A Critique of the Current Anti-Smoking Efforts in Egypt – Gilan Abdelmegeed
In August 2007 the Egyptian government established the Smoking Control Department (SCD). The objective of the SCD is to create successful public health anti-smoking campaigns. After numerous unsuccessful anti-smoking laws, the SCD was established. Since 1977, a ban on all tobacco radio and television advertisements has been put into affect. A 1981 legislation required tobacco companies to print health warning labels on cigarette packs. It also banned smoking in enclosed public areas and on public transportation, including the subways and buses. The 1981 legislation was amended in 1994 to include a fine for smoking violations. In spite of the tobacco legislation implemented by the Egyptian government thus far, there has not been a decrease in smoking prevalence amongst Egyptians (3, 7).
Smoking in the Arab Republic of Egypt has evolved within the past 30 years to become a socially integrated behavior.
On August 1, 2008 the SCD launched an anti-smoking campaign. The strategy of the campaign is to reduce smoking prevalence through educating the public on the health affects of smoking on the smoker and on women and children through second hand smoke. The campaign requires tobacco companies to print graphic labels on cigarette packs depicting the health effects of smoking. The use of women and children targets the importance of family and children in the Egyptian community. It does not indicate that only males smoke, but instead, that the affect of second hand smoking on women affect children and family life consequently. This campaign fails in reducing smoking rates in
Argument 1: Education does not Result in Action
The SCD fails to reduce smoking prevalence because education does not lead to action. The information written on the cigarette packs convey the negative health affects on the smoker and on smoker’s family life. These health effects include the health risks on spouses, children and developing fetuses. The graphic labels on the cigarette packs also illustrate the negative affect smoking has on personal and sexual relationships. Research has been conducted which supports the claim that education does not have a direct causal relationship with behavior change. The SCD campaign, which lacks an official title, is a classic example of the Health Belief Model (HBM). The HBM is a Behavior Change model which states individuals judge a behavior change by comparing the perceived severity and perceived susceptibility of the outcome of their current behavior. Individuals then compare the perceived benefits and the perceived barriers of the new behavior and from there, create an intention to act, which entails either changing the behavior or not. The intention is the only factor affecting the decision to act (2, 4).
The HBM, as well as the SCD campaign, are both too simplistic in their approach. The assumption that education will naturally lead to a change in behavior is naïve and flawed. There have been other Behavior Change models which demonstrate the flaws in the argument that solely education can cause action. The Theory of Reasoned Action (TRA) is a behavior model that builds on the HBM and states that the attitudes towards, and the perceived social norms of, the behavior change play a vital role in adopting an action. TRA also introduces the concepts of belief, attitudes and irrational behavior. The Theory of Planned Behavior (TPB) builds on the HBM even more to add a vital concept of behavior change: Self-efficacy. Self-efficacy is an individual’s belief in whether he/she can carry out the behavior change. The TRA and TPB demonstrate that intention is only a small part of executing an action (1, 2).
The current data on the demographics of smokers in
Argument # 2: The Campaign Doest not Address Self-Efficacy.
The SCD campaign fails to provide the self-efficacy smokers need in order to quit smoking. Self-efficacy is an essential factor in promoting health behavior change. Three Behavior Change models support this: The Theory of Planned Behavior, The Social Learning Theory and The Social Cognitive Theory. All three theories state that self-efficacy is a vital part of behavior change. The Theory of Reasoned Action goes further to say that without self-efficacy one does not even have the intention to act (1, 2). The campaign ignores three important factors for smoker’s self-efficacy: the addictive nature of nicotine, the pleasures derived from smoking, and the habitual nature of smoking in
The campaign falls short on addressing the addictiveness of nicotine. It does not provide alternatives to smoking, like the patch, nicotine gum or a social support network. The existence of such alternative measures is overall scarce in
The SCD campaign does not provide the self-efficacy needed for smokers to give up their personal gains from smoking. Smokers in
The SCD does not acknowledge the habitual nature of smoking. Smoking is a daily or even hourly habit, easily accessible and affordable in
Argument # 3: To change a social behavior you need to address the social norms
The campaign fails to address the fundamental social influence on smoking. It regards smoking as an individual problem, not as a group-level one. The campaign does not account for the pervasive nature of smoking, the cultural aspects which embed it into daily routine, or an alternate to, reduce the incidence of smoking.
Tobacco advertising on television and radio stations has been illegal since 1977 (7). However, tobacco companies simply do not need to promote cigarettes because social norms and networks have become the promoters. The popularity of smoking has been embedded into the culture and become socially acceptable. There is no stigma against it, and no encouragement for people to stop smoking. The SCD’s campaign is directing its efforts towards individuals to stop smoke. Instead, SCD needs to target the social networks. The Social Networking Theory (SNT) states that people exist in social networks not as individuals and people change as networks and not as individuals (1, 2). As smoking has become such a vast practice in
The SCD ignores the traditional and cultural aspects of smoking in
The priority of smoking in the household is further evidence that smoking in
Smoking builds on traditional Egyptian customs and hence should be approached using social behavioral change theories. Cigarette smoking is similar to the “Shisha” or tobacco water pipe, which is consumed on a daily basis in social settings such as traditional Egyptian cafés, bars and restaurants. Smoking shisha has been a tradition for centuries. 92% of Egyptians who smoke cigarettes also smoke Shisha (3). This strong correlation suggests their influence on each other. Cigarette smoking mirrors the cultural practices, has become a tradition like the Shisha, and has been practiced everywhere. Interventions and campaigns will not be influential enough to stop this habit if they do not approach smoking as a tradition (3).
The SCD campaign ignores the social pressures to start smoking by not promoting smoking prevention methods. With such a large portion of smokers starting at a young age, smoking is socially embedded. The Branding Theory and The Framing Theory support a reframing of how people think of the behavior, reinforcing the core values of society. By ignoring the social factors of smoking in
The SCD campaign builds on the assumption that human behavior is rational, intentional and controllable. However, smoking counters these three fundamental behavior assumptions. Tobacco education is an important step towards reducing tobacco usage, but it is not enough. The SCD did not create a campaign built to target the Egyptian smoker specifically. The SCD is trying to promote quitting; yet it ignores the need to create preventative campaigns, the addictive nature of smoking and the social pressures pertaining to smoking in
1Ball-Rokeach, Sandra. Defleur, Melvin. Theories of Mass Communication.
2Edberg, Mark. Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett. 2007
3Nasser, Heba. The Economics of Tobacco in
4Rosenstock IM. Historical origins of the Health Belief Model. Health Educ Monogr. 1974;2:328-335.
5Salazar, Mary Kathryn. Comparison of Four Behavioral Theories. AAOHN Jounral. 1991;39 128-135
6Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.
7World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in
Role Models as a Means to Alter Smoking Behavior Patterns - Gilan AbdelMegeed
Tahader is a novel anti-smoking campaign aimed at addressing the ubiquity of smoking in
Section 1: Smoker’s Self-efficacy to Quit.
Tahader addresses self-efficacy of smokers by establishing support groups and by promoting the use of smoker alternatives such as nicotine gum and nicotine patches. The structure of the support groups are group meetings similar to the concept of Alcoholics Anonymous. These groups are complete with trained rehab doctors, rehab and medical facilities, and anonymity of members. Individuals can recruit themselves, or friends and family can call to recommend someone to join. Friends smoke together, but rarely quite together or support quitting. The support groups will provide an additional source of encouragement and support.
The alternatives to smoking, such as the nicotine patch and gum, will be advertised to the public through the media advertisements using the role models. This will allow for both a promotion of alternatives and a visual confirmation of their success and feasibility. Successfully promoting these alternatives is important as the public is not generally aware of them. Promoting alternatives will increase their self-efficacy as a majority of Egyptians perceive smoking to be an insurmountable biological addiction. The media advertisements will display the role models actively and effectively using these alternatives. Providing both social support groups and medical assistance will provide Egyptians smokers with the self-efficacy needed to stop smoking.
Section 2: Decreasing the Accessibility of Cigarettes
The second part of the campaign is to decrease the accessibility of cigarettes to children, youth, and adults alike. Enacting and enforcing laws prohibiting minors’ possession of tobacco have been ineffective (4, 5). Tahader is proposed to the Egyptian government for implementation. This campaign therefore proposes enacting laws to increase the taxes on tobacco products. Tahader decreases the accessibility of cigarettes by increasing the taxes on tobacco products. From the tobacco tax increases in 1995 and 2000, data show a decrease in cigarette consumption (4). The data also show a correlation between price and consumption. By increasing the price, the consumption of tobacco products decreased. Following this pattern, enacting an additional tobacco tax will result in a decrease in accessibility of cigarettes and a decrease in tobacco consumption.
Tahader tackles why youth start smoking, and provides the much needed role models that set the example for a smoking-free life. Youth start smoking due to boredom, expectancies, and social pressure (3). There are documentaries and films produced in
This campaign furthermore decreases accessibility by encouraging a more responsible adult-child relationship. Many Egyptian smokers begin at a young age (4, 5). Children obtain a large proportion of their cigarettes from adults, parents, and superiors at work and school (3, 4). The media advertisements include the role models displaying a more responsible approach to the adult-child relationship with respect to cigarettes. This includes refusing children tobacco, removing tobacco from easily accessible areas, and encouraging a smoke-free child environment. It redefines responsible adult behavior, encouraging adults to deal with tobacco in a manner that protects the youth from it. Increasing the tobacco taxes and promoting a responsible adult-child relationship concerning tobacco products will lead to an overall decrease in Egyptian smoker’s accessibility of tobacco.
Section 3: Stimulating a Social Change
Egyptian adolescents have a lack of local role models and this hinders changing smoking behavior patterns (1). Tahader creates role models who are reflective of the Egyptian culture and are representatives of Egyptians. The purpose of the role models is to help every youth in
In the media advertisements, the role models will each depict one of the four characters. In the advertisement, the role models will also demonstrate an active refusal to smoke by discarding of a cigarette or a cigarette pack. The role models will depict the characters by cliché actions. For example, the Successful Entrepreneur will be depicted by attaining a promotion at work or achieving high grades in school. The role models will be transparent and will have achievements within reach to the average Egyptian. These attainable goals send the positive message that Egyptians can become their role models. The visual affirmation of role models and of role model behavior will induce a social change in the attitude of smoking, not because of health risks, but because of a responsibility towards acting like the role models.
Tahader reframes smoking because it does not exclusively address the health affects. The campaign addresses how smoking affects an individual and national goal in
1Raweh Rageh, Egypt’s Youth Lack Local Role Models. Al Jazeera Network. 2009
2Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett. 2007
3Moustafa, Mohammed. Awqat Faragh, The Movie. Kalla, Hussein. 2006
4Nasser, Heba. The Economics of Tobacco in
5Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.
6World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in