Assessment of second-hand smoking among princess Nourah Bint Abdulrahman University students, Riyadh, Saudi Arabia

Background: Smokers destroy their health and the health of people around them through spread the most prevalent indoor environmental exposures which is called secondhand smoking. The objective of this study is the assessment of knowledge, attitude and exposure among students of Princess Nourah Bint Abdulrahman University. Methods: A cross-sectional study started in September 2019 to April 2020 among 553 female students. Multistage technique was used to recruit students from health and non-health colleges. Data designed to assess knowledge, attitude, and exposure among female students using the health belief model. Results: The results showed that students were sometimes exposed to secondhand smoking in public places (66.5%), and the higher exposure in all places was among those who live with their parents (52.94%), as for the level of knowledge and attitude, less than half of the students showed a good level. Conclusion: The study revealed that the prevalence of exposure among university students was slightly low. Moreover, the students’ knowledge and attitude is consider to be in the acceptable level.


Introduction
Tobacco smoking is one of the leading causes of death all over the world, not harmful to smokers only, but it also have a harmful impacts on those who never hold a cigarette [1] . That has led to another public health problem called secondhand smoking (SHS), which is considered to be one of the most prevalent indoor environmental exposures where the unwanted smoke is exhaled by the smoker and spread on the surrounding environment [2,3,4] . SHS is also known as passive smoking, involuntary smoking, environmental tobacco smoke, and all of these give the same meaning, which is breathing-in other people's tobacco smoke. According to World Health Organization (WHO), the tobacco epidemic is one of the largest public health dangers the world has ever faced, killing more than eight million people a year around the world, while around 1.2 million of those deaths were associated with being exposed to SHS. WHO have growing evidence suggesting the causal relationship between SHS exposure and preterm delivery, sudden/unexpected death in the first 12 months and low birth weight [4] . Around 1.1 billion smokers worldwide live in low-and middle-income countries, where the burden of tobacco-related diseases and deaths is considered to be the heaviest [5,6,7,8] . According to the Saudi Health Interview Survey (SHIS, 2014), there are 17.2% of Saudis breathe passive smoking at home, with an average exposure of 5.1 days per week, while 14.8% of Saudis are exposed to SHS at work with an average of 2.2 days per week [9] . Smokers destroy their health and the health of people around them with each puff they give, as there are hundreds of toxic chemicals are contained in tobacco smoke which are the leading cause of illnesses and death [5,10,11] . Secondhand smoke exposure is globally widely spread among adults in 2016, one-third of females and one-fifth of males are exposed to SHS [12] . According to the WHO breathing SHS can cause serious health effects, and there is a sufficient evidence assured that SHS is linked with various diseases among adults [4] .
~ 24 ~ Moreover, the Center for Disease Control and Prevention (CDC) has confirmed the relationship between exposure to SHS and cardiovascular disease including, coronary heart disease and stroke [11,13] . Children are important vulnerable group to SHS, where it was found that 65000 children die each year from illnesses attributable to SHS [14] . Many of those who are exposed to SHS do not show symptoms immediately, but they will suffer problems over time [15] . Children whose parents smoke get ill more frequently with lung infections, ear infections, and they are more prone to cough and wheezing [16] . The primary sources of SHS are cigarette, cigar, and pipe smoking. It is more dangerous in closed places as in restaurants, homes/workplaces, and transportations [15,16] . This study aimed to assess knowledge and attitude towards tobacco SHS among students of Princess Nourah Bint Abdulrahman University in Riyadh, Saudi Arabia.

Methods
Study Design: This is a descriptive cross-sectional study design to assess knowledge and attitude toward secondhand smoking and measure the prevalence rate of exposure to secondhand smoking. Settings: Princess Nourah Bint Abdulrahman -female-University, Riyadh, Saudi Arabia. Study population and duration: It was conducted among students of Princess Nourah Bint Abdulrahman University, from September 2019 to April 2020. The total number of students in Princess Nourah Bint Abdulrahman University is 38986 [17] .
Sample size: Sample size is calculated using the "n4studies application" software application [18] . Because the study design is a cross-sectional one, and the target population is more than ten thousand, the infinite population proportion is chosen using the following formula: Where, p = proportion of the characteristic understudy = home exposure 17.2 % [9] . z = standard normal deviate usually set at 1.96 which corresponds to 95% confidence limit. d = degree of accuracy = usually set at 0.05 level n = desired sample size α = alpha sample = 0.05 Design effect = 2 This gives a sample size of 438 students. A 20% (88 students) dropout is added to the sample, giving a total number of 526 students.

Sampling techniques
Colleges of Princess Nourah Bint Abdulrahman University are classified into four major fields (humanities' colleges, science colleges, community colleges, and health colleges). Each major field has different colleges and every college has different academic programs.
Multistage technique has been used to recruit the students from the colleges to represent the different major fields. First, colleges are stratified into health colleges and nonhealth colleges (humanities' colleges, science colleges, and community colleges). Then by simple random technique two colleges are selected: one college from the health colleges and another college from the non-health colleges. Second, by simple random technique, two academic programs (clusters) are chosen from each selected college. All students (level 3+) in the four selected academic programs are recruited in the study. Students are approached by online survey to distribute the study questionnaire, after making announcement on social media (using Twitter and WhatsApp) and visiting the selected colleges to inform the students and encourage them to participate in the study. The 526 sample students will be divided proportionally between the two colleges according to the size of their students, as follows: nh = (Nh / N) * n (where nh is the sample size for stratum h, Nh is the population size for stratum h, N is total population size, and n is total sample size). Total number of target population = 38986 female students, Total sample size = 526 students, Population size of health colleges = 3169 students, while population size of non-health colleges = 35817 students. So, the planned sample size is 43 students will be recruited from health colleges, while 483 students will be recruited from non-health colleges. The actual data was collected from 44 students of health colleges (College of Medicine), and from 510 students of non-health colleges (College of Languages, French section), giving a total collected data from 553 students, with a response rate of 100%. Being a smoker was the only exclusion criterion. Data was collected using a pre-designed questionnaire including questions on socio-demographic data, and on knowledge, attitude and exposure to SHS.

Results
This study was conducted on 553 students of Princess Nourah Bint Abdulrahman University. The study population age ranged from 17 to 24 years old, with 20-22 years as the most frequent age group (60.8%). Most the students are living in Riyadh with their parents (93.3%) and the rest are living either in with a relative, in the campus, or independently. The majority of the students were from nonhealth college (92%). Most of the students were in their second and third academic years. Table (1) demonstrates the frequency of exposure to SHS among the students in different places. The majority of the students were never exposed to SHS at home (70.2%), while 7.2% of them were exposed all the time "always". Regarding the exposure in public places, more than half of the students were exposed "sometimes" (66.5%) to SHS, and only 16.2% got exposed all the time "always". Most of the students never got exposed to SHS inside cars (67.1%), while only 6.1% got exposed all the time. The majority of the students were not exposed to SHS inside the university (82.4%), while only 9.6% got exposed. ~ 25 ~  (1) shows the existence of friends who are currently smokers. More than half of participants did not have friends who currently smoke (65%), while 14% have friends who currently smoke and they set with them while smoking.    Table (3) illustrates the health belief model constructs on SHS regarding perceived barriers. In the first question, more than half of the students stated that there is an effort in the community to educate people toward SHS (52.62%), while 11.94% did not have any idea. Following the previous question, the majority of the students found it socially acceptable to ask others not to smoke in closed or public places (76.13%), whereas 7.05% disagreed with that. Cues to action included three questions. First and foremost, more than half of the students stated that it would be a decline in lung cancer rates after banning smoking in public places (69.08%), while 7.05% reported that it would cause decline in colds and flu rate. In the second question, more than half of the students agreed that ventilation systems could be an effective way to reduce exposure to SHS (60.39%), while 11.22% of participants disagree. The third question included, more than half of the students agreed that adds are an effective way of motivating people to reduce exposure to SHS (54.97%), while more than a quarter of the students disagree with that (18.08%). Out of three questions distributed in self-efficacy, most of the students agreed that it is easy to ask family members or friends to stop smoking while present (45.93%), unlike 21.88% of the students disagreed. In the second question, approximately half of the students reported that they would stop eating at desirable restaurant or coffee shop due to the ~ 27 ~ existence of SHS (51.72%), and 23.69% refers to the presence of SHS will not affect their desire toward eating at restaurant or coffee shop. Along with the last question, it found that half of the students agreed that it is easy to avoid meeting a friend who is usually smoke while present (49.91%). In contrast, 21.7% disagreed with this point.  Table (5) represents the association between total score of exposure to SHS and total score of attitude toward SHS. Most of students with positive attitude had low and average exposure to SHS (68.6% and 70.6%), while most of those with negative attitude were highly exposed to SHS (41.2%). The association was statistically significant (X2= 28.330, p<0.0001). Table 5: The association between total score of exposure to SHS and total score of attitude toward SHS Variable Total score of exposure Likelihood Ratio test Highly exposed Average exposed Low exposed N (%) N (%) N (%) Total score of attitude

Discussion
Exposure to secondhand smoking is a preventable leading cause of death. The current study investigated the difference of knowledge, attitude and level of exposure toward secondhand smoking among female students in medical and non-medical colleges in princess Nourah Bint Abdulrahman University. The current study has found that there is a high proportion of students never got exposed to SHS at home which is less than another study conducted among adolescents in South China showed that less than half of the study participants were exposed to SHS at home [19] . This might be explained by fact that the Saudi culture and morals make the young smokers avoid smoking inside homes as a respect to their parents during family gatherings. Also, old men are spending most of daytime outside doing their businesses. These two factors decreased the inside home smoking. On the other hand, this study found that more than half of the students were exposed to SHS sometimes in public places which is consistent with a previous study conducted among adolescents in South China which found that almost half of participants were exposed to SHS in public places [19] . This finding might justified by the fact that smoking became more prevalent in some public places and females who tend to sit with their friends while they smoke during their free time.
The current study showed that 17.6% of the students who live in the university campus are highly exposed to SHS, which is less than another study conducted in Korea among college students to explore the prevalence of exposure to ~ 28 ~ SHS at two locations and showed that the majority of students were exposed to SHS on campus [20] . The lower level of exposure in the current study might be contributed to the presence of university anti-smoking policies and students' compliance to those policies. Also, all the target population are females with less prevalent smoking than males. In this study, knowledge and attitude regarding SHS were described. The majority of the students stated that SHS can cause real health complications such as death, which is almost compatible with another study conducted among East West University students in Aftabnagar, where more than half of the students stated that SHS can cause real health complications, and less than one quarter thought that it can cause death [2] . This relatively good level of knowledge regarding the effect of SHS could be the result of efforts done by Ministry of Health in educating people about the effect of smoking and SHS. Also, students of health colleges are expected to have reasonable knowledge regarding smoking and SHS effects. Also, the majority of students agreed that they are concerned about the effects of SHS on their health, similar to the results of Aftabnagar study [21] . This might be contributed to the students' level of knowledge, as was mentioned before, making them aware of the effects of SHS and shaping their concern. The majority of the students agreed that SHS exposure bothers them, which is consistent with the Aftabnagar study results [21] . This finding is expected since the smell of the exhaled smoke by the smoker is unpleasant and it causes difficulty of breathing among the non-smokers. Most of students found it is not easy to ask their family members and friends to stop smoking around them, which is supported by what was found in a study conducted among university students in Korea and reported that the majority of the students did not have the self-assertive behavior of asking others to stop smoking [22] . Despite the importance of the self-assertive behavior, this finding in the current study might be due to the fact that young people usually have a tendency of avoiding conflict with their loved ones. Regarding the total knowledge of students, the results showed that around half of students had a good level of knowledge about SHS, of whom the majority were from Health Colleges and this is due to their medical background, while one quarter of all students had low level of knowledge. Furthermore, another study conducted among young adults to assess SHS exposure, knowledge, attitudes and was found that the majority of respondents had suitable knowledge about SHS and its health impacts [23] . The lower proportion of poor level of knowledge might be justified by the existence of frequent health education programs which aim at raising awareness among students and existence of health educational clubs in the university.

Conclusion
The level of exposure to SHS among Princess Nourah Bint Abdulrahman University students was slightly low. As for their level of knowledge, overall the students showed a good level of knowledge. Regarding the attitude, there was a positive attitude in connection to the students' average level of knowledge and exposure.

Recommendation
1. Health education of the students regarding self-assertive behavior of asking people around them to stop smoking in their presence and to motivate smokers to comply with the anti-smoking policies. 2. Enforced the laws to control SHS exposure in public places. 3. Strict supervision of the implementation of antismoking policy in the university campus. 4. There is a need for more studies to assess knowledge and attitude among female in Saudi Arabia.

Limitation
A number of students refused to answer the questions of exposure to secondhand smoking at university campus, which might have an effect on the results of this part.