The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study

  • Souheil HallitEmail author
  • Nelly Layoun
  • Diana Malaeb
  • Miguella Outayek
  • Marie-Josée Boueid
  • Mirna Waked
  • Zeina Aoun Bacha
  • Pascale Salameh
Research Article


Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.


Waterpipe Motivation Intention to quit Pictorial warning Textual warning 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. Aboaziza E, Eissenberg T (2015) Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence? Tob Control 24(Suppl 1):i44–i53. CrossRefGoogle Scholar
  2. Afifi R, Khalil J, Fouad F, Hammal F, Jarallah Y, Abu Farhat H, Ayad M, Nakkash R (2013) Social norms and attitudes linked to waterpipe use in the Eastern Mediterranean Region. Soc Sci Med 98:125–134. CrossRefGoogle Scholar
  3. Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Irani J (2013) Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J 10:12. CrossRefGoogle Scholar
  4. Al Suwaidi J, Zubaid M, El-Menyar AA, Singh R, Asaad N, Sulaiman K et al (2012) Prevalence and outcome of cigarette and waterpipe smoking among patients with acute coronary syndrome in six Middle-Eastern countries. Eur J Prev Cardiol 19(1):118–125. CrossRefGoogle Scholar
  5. Ali M, Jawad M (2017) Health effects of waterpipe tobacco use: getting the public health message just right. Tob Use Insights, 10, 1179173X17696055. CrossRefGoogle Scholar
  6. American Psychological Association (n.d.). Education and Socioeconomic Status. Available from:
  7. Aryanpur M, Masjedi MR, Mortaz E, Hosseini M, Jamaati H, Tabarsi P, Soori H, Heydari GR, Kazempour-Dizaji M, Emami H, Mozafarian A (2016) Intention to quit smoking and associated factors in smokers newly diagnosed with pulmonary tuberculosis. Tanaffos 15(1):17–24Google Scholar
  8. Asfar T, Ward KD, Eissenberg T, Maziak W (2005) Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers. BMC Public Health 5:19. CrossRefGoogle Scholar
  9. Athamneh L, Sansgiry SS, Essien EJ, Abughosh S (2015) Predictors of intention to quit waterpipe smoking: a survey of arab americans in houston, Texas. J Addict 2015:575479. CrossRefGoogle Scholar
  10. Awaisu A, Alsalimy N (2015) Pharmacists’ involvement in and attitudes toward pharmacy practice research: a systematic review of the literature. Res Soc Adm Pharm 11(6):725–748. CrossRefGoogle Scholar
  11. Borland R, Yong HH, Balmford J, Cooper J, Cummings KM, O'Connor RJ, McNeill A, Zanna MP, Fong GT (2010) Motivational factors predict quit attempts but not maintenance of smoking cessation: findings from the International Tobacco Control Four country project. Nicotine Tob Res 12(Suppl):S4–S11. CrossRefGoogle Scholar
  12. Bursac Z, Gauss CH, Williams DK, Hosmer DW (2008) Purposeful selection of variables in logistic regression. Source code for biology and medicine 3(1):17CrossRefGoogle Scholar
  13. Coleman T (2010) Motivation, physical activity and smoking cessation. Patient Educ Couns 79(2):141–142. CrossRefGoogle Scholar
  14. Cunningham R (2009) Gruesome photos on cigarette packages reduce tobacco use. Bull World Health Organ 87(8):569–569CrossRefGoogle Scholar
  15. Cunningham R (2013) Cigarette package warning size and use of pictures: international summary. Canadian Cancer Society, Ottawa Google Scholar
  16. Daoud N, Hayek S, Sheikh Muhammad A, Abu-Saad K, Osman A, Thrasher JF, Kalter-Leibovici O (2015) Stages of change of the readiness to quit smoking among a random sample of minority Arab male smokers in Israel. BMC Public Health 15:672. CrossRefGoogle Scholar
  17. DS A, Rajesh G, Mohanty VR (2010) Insights into pictorial health warnings on tobacco product packages marketed in Uttar Pradesh, India. Asian Pac J Cancer Prev 11:539–543Google Scholar
  18. Fong GT, Hammond D, Jiang Y, Li Q, Quah AC, Driezen P et al (2010) Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study. Tob Control 19(Suppl 2):i69–i77. CrossRefGoogle Scholar
  19. Foundation for a smoke-free world (n.d.). State of smoking in Lebanon. Available from:
  20. Hallit S, Hallit R, Haddad C, Youssef L, Zoghbi M, Costantine R, Kheir N, Salameh P (2019) Previous, current, and cumulative dose effect of waterpipe smoking on LDL and total cholesterol. Environ Sci Pollut Res Int 26(8):8194–8201. CrossRefGoogle Scholar
  21. Hallit S, Zoghbi M, Hallit R, Youssef L, Costantine R, Kheir N, Salameh P (2017) Effect of exclusive cigarette smoking and in combination with waterpipe smoking on lipoproteins. J Epidemiol Glob Health 7(4):269–275. CrossRefGoogle Scholar
  22. Heinz AJ, Giedgowd GE, Crane NA, Veilleux JC, Conrad M, Braun AR, Olejarska NA, Kassel JD (2013) A comprehensive examination of hookah smoking in college students: use patterns and contexts, social norms and attitudes, harm perception, psychological correlates and co-occurring substance use. Addict Behav 38(11):2751–2760. CrossRefGoogle Scholar
  23. Ibrahim WH, Rasul KI, Khinji A, Ahmed MS, Bener A (2010) Clinical and epidemiological characteristics of lung cancer cases in Qatar. East Mediterr Health J 16(2):166–170CrossRefGoogle Scholar
  24. Islam F, Salloum RG, Nakkash R, Maziak W, Thrasher JF (2016) Effectiveness of health warnings for waterpipe tobacco smoking among college students. Int J Public Health 61(6):709–715. CrossRefGoogle Scholar
  25. Jaam M, Al-Marridi W, Fares H, Izham M, Kheir N, Awaisu A (2016) Perception and intentions to quit among waterpipe smokers in Qatar: a cross-sectional survey. Public Health Action 6(1):38–43. CrossRefGoogle Scholar
  26. Janis IL (1967) Effects of fear arousal on attitude change: recent developments in theory and experimental research1 Advances in experimental social psychology (Vol. 3, pp. 166-224): Elsevier.Google Scholar
  27. Jawad M, Bakir A, Ali M, Grant A (2015a) Impact of waterpipe tobacco pack health warnings on waterpipe smoking attitudes: a qualitative analysis among regular users in London. Biomed Res Int 2015:745865. CrossRefGoogle Scholar
  28. Jawad M, El Kadi L, Mugharbil S, Nakkash R (2015b) Waterpipe tobacco smoking legislation and policy enactment: a global analysis. Tob Control 24(Suppl 1):i60–i65. CrossRefGoogle Scholar
  29. Jawad M, Lee JT, Millett C (2016) Waterpipe tobacco smoking prevalence and correlates in 25 Eastern Mediterranean and Eastern European Countries: cross-sectional analysis of the Global Youth Tobacco Survey. Nicotine Tob Res 18(4):395–402. CrossRefGoogle Scholar
  30. Khattab A, Javaid A, Iraqi G, Alzaabi A, Ben Kheder A, Koniski ML et al (2012) Smoking habits in the Middle East and North Africa: results of the BREATHE study. Respir Med 106(Suppl 2):S16–S24. CrossRefGoogle Scholar
  31. Kheirallah KA, Alsulaiman JW, Mohammad HA, Alzyoud S, Veeranki SP, Ward KD (2016) Waterpipe tobacco smoking among Arab youth; a cross-country study. Ethn Dis 26(1):107–112. CrossRefGoogle Scholar
  32. La Torre G, Saulle R, Nicolotti N, de Waure C., Gualano, M. R., & Boccia, S. (2013). From nicotine dependence to genetic determinants of smoking Smoking Prevention and Cessation (pp. 1-29): Springer.Google Scholar
  33. Layoun N, Hallit S, Waked M, Aoun Bacha Z, Leveque A, Dramaix M, Salameh P (2018) Predictors of Past Quit Attempts and Length of Abstinence among Waterpipe Smokers in Lebanon. Journal of Clinical and Diagnostic Research 12(10):LC04-LC08.Google Scholar
  34. Mansour, A. Y., & Bakhsh, Z. (2017). Factors affecting the perceived effectiveness of pictorial health warnings on cigarette packages in gulf countries: a cross-sectional study. Tob Use Insights, 10, 1179173X17698462. doi: CrossRefGoogle Scholar
  35. Mathur S, Singh N (2015) Characteristics of smokers with intentions to quit, with a focus on occupational status, race/ethnicity, and cognitive behavior. Epidemiol Biostat Public Health 12(1)Google Scholar
  36. Mayerl H, Stolz E, Freidl W (2018) Responses to textual and pictorial cigarette pack health warnings: findings from an exploratory cross-sectional survey study in Austria. BMC Public Health 18(1):442. CrossRefGoogle Scholar
  37. Maziak W (2011) The global epidemic of waterpipe smoking. Addict Behav 36(1):1–5CrossRefGoogle Scholar
  38. Maziak W, Ben Taleb Z, Jawad M, Afifi R, Nakkash R, Akl EA et al (2017) Consensus statement on assessment of waterpipe smoking in epidemiological studies. Tob Control 26(3):338–343. CrossRefGoogle Scholar
  39. Maziak W, Taleb ZB, Bahelah R, Islam F, Jaber R, Auf R, Salloum RG (2015) The global epidemiology of waterpipe smoking. Tob Control 24(Suppl 1):i3–i12. CrossRefGoogle Scholar
  40. Mohammed HT, Hammond D, Fong GT, & McDonald P. (2013). The efficacy of viewing health warnings on shisha smoking among shisha smokers. PhD Thesis. Available from: . The University of Waterloo.
  41. Mohammed KA, Geneus CJ, Yadgir S, Subramaniam DS, Burroughs TE (2017) Correlates of hookah pipe awareness and perceived harmfulness among U.S. adults. Am J Prev Med 52(4):513–518. CrossRefGoogle Scholar
  42. Mostafa A, Mohammed HT (2017) Graphic health warnings and their best position on waterpipes: a cross-sectional survey of expert and public opinion. Tob Prev Cessat 3:116CrossRefGoogle Scholar
  43. Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A, Hoek J (2018) Plain packaging of waterpipe tobacco? A qualitative analysis exploring waterpipe smokers’ and non-smokers’ responses to enhanced versus existing pictorial health warnings in Egypt. BMJ Open 8(10):e023496. CrossRefGoogle Scholar
  44. Mostafa A, Mohammed HT, Hussein WM, Elhabiby M, Safwat W, Labib S, Aboul Fotouh A, Hoek J (2019) Would placing pictorial health warnings on waterpipe devices reduce waterpipe tobacco smoking? A qualitative exploration of Egyptian waterpipe smokers’ and non-smokers’ responses. Tob Control 28(4):475–478. CrossRefGoogle Scholar
  45. Mutti, S., Reid, J. L., Gupta, P. C., Pednekar, M. S., Dhumal, G., Nargis, N., . . . Hammond, D. (2015). Perceived effectiveness of text and pictorial health warnings for smokeless tobacco packages in Navi Mumbai, India, and Dhaka, Bangladesh: findings from an experimental study. Tobacco control, tobaccocontrol-2015-052315.Google Scholar
  46. Nakkash R, Khalil J (2010) Health warning labelling practices on narghile (shisha, hookah) waterpipe tobacco products and related accessories. Tob Control 19(3):235–239. CrossRefGoogle Scholar
  47. Nakkash RT, Khalil J, Afifi RA (2011) The rise in narghile (shisha, hookah) waterpipe tobacco smoking: a qualitative study of perceptions of smokers and non smokers. BMC Public Health 11:315. CrossRefGoogle Scholar
  48. Prochaska JO, Norcross JC, DiClemente CC (2013) Applying the stages of change. Psychotherapy in Australia 19(2):10Google Scholar
  49. Salameh P, Waked M, Aoun Z (2008) Waterpipe smoking: construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11). Nicotine Tob Res 10(1):149–158. CrossRefGoogle Scholar
  50. Salloum RG, Abu-Rmeileh N, Hamadeh R, Thomas J, Mostafa A, Yusufali A et al (2017) Policy-relevant context of waterpipe tobacco smoking among university students in six countries across the eastern mediterranean region: a qualitative study. Asian Pac J Cancer Prev 18(9):2533–2540. CrossRefGoogle Scholar
  51. Smith-Simone S, Maziak W, Ward KD, Eissenberg T (2008) Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples. Nicotine Tob Res 10(2):393–398. CrossRefGoogle Scholar
  52. Witte K, Allen M (2000) A meta-analysis of fear appeals: implications for effective public health campaigns. Health Educ Behav 27(5):591–615. CrossRefGoogle Scholar
  53. World Health Organization. (2003). Conference of the parties to the WHO FCTC WHO Framework Convention on Tobacco Control. Available from:
  54. World Health Organization. (2008a). Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control: Packaging and Labelling of Tobacco Products. Available from:
  55. World Health Organization. (2008b). MPOWER: Six policies to reverse the tobacco epidemic. Available from:

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Faculty of Medicine and Medical SciencesHoly Spirit University of Kaslik (USEK)JouniehLebanon
  2. 2.INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et ToxicologieBeirutLebanon
  3. 3.Faculty of PharmacyLebanese UniversityBeirutLebanon
  4. 4.School of PharmacyLebanese International UniversityBeirutLebanon
  5. 5.Department of Life Sciences and HealthParis-Est UniversityParisFrance
  6. 6.Faculty of Arts and SciencesHoly Spirit University of Kaslik (USEK)JouniehLebanon
  7. 7.Department of PulmonologySt George Hospital University Medical CenterBeirutLebanon
  8. 8.Faculty of MedicineBalamand UniversityKouraLebanon
  9. 9.Department of Pulmonary and Critical Care MedicineHotel-Dieu de FranceBeirutLebanon
  10. 10.Faculty of MedicineLebanese UniversityBeirutLebanon

Personalised recommendations