Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adults: An application of Socio-ecological Model

Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adults: An application of Socio-ecological Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adults: An application of Socio-ecological Model Fatemeh Bakhtari, Nader Alizadeh, Haidar Nadrian, Christoph Augner, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-42202/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Jan, 2021 Read the published version in BMC Public Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background The aim of the present study was to investigate the effects of a multi-level intervention based on the social ecological model on the frequency and duration of hookah smoking among a sample of Iranian adults. Methods In this study, two comparable cities in Iran were selected to participate in an intervention program based on a social ecological model (SEM). In each city, 133 hookah smokers in coffee houses were selected. Environmental changes in coffee houses such as serving light foods and games were conducted. A virtual group named "no hookah" was established on the Telegram application to train participants in the intervention group. Messages, pictures and short videos were sent to the participants through that virtual network. The frequency and duration of hookah consumption were assessed in both groups at baseline and after the intervention. Results The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per session decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Conclusions Using multi-level interventions through a social ecological model can reduce hookah consumption in young people. Health Economics & Outcomes Research Biostatistics Epidemiology Water-pipe Tobacco smoking Socio-ecological model Multi-level intervention. Figures Figure 1 Background Several studies show that the harmful effects of smoking hookahs are even more serious than the disadvantages of smoking cigarettes. Research indicates that smoking hookah can result in health problems such as lung cancer, pulmonary diseases, oral cancers like lip, tongue and cheek cancers, cardiovascular diseases, high blood pressure and chronic respiratory diseases [ 1 ]. The prevalence of hookah smoking across Iran has been reported to be between3.5%[ 2 – 4 ]and 8.2% [ 5 ]. In many in the Eastern Mediterranean Region (EMRO)countries, smoking hookah has reached 20 to 30 percent among adults and its consumption rate among younger individuals is increasing [ 6 , 7 ]. As far as we know, the evaluation of interventions carried out for reducing hookah smoking include a study conducted by Huang et al on the peers influence and the effects of online and offline networks of friends on using narcotics[ 8 , 9 ], a study by Haddad on increasing knowledge through a web-based method[ 10 , 11 ] and Lipkus et al's study on the effect of receiving information on the perception of risk and increase in concern about the harmful effects of smoking hookah[ 12 ], as well as educational behavioral interventions and bupropion use in the countries of Egypt, Pakistan and the United States[ 12 – 14 ]. In all the studies mentioned above, more intervention studies are suggested. Recent researches have focused more on individual behavior and have neglected environmental and social variables. However, recent evidence from Iran shows that environmental and social factors might affect individual's behavior and their choice to smoke hookahs. Such factors include having a friend who smokes hookah, low social support for the individual[ 4 , 15 ], an environment that encourages people to smoke hookahs, lack of healthy entertainment for the youth that can be an alternative to drug consumption, common use of hookahs among families and groups of friends and its being a norm in the public culture[ 16 ]. In addition, due to increase of smoking hookahs it seems necessary to apply appropriate intervention in order to reduce hookah consumption[ 17 ]. In the field of public health, ecological models describe people’s interactions with their physical and socio-cultural surroundings[ 18 ]. Socio-ecological model (SEM) examines the health issue and its determinants with a multilevel approach, from individual and interpersonal levels to organizational and political levels[ 19 ]. In Iran, the SEM frameworks have widely been used to treat different health problems[ 18 , 20 ]. Since the smoking of hookahs has increased among the Iranian youth[ 4 , 16 ] and because a behavior such as smoking hookahs should be considered in a social context, the best way to reduce the spread of using hookahs in the society appears to be the application of widespread social programs as well as the formation of multiple channels of control[ 21 , 22 ]. Up to now, no multi-level interventions have been conducted using SEM analysis. Therefore, in this intervention research study, we aimed to study (1) the conditions of smoking hookahs and (2) to design, apply and evaluate a low cost and multi-faceted intervention program based on a SEM in order to reduce hookah smoking among young adults. Methods This study was a quazi-experimental field study with control group design conducted in the coffee shops of Hashtrud (intervention group) and Qarah-Aghaj (control group) counties in Eastern Azerbaijan province, Iran. The study was conducted in two phases. In the first phase (pre-test), the frequency and the determinants of hookah smoking behavior was investigated based on Socio-ecological model (SEM) to find the significant predictors of the behavior among the participants. Based on the results found at the pre-test phase, a health promotion intervention program was designed and implemented in Hashtrud County, as the setting of intervention. The underlying idea is that interventions should include multilevel strategies focusing on individual behavior, social and environmental levels[ 23 ]. Following aspects were emphasized during intervention group: individual (education based on telegram), social approaches (create social network, social support of peers and reward to decrease hookah use) and environmental levels (changes in coffees). Instrumentation The instruments used in the present study included a demographic data form, three items about the frequency of hookah smoking, hookah use-related individual and social level factors questionnaires and an environmental level factors checklist. The questionnaires applied to assess the individual level factors and perceived rewards(from the social level factors)were developed and validated in a previous study [ 24 ]. To assess validity of the researcher-made instruments, a panel of 10 scholars (in the fields of health education and behavior, sociology, psychology and epidemiology) reviewed and assessed the items, orally, and evaluated the appropriateness and relevance of the items to the participants. They confirmed the items to be representative of the constructs in order to confirm content validity of the instruments. We used the experts’ feedback on the instruments to revise and modify the items. Content Validity Ratio (CVR) with the feature of "necessity" and Content Validity Index (CVI) with two features of "relevance" and "sufficiency of each construct" were measured. In order to examine the utility of the scales and to identify the problems/benefits associated with the design, the instruments were pilot-tested by a sample of 30 hookah users not included in the final study. We used the data to estimate the internal consistency of the scales using Cronbach’s Alpha coefficient. Following consultation with the multidisciplinary team, the first draft was prepared. The demographic data form included age, level of education, marital status, employment status and level of income. The frequency of smoking was investigated applying three researcher-made self-report items. The items were as follow: “In previous 3 months, how many times per week have you smoked hookah?”, “How long is the duration of your hookah smoking per serving?” and “How many cigarettes have you smoked in previous seven days?” The CVI and CVR scores for the items of frequency of smoking were 91.0 and 86.6, respectively. The scales of individual level factors included perceived sensitivity (5 items) and perceived severity (8 items). Examples of the items for perceived susceptibility and severity were "Using hookah will increase my chance for getting lung cancer ", and “Smoking hookah will reduce my chance for getting a suitable job", respectively. Perceived internal and external rewards acquired from hookah use were also investigated applying a nine-item scale. One item, as an example, was "By smoking hookah, I feel that I am grown-up and feel like a man". The triple scales were rated based on a five-point Likert-type scaling (ranging from 1 = totally disagree to 5 = totally agree). The scores of the scales were then summed to acquire a total score. The maximum total score for perceived susceptibility, severity and rewards were 25, 40, and 45, respectively. The higher the scores in the triple scales indicated the higher levels of perceived susceptibility, severity and internal and external rewards among the individuals to smoke hookah. All scales are developed and validated in a previous study in Iran {Sabzmakan, 2018 #1} {Ghasemi, 2015 #45;Sabzmakan, 2018 #152}. Perceived social support questionnaire including 14 items was applied to assess the social level factors. Examples of the subjects presented in the items included “encouraged you not to go to the coffee shops to smoke hookah” and “encouraged you not to smoke hookah”. The response format was based on a 5-point Likert-type scale (from never [ 1 ] to always [ 5 ]). The total score was ranged from 14 to 70. The higher the score, the higher the level of social support was perceived by the individuals to smoke hookah. CVI and CVR values for the scale were 90.64 and 74.42, respectively, and the alpha Cronbach's coefficient was 0.72. A researcher-made 11-item environmental checklist was used to assess the environmental level factors. A dichotomous Yes/No scale was considered as response format. An example of the items in the checklist was "Is there any game/ entertainment tool available in the coffee shop?" Sampling and data collection In order to conduct the study, Hashtrud County was considered as the setting to conduct the intervention. All coffee shops in Hashtrud (11 cases as intervention group) and Qarah-Aghaj (center of Charuymaq County) (7 cases as control group) were selected as the study centers. As primary coordination, the first researcher personally went to the coffee shops and explained to the administrators about the purpose of study and the way it would be conducted at the coffee shops. Then, the purpose of the study was explained to the hookah smokers in the coffee shops and they were invited to participate in the study. Informed consent was obtained from both the administrators and the hookah smokers accepted to participate in the study and all signed consent forms. They were also assured on the confidentiality of their information. Along with data collection, applying the SEM-based questionnaire, the environmental checklist was also filled out based on the observations conducted by the second author. In each County, 133 hookah smokers at the coffee shops were included in the study. The flowchart of the study is illustrated in Fig. 1. The intervention was performed in all Hashtrud coffee shops during eight weeks from January to March, 2017. Inclusion criteria were willingness to quit hookah smoking in the following 6 months, willingness not to refer to the usual coffee shop to smoke hookah in the following 6 months, older than 15 and younger than 35, daily using of Telegram virtual network, and having at least one year of hookah smoking history. Exclusion criteria were using drugs and narcotics other than cigarettes and the tobacco used in hookah, illiteracy, having plans to quit hookah smoking and suffering from psychological disorders or mental problems such as depression. Interventional Program Based on the pre-test data analyses, the problems and weak points at the individual, environmental and social level factors related to hookah smoking were identified. Therefore, the interventional program was designed and implemented as follows: A virtual group named "No to hookah smoking" was established on the Telegram application to train the participants in the intervention group, informally. In order to promote their level of perceived sensitivity and severity, the participants were encouraged to share the group members with text messages, pictures and short videos regarding the outcomes of hookah smoking, health disadvantages of the behavior, the mechanisms via hookah smoking may damage human health, the ways and benefits of quitting hookah use and how to resolve the obstacles, how to alleviate and control the temptation to smoke hookah, and alternatives for hookah smoking in the coffee shops. We initiated a group discussion to talk about the contents. To promote internal and external rewards among the participants, potential alternative rewards that may be achieved by reducing or quitting hookah use were discussed among the group members. The group members were socially supported by the managers of the group and the peers. The members received a variety of informational, emotional, and instrumental support. Group members rewarded each other by verbal encouragements as well as low internet service charges. The resources and costs needed to implement the program included the coffee shops, the cost of internet service provision and the time required to send messages. The key strategies applied to design the program were network-based education, consciousness raising, environmental reconstruction, environmental reevaluation, role modeling, and perceived thread rising. The main processes applied to implement the program were experimental informal teaching methods (incorporating in the virtual social network and discussing the messages in the virtual group and reaching census, problem-solving discussions), discussing the early negative consequences of hookah smoking (e.g., coughs early in the mornings), and revisiting the services provided to customers in the coffee shops. The training team at the group consisted of a public health expert and two researchers of the study (an epidemiologist and a health educationist) who managed the virtual group with 614 members. Also, 11individuals, who used to smoke hookah but have then managed to quit, were included in the group, as lay persons. They played the role of peers in the virtual group and discussed different ways of quitting hookah use with the group members. In order to revise the services provided to customers in the coffee shops we conducted several changes. To help the participants in accessing healthy food choices in the coffee shops, the administrators were requested to have serving desserts and different kinds of drinks and healthy foods like lentil soup, omelet, ice-cream, figs and broad beans. The participants in the coffee shops were also provided with intellectual game accessories (like chess, mensch, and others) as alternative entertainment instruments. Moreover, hookah smoking-related posters and banners with specific focuses were installed in close to the coffee shops. Two weeks after completing the implementation of program, the questionnaires were again completed by the participants in the experimental and control groups. The protocol of the study was approved by Ethics Committee in an Iranian medical sciences university [Ethics code: IR.TBZMED.REC.1396.175]. Data analysis SPSS version 23 was used to analyze the data. Descriptive statistics were calculated to determine mean and standard deviation in quantitative data and frequency and percentage in qualitative data. Independent t-test and Chi-square were used to compare the mean between the groups. Logistic models were used to evaluate the effect of multidimensional intervention on changes in the frequency and duration of hookah consumption by controlling for potential confounders. We used analysis of covariance test to compare the means after adjustment for the dependent variables and potential confounders. Results Participants’ characteristics at baseline are shown in Table 1 . We observed significant differences in some demographic aspects between intervention and control group. Table 1 : Participants’ characteristics in the intervention and the control groups in the first phase of the study (Iran, 2017) Characteristic Intervention (n=133) Control (n=133) P-value Age (years) 26.11± 4.99 31.55± 5.61 <0.001 Marital status Married 40 (30.1) 99 (74.4) <0.001 Single 93 (69.9) 34 (25.6) Education level Middle school 9 (6.8) 9 (6.8) 0.520 High school 68 (51.1) 59 (44.3) Academic study 56 (42.1) 65 (48.9) Employment status Employed 100 (75.2) 125 (94.0) <0.001 Unemployed 33 (24.8) 8 (6.0) Values are presented as number (%) or mean± standard deviation. Comparison of the frequency of tobacco consumption among two groups in the two phases of the study is presented in Table 2 . The frequency of hookah use and the duration of hookah consumption per serving in the second phase of the study compared to the first phase decreased significantly in the intervention group. There were no considerable changes in the control group. Although smoking cigarettes in both groups did not show any significant difference after the intervention. The end part of Table 2 represents comparison of the changes in the frequency and duration of hookah consumption among two intervention and control groups. As shown in this table, the frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per serving decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Table 2 : Comparison of the frequency of tobacco consumption and its changes among two groups of the study (Iran, 2017) Frequency of consumption Intervention group Control group Phase 1 Phase 2 Phase1 Phase 2 Frequency of hookah consumption Once a week or less 24 (18.1) 64 (51.6) 30 (22.6) 28 (21.9) More than once a week 15 (11.3) 47 (37.9) 76 (57.1) 62 (48.4) Once per day 68 (51.1) 8 (6.5) 18 (13.5) 21 (16.4) More than once per day 26 (19.5) 5 (4.0) 9 (6.8) 17 (13.3) P-value <0.001 0.252 Duration of hookah consumption per serving Less than 30 minutes 32 (24.1) 50 (40.3) 9 (6.8) 5 (3.9) 30-60 minutes 56 (42.1) 63 (50.8) 59 (44.4) 62 (48.4) More than 60 minutes 45 (33.8) 11 (8.9) 65 (48.8) 61 (47.7) P-value <0.001 0.536 Cigarette smoking status Never smoker 73 (54.8) 76 (58.5) 73 (54.9) 64 (50.0) Less than 10 cigarette per week 34 (25.6) 19 (14.6) 19 (14.3) 24 (18.8) 10-20 cigarette per week 17 (12.8) 23 (17.7) 27 (20.3) 29 (22.7) More than 20 cigarette per week 9 (6.8) 12 (9.2) 14 (10.5) 11 (8.6) P-value 0.133 0.680 Change in the frequency of hookah consumption Unchanged or increased 34 (27.4) 120 (93.8) Decreased 90 (72.6) 8 (6.3) P-value <0.001 Change in the duration of hookah consumption per serving Unchanged or increased 75 (60.5) 121 (94.5) Decreased 49 (39.5) 7 (5.5) P-value <0.001 Values are presented as number (%). We used two logistic models to evaluate the effect of multidimensional intervention on the frequency and duration of hookah consumption by controlling for potential confounders (differences in the two groups at baseline: age, marital status and employment status). The results indicated that the being in the intervention group increased 72.1 (OR = 72.1, 95% CI: 23.0- 225.7, P < 0.001) and 24.1 (OR = 24.1, 95% CI: 7.5–77.4, P < 0.001) times the odds of decreasing in the frequency of hookah consumption and decreasing in the duration of hookah consumption per serving, respectively. Mean scores according to SEM levels are given in Table 3 . After adjustment for value of the dependent variable in the phase 1, age, marital status and employment status, at the individual level, the mean perceived sensitivity in the intervention group was higher at the end of the study compared to that of the control group. Moreover, the mean perceived severity in the intervention group was higher compared to its rate in the control group. As it is displayed in this table, after adjustment for value of the dependent variable in the phase 1, age, marital status and employment status, at the social level, the mean perceived reward was lower and the perceived social support was higher among intervention group in comparison to participants in control group. Table 3: P ersonal, social and environmental level of SEM before and after of the multilevel intervention between the two groups (Iran, 2017). level of SEM Phase 1 Phase 2 Adjusted* mean for phase 2 P-value Intervention group Control group Intervention group Control group Intervention group Control group Perceived sensitivity 11.7± 2.1 12.6± 2.4 16.2± 1.7 12.9± 2.1 16.5± 1.7 12.8± 2.2 <0.001 Perceived severity 25.9± 3.5 25.2± 3.1 30.6± 2.5 25.5± 3.0 30.5± 2.6 25.6± 3.1 <0.001 Perceived rewards 32.4± 5.6 35.1± 5.2 19.1± 5.2 34.5± 6.1 20.3± 5.1 33.8± 6.1 <0.001 Social support 35.7± 6.4 36.7± 4.0 43.6± 4.4 35.6± 3.6 43.9± 4.5 35.3± 3.6 <0.001 Values are presented as mean± standard deviation. * Adjusted for value of the dependent variable in the phase 1, age, marital status and employment status With regard to contextual changes in coffee houses, it should be noted that in the first phase of the study, from among the 7 coffee houses existing in QarahAghaj city (the control group), only two of them served food before the intervention. From the 11 coffee houses in the intervention group, 5 of them served light food and one had games like chess and mensch. One of the coffee houses in the intervention group was omitted from the study due to the owner's avoidance to cooperate with the researchers during the study. Before intervention, 9.1% of the coffee houses had games and entertainment facilities while such facilities were available in all the coffee houses after the intervention. At the beginning of the intervention, 83% of a total of 6 coffee house owners who provided customers with games and food were satisfied with the changes applied while after the intervention, 100% of the owners of 10 coffee houses were satisfied with the changes. In addition, coffee house owners stated the changes had been effective in raising their income. Control group coffee houses did not show any changes in the level of owner satisfaction or income since environmental variables had remained intact. Discussion The purpose of this study was to determine the effect of an intervention based on an SEM model on reducing hookah use among the youth in the city of Hashtroud. The results indicate that the intervention reduced hookah smoking significantly. Moreover, frequency of hookah use and the duration of smoking hookah in one session showed significant decrease in the intervention group but not in the control group. The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per serving decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Evidence from other studies support our results. An intervention study conducted in Israel resulted in a reduction of hookah smoking of 22.2.% [ 11 ]. In the Lipkus et al study [ 12 ], the effect of the intervention was a reduction of 62% which was almost similar to the result of the present study. Most studies show, that individuals smoke hookah and cigarettes simultaneously [ 4 , 25 , 26 ]. According to the results of present study at baseline about 45% of hookah smokers in both groups were cigarette smoker as well. Thus, it can be stated, that interventions in tobacco use must be designed in a way that reduction in the use of one type of smoking would not lead to increase in the use of another. Consistent with the previous studies[ 11 , 27 , 28 ] there was no significant change in cigarette smoking status between two phases of study in intervention group. The results of this study showed that after intervention, individual level factors in SEM (perceived severity and perceived sensitivity) in intervention group significantly were higher than control group by adjusting for their values in the baseline and potential confounders. Different studies showed that the higher the perceived sensitivity about a particular behavior, the more the individual considers him/herself exposed to illness and the more willingly takes action to create positive behavioral changes[ 25 , 29 , 30 ]. Moreover, the perceived intensity can make health problems caused by smoking serious in the eyes of the individuals regarding their physical, psychological and social effects[ 25 ]. Different studies show that perceived sensitivity and intensity are two of the most important predictors for conducting certain behavior or refraining from doing so [ 25 , 29 , 30 ]. At the social level, in comparison to control group, the adjusted mean of perceived reward in the intervention group considerably was low and the adjusted mean of social support in the intervention group considerably was high. Studies have indicated that the perceived reward gained from substance use including feelings of greatness, pride, etc. is one of the most important factors that predicts such behavior[ 4 , 30 ]. On the same basis, messages whose content was positive perceived reward in order not to smoke hookahs, replaced negative rewards through the telegram virtual network. It may be concluded, that using social networks for sending messages to individuals with positive reward content can have a significant effect on quitting smoking hookahs or reducing its use. Studies show that individuals smoke hookahs with their close friends[ 4 ] and behaviors are normally reinforced inside networks of friends. Moreover, cigarette and hookah users consider smoking an enjoyable social amusement which reinforces the feeling of togetherness among different individuals[ 31 ]. Interestingly, decision to quit smoking is usually not made individually but such decisions are often made by a group of individuals connected with each other directly or indirectly in a network [ 22 ]. According to the ecological approach to the creation of changes at individual and social levels, it is necessary to pave the way for environmental changes and establish such changes. This study showed that effective low cost changes can be made in coffee houses very easily. We conducted the study in Hashtroud and QarahAghaj – small towns with fewer leisure opportunities than larger cities. Thus, coffee houses are accessible and cheap options to be used as places for friendly get-togethers. In coffee houses, drinking tea and smoking hookah are common. The intervention in this study was able to reduce hookah use in the coffee houses an interesting aspect of this study was that changes took place at all levels simultaneously. At the individual level, the perceived sensitivity and intensity was increased. At the social level, the virtual network entitled "saying no to hookahs" was formed. Increase in relations among friends in order to reduce hookah use, change in perceived rewards, and creation of social support through social networks, sending messages and discussions by lay persons and participants in virtual groups simultaneous with environmental changes in coffee houses all resulted in a kind of aggregation in efforts to reduce hookah use. As can be seen in different studies simultaneous changes at different levels can be effective in increasing health behavior [ 23 , 32 , 33 ]. Conclusion The present study was able to reduce hookah use by the creation of environmental changes in coffee houses as well as through the establishment and development of social networks and making use of virtual networks' capabilities to increase social support and perceived reward gained from quitting hookah use and sending messages to change the perceived sensitivity and intensity at the individual level. Therefore, it can be concluded that using multi-level strategy interventions would play a considerable role in reducing hookah use. The results of this study can be useful for policy-makers and consultants in the field of narcotics consumption control as well as researchers in this field. Abbreviations SEM Social Ecological Model EMRO Eastern Mediterranean Region CVR Content Validity Ratio CVI Content Validity Index Declarations Ethics approval and consent to participate Participants completed informed written consent. The protocol of the study was approved by Ethics Committee in an Iranian medical sciences university [Ethics code: IR.TBZMED.REC.1396.175]. Consent for publication Not Applicable. Availability of data and materials The data collection tools and datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Tabriz University of Medical Sciences provided funding sources for this study. Employees of the funder (FBA, NA, HN, AS) participated as scientific collaborators in the study. The findings and conclusions in this paper are those of the authors and do not represent the views of the Tabriz University of Medical Sciences. The funding body has no any role in the design of the study and collection, analysis, interpretation of the data, in writing the manuscript and publication as well. Authors’ contributions FBA and AM are the main investigator and were involved in the study Design. FBA, NA and AM were also involved in the data collection and analysis. FB, CA and HN contributed to the theory and design of the manuscript, and critically revised the final article. All authors read and approved the final manuscript. Acknowledgements The authors would like to greatly acknowledge financial support for this study from Tabriz University of Medical Sciences. They also wish to thank all the participants of this study for their valuable cooperation and participation. References Urkin J, Ochaion R, Peleg A. Hubble bubble equals trouble: the hazards of water pipe smoking. The Scientific World Journal. 2006;6:1990-7. Alwan A. Global status report on noncommunicable diseases 2010: World Health Organization; 2011. Aboaziza E, Eissenberg T. Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence? Tobacco control. 2015;24(Suppl 1):i44-i53. 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What Factors are Associated with Electronic Cigarette, Shisha-Tobacco and Conventional Cigarette Use? Findings from a Cross-Sectional Survey of Australian Adolescents? Substance use & misuse. 2018:1-11. Aljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tobacco induced diseases. 2009;5(1):16. Jamil H, Janisse J, Elsouhag D, et al. Do household smoking behaviors constitute a risk factor for hookah use? Nicotine & tobacco research. 2011;13(5):384-8. Davaji RBO, Shahamat YD, Davaji FH, et al. Patterns, Beliefs, Norms and Perceived Harms of Hookah Smoking in North Iran. Asian Pacific journal of cancer prevention: APJCP. 2017;18(3):823. Sharifi RG, Charkazi A, Shahnazi H, et al. Smoking behavior among male students bases on trans- theoretical model.journal of education and promotion health. 2012; 1 (22). Yan Y, Jacques-Tiura AJ, Chen X, et al. Application of the protection motivation theory in predicting cigarette smoking among adolescents in China. Addictive behaviors. 2014;39(1):181-8. Roohafza H, Sadeghi M, Shahnam M, et al. Social norms of cigarette and hookah smokers in Iranian universities. ARYA atherosclerosis. 2013;9(1):45. Akbari bayatiani A, Gangealivand N, et al. The Investigation of Relationship Between Social Network Size and Physical Health in Parents With Educable Mentally-Retarded Students. Scientific Journal of Ilam University of Medical Sciences 2013 21(5):34-43. Baghianimoghaddam MH, Bakhtari F, et al. The effect of a pedometer-based program improvement of physical activity in Tabriz university employees. International Journal of Preventive Medicine . 2016;7(1):50. Supplementary Files Additionalfile1.docx Additional file 1: Hookah Use Questionnaire Description of data: The validity and reliability of this researcher-made questionnaire have approved in this study. Additionalfile2.docx Additional file 2: Social support for hookah smoking Questionnaire Description of data: This instrument was the researcher-made questionnaire that developed in this study. In the present study to investigate the factors at the social level were used two questionnaires including perceived reward of tobacco use that has been validated in a previous study (24) and the social support for hookah smoking questionnaire that was developed in this study. Additionalfile3.docx Additional file 3 Title of data: Environmental cheklist for coffe shop Description of data: To investigate the factors at the physical environmental level, environmental cheklist for coffe shop was developed and applied in the present study. Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2021 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Minor revision 21 Nov, 2020 Review # 1 received at journal 11 Nov, 2020 Review # 2 received at journal 06 Nov, 2020 Reviewer # 2 agreed at journal 31 Oct, 2020 Reviewer # 1 agreed at journal 27 Oct, 2020 Reviewers invited by journal 24 Oct, 2020 Editor assigned by journal 10 Sep, 2020 Submission checks completed at journal 09 Sep, 2020 Editor invited by journal 09 Sep, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-42202","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":2795992,"identity":"ff6c9a25-5331-47b7-a985-10f6ab9ba090","order_by":0,"name":"Fatemeh Bakhtari","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Bakhtari","suffix":""},{"id":2795993,"identity":"2bc66f92-fe6e-4a1e-91a8-bf045d868cf5","order_by":1,"name":"Nader Alizadeh","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nader","middleName":"","lastName":"Alizadeh","suffix":""},{"id":2795994,"identity":"74a36f1f-4290-412b-89bb-3a9d7d85861b","order_by":2,"name":"Haidar Nadrian","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haidar","middleName":"","lastName":"Nadrian","suffix":""},{"id":2795995,"identity":"c1ce213a-bc2e-4684-a267-21cfdfbed558","order_by":3,"name":"Christoph Augner","email":"","orcid":"","institution":"Salzburg university of medical sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Christoph","middleName":"","lastName":"Augner","suffix":""},{"id":2795996,"identity":"13ab804f-f300-4c72-b843-5e1ebd5afaec","order_by":4,"name":"Asghar Mohammadpoorasl","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYDADPvYGIGlgQYIWNp4DIC0SpGiRSABRRGjhn3b24IOPe+zs2SSfX93wo0CCgb+9OwGvFonbecmGM54lJ7ZJ55Td7AE6TOLM2Q34rbmdYybNc4A5gU06J+0GD1CLgUQufi3yEC31QIedSbv5hxgtBhAthxnbJNiP3SbKFkOwXw4cT2zjyWG7LWMgwUPQL3K3cw8++HCg2p6f/fizm2/+2Mjxt/cS8D4DD5xhgMIlRgv7AyJUj4JRMApGwUgEACcBQ5wFcCWKAAAAAElFTkSuQmCC","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Asghar","middleName":"","lastName":"Mohammadpoorasl","suffix":""}],"badges":[],"createdAt":"2020-07-13 19:02:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-42202/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-42202/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-021-10219-8","type":"published","date":"2021-01-21T15:01:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2687335,"identity":"bd09a68a-9ad3-41e7-9a1a-58c027fb7f22","added_by":"auto","created_at":"2020-09-29 19:31:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":374079,"visible":true,"origin":"","legend":"Flow chart of the study.","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-42202/v1/1.png"},{"id":13596903,"identity":"085ad258-83f9-4e8e-b926-2fdfe39f990d","added_by":"auto","created_at":"2021-09-17 05:30:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":555185,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-42202/v1/dc849f3d-315e-411c-85ba-7fc3a70fdabd.pdf"},{"id":2687337,"identity":"1e60075b-20fc-4198-ad6a-d1f61c0675d9","added_by":"auto","created_at":"2020-09-29 19:31:10","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14031,"visible":true,"origin":"","legend":"Additional file 1: Hookah Use Questionnaire\nDescription of data: The validity and reliability of this researcher-made questionnaire have approved in this study.\n","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-42202/v1/Additionalfile1.docx"},{"id":2687338,"identity":"396804f2-3730-4fba-af0b-2ef35a30cf94","added_by":"auto","created_at":"2020-09-29 19:31:10","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15124,"visible":true,"origin":"","legend":"Additional file 2: Social support for hookah smoking Questionnaire \nDescription of data: This instrument was the researcher-made questionnaire that developed in this study.\n In the present study to investigate the factors at the social level were used two questionnaires including perceived reward of tobacco use that has been validated in a previous study (24) and the social support for hookah smoking questionnaire that was developed in this study. \n","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-42202/v1/Additionalfile2.docx"},{"id":2687339,"identity":"a500eefa-7cb2-415f-832a-0074edc35826","added_by":"auto","created_at":"2020-09-29 19:31:10","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15297,"visible":true,"origin":"","legend":"Additional file 3 \nTitle of data: Environmental cheklist for coffe shop\nDescription of data: To investigate the factors at the physical environmental level, environmental cheklist for coffe shop was developed and applied in the present study.\n","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-42202/v1/Additionalfile3.docx"}],"financialInterests":"","formattedTitle":"Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adults: An application of Socio-ecological Model","fulltext":[{"header":"Background","content":" \u003cp\u003eSeveral studies show that the harmful effects of smoking hookahs are even more serious than the disadvantages of smoking cigarettes. Research indicates that smoking hookah can result in health problems such as lung cancer, pulmonary diseases, oral cancers like lip, tongue and cheek cancers, cardiovascular diseases, high blood pressure and chronic respiratory diseases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of hookah smoking across Iran has been reported to be between3.5%[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]and 8.2% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In many in the Eastern Mediterranean Region (EMRO)countries, smoking hookah has reached 20 to 30 percent among adults and its consumption rate among younger individuals is increasing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs far as we know, the evaluation of interventions carried out for reducing hookah smoking include a study conducted by Huang et al on the peers influence and the effects of online and offline networks of friends on using narcotics[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], a study by Haddad on increasing knowledge through a web-based method[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and Lipkus et al's study on the effect of receiving information on the perception of risk and increase in concern about the harmful effects of smoking hookah[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], as well as educational behavioral interventions and bupropion use in the countries of Egypt, Pakistan and the United States[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In all the studies mentioned above, more intervention studies are suggested. Recent researches have focused more on individual behavior and have neglected environmental and social variables. However, recent evidence from Iran shows that environmental and social factors might affect individual's behavior and their choice to smoke hookahs. Such factors include having a friend who smokes hookah, low social support for the individual[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], an environment that encourages people to smoke hookahs, lack of healthy entertainment for the youth that can be an alternative to drug consumption, common use of hookahs among families and groups of friends and its being a norm in the public culture[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, due to increase of smoking hookahs it seems necessary to apply appropriate intervention in order to reduce hookah consumption[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the field of public health, ecological models describe people\u0026rsquo;s interactions with their physical and socio-cultural surroundings[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Socio-ecological model (SEM) examines the health issue and its determinants with a multilevel approach, from individual and interpersonal levels to organizational and political levels[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In Iran, the SEM frameworks have widely been used to treat different health problems[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince the smoking of hookahs has increased among the Iranian youth[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and because a behavior such as smoking hookahs should be considered in a social context, the best way to reduce the spread of using hookahs in the society appears to be the application of widespread social programs as well as the formation of multiple channels of control[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUp to now, no multi-level interventions have been conducted using SEM analysis. Therefore, in this intervention research study, we aimed to study (1) the conditions of smoking hookahs and (2) to design, apply and evaluate a low cost and multi-faceted intervention program based on a SEM in order to reduce hookah smoking among young adults.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThis study was a quazi-experimental field study with control group design conducted in the coffee shops of Hashtrud (intervention group) and Qarah-Aghaj (control group) counties in Eastern Azerbaijan province, Iran. The study was conducted in two phases. In the first phase (pre-test), the frequency and the determinants of hookah smoking behavior was investigated based on Socio-ecological model (SEM) to find the significant predictors of the behavior among the participants. Based on the results found at the pre-test phase, a health promotion intervention program was designed and implemented in Hashtrud County, as the setting of intervention. The underlying idea is that interventions should include multilevel strategies focusing on individual behavior, social and environmental levels[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Following aspects were emphasized during intervention group: individual (education based on telegram), social approaches (create social network, social support of peers and reward to decrease hookah use) and environmental levels (changes in coffees).\u003c/p\u003e \u003cp\u003eInstrumentation\u003c/p\u003e \u003cp\u003eThe instruments used in the present study included a demographic data form, three items about the frequency of hookah smoking, hookah use-related individual and social level factors questionnaires and an environmental level factors checklist. The questionnaires applied to assess the individual level factors and perceived rewards(from the social level factors)were developed and validated in a previous study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo assess validity of the researcher-made instruments, a panel of 10 scholars (in the fields of health education and behavior, sociology, psychology and epidemiology) reviewed and assessed the items, orally, and evaluated the appropriateness and relevance of the items to the participants. They confirmed the items to be representative of the constructs in order to confirm content validity of the instruments. We used the experts\u0026rsquo; feedback on the instruments to revise and modify the items. Content Validity Ratio (CVR) with the feature of \"necessity\" and Content Validity Index (CVI) with two features of \"relevance\" and \"sufficiency of each construct\" were measured. In order to examine the utility of the scales and to identify the problems/benefits associated with the design, the instruments were pilot-tested by a sample of 30 hookah users not included in the final study. We used the data to estimate the internal consistency of the scales using Cronbach\u0026rsquo;s Alpha coefficient. Following consultation with the multidisciplinary team, the first draft was prepared.\u003c/p\u003e \u003cp\u003eThe demographic data form included age, level of education, marital status, employment status and level of income.\u003c/p\u003e \u003cp\u003eThe frequency of smoking was investigated applying three researcher-made self-report items. The items were as follow: \u0026ldquo;In previous 3 months, how many times per week have you smoked hookah?\u0026rdquo;, \u0026ldquo;How long is the duration of your hookah smoking per serving?\u0026rdquo; and \u0026ldquo;How many cigarettes have you smoked in previous seven days?\u0026rdquo; The CVI and CVR scores for the items of frequency of smoking were 91.0 and 86.6, respectively.\u003c/p\u003e \u003cp\u003eThe scales of individual level factors included perceived sensitivity (5 items) and perceived severity (8 items). Examples of the items for perceived susceptibility and severity were \"Using hookah will increase my chance for getting lung cancer \", and \u0026ldquo;Smoking hookah will reduce my chance for getting a suitable job\", respectively. Perceived internal and external rewards acquired from hookah use were also investigated applying a nine-item scale. One item, as an example, was \"By smoking hookah, I feel that I am grown-up and feel like a man\". The triple scales were rated based on a five-point Likert-type scaling (ranging from 1\u0026thinsp;=\u0026thinsp;totally disagree to 5\u0026thinsp;=\u0026thinsp;totally agree). The scores of the scales were then summed to acquire a total score. The maximum total score for perceived susceptibility, severity and rewards were 25, 40, and 45, respectively. The higher the scores in the triple scales indicated the higher levels of perceived susceptibility, severity and internal and external rewards among the individuals to smoke hookah. All scales are developed and validated in a previous study in Iran {Sabzmakan, 2018 #1} {Ghasemi, 2015 #45;Sabzmakan, 2018 #152}.\u003c/p\u003e \u003cp\u003ePerceived social support questionnaire including 14 items was applied to assess the social level factors. Examples of the subjects presented in the items included \u0026ldquo;encouraged you not to go to the coffee shops to smoke hookah\u0026rdquo; and \u0026ldquo;encouraged you not to smoke hookah\u0026rdquo;. The response format was based on a 5-point Likert-type scale (from never [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] to always [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]). The total score was ranged from 14 to 70. The higher the score, the higher the level of social support was perceived by the individuals to smoke hookah. CVI and CVR values for the scale were 90.64 and 74.42, respectively, and the alpha Cronbach's coefficient was 0.72.\u003c/p\u003e \u003cp\u003eA researcher-made 11-item environmental checklist was used to assess the environmental level factors. A dichotomous Yes/No scale was considered as response format. An example of the items in the checklist was \"Is there any game/ entertainment tool available in the coffee shop?\"\u003c/p\u003e \u003cp\u003eSampling and data collection\u003c/p\u003e \u003cp\u003eIn order to conduct the study, Hashtrud County was considered as the setting to conduct the intervention. All coffee shops in Hashtrud (11 cases as intervention group) and Qarah-Aghaj (center of Charuymaq County) (7 cases as control group) were selected as the study centers. As primary coordination, the first researcher personally went to the coffee shops and explained to the administrators about the purpose of study and the way it would be conducted at the coffee shops. Then, the purpose of the study was explained to the hookah smokers in the coffee shops and they were invited to participate in the study. Informed consent was obtained from both the administrators and the hookah smokers accepted to participate in the study and all signed consent forms. They were also assured on the confidentiality of their information. Along with data collection, applying the SEM-based questionnaire, the environmental checklist was also filled out based on the observations conducted by the second author. In each County, 133 hookah smokers at the coffee shops were included in the study. The flowchart of the study is illustrated in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eThe intervention was performed in all Hashtrud coffee shops during eight weeks from January to March, 2017. Inclusion criteria were willingness to quit hookah smoking in the following 6 months, willingness not to refer to the usual coffee shop to smoke hookah in the following 6 months, older than 15 and younger than 35, daily using of Telegram virtual network, and having at least one year of hookah smoking history. Exclusion criteria were using drugs and narcotics other than cigarettes and the tobacco used in hookah, illiteracy, having plans to quit hookah smoking and suffering from psychological disorders or mental problems such as depression.\u003c/p\u003e \u003cp\u003eInterventional Program\u003c/p\u003e \u003cp\u003eBased on the pre-test data analyses, the problems and weak points at the individual, environmental and social level factors related to hookah smoking were identified. Therefore, the interventional program was designed and implemented as follows: A virtual group named \"No to hookah smoking\" was established on the Telegram application to train the participants in the intervention group, informally. In order to promote their level of perceived sensitivity and severity, the participants were encouraged to share the group members with text messages, pictures and short videos regarding the outcomes of hookah smoking, health disadvantages of the behavior, the mechanisms via hookah smoking may damage human health, the ways and benefits of quitting hookah use and how to resolve the obstacles, how to alleviate and control the temptation to smoke hookah, and alternatives for hookah smoking in the coffee shops. We initiated a group discussion to talk about the contents. To promote internal and external rewards among the participants, potential alternative rewards that may be achieved by reducing or quitting hookah use were discussed among the group members. The group members were socially supported by the managers of the group and the peers. The members received a variety of informational, emotional, and instrumental support. Group members rewarded each other by verbal encouragements as well as low internet service charges.\u003c/p\u003e \u003cp\u003eThe resources and costs needed to implement the program included the coffee shops, the cost of internet service provision and the time required to send messages. The key strategies applied to design the program were network-based education, consciousness raising, environmental reconstruction, environmental reevaluation, role modeling, and perceived thread rising. The main processes applied to implement the program were experimental informal teaching methods (incorporating in the virtual social network and discussing the messages in the virtual group and reaching census, problem-solving discussions), discussing the early negative consequences of hookah smoking (e.g., coughs early in the mornings), and revisiting the services provided to customers in the coffee shops.\u003c/p\u003e \u003cp\u003eThe training team at the group consisted of a public health expert and two researchers of the study (an epidemiologist and a health educationist) who managed the virtual group with 614 members. Also, 11individuals, who used to smoke hookah but have then managed to quit, were included in the group, as lay persons. They played the role of peers in the virtual group and discussed different ways of quitting hookah use with the group members.\u003c/p\u003e \u003cp\u003eIn order to revise the services provided to customers in the coffee shops we conducted several changes. To help the participants in accessing healthy food choices in the coffee shops, the administrators were requested to have serving desserts and different kinds of drinks and healthy foods like lentil soup, omelet, ice-cream, figs and broad beans. The participants in the coffee shops were also provided with intellectual game accessories (like chess, mensch, and others) as alternative entertainment instruments. Moreover, hookah smoking-related posters and banners with specific focuses were installed in close to the coffee shops.\u003c/p\u003e \u003cp\u003eTwo weeks after completing the implementation of program, the questionnaires were again completed by the participants in the experimental and control groups.\u003c/p\u003e \u003cp\u003eThe protocol of the study was approved by Ethics Committee in an Iranian medical sciences university [Ethics code: IR.TBZMED.REC.1396.175].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eSPSS version 23 was used to analyze the data. Descriptive statistics were calculated to determine mean and standard deviation in quantitative data and frequency and percentage in qualitative data. Independent t-test and Chi-square were used to compare the mean between the groups. Logistic models were used to evaluate the effect of multidimensional intervention on changes in the frequency and duration of hookah consumption by controlling for potential confounders. We used analysis of covariance test to compare the means after adjustment for the dependent variables and potential confounders.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eParticipants\u0026rsquo; characteristics at baseline are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We observed significant differences in some demographic aspects between intervention and control group.\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003eTable\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003e1\u003c/span\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003e: Participants\u0026rsquo; characteristics in the intervention and the control groups in the first phase of the study (Iran, 2017)\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eCharacteristic\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eIntervention\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e(n=133)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eControl\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e(n=133)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eAge (years)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e26.11\u0026plusmn; 4.99\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e31.55\u0026plusmn; 5.61\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:203.4pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eMarital status\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:203.4pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMarried\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e40 (30.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e99 (74.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width:203.4pt;border:none;padding:0in 5.4pt 0in 5.4pt;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eSingle\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e93 (69.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e34 (25.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eEducation level\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMiddle school\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e9 (6.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e9 (6.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e0.520\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eHigh school\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e68 (51.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e59 (44.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eAcademic study\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e56 (42.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e65 (48.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eEmployment status\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eEmployed\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e100 (75.2)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e125 (94.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 203.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eUnemployed\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.5in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e33 (24.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1.25in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e8 (6.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003eValues are presented as number (%) or mean\u0026plusmn; standard deviation.\u003c/span\u003e\u003c/p\u003e \u003cp\u003eComparison of the frequency of tobacco consumption among two groups in the two phases of the study is presented in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The frequency of hookah use and the duration of hookah consumption per serving in the second phase of the study compared to the first phase decreased significantly in the intervention group. There were no considerable changes in the control group. Although smoking cigarettes in both groups did not show any significant difference after the intervention. The end part of Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e represents comparison of the changes in the frequency and duration of hookah consumption among two intervention and control groups. As shown in this table, the frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per serving decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group).\u003c/p\u003e\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003eTable\u0026nbsp;\u003c/span\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003e2\u003c/span\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003e: Comparison of the frequency of tobacco consumption and its changes among two groups of the study (Iran, 2017)\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border-right: none;border-bottom: none;border-left: none;border-image: initial;border-top: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eFrequency of consumption\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eIntervention group\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eControl group\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:6.0pt;margin-right:0in;margin-bottom: 6.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ePhase 1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:6.0pt;margin-right:0in;margin-bottom: 6.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ePhase 2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:6.0pt;margin-right:0in;margin-bottom: 6.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ePhase1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:6.0pt;margin-right:0in;margin-bottom: 6.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ePhase 2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eFrequency of\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ehookah\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003econsumption\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eOnce a week or less\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e24 (18.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e64 (51.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e30 (22.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e28 (21.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMore than once a week\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e15 (11.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e47 (37.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e76 (57.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e62 (48.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eOnce per day\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e68 (51.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e8 (6.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e18 (13.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e21 (16.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMore than once per day\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e26 (19.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e5 (4.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e9 (6.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e17 (13.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e0.252\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 3.45in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eDuration of hookah consumption per serving\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.5in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eLess than 30 minutes\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e32 (24.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e50 (40.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e9 (6.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e5 (3.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e30-60 minutes\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e56 (42.1)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e63 (50.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e59 (44.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e62 (48.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMore than 60 minutes\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e45 (33.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e11 (8.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e65 (48.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e61 (47.7)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e0.536\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eCigarette smoking status\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eNever smoker\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e73 (54.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e76 (58.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e73 (54.9)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e64 (50.0)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eLess than 10 cigarette per week\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e34 (25.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e19 (14.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e19 (14.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e24 (18.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e10-20 cigarette per week\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e17 (12.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e23 (17.7)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e27 (20.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e29 (22.7)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eMore than 20 cigarette per week\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 63pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e9 (6.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e12 (9.2)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e14 (10.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e11 (8.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e0.133\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e0.680\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eChange in the frequency of\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003ehookah\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003econsumption\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eUnchanged or increased\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e34 (27.4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e120 (93.8)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eDecreased\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e90 (72.6)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e8 (6.3)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 240.7pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003eChange in the duration of hookah consumption per serving\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eUnchanged or increased\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e75 (60.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e121 (94.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eDecreased\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 121.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e49 (39.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 119.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e7 (5.5)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 221.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 240.7pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height: 115%;\"\u003e\u0026lt;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"border:none;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:200%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:200%;\"\u003eValues are presented as number (%).\u003c/span\u003e\u003c/p\u003e \u003cp\u003eWe used two logistic models to evaluate the effect of multidimensional intervention on the frequency and duration of hookah consumption by controlling for potential confounders (differences in the two groups at baseline: age, marital status and employment status). The results indicated that the being in the intervention group increased 72.1 (OR\u0026thinsp;=\u0026thinsp;72.1, 95% CI: 23.0- 225.7, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and 24.1 (OR\u0026thinsp;=\u0026thinsp;24.1, 95% CI: 7.5\u0026ndash;77.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) times the odds of decreasing in the frequency of hookah consumption and decreasing in the duration of hookah consumption per serving, respectively.\u003c/p\u003e \u003cp\u003eMean scores according to SEM levels are given in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. After adjustment for value of the dependent variable in the phase 1, age, marital status and employment status, at the individual level, the mean perceived sensitivity in the intervention group was higher at the end of the study compared to that of the control group. Moreover, the mean perceived severity in the intervention group was higher compared to its rate in the control group. As it is displayed in this table, after adjustment for value of the dependent variable in the phase 1, age, marital status and employment status, at the social level, the mean perceived reward was lower and the perceived social support was higher among intervention group in comparison to participants in control group.\u003c/p\u003e \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"font-size:16px;line-height:115%;\"\u003e\u0026nbsp;\u003c/span\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eTable\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e3: P\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:16px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eersonal, social and environmental level of SEM before and after of the multilevel intervention between the two groups (Iran, 2017).\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width: 4.9e+2pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003elevel of SEM\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 127.75pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003ePhase 1\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 1.75in;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003ePhase 2\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 1.75in;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eAdjusted* mean for phase 2\u003c/span\u003e\u003c/p\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eP-value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69.45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eIntervention group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.3pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eControl group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eIntervention group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eControl group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eIntervention group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003eControl group\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:16px;font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003ePerceived sensitivity\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e11.7\u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e12.6\u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e16.2\u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e12.9\u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e16.5\u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e12.8\u0026plusmn; 2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003ePerceived severity\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e25.9\u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e25.2\u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e30.6\u0026plusmn; 2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e25.5\u0026plusmn; 3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e30.5\u0026plusmn; 2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e25.6\u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003ePerceived rewards\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e32.4\u0026plusmn; 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e35.1\u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e19.1\u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e34.5\u0026plusmn; 6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e20.3\u0026plusmn; 5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e33.8\u0026plusmn; 6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.15pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:16px;font-family:\"Times New Roman\",serif;'\u003eSocial support\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69.45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e35.7\u0026plusmn; 6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 58.3pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e36.7\u0026plusmn; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e43.6\u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e35.6\u0026plusmn; 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e43.9\u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0.75in;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e35.3\u0026plusmn; 3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin-top:0in;margin-right:0in;margin-bottom:0in;margin-left:0in;text-align:left;line-height:normal;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:12px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003eValues are presented as mean\u0026plusmn; standard deviation.\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin-top:0in;margin-right:0in;margin-bottom:10.0pt;margin-left:0in;text-align:left;line-height:115%;font-size:15px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-size:12px;line-height:200%;font-family:\"Times New Roman\",serif;'\u003e* Adjusted for value of the dependent variable in the phase 1, age, marital status and employment status\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eWith regard to contextual changes in coffee houses, it should be noted that in the first phase of the study, from among the 7 coffee houses existing in QarahAghaj city (the control group), only two of them served food before the intervention. From the 11 coffee houses in the intervention group, 5 of them served light food and one had games like chess and mensch. One of the coffee houses in the intervention group was omitted from the study due to the owner's avoidance to cooperate with the researchers during the study. Before intervention, 9.1% of the coffee houses had games and entertainment facilities while such facilities were available in all the coffee houses after the intervention. At the beginning of the intervention, 83% of a total of 6 coffee house owners who provided customers with games and food were satisfied with the changes applied while after the intervention, 100% of the owners of 10 coffee houses were satisfied with the changes. In addition, coffee house owners stated the changes had been effective in raising their income. Control group coffee houses did not show any changes in the level of owner satisfaction or income since environmental variables had remained intact.\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eThe purpose of this study was to determine the effect of an intervention based on an SEM model on reducing hookah use among the youth in the city of Hashtroud. The results indicate that the intervention reduced hookah smoking significantly. Moreover, frequency of hookah use and the duration of smoking hookah in one session showed significant decrease in the intervention group but not in the control group. The frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per serving decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group). Evidence from other studies support our results. An intervention study conducted in Israel resulted in a reduction of hookah smoking of 22.2.% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the Lipkus et al study [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the effect of the intervention was a reduction of 62% which was almost similar to the result of the present study.\u003c/p\u003e \u003cp\u003eMost studies show, that individuals smoke hookah and cigarettes simultaneously [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. According to the results of present study at baseline about 45% of hookah smokers in both groups were cigarette smoker as well. Thus, it can be stated, that interventions in tobacco use must be designed in a way that reduction in the use of one type of smoking would not lead to increase in the use of another. Consistent with the previous studies[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] there was no significant change in cigarette smoking status between two phases of study in intervention group.\u003c/p\u003e \u003cp\u003eThe results of this study showed that after intervention, individual level factors in SEM (perceived severity and perceived sensitivity) in intervention group significantly were higher than control group by adjusting for their values in the baseline and potential confounders. Different studies showed that the higher the perceived sensitivity about a particular behavior, the more the individual considers him/herself exposed to illness and the more willingly takes action to create positive behavioral changes[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, the perceived intensity can make health problems caused by smoking serious in the eyes of the individuals regarding their physical, psychological and social effects[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Different studies show that perceived sensitivity and intensity are two of the most important predictors for conducting certain behavior or refraining from doing so [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the social level, in comparison to control group, the adjusted mean of perceived reward in the intervention group considerably was low and the adjusted mean of social support in the intervention group considerably was high. Studies have indicated that the perceived reward gained from substance use including feelings of greatness, pride, etc. is one of the most important factors that predicts such behavior[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. On the same basis, messages whose content was positive perceived reward in order not to smoke hookahs, replaced negative rewards through the telegram virtual network. It may be concluded, that using social networks for sending messages to individuals with positive reward content can have a significant effect on quitting smoking hookahs or reducing its use. Studies show that individuals smoke hookahs with their close friends[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and behaviors are normally reinforced inside networks of friends. Moreover, cigarette and hookah users consider smoking an enjoyable social amusement which reinforces the feeling of togetherness among different individuals[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Interestingly, decision to quit smoking is usually not made individually but such decisions are often made by a group of individuals connected with each other directly or indirectly in a network [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the ecological approach to the creation of changes at individual and social levels, it is necessary to pave the way for environmental changes and establish such changes. This study showed that effective low cost changes can be made in coffee houses very easily. We conducted the study in Hashtroud and QarahAghaj \u0026ndash; small towns with fewer leisure opportunities than larger cities. Thus, coffee houses are accessible and cheap options to be used as places for friendly get-togethers. In coffee houses, drinking tea and smoking hookah are common. The intervention in this study was able to reduce hookah use in the coffee houses an interesting aspect of this study was that changes took place at all levels simultaneously. At the individual level, the perceived sensitivity and intensity was increased. At the social level, the virtual network entitled \"saying no to hookahs\" was formed. Increase in relations among friends in order to reduce hookah use, change in perceived rewards, and creation of social support through social networks, sending messages and discussions by lay persons and participants in virtual groups simultaneous with environmental changes in coffee houses all resulted in a kind of aggregation in efforts to reduce hookah use. As can be seen in different studies simultaneous changes at different levels can be effective in increasing health behavior [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThe present study was able to reduce hookah use by the creation of environmental changes in coffee houses as well as through the establishment and development of social networks and making use of virtual networks' capabilities to increase social support and perceived reward gained from quitting hookah use and sending messages to change the perceived sensitivity and intensity at the individual level. Therefore, it can be concluded that using multi-level strategy interventions would play a considerable role in reducing hookah use. The results of this study can be useful for policy-makers and consultants in the field of narcotics consumption control as well as researchers in this field.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial Ecological Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMRO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEastern Mediterranean Region\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent Validity Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eContent Validity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eParticipants completed informed written consent. The protocol of the study was approved by Ethics Committee in an Iranian medical sciences university [Ethics code: IR.TBZMED.REC.1396.175].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot Applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e \u003cp\u003eThe data collection tools and datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eTabriz University of Medical Sciences provided funding sources for this study. Employees of the funder (FBA, NA, HN, AS) participated as scientific collaborators in the study. The findings and conclusions in this paper are those of the authors and do not represent the views of the Tabriz University of Medical Sciences. The funding body has no any role in the design of the study and collection, analysis, interpretation of the data, in writing the manuscript and publication as well.\u003c/p\u003e \u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e \u003cp\u003eFBA and AM are the main investigator and were involved in the study Design. FBA, NA and AM were also involved in the data collection and analysis. FB, CA and HN contributed to the theory and design of the manuscript, and critically revised the final article. All authors read and approved the final manuscript.\u003c/p\u003e \u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors would like to greatly acknowledge financial support for this study from Tabriz University of Medical Sciences. They also wish to thank all the participants of this study for their valuable cooperation and participation.\u003c/p\u003e "},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUrkin J, Ochaion R, Peleg A. Hubble bubble equals trouble: the hazards of water pipe smoking. The Scientific World Journal. 2006;6:1990-7.\u003c/li\u003e\n\u003cli\u003eAlwan A. Global status report on noncommunicable diseases 2010: World Health Organization; 2011.\u003c/li\u003e\n\u003cli\u003eAboaziza E, Eissenberg T. Waterpipe tobacco smoking: what is the evidence that it supports nicotine/tobacco dependence? Tobacco control. 2015;24(Suppl 1):i44-i53.\u003c/li\u003e\n\u003cli\u003e\u0026nbsp; Bakhtari F, Mohammadpoorasl M, Nadrian H,Alizadeh N,Jahangiri L, Ponnet K.. Determinants of hookah smoking among men in the coffee houses: an application of socio-ecological approach. Substance abuse treatment , prevention , and policy. 2020; 15 (62).\u0026nbsp; \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"5\"\u003e\n\u003cli\u003eFakhari A, Mohammadpoorasl A, Nedjat S, et al. Hookah smoking in high school students and its determinants in Iran: a longitudinal study. American journal of men's health. 2015;9(3):186-92.\u003c/li\u003e\n\u003cli\u003eAkl EA, Gaddam S, Gunukula SK, et al. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. International journal of epidemiology. 2010;39(3):834-57.\u003c/li\u003e\n\u003cli\u003eKarimy M, Niknami S, Heidarnia A, et al. Assessment of knowledge, health belief and patterns of cigarette smoking among adolescents. Journal of Fasa University of Medical Sciences. 2011;1(3):142-8.\u003c/li\u003e\n\u003cli\u003eHuang GC, Unger JB, Soto D, et al. Peer influences: the impact of online and offline friendship networks on adolescent smoking and alcohol use. Journal of Adolescent Health. 2014;54(5):508-14.\u003c/li\u003e\n\u003cli\u003eChristakis NA, Fowler JH. The collective dynamics of smoking in a large social network. New England journal of medicine. 2008;358(21):2249-58.\u003c/li\u003e\n\u003cli\u003eRomano PS, Bloom J, Syme SL. Smoking, social support, and hassles in an urban African-American community. American journal of public health. 1991;81(11):1415-22.\u003c/li\u003e\n\u003cli\u003eEssa-Hadad J, Linn S, Rafaeli S. A web-based program to increase knowledge and reduce cigarette and nargila smoking among Arab university students in Israel: mixed-methods study to test acceptability. Journal of medical Internet research. 2015;17(2).\u003c/li\u003e\n\u003cli\u003eLipkus IM, Eissenberg T, Schwartz-Bloom RD, et al. Affecting perceptions of harm and addiction among college waterpipe tobacco smokers. Nicotine \u0026amp; Tobacco Research. 2011;13(7):599-610.\u003c/li\u003e\n\u003cli\u003eMohlman MK, Boulos DN, El Setouhy M, et al. A randomized, controlled community-wide intervention to reduce environmental tobacco smoke exposure. nicotine \u0026amp; tobacco research. 2013;15(8):1372-81.\u003c/li\u003e\n\u003cli\u003eDogar O, Jawad M, Shah SK, et al. Effect of cessation interventions on hookah smoking: post-hoc analysis of a cluster-randomized controlled trial. nicotine \u0026amp; tobacco research. 2013;16(6):682-8.\u003c/li\u003e\n\u003cli\u003eTaraghi Jah S, Hamdiye M, Yaghubi M. Predictor factors of smoking and hookah use in governmental universities. Journal of the Shaheed Beheshti University of Medical Sciences and Health Services. 2011;34(4):249-56.\u003c/li\u003e\n\u003cli\u003eJahanpour F, Vahedparast H, Ravanipour M, et al. The trend of hookah use among adolescents and youth: A qualitative study. J Qual Res Health Sci. 2015;3(4):340-8.\u003c/li\u003e\n\u003cli\u003eMaziak W, Jawad M, Jawad S, et al. Interventions for waterpipe smoking cessation. The Cochrane Library. 2015.\u003c/li\u003e\n\u003cli\u003eBakhtari Aghdam F, Moghaddam MHB, et al. Explaining the role of personal, social and physical environment factors on employed women's physical activity: a structural equation analysis. Global journal of health science. 2013;5(4):189.\u003c/li\u003e\n\u003cli\u003eKrug EG, Mercy JA, Dahlberg LL, et al. The world report on violence and health. The lancet. 2002;360(9339):1083-8.\u003c/li\u003e\n\u003cli\u003eBakhtari F, Nadrian H, Matlabi H, et al. Personal, Interpersonal, and Organizational Predictors of the Mode of Delivery Among Urban Women: A Prospective Study With Socio-Ecological Approach. Clinical nursing research. 2017:1054773817740530.\u003c/li\u003e\n\u003cli\u003eGriffiths MA, Ford EW. Hookah smoking: behaviors and beliefs among young consumers in the United States. Social work in public health. 2014;29(1):17-26.\u003c/li\u003e\n\u003cli\u003eSmith KP, . CN. Social networks and health. . Annu Rev Sociol. 2008;34:405-29.\u003c/li\u003e\n\u003cli\u003eDe Cocker KA, De Bourdeaudhuij IM, Cardon GM. The effect of a multi-strategy workplace physical activity intervention promoting pedometer use and step count increase. Health education research. 2009;25(4):608-19.\u003c/li\u003e\n\u003cli\u003eSabzmakan L, Ghasemi M, Asghari M, Kamalikhah T, Chaleshgar M,. Factors Associated with Tobacco Use among Iranian Adolescents: An Application of Protection Motivation Theory. Substance use \u0026amp; Misuse. 2018;53(9):15111-18.\u003c/li\u003e\n\u003cli\u003eWilliams T, White V. What Factors are Associated with Electronic Cigarette, Shisha-Tobacco and Conventional Cigarette Use? Findings from a Cross-Sectional Survey of Australian Adolescents? Substance use \u0026amp; misuse. 2018:1-11.\u003c/li\u003e\n\u003cli\u003eAljarrah K, Ababneh ZQ, Al-Delaimy WK. Perceptions of hookah smoking harmfulness: predictors and characteristics among current hookah users. Tobacco induced diseases. 2009;5(1):16.\u003c/li\u003e\n\u003cli\u003eJamil H, Janisse J, Elsouhag D, et al. Do household smoking behaviors constitute a risk factor for hookah use? Nicotine \u0026amp; tobacco research. 2011;13(5):384-8.\u003c/li\u003e\n\u003cli\u003eDavaji RBO, Shahamat YD, Davaji FH, et al. Patterns, Beliefs, Norms and Perceived Harms of Hookah Smoking in North Iran. Asian Pacific journal of cancer prevention: APJCP. 2017;18(3):823.\u003c/li\u003e\n\u003cli\u003eSharifi RG, Charkazi A, Shahnazi H, et al. Smoking behavior among male students bases on trans- theoretical model.journal of education and promotion health. 2012; 1 (22).\u003c/li\u003e\n\u003cli\u003eYan Y, Jacques-Tiura AJ, Chen X, et al. Application of the protection motivation theory in predicting cigarette smoking among adolescents in China. Addictive behaviors. 2014;39(1):181-8.\u003c/li\u003e\n\u003cli\u003eRoohafza H, Sadeghi M, Shahnam M, et al. Social norms of cigarette and hookah smokers in Iranian universities. ARYA atherosclerosis. 2013;9(1):45.\u003c/li\u003e\n\u003cli\u003eAkbari bayatiani A, Gangealivand N, et al. The Investigation of Relationship Between Social Network Size and Physical Health in Parents With Educable Mentally-Retarded Students. Scientific Journal of Ilam University of Medical Sciences 2013 21(5):34-43.\u003c/li\u003e\n\u003cli\u003eBaghianimoghaddam MH, Bakhtari F, et al. The effect of a pedometer-based program improvement of physical activity in Tabriz university employees. \u003ca href=\"https://rsf.research.ac.ir/Index.php?itemId=2974\"\u003eInternational Journal of Preventive Medicine\u003c/a\u003e. 2016;7(1):50.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Water-pipe, Tobacco smoking, Socio-ecological model, Multi-level intervention.","lastPublishedDoi":"10.21203/rs.3.rs-42202/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-42202/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe aim of the present study was to investigate the effects of a multi-level intervention based on the social ecological model on the frequency and duration of hookah smoking among a sample of Iranian adults.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this study, two comparable cities in Iran were selected to participate in an intervention program based on a social ecological model (SEM). In each city, 133 hookah smokers in coffee houses were selected. Environmental changes in coffee houses such as serving light foods and games were conducted. A virtual group named \"no hookah\" was established on the Telegram application to train participants in the intervention group. Messages, pictures and short videos were sent to the participants through that virtual network. The frequency and duration of hookah consumption were assessed in both groups at baseline and after the intervention.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe frequency of hookah consumption decreased in 72.6% of participants in the intervention group (vs. 6.3% in the control group); and the duration of hookah consumption per session decreased in 39.5% of participants in the intervention group (vs. 5.5% in the control group).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eUsing multi-level interventions through a social ecological model can reduce hookah consumption in young people.\u003c/p\u003e","manuscriptTitle":"Effects of a multi-level intervention on hookah smoking frequency and duration among Iranian adults: An application of Socio-ecological Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-09-29 19:31:08","doi":"10.21203/rs.3.rs-42202/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-11-22T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-12T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\n2020 Review PUBH-D-20-03434 R1\n\nThe manuscript's focus is critical because the smoke from a hookah contains toxic agents known to cause lung and bladder cancers. Tobacco juices from hookahs irritate the mouth and increase the risk of oral cancers. Also, hookah smoking is common in Iran, and recent studies have found an increasing prevalence of hookah smoking among younger Iranians. The manuscript looked at interventions to address and reduce the popular leisure activity of smoking hookah at coffee shops\n\nAs I started to read the manuscript line by line, I had an immediate concern from my initial review of the article. The manuscript for review PUBH-D-20-03434 R1 included the authors on lines 3 \u0026 4. \nThere is a self-citation on lines 384-386\nBakhtari, F., Mohammadpoorasl, A., Nadrian, H., Alizadeh, N., Jahangiry, L., \u0026 Ponnet, K. (2020). Determinants of hookah smoking among men in the coffee houses: An application of socio-ecological approach. Substance Abuse Treatment, Prevention, and Policy, 15(1), 62. https://doi.org/10.1186/s13011-020-00305-2\nhttps://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-00305-2\n\nPlease see the two direct quotations below- self-citation article\n\"This study was conducted in the coffee houses of Hashtrud and Qarah Aghaj counties in East Azerbaijan, Iran. Data collection was conducted from the entire coffee house (n = 18) from April to June 2017.\"\n\"In addition, given the youth spend their leisure time in coffees, policymakers need to develop interventions to create alternative recreational sites, and also the owners of the coffee houses should provide healthy alternative materials such as healthier foods or healthier recreations that appropriate to regional Iranian culture.\"\nTable 1 Demographic characteristics and their associations with the frequency of hookah consumption among the participants (n = 266)\nPUBH-D-20-03434 R1\nStarting at line 150 the manuscript reads, \"the intervention was performed in al Hashtrud coffee shops during eight weeks from January to March 2017.\"\nHow could the published study making the recommendation do research on healthier foods or healthier recreations be completed after this study which is the main emphasis of the authors of PUBH-D-20-03434 R1 regarding the manuscript's contribution to the body of knowledge? \nAfter comparing the tables of the two papers, additional concern and questions surfaced regarding the study design.\nWhy didn't you randomize the intervention and control groups between the coffee shops in Hashtrud and Qarah-Aghaj?\nWere you concerned about the imbalance of the intervention and control groups, particularly the marital status? Your published paper shows that hookah consumption frequency for single and married participants is significantly different. \nDid you consider the imbalance in phase 1, where the intervention group had 68 once per day hookah smokers and the control on had 18 smokers? \nThe telegram virtual network on line 150 needs to be explained.\nHow did you address the possibility of introducing bias into your study by providing low-cost internet services to your group members on line 175?\nHow did you address the possibility of introducing bias into your study by providing resources to the coffee shops on line 176?\nDid the study pay the coffee shop to provide healthier foods? If the participants are eating, it makes sense that they might not be smoking as much hookah.\nOn line 187 the study mentioned there were 614 members; how did you decide on individuals for the study?\nThere is an in-text citation of line 214; where is the reference?\nTable 2 on line 237. Why is the increase in cigarette smoking of the intervention group not discussed in greater detail?\nOn line 240 you discuss controlling for potential confounders; please expand in greater detail and how this might influence your OR findings. \nThe OR of 72.1 on line 242 needs more clarification. \nPlease explain lines 267-273; what does it mean that 100% of the owners were satisfied with the changes. What changes? Are you meaning receiving games and funding? How did this raise their income? What was the amount of lost revenue due to less hookah smoking at their coffee house?\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests. RK**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-11-07T00:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\n\nPlease overwrite this text when adding your comments to the authors.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **None**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-11-01T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-28T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-10T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9fb6edf9-705a-43ee-82b0-3cb6eef93da2","owner":[],"postedDate":"September 29th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":647491,"name":"Health Economics \u0026 Outcomes Research"},{"id":647492,"name":"Biostatistics"},{"id":647493,"name":"Epidemiology"}],"tags":[],"updatedAt":"2021-01-26T15:04:00+00:00","versionOfRecord":{"articleIdentity":"rs-42202","link":"https://doi.org/10.1186/s12889-021-10219-8","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2021-01-21 15:01:03","publishedOnDateReadable":"January 21st, 2021"},"versionCreatedAt":"2020-09-29 19:31:08","video":"","vorDoi":"10.1186/s12889-021-10219-8","vorDoiUrl":"https://doi.org/10.1186/s12889-021-10219-8","workflowStages":[]},"version":"v1","identity":"rs-42202","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-42202","identity":"rs-42202","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}