Background 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.
Background: Alcohol use is a major risk factor in premature death and disability, especially among youth. Evidence-based policies to prevent and control the detrimental effect of alcohol use have been recommended. In countries with weak alcohol control policies—such as Lebanon, stakeholder analysis provides critical information to influence policy interventions. This paper assesses the views of stakeholders regarding a national alcohol harm reduction policy for youth. Methods: We interviewed a total of 22 key stakeholders over a period of 8 months in 2015. Stakeholders were selected purposively, to include representatives of governmental and non-governmental organizations and industry that could answer questions related to core intervention areas: affordability, availability, regulation of marketing, and drinking and driving. We analyzed interview transcripts using thematic analysis. Results: Three themes emerged: Inadequacy of current alcohol control policies; weak governance and disregard for rule of law as a determinant of the status quo; and diverting of responsibility towards ‘other’ stakeholders. In addition, industry representatives argued against evidence-based policies using time-worn strategies identified globally. Conclusions: Our findings indicate that alcohol harm reduction policies are far from becoming a policy priority in Lebanon. There is a clear need to shift the narrative from victim blaming to structural conditions.
This study aims to explore the perceived effectiveness of waterpipe (WP) tobacco specific health warning labels (HWLs) among young adult WP smokers and nonsmokers in Lebanon. Before participating in focus group discussions, participants (n = 66; WP smokers n = 30; nonsmokers n = 36; age 18–33) completed a brief survey to rate the effectiveness of 12 HWLs’ and rank them according to four risk themes (WP health effects, WP harm to others, WP-specific harm, and WP harm compared to cigarettes). Differences in HWLs ratings by WP smoking status were examined and the top-ranked HWL in each theme were identified. HWLs depicting mouth cancer and harm to babies were rated as the most effective by both WP smokers and non-smokers. WP smokers rated HWLs which depicted harm to children and infants as more effective than non-smokers. The top-ranked HWLs for perceived overall effectiveness were those depicting “oral cancer”, “harm to babies”, “orally transmitted diseases” and “mouth cancer”. HWLs depicting oral lesions and harm to babies were rated as most effective, while HWLs showing the harmful effects of WP secondhand smoke on infants and children were rated as less effective by nonsmokers compared to smokers. Our study provides evidence on the potential effectiveness of HWLs for further evaluation in Lebanon and the Eastern Mediterranean region. The results will inform and guide the development and implementation of tobacco control policy.
PurposeWaterpipe 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.MethodsWe 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.ResultsCompared 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.ConclusionsPictorial 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.
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 warnings 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. 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 waterpipe-specific pictorial health warning labels (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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