TOBACCO CONTROL IN SAUDI ARABIA: WILL IT WORK?

Smoking has long been associated with preventable morbidity and premature death in human population.¹ Several studies have specifically implicated smoking with lung cancer, coronary heart disease, chronic obstructive pulmonary disease, stroke and Polycythemia.^2–6 Moreover, the extension of the damaging effects of smoking on health of non-smokers is increasingly being recognized and reported.⁸

The World Health Organization described tobacco smoking as an epidemic, with an estimated three million deaths annually, worldwide, because of smoking. This figure is expected to rise to ten million a year by the years 2020s or early 2030s, if the current trends of smoking continues. Seventy percent of these deaths will occur in developing countries.⁹

In addition to its health consequences, tobacco smoking is a significant economic burden.¹⁰,¹¹ The estimated annual global cost is about US Dollars 200 billion, and this includes direct medical care offered for tobacco-induced illness, absence from work, reduced productivity and loss of life because of early death, half of these losses occurring in developing countries.¹⁰

In Saudi Arabia, smoking is known for more than 50 years. Tobacco imports have increased very dramatically over the years,¹² with an average of six hundred million Saudi Riyals spent annually on tobacco.¹²,¹³

Although there is no nationwide studies on the prevalence of tobacco smoking in Saudi Arabia, the available small scale studies have shown a prevalence between 8% to 47%.^14–20 A more recent household survey in three regions have shown a prevalence of 12% among adults, above 14 years of age, with a very high male preponderance.²¹

As to the long-term health consequences of smoking, they are also not very well documented in the Kingdom. Lung cancer is now ranked the fourth malignant disease among males, with an incidence of 4.5%.²² On the other hand the short-term respiratory and other effects of smoking, both cigarettes and Sheesha, have been well reported.²³,²⁴

Since the tragic health and economic consequences of tobacco smoking are now well established control of tobacco becomes of paramount importance. Several pharmacological and non-pharmacological strategies of tobacco control were found to be significantly effective.²⁵,²⁶ These include tobacco taxation,²⁷ banning smoking at work,²⁸ physician advice, complementary therapies,²⁵ smoking cessation clinics²⁸ and nicotine replacement therapies.³⁰ Nevertheless, comprehensive strategies are still needed to achieve better tobacco control.⁹

The World Health Organization has recently provided countries with guidelines for comprehensive national control programmes of tobacco.⁹ These guidelines include: health promotion activities, media advocacy, encouragement of smoking cessation, legislative measures, fiscal measures such as tobacco taxation, and effective protective measures against the involuntary exposure to smoke.⁹ Moreover, the WHO has also provided countries with comprehensive methods of evaluation of important measures of tobacco control.³¹ In this respect, several countries have succeeded in reducing tobacco smoking using different measures of control; the comprehensive approach proving most effective.⁹

In the Kingdom, there is no clear policy for the control of tobacco on the national level. The current efforts of control are sporadic, fragmented and not well coordinated. Although tobacco advertisement and promotion is prohibited in the local media, and smoking is not allowed in the government buildings or on board domestic flights, there is no close monitoring of non-compliers.

The Saudi Smoking Control Charitable Society, over the last 14 years, has established a total of 33 anti-smoking clinics all over the country. The uptake of these clinics is still limited, with a quitting rate of 13%.³² However, this figure should be interpreted with caution, since there is no precise data on the duration of follow up and the relapse rate.

In this issue of the Journal of Family and Community Medicine, Saleh and co-authors³³ report the results of their study of the determinants of outcome among smokers in a smoking cessation programme in the city of Buraydah. This is the first and probably the only published work that presented data on tobacco control in Saudi Arabia.

Although the results of the study may be very encouraging and it has explored factors that are likely to affect the outcome in such a programme, it should be interpreted with caution. Firstly, the studied group is motivated and willing to quit smoking as it appeared that they initiated the visit to the anti-smoking centre. Secondly, the methods of tobacco control used in the programme were not presented in details, and finally, the study reported a quitting rate after only six months period which is relatively short. The World Health Organization has recommended that smoking cessation programmes should present outcome data after a period of one year, or even longer, if possible.³¹

Despite these limitations of the study and even if we assume that the majority of smokers will relapse, the results obtained are very encouraging and give a good ground for optimism, bearing in mind that a cessation programme of this kind is part of a comprehensive programme.

Let us hope that this will be a starting point for a well coordinated, comprehensive tobacco control programme in Saudi Arabia, and, more importantly, gives support and encouragement to the efforts that exist at the moment. My feeling is that we will succeed.