LAUSR

I read with interest Morgan et al’s review entitled ‘How people think about the chemicals in cigarette smoke: a systematic review’ (Morgan, Byron, Baig, Stepanov, & Brewer, 2017), and agree that describing the chemical composition of smoke to the public has the potential to change behaviour and lead to reduced cigarette use. I note, however, that the authors were not mindful that consumers, particularly young people, could be exposed to and use tobacco products beyond cigarettes, which can make tobacco-based health promotion in the current climate challenging. For example, past-30 day waterpipe tobacco use (commonly known as hookah, shisha or narghile) is reported by 5.4% of Canadian youth (Minaker, Shuh, Burkhalter, & Manske, 2015) and 11.4% of US youth (Manderski, Michelle, Hrywna, & Delnevo, 2012), and it is commonly viewed as less harmful than cigarettes (Akl, Jawad, Lam, Obeid, & Irani, 2013; Akl et al., 2015). Good quality information on the health effects of waterpipe tobacco is lacking (Waziry, Jawad, Ballout, Al Akel, & Akl, 2016), though interestingly, its health promotion messages tend to focus on chemicals found in its smoke, and further tend to focus on quantitative comparisons with cigarettes. For instance, in an analysis of over 1000 news articles reporting on the health effects of waterpipe tobacco, over half benchmarked the harms of waterpipe tobacco against cigarettes, and a fifth made scientifically incorrect claims in trying to numerically compare their smoke constituents (Jawad, Bakir, Ali, Jawad, & Akl, 2015). Therefore, how people think about chemicals in cigarette smoke has implications for how they assess the risk of other tobacco products, and these should be considered in the development of health promotion messages in poly-tobacco markets. The World Health Organisation Framework Convention on Tobacco Control prohibits the tobacco industry from making statements or delivering impressions that create a perception that some brands of cigarettes are less harmful than others (World Health Organisation. Framework Convention on Tobacco Control, 2003). In poly-tobacco markets, health promotion messages must follow suit. What we witness with waterpipe tobacco use is a consistent portrayal that it is more harmful than cigarettes, based on direct chemical comparisons between these tobacco products. By claiming waterpipe tobacco contains more of chemical ‘x’ in its smoke compared with cigarettes, this well-intentioned message may inadvertently reinforce a message that cigarettes are less harmful than waterpipe tobacco. I agree with the authors that quantifications of chemicals in tobacco smoke should be avoided, but urge them to extend their advocacy calls for increased research and understanding of this area of behavioural science to the polytobacco context.