Waterpipe Smoking Is Increasing Globally, but Health Warning Labels Reduces Satisfaction in Users, Researchers Find

Taghrid Asfar, M.D., MSPH, research assistant professor at the University of Miami Miller School of Medicine’s Department of Public Health Sciences, and Wasim Maziak, MD, Ph.D., professor and chair of the Department of Epidemiology at Florida International University, initiated a five-year project funded by the National Institute of Health and the Fogarty International Center in 2017. The goal of the project is to develop and test waterpipe-specific health warning labels (HWLs) in Tunisia and Lebanon, two countries in the Eastern Mediterranean Region (EMR) and equip them with the means to implement them successfully.

Waterpipe smoking (WP) – also known as Hookah – has globally become one of the leading tobacco-use methods. In particular, WP smoking is now the No. 1 tobacco-use method among youth in the EMR. There have also been widespread misconceptions that WP smoking is less harmful and addictive than cigarettes.

Given these misperceptions and the value of HWLs in communicating smoking-related risks, the development of the labels is a priority for WP smoking control.

“The impact of this dramatic rise is amplified by the mounting evidence that WP smoking has an addictive and harmful nature that can cause diseases like lung cancer and heart disease. There is also a lag of policy response to it,” said Dr. Asfar.

Dr. Asfar led the first stage by developing the labels using a Delphi study among international tobacco control experts. In this study, which was published in Tobacco Control, 28 HWLs were developed. The labels communicated WP smoking's health risks, its harm to others, specific harm to users, and harm compared to cigarettes. A three-round Delphi study was conducted among an international panel of tobacco control experts to reach consensus on a set of the most effective HWLs for each theme. The top-ranked HWLs in each theme were then selected for the final list of 12 HWLs.

Dr. Asfar and Dr. Maziak also conducted a proof-of-concept pilot study to test how HWLs on WP smoking devices would affect the satisfaction of WP smokers and their exposure to toxins. This pilot study showed that placing HWLs on WP devices has the potential to reduce the positive experiences of WP smokers, as well as their exposures to carbon monoxide, nicotine, suggesting a strong consideration for the labels.

The research team will now test the effectiveness of the developed HWLs in Lebanon and Tunisia using focus groups and experimental study. “Findings will likely benefit other countries trying to curb WP trends among youth, including the U.S.,” said Dr. Asfar.

Written by Amanda Torres

July 30, 2019