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BMC Pediatrics
Published in: BMC Pediatrics 1/2024

Open Access 01-12-2024 | Research

Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents

Authors: Diana Malaeb, Bassam Abdul Rasool Hassan, Ali Haider Mohammed, Sinan Subhi Farhan, Omar Abdulwahid Al-Ani, Abir Sarray El Dine, Feten Fekih-Romdhane, Sahar Obeid, Souheil Hallit

Published in: BMC Pediatrics | Issue 1/2024

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Abstract

Background

Waterpipe tobacco smoking has increased tremendously at a global level among all age groups, particularly young people. Previous studies have examined the impact of waterpipe tobacco pictorial health warnings on adults but scarce studies were done on adolescents. The aim of this study was to assess the association of textual versus pictorial warnings on tumbac boxes and the motivation to quit waterpipe smoking among adolescents located in two Eastern Mediterranean countries Lebanon and Iraq.

Methods

A cross-sectional study was conducted between May and November 2022, involving 294 adolescents waterpipe smokers from Lebanon and Iraq. The questionnaire included the Lebanese Waterpipe Dependence Smoking-11, the Depression, Anxiety and Stress Scale, the Waterpipe Harm Perception Scale, Waterpipe Knowledge Scale, Waterpipe Attitude Scale, the Fagerstrom Test for Nicotine Dependence, and the Motivation to Stop Scale.

Results

When adjusting the results over confounding variables, the results showed that compared to finding the warnings to stop smoking not efficacious at all, adolescents who find the warnings moderately (aOR = 2.83) and very (aOR = 6.64) efficacious had higher motivation to quit. Compared to finding the warnings not increasing their curiosity for information about how to stop waterpipe smoking at all, participants who confessed that warnings increased their curiosity a little (aOR = 2.59), moderately (aOR = 3.34) and very (aOR = 3.58) had higher motivation to quit. Compared to not considering changing the tumbac brand if the company uses pictorial warnings, adolescents who would consider changing the tumbac brand (aOR = 2.15) had higher motivation to quit.

Conclusion

Pictorial and textual warnings on waterpipe packs were associated with higher motivation to stop waterpipe smoking. Public health education programs for this purpose seem warranted.
Literature
1.
Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R, Salloum RG. The global epidemiology of waterpipe smoking. Tob Control. 2015;24(Suppl 1):i3–i12.PubMedCrossRef
2.
Farran D, Khawam G, Nakkash R, Lee J, Abu-Rmeileh N, Darawad MW, Mostafa A, Kheirallah KA, Salama M, Hamadeh RR. Association of health warning labels and motivation to quit waterpipe tobacco smoking among university students in the Eastern Mediterranean Region. Tob Prev Cessat 2021, 7.
3.
Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA. The prevalence and trends of waterpipe tobacco smoking: a systematic review. PLoS ONE. 2018;13(2):e0192191.PubMedPubMedCentralCrossRef
4.
Jawad M, Lee JT, Millett C. Waterpipe tobacco smoking prevalence and correlates in 25 Eastern Mediterranean and Eastern European countries: cross-sectional analysis of the Global Youth Tobacco Survey. Nicotine Tob Res. 2016;18(4):395–402.PubMedCrossRef
5.
Arshad A, Matharoo J, Arshad E, Sadhra SS, Norton-Wangford R, Jawad M. Knowledge, attitudes, and perceptions towards waterpipe tobacco smoking amongst college or university students: a systematic review. BMC Public Health. 2019;19(1):1–11.CrossRef
6.
Jawad M, Jawad S, Mehdi A, Sardar A, Jawad A, Hamilton F. A qualitative analysis among regular waterpipe tobacco smokers in London universities. Int J Tuberc Lung Dis. 2013;17(10):1364–9.PubMedCrossRef
7.
Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J. Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J. 2013;10:1–10.CrossRef
8.
Romani M, Jawhar S, Shalak M, Antoun J. Waterpipe smoking cessation: knowledge, barriers, and practices of primary care physicians-a questionnaire-based cross-sectional study. BMC Fam Pract. 2020;21:1–7.CrossRef
9.
Al-Sawalha NA, Almomani BA, Al-Shatnawi SF, Almomani BN. Attitudes and knowledge of the Harmful effects of Waterpipe Tobacco Smoking among university students: a study from Jordan. Environ Sci Pollut Res Int. 2021;28(32):43725–31.PubMedPubMedCentralCrossRef
10.
Smith-Simone S, Maziak W, Ward KD, Eissenberg T. Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine Tob Res. 2008;10(2):393–8.PubMedCrossRef
11.
Al-Sawalha NA, Almomani BA, Al-Shatnawi SF, Almomani BN. Attitudes and knowledge of the Harmful effects of Waterpipe Tobacco Smoking among university students: a study from Jordan. Environ Sci Pollut Res. 2021;28:43725–31.CrossRef
12.
Alzyoud S, Massoud F. Waterpipe and cigarette tobacco smoking and depressive symptoms among public school students in central Jordan. J Health Res. 2020;35(3):240–8.
13.
Karaman NG, Çeber ÇÜ, Eraslan S. Waterpipe tobacco smoking among university students in Turkey. Addict Behav Rep. 2022;15:100409.PubMedPubMedCentral
14.
Abbadi A, Alnahar J, Zoghoul S, Bsoul A, Alarood S, Al-Mistarehi A-H, Alzyoud S. Waterpipe nicotine dependence and depressive symptoms among adolescent waterpipe and dual users. J Environ Public Health. 2020;2020:1–10.CrossRef
15.
Control IfGT. State of evidence review: health warning labels on tobacco products. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health; 2013.
16.
World Health Organization framework convention on. Tobacco control: guidelines for implementation of article 5. 3, Articles 8 To 14.
17.
Hammond D, Reid JL, Driezen P, Thrasher JF, Gupta PC, Nargis N, Li Q, Yuan J, Boudreau C, Fong GT. Are the same health warnings effective across different countries? An experimental study in seven countries. Nicotine Tob Res. 2019;21(7):887–95.PubMedCrossRef
18.
Maziak W, Taleb ZB, Kalan ME, Eissenberg T, Thrasher J, Shihadeh A, Asfar T. Pictorial health warning labels on the waterpipe device are effective in reducing smoking satisfaction, puffing behaviour and exposure to CO: first evidence from a crossover clinical laboratory study. Tob Control. 2019;28(e1):e37–e42.PubMedCrossRef
19.
Ngo A, Cheng K-W, Shang C, Huang J, Chaloupka FJ. Global evidence on the association between cigarette graphic warning labels and cigarette smoking prevalence and consumption. Int J Environ Res Public Health. 2018;15(3):421.PubMedPubMedCentralCrossRef
20.
Thrasher JF, Carpenter MJ, Andrews JO, Gray KM, Alberg AJ, Navarro A, Friedman DB, Cummings KM. Cigarette warning label policy alternatives and smoking-related health disparities. Am J Prev Med. 2012;43(6):590–600.PubMedPubMedCentralCrossRef
21.
Mutti-Packer S, Reid JL, Thrasher JF, Romer D, Fong GT, Gupta PC, Pednekar MS, Nargis N, Hammond D. The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: a moderated-mediation analysis. Addict Behav. 2017;73:22–9.PubMedPubMedCentralCrossRef
22.
Sutton JA, Yang S, Cappella JN. Perceived effectiveness of objective features of pictorial warning messages. Tob Control. 2019;28(e1):e24–e30.PubMedCrossRef
23.
Yong H, Borland R, Thrasher J, Thompson M, Nagelhout G, Fong G, Cummings KM. Mediational pathways of the impact of cigarette warning labels on quit attempts. Health Psychol. 2014;33(11):1410.PubMedPubMedCentralCrossRef
24.
Evans AT, Peters E, Strasser AA, Emery LF, Sheerin KM, Romer D. Graphic warning labels elicit affective and thoughtful responses from smokers: results of a randomized clinical trial. PLoS ONE. 2015;10(12):e0142879.PubMedPubMedCentralCrossRef
25.
Siru R, Hulse GK, Tait RJ. Assessing motivation to quit smoking in people with mental illness: a review. Addiction. 2009;104(5):719–33.PubMedCrossRef
26.
Irvin JE, Brandon TH. The increasing recalcitrance of smokers in clinical trials. Nicotine Tob Res. 2000;2(1):79–84.PubMedCrossRef
27.
Ramírez AS, Freres D, Martinez LS, Lewis N, Bourgoin A, Kelly BJ, Lee C-J, Nagler R, Schwartz JS, Hornik RC. Information seeking from media and family/friends increases the likelihood of engaging in healthy lifestyle behaviors. J Health Communication. 2013;18(5):527–42.PubMedCrossRef
28.
Snell LM, Colby S, DeAtley T, Cassidy R, Tidey J. Associations between nicotine knowledge and smoking cessation behaviors among US adults who smoke. Nicotine Tob Res. 2022;24(6):855–63.PubMedCrossRef
29.
Upadhyay S, Lord J, Gakh M. Health-information seeking and intention to quit smoking: do health beliefs have a mediating role? Tob use Insights. 2019;12:1179173X19871310.PubMedPubMedCentralCrossRef
30.
Hallit S, Layoun N, Malaeb D, Outayek M, Boueid M-J, Waked M, Bacha ZA, Salameh P. The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study. Environ Sci Pollut Res. 2019;26:36647–57.CrossRef
31.
Malaeb D, Akel M, Sacre H, Haddad C, Obeid S, Hallit S, Salameh P. Association between cumulative cigarette and waterpipe smoking and symptoms of dependence in Lebanese adults. BMC Public Health. 2021;21(1):1583.PubMedPubMedCentralCrossRef
32.
Bacha ZA, Layoun N, Khayat G, Hallit S. Factors associated with smoking cessation success in Lebanon. Pharm Pract (Granada). 2018;16(1):1111.PubMedCrossRef
33.
Jebai R, Asfar T, Nakkash R, Chehab S, Romdhane HB, Maziak W. Examining the effect of waterpipe specific pictorial health warning labels among young adults in Lebanon and Tunisia: protocol of a factorial experiment study design. Contemp Clin Trials Commun. 2021;23:100797.PubMedPubMedCentralCrossRef
34.
Parliament L. 174: Tobacco Control and Regulation of Tobacco Products’ Manufacturing. Packaging and Advertising; 2011.
35.
Jebai R, Asfar T, Nakkash R, Chehab S, Wu W, Bursac Z, Maziak W. Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study. Tob Control. 2023;32(6):715–22.PubMedCrossRef
36.
37.
Society CC. Cigarette package health warnings: international status report. Canadian Cancer Society 2014(sl).
38.
Salloum RG, Abu-Rmeileh N, Hamadeh R, Thomas J, Mostafa A, Yusufali A, Kheirallah KA, Macauda MM, Theis RP, El Kadi L. Policy-relevant context of waterpipe tobacco smoking among university students in six countries across the Eastern Mediterranean Region: a qualitative study. Asian Pac J cancer Prevention: APJCP. 2017;18(9):2533.
39.
Islam F, Salloum RG, Nakkash R, Maziak W, Thrasher JF. Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health. 2016;61(6):709–15.PubMedCrossRef
40.
Kumar J. Exposure to health warning labels on Waterpipe Tobacco packages: an application of the modified extended parallel process model on quitting behavior from three waves of the PATH study. The University of Memphis; 2019.
41.
Darawad MW, Salloum R, Alhussami M, Maharmeh M. Evaluating health warning messages specific to waterpipe smoking among university students in Jordan. J Am Association Nurse Practitioners. 2019;31(2):133–8.CrossRef
42.
Hallit S, Layoun N, Malaeb D, Outayek M, Boueid M-J, Waked M, Bacha ZA, Salameh P. The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study. Environ Sci Pollut Res. 2019;26(36):36647–57.CrossRef
43.
Alzyoud S, Boukerdenna H, Abbadi A, Weglicki LS. Knowledge and beliefs about the Inclusion of Health Warnings on Waterpipe Tobacco Packaging in Jordan. Global J Health Sci. 2021;13(6):134.CrossRef
44.
Ma C, Yang H, Zhao M, Magnussen CG, Xi B. Prevalence of waterpipe smoking and its associated factors among adolescents aged 12–16 years in 73 countries/territories. Front Public Health 2022, 10.
45.
Obeid S, Hallit S, Sacre H, Salameh P. Factors associated with the onset of smoking and alcohol consumption: a cross-sectional study among Lebanese adolescents in schools. Archives de Pédiatrie. 2022;29(3):194–9.PubMedCrossRef
46.
47.
48.
49.
Melki I, Beydoun H, Khogali M, Tamim H, Yunis K. Household crowding index: a correlate of socioeconomic status and inter-pregnancy spacing in an urban setting. J Epidemiol Community Health. 2004;58(6):476–80.PubMedPubMedCentralCrossRef
50.
Weary-Smith KA. Validation of the physical activity index (PAI) as a measure of total activity load and total kilocalorie expenditure during submaximal treadmill walking. University of Pittsburgh; 2007.
51.
Hallit S, Obeid S, Sacre H, Salameh P. Lebanese waterpipe dependence scale (LWDS-11) validation in a sample of Lebanese adolescents. BMC Public Health. 2021;21(1):1–6.CrossRef
52.
Salameh P, Waked M, Aoun Z. Waterpipe smoking: construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11). Nicotine Tob Res. 2008;10(1):149–58.PubMedCrossRef
53.
Ali AM, Hori H, Kim Y, Kunugi H. The Depression anxiety stress scale 8-Items expresses Robust Psychometric properties as an Ideal Shorter Version of the Depression anxiety stress scale 21 among healthy respondents from three continents. Front Psychol. 2022;13:799769–9.PubMedPubMedCentralCrossRef
54.
Hallit S, Haddad C, Bou Malhab S, Khabbaz LR, Salameh P. Construction and validation of the water pipe harm perception scale (WHPS-6) among the Lebanese population. Environ Sci Pollut Res. 2020;27:3440–8.CrossRef
55.
Farah R, Haddad C, Sacre H, Hallit S, Salameh P. Knowledge and attitude toward waterpipe smoking: scale validation and correlates in the Lebanese adult population. Environ Sci Pollut Res. 2020;27(25):31250–8.CrossRef
56.
Tf H, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom Tolerance Questionnaire. Brit J Addict. 1991;86(9):1119–27.CrossRef
57.
Salameh P, Khayat G, Waked M. The Lebanese cigarette dependence (LCD) score: a comprehensive tool for cigarette dependence assessment. Int J Behav Med. 2014;21(2):385–93.PubMedCrossRef
58.
Hummel K, Candel MJ, Nagelhout GE, Brown J, van den Putte B, Kotz D, Willemsen MC, Fong GT, West R, de Vries H. Construct and predictive validity of three measures of intention to quit smoking: findings from the International Tobacco Control (ITC) Netherlands Survey. Nicotine Tob Res. 2018;20(9):1101–8.PubMedCrossRef
59.
Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Fotouh AA, Hoek J. Would placing pictorial health warnings on waterpipe devices reduce waterpipe tobacco smoking? A qualitative exploration of Egyptian waterpipe smokers’ and non-smokers’ responses. Tob Control. 2019;28(4):475–8.PubMedCrossRef
60.
Islam F, Salloum RG, Nakkash R, Maziak W, Thrasher JF. Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health. 2016;61:709–15.PubMedCrossRef
61.
Süssenbach P, Niemeier S, Glock S. Effects of and attention to graphic warning labels on cigarette packages. Psychol Health. 2013;28(10):1192–206.PubMedCrossRef
62.
Pollay RW. The role of packaging seen through industry documents. Expert report prepared for: JTI-Macdonald, Imperial Tobacco Canada Ltd and Rothmans, Benson & Hedges Inc v Attorney General of Canada and Canadian Cancer Society (Intervenor) Supreme Court, Province of Quebec, District of Montreal Defense Exhibit D-116 2001.
63.
Mead EL, Cohen JE, Kennedy CE, Gallo J, Latkin CA. The role of theory-driven graphic warning labels in motivation to quit: a qualitative study on perceptions from low-income, urban smokers. BMC Public Health. 2015;15(1):1–11.CrossRef
64.
Lakhdar CB, Deplancke A, Le Lec F, Massin S, Piermatteo A, Vaillant N. Protocol for creating new warnings on cigarette packs and evaluating their efficacy in a randomised experimental setting. BMJ open. 2020;10(6):e036166.PubMedPubMedCentralCrossRef
65.
Hassan LM, Shiu E, Thrasher JF, Fong GT, Hastings G. Exploring the effectiveness of cigarette warning labels: findings from the United States and United Kingdom arms of the International Tobacco Control (ITC) Four Country Survey. Int J Nonprofit Voluntary Sect Mark. 2008;13(3):263–74.CrossRef
66.
Borland R, Wilson N, Fong GT, Hammond D, Cummings KM, Yong H-H, Hosking W, Hastings G, Thrasher J, McNeill A. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control. 2009;18(5):358–64.PubMedCrossRef
67.
Salloum RG, Lee J, Mostafa A, Abu-Rmeileh NM, Hamadeh RR, Darawad MW, Kheirallah KA, Salama M, Maziak W, Nakkash R. Waterpipe tobacco smoking among university students in three eastern Mediterranean countries: patterns, place, and price. Subst Use Misuse. 2019;54(14):2275–83.PubMedCrossRef
Metadata
Title
Association between textual and pictorial warnings on tumbac (waterpipe tobacco) boxes and motivation to quit waterpipe smoking among Lebanese and Iraqi adolescents
Authors
Diana Malaeb
Bassam Abdul Rasool Hassan
Ali Haider Mohammed
Sinan Subhi Farhan
Omar Abdulwahid Al-Ani
Abir Sarray El Dine
Feten Fekih-Romdhane
Sahar Obeid
Souheil Hallit
Publication date
01-12-2024
Publisher
BioMed Central
Published in
BMC Pediatrics / Issue 1/2024
Electronic ISSN: 1471-2431
DOI
https://doi.org/10.1186/s12887-024-04649-7

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