Matern Child Health J (2012) 16:1828–1836
DOI 10.1007/s10995-011-0929-z
Factors Affecting Tobacco Use Among Middle School Students
in Saudi Arabia
H. K. Park • D. E. Al Agili • A. Bartolucci
Published online: 1 January 2012
Ó Springer Science+Business Media, LLC 2011
Abstract A rapid rise in the number of tobacco users in
Saudi Arabia has occurred in the past decade, particularly
among the youth. This study identified socio-cultural deter-
minants of tobacco use and explored possible approaches to
prevent adolescents’ tobacco use in Saudi Arabia. A cross-
sectional survey was administered using a self-administered
questionnaire for collecting information on risk and protec-
tive factors for tobacco use among middle school students.
School selection was stratified by region, gender, and type
(public or private). Of 1,186 7–9th grade students, 1,019
questionnaires were analyzed. Risk factors affecting tobacco
use included all important others’ perceptions; mother, sis-
ter, friend, teacher and important person’s tobacco use;
pressure to use tobacco from brother, sister, friend and
important persons; easy access to tobacco and frequent
skipping of classes. Protective factors for tobacco use
included family’s perception; friend, teacher and important
person’s tobacco use; parents’ help; support from family,
friends, and teachers; accessibility to tobacco; school per-
formance and family income, father’s education, and district
of residence. The findings of this study show clear gender
differences in social influences and attitudes towards tobacco
H. K. Park (&)
College of Health Sciences and Nursing,
University of Phoenix, Phoenix, AZ 85304, USA
e-mail: parkhk@email.phoenix.edu; phkvision@hotmail.com
D. E. Al Agili
Preventive Dental Sciences Department/Faculty of Dentistry,
King Abdulaziz University, Jeddah 21589, Saudi Arabia
e-mail: dalagili@kau.edu.sa; dalagili@yahoo.com
A. Bartolucci
Department of Biostatistics, The University of Alabama
at Birmingham, Birmingham, AL 35294, USA
e-mail: abartolucci@ms.soph.uab.edu
123
use. Religious beliefs and access to tobacco products were
significantly associated with attitudes towards tobacco use
and future intention of use. Developing and implementing
effective gender specific school-based tobacco prevention
programs, strict reinforcement of tobacco control policies,
and a focus on the overall social context of tobacco use are
crucial for developing successful long-term tobacco pre-
vention programs for adolescents.
Keywords Adolescent
Tobacco use
Prevention

Determinants
Saudi Arabia
Introduction
Tobacco use is one of the major preventable causes of
premature death and disease in the world [1, 2]. The impact
of smoking is well known worldwide, yet teen smoking
rates are still high [3].
The early initiation of smoking is associated with lower
cessation rates, longer duration of smoking, and higher
nicotine dependence in adulthood [4]. Although adoles-
cents may believe that they can quit tobacco use at any
time, an estimated 70% of adolescent smokers are likely to
become regular adult smokers [5].
Cigarette smoking is a serious public health problem in
Saudi Arabia. The country is ranked 3rd worldwide in the
number of children and youth smoking [6]. According to
the recent Global Youth Tobacco Survey (GYTS) in Saudi
Arabia, 19.3% of children and youth were smokers (24%
males; 11.2% females) [7]. The estimated social, eco-
nomic, and health losses related to tobacco use were SR 5.2
billion (US $ 1.4 billion) in 2010 [8]. This is likely to
exhaust healthcare resources of the country in the future
[9].
Matern Child Health J (2012) 16:1828–1836
Tobacco use is a result of complex interactions made up
of personal, familial, cultural, and social factors. Previous
studies have indicated that attitudes towards smoking,
perceived social norms, and self efficacy concerning
smoking resistance may explain and predict smoking ini-
tiation. It is critical and useful to explore these factors in
order to understand why certain adolescents initiate
tobacco use, some continue use, and others do not continue
use following initiation [10].
The aims of this study were to identify the socio-cultural
determinants of tobacco use and to explore possible
approaches to prevent adolescents’ tobacco use in Saudi
Arabia. To identify these determinants, we investigated
possible risk and protective factors of tobacco use by
analyzing the associations between positive and/or nega-
tive attitudes towards tobacco use and social influences.
Furthermore, we investigated the factors that affect inten-
tion to use tobacco using social influences.
Methods
Study Design and Procedures
A cross-sectional survey was administered using a self-
administered questionnaire in 2010. A total of 1,186 7–9th
grade students in Jeddah, Saudi Arabia were included.
According to the 2008–2009 school statistics, there were
376 public and private middle schools and a total of
113,884 (60,397 male and 53,487 female) students in
Jeddah. The schools in Saudi Arabia are segregated by sex.
School selection was stratified by region (geographic
location in the city) and type (public or private) using the
Jeddah City school list and then proportional random
sampling was applied to select schools from each region. A
total of 34 schools were selected; 24 public and 10 private
schools. Classes were selected randomly based on an
estimated class size of 30 students. A total of 43 classes
were selected and all 1,186 students in these classes were
included in the study.
To improve the confidentiality of the survey, school
teachers and staff were instructed not to enter the class-
room during survey administration. Saliva samples were
collected from students prior to questionnaire administra-
tion. The students were informed that the cotinine in saliva
can be used to assess tobacco use. The collection of saliva
samples or other objective measures of tobacco use have
been shown to enhance the validity of self-reported tobacco
use [11, 12].
The project was approved by the Ethics Committee of
the Deanship of Scientific Research in King Abdulaziz
University, Jeddah, Saudi Arabia. Furthermore, a study
clearance was obtained from the Directorates of the male
1829
and female Departments of Education and the schools
observed their own policies for informing parents about
the study.
Instruments
A self-administered questionnaire was developed based on
the European Smoking Prevention Framework Approach
(ESFA) questionnaire. Selection and formulation of ques-
tions were validated and localized to the Saudi Arabian
context through focus groups interviews conducted during
questionnaire development with a similar population of
adolescents in a public school in Jeddah [13–16].
The questionnaire was created in English, then trans-
lated into Arabic, then translated back to English before
using it in Arabic.
The questionnaire included six sections: social influ-
ences measured by assessing social norms, social model-
ing, and social pressure from important persons such as
father, mother, brother, sister, teacher, best friend and
classmates; attitudes towards tobacco use; self efficacy;
social support; socio-demographic questions; and tobacco
behaviors including a participant’s intention to use tobacco.
The questionnaire was pretested among similar students
from two public schools, one male and one female. The
results were reviewed and discussed, and changes were
applied to the questionnaire. To assess the reliability of
questions, Cronbach’s coefficient alpha was calculated
(a = 0.92 for Social norms; for social pressure, the Cron-
bach alpha was not generated in the pretest, because all
students responded ‘never (1)’to ‘How often have you felt
pressure to use tobacco from your grandmother’; a = 0.90
for the pros of smoking and a = 0.92 for the cons of
smoking; and a = 0.97 for self efficacy in the pre-test).
Social norms assessed how adolescents perceived
important persons’ thoughts on their tobacco use. A total of
7 questions were created and measured on a 5-point scale,
ranging from 1 = strongly disagree to 5 = strongly agree
(a = 0.83). A high score indicates positive social norms
towards tobacco use and a low score indicates negative
social norms towards tobacco use. In factor analysis
important persons were divided into two groups, family
(a = 0.83) and friend and teacher (a = 0.75). Social
modeling assessed the perceived tobacco use of important
persons using a total of 7 questions (Yes, No). Factor
analysis resulted in five variables which were divided into
two factors: female family members (a = 0.47) and others
(a = 0.51). Social pressure assessed the perceived feeling
of pressure to use tobacco by important persons. A total of
6 questions were created and measured on a 5-point scale,
ranging from 1 = never to 5 = very often (a = 0.68). A
higher score indicates stronger social pressures to use
tobacco and a lower score indicates lesser social pressure.
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Factor analysis yielded six variables which were divided
into two groups, parents (a = 0.69) and others (a = 0.71).
A total of 10 statements about attitudes towards tobacco
use were created whereby an agreement with them indicates
an attitude in favor of tobacco use (e.g. Using tobacco makes
people cool; a = 0.77) and 13 statements whereby an
agreement with them indicates an attitude against tobacco
use (e.g. Tobacco tastes horrible; a = 0.87). They were
measured on a 5-point scale, ranging from 1 = strongly
disagree to 5 = strongly agree. Factor analysis yielded six-
teen variables and these were divided into four factors:
negative value towards tobacco use (a = 0.82), perceived
negative side effects of tobacco use (a = 0.69), positive
feeling towards tobacco use (a = 0.75), and positive
acceptance of tobacco use (a = 0.46).
Self efficacy assessed the confidence not to use tobacco.
A total of 11 questions were created and measured on a
5-point scale, ranging from 1 = not at all confident to
5 = very confident (a = 0.95). A higher score indicates a
stronger confidence in not using tobacco and a lower score
indicates less confidence in not using tobacco. Factor
analysis could not be performed as only one factor was
retained by the MINEIGEN criterion.
A total of 13 questions were created to assess whether a
student’s situation was supportive or not (Yes, No). Factor
analysis produced eleven variables and these were divided
into four factors: parents’ help (a = 0.82); parents’ infor-
mation on tobacco (a = 0.69); support from family, friends
and teachers (a = 0.53); and accessibility to tobacco
(a = 0.42). Socio-demographic questions were created to
identify risk and protective factors that may affect ado-
lescents’ tobacco use. A single question on a participant’s
intention to use tobacco in the next year was added. It was
measured by selecting one item on a 5-point scale, ranging
from 1 = not at all likely to 5 = definitely likely.
Data Analysis
The SAS 9.2 version, a software package for statistical
analysis, was used to compute descriptive statistics of par-
ticipants’ information by gender and tobacco use. Factor
analysis was employed to determine which items of each
section such as social norms, social modeling, social pres-
sure, attitudes towards tobacco use, social support and socio-
demographic questions formed separate, interpretable and
independent dimensions. Then, using factors extracted
within each section, further analyses were performed to
identify whether there was a group effect. To examine dif-
ferences in social influences, attitudes, and self efficacy
between males and females, and between tobacco users and
nonusers, t test was used. The association between the risk/
protective factors and attitudes of pros or cons of tobacco use
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Matern Child Health J (2012) 16:1828–1836
was assessed using multiple regression analyses. To identify
risk and protective factors related to intention to use tobacco,
multiple regression analyses were also used.
Overall, R-squares in Table 3 (range 0.01–0.12) and 4
(range 0.11–0.23) were very low due to measuring constructs
such as perception and attitude, which are common findings
in social sciences. Therefore, we calculated reliability scores
and tested multicollinearity by using the variance inflation
factor (VIF) for each social influence including demographic
characteristics. The VIF values were low across all social
influences and ranged from 1.1 to 1.4. Values of P \ 0.05
were considered statistically significant.
Results
All selected schools and 86.2% (1,022) of the originally
selected 7–9th grade students participated in this study.
There were 164 absent students at the time of survey and
three surveys were later eliminated from the analysis. The
final sample comprised of 1,019 surveys. The mean age of
the participants was 14.3 years (SD = 1.2) ranging from
11 to 19, and males comprised 54% of the sample.
Differences in Determinants of Tobacco Use Between
Male and Female Students
The differences between male and female students in the
way they received influences from their social environment
are presented in Table 1. Compared to female students, male
students were more significantly affected by the opinions of
friends and teachers regarding tobacco use, had more friends
and teachers who use tobacco, had more brothers, sisters,
friends and important others who pressured them to use
tobacco, had more negative value towards tobacco use, had
more parents’ help, and had more conversations about the
effects of tobacco use with parents. Alternatively, female
students had significantly more mothers and sisters who use
tobacco, had more positive feelings towards tobacco use,
had higher perceptions of negative side effects of tobacco
use, and were more confident not to use tobacco.
Differences in the Determinants of Tobacco Use
Between Tobacco Users and Non-Users
About 10% of all surveyed students reported current
tobacco use. Table 2 shows the differences between
tobacco users and non-users in the way they received
influences from their social environment. Compared to
non-users, tobacco users were more affected by all social
influences including social norms, social modeling, and
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Table 1 Mean scores (SD) of

Male Female P-value
social determinants of tobacco
N = 547 N = 466
use among male and female
students Social norms (1–5) 1.52 (0.62) 1.45 (0.54) 0.105
Family 1.27 (0.53) 1.28 (0.50) 0.688
Friend and teacher 1.88 (0.95) 1.66 (0.76) \0.0001
Social modeling (0, 1) 0.33 (0.22) 0.18 (0.21) \0.0001
Mothers and sisters 0.04 (0.16) 0.08 (0.22) \0.001
Friend, teacher, other 0.53 (0.33) 0.24 (0.25) \0.0001
Social pressure (1–5) 1.10 (0.29) 1.05 (0.22) \0.01
Parents 1.02 (0.16) 1.02 (0.20) 0.891
Brother, sister, friends, others 1.15 (0.40) 1.07 (0.31) \0.01
Attitudes
Positive feeling towards tobacco use 2.45 (0.96) 2.68 (0.93) \0.001
Positive acceptance of tobacco use 2.20 (0.99) 2.27 (0.99) 0.267
Negative value towards tobacco use 4.19 (0.93) 4.08 (0.78) \0.05
Perceived negative effects of tobacco use 3.57 (1.18) 3.70 (0.84) \0.05
Self efficacy (1–5) 4.29 (1.05) 4.41 (0.90) \0.05
Social support (0,1) 0.63 (0.20) 0.60 (0.19) \0.05
Parents’ help 0.76 (0.39) 0.68 (0.43) \0.01
Parents’ information on tobacco effects 0.63 (0.42) 0.51 (0.43) \0.0001
Support from family, friends and teachers 0.71 (0.32) 0.73 (0.31) 0.384
Accessibility 0.44 (0.40) 0.42 (0.38) 0.438

Table 2 Mean scores (SD) of

Tobacco users Non-tobacco users P-value
social determinants of tobacco
N = 99 N = 920
use among tobacco users and
non-users Social norms (1–5) 2.09 (0.86) 1.43 (0.51) \0.0001
Family 1.64 (0.87) 1.24 (0.45) \0.001
Friends and teacher 2.72 (1.13) 1.68 (0.78) \0.0001
Social modeling (0, 1) 0.46 (0.23) 0.26 (0.21) \0.0001
Mothers and sisters 0.17 (0.32) 0.05 (0.17) \0.001
Friend, teacher, other 0.66 (0.31) 0.41 (0.33) \0.0001
Social pressure (1–5) 1.34 (0.43) 1.05 (0.22) \0.0001
Parents 1.05 (0.39) 1.01 (0.14) 0.337
Brother, sister, friends, others 1.47 (0.62) 1.07 (0.30) \0.0001
Attitudes
Positive feeling towards tobacco use 2.98 (0.92) 2.52 (0.94) \0.0001
Positive acceptance of tobacco use 2.94 (1.03) 2.16 (0.96) \0.0001
Negative value towards tobacco use 3.76 (0.84) 4.18 (0.85) \0.0001
Perceived negative effects of tobacco use 3.67 (0.86) 3.63 (1.05) 0.692
Self efficacy (1–5) 3.42 (0.95) 4.45 (0.94) \0.0001
Social support (0,1) 0.60 (0.20) 0.62 (0.19) 0.518
Parents’ help 0.65 (0.43) 0.73 (0.41) 0.073
Parents’ information on tobacco effects 0.54 (0.40) 0.58 (0.44) 0.355
Support from family, friends and teachers 0.62 (0.32) 0.73 (0.31) \0.001
Accessibility 0.66 (0.36) 0.40 (0.39) \0.0001

social pressure. Furthermore, users showed more positive confident in their ability not to use tobacco. Moreover,
feeling towards tobacco use, better acceptance of tobacco tobacco users reported less support from family, friends,
use, less negative value towards tobacco use, and were less and teachers and easier access to tobacco.

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Factors Affecting Positive Attitudes Towards
Tobacco Use
Multiple regression analyses were used to identify the
factors affecting positive attitudes towards tobacco use
(Table 3). Students’ perceptions of all important persons’
thoughts on their tobacco use; mother and sister’s tobacco
use; friends, teachers, and important other’s tobacco use;
pressure to use tobacco from brothers, sisters, friends, and
important other; accessibility to tobacco; and frequency of
skipping classes were positively associated with positive
attitudes towards tobacco use.
When applying the multiple regression models without
factor analysis, a student’s perception of disapproval of
Table 3 Social influences affecting positive and negative attitudes
towards tobacco use
Pros of using Cons of using
tobacco tobacco
P-value P-value
tobacco use by his/her teacher, being supported by teach-
ers, being more religious, and having more educated
fathers were negatively associated with positive attitudes
towards tobacco use.
Factors Affecting Negative Attitudes Towards
Tobacco Use
Table 3 also shows the factors affecting negative attitudes
towards tobacco use. Friends, teachers and important oth-
ers’ tobacco use; parents’ help; support from family,
friends, and teachers; accessibility to tobacco; and family
income/father’s education/district of residence were posi-
tively associated with negative attitudes towards tobacco
use. Student perception of family’s positive thoughts on
their tobacco use; pressure to use tobacco from brothers,
sisters, friends and important other; and poor school per-
formance were negatively associated with negative atti-
tudes toward tobacco use.
Factors Affecting Intention to Use Tobacco

Social norms  Multiple regression analyses were used to determine indi-

Family \0.0001 \0.05 vidual predictors of intention of future use of tobacco
Friend and teacher \0.0001 0.08 (Table 4). Students’ perceptions of all important persons’
Social modelingà thoughts on their tobacco use; mother and sister’s tobacco
Mothers and sisters \0.001 0.22 use; friends, teachers and important others’ tobacco use;
Friend, teacher, other \0.05 \0.05 pressure to use tobacco from all important persons; watching
Social pressure§ TV; being worried; easy access to tobacco; poor school
Parents 0.214 0.264 performance; frequent skipping of classes; and family
Brother, sister, friends, others \0.0001 \0.001 income/father’s education/district of residence were statis-
Social support|| tically significant positive predictors of intention to use
Parents’ help 0.387 \0.0001 tobacco.
Parents’ information on tobacco 0.971 0.113 Students who reported being with friends who use
effects tobacco; being depressed; receiving parents’ help; and hav-
Support from family, friends and 0.179 \0.01 ing a perception of being supported by family, friends and
teachers
teachers were significantly less likely to use tobacco in the
Accessibility to tobacco \0.0001 \0.01
future. Finally, having strong religious beliefs was also a
Sociodemographic characteristics}
negative predictor of intention to use tobacco (P \ 0.0001).
School performance 0.655 \0.0001
Frequency of skipping classes \0.0001 0.221
Family income, father’s 0.474 \0.01 Discussion
education, district
 
Pros of using tobacco: F = 46.95, P \ 0.0001; Cons of using Social Influences and Adolescent Tobacco Use
tobacco: F = 3.21, P = 0.041
à
Pros of using tobacco: F = 10.33, P \ 0.0001; Cons of using
A rapid rise in the number of tobacco users in Saudi Arabia
tobacco: F = 2.68 P = 0.0699
§ has occurred in the past decade, particularly among the
Pros of using tobacco: F = 21.04, P \ 0.0001; Cons of using
tobacco: F = 7.31, P = 0.0007 youth. In this study, we investigated factors that affect ado-
||
Pros of using tobacco: F = 11.02, P \ 0.0001; Cons of using lescent tobacco use and their attitudes toward tobacco use.
tobacco: F = 11.37, P \ 0.0001 Our findings agreed with other studies in those social
}
Pros of using tobacco: F = 13.94, P \ 0.0001; Cons of using influences such as peer and parental smoking, lower parental
tobacco: F = 13.78, P \ 0.0001 monitoring, and relaxed parental attitudes towards adoles-
All VIFs were less than 1.4 cent smokers were associated with adolescent tobacco use

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Table 4 Regression results of predictors of intentions to use tobacco had more positive attitudes towards tobacco use. These
Intention to use tobacco ß P-value
findings agree with results from another study of middle
and high school students from Tabuk, Saudi Arabia, where
Social norms  a significantly higher percentage of female students
Family 0.091 \0.0001 reported having at least one parent who was a smoker and
Friends and teacher 0.066 \0.0001 were significantly more positive towards smoking than
à
Social modeling male students. However, these results are contradictory to
Mothers and sisters 0.213 \0.0001 those of Fritz et al. [28] who reported insignificant gender
Friend, teacher, other 0.478 \0.0001 differences in the perception of smoking among adolescent
Social pressure§ smokers and concluded that gender specific cessation
Parents 0.23 \0.01 programs might not be necessary.
Brother, sister, friends, others 0.215 \0.0001 Compared to modern Western societies, our results are
Self efficacy ||
typical in the light of the socio-cultural context in Saudi
When I am with my friends who use -0.0.2081 \0.0001 Arabia. Generally, boys are encouraged to spend more time
tobacco with peers and are not as strictly supervised as girls are.
When I am watching TV 0.099 \0.01 They use tobacco as means of preserving their masculine
When I am worried 0.128 \0.01 image and maturity among peers [3]. Although the girls are
When I am depressed -0.144 \0.001 closely supervised by their families, they are far less
Social support} exposed to tobacco education in schools and even at home
Parents’ help -0.161 \0.05 [4, 29], unlike the boys who receive in school tobacco
Parents’ information on tobacco effects -0.082 0.212 education and have more conversations with parents about
Support from family, friends and teachers -0.375 \0.0001 tobacco’s effects. Our culture also affects tastes and pref-
Accessibility to tobacco 0.641 \0.0001 erences for tobacco products. Nargila (water pipe) use is
Sociodemographic characteristicsP more acceptable to female adolescents whereas cigarette
School performance 0.109 \0.01 smoking and dipping (nushoog) is more acceptable to male
Frequency of skipping classes 0.295 \0.0001 adolescents [29]. The effect of this culture coupled with
Family income, father’s education, district 0.054 \0.01 strong direct and indirect tobacco advertisements which
 
link tobacco use with women’s independence, power,
F = 65.87, P \ 0.0001; àF = 26.66, P \ 0.0001; §F = 75.58,
P \ 0.0001; ||F = 26.96, P \ 0.0001; }F = 23.71, P \ 0.0001; sophistication, and weight control shape female adoles-
P
F = 53.98, P \ 0.0001 cents’ attitudes towards tobacco use [17, 30–34]. This
All VIFs were less than 1.4 except|| further clarifies our unusual findings which showed that
students who have highly educated mothers had positive
attitudes towards tobacco use and had future intentions of
[17–26]. Adolescent perceptions of societal norms are using tobacco.
reflected in their attitudes toward smoking and their per-
ceptions of smoking prevalence among their peers [17]. It
is likely that adolescents use their friends’ norms and The Effect of Teachers on Attitudes Towards
approval as a reference in deciding to quit, continue, or Tobacco Use
even increase their levels of tobacco use [10]. Therefore, it
is imperative to develop a protective environment for Our study’s findings regarding teacher’s social influences
adolescents which support positive social norms in order to on student’s tobacco use showed that the majority of stu-
prevent the spread of negative social behaviors among dents had negative attitudes towards tobacco use. Students
adolescents [27]. who had teachers that provided them with moral support
and values had negative attitudes towards tobacco use.
Surprisingly, students who had teachers that use tobacco or
Gender Differences in Social Influences and Attitudes approved of adolescent tobacco use also had negative
Towards Tobacco Use attitudes towards using tobacco. It appears that students
established the perception that tobacco use is negative,
Our results showed that males were significantly more regardless of their teacher’s perception or use of tobacco.
influenced by the opinion of friends, teachers, and impor- Therefore, choosing to use or not to use tobacco depends
tant persons; had more friends and teachers who use on how adolescents perceive social norms regarding
tobacco; and were more susceptible to peer pressure. tobacco use [17]. In essence, students neither support nor
Females had more mothers and sisters who use tobacco and approve tobacco use in the school environment.

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The Effect of Religion on Attitudes Towards
Tobacco Use
Religious beliefs emerged as strong predictors of intention
to use tobacco and were significantly associated with
negative attitudes towards tobacco use. Al-Damegh et al.
[35] reported that high school students in Riyadh who were
affiliated with Islamic secondary institutes had significantly
lesser prevalence of smoking compared to students enrol-
led in general, commercial, and technical secondary
schools. Other local studies found that religion was
reported as a reason for not smoking among adolescents
[36–38]. Studies from the USA, UK, and other countries
also reported on the positive role of religion in preventing
tobacco use [18, 35].
The Effect of Access to Tobacco Products on Attitudes
Towards Tobacco Use
Access to tobacco products was significantly associated
with attitudes towards tobacco use and future intention of
use. In Saudi Arabia, an average pack of cigarettes is sold
for SR 7 ($ 1.86) and is easily accessed by minors. Fur-
thermore, nushoog (a form of local smokeless tobacco) is
illegally prepared and sold in variously sized packets for an
even cheaper price. The easy access and low price of
tobacco products facilitate the initiation of adolescents’
tobacco use.
Critical Factors in the Development of Tobacco
Prevention Programs
Saudi Arabia is currently going through a period of rapid
modernization. During this period, societal and cultural
traditional values related to socializing out of the home
environment are evolving. Adolescents particularly
females are determined to show their independence by
spending more time out of the home, with their peers. This
time is usually spent in the hastily growing nargila cafes/
restaurants [6]. This form of modernization along with
ineffective policies regarding tobacco use and the low
awareness levels of tobacco hazards particularly among
female adolescents is an alarming issue that calls for
immediate attention.
There is a pressing need for developing and providing
effective school-based prevention programs that focus on
the overall socio-cultural context of tobacco use, take into
account risk and protective factors, and reflect gender
differences in tobacco preferences and social influences.
Gender specific tobacco prevention school programs
become necessary in a culture where girls and boys are
generally segregated, are influenced by different figures,
and receive different tobacco related messages. The school
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Matern Child Health J (2012) 16:1828–1836
programs should involve and educate the parents as well.
Encouraging parents to monitor their children and to be
unambiguously strict in their attitudes toward tobacco use
will help decrease youth susceptibility and access to
tobacco [26].
Furthermore, laws which ban sales of tobacco products
to minors must be passed immediately and charges must be
imposed on store owners who violate these laws [8]. In
addition, a price increase seems necessary and rational to
dissuade adolescents from initially trying tobacco products
and subsequently developing a lifetime addiction to nico-
tine [26].
Finally, advocating abstinence from and cessation of
tobacco use based on religious and moral beliefs by families,
schools, and religious institutions seems effective in a reli-
giously oriented community such as that of Saudi Arabia.
Strengths and Limitations
Our study was conducted on a large representative random
sample of both boys and girls schools in Jeddah to assess
factors associated with their tobacco use. Jeddah as the
second largest city and the first sea port in the country
represents a mixture of all ethnicities in the country.
Therefore, we believe that the implications of our findings
can be extrapolated to most adolescents in the country who
share similar cultural and traditional values.
To enhance the validity of self-reported tobacco use, we
collected saliva samples from students prior to question-
naire administration. The questionnaire was pretested to
determine whether the questions were worded properly and
understandable. Across the sections of the questionnaire,
internal consistency was moderate to high.
Despite our efforts to develop appropriate survey ques-
tions targeting our population’s level of comprehension
and pretesting them, some students still did not understand
some questions fully during the survey. Whether this is
related to students’ true misinterpretation of questions or
attitudes towards the survey, data collectors have captured
most of it, explained vague questions, and managed to
motivate students to cooperate to complete their surveys as
accurately as possible. Finally, the conclusions derived
from this study are based on associations that are not causal
which is an inherent nature of all cross-sectional studies.
Conclusion
The findings of this study help in understanding tobacco
use behaviors among adolescents in Saudi Arabia. These
findings should be used to develop tobacco prevention
programs and policies that support and protect adolescents’
health and control tobacco use in the country.
Matern Child Health J (2012) 16:1828–1836
Acknowledgments This project was funded by the Deanship of
Scientific Research (DSR), King Abdulaziz University, Jeddah under
grant number (429/014-9). The authors, therefore, acknowledge with
thanks DSR’s technical and financial support. The authors would like
to extend their thanks to the Directorates of both male and female
Education Departments for supporting the study and facilitating
access to and cooperation of the schools’ administrations. Special
thanks are due to Mr. Ramzy Al-Zahrani, principal of Maslama bin
Abdulmalek School, for his constant support and for providing us
with student users of tobacco to help us conduct focus interviews and
develop our questionnaire. We are also grateful to: the dental interns
who assisted with questionnaire administration for their hard work
and commitment; the principals, teachers, and staff of all participating
schools for their support and cooperation; and the students for
cooperating with the survey.
Conflict of interest The authors have no conflicts of interest and no
financial disclosures to report.
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