Many hookah makers failed to comply with FDA-mandated nicotine warning labels, study finds

Since August 2018, the United States Food & Drug Administration has required all manufacturers of hookah (also called waterpipe tobacco or shisha) to include a nicotine warning on their packaging to communicate the harms of tobacco present in their products.

But two years after the mandate was implemented, hookah businesses’ compliance with these federal regulations remained low, according to a new study led by a Boston University School of Public Health (BUSPH) researcher.

Published in the journal Open JAMA NetworkThe study found that only 3 brands out of 33 brands assessed were 100% compliant with all warning label requirements, which mandated a range of placement and formatting elements.

The study is the first to examine this compliance with warning requirements on hookah packaging in the country.

Warning labels on hookah packaging are particularly important because, despite popular belief, smoking hookah is not safer than smoking cigarettes. Hookah tobacco smoke contains many of the same harmful components as cigarette smoke, including nicotine, tar, heavy metals and carbon monoxide.

But people who smoke hookah can inhale up to 70 times more tar and 11 times more carbon monoxide from water pipes than from cigarettes, partly because of the length of hookah smoking sessions, which usually last at least an hour.

These toxic exposures can increase the risk of developing cancers, heart disease, respiratory problems and blood pressure complications, according to the FDA and the Centers for Disease Control & Prevention.

“We know that warnings are an effective way to communicate to people the harms associated with smoking all types of tobacco, but to be effective, they must first exist,” says Dr. Jennifer Ross, associate professor and corresponding author of the study. of health law, policy and management at BUSPH.

“We hope that this study will draw attention to the low levels of compliance among hookah manufacturers so that additional steps can be taken to increase compliance. We also hope that these findings will lead to efforts to further increase compliance. impact of hookah warnings, such as implementing more warnings and in more locations to increase people’s exposure to warning labels.

Younger people, in particular, could benefit from these warnings, as an estimated one in six young adults aged 19 to 30 reported smoking hookah in the past year in 2018. Smoking hookah is often pitched to this demographic as a relaxing, social activity featuring a variety of fruit-flavored tobacco.

“Young people often have misconceptions about the dangers of smoking tobacco in a hookah, for example thinking that the water from the water pipe ‘purifies’ the tobacco, which is untrue,” says Dr Ross.

For the study, Dr. Ross and colleagues from Wake Forest University School of Medicine and East Carolina University identified all hookah brands available for purchase online in 2020 , for a total of 66. They limited their analysis to 33 brands, including a total of 181 packages. , based on a combination of highest product prevalence and random selection.

The team found that 97, or about half, of the packages observed contained the required nicotine warning. Of the 33 brands in the sample, 10 of them did not include any nicotine warnings on their packaging. Among packages with nicotine warnings, nearly a third did not display the warnings in the FDA-required area of ​​the package (on the front or top and back).

Similarly, nearly a third of hookah packages with warnings did not meet FDA label style and formatting requirements.

In addition to federal enforcement of tobacco warning labels, researchers hope to see future studies explore the impact of these warnings on consumer perceptions and behaviors regarding hookah smoking.

“This is the first study to assess compliance with the federal hookah warning law, and our results show that many brands are not in compliance,” says Dr. Erin Sutfin, lead author of the study. study, professor of social sciences and health policy at Wake Forest University. Medicine School.

“The ultimate goal of the warnings is to provide information about the health risks associated with the use of the product directly to consumers so that they can make informed decisions. We hope that these results will be useful to the FDA and promote enforcement action against non-compliant companies.”