J Community Health (2014) 39:901–907 DOI 10.1007/s10900-014-9909-8

ORIGINAL PAPER

Smoking Among Saudi Students: A Review of Risk Factors and Early Intentions of Smoking Khalid M. Almutairi

Published online: 2 July 2014 Ó Springer Science+Business Media New York 2014

Abstract This review aims to determine the prevalence of smoking among Saudi students and to study and to identify, synthesize and summarize the predictors that initiate smoking among students in different ages in Saudi Arabia. Different databases were searched (Web of Science, Google Scholar, Pub Med and Science Direct) with keywords. This search was carried out in October 2013. Studies that included were evaluated for methodological soundness by giving a quality score based on Russell and Gregory’s criteria. A total 12 relevant articles were included in this review. The findings show that the prevalence of smoking is still in higher rates. The age of smoking was started among adolescents ranged from 10 to 15 years old while from university students were from 16 years old. The main reason for smoking among adolescents was influenced by friends. Among college students were peer pressure followed by the stress, media and imitation of others. Curiosity was a reason for having tried smoking and parents was perceived to be the first source for smoking. Religion was considered the main factor against smoking among the adolescent non-smokers and health consideration among college students. Appropriate smoking control programs on adolescent should be initiated they become the future professionals of the society. Smoking control programs should be considered in this group. Keywords Smoking  Adolescent smoking  Smoking among students  Saudi Arabia

K. M. Almutairi (&) Community Health Science Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia e-mail: [email protected]

Introduction Tobacco use is currently responsible for the death around the world which considers a public health problem worldwide. Tobacco smoking is a direct cause of high morbidity all over the world, which could be prevented. Substantial and sustained efforts are required to further reduce smoking prevalence and the associated morbidity and mortality [1]. Smoking causes different diseases such as cancer; about 90 % of all lung cancer deaths in men and 80 % of all lung cancer deaths in women [2, 3]. The effect of this result may not only effect on the health of individuals, but also an economic burden which includes direct medical care for tobacco-induced illnesses and loss of life from early death [4]. Smoking is not socially acceptable in Saudi Arabia, which its civilization is founded on Islamic Shari’ah rules, in which smoking is considered unacceptable behavior among both genders, particularly among females [5]. However, according to Arab news sources, Saudi Arabia is ranked 23rd for tobacco consumption globally [6]. Smoking is a behavior that generally starts in adolescents. An early exposure or initiation of smoking is associated with lower cessation rates, longer duration of smoking, and higher nicotine dependence in adulthood [7]. About 70 % of adolescent smokers are likely to become adult smokers because some adolescent may believe that can quit smoking at any time [8]. It is attention-grabbing how Saudi Arabia, which considered smoking is socially unacceptable and religiously banned and several smoking control measures were implemented and apprehended, has continuously increased levels of smoking prevalence especially among youth. Since students will become the future professionals of the society the smoking control programs should be

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considered among students, thus determining the prevalence and factors associated with this behavior will be an essential point for planning and formulating a program or suitable intervention strategies. This review aims to determine the prevalence of smoking among students in Saudi Arabia. Another purpose of this study is to identify, synthesize and summarize the predictors that initiate smoking among students in different aged group in Saudi Arabia.

J Community Health (2014) 39:901–907

article answered each of the following questions: (1) is the research question clear and adequately substantiated?, (2) is the design appropriate for the research question?, (3) was the sampling method appropriate for the research question and design?, (4) were data collected and managed systematically?, (5) were the data analyzed appropriately?

Results Description of Included Studies

Methodology Search Strategy Studies that examine the prevalence and factors that initiate smoking were identified through online literature using the following database: Science Direct, Web of Science, Google Scholar and Pubmed. The search term used were Saudi Arabia, adolescents, Colleges, students and smoking with probable combinations of conjunction names ‘‘and/ or’’. A specialist was consulted for further search terms. No restrictions were made by language or year of publication. This search was carried out in October 2013. Reference list of included studies was evaluated to increase sensitivity and to select more studies. Inclusion and Exclusion Criteria We included studies that met three criteria: (1) focus on the smoking status of students in Saudi Arabia neither in grade school or college level, (2) focus on factors that initiate smoking among students, and (3) studies published in English and in peer-reviewed journals. We included studies that carried out different methods of analysis. Studies not carried out in Saudi Arabia were excluded from the study. Data Extraction Two researchers independently searched and assessed each database for inclusion and exclusion criteria. Titles and abstracts were screened by a specialist for significance and for possible duplication. After the preliminary screening, details of the author, sample and location of the study and major findings of the included studies were extracted. Quality Appraisal After the extraction of all included articles, all studies were reviewed and appraised for relevance, methodological rigor, and credibility using the Russell and Gregory criteria [9]. Each of the studies was given a quality score ranging from 1 to 5 (5 is the highest score) based on whether the

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After an extensive search, this literature search identified relatively few studies that focused on the prevalence of smoking and the predictors that initiate smoking among students in different ages in Saudi Arabia. In total, 12 studies identified the smoking used among students in Saudi Arabia. Six of these studies examined the smoking among adolescents’ [7, 10–14] and six studies covering college students in Saudi Arabia [15–20]. The three studies that identified tobacco smoking among college students focus on the medical students, one study examined nursing and laboratory students and two studies examined the general population. All of the studies used a cross sectional approach of methodology and study design. The cities and regions in which the studies were conducted were: Riyadh (n = 5), Dammam (n = 2), Jazan (n = 1), Al Hassa (n = 1), Tabuk city (n = 1), Jeddah (n = 1) and Eastern Region (n = 1). All the articles were published after 1999. Details of the quality assessment of all articles included in the study were shown in Table 1. Smoking Among Students Table 2 show the summary of all subjects identified the prevalence and factors that initiate smoking among students in Saudi Arabia. A number of significant findings with smoking among different ages of students in Saudi Arabia were shown in this review study. Adolescents A total of six studies show the prevalence of smoking among intermediate and secondary school students in Saudi Arabia. The overall prevalence of current smoking appears wide variation from location. Two studies of intermediate and secondary students in Riyadh reported 20 and 30 % of current smokers respectively [10, 12]. One study of secondary students in Al Hassa reported almost 22 % of current smokers [11]. Furthermore, high prevalence of smoking was reported in Jeddah and Tabuk city (37 and 22 %) [7, 14]. Jazan city appeared to have a low smoking rate (10 %) compared to other cities [13].

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Table 1 Quality Assessment Reviewed Studies Research Study

Is the research question clear and adequately substantiated?

Is the design appropriate for the research question?

Was the sampling method appropriate for the research question and design?

Were data collected and managed systematically?

Were the data analyzed appropriately?

Quality score

Predicting tobacco use among high school students by using the global youth tobacco survey in Riyadh, Saudi [10]

Yes

Yes

Yes

Yes

Yes

5

Psychosocial predictors of smoking among secondary school students in Al-Hassa, Saudi Arabia [11]

Yes

Yes

Yes

Yes

Yes

5

Prevalence of Smoking and its Related Behaviors and Beliefs Among Secondary School Students in Riyadh, Saudi Arabia [12]

Yes

Yes

No

Yes

Yes

4

Sociodemographic Factors Associated With Tobacco Smoking Among Intermediate and Secondary School Students in Jazan Region of Saudi Arabia [13]

Yes

Yes

Yes

Yes

Yes

5

Prevalence of smoking among male secondary school students in Jeddah, Saudi Arabia [14]

Yes

Yes

Yes

Yes

Yes

5

Gender differences in smoking behavior among adolescents in Saudi Arabia [7]

Yes

Yes

Yes

Yes

Yes

5

Knowledge, attitude and practice of tobacco smoking by medical students in Riyadh, Saudi Arabia [15]

Yes

Yes

No

Yes

Yes

4

Cigarette smoking among female students in five medical and nonmedical colleges [16]

Yes

Yes

Yes

Yes

Yes

5

Smoking pattern among female college students in Dammam, Saudi Arabia [17]

Yes

Yes

Yes

Yes

Yes

5

Water pipe (shisha) smoking among male students of medical colleges in the eastern region of Saudi Arabia [18]

Yes

Yes

No

Yes

Yes

4

Knowledge, Attitude and Smoking patterns among Nursing and Laboratory technology students, Dammam, Saudi Arabia [19]

Yes

Yes

Yes

Yes

Yes

5

Prevalence and associated factors of cigarette smoking among medical students at King Fahad Medical City in Riyadh of Saudi Arabia [20]

Yes

Yes

Yes

Yes

Yes

5

College students

Majority of the studies reported that ‘meeting with friends’ or ‘having smoker friends’ are considered the primary predictors of smoking [7, 10–14]. Factors that initiated smoking were easy access to cigarettes (OR 5.68, CI 2.09–15.48) [10], outing with friends, passing of time, imitation of father and brothers and presence of friends who smoke and persons at home who smoke (OR 4.81,

95 % CI 2.53–9.16 and OR 2.85, 95 % CI 2.00–4.05) [11, 14]. Furthermore, one study in Riyadh reported that majority of the respondents seen one of their teachers smoking [12]. The mean age of smoking among the intermediate and secondary students was 13 years old [12– 14]. Religion was considered the main factor against smoking among the non-smokers [12].

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Riyadh

Al Hassa

Riyadh

Jazan

Jeddah

Tabuk city

1 Al Moamary et al. [10]

2 Amin et al. [11]

3 Al Nohair [12]

4 Gaffar et al. [13]

5 Fida et al [14]

6 Abdalla et al. [7]

Riyadh

Riyadh

Dammam

Eastern Region

1 Al Haqwi et al [15]

2 Abdulghani et al [16]

3 Koura et al. [17]

4 Taha et al. [18]

College students

Location

Study name

Waterpipe (shisha) smoking

Any type of tobacco

Cigarette smoking

Any type of tobacco

Any type of tobacco

Any type of tobacco

Any type of tobacco

Any type of tobacco

Any type of tobacco

Cigarette

Type of tobacco used

Table 2 Summary of study characteristics

371

1,020

907

215

1,505

695

3,923

30

1,652

1,272

Sample size (N)

13 %

9%

4%

19 %

22 %

37 %

11 % (95 % CI 9.75–11.78).

29.8 %

22 %

20 %

Prevalence of smoking (%)



Mean age 20.4





12–19



15–19 years old

12–18 years

15 – 19 years

15–18 years

Age range

16 to 18 years

Mean age 16

high school or intermediate school levels





14 years or less

Mean age 12.96 years for males and 12.49 years for females

13.4 years old





Age of first tobacco use

About one-fifth of students smoked shisha during examination times (n = 10, 21.3 %) and when angry or stressed (n = 9, 19.1 %). Cafe´s or restaurants were the favorite places for shisha smoking for the majority of students (n = 33, 70.2 %). A high proportion of students had the habit of smoking shisha with friends at any time (n = 31; 66 %), after eating (n = 25; 53.2 %) and with tea and coffee (n = 18; 38.3 %)

The main motive for smoking was curiosity (44.3 %), followed by relief of tension (26.1 %). Parents or friends were the main source of the first cigarette smoked

Com-mon cause of starting smoking was entertainment (54 %) and to get relief from psychological pressures (29.4 %)

The influence of friends and peer pressure was perceived as the main reason for smokinga

Approximately 57 % of males obtained cigarettes from a store, while approximately 59 % of females stole cigarettes from home. A majority of males (68.5 %) usually smoked in public places and gatherings, while 80 % of the females usually smoked at home

The presence of friends who smoked and persons at home who smoked (OR 4.81, 95 % CI 2.53–9.16 and OR 2.85, 95 % CI 2.00–4.05)

The most important independent predictors of smoking were academic performance (odds ratio [OR] 5.32), having friends who used khat (OR 3.23), and having friends who used tobacco (OR 2.88)

Friends who smoked were strongly associated to the habit of smoking (60.5 %). Most of the smokers stated that they have seen one of their teachers smoke. Religion was the main factor against smoking among the non-smoking group (42.3 %)

The most frequently stated motives among 75 % of the current smokers were meeting friends and family members, outing with friends, passing of time, and imitation of father and brothers

Friends were considered the reason for smoking and identified that has strong association (OR 8.17, CI 5.56–12.00). Another strong factor that increases the chance of smoking was lack of refusal to sell cigarettes (OR 5.68, CI 2.09–15.48). The strongest association among the variable was ‘‘offered a cigarette by a friend’’ (OR 17.46, CI 11.59–26.27)

Reasons of smoking

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Almost half the smokers (46.7 %) indicated that friends or parents had been the source of the first cigarette. Curiosity (53.5 %), and stress (33.3 %) were the most important reported motives for initiating the habit The most important reasons for smoking were leisure followed by imitation of others or means of relieving psychological pressure. Health considerations were the most important motives followed by religious considerations for not smoking

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College Students In total six studies determined the prevalence and factors that initiate smoking among university and college students in Saudi Arabia [15–20]. Three of these studies revealed smoking among medical and non-medical students in Riyadh [16, 17, 19]. The results show that the prevalence of smoking among medical students were 19 % [15, 20], while non-medical students smoking rate was 4 % [16]. Two studies from Dammam found a low percentage of current smoking among female colleges (9 %) and nursing and laboratory technician students (6 %), [17, 19]. A study in Eastern region of Saudi Arabia reported 13 % current waterpipe (shisha) smoking [18]. Based on the findings, three studies reported that the most important factors that initiate smoking among college students was the influence of friends and peer pressure [15, 17, 19]. Other motive was psychological reliefs, curiosity and entertainment [16, 18]. One study reported that parents and friends were the main source of their first cigarette [19]. Imitation of others was another motive that initiates smoking. Health and religion were the most important factor not being a smoker [20].

– 19 - 21

a

Riyadh 6 Al Kaabba et al [20]

Any type of tobacco (cigarette and shisha)

18 % 153

Dammam 5 Mandil et al [19]

Cigarette smoking

Location

Any type of tobacco

266

6%





Discussion

Study name

Table 2 continued

Type of tobacco used

Sample size (N)

Prevalence of smoking (%)

Age range

Age of first tobacco use

Reasons of smoking

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This study summarizedand provides insight into the prevalence of smoking among students and factors of early intention of smoking among students in different ages. The prevalence of current smoking found in this review study among students was alarming especially among adolescents. The highest prevalence rate among adolescents wasin Al Hassa (22 %) on 1652 students [11]. The finding was similar from other studies of smoking among adolescent, Hungary (23 %), Slovenia (20 %), and the Philippines (18 %) [21]. Our findings also do parallel results of national surveys conducted by the WHO and global youth tobacco survey (GYTS) in Saudi Arabia [22]. This finding should be considered especially for policy makers that will provide specific strategy to decrease the rate of smoking because at early aged is expected to become a lifelong habit which will make quitting more difficult in the future [23]. Moreover, high prevalence rate of smoking among college student was found in this study. Even though there is a contrasting result between the prevalence of smoking among medical and non-medical students. The findings are still at high level as for students who will become the future professionals and who has knowledge to the detrimental effects of smoking. The review show that influenced of friends is the main reason among adolescents and university students followed

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by the stress, curiosity and imitation of others. Other recent studies done in other countries, peer pressure was also the reason, initiating from smoking [24, 25]. Thus the role of peers among students was a strong factor starting the habit. As for psychological pressure or stressed, similar findings were also reported in other countries [26]. Moreover, the majority of the non-smokers reported that religion constitutes as the main factor against smoking among the nonsmokers followed by health consideration. These results might have contributed another perspective among the university administrators and smoking control policy makers in formulating smoking control policies. According to the present study, the age smoking was started at an early age among adolescents and college students. One study found imitation of father and brother were the most frequently stated motives of tobacco smoking, as well as students have seen one of their teacher smoking [12]. Another study found a significantly higher association of parental smoking among smoking initiation in adolescent offspring [27]. Imitation of a child among adults or children among his/her parents is a part of a child’s developmental stage, which a child begins to imitate and observed actions. Further more, there is likewise a strong evidenced that active parental smoking has a bigger danger of smoking initiation among offspring rather than children who exposed whose parents had never smoked [27–29]. There are limitations that should be considered in this review. Although, lot of studies have been carried out in the field of smoking in recent years in the Saudi Arabia. A variation in number of samples in reporting the prevalence was the most important limitation of the study. Thus, researchers could not say they cover the whole population of students in Saudi Arabia. The second limitations that should be considered in this review is majority of reviewing studies were performed using a cross sectional analysis that cannot infer causality, and can only describe association. Another limitation of the study is some of the study focus only on one gender. Hence, there is a need for additional investigations, which covers a large sample on both genders across different universities and schools in Saudi Arabia.

Conclusion This study emphasizes the importance to recognize the uprising rate of smoking particularly among adolescents. The awareness of parents on the smoking behavior of adolescents’ should be tailored, in which the presence of a smoking member of the household influenced adolescent in smoking habit and early age of smoking. The study shows that at the time when adolescents start to socialize with their friends, the smoking behavior of peers had a considerable

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effect. Therefore, we recommend appropriate smoking control programs, especially in adolescent should be initiated. A strict smoking policy should be implemented and early counseling among adolescents and awareness campaigns to the health effects of smoking and the prevailing beliefs that smoking habit can easily quit. As they become the future professionals of the society. Smoking control programs should be considered in this group. Acknowledgments The authors extend their appreciation to the Research Center at the College of Applied Medical Sciences and the Deanship of Scientific Research at King Saud University for funding this work.

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Smoking among Saudi students: a review of risk factors and early intentions of smoking.

This review aims to determine the prevalence of smoking among Saudi students and to study and to identify, synthesize and summarize the predictors tha...
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