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Kidanu AW, Shi R, Cruz-Cano R, Feldman RH, Butler J, Dyer TV, Fryer CS, Varshney A, Lee E, Clark PI. Visual Attention to Health Warning Labels on Waterpipe Venue Menus in Immersive Virtual Reality. Nicotine Tob Res 2022; 24:1469-1477. [PMID: 35135010 PMCID: PMC9356687 DOI: 10.1093/ntr/ntac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/13/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. AIMS AND METHODS A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. RESULTS Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. CONCLUSIONS The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. IMPLICATIONS The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.
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Affiliation(s)
- Azieb W Kidanu
- Corresponding Author: Azieb W. Kidanu, PhD, CHES, School of Public Health, University of Maryland, College Park, MD 20742, USA. Telephone: 301-405-8740; E-mail:
| | - Rui Shi
- College of Communication and Creative Arts, Rowan University, Glassboro, NJ, USA
| | - Raul Cruz-Cano
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Robert H Feldman
- School of Public Health, University of Maryland, College Park, MD, USA
| | - James Butler
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Typhanye V Dyer
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Craig S Fryer
- School of Public Health, University of Maryland, College Park, MD, USA
| | - Amitabh Varshney
- College of Mathematics and Natural Sciences, University of Maryland, College Park, MD, USA
| | - Eric Lee
- University of Maryland Institute for Advanced Computer Studies, College Park, MD, USA
| | - Pamela I Clark
- School of Public Health, University of Maryland, College Park, MD, USA
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Kidanu AW, Shi R, Cruz-Cano R, Feldman RH, Butler J, Dyer TV, Fryer CS, Clark PI. Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings. HEALTH EDUCATION & BEHAVIOR 2021; 49:618-628. [PMID: 34176309 DOI: 10.1177/10901981211020990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). AIMS The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). METHOD Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors. RESULTS Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. DISCUSSION Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. CONCLUSION The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.
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Affiliation(s)
| | - Rui Shi
- Rowan University, Glassboro, NJ, USA
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Farran D, Khawam G, Nakkash R, Lee J, Abu-Rmeileh N, Darawad MW, Mostafa A, Kheirallah KA, Salama M, Hamadeh RR, Thrasher JF, Salloum RG. Association of health warning labels and motivation to quit waterpipe tobacco smoking among university students in the Eastern Mediterranean Region. Tob Prev Cessat 2021; 7:44. [PMID: 34141959 PMCID: PMC8176861 DOI: 10.18332/tpc/134561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/01/2021] [Accepted: 03/17/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION This study aimed to determine associations between health warning label content and motivation to quit waterpipe smoking by gender and smoking location. METHODS Convenience samples of university students in three Eastern Mediterranean countries – Egypt (n=442), Jordan (n=535) and Palestine (n=487) – completed an online survey assessing health warning labels. Multinomial logit regression models were conducted to determine the association between different variables, particularly gender and smoking location, with motivation to quit. RESULTS In Palestine, female smokers were more motivated to quit waterpipe smoking when seeing textual warning labels related to children (T2) and pregnancy (T6) [T2: 1.8 (95% CI: 1.1–2.8), T6: 2.7 (95% CI: 1.6–4.3)] compared to males. Similar results were found in Jordan [T2: 1.6 (95% CI: 1.0–2.6), T6: 1.8 (95% CI: 1.1–3.0)]. As for the smoking location, home-only smokers in Palestine were more likely to quit in response to the following warnings: waterpipe smoking is addictive T1: 2.3 (95% CI: 1.4–3.7), harmful for children T2: 2.3 (95% CI: 1.4–4.1), harmful for the baby during pregnancy T6: 2.4 (95% CI: 1.3–4.3), and to believe that quitting reduces the health risks T9: 1.8 (95% CI: 1.0–3.1). These results were not found in Jordan nor Egypt. Smokers reported that the most noticeable location of a HWL on a waterpipe device is the mouthpiece. CONCLUSIONS A better understanding of motivation to quit and its association with various warnings and smoking location could guide countries on which warnings to require in legislation and where best to require them particularly in relation to location.
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Affiliation(s)
- Dina Farran
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Grace Khawam
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Centre for Development and Emergency Practices, Oxford Brookes University, Oxford, United Kingdom
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Juhan Lee
- College of Health and Human Performance, University of Florida, Gainesville, United States
| | - Niveen Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
| | | | - Aya Mostafa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Khalid A Kheirallah
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, American University in Cairo, Cairo, Egypt
| | - Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, United States
| | - Ramzi G Salloum
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,College of Medicine, University of Florida, Gainesville, United States
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Klein EG, Alalwan MA, Pennell ML, Angeles D, Brinkman MC, Keller-Hamilton B, Roberts ME, Nini P, Ferketich AK. Waterpipe Warning Placement and Risk Perceptions: An Eye Tracking Study. Am J Health Behav 2021; 45:186-194. [PMID: 33402248 PMCID: PMC7898276 DOI: 10.5993/ajhb.45.1.15] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objectives: The purpose of this study was to select a health warning message location on a waterpipe (WP) that both attracted visual attention and conveyed the risks associated with WP smoking. Methods: During June through November 2019, we conducted a within-subjects randomized experiment (N = 74) using eye tracking equipment to examine visual attention to 3 placements of a health warning on the WP (stem, water bowl, hose). We asked young adult ever WP users 3 questions about WP harm perceptions. We used generalized linear mixed models to examine the amount of fixation time spent on the placement locations; we used repeated measures ANOVA to model changes in harm perceptions. Results: There were statistically significant differences across all 3 placement locations; regardless of place, all HWLs attracted a comparable amount of visual attention. Absolute WP harm perceptions significantly increased following the experiment and remained significantly higher at the one-week follow-up, compared to baseline. Conclusions: Warnings on WPs attracted visual attention and increased harm perceptions, and those harm perceptions remained high one week after the experiment. Findings indicate the value of including a warning on the WP device, and underscore the necessity and effectiveness of those health warnings to combat WP harm misperceptions.
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Affiliation(s)
- Elizabeth G Klein
- Elizabeth G. Klein, Associate Professor, The Ohio State University College of Public Health, Columbus, OH, United States;,
| | - Mahmood A Alalwan
- Mahmood A. Alalwan, Student Research Assistant, The Ohio State University College of Public Health, Columbus, OH, United States
| | - Michael L Pennell
- Michael L. Pennell, Associate Professor, The Ohio State University College of Public Health, Columbus, OH, United States
| | - David Angeles
- David Angeles, Graduate Research Assistant, The Ohio State University, Columbus, OH, United States
| | - Marielle C Brinkman
- Marielle C. Brinkman, Senior Research Scientist, The Ohio State University College of Public Health, Columbus, OH, United States
| | - Brittney Keller-Hamilton
- Brittney Keller-Hamilton, Research Scientist, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Megan E Roberts
- Megan E. Roberts, Assistant Professor, The Ohio State University College of Public Health, Columbus, OH, United States
| | - Paul Nini
- Paul Nini, Professor, The Ohio State University, Columbus, OH, United States
| | - Amy K Ferketich
- Amy K. Ferketich, United States, Professor, The Ohio State University College of Public Health, Columbus, OH, United States
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Hallit S, Haddad C, Bou Malhab S, Khabbaz LR, Salameh P. Construction and validation of the water pipe harm perception scale (WHPS-6) among the Lebanese population. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2020; 27:3440-3448. [PMID: 31845251 DOI: 10.1007/s11356-019-07247-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/02/2019] [Indexed: 05/26/2023]
Abstract
Compared to cigarettes, water pipe is misconceived as being less addictive and containing less nicotine. This study aimed at constructing and validating a water pipe harm perception scale among a sample of the Lebanese population. A cross-sectional study was carried out between February and December 2017 using a proportionate cluster sample of Lebanese adults (492 participants). The water pipe harm scale items converged over a solution of one factor that had an eigenvalue over 1, explaining a total of 66.75% of the variance. The model used was adequate (Kaiser-Meyer-Olkin measure = 0.862 and Bartlett's test of sphericity p < 0.001). The reliability of all scale's items was high (Cronbach's alpha = 0.896). Higher cigarette dependence (LCD score) was significantly associated with higher water pipe harm perception scores, whereas exclusive water pipe smokers (Beta = - 2.142) and dual water pipe and cigarette smokers (Beta = -2.142) compared to nonsmokers, as well as those with high monthly income compared to a low one (Beta = -0.614), were significantly associated with lower water pipe harm perception scores. We constructed the first scale for measuring water pipe harm perception: the WHPS-6. The results of the present study demonstrate that the WHPS-6 can be used in clinical practice and research to assess the harm perception induced by water pipe smoking.
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Affiliation(s)
- Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon.
- INSPECT-LB:, Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Beirut, Lebanon.
| | - Chadia Haddad
- Research Department, Psychiatric Hospital of the Cross, Jal Eddib, Lebanon
| | - Sandrella Bou Malhab
- Ecole Doctorale des Sciences et Technologie, Lebanese University, Hadat, Lebanon
- Laboratoire de Pharmacologie, Pharmacie clinique et Contrôle de Qualité des Médicaments (LPCQM), Pôle Technologie- Santé (PTS) Faculté de Pharmacie, Beirut, Lebanon
- Ecole Doctorale Sciences et Santé, Université Saint-Joseph, Rue de Damas - Beyrouth, Lebanon
| | - Lydia Rabbaa Khabbaz
- Laboratoire de Pharmacologie, Pharmacie clinique et Contrôle de Qualité des Médicaments (LPCQM), Pôle Technologie- Santé (PTS) Faculté de Pharmacie, Beirut, Lebanon
- Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon
| | - Pascale Salameh
- Faculty of Pharmacy, Lebanese University, Hadat, Lebanon
- Faculty of Medicine, Lebanese University, Hadat, Lebanon
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Hallit S, Layoun N, Malaeb D, Outayek M, Boueid MJ, Waked M, Bacha ZA, Salameh P. The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2019; 26:36647-36657. [PMID: 31734838 DOI: 10.1007/s11356-019-06801-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 10/16/2019] [Indexed: 06/10/2023]
Abstract
Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.
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Affiliation(s)
- Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon.
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon.
| | - Nelly Layoun
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon
| | - Diana Malaeb
- School of Pharmacy, Lebanese International University, Beirut, Lebanon
- Department of Life Sciences and Health, Paris-Est University, Paris, France
| | - Miguella Outayek
- Faculty of Arts and Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Marie-Josée Boueid
- Faculty of Arts and Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon
| | - Mirna Waked
- Department of Pulmonology, St George Hospital University Medical Center, Beirut, Lebanon
- Faculty of Medicine, Balamand University, Koura, Lebanon
| | - Zeina Aoun Bacha
- Department of Pulmonary and Critical Care Medicine, Hotel-Dieu de France, Beirut, Lebanon
| | - Pascale Salameh
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon
- Faculty of Pharmacy, Lebanese University, Beirut, Lebanon
- Faculty of Medicine, Lebanese University, Beirut, Lebanon
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King JL, Reboussin BA, Ross JC, Sutfin EL. 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. Tob Control 2019; 28:e16-e23. [PMID: 30158209 PMCID: PMC6395506 DOI: 10.1136/tobaccocontrol-2018-054562] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Jessica L King
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Beth A Reboussin
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jennifer Cornacchione Ross
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Erin L Sutfin
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A, Hoek J. Would placing pictorial health warnings on waterpipe devices reduce waterpipe tobacco smoking? A qualitative exploration of Egyptian waterpipe smokers' and non-smokers' responses. Tob Control 2019; 28:475-478. [PMID: 29980654 PMCID: PMC6589487 DOI: 10.1136/tobaccocontrol-2018-054494] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/31/2018] [Accepted: 06/11/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Although Egypt places four generic pictorial health warnings (PHWs) on the front and back half of waterpipe tobacco packs (WTPs), waterpipe tobacco smoking (WTS) rates have continued to rise. It has been suggested that PHWs would be more salient if placed on the waterpipe device itself. This qualitative study explored how participants perceived the effects placing PHWs on waterpipe devices would have on warning salience and uptake or quitting of WTS. METHODS We conducted 10 focus groups and 10 in-depth interviews with 90 adult waterpipe smokers and non-smokers, men and women, who lived in rural, semi-urban and urban regions of Egypt. We presented participants with four novel PHWs of different sizes positioned randomly at four locations on a waterpipe device (the glass body, metal holder, mouthpiece or hose), one at a time. At each session, participants viewed a PHW on all four locations. Novel warnings were shown on plain labels with a dark uniform background and featured pictures, text and the quitline number. Transcripts were analysed using thematic analysis. RESULTS Participants thought placing PHWs on waterpipe devices might increase salience, prevent WTS initiation or trigger quit attempts; they favoured placing PHWs on the glass body, mouthpiece or waterpipe hose. Both waterpipe smoker and non-smoker participants thought these potential effects would affect non-smokers or non-established smokers more than established waterpipe users. CONCLUSIONS Our exploratory study suggests that PHWs featured prominently on waterpipe devices could potentially deter experimentation with waterpipe tobacco products and promote cessation, especially among non-established users.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba Tallah Mohammed
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Wafaa Mohamed Hussein
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elhabiby
- Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Safwat
- Egyptian Tobacco Control Coalition, Cairo, Egypt
- Egypt Health Foundation, Cairo, Egypt
| | - Sahar Labib
- Tobacco Control Unit, Ministry of Health, Cairo, Egypt
| | - Aisha Aboul Fotouh
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Janet Hoek
- Departments of Public Health and Marketing, University of Otago, New Zealand
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Mostafa A, Mohammed HT, Hussein RS, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A. Do pictorial health warnings on waterpipe tobacco packs matter? Recall effectiveness among Egyptian waterpipe smokers & non-smokers. PLoS One 2018; 13:e0208590. [PMID: 30562376 PMCID: PMC6298733 DOI: 10.1371/journal.pone.0208590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 11/20/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Despite 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 METHODS We 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. RESULTS Participants' 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. CONCLUSIONS Findings 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.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba Tallah Mohammed
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Rasha Saad Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wafaa Mohamed Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elhabiby
- Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Safwat
- Egyptian Tobacco Control Coalition, Cairo, Egypt
- Egypt Health Foundation, Cairo, Egypt
| | - Sahar Labib
- Tobacco Control Unit, Ministry of Health, Cairo, Egypt
| | - Aisha Aboul Fotouh
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A, Hoek J. Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers' and non-smokers' responses to enhanced versus existing pictorial health warnings in Egypt. BMJ Open 2018; 8:e023496. [PMID: 30355793 PMCID: PMC6224725 DOI: 10.1136/bmjopen-2018-023496] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Despite the global increase in waterpipe tobacco smoking (WTS) including in Egypt, few studies have assessed the effectiveness of waterpipe tobacco (WT) health warnings. Egypt has used pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) and has rotated these every two years since 2008. We explored in this qualitative study how participants perceived existing PHWs on WTPs, assessed how they interpreted novel plain packaging of WT featuring enhanced PHWs, and probed perceptions of how existing and novel sets would affect uptake or cessation of WTS. DESIGN We conducted ten qualitative focus groups and ten in-depth interviews. We explored participants' views of the four existing PHWs (occupied 50% of the front and back of WTPs, displayed cancers, and featured colourful fruits and flavors) and four novel PHWs (occupied 80% of the front and back of WTPs, displayed different topical content, with plain packaging). Transcripts were analyzed using thematic analysis. SETTING Rural Menoufia, urban and semi-urban Cairo, Egypt. PARTICIPANTS 90 waterpipe smokers and non-smokers, men and women, aged 18 years or older. OUTCOMES Perceived potential effect on WTS uptake or cessation, probing factors related to PHW content and WTP design. RESULTS Participants in focus groups and in-depth interviews thought existing WT PHWs elicited affective responses, but found them unclear or unrealistic and thought the colourful packaging detracted from the warnings. In contrast, they thought novel and larger WT PHWs presented in plain packaging might prevent WTS initiation or trigger quit attempts. Participants regarded warnings featuring proximal health risks as most likely to be acceptable. CONCLUSIONS Our exploratory study suggests larger WT PHWs featuring proximal risks and presented on plain WTPs could potentially deter experimentation with WT products among non-users and promote cessation among existing users.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Heba Tallah Mohammed
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- School of Pharmacy, University of Waterloo, Ontario, Canada
| | - Wafaa Mohamed Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud Elhabiby
- Department of Psychiatry Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Wael Safwat
- Egyptian Tobacco Control Coalition, Cairo, Egypt
- Egypt Health Foundation, Cairo, Egypt
| | - Sahar Labib
- Tobacco Control Unit, Ministry of Health, Cairo, Egypt
| | - Aisha Aboul Fotouh
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Janet Hoek
- Departments of Public Health and Marketing, University of Otago, Otago, New Zealand
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Abu-Rmeileh NM, Alkhuffash O, Kheirallah K, Mostafa A, Darawad M, Al-Farsi Y, Yusufali A, Thomas J, Salama M, Hamadeh RR, Nakkash R, Salloum RG. Harm perceptions of waterpipe tobacco smoking among university students in five Eastern Mediterranean Region countries: A cross-sectional study. Tob Induc Dis 2018; 16:20. [PMID: 31516420 PMCID: PMC6659482 DOI: 10.18332/tid/89966] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. METHODS This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. RESULTS A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. CONCLUSIONS Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.
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Affiliation(s)
- Niveen M.E. Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Occupied Palestinian Territories
| | - Ola Alkhuffash
- Statistic Department, Hacettepe University, Ankara, Turkey
| | - Khalid Kheirallah
- Department of Public Health, Medical School, Jordan University of Science and Technology, Irbid, Jordan
| | - Aya Mostafa
- Department of Community Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | | | | | | | - Randah R. Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Rima Nakkash
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ramzi G. Salloum
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida, United States
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