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Correlates of smoking behaviour among Egyptian adolescents

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Correlates of smoking behaviour among Egyptian adolescents

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Content CORRELATES OF SMOKING BEHAVIOUR
AMONG EGYPTIAN ADOLESCENTS
by
Sondos Mohamed Saleh Islam
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTIVE MEDICINE/HEALTH BEHAVIOR RESEARCH)
May 2005
Copyright 2005 Sondos Mohamed Saleh Islam
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UMI Number: 3180357
Copyright 2005 by
Islam, Sondos Mohamed Saleh
All rights reserved.
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DEDICATION
To Peace and Health in the Middle East
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ACKNOWLEDGMENTS
I would like to thank each of my guidance committee members for their
patience and understanding of the problems and the complexities I encountered
during completion of this research study in Egypt: Edward Ransford, Ph.D., for
pointing out the importance of qualitative research, and for always wishing me to
go straight ahead; Jennifer Unger, Ph.D., for always being there to answer any of
my questions, even the silliest ones; Lourdes Baezconde-Garbanati, Ph.D., for
introducing and supplying me with the all the necessary documentation necessary
to understand the methods of conducting focus groups; Stan Azen, Ph.D., for his
great personality and sense of humor, which made biostatistics an interesting and
fun subject to study; and especially Dr. Andy Johnson, for being my mentor,
having faith in my capabilities, always pointing me in the right direction,
understanding and accommodating my personal problems and difficulties while
pursuing this degree, and for his support and sponsorship of this research as a sub
study of the USC Transdisciplinary Tobacco Use Research Center.
I would also like to thank Dr. Khaled Al-Angari, the Saudi Arabian
Minister of Higher Education, for his continuous support and faith in my
capabilities; my close friend and father of my children, Sadad Islam, who was
always there for me to solve any problems I encountered; My childhood best
friend Dr. Amani Massoud, for her complete support and generosity, and her
amazing husband, Dr. Fouad Shohayab, my dearest friend, who went beyond the
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call of duty to facilitate the completion of my study in Egypt and pursuing every
possible venue to get the official clearances from the Egyptian authorities
necessary for the data collection, without which this study would not have been
accomplished; the Alexandria Rotary Club, for sponsoring my study and
facilitating the means to approach the school gatekeepers; Mamy Barovich for
being a genuine friend, and for her continues encouragement and help in all
matters, big or small; Michelle Orsillo and Jolanda Lisath for always being there to
help me out in any issue I encountered ; Dr. Paula Palmer for the help in dealing
with issues of the USCIRB; My siblings, all eight of them, for their continuous
support, for having faith in me and for always encouraging me to pursue my
dreams; My father (God rest his soul), always ahead of his time, for giving us the
best education possible in the Middle East, and instilling in us the notion that
pursuing a higher education is the most valuable endeavor one could achieve; My
mother (God rest her soul), for teaching me compassion, patience, endurance and
humility, and without whom I would not be the person I am today; Dr. Rashed
Elyas, for understanding what I was going through, for proof reading my papers,
for breaking the monotony of my studies, for cheering me up and making me laugh
when I was down, and for being who he is.
Most of all, I am especially grateful and thankful for the unconditional love,
support and understanding of my beloved sons, Bassam and Sharif Islam, for
always being there for me, for continuously being proud of my endeavors, for
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having faith in me as a mother and a graduate student, for their patience with my
occasional outbursts, for never complaining when their needs became secondary to
my studies’, and for putting up with my mood changes during the stressful and
anxious times in pursuing this degree, always with a comforting smile and a big
hug. They are my reason for living.
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TABLE OF CONTENTS
Dedication ii
Acknowledgments iii
List of Tables vii
List of Figures viii
Abstract ix
Chapter 1: Introduction 1
Chapter 2: Methods 9
Chapter 3: Influence of Known Psychosocial Smoking Risk Factors on
Egyptian Adolescents’ Smoking Behavior 17
Chapter 4: The Role of Cultural Influences on Egyptian Adolescents’
Smoking Behavior 36
Chapter 5: Influence of Known Psychological Smoking Risk Factors on
Egyptian Adolescents’ Smoking Behavior 57
Chapter 6: Influence of Pro-Tobacco Media on Egyptian Adolescents’
Smoking Behavior 74
Chapter 7: Western Media’s influence on Egyptian Adolescents’
Smoking Behavior: The Mediating Effect of Positive Beliefs about
Smoking 91
Chapter 8: Summary and Conclusion 113
Bibliography 123
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LIST OF TABLES
Table 1: Demographic Characteristics of the Study Sample 24
Table 2: Psychosocial Smoking Risk Factors Significantly Associated with
Ever-Smoking Behavior 26
Table 3: Psychosocial Smoking Risk Factors Significantly Associated with
30-Day Smoking Behavior 26
Table 4: Psychosocial Smoking Risk Factors Significantly Associated with
Susceptibility to Smoking, by Gender 28
Table 5: Pearson’s Correlation Coefficients between Cultural Factors and
Smoking Behavior 46
Table 6: Cultural Factors Associated with Ever-Smoking, by Gender 47
Table 7: Cultural Factors Associated with 30-Day Smoking, by Gender 47
Table 8: Cultural Factors Associated with Susceptibility to Smoking, by
Gender 48
Table 9: Associations of Hostility and Sensation Seeking Tendencies with
Ever-Smoking and 30-Day Smoking Behavior, by Gender 67
Table 10: Psychological Factors Associated with Susceptibility to Smoking
across Genders of Egyptian Adolescents 68
Table 11: Pearson’s Correlation Coefficients between Exposure and
Receptivity to Pro-Tobacco Media and Smoking Behavior 83
Table 12: Effects of Exposure and Receptivity to Pro-Tobacco Media on
Smoking Behavior 84
Table 13: Similarities/Differences in Risk/Protective Factors Associated
with Ever-Smoking Behavior, between Egyptian and Western Adolescents 118
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LIST OF FIGURES
Figure 1: Measures of Perceptions of Social Smoking Norms and Refusal
Self-Efficacy 22
Figure 2: Measures of Positive Beliefs and Knowledge of the
Consequences of Smoking 23
Figure 3: Smoking Behavior by Gender among Egyptian 7th , 9th and
12th Grade Adolescents in the city of Alexandria, Egypt (N=l,930) 25
Figure 4: Interaction between Social Conformity and Peer Smoking on
Susceptibility to Smoking among Egyptian Adolescent Males 49
Figure 5: Mediational Path Diagram of the Role of Positive Beliefs
about Smoking in the Association between Exposure/Receptivity to
Western Media and Susceptibility to Smoking 102
Figure 6: Mediational Path Diagram of the Role of Positive Beliefs
about Smoking in the Association between Exposure/Receptivity to
Western Media and Ever-Smoking Behavior 104
Figure 7: Mediational Path Diagram of the Role of Positive Beliefs
about Smoking in the Association between Exposure/Receptivity to
Western Media and 30-Day Smoking Behavior, among Egyptian
Ado lescent Males 105
Figure 8: Conceptual Model of the Risk/Protective Factors Associated
with Egyptian Adolescents’ Ever-Smoking Behavior 114
vm
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ABSTRACT
Background: Tobacco use is on the rise in developing countries. One such
country is Egypt, which has the highest rate of smoking in the developing Arab
world (33.5% are daily smokers, of which 19.6% are under 15 years).
Understanding the correlates of smoking behavior among Egyptian adolescents
may aid researchers develop effective adolescent smoking prevention programs to
help curb the rising smoking epidemic in that country.
Methods: A school-based cross-sectional survey of 1,930 actively
consenting Egyptian adolescents in 7th, 9th and 12th grades, from randomly
selected public and private schools, in Alexandria Egypt. Measures included
demographics, smoking behavior, psychosocial, psychological and cultural factors,
and exposure/receptivity to western and pro-tobacco media.
Results: Overall prevalence of ever, 30-day, current smoking and
susceptibility to smoking was 25%, 12%, 6% and 38% respectively, with males
having significantly higher smoking rates than females. Adolescent smoking
behavior was positively associated with family and peer smoking, perceived social
smoking norms, and positive beliefs about smoking. Refusal self efficacy was
protective against ever smoking and susceptibility to smoking, while knowledge of
the short-term negative consequences of smoking was protective against
susceptibility to smoking for females. Familism/obedience to parents and religious
relevance were protective against any smoking behavior, while social conformity
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and gender specific norms were smoking risk factors for males only. Impulsive
behavior was positively associated with smoking behavior across genders, hostility
and sensation seeking were risk factors for ever and 30-day smoking for males
only, and risk factors for susceptibility to smoking across genders. Exposure and
receptivity to pro-tobacco and western media increased the risk of adolescent
smoking behavior. Positive beliefs about smoking partially mediated the
association between western media and ever smoking and susceptibility to
smoking, and completely mediated the relationship between western media and 30-
day smoking.
Conclusion: Results of this study provide important new information about
the correlates of smoking behavior among Egyptian adolescents. Smoking
prevention programs targeting Egyptian adolescents should be culturally tailored,
gender specific and multicomponent, and should go hand in hand with adult
smoking cessation interventions.
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Chapter 1
Introduction
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Tobacco Use as a Major Global Public Health Problem
In the past few decades, the morbidity and mortality associated with
tobacco use has been shifting from the developed world to developing countries,
especially low and middle income Arab countries (Jha and Chaloupka, 2000). The
World Health Organization (WHO) attributes 4.9 million deaths a year to tobacco
use, a figure expected to rise to more than 10 million by 2030, if the current trend
continues (Peto and Lopez, 2001, Satcher, 2001). Almost 70% of these premature
deaths will be in developing countries, 1/3 of which (~ 250 million) will be
children (World Health Organization, 1999).
Tobacco companies have come under great criticism in the west for
targeting adolescents in their advertising. As a result, many companies have started
focusing more on targeting adolescents in overseas markets, especially adolescents
in the developing Arab world, using aggressive marketing campaigns to maintain
their profits (Ahmed et al., 1999, Dowell, 1997).One such country, which has the
highest rate of tobacco consumption in the Middle East and North Africa
(MENA)1 , is Egypt (Corrao et al., 2000, Hassan, 2003). It is estimated that 34% of
Egyptians are daily smokers, with males having significantly higher daily smoking
rates than females (43.4% males, 18% females) (Centers for Disease Control and
Prevention (CDC) Nations, 2001, ERC Statistics International, 2001).
1 MENA region includes Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait,
Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, United Arab
Emirates (UAE) and Yemen
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Culture under Study: Egypt
Egypt, on the north coast of Africa, covers approximately one million
square kilometers of land and is about the same size as Texas and New Mexico
combined (Library of Congress, 1990). Its population of almost 71 million (CDC
Nations, 2002), is relatively young with around 60% of all Egyptians below the
age of 24 (Mena Business, 2000). Almost 90% of Egyptians are Muslims, with
Orthodox Coptic Christians comprising the remaining 10% of the population
(Library of Congress, 1990). Arabic is the official language, but educated
Egyptians normally speak English and French (Library of Congress, 1990).
Egyptian society is a predominantly Muslim patriarchal collective society governed
by traditional cultural and Islamic values (Bernard, 1994).
The Rising Smoking Epidemic in Egypt
Over the past 30 years, the number of smokers in Egypt increased 8-9% on
a yearly basis, over twice as fast as the population growth rate (2 %) (Hassan, 2003,
Who Health Organization- Eastern Mediterranean Regional Office, 2003). From
1970 through 1998, Egypt had an increased per capita consumption of cigarettes
compared to the rest of the 22 MENA countries (Corrao et al., 2000). Cigarette
consumption in Egypt increased from 12,027 million sticks in 1970 to 46,600
million sticks in 1999, or 24% of the total MENA consumption, despite that Egypt
only accounted for 21% of MENA’s total population (World Bank, 2001). Some
studies have noted that Egyptian families spend 5% of their annual income on
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cigarettes (Dous, 2003, Hassan, 2003), although other sources have quoted a much
higher figure of nearly 22 % (GLOBALink, 2002), compared to 2-3% on health
care (Moyer, 2000). In 2000, approximately 13 million Egyptians were current
smokers, of which 500,000 (4 %) were under the age of 15 and 73,000 (0.6%) were
under the age of 10, who consumed a total of 85 million sticks (Dous, 2003).
According to the results of the Global Youth Tobacco Survey (GYTS) (2001),
13.8% of Egyptian students surveyed, aged 13-15 years, had ever smoked
cigarettes, 19.6% had used any tobacco product, and 4.1% were current smokers
(Global Youth Tobacco Survey, 2001). WHO reports that smoking causes 90% of
the lung cancer cases in Egypt, and tobacco-related cancers as a percentage of all
cancers are on the rise (Hassan, 2003). The usual long-term delay before smoking-
related morbidity occurs, especially in a country with a relatively young population,
ensures a heavy future public health burden on Egypt.
The Risk of Adolescent Tobacco Use
Studies of the natural history of smoking have shown that most adult
smokers start smoking when they are adolescents and that adolescent smoking
status is a strong predictor of adult smoking status (Chassin et al., 1996, Lee et al.,
1993). Smokers who initiate smoking at younger ages are more likely to continue
smoking, have more severe health consequences and a lower probability of quitting
(Chassin et al., 1996, Pierce et al., 1996, USDHHS, 1979). Adolescents begin to
experiment with cigarettes without realizing the addictive nature of nicotine, and
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within a short period of time, they become habitual smokers (USDHHS, 1994). If
children can be guided through their teenage years without becoming addicted to
nicotine, the likelihood of becoming a life-long tobacco user drops dramatically
(Kessler et al., 1997).
Adolescent Smoking Prevention Programs
One solution to curb the rising smoking epidemic in Egypt is to implement
culturally appropriate adolescent smoking prevention programs. Most of the
effective western smoking prevention programs are based on the social influence
model which targets the proximal smoking risk factors believed to promote
adolescent smoking, on the basis that the impact of the intervention on cigarette
behavior is mediated by the changes it produces on these mediating variables
(Kumpfer, 2000, MacKinnon et al., 1991).
Numerous studies, conducted in the U.S., Europe and Asia, have produced a
collection of factors which influence adolescents’ smoking initiation (Adrados,
1995, Bener and al-Ketbi, 1999, Conrad et al., 1992, Unger et al., 2001b, Unger et
al., 2002). These factors were grouped into a number of categories including
demographic characteristics (older age, lower socio-economic status and being
male), psychosocial factors (peer and family smoking, perceived social smoking
norms, knowledge of the consequences of smoking, perceived positive beliefs
about smoking and refusal self-efficacy skills), psychological factors and
predispositions (depression, hostility, impulsivity and sensation seeking
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tendencies), the influence of pro-tobacco (advertising and promotional activities)
and western media (films, television shows, music and magazines), and cultural
factors (Adler et al., 1994, Adrados, 1995, Altman et al., 1996, Barraclough, 1999,
Beltramini and Bridge, 2001, Borzekowski et al., 1999, Chen et al., 1999, Conrad
et al., 1992, Dalton et al., 2003, Dalton et al., 2002, Eide et al., 1997, Evans et al.,
1995, Freeman, 1993, Gidwani et al., 2002, Gilpin and Pierce, 2001, Glantz, 2003,
Glantz, 2001b, Hazan et al., 1994, Hazan and Glantz, 1995, Heath et al., 1993,
Hoek and Sparks, 2000, Landrine et al., 1994, Marcos and Johnson, 1988,
Markham et al., 2001, Pechmann, 1998, Sargent et al., 2001a, Schooler et al.,
1996b, Tickle et al., 2001, Unger et al., 1995, Unger et al., 2001a). However, the
majority of these studies focused primarily on western youth (Mermelstein, 1998),
and as a result, we know much less about the similarities or differences of the
influences of the known smoking risk factors on adolescents from Arab cultures.
Previous research on adolescent smoking in Egypt has focused mainly on
providing prevalence data (Ahmed, 1999, Dous, 2003), and information about
some of the determinants of adolescent smoking such as access/availability and
price, environmental tobacco smoke exposure (ETS), cessation, and school
curriculum (Dous, 2003). There is a scarcity of quantitative studies investigating
the influences of known smoking risk factors and/or cultural factors on Egyptian
adolescents’ smoking behavior, on which effective smoking prevention programs
may be based.
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The Current study
The current study investigates the influences of the risk and protective
factors known to be associated with western adolescents’ smoking behavior, on
Egyptian adolescents’ smoking behavior, in order to shed some light on the
similarities and differences between the two adolescent populations. Results of this
study may provide new information on the significant risk and protective factors
associated with the Egyptian adolescents’ smoking behavior. Since most
immigrants tend to bring with them their homeland’s cultural habits, understating
the correlates of smoking behavior among Egyptian adolescents may not only aid
in the design of culturally appropriate smoking prevention programs for Egyptian
youth, but also for other Arab adolescents from similar collective cultures, and for
adolescents from Arab immigrant families living in developed countries.
The following seven chapters describe the methods used in the current study
(Chapter 2), the results of the data analysis investigating the influences of the
known western adolescents’ psychosocial smoking risk factors (Chapter 3),
Egyptian cultural factors (Chapter 4), psychological and temperament trait factors
(Chapter 5), exposure and receptivity to pro-tobacco media (Chapter 6), and
exposure/receptivity to western media (Chapter 7), on Egyptian adolescents’
smoking behavior (ever-smoking, 30-day smoking and susceptibility to smoking).
Chapter 8 is a summary of the overall findings of this study, including a conceptual
model of the risk and protective factors associated with Egyptian adolescents’ ever-
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smoking behavior, a comparison table of the similarities and differences between
the risk and protective factors influencing Egyptian adolescents versus western
adolescents’ ever-smoking behavior, and implications and future directions based
on the application of the present research findings into practice.
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Chapter 2
Methods
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This study was conducted in the city of Alexandria, Egypt in May of 2003.
Alexandria is Egypt's second largest city and main seaport. It has a population of
more than 4 million people comprised primarily of indigenous ethnic Egyptian
groups (Ashmawy, 2000).
Study Design and Sample Selection
This is a cross-sectional study of 7th , 9th and 12th grade students from
stratified random sampling of public and private schools, in the city of Alexandria,
Egypt.
Egyptian schools are either public or private and vary according to the
gender of the student population. Private schools are either gender specific or co
educational, whereas public schools serve only one gender (males or females). Co
educational schools were excluded from the study because of the lack of public
schools’ equivalent student population.
Schools were stratified based on school type (public/private) and gender of
students. Two schools from within each stratum were randomly selected, for a total
of eight of schools. Three classes per grade under study were randomly selected to
participate in the study.
Data were obtained from all consenting students in grades 7 (mean age 13.7
years), 9 (mean age 15.4 years) and 12 (mean age 17.1 years). This wide range of
age group was selected to be able to include adolescents during all four periods of
smoking, from the early middle years of the preparation period where susceptible
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adolescents may be present, through the senior years where the final period of
addiction to nicotine may have been established.
To assess the smoking risk factors, students completed a 112 item written
questionnaire during regular classroom hours. The survey questionnaire included
questions in either a Yes/No format or in a 1 to 4 point response scale (Never-
Always). The questionnaire was administered by trained data collectors, including
the author, not otherwise associated with the schools or students. The surveys were
identified only by a code number and no identifying information linked students to
the survey. Consent forms were sent to parents of all students two weeks prior to
questionnaire administration. Parents were instructed to sign and return the consent
form if they allowed their child permission to participate. Prior to data collection,
the purpose of the survey was explained to the students and student assent was
obtained. Students were given the option not to participate in the study, if they so
chose, even after having consented. The study was approved by the University of
Southern California (USC) Institutional Review Board (IRB), as part of a larger set
of studies operating out of the USC Transdisciplinary Tobacco Use Research
Center, and by the Rotary International Alexandria IRB.
A total of 2,150 students from the eight schools were invited to participate.
Of the 2,150 students, 65 (3 %) did not provide parental consent and 145 (6.7 %)
were absent from school on the day of data collection. Of the remaining 1,940, 10
had missing values for gender. These were excluded from the analysis. This study
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reports the results of the remaining 1,930 students or approximately 90 % of the
population invited to participate.
Measures
Measures of demographics, smoking behavior and psychosocial variables
were obtained from existing surveys used by the Pacific Rim Integrated Research
Program (PRIRP) (Unger et al., 2001a) and the Wuhan Smoking Prevention Trial
(Unger et al., 2001b), two social influence-based tobacco use prevention programs
targeting Pacific Rim populations in the US and Chinese adolescents in Wuhan,
China, currently being conducted at USC. Questions from the existing surveys were
translated from English to Arabic and then back translated to English by a group of
bilingual professionals, who ensured that the translation was idiomatically
appropriate for Egyptian adolescents and that there was no disparity between the
back-translated version and the original surveys.
Measurement of Smoking Behavior Outcome Variables
Smoking outcome (dependent) variables include experimentation with
cigarettes (ever-smoking), 30-day smoking and susceptibility to smoking. For this
study, ever-smokers are defined as adolescents who have tried smoking at least
once in their lifetime, even a few puffs, 30-day smokers are adolescents who have
smoked at least once in the 30 days prior to the survey administration and
susceptible adolescents are those who do not rule out smoking in the near future.
Susceptible adolescents included never smokers, experimenters, 30-day smokers,
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current smokers and/or ex-smokers, as long as they did not adamantly rule out the
possibility of future smoking (Pierce, 1998). Longitudinal studies have shown an
increased likelihood of future smoking among susceptible adolescents and
experimenters (Pierce, 1996; Pierce, 1998; Unger, 1997), and although not all
adolescents who experiment with smoking will go on to become addicted,
experimentation is a necessary step for the eventual smoking uptake process
(Chassin, 1996; Choi, 1997; Unger, 1997).
Ever-smoking was assessed by the following question, "Have you ever tried
smoking a cigarette, even a few puffs?” Respondents answered "yes" or "no".
Students who responded “yes” were classified as ever smokers and coded as “1”,
those who responded “no” were classified as nonsmokers and coded as “0”.
Past 30-day smoking was measured by asking, “Think about the last 30
days, on how many of these days did you smoke cigarettes?” Responses were
coded on a 6-point scale ranging from “I don’t smoke” to “all 30 days”.
Respondents who answered, “I don’t smoke” were classified as non-smokers and
coded as “0”, all other responses were classified as having smoked in the past 30
days, and coded as “1”.
Current smoking status was measured by the question, “Have you smoked
at least 100 cigarettes in your life?” Respondents answered "yes" or "no". Students
who responded “yes” were classified as current smokers and coded as “1”; those
who responded “no” were classified as non-current smokers, and coded as “0”.
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Susceptibility to smoking was measured using two items, based on the
definition of susceptibility to smoking by Pierce et al. (Pierce et al., 1996) as
follows; “ Do you think that you will smoke in the next year?” and “ Do you think
that you will smoke when you are older?” (standardized a = 0.8). Responses were
rated on a 4-point scale in the form of “yes, definitely”, “yes, maybe”, “maybe not”
and “definitely not”. Respondents who answered “definitely not” to both questions
were classified as not susceptible to future smoking, and coded as “0”. Any other
response categorized the adolescent as susceptible to future smoking and coded as
Measurement of Independent Variables
Measurements of the independent variables under study
(psychosocial, cultural, psychological, exposure and receptivity to pro-tobacco and
western media variables) are explained under each chapter discussing the results of
the analysis of the association of these variables with the smoking outcome
variables.
Measurement of Covariates
Covariates in this study include sex, age and socioeconomic status (SES).
To assess students’ SES, respondents were asked about their parents’ educational
level and their weekly allowance by the following questions, “What is your father’s
highest educational level?” and “What is your mother’s highest educational level?”
Responses ranged from 1= “Illiterate” to 8= “Ph.D.” and “How much pocket
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money do you get each week to spend any way you want?’ Responses ranged from
1= “None” to 8 = “over 30 Egyptian pounds”, with increments of 5 Egyptian
pounds. The SES index was formed by summing the responses to the above three
items. Higher values indicated higher SES.
Data Analysis
Descriptive statistics (frequencies, percentages and means) were used to
examine smoking prevalence and age of respondents. Chi-square analyses were
used to compare the prevalence of smoking behavior across genders and T-test
analyses were used to compare the mean age across genders.
Dependent variables were naturally dichotomized. Multiple logistic
regressions were used to assess the associations between the independent and
dependent variables. Each model included the main effects of all the variables
under study, and the interaction terms of the independent variables with sex,
adjusting for age and SES. Interaction terms are used to test for the differential
influence of one variable on another. For example, to test for the influence of peer
smoking on smoking behavior on each gender, an interaction term is created (peer
smoking * sex), included in the model and tested for its significance. Whenever
there was a significant interaction with sex, the model was reanalyzed for each
gender, controlling for age and SES.
All statistical analysis was completed using the SAS system version 9.0.
(SAS Institute, 2002). All variables used in this study were re-coded according to
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the definitions specified in the measures section of this study before statistical
analysis and computation were performed.
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Chapter 3
Influence of Known Psychosocial Smoking Risk Factors
Egyptian Adolescents’ Smoking Behavior
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Background
A number of psychosocial factors have been shown to influence western
adolescents’ smoking behavior (Adrados, 1995, Bener and al-Ketbi, 1999, Conrad
et al., 1992, Unger et al., 2001b, Unger et al., 2002). These factors include social
learning and influences, perception of social smoking norms, attitudes and beliefs
about smoking, knowledge about the consequences of smoking, and refusal self-
efficacy skills.
Social learning occurs when the child has the opportunity to observe the
behavior and attitudes of others, especially those of peers and family members, and
emulates them (Gilpin and Pierce, 2001). Most studies have demonstrated that
having friends who smoke and perceptions of how prevalent smoking is among
peers (perceived peer smoking norms) was highly predictive of adolescent smoking
behavior (Biglan et al., 1995, Charlton et al., 1999, Cohen et al., 1994, Conrad et
al., 1992, Fisher et al., 1993, Flay et al., 1994, Landrine et al., 1994, Stanton and
Silva, 1992, USDHHS, 1998, Wang et al., 1995). Correction of perceived peer
smoking norms has proven to be one of the most modifiable risk factors and one of
the most effective in reducing the risk for smoking onset among western
adolescents (Hansen et al., 1987, MacKinnon et al., 1991). Other studies have
shown that adolescents whose family members smoke (parents and/or siblings)
were at an increased risk of smoking (CDC, 1998, Conrad et al., 1992, Gilpin and
Pierce, 2001, Mermelstein, 1998, USDHHS, 1998, Wang et al., 1995).
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Studies have also shown a strong positive association between positive
beliefs about smoking and future smoking behavior among adolescents (Ajzen and
Fishbein, 1980, Brownson et al., 1992, CDC, 2000, Conrad et al., 1992, Greenlund
et al., 1997, Lee et al., 2001). Other studies have shown that increasing adolescents’
knowledge about the negative consequences of smoking appears to decrease their
likelihood of future smoking (CDC 1998), although increasing the knowledge of
the long-term harmful effects of smoking was not consistently protective against
future smoking as increasing their knowledge about the short-term negative
consequences (Filice et al., 2003, Goldman and Glantz, 1998, Mermelstein, 1998,
Meyrick, 2001).
Refusal self-efficacy, which is the adolescent’s perceived ability in refusing
cigarette offers from friends and/or loved ones, has been shown to be protective
against future smoking (Bandura, 1984, Bandura, 1986, Botvin et al., 1992, Botvin
et al., 1994a). Studies have reported that adolescents who doubted their ability to
refuse cigarettes offers from friends and/or loved ones were at a higher risk for
smoking initiation (Botvin et al., 1994b, Brownson et al., 1992, Charlton et al.,
1999, Conrad et al., 1992, Epstein et al., 2000, Greenlund et al., 1997).
Most of our understanding of adolescents’ psychosocial smoking risk
factors is based mainly on western studies. There is a scarcity of quantitative
studies investigating the influence of these factors among adolescents from
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developing collective societies, like Egypt, who may differ from adolescents in
developed individualistic societies.
This chapter reports the results of analysis of the influences of the known
psychosocial smoking risk factors on Egyptian adolescents’ ever-smoking
behavior, 30-day smoking behavior, and susceptibility to future smoking.
Measures
Measures of Known Psychosocial Smoking Risk Variables
Peer smoking was assessed by the following two questions: "How many of
your friends have ever tried smoking?” and “How many of your friends smoke
cigarettes at least once a month? (standardized a = 0.85). Responses were rated on
a six-point scale; “1= none”, “2= 1 ”, “3= 2”, “4= 3”, “5= 4” and “6 = >4”. Peer
smoking was coded as a dichotomous variable such that those who indicated
“None” for both questions were classified as unexposed to peer smokers and coded
as “0”, all other responses were classified as having peers who smoke, and coded as
Parent smoking was assessed by the question: "Do either of your parents
smoke cigarettes now?” Respondents answered "yes" or "no". A positive response
classified the student as being exposed to parental smoking and coded as “1”, while
a negative response classified the student as not being exposed to parental smoking
and coded as “0”. The purpose of this measure was to assess the influence of parent
smoking on their children’s smoking behavior, regardless of whether the student
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lived with both birth parents or not, the underlying assumption being that students
who did not live with both birth parents would still be exposed to parental smoking
during their visits with the other parent, if that parent was the smoker.
Sibling smoking status was similarly assessed by the following question,
“Do any of your siblings smoke now?” Respondents answered "Yes" or "No".
Positive responses classified the respondent as having siblings who smoked,
regardless of the age of the sibling, and coded as “1”, negative responses were
coded as “0”.
Figures 1 and 2 present the measures assessing the rest of the psychosocial
variables under study and their corresponding standardized Cronbach alphas.
Perceived peer and adult smoking norms, and refusal self-efficacy are presented in
Figure 1, while measures of positive beliefs about smoking and knowledge of the
long and short-term consequences of smoking are presented in Figure 2.
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Figure 1 : Measures of Perceptions of Social Smoking Norms and Refusal Self-Efficacy
Psychosocial Variable Measure
Perceived Peer Smokingf
(standardized Cronbach a = 0.8)
- Out of 10 boys your age, how many do you think smoke
cigarettes at least once a month?
- Out of 10 girls your age, how many do you think smoke
cigarettes at least once a month?
l=None 2=1-2 3=3-4
4=5-6 5=7-8 6=9-10
Perceived Adult Smokingf
(standardized Cronbach a = 0.8)
- Out of 10 adult men, how many do you think smoke
cigarettes at least once a month?
- Out of 10 adult women, how many do you think smoke
cigarettes at least once a month?
l=None 2=1-2 3=3-4
4=5-6 5=7-8 6=9-10
Refusal Self-Efficacy f
(standardized Cronbach a = 0.85)
- I am confident that I can refuse a cigarette, even if my
best friend offers it to me
- I am confident that I can refuse a cigarette, even if my
girl/boy friend offers it to me
- I am confident that I can refuse a cigarette, even if my
sibling offers it to me
1 = yes, definitely 3= maybe not
2 = yes, maybe 4= definitely not
Notes:
f Responses were recoded such that higher numbers indicated higher levels of variable undo- study.
The index for each variable was formed by summing the responses to all items assessing the
measure. Higher numbers indicated higher levels of the variable.
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Figure 2: Measures of Positive Beliefs and Knowledge of the Consequences of Smoking
Psychosocial Variable Measure
Positive Beliefs about Smoking f
(standardized Cronbach a = 0.8)
- Do you think smoking can help reduce stress?
- Do you think smoking can help relieve boredom?
- Do you think smoking can help one concentrate while
studying?
- Do you think smoking makes one look cool?
- Do you think smoking makes one look more mature?
and
- Do you think smoking makes one look more
westernized?
1 = yes, definitely 3= maybe not
2 = yes, maybe 4= definitely not
Knowledge of the Long-term consequences of Smokingf
(standardized a Cronbach = 0.8)
- Smoking cigarettes can cause heart disease
- Smoking cigarettes can cause lung cancer
- Smokers have shorter lives than non-smokers
1 = yes, definitely 3= maybe not
2 = yes, maybe 4= definitely not
Knowledge of the Short-term consequences Smoking f
(standardized a Cronbach = 0.6)
- Smoking cigarettes causes bad breath
- Smoking cigarettes causes teeth to become yellow
- Smoking cigarettes causes clothes to smell bad
1 = yes, definitely 3= maybe not
2 = yes, maybe 4= definitely not
Notes:
f Responses were recoded such that higher numbers indicated higher levels of the variable under
study.
The index for each variable was formed by summing the responses to all items assessing the
measure. Higher numbers indicated higher levels of the variable.
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Results
Demographic Characteristics of the Sample
The population sample of 1,930 students was comprised of 51% males and
49 % females. The age of the students ranged from 13 to 19 years, with a mean age
of 15.2 (SD=1.4) years. T test revealed no significant difference in the mean age
between the sexes (t = 1.78, df = 1928, p= 0.08). Table 1 presents the demographic
characteristics of the study sample.
Table 1 : Demographic Characteristics of the Study Sample
Grades Public Private Mean Age (SD)f Total N%)*
7th 251 103 13.7 (0.5) 354 (36)
Males 9th 178 268 15.5 (0.6) 446 (45)
12th 103 84 17.1 (0.9) 187(19)
All Grades 532 455 15.2(1.4) 987 (100)
7th 64 189 13.6 (0.5) 253 (27)
Females 9th 305 168 15.4 (0.6) 473 (50)
12th 146 71 17.0 (0.9) 217(23)
All Grades 515 428 15.3 (1.4) 943 (100)
Total All Grades 1047 883 15.2 (1.4) 1930 (100)
Notes:
f SD = Standard Deviation
* N is the number of subjects for each row, and (%) are the row percentages
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Smoking Prevalence
The overall prevalence of ever-smoking, 30-day smoking, current smoking
and susceptibility to smoking was 25%, 12%, 6% and 38% respectively, with males
having significantly higher ever-smoking (x2 = 82.93, df=l, p <0.0001), 30-day
smoking (x2 = 40.8, df=l, p < 0.0001), current smoking ( y2= 12.64, df=l, p <
0.0001) and susceptibility to smoking (%2 = 127.13, df=l, p < 0.0001) rates than
females. Figure 3 presents the prevalence of smoking rates by gender.
Figure 3: Smoking Behavior by Gender among Egyptian 7th , 9th and 12th Grade
Adolescents in the city of Alexandria, Egypt (N= 1,930)
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■ Males
□ Females
L m
16
I I ■!
Ever-smoking 30-day Smoking Current Smoking Susceptibility
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Main Effects Associated with Ever-Smoking and 30-Day Smoking Behavior
There was no significant interaction between any of the independent
variables and ever-smoking or 30-day smoking, therefore logistic regression
analysis was performed for the whole sample, adjusting for sex, age and SES.
Tables 2 and 3 present the odds ratio (OR), 95% confidence intervals (Cl) and p
values of the psychosocial smoking risk factors significantly associated with
Egyptian adolescents’ ever smoking and 30-day smoking behavior, respectively.
Table 2: Psychosocial Smoking Risk Factors Significantly Associated with Ever-Smoking
Independent Variable OR (95% Cl) P-value
Sibling Smoking 3.5 2.3-5.2 <0.0001
Parent Smoking 2.3 1.6-3.2 <0.0001
Peer Smoking 2.1 1.4-2.9 0.0002
Perceived Adult Smoking 1.7 1.6-1.9 <0.0001
Perceived Peer Smoking 1.3 1.2-1.4 <0.0001
Positive Beliefs about Smoking 1.2 1.1-1.2 <0.0001
Refusal Self-Efficacy 0.9 0.8-0.9 0.0002
Note: Adjusted for Sex, Age and SES
Table 3: Psychosocial Smoking Risk Factors Significantly Associated with 30-Day
Smoking Behavior
Independent Variable OR (95% Cl) P-value
Sibling Smoking 3.9 2.6- 6.1 <0.0001
Peer Smoking 2.6 1.4- 4.6 0.001
Parent Smoking 2.1 1.4- 3.1 0.0007
Perceived Peer Smoking 1.3 1.2- 1.5 <0.0001
Positive Beliefs 1.3 1.2- 1.3 <0.0001
Perceived Adult Smoking 1.2 1.1- 1.4 0.0002
Note: Adjusted for Sex, Age and SES
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Controlling for all other variables under study, sibling smoking had the
highest odds for ever-smoking (OR = 3.5, 95% CI= 2.3-5.2) and 30-day smoking
(OR= 3.9,95% CI= 2.6-6.1). Adolescents whose parents smoked were at a slightly
higher odds for ever smoking (OR= 2.3, 95% CI= 1.6-3.2) than those whose peers
smoked (OR= 2.1,95% CI= 1.4-2.9) (Table 2). However, peer smoking appears to
increase the odds of adolescents’ 30-day smoking behavior (OR= 2.6, 95% CI=
1.4-4.6) more than parent smoking (OR= 2.1, 95% CI= 1.4-3.1) (Table 3).
High levels of perceived adult smoking norms increased the odds of
adolescent’s ever-smoking behavior (OR= 1.7, 95% CI= 1.6-1.9) more than high
levels of perceived peer smoking norms (OR= 1.3, 95% CI= 1.2-1.4) (Table 2).
There was almost no difference in the odds of perceived adult smoking norms
(OR= 1.2, 95% CI= 1.1-1.4) and perceived peer smoking norms (OR= 1.3, 95%
CI= 1.2-1.5) on the risk of 30-day smoking behavior (Table 3).
Having positive beliefs about smoking was significantly associated with
both ever-smoking (OR= 1.2, 95% CI= 1.2-1.2) and 30-day smoking (OR= 1.3,
95% CI= 1.2-1.3). Refusal self-efficacy was protective against ever-smoking (OR=
0.9, 95% CI= 0.8-0.9), but not against 30-day smoking (p>0.05). Knowledge of the
consequences of smoking, both long-term and short-term, was not significantly
associated with either ever-smoking or 30-day smoking behavior.
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Main Effects Associated with Susceptibility to Smoking
There was a significant interaction between gender and knowledge of the
short-term negative consequences of smoking, therefore the multivariate logistic
regression analysis was performed for each gender. Tables 4 presents the
psychosocial risk factors significantly associated with susceptibility to smoking by
gender.
Knowledge of the short-term negative consequences of smoking was
protective against susceptibility to smoking only for females (OR= 0.8, 95%
CI=0.7-0.9). High levels of perceived adult smoking norms, not perceived peer
smoking norms, increased the risk for susceptibility to smoking among both
genders. Sibling, parent and peer smoking, and high levels of positive beliefs about
smoking had the same influence on increasing the odds of susceptibility to smoking
as they did on ever smoking behavior, while high levels of refusal self-efficacy was
protective against susceptibility to future smoking for both genders (Table 4).
Table 4: Psychosocial Smoking Risk Factors Significantly Associated with Susceptibility
to Smoking by Gender, among Egyptian Adolescents
Males Females
OR (95% CD________OR (95% CD
Sibling Smoking 3.5 2.2-5.6 2.9 1.7-4.8
Parent Smoking 2.3 1.7-3.1 2.8 1.9-4.0
Peer Smoking 2.1 1.5-2.9 1.7 1.1-2.5
Positive Beliefs 1.2 1.1-1.3 1.2 1.1-1.3
Perceived Adult Smoking 1 .1 1.1-1.2 1.2 1.1-1.3
Refusal Self-Efficacy 0.8 0.7-0.9 0.8 0.8-0.9
Short-term Negative Consequences 0.9f 0.9-1.If
0.7 0.6-0.8
Note: Adjusted for Age and SES
f NS= Not significant at the 0.05 level
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Discussion
Consistent with previous studies (Brownson et al., 1992, Doyal, 2001,
Grunberg et al., 1991), males were at a much higher risk for smoking behavior than
females. Egypt is a patriarchal society governed by traditional gender differentiated
roles and values, (Bernard, 1994) a factor that has been shown to be a risk factor for
smoking behavior among males (Morrow et al., 2002, Shiffman, 1998). Egyptian
adolescent males may perceive that smoking is an acceptable male social
characteristic that increases their mature masculine image. On the other hand,
Egyptian adolescent females may perceive that smoking reflects an undesirable
feminine image, which may affect their reputation and prospects of a good
marriage, and therefore be less susceptible to any smoking behavior than their male
counterparts (Islam and Johnson, 2003).
The interesting factor that emerges from this study is the strength of the
influence of sibling and parental smoking, and adult smoking norms on Egyptian
adolescents’ smoking behavior. Although western studies have shown that family
smoking status is a significant smoking risk factor for adolescents (CDC, 1998,
Gilpin and Pierce, 2001, Mermelstein, 1998), peer smoking and perceived peer
smoking norms were consistently stronger smoking risk factors than family
smoking among western adolescents (Biglan et al., 1995, Conrad et al., 1992,
Hansen et al., 1987, USDHHS, 1998). Though peer smoking is a consistent
smoking risk factor for Egyptian adolescents, its influence is not as strong as those
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of sibling and parental smoking for ever smokers (Table 2) and susceptible
adolescents (Tables 4). However, peer smoking appears to have a stronger
influence than parental smoking for 30-day smokers, a point at which the
adolescent may be smoking more often and therefore may be more influenced by
his/her peer smoking behavior than his/her parent smoking behavior.
Egypt is a traditional collective society, where the family unit is more
important than the individual and/or his/her peers, and respect to elders in one’s
environment is paramount (Abd Al Hameed and Al Sheikh, 1978). Adolescents
may look up to their parents, older siblings and adults in their community, respect
their behavior and try to emulate it, rather than emulating their peers’. If the
adolescent’s siblings or parents smoke, the adolescent perceives that smoking is a
normative and acceptable social behavior and that some benefit must accrue from
smoking if those he/she loves and respects, engage in it (Gilpin and Pierce, 2001).
Accordingly, the influence of the family smoking behavior and perceived adult
smoking norms would have a stronger influence on the adolescent’s
experimentation with cigarettes and susceptibility to smoking than those of his/her
peers. Results of this study supports other studies which have found that
adolescents from collective cultures might be less affected by their peer smoking
norms and more affected by their family and adult smoking norms (Unger et al.,
2001a).
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Another interesting difference among this population is the influence of
perceived peer smoking norms (overestimation of the number of peers who smoke)
on adolescents’ smoking behavior. Perceived peer smoking norms appears to be a
smoking risk factor among adolescents who have already experimented with
cigarettes (Table 2), and a stronger risk factor than perceived adult smoking norms
for 30-day smokers (Table 3); however it does not appear to influence adolescents’
susceptibility to smoking (Table 4). One explanation may be that adolescents who
have already experimented with smoking or are 30-day smokers may feel the need
to over-estimate the prevalence of their peers smoking in an effort to rationalize
their own smoking behavior (Islam and Johnson, 2003).
Positive beliefs about smoking outcomes appear to have the same influence
on western and Egyptian adolescents. Egyptian adolescents who perceived higher
positive outcomes from smoking were at a higher risk for all three smoking
behaviors under study. On the other hand, adolescent’s perception of his/her refusal
self-efficacy skills appears to be protective against ever-smoking (Table 2) and
susceptibility to smoking (Table 4), but not against 30-day smoking. It may be that
once an adolescent becomes a 30-day smoker, the belief in his/her refusal self
efficacy skills are reduced, since at this stage, the influence of sibling and peers
smoking is stronger (Table 3), than during experimentation (Table 2 ), and the
positive beliefs about smoking may have been reinforced at this stage, such that the
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adolescent doubts his/her capability in refusing cigarette offers from friends and/or
siblings.
Knowledge of the short term negative consequences of smoking was
protective against susceptibility to smoking, but only for females (Table 4).
Egyptian adolescent females may place a higher value on their appearance than
their male counterparts, and thus may be less susceptible to a behavior which may
reduce their attractiveness to the opposite sex, and lower their prospects of a good
marriage, an integral goal of any Arab female. Egyptian adolescent males, on the
other hand, may not place importance on their physical appearance, since
culturally, it is presumed that a man’s affluence, rather than his physical
appearance, is what attracts the opposite sex, and therefore knowledge of the short
term negative consequences would not protect Egyptian adolescent males from the
uptake of smoking. Interestingly though, females who had already experimented
with cigarettes or were 30-day smokers were no longer influenced by the
knowledge of the immediate negative consequences of smoking. It may be that at
this stage of the smoking uptake process, other underlying smoking risk factors,
such as higher positive beliefs about smoking may outweigh and negate the
protective effects of the knowledge of the short-term negative consequences of
smoking. The protective significance of the knowledge of the immediate, rather
than the long term, negative consequences of smoking, although only for the
females, is consistent with studies that have shown that messages emphasizing the
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immediate consequences rather than the long term effects of smoking on health
have a higher impact on adolescent smoking behavior (Creswell et al., 1971, Flay
et al., 1983).
The results of this study point to the notion that some of the known smoking
risk factors associated with western adolescents’ smoking behavior, such as
positive beliefs about smoking, are consistent smoking risk factors across cultures
and gender, while other social factors, such as family smoking versus peer
smoking, perceived adult smoking norms versus perceived peer smoking norms,
may be culture specific and their degree of influence may depend on the type of
society (collective versus individualistic) under study.
Implications
The results of this study provide important new information about the
universality of some of the known psychosocial smoking risk factors. Correcting
perceived positive beliefs about smoking and increasing adolescents’ refusal self-
efficacy skills at the early stages of the smoking uptake process should be
incorporated in any smoking prevention program aimed at adolescents from any
culture. Smoking prevention programs aimed at adolescents from collective
cultures, like Egypt, should be multicomponent programs that include the whole
family and community members. Families, especially older siblings, and
community adults members must be made aware of their smoking behavior’s
influence on their youth. As long as Egypt remains a collective society, where the
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influences of family and adult social norms play such an influential role in the
adolescent’s behavior, implementing school-based smoking prevention programs
only would not suffice. Smoking prevention programs aimed at Egyptian
adolescents should go hand in hand with smoking cessation interventions aimed at
Egyptian adults.
Limitations
Results of this study are based on cross-sectional data, so causal influences
cannot be determined. The reverse direction of casualty is plausible. Adolescents
who have already experimented with cigarettes might choose to befriend others
who have also experimented with cigarettes, so as not to feel different, and not vice
versa. To develop a better understanding of the conditions under which these
variables operate as causal factors more longitudinal study designs are required.
However, the influences of family smoking on adolescent smoking behavior cannot
be explained by this reversal of causality and remains an important smoking risk
factor that needs to be addressed for this population.
Another limitation of this study is the lack of follow-up information on the
smoking behavior of the absentees (6.7%) and their parents. It is possible that
absentees and their parents had higher smoking prevalence than those surveyed.
This may have caused an underestimation of the smoking prevalence rates in this
study. Longitudinal western studies have shown a higher smoking prevalence
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among absentees and their parents (Charlton, 1997; Charlton, 1989). Whether this
is true among Egyptian adolescents cannot be determined by this study.
The results of smoking behavior are based on students' self-reports.
Although respondents were assured of their anonymity, Egyptian students may
have been suspicious and fearful of entrapment, especially the female students, and
therefore may have underreported their smoking behavior in an attempt to appear
socially correct. Though adolescents' self-reports of smoking obtained under
similar conditions in the United States, have been shown to be quite accurate across
ethnic groups (Wills and Cleary, 1997), it is not known whether this is also true for
Egyptian adolescents.
This study is based on random sampling of schools and students in the city
of Alexandria, Egypt, therefore the results can only be generalized to Egyptian
adolescents living in Alexandria, and cannot be generalized to the rest of
adolescents in other Egyptian cities. Variables found to be significantly associated
with smoking behavior among these adolescents may differ for other Egyptian
adolescents in other cities, especially if they live in the more westernized capital
city of Cairo, or in the more traditional suburban cities that make up Egypt.
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Chapter 4
The Role of Cultural Influences on Egyptian Adolescents’
Smoking Behavior
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Background
A number of western studies have noted the importance of cultural values
and traditions on the behavior and development of adolescent personalities (Cukier
and Middleton, 1996, Triandis and Suh, 2002), and on the initiation and uptake of
adolescent smoking (Adler et al., 1994, Adrados, 1995, Barraclough, 1999, Chen et
al., 1999, Conrad et al., 1992, Eide et al., 1997, Freeman, 1993, Heath et al., 1993,
Landrine et al., 1994, Marcos and Johnson, 1988, Markham et al., 2001, Unger et
al., 2001a). Culture is an enacted system of beliefs, attitudes, priorities and
behaviors that are emphasized, encouraged and viewed as desirable in a particular
society (Cukier and Middleton, 1996, Harris and Moran, 1991, Hofstede, 1991).
Egyptian Cultural Factors under Study
Egypt is one of the oldest Arab countries rich in cultural values and
traditions. Most of the Egyptian cultural values stem from religious teachings and
beliefs. Egypt is comprised of 90% Muslims and 10% Coptic Christians (Library
of Congress, 1990). Social attitudes are of central importance to both religions
(Ingram, 1999). Both preach the importance of family over self, obedience and
respect to parents and elders, social conformity to attitudes and behaviors
prescribed by the religious principals and societal laws, and gender differentiated
roles and norms (Denny, 1993, Nydell, 1987). Due to the addictive nature and
detrimental effects of smoking on health, both religious authorities, in Egypt, have
recently condemned smoking as either a sinful behavior (Who Health Organization-
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Eastern Mediterranean Office, 2001), or an evil that should be avoided at all costs
(Father Marcus, 2001).
Familism is the orientation toward the welfare of one's immediate and
extended family and their interdependence for support, loyalty, and solidarity
(Gaines et al., 1997, Magana, 1999). It is the obligation to help one’s family
members when they are in need, as well as the confidence that one’s family
members will be available to provide emotional and social support when needed.
Group values are preeminent, casting the individual in a subordinate, even
vulnerable, role (Cohen, 1987). Years of research in developmental psychology and
social learning theory demonstrate that family socialization processes are the
primary predictors of children's and adolescents’ behavior (Kumpfer et al., 2002).
Studies in the U.S. have shown that familism provides a network of social support
and protects individuals against mental and behavioral problems (Abraido-Lanza et
al., 1996, Gaines et al., 1997, Magana, 1999).
In Egypt, as in most predominantly Muslim cultures, family is of cardinal
importance; loyalty to one's immediate and extended family takes precedence over
one’s personal needs (Al Faruqi, 2001, Femea, 1991). Maintenance of a person’s
reputation is of great importance, since the reputation of any one member reflects
on all family members (Ingram, 1999).
Obedience to parents and older family members, which is strongly
emphasized in Arab cultures, refers to one’s respecting, honoring and obeying both
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parents, grandparents, older siblings, uncles and aunts, with uncritical acceptance of
their authority (Bernard, 1994), and to conduct oneself in a manner to bring honor
and not disgrace to the family name (Bernard, 1994, Choueiri, 1996, Nydell, 1987,
Ritts, 1999). Egyptian parents pride themselves on the obedience of their children,
and fear of being blamed if one of the children disgraces the family name by
engaging in unsanctioned behavior (Ingram, 1999, Nydell, 1987, Ritts, 1999).
Social conformity is a cultural value present in all collective societies,
where the will of the group determines the behavior of its members (Cukier and
Middleton, 1996, Ng and Van Dyne, 2001, Oyserman et al., 2002, Triandis, 1989,
2001). Egypt is a collective society where individuality is discouraged and social
conformity is the norm (Bernard, 1994, Cohen, 1987, Ingram, 1999, Ritts, 1999,
Trandis et al., 1988, Zaharna, 1995). Egyptian individuals are more concerned with
how they will appear in the eyes of others, and therefore may have the tendency to
socially conform to their societal norms, even if these norms may pause individual
health risks, rather focus on their own individual behavior (Haynes, 1994).
Gender specific roles and norms is another cultural tradition prevalent in
most Arab societies, including Egypt. Studies in the U.S. have suggested that
gender may shape health-related behaviors, particularly during adolescence
(Verbrugge, 1983), when perceived cultural norms about gender roles and relations
emerge within the adolescent peer group (Kaplan, 1997, Maccoby, 1998). Previous
studies have found gender differences in susceptibility to social influences (Chassin
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et al., 1986) , levels of social skills (French and Perry, 1996), and reliance on
smoking as a coping strategy (Fried, 1994). Other studies have linked gender
specific roles and norms to a number of health related behaviors, including tobacco
use and psychological well being (Evans and Steptoe, 2002, Gjerdingen et al.,
2000, Hong, 2000, Risberg, 2000, Russell et al., 2000). In predominantly Islamic
societies, such as Egypt, differentiated gender roles and norms are emphasized and
taught from early childhood, both at home and at school (Al Faruqi, 2001, Badawi,
1999).
This study investigates the influence of the above cultural factors on
Egyptian adolescents’ smoking behavior. The study hypothesizes that familism,
obedience to parents and the relevance of the religious standing on smoking
behavior to the adolescent will be protective against all smoking behavior for both
genders, while social conformity and gender differentiated norms will be associated
with an increased risk of smoking behavior among Egyptian adolescent males, and
a lower risk of smoking behavior among Egyptian adolescent females. The study
also hypothesizes that adolescent males who exhibit high social conformity and
have friends who smoke will be more likely to engage in smoking behavior than
those who exhibit high social conformity who do not have friends who smoke.
The study of the Egyptian cultural factors that may be associated with
adolescent smoking behavior may add to the body of knowledge about the risk and
protective factors of adolescent smoking in predominantly Muslim countries, like
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Egypt. The results of this study may not only aid in the development and design of
the appropriate smoking prevention programs aimed at Egyptian adolescents, but
also for the design of smoking prevention programs aimed at adolescents in
predominantly Muslim societies who share common cultural values and traditions
with Egypt.
Measures
Measurements of Cultural Factors under Study
A search of the literature revealed no Arab or Egyptian cultural value
scales. Therefore, this study developed new measures for an Egyptian cultural
values scale. A list of items tapping into each of the constructs under study was
formulated by the authors of this study. 8 Egyptian judges, not associated with the
study (2 adolescent males, 2 adult males, 2 adolescent females and 2 adult
females), were asked to rate the items tapping into each of the 4 constructs on a 1 to
4 rating scale, from “Strongly unfavorable to the concept” to “Strongly favorable to
the concept”. The judges were instructed to judge each item by how favorable it is
with respect to the construct and not by their own beliefs. Candidate items that
were rated as either “Favorable to the concept” or “Strongly favorable to the
concept” were included in the scale. Although there is no fixed cut-off point for
excluding candidate items with low item-total correlation, the recommended value
is 0.6 (Trochim, 1999), therefore items for each construct with item - total
correlation scores of less than 0.6 were excluded from the index for that construct.
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Familism was measured by the following three items: “I expect my family
to help me whenever I need them”, “If anyone in my family needs help, we would
all be there to help them”, “My family can help me solve all my problems”.
Response choices were rated on a four-point scale; “1 = never”, “2 = occasionally”,
“3 = often” and “4 = always”, (standardized a = 0.7).
Obedience to parents was similarly measured by the three items: “I always
follow the advice of my parents”, “I want to be an ideal person so that others
acknowledge that my parents raised me well”, and “I respect my parents’ wishes,
even if I don’t agree with them”. Response choices were rated on a four-point scale
from “1 = never”, “2 = occasionally”, “3 = often” to “4 = always”, (standardized a
= 0.7).
Exploratory factor analysis revealed that both the familism and obedience to
parents’ items loaded on the same construct, and the standardized Cronbach
correlation alpha for the combined 6 items was 0.9. Therefore the 6 items were
combined under one construct, and the familism/obedience index was formed by
summing the responses to the above six items. Higher numbers indicated higher
levels of familism/obedience.
Social conformity was measured by the following three items: “Behaving
like everyone else is better than being different”, “I do things which I don’t approve
of so as not to be different than those around me”, and “I like to act and dress like
my friends do”. Response choices were rated on a four-point scale from “1 =
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never”, “2 = occasionally”, “3 = often” to “4 = always”, (standardized a = 0.8). The
social conformity index was formed by summing the responses to the above three
items. Higher numbers indicated higher levels of social conformity.
Gender-specific norms with regards to smoking behavior were measured by
the following 2 items “Do you think it is socially acceptable for an adult man to
smoke?” and “Do you think it is socially acceptable for an adult woman to smoke?”
Respondents answered “yes” or “no”. Respondents who indicated a “yes” for the
social acceptability of a man to smoke and a “no” for the social acceptability of a
woman to smoke were considered to have traditional gender specific norms and
were coded as “1”; all other response combinations were coded as “0”.
Due to the current political sensitivities of religiosity issues in the Middle
East, the Egyptian authorities did not allow surveying the students about their
religiosity levels, but allowed only one item referring to religion on the survey; “A
religious person does not smoke”. Respondents answered “yes” or “no”. This item
was used as a proxy measure for the importance of religious relevance to the
adolescent. Respondents who indicated a “yes” were considered to attribute a high
relevance to their religion’s standing on smoking behavior and were coded as “1”,
those who responded “no” were considered not to attribute any relevance to their
religion’s standing on smoking behavior and were coded as “0”.
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Measurement of Covariates
Relevant covariates included age, gender, SES, and the psychosocial
variables shown to be associated with Egyptian adolescents’ smoking behavior,
peer and family smoking status, perceived peer smoking norms and perceived adult
smoking norms, (chapter 3). Family smoking was assessed by combining the parent
and sibling smoking variables (chapter 3) such that respondents who answered “no”
to both of the following questions, "Do either of your parents smoke cigarettes
now?” and "Do any of your siblings smoke cigarettes now?” were considered not
exposed to family smoking and coded as “0”. Any other response was considered
as being exposed to family smoking and coded as “1”. Measurements of the
outcome smoking variables and the other relevant covariates were described in
chapters 2 and 3 of this study.
Data Analysis
Univariate analysis was used to test for the normality of the independent
cultural variables. Correlation analysis was used to examine the correlation of the
independent and dependent variables under study, and to examine the item-total
correlation and the Cronbach alpha for each construct of the cultural value scale.
Exploratory factor analysis was used to determine which cultural value items load
most highly on their respective factors. Factor loadings of 0.6 or greater were
considered meaningful for the new cultural scale (Kim and Mueller, 1978).
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Multiple logistic regression was used to assess the odds ratios (OR) and
95% confidence intervals (Cl) for the association between the independent and
dependent variables. Three separate regression models for the three dependent
variables were analyzed. Each model included all cultural variables under study,
controlling for known smoking risk factors (peer smoking, family smoking, and
perceived smoking norms), and adjusted for sex, age and SES. Interaction variables
were created by centering dichotomized components (median splits) and
multiplying them together. For example, for the interaction between social
conformity and peer smoking, the social conformity index variable was centered
then dichotomized; the peer smoking variable was naturally dichotomized. The
dichotomized variables were then multiplied to form the interaction variable.
Interactions of the independent variables with sex were tested for each model, and
where there appeared to be a positive interaction of the independent variables with
sex, each model was then analyzed for each gender.
Results
Univariate analysis revealed that the independent cultural variables under
study were normally distributed. Table 5 presents the Pearson correlation
coefficients for the cultural variables with the smoking behavior outcome variables.
Both social conformity and gender specific norms were positively and significantly
correlated with all three smoking behaviors under study, while the
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familism/obedience index and religious relevance were negatively and significantly
correlated with the smoking behavior variables (Table 5).
Table 5: Pearson’s Correlation Coefficients between Cultural Factors and Smoking
Behavior
Ever-Smoking 30-day Smoking Susceptibility
Gender-specific Norms 0.4* 0.3* 0.3*
Social Conformity 0.4* 0.4* 0.3*
Familism/Obedience -0.5* -0.4* -0.4*
Religious Relevance -0.3* -0.2* -0.2*
Note: * p < 0.0001
Main Effects of Cultural Factors on Smoking Behavior
There were no interactions between familism and gender or between
religious relevance and gender; therefore the analysis was performed for the whole
sample. Controlling for demographics and psychosocial smoking risk factors, both
familism /obedience to parents and religious relevance were protective against any
of the smoking behavior variables under study. Adolescence with high levels of
familism/obedience were less likely to have experimented with smoking, smoked in
the past 30 days, or be susceptible to future smoking than those with lower levels of
familism/obedience (OR= 0.8 95% CI= 0.8-0.9, OR= 0.8 95% CI= 0.8-0.9, OR=
0.9 95% CI= 0.8-0.9 respectively). Similarly religious relevance decreased the odds
of ever-smoking, 30-day smoking and susceptibility to smoking (OR= 0.4 95% CI=
0.3-0.5, OR= 0.3 95% CI= 0.2-0.5, OR= 0.5 95% CI= 0.4-0.6 respectively).
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There was a significant interaction between social conformity and sex, and
between gender specific norms and sex, therefore the multiple logistic regression
model for each dependent smoking variables was analyzed for each gender,
controlling for age, SES and the psychosocial smoking risk factors. Tables 6, 7 and
8 present the odds ratios and 95% Cl, by gender, for the gender specific norms and
social conformity constructs associated with ever-smoking, 30-day smoking and
susceptibility to smoking, respectively.
Table 6: Cultural Factors Associated with Ever Smoking, by Gender
Males Females
OR 195% c n OR 195% CD
Gender Specific Norms 6.0* 3.7-9.7 1.4 f 0.7-2.7
Social Conformitv 1.3* 1.2-1.5 1.01 0.8-1.1
Note: Controlled for family and peer smoking, perceived peer and adult smoking norms, age and
SES
* p <0.0001
| Not significant, i.e. p > 0.05
Table 7: Cultural Factors Associated with 30-Day Smoking, by Gender
Males Females
OR 195% CD OR 195% CD
Gender Specific Norms 6.8* 3.6-12.9 0.9f 0.4-2.3
Social Conformitv 1.8* 1.6-2.1 1.11 0.9-1.3
Note: Controlled for family and peer smoking, perceived peer and adult smoking norms, age and
SES
* p <0.0001
t Not significant, i.e. p > 0.05
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Table 8: Cultural Factors Associated with Susceptibility to Smoking, by Gender
Males Females
OR (95% CD OR (95% CD
Gender Specific Norms 3.2* 2.2-4.6 1 .1 f 0.8-1.7
Social Conformitv 1.2* 1.1-1.3 1.01 0.9-1.1
Note: Controlled for family and peer smoking, perceived peer and adult smoking norms, age and
SES
*p <0.0001
t Not significant, i.e. p > 0.05
As hypothesized, social conformity was associated with an increased risk of
ever-smoking, 30-day smoking and susceptibility to smoking for males (P = 0.29, p
< 0.0001, p= 0.6, p < 0.0001, p= 0.14, p = 0.0005 respectively), but not for
females. Similarly, gender specific norms was associated with an increased risk of
ever-smoking, 30-day smoking and susceptibility to smoking for males (P= 1.7, p
< 0.0001, P= 1.9, p < 0.0001, p= 1.02, p < 0.0001 respectively), but not for
females.
Interaction between Social Conformity and Peer Smoking
There was a statistically significant interaction between social conformity
and peer smoking on susceptibility to future smoking among the adolescent male
population (p=0.02). Males with who exhibited high social conformity and had
friends who smoked were significantly more likely to be susceptible to future
smoking (OR= 3.5 95% CI= 2.5-5.1) than those who exhibited high social
conformity and whose friends did not smoke (OR= 1.7 95% CI= 1.0-2.8). Figure 4
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presents the interaction graph of social conformity and peer smoking for the male
population among Egyptian adolescents under study.
Figure 4: Interaction between Social Conformity and Peer Smoking on Susceptibility to
Smoking among Egyptian Adolescent Males
2 5 0
200
S' 1 5 0
Peer Smoking = Yes
Peer Smoking = No
J * io o
Low High
Social Conformity
Discussion
The results of this study are consistent with other studies that have shown
that adolescent males were at a much higher risk for smoking behavior than
adolescent females (Brownson et al., 1992, Doyal, 2001, Grunberg et al., 1991).
Egyptian adolescent males in this study were almost twice as likely as the females
to engage in any of the smoking behaviors under study. This difference may be
explained by some of the Egyptian cultural factors, such as gender specific norms
and social conformity, which appear to act differentially between the genders.
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As hypothesized, both social conformity and gender specific norms were
significantly associated with an increased risk of smoking behavior for Egyptian
adolescent males but not the females, after controlling for demographics and
psychosocial smoking risk factors. This differential influence may be due to the
fact that Egypt is a patriarchal society governed by traditional gender differentiated
roles and norms (Bernard, 1994), a factor that has been shown to be a risk factor for
smoking behavior among males (Morrow et al., 2002, Shiftman, 1998). Gender
differentiated norms are reinforced through the masculinity /femininity concept
prevalent in Arab cultures. This concept is the Arab equivalent of the
machismo/marianismo characteristic prevalent in Latin culture (Cuellar et al., 1995,
Neff et al., 1991). Masculinity is an Arab male gender characteristic and role that
emphasizes male dominance, physical strength, virility, bravado, protectiveness of
females, and financial responsibility and emotional support to family and friends,
while repudiating all feminine characteristics (Abd Al Hameed and Al Sheikh,
1978b, Al Ansari, 1996, Kamal Ahmad 'Awn, 1955, Moussa, 1992). Whereas
femininity is an Arab female characteristic and role that emphasizes modesty,
kindness, passiveness, sacrifice for family and children, obedience to family and
spouse, and contentment with bearing and rearing children, while repudiating all
masculine characteristics (Abd Al Hameed and Al Sheikh, 1978a, Al Ansari, 1996,
Al Faruqi, 2001). It is not surprising that Egyptian adolescent males who believe in
gender-specific norms would be at an increased risk for smoking initiation than
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their female counterparts. This may be due to the underlying sociocultural beliefs
of their mainstream society, which may include beliefs that smoking helps promote
an image of masculinity, maturity and toughness, characteristics that are idealized
by young males in the Egyptian culture. For Egyptian adolescent females, smoking
behavior is considered contrary to the ideal feminine image reinforced in Egyptian
society and aspired to by most adolescent girls. Smoking may be regarded as a
male characteristic which young respectable females should avoid. Adolescent
females may perceive that engaging in smoking behavior may affect a girl’s
reputation and prospects of a good marriage, and therefore adolescent females may
be less likely to engage in any smoking behavior than their male counterparts
(Islam and Johnson, 2003). Therefore, interestingly and contrary to our hypothesis,
gender specific norms appeared to be risk factors for ever-smoking and
susceptibility to future smoking among the females, although not statistically
significant. One explanation may be an underlying feeling of rebelliousness against
the differentiated cultural norms and expectations imposed upon the Arab females.
Egyptian adolescent females may perceive that since smoking is a socially and
culturally acceptable behavior for males but not females, engaging in smoking
behavior would be one way to express their rebelliousness against these cultural
and societal norms.
As mentioned earlier, Egypt has the highest adult smoking prevalence
among the Arab countries (WHO, 1997) , with 40% of the Egyptian adult male
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population being current daily smokers, compared to only 18% of the adult female
population (ERC Statistics International, 2001). Social conformity, as
hypothesized, appears to be a smoking risk factor for adolescent males but not
adolescent females. Adolescent males may look up to the adult male population and
their peers for acceptable social behavior and norms, and then try to emulate that
behavior, including the uptake of smoking. Although adolescents tend to
overestimate the prevalence of smoking among their peers (Sussman et al., 1988),
social conformity among adolescent males was associated with an increased risk of
all three smoking behaviors under study, even after controlling for perceived peer
and adult smoking norms, family smoking, peer smoking, age and SES. On the
other hand, adolescent females high in social conformity values would be expected
to conform to the behavior of other females in a culture where smoking is
unacceptable for women and where female smoking prevalence is much lower than
that of the males. Therefore, having high levels of social conformity would not
pose any risk for the initiation of smoking among Egyptian adolescent females.
Although this study did not find any significant interaction effects between
social conformity and peer-smoking on ever-smoking and 30-day smoking
behaviors, as hypothesized, there was a significant interaction effect between the
level of social conformity and peer smoking on susceptibility to future smoking.
The lack of statistical significance for the interaction on ever smoking and 30-day
smoking may be due to low statistical power, whereas, the power to demonstrate an
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effect for susceptible individuals would be greater than the other two smoking
behaviors, since susceptible individuals include ever-smokers and 30-day smokers.
The presence of a statistically significant interaction between the level of
social conformity and peer smoking on susceptibility to future smoking among the
male population demonstrates that adolescent males with high levels of social
conformity and who have friends who smoke were more likely to be susceptible to
future smoking than those with high levels of social conformity whose friends did
not smoke. Adolescent males with high levels of social conformity may attempt to
fit in with their peers by emulating and conforming to their peers’ smoking
behavior, rather than distinguishing themselves from them (Alexander et al., 1999,
Comeau et al., 2001, Pederson et al., 1997). They may look to their peer group for
social norms about whether smoking is appropriate or not, and then they may alter
their own smoking behavior to conform to their peer s’ smoking behavior(Unger et
al., 2001a). Although social conformity in itself is an adolescent male smoking risk
factor, having friends who smoke exacerbates the risk of future smoking.
As hypothesized, familism/obedience to parents and religious relevance
both appeared to have a protective influence against the uptake of smoking across
genders. Adolescents who have high levels of familism/obedience may not attempt
to initiate a behavior that may cause shame to their family, disrespect to their
parents and affect their family’s reputation. Therefore, the higher the level of
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familism/obedience to the adolescent, the less likely it is that the adolescent would
engage in any smoking behavior.
Religious relevance appears to be the most protective cultural factor against
adolescent smoking behavior for both genders. Although this construct was
measured by only one item, it still points to the importance and relevance of the
religious standing on the acceptability of smoking behavior for the Egyptian
adolescent. Adolescents who believe in complying with their religious teachings
appear to be less likely to engage in risky behaviors such as smoking. This result
supports other studies from the United States, Europe and Israel that have shown
that high levels of religiosity was associated with lower smoking rates among
adolescents (Atkins et al., 2002, Heath et al., 1999, Kandel et al., 1981, Patock-
Peckham et al., 1998, Sperber et al., 2001, Sutherland and Shepherd, 2001).
Implications
The results of this study points to the notion that smoking prevention
programs aimed at Egyptian adolescents should be culturally tailored and gender
specific. Emphasizing and encouraging cultural factors, among both genders, such
as familism and obedience to parents, and incorporating religious messages that
emphasize the unacceptability of any smoking behavior in either religions, during
the early years of adolescence, may reduce adolescent smoking prevalence,
initiation and susceptibility to future smoking across genders.
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Smoking prevention programs aimed at Egyptian adolescent males should
correct the erroneous perception of the social acceptability of male smokers, and
emphasize that smoking is a socially unacceptability behavior for either gender,
while encouraging the incorporation of the positive aspects of the traditional gender
differentiated roles and norms, such as responsibility and loyalty to family and
friends. These programs should emphasize that smoking does not make the
adolescent male more masculine and/or more mature, but on the contrary, smoking
behavior may make the adolescent appear careless of his future and disrespectful
for his family name. This may be a difficult and sensitive issue when dealing with
Arab adolescent males, and care must be taken when delivering this message so as
not to alienate the adolescent male by admonishing a cultural value he believes in
and which has been the norm for Arab males for ages. The same applies to the
social conformity cultural value. Smoking prevention program aimed at Egyptian
adolescent males should encourage social conformity to healthy behaviors and
individual decision making in situations when the adolescent’s peer group appears
to be engaging in risky behaviors including smoking.
Limitations
Results of this study are based on cross-sectional data, so causal influences
cannot be determined. The reverse direction of casualty is plausible. Male
adolescents who have already experimented with cigarettes might rationalize their
behavior by an increase in their belief that it is an acceptable behavior for males yet
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not for females, and not vice versa. Also male adolescents who have already tried
smoking may associate themselves with peers who smoke which would give the
appearance that they are socially conforming to their peers, though the direction of
causality is actually reversed.
The religious relevance variable is assessed by one item only, which may
weaken its construct validity. Future surveys measuring this construct should
include at least 3 relevant items with high a Cronbach alpha to improve its
construct validity.
This study is based on random sampling of schools and students in the city
of Alexandria, Egypt, therefore the results can only be generalized to Egyptian
adolescents living in Alexandria, and cannot be generalized to the rest of
adolescents in other Egyptian cities. Cultural variables found to be significantly
associated with smoking behavior among these adolescents may differ for other
Egyptian adolescents in other cities, especially if they live in the more westernized
capital city of Cairo, or in the more traditional suburban cities that make up Egypt.
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Chapter 5
Influence of Known Psychological Smoking Risk Factors
Egyptian Adolescents’ Smoking Behavior
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Background
Numerous western studies have shown an association between
psychological factors and predispositions involved in temperament traits and affect
regulation and adolescent smoking behavior (Biglan et al., 1995, CDC, 1998,
Charlton et al., 1999, Cohen et al., 1994, Conrad et al., 1992, Fichtenberg and
Glantz, 2002, Fisher et al., 1993, Flay et al., 1994, Gilpin and Pierce, 2001,
Landrine et al., 1994, Ling et al., 2002, Mermelstein, 1998, Stanton and Silva,
1992, Unger et al., 1997, Unger et al., 2001b, Unger et al., 2002, USDHHS, 1998,
Wang et al., 1995). This association may be due to the underlying physiologic
effects of nicotine and its various actions on the brain chemical systems (Center of
Addiction and Mental Health, 1998). The metabolic effects of nicotine include the
stimulation and release of specific neurotransmitters such as dopamine,
acetylcholine, norepinephrine, serotonin, and beta-endorphin (Center of Addiction
and Mental Health, 1998, Institute of Medicine, 1994, Little, 2000, Pomerleau and
Pomerleau, 1984, USDHHS, 1988), which are associated pleasure and euphoria,
improved cognitive performance and reduction of anxiety and depression (Institute
of Medicine, 1994, Little, 2000). The theory of "self-medication" proposes that
tobacco use may be the result of underlying intrapsychic distress and may be seen
as a way of dealing, at least temporarily, with emotional disorders (Carmody, 1989,
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Glantz and Pickens, 1992, Khantzian and Khantzian, 1984, Pomerleau and
Pomerleau, 1984).
During adolescence, significant physical, emotional and hormonal changes
occur (World Book Medical Encyclopedia, 1998), which may affect adolescents’
interpersonal social roles (Oetting et al, 1998). Adolescents, who have difficulty
adjusting to these changes, may become depressed and be motivated to initiate
smoking to relieve their symptoms and improve their mood (Carmody, 1989,
Pomerleau and Pomerleau, 1984). Alternately, there are times when spurts of
intense physical energy may lead adolescents to unbounded enthusiasm for risky
behaviors, which may be counterproductive to their well-being, such as smoking
and excess alcohol consumption (Institute of Medicine, 1999).
The self-medication theory of smoking has been supported by a number of
western studies which have demonstrated a positive association between depression
and smoking initiation and maintenance among adolescents (Conrad et al., 1992,
Escobedo et al., 1996, Murphy and Price, 1988, Patton et al., 1998, Warburton,
1985). However, there is a scarcity of studies investing whether the relationship
between depression and smoking behavior is supported by the self-medication
theory among Arab adolescents. This study investigates the association between
depression and smoking behavior among Egyptian adolescents to see whether the
self-medication theory also applies to Egyptian youth.
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Other temperament traits found to be associated with adolescent smoking
behavior include hostility, impulsivity and sensation seeking tendencies. Numerous
studies have reported positive associations between smoking behavior and anti
social tendencies for adults, adolescents and children (Brook et al., 1995a, Brook
et al., 1995b, Fallon et al., 2004, Johnson et al., 1989, Oetting et al., 1998,
Reynolds and Nichols, 1976, Whiteman et al., 1997). Brook et al. (1995) proposed
that childhood hostility may lead to rebellion against societal norms during
adolescence and may be expressed in the form of tobacco use (Brook et al., 1995a).
Recently, Fallon et al. (2004) found biological evidence that people with hostile
personalities were more predisposed to cigarette addiction than non-hostile
individuals, and were more likely to get hooked on smoking if they ever
experiment with cigarettes (Fallon et al., 2004). Nicotine appears to have a calming
effect on hostile smokers by reducing the effect of anger in these subjects, through
its metabolic effects on the brain (Delfino et al., 2001, Jamner et al., 1999, Whalen
et al., 2001).
Impulsivity has been defined in a number of ways, depending on whether
the definition is from the personality or the behavioral literature. Personality
theorists equate high levels of impulsivity with preferences for immediate
gratification, lack of planning or thinking, risky activities, and easier routes to self
gratification (McCown et al., 1993, Mitchell, 1999, Patton et al., 1995). In the
behavioral literature, impulsive behavior is defined as choosing a small, relatively
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immediate reward over a larger but more delayed reward (Acton, 2001, Ainslie,
1975, Eysenck and Eysenck, 1977, Logue et al., 1986, McCown et al, 1993,
Mitchell, 1999, Rachlin, 1995), as well as an individual’s tendency to make rapid
behavioral decisions to a given stimulus without deliberation and evaluation of the
consequences regardless of the loss of a later reward of greater magnitude (Gerbing
et al., 1987, Little, 2000). A number of studies found a positive association between
impulsivity and western adolescent smoking behavior (Foreyt et al., 1993, Johnson
et al., 1996, Kawakami et al., 2000, Mitchell, 1999, Patton et al., 1993,1997,
Poulos et al., 1995, Poulos et al., 1998).
Sensation seeking is the characteristic of continuously looking for new
experiences to fulfill a need for excitement. People who require high levels of
stimulation are more likely to have sensation seeking tendencies, than those
requiring low levels of stimulation (Rothbart and Ahadi, 1994). Individual
differences in sensation seeking tendencies have consistently differentiated smokers
from non-smokers(Gilbert and Gilbert, 1995, Zuckerman et al., 1990). Numerous
studies have shown that smoking initiation and maintenance was higher in
personalities with high sensation seeking tendencies than in the general population
(Donohew et al., 1999, Gilbert and Gilbert, 1995, Heath et al., 1995, Hobfoll and
Segal, 1983, Newcomb and McGee, 1991, Pomerleau et al., 1992, Spielberger and
Jacobs, 1982, Stacy and Newcomb, 1999, Teichman et al., 1989, Zuckerman et al.,
1990). Some studies have found that the relationship between sensation seeking
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and smoking may vary across cultural groups (Cherpitel, 1999, Kaestner et al.,
1977, Simon et al., 1994). Whether hostility, impulsivity and sensation seeking
tendencies have the same positive influence on Egyptian adolescents’ smoking
behavior remains to be seen.
The current study investigates the impact of the above psychological
smoking risk factors on Egyptian adolescents’ smoking behavior, to see whether
they have the same impact on Egyptian adolescents’ smoking behavior as they do
on western adolescents’ smoking behavior. Results of this study may help
researchers design more effective smoking prevention programs aimed at Egyptian
adolescents to help curb the rising smoking epidemic in Egypt.
Measures
Measures of Psychological Factors
Depression was assessed using the abridged scale of the Center for
Epidemiological Studies Depression scale (CES-D) (Radioff, 1977), used by Galaif
et al. (1998) (Galaif et al., 1998). This scale selected the five items that loaded the
highest on the first order factor, called “depression” in the CES-D scale. Students
were asked to think about how they felt during the past 7 days, and respond to the
following 5 questions; “I had trouble shaking off sad feelings”, “I felt depressed”,
“I felt like crying for no apparent reason”, “I felt lonely” and “I felt sad”. Response
choices were rated on a four-point scale,“1 = rarely or none of the time (less than 1
day)”, “2 = some or little of the time (1-2 days), “3 = occasionally or a moderate
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amount of time (3-4 days)” to “4 = most or all of the time (5-7 days)”,
(standardized a = 0.78). The depression index was formed by summing the
responses to the above five items. Higher numbers indicated higher levels of
depression.
Hostility was assessed based on items in the “Irritability” and “Verbal”
subscales of the Buss-Durkee Hostility Inventory Scale (Buss and Durkee, 1957).
Students were asked to respond to the following 6 questions; “I lose my temper
easily, “Sometimes people bother me just by being around”, “I can’t help being a
little rude to people I don’t like”, “Lately, I have been kind of grouchy”, “When
people annoy me, I tell them what I think of them” and “I can’t help getting into
arguments when people disagree with me”. Response choices were rated on a four-
point scale, “1 = never”, “2 = occasionally”, “3 = often” and “4 = Always”,
(standardized a = 0.8). The hostility index was formed by summing the responses
to the above six items. Higher numbers indicated higher levels of hostility.
Impulsivity in this study is defined as the inclination for behaving in a
certain manner without thinking about the future consequences of such behavior.
Impulsivity was assessed using the motor impulsiveness subscale of the Barratt
Impulsiveness Scale (BIS-11) (Patton et al., 1995), which measures behaviors that
are performed without thinking, i.e. “acting on the spur of the moment”. The BIS-
11 has been used in a number of studies investigating impulse control and
substance use, including smoking (Mitchell, 1999, Moeller et al., 2001, Petry,
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2001), and the translated versions of this scale has been shown to have good
reliability in a number of studies in Japan, Italy and France (Bayle et al., 2000,
Fossati et al., 2001, Someya et al., 2001). Accordingly, students were asked to
respond to the following 4 items, “I act on impulse”, “I buy things on impulse”, “I
make up my mind quickly” and “I do things without thinking”. Response choices
were rated on a four-point scale, “1 = never”, “2 = occasionally”, “3 = often” and
“4 = Always”, (standardized a = 0.8). The impulsivity index was formed by
summing the responses to the above four items. Higher numbers indicated higher
levels of impulsivity.
Sensation seeking was assessed using 5 items from the Zuckerman-Kuhlman
Personality Questionnaire subscale (Simon et al., 1994). Students were asked to
respond to the following five items, “I like to have new and exciting experiences
and sensations even if they are a little frightening”, “I like to do things just for the
thrill of it”, “I sometimes like to do things that are a little frightening”, “I
sometimes do crazy things just for fun”, and “I prefer friends who are exciting and
unpredictable”. Response choices were rated on a four-point scale, “1 = never”, “2
= occasionally”, “3 = often” and “4 = Always”, (standardized a = 0.86). The
sensation seeking index was formed by summing the responses to the above four
items. Higher numbers indicated higher levels of sensation seeking.
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Measurement of Covariates
The relevant covariates included demographic variables (age, gender and
SES), peer and family smoking status, perceived peer and adult smoking norms,
and the cultural factors, familism/obedience and religious relevance. These
covariates were included in this study since they have been shown to be associated
with the Egyptian adolescents’ smoking behaviors (chapters 3 and 4).
Measurements of the outcome smoking variables and the relevant covariates are
described in chapters 2,3 and 4 of this overall study.
Data Analysis
Descriptive statistics (frequencies, percentages and means) were used to
examine smoking prevalence and age of respondents. Correlation analysis was used
to examine the correlation of the independent and dependent variables under study,
and to examine the Cronbach alpha for each psychological construct under study.
Chi-square analyses were used to compare the prevalence of ever smoking, 30-day
smoking, current smoking and susceptibility to smoking across genders. T-tests
analyses were used to compare the mean age across genders.
Multiple logistic regressions were used to assess the odds ratios (OR) and
95% confidence intervals (Cl) of the association between the independent and
dependent variables. Three separate regression models for the three dependent
variables were analyzed. Each model included all psychological variables under
study, controlling for demographic smoking risk factors (sex, age and SES), known
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social and psychosocial smoking risk factors (peer smoking, family smoking,
perceived peers and adults smoking norms), familism/obedience and religious
relevance. Interactions of the independent variables with sex were tested for each
model, and where there appeared to be a significant interaction of the independent
variables with sex, each model was then analyzed by gender.
All statistical analysis was completed using the SAS system version 9.0
(SAS Institute, 2002).
Results
Main Effects of Psychological Factors on Ever and 30-Day Smoking Behavior
There was no interaction effect between depression and gender or between
impulsivity and gender on ever-smoking or on 30-day smoking behavior; however,
there was a statistically significant interaction between gender and hostility and
between gender and sensation seeking on ever-smoking and 30-day smoking
behavior. Accordingly, logistic regression models for ever-smoking and 30-day
smoking were analyzed twice, once for the whole sample with depression and
impulsivity as independent variables, and once by gender with hostility and
sensation seeking as independent variables. All logistic models were controlled for
family smoking, peer smoking, perceived peer and adult smoking norms,
familism/obedience to parent, religious relevance, sex, age and SES.
Depression was not significantly associated with ever-smoking or 30-day
smoking for either of the genders (p = 0.06, p =0.43, respectively). While
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impulsivity increased the risk of ever-smoking (OR =1.1,95% Cl = 1.1-1.2, p
<0.0001) and 30-day smoking (OR = 1.2,95% Cl = 1.1-1.2, p = 0.0005) for both
genders.
Table 9 presents the ORs and 95% Cl for the associations of hostility and
sensation seeking with ever-smoking and 30-day smoking by gender. Hostility was
positively and significantly associated with ever-smoking and 30-day smoking
behavior for males but not for females. Hostile males were 1.2 times more likely to
have experimented with cigarettes and 1.3 times more likely to have smoked in the
past 30 days than their female counterparts. Similarly, sensation seeking tendencies
appeared to influence the males smoking behavior, but not the females. Males with
sensation seeking tendencies were 1.2 times more likely to have experimented with
cigarettes, and 1.1 times more likely to have smoked in the past 30 days than
females (Table 9).
Table 9: Associations of Hostility and Sensation Seeking Tendencies with Ever-Smoking
and 30-day Smoking behavior, by Gender
Ever-Smoking 30-Day Smoking
Males Females Males Females
OR 95% Cl OR 95% Cl OR 95% Cl OR 95% Cl
Hostility 1.2 1.1-1.3 l.Of 0.8-1.0 1.3 1.2-1.4 l.Of 0.9-1.1
Sensation Seeking 1.2 1.1-1.3
- H ?
0
v ©
1
1 .1 1.1-1.2 l.Of 0.95-1.1
Note: Adjusted for family smoking, peer smoking, perceived peer and adult smoking norms,
familism/obedience, religious relevance, age and SES
f Not significant p > 0.05
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Main Effects of Psychological Factors on Susceptibility to Smoking
There was no interaction between sex and any of the psychological
variables under study for susceptibility to smoking; therefore the logistic regression
model was analyzed for the whole sample. The model included all the
psychological independent variables controlling for family smoking, peer smoking,
perceived peer and adult smoking norms, familism/obedience to parent, religious
relevance, sex, age and SES.
Depression was not associated with susceptibility to smoking ( p= 0.3).
High levels of impulsivity, hostility and sensation seeking were all positively
associated with susceptibility to smoking for both genders (P = 0.15, p < 0.0001, P
= 0.097, p < 0.0001, p= 0.07, p < 0.0001, respectively). Table 10 presents the
ORs and 95% Cl of the associations of impulsivity, hostility and sensation seeking
with susceptibility to smoking.
Table 10: Psychological Factors Associated with Susceptibility to Smoking across Genders
of Egyptian Adolescents
Susceptibility to Smoking
OR 195% CD
Impulsivity 1.2 1.1-1.2
Hostility 1 .1 1.1-1.14
Sensation Seeking 1 .1 1.04-1.1
Note: Adjusted for family smoking, peer smoking, perceived peer and adult smoking norms,
familism/obedience, religious relevance, sex, age and SES
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Discussion
It is interesting that the association between depression and smoking
behavior differs among Egyptian and western adolescents. It may be because, in
general, Egyptians, especially the Muslims, regard the ability to experience
depression as a mark of depth of personality and wisdom (Ritts, 1999). Muslims
rarely complain of a depressed mood and when they do, it is manifested in somatic
symptoms (Good et al., 1985). Therefore, the self-medication theory of smoking
does not appear to apply to Egyptians, since smoking will not alleviate somatic
symptoms of depression.
The results of the analysis for the association of impulsivity and smoking
behavior for this population are consistent with previous studies among western
adolescents which demonstrated a positive association between impulsivity and
smoking behavior across gender (Donohew et al., 1999, Gilbert and Gilbert, 1995,
Heath et al., 1995, Johnson et al., 1996, Kawakami et al., 2000, Mitchell, 1999,
Patton et al., 1997, Pomerleau et al., 1992, Poulos et al., 1995, Poulos et al., 1998,
Stacy and Newcomb, 1999, Zuckerman et al., 1990). Egyptian adolescents with
higher impulsive behavior tendencies appear to be at a higher risk for
experimentation with cigarettes, 30-day smoking and susceptibility to future
smoking, than adolescents with lower impulsive behavior tendencies. Impulsive
adolescents are most probably choosing the immediate reinforcing effects of
nicotine over the delayed benefit of healthier future.
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Interestingly, there appears to be a differential effect of hostility and
sensation seeking tendencies on gender for ever-smoking and 30-day smoking
behavior, though both are positively and significantly associated with susceptibility
to smoking across genders. This may be due to some of the underlying Egyptian
cultural factors which allow certain behaviors for males, but not for the females
(Chapter 4) . Susceptible females with high levels of hostility and sensation seeking
tendencies may perceive that smoking is an exciting behavior and a way to express
their antisocial tendencies, so they may not adamantly rule out the possibility of
future smoking. Since Egypt is a patriarchal collective Muslim society governed by
traditional cultural values (Bernard, 1994), behaviors associated with hostility and
sensation seeking tendencies may be better tolerated for males than females. The
differential tolerance for Egyptian males’ temperament trait tendencies and
behaviors stems from a cultural factor that is common in most Arab countries, the
masculinity/femininity concept. Masculinity is a male gender characteristic that
emphasizes male dominance, physical strength, virility, bravado and responsibility
for one’s family, whereas femininity is the female counterpart that emphasizes
kindness, passiveness, modesty, sacrifice, obedience and contentment with
whatever life has to offer (Al Ansari, 1996, Al Faruqi, 2001, Moussa, 1992). This
gender differentiated role and norm may be an underlying factor in facilitating the
expression of hostility and sensation seeking tendencies among Egyptian males,
while prohibiting Egyptian females from expressing the same tendencies. Females
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who have hostility and sensation seeking tendencies may try to exert more self-
control in expressing those tendencies for fear of being labeled as unfeminine and
having masculine characteristics, which may in turn ruin their reputation and lower
their prospects of a good marriage. Therefore, it is not surprising that males with
hostility and sensation seeking tendencies would be at a higher risk for smoking
initiation than their female counterparts, especially if the males perceive that
smoking helps promote an image of masculinity.
Implications
Depression among this population of Egyptian adolescents does not appear
to be associated with smoking behavior for either gender, and therefore should not
be considered as a smoking risk factor when designing a selective smoking
prevention program for this population.
Since Egyptian cultural factors may predispose Egyptian adolescent males
with certain temperament traits to an increased risk of smoking behavior, therefore
smoking prevention programs aimed at Egyptian adolescents should be selective
and gender specific. Selective smoking prevention programs targeting adolescent
males in the early years, who exhibit the temperament trait tendencies investigated
in this study, may be helpful in preventing smoking initiation among this male
population.
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Limitations
Results of this study are based on students' self-reports of their smoking
behavior. Although respondents were assured of their anonymity, Egyptian students
may have been suspicious and fearful of entrapment, especially female students,
and therefore may have underreported their smoking behavior in an attempt to
appear socially correct. Though adolescents' self-reports of smoking obtained under
similar conditions in the United States, have been shown to be quite accurate across
ethnic groups (Wills and Cleary, 1997), it is not known whether this is also true for
Egyptian adolescents.
Another limitation is that the results of this study are based on cross-
sectional data, so causal influences cannot be determined. The reverse direction of
casualty is plausible, though it is hard to explain how adolescents who have already
experimented with cigarette smoking or are 30-day smokers would choose to be
impulsive, or for males who have already experimented with cigarette smoking or
are 30-day smokers to choose to be more hostile or start to prefer sensation seeking
activities.
This study is based on random sampling of schools and students in the city
of Alexandria, Egypt, therefore the results can only be generalized to Egyptian
adolescents living in Alexandria, and cannot be generalized to the rest of
adolescents in other Egyptian cities. Cultural variables found to be significantly
associated with smoking behavior among these adolescents may differ for other
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Egyptian adolescents in other cities, especially if they live in the more westernized
capital city of Cairo, or in the more traditional suburban cities that make up Egypt.
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Chapter 6
Influence of Pro-Tobacco Media on Egyptian Adolescents
Smoking Behavior
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Background
Numerous western studies have implicated the tobacco industry’s
advertising, promotion and marketing activities as possible causal agents in the
uptake of smoking among adolescents (Altman et al., 1996, Beltramini and Bridge,
2001, Borzekowski et al., 1999, Cummings and Shah, 1995, Di Franza et al., 1991,
Evans et al., 1995, Hoek and Sparks, 2000, Schooler et al., 1996a, Schooler et al.,
1996 b). Pierce et al. (1994,1995) demonstrated a sharp increase in adolescent
smoking that coincided with the conduct of effective tobacco promotional
campaigns (Pierce and Gilpin, 1995, Pierce et al., 1994). Pierce et al. (1998) also
found that adolescents who were receptive to tobacco promotional activities were
more susceptible to progression towards future smoking (Pierce et al., 1998) than
those who were less receptive to tobacco promotions.
With the increased legislations and regulations for tobacco advertising and
promotion in the developed world (Hoek and Sparks, 2000), the effect of
globalization in increasing the liberalization of trade by decreasing trade
restrictions of most goods, including tobacco products (Taylor et al., 2000), and the
sharp criticism towards tobacco manufacturers for targeting adolescents in the west,
the tobacco industry started exploring new markets and new promotional vehicles
in the developing world (Taylor et al., 2000, Warner, 1986), where people are less
aware of the hazards of tobacco use (Cornwell, 1997). Potential smokers in low and
middle income countries, with little or no experience in consumer advertising, may
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be more influenced by the sophisticated marketing techniques of tobacco
companies than are potential smokers in the developed western world today
(Andrews and Franke, 1991).
To understand the influence of tobacco advertising on adolescents, one first
needs to define what is meant by advertising. Advertising can be defined as the use
of media to create positive product imagery and/or associations and to connect the
product with desirable personal traits, activities and outcomes (Taylor et al., 2000).
In the case of tobacco advertising, and since most adult smokers initiate smoking
during adolescents (Chassin et al., 1996, Lee et al., 1993), tobacco companies
concentrate all their efforts in advertising, promoting and marketing their product
to susceptible adolescents to recruit new smokers and reinforce existing use.
Research has begun to document the fact that adolescents have a heightened
sensitivity to image advertising and promotion, since they are often struggling to
define their own identities (Basil et al., 2000, Borzekowski et al., 1999). Early
adolescence in particular may be a time of increased susceptibility to the appeal of
advertising that promotes certain images attractive to young teenagers
(Borzekowski et al., 1999). Adolescents from developing countries are erroneously
led to believe that tobacco consumption is a social norm among attractive, vital,
successful people who seek to express their individuality, enjoy life, and are
socially secure (Institute of Medicine, 1999, Schooler et al., 1996a, Schooler et al.,
1996b). This message is driven home to adolescents by their near-constant
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exposure to pro-tobacco messages and images designed to create a fantasy of
sophistication, pleasure and social success associated with the glamorous western
life-style (Taylor et al., 2000), such that initiating smoking is perceived as a link to
this aspired to life-style.
There is a scarcity of studies investigating the influence of tobacco
advertising and marketing in low and middle income countries of the developing
Arab world, where adolescent smoking has been on the rise for the past few
decades (WHO, 1997). One such lower middle income Arab country which has
been aggressively targeted by the tobacco industry, is Egypt (Ahmed et al., 1999,
Dowell, 1997, Jha and Chaloupka, 2000).
Egypt has the highest rate of tobacco consumption in the Arab world
(WHO, 1997). It is estimated that 33.5% of Egyptians are daily smokers (CDC
Nations, 2001), with adult males having significantly higher daily smoking rates
than adult females (40 % males, 18% females) (ERC Statistics International, 2001).
According to the Global Youth Tobacco Survey (GYTS), conducted for the Centers
of Disease Control and Prevention in 2001, 19.6% of Egyptian youth aged 13-15
years were current smokers (22.8% males,15.8% females) (Global Youth Tobacco
Survey Collaborative Group, 2002). Over the past 30 years, the number of smokers
in Egypt has increased 8-9% on a yearly basis, over twice as fast as the birth rate
(Global Initiatives, 1998, Hammond, 2002). In 1997, there were six million
Egyptian smokers, of which 513,000 were children under the age of 10 (Arab
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News, 1997). In 2002, the number of smokers in Egypt rose to 16 to 17 million
(Hammond, 2002).
Like many developing countries, Egypt has only partial restrictions on the
sale and promotion of tobacco products (Brigden, 2001, Saffer, 2000, WHO, 1997).
Tobacco sales to minors (under 18 years) is prohibited, however, the law is not
enforced, such that 93% of adolescent current smokers surveyed in the GYTS, had
no problem purchasing cigarettes from shop owners and were not refused because
of their age (Dous, 2003) .While tobacco advertising is banned on radio and
television (Pomeroy et al., 1999, WHO, 1997), and the price of cigarettes is
controlled by the government (Dowell, 1997), there is no restrictions on magazines
and billboard advertisements or on the distribution of free tobacco products and
merchandize with tobacco companies’ logos (Dowell, 1997, WHO, 1997).
Consequently, tobacco companies use aggressive marketing campaigns to build
brand recognition and attract new smokers from among the Egyptian youth
(Dowell, 1997). These marketing strategies include promotions of contests
promising trips to exotic places, distribution of free samples, placing tobacco
companies’ logos on t-shirts, backpacks and other items popular with youth, and
tobacco ads in magazines portraying images of healthy and dynamic young men
and woman enjoying exciting, glamorous and adventurous lifestyles, while
smoking (Brigden, 2001).
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The purpose of this study is to investigate the influence of pro-tobacco
media on the smoking behavior of Egyptian adolescents. The study controls for the
influence of other established smoking risk factors, such as demographics, peer and
family smoking behavior, positive beliefs about smoking and the influence of
exposure and receptivity to western media, in an effort to isolate the influence of
pro-tobacco media on the smoking behavior of Egyptian adolescents.
Measures
Measurement of Exposure to Pro-Tobacco Media
Exposure to pro-tobacco media was assessed using the format used by
Schooler et al. (1996) (Schooler et al., 1996a). Respondents were asked to rate how
often they see pro-tobacco advertising in magazines, on billboards and stores with
the following three questions; “When you read magazines (Western or Arabic),
how often do you see advertisements for cigarettes?”, “When you go to the market
(small or super), how often do you see advertisements for cigarettes?” and “How
often do you see advertisements for cigarettes on billboards?” Response choices
were rated on a four-point scale ranging from “1 = never”, “2 = hardly ever, “3 =
sometimes” to “4 = a lot” (standardized a = 0.76). The tobacco exposure index was
formed by summing the responses to the above three items. Higher numbers
indicated higher levels of exposure to pro-tobacco media.
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Measurement of Receptivity to Pro-Tobacco Media
Receptivity to pro-tobacco media was assessed using the scale developed by
Pierce at al. (1998) (Pierce et al., 1998). Pierce et al. (1998) found that receptivity
to tobacco promotional items and recall of cigarette advertisements were both
positively associated with intended and current smoking behavior. This scale asks
respondents if they own a tobacco promotional item “Do you own, or have you
ever received any item with tobacco company names or pictures on them, like T-
shirts, caps, lighters...etc?”, and/or are willing to use a tobacco promotional item
“Do you think you would wear or use something with a tobacco company name or
picture on it, such as a T-shirt or a cap?” Response for these two items were in the
“yes” “no” format. Respondents were then asked if they can recall the cigarette
brand that was advertised the most “What brand of cigarettes is advertised the
most?” Response choices were “1= I don’t know” and “2= open ended”, and if they
have a favorite cigarette advertisement brand “What is the name of the cigarette
brand of your favorite advertisement?” Response choices were “1= I don’t have a
favorite” and “2= open ended”. Respondents who have a tobacco promotional item
or who are willing to use one were classified as highly receptive to pro-tobacco
media and coded as “3”. Of the remaining respondents, those who did not name a
cigarette brand or those who did name a brand but didn’t have a favorite
advertisement were considered as minimally receptive and coded as “1”, while
those who named a cigarette brand as the most advertised and had a favorite
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advertisement were classified as moderately receptive and coded as “2” (Pierce et
al., 1998).
Measurement of Covariates
Relevant covariates included demographic variables (sex, age SES), the
psychosocial variables positively associated with Egyptian adolescents’ smoking
behavior (Chapter 3), and exposure/receptivity to western media.
Exposure/receptivity to western media was included as a covariate because it has
been shown as a significant smoking risk factor among western and Egyptian
adolescents (Chapter 7), and to isolate the influence of exposure and receptivity to
pro-tobacco media on the smoking behavior outcome variables.
Exposure/receptivity to western media was assessed based on the format
used by Schooler et al. (1996) (Schooler et al., 1996b). Respondents were asked to
rate how often they watch western movies and TV shows, listen to western music
and read western magazines, with the following three items; “I watch western
movies and/or TV shows”, “I listen to western music” and “I read western
magazines and newspapers”, while receptivity to western media was measured by
the three items; “How much do you enjoy watching western movies and or TV
shows made in the US and Europe?”, “How much do you enjoy listening to western
music?” and “How much do you enjoy reading western magazines and newspapers
from the US and Europe?” All responses choices were rated on a four-point scale
ranging from “1 = never”, “2 = hardly ever, “3 = sometimes” to “4 = a lot”
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(standardized a = 0.92). The media exposure/receptivity index was formed by
summing the responses to the above six items. Higher numbers indicated higher
levels of exposure and receptivity to western media.
Measurement of the outcome smoking variables and the relevant
psychosocial covariates are described in chapters 2 and 3.
Data Analysis
Descriptive statistics (frequencies, percentages and means) were used to
examine smoking prevalence and age of respondents. Correlation analysis was used
to examine the correlation of the independent and dependent variables under study.
Chi-square analyses were used to compare the prevalence of ever smoking, 30-day
smoking, current smoking and susceptibility to smoking across genders. T-tests
analyses were used to compare the mean age across genders.
Multiple logistic regressions were used to assess the odds ratios (OR) and
95% confidence intervals (Cl) of the association between the independent and
dependent variables. Three separate regression models for the three dependent
variables (ever-smoking, 30-day smoking and susceptibility to smoking) were
analyzed. Each model was analyzed twice, once with the pro-tobacco media
variables only, and once with the same independent variables controlling for other
known smoking risk factors (peer smoking, parent and sibling smoking, perceived
peers and adults smoking norms, positive beliefs about smoking, and exposure and
receptivity to western media). All models were adjusted for sex, age and SES.
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All statistical analysis was completed using the SAS system version 9.0
(SAS Institute, 2002).
Results
Table 11 presents the Pearson’s correlation coefficients between the
smoking outcome variables under study and the exposure and receptivity to pro
tobacco media variables. Both exposure and receptivity to pro-tobacco media were
positively and significantly correlated with all three smoking behaviors under study
(Table 11).
Table 11: Pearson’s Correlation Coefficients between Exposure and Receptivity to Pro-
Tobacco Media and Smoking Behavior
Ever-Smoking 30-Day Smoking Susceptibility
Exposure to Pro-Tobacco Media 0.5* 0.5* 0.5*
Receptivity of Pro-Tobacco Media 0.5* 0.4* 0.5*
*p<0.0001
Main Effects of Pro-Tobacco Media on Egyptian Adolescents’ Smoking
Behavior
There was no significant interaction between gender and exposure to or
receptivity of pro-tobacco media on any of the smoking behavior variables under
study, therefore the logistic regression analyses were performed for the whole
sample.
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Both exposure to and receptivity of pro-tobacco media were strongly
associated with all three smoking behaviors before and after controlling for known
smoking risk factors. Controlling for demographics only, exposure to pro-tobacco
media was significantly associated with ever-smoking (OR = 1.8,95% Cl = 1.7-
1.9), 30-day smoking (OR = 2.4, 95% Cl = 2.1-2.8) and susceptibility to smoking
(OR = 1.7, 95% Cl = 1.6-1.8), and receptivity to pro-tobacco media was also
strongly associated with ever-smoking (OR = 2.4,95% Cl = 2.1-2.8), 30-day
smoking (OR = 4.1, 95% Cl = 3.0-5.7) and susceptibility to smoking (OR = 2.5,
95% Cl = 2.2-2.9).
Exposure to and receptivity of pro-tobacco media remained strongly
associated with adolescent smoking behavior even after controlling for known
psychosocial smoking risk factors, exposure/receptivity to western media and
demographics. Table 12 presents the ORs and 95% Cl for exposure and receptivity
to pro-tobacco media, controlling for demographics and relevant smoking risk
factors.
Table 12: Effects of Exposure and Receptivity to Pro-Tobacco Media on Smoking
Behavior
Ever-Smokine 30- Dav Smokine Susceptibility
Independent variable OR 195% CD OR 195% CD OR 195% CD
Exposure to Pro-Tobacco Media 1.5* 1.3-1.6 1.9* 1.6-2.2 1.5* 1.4-1.7
Receptivity to Pro-Tobacco Media 1.8* 1.3-2.1 2.8* 1.9-4.1 1.9* 1.6-2.2
Note: Controlled for peer, parent and sibling smoking, perceived peer and adult smoking norms,
exposure/receptivity to western media, sex, age and SES
*p<0.0001
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Discussion
Consistent with previous studies among western adolescents (Altman et al.,
1996, Altman et al., 1999, Beltramini and Bridge, 2001, Biener and Siegel, 2000,
Borzekowski et al., 1999, Evans et al., 1995, Hoek and Sparks, 2000, Pierce et al.,
1998, Pollay et al., 1996, Schooler et al., 1996a, Schooler et al., 1996b), exposure
and receptivity to pro-tobacco media are strongly associated with the smoking
behavior of Egyptian adolescents, even after controlling for other smoking risk
factors. Receptivity to pro-tobacco media (accepting of tobacco promotional items
and recalling brand names and advertisements) appears to be the strongest risk
factor for all three smoking behaviors under study (Tables 12). This is not
surprising, since one would expect that in a low income country, offers of free gifts,
which are otherwise unattainable, especially those that reflect western cultures,
would be gladly accepted, and may even be appreciated by impressionable
adolescents. Owning western products, such as cool T-shirts, sun-visors, pens and
backpacks, even if encrusted with a tobacco company’s logo, may increase the
adolescent’s perception of achieving a western lifestyle that many of them aspire
to. Adolescents who are receptive to such offers and can easily recall their favourite
advertisement are primed to accept smoking behavior as normative and exciting,
especially as they are being consistently exposed to images of popular movie stars
and healthy young individuals enjoying life, socializing with attractive people and
happily embarking on adventures in far away places, while smoking. These images
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not only enforce the notion that smoking is a normative and acceptable behavior for
young individuals, but also that positive consequences result from such a behavior.
Therefore, if and when the situation presents itself, these adolescents, already
psychologically primed to accept smoking as normative, would have no problem
initiating and/or experimenting with smoking.
One option to curb the rising tobacco epidemic in Egypt may be to
implement a culturally appropriate adolescent smoking prevention program to help
students recognize and refute smoking cues which they typically encounter in
tobacco advertising and promotion, and to make them aware of the difference
between the overall role of advertising used in anti-smoking media campaigns,
which informs and persuades, versus the tobacco industry’s advertising role which
puts more emphasis on persuading rather than informing about the true
consequences of smoking. However, although such smoking prevention programs
may be effective in reducing adolescent smoking in developed western countries,
they may not suffice, on their own, in the developing world.
Western governments have strict tobacco regulations and enforcements, and
tobacco merchandizing and product give-aways are prohibited (Hoek and Sparks,
2000, Jha and Chaloupka, 2000), giving a better chance for adolescent smoking
prevention programs to succeed. However, tobacco promotions and merchandizing
remain unfettered in markets of the developing world (Hoek and Sparks, 2000). It
may be unrealistic to expect adolescents from low/middle income countries to
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refuse tobacco logo-encrusted free merchandize, especially if they were western
product give-aways, even if they were made aware of the tobacco industry’s
manipulative advertising to lure them into initiating smoking. The immediate
benefit of owning western products would outweigh the risk of the long-term health
consequences of smoking.
Local governments of the developing world should have stricter tobacco
regulations and enforcements where tobacco advertising and promotion is
concerned. Unfortunately, governments of low /middle income countries, like
Egypt, have more pressings social and economic problems to deal with than
worrying about the practices of western tobacco companies in their country.
Besides, western tobacco companies usually boost local economies by hiring locals
for their promotional and marketing activities (Hoek and Sparks, 2000).
It would seems only ethical that measures restricting tobacco promotion in
western countries, especially tobacco producing countries, should also be extended
to third world countries, where these companies trade. Western governments
should ensure that its tobacco producing companies conform to its national
regulations in their international trading practices. However, it seems that due to
the financial benefits in tax revenues brought by the tobacco companies’
international trade (Crompton, 1993, Hoek and Sparks, 2000), little is being done
by western governments to protect the citizens of the developing world from the
health hazards of their tobacco companies’ overseas activities (Hoek and Sparks,
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2000). It seems that when it comes to the health hazards of tobacco use in third
world countries, the immediate economic benefits to western and local
governments from the tobacco companies’ international practices outweigh the as
yet intangible health-related costs associated with smoking.
A step in the right direction is the issuance of the first legal instrument
designed to reduce tobacco-related deaths and disease around the world by the
WHO. The WHO Framework Convention on Tobacco Control (FCTC) which, on
May 21s t, 2003, was unanimously adopted by the 192 member states (World Health
Organization, 2003), requires all member countries to impose restrictions on
tobacco advertising, sponsorship and promotion; establish new packaging and
labeling of tobacco products; establish clean indoor air controls; and strengthen
legislation to clamp down on tobacco smuggling. However, whether all countries
will sign, ratify and abide by the treaty and abide by its rules remains to be seen.
Implications
The immediate financial benefits arising from the tobacco industries’ promotional
activities in Egypt should not outweigh the public health consequences of smoking
nor the economic burdens that will ensue in the near future. Egypt should start by
banning all tobacco advertising and promotional activities, including free give
aways. It should enforce existing tobacco regulations, such as cigarette sales to
minors, and raise awareness of the health hazards of tobacco use. This may be
accomplished by raising tobacco taxes and using that money for mass media anti-
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smoking campaigns to correct the erroneous glamorous perceptions of smoking
perpetrated by the tobacco industry. Only after the control of the tobacco industry’s
advertisement and promotional activities would multi-component smoking
prevention programs, in countries like Egypt, have a chance to succeed in reducing
adolescents’ smoking initiation and use.
Limitations
Results of this study are based on cross-sectional data, so causal influences
cannot be determined. The reverse direction of casualty is plausible. Adolescents
who had greater recall of smoking advertisements and owned items with tobacco
companies’ logo would do so because they were already more interested in
smoking, and not because the advertisements stimulated their interest. To develop a
better understanding of the conditions under which tobacco advertising and
promotion operate as causal factors, more longitudinal study designs are required.
Another limitation, as mentioned in the previous chapters, is that this study
is based on students' self-reports of their smoking behavior. Although respondents
were assured of their anonymity, Egyptian students may have been suspicious and
fearful of entrapment, especially female students, and therefore may have
underreported their smoking behavior in an attempt to appear socially correct.
Though adolescents' self-reports of smoking obtained under similar conditions in
the United States, have been shown to be quite accurate across ethnic groups (Wills
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and Cleary, 1997), it is not known whether this is also true for Egyptian
adolescents.
This study is based on random sampling of schools and students in the city
of Alexandria, Egypt, therefore the results can only be generalized to Egyptian
adolescents living in Alexandria, and cannot be generalized to the rest of
adolescents in other Egyptian cities.
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Chapter 7
Western Media’s influence on Egyptian Adolescents’
Smoking Behavior: The Mediating Effect of Positive Beliefs about
Smoking
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Background
The tobacco control movement in the United States has spent years and
millions of dollars to prevent and/or reduce adolescent smoking uptake through
school-based smoking prevention programs, and by implementing policies which
restrict youth access to cigarettes, increase tobacco sales taxes and regulate the
tobacco industry’s advertising and promotional activities (Glantz, 2003).
Unfortunately, adolescent smoking prevalence has not been affected as yet
(Fichtenberg and Glantz, 2002, Glantz, 2003, Ling et al., 2002).
A significant adolescent smoking risk factor that has yet to be regulated is
the influence of exposure and receptivity to western media. Portrayal of smoking in
western media has been shown to increase the risk of adolescent smoking initiation
and behavior in a number of western studies (Dalton et al., 2003, Dalton et al.,
2002, Gidwani et al., 2002, Glantz, 2003, Glantz, 2001b, Hazan et al., 1994, Hazan
and Glantz, 1995, Pechmann, 1998, Sargent et al., 2001a, Sargent et al., 2001b
Tickle et al., 2001). Pro-tobacco media and western media are intimately linked,
because pro-tobacco media is prevalent in western media (Dixon et al., 2001,
Glantz, 2001b, Mekemson and Glantz, 2003). Films made in Hollywood offer a
major marketing vehicle for the tobacco industry worldwide, and a way to present
smoking as a way to the glamorous "American" way of life, although today,
smoking is a socially unacceptable behavior in America (Glantz, 2001b, Mekemson
and Glantz, 2003). The tobacco industry has been well aware of the positive
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subliminal influence of portraying smoking in movies for decades (Glantz, 2003),
and has cultivated its relationship with the movie industry through large payments
to film studios to endorse their brands in movie scenes (Glantz, 2001a). It was only
after 1989, when the United States Congress held hearings regarding the tobacco
industry’s practices in Hollywood, that the tobacco industry voluntarily ended
product placement in movies (Glantz, 2001a). However, the amount of smoking
portrayal in American films has increased since 1991 and now exceeds that present
in the 1960s (Glantz, 2001b, Hazan et al., 1994), and endorsement of cigarette
brands in movies by actors has also increased substantially over the past decade
(Dalton et al., 2003, Sargent et al., 2001b).
A number of studies from the U.S. have positively associated adolescent
smoking uptake with the portrayal of smoking in movies (CDC, 2000, Dalton et
al., 2003, Dalton et al., 2002, Glantz, 2003, Glantz, 2001b, Pechmann, 1998,
Sargent et al., 2001a, Tickle et al., 2001), music videos (DuRant et al., 1997),
television shows (CDC, 2000, Gidwani et al., 2002, Hazan and Glantz, 1995) and
magazines (Basil et al., 2000, Feit, 2001, King et al., 1991). Movie stars portray
images that are desirable to teenagers, and many adolescents look to movie stars as
role models (Sargent et al., 2001a, Sargent et al., 2001b, Tickle et al., 2001). When
these stars smoke, adolescents may see that as integral to the image they aspire to
and may then initiate smoking (Sargent et al., 2001a, Tickle et al., 2001). Sargent et
al. (2001) found that the more teenagers see smoking in films, the more likely they
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are to smoke (Sargent et al., 2001a).Dalton et al. (2003) have shown that, after
controlling for a wide variety of other smoking risk factors, 52.2 % of smoking
initiation in the 10-14 year olds studied was attributed to seeing smoking in movies
(Dalton et al., 2003).Tickle et al. (2001) found that adolescents whose favorite
movie stars smoke on-screen were significantly more likely to be smokers
themselves and to have more positive beliefs toward smoking than adolescents who
prefer non-smoking stars (Tickle et al., 2001).
With the globalization of broadcasting and telecommunication, it has
become increasingly easier to influence a wider audience of adolescents worldwide
(Jha et al., 2000). Studies conducted in China and New Zealand have shown that
preference of their youth to western films and television shows is one of the
strongest risk factors for adolescent smoking (Lam et al., 1998, McCool et al.,
2001). McCool et al. (2001) found that favorable portrayals of smoking in the
media was a potential motivator for the initiation of smoking among New Zealand
adolescents and that most students in the study regarded on-screen-smoking
imagery as an accurate reflection of reality, and consequently had very high
perceived social smoking norms (McCool et al., 2001).
There is a scarcity of studies investigating the influence of exposure and
receptivity to western media on adolescent smoking behavior in developing Arab
countries. One such country is Egypt. Egypt, a low/middle income developing Arab
country, has the highest rate of tobacco consumption in the Arab world (WHO,
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1997). It is estimated that 33.5% of Egyptians are daily smokers (CDC Nations,
2001), with adult males having significantly higher daily smoking rates than adult
females (40 % males, 18% females) (ERC Statistics International, 2001).
According to the Global Youth Tobacco Survey (GYTS), conducted for the Centers
of Disease Control and Prevention in 2001,19.6% of Egyptian youth aged 13-15
years were current smokers (22.8% males, 15.8% females) (Global Youth Tobacco
Survey Collaborative Group, 2002). Over the past 30 years, the number of smokers
in Egypt has increased 8-9% on a yearly basis, over twice as fast as the birth rate
(Global Initiatives, 1998, Hammond, 2002). In 1997, there were six million
Egyptian smokers, of which 513,000 were children under the age of 10 (Arabic
News.com, 1997). In 2002, the number of smokers in Egypt rose to 16 to 17
million (Hammond, 2002).
Since the introduction of the global satellite transmission in Egypt, more
Egyptian adolescents are now exposed to western movies, music videos and
television (TV) programs (WHO, 1997). These western media vehicles portray
popular movie stars enjoying exciting, glamorous and adventurous lifestyles, while
smoking (Brigden, 2001). Exposure and receptivity to western media may increase
the adolescent’s perception that smoking is not only a normative behavior among
popular individuals, but that it also results in positive consequences, such as stress
relief, higher concentration, and appearing more mature, westernized and “cool”.
Accordingly, Egyptian adolescents, or adolescents from any developing country for
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that matter, may perceive that smoking is one way to emulate the glamorous
western lifestyle they aspire to, and thus initiate smoking.
This study investigates the influence of exposure and receptivity to western
media on Egyptian adolescents’ smoking behavior and the possible underlying
mechanism of that influence. This study hypothesizes that positive beliefs about
smoking, a strong adolescent smoking risk factor (CDC, 2000), mediates the
relationship between exposure and receptivity to western media and Egyptian
adolescent smoking behavior, such that exposure/receptivity to western media
would increase adolescents’ positive beliefs about smoking which in turn would
increase the likelihood of their smoking behavior.
Results of this study may highlight additional venues to be used by
researchers in the fight against the rising smoking epidemic in Egypt, by designing
more effective smoking prevention programs aimed at Egyptian adolescents.
Measures
Measurement of Exposure /Receptivity to Western Media
Exposure /receptivity to western media was assessed based on the format
used by Schooler et al. (1996) (Schooler et al., 1996b). Respondents were asked to
rate how often and how much they enjoy watching western media, by answering
the following six items; “I watch western movies and/or TV shows”, “I listen to
western music” , “I read western magazines and newspapers”, and “How much do
you enjoy watching western movies and or TV shows made in the US and
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Europe?”, “How much do you enjoy listening to western music?” and “ How much
do you enjoy reading western magazines and newspapers from the US and
Europe?”. Responses choices were rated on a four-point scale ranging from “1 =
never”, “2 = hardly ever, “3 = sometimes” to “4 = a lot” (standardized a = 0.92).
The media exposure/receptivity index was formed by summing the responses to the
above six items. Higher numbers indicated higher levels of exposure and
receptivity to western media.
Measurement of Covariates
Relevant covariates included demographic variables (sex, age, SES), type of
school, the psychosocial variables associated with Egyptian adolescents’ smoking
behavior (chapter 3), and exposure and receptivity to pro-tobacco media. These
covariates were included because they have been shown to be significantly and
positively associated with the Egyptian adolescents’ smoking behaviors in the
previous chapters. Measurements of the outcome smoking variables and the
relevant covariates are described in the chapters 2, 3 and 6 of this study.
Data Analysis
Multiple logistic regressions were used to assess the associations between
the independent and dependent (outcome) variables. Three separate regression
models for the three dependent variables (ever-smoking, 30-day smoking and
susceptibility to smoking) were analyzed for the main effects of the
exposure/receptivity to western media. Analysis for each outcome variable was
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performed twice, once controlling for demographics only (sex, age and SES), and
once controlling for demographics, type school, the psychosocial covariates and
exposure and receptivity to pro-tobacco media. Dependent variables were naturally
dichotomized. Each model was tested for interaction of the exposure/receptivity to
western media index with sex. If an interaction with sex was present, the logistic
model as reanalyzed by gender.
Mediational Analysis
To test for mediation, the methodology of Baron and Kenny (1986) (Baron
and Kenny, 1986) was used to determine if positive beliefs about smoking
mediated the effect of exposure/ receptivity to western media on Egyptian
adolescents’ smoking behavior (ever smoking, 30-day smoking). According to
Baron and Kenny (1986), four regression models should be performed to
demonstrate a mediated effect. First, the dependent variable is regressed on the
predictor (independent) variable, excluding the hypothesized mediator, to calculate
the significance of the approximate total effect of the predictor variable on the
dependent variable. The parameter estimate (regression coefficient beta) of the
predictor variable should be significant. Second, the hypothesized mediator is
regressed on the predictor variable. The regression coefficient of the predictor
variable should be significant. Third, the dependent variable is regressed on the
hypothesized mediator, controlling for the predictor variable. The regression
coefficient of the hypothesized mediator must be significant, i.e. the mediator must
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affect the dependent variable. Fourth, when the hypothesized mediating variable is
added to the model, the magnitude of the parameter estimate (regression
coefficient) of the predictor variable must diminish or become insignificant. To
determine whether the indirect effect (mediated effect) of the predictor variable on
the outcome variable via the mediator is significant, it is necessary to multiply the
predictor-mediator regression coefficient by the mediator-outcome regression
coefficients, divide this product by a specific standard error formula and then test
whether this ratio is significantly different from zero (Baron & Kenny, 1986). If
this ratio is significant, then the test for mediation is significant and the
hypothesized mediator is said to account for at least a portion of the influence of
the predictor variable on the outcome variable.
All regression models for the mediational analysis were controlled for the
above relevant covariates. Statistical analysis was completed using the SAS system
version 9.0 (SAS Institute, 2002).
Results
Main Effects of Exposure/Receptivity to Western Media on Ever-Smoking
Behavior and Susceptibility to Smoking
There was no significant interaction between sex and the exposure/
receptivity to western media on ever smoking or susceptibility to smoking,
therefore the logistic regression analyses were performed for the whole sample for
these two outcome smoking variables.
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Controlling for demographics only, exposure and receptivity to western
media was positively and significantly associated the ever-smoking (OR =1.4 95%
CI= 1.4-1.5) and susceptibility to smoking (OR=1.3 95% CI= 1.3-1.4). The
association between exposure/receptivity to western media, ever-smoking and
susceptibility to smoking remained positively significant even after controlling for
pro-tobacco media exposure and receptivity, and the relevant psychosocial
covariates. Egyptian adolescents with higher levels of exposure/receptivity to
western media were 20% more likely to have experimented with cigarette smoking
than those with lower levels of exposure/receptivity to western media (OR= 1.2,
95% Cl = 1.2-1.3). Similarly, Egyptian adolescents with higher levels of
exposure/receptivity to western media were 20% more likely to be susceptible to
future smoking than those who did not adamantly rule out smoking in the future
(OR= 1.2, 95% Cl = 1.2-1.3).
Main Effects of Exposure/Receptivity to Western Media on 30-Day Smoking
Behavior
There was an interaction between exposure/receptivity to western media
and gender on 30-day smoking behavior, therefore the multiple logistic analyses
was carried out for each gender. Controlling for age and SES only,
exposure/receptivity to western media was positively and significantly associated
with 30-day smoking for males (OR =1.5, 95% Cl = 1.4-1.6), and females (OR =
1.3, 95% Cl = 1.2-1.4). However, after controlling for all the other covariates under
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study, the association between exposure/receptivity to western media and 30-day
smoking behavior among the females became insignificant (p= 0.7), while its
association with the males’ 30-day smoking behavior remained statistically and
positively significant (beta= 0.11 ,p =0.02). Adolescent males with higher levels of
exposure/receptivity to western media were 10% more likely to having smoked in
the past 30 days than adolescent males with lower levels of exposure/receptivity to
western media (OR= 1.1, 95% Cl = 1.1-1.2).
The Mediating Role of Positive Beliefs about Smoking between the Association
of Exposure/Receptivity to Western Media and Susceptibility to Smoking
The approximate total effect of exposure/receptivity to western media on
susceptibility to smoking (excluding the positive beliefs about smoking index from
the model) was statistically significant (beta = 0.166, p <.0001).
Exposure/receptivity to western media was positively and significantly associated
with the positive beliefs about smoking index (beta = 0.187, p <0.0001).
Controlling for exposure/receptivity to western media, the positive beliefs about
smoking index was positively and significantly associated with susceptibility to
smoking, (beta = 0.149, p < 0.0001). The direct effect of exposure/receptivity to
western media on susceptibility to smoking, when the positive beliefs about
smoking index was in the model, was reduced, yet remained significantly
associated with susceptibility to smoking (beta= 0.145, p <0.0001), and the
mediated effect was statistically significant ( beta = 0.0279, p <0.0001). The total
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effect (direct effect + mediated effect) of western media on susceptibility to
smoking was 0.17. Accordingly, approximately 18 % (mediated effect/total effect)
of the total effect of exposure and receptivity to western media on susceptibility to
smoking is explained by the mediated influence of positive beliefs about smoking.
Figure 5 presents the path diagram of the mediating effect of positive
beliefs about smoking between exposure/receptivity to western media index and
susceptibility to smoking.
Figure 5 Mediational Path Diagram o f the Role o f Positive Beliefs about Smoking in the
Association between Exposure/Receptivity to Western M edia and Susceptibility to
Smoking
0.18(0.019)*
Positive Beliefs
about Smoking
0.15 (0.023)*
Exposure/Receptivity
to W estern Media
Approx. Total Effect = 0.17 (0.018)*
Direct Effect = 0.14(0.018)*
Mediated effect = 0.03 (0.005)*
Susceptibility
to Smoking
Notes: Adjusted for pro-tobacco media exposure, pea- smoking, parent smoking, sibling smoking,
perceived peer smoking norms, perceived adult smoking norms, type of school, sex, age and SES
Values are metric betas (SE)
* P < 0.0001
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The Mediating Role of Positive Beliefs about Smoking between the Association
of Exposure/Receptivity to Western Media and Ever-Smoking Behavior
Figure 6 presents the path diagram of the mediating effect of positive
beliefs about smoking between western media and ever-smoking for both genders.
The approximate total effect (excluding positive beliefs from the model) of western
media on ever-smoking was statistically significant (beta = 0.137,/? <.0001).
Western media was positively and significantly associated with the positive beliefs
about smoking (beta = 0.181,/? <0.0001). Controlling for exposure/receptivity to
western media, positive beliefs about smoking was positively and significantly
associated with ever-smoking (beta = 0.118,/? < 0.0001). Controlling for positive
beliefs about smoking, the direct effect of exposure/receptivity to western media on
ever-smoking behavior was reduced, compared to the approximate total effect, yet
remained positively and significantly associated with ever-smoking behavior (beta=
0.117,/? <0.0001). The mediated (indirect) effect was statistically significant (beta
= 0.021, p <0.0001). The total effect (direct + mediated effect) of
exposure/receptivity to western media on ever-smoking behavior was 0.138.
Accordingly, approximately 15 % of the total effect of exposure/receptivity to
western media on Egyptian adolescent ever-smoking behavior may be explained by
the mediated influence of positive beliefs about smoking (mediated effect/total
effect).
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Figure 6: Mediational Path Diagram of the Role of Positive Beliefs about Smoking in the
Association between Exposure/Receptivity to Western Media and Ever-Smoking Behavior
Positive Beliefs
about Smoking
Approx. Total Effect = 0.14 (0.02)
Exposure/Receptivity ------------------------------------------------------- ► Ever-Smoking
To Western M edia Direct Effect = 0.12 (0.02) *
►
M ediated effect = 0.02 (0.005) *
►
Notes: Adjusted for pro-tobacco media exposure, pea- smoking, parent smoking, sibling smoking,
perceived peer smoking norms, perceived adult smoking norms, type of school, sex, age and SES
Values are metric betas (SE)
*P< 0.0001
The Mediating Role of Positive Beliefs about Smoking between the Association
of Exposure/Receptivity to Western Media and 30-day-Smoking Behavior
among Egyptian Adolescent Males
Since the influence of exposure/receptivity to western media on the
females’ 30-day smoking behavior was insignificant, the mediational analysis for
the 30-day smoking behavior was carried out for the male population only.
The approximate total effect of western media on 30-day-smoking was
statistically significant (beta = 0.104,p = 0.0005). Exposure/receptivity to western
media was significantly associated with the positive beliefs about smoking (beta =
0.214, p <0.0001). Controlling for exposure/receptivity to western media, positive
beliefs about smoking was statistically and significantly associated with 30-day-
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smoking (beta = 0.232, p < 0.0001), and the mediated effect was statistically
significant (beta = 0.0496, p <0.0001). However, controlling for positive beliefs
about smoking, the direct effect of exposure/receptivity to western media on 30-
day-smoking behavior became insignificant (beta = 0.049, p = 0.2), indicating that
positive beliefs about smoking completely mediated the effect of
exposure/receptivity to western media on the 30-day smoking behavior among the
males.
Figure 7 presents the path diagram of the mediating effect of the positive
beliefs about smoking between exposure/receptivity to western media and 30-day-
smoking behavior
Figure 7: M ediational Path Diagram o f the Role o f Positive Beliefs about Smoking in the
Association between Exposure/Receptivity to Western M edia and 30-Day Smoking
Behavior, among Egyptian Adolescent Males
Positive Beliefs
about Smoking
b = 0.23 (0.04) a = 0.21 (0.03)
Approx. Total Effect = 0.10 (0.03) §
>- 30-Day Smoking Exposure / Receptivity
To Western M edia Direct Effect = 0.05 (0.04) f
►
Mediated effect = 0.05(0.01)*
►
Notes: Adjusted for pro-tobacco media exposure, pea- smoking, parent smoking, sibling smoking,
perceived peer smoking norms, perceived adult smoking norms, type of school, sex, age and SES
Values are metric betas (SE)
*P<0.0001
§ P = 0.0005
f Not statistically significant (p = 0.9)
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Discussion
Results of this study are consistent with previous research that has shown a
positive association between exposure to western media and an increase in the risk
of adolescent smoking behavior (Dalton et al., 2003, Gidwani et al., 2002, Glantz,
2001b, Lam et al., 1998, Mccool et al., 2001, Sargent et al., 2001, Tickle et al.,
2001). The results also shed a light on the possible under lying process for the above
association among Egyptian adolescents. The results indicate that the positive
association between exposure and receptivity to western media and adolescent
smoking behavior, among the study population, is at least partly due to western
media’s influence on increasing adolescents’ positive beliefs about smoking.
The positive association between exposure/receptivity to western media and
Egyptian adolescents’ smoking behavior is independent of the influence of
exposure to pro-tobacco media, a significant and strong predictor of adolescent
smoking initiation, or the influence of the psychosocial risk factors associated with
Egyptian adolescents’ smoking behavior (Islam and Johnson, 2005). Accordingly,
exposure to western media should be considered a strong adolescent smoking risk
factor among Egyptian adolescents. As the level of exposure and receptivity to
western media increases, adolescents become more susceptible to initiate future
smoking in the near future and the risk of experimentation with cigarettes increases
across the genders. Susceptibility to future smoking and experimentation with
cigarettes are preliminary steps in the eventual uptake of habitual smoking, and
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therefore are viable smoking risk factors that need to be addressed in smoking
prevention programs.
The influence of exposure to western media seems to have a differential
influence on the genders as the adolescent progresses from experimentation to the
more frequent 30-day smoking behavior. Interestingly, exposure to western media
appears to influence the 30-day smoking behavior among adolescent males only.
This differential gender influence may be due to a number of reasons, one of which
may be the underlying cultural norms of the Egyptian society.
Egypt is an Arab patriarchal collective society governed by traditional
gender differentiated roles and norms, (Bernard, 1994). Smoking cigarettes is often
viewed as an acceptable social behavior for males but not for females (Hassan,
2003, Islam and Johnson, 2003), a factor that has been shown to be a smoking risk
factor among males from traditional collective societies (Morrow et al., 2002,
Shiffman, 1998). Egyptian adolescent males may perceive that smoking is an
acceptable male social characteristic that increases their mature masculine image,
and therefore may be susceptible to progress along the smoking continuum, from
susceptibility to smoking, to experimentation, to 30-day smoking to the eventual
habitual current use. On the other hand, Egyptian adolescent females may perceive
that since smoking is considered an unacceptable social behavior for females (a
cultural taboo), experimentation with cigarette smoking may be sufficient to satisfy
their curiosity regarding any perceived benefits of smoking, and engaging in the
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more frequent 30-day smoking behavior may reflect an undesirable feminine image
which may negatively impact their reputation (Islam and Johnson, 2003).
Accordingly, the influence of exposure to the positive images of smoking behavior
portrayed in western media may have less of an impact on Egyptian adolescent
females’ 30-day smoking behavior than on their male counterparts’ behavior.
On the other hand, the relatively low smoking rates among adolescent
females may be just a reflection of the cultural taboo associated with Egyptian
female smoking behavior, and therefore may be an underestimate of the true female
smoking prevalence rates, since many young females may be reluctant to admit to
more frequent smoking behavior for fear of projecting a negative rebellious
feminine image. This underestimation, especially for the 30-day smoking behavior,
may have caused a reduction in the statistical power necessary to achieve
statistically significant results.
Another possible reason for the gender differentiated influence of western
media exposure on 30-day smoking behavior may be due to the gender of the
movie stars portraying the positive smoking behavior. According to Dr. Glantz, a
strong advocate of smoke free movies, there are many more popular male movie
stars portraying smoking behavior in western movies than female stars (Glantz,
2001a). Many of these movie stars are male adolescent idols. When these male
movie star idols are portrayed as having exciting, adventurous and glamorous lives
while smoking, it is not surprising that these images would differentially influence
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the Egyptian adolescent male, who is already predisposed to an increased risk of
smoking behavior due to the underlying cultural smoking risk factors (Islam and
Johnson, 2003), and subliminally increase his positive beliefs about smoking.
Without realizing it, the adolescent male may embark on the next normative step,
which is to emulate their favorite movie star’s characteristics and lifestyle, as
depicted in western media, and embark on more frequent smoking behavior. This
process is not surprising, since previous research has shown that adolescence is a
time of heightened sensitivity especially to promotional messages (Basil et al.,
2000, Borzekowski et al., 1999), and many adolescents tend to imitate specific
behaviors they see modeled and which they perceive to have some beneficial
consequences (Bandura, 1965, Bushman and Anderson, 2003).
The significance of increasing the adolescent’s positive beliefs about
smoking is clearly demonstrated in the results of the mediational analysis of
positive beliefs about smoking between the association of exposure/receptivity to
western media and 30-day smoking behavior among the Egyptian adolescent males
under study. Positive beliefs about smoking completely mediated the association
between exposure/receptivity to western media and 30-day smoking behavior, in
other words, the significant positive influence of exposure to western media on
increasing adolescent males’ 30-day smoking behavior is accomplished only
through invoking higher positive beliefs about smoking, a strong and significant
adolescent smoking risk factor (Centers for Disease Control and Prevention, 2000).
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With evidence from the numerous studies linking exposure to western
media and adolescent smoking behavior, it is surprising that there are no regulatory
processes, as yet, limiting the amount and glamorization of smoking scenes in
western media. Hollywood producers and movie stars should be made more aware
of the influence of portraying smoking as either an exciting and glamorous
behavior or as a means to relieve stress and boredom, on adolescent smoking
behavior, and consequently, on the propagation of the global smoking epidemic.
Adolescents from low/middle income developing countries, who may aspire to the
western lifestyle portrayed in the media, may be especially vulnerable to the
glamorization of smoking behavior portrayed by their favorite movie stars. If
western media producers exclude scenes portraying positive smoking images and
behavior, the risk of adolescent smoking behavior, worldwide, may drop
dramatically.
Implications
Until the right steps are taken to regulate the amount and the
glamorous portrayal of smoking in western media, smoking prevention programs
aimed at Egyptian adolescents, or at adolescents from any developing country, for
that matter, should include modules that correct the erroneous perception that
positive consequences arise from smoking behavior. These programs should
emphasize that the portrayal of smoking by popular movie stars, as depicted in the
western media, does not reflect reality, that smoking is an unacceptable social
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behavior in today’s western societies, that smoking is not a normative behavior
among popular individuals, and that it does not lead to a glamorous lifestyle.
Limitations
Results of this study are based on cross-sectional data; therefore causal
influence can not be determined. The reverse direction of casualty is plausible; that
is, adolescents who had experimented with cigarettes or were 30-day smokers, at
the time of the survey administration, may have already formed positive beliefs
about smoking and not vice-versa. However, it is harder to explain the reverse
causality of adolescents’ smoking behavior with higher exposure and receptivity to
western media, and the direction of causality from exposure to western media to
smoking behavior would seem to have more face value than a reverse direction.
Nonetheless, to develop a better and more accurate understanding of the role of
western media as a causal factor in the uptake of adolescent smoking, more
longitudinal study designs are required.
Another limitation of this study is the lack of follow-up information on the
smoking behavior of the absentees (6.7%). It is possible that absentees, especially
female absentees, had higher smoking prevalence than those surveyed. This may
have caused an underestimation of the smoking prevalence rates. Longitudinal
western studies have shown a higher smoking prevalence among absentees
(Charlton and Blair, 1989, Charlton et al., 1997). Whether this is true among
Egyptian adolescents cannot be determined by this study.
I ll
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Smoking behaviors reported in this study are based on students' self-reports.
Although respondents were assured of their anonymity, Egyptian students may
have been suspicious and fearful of entrapment, especially female students fearing
the cultural taboo associated with female smoking behavior, and therefore may
have underreported their smoking behavior in an attempt to appear socially correct.
Though adolescents' self-reports of smoking obtained under similar conditions in
the United States, have been shown to be quite accurate across ethnic groups (Wills
and Cleary, 1997), it is not known whether this is also true for Egyptian
adolescents.
This study is based on random sampling of schools and students in the city
of Alexandria, Egypt, therefore the results can only be generalized to adolescents
living in Alexandria. Variables found to be significantly associated with smoking
behavior among these adolescents may differ for other Egyptian adolescents in
other cities, especially if they live in the more westernized capital city of Cairo, or
in the more traditional suburban cities that make up Egypt.
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Chapter 8
Summary and Conclusion
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To summarize the overall findings of this study, Figure 8 presents a
conceptual model of the association between the risk and protective factors studied
and Egyptian adolescents’ ever-smoking behavior.
Figure 8: Conceptual Model o f the Risk/Protective Factors Associated with Egyptian
Adolescents’ Ever-Smoking Behavior
Family Smoking
Peer Smoking
Perceived Smoking
Norms
Refusal SelfEfncacy
Impulsivity
Pro-Tobacco Media
Positive Beliefs
about Smoking
Western Media Ever-Smoking
Familism/Obedience
Religious Relevance
Gender
Gender Specific Norms
Social Conformity
Hostility
Sensation Seeking
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The results of this study point to the notion that some adolescent smoking
risk and protective factors may be universal, i.e. across cultures, while others may
be culture and gender specific, depending on whether the adolescents come from a
collective or an individualistic society.
Chapter 3 examined the influence of known western psychosocial smoking
risk factors on Egyptian adolescents’ smoking behavior. Both positive beliefs about
smoking and refusal self-efficacy skills appear to have the same influence on
Egyptian adolescents’ smoking behavior as they do on western adolescents’
smoking behavior, i.e. an increase in positive beliefs about smoking is associated
with an increased risk of smoking behavior, and an increase in refusal self-efficacy
skills appears to be protective against the initiation of smoking. Thus both of these
variables may be considered as universal risk and protective factors. The results
also show that peer smoking and perceived peer smoking norms are risk factors for
Egyptian adolescents’ smoking behavior, however, family smoking and perceived
adult smoking norms appear to have a stronger influence on the smoking behavior
of Egyptian adolescent than on western adolescents. This may be attributed to the
nature of the collective patriarchal Egyptian society where the influence of family
behavior on adolescent behavior may be stronger than that of his/her peers.
Although some western studies have shown that increasing adolescents’
knowledge of the negative consequences of smoking decreases their likelihood of
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smoking uptake, this does not seem to be the case among this population of
Egyptian adolescents. Again this may be due to the Egyptian Islamic culture which
tends to be fatalistic in nature, with the assumption that if one gets ill, then it is
God’s wish and nothing can be done to change the course of what is expected to
happen.
Chapter 4 investigates some of the Egyptian cultural factors that may
influence Egyptian adolescents’ smoking behavior. Familism/obedience to parents
and religious relevance appear to be protective factors against smoking initiation,
maintenance and susceptibility for both genders. Social conformity and gender
specific norms appear to be smoking risk factors for adolescent males only. The
differential influence of social conformity and gender specific norms on Egyptian
adolescent males’ smoking behavior should be regarded as crucial factors when
designing the appropriate smoking prevention program aimed at this population.
Chapter 5 investigates the associations between known psychological
smoking risk factors and Egyptian adolescents’ smoking behavior. Results of the
study indicate that unlike the positive association of depression with the smoking
behavior among western adolescents, depression does not seem to be associated
with Egyptian adolescents’ smoking behavior, and therefore the results of this
study do not support the self-medication theory of adolescent smoking. On the
other hand, impulsive behavior appears to be associated with an increased risk of
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smoking behavior among both genders of Egyptian adolescents as it is among
western adolescents.
Although both hostility and sensation seeking tendencies have been
positively associated with western adolescents’ smoking behavior, they appear to
be risk factors for ever-smoking and 30-day smoking among Egyptian adolescent
males only (Chapter 5). This differential influence may again be due to some of the
underlying Egyptian cultural factors which allow social acceptability of certain
behaviors for males, but not for the females.
Chapter 6 examines the influence of exposure and receptivity to pro-tobacco
media, and results indicate that the influence of pro-tobacco media seems to be
universal across cultures, even after controlling for other important smoking risk
factors, i.e. exposure and receptivity to pro-tobacco media is strongly associated
with an increased risk of smoking initiation, maintenance and susceptibility to
future smoking among this population of Egyptian adolescents.
Exposure and receptivity to western media appears to be a significant
smoking risk factor for Egyptian adolescents as it is for western adolescents. The
results also shed light on the possible underlying process of the above association.
Depending on where the adolescent is on the smoking continuum, the data suggest
that the significant positive association between exposure and receptivity to
western media and Egyptian adolescent smoking behavior is at least partly due to
the effects of increasing positive beliefs about smoking, which has been shown to
117
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be a strong positive predictor of adolescent smoking behavior in numerous studies
(Chapter 7).
The overall findings of this study indicate that there are similarities and
differences in the risk and protective factors associated with Egyptian versus
western adolescents’ smoking behavior. Table 14 presents the overall results of the
similarities and differences in the influences of the known smoking risk and
protective factors on ever smoking behavior between Egyptian and Western
adolescents.
Table 13: Similarities/Differences in Risk and Protective Factors associated with Ever-
Smoking Behavior, between Egyptian and Western Adolescents.
Factors Associated with
Ever Smoking Behavior
Influence on Egyptian
Adolescents
Influence on
Western Adolescents
Sibling Smoking Very Strong Risk Risk
Parent Smoking Strong Risk Risk
Perceived adult smoking norms Strong Risk Risk
Peer Smoking Risk Risk
Perceived peer smoking norms Risk Risk
Negative Consequences o f smoking None Protective
Positive beliefs about Smoking Risk Risk
Refusal Self Efficacy Protective Protective
Depression None Risk
Impulsivity Risk Risk
Sensation Seeking Risk for males only Risk
Hostility Risk for males only Risk
Pro-Tobacco Media Risk Risk
W estern Media Risk Risk
Familism/Obedience Protective N/A
Religious Relevance Protective N/A
Social Conformity Risk for males only N/A
Gender Specific Norms Risk for males only N/A
118
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Implications and Future Recommendations
Western adolescent social influence based smoking prevention programs
may be helpful in curbing the rising smoking epidemic in Egypt, as long as these
programs are culturally modified to address the differences in the smoking risk
factors among Egyptian and western adolescents, and in some cases should be
selective and gender-specific.
The following recommendations, based on the application of findings of
this study into practice, may help researchers design more culturally appropriate
smoking prevention programs for this population:
- Correct the erroneous perceptions of the positive beliefs about of smoking, not
through the scare tactics of the negative consequences of smoking, either short
or long-term, but through explaining the scientific nature of nicotine addiction
and its physiological effect on primary body functions.
- Increase the adolescent’s refusal self-efficacy skills by incorporating role
playing scenarios to help adolescents practice and increase their ability to
refuse cigarette offers from loved ones.
- Smoking prevention programs aimed at adolescents from collective cultures,
like Egypt, should be multicomponent programs that include the whole family
and community members. Families, especially older siblings, and community
adults members must be made aware of their smoking behavior’s influence on
their youth.
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- Multicomponent smoking prevention programs, in Egypt, should go hand in
hand with smoking cessation interventions aimed at Egyptian adults.
- Smoking prevention programs should be culturally tailored by:
■ Emphasizing and encouraging smoking protective cultural factors such as
familism and obedience to parents
■ Incorporating religious messages that emphasize the unacceptability of
any smoking behavior for both religions.
■ Encouraging the incorporation of the positive aspects of social conformity
for females while avoiding the negative ones for males.
- Gender specific smoking prevention programs targeting Egyptian adolescent
males should:
■ Correct the erroneous perception of the social acceptability of male
smokers.
■ Encourage the incorporation of the positive aspects of the traditional
gender differentiated roles, such as responsibility and loyalty to family
and friends.
■ Emphasize that smoking does not make the adolescent male more
masculine and/or more mature, but that smoking behavior may project the
male adolescent as careless, irresponsible and disrespectful of his family’s
standing in the community.
■ Encourage social conformity to healthy behaviors and attitudes
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■ Encourage individual decision making in situations when the adolescent’s
peer group appears to be engaging in risky behaviors such as smoking.
■ Selective smoking prevention programs for adolescent males exhibiting
temperament traits such as hostility, impulsivity and sensation seeking
tendencies.
Help students recognize and refute the smoking cues they typically encounter
in tobacco advertising and promotion.
Make the students aware of the difference between the overall role of
advertising used in anti-smoking media campaigns, which informs and
persuades, versus the tobacco industry’s advertising role which puts more
emphasis on persuading rather than informing about the true consequences of
smoking.
Make the students aware of the intimate link between pro-tobacco media and
western media by explaining how the pro-tobacco media has used the western
media as a major vehicle to promote its product through the subliminal effect
of portraying smoking in films, TV shows, music videos and magazines.
Explain to students that when they see smoking portrayed in western media it
is not a reflection of reality, because smoking is not considered a glamorous
and exciting behavior in the western world any more, but only a means to get
them addicted to a product that will increase the tobacco companies’ profits.
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In conclusion, the implementation of school-based smoking prevention
programs alone would not suffice to curb the rising smoking epidemic in Egypt. A
consorted effort, including the Egyptian government’s regulation of the exposure to
pro-tobacco media, should be accompanied by multi-component (school, family
and community) smoking prevention and cessation programs, which include
modules for the correction of the erroneous perceptions that smoking results in
positive consequences, as depicted in the western and pro-tobacco media.
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Asset Metadata

Creator Islam, Sondos Mohamed Saleh (author)

Core Title Correlates of smoking behaviour among Egyptian adolescents

School Graduate School

Degree Doctor of Philosophy

Degree Program Preventive Medicine/Health Behavior Research

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, public health,OAI-PMH Harvest,psychology, behavioral,psychology, social

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Azen, Stanley (committee member), Baezconde-Garbanati, Lourdes (committee member), Johnson, C. Anderson (committee member), Ransford, Edward (committee member), Unger, Jennifer (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-348317

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Identifier 3180357.pdf (filename),usctheses-c16-348317 (legacy record id)

Legacy Identifier 3180357.pdf

Dmrecord 348317

Document Type Dissertation

Rights Islam, Sondos Mohamed Saleh

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

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