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ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 146-150

What encourages Saudis to quit smoking?


1 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
2 Department of Internal Medicine, Faculty of Medicine, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
3 Department of Basic Sciences, College of Science and Health Professions, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication7-Apr-2016

Correspondence Address:
Hana M. A. Fakhoury
Department of Basic Sciences, College of Science and Health Professions, King Saud Bin Abdulaziz University, Riyadh
Kingdom of Saudi Arabia
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DOI: 10.4103/1658-600X.179825

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  Abstract 

Context: Despite the noticeable increase in public awareness among Saudis, Saudi Arabia is still ranked as the fourth largest tobacco importer in the world. A very limited number of studies have studied ex-smokers in the Saudi population.
Aims: In this study, we aimed to analyse the socio-demographic characteristics of ex-smokers in an attempt to determine who is most likely to quit smoking among Saudis.
Settings and Design: This study is an extension to a previous cross-sectional study, which was conducted in Saudi Arabia during the period between April and May 2013.
Subjects and Methods: A new questionnaire was developed and manually distributed electronically through different popular Twitter accounts. The questionnaire was written in Arabic and included information about socio-economic factors and smoking history.
Results: The results of 2057 questionnaires showed that 808 (39%) were current smokers, 460 (22%) were ex-smokers while the remaining 808 (39 %) never smoked. The majority of ex-smokers (57%) decided to quit because of religious and social reasons. In addition, health reasons were the drive for 40% of the quitters while only 2.7% of the quitters made the decision because of financial reasons. In the multivariate analysis for reasons to stop smoking, we found that quitting was not influenced by gender, income or age at the onset of smoking.
Conclusions: We have looked at smoking cessation from a broader perspective, analysing different categories of the Saudi population. Social, religious and health reasons must be emphasised by counsellors assisting Saudi smokers to quit.

Keywords: Cessation, cigarette, Saudi Arabia, smoking


How to cite this article:
Al-Mohrej OA, Al-Shirian SD, Altraif SI, Tamim HM, Fakhoury HM. What encourages Saudis to quit smoking?. J Health Spec 2016;4:146-50

How to cite this URL:
Al-Mohrej OA, Al-Shirian SD, Altraif SI, Tamim HM, Fakhoury HM. What encourages Saudis to quit smoking?. J Health Spec [serial online] 2016 [cited 2018 Jan 23];4:146-50. Available from: http://www.thejhs.org/text.asp?2016/4/2/146/179825


  Introduction Top


Despite the noticeable increase in public awareness among Saudis and the millions spent by the government to fight the smoking epidemic,[1] Saudi Arabia is still ranked as the fourth largest tobacco importer in the world.[2] This shows that the smoking epidemic is well established in the Kingdom.[3],[4],[5] The prevalence of current smokers varies from 22% to 28% in different studies.[6],[7] In addition, smoking has become a significant problem among high school, college and medical students where the rates of current smokers have been reported to be 20%, 15% and 25%, respectively.[8],[9],[10]

Previous studies conducted in Saudi Arabia focussed on the prevalence of the problem in specific age groups only. For example, many studies described the prevalence of smoking in adolescents,[10],[11] young adults [9],[12] and adults.[13],[14] Hence, there were many variations in prevalence among these studies.

Smoking is thought to be a stigma in the Kingdom of Saudi Arabia since it is prohibited by Islam.[15] Smoking is more common among males since smoking is regarded as a social taboo, especially by women.[14],[15] This is considered to be one of the main differences between Arab and Western cultures where female smokers are more commonly seen.[16]

There are many factors associated with smoking in Saudi Arabia. These factors include lower economic status, low level of education, young age, social stressors and certain occupations such as military and self-employment.[17],[18] Due to the fact that the cigarette is cheaper in Saudi Arabia compared to the gross domestic product per capita, we can see that smoking is more common among individuals with low income and young children compared to other countries.[14],[18]

Nevertheless, a very limited number of studies have studied ex-smokers in the Saudi population.[15],[17],[19] One of these studies showed that 70% of smokers had considered quitting and that 58% had actually tried quitting.[19] However, lack of determination, friend or family influence, social problems and withdrawal symptoms were the main causes of their failure quitting.[19] On the other hand, a recent study on female college students showed that the most common reason for quitting was health concerns, followed by religious beliefs and then parents' advice.[15]

Another study showed that adolescents were most likely to quit smoking compared to other age groups.[17] Because cigarettes are cheaper in Saudi Arabia, prices of cigarettes were not an important factor in quitting among the adolescent age group.[17],[20]

In this study, we aimed to analyse the socio-demographic characteristics of ex-smokers in comparison to smokers. We also looked at smoking history and the reasons for quitting. We analysed the risk factors for quitting to determine who was most likely to quit smoking.


  Subjects and Methods Top


This work is part of a cross-sectional study conducted in Saudi Arabia during the period between April and May 2013. An Arabic questionnaire was uploaded as a Google document and distributed to the Twitter accounts of Saudi celebrities with more than 1 million followers. The celebrities included writers, politicians, TV presenters, sports personnel and religious leaders. The authors contacted these celebrities to participate in providing a link to their followers for them to fill up; this was done to get a bigger number of Saudi participants, especially in provinces out of Riyadh City.

The questionnaire was written in Arabic and included both yes/no and multiple-choice questions. The questionnaire included a section on demographic and socio-economic factors, another section focused on smoking history while the final section addressed the prices of cigarette in Saudi Arabia. The missing data were addressed using the previous study done by the authors as a reference for comparison in the statistical analysis since there were only few studies done about smoking cessation in Saudi Arabia.

Saudi individuals, both male and female, aged 11 to 70 years, were included. The adjective “ex-smokers” was used to refer to “individuals who had ever smoked (but did not smoke at the time of the survey) would be defined as ex-smokers, regardless of their age at quitting and length of time since they quit.”[21] Individuals who were smokers or previous smokers were given the questionnaire to fill out. We were able to get a bigger number of participants due to the fact that their names were not required. However, we could state that controlling that sample and making it only limited to Saudi citizens was hard due to the fact that distribution of the questionnaire was through famous social media accounts and participants filled out the questionnaire anonymously. With that said, we believe that this could be a source of bias, but we tried to control this by asking the respondent's nationality in the questionnaire, hence enabling us to exclude non-Saudis.

The sample size was determined using an online sample size calculator Raosoft (2004) Raosoft Sample Size Calculator. (Raosoft, Inc., Seattle). It was decided to use the common numbers for all the variables because this kind of study was never done before in Saudi Arabia. A conservative choice of the agreement on the relationship between the consumption and price increase was set at 50%. Consequently, a sample of 2000 students was calculated to achieve a 95% confidence interval (CI) for the prevalence with a margin of error at 2.1%. The sample size calculation was performed based on a previously conducted study.[20]

Data management and analyses were carried out using the Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp. Released 2013. IBM SPSS Statistics for Mac, Version 21.0. Armonk, NY: IBM Corp). Descriptive analyses were carried out by reporting the number and percentage for the different categorical variables. The association between smoking status and different factors was assessed using the Chi-square test. To analyse risk factors for ex-smokers, we carried out multivariate logistic regression analysis where the variables included in the model were the ones that showed statistical significance at the bivariate level. Interaction between these variables was assessed. The variables included in the model were considered as reported, and the odds ratios (ORs) represented the groups as they are. For this, adjusted OR (aOR) and 95% CI were reported. A P < 0.05 was used to indicate significant statistics.

Ethical approval was obtained from the local Institutional Review Board at King Abdullah Medical International Research Centre, Riyadh, National Guard Health Affairs, Saudi Arabia.


  Results Top


Multivariate analyses of quitting factors

There were 2160 completed questionnaires. A total of 103 questionnaires were excluded since they were completed by non-Saudis. The results of the remaining 2057 questionnaires were analysed. Among the included questionnaire respondents, 808 (39 %) were current smokers while 460 (22%) were ex-smokers. [Table 1] summarises the socio-demographic variables according to smoking status.
Table 1: Socio-demographic variables according to smoking status

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The majority of ex-smokers (79%) were aged 30 and less. When analysing income, we found that people with income <800 US dollars constituted the majority of ex-smokers (52%). Further, individuals with higher level of education formed the majority of ex-smokers (55%). Concerning the number of cigarettes consumed, individuals who smoked <5 cigarettes per day formed a reasonable percentage of ex-smokers (38%) compared to lower percentage for those who smoked more than a packet per day (14%).

Smoking history and reason for quitting

Regarding the past smoking history, a majority of ex-smokers (49%) smoked only on rare occasions compared to a minority (17%) who had a smoking history of 10 years and more.

Concerning the reason for quitting, we found that the majority of ex-smokers (57%) had decided to quit because of religious and social reasons. In addition, health reason was the reason for 40% of the quitters while only 3% of quitters made the decision because of financial constraints.

Details of the smoking history and reasons for quitting are found in [Table 2].
Table 2: Smoking history and reason for quitting, n = 460 (%)

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Baseline characteristics in relation to smoking status

The details of the multivariate analyses are summarised in [Table 3]. In brief, gender, income and age at onset of smoking did not significantly affect the risk of becoming an ex-smoker. In other words, quitting was not influenced by gender, income or age at onset of smoking.
Table 3: Multivariate analyses of the factors of quitting

Click here to view


On the other hand, our results showed that the more older the individual, the greater the odd of quitting with aOR and 95% CI of 1.47 (1.10 - 1.97), which means that older individuals were more likely to quit. Interestingly, we found that the higher the level of education the lower the odd of quitting with aOR and 95% CI of 0.71 (0.66 - 1.01), which suggests that more educated individuals were less likely to quit.

We also found that the greater the number of consumed cigarettes, the lower the odd of quitting with OR and CI of 0.48 (0.40–0.57); in other words, heavy smokers were less likely to quit.


  Discussion Top


The study with its specified objectives represents a wide range of Twitter users in the Saudi community, which makes it a unique study because similar studies only analysed quitting behaviour in specific groups only.[17] Here, we have looked at quitting from a broader perspective analysing different categories of the Saudi population. In addition, factors that determine who was most likely to quit smoking are studied. All of these predictors were not studied with such details previously. Correspondingly, our study considers a new community sample and utilises the smoking characteristics and risk factors from another point of view. To emphasise, local studies have mainly focused on the prevalence and smoking history.

In addition, our approach to gathering information is thought to be novel since it is depended on Twitter, which in comparison to other social media networks is the fastest growing platform in the world.[22],[23],[24] Along with its increasing popularity, especially in Saudi Arabia, Twitter is considered to be an efficient source for large-scale data collection and analysis.[22],[23],[24] This novel approach was used to increase the participant's preparedness to declare smoking since it is considered a stigma in Saudi Arabia. However, information gathered in this wide social media network makes it a source of bias. This is because social media is used by different nationalities around the world, and any person could access the questionnaire even if they were non-Saudis. In addition, due to the fact that the questionnaire was filled out anonymously and through the internet, people are able to fill out this questionnaire more than once. However, we tried to control this by limiting the number of participants and also asking for their nationality in the questionnaire. Even with the bias mentioned, we still believe that this approach of analysis delivers new and important information regarding the smoking-related behaviours and risk factors which can help smoking cessation among Saudis. This is because people not having to disclose their identity encourages them to reveal their true beliefs about this matter, which helps in gathering more truthful information regarding this stigmatic issue.

Smoking behaviour is increasing with a 39% of the sample, but the number of ex-smokers is also high with a 22% of the sample. However, too many differentiations were revealed here by this comparison between our samples of current smokers and ex-smokers. Concerning the number of cigarettes, individuals who consumed lower numbers of cigarettes smoked formed the higher percentage of ex-smokers. In addition, this study showed expected results regarding the smoking history. Likewise, ex-smokers were smoking less number of times, such as smoking in specific occasions. Further, the major finding of this study is that religious and social factors were the major motives for Saudi smokers to quit. Nevertheless, financial reasons did not play a major effect in the quitting decision. This comes to us as no surprise, especially that it was previously demonstrated that the price of cigarette in the Kingdom must be at least tripled to make smokers quit.[20]

Moreover, quitting was not influenced by gender, income or age at onset of smoking. Interestingly, we have found that individuals with higher level of education were less likely to quit. We were surprised to find that older individuals were more likely to quit. Despite the fact that we found that the majority of ex-smokers (78%) were aged <30, the association between quitting and younger age did not hold true once we conducted the multivariate analysis. The fact that older individuals were more likely to quit can be explained by confounding. Indeed, the effect of age on quitting was confounded by other factors such as number of cigarettes smoked which had more effect and masked the effect of age. It is also important to note that smoking among females is much less compared to Saudi males, where only 62 females are current smokers compared to 746 males who do so. We believe that this is due to the stigma of smoking among female citizens and the shame associated with it. It is also relevant to say that the pressures of family and society are the main reasons for women to not smoke, whereas for female ex-smokers, health issue was the main reason to quit smoking.

Limitations

The results of this study should be interpreted bearing in mind its limitations. The questionnaire that we developed still needs to be validated. Future analysis with more variables to assess the quitting behaviours among Saudi smokers is also needed. Smokers in the Arab countries tend also to smoke water pipe, an increasingly growing habit among people of all ages. Hence, studies addressing all types of smoking are also needed for this population.


  Conclusion Top


Compared to previously published studies on smoking in Saudi Arabia, here we have looked at quitting from a broader perspective, analysing different categories of the Saudi population. Social, religious and health reasons must be emphasised by counsellors assisting Saudi smokers to quit.

Acknowledgement

The authors would like to thank Prof. Ali H. Hajeer for his supervision of this student research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3]


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