Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study.

PURPOSE: Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes. METHODS: We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted. RESULTS: Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only. CONCLUSIONS: Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

"Scary and Effective, Definitely Pushes Me to Quit Smoking": Developing Waterpipe Pictorial Health Warnings Targeting Young Adults in Lebanon.

INTRODUCTION: Waterpipe (WP) smoking is the leading tobacco use method among young adults in Lebanon. WP use is harmful, yet misperceptions about its safety exist. Implementing pictorial health warning labels (HWLs) on WP products is a promising strategy to correct this misperception. This study aimed to culturally adapt a set of 12 pictorial HWLs recently developed by an international expert panel to young adults in Lebanon. HWLs were grouped into four themes: WP health risks, WP harm to others, WP-specific harms, and WP harm compared to cigarettes. AIMS AND METHODS: We conducted nine focus groups among WP smokers and nonsmokers (N = 77; 52% females; age 18-34 years) to explore participants' perceptions of the developed HWLs on attention, reaction (fear, avoidance), effectiveness (harm perception), and improvement (design/content, relatedness). Sessions were audio-taped, transcribed verbatim, and analyzed using directed qualitative content analysis. RESULTS: Emotionally provocative warnings were perceived as most effective, while symbolic and abstract warnings were found not believable. Warnings depicting visible bodily health effects and harm to babies seemed most promising. Participants were generally skeptical about Theme 4 because it might encourage switching to cigarettes. For cultural adaptation, participants recommended using shorter text with affirmative phrases, increasing the picture's size and improving their quality, adding the WP device picture to enhance HWLs' relatability, and develop testimonial messages that depict real people and stories. CONCLUSIONS: Results will provide Lebanon and perhaps other countries in the Eastern Mediterranean Region with evidence-based HWLs that they can further develop, test, and implement within their specific culture. IMPLICATIONS: Results provide Lebanon with evidence-based WP-specific pictorial HWLs that can be further developed and tested. HWLs provoking negative affect, with visible health consequences, and depicting harm to babies are promising. Participants recommended using definitive scientific claims presenting the health risks in numerical form. However, this needs to be balanced against protecting the credibility of HWLs scientifically and legally. Increasing the HWLs size and adding the WP device picture to the HWLs can enhance their relatability. Further research can help address some questions raised by this study, such as the potential of testimonial warnings that depict real people.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health.

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

A call to advance and translate research into policy on governance, ethics, and conflicts of interest in public health: the GECI-PH network.

Efforts to adopt public health policies that would limit the consumption of unhealthy commodities, such as tobacco, alcohol and ultra-processed food products, are often undermined by private sector actors whose profits depend on the sales of such products. There is ample evidence showing that these corporations not only try to influence public health policy; they also shape research, practice and public opinion. Globalization, trade and investment agreements, and privatization, amongst other factors, have facilitated the growing influence of private sector actors on public health at both national and global levels. Protecting and promoting public health from the undue influence of private sector actors is thus an urgent task. With this backdrop in mind, we launched the "Governance, Ethics, and Conflicts of Interest in Public Health" Network (GECI-PH Network) in 2018. Our network seeks to share, collate, promote and foster knowledge on governance, ethical, and conflicts of interest that arise in the interactions between private sectors actors and those in public health, and within multi-stakeholder mechanisms where dividing lines between different actors are often blurred. We call for strong guidance to address and manage the influence of private sector actors on public health policy, research and practice, and for dialogue on this important topic. Our network recently reached 119 members. Membership is diverse in composition and expertise, location, and institutions. We invite colleagues with a common interest to join our network.

Waterpipe industry products and marketing strategies: analysis of an industry trade exhibition.

INTRODUCTION: Understanding product development and marketing strategies of transnational tobacco companies (TTCs) has been of vital importance in developing an effective tobacco control policy. However, comparatively little is known of the waterpipe tobacco industry, which TTCs have recently entered. This study aimed to gain an understanding of waterpipe tobacco products and marketing strategies by visiting a waterpipe trade exhibition. METHODS: In April 2014, the first author attended an international waterpipe trade exhibition, recording descriptions of products and collecting all available marketing items. We described the purpose and function of all products, and performed a thematic analysis of messages in marketing material. RESULTS: We classified waterpipe products into four categories and noted product variation within categories. Electronic waterpipe products (which mimic electronic cigarettes) rarely appeared on waterpipe tobacco marketing material, but were displayed just as widely. Claims of reduced harm, safety and quality were paramount on marketing materials, regardless of whether they were promoting consumption products (tobacco, tobacco substitutes), electronic waterpipes or accessories. CONCLUSIONS: Waterpipe products are diverse in nature and are marketed as healthy and safe products. Furthermore, the development of electronic waterpipe products appears to be closely connected with the electronic cigarette industry, rather than the waterpipe tobacco manufacturers. Tobacco control policy must evolve to take account of the vast and expanding array of waterpipe products, and potentially also charcoal products developed for waterpipe smokers. We recommend that tobacco substitutes be classified as tobacco products. Continued surveillance of the waterpipe industry is warranted.

Waterpipe tobacco smoking legislation and policy enactment: a global analysis.

OBJECTIVE: (1) To review how current global tobacco control policies address regulation of waterpipe tobacco smoking (WTS). (2) To identify features associated with enactment and enforcement of WTS legislation. DATA SOURCES: (1) Legislations compiled by Tobacco Control Laws (www.tobaccocontrollaws.org). (2) Weekly news articles by 'Google Alerts' (www.google.com/alerts) from July 2013 to August 2014. STUDY SELECTION: (1) Countries containing legislative reviews, written by legal experts, were included. Countries prohibiting tobacco sales were excluded. (2) News articles discussing aspects of the WHO FCTC were included. News articles related to electronic-waterpipe, crime, smuggling, opinion pieces or brief mentions of WTS were excluded. DATA ABSTRACTION: (1) Two reviewers independently abstracted the definition of "tobacco product" and/or "smoking". Four tobacco control domains (smokefree law, misleading descriptors, health warning labels and advertising/promotion/sponsorship) were assigned one of four categories based on the degree to which WTS had specific legislation. (2) Two investigators independently assigned at least one theme and associated subtheme to each news article. DATA SYNTHESIS: (1) Reviewed legislations of 62 countries showed that most do not address WTS regulation but instead rely on generic tobacco/smoking definitions to cover all tobacco products. Where WTS was specifically addressed, no additional legislative guidance accounted for the unique way it is smoked, except for in one country specifying health warnings on waterpipe apparatuses (2) News articles mainly reported on noncompliance with public smoking bans, especially in India, Pakistan and the UK. CONCLUSIONS: A regulatory framework evaluated for effectiveness and tailored for the specificities of WTS needs to be developed.

The effect of taxation on tobacco consumption and public revenues in Lebanon.

BACKGROUND: Tobacco consumption rates in Lebanon are among the highest worldwide. The country ratified the Framework Convention on Tobacco Control in 2005. A law was passed in 2011 which regulates smoking in closed public spaces, bans advertising, and stipulates larger warnings. Despite international evidence confirming that increasing taxation on tobacco products lowers tobacco consumption, no such policy has yet been adopted: a cigarette pack costs on average US$1.50. To date no studies in Lebanon have addressed the welfare and public finance effects of increasing taxes on tobacco products. METHODS: Using the 2005 national survey of household living conditions, we estimate an almost ideal demand system to generate price elasticities of demand for tobacco. Using estimated elasticities and a conservative scenario for expected smuggling, we simulate the consumption and tax revenue effects of a change in the price of tobacco under various tax schemes. RESULTS: Increasing taxes on all tobacco products so as to double the price of imported cigarettes would lower their consumption by 7% and consumption of domestically produced cigarettes by over 90%. Young adults (ages 15-30) are more sensitive: consumption would drop by 9% for imported cigarettes and by 100% for domestic cigarettes. Government revenues would increase by approximately 52%. CONCLUSIONS: The estimated elasticities indicate that an increase in taxes on all tobacco products would lead to a reduction in consumption and an increase in government revenue. Evidence from Lebanon on the effectiveness of increased taxation may help initiate national debate on the need to raise taxes.

Point-of-sale tobacco advertising in Beirut, Lebanon following a national advertising ban.

BACKGROUND: The objective of this study was to conduct an audit of point-of-sale (POS) tobacco advertising and assess compliance with an advertising ban in a large district of Beirut, Lebanon. METHODS: The audit was conducted 3 months following the ban on tobacco advertising. Trained students observed all tobacco retail outlets (n = 100) and entered data into a web-based form using iPad(®) technology. Presence of tobacco advertisements was assessed to determine compliance with the national advertising ban. RESULTS: Among the 100 tobacco retail outlets, 62% had tobacco advertisements, including 7% with a tobacco brand logo as part of the main exterior store sign. CONCLUSIONS: POS tobacco advertising is widespread in Beirut despite the national advertising ban. These findings point to an urgent need for the enforcement of the advertisement ban with tobacco retail outlets in Lebanon.

Health and economic impacts of introducing specific excise tax to waterpipe tobacco in Egypt: a simulation model of simple and mixed tax policy approaches.

INTRODUCTION: Waterpipe tobacco is taxed at half the rate of cigarettes in Egypt and, unlike cigarettes, does not have a specific excise component. We aimed to simulate the introduction of a specific excise tax on waterpipe tobacco consumption, premature deaths and government waterpipe tobacco revenue in Egypt. METHODS: We took model inputs from the latest available data on consumption, market shares and market share prices, price elasticities of demand, tax structure and from discussions with government officials. We modelled increases to specific excise to produce a 45%, 55%, 65% and 75% tax burden and compared a simple (specific only) structure with a mixed (specific and ad valorem) structure. RESULTS: Under the simple approach, introducing a US$2.1 specific tax would result in a 75% tax burden with 67% fewer waterpipe tobacco units smoked, 1 004 604 averted premature deaths and a 236% increase in government revenue relative to the current tax structure. At the 75% tax burden, the simple approach resulted in 1.5% fewer waterpipe tobacco units consumed, 9000 more averted premature deaths and 12.7% more government revenue compared with the mixed approach. Results for other tax burdens are presented and remained robust to sensitivity analyses. CONCLUSIONS: Introducing a specific excise tax on waterpipe tobacco in Egypt can yield considerable government revenue and public health gains. We recommend the simple approach, in line with the WHO recommendations, which produces greater economic and public health gains than the mixed approach and is easier to administer for the Egyptian government.

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS.

BACKGROUND: Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings. METHODS: The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes. DISCUSSION: The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Process evaluation of a community-based mental health promotion intervention for refugee children.

Public health interventions are complex in nature and composed of multiple components. Evaluation of process and impact is necessary to build evidence of effectiveness. Process evaluation involves monitoring extent of implementation and comparison against the program plan. This article describes the process evaluation of the 'Qaderoon' (We are Capable) intervention; a community-based mental health promotion intervention for children living in a Palestinian refugee camp of Beirut, Lebanon. The manuscript describes the context of Palestinian refugees in Lebanon, the intervention, the process evaluation plan and results. The process evaluation was guided by the literature and by a Community Youth Committee. Findings indicated that attendance was 54 and 38% for summer and fall sessions, respectively. Session objectives and activities were commonly achieved. Over 78.4% of activities were reported to be implemented fully as planned. Over 90% of the children indicated high satisfaction with the sessions. Contextual facilitators and challenges to implementing the intervention are discussed. The most challenging were maintaining attendance and the actual implementation of the process evaluation plan. Findings from process evaluation will strengthen interpretation of impact evaluation results.

The relaxation exercise and social support trial-resst: study protocol for a randomized community based trial.

BACKGROUND: Studies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health. METHODS/DESIGN: This is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used. DISCUSSION: The results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress). TRIAL REGISTRATION: The trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241.

The case for developing a cohesive systems approach to research across unhealthy commodity industries.

OBJECTIVES: Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. METHODS: We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. RESULTS: There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. CONCLUSION: UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.

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

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.

Implementation of a free smoking-cessation program in a Lebanese academic medical center.

INTRODUCTION: Despite the exceptionally high prevalence of tobacco use in Lebanon, few cessation programs exist. The American University of Beirut (AUB) developed one of the first smoking-cessation programs in the country in 2015, and the program became free-of-charge to patients in 2018. The program offers initial visit(s) with a primary care provider, in-person and/or telephone counseling, acupuncture, and medications. METHODS: We assessed patient characteristics, treatments used, and patient outcomes in the first year of implementing the free smoking-cessation program, compared to the original program. We compared 87 smokers who initiated treatment in the free program with 47 patients in the original program. RESULTS: At baseline, smokers in the free program were younger, smoked fewer cigarettes per day, and had lower CO levels than smokers in the original program. At 1 month follow-up, 72.9% were abstinent in the free program, compared with 42.2% in the original program (p<0.001). Smokers who had ≥2 primary care visits and those who had ≥1 acupuncture visits had higher rates of abstinence at 1 month and those who were prescribed bupropion had higher rates of abstinence at 12 months. CONCLUSIONS: Implementation of the free smoking cessation program demonstrates preliminary efficacy, with telephone support offering potential for scalability.

Effect of tobacco control policies on intention to quit smoking cigarettes: A study from Beirut, Lebanon.

INTRODUCTION: In Lebanon, the tobacco control policy, Law 174, became effective in 2011. Using the International Tobacco Control Policy Evaluation Project (ITC) conceptual model, this study aims to assess the association between exposure to control measures related to the policy and the intention to quit, which is a mediator in the pathway leading to behavioral change (quitting). METHODS: This is a secondary data analysis of 154 cigarette smokers from a cross-sectional survey that assessed compliance with Law 174 among Beirut residents aged 15-65 years. Data were collected face-to-face, three months after the implementation of indoor public places and tobacco advertisement/promotion bans. Intention to quit smoking was the main outcome. Exposure to policy control measures such as seeing smokers in restaurants, and noticing warning labels on cigarette packs were the explanatory variables. Sociodemographics, past smoking behavior, and psychosocial variables were also considered for their moderating and mediating effects, respectively. Crude and adjusted odds ratios (ORs) were generated. Sobel test was used to check for possible mediation. RESULTS: Intention to quit was reported by 24% of cigarette smokers. The association between noticing warning labels and having intentions to quit was statistically significant (adjusted OR=6.27). Concerns about influencing children's smoking behavior had a statistically significant mediation effect on the relationship. After adding the interaction term between noticing the warnings and previous quit attempts, the OR was inflated to 12.92, suggesting a possible interaction. CONCLUSIONS: This study offers preliminary insight into how Lebanese smokers are influenced by policy related control measures like health warning labels on cigarette packs. Tobacco control policy advocates should push for stronger enforcement of public smoking bans in general. Behavioral intervention should work on the mediator variables to influence smoking behavior and encourage quitting. Further prospective studies modelling quitting as outcome are needed.

"Everyone Has the Right to Drink Beer": A Stakeholder Analysis of Challenges to Youth Alcohol Harm-Reduction Policies in Lebanon.

BACKGROUND: Alcohol use is a major risk factor in premature death and disability, especially among youth. Evidence-based policies to prevent and control the detrimental effect of alcohol use have been recommended. In countries with weak alcohol control policies-such as Lebanon, stakeholder analysis provides critical information to influence policy interventions. This paper assesses the views of stakeholders regarding a national alcohol harm reduction policy for youth. METHODS: We interviewed a total of 22 key stakeholders over a period of 8 months in 2015. Stakeholders were selected purposively, to include representatives of governmental and non-governmental organizations and industry that could answer questions related to core intervention areas: affordability, availability, regulation of marketing, and drinking and driving. We analyzed interview transcripts using thematic analysis. RESULTS: Three themes emerged: Inadequacy of current alcohol control policies; weak governance and disregard for rule of law as a determinant of the status quo; and diverting of responsibility towards 'other' stakeholders. In addition, industry representatives argued against evidence-based policies using time-worn strategies identified globally. CONCLUSIONS: Our findings indicate that alcohol harm reduction policies are far from becoming a policy priority in Lebanon. There is a clear need to shift the narrative from victim blaming to structural conditions.

Harm perceptions of waterpipe tobacco smoking among university students in five Eastern Mediterranean Region countries: A cross-sectional study.

INTRODUCTION: Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. METHODS: This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. RESULTS: A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. CONCLUSIONS: Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon.

Waterpipe tobacco smoking (WTS) is spreading worldwide. Research has indicated health consequences of WTS similar to cigarettes. Prevalence of WTS is high among young people. In Lebanon, current use rates of 35% have been documented among 13⁻15 year olds. We evaluated a school-based intervention. Method: We conducted a randomized-controlled-trial of a theory-informed WTS intervention. The intervention consisted of ten sessions based on social cognitive theory and the social influences approach. Thirty-one schools participated: 14 intervention and 17 control; a total of 1279 students completed pre and post assessments. We measured knowledge, attitudes and self-reported behaviors related to WTS using Chi-square tests and regression analyses to compare results between the two study arms. Results: The intervention increased knowledge of intervention group compared to control group participants-about WTS constituents and health consequences; and shifted attitudes of intervention group participants to be even more unfavorable towards WTS. We found no impact of the intervention on WTS behaviors. Discussion: The effectiveness of the intervention on knowledge and attitudes supports previous research. The lack of intervention effect on behavior is not surprising given the timing of the post assessment immediately after the intervention, and the social context that was supportive of waterpipe use.