Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers

Abstract

IntroductionDespite the global rise in waterpipe tobacco smoking (WTS), the effectiveness of waterpipe tobacco health warnings remain understudied, especially in countries with high WTS rates. Egypt has been employing waterpipe tobacco labelling for a decade, however, their effectiveness is unknown. Our overall aim was to measure the effectiveness of pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) through participant memory recall and to investigate whether they induced behavioural responses in waterpipe smokers and deterred uptake of WTS in non-smokers, examining the differentials of effectiveness among socio-demographic subgroups.Subjects and methodsWe conducted two surveys including 1490 adult current waterpipe smokers, 73 former waterpipe smokers, and 451 non-smokers in Cairo and a rural village in Egypt between 2015–2017. Participants who noticed PHWs on WTPs were asked questions about salience, communication of health risks, public support, cognitive processing, and self-reported behavioural responses (current waterpipe smokers: reduce consumption, forgo a smoke, quit attempts; former waterpipe smokers: quit; non-smokers: deter WTS initiation). Univariate and multivariable statistical analyses were performed.ResultsParticipants’ mean age was 35 years, mostly males (90.4%), waterpipe smokers (74.0%) and rural residents (59.3%). Approximately two-thirds of participants noticed PHWs on WTPs. Salience was significantly less among females, urban residents and participants with high literacy. More than three-quarters of participants reported that WTS health risks were communicated through the warnings. At least half of participants cognitively processed the warnings: 56.3% thought of the warnings when WTPs were out of sight; non-smokers understood the warnings (83.2%) and discussed them with others (90.3%) significantly more than current (76.0% and 72.5%, respectively) and former waterpipe smokers (81.0% and 61.9%, respectively). Participants reported that PHWs on WTPs motivated 58.5% of waterpipe smokers to think about quitting; 64.5% to reduce their consumption; 42.2% to forgo a smoke; 24.5% to attempt to quit; 57.1% of former waterpipe smokers to successfully quit; and 59.3% of non-smokers to remain smoke-free.ConclusionsFindings suggest that inserting PHWs on WTPs is an effective waterpipe tobacco labelling policy. Countries with similarly high rates of WTS should consider adopting WTP PHWs within a comprehensive regulatory framework.

Options for waterpipe product regulation: A systematic review on product characteristics that affect attractiveness, addictiveness and toxicity of waterpipe use

“…Health warning labels are effective in communicating health risks associated with waterpipe smoking 41 , 42 , motivating waterpipe smokers to think about quitting 42 - 44 or reducing their consumption 42 , and motivating non-smokers to remain smokefree 42 . Two studies among college students smoking waterpipe showed that text-only messages and pictorial labels warning about harm to (unborn) children were the most effective in motivating waterpipe smokers to think about quitting 43 , 44 .…”

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design

“…To date, limited research has examined the effectiveness of pictorial HWLs specific to WTS in the EMR. For example, the cross-sectional survey conducted in Egypt [ 29 ] assessed the effectiveness of existing generic pictorial HWLs that are not specific to WTS on waterpipe tobacco packs among smokers and non-smokers. Similarly, cross-sectional study designs were used in Lebanon [ 55 ] and Jordan [ 28 ].…”

“…A similar study conducted among waterpipe smokers in Jordan found that placing HWL on the waterpipe handle or head was more effective since those parts are more obvious to the smokers [ 28 ]. A cross-sectional study conducted in Egypt found that HWLs on tobacco packages motivated waterpipe smokers to change their smoking behaviors (think about quitting, reduce their consumption, forgo a smoke, or increase quit attempt), helped former smokers to quit WTS and non-smokers to remain smoke-free [ 29 ]. Another qualitative study conducted in Egypt showed that placing HWLs on the device (glass body, mouthpiece, or waterpipe hose) might prevent WTS initiation or promote cessation [ 30 ].…”

E8-LWDS: Factorial Structure and Psychometric Properties of the Lebanese Waterpipe Dependence Scale-11 in 1490 Egyptian Waterpipe Tobacco Smokers—A Critical Approach

“…Data for the current study was collected during conducting a larger study on WT smokers in Egypt. Details of the larger study design, sampling, participants, instrument, and procedures have been described elsewhere [4,7,20]. It comprised two identical crosssectional surveys.…”

“…Waterpipe tobacco smoking (WTS) is a rapidly evolving global public health concern because of its associated toxicant inhalation, disease risk, and dependence [1]. Misperception of WTS harm and nicotine content has partly contributed to its increasing popularity worldwide [2][3][4]. WTS rates in youth reached 11.4%, 22.7% and 37.2% in some reports from the United States, Latvia, and Lebanon, respectively [5].…”