Sociology

I found the analysis much more compelling than previously, you tend to include a degree of repetition and also, I note that you sometimes pass opinions that although seemingly valid, are unreferenced and need a source in the literature to support them. A point that strikes us most forcibly is how you will tackle the study in practical terms I made some detailed comments about the sort of information I need to include in the initial Chapter that warns the reader of what will happen and when. I think also this is important to signpost the rest of the thesis. In this regard we mentioned a Chart that defines a study design and methods that you might wish to consider The methodology is the next issue for attention.

The current situation in Saudi Arabia is a cause of serious concern as smoking has become increasingly prevalent in the community. Annual consumption of cigarettes has reached 40,000 tons, which is 15 billion cigarettes. Saudis also spend about 2.2 billion annually to satisfy this habit. Almost five out of six million Saudi smokers are men. Smokers are one fourth of the total population. In a global ranking for tobacco consumption, the Kingdom of Saudi Arabia is placed 23rd (Al Saleh, 2009). Smoking is one of the major avoidable causes of illness and death in Saudi Arabia, causing many chronic health problems such as heart disease, cancer, strokes and chronic obstructive pulmonary disease (WHO, 1998). It is surprising to see the increasingly prevalent use of tobacco despite the health dangers and the publics awareness of these dangers. According to the findings of a national cross-sectional survey on smoking, conducted in 1999, the prevalence of smoking in the Kingdom is 21.1 for men and 0.9 for women (Jarallah, et. al., 1999). Smoking is not just a danger to individuals, but also entails costs to society, as the detrimental effects of tobacco smoking contribute to societys healthcare burden (Parrott, et. al., 1998).

Smoking has become a critical health issue in Saudi Arabia not just for adult males but also for adolescents. Studies have shown that between 15 and 30 of adolescents smoke in Saudi Arabia (Abolfotouh et al. 1997). Smoking among adolescents is growing, as more of them are becoming regular tobacco users every day. This means that a whole generation of youth in Saudi Arabia is acquiring an addiction to nicotine and is at danger from the harmful consequences of using tobacco.
 Primary health centres in the Kingdom have been inconsistent in their implementation of smoking cessation guidelines for counselling on smoking (Shahri et. al., 1997). These centres are using different and, in many places, ineffective or unproven techniques for smoking cessation, such as acupuncture (White, et. al., 1999). There are many advanced methods available today to help smokers to quit the smoking habit more effectively, like nicotine replacement therapy  NRT - (Okuyemi, et. al., 2000) (gum, nicotine patch, inhaler, nasal spray), which has proved effective in 20 of cases over 6 months, or non-nicotine drugs like Buproprion, which has been effective in 27 of cases over 6 months (Okuyemi, et. al., 2000). However, health care providers in the Kingdom are not consistent in treating smoking addiction cases successfully (Silay, et. al., 2000).The role of physicians in smoking cessation clinics is questionable, although they are aware of the seriousness of health problems caused by smoking. There are factors interfering with the assessment and handling of smokers by practitioners, most notably a lack of basic knowledge (Al-Doghether 2001). Physicians are not quick and proficient in identifying smokers. They have limited knowledge about the effective methods of treatments available, such as nicotine replacement therapy, applications of such treatments or the relative efficacy of multiple treatments (Bishop, et. al., 1998). The involvement of clinicians, therefore, does not always result in successful treatment as they do not have enough knowledge to identify smokers quickly and they sometimes find it difficult to assess which treatments are efficacious and are best in clinical settings.

Another reason for this inconsistency of treatment in primary health centres is insufficient or inappropriate institutional support to assess and treat smoking (Raw, et. al., 1998). Many anti-smoking clinics are operating in the Kingdom of Saudi Arabia. Although research has shown that health professionals have a positive attitude towards implementing guidelines (Watkins, et. al., 1999), until now no national guidelines for smoking cessation have been introduced by the Saudi government. So, the question arises is there a need for such guidelines

The necessity can be determined by considering various factors prevalence, morbidity, mortality, economic burden due to the condition, variation in clinical practice in treating the addiction, potential options and methods to improve health care and, finally, the data available that is the basis of health care recommendations (Agency for Health Care, 1996).

History of Tobacco Use in Saudi Arabia
    Tracing the historical roots of tobacco smoking has indeed come a long way, thanks to the studies undertaken by researchers who have tried to establish the origin of tobacco since ancient times. In the context of Saudi Arabia, tobacco smoking has been studied in relation to the spread of tobacco use in the Middle East. In order to fully understand the evolution of tobacco use in the world, it is essential that important historical events that led to its origins are fully understood.

    Researchers believe that the smoking of tobacco was introduced by native American peoples when they started looking for ways to use the leaves of plants that belong to the genus Nicotiana. They devised numerous means of using tobacco, including smoking. The native Americans also used tobacco as a form of hallucinogenic enema. Between 600 and1000 CE, the first periodical record of smoking was recorded in Uaxactun, Guatemala. Anthropologists found a pottery vessel dated before the 11th century. The pottery vessel showed a Mayan smoking a roll of tobacco leaves which was tied by means of a string. The Mayans referred to smoking as sikar (Borio, 2007).

    The journal of Christopher Columbus also helps in tracing the history of smoking.  In his journal in 1492, Columbus described the habit of smoking tobacco leaves among the indigenous people in America. Later, during the 16th century, a writer named Oviedo discussed the smoking habits of the Americans. He said that they smoked tobacco leaves by using a Y-shaped, small wooden tube that they called a tobago. Two points of the tobago were inserted in the nose of the smoker while the other end was used to burn the leaves. There are also other researches which claim that the Mexicans called the herb that they smoked as tobacco (World Health Organization Regional Office for the Eastern Mediterranean, 2006).

    Tobacco was able to reach Europe through Spain. Jean Nicot, the French ambassador in Portugal, took tobacco seeds from Spain and brought them to France. As a result, the genus Nicotiana, which is the source of one of the most essential derivatives of tobacco - nicotine - is named after this French ambassador. During the 17th century, tobacco smoking expanded all over the world. The Turks are among those responsible for introducing tobacco smoking in Africa and the Middle East, which also includes the present day Saudi Arabia (World Health Organization Regional Office for the Eastern Mediterranean, 2006).

    It was also during the 17th century that the Ottomans introduced the shisha. The shisha is an instrument for smoking tobacco in which the smoke is cooled and filtered by means of passing it through water. Research has shown that shisha became popular in the Middle East only after the arrival of tobacco. The great developments of the Turkish glass industry between the 16th and 18th centuries also resulted in the greater use of shisha because glass started to be used to make the body of this instrument (World Health Organization Regional Office for the Eastern Mediterranean, 2006). Unlike western custom, where tobacco is smoked plain, shisha is mixed with fruit, molasses or even honey, giving it a sweet and flavorsome taste (New Muslim Umra Tour, 2009).     

About 50 years ago, cigarettes were supplied into the Kingdom of Saudi Arabia through smuggling from other neighbouring countries. However, the development of links among countries, especially in terms of trade partnership, has paved the way for foreign companies to supply tobacco in Saudi Arabia. As a result, the Saudis have easier access to tobacco, which is one of the major factors underlying the countrys health problems in terms of diseases related to cigarette smoking.

Site Selected for Primary Research
    We are very interested to know what this study will look like and how you will conduct it. In order to further elaborate on the health and social care smoking cessation systems and services in Saudi Arabia, the researcher will conduct a study among male smokers in the al Qassim region, specifically in al Qassim University.  Al Qassim University is a public institution in Saudi Arabia. The main campus of the university is located at Qassim province. Qassim University is the preferred school for this study, which is located at the centre of Qassim Province. The male college students who smoke cigarettes will be studied in relation to health and social care smoking cessation systems and services. 

Aim of study
Can you go into more detail about the in-depth study The aim of this research is to conduct an in-depth study into the health and social care systems and services in place in the al Qassim region of Saudi Arabia to help smokers to quit their smoking habit. The research will focus specifically on male smokers, as these forms the overwhelming majority of smokers in Saudi Arabia.

Objectives
In order to achieve this aim, the study will focus on the following objectives
Identification of the evolution and extent of the problems  caused by smoking in the Kingdom of Saudi Arabia as a whole, as identified by existing studies, in order to situate this research within the wider national context. What research method will be used A comprehensive literature review
Identification of the specific at risk groups within the population. What research method A survey
Review of the forms of treatment available and the role of health professionals. E.g. by comprehensive literature review of effectiveness and cost-effectiveness of interventions to promote smoking cessation

Presentation of an overview of the role of government in Saudi Arabia in terms of legislation, propaganda and education, training of professionals and provision of resources. By a comprehensive literature review with specified dates to describe historical context

Assessment of the effects of interventions made by official national bodies, the media and international organizations. By a comprehensive literature review with use of data from specified databases or surveys to illustrate changes in smoking

Determination through a local study (the al Qassim region) of attitudes among male smokers, to include problems in quitting smoking, awareness of the dangers and problems caused by addiction to smoking in terms of health and familysocial costs. By in-depth interview or anonymised survey
Establishment of the generalisability of the results of the local study within the wider national context. What are your thoughts on how to do this

Assessment of the relevance of the research to the development and implementation of effective smoking cessation strategies in the Kingdom. What are your thoughts on how to do this

Study Questions
First Question What is the efficiency level of social welfare services provided to help males to stop smoking in the al Qassim region Will this include consideration of the cost-effectiveness interventions for smoking cessation

Second Question What is the relationship between the variable relating to the characteristics of male smokers and their assessment of the level of efficiency of social welfare services provided to help them to quit smoking Not sure what you mean here. Are you going to develop a hypothesis from reviewing the published data then, state your hypotheses and then test this statistically
Third Question What are the barriers that prevent making use of social welfare services presented to male smokers Do you mean among the group of male university students with whom you will generate your data or more broadly

Fourth Question What are the suggestions necessary to support the social welfare services in their aim to help male smokers to quit smoking in the al Qassim region Do you mean that if your results are found to be generalisable, you might consider making recommendations for the policy-makers

Interventions Available as Compared to Other Countries
In Saudi clinics, tobacco dependence is treated through repeated interventions depending upon the chronic condition of the male smoker. Physicians use effective interventions that achieve long-term cessation at about double the rate of cessation attained by smokers without treatment, which is 20 vs. 8 (Al-Doghether, 2001). Due to the proven health benefits, every smoker can be treated by intervention that at one stage includes pharmacotherapy. Since pharmacotherapy increases the quit rates of many of the cessation techniques, every smoker is given suitable pharmacotherapy that supports his cessation attempts, except when contra-indicated. Most of the pharmacotherapy methods are safe and effective.

Clinicians normally use nicotine replacement therapy (NRT), anti-depressants and other drugs like Bupropion-SR that have an efficacy of 27 at 6 months  and these have proved to be the most effective cessation aids (Al-Doghether, 2001). Other cessation methods such as acupuncture and hypnotherapy are also practised but these methods need to be further research in order to assure its efficiency in addressing the smoking problems of individuals.

Although many smokers quit smoking on their own, this is generally after several attempts. More than 90 of unaided cessation attempts fail (US Department of Health, 2000). By using appropriate pharmacotherapy, smoking cessations rates are increased up to two or three times (Al-Doghether, 2001). 

Various pharmacological interventions for smoking cessation have been devised in recent years (Hurt, 1999). The types of pharmacotherapy available to male smokers in the Kingdom are as follows
 Nicotine replacement therapies such as transdermal patches or chewing gums or, less frequently, nasal sprays, aerosol inhalers and lozenges (but not available in every PHC).
 Anxiolytic medications these control and eliminate the anxiety symptoms resulted during withdrawal
 Antidepressants only a few classes are available like Bupropion-SR (Zyban).
 Different types of pharmaceutical therapies. These include nortriptyline, mecamylamine, clonidine, naltrexone and silver acetate.

Nicotine replacement therapy (NRT) is a major intervention for smoking cessation in many developed countries like the US (Fiore, et. al., 2000) and the UK (West, et. al., 2000). Following UK guidelines, UK health professionals use NRT or Bupropion for people smoking 10 cigarettes each day (West, et. al., 2000). However, the US and Scottish directives recommend their health professionals to offer all smokers an appropriate pharmacotherapy. NRT or bupropion is their primary choice except when contra-indicated (Fiore, et. al., 2000). There are concerns regarding the safety of NRT in patients having cardiac problems. However, empirical studies have shown that the nicotine patch is safe in smokers having stable cardiac disease (Fiore, et. al., 2000). In Saudi Arabia, male smokers are treated with several different forms of nicotine replacement therapy like
 Chewing gum (dosages 2 mg and 4 mg).
 Transdermal patches (dosage 16-hr and 24-hr).
 Inhalers.
 Nasal sprays.
 Sublingual pills and lozenges.

Nicotine chewing gum and transdermal patches are the most frequently recommended types of nicotine therapy in the Kingdom. These are available in 2 mg and 4 mg preparations and are sold without a prescription from physicians. This gives an opportunity for Saudi male smokers to obtain a prescription at the time of purchase.

Saudi male smokers use transdermal patches in many sizes. The patches produce nicotine between 7-mg and 22-mg during 24-hours. The intervention produces plasma levels that are the same as the trough levels observed in heavy smokers.

The use of nicotine gum, nicotine transdermal patches, nicotine nasal sprays, nicotine inhalers and nicotine sublingual tableslozenges have effectively raised quit rates at 5-12 months in Saudi male smokers, which is approximately double the rate of cessation achieved by those using a placebo (Silagy, 2003).

Even more effective results have been achieved by combining different NRT interventions. The use of nicotine patches and inhalers show a 25 abstinence rate at 6 months and 19.5 at 12 months. This is a higher rate than placebo patches and inhalers that result in 22.5  abstinence at 6 months and 14  at 12 months (Bohadana, 2000). Bupropion is used with a nicotine patch to make it more effective than a nicotine patch alone (Jorenby et. al, 1999).

The Ministry of Health also considers the negative impacts of medicines being offered for smoking cessation to Saudi male smokers. In 2009, two major smoking cessation drugs were banned due to their serious side-effects for creating suicidal tendencies among Saudi males (Al-Meqatti, 2009).
In Saudi Arabia, Varenicline, also known by its trade name Chantix or Champix, was being offered as it was successful in reducing craving for nicotine and the pleasure derived from smoking among Saudi males. The Ministry of Health started offering the medicine as research showed that the ratios of quitting tobacco use through Champix were almost double (44) that of Buproprion and four times that of the placebo. However, it is no longer on offer as Saudi male smokers using these smoking cessation drugs reported mood changes and symptoms of depression and, in some cases, experiencing thoughts of suicide or dying, so it is not being offered now (Al-Meqatti, 2009).

Varenicline and Buproprion (Yaba) were withdrawn from offer to the public in Saudi Arabia after the issuance of a black box warning from the US Food and Drugs Administration (FDA). A black box warning is the top warning any medicine can receive on account of its mental health risks. The FDA indicated that Varenicline has the potential to induce depression and suicidal thoughts in users (Al-Meqatti, 2009). Varenicline can also manifest its side-effects in the form of serious accidents and falls. The Ministry of Health banned Varenicline for its potentiality to create lethal cardiac rhythm disturbances, skin problems, myocardial infraction, seizures, diabetes, psychosis and aggression in Saudi male smokers. Buproprion is another popular medicine among Saudi male smokers, but it is now banned as it is suspected to induce similar adverse reactions (Al-Meqatti, 2009).

Smoking Cessation Services
Nicotine replacement therapy is available with strengths of 7-mg, 14-mg and 21-mg in the form of a transdermal patch. However, in Saudi Arabia, the government must review and address the barriers to access it by following other examples. The UK is making NRT available across a wide range of retail outlets and settings and not restricting it to pharmacies only. The Health Ministry of Saudi Arabia must also consider the UKs approach and implement it in the Kingdom. The establishment of wider distribution outlets for NRT is essential to make therapy as easily available to smokers as cigarettes themselves. It should be readily accessible to Saudi male smokers who want to quit smoking.
The Saudi government is not subsidizing the cost of NRT for consumers as is the practice in the UK. Male smokers using a transdermal patch for 10 weeks (a standard course) incur an almost equal cost during this time as they would purchase cigarettes. Subsidized NRT will reduce the cost and increase the use of NRT. There is evidence that reduced out-of-pocket costs for NRT increase not only the use of NRT therapy but also the cessation rates (Hopkins et. al, 2001).

There are critical factors associated with smoking cessation that need to be understood. Smoking is considered as an anti-social behaviour that puts at risk the health of both the smokers and passive smokers around them. Realizing the criticality of the matter, the UK government planned to reduce smoking rates in adults from 26 in 2002 to 21  by the end of 2010, but no such target has been set by the Ministry of Health in Saudi Arabia. The UK is backing its targets and efforts through endorsing the strategy of the government to promote the use of NRT.

Tobacco dependent Saudi males need appropriate treatment. Effective treatments have been introduced and are being practised today in the US and the UK. They should be offered and used with every current and former Saudi male smoker in the Kingdom. Primary care professionals working in PHC must be equipped and supported with the tools required to effectively treat Saudi male smokers. The recent developments in effective pharmacotherapy for smoking cessation offer health professionals a variety of treatment modalities. When used appropriately, all currently available products and tools can give better results.

However, the patients preference, co-morbidities and a severe effects profile of approved products must direct treatment selection. Health care professionals must be aware of the special conditions and requirements of Saudi male smokers, light smokers and smokers with cardiovascular diseases. Health professionals may regard smoking intervention cessations as less effective compared with that of other methods such as the use of antibiotics or antihypertensive drugs for serious clinical conditions. However, smoking cessation needs to be dealt with in perspective. If Saudi health professionals succeed in achieving a 5 quit rate in 70 of Saudi male smokers in one year, this means they have helped thousands of Saudi male smokers to quit smoking in one year. It is necessary for the Ministry of Health to ensure the provision of the best clinical interventions available today for reducing illness, preventing death and increasing the quality of life of Saudi male smokers.

Legislative and Policy Position of Saudi Arabia on Smoking Cessation
Since its establishment, the Saudi Arabian Ministry of Health has been providing comprehensive and integrated public health care services to each citizen of the country. The system ensures that all services are equitable, affordable and well organized.

The government have devised effective policies to discourage the smoking culture in Saudi Arabia. Recently, the northern Saudi city of Hail has banned the sale of cigarettes. The ban was imposed after complaints had been received from residents of the area who pointed out the increasing trend of smoking among youth. Turki Al-Dhaban (the chairman of the Municipal Council in Hail) stated that shops and food stores breaching the new regulations would be closed by the Environmental Health Department and could receive hefty fines (Baxter, 2009).

This act shows the awareness about the harmful effects of tobacco among Saudi people. Local residents demanded that the municipal council in Hail impose a ban on cigarette sales in food stores operating in residential districts when they observed that expatriate workers from various countries outside Saudi Arabia were selling cigarettes to youngsters. This new law is a part of the government policy to discourage young males from smoking (Baxter, 2009).

The Saudi government is renewing another policy for the enforcement of the ban on smoking in airports across the country. All the airports in the Kingdom are developed to standards that can be compared with airports in any other country. However, people entering them are still able to smell cigarette smoke. The Saudi government is passing new legislation aimed at eradicating the smoking culture and helping in smoking cessation efforts. To set an example to others, all airport staff will be required not to smoke (Baxter, 2009).

A Saudi law passed in 1973 bans smoking in government offices and ministries. The law also makes obligatory the display of signs and posters warning of the dangers of smoking at prominent places within the workplace. Four years later another law was introduced that strengthened the strict implementation of the previous 1973 law (Al-Khatrash, 2003).

In August 2003, the Cabinet sanctioned a new anti-smoking law. Although these regulations have not been implemented to date, as it is in its final stage the system is sure to be implemented in the Kingdom in 2010. According to this new system, specific punishments in the form of huge fines (ranging from SR200-20,000) will be imposed on the users and distributors of cigarettes in the Kingdom. Article 13 of this law defines the punishments people or companies involved in illegal planting or production of tobacco in the Kingdom will be fined SR20, 000 and people smoking in public places will receive a fine of SR200 (Sidiya, 2009).

The government of Saudi Arabia invests millions of Saudi Arabian dollars in anti-smoking programs with mixed results. Selling cigarettes is banned in many cities like the holy city of Medina. The Unaizah region also imposed a ban in November 2009. Tobacco advertisements and commercials are also banned in all forms of the mass media. This includes imported newspapers and magazines. The Saudi Ministry of Health estimated that each year about 2.5 billion is spent to curb chronic diseases caused by smoking (Al Saleh, 2009). According to the findings of an anti-smoking campaign conducted in 2003 by the Ministry of Health, Saudi Arabia bore an economic loss of about 83 billion from 1961 to 2003 due to tobacco use. This loss resulted from reduced productivity and early deaths among Saudi male smokers (Al Saleh, 2009).

According to a study recently conducted in thirteen schools, students in secondary schools are taking up smoking in increasing numbers and the figure is now 38. Moreover, 27 of them start smoking in elementary level. According to a statement in a report from the WHO (World Health Organization) published in 2009, smoking causes almost 21,000 deaths per year among males and females in the Kingdom of Saudi Arabia, compared with 30,000 deaths in the 6 Gulf Cooperation Council nations.
According to an estimate given by KFSHRC Oncology Centre in Riyadh, which is one of the largest hospitals in the Kingdom, there have been 27,000 cases of patients admitted with problems caused by smoking. The diseases of patients include chronic cases of cancer of major organs and respiratory diseases. Another Saudi medical centre reported 1,500 such cases. The findings showed that in 7,000 cases, smoking is the cause of diseases this includes 4,200 cases of patients whose condition had become incurable (Al Saleh, 2009).

The Anti-Smoking Charitable Association is the major and largest organization aimed at combating tobacco use in Saudi Arabia. It has 55 clinics that support Saudis who want to stop smoking. The association organizes awareness campaigns and seminars to address the disease. It campaigns on the basis that the best way to combat smoking is to impose high customs duties on tobacco imports. The duties must be high, up to 200 of the prices in order to lessen the consumption of cigarettes in Saudi Arabia (Al-Saleh 2009).

Role of Government
    The government is the sole entity that could protect and control people in order to attain much improved health and social outcomes for individuals. The power of government means that it is capable of passing different laws that could reduce the popularity of smoking in Saudi Arabia. As mentioned earlier, the aspect of smoking in Saudi Arabia is one of the most important healthcare issues in the country. It has been mentioned in different articles that Saudi Arabia is the fourth largest tobacco importer in the world. Hence, more and more people are inclined to take up smoking. Based on the statistics provided by the Khaleej Times, there are 6 million smokers in Saudi Arabia, if all the different parts of the country are included. In an interview, Dr. Mohammed Al Baddah, a supervisor of the anti-smoking programme in the Health Ministry of Saudi Arabia stated that the current rate of cigarette smoking is alarming due to the resulting health issues which are currently affecting smokers and non-smokers (Bedu, 2009).

     In order to address the problem of smoking, Saudi Arabia has undertaken various actions to reduce individual smoking consumption.  During Ramadan, the whole nation is obliged to stop smoking during the day time as a sign of respect for the countrys religious beliefs. On regular days, however, some places are very lenient with regard to smoking. More and more cafes and restaurants have larger areas for smokers compared to non-smokers. Hence, there has been a tolerant and even welcoming attitude towards smokers. This has been the case in many commercial establishments. Through this, smoking is undoubtedly encouraged in society. However, due to the grave problem of smoking in Saudi Arabia and the concerns raised, there are many public places in which smoking is restricted. Hence, the government is already aware that there is a need for the whole nation to limit its consumption of cigarettes (Ghafour, 2004). 

    In a document published by the Ministry of Health in Saudi Arabia it was stated that there was a royal decree limiting the public places where people could smoke. The document refers to Royal Decree number 778 in 1111404 H, which insists upon the prohibition of smoking in ministry offices, governmental agencies, public institutions and their branches and all their subordinate units, and the placing of No Smoking signs along with the measures that will be taken to ensure compliance. The decree therefore promotes non-smoking in government agencies and establishments. Thus, the royal decree serves as the law which limits consumption in certain locations (Al-Munif, 2009).

    Another law was amended with the support of the first Royal Decree regarding smoking. Royal Decree number 7772 in 931404 H banned smoking advertisements in the press. The aspect of promoting cigarette smoking is now very limited. Hence, advertising in many forms of the media cannot be supported by tobacco companies. There are thus strong measures in place against the promotion of the act of cigarette smoking, most especially for young people (Al-Munif, 2009).

    In other royal decrees, there are issues which are also addressed by the government. Tobacco companies are obliged to print the harmful consequences of smoking on the labels of their packets. In addition, the government of Saudi Arabia has also implemented higher custom duties to be placed on manufacturing companies to discourage greater consumption of cigarettes. It is reasoned that through the increase of tax, the prices of the products would increase and later on result in a lower consumption of cigarettes.

Furthermore, Saudi Arabia has become one of the signatories of the convention regarding tobacco control. Through the ratification of this convention, the signatories agree to take steps to reduce tobacco consumption in their country. Therefore, the reduction of tobacco consumption is not only practiced by Saudi Arabia but also by other states (Al-Munif, 2009).

Organization of Services and their Role in Smoking Cessation
In Saudi Arabia, health professionals consider themselves as role models in their behaviour. About 80 of non-smoking physicians believe that a smoking practitioner does not advise hisher patients to quit this habit. 64 of respondents from among health professionals who do smoke also indicate this as an issue (Halperin et al. 2006).

So, it is a fact, as acknowledged by majority of physicians of both categories, that health care practitioners are significant as role models. Their advice is valuable for Saudi male smokers who want to stop smoking.

Given the prevalence of smoking among males in Saudi Arabia, counselling, self-help and medication are still limited in their extent and availability. Physicians assessment of their preparedness for counselling patients to stop smoking determines whether they can deliver it to their patients. 69 of well prepared health care professionals use counselling. However, the figure drops to 39  when health professionals are not at all prepared. Moreover, practitioners feeling not at all prepared use methods other than counselling while assisting male smokers how to quit smoking. They prefer using self-help material (19.3), traditional options (12.2) or medication (9.3) (Al-Doghether, 2001).

Health professionals in Saudi Arabia know the harm caused by smoking (Ministry of Health KSA, 2009). They realize the significance of non-smoking health practitioners as role models to support male smokers in quitting this habit. Almost 1 out of 6 practitioners smoke in the Kingdom. Policies to support smoking cessation for health professionals themselves can bring benefits in two ways it will improve health of physicians who successfully quit the smoking habit and create a larger pool of health care providers as role models to help other Saudi male smokers in smoking cessation.

Role of Health Professionals
In the case of smoking, one of the most important aspects of its effects lies with health concerns. As noted and discussed by different authors, smoking is has a marked effect on the body of different individuals, whether they are regular smokers or non-smokers. Hence, it is the duty of health professionals to provide the best options to promote different health issues and prevent further harmful effects of smoking. Although this is the case, the government can still control, support and influence the provision of necessary healthcare needs for individuals.

In the light of this, health professionals working together with different organizations concerned with the maintenance and promotion of public health must afford the maximum protection for the health of the population. In general, different individuals have a disposition towards particular illnesses or diseases. Hence, it is the responsibility of health practitioners to promote different programs to create awareness and prevent the spread of more deadly diseases in the future.

As a part of the mission-vision of the Health Ministry of Saudi Arabia, the Ministry believes that the organization must adopt a comprehensive perspective in order to maintain and improve the health care welfare of different groups and individuals in society, especially those who are elderly or disabled. Hence, it is the Ministry of Healths vision that, in the year 2020, everyone in the Kingdom of Saudi Arabia shall receive effective and efficient care and will be relieved from the financial burden brought about by illness and disease. Through this vision, the Ministry aims to satisfy the health care needs of its people. In order to do this, it is the responsibility of the Ministry of Health to create policies that will prevent increases in potentially life-threatening diseases that presently account for the deaths of many Saudis. It is also the role of the Ministry of Health and health practitioners to make available efficient health insurance services that will enable people to enjoy all the health care benefits that they need (Ministry of Health KSA, 2009). 

Accordingly, it is also the responsibility of the Health Ministry, together with its members, to ensure that there are national health strategies in place that concentrate on different health care problems in Saudi Arabia, for example smoking, AIDS and nutrition. The strategy must offer equality of access to health services. One aspect of health care which is advocated by the Ministry of Health also emphasizes the aspect of using the most advanced technologies to provide faster and wider services for patients at all levels (Ministry of Health KSA, 2007).

The mission statement of the Health Ministry aims to provide better comprehensive as well as integrative therapy and a rehabilitative and supportive type of health care that will also uphold the values and principles of Islam. Through these perspectives and mission, the ideal for Saudi Arabia is to provide a highly upgraded form of healthcare program and awareness on the part of families, societies and individuals. Together with the government and its goals, the Health Ministry is entirely responsible for the basic needs of the people in order to improve the public health of the nation.  Through the specialization of different health practitioners, the cases of health care problems would be addressed. Specifically, the number of individuals who are affected by smoking shall be abridged and preventive measures undertaken (Ministry of Health, 2009).

Law on the Sale of Tobacco in Saudi Arabia
    The law on the sale of tobacco in the Kingdom of Saudi Arabia has also been greatly affected owing to the increasing number of smokers in the country. Saudi Arabia is experiencing an enormous healthcare burden, especially due to chronic illnesses that have been brought about by cigarette smoking. It can be prevented because smoking can be curtailed by the imposition of appropriate disciplinary measures on those Saudis who smoke (Al-Ghamdi, 2010). The government of Saudi Arabia has exerted efforts to make wholesale changes to the law on the sale of tobacco in the country, as it believes that this is an important step in order to properly address the health-related problems of cigarette smoking (Al-Ghamdi, 2010).

      The Kingdom of Saudi Arabia implemented a law making it illegal to purchase tobacco for those under the age of 18. This same law also made selling cigarettes among minors prohibited in Saudi Arabia, recognizing that the ill-effects of cigarette smoking can result in particularly harmful effects on the bodies of teenagers. It also recognizes that cigarette smoking at a young age would only increase their addiction to tobacco in the early years of their life, which would eventually continue as they grow older (Sujudi, 2004).

    Saudi Arabia uses Islamic teachings as a guide in the laws that are passed and implemented in the country. As a result, Islam also influences the perspective of the government when it comes to laws regarding the selling of tobacco. Based on Islamic teachings, smoking is haram, meaning forbidden, because it degrades the body and offends human dignity (Sujudi, 2004). Since cigarette smoking is against the Islamic faith, the government of Saudi Arabia has implemented a ban among local producers of cigarettes. The country does not now have any local manufacturers of cigarettes, which is why all the tobacco consumed by Saudis comes from international manufacturers. Saudi Arabia is a net importer of tobacco and tobacco products. Imported Western brands of cigarettes are the most popular in the country, with Philip Morris (US) the market leader, followed by British American Tobacco (UK). Other countries like the Philippines with its Fortune Tobacco and Yemen with MTM also export cigarettes to the Kingdom (Zawya, 2008).    

    The Saudi Arabian government has implemented a ban on the free distribution of cigarettes in order to address the proliferation of smoking. Cigarette smoking is also prohibited in government buildings, educational facilities and healthcare establishments. In addition, the government does not allow the sale of cigarettes to minors, especially in shops located near educational facilities (Zawya, 2008).

    Saudi Arabia is one of the signatories of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). As a result, the country is responsible for ratifying into law the corresponding provisions that are included in the treaty. The provisions of the FCTC include mandating specific requirements regarding the international standards on tobacco when it comes to price and tax increases, tobacco advertising and sponsorship, labeling, illicit trade and second-hand smoking (World Health Organization, 2004).

    In accordance with Saudi Arabias responsibility as a signatory of the WHO FCTC, a 20-article Anti-Smoking Law was drafted, which will be reviewed by the Shoura Council. The 20-article Anti-Smoking Law has as its main objective prohibiting the cultivation and production of tobacco as well as other tobacco derivatives in Saudi Arabia. Some of the articles in this Anti-Smoking Law emphasize the proposed law in increasing the customs tariffs on tobacco and tobacco derivatives in yearly cumulative percentages, which will not exceed 300. Tobacco companies will also be required to put necessary warnings regarding the danger of smoking on cigarette packets. In addition, the sale of imitation cigarette sweets would also be prohibited (Al-Ghamdi, 2010).

    As previously stated, the sale of tobacco products to individuals under the age of 18 is illegal and this is further reinforced in the 20-article Anti Smoking Law. In relation to this, the sale of cigarettes from vending machines and promotion through giving free or discount samples would be banned. The new proposed law also expanded its scope because it will cover cigarettes, cigars, tobacco, shisha (hubble-bubble pipes) and any other products with tobacco ingredients (Al-Ghamdi, 2010). Once the 20-article Anti- Smoking Law is reviewed and approved by the Shoura Council, it will eventually be referred for the royal approval (Al-Ghamdi, 2010).

Law on Advertising of Tobacco Products
    In the earlier section, reference was made to the fact that Saudi Arabia has already implemented a Royal Decree to restrict the utilization of different types of media to advertise cigarette smoking. Therefore, television channels will not be able to present tobacco commercials. Thus, the form of media most utilized by the tobacco companies  television - will not be available to proclaim their messages. Although the media restriction is implemented, the country does not impose the same strict limitations on small businesses that are able to display materials such as posters, leaflets and other promotional items (Al-Munif, 2009). 

    Given that the means of advertising a product do not entirely lie in the media, there are other ways that tobacco corporations market their products. Saudi Arabia is still one of the top countries that imports tobacco products and the influence of forms of media such as the internet, imported films and DVDs must be acknowledged in the growing popularity of cigarette smoking.

    Another concern that is important to note is the aspect of the openness of society with regards to cigarette smoking. In the earlier sections of this paper, it is mentioned that there are many times that society has opened up to provide for the habits of smokers. However, due to the countrys conservative perspective, this has had an important role in limiting the spread of such habits. Hence, the influence of society is already a significant factor in reducing tobacco consumption.

Law on smoking in airports, hospitals, schools and offices   
In the twelfth clause of the Royal Decree it is noted that there should be education of the public regarding smoking. Recognizing that there are different aspects of learning, the government laid down that education must be provided to students who are often peer pressured to use cigarettes. Hence, Saudi Arabia is willing to create different strategies in order for different types of people to learn. One of the target areas of the government are universities and schools which are the best places to educate young people and stop them from any attempt to try smoking. Furthermore, there are also plans with regards to different seminars as well as training programs which will enhance and elaborate the learning of each Saudi to prevent the potentially deadly consequences of smoking (Al-Munif, 2009).

In hospitals, offices and airports, it was assumed that factors which contributed to the habit of smoking must be tackled by the authorities. Through the royal decree, the act of smoking in different areas, most especially in government owned buildings, is not allowed. There will only be certain locations where smoking cigarettes shall be allowed. Through this decree, people will not be able to smoke anywhere and anytime they desire.  Therefore, aspects relating to the concern for reducing tobacco consumption are tackled through reducing places which allow cigarette smoking (Al-Munif, 2009).

Moreover, access to places which are normally utilized by the public is denied to people who want to smoke. Private places are the most common place for smokers to have a cigarette.  In smoking within a public place, an individual must be well aware if the rules and locations allow smoking. If not, it is likely that an irresponsible smoker will be punished based on the laws of Saudi Arabia. Thus, a smoker is encouraged to smoke in different designated areas in order to follow the rules of the Royal Decree.

Cultural Attitude, Social Class, Islam and Smoking
Islam and Saudi culture are the two major factors in the campaign against smoking. Society and culture of Saudi Arabia regard smoking as disrespectful habit and conservative families ensure that a suitor proposing to their daughter does not smoke. In all the cities of al Qassim province, people regard smoking as a sin. It is considered equally unlawful and Islams ruling is same as for forbidden sexual relations and drinking alcohol.

In Saudi Arabia, as in other countries of the world, the media and technological advances have promoted the smoking habit among Saudi male youth. The act is considered to be a sign of high social class. Its harm is ignored and only the sense of sophisticated  status that a person acquires while puffing tobacco has become a major hurdle in a way of successful eradication of smoking from Saudi society. Despite bans, Saudi males can still see the advertisements that promote cigarettes. However, Saudi people are aware and conduct activities for creating awareness among their brethren to quit this habit.

Saudi Arabia has one of the largest Muslim populations in the world and is a cultural centre of the Muslim world. Unfortunately, Muslims residing in the Kingdom are acquiring the smoking habit and the number of Saudi males who smoke is increasing.

Islam has a strong influence on the social values and customs of the population of Saudi Arabia. In Saudi Arabia, Islam ensures the safety of Muslims following the religion, particularly in respect of their health and the safety of people around them. Although there was no such thing as tobacco smoking when Islam emerged, yet the religion provides a framework to devise new rules applicable to any period in history. Islam teaches that if a person becomes a habitual smoker, he is indirectly poisoning himself slowly and, for a Muslim, that is akin to committing suicide.

When tobacco was first introduced in Saudi Arabia, the Saudis were still not aware of the effects of smoking on their health, which made it a socially acceptable activity. However, people later started discouraging smoking as a result of awareness of its adverse effects on health. In Saudi Arabia, although smoking is a lawful act, it is not encouraged and is condemned for its consequences for the human body. As smoking does not only affect the smoker, but also harms passive smokers affecting their lives, Islam has adopted a stand against smoking.

Islam, through its religious injunctions, called fatwas, classifies smoking as a disrespectful and prohibited act that should not be associated with Muslims. Since the Holy Quran prohibits Muslims from indulging in acts that may cause harm, religious scholars regarded the act of smoking as lawful but to be discouraged, which is known as a mukrooh act.


International Standing for Smoking Cessation and Potential Impacts on Saudi Males
The participation of the international community is critical in making the treatment of tobacco dependence readily accessible and available (Wilson, 2002). As the Kingdom of Saudi Arabia is still in the stage of developing its national policy and guidelines for smoking cessation, the international community can support it in many ways. Saudi Arabia can share and access information in international forums. International support can help Saudi Arabia in forming guidelines and reviewing the best practices, fund-raising and strengthening partnerships with academic and research institutions from other countries.

Several international organizations, universities and social groups are acting for smoking cessation around the world. They support environmental changes for the promotion of non-smoking as a social norm and they promote the benefits of smoking cessation. Internationally, there are various avenues for health cooperation (Wilson, 2002).

Increasing Accessibility to Smoking Cessation Products
It is important to make smoking cessation products readily available and affordable to smokers who have not been able to purchase them. It is advisable initiating a campaign to reduce smoking for the reason that the high rates of smokers are getting higher and higher compared to the past studies (Wilson, 2002) similar to that organized for AIDS treatment in African countries. Significant international pressure was put on pharmaceutical companies to review their product prices and policy for AIDS drugs in the poor African nations where the epidemic was spreading.

Similarly, there are efforts to make cheap generic classes of smoking cessation products like NRT and Zyban more easily available. The relaxation of regulations for smoking cessation products is demanded as an extremely high death toll is being caused by smoking in Saudi Arabia. The document of the WHO FCTC mentions the need for affordability and the availability of interventions for smoking patients in the Kingdom. It is stated that countries shall develop collaboration with other countries to increase access and reduce prices for treatment of tobacco dependence.

Bans on Advertisements
An international effort to ban tobacco-product advertisements could have a great impact on smoking rates in Saudi Arabia. The Canadian Cancer Society Studies have proved that marketing is a key tool in supporting addiction and deterring current smokers from quitting (Canadian Cancer Society, 2001). The WHO Framework Convention on Tobacco Control also identifies this fact. The aforementioned organization states that by taking comprehensive measures towards banning tobacco advertising, promotion and sponsorship, the consumption of tobacco products can be reduced substantially. It stipulates that each country shall impose comprehensive bans over all supporting elements that promote tobacco products in conformity with the countrys constitution and constitutional principles.

Facts Revealed through Previous Studies on Smoking Cessation Services
A cross-sectional school-based study was conducted in Tabouk Government schools with grades 7 to 12. Students of these intermediate and secondary schools were aged from 12 to 19 years. The study identified that quit rates are influenced by friends, peers and other members in the family. In Arab culture, the family is a major social unit and the smoking habit for adolescents is initiated through family members and people around them. Parental smoking history is a significant factor in adolescent smoking at an early age. Above 30 of the students were reported as living in company with at least one active smoking parent. Although parental smoking cessation has an effect on adolescent smoking, in each case the results are different as they depend on the childs age when the parents quitted smoking (Abdulrahman et al 2008).

The rate for an adolescent child to be an addicted smoker is seen to be high if either of the parents had stopped smoking when the child was aged 11 to 14, whereas the rate is low when parents quitted before the child reached 7. These findings, which indicate that family environment can have a major impact on quitting smoking, are similar to those of many previous studies. Adolescents living in a household with a number of smokers are less likely to stop (Abdulrahman et al, 2008).

Nearly 36 of the adolescents in Saudi Arabia reported that their family members had advised them to quit smoking. The findings further reveal that 11 of ex-smokers used tobacco before reaching the age of 10 and more than 70 have tried it between the age of 10 and 15. Yet, only 17 of the adolescents joined cessation programs (Abdulrahman et al., 2008). Hence, there is a need to make these health care services known to all adolescent smokers and to make them more attractive to young Saudi Arabian male smokers.

However, some smoking cessation services led by health professionals in the Primary Health Care clinics have been observed to be inconsistent in advising and counselling against smoking. Physicians use different and often ineffective interventions and techniques for smoking cessation. The findings show that the Kingdom seems to be facing a huge challenge in persuading Saudi Arabian male smokers to quit smoking. Nicotine replacement therapy and other pharmacologic methods are not widely in use and their availability is limited to few health centres. Thus, the results of the study conducted by Health Department of Saudi Arabia must be evaluated for the development of new policies related to the health and trade in the Kingdom of Saudi Arabia (Abdulrahman et al., 2008).
As mentioned by the government comprehensive national strategy is needed to promote smoking cessation activities. Such activities should be directed by clear guidelines within the framework of a comprehensive plan. The media in its different forms (television, internet, magazines etc.) can be a powerful tool to increase awareness and education about health care. For Saudi male smokers of all ages, whether they are elderly or adolescents, smoking cessation programs must be effective, attractive and appealing. These anti-smoking activities could also be based on internet and mobile phone messages as these contemporary platforms help in reaching every individual instantly (Abdulrahman et al, 2008).

Educational professionals must realize and strengthen their role as their significance is proven (through their influence) in terms of encouraging and sustaining smoking cessation in Saudi male smokers. Support from friends and family will build up the morale of Saudi male smokers in quitting.
All these considerations are important while developing and evaluating smoking cessation methods in the Kingdom of Saudi Arabia.

Comparison and Contrast between the United Kingdom and Saudi Arabia
In the United Kingdom, smoking is regarded as the main cause of preventable disease and premature death in the country. England alone has already recorded more than 80,000 deaths per year due to cigarette smoking and, despite this reality, 8.5 million people still currently smoke in this part of the UK (Department of Health, n.d.). In the same manner, the Kingdom of Saudi Arabia is also experiencing a similar phenomenon because cigarette smoking is also the leading cause of preventable diseases in the country. In addition to this, the number of people who smoke cigarettes in Saudi Arabia is still increasing (Habib, 2010).

The government of the United Kingdom is taking the necessary steps in order to address the problems related with cigarette smoking, especially in terms of its adverse effects on the health of individuals. Due to this, the United Kingdom government has launched a tobacco control strategy, which has as its main goals the eradication of the harmful effects of tobacco smoking and the establishment of a smoke-free future. The Department of Health is actively participating in the objective of curbing cigarette smoking. In delivering a smoke-free future, the United Kingdom government has three visions namely (1) to stop the inflow of young people recruited as smokers (2) to motivate every smoker to quit (3) to protect families and communities from tobacco-related harm (Department of Health, n.d.). The Health Bill 2009 exemplifies the efforts of the government when it comes to eradicating tobacco smoking. The Health Bill 2009 proposed the prohibition of displaying tobacco in shops and also the sale of cigarettes in vending machines (Department of Health, n.d.). Similarly, the Saudi Arabian government is also implementing the necessary laws and protection in order to solve the problems that are related with tobacco smoking. Saudi Arabia has an Anti-Smoking Law of 20 articles, which also proposes banning the sale of cigarettes in vending machines (Sujudi, 2004).
 In addition, Saudi Arabia also wants to eradicate cigarette smoking since it is against the Islamic faith, as it destroys the body and integrity of an individual. Nevertheless, despite the similarities of the United Kingdom and Saudi Arabia when it comes to tobacco smoking problems and their respective ways of addressing them, these two countries differ significantly when it comes to the results of the respective efforts of their governments. Since 1998, the rate of adult smoking in England has fallen from 28 in 1998 to 21 in 2007, which is a decline of almost 2.5 million smokers (Department of Health, n.d.). On the other hand, Saudi Arabia experienced an alarming increase in the number of smokers in 2007. Saudi smokers have increased to 6 million, which includes 600,000 women smokers and 772,000 teenage smokers (Habib, 2010).        

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