Project 1: Developing and testing pictorial health warning labels for young hookah smokers in Florida

Evidence suggests that hookah smoking is addictive and harmful. Hookah smoking increases risks of developing health conditions such as lung cancer, heart, and respiratory diseases.

Using the Delphi method among tobacco control experts, our team developed 28 health warning labels corresponding to 6 themes; addiction, hookah harm compared to cigarettes, harm to others, health risks, health risks- COVID-19, quitting hookah smoking, and hookah specific harm.¹ The top-ranked health warning labels by an international expert panel in each theme were then selected for the final list of 12 health warning labels. These health warning labels were then discussed in focus groups in 2 countries (Lebanon, Tunisia) for further adaptation to the target population.^2,3 Later, a set of 12 health warning labels along with two more themes, health risks COVID-19 and quitting hookah smoking, were implemented. Resulting in a set of 24 health warning labels corresponding to 6 health themes (addiction, hookah harm compared to cigarettes, harm to others, health risks and health risks COVID-19, quitting hookah smoking, and hookah-specific harm).

Building on this work and using a mixed-method approach incorporating qualitative and quantitative research, we will adapt the developed health warning labels to young hookah smokers in Florida and test them. We will recruit young hookah smokers between the ages of 21-35 to:

1. Conduct focus groups to adapt the 24 health warning labels to our local population of young adults and explore optimal health warning label placement and size.
2. Conduct a clinical lab experiment among hookah smokers to test the performance of the top 4 health warning labels on the hookah device compared to no-health warning label (control) on harm perception, intention to quit, puffing behavior, dependence (e.g. satisfaction, withdrawal), and toxicant exposure (CO, nicotine, oxidative stress).
3. Partner with Golin, Tobacco-Free Workgroup, and Truth Initiative to advocate for the adoption of health warning label policies and disseminate knowledge about hookah harmful effects to young people in Florida and nationally.

Project 2: Develop and test pictorial health warning labels for e-cigarettes

In this project, we will build on the experience of the hookah health warning labels study, to systematically develop health warning labels for e-cigarettes. This project aims to:

1. Conduct a Delphi study among experts to enhance the developed pictorial health warning labels for e-cigarettes and reach experts’ consensus on the top 12 health warning labels
2. Adapt the top 12 health warning labels to young e-cigarette users using feedback from e-cigarette users collected during focus groups.
3. Test the impact of health warning labels on the e-cigarette devices on a myriad of subjective and objective outcomes in a clinical lab study.

This approach will provide a comprehensive, holistic, and stepwise buildup of rigorous evidence needed to advance health warning label policies and withstand expected scrutiny and challenges.

Project 3: Develop and test culturally sensitive pictorial health warning labels to young adults in Lebanon and Tunis

Supported by the Fogarty International Center since 2002, our team at the Syrian Center for Tobacco Studies (SCTS; https://www.scts-sy.org/) has been on the forefront of characterizing the hookah epidemic and its health and addictive properties. Such groundwork has prepared us to plan for the next stage of translating evidence into policy to support Eastern Mediterranean Region’s efforts to control the hookah epidemic.

Building on our ongoing collaboration with Lebanon (American University of Beirut) and Tunisia (University of Tunis), we will assist these countries in developing and implementing effective health warning labels for the hookah and in building their national capacity in tobacco control policy research. This project aims to:

1. Develop and test hookah health warning labels for the Eastern Mediterranean Region using a mixed methods approach with the involvement of members of the target population comprised mostly of young adults.

References

1. Asfar, T., et al. (2019). "Delphi study among international expert panel to develop waterpipe-specific health warning labels." Tobacco control: tobaccocontrol-2018-054718.
2. Ben Mansour, N., et al. (2019). Developing health warning labels for waterpipe smokers in Tunisia: Results from a qualitative study. Presented at the SRNT-Europe Conference, Oslo, Norway on 12-14 September 2019.
3. Nakkash, Rima, Malak Tleis, Sara Chehab, Wu Wensong, Michael Schmidt, Kenneth D. Ward, Wasim Maziak, and Taghrid Asfar. "Novel Insights into Young Adults’ Perceived Effectiveness of Waterpipe Tobacco-Specific Pictorial Health Warning Labels in Lebanon: Im