Background:
Only a few countries have adopted pictorial health warnings (PHWs) on waterpipe tobacco (WT) packs, despite the global increase in WT smoking. Moreover, scarce information is available on their post-marketing effectiveness. We measured the recall effectiveness of the existing PHWs on WT packs in the Egyptian market among WT smokers and non-smokers.

Methods:
We conducted a population-based survey including a convenience sample of 1490 adult WT smokers and 524 non-smokers of both genders in Cairo and a rural village in Egypt. Participants who reported ever noticing PHWs on WT packs were asked to answer questions through memory recall about PHWs' effect on salience, depth of processing, behavioral control and quit attempts. Descriptive and univariate statistical analyses were performed.

Results:
Salience: About two-thirds of WT smokers (63.8%) and non-smokers (59.2%) acknowledged the presence of PHWs on WT packs, most of whom correctly recalled their position (98.7% versus 97.4%, respectively). The information on the packs´ side were the least recalled (1.1%) (Table 1). Depth of processing: 77.6% of all participants who ever noticed PHW on WT packs understood them. PHW significantly increased information on WT smoking health hazards in non-smokers than WT smokers (80.3% versus 74.3%, p=0.033). Non-smokers were significantly more likely to discuss PHW with others (86.4% versus 72.4%, p< 0.001), while WT smokers avoided looking at the PHWs (74.6%) significantly more than non-smokers (60.0%) (p=0.002) (Table 1). Behavioral control and quit intentions: PHWs on WT packs encouraged 64.5% of WT smokers to reduce the number of smoked hagars, made 42.2% forgo a smoke, and 58.5% more likely to quit. They also made 38.4% of former WT smokers actually quit and discouraged 59.0% of non-smokers to start WT smoking.

Conclusions:
Findings suggest that inserting PHWs on WT packs is an effective WT labelling policy. More countries should consider adopting it within a comprehensive regulatory framework.

[Table 1. Recall effectiveness of Pictorial Health ]