PT  - JOURNAL ARTICLE
AU  - Aya Mostafa
AU  - Heba Tallah Mohammed
AU  - Wafaa Mohamed Hussein
AU  - Mahmoud Elhabiby
AU  - Wael Safwat
AU  - Sahar Labib
AU  - Aisha Aboul Fotouh
AU  - Janet Hoek
TI  - Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers’ and non-smokers’ responses to enhanced versus existing pictorial health warnings in Egypt
AID  - 10.1136/bmjopen-2018-023496
DP  - 2018 Oct 01
TA  - BMJ Open
PG  - e023496
VI  - 8
IP  - 10
4099  - http://bmjopen.bmj.com/content/8/10/e023496.short
4100  - http://bmjopen.bmj.com/content/8/10/e023496.full
SO  - BMJ Open2018 Oct 01; 8
AB  - Objective Despite the global increase in waterpipe tobacco smoking (WTS) including in Egypt, few studies have assessed the effectiveness of waterpipe tobacco (WT) health warnings. Egypt has used pictorial health warnings (PHWs) on waterpipe tobacco packs (WTPs) and has rotated these every two years since 2008. We explored in this qualitative study how participants perceived existing PHWs on WTPs, assessed how they interpreted novel plain packaging of WT featuring enhanced PHWs, and probed perceptions of how existing and novel sets would affect uptake or cessation of WTS.Design We conducted ten qualitative focus groups and ten in-depth interviews. We explored participants’ views of the four existing PHWs (occupied 50% of the front and back of WTPs, displayed cancers, and featured colourful fruits and flavors) and four novel PHWs (occupied 80% of the front and back of WTPs, displayed different topical content, with plain packaging). Transcripts were analyzed using thematic analysis.Setting Rural Menoufia, urban and semi-urban Cairo, Egypt.Participants 90 waterpipe smokers and non-smokers, men and women, aged 18 years or older.Outcomes Perceived potential effect on WTS uptake or cessation, probing factors related to PHW content and WTP design.Results Participants in focus groups and in-depth interviews thought existing WT PHWs elicited affective responses, but found them unclear or unrealistic and thought the colourful packaging detracted from the warnings. In contrast, they thought novel and larger WT PHWs presented in plain packaging might prevent WTS initiation or trigger quit attempts. Participants regarded warnings featuring proximal health risks as most likely to be acceptable.Conclusions Our exploratory study suggests larger WT PHWs featuring proximal risks and presented on plain WTPs could potentially deter experimentation with WT products among non-users and promote cessation among existing users.