Pictorial warning labels on hookahs reduce smoking satisfaction


In the first clinical laboratory study to provide evidence on the effects of warning labels on waterpipes, also known as hookahs, researchers at FIU Robert Stempel College of Public Health and Social Work found pictorial warning labels are effective in reducing smokers’ positive experiences.

The study found that by including a graphic with the text warning labels about adverse health risks (such as cancer) associated with waterpipe smoking, smokers report less satisfaction and are exposed to less toxicants than smoking warning-free waterpipes.
Epi Hookah Study - warning label1

“Many see smoking a waterpipe as a social practice, especially as more hookah cafes attract young customers, and they do not realize that the risks are likely comparable to smoking cigarettes,” said Wasim Maziak, professor and chair of the epidemiology department. “We found that smokers became more aware of the dangers of smoking once they saw the labels directly on the waterpipe.”

The study examined 30 individuals during two smoking sessions, one with the warning label and one without. The study found that there were significant differences in carbon monoxide (eCO) levels inhaled, with lower levels of eCO recorded once the warning label was added. This was closely correlated with participants’ puffing behavior – they had more puffs and inhaled more smoke per session when smoking the waterpipe without the warning label.

Further, participants reported greater satisfaction, taste and puff enjoyment when smoking the waterpipe without the warning label.

Smoking waterpipes has become increasingly popular in the U.S., especially among adults, with more than 18 percent reporting current use, according to the Population Assessment of Tobacco Ad Health. According to the Centers for Disease Control and Prevention, the average hour-long waterpipe smoking session involves an estimated 200 puffs, while smoking a cigarette involves about 20 puffs.

In 2018, the Food and Drug Administration began requiring textual warning labels on waterpipe tobacco about its nicotine content and its addictiveness.

“While warning labels on the tobacco represent a good first step, showing a photo of a smoking-related disease with the text paints a more serious picture,” Maziak said. “More importantly, about 40 percent of U.S. waterpipe smokers do so in cafes, where they never see the tobacco packaging. Displaying pictorial warning labels directly on the waterpipe device allows protracted contact during long waterpipe smoking sessions and offers the best opportunity to communicate health risks to the smokers.”