Increasing Rates of Smoking Among Young Adults / Young Women in Saudi Arabia

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An Investigation of Why There Are Increasing Rates of Smoking Among Young Adults/ Or Young Women in Kingdom of Saudi Arabia 1.0 Introduction 1.1 Background Smoking has been recognized as a health challenge across the globe. People who smoke are at increased risk of developing potentially life-threatening diseases such as lung cancer, heart disease, and other chronic illnesses. Statistics indicate that there are increasing incidences of smoking among the Saudi population, which is significant among women, whereby the number of women who smoke has been significantly growing. Women who smoke are exposed to various gender-specific effects, which mainly include adverse effects on health. Nonetheless, the prevalence of smoking among women is characteristically lower than that of women, which is primarily attributed to culture and traditions. However, the situation changes as the epidemic of smoking among women in the Gulf region is increasing.

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There is no significant justification for the increase of smoking among the young population in the KSA. The government has been implementing various curb tobacco smoking measures to protect the population from tobacco's harmful effects (Ansari & Farooqi, 2017).

Smoking is associated with adverse health effects. Some of the health issues associated with smoking include cancer, heart disease, stroke, respiratory conditions diabetes, as well as chronic obstructive pulmonary disease (Salameh et al., 2012). Despite the health dangers of smoking, there is a worrying upward trend and pattern in the number of people being initiated into smoking, which is a challenge of urgent public health concern (Ansari & Farooqi, 2017).

Therefore, the study is part of an initiative to investigate the contributing factors to the upward trend in smoking cases among young people, particularly women in the KSA. Merdad et al. (2007) noted that Eastern Mediterranean countries such as Saudi Arabia have been following the same global trend in gender patterns in smoking patterns. According to Tahir (2019), the high prevalence of smoking among the Saudi population is associated with the rapid modernization and external influence from globalization, resulting in changing habits and lifestyles. However, Tahir (2019) has established that smoking individuals' prevalence is higher among men than women. Estimation shows that 32% of men are smokers, with female smokers being significantly lower at 4%. Nonetheless, despite the number of women smokers being relatively low, the number has been steadily increasing, showing that over the past few decades, amidst the increasing awareness of the dangers of smoking (Alnumair et al., 2020).

Various studies indicate that smoking prevalence is characteristically high in the Kingdom of Saudi Arabia (KSA) (Taha et al., 2010; Merdad et al., 2007). However, most of these studies have been conducted among males, limiting cigarette smoking among residents in

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the central region (Merdad et al., 2007). Ansari and Farooqi (2017) noted that the prevalence of smoking among Saudi women is significantly low compared to their Western counterparts.

However, despite the level being low, it has been increasing over the recent past. Data shows that smoking is significantly common among females in Arab countries compared with Western nations. Ansari and Farooqi (2017) noted that smoking among females in Arab countries is characteristically low in Arab nations than in Western countries. In the Gulf region, smoking among women ranks between 0.3 to 7.9%, whereas in the Western nations, it ranks between 13.7 to 31.1% (Ansari, K., & Farooqi, 2017). Whereas the number of women smokers in the Gulf region remains significantly low, it has been increasing steadily in the Gulf region, which is the subject of investigation in the current study. According to Azhar and Alsayed (2016), smoking among females is highest among women between 20 and 25. The population mainly includes college students and young independent women who have completed high school. The prevalence of smoking has been established at 9.1 % among Saudi university students (Azhar & Alsayed, 2016). In addition to cigarette smoking, water pipes are also gaining popularity among the younger population. Whereas there are available figures regarding the widespread of smoking in terms of gender, there lacks significant research to establish the factors leading to increase in smoking rates among young women in Saudi Arabia. Most research has been targeted to the factors contributing to smoking among the general population, without considering the evident variations in gender.

There is a gap in research investigating the variations in gender in smoking among young adults in the KSA. Therefore, the current study seeks to aspects that lead to elevation in smoking rates among young women in the KSA. The research aims to establish the prevalence and trends in smoking rates among young Saudi women and establish the factor influencing people's

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smoking behavior and knowledge about the underlying adverse health impacts. The research is conducted to investigate the effects of family and company in influencing a person's decision to smoke and general participants’ knowledge regarding the dangers of smoking and how this contributes to variations in the number of female smokers in the KSA. 1.2 Research Questions The questions that will be addressed in the research are as follows: a) What is the impact of family and company in influencing young women to become smokers? b) What is the impact of gender in influencing a person to be a smoker? c) What is the population's perception of smoking, and how does this deter or influence young Saudi women to be smokers? d) What factors are attributed to the increase in the number of women smokers in Saudi Arabia? e) What are the health impacts of smoking among young Saudi women? f) What are the factors that influence respondents to become smokers or attempt smoking? g) How does knowing someone who smokes or interacting with them influence an individual to be a smoker?

1.3 Definition of Terms Smoking: Smoking is described as a route of drug administration for recreational purposes. The substances taken include tobacco or other dried substances vaporized to deliver an active effect on the body system (Salameh et al., 2012).

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Tobacco Smoking: Tobacco smoking is described as the practice of burning and ingesting smoke from tobacco. The inhalation of smoke is mostly from cigarettes, inhaled and released through the mouth, and is generally practiced with cigars or pipes.

Water pipe tobacco smoking: The practice entails passing tobacco smoke through water before inhalation, and this is a serious health challenge globally.

Chronic obstructive pulmonary disease (COPD): COPD is one of the effects of smoking and is a chronic inflammatory lung disease that obstructs airflow into the lungs (Salameh et al., 2012).

1.4 Literature Search The literature search will be conducted on the university library on databases. The search is facilitated through a key term and subject search to identify relevant sources in the analysis.

The four databases from which the sources will be searched include PubMed, ProQuest, CINAHL, and EBSCOHOST. The databases are selected for literature search because they are comprehensive and subject-specific to smoking and health aspects. The investigation seeks to establish why there is an increasing smoking rate among young women in the KSA. Therefore, the key terms and subject search terms used in the search include smoking, young women, Saudi Arabia, smoking effects, and smoking prevalence. Keyword combination was done to obtain the most relevant articles published within the past ten years to effectively establish cigarette smoking trends and the factors contributing to women's habit in the KSA. 2.0 Literature Review There is an increasing health concern about the high prevalence of cigarette smoking in the KSA; thus, there is an expanding body of literature seeking to investigate the factors contributing to smoking among young people in the KSA. In an investigation by Koura et al.

(2011), researchers sought to determine smoking patterns and risk factors among Saudi students,

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the study's findings indicate that tobacco use increases among young people nations, with the highest prevalence reported among males, including fathers and young adults. The most important predictors of smoking have been identified as an influence by friends smoking, sisters smoking, mothers’ smoking, single status, and achieving legal age. Therefore, tobacco consumption has been identified as being influenced by family members and friends, with the consumption patterns signifying an increase in smoking cases in the region.

Previous literature shows an overall increase in the prevalence of smoking among Saudi residents. In a systematic review by Alotaibi and Durgampudi (2020), it was established that smoking is highest among young people in Saudi Arabia, especially those in college. The findings resonate with Al Moamary et al. (2012), who cite access to cigarettes and peer influence as factors that contribute to increased smoking cases among young people.

Previous literature shows an increasing trend in tobacco smoking prevalence globally and the Saudi Arabia context. According to Alotaibi et al. (2019), tobacco use in various forms is linked to the occurrence of a wide range of chronic diseases and preventable deaths. A study published in 2018 indicated that tobacco-associated deaths were responsible for the deaths of over 7 million people in 2016 alone (Wolf et al., 2018). Projections indicate that with the continuing trend, over 8 million people could die globally by 2030 if no sufficient measures are put into place to curb the challenge (Alotaibi et al., 2019). In high-income countries like the KSA, there has been a statistically significant increase in tobacco smoking levels over the past decade, which has been attributed to a rise in chronic conditions.

The rate of smoking in the KSA remains significantly high, with an estimated $3.4 billion worth of tobacco products imported to the country between 2010 and 2014 (Taha, 2014). The implication of these high tobacco imports translates to both economic and health burdens from

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tobacco use. To curb the widespread use and effects of tobacco smoking, the KSA has been implementing policies to control tobacco use to minimize its adverse impacts on the population.

According to Alrabah et al. (2018), the policies include banning tobacco use in government agencies, schools, parks, airports, and other designated areas that have been marked as smokingfree zones. Similarly, Alrabah et al. (2018) cite the use of international smoke cessation programs as part of KSA's efforts to control tobacco use. The associated policies entail the imposition of total taxation on tobacco products imported to the region to deter tobacco products' importation and use. In addition to policy interventions to curb tobacco use, the government, alongside private agencies, has been enforcing restrictions aimed at curbing widespread tobacco smoking among residents (Alrabah et al., 2018).

Implementing strategies to curb smoking in the KSA has achieved considerable success in curbing the issue, but smoking remains considerably high. Statistics on tobacco consumption in the KSA, as outlined by Moradi-Lakeh et al. (2015), indicate that an overall 12.1 % of Saudis report that they currently smoke tobacco. The prevalence is reported at 23.7% among males, whereas among females, it is 1.5%. Recently published literature has identified the prevalence and risks linked to smoking in the KSA. In one study by Tobaiqy et al. (2020), it was established that challenge of smoking in Saudi Arabia began to take momentum in the 1990s yet remained very widely used in the country. Smoking in Saudi Arabia has been described as a significant risk factor causing many illnesses (Tobaiqy et al., 2020). Several studies across Saudi Arabia have been conducted to examine the population's views and attitudes and the factors contributing to smoking among the population.

One study conducted in 2016 investigated the demographic factors, patterns of use, and cessation behavior associated with smoking in South -West Saudi Arabia (Abdelwahab et al.,

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2016). The study established that there are variations in smoking prevalence among the study participants, with 48% of those smoking having attempted it more than once. Based on the study's findings, married, college-educated men with a high income were established as the category most likely to smoke (Abdelwahab et al., 2016). The findings are in line with those of Tahir (2018), who established that smoking in the KSA is significantly high compared to other nations in the region. The high rate of smoking in the KSA compared to other countries in the region indicate a looming public health challenge as interventions implemented have not been effective in curbing the high prevalence of tobacco smoking. Therefore, tobacco smoking in the KSA continues to be a significant public health challenge, primarily affecting young adults.

Based on past research, there are indications that the rate of smoking has been increased.

Although it remains significant among males, there is an upward trend among women (Tahir, 2019). Cigarette smoking and associated products are ranked as the major contributor to premature deaths worldwide, with over 5 million lives lost from cigarette smoking-associated conditions (Ansari & Farooqi, 2017). There is extensive variation among females in terms of the prevalence of smoking compared to females in Arab countries with Western nations. Ansari and Farooqi (2017) noted that smoking among females in Arab countries is characteristically low in Arab nations than in Western countries. Smoking among women ranks between 0.3 to 7.9% in the Gulf region, whereas it ranks between 13.7 to 31.1% (Ansari & Farooqi, 2017).

Based on World Health Organization (WHO) 2009, data drawn from 151 countries indicates that smoking is the highest at present (WHO, 2009). The same statistics by the WHO suggest that waterpipe smoking is increasing in popularity because it is considered fashionable among young women in the Middle East, making the prevalence of smoking higher (Azhar & Alsayed, 2012). Further, the accessibility of electronic cigarettes makes more females,

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adolescents, and people with low education influence smoke. With the measures put into place to curb smoking, the prevalence of smoking in developing nations has decreased significantly. In Arab countries, the level of smoking has been increased. In a study by Abdalla et al. (2007), the factors associated with increased smoking cases among the population include imitation, relieving pressure, enhancing social status, relieving anxiety, enhancing curiosity, being influenced by advertisements, and being in contact with smokers. Whereas there is significant literature document the rate of smoking, the risk factors, and impacts on health, there lacks no substantive research investigating the gender differences in smoking and the factors contributing to the increasing prevalence of cigarette smoking among young Saudi women. Therefore, the current study seeks to examine the gender variation in tobacco smoking and why the number of women smoking has increased in the recent past across Saudi Arabia.

Research Proposal The proposed research seeks to examine the specific factors contributing to increased smoking rates among young Saudi women. The study is significant in identifying the gender variation in smoking and contributing to increase of cases of smoking among Saudi women. A number of measures have been enforced to address the high cases of smoking, including implementing policy and other restrictions controlling the sale and use of tobacco products.

Whereas there is increased awareness among the population on the health dangers of smoking, there is a lack of sufficient measures to deter individuals from adopting the habit, so the smoking prevalence level has been increasing. Therefore, the study is needed to identify the factors contributing to the increasing number of women smokers in Saudi Arabia. The project population of the analysis features young adults aged between 19 and 25, and the findings of the study will be generalized to the entire Saudi population of young people.

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3.0 Method/Approach The research population includes young people in the KSA and will consist of both smokers and nonsmokers. The research is a cross-sectional quantitative survey, whereby data will be collected from the target population, then the findings will be generalized to the overall population. According to Watson (2014), a quantitative cross-sectional study seeks to investigate the population at a specific point in time, and the variables are recorded for each participant.

Quantitative research is mainly focused on numerical data. The research is based on a hypothesis that specific factors are associated with high level smoking rates among Saudi women.

Therefore, numerical data will be collected through a survey and focus group on testing the hypothesis.

3.1 Data Collection Method Data for the research will be collected by administering an online questionnaire of university students to establish their perception of the factors that contribute to increasing cigarette smoking incidences among young females. The questionnaire development will be based on the investigation topic to establish the factors associated with an increase in the prevalence of cigarette smoking among the population.

The questionnaire that will be used for the research is a pre-designed self-administered Arabic questionnaire. The questionnaire is customized for the current study using the WHO Global Youth Tobacco Survey Questionnaire (WHO, 2009). The questionnaire will be comprised of two sections. The first section will include general information about the respondent, and the aspects covered will consist of gender, age, level of education, and occupation. The second section of the questionnaire will include the study's independent variables, which are the factors associated with an increase in the number of young women

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smokers in the KSA. The aspects included aligning with the research questions. They include the impact of family, gender influence, population perception on smoking, and perception of the factors contributing to increasing women smokers in the KSA. The respondents will also answer questions regarding their awareness of smoking's health impacts, the factors that influence individuals to overcome smokers, and how interaction with smokers influences a nonsmoker to adopt the habit. The questionnaire will be administered through the Survey Monkey online tool.

Respondents will be provided with the survey monkey link and manually enter their responses on the survey.

3.2 Population and sample The study's overall population includes Young women in Saudi Arabia between the age of 19 and 25. Therefore, a representative sample will be selected to be included in the research.

The study's featured model will comprise 60 respondents (N=60), whereby the respondents will be randomly selected and will include both males and females. The sample will be selected through a strategic sampling approach to select the most representative sample. The researcher seeks to apply a purposive sampling approach to choose a reliable sample based on a nonprobabilistic system.

To select the sample, the researcher will determine the state that the population will be divided into, then choose the number of participants necessary for each stream. The analysis units will be split into the respective strata. Then the participants will be randomly selected from within the group. The goal of the approach is to enhance the validity and reliability of the data collected as well as the generalizability of the entire population's findings. Once the sample has been selected, the questionnaire will then be administered.

3.3 Access and recruitment

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The access and recruitment of research participants involve identifying the potential participants and presenting them with information about the study before enrollment. This is imperative in establishing their interest and willingness to participate in the study as research participants. The study seeks to enroll young adults as participants. Thus, the researcher targets possible avenues where the population of interest is likely to be found. Therefore, the recruitment for the participants of the research will be through email.

To recruit participants in the survey, the researcher will share the Survey Monkey link on the target respondent's email. The questionnaire will include an overall representation of the study, including a statement that the study is voluntary, and a statement on protecting the users' privacy (Munhall, 1998). The participants will be requested to send back a confirmation email notifying the researcher about their willingness to participate in the study.

3.4 Ethics Ethical consideration when conducting the study will be ensured in terms of allocating research materials and processes to ensure that the research participants' confidentiality and privacy are upheld. The research participants' recruitment will take into consideration their privacy concerns to guarantee the respondents that their identity will not be revealed during the research and that the collected data will be solely used for the intended purpose (Munhall, 1998).

Participation in the research will be voluntary. Thus, the investigation will be introduced in a manner that allows the participants adequate time and ability to independently consider whether they wish to take part in the study or not. The participant will be notified about the study a week before it is conducted so that they have sufficient time to prepare for the study and decide on whether or not they will take part. There was no any form of inducement given to the participants.

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The study's description will be accurate and precise, and all information shared with the participants will be clear and easy to understand. Aspects regarding eligibility criteria will align with the proposed research plan regarding the participants' age range. Further, ethics will be ensured in the study through the unbiased presentation of the study information in a balanced manner free of misleading emphasis that could affect the collected data's validity, reliability, and resulting findings (Munhall, 1998). Therefore, the study's description will ensure the respondents understand the research's purpose and their role in the study.

3.5 Data analysis The approach used in the research is cross-sectional quantitative research that seeks to investigate factors contributing to the increase in the rate of female smokers Saudi Arabia. Once the respondents have filled in the survey and submitted it, the findings will be analyzed. The resulting data will be filtered to focus on specific subsets of the data based on defined criteria guided by the study's variables on the Survey Monkey application. Once the data has been collected, all variables will be checked for accuracy and completeness then coded and analyzed using the SPSS program. The data analysis will include calculating the smoking index by multiplying the cumulative number of cigarette that the person smokes on a daily basis and the number of years of active smoking. The analyzed data will be presented in frequency tables and charts. Appropriate statistical techniques will also be performed.

3.6 Dissemination of findings The research findings will be published in various publications to influence action among involved parties and create public knowledge. The findings will be published in policy briefs to inform the KSA government on this serious public health issue so that proactive action can address the high rate of smoking among women in the KSA. The research findings will also be

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published in health journals to inform stakeholders on the increasing prevalence of smoking so that proactive measures can be implemented to curb this upward smoking trend. Besides, the summary of findings can also be presented to the local community by presenting them during public forums or publishing the local dailies' findings to notify the public about this serious public health concern.

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