Characteristics of Waterpipe Health Warning Labels in the United States

Objectives: In this paper, we assess characteristics of health warning labels (HWLs) on water-pipe tobacco packages sold in the US and changes after the FDA's minimum required warning statement went into effect in August 2018. Methods: We sampled 16 brands and 45 sub-brands/flavors of the most popular waterpipe tobaccos 6 months before and 4 months after the FDA's compliance deadline. HWL characteristics assessed included type (pictorial or text), message theme, location, and relative size. Results: Before the deadline, all packages had at least one text-only HWL that covered <25% of the surface, with most inconspicuously placed (such as side panel), and focusing on general health risks of tobacco rather than waterpipe-specific risks. After the deadline, only 1 of 10 brands had adopted the new required HWL, adding it to the existing one. Conclusions: HWLs were common on waterpipe tobacco packages in the US prior to the FDA mandate, but did not adhere to recommended standards of being pictorial, large (least 50% of the package), conspicuously placed, and using relevant, rotating message themes. The FDA's required warning has not yet been adopted by most brands. Doing so may improve the efficacy of HWLs to reduce smoking.