|
Pattern of current tobacco
use among the Saudi adult population: results
of the national Survey of Risk Factors of Non-Communicable
Diseases
Abdelshakour
M. Abdalla (1)
Lamiaa Z. Abuzaid (2)
Waleed S. Al-Hussain (3)
Nasser A. Al-Hamdan (1)
Abdalla A. Saeed (1)
Ahmed A. Bahnassy (1)
(1) King Saud Bin Abdulaziz University for
Health Sciences, Department of Community Medicine,
Faculty of Medicine, King Fahad Medical City,
PO Box 59046, Riyadh 11525, Saudi Arabia
(2) Department of Public Health, Community &
Occupational Medicine, and Environmental Heath,
Faculty of Medicine, Suez Canal University,
Ismailia, Egypt.
(3) Internship, King Fahad Medical City, PO
Box 59046, Riyadh 11525, Saudi Arabia
Correspondence:
Dr. Abdelshakour
M. Abdalla
King Saud Bin Abdulaziz University for Health
Sciences,
Department of Community Medicine,
Faculty of Medicine,
King Fahad Medical City,
PO Box 59046, Riyadh 11525,
Saudi Arabia
Tel. 0501225427
Email: Abdallaali63@hotmail.com
|
Abstract
Objective:
The aim of this study is to describe the
tobacco use status and determine the prevalence
and pattern of current tobacco smoking
among adult Saudi population to provide
baseline data that may assist national
health policies to control tobacco use
in Saudi Arabia
Methods: 4,751 Saudis aged 15-64
years were analyzed, for pattern of tobacco
use, from a national cross-sectional survey
of non-communicable disease (NCD) risk
factors. Data were collected using the
standardized stepwise approach for NCD
risk factor surveillance, of the World
Health Organization (WHO).
Results: According to this study,
most current tobacco users are tobacco
smokers (92%). The overall prevalence
of current tobacco smokers is 12.9% (611)
of the total participants, with significantly
higher proportion of male smokers than
females (24.7% of males and 1.4% of females).
Most current smokers are daily smokers
(86%), of these 72.5% use manufactured
cigarettes, with significantly more proportion
of males than of females. The prevalence
of current use of smokeless tobacco among
the participants was estimated at 1.1%
and more common among males than females,
1.7% and 0.5% respectively. But there
was no significant difference.
In all the smoking status categories,
the proportion of male tobacco users is
significantly higher than female tobacco
users even among the former smokers
Univariate analysis
shows that smoking prevalence was higher
among males, age group 25-34, northern
and eastern regions, educated people,
and among those in certain occupations:
unemployment and nongovernmental employee,
and participants with income equal or
more than 15000 Saudi Riyals per Month.
Using logistic model, significant predictors
for current smoking were: Male, younger
adults, being in the eastern or northern
regions, and being unemployed.
Conclusion:
Unlike adult females, tobacco smoking
was prevalent among adult males in Kingdom
of Saudi Arabia. Significant predictors
for current smoking were: Male sex, younger
adults, being in the eastern or northern
regions, and being unemployed.
Further explanatory research, considering
gender differences and other socio-demographic
subcategories in tobacco use is recommended
to develop an effective anti-smoking intervention
program.
Key words: Tobacco use, Pattern,
Adults, Saudi Arabia
|
Tobacco use is a major cause of morbidity and
mortality all over the world, with more burdens
in the developing countries. There is evidence
that tobacco use is a main risk factor of the
non-communicable diseases, which are steadily
increasing all over the world, and contributed
to 36 million deaths in 2008 (1,2).
The 1.3 billion adult world smokers in 2003
are predicted to rise up to 1.7 billion between
2020 and 2025 if the high level of tobacco use
remains constant (3,4). The mortality rate is
expected to increase from 5.4 million to 8.3
million a year in 2030, and 80% of these deaths
are expected to be in developing countries (5,
6).
Tobacco consumption reasons are different in
different subgroups.
This is why the tobacco industry takes into
consideration the specific differences in their
target groups according to sex, age group, ethnicity,
and class, in efforts to broaden tobacco sales
and promote tobacco use. Also there is evidence
that tobacco smoking affects different subgroups
differently. Therefore various subgroups need
specific tobacco control measures to be effective
(4). This emphasizes the importance of properly
and appropriately studying the patterns of tobacco
use according to the various subgroups in Saudi
Arabia and other communities. This will enable
the authorities to plan and implement intervention
strategies.
Several studies were conducted in the Kingdom
of Saudi Arabia (KSA) among different sectors
of the communities. Those include students,
health professionals and others. The prevalence
among adults ranged from 11.6 to 52.3 % (median
22.6 %) (7). The only national study among Saudi
adults reported that 19.1% of them were current
smokers (8).
The aim of this study is to describe the tobacco
use status and determine the prevalence and
pattern of current tobacco smoking among adult
Saudi population to provide baseline data that
may assist national health policies to control
tobacco use in Saudi Arabia.
This is a cross-sectional community based study
covering the whole of the Kingdom of Saudi Arabia
to estimate the prevalence of some of the risk
factors of non communicable diseases, including
tobacco smoking. The WHO STEPwise approach to
Surveillance (STEPS) of NCD risk factors was
the basis for conducting the survey and collecting
data (9, 10).
Study population:
The study population was all Saudi population
of all the 20 health regions of the country,
of persons aged 15 - 64 years.
Sampling:
A multistage stratified cluster random sampling
technique was used to recruit the study subjects.
Stratification was based on age (five 10 year
age groups) and gender (2 groups) in all the
health regions of the country. Based upon proposed
methodology of the WHO STEPwise approach a sample
size of 196 was calculated for each of these
ten strata. To adjust for regional variation,
the sample size was inflated to 5,000. A list
of all Primary Health Care Centers (PHCCs) in
each region was prepared and 10% of these PHCCs
were randomly chosen, and were allocated a regional
sample proportionate to the size of their catchment
population in sampled PHCCs. To identify the
households a map of the health center coverage
area was used to choose the houses. Each house
was assigned a number and a simple random draw
was made. Within identified households, a list
of all individuals aged 15-64 years was made
and the study subject was selected using Kish
method.
Data collection:
Tool used:
Data was collected using the WHO STEPwise approach
which includes a questionnaire, physical measurements
plus biochemical measurements covering tobacco
use and other risk factors for the chronic diseases.
Data on tobacco use addressed in this communication
included current tobacco use. The questionnaire
used for data collection was translated into
Arabic by a team of physicians, and was back
translated to ensure the accuracy of translation.
Arabic instrument was pretested on 51 eligible
respondents for wording and understanding of
the questions, and necessary adjustments were
made in the instrument in light of the pretest.
The questionnaire includes socio-demographic
data, tobacco consumption and data on other
diseases and risk factors. The identified subject
was interviewed using a questionnaire after
obtaining consent. This communication deals
only with current tobacco use and includes socio-demographic
data.
Data collectors:
Data was collected by 54 males and 54 female
data collectors, who work in teams. Each field
team was made up of four persons a male data
collector, a female data collector, a driver
and a female assistant. Data collection teams
were supervised by a hierarchy of local supervisor,
regional coordinators and national coordinator.
Training of data collectors:
All individuals involved in data collection
attended a comprehensive training workshop that
included interview techniques, data collection
tools, practical applications and field guidelines.
The following definitions were used to describe
smoking status:
Tobacco: means any
product obtained from leaf of Nicotina Tobacum
plant.
Never smoker: Participant
who never experimented with tobacco smoking
Ever smoker: Participant
who had ever smoked any of tobacco products
in the past. Ever smokers are further classified
as current smokers and ex smokers.
A current smoker:
is someone who at the time of the survey smokes
any tobacco product and ex-smoker is someone
who doesn't smoke at time of the survey.
The group of current smokers
can be further divided into two categories:
Daily smoker: someone who smokes a tobacco product
at least once a day (regular smoker) and occasional
smoker who smokes but not on a daily basis (irregularly
smoker).
Data management and analysis:
Questionnaires collected from the field were
reviewed by team leaders assigned to each team
before submitting them to the headquarters for
data entry. Double entry of the questionnaires
was performed using EPI-INFO 2000 software and
EpiData software developed by the Menzes centre
for validation. After data entry, data cleaning
was conducted. New variables were defined by
adopting the standard Steps variables (STEPS
Data Management Manual, Draft version v1.5,
October 2003). Data analysis was conducted for
4,751 participants using SPSS software.
Statistical Analysis:
Descriptive statistics, Chi square test, t-test,
Mann Whitney test and ANOVA or Kruskal Wallis
were used as appropriate after checking for
normality. Level of significance level was set
to be < 0.05 throughout the study. The data
were processed in SPSS version 17.
Ethical clearance and confidentiality:
The protocol and the instrument of the surveillance
were approved by the Ministry of Health, Center
of Biomedical Ethics and the concerned authorities
in the Kingdom. Informed consent of all subjects
was obtained. Confidentiality of data was assured
and that data will be used only for the stated
purpose of the survey. Further details of the
method used and sampling procedures can be found
in Saudi Arabia STEPwise document (9, 10).
A
total
of
4,883
people
participated
in
the
study
with
97.7%
response
rate.
Final
analysis
included
4,751
participants
after
132
records
were
excluded
because
of
major
deficiencies
in
the
data.
There
were
no
significant
differences
in
the
socio-demographic
characteristics
of
the
excluded
participants
compared
to
the
included
participants.
About
49%
of
the
participants
were
males.
Approximately
half
of
the
participants
were
of
age
25
to
44
years
(48.2%)
and
more
than
half
of
the
participants
had
attained
primary
level
of
education
or
less
(52.2%).
About
a
third
of
participants
have
less
than
3000
Saudi
Riyals
as
house
hold
monthly
estimated
earnings.
The
overall
prevalence
of
current
smoked
tobacco
was
12.9%
with
significant
gender
differences
(24.7%
males
compared
to
1.4%
females;
p
<
0.001).
There
were
also
significant
age,
geographical
and
sociodemographic
differences
as
shown
in
Table
1.
Current
smoking
was
significantly
more
in
age
group
25
-
34
years,
among
higher
income
earners,
residents
of
the
eastern
and
northern
regions,
among
the
unemployed
and
non-government
employees,
and
among
participants
with
vocational
training.
Current
tobacco
smokers
are
divided
into
further
categories;
regular
smokers
(daily
smokers)
and
occasional
smokers.
Most
current
smokers
in
this
study
are
daily
smokers
(86%),
and
only
14%
are
occasional
smokers
(Table
2).
About
three-quarters
(72.5%)
of
daily
smokers
use
manufactured
cigarettes
with
significantly
more
proportion
of
males
than
females
(73%,
and
53%
respectively).
Table
1:
Frequency
of
current
tobacco
smoking
according
to
participants
socio-demographic
characteristics
 Note:
There
are
very
few
missed
data
on
three
variables,
income
5%,
employment
0.12%
and
level
of
education
0.18%
In
all
the
smoking
status
categories,
the
proportion
of
male
tobacco
users
is
significantly
higher
than
female
tobacco
users
(Table
2).
Table
2:
shows
the
smoking
status
according
to
the
gender
The
prevalence
of
current
use
of
smokeless
tobacco
among
the
participants
was
estimated
at
1.1%
and
was
more
common
among
males
than
females,
1.7%
and
0.5%
respectively.
But
there
was
no
significant
difference.
These
results
are
shown
in
Table
2.
All
significant
risk
factors
in
univariate
analysis
were
included
in
a
multiple
logistic
model
for
predictors
of
current
smoking
(Table
3).
Significant
predictors
for
current
smoking
were:
Male
sex
(odds
ratio
(OR)
=
21.037),
Younger
adults
(OR=
1.189),
being
in
the
eastern
or
northern
regions
(OR=
1.461),
and
being
unemployed
(OR=
1.037).
Table
3:
Multiple
logistic
regression
analysis
for
predictors
of
smoking
Variables
entered:
Age,
gender,
education,
occupation,
region,
income
OR*
=
Odds
Ratio
C.
I.#.
=
Confidence
Interval
This
study
found
that
the
overall
prevalence
of
current
tobacco
smokers
is
12.9%
(24.7%
males
and
1.4%
females)
of
the
total
participants.
Most
current
smokers
are
daily
smokers
(86%).
Smoked
tobacco
products
were
the
most
preferred
types
for
92%
of
adult
smokers
and
the
rest
(8%)
preferred
smokeless
tobacco
products.
For
smoked
products
72.5%
of
smokers
prefer
manufactured
cigarettes.
The
prevalence
of
the
current
smoking
in
this
study
was
within
the
reported
ranges
in
the
previous
studies
in
Saudi
Arabia,
from
11.6-52.3%,
but
less
than
the
median
(22.6%).
While
the
prevalence
among
males
was
consistent
with
the
median
of
the
previous
studies
(26.5%),
in
females
it
was
obviously
less
than
the
median
of
the
previous
studies
(9%)
(7).
Studies
in
other
countries
such
as
Iran
in
agreement
with
our
findings
reported
prevalence
of
current
smoking
as
12.5%
(23.4%
males
and
1.4%
females)
(11).
Lower
prevalence
was
reported
from
Nigeria,
Ghana
and
Ethiopia
(8.0,
8.8%,
and
8.3%
respectively),
while
higher
prevalence
was
reported
from
Libya
(27.26%)
and
Kenya
(22.9%,)
(6,12,13).
For
both
types,
smoked
and
smokeless
tobacco
products,
male
users
were
significantly
more
than
females,
in
agreement
with
all
previous
studies
in
the
Kingdom
and
almost
all
other
communities.
(7,
11-16).
Underreported
tobacco
smoking
could
not
be
excluded
in
this
study,
especially
among
females,
because
tobacco
consumption
is
a
stigma
for
women
in
Saudi
Arabia
where
smoking
is
socially
unacceptable
among
females.
In
addition
to
gender,
age
was
also
associated
with
smoking
with
younger
adults
having
a
significantly
higher
prevalence.
This
agrees
with
findings
of
other
studies
(
12,15)
but
also
disagrees
with
others
(17).
Other
factors
associated
with
smoking
in
our
study
include
employment
and
geographical
location.
Some
studies
support
the
current
findings
that
the
higher
prevalence
rate
of
tobacco
smoking
was
among
the
unemployed
(18)
.The
study
done
in
sub-Sahara
Africa
among
14
nations,
support
the
opposite
position
that
the
unemployed
smoked
less
(12).
Saudi
Arabia
is
a
rich
country;
even
unemployed
persons
seem
to
have
enough
money
to
buy
cigarettes,
mostly
from
other
family
members,
unlike
those
in
sub-Sahara
Africa.
Residents
of
the
northern
and
eastern
regions
in
our
study
showed
a
significantly
higher
smoking
prevalence
than
the
other
regions.
The
Northern
region
is
on
the
border
with
Jordan
and
Syria,
while
the
eastern
region
is
on
the
border
with
Bahrain,
which
has
a
higher
adult
smoking
prevalence
(19).
These
differences
in
smoking
prevalence
according
to
sociodemographic
characteristics
may
be
due
to
varying
sampling
procedures,
definition
of
smoking
uses,
bias
in
reporting,
in
addition
to
real
cultural,
traditional
differences
and
population
characteristics.
Estimates
for
tobacco
smoking
were
based
on
self-reports
and
not
biochemical
tests,
so
underreport
of
tobacco
smoking
was
suspected
in
this
study,
especially
among
females.
Unlike
adult
females,
tobacco
smoking
was
highly
prevalent
among
adult
males
and
significant
predictors
for
current
smoking
were,
male
sex,
younger
adults,
being
in
the
eastern
or
northern
regions,
and
being
unemployed.
Smoking
is
the
most
common
method
of
consuming
tobacco
and
cigarette
was
the
most
common
tobacco
product
smoked.
Further
explanatory
research,
considering
gender
differences
and
finding
why
females
significantly
are
smoking
less
was
recommended,
to
control
the
male
smoking
epidemic.
This
study
increases
our
understanding
about
the
prevalence
and
correlates
of
tobacco
smoking
among
adults
in
Saudi
Arabia.
This
may
contribute
to
the
development
of
an
effective
smoking
cessation
and
prevention
program.
1.
World
Health
Organization.
World
Health
Statistics
2011.
Geneva:
WHO;
2011
2.
U.S.
Department
of
Health
and
Human
Services.
The
Health
Consequences
of
Smoking:
A
Report
of
the
Surgeon
General.
Atlanta:
U.S.
Department
of
Health
and
Human
Services,
Centers
for
Disease
Control
and
Prevention,
National
Center
for
Chronic
Disease
Prevention
and
Health
Promotion,
Office
on
Smoking
and
Health,
2004
[accessed
2011
Mar
11].
http://www.thriveri.org/documents/4g_health_consequences_smoking.pdf
3.
Guindon
GE,
Boisclair
D.
Past,
current,
and
future
trends
in
tobacco
use.
Washington
DC:
World
Bank,
2003.
Available
at:
http://www.1.worldbank.org/tobacco/publications.asp
4.
WHO
(2007).
Gender
and
Tobacco
Control:
A
Policy
Brief,
Geneva
Available
at:
www.who.int/tobacco/resources/publications/general/policy_brief.pdf.
5.
Mathers
CD,
Loncar
D
(2006).
Projections
of
global
mortality
and
burden
of
disease
from
2002
to
2030.
PLoS
Med.,
3:
442.
6.
World
Health
Organization.
World
Health
Statistics
2008.
Geneva:
WHO;
2008
7.
Bassiony
MM.
Smoking
in
Saudi
Arabia.
Saudi
Med
J.
2009;
30
(7):876-881
8.
Al-Nozha
MM,
Arafah
MR,
Al-Mazrou
YY,
Al-Maatouq
MA,
Khan
NB,
Khalil
MZ,
Al-Khadra
AH,
Al-Marzouki
K,
Abdullah
MA,
Al-Harthi
SS,
Al-Shahid
MS,
Nouh
MS,
Al-Mobeireek
A.
Coronary
artery
disease,
in
Saudi
Arabia.
Saudi
Med
J.
2004
Sep;25(9):1165-1171
9.
Bonita
R,
de
Courten
M,
Dwyer
T,
Jamorzik
K,
Winkelmann
R,
"Surveillance
of
risk
factors
for
Non
Communicable
diseases,"
The
WHO
Stepwise
approach:
WHO,
2001.
10.
http:/
/www.who.int
/
chp
/
steps
/
2005
Saudi
Arabia
STEPS
Report
EN.pdf.
11.
Alipasha
Alipasha
Meysamie,
Reza
Ghaletaki,
Mehrdad
Haghazali,
Fereshteh
Asgari,
Armin
Rashidi,
Omid
Khalilzadeh,
Alireza
Esteghamati,
Mehrshad
Abbasi.
Pattern
of
tobacco
use
among
the
Iranian
adult
population:
results
of
the
national
Survey
of
Risk
Factors
of
Non-Communicable
Diseases.
Tob
Control
2010;19:125-128
http://www.dph.gov.my/ncd/surveillance/index.php?
12.
Pampel
F.
Tobacco
use
in
sub-Saharan
Africa:
Estimates
from
the
demographic
health
surveys.
Soc.
Sci.
Med.
2008;
66:
1772-1783.
13.
R.K.Pal
and
Ali
Grera.
Coronary
Artery
Disease
in
Africa:
Community
based
study
of
Risk
Factors.
:
BJMP
2010;3(2):326
(from
the
journal
6-10)
14.
MOH.
NCD
Surveillance
2005/06:
Report
on
NCD
risk
factor
in
Malaysia.
Ministry
of
Health,
Malaysia.
Available
from
URL
here.
(accessed
13
February
2008)
15.
Jarallah
JS,
al-Rubeaan
KA,
al-Nuaim
AR,
al-Ruhaily
AA,
Kalantan
KA.
Prevalence
and
determinants
of
smoking
in
three
regions
of
Saudi
Arabia..
Tob
Control.
1999;
8(1):53-56.
16.
Sarraf-Zadegan
N,
Boshtam
m.
Tobacco
use
among
Iranian
men,
women,
and
adolescents.
Eur
J
public
Health
2004;
14:76-78)
17.
Sibai
AM
and
Hwalla
N.
WHO
STEPS
Chronic
Disease
Risk
Factor
Surveillance:
Data
Book
for.
Lebanon,
2009.
American
University
of
Beirut,
2010.
18.
Hammarström
A,
Janlert
U.
Unemployment.
An
important
predictor
for
future
smoking:
a
14-year
follow-up
study
of
school
leavers.
Scand
J
Public
Health.
2003;31(3):229-32.
19.
Maziak
W,
Nakkash
R,
Bahelah
R,
Husseini
A,
Fanous
N,
Eissenberg
T.
Tobacco
in
the
Arab
world:
old
and
new
epidemics
amidst
policy
paralysis.
Health
Policy
Plan.
2014
Sep;29(6):784-94.
|
