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Delphi study among international expert panel to develop waterpipe-specific health warning labels
  1. Taghrid Asfar1,2,3,
  2. Michael Schmidt4,
  3. Mohammad Ebrahimi Kalan5,
  4. Wensong Wu6,
  5. Kenneth D Ward2,7,
  6. Rima T Nakkash8,
  7. James Thrasher9,10,
  8. Thomas Eissenberg2,11,
  9. Habiba Ben Romdhane12,
  10. Wasim Maziak2,5
  1. 1 Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
  2. 2 Syrian Center for Tobacco Studies, Aleppo, Syria
  3. 3 Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, Florida, US
  4. 4 Department of Art, The University of Memphis, Memphis, Tennessee, USA
  5. 5 Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, Florida, USA
  6. 6 Department of Mathematics and Statistics, Florida International University, Miami, Florida, USA
  7. 7 School of Public Health, The University of Memphis, Miami, Florida, USA
  8. 8 Health Behaviour and Education Department, American University of Beirut, Beirut, Lebanon
  9. 9 Health Promotion, Education, and Behavior, School of Public Health, University of South Carolina, Columbia, South Carolina, USA
  10. 10 Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
  11. 11 USA Center for the Study of Tobacco Products, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
  12. 12 Cardiovascular Epidemiology and Prevention Research Laboratory, Faculty of Medicine of Tunis-Tunisia, Tunis, Tunisia
  1. Correspondence to Dr Taghrid Asfar, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33136, USA; tasfar{at}


Background Waterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate smoking-related risks and address reduced-harm misperceptions. Therefore, the development of WP-specific HWLs represents a priority for WP control.

Methods A panel of experts in WP science developed 28 WP-specific HWLs corresponding to five themes (health risks, addiction, harm to others, WP-specific harm, WP harm compared to cigarettes). Subsequently, a three-round Delphi study was conducted among international expert panel to reach consensus on a set of the most effective HWLs for each theme. Levels of agreement between participants were assessed using interquartile deviations, and the rank between the tied HWLs was based on the median.

Results Starting with 28 candidate HWLs stratified according to five WP-related themes, our international expert panel reached consensus on the 13 most important WP-specific HWLs. Labels with the highest agreement were related to oral and heart disease, WP’s harmful effects on newborn children and the amount of smoke inhaled from WP compared to cigarettes.

Conclusion This study is the first to systematically develop and evaluate potential WP-specific HWLs based on the scientific evidence about WP’s harmful effects, scientific understanding of HWL for cigarettes and the opinions of experts in WP science, tobacco control and health communication. The final selected HWLs can be adapted based on the context and policy landscape of the target country and can be further fine-tuned based on feedback from WP smokers and non-smokers.

  • global health
  • packaging and labelling
  • public policy

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  • Contributors For the current study, TA, MS, MEK, WW and WM 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 significant intellectual content. KDW, RN, IFT, TE and HBR contributed to interpretation of the results and critically revised the manuscript for important intellectual content. All authors approved the final draft of the manuscript as submitted and agreed to be responsible for all aspects of the study.

  • Funding This work was supported by the National Health Institute and Fogarty International Center (R01TW010654).

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH. We confirmed that we are happy to proceed with the proof.

  • Patient consent Not required.

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