Implementing Pictorial Health Warning Labels on Waterpipe Tobacco Products in Lebanon: A Policy Framework Analysis of Content, Actors, Context, and Process.

Introduction: Lebanon has one of the world's highest waterpipe (WP) consumption rates. Research has documented the effectiveness of implementing pictorial health warning labels (PHWLs) on WP products at encouraging smoking cessation and discouraging youth uptake of smoking.

Aims and methods: This study aims to gain insight into key informants' (KIs) views on the issuance, implementation, and compliance of a decree for PHWLs on WP products. Thirteen KIs (policy makers, media, and international/local nongovernment organization representatives) were interviewed online and asked about potential barriers and facilitators they saw to issuing and implementing a PHWL decree. They were shown examples of PHWLs and asked about processes needed for implementation and compliance. The policy triangle framework (content, actors, context, and process) was used to interpret findings.

Results: Although there was clear discrepancy and ambiguousness among the KIs' views regarding process and actors, there was more consensus and clarity around context and content. Challenges to implementation were: (1) multiple sources of production and supply of WP, (2) uncertainty regarding the responsible actors for each step, (3) prioritization of a tobacco control decree amidst a political and economic crisis, and (4) challenges to practicality of applying PHWL on the WP given its multicomponent nature.

Conclusions: This research provides an in-depth understanding of KI's views regarding content, actors, context, and process in relation to the issuance, implementation, and compliance to PHWLs on WP products. Noted challenges require careful consideration if progress is to be made to introduce PHWLs.

Implications: A growing research base has documented the potential effectiveness of PHWLs on reducing WP consumption. Findings of this study show that implementing PHWLs on WP products requires a distinct understanding of the policy environment and context, as well as content, actors, and processes. Implementing PHWLs on WP tobacco products needs to address the complex nature of WP smoking as a multicomponent tobacco use method.