Abstract

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Objective:

To estimate the prevalence of smoking among secondary school students in National Guard area of
Riyadh, and explore the reasons for the smoking and the attitude of non-smoker toward smoking habit.

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Design:

A cross-sectional study was conducted in June 2009. By random sampling technique 255 students were
enrolled from secondary school of National Guard area, Riyadh, Saudi Arabia. A self-administered
questionnaire was used for data collection.

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Results:

Current smokers represented 28.6% of the students. The most common reasons for smoking were:
having free time (81.6%), for the relief of stress (63.2%) and seeing some of their teachers smoking
(61.8%).

Most of the smokers started the habit before the age of 15 years old (89%). 84% of non-smokers
suggested to ban smoking in public places. 42.2% of students were planning to start smoking in future.

Religion was the most important reason for not smoking among non smokers.

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Conclusion:

The prevalence of smoking is big enough a problem to be considered as a warning for an impending
epidemic Health education provision should have a greater role in schools Governmental commitment
and social support are vital if health education and awareness and especially quit smoking programs are
to be implemented and sustained.
Keywords: Secondary school student, smoking, shisha, magha, Riyadh

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Introduction

Tobacco is the single, most important preventable cause of death and the most important public health
issue in the current time. Cigarette smoking is considered the single most preventable cause of
premature deaths in some industrial countries. (1)

Tobacco addiction is an epidemic devastating the countries and regions that can least afford it in terms
of disability, disease and even death. (2) WHO described tobacco smoking as an epidemic with an
estimated three million deaths annually worldwide because of smoking. This figure is expected to rise to
10 million by the year 2020 or early 2030, if the current trends of smoking continue. Seventy percent of
these deaths will occur in the developing countries. (3)

The Prevalence of cigarette smoking among adults in the United States in 2004 was 20.9%. (4)

Although Saudi Arabia does not grow tobacco or manufacture cigarettes, an average of 600 million SR
(approximately US$ 150 millions) are spent annually on tobacco. (4) Saudi Arabia is now ranked 8th in
the world in terms of tobacco consumption and currently imports 20,000 million cigarettes per year,
which cost about 351.8 million US dollars. (3)

In 2002, the two holy cities of Mecca and Medina in Saudi Arabia were declared tobacco free by the
Custodian of the Two Holy Mosques. Since then, tremendous efforts are being exerted by the Tobacco
Control Program, Ministry of Health and the Anti-Smoking Committee (nongovernmental organization)
towards maintaining and ensuring the continuity of this initiative. (6)

Despite these alarming figures only few studies have been conducted to find out the prevalence of
smoking among adolescent in Saudi Arabia. (7,9)

A study conducted in 1999 on male secondary school students in three region of Saudi Arabia reported a
prevalence rate of 21.1%. (7) Another study conducted in 1995, and found the prevalence to be 17%
among secondary school students in Riyadh. (9) In these studies, the definition of smoking was
restricted to cigarette smoking only and not concerned other forms of tobacco smoking like shisha etc.

In other Gulf countries also only a few studies were found on this important topic and even those were
not done on adolescents.

In Kuwait the prevalence of smoking was 34.4%. in men and 1.9% among women. (5) Among men, the
highest prevalence was observed in the youngest age group (20 years or below).

In the Kingdom of Bahrain, the prevalence of smoking shisha is (13.0%) among young male students.
(10) Most studies have showed that, the family history of smoking is strongly associated with youth
smoking. (10) This study also showed that, 43.2% of the smokers stated that their best friend was a
smoker compared with 15.4% of non-smokers. (10)

In another study, 32.10% of secondary school students smoke in front of their teachers with no feeling
of embracement. (9) This study however also found that the main factor against smoking among the
non-smoking secondary school students was religion (69.6%). (9)

Adolescents who start to smoke early in their life are more likely to continue smoking as adults. (11)

Based on the facts that only few studies are available on this subject and even these are not recent,
there was a need to find out the current prevalence of tobacco use and the factors affecting smoking
behavior among adolescent in Saudi Arabia

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Research Objectives

Primary Objective:

To determine the prevalence of smoking among students in the secondary school at National Guard
area.
Secondary Objective:

To explore the reasons for starting smoking

To assess the attitude of non-smokers towards smoking,

To explore the reasons of abstinence of non-smokers,

To assess the influence of teachers on students regarding smoking.

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Methodology

DESIGN:

Cross sectional descriptive study.

SETTING: King Khaled Secondary School, King Abdulaziz City, National Guard Area, Riyadh.

TARGET POPULATION: Students of the secondary school aged between 16–22 years.

SAMPLE SIZE: The study sample size of 255 was calculated using the formula N = (Z)2 p(l-p) /d2. Where
prevalence p= 21% accuracy d = 0.05, alpha of 0.05, and power of 0.8. Prevalence of smoking among
teenagers was obtained from a study conducted in three regions of Saudi Arabia. (7)

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QUESTIONNAIRE:

The questionnaire was prepared based on risk factors and teenage practices related to smoking noted in
earlier studies. Questions were grouped into following sections: demographics, current smoking
practices, smoker section and non-smoker section.

The smoker section explored in detail the practice of smoking, reasons for initiation and continuation of
smoking, attitude toward smoking, readiness to quit and basic knowledge.
The non-smoker section explored knowledge of passive smoking, environmental influences, attitude
toward smokers and their recommendations.

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Data Entry & Analysis

Data was entered to a computer & analyzed by using SPSS version 18.

Descriptive analysis was carried out on all questions in the survey form, including mean, median, mode,
frequencies and percentages.

Relationships were explored between the demographic variables, smoking behavior and non-smoker
attitudes using chi-square, t-test, linear regression and ANOVA where applicable.

Questions 21 – 33 were used for smokers’ reasons to Smoke preliminary analysis and questions 34–49
were used for Non-smokers’ Attitude.

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Results

A total of 255 secondary school students in King Abdulaziz City, Riyadh, answered the questionnaires
during the study period, with a response rate of 85%.

This study demonstrates several important findings, the overall prevalence of smoking among male
secondary school students at King Abdulaziz City; Riyadh was (29.8%).

In our study, the student’s smoking status and having a friend who smoked were strongly related to the
habit of smoking (60.5%).

It was found that 63% of smokers have seen one of their teachers smoke. In our study, more smokers
confirms the most important age to start smoking was at 15 years old which was clinically significant (p-
value <0.05).
We also found that, the relationship between number of cigarettes smoked and the age of first cigarette
was proportional inversely, those who smoke more cigarette started smoking at an early age.

Religion constituted the main factor against smoking among the non-smoking group (42.3%).

Also, from our study we found low smoking status among the students in legitimate department
secondary school as compared to scientific department with significant p-value.

From our non-smoker participants 80% of them suggested to prevent smoking in public places and 80%
of non-smoker participants encourage increasing the price of cigarette.

Table (1) presents the general demographics (age at which first cigarette was smoked and age at which
regular smoking was started) as well as smoking behavior. A teenager with family history of smoking is
more likely to be currently smoking, therefore, the chance of smoking is increases with family history of
smoking by (5.78) compared to those with no family history. (Chi-sq 37.22, p value <0.001).

Table (1).

General Demographics & Smoking Behavior.

Variable Number Mean (SD) Min-Max

Age of first cigarette (years) 76 13.4 (2.5) 7–18

Age of regular smoking (years) 76 15.1 (1.8) 10–20

Cigarettes / day 70 14.7 (7.5) 1–60

Shisha days / week 26 3.6 (1.8) 1–7

Smoking in front of relatives 64 / 76 84.2

Self buyers of cigarettes / shisha 64 / 76 84.2

Believes smoking is hazardous 71 / 76 93.4

Heard of Anti-smoking Society 59 / 76 77.6

Ever think of quitting smoking 68 / 76 89.5

Ever quit smoking for 1 week 44 / 76 57.9

Not ready to quit in 6 months 44 / 76 57.9

Shisha users* 26 / 76 34.2

Figure (1) shows almost 20% of the students smoked their first cigarette at 15 years of age and < 5%
started before 10 years of age. This high percentage might predict future prevalence of smoking and
complications from this habit.

An external file that holds a picture, illustration, etc.

Object name is ijhs5_1p051f1.jpg

Fig. (1).

Histogram showing the age of students when they first tried to smoke.

Figure (2). Type of Tobacco Use.

An external file that holds a picture, illustration, etc.

Object name is ijhs5_1p051f2.jpg

Fig. (2).

shows nearly 95% of the smokers used cigarettes and over 1/3rd smoked shisha.

Table (2) shows the reasons for smoking; these can be divided into two categories (personal and social).

Table (2).

Reasons for Smoking (N = 76)

(Percentages rounded to nearest).

Reason Agree (%) Not agree (%) Not sure (%)

Mimic others 40 (52) 22 (29) 14 (18)

Smokers in family 23 (30) 42 (55) 11 (15)

Teachers smoke47 (62) 26 (34) 3 (4)

Feel relaxed 38 (50) 20 (26) 18 (24)

Free time 62 (82) 13 (17) 1 (1)

Stress relief 48 (63) 22 (29) 6 (8)

Feeling strong 16 (21) 54 (71) 6 (8)

Interest 35 (46) 33 (43) 8 (10)

Special smell 25 (32) 35 (46) 16 (21)

Influence of friends 46 (61) 7 (9) 23 (30)

To attract attention 31 (41) 40 (53) 5 (6)

Advertisement 24 (32) 38 (50) 14 (18)

To sit with friends 30 (40) 20 (26) 26 (34)

Personal reasons include mimicry, feeling relaxed, free time, stress, feeling strong, interested in smoking
habit, to attract attention of others, special smell like shisha.

Social reasons include seeing one of his teachers smoking, copying one’s friend. By analyzing personal
reasons we found that the majority confessed to have free time (81.6%) followed by stress (63.2%). The
highest disagreement was smoking to feel strong (71.1%) followed by to attract attention of others
(52.6%).

The highest answer of not sure was for feeling relaxed (23.7%), then special smell like shisha (21.1%).

Seeing one of his teachers smoking was among the strongest social driving force to start & continue
smoking possibly because teachers are seen as people who are righteous and good example.

Table (3). shows that a majority of non-smoker students (92.6%) feel sad for the smokers. 90.9 % of
them saw at least their teacher smoking. 15.4 % of non-smoker students do not suggest increasing the
price of cigarette. 57.7 % of non-smoker students did not intend to start smoking at any time in their life
compared to 42.3% who showed intent for smoking in the future.

Table (3).

Attitude of Non-smoker toward Smoking (N 175).

Attitude Yes (%) No (%)

Feel sad for smokers 162 (93) 13 (7)

Saw care providers smoke 146 (83) 29 (17)

Saw teachers smoke 159 (91) 16 (9)

Increase cigarette price 148 (85) 27 (15)

Ban smoking in public areas 147 (84) 28 (16)

Punish for public smoking 125 (71) 50 (29)

Ever think of smoking 74 (42) 101 (58)

Ever ask smoker to stop 130 (74) 45 (26)

Sitting with smokers 117 (67%) 58 (33)

Physicians lack in health education 109 (62) 66 (38)

Teachers lack in health education 124 (71) 51 (29)

Passive smoking hazardous 173 (99) 2 (1)

Smoking increases hashish use 146 (83) 29 (17)

Smoking increases amphetamine use 135 (77) 40 (23)

Will you stop a smoker in restaurant? 33 (19) 142 (81)

Open in a separate window

Over 2/3rd of non-smokers used to sit with smokers and 98.9% of them think passive smoking affect
their health. Nearly 2/3rd of non-smoker students think that the physicians are not doing their best in
terms of providing education about the dangers of smoking compared to 70.9% who think the teachers
have the same problem. Mixed reactions were elicited and reported as mentioned toward the behavior
of smoking from the perspective of non-smokers.

Go to:

Discussion

Although Saudi Arabia does not grow tobacco or manufacture cigarettes, an average of 600 million SR
(approximately US$ 150 millions) are spent annually on tobacco. (8)

Our study reported a higher prevalence rate as compared to other studies done previously in Saudi
Arabia. (7, 9)

This is partly explained by difference in the definition of smoker in the previous study. The definition
was restricted to cigarette smoking, not included other type of smoking as shisha (water-pipe).
Cigarettes were the most commonly used type of tobacco in our study (64.4 %), while shisha (water –
pipe) was smoked by 5.5 % and those who smoke both were 30.1%.

As in this study smokers confirms the most important age to start smoking is at 15 years, it should
prompt the ministry of health to start advising about the harmful effects of smoking in primary and
intermediate schools classes.

Since the number of cigarettes smoked and the age at which first cigarette smoked is inversely
proportional, we need more regulation in the market tobacco regarding not to sell cigarette to those
less than 18 years old. The government should adopt a policy of regular increase in cigarette taxes to
cover part of the cost of treating smoking-related disease. There were some limitations however in our
study. Our survey was only among male students, this may in future encourage female physician to do
similar study among female students.

We included only one area which obviously does not represent the national trend and the prevalence in
the whole kingdom. Also adolescents who do not go to the schools were not included

Go to:
Conclusion and Recommendations

Emphasis on the exemplary role of parents and teachers should be stressed in these programs. School
‘quit’ program should be considered to combat the addictive nature of tobacco. Government
commitment and social support are vital if these programs are to be implemented and sustained.
Provide intellectual faculties in delivering lectures& providing input in workshops and do meeting with
those concerned. Launching a website specifically aimed to smokers in the whole kingdom of Saudi
Arabia and teenagers in particular should definitely be expected to help.

Mobile smoking cessation clinics should be set up to assist smokers quit smoking. Encourage researchers
to conduct studies about the effects of smoking. Encourage school administration to arrange regular
visits to anti-smoking charitable associations. Inform teachers to be a role model & leaders for anti-
smoking campaign. Help in establishing a large number of satellite anti-smoking clinics and help in
training of their staff.

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References

1. Al Nasir FAL. Bahrain school teacher knowledge of the effects of smoking. Ann Saudi Med. 2004
Dec;24(6):448–452. [PubMed]

2. WHO WHO’s World no tobacco day ‘2006, Tobacco deadly in any form of disguise, Tobacco free
initiative. 2006. [Homepage on the Internet] www.who.int/tobacco; Cited: 2006, Retrieved: 04 May
‘2011 available from: www.who.int/tobacco/communications/events/wntd/2006/en/index.html.

3. World Health . Guidelines for controlling and monitoring the tobacco epidemic. Geneva: World Health
Organization; 1998.

4. Center for Disease Control and Prevention State-Specific Prevalence of Cigarette Smoking and
Quitting Among Adults United States. 2004. MMWR Morb Mortal Wkly Rep. 2005;54(44):1124–1127.
[PubMed]

5. Memon A, Moody PM, Sugathan TN, El-Gerges N, Al-Bustan M, Al-shatti A, Al-Jazzaf H. Epidemiology
of smoking among Kuwaiti adults, prevalence, characteristics, and attitudes. Bull World Health Org.
2000;78(11):1306–15. [PMC free article] [PubMed]

6. WHO [Homepage on the Internet], 2006. Together for tobacco free Hajj 2006 (1426 Hegira). Religion
and tobacco; Cited 2006. Retrieved: 04 May ‘2011 available from:
http://www.emro.who.int/tfi/TobaccofreeMecca_Medina.htm.
7. Jarallah JS, AL-Rbeaan KA, AL-Nuaim AA, AL-Ruhaily AA, Kalantan KA. Prevalence and Determinants of
Smoking in Three Region of Saudi Arabia. Tobacco Control. 1999;8:53–56. [PMC free article] [PubMed]

8. Foreign trade statistics in Saudi Arabia. Riyadh, Ministry of Finance and National Economy, Saudi
Arabian Central Department of Statistics. 1985–1995.

9. AL-Faris EA. Smoking Habits of Secondary School Boys in Rural Riyadh, Public Health. 1995;109:47–55.
[PubMed]

10. Al-Haddad1 N, Hamadeh RR. Smoking among secondary-school boys in Bahrain: prevalence and risk
factors, Eastern Mediterranean Health Journal. 2003 Jan;9(1/2):1–1. [PubMed]

11. Wang MQ, Fitzhugh EC, Turner LW, Fu Q. A retrospective study of social influence on southern
adolescents' smoking transition. Southern Med J. 1997;90(2):218–222. [PubMed]

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Persons using assistive technology might not be able to fully access information in this file. For
assistance, please send e-mail to: mmwrq@cdc.gov. Type 508 Accommodation and the title of the
report in the subject line of e-mail.

Prevalence of Cigarette Smoking Among Secondary School Students --- Budapest, Hungary, 1995 and
1999

The average per capita cigarette consumption in Hungary is among the highest in the world (World
Health Organization [WHO], unpublished data, 1997) (1). In 1999, the Metropolitan Institute of State
Public Health and Public Health Officer Service, Budapest, Hungary, collaborating with CDC, conducted a
survey of cigarette smoking among secondary school students aged 14--18 years in Budapest (1999
population of Budapest: approximately 2 million), similar to a survey conducted in 1995 (2). This report
summarizes the survey findings, which indicate that current smoking among secondary school students
in Budapest increased from 36% in 1995 to 46% in 1999.

The objective of the 1999 survey was to compare changes that had occurred since the 1995 survey in
the prevalence of current* cigarette smoking, in the factors associated with current cigarette smoking,
and in the smoking behaviors of current cigarette smokers (i.e., number of cigarettes smoked per day
and number of days smoking occurred on school property). Among the 80,352 secondary school
students in Budapest in 1999, 67,253 attended traditional high schools and 13,099 attended
vocational/technical schools. Of 222 secondary schools (grades 9--12), 21 traditional high schools and
nine vocational/technical schools were selected with a probability proportional to enrollment size.
Classrooms in the 30 schools were selected randomly. All selected schools and classrooms agreed to
participate, and all students in the selected classrooms were eligible to participate.

From March through May 1999, 2615 (85%) of 3092 eligible students† completed a pretested,
standardized questionnaire that included questions about tobacco use translated from the U.S. Youth
Risk Behavior Survey (3). Of the 2615 completed surveys, 2434 (93%) were from students aged 14--18
years; 24 (<1.0%) were age 14 years, a number too small for meaningful analysis. Therefore, analysis of
data from 1999 was limited to students aged 15--18 years. The 1995 data for students aged 15--18 years
were compared with 1999 data using Epi Info version 6.0. Prevalence odds ratios (POR)§ and 95%
confidence intervals (CIs) were calculated using CSAMPLE to account for the complex survey design (4).
Among the 2410 students, 1148 (46.0%) (95% CI=42.4%--49.5%) reported current smoking (Table 1).
Prevalence of current smoking among male and female students was similar (44.9% and 46.9%,
respectively) (POR=0.9; 95% CI=0.8--1.1). Students aged 18 years were more likely to be current smokers
than students aged 15 years (51.8% and 37.2%, respectively) (POR=1.8; 95% CI=1.3--2.6). Prevalence of
current smoking was higher among vocational/technical students than traditional high school students
(60.2% and 43.1%, respectively) (POR=2.0; 95% CI=1.5--2.6); among students whose friends smoked
than those whose friends did not smoke (51.9% and 5.2%, respectively) (POR=19.5; 95% CI=9.8--38.9);
among students who reported that they had seen a teacher smoking during the school year than those
who had not seen a teacher smoking (47.2% and 35.8%, respectively) (POR=1.6; 95% CI=1.4--1.9); and
among students with a family member who smoked than students whose family members did not
smoke (51.9% and 36.6%, respectively) (POR=1.9; 95% CI=1.5--2.3). The prevalence of current smoking
was similar among students who discussed issues related to smoking and health in any of their classes
and those who did not receive such instruction (44.8% and 48.6%, respectively) (POR=0.9; 95% CI=0.7--
1.1). Among students who were current smokers, 23.5% smoked >11 cigarettes on the days that they
smoked, 46.7% smoked daily, and 36.9% smoked on school property on >10 days during the preceding
month.

From 1995 to 1999, current smoking increased among female students (35.2% versus 46.9%), 17-year-
old students (39.4% versus 49.4%), 10th graders (32.8% versus 45.5%), and traditional high school
students (31.5% versus 43.1%). Although the prevalence of daily smoking was similar among male and
female students in 1999 (46.2% and 46.4%, respectively), daily smoking among female students
increased from 32% in 1995 while the rate for male students remained stable. The percentage of
secondary school students in Budapest who smoked >11 cigarettes per day during the preceding month
increased from 1995 to 1999 (Table 2).

Reported by: É Kiss, MD, Div of Health Promotion and Protection; F Ferenczi, E Végh, MD, Dept of Child
and Youth Health, Div of Health Promotion and Protection; K Lun, MD, Metropolitan Institute of State
Public Health and Public Health Officer Svc, Budapest, Republic of Hungary. Epidemiology Br, Office on
Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; and an EIS
Officer, CDC.

Editorial Note:

The survey findings indicate that the prevalence of current cigarette smoking among secondary school
students aged 15--18 years in Budapest increased significantly from 1995 to 1999. In 1999, the
prevalence of current smoking among adolescents aged 15 years was 37.2%. This finding is consistent
with smoking rates among adolescents aged 13--15 years during 1999 in the Russian Federation,
Moscow, where 33.4% were current smokers (5). The estimated 46% smoking prevalence for students in
Budapest in 1999 is higher than the estimated 28.4% prevalence for U.S. high school students (grades 9--
12) who participated in the 1999 National Youth Tobacco Survey (6).

In 1999, the Hungarian Parliament passed stronger legislation to enforce restrictions on smoking in the
workplace and other public places. However, factors that may have contributed to the increased
prevalence of smoking among youth in Budapest include a lack of regulation of the sale of cigarettes to
minors until 1999 (T. Szilágyi, Health 21 Hungarian Foundation, personal communication, 2000), fewer
advertising restrictions since 1997, free distribution of cigarette samples, weak health warnings,
availability of contraband cigarettes, low fines for advertising violations, and lack of enforcement of
existing regulations (1).

The findings in this report are subject to at least one important limitation. These data apply only to
youth who attended secondary school and are not representative of all persons in this age group (e.g.,
secondary school students who dropped out and approximately 80% of gypsy children who do not
attend secondary school) (7).

To better understand increasing prevalence rates of smoking among youth in Budapest and other
central and eastern European countries, national health agencies must expand and evaluate tobacco
prevention efforts and continue surveillance of trends in tobacco use among youth. The Global Youth
Tobacco Survey (GYTS), sponsored by WHO's Tobacco Free Initiative (8) and CDC, will be conducted in
Budapest by the end of 2000 and throughout Hungary in 2001. GYTS will evaluate a wide range of
variables, including knowledge and attitudes about tobacco, exposure to environmental tobacco smoke,
familiarity with prosmoking and antismoking media messages, and exposure to tobacco-use prevention
curricula in schools. These efforts, along with Hungary's development of a plan for tobacco control as
part of the Framework Convention on Tobacco Control (8), are important steps in curbing the increase in
smoking among secondary school students in Hungary.

References

World Tobacco Marketfile. Emerging markets in central and eastern Europe. Available at
http://www.marketfile.co.uk/tobacco. Accessed March 2000.

CDC. Prevalence of cigarette smoking among secondary school students---Budapest, Hungary, 1995.
MMWR 1997;46:56--9.

CDC. Youth risk behavior survey---United States, 1997. MMWR 1998;47(no. SS-3).
Dean AG, Dean JA, Coulombier D, et al. Epi Info, version 6: a word processing, database, and statistics
program for public health on IBM-compatible microcomputers. Atlanta, Georgia: US Department of
Health and Human Services, CDC, 1996.

Canadian Public Health Association. Tobacco, smoking and youth. CPHA Health Digest April 1999;23:1--
8.

CDC. Tobacco use among middle and high school students---United States, 1999. MMWR 2000;49:49--
53.

Kézdi G. Secondary school education of Roma youngsters. In: Hungarian Academy of Sciences, ed.
Gypsies in Hungary. Budapest, Hungary: Hungarian Academy of Sciences, 1999.

World Health Organization. The world health report 1999---making a difference. Combating the tobacco
epidemic. Geneva, Switzerland: World Health Organization, 1999.

* Smoked on at least 1 day during the 30 days preceding the survey.

† 350 were absent; 127 refused to participate.

§ Used to calculate odds ratios from cross-sectional data; an odds ratio from studies of prevalent rather
than incident cases.

Table 1

Table 1

Return to top.

Table 2

Table 2
The Philippine Department of Health (DOH) said on Monday/March 20 that a number of tobacco control interventions,
particularly tobacco taxation has led to a significant drop in current smokers from 17 million (2009) to 15.9 million
(2015). The Tobacco Tax Reform Law of 2012 is also called an “anti-cancer tax” that has a significant health outcome
and has increased funds available for health.

“This figure represents a relative reduction of close to 20% of smokers or in simpler terms, one million Filipinos have
quit tobacco use --- the biggest decline we have seen in Philippine history, and we can do more to stop the suffering
caused by this epidemic.” Other measures that have contributed to the decline in smoking are graphic health
warnings, local ordinances and advocacy of the health sector in strong partnership with civil society.

This notable reduction in tobacco use translates to a million Filipinos at lower risk for cancer, heart disease asthma
and chronic obstructive pulmonary disease, Philippine health officials said.

The 2015 Philippines’ Global Adult Tobacco Survey (GATS) reported that currently only 15.9 Filipino adults currently
smoked tobacco products – 40.3 among men and 5.1 % among women. Smoking among women declined by close
to 50% - also a sign that measures to counteract smoking among women are working.

Health Secretary Paulyn Jean Rosell-Ubial also said that the 2015 GATS shows that 3 out of 4 smokers in the
Philippines wants to quit and that families and health providers should support Filipinos who want to get out of
nicotine addiction. “We need to sustain and protect our gains in tobacco taxation, expand the scope of smoke-free
policies and intensify our warnings against tobacco use.”

Secretary Ubial expressed concern that while exposure to cancer-causing second hand smoke had declined
significantly in public transport, government offices and workplaces --- exposure to smoking in bars and nightclubs is
as high as 86.3%, and in restaurants 33.6% - posing a threat to the health of non-smoking workers in bars, nightclubs
and restaurants. She also warned families against going to restaurants where smoking is still allowed indoors, even
in smoking designated areas --- “ second hand smoke circulates in any enclosed area, it is carcinogenic; therefore
smoking designated areas in restaurants threaten the health of children and senior citizens, in particular”, she added.

“The Philippines, as party to the WHO Framework Convention on Tobacco Control (FCTC) should comply with Article
8 of the Treaty that calls for a complete ban on smoking in public places. The Philippines has taken positive
measures that led to the doubling of the prices of tobacco products and the imposition of strict labelling requirements
on cigarette packs. In support of President Duterte’s desire to replicate Davao City’s strict enforcement of smoke-free
policies we need to do more to prevent 87,000 annual deaths among Filipinos, which are more than the number of
deaths due to HIV/AIDS, tuberculosis and malaria combined leading to an annual economic loss of approximately
Php 188 billion from tobacco-related hospitalization and productivity losses”, the Secretary added.

“The Department of Health stands firmly behind all initiatives that impose smoking bans in public places where non-
smokers become unwillingly exposed to second-hand smoke. It is incumbent on both the national and local
governments to protect the health of all Filipinos who choose not to be exposed to cancer-causing substances in
second hand smoke.” Secretary Ubial said.

While the taxation measures imposed on tobacco products since 2013 have made these products less affordable and
less accessible, there are still too many Filipinos who shell out substantial amount of their monthly income to support
their smoking habit. “There is still much to be done in our country’s efforts to limit and curtail tobacco use, especially
for our economically disadvantaged countrymen who are the most affected with diseases linked to long use of
tobacco products,” she said.

The World Health Organization (WHO) Representative in the Philippines, Dr. Gundo Weiler, congratulated the
Philippine government and its partners from the civil society sector for their steadfast commitment in the overall
collective advocacy and campaign to reduce the negative impact of tobacco on the health of Filipinos. “The
outstanding results of the GATS affirm that the Philippines has achieved a level of international best practice, with the
largest number of smokers that have quit in a short period of time in the Western Pacific. I congratulate the Philippine
government, the health and finance departments who have worked together to make this happen.” Dr. Weiler said.
The WHO Representative said that the Philippines has achieved one of the most pronounced decreases in
prevalence of tobacco use among countries in Asia over the last several years. “While this is truly a great
achievement, we need to redouble our efforts and intensify the interventions that have been proven to be effective,”
Dr. Weiler said.

He reiterated the need to impose smoking bans in public places nationwide and the full implementation of the FCTC,
including the tobacco taxation law.

Current data indicate that even as the prevalence of tobacco use in the Philippines has gone down significantly since
2009, the number of Filipinos who smoke is still much higher than in other countries.

Dr. Weiler said the WHO will continue to support effort by the Philippine government to reduce the morbidity and
mortality among Filipinos linked to tobacco use.

The Philippine Department of Finance (DOF) has been closely monitoring the implementation of the restructured
taxation schedule for tobacco products, passed by Congress in 2012.

Finance Assistant Secretary Ma. Teresa Habitan said this particular legislative measure was the first
instance in which a flat tax rate was imposed on cigarette products. The assistant secretary said that the
law should first be allowed to be fully implemented in order to determine whether it fulfills its objectives to
significantly curb smoking prevalence among Filipinos, while generating appropriate revenue for the
government at the same time.

“We look forward to more positive outcomes from Republic Act 10351 in the long run,” she said.

Secretary Ubial said the progress and achievements of the tobacco control policies and advocacies
should be maximized and pushed further by maintaining the unitary excise tax structure for tobacco
products.

“The success of these efforts is living proof that health for all can truly be achieved when all partners work toward the
same goal,” Secretary Ubial said.
Prevalence of Smoking Among Secondary School Students in Sarawak

O Juslina,corresponding author 1 M Leelavathi, 2 O Khairani, 2 and T Iryani 3

Author information ► Copyright and License information ► Disclaimer

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Abstract

Adolescent smoking is an emerging health concern in the developing countries. A cross-sectional study is
conducted to determine the prevalence and smoking behaviour of adolescents in Sarawak. The
prevalence of smoking is 32.8% with mean age of initiation at 12.8±1.9 years. Most (67.2%) adolescents
are experimental smokers and the majority (67.9%) did not smoke on a daily basis. Branded cigarettes
are preferred (83.1%) and the cigarettes are obtained either from friends (49.1%) or self purchased
(43.6%). Students prefer to smoke at their friend’s house (31.0%) or at school (25.3%). Smoking
prevalence among adolescents in Sarawak is high and begins early. Early intervention on smoking
prevention and risk awareness is perhaps more effective if initiated before the age of 12 years.

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INTRODUCTION

Locally, there is abundance of data on adolescent smoking in Malaysia. However, there is limited data,
particularly from East Malaysia. The objective of this study is to determine the smoking prevalence and
smoking behaviour among the adolescents in Sarawak.

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METHOD

A cross-sectional study was conducted at a secondary school in Kuching, East Malaysia, in the year 2006.
Students were selected using stratified cluster random sampling (single stage). The students were
stratified into five stratum starting from Form One to Form Five. Three classes were selected randomly
from five in each stratum using paper ballot method. Each class consists of 30-35 students and all the
students from the selected classes were included. Students who were absent and did not consent were
excluded. Prior parental consent was obtained and students were assured of anonymity and
confidentiality.

The contents of the self-administered questionnaire were:

Smoking status:

Ever or experimental smoker: one who reported smoking only few puffs in the last 30 days.1,2

Current smoker: one who has smoked cigarette on one or more days during the last 30 days preceding
the survey.1,2

Non-smoker: one who had never tried smoking before.1,2

Smoking habits were divided based on the WHO categories:3

Young daily smoker: one who smokes any tobacco product daily at the time of filling the questionnaire.

Young weekly smoker: one who smokes at least once a week, but not every day at the time of filling the
questionnaire.

Young uncommitted smoker or occasional/sporadic smoker: one who smokes less than once a week.

Age of smoking initiation/first started smoking (based on student’s recall).

Types of cigarette smoked.

Source of cigarette.

Number of cigarettes smoked per day.

Place of smoking.

The questionnaire was translated to national language, back translated and a pilot study was done on
students from another school and minor amendments were made.

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RESULTS

A total of 445 students were selected and 399 completed questionnaire (response rate of 89.6%).

The prevalence of smoking among these students is 32.8% (n=131). Most (67.2%, n=88) of them
belonged to the category of ever or experimental smokers while the rest were current smokers (10.7%,
n=43). The common age of initiating the habit was between 12 to 14 years with the mean age of
12.8±1.9 years.
Most (67.9%, n=89) of them did not smoke on a daily basis. The majority (74.8%) of daily smokers
consumed an average of one to three cigarettes a day. Branded cigarette (83.1%, n=113) was the
preferred choice among students. Cigarettes were obtained either from friends (49.1%, n=81) or self
purchased (43.6%, n=72). Students preferred to smoke at their friend’s house (31.0%, n=49) and at
school (25.3%, n=40). Smoking habit of students is depicted in Table 1.

Table 1

Smoking habits

N (%)

Smoking status(n=399)

Non-smokers 268 (67.2)

Ever/experimental smokers 88 (22.1)

Current smokers 43 (10.7)

Age of smoking initiation (n=131)

<12 years old 26 (19.8)

12-14 years old 86 (65.7)

>14 years old 19 (14.5)

Frequency (n=131)

Daily 31 (23.7)

Once a week 51 (38.9)

Once a month 38 (29.0)

Did not respond 11 (8.4)

Number of cigarettes smoked (n=123)

1-3 92 (74.8)

4-6 23 (18.6)

7-10 4 (3.3)

>10 4 (3.3)
Types of cigarette smoked (n=136)*

Branded cigarette 113 (83.1)

Hand-rolled 12 (8.8)

Pipes/Cigars 4 (2.9)

Others 7 (5.2)

Source of cigarette (n=165)*

Friends 81 (49.1)

Self-purchased 72 (43.6)

Home 8 (4.9)

Others 4 (2.4)

Place where students usually smoked (n=158)*

Friend’s house 49 (31.0)

School 40 (25.3)

Parties 38 (24.1)

Home 31 (19.6)

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*Participants were allowed to give more than one answer

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DISCUSSION

Smoking prevalence among adolescents in this study is 32.8%. This shows a growing trend from previous
figures (Lee LK, 14.7% and NHMM II, 22.3%).4,5 A majority (67.2%) of the adolescent smokers in this
study were experimental smokers. This is higher compared to Singapore (21.9%), Indonesia (46.7%) and
Philippines (41.9%).1,6
About 19.8% of students started smoking before the age of 12 years. These figures are similar to other
local and regional studies.1,7 The early initiation of smoking predicts stronger dependence even before
the development of nicotine addiciton.8

Branded cigarette although highly priced, is the preferred choice among adolescents and a similar trend
was noted in the NHMS III.9 Possible contributing factors include rising standard of living, easily
available and fashionable. Students commonly smoked at their friend’s home or at the school and
obtain their cigarettes either from friends or purchased it themselves. Parents need to monitor their
children’s activities and expenses while school authorities need to prevent students from smoking
within school compound. Perhaps installation of smoke detectors in school toilets could be beneficial.

The prevalence of smoking among adolescents in Sarawak is high with initiation of the habit as early as
twelve years of age. This suggests that any intervention on smoking prevention or risk awareness is
probably best implemented before the age of 12 years. Joint effort from parents, school and
enforcement authorities can change the smoking trend of the future.

Methods: The GYTS employs a standard methodology where self administered questionnaires,
consisting of a set of core questions, are completed by a representative school based sample of students
primarily between the ages of 13–15 years.

Results: Data are presented from 75 sites in 43 countries and the Gaza Strip/West Bank region. Current
use of any tobacco product ranges from 62.8% to 3.3%, with high rates of oral tobacco use in certain
regions. Current cigarette smoking ranges from 39.6% to less than 1%, with nearly 25% of students who
smoke, having smoked their first cigarette before the age of 10 years. The majority of current smokers
want to stop smoking and have already tried to quit, although very few students who currently smoke
have ever attended a cessation programme. Exposure to advertising is high (75% of students had seen
pro-tobacco ads), and exposure to environmental tobacco smoke (ETS) is very high in all countries. Only
about half of the students reported that they had been taught in school about the dangers of smoking
during the year preceding the survey.

Conclusions: Global youth tobacco use is already widespread throughout the world, but there is great
variation among nations. Valid and reliable data on the extent of youth tobacco use, and correlates of
use, are essential to plan and evaluate tobacco use prevention programmes. The GYTS has proven the
feasibility of an inexpensive, standardised, worldwide surveillance system for youth tobacco use. The
GYTS will be expanded to the majority of countries in the next few years, and can serve as a baseline for
monitoring and evaluating global and national tobacco control efforts.

Tobacco use is one of the major preventable causes of premature death and disease in the world. A
disproportionate share of the global tobacco burden falls on developing countries, where an estimated
84% of the world's 1.3 billion current smokers live. The Global Youth Tobacco Survey (GYTS), part of the
Global Tobacco Surveillance System (GTSS) initiated by the World Health Organization (WHO) and CDC,
was developed to monitor youth tobacco use, attitudes about tobacco, and exposure to tobacco smoke,
and has been completed by approximately 1.4 million students in 133 countries. A key goal of GTSS is for
countries to conduct the GYTS every 4 years. This report presents findings from the GYTS conducted in
the Philippines in 2000 and 2003, which revealed substantial declines in the proportions of students
aged 13-15 years who currently smoked cigarettes, currently used other tobacco products, were likely to
start smoking in the next year, or were exposed to secondhand smoke in public places. The findings also
indicated an increase in the proportion of students who supported bans on smoking in public places,
had learned about the dangers of tobacco use in school, and had seen antitobacco messages in media
and advertising. Public health authorities in the Philippines should evaluate their current tobacco-
control programs and enhance or expand them to further reduce youth smoking.

On this day in 1988, the World Health Organization (WHO) passed a resolution that marks every May 31
as a day of raising awareness on the issue of tobacco use.

This awareness highlights the health risks related with tobacco use and advocates effective policies to
reduce tobacco consumption.

WHO claims that tobacco kills nearly 6 million people each year. In the Philippines, 23% of Filipino adults
smoke, and 240 individuals die every day from tobacco-related diseases as of 2011, according to the
Department of Health (DOH).

Take the quiz below to find out more information about tobacco, its effects on our health, and policies
against its use.
Home > Countries > Philippines > Health > Risk factors

Philippines - Smoking prevalence, females (% of adults)

Definition: Prevalence of smoking, female is the percentage of women ages 15 and over who smoke any
form of tobacco, including cigarettes, cigars, pipes or any other smoked tobacco products. Data include
daily and non-daily or occasional smoking.

Source: World Health Organization, Global Health Observatory Data Repository

(http://apps.who.int/ghodata/).

See also:

Thematic map

Country comparison

Country ranking

Download data to Excel

2000200220042006200820102012201420160.002.004.006.008.0010.0012.0014.0016.00

Year Value

2000 12.90

2005 11.20

2010 9.70

2012 9.20

2015 8.50

Statistical Concept and Methodology: The limited availability of data on health status is a major
constraint in assessing the health situation in developing countries. Surveillance data are lacking for
many major public health concerns. Estimates of prevalence and incidence are available for some
diseases but are often unreliable and incomplete. National health authorities differ widely in capacity
and willingness to collect or report information. To compensate for this and improve reliability and
international comparability, the World Health Organization (WHO) prepares estimates in accordance
with epidemiological models and statistical standards. Smoking is the most common form of tobacco
use and the prevalence of smoking is therefore a good measure of the tobacco epidemic. (Corrao MA,
Guindon GE, Sharma N, Shokoohi DF (eds). Tobacco Control Country Profiles, 2000, American Cancer
Society, Atlanta.) Tobacco use causes heart and other vascular diseases and cancers of the lung and
other organs. Given the long delay between starting to smoke and the onset of disease, the health
impact of smoking will increase rapidly only in the next few decades. The data presented are age-
standardized rates for adults ages 15 and older from the WHO.

MANILA, Philippines - Despite the passage of the sin tax law in 2013 that raised taxes on cigarettes,
smoking remains prevalent in the Philippines.

In a presentation on the last day of the two-day 37th Annual Scientific Meeting of the National Academy
of Science and Technology (NAST) at the Manila Hotel yesterday, Stella Luz Quimbo of the University of
the Philippines College of Economics said that this was mainly due to the rise of small tobacco
companies that came out with low-priced brands that gave Filipino smokers the capacity to continue
their unhealthy habit.

Quimbo, in her presentation titled “Does Taxing Sin Deliver us from Disease: An Initial Assessment of the
Health Impact of Sin Taxes in the Philippines,” said that the enforcement of the historic 2013 Sin Tax Law
resulted in the emergence of small tobacco companies that offered cheap cigarettes, which she dubbed
as the “Mighty effect.”

She said when the new sin tax rates were implemented, cigarettes under the Mighty brand were priced
at a little over P20 per pack.

Quimbo noted that the two-tiered structure of implementation of the upward adjustment of taxes on
tobacco and alcohol had resulted to a tobacco war.

“It’s an intense struggle. In 2012, to be honest, we didn’t really anticipate the Mighty effect,” Quimbo
said.

“As a researcher, I didn’t realize that there was going to be an extremely viable low priced brand,” she
said.

She said obviously Mighty cigarettes were eating into the market share of major brands like Philip
Morris.

Quimbo said that the solution to this tobacco war was the implementation of a uniform tax rate.

“For as long as we don’t have a uniform tax rate, then that’s going to be a problem. That’s the reason
why we’re probably seeing very low average cigarette prices,” Quimbo said.
National Academician and UP College of Medicine professor Antonio Miguel Dans said that the unitary
sin tax rate was going to be implemented two years from now in 2017.

From 2013 up to the present, he said that the sin taw law was estimated to have prevented some 3
million people from starting smoking, and prevented 32,000 deaths from smoking already.

“We wanted ti to be unitary from the start. But it was a bargaining chip to the tobacco farmers, tobacco
industry, to the northern bloc lawmakers,” Dans said.

The NAST, for its part, lamented the “Mighty effect” as it declared the Philippines in a crisis of lifestyle-
related non-communicable diseases (NCDs).

The NAST tackled NCDs for its main theme on their 37th Annual Science Meeting this week – “The
Challenges of Non-Communicable Diseases: Responding through Multi-sectoral Action.”

“The prevalence of smoking is high because tobacco is cheap, and we are flooded with promotional
materials at an early age,” it noted.