INTRODUCTION
Smoking is defined as the inhalation of the smoke of burnt tobacco1. There are various types of smoking, including cigarettes, cigars, cigarillos, bidis, shisha, and kretek pipes or waterpipes, etc.2-4. Nowadays, smokeless tobacco is becoming fashionable and popular in many parts of the globe2. Hence, smoking has become one of the top and most common factors among young people for their poor health and high-risk factors for chronic diseases such as lung cancer and heart disease5.
Smoking is known to induce significant health problems; while it is widespread among young and college students, it can be controllable through preventive measures6-8. In 2019, it was reported that smoking has emerged as a significant issue of public health as it caused 8.71 million deaths and 229.77 DALYs (disability-adjusted life years) worldwide9. Among these deaths, 30% were due to smoking-induced cancer7.
It is suggested that college students face an elevated susceptibility to smoking, primarily attributed to a heightened probability of ready access to cigarettes6,10. Several modifiable factors exist to mitigate or regulate smoking prevalence among young students, with a notable factor being their academic tenure, particularly among final-year students who are believed to exhibit a greater inclination for smoking than their first-year counterparts. Additionally, the influence of family history, peer smoking behavior, and the broader social environment exerts a substantial impact on the initiation and continuation of smoking habits11.
The escalating prevalence of cigarette and tobacco smoking has emerged as a significant public health concern within the Kingdom of Saudi Arabia (KSA), particularly impacting adolescents and college students12,13. Recognizing the magnitude of this issue, identifying accumulated prevalence rates and pertinent influencing factors is crucial in formulating effective tobacco consumption prevention strategies14.
Hence, the current study aimed to collect the available evidence of smoking prevalence over the past decade (2014–2023) among college students in KSA and to find its pooled prevalence.
METHODS
Reporting method
A systematic search was conducted on smoking prevalence among undergraduate students in PubMed from 2014 to June 2023. The standard guidelines as per Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) were utilized to ensure that all relevant information was presented clearly and comprehensively.
Search strategy and selection criteria
A systematic search was conducted for all English-language articles originating from the KSA on smoking prevalence, epidemiology, and associated factors among undergraduate, college-going, or secondary school students. The search process employed Boolean operators (AND/OR) and utilized keywords such as: ‘smoking among students’, ‘prevalence of smoking among students’, ‘cigarette smoking’, etc.
Inclusion criteria
All free full-length articles published in selected search engines, with selected keywords, in the English language with clear objectives having prevalence/ frequency/behavior or status of smoking, were included.
Exclusion criteria
Previous systematic reviews and review articles15-20 and other articles were excluded if they were conducted on staff and students, any RCTs, where the impact of tobacco on any health-related issue was seen, and where smoking was considered a dependent/contributor variable. Figure 1 shows the study PRISMA flowchart.
Data extraction technique
A data extraction form was designed to collect data from the short-listed studies. The author’s information, year, research design, sample size, prevalence of smoking, and study population were all included on the form. To facilitate a comprehensive reassessment of the articles and rectify any disparities or partialities in the presented data, a rigorous deliberation was undertaken with two experts in the respective field to reduce potential biases. The disagreement or ambiguity in the recovered data was resolved by having a conversation and coming to an agreement.
Statistical analysis
Microsoft Excel was used to create a meta-analysis table that included the research headings: study, total numbers taken in the study, number of smokers, and its percentage (considered as prevalence). The application medCalc was used to calculate the pooled prevalence (95% CI). Funnel and forest plots were used. The heterogeneity test was conducted using Q statistics and I2, and publication bias was tested through Egger’s and Begg’s tests (Kendall’s tau); a p<0.05 was considered significant. Due to high I2 values – more than 75%, which is regarded as a strong heterogeneity – a random effects models was used21,22.
RESULTS
Among the 258 initial pool of articles, only 34 articles were selected in this study and used for further meta-analysis (Figure 1). Most articles were conducted on medical students. The minimum and maximum sample sizes taken in these studies were 20823 and 332224. The lowest prevalence was 7.9%25 (95% CI: 5.19–11.46) in male university students. The other lowest prevalence among medical students was 10.6%26 (95% CI: 7.07–14.97). One of the highest prevalence was reported as 50.5%23 (95% CI: 43.48–57.47) and 59.57%27 (95% CI: 54.38–64.60) among specifically male university students and overall university students. Table 1 shows the study characteristics and smoking pooled prevalence.
Table 1
Studies characteristics and pooled prevalence of smoking
| Authors Year | Total n | Smokers | Weight | Study population | |||
|---|---|---|---|---|---|---|---|
| n | % | 95% CI | Fixed | Random | |||
| Bin Abdulrahman et al.28 2022 | 895 | 307 | 34.3 | 31.20–37.51 | 4.25 | 3.00 | Medical students |
| Albangy et al.29 2019 | 240 | 98 | 40.8 | 34.554–47.342 | 1.14 | 2.85 | Male secondary school students |
| Almogbel et al.30 2021 | 928 | 185 | 19.93 | 17.410–22.653 | 4.40 | 3.00 | University students |
| Alkhalaf et al.31 2021 | 354 | 44 | 12.4 | 9.178–16.325 | 1.68 | 2.91 | Medical students |
| Alnasser et al.32 2022 | 421 | 107 | 25.4 | 21.323–29.857 | 2.00 | 2.94 | Medical students |
| Alwhaibi et al.33 2022 | 675 | 137 | 20.3 | 17.323–23.532 | 3.21 | 2.98 | Pharmacy students |
| Almogbel et al.25 2020 | 316 | 25 | 7.9 | 5.185–11.457 | 1.50 | 2.90 | Male university students |
| Ahmad et al.34 2021 | 388 | 77 | 19.84 | 15.991–24.167 | 1.84 | 2.93 | Medical students |
| Al-Qahtani35 2022 | 454 | 117 | 25.77 | 21.807–30.054 | 2.16 | 2.94 | University students |
| Algorinees et al.12 2016 | 287 | 56 | 19.5 | 15.089–24.577 | 1.37 | 2.88 | Medical students |
| Alenazi et al.36 2023 | 400 | 111 | 27.8 | 23.416–32.417 | 1.90 | 2.93 | Male high school students |
| Mansour37 2017 | 336 | 84 | 25.0 | 20.460–29.987 | 1.60 | 2.91 | Dental students |
| Qanash et al.38 2019 | 1007 | 142 | 14.1 | 12.009–16.405 | 4.78 | 3.00 | Health science students |
| Alshayban and Joseph39 2019 | 464 | 106 | 22.8 | 19.101–26.939 | 2.20 | 2.95 | University students |
| Salih et al.40 2020 | 405 | 138 | 34.0 | 29.466–38.917 | 1.92 | 2.93 | University students |
| Aqeeli et al.41 2022 | 775 | 163 | 21.0 | 18.213–24.074 | 3.68 | 2.99 | Undergraduate students |
| Almutairi42 2016 | 715 | 213 | 29.8 | 26.457–33.291 | 3.39 | 2.98 | Male college students |
| Almutairi42 2016 | 492 | 112 | 22.7 | 19.131–26.729 | 2.34 | 2.95 | Male college students |
| Sharanesha et al.43 2022 | 400 | 176 | 44.0 | 39.071–49.019 | 1.90 | 2.93 | Dental students |
| Almutairi44 2014 | 1789 | 202 | 11.3 | 9.861–12.850 | 8.49 | 3.03 | Medical students |
| Alzahrani et al.23 2021 | 208 | 105 | 50.5 | 43.482–57.466 | 0.99 | 2.82 | Male university students |
| Al-Zalabani45 2015 | 870 | 181 | 20.8 | 18.152–23.656 | 4.13 | 3.00 | Male secondary school students |
| Ansari et al.46 2016 | 340 | 95 | 28.0 | 23.235–33.036 | 1.62 | 2.91 | College students |
| Awan et al.47 2016 | 535 | 198 | 37.0 | 32.906–41.257 | 2.54 | 2.96 | Health science students |
| AlSwuailem et al.48 2014 | 400 | 68 | 17.0 | 13.450–21.047 | 1.90 | 2.93 | Dental students |
| Al-Zalabani and Kasim24 2015 | 3322 | 504 | 15.2 | 13.968–16.437 | 15.75 | 3.04 | Intermediate and secondary schools |
| Muzammil et al.27 2019 | 371 | 221 | 59.6 | 54.380–64.603 | 1.76 | 2.92 | University students |
| Ansari and Farooqi49 2017 | 332 | 44 | 13.3 | 9.797–17.381 | 1.58 | 2.90 | Female medical students |
| Habib et al.50 2020 | 401 | 49 | 12.2 | 9.178–15.831 | 1.91 | 2.93 | Medical students |
| Albgami et al.51 2023 | 319 | 128 | 40.1 | 34.704–45.732 | 1.52 | 2.90 | Male medical students |
| Rayes et al.52 2023 | 534 | 109 | 20.6 | 17.071–24.084 | 2.54 | 2.96 | Adolescent population |
| Almutham et al.26 2019 | 256 | 27 | 10.6 | 7.066–14.973 | 1.22 | 2.86 | Medical students |
| Alshanberi et al.53 2021 | 910 | 289 | 31.8 | 28.742–34.893 | 4.32 | 3.00 | Medical students |
| Alzahrani et al.54 2023 | 519 | 125 | 24.0 | 20.466–28.001 | 2.47 | 2.96 | Medical students |
| Total (fixed effects) | 21058 | 21.9 | 21.317–22.438 | 100 | 100 | ||
| Total (random effects) | 21058 | 24.5 | 21.013–28.090 | 100 | 100 | ||
The test of heterogeneity was determined by Q-test (1188.026, p<0.0001) and I2 test [97.22% (95% CI: 96.70–97.66)]; both indicating a strong heterogeneity. Therefore, the random effects model was used for pooled prevalence. The publication bias was tested using Egger’s test [7.9934 (95% CI: 2.2482 –13.7385), p=0.0079] and Begg’s test/Kendall’s tau (p=0.2463), indicating that it was insignificant. A forest plot was applied to provide a visual indication of the degree of study heterogeneity and the estimated common impact. A funnel plot was utilized to compare the findings and precision of individual studies or the degree to which the estimated intervention effect size is near the genuine effect size. So, there was no relationship between effect size and its standard error (Figures 2 and 3). Hence, using the random effect model, the pooled prevalence was 24.6% (21.01–28.09) (Table 1).
DISCUSSION
Tobacco consumption is still the world’s greatest health concern among college students28. Tobacco smoking among college students presents a pressing public health concern involving various physical, mental, and social challenges. It has become one of the leading factors or causes of illness, bad health, and death28. The college environment, usually characterized by academic stressors, feelings of independence, and peer influences, can contribute to the initiation and continuation of smoking habits55. The consequences of tobacco use during these formative years extend beyond immediate health risks, including long-term implications for both individuals and the broader community55. Smoking can adversely affect students’ academic performance, exacerbating stress and hindering concentration. Studies have shown that smoking causes an estimated 8 million premature deaths annually55.
This meta-analysis study indicated the pooled prevalence was 24.5% (95% CI: 21.013–28.090). Nevertheless, a meta-analysis conducted on Iranian students reported that the pooled prevalence of smoking was 19.8% (95% CI: 17.7–21.9) among male students and 2.2% (95% CI: 1.4–3.02) among female students56. Furthermore, two meta-analyses from Ethiopian university students reported pooled prevalence of the current status of smoking as 15.9% (95% CI: 12.21–19.63)57 and 12.55% (95% CI: 10.39–14.72), with no publication bias58. In the current meta-analysis, the pooled prevalence is high, signaling a notably elevated incidence compared to findings in other relevant studies. This higher prevalence underscores the significance of the observed phenomenon and suggests a potentially heightened public health concern compared to existing research.
It is well-known that the average onset of smoking occurs during the younger age28, which has made smoking a concerning issue among college students18. In one study, a response rate of 38.02% was achieved from a sample of 354 students, comprising 51.7% males and 48.3% females. Among them, 12.4% of medical students reported smoking occasionally, while 39.9% of all medical students reported they were exposed to passive smoking. According to the study, 5.9% of female and 18.6% of male medical students smoked regularly. With regard to the type of tobacco used, the study showed that 47% of smokers who were males did so using a waterpipe, compared to 77.8% of smokers who were females31.
Yet another study revealed that, of the 895 students who answered the poll, the majority (76.4%) said they had never tried or smoked tobacco. The majority of smokers started during the past five years (46.4%), suggesting that they probably started as soon as they enrolled in college. When they were asked whether they would like to smoke, the majority of students (57.1%) responded they would when they were anxious or under pressure. There was a significant correlation (53.1%) between smoking and having a family member who smokes28. In a study conducted on 421 respondents, 243 (57.7%) were aged 18–24 years, 255 (60.6%) were females, and 164 (39%) were from the Eastern Province of KSA. Males had a larger prevalence of smoking than females, with 44% and 13.3%, respectively (p<0.001), making the total prevalence of smoking 25.4%32.
Even though the prevalence of non-smokers among pharmacy students is high, there is a limited understanding of modifiable determinants contributing to the escalating trend. Therefore, it is advisable to promptly initiate awareness programs to guide students in abstaining from smoking, allowing them to concentrate on their studies while maintaining optimal physical and mental health33.
A study showed that among secondary school students, cigarette smoking was the most prevalent form of smoking (67.3%), followed by shisha smoking (22.4%). Only 2.1% of students reported smoking in other ways, such as hashish, etc. Of the individuals surveyed, 29.6% smoked more than five cigarettes a day, accounting for 39.8% of daily smokers29. Similarly, 336 dentistry students participated in another study; of them, 25% reported using tobacco products either currently or in the past, and 96% reported having exposure to passive smoke. Approximately 50% of smokers started during the study of the dentistry program37.
Studies show that students in KSA have insufficient knowledge about the hazards, addiction, and health consequences of smoking. In order to minimize the prevalence of smoking among college students, education and awareness programs must be given a high priority in the medical school curriculum59. Moreover, it is imperative to start tobacco control programs in order to limit and/or prevent tobacco smoking30,37. Furthermore, effective measures should be maintained, such as a combination of smoke-free legislation, higher tobacco prices, easier access to therapies for quitting smoking, and media campaigns against tobacco use7. In order to improve tobacco-related global health and decrease smoking among medical students, doctors, and patients, a medical curriculum on tobacco-related health concerns and smoking cessation should be made mandatory60.
CONCLUSIONS
As the pooled prevalence of smoking is high, it is recommended to take immediate interventions to control smoking through educational programs targeted at college students to improve their awareness about tobacco smoking and its health hazards. Moreover, educational programs should be a continuous process of quality control and maintenance to ensure the minimization of smoking and subsequently associated morbidity and mortality with it.
