Assessing Risk Factors for Hookah Smoking in Adolescent Girls: An Application of the Prototype Willingness Model (PWM)

Hookah smoking (HS) among teenagers, especially girls, has been increasing in recent years in Iran. This phenomenon not only threatens the physical and mental health of adolescents but also brings significant social and economic costs (1). The importance of this issue becomes even more evident as research indicates that the adverse effects of HS could be more pronounced in women compared to men in some aspects (2).

Various concepts and determinants influence the tendency toward HS, among which a positive attitude toward it is one of the key factors and may serve as a stronger predictor (3, 4). In some studies, subjective norms, behavioral intention, and a person's perceptions of hookah and people who smoke hookah have been mentioned as predictive factors in HS (5, 6). Several theories and models have been used to understand the reasons behind hookah use among teenagers, but none have been able to fully explain all aspects of it due to its multifactorial causal nature. In this regard, a collection of models and patterns in health education and health promotion have addressed the issue of hookah use (7).

When individuals consider engaging in risky behavior, such as smoking hookah, they weigh all aspects of the behavior before deciding whether to proceed or not. In this decision-making process, false beliefs about hookah, such as it being less harmful and the idea that water filters out toxins, can lead individuals to underestimate the risks, thereby encouraging them to engage in the behavior (8). In the second case, the person performs the risky behavior without any rational intention and decision, based only on imaginations, desires, and special circumstances that have arisen. The prototype willingness model (PWM) addresses this issue (6).

The PWM model consists of several constructs, including attitude, subjective norms, prototype perceptions, willingness, intention, and behavior (6). This model, proposed by Gibbon et al. (9), states that the intention to perform a behavior is predicted by two factors: (A) attitude, which is a person's positive or negative evaluation of performing a behavior, and (B) subjective norms, which are the social pressures perceived by the person to perform or not perform the target behavior. Furthermore, in this model, the framework of prototype perceptions — or the mental images individuals have of those who engage in risky behaviors — shapes behavior by influencing their willingness to act. The effectiveness of this model has been confirmed in some studies (10).

Despite the importance of HS, comprehensive and in-depth studies are inadequate in Iran to examine the reasons and motivations behind this behavior in adolescent girls. Iranian culture and social norms shape the factors influencing adolescent behavior in a way that differs from other societies. Given the need to identify the determinants of HS behavior, this study was designed and conducted.

The aim of this study was to determine the predictors of HS among girl students based on the PWM.

Most of the students were 17 years old and were enrolled in humanities or experimental sciences. Most of the parents had a high school diploma, and the father's occupation was self-employed. According to the findings, 10.56% of the students had smoked hookah in their lifetime, and 5.6% had smoked hookah in the past year. Part of the descriptive results of this research has been presented elsewhere (11). The data related to the structure of the model will be explained in the following tables.

Table 1 indicates that participants who had tried hookah before showed a significantly greater intention to continue smoking hookah compared to those who had never tried it (P < 0.01). However, the willingness to quit hookah did not differ significantly between participants with and without prior experience of using it (P = 0.123).

Table 2 indicates that both intention and willingness were related to hookah use behavior, after controlling for prototype perceptions. Specifically, as intention increased, the likelihood of using hookah also increased. Willingness also had a positive correlation with hookah use, but its impact was weaker compared to intention.

Table 3 demonstrates that both attitude and subjective norms were significantly associated with intention. Between these two variables, subjective norms had a stronger association, as indicated by its larger standardized beta value (B = 0.369). However, because the R² value was low (R² = 0.394), these variables (attitude and subjective norms) were not strong predictors of intention overall.

Table 4 indicates that attitude, subjective norms, and prototype perceptions were all significantly related to willingness. Among these three factors, subjective norms had the strongest association, as shown by its higher standardized beta value compared to the other two variables (B = 0.172). However, since the R² value was low, these three variables (attitude, subjective norms, and prototype perceptions) were not strong predictors of willingness overall.

Table 5 shows that the variance of those who are offered hookah by friends is 6.07 times greater than those who do not receive this offer (P = 0.002).

The findings of this study underscore the critical roles of subjective norms, attitude, and prototype perceptions in shaping hookah consumption behaviors among adolescent girls, mediated through their correlations with intention and behavioral willingness. These results align with the PWM but also reflect unique cultural dynamics specific to Kermanshah’s sociocultural landscape. In Iran, where familial and societal expectations may heavily affect adolescent behavior (12-17), subjective norms such as peer approval or familial acceptance of hookah use may carry disproportionate weight. For instance, HS is often socially normalized in certain gatherings, particularly in urban settings, despite its health risks (18). This cultural ambivalence creates a conflict between perceived social rewards and health-related prototype perceptions, a tension amplified by gendered norms that scrutinize adolescent girls’ behaviors more intensely than boys’ (18).

Furthermore, the influence of familial and societal expectations on adolescent hookah use must be contextualized within geographical disparities observed across Iran. A recent study highlights significant regional variations, with certain provinces reporting markedly higher rates of hookah consumption. This geographical divergence suggests that localized cultural norms and socioeconomic conditions may exacerbate or attenuate the social dynamics previously discussed (19).

Attitudes toward hookah use are often shaped by misconceptions about its harmfulness compared to cigarettes, a phenomenon documented in studies highlighting the role of media and social networks in perpetuating these beliefs (20). The interplay between low prototype perceptions and positive social reinforcement may explain why intentions to abstain fail to translate into behavioral resistance, particularly in contexts where hookah is framed as a marker of social cohesion or maturity.

This study’s emphasis on cultural context is pivotal. For example, the collectivist nature of Iranian society, where group conformity often overrides individual health decisions, may amplify the association of subjective norms. Interventions targeting hookah use among Iranian adolescent girls must therefore address these culturally embedded drivers, e.g., through community-based campaigns involving family members and leveraging religious leaders to reframe social narratives (21).

The family interaction theory proposed by Brook also emphasizes the importance of the parent-child bond as a protective factor. It highlights three key aspects of parenting that contribute to healthy child development: Positive emotional bonding, consistent rules, and flexibility. A supportive and nurturing home environment is essential for adolescent well-being (17). Individuals' experiences and positive interactions with people who refrain from using hookah can positively influence their perceptions of hookah abstinence. These experiences can lead to a more positive evaluation of abstaining from hookah use and a greater willingness to engage in this behavior in the future (18).

The behavioral analysis presented in Table 2 demonstrates that both intention and willingness are associated with hookah use behavior. The results indicate that intention is the strongest predictor of hookah use behavior (OR = 1.99, P < 0.001). This finding is consistent with psychological models such as the theory of planned behavior (TPB), which emphasizes intention as a key determinant of behavioral engagement (22). A one-unit increase in intention nearly doubles the likelihood of hookah use, underscoring the critical role of cognitive planning in health-related behaviors. This suggests that interventions aimed at reducing hookah consumption should focus on modifying attitudes and reinforcing intentions to abstain.

Contrary to expectations, willingness exhibited a weaker association with hookah use (OR = 0.836, P = 0.028). This result implies that willingness alone may not be a robust predictor of behavior and could be mediated by external factors such as social norms or accessibility. The analysis controlled for prototype perceptions, revealing that intention and willingness remain significant predictors even after accounting for these factors.

The results of this study highlight the necessity of developing targeted communication strategies that underscore the dangers of hookah use, particularly to elevate risk perception among high school-aged girls. Empirical evidence indicates that interventions focusing on modifying beliefs, attitudes, and behavioral intentions toward hookah consumption can significantly shape usage patterns (23).