Smoking Prevalence, Susceptibility to Cigarette Smoking, and Its Causes in 568 Adolescent Male High School Students in Southern Saudi Arabia: A Cross-Sectional Study

Introduction

Smoking is a widely prevalent form of tobacco consumption and is recognized globally as a leading cause of preventable morbidity and mortality [1]. Tobacco use remains one of the most significant public health challenges globally [2]. According to the World Health Organization (WHO), tobacco use is responsible for more than 6 million deaths each year, with projections suggesting that this number could rise to 8 million annually by 2030 if current trends persist [2,3]. In most countries, smoking is the most common form of tobacco consumption. The prevalence of smoking remains particularly high in low- and middle-income countries, with a large proportion of initiation occurring during adolescence and early adulthood [3]. Many smokers start smoking before the age of 18 [4]. The importance of smoking cessation is evident during adolescence, as early introduction of tobacco consumption increases the likelihood of persistent smoking in adulthood [5]. Furthermore, tobacco consumption during adolescence often leads to other substance dependencies also, this adolescent smoking highlights the critical public health issue [5]. These alarming statistics emphasize the urgency of tobacco control efforts, particularly among vulnerable populations such as adolescents.

The increase in e-cigarette vaping has driven additional concerns, as vaping increased the likelihood of transforming to traditional tobacco use, including cigarettes [6]. In Saudi Arabia, high rates of adolescent smoking due to availability, no age restrictions to buy tobacco products, rapid westernization, and changing social patterns [7]. Most adolescents spend many hours a day with peers outside of the home, leading to increased smoking [7]. Early initiation of smoking is a significant predictor of persistent smoking into adulthood, with young smokers often developing deep-rooted habits that are difficult to break [7]. The risk of exposure to second-hand smoke increases, as adolescents who are frequently exposed are more likely to assume smoking themselves, with significant implications for long-term health [8].

Adolescents are at a critical stage of development, during which they are highly susceptible to initiating risky behaviors, including smoking. In Saudi Arabia, a national survey indicated that nearly 1 in 5 male adolescents is either a smoker or at risk of becoming one, which underscores the urgent need for targeted preventive strategies. The prevalence of smoking is 12–30%, with significant regional and gender disparities. Adolescent smoking rates are influenced by the widespread availability of tobacco, weak enforcement of age restrictions, cultural shifts, and peer influences [9,10]. According to a study conducted in the Jeddah (37.1%) [11] and Riyadh regions, 31.2% of high-school-age males were current smokers [12]. Curiosity and susceptibility to smoking (SS) are the 2 cognitive behaviors that were determined as attributes for smoking initiation. Despite national campaigns and policy reforms, recent studies have shown that many Saudi adolescents continue to experiment with smoking, with male high school students particularly at risk. SS refers to the absence of a firm intention to quit smoking, and research has consistently demonstrated that this attitude, along with curiosity, is a strong predictor of smoking initiation among adolescents [13], The Extended Susceptibility to Smoking Index (ESSI) includes these 2 factors, providing a valuable tool for distinguishing youths at a higher risk of smoking onset [14].

This study used the Expanded Susceptibility to Smoking Index (ESSI), which builds upon earlier models by incorporating curiosity and intention-based factors to more comprehensively identify at-risk individuals. To assess predictors of smoking susceptibility and behavior, we used 3 validated psychometric tools. The Expanded Susceptibility to Smoke Index (ESSI) is an adaptation of Pierce’s original susceptibility index and captures a broader spectrum of psychological readiness to smoke, including cognitive and social aspects of smoking intentions [15]. Additionally, impulsivity has been identified as a psychological factor that can influence the likelihood of smoking initiation. The short version of the UPPS-P Impulsive Behavior Scale assesses 5 dimensions – impulsivity, negative urgency, lack of premeditation, lack of perseverance, and sensation seeking – each of which are related to risky behaviors such as smoking [16]. Impulsivity has emerged as a significant factor for smoking. The UPPS-P Impulsive Behavior Scale is widely used to measure impulsivity. The UPPS-P Impulsive Behavior Scale shorter version evaluates 5 distinct aspects of impulsive behavior: lack of perseverance, lack of premeditation, urgency, positive urgency, and sensation seeking [17,18]. These 5 impulsive behaviors have been linked to risky behaviors such as smoking. The SUPPS-P shorter version scale was developed to provide a more efficient assessment tool without compromising reliability and validity [19]. Emotional states also play a crucial role in adolescent behavior. The Positive and Negative Affect Schedule (PANAS) is a validated instrument used to measure individuals’ tendency toward positive or negative emotions, both of which have been linked to health-related behaviors. It evaluates individual differences in affect, providing insight into the emotional context that can influence smoking-related behaviors and decisions [20].

Mood and affect have also been observed to influence smoking behavior. The Positive and Negative Affect Schedule (PANAS), a reliable self-report measure, captures positive and negative emotions, both of which have been linked to smoking [21]. Similar studies have examined susceptibility to smoking in diverse global settings. For instance, Santano-Mogena et al [14] explored smoking predictors among high school students in western Spain and found strong associations with emotional and behavioral factors. Peng et al [22] identified key determinants of smoking susceptibility among Chinese medical students, and Jallow et al [23] reported on behavioral and sociodemographic predictors among adolescents in Gambia. These studies support the inclusion of psychological and affective assessments in tobacco control research, particularly in high-risk youth populations.

Therefore, this study aimed to evaluate the prevalence of cigarette smoking in 568 adolescent male high school students in southern Saudi Arabia and to assess their susceptibility to smoking using the ESSI, the short version of the UPPS-P Impulsive Behavior Scale, and the PANAS.

Material and Methods

STUDY DESIGN:

Ethics approval for this cross-sectional study to determine the prevalence of cigarette smoking and susceptibility among adolescent male students was obtained from the Research Board of the College of Dentistry, King Khalid University (Approval No. IRB/KKUCOD/ETH/2021-22/016). Permission was also secured from the administrations of the participating schools. Informed consent was obtained from the parents or legal guardians of all participating students, and consent was obtained from the students themselves through information letters that clearly outlined the study objectives, procedures, and confidentiality measures.

STUDY POPULATION, AND SETTINGS:

This study was focused on high school adolescents aged 16–18 years in the southern Saudi Arabian cities of Abha and Khamis Musait.

SAMPLING:

Purposive sampling was used to select the 4 schools in Abha and Khamis cities, and the students were selected by simple random sampling without a replacement method. Within each selected school, we enrolled high school students aged 16–18 years in Abha or Khamis Musait, with written informed consent from their parents or legal guardians, and who agreed to participate. Students with known ill health or cognitive impairments that would have made it difficult for them to interpret the questionnaire or take part in the research were excluded.

SAMPLE:

From the local authorities, we obtained a list of all high schools in the Abha-Khamis Musait region. Based on the published tobacco susceptibility prevalence of 25% [24,25], the minimum sample size was estimated as 469 at a 95% confidence interval and 5% margin of error, to which we added 10% (46 participants) non-response errors and incomplete submissions, yielding a minimum required sample size of 514. Finally, a total of 568 students were enrolled in the study based on the eligibility criteria.

DATA COLLECTION:

Data were collected through a structured, self-administered questionnaire distributed in person during school hours under the supervision of trained research assistants. The questionnaire consisted of 4 main sections: (1) demographic information (eg, age, grade level, parental smoking status), (2) smoking behavior and history, (3) psychological evaluation using the Expanded Susceptibility to Smoking Index (ESSI), the short version of the UPPS-P Impulsive Behavior Scale, and the Positive and Negative Affect Schedule (PANAS), and (4) environmental and social factors associated with smoking.

STUDY TOOL:

The ESSI assessed students’ openness to smoking through a series of validated questions targeting curiosity, intention, and peer influence. The UPPS-P scale measured 5 dimensions of impulsivity, while PANAS assessed positive and negative emotional states. Responses were scored according to standardized scoring protocols for each tool.

The questionnaire was first prepared in English, then translated into Arabic by language experts, and back-translated by an independent expert to ensure accuracy. To evaluate the questionnaire’s clarity and comprehensibility, a pilot study was done with 20 participants. The input received from this pilot study was applied to make necessary changes, resulting in a final version with excellent internal consistency (Cronbach’s alpha=0.089).

To evaluate the susceptibility to tobacco use, the following questions were asked, using the 3-item response to Smoke Index [15]:

Responses were recorded on a Likert scale (4 points) of 1 (“definitely not”) to 4 (“definitely yes”). Participants were classified as “not susceptible” if they answered “definitely not” to all 3 questions. If they responded “definitely yes”, they were classified as “highly susceptible”. If they replied to at least 1 question with “probably yes”, they were classified as “susceptible” (Cronbach’s alpha=0.89). Curiosity about consuming tobacco was evaluated using the question “Have you ever been curious about smoking cigarettes?” Responses used were recorded on a Likert scale, with participants classed as “not curious”, “curious”, or “highly curious”.

The Expanded Susceptibility to Smoking Index (ESSI) was used to evaluate participants’ openness to future smoking. This index includes multiple items that assess curiosity, intention, and perceived social acceptability of smoking. Responses were collected on a Likert-type scale and were summed to yield a composite susceptibility score. Each variable (smoking susceptibility and curiosity) was rated: a score of 0 was classified as not susceptible/not curious and a score of 2 was classified as very susceptible/extremely interested. The total possible ESSI score was 0–4. The participants were categorized based on the ESSI scores: 0 means not susceptible, 1–2 means susceptible, and 3–4 means highly susceptible.

The short UPPS-P Impulsive Behavior Scale measured 5 facets of impulsivity: negative urgency, lack of perseverance, lack of premeditation, sensation seeking, and positive urgency. This 20-item self-report scale is widely used for its reliability and efficiency in behavioral research [13]. The UPPS-P Impulsive Behavior Scale contains 20 items assessed on a 5-point Likert scale and focuses on 4 aspects of impulsivity: sensation seeking, urgency, lack of perseverance, and lack of premeditation. The UPPS-P Impulsivity Scale assesses various aspects of impulsivity – Negative Urgency, Positive Urgency, Lack of Perseverance, Lack of Premeditation, and Sensation Seeking – with a total impulsivity score derived from the sum of these components.

The Positive and Negative Affect Schedule (PANAS) was included to assess participants’ current emotional state. The scale includes 10 items for positive affect and 10 for negative affect, rated on a 5-point Likert scale. Scores for positive and negative affect were calculated separately and considered as potential moderators of susceptibility to smoking. The PANAS in adolescents shows acceptable internal consistency (Cronbach’s alpha=0.74) [16].

STATISTICAL ANALYSIS:

The data analysis was conducted using SPSS software version 22.0. All data were anonymized and coded for analysis. Descriptive statistics and inferential analysis using chi-square tests and logistic regression were performed to evaluate associations between smoking behavior and psychological and environmental variables. At 95% confidence interval, P values <0.05 are considered statistically significant.

Results

ENVIRONMENTAL FACTORS:

Smokers and non-smokers had significant differences in smoking environments over the past 30 days. The proportion of smokers who reported that a household/family member smoked was significantly greater than among non-smoking participants (p<0.001). Further, the probability of exposure to passive smoke was significantly higher among participants who shared a household with a smoker (p<0.001). Additionally, compared to non-smokers, smokers were more likely to believe that smoking was common among their friends (p<0.001). The smoking behaviors of participants’ 5 closest friends also differed significantly between smokers and non-smokers (p<0.001) (Table 2).

SUSCEPTIBILITY TO SMOKING:

The ESSI scores among non-smokers categorized as “not susceptible” 192 (41.9%), “susceptible” 160 (34.9%), and “highly susceptible” 106 (23.2%) the differences were not statistically significant when compared to sociodemographic groups. Although many non-smokers had both parents who were at least university educated, despite higher percentages in the “highly susceptible” group, the differences were not statistically significant (Table 3).

Despite the ESSI categories, no significant associations were found regarding household smoking, second-hand smoke exposure, perception of peer smoking, or the smoking habits of the 5 best friends, but the perception of household smoking was significantly linked with ESSI scores (p<0.020) (Table 4).

PSYCHOLOGICAL TRAITS AND SMOKING BEHAVIOR:

All the 568 (100%) smokers and non-smokers were assessed for emotional and impulsivity. Non-smokers displayed a significantly higher average in Negative Urgency (10.5) than smokers (9.3), indicating an observable inclination among non-smokers toward impulsive actions in response to negative emotions (p<0.002). However, for Lack of Perseverance and Lack of Premeditation, scores were almost the same between smokers and non-smokers, exhibiting no statistically significant differences (p>0.976 and p>0.732, respectively). A higher score was attained by Non-smokers in Sensation Seeking (8.7) as compared to smokers (7.7), a significant difference with a p-value of <0.0003, showing that non-smokers have a higher tendency to engage in new and exciting experiences. The scores for Positive Urgency of non-smokers were higher (11.5) than for smokers (10.5), which suggests higher rates of impulsive behavior in response to positive emotions (p<0.0048) among non-smokers. The total SUPPS-P Impulsivity Score was lower in smokers (50.2) than in non-smokers (53.3), and the difference was highly significant (p<0.0001), suggesting overall greater impulsivity among non-smokers.

The PANAS scale provides both positive and negative impact (emotional states), with subscales for Positive Affect (PA) and Negative Affect (NA), as well as a total PANAS score. Smokers and non-smokers scored comparably in Positive effect (25.9) for smokers and (26.3) for non-smokers, exhibiting no significant difference (p>0.749. For the negative effect, smokers had a slightly higher mean score (27.9) than non-smokers (27.4), but this difference was not significant (p>0.129). The PANAS score, which combines both positive and negative effects, also displayed no significant difference between smokers (53.8) and non-smokers (53.7), (p>0.417).

ASSOCIATIONS BETWEEN PREDICTORS AND SMOKING SUSCEPTIBILITY:

We compared smokers and non-smokers based on scores from the SUPPS-P Impulsive Behavior Scale and the PANAS. Smokers exhibited significantly lower scores in Negative Urgency, Sensation Seeking, Positive Urgency, and Total Impulsivity compared to non-smokers, with all differences reaching statistical significance (p<0.05). However, there were no significant differences between the 2 groups in terms of Lack of Perseverance, Lack of Premeditation, or PANAS scores (Positive Affect, Negative Affect, and Total PANAS). These findings suggest that certain dimensions of impulsivity are notably associated with smoking behavior among adolescents, while emotional affect, as measured by PANAS, did not differ significantly (Table 5). When comparing the ESSI groups with scores from the SUPPS-P Impulsivity Scale and the PANAS, a significant difference was found only in the Negative Urgency component of the SUPPS-P across the ESSI categories (p=0.0230). No significant differences were identified in the overall mean SUPPS-P scores among the ESSI groups. Likewise, no significant differences were found in the total PANAS scores or any of its components across the ESSI groups (p>0.05) (Table 6).

Multivariate logistic regression analysis uncovered numerous independent variables linked to ESSI as the dependent variable. Age (adjusted OR=0.395, p<0.018), and PANAS Negative Affect (adjusted Odds Ratio [aOR=0.783], p<0.001) were significant. The correlation with ESSI and other demographic and environmental variables such as the father’s education (aOR=1.525, p>0.410), mother’s education (aOR=0.953, p>0.901), exposure to passive smoke (aOR=2.535, p>0.062), household/family member smoking (aOR=2.241, p>0.115), perception of household smoking (aOR=0.666, p>0.572), peer smoking (aOR=3.377, p>0.986), and SUPPS-P scores (aOR=0.956, p>0.286) were not significantly associated.

Discussion

This study investigated the prevalence of and susceptibility to cigarette smoking among adolescent male high school students in southern Saudi Arabia. The findings revealed a high prevalence of current smokers, with psychological factors such as impulsivity (measured by the UPPS-P), emotional affect (measured by PANAS), and susceptibility (measured by ESSI) significantly associated with smoking behavior. Higher scores in impulsivity and negative affect were particularly linked with greater susceptibility to smoking. The tobacco industry promotes smoking through mass media advertising and various promotional strategies to increase the likelihood of smoking, particularly in adolescents. The main objective of tobacco companies’ marketing is to increase sales by attracting new consumers while retaining the existing ones by increasing the total number of smokers. Tobacco company advertisements focus on increasing curiosity and not highlighting the risks associated with smoking, particularly when individuals perceive the costs of experimenting with the product as low [27]. The influence we found of sociodemographic, intrapersonal, and social factors on adolescent smoking aligns with findings from previous studies [14,27,28].

Of the 568 students we surveyed, 19.4% were current smokers of cigarettes and hookahs and e-cigarette vaping. Our results agree with studies from Western countries, where e-cigarettes are the most popular product in school-age populations, followed by pipes, cigars, and smokeless tobacco [29]. In the USA, 31.2% and 12.5% of high school and middle school students, respectively, use tobacco products, including e-cigarettes, hookahs, and cigarettes [29]. A study conducted in Africa found that 10% of students from 68 schools were current tobacco users [30]. In Saudi Arabia, smoking prevalence among secondary school students ranges has been reported to range from 9.72% to 37.0%, in agreement with our finding of 36%, in line with previous national data [7,11].

Similar to Santano-Mogena et al, we found many non-smokers were “susceptible” or “highly susceptible” to smoking [14]. Other research has shown that curiosity about smoking, particularly hookahs, is a gateway to smoking among youth [14,31,32]; therefore, it is likely that many current non-smokers will become smokers due to their curiosity about tobacco products, and curiosity is the most common reason for beginning smoking [14].

Our findings revealed that peer influence was a significant predictor of smoking susceptibility among the surveyed adolescents. Peer pressure is one of the most important predictors of smoking and passive smoking in adolescents, and previous studies found that peer influence plays a crucial role in youth smoking behavior. This aligns with the literature suggesting that adolescents are highly influenced by the behaviors and attitudes of their peers, particularly in contexts where smoking is normalized within social circles [27,28,33]. Studies conducted in neighbouring Gulf countries such as Kuwait and the United Arab Emirates have also reported strong associations between peer influence and adolescent smoking initiation [34,35]. We also observed smokers are more likely to have smoking family/household members and peers, suggesting the importance of social context in shaping smoking behavior.

The Extended Susceptibility Index (ESSI) is a highly sensitive tool for identifying adolescents at risk of smoking. The present study categorized many non-smokers into either “susceptible” or “highly susceptible”, suggesting the need for early intervention strategies targeting curiosity and susceptibility in adolescents to prevent initiation of smoking in the near future [15]. Furthermore, this study found that current smokers perceived higher levels of smoking among peers and were more likely to be subjected to second-hand smoke, showing the role of social influence in smoking behavior.

Although some studies have reported that impulsivity can predict risky behaviors such as smoking, the findings have been inconsistent [17,36]. Our study found that both Positive and Negative Urgency scores were significantly higher among non-smokers, which may indicate the possibility of smoking in the future. Sensation seeking has also been linked to smoking initiation [37], and higher sensation seeking scores were observed among non-smokers in this study, suggesting a potential for risk-taking behaviors. Although negative affect (NA) has been associated with smoking in previous studies [38], no significant differences in PANAS scores among smoking status or ESSI groups were found in this study.

Despite its valuable insights, this study has several limitations. First, the cross-sectional design limits causal inferences between psychological traits and smoking behavior. Second, data collection relied on self-reported measures, which are subject to response bias, particularly in culturally sensitive topics like smoking. Additionally, while validated tools (ESSI, UPPS-P, PANAS) were used, their application among Arabic-speaking adolescents may require further cultural adaptation and psychometric validation. Future studies should consider longitudinal designs and incorporate objective measures such as biochemical validation of smoking status.

Conclusions

This study shows a concerning prevalence of cigarette smoking (19.4%) among adolescent male high school students in southern Saudi Arabia, with a significant proportion of non-smokers showing susceptibility to smoking. Psychological factors such as impulsivity and emotional states were significantly associated with this susceptibility. The use of validated assessment tools – the Expanded Susceptibility to Smoking Index (ESSI), the short version of the UPPS-P Impulsive Behavior Scale, and the Positive and Negative Affect Schedule (PANAS) – enabled comprehensive psychological profiling of students at risk. These findings underscore the urgent need for school-based anti-smoking campaigns, building refusal skills, and increasing awareness of the social and health risks of smoking that address smoking curiosity and susceptibility, as well as implementation of prevention programs that incorporate peer-led interventions, interactive workshops, and psychological support to manage impulsivity and negative affect, targeting both behavioral and emotional predictors of tobacco use in this vulnerable population.

Availability of Data

The datasets used and/or analyzed in this study are available with the principal author upon reasonable request and will be provided by masking the identification of the individuals.