Predictive Factors of Stages of Change in Hookah Smoking Cessation Among Iranian Adults Based on the Transtheoretical Model

Document Type : Original Article

Authors

1 Department of Health Education and Health Promotion, Faculty of Health, Bushehr University of Medical Sciences, Bushehr, Iran

2 Department of Epidemiology and Biostatistics, Faculty of Health, Bushehr University of Medical Sciences, Bushehr, Iran

3 Department of Health Education and Health Promotion, Bushehr University of Medical Sciences, Bushehr, Iran

10.34172/ahj.2023.1347

Abstract

Background: Hookah, as a traditional method of smoking, is widely used in Iran, especially in Bushehr province. It is essential to 
identify the most important determinants of modifying hookah smoking behavior. This study aimed to investigate the predictors of the stages of change in quitting hookah smoking in 15-60-year-old individuals in Bushehr province, southern Iran, based on the 
transtheoretical model (TTM).  
Methods: This descriptive-analytical study was conducted on 1173 Hookah smokers in Bushehr province. The samples were selected by two-stage random sampling from 10 cities. Data were collected using a valid and reliable questionnaire consisting of 5 sections (demographic characteristics, stages of change, processes of change, decisional balance, and self-efficacy). Data were analyzed by R version.3.3.1 using analysis of variance and ordinal logistic regression at a significant level of 0.05. 
Findings: The data revealed 82% of the participants were in the preparatory phase (55.3% in pre-contemplation and 26.7% in 
contemplation stages). Marital status, family members smoking hookah, cigarette smoking, level of education, number of family 
members, number of quitting attempts, self-efficacy, self-reevaluation, counter-conditioning, reinforcement management, and 
stimulus control were predictors of quitting hookah smoking.
Conclusion: Given that most study participants were in the inactive stages of quitting hookah smoking, it seems necessary to design and implement behavioral interventions based on the predictive TTM constructs in this population. 

Highlights

Adel Moqaddas: (Google Scholar) (PubMed)

Mahnoush Reisi: (Google Scholar) (PubMed)

Marzieh Mahmoodi: (Google Scholar) (PubMed)

Homamodin Javadzade: (Google Scholar) (PubMed)

Keywords


1. World Health Organization (WHO). WHO Report on the Global Tobacco Epidemic, 2011. Geneva: WHO; 2011.
2. Burki TK. WHO releases latest report on the global tobacco epidemic. Lancet Oncol. 2021;22(9):1217. doi:10.1016/s1470-2045(21)00464-2.
3. Dehdari T, Jafari A, Joveyni H. Students’ perspectives in Tehran University of Medical Sciences about factors affecting smoking 
hookah. Razi J Med Sci. 2012;19(95):17-24. [Persian].
4. Khodadost M, Maajani K, Abbasi-Ghahramanloo A, Naserbakht M, Ghodusi E, Sarvi F, et al. Prevalence of hookah 
smoking among university students in Iran: a meta-analysis of observational studies. Iran J Public Health. 2020;49(1):1-13.
5. Yousefi F, Darabi H, Nabipour I, Assadi M, Vahdat K, Kardeh E, et al. Prevalence of tobacco smoking in Bushehr province: 
comparison of two phases of the Persian Gulf Healthy Heart Study. Iran South Med J. 2014;17(3):487-95. [Persian].
6. Nemati S, Rafei A, Freedman ND, Fotouhi A, Asgary F, Zendehdel K. Cigarette and water-pipe use in Iran: 
geographical distribution and time trends among the adult population; a pooled analysis of national STEPS surveys, 
2006-2009. Arch Iran Med. 2017;20(5):295-301.
7. Daher N, Saleh R, Jaroudi E, Sheheitli H, Badr T, Sepetdjian E, et al. Comparison of carcinogen, carbon monoxide, 
and ultrafine particle emissions from narghile waterpipe and cigarette smoking: sidestream smoke measurements 
and assessment of second-hand smoke emission factors. Atmos Environ (1994). 2010;44(1):8-14. doi: 10.1016/j.
atmosenv.2009.10.004.
8. Schubert J, Heinke V, Bewersdorff J, Luch A, Schulz TG. Waterpipe smoking: the role of humectants in the release 
of toxic carbonyls. Arch Toxicol. 2012;86(8):1309-16. doi: 10.1007/s00204-012-0884-5.
9. Bhatnagar A, Maziak W, Eissenberg T, Ward KD, Thurston G, King BA, et al. Water pipe (hookah) smoking and cardiovascular 
disease risk: a scientific statement from the American Heart Association. Circulation. 2019;139(19):e917-e36. doi: 
10.1161/cir.0000000000000671.
10. Nguyen V, Salama M, Fernandez D, Sperling JD, Regina A, Rivera R, et al. Comparison between carbon monoxide poisoning from hookah smoking versus other sources. Clin Toxicol (Phila). 2020;58(12):1320-5. doi: 10.1080/15563650.2020.1745225.
11. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: a direct comparison 
of toxicant exposure and subjective effects. Nicotine Tob Res. 2011;13(2):78-87. doi: 10.1093/ntr/ntq212.
12. Jacob P 3rd, Abu Raddaha AH, Dempsey D, Havel C, Peng M, Yu L, et al. Nicotine, carbon monoxide, and carcinogen 
exposure after a single use of a water pipe. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2345-53. doi: 10.1158/1055-
9965.epi-11-0545.
13. St Helen G, Benowitz NL, Dains KM, Havel C, Peng M, Jacob P 3rd. Nicotine and carcinogen exposure after water pipe 
smoking in hookah bars. Cancer Epidemiol Biomarkers Prev. 2014;23(6):1055-66. doi: 10.1158/1055-9965.epi-13-0939.
14. Morovatdar N, Poorzand H, Bondarsahebi Y, Hozhabrossadati SA, Montazeri S, Sahebkar A. Water pipe tobacco smoking 
and risk of coronary artery disease: a systematic review and meta-analysis. Curr Mol Pharmacol. 2021;14(6):986-92. doi: 
10.2174/1874467213666201223121322.
15. Wu F, Chen Y, Parvez F, Segers S, Argos M, Islam T, et al. A prospective study of tobacco smoking and mortality in 
Bangladesh. PLoS One. 2013;8(3):e58516. doi: 10.1371/journal.pone.0058516.
16. Khoramdad M, Vahedian-Azimi A, Karimi L, Rahimi-Bashar F, Amini H, Sahebkar A. Association between passive smoking 
and cardiovascular disease: a systematic review and metaanalysis. IUBMB Life. 2020;72(4):677-86. doi: 10.1002/
iub.2207.
17. World Health Organization (WHO). Tobacco. 2018. Available from: http://www.who.int/news-room/fact-sheets/
detail/tobacco.
18. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. John Wiley & 
Sons; 2008.
19. Kim Y, Kang S, Vongjaturapat N. Application of transtheoretical model to explain adolescents’ smoking behavior. J Subst Use. 
2023;28(2):200-5. doi: 10.1080/14659891.2021.2019328.
20. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Viswanath 
K, eds. Health Behavior: Theory, Research, and Practice. John Wiley & Sons; 2015. p. 125-48.
21. Di Noia J, Prochaska JO. Dietary stages of change and decisional balance: a meta-analytic review. Am J Health 
Behav. 2010;34(5):618-32. doi: 10.5993/ajhb.34.5.11.
22. Collins SE, Eck S, Torchalla I, Schröter M, Batra A. Decisional balance proportion: quantifying qualitative data to represent 
motivation to change among treatment-seeking smokers. Drug Alcohol Depend. 2010;111(1-2):82-8. doi: 10.1016/j.drugalcdep.2010.03.012.
23. Bandura A. Self‐efficacy. In: The Corsini Encyclopedia of Psychology. American Cancer Society; 2010. p. 1-3.
24. Latifi A, Mohammadi S, Barkhordari A, Khezeli M, Khezeli M, Salmani B, et al. Self-efficacy of young adults across stages 
of waterpipe cessation-a model-based cross-sectional study. J Evol Med Dent Sci. 2017;6(92):6545-50. doi: 10.14260/
jemds/2017/1419.
25. Kumar A, Tiwari A, Gadiyar A, Gaunkar RB, Kamat AK. Assessment of readiness to quit tobacco among patients with 
oral potentially malignant disorders using transtheoretical model. J Educ Health Promot. 2018;7:9. doi: 10.4103/jehp.
jehp_75_17.
26. Carlson LE, Taenzer P, Koopmans J, Casebeer A. Predictive value of aspects of the transtheoretical model on smoking 
cessation in a community-based, large-group cognitive behavioral program. Addict Behav. 2003;28(4):725-40. doi: 
10.1016/s0306-4603(01)00268-4.
27. Araban M, Karimy M, Taher M, Baiati S, Bakhtiari A, Abrehdari H, et al. Predictors of tobacco use among medical students 
of Ahvaz university: a study based on theory of planned behavior. J Educ Community Health. 2015;2(1):10-8.
28. Athamneh L, Sansgiry SS, Essien EJ, Abughosh S. Predictors of intention to quit waterpipe smoking: a survey of Arab 
Americans in Houston, Texas. J Addict. 2015;2015:575479. doi: 10.1155/2015/575479.
29. Parashar M, Singh M, Agarwalla R, Panda M, Pathak R. Predictors of intention to quit tobacco among construction site 
workers in Delhi, India. Indian J Psychiatry. 2017;59(2):208-13. doi: 10.4103/psychiatry.IndianJPsychiatry_368_16.
30. Abughosh S, Wu IH, Hawari F, Peters RJ, Yang M, Crutchley R, et al. Predictors of intention to quit cigarette smoking 
among Jordanian adults. Epidemiology. 2011;1(2):103. doi: 10.4172/2161-1165.1000103.
31. Narimani S, Farmanbar R, Kazemnejad Leyli E. Predictors of intention to quit smoking among hospital male staff. J 
Res Health. 2017;7(2):674-81. doi: 10.18869/acadpub.jrh.7.2.674.
32. Martinez E, Tatum KL, Glass M, Bernath A, Ferris D, Reynolds P, et al. Correlates of smoking cessation self-efficacy in a 
community sample of smokers. Addict Behav. 2010;35(2):175-
8. doi: 10.1016/j.addbeh.2009.09.016.
33. Girma E, Assefa T, Deribew A. Cigarette smokers’ intention to quit smoking in Dire Dawa town Ethiopia: an assessment using 
the transtheoretical model. BMC Public Health. 2010;10:320. doi: 10.1186/1471-2458-10-320.
34. Wagner J, Burg M, Sirois B. Social support and the transtheoretical model: Relationship of social support to 
smoking cessation stage, decisional balance, process use, and temptation. Addict Behav. 2004;29(5):1039-43. doi: 
10.1016/j.addbeh.2004.02.058.
35. Ham OK, Lee YJ. Use of the transtheoretical model to predict stages of smoking cessation in Korean adolescents. 
J Sch Health. 2007;77(6):319-26. doi: 10.1111/j.1746-1561.2007.00213.x.
36. Chouinard MC, Robichaud-Ekstrand S. Predictive value of the transtheoretical model to smoking cessation in 
hospitalized patients with cardiovascular disease. Eur J Cardiovasc Prev Rehabil. 2007;14(1):51-8. doi: 10.1097/
HJR.0b013e328014027b.
37. Prochaska JO, DiClemente CC, Velicer WF, Ginpil S, Norcross JC. Predicting change in smoking status for self-changers. 
Addict Behav. 1985;10(4):395-406. doi: 10.1016/0306-4603(85)90036-x.