Background:
Despite the global increase in waterpipe smoking, current evidence is limited in assessing health warning labeling practices on waterpipe tobacco (WT) products. This qualitative study aimed to
a) understand how participants perceive pictorial health warnings (PHW) on WT packs
b) explore their attitude towards a newly designed set and
c) explore their opinion of placing PHWs on the waterpipe device and accessories.

Methods:
Ten focus group and ten in-depth interview sessions were conducted in Egypt with 90 waterpipe smokers and non-smokers, of both genders, and different age-groups (18-24 and 25+) within rural and urban regions. Verbatim transcripts were analyzed using thematic analysis.

Results:
Participants thought that the current PHW set triggered affective reactions; still some were unclear, or unrealistic. The majority considered it attractive because of the bright colorful designs of fruits and flavors. In contrast, participants thought that the newly designed set had more positive elements that might help in preventing smoking initiation or inducing quit attempts, such as the absence of attracting flavors, the contrasting dark background, the believable contents, and the larger label size. Participants' views of effective warnings were leaning towards those posing proximal health risks. Most of the participants believed that inserting PHWs on waterpipe device may enhance their effectiveness. Participants equally favored placing them on the glass body, or on the mouthpiece and hose.

Conclusions:
Findings implicate a policy need to extend WT labeling regulations to the waterpipe device and employ evidence-based practices to customize PHWs' content, design, and placement on WT products.