Background: Adolescent hookah pipe use is a public health concern because it poses several health, environmental, and economic risks. Self-determination theory (SDT) posits that people are motivated to engage in certain behaviours in an attempt to satisfy their basic psychological needs (BPN). Aim: This study aimed to design an intervention to reduce adolescent hookah pipe use and satisfy their BPN. Method: This study was located in the Western Cape, South Africa. A mixed methods methodology using a sequential explanatory research design and intervention mapping framework was employed in this study. This study consisted of two phases: Phase 1 identified the problem and comprised three stages: (1) systematic reviews focusing on determinants and interventions; (2) assessing prevalence of hookah pipe use and comparing users’ and non-users’ harm perception, needs, motivation, and the role of the family using a battery of tests; and (3) exploring users’ and non-users’ motivation and needs by using semi-structured interviews. Phase 2 focused on the design of the intervention using a modified Delphi approach. Results: Adolescent hookah pipe use is determined by an interplay of family factors, peer/friends factors, individual factors, school factors, the actual hookah pipe mechanism, advertisements, and awareness of hookah pipe lounges or bars. Existing hookah pipe cessation interventions focused solely on the user and were mainly supportive, educational or counselling sessions. Based on the current study, 21% of adolescents were users. Users and non-users had similar views in terms of the dangers of smoking the hookah pipe. Users and non-users were intrinsically motivated to either smoke or not smoke. There were no significant differences between users’ and non-users’ BPN. These findings were contradicted in the qualitative stage of the study where adolescents revealed that satisfaction or frustration of BPN, in particular, competence and relatedness, influences their decision to smoke or not smoke the hookah pipe. Users experienced more needs frustration compared to non-users. Also, users were more extrinsically motivated to smoke, whereas non-users were intrinsically motivated not to smoke. Family, lack of parental involvement, substance abuse in the family, trauma, violence, and approval of hookah use by family members had an important role in adolescents’ decision to smoke the hookah pipe. Therefore, a four-pronged approach focusing on (1) the hookah pipe user, (2) the family, (3) after school recreation activities, and (4) the teacher and community was designed as an intervention. The intervention was described using the RE-AIM Framework which considers reach, efficacy, adoption, implementation, and maintenance of the intervention. Conclusions: This study revealed important conclusions. The idea to focus on the internal factors, the role of family, the school and community when intervening in adolescent hookah pipe use is a relatively new perspective. There have been no known studies that try to understand hookah pipe use from a SDT perspective. This intervention would be beneficial to adolescents, their families, and communities. This study contributes to the growing body of knowledge and it is a starting point for intervening in hookah pipe use.