The predictors of adolescents’ smoking in Egypt, the global youth tobacco survey findings

This study secondary analysed the last Global Youth Tobacco Survey (GYTS) implemented in Egypt which is a cross-sectional school-based survey used self-administered questionnaire to research smoking among a national representative sample of (2,141) adolescents aged 13–15 years. The study identified that male adolescents are more likely to smoke than female adolescents in Egypt. The likelihood of adolescents’ smoking in Egypt was significantly associated with age; low educational level of fathers; having no weekly pocket of money; poor self-confidence to refuse friends’ smoking offers; absence of restriction on selling cigarettes to adolescents near their schools; and observing teachers’ smoking inside schools. Whereas accessing information, through schools, about smoking consequences prevents adolescents’ smoking. Adolescence is critical period for experimenting and continue smoking. The study identified some personal, parenteral, and school related factors that influence adolescents’ smoking in Egypt. These factors should be considered in designing smoking prevention program that targets adolescents. ARTICLE HISTORY Received 27 August 2021 Accepted 5 October 2021


Introduction
Globally, tobacco is the main cause of preventable morbidity and premature death (WHO, 2019).
Smoking increases the risk of non-communicable diseases (NCD) (WHO, 2013) which cause 68% of the global deaths; 82% of these deaths happen in Low-and Middle-Income Countries mainly before the age of 70 (WHO, 2014(WHO, , 2019. NCDs cause 84.7% of all Egyptian deaths (WHO, 2016). One in four Egyptian adults dies prematurely (between 30 and 70 years old) from tobacco-related NCDs (WHO, 2014(WHO, , 2019. Egyptian adults mainly use smoked tobacco, manufactured cigarettes followed by Shisha (water-pipe) (MOHP, WHO & CDC, 2009). There is a noticeable increase in E-cigarette smoking in Egypt, but its national prevalence was not documented in the available literature. (ABO-ELKHEIR & SOBH, 2016;Dwedar et al., 2019;LUNDBÄCK et al., 2016). Egyptian smokers spend 23.1% of their family income on smoking, the poor smokers spend at least 10% of their income on smoking (SALEH et al., 2009). Egyptians' smoking rate increases annually more than the population growth rate (8-9% versus 2%) (SALEH et al., 2009). The last Global Adults Tobacco Survey revealed that the rate of tobacco use in Egypt is the highest in the Arab world and the second highest rate in the MiddleEast (ASMA et al., 2015), as 23.8% and 19.7% of Egyptian adults had ever tried tobacco (MOHP, WHO & CDC, 2009) or currently use tobacco (ASMA et al., 2015) respectively. This smoking epidemic should be prevented by targeting adolescents because most Egyptians start smoking at adolescence age (MOHP, WHO & CDC, 2009).

Smoking among Egyptian adolescents
National surveys reveal that adolescents' smoking (cigarettes and Shisha) is a public health problem in Egypt (MOHP, 2015;WHO & CDC, 2014b). One in three (31.3%) adolescents, aged 13-15, had everused tobacco (smoked or smokeless) and one in seven (13.6%) currently use tobacco products (WHO & CDC, 2014b). Current tobacco use by adolescents, aged 13-15, has increased after a decline between 2001 and 2009, see Figure 1.
Egyptian adolescents mainly use smoked tobacco as 74.3% of current tobacco users smoke either cigarettes or Shisha (WHO & CDC, 2014b). Therefore, this study focuses on analysing the predictors of using smoked tobacco among adolescents in Egypt. Manufactured cigarettes were the most popular among adolescents until 2009, used by 74.2% of current smokers (WHO & CDC, 2005, WHO;) but then became less popular than other smoked tobacco (mainly Shisha), used by 35% (versus 42%) (WHO & CDC, 2014b). Although Shisha smoking was previously a male adults behaviour (Elawa et al., 2010), Shisha venues catering for youths consciously increase in Egypt and most Shisha smokers usually smoke cigarettes too (El-gilany et al., 2008). Over half of smoker adolescents are heavy and frequent smokers, therefore exposed to serious risks (WHO & CDC, 2014b).
Smoker adolescents are at risk of becoming smoker adults, nicotine dependants, substancesabusers and developing physical and psychological complications of NCDs (Tucker et al., 2003;VIANNA et al., 2008;Williams & SANDLER, 2001). However, these complications take years before been recognized (WHO, 2013). To avoid burdening the Egyptian health system, adolescents' smoking should be prevented as Egyptians start smoking at adolescence age (MOHP, WHO & CDC, 2009) and smoking rates increase with age (ASMA et al., 2015).
Few studies searched predictors of adolescents' smoking at specific sites of Egypt but there is limited evidence on these predictors at the national level. Understanding these predictors at the national level is required in order to design effective national interventions for preventing adolescents' smoking, as this is a key step in designing effective behaviour change interventions (MICHIE et al., 2014). This study aimed to identify factors that influence smoking among adolescents in Egypt using the recent national GYTS data (WHO & CDC, 2014b). Due to the limitation of funds, the last GYTS was conducted in 2014 and there was no opportunity to conduct another recent national survey to achieve the aim of this study.

Methods
The GYTS is a global standard cross-sectional school-based survey that aims at monitoring tobacco use among adolescents across countries over time . To allow this comparison standard methods (questionnaire, sampling techniques, indicators, data collection and processing methods) are used in all GYTS (CDC, 2016).

Sampling
A two-stage cluster sample design was used to select a national representative sample of 2,471 pupils aged 13-15 years enrolled in the first, second and third grades at preparatory schools across all the Egyptian governorates (WHO & CDC, 2014b). Schools are selected in the first stage, the sampling frame in each governorate includes all preparatory schools in this governorate but the probability of selecting schools was proportional to school enrolment size. Then classes are randomly selected in the second sampling stage. All pupils in the selected classes who attended schools in the survey day were eligible to participate in this survey but their participation was voluntary (WHO & CDC, 2014a). The response rate was 98.2% (WHO & CDC, 2014b).

Data collection instrument
The GYTS core questionnaire was adapted, translated, and back translated, then piloted with pupils aged 13-18 years to check accuracy and pupils' comprehension of the questions. Participants filled this self-administered questionnaire which included questions about: tobacco use (smoked and smokeless); knowledge and attitudes about tobacco; exposure to smoking; availability and accessibility of tobacco products; receiving educational messages inside or outside schools about smoking consequences; and susceptibility to smoking (CDC, 2016). Pupil's responses were anonymized to ensure confidentiality.

Data analysis
The SPSS software package, version 16, was used to secondary analyse the 2014 GYTS data.
Logistic regression was used to identify the predictors of being ever or current smoker; odds ratios (OR) were reported with the corresponding 95% confidence intervals (CI). The findings of the OR are considered statistically significant at the P < 0.05 level if the 95% CI does not include the one. The predictors are considered as negative predictors if OR > one and considered as protective when OR < one (Armitage et al., 2008).
Smoking behaviour was described using two dependent variables: ever smoking and current smoking. These variables are defined according to the GYTS as follow: 'ever smokers are those who have tried smoking at least once in their lifetime, even a puff or two' while 'current smokers are those who have smoked at least once in the 30 days prior to surveys administration' (ASMA et al., 2015;WHO & CDC, 2014b). Smoking in this article refers to any form of smoking, as the GYTS was not disaggregated by the type of smoked tobacco to allow separating the predictors of Shisha and cigarettes smoking.
Various explanatory variables were considered in the analysis including: age; gender; parents' educational level; average weekly pocket of money; existence of age-restriction of purchasing tobacco; ability to purchase tobacco near to school; awareness of smoking consequences; beliefs or attitude towards tobacco use (e.g. attractiveness, difficulty to quit, harms stop immediately after quitting); observing teachers smoking in schools; discussing tobacco harms with relatives; susceptibility to use tobacco in next 12 months or if offered by best friend.

Ethical approval
Ethical approval for the project and licence to access and re-analyse the GYTS data were obtained in accordance with the ethical standards of the Helsinki Declaration (1964,2008) of the World Medical Association.

Results
The GYTS data revealed that one third (31.3%) of, the included 2,141, adolescents had ever-used tobacco (smoked or smokeless) before the age of 15 years and 13.6% of them are current users of any tobacco products. Three quarters (74.3%) of adolescents who are current tobacco users smoke either cigarette or Shisha, the rest (25.7%) use either e-cigarettes or smokeless tobacco. The rate of smoking manufactured cigarette is slightly lower (35%) than Shisha smoking (42%) among current tobacco users. The available GYTS data did not distinguish those who smoke e-cigarettes, hand-rolledcigarettes and those who smoke more than one type of tobacco products.
This study explored several factors in relations to ever and current smoking among Egyptian adolescents. According to Blum's framework (Blum et al., 2001), these factors are classified into factors related to individuals, parents, friends and the environment inside and around schools. Factors that showed (positive or negative) influence on adolescents' smoking in Egypt at each level are discussed below. Table 1 summarizes individual and parenteral factors that influence (ever and current) smoking by Egyptian adolescents. The analysis shows that the risk of experimenting smoking increases with age as adolescents aged 14 years are more likely to experiment smoking than those aged 13. Also, adolescents at the age of 15 are more likely to be current smokers compared with those aged 13 years. Males have significantly higher odds ratio compared to females for being ever and current cigarette smokers.

Factors related to individuals and their parents
Adolescents whose fathers have lower educational levels have significantly higher odds ratio of experimenting smoking compared with those whose fathers are university educated. The opposite was observed in the association between fathers' educational level and the current smoking status of adolescents. Compared to adolescents whose mothers were illiterate, adolescents whose mothers have a higher educational level were significantly less likely to be ever or current smokers, see Table  1 . No significant gender difference was identified in the association between parents' education and adolescents' smoking.
The risk of experimenting smoking is inversely associated with the amount of weekly pocket money. For example, the odd ratio of ever smoking among adolescent who get more than 50 Egyptian bounds per week is lower than those who do not get any weekly pocket money at all. The odd ratio of ever and current smoking was higher among adolescents who discussed some negative consequences of smoking with their family members compared with those who did not.

Awareness and beliefs about smoking
Awareness of smoking harm to health reduces the likelihood of experimenting smoking by adolescents, see Table 1 . Adolescents who are not sure about smoking health consequences are less likely to be ever or current smokers compared with those who believe that smoking has no harms on health. Additionally, pupils who believe that smoking, even for a short period, is unsafe are less likely to be current smokers than those who believe that smoking for one or two years is safe.
Pupils who believe that smoking influences their attractiveness (positively or negatively) are more likely to experiment and continue smoking than those who believe that smoking doesn't influence their attractiveness. Moreover, pupils' belief that smoking makes them more comfortable in celebrating parties increases their probability to experiment and continue smoking. Simultaneously, adolescents' beliefs that smoking makes people less comfortable in celebrating parties positively associated with ever and current cigarette smoking (OR = 3.5, CI = 3.4-3.5 and OR = 5.7, CI = 5.37-5.95 respectively).
Adolescents who believe that quitting smoking is difficult are significantly less likely to experiment smoking (OR = 0.75, CI = 0.73-0.76) but the odd ratio of current smoking is higher among them compared with those who believe that quitting smoking is possible (OR = 2.75, CI = 2.54-2.98). Adolescents who never smoked but are unconfident about their ability to avoid smoking in the future are more likely to experiment smoking than those who are confident about their ability to avoid smoking in future even if they received free tobacco products. Table 2 shows that adolescents who would accept smoking offers by their friends are at higher risk to experiment and continue smoking than those who mentioned that they will reject smoking offers by their friends. Additionally, lack of self-confidence to refuse smoking offers by friends increases the likelihood of experimenting and continue smoking. Pupils who believe that their smoking status doesn't affect number of their friends are more likely to try smoking than those who believe that smoking would influence their friends' number. However, pupils who believe that either smoking is a way to attract friends or smoking dis-attract friends are more likely to be current smokers than those who believe that their smoking status doesn't affect their friendships. Table 3 summarizes factors related the environment inside and around schools that influence adolescents' smoking. For example, pupils who daily observe their teachers smoke inside schools are four times more likely to experiment smoking (CI = 4.86-5.07) and 32 times more likely to be current smokers (CI = 29.29-34.93) than those who never observe teachers smoking inside schools. The occasional observation of teachers' smoking inside schools also increases the likelihood of pupils' experimentation of smoking three times compared with the absence of this observation inside schools (CI = 3.62-3.78). Pupils who were taught in schools the danger of smoking are less likely to be ever or current cigarette smokers. The Odd-ratio of current smoking was 52.7 ) among those who can easily purchase tobacco from shops closed to their schools compared with those who can't do that. Additionally, absence of restrictions on selling cigarette to adolescents was a significant predictor of ever and current cigarette smoking (OR = 62.3, CI = 60.17-64.58 and OR = 65.7, CI = 60.48-71.44 respectively).

Discussion
The used GYTS data is the best available national data to understand the influencers of adolescents' smoking in Egypt for the following reasons: 1) although school-based surveys are limited to pupils, GYTS data represents majority of adolescents in Egypt because of the high (98%) regular school attendance rates (UNESCO, 2019). 2) Although school-based survey findings only apply to pupils who present on survey days, the response rates was high (98.2%) in 2014 GYTS (WHO & CDC, 2014b), which limits biases attributable to non-response or absence. 3) Specific test-retest results for similar tobacco-related questions were used to increase reliability and reduce biases caused by adolescents self-reporting of their smoking behaviour and attitude (Warren et al., 2008). 4) The GYTS sample was weighted by a weighting factor that is applied to each pupil to adjust for non-response (by school, class, and student) and variation in the probability of selection at schools and class levels (WHO & CDC, 2014a). This weighting approach makes the survey sample nationally representative of all Egyptian pupils in preparatory schools (Armitage et al., 2008).
The findings show that the risk of experimenting smoking in Egypt increases with age and males are more likely to experiment and continue smoking than females. Other national surveys emphasized that smoking at adolescence ages markedly varies by gender in Egypt, see Figure 1 Ever smoking is inversely associated with fathers' educational level. However, the opposite was true in relation to mothers' education as adolescents of low educated mothers are less likely to experiment and continue smoking than those of university-educated mothers No significant gender difference was identified in the association between parents' education and adolescents' smoking. Data about family income, an important confounding factor of the association between parents' education and adolescents' smoking, was unavailable to be explored.
Having no weekly pocket of money seems to increase the risk of being current smoker while that the risk of experimenting smoking inversely associated with the amount of weekly pocket money. Limited data was available about confounding factors of this association such as the working status of adolescents, other sources of money and accessibility to tobacco products through their households, friends, and other sources. Other studies (El-gilany et al., 2008;GADALLA et al., 2003;ISLAM & Johnson, 2005) indicate that many Egyptian smokers in different ages commonly share cigarettes. This means that adolescents could share cigarettes with their friends if they don't have enough money to buy cigarettes for themselves. Studies conducted in Arabic and European contexts concluded that being dependants on friends increases the risk of adolescents' smoking (Al-damegh et al., 2004;BAHAJ et al., 2010;Harbour, 2011;MOHP, WHO & CDC, 2009;MORADI-LAKEH et al., 2010;WELLMAN et al., 2016).
Awareness of smoking consequences on health and addiction is more likely to protect adolescents from experiencing smoking whereas believing that smoking makes people more comfortable in celebration increases the likelihood to experiment and continue smoking among Egyptian adolescents. Similar findings were identified in other contexts (JABER et al., 2016;WELLMAN et al., 2016).
Adolescents who discussed smoking consequences with their parents or siblings are more likely to experiment smoking or be current smokers compared with those who did have this discussion. However, limited data was available about the smoking status of these family members, the times and situation of this discussion, and reasons for this discussion. For example, it was unclear if this discussion took place after recognizing adolescent's smoking or positive attitude towards smoking or it was a preventing advice and open discussion? The timing and contents of parents' discussion of smoking consequences with adolescents need to be explored in further studies in order to explain this finding.
Susceptibility to smoking, defined as inability to rule out smoking in the next 12 months (ASMA et al., 2015), increases the probability of (current and ever) smoking by Egyptian adolescents. This findings is also applicable to other contexts (WELLMAN et al., 2016).
The analysis showed that adolescents' beliefs that smoking would influence their friendships markedly increase their risk of maintaining (not experimenting) smoking. Other studies emphasizes that smoking initiation by Egyptian adolescents is markedly influenced by smoking of friends and parents and the influence of smoking by friends increases with age in Egypt (Harbour, 2011;ISLAM & Johnson, 2005) and other countries (JABER et al., 2016;Scalici & Schulz, 2014;WELLMAN et al., 2016).
The analysis revealed that either willing to accept smoking offers of friends or lack of selfconfidence to refuse friends' smoking offers increase the risk of ever and current smoking among Egyptian adolescents. Evidence from other contexts also emphasizes the role of poor-self efficacy on adolescents' smoking (WELLMAN et al., 2016).
Smoking by adolescents is markedly influenced by the environment inside and around schools. Observing teachers' smoking inside schools was significantly associated with being ever or current smoker adolescents. Whereas pupils' accessibility to information on smoking consequences at schools protects them from experimenting and continue smoking. Moreover, pupils' ability to purchase cigarettes near their schools was significantly associated with experimenting and maintaining cigarette smoking among adolescents in Egypt (Harbour, 2011;ISLAM & Johnson, 2005) and other countries (JABER et al., 2016;Scalici & Schulz, 2014;WELLMAN et al., 2016).

Limitations and implications for future research
This study is limited by using self-administered questionnaire in the GYTS which may have caused over or underreporting of responses. Additionally, the GYTS data is cross-sectional which resects identifying causality and only allows exploring associations. A longitudinal study is needed for better identification of predictors of adolescents' smoking in Egypt.
It was impossible to differentiate the predictors of e-cigarettes and Shisha smoking from those of cigarettes smoking because the available GYTS data was not disaggregated by the type of smoked tobacco. There is an alarming growth of shisha smoking among Egyptian adolescents (KHEIRALLAH et al., 2016;WHO & CDC, 2014b, WHO;). This urges the need for exploring the predictors of Shisha smoking by Egyptian adolescents and if these predictors vary by gender and are different from the predictors of cigarettes smoking. There is also a need to identify the national prevalence and predictors of e-cigarette smoking as its use is noticeably increasing in Egypt like other countries (ABO-ELKHEIR & SOBH, 2016;Dwedar et al., 2019;LUNDBÄCK et al., 2016). Although e-cigarettes has being marketed as safer alternatives to smoking, the evidence of its harms to lung and cardiovascular functions are increasing (DARABSEH et al., 2020;Magalhaes, 2021). Also there is growing evidence that e-cigarette use is associated with a high risk of subsequent cigarette smoking (East et al., 2019;MCCABE et al., 2018;SONEJI et al., 2017;TREUR et al., 2018). However, context-specific exploration of this association is needed as it may depend on local factors.
A qualitative study is needed to explore the timing and contents of parents' discussion of smoking consequences with adolescents and why those who received information from parents about smoking consequences are more likely to smoke than those who never discussed that with their parents. There is also a need to explore how adolescents' smoking behaviour is influenced by the smoking status of parents who provided information on smoking consequences.

Conclusion
This study demonstrated that the likelihood of adolescents' smoking in Egypt was significantly associated with age; low educational level of fathers (not mothers); having no weekly pocket of money; willing to accept smoking offers of friends or lack of self-confidence to refuse friends' smoking offers; absence of restriction on selling tobacco products to adolescents near their schools; and observing teachers' smoking inside school premises. Whereas improving pupils' accessibility to the information on smoking consequences at schools protect protects adolescents from smoking behaviour.

Disclosure statement
No potential conflict of interest was reported by the author(s).