Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Mar 24;18(3):e0279014.
doi: 10.1371/journal.pone.0279014. eCollection 2023.

Adapting waterpipe-specific pictorial health warning labels to the Tunisian context using a mixed method approach

Nadia Ben Mansour  1   2 , Salsabil Rejaibi  1   2 , Asma Sassi Mahfoudh  1 , Sarra Ben Youssef  1 , Habiba Ben Romdhane  1 , Michael Schmidt  3 , Kenneth D Ward  4   5 , Wasim Maziak  5   6 , Taghrid Asfar  5   7   8
Affiliations

Adapting waterpipe-specific pictorial health warning labels to the Tunisian context using a mixed method approach

Nadia Ben Mansour et al. PLoS One. .

Abstract

Background: Waterpipe (WP) use is rapidly increasing among young people worldwide due to the widespread misperception that it is safer than cigarette smoking. Health warning labels (HWLs) can effectively communicate tobacco-related health risks but have yet to be developed for WP. This study aimed to optimize and adapt a set of 16 pictorial WP-specific HWLs, developed by an international Delphi study, to the Tunisian context. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes.

Methods: Using a mixed method approach, we conducted ten focus groups combined with a survey among young WP users and nonusers (N = 63; age 18-34 years). In the survey, participants rated the HWLs on several communication outcomes (e.g., reaction, harm perception, effectiveness) and were then instructed to view all HWLs in each theme and rank them in the order of overall perceived effectiveness, from the most to the least effective. Afterward, participants provided in-depth feedback on HWLs and avenues for improvement. Mean effectiveness rating scores and percentages of participants' top-ranked HWLs were calculated. Discussions were audio-taped, transcribed verbatim, and analyzed thematically.

Results: The top-ranked HWLs were those showing oral cancers, orally transmitted diseases, and a sick child. Focus group discussion illustrated that these selections were based on participants' reactions to the direct impact of WP on a person's physical appearance and evoking guilt over children's exposure to WP smoke. Suggestions for improvement highlighted the need to use the local dialect and more affirmative statements (e.g., avoiding "may" or "can").

Conclusions: This study is the first in North Africa to attempt to advance HWLs policy as the World Health Organization recommended. The results of this study can be used as a basis for implementing WP-specific health messages in the Eastern Mediterranean Region.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Health warning labels tested in the study.
See this image and copyright information in PMC

References

    1. 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). doi: 10.1371/journal.pone.0192191 - DOI - PMC - PubMed
    1. Al-Mandhari A, Hammerich A, El-Awa F, Bettcher D, Mandil A. Full implementation of the WHO Framework Convention on Tobacco Control in the Eastern Mediterranean Region is the responsibility of all. Eastern Mediterranean Health Journal. 2020;26(1):4–5. doi: 10.26719/2020.26.1.4 - DOI - PubMed
    1. WHO FCTC. 2020—CORE QUESTIONNAIRE OF THE REPORTING INSTRUMENT OF WHO FCTC. 2020.
    1. Nasser AM, Geng Y, Al-Wesabi SA. The prevalence of smoking (cigarette and waterpipe) among university students in some Arab countries: a systematic review. Asian Pacific journal of cancer prevention: APJCP. 2020;21(3):583. doi: 10.31557/APJCP.2020.21.3.583 - DOI - PMC - PubMed
    1. Global Youth Tobacco Survey. Global Youth Tobacco Survey (GYTS, 2017) Fact Sheet, Tunisia, 2010 2010 [https://untobaccocontrol.org/impldb/wp-content/uploads/reports/tunisia_2...]

Publication types