Development and Testing of Waterpipe Tobacco Text and Pictorial Warnings Among Young Adults in the United States

Waterpipe tobacco smoking (WTS) is associated with health harms, yet the United States requires only a single text warning.

We developed 30 text warnings, across 12 health themes, based on scientific evidence and expert input. Text warnings were tested in an online survey among a national convenience sample of US young adults (18-29, Study 1). We then selected six text warnings and paired each with three images, creating 18 pictorial warnings that were tested in an online survey among a second national convenience sample of US young adults (18-29, Study 2).

Study 1 had 822 participants (33% past-year WTS, 43.6% susceptible, 23.5% not susceptible). Text warnings performed similarly, and there were no differences across themes on perceived message effectiveness (PME) (Means = 3.59-3.79), learning (Means = 2.71-2.91), or cognitive elaboration (Means = 3.48-3.68). There were differences between user groups for PME (F1,2 = 32.26, p < .05), cognitive elaboration (F1,2 = 32.26, p < .05), and learning (F1,2 = 9.53, p < .05); yet differences did not vary by theme. Study 2 had 902 participants (33.5% past-year WTS, 33.4% susceptible, 33.2% not susceptible). We found significant differences in PME, emotional reactions, and visual-verbal congruency between the three pictorial warnings tested for each text warning; however, ratings were similar across user groups. We selected the most promising pictorial warning for each corresponding text warning.

Text warnings covering a range of health harms may be effective and should be considered by the US Food and Drug Administration. Moreover, the United States and other countries should consider utilizing pictorial warnings to further enhance comprehension and potential effectiveness in discouraging WTS.

We developed and tested text and pictorial warnings that could be used to communicate the harms of WTS to young adults in the United States, who have the highest rates of WTS. A wide range of text warning statements was found to elicit moderately high ratings of perceived message effectiveness and cognitive elaboration. A more comprehensive set of text warnings could provide further understanding of the harms of WTS. Moreover, pictorial warnings could further enhance comprehension of health harms and potentially discourage WTS.