Effectiveness of Text and Pictorial Waterpipe Tobacco Package Warnings Among Young Adults in the U.S

Waterpipe tobacco smoking (WTS) is associated with health harms, and package warnings can inform users about these harms. This study examined the impact of newly developed package warnings on young adults' WTS intentions, knowledge, and perceptions. We conducted an online between-subjects experiment with three conditions (text, pictorial, no warnings) among a nationally representative sample of 1,215 young adults, aged 18-29, who used waterpipe tobacco in the past year or were susceptible to use. Participants were 65% female, 78% non-Hispanic, 61% white, and mean age was 25 (SD = 3.3). Thirty-eight percent reported past year WTS. Compared to the control package, those exposed to packages with warnings had significantly lower behavioral intentions; higher knowledge of health harms, outcome expectancies, worry, and harm perceptions; and lower product appeal and likelihood of trying (all p-values < .05). Compared to text warnings, those exposed to pictorial warnings reported higher quit intentions (among past-year users), higher harm perceptions, lower product appeal, and lower likelihood of trying the product (all p-values < .05). Findings indicate that our warnings were associated with lower behavioral intentions, increased WTS quit intentions (among those who use), and influenced several behavioral antecedents that discourage WTS. Effect varied across outcomes; pictorial warnings generally outperformed text warnings, and text warnings generally outperformed packages with no warnings. Findings provide critical information to policymakers tasked with monitoring the impact of the FDA-mandated nicotine warning in the United States and support strengthening warnings internationally to better inform the public of the health harms of WTS.