Edited by: Milena Santric Milicevic, University of Belgrade, Serbia
Reviewed by: Ismaeel Yunusa, University of South Carolina, United States; Enver Envi Roshi, University of Medicine, Tirana, Albania
This article was submitted to Health Economics, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
To determine whether the increased tobacco price due to tax implementation on tobacco products (including cigarettes) has a significant effect on smoking cessation among Saudi Arabian adult smokers.
An interviewer-administered questionnaire was used to obtain data from adult Saudi smokers and recent quitters attending smoking cessation clinics between January 2018 and September 2019. The responses of the participants were summarized and analyzed.
In total, 660 participants were interviewed, of which 98% were men who resided in the western region (33%). Taxation had no effect on smoking in 387 participants [58.6%; 95% confidence interval (CI): 54.9, 62.4], some effect in 220 participants (33.3%; 95% CI: 29.7, 36.9), and a substantial effect in 50 participants (7.6%; 95% CI: 5.6, 9.6). Strategies adopted to cope with the tax implementation included cutting down on the number of cigarettes smoked (302; 45.8%), changing to a cheaper brand of cigarette (151; 22.9%), purchasing in bulk (105; 15.9%), attempting to quit (453; 68.6%), and doing nothing (108; 16.4%). The rate of quitting smoking after attending the clinic was 20.7% (95% CI: 17.7, 23.9). Occupation (
Tobacco taxation influenced 40% of the participants. Their attempts to opt for alternatives should be recognized in evaluating policies to reduce adverse health impacts caused by tobacco abuse.
Tobacco use is the leading cause of 6 million annual deaths worldwide; however, the global tobacco epidemic has reached significant levels, with ~1.3 billion tobacco users (
According to Article 6 of the WHO FCTC, price and tax measures effectively reduce tobacco use. Countries are responsible for setting, implementing, and maintaining tax policies (
Similarly, a study was conducted assessing the impact of a simulated 10% tax-induced cigarette price increase across 36 European countries. It demonstrated an overall 3.1% drop in the total cigarette consumption (
The Eastern Mediterranean Region of the WHO consists of 22 countries, which vary in their levels of income. Tobacco consumption is expected to grow by 25% in 2025, despite a reduction in Asia, North America, and Europe (
Based on the foregoing statistics, cigarette smoking and tobacco use are rather rampant in Saudi Arabia. Since 2005, when smoking and/or tobacco consumption statistics were made available through empirical research, there has been a steady increase in the number of people smoking cigarettes or using tobacco. Consequently, the Saudi Ministry of Health established a tobacco control program in 2002. The Tobacco Control Program is a government-sponsored program that develops regulations, policies, and procedures for tobacco control. It provides multiple services, including raising awareness through multiple channels, establishing clinics for smoking cessation around the Kingdom as a part of the national health care system wherein the government provides free health care services and most importantly, gathering data on the smoking status in Saudi Arabia (
This study was approved by the Saudi ministry of health Institutional Research and Ethical Committee. Data were gathered by the Tobacco Control Program of the Ministry of Health, Saudi Arabia. Details of the study explained to all participants, personal information was not required or used in the study. The consent form was read and verbally explained to all participants in order to ensure that each one of them took part in the study based on their informed consent and not out of coercion or compulsion. Participants were ensured that participation in the study (and especially in the questionnaire surveys) was voluntary and involvement in the survey implied the participants' consent to the study. All participants were that their participation and roles in the study would be anonymous and confidential.
All tenets of the Declaration of Helsinki were strictly adhered to throughout the research. Saudi Arabian government has implemented a 100% tobacco taxation (including cigarettes) policy in the second quarter of 2017 (
A total of 110,925 adult smokers attended 20 smoking cessation clinics under the tobacco control program during the study period (
The attendees of 20 clinics provided from the Tobacco control program were listed into a Microsoft Excel spreadsheet, and stratified random sampling method was used to select the required sample in each zone proportionally.
A physician conducted telephonic interviews in Arabic with adult smokers and recent quitters for participants recruited to the telephone survey using simple random sampling through the Excel spreadsheet provided by from the Tobacco control program.
A pilot study was performed to test the survey tool which was altered before the main survey to improve its effectiveness.
Demographic information of the participants included age, sex, education, occupation, and income as well as their clinic location. Participants were grouped as follows based on their reported age: 18–29 years, 30–54 years, and 55 years or older. Monthly income was converted from riyals to US dollars considering 1,000 US $ = 3,750 SR. Regarding education, the participants were grouped as, “school graduates, college graduates, and graduates with degree higher than a college degree.” Occupation was grouped as unemployed, retired, and public and private sector jobs. The questionnaire included aspects on current smoking status, the purpose of attending the smoking cessation clinic.
Participants were asked current smoking status, the purpose of attending the smoking cessation clinic. Participants were asked what effect, if any, the increasing price of cigarettes had on them when: (a) cut down of consumption; (b) changed to lower price brand; (c) bought in bulk; (d) tried quitting; or (e) no change. Multiple responses were allowed. Participants were asked how much the increasing price of cigarettes affected them to quit (a) no effect; (b) some effect; or (c) great effect.
Data were collected on a pretested data collection form and transferred to the Statistical Package for Social Sciences spreadsheet (SPSS 25, IBM, NY, USA). Qualitative variables are presented as numbers and percentages. Quantitative variables are presented as the mean and standard deviation. To compare outcomes of the subgroups' variables, we estimated the chi-square values, degrees of freedom, and two-sided
We enrolled 660 participants in the survey. The number and proportion of participants in the five regions of Saudi Arabia and those attending smoking cessation clinics are shown in
Proportion of population and survey participants in the five zones of Saudi Arabia.
Central | 23,438 | 22.1 | 139 | 21.2 |
Eastern | 11,734 | 11.0 | 98 | 14.8 |
Northern | 15,718 | 14.8 | 94 | 14.2 |
Western | 36,345 | 34.2 | 215 | 32.6 |
Southern | 19,018 | 17.9 | 113 | 17.1 |
Total | 1,06,253 | 100 | 660 | 100 |
The profiles of the participants are listed in
Profile of Saudi adults attending the smoking cessation clinic who participated in the survey.
Gender | Male | 646 | 98 |
Female | 13 | 2 | |
Education | Uneducated | 3 | 0.3 |
School graduate | 313 | 47.4 | |
College graduate | 324 | 49.1 | |
Higher education | 20 | 3 | |
Occupation | Unemployed | 80 | 12.1 |
Retired | 52 | 7.9 | |
Govt employee | 328 | 49.7 | |
Non-govt employee | 200 | 30.3 | |
Residents of Saudi Arabia | Central | 139 | 21.1 |
Eastern | 98 | 14.8 | |
Northern | 94 | 14.2 | |
Western | 216 | 32.7 | |
Southern | 113 | 17.1 | |
Monthly income (US $) | <1,334 | 215 | 32.6 |
1,334–2,667 | 287 | 43.5 | |
2,668–4,000 | 145 | 22 | |
≥ 4,001 | 13 | 2 |
Altogether, 220 adult smokers (33.3%) believed that the increased tobacco prices due to taxation partially affected their smoking habits (95% CI: 29.7, 36.9). However, only 50 smokers (7.6%) believed that taxation-based price increase had a significant effect on their smoking habits (95% CI: 5.6, 9.6).
The participants' responses to current smoking habits suggested that after attending the smoking cessation clinic, 137 (20.7%; 95% CI: 17.7, 23.9) quit smoking, while 523 (79.2%; 95% CI: 77.1, 83.2) continued smoking.
The association between the increased price of tobacco due to taxation and altered smoking habits by determinants is presented in
Factors associated with the response to taxation in smoking cession motivation based on a univariate analysis.
Sex | Male | 377 | 97.4 | 218 | 99.1 | 50 | 100 | |
Female | 9 | 2.3 | 2 | 0.9 | 0 | 0 | ||
Monthly income (US $) | Less than 1,334 | 125 | 32.3 | 68 | 30.9 | 16 | 32 | |
1,334 to 2,667 | 161 | 41.6 | 103 | 46.8 | 23 | 46 | ||
2668 to 4,000 | 91 | 23.5 | 45 | 20.5 | 9 | 18 | ||
4,001 and more | 8 | 2.1 | 3 | 1.4 | 2 | 4 | ||
Occupation | Unemployed | 52 | 13.4 | 20 | 9.1 | 5 | 10 | χ2 = 19.2 |
Retired | 30 | 7.8 | 16 | 7.3 | 6 | 12 | Df = 11 | |
Government employee | 195 | 50.4 | 108 | 49.1 | 24 | 48 | ||
Non-government employee | 109 | 28.2 | 75 | 34.1 | 15 | 30 | ||
Education | Uneducated | 1 | 0.3 | 0 | 0 | 1 | 2 | χ2 = 13.2 |
School graduate | 193 | 49.9 | 91 | 41.4 | 29 | 58 | Df = 11 | |
College graduate | 178 | 46 | 124 | 56.4 | 20 | 40 | ||
Higher education | 14 | 3.6 | 5 | 2.3 | 1 | 2 | ||
Age | 35.2 | 35.6 | 37.5 | |||||
9.2 | 9.4 | 10.5 | ||||||
Purpose to attend clinic | To quit | 368 | 95.1 | 211 | 95.9 | 45 | 90 | |
To reduce smoking | 19 | 4.9 | 7 | 3.2 | 5 | 10 | ||
Current smoking status | Quit | 70 | 18.1 | 52 | 23.6 | 13 | 26 | |
Smoking | 317 | 81.9 | 168 | 76.4 | 37 | 74 | ||
Zone of Saudi Arabia | Central | 92 | 23.8 | 41 | 18.6 | 6 | 12 | |
East | 49 | 12.7 | 35 | 15.9 | 13 | 26 | ||
North | 61 | 15.8 | 26 | 11.8 | 7 | 14 | ||
West | 131 | 33.9 | 69 | 31.4 | 15 | 30 | ||
South | 54 | 14 | 49 | 22.3 | 9 | 18 |
The change in smoking approach adopted to address the increased price of tobacco products due to taxation were as follows: 453 (68.6%) attempted to quit, 302 (45.8%) tried cutting down on the number of cigarettes smoked, 151 (23%) opted for a cheaper brand of tobacco products, 105 (16%) opted to buy in bulk, and 108 (16.4%) did not change their smoking habits. The majority of participants tried a combination of these strategies (
Change in smoking approach adopted in response to increased taxation on tobacco products by determinants.
Sex | Male | 299 | 46.5 | 151 | 23.5 | 105 | 16.3 | 446 | 69.4 | 104 | 16.2 | χ2 = 4, df = 4, |
Female | 3 | 25.0 | 0 | 0.0 | 0 | 0.0 | 7 | 58.3 | 4 | 33.3 | ||
Age group | 18–29 | 98 | 46.2 | 55 | 25.9 | 31 | 14.6 | 137 | 64.6 | 44 | 20.8 | χ2 = 12, df = 8, |
30–54 | 193 | 45.5 | 91 | 21.5 | 74 | 17.5 | 298 | 70.3 | 66 | 15.6 | ||
55 < | 11 | 52.4 | 6 | 28.6 | 0 | 0.0 | 20 | 95.2 | 1 | 4.8 | ||
Education | School | 140 | 44.4 | 77 | 24.4 | 45 | 14.3 | 213 | 67.6 | 57 | 18.1 | χ2= 6, df = 8, |
College | 154 | 47.5 | 69 | 21.3 | 56 | 17.3 | 228 | 70.4 | 49 | 15.1 | ||
Higher education | 5 | 25.0 | 5 | 25.0 | 4 | 20.0 | 14 | 70.0 | 5 | 25.0 | ||
Monthly income (US $) | > 1,334 | 87 | 41.0 | 58 | 27.4 | 30 | 14.2 | 135 | 63.7 | 48 | 22.6 | χ2 = 17, df = 12, |
1,334–2,667 | 136 | 47.4 | 63 | 22.0 | 45 | 15.7 | 207 | 72.1 | 39 | 13.6 | ||
2,668–4,000 | 74 | 51.0 | 29 | 20.0 | 25 | 17.2 | 105 | 72.4 | 22 | 15.2 | ||
4,001 ≤ | 6 | 46.2 | 2 | 15.4 | 5 | 38.5 | 8 | 61.5 | 2 | 15.4 | ||
Occupation | Unemployed | 21 | 26.9 | 19 | 24.4 | 11 | 14.1 | 34 | 43.6 | 30 | 38.5 | χ2 = 30, df = 12, |
Retired | 26 | 50.0 | 12 | 23.1 | 5 | 9.6 | 39 | 75.0 | 6 | 11.5 | ||
Government employee | 150 | 45.7 | 72 | 22.0 | 58 | 17.7 | 231 | 70.4 | 50 | 15.2 | ||
Non-government employee | 105 | 52.5 | 49 | 24.5 | 30 | 15.0 | 151 | 75.5 | 26 | 13.0 |
Impact of taxation on smoking cessation attempts of adult smokers in published studies and the present study.
Boyle et al. ( |
USA | 1,382 | 15.6% quit | E-cigarette use |
60% attempted quitting | ||||
Schafferer et al. ( |
36 European countries | – | 3.1% quitting rate | Licit consumption rate decline by 18.4% |
Dunlop et al. ( |
Australia | 997 | 47.5% smoking changes | 11.4% product-related changes |
Han ( |
Korea | 45,686 | 3.8% quit | 22.8% reduced smoking |
5.4% switched to e cigarette | ||||
Park et al. ( |
USA | – | 8% quit | 40% altered smoking habit |
AlGhamdi et al. ( |
Saudi Arabia | 376 | No change 39.6% | 29.8% changed to cheaper brand |
AlQarni ( |
Saudi Arabia | 334 | 10% reduced consumption | 20% switched to cheaper brand |
60% no change | ||||
Present study | Saudi Arabia | 660 | 20% quit | 68.6% attempted quitting |
45.8% reduced quantity | ||||
23% switched to cheaper brand |
In total, 40% of the participants believed that the increased price of tobacco had either substantial or some influence on their decision to visit the Saudi Ministry of Health's smoking cessation clinic, and more than half believed that the increased price of tobacco products had no influence on their decision to join the program or quit smoking. Similarly, one-third of the participants admitted that the increased price of tobacco products had a temporary effect, and only one in 12 participants believed it had a significant positive effect.
The participants of the present study were adult Saudi smokers willing to address their issues with tobacco consumption by attending smoking cessation clinics organized by the Ministry of Health. Our study participants understood their substance abuse issues and sought for help. Increasing taxation on tobacco products had a positive impact on only one-fifth of the participants. However, the willingness of all participants to reduce tobacco consumption could be a positive step in reaching the goal of quitting smoking in the future and can be explained by the increased prices of tobacco products or the attendance of smoking cessation clinics. Policymakers should therefore, focus on this population and support them by offering alternative smoking cessation strategies in addition to increasing the prices of tobacco products.
The smoking cessation rate in the present study compared with that of other studies shows that the increased prices due to taxation, which makes tobacco products expensive to the consumer, helped 20% of the adult smoking population to quit smoking, attempt to quit smoking, or reduce the smoking frequency (
In our study, high education had a positive impact on both quitting/reducing smoking and adopting alternative strategies. The higher awareness of the negative effects of smoking among educated Saudi Arabians, as observed among the Polish, could explain their greater willingness and attempts to quit smoking compared to the uneducated people (
Government employees had significantly higher rates of maintaining their smoking habits and adopting alternative strategies. This could be due to better income and secured financial status; thus, the increased price of tobacco products had less effect on their smoking habits. This could also be explained by the positive impact of acculturation, which is more evident among those working in the private sector and outdoor sales jobs (
In our study, the female-to-male ratio was 1:50, which is well above the 1:38 ratio reported among Egyptian smokers (
The findings of this study will effectively fill gaps in knowledge on the effectiveness of tobacco taxation in minimizing tobacco use. Targeting the entire population makes the findings easier to generalize. Therefore, this study has some limitations. First, the participants were recruited from smoking cessation clinics, which could have biased the findings because they were in favor of quitting/reducing smoking, and the findings of the present study may not be applicable to adult smokers who have not yet visited such clinics. Thus, a highly trained and skilled team is needed to survey a large population to obtain a representative result. However, to the best of our knowledge, adult Saudi smokers willing to quit and attend smoking cessation clinics have not yet been surveyed. Second, shisha is prevalent among young Saudi smokers (33% compared with 13% who smoke cigarettes) (
The findings of our study showed the effect of the tobacco taxation policy during its first 3 years (approximately) of implementation among Saudi adult smokers attending smoking cessation clinics. However, a significant percentage of people did not reduce their smoking frequency or quit smoking. If the results could be generalized to the larger Saudi population, this would indicate that implementing a tobacco tax is one of the most critical effective measures in reducing smoking. Other strategies or policies should be considered to encourage smoking cessation. Considering the taxation policy, it is evident that it has been implemented as envisaged and has produced some intended outcomes in a short period based on the findings from the present study and previous literature (
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
The studies involving human participants were reviewed and approved by Ministry of Health IRB. The patients/participants were ensured that participation in the study (and especially in the questionnaire surveys) was voluntary and involvement in the survey implied the participants' consent to the study. All participants were that their participation and roles in the study would be anonymous and confidential.
NA: planning, data collection, field part, data management, and manuscript writing. RB: study design and revising manuscript. AA: data acquisition and result discussion. MA: logistical support, data acquisition, result discussion, and revising manuscript. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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