP without HWL vs WP with HWL) in a crossover design study. Exhaled carbon monoxide (eCO) was measured before and after each smoking session. Puff topography was recorded throughout the smoking session, and participants completed survey questionnaires assessing subjective smoking experiences and harm perception.

Results Significant differences were observed in eCO levels between the two study conditions, with lower levels of eCO boost recorded following smoking the WP fitted with HWL (16 ppm) compared with WP without HWL (22.7 ppm). Participants had more puffs, shorter interpuff intervals and a higher total puff volume during smoking the WP without HWL relative to WP with HWL (p values <0.05). We documented enhanced reports of satisfaction, taste and puff liking following smoking the WP without HWL compared with the WP with HWL. WP harm perception was significantly higher among participants after smoking the WP with HWL compared with WP without HWL.

Conclusion This pilot study shows that placing HWL on the WP device is effective in reducing WP smoker’s positive experiences, puffing parameters and exposure to carbon monoxide. HWLs lead also to more appreciation of WP harmful effects, making them a promising regulatory approach for addressing the spread of WP smoking among young adults in the USA.

  • smoking topography
  • prevention
  • toxicology

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors WM, ZBT and MEK conceptualised and designed the study, supervised data collection, performed the initial analyses, contributed to interpretation of the data and drafted the initial manuscript and critically revised the manuscript for important intellectual content. TE, JT, AS and TA contributed to interpretation of the data and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

  • Funding This study was supported by the National Institute on Drug Abuse/Food and Drug Administration (FDA) award R01 DA042477 and Fogarty International Center (FIC) award R01 TW010654. TE and AS are funded, in part, by the National Institute on Drug Abuse of the National Institutes of Health under Award Number P50DA036105 and U54DA036105 and the Center for Tobacco Products of the US FDA.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.

  • Competing interests None declared.

  • Ethics approval This study was approved by Florida International University Institutional Review Board.

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

  • Patient consent for publication Not required.