“Scary and Effective, Definitely Pushes Me to Quit Smoking”: Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon

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.

Introduction

While cigarette smoking has been declining globally, waterpipe (WP) smoking (aka hookah) has increased dramatically, particularly in the Eastern Mediterranean Region (EMR).^1,2 In Lebanon, WP smoking is the leading tobacco use method among young adults.¹ A 2018 systematic review on WP use in 68 countries across the six World Health Organization regions indicated that ever WP use (defined as having ever smoked WP in the past) was highest among Lebanese university students (65.3%), and current WP use (in the past 30 days) was highest among Lebanese youth (37.2%).¹ The increased socio-cultural acceptability of WP smoking is the main reason for WP use among Lebanese young people.³ Other factors contributing to the spread of WP use include the introduction of Maassel (a syrupy tobacco mix containing molasses, vegetable glycerol, and various flavorings which is smoked in a WP), the thriving café culture, the rise of the Internet and social media, and the lack of WP-specific regulations and policies.² WP smoking is associated with cancer, cardiopulmonary disease, and nicotine addiction.^4,5 Additionally, the use of charcoal results in exposure to high levels of carcinogens,⁶ while sharing WPs increase the risk of communicable diseases (eg, tuberculosis).⁷ WP use also is deemed a gateway to cigarette smoking.^8,9 Still, many WP users believe that it is safer than cigarettes, which indicates an important gap in communicating evidence about the harmful nature of WP smoking to users.¹⁰

Applying health warning labels (HWLs) on tobacco products is effective in communicating tobacco-associated risks.¹¹ Pictorial HWLs on cigarette packages are proven to be cost-effective in reducing smoking and smoking-related morbidity and mortality.¹² Article 11 of the World Health Organization Framework Convention on Tobacco Control requires the implementation of pictorial HWLs on WP tobacco products,^13,14 yet most Framework Convention on Tobacco Control-ratified countries have not complied with this requirement.¹⁵ In Lebanon, a textual HWL stating “Smoking leads to fatal and serious disease” is currently required on WP tobacco packaging. Recommendations suggest HWL developers consider product characteristics and the target population’s perceptions that influence message response.¹⁶ Given the superior performance of pictorial HWLs and the need for HWLs to accommodate WP’s unique users and harm,¹¹ Lebanon’s generic HWL is inadequate.⁴ Few studies have tested the effectiveness of WP pictorial HWLs worldwide, and all these studies used generic, not WP-specific, HWLs without consideration of the target population’s cultural context.^17–22 Therefore, there is a need to systematically develop WP-specific pictorial HWLs focusing on WP’s unique harms and the cultural context of the target population.^10,17,23

Our team has started in 2017 an international project aimed at developing and testing WP-specific pictorial HWLs for two countries in the EMR, Tunisia, and Lebanon. As part of this project, we developed a set of 12 WP-specific pictorial HWLs using the Delphi method among an international expert panel. These HWLs were grouped into four Themes (T): (T1) WP health effects, (T2) WP harm to others, (T3) WP-specific harms, and (T4) WP harm compared to cigarettes (Figure 1).^24,25 In this study, we conducted focus groups to culturally adapt the content and design of these 12 HWLs to young adults’ unique values and beliefs in Lebanon.²⁴ Focus groups discussed the participants’ perceptions of the HWLs’ design, content, effectiveness, and improvement before broader testing. Results from this study will advance WP regulations through the implementation of WP-specific HWLs in Lebanon, facilitate knowledge dissemination about WP’s harmful effects, and aid further HWL development and adaptation by researchers in other EMR countries.

Figure 1.

The 12 Health Warning Labels that were tested in the focus groups divided by Theme.

Methods

Design

The study was approved by the Institutional Review Boards at the American University of Beirut in Lebanon, Florida International University, and University of Miami in the United States. Nine mixed-gender focus groups were conducted among young adults in Beirut, Lebanon (N = 77; 52% females; age 18–34 years) between February and July of 2019. This age range was selected because it is at especially high risk of initiation, prevalence, and progression of WP use in Lebanon.^2,3 Four groups were comprised of current WP smokers (smoked WP at least once in the past 30 days),²⁶ and five groups were comprised of nonsmokers (have not used any tobacco/nicotine product in the past year).²⁷ Participants who reported using other tobacco products (eg, cigarette, e-cigarette) were included to increase the generalizability of the results, since concurrent tobacco use is common among young WP smokers in Lebanon.³ Methodological details including participant characteristics, recruitment approach, consent form, procedures, the PowerPoint presentation, the discussion guide, and the baseline assessment are provided in the supplement.

Participants

Eligibility requirements were being a young adult 18–34 years old and a current WP smoker or nonsmoker. A combination of online (eg, Listservs and social media), offline (eg, flyers), and in-person (eg, leaflets, word-of-mouth) recruitment methods were used in Beirut, particularly in the vicinity of four universities, popular restaurants, hookah cafes, and public spaces.²⁸ Prospective participants were screened for eligibility by phone, scheduled for a focus group session, and provided the time/place of their focus group.

Procedures

Focus group sessions were held in a private conference room at the American University of Beirut. Each session started with a discussion on the nature and confidentiality for the group discussion. Written informed consent was obtained, and participants completed a baseline assessment of their demographic characteristics and smoking history. The group discussion entailed four segments (one per theme), each began with a PowerPoint presentation about the WP health effects relevant to the segment’s theme, followed by a discussion of each HWL in that theme. The main purpose of the PowerPoint presentation was to create shared baseline information that can guide and anchor the discussion around available evidence of WP health effects and related messages that they will be exposed to. While it is true that greater ecological validity might have been achieved by not exposing participants to information about WP health effects prior to exposure to HWLs, we had to balance this concern with the need to ensure that all participants had accurate foundational knowledge to guide and anchor the discussion. Not doing so likely would have resulted in tangential issues being raised about whether WPs truly damage health, or whether HWLs were appropriate. Discussions focused on: (1) attention (general design); (2) reaction (fear, believability, avoidance); (3) effect (harm perception); and (4) improvement (relatedness, clarity). Focus groups lasted approximately 150 min and were moderated by two public health researchers trained in qualitative methods. Group discussions and analysis were guided by a semi-structured script based on the Message Impact Framework.¹² Participants received a $15 incentive for participating in the study.

Analysis

Focus groups were audio-recorded and transcribed. Transcripts were coded in Dedoose using directed qualitative content analysis.^29,30 Coding of participants’ reactions to the HWLs proceeded deductively from theoretical constructs used in the four study themes. Meaning units (quotes) were grouped under their respective constructs (main categories) and summaries were drafted. A second coder reviewed the summaries and compared them to the data. Differences were resolved through peer debriefing.³¹ Coding of participants’ recommendations for HWL changes proceeded inductively, allowing for new main categories to emerge. The constant comparative method was used to identify patterns in the data and refine the categories.³² Our frequent peer debriefing sessions included questioning each other’s interpretations of responses from several perspectives: our own ethnic and social backgrounds, personal histories, and whether and to what extent our characteristics, prior experiences, and knowledge influenced our interpretations of the data. Where potentially biased interpretations arose, we assessed the fitness of meaning units (quotes) to their main categorization and preliminary codes.^33–36 This process was conducted iteratively, as data analysis progressed.

Results

Participant Characteristics

The number of participants in each group ranged from five to eleven and was balanced by gender (Table 1). Overall, 70.0% of participants had completed a university degree (Table 2). Among WP smokers, 50% initiated WP smoking between the ages of 14–18 years, and 51.0% smoked five WPs per/month (Table 1).

Table 1.

Characteristics of the Focus Group Participants (n = 77)

Characteristics	Smokers N (%)a	Nonsmokers N (%)a
Total	38 (49.4)	39 (50.6)
Gender
Females	19 (50.0)	23 (59.0)
Males	19 (50.0)	16 (41.0)
Age
18–20	13 (35.1)	6 (15.4)
21–25	13 (35.0)	17 (44.0)
26–30	8 (22.0)	15 (38.0)
>30	3 (8.1)	1 (2.6)
Education
Undergraduate degree/Bachelor’s degree	17 (81.0)	21 (58.3)
Graduate degree/Master’s degree	3 (14.3)	14(38.9)
Technical school	1 (4.8)	1 (2.8)
University students	13 (59.1)	16 (51.6)
Current cigarette smoking (yes; daily and weekly)	11 (31.4)	5 (12.8)
Current cigar/cigarillo smoking (yes)	2 (7.7)	1 (3.1)
Current electronic cigarette vaping (yes)	2 (7.2)	3 (8.7)
Age of waterpipe initiation
13–18	15 (55.5)	---
19–25	10 (37.0)	---
26–34	1 (3.7)	---
Attachment to waterpipe
Not hooked	17(48.6)	---
Somehow hooked	12 (34.3)	---
Very hooked	6 (17.1)	---
Average number of waterpipe smoked per month
1–5	15 (47.0)	---
10–25	11 (34.0)	---
≥30	6 (19.0)	---
Harm perception of waterpipe compared to cigarettes
Less harmful	4 (12.5)	---
Equally harmful	8 (25.0)	---
More harmful	16 (50.0)	---
Don’t know	4 (12.5)	---
Intention to quit waterpipe smoking in future
Within next month	3 (10.3)	---
Within next 6 months	3 (10.3)	---
Beyond 6 months	10 (34.5)	---
Not planning to quit	13 (44.8)	---
Tried to quit before(yes)	13 (40.6)	---

Differences in percentages account to missing data.

Table 2.

Additional Quotes on the Health Warning Reactions, Attention, and Perceived Effectiveness

Warnings	Outcomes	Quotes
T1-HWL1	Reactions	+ It made me uncomfortable in agood way (smoker) - Some people will cover the picture in the box just to avoid looking at it (smoker)
	Attention	+ The picture will be memorized (smoker) - I read the text only to avoid looking at the picture (nonsmoker)
	Effectiveness	+ I think it will disgust people enough to make them stop smoking (smoker) - Addicted smokers won’t stop smoking due to this picture (nonsmoker)
T1-HWL2	Reactions	- The picture is not expressive (nonsmoker) - It took me a while to understand that these are lungs. I’veseen better pictures of lung cancer (smoker)
	Attention	- For me, it did directly link to the topic of smoking (nonsmoker) - We used to see it in biology books when we were young (nonsmoker)
	Effectiveness	- I’ve seen it a lot before on advertisings but not on the waterpipe. Once you put it on the waterpipe, you start thinking about it more (smoker)
T1-HWL3	Reactions	- Smoking can cause wrinkles around the eyes, but not to this extent (nonsmoker) - People will age no matter what they do (non-smoker)
	Attention	+ Women care about their look so every time they see this warning they will thinkthatthis can happen (nonsmoker) - It’s very old, we see it a lot, it is very cliché (nonsmoker)
	Effectiveness	- People will say that we will all grow old. It is not necessarily from waterpipe (nonsmoker) - Put old women, one has a lot of wrinkles and holding waterpipe and the other is not (smoker)
T2-HWL4	Reactions	+ It makes you upset that you are harming your children due to waterpipe (smoker) - The child might have something else wrong with him, not related to waterpipe (nonsmoker)
	Attention	- If you split the picture from the text, then the message will not beunderstood at all (smoker) - I’ve seen the same picture before on cigarette boxes (smoker)
	Effectiveness	+ This subject affects me a lot because nobody knows how harmful the smoke they inhale is (smoker) - The picture is very weak; it is unrelated to the text. The child can have asthma let’s say (smoker)
T2-HWL5	Reactions	+ Very touching, it makes me cry; hurts my heart (smoker) - Some smokers might ask for another warning just to avoid looking at this one (smoker)
	Attention	+ It’s so irritating,people will stop smoking (smoker) + I learned something new from this warning (nonsmoker)
	Effectiveness	+ The picture is very strong (nonsmoker) + The warnings for children are very affective towardssmoking mother (smoker)
T2-HWL6	Reactions	- You don’t sympathize with it (nonsmoker) - It’s an illustration, it’s not a real photo (nonsmoker)
	Attention	- It is very cartoonish (nonsmoker) + I think it sends a clear message about being pregnant and how it will affect the baby (nonsmoker)
	Effectiveness	+ This warning is very strong and realistic, but not everyone will understand it (smoker) - It’s not real, if you use a real photo, it would be more convincing (smoker)
T3-HWL7	Reactions	- It is hard to understand if it is a mouth ulcer or a dermatological disease (smoker) + I believed this warning (nonsmoker)
	Attention	- Some people will say they will use their own mouthpiece so the disease will not spread (nonsmoker)
	Effectiveness	+ It is not threatening enough, it’s not scary. good point though, that text is informative (nonsmoker)
T3-HWL8	Reactions	- It is missing the point (smoker) - The text is not connected with the picture (smoker)
	Attention	- This one is hard to understand (nonsmoker) - Even if it has a skull on it, itdoesn’t deliver the message (nonsmoker)
	Effectiveness	- The picture is meaningless; it is not effective at all … not even the text (non-smoker) - This picture could be tempting for youth (smoker)
T3-HWL9	Reactions	+ Creates aversion (nonsmoker) +Gruesome (smoker)
	Attention	- It is not clear that this is a result of sharing the WATERPIPE (smoker) + The picture is very bright, it grabs attention (nonsmoker)
	Effectiveness	+ It will keep me thinking because the picture is very disturbing(nonsmoker) - This warning tells us to stop sharing waterpipe more than to stop smoking waterpipe (smoker)
T4-HWL10	Reactions	- This person is old and seems to be sick, but he doesn’t look like he is a waterpipe smoker (smoker)
	Attention	- Slow death, closed veins and arteries, and diseased lungs … we are used to it (smoker) - This warning is a double-edged sword, it’s like you’re saying that smoking cigarettes is better (smoker)
	Effectiveness	- This warning is prohibiting waterpipe smoking but encouraging cigarettes smoking (nonsmoker) - If someone wants to smoke, he won’t care at all about how many a waterpipe is equivalent to cigarette (smoker)
T4-HWL11	Reactions	- Young people will feel less targeted by this warning becausethey don’t have any heart problems (smoker)
	Attention	+ A person who suffers from it will get affected by it for sure (smoker)
	Effectiveness	+ Very effective for someone who is sick. It is a symbol for life or death (nonsmoker)
T4-HWL12	Reactions	- I have never seen this happen to anyone before. I might not believe it (smoker) + It is too ugly to look at (nonsmoker)
	Attention	+ It is comparing cigarette with waterpipe smoking. It shows that both are bad (smoker) + The double message is a goodthing (nonsmoker)
	Effectiveness	+ This picture will affect your psychological wellbeing, but it can backfire because it is so extreme (smoker)

Perceptions of the HWLs

Overall, smokers were more skeptical about the HWLs than nonsmokers. In T1, HWL1 was considered the most effective, while T1-HWL2 was not attractive because it was widely used before, and T1-HWL3 lacked believability. All HWLs in T2 provoked strong emotions and were deemed very effective. Two labels (HWL 7 and 9) in T3 were seen as very relatable and prompted strong fear and disgust reaction. T4 was not perceived well because WP smokers might consider it a prompt to switch to cigarettes. Below we report the main results for each HWL according to the four themes. Supplementary quotes are provided in Table 2.

T1: WP Health Risks

T1-HWL1.

Chemicals in hookah can cause oral cancer. This HWL was considered the most effective in T1. According to one participant, this HWL was “both scary and effective, definitely pushes [me] to quit smoking” (smoker). This could in part be because it was a depiction of visible health consequences of WP smoking, as stated by one nonsmoker, “because the cancer is in the mouth it’s very apparent, not like the lung or stomach” (nonsmoker). Participants thought that the text is “too long” to an extent that they “don’t think anyone will read it,” while the picture gave “goosebumps” (nonsmoker) and “made [them] uncomfortable in a good way” (smoker) by making them think about WP risk. Smokers, however, felt that the HWL is unrealistic and hyperbolic, saying, “I doubt this happens in real life” (smoker). One participant said, “some people will cover the picture in the box just to avoid looking at it” or that “they will remove the picture, so they are not disgusted to smoke” (smoker).

T1-HWL2.

Chemicals in hookah can cause lung cancer. Both smokers’ and nonsmokers’ reactions to this HWL were mild, mainly because it has been widely used before: “People are very used to it, they won’t care” (smoker); “Very cliché” (nonsmoker). This HWL was not seen as effective: “It won’t be as effective as when people see something visually disturbing in front of them” (nonsmoker).

T1-HWL3.

Hookah smoking causes skin wrinkles; when you smoke, it shows. Participants considered this HWL to lack believability: “It is fake, it might be photoshopped” (nonsmoker), looks like a “Face cream advertisement” (smoker), and “Superficial to an extent” (nonsmoker). Participants perceived this warning as not effective for men, saying, “Men smoke more than women, and this is the last thing males would care about” (nonsmoker).

T2: WP Harms to Others

T2-HWL4.

Hookah smoke can harm your children. Most participants felt strongly affected by this HWL because “It targets our weak point, the children” (nonsmoker), and “It hits home for both, people who have and do not have children” (smoker). Some participants thought that this HWL was specific to married people or parents: “I am young, it doesn’t mean anything to me, but if someone is married or a parent then s/he will care about it for sure” (smoker). Other skeptical views came from participants who considered the message unclear and potentially interpreted as “Don’t smoke around your children” rather than “Don’t smoke” (nonsmoker). Others stated the “Picture is not related to the text, just referring to a child with asthma” (smoker) and “Adding a person smoking WP around the child” (smoker) could make it more relatable.

T2-HWL5.

Hookah smoking during pregnancy can harm your baby. Smokers’ emotional reaction to this HWL was strong: “This HWL makes you feel guilty” (smoker), “It is very touching, it makes me cry” (smoker). This HWL was generally perceived as extremely effective. Participants stated that “Affection towards babies is embedded in our instincts. It is a weakness” (smoker). Another smoker added, “This was the most effective picture out of all the HWLs.” Skeptical views included feeling that the message is targeted more toward women: “The picture affects me as a man, but the text doesn’t, not like I’m the one who’s getting pregnant” (nonsmoker), or that the HWL was “An exaggeration” (nonsmoker). Others stated the picture was unclear and might indicate “Complications during pregnancy” (nonsmoker).

T2-HWL6.

Hookah smoking during pregnancy can harm your baby. This HWL did not elicit much emotion among participants: “You don’t sympathize with it” (nonsmoker), and many thought the picture was unclear: “You don’t notice that the baby is smoking in her belly; I’m sure nobody noticed” (smoker). However, nonsmokers were more likely to think that “It delivers the message: Just like you are smoking, the fetus is smoking.” Still, some participants thought that this HWL was effective and “Expressive” as “It sends a clear message about being pregnant and how it would affect the baby” (smoker). Meanwhile, others found “The idea of the baby smoking WP is too comical” (smoker) and “Vague” (nonsmoker).

T3: WP Specific Harms

T3-HWL7.

Smoking hookah can spread infectious diseases. This HWL was believable to some due to personal experiences. A nonsmoker participant said, “I know someone at work who was absent for a week. She said she caught a virus from the WP hose - so it’s real right?” Others, in particular smokers, denied any association with infection and considered the picture unbelievable, saying, “This is a mouth ulcer, or a dermatological disease, not WP use related.” A nonsmoker said that the message was not clear, because “Some people might not understand that this is from WP.” Most participants felt that this HWL was ineffective, because smokers might give excuses to find a way around this HWL: “He can tell you that I smoke WP at home or that I only use my personal hose” (nonsmoker).

T3-HWL8.

The water in the hookah does not filter out toxins. Both WP smokers and nonsmokers did not value the picture and felt it was more like “An advertisement” (smoker) or a “Decoration” to sell the WP (nonsmoker). This HWL was seen as the least effective for this theme and sending the wrong message: “Some people like the pictures of skull and bones and will feel like it’s cool - just like a tattoo” (nonsmoker).

T3-HWL9.

Sharing hookah can spread mouth disease. This HWL seemed to induce substantial negative affect. It was seen as “Disgusting” (nonsmokers), “Repulsive” (nonsmoker), and intolerable: “I couldn’t stand this warning from the first time I saw it” (smoker). Most participants were shocked and did not believe that the disease “Is a result of sharing the WP” (nonsmoker) and thought that most smokers will try to avoid looking at it: “S/he will turn the picture over and then buy the tobacco box” (smoker). The picture was “Very bright and clear” (nonsmoker) and was strong because it was “Disturbing; it influences your psychological wellbeing” (smoker). Some smokers thought it was very effective: “I might stop buying tobacco boxes only because the picture is disturbing” (smoker). However, some participants mentioned that the message might be interpreted as “Stop sharing WP rather than stop smoking WP” (smoker).

T4: WP Harms Compared to Cigarettes

T4-HWL10.

Hookah smokers inhale about 100 times more smoke than cigarette smokers. Most participants thought that this HWL was “A double-edged sword; it’s like saying that smoking cigarettes is better” (smoker), and therefore they were skeptical about it: “What I hate about it is that it compares something bad [the WP] to something that is also bad” (nonsmoker). Several participants also mentioned that they had seen this picture before: “This picture was popular for cigarettes” (nonsmoker) and “We all know that smoking hurts the heart and causes diseases” (smoker).

T4-HWL11.

Both cigarettes and hookah cause heart disease. Some smokers felt that this HWL was irrelevant for youth because “Young people will think that they will not have any heart problems.” In addition, at first glance, the text for this HWL was found to be “More powerful than the picture” (nonsmoker). In other cases, however, “Both the text and the picture were meaningless” (nonsmoker). The HWL was not seen as effective, particularly by smokers who felt that the comparison between cigarette and WP is not important or helpful: “Don’t let them compare; just tell them this kills” (smoker).

T4-HWL12.

As with cigarettes, hookah can cause oral cancer. Generally, nonsmokers considered this HWL more effective than smokers. It was seen by nonsmokers as “too ugly to look at” and “Shocking; you will be provoked for a week.” Smokers, on the other hand, “Would look the other way,” and stated that they would get rid of the packaging and “Put the tobacco in a Tupperware” (smoker). Skeptics included one smoker saying, “I have never seen this happen to anyone before” (smoker).

Suggestions for Improvements

Participants’ suggestions for improvements to the HWLs are briefly listed here and summarized in Table 3.

Table 3.

Suggested Improvements for the 12 Developed Health Warning Labels by Focus Group Participants

Health warning label	Participants’ suggestion
T1-HWL1 Chemicals in hookah can cause oral cancer.	• Increase the size of the picture“Show the bigger picture, his whole face. Show how it is affecting his whole face, and the deformity (nonsmoker) • Improve the picture quality “The colours are very dark” (nonsmoker)
T1-HWL2 Chemicals in hookah can cause lung cancer	• Add people suffering from the disease instead of diseased body organs“Put a picture of two people with their lungs showing, one of them smoking with disease lung and the other not smoking with healthy lungs” (nonsmoker). • Having a concise phrase in the text “Smoking waterpipe causes lung cancer- That’s it” (smoker) or as an equation “waterpipe smoking = lung cancer” (nonsmoker).
T1-HWL3 Hookah smoking causes skin wrinkles; when you smoke, it shows	• Add “more wrinkles to the face and around the mouth and add a waterpipe hose” (smoker). • Articulate the process by “Putting the progression of smoking . . . after 1 year and add how old she is and if she is a heavy smoker” (nonsmoker). • Use shorter and direct text “Smoking causes wrinkles - that would be enough” (smoker).
T2-HWL4 Hookah smoke can harm your children	• Show how waterpipe smoke harms children “If you show someone old smoking and thesmoke goes into the child’s face it would be more catching than a child suffocating” (nonsmoker). • The text should be concise “waterpipe smoke is harmful for children- Full stop!” (smoker).
T2-HWL5 Hookah smoking during pregnancy can harm your baby	• Improve the picture by“Dividing the HWL into 2 halves, first half have the mother smoking waterpipe and the second half have this baby” (nonsmoker). • In the text, mention “Not only smoking, but also being exposed to waterpipe smoke, if she’s not the one smoking then the person next to her is smoking and blowing the smoke in her face too; so second-hand smoking, might lead to this” (nonsmoker).
T2-HWL6 Hookah smoking during pregnancy can harm your baby	• Use “Realistic pictures are more effective than pictures like this” (nonsmoker). • A suggestion for improving the picture was to “Have the mother sitting in a café and smoking waterpipe and put a second waterpipe for the baby to smoke” (nonsmoker), this is because “To me it just doesn’t make sense, put an actual person smoking a waterpipe while pregnant- that would be a very strong message - instead of illustration” (smoker). • The text must “Be direct: harms your foetus,” and to “Put fetus, not child” (nonsmoker).
T3-HWL7 Smoking hookah can spread infectious diseases	• Included people in the picture “to create a scenario of people gathered and sharing waterpipe and you can see the signs of infection on them” (nonsmoker). • Another was to “emphasize with a red color the parts that are infectious and then also show that it is transferring from one to another” (smoker). • In the text “specify what the diseases like fungus, or herpes, or tuberculosis” (smoker).
T3-HWL8 The water in the hookah does not filter out toxins	• Use more clearer picture such as “Put the danger sign on the glass and the fumes. The design would make more sense” (smoker). • Change “The colors to be darker” (smoker). • Improve the text to “Clarify what the toxic substances are because not everyone knows that it contains toxins” (nonsmoker).
T3-HWL9 Sharing hookah can spread mouth disease	• Alternative pictures were suggested such as “Put the waterpipe hose under a microscope to show the viruses and bacteria that are on it” (FG1, non-smoker) or to “Show a picture of a waterpipe with 2 hoses and 2 people each holding a hose with the bacteria transferring” (smoker). • Improve the text by “Stating that using the waterpipe hose help spreading the diseases instead of saying - sharing” (non-smoker).
T4-HWL10 Hookah smokers inhale about 100 times more smoke than cigarette smokers	• Alternative pictures were suggested such as “put a scale on one side that has a lot of cigarettes and the other side has one waterpipe, and the waterpipe is still heavier” (smoker), or to “Put a picture of a waterpipe head = to the number of cigarettes” (smoker).
T4-HWL11 Both cigarette and hookah cause heart disease	• Suggestions included to show “the nasal tube delivering oxygen is better than the nebulizer, since having nebulizers at home is a very common thing these days” (smoker). • To change the picture to “end the EKG with a flat line indicating death” (nonsmoker). • For the text, specifying “what the heart diseases are” (nonsmoker) and do not “compare cigarettes and waterpipe just tell them that smoking kills” (smoker).
T4-HWL12 As with cigarettes, hookah can cause oral cancer	• In the text, “remove cigarettes from the text and use equation sign: waterpipe = cancer” (smoker)

Improving the Text

Participants suggested using short text with affirmative phrases about the scientific facts. For example, a WP smoker suggested improving the text in T1-HWL2 by using a concise expression: “Smoking WP causes lung cancer” instead of “Can cause.”

Improving the Pictures

Participants suggested increasing the pictures’ size and improving their quality. For example, a nonsmoker suggested improving the picture in T1-HWL1 (mouth cancer) by “Showing a bigger picture, his whole face. Show how it is affecting his whole face, and the deformity.” Many participants suggested adding the WP device or someone who is smoking WP in the pictures to improve relatability. For example, to improve the picture in T2-HWL5 (harm to the baby) a nonsmoker suggested “Dividing the HWL into two halves, half with the mother smoking WP and half with the baby.”

Other Suggestions

Participants suggested adding real people suffering instead of body organs: “Put a picture of two people with their lungs showing one of them smoking with a diseased lung and the other not smoking with healthy lungs” (nonsmoker). Also, participants suggested creating “A scenario of people gathering and sharing WP with signs of infection on them” (nonsmoker). Participants did not appreciate figurative or non-literal pictures: “To me, it just doesn’t make sense, put an actual woman smoking a WP while pregnant” (smoker). Finally, participants generally did not appreciate the HWLs in T4, which compared WP risk with cigarette risk, because they are both harmful and WP smokers might switch to cigarette: “Do not compare cigarettes with WP; just tell them that smoking kills” (smoker).

Discussion

This study provides in-depth insight from WP smokers and nonsmokers on the perceived effectiveness of 12 WP-specific pictorial HWLs to adapt them to the Lebanese culture. Participants perceived fear-arousing and emotion-provoking graphic images as most effective, while warnings with figurative or non-literal images were found to lack believability. Specifically, graphic messages depicting visible bodily health effects (eg, oral cancer, mouth disease) and harm to babies seem most promising. Participants were skeptical about Theme 4, “comparing WP harm to cigarette harm,” because WP smokers might consider it a prompt to switch to cigarettes. Compared to nonsmokers, smokers tended to be more skeptical about WP risk information presented in the HWLs and to intend to avoid exposure to the more graphic warnings. The main recommended adaptations to the HWLs to be culturally sensitive were using shorter text with direct and affirmative phrases rather than phrases such as “can cause,” presenting the health risks in numerical form (eg, percentages), improving the quality of the pictures, and increasing their size, adding the WP device picture to all HWLs to enhance their relatability, and developing testimonial or narrative messages that depict real people and stories.

Though unique to WP smoking and Lebanese culture, some of our findings are consistent with the large body of evidence demonstrating that graphic warnings depicting the bodily harms of smoking are perceived as most effective.^{19,21,37–39} Studies with cigarette smoking HWLs suggest that fear-arousing imagery is more likely to be read and noticed by smokers and is associated with greater motivation to quit.⁴⁰ They also suggest that such HWLs may provoke viewers to avoid looking at the warnings,⁴¹ though this did not seem to affect their impact at the population level.⁴² WP smokers in our study were more likely to report strategies to avoid seeing the warnings than nonsmokers, which appeared to arise from the smokers’ fear, disgust, and revulsion in response to these HWLs.^42,43 In addition, consistent with prior research, warnings with figurative or nonliteral images were not found particularly convincing or effective by our participants.^37,38

Interestingly, there was some consensus among our participants against using warnings in Theme 4 “comparing WP harm to cigarette harm.” Specifically, they viewed the warnings in this group as “a double-edged sword,” because WP smokers might understand them as a prompt to switch to cigarette smoking. In contrast, an experimental study investigating these types of messages among young adults in the United States found them promising.⁴⁴ It is likely to reflect, in part, different stages of awareness and attitudes towards WP smoking across populations. Societies where tobacco control is more advanced and anti-smoking policies are strongly implemented may be less likely to perceive such comparative HWLs as promoting cigarette smoking.⁴⁵ Therefore, there is a need to further explore the potential of these messages and how to develop them for different settings and cultural contexts.⁴⁶

Some of our findings may reflect the younger age of our study group, and WP smokers in general, than what is known from the cigarette literature. For example, warnings showing externally visible health effects such as oral cancer and mouth disease (eg, herpes) were perceived as very effective, perhaps because they influence appearance. In contrast, participants perceived warnings related to chronic diseases typically affecting older adults, such as heart disease and skin wrinkles, to be unrelatable to them. In addition, warnings depicting harm to babies provoked strong emotions such as feeling “guilt” and were deemed amongst the most effective warnings. The fact that our participants are at peak reproductive age may have contributed to such a close-to-the-heart perception of these HWLs. Similar findings were reported among young WP smokers in the United States and other EMR countries.^17,47

Participants’ recommendations to use definitive scientific claims need to be balanced against protecting the credibility of HWLs to prevent challenges to them (eg, scientific, legal).^46,48 To improve the pictures, participants suggested increasing their size, improving their quality (eg, bright colors), and adding the WP device picture to the warnings to enhance their relatability. These suggestions are consistent with World Health Organization Framework Convention on Tobacco Control recommendations, and have been shown to be effective.^12,38 Finally, participants recommended using testimonial or narrative messages that depict real people and stories. Testimonials may be particularly compelling in countries with traditions of sharing knowledge through storytelling, or for more extended forms of warnings such as TV advertisements.³⁷ So far, the use of this type of messaging for cigarette health warnings has been associated with inconsistent results across populations.³⁸

The strengths of this study include conducting it among WP smokers and nonsmokers, being guided by a theoretical model of message impact¹¹ and looking at novel strategies to combat WP smoking in a high-risk population and region. However, these findings may not reflect the broader population (e.g., adolescent, older ages), or the cultural contexts of other countries in the EMR. For example, messages may not be maximally effective in countries where WP is less the norm, or where religious injunctions may be more effective at changing behavior than health warnings.⁴⁹ Another limitation to our study is that 70% of the sample had a university degree. However, the majority of WP smokers in Lebanon are highly educated.²

In summary, this study was the first attempt to adapt and optimize a set of WP-specific pictorial HWLs for a country with a high level of WP smoking. Results will provide Lebanon and perhaps other countries in the EMR with evidence-based HWLs that they can further develop and test. HWLs that provoke negative affect, with visible health consequences, and depict harm to babies were the most promising warnings for young adults in Lebanon. Further research can help address some questions raised by this study, such as the potential of warnings comparing WP harm to cigarette harm or testimonial warnings that depict real people.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This work was supported by the Fogarty International Center of the National Institutes of Health (R01TW010654).

Declaration of Interests

All authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Data Availability Statement

The data underlying this article cannot be shared publicly due to ethical considerations. The data will be shared on reasonable request to the corresponding author.