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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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Seitz CM, Ward KD, Kabir Z. Country Participation in the WHO Framework Convention on Tobacco Control Health Warnings Database. Tob Use Insights 2021; 14:1179173X211064214. [PMID: 34880697 PMCID: PMC8646821 DOI: 10.1177/1179173x211064214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/03/2021] [Indexed: 12/05/2022] Open
Abstract
Background The World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Health Warnings Database is an online, publicly available resource created for countries to upload and share pictorial health warnings for tobacco packaging. The purpose of this study was to evaluate the extent to which the database is used by countries for the sharing of pictorial warnings. Methods The study’s sample included parties to the FCTC who required graphic health warning labels on cigarette packaging from. Those countries were categorized as having a low, middle, and high Socio-Demographic Index (SDI). The Health Warnings Database was then analyzed for those countries’ unique pictorial images, as well as the number of pictorials that were shared between countries. Results Of the 110 countries that required pictorial warnings on cigarette packaging, only 53 (48%) voluntarily contributed pictorials to the database, with most of those (53%) being high SDI-level countries. There were 342 unique pictorials on the database, with 62 images posted by seven countries that were used by 13 other countries. Conclusion While sharing was evident from the database, there remains a need for more countries to upload the pictorials to the database. There is also a need to expand the database to include alternative tobacco products, such as waterpipe tobacco and e-cigarettes.
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Affiliation(s)
- Christopher M Seitz
- Department of Health & Exercise Science, Appalachian State University, Boone, NC, USA
| | - Kenneth D Ward
- Division of Social and Behavioral Sciences, The University of Memphis, Memphis, TN, USA
| | - Zubair Kabir
- School of Public Health, University College Cork, Cork, Ireland
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Mostafa A, El Houssinie M, Hussein RS. Perceived efficacy of existing waterpipe tobacco warning labels versus novel enhanced generic and waterpipe-specific sets. PLoS One 2021; 16:e0255244. [PMID: 34314460 PMCID: PMC8315518 DOI: 10.1371/journal.pone.0255244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Since 2008, Egypt has four existing generic bi-annually rotating warning labels (WLs) on 50% of the waterpipe tobacco packs (WTPs). The Ministry of Health Tobacco Control Unit proposed increasing WL size to 80%, removing colours and flavour imagery from WTPs, and plain packaging to help curb the rising epidemic of waterpipe tobacco smoking. Therefore, we measured the perceived efficacy of existing against novel enhanced (generic and waterpipe-specific) WTP WLs and the associated factors among Egyptian waterpipe smokers and nonsmokers. METHODS A purposive quota sample of 2014 adults was surveyed in two rounds using face interviews. At each round, participants were randomly shown one of four existing WLs, then one of four novel WLs. Participants rated the perceived efficacy of existing and novel WLs regarding the salience, depth of processing, affective reactions, credibility, relevance, perceived harm and perceived behavioural control. Data were analysed using Generalized Estimating Equations. RESULTS Participants rated novel WTP WLs with higher mean perceived efficacy scores than existing WLs for all measures, although both sets collectively scored modestly (59.7; 95% CI: 58.9-60.5 vs 53.0; 95% CI: 52.1-54.0, respectively; p<0.001). Relative to the existing WTP WLs, novel WLs were particularly able to induce higher salience, affective reactions, and depth of processing. Relative to the generic novel WTP WLs, waterpipe-specific WLs induced higher relevance, perceived harm, and affective reactions. Nonsmokers scored higher than waterpipe tobacco smokers, specifically for perceived behavioral control (65.0±32.5 vs 43.6±19.8, respectively; p<0.001). WTP WLs featuring proximal risks, such as dental effects (β = 9.70; 95% CI: 7.00-12.40), fetal harm (β = 9.42; 95% CI: 6.75-12.10), or toxic contents (β = 9.14; 95% CI: 6.58-11.70) were strongly associated with participants' perceived efficacy scores. Among other independent factors, rural residence (β = 24.09; 95% CI: 22.21-25.97), being a nonsmoker (β = 10.51; 95% CI: 8.92-12.10), survey round 2 (β = 6.96, 95% CI: 5.73-8.19), the novel WTP WL set (β = 6.68; 95% CI: 6.19-7.17), and having higher education (β = 6.31; 95% CI: 4.34-8.27) were highly associated with participants' perceived efficacy scores. CONCLUSIONS Waterpipe-specific WLs on plain WTPs that feature proximal risks and address different population subgroups need to be developed in conjunction with awareness raising campaigns on WTS harms to reinforce the credibility of WTP WLs. Our findings suggest the proposed WTP WL enhancements by the Tobacco Control Unit may support a more effective WTP labelling policy within a comprehensive waterpipe-specific tobacco control framework.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- * E-mail:
| | - Moustafa El Houssinie
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rasha Saad Hussein
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design. Contemp Clin Trials Commun 2021; 23:100797. [PMID: 34235290 PMCID: PMC8249778 DOI: 10.1016/j.conctc.2021.100797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/23/2021] [Accepted: 06/03/2021] [Indexed: 02/06/2023] Open
Abstract
Waterpipe tobacco smoking (WTS) has increased substantially in the Eastern Mediterranean Region (EMR), affecting young adults who perceive waterpipe as safer than cigarette smoking. Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, there are few experimental studies that examined pictorial HWLs specific to WTS. Methods/design: This report describes the design and protocol of the first factorial experimental study that aims to test the effectiveness of pictorial HWLs based on their placement on waterpipe device, tobacco, and charcoal packages among young adult smokers and non-smokers residing in Lebanon and Tunisia. After completing a baseline assessment, participants will be randomly assigned to 3 experimental conditions in a 3 (HWL: pictorial HWL on tobacco package vs. pictorial HWL on 3 placements [device, tobacco, and charcoal packages] vs. text-only HWL on tobacco package) x 4 (pictorial HWLs) x 2 (waterpipe smokers vs. non-smokers) factorial design. We will use a within/between-subject design, where pictorial HWLs and time (pre vs. post-exposure) are the within-subject factors and waterpipe smoking status as the between-subjects factor. Participants will complete post-exposure measures that include attention, perceived harm, intention to quit (smokers) or initiate smoking (non-smokers). Discussion: This is the first international study examining the placements of pictorial HWLs using efficient within/between subject design. Findings will provide additional evidence to convince policymakers to consider three placements of HWLs specific to WTS as a promising regulatory target to curb WTS.
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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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Hamadeh RR, Lee J, Abu-Rmeileh NME, Darawad M, Mostafa A, Kheirallah KA, Yusufali A, Thomas J, Salama M, Nakkash R, Salloum RG. Gender differences in waterpipe tobacco smoking among university students in four Eastern Mediterranean countries. Tob Induc Dis 2020; 18:100. [PMID: 33299390 PMCID: PMC7720794 DOI: 10.18332/tid/129266] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Males have a higher prevalence of waterpipe tobacco smoking (WTS) than females in most Eastern Mediterranean Region (EMR) countries, with a smaller gender gap than that of cigarette smoking. The objective of this study was to determine gender differences among university students with respect to WTS initiation, smoking behavior, tobacco flavors, and expenditure on WTS, in four EMR countries. METHODS A cross-sectional online survey was conducted based on convenient samples of ever waterpipe smokers among university students in four EMR countries (Egypt, Jordan, Occupied Palestinian Territories, and the United Arab Emirates) in 2016. The total samples included 2470 participants. Study participants were invited through flyers, university portals, emails and Facebook, followed by emails with links to the internet survey. RESULTS Females (80.4%) were more likely than males (66.4%, p<0.001) to be in the younger age group (18–22 years) and they were less likely to be current waterpipe smokers (females, 60.0%; males 69.5%, p<0.001). Two-thirds of students across both genders smoked their first waterpipe at the age of 15–19 years, with more females starting with family members. Over one-third of males and 14.9% of the females usually smoked ≥10 heads (p<0.001). About half (46.6%) of females smoked for less than half an hour compared to 30.5% of males (p<0.001). Only 1% of females smoked non-flavored tobacco compared to 11% of males (p<0.001). There was a significant (p=0.05) positive correlation (r=0.808) with respect to tobacco flavor usually smoked between males and females with apple/double apple being the most popular. CONCLUSIONS There were gender differences in WTS in several aspects. The study has implications for educational establishments, tobacco control and women civil society groups, as well as policymakers.
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Affiliation(s)
- Randah R Hamadeh
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Juhan Lee
- Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, United States
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Birzeit, Occupied Palestinian Territories
| | | | - Aya Mostafa
- Department of Community, Environmental and Occupational Medicine, Ain Shams University, Cairo, Egypt
| | - Khalid A Kheirallah
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Justin Thomas
- Department of Psychology, Zayed University, Abu Dhabi, United Arab Emirates
| | - Mohamed Salama
- Institute of Global Health and Human Ecology, The American University in Cairo, New Cairo, Egypt
| | - Rima Nakkash
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, United States
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Kienhuis AS, Talhout R. Options for waterpipe product regulation: A systematic review on product characteristics that affect attractiveness, addictiveness and toxicity of waterpipe use. Tob Induc Dis 2020; 18:69. [PMID: 32934615 PMCID: PMC7485441 DOI: 10.18332/tid/125079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/05/2020] [Accepted: 07/08/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Despite its known adverse effects on human health, waterpipe smoking is increasing in popularity worldwide. However, compared to cigarettes, regulation of waterpipe product smoking lags behind and presents unique challenges. In search for regulatory options, this systematic review analyzes 36 studies on the differential effects on human health of the waterpipe characteristics including smoking products, heating sources, device components, and packages. METHODS A systematic review was performed according to PRISMA guidelines, revealing 443 unique citations. After screening, 36 studies were included in the results. Research articles were selected to inform on differential effects caused by product characteristics on adverse health effects, attractiveness, addictiveness and prevalence of waterpipe use. RESULTS Flavors are the key aspect that defines attractiveness of waterpipe product smoking. All waterpipe products, with or without nicotine, produce toxicants in similar quantities as cigarettes. Heating sources for waterpipe tobacco include charcoals and electrical heating. Both heating sources increase toxicant emissions in different ways. Hoses and mouth tips are device components that are often shared in waterpipe smoking. Sharing influences attractiveness by enriching the social experience. At the same time, it influences the transfer of infectious diseases by bacteria and viruses from one smoker to another. Studies showed that more generic and less attractive packages with health warnings are effective in reducing the attractiveness of waterpipe smoking. CONCLUSIONS Based on our findings, we advise to include all waterpipe products, tobacco and non-tobacco, with or without nicotine, in tobacco product regulations and smoking bans in order to: ban waterpipe molasses with characterizing flavors or ban the use of flavorings at any level; mandate dissemination of information on all waterpipe tobacco elements to the national regulator; prescribe testing to regulate contents of waterpipe smoking products and heating sources. Moreover, we advise to stimulate research on emissions of waterpipes.
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Affiliation(s)
- Anne S Kienhuis
- Centre for Health Protection, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Reinskje Talhout
- Centre for Health Protection, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
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Abstract
Coronavirus disease 2019 (COVID-19) has been recognized as a pandemic by the World Health Organization. Global efforts have been exerted to prevent the spreading of the disease through political decisions together with personal behaviors, which depend on awareness of the public. The goal of this study is to assess the knowledge, perceptions and attitude of the Egyptian public towards the COVID-19 disease. We conducted a cross-sectional survey about these points, which was distributed among adult Egyptians. Five hundred and fifty nine persons completed the survey. The mean knowledge score was 16.39 out of 23, gained mainly though social media (66.9%), and the internet (58.3%). Knowledge was significantly lower among older, less educated, lower income participants, and rural residents. Most participants (86.9%) were concerned about the risk of infection. While 37.6% thought that their salary will be continued if they become isolated, 68.5% believed that it should be continued during this period. About 73.0% were looking forward to get the vaccine when available. In general, participants had a good knowledge about the disease and a positive attitude towards protective measures. This knowledge is gained mainly through novel media channels, which have pros and cons. Although the government has taken major steps to educate the public and limit the spread of the disease, more effort is needed to educate and support the lower economic strata. If a vaccine or a treatment is approved, we recommend a government control over its use to preserve the rights of the vulnerable and needy groups.
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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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Maziak W, Osibogun O, Asfar T. Waterpipe smoking: the pressing need for risk communication. Expert Rev Respir Med 2019; 13:1109-1119. [PMID: 31519113 PMCID: PMC7004232 DOI: 10.1080/17476348.2019.1668271] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/12/2019] [Indexed: 01/21/2023]
Abstract
Introduction: Waterpipe (WP) smoking is an important public health problem that is rapidly evolving globally. Much of WP spread among youth is perpetuated by a misperception of reduced harms compared to cigarettes. Increasing awareness about WP smoking harms through health warning labels (HWLs) represents a promising policy and regulatory strategy to curb WP smoking. Areas covered: Peer-reviewed publications indexed in PubMed and CINAHL were searched in March 2019. This review focuses on the current knowledge of WP smoking characteristics, its spread and patterns of use globally, and some of the major WP-related health effects. This knowledge is utilized to advance a promising policy and regulatory avenue to curb WP smoking by increasing awareness of its potential harms through HWLs. It also addresses product configuration and unique features that influence the adaptation of HWLs for WP smoking. Expert opinion: HWLs are effective in communicating smoking-related risks to WP smokers in a way that affects their smoking behavior and experience as well as interest in quitting. Although based on limited data, the WP device appears to be a promising location for HWLs as it offers prolonged contact with smokers and those surrounding them.
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Affiliation(s)
- Wasim Maziak
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
- Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
| | - Olatokunbo Osibogun
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA
| | - Taghrid Asfar
- Syrian Center for Tobacco Studies, Aleppo, Syrian Arab Republic
- Division of Epidemiology, Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA
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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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