A Critique of the Current Anti-Smoking Efforts in Egypt – Gilan Abdelmegeed

Introduction:

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. Egypt has the highest rate of tobacco consumption in the Arab world, with a current prevalence of 40%, increasing at a rate of 8% per year. This percentage rises among certain professions with 45% of teachers and 43% of physicians smoking. There are 25 new smokers in Egypt per hour. According to the WHO, 1/3 of Egyptian smokers start before the age of 10, with the majority of adult smokers’ beginning before the age of 18. Smoking is responsible for over 150,000 deaths in Egypt annually. The direct annual cost of treating diseases caused by tobacco use is estimated at US$ 545.5 million. Smoking has become a way of life in Egypt, where children and adults alike are socially accepted to practice it (3, 6).

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 Egypt because education does not result in action, it does not address smoker’s self-efficacy to quit smoking, and it does not acknowledge the social factors which are in fact the root of the smoking crisis in Egypt (3, 7).

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 Egypt illustrate that education is not sufficient for this campaign. First, with the prevalence of smoking being higher among the most medically educated proportion of society, education clearly does not have a negative affect on smoking. Second, in a study by the WHO in 2001, 82.1% of smokers said they had the intention to stop smoking. 60.9% of these people wanted to quit due to known health reasons (3). The majority of the population is already aware of the health affects, have the intention of quitting but are unable. Again, education alone is clearly insufficient. Third, the campaign is based exclusively on written health information, and at a 30% national illiteracy rate, the campaign is unable to reach a large proportion of the society (3).

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 Egypt.

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 Egypt and are not well advertised nor understood. The campaign needs to acknowledge the need for biological and psychological nicotine rehabilitation. 45.4% of Egyptian smokers perceive smoking as an addiction. This campaign provides no means to show smokers that they have the ability to stop smoking. In fact, it shows that smoking is a circle of unhealthy, uncontrollable behavior (3).

The SCD campaign does not provide the self-efficacy needed for smokers to give up their personal gains from smoking. Smokers in Egypt identified the personal gains from smoking to be self-confidence, being fashionable and social acceptance. 26.3% of Egyptians say smoking increases their self-confidence and 24.6% say they find it fashionable (3). The campaign does not illustrate how one can quit smoking yet still maintain the perceived benefits.

The SCD does not acknowledge the habitual nature of smoking. Smoking is a daily or even hourly habit, easily accessible and affordable in Egypt. 46.6% of Egyptians perceive smoking to be a habit, resulting in 71.2% of smokers smoking at least once a day (3). The message is not given by smokers, instead by a government whom the average public has a hostile attitude towards. 88% of Egyptians believe that advertisement countering smoking is not enough (3). The campaign provides no successful examples of individuals who have been able to quit. Especially in Egypt where the default health role models, doctors and teachers, heavily smoke, the need for good examples to imitate is essential. Behavior Change Theories support the need for positive role models and outcomes. The Marketing Theory and Branding Theory both establish that you need to have a set of associations with what you are selling (1). In theory the SCD campaign is selling “stop smoking”; however it is not advertising it well. The SCD needs to represent the positive outcomes of the behavior change. It needs to represent the ability to make that change and to provide the self-efficacy.

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 Egypt, targeting each of the 35 million smokers as individuals, rather than as social networks, to quit is a resource-wasteful method.

The SCD ignores the traditional and cultural aspects of smoking in Egypt. Smoking in Egypt is socially acceptable where many smokers start early in their youth. Smoking is placed as a priority in social households and it builds on traditional Egyptian customs such as the Egyptian tobacco water-pipe, also known as the “shisha”. A number of Behavior Change theories state that social agendas need to be incorporated into campaigns. These theories include the SNT, The Agenda Setting Theory and The Framing Theory. All three focus on changing behavior at a social level that includes factors that influence the social, rather than the personal attitudes towards smoking. Smoking in Egypt is a cultural phenomenon; therefore, it needs to be addressed as a social problem. Most smokers start while they are still minors, with a 1/3 of smokers starting before the age of 10 (3). Youth are commonly sent to buy cigarettes, are given cigarettes by adults and often work in stores, markets and cafes which either sell cigarettes or serve “Shisha”. Their childhood involves cigarettes and smoking on a daily basis. By the time they reach adulthood, smoking has become a part of the norm.

The priority of smoking in the household is further evidence that smoking in Egypt is an acquired social practice. On average, 6% of the total Egyptian household expenditure is spent on tobacco (3, 7). This rate reflects a slight increase in total tobacco expenditure despite inflation in prices. Tobacco is considered an inelastic commodity in Egypt. Hence, even with the increase in tobacco taxation, the sales of cigarettes did not significantly decrease. Heads of family were simply increasing the percentage of income spent on cigarettes, where they have spent more on cigarettes than on activities and sports for their children combined. Smoking takes precedence over the activities and development of children which reflects the primacy of smoking in Egyptian households and hence Egyptian culture (3).

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 Egypt, the SCD is overseeing possible important points of intervention that are more influential. The objective of the SCD should be to reduce the prevalence of smoking and to reduce its incidence of smoking in Egypt as well (1, 5).

Conclusion:

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 Egypt. It is far easier to prevent one from smoking, than to try to have them overcome an addictive behavior. Maintaining the SCD campaign will lead to minute results. To build a campaign based on educating individuals on the harms of a culturally integrated practice in Egypt is ignoring the fundamental problems and reasoning behind the harmful behavior.

References

¹Ball-Rokeach, Sandra. Defleur, Melvin. Theories of Mass Communication. White Plains, NY. Longman Inc. 1989

²Edberg, Mark. Essentials of Health Behavior: Social and Behavorial Theory in Public Health. Jones and Bartlett. 2007

³Nasser, Heba. The Economics of Tobacco in Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

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 Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.

Role Models as a Means to Alter Smoking Behavior Patterns - Gilan AbdelMegeed

Introduction

Tahader is a novel anti-smoking campaign aimed at addressing the ubiquity of smoking in Egypt. Tahader roughly translates from Arabic to mean development. In fact, Tahader means more than the development of infrastructure, health, and housing; it extends to the social and economical growth required for progress to occur. It is the concept that building personal traits, such as education, is needed for development. Tahader is a national goal. This campaign title links the concept of national and personal development to a smoke-free environment. It reframes the effects of smoking from an individual-level health problem to an issue of national development. The campaign utilizes Egyptian role models as a key means of improvement and change. The campaign creates role models, based on exalted personalities in Egypt. These role models are the major players in changing the social attitude towards smoking. The campaign is launched using the radio, television and billboards and well as other non-media methods. The role models are displayed through the media to increase the self-efficacy of smokers to quit, to reduce the accessibility of cigarettes and to bring about social change.

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 Egypt which portray the common life of the Egyptian adolescent. These documentaries reflect on Egyptian adolescent’s relationship with smoking, it being a habitual behavior to fill the void of daily activities (1, 3, 5).

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 Egypt believe that they can become a role model as well. The role models are from four age groups: children, teenage adolescents, young adults and adults. These four categories are designated in order for the campaign to address each Egyptian with a representative of their age group. It will be more effective to have an adolescent address an adolescent as opposed to having an adult address an adolescent (2,3). Among each age group four different characters are demonstrated: the Rebel, the Family man, the Patriot, and the Successful Entrepreneur. These four characters were chosen because they represent four highly exalted personalities in Egypt (1, 3, 5). These four characters were also chosen because they play a role in Egyptian’s perception of Tahader. Development in Egypt goes hand in hand with education, success, patriotism, and family/friend commitment (1, 3).

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.

Conclusion

Tahader reframes smoking because it does not exclusively address the health affects. The campaign addresses how smoking affects an individual and national goal in Egypt. Tahader personalizes the problems arising from smoking. An increasing number of Egyptian youth and adults are suffering from a lack of role models (1). The role models provide a compass for behavior change, and are messengers and representations of commended personalities in Egypt. They add to the self-efficacy of smoking behavior change, and promote a responsible adult-child relationship regarding tobacco products. This campaign triggers a change in the attitude towards smoking. Tahader provides a different perspective on the types of damage smoking causes. Targeting matters of the heart induce the most response. The success of Tahader lies in encouraging Egyptians to become their own role model, and in doing so, alters their smoking behavior patterns.

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 Egypt, A New Analysis of Demand. The International Bank for Reconstruction and Development/The World Bank. 2003.

⁵Saker, Hala. Anti-Smoking Scores. Al-Ahram Weekly. 2002.

⁶World Health Organization. The tobacco industry’s tactics and plans to undermine control efforts in Egypt and North Africa. Second Edition. Regional Office for the Eastern Mediterranean. 2008.