Wellness of School Children Against Tobacco Smoking

The Case of West Bank and Gaza

by Khuloud Jamal Khayyat Dajani (Author)
©2021 Monographs XXXII, 214 Pages


No previous research has ever explored thoroughly the types and trends of smoking and the different models of tobacco smoking among Palestinian children. This study was designed to identify the factors that increase or mitigate risk associated with smoking among school children and adolescents living within the Palestinian territories. An ecological framework serves as the theoretical framework for the study, incorporating multiple levels of children’s and adolescents’ lives, including individual, family, school, peers, and community dimensions. The study is based on theory that considers the school as a central component of socialization and also on problem behavior theory, suggesting that humans develop clusters of dangerous behaviors that become part of their daily lives. This research study is based on the data set of the Health Behaviors in School-aged Children (HBSC) international survey, and employed a dual focus on individuals and schools. It revealed the high prevalence of tobacco smoking, the risk and protective factors affecting smoking, and showed that Nargilah ranked first among tobacco smoking habits. In an era of narrow agendas of “effectiveness” and “control,” this book suggests a way to incorporate schools as venues and spaces for behavioral transformation, growth, and positive change, and shows how awareness can be created within the families and the relevant agencies. Health promotion and risk prevention initiatives can help control tobacco smoking, the most preventable cause of death and disease in the nation. Those who smoke must quit, and we must work together to prevent children from starting this endangering health behavior.

Table Of Contents

  • Cover
  • Title
  • Copyright
  • About the author
  • About the book
  • This eBook can be cited
  • Table of Contents
  • List of Tables
  • List of Figures
  • Preface
  • Acknowledgements
  • Abbreviations
  • Summary: Assessment of Health Behavior among Palestinian Adolescent School Children in the West Bank and Gaza Strip: The Case of Tobacco Smoking
  • 1 Introduction
  • 1.1 Statement of the Problem
  • 1.2 Rationale
  • 1.3 Relevance to the Current Palestinian Situation
  • 1.4 Study Questions
  • 2 Review of the Literature
  • 2.1 Policy, Conceptual, and Theoretical Framework
  • 2.1.1 Policy Framework: Health Behavior among School Children
  • 2.1.2 Age of Maturity
  • 2.1.3 Ecological Theory of Development
  • 2.1.4 School Context
  • 2.1.5 Adolescence: The Developmental Model
  • 2.1.6 Adolescent School Health
  • 2.1.7 Nargilah (Water Pipe, Shisheh)
  • 2.2 Endangering Health Behavior: The Case of Tobacco Smoking
  • 2.2.1 Determinants of Health Behavior: Psychosocial Analysis
  • 2.2.2 Explanatory Theories
  • 2.2.3 Psychological Theories
  • 2.2.4 Pharmacological Theories
  • 2.2.5 Bio-Behavioral Explanations of Smoking
  • 2.3 Adolescent Smoking and Public Health
  • 2.3.1 Tobacco Addiction (Annex)
  • 2.3.2 Individual Personality and Psychopathology and Smoking
  • 2.3.3 Smoking Behavior among Adolescent School Children
  • 2.3.4 Prevalence of Smoking in Adolescents
  • 2.3.5 Tobacco Control Policy
  • 2.3.6 Tobacco Country Profiles for the Eastern Mediterranean Region
  • 2.4 Smoking Behavior and Influential Factors
  • 2.4.1 Individual Factors and Smoking
  • 2.4.2 Smoking and Other Risk Behaviors
  • 2.4.3 Smoking and Parental Care, Attitudes, and Practices
  • 2.4.4 Family Factors and Smoking: Communication and Relationships
  • 2.4.5 Peer Relationships and Smoking
  • 2.4.6 School Settings and Smoking Behavior
  • 2.4.7 Social Activities and Adolescents Smoking
  • 3 Methodology
  • 3.1 Introduction
  • 3.2 Study Objectives, Questions, and Hypothesis
  • 3.3 Target Population, Sampling Procedures, and the Sample
  • 3.4 Measurement Instrument
  • 3.5 Data Collection, Study Design, and Statistical Analysis
  • 3.6 Measures and Indices for Variables
  • 3.7 Study Limitations
  • 4 Findings and Results
  • 4.1 Descriptive Epidemiological Analysis of School Tobacco Smoking
  • 4.1.1 Description of the Study Sample by Region, Gender, Grade, and Type of School
  • 4.1.2 Frequency and Type of Tobacco Smoking among the Study Sample Students
  • 4.1.3 Frequency and Prevalence of School Children Ever-Smoking Cigarettes and/or Nargilah
  • 4.1.4 The Age of Smoking Initiation among the School Children Smokers of the Study Population
  • 4.1.5 Relationship between Student Age and the Level of Cigarettes Consumption
  • 4.2 Analytical Epidemiology: Examining the Research Hypotheses
  • 4.2.1 Smoking of Adolescent School Children and Individual Characteristics
  • 4.2.2 Smoking of Adolescent School Children and Socio-Economic Status
  • 4.2.3 Smoking of Adolescent School Children and Their Health
  • 4.2.4 Smoking of Adolescent School Children and Other Health Risk Behaviors
  • 4.2.5 Smoking of Adolescent School Children and Parents’ Smoking and Attitudes toward Their Children’s Smoking
  • 4.2.6 Smoking of Adolescent School Children and Parental and Family Conditions
  • 4.2.7 Smoking of Adolescent School Children and Peer Groups
  • 4.2.8 Smoking of Adolescent School Children and Their Perceptions of School
  • 4.2.9 Smoking of Adolescent School Children and Their Social Involvement
  • 4.2.10 Smoking of Adolescent School Children and Intervention Programs for Health Education
  • 4.3 A Model for Predicting Tobacco Smoking Habits
  • 4.3.1 Univariate Logistic Regression Analysis
  • 4.3.2 Multi-Variable Logistic Regression Analysis
  • 4.3.3 Multivariable Stepwise Logistic Regression Analysis (Hierarchical)
  • 5 Discussion, Implications, and Recommendations
  • 5.1 Discussion
  • 5.1.1 Smoking among Palestinian School Students in General
  • 5.1.2 Smoking and Individual Characteristics
  • 5.1.3 Smoking and Other Risk Behaviors
  • 5.1.4 Smoking and Parents’ Attitudes, Supervision, and Support
  • 5.1.5 Smoking and Family Socio-Economic Status
  • 5.1.6 Smoking and Peer Groups
  • 5.1.7 Smoking and the School
  • 5.1.8 Smoking and Social Involvement and Policies
  • 5.2 Implications
  • 5.3 Study Recommendations
  • Annex: Tables and Documents
  • References and Bibliography
  • Series index


Table 1: Characteristics of the study sample

Table 2: Distribution of the study sample by region, gender, grade, and school type

Table 3: Description of the study sample by region, school type, grade, and gender

Table 4: Frequency and type of tobacco smoking among the study sample

Table 5: Distribution of smoking habit among smoking school students by gender

Table 6: Cross-tabulation of students ever-smoked cigarettes and/or nargilah

Table 7: Tobacco ever-smoking among school children

Table 8: Frequency of ever-smoking school children by gender and smoking type

Table 9: The statistical age range for smoking initiation

Table 10: Age of smoking initiation among smokers of the study sample

Table 11: Age of smoking initiation among smoking girls

Table 12: Age of smoking initiation among smoking boys

Table 13: Smoking school children and the level of cigarette consumption←xi | xii→

Table 14: Level of cigarette smoking consumption by age among smoking children

Table 15: Students’ tobacco smoking by region, gender, age, grade, religion, and school type

Table 16: School children ever-smoking tobacco by gender, grade, age and region

Table 17: School children experimenting tobacco smoking by gender, grade, age, and region

Table 18: School children ever-smoking nargilah, by region, gender, grade, and school type

Table 19: Relationship between family economic status and students’ smoking

Table 20: Parental social and professional status and smoking among school adolescent children

Table 21: Combined effect of parents’ smoking on their children’s smoking

Table 22: Relationship between school children’s health and smoking

Table 23: Relationship between violence/bullying and smoking

Table 24: School children’s grade, gender, and permission to smoke cigarettes at home

Table 25: School children allowed smoking cigarettes at home by gender

Table 26: School children allowed smoking cigarettes at home by grade and gender

Table 27: Types of tobacco smoking and permission to smoke cigarettes at home; frequency and correlation

Table 28: Correlation between gender, grade, and parental approval of nargilah smoking

Table 29: Types of tobacco smoking and parental approval of nargilah smoking; frequency and correlation

Table 30: Prevalence of cigarette smoking among parents of the study population

Table 31: Relationship between parents’ cigarette smoking and children smoking

Table 32: Distribution of smoking school children by either or both parents’ tobacco smoking

Table 33: Parental monitoring and their children’s smoking

Table 34: Parents’ care, supervision, and attitudes and children’s smoking

Table 35: Relationship between children’s family communication and smoking←xii | xiii→

Table 36: Relationship between peers and friends and students’ smoking

Table 37: Relationship between school performance and attendance and students’ smoking

Table 38: Relationship between school setting and students’ smoking

Table 39: Relationship between teachers’ attitudes and students’ smoking

Table 40: Relationship between parents’ support in school and their children’s smoking

Table 41: Relationship between school peers and students’ smoking

Table 42: Relationship between community involvement and students’ smoking

Table 43: School health education programs and students’ smoking

Table 44: Summary of Diagnostic and Statistical Manual of Mental Disorders

Table 45: Examples of DSM-IV Nicotine Dependence Criteria

Quantitative research questionnaire: Version (b): an expansion of the subjects of family, school, and peer groups

Quantitative research questionnaire: Version (a): an expansion of the subject of risk behaviors


Throughout my career, I have dedicated a lot of my efforts to fight against tobacco smoking, as a student of medicine and health sciences, as a practicing doctor and as a specialist in community medicine in Jordan and Palestine. I co-founded the anti-smoking society in Jordan, priding ourselves to have Princess Haya Bint Al-Hussein as the honorary chair of the society and to have worked hard on raising awareness, enforcing the tobacco control laws, and preventing smoking in public places. I learned how important it is to study all aspects of the prevailing tobacco smoking problem, in order to mobilize the needed efforts and means toward ending the harmful effects and diseases it causes people, especially children. In the early 1990s, I wrote a book in Arabic on smoking and prepared a standard lecture to increase awareness among people about the harm of tobacco smoking. Therefore, it was only natural that my PhD subject will be on smoking among children, the most vulnerable population when it comes to smoking.

This work, in particular, was conducted during my time as founder of the child institute and founding dean of the school of public health at Al-Quds University, and as a community medicine specialist who believes in the investment in children’s health as a basic foundation toward having responsible citizens, who are expected to be socially active, economically productive, and mentally intelligent.←xvii | xviii→

The present study was based on the data of the Healthy Behaviors among School Children (HBSC) international survey, carried out by the WHO, after Palestine joined in 2004. Although I did not have the chance to publish it earlier, the research’s continuous relevance, the importance of the subject and the increasing prevalence and harm of smoking and substance abuse in the Middle East and the world, has led Peter Lang Publication to offer to publish it now. Especially that evidence-based research has been showing that the number of tobacco smokers, among children and females, are rocketing.

Research about tobacco smoking types, factors, trends, and the different models of tobacco smoking among Palestinian children in the West Bank and Gaza, was found to be limited. Therefore, this study employed a dual focus on individuals and schools, attempted to explain why youngsters smoke tobacco, and aimed to identify the risk and protective factors associated with smoking (cigarette, nargilah, or both) among school children and adolescents living within the Palestinian territories, and offered recommendations for preventative action. The theoretical framework chosen was an ecological framework, incorporating multiple levels such as individual, family, school, peer, and community. The study design was based on the theory of socialization, and problem behavior theory, suggesting that humans develop clusters of dangerous behaviors that become part of their daily life.

The present study results revealed the high prevalence of tobacco smoking, namely nargilah smoking, as the highly prevailing risk behavior among Palestinian school children, and the early age of smoking initiation among the smoking school children with 75% of them smoking under the age of 14, making the age of 14 an easy gateway to more substance abuse and addiction. The study also demonstrated that there is a high association between smoking, violence, and decreased academic achievement as a threatening triad affecting our school children.

Today, nargilah smoking ranks first on the list of tobacco smoking habits. Social acceptance and approval of nargilah smoking at home and at social events, as well as the increasing number of nargilah shops present a new challenge, especially after the success of tobacco control laws and policies in prohibiting smoking in public places and transportation. For the first time in Palestinian research on tobacco smoking, this study brings the alarming signs of a new nargilah epidemic among Palestinian adolescents to the attention of health care professionals and scientific researchers. Therefore, an innovative approach is needed to halt the spreading of nargilah smoking in our community.←xviii | xix→

While we are witnessing the continued threat of production and dissemination of all kind of tobacco around the world, including the dangerous electronic cigarettes and the transfer of nargilah smoking from the East to the West as a new epidemic of tobacco addiction versus the old epidemic of cigarettes smoking which was transferred from the West to the East; in an era of narrow agendas of “effectiveness” and “control,” this study suggests a way to incorporate schools as venues and spaces for behavioral transformation and growth, as well as positive change. The study shows how awareness can be created within the families and the agencies acting for behavioral and social change.


I would like to recognize and thank many people who stood by me and helped me reach the end of this educational journey.

I am forever grateful for their support, help, encouragement, guidance, inspiration, suggestions, and explanations. First and foremost, special thanks go to Al-Quds University (AQU) Former President Professor Sari Nusseibeh, the sensible Professor, honest Philosopher, and courageous Palestinian leader for his vision and wisdom that led us to establish the school of Public Health at Al-Quds University and for giving me and others the opportunity to pursue the higher education needed to improve public health and community medicine. Also to Current President Professor Imad Abu Kishek, and Dean of Public Health Dr. Motasem Hamdan, for their blessed efforts in strengthening higher education and their continued support. My gratitude also goes to Professor R. Kevin Lacey, for editing my book.

Special thanks go to my committee chair Professor Raffael Carel, of BGU, my co-author in the article “Neighbors and Enemies,” my colleague in devising improved strategies for public health, and my mentor. Words cannot express the admiration and gratitude he deserves as an individual, professor, advisor, researcher, and an outstanding Public Health and Occupational Medicine scholar.←xxi | xxii→


XXXII, 214
ISBN (Hardcover)
Publication date
2021 (August)
New York, Bern, Berlin, Bruxelles, Oxford, Wien, 2021. XXXII, 214 pp., 15 b/w ill., 69 tables.

Biographical notes

Khuloud Jamal Khayyat Dajani (Author)

Khuloud Jamal Khayyat Dajani (MD, MSc, CMD, PhD) is Professor of Community Medicine and Health Policy, founding dean of the Public Health Faculty and Child Institute, and former acting president and vice president at Al-Quds University in Jerusalem, and was a member of the IAU Board. She has also served as a community medicine specialist and public health expert at the Jordanian Ministry of Health, and she serves on the board of the Arab Board for Health Specialties and other health, academic, and community organizations. She received a certificate of excellence for her work from the Arab League in 2004.


Title: Wellness of School Children Against Tobacco Smoking
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