The participants’ characteristics
Of the 47 women invited to be interviewed, 36 agreed to participate in the study and 11 refused to participate in the study because of their disagreement with the recording of their voices and their opposition of their spouses. The participants aged between 15 and 67 years with an average age of 40 ± 16.20 years and had a history of hookah consumption between 6 months and 46 years. Other information can be seen in )Table 1(.
Initially, 494 codes were extracted. When they were compared and those alike were omitted or integrated, they finally made 271 codes, 16 sub-categories and 6 categories.
In total, six main categories were extracted,1.Incentive backgrounds. 2.The need for liberation. 3. Control of external stimuli 4. Religious norms.5. Self-efficacy 6. Political factors. Since there was a high volume of data in this study, addressing all categories were not possible in a single study, so only four categories were discussed in this paper. The other two categories(Control of external stimuli and Political factors) will be discussed in another paper.
The quotes were described based on the age and type of cessation (successful, unsuccessful) and the duration of cessation.
Category 1: Incentive backgrounds
This category was one of the broadest and most important categories in cessation/reduction of hookah consumption, which included several sub-categories, such as the existence and advice of influential people, family support, meeting psychosocial needs, and increasing knowledge. Each of these subcategories was supported below by the quotes of the participants:
1.1-Existence and advice of influential people
Most of the women with successful and unsuccessful quitting attempts referred to the advice of their loved ones that played an important role in reducing or quitting the consumption of hookah. The women had a high incentive to follow the wishes of their loved ones. One participant in this regard stated:
"I stopped hookah smoking for 8 years because my mom asked me to do so. She said she is very upset because of my hookah smoking. I stopped it just because of my mother’s request; when someone is dear to you and you have respect for him/her, you listen to him/her and stop smoking." (37 year old, unsuccessful cessation, 8 years)
Family support was another sub-category that most women referred to as a contributing factor in reducing and quitting hookah. Emotional communication among family members, proper care and supervision of the family, and spouse's support also persuaded the women to reduce or quit hookah.
"When my husband realized that I was smoking hookah, he encouraged me to quit. He was very supportive, and bought me a prize and a gift and was very careful about my smoking. This support and care of my husband helped me to set it aside for a year now." (30 years, unsuccessful cessation, 1 year)
1.3- Meeting psychological and social needs
Another sub-category that the participants expressed as motivational factors in reducing and quitting smoking was meeting psychosocial and social needs. Good economic status, high self-esteem, alternative amusements, and awareness about the harms of hookah were among the incentive factors in reducing and quitting the hookah.
According to the participants, having peace of mind and calmness that comes from good economic status can play an important role in reducing and quitting the hookah. They point out that, in families with good income, there is a possibility of healthy recreational activities, children's education and healthy leisure times.
"When a person has a good income, he can go on a journey and have good fun. He can go to the university if he is young. He does not need to sit at home and think about money anymore and then, to calm himself down, start to smoke hookah." (56 years old, successful cessation for 15 years)
The existence of alternative amusements was another factor abundantly referred to by women with unsuccessful cessation attempt. According to them, if women are busy working outside the home, their likelihood of being interested in hookah is very weak, or if they are users, they are more likely to quit or reduce. In the present study, women pointed out that, although they have not quitted hookah yet, after finding a desired job, their number of hookah smoking sessions was significantly reduced. In some women, hobby and amusement were able to help them to stop hookah smoking successfully. The majority of women, with unsuccessful cessation, have pointed to the role of alternative amusement (education, work, sports) as one of the most important factors in the temporary cessation of hookah.
"Something that really helped me to quit hookah was my sewing hobby at my own manufacturing workshop. I was working at the offices constantly, and I had little time to sit down. Work is really important, and I did not have time to smoke hookah with my friend." (67 years old, successful cessation, 4 years old)
High self-esteem was another effective factor in quitting or reducing the hookah smoking. Most women with a history of successful cessation referred to the role of high self-esteem in helping to quit hookah. They believe that people who love and value themselves do not harm their bodies, because they have come to the conclusion that their health and body are very valuable. Most of them pointed to the value of their health. This is why, women with unsuccessful cessation attempts often failed to consider their health as one of the reasons for re-use of hookah.
"Although I still have some illnesses and I'm recovering, the thought does not come to me that I am sick and I am going to die soon, so let’s smoke hookah. I never think that way again, because I love myself now and I do not want to harm my own body. Our body is God's trust in our hands, so we must take care of it." (50 years old, successful cessation, 8 months)
Awareness about the harms of hookah was one of the factors that encouraged people to quit or reduce the consumption of hookah. Most women with successful cessation pointed out that, they were not fully aware of the precise complications of hookah at the time of consumption. They said that there is not much information available in this regard, and that is why they did not know about the complications of hookah until they have seen their effects on their body. They acknowledged that some consumers are unaware of hookah's disadvantages, and if they would be fully aware, they would probably replace the hookah with a useful and healthy activity.
"I did not really know about the harms of hookah when I was consuming it. After the night that I was feeling so bad, my friend introduced me to the nicotine sessions. There, I became aware of the hookah’s harms, and when I realized it was so damaging, I stopped it." (56 years old, successful cessation, 15 years)
Category 2: The need for liberation
Another main category that emerged from this research was the need for liberation, which consisted of two sub-categories of perceived risk and being tired of present situation, which were supported by the following participants’ quotes:
2.1 Perceived risk
The majority of participants with successful cessation, especially women over 50 years of age, after touching on and observing the dangers of hookahs, including fear of death, frequent hospital admissions, chronic illnesses, endangering children's health, premature death and child neglect, being a bad role-model for children and seeing the signs of aging on the face, decided to quit hookah. Also, most women with unsuccessful cessation, have stopped hookah for a short time due to physical problems (respiratory problems, physician's advice, pregnancy), and after healing, they began to smoke hookah again.
"I developed a heart problem, my cardiac veins were closed and after three angiographies they were opened. I have a stent in my heart now and I'm afraid my heart will be closed again. I'm afraid of being hospitalized in the hospital, where they cut you open, so I'm not smoking again." (60 years old, successful cessation, 6 years)
2.2-Being tired of the current situation
The participants in the present research referred to the low quality of tobacco flavors, sense of conflicting harm to others, numerous cessation attempts, financial losses, fear of conflicting harm to family livelihood, economic problems and inability to buy flavored tobacco, taking immoral and antisocial behaviors such as deceiving and lying to get flavored tobacco, impossibility of taking hookah to parties and trips, as the reasons for their hookah cessation. These factors had caused women to be tired and worried about their hookah smoking behaviors.
"I was completely fed-up, and the flavors were lousy and bitter. I was going to my neighbors’ house for smoking. I was really tired lately, so I decided to stop.” (61 years old, successful cessation, 7 years)
Category 3: Religious norms
Another important factor contributing to the cessation and reduction of hookah smoking was religious norms. The participants believed that strong belief in God and relaying on Imams helped them in successful quitting of the hookah. The majority of women contributed their successful hookah cessation to God's will and help. They stated that, they failed each time they attempted to quit hookah, but by believing in God and asking for his help, they found more power within themselves and were able to successfully quit hookah.
In confirmation of the above statements, a participant with successful cessation (15 years) stated: "I quitted many times and again I was tempted to smoke, until I went to Hajj and I prayed and begged Allah to help me get away from hookah temptation. I believe in God's and Imams, so when I came back from pilgrimage of the Hajj until now, it is 15 years that I have stooped hookah smoking. I am sure without God’s help I would have been tempted again."
Category 4: Self-efficacy
Another major category that emerged from data analysis was the self-efficacy. Most participants considered the ability and skills of people in hookah cessation as important. They believe that hookah cessation is done only with confidence in the ability and skills of individuals.. The participants believed that women should be more stubborn and serious in stopping hookah and should believe in their abilities.
“You must be willing to quit hookah, otherwise nothing and nobody can force you to quit it. You must first trust yourself that you can do it. I saw my friend smoking hookah for a long time, but she could quit it, so I told myself I can quit it too. I have the ability to do it. The first and second days were hard, but I did it thanks to God.” (43 years old, successful cessation, 7 months)