Evaluation of ‘Shisha No Thanks’ – A Codesign Social Marketing Campaign on the Harms of Waterpipe Smoking

Evaluation of ‘Shisha No Thanks’ – A Codesign Social Marketing Campaign on the Harms of Waterpipe Smoking | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of ‘Shisha No Thanks’ – A Codesign Social Marketing Campaign on the Harms of Waterpipe Smoking Lilian Chan, Nouhad El-Haddad, Becky Freeman, Ross MacKenzie, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-536851/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Waterpipe (shisha) is becoming increasingly popular worldwide, particularly among young people; and in some countries, it is one of the few forms of tobacco use that is increasing. While there is a growing body of evidence of the harms of waterpipe smoke, there is a scarcity of research of interventions to address this form of tobacco consumption. Methods: The Shisha No Thanks project was a codesign social marketing campaign that aimed to raise awareness of the harms of waterpipe smoking among young people from an Arabic speaking background in Sydney, Australia. The campaign distributed material through social media and community events. We evaluated the project through an SMS community panel using a longitudinal study design. The cohort were sent questions before and after the project asking about their awareness of messages of harms, attitudes, intention to reduce waterpipe smoking, and awareness of support services. Data was analysed as matched pre- post- data. Results: The evaluation recruited 133 people to the panel. There was a significantly greater proportion of people who reported seeing, hearing or reading something about the harms of waterpipe smoking after the campaign (67.5%) compared with before (45.0%) (c 2 =9.03, p=0.003). Post-campaign, there were higher proportions of people who strongly agreed that waterpipe smoking causes damage, and that it contains cancer-causing substances, but these increases were not statistically significant. There was low awareness of waterpipe cessation services at baseline and post campaign (22.5%). Conclusions: The Shisha No Thanks project increased awareness of messages about the harms of waterpipe smoking. Although this is a small study, the longitudinal evaluation findings have international relevance and make a useful contribution to the understanding of the impact such interventions can have in addressing one of the few forms of tobacco use that is growing in both developed and developing countries. Health Policy waterpipe smoking tobacco control campaign social marketing Figures Figure 1 Figure 2 Background The dramatic rise in prevalence and geographic spread of waterpipe use (also known as shisha, arghile, nargile, hubbly bubbly) has been described as a “global phenomenon”, and has become more prevalent than cigarette smoking among young people in some Middle Eastern countries. 1 Suggested reasons for this dramatic increase in popularity, predominantly among young people, include the introduction of flavoured tobacco, widespread dissemination via social media, and frequent uncertainty around regulation and enforcement. 1,2 Waterpipe use is particularly popular with Arabic speaking young people in North America, Europe and other western countries. 1, 3 In the United States, for example, a 2018 study estimated that 480,000 high school students and 150,000 middle school students used waterpipes. 4 Among US adults, 16.4% were reported to have ever used a waterpipe to smoke tobacco, and of daily or weekly users, 66% were young adults (18-24 years). 5 In Australia, waterpipe use accounts for a relatively small proportion of tobacco use, with 2.5% of people 14 years and older using waterpipes to smoke tobacco; 6 however, rates are much higher among Australian people of Arabic speaking background. A 2004 survey of Arabic speakers in Sydney reported that 11.4% of respondents used waterpipes and that 1% were daily users; 7 while a 2010 survey of Arabic speakers in Melbourne found that 38% of respondents had smoked a waterpipe, with 4% reporting daily use. 8 As is common elsewhere, 1 waterpipe use among Arabic-speakers in Australia has powerful social and cultural dimensions, 9 and there is considerable scepticism regarding potential health risks, and a belief that it is less harmful than cigarette smoking. 2 The perception that waterpipe smoking is not harmful is a dangerous misconception that ignores related health risks, of both direct use and secondary exposure to waterpipe smoke, and discounts addiction.Studies have found that waterpipe smoking is associated with emphysema, chronic obstructive pulmonary disease, coronary artery disease and oesophageal, gastric and lung cancer. 10 Further, the social nature and communal use of waterpipes has been linked to the transmission of a range of infections, such as respiratory viruses, 11 and are “ideal for transmission and may exacerbate the risk for severe COVID-19 through shared use”. 12 The growing research into waterpipe use has primarily focused on prevalence, toxins and health effects, but there has been relatively little analysis on the effectiveness of health promotion interventions targeting waterpipe smoking. A scoping review of health promotion interventions targeting waterpipe smoking found only 10 published intervention studies – 5 policy interventions, 3 web-based educational interventions, 1 behavioural intervention, and only 1 community-level awareness campaign. 13,14 Given the lack of evidence-based interventions targeting waterpipe smoking, the ‘ Shisha No Thanks’ project was a novel intervention that drew upon practices that have been used in other areas of tobacco control. The ‘ Shisha No Thanks’ project was a codesign, social marketing health promotion campaign targeting waterpipe smoking among young people of Arabic speaking background in Sydney, Australia. Social marketing is a widely used approach to reduce cigarette smoking, 15 and key strengths of such interventions include the mix of strategies, targeting of specific audiences, and the ‘client-oriented’ approach. 16, 17 The use of a co-design approach taken for the ‘ Shisha No Thanks’ project aimed to ensure the intervention was culturally appropriate and acceptable. This study evaluates the effectiveness of the ‘ Shisha No Thanks’ project and contributes to the limited existing research on health promotion interventions aimed at waterpipe users. As the target audience of the project is young adults, who are more difficult to engage in research studies, 18 the evaluation also used a novel method of data collection, which was establishing an ‘SMS community panel’ who responded to evaluation survey questions through weekly SMS correspondence. METHODS The Shisha No Thanks project The aims of the Shisha No Thanks project were to highlight and raise awareness about the health risks of waterpipe smoking among young people (18-35 years old) from an Arabic speaking background and to encourage discussion around quitting or reducing waterpipe smoking. The project ran from October 2019 to June 2020, predominately in the South East, South West, and Western areas of Sydney, Australia, where there is a higher proportion of people who identify as being of Arabic speaking background. The project was run by a government local health district (South Eastern Sydney Local Health District), in partnership with a community organisation (Lebanese Muslim Association) and was funded by the Cancer Institute NSW (a state government cancer control agency). Shisha No Thanks was a codesign project that involved the project team working closely with the community partner organisation, members of the community, community champions and health professionals to identify the key messages and strategies for the awareness raising campaign. The project team were mindful throughout the entire process to ensure that the campaign was run respectfully towards the community and was culturally appropriate. Campaign resources were developed from the community co-design workshops and evidence-based research, and included a feature campaign video, 19 a large collection of social media content (such as short videos clips, memes and graphics), and a suite of factsheets for young people, pregnant women and families, community workers and health professionals 20 (See Figure 1 and Appendix 1 for examples). These campaign resources were disseminated to the community through the campaign’s website 20 and social media accounts (Facebook, 21 Instagram 22 and YouTube 22 ). The project also engaged the community through local media coverage (English and Arabic speaking media; TV, radio and online), by attending community events (e.g. expos and information days) and conducting community worker information sessions. Study design, participants and data collection The impact evaluation used a cohort design to measure awareness before and after the project among the target audience. A community panel was recruited through the Lebanese Muslim Association’s communication channels (email newsletter, social media accounts), community champions, and flyers at events (see Appendix 2 for examples of recruitment material). Participants were required to be 18-35 years old and either smoke shisha or know someone who does. Potential participants were directed to complete an online recruitment survey to confirm eligibility in the study, provide demographic details (including their waterpipe smoking activity) and their mobile phone number (See Appendix 3 for Recruitment Survey). Participants were then sent a weekly SMS text message with a survey question about their knowledge and attitudes about waterpipe smoking. As most young people use their mobile phones frequently each day, an SMS survey was an effective way of easily reaching the target audience. Participants were sent 8 questions before the project started (Aug-Oct 2019), and the same 8 questions towards the end of the project (Jan-Mar 2020). In the interim period, participants were sent other questions related to waterpipe smoking to maintain communication between participants and the project. (See Appendix 4 for Survey Questions). Main participant recruitment documents and all data collection surveys were produced in English and Arabic, and participants were given the option to choose which language they preferred to use for the study. Survey measures The SMS survey questions were adapted from the Cancer Institute NSW Tobacco Tracking Survey 23 and the Syrian Center for Tobacco Studies Narghile-Waterpipe Users Survey. 24 The questions were related to participants’ awareness of messages about the harms of waterpipe smoking, attitudes towards the health impacts of waterpipe smoking, intention to reduce waterpipe smoking, community conversations about waterpipe smoking, and awareness of services to support cessation of waterpipe smoking. Questions were designed to be short and succinct to fit with the SMS format, and were either multiple choice response, or short free-text response. Participants were reimbursed for their involvement in the study with three $50AUD e-vouchers. The survey used the Qualtrics platform which has the capacity to send SMS messages to the study participants’ mobile phone number. Analysis Data extracted from Qualtrics was entered into an Excel spreadsheet file. Data was then analysed using IBM SPSS Statistics v26. For the 8 questions that were asked before and after the project, only paired data (i.e. data where the participant had responded to the same question at both baseline and post-campaign) were used for analysis and reported. Given the matched nature of the data, binary categorical responses were analysed using McNemar’s test, 25, 26 and non-parametric scaled data was analysed using Wilcoxon Signed Rank test. 27 Subgroup analysis was also conducted based on age group, gender and waterpipe use. For the 6 questions that were asked only once (in the interim period), descriptive analysis was conducted. Results In total, 133 people were recruited to the study’s SMS community panel (see Table 1). 86 (64.7%) were female, the mean age of the panel was 25.8 years old, and 87 (65.4%) participants reported speaking English and Arabic at home. 100 (75.2%) participants reported smoking shisha, with 22 reporting smoking shisha daily, 35 smoking shisha at least once per week (but not daily), and 37 reporting smoking shisha less than once per week. The number of participants who responded to each question both at baseline and post-campaign ranged from 80 to 92 (see Table 2 and Appendix 5). Table 1 - Demographic characteristics of SMS panel participants n=133 % Age 18-26 years old 80 60.2 27-35 years old 53 39.8 Gender Male 47 35.3 Female 86 64.7 Language spoken at home English 28 21.1 Arabic 12 9.0 English and Arabic 87 65.4 Other 6 4.5 Smoking shisha at recruitment Yes 100 75.2 No 32 24.1 Not sure 1 0.8 Frequency of shisha smoking* Daily 22 16.8 At least once per week, but less than daily 35 26.7 Less than once per week 37 28.2 Not applicable 37 28.2 * Data for 2 participants missing When asked whether they had seen, heard or read anything about the harms of shisha smoking, there was an increase in the proportion who reported they had post-campaign (n=54, 67.5%) compared with baseline (n=36, 45.0%). This is the only statistically significant change identified in this study (c 2 =9.03, p=0.003) (see Table 2). In the subgroup analyses, this result was significant among women, people in the older age group (27-35 year olds) and people who did not smoke shisha (see Figure 2). When asked to describe what they had seen, heard or read, 34 of the 44 valid responses were consistent with the main messages or resources of the Shisha No Thanks project. When asked about the health harms of waterpipe smoking, there was a slightly higher proportion of people who strongly agreed that it could cause physical damage post-campaign; however this result was not statistically significant (see Table 2). Similar results were obtained when asked whether waterpipes contain cancer-causing substances (see Table 2). There were no statistically significant differences in the proportion of participants who considered reducing or quitting waterpipe smoking before or after the campaign (c 2 =0.15, p=0.70). There was also no statistically significant difference in the proportion of participants who had talked to someone about the harms of waterpipe smoking before or after the campaign (c 2 =3.68, p=0.05). Finally, the proportion of participants who were aware of where to obtain information or support to help quit smoking shisha was low both at baseline and post campaign (22.5%) (see Table 2). The questions that were asked between the baseline and post-campaign survey questions provided insight into behaviours related to waterpipe smoking (see Table 3). 46.7% of respondents reported having searched for information about shisha on the internet. Of those who had, 37.0% had searched where to buy or smoke shisha and 41.3% had searched about the harms of shisha smoking. In terms of location, 55.2% of those who smoked shisha reported doing so at home, while 32.8% reported they smoked at a restaurant. Panel members were asked an open-ended question about the reasons they smoke shisha. The responses generally related to the social aspects, relaxation or de-stress, enjoying the taste or smell of shisha, having fun, the cultural or family aspect, or peer pressure. Finally, panel members were also asked about whether they smoked other tobacco products. There was strong evidence of an association between shisha smoking and smoking of other tobacco products, with 37.0% of people who smoked shisha also reporting smoking other tobacco products, compared with 7.1% of non-shisha smokers smoking other tobacco products (c 2 =7.41, p=0.006). Table 2 - Paired responses at baseline and post-campaign Baseline Post-campaign p n % n % Have you seen, heard or read anything about harms of shisha smoking (n=80) p=0.003* Yes 36 45.0 54 67.5 No or Don’t know 44 55.0 26 32.5 Shisha contains cancer-causing substances (n=84) p=0.13 Strongly agree 36 42.9 47 56.0 Somewhat agree 29 34.5 20 23.8 Neutral / Don’t know 17 20.0 15 17.9 Somewhat disagree 1 1.2 1 1.2 Strongly disagree 1 1.2 1 1.2 What are the health effects of smoking shisha compared to cigarettes? (n=81) p=0.82 Same or more harmful 55 67.9 53 65.4 Less harmful or Don’t know 26 32.1 28 34.6 Smoking shisha can cause damage to your body (n=85) p=0.31 Strongly agree 46 54.1 52 61.2 Somewhat agree 28 32.9 23 27.1 Neutral / Don’t know 9 10.6 9 10.6 Somewhat disagree 2 2.4 1 1.2 Strongly disagree 0 0.0 0 0.0 Have you thought about reducing the amount of shisha you smoke? (n=92) p=0.70 Yes, [Within the next 30 days/ next 6 months/ completely stopping] 43 46.7 46 50.0 No / Don’t know 49 53.3 46 50.0 Have you talked to someone about the harms of smoking shisha? (n=70) p=0.05 Yes 44 62.9 34 48.6 No / Don’t know 26 37.1 36 51.4 Do you know where to find information or support to help quit smoking shisha? (n=80) p=1.00 Yes 18 22.5 18 22.5 No / Don’t know 62 77.5 62 77.5 Table 3 - Survey responses for other questions n % Have you ever searched for information about smoking shisha on the internet (n=107) Yes 50 46.7 No 53 49.5 Not sure 4 3.7 If you have ever searched for information about smoking shisha on the internet, what was it about? (n=46) How to smoke shisha 2 4.3 Where to buy or smoke shisha 17 37.0 What are the harms of smoking shisha 19 41.3 How to quit smoking shisha 4 8.7 Other 4 8.7 If you smoke shisha, where do you mostly smoke it? (n=67) At home 37 55.2 At restaurant 22 32.8 At a park, or other public area 3 4.5 Other 5 7.5 Do you currently smoke cigarettes, pipes or other tobacco products (excluding shisha)? (n=101) Yes 29 28.7 No 69 68.3 Don’t know 3 3.0 How often do you now smoke cigarettes, pipes or other tobacco products (excluding shisha)? (n=26) Daily 13 50.0 At least weekly (not daily) 4 15.4 Less often than weekly 6 23.1 Not at all, but I have smoked in the last 12 months 3 11.5 Discussion By using an SMS community panel, this evaluation study showed that the Shisha No Thanks project was able to increase awareness of messages about the harms of waterpipe smoking among the target audience of young adults of Arabic speaking background. This adds to the limited number of studies of interventions addressing waterpipe smoking, and indicates that a codesigned social marketing approach, using social media and community events constitutes an effective strategy to raise awareness of this issue. This evaluation also identified there is a baseline level of awareness of the harms of waterpipe smoking among young adults. The openness of the panel participants towards health messages on this topic could partly be due to the way participants were recruited, and the codesign approach taken for the development of this project. Given the strong cultural associations of waterpipe smoking, it is recommended that future interventions also work closely with the target audience for the intervention to be broadly accepted by communities. 2 In the context of other waterpipe smoking interventions, our results are similar to those of a community-based education and awareness intervention in Egypt 28 that had no impact on waterpipe smoking behaviours, but did have an effect on the awareness of the harms of waterpipe smoking. This suggests that future campaigns could be more effective if run in conjunction with other strategies, 13 which is in line with the comprehensive approach found to be most effective for tobacco control. 29 For example, our evaluation showed consistent low levels of awareness of support services for people who would like to quit smoking shisha, demonstrating the need for greater provision and promotion of support services for people who would like to reduce or quit waterpipe smoking. Policy interventions, similar to those adopted to regulate use and marketing of conventional cigarettes, including smoke-free laws to manage the popular trend of shisha smoking bars and lounges, regulations on flavouring additives, and health warning labels on products and related accessories, are other strategies that should be used together with social marketing campaigns. Increased levels of awareness of harms have been found to improve community attitudes towards waterpipe smoking bans, 30 and social marketing campaigns that increase awareness could support the implementation of such policy measures. Incorporating waterpipe use into broader tobacco control strategies could lead to more sustained progress in reducing this type of tobacco smoking within both the social and cultural groups in which it has been traditionally popular and the growing trend of waterpipe use among the community at large. The culturally appropriate and research-based resources developed for this campaign can be used by other public health organisations, practitioners and cultural groups who can tailor them for use in other geographical areas. This study did not evaluate the campaign messaging or framing specifically. Research into the type of messaging that resonates most with the target audience would be beneficial for future campaigns. For example, identifying whether messages should aim to increase knowledge, target people’s health worries, address image perceptions or challenge social norms, would help inform future campaigns. Strengths and limitations To our knowledge, this is one of a limited number of studies that have evaluated the impact of a waterpipe smoking intervention, particularly one with a health promotion ethos. 14 The longitudinal study design is a key strength of this study, along with the satisfactory response rate for each question, despite the prolonged duration of the survey and the perception that young adults are difficult to keep engaged in this type of research. An additional strength is that the survey and all recruitment material, were provided in both English and Arabic, which ensured that people were not excluded from the study based on their primary language. One limitation of this study is the moderate sample size, which limits its ability to detect small changes, particularly for the subgroups we analysed. However, given the resources available, and the size and nature of the project’s target audience, this was a practical compromise in study design. In addition, only including data that had baseline and post-campaign responses could potentially bias results to people who are more engaged with the topic. As the SMS community panel was recruited through the community partner’s communication channels, it is possible that there was an overlap in the people who participated in the codesign workshops with those who were recruited to the panel, which could account for the high proportion of people who responded that they talked to someone about the harms of waterpipe smoking before the campaign. Finally, an additional limitation of this study is that the use of an SMS survey allowed for only short-response format questions. Conclusion This is one of the first published evaluations of a health promotion intervention targeting young people to address the growing global trend of waterpipe smoking. It makes a timely and important contribution that demonstrates that codesign social marketing campaigns can raise awareness of messages about the harms of waterpipe smoking among young people of Arabic speaking background. While the project was not successful in changing attitudes and intentions to quit waterpipe smoking, longer term campaigns, incorporating lessons from other areas of tobacco control could be used to address the growing popularity of waterpipe smoking. Declarations Ethics approval This study was approved by the University of New South Wales Human Research Ethics Committee HC190149. The study was carried out in accordance with ethical guidelines of the University of New South Wales. Informed consent was obtained from all the participants involved in the study. Consent for publication Not applicable Availability of data and materials The dataset used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests LW, DK and LC work for NSW Multicultural Health Communication Service, one of the implementing partners of the Shisha No Thanks project. Funding The Shisha No Thanks project was funded by the Cancer Institute NSW. The University of New South Wales was contracted to undertake the evaluation component of the project. LC receives support from the Prevention Research Support Program, funded by the New South Wales Ministry of Health. Author contributions LC designed the study, collected and analysed data and drafted the manuscript. NEH and DK designed the study, collected data, revised the manuscript, and provided technical support. BF and RM conceived and designed the study, interpreted the data and revised the manuscript. LW conceived, designed and obtained funding for the study. BOH and revised the manuscript and provided technical support. BHR conceived, designed and obtained funding for the study, interpreted the data and revised the manuscript. All authors provided input on the final manuscript. Acknowledgements We acknowledge the involvement of the following organisations in the development, implementation and evaluation of the Shisha No Thanks project: SESLHD Priority Populations Unit and Health Promotion Service, Lebanese Muslim Association, SESLHD Health Promotion Service, SWSLHD Health Promotion Service, SLHD Health Promotion Service and Multicultural Health Service, NSW Multicultural Health Communication Service, Centre for Primary Health Care and Equity (CPHCE), UNSW References Maziak W, Taleb ZB, Bahelah R, et al. The global epidemiology of waterpipe smoking. Tobacco Control 2015;24(Suppl 1):i3-i12. doi: 10.1136/tobaccocontrol-2014-051903 Kearns R, Gardner K, Silveira M, et al. 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Syrian Center for Tobacco Studies, University of Memphis Center for Community Health. Narghile-Waterpipe users Survey. Berenson M, Koppel N. McNemar Test for significant of changes. In: Salkind J, ed. Encyclopedia of measurement and statistics. CA: SAGE Publications 2007. Adedokun OA, Burgess WD. Analysis of Paired Dichotomous Data: A Gentle Inftroduction to the McNemar Test in SPSS. Journal of Multidisciplinary Evaluation 2012;8(17):125-31. Nahm FS. Nonparametric statistical tests for the continuous data: the basic concept and the practical use. Korean Journal of Anesthesiology 2016;69(1):8. doi: 10.4097/kjae.2016.69.1.8 Mohlman MK, Boulos DNK, El Setouhy M, et al. A Randomized, Controlled Community-Wide Intervention to Reduce Environmental Tobacco Smoke Exposure. Nicotine & Tobacco Research 2013;15(8):1372-81. doi: 10.1093/ntr/nts333 Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. The Lancet 2010;376(9748):1261-71. doi: 10.1016/s0140-6736(10)60809-4 Haddad C, Lahoud N, Akel M, et al. Knowledge, attitudes, harm perception, and practice related to waterpipe smoking in Lebanon. Environmental Science and Pollution Research 2020 doi: 10.1007/s11356-020-08295-1 Additional Declarations Competing interest reported. Lilian Chan works for NSW Multicultural Health Communication Service, one of the implementing partners of the Shisha No Thanks project. Dr Nouhad El-Haddad declares no competing interests. A/Prof Becky Freeman declares no competing interests. Dr Ross MacKenzie declares no competing interests. Dalya Karezi worked for NSW Multicultural Health Communication Service at the time of the study, one of the implementing partners of the Shisha No Thanks project. Lisa Woodland works for NSW Multicultural Health Communication Service, one of the implementing partners of the Shisha No Thanks project. Dr Blythe O'Hara declares no competing interests. A/Prof Ben Harris-Roxas declares no competing interests. Supplementary Files SupplementalMaterial1ProjectResources.pdf SupplementalMaterial2RecruitmentMaterial.pdf SupplementalMaterial3RecruitmentSurveyQuestions.pdf SupplementalMaterial4SurveyQuestions.pdf SupplementalMaterial5Numberofresponsesbyquestion.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 04 Jun, 2021 Editor invited by journal 04 Jun, 2021 Submission checks completed at journal 04 Jun, 2021 First submitted to journal 18 May, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-536851","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":31128932,"identity":"19ac1b44-7222-4e34-a091-090df99f43da","order_by":0,"name":"Lilian Chan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYBACPmbmhgMghgEDA+MDBgZmiDAPHi1szIxwLcwGxGlhYGxggGphkyBOCztj44GfOxjkzdnPHqv82Wadxy+RwPjgbRuDvMEB3A472HuGwXBnT17abd629GLJGQnMhnPbGAw34NFygLeNIcHgQI7Zbca2w4kbbiSwSQNFGPFpOfgXpOX8G7PCn0At+28ksP8GarHHp+Uw2JYbOWYMvCBbJBLYmIEiiXi1yLZJGG648cZYmudceuKMMw+bJeeck0ieiUMLP//hwx/fttnIG5zPMfz4o8w6sb89+eCHN2U2tn04tECBBIRiZAMSAokNCBHC4A/IYvymj4JRMApGwcgDAGFnXAGdCI2aAAAAAElFTkSuQmCC","orcid":"","institution":"The University of Sydney","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Lilian","middleName":"","lastName":"Chan","suffix":""},{"id":31128933,"identity":"508c132e-fcc3-4c50-87ae-1214709e017f","order_by":1,"name":"Nouhad El-Haddad","email":"","orcid":"","institution":"University of New South Wales","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nouhad","middleName":"","lastName":"El-Haddad","suffix":""},{"id":31128934,"identity":"2e57310d-72c3-43a1-84b4-e23e1eb5ed43","order_by":2,"name":"Becky Freeman","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Becky","middleName":"","lastName":"Freeman","suffix":""},{"id":31128935,"identity":"6617ccfa-8b9f-4e42-9448-eaf0cf68574e","order_by":3,"name":"Ross MacKenzie","email":"","orcid":"","institution":"University of New South Wales","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ross","middleName":"","lastName":"MacKenzie","suffix":""},{"id":31128936,"identity":"c964b109-accf-46e1-96d9-98b32ebccc26","order_by":4,"name":"Dalya Karezi","email":"","orcid":"","institution":"South Eastern Sydney Local Health District","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dalya","middleName":"","lastName":"Karezi","suffix":""},{"id":31128937,"identity":"ff4f12fc-0f53-49c2-bc5f-cd36ce43c868","order_by":5,"name":"Lisa Woodland","email":"","orcid":"","institution":"South Eastern Sydney Local Health District","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Woodland","suffix":""},{"id":31128938,"identity":"b389ec79-f3c0-4391-8598-d2d6b28418f3","order_by":6,"name":"Blythe O’Hara","email":"","orcid":"","institution":"The University of Sydney","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Blythe","middleName":"","lastName":"O’Hara","suffix":""},{"id":31128939,"identity":"46b7968f-5e8f-47e1-83fe-8453c31d314e","order_by":7,"name":"Ben Harris-Roxas","email":"","orcid":"","institution":"University of New South Wales","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ben","middleName":"","lastName":"Harris-Roxas","suffix":""}],"badges":[],"createdAt":"2021-05-18 06:59:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-536851/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-536851/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":10093924,"identity":"37f49a42-ec65-4fd4-9fed-983965cfd45c","added_by":"auto","created_at":"2021-06-07 21:50:58","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":243207,"visible":true,"origin":"","legend":"Selected ‘Shisha No Thanks’ project resources","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/10b97e694154e95e275f82f6.jpg"},{"id":10093840,"identity":"2abae040-4c11-40d2-bdc4-645177e2e3b8","added_by":"auto","created_at":"2021-06-07 21:47:58","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139634,"visible":true,"origin":"","legend":"Proportion of people who had seen, heard or read about the harms of shisha smoking","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/10bd2074c1eba6c477a0adae.jpg"},{"id":15672796,"identity":"305b1e06-8b5f-42c2-9502-88163f71ae31","added_by":"auto","created_at":"2021-11-18 14:14:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":696178,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/cc3be653-ea7e-494f-83f2-d2d520c4817c.pdf"},{"id":10093925,"identity":"6cc3a924-a075-4a6c-8d97-e156d0efe5fb","added_by":"auto","created_at":"2021-06-07 21:50:59","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":244268,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial1ProjectResources.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/ca2cbfb8e0ce8bf58d570c24.pdf"},{"id":10093845,"identity":"1f336092-8308-4444-9586-2b7ea8761aa2","added_by":"auto","created_at":"2021-06-07 21:47:59","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":184356,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial2RecruitmentMaterial.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/7a343306e36b54af7aa4a3e2.pdf"},{"id":10093932,"identity":"1f185931-16d1-4172-af55-686164de6bf5","added_by":"auto","created_at":"2021-06-07 21:53:59","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":146826,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial3RecruitmentSurveyQuestions.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/d83c1923c8d3e692d6a4930b.pdf"},{"id":10093843,"identity":"a77c3c49-1d42-42b9-b11a-a60e83d33fba","added_by":"auto","created_at":"2021-06-07 21:47:59","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":130771,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial4SurveyQuestions.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/2bd70fc18de688b2fb915cad.pdf"},{"id":10093926,"identity":"682500b6-5157-454e-b503-4138b8cc9af7","added_by":"auto","created_at":"2021-06-07 21:50:59","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":32925,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterial5Numberofresponsesbyquestion.pdf","url":"https://assets-eu.researchsquare.com/files/rs-536851/v1/2d47d4b2602ba3cf1acfad98.pdf"}],"financialInterests":"Competing interest reported. Lilian Chan works for NSW Multicultural Health Communication Service, one of the implementing partners of the Shisha No Thanks project.\nDr Nouhad El-Haddad declares no competing interests.\nA/Prof Becky Freeman declares no competing interests.\nDr Ross MacKenzie declares no competing interests.\nDalya Karezi worked for NSW Multicultural Health Communication Service at the time of the study, one of the implementing partners of the Shisha No Thanks project.\nLisa Woodland works for NSW Multicultural Health Communication Service, one of the implementing partners of the Shisha No Thanks project.\nDr Blythe O'Hara declares no competing interests.\nA/Prof Ben Harris-Roxas declares no competing interests.","formattedTitle":"\u003cp\u003eEvaluation of \u003cem\u003e‘Shisha No Thanks’\u003c/em\u003e – A Codesign Social Marketing Campaign on the Harms of Waterpipe Smoking\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe dramatic rise in prevalence and geographic spread of waterpipe use (also known as shisha, arghile, nargile, hubbly bubbly) has been described as a \u0026ldquo;global phenomenon\u0026rdquo;, and has become more prevalent than cigarette smoking among young people in some Middle Eastern countries.\u003csup\u003e1\u003c/sup\u003e Suggested reasons for this dramatic increase in popularity, predominantly among young people, include the introduction of flavoured tobacco, widespread dissemination via social media, and frequent uncertainty around regulation and enforcement.\u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWaterpipe use is particularly popular with Arabic speaking young people in North America, Europe and other western countries.\u003csup\u003e1, 3\u003c/sup\u003e In the United States, for example, a 2018 study estimated that 480,000 high school students and 150,000 middle school students used waterpipes.\u003csup\u003e4\u003c/sup\u003e Among US adults, 16.4% were reported to have ever used a waterpipe to smoke tobacco, and of daily or weekly users, 66% were young adults (18-24 years).\u003csup\u003e5\u003c/sup\u003e In Australia, waterpipe use accounts for a relatively small proportion of tobacco use, with 2.5% of people 14 years and older using waterpipes to smoke tobacco;\u003csup\u003e6\u003c/sup\u003e however, rates are much higher among Australian people of Arabic speaking background. A 2004 survey of Arabic speakers in Sydney reported that 11.4% of respondents used waterpipes and that 1% were daily users;\u003csup\u003e7\u003c/sup\u003e while a 2010 survey of Arabic speakers in Melbourne found that 38% of respondents had smoked a waterpipe, with 4% reporting daily use.\u003csup\u003e8\u003c/sup\u003e As is common elsewhere,\u003csup\u003e1\u003c/sup\u003e waterpipe use among Arabic-speakers in Australia has powerful social and cultural dimensions,\u003csup\u003e9\u003c/sup\u003e and there is considerable scepticism regarding potential health risks, and a belief that it is less harmful than cigarette smoking.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe perception that waterpipe smoking is not harmful is a dangerous misconception that ignores related health risks, of both direct use and secondary exposure to waterpipe smoke, and discounts addiction.Studies have found that waterpipe smoking is associated with emphysema, chronic obstructive pulmonary disease, coronary artery disease and oesophageal, gastric and lung cancer.\u003csup\u003e10\u003c/sup\u003e Further, the social nature and communal use of waterpipes has been linked to the transmission of a range of infections, such as respiratory viruses,\u003csup\u003e11\u003c/sup\u003e and are \u0026ldquo;ideal for transmission and may exacerbate the risk for severe COVID-19 through shared use\u0026rdquo;.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe growing research into waterpipe use has primarily focused on prevalence, toxins and health effects, but there has been relatively little analysis on the effectiveness of health promotion interventions targeting waterpipe smoking. A scoping review of health promotion interventions targeting waterpipe smoking found only 10 published intervention studies \u0026ndash; 5 policy interventions, 3 web-based educational interventions, 1 behavioural intervention, and only 1 community-level awareness campaign.\u003csup\u003e13,14\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eGiven the lack of evidence-based interventions targeting waterpipe smoking, the \u0026lsquo;\u003cem\u003eShisha No Thanks\u0026rsquo; \u003c/em\u003eproject was a novel intervention that drew upon practices that have been used in other areas of tobacco control. The \u0026lsquo;\u003cem\u003eShisha No Thanks\u0026rsquo; \u003c/em\u003eproject was a codesign, social marketing health promotion campaign targeting waterpipe smoking among young people of Arabic speaking background in Sydney, Australia. Social marketing is a widely used approach to reduce cigarette smoking,\u003csup\u003e15\u003c/sup\u003e and key strengths of such interventions include the mix of strategies, targeting of specific audiences, and the \u0026lsquo;client-oriented\u0026rsquo; approach.\u003csup\u003e16, 17\u003c/sup\u003e The use of a co-design approach taken for the \u0026lsquo;\u003cem\u003eShisha No Thanks\u0026rsquo; \u003c/em\u003eproject aimed to ensure the intervention was culturally appropriate and acceptable.\u003c/p\u003e\n\u003cp\u003eThis study evaluates the effectiveness of the \u0026lsquo;\u003cem\u003eShisha No Thanks\u0026rsquo;\u003c/em\u003e project and contributes to the limited existing research on health promotion interventions aimed at waterpipe users. As the target audience of the project is young adults, who are more difficult to engage in research studies,\u003csup\u003e18\u003c/sup\u003e the evaluation also used a novel method of data collection, which was establishing an \u0026lsquo;SMS community panel\u0026rsquo; who responded to evaluation survey questions through weekly SMS correspondence.\u003c/p\u003e"},{"header":"METHODS ","content":"\u003ch2\u003eThe \u003cem\u003eShisha No Thanks\u003c/em\u003e project\u003c/h2\u003e\n\u003cp\u003eThe aims of the \u003cem\u003eShisha No Thanks \u003c/em\u003eproject were to highlight and raise awareness about the health risks of waterpipe smoking among young people (18-35 years old) from an Arabic speaking background and to encourage discussion around quitting or reducing waterpipe smoking. The project ran from October 2019 to June 2020, predominately in the South East, South West, and Western areas of Sydney, Australia, where there is a higher proportion of people who identify as being of Arabic speaking background. The project was run by a government local health district (South Eastern Sydney Local Health District), in partnership with a community organisation (Lebanese Muslim Association) and was funded by the Cancer Institute NSW (a state government cancer control agency).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eShisha No Thanks \u003c/em\u003ewas a codesign project that involved the project team working closely with the community partner organisation, members of the community, community champions and health professionals to identify the key messages and strategies for the awareness raising campaign. The project team were mindful throughout the entire process to ensure that the campaign was run respectfully towards the community and was culturally appropriate.\u003c/p\u003e\n\u003cp\u003eCampaign resources were developed from the community co-design workshops and evidence-based research, and included a feature campaign video,\u003csup\u003e19\u003c/sup\u003e a large collection of social media content (such as short videos clips, memes and graphics), and a suite of factsheets for young people, pregnant women and families, community workers and health professionals\u003csup\u003e20\u003c/sup\u003e (See Figure 1 and Appendix 1 for examples).\u003c/p\u003e\n\u003cp\u003eThese campaign resources were disseminated to the community through the campaign\u0026rsquo;s website \u003csup\u003e20\u003c/sup\u003e and social media accounts (Facebook,\u003csup\u003e21\u003c/sup\u003e Instagram\u003csup\u003e22\u003c/sup\u003e and YouTube\u003csup\u003e22\u003c/sup\u003e). The project also engaged the community through local media coverage (English and Arabic speaking media; TV, radio and online), by attending community events (e.g. expos and information days) and conducting community worker information sessions.\u003c/p\u003e\n\u003ch2\u003eStudy design, participants and data collection\u003c/h2\u003e\n\u003cp\u003eThe impact evaluation used a cohort design to measure awareness before and after the project among the target audience. A community panel was recruited through the Lebanese Muslim Association\u0026rsquo;s communication channels (email newsletter, social media accounts), community champions, and flyers at events (see Appendix 2 for examples of recruitment material). Participants were required to be 18-35 years old and either smoke shisha or know someone who does. Potential participants were directed to complete an online recruitment survey to confirm eligibility in the study, provide demographic details (including their waterpipe smoking activity) and their mobile phone number (See Appendix 3 for Recruitment Survey).\u003c/p\u003e\n\u003cp\u003eParticipants were then sent a weekly SMS text message with a survey question about their knowledge and attitudes about waterpipe smoking. As most young people use their mobile phones frequently each day, an SMS survey was an effective way of easily reaching the target audience. Participants were sent 8 questions before the project started (Aug-Oct 2019), and the same 8 questions towards the end of the project (Jan-Mar 2020). In the interim period, participants were sent other questions related to waterpipe smoking to maintain communication between participants and the project. (See Appendix 4 for Survey Questions). Main participant recruitment documents and all data collection surveys were produced in English and Arabic, and participants were given the option to choose which language they preferred to use for the study.\u003c/p\u003e\n\u003ch2\u003eSurvey measures\u003c/h2\u003e\n\u003cp\u003eThe SMS survey questions were adapted from the Cancer Institute NSW Tobacco Tracking Survey \u003csup\u003e23\u003c/sup\u003e and the Syrian Center for Tobacco Studies Narghile-Waterpipe Users Survey.\u003csup\u003e24\u003c/sup\u003e The questions were related to participants\u0026rsquo; awareness of messages about the harms of waterpipe smoking, attitudes towards the health impacts of waterpipe smoking, intention to reduce waterpipe smoking, community conversations about waterpipe smoking, and awareness of services to support cessation of waterpipe smoking. Questions were designed to be short and succinct to fit with the SMS format, and were either multiple choice response, or short free-text response.\u003c/p\u003e\n\u003cp\u003eParticipants were reimbursed for their involvement in the study with three $50AUD e-vouchers. The survey used the Qualtrics platform which has the capacity to send SMS messages to the study participants\u0026rsquo; mobile phone number.\u003c/p\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003eData extracted from Qualtrics was entered into an Excel spreadsheet file. Data was then analysed using IBM SPSS Statistics v26. For the 8 questions that were asked before and after the project, only paired data (i.e. data where the participant had responded to the same question at both baseline and post-campaign) were used for analysis and reported. Given the matched nature of the data, binary categorical responses were analysed using McNemar\u0026rsquo;s test,\u003csup\u003e25, 26\u003c/sup\u003e and non-parametric scaled data was analysed using Wilcoxon Signed Rank test.\u003csup\u003e27\u003c/sup\u003e Subgroup analysis was also conducted based on age group, gender and waterpipe use. For the 6 questions that were asked only once (in the interim period), descriptive analysis was conducted.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 133 people were recruited to the study\u0026rsquo;s SMS community panel (see Table 1). 86 (64.7%) were female, the mean age of the panel was 25.8 years old, and 87 (65.4%) participants reported speaking English and Arabic at home. 100 (75.2%) participants reported smoking shisha, with 22 reporting smoking shisha daily, 35 smoking shisha at least once per week (but not daily), and 37 reporting smoking shisha less than once per week. The number of participants who responded to each question both at baseline and post-campaign ranged from 80 to 92 (see Table 2 and Appendix 5).\u003c/p\u003e\n\u003cp\u003eTable 1 - Demographic characteristics of SMS panel participants\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003en=133\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"302\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e18-26 years old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e60.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e27-35 years old\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e39.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"302\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e35.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e64.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"302\"\u003e\n\u003cp\u003e\u003cstrong\u003eLanguage spoken at home\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eEnglish\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e21.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eArabic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e9.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eEnglish and Arabic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e65.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e4.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"302\"\u003e\n\u003cp\u003e\u003cstrong\u003eSmoking shisha at recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e75.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e24.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eNot sure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"302\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrequency of shisha smoking*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eDaily\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e16.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eAt least once per week, but less than daily\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e26.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eLess than once per week\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e28.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"257\"\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e28.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Data for 2 participants missing\u003c/p\u003e\n\u003cp\u003eWhen asked whether they had seen, heard or read anything about the harms of shisha smoking, there was an increase in the proportion who reported they had post-campaign (n=54, 67.5%) compared with baseline (n=36, 45.0%). This is the only statistically significant change identified in this study (c\u003csup\u003e2\u003c/sup\u003e=9.03, p=0.003) (see Table 2). In the subgroup analyses, this result was significant among women, people in the older age group (27-35 year olds) and people who did not smoke shisha (see Figure 2). When asked to describe what they had seen, heard or read, 34 of the 44 valid responses were consistent with the main messages or resources of the \u003cem\u003eShisha No Thanks\u003c/em\u003e project.\u003c/p\u003e\n\u003cp\u003eWhen asked about the health harms of waterpipe smoking, there was a slightly higher proportion of people who strongly agreed that it could cause physical damage post-campaign; however this result was not statistically significant (see Table 2). Similar results were obtained when asked whether waterpipes contain cancer-causing substances (see Table 2).\u003c/p\u003e\n\u003cp\u003eThere were no statistically significant differences in the proportion of participants who considered reducing or quitting waterpipe smoking before or after the campaign (c\u003csup\u003e2\u003c/sup\u003e=0.15, p=0.70). There was also no statistically significant difference in the proportion of participants who had talked to someone about the harms of waterpipe smoking before or after the campaign (c\u003csup\u003e2\u003c/sup\u003e=3.68, p=0.05). Finally, the proportion of participants who were aware of where to obtain information or support to help quit smoking shisha was low both at baseline and post campaign (22.5%) (see Table 2).\u003c/p\u003e\n\u003cp\u003eThe questions that were asked between the baseline and post-campaign survey questions provided insight into behaviours related to waterpipe smoking (see Table 3). 46.7% of respondents reported having searched for information about shisha on the internet. Of those who had, 37.0% had searched where to buy or smoke shisha and 41.3% had searched about the harms of shisha smoking. In terms of location, 55.2% of those who smoked shisha reported doing so at home, while 32.8% reported they smoked at a restaurant.\u0026nbsp; Panel members were asked an open-ended question about the reasons they smoke shisha. The responses generally related to the social aspects, relaxation or de-stress, enjoying the taste or smell of shisha, having fun, the cultural or family aspect, or peer pressure.\u003c/p\u003e\n\u003cp\u003eFinally, panel members were also asked about whether they smoked other tobacco products. There was strong evidence of an association between shisha smoking and smoking of other tobacco products, with 37.0% of people who smoked shisha also reporting smoking other tobacco products, compared with 7.1% of non-shisha smokers smoking other tobacco products (c\u003csup\u003e2\u003c/sup\u003e=7.41, p=0.006).\u003c/p\u003e\n\u003cp\u003eTable 2 - Paired responses at baseline and post-campaign\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"113\"\u003e\n\u003cp\u003eBaseline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"113\"\u003e\n\u003cp\u003ePost-campaign\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eHave you seen, heard or read anything about harms of shisha smoking (n=80)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.003*\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e45.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e67.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNo or Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e55.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e32.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eShisha contains cancer-causing substances (n=84)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.13\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eStrongly agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e42.9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e56.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eSomewhat agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e34.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e23.8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNeutral / Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e17.9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eSomewhat disagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eStrongly disagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eWhat are the health effects of smoking shisha compared to cigarettes? (n=81)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.82\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eSame or more harmful\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e67.9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e65.4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eLess harmful or Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e32.1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e34.6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eSmoking shisha can cause damage to your body (n=85)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.31\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eStrongly agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e54.1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e61.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eSomewhat agree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e32.9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e27.1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNeutral / Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e10.6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e10.6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eSomewhat disagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eStrongly disagree\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eHave you thought about reducing the amount of shisha you smoke? (n=92)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.70\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eYes, [Within the next 30 days/ next 6 months/ completely stopping]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e46.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e50.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNo / Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e53.3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e50.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eHave you talked to someone about the harms of smoking shisha? (n=70)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=0.05\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e62.9\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e48.6\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNo / Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e37.1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e51.4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"293\"\u003e\n\u003cp\u003e\u003cstrong\u003eDo you know where to find information or support to help quit smoking shisha? (n=80)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u003cem\u003ep=1.00\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e22.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e22.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNo / Don\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e77.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003e77.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 - Survey responses for other questions\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"416\"\u003e\n\u003cp\u003e\u003cstrong\u003eHave you ever searched for information about smoking shisha on the internet (n=107)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e46.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e49.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eNot sure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e3.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"416\"\u003e\n\u003cp\u003e\u003cstrong\u003eIf you have ever searched for information about smoking shisha on the internet, what was it about? (n=46)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eHow to smoke shisha\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eWhere to buy or smoke shisha\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e37.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eWhat are the harms of smoking shisha\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e41.3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eHow to quit smoking shisha\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"416\"\u003e\n\u003cp\u003e\u003cstrong\u003eIf you smoke shisha, where do you mostly smoke it? (n=67)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eAt home\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e55.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eAt restaurant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e32.8\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eAt a park, or other public area\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e7.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"416\"\u003e\n\u003cp\u003e\u003cstrong\u003eDo you currently smoke cigarettes, pipes or other tobacco products (excluding shisha)? (n=101)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e28.7\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e68.3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e3.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"416\"\u003e\n\u003cp\u003e\u003cstrong\u003eHow often do you now smoke cigarettes, pipes or other tobacco products (excluding shisha)? (n=26)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eDaily\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e50.0\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eAt least weekly (not daily)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e15.4\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eLess often than weekly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e23.1\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"45\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"371\"\u003e\n\u003cp\u003eNot at all, but I have smoked in the last 12 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003e11.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":" \u003cp\u003eBy using an SMS community panel, this evaluation study showed that the \u003cem\u003eShisha No Thanks\u003c/em\u003e project was able to increase awareness of messages about the harms of waterpipe smoking among the target audience of young adults of Arabic speaking background. This adds to the limited number of studies of interventions addressing waterpipe smoking, and indicates that a codesigned social marketing approach, using social media and community events constitutes an effective strategy to raise awareness of this issue.\u003c/p\u003e \u003cp\u003eThis evaluation also identified there is a baseline level of awareness of the harms of waterpipe smoking among young adults. The openness of the panel participants towards health messages on this topic could partly be due to the way participants were recruited, and the codesign approach taken for the development of this project. Given the strong cultural associations of waterpipe smoking, it is recommended that future interventions also work closely with the target audience for the intervention to be broadly accepted by communities.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn the context of other waterpipe smoking interventions, our results are similar to those of a community-based education and awareness intervention in Egypt \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e that had no impact on waterpipe smoking behaviours, but did have an effect on the awareness of the harms of waterpipe smoking. This suggests that future campaigns could be more effective if run in conjunction with other strategies,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e which is in line with the comprehensive approach found to be most effective for tobacco control.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e For example, our evaluation showed consistent low levels of awareness of support services for people who would like to quit smoking shisha, demonstrating the need for greater provision and promotion of support services for people who would like to reduce or quit waterpipe smoking. Policy interventions, similar to those adopted to regulate use and marketing of conventional cigarettes, including smoke-free laws to manage the popular trend of shisha smoking bars and lounges, regulations on flavouring additives, and health warning labels on products and related accessories, are other strategies that should be used together with social marketing campaigns. Increased levels of awareness of harms have been found to improve community attitudes towards waterpipe smoking bans,\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e and social marketing campaigns that increase awareness could support the implementation of such policy measures.\u003c/p\u003e \u003cp\u003eIncorporating waterpipe use into broader tobacco control strategies could lead to more sustained progress in reducing this type of tobacco smoking within both the social and cultural groups in which it has been traditionally popular and the growing trend of waterpipe use among the community at large. The culturally appropriate and research-based resources developed for this campaign can be used by other public health organisations, practitioners and cultural groups who can tailor them for use in other geographical areas.\u003c/p\u003e \u003cp\u003eThis study did not evaluate the campaign messaging or framing specifically. Research into the type of messaging that resonates most with the target audience would be beneficial for future campaigns. For example, identifying whether messages should aim to increase knowledge, target people\u0026rsquo;s health worries, address image perceptions or challenge social norms, would help inform future campaigns.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is one of a limited number of studies that have evaluated the impact of a waterpipe smoking intervention, particularly one with a health promotion ethos.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The longitudinal study design is a key strength of this study, along with the satisfactory response rate for each question, despite the prolonged duration of the survey and the perception that young adults are difficult to keep engaged in this type of research. An additional strength is that the survey and all recruitment material, were provided in both English and Arabic, which ensured that people were not excluded from the study based on their primary language.\u003c/p\u003e \u003cp\u003eOne limitation of this study is the moderate sample size, which limits its ability to detect small changes, particularly for the subgroups we analysed. However, given the resources available, and the size and nature of the project\u0026rsquo;s target audience, this was a practical compromise in study design. In addition, only including data that had baseline and post-campaign responses could potentially bias results to people who are more engaged with the topic. As the SMS community panel was recruited through the community partner\u0026rsquo;s communication channels, it is possible that there was an overlap in the people who participated in the codesign workshops with those who were recruited to the panel, which could account for the high proportion of people who responded that they talked to someone about the harms of waterpipe smoking before the campaign. Finally, an additional limitation of this study is that the use of an SMS survey allowed for only short-response format questions.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThis is one of the first published evaluations of a health promotion intervention targeting young people to address the growing global trend of waterpipe smoking. It makes a timely and important contribution that demonstrates that codesign social marketing campaigns can raise awareness of messages about the harms of waterpipe smoking among young people of Arabic speaking background. While the project was not successful in changing attitudes and intentions to quit waterpipe smoking, longer term campaigns, incorporating lessons from other areas of tobacco control could be used to address the growing popularity of waterpipe smoking.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the University of New South Wales Human Research Ethics Committee HC190149. The study was carried out in accordance with ethical guidelines of the University of New South Wales. Informed consent was obtained from all the participants involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLW, DK and LC work for NSW Multicultural Health Communication Service, one of the implementing partners of the \u003cem\u003eShisha No Thanks \u003c/em\u003eproject.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eShisha No Thanks\u003c/em\u003e project was funded by the Cancer Institute NSW. The University of New South Wales was contracted to undertake the evaluation component of the project. LC receives support from the Prevention Research Support Program, funded by the New South Wales Ministry of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLC designed the study, collected and analysed data and drafted the manuscript. NEH and DK designed the study, collected data, revised the manuscript, and provided technical support. BF and RM conceived and designed the study, interpreted the data and revised the manuscript. LW conceived, designed and obtained funding for the study. BOH and revised the manuscript and provided technical support. BHR conceived, designed and obtained funding for the study, interpreted the data and revised the manuscript. All authors provided input on the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the involvement of the following organisations in the development, implementation and evaluation of the \u003cem\u003eShisha No Thanks\u003c/em\u003e project: SESLHD Priority Populations Unit and Health Promotion Service, Lebanese Muslim Association, SESLHD Health Promotion Service, SWSLHD Health Promotion Service, SLHD Health Promotion Service and Multicultural Health Service, NSW Multicultural Health Communication Service, Centre for Primary Health Care and Equity (CPHCE), UNSW\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMaziak W, Taleb ZB, Bahelah R, et al. 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Tobacco control priorities for Arabic speakers: key findings from a baseline telephone survey of Arabic speakers residing in Sydney\u0026rsquo;s south-west. \u003cem\u003eHealth Promotion Journal of Australia\u003c/em\u003e 2007;18:121-6.\u003c/li\u003e\n\u003cli\u003eGregov M, Baker J, Hayes L. Waterpipe smoking: behaviour, knowledge and attitudes among the Arabic speaking community in Victoria, Australia.: Quit Victoria, 2011.\u003c/li\u003e\n\u003cli\u003eJaworski A, Green B, Kennet K, et al. Tobacco cessation experiences and needs: perspectives from Arabic-speaking communities. \u003cem\u003eJournal of Ethnicity in Substance Abuse\u003c/em\u003e 2020 doi: 10.1080/15332640.2020.1824837\u003c/li\u003e\n\u003cli\u003eEl-Zaatari ZM, Chami HA, Zaatari GS. Health effects associated with waterpipe smoking. \u003cem\u003eTobacco Control\u003c/em\u003e 2015;24:i31-i43.\u003c/li\u003e\n\u003cli\u003eWHO Regional Office for the Eastern Mediterranean. Tobacco and waterpipe use increases the risk of COVID-19 2020 [16/11/2020]. Available from: http://www.emro.who.int/tfi/know-the-truth/tobacco-and-waterpipe-users-are-at-increased-risk-of-covid-19-infection.html.\u003c/li\u003e\n\u003cli\u003eShekhar S, Hannah-Shmouni F. Hookah smoking and COVID-19: call for action. \u003cem\u003eCanadian Medical Association Journal\u003c/em\u003e 2020;192(17):E462-E62. doi: 10.1503/cmaj.75332\u003c/li\u003e\n\u003cli\u003eGardner K, Kearns R, Woodland L, et al. A Scoping Review of the Evidence on Health Promotion Interventions for Reducing Waterpipe Smoking: Implications for Practice. \u003cem\u003eFrontiers in public health\u003c/em\u003e 2018;6:308-08. doi: 10.3389/fpubh.2018.00308\u003c/li\u003e\n\u003cli\u003eMaziak W, Jawad M, Jawad S, et al. Interventions for waterpipe smoking cessation. \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e 2015 doi: 10.1002/14651858.cd005549.pub3\u003c/li\u003e\n\u003cli\u003eAlmestahiri RD, Rundle-Thiele S, Parkinson J, et al. The Use of the Major Components of Social Marketing. \u003cem\u003eSocial Marketing Quarterly\u003c/em\u003e 2017;23(3):232-48. doi: 10.1177/1524500417704813\u003c/li\u003e\n\u003cli\u003eKotler P, Roberto N, Lee N. Social Marketing Improving the Quality of Life. 2 ed. California, USA: Sage Publications 2002.\u003c/li\u003e\n\u003cli\u003eHastings G, Domegan C. Social Marketing: Rebels with a cause. 3rd ed: Routledge 2018.\u003c/li\u003e\n\u003cli\u003eDelnevo CD, Bauer UE. Monitoring the tobacco use epidemic III. \u003cem\u003ePreventive Medicine\u003c/em\u003e 2009;48(1):S16-S23. doi: 10.1016/j.ypmed.2008.09.008\u003c/li\u003e\n\u003cli\u003eShisha No Thanks [Video]. 2019 [Available from: https://www.youtube.com/watch?v=2wymSx1_FeA\u0026amp;feature=youtu.be accessed December 2020.\u003c/li\u003e\n\u003cli\u003eShisha No Thanks - Know the Facts 2019 [Available from: http://shishanothanks.org.au accessed December 2020.\u003c/li\u003e\n\u003cli\u003eShisha No Thanks [Available from: https://www.facebook.com/ShishaNoThanks/ accessed December 2020.\u003c/li\u003e\n\u003cli\u003eshishanothanks [Available from: https://www.instagram.com/shishanothanks/ accessed December 2020.\u003c/li\u003e\n\u003cli\u003eCancer Institute. 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Nonparametric statistical tests for the continuous data: the basic concept and the practical use. \u003cem\u003eKorean Journal of Anesthesiology\u003c/em\u003e 2016;69(1):8. doi: 10.4097/kjae.2016.69.1.8\u003c/li\u003e\n\u003cli\u003eMohlman MK, Boulos DNK, El Setouhy M, et al. A Randomized, Controlled Community-Wide Intervention to Reduce Environmental Tobacco Smoke Exposure. \u003cem\u003eNicotine \u0026amp; Tobacco Research\u003c/em\u003e 2013;15(8):1372-81. doi: 10.1093/ntr/nts333\u003c/li\u003e\n\u003cli\u003eWakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. \u003cem\u003eThe Lancet\u003c/em\u003e 2010;376(9748):1261-71. doi: 10.1016/s0140-6736(10)60809-4\u003c/li\u003e\n\u003cli\u003eHaddad C, Lahoud N, Akel M, et al. Knowledge, attitudes, harm perception, and practice related to waterpipe smoking in Lebanon. \u003cem\u003eEnvironmental Science and Pollution Research\u003c/em\u003e 2020 doi: 10.1007/s11356-020-08295-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"waterpipe, smoking, tobacco control, campaign, social marketing","lastPublishedDoi":"10.21203/rs.3.rs-536851/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-536851/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Waterpipe (shisha) is becoming increasingly popular worldwide, particularly among young people; and in some countries, it is one of the few forms of tobacco use that is increasing. While there is a growing body of evidence of the harms of waterpipe smoke, there is a scarcity of research of interventions to address this form of tobacco consumption. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The \u003cem\u003eShisha No Thanks\u003c/em\u003e project was a codesign social marketing campaign that aimed to raise awareness of the harms of waterpipe smoking among young people from an Arabic speaking background in Sydney, Australia. The campaign distributed material through social media and community events. We evaluated the project through an SMS community panel using a longitudinal study design. The cohort were sent questions before and after the project asking about their awareness of messages of harms, attitudes, intention to reduce waterpipe smoking, and awareness of support services. Data was analysed as matched pre- post- data. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The evaluation recruited 133 people to the panel. There was a significantly greater proportion of people who reported seeing, hearing or reading something about the harms of waterpipe smoking after the campaign (67.5%) compared with before (45.0%) (c\u003csup\u003e2\u003c/sup\u003e=9.03, p=0.003). Post-campaign, there were higher proportions of people who strongly agreed that waterpipe smoking causes damage, and that it contains cancer-causing substances, but these increases were not statistically significant. There was low awareness of waterpipe cessation services at baseline and post campaign (22.5%). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The \u003cem\u003eShisha No Thanks\u003c/em\u003e project increased awareness of messages about the harms of waterpipe smoking. Although this is a small study, the longitudinal evaluation findings have international relevance and make a useful contribution to the understanding of the impact such interventions can have in addressing one of the few forms of tobacco use that is growing in both developed and developing countries.\u003c/p\u003e","manuscriptTitle":"Evaluation of ‘Shisha No Thanks’ – A Codesign Social Marketing Campaign on the Harms of Waterpipe Smoking","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-07 21:47:57","doi":"10.21203/rs.3.rs-536851/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2021-06-04T11:02:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-06-04T09:42:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-06-04T09:30:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2021-05-18T06:53:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0d45aea-e207-4a8b-9a9d-8297d88802d0","owner":[],"postedDate":"June 7th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":4852016,"name":"Health Policy"}],"tags":[],"updatedAt":"2022-02-14T07:29:12+00:00","versionOfRecord":[],"versionCreatedAt":"2021-06-07 21:47:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-536851","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-536851","identity":"rs-536851","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}