Mutaz Mohammed

Tobacco smoking (TS) is one of the major global public health problems. Although many efforts have been made to minimize TS among all age groups and especially adolescents, it remains the leading cause of preventable death worldwide. In Saudi Arabia, most interventions applied to reduce TS lack published evaluations. Little is known about the motivational factors that endear TS to adolescents. Accordingly, school-based smoking prevention programmes with evaluations of their effectiveness are highly needed. This thesis describes the development, implementation, and evaluation of a school-based smoking prevention programme. The overall goal of the project was to prevent smoking initiation among Saudi male adolescents. The thesis has the following objectives:

- To explore adolescents’ views on smoking and their opinions about a smoking prevention programme (Chapter 2).
- To investigate whether social cognitive models, such as the I-Change model, can be fruitfully applied in order to understand and change the smoking behaviour of Saudi adolescents (chapter 3, 4 and 5).
- To determine demographic differences between smokers and non-smokers (Chapter 3).
- To assess differences between smokers and non-smokers concerning attitude, perceived social influences, self-efficacy and intention towards smoking (Chapter 3 and 4).
- To study if the resulting programme changes adolescents’ attitudes towards non-smoking in a positive direction and whether the programme is able to strengthen adolescents’ self-efficacy against social pressure, modelling, and norms (Chapter 5).
- To study the effects of the programme on smoking onset (Chapter 5).

This thesis starts with an overview of smoking prevalence among different age groups in SA in Chapter 1, focusing on adolescents and the history of tobacco in the region. This introductory chapter also addresses the different intervention approaches and health promotion theories used to minimize and prevent smoking initiation among adolescents. As recommended by the stepwise approach of the pragmatic methodology chosen, the chapter started with choosing the theoretical model, followed by setting the goal and objectives of the programme, and identifying salient beliefs and determinants of smoking behaviour using the literature. The next steps in the next chapters consisted of conducting qualitative and quantitative research and designing, implementing, and evaluating the intervention programme. As a theoretical background and rationale that can be used to understand and change the smoking behaviour of Saudi adolescents, we used the integrated model for behaviour change (the I-Change Model). This model originated from the ASE (Attitude-Social influence-Efficacy) model. The first chapter ends with a description of the context and outline of the research project on which this thesis is based.

Chapters 2, 3, and 4 describe the three different types of studies that preceded the intervention: a qualitative, cross-sectional, and longitudinal study aimed at identifying the salient beliefs of smoking behaviour of Saudi adolescents and their preferences for the smoking prevention intervention.

Chapter 2 elaborates on the qualitative study, analysing 11 focus group discussions, describing the different views of Saudi adolescents, investigating the determinants of their smoking behaviour, and explaining their preferences regarding a smoking prevention intervention. The results revealed that smokers smoke because of the good taste of cigarettes and because they find no alternatives to smoking, believe there is no negative impact on health, and feel like they are not kids when they smoke and look Westernized. Non-smokers do not smoke because of the nasty breath smoking causes, because of the bad effect of smoking on health, and because smoking is against their religious (Islamic) teachings.

To increase insights into factors associated with smoking initiation and continuation, Chapter 3 describes the results of the quantitative study concerning the determinants of smoking. This chapter outlines the factors related to smoking behaviour among adolescents and assesses the need for an anti-smoking intervention programme. The cross-sectional study included 695 respondents from the seventh to the ninth grade, in which adolescents from affluent families with more daily pocket money and lower academic performance were more susceptible to smoking. Non-smokers had a negative attitude towards smoking, lower perceived social influences encouraging smoking, a higher perceived self-efficacy in resisting pressure to smoke, and a lower intention to smoke than smokers. The chapter also discusses whether the I-Change Model is suitable for understanding TS behaviour in Saudi Arabia.

Since the cross-sectional study can increase insights into factors associated with smoking initiation and continuation but not the process of smoking initiation, Chapter 4 discusses and shows the results of the longitudinal study, which assessed the smoking predictors. In this study, we recruited the non-smokers from the control group at wave 1 to the randomized controlled trial and compared smoking initiators with those who did not pick up smoking after six months (wave 2). We used T-tests to assess the mean differences between smokers and non-smokers and logistic regression analyses to discover the predictors for smoking onset among Saudi adolescents. The findings of this chapter support the findings of the preceding chapters, in which smoking initiators were those with a relatively high monthly income, of low academic achievement, and living in disrupted families. Smokers have a high perceived pressure to smoke coming from parents and teachers, with smoking-supportive norms of parents, and have a high intention to smoke in the future.

Chapter 5 outlines the development, implementation, and evaluation of the anti-smoking intervention programme, in which a randomized control study, with 10 schools randomly selected for the experimental group and nine schools for the control group, was conducted. Our intervention consisted of five lessons and used different behaviour change techniques, as recommended by the taxonomy of the intervention mapping. Six months after implementation, we found that smoking initiation was 3.2% in the experimental group and 8.8% in the control group (p < 0.01), with a significantly more negative attitude towards smoking, stronger social norms against smoking, a higher self-efficacy regarding non-smoking, more action planning to remain a non-smoker, and lower intentions to smoke in the future among the experimental group. Chapter 6 is the concluding chapter of the thesis, which discusses the main findings of the various studies on smoking prevention for Saudi adolescents, summarizes the methodological strengths and limitations of the entire thesis, and addresses implications for future research and the practice of smoking prevention programmes. This chapter also discusses what could be improved, other approaches that could be used, and recommendations for tobacco control programmes in SA. It is worth mentioning that the questionnaires used in this thesis were based on the European Smoking prevention Framework Approach (ESFA), which was previously used to assess and influence smoking behaviour among adolescents in many European countries and lately in Jordan. In all these studies, the ESFA questionnaire was reported as being reliable and valid for assessing smoking behaviour among adolescents. For the purpose of the current thesis, the questionnaire was translated into Arabic, with some minor adaptations to make it suitable for Saudi norms. Finally, the studies in this thesis included only boys, because the educational system in SA is gender-specific, smoking is officially not considered a problem for schoolgirls, and funding was not available to develop an approach targeting girls. Hence, more research targeting both male and female adolescents is needed to explore a more refined set of proximal and distal factors related to smoking behaviour, with a short- and long-term effect assessment.