3.1. Hookah-smoking Friends

All study participants [26] identified having hookah-smoking friends as the main reason for the start of hookah consumption. It usually occurs as result of spending time with hookah-smoking friends in cafes. Going to the recreational centers or cafes that serve hookah with friends encourage teenagers or young people to begin smoking hookah.

“Look, I think the first reason for consumption of hookah is having hookah smoking friends. Your friend suggests; let’s go to cafe and even if you don’t smoke, just come and join us. Then you go with them once or twice, but start to smoke at the third time.” (p. 2)

3.2. Blaming Unemployed People in Small Neighborhoods

Unemployment was another important cause of hookah consumption, which was pointed out by the 21 of the participants in the study. The lack of entertainment and recreational activities as well as massive unemployment in the Turkmen region makes people to seek their friends’ company and spend time with them. Therefore, they begin to smoke hookah or continue to consume it. Unemployment causes young people to gather around public places and their village’s squares to have conversation. Meanwhile, they are blamed by other local people for being unemployed. So, to escape from this blaming, they take refuge in hookah cafes to avoid being humiliated by locals.

“When we go to the village and hang around the crossroads, we talk and laugh, so people tell us; what are you doing? And start to blame us. That’s why we come here with friends and sit down, play and laugh.” (p. 10)

3.3. Curiosity and Sense of Adulthood

According to the participants, the curiosity of people was an important reason for the initiation of hookah consumption. Hookah smoking by friends and others, especially the elderly, was new to them and made them curious about it. So, they began to smoke hookah.

Passing through the childhood and entering a turbulent period of adolescence with new sense of adulthood had caused some of them to show their entry to adulthood with risky behaviors such as hookah smoking.

“The most common cause of hookah consumption is curiosity. These kids who just turned teenagers to demonstrate their adulthood or to show their pride and play uncle game, start to smoke hookah.” (p. 4)

3.4. Consumption of Hookah by Family Members

The consumption of hookah by older brother or father was another cause of hookah consumption, which was mentioned by some of the participants. Fathers or brothers were the family members encouraging these individuals to hookah smoking; however, it is expected that other family members such as uncles or grandparents could play the same role if these participants lived with them in the same household.

“I say I became hookah smoker as my father, who was also a smoker; one day brought an antique hookah at home, so this created a favorable ground for my hookah consumption. Bringing a hookah at home meant that he is in favor of hookah smoking. Incidentally, the first time he realized that I smoke hookah, he told me my son let’s smoke together. Then, I put the charcoal and made a fire and suddenly, I saw my brother come out of the room and said; hey, you’re smoking alone. Yes, this will increase the solidarity between the family members.” (p. 19)

3.5. Cultural Influence

Cultural influences and the exchange between different cultures have been identified as the factors leading to the start of the hookah consumption among some of the participants. These individuals claim that hookah consumption was rarely practiced by them in the past.

“The hookah smoking was quite common among the Fars, and now it has spread among the Turkmens. It is all about culture and people start to learn about it, that’s how it spreads among us. I think this is the reason. For example, how was your dressing fashion when you were young? And how is it now? This is the same.” (p. 18)

3.6. Fewer Perceived Risks Compared with Other Substances

According to 23 participants, hookah is not harmful to the health and has less risks than other substances:

“In general, people become interested in hookah as they believe hookah does not have any harmful effect on humans. They also think it has lower-risk than other substances.” (p. 14)

3.7. Hookah’s Sensory Attractions

Many of the participants have become interested in hookah because of its attraction and appearance. For instance, one of the attractions is exhaling the smoke of hookah in the form of a ring.

“Another reason is that, some people come and smoke hookah for the first time because they love to exhale the smoke in the form of a ring; that’s why they start to smoke hookah.” (p. 17)

Some of the participants also referred to the attractive appearance of hookah as a reason for their consumption.

“My brother brought a hookah at home, so I used it too. The hookah was so pretty, so I went and start smoking it. Yes, its appearance was very attractive.” (p. 3)

3.8. Greater Social Acceptance Compared with Other Substances

Greater social acceptance of hookah compared with other substances, such as cigarettes and opium, was among the other reasons for hookah consumption according to the participants. Several participants believed that the social stigma of hookah is lower compared with cigarettes and Nass, and its consumption does not surprise others and the community.

“When you smoke cigarette, your family members say that, look he is smoking and talk behind your back, but hookah is different. Hookah is acceptable socially and is a common practice unlike cigarette. For example, when you smoke cigarette or take Nass, people are fast to talk behind your back, but hookah is not the same. Hookah is normal and does not surprise anybody, so they do not talk behind your back. Furthermore, the government has announced that hookah smoking is not band.” (p. 21)

In addition, 21 of the participants mentioned that usually parents would be content with their children’s hookah consumption because they do not want their children to use other substances, such as opium or cigarettes. For Iranian families, hookah is more acceptable than other tobacco products as well as narcotics.

“Yes, parents do not object their children’s hookah consumption in order to prevent their children use other substances. My parents did not object my hookah consumption and let me freely smoke it. Because they wanted to prevent me from using other substances. They told me, whenever you want to smoke hookah let us know to buy you one, but just smoke it inside the home. They told me I am free to smoke hookah at any time, but I should not touch cigarette or opium.” (p. 3)

3.9. Easy Access to Hookah

Easy and convenient access to cafes or shops serving hookah was another reason mentioned by some of the participants as contributing factors for hookah consumption. The abundance of hookah cafes in the city and even in the villages makes access to hookah easy for people.

“Previously, there were 3 or 4 licensed tea houses in the harbor, but they came and sealed them, and the result: 3–4 tea houses became 400 tea houses.” (p. 9)

4.1. Hookah-smoking Friends

Our findings indicated that all the participants in this study [26] approved that one of the most important reasons for the start of hookah consumption was having hookah-smoking friends. Most of the participants in this study believed that observing friends who use hookah over time have created a positive attitude toward hookah among them. This forces them to start smoking hookah to show their peers that they follow friends’ choices and interests. This finding is consistent with the results of a study by Subramaniam et al. that was conducted on the teenagers and young people in Singapore. Subramaniam et al. [23] discuss that many of the participants in their study believed that hookah smoking is accepted as a normative standard among their group, and they started to smoke hookah because of their sense of belonging to the group and the feeling of shame that they were the only non-alike member of the group. In another study, 90% of students stated that they smoked hookah for the first time at the presence of their family and friends [24].

4.2. Blaming Unemployed People in Small Neighborhoods

The lack of recreational activities and massive unemployment in the Turkmen region forces people to find alternatives to spend their free time. Most participants claimed that they were unemployed and had no entertainment, so they considered hookah as a kind of recreation. The tradition of getting together, especially among adolescents and young people, in front of grocery stores, especially during the evenings and at nights, is one of the traditional conventions for socializing among Turkmen villagers and town dwellers. This kind of gathering is somewhat blamed by adults and elders and they consider these gatherings inappropriate for teenagers and young people. To escape from this negative attitude, young people take refuge in places, such as hookah cafes, where they get together and smoke a hookah. Results of Ghasemi and Sabzmakan’s [25] study on students showed that peer pressure, having hookah-smoking friends, and lack of recreational activities are among the most important factors in tobacco use among students.

4.3. Curiosity and Sense of Adulthood

Curiosity and sense of adulthood was mentioned by a significant number of participants as one of the factors causing the consumption of hookah. This can be one of the most important factors in adolescence. In a study by Subramaniam et al., several participants referred to curiosity as the cause of hookah smoking. Some also referred to the start of hookah consumption as a rebellion against parents and school regulations, believing hookah smoking gives them independence and a sense of adulthood [23]. Some younger consumers believe smoking hookah is giving them a feeling of maturity and masculinity [26,27]. Educational public health programs in the schools should be organized to give information and knowledge to the students and their parents about the long-term health risks of hookah smoking.

4.4. Consumption of Hookah by Family Members

Observing hookah smoking by other family members serves as an action guide and an external stimulus, and makes the younger family members more likely to find a positive attitude toward the hookah and become curious about it and experience it. This is explained in a 2011 study by Griffiths et al. [10], the frequency of observing hookah smoking by relatives and family members results in the reduced embarrassment of smoking and this might even make it a desirable issue. This finding is supported by the results of a study by Rezaei et al. [28] that the consumption of hookah by father or brother increases the chance of hookah consumption by 5.33 and 31.6 times.

4.5. Cultural Influence

One of the influential factors regarding smoking hookah, is how hookah smoking is viewed by society’s culture. This factor is distinctively significant in the Middle East, including Iran [29]. Cultural influence has led to the widespread use of hookah among Turkmen in the past two decades. Turkmens were using Nass or cigarettes in the past and the phenomenon of hookah smoking has been rarely seen among them. The social and economic changes over the past two decades have led to more interaction of Turkmen culture with the dominant culture of society, and the consumption of hookah from the mainstream culture of society has also been transmitted to this subculture. Meanwhile, factors like the media are also effective. Some hookah consumers consider hookah as a hereditary issue and a desirable way to get in touch with other tribes [30–32]. The effect of culture in hookah smoking has been discussed in a study by Madjzadeh et al. In this study, some hookah smokers, especially adults, believed that smoking hookah was rooted in public culture and tradition, and was a social sign of communication in familial and friendly gatherings [33]. Today, the globally oriented hookah has expanded to other countries and cultures [34].

4.6. Fewer Perceived Risks Compared with Other Substances

Participants in this study believed that the fewer perceived risks of hookah compared with other substances are another reason for the start of hookah consumption. This view has been reported in numerous studies. For example, the study by Barnett et al. [35] showed that in the focus group discussion between the group of young people involved in the study regarding the heat of burning charcoal in the hookah, its toxic substances, and the potential risks and side effects, the participants either were lacking knowledge or poorly understood these facts, although they were well aware of the dangers of cigarettes. The result of a study by Griffiths and Ford [36] showed that the participants believed the aroma of tobaccos used in hookah comes from natural plants in them, which in turn makes the tobacco burn better and, consequently, makes hookah tobacco less cancerous than cigarette that contains only pure tobacco. Moreover, the study by Song et al. showed that hookah consumers not only do not understand the long-term risks of hookah consumption but also have little knowledge about the harmful effects of hookahs, which usually comes from invalid sources or unreliable internet resources. They moderate their hookah-smoking behavior and advocate their beliefs about nonaddictive and nonharmful effects of hookah [37]. Hookah is perceived as a less harmful alternative for cigarette smoking [38]. However, not only is hookah not less harmful than cigarettes, but it is also associated with higher risks for respiratory diseases and cancers [39], and in some cases, its damages are more severe [11,39]. Therefore, health communication about the health risk and damages of hookah and more pervasive restrictions on smoking hookah in public places seems necessary [40].

4.7. Hookah’s Sensory Attractions

The result of a study by Castañeda et al. indicates that one of the reasons for the start of hookah smoking among his study population was the sensory perception of hookah, which classified it as “entertainment”. In their study, many participants believed that exhaling the smoke in the form of a ring and seeing the water inside the hookah bubbling are fun and act as visual stimuli for the start of hookah consumption [34]. The result of a systematic review of 10 qualitative studies by Kowitt et al., which aimed to investigate the perceptions and experiences associated with aromatic tobacco products, showed most participants referred to the smell and taste of hookah as pleasant. Also, in two studies conducted in Lebanon and Canada, the participants referred to the taste and smell of hookah as the reason for their motivation to start hookah consumption [29].

In a study in the UK conducted by Kowitt et al. [41], young people also believed that they have been addicted to this smoky product due to the smell and taste of hookah. Fruit fragrances that are added to hookah tobacco promote smoking of hookahs as a healthy choice and hides the real nature of tobacco [42]. The sensory characteristics of waterpipe smoking are important factors in the initiation and continuation of hookah smoking. This is supported in a study conducted by Nakkash et al. in Lebanon. Participants in this study noted the sensory qualities evoked from waterpipe tobacco smoking as reasons that motivated smoking. Men and women equally attributed motivation to the sensory qualities such as taste, smell, the sight of smoke, and bubbly sounds of the water in the bowl [43].

4.8. Greater Social Acceptance Compared with Other Substances

Another reason for the initiation of hookah consumption that was mentioned by participants in many studies was the greater acceptance of hookah by the society than other substances such as cigarettes and narcotics including opium and hashish. The social acceptance of hookah has often been mentioned in many studies [23,29,34]. For instance, the results of a study by Montgomery et al. [44] found that students who perceived hookah more socially acceptable were 21 times more likely to be consumers of hookah. Participants in our study also believed that hookah smoking was socially more accepted compared with other drugs. They pointed out two important aspects that have not been mentioned in other studies. First, the consumption of substances such as cigarettes, Nass, or opium causes consumption stigma and results in the consumer being called names such as smoker, opium or Nass addict, and so on, whereas consumption of hookah does not produce consumption stigma and does not put hookah in the same level as other substances. Second, this acceptance exists with the parents too, and they easily allow their children to smoke hookah to prevent them from using other drugs such as opium, methamphetamine, and cannabis, believing that smoking hookah prevents tendency toward other substances.

This finding is supported by a qualitative study conducted by Moradi et al. on a group of adolescents from the Youth Detention Center in Tehran province. In this study, participant’s parents instead of forbidding hookah use would even offer a better hookah house to their children and they said hookah is not something dangerous [45]. In the study by Moradi et al. [45], cigarettes and hookah have been discussed as “gateway drugs” to prevent consuming other drugs in families with inadequate supervision or with fathers who are drug users. On the other hand, it must be stated that viewing hookah as socially acceptable is not supported by some other studies. For instance, participants in a study conducted by Ahmed et al. [46] in the San Francisco Bay Area, considered hookah smoking as unacceptable and undesirable. This could be related to the socioeconomic difference and geographic location of the participants and their knowledge about health risks of hookah smoking as a result of public educational programs.

4.9. Easy Access to Hookah

Easy access to hookah was another cause for hookah consumption, which was mentioned by many participants in different studies conducted in the past. The rapid growth of hookah cafes, even in villages, has caused people, especially teenagers and younger adults, to have easy access to hookah. Lack of unified governmental policy has failed to control the easy access of young people to hookah. Although at times it has temporarily led to the closure of hookah bars, practically this policy has failed, and now the cafes are easily accessible in every village and town that could be related to the unemployment in the region and lack of recreational facilities. This has resulted in easy access to hookah for teenagers and young people. Even though, according to the regulations, people under the age 18 are not permitted to the hookah bars, unfortunately, there is no regulation or mechanism to prevent access of the individuals under the age 18 to the hookah bars. Numerous studies have discussed that convenient access leads to onset and continuation of hookah smoking. One of the studies conducted by Momenabadi et al. [29] showed that easy access is one of the most important reasons for the initiation of hookah smoking. The result of a qualitative study by Castañeda et al. [34] showed that convenience is one of the main factors in the initiation of hookah consumption so that hookah and its accessories can be found in every shop, even online, or at gas stations. In other studies, one of the main drivers of hookah consumption has been the expansion of hookah cafes. In general, in communities with easy access to tobacco, a high prevalence of smoking is seen as a social norm [5,47].

It must be noted that this study did not recruit any participants from cities such as Maraveh-Tapeh and Kalaleh and the Turkmen living in the province of North Khorasan. This was due to the limited budget and the resources allocated to conduct this study. The results of the present study could be transferred to government officials or research institutes to absorb financial resources to conduct larger studies, design prevention programs, and develop educational programs based on the identified factors causing initiation of hookah especially among youth.