Cross Sectional Online Survey to Determine the Prevalence, Knowledge, Attitude and Practice of Smoking Tobacco Among Students of Medical Science College in Dammam, Saudi Arabia.

OBJECTIVES: The present study was conducted to examine the prevalence of tobacco smoking among students' of different departments of private medical science college at Dammam, as well as to assess students' attitude, practice, knowledge, and awareness towards smoking and its harmful effects.
MATERIALS AND METHODS: A cross-sectional study was performed at Mohammed Al-Mana College for Medical Sciences (MACHS) in February 2020. Data were obtained through adopted pretested validated questionnaire based on the Global Adult Tobacco Survey. The questionnaire contains demographic details, smoking behavior, knowledge, and behavior attitude toward smoking.
RESULTS: A total of 388 students completed the questionnaire out of them 108 males (27.8%) and 280 females (76.2%), the prevalence ratio of tobacco use 19.84%. The prevalence ratio of female current smokers was 7.9%, whereas male 11.8%, even though the number of female participants were high. Female students had better knowledge in comparison with male students regarding the harmful effects of tobacco smoking on health (78.7% vs. 82.8%; P ≤ 0.001), and as a risk factor of brain thrombosis (59.2% vs. 60%; P ≤ 0.001), gastric ulcer (55.5% vs. 62.1%; P ≤ 0.001), asthma (62.9% vs. 72.1%; P ≤ 0.001), and lung cancer (81.4% vs. 86.7%; P ≤ 0.001).
CONCLUSION: The prevalence of smoking tobacco was relatively low among MACHS students who had good general knowledge regarding the harmful effects of smoking tobacco. This study results showed the harmful effects of smoking and can be used as a basis for the development of tobacco education programs at MACHS and any other institution for providing professional support for students to quit smoking. Copyright:

INTRODUCTION

Cigarette smoking and other forms of tobacco use impose a large and growing global public health burden. Worldwide, tobacco use is estimated to kill about 5 million people annually, accounting for 1 in every 5 male deaths and 1 in 20 female deaths of those over the age of 30 years. On current smoking patterns, annual tobacco deaths will rise to 10 million by 2030.[12]

In Saudi Arabia, the prevalence rate of smoking has been reported 52.3%, and between school and university students range 30% and 50%, respectively.[3456] In addition, tobacco consumption rates have increased in Saudi Arabia (21.9% of males and 0.6% of females in 1996–37% of males and 6% of females in 2012).[78]

The WHO admitted that more than 7 million deaths each year, globally associated with smoking. Moreover, as per the WHO, smoking tobacco is the only legal product that causes the death of its regular users. Approximately 1.2 million nonsmokers dying from passive smoking and the overall yearly death toll is above 8 million.[910] The WHO reported that during COVID-19 pandemic many factors associated with death from noncommunicable chronic diseases including ill-condition and disability, frequently, though, tobacco smoking is one of the increased risk factors associated with death from communicable diseases. In 2018, WHO highlighted Saudi Arabia offering tobacco dependence treatment became one of the 23 best practice countries.[910]

Tobacco smoking causing lungs diseases and affects body immunity.[11] Tobacco is hazardous in any form as it affects the whole body. Tobacco smoking is associated with high-risk factor of many diseases, especially cancer and heart attacks.[12]

Health professionals educate their patients on the hazards of smoking. They usually serve as role models for their patients and the public and therefore, play an important role in discouraging people from smoking. The participation of Health professionals in prevention and cessation counseling could be part of the strategies to minimize tobacco-related deaths in the future. For health professionals to convince others, they should be nonsmokers. Health professionals including physicians, dentists, pharmacist and nurses, medical sciences students are considered a primary target of tobacco prevention programs. They can, therefore, play a positive role in preventing smoking among people in their community.[13] They may deliver health education, support anti-smoking policies, and influence national and global tobacco control efforts.[131415]

Previous studies in Saudi Arabia reported smoking prevalence majority in medical students but very few studies conducted on health college students.[4616171819] Mohammed Al-Mana College for Medical Sciences (MACHS) is placed in the Eastern Province of Saudi Arabia. MACHS consists of 6 departments namely: Preparatory year, Pharmacy, Clinical laboratory sciences, Nursing, Physical therapy, and Respiratory care for male and female students. Approximately 1500 students registered in the college. The aim of this study to determine the prevalence rate of smoking of different department students in MACHS, and examine attitude, practice, and knowledge toward the harmful effects of smoking.

MATERIALS AND METHODS

Our cross-sectional study was carried out in the month of February 2020 and involved students from six different departments in Dammam, at MACHS. The study population included male and female students enrolled in Pharmacy, Nursing, Clinical Laboratory Sciences, Physical Therapy, Preparatory year and Respiratory Care Department in MACHS, Dammam. The sample size was calculated to be 385 according to the statistical website “Raosoft” based on 5% margin of error, 95% level of confidence. We distributed this questionnaire to 450 students only 388 were responded and rest of them were excluded from the study. To conduct this study, ethical approval was obtained from the scientific research unit of MACHS (letter no. SR/RP/36) Dammam, KSA.

Data were collected using a validated pretested adopted questionnaire[8] based on the Global Adult Tobacco Survey. The questionnaire was written in English and Arabic language, and contained 33 questions about demographic details (age in years, college, academic year, marital status, current and permanent residence, living with parents or not), smoking behavior (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). These questionnaires were distributed to the students, after informed consent obtained from every participant and to response the questionnaire need only 10–15 min.

Statistical analysis

Values of collected data were expressed as percentage or as mean and standard deviation.

P value was calculated using Chi-square test and < 0.05 were considered significant. Data were analyzed using the Statistical Package for the Social Science version 21 (SPSS, Inc., Chicago, IL, USA).

RESULTS

A total of 388 students completed the questionnaire out of them 108 males (27.8%) and 280 females (76.2%). The distribution of the participants among different departments in the college is shown in Figure 1. The sociodemographic characteristics are listed in Table 1.

Figure 1

Distribution of the students by departments

Table 1

Sociodemographic characteristics of students

Characteristic	Male students (n=108), n (%)	Female students (n=280), n (%)	p
Age
18-20	27 (25)	110 (39.28)	<0.001
21-23	37 (34.25)	92 (32.85)
23-25	18 (16.66)	30 (10.71)
26-28	12 (11.11)	19 (6.78)
≥29	14 (12.96)	29 (10.35)
Academic year
First	22 (20.37)	78 (27.85)	<0.001
Second	21 (19.44)	63 (22.5)
Third	19 (17.59)	40 (14.27)
Fourth	21 (19.44)	20 (7.14)
Fifth	17 (15.74)	44 (15.71)
Internship	8 (7.40)	35 (12.5)
Marital status
Single	80 (74.07)	190 (67.85)	<0.001
Married	24 (22.22)	84 (30)
Divorced	4 (3.70)	6 (2.14)
Personnel living
With family	85 (78.70)	235 (83.92)	<0.001
Personal rented home	11 (10.18)	31 (11.07)
Rented home with friends	12 (11.11)	15 (5.35)
Department
Pharmacy	50 (46.29)	110 (39.28)	<0.001
Nursing	14 (12.96)	41 (14.64)
Clinical laboratory service	15 (13.88)	28 (10)
Physical therapy	9 (8.33)	15 (5.35)
Preparatory foundation	10 (9.25)	50 (17.85)
Respiratory care	10 (9.25)	36 (12.85)

In the current study 77 (19.84%) students out of 388 of different departments consumed different tobacco forms (cigarettes, shisha, and smokeless tobacco), the prevalence ratio of tobacco use 19.84%. The prevalence ratio of male current smokers was 11.8%, whereas female 7.9%, however, the number of female participants was high, but the prevalence rate was low. The practice of pattern and prevalence of tobacco use among male students are listed in Table 2.

Table 2

Prevalence and patterns of tobacco smoking by male students

Characteristic	Male students (n=108), n (%)
Current smoker
Yes	46 (42.59)
No	62 (57.40)
Former smoker
Yes	48 (44.44)
No	60 (55.55)
Age starting smoking (years)
≤12	6 (5.55)
12-15	16 (14.81)
16-19	23 (21.29)
≥20	12 (11.11)
NA	51 (47.22)
Number of cigarettes smoked daily
1-5	16 (14.81)
6-10	19 (17.59)
≥11	20 (18.51)
NA	53 (49.07)
Time of starting smoking after awakening
Within 5 min	15 (13.88)
6-60 min	24 (22.22)
≥60	17 (15.74)
NA	52 (48.14)
Trying to quit smoking
Yes	32 (29.62)
No	20 (18.51)
NA	56 (51.85)
Reasons for trying to quit smoking
Personnel	26 (24.07)
Family advice	10 (9.25)
Health problem	18 (16.66)
NA	54 (50)
Current smoker of smokeless (vape)
Yes	35 (32.40)
No	73 (67.59)
Smoking shisha
Yes	44 (40.74)
No	64 (59.25)
Duration of smoking shisha
Minutes	16 (14.81)
Hours	39 (36.11)
NA	53 (49.07)
Place of smoking shisha
Home	20 (18.51)
Coffee shop	30 (27.77)
Restaurant	4 (3.70)
NA	54 (50)

NA: Not applicable

The rate of current cigarette prevalence was 19.84%. The students of the pharmacy and clinical laboratory department had the highest prevalence of smoking 6.18% and 4.38%, respectively, as compared to respiratory care (3.35%) and nursing (2.57%) departments. Whereas the lowest prevalence (1.8%) was in the preparatory year and physical therapy (1.5%) department [Figure 2].

Figure 2

Prevalence of smoking among students by departments

The majority (46%) smoked 1–5 cigarettes every day. The currents smokers 61% had tried to quitting for personnel reasons (57%), family advice (15%) and due to health problem (27%). The prevalence of shisha smoking in students of different departments was 23.4%. The majority (62%) of them smoked shisha for hours. Approximately 49% of the shisha smokers smoked at coffee shops, 42% at home, and 8% at restaurant. Only 16% of smokers used smokeless tobacco (vape).

Comparison of the male and female students knowledge, attitude regarding tobacco use are presented in Table 3. The maximum percentage of students was well aware regarding smoking causes dangerous diseases. Moreover, female students had more knowledge in comparison with male students with a significant differences about the knowledge that smoking causes dangerous diseases (78.7% vs. 82.8%; P ≤ 0.001), and about as a risk factor of brain thrombosis (59.2% vs. 60%; P ≤ 0.001), gastric ulcer (55.5% vs. 62.1%; P ≤ 0.001), asthma (62.9% vs. 72.1%; P ≤ 0.001) and lung cancer (81.4% vs. 86.7%; P ≤ 0.001). Whereas male students had little better responded as compared to female students for smoking tobacco cause heart attack (75.9% vs. 73.2%; P ≤ 0.001). Furthermore, male students understood smokeless tobacco (29.6% vs. 17.1%; P < 0.001) and shisha smoking (25.9% vs. 12.1%; P < 0.001) are less dangerous as compared to female students. However, female students recognized tobacco and shisha smoking as types of addiction more than the male students (76.8% vs. 84.6%; P < 0.001, and (69.4% vs. 77.5%; P ≤ 0.001, respectively). In addition, male and female students believed that tobacco products taxes should be increased and all cigarette advertising should be banned (43.5% vs. 65.3%; P < 0.001, and (59.2% vs. 76.4%; P ≤ 0.001, respectively) [Figure 3]. A 339 students (87.3%) reported that smoking cigarette and shisha causing harmful effects on health [Figure 4].

Table 3

Comparative knowledge of harmful effects of tobacco smoking on health among students of different departments

Characteristic	Male students, n (%)	Female students, n (%)	p
Smoking tobacco causes dangerous diseases
Yes	85 (78.70)	232 (82.85)	<0.001
No	4 (3.70)	3 (1.07)
I don't know	19 (17.59)	45 (16.07)
Smoking tobacco causes brain thrombosis
Yes	64 (59.25)	168 (60)	<0.001
No	8 (7.40)	10 (3.57)
I don't know	36 (33.33)	102 (36.42)
Smoking tobacco cause heart attack
Yes	82 (75.92)	205 (73.21)	<0.001
No	6 (5.55)	8 (2.85)
I don't know	20 (18.51)	67 (23.92)
Smoking tobacco causes gastric ulcer
Yes	60 (55.55)	174 (62.14)	<0.001
No	12 (11.11)	19 (6.78)
I don't know	36 (33.33)	87 (31.07)
Smoking tobacco causes asthma
Yes	68 (62.96)	202 (72.14)	<0.001
No	14 (12.96)	19 (6.78)
I don't know	26 (24.07)	59 (21.07)
Smoking tobacco causes lung cancer
Yes	88 (81.48)	243 (86.78)	<0.001
No	7 (6.48)	5 (1.78)
I don't know	13 (12.03)	32 (11.42)
Smokeless tobacco is less dangerous
Yes	32 (29.62)	48 (17.14)	<0.001
No	34 (31.48)	82 (29.28)
I don't know	42 (38.88)	150 (53.57)
Shisha smoking is less dangerous
Yes	28 (25.92)	34 (12.14)	<0.001
No	57 (52.77)	176 (62.85)
I don't know	23 (21.29)	70 (25)
Smoking is a type of addiction
Yes	83 (76.85)	237 (84.64)	<0.001
No	8 (7.40)	15 (5.35)
I don't know	17 (15.74)	28 (10)
Smoking shisha is a type of addiction
Yes	75 (69.44)	217 (77.5)	<0.001
No	17 (15.74)	27 (9.64)
I don't know	16 (14.81)	36 (12.85)
Islam forbids smoking
Yes	50 (46.29)	120 (42.85)	<0.001
No	34 (31.48)	79 (28.21)
Don't know	24 (22.22)	81 (28.92)
Tobacco products taxes should be increased
Yes	47 (43.51)	183 (65.35)	<0.001
No	41 (37.96)	50 (17.85)
Don't know	20 (18.51)	47 (16.78)
All cigarette advertising should be banned
Yes	64 (59.25)	214 (76.42)	<0.001
No	27 (25)	30 (10.71)
Don't know	17 (15.74)	36 (12.85)

Figure 3

Comparative knowledge of harmful effects of tobacco smoking on health among students of different departments

Figure 4

Perception of students regarding smoking

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 the prevention of tobacco-related diseases. The prevalence of tobacco smoking among male students in the current study (11.8%) was lower as compared to some previous studies ranging from 14% to 21.6% in Saudi Arabia.[34581819] The prevalence rate of other Arabic countries revealed 27% in Bahrain,[20] 26.3% in Jordan,[21] 34.8% in Kuwait,[22] 31.5% in Morocco,[23] 26.3% in Lebanon,[24] 26.1% in Syrian Arab Republic,[25] and 22.1% in Turkey.[26]

The present study results revealed that the rate of smoking prevalence varied between students at different departments, which is accordant with earlier studies in Saudi Arabia and other nations. This outcome interpreted with caution due to the influence that future healthcare professionals (HCPs) will have on the community. The WHO is boosting HCPs to deliver general information regarding the harmful effects of smoking on patient's health and to help in withdrawing smoking. In addition, physicians are like act as role models to patients who encourage tobacco-free lifestyles.[2728]

Physician's attitudes and behavior play a primary role on the psychology of the patients regarding smoking. Among health sciences, students, hygiene practices, and health-related activities have a more impact on their academic performances and future professional prospects.[29]

The prevalence of smoking among female students was less as compared to male students, the result that goes in accordance with some previous Saudi studies ranging from 0.5% to 16%.[345618] Another study conducted in Pakistan revealed that smoking prevalence among females was lower.

This outcome could be because of similar cultural influences as smoking is considered as a taboo, due to this females infrequently smoke or never exposed their smoking habit to society.[30]

In the present investigation, approximately 29.4% of current smokers informed smoking more than 11 cigarettes every day, and around 46% of smokers reported that they start smoking cigarette after 1 h. Awakening in the morning. These smoking patterns suggest a low level of nicotine dependence. Shisha smoking is the most commonly used practice of smoking tobacco.

Smoking shisha is another form of tobacco consumption and it is the most commonly used practice of smoking around the world including in Saudi Arabia. In the current study, the prevalence rate of shisha smokers 23.4% and smoker of smokeless (vape) 16.7% was within the range reported in previous Saudi studies.[35671718]

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%).[5789101112132122]

In this study, approximately 16% of students reported that smokeless tobacco is less dangerous and 20% indicated Shisha smoking is less dangerous. However, shisha smoking may be more harmful due to 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.[31] Therefore, shisha smoking may be more harmful to health, so shisha-specific interventions and policies are needed to control smoking in Saudi Arabia.[32] These results strongly suggested that tobacco control programs must include all other forms of tobacco use, in addition to cigarette smoking.

In the present study, 87.3% of students indicated that smoking harmful to health and only 2.5% reported no effect on health. The students had positive attitude toward banning smoking by law, results that go in accordance with a study done in Riyadh, KSA, where students showed positive attitude toward minimizing passive smoking through their support of banning smoking in public areas as well as their willingness to discuss and advise their patients to quit smoking.[33]

CONCLUSION

The rate of prevalence of cigarettes and shisha smoking among students of different departments in MACHS is medium. Female students had better knowledge about the harmful effect of smoking as compared to male students. Students showed positive attitude toward reducing passive smoking through their support of banning cigarette advertising and increase tax on tobacco products, also provide professional help and advice for students to quit cigarette smoking. Smoking is an upcoming alarming threat for different tobacco-related diseases in Saudi Arabia. It could be controlled by more awareness of harmful effects on health due to tobacco smoking and the development of tobacco education programs for quit smoking cigarettes and its other forms.

Limitations

This study had some limitations. First, the data are based on self-reporting by the students, although anonymity was guaranteed for data collection. Another limitation is that the study was conducted only among MACHS students, so its results cannot be generalized to other medical college. Furthermore, in this study, majority of participants were female because this college having more female students compare to male students.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.