|Year : 2017 | Volume
| Issue : 1 | Page : 35-41
Knowledge, attitude and practice of tobacco smoking among health colleges' students at Najran University, Saudi Arabia: A cross-sectional descriptive study
Jobran Miree AlQahtani
Department of Pediatrics, College of Medicine, Najran University, Najran, Kingdom of Saudi Arabia
|Date of Web Publication||20-Jan-2017|
Jobran Miree AlQahtani
Department of Pediatrics, College of Medicine, Najran University, Najran
Kingdom of Saudi Arabia
Objectives: To assess the prevalence of tobacco smoking among health colleges' students at Najran University, and to investigate the students' attitude, practice and knowledge towards smoking and its risks.
Settings and Design: A cross-sectional descriptive study was conducted at Najran University during the month of March 2014.
Subjects and Methods: A pre-tested validated questionnaire based on the Global Adult Tobacco Survey was answered by 433 students (226 males and 207 females).
Results: The prevalence of current cigarettes smokers was 30.1% for males and 0.5% for females (P < 0.001). For males, the prevalence of shisha smoking, snuff and smokeless tobacco usage was 28.3%, 16.8% and 14.6%, respectively. Applied medical sciences college's students had the highest prevalence (72%) of smoking, compared to 4% only at the college of medicine. Females had a better knowledge than males regarding the hazardous effects of smoking on health (87.1% vs. 99.5%; P = 0.007) and as a risk factor of brain thrombosis (67.2% vs. 94.2%; P = 0.001), heart attack (78.3% vs. 95.7%; P = 0.005) and lung cancer (82.3% vs. 99.5%; P = 0.001). Male and female students believed smokeless tobacco and shisha smoking are less harmful (59.7% vs. 30%; P = 0.001 and 38.5% vs. 7.7%; P = 0.001, respectively).
Conclusions: Our results highlight the importance of initiating on-campus managed tobacco dependence treatment clinics to provide professional help for students to quit smoking. The results of this study can be used as a basis for the development of tobacco education programmes at Najran University and elsewhere.
Keywords: Cigarettes, health colleges, Najran, shisha, snuff, tobacco
|How to cite this article:|
AlQahtani JM. Knowledge, attitude and practice of tobacco smoking among health colleges' students at Najran University, Saudi Arabia: A cross-sectional descriptive study. J Health Spec 2017;5:35-41
|How to cite this URL:|
AlQahtani JM. Knowledge, attitude and practice of tobacco smoking among health colleges' students at Najran University, Saudi Arabia: A cross-sectional descriptive study. J Health Spec [serial online] 2017 [cited 2019 Aug 25];5:35-41. Available from: http://www.thejhs.org/text.asp?2017/5/1/35/198801
| Introduction|| |
Smoking is a leading cause of preventable morbidity and mortality worldwide. The harmful consequences of smoking on health have been well documented. Data from recent studies have confirmed the quantitative relationship between smoking and many diseases such as coronary artery disease, lung cancer, bladder cancer, oral cancer, pulmonary emphysema and chronic bronchiolitis., Smoking is very harmful to pregnant women and to their babies whether as an active, or as a second-hand (passive) smoking, leading to stillbirth, low birth weight, congenital anomalies and contribute significantly to respiratory tract infections in infants.
The World Health Organization (WHO) has estimated that five million deaths occur annually due to tobacco use. This number of deaths is expected to reach more than eight million by the year 2030, with most of the tobacco-related morbidity and mortality occurring disproportionately in low- and middle-income countries. In Saudi Arabia, the prevalence of smoking has been reported to be as high as 52.3%, and among school and university students, it has reached an alarming rate of 30% and 50%, respectively.,,, Furthermore, tobacco consumption rates in Saudi Arabia have risen from 21.9% of males and 0.6% of females in 1996 to 37% of males and 6% of females in 2012. More recent study, though it gave a lower rate of smoking among medical students, it still alarming rates, and more seriously, a hidden problem in such a conservative culture.
Healthcare professionals (HCPs) are in an ideal position to advise and educate patients about the dangers of smoking. Moreover, they act as visible role models and may unintentionally affect the smoking behaviour of others. The WHO Framework Convention on Tobacco Control emphasises on the role of professional healthcare providers and organisations in reducing tobacco consumption. The WHO encourages HCPs, including physicians, dentists, nurses and pharmacists, to take a leadership role in reducing the use of tobacco. As one can assume many personal smoking behaviours and beliefs of HCPs are formed during their university education. Therefore, any successful tobacco control measures within the medical profession will need to begin before graduation from health colleges., Investigation of the proficiency of health colleges' students in controlling tobacco smoking and the impact of medical education on their knowledge and attitude about tobacco smoking have demonstrated that health college' students as future HCPs, educators and researchers are in a key position to influence future tobacco cessation and control programmes in Saudi Arabia as it is elsewhere.,, Unfortunately, only a few studies investigated smoking prevalence and patterns among health colleges' students in Saudi Arabia and most of which were directed to study medical or dental students only.,,,,, Moreover, some studies did not investigate female students.
The Najran region is located in the southwest of Saudi Arabia along the border with neighbouring Yemen. The University of Najran consists of 15 and 10 colleges for males and females, respectively, with overall of 25 thousands students registered for the time being. As a newly established university, we have only male and female students at the college of medicine, and at Radiological Science Department. In the rest of health specialities, we have male or female students only, which were reflected on the samples obtained.
The objectives of this study were to assess the prevalence of tobacco smoking among male and female students in different health colleges at Najran University, and to investigate students' attitude, practice and knowledge towards the risk factors of smoking.
| Subjects and Methods|| |
A cross-sectional descriptive study was conducted at Najran University. The study population included male and female students enrolled in health colleges of Medicine, Dentistry, Pharmacy, Applied Medical Sciences and Nursing, during the month of March 2014. The sample size was calculated by Epi Info (WHO, Geneva, Switzerland) based on a prevalence of 30% of smoking among students in a previous study  and a worst expected frequency of ±3% at a confidence level of 95%. Accordingly, the minimum required sample size was 420 students. Taking into consideration, a non-response rate of about 15%, the final sample size was estimated as 480 students, selected by a multistage stratified random sampling technique with proportional allocation.
Data were collected using a pre-tested validated questionnaire based on the Global Adult Tobacco Survey. This aims to assess main issues related to tobacco consumption, which has been developed and validated by the collaboration of Centers for Disease Control and Prevention (CDC), WHO and CDC Foundations. The questionnaire was written in English and contained questions about demographic details (age in years, college, academic year, marital status, current and permanent residence, living with parents or not), smoking behaviour (use of cigarettes or shisha), smoking habits among families, duration and frequency of smoking (daily cigarette or shisha consumption), general knowledge of the consequences of smoking and whether they had thought about quitting smoking as well as reasons for quitting (if at all). The final form of the questionnaire was field tested on twenty students from the medical college who were not part of the sample. Then, the questionnaires were distributed to the students, after informed consent obtained from every participant. Students were given 15 - 20 min to answer the questionnaire, while the class instructor was outside the lecture halls to ensure that students completed the questionnaire unaided and to ensure confidentiality. The questionnaires were distributed and collected by medical students as they were known and trusted by their colleagues. Ethical approval was obtained from Najran University Research Ethics Committee, as well as administrative approval in different college departments before the commencement of the study.
Values were expressed as percentages for discrete variables or as mean and standard deviation (SD) for continuous variables. The socioeconomic score index (mean ± SD) was calculated for male and female students as previously reported  on the basis of students' response to several questions (the financial income of the family, living in rented or owner-occupied housing, self-perceived financial situation, the ratio of number of people to the number of rooms in the household, father and mother level of education and self-possessions of car, DSL, laptop, home pool, electric gangway and table tennis). Differences in variables of smoking knowledge were compared using the Chi-square, or the Student's t-test, or Fisher's exact test, as appropriate. Statistical significance was defined as P < 0.05. All analyses were performed with the Statistical Package for the Social Sciences (SPSS), Version 15.0 (SPSS Inc., Chicago, IL, USA).
| Results|| |
A total of 433 of 480 students completed and returned the questionnaire, yielding an overall response rate of 90.2%. Among the respondents, 226 were males (mean age: 22.6 ± 1.7) and 207 were females (mean age: 23.6 ± 2.4). The distribution of the respondents among different health colleges and departments is presented in [Figure 1]. The sociodemographic characteristics of the participants are listed in [Table 1].
|Figure 1: Distribution of the students by health colleges and departments.|
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In this study, 204 of 433 students used different tobacco forms (cigarettes, shisha, snuff and smokeless tobacco) yielding an overall tobacco use prevalence of 47.1%. The prevalence of female current cigarettes smokers was 0.5% (one student at the radiology department). The prevalence and patterns of tobacco use among male students are listed in [Table 2]. The prevalence of current cigarettes smokers was 30.1%. The students at the college of applied medical sciences had the highest prevalence of smoking (34% for laboratory sciences, 20% for physiotherapy and 18% for radiology) compared with those at colleges of pharmacy (15%) and dentistry (9%), whereas the lowest prevalence (4%) was at the college of medicine. The majority (69%) smoked 10 cigarettes or less per day. Among the current smokers, 72% had tried quitting for personal reasons (69%) or family advice (20%). The prevalence of shisha smoking among male students was 28.3%. The majority (84%) of them smoked shisha for hours (range: 1 - 4 h, mean: 2 ± 1.6). Nearly two-thirds of the shisha users smoked at coffee shops. The percentages of smokers who used other forms of tobacco products were 16.8% for snuff and 14.6% for smokeless tobacco.
The student's knowledge and attitude about tobacco use are shown in [Table 3]. The majority of the students were well aware that smoking causes dangerous diseases. However, female students had better knowledge than male students with a significant difference regarding the knowledge that smoking causes dangerous diseases (87.1% vs. 99.5%; P = 0.007), and as a risk factor of brain thrombosis (67.2% vs. 94.2%; P = 0.001), heart attack (78.3% vs. 95.7%; P = 0.005) and lung cancer (82.3% vs. 99.5%; P = 0.001). Moreover, male students compared to female students believed smokeless tobacco (59.7% vs. 30%; P < 0.001) and shisha smoking (38.5% vs. 7.7%; P < 0.001) are less harmful. In addition, male students recognised tobacco smoking, and smoking shisha as types of addiction less than the female students did (65.9% vs. 77.3%; P < 0.001, and (54.8% vs. 74.4%; P = 0.003, respectively).
|Table 3: Comparison of tobacco use knowledge between male and female students|
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| Discussion|| |
The data of tobacco use prevalence among the youth are important to assess tobacco as a risk factor for serious health problems, and to establish control measures for prevention of tobacco-related diseases. The prevalence of current cigarettes smokers among male students in this study (37.1%) was higher than that reported in some previous Saudi studies, which found values ranging from 14% to 21.6%.,,, However, in a recent study, the prevalence of current smokers was 30.9% among 337 male students at three Saudi universities. Data from Middle Eastern countries revealed prevalence rates of 34.8% in Kuwait, 31.5% in Morocco, 26.3% in Lebanon, 26.1% in Syrian Arab Republic  and 22.1% in Turkey.
Our results showed that the prevalence of smoking varied among students at different health colleges, which is consistent with previous studies in Saudi Arabia and other countries.,,, Not surprisingly, we found higher rates of smoking by non-medical students than medical students. This means more attention needs to be given to them in programmes of prevention and controlling tobacco smoking. Although the prevalence of smoking was lower among medical students, this finding should be interpreted with caution, due to the influence that future physicians will have on the community. The WHO is encouraging HCPs to provide patients with information about the health consequences of smoking, to help patients to quit smoking and to act as role models who promote tobacco-free lifestyles., It was found that non-smoking physicians are more likely to provide a systematic counselling to patients about smoking cessation, and generally hold strong beliefs about the adverse effects of tobacco use. Conversely, even a small number of smoking physicians in a population that serves as a role model can have a negative effect on smoking control programmes, especially on strategies for prevention and smoking cessation.,
The prevalence of female smokers in this study (0.5%) was the lowest among many previous Saudi studies, which found values ranging from 0.5% to 16% with a median of 9%.,,,, This finding may be related to culture and social issues in Saudi Arabia, where there is a strict observation conducted over females, and most of Saudis consider female smoking as social stigma. Our result is congruent with many previous reports from Arab and some Mediterranean countries, in which smoking behaviours are more prevalent among males than females, where female smoking is an unacceptable social behaviour.,, In addition, the conservative Bedouin society may be considered an additional important factor in Najran region.
Previous reports showed that the proportion of smoking increases with age, and adolescents who start to smoke early are more likely to continue smoking as adults. The prevalence of smokers found in our study population in the ages up to 16 years was lower than that reported in other Saudi studies (32.3% vs. 66.5 - 83.7%), whereas at the ages of 16 - 19 years, the corresponding prevalence was higher in our study (47.1% vs. 33.5 - 41%),,, thus possibly indicating a selective subpopulation among all participants. In our study, the crucial time for initiation of smoking among students seems to be the 1st year of university education. Actually, one would expect that with each year of health sciences education, more students would realise the adverse effects of smoking not only on their own health but also on the health of people they have to care for. It was found that medical education does not have preventative effects or rather does not influence the antismoking attitudes and behaviours of the students. A complex set of reasons is implicated in this paradox, which requires further exploration.,
In this study, almost 70% of current smokers reported smoking 10 cigarettes or less per day, and about half of all smokers indicated that they consume their first cigarette 1 h or more after waking up in the morning. These tobacco use patterns suggest a low level of nicotine dependence.
The shisha form of tobacco use, other than cigarettes, is the most commonly used smoking practice across the globe including Saudi Arabia. In our study, the prevalence of current shisha smokers (28.3%) was consistent with that reported in previous Saudi studies (4.5 - 43.6%).,,,,, Many people consider that shisha smoking is less harmful than cigarettes because they believe that the water filters out harmful substances. In our study, 75% of the students claimed that shisha smoking is less dangerous. In fact, shisha smoking may be more damaging since the level of plasma nicotine resulting from smoking one water pipe was found to be 20% higher than the level of plasma nicotine resulting from smoking 21 cigarettes. Therefore, shisha smoking may bear larger risks to health. These findings strongly imply that tobacco control programmes must address all other forms of tobacco consumption, in addition to cigarette smoking.
The HCPs can play an important role in reducing tobacco use among the general population if they are knowledgeable about the hazards of tobacco use and are well trained in delivering effective tobacco intervention strategies. In this study, all students had good knowledge that cigarette smoking is associated with health problems, but female students were significantly superior to male students, regarding the hazards of smoking, and its association with comorbidities as well as danger of other tobacco forms. Many previous studies showed that cigarette smoking was prevalent among health-related college students despite their knowledge and realisation of its dangerous effects on the human bodies.,,,,, Kawakami reported that the knowledge of the harmful effects of smoking and intention to perform smoking intervention in the future doctors seemed unsatisfactory among medical students. In fact, the undergraduate years provide a perfect opportunity for making medical students fully aware of the harmful effects of smoking. Therefore, it is of paramount importance to design a more comprehensive approach for tobacco dependence education in the curricula of all health colleges including clinical training and experience for the students in helping their patients to quit tobacco., It is noteworthy that the policymakers should support the development of prevention and treatment programmes for tobacco-using students, and to encourage undergraduate students to actively participate in these programmes.
This study had some limitations. First, the data are based on self-reporting by the students. Although anonymity was guaranteed for data collection, smoking is socially unacceptable in the Saudi Arabian community. Therefore, under-reporting and may be over-reporting, could not be ruled out. Second, smoking habits and related risk factors among the students were determined using self-administrated questionnaire without physiological or biochemical measurements of nicotine levels or expired carbon monoxide to confirm tobacco use. Finally, the study was conducted in one institution in the South-western region, and although the results were compared with the results from institutions in other Saudi regions, a national multicentre study would be more representative and valuable.
| Conclusions|| |
The prevalence of cigarettes and shisha smoking among male students in health colleges is high and alarming. Female students had better knowledge of tobacco harms and expressed greater antitobacco attitudes compared to males. Our results highlight the importance of initiating special on-campus tobacco dependence treatment clinics to provide professional help for students to quit cigarettes smoking. In addition, an emphasis on prevention of shisha smoking should not be forgotten. On the other hand, the results of this study can be used as a basis for enhancing the capacity to develop and implement tobacco education programmes and training in smoking cessation techniques into the curricula of health.
The author would thank Dr. Mervat H. Hasanin and Dr. Nahla K. Al-Feky, Community Medicine Department, for their help in conducting the survey in female health colleges. My special thanks for Prof. Ahmed M. Asaad, the scientific assistant of the chair. This work was supported by a grant from Prince Mishaal bin Abdullah bin Abdulaziz Chair, for Endemic Diseases, Najran University.
Financial support and sponsorship
This work was supported by a grant from Prince Mishaal bin Abdullah bin Abdulaziz Chair, for Endemic Diseases, Najran University.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]