Waterpipe users' reactions and perceived effectiveness of waterpipe-specific pictorial health warning labels: A mixed-method study among US young people.

Abstract

Waterpipe (WP) smoking has surged among young adults in the US. However, it presents serious health risks that can equal or exceed those of cigarettes. Pictorial warning labels (PWLs) can effectively educate consumers about WP risk. This study engaged young WP users through a mixed-methods approach, including survey and focus group discussions, to evaluate 24 WP-specific PWLs. We conducted 17 mixed-gender focus groups with 44 WP smokers (50% females, aged 21-35 years) via HIPAA-compliant Zoom. Guided by the Message Impact Framework, participants completed an anonymous rating survey of the PWLs, assessing their attention, emotional reactions, and perceived effectiveness, followed by in-depth discussions of each warning. Descriptive statistical analysis was conducted for the rating survey. Focus group sessions were audio-recorded, transcribed, and analyzed using the constant comparative method. PWLs highlighting severe diseases (e.g., cancer) and WP-specific risks (e.g., transmitted infections) were perceived as the most impactful, while nicotine addiction PWLs were perceived as less compelling. Group discussions revealed visceral and emotional reactions, such as disgust and fear, alongside cognitive responses to PWLs clarity (e.g., realistic images, direct text) and relevance, substantially shaped participants' harm perception. Furthermore, the elicitation of these multiple reactions to each PWL appeared sufficient to decisively motivate participants' intentions to avoid, or entirely quit, WP smoking. This study identified potential warnings for young WP users and provided insights to further tailor them based on their feedback. Using graphics in the warnings enhances their visual impact. Clarity and relevance of the warnings were important attributes that enhanced their perceived effectiveness, indicating the need to diversify themes to effectively engage different segments of society. The resulting warnings can be used in health promotion campaigns, patient counseling, or as warning labels. They can also be tailored and tested across diverse US populations (e.g., adolescents).