How do Iranian High School Students Explain Social Undesirability of Hookah Smoking? A Qualitative Study

Background: Despite the speculations in literature regarding the importance of “social undesirability of hookah smoking”, to our knowledge, no study has yet clearly attempted to dene this phenomenon and to make sense of it in terms of the meanings adolescents bring to the concept. The present study was aimed to explore the perceptions of high school students on Social Undesirability of Hookah Smoking (SUoHS). Method: In this qualitative study, 31 students (16 boys and 15 girls) at the range of 15 to 17 years of age in Tabriz, Iran, were invited to participate in semi-structured individual interviews (18 participants) and focus group discussions (FGDs) (13 participants). The data were managed applying MAXQDA-10, and analyzed using interpretative thematic analysis. Results: The SUoHS was viewed at the “highly negative attitude towards hookah smoking and hookah smokers”. The students also explained the SUoHS in “the disvaluing to hookah smoking and smokers in the society”, “the negative attitude towards hookah smokers and their families”, and “the consequences of hookah smoking”. Conclusion: The SUoHS originates from the social context of society, and is rooted from the social values and norms within communities. These social values may affect the attitude and subjective norms of adolescents toward the behavior. Adolescents’ conceptions on SUoHS should be considered while designing hookah smoking prevention/cessation programs with the hope to bridge the gap between their recognition of SUoHS and subsequent behavior change.


Background
Tobacco smoking is a preventable risk factor for disease morbidity and mortality [1]. Among the modes of using tobacco, hookah smoking (HS) is a remerging phenomenon that may increase the risk of oral, esophageal, and pulmonary cancer, as well as reduced pulmonary system function [2]. The word "hookah" is generally used for a particular method of tobacco smoking, in which smoke passes through water before inhalation [3]. Globally, the popularity of HS, as a social and entertaining behavior, is increasing [4][5][6][7] among adolescents and youths [8,9], particularly in the African and Middle East Region (EMR) countries [10], like Iran [11]. The increased tendency towards HS among adolescents may be associated to their misunderstanding on the harmlessness of the behavior, compared to other forms of tobacco smoking. Considering such an increasing popularity, HS is the new mode of tobacco smoking with a lower level of 'qabahat' (social undesirability), compared to other modes of tobacco use, in the 21st century [12,13].
'Qabahat' (qa(e)bāhat) is an originally Arabic term rooted from the term 'qobh', which means socially undesirable and unaccepted, aberrant, and deviant [14]. In Persian language, 'qabahat' also means not in accordance with accepted rules, social norms or standards [14]. Findings of a study among students in Najaf-Abad County, Iran, have shown that the perception of low Social Undesirability of Hookah Smoking (SUoHS), compared to other modes of tobacco use, caused the adolescents to easily tend to the behavior [15]. In another study in the U.S., one of the most frequent reasons for the university students' tendency towards HS was their perceptions on the high levels of social acceptance and popularity for HS [16]. It is usually postulated that HS at home reduces its social undesirability for children and adolescents and such reduced undesirability may facilitate the initiation and continuation of the behavior. Jahanpour et al. in a qualitative study, reported that the high popularity and the common use of hookah may have decreased the SUoHS among adolescents and have rendered it as a normal and acceptable practice [12].
Sabahy et al. also noted low the SUoHS as a facilitating factor for the inclination of youth toward HS [17].
Despite the above-mentioned speculations in literature regarding the importance of SUoHS, to our knowledge, no study has yet clearly attempted to de ne this phenomenon and to make sense of it in terms of the meanings people bring to the concept. Due to the increasing rate of HS among Iranian adolescents and the association of social desirability with their tendency towards HS, we aimed to explore the concept of SUoHS from the perspective of Iranian high school students. We are interested in nding out how the high school students perceive the SUoHS. This will inform future researchers on how to consider SUoHS while investigating the cognitive determinants of HS among adolescents. Finding a better understanding on the phenomenon and its possible domains may also provide the future researchers with a comprehensive conceptual framework while designing HS cessation programs among adolescent and young populations. The following research question guided our study: "How do Iranian high school students explain social undesirability of hookah smoking?"

Participants and design
This was a qualitative study with thematic analysis approach conducted to explore the social undesirability of HS among high school students. The study setting was the high schools in Tabriz, East-Azerbaijan province, Iran. The participants were 31 students (16 boys and 15 girls) at the range of 15 to 17 years of age in Tabriz high schools. The participants were not asked about their history of hookah smoking. In order to obtain views across a range of social circumstances, the students were selected from different socioeconomic backgrounds, based on their records at the schools. Inclusion criteria for the study were living in Tabriz, studying at the grades two and three of the high school (11th and 12th grades) and willingness of both the students and their parents to participate in the study. Ethical approval to conduct the study was obtained from Ethics Committee in Tabriz University of Medical Sciences.
Among ve education districts of Tabriz, a district was selected as the setting of work, and the participants were selected from the high schools situated in the district of interest. The rst researcher visited the schools and clari ed the objectives of study to the administrators of schools. Then, the students were randomly invited to participate in the study, and if agreed were suggested to have an appointment with the rst researcher in a private room at their school. Prior to setting the appointment, one parent of the students was contacted on the phone and informed on the objectives of the study. In the case of their oral agreement with the participation of their child in the study, the appointment with the student was set. After primary coordination, interviews were conducted in the time and place preferred by the participants. So, the students who were willing to participate in the interviews were included after obtaining informed consent. Before the interviews, the research objectives were rst explained to the participants and, written informed consent was obtained from both the students and one of their parents. The interviews were voice recorded with their permission.

Data collection
We developed an interview schedule contained open-ended questions to explore the students' perceptions of the SUoHS. Firstly, three Focus Group Discussions (FGDs) with 13 participants (4-5 students in each FGD) were conducted to nd a general understanding on the students' views of the phenomenon. Then, eighteen students were individually interviewed to dig deeper down into their perceptions of the SUoHS. The main question initially asked from the participants was 'how would you explain hookah smoking?', and then some probing questions (Table 1) were asked according to the interview schedule and the participants' answers. In the two modes of data collection, the probing questions were different and varied from one interview to another. The selection of probing questions for an interview was based on the results discovered during the data analysis of prior interview. The rst researcher, with considerable experience in conducting qualitative interviews with adolescents, conducted the FGD sessions and facilitated the discussions by asking some probing questions and encouraging all participants to join in the discussions. Another researcher of the study, who did not have any participation in the discussions, supervised the sessions and wrote down the required notes and comments to promote the discussion process. On average, the FGDs and the individual interviews lasted 1.15 hour and 45 minutes, respectively. All interviews were audiotaped applying a digital voice recorder. With fteen interviews, we achieved theoretical saturation of the data and no new code, category and theme emerged in the last interview. Table 1 The main question and its probing questions that were asked from the participants How do you see the social acceptance and popularity of hookah smoking? Please describe it.
How do you describe a boy or a girl who is smoking hookah?
How do you see the family of a person who use hookah?
What bears in your mind, when you see that your friend is smoking hookah?
What are the characteristics of a hookah user in your society? Based on your viewpoint, why does he/she smoke hookah? What the reasons may be?
How would you describe a ring of friends in a coffee shop who are smoking hookah?
Based on your opinion, how do you explain hookah smoking among women?
In your idea, what are the outcomes/consequences of hookah smoking? Who gets these consequences? Are they favorable or adverse?
What would happen if hookah smoking does not exist? How would life change?

Data analysis
We transcribed the interviews verbatim and reviewed the text for accuracy. We then carried out a thematic analysis using the qualitative data analysis software MAXQDA 10 (2011). Individual interviews and FGDs were initially integrated for the purposes of data completeness and con rmation. We assumed that each interview method reveals different parts of the SUoHS and thus provides us with complementary views on the phenomenon. We also assumed that such an integration may be helpful in expanding the breadth and the depth of our ndings. So, we conducted the individual interviews and the FGDs to explore personal experiences of the students on the SUoHS and to examine their beliefs and opinions on the phenomenon, respectively. Moreover, during FGDs, three students were unable and/or refused to participate in a focus group. So, as a pragmatic reason to combine the interviews, we invited them to take part in an individual interview.
As suggested by Braun and Clarke [18], thematic analysis may be approached in two ways; an essentialist/realist way or a constructionist way. In the rst way, a qualitative researcher reports the experiences, meanings and the realities of participants, and in the latter way, the researcher explores the ways that experiences may be affected by a range of discourses within a community. We presumed that the students' views of the SUoHS may be in uenced by social determinants, like the history of contacts with the behavior, culture, and socioeconomic status of their families. We, therefore, applied a constructionist framework, with a focus on latent/interpretative level of the underlying viewpoints, assumptions and conceptualizations of the students. We read and re-read the transcripts, and drew the initial codes from the data. Then, in close discussion within the research team, we collated the codes into themes, and developed a coding frame. All interviews were conducted and analyzed by the rst author, and she derived the themes by her preconceptions. When conducting and analyzing the interviews, she had the research question in mind. We, thus, took an epistemological strategy to uncover the adolescents' perceptions of the SUoHS, as a concept with a high degree of subjectivity. In order to account for interrater reliability, a second researcher randomly selected and coded one in six raw transcripts. We, thus, checked the agreement with the themes and ensured that both researchers deduced similar themes from the texts. We, eventually, made some minor changes to terminology, although no change was made to the emerging themes.

Results
The students were between 15-17 years of age, and were studying either at the 10th or the 11th grades of high school.
During thematic analysis, the predominant theme aroused was termed as "highly negative attitude towards HS and hookah smokers". The students explained the SUoHS in the indecency of the behavior as well as the impudence, impertinence and rudeness of the hookah smokers. The participants perceived HS as a rude and disrespectful behavior. They also considered the smokers as individuals that disrespect the people around them while smoking. The results were universal across the students, regardless of their age and gender.
Themes were grouped as follow: social disvaluing of hookah smoking and smokers, negative attitude towards hookah smokers and their families, and consequences of hookah smoking.

Social disvaluing of hookah smoking and smokers
Based on the students' opinion, the SUoHS was seen in the disvaluing of the society to the behavior and those who perform it. They believed that the people in the society have a highly negative opinion of the hookah smokers. For this theme, three main categories were identi ed as follow: Behaving against social values and norms: As participants believed, hookah users behave against the social norms and values, and disregard the culture of society. "These people have come to value a thing [hookah smoking] that is, in fact, a disvalue. This behavior is against religious and social values"(p. 7). They believed that hookah smokers were a plague and burden on society. "I say they're a burden on society because these are the people who do not serve it. They just cause trouble"(p. 6). "I say, you're a plague on society"(p. 5).

Violating the others' rights
The students believed that hookah smokers violate the rights of people in the community. The smokers bother people around them because of the bad smoke and the bad smell of hookah. "Hookah use may disturb others as well. Maybe those around you cannot tolerate it"(p. 6). They also reported that hookah smokers do not respect others and are troublemakers for their society. "This behavior is not respectful; they do not respect others" (p. 7). According to another participant, hookah users may, "harass some people... may insult girls..."(p. 29).

Being untrustworthy
The participants believed that hookah users are untrustworthy and cannot be acknowledged or approved by others. "Maybe these are people we cannot trust anymore"(p. 6).

Negative attitude towards hookah smokers and their families
The students considered the SUoHS in the negative attitude towards the smokers and their families. This theme was grouped into three categories: Negative attitude towards hookah smokers The students perceived HS as a rude behavior, because the smokers were seen as individuals with playfulness, weak willpower, irresponsibility, poor knowledge/experience, and promiscuity. They believed that the smokers were bad role models within community and may be also attracted toward addiction. According to them, hookah users pave the way for ruder behaviors by smoking hookah, as this behavior may mark the beginning of using narcotics, and addiction. "Hookah itself is very addictive and one becomes dependent on it by experimenting it even once with friends"(p. 11). Participants believed that hookah users have lost their identity, do not pursue any clear goal in life, and waste their life. "First, they have lost their identity. Second, they have lost themselves by doing this"(p. 5). They also believed that hookah users have a weak willpower and they lack the skill of saying no. "Hookah users may have no willpower. That is, they lack the will not to pursue it [hookah smoking]"(p. 29). "These people are playful.
They do not care about anything else"(p. 13).
According to them, hookah users are ignorant and are, unmindfully, proud of their HS. "One can say that these people are ignorant of what they are doing"(p. 7). Participants also believed that hookah users are promiscuous, improvident, hooligans, rowdy, and dishonorable, and may do anything. "Maybe one can refer to them as a hooligan person with improvident and undisciplined behavior"(p. 28). "I believe those who use hookah are promiscuous"(p. 14). Participants considered hookah users as smoky, shameless, liars, criminals, and abusive individuals. In total, they perceived hookah users as a negative role model in the society. They also believed that hookah users have a bad personality, and can mislead others. "These people are considered as smokers in the society"(p. 11). "What you expect of a graceful and digni ed person in terms of the language they use and the way they dress?"(p. 6).

Highly negative attitude towards female hookah smokers
Many students believed that female hookah users have forgotten their true nature (as a beauty symbol), messed up their physical and spiritual beauty, and may even have illegitimate relations with others. "I think she [a female hookah smoker] has forgotten her nature and the goal of her creation"(p. 7). They presented a more negative attitude toward HS for females, compared to males. They considered these women shameless, unchaste, nasty, notorious, and rowdy. "When we see some of them are smoking hookah, they seem to be nasty and notorious"(p. 6).
They also believed that these women are Khiabani girls [street girls: a local folk expression used to explain the women (particularly girls) who have run away from their family] who desert their families and home, turn to whorehouses, and go astray. "These are often girls running from home and having problems with their parents. They've turned to streets and men"(p. 22).

Negative attitude towards the family of hookah users
The students would often report that in the families of hookah users there were not a good parent-child relationship. Due to their familial problems, the parents mistrust their children. "[It is] a family who never trust their children"(p. 25). "their parents may have problems and do not have good relationships"(p. 29). They also believed that such families do not raise their children well and cannot control them. "They do not have the culture of parenting, have not raised their children well"(p. 14). Based on their ideas, these families were either too strict or too lenient. "They may be families who have imposed too many limitations on their children from the beginning"(p. 31). "I think they are careless and do not care about their children at all"(p. 25).
According to them, such families are unaware and ignorant families who consider HS as a healthy hobby and do not know its harms. "They think it is a healthy hobby"(p. 19). They also believed that HS is a normal behavior in the users' families. They viewed these families as promiscuous, shameless, degenerate, ignorant, uncultured, and lowborn families. "They have not been born in a high-class family"(p. 14). "The family of hookah users is too uncultured family"(p. 28).

Consequences of hookah smoking
Based on the students' ideas, HS was considered to be a socially undesirable behavior because it damages the physical, mental and familial health of the smokers. They also believed that the behavior may damage their social health. The sub-categories are explored in more detail below:

Self-harm
A majority of participants believed that HS was harmful and may cause cardiac and pulmonary diseases and cancer, and may damage one's physical beauty. "Those who use hookah may be suffered with different diseases, like pulmonary diseases"(p17). "It makes you lose your physical beauty"(p14). They commented that hookah users are dependent to the behavior, and explained the users as unhealthy individuals with poor mental health who may even attempt suicide. "Hookah users are depressed guys who may attempt to kill themselves"(p. 14).
Harm to the society According to students, HS may damage the community health and development. They perceived HS as a behavior that facilitates the spread of different diseases and substance use within community, and thus endangers community health. "Hookah endangers our health and destroys the health of our family, community, and society"(p. 3). Not commonly commented on, some students believed that the individuals from different age groups congregate in hookah lounges where ghting, violence, and ethnic groupings are common. The promotion of behavior within society results in development of hookah lounges, which consequently promote violent behaviors in the community. "In these places, there are many delinquents, and ghts and violence are common, ethnic grouping is common"(p. 18).
Harm to the family ties Many students believed that the smokers do not pay attention to their family, have misbehavior with their family members, and have weak parent-child ties. "A characteristic of hookah smokers is that they do not pay any attention to their family"(p. 28). As they noted, it may also cause detachment between the smoker and his/her family and what he/she was going on. "It makes you move away from things you like"(p31). "[hookah smokers] actually destroy God's blessing with their own hands"(p7). "they [hookah smokers] do not respect their parents or do not ask their permission"(p23).

Discussion
To the best of our knowledge, this was the rst qualitative study to explain the SUoHS from the viewpoints of adolescents. The students explained the SUoHS in the disvaluing of hookah smokers and their behavior within the society, and in the negative attitude towards the smokers and their families. They also perceived the SUoHS in the consequences of behavior. These ndings suggest that the concept of the SUoHS originates from the social context of society, and is rooted from the social values and norms related to smoking within communities. The social values affect the attitude and subjective norms of individuals toward the behavior. The present study helps to explain why smoking prevention and/or cessation programs may not lead to behavior change. According to the theory of planned behavior [19,20], the rst step to hookah smokers implementing HS cessation involves them perceiving themselves to be at risk of health problems as a result of smoking. They would be also affected by the signi cant others around them in terms of either continuing or quitting the behavior. They would then need to believe on their ability to stop smoking. Prior to these cognitive factors, there may be considerations on the signi cant role of social factors, like social valuing of the smokers and their behavior. The perception of adolescents on the way that society values their behavior may in uence their attitude and subjective norms toward HS. All these factors together may constitute the perception of adolescents on the SUoHS, which may in turn, in uence their intention to practice the behavior. In other words, as a possible presumption, HS may not be prevented or quitted if there would be no consideration on the role of the SUoHS.
Based on our data, the students perceived hookah users as untrustworthy individuals who do not respect the rights of others. They believed that HS is against social values and norms. These ndings are consistent with those reported by Khalil et al. [21] in a qualitative study in the EMR. Their results described HS by women as a behavior that opposes the society and social norms. As they suggested, the social context of HS is crucial to understanding the behavior. In more conservative communities where norms and customs are well-de ned and con rmed, there may be some social limitations for HS as compared to more liberal societies. Maziak et al. [22] in a study in Syria reported traditions and norms as the main reasons noted by women for not smoking.
Our data indicated that the SUoHS lies in the negative attitude towards hookah users, particularly female hookah users, and their families. Our participants perceived hookah user as promiscuous, playful, and irresponsible individuals. Similarly, Gholami et al. [23] in a qualitative study in Iran identi ed that people had a negative attitude towards hookah users, demonstrating the decreased popularity of the users in the society. Our participants also believed that the social undesirability of this behavior is much stronger for women, compared to men, and explained such women as shameless and promiscuous; a nding consistent with previous research [21], suggesting that being a female hookah user is viewed as cheap and shameful. The SUoHS was also explained in the perceptions of adolescents on the family of hookah users. Based on our data, when HS is common within family, the social undesirability of behavior is broken down. In such families, the child may feel free to perform other obscene behaviors, like cigarette smoking and alcohol misuse, within family environment, which may attenuate respectfulness towards parents over time. Roskin and Aveyard [24], in a qualitative study in Canada, identi ed that regular HS within family was considered as a normal activity, which may be similar to watching television over time. Another Iranian study among adolescents showed that lack of family supervision increased the odds of HS [15].
Our data also indicated that the SUoHS may be partly due to the consequences of behavior. Students believed that HS was socially undesirable because it could damage the users and their society. In a systematic review [25] on the motives, beliefs, and attitudes towards HS, achieving peace and pleasure was among the main motives for HS. Mohammadkhani and Rezaei [15] also showed associations between HS and hopelessness among adolescents. They also revealed that family con icts have signi cant correlations with the tendency towards HS. Similarly, the students in our study contended that HS was undesirable because it weakened users' relationship with their families. Accordingly, they could gradually get away from their families, and have poor and strained relationships with their parents.
Jahanpour et al. [12] in an Iranian qualitative study reported relationships between culture and the tendency of adolescents/youths towards HS. According to our participants, the SUoHS was partly seen in the damage that it may cause to the community health and development. They believed that HS is now getting to be considered as an acceptable norm in public places, as it is easily accessible. Such a high level of accessibility within the community may have decreased the SUoHS, and has consequently increased the frequency of behavior in the society. In a qualitative study in Malaysia, availability and inexpensiveness were reported as the factors leading to tendency towards HS [26].

Limitations
We were able to include students from a range of socioeconomic backgrounds, however, the ndings may not represent the views of students who did not participate in the study and may therefore be biased towards students who are more interested in participating scienti c researches. We triangulated our data in the FGD sessions with the data collected during individual interviews to con rm and cross-validate the ndings from different interview methods. However, considering the methodology, social desirability bias may be possible. In order to limit this threat, we selected an interviewer with experience in conducting qualitative interviews and focus groups.

Conclusions
Adolescents in our study described the SUoHS from different dimensions. They perceived the social undesirability of HS in the social disvaluing of the hookah smokers and their behavior, the negative attitude towards the smokers and their families, and the consequences of behavior. The SUoHS originates from the social context of society, and is rooted from the social values and norms within communities. These social values may affect the attitude and subjective norms of individuals toward the behavior.
Adolescents' perceptions on the SUoHS should be considered while designing HS prevention/cessation programs with the hope to bridge the gap between adolescent recognition of the SUoHS and subsequent behavior change. The results of present study can serve as a basis for future studies on the role of the SUoHS in adolescents' tendency towards the behavior. Future studies should consider our results to develop relevant indicators/instruments for measuring the SUoHS among adolescents, with the hope to provide su cient evidence for HS prevention/cessation interventions.

Declarations
Ethics approval and consent to participate This research was approved by the Ethics Committee in Tabriz University of Medical Sciences (ethical approval code: IR.TBZMED.REC.1396.1067). The participants were told about the aim of study and were assured on the con dentiality of data. All participants and one of their parents signed a consent form before data collection.

Consent for publication
Not applicable.
Availability of data and materials