Health Warnings for Hookah Smoking

Overseen by Erin Sutfin, PhD

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Waitlist Available

Sponsor: Wake Forest University Health Sciences

No Placebo Group

Trial Summary

What is the purpose of this trial?

This trial tests if health warnings in hookah cafés can reduce smoking. The study targets café customers and uses warnings to make them more aware of the risks, hoping they will smoke less.

Do I have to stop taking my current medications to join the trial?

The trial protocol does not specify whether you need to stop taking your current medications.

What data supports the idea that Health Warnings for Hookah Smoking is an effective treatment?

The available research shows that pictorial health warnings on waterpipe tobacco products are more effective than text-only warnings. For example, a study in Lebanon found that nonsmokers paid more attention and had stronger reactions to pictorial warnings compared to text-only warnings. This suggests that pictorial warnings can be a powerful tool to prevent young adults from starting to smoke waterpipes. Additionally, similar studies on cigarette packs have shown that pictorial warnings increase the intention to quit smoking more than text-only warnings. This evidence supports the idea that using pictorial health warnings is an effective way to communicate the risks of hookah smoking and encourage people to avoid or quit it. ^{1 2 3 4 5}

What safety data exists for health warnings on hookah smoking?

Research indicates that pictorial health warning labels (HWLs) on waterpipe (hookah) products are effective in communicating health risks and changing perceptions among young adults. Studies conducted in Lebanon and Tunisia show that pictorial HWLs, especially when placed on multiple parts of the waterpipe, attract attention, increase perceived harm, and may influence smoking intentions. These findings suggest that HWLs can be a promising regulatory strategy to reduce waterpipe smoking and its associated health risks. ^{1 3 6 7 8}

Is using health warnings for hookah smoking a promising treatment?

Yes, using health warnings for hookah smoking is a promising treatment. Studies show that pictorial health warnings on hookah products can effectively increase awareness of the health risks and encourage people to quit or avoid starting hookah smoking. ^{1 7 8 9 10}

Research Team

Erin Sutfin, PhD

Principal Investigator

Wake Forest University Health Sciences

Eligibility Criteria

This trial is for English-speaking individuals who plan to smoke hookah at a café and won't smoke cigarettes, cigars, or other tobacco products there. It's not open to those who've been asked to join this study elsewhere.

Inclusion Criteria

Have not previously entered the café on the same day/night as data collection

Is not an employee of the café

I am 18 years old or older.

Exclusion Criteria

I do not speak English.

Has been approached to participate in the study previously

Is an employee of the café

Treatment Details

Interventions

• No Warnings (Behavioural Intervention)
• Pictorial Warnings (Behavioural Intervention)
• Text-only Warnings (Behavioural Intervention)

Trial Overview The study is testing if health warnings at hookah cafés can make people smoke less compared to no warnings. This will be measured by the change in expired carbon monoxide levels before and after visiting the café.

Participant Groups

Group I: Intervention - Health Warnings Experimental Treatment 1 Intervention

Cafes will display text-only warning signs

Group II: Control - No Warnings Experimental Treatment 1 Intervention

No warnings posted in the hookah café

Who Is Running the Clinical Trial?

Wake Forest University Health Sciences

Lead Sponsor

Trials

1,432

Recruited

2,506,000+

Dr. L. Ebony Boulware

Wake Forest University Health Sciences

Chief Medical Officer since 2022

MD from Duke University School of Medicine, MPH from Johns Hopkins Bloomberg School of Public Health

Dr. Julie Ann Freischlag

Wake Forest University Health Sciences

Chief Executive Officer since 2020

BS from University of Illinois, MD from Rush University

National Cancer Institute (NCI)

Collaborator

Trials

14,080

Recruited

41,180,000+

Dr. Douglas R. Lowy

National Cancer Institute (NCI)

Chief Executive Officer since 2023

MD from New York University School of Medicine

Dr. Monica Bertagnolli

National Cancer Institute (NCI)

Chief Medical Officer since 2022

MD from Harvard Medical School

Findings from Research

This study is the first of its kind to experimentally test the effectiveness of pictorial health warning labels (HWLs) on waterpipe tobacco smoking (WTS) among young adults in Lebanon and Tunisia, aiming to assess their impact on perceived harm and smoking intentions.

By comparing different placements of HWLs on waterpipe devices, tobacco, and charcoal packages, the study seeks to provide evidence that could influence policymakers to implement more effective regulations against WTS, which is perceived as safer than cigarette smoking.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design. Jebai, R., Asfar, T., Nakkash, R., et al.[2023]

Health warning labels (HWLs) with images and text depicting diseases like bowel cancer were found to significantly reduce the desire to consume alcoholic drinks and energy-dense snacks, indicating their potential effectiveness in changing consumption behaviors.

While HWLs were effective in eliciting negative emotional responses, they were less acceptable for alcoholic drinks, with only 3 out of 21 labels rated as acceptable, compared to 13 out of 18 for snacks, suggesting a need for further research on their public acceptance.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability. Pechey, E., Clarke, N., Mantzari, E., et al.[2020]

In a study of 403 young adults in Lebanon, pictorial health warning labels (HWLs) on tobacco packages were found to capture more attention and provoke stronger cognitive reactions among nonsmokers compared to smokers, suggesting that these labels are more effective for health communication in preventing tobacco use.

Pictorial HWLs placed on all parts of the waterpipe (device, tobacco, and charcoal packages) elicited higher perceived message effectiveness and cognitive reactions in nonsmokers, indicating that comprehensive labeling could be a valuable strategy for reducing waterpipe use and associated health risks among young adults.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study. Jebai, R., Asfar, T., Nakkash, R., et al.[2023]

A study involving 2,629 Lebanese youth showed that pictorial health warnings on cigarette packs were significantly more effective than the current text warnings in motivating intentions to quit or not start smoking.

Specific pictorial warnings, such as those depicting lung damage and economic impacts, had a strong influence on non-smoking students' intentions not to start smoking and on smoking students' intentions to quit, highlighting the effectiveness of visual messages in tobacco control.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students. Alaouie, H., Afifi, RA., Haddad, P., et al.[2022]

In a study involving 661 Chinese working-age adults, graphic pictorial warning labels on cigarette packs significantly increased smokers' intention to quit and their perception of the harms associated with smoking compared to text-only labels.

The research suggests that less nicotine-dependent smokers who recognize the risks of smoking are more likely to attempt to quit, highlighting the effectiveness of graphic warnings in tobacco control efforts.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Reactions to Pictorial and Text Cigarette Pack Warning Labels among Chinese Smokers. Wang, L., Yao, X., Wang, G., et al.[2023]

Pictorial health warning labels (HWLs) on tobacco packages significantly increased attention and perceived effectiveness compared to text-only warnings, suggesting they are more effective in communicating the risks of waterpipe tobacco smoking (WTS).

The study, involving 276 young waterpipe smokers, indicates that implementing pictorial HWLs could help correct misconceptions about the safety of WTS and enhance awareness of its health effects.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study. Jebai, R., Asfar, T., Nakkash, R., et al.[2023]

A study involving 77 young adults in Lebanon found that emotionally provocative pictorial health warning labels (HWLs) on waterpipe (WP) products were perceived as the most effective in conveying health risks, particularly those showing visible health effects and harm to babies.

Participants suggested improvements for HWLs, such as using shorter text, larger and higher-quality images, and including pictures of the WP device to enhance relatability, indicating a need for culturally adapted and scientifically credible messaging to effectively combat misconceptions about WP safety.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon. Asfar, T., Chehab, S., Schmidt, M., et al.[2023]

A study involving 74 young adult waterpipe users found that health warning labels placed on different parts of the waterpipe effectively attracted visual attention and increased awareness of the associated risks of smoking.

Participants' perceptions of the harm of waterpipe smoking significantly increased after viewing the warnings, and this heightened awareness persisted for at least one week, highlighting the effectiveness of health warnings in addressing misconceptions about waterpipe use.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Waterpipe Warning Placement and Risk Perceptions: An Eye Tracking Study. Klein, EG., Alalwan, MA., Pennell, ML., et al.[2022]

Approximately 16.4% of adults in the U.S. have ever smoked hookah, with 31.9% of those reporting use in the past year, highlighting a significant prevalence of hookah smoking among adults.

Daily or weekly hookah users tend to be younger (66% aged 18-24) and exhibit distinct behaviors, such as more frequent refilling of the hookah and less sharing, which could inform targeted prevention strategies and regulations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Characteristics of Hookah Tobacco Smoking Sessions and Correlates of Use Frequency Among US Adults: Findings From Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Robinson, JN., Wang, B., Jackson, KJ., et al.[2022]

Among adults aged 18-40 in the US, the lifetime prevalence of hookah use is 3.9%, with a past month prevalence of only 0.6%, indicating that while not extremely common, it is present in this age group.

Demographic factors such as being male, non-Hispanic white, a student, and a current cigarette smoker significantly increase the likelihood of lifetime hookah use, suggesting targeted public health efforts are needed to address this trend.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Prevalence and correlates of hookah use: a nationally representative sample of US adults ages 18-40 years old. Grinberg, A., Goodwin, RD.[2022]

References

1. Netherlands pubmed.ncbi.nlm.nih.gov

Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: Protocol of a factorial experiment study design. [2023]

2. England pubmed.ncbi.nlm.nih.gov

Image-and-text health warning labels on alcohol and food: potential effectiveness and acceptability. [2020]

3. England pubmed.ncbi.nlm.nih.gov

Comparisons between young adult waterpipe smokers and nonsmokers' reactions to pictorial health warning labels in Lebanon: a randomized crossover experimental study. [2023]

4. England pubmed.ncbi.nlm.nih.gov

Effectiveness of pictorial health warnings on cigarette packs among Lebanese school and university students. [2022]

5. Switzerland pubmed.ncbi.nlm.nih.gov

Reactions to Pictorial and Text Cigarette Pack Warning Labels among Chinese Smokers. [2023]

6. England pubmed.ncbi.nlm.nih.gov

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study. [2023]

7. England pubmed.ncbi.nlm.nih.gov

"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon. [2023]

8. England pubmed.ncbi.nlm.nih.gov

Waterpipe Warning Placement and Risk Perceptions: An Eye Tracking Study. [2022]

9. England pubmed.ncbi.nlm.nih.gov

Characteristics of Hookah Tobacco Smoking Sessions and Correlates of Use Frequency Among US Adults: Findings From Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. [2022]

10. England pubmed.ncbi.nlm.nih.gov

Prevalence and correlates of hookah use: a nationally representative sample of US adults ages 18-40 years old. [2022]