Prevalence, and associated factors of tobacco smoking among adults in the United Arab Emirates; results from national health survey

Cigarette smoking is one of the major public health concerns and is the primary cause of preventable illness and premature death. This study examined the prevalence, and associated factors of tobacco smoking among adults living in the United Arab Emirates (UAE). The study further aims to study the socioeconomic determinants such as employment, education, and income of the UAE population, with respect to the status of smoking. A population-based survey of adults aged 18+ was undertaken. Around 10,000 randomly selected households across all seven Emirates were selected to yield representative data. A total of 8188 adults (18 years and above) participated in the national health survey. The overall response rate was 87% among adult participants. Overall, the prevalence of current smoking was 9.1% among the selected population; 0.8% of the respondents smoked tobacco on a daily basis. Smoking rates were higher in individuals having lower levels of education, students studying in university, and people who had no income. Providing data on the prevalence and factors associated with smoking among specific populations may offer an improved understanding of tobacco use patterns, and will help to develop interventions or health-related policies.


Introduction
Controlling the use of tobacco is a key public health problem. Use of tobacco contributes to major health issues across the globe and in the United Arab Emirates (Cahill et al. 2013). The evidence on causality for tobacco use as a cause of disease and death has become irrefutable. Tobacco use is an established risk factor for cardiovascular diseases and cancer and is also a public health threat; it tends to jeopardize human health and also adds a financial burden to the smokers (Saha et al. 2007a, b). A national agenda of the United Arab Emirates includes ten specific goals to be achieved by 2021, five of which are related to non-communicable diseases (NCDs): tackling cardiovascular diseases (CVD), cancer, diabetes, obesity, and smoking.
Globally, deaths arising from use of tobacco are projected to rise in the upcoming years, if continuous successful actions are not applied to mitigate this surging evolution of smoking habits at the population level. A Ministry of Health and Prevention report in 2010 indicated that the prevalence of smoking any tobacco product is 21.6% among men, and 1.9% among women (Razzak et al. 2020). Most of the surveys have been formerly commenced in an attempt to monitor the smoking prevalence among adults. The majority of these surveys were not found to be nationwide or representative of the country's adult population. In the light of this, a series of legislative measures have been newly implemented in an effort to reduce tobacco consumption such as treating nicotine addiction, restricting indoor smoking, and increasing tobacco taxation. Furthermore, there is a dearth of information on the tobacco use burden in the UAE (Younis et al. 2003;Akl et al. 2011).
Limited studies have assessed the tobacco use prevalence among adults across the UAE (Aden et al. 2013;Alblooshi et al. 2016;Al-Houqani et al. 2012a, b;Obaid et al. 2015;Al Shemmari et al. 2015). Beyond showing that smoking is unhealthy, epidemiologic research also contributes to identifying predictors of smoking behaviour, assessing smoking cessation interventions, and measuring the effects of anti-smoking regulations. Providing data on the prevalence and factors associated with tobacco use among UAE populations may provide a better understanding of tobacco use patterns ,along with assisting in developing interventions or health policies. The objective of the present study was to explore the prevalence and associated risk factors of smoking in a nationally representative sample of the UAE population. The study further aims to study the socioeconomic determinants such as employment, education, and income of the UAE population with respect to the status of smoking.

Design and settings
A cross-sectional data from the 2018 national health survey in the United Arab Emirates was used. United Arab Emirates (UAE) is a sovereign nation that is constituted as a federal Middle East monarchy, located in the Arabian Peninsula. It is composed of seven emirates (Abu Dhabi, Ajman, Dubai, Fujairah, Ras Al Khaimah, Sharjah, and Umm Al Quwain). Oil is the main source of income and the essential component of its GDP. The discovery of oil drove noteworthy industrial and economic development in the UAE, which has impacted the demographic landscape of the nation.
The national health survey was a population-based crosssectional survey conducted by the UAE Ministry of Health and Prevention in 2017-2018. The primary targeted population included private households and families. All labour camps and collective households were excluded from the survey. The survey included both local citizens and non-local residents of UAE. The WHO STEPwise approach to surveillance of non-communicable diseases (STEPS) was integrated with survey design.

Sampling/ sample size/ inclusion and exclusion criteria
The survey was distributed to 10,000 randomly selected households across all seven Emirates. This sample was designed to produce representative data. A total of 8188 adults (18 years and above) participated in the survey. Of these, 4143 were males and 4045 were females. The overall response rate was 87% among adults' participants. Multi-stage cluster sampling and random probability sampling techniques were used for the purpose of recruiting the participants in the study.

Data collection/ questionnaire/instrument
The UAE World Health-Household Survey questionnaire for persons 18 years and above was used in the study. The formerly validated WHO STEPwise questionnaire consisted of three major items: behavioural and demographic data, and measurements. This instrument was locally adapted, and a pilot study which involved 15 respondents was conducted to validate its suitability in the local setting, as well as to test the effectiveness of the research process. The demographics included were age groups, gender, and emirate of residence, nationality, marital status, education level, and income (AED), while behavioural questions included smoking status, smoking categories, types of tobacco products, and prevalence of smoking. Trained research assistants gathered pertinent data on behavioural and demographic characteristics using the WHO STEPwise questionnaire. The questionnaire was administered face-to-face, using computer-assisted personal interview (CAPI) techniques. The CAPI tool is a digital version of the questionnaires, wherein all the questionnaires were programmed onto an Android-based application.

Data analysis
Data will be entered in a computerized system and analysed by SPSS (Statistical Package of the Social Sciences) version 25. Inferential and descriptive statistics was used for analysing the data. Percentages (%) and frequencies (n) were reported for categorical variables. The associations between the demographic variables and smoking were assessed through bivariate analysis or Chi-square test.

Ethical considerations
Ethical approval was acquired from the Ethical Review Board of the Ministry of Health and Prevention, Dubai. Moreover, the participants were informed about the confidentiality and anonymity of all collected information during the survey. The voluntary nature of the participation in the study was also emphasized. A consent form was reviewed and signed by the respondents during the NHS survey before completing the questionnaire, assuring that the collected data would only be used for scientific purposes. The respondents were also informed that the information provided on the questionnaire would remain confidential. Confidentiality was assured of all research information. Ethical considerations were taken into consideration through all research steps. Table 1 demonstrates the demographic characteristics of the selected participants. A total of 8188 respondents were included in the study. Mean age of the respondents was 37.9 (SD =11.6), with age range 18 and above. Most of the respondents were males (50.6%), married (82%), and had attained at least a university degree (65%). Almost 33% of the respondents were unemployed, and 46.2% of them reported income more than 20,001 AED; some of the respondents did not report their monthly income. The number of male smokers was significantly higher than female smokers among all respondents, in both the Emirati and non-Emirati population.

Results
As shown in Table 1, 747 (9.1%) of the respondents were current smokers, 210 (3%) were ex-smokers, and 7231 (88%) never smoked. As per Table 2, around 463 (23.9%) consumed fewer than five cigarettes in a day. As can be seen, the most common form of smoked tobacco use was in the form of manufactured cigarettes, followed by shisha, medwakh and E-cigarettes. From 747 respondents who reported the use of tobacco products, 69.8% were known to be using manufactured cigarettes, 0.5% used hand-rolled cigarettes, and 0.8% were reported to use pipes full of tobacco and cigars, cheroots, or cigarillos. Of the others, 9.1% were reported to smoke shisha, 2.3% used e-cigarettes, and 6.6% were reported to use medwakh. Smoking prevalence rises to 9.7% in households earning 15,001-20,000 AED, and drops to 2.8% in households earning 5001-10,000 AED (p = 0.42). The highest reported smoking age group was 30-44 (9.8%) ,while lowest reported smoking age group was among elders aged 60+ (5.8%). Compared to smokers, the majority of the nonsmokers were in the age group 60 and above.

Secondary smoking
Overall, 2.9% (n = 240) of the non-smoking respondents were exposed to passive smoking either at workplace or home. Male respondents were found to smoke more (15.7%) than females (2.4%). Government employees had the highest prevalence of smoking (13.7%) compared with semi-state (12.6%) and unemployed participants (2.5%). Participants who were single used tobacco products more (14.6%) compared to their married counterparts (8.2%). University students had highest prevalence of smoking compared to those in secondary levels of education (19.4%).
As demonstrated in Table 3, gender (p = 0.001), marital status, (p = 0.001), age (p = 0.031), level of education (p = 0.019) and employment status (p = 0.001) were significantly associated with smoking while, the income (p = 0.42) is not significantly associated with smoking. Male participants used tobacco products more (15.7%) than their female counterparts (6.5%). Participants who were separated used tobacco products more (18.5%) than single people (14.6%). Also, participants in university had the highest prevalence of tobacco use (62.6%) compared with those with no form of education (0.7%). Compared with subjects who reported being in college or higher education, the odds ratios (95% CI) for participants who took no education were 3.881 (1.283-11.743).

Discussion
Our study examined the burden of smoking among individuals of age 18 and above in the United Arab Emirates. It is well known that cigarette smoking is a significant and independent risk factor for premature death, certain types of cancers, and cardiovascular disease (Saha et al. 2007a, b). We found the current smoking prevalence to be 9.1% among the selected population, whereas 0.8% of the respondents smoked tobacco on daily basis. These results were obtained may be due to the effect of epidemiological transition and globalisation (Reubi 2016).
The World Health Organization has reported a global increase in cigarette smoking (WHO 2019). The prevalence reported in our study was shown to be considerably lower than the national prevalence reported previously in the year 2010, around 21.6% among men and 1.9% among women respectively (Zain 2016). The percentage of smokers over the age of 18 years has gone as low as 9.1%, down from 11.1% in 2010 (MOHAP 2019). This decline may be due to activating tobacco control laws and regulations across UAE, health awareness campaigns, strengthening smoking cessation services, the Federal Law No.15 of 2009 regarding the tobacco control public health draft law, increasing the number of smoking cessation clinics, and levying excise tax on tobacco products among other initiatives.
Our results also suggested that university students had the highest prevalence of smoking compared to those in secondary levels of education (19.4%). The prevalence rate reported in our study was lower compared with the results from other studies in Arab countries conducted among health-related students, including 17.2% in Jordan (Alomari et al. 2006) 46.7% in Egypt (Khan et al. 2012), 46% in Kuwait (Husain et al. 2016), and 26.3% in Lebanon (Jradi et al. 2013). The results of our current study additionally substantiated a documented decline in the smoking prevalence. These results are commendable, since continuous monitoring is performed to sustain the effectiveness of tobacco-control policies in the country. Thus, smoking prevalence recorded in this study was less than those reported in some other developing countries. A large cross-sectional study conducted in Abu Dhabi reported modes of tobacco consumption and prevalence in the UAE. Overall, smoking prevalence reported in males was 24.3% and 0.8% in females. Highest prevalence was reported in males aged 20-39 years. Smoker's mean age was 32.8 (SD = 11.1) years -35.7 (SD = 12.1) in females, and 32.7 (SD = 11.1) in males. One of the commonest forms of tobacco use was cigarette smoking (77.4%), which was followed by 15.0% midwakh use, 6.8% shisha (water pipe), and 0.66% cigar use (Al-Houqani et al. 2012a, b). In comparison, in our study the most common form of smoked tobacco use was in the form of manufactured cigarettes, followed by shisha, medwakh and E-cigarettes. Furthermore, our results also suggest that the prevalence rate of smoking was affected significantly by family income, which includes the fact that the smoker's percentage among adults from families with no income was higher than those from high-income ones. These results were in conformity with the WHO survey that states that the poorest men were over 2.5 times more likely to smoke than the richest men in several countries (Hosseinpoor et al. 2012). A possible reason also could be that individuals with a lower socioeconomic status had more psychosocial, physical, and emotional problems. It should also be noted that not only wealth but other proxies of household socio-economic statussuch as single-parent families, low levels of education and employmentare also associated with higher prevalence of smoking. The smokingrelated factors identified in this study should be considered in the adoption of anti-smoking programmes, which could make them more operational and better capable of influencing the behaviours and attitudes of smokers.

Strengths and limitations
The major strength of the study was its large sample size having a variety of characteristics. Even though a standardised procedure and questionnaire was used in the study, some limitations in the study cannot be ignored. As the study was a cross-sectional questionnaire-based survey, results were therefore self-reported, which might have introduced some bias or led to under-reporting of the true prevalence of smoking/ tobacco use. The cross-sectional nature of the study did not permit us to establish cause and effects of the studied variables. Sampling of patient aged 18 years and above may have led to the under-reporting of tobacco use prevalence among youth, since tobacco use has been reported to rise among the younger population. However, a larger sample size gave credence to the results of the study. The study will provide useful epidemiological data to help decision makers in developing effective interventions that can be implemented across the country.

Conclusion
In conclusion, the data from the national health survey helped us to determine the prevalence of smoking among adults in the United Arab Emirates. This study is among the first to detail and provide the baseline information about the prevalence of tobacco use in a nationally representative sample from the United Arab Emirates. The socioeconomic factors significantly associated with smoking are age, sex, marital status, educational level, and employment status. Among the studied age groups, smoking was mostly found among middle-aged people (30-44-year-olds), followed by those in the 19-27-yearold age group. As noted earlier, smoking is more prevalent among males. With regard to the level of education, smoking was more common among university degree holders. Although income was not significantly associated with smoking, it was noted that smoking was commonly found among those with no income. On the other hand, smoking was least found among those aged 60 years or more, widowed, those with no education, and those with informal employment among the corresponding categories. Compared to the previous screening in 2010, the prevalence of smoking has been reduced, which can be attributed to the restrictions and laws initiated. More educational and awareness campaigns are required among the categories with a high prevalence of smoking. More restrictions can be applied to cigarette smoking, especially for young persons. Moreover, tobacco control measures implemented by the UAE government had a favourable impact on motivating people to quit tobacco use. Our results also showed that some of the socio-demographic factors are associated with smoking among the UAE adult population. These factors should therefore be taken into consideration while developing evidence-based prevention programs and interventions that target risk groups. However, more awareness about the dangers of tobacco usage should be created. Results of the study may help to inform the tobacco policy agencies about the prevalence and comparison of the use of different tobacco products. Furthermore, strengthening tobacco-control policies and promotion of a comprehensive smoking-free law may help to prohibit smoking in all indoor areas without any exceptions, resulting in decreased smoking prevalence in the near future. The strategies should target people throughout the educational and socioeconomic spectrum, in order to ensure that cessation programs as well as smoking prevention can reach the entire population. The data summarized in the study will help decision-makers to take informed actions in the light of robust data to ensure fruitful results.