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Combating tobacco in Saudi Arabia: a review of recent initiatives

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Ramaiah Itumalla1 and Badr Aldhmadi1

1Department of Health Management, College of Public Health and Health Informatics, University of Hail, Hail, Saudi Arabia (Correspondence to: R. Itumalla: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: The tobacco use epidemic is one of the major global public health challenges and causes > 7 million deaths each year, including ~70 000 Saudis who die from smoking-related diseases.

Aims: To present recent government initiatives in Saudi Arabia that have been designed to combat tobacco use in the country.

Methods: This was a review based on secondary data sources such as published reports, articles in newspapers, and research studies published in various journals.

Results: We present initiatives taken from June 2017 to April 2019 by the Saudi government to combat tobacco use, including value-added tax on tobacco, antismoking campaigns, antismoking clinics, mobile apps and other initiatives.

Conclusion: The study suggests that the government should evaluate the impact of these initiatives on tobacco control in Saudi Arabia.

Keywords: antismoking campaign, antismoking clinics, mobile app, Saudi Arabia, tobacco

Citation: Itumalla R; Aldhmadi B. Combating tobacco in Saudi Arabia: a review of recent initiatives. East Mediterr Health J. 2020;26(9):xxx-xxx http://doi.org/10.26719/emhj.20.019

Received: 28/02/19; accepted: 26/11/19

Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

Introduction

The government of Saudi Arabia is determined to enhance the quality of preventive and therapeutic healthcare services as part of its Vision 2030. The public sector is focusing on promoting preventive care and reducing infectious diseases in the country (1). The tobacco use epidemic is one of the world’s major public health challenges and causes > 7 million deaths per year according to the World Health Organization’s (WHO’s) “Tobacco key facts” (2). More than 6 million of these deaths are the direct result of tobacco use, while ~890 000 deaths are the result of nonsmokers being exposed to secondhand smoke (2). The prevalence of tobacco use and the dangers posed to users as well as secondhand smokers are among the major health concerns in Saudi Arabia. Control of tobacco use is urgently needed in the country, as the numbers of smokers and deaths from smoking are rising fast (3). It is reported that ~70 000 Saudis die annually from smoking-related diseases (4).

The prevalence of tobacco use in Saudi Arabia is presented in the WHO report on the global tobacco epidemic, 2017 (country profile: Saudi Arabia) (5). The total prevalence of tobacco use among adolescents was 14.9%, compared with 12.2% among adults. Moreover, the prevalence of cigarette smoking was 8.9% among adolescents; whereas the prevalence of smokeless tobacco use among adolescents was 3.4% but only 0.9% among adults. The Saudi Health Information Survey, 2014 revealed that 17.2% of Saudis were exposed to secondhand smoke at home and 14.8% at work (6). The survey also found that 14.6% of smokers were aged 35–44 years. Moreover, the survey identified that the prevalence of smoking increased among those people age 25–64 years from 12.2% in 2005 to 15.3% in 2013. Statistics from the Saudi Ministry of Health in 2019 reveal that the total number of smokers in the country reached 5.5 million or 23% of the population (7).

The government of Saudi Arabia has been striving to control tobacco use. In the Gulf Cooperation Council (GCC), tobacco control activities started in January 1979, when Saudi Arabia presented an initial scientific proposal at the 6th GCC Health Ministers’ Council Conference on combating smoking in the region. The WHO Framework Convention on Tobacco (FCTC) treaty was launched in May 2003 and has subsequently been signed by the majority of the GCC member states, including Saudi Arabia, United Arab Emirates, Kuwait and Qatar (8). Notably, every single member state has endorsed FCTC. Also in 2003, the Saudi government initiated its own antismoking campaign for the first time. All GCC member states, including Saudi Arabia, have a national level agency to control tobacco use.

In 2008, WHO presented the MPOWER measures (Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco) to the member states in fulfilling their WHO FCTC commitments. The MPOWER measures provide useful support to implementation of the tobacco control initiatives in Saudi Arabia (8). The Saudi government has strictly banned any marketing efforts by tobacco companies and it also launched a 6-month-long antismoking drive in May 2010 (9). The national Anti-Smoking Committee has been working towards stricter tobacco control. The government passed an Anti-Smoking Law in 2015 to combat smoking by taking necessary measures at the various levels of state, community and individuals (10). The Saudi government started implementing anti-tobacco regulations from 7 June 2016 (11). As per the 7th article in the 2015 law, smoking is prohibited in the following places: 1) areas and yards surrounding mosques; 2) ministries, government-owned factories, public institutions and authorities and their branches, as well as other public bodies; 3) educational, health, sports, cultural and social institutions, as well as charities; 4) work places in companies, institutions, organizations, factories and banks; 5) public transport (land, air or sea), as prescribed by the Executive Regulations; 6) places for producing, processing and packaging of food, foodstuffs and beverages; 7) sites for producing, transporting, distributing and refining petroleum and its products, as well as fuel and gas distribution and sales points; 8) warehouses, elevators and lavatories; and 9) any public places not mentioned in the list. However, if such places allocate areas for smoking, the person in charge must ensure that they are isolated, restricted, and are not accessible to persons aged < 18 years (10).

In 2017, Saudi Arabia joined other WHO member states in a campaign to increase public awareness about the dangers of tobacco use (3). The Saudi Ministry of Health has allocated sizable budgets to fund the various tobacco control programmes in the country. Government expenditure on tobacco control was SAR 18 000 000 in 2008 (most recently available data) (5). The main objective of the current study was to present the recent initiatives of the Saudi government in its fight against tobacco use in the country. The study covered the recent initiatives from 2017; the year Saudi Arabia joined WHO in combating tobacco use and imposed an excise tax of 100% on tobacco products through to April 2019.

Methods

This study was a review based on secondary data sources, including published reports, articles in newspapers, and research studies published in various journals. The relevant literature regarding tobacco control in Saudi Arabia was searched from PubMed, Scopus and Google Scholar from January to April 2019. Key phrases such as “tobacco use in Saudi Arabia”, “smoking in Saudi Arabia” and “tobacco control in Saudi Arabia” were used. The main inclusion criterion for selection was that the article had to discuss tobacco control programmes in Saudi Arabia. Articles that were not available in English with free full text were excluded. Table 1 lists the selected studies on smoking in Saudi Arabia.

The 2013 and 2017 WHO reports on the global tobacco epidemic, the Saudi Health Information Survey, Saudi Ministry of Health and 2015 Anti-Smoking Law were the main sources of information for this study. Their focus was on presenting the prevalence of tobacco use and government initiatives to control and reduce such use. Relevant news articles published in the leading Saudi newspapers such as the “Saudi Gazette”, “Arab News” and “Arabian Business” were also used as contributing sources, as well as papers published in academic journals. The gathered secondary information was analysed carefully in the light of existing facts and the official information provided on the websites of various organizations.

Results

Saudi Arabia has undertaken several initiatives to reduce tobacco use among its population. Over the past 2 years, initiatives have included value-added tax (VAT) and fines, launching an antismoking campaign, establishing antismoking clinics, introducing mobile apps and other initiatives.

VAT and fines

One of the recent policy initiatives by the Saudi government was implementation of VAT on tobacco from 11 June 2017 that imposed 100% excise duty on tobacco products (12). This led to a 213% increase in demand from people seeking help to give up smoking because of the rise in tobacco prices (13). After a year, it was reported that the increase in tobacco prices had helped people to quit smoking, and the demand for smoking cessation clinics increased by 302% (14). The government was also strict with any commercial organizations responsible for violations of anti-tobacco policies, and fines of up to SAR 5000 were imposed on offenders (15).

Implementation of 100% VAT on tobacco products resulted in a significant 43.1% decrease of tobacco imports into Saudi Arabia from 2017 to 2018, which decreased from SAR 3.13 billion to 1.78 billion. According to the Saudi Customs Authority, the country imported SAR 500 million worth of tobacco products during the first quarter of 2019 (16). The decrease in tobacco imports is one of the positive effects of the government initiatives.

Anti-smoking awareness campaigns

Ramadan 2017 was a landmark in combating tobacco use in Saudi Arabia. The Ministry of Health launched an antismoking drive to coincide with the holy month of Ramadan and World No Tobacco Day on 31 May 2017 (3).

In continuation of its efforts to combat smoking and to coincide with the World No Tobacco Day on 31 May 2018, the Saudi Ministry of Health launched an antismoking campaign under the theme “Help Us …We Will Help You”. The Ministry of Health aimed to develop the therapeutic and awareness services to help smokers who wish to quit by: (1) opening a number of antismoking clinics across the country; (2) issuing the Saudi Guide for Tobacco-Cessation Services as a guide for service providers; (3) holding many theoretical and practical courses for workers in the field; and (4) providing free antismoking drugs to citizens (17).

As recently as 2019, the Ministry of Health started a campaign to monitor the spread of tobacco use among adult men and women in 12 800 households in all parts of the country. The campaign is a joint undertaking with the Saudi Government’s General Authority for Statistics under the supervision of WHO. This survey initiative, which is being conducted for the first time in Saudi Arabia, is a unified international measure to assess the prevalence of smoking among adult men and women to create strategies to combat that development (18). However, the smoking prevention programmes in the country need to reinforce nonsmoking attitudes, and address how to resist pressure to smoke, and how to develop high self-efficacy towards nonsmoking in various situations (19).

Antismoking clinics

Besides campaigns to increase antismoking awareness among the population, the Saudi Government also focused on providing treatment services to people affected by smoking. The Saudi Ministry of Health established antismoking clinics in different regions of the country. The aim of these clinics was to provide therapeutic and awareness services for the target smokers and nonsmokers, highlighting antismoking regulations, providing counselling and health education, as well as reducing the overall level of smoking and passive smoking (17).

In 2017 there were 160 antismoking clinics that provided free awareness services, medical consultations and therapeutic services to smokers of both sexes to help them to quit smoking. It is noteworthy that antismoking clinics in healthcare centres and hospitals in Riyadh received > 7000 patients since the beginning of 2017 (3). People seeking help from clinics increased by 213% from July to September 2017. According to the head of the Ministry’s smoking cessation clinics, taxes were the most effective way to help people, especially adolescents, who wanted to quit smoking (13). However, some of the reasons for not quitting smoking, such as: lack of willpower; other smokers around a person; and stress at home/work are posing challenges to the nation’s fight against tobacco use (20).

There was an increase in the number of antismoking clinics and people visiting them in 2018. The Ministry of Health activated 262 antismoking clinics and found that the antismoking campaign launched at the beginning of Ramadan 2017 increased the number of visitors to antismoking clinics by 321% (17). Establishment of antismoking clinics has continued in various parts of the country and in 2019 reached a total of 542 (18). These clinics are run by trained medical staff to help people who want to quit smoking by providing counselling and follow-up services, as well as the free medication initiatives already mentioned above (14). Smoking cessation counselling and therapy provided by physicians can play an important role in helping smokers to quit (21). The working hours of these clinics are from 21:00 hours to midnight and they have a capacity of 20 clients per clinic. In addition to these measures, the website of the Ministry of Health displays antismoking clinics’ locations on Google Map as well as the Antismoking Clinics Directory in the public domain. People should be able to find the location of clinics easily and can download the directory when required (22). According to the Ministry of Health, the antismoking clinics helped 11 441 smokers to give up smoking during the first half of 2019 (23).

Mobile app to catch violators of antismoking regulations

mHealth refers to the use of mobile computing and communication technology in health care and public health and is a rapidly expanding area of research and practice (24). Mobile technology has the potential to bridge systemic gaps needed to improve access to, and use of, health services (25). The Saudi Government took the initiative to use the potential of mHealth in the battle against smoking. The Saudi Ministry of Health launched a mobile app as a part of its antismoking drive (17). This novel initiative was helpful for reporting and monitoring violations of antismoking regulations, such as smoking in public places, selling tobacco to the children aged < 18 years, and advertising cigarette or shisha smoking on any local television channels. The mobile app is available for all and the violations can be reported to the relevant officials (15).

Other initiatives

Apart from the above initiatives, the Saudi Ministry of Health published various health educational materials. They include books and pamphlets explaining the dangers of smoking, as well as providing free medication to smokers who want to quit (18). The Ministry also developed a range of awareness-raising materials via films and publishing in the mass media and social media platforms (17). The influence of friends and parents smoking played an important role in the increased risk of smoking in adolescents (26). Factors such as sex and family influence were identified as the main pro-smoking risk factors, while improved knowledge of health risks was found to be a protective factor (27). Hence, the pro-smoking risk factors need to be given greater priority and could be included in antismoking education programmes targeting adolescents and adults.

Discussion

The Saudi Ministry of Health and National Tobacco Control Committee have both played key roles in controlling tobacco use with periodic policies and initiating novel programmes. However, there is still a long way to go to achieve the desired results. The tobacco control initiatives of the Saudi Government are in line with the WHO MPOWER measures. According to the WHO 2017 report on the global tobacco epidemic, the total prevalence of tobacco use, as well as smokeless tobacco use, among adolescents were greater than among adults in Saudi Arabia. Despite the robust efforts of tobacco control agencies in Saudi Arabia to combat smoking, a recent study showed that prevalence rates among adolescents were around 12.1%, with no indications of a decline (28). A recent meta-analysis revealed that the pooled estimate of smoking prevalence among college students in Saudi Arabia was 17% (29). Moreover, another contemporary work on the prevalence of cigarette smoking in Saudi Arabia in 2018 found that the prevalence of cigarette smoking was 21.4% of the population (30). In the light of these findings, it can be argued that the prevalence of tobacco use is still high, although the county has run several antismoking initiatives. This is an alarming situation facing the country’s policy-makers in which they need to reassess antismoking initiatives to take necessary actions to control tobacco use effectively. The antismoking awareness programmes need to focus more on adolescents, without neglecting adults.

The implementation of excise tax on tobacco products has yielded positive results for controlling tobacco use. Additionally, it has become one of the reasons to quit smoking in Saudi Arabia. The antismoking clinics have played a crucial role in the fight against smoking. The increase in the number of antismoking clinics and people using the services provided by these clinics, shows a positive trend towards the control of tobacco use in Saudi Arabia. The introduction of a mobile app is one of the novel initiatives by the Saudi Ministry of Health and it is time to utilize this app in the battle against tobacco use by increasing people’s participation.

The current study had some limitations. First, the study was based on secondary data. Second, it considered only the recent initiatives for tobacco control in the country.

Conclusion

The present study presented the recent initiatives of the Saudi Government to combat tobacco use. These initiatives included: (1) increased VAT on tobacco; (2) launch of antismoking campaigns; (3) establishment of antismoking clinics; (4) introduction of a mobile app; and (5) other initiatives. Although various initiatives have been undertaken by the Government to reduce tobacco use, the study suggests that the Government should evaluate the impact of these initiatives on tobacco control in Saudi Arabia.

Funding: None.

Competing interests: None declared.

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