الفهرس 
Regional: Eastern Mediterranean RegionOnly 14 pages are availabe for public view
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Abstract
Tobacco consumption is one of the greatest public health threats in the 21st century. WHO estimates that there are 4.9 million tobacco-attributable deaths each year, which is about 7% of all deaths. Tobacco products have been implicated for at least 25 non communicable diseases affecting various body systems as respiratory system, cardiovascular system and gastrointestinal system. Tobacco consumption is also an important cause of morbidity affecting quality of life of women through increasing their risks for infertility, delayed conception, pregnancy complications as low birth weight and stillbirth. This study represents a comprehensive approach to the epidemiology of smoking among different population subgroups in Alexandria; with special focus on behavioral determinants of smoking among women who were recently widely observed to take up and maintain this habit.
Aim of the study:
General objective:
To study the epidemiology and behavioral factors associated with tobacco consumption in Alexandria with special emphasis on female tobacco use.
Specific objectives:
o To estimate magnitude and describe the pattern of tobacco consumption among selected population subgroups in Alexandria.
o To assess knowledge, beliefs and attitude concerning tobacco consumption among the same population subgroups.
o To investigate factors associated with initiation of the habit of tobacco consumption among the same population subgroups, with special emphasis on female tobacco use.
o To design, implement and evaluate a tobacco use educational prevention program for primary school children in Alexandria, based on the study outcomes.
Materials and methods:
Two designs were used to fulfill the objectives of this study:
o An observational cross sectional design was conducted among 4000 individuals (1000 belonged to each population subgroup) to detect magnitude and study consumption pattern, knowledge, attitude and behavioral factors of tobacco-use in Alexandria
o An interventional approach (quasi-experimental) was used for the design, implementation and evaluation of a tobacco use prevention program for primary school children. (100 students belonged to the experimental group and 100 students belonged to the control group)
Study setting:
The study was conducted in selected settings in Alexandria involving different population subgroups (governmental secondary schools; Alexandria university colleges; hospitals and clinics of University of Alexandria; two sporting and social clubs (Sporting and Smouha) and two main shopping malls in Alexandria (Green Plaza and Carrefour).
Study population:
o Population subgroups in different settings with potential smokers in Alexandria, including: secondary school students; university students; attendees of Sporting and Smouha clubs; visitors of Green Plaza and Carrefour shopping malls; all employees in university student’s hospital and clinics and employees in surgery departments of the Main university teaching hospital (for quantitative study)
o Smoking females from different social classes and different age groups to fulfill the focus group sessions. (for qualitative study)
o Primary school children who were students in El Azhar schools in Alexandria. (for the intervention program).
Study tools:
A. A specially designed questionnaire; it comprised the following sections; socio-demographic data, knowledge about hazards of smoking, certain statements that assess belief and attitude towards tobacco consumption, questions that assess smoking prevalence and pattern, detailed information about smoking behavior, factors associated with taking up the habit of tobacco consumption, history of previous tobacco related diseases and quitting trials.
B. A specially designed interview scheme (set of questions) was designed; mostly open ended questions for each focus group that comprises the following key items; reasons behind a female starting to smoke, experience of smoking the first cigarette, health consequences of smoking in general and on women specifically, effect of passive smoking on children’s health, Benefits of smoking if you think that there are benefits, experience of shishah smoking, causes that enforce women to smoke tobacco (shishah or cigarettes), smoking females perceived opinion regarding which is more harmful cigarettes or shishah, the opinion of the smoking female’s family on smoking woman in general, smoking females perceived opinion regarding women smoking in public and men smoking in public ,quitting experience of the participated smoking females including reasons that make women stop smoking, the need of a specialist to help quitting and the reasons that enforce women to continue smoking
The intervention:
A questionnaire was designed to test knowledge and attitude of the students before the intervention program; the same test was applied twice after the end of the intervention (immediately and 2 months later) for evaluation. The anti tobacco health education program included two health education lectures, three lecture discussions that covered the following item ”why do people smoke?” and emphasized that smoking is addictive not just a bad habit. Two other sessions were held using demonstration and role playing techniques to teach students refusal skills in any risky situations.
The results obtained in the present survey could be summarized in the following headings:
Magnitude of tobacco consumption among different population subgroups in Alexandria:
• The highest prevalence rate of tobacco consumption was reported among participating attendees of clubs and malls (25.9%) while the prevalence among employees’ , secondary school students’ and university students’ samples was found to be 17.6%, 17.1% and 17.1% respectively.
• The prevalence rate of smoking among men in the present survey varied from 29.2% in the university students’ sample to 43.6% in the social clubs and shopping malls attendees.
• The prevalence rate of smoking among women in the present work varied among different population subgroups: employees’ sample (1.6%), university students’ sample (5%), social clubs and shopping malls attendees’ sample (8.2%) and secondary school students’ sample (9%).
• The prevalence rate of smoking among health care workers was 12.6% while 22.6% of non health care workers were current smokers. Smoking prevalence is higher among university students who are submitted to non health related faculties than those who study in health related faculties (17.8% versus 16.4%).
• Men were more likely than women to smoke daily among the four population subgroups (daily smoking prevalence among smoking men ranged from 67.8% to 83.9% while it varied among smoking women from 39% to 75%). Concerning the occasional form of smoking; it ranges between 16.1% and 34.1% in men and between 25% and 61% in women.
• Regarding forms of smoking consumed in the present study, cigarette consumption was the dominant used form as reported by current smokers in the four population subgroups (prevalence was ranged between 46.8% and 68.1%) while water pipe (shisha) consumption prevalence rate varied between 8.2% and 17.8%. No other type of tobacco was used in the surveyed population.
Knowledge and attitude concerning tobacco use:
• Level of knowledge: It is obvious in this research that a small proportion of participants in each subgroup (ranging from 19.7% to 39.5%) had good level of knowledge about smoking (its harmful effects, its components and passive smoking with its hazardous effects).
• Comparison between smokers and non smokers regarding mean knowledge scores: There was a significant difference between smokers and non smokers regarding their knowledge about the harms of both smoking and passive smoking among employees’, university students’ and clubs and malls samples (non smokers were more aware than smokers). While there was no difference between smokers and non smokers among secondary students’ subgroup as regard their awareness about the association between tobacco consumption and certain health problems.
• Level of attitude: almost all of the participants in the present research have either neutral or negative attitude towards smoking. Negative attitude means antagonistic attitude towards smoking behavior and towards any action that encourages or permits tobacco use in public places, school, university and work.
• Comparison between smokers and non smokers regarding mean attitude scores: Concerning participants’ attitude towards tobacco use, there was a significant difference between smokers and non smokers among the four population subgroups (as expected non smokers have higher mean attitude scores which denote more negative attitude towards tobacco consumption than current smokers).
• Health care workers and students belonged to health related faculties: The mean knowledge score was significantly higher among health care workers and among students belonged to health related faculties than among non health care workers and those students belonged to non health related faculties respectively. Significantly higher attitude score was recorded among health care workers than among non health care workers. However medical education does not affect attitude towards tobacco use among the participating students of health related colleagues’ sample.
Factors behind initiation of tobacco consumption:
• Reported causes of cigarette smoking initiation among smoking males: Concerning factors that initiate cigarette smoking among smoking males in the present work, it was found that the most frequent reported causes among the four population subgroups are; curiosity, imitation of friends, peer’s pressure and stress relief or as a way of helping in problem solving. Many of smoking males in the secondary students’ sample mentioned that they initiate cigarette consumption to feel that they are grown up.
• Reported causes of cigarette smoking initiation among smoking females: The most common factors that encourage cigarette consumption among smoking females belonged to the four subgroups in this study were curiosity, stress relief, imitation of friends, and imitation of teachers. Peer’s pressure was mentioned by considerable proportion of smoking females in the social clubs and malls sample while others (in the employees’ and the secondary students’ samples) reported that they initiate that bad habit to feel that they are grown up. This study pointed a finger towards husbands of some smoking women who mentioned that they initiate cigarette consumption when their husbands encourage them to smoke.
• Reported causes of initiation of shisha smoking among males: The most frequent causes behind initiation of waterpipe smoking as mentioned by males were curiosity, socialization with friends, stress relief, peer’s pressure and its better aroma. Many of smoking males in the secondary students’ sample mentioned that they initiate shisha consumption to feel that they are grown up and mature.
• Reported causes of initiation of shisha smoking among females: Curiosity and socialization with friends were the most common reported causes in this survey for initiation of shishah use among smoking females. A considerable proportion of smoking females who were belonged to the employees’ and secondary students’ samples mentioned that they initiate shisha consumption because they belief that waterpipe smoking is less harmful than cigarette smoking and to attract attention.
Pattern of tobacco consumption
• Mean age of initiation: Concerning pattern of smoking among smoking males in the present study, mean age of initiation of cigarette consumption was reported to be 17 years by employees’, university students’ and clubs and malls attendees’ samples; while participating females recorded lower mean age of initiation than men in the following population subgroups (16.8 years for the employees group, 15.2 years for university students).
• Duration and type of smoking: Most of smoking male participants recorded less than 5 years duration of smoking and were heavy smokers while females reported longer duration of smoking than males in employees’ sample (more than 20 years) and in the clubs and malls (more than 10 years) and there was no consistent pattern of tobacco use between the four population subgroups among women concerning the numbers of daily consumption of cigarettes.
• Favorable place for smoking and percent of friends who smoke: Cafeterias were the preferable places for smoking as reported by smoking men belonged to secondary school students’ and university students’ samples in the present work. It is very obvious in the present study that the majority of smoking males in the four population subgroups reported that some, most or all of their friends were smokers.
• Previous trials to quit smoking: Regarding previous trials to quit smoking, many of the smoking participants whether males or females in the present work tried to stop smoking but they failed to remain non smokers.
• Reported causes of previous quitting trials among smoking males: Concerning reported causes of quitting trials among males, health reasons were the first reported motive to quit in all the four population subgroups. The belief that smoking is forbidden in religion was an important cause among the employees’, secondary students’, and university students’ samples of men.
• Reported causes of previous quitting trials among smoking females: Concerning reported motives behind quitting trials among females in the present work, the majority of those who tried quitting among employees’ sample reported religious belief that smoking is forbidden as a cause, while health reasons were mentioned by large proportion of those females in the students’ samples (secondary and university) who tried to stop that bad habit before.
• Shisha smoking: current tobacco users of females whether secondary or university students and those who participated from the clubs and malls are more likely to smoke water pipe (shisha) than current smokers of males belonged to the same population subgroups. Most shisha smokers whether males or females use less than 5 Hagars per week.
Evaluation of the Interventional Tobacco Consumption Prevention Program is shown in the following items:
o Findings of the intervention program suggest that the ”kids against smoking” is having a positive impact on the primary school children in the intervention school as there was a highly statistically significant increase in the mean knowledge value immediately after the end of the intervention program and after 2 months in the experimental school.
o There was statistically significant increase in the mean attitude score in the same school immediately and two months after implementation of the intervention program.
o Regarding the control school there was small but statistically significant increase in the mean knowledge score and highly statistically significant increase in the mean attitude score values immediately and two months after the end of tobacco prevention program
o However the difference in mean percent changes among both the intervention and control schools was highly statistically significant regarding the mean percent change for knowledge only not for attitude.
Results of Focus group discussions that targeting smoking females could be summarized as follows:
o Factors behind initiation of smoking: All participants in this work who participated in the qualitative approach agreed that smoking is a source of pleasure and has calming effect. FGD confirm causes that were mentioned behind initiation of the habit among participants in the quantitative approach; a key personal factor for smoking among women who are belonged to the highly educated groups is the need for social prestige, curiosity and experimentation. The participants emphasized that parents play an important role in their smoking behavior through role modeling effects.
o Causes of shisha smoking among females: Participants revealed that waterpipe smoking is growing sharply among females due to the strong belief that it is a fashionable habit which denotes high social class, the belief that waterpipe use is less harmful that cigarette consumption and due to the establishment of many cafes that offer shisha in different attractive colors and flavors.
o Misconceptions about smoking: These in depth interviews revealed some important misconceptions and beliefs that are rooted in the mind of our participants and so encourage them to continue smoking; they belief that because diseases are related to destiny so no need for prevention. Other false belief that was reported by smoking females in this study is (being dangerous and fatal does not necessitate quitting or abstain).
o Almost all participants in the FGD of the present work indicated health problems as drawbacks of smoking, however they continue to smoke.
It can be concluded from this study that smoking is prevalent among males in different population subgroups in Alexandria. Although the prevalence of tobacco use among females is much lower than among males, however the trend of smoking among females is steadily increasing with more spread of waterpipe consumption phenomena. It must be put in consideration that there is under reporting of smoking problem among females in the present research. Participants in this survey were aware about the most common diseases that could be caused by smoking as cancer lung and coronary heart diseases, but much of them need more health orientation as regards effects of smoking on reproductive system, fertility and other body system; while others need more health education about the dangerous components of cigarettes and the adverse outcomes of passive smoking. Prevention of this harmful habit is multisectorial and needs collaboration from all individuals and organizations in the Egyptian community; primary prevention in the form of well organized health education programs especially for primary school children must be the target of public health specialists to prevent initiation of tobacco consumption at early age. Secondary prevention which includes helping individuals who started to smoke especially if they have the desire to quit is crucial.