J Relig Health DOI 10.1007/s10943-015-0003-z ORIGINAL PAPER
Predicting Relationship of Smoking Behavior Among Male Saudi Arabian College Students Related to Their Religious Practice Khalid M. Almutairi
Ó Springer Science+Business Media New York 2015
Abstract This study describes the relationships of smoking behavior among a sample of male college students in Kingdom of Saudi Arabia (KSA) to their religious practice, parents’ smoking behaviors and attitudes, peers’ smoking behaviors and attitudes, and knowledge about the dangers of smoking. A 49-item questionnaire was developed and pilot tested in KSA. This questionnaire was completed during the academic year 2013 by 715 undergraduate male students at the King Saud University in Riyadh. 29.8 % of the students were smokers (13.8 % cigarette smokers, 7.3 % sheesha smokers, and 27 % cigarette and sheesha smokers). Students in the College of Education were much more likely to be smokers than the students in the College of Science. The differences between the College of Education and the College of Science was statistically significant (v2 = 16.864. df = 1, p = .001). Logistic regression analysis suggested that students who were more faithful in their practice of Islam were 15 % less likely to smoke. Students who were more knowledgeable about the dangers of smoking were 8 % less likely to smoke. The logistic analysis identified peers (friends) as the most powerful factor in predicting smoking. The fourfactor model had an overall classification accuracy of 78 %. The need to understand more fully the dynamics of peer relations among Saudi Arabian males as a basis for developing tobacco education/prevention programs. Prevention programs will need to include education and changes in the college level or earlier in KSA. Keywords
Smoking behavior Saudi Arabian Religious practice
Introduction Smoking is a major risk factor for heart disease, stroke, lung cancer, and chronic lung disease, the leading causes of death. Nearly 6 million people each year and more than
K. M. Almutairi (&) Community Health Science Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia e-mail: [email protected]
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5 million of those deaths are the result of direct tobacco use, while more than 600,000 are the result of non-smokers being exposed to second-hand smoke (WHO 2013a, b, c, d, e, f). Environmental tobacco smoke (ETS) or second-hand smoke includes more than 7,000 chemicals that are toxic and can cause significant lung condition, especially asthma and bronchitis among children and risk of heart disease and cancer for adults (U.S. Department of Health and Human Services 2000, 2010). Based on the World Health Organization report, tobacco use was predicted to cause 10 million deaths annually by the year 2030 (WHO 2013a, b, c, d, e, f). The negative health effects of tobacco smoking causes a massive rate of mortality and morbidity; direct costs of tobacco-related deaths and their related productivity losses. Tobacco Smoking Rates Worldwide Worldwide tobacco use has been identified as the single most important source of preventable morbidity and mortality worldwide. In 2009, smoking among men was highest in the Western Pacific Region, with 51 % of men aged 15 and above smoking some form of tobacco. Smoking among women was highest at 22 % in the European Region. As of 2012 different countries like China (28 %), USA (19 %), and Great Britain (22 %), tobacco prevalence is still in higher rates (CDC, WHO China, WHO 2013a, b, c, d, e, f, National Stat. (UK), Giovino 2002). If this current trend persists for the next 30 years, it is estimated that 10 million people will die every year from smoking-related diseases (WHO 2013a, b, c, d, e, f). Tobacco Smoking in Saudi Arabia Tobacco smoking is one of the public health problem in Saudi Arabia. It is estimated that 37 % of adult male and 6 % of adult female are current smokers. This numbers are expected to increase according to World Health Organization (WHO EMRO, Saudi Arabia 2010). The economic burden of tobacco consumption over the last 10 years (2001–2010) in the Kingdom of Saudi Arabia (KSA) was 20.5 billion US$ (2011 US$ prices) without accounting for smuggled tobacco (AlBedah and Khalil 2013). Moreover, cigarettes were the principal source of tobacco consumption in KSA, among students (62.6 %) and adults (59 %) smokers (Jarallah et al. 1999; Bassiony 2009; Amin et al. 2011). Secondly, nargile or water pipes (sheesha) were most frequently source of tobacco consumption especially among women (Subhan et al. 2009; Mandila et al. 2010; Koura et al. 2011). Multiple studies documented the prevalence rate of smoking in the Kingdom. In a study of students at King Faisal University, Saudi Arabia, Al-Mohamed and Amin found that 21.8 % of students were cigarettes smokers. The smoking prevalence rates are higher among the males than females. In a cross-sectional study by Al Gobain et al. (2011) among secondary schools in Saudi Arabia, prevalence among boys and girls were 19.5 % (31.2 % of boys and 8.9 % of girls). Studies shown that prevalence of smoking in KSA was comprising of different age groups and genders. Different factors associated with tobacco smoking should be determined in order to provide appropriate measures, cessation programs especially among youth. Factors Associated with Smoking Determining factors such as knowledge, behaviors, and attitude that initiate people to smoke is important in helping prevent from starting. The relationship of tobacco smoking
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to religious practice, parental and peer smoking practices and attitudes and knowledge of the dangers of tobacco constitutes an important risk factor for the tobacco smoking. Numerous studies have suggested that religious involvement may promote health and deter negative health behaviors, including smoking, alcohol and substance use/abuse. In a study of medical students at King Fahad Medical City, Al Kaaba found that 35.4 % of the students never try from smoking because of religious beliefs. Saudi Arabia is a Moslem country, and Islam is practice by all Saudi citizens. The teaching of Mohammed (Peace Be Upon Him) directly influences behaviors like smoking, however, not all Saudis are equally devoted to their religion. A scale to measure religious involvement was developed as part of this study. Based on research in the USA, parental behavior and attitudes clearly influence the smoking practice of their adolescent children. Cigarette smoking is likely affected by more than parents’ actual smoking behaviors and attitudes toward cigarette smoking. The relationship of adolescents and their parents likely affect the significance of parents’ attitudes and behaviors. Moreover, knowledge was a variable that most people in Saudi Arabia would expect to be the focus of any tobacco education program. Although there is no assurance of behavior change, simply providing knowledge and measuring along with attitudes and behavior will identify factors that continually increase smoking behavior. This study aims to describe the relationships of smoking behavior among male college students in Saudi Arabia to their religious practice, parents smoking behaviors and attitudes, peers’ smoking behaviors and attitudes, and knowledge about the dangers of smoking
Methods The setting of this study was Riyadh City, Saudi Arabia, which has a population approximately 24 million. The Saudi government lays heavy emphasis on education and spends considerable money on basic and higher education. As of 2001, Saudi Arabia had a total of eight government universities and 15 private colleges. King Saud University, the largest and most prestigious, enrolled some 25,000 students. Sample The sample for this study included 715 male college students enrolled during the academic year 2013 in the College of Education and College of Science, King Saud University, Riyadh, Saudi Arabia. The sample site was selected for convenience and the age of students on the basis of the likelihood they would be new tobacco users. Males were selected because the investigator was male; and in Saudi Arabia, it would not have been acceptable for a male to study female behaviors. As such, it was recognized that the generalizability of this research would be limited. However, it was also recognized that male college students of this age in King Saud University were probably like male college students at the other seven government universities in Saudi Arabia. The participants’ ages ranged from 19 to 28 years. The investigator asked the professors of general studies courses with large enrollment for permission to administer the survey in their classes. Students were told about the survey and asked if they would be willing to participate. Those who agreed were given a questionnaire. No names or other identification was collected. The questionnaire stated that
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each individual had the right to decline to complete the survey or to answer any specific questions. The questionnaire consisted of 49 questions used to describe the demographic characters of the sample, the practice of Islam, cigarette smoking status, sheesha smoking status, parents’ tobacco use and attitudes, peers’ tobacco use and attitudes, and knowledge of the dangers about the tobacco use. The survey was based on a literature review and suggestions from a panel of experts. The instrument was pilot tested, revised, and translated from English to Arabic and back to English. The proposal of this study had been approved by the ethics committee of King Saud University Data Analysis The data collected from the survey will be coded and entered into the mainframe computing system using SPSS version 16 (Chicago, IL, USA). A significance level of 0.05 was set to determine statistical significance for all tests. The demographic characteristics of the sample were analyzed using frequency statistics. Cronbach’s Alpha was used to establish the reliability of the responses to the survey questions. Logistic regression analysis were used to predict smoking behavior from the practice if Islam, parental peers tobacco use and Table 1 Demographic characteristics Education
Science
v2
Total
N
%
N
%
N
%
194
53.4
259
73.5
453
63.4
Age 19–21
42.705*
22 age older
169
46.6
93
26.5
262
36.6
Total
363
100
352
100
715
100
v2 = 42.705
df = 1
p = .000
69
19
47
13
116
16.3
Father education Illiteracy
10.522*
Elementary
69
19
71
20
140
19.6
Secondary
72
20
55
16
127
17.8
High school
66
18
63
18
129
18
College or post-college
87
24
116
33
203
28.3
Total
363
100
352
100
715
100
v2 = 10.522
df = 4
p = .032
125
35
114
32
239
33.4
Mothers education Illiteracy
10.522*
Elementary
109
30
87
25
196
27.4
Secondary
44
12
41
12
85
11.9
High school
55
15
57
16
112
15.7
College or post-college
30
8
53
15
83
11.6
Total
363
100
352
100
715
100
v2 = 9.324
df = 4
p B .53
* p-value significant at p \ 0.05
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attitudes. Logistic regression analysis was also used to predict smoking behavior from the measure of knowledge of the danger of smoking. The dependent variable was tobacco use (‘‘0’’ coded as non-smoker and ‘‘1’’ coded as smoker). Respondents were defined as current smokers, if they were smoking at the time of the survey and smoke at least one cigarette every day for the last 30 days; they were defined as non-smokers, if they did not smoke during the past 30 days.
Results Tobacco use has been identified as the single most important source of preventable morbidity and mortality worldwide. However, there is limited research on tobacco use in Saudi Arabia. The purpose of this study was to explore the role of religion, parents, peer behavior and attitudes, and knowledge about the dangers of smoking on smoking behavior among young users. A sample of 715 college students voluntarily completed an anonymous survey that described their religious practice, parents’ tobacco use and their attitudes toward their fiends smoking and knowledge of the danger of tobacco use. Description of the Sample Male students in the College of Education and College of Science in King Saud University in Riyadh Saudi Arabia were surveyed. A total of 800 surveys were distributed with 734 Table 2 Tobacco smoking status Education N
Science %
N
v2
Total %
N
%
Cigarette smoking status Non-smokers
260
71.6
294
83.5
554
77.5
Smokers
103
28.4
58
16.5
161
22.5
352
100
715
100
Total
363
100
v2 = 17.550
df = 1
p = .000
17.550*
Sheesha smoking status Non-sheesha smokers
292
80.5
309
87.8
601
84
Sheesha smokers
71
19.5
43
12.2
114
16
Total
363
100
352
100
715
100
v2 = 18.275
df = 1
p = .000
Non-smokers
231
63.6
271
77
502
70.2
Cigarette smokers
61
16.8
38
10.8
99
13.8
Sheesha smokers
29
8
23
6.5
52
7.3
Cigarette and sheesha smokers
42
11.6
20
5.7
62
8.7
Total
363
100
352
100
715
100
v2 = 16.864
df = 1
p = .001
18.275*
Tobacco smoking 16.864*
* p-value significant at p \ 0.05
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(91.7 %) returned. Results from 715 completed surveys were recorded and analyzed with SPSS 16. Table 1 shows the demographic characteristics of the sample (N = 715). Three hundred sixty-three (50.8 %) students were from the College of Education, and 352 (49.2 %) were from the College of Science. Students in the College of Education were older than those in the College of Science, 46.7 % of the education students, and 26.5 of the College of Science student being 22 years and older. The age between the two colleges was statistically significant (v2 = 42,705, df = 1, p \ .05). Therefore, the College of Science’s students were likely to be younger than the College of Education’s students. With respect to fathers’ educational status, 16.3 % were illiterate, 19.6 % had elementary level, 35.8 % had a secondary or high school degree, and 57 % had a college or post-college degree. The difference in fathers’ education between the College of Education and the College of Science was statistically significant difference (v2 = 10.522, df = 4, p \ .05), with fathers of the College of Science students being more likely to be educated than the fathers of the College of Education. With respect to mothers’ educational status, 33.4 % of the mothers were illiterate, 27.4 % had elementary education, 27.6 % had a secondary or high school degree, and 11.6 % had a college or post-college degree. There was no statistically significant difference between the mothers’ education of students in two colleges (v2 = 9.324, df = 5, p [ .05). For this study, anyone who had smoked at least one cigarette daily in 30 days prior to the survey was a smoker. Table 2 clearly suggests that students in the College of Education
Table 3 Binomial logistic regression model for religion, knowledge, and predicting smoking behavior Variable
B
SE
Wald v2
p
Religion
-0.159
0.027
33.96
0.000*
0.853
.808–.900
Knowledge
-0.91
0.39
5.52
0.019
0.91
.84–.98 2.38–9.69
Odds ratio
95 % CI
Peers behavior smoking status (non-smoker as a reference) Few
1.57
0.35
19.32
0.000*
4.81
Half
2.55
0.37
46.47
0.000*
12.86
6.17–26.82
All of them
2.68
0.37
51.15
0.000*
14.67
7.03–30.64
Peers’ smoking attitude (disagree as a reference) Neutral
1.37
0.29
22.48
0.000*
3.96
2.24–7.01
Agree
1.68
0.2
70.58
0.000*
5.38
3.63–7.96
0.00*
0.89
.84–.95
0.4
1.9
1.0–3.6
0.000*
3
1.9–4.5
Logistic regression model predicting smoking behavior Religiona
-0.109
0.02
15.32
Peers attitudesa (non-smokers as reference) Neutral
0.65
0.32
4.2
Agree
1.09
0.21
25.38
Peer behaviorsa (non-smoker as reference) Few
1.1
0.37
8.97
0
3
1.4–6.2
Half
1.9
0.39
23.56
0
6.7
3.1–14.6
All of them
2
0.39
27.97
Knowledgea
-0.82
0.04
3.6
0
8
3.7–17.4
0.04*
0.92
.84–.99
* p-value significant at p \ 0.05 a
Where -2log likelihood = 737.79; Cox and Snell R2 = .10; adjusted Nagelkerke R2 = .15
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were much more likely to be smokers than the students in the College of Science. In the College of Education, 28.4 % were smokers and 16.5 % were smokers in College of Science. The differences between the two colleges were statistically significant (v2 = 17.550, df = 11 p \ .05). 63.6 % were non-smokers compared to 77 % in the College of Science. In the College of Education 16.8 % of the students smoked cigarettes and in the College of Science, it was 10.8 %, while 8.0 % of the students in College of Education smoked sheesha and 6.5 % in the College of Science. In the College of Education, 11.6 % of the students smoked both cigarettes and sheesha and 5.7 in the College of Science. Almost 30 % (29.8 %) of the two colleges’ students were smokers. The differences between the College of Education and the College of Science were statistically significant (v2 = 16.864. df = 1, p = .001). A direct logistic regression analysis was performed with smoking behavior as the outcome and four independent predictors being: practice Islam, knowledge about the dangers of smoking, peers’ smoking status and attitudes toward smoking, and peers approval of smoking. Parents were excluded from the model, because of insufficient variance in parental attitudes and smoking behaviors. Table 3 shows that students who practice Islam would be less likely to smoke (cigarettes or sheesha). The odds ratio (.85) was less than 1 indicating a decreased likelihood of a student who practices Islam of smoking (Table 14). Students who practice their religion were 15 % less likely to smoke. Result also shows that students with peers who do not smoke would be less likely to smoke. Students who reported having a few peers who smoked (non-smokers as reference) were almost five times more likely to smoke; students who reported that half of their peers smoked were 12 times more likely to smoke. Students who reported that all of their peers smoked were 14 times more likely to smoke. Results also supported (Table 3) that students with peers who approved of their friends smoking were more likely to smoke. Students who reported that their peers were neutral in their attitude toward their smoking were 3.96 times more likely to smoke, and those who reported their peers agree with their smoking were 5.38 times more likely to be smokers. Table 3 also shows that all of the remaining four predictors significantly predicted smoking behaviors. The model had an overall classification accuracy of 78 %. The important contributing variables in the model were peers’ behaviors. Peers who reported a few of their friends smoked were three times more likely to smoke than peers who reported their friends did not smoke, peers who reported half of their friends smoked were almost seven times more likely to smoke than peers who reported their friends did not smoke, and peers who reported all of their friends smoked were eight times more likely to smoke than peers who reported their friends did not smoke.
Discussion This study examined smoking behavior among students in the College of Education and the College of Science in King Saud University in Riyadh, Kingdom of Saudi Arabia. This was the first-known study of the influence of religion, parent and peer behavior and attitudes toward smoking, and knowledge about the dangers of tobacco smoking among male college students in Saudi Arabia. The results showed that 29.8 % of males were smokers (13.8 % cigarette smokers, 7.3 % sheesha smokers, and 8.7 % cigarette and sheesha smokers). The prevalence of smoking reported here was higher than the prevalence reported in previous studies (Subhan et al. 2009; Mandila et al. 2010; Al-Kaabba et al. 2011) in Saudi Arabia. The actual
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prevalence may be even higher than 29.8 %, because the Saudi government banned smoking on religious principle since 1926, as well as smoking—free policies on public places were implemented. Religious, cultural, and social constraints may have discouraged smokers from reporting their smoking habits and (Park et al. 2012). A number of studies have investigated the influence of religion, parent and peer behaviors and attitudes toward smoking, and knowledge about the dangers of tobacco use on smoking behavior (Mahabee-Gittens et al. 2013; Park et al. 2012; Al Azhar and Al Sayed 2012; Villanti et al. 2011; Al Nohair 2011; Al-Kaabba et al. 2011; Al Ghobain et al. 2011; Al Moamary et al. 2012; Wali 2011; Koura et al. 2011; Luk et al. 2010). In study, these four factors were examined independently and all together. Religion In this study, religious practices significantly predicted smoking behavior. Students who practiced Islam (that is, students who answered affirmatively questions about reading Quran, reciting Quran, performing prayers at the Mosque, maintaining the five daily prayers, giving to charity, and faithful status) were less likely to smoke. These findings are compatible with (McFadden et al. 2011) who noted that an increasingly higher proportion of the non-religious used tobacco. The Quran prohibits physically harmful behaviors, and tobacco use is considered haram (unlawful) in Islam. Because Saudi Arabia is an overwhelmingly Islamic country and Saudi people readily accept teachings that reference principles found in the Quran, it is recommended that religious principles be included in smoking prevention programs for use in Saudi Arabia. Parents’ Behaviors and Attitudes Parental disapproval of smoking was almost universal in this sample. Ninety-three percent of the students reported their fathers disapproved of smoking; 96.8 reported their mothers disapproved. The effects of parents; smoking behaviors and attitudes could not be examined in this study because of the lack of variance in the data. Disapproval of parents about tobacco use is an important predictor of student’s intention to smoke. Therefore, programs developed to prevent and reduce tobacco use by young people should reinforce parent’s disapproval, and parents should be encouraged to make sure their children know of their disapproval (Kong et al. 2012). Peers’ Behaviors and Attitudes The influence of peers’ smoking behaviors has been well documented (Mahabee-Gittens et al. 2013; Park et al. 2012; Al Azhar and Al Sayed 2012; Al Nohair 2011; Al-Kaabba et al. 2011; Al Ghobain et al. 2011; Al Moamary et al. 2012; Wali 2011; Koura et al. 2011; Kong et al. 2012; Villanti et al. 2011). Clearly, logistic regression showed that smoking behavior in this was significantly predicted by the peers’ smoking behaviors. The magnitude of odds ratio for tobacco use as predictor for tobacco use increased substantially as the number of friends who smoked increased. The model predicted cigarette and sheesha smoking. Helping young people understand the power of peer pressure and develop strategies to deal with peer pressure will need to be an important part of any educational program that is developed to reduce smoking behavior in Saudi Arabia. While there are many examples of
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this type of educational program developed in Western countries, there are none that have been developed for Saudi Arabia. Developing an educational program to deal with peer pressure that is acceptable to and effective with Saudi Arabian youth will require careful research of the specific dynamic of smoking and non-smoking peer pressure in the culture of Saudi Arabia. Knowledge These results demonstrated that knowledge about the danger of smoking was a predictor of smoking behavior. Risk awareness alone seems insufficient to deter smoking (Hamner and Stumpfa 2001). To be acceptable to the public in general, any educational program to reduce smoking behavior will need to include a section on knowledge of danger, because that is what the public expects. The contribution of knowledge to behavior change, although significant in this study, was very small. The results of this study suggest that the prevalence of smoking among college students is higher than previously reported. The need for prevention program to reduce smoking— related morbidity and mortality is supported. Prevention program at the college level or earlier is needed in Saudi Arabia, if the rates of smoking are to decline. Prevention programs will need to include education and changes in public policy. More research is needed to develop prevention plans. This research suggest that effective prevention program will need to address three of the four factors studied in this research: religion, peer’ attitudes, peers’ behaviors, and knowledge. Unless a prevention program in Saudi Arabia is multidimensional and addresses these factors and probably other, it will likely fail. Without a full understanding of how these factors interact and a better understanding of the behavior change of quitting and taking up smoking, it will be difficult to design effective prevention programs. Based on the results of other research (Mahabee-Gittens et al. 2013; Villanti et al. 2011; Kong et al. 2012; Luk et al. 2010), it is likely that prevention programs also will need to include the involvement of parents. Because of the absence in statistical variance in the data collected in this research, it is not possible to say anything definitive about the parental influences. The most significant finding of this study is the importance of the effect of peer behavior and peer attitudes toward smoking on the smoking behavior of adolescents. There is a clear need to more fully understand the dynamics of peer relationships, if prevention programs are to help young people manage peer relationships in regard to tobacco use. To better understand peer dynamics among male Saudi youth, it is likely that qualitative research methods will yield the most valuable data. Knowing about the dynamics of peer relationships and peer pressure, as seen by the young people themselves, will be necessary first step in developing more sophisticated quantitative measures. Individual interviews with young men and focus groups with young men, both carefully planned and carried out with trained researchers, should generate valuable data for developing both more sophisticated measures of peer dynamics and educational programs to help young men manage peer pressure. This study confined itself to studying males in two Saudi Arabian colleges and therefore, the generalizability of the results is limited. However, it is likely that the male college students in this study were not significantly different from male students in other colleges. Therefore, it is likely that the finding of this study generalize to other male college students. There is little research about adolescent smoking behavior in Saudi Arabia. There is a need for: (1) Studies exploring further the dynamics of peer relationships, (2) basic
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descriptive research of smoking behaviors among non-college young people and among women, (3) increased research in each of the areas explored in this research, (4) detailed studies of sheesha smoking, following the pattern used for cigarette research, (5) studies of the effects of the government’s policies on tobacco marketing on adolescent smoking rates, and (6) studies that carefully evaluate the effectiveness of prototype smoking prevention programs. References Al Azhar, A., & Al, Sayed N. (2012). Prevalence of smoking among female medical students in Saudi Arabia. Asian Pacific Journal of Cancer Prevention, 13(9), 4245–4248. Al Ghobain, M. O., Al Moamary, M. S., Al Shehri, S. N., & Al-Hajjaj, M. S. (2011). Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia. Annals of Thoracic Medicine, 6(3), 137–140. doi:10.4103/1817-1737.82447 Al Moamary, M. S., Al Ghobain, M. O., Al Shehri, S. N., Gasmelseed, A. Y., & Al-Hajjaj, M. S. (2012). Predicting tobacco use among high school students by using the global youth tobacco survey in Riyadh, Saudi Arabia. Annals of Thoracic Medicine, 7(3), 122–129. doi:10.4103/1817-1737.98843 Al Nohair, S. F. (2011). Prevalence of Smoking and its related behaviors and beliefs among secondary school students in Riyadh, Saudi Arabia. International Journal of Health Sciences, 5(1), 57. AlBedah , A. M. N., & Khalil, M. K. M. (2014). The economic costs of tobacco consumption in the Kingdom of Saudi Arabia. Tobacco Control, 23, 434–436. doi:10.1136/tobaccocontrol-2012-050665. Al-Kaabba, A. F., Saeed, A. A., Abdalla, A. M., Hassan, H. A., & Mustafa, A. A. (2011). Prevalence and associated factors of cigarette smoking among medical students at King Fahad Medical City in Riyadh of Saudi Arabia. Journal of Family and Community Medicine, 18(1), 8–12. Amin, T. T., Monhem Amr, M. A., & Zaza, B. O. (2011). Psychosocial predictors of smoking among secondary school students in Al-Hassa, Saudi Arabia. Journal of Behavioral Medicine, 34, 339–350. Bassiony, M. (2009). Smoking in Saudi Arabia. Saudi Medical Journal, 30, 876–881. Giovino, G. A. (2002). Epidemiology of tobacco use in the United States. Oncogene, 21(48), 7326–7340. Hamner, R. T., & Stumpfa, S. H. (2001). Survey of smoking knowledge, attitudes and practice in school children in Honduras. Familiy Practice, 18(6), 627–628. Jarallah, J. S., Al-Rubeaan, K. A., Al-Nuaim, A. R., Al-Ruhaily, A. A., & Kalantan, K. A. (1999). Prevalence and determinants of smoking in three regions of Saudi Arabia. Tobacco Control, 8, 53–56. Kong, G., Camenga, D., & Krishnan-Sarin, S. (2012). Parental influence on adolescent smoking cessation: Is there a gender difference? Addictive Behaviors, 37(2), 211–216. Koura, M. R., Al-Dossary, A. F., & Bahnassy, A. A. (2011). Smoking pattern among female college students in Dammam, Saudi Arabia. Journal of Family and Community Medicine, 18(2), 63–68. doi:10.4103/ 2230-8229.83370. Luk, J. W., Farhat, T., Iannotti, R. J., & Simons-Morton, B. G. (2010). Parent–child communication and substance use among adolescents: Do father and mother communication play a different role for sons and daughters? Addictive Behaviors, 35, 426–431. Mahabee-Gittens, E. M., Xiao, Y., Gordon, J. S., & Khoury, J. C. (2013). The dynamic role of parental influences in preventing adolescent smoking initiation. Addictive Behaviors, 38, 1905–1911. Mandila, A., BinSaeeda, A., Ahmada, S., Al-Dabbagha, R., Alsaadib, M., & Khanc, M. (2010). Smoking among university students: A gender analysis. Journal of Infection and Public Health, 3, 179–187. McFadden, D., Croghan, I. T., Piderman, K. M., Carl Lundstrom, C., Schroeder, D. R., & Taylor Hays, J. T. (2011). Spirituality in tobacco dependence: A Mayo clinic survey. Explore, 7, 162–167. Park, H. K., Al- Agili, D. E., & Bartolucci, A. (2012). Factors affecting tobacco use among middle school students in Saudi Arabia. Maternal and Child Health Journal, 16, 1828–1836. Subhan, M. M., Al-Khlaiwi, T., & Ghandourah, S. O. (2009). Smoking among health science university students in Riyadh, Saudi Arabia. Saudi Medical Journal, 30(12), 1610–1612. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving Health. Washington, DC Author. Accessed 2 Oct 2013, http://www.healthy.gov/ healthypeople. U.S. Department of Health and Human Services (2010). A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What It Means to You. 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, 2010. Accessed 10 Oct 2013. http://www.cdc. gov/tobacco/data_statistics/sgr/2010/.
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J Relig Health Villanti, A., Marc Boulay, M., & Juon, H. S. (2011). Peer, parent and media influences on adolescent smoking by developmental stage. Addictive Behaviors, 36, 133–136. Wali, S. O. (2011). Smoking habits among medical students in Western Saudi Arabia. Saudi Medical Journal, 32(8), 843–848. World Health (WHO) (2013a). Tobacco. MPOWER measures. Accessed Sept 2013. www.who.int/tobacco/ mpower/appendix_4_crude_adult_prevalence.xls. World Health Organization (WHO); Global Health Observatory (2013b). Prevalence of tobacco use. Accessed Sept 2013. http://www.who.int/gho/tobacco/use/en/. World Health Organization (WHO) (2013c). Tobacco. China smoking prevalence tobacco economy. Accessed Sept 2013. www.who.int/tobacco/media/en/China.pdf. World Health Organization (WHO) (2013d). WHO Report on the Global Tobacco Epidemic 2013. Accessed Sept 2013. http://www.who.int/tobacco/global_report/2013/en/. World Health Organization (WHO) (2013e). WHO Tobacco factsheet. Updated 2013 July. Accessed Sept 2013. http://www.who.int/mediacentre/factsheets/fs339/en/. World Health Organization Regional Office for the Eastern Mediterranean (2013f). Saudi Arabia Profile. [Updated 2010 August]. Accessed 13 Sept 2013. http://www.who.int/tobacco/surveillance/policy/ country_profile/sau.pdf.
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Predicting Relationship of Smoking Behavior Among Male Saudi Arabian College Students Related to Their Religious Practice Khalid M. Almutairi
Ó Springer Science+Business Media New York 2015
Abstract This study describes the relationships of smoking behavior among a sample of male college students in Kingdom of Saudi Arabia (KSA) to their religious practice, parents’ smoking behaviors and attitudes, peers’ smoking behaviors and attitudes, and knowledge about the dangers of smoking. A 49-item questionnaire was developed and pilot tested in KSA. This questionnaire was completed during the academic year 2013 by 715 undergraduate male students at the King Saud University in Riyadh. 29.8 % of the students were smokers (13.8 % cigarette smokers, 7.3 % sheesha smokers, and 27 % cigarette and sheesha smokers). Students in the College of Education were much more likely to be smokers than the students in the College of Science. The differences between the College of Education and the College of Science was statistically significant (v2 = 16.864. df = 1, p = .001). Logistic regression analysis suggested that students who were more faithful in their practice of Islam were 15 % less likely to smoke. Students who were more knowledgeable about the dangers of smoking were 8 % less likely to smoke. The logistic analysis identified peers (friends) as the most powerful factor in predicting smoking. The fourfactor model had an overall classification accuracy of 78 %. The need to understand more fully the dynamics of peer relations among Saudi Arabian males as a basis for developing tobacco education/prevention programs. Prevention programs will need to include education and changes in the college level or earlier in KSA. Keywords
Smoking behavior Saudi Arabian Religious practice
Introduction Smoking is a major risk factor for heart disease, stroke, lung cancer, and chronic lung disease, the leading causes of death. Nearly 6 million people each year and more than
K. M. Almutairi (&) Community Health Science Department, College of Applied Medical Sciences, King Saud University, P.O. Box 10219, Riyadh 11433, Saudi Arabia e-mail: [email protected]
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5 million of those deaths are the result of direct tobacco use, while more than 600,000 are the result of non-smokers being exposed to second-hand smoke (WHO 2013a, b, c, d, e, f). Environmental tobacco smoke (ETS) or second-hand smoke includes more than 7,000 chemicals that are toxic and can cause significant lung condition, especially asthma and bronchitis among children and risk of heart disease and cancer for adults (U.S. Department of Health and Human Services 2000, 2010). Based on the World Health Organization report, tobacco use was predicted to cause 10 million deaths annually by the year 2030 (WHO 2013a, b, c, d, e, f). The negative health effects of tobacco smoking causes a massive rate of mortality and morbidity; direct costs of tobacco-related deaths and their related productivity losses. Tobacco Smoking Rates Worldwide Worldwide tobacco use has been identified as the single most important source of preventable morbidity and mortality worldwide. In 2009, smoking among men was highest in the Western Pacific Region, with 51 % of men aged 15 and above smoking some form of tobacco. Smoking among women was highest at 22 % in the European Region. As of 2012 different countries like China (28 %), USA (19 %), and Great Britain (22 %), tobacco prevalence is still in higher rates (CDC, WHO China, WHO 2013a, b, c, d, e, f, National Stat. (UK), Giovino 2002). If this current trend persists for the next 30 years, it is estimated that 10 million people will die every year from smoking-related diseases (WHO 2013a, b, c, d, e, f). Tobacco Smoking in Saudi Arabia Tobacco smoking is one of the public health problem in Saudi Arabia. It is estimated that 37 % of adult male and 6 % of adult female are current smokers. This numbers are expected to increase according to World Health Organization (WHO EMRO, Saudi Arabia 2010). The economic burden of tobacco consumption over the last 10 years (2001–2010) in the Kingdom of Saudi Arabia (KSA) was 20.5 billion US$ (2011 US$ prices) without accounting for smuggled tobacco (AlBedah and Khalil 2013). Moreover, cigarettes were the principal source of tobacco consumption in KSA, among students (62.6 %) and adults (59 %) smokers (Jarallah et al. 1999; Bassiony 2009; Amin et al. 2011). Secondly, nargile or water pipes (sheesha) were most frequently source of tobacco consumption especially among women (Subhan et al. 2009; Mandila et al. 2010; Koura et al. 2011). Multiple studies documented the prevalence rate of smoking in the Kingdom. In a study of students at King Faisal University, Saudi Arabia, Al-Mohamed and Amin found that 21.8 % of students were cigarettes smokers. The smoking prevalence rates are higher among the males than females. In a cross-sectional study by Al Gobain et al. (2011) among secondary schools in Saudi Arabia, prevalence among boys and girls were 19.5 % (31.2 % of boys and 8.9 % of girls). Studies shown that prevalence of smoking in KSA was comprising of different age groups and genders. Different factors associated with tobacco smoking should be determined in order to provide appropriate measures, cessation programs especially among youth. Factors Associated with Smoking Determining factors such as knowledge, behaviors, and attitude that initiate people to smoke is important in helping prevent from starting. The relationship of tobacco smoking
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to religious practice, parental and peer smoking practices and attitudes and knowledge of the dangers of tobacco constitutes an important risk factor for the tobacco smoking. Numerous studies have suggested that religious involvement may promote health and deter negative health behaviors, including smoking, alcohol and substance use/abuse. In a study of medical students at King Fahad Medical City, Al Kaaba found that 35.4 % of the students never try from smoking because of religious beliefs. Saudi Arabia is a Moslem country, and Islam is practice by all Saudi citizens. The teaching of Mohammed (Peace Be Upon Him) directly influences behaviors like smoking, however, not all Saudis are equally devoted to their religion. A scale to measure religious involvement was developed as part of this study. Based on research in the USA, parental behavior and attitudes clearly influence the smoking practice of their adolescent children. Cigarette smoking is likely affected by more than parents’ actual smoking behaviors and attitudes toward cigarette smoking. The relationship of adolescents and their parents likely affect the significance of parents’ attitudes and behaviors. Moreover, knowledge was a variable that most people in Saudi Arabia would expect to be the focus of any tobacco education program. Although there is no assurance of behavior change, simply providing knowledge and measuring along with attitudes and behavior will identify factors that continually increase smoking behavior. This study aims to describe the relationships of smoking behavior among male college students in Saudi Arabia to their religious practice, parents smoking behaviors and attitudes, peers’ smoking behaviors and attitudes, and knowledge about the dangers of smoking
Methods The setting of this study was Riyadh City, Saudi Arabia, which has a population approximately 24 million. The Saudi government lays heavy emphasis on education and spends considerable money on basic and higher education. As of 2001, Saudi Arabia had a total of eight government universities and 15 private colleges. King Saud University, the largest and most prestigious, enrolled some 25,000 students. Sample The sample for this study included 715 male college students enrolled during the academic year 2013 in the College of Education and College of Science, King Saud University, Riyadh, Saudi Arabia. The sample site was selected for convenience and the age of students on the basis of the likelihood they would be new tobacco users. Males were selected because the investigator was male; and in Saudi Arabia, it would not have been acceptable for a male to study female behaviors. As such, it was recognized that the generalizability of this research would be limited. However, it was also recognized that male college students of this age in King Saud University were probably like male college students at the other seven government universities in Saudi Arabia. The participants’ ages ranged from 19 to 28 years. The investigator asked the professors of general studies courses with large enrollment for permission to administer the survey in their classes. Students were told about the survey and asked if they would be willing to participate. Those who agreed were given a questionnaire. No names or other identification was collected. The questionnaire stated that
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each individual had the right to decline to complete the survey or to answer any specific questions. The questionnaire consisted of 49 questions used to describe the demographic characters of the sample, the practice of Islam, cigarette smoking status, sheesha smoking status, parents’ tobacco use and attitudes, peers’ tobacco use and attitudes, and knowledge of the dangers about the tobacco use. The survey was based on a literature review and suggestions from a panel of experts. The instrument was pilot tested, revised, and translated from English to Arabic and back to English. The proposal of this study had been approved by the ethics committee of King Saud University Data Analysis The data collected from the survey will be coded and entered into the mainframe computing system using SPSS version 16 (Chicago, IL, USA). A significance level of 0.05 was set to determine statistical significance for all tests. The demographic characteristics of the sample were analyzed using frequency statistics. Cronbach’s Alpha was used to establish the reliability of the responses to the survey questions. Logistic regression analysis were used to predict smoking behavior from the practice if Islam, parental peers tobacco use and Table 1 Demographic characteristics Education
Science
v2
Total
N
%
N
%
N
%
194
53.4
259
73.5
453
63.4
Age 19–21
42.705*
22 age older
169
46.6
93
26.5
262
36.6
Total
363
100
352
100
715
100
v2 = 42.705
df = 1
p = .000
69
19
47
13
116
16.3
Father education Illiteracy
10.522*
Elementary
69
19
71
20
140
19.6
Secondary
72
20
55
16
127
17.8
High school
66
18
63
18
129
18
College or post-college
87
24
116
33
203
28.3
Total
363
100
352
100
715
100
v2 = 10.522
df = 4
p = .032
125
35
114
32
239
33.4
Mothers education Illiteracy
10.522*
Elementary
109
30
87
25
196
27.4
Secondary
44
12
41
12
85
11.9
High school
55
15
57
16
112
15.7
College or post-college
30
8
53
15
83
11.6
Total
363
100
352
100
715
100
v2 = 9.324
df = 4
p B .53
* p-value significant at p \ 0.05
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attitudes. Logistic regression analysis was also used to predict smoking behavior from the measure of knowledge of the danger of smoking. The dependent variable was tobacco use (‘‘0’’ coded as non-smoker and ‘‘1’’ coded as smoker). Respondents were defined as current smokers, if they were smoking at the time of the survey and smoke at least one cigarette every day for the last 30 days; they were defined as non-smokers, if they did not smoke during the past 30 days.
Results Tobacco use has been identified as the single most important source of preventable morbidity and mortality worldwide. However, there is limited research on tobacco use in Saudi Arabia. The purpose of this study was to explore the role of religion, parents, peer behavior and attitudes, and knowledge about the dangers of smoking on smoking behavior among young users. A sample of 715 college students voluntarily completed an anonymous survey that described their religious practice, parents’ tobacco use and their attitudes toward their fiends smoking and knowledge of the danger of tobacco use. Description of the Sample Male students in the College of Education and College of Science in King Saud University in Riyadh Saudi Arabia were surveyed. A total of 800 surveys were distributed with 734 Table 2 Tobacco smoking status Education N
Science %
N
v2
Total %
N
%
Cigarette smoking status Non-smokers
260
71.6
294
83.5
554
77.5
Smokers
103
28.4
58
16.5
161
22.5
352
100
715
100
Total
363
100
v2 = 17.550
df = 1
p = .000
17.550*
Sheesha smoking status Non-sheesha smokers
292
80.5
309
87.8
601
84
Sheesha smokers
71
19.5
43
12.2
114
16
Total
363
100
352
100
715
100
v2 = 18.275
df = 1
p = .000
Non-smokers
231
63.6
271
77
502
70.2
Cigarette smokers
61
16.8
38
10.8
99
13.8
Sheesha smokers
29
8
23
6.5
52
7.3
Cigarette and sheesha smokers
42
11.6
20
5.7
62
8.7
Total
363
100
352
100
715
100
v2 = 16.864
df = 1
p = .001
18.275*
Tobacco smoking 16.864*
* p-value significant at p \ 0.05
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(91.7 %) returned. Results from 715 completed surveys were recorded and analyzed with SPSS 16. Table 1 shows the demographic characteristics of the sample (N = 715). Three hundred sixty-three (50.8 %) students were from the College of Education, and 352 (49.2 %) were from the College of Science. Students in the College of Education were older than those in the College of Science, 46.7 % of the education students, and 26.5 of the College of Science student being 22 years and older. The age between the two colleges was statistically significant (v2 = 42,705, df = 1, p \ .05). Therefore, the College of Science’s students were likely to be younger than the College of Education’s students. With respect to fathers’ educational status, 16.3 % were illiterate, 19.6 % had elementary level, 35.8 % had a secondary or high school degree, and 57 % had a college or post-college degree. The difference in fathers’ education between the College of Education and the College of Science was statistically significant difference (v2 = 10.522, df = 4, p \ .05), with fathers of the College of Science students being more likely to be educated than the fathers of the College of Education. With respect to mothers’ educational status, 33.4 % of the mothers were illiterate, 27.4 % had elementary education, 27.6 % had a secondary or high school degree, and 11.6 % had a college or post-college degree. There was no statistically significant difference between the mothers’ education of students in two colleges (v2 = 9.324, df = 5, p [ .05). For this study, anyone who had smoked at least one cigarette daily in 30 days prior to the survey was a smoker. Table 2 clearly suggests that students in the College of Education
Table 3 Binomial logistic regression model for religion, knowledge, and predicting smoking behavior Variable
B
SE
Wald v2
p
Religion
-0.159
0.027
33.96
0.000*
0.853
.808–.900
Knowledge
-0.91
0.39
5.52
0.019
0.91
.84–.98 2.38–9.69
Odds ratio
95 % CI
Peers behavior smoking status (non-smoker as a reference) Few
1.57
0.35
19.32
0.000*
4.81
Half
2.55
0.37
46.47
0.000*
12.86
6.17–26.82
All of them
2.68
0.37
51.15
0.000*
14.67
7.03–30.64
Peers’ smoking attitude (disagree as a reference) Neutral
1.37
0.29
22.48
0.000*
3.96
2.24–7.01
Agree
1.68
0.2
70.58
0.000*
5.38
3.63–7.96
0.00*
0.89
.84–.95
0.4
1.9
1.0–3.6
0.000*
3
1.9–4.5
Logistic regression model predicting smoking behavior Religiona
-0.109
0.02
15.32
Peers attitudesa (non-smokers as reference) Neutral
0.65
0.32
4.2
Agree
1.09
0.21
25.38
Peer behaviorsa (non-smoker as reference) Few
1.1
0.37
8.97
0
3
1.4–6.2
Half
1.9
0.39
23.56
0
6.7
3.1–14.6
All of them
2
0.39
27.97
Knowledgea
-0.82
0.04
3.6
0
8
3.7–17.4
0.04*
0.92
.84–.99
* p-value significant at p \ 0.05 a
Where -2log likelihood = 737.79; Cox and Snell R2 = .10; adjusted Nagelkerke R2 = .15
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were much more likely to be smokers than the students in the College of Science. In the College of Education, 28.4 % were smokers and 16.5 % were smokers in College of Science. The differences between the two colleges were statistically significant (v2 = 17.550, df = 11 p \ .05). 63.6 % were non-smokers compared to 77 % in the College of Science. In the College of Education 16.8 % of the students smoked cigarettes and in the College of Science, it was 10.8 %, while 8.0 % of the students in College of Education smoked sheesha and 6.5 % in the College of Science. In the College of Education, 11.6 % of the students smoked both cigarettes and sheesha and 5.7 in the College of Science. Almost 30 % (29.8 %) of the two colleges’ students were smokers. The differences between the College of Education and the College of Science were statistically significant (v2 = 16.864. df = 1, p = .001). A direct logistic regression analysis was performed with smoking behavior as the outcome and four independent predictors being: practice Islam, knowledge about the dangers of smoking, peers’ smoking status and attitudes toward smoking, and peers approval of smoking. Parents were excluded from the model, because of insufficient variance in parental attitudes and smoking behaviors. Table 3 shows that students who practice Islam would be less likely to smoke (cigarettes or sheesha). The odds ratio (.85) was less than 1 indicating a decreased likelihood of a student who practices Islam of smoking (Table 14). Students who practice their religion were 15 % less likely to smoke. Result also shows that students with peers who do not smoke would be less likely to smoke. Students who reported having a few peers who smoked (non-smokers as reference) were almost five times more likely to smoke; students who reported that half of their peers smoked were 12 times more likely to smoke. Students who reported that all of their peers smoked were 14 times more likely to smoke. Results also supported (Table 3) that students with peers who approved of their friends smoking were more likely to smoke. Students who reported that their peers were neutral in their attitude toward their smoking were 3.96 times more likely to smoke, and those who reported their peers agree with their smoking were 5.38 times more likely to be smokers. Table 3 also shows that all of the remaining four predictors significantly predicted smoking behaviors. The model had an overall classification accuracy of 78 %. The important contributing variables in the model were peers’ behaviors. Peers who reported a few of their friends smoked were three times more likely to smoke than peers who reported their friends did not smoke, peers who reported half of their friends smoked were almost seven times more likely to smoke than peers who reported their friends did not smoke, and peers who reported all of their friends smoked were eight times more likely to smoke than peers who reported their friends did not smoke.
Discussion This study examined smoking behavior among students in the College of Education and the College of Science in King Saud University in Riyadh, Kingdom of Saudi Arabia. This was the first-known study of the influence of religion, parent and peer behavior and attitudes toward smoking, and knowledge about the dangers of tobacco smoking among male college students in Saudi Arabia. The results showed that 29.8 % of males were smokers (13.8 % cigarette smokers, 7.3 % sheesha smokers, and 8.7 % cigarette and sheesha smokers). The prevalence of smoking reported here was higher than the prevalence reported in previous studies (Subhan et al. 2009; Mandila et al. 2010; Al-Kaabba et al. 2011) in Saudi Arabia. The actual
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prevalence may be even higher than 29.8 %, because the Saudi government banned smoking on religious principle since 1926, as well as smoking—free policies on public places were implemented. Religious, cultural, and social constraints may have discouraged smokers from reporting their smoking habits and (Park et al. 2012). A number of studies have investigated the influence of religion, parent and peer behaviors and attitudes toward smoking, and knowledge about the dangers of tobacco use on smoking behavior (Mahabee-Gittens et al. 2013; Park et al. 2012; Al Azhar and Al Sayed 2012; Villanti et al. 2011; Al Nohair 2011; Al-Kaabba et al. 2011; Al Ghobain et al. 2011; Al Moamary et al. 2012; Wali 2011; Koura et al. 2011; Luk et al. 2010). In study, these four factors were examined independently and all together. Religion In this study, religious practices significantly predicted smoking behavior. Students who practiced Islam (that is, students who answered affirmatively questions about reading Quran, reciting Quran, performing prayers at the Mosque, maintaining the five daily prayers, giving to charity, and faithful status) were less likely to smoke. These findings are compatible with (McFadden et al. 2011) who noted that an increasingly higher proportion of the non-religious used tobacco. The Quran prohibits physically harmful behaviors, and tobacco use is considered haram (unlawful) in Islam. Because Saudi Arabia is an overwhelmingly Islamic country and Saudi people readily accept teachings that reference principles found in the Quran, it is recommended that religious principles be included in smoking prevention programs for use in Saudi Arabia. Parents’ Behaviors and Attitudes Parental disapproval of smoking was almost universal in this sample. Ninety-three percent of the students reported their fathers disapproved of smoking; 96.8 reported their mothers disapproved. The effects of parents; smoking behaviors and attitudes could not be examined in this study because of the lack of variance in the data. Disapproval of parents about tobacco use is an important predictor of student’s intention to smoke. Therefore, programs developed to prevent and reduce tobacco use by young people should reinforce parent’s disapproval, and parents should be encouraged to make sure their children know of their disapproval (Kong et al. 2012). Peers’ Behaviors and Attitudes The influence of peers’ smoking behaviors has been well documented (Mahabee-Gittens et al. 2013; Park et al. 2012; Al Azhar and Al Sayed 2012; Al Nohair 2011; Al-Kaabba et al. 2011; Al Ghobain et al. 2011; Al Moamary et al. 2012; Wali 2011; Koura et al. 2011; Kong et al. 2012; Villanti et al. 2011). Clearly, logistic regression showed that smoking behavior in this was significantly predicted by the peers’ smoking behaviors. The magnitude of odds ratio for tobacco use as predictor for tobacco use increased substantially as the number of friends who smoked increased. The model predicted cigarette and sheesha smoking. Helping young people understand the power of peer pressure and develop strategies to deal with peer pressure will need to be an important part of any educational program that is developed to reduce smoking behavior in Saudi Arabia. While there are many examples of
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this type of educational program developed in Western countries, there are none that have been developed for Saudi Arabia. Developing an educational program to deal with peer pressure that is acceptable to and effective with Saudi Arabian youth will require careful research of the specific dynamic of smoking and non-smoking peer pressure in the culture of Saudi Arabia. Knowledge These results demonstrated that knowledge about the danger of smoking was a predictor of smoking behavior. Risk awareness alone seems insufficient to deter smoking (Hamner and Stumpfa 2001). To be acceptable to the public in general, any educational program to reduce smoking behavior will need to include a section on knowledge of danger, because that is what the public expects. The contribution of knowledge to behavior change, although significant in this study, was very small. The results of this study suggest that the prevalence of smoking among college students is higher than previously reported. The need for prevention program to reduce smoking— related morbidity and mortality is supported. Prevention program at the college level or earlier is needed in Saudi Arabia, if the rates of smoking are to decline. Prevention programs will need to include education and changes in public policy. More research is needed to develop prevention plans. This research suggest that effective prevention program will need to address three of the four factors studied in this research: religion, peer’ attitudes, peers’ behaviors, and knowledge. Unless a prevention program in Saudi Arabia is multidimensional and addresses these factors and probably other, it will likely fail. Without a full understanding of how these factors interact and a better understanding of the behavior change of quitting and taking up smoking, it will be difficult to design effective prevention programs. Based on the results of other research (Mahabee-Gittens et al. 2013; Villanti et al. 2011; Kong et al. 2012; Luk et al. 2010), it is likely that prevention programs also will need to include the involvement of parents. Because of the absence in statistical variance in the data collected in this research, it is not possible to say anything definitive about the parental influences. The most significant finding of this study is the importance of the effect of peer behavior and peer attitudes toward smoking on the smoking behavior of adolescents. There is a clear need to more fully understand the dynamics of peer relationships, if prevention programs are to help young people manage peer relationships in regard to tobacco use. To better understand peer dynamics among male Saudi youth, it is likely that qualitative research methods will yield the most valuable data. Knowing about the dynamics of peer relationships and peer pressure, as seen by the young people themselves, will be necessary first step in developing more sophisticated quantitative measures. Individual interviews with young men and focus groups with young men, both carefully planned and carried out with trained researchers, should generate valuable data for developing both more sophisticated measures of peer dynamics and educational programs to help young men manage peer pressure. This study confined itself to studying males in two Saudi Arabian colleges and therefore, the generalizability of the results is limited. However, it is likely that the male college students in this study were not significantly different from male students in other colleges. Therefore, it is likely that the finding of this study generalize to other male college students. There is little research about adolescent smoking behavior in Saudi Arabia. There is a need for: (1) Studies exploring further the dynamics of peer relationships, (2) basic
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descriptive research of smoking behaviors among non-college young people and among women, (3) increased research in each of the areas explored in this research, (4) detailed studies of sheesha smoking, following the pattern used for cigarette research, (5) studies of the effects of the government’s policies on tobacco marketing on adolescent smoking rates, and (6) studies that carefully evaluate the effectiveness of prototype smoking prevention programs. References Al Azhar, A., & Al, Sayed N. (2012). Prevalence of smoking among female medical students in Saudi Arabia. Asian Pacific Journal of Cancer Prevention, 13(9), 4245–4248. Al Ghobain, M. O., Al Moamary, M. S., Al Shehri, S. N., & Al-Hajjaj, M. S. (2011). Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia. Annals of Thoracic Medicine, 6(3), 137–140. doi:10.4103/1817-1737.82447 Al Moamary, M. S., Al Ghobain, M. O., Al Shehri, S. N., Gasmelseed, A. Y., & Al-Hajjaj, M. S. (2012). Predicting tobacco use among high school students by using the global youth tobacco survey in Riyadh, Saudi Arabia. Annals of Thoracic Medicine, 7(3), 122–129. doi:10.4103/1817-1737.98843 Al Nohair, S. F. (2011). Prevalence of Smoking and its related behaviors and beliefs among secondary school students in Riyadh, Saudi Arabia. International Journal of Health Sciences, 5(1), 57. AlBedah , A. M. N., & Khalil, M. K. M. (2014). The economic costs of tobacco consumption in the Kingdom of Saudi Arabia. Tobacco Control, 23, 434–436. doi:10.1136/tobaccocontrol-2012-050665. Al-Kaabba, A. F., Saeed, A. A., Abdalla, A. M., Hassan, H. A., & Mustafa, A. A. (2011). Prevalence and associated factors of cigarette smoking among medical students at King Fahad Medical City in Riyadh of Saudi Arabia. Journal of Family and Community Medicine, 18(1), 8–12. Amin, T. T., Monhem Amr, M. A., & Zaza, B. O. (2011). Psychosocial predictors of smoking among secondary school students in Al-Hassa, Saudi Arabia. Journal of Behavioral Medicine, 34, 339–350. Bassiony, M. (2009). Smoking in Saudi Arabia. Saudi Medical Journal, 30, 876–881. Giovino, G. A. (2002). Epidemiology of tobacco use in the United States. Oncogene, 21(48), 7326–7340. Hamner, R. T., & Stumpfa, S. H. (2001). Survey of smoking knowledge, attitudes and practice in school children in Honduras. Familiy Practice, 18(6), 627–628. Jarallah, J. S., Al-Rubeaan, K. A., Al-Nuaim, A. R., Al-Ruhaily, A. A., & Kalantan, K. A. (1999). Prevalence and determinants of smoking in three regions of Saudi Arabia. Tobacco Control, 8, 53–56. Kong, G., Camenga, D., & Krishnan-Sarin, S. (2012). Parental influence on adolescent smoking cessation: Is there a gender difference? Addictive Behaviors, 37(2), 211–216. Koura, M. R., Al-Dossary, A. F., & Bahnassy, A. A. (2011). Smoking pattern among female college students in Dammam, Saudi Arabia. Journal of Family and Community Medicine, 18(2), 63–68. doi:10.4103/ 2230-8229.83370. Luk, J. W., Farhat, T., Iannotti, R. J., & Simons-Morton, B. G. (2010). Parent–child communication and substance use among adolescents: Do father and mother communication play a different role for sons and daughters? Addictive Behaviors, 35, 426–431. Mahabee-Gittens, E. M., Xiao, Y., Gordon, J. S., & Khoury, J. C. (2013). The dynamic role of parental influences in preventing adolescent smoking initiation. Addictive Behaviors, 38, 1905–1911. Mandila, A., BinSaeeda, A., Ahmada, S., Al-Dabbagha, R., Alsaadib, M., & Khanc, M. (2010). Smoking among university students: A gender analysis. Journal of Infection and Public Health, 3, 179–187. McFadden, D., Croghan, I. T., Piderman, K. M., Carl Lundstrom, C., Schroeder, D. R., & Taylor Hays, J. T. (2011). Spirituality in tobacco dependence: A Mayo clinic survey. Explore, 7, 162–167. Park, H. K., Al- Agili, D. E., & Bartolucci, A. (2012). Factors affecting tobacco use among middle school students in Saudi Arabia. Maternal and Child Health Journal, 16, 1828–1836. Subhan, M. M., Al-Khlaiwi, T., & Ghandourah, S. O. (2009). Smoking among health science university students in Riyadh, Saudi Arabia. Saudi Medical Journal, 30(12), 1610–1612. U.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving Health. Washington, DC Author. Accessed 2 Oct 2013, http://www.healthy.gov/ healthypeople. U.S. Department of Health and Human Services (2010). A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What It Means to You. 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, 2010. Accessed 10 Oct 2013. http://www.cdc. gov/tobacco/data_statistics/sgr/2010/.
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J Relig Health Villanti, A., Marc Boulay, M., & Juon, H. S. (2011). Peer, parent and media influences on adolescent smoking by developmental stage. Addictive Behaviors, 36, 133–136. Wali, S. O. (2011). Smoking habits among medical students in Western Saudi Arabia. Saudi Medical Journal, 32(8), 843–848. World Health (WHO) (2013a). Tobacco. MPOWER measures. Accessed Sept 2013. www.who.int/tobacco/ mpower/appendix_4_crude_adult_prevalence.xls. World Health Organization (WHO); Global Health Observatory (2013b). Prevalence of tobacco use. Accessed Sept 2013. http://www.who.int/gho/tobacco/use/en/. World Health Organization (WHO) (2013c). Tobacco. China smoking prevalence tobacco economy. Accessed Sept 2013. www.who.int/tobacco/media/en/China.pdf. World Health Organization (WHO) (2013d). WHO Report on the Global Tobacco Epidemic 2013. Accessed Sept 2013. http://www.who.int/tobacco/global_report/2013/en/. World Health Organization (WHO) (2013e). WHO Tobacco factsheet. Updated 2013 July. Accessed Sept 2013. http://www.who.int/mediacentre/factsheets/fs339/en/. World Health Organization Regional Office for the Eastern Mediterranean (2013f). Saudi Arabia Profile. [Updated 2010 August]. Accessed 13 Sept 2013. http://www.who.int/tobacco/surveillance/policy/ country_profile/sau.pdf.
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