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Jebai R, Asfar T, Cano MÁ, Nakkash R, Schmidt M, Wu W, Bursac Z, Maziak W. Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis. Nicotine Tob Res 2024; 26:764-770. [PMID: 37952202 DOI: 10.1093/ntr/ntad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Pictorial health warning labels (HWLs) on waterpipe (WP) tobacco packages represent a better strategy for communicating the health risks associated with WP use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown. AIMS AND METHODS This study explores how pictorial warnings versus text-only induces higher quit intention among a sample of young adult WP smokers in Lebanon. An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult WP smokers who were exposed to two conditions: pictorial HWLs and text-only warnings on WP tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (eg, attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit. RESULTS Using serial mediation, exposure to pictorial warnings versus text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect (β = 0.063; [95% bootstrap CI = 0.004 to 0.149]) and cognitive elaboration (0.047; [0.001 to 0.114]) were statistically significant. CONCLUSIONS The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb WP tobacco smoking. IMPLICATIONS This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial HWLs on intention to quit in a sample of current WP smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing WP-HWLs regulations in Lebanon and other countries to curb WP tobacco smoking.
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Affiliation(s)
- Rime Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Miguel Ángel Cano
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
| | - Michael Schmidt
- School of Public Health and Department of Art, University of Memphis, Memphis, TN, USA
| | - Wensong Wu
- Department of Mathematics and Statistics, Florida International University, Miami, FL, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
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Jebai R, Asfar T, Nakkash R, Chehab S, Schmidt M, Wu W, Bursac Z, Maziak W. Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study. HEALTH EDUCATION RESEARCH 2023; 38:537-547. [PMID: 37436823 PMCID: PMC10714039 DOI: 10.1093/her/cyad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 06/09/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023]
Abstract
This study compares the impact of pictorial health warning labels (HWLs) and their placements on waterpipe parts (device, tobacco and charcoal packages) on health communication outcomes between waterpipe smokers and nonsmokers in Lebanon. An online randomized crossover experimental study was conducted among young adults (n = 403, August 2021) who observed three conditions of HWLs: pictorial HWLs on the tobacco package, pictorial HWLs on all waterpipe's parts and text-only HWL on the tobacco package in random order. Participants completed post-exposure assessments of health communication outcomes after each image. Using linear mixed models, we examined the differences in the effect of HWL conditions on several outcomes (i.e. warning reactions) between waterpipe smokers and nonsmokers, controlling for confounders (i.e. age, sex). Nonsmokers reported greater attention (β = 0.54 [95% confidence interval: 0.25-0.82]), cognitive elaboration (0.31 [0.05-0.58]) and social interaction (0.41 [0.18-0.65]) for pictorial HWLs on the tobacco packages than text-only compared with smokers. Pictorial HWLs on three parts versus one part elicited higher cognitive reactions and perceived message effectiveness in nonsmokers compared with waterpipe smokers. These findings provide valuable information for policymakers about the potential of implementing HWLs specific to waterpipes to prevent their use among young adults and limit tobacco-related morbidity and mortality in Lebanon.
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Affiliation(s)
- R Jebai
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - T Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 919, Miami, FL 33136, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 5555 Ponce De Leon Blvd, Miami, FL 33136, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - R Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh 1107 2020, Beirut 11-0236, Lebanon
- Department of Global and Community Health, College of Health and Human Services, George Mason University, 4400 University Drive, MS: 5B7, Fairfax, VA 22030, USA
| | - S Chehab
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Riad El-Solh 1107 2020, Beirut 11-0236, Lebanon
| | - M Schmidt
- Department of Art, University of Memphis, 101 Wilder Tower, Memphis, TN 38152, USA
| | - W Wu
- Department of Mathematics and Statistics, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - Z Bursac
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
| | - W Maziak
- Department of Epidemiology, Robert Stempel College of Public Health, Florida International University, 11200 SW 8th St, Miami, FL 33199, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
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Jebai R, Asfar T, Nakkash R, Chehab S, Wu W, Bursac Z, Maziak W. Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study. Tob Control 2023; 32:715-722. [PMID: 35444030 PMCID: PMC9582042 DOI: 10.1136/tobaccocontrol-2021-057202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/04/2022] [Indexed: 11/03/2022]
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.
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Affiliation(s)
- Rime Jebai
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, Florida, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Rima Nakkash
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, USA
| | - Sara Chehab
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Wensong Wu
- Department of Mathematics and Statistics, College of Arts, Sciences & Education, Florida International University, Miami, Florida, USA
| | - Zoran Bursac
- Department of Biostatistics, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA
| | - Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida, USA
- Syrian Center for Tobacco Studies, Aleppo, Syria
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Asfar T, Chehab S, Schmidt M, Ward KD, Maziak W, Nakkash R. "Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon. Nicotine Tob Res 2022; 24:1458-1468. [PMID: 35196373 PMCID: PMC9356692 DOI: 10.1093/ntr/ntac053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. AIMS AND METHODS We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. RESULTS Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories. CONCLUSIONS Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. IMPLICATIONS Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.
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Affiliation(s)
- Taghrid Asfar
- Department of Public Health Sciences, University of Miami, Miller School of Medicine, Miami, FL, USA,Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA,Syrian Center for Tobacco Studies, Aleppo, Syria
| | - Sara Chehab
- Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Kenneth D Ward
- Syrian Center for Tobacco Studies, Aleppo, Syria,School of Public Health, University of Memphis, Memphis, TN, USA
| | - Wasim Maziak
- Syrian Center for Tobacco Studies, Aleppo, Syria,Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International, Miami, FL, USA
| | - Rima Nakkash
- Corresponding Author: Rima Nakkash, DrPH, Department of Health Promotion and Community Health, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Van Dyck Building, PO Box 11-0236, Beirut, Lebanon. Telephone: 961 1 350000 ext. 4667; Fax: 961-1-744470; E-mail:
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