Data collection

Data were collected through individual semi-structured interviews and focus group discussions. The main question was: ‘what triggers the consumption of nass?’. Three focus group interviews were also carried out to examine group, social and cultural dynamics of participants in their natural environments⁹. Interviews were done in public places, such as in front of shops. Interviews were continued until data saturation was reached (no new information was obtained). All interviews were carried out by the first author who is a Turkmen. Interviews were done in the Turkmen language. On average, each interview took half an hour; and each focus group discussion lasted an hour. Before each interview, the purpose of the interview was explained to the participants and they were assured that the interviews will not have any negative effect on them. The participants were also told that they did not need to disclose their names and could terminate the interview and withdraw from the study at any time without being asked for a reason. Participants were assured that the collected information would be kept confidential. All interviews were audio recorded and transcribed to text in the Turkmen language, as soon as possible. Upon completion of the interview, participants were given a mobile phone charge worth 50 thousand Rial (about US$0.5) as a token of appreciation for their participation in the study.

This study, with the project number: 9504010770 and code of ethics IR.GOUMS.REC.1395.86, was approved by the Ethics Committee of the Research and Technology Department of the Golestan University of Medical Sciences.

Data analysis

Themes contributing to nass consumption were extracted through conventional content analysis. Statistical software MAXQDA, Version 10, was used to manage the codes. To avoid loss of meaning through translation, analyses were done in the Turkmen language.

Cultural, social and environmental facilitators

Cultural background was described as one of the factors contributing to nass consumption. People become familiar with nass as they watch their elders use it. One of the participants stated: “nass has traditionally been here and people have been using it. We see our elders use it and we learn from them. Youngsters see it in their elders’ hands and they learn.” (Participant No.12 or P.12).

Easy and convenient access to nass was another contributing factor to its consumption. In those areas, one could easily find nass in any store. Another participant said: “You know, it is very accessible. Wherever you go you can see it in shops [and you can buy it] without any restrictions. It is easy to obtain. For example, you do not need to go to a dealer’s house or see anyone else. It is easy to get. A Japanese proverb says ‘for a Samurai, everywhere is Japan’, we say ‘for a nass user, nass is everywhere’.” (P.22).

When non-users of nass frequently interact with nass consumers, they become curious. Easy access to nass and the sense of curiosity due to frequent observation of its use by others could contribute to initiating nass consumption. “This is Turkmen-Sahra and all Turkmen use nass. You see it in the hands of others and you become curious. So you say to yourself, let’s try it to see what it is. That’s how I started using it.” (P.24).

The lower price of nass compared to cigarettes also boosts people’s tendency to start using it. On the other hand, a pack of nass lasts much longer than a pack of cigarettes; therefore, it is more economical to use nass. “A pack of nass is 500 Toomans, which is more economical than cigarettes, right? You buy a pack of cigarettes for two thousand Toomans and that may last for a day. But a package of nass that you buy for 500 Toomans may last you for three to four days.” (P.3).

Offering nass to friends is a common practice among Turkmen. Some participants claimed that they started using nass since it was offered to them by their friends: “Suppose someone is using it now and tells you ‘come on do you want to use some? Take some’. This is a common practice among Turkmen, and is like a tradition. Even if you have used some a few minutes ago, they say ‘come on, let’s use some together’. Nass is not something strange among Turkmen and they recommend it to each other.” (P.32).

Also, when one starts using nass he may initially suffer from gastrointestinal problems, such as nausea and vomiting. Other common side effects are confusion and severe dizziness. Therefore, some experienced nass consumers tell adolescents and young people, who have not used nass before, that consumption of nass is not for everyone, and if they use it they won’t be able to tolerate the side effects. Sometimes, instead of discouraging, such comments challenge the young people to prove their strength and endurance, hence they start using nass to show that they are capable to do so. “In our village there is a shop which is known as a distribution center for nass. When you use nass for the first time, it makes you dizzy. Kids gather in front of the shop and bet on who can keep Afghan nass under his tongue for a longer time. So whoever keeps it in his mouth longer is the winner and the looser must fill the belly of the winner. It means that, the winner eats whatever he wants from the shop and the looser must pay for it.” (P.1).

Social factors, such as high unemployment rate and lack of proper recreation facilities in the area, were among other causes of nass consumption. “I say that, unemployment and lack of healthy recreation centers are the reasons for nass consumption. I think it is unemployment, because they are all unemployed and hang around here and there. Especially in villages like our village people are more likely to use it. You know, in big cities, you are busy with this and that. There may be nass in cities too, but it is less than here. Here, its percentage is too high.” (P.10).

Lack of crackdown and restriction by the government, on production, supply and use of nass, was considered another factor facilitating nass consumption. “We do not have a proper government. If it was a decent government, it would have arrested all these opium dealers and put them in jail. It would have stopped all these new drugs and crimes. This is not the country of Turkmenistan; over there they quickly arrest the dealers and put them in jail. In Turkmenistan who can show nass to a government official?! They punish you. The use of nass and cigarette is forbidden, never mind opium and spirit; if they catch you with them, you will be punished. They do not allow you to use nass and cigarettes.” (P.26).

Alternative to smoking

Many participants said they use nass to help them quit smoking cigarettes. They mentioned the health of their families and friends as their reason for using nass instead of cigarettes. “I used to smoke cigarettes but I can’t smoke anymore because of my wife and children. You are the one who smokes, but it harms the people around you. If you draw on a cigarette and send half of its smoke into your lungs and exhale the other half, that is something. But if with every draw on your cigarette, you exhale all the smoke out, that is something else; that will harm your wife and children significantly.” (P.7).

Lack of odor was another reason for consumption of nass. The participants considered the smell of cigarette smoking very annoying. Nass, however, does not have any odor or its smell is negligible. “I use it because it does not smell like a cigarette; that smell that stays with you anywhere you go.” (P.19).

According to the participants, unlike cigarette, nass consumption does not require special preparation. Also, it can be used indoors. Nass can be consumed very quickly, in a matter of a few seconds, and it does not attract others’ attention like cigarettes do. One participant stated: “Using nass is much easier than using cigarettes because when you smoke a cigarette everybody can see you. For people like me, who do not smoke in front of their fathers and uncles out of respect for them, nass is a very good alternative. I personally know some people in the village who use nass and almost no one is aware of that.” (P.3).

Intensifying the effect of opium and other drugs

Simultaneous addiction encourages nass consumption. Participants believed that consumption of nass after taking opium, alcohol, or Tramadol, intensifies the effect of these substances, sometimes doubling or tripling their effect and the accompanying pleasure. “Because when you take drugs your mouth dries up and nass remains in your mouth longer and does not melt. Yeah, when you use nass after drug, it gives you a certain feeling; it’s like you are floating. In other words it doubles the euphoria.” (P.10).

Believing that nass prolongs the effect of opium and causes the euphoria to last longer was another contributing factor mentioned by the participants: “You know, the use of nass doubles the effect of opium. Usually one or two hours after the use of opium its effect starts to wear off. To overcome this, people use nass. They do this twice or three times until opium completely wears off and they have to use it again.” (P.3).

Special occupations and job environments

Participants claimed that certain occupations and job environments, including fishing, truck drivers and military service, encourage nass use. Illegal and unlicensed fishing from the Caspian Sea is common in those areas. “The job of most people here is fishing, [where] they work in the sea. You cannot smoke cigarette when you have gone fishing illegally, you will get spotted and caught because of the cigarette light. Instead, they use nass which is smokeless and reduces the chance of being caught. For example, you are in a boat waiting for fish to catch, if you light a cigarette, you will be spotted. So you tell yourself ‘I cannot smoke cigarette till morning, so let’s use some nass instead.’ If you light your cigarette in the night, you will be captured by the guards.” (P.8). Many people had started consuming nass while on military service. They believed that nass keeps you warm and helps you stay awake at night. “When it was my turn to guard at night time, I put some nass in my pocket before heading to my post. When you use nass, particularly in cold weather, you feel stronger against cold. It also keeps you awake and more alert.” (P.27).

Nass consumption was very common among truck drivers and their helpers. In those areas, the weather is warm during the harvest season of June and July. Therefore, truck drivers and their assistants prefer to use nass instead of cigarettes to prevent the potential danger of fire caused by careless use of cigarettes or improperly discarded cigarette butts. “I started using nass when I became a truck driver and during the first harvest season. Well, I was smoking prior to that time and people advised me not to smoke while driving a combine because it may cause fire and burn the products. So, my colleagues suggested that I use nass instead and that is how I started using nass.” (P.16).

Beliefs related to nass

Some people had strong views and beliefs about nass, including its remedial effects; and such beliefs had motivated them to start using nass. For instance, nass is recommended by some older people as a remedy for toothache. “I was a teenager, about 12 or 13 years old, and one night I had a severe toothache and my grandfather, who was a nass user, gave me nass to stop my toothache.” (P.12).

Some participants believed that nass gives them the feeling of mental relaxation and comfort, and considered that to be the reason for starting nass consumption. “I learned this while serving in the military. You are constantly nervous and stressed when serving in military. Whenever I used nass, I felt calm and my nervousness and agitation disappeared. Those were tough times and I was constantly nervous. When you take nass, you feel free and your pain disappears. So I started using nass to keep myself calm and relax.” (P.12).

Some young people believed that using nass increased their physical strength, and that encouraged them to use nass. “I was working on a construction site with my friends. One of my friends suggested we use nass to boost our physical strength. That’s how I started using it.” (P.14).

Limitations

This was the first qualitative study that explored the factors contributing to nass consumption among people in Turkmen-Sahra. In this study, individual interviews and focus group discussions were conducted in natural environments and social contexts. The participants were selected from 4 cities with higher prevalence of nass consumption. They were from different age groups and had different occupations, allowing the researchers to achieve a deeper understanding of the factors that encouraged use of nass. However, the study had a number of limitations. Although nass consumers are generally males, lack of female participants was one of the limitations of this study. Furthermore, future studies should consider recruiting participants from towns such as Maraveh-tapeh and Kalaleh where the prevalence of nass consumption is lower and also from Turkmen living in the province of North Khorasan.

Implications for policies and research

Findings of the present study are useful for health policy makers in planning and implementing intervention strategies to prevent nass consumption. Nass consumption prevention strategies in Turkmen society should focus on teenagers, a population at greater risk. Additionally, the results support the fact that easy access to nass is one of the main factors contributing to its consumption and hence should be given serious consideration when planning preventive strategies. Moreover, strict rules and policies should be created and implemented to regulate and control nass production and its distribution and sale in the society. Establishing ‘stop smoking’ clinics should also be considered to help those who want to quit smoking and prevent them from switching to nass.