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Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 39-43

Auditing the prevalence and effects of smoking to lead a successful smoking cessation campaign

Department of Medical Protocol, King Abdulaziz Medical City, National Guard Health Affairs, Ministry of National Guards, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication16-Apr-2018

Correspondence Address:
Anhar Hamza
Department of Medical Protocol, King Abdulaziz Medical City, National Guard Health Affairs, Ministry of National Guards, P.O. Box 3660, Riyadh 11481
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_104_17

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Background: Smoking is the largest single preventable cause of death and disability worldwide. Cultural barriers, lack of smoking cessation training, and patients' complaints are among the reasons why health professionals avoid asking about or advising against smoking. Aim: The aim of the audit was to assess the prevalence and effects of smoking to lead a successful smoking cessation campaign. Materials and Methods: The project was divided into two phases. The first phase was the audit and the second phase was the smoking cessation campaign. Results: A 6-week audit at the Medical Protocol Department at King Abdulaziz Medical City, Riyadh, Saudi Arabia, showed that (1) there is a trend of increasing use of hookah among females; (2) A large percentage of smokers have dyslipidemia, hypertension, and diabetes; (3) There is a strong association between smoking (both cigarettes and hookah) and obesity. During the smoking cessation campaign week, 54 patients were enrolled onto the smoking cessation program. Four weeks following the patient's chosen quit date, 12 patients (22%) had successfully quit completely. A total of 21 patients reported that they have significantly cut down, 11 patients had not quit yet and the remaining 10 patients were not contactable. Conclusions: Smoking cessation campaigns and programs are successful at helping people quit smoking. They are by far one of the most cost-effective life-preserving clinical services and should be integrated into routine clinical care. Treating physicians need to specifically ask about smoking status and promptly refer patients to smoking cessation clinics.

Keywords: Saudi Arabia, smoking cessation, smoking prevalence

How to cite this article:
Hamza A, Al Hussein F. Auditing the prevalence and effects of smoking to lead a successful smoking cessation campaign. Saudi J Health Sci 2018;7:39-43

How to cite this URL:
Hamza A, Al Hussein F. Auditing the prevalence and effects of smoking to lead a successful smoking cessation campaign. Saudi J Health Sci [serial online] 2018 [cited 2022 Jun 28];7:39-43. Available from: https://www.saudijhealthsci.org/text.asp?2018/7/1/39/230224

  Introduction Top

Smoking is responsible for one in every five deaths in adults aged over 35 and half of long-term smokers will die prematurely due to a smoking-related disease.[1] Furthermore, smoking is reducing the female advantage in life expectancy, and it remains the largest single preventable cause of death and disability worldwide.[1]

Governments have attempted to reduce tobacco use by increasing the price of tobacco, restricting advertising, and providing free smoking cessation programs.[2],[3] However, the deleterious health consequences of smoking at both personal and national levels invites for more radical interventions.

In the field of smoking cessation, it has long been recognized that identifying effective behavior change relies on “Very Brief Advice.”[4] This is where one relies on the acronym of the 4 As, which is namely Asking the patient about current and past smoking behavior, Advising them on the consequences of smoking, Assisting them to stop smoking by giving smoking cessation advice and medication, and Arranging follow-up.

In order for us to introduce the first well-established smoking cessation clinic in National Guards Hospital-Riyadh, we divided the project into two phases. The first phase is the audit phase where we collected data on the number of smokers and their associated morbidity. This is a fundamental part, as it will give us an indication of the smoking prevalence within the study population and its correlation with different health conditions. Once this data is gathered, then we will resume the second phase of the study, which is the smoking campaign. This is where we will invite the smoking patients and give them tailored specialist advice, medication, and follow-up to help them quit smoking.

Preliminary data about smoking habits and smoking cessation at the Medical Protocol Department (MPD) of King Abdulaziz Medical City, Riyadh, Saudi Arabia (KAMC) has suggested that little work has been done in this field. There were no formal smoking cessation clinics or scheduled follow-up of the quitters.

On further in-depth analysis of the data, it became apparent that the lack of training of the multidisciplinary team and the language barrier between nursing staff and patients were major contributing factors in the reluctance of staff to ask about smoking habits or offer smoking cessation advice. The above stance is compounded further by the fear of patients' complains. Having identified the above, a 2-day smoking cessation workshop was scheduled. It was hosted by the Ministry of Health to provide basic training to all members of the multidisciplinary team.

Given the increasing burden of smoking on our population, the Health Promotion team at the MPD at KAMC decided to conduct the second phase of the study by launching awareness and smoking cessation campaign. This would constitute a 1-week campaign with representatives from the pulmonary, cardiology, and dental teams along with smoking cessation advisors. It was chosen to coincide with World No Tobacco Day on May 31.

  Materials and Methods Top

The target population for this study was all of the MPD patients who attended the family medicine outpatient clinics during the chosen 6-week period. As such and to get an accurate prevalence, all of the patients were included, and there were none excluded. The patient's verbal consent was gained to assess their smoking status and to be included as part of the study. The design of this study was to assess the severity and the burden of smoking on our cohort of patients; an audit was performed within the MPD outpatient clinics from April 4, 2016 to May 15, 2016. This included gathering data on patients who were attending their family physician clinics for routine and urgent appointments. Demographic data were collected along with the smoking status, gender, age, body mass index (BMI), and past medical history of each patient.

The objectives of the audit are that before launching an effective smoking cessation campaign, it is fundamental to assess the prevalence of smoking and smoking-related morbidity within the target population. It is also important to understand the patients' characteristics and the cultural believes that underline their smoking habits. This will allow the smoking cessation advisor to effectively tackle those believes to affect behavioral change and encourage quitting.

The patients who smoke were given smoking cessation leaflets and were invited to the upcoming smoking cessation campaign under the slogan of “Let us help you quit smoking in Ramadan.” This title was carefully chosen because the holy month of Ramadan was looming and the majority of our target population observes Ramadan by fasting. This is where they abstain from eating, drinking, and smoking from sunrise to sunset. All of those who fast are able to obey this successfully which means that they can stop themselves from smoking for an average of 14 h a day. We identified this as a good opportunity to encourage the smokers to use this positive indicator to quit smoking altogether. In other words, if patients are able to stop smoking for 14 hours a day, then we can help them to continue to abstain for the remaining 10 h/day and as such successfully quit smoking.

The patients' computerized record of “BestCare ©” was used to get updated data such as previous hospital admissions and past medical history. This included a detailed review of recent blood results, radiology, and clinical reports.

Statistical analysis

The data were managed by SPSS software version 16 for Windows (SPSS, Inc., Chicago, IL, USA). The SPSS program was used to analyze and produce the Pareto diagram along with the descriptive analysis (Crosstabs). Graphs were produced using Microsoft ® Excel ® for Mac 2011, version 14.5.1.

  Results Top

[Figure 1] shows the Pareto principle (also known as the 80/20 rule, the law of the vital few, or the principle of factor sparsity) states that, for many events, roughly 80% of the effects come from 20% of the causes. The principle was suggested by management thinker Joseph M. Juran. It was named after the Italian economist Vilfredo Pareto, who observed that 80% of income in Italy was received by 20% of the Italian population.[5] The assumption is that most of the results in any situation are determined by a small number of causes.
Figure 1: Pareto analysis of smoking-related illnesses

Click here to view

The authors have applied the principle above to analyze the audit data from the initial phase that looks at the comorbidities associated with smoking. A line was drawn at 80% on the Y-axis running parallel to the X-axis, and then a line was dropped at the point of intersection with the curve on the X-axis. This point on the X-axis separates the important causes on the left (vital few) from the less important causes on the right (trivial many). It can, therefore, be seen that the most common and arguably most deleterious effects of smoking are dyslipidemia, hypertension, and diabetes.

This result fits in with the literature that strongly links smoking to lower levels of high-density lipoproteins (HDL) and increased risk of coronary heart disease.[6] Less than half of the patients were suffering with diabetes and hypertension (40% and 43%, respectively), which together puts the smokers at a significant risk of Ischemic Heart Disease and strokes.

The cancers suffered by the smokers included lung, floor of mouth, vocal cords, thyroid, neuroendocrine, renal, testicular, prostate, and bladder.

The prevalence of smoking within the medical protocol patients, in our study population; there were 102 smokers out of 1310 study population. This gave a smoking prevalence of 7.79% among this population. The average number of cigarettes smoked was 22, and the range was 1–100 cigarettes/day. The average age of the smokers was 54 years with a range of 17–88 years. Three of the patients admitted to previous failed quitting attempts and attributed it to the fact that they have been smoking for >30 years.

Out of the 102 smokers, 15 (14.71%) smokers were female, giving a prevalence of 1.7% among females. The highest numbers of smokers were among 87 men, giving a prevalence of 20.4%. Hookah was used by 13.7% of the smokers, the majority of which were females. In other words, cigarette smoking was common among men, whereas Hookah usage was common among females.

Seventy-eight percent of the smokers received a smoking cessation bundle of leaflets. The bundle is composed of 5 sheets addressing: (1) the services provided by the smoking cessation clinic, (2) what happens after one quits smoking, (3) passive smoking, (4) effects of Hookah, and (5) how the patient can be stronger without smoking.

About 18.6% of the patients who were offered the “Stop Smoking bundle of leaflets” refused it. Those 19 patients were an interesting mix of ages and had various comorbidities. Their refusal is possibly because patients who believe that they are unlikely to successfully give up may be reluctant to engage with the services so that they do not fail.

The rate of obesity among the smoking population is usually defined in terms of BMI. The world health organization [1] defines obesity in three grades: BMI 25–29.9 kg/m 2 = Grade 1 obesity (moderate overweight); BMI 30–39.9 kg/m 2 = Grade 2 obesity (severe overweight); and BMI ≥40 kg/m 2 = Grade 3 obesity (massive/morbid obesity). Underweight is usually defined as a BMI of <18.5 kg/m 2.

[Figure 2] clearly demonstrates that 71% of the smokers were either overweight or obese. This is fundamentally important because research suggests that overweight or obese smokers may possess metabolic and neurobiological features that contribute to difficulty achieving cessation using regular nicotine replacement therapy.[6],[7] It follows that more extensive attention and pharmacological therapy is needed to reduce mortality and morbidity among this vulnerable population.
Figure 2: The body mass index of the smokers

Click here to view

  Discussion Top

Trying to assess the exact prevalence of smoking within the Saudi population is rather difficult. This was demonstrated in a 2009 study published in the Saudi Medical Journal [8] where the prevalence of smoking ranged from 2.4% to 52.3%. Factors such as age, educational status, and peer pressure play a significant role on whether people take up and continue to smoke.

Although many users think it is less harmful, hookah smoking has many of the same health risks as cigarette smoking.[9] Given the way hookah is used, smokers may absorb higher levels of carbon monoxide, metals, and cancer-causing chemicals than those found in cigarette smoke. According to the American Lung Association,[10] an hour-long hookah smoking session involves 200 puffs while smoking an average cigarette involves 20 puffs.

The results of this audit demonstrate an increasing trend in smoking among females, especially in the use of hookah. This is interesting because the Eastern culture frowns upon and subconsciously denies female smoking, which suggests that smoking cessation programs tend to be targeted more towards males. This observation was picked up and was addressed in our smoking campaign, as the effects of smoking in females are potentially more deleterious. According to Nuwayhid et al.,[11] babies born to women who smoked hookah every day while pregnant weigh less at birth (at least 3½ ounces less) than babies born to nonsmokers. They are also at an increased risk of respiratory diseases. Smoking cigarettes carries risks that include spontaneous abortions, underweight babies, and increased illness in children within the household from passive smoking (increased otitis media and asthma).

It was not a surprise that one of the patients who refused the smoking cessation leaflets was a gentleman who had renal cell carcinoma, inguinal hernia, asthma, and cataract. He smokes 40 cpd, and had a 50-pack year history. Although the wishes of patients who refused the information leaflets were respected, they were still invited to the smoking cessation campaign. Those group of patients were given careful attention to elicit their beliefs and barriers to quitting and helping them to address it to contemplate change.

Although 66% of smokers had dyslipidemia, it is difficult to attribute a definite causative link between smoking and dyslipidemia. In other words, smoking is known to decrease HDL [12] and so does high BMI.[13] It is therefore possible that because 71% of the smokers were overweight/obese, their dyslipidemia is due to their body habitus and not a direct consequence of their smoking. It is also possible that both obesity and smoking have contributed individually and cumulatively to the increased morbidity seen in the smoking population.

A study published in the Lancet suggested that obesity and smoking have a strong pro-aging effects.[13] This is an important finding because 23% of the smokers are under the age of 40 and out of those young smokers, 55% are either overweight or obese. It follows that the young overweight/obese individuals are at an increased risk of smoking related morbidity, a finding that should be used to raise awareness among the smokers in the campaign and in the smoking cessation clinic. It should also encourage regular medical screening of this age group.

The limitation of the audit and smoking cessation campaign, including the data collection tool was carefully designed and its implementation was discussed with the nurses. In particular, they were advised to be tactful when assessing the smoking status of females. This is because of the potential cultural barriers along with the perceived repercussions if their family or physician became aware of their smoking status. As such, patients were assured of confidentiality of the data. The clinic nurses were responsible for accurately documenting the patient's details along with their smoking status in the data information collection. This would invariably carry a potential for human error. However, to mitigate the risks of wrong data entry, the handwritten sheets were electronically entered and checked by two independent nurses.

At the stage of data analysis, it was challenging to quantify the amount of smoking when patients were using hookah. As such, those patients were counted with the smokers, but their data were not used to calculate the average number of cigarettes smoked. Again, this may falsely lessen the effects of smoking given that the amount of nicotine in hookah far outweighs that in cigarettes.

Passive smoking has been recognized to have health consequences that are just as bad as smoking if not more. Unfortunately, the data collected focused on smokers and did not include those who suffer passive smoking. This was highlighted when patients said that they do not smoke but someone in their household does. This is potentially useful and can be included in a future study to allow us to look for a link between passive smoking and established morbidity.

In our upcoming re-audit “Stop Smoking Campaign,” we will aim to tackle any misconceptions raised by the smokers and support them in quitting smoking. A subsequent audit will be conducted to assess the abstinence rate of those who quit during the smoking cessation campaign in Ramadan. This is an important step as the rate of relapse can sometimes be high if patients are not followed up and supported after they quit.

  Conclusion Top

This audit acts as an eye opener in the sense that smoking continues to be a health problem in both males and females. This is evident by the fact that some patients are smoking 100 cpd/day, which will be associated with higher levels of morbidity and mortality.

The acceptance of hookah in social gatherings together with the misconception that it is safer than smoking has encouraged more females to use it. The increase in usage was demonstrated by the results of this audit. As such, the message of the dangers of hookah on females and their unborn babies and children needs to be highlighted. These findings raise a potential epidemic where unborn babies, children along with their parents are put at an increased risk of multiple health consequences because of smoking.

The audit further demonstrated a strong association between smoking and obesity, especially among the young smokers. An updated register of smokers needs to be kept along with regular preventative screening and follow-up. Furthermore, the general physicians have to give brief smoking cessation advice to initiate a change in behavior. Then, once the smoking cessation clinic is up and running; staff at the MPD have to encourage smokers to attend it.

Smoking cessation is one of the most cost-effective life-preserving clinical services. As such, the aim is to make the case for allocation of funds to smoking cessation and to propose the integration of smoking cessation interventions into routine clinical care throughout the health-care system.


The authors are grateful to the patients for taking the time to answer our questions and to the nursing staff at the medical protocol department for their dedication in collecting the data. Special thanks to Staff Nurse Rasha Aiad, Mr. Jayson Genita, and Mr. Kevin Pelias for their help with this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2015: Raising Taxes on Tobacco. New York-United States: World Health Organization; 2015.  Back to cited text no. 1
Raw M, McNeill A. The prevention of tobacco-related disease. Addiction 1994;89:1505-9.  Back to cited text no. 2
Reid DJ, Killoran AJ, McNeill AD, Chambers JS. Choosing the most effective health promotion options for reducing a nation's smoking prevalence. Tob Control 1992;1:185.  Back to cited text no. 3
Heckman CJ, Egleston BL, Hofmann MT. Efficacy of motivational interviewing for smoking cessation: A systematic review and meta-analysis. Tob Control 2010;19:410.  Back to cited text no. 4
Craft RC, Leake C. The Pareto principle in organizational decision making. Manage Decis 2002;40:729.  Back to cited text no. 5
Bray GA. Medical consequences of obesity. J Clin Endocrinol Metab 2004;89:2583.  Back to cited text no. 6
Valdes AM, Andrew T, Gardner JP, Kimura M, Oelsner E, Cherkas LF, et al. Obesity, cigarette smoking, and telomere length in women. Lancet 2005;366:662.  Back to cited text no. 7
Bassiony MM. Smoking in Saudi Arabia. Saudi Med J 2009;30:876.  Back to cited text no. 8
Health, U.D.o. and H. Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. p. 3.  Back to cited text no. 9
Association A. L. Hookah Smoking: A Growing Threat to Public Health Issue Brief. Smokefree Communities Project; 2011.  Back to cited text no. 10
Nuwayhid IA, Yamout B, Azar G, Kambris MA. Narghile (hubble-bubble) smoking, low birth weight, and other pregnancy outcomes. Am J Epidemiol 1998;148:375.  Back to cited text no. 11
Strong DR, David SP, Johnstone EC, Aveyard P, Murphy MF, Munafò M. Differential efficacy of nicotine replacement among overweight and obese women smokers. Nicotine Tob Res 2015;17:855-61.  Back to cited text no. 12
Bray GA. Handbook of obesity. Epidemiology, Etiology, and Physiopathology. 3rd ed., Vol. 1. New York-United States: CRC Press; 2014.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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