Drivers, Barriers, Maintenance, and Discontinuation of Hookah Smoking Among Women: A Qualitative Study Using Content Analysis Publisher



Hosseini SH ; Rajabzadeh R ; Abbasi B ; Mehri A ; Jafari Y ; Mohaddes Hakkak HR
Source: Emerging Trends in Drugs, Addictions, and Health Published:2026

Abstract

Background: Hookah smoking has become the most widespread form of tobacco use among Iranian women, with a significant upward trend over the past decades. Investigating the complex set of factors that drive the initiation, continuation, and cessation of hookah use in this population is essential for developing effective preventive and intervention policies. Methods: This qualitative study was carried out in Bojnurd, Iran, in 2023, employing a content analysis approach based on the framework of Graneheim and Lundman. Twenty women aged 14 to 46, who actively used hookah, were recruited through purposive and snowball sampling methods. Data were collected using in-depth semi-structured interviews, transcribed verbatim, and analyzed with MAXQDA software. Lincoln and Guba’s criteria, including credibility, transferability, dependability, and confirmability, were applied to enhance the trustworthiness and rigor of the findings. Results: The analysis revealed that women’s hookah use is shaped by interconnected individual, familial, social, and cultural influences. Factors motivating initiation and persistence included the experience of pleasure and relaxation, opportunities for social interaction and friendship, the influence of family members and peer groups, and the appeal of novelty or variety. These drivers contributed to the normalization and acceptance of hookah smoking within daily routines and family or community gatherings. On the contrary, several women reported that personal concerns such as fear and embarrassment, disapproval or objection by their families, and cultural and ethnic values acted as significant inhibitors to starting or continuing use. Maintenance of hookah smoking was often linked to enjoyable emotions, social cohesion, perceived dependence, and the presence of enabling environments, while decisions to reduce or quit were mainly attributed to health concerns, guidance from others to stop, realization of the harmful effects, and deliberate efforts to moderate or control use. Overall, the findings suggest that experiences of hookah smoking among women are dynamic, context-dependent, and influenced by both reinforcing and prohibitive factors at multiple levels. Conclusion: Given the multiplicity and interplay of factors influencing the use and persistence of hookah smoking among women, designing preventive and cessation interventions requires a comprehensive and culturally sensitive approach. Policies and programs should simultaneously address familial, social, personal, and cultural dimensions to increase the effectiveness of tobacco control and harm reduction strategies in this vulnerable population. © 2026 Published by Elsevier Ltd on behalf of International Society for the Study of Emerging Drugs. This is an open access article under the CC BY-NC-ND license. http://creativecommons.org/licenses/by-nc-nd/4.0/