Background

Smoking is an addictive behavior that leads to multiple long-term health problems, both physical and psychological (Mandil et al., 2007).  As a result, the Ministry of Health in the United Arab Emirates (UAE) has been working hard to reduce smoking in all elements of the population, primarily through regulatory channels.  Public Health is of great concern throughout the Middle East (Redfern, 2010).  The WHO claims that 8% of UAE adults smoke, the highest in the immediate area, but low for the entire Middle East, where as many as 36% of adults smoke in countries such as Jordan (Consumer goods retail report, 2010).   The WHO estimates that approximately half (47%) of the health issues in the Middle East arise from non-communicable diseases, which are mediated by lifestyle choices (Redfern, 2010).  The UAE has made a national push to reduce smoking in all portions of its population through regulatory efforts (Arab League honours UAE for anti-smoking efforts, 07 Jun 2010; Ministry of Health discusses anti-tobacco executive regulatory by-laws, 12 May 2010).  Despite these strong regulations, in 2010 it was estimated that as many as 40% of teenagers between 13 and 15 years are smokers, which is an increase from 24% only five years earlier (Ismail, 19 Dec. 2010).  Tobacco is also commonly combined with other aromatic leaves and bark herbs in a mixture called dokha (DK), which is then smoked by teenagers in a medwakh pipe to achieve a buzz (Ismail, 19 Dec. 2010).

Smoking cessation interventions for teens generally fall into one of four categories: those focused on school settings, those focused on healthcare settings, those based on pharmacological approaches (i.e., nicotine patches), and Internet-based approaches. Among other criteria for success, those with more frequent contacts with the teens appear to have greater efficacy (Mermelstein, 2003).

Problem Statement

There is a need to reduce teenage smoking of all types of tobacco and tobacco products in the UAE to reduce the incidence of long-term health conditions  such as heart disease, cancer, hypertension, and other problems (Mandil et al., 2007). While the government has established strong regulations on controlling the sale of tobacco products to minors, the rules have proved less than effective at stemming the availability of tobacco to teens, as demonstrated by the sharp increase in teen smoking over the years from 2005 to 2010 (Ismail, 19 Dec. 2010).  Thus, this research study attempts to determine if interventions with the teenage population can reduce the amount of smoking by teenagers in the UAE.

Proposed  Intervention           

The proposed study will determine the effectiveness of an Internet-based intervention to determine its relative efficacy for young adults in the UAE as compared to more traditional in-person approaches to curbing teenage smoking.  In the proposed Internet-based intervention, participants attend a single informational orientation meeting, and then receive regular emails and contacts via the Internet. They will have access to online resources, and be able to do on-line chats for support. There will also be a community forum for participants to share among themselves. It will be combined with telephone support as needed.

Comparators of Interest

The first comparator of interest is whether the Internet-based  delivery method is effective at reaching teenagers.  This involves both determining the success rate for smoking cessation, but also the dropout rate from the program.  In addition, participant satisfaction with their intervention program will be assessed every three months, and an open-ended interview conducted to obtain suggestions from participants on how to make the program more effective.  Thus, this will be a mixed-methods study, triangulating the results from both quantitative and qualitative data to determine more effective interventions with teenagers.

Research Perspective

The research project will take the perspective of the health impact of smoking on teenagers both immediately and in later life.  As noted earlier, smoking is of great concern in the U.A.E. because of the long-term health impacts from smoking. With nearly half of the non-communicable health issues in the Middle East a result of smoking (Redfern, 2010), and considering the sharp rise in teenage smoking in the five years from 2005 to 2010 (Ismail, 19 Dec. 2010), the importance of controlling those long-term health impacts by reducing teenage smoking is clear.  It also is important to note that teenagers have a very low level of “spontaneous” smoking cessation, i.e., they rarely stop smoking without some form of intervention (Mermelstein, 2003).  Also, teenagers seem to be particularly vulnerable to nicotine addiction; up to 22% of teens who are “occasional” smokers already demonstrate the physical signs of nicotine addiction (Mermelstein, 2003). Furthermore, studies have demonstrated that the most frequent reasons teens express for wanting to quit smoking are health impact reasons (Mermelstein, 2003). Thus, the perspective for this project will be focusing on the health aspects of teenage smoking.

Study Hypothesis

The hypothesis,  H₁, behind this study is that Internet-based smoking-cessation interventions will be more effective in the young adult population than those based on in-person meetings. The null hypothesis, H₀,  is that Internet-based interventions are not more effective.

H₁: Internet-based smoking cessation programs are more effective with young adults than in-person meetings.

H₀: Internet-based smoking cessation programs are more effective with young adults than in-person meetings.

Study Population

The study population will be University of Sharjah students who smoke and who volunteer for a stop-smoking program (i.e., have expressed personal interest in stopping); the university is located in Sharjah (near Dubai).  There are approximately 10,000 total students in University of Sharjah, with up to 4,000 of them smokers.  Demographics collected from the study population will be compared to those of overall U.A.E. adolescents to determine the degree to which this group’s results can be generalized to the overall adolescent population in the U.A.E.

Analytic Time Horizon

The intervention will occur with a time horizon of one academic year, i.e., August to June, with the first three to six months focused on smoking cessation, depending on individual patterns, and the remaining time focusing on maintaining a smoke-free lifestyle.  Little is understood at this time of the time horizon needed for effective adolescent smoking cessation and to minimize relapse rates (Mermelstein, 2003).  It is hoped that this study will contribute to determining if adolescent smoking cessation efforts across a single academic year are sufficient to ensure permanent smoking cessation in this population.

Model Costs

The costs for the Internet interventions are assumed to take place within a single 12-month period, thus there is no need for discounting.  All costs of this intervention will be reported in U.S. dollars. Most such costs will be incurred in the weeks prior to the actual start of the intervention to pay for development of the Internet website; later costs will involve ongoing maintenance of the site as needed during the study period.  Studies with teenagers and Internet-based interventions have noted that teens are far more receptive to flashy websites with animations, flash displays, and other aspects of website “razzle-dazzle,” so it is important that the website have a high degree of professional gloss (Mermelstein, 2003). To the greatest extent possible consistent with achieving a timely website development effort, volunteer student developers will be used to create the Internet site and maintain it as part of an independent study class credit. Using student developers is particularly important because they can provide input on the types of features that appeal to their peers.  Development of the Internet-based intervention will use the same information provided in the in-person comparison  process.  The cost of the website domain and hosting will run approximately $25/month for approximately 11 months (allowing for development time), plus an additional $25 for domain name, for a total of $300.

Printed materials to be used in the in-person intervention are readily available on the internet for free, with the only cost that of printing them.  Estimated cost of printed materials is approximately $5 per participant.  It is assumed that in-person meetings will be held on campus at University of Sharjah., which is approximately 10 miles (17 km) from Dubai.  Volunteers from Dubai’s Health City will provide the in-person meeting staff.  A societal cost based on these volunteers’ time is clearly incurred. While no compensation costs are included for volunteers in this cost assessment, this does not quite reflect the reality that even volunteers need to be managed and organized.  The expected direct financial cost would be a weekly charge of approximately $5round trip for the volunteers (at $0.50/mile reimbursement rate).

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