Background:
Waterpipe tobacco smoking is a global public health problem that originated in the Eastern Mediterranean region (EMR). It is highly prevalent among university students, and has been increasing in popularity despite mounting evidence showing it is harmful to health. The aim of this study was to evaluate responses to various health warning messages and their location on waterpipe devices, among young residents of EMR countries.

Methods:
Adult university students who were waterpipe smokers completed an Internet-based survey across 5 EMR countries (Egypt [N=728], Jordan [N=790], Oman [N=117], Palestine [N=772], and UAE [N=180]). The survey evaluated their responses to text-only and pictorial waterpipe-specific health warnings and their location on waterpipe devices.

Results:
Among both text-only warnings and text + pictorial warnings, messages that communicated harm to children were rated highest in raising concerns about the health consequences of smoking and in motivating smokers to think about quitting. In terms of warning location, the mouthpiece was rated as most noticeable to smokers.

Conclusions:
This study is the first to compare responses to waterpipe-specific health warnings across EMR countries. Requiring health warnings on waterpipe devices may be an effective policy to educate smokers about the consequences of waterpipe use.