|Year : 2014 | Volume
| Issue : 3 | Page : 173-178
|Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia
Ahmed Mandil1, Mohammad Yamani2, Abdulaziz BinSaeed1, Shaffi Ahmad1, Afnan Younis1, Ahmad Al-Mutlaq3, Omar Al-Baqmy3, Abdulaziz Al-Rajhi3
1 Department of Family and Community Medicine, College of Medicine, Riyadh, Saudi Arabia
2 Department of Clinical Pharmacy, College of Pharmacy, Riyadh, Saudi Arabia
3 College of Medicine, King Saud University, Riyadh, Saudi Arabia
|Date of Submission||10-Jan-2014|
|Date of Acceptance||03-Mar-2014|
|Date of Web Publication||7-Jun-2014|
Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh
| Abstract|| |
Aim: This study aimed at assessing prevailing patterns and risk factors of tobacco consumption among clients, food handlers and employers of food facilities, in Riyadh, Saudi Arabia.
Methods: A cross-sectional approach to a representative sample of food facilities in Riyadh was used. A sample of 3000 participants included clients (75%); food handlers/hospitality workers (20 %) and employers (5 %). Participants were reached at restaurants, food courts or cafes. A modified version of the WHO-CDC-Global Youth Tobacco Survey questionnaire was used for data collection.
Results: The prevalence of tobacco use at food facilities was found to be 40.3 %, of which 74% were customers, 18.8% were food handlers and 7.2% were managers. The consumption of tobacco was higher at restaurants (39.9%), but lowest at food courts of shopping malls. Water pipe (55.3%) was the main consumption type, followed by cigarettes (42.6%) and chewing tobacco (2.1%). Multivariate analysis showed that gender (male), marital status (single), and type of food facility (Estaraha and café/coffee shop) were independent risk factors associated with tobacco use at food facilities.
Conclusion: Tobacco use is very common in food facilities in Riyadh as reflected by results of our study, especially among single males Saudis. We should build on success encountered in banning smoking in airports, airplanes, shopping malls, market places, educational institutions and healthcare facilities, extending the ban to include food facilities as well. This is important for the health of non-smokers as well as smokers themselves.
Keywords: Food facilities, Riyadh, Saudi Arabia, tobacco use
|How to cite this article:|
Mandil A, Yamani M, BinSaeed A, Ahmad S, Younis A, Al-Mutlaq A, Al-Baqmy O, Al-Rajhi A. Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia. Ann Thorac Med 2014;9:173-8
|How to cite this URL:|
Mandil A, Yamani M, BinSaeed A, Ahmad S, Younis A, Al-Mutlaq A, Al-Baqmy O, Al-Rajhi A. Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia. Ann Thorac Med [serial online] 2014 [cited 2020 Jul 16];9:173-8. Available from: http://www.thoracicmedicine.org/text.asp?2014/9/3/173/134075
Tobacco use is the leading preventable cause of death in the world and one of the biggest threats the world has ever faced. Although tobacco deaths rarely make headlines, tobacco kills one person every six seconds. Today, tobacco use causes 1 in 10 deaths among adults worldwide, more than five million people a year.  Tobacco consumption is associated with a series of illnesses including: different types of cancers; pulmonary diseases, cardiovascular diseases. 
Tobacco is widely used in EMR mainly in the form of cigarette or shisha smoking. , In 2002, the Ministry of Health of Saudi Arabia launched an initiative to make the two holiest cities in Islam: Mecca and Madina, not just smoke-free but literally tobacco-free. The aim was not just to restrict smoking in the two cities, but also to prohibit all commercial activities involving tobacco. 
Several studies have been conducted on tobacco consumption in Saudi Arabia. These studies targeted different subgroups of the population including: secondary school students, ,,,,, college students, ,,,,,,,,,,,,,,,,, university employees, , both males and females, and explored their knowledge, attitudes and beliefs towards smoking in addition to prevalence of tobacco use in such subgroups. In addition, wider scale general population-based tobacco-use surveys are also cited in the literature. ,,,
Only few studies - locally and globally - looked into knowledge, attitudes and beliefs of people in food facilities ,, although they represent an example of public places where several categories of persons are exposed to "environmental tobacco smoke" (ETS); these include clients, workers as well their managers or employers. None of these studies have analyzed the risk factors for tobacco users among those participants.
Other studies, as the systematic review of Calinan et al.,  compared exposure of participants in food facilities to tobacco before and after implementation of tobacco-free legislations. Fifty studies were included in such review. Of 31 studies which reported exposure to ETS, only 19 measured it using biomarkers. There was consistent evidence that tobacco use bans reduced exposure to ETS in workplaces, restaurants, and public places. Nevertheless, there was more reduction in ETS exposure among hospitality workers when compared to general population. Overall tobacco use was reported to go down in studies where prevalence went down.
Many countries in Europe and North America have passed legislations that ban tobacco use in public places, including food facilities. Studies performed in Europe as in Finland,  Georgia,  Germany, , Sweden,  Spain  and Italy  as well as North America as in Canada  and USA , have shown that degrees of exposure to ETS among hospitality workers in food facilities and entertainment places have dramatically decreased following bans of smoking in public places, which was strictly implemented in such countries, compared to pre-ban levels.
While no official ban of tobacco use in food facilities (including restaurants, cafes and food courts within shopping malls) was implemented in Saudi Arabia until the data for this research was collected, and because of lack of previous studies investigating tobacco use in food facilities in Riyadh, this research provides baseline information that can be used in the future when comparing the effect on tobacco use before and after the ban of smoking in public places.
Thus the current study aimed at assessing prevailing patterns and risk factors of tobacco consumption among clients, food handlers and employers, in Riyadh, Saudi Arabia during 2012.
| Methods|| |
This cross-sectional study during 2011-2012 was carried out on a representative sample of food facilities in Riyadh based on an estimated prevalence of tobacco use in Saudi Arabia of 25% among adult males, with the width of confidence interval as 2%, at 5% level of significance, and assuming 20% non-response from the study subjects. An estimated sample of 3000 participants was estimated to include clients (75%); food handlers/hospitality workers (20 %) and employers (5 %). The sample was stratified according to the five regions of Riyadh city (Eastern, Western, Central, Southern and Northern) then clusters of restaurants/cafes/food-courts within malls /"Estarahat (cafes located at outskirts of Riyadh)" were selected by using probability proportion sampling. Participants were reached at restaurants, food courts, cafes and estarahas. The sample included "clients" who were ordering food or drinks, besides food/beverage "handlers", "employers or managers" at these places.
A modified version of the WHO-CDC-Global Youth Tobacco Survey Arabic questionnaire was used for data collection.  The tool was revised and piloted to test its validity and reliability before it was finally utilized and distributed.
Thus, the tool included questions on: (I) demographic data: age; gender; marital status; occupation, education, income, reason for being in food facility etc (II) behavioral patterns with respect to tobacco use: smoking frequency; age of initiation of smoking; intention for cessation of smoking. etc
Data was collected by KSU medical students, reviewed for completeness and accuracy, and managed using SPSS PC+ version 19.0 (Chicago, USA) statistical software. Descriptive statistics (frequencies and percentages) were used to describe the categorical study and outcome variables. Pearson's chi-square test and odds ratios were used to test and measure the association between categorical study and outcome variables. Multivariate binary stepwise logistic regression was used to identify the independent risk factors for tobacco use in food facilities. A P-value of <0.05 and 95% confidence intervals were used to report the statistical significance and precision of the estimates.
| Results|| |
Of the 2932 study subjects, 27.9% (818) were from central, 21.6% (632) from Eastern and the least number of study subjects, i.e. 10.8% (316) were from southern region of Riyadh city. About 44.7% (1296) of study subjects were interviewed from restaurants, the rest from remaining coffee shops, food courts of shopping malls and Estarahat. Study subjects were customers (71.7%), food handlers (20.7%) or managers (7.7%). About two-thirds of participants were Saudis (62.3 %), the rest (37.7%) were non Saudis. Just above half (52.8%) were married, while 40.4% earned SAR 1000 to < 5000 per month. The occupation of study subjects was variable, ranging from students (24.5%) to retired people (1.2%) [Table 1].
|Table 1: Socio-Demographic characteristics of study subjects, food facilities, Riyadh|
Click here to view
The prevalence of tobacco use at food facilities was found to be 40.3% (1183), of which 74% were customers, 18.8% were food handlers and 7.2% were managers. The consumption of tobacco was higher at restaurants (39.9%), and lower at food courts of shopping malls. Water pipe (shisha) was the main consumption type (55.3%), followed by cigarettes (42.6%) and chewing tobacco (2.1%) [Table 2].
|Table 2: Tobacco use by study subjects and family members, food facilities, Riyadh|
Click here to view
Comparison of various associated factors between the study subjects who use and who do not use tobacco at food facilities showed that nationality (being Saudi), gender (male), marital status (single), in the three income ranges (1000 - <5000; 5000- <10000; and 10000+), type of study subject (customer), type of food facility (restaurant, coffee shop and estaraha), occupation (military related), smoking family member, and who smokes in the family (father, brother and more than 2 family members) were statistically significantly associated factors with tobacco use. The odds of being a male study subject who uses tobacco at a food facility in our sample was 8.9 times compared to female study subjects, which was found to be highly statistically significant (P < 0.0001). The Estaraha and coffee shop/café food facilities were mostly used for tobacco use, when compared to food courts/shopping mall facilities (OR = 13.2 and 6.7) indicating a high statistically significant association. Reported military occupation (of clients) at food facilities was associated with more use of tobacco, when compared to other occupations. Having a smoking family member/more than two smoking family members was associated with higher estimated risk for a study subject to use tobacco at a food facility in our sample. Among the family members, father and brother being smokers was significantly associated with the use of tobacco at a food facility [Table 3].
The stepwise multivariate logistic regression analysis with all significant variables of bivariate analysis shows that: gender (male), marital status (single), income per month (1000 to <5000; 5000 to <10000 and 10000+) and type of food facility (Estaraha and café/coffee shop) were independent factors associated with the use of tobacco at food facilities. The variables (nationality, type of study subjects, occupation, smoking family member, who smokes in the family?) were not independently statistically significantly associated with the use of tobacco at food facilities [Table 4].
| Discussion|| |
The prevalence of tobacco use at food facilities in our sample was estimated at a high rate of 40%, but highest among customers (74%), followed by food handlers (19%) and managers (7%). A study among male restaurant workers in Boston's Chinatown indicated that 83% of them were current smokers.  Nevertheless, our overall estimate (40%) is not very different from estimates among the general population which ranged between 17-34% among adult males during the past 15 years. ,,,
Amongst food facilities, consumption of tobacco was higher in restaurants (40%) compared to food courts located within shopping malls, which is an expected outcome, as the latter are considered smoke-free areas. It was interesting to find out that water pipe (shisha) was the main consumption type (55%), followed by cigarettes (43%) and chewing tobacco (2%) among tobacco users in our sample population. This is in contradistinction to other studies which consistently report higher cigarette consumption among tobacco users, including the major study on King Saud University (KSU) students,  which reported 48% cigarette use, compared to 36% water-pipe use amongst an overall tobacco use of 14.5% of a sample of more than 6000 KSU students. "Estarahat" and coffee shops were more used for tobacco use compared to food courts within shopping malls (OR = 13.2 and 6.7, respectively). This is also an expected outcome, as many people use such places as outlets for tobacco consumption, at a time when it is now prohibited in most other public places, including educational institutions, healthcare facilities, transportation facilities (especially airports and aircrafts) as well as food courts in public shopping malls.
Bivariate analyses showed that single Saudi males in different food facilities who have one or more smoking family member (father, brother, etc) were more prone to be smokers compared to other equivalent categories. Specifically, males in sampled food facilities were 8.9 times more liable to use tobacco compared to females (P < 0.0001). If any of the family members, especially more than two family members of study subjects were using tobacco, then the odds were much higher for a study subject to use tobacco at food facilities in our sample. Such conclusions were confirmed by results of multivariate logistic regression analysis which showed that gender (male), marital status (single), and type of food facility (Estaraha and coffee shop) were independent risk factors for tobacco consumption among visitors of food facilities.
Such results seem to generally concur/differ with prior reports. In fact, Mandil et al.,  reported friends' smoking and being a single male to be among important risk factors for tobacco use among King Saud University (KSU) students. On the other hand, Al-Turki et al.,  reported that low socio-economic status, low education, divorce, self-employment to be associated with smoking in more than 196,000 Eastern Province adults 30 years and above. About a decade earlier, Jarallah et al.,  mentioned that being male, married, less educated, carrying out manual work, being an army officer/office-worker to be important predictors of tobacco use among 8310 inhabitants in three regions of Saudi Arabia; while Saeed et al.,  reported that being a single male with higher education to be more associated with smoking among 1534 adult Saudis in Riyadh. Generally speaking, it seems that male gender and single status were reported from more than one report, while other factors are variable. Such differences may be attributed to different times, methodology, studied population where ours were predominantly young people in food facilities, spending time eating and consuming tobacco.
| Conclusion and Recommendations|| |
Tobacco use is very common in food facilities in Riyadh as reflected by results of our study, especially among single males. Some of such facilities are even designed to host tobacco users, providing them with facilities which help such habit (e.g. shisha smoking in Estrahat). While many nations in the developed world (as in western Europe and northern America) have adopted and strictly implemented legislations for banning smoking in public places in general, food and entertainments facilities in specific, similar legislations in Saudi Arabia did not seem to find their way of implementation in food facilities. We should build on success encountered in banning smoking in airports, airplanes, shopping malls, market places, educational institutions and healthcare facilities, extending such bans to include food facilities, as well. We think that food facilities, including restaurants, coffee-shops and Estrahat should be smoke-free. This should be looked upon as encouraged not only for the sake of protection of non-smokers from Environmental Tobacco Smoke, but should also keep in mind the health of smokers themselves, en route of their quitting tobacco use, once they find less and less available public places where they can smoke.
| References|| |
|1.||The WHO Report on Global Tobacco Epidemic, 2008. Retrieved on January 17, 2009. Available from: http://www.who.int/tobacco [Last accessed on 2013, Oct 25]. |
|2.||Tobacco: Deadly in any form or disguise. World Health Organization, 2006. Available from: http://www.who.int/tobacco/communication/events/wntd/2006 [Last accessed on 2013, November 15]. |
|3.||Maziak W, Rastam S, Eissenberg T, Asfar T, Hammal F, Bachir M, et al. Gender and smoking status based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria. Prev Med 2004;38:479-84. |
|4.||Tobacco use in Shisha: Studies on water-pipe smoking in Egypt. WHO Regional Office for the Eastern Mediterranean, 2006. |
|5.||Saloojee Y, Chaouki N. Tobacco-free Mecca and Madina. WHO Regional Office for the Eastern Mediterranean, 2007. |
|6.||Felimban F, Jarallah J. Smoking habits of secondary school boys in Riyadh, Saudi Arabia. Saudi Med J 1994;15:438-42. |
|7.||Al-Yousef M, Karim A. Prevalence of smoking among high school students. Saudi Med J 2001;22:872-4. |
|8.||Al-Faris E. Smoking habits of secondary school boys in Rural Riyadh. Public Health 1995;109:47-55. |
|9.||Jarallah J, Bamgboye E, Al-Ansari L, Kalantan K. Predictors of smoking among male junior secondary school students in Riyadh, Saudi Arabia. Tob Control 1996;5:26-9. |
|10.||Al-Damegh S, Saleh M, Al-Alfi M, Al-Hogail IA. Cigarette smoking behavior among male secondary school students in the central region of Saudi Arabia. Saudi Med J 2004;25:215-9. |
|11.||Amin TT, Amr MAM, Zaza BO, Suleman W. Harm perception, attitudes and predictors of water-pipe (shisha) smoking among secondary school adolescents in Al-Hassa, Saudi Arabia. Asian Pac J Cancer Prev 2010;11:293-301. |
|12.||Al-Turki Y. Smoking habits among medical students in central Saudi Arabia. Saudi Med J 2006;27:700-3. |
|13.||Hashim T. Smoking habits of students in college of applied medical science, Saudi Arabia. Saudi Med J 2000;21:76-80. |
|14.||Merdad L, Al-Zahrani M, Farsi J. Smoking habits among Saudi female university students: Prevalence, influencing factors and risk awareness. Ann Saudi Med 2007;27:366-9. |
|15.||Abdolfotouh M, Abdel Aziz M, Alakija W, Al-Safy A, Khattab M, Midad S, et al. Smoking habits of King Saud University students in Abha, Saudi Arabia. Ann Saudi Med 1998;18:212-6. |
|16.||Al-Arifi M. Smoking habits among pharmacy students at a university in central Saudi Arabia. Saudi Med J 2005;26:893-5. |
|17.||Al-Turki Y, Al-Rowais N. Prevalence of smoking among female medical students in the College of Medicine, Riyadh, Saudi Arabia. Saudi Med J 2008;29:311-2. |
|18.||Felimban F. The smoking practices and attitudes towards smoking of female university students in Riyadh. Saudi Med J 1993;14:220-4. |
|19.||Mandil AM, Bahnassy AA, Aboul-Azm SM, Bashawri LA. Knowledge, attitudes and smoking pattern among nursing and laboratory technology students, Dammam, Saudi Arabia. J Family Community Med 1999;6:51-8. |
|20.||Jarallah J. Smoking habits of medical students at King Saud University, Riyadh. Saudi Med J 1992;13:510-3. |
|21.||Saeed AA. Smoking habits of students in College of Allied Medical Sciences, Riyadh. J R Soc Health 1987;107:187-8. |
|22.||Taha A, Bener A, Noah M, Saeed A, AL-Harthy S. Smoking habits of King Saud University students in Riyadh. Ann Saudi Med 1991;11:141-3. |
|23.||Al-Mahmoudi H, Amin T. Pattern and prevalence of smoking among students at King Faisal University, Al-Hassa, Saudi Arabia. East Mediterr Health J 2010;16:56-64. |
|24.||Abdelshakour A, Al-Kaabba A, Saeed A, AbdulRahman M, Raat H. Gender differences in smoking behavior among adolescents in Saudi Arabia. Saudi Med J 2007;28:1102-8. |
|25.||Merdad LA, Al-Zahrani MS, Farsi JM. Smoking habits among Saudi female university students : Prevalence, influencing factors and risk awareness. Annals Saudi Med 2007;27:366-9. |
|26.||Mandil A, BinSaeed A, Ahmad S, Al-Dabbagh R, Alsaadi M, Khan M. Smoking among university students: A gender analysis. J Infect Public Health 2010;3:179-87. |
|27.||Mandil A, BinSaeed A, Dabbagh R, Shaikh SA, AlSaadi M, Khan M. Smoking among Saudi university students: Consumption patterns and risk factors. East Mediterr Health J 2011;17:309-16. |
|28.||Koura MR, Al-Dossary AF, Bahnassy AA. Smoking pattern among female college students in Dammam, Saudi Arabia. J Family Community Med 2011;18:63-8. |
|29.||Al Ghobain MO, Al Moamary MS, Al Shehri SN, Al-Hajjaj MS. Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia. Ann Thorac Med 2011;6:137-40. |
|30.||Bassiouny M. Smoking in Saudi Arabia. Saudi Med J 2009;30:876-81. |
|31.||Milaat M, Al-Bar H, Ghabrah T, Abalkhail B, Suliman N. Preventive practices and non healthy behaviours among female university employees in Saudi Arabia. Bahrain Med Bull 1999;21:75-9. |
|32.||Saeed AA, Khoja T, Khan SB. Smoking behavior and attitudes among adult Saudi nationals in Riyadh City, Saudi Arabia. Tob Control 1996;5:215-9. |
|33.||Jarallah J, Al-Rubeaan K, Al-Nuaim A, Al-Ruhaily A, Kalantan K. Prevalence and determinants of smoking in three regions of Saudi Arabia. Tob Control 1999;8:53-6. |
|34.||Siddiqui S, Ogbeide D, Al Khalifa I. Smoking in a Saudi community: Prevalence, influencing factors, and risk perceptions. Family Med 2001;33:367-70. |
|35.||Al-Turki K, Al-Baghli N, Al-Ghamdi J, El-Zubaier A, Al-Ghamdi R, Alameer M. Prevalence of current smoking in Eastern province, Saudi Arabia. East Mediterr Health J 2010;16:671-6. |
|36.||Averbach A, Lam D, Lam LP, Sharfstein J, Cohen B, Koh H. Smoking behaviours and attitudes among male restaurant workers in Boston′s Chinatown: A pilot study. Tob Control 2002;11 (Suppl II):ii34-7. |
|37.||King BA, Dube SR, Tynan MA. Attitudes toward smoke-free workplaces, restaurants, bars, casinos, and clubs among U.S. Adults: Findings from the 2009-2010 National Adult Tobacco Survey. Nicotine Tob Res 2013;15:1464-70. |
|38.||Jones S, Love C, Thomson G, Green R, Howden-Chapman P. Second-hand smoke at work: The exposure, perceptions and attitudes of bar and restaurant workers to environmental tobacco smoke. Aust N Z J Public Health 2001;25:90-3. |
|39.||Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption. Cochrane Database Syst Rev 2010;14:CD005992. |
|40.||Reijula JP, Johnsson TS, Kaleva PS, Reijula KE. Exposure to tobacco smoke and prevalence of symptoms decreased among Finnish Restaurant workers after the smoke-free law. Am J Ind Med 2011;55:37-43. |
|41.||Gvinianidze K, Bakhturidze G, Magradze G. Study of implementation level of tobacco restriction policy in cafes and restaurants of Georgia. Georgian Med News 2012;206:57-63. |
|42.||Bolte G, Heitmann D, Kiranoglu M, Schierl R, Diemer J, Koerner W, et al. Exposure to environmental tobacco smoke in German restaurants, pubs and discotheques. J Expo Sci Environ Epidemiol 2008;18:262-71. |
|43.||Schneider S, Seibold B, Schunk S, Jentzsch E, Pötschke-Langer M, Dresler C, et al. Exposure to secondhand smoke in Germany: Air contamination due to smoking in German restaurants, bars, and other venues. Nicotine Tob Res 2008;10:547-55. |
|44.||Larsson M, Boëthius G, Axelsson S, Montgomery SM. Exposure to environmental tobacco smoke and health effects among hospitality workers in Sweden - before and after the implementation of a smoke-free law. Scand J Work Environ Health 2008;34:267-77. |
|45.||Martínez-Sánchez JM, Fernández E, Fu M, Pérez-Ríos M, López MJ, Ariza C, et al. Impact of the Spanish smoking law in smoker hospitality workers. Nicotine Tob Res 2009;11:1099-106. |
|46.||Valente P, Forastiere F, Bacosi A, Cattani G, Di Carlo S, Ferri M, et al. Exposure to fine and ultrafine particles from secondhand smoke in public places before and after the smoking ban, Italy 2005. Tob Control 2007;16:312-7. |
|47.||Lemstra M, Neudorf C, Opondo J. Implications of a public smoking ban. Can J Public Health 2004; 99:62-5. |
|48.||Zellers L, Thomas M, Ashe M. Legal risks to employers who allow smoking in the workplace. Am J Public Health 2007;97:1376-82. |
|49.||Farrelly M, Nonnemaker J, Chou R, Hyland A, Peterson K, Bauer U. Changes in hospitality workers′ exposure to secondhand smoke following the implementation of New York′s smoke-free law. Tob Control 2005;14:236-41. |
|50.||Smoking and tobacco use. GYTS core questionnaire. Centers for Disease Control and Prevention. Available from: http://www.cdc.gov/tobacco/global/gyts/questionnaire.htm [Last accessed on 2013, September 10]. |
[Table 1], [Table 2], [Table 3], [Table 4]