Waterpipe tobacco is one of the most commonly used tobacco products among U.S. young adults. Waterpipe
tobacco exposes users to high levels of carcinogens and other harmful toxicants, can lead to long-term
addiction, and is associated with cancer and other negative health outcomes. Despite this evidence, young
adults do not view waterpipe tobacco to be harmful or addictive, perceptions that contribute to the high
prevalence of use. Waterpipe tobacco intervention research has focused on clinical cessation interventions
among older, dependent users. These interventions likely have limited impact among young adults because
their use of clinical cessation interventions is generally low and they do not view themselves to be in need of
such cessation supports for waterpipe. Our research indicates public health messaging conveying the harms
and addictiveness of waterpipe tobacco may be effective to shift young adult waterpipe tobacco users’
perceptions and motivate behavior change. This study builds from our preliminary work and addresses a
critical gap in this research area by rigorously examining the effects of messages conveying the harms and
addictiveness of waterpipe tobacco using text and visual imagery and delivered by mobile phone multimedia
messaging service (MMS) among young adults ages 18 to 30 who use waterpipe tobacco. Our approach
leverages online crowdsourced data collection for message refinement and two-way, interactive mobile phone
technology to engage with participants, deliver MMS messages containing text and visual imagery, and test the
added effects of personally tailored MMS message content. Participants will complete baseline measures,
receive basic message content on the harms and addictiveness of waterpipe tobacco use, and be randomized
to three conditions: 1) a control condition receiving no additional messaging, 2) an untailored MMS condition,
or 3) a tailored MMS condition. For a 1 month period, participants assigned to MMS conditions will receive text
message prompts on two days each week delivered to their mobile phones via an interactive messaging
system to assess waterpipe tobacco perceptions and behavior. After responding to prompts, participants will
immediately receive MMS messages on the harms and addictiveness of waterpipe tobacco. For the tailored
MMS condition, message content will be personalized to their responses to baseline measures and
dynamically through the interactive text message exchanges during the intervention period. Waterpipe tobacco
use and hypothesized mediators will be reassessed 1-, 3-, and 6-months post-baseline. Our study will
generate critically needed data on the effects of mobile MMS messaging and tailored MMS message content to
inform waterpipe tobacco use interventions. Our study directly addresses National Cancer Institute tobacco
control research priorities, and now that waterpipe tobacco is regulated by the Food and Drug Administration
(FDA) this study can guide the FDA’s efforts to educate the public about the harms of waterpipe tobacco.
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