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Tobacco Smoking Prevalence, Health Risk, and Cessation in the UAE

Objectives Tobacco smoking is a major public health concern and a leading cause of preventable death. We sought to review epidemiological studies available on the prevalence of tobacco use, the associated health effects, and interventions that have undergone evaluation concerning smoking cessation and prevention in the UAE. Methods An electronic search of the PubMed and Scopus databases was conducted using appropriate keywords for articles published between 2007 and 2017. We included all English-language articles in addition to research articles on the UAE populations (including both citizens and expatriates). Results Fourteen articles were included, of which 11 were cross-sectional studies, one was a cohort longitudinal study, one was quasi-experimental, and one case-control study. Our results suggest that current smoking prevalence estimates vary widely. This is the first study in the region to review the smoking prevalence, health risk, and interventions in the UAE. Conclusions UAE Government demonstrated excellent efforts by raising the cost of smoking through taxation, mounting sustained social marketing campaigns, and ensuring that health professionals routinely advise smokers to stop smoking accompanied by behavioral and pharmacological support for cessation. Hence, future research should be more focused on evaluating the outcome and impact of current anti-smoking campaigns.

addictive, and the cessation of smoking is hard, with recurrent relapses common among people planning to quit smoking. 1 Continuous research on the efficiency of different interventions related to smoking cessation is underway. Cytisine, varenicline, bupropion, and nicotine replacement therapy (NRT) have been demonstrated to progress the possibility of quitting, with varenicline signifying the highest advantage. Nevertheless, such products tend to have considerably low product satisfaction and customer appeal. 4 Evidence indicates that smoking cessation and its psychosocial interventions, for example, self-help interventions, telephone support, and behavioral counseling are operative. These interventions are pooled with pharmacotherapy that mainly enriches the degree of success to give up smoking. 6,7 Controlling the use of tobacco is a foremost public health concern, particularly in developing nations. Healthcare professionals hold an opportunity and the means to help reduce the prevalence of smoking as well as encourage smokers to quit smoking through cessation and prevention intervention. 8 Short-term counseling related to health problems are associated with cigarette and tobacco use while the importance of quitting is one of the most useful behavioral interventions that can be used to help smokers quit. Globally, healthcare professionals lack the training to counsel individuals and do not offer effective treatment and counseling to the people. 9 Healthcare providers in the UAE have reinforced smoking as a major health priority, supported antitobacco policies, modeled good health, and offered clinical interventions to individuals who smoke.
This review aims to offer a comprehensive understanding of the health risk of tobacco smoking and aims to review previous evidence about the prevalence and interventional/counseling practices offered in the UAE.

M ET H O D S
The study used 'systematic review' as a research approach. To locate primary studies relevant to the aims and objectives of the study, we performed a systematic search of the PubMed and Scopus electronic databases covering the period between 2007 and 2017 [Box 1]. Search strings for conducting the electronic searches were made to retrieve targeted evidences by combining the following Medical Subject Headings (MeSH) terms, including 'smoking' , 'tobacco use' , 'health risk' , 'cigarette smoking' , 'prevention' , 'prevalence' , 'interventions' , 'counseling' 'UAE' , 'Dubai' , 'Ras Al Khaimah' , 'Abu Dhabi' , 'Ajman' , 'Al Ain' , 'Sharjah' , 'Fujairah' , and 'Umm Al Quwain' . Furthermore, reference lists of the chosen studies were perused to categorize the relevant citations manually.
For inclusion in the study, publications had to meet the following criteria: primary research articles published in peer-reviewed journals; studies either estimates the prevalence of smoking in the population or determines its possible health risk or interventions; and published in the English language between 2007 and 2017. Figure 1 specifies the search-related process followed in detail. Articles not available in the English language, including a nonrelevant topic, or not conducted in the UAE were excluded from this review. The search was limited to English language articles only because articles mainly in other languages could not be translated feasibly.
Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, retrieved citations were screened, duplicates were eliminated, and the remaining citations were organized. The investigator then examined the abstracts and titles and only relevant articles were recovered. Further, two researchers independently reviewed as well as screened the titles, abstracts, and full texts for inclusion, reaching a strong agreement (Cohen's Kappa = 0.83). This confirmed that only articles pertinent to the aims and objectives of this review were included. The selected articles primarily focused on reviewing the prevalence of tobacco smoking, determining its possible health risk, and interventions precisely involving the UAE population. Overall, 182 records were identified, 117 of which remained after duplicates were removed. The two researchers then independently reviewed as well as screened the articles and 48 were further excluded at this stage. In total, 14 articles were then retrieved as full text, synthesized, and evaluated for cautious reading and evaluation.

R E SU LTS
The results of the literature search yielded 14 published papers that had been conducted in the UAE with regards to smoking intervention, prevalence, or health risk. The study results are discussed below, including epidemiology, counseling practices/interventions, and the health effects of tobacco smoking.

Prevalence of tobacco smoking
Six prevalence studies were conducted in different states of the UAE: two studies were conducted in Dubai, 10,11 three in Abu Dhabi, [12][13][14] and one in Ajman. 15 Of the six studies reporting on the prevalence of tobacco smoking, five were cross sectional, [10][11][12]14,15 and one was a cohort longitudinal study [ Table 1]. 13 More men smoked tobacco in the included studies than women. A cross-sectional descriptive study conducted in Abu Dhabi demonstrated that Arab expatriates (31.9%) had the highest smoking prevalence, followed by other nationals (21.6%) and expatriates (22.6%). More men (19.2%) were cigarette smokers compared to women (3.5%). Arab expatriate women reported a higher prevalence of cigarette smoking (31.4%) than national women (0.7%). 12 A cohort study conducted in Abu Dhabi specified significant factors that were associated with 'substance use' such as marital status and smoking. 13 A large cross-sectional study conducted in Abu Dhabi reported 'modes of tobacco consumption' and its prevalence in the UAE. Overall, smoking prevalence reported in males was 24.3% and 0.8% in females. The highest prevalence was reported in males aged 20-39 years. Smoker's mean age was 32.8±11.1 years; 35.7±12.1 in females and 32.7±11.1 in males. One of the most common forms of tobacco use included cigarette smoking (77.4%) followed by 15.0% midwakh use (a small pipe used for smoking tobacco), 6.8% waterpipe, and 0.66% cigar use. 14 A school-based intervention program conducted among 2457 students aged 10-20 years found that tobacco users made up 14.6% of participants, of which 2.2% used water-pipes and 11.2% smoked cigarettes. The primary reasons leading to smoking included peer influence (21.9%), stress relief (22.5%), and for the experience (29.4%). 10 While, dokha smoking (a tobacco product, including dried and finely shredded tobacco flakes mixed with spices and herbs) prevalence among secondary school students (precisely males) in Ajman was reported to be high (39% ever smokers, 36% ever dokha smokers, and 24% current dokha smokers). 15 Similarly, high school student residents in Dubai reported a prevalence of 23.4%. 11

Interventions/counseling practices
Tobacco addiction is the most important preventable cause of mortality and morbidity. Interventions/ counseling practice studies addressed best practices for effective and brief treatment and counseling for tobacco addiction. Most importantly, smoking cessation interventions are a cost-effective way of reducing ill-health and preserving life. Of the five studies reporting tobacco cessation intervention, all were cross-sectional studies 16,18-20 except one which included a case-control study conducted in Abu Dhabi. 17 The interventional study explored the most readily available and common interventions that take the form of brief interventions/health education on tobacco cessation, 18-20 telephone counseling, group behavior therapy programs, and individual behavioral counseling. 16,17 A cross-sectional survey conducted in Sharjah, Dubai, and Abu Dhabi indicated that the young age population is of specific interest because these are the most effective groups for targeting smoking prevention programs. The study, therefore, assessed the delivery of smoking related preventive counseling in young Arab population (age 9-24 years) and examined counseling behaviors and barriers to counseling. 16 Barriers to counseling involved lack of   Mean increase was observed in heart rates (20 ± 2 bpm); systolic BP (12 ± 1 mmHg), and respiratory rates (4 ± 1 breaths/min). Mean decrease was observed in diastolic BP (1 ± 1 mmHg) The study will help policy makers on the control of tobacco in UAE to take account of this smoking form with the health education campaign based on evidence. Table 1: Characteristics of the included research studies.
-continued patient educational materials, lack of time, and lack of community resources. Another cross-sectional mail survey was undertaken in a random sample of general practitioners (GPs) in Sharjah, Dubai, and Abu Dhabi to document cessation-counseling practices. 19 Despite favorable attitudes and beliefs regarding cessation counseling, only 47% of GPs stated that they hold adequate skills to benefit and support patients to quit smoking.

Health risks of tobacco smoking
Of the three studies reported for health risks of tobacco smoking, two were cross-sectional and one was a quasi-experimental study conducted in different regions of the UAE [ Table 1]. The findings of these studies demonstrated that tobacco smoking causes high blood pressure, 23 influence the epithelial dysplasia status, 22 and is a significant predictor of dry cough and wheeze. 21

D I S C U S S I O N
The studies reviewed earlier reported prevalence of smoking in the UAE. This study adds to the growing body of knowledge in the developing world, showing evidence of the hazards of tobacco use, with a focus on the association of cigarette smoking with hospitalization. Current prevalence rates of smoking in UAE from this study were estimated to range from 23.4%-24.7% in men and 0.8% in women. In Arab regions, the prevalence of smoking varies from as low as 20% in Bahrain and Egypt to high rates in Tunisia (31%) and Kuwait (34.4%). 3,24,25 The prevalence in the UAE is reported to be lower than many other Middle East countries. 26 Cross-sectional surveys found an alarming prevalence of the smoking among young population (mainly UAE nationals) in the UAE. 12 By nationality, UAE nationals had a prevalence of 16% for midwakh use, followed by 4% for Arab expatriates and 3% for other expatriates. Among adults, the point prevalence of active cigarette smoking was < 1% in women and 24% in men, as stated by one of the largest cross-sectional surveys on adult tobacco use in the UAE. 14 The smoking prevalence was consistently higher in men compared to women in other evaluated studies. 12,14 Furthermore, the studies also suggested the use of dokha tobacco being the second most common type of tobacco smoked (after cigarettes) among the male UAE population specifically in Abu Dhabi. 14,15 limited published literature exists regarding midwakh use prevalence in any population with only one previously reported small cross-sectional survey of high school students in Dubai that showed 23.4% of students reported regular use of tobacco. 11 This increase in the rate of tobacco use reported in a similar age group in one of the current US national data 27 is similar to the prevalence in UK. 28 The study also reported similar outcomes of the high acceptance of dokha among young age groups despite the different demographics of the existing sample. 29 Hence, the reviewed studies demonstrate that relatively young population smoke midwakh on top of smoking at an earlier age compared to other tobacco types. Most of the young smokers favor midwakh as it can be used with different pipe styles in addition to flavored tobacco.
Although most GPs in the UAE have favorable attitudes regarding their role in counseling on smoking cessation, the actual practices fall below current recommendations. 30 Consistent with the findings in other countries that showed GPs do not adhere to the counseling recommendations, 31,32 a cross-sectional study reviewed suggests that half of the physicians in the UAE provide smoking assistance or preventive advice to pre-adolescents (9-12 years), 50% GPs provided preventive advice to adolescents (13-19 years), and 65% of GPs provided preventive advice to young adults (20-24 years). 16 Another survey indicated that 47% of GPs had skills to help patients quit smoking, and 24% knew about the community resources to refer their patients to. 19 More than half of the physicians in the study reported community resources, lack of patient educational material, and lack of time as barriers to offering smoking prevention. 16 Positive results were found for warning individuals regarding the dangers of tobacco through mass media campaigns. 17 Furthermore, additional efforts have to reach the younger age group, which is the most vulnerable to addiction. [33][34][35] No research was identified highlighting the monitoring of tobacco use and prevention policies; thus, suggesting a need for research syntheses on its effectiveness. Self-help materials are considerably recommended to upsurge the motivation of the patients to quit smoking and teach them smoking cessation skills. 18 Smoking and potential harms that might result from it were also reviewed. A small pre-post study with no control was led to examine the acute effects of dokha smoking. Ninety-seven volunteers, male university students (Arabs, Emiratis, and other nationalities) were consecutively sampled. The findings were comparable to those found with other smoking forms with a mean increase in the respiratory rate (4±1 breaths/min), heart rate (20±2 bpm), and systolic blood pressures (12±1 mmHg). 23 Another study provided the well-known evidence linking tobacco smoking to the development of oral epithelial dysplasia. 22 A cross-sectional survey conducted in nine regions of UAE also reported the impact of different risk factors on respiratory health. 21 This is consistent with other international studies, where chronic bronchitis was associated with passive smoking, cigarette smoking, air pollution, and exposure to dust or gas. 36,37 Regardless of the triumphs and endeavors in the tobacco control by the UAE, there remain many obstacles to achieve the goal. Such barriers may include pressure imposed by the tobacco companies and a dearth of defiance to campaigning as well as partially executing the tobacco controlling endeavors plus limited supervision concerning tobacco-related legislation. 38 Keeping in mind the current regulatory frameworks 39 and advancements in controlling the tobacco use by implemented taxes, it is evident that supplementary efforts can explicitly work towards the management of the current, well-organized strategies. This may include raising the minimum age to purchase tobacco to 21. Additionally, telephone-based services can help to design a stop smoking program that meets an individual need. Setting up support networks for quitting helps to decide which smoking aids should be used for cessation. Choices may include support programs, NRT, and medicines.

C O N C LU S I O N
Current smoking prevalence from the studies reviewed varied widely. Even though the tobacco smoking prevalence in the UAE is less than many other Middle Eastern countries, it is a prevalent habit among young individuals and can inevitably lead to the rise in smoking-associated comorbidities. Concerted efforts and excellent accomplishment at the country level in the areas of funding, prevention and control, health education programs, and surveillance have been made to curb this increasing problem. The general population are also provided with education about the harmful effects of smoking.
The previous evidence also suggest that mass media campaigns can have a significant impact on reducing the smoking initiation in the young population and adults. Increasing the price of tobacco in UAE is also well supported by the literature. Future research should be focused on evaluating the outcome and impact of current anti-smoking campaigns initiated in the UAE and to assess its integration in the comprehensive tobacco control program.