School-Based Intervention to Prevent Smoking Initiation among Adolescents in Egypt

Background: Egypt has the highest prevalence rate of current smoking (19.7% among adults) among Arab countries. Unless prevented, smoking would cause a heavy public health burden on Egypt in the future. Adolescents should be prevented from smoking as most Egyptians smokers initiate smoking before the age of 14 years and adolescents’ smoking is a predictor of adults’ smoking. School-based interventions are effective and cost-effective and commonly used in preventing adolescents from smoking initiation in many countries and appropriate for Egypt because of the high school attendance rates in both sexes. However, there are limited existing school-based smoking prevention interventions (SBSPIs) in Egypt. This thesis aims to explore what needs to be implemented in schools to prevent Egyptian adolescents from smoking initiation and make recommendations towards designing culturally sensitive SBSPIs in Egypt. This aim was achieved through three complementary studies: 1) a literature review that determined factors that influence adolescents’ smoking in Egypt. 2) A systematic review that identified factors which influenced the effectiveness of SBSPIs in Arabic and/or Low and Middle-income countries (LMICs) in terms of theoretical constructs, intervention functions, and cultural- appropriateness. 3) Then a qualitative study that explored the current and anticipated role of preparatory schools in preventing smoking initiation by adolescents in Upper-Egypt. The finding from the three sub-studies emphasised that in order to increase pupils’ capability, motivations and opportunities to avoid smoking initiation, SBSPIs in Upper-Egypt should: 1) raise awareness about various consequences of different forms of smoked tobacco using appealing and memorable educational methods through curricular and extracurricular activities and attractive school-posters. 2) Enhance skills of refusing smoking offers, positive self-assertiveness, stress management, problem-solving, decision-making and goals' setting, monitoring and achieving. 3) Encourage considering the social unacceptability of adolescents' smoking, especially by females. 4) Encourage imitating successful never-smokers and represent smokers in disliked pictures to create negative images about smoking. 5) Continue restricting pupils’ smoking and carry of cigarettes inside schools and obtaining written commitments from pupils, witnessed and signed by parents, to do so. 6) Reward non-smokers, financially or socially, alongside penalizing smoker pupils. 7) Encourage and facilitate practicing hobbies and exercises as alternatives to smoking in burning negative emotions and using of free time. 7) Restrict smoking by staff, parents, and visitors inside schools; educate them on smoking consequences; encourage them to be role-models; enable smoker staff and parents to quit; and use non-financial or feasible financial punishments if staff smoke in schools. 9) Train nominated volunteers of never-smoked pupils to provide informal peer-education and peer support to resist peer pressure to smoke and create peer-pressure to avoid smoking. The thesis was concluded with an Egypt-tailored version of the Capability, Opportunity and Motivation (COM-B) model of the Behaviour Change Wheel (BCW)