Tobacco use is an important public health issue. Morocco implemented a tobacco control programme, which has been ongoing among students at middle and secondary schools since 2010.
This study aims to compare the trend in smoking among the programme beneficiaries with the results of the initial study conducted prior to the implementation of the programme.
This study was conducted in middle and secondary schools of the Gharb Region in Morocco between 2010 and 2015.
Two cross-sectional studies were conducted in 2010 and 2015 in the middle and secondary schools of the Gharb Region. Multistage cluster sampling was used. The information was collected using a self-administered questionnaire.
In the first study in 2010, 5312 students participated, and in the second one in 2015, 4208 students participated. The level of information on smoking and its effects was higher in 2015 (94.0%) than in 2010 (92.5%). In 2010, parents, primary schools and television and radio were more involved in student information on smoking compared to 2015. The proportion of students claiming that tobacco was not a pleasure (86.3%) and that it does not calm nerves (76.5%) was significantly higher in 2015 than in 2010. The prevalence of smoking increased significantly in 2015 (2.9%) against 2010 (1.8%).
This study reports the general positive evolution in knowledge about smoking and its effects. Despite that the prevalence of smokers increased in 2015. The results suggest the need to address family influences on adolescent smoking and to investigate participation of schools in education and training students in tobacco dependence prevention.
Tobacco use is an important public health issue, and it is the single biggest avoidable cause of death and disability worldwide.
In Morocco, the results of the Global Youth Tobacco Survey (GYTS) conducted by the Moroccan Ministry of Health in schools highlighted the need for awareness of the prevalence of youth smoking. Prevalence in the 13–15-year age group was 10.8% (in 2001), 11% (2006) and 9.5% (2010).
The activities of this programme include the placement of smoking cessation signs in all schools, training health professionals in tobacco cessation consultation and training of teachers and peer educators of health clubs established in the schools in information, education and communication on the harmful effects of tobacco consumption.
Objectives of the programme include raising awareness and changing knowledge, attitudes and practices regarding the consumption of tobacco products, protecting smokers and non-smokers, and reducing the number of users.
The follow-up of the evolution of tobacco smoking provides important information to follow the dynamic of this public health issue. Our study aims to examine the trend of smoking by comparing two cross-sectional studies, to measure change in the degree of awareness and knowledge, attitudes and practices regarding the consumption of tobacco products. The first study was conducted in 2010 before the implementation of a national programme against smoking, and the second one in 2015, 5 years after the initial implementation.
Two cross-sectional studies were conducted in 2010 and 2015 among students of middle and secondary schools of the Gharb Region in Morocco.
The study lasted for 5 years, from December 2010 to December 2015.
To be included in the study, children had to be aged between 10 and 20 years old, must have had informed consent provided by their tutors, and had to belong to the selected middle and secondary schools in the region of Gharb-Chrarda-Béni-Hssen.
A steering committee was constituted to lead and coordinate all the activities concerning the two studies. This committee included principal investigators of the study, a representative of the Ministry of Education, local authorities and parents’ union representatives of the selected schools.
The region where the studies took place was situated in the north-west of Morocco. The population of the Gharb-Chrarda Region is 2 million inhabitants (6% of the Moroccan population); it contains both rural and urban areas, and all socio-economic classes are represented (National Statistics Department 2014). Subsequently, factors influencing smoking are the same as in other parts of the country.
The list of middle and secondary schools (and classes) was obtained from the Ministry of Education of Morocco.
In 2010, the study included 10% of all the schools of the region.
In 2015, the sample calculation was done using the formula of prevalence studies
The cluster sampling was accomplished in two steps:
The size of the sample was divided by the number of grade levels (first, second and third year of middle school and first, second and third year of secondary school). This allowed us to reach the subpopulation (age and sex) on which the estimates would be made; the total size was divided per level.
Then a cluster sample proportional to the size of the classes (cluster) was selected: 66 classes from 34 secondary schools and 66 classes from 50 middle schools were identified in 2015. The investigation allowed participation of all students who were present on the day of the investigators’ visit.
Three teams were designated, one for each city (Kenitra, Sidi Kacem and Sidi Slimane are the three cities of the Gharb Region). Each team was led by a supervisor and two investigators. A training session was organised for the investigators in preparation for the two studies. The aim was to explain the objectives and the methodology to all the investigators, to explain the tasks of each one. The questionnaire was reviewed following the sessions.
A pilot test was conducted in four classes of different levels in a non-participant school. Its main objectives were to test the questionnaire – to estimate the average time required to administer it and to test its comprehension by the students. A debriefing meeting was organised; the study organisation and questionnaire were adapted and validated. The questionnaire was reviewed by the steering committee.
The identified schools were informed by their administrative authorities of the schedule of the study. Once the investigators were present in the schools, a short meeting was organised with the director and the administrative staff.
An auto administered questionnaire was used in the two studies. The same instrument was used for both studies for the most part, with some items regarding the specific objectives of each of the two studies.
For both of the studies, the questionnaire was administered by a staff of health specialists and from the Ministry of Education.
At the entry of each selected class, the objectives of the study were explained for the students and their teacher. The investigators stayed in the class to collect the questionnaires and to respond to the students’ questions, if any.
Data regarding tobacco use were collected at the beginning of the study from children in all subject groups, using a self-administered questionnaire.
We collected data on demographic characteristics, the extent of information on smoking, sources of information on smoking, perceptions of smoking and prevalence.
Since its implementation the programme has defined smoking as follows:
Data analysis was done by the software IBM SPSS Statistics version 20. The nominal variables were presented as proportion. A chi-square test was used to test independence between nominal variables. In the case of cells with a theoretical frequency
The purpose and the protocol of the study were presented and explained to the local authorities, regional medical representatives, school headmasters, teaching staff and parents’ union representatives in schools, who in turn explained clearly the benefits of the study to the children’s parents. Subsequently, oral consent was obtained from children and their parents or tutors, respectively, before the beginning of the survey. Volunteering parents and children were included in the study.
This study received approval from the Ministry of National Education. The ethical clearance number is 18/23.
The demographic characteristics are presented in
Demographic characteristics of schoolchildren enrolled in the study in 2010 and 2015.
Variables | 2010 |
2015 |
|||
---|---|---|---|---|---|
% | % | ||||
Sex | |||||
Female | 2931 | 55.2 | 1995 | 49.3 | 0.0001 |
Male | 2380 | 44.8 | 2053 | 50.7 | |
Sum | 5311 | - | 4048 | - | |
Years strata | |||||
10–12 years | 213 | 4.0 | 42 | 1.1 | < 0.001 |
13–15 years | 2862 | 54.1 | 1526 | 38.5 | |
16–17 years | 1545 | 29.2 | 1245 | 31.4 | |
≥ 18 years | 672 | 12.7 | 1155 | 29.1 |
Note: Results are presented as frequencies and proportions,
,
The level of information on smoking and its harmful effects are illustrated in
Level of information on smoking among schoolchildren involved in the study in 2010 and 2015.
Variables | 2010 study |
2015 study |
|||
---|---|---|---|---|---|
% | % | ||||
Not informed | 399 | 7.5 | 247 | 6.0 | > 0.05 |
Informed | 4913 | 92.5 | 3882 | 94.0 | > 0.05 |
Note: Results are presented as frequencies and proportions,
,
Comparison of sources of information on smoking in 2010 and 2015.
Variables | 2010 |
2015 |
|||
---|---|---|---|---|---|
% | % | ||||
Parents | |||||
Yes | 3908 | 73.6 | 2397 | 62.6 | < 0.0001 |
No | 1402 | 26.4 | 1433 | 37.4 | |
Primary school | |||||
Yes | 3368 | 63.4 | 1869 | 49.0 | < 0.0001 |
No | 1943 | 36.6 | 1947 | 51.0 | |
High school | |||||
Yes | 3329 | 62.7 | 2412 | 63.4 | < 0.0001 |
No | 1982 | 37.3 | 1394 | 36.6 | |
TV and radio | |||||
Yes | 4609 | 86.8 | 3190 | 83.0 | < 0.0001 |
No | 702 | 13.2 | 655 | 17.0 |
Note: Results are presented as frequencies and proportions,
,
Comparing students’ perceptions of smoking in 2010 and 2015.
Variables | No |
Yes |
|||
---|---|---|---|---|---|
% | % | ||||
Expensive | |||||
2010 | 1720 | 32.4 | 3591 | 67.6 | < 0.0001 |
2015 | 1106 | 60.1 | 2574 | 69.9 | |
A trap | |||||
2010 | 856 | 16.1 | 152 | 83.9 | < 0.0001 |
2015 | 784 | 20.7 | 3010 | 79.3 | |
A pleasure | |||||
2010 | 3766 | 70.9 | 1545 | 29.1 | < 0.0001 |
2015 | 3032 | 86.3 | 482 | 13.7 | |
Calms the nerves | |||||
2010 | 2994 | 56.4 | 2317 | 43.6 | < 0.0001 |
2015 | 2741 | 76.5 | 842 | 23.5 | |
Disturbs others | |||||
2010 | 455 | 8.6 | 4856 | 91.4 | < 0.0001 |
2015 | 498 | 13.1 | 3304 | 86.9 | |
Bad for health | |||||
2010 | 239 | 4.5 | 5072 | 95.5 | < 0.0001 |
2015 | 224 | 5.6 | 3806 | 94.4 |
Note: Results are presented as frequencies and proportions,
,
Comparison of smoking prevalence among students in 2010 and 2015.
Variable | 2010 study |
2015 study |
|||
---|---|---|---|---|---|
% | % | ||||
Non-smoker | 5066 | 95.4 | 3931 | 93.4 | > 0.05 |
Former smoker | 150 | 2.8 | 128 | 3.0 | > 0.05 |
Smoker | 95 | 1.8 | 121 | 2.9 | > 0.05 |
Note: Results are presented as frequencies and proportions,
,
Exposure to smoking among students in 2015.
2015 | Yes |
Sum | |
---|---|---|---|
% | |||
Students exposed to smoking at home | 1420 | 36.9 | 3849 |
Students exposed to smoking by their peers | 1343 | 32.9 | 4076 |
Parents of students are smokers | 1124 | 27.5 | 4080 |
Brothers of students are smokers | 640 | 15.8 | 4059 |
Note: Results are presented as frequencies and proportions,
Worldwide, the health impact of smoking is now well documented.
Our results showed that Moroccan students have favourable knowledge of the health risks associated with tobacco smoking. Indeed, the prevalence of informed students about tobacco and its harmful effects is slightly higher in the 2015 study (94.0%) compared to the 2010 study (92.5), and the prevalence of students claiming that tobacco is not a pleasure and does not calm the nerves was significantly higher in the 2015 study than in the 2010 study (86.3% and 76.5% in 2015 versus 70.9% and 56.4% in 2010, respectively). Moreover, the prevalence of students who smoked increased slightly in 2015 (2.9%) against 2010 (1.8%). It is not easy to compare our findings with those from other countries owing to the different methodologies used. However, the smoking prevalence in our sample was much lower than that reported in a large sample of high school students in Porto, Portugal, which found that 21.5% of the participants were current smokers.
On the other hand, our results showed that in the 2010 study, parents, primary school and TV and radio were the primary sources of information to the students about smoking and its harmful effects compared to the study in 2015. This could be explained either by the differences in the two samples or the place of tobacco control in the primary and middle school curriculum, which may be less marked.
Although it is widely recognised that children smoke their first cigarette while attending primary school, smoking is most likely to begin during adolescence,
This study reports the positive evolution in the knowledge of students about smoking and its effects. The prevalence of students who smoked increased slightly in 2015. Efforts must be made to reach the long-term objective of reducing the prevalence of smoking among the students. The results of this study suggest the need to address family influences on adolescent smoking and to investigate the introduction of a programme for education and training of students on tobacco dependence prevention, because schools are expected to be the favoured vehicle for health promotion.
We are grateful for the contributions of students who participated in this study, their parents, teachers, health workers, and local authority’s data management and other support staff.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
All authors have contributed to this publication and hold themselves jointly and individually responsible for the content. The authors’ responsibilities were as follows: S.M., E.M., L.B., Y.C.K. and H.E. conceived and designed the study, supervised the data collection tools, training of staff, quality control, and S.M., F.E.Z. and E.M. analysed data, performed the statistical analysis, interpreted the results, conducted literature research and edited the article.
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.