From knowledge production to knowledge translation: Waterpipe tobacco control research in the Eastern Mediterranean Region.

Waterpipe tobacco smoking (WTS) rates in the Eastern Mediterranean Region (EMR) are the highest worldwide, particularly among young people. Although fiscal policies to curb tobacco use have been recommended by the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), implementation has been suboptimal. The Eastern Mediterranean Consortium on the Economics of Waterpipe Tobacco Smoking (ECON-WTS) was formed in response to this need to produce knowledge on the economics of WTS in the EMR and apply a comprehensive Knowledge translation (KT) framework. The KT framework comprised priority setting, evidence synthesis, knowledge translation, and knowledge uptake. In this article, we discuss the approaches followed in applying the KT framework to WTS control, providing examples and noting challenges and lessons learned where possible.

Factors associated with intentions to quit tobacco use in Lebanon: A cross-sectional survey.

Introduction: The prevalence of tobacco smoking in Lebanon is among the highest globally. This study aims to determine past attempts to quit smoking among adults and identify factors associated with intentions to quit. Methods: A nationally representative telephone survey was conducted between June and August 2022. Eligibility criteria included people aged >=18 years residing in Lebanon. The questionnaire was divided into three components: socio-demographic characteristics, cigarette and waterpipe tobacco use behaviours. Binary logistic regression was used to examine factors associated with intention to quit cigarette and waterpipe tobacco use. Results: A total of 2003 respondents were included in the study. The prevalence of any tobacco product use was 41%, the prevalence of current cigarette smoking was 41% and the prevalence of current waterpipe tobacco use was 20%. Approximately 24% of adults who smoke cigarettes and 26% of those who use waterpipe tobacco had previous quit attempts mainly due to health concerns. Intentions to quit smoking within the next 6 months were reported among 12% of survey respondents. Among adults who smoke, past quit attempts increased the likelihood of intentions to quit cigarette smoking by 5-fold (OR: 5.11; 95% CI: 1.80-14.47, p = 0.002) and waterpipe tobacco use by 7-fold (OR: 6.98, 95% CI: 2.63-18.51, p = <0.001). Age and income were associated with intentions to quit cigarette but not waterpipe tobacco use. Conclusion: Intention to quit smoking was strongly associated with past quitting attempts. Understanding factors associated with intentions to quit can help inform the development of context specific smoking cessation interventions.

Benefits and risks: Views of humanitarian organizations in Lebanon on corporate assistance.

Compounding humanitarian and political crises within and across countries have been met with shrinking public resources for coordination, recovery, and mitigation. This resource constrained humanitarian environment presents opportunities for multinational corporations to supplement budgets and actively participate in new markets through connecting with humanitarian work. Given the well-established influence of corporations on public health, an assessment of industry funding to humanitarian assistance is necessary especially in the fragile context of Lebanon with a substantial refugee population and multiple compounding crises. This paper examines three aspects of corporate assistance in humanitarian crises in Lebanon. It investigates the modality of corporate assistance to humanitarian agencies, the extent to which humanitarian agency staff are aware of implications of this assistance along with any ethical considerations related to it, and both the risks and benefits for corporations and people. This study explores the views of 14 local and international humanitarian agencies in Lebanon) through in-depth interviews conducted between 2020 and 2022. Interviews were recorded, transcribed and subject to thematic analysis. All agencies participating in the study provided social and health assistance as well as education, vocational training, and other services to refugees or Lebanese. Findings indicate that the majority of them receive corporate funding in varying amounts and in-kind contributions to support various projects. Despite imposed conditions by the corporations, such as posting logos and stories, the agencies perceived the benefits of partnering, mentioning financial assistance in time of need, and flexible agendas that outweigh the risks of conflicts of interest of corporate branding on the populations they serve. Benefits to the corporations themselves relate to corporate social responsibility, increased market reach and visibility. Challenges in partnering with for-profits include ethical considerations and programmatic issues, however no guidelines were reported to exist to detect corporate conflicts of interest, instead most of the agencies rely on their value systems for screening.

Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis.

INTRODUCTION: Pictorial health warning labels on waterpipe tobacco packages represent a better strategy for communicating the health risks associated with waterpipe use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown. This study explores how pictorial warnings vs. text-only induce higher quit intention among a sample of young adult waterpipe smokers in Lebanon. METHODS: An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult waterpipe smokers who were exposed to two conditions: pictorial health warning label and text-only warning on waterpipe tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (e.g., attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit. RESULTS: Using serial mediation, exposure to pictorial warnings vs. text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect [ß= 0.063; (95% bootstrap CI=0.004, 0.149)] and cognitive elaboration [0.047; (0.001, 0.114)] were statistically significant. CONCLUSIONS: The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb waterpipe tobacco smoking. IMPLICATIONS: This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial health warning labels on intention to quit in a sample of current waterpipe smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing waterpipe health warning labels regulations in Lebanon and other countries to curb waterpipe tobacco smoking.

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.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation.

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Understanding Determinants of Electronic Cigarette and Heated Tobacco Product Use among Young Adults in Lebanon: Prevention and Policy Implications.

In line with the global trends, electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) have found their way to the Lebanese market. The present study aims to explore the determinants of e-cigarette and HTP use among young adults in Lebanon. Convenience and snowball sampling were used to recruit participants aged 18-30 residing in Lebanon, who were familiar with e-cigarettes products. Twenty-one consenting participants were interviewed via Zoom and the verbatim transcriptions were analyzed thematically. The outcome expectancy theory was used to categorize the results into determinants and deterrents of use. HTPs were viewed by participants as another mode of smoking. The results showed that most participants perceived e-cigarettes and HTPs to be healthier alternatives to cigarettes/waterpipes and to be used as smoking cessation tools. Both e-cigarettes and HTPs were found to be easily accessible in Lebanon; although, in the recent economic crisis, e-cigarettes have become unaffordable. More research is needed to investigate the motivations and behaviors of e-cigarette and HTP users if effective policies and regulations are to be developed and enforced. Furthermore, greater public health efforts need to be made to increase awareness of the harmful impacts of e-cigarettes and HTPs and to implement evidence-based cessation programs tailored to those modes of smoking.

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.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment.

BACKGROUND: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine. METHODS: A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption. RESULTS: The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers. CONCLUSIONS: These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

Developing Capacity in Dissemination and Implementation Research in the Eastern Mediterranean Region: Evaluation of a Training Workshop.

As the demand for dissemination and implementation (D&I) research grows globally, there is a need for D&I capacity building in regions where D&I science is underrepresented. The Workshop on Dissemination and Implementation Research in Health (WONDIRH) was aimed for participants in the Eastern Mediterranean region to (1) appreciate the complex process of bridging research and practice in a variety of real-world settings, and (2) develop research that balances rigor with relevance and employs study designs and methods appropriate for the complex processes involved in D&I. The present exploratory study investigates participants' satisfaction with the workshop, the enhancement of their self-rated confidence in D&I skills, as well as their intention to apply the learned content into practice. The workshop included four weekly 90-min virtual interactive training sessions in conjunction with open access content from the National Cancer Institute Training Institute in Implementation and Dissemination Research in Cancer (TIDIRC). We applied a one-group pre-post design for the evaluation of workshop. Participants were invited to self-rate their confidence in D&I competencies (15 items, pre and post workshop). At the end of the workshop, participants additionally were asked to rate their satisfaction (5 items, 1-5 scales), and their intention to apply the learned content into practice (4 items, 1-5 scales). Of the 77 workshop participants, 34 completed the evaluation. Confidence improved between pre- and post-workshop assessments in all 15 self-rated D&I competencies. Respondents were generally satisfied with the workshop (mean satisfaction range 3.82-4.26 across the 5 items) and endorsed intentions to apply workshop topics (mean intention range 4.03-4.35 across the 4 items). This initial workshop demonstrated the ability to attract and engage participants to enhance their confidence in D&I research competencies and skills and to build capacity in D&I research. Future efforts should consider offering targeted training for researchers at different stages and to clearly articulate learning objectives. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-022-00067-y.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling.

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Gender differences in the price elasticity of demand for waterpipe and cigarette smoking in Lebanon, Jordan and Palestine: a volumetric choice experiment.

OBJECTIVES: This study assessed the extent to which the elasticity of cigarette and waterpipe tobacco products differs between men and women. We also explored the levels of substitution and complementarity in tobacco products among men and women. SETTING: The study examines tobacco elasticities in three Arab countries: Lebanon, Jordan and the West Bank of Palestine. PARTICIPANTS: We used data from nationally representative surveys of adults aged ≥18 years in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679). The proportion of women was 50.0% of the sample in Lebanon and Palestine, and 44.6% in Jordan. PRIMARY AND SECONDARY OUTCOME MEASURES: A zero-inflated Poisson regression model estimated own-price and cross-price elasticities for two variations of cigarettes and five variations of waterpipe tobacco products. Elasticities were measured based on eight scenarios of prices. RESULTS: Demand for waterpipe tobacco products was elastic for both men and women. The cross-price elasticities in the three countries indicate the existence of substitution between cigarettes and waterpipe products and by different varieties within each of the two tobacco products. Gender differences varied across the three countries whereby higher cross-price elasticities were observed for women in Jordan and Palestine. For example, the price elasticity for discount waterpipe was -1.4 and -0.6 for women and men in Jordan, respectively. CONCLUSIONS: Results on the elasticity of demand for tobacco products and the existence of substitution between tobacco products reveal the higher responsiveness of men and women to changes in tobacco prices. This should be taken into consideration in tobacco control strategies particularly when reducing tobacco consumption via taxation policies.

Corporations and Health: The Need to Combine Forces to Improve Population Health.

The recent concerns raised about commercial determinants of health (CDoH) are not new. Numerous organizations around the world are working on these issues. These groups have emerged in response to specific issues and contexts and bring with them a diversity of interests, worldviews and strategies for change. In creating the 'Governance, Ethics and Conflicts of Interest in Public Health' network in 2018, our hope was to broaden our engagement with other actors advocating for change and strengthen our collective efforts. For academics, this requires moving further beyond the collective comfort zone of peer-reviewed publications, working with the media and those with political expertise, and learning from and supporting other stakeholders with a common vision.

Waterpipe tobacco smoking (WTS) control policies: global analysis of available legislation and equity considerations.

INTRODUCTION: The Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities. METHODS: We reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation's Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available. RESULTS: Our results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal. CONCLUSIONS: Our recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.

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.

Prevalence of cigarette and waterpipe tobacco smoking among adults in three Eastern Mediterranean countries: a cross-sectional household survey.

OBJECTIVES: Tobacco smoking is on the rise in the Eastern Mediterranean region. In light of limited surveillance of smoking in the region, this study sought to understand the prevalence of cigarette and waterpipe smoking among adults and the factors associated with smoking in Lebanon, Jordan and Palestine (West Bank only). DESIGN, SETTING AND PARTICIPANTS: Household surveys were conducted with participants over the age of 18 in Lebanon (n=1680), Jordan (n=1925) and Palestine (n=1679) between June and August 2019. A multistage cluster sampling approach with probability-proportional-to-size random selection method was followed in the three countries. PRIMARY AND SECONDARY OUTCOME MEASURES: Gender-specific prevalence rates for cigarette and waterpipe smoking were estimated. Multivariable logistic regression was used to examine factors associated with current cigarette and waterpipe tobacco smoking. RESULTS: The prevalence of cigarette smoking among males and females respectively was 48.6% and 21.5% in Lebanon, 50.4% and 9.1% in Jordan, and 53.4% and 3.1% in Palestine. The prevalence of waterpipe smoking among males and females respectively was 32.7% and 46.2% in Lebanon, 13.4% and 7.8% in Jordan, and 18.0% and 7.9% in Palestine. Cigarette smokers were significantly (p<0.05) more likely to be male, younger and with lower educational attainment across the three countries. Waterpipe smokers were more likely to be young adults across the three countries (p<0.001). They were more likely to be male in Jordan and Palestine, and more likely to be female in Lebanon. CONCLUSIONS: The high prevalence rates of smoking in Lebanon, Jordan and Palestine are concerning. Continued surveillance is key to monitor smoking patterns and inform stronger tobacco control measures.

"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.

Impact of waterpipe tobacco taxation on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine: a simulation study.

INTRODUCTION: Despite the high prevalence of waterpipe tobacco smoking in the Eastern Mediterranean region, evidence supporting its fiscal measures is limited. We modelled the impact of waterpipe tobacco-specific excise taxes on consumption, government revenue and premature deaths averted in Jordan, Lebanon and Palestine. METHODS: We developed a simulation model using country-specific and market share-specific price, consumption and price elasticity data from WHO, UN Comtrade and nationally representative surveys. We modelled increases to specific excise taxes to meet a 35.9% tax burden on 20 g of waterpipe tobacco in Lebanon and Jordan, in line with the global average, and to double government revenues from excise duties in Palestine, which has surpassed this average. RESULTS: Specific excise tax was raised by $1.14 ($0.18-$1.32) in Jordan, $2.41 ($0.03-$2.44) in Lebanon (alongside removal of ad valorem taxes) and $2.39 ($1.72-$4.11) in Palestine per 20 g of waterpipe tobacco. Government revenue increased by $126.3 million in Jordan, $53.8 million in Lebanon and $162.4 million in Palestine while waterpipes smoked decreased by 32.4% in Jordan, 71.0% in Lebanon and 16.3% in Palestine. The corresponding numbers of premature deaths averted annually were approximately 162 000; 1 000 000; and 52 000. DISCUSSION: Increases in waterpipe tobacco-specific excise taxes substantially reduce smoking and increase government revenue and averted premature deaths in Jordan, Lebanon and Palestine. This has positive implications for both public health and financing and should be considered a policy priority.