Smoking Prevalence, Attitude, Knowledge and Practice Among Applied Medical Sciences Saudi Students in King Abdalaziz University-Juniper publishers
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Background: Smoking is one of the major causes
of death as and it has been predicted to cause the deaths of 10 million
per year by 2020 worldwide. However, In Saudi Arabia, tobacco
consumption is a major public health problem, with increasing use among
adolescents.
Objective: The aim of this study was to detect
smoking prevalence, attitude, knowledge and practice among Applied
Medical Sciences Saudi students in King Abdalaziz University.
Material and Methods: The present study included 494 students who are in the 2nd to the 4th
year participated in this study. Hard copy questionnaire were
distributed among the students during lecture times. The questionnaire
was composed of four sections. The first section contained the questions
related to demographic data (Gender, age, marital status etc.) of the
participants. Second section of the questionnaire which contained 3
questions in total was about the knowledge of students regarding effects
of smoking on health. Third section was about the general attitude of
participants regarding smoking and it contained 11 questions. The fourth
and last section contained 9 questions about the practicing of smoking
among medical students and family members as well. The questionnaire was
anonymous, self-written and adopted from Global Adult Tobacco Survey
(GATS). The questionnaire takes around 10 minutes to be answered.
Results: The current study revealed a
considerable higher prevalence of smoking among male than female
students in Faculty of Applied Medical Sciences, King Abdul-Aziz
University, Jeddah City, Saudi Arabia. One of the major and important
findings of this current study was the positive attitudes of all studied
students and smokers in particular towards smoking.
Conclusion: This finding of this study has to
motivate and encourage the Ministry of Health to increase the number of
smoking clinics and activate them and make them more popular and attract
the smoker students to utilize helping them to quit smoking. In
addition, it would be very helpful to organize smoking campaigns in the
various faculties at the university to increase the awareness about the
dangerous of smoking.
Keywords: Smoking; Prevalence; Attitude; Students; Saudi arabia
Introduction
World Health Organization (WHO) 2015, reported that
case fatality rate in case of tobacco smoking addiction is more than 15%
of the total population around the globe. Estimates in 2015 have shown
that 6 million people die because of direct cost of tobacco smoking (or
other less common addiction methods). More than 3/4th of all such deaths
are due to direct smoking causes; and the rest are attributed to
passive smoking. Nearly 80% of smokers are residents of low or middle
income and/or developing countries [1].
In Saudi Arabia, for the general population many
studies investigated the prevalence of smokers. These studies indicated
that the prevalence of current smoking in Saudi Arabia ranged between
(9-35%), and among school students, the smoking prevalence was 16.5%, in
university students 13.5%, among adults 22.6%, elderly peoples 25%, and
males 26.5% while in females 9% [2-4].
In fact, some studies investigated the prevalence of
smokers among Saudi universities and colleges students in general, which
found to be 14.5% [5].
Other studies focused on students who study in the health colleges
(such as medicine and dentistry), and found the prevalence to be 16%,
which considered be higher than the previous percentage, and when it
compared male students in different health colleges on a national scale
in Saudi Arabia as (Central: Kind Saud University ,King Fahad Medical
City, Qassim university; North: Aljouf university, Hail university,
Tabuk university ;South: Najran university, Jazan university, King
Khalid University; East: Dammam university; and West: King Abdulaziz
University and Taibah university) and indicated that
dental students smoke more than medicine students [6].
As the prevalence among dental students was 18% compared to medical
students with a prevalence of 14% .However, this study did not include
females, and did not consider Universities of Makkah city, despite the
fact Makkah is considered one of the major cities nationally.
Furthermore, a recent study was conducted in Najran university among
health college students and found that the prevalence of smoking in male
and female students (30.1%, 0.5%) respectively, the students at the
college of applied medical sciences had the highest prevalence of
smoking 34% followed by the students at colleges of pharmacy (15%) and
dentistry (9%), and the lowest prevalence (4%) was at the college of
medicine [7].
During medical school education, students are
considered more cautious and logical about the hazards of smoking.
However, opposite situation has been noticed in this case, as medical
students are more likely to become smokers during their medical studies
and an increase in the consumption of tobacco has noticed for the
students who are already smokers. However, medical college students are
different from non-medical college students as they are more likely to
become occasional smokers [8].
There were no smokers in the first year of medical course but in the final year prevalence was 45.5% in Bahrain [9].
However, there is a study to measure the prevalence of smokers in the
Umm al-Qura in college of medicine among male students and found that
the prevalence of smoking was 30% [10].
According to our knowledge there was no previous studies carried out to
investigate smoking among undergraduate students of Applied Medical
Sciences in King Abdalaziz University. Thus, the aim of the present
study was to detect smoking prevalence, attitude, knowledge and practice
among Applied Medical Sciences Saudi students in King Abdalaziz
University.
Subjects & Methods
Research design
A descriptive cross-sectional study was conducted
among students of the Faculty of Applied Medical Sciences in King
Abdalaziz University, Jeddah, Saudi Arabia, from 10 September to 7
December 2017 with the aim of assessing their awareness, attitudes and
practices of smoking. The survey was conducted with permission and an
approval from the Ethical Research board at the faculty of Applied
Medical Sciences, King Abdalaziz University. As there have been no
invasive procedure would be used, only verbal consent was taken from the
participants.
Settings
This study was conducted in the Faculty of Applied
Medical Sciences, included Department of Medical Laboratory Technology,
Department of Diagnostic Radiology, Department of Physical Therapy and
Department of Clinical Nutrition in King Abdalaziz University.
Subjects of the study
A sample of 494 students at the faculty of Applied Medical Sciences, King Abdalaziz University, Saudi Arabia who are in the 2nd to the 4th year was included in this study. Students in the 1st
(preparatory year) and interns were excluded from this study. A hard
copy questionnaire was distributed among students. Inclusion criteria
included students who accepted to participate in this study, while
exclusion criteria included students who refused to give informed
consent. The questionnaire was disseminated to the students during
lecture times by the assistance of the academic office in each college,
and after the permission of lecturers, to be filled after the lecture
time. The data collector was available to answer any question raised by
students. After students fill the questionnaires, they were taken back.
Instrumentation
The data of the study was collected through a
self-written questionnaire which was mainly adopted from Global Adult
Tobacco Survey (GATS). This survey has been developed by many
organizations and institutes including World Health Organization (WHO)
and Centers of Disease Control and Prevention (CDC), and was designed to
assess major issues related to smoking. The validity of the questions
could be assumed as the same questionnaire has been used in many
previous studies, in addition to the validation of the developing
institutes [11,12].
The questionnaire has translated into Arabic language, and had been
modified according to the local culture and religion. Another researcher
to ensure accuracy did back translation. The questionnaire included 31
core questions related to social and smoking status, as well as the
knowledge and attitude towards cigarette smoking. The questionnaire
takes around 10 minutes to be answered.
An interview questionnaire sheet was developed by the
researchers in Arabic language to collect information which divided
into 4 major sections were used in this study. Both open and close-ended
questions were included in questionnaire. The first section contained
the questions related to demographic data (Gender, age, marital status
etc.) of the participants. Second section of the questionnaire which
contained 3 questions in total was about the knowledge of students
regarding effects of smoking on health. Third section was about the
general attitude of participants regarding smoking and it contained 11
questions. In this section, mostly question was answerable by choosing
the options among, "disagree, undecided or agree" option. This section
contained questions like effect of smoking status of physicians on their
patients and relationship of medical education on smoking prevalence
among medical professionals. The fourth and last section contained 9
questions about the practicing of smoking among medical students and
family members as well. Mostly questions in this question were of
multiple choice questions type in which participant has to choose one or
more than one option. Questions regarding smoking
status of their family members were included in this section so that the
correlation of family member's smoking status and smoking status of
participants could be assessed.
Data collection
After obtaining the ethical approval from the
Research Ethical Committee at Faculty of Applied Medical Sciences, King
Abdalaziz University and once the participants who meet inclusion
criteria are identified, the research assistants explained the aim of
the questionnaire to all students. Then the questionnaires were
distributed to the students after informed consent obtaining from all
participants. The questionnaire was administered to participants in
their classrooms in order to get maximum response rate. Sufficient time
was allotted to fill in the questionnaire. If the participation rate was
low in any class, a second visit was done to cover those students who
were absent in the first session. Finally, questionnaire was collected
from all the participants and the information contained in these
questionnaires was saved.
Data analysis
Data was analyzed by using Statistical Package for
the Social Sciences (SPSS) version 23. However, descriptive statistics
were accomplished for the participant's knowledge, attitude and practice
regarding smoking. Moreover, Chi- square test was used for categorical
variables (p≤ 0.05).
Results
Demographic characteristics
Out of 494 medical students participated in this
study only 47 students (9.5%) were smokers while remaining 447 (90.5%)
were not smokers. Average age ofthe participants was 20.56�1.93 years,
and 96.1% of the participants were from Jeddah area and 3.9% from
outside Jeddah areas. There was an increase in smoking trend as the
students were promoting from the second to fourth professional years
that is in second professional year there was only 10 smokers (6.3%) as
compared to the fourth professional year which had 20 smokers (11.2%)
which means a double upsurge was observed in the presence of smokers
when comparison was done between the second and fourth professional
year. Third and fourth year had the same percentage of smokers’ that is
10.8% and 11.2% respectively with a minor difference. However, second
professional year had the least presence of smokers and they counted
only 10 (6.3%).While, the income of families per month imposes an
influence on the smoking status of a person as the students who had
reward and extra money sources were more prone to smoking as compare to
the students had Reward only (18.3% versus 8.3%). Moreover, data depicts
that tobacco usage was about 5 times (19.2%) among males as compare to
the smoking prevalence among females (2.75%). Correspondingly,
proportion of female nonsmokers (97.2%) is much higher as compare to the
non-smokers present among the male students (80.8%). Finally, there was
an increase in smoking trend as the students were resident alone to
with family that was in resident alone there was only 3 smokers (27.3%)
as compared to with family where 37 smokers (8.3%) which means a triple
upsurge was observed in the presence of smokers when comparison was done
between the resident alone and with family. However, resident with
friends and resident alone had the same percentage of smokers' that was
27.3%% and 20.0% respectively with a minor difference (Table 1).
Knowledge of students regarding smoking effects on health
Generally, all the FAMS students (98.9%) participated
in this study were well aware about the harmful effects of smoking
irrespective of their medical professional year. However only 5 students
(1.1%) out of 494 FAMS students took the effects of the smoking in a
positive way that smoking is beneficial during the examination period,
as nicotine stimulates the nervous system and improves the cognitive
ability. In addition, FAMS Students had thorough knowledge of the major
diseases which are directly or indirectly associated with smoking.
However, Table 2
depicts the familiarization of 494 FAMS students regarding a number of
diseases and malignancies which are linked with usage of tobacco. From
the table it is clear that, lung malignancies and other pulmonary
diseases (bronchitis, emphysema, COPD etc.) were the most common
complication about which students knew their association with the
smoking in a well manner. In this regard, 472 students (95.5%) were
acquainted with the bronchitis, emphysema, COPD etc. and 470 students
(95.1%) knew that lung malignancies were directly related with smoking.
However, a very few number of students (0.4%) had knowledge regarding
link of lung malignancies with the smoking. On the contrary,
malignancies, which are apart from lungs and including other organs as
breast, urinary bladder etc. were the least complications about which
students, had knowledge about it. Approximately 74.7% of the students
were well aware about relation of such malignancies with the smokers.
Likewise, longterm complications like hypertension and
hypercholesterolemia, which are the results of regular smoking, were
well acquainted among the medical students (77.1%).
General attitude of FAMS students regarding smoking
Table 3
represents the general attitude of medical students regarding smoking
usage and influence of friends and family members who smoke, on
themselves. About 86.6% students thought that there is a solid
inspiration of smoking on the non-smoker members of a family if a family
member smokes. Chances of becoming a smoker for a non-smoker are
increased up to more than 94% if a person has smoking friends as
compared to smoking family members. Similarly, 416 students (84.2%) out
of 494 had same thought in this regard that if someone smokes in a
community it can disturb his or her relation with the others. In
addition, only 25.1% students considered that they could be open to
their guardians regarding their tobacco usage as compare to 60.9%
students who preferred to be quiet about their tobacco usage. Moreover,
smoking status can affect smoker's relation with someone fellows or
friends and this is the reason that 411 students (83.2%) also had the
same opinion. Likewise, in the opinion of 470 (95.1%) medical students
if they smoke, it will not inspire the others to smoke, as smoking is
based on person's own discretion usually.
Table 4
represents the attitude of medical students about association of
education and usage of tobacco, and about the initiatives, which has
taken by the government to halt the smoking. From the table it can be
illustrated that more than 37% of the students were very unsatisfied by
the steps that Ministry of Health in Saudi Arabia has taken to reduce
the usage of tobacco in the country. Moreover, in the opinion of
379(76.8%) students' statuary warnings that is imposed by the cigarette
manufacturing companies on the cigarette packs are not enough that it
can help or motivate a smoker to quit smoking. Educational level of a
person is the major obstacle which can prevent a person to indulge
yourself in smoking, and 251 students (50.8%) had the same opinion in
this regard, however less than quarter of the total students (24.3%)
thought that education has nothing to do with a person’s choice
regarding usage of tobacco. More than 84% of the medical students
contemplated that as the medical professionals and medical students are
the prime model of health for the society so if they smoke then it may
discourage a patient to give up his or her smoking habit.
General Performance regarding smoking
Regarding usage of electronic cigarette is not as
common in Saudi Arabia as it is a contemporary way of consuming tobacco
and this is the reason that FAMS students had not much cognizance about
such practice of tobacco smoke inhalation. Out of494 FAMS students,
only 26 participants (5.3%) had ever heard about electronic cigarette
whereas remaining never heard about its usage among the smokers.
Concerning the intake of the anti-smoking drugs offered by the Ministry
of Health in Saudi Arabia, out of 47 FAMS smoker students, only 3
participants (6.4%) had ever used these anti-smoking drugs whereas
remaining never used these drugs among the smokers. However, Table 5
categorizes the students as a smoker and non-smoker according to the
presence of smoker or non-smoker family member within the family. If a
family member smoke in a family, it definitely effects the other members
of the family who are non-smokers (p-value = 0.013). Therefore, it is
concluded that students who had smoking family member in their family
were more likely to become tobacco user as compared to students who did
not have any family member who smoke. Out of 47 smoking medical
students, 31 medical students (8.1%) had smoking family member whereas
families of 16 FAMS students (14.7%) did not have any smoking family
member (Table 5).
Concerning the anti-smoking campaigns, there was very
less proportion of FAMS students who had participated in some sort of
anti-smoking campaign to play their role as medical professionals to
tackle the problem of smoking in their had attended anti-smoking
campaign in their career (Table 6).
Discussion
Smoking has been classified by the WHO as an epidemic
because of its fast spread among peoples and its dangerous effect on
human worldwide [13].
However, our study showed that the total percentage of FAMS students
who are currently smoking was 9.5%.The findings of this study confirm
lower smoking prevalence among high schools and Universities students in
other region and cities in Saudi Arabia. A high prevalence of
adolescent and young adult smoking was also reported in recent Saudi
studies conducted in Jeddah [14] and Riyadh [15].
The reported prevalence rates in those studies were 37%, 29.0% and
31.0%, respectively, with a significant higher prevalence of smoking
among male compared to female students in a study conducted in Riyadh
study [15].
In addition, a cross-sectional study was conducted to assess the
smoking prevalence among dental students at King Saud University
revealed that the overall 17% of the sampled students reported that they
are current smokers [16].
Although this prevalence seems to be high considering their work in a
health-related profession, similar prevalence rates have been reported
among medical students. For example, Al-Kaabba and colleagues reported
that 18% of medical students in Riyadh, Saudi Arabia smoked [17]. Similarly, Al-Haqwi and colleagues found that 19% of students smoked in two new medical colleges in Riyadh [12].
In a review of smoking rates among dental students in 19 countries,
Smith and colleagues reported rates between 3% in Canada to 47% in
Greece [18].
Moreover, the findings of the Agilley and colleagues study indicated
that, the percentage of smokers among students of health colleges is
only 8% [19].
The low percentage of health care students who smoke may be due to the
greater awareness of them with respect to tobacco, to being health care
professionals and being able to see its pernicious effects directly in
their daily clinical practice. These results were agreed with previous
study which shown that the prevalence of smokers among dentists is
considered a small percentage compared with the public [20].
Regarding gender, our results revealed that tobacco
usage was about 5 times (19.2%) among males as compare to the smoking
prevalence among females (2.75%). The findings of this study confirm
similar smoking prevalence among high schools and Universities students
in other region and cities in Saudi Arabia [21], these findings consistent with other studies [12,17,22,23].
In addition, Al-Swuailem and colleagues found a significant difference
in smoking rates between male (27.8%) and female (2.4%) dental students [16].
However, these results agreed with Agilley and colleagues reported that
smoking behaviors are more prevalent among males than females [19].
Lower smoking rates among female students could reflect the fact that
smoking by females is culturally unacceptable, especially in
conservative societies like Saudi Arabia [18,24].
Concerning comparison between senior year students
and junior year students Tobacco smoking, There was an increase in
smoking trend as the students were promoting from the second to fourth
professional years. These findings agreed with Alrehaili and colleagues
found significantly higher rate of smoking among the former student
group [21].
In contrast, previous studies conducted at Saudi Arabia have been
reported the same findings regarding age group in addition to other
studies found higher smoking rates among senior dental students than
junior students [25,26].
Moreover, Newbury-Birch and colleagues assessed changes in smoking
rates among 47 dental students in the University of Newcastle, UK, in
the second year, fifth year, and 1 year after graduation. In that study,
the prevalence of cigarette smoking dropped as students’ progress in
school from 11% in the second year to 4% and 6% in the fifth year and
after graduation as dentists, respectively [27].
This higher rate of smoking among students of the fourth professional
years is probably due to increased stress faced by the students with
their progression, over the years.
The results of the present study showed that chances
of becoming a smoker for a non-smoker are increased up to more than 94%
if a person has smoking friends, so that the main reason for smoking is
the pressure and simulation of their friends practiced smoking. These
results are congruent with findings of previous studies reported that,
friends were considered the major reason for starting smoking [25,26,28,29,30].
The effect of having close friends that smoke may increase the rate of
smoking among medical students in Saudi Arabia as much as 5-fold [28].
We found an association between the presence of a
smoking family member (father, mother, brother, or sister) and smoking
habits. This finding agreed with the findings of Dar-Odeh and his group
who reported a significant association between student and parental
smoking habits [29].
Similarly, for students in the College of Applied Medical Sciences at
King Saud University reported that the existence of smoking parents or
siblings was significantly associated with higher rates of smoking among
students [30]. Similarly in several studies, parental smoking was an important risk factor in adolescents’ and young adults’ smoking [3,4,14,15,21] and international studies [31,32].
As most of youths look up to their parents and other close relatives in
their society and attempt to mimic their demeanor , parents smoking
showed to be the most important factor related to adolescents and young
adults smoking in this and other studies [33].
Concerning knowledge level of FAMS students regarding
various diseases associated with smoking, about 99% of students
participated in this study were well aware about the harmful effects of
smoking irrespective of their medical professional year. These findings
agreed with findings of many previous studies [34-36]
as our study results showed that Applied Medical Sciences students are
more knowledgeable and aware about smoking negative effects and showed
greater willingness to stop smoking than non- medical students do. This
may be explained as curriculum courses of medical specializations- in
general- addresses to smoking hazardous effects and how to stop smoking.
Despite their awareness, about 9.5% of the medical students in this
study keep on smoking , it is obvious from the results of this study
that there is defect in advisory and educational roles of health and
community organizations in spreading health awareness in society, and
this will affect the behaviors of citizens toward smoking especially
young people [37].
Concerning the anti-smoking campaigns, there were
only 28.1% of FAMS students participated in some sort of antismoking
campaign to play their role as medical professionals to tackle the
problem of smoking in their community. However, more than 37% of the
students were very unsatisfied by the steps that Ministry of Health in
Saudi Arabia has taken to reduce the usage of tobacco in the country.
Moreover, less than quarter of the total students (24.3%) thought that
education has nothing to do with a person's choice regarding usage of
tobacco. The active participation of healthcare providers in tobacco
cessation programs is important because most smoking patients either
want or have attempted to stop smoking, but have failed due to
uncertainty on “how to quit” [24].
Thus, a gap exists between the knowledge of tobacco health risks and
the level of training in tobacco counseling among students [38,39]. The available literature encourages reforming curricula to accommodate tobacco cessation programs [23,40].
The present study has points of strengths and
limitations. Strengths of this study include being a university-based
with a high response rate from the participated students, and according
to our best knowledge, this study is the first to study smoking habit
and attitudes among Faculty Applied Medical Sciences male students of
King Abdul-Aziz University. However, limitations of this study include
using a self-administered questionnaire without validation of the
collected data through biochemical tests due to financial constraints,
which might underestimate the actual prevalence of smoking in the
studied students. One limitation of this study is related to the issue
of validity for selfreported information, a common issue for surveys.
Conclusion
The current study revealed a considerable high
prevalence of smoking among students in Faculty of Applied Medical
Sciences, King Abdul-Aziz University, Jeddah City, Saudi Arabia. One of
the major and important findings of this current study was the positive
attitudes of all studied students and smokers in particular towards
smoking. This finding of this study has to motivate and encourage the
Ministry of Health to increase the number of smoking clinics and
activate them and make them more popular and attract the smoker students
to utilize helping them to quit smoking. In addition, it would be very
helpful to organize smoking campaigns in the various faculties at the
university to increase the awareness about the dangerous of smoking.
Recommendations
From the results of current study, it recommend to:
a. Critically integrate cessation-counseling training into medical and non-medical sciences education.
b. Develop educational program for people early in
adolescence stage, and activate the role of medical related organization
in spreading health awareness in the community.
c. Medical students must be acquainted with the
latest methods of smoking like electronic cigarettes, so that they can
deal with their patients with full competency.
d. It should be compulsory for all the medical
students to be involved in some anti-tobacco policies and programs and
similar workshops regarding smoking cessation techniques and other
related matters so that before practicing as professional doctors they
become fully trained in this field.
e. Introduce special courses for smoking behaviors
and cessation in the curriculum for medical students to increase their
awareness and encourage them to stop smoking and this boost their
credibility as health care providers especially in cases of health
education and consultation.
f. Activate the celebration of World No Tobacco Day on 31st May each year.
g. In addition, it would be very helpful to organize
smoking campaigns in the various faculties at the university to increase
the awareness about the dangerous of smoking.
The authors acknowledge with thanks all students who
shared in distribution of survey and collection students response to the
survey.
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