Pictorial health warnings on waterpipe tobacco packs: rating of efficacy in comparison to an alternative waterpipe-specific set

Background We measured the efficacy of the existing pictorial health warning (PHW) set displayed in the Egyptian market on Waterpipe tobacco packs (WTP) in comparison to an alternative one. We aimed to examine their possible effect in encouraging cessation among waterpipe smokers and preventing initiation among non-smokers. Methods A convenience sample of 2014 adult participants of both genders were surveyed within rural and urban regions of Egypt. Socio-demographic data and tobacco use were recorded. Participants were shown at random one of the existing PHWs on WTPs, then one of the alternative set. The alternative set was designed to display pictures and text that were more water-pipe specific, and occupied around 80% of the WTP with plain packaging features. Participants were asked to rate both PHWs' efficacy on a scale from 1 to 10 regarding their salience, depth of processing, affective reactions, credibility, relevance, perceived behavioral control and quit intentions. Univariate and multivariate statistical analyses were performed. Results Participants were on average 35 years old, with 10% females, 74% were current waterpipe smokers. Paired mean efficacy ratings of the alternative PHW set were significantly higher than those of the existing one regarding all measures, yet both sets collectively scored modestly (5.8±1.7 versus 5.1±2.1, p< 0.001). The highest mean score differences were noted for grabbing attention, inducing affective reactions, making participants look closely at the PHW, and in encouraging quit attempts. Participants rated both PHW sets of possible relatively high efficacy in discouraging waterpipe tobacco smoking (6.3±3.4 versus 5.7±3.7, p< 0.001). Furthermore, significantly higher mean efficacy scores were reported by non-smokers (6.2±1.6 versus 5.6±1.8, p< 0.001), males (5.8±1.7 versus 5.1±2.3, p< 0.001), younger adults (6.0±1.7 versus 5.7±1.8, p< 0.001), and rural residents (6.4±1.3 versus 4.9±2.0, p< 0.001). Conclusions There is an urgent need to research evidence-based effective PHW content and design that address different population subgroups.