J Community Health DOI 10.1007/s10900-014-9900-4
ORIGINAL PAPER
Prevalence of Tobacco Use and Exposure to Environmental Tobacco Smoke Among Saudi Medical Students in Riyadh, Saudi Arabia Khalid M. Almutairi
Ó Springer Science+Business Media New York 2014
Abstract This study was designed to determine the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Riyadh, Saudi Arabia, and to examine their attitudes and beliefs towards tobacco control programs. The investigation was a cross-sectional study conducted during the first semester of 2013 at King Saud University School of Medicine located in Riyadh, Saudi Arabia. Invited to participate in this study were 1,789 medical students. A descriptive data analysis was performed. A total of 805 medical students completed the questionnaire. The prevalence of experimentation with cigarette smoking was 11.3 %. The estimated prevalence of current smoking among the study participants was 4.7 %. The majority of the students held positive attitudes toward tobacco control and approximately 93.1 % of the students felt that health care professionals should be required to receive training for cessation counseling while only 36.8 % of the students reported having received any training in this area. Over the study’s duration 57.7 % of participants reported that ETS exposure was much higher in public places, while 13.9 % reported exposure at home. This investigation revealed that ETS exposure among medical students in Riyadh is at an alarmingly high rate. The data suggests a need for a more robust smoke-free policy and a commitment to greater enforcement in public places. The results of the study also demonstrate a positive attitude among participants for tobacco control. It also indicates a need for cessation counseling and training which could be incorporated into medical school curriculum.
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]
Keywords Tobacco control policies Environmental tobacco smoke exposure Tobacco use among medical students in Saudi Arabia Tobacco use among healthcare professionals Smoking cessation training for healthcare professionals Introduction As reported by the World Health Organization (WHO), tobacco use is currently responsible for more than 6 million deaths each year, and is considered a worldwide public health threat [6]. Its usage is in direct correlation with the high rates of morbidity all over the world, and it is a situation that is preventable. Substantial and sustained efforts are required to further reduce smoking prevalence and its associated mortality rates [1]. In Saudi Arabia, the smoking rates reported in this publication were determined by averaging statistics from several studies conducted over a 16 year period. These figures demonstrated that 35–40 % of adult males and 24 % of preparatory school students were considered to be regular smokers [2]. From 1996 through 2012, tobacco consumption rates in Saudi Arabia have risen from 21.9 % of males and 0.6 % of females in 1996 to 37 % of males and 6 % of females in 2012. According to these studies the current rate of tobacco consumption among Saudi males was 37 %, and 6 % among females. Further review of the data reveals that from 1996 to 2000 the tobacco prevalence rate among male Saudis was 21.0 % and 0.6 % for female Saudis; while from 2001 to 2005 the rate of tobacco use among Saudi males was 20.9 % and 1.2 % for females [3– 6]. While there was a slight decrease in the early part of the century, the data suggests that there has been a dramatic increase in tobacco use over the past 10 years among health care professionals in Riyadh.
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J Community Health
According to results from a study conducted in 2006 in Riyadh, Saudi Arabia, among 322 medical students, the prevalence of daily smokers was 13.0 %. Furthermore, approximately 122 of these students (38.2 %) were regularly exposed to second hand smoke and 54.7 % of the respondents reported that smoking cessation programs were unavailable in their academic environment [7]. As a result, concerns have been raised about the current status of tobacco use among medical scholars and researchers in Saudi Arabia. In 2004, the WHO working in conjunction with other reputable international health organizations (U.S. Centers for Disease Control and Prevention, and Canadian Public Health Association) developed the Global Health Professionals Survey (GHPS) that is collectively used to gather data about pervasiveness of tobacco use and the development and implementation of cessation education and treatments among medical and health professional students in all WHO member states [8, 9]. It is a school-based survey of third-year students pursuing professional degrees in medicine, pharmacy, dentistry and nursing. The GHPS adopts a core questionnaire to collect information on demographic data, prevalence of tobacco use (e.g. cigarettes, cigars or pipes), knowledge and attitudes towards tobacco use, ETS exposure, and their opinions on and willingness to stop smoking [9]. Health care professionals play a crucial role in educating the public about the risks of tobacco use, in motivating their patients to quit as well as providing advice and guidance on overall health in general. Because of this, the first step in establishing a successful anti-tobacco campaign is to assess the views and attitudes of health care professionals; and from there determine which measures would provide the best rate of success in the reduction of tobacco use. It is without a doubt that with strong tobacco education, prevention and treatment programs in place, future health care professionals will serve as front line educators for their patients on the hazards of tobacco consumption. This study was designed to estimate the prevalence of active smoking among medical students in Riyadh, Saudi Arabia, as well as their attitudes and beliefs towards tobacco control measures. This study also aims to determine the extent of ETS exposure within their community.
Methods This study has been approved by institutional review board i.e. Ethical Review Committee, King Saud university. All the subjects have been informed and have given the consent for using the data/samples for investigations, which has been documented in attested performa by the investigator.
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This research was a cross-sectional study conducted at King Saud University, Riyadh, Saudi Arabia during the first semester of 2013. A total of 1,789 medical students ranging from the first- year to the fifth-year were invited to participate in the study. A standard self-administered questionnaire was derived from the GHPS. The questionnaire requests information about demographics, prevalence of tobacco usage, attitudes, desire for smoking cessation, ETS exposure and training received on smoking cessation counselling and techniques. The questionnaire was distributed to the students prior to a group lecture in an effort to include as many respondents as possible, and was also translated from English to Arabic and back to enhance the response rate. Before the start of the survey, the investigator received permission from professors to administer the survey. Students were then advised about the survey and asked if they would be willing to participate. No names or other identifying information were collected. The questionnaire stated that each individual had the right to decline to complete the survey or to answer any specific questions. For the purpose of the study, self-identified smokers were defined into three groups: current smokers, former smokers and ever smokers. Current smokers as a group were defined by those who had smoked any tobacco products daily or occasionally and at any point during the study. Former smokers were defined as those who had previously had a daily smoking habit for a continuous period of[6 months, but had given up smoking by the time of the inquiry. Ever smokers included both current and former smokers. ETS exposure was defined for the purposes of this study as experiencing the inhalation of second hand smoke during the previous 7 days. The proposal for this study was approved by the ethics committee of King Saud University, Riyadh, Saudi Arabia. Data from the questionnaires was entered into a computer, and analyzed using statistical analyses performed with SPSS 20.0 for Windows software (SPSS Inc., Chicago, IL, USA) and was presented as percentages (%) for enhanced data comparisons between the claimed similarities and differences. A Chi squared test was used for categorical data to compare the differences in proportion. The significance level was set at P \ 0.05. Because the GHPS pilot study was conducted among third-year students, our study also focused on the responses from third-year medical students for the purposes of a valid comparison.
Results From the pool of 1,789 invited participants, a total of 805 first-year to fifth-year medical students completed the survey, providing a response rate of 44.9 % (77.3 % male,
42.6 (30.2–54.4) [73]
7.0 (0–16.4) [12]
0
0
2.3 (0–5.3) [4]
4.7 (0–10.7) [8]
Total (n = 171) % (95 % CI) [n]
8.7 (0–17.4) [15]
7.01 (0–8.7) [12]
J Community Health
22.7 % female). The prevalence of tobacco use and ETS exposure among Saudi medical students are shown in Table 1. Attitudes, beliefs and education about tobacco control among Saudi medical students are represented in Table 2.
45.2 (30.1–60.3) [14] 54.5 (52.2–63.2) [439] 52.4 (48.9–62.7) [326] Place other than home
61.7 (56.3–74.5) [113]
42.4 (23.6–61.2) [59]
12.9 (1.5–24.3) [4] 5.7 (0–21.1) [8] 13.9 (11.2–20.2) [112] 15.4 (11.2–25.4) [96] Home
Sources of ETS exposure
18.4 (14.2–25.8) [34]
0 0
0
1.7 (0.3–4.1) [14]
0 Inside university building
1.0 (0–2.8) [2]
0
1.9 (0–5.4) [12]
0
University premises (outside)
Place of smoking on campus
0
6.7 (0–16.8) [2] 4.2 (0–14.5) [6] 3.3 (0–8.1) [21] Former
6.5 (2.8–9.8) [12]
3.9 (1.1–6.7) [33]
0 2.8 (0–7.5) [4] 4.7 (3.8–5.6) [34]
6.4 (0–13.4) [2] 7.1 (0–11.7) [10] 3.3 (0–6.7) [67]
5.3 (4.3–7.7) [33] Current
7.1 (0–6.0) [13] 8.6 (0–9.3) [54] Ever
Daily smoking habits
12.2 (7.2–19.5) [76] Ever tried or experimented with cigarette smoking, even one or two puffs
Smoking status
0.6 (0–1.6) [1]
8.5 (3.3–20.3) [12] 11.3 (9.4–16) [91] 9.8 (5.3–20.1) [18]
Male (n = 140) % (95 % CI) [n] Total (n = 805) % (95 % CI) [n] Female (n = 183) % (95 % CI) [n] Male (n = 622) % (95 % CI) [n]
All students
Table 1 Prevalence (%) of active smoking and ETS exposure among Saudi medical students by gender, 2013
Third-year students
Female (n = 31) % (95 % CI) [n]
9.6 (3.9–23.1) [3]
Smoking Prevalence and ETS Exposure The percentage of current smokers among medical students involved in this study was 4.7 % (95 % CI 3.8–5.6). The percentage of those who had ever tried or experienced cigarette smoking was 11.3 % (95 % CI 9.4–16). In addition, the number of males within the ever smoker group was 3.5 % (95 % CI 0–9.3), while female ever smokers was 2.7 % (95 % CI 0–6.0) providing a total prevalence of 3.3 % (95 % CI 0–6.7). The rate of ever or current smokers among third-year students was higher compared to other groups in this study (first-year, second-year, fourth-year and fifth-year), but this difference was not statistically significant. This investigation found that the majority of current smokers among this control group were males; however, more females had reported being ever smokers (Table 1). According to the data, none of the study participants smoked inside the university facilities. Over the 7 day study period 57.7 % (95 % CI 52.2–63.2) of the participants reported that their ETS exposure was much higher in public places, while 13.9 % (95 % CI 11.2–20.2) of the participants reported regular ETS exposure at home. Attitudes, Beliefs and Training Regarding Tobacco Control Table 2 represents the patterns of students’ attitudes, beliefs and education received about tobacco control. Nearly all of the respondents agreed that tobacco sales among adolescents should be banned (89.4 %). The great majority of the respondents (87 %) believed that health care professionals should serve as public health role models, that advertisements for tobacco products be banned; that smoking in public places be banned, and that health care professionals be required to receive extensive training on smoking cessation techniques. The patterns of attitudes and beliefs among third-year students were similar to those among the entire control group. Likewise, almost all of the participants believed that health care professionals who smoked were less likely to advise their patients to stop smoking (77.4 %). In regards to tobacco control education, nearly all the study participants had learned about the hazards of smoking (91.5 %) and most had been exposed to information about nicotine replacement products (90.2 %). Similarly, 94 % of the participants believed that health care
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J Community Health Table 2 Attitudes, beliefs and training about tobacco control among Saudi medical students by gender, 2013 (%) All students Male (n = 622) % [n]
Third-year students Female (n = 183) % [n]
Total (n = 805) % [n]
Male (n = 140) % [n]
Female (n = 31) % [n]
Total (n = 171) % [n]
Attitudes Tobacco sales to adolescents should be banned
89.0 [556]
90.8 [164]
89.4 [720]
90.7 [127]
83.9 [26]
89.5 [153]
A complete ban of tobacco product advertising
79.0 [487]
88.8 [163]
81.4 [650]
75.7 [106]
90.3 [28]
78.4 [134]
Ban on smoking in restaurants
94.8 [592]
96.7 [178]
95.3 [770]
96.4 [135]
100 [31]
97.1 [166]
Ban on smoking in all enclosed public areas
89.0 [560]
90.8 [168]
89.4 [728]
93.6 [131]
96.8 [30]
94.2 [161]
Believe health care professionals should obtain specific training on smoking cessation techniques
91.7 [582]
94.1 [172]
92.3 [754]
100 [140]
93.5 [29]
98.8 [169]
Believe health care professionals serve as a role models
84.0 [536]
92.1 [160]
85.9 [696]
93.6 [131]
64.5 [20]
88.3 [151]
Believe health care professionals should provide advice about smoking cessation
93.2 [580]
92.8 [172]
93.1 [752]
93.6 [131]
100 [31]
94.7 [162]
Health professionals who smoke are less likely to advise their patients to smoke
78.4 [483]
76.9 [139]
77.4 [622]
77.8 [109]
70.9 [22]
76.6 [131]
Health professionals who use other tobacco products were less likely to advise their patients to stop smoking
75.5 [469]
75 [137]
75.4 [606]
75.0 [105]
74.2 [23]
74.8 [128]
Beliefs
Curriculum/training Received knowledge about the hazards of smoking
90.1 [578]
93.4 [172]
91.5 [750]
100 [140]
96.8 [30]
99.4 [170]
Received formal training about smoking cessation approaches
36.1 [204]
38.8 [63]
36.8 [267]
21.4 [30]
12.9 [4]
19.9 [34]
Ever heard of nicotine replacement products
89.8 [573]
91.4 [169]
90.2 [742]
100 [140]
96.8 [30]
99.4 [170]
professionals should obtain some form of training about smoking cessation, while 36.8 % reported that they had received formal training regarding smoking cessation techniques.
Discussion Medical students are future health care professionals who will have the responsibility of providing information about the dangers of smoking and regular tobacco use to the public, and provide support in smoking cessation for their patients. Thus, it is important in the development of effective smoking cessation policies, to determine their attitudes and beliefs in regards to this issue. Previous studies in Saudi Arabia have shown that smoking among health care students in Abha 13.6 % and 13 % in Riyadh is quite high [7, 10]. Other studies have suggested that smoking rates were high among health care professionals even though they were educated about the harmful effects of tobacco use [11, 12, 16–18]. In this survey, the prevalence of smoking among Saudi medical students was low in comparison to those previous studies, with approximately 12.2 % males and 9.8 % females who
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had ever tried smoking. In addition, these figures were lower compared with previous studies conducted among other medical students in other countries (Greece, Poland, Spain, Italy, Syria and Germany, Fig. 1) [13–15]. However, though the results of smoking prevalence demonstrated in this study were low compared with previous studies in Saudi Arabia and other countries, our data did demonstrate that ETS exposure was high, especially in public locations. The percentage of medical students in this study that reported being exposed to ETS in public places for the 7 day period were relatively high, reaching about 54.5 % of overall response from the participants. Research has shown that prolonged exposure to secondhand smoke is as deadly as smoking itself [19, 20]. Evidence has suggested that there is no safe level of exposure, and that prolonged exposure to cigarette smoke leads to disease such as cancer, heart disease, stroke, asthma, and demonstrates a strong correlation to high death rates among non-smokers [19, 20]. The present study showed that the majority of the participants felt that smoking should be banned in all enclosed public places. Other studies on this topic also expressed concerned about secondhand smoke exposure, and most participants were well aware of the associated
J Community Health Fig. 1 Smoking prevalence among European and Middle Eastern countries
hazards and impacts [18, 21]. Implementing a smoke free policy for public places would not only protect nonsmokers from hazards of ETS exposure but may also encourage smokers to either quit or decrease their consumption [22]. Study participants demonstrated positive attitudes towards tobacco cessation as well as a belief that all health care students should receive formal education about smoking cessation approaches. Similar attitudes were also observed in other studies, but again, the number of students who receive formal training is minimal [23]. Introducing tobacco cessation techniques into the medical school curriculum and education about cessation counseling for smokers is an important topic that any medical university or institution should implement [8, 24]. Medical universities and health institutions have a professional responsibility to help their students quit smoking and provide education that will allow them to help their patients in the future [25]. Another interesting development from this study is the belief among health care students that health care professionals who smoke are less likely to advise their patients to stop smoking. According to Pipe et al., non-smoking physicians are more likely to provide a systematic counseling to patients about smoking cessation, and generally hold strong beliefs about the adverse effects of tobacco use [26]. Moreover, most medical students also feel that healthcare professionals should serve as responsible role models for the community and the general population. Thus, this belief may continue to grow as these medical students move into their professional roles within the community. Another interesting discovery from this study is the high prevalence of ETS exposure at home and in public places, demonstrating an urgent need for tobacco control programs to be created and circulated among the general population.
The positive attitudes toward tobacco cessation as reported by the study participants suggested a raised interest in the subject. This interest could be a signal that the time is right for the creation of an effective tobacco control program. To facilitate this, an anti-tobacco campaign should be implemented among current medical students, who will then promote the initiative among their patients, colleagues and local communities. It is a combined effort that will compound as more medical students are trained in this program. This study does present some limitations, the first of which is the design of the survey. A cross sectional survey was used to collect data on smoking prevalence, beliefs, attitude and a possible bias in the information could have occurred. However, a detailed questionnaire was used for data collection. Secondly, the study samples are not fully representative of the entire country. However, the author does believe that the findings from this study can help promote public health awareness and tobacco control programs particularly within healthcare institutions. In conclusion, the present study revealed the prevalence of smoking among Saudi medical students. Although the prevalence was low, the biggest concern is that ETS exposure is particularly high in public places and at home. The results also suggest a positive attitude among survey participants for tobacco control programs; the author believes that this particular finding will be of interest to medical institutions. This study suggests that a detailed tobacco control program and training in smoking cessation techniques be introduced into the curriculum of all medical institutions in Saudi Arabia. Acknowledgments The authors extend their appreciation to the Research Center at the College of Applied Medical Sciences and the Deanship of Scientific Research at King Saud University for funding this work.
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J Community Health Conflict of interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Ethical standard The proposal for this study was approved by the ethics committee of King Saud University, Riyadh, Saudi Arabia.
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14. Almerie, M. Q., Matar, H. E., Salam, M., Morad, A., Abdulaal, M., Koudsi, A., et al. (2008). Cigarettes and waterpipe smoking among medical students in Syria: A cross-sectional study. International Journal of Tuberculosis and Lung Disease, 12(9), 1085–1091. 15. Alexopoulos, E. C., Jelastopulu, E., Aronis, K., & Dougenis, D. (2010). Cigarette smoking among university students in Greece: A comparison between medical and other students. Environmental Health and Preventive Medicine, 15(2), 115–120. doi:10. 1007/s12199-009-0110-0. 16. Chatterjee, T., Haldar, D., Mallik, S., Sarkar, G. N., Das, S., & Lahiri, S. K. (2011). A study on habits of tobacco use among medical and non-medical students of Kolkata. Lung India, 28(1), 5–10. doi:10.4103/0970-2113.76293. 17. Bian, J., Du, M., Liu, Z., Fan, Y., Eshita, Y., & Sun, J. (2012). Prevalence of and factors associated with daily smoking among Inner Mongolia medical students in China: A cross-sectional questionnaire survey. Substance Abuse Treatment, Prevention, and Policy, 7, 20. doi:10.1186/1747-597X-7-20. 18. Cauchi, D., & Mam, J. (2012). Smoking health professional student: An attitudinal challenge for health promotion? International Journal of Environmental Research and Public Health, 9, 2550–2561. doi:10.3390/ijerph9072550. 19. US Department of Health and Human Services. (2006). The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general (pp. 11(3 & 4). http://www.sur geongeneral.gov/library/reports/secondhandsmoke/fullreport.pdf. 20. World Health Organization. (2007). Protection from exposure to second-hand tobacco smoke. Policy recommendations. 21. Barbouni, A., Hadjichristodoulou, C., Merakou, K., Antoniadou, E., Kourea, K., Miloni, E., et al. (2012). Tobacco use, exposure to secondhand smoke, and cessation counseling among health professions students: Greek data from the Global Health Professions Student Survey (GHPSS). International Journal of Environmental Research and Public Health, 9(9), 3317. 22. Fichtenberg, C., & Glantz, S. (2002). Effect of smoke-free work places on smoking behavior: Systematic review. BMJ, 325, 188. 23. Kusma, B., Quarcoo, D., Vitzthum, K., Welte, T., Mache, S., Meyer-Falcke, A., et al. (2010). Berlin’s medical students’ smoking habits, knowledge about smoking and attitudes toward smoking cessation counseling. Journal of Occupational Medicine and Toxicology, 5, 9. doi:10.1186/1745-6673-5-9. 24. Chatkin, J., & Chatkin, G. (2009). Learning about smoking during medical school: Are we still missing opportunities? The International Journal of Tuberculosis and Lung Disease, 13, 429–437. 25. Warren, C. W., Jones, N. R., Chauvin, J., Peruga, A., & GTSS Collaborative. (2008). Data from the Global Health Professions Student Survey (GHPSS), 2005–7 cross-country. Tobacco Control, 17, 238–247. 26. Pipe, A., Sorensen, M., & Reid, R. (2009). Physician smoking status, attitudes toward smoking, and cessation advice to patients: An international survey. Patient Education and Counseling, 74(1), 118–123. doi:10.1016/j.pec.2008.07.042.
ORIGINAL PAPER
Prevalence of Tobacco Use and Exposure to Environmental Tobacco Smoke Among Saudi Medical Students in Riyadh, Saudi Arabia Khalid M. Almutairi
Ó Springer Science+Business Media New York 2014
Abstract This study was designed to determine the prevalence of active smoking and environmental tobacco smoke (ETS) exposure among medical students in Riyadh, Saudi Arabia, and to examine their attitudes and beliefs towards tobacco control programs. The investigation was a cross-sectional study conducted during the first semester of 2013 at King Saud University School of Medicine located in Riyadh, Saudi Arabia. Invited to participate in this study were 1,789 medical students. A descriptive data analysis was performed. A total of 805 medical students completed the questionnaire. The prevalence of experimentation with cigarette smoking was 11.3 %. The estimated prevalence of current smoking among the study participants was 4.7 %. The majority of the students held positive attitudes toward tobacco control and approximately 93.1 % of the students felt that health care professionals should be required to receive training for cessation counseling while only 36.8 % of the students reported having received any training in this area. Over the study’s duration 57.7 % of participants reported that ETS exposure was much higher in public places, while 13.9 % reported exposure at home. This investigation revealed that ETS exposure among medical students in Riyadh is at an alarmingly high rate. The data suggests a need for a more robust smoke-free policy and a commitment to greater enforcement in public places. The results of the study also demonstrate a positive attitude among participants for tobacco control. It also indicates a need for cessation counseling and training which could be incorporated into medical school curriculum.
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]
Keywords Tobacco control policies Environmental tobacco smoke exposure Tobacco use among medical students in Saudi Arabia Tobacco use among healthcare professionals Smoking cessation training for healthcare professionals Introduction As reported by the World Health Organization (WHO), tobacco use is currently responsible for more than 6 million deaths each year, and is considered a worldwide public health threat [6]. Its usage is in direct correlation with the high rates of morbidity all over the world, and it is a situation that is preventable. Substantial and sustained efforts are required to further reduce smoking prevalence and its associated mortality rates [1]. In Saudi Arabia, the smoking rates reported in this publication were determined by averaging statistics from several studies conducted over a 16 year period. These figures demonstrated that 35–40 % of adult males and 24 % of preparatory school students were considered to be regular smokers [2]. From 1996 through 2012, tobacco consumption rates in Saudi Arabia have risen from 21.9 % of males and 0.6 % of females in 1996 to 37 % of males and 6 % of females in 2012. According to these studies the current rate of tobacco consumption among Saudi males was 37 %, and 6 % among females. Further review of the data reveals that from 1996 to 2000 the tobacco prevalence rate among male Saudis was 21.0 % and 0.6 % for female Saudis; while from 2001 to 2005 the rate of tobacco use among Saudi males was 20.9 % and 1.2 % for females [3– 6]. While there was a slight decrease in the early part of the century, the data suggests that there has been a dramatic increase in tobacco use over the past 10 years among health care professionals in Riyadh.
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J Community Health
According to results from a study conducted in 2006 in Riyadh, Saudi Arabia, among 322 medical students, the prevalence of daily smokers was 13.0 %. Furthermore, approximately 122 of these students (38.2 %) were regularly exposed to second hand smoke and 54.7 % of the respondents reported that smoking cessation programs were unavailable in their academic environment [7]. As a result, concerns have been raised about the current status of tobacco use among medical scholars and researchers in Saudi Arabia. In 2004, the WHO working in conjunction with other reputable international health organizations (U.S. Centers for Disease Control and Prevention, and Canadian Public Health Association) developed the Global Health Professionals Survey (GHPS) that is collectively used to gather data about pervasiveness of tobacco use and the development and implementation of cessation education and treatments among medical and health professional students in all WHO member states [8, 9]. It is a school-based survey of third-year students pursuing professional degrees in medicine, pharmacy, dentistry and nursing. The GHPS adopts a core questionnaire to collect information on demographic data, prevalence of tobacco use (e.g. cigarettes, cigars or pipes), knowledge and attitudes towards tobacco use, ETS exposure, and their opinions on and willingness to stop smoking [9]. Health care professionals play a crucial role in educating the public about the risks of tobacco use, in motivating their patients to quit as well as providing advice and guidance on overall health in general. Because of this, the first step in establishing a successful anti-tobacco campaign is to assess the views and attitudes of health care professionals; and from there determine which measures would provide the best rate of success in the reduction of tobacco use. It is without a doubt that with strong tobacco education, prevention and treatment programs in place, future health care professionals will serve as front line educators for their patients on the hazards of tobacco consumption. This study was designed to estimate the prevalence of active smoking among medical students in Riyadh, Saudi Arabia, as well as their attitudes and beliefs towards tobacco control measures. This study also aims to determine the extent of ETS exposure within their community.
Methods This study has been approved by institutional review board i.e. Ethical Review Committee, King Saud university. All the subjects have been informed and have given the consent for using the data/samples for investigations, which has been documented in attested performa by the investigator.
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This research was a cross-sectional study conducted at King Saud University, Riyadh, Saudi Arabia during the first semester of 2013. A total of 1,789 medical students ranging from the first- year to the fifth-year were invited to participate in the study. A standard self-administered questionnaire was derived from the GHPS. The questionnaire requests information about demographics, prevalence of tobacco usage, attitudes, desire for smoking cessation, ETS exposure and training received on smoking cessation counselling and techniques. The questionnaire was distributed to the students prior to a group lecture in an effort to include as many respondents as possible, and was also translated from English to Arabic and back to enhance the response rate. Before the start of the survey, the investigator received permission from professors to administer the survey. Students were then advised about the survey and asked if they would be willing to participate. No names or other identifying information were collected. The questionnaire stated that each individual had the right to decline to complete the survey or to answer any specific questions. For the purpose of the study, self-identified smokers were defined into three groups: current smokers, former smokers and ever smokers. Current smokers as a group were defined by those who had smoked any tobacco products daily or occasionally and at any point during the study. Former smokers were defined as those who had previously had a daily smoking habit for a continuous period of[6 months, but had given up smoking by the time of the inquiry. Ever smokers included both current and former smokers. ETS exposure was defined for the purposes of this study as experiencing the inhalation of second hand smoke during the previous 7 days. The proposal for this study was approved by the ethics committee of King Saud University, Riyadh, Saudi Arabia. Data from the questionnaires was entered into a computer, and analyzed using statistical analyses performed with SPSS 20.0 for Windows software (SPSS Inc., Chicago, IL, USA) and was presented as percentages (%) for enhanced data comparisons between the claimed similarities and differences. A Chi squared test was used for categorical data to compare the differences in proportion. The significance level was set at P \ 0.05. Because the GHPS pilot study was conducted among third-year students, our study also focused on the responses from third-year medical students for the purposes of a valid comparison.
Results From the pool of 1,789 invited participants, a total of 805 first-year to fifth-year medical students completed the survey, providing a response rate of 44.9 % (77.3 % male,
42.6 (30.2–54.4) [73]
7.0 (0–16.4) [12]
0
0
2.3 (0–5.3) [4]
4.7 (0–10.7) [8]
Total (n = 171) % (95 % CI) [n]
8.7 (0–17.4) [15]
7.01 (0–8.7) [12]
J Community Health
22.7 % female). The prevalence of tobacco use and ETS exposure among Saudi medical students are shown in Table 1. Attitudes, beliefs and education about tobacco control among Saudi medical students are represented in Table 2.
45.2 (30.1–60.3) [14] 54.5 (52.2–63.2) [439] 52.4 (48.9–62.7) [326] Place other than home
61.7 (56.3–74.5) [113]
42.4 (23.6–61.2) [59]
12.9 (1.5–24.3) [4] 5.7 (0–21.1) [8] 13.9 (11.2–20.2) [112] 15.4 (11.2–25.4) [96] Home
Sources of ETS exposure
18.4 (14.2–25.8) [34]
0 0
0
1.7 (0.3–4.1) [14]
0 Inside university building
1.0 (0–2.8) [2]
0
1.9 (0–5.4) [12]
0
University premises (outside)
Place of smoking on campus
0
6.7 (0–16.8) [2] 4.2 (0–14.5) [6] 3.3 (0–8.1) [21] Former
6.5 (2.8–9.8) [12]
3.9 (1.1–6.7) [33]
0 2.8 (0–7.5) [4] 4.7 (3.8–5.6) [34]
6.4 (0–13.4) [2] 7.1 (0–11.7) [10] 3.3 (0–6.7) [67]
5.3 (4.3–7.7) [33] Current
7.1 (0–6.0) [13] 8.6 (0–9.3) [54] Ever
Daily smoking habits
12.2 (7.2–19.5) [76] Ever tried or experimented with cigarette smoking, even one or two puffs
Smoking status
0.6 (0–1.6) [1]
8.5 (3.3–20.3) [12] 11.3 (9.4–16) [91] 9.8 (5.3–20.1) [18]
Male (n = 140) % (95 % CI) [n] Total (n = 805) % (95 % CI) [n] Female (n = 183) % (95 % CI) [n] Male (n = 622) % (95 % CI) [n]
All students
Table 1 Prevalence (%) of active smoking and ETS exposure among Saudi medical students by gender, 2013
Third-year students
Female (n = 31) % (95 % CI) [n]
9.6 (3.9–23.1) [3]
Smoking Prevalence and ETS Exposure The percentage of current smokers among medical students involved in this study was 4.7 % (95 % CI 3.8–5.6). The percentage of those who had ever tried or experienced cigarette smoking was 11.3 % (95 % CI 9.4–16). In addition, the number of males within the ever smoker group was 3.5 % (95 % CI 0–9.3), while female ever smokers was 2.7 % (95 % CI 0–6.0) providing a total prevalence of 3.3 % (95 % CI 0–6.7). The rate of ever or current smokers among third-year students was higher compared to other groups in this study (first-year, second-year, fourth-year and fifth-year), but this difference was not statistically significant. This investigation found that the majority of current smokers among this control group were males; however, more females had reported being ever smokers (Table 1). According to the data, none of the study participants smoked inside the university facilities. Over the 7 day study period 57.7 % (95 % CI 52.2–63.2) of the participants reported that their ETS exposure was much higher in public places, while 13.9 % (95 % CI 11.2–20.2) of the participants reported regular ETS exposure at home. Attitudes, Beliefs and Training Regarding Tobacco Control Table 2 represents the patterns of students’ attitudes, beliefs and education received about tobacco control. Nearly all of the respondents agreed that tobacco sales among adolescents should be banned (89.4 %). The great majority of the respondents (87 %) believed that health care professionals should serve as public health role models, that advertisements for tobacco products be banned; that smoking in public places be banned, and that health care professionals be required to receive extensive training on smoking cessation techniques. The patterns of attitudes and beliefs among third-year students were similar to those among the entire control group. Likewise, almost all of the participants believed that health care professionals who smoked were less likely to advise their patients to stop smoking (77.4 %). In regards to tobacco control education, nearly all the study participants had learned about the hazards of smoking (91.5 %) and most had been exposed to information about nicotine replacement products (90.2 %). Similarly, 94 % of the participants believed that health care
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J Community Health Table 2 Attitudes, beliefs and training about tobacco control among Saudi medical students by gender, 2013 (%) All students Male (n = 622) % [n]
Third-year students Female (n = 183) % [n]
Total (n = 805) % [n]
Male (n = 140) % [n]
Female (n = 31) % [n]
Total (n = 171) % [n]
Attitudes Tobacco sales to adolescents should be banned
89.0 [556]
90.8 [164]
89.4 [720]
90.7 [127]
83.9 [26]
89.5 [153]
A complete ban of tobacco product advertising
79.0 [487]
88.8 [163]
81.4 [650]
75.7 [106]
90.3 [28]
78.4 [134]
Ban on smoking in restaurants
94.8 [592]
96.7 [178]
95.3 [770]
96.4 [135]
100 [31]
97.1 [166]
Ban on smoking in all enclosed public areas
89.0 [560]
90.8 [168]
89.4 [728]
93.6 [131]
96.8 [30]
94.2 [161]
Believe health care professionals should obtain specific training on smoking cessation techniques
91.7 [582]
94.1 [172]
92.3 [754]
100 [140]
93.5 [29]
98.8 [169]
Believe health care professionals serve as a role models
84.0 [536]
92.1 [160]
85.9 [696]
93.6 [131]
64.5 [20]
88.3 [151]
Believe health care professionals should provide advice about smoking cessation
93.2 [580]
92.8 [172]
93.1 [752]
93.6 [131]
100 [31]
94.7 [162]
Health professionals who smoke are less likely to advise their patients to smoke
78.4 [483]
76.9 [139]
77.4 [622]
77.8 [109]
70.9 [22]
76.6 [131]
Health professionals who use other tobacco products were less likely to advise their patients to stop smoking
75.5 [469]
75 [137]
75.4 [606]
75.0 [105]
74.2 [23]
74.8 [128]
Beliefs
Curriculum/training Received knowledge about the hazards of smoking
90.1 [578]
93.4 [172]
91.5 [750]
100 [140]
96.8 [30]
99.4 [170]
Received formal training about smoking cessation approaches
36.1 [204]
38.8 [63]
36.8 [267]
21.4 [30]
12.9 [4]
19.9 [34]
Ever heard of nicotine replacement products
89.8 [573]
91.4 [169]
90.2 [742]
100 [140]
96.8 [30]
99.4 [170]
professionals should obtain some form of training about smoking cessation, while 36.8 % reported that they had received formal training regarding smoking cessation techniques.
Discussion Medical students are future health care professionals who will have the responsibility of providing information about the dangers of smoking and regular tobacco use to the public, and provide support in smoking cessation for their patients. Thus, it is important in the development of effective smoking cessation policies, to determine their attitudes and beliefs in regards to this issue. Previous studies in Saudi Arabia have shown that smoking among health care students in Abha 13.6 % and 13 % in Riyadh is quite high [7, 10]. Other studies have suggested that smoking rates were high among health care professionals even though they were educated about the harmful effects of tobacco use [11, 12, 16–18]. In this survey, the prevalence of smoking among Saudi medical students was low in comparison to those previous studies, with approximately 12.2 % males and 9.8 % females who
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had ever tried smoking. In addition, these figures were lower compared with previous studies conducted among other medical students in other countries (Greece, Poland, Spain, Italy, Syria and Germany, Fig. 1) [13–15]. However, though the results of smoking prevalence demonstrated in this study were low compared with previous studies in Saudi Arabia and other countries, our data did demonstrate that ETS exposure was high, especially in public locations. The percentage of medical students in this study that reported being exposed to ETS in public places for the 7 day period were relatively high, reaching about 54.5 % of overall response from the participants. Research has shown that prolonged exposure to secondhand smoke is as deadly as smoking itself [19, 20]. Evidence has suggested that there is no safe level of exposure, and that prolonged exposure to cigarette smoke leads to disease such as cancer, heart disease, stroke, asthma, and demonstrates a strong correlation to high death rates among non-smokers [19, 20]. The present study showed that the majority of the participants felt that smoking should be banned in all enclosed public places. Other studies on this topic also expressed concerned about secondhand smoke exposure, and most participants were well aware of the associated
J Community Health Fig. 1 Smoking prevalence among European and Middle Eastern countries
hazards and impacts [18, 21]. Implementing a smoke free policy for public places would not only protect nonsmokers from hazards of ETS exposure but may also encourage smokers to either quit or decrease their consumption [22]. Study participants demonstrated positive attitudes towards tobacco cessation as well as a belief that all health care students should receive formal education about smoking cessation approaches. Similar attitudes were also observed in other studies, but again, the number of students who receive formal training is minimal [23]. Introducing tobacco cessation techniques into the medical school curriculum and education about cessation counseling for smokers is an important topic that any medical university or institution should implement [8, 24]. Medical universities and health institutions have a professional responsibility to help their students quit smoking and provide education that will allow them to help their patients in the future [25]. Another interesting development from this study is the belief among health care students that health care professionals who smoke are less likely to advise their patients to stop smoking. According to Pipe et al., non-smoking physicians are more likely to provide a systematic counseling to patients about smoking cessation, and generally hold strong beliefs about the adverse effects of tobacco use [26]. Moreover, most medical students also feel that healthcare professionals should serve as responsible role models for the community and the general population. Thus, this belief may continue to grow as these medical students move into their professional roles within the community. Another interesting discovery from this study is the high prevalence of ETS exposure at home and in public places, demonstrating an urgent need for tobacco control programs to be created and circulated among the general population.
The positive attitudes toward tobacco cessation as reported by the study participants suggested a raised interest in the subject. This interest could be a signal that the time is right for the creation of an effective tobacco control program. To facilitate this, an anti-tobacco campaign should be implemented among current medical students, who will then promote the initiative among their patients, colleagues and local communities. It is a combined effort that will compound as more medical students are trained in this program. This study does present some limitations, the first of which is the design of the survey. A cross sectional survey was used to collect data on smoking prevalence, beliefs, attitude and a possible bias in the information could have occurred. However, a detailed questionnaire was used for data collection. Secondly, the study samples are not fully representative of the entire country. However, the author does believe that the findings from this study can help promote public health awareness and tobacco control programs particularly within healthcare institutions. In conclusion, the present study revealed the prevalence of smoking among Saudi medical students. Although the prevalence was low, the biggest concern is that ETS exposure is particularly high in public places and at home. The results also suggest a positive attitude among survey participants for tobacco control programs; the author believes that this particular finding will be of interest to medical institutions. This study suggests that a detailed tobacco control program and training in smoking cessation techniques be introduced into the curriculum of all medical institutions in Saudi Arabia. Acknowledgments The authors extend their appreciation to the Research Center at the College of Applied Medical Sciences and the Deanship of Scientific Research at King Saud University for funding this work.
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J Community Health Conflict of interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Ethical standard The proposal for this study was approved by the ethics committee of King Saud University, Riyadh, Saudi Arabia.
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