Understanding Smoking Behaviour among Secondary School Students in Amman, Jordan: A Qualitative Study

Shadid HM and Hossain SZ^*

Faculty of Health Science, Discipline of Behavioural and Social Sciences in Health, University of Sydney, NSW, Australia

*Corresponding Author:

Syeda Z. Hossain, PhD
Faculty of Health Science
University of Sydney, PO BOX 170
East Street, Lidcombe, NSW 1825, Australia
E-mail: zakia.hossain@sydney.edu.au

Received date: December 19, 2012; Accepted date: February 11, 2013; Published date: February 13, 2013

Citation: Shadid HM, Hossain SZ (2013) Understanding Smoking Behaviour among Secondary School Students in Amman, Jordan: A Qualitative Study. J Community Med Health Educ 3:199. doi: 10.4172/2161-0711.1000199

Copyright: © 2013 Shadid HM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Tobacco smoking is the most preventable cause of death in many countries. Globally, it accounts for 4.9 million deaths per annum, 70% of which occur in developing countries. With the growing economic development of countries in the ‘East’ and ‘South’, the international tobacco industry has been shifting its marketing towards these areas. Evidence shows that the majority of the smokers start smoking as early as high school level and the number of young smokers is increasing rapidly, which is a concern. In Jordan, smoking has reached alarming proportions, but as yet limited data is available about young Jordanians’ smoking behaviour. This research is an attempt to bridge the gap.
Methods: A qualitative study was conducted on secondary school students of Amman, the capital of Jordan in 2010. The participants of the study were 16-18 year-old students of public and private schools in eastern and western suburbs of Amman, who were recruited using stratified random sampling. Five focus group discussions (FGDs), two for males and three for females with six participants per group were conducted. The FGDs used open-ended questions to focus discussion on four broad areas: smoking behaviour, reasons and place of smoking, accessibility of tobacco products, and quitting smoking.
Results: The results show that 40% of students were current smokers, and that 66.7% of these were males. The age at which they started the habit was as early as 11 among males and 16 among females. Family environment was found to be positively associated with participants’ smoking behaviour. Hookah smoking was considered socially acceptable in some families, with the perception that it was less harmful than cigarettes. Females tended to smoke alone within contained/secret places, whereas males were more likely to smoke in a group environment on the street or near where they lived.
‘Stress’ was the main reason for participants to start and/or continue smoking, followed by ‘peer  pressure’, ‘belonging’ and ‘being cool’. Other factors such as easy accessibility, availability and money issues also played an important part in their smoking. The health risks and consequences of smoking were underestimated by the students, and they expressed no interest in quitting or taking familial advice against smoking seriously. Fear that their fathers might learn of their habit and the possible consequences thereof, i.e., ‘harsh punishment’, was a prime factor for students not to smoke. Despite legislation, students were able to obtain tobacco products easily. The school environment was an important predictor of students’ smoking as teachers smoked within the school vicinity, even in the lass, and the school curriculum did not tackle the issue of tobacco appropriately.
Conclusion: Certain measures taken to control youth smoking have not been effective due to lack of understanding of how young people perceive smoking and hence act. This paper sheds some light on 16-18 years old students’ smoking behaviour, factors that encourage their smoking and areas where attention is needed to prevent youth smoking.

Keywords

Youth; Smoking behaviour; Quitting smoking; Family and school environment; Qualitative study; Jordan

Introduction

Tobacco is the only consumer product that, when used as recommended by its manufacturers, eventually kills half its regular users [1]. Smoking is the single most known preventable cause of death in many countries. The World Health Organization (WHO) attributes 4.9 million deaths a year to tobacco smoking, a figure that is expected to rise to more than 10 million by 2030 if no action is taken [2]. The morbidity and mortality associated with tobacco use is shifting from developed to developing countries [3,4] which are almost 70% of those death will occur [3,5].

Since the beginning of the new millennium, the losses in lawsuits, noticeable decreases in consumption of tobacco and tighter laws on tobacco marketing in developed countries have prompted the tobacco industry to go “East and South”. Tobacco companies have consequently been expanding their international operations into Eastern Europe, Asia Pacific, Latin America, Arab nations and Africa [6], where there is inadequate anti-tobacco legislation to withstand their marketing attacks, and where the poor economic status of these countries makes it difficult for governments to resist the considerably high tax revenues that result from selling tobacco products.

The most fruitful target for tobacco companies will always be young people since, given the addictive nature of tobacco products, enticing them to smoke will guarantee years of consumption; i.e., it is an extremely effective long-term investment. It is reported that the younger a person starts smoking, the more consequences he/ she suffers and more difficult it is to quit [7,8]. It is well documented that the majority of smokers start their smoking experience before or at high school age [9,10]. The incidence of smoking as a habit has been found to increase three-fold from the age of 18 to 21 [11]. Other factors that help young people to pick up the habit include poverty [3], unemployment [12,13], absence of security [14], family environment [5] and school environment, all of which are common in the so-called “developing” countries.

One of those “developing” countries suffering from this epidemic is Jordan. The Hashemite Kingdom of Jordan (Jordan) is one of the Middle East North Africa Regions (MENA) classified by the World Bank as an upper-middle-income country [15]. Its population of 6 million is one of the highest consumers of tobacco within the region [16]. A considerable portion of the total population, approximately a quarter, is aged between 10-19 years [17]; this group is a vital part of the country’s future.

Adult smoking in the Kingdom is twice as high as in the surrounding countries. Some 61.2% of Jordanian males aged 15 and above smoke compared to only 32% of males within the region; among women smoking is also on the rise with a prevalence of 9.6% among Jordanian women compared to 4.4% of women within the region [16]. In such an environment, it is difficult not to see this behaviour affecting and possibly driving young Jordanians to adopt the habit as Islam and Johnson suggest a strong association between parental smoking and youth smoking, an association they believe to have a more causal effect than peer pressure [5], especially in this part of the world where family ties are still coherent [18].

The existing research on Jordanian youth in regard to smoking is minimal. The WHO periodically performs a Global Youth Tobacco Survey (GYTS) [19] for the 13-15 years of age category in which data on this group is gathered and analysed in a global perspective. Certain universities have conducted some research on their own students and published the results [20]. However, little if any research exists regarding the smoking behaviour and related issues of 16-18 year-old Jordanians; this research is an attempt to bridge this gap.

Materials and Methods

A qualitative study was conducted among secondary school students in Amman, the capital of Jordan. Participants of the study were male and female students aged between 16-18 years from public and private schools in eastern and western suburbs of Amman. Western Amman is generally inhibited by high-income families while those in eastern parts of the capital are generally low-income; the use of these two distinctly different sample areas was to enable the investigation of socio-economic status (SES) factors. Schools were selected from the Secondary School list of the Ministry of Education using stratified random sampling. The selected schools were informed about the aims and objectives of the study and students’ voluntary participation in the study. A total of 30 students were recruited equally from 10^th, 11^th and 12^th grades to form five discussion focus groups of six participants each, two for males and three for females. The groups were unisex to conform to social norms and to ensure free discussion. Each group of six comprised of three participants from each type of school, three from each area of the city and two per level of school. The number of students was limited to six per group in order to give the participants sufficient time and opportunity to discuss and interact freely and still be easily managed by the moderator. Ethical clearance of the study was obtained from the Human Research Ethics Committee of the University of Sydney. The research instrument and all permissions obtained from the related Jordanian authorities were reviewed by the ethics committee of the University of Sydney, the research was cleared by the committee under Protocol No: 10785.

Five focus group discussions (FGD) were held with the first author (Shadid HM) mediating the session. The initial plan was to have two sessions for each gender. However, the moderator soon noticed that in the female FGD, participants were reluctant to participate and hesitated rather than freely and effectively contributing to the discussion, hence the researchers decided to have another session for female participants led by a trained female facilitator. Thus three FGDs were carried out for female participants.

The meetings were held in a well-known easy-to-reach building (the complex for professional labour unions in Shmaisani), in a well-serviced area within the capital. All students were contacted the day before and again on the same day to insure their arrival and participation. Participants’ consent was obtained in writing prior to their participation in the FGDs once they had been assured that nothing they said could be used against them and that their anonymity and confidentiality would be maintained throughout the research process. They were also informed of their right to leave or withdraw from the study at any time without prejudice. Participants were compensated for their transportation and time; each was given 10 JD (1 JD=1.4 US$) at the end of their session.

The focus group discussions concentrated on four major areas related to smoking, namely:

Smoking behaviour (8 questions), Reasons for and place of smoking (8 question), Accessibility of tobacco products (5 questions), and Quitting smoking (8 questions). The FGDs were held in Arabic, the local language of Jordan, and recorded with permission of the participants. (Participants were assured that these records would be kept safe and secure).

The data collected via the FGDs were transcribed and then translated into English by the first author (Shadid HM), who is a bilingual (Arabic and English). His translations were cross-checked by an academic fluent in both Arabic and English in order to assure their validity and reliability. Thematic analysis of the data was used and the results are presented below under the broad themes.

Results

Results of the focus group discussion are presented under the broad themes identified from the FGDs.

Smoking behaviour

Of the 30 participants of the FGD’s, 40% (N=12) were smokers, two were ex-smokers. Some 66.7% of the smokers were male of which some had begun the habit as early as 11 years of age. One male participant stated,

“I was 12 years old when I had my first cigarette, I am17 years old now...5 years already!”

There were only two female smokers, both of whom started at a later age: 16-17 years. One of them said,

“I only started 6 months ago”.

Male participants’ smoking habits ranged from 5-7 cigarettes in a normal day to a whole packet of 20 per day. For one this was dictated by opportunity:

“There is no number in particular, whenever I have a chance; I will take one or two cigarettes”.

Females smoked less than their male counterparts, consuming only 2-7 cigarettes per day. As one said:

“I don’t smoke too much, I only need 2-3 cigarettes a day, it is enough”.

While some smoke cigarettes only, others mentioned using ‘Shisha’, a hookah, or other forms of tobacco.

“Anything that could be smoked, I will, I will not save anything”.

One female participant suggested

“It depends where you are; I smoke cigarettes in the streets but love to have my Shisha when I am in cafe’s with my friends, adding, if I have the money, of course”.

All participants agreed that their preference was for foreign brands of cigarettes, specifically mentioned Marlboro and Dunhill, in spite of the high cost of these imports. When asked about the reason, the general opinion was that they were ‘smoother’ and produced more smoke. As one student stated:

“When you take Marlboro, you feel you are smoking tobacco; the national brands, you feel you are smoking green grass”.

A female participant felt that

“Yes, it is expensive, but it is worth it as the difference is vast between the national and the imported products”.

Smoking and gender

When asked about their sources of information regarding the risks of smoking and whether they had received any advice from anyone, it became apparent that families focused more on advising their sons not to smoke than their daughters because they believed their daughters to be non-susceptible to the risk. As one of the female participants put it:

“They think we are angels”.

Shisha, or sharing a hookah, was considered socially acceptable in many families such that young people who were forbidden to smoke cigarettes were allowed to partake of shisha during family gatherings. The latter seemingly did not constitute smoking; as one female participant stated:

“No, I don’t smoke, I take shisha”.

There is a strong perception among Jordanians that shisha is less harmful than cigarettes. That and the fact that its consumption is more social makes shisha more acceptable to families, and fathers in particular, than cigarette smoking by the student alone. One female participant said she used shisha,

“In front of my mother and with her”.

But admitted that she smoked cigarettes,

“Without my parents knowing”.

Environment and smoking

Results show that the family environment is an important factor regarding the smoking behaviour of the participants of the study. Participants were more likely to smoke in families where their father, siblings or extended family members smoked. A great majority of the all FGD participants (81%) confirmed that at least one of their family members smoked, usually the father. Typical observations were:

“My father has been a heavy smoker, for as long as I can remember”

“My father and two of my brothers are smokers and I am expecting my younger brother to join in within a short time”

“When my uncles visit us, the house turns into a big smoke” and

“Yes, I hear my father cursing the day he started smoking, while he is grabbing his cigarette, then he starts threatening us if he discovers anyone of us doing the same?! That is hypocrisy, don’t you think?”

Almost all participants who were smokers at the time of FGDs were scared that their parents would find out that they were smoking because this would result in severe punishment including physical abuse, beating, having their pocket money cut or public embarrassment. In some instances this ‘fear’ was what stopped participants from taking up smoking or, for those who were smokers, was the catalyst which made them quit. One of the ex-smokers recounted:

“When my father came to know about my smoking, I was physically beaten really hard and my allowance was cut for a month; this in spite of the fact that my father is a heavy smoker himself”.

Another male student was certain that,

“If my father comes to know about my smoking, I recon he will tie me in the ceiling fan”.

All participants agreed that their mothers’ reactions would not be as brutal/severe as their fathers’, despite their equally strong objection to smoking.

The fact that parents, in particular fathers/male members, smoke in front of their children within the house suggests that there is little or no awareness of passive smoking and its consequences in this society. Instead, participants confirmed that smoking in the home is common and very acceptable in Jordanian society. As one male participant stated:

“Where do you want my father to smoke, if you are implying getting him out to smoke? Forget it, he will get the whole family to get out and still smoke within the house”.

The observation

“When my uncles come to visit, the house turns into a big smoke”, referred to earlier was echoed by the majority of participants.

When questions were asked about the prevalence of smoking in the school grounds and in the classroom per se, all participants confirmed that a great majority of their teachers smoked within the school vicinity. One participant stated that teachers would even

“Ask us to go to the nearby shop to buy them cigarettes”.

According to several participants from public schools, some teachers smoked during class; this was not the case at private schools. Instead a female student from a private school stated that

“They would definitely fire the teacher if seen smoking within the vicinity of the school”.

Reasons for smoking

When participants were asked what drove them to smoke, the majority mentioned ‘stress’ as the key reason for starting and/or continuing smoking. Stress was mentioned or seconded by 90% of the participants and was reported as associated mainly with study, family environment and parental control. Smoking was perceived by the students who smoked to relieve stress and promote a sense of control. As a male student described it,

“When you breathe in the smoke, you feel in control of your stress”.

Another stated:

“Instead of burning your heart, light a cigarette and burn it, it smooths your feelings”.

‘Peer pressure’ as described in the literature certainly applied to the participants, however, the severity of this in instances reported by students would be more aptly termed ‘peer force’. Participants suggested that in certain places in Amman non-smokers were coerced into smoking by their more influential colleagues, under the threat of being bullied or being excluded from the group.

One student conveyed the typical male attitude as:

“Isn’t he a man? Why wouldn’t he accept to smoke, he is not different than us, he has to smoke to be welcomed in the group”.

Other reasons participants gave for smoking were the feelings of independence and maturity and being attractive to the opposite sex that smoking gave them. While female participants were more likely to be attracted to smoking for the image of maturity and independence:

“I am not a kid any more to buy chocolate, or candies, I buy cigarettes”

“I feel free and independent when I puff the smoke out”

Males generally felt it enhanced their attractiveness, e.g.

“You will always feel cool and sexy with a cigarette in your hands”.

Places of smoking

When asked about where they smoked, the majority of smokers (males and females) agreed that the principal attribute for a place to be suitable for smoking was for it to be hidden.

“Any place is a good place for smoking if it protects your identity”.

“What is important is that no one will recognise you and tells your father”.

While at school, the toilets were the most popular place for students to smoke. However, outside of school, females tended to smoke within closed or secured places like their rooms in the house, near the window or on their balconies if not exposed. Timing, it seemed, was also essential:

“It is dangerous as you could be discovered but I choose good timing to do so”.

Male participants usually liked to smoke on the street where they would not be recognised, in places close to where they lived, or in the very shops they bought their cigarettes. Some shopkeepers provided a shelter, such as at the back of the shop, to young men for smoking; this was especially useful in winter. A male participant explained that the owner of the shop close by to his home sold him the cigarettes and the place to smoke;

“I actually hide my pack in his shop”.

Accessibility

Questions such as, ‘Where do you get your cigarettes?’ and ‘How difficult it is to access these places?’ were asked to assess the accessibility of cigarettes by the young people.

There was unanimous agreement on the ease of accessibility of tobacco from shops or other sources, be it buying them from small grocery stores or supermarkets, stealing a couple from their fathers’ packets, or getting them from friends, siblings, or smokers in the street:

“Any smoker in the road will give you a cigarette if you ask”.

“My friends will never reject a request to have a cigarette; it’s a giveand- take status”.

One participant did note:

“My father is going crazy as both me and my brother steel from his pack”.

All smokers and non-smokers (buying for their fathers or friends) agreed that it was the easiest thing to buy a pack of cigarettes from any place within their areas, no questions asked. A female smoker commented as follows:

“You think they [shop keepers] care about how old you are? They only care about the money in your pocket”.

Quit smoking

A number of questions were asked about quit smoking, such as ‘Have you ever tried to quit smoking?’, ‘How many times have you tried to quit smoking?’ and ‘What are the obstacles to quit smoking?’

All of the participants who smoked stated that they had tried to quit but failed due to ‘stress’, anxiety, and peer pressure. Below are two typical responses from male participants about their quitting experience:

“I tried, but it lasted for days; I was watching a football game and felt I needed a cigarette”.

“I would like to, but studying is so hard and I am doing my last year now, a cigarette would help me focus and reduce the pressure, I will quit after I have passed the exams”.

Students did not consider quitting because of the health problems associated with smoking. For the majority of participants, the main reason they would quit and considered quitting was the consequences they could expect should their family members, ‘especially their fathers’, come to know about their smoking. When the health risks of smoking were brought to the discussion table, the response was that no one would die ‘before their time’ regardless of whether they smoked:

“When your time to death is due, nothing will stop it”.

“No one will die before hand”.

Female smokers conservatively agreed to the principle outlined by these statements when mentioned by the interviewer.

Asked about whether they had received any advice against smoking from parents and/or teachers, whether any bans on smoking were imposed in school, and how effective either of these measures was in influencing their smoking behaviour, participants’ responses were mixed. 33% of male students (N=4) remembered the topic having been mentioned by their teachers briefly as part of a health and physical education lesson; the remaining male students denied hearing anything from their teachers at school. In contrast, 78% of the female students (N=14) reported discussing the risks of smoking in class. All participants of both genders agreed that there was no subject curriculum at school set to address smoking. Reflecting on this, one female participant stated:

“The only time I heard about the harmful effects of smoking in school was through a campaign done by the UNICIEF; they came and showed a movie for 20-30 minutes and disappeared”.

All of male students admitted having been told not to smoke by at least one of their parents and reminded of the consequences awaiting them if they did smoke; consequences that are both future health related and punishment by the family. Only 4 female students (22.2%) reported having been warned of the dangers of smoking by their mothers. However, the advice offered by families and teachers was considered by many students to be hypocritical. As one male participant said:

“Don’t you think it is hypocrisy to ask me to quit and never smoke while you are puffing smoke all around me?!”

All participants knew that smoking is forbidden in schools and they were reminded of it during recess or before the morning gathering. There was, however, a distinct difference in response towards this ban depending on the type of school participants attended: Public school students tended to trivialize the ban and any preaching of this ban by their teachers. As two public school students commented:

“It is written on the school walls all over the place, but who cares?”

“Who cares about the ban, [when] teachers are breaching it, do you want us to abide?!”

The same attitude was not observed among private school students. In general, these showed more respect for the ban, and stated that they did not smoke within the school or see teachers smoke in front of them within the vicinity of the school.

Discussion

Although smoking is a widespread habit among adults in Jordan, it is still viewed as unacceptable if carried out by youths. Thus, although a considerable amount of young people in Jordan are raised in a house in which at least one person smokes in their presence, they will be told not to smoke and threatened with severe consequences if they do. Despite this, the results show that a large percentage of young Jordanian males emulate their parents’ behaviour by smoking. This finding confirms the observation made in other studies that males in Arab countries tend to model their behaviour on that of their fathers [21,22].

The results show gender differences in terms of smoking behaviour, in particular the age at which young people start smoking, their reasons for smoking, social perception of their smoking, and opportunity to smoke. Young males tend to start smoking at an earlier age (11-13) than their female counterparts (16-17 years). This could be due to the perception in this fairly ‘conservative’ male-dominated society that ‘good’ girls do not smoke, and that doing could get them into serious trouble and jeopardise their reputation irrevocably. A similar attitude towards female smoking has been observed in other male-dominated societies in region [5,23]. The fact that male students tend to smoke outside and in groups more than the females, is essentially an extension of the same differentiated views as Young men are more mobile than their female counterparts. This is because, unlike girls, they do not need permission to go out or ‘hang out’ with friends outside the home. Thus the opportunities for young females to smoke with others are significantly fewer.

From the Focus Group Discussions it was obvious that families do not discuss smoking-related issues with their daughters but do with their sons, either directly or indirectly. Young females are taken for granted as non-smokers perhaps because parents are confident that the social taboo of female smoking will in itself suffice to deter them.

In general, passive smoking is prevalent in Jordan. The findings of the study show that parents are likely to smoke in the home and in the presence of their children with no concern for the consequences. There was some amusement at the suggestion that parents might go outside to smoke. This finding was also recorded by the WHO in their 2002 tobacco atlas, which placed Jordanians in third place worldwide in the category of youth exposed to passive smoke in the house [6].

When discussing the reasons for smoking with this group of young students, it was surprising how frequently they used words like ‘stress’, ‘pressure’ and ‘load’, all of which seemed inappropriate for their age. In fact, young Jordanians “in general” are not expected to perform any other duties apart from their schoolwork. Yet, a majority of the participants mentioned stress as the main reason for smoking. ‘Pressure’ was also mentioned by a good number of participants, who were, not only referring to ‘peer pressure’, but also to pressure from parental expectations of their academic achievement, which mount more pressure on these students especially on their final school years.

During the discussions, it became clear that there are some considerable misconceptions about smoking among this group of young students despite their fairly high level of knowledge about its harmful effects. Participants tended not to take the consequences of smoking seriously, as they believed an extended time and intensity of smoking was required before cigarettes caused harm and that it would not be harmful to smoke for short periods. The problem of addiction appears to be vastly underestimated and students are under the false impression that they can quit at any time.

Students are aware of the laws and restrictions in place against smoking but seem to blatantly disregard these. The only deterrent of any significance appears to be fear of being found out by their families, in particular their fathers, and the severe punitive consequences of being caught. This finding is consistent with the finding of other studies e.g. Simons-Morton et al. who made their research on students of 6^th-8^th graders in Maryland school district- Washington DC. They reported that authoritive parenting which includes both, demanding and responding to their adolescent children, appears to protect youth against smoking and drinking’ [24].

Another important aspect of youth smoking is the phenomenon recognised as peer pressure [24-26]. We understand this as the psychological pressure exerted on a non-smoker who already socialises with a group of smokers or who desires to join such a group. In Jordan this peer pressure seems to take on an even stronger dynamic, one which might be called ‘peer force’. It was voiced by one male interviewee in the following statement, which was then confirmed by other students:

“You can’t be a non-smoker within a certain class because the majority are smokers and hence you will have to start smoking, and refusal to that would not be tolerated”.

While it could be argued that students could seek intervention by their fathers or the school administration to protect them from this pressure, at this age few young people would do so and risk losing face within their peers. This finding was not echoed by any other focus groups and could not be matched in the literature which implicates more research.

It was evident from the findings that, regardless of age tobacco products are easily obtainable from a variety of sources. Despite the laws and legislations that have been in effect for many years, the sale of tobacco products to minors/under-aged people is common and continues unabated in this part of the world. This ready availability remains a problem even in other countries, even ‘developed’ ones [27-29].

It is obvious from the findings that the education system fails regarding the issue of smoking, and that schools and teachers do not take their role in educating students on the risks of smoking seriously. The curriculum does not specifically cover smoking and the very minimal information students are given is taught incidentally as part of other major subjects. By not allocating sufficient time and resources to discuss the issues of smoking, the importance of understanding the health risks associated with it is undermined. This is exacerbated by the fact that, according to most participants, teachers openly defy the laws against smoking in school by not only doing so in the vicinity but even in the actual class in front of the students they are teaching. The FGDs revealed that on occasion, students were even sent to purchase cigarettes from the local shop for their teachers. This ‘culture’ of cigarette smoking needs to change in order to prevent young people from smoking cigarettes; this could be achieved by enforcing the laws that already exist.

Young males and females do not tend to value or follow the advice given to them by their parents and or teachers on smoking. This is largely because they perceive being told not to smoke by one who does so him/herself as meaningless hypocrisy. Although young Jordanians might listen to parents or teachers out of respect without challenging them directly, they will dismiss any advice not to smoke without further thought if it comes from a smoker, regardless of how close their advisors might be.

Limitations of the Study

Given that this qualitative study was conducted on a small sample of only 30 high school students aged between 16-18 years attending school in the eastern and western suburbs of Amman, Jordan, caution must be taken regarding any generalization. The findings may not be representative of all school students within the capital because only selected locations were chosen and not all 16-18 year olds attend school. Nevertheless, the findings of this paper suggest that further largescale research to better understand the perceptions and beliefs about smoking and its impacts on health of this crucial population would be warranted. The authors have since conducted a large quantitative study of smoking among the same group of people in Amman, the results of which are yet to be published.

Summary/Conclusions

The results of the study found 40% of the participants to be smokers at the time of the study, that most of them had started smoking cigarettes as early as at age 11, and that there had been easy access to cigarettes. Although smoking among school students is not approved of, shisha smoking is a cultural tradition considered socially acceptable and allowed in the presence of family members who would never tolerate cigarette smoking. Parental concern about cigarette smoking is strong regarding their young sons but does not extend to female children as they are not considered at risk of perpetrating such vice. Cigarettes are readily available and those who give the advice to- and demand obedience from- this group of the population are themselves smokers who smoke in front of those young people. It is apparent from this qualitative research conducted on this particular category of students in Amman that the traditional approach to tackling this epidemic is not working and should be discontinued. This age group spends their time equally among their families, at schools and with friends. Thus these three environments will to work together in a creative but measurable way for progress to occur and this behaviour to be curbed.

The way families view their daughters needs to change in this dynamic globalized world. The traditional way of treating females as the weak and innocent members of the family, who would never smoke, is outdated. Female and male students need to be treated as equally responsible and active members of their families and society, and to be educated on how to counter ‘peer pressure’ and ‘peer force’. This could be done by improving their communication skills and self-confidence at home and at school. Any proposed policies to reduce smoking behaviour among Jordanian youth will need to involve families and schools in particular to create awareness that thus far they are part of the problem not the solution.

This paper has revealed a number of issues that suggest we need re-conceptualize measures to influence the behaviour of young people in this part of the developing world.

Acknowledgements

The authors would like to thank the participating Schools, Ministry of Education and the students for their much appreciated support with the data collection for the project. This study was not funded by any organisation.

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