Graphic health warnings and their best position on waterpipes: A cross-sectional survey of expert and public opinion

INTRODUCTION: Our aim was to assess the visibility and efficiency of graphic health warnings (GHWs) on waterpipe tobacco packs (WTPs) and to explore other more effective places to display them for better impact. We also evaluated the visibility of GHWs when placed on the waterpipe device. METHODS: We conducted 3 cross-sectional study phases using face-to-face survey questionnaires in 2014-2015. Phase I surveyed 31 tobacco control experts, while Phase II surveyed 700 participants and Phase III surveyed 348 from the public in Cairo, Egypt. RESULTS: Approximately half of the experts and participants in Phases II and III thought that GHWs on WTPs are not adequately visible, and 68.9% and 79.6% in Phases II and III, respectively, suggested posting warnings also in other places. About one-third of experts and 69.1% of Phase II participants suggested posting GHWs inside cafés or in public places, while 46.9% of Phase III participants favored placing them on waterpipes. After viewing our suggested positions on a waterpipe, all experts, 80.6% of participants in Phase II, and 81.6% in Phase III acknowledged that GHWs would be more visible there. The mouthpiece was the location selected most often across all phases (31.1% in Phase I, 35.6% in Phase II and 36.3% in Phase III). Lung and throat cancers were similarly effective in raising participants’ concern about waterpipe smoking health risks (24.7%). CONCLUSIONS: This is the first population-based study to explore the best location to place GHWs on waterpipes. Policymakers should consider enacting a regulatory framework for placing GHWs on waterpipe devices.