Overall, 42 persons participated in this study. Thirty four participants were women with WTS experience and with mean (SD) age of 22.97(4.89) years, on average.
Twenty nine of these women (85%) still smoked waterpipe tobacco at the time of the study, while five of them had ceased WTS. The remaining eight participants were two mothers, one girlfriend, and one boyfriend, two male waterpipe tobacco smokers who worked in hookah bars, one female teacher, and a male smoking control staff. Their mean (SD) age of years was 34 (9.95). Table 1 shows participants’ demographic characteristics.
Sociocultural factors contributing to WTS were categorized into four main categories. These categories were waterpipe glamorization by its producers and sellers, media advertisement or silence, common sociocultural traditions, and governmental policies and regulations. Together with their subcategories, these categories are shown in Table 2 and are explained in the following.
1. Waterpipe glamorization by its producers and sellers
This main category consisted of two subcategories, namely innovative and tempting techniques for the continuous glamorization of waterpipe by its producers, and marketing and customer attraction techniques used by WTS providers.
1.1. Innovative and tempting techniques for the continuous glamorization of waterpipe by its producers
Waterpipe producers continuously attempt to design and produce as attractive as possible waterpipe and waterpipe accessories in order to tempt different individuals into WTS.
Using a single type of waterpipe is boring. I have two waterpipes. One of them is like the Eiffel tower and the other is smaller. I use them intermittently. Every day, they produce new types of waterpipe which I like. (Current smoker, 28year old)
The wide variety of tobaccos and their flavors is also a significant factor contributing to WTS among young women. Participants considered the different aromas used for tobaccos as a tempting factor for their WTS.
I ceased WTS; but this new tobacco, which has a pleasant aroma, tempted me into its use, particularly with these new waterpipes. (Former smoker, 26 year old)
1.2. Marketing and customer attraction techniques used by WTS providers
The participating waterpipe tobacco smokers, hookah bar staff, and smoking control staff noted that hookah bars compete with each other for attracting more customers and hence, use different marketing and customer attraction techniques based on their customers’ personal preferences. One of these techniques was to offer a wide variety of tobaccos with different flavors and waterpipes with different shapes.
There are different tobaccos with different fruit flavors. We offer them to our customers in order to satisfy them. (Worker in hookah bars, male, 27 year old)
Some participants referred to the beautiful interior decoration and the pleasant environment of hookah bars as significant factors contributing to WTS by young women.
Our hookah bar has a pleasant environment and nice atmosphere and hence, attracts many people, particularly families and women. (Worker in hookah bars, male, 27 year old)
Another participant said,
The interior decoration of hookah bars is really luxury. They use colorful or wooden decorations and use different colors for decoration. Such decoration tempts me into going there and smoking waterpipe. (Former smoker, 20 year old)
Some participants noted that special discounts on waterpipe, for instance discount for students, tempt even those people who do not intend to smoke waterpipe into WTS.
We had gone to a traditional restaurant for launch. We never intended to smoke waterpipe. However, they offered discount on waterpipe for students and hence, we tested waterpipe for the first time. (Current smoker, 22 year old)
In addition to waterpipe, hookah bars offer different services to attract customers. Examples of these services are traditional foods, different drinks, confections, nuts, free high-speed internet, and live music. Such holistic approach to service delivery satisfies different needs of customers at a single time and place and hence, causes them to refer to those places again.
Here, we both enjoy live music, use free high-speed internet, have our foods, and smoke a nice waterpipe after food. In addition, they serve us with confections and nuts. We also drink tea with candy in order to prevent blood pressure decline. With all these services at a single place, why should we go to another place? (Current smoker, 16 year old)
As another customer attraction technique, hookah bars also provide their customers with a safe and private place for other recreations such as group dance or intimate circles.
Bowers in hookah bars provide you with a private place to be with friends. There, you can hold celebrations and dance without any disturbance. Certainly, we also need to order waterpipe. (Current smoker, 17 year old
Another customer attraction technique of hookah bars is to provide a place for hidden norm violation. Intimate relationships among friends of opposite genders are against social norms in Iran. Hookah bars attempt to attract more customers by offering private places for such relationships and WTS.
I cannot spend time with my boyfriend in the society because the society forbids me. Thus, I have to come here to have a private place to be with my boyfriend. Here, they offer us waterpipe and we have no option but to use it though my boyfriend and I are not interested in WTS. (Current smoker, 23 year old)
The other technique used by hookah bars is telephone-based waterpipe delivery services locally called “Hallo waterpipe”. Such services make WTS easily accessible.
Hallo waterpipe is a new service which has recently introduced. You order a ready-to-use waterpipe over the phone and they bring it to your address. You can use it for several hours. (Current smoker, 16 year old)
2. Media advertisement or silence
The two subcategories of this main category were media advertisement for WTS and mass media silence respecting WTS.
2.1. Media advertisement for WTS
According to the participants, WTS advertisement, particularly in non-official media such as the Instagram and Telegram, is sometimes effective in tempting young women into WTS.
For the first time, I heard about the “Hallo waterpipe” service in the Instagram. Afterwards, whenever I was not in mood for going out, I called a “Hallo waterpipe” provider and they immediately brought me a ready-to-use waterpipe. (Current smoker, 18 year old)
2.2. Mass media silence respecting WTS
Some participants referred to mass media silence as another factor contributing to WTS by young women. They noted that there are no well-organized WTS-related educational programs in the national media.
The mass media has adequately covered addictive drugs such as marijuana so that the public has completely been informed about its harmful effects. However, there are limited educational programs on WTS in the television and they did not cover the whole reality of WTS in their movies. (Current smoker, 26 year old)
Participants noted that not only the mass media treats WTS with silence, but also shows movies and serials which promote WTS.
For instance, a popular serial depicted an actress who was smoking waterpipe in a family circle. Such depiction of WTS by a woman promotes WTS among people, particularly girls. (Current smoker, 22 year old)
On the other hand, some participants referred to anti-WTS campaigns in media in which well-known artists and athletes give anti-WTS messages to the public.
The “Turn waterpipes into flowerpots campaign” was very good. The administrators of this campaign employed artists and athletes and I think it was effective in sensitizing people to WTS. These programs can broaden people’s knowledge about the harmful effects of WTS and thereby, can reduce WTS. (Mother, 42 year old)
3. Common sociocultural traditions
Another main sociocultural factor contributing to WTS was common sociocultural traditions. This main category included two subcategories, namely WTS as a norm transgression and social acceptance of WTS by women.
3.1. WTS as a norm transgression
Our participants’ experiences showed that WTS by girls and women is considered as deviation from social norms in some areas.
WTS by girls is not approved by our society; yet, some girls go to hookah bars for this deviant behavior. (Female teacher, 50 year old)
3.2. Social acceptance of WTS by women
In some communities in Iran, WTS is traditionally used in different parties and ceremonies. In fact, WTS is more acceptable than other tobacco-smoking methods in the Iranian society. Some participants noted that their WTS behavior was formed by such traditions.
When I was a child, I went to a religious memorial ceremony where there was a row of waterpipe for old women. There, I was tempted into WTS and smoked waterpipe for the first time. (Current smoker, 14 year old)
Some participants recommended the use of healthy entertainment activities in ceremonies as a strategy for reducing the social acceptance of WTS by women.
In our night parties, we play traditional games. Brain games are also good substitute for WTS. Such games can reduce the acceptance of WTS in the society and families. (Mother, 39 year old)
4. Governmental policies and regulations
Ineffective enforcement of WTS-related regulations and inadequate supervision of the production, import, and export of tobacco, along with inadequate control over WTS in hookah bars significantly contribute to the increasing prevalence of WTS among women. The two subcategories of this category were ineffective enforcement of WTS-related regulations and inadequate supervision of tobacco production, supply, import, and export.
4.1. Ineffective enforcement of WTS-related regulations
Some participants noted that the wide variety of WTS-related regulations and their ineffective enforcement have reduced WTS providers’ and users’ compliance to these regulations.
They enacted a regulation which forbade WTS. Then, another regulation was enacted to make WTS in hookah bars legal. After that, they re-forbade WTS. Such non-strict regulations cause both WTS providers and users not to take the regulations serious and thus continue WTS. (Smoking control staff, male, 33 year old)
According to the participants, WTS-related regulations are just enacted and are not effectively enforced.
Regulations forbid the selling of tobacco to people under eighteen. However, such regulations are not effectively enforced. (Boyfriend, 23 year old)
Non-strict regulations and their ineffective enforcement have significantly increased the number of hookah bars in Iran and made WTS services more easily accessible.
Hookah bars are available everywhere. For instance, there is several traditional hookah bars near our university, where we easily access and smoke waterpipe. Such easy access to WTS services has promoted WTS among us, the girls. (Current smoker, 19 year old)
Poor tax policies on tobacco has also made WTS less expensive than the other types of recreational activities in Iran.
WTS is the most cost-effective recreational activity. There is no high tax on WTS and most people can afford it, while not everybody can afford the costs of going to amusement parks. (Current smoker, 25 year old)
4.2. Inadequate supervision of tobacco production, supply, import, and export
Some participants attributed the increasing prevalence of WTS in Iran to governmental support for tobacco use.
The government can easily eradicate WTS like the eradication of many other things; however, it unfortunately supports it because tobacco is a domestic product. (Current smoker, 22 year old)
Ineffective supervision of the enforcement of regulations related to tobacco production, supply, import, and export also significantly contributes to the prevalence of WTS among young women.
We have fundamental problems. The easy and non-supervised import and export of tobacco increase WTS in our country. (Current smoker, 25 year old)
Moreover, regulations and supervisions of WTS by women are not effective and hence, stricter policies are needed to reduce WTS prevalence among women.
The cancellation of WTS in hookah bars and restaurants is impossible. The government needs to develop more effective policies. For instance, the creation of more employment opportunities for young people by the government can help reduce WTS prevalence. (Current smoker, 26 year old)