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      Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories

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          Abstract

          Background

          Waterpipe tobacco smoking prevalence is increasing around the globe despite current evidence that smoke emissions are toxic and contain carcinogenic compounds.

          Objective

          To evaluate current health warning labelling practices on waterpipe tobacco products and related accessories.

          Methods

          All waterpipe tobacco products, as well as waterpipe accessories, were purchased from Lebanon and a convenience sample was obtained from Dubai (United Arab Emirates), Palestine, Syria, Jordan, Bahrain, Canada, Germany and South Africa.

          Findings

          Of the total number of waterpipe tobacco products collected from Lebanon, the majority had textual health warning labels covering on average only 3.5% of total surface area of the package. Misleading descriptors were commonplace on waterpipe tobacco packages and related accessories.

          Conclusions

          There are no WHO FCTC compliant waterpipe-specific health warning labels on waterpipe tobacco products and related accessories. Introducing health warnings on waterpipe tobacco products and accessories will probably have worldwide public health benefits.

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          Most cited references19

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          Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic.

          T Eissenberg, Rabab Ward, W Maziak … (2004)
          The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Current research, treatment, and policy efforts focus on cigarettes, while many people in developing regions (Asia, Indian subcontinent, Eastern Mediterranean) smoke tobacco using waterpipes. Waterpipes are increasing in popularity, and more must be learned about them so that we can understand their effects on public health, curtail their spread, and help their users quit. To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy. A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used. Every identified published study related to waterpipe use was included. Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications. More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.
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            Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study.

            Pete Driezen, David Hammond, Geoffrey Fong … (2007)
            Health warnings on cigarette packages provide smokers with universal access to information on the risks of smoking. However, warnings vary considerably among countries, ranging from graphic depictions of disease on Canadian packages to obscure text warnings in the United States. The current study examined the effectiveness of health warnings on cigarette packages in four countries. Quasi-experimental design. Telephone surveys were conducted with representative cohorts of adult smokers (n=14,975): Canada (n=3687), United States (n=4273), UK (n=3634), and Australia (n=3381). Surveys were conducted between 2002 and 2005, before and at three time points following implementation of new package warnings in the UK. At Wave 1, Canadian smokers reported the highest levels of awareness and impact for health warnings among the four countries, followed by Australian smokers. Following the implementation of new UK warnings at Wave 2, UK smokers reported greater levels of awareness and impact, although Canadian smokers continued to report higher levels of impact after adjusting for the implementation date. U.S. smokers reported the lowest levels of effectiveness for almost every measure recorded at each survey wave. Large, comprehensive warnings on cigarette packages are more likely to be noticed and rated as effective by smokers. Changes in health warnings are also associated with increased effectiveness. Health warnings on U.S. packages, which were last updated in 1984, were associated with the least effectiveness.
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              Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe.

              Wasan R. Saleh, Alan Shihadeh (2005)
              A smoking machine protocol and yields for "tar", nicotine, PAH, and CO are presented for the standard 171-puff steady periodic smoking regimen proposed by Shihadeh et al. [Shihadeh, A., Azar, S., Antonios, C., Haddad, A., 2004b. Towards a topographical model of narghile water-pipe cafe smoking: A pilot study in a high socioeconomic status neighborhood of Beirut, Lebanon. Pharmacology Biochemistry and Behavior 79(1), 75]. Results show that smokers are likely exposed to more "tar" and nicotine than previously thought, and that pyronsynthesized PAH are present in the "tar" despite the low temperatures characteristic of the tobacco in narghile smoking. With a smoking regimen consisting of 171 puffs each of 0.53l volume and 2.6s duration with a 17 s interpuff interval, the following results were obtained for a single smoking session of 10 g of mo'assel tobacco paste with 1.5 quick-lighting charcoal disks applied to the narghile head: 2.94 mg nicotine, 802 mg "tar", 145 mg CO, and relative to the smoke of a single cigarette, greater quantities of chrysene, phenanthrene, and fluoranthene. Anthracene and pyrene were also identified but not quantified. The results indicate that narghile smoke likely contains an abundance of several of the chemicals thought to be causal factors in the elevated incidence of cancer, cardiovascular disease and addiction in cigarette smokers.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Tob Control
                Journal ID (publisher-id): tc
                Journal ID (hwp): tobaccocontrol
                Title: Tobacco Control
                Publisher: BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Print): 0964-4563
                ISSN (Electronic): 1468-3318
                Publication date (Electronic): 25 May 2010
                Publication date (Print): June 2010
                Publication date PMC-release: 25 May 2010
                Volume: 19
                Issue: 3
                Pages: 235-239
                Affiliations
                Department of Health Behavior and Education, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
                Author notes
                Correspondence to Dr Rima Nakkash, Health Behavior and Education Department, Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, PO, Riad El Solh, Beirut 1107 2020, Lebanon; rima.nakkash@ 123456aub.edu.lb
                Article
                Publisher ID: tobaccocontrol31773
                DOI: 10.1136/tc.2009.031773
                PMC ID: 2989164
                PubMed ID: 20501497
                SO-VID: 384ed198-a11f-425d-8281-504f1e25af5d
                Copyright © © 2010, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                Date received : 22 May 2009
                Date accepted : 26 February 2010
                Categories
                Subject: Research Paper
                Subject: 1506

                ScienceOpen disciplines: Public health
                Keywords: public policy,shisha,nontraditional modes of tobacco use,tobacco products,who fctc article 11,hookah,waterpipe,narghile,packaging and labelling,health warnings
                Data availability:
                ScienceOpen disciplines: Public health
                Keywords: public policy, shisha, nontraditional modes of tobacco use, tobacco products, who fctc article 11, hookah, waterpipe, narghile, packaging and labelling, health warnings

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