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Themes
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Description of themes
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Example quotes
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| 1. Smoking larger amounts of tobacco or over a longer period of time |
Dependence due to increased dosage, intensity, and frequency of smoking WP |
“I am sure that the smoker who smokes two or three WPs daily, or two or three heads in one session, is an addict.”
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| 2. A great deal of time is spent in activities necessary to obtain or use waterpipe |
Considerable amount of time spent smoking WP with friends, within households, or while doing routine activities |
“I have WP at home, at work, at my parents’ home, at my parents-in-law’s home, and at all my friends’ homes, and when I go somewhere else, I have my own WP in the car.”
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| 3. Craving and a strong desire to use waterpipe elicited by social and sensory cues |
Increased urge to smoke WP while at restaurants or cafés, seeing others smoke, after meals, and doing leisure activities |
“After eight o’clock, I need to smoke WP, at home or in the restaurant, it doesn’t matter.”
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| 4. Maintaining WP smoking at any cost |
Accommodating WP smoking in daily routine activities and transitioning from social to solitary smoking behavior |
“At first, the WP was connected with special atmosphere; with time this connection is lost and what remains is the habit. I think that changing from smoking in the restaurants only to smoking in the restaurant and home is an important indicator of dependence.”
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| 5. Tolerance to nicotine and need to increase waterpipe smoking |
Increased WP smoking to achieve desired effects or diminishing effect with continued smoking over time. |
“At first, the smoker enjoys smoking WP, but with time, this feeling fades and disappears.”
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| 6. Risk denial and continued waterpipe use despite adverse physical health or psychological issues |
Experiencing, denying, or minimizing the health-damaging effects of WP |
“I was suffering from serious lung disease, and I was coughing up blood, I could not stop smoking, I believe I am an addict.”
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| 7. Difficulty controlling or quitting waterpipe smoking |
Certain barriers such as feeling addicted, habit, life stressors, wide availability of the WP, and withdrawal symptoms made WP quitting difficult |
“For me it is impossible to quit; the availability of the WP everywhere is a serious obstacle for me, I may quit but as soon as I see someone smoking WP in the restaurant or at home, I will immediately ask for one.”
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