SMOKING HABITS OF KING SAUD UNIVERSITY STUDENTS IN ABHA, SAUDI ARABIA

SMOKING HABITS OF KING SAUD UNIVERSITY STUDENTS IN ABHA, SAUDI ARABIA Mostafa A. Abolfotouh, DrPH; Mostafa Abdel Aziz, MD; Wole Alakija, MD; Abdullah Al-Safy, PhD; Majed S. Khattab, MD; Soleiman Mirdad, MD; AbdulRahman Al-Juhani, PhD; Mohammed Al-Humaidi, MD Background: The aim of this study was to estimate the prevalence of smoking among university students of King Saud University in Abha City, to determine ecological factors for the problem, and to assess the students knowledge about the health effects of smoking, and attitudes towards public action against smoking. Materials and Methods: All medical students at the University College of Medicine () (n=202), and a representative sample of students of the College of Education () (n=300), were subjected to a modified Arabic version of the World Health Organization standard questionnaire for young people to study their knowledge, attitudes and practices of smoking. Results: The study revealed the following results among students of the and those of the, respectively. Prevalence of regular smoking (17.5% vs. 13.6%; P=0.25); heavy smokers (39.5% vs. 27.8%; P=0.38); smokers of moderate- to high-nicotine yield (92.7% vs. 50%, P=0.0004), and tar yield (48.8% vs. 16.7%, P=0.02). Curiosity was the main reason for initiation of smoking (41.2% vs. 51.9%), followed by the desire to show off (27.5% vs. 51.9%, P=0.03), and peer pressure (27.5% vs. 7.4%, P=0.04). Friends were the main source of the first cigarette (53.1% vs. 55.6%), followed by parents (2% vs. 40.7%, P=0.0001). Most students were knowledgeable about smoking and had favorable attitudes against it. However, students were significantly more knowledgeable than those of the. Conclusion: Smoking still constitutes a major problem among university students in Abha, in spite of their knowledge of its hazards. This may be due to the addictive effect of smoking, peer pressure, negative parental attitudes and other reasons. There is a need to implement an anti-smoking program for college students, and possibly legislation to limit the amount of tar and nicotine in cigarettes. Ann Saudi Med 1998;18(3):212-216. Key words: Smoking prevalence and habits. Smoking is a major worldwide public health problem. It is now by far the largest preventable cause of death in the industrialized world. 1 Although there is a health warning on every packet of cigarettes indicating that smoking is the main cause of lung cancer, lung diseases and of heart and artery diseases, and in spite of the anti-smoking clinics distributed all over the Kingdom, smoking in Saudi Arabia is increasing rapidly, particularly among the young, partly due to aggressive marketing by tobacco companies. 2 The aim of this study was to examine the problem of smoking among university students of the College of Education () and those of the Medical College () at the Abha branch of King Saud University, who will in the near future become doctors and teachers and will, therefore, have the professional responsibility of setting an From the Colleges of Medicine and Education, King Saud University, Abha, Saudi Arabia. Address reprint requests and correspondence to Dr. Abolfotouh: Family and Community Medicine, College of Medicine, King Saud University, P.O. Box 641, Abha, Saudi Arabia. Accepted for publication 24 February 1998. Received 9 October 1997. example to the public at large in promoting anti-smoking campaigns. Our aim was achieved through: 1) determination of the prevalence of regular smoking; 2) determination of some ecological factors for the problem in terms of age of and reasons for initiation, source of the first cigarette, type of smoker, type of cigarettes, and smoking environment; and 3) determination of the levels of knowledge about the health effects of smoking and attitudes towards public action against smoking. Materials and Methods The total number of students at the time of the study was 2419. The sample size was obtained by using the prevalence of smoking in the control group as 0.20 and the prevalence of smoking in the study group as 0.28, with a 5% level of significance. The calculated sample size was 288.46, and so a sample size of 300 students was decided on, representing 12% of all students. Applying the stratified random sampling technique, 12% of students were chosen out of each educational level in each 212 Annals of Saudi Medicine, Vol 18, No 3, 1998

SMOKING HABITS IN ABHA department of the College. Of these, 291 students responded, giving a response rate of 97%. All medical students of the at the time of study (n = 202) were included, with 198 students responding (response rate = 98%). Technique All students of the study sample were given a modified Arabic version of the World Health Organization (WHO) standard questionnaire for young people. 3 The estimated reliability co-efficient of the modified questionnaire was more than 90. It was grouped under three major areas: 1) Smoking behavior: smokers were classified into daily, weekly and experimental smokers, as recommended by WHO. 3 For estimating the prevalence rate of smoking, we took into account daily and weekly smokers, who constituted together the regular smokers. Detailed information was collected from smokers relating to their smoking behavior, such as age of starting, reasons, future intention, the smoking environment and lastly, the brand of cigarettes smoked. Cigarettes were classified according to the amount of tar and nicotine present in each cigarette. The amount of tar was classified after Omar et al. 4 into very low tar yield (<5 mg/cig.); low (5-9.9 mg/cig.); moderate (10-14.9 mg/cig.); and high (15-19.0 mg/cig.). The amount of nicotine was classified after Maron and Fortman 5 into ultra low nicotine yield (<0.21 mg/cig.); low (0.21-0.60 mg/cig.); medium (>0.60-1.0 mg/cig.); and high (>1.0 mg/cig.). 2) Knowledge about the harmful effects of smoking: this area of the questionnaire comprised eleven factual questions about the negative effects of smoking on students health and the health of others. Using the three response scale, students were requested to give true, false or do not know response to all questions. One point was given for a correct answer and zero for an incorrect one. The total score ranged from 0-11 points. The level of knowledge was considered good on attaining 9 or more points, average on attaining 7-8 points, and poor on attaining <7 points. 3) Attitudes towards public action against smoking. This area comprised nine attitudinal questions to evaluate student attitudes and beliefs towards public measures against smoking. Using a four-response scale, students were requested to choose the response of strongly agree, agree, disagree or strongly disagree for all questions. For assessing the attitude of students, a scoring system was applied: the negative attitude statements were scored from 0-3 as follows: 0 was given to those who strongly agreed, 1 to those who agreed, 2 to those who disagreed, and 3 to those who strongly disagreed, and the reverse of this scoring system was used for the positive attitude statements. Accordingly, maximum total score for attitude questions was equal to 27 (9 statements x 3 points = 27), and minimum total score was equal to 0 (9 statements x 0 point = 0). For every student, the percentage of attitude TABLE 1. Type and prevalence of smoking behavior among male university students in Abha, Saudi Arabia. Type College of Education (n=291) Medical College (n=198) Daily 46 (88.5%) 21 (72.4%) Weekly 5 (9.6%) 6 (20.7%) Experimental 1 (1.9%) 2 (6.9%) # of smokers 52 (100%) 29 (100%) Prevalence * 17.5% 13.6% * Prevalence was calculated based upon regular smokers (daily and weekly smokers). TABLE 2. Type of smoking among male university students in Abha. Type of smoking College of Education (n=51) Medical College (n=27) Cigarette 43 (84.3%) 19 (70.4%) Sheesha 20 (39.6%) 14 (51.9%) Cigar 2 (3.9%) 1 (3.7%) was calculated as follows: % attitude = (sum of the score of attitude / 27x100). Thus, the students were classified according to % attitude as follows: <30%, strongly negative attitude; 30% to <65%, negative attitude; 65% to <85%, positive attitude; and >85%, strongly positive attitude. All questions were completed anonymously. The questionnaire was completed by the students in 20-30 minutes, while the class instructor was outside the teaching room to ensure that students completed the questionnaire unaided and to ensure confidentiality. Data Analysis There were a number of missing responses for some items of the questionnaire. Only questionnaires with two or fewer missing responses were considered satisfactory and represented the sample upon which all analyses were based. Data was analyzed by comparing the students of the College of Education with those of the College of Medicine, using the Pearson chi-squared test (with Yates correction when needed), chi-squared test for linear trend, z-test, and Student s t-test (two-tailed). P-value greater than 0.05 was considered statistically significant. Results Prevalence of Smoking The results showed that regular smoking has a prevalence rate of 17.5% and 13.6% among students of the and, respectively (X 2 =1.33, P=0.25). Daily smokers constituted 88.5% and 72.4% of both groups, respectively (Table 1). Cigarette smoking ranked first for both groups of students (84.3% and 70.4%), followed by the sheesha (the traditional Arabic smoking pipe) (39.6% and 51.9%), while cigar ranked last (3.9% and 3.7%) (Table 2). Practice of Smoking Annals of Saudi Medicine, Vol 18, No 3, 1998 213

ABOLFOTOUH ET AL Table 3 shows the distribution of regular smokers according to their smoking practices. 1) Type of smoker: About 40% and 28% of current smokers of the and, respectively, were heavy smokers (P=0.38). Light smokers constituted about 23% and 39% of such groups (P=0.21). 2) Type of cigarette: About half of the smokers of the (48.8%) smoke moderate tar yield cigarettes, compared to only 16.7% of smokers of the ( X 2 =5.42, P=0.02). Cigarettes of moderate- and high-nicotine yield were smoked by more than 90% of smokers of the, compared to only 50% of those of the ( X 2 =12.67%, P=0.0004). 3) Favorite smoking place: Three-quarters of smokers enjoy smoking with their friends outside home and college, while home was the favorite environment for 40.7% of smokers (X 2 =6.0; P=0.05). Initiation of Smoking Current smokers were distributed according to the following factors relating to the initiation of smoking: 1) Age of first cigarette: Students who started smoking at/or above the age of 18 years constituted significantly higher proportions of smokers among students than those of the (72% vs. 46.8%; X 2 =4.19, P=0.04). However, the mean age of initiation was not different between the two groups (t=1.09, P=0.14). 2) Source of first cigarette smoked: Friends were the source of the first cigarette smoked for more than half of current smokers of both groups of students (53.1% and 55.6%). Although parents were the least frequent source for supply of the first cigarette to smokers of the (2%), 40.7% of smokers of the were given the first cigarette by their parents (X 2 =18.81, P=0.0001). 3) Reasons for smoking the first cigarette: Curiosity was the main reason for initiation of smoking among students of the (41.2%) and (51.9%). The effect of peer pressure was reported by 27.5% of students compared to only 7.4% of those of the (X 2 =4.35, P=0.04). On the other hand, the desire to show off was mentioned as a reason for initiating smoking by 51.9% of smokers, compared to only 27.5% of those of the ( X 2 =4.57, P=0.03). Beliefs About Smoking Table 4 shows the distribution of regular smokers according to their beliefs about smoking. 1) Possible advantages of smoking: More than half of smokers (57.7%) and more that one-third of smokers (35.3%) reported that smoking calms them down. About 22% and 23% of and smokers, respectively, reported that smoking helps them to concentrate. However, those who reported that smoking has no advantages constituted 27.5% of smokers, as compared to only 7.7% of smokers (X 2 =3.92, P=0.05). 2) Attempts to stop smoking: Previous attempts to stop smoking were reported by three-quarters of smokers and half of the smokers (X 2 =2.89; P=0.09). TABLE 3. Distribution of current smokers according to smoking practices among university students in Abha. Statistical difference Smoking practices X 2* P Type of smoker Light ( 10 cig./day) Moderate (11-20 cig./day) Heavy (>20 cig./day) Type of cigarette Tar yield: Very low Low Moderate High Nicotine yield: Very low Low Moderate High Favorite place for smoking Colleges Home Other 10 (23.3%) 16 (37.2%) 17 (39.5%) 43 (100%) 3 (7.3%) 18 (43.9%) 20 (48.8%) 3 (7.3%) 38 (92.7%) 41 (100%) 3 (5.9%) 9 (17.6%) 39 (76.5%) 51 (100%) 7 (38.9%) 5 (27.8%) 18 (100%) 7 (38.9%) 8 (44.4%) 18 (100%) 1.54 0.76 5.42 12.67 0.21 0.38 0.02 ** 0.0004 ** 11 (40.7%) 16 (59.3%) 27 (100%) 6.0 0.05 ** * Pearson chi-squared test was applied; ** statistically significant difference at 0.05 level of significance. TABLE 4. Distribution of current smokers according to their beliefs about smoking among university students in Abha. Statistical difference Beliefs and behavior X 2* P Advantages Helps me to concentrate Calms me down Helps me to sleep Other Has no advantage Attempted to stop Yes No Intention to stop in the future Yes No 10 (21.6%) 17 (35.3%) 1 (2%) 7 (3.6%) 13 (27.5%) 48 (100%) 33 (75%) 11 (25%) 44 (100%) 39 (81.3%) 9 (18.8%) 48 (100%) 6 (23.1%) 15 (57.7%) 1 (3.8%) 2 (7.7%) 2 (7.7%) 26 (100%) 15 (55.6%) 12 (44.4%) 27 (100%) 17 (63%) 10 (37%) 27 (100%) 3.41 3.92 0.06 0.005 ** 2. 89 0.09 3.93 0.05 ** * Pearson chi-squared test was applied; ** statistically significant difference at 0.05 level of significance. 3) Future intention to stop smoking: About 81% of smokers reported that they intend to stop smoking, as compared to 63% of smokers ( X 2 =3.93, P=0.05). Knowledge About Health Effects of Smoking Table 5 shows the distribution of students of the and according to their smoking behavior and level of knowledge about the health effects of smoking. students were significantly more knowledgeable than those 214 Annals of Saudi Medicine, Vol 18, No 3, 1998

SMOKING HABITS IN ABHA of the, with 73.2% of students showing good knowledge, compared to 60.5% of students ( X 2 =6.8, P=0.009). However, such difference was evident among the non-smokers (X 2 =7.68, P=0.006) but not among the smokers (X 2 =0.01, P=0.93). Generally speaking, nonsmokers were more knowledgeable than smokers in both groups of students. Attitudes Towards Public Action Against Smoking Most students of both groups showed either positive or strongly positive attitudes towards public action against smoking (about 86% of each group). However, smokers showed less positive attitude than did non-smokers, especially smokers of the, who showed a significantly smaller proportion of students with positive attitudes than did smokers of the (about 25% vs. 59%, P=0.0004). Discussion In this study, the prevalence rates of regular smoking among male university students of both the College of Education () and the Medical College () at the Abha branch of King Saud University are 17.5% and 13.6%, respectively, with a higher prevalence among students of the. Such prevalences are generally much lower than the prevalences of 37% and 33% among the corresponding students of the same university in Riyadh, 6,7 and even significantly lower than the prevalence in nearby countries such as Jordan. 8 This may be due to the fact that Abha, the capital city of the Asir region, is less urbanized and people in the Asir region constitute a traditional society where smoking is an unacceptable social habit. Students in Abha also initiated smoking at a later age when compared to students from other areas, 6-9 a finding that emphasizes that antismoking programs such as those recommended for schoolchildren 6,7,10 need to be tailored for university students in the Asir region. Although cigarettes were used by most smokers in both groups of students, sheesha, although relatively unpopular among educated people, was smoked by many regular smokers, being common in the Western region of the Kingdom. Curiosity about smoking was the reason given by most of the current smokers of both groups for trying their first cigarette. This finding was similar to those reported by many others. 11-13 The data of this study reveal that most of the university students of both groups have good knowledge about the harmful effects of smoking, with some differences between the groups of students. Medical students were significantly more knowledgeable than students of the, which can probably be attributed to the positive impact of the medical information available to medical students. In a previous study of secondary school students in the Asir region, we revealed that Science students were more knowledgeable about the effects of smoking than Arts students, and attributed that finding to the fact that they knew more about the physiology and pathophysiology of the human body. However, the possible positive impact of this TABLE 5. Distribution of university students in Abha according to knowledge about health effects of smoking and their smoking behavior. Level of knowledge (%) Statistical difference Smoking behavior Poor Average Good X 2* P Smoker Non-smoker 9 (18) 4 (14.8) 13 (5.4) 7 (4.1) 22 (7.5) 11 (5.6) 22 (44) 14 (51.9) 71 (29.5) 28 (16.4) 93 (32) 42 (21.2) 19 (38) 9 (33.3) 0.01 0.93 50 (100) 27 (100) 7.68 0.006 ** 157 (65.1) 241 (100) 136 (79.5) 171 (100) 176 (60.5) 291 (100) 6.8 0.009 ** 145 (73.2) 198 (100) * Chi-squared test for linear trend was applied; ** statistically significant difference at 0.05 level of significance. knowledge was evident only among non-smoking medical students. This might be explained by the fact that student smokers more often have friends and family members who smoke and therefore engage in risk-taking behavior more often than non-smokers. 14 The data of the present study show also that most of these university students have favorable attitudes towards public measures against smoking. However, despite their access to medical information on the hazards of smoking, medical student smokers had a strongly negative attitude to these public measures, a finding that could explain the lower proportion of smokers who reported previous attempts to quit, and the lower proportion who reported a future intention to stop smoking. This reflects the inadequacy of the medical curriculum in changing the attitude of students towards smoking, and the need to stress efforts in this direction. The question that arises is why smoking is still a sizeable problem among these students in spite of their knowledge of and attitudes against smoking. There must be some barriers against the acquisition of healthy behavior, as is shown by failed attempts to quit smoking by many of the smokers. One such barrier may be the addictive effect of the moderate- and high-nicotine yield cigarettes smoked by many of students, especially those of the, although the Gulf Cooperation Council 15 has introduced legislation to limit the amount of tar and nicotine in cigarettes to 10 mg and 0.6 mg, respectively. Other barriers might be the effects of peer pressure, 9,16,17 especially among students of the, who prefer to smoke with friends outside home and college, as well as the possible negative attitudes of parents, 18 who were the main source of the first cigarette for 40% of medical students. Moreover, incorrect beliefs about the possible advantages of smoking 12,19 might add to such barriers. For instance, Annals of Saudi Medicine, Vol 18, No 3, 1998 215

ABOLFOTOUH ET AL many smokers in the present study reported the fact that smoking calmed them down. Conclusion Even though students of the Abha branch of King Saud University have a sound knowledge of the harmful effects of smoking, and a generally favorable attitude towards public measures against the habit, smoking still constitutes a sizeable problem among them, possibly due to the addictive effect of nicotine, peer pressure, negative parental attitudes and other factors. Thus, legislation introduced by the members of the Gulf Cooperation Council to limit the amount of tar and nicotine in cigarettes must be implemented in order to reduce the high proportion of those who smoke high-tar and nicotine-yield cigarettes. An anti-smoking education program needs to be tailored to university students in the Abha area and college curriculae must have a role in such programs. References 1. Jacobson B. Smoking and health: a new generation of campaigners. Br Med J 1983;287:483-4. 2. Anonymous. Health or smoking (editorial). Br Med J 1983;287:1570-1. 3. Guidelines for the conduct of tobacco smoking surveys of general population. Report of a WHO meeting held in Helsinki, Finland, 29 November - 4 December 1982. WHO/SMO/83.4. 4. Omar SH, Hussein M, Ebeid N, El Aaser A, Galal A. Prevention of the smoking epidemic in a developing country, Egypt. Armed Forces Med J 1984;27:138. 5. Maron DJ, Fortman STP. Nicotine yield and measures of cigarette smoke exposure in a large population. Are lower yield cigarettes safer? Am J Publ Hlth 1987;77:446. 6. Taha A, Bener A, Noah MS, Saeed A, Al-Harthy S. Smoking habits of King Saud University students in Riyadh. Ann Saudi Med 1991;11:141-3. 7. Jarallah JS. Smoking habits of medical students at King Saud University, Riyadh. Saudi Med J 1992;13:510-3. 8. Awidi AS. Patterns of cigarette smoking in Jordan: a study of the greater Amman area. Ann Saudi Med 1991;11:144-7. 9. Abed JSM, Al-Dabbagh SA, Khalil HM, Al-Selevany BK. Cigarette smoking: epidemiology and effects on some cardiovascular parameters in medical students. Ann Coll Med Mosul 1988;14:33-9. 10. Abolfotouh MA, Abdel Aziz M, Badawi IA, Alakija W. Impact of a one-day antismoking program on male secondary school adolescents in southwestern Saudi Arabia. Am J Prev Med 1997;13:151-2. 11. McGuffin SJ. Smoking: the knowledge and behavior of young people in Northern Ireland. Health Educ J 1982;141:53. 12. Jandoo SC, Budd RY, Eiser JJ, Morgan M, Gammage P, Gray E. The Avon prevalence study: a study of cigarette smoking in secondary school children. Health Educ J 1985;45:40. 13. Tayel KH, Wasfy A, Abdelkader E, AbouRayan M, Abolfotouh M, Nofal L, et al. Problem of cigarette smoking among secondary school students in Alexandria. Bull High Inst Publ Hlth 1991;21:501-23. 14. Stone SL, Kristeller JL. Attitudes of adolescents toward smoking cessation. Am J Prev Med 1992;8:221-5. 15. Gulf Cooperation Council. Forty-third Meeting of the Council of Ministers of Health for the GCC Countries. Sanction No. 3 for the Control of Smoking, 6th May 1997, Geneva. 16. Revill J, Drury CG. An assessment of the incidence of cigarette smoking in fourth year school children and the factors leading to its establishment. Public Hlth 1980;94:243. 17. Ashton H. Patterns of smoking: social and psychological factors. Practitioner 1983;1415:23. 18. Nolte AE, Smith BJ, O Rourke T. The relative importance of parental attitudes and behaviour upon youth smoking behaviour. J Sch Hlth 1983;53:264. 19. Hardes GR, Alexander HM, Dorson AJ, Lloyd DM, Leeder SR. Cigarette smoking and drug use in school children in the Hunter Region. Med J Aust 1981;1:579. 216 Annals of Saudi Medicine, Vol 18, No 3, 1998