In this study, the average age of the females was 36.5±7.08 and the mean years of WP smoking among them was 10.7 years (SD= 3.26). Other demographic characteristics of the interviewees were shown in Table 2. According to the questions of research, the data analysis resulted in 153 primary codes, which after initial review, first, 101 codes into 6 sub-categories and then into 4 categories of the TPB were placed.
Table 2: Demographic characteristics of the participants
Variable
|
Number
|
Percent
|
Marital status
|
|
|
Single
|
11
|
42.3
|
Married
|
8
|
30.77
|
Windowed
|
2
|
7.7
|
Divorced
|
5
|
19.23
|
Education
|
|
|
Diploma
|
8
|
30.77
|
Associate
|
5
|
19.23
|
Bachelor and Higher
|
13
|
0.50
|
Occupation
|
|
|
Housewife
|
5
|
19.23
|
Unemployment
|
11
|
42.3
|
Staff
|
10
|
38.46
|
Intention to quite WP smoking: Although almost all participants were aware about adverse effects of WP smoking, they did not intend to quit it in that time period. Most of them only wanted to reduce the frequency of it. However, some females expected of themselves, in the future, due to reasons such as marriage or pregnancy would have stopped WP smoking.
"Currently, I have no intention to quit WP smoking. However, I am going to reduce it, and may slowly stop it. I think if I marry or become pregnant, I'm going to quit it” (Single woman, 33 years old, WP smoking for 12 years).
Attitude towards quitting WP: Most participants considered the use of WP enjoyable and pleasant. Although most of them believed that would benefit from quitting WP smoking, they felt its cessation is unpleasant. The females did not have positive attitude toward quitting WP. Many participants believed that WP is less harmful than cigarette to health because they believed that the passing of the smoke through water deletes toxins. They were also willing to smoke flavored WP and believed that it was not harmful and addictive.
" In my opinion, quitting WP smoking may be beneficial, but I don’t really agree with that WP smoking is addictive. So, I think I can quit it anytime that I want. To be honest, I enjoy smoking WP. It gives me pleasant feeling” (Single woman, 24 years old, WP smoking for 10 years).
"I am not thinking about quitting WP smoking right now since I do not feel any risks. I will smoke WP as far as I want unless I feel it hurts me or feel my health is at risk. I don’t think it is bad thing” (A divorced woman, 31-year-old, WP smoking for 10 years).
The category of attitude is formed by sub-categories of behavioral beliefs and outcome evaluation. Therefore, women’s attitudes toward quitting WP smoking were categorized in these two sub-categories as follow.
Behavioral beliefs: On the one hand, most women believed that WP smoking cessation was beneficial and useful to their well-being. For example, they stated the advantages of quitting hookah smoking such as improvement their health, making their skin look better, keeping their respiratory system healthy, making their teeth whiter and healthier, causing them to be more accepted by others, improving heart health, making them a role model for others, and having positive effect on fertility. On the other hand, they claimed that WP smoking relaxed, attracted, entertained, and got rid them of stress and obsessive thoughts, and it was considered a good opportunity for gathering with their friend and family who were hookah smoker. However, few women believed that WP smoking could bring about cancer.
"Quitting WP smoking increases health. If I stop it, my teeth will not change color to yellow, my skin will become look better. One of the advantages is when walking or exercising I will not suffer from shortness of breath. It is even good to my heart. From a social viewpoint, smoking WP is not acceptable” (A married woman, 41 years old, smoking WP for 15 years).
“Quitting WP is even good for my child’s health and makes me look better in front of people. It is also good for people around me since they will not be exposed to secondhand smoking. If I quit WP, I can be a good role model for others” (A divorced woman, 30-year-old, smoking WP for 14 years)”.
Outcomes evaluation: From most participants’ viewpoint, the outcomes associated with WP smoking cessation were evaluated positive. For example, they believed quitting WP smoking had positive consequences such as improving health and bringing about social acceptability. However, most women felt that quitting WP smoking was associated with lack of pleasure, calm, as well as losing gathering with family members and peers who smoked WP. Therefore, these disadvantages were judged negative by most hookah users.
"Being healthy and having healthy lungs, beautiful skin and teeth and a health fertility are important to me. But, the most important disadvantage of cessation is losing gathering with peers and family when smoking WP. It is also important to me that I would lose the pleasure that I experience when smoking WP because I have no problem right now, I do not want to quit it "(Single woman, 26 years old, WP smoking for 4 years).
"Health is important to me. The only downside of stopping WP is that I loss fun and company with my friends. Also, when people ask me to smoke WP with them, if I do not follow them, I may miss them or is mocked by them” (A married woman, 27 years old, WP smoking for 5 years).
Subjective norms: Although some participants stated that their parents or peers who were not hookah smoker encouraged them to quit WP smoking, the majority of WP users claimed that their family members (parents, sibilants, and spouse) and peers smoked WP and did not ask them to quit hookah smoking. Therefore, most females under social pressure be encouraged to smoke WP and not be motivated for cessation.
"My mother hates WP smoking and advises me to quit it because she believes that it is harmful for me. But some of my sisters and brothers and a lot of people around me smoke WP” (A widowed woman, 30-year-old, WP smoking for 14 years)".
"My father does not like me to smoke WP, and I try not to smoke WP in front of my father. Also, one of my sisters disagrees with my WP smoking. However, my husband, another sister and some of my relatives consume WP” (Married women, 41-year-old, WP smoking for 15 years)
The category of subjective norm consists of sub-categories of normative beliefs and motivation to comply. Therefore, perceived social pressure were categorized in these two sub-categories as follow.
Normative beliefs: Most participants stated that among family members, peers, and relatives, their family members, who did not use WP, were more likely to encourage them for quitting WP smoking. However, many women, who their family members and peers were WP smoker, stated that the behavior of WP smoking was approved by them, so the participants did not have a role model to quit WP. In addition, most participants stated that their smoker peers played a vital role in continuing WP smoking.
"Around me, a lot of people smoke WP; my sisters, many of my friends, and some relatives especially when we get together, and as far as I know, none of them intends to quit WP smoking” (Single woman, 24 years old, WP smoking for 7 years).
Motivation to comply: Although some participants said that family members’ advice especially their parents was important to them, they were not following their advice. Almost all females were willing to smoke WP and stated a little bit motivation to comply with significant others ‘expectations. Only a few of them tried to smoke WP outside home at the request of family members. In addition, they believed that even if people around them, who smoked WP, stopped WP smoking, it would not influence their behavior. As a result, most participants were not paying great attention to significant others ‘expectation and maintained that would quit WP smoking only when they wanted.
"I don’t stop WP smoking unless I want, even if my family or my husband asks me to do. I should myself realize that WP smoking is not good for my health and decide quitting it. Others expectation for cessation is not useful to me and I do not care them” (A married woman, 27 years old, WP smoking for 3 years).
“I try to not smoke anywhere because of people’s gossip. For instance, I do not smoke WP in front of my relatives or parents. I do not follow anyone as role model to quit unless I decide that I want to quit” (Single women, 33 years old, WP smoking for 15 years).
Perceived behavioral control: A lot of women felt a high self-efficacy for cessation and though that were able to quit the use of WP anytime they wanted. Indeed, they believed that quitting WP smoking was up to them. In addition, most women believed that WP smoking was not addictive, so its cessation would not be difficult and did not think quitting WP was beyond their control. However, some women felt several factors hindered hookah smoking cessation. For example, when the females were tempted, they could not resist WP smoking.
"I see a lot of ability in myself to quit WP smoking and whenever I want, I will quit it without difficulty. But I might sometimes get tempted again”. (Single woman, 22 years old, smoked for 6 years).
"I have high ability to quit hookah because it is just fun for me and an excuse to get together with friends, but I am able to quit it if I want” (A widow woman, 31-year-old, smoked hookah for 10 years).
The category of perceived behavioral control comprises sub-categories of control beliefs and control power. Therefore, women ‘perceptions about how to deal with the obstacles and whether quitting WP smoking is easy or difficult were categorized in the two sub-categories as the following.
Control beliefs: Almost all participants believed that their willingness for cessation was more important than other factors. However, they pointed out that some obstacles for cessation such as lack of laws that prohibited WP smoking in public places, lack of awareness and education about adverse effects of WP smoking, having peers or family who smoked WP or approved its use, the existence of hookah cafes and restaurants, having easy access to water-pipe in anywhere, lack of beneficial recreational activities, more prevalent its use in today’s society especially among women, psychological dependency, socio-psychological problems such as unemployment, stress, and nervousness. Also, having false beliefs such as WP was not addictive and harmful were mentioned as other barriers.
"There are a vast number of hookah cafes, and one can have easy access to WP at their home. I smoke WP when I am upset or nervous. I remember when I heart break; I used to smoke WP every day. All these reasons discouraged me from quitting WP smoking” (Single woman, 28 years old, WP smoking for 4 years).
" Divorce, unemployment, and financial problems cause to go towards WP smoking. I am unable to find solutions for my problems. So, the use of WP is the easiest way to calm myself down” (Single woman, 33 years old, WP smoking for 11 years).
Control power: The participants believed that were able to control more obstacles of quitting WP smoking. However, they pointed out that some barriers were related to organization and community levels and the government and policymakers were responsible for solution them. Some of these barriers were lack of beneficial recreational activities in the community, the existence of hookah cafes and restaurants, having easy access to water-pipe, socio-psychological problems and lack of efficient educational programs.
"We women cannot control some problems. The government is responsible. For example, I and many my friends who smoke WP are unemployed and staying at home. Some my friends are divorced. Some of them have a lot of conflicts with their husband because of financial problems or cheating in their relationship. In addition, people do not have access to beneficial and inexpensive recreational activities. As you know, hookah smoking is an accessible and low-cost fun, so it is considered as a good replacement in these situations. It gathers people and helps to forget their problems” (Single woman, 34 years old, WP smoking for 23