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Abstract
Purpose Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes.
Methods We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18–34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted.
Results Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only.
Conclusions Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers’ awareness of the health effects of WTS and correct false safety perceptions.
- non-cigarette tobacco products
- packaging and labelling
- low/middle income country
- cessation
Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request. Deidentified data are available upon reasonable request to WM, MD, PhD, Professor, Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL. Phone: 305-348-4501. Email: wmaziak@fiu.edu.
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Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request. Deidentified data are available upon reasonable request to WM, MD, PhD, Professor, Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL. Phone: 305-348-4501. Email: wmaziak@fiu.edu.
Footnotes
Contributors WM, TA and RN contributed to the conception and design of the study, supervised data collection, contributed to interpretation of the data and critically revised the manuscript for important intellectual content. SC performed participant recruitment and data collection. RJ performed data cleaning, data analyses and original draft writing. WW and ZB contributed to the analyses and interpretation of the data. All authors contributed to interpretation of the data and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final draft. WM is responsible for the overall content of this study. This manuscript was written by RJ with input from all coauthors who read and approved the final version.
Funding Research reported in this publication was supported by the National Institutes of Health and Fogarty International Center (NIH FIC) under award number R01TW010654. RJ is supported by NIH FIC (R01TW010654). ZB is supported by NIMHD (U54MD012393). WM is supported by the National Institute on Drug Abuse (NIDA) (R01DA055937, R01DA053587, R01DA051836), the Fogarty International Center (NIH-HHS) (R01TW010654), and the Florida Department of Health (FDOH) James and Esther King (JEK) Biomedical Research Program (20K10).
Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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