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Journal of Behavioral Medicine ISSN 0160-7715Volume 34Number 5 J Behav Med (2011) 34:339-350DOI 10.1007/s10865-011-9319-7

Psychosocial predictors of smokingamong secondary school students in Al-Hassa, Saudi Arabia

Tarek Tawfik Amin, Mostafa AbdelMonhem Amr & Burhan Omar Zaza

1 23

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Psychosocial predictors of smoking among secondary schoolstudents in Al-Hassa, Saudi Arabia

Tarek Tawfik Amin • Mostafa Abdel Monhem Amr •

Burhan Omar Zaza

Received: March 27, 2010 / Accepted: January 19, 2011 / Published online: February 1, 2011

� Springer Science+Business Media, LLC 2011

Abstract The objective of this study was to determine

the prevalence and determinants of the current smoking

status among secondary school students in Al-Hassa, Saudi

Arabia. A total of 1,652 secondary school adolescents were

selected by multistage proportionate sampling method.

Data collection was carried out through self-administered

anonymous questionnaire including: Arabic version of the

Global Youth Tobacco Survey, modified Fagerstrom Test

for Nicotine Dependence and Patient Health Questionnaire

to asses for anxiety and depressive disorders. This study

revealed that the prevalence of current smokers was 21.7.

Seventy-one percent of current cigarette smokers were

minimally nicotine dependent. Major depressive and anx-

iety disorders were significantly higher among current

smokers. Hierarchical regression analysis shows that, male,

older age, smoking of close relatives and friends, anxiety

disorders and socializing motives were statistically signif-

icant determinants of current smoking status among the

included adolescents. Family members should be made

aware of the detrimental influence their smoking behavior

has on their youth. Counseling and preventive psychiatric

services should be an integral part of the clinical facilities

caring for secondary school students.

Keywords Smoking � Smoking predictors �Secondary schools � Adolescents � Saudi Arabia

Introduction

The World Health Organization (WHO) attributes 4.9

million deaths a year to tobacco use, a figure expected to

rise to[10 millions by 2030 if the current trend continues

(Peto and Lopez 2001). Almost 70% of these premature

deaths will be in the developing countries, one-third (*2.3

millions) of which will be among children (WHO 1999).

Morbidity and mortality associated with tobacco use is

shifting from the developed to developing countries,

especially low and middle-income Arab countries (Jha and

Chaloupka 2000). According to the WHO reports, smoking

prevalence among young people in Arab countries differs

greatly: 7% in Oman, 14% in Iran, 18% in Kuwait, 23% in

Iraq, 25% in Jordan, 31% in Syria, 43% in Yemen and 53%

in Lebanon (WHO 2001). Smoking is a major public health

problem in Saudi Arabia and it is increasing at an alarming

rate (Al-Turki 2006; Merdad et al. 2007; Al-Turki and

Al-Rowais 2008). In Riyadh, among a sample of 230 health

care providers, 29% of males and 11.6% of females

smoked cigarettes at the time of their study (Siddiqui and

Ogbeide 2001). Jarallah et al. (1999) surveyed Saudi

nationals in three regions of Saudi Arabia and reported that

the overall prevalence of current smoking was 21.1% for

males and 0.9% for females. Most smokers (78%) were

young to middle-aged (21–50 years). Smoking prevalence

T. T. Amin (&)

Family and Community Medicine Department, College

of Medicine-Al Hassa, King Faisal University, PO Box 400,

Al-Hassa 31982, Saudi Arabia

e-mail: amin55@myway.com

T. T. Amin

Community Health Department, Faculty of Medicine,

Cairo University, Cairo, Egypt

M. A. M. Amr

Department of Clinical Neuroscience, College of Medicine-Al

Hassa, King Faisal University, Al-Hassa, Saudi Arabia

B. O. Zaza

School Health Program Technical Manager, Ministry

of Education, Local Directorate-Al Hassa, Al Hassa,

Saudi Arabia

123

J Behav Med (2011) 34:339–350

DOI 10.1007/s10865-011-9319-7

Author's personal copy

was higher among married, uneducated, and those in certain

occupations including manual workers, businessmen, army

officers, and office workers. Saudi Authorities banned

smoking based on religious backgrounds (Fatwa) since

1926. The existence of many social, cultural, and religious

inhibitions may prevent smokers from providing accurate

information about their smoking status (Bassiony 2009).

Several explanations for the increased trend of tobacco use

among Saudi population were provided. First, despite the

recent increase in tobacco taxes; cigarettes are still very

inexpensive in Saudi Arabia compared with other countries;

the average price for a pack of 20 cigarettes in Saudi Arabia

is $1.3 compared with about $3 in the United States and

$5.4 in Norway (Schultz et al. 1998). In Saudi Arabia

people on low income and young children can obtain cig-

arettes easily (Abdalla et al. 2009). Second, the increase in

tobacco use might represent a relief from psychological

distress that may be attributable to increased stress on Saudi

families undergoing rapid social and cultural transformation

(Al-Gelban 2007) and lastly, the incorrect beliefs about the

possible advantages of smoking might add to this high

prevalence. For instance, many Saudi smokers reported that

smoking calmed them down (Abolfotouh et al. 1998). Over

the past 30 years, the number of young Saudi smokers has

increased. The prevalence of regular smokers among male

secondary school students was 12% in 1987 (Rowlands and

Shipster 1987), 22% in 1993 (Saeed et al. 1993) and 29.8%

in 2004 (Al-Damegh et al. 2004). The prevalence of

smoking among females was much less; about 14% in 1993

(Saeed et al. 1993), 11.1% in 2006 (Abdalla et al. 2007) and

14.9% in 2009 (Abou-Zeid et al. 2009). Recent studies have

shown that peer smoking seemed to be the most important

factor influencing smoking behavior among young people

(Qidwai et al. 2010; Ferreira and Torgal 2010). In addition,

interviews with adolescents who have begun smoking

showed that a large majority (80%) of initial cigarette

smoking experimentation occurs in the presence of other

adolescents who are smoking (Friedman et al. 1985). In

fact, smoking is usually a shared activity with important

socialization functions for youth (McGraw et al. 1991).

Desire, Idleness, imitation, relief from psychological ten-

sion and improve self-esteem are among the motives to

smoke among Saudis (Al-Faris 1995). Smoking parents and

siblings seems to be important in the initiation as well as the

continuation of smoking behavior. Al-Mohamed and Amin

(2010) found that those aged 19–20 years whose relatives

‘especially parents and siblings’ currently smoke were

almost twice as likely to smoke as those whose relatives had

never smoked (Al-Mohamed and Amin 2010). In addition, a

study from Saudi Arabia reported that the average starting

age for current smokers was 13.8 years and the proportion

of adolescents smoke increases with age (Al Yousef and

Karim 2001).

A series of studies noted that cigarette smoking among

youth is a complex behavior with several identifiable

determinants including: interpersonal factors (such as fam-

ily and peer influence), intrapersonal factors (self-esteem),

individual motivational and attitudinal determinants as well

as cultural settings (Goddard 1990; O’Loughlin et al. 1998;

Kandel et al. 2007). Furthermore, there is an increasing body

of research demonstrating the presence of psychiatric dis-

orders among tobacco smokers compared with nonsmokers

(Sonntag et al. 2000; Griesler et al. 2008). For example, two

epidemiological studies found that cigarettes smoking to

be correlated significantly with depression (Nelson and

Wittchen 1998; Dierker et al. 2001). Similarly, Breslau and

Klein (1999) reported an association between tobacco

smoking and higher incidence of panic symptoms. In Egypt,

in a nationwide representative survey of general secondary

school students it was reported that smokers had signifi-

cantly more behavioral deviations and receiving psychiatric

treatment more often than nonsmokers (Soueif et al. 1990).

In Saudi Arabia, surprisingly little attention has been paid

to psychiatric morbidity, especially anxiety and depres-

sive symptoms among young smokers and considerable

researches have focused only on the smoking habits as well

as the related demographic and socioeconomic parameters.

To address the existing gap in the literature on smoking

among adolescents we have tested the following hypothe-

ses: First, older male adolescents are more likely to smoke

tobacco than younger and female adolescents. Second,

smoking among close relatives (environmental tobacco

exposure) and friends (peer pressure) would increase the

likelihood (risk) of being current smoker. Finally, certain

motives (socializing, imitation, outing, rather than relieve of

stress and pleasure) and the presence of depressive and/or

anxiety disorders may represent potential predictors for the

current smoking status among adolescents. To the best of the

authors’ knowledge, there are no previous studies in Saudi

Arabia that address the psychosocial predictors of smoking

status among this age group. In this study, we attempted to

provide baseline information on the psychosocial determi-

nants and prevalence of smoking among adolescents in

secondary school in Al Hassa, KSA, for proper design of

practical and effective intervention strategy.

Methods

A cross-sectional descriptive study carried out in Al-Hassa

Governorate, located in the Eastern Province of Saudi

Arabia, populated with nearly one million Saudis. Al-Hassa

is comprised of three areas; urban, populated by about 60%

of total population and consisted of five major districts,

rural, consisted of eight major villages and 15 other rural

collections, occupied by 35% and Hegar ‘‘Bedouin scattered

340 J Behav Med (2011) 34:339–350

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communities’’ represented 5% ‘‘nearest Hegar is about

65 km distance’’.

Participants

The total students enrolled at secondary schools in Al

Hassa according to the local Directorate of Education year

2009 were 50,399, of which 24,466 were males distributed

in 52 schools in urban (N = 14,337) and rural (N =

10,129) areas. Females secondary schools (N = 51) with a

total population of 25,933; 16,753 in urban and 9,180 in

rural. Considering smoking prevalence of 30% (Abdalla

et al. 2007), the worst acceptable frequency of 27%, using

a confidence level of 95%; the minimum sample size would

be 1,490 students.

An additional 30% was added for the possible non-

response; subsequently, the total sample size would be

1,930: of which males would constitute 49% (N = 950).

Appropriate sampling fraction was used to calculate urban–

rural samples; 1,200 subjects were targeted from urban and

750 from rural schools. Secondary schools were randomly

assigned using an updated sampling frame, where 10 urban,

two from each urban district (5 males and 5 females) and

8 rural schools, one from each major village (4 male and

4 females) were selected. Proportionate sample size was

selected from each school according to the number of

enrolled students in the assigned schools. In the final phase

we employed a systematic technique using the academic

number from school roster to randomly select Saudi students.

Research protocols and data collection tools were approved

by our institution and the local Directorate of Education.

Consent forms were sent to students’ parents/guardians at

home following subjects’ selection a week before the data

collection phase. Those demonstrated parental/guardians’

approvals with signed consent forms were included. Assents

were obtained from the included students. Proper orientation

was carried out to explain the objectives of the study with

emphasis on the right of non participation. The data confi-

dentiality was preserved throughout.

Measures

Anonymous self-administered questionnaire was used for

data collection included the following:

Socio-demographic characteristics: age in years, gender,

residence, parental occupational and educational status,

family income in Saudi Riyals, the presence of any

co-morbid disease or chronic conditions ‘verified through

asking the teachers and revision of school files’.

The Arabic version of the Global Youth Tobacco Survey

2001 (GYTS 2001) developed by Centers for Diseases

Control (CDC, Atlanta, GA, USA) for smoking survey

among youth was used to determine pattern and prevalence

of smoking, similar questions were used to assess water-

pipe (WP) or shisha smoking. Those who had not smoked

in the previous 12 months or longer were asked to consider

themselves as former smokers. Ever smokers included both

current and former smokers while current smoker was

defined as those who smoked one or more cigarette(s) and/

or WP within the past 30 days.

Nicotine dependence: This item was measured using the

modified Fagerstorm test for nicotine dependence (FTND)

(Fagerstrom and Schneider 1989). A widely used and

validated 6-items questionnaire to assess severity of nico-

tine dependence with scores that ranges from 0 to 10. A

score of B4 suggests a low level of nicotine dependence,

while a score C6 usually indicates high dependence level.

A clinically validated screening instrument; the Patient

Health Questionnaire (PHQ) was administered to deter-

mine the prevalence of current depressive and anxiety

disorders: Depression was measured using the Patient

Health Questionnaire (PHQ-9) which is a nine-item

instrument based on the nine DSM-IV criteria for a major

depressive episode. This instrument asks the respondent to

indicate the frequency of various symptoms over the past

2 weeks. Following the standard algorithms for interpret-

ing the results of PHQ-9 (Spitzer et al. 1999), we catego-

rized students as screening positive for major depression,

other depressive disorders including mild depression, dys-

thymia and minor depression. This tool has been validated

as being highly correlated with diagnosis made by mental

health professionals and other depression assessment tools

(Diez-Quevedo et al. 2001; Henkel et al. 2004; Kroenke

et al. 2001) in a variety of populations. In the original

validation study, the sensitivity and specificity were 73%

and 98%, respectively, for major depression among pri-

mary care patients (Spitzer et al. 1999).

Anxiety was measured using items from the Patient-

Health-Questionnaire (PHQ). Items asked about symptoms

of panic and generalized anxiety disorders over the past

4 weeks. Standard algorithm was employed to categorize

students as screening positive for panic disorder, general-

ized anxiety disorder, both, or neither (Spitzer et al. 1999).

In the original validation study the sensitivity and speci-

ficity of the PHQ anxiety scale were 81 and 99%, respec-

tively, for panic disorder, and 63 and 97% for generalized

anxiety disorder (Spitzer et al. 1999).

Three questions from the National Comorbidity Survey

Replication (Kessler et al. 2005) were used to assess

suicidality in the past 4 weeks. These questions asked

whether in the past 4 weeks the respondent ever seriously

thought about committing suicide, made a plan for com-

mitting or attempted suicide.

School visits were carried out to conduct orientation

sessions for schools administration staff and selected

J Behav Med (2011) 34:339–350 341

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students regarding the objectives, contents and data confi-

dentiality. With regards to female schools, female teachers

were assigned for procedures of orientation, and data col-

lection under the supervision of a female research assistant

and in response to the conservative nature of Saudi culture.

Questionnaire administration was carried out at school’s

library or computer laboratory in anonymous and solicited

setting after reading it loudly.

Pilot testing and reliability analysis: Initial data collec-

tion form was tested on 102 secondary school students

beyond the sample size, at a nearby school for convenience.

Pilot testing was used to identify the possible common

motives for smoking behavior and for reliability testing of

the used data collection tools. The reliability coefficients

(Cronbach’s a) for PHQ-9 were 0.79, PHQ selected anxiety

items was 0.76, and for suicidality it was (0.73).

Statistical analysis

Questionnaires with missing of more than two elements

were discarded (N = 71). The overall response rate was

89.3% and it was 66.8% among urban female secondary

schools.

Data entry and analysis was carried out using SPSS

version 13.0 (SPSS Inc., Chicago IL, USA). Categorical

data were reported in frequency, proportion and percent-

age, univariate analysis with estimation of Odds ratio and

95% confidence intervals, Chi-square, Fisher exact and

Z test for proportions tests of significance were used for

comparisons. Continuous data were expressed using mean,

median and standard deviation, student’s t and Mann–

Whitney tests of significance were used for comparisons.

Scores of the PHQ were classified according to the pro-

posed algorithm (Spitzer et al. 1999) into any depression,

major depression, panic and anxiety disorders.

Regression analysis: Hierarchical logistic regression

analysis was generated to determine whether socio-demo-

graphic variables (age, gender), exposure to environmental

tobacco (smoking among close relatives and friends), the

motives for smoking and the presence of psychiatric mor-

bidity in the form of depression or anxiety are potential

determinants for the adoption of the current smoking status.

Predictors were entered in three steps according to a

specified hierarchy (O’Loughlin et al. 1998; Jarallah et al.

1996): The first step included forced entry of demographic

variables (gender, age in years). The second step entailed

entry of smoking among close family members and close

friends. The final step entailed entry of possible psycho-

social predictors; motives for current smoking status

(socializing, outing, vs. relieving stress) and the presence

of depressive or anxiety disorders.

This procedure for constructing hierarchy was recom-

mended by (DeCoster 2006) to reduce potential problems

with multicollinearity. Odds ratio with 95% confidence

intervals, change in v2 were evaluated at the final step of

the regression equation when all variables were entered.

Because there are no agreed-upon measures for R2 contri-

butions to date in multilevel logistic regression, we ana-

lyzed the data as a single level model to obtain the

Nagelkerke R2 statistic (Nagelkerke 1991), which com-

pares the null model and fitted model likelihood functions

as a proportion of the maximum possible R2 value. The R2s

for all predictors and Chi-square statistic with its signifi-

cance were reported for the single-level logistic regression,

since there are no agreed-upon measures in hierarchical

logistic multivariate analysis. Dummy codes were used in

entering of dichotomous variables for the generation of

intercorrelation matrix (Pearson correlation coefficients)

and hierarchical models: Gender (1 = male, 0 = female),

smoking among close relatives (1 = father and/or brothers,

0 = others or none), smoking among friends (1 = All or

most of them, 0 = some or none), motives (1 = socializ-

ing, imitation, outing, 0 = relieve of stress, pleasure),

depression (1 = any depression, 0 = none), Anxiety dis-

orders (1 = present, 0 = none). Probability used for

inclusion in the regression model was 0.05 and for removal

was set at P = 0.10. Statistical significance was set at 0.05.

Results

The sample composed of 1,652 secondary school students,

of which 60.4% were males. Age ranged from 15 to

19 years with a mean of 17.5 ± 1.0 (males 17.4 ± 1.1 and

females 17.4 ± 1.0) years. Urban students represented

57.5% of the sample.

Prevalence of smoking: For any type of tobacco; 358

(21.7%) were considered as the current smokers (both

genders). The prevalence of current smokers was 30.3 and

8.5% among males and females, respectively. Of the total,

419 (25.4%) were ever smokers as 43 males and 18 females

reported as being former smokers (ever smokers were 34.6

and 11.3% among males and females, respectively), 1,233

were never smokers (74.6 and 88.7% among males and

females, respectively). Forms of tobacco use among cur-

rent smokers includes: cigarettes in 224 (62.6%) as the only

method of tobacco use (in 175/224 78.1% of current

smokers) or in combination with WP/shisha in 59/224

(26.3%). WP as a method of tobacco was mentioned by

193/358 (53.9%) of current tobacco users, while both

cigarettes and WP smoking were used by 59/358 (16.5%).

Table 1 demonstrates the socio-demographics of the

included students in relation to their current smoking sta-

tus: Male gender (Odds ratio ‘OR’ = 4.65), higher years at

secondary school (3rd grade, OR = 1.77, P = 0.001),

older age of students ([18 years, OR = 2.34, P = 0.001)

342 J Behav Med (2011) 34:339–350

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and lower parental educational statuses were all associated

with significantly higher likelihood for being current

smokers.

Table 2 shows the results of the PHQ-9, PHQ and

National Comorbidity Survey Replication of the total sam-

ple in relation to gender of the included secondary school

adolescents. Females were significantly more affected with

mild, minor depression compared to males (P = 0.002) as

revealed by the results of PHQ-9. Results obtained from

PHQ showed that female students were more likely to suffer

from generalized anxiety disorder (P = 0.001) and any

depression or anxiety disorder (P = 0.002). Suicidal idea-

tion was also significantly more among female. Table 2 also

demonstrates the distribution of mental illnesses among the

current smokers compared to the total sampled population.

Current smokers showed a significantly higher likelihood

of major depression (Odds ratio, OR = 1.81, Confidence

Intervals CI = 1.02–3.18, P = 0.032), any depression

(OR = 1.43, CI = 1.07–1.91, P = 0.002), generalized

anxiety disorder (OR = 1.83, CI = 1.36–2.47, P = 0.001),

and any depression or anxiety (OR = 2.65, CI = 2.08–3.37,

P = 0.001). Although current smokers demonstrated a

higher frequency of other depressive disorders (mild, minor

and dythymia), this difference was not statistically signifi-

cant (OR = 1.33, CI = 0.96–1.85, P = 0.071).

Smoking Patterns among current tobacco users: Table 3

displays some characteristics of the current smokers ‘cig-

arettes and WP/shisha’ in relation to gender. Cigarettes’

smoking was the chief method used by females, while

males showed more prevalent usage of WP with/without

cigarettes. The age at initiation for cigarettes smoking was

significantly lower compared to WP or both. Age at initi-

ation of cigarette smoking was significantly lower among

males (P = 0.022). FTND shows a total score of 2.9 ± 1.2

among current cigarettes smokers, males demonstrated

higher scores than female (P = 0.011). Overall, 159 (71.0%)

of current cigarettes smokers had a score of\4 (minimally

dependent), more among females (78.2% vs. 68.6% for

Table 1 Socio-demographics

and mental health measures of

the included secondary school

students according to their

current smoking status-Al Hassa

CI Confidence intervals

* P \ 0.05; ** P \ 0.001

Socio-demographics Total

(N = 1,652)

No. (%)

Current smokers

(N = 358)

No. (%)

Odds ratio (95% CI)

Gender

Males 997(60.4) 302(30.3) 4.65(3.93–6.38)**

Females 655(39.6) 56(8.5) Reference

Residence

Urban 950(57.5) 203(21.4) 1.26(0.98–1.63)

Rural 702(42.5) 155(22.1) Reference

School grades

1st 454(27.5) 79(17.4) 0.69(0.52–0.92)*

2nd 629(30.1) 118(18.8) 0.75(0.58–0.97)*

3rd 569(34.4) 161(28.3) Reference

Age ‘‘years’’

16 364(22.0) 61(16.8) 0.67(0.49–0.92)*

17 481(29.1) 83(17.3) 0.70(0.52–0.92)*

18 494(29.9) 105(21.3) 1.16(0.89–1.51)

19 313(19.0) 109(34.8) Reference

Mother’s education

Illiterate/read and write 475(28.8) 104(21.9) 1.02(0.78–1.33)

Primary/intermediate 493(29.8) 109(22.1) 1.03(0.79–1.34)

Secondary 415(25.1) 79(19.0) 0.81(0.60–1.08)

University/higher 269(16.3) 66(24.5) Reference

Father’s education

Illiterate/read and write 391(23.7) 99(25.3) 1.31(1.00–1.73)*

Primary/intermediate 561(34.0) 129(23.0) 1.12(0.87–1.45)

Secondary 441(26.7) 86(19.5) 0.84(0.63–1.11)

University/higher 259(15.7) 44(17.0) Reference

Presence of co-morbidities

Yes 116(7.0) 33(28.4) 1.48(0.95–2.30)

No 1,536(93.0) 325(21.2) Reference

J Behav Med (2011) 34:339–350 343

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females), while 42/224 (18.8%) of the current smokers had a

score range of 4–6 ‘‘moderately dependent’’. Highly

dependent group; included 23 (10.3%) of the current ciga-

rettes smokers.

Table 4 displays the smoking status among family

members and close friends of the current smokers. It shows

that father (25.7%), brothers (16.5%), both father and

brothers (12.0%) were the chief source for environmental

tobacco exposure compared to 15.8, 9.7, and 8.3% among

the non smokers group, respectively. Among current

smokers, smoking among all close friends (32.4%,

OR = 9.1, P = 0.001), and most of close friends (27.9%,

OR = 5.25, P = 0.001) were statistically significant com-

pared to the non-smokers group.

Table 4 also depicts the stated motives for the current

smoking status among the included adolescents. Meeting

friends and family members, outing with friends, passing

of time, and imitation of father and brothers were the

most frequently stated motives and accounting for [75%

of the responses among current smokers. Role of smoking

in relieve of tension and stress, emotional and family

problems, and as a source of pleasure and happiness were

mentioned by about 20%. Among females, family negli-

gence, passing of time and imitations were mentioned by

about 76%, while for males, outing, meeting of friends

and family and imitations of the others were the main

motives mentioned.

Predictors for current smoking status: Table 5 demon-

strates the results of the hierarchical regression analysis

model for the possible psychosocial determinants that favor

the adoption of current smoking status among the sec-

ondary school adolescents.

In model one, increasing age and male gender were

significant positive predictors for the current smoking sta-

tus. On entry of the environmental tobacco exposure in the

form of smoking among family and close friends, smoking

among family members remained the most positive pre-

dictors in this step. In the last step the third model displays

that motives in the form of socializing, outing versus

reliving of stress and the presence of anxiety disorders

were positively associated with increased likelihood of

smoking status.

Table 2 Results of Patient Health Questionnaire in relation to gender and current smoking status of the included secondary school adolescents-

Al Hassa

Variables Total population

(N = 1,652)

No. (%)

Gender P valuea Current smokers

(N = 358)

No. (%)

P valuea

Males (N = 997)

No. (%)

Females (N = 655)

No. (%)

PHQ-9 scores

0–4 524(31.7) 251(25.2) 273(41.7) 0.001 102(28.5) 0.156

5–9 835(50.6) 598(60.0) 237(36.2) 0.001 173(48.3) 0.373

10–14 230(13.9) 109(10.9) 121(18.5) 0.002 62(17.3) 0.044

15–19 41(2.5) 27(2.1) 14(2.7) 0.57 13(3.6) 0.165

C20 22(1.3) 12(1.2) 10(1.5) 0.733 8(2.2) 0.154

Depressive disorders (PHQ-9)

Major depression 63(3.8) 39(3.9) 24(3.7) 0.899 21(23.1) 0.032

Other depressionb 230(13.9) 109(10.9) 121(18.5) 0.002 62(23.8) 0.071

Any depression (PHQ-9) 293(17.7) 148(14.8) 145(22.1) 0.001 83(28.3) 0.002

Anxiety disorders (PHQ)

Panic disorder 39(2.4) 22(2.2) 17(2.6) 0.731 15(19.2) 0.692

Generalized anxiety disorder 247(15.0) 113(11.3) 134(20.5) 0.001 83(33.6) 0.001

Any depression or anxiety (PHQ) 381(23.1) 204(20.5) 177(27.0) 0.002 161(44.9) 0.001

Suicidality

Ideation 19(1.2) 6(0.6) 13(2.0) 0.004 5(1.4) 0.903

Plan 3(0.2) 3(0.3) 0 – 0 –

Attempt 0 0 0 – 0 –

PHQ-9: Patient Health Questionnaire-nine items for depressive disorders; PHQ: Patient Health Questionnaire for anxiety disorders; suicidality:

items from national comorbidity survey replicationa Z test for proportionsb Minor depression, dysthymia, and mild depression

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Discussion

The prevalence rates of current and ever smoking among

secondary school students in Al-Hassa are accounted for

21.4 and 25.4%, respectively. Such prevalence are in

accordance with the findings of others conducted in many

parts of Saudi Arabia (Al Yousef and Karim 2001;

Al-Damegh et al. 2004; Abdalla et al. 2007) and in other

countries of the Arab gulf, Middle East, Africa, Europe,

Asia and Latin America (Al-Haddad and Hamadeh 2003;

Maziak and Mzayek 2000; Kwamanga et al. 2003; Golan

et al. 2004; Valdivia et al. 2004; Washio et al. 2003).

Our figures are higher than those reported 20 years earlier

in similar studies by Felimban and Jarallah (1994) and

Al-Faris (1995) (12 and 17%, respectively). However, the

ever smoking prevalence rate is lower than the preva-

lence of 43.7% among the corresponding students in

Tabuk at the Western region of Saudi Arabia (Abdalla

et al. 2009).

Although cigarettes were used by most smokers in both

males and females in Saudi Arabia, WP or shisha although

relatively unpopular among educated people, was smoked

by many regular smokers, being common in the Western

region of Saudi Arabia (Abolfotouh et al. 1998). Many

people consider that WP smoking is less harmful than

cigarettes because they believe that the water filters out

harmful substances (Zahran et al. 1985). Our study

revealed a higher percentage of current smokers used

WP (53.9%) than other studies in Saudi Arabia; 43.6%

(Abolfotouh et al. 1998), or other Arab countries; 24.6% in

Kuwait (Mohammed et al. 2006) and 25.5% in Syrian Arab

Republic (Maziak et al. 2004). This could be explained by

the increasing popularity of WP smoking. The widespread

attention focused on the dangers of cigarette smoking,

Table 3 Pattern of smoking among current tobacco users of the included secondary school students in relation to gender

Smoking characteristics Gender P value

Males

(N = 302)

No. (%)

Females

(N = 56)

No. (%)

Total

(N = 358)

No. (%)

Smoking type (regular smokers)

Cigarettes only 116(38.4) 49(87.5) 165(46.1)

Shsisha (water pipe/Maassel) only 133(44.0) 1(1.8) 134(37.4) 0.010a

Cigarettes and Shisha 53(17.5) 6(10.7) 59(16.5)

Age at initiation

Cigarettes

B10 years 29(25.0) 0 29(17.5)

11 to \ 14 years 50(43.1) 8(16.3) 58(35.2) 0.001a

C14 years 37(31.9) 41(83.7) 78(47.3)

Mean ± SD (median) 12.7 ± 2.8(13.0) 13.9 ± 3.6(14.0) 13.2 ± 2.9(13.0) 0.022b

Shisha ‘‘Maassel’’

B10 years 5(3.8) 0 5(3.7)

11 to \ 14 years 43(32.3) 0 43(32.1)

C14 years 85(63.9) 1(100.0) 86(64.2) –

Mean ± SD (median) 15.1 ± 2.1(15.0) – – –

Cigarettes/Shisha

B10 years 7(13.2) 0 7(11.9)

11 to \ 14 years 23(43.4) 0 23(39.0) –

C14 years 23(43.4) 6(100.0) 29(49.1)

Mean ± SD (median) 14.7 ± 3.3(15.0) 16.4 ± 1.7(16.0) 15.4 ± 2.7(15.0) 0.231b

Total FTND score (for cigarettes) 169(56.0) 55(98.2) 224(62.3)

3.01 ± 1.27 2.03 ± 0.44 2.90 ± 1.17 0.011c

FTND Fagerstorm Nicotine Dependence scorea Fisher exactb t testc Mann–Whitney test

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coupled with the stigma associated, might unintentionally

encourage WP smoking (Mohammed et al. 2006). Other

reasons for this increasing trend may be because WP use is a

cultural form of hospitality among adults of the Middle East

and as youth approach adulthood this behavior becomes

more and more acceptable (Kandela 2000). These findings

suggest that tobacco-control programs must address all

forms of tobacco use, not just cigarettes. Consistent with

Table 4 Stated motives among

current smokers and smoking

among close family members

and close friends among

secondary school students-Al

Hassa

CI Confidence intervals

** P = \0.001a Sisters, mothers, grand

parents and other resident

family membersb More than one response was

mentioned� Only currently smokers

Variables Total

(N = 1,652)

No. (%)

Smokers�

(N = 358)

No. (%)

Odds ratio (95% CI)

Smoking among close family

Father 296(17.9) 92(31.1) 1.85(1.38–2.74)**

Brothers 185(11.2) 59(31.9) 1.83(1.29–2.59)**

Father and brothers 151(9.1) 43(28.5) 1.50(1.01–2.21)**

Othersa 110(6.7) 23(20.9) 0.95(0.58–1.57)

None 910(55.1) 141(15.5) Reference

Smoking close friends

All of them 131(7.9) 116(88.5) 9.06(6.41–12.83)**

Most of them 139(8.4) 100(71.9) 5.25(3.78–7.28)**

Some of them 425(25.7) 78(18.4) 0.76(0.57–1.01)

None 957(57.9) 64(6.7) Reference

Primary motives for smokingb

Meeting friends and family – 269(75.1) –

Outing with friends and company – 291(81.4) –

Boredom/passing of time – 272(76.0) –

Negligence by the family – 171(47.8) –

Imitations of father and brothers – 199(55.6) –

Relieve of tension and stresses – 73(20.4) –

Emotional and family problems – 62(17.3) –

Pleasure and happiness – 32(8.9) –

Table 5 Hierarchical regression analysis for smoking predictors among current secondary school smoking adolescents

Steps Variables entered Odds ratio (95% confidence intervals)

Model 1 Model 2 Model 3

1. Socio-demographics Age 1.83(1.24–2.70)*** 1.62(1.13–2.32)** 1.23(1.15–2.58)**

Gender 3.4(1.46–8.35)*** 2.71(1.61–4.56)*** 1.79(1.17–2.74)*

2. Environmental tobacco exposure Close relatives 3.30(2.1–5.17)*** 2.09(1.22–3.58)**

Friends 2.78(1.28–6.07)** 1.51(0.62–1.94)

3. Motives and psychiatric morbidity Motives 1.98(1.34–2.93)**

Depression 1.39(0.83–2.33)

Anxiety 2.18(1.42–3.34)**

Constant 13.35 13.08 12.25

R2! 0.133 0.195 .216

Dv2 26.44 28.17 31.32

Significance 0.001 0.003 0.005

Gender (1 = male, 0 = female), age in years, smoking among close relatives (1 = father and brothers, 0 = others or none), smoking among

friends (1 = All or most of them, 0 = some or none), motives (1 = socializing, imitation, outing, 0 = relieve of stress, pleasure), depression

(1 = any depression, 0 = none), anxiety disorders (1 = present, 0 = none)

R2!: Using Nagelkerke likelihood ratio

* P \ 0.05; ** P \ 0.01; *** P \ 0.001

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previous studies from Saudi Arabia and other Arab cultures,

male adolescents were at a much higher risk for smoking

behavior than female adolescents (Saeed et al. 1993;

Abdalla et al. 2007; WHO–EMRO 2003). In Saudi com-

munity there is a social stigma against women smoking,

which is seen as shameful (Jarallah et al. 1999). Accord-

ingly, the relatively low smoking rates among females may

simply be a reflection of a cultural taboo, and may be an

underestimate of the true female prevalence, since many

young females may be reluctant to admit their smoking

status (Hassan 2003). In a study from Riyadh, Abdalla et al.

(2007) found that there were significant gender differences

among secondary school students with respect to source of

cigarettes, usual place of smoke, intensity of smoking,

knowledge on addiction of tobacco, exposure to education

on tobacco, attitudes, and exposure to tobacco smoke in

public places. However, there was no difference regarding

age of initiation, health hazards knowledge, media expo-

sure, quit motivations, and home exposure. In a recent study

among female university students in Jeddah, the prevalence

of cigarettes smoking was 5% while 8.7% were users of

WP/shisha (Merdad et al. 2007). Another recent study in

Riyadh found that 70% of female medical students were

smoking WP/shisha (Al-Turki and Al-Rowais 2008). While

in male medical students, 44% were smoking WP and 24%

were smoking both WP and cigarettes (Al-Turki 2006). A

much lower rate of WP use among females in our study may

be due to the fact that Al-Hassa, in Eastern region, is less

urbanized and people constitutes a traditional society which

less tolerates to female smoking and with little access to

places for WP smoking.

Data showed that the proportion of adolescents who

smoke increases with age (Bilir et al. 1997). Also, adoles-

cents who start to smoke early are more likely to continue

smoking as adults (Rend et al. 1995). In the present survey,

we found a positive association between smoking status and

age which support the first statement. Also, the mean age at

initiation of smoking cigarettes was 13 years; the mean age

of initiation for those smoke both WP and cigarettes was

15 years. These results were lower than those obtained by

similar study in Saudi Arabia where about 59% started

smoking at or above the age of 18 years (Abolfotouh et al.

1998), whereas another study conducted in secondary

schools found that 83.7% of the current smokers started at

age 15 years or below (Al-Damegh et al. 2004).

The interesting finding that emerges from this study is

that unlike Western adolescents, Saudi youth seem to be

more influenced by their parents’ smoking than peer

smoking. Although Western studies have shown that fam-

ily smoking increases the risk of smoking among adoles-

cents, peer smoking are consistently stronger risk factors

than family smoking (Goddard 1990; Kandel et al. 2007;

Gilpin and Pierce 2001).

This is not surprising since Saudi Arabia is a traditional

conservative society where the family unit is more

important than the individual or his peers (Al-Sabie 1989).

Young adults in the Eastern part of the world adopt a

collective identity. Children are encouraged through a

process of strict and consistent socialization to obey and

submit to their families hence the self is not differentiated

from family. One’s needs, manners, style of thinking,

attitudes, and beliefs are not distinct from those of the

family (Dewairy 1999).

To some degree this pattern of development acts as a

catalytic promoter of smoking among adolescents in their

milieu. This result is consistent with Bandore’s Cognitive

Social Theory which believes that through observational

learning or modeling of the behaviors of others, we adopt

these behaviors ourselves especially if the model is

someone respected like the father (Santrock 1995).

This study showed that father’s smoking habit is

strongly associated with student’s current smoking status

and remained so among Saudi Adolescents similar to that

found in studies conducted outside Saudi Arabia. Maziak

and Mzayek (2000) reported that among Syrian adolescents

parental and siblings smoking was the strongest predictor

of the smoking status (Odds ratio of 4.4) (Maziak and

Mzayek 2000). In Kuwait, another Arab country, among a

sample of 761 university students, 96.4% of WP smokers

smoked in their homes. Forty-three percent of the male WP

smokers and 74.1% of the female smokers reported two or

more other smokers living in their homes (Mohammed

et al. 2006). Also in Singapore, it was found that family

factors especially the father’s smoking habit and the pres-

ence of negative role models within the home were sig-

nificantly associated with current smoking habits among

secondary school students (Shamsuddin and Haris 2000).

In the present study, a higher prevalence of anxiety

disorders measured by the PHQ is associated with the

current smoking status. This finding is consistent with

previous research in developing and developed countries

(Soueif et al. 1990; Sonntag et al. 2000). Although in our

sample those with any depression or anxiety disorder were

found to be significantly higher in the smoker group, this

effect was attenuated when controlling for other factors and

demographic effects. Prospective analyses might reveal the

specific relation between anxiety and tobacco use and if

adolescents with prior anxiety disorders tend to smoke

more.

Limitations

Results of this study are based on cross-sectional data

rather than longitudinal, this limited the extent to which

conclusions about causality could be drawn. To develop a

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better understanding of the conditions under which these

variables operate as causal factors, more longitudinal study

designs are required. However, the influences of family

smoking and anxiety disorders on adolescent’s smoking

behavior cannot be explained by this reversal of causality

and remains an important risk factor that needs to be

addressed. Another limitation of is the lack of information

on the smoking behavior of the non-responders particularly

in females and those adolescents outside schools. It is

possible that non-responders had higher smoking preva-

lence than those surveyed which may have caused an

underestimation of the smoking prevalence rates in this

study. The results of smoking behavior in this study were

based on students’ self-reports. The use of self reported

measures may be unable to investigate the anxiety and

depressive disorders. It might be better to use more

objective measures of psychiatric comorbidity such as

standardized interviews. Although adolescents’ self-reports

of psychiatric morbidity obtained under similar conditions

in the United States have been shown to be quite accurate

across ethnic groups (Spitzer et al. 1999), it is not known

whether this is also true for Saudi adolescents. The results

of this study point to the notion that some of the smoking

risk factors associated with eastern adolescents’ smoking

behavior such as anxiety disorders and socializing moti-

vation might be addressed and appropriate prevention

programs should be tailored depending on the concerned

culture. The present results from a standardized question-

naire (PHQ) that depends on self-report to assess for the

depressive symptoms over the past 2 weeks and suicidality

in the past 4 weeks is very limited and is likely to pick up

only a small proportion of available diagnoses of depres-

sion and suicidal behavior, likewise for panic and gen-

eralized anxiety disorder over the past few weeks.

Moreover, unfortunately the PHQ do not include items for

the diagnosis of phobias.

Study implications

The results of this study provide important new informa-

tion about some of the psychosocial smoking risk factors in

Saudi adolescents. Smoking prevention programs aimed at

adolescents in Saudi Arabia, should be a collaborative

multidisciplinary involving schools, family, community

members and the media. Families and community adult

members should be made aware of the detrimental influ-

ence their smoking behavior has on their youth. Therefore,

smoking prevention programs aimed at Saudi adolescents

should go hand in hand with smoking cessation interven-

tions aimed at Saudi adults. The results of this study

show that it is necessary to pay attention to the levels of

anxiety among current adolescent smokers. Counseling and

preventive psychiatric services should be an integral part of

the clinical facilities caring for secondary school students

in Al-Hassa, Saudi Arabia.

Conflict of interest None.

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