Smoking, as recreational activity, is being practiced by over 1 billion people globally. The main objective of the present study was to explore smoking prevalence, its effects and people attitude in the Kingdom of Saudi Arabia (KSA) by literature review. PubMed was used for systematic search. Search was made with key words ‘Smoking AND Saudi Arabia’ and a total of 790 articles were found. When limits were applied with English language and studies on human, 502 articles were left. All abstracts of these articles were reviewed with the application of inclusion criteria of studies in the KSA and Saudi Arabia population and 75 articles were left. Then, these articles were categorised according to content, attitudes, cross-sectional studies, factors or diseases, its effects and associations to risk factors, original articles, prospective and retrospective studies, studies about smoking, surveys, studies showed different prevalences of smoking among schoolchildren, medical colleges, university students, health professionals and other population. Tobacco smoking was a major and modifiable risk factor for cardiac diseases and other diseases in Saudi Arabian population. Majority of smokers were found motivated to quit smoking, needed guidance and treatment. Second-hand smoke (SHS) affects newborns and children's health. Waterpipe smoking and SHS were potential threats for population's health in SA. It was concluded that in the KSA, smoking is a forthcoming alarming threat for different tobacco-related diseases. Now, it can be controlled in minimal time with lesser efforts by strategic planning, designing tobacco control programmes according to sex, age groups and education levels.
Keywords: Diseases, Saudi Arabia, smoking, tobacco
| Introduction|| |
Tobacco products are made entirely or partly from leaves of the tobacco plant. For smoking, its dried leaf is mainly used in cigarette, cigar and waterpipe (WP). There are also other ways for consuming tobacco, other than smoking, such as snuff and snus. All tobacco products contain highly addictive psychoactive ingredient, nicotine. Tobacco use is one of the main risk factors for several chronic diseases, including cancer, lung diseases and cardiovascular diseases.
Tobacco is the only legal product that causes death of about one-half of its regular users. The World Health Organisation estimates that tobacco kills >7 million people each year globally. As a result of direct tobacco use, >6 million of those deaths are estimated while >890,000 deaths are the result of second-hand smoke (SHS) exposures to non-smokers.
Smoking affects not only lungs but also body immunity. Smoking affects host innate immunity, brings structural and functional changes in the respiratory ciliary epithelium, lung surfactant protein and immune cells in the body such as alveolar macrophages, neutrophils, lymphocytes and natural killer cells.
Tobacco is dangerous in any shape as it affects the whole body. Tobacco smoke gives rise to reactive oxygen species both through activated macrophages during inflammation and the particulate phase of tobacco smoke which contains >1017 free radicals/gram. The free radicals in the particulate phase are long-lived (hours to months) and are dangerous, whereas the free radicals in the gas phase are short-lived (<5 min).
WP smoking has become a global public health problem. Tobacco smoking is risk factor of many diseases, particularly cancer and heart attacks. WP supports nicotine/tobacco dependence as it is associated with nicotine release and some smokers experience drug withdrawal symptoms when they abstain from it. They also have change in their behaviours and feel difficulty in quitting, even when motivated to do so, shows dependence or addiction.
The Kingdom of Saudi Arabia (KSA) is currently going through a period of rapid modernisation so societal and cultural traditional values related to socialising out in cafes and restaurants where WP smoking has become a tradition. WP tobacco smoking is probably as dangerous to health as cigarette smoking and smoke contains significant concentration of toxicants and includes 27 known or suspected carcinogens.
In the KSA, mostly people are non-smokers and among smokers, the prevalence of current smoking is much higher in males than in females at different ages. When non-smokers start smoking, they believe that they can quit tobacco use at any time, but they are unaware that it is an addiction.
The main reason for start of smoking among adolescents is friends influence, as they are very close to them. Curiosity is at high level among non-smokers and is a reason for having tried smoking. The age of start of smoking among adolescents ranged from 10 to 15 years old, while university students started smoking from 16 years of age. Once they start smoking, it is difficult for them to leave as it is an addiction.
The main aim and objective of the present study was to explore tobacco smoking prevalence, its effects and people attitude in the KSA by literature review.
| Methods|| |
PubMed was used for systematic search. Main search was made with key words ‘Smoking AND Saudi Arabia’ and inclusion criteria, below, was applied for selection of articles for review.
- Studies done in the KSA and on Saudi Arabia's population
- Original articles
- Prospective and retrospective studies
- Cross-sectional studies
- All published scientific studies, performed in KSA and only on Saudi Arabian population, about smoking, attitudes toward smoking, tobacco usage, its effects, risk factors and associated diseases
I started the search, using the key words ‘Smoking AND Saudi Arabia’, in PubMed on 13 November 2017 at 900 h, selected articles according to inclusion criteria and completed the articles selection work at 1900 h on 20 November 2017.
A total of 790 articles were found and when limits were applied with English language and studies on human, 502 articles were left. All abstracts of these 502 articles were reviewed and based on inclusion criteria, 75 articles were selected for the study. The selected articles were then categorised according to their contents as follows:
- Articles related to general population A = 17
- Articles related to studies in schoolchildren B = 20
- Articles related to universities students C = 06
- Articles related to medical students and health professional D = 11
- Articles related to associations with factors, diseases, etc., E = 15
- Articles related to SHS F = 04
- Articles related to awareness G = 02 Total selected articles for review = 75
- Articles did not fulfill inclusion criteria = 427 Total articles = 502.
The details of selected articles are categorised:
- Articles related to general population,,,,,,,,,,,,,,,,
- Articles related to studies in schoolchildren,,,,,,,,,,,,,,,,,,,
- Articles related to universities students,,,,,
- Articles related to medical students and healthcare professionals,,,,,,,,,,
- Articles related to associations with factors, diseases, etc.,,,,,,,,,,,,,,
- Articles related to SHS,,,
- Articles related to awareness.,
| Results|| |
Articles related to general population
The articles,,,,,,,,,,,,,,,, show smoking prevalence, smoking types, desire to quit, male and female difference in smoking and oral hygiene.
Studies have shown different prevalences of tobacco smoking in general population. The highest prevalence of cigarette smoking was found 34.4% and the lowest was discovered 12.2%. In Bedouin population, the prevalence was 15%, while among other general population smoking prevalences were found 22.3% and 23.5%. Male smoker's prevalence was generally more than female in the studies, but in another study, it was found that men had high smoking prevalence rate at younger age than women while women in older age had high prevalence in smoking than men.
It was found that tobacco smoking prevalence among Northern Saudi civilians was relatively high and higher among urban than rural population. Waterpipe smoking was also found among general population.,, Waterpipe smokers used unusual materials or substances. They used different fluids other than water like soft drinks in the water pipe tank, and tobacco mixed with different spices or drugs. Smokers take care of their oral hygiene and clean their teeth more than non-smokers. Among smokers 92.8% wanted and 72% tried to quit smoking.
Articles related to schoolchildren
The articles,,,,,,,,,,,,,,,,,,, mainly showed smoking prevalence, types of smoking and factors and attitude towards quitting smoking among schoolchildren.
In the Global Youth Tobacco Survey 2007, current smokers' prevalence found 13%, while in different studies, it ranged from 9.72% to 21.7%,,, and high prevalence 37% was among schoolchildren in Jeddah. Among schoolchildren, WP smoking was also present, 53.9% in current tobacco users.
In a study in Tabuk, ever smoked children prevalence was 43.7%. In government schools, 22.3% were current smokers. In a study in 15 schools in Riyadh, school boys' current smokers' prevalence was 13.2%, and in rural secondary schools, 17% were current smokers. This shows higher prevalence in rural area school children.
Articles related to universities students
Studies,,,,, were conducted among university students. The studies showed smoking prevalence and factors for attraction towards smoking. Peer pressure was an important factor of smoking in the students.
In undergraduate students, the prevalence of current smokers was 16.8% and estimated was 14.5%. In a study of nine colleges, current smokers' prevalence was 28.1%, importantly among current smokers 14.6% used WP.
In three universities study, male current smokers were 30.9% and 2% female students' smokers had very good oral hygiene than 13% male student's smokers.
Articles related to medical students and healthcare professionals
The studies,,,,,,,,,, included are related to medical colleges students and health professionals.
In medical students in Jeddah, smoking prevalence was 2.8%, and in another study, female medical students showed very less prevalence, 0.32% as compared to non-medical students. Medical students smoked at the time of study and may be due to some stress, smoking prevalence was found 24.8% in male and 9.1% in female medical students. WP (shisha) smoking was found 12.6% in male medical students which is significant due to medical profession.
Smoking prevalence among health professionals was 8.4%, among healthcare workers 26.3%, healthcare professional students 29%, and in secondary health institute students was 22%. The smoking among these professionals in important to consider and discuss as they are related with the healthcare of others.
Articles related to associations with factors, diseases, etc.
The articles included,,,,,,,,,,,,,, showed smoking effects.
Smoking is significantly associated with Chronic Obstructive Pulmonary Disease (COPD), lowers lungs functions, and decreases pulmonary function values. Parental smoking at home is important, it increases risk of respiratory symptoms among children, and chest wheeze and rhinitis have significant link to it, so asthmatic children have great risks while living with smoker parents.
There is association of smoking and periodontal disease. In smokers, overall vertical periodontal bone defects prevalence increases, bone height is reduced, and periodontal attachment loss observed. High prevalence of 88.8% of soft-tissue lesions observed in smokers and smoking has association with benign mucosal lesions.
Tobacco smoking is a major and important risk factor for cardiac diseases in the Saudi population. Smoking increases carboxyhaemoglobin (COHb) level, and in shisha smokers, it is higher than cigarette smokers. There is a significant increase in serum amyloid protein A, rheumatoid factor, and effects of Down syndrome first-trimester markers.
Articles related to second-hand smoke
The articles,,, are about SHS which is more than 80% invisible and odourless.
Saudi pregnant women exposure to SHS prevalence found high 31%, results shorter length and low birth weight of newborn., In another study, anthropometric measurement found reduced in infants born from mothers who were exposed to second-hand smoking/smoke. There are health hazards with SHS in all age groups. SHS exposure prevalence among adolescents was found 32.7%, inside home, it was 49.3% which is very high and alarming for health.
Articles related to awareness
The articles, are related to awareness about smoking and risk factors. It was found that medical students were very aware of the relationship of cigarette smoking and cancer, and almost 75% fifth-year medical college students knew the health hazards/risks of SHS. The training in treatment of tobacco dependence is after the graduation so knowledge is sufficient.
| Discussion|| |
In this review, it is evident that majority of the Saudi population are non-smokers. Cigarette and WP smoking are potential threats and affected almost all populations, especially general population, schoolchildren and university students. The smokers showed desire to quit smoking and they tried also, and they need support, special programmes and treatments. Poor knowledge of WP smoking is increasing the trend. SHS in home is important for health of newborns, children, adolescents and non-smokers living there.
The selected research papers for this review reveal that tobacco smoking prevalence in KSA is present in all age groups. WP smoking is a growing trend among adolescents, medical students, university students and almost all groups. Studies show that among medical college students smokers, 14.6% WP smokers, 44.1% shisha smokers, 23.7 use both cigarettes and shisha, WP smoking is 12.6%, 8.6% only shisha smokers, while 4% use shisha and cigarettes. In high school students, there is high prevalence of WP smoking. Other studies also show WP smoking in inhabitants in the KSA and it becomes alarming when there are daily shisha smokers.
WP smoking is more socially accepted than cigarettes, so its trend is increasing in the KSA. Poor knowledge of WP health-related hazards is increasing its trend in schools and universities students., If people get awareness about health problems related to WP smoking, then it can be controlled. ‘Smoke-free Campus’ programme may be the reason of very low prevalence of tobacco use among medical students in Jeddah KSA, female medical students also showed very low smoking prevalence, 0.32% as compared to other female students.
Smoking is a risk factor for cardiac diseases in the Saudi population, also associated with benign oral mucosal lesions, WP smoke causes deoxyribonucleic acid (DNA) damage in the buccal cells. WP smoking is related with changes in vascular function, which are aggravated in individuals with low habitual physical activity and less physical fitness. Smoking is associated with vertical periodontal bone defects, COPD, and decrease in lung functions,
For designing programmes for tobacco smoking control in the KSA, it is important to know about the age of start of smoking. Studies show start age of smoking, before 12 years of age, at or before 15 years and,, WP smoking at the age of 16–18 years of age. The behaviour change programmes are needed for these age groups.
Reasons of smoking among secondary schoolchildren smokers in the KSA show, idleness 28%, looking at others and getting inspired 22%, enjoyment 20% and desire 32%, and these can be addressed by different programmes according to age, cultural and norms. Creating recreational activities, designing attractive programmes to minimise idleness, banning at all inspiring advertisements and engaging them in physical activities may decrease the trend of smoking.
In 7–9 grade students, study in the KSA reveals that the majority of students have negative attitude towards smoking. The study found that the refraining attitudes towards tobacco use among students were due to teachers changing behaviour strategies and education about smoking hazards. This study can guide in designing programmes and taking measures to control smoking in KSA.
SHS in homes is important for children and those who do not smoke, as it is very difficult for them to avoid, they become passive smokers and is dangerous for their health. In KSA, parent smokers are increasing with passage of time so children get SHS exposure more at homes and outside the homes. SHS increases risk of respiratory symptoms. There is strong link between SHS and chest wheeze in children. There is association between parental smoking in the home and bronchial asthma in young children, and it is significant that asthmatic children parents smoking rate is higher than normal children parents.
SHS also effects newborns,, Smoke can cause damage to fetuses of pregnant women and a variety of DNA damage in both active smokers and those who take SHS which shows that substances from tobacco smoke are spread effectively throughout the body. In Riyadh, environmental tobacco smoke (ETS) exposure is at an alarmingly high rate and needs special measures to control it. There is also need to check in other areas to minimise the health risks.
The most important thing is that if a person does not want to quit smoking, then it becomes difficult, not impossible, to change his attitude and needs continuous sessions. In this review, it is an important thing that mostly smokers wanted to quit smoking, desired to learn methods and tried also, so it needs special attention to design programmes for them, and success rate seems to be excellent.
About half of smokers want and attempted to quit smoking, among smokers 72% tried to stop smoking, 92.8% of all smokers want to learn smoking cessation strategies, 71.7% smokers of intermediate and secondary school showed intention to refrain from smoking, in male secondary schools 75.1% want and tried to relinquish smoking, 57.1% current smokers of medical colleges students are motivated to give up smoking. All studies in this review show that smokers want to get rid of smoking but need treatments of withdrawal symptoms, sessions and health promotion sessions and programmes.
A study estimated that there was US$ 20.5 billion economic loss to KSA due to tobacco use in 10 years (2001–2010). If 10% to 25% tobacco smuggling (illegal import) was cogitated then the economic loss would had been US$ 22.6 or 25.6 billion respectively. The decrease in tobacco use in Saudi Arabia will result short-term and long-term economic benefits.
A study in Saudi Arabia, based on suggestions from smokers and non-smokers, suggests that there should be contributions of mass media and Ministry of Health and Ministry of Education in the designing and implementation of anti-smoking programmes. Majority of study's participants recommended ban of cigarettes sale to adolescents, health education about tobacco and its risks and forcible restriction of tobacco smoking at workplaces. They did not suggest involvement of El-Emera, policemen and municipality of Madinah Munawara city.
The health promotion and anti-smoking programmes should be according to local norms and cultures, and this study provides guidelines for any stop/control smoking programme in the KSA. Increase in tax will increase tobacco price, is an important intervention to decrease tobacco use and WP smoking is associated with much of the harmful effects than cigarette smoking so WP-specific interventions and policies are needed to control smoking in KSA.
| Conclusion|| |
In the KSA, smoking is a forthcoming alarming threat for different tobacco-related diseases. Now, it can be controlled in minimal time with lesser efforts by strategic planning, designing tobacco control programmes according to sex, age groups and education levels.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Muhammad Zubair Tahir,
Fana Global Consultancy and Business Limited, 1 St. Agatha's Road, Ward End, Birmingham, B8 2TU
Source of Support: None, Conflict of Interest: None