Health Warnings for Hookah Smoking

Overseen By Erin Sutfin, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Wake Forest University Health Sciences

Disqualifiers: Under 18, Non-English, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 2

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to evaluate the effectiveness of different health warnings in reducing hookah smoking in real-world settings. Participants will be divided into groups: some will see text-only warning signs in the café, while others will not see any warnings. The study will compare smoking behavior based on these differences. Individuals who plan to smoke hookah inside the café and speak English are suitable candidates for this trial. As an unphased trial, this study allows participants to contribute to important research on public health interventions.

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 prior data suggests that these health warnings are safe for use in hookah cafés?

Research shows that health warnings, whether they include pictures or just text, are safe to use in studies like this one. These warnings are messages placed in cafes to alert people about the dangers of smoking hookah. Without any physical treatment or medication involved, there are no safety concerns about side effects.

Studies have found that text-only warnings can effectively communicate risks. For example, students rated the message "WARNING: Hookah smoke contains poisons that cause lung and oral cancers" as very effective. While these warnings aim to inform and possibly reduce smoking, they do not pose any risk to participants. Essentially, the warnings are just messages, so they are well-tolerated and have no negative effects on health. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it aims to uncover how different types of warnings can impact hookah smoking behaviors. Unlike standard approaches that might focus on education or cessation programs, this trial specifically tests the effectiveness of health warnings displayed in hookah cafes. The unique feature here is the comparison between no warnings, pictorial warnings, and text-only warnings. By understanding which type of warning is most effective, this research could lead to new strategies for reducing hookah smoking rates and improving public health outcomes.

What evidence suggests that this trial's treatments could be effective for reducing hookah smoking?

Research shows that warning labels, both text-only and with pictures, can prompt people to consider quitting smoking waterpipes, also known as hookahs. Studies have found that these warnings, especially those focused on waterpipe smoking, can motivate smokers to think about quitting. In this trial, some cafes will display text-only warning signs, which effectively raise awareness of the risks, particularly when they mention harm to children. Although picture warnings often have a stronger impact than text-only ones, both types help explain the health risks of hookah smoking. As a result, placing text warnings in hookah cafés might encourage some customers to smoke less. ^{1 3 4 6 7}

Who Is on the Research Team?

Erin Sutfin, PhD

Principal Investigator

Wake Forest University Health Sciences

Are You a Good Fit for This Trial?

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

English speaking

Exclusion Criteria

Has been approached to participate in the study previously

Is an employee of the café

Planning to smoke cigarettes, cigars, or marijuana while at the hookah café

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

1 day

1 visit (in-person)

Intervention

Participants are exposed to health warnings in the café and complete surveys and breath samples before and after café visit

Up to 10 hours

1 visit (in-person)

Follow-up

Participants are monitored for changes in smoking behavior and health knowledge after café visit

1 month

What Are the Treatments Tested in This Trial?

Interventions

• No Warnings
• Pictorial Warnings
• Text-only Warnings

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.

How Is the Trial Designed?

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+

National Cancer Institute (NCI)

Collaborator

Trials

14,080

Recruited

41,180,000+

Published Research Related to This Trial

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]

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]

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 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]

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]

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]

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]

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]

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]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC4992403/

Effectiveness of Health Warnings for Waterpipe Tobacco ... Text-only messages and pictorial labels warning about harm to children were the most effective in motivating waterpipe smokers to think about quitting.

2. sciencedirect.com sciencedirect.com/science/article/pii/S2451865421000983

Examining the effect of waterpipe specific pictorial health ... Applying pictorial health warning labels (HWLs) on tobacco products has been effective in communicating health risks associated with tobacco smoking. However, ...

3. tobaccopreventioncessation.com tobaccopreventioncessation.com/Association-of-health-warning-labels-and-motivation-to-quit-waterpipe-tobacco-smoking,134561,0,2.html

Association of health warning labels and motivation to quit ... This study aimed to determine associations between health warning label content and motivation to quit waterpipe smoking by gender and smoking location.

4. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC9582042/

Impact of Pictorial Health Warning Labels on Smoking ... This experimental study showed that waterpipe-specific pictorial HWLs on tobacco packages are more effective than text-only for several communication outcomes.

5. tobaccocontrol.bmj.com tobaccocontrol.bmj.com/content/19/3/235

Health warning labelling practices on narghile (shisha ... Waterpipe tobacco smoking contains toxic and carcinogenic compounds. · This research demonstrates the lack of appropriate health warning labels on waterpipe ...

6. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC8323771/

Waterpipe Tobacco Warnings Need to Inform Users of Harm In the random sample of students, the top message (WARNING: Hookah smoke contains poisons that cause lung and oral cancers) had high effectiveness (M = 4.49) ...

7. withpower.com withpower.com/trial/phase-waterpipe-tobacco-smoking-5-2023-3d8d6

Health Warnings for Hookah Smoking · Info for Participants The available research shows that pictorial health warnings on waterpipe tobacco products are more effective than text-only warnings. For example, a study in ...