Introduction

Tobacco use remains one of the most pressing global public health challenges, significantly contributing to premature mortality, disease burden, and economic costs1. The health consequences of tobacco consumption include increased risks of non-communicable diseases such as cardiovascular diseases, respiratory illnesses, and cancers2,3,4. In the Kingdom of Saudi Arabia (KSA), tobacco use continues to pose a serious threat to population health, despite government efforts to reduce its prevalence5. Between 1990 and 2017, years lived with disability (YLDs) attributable to tobacco use in the KSA increased by 9.9%, reflecting a rising burden of tobacco-related disease in the country6. Accordingly, preventing tobacco initiation and promoting cessation remain essential strategies for improving public health in the KSA.

Although the global share of smokers is declining—representing one of the most positive developments in global health, contributing to longer and healthier lives for millions—the KSA remains among the top countries in terms of tobacco sales and importation7. While thousands of people lose their lives each year due to tobacco-related disease, millions of adults still use tobacco daily, including the use of smokeless tobacco8. A study from 2013 estimated the prevalence of tobacco use in the KSA at approximately 12.2%, with men more likely to smoke than women (21.5% vs. 1.1%). Additionally, 23.3% of the Saudi population—including 32.3% of men and 13.5% of women—were exposed to second-hand smoke for at least 24 h/week at work, school, or home9. Recent data from the Global Adult Tobacco Survey (GATS) 2019 showed that 19.8% of adults aged 15 years and older in the KSA currently use tobacco, including 30.0% of males and 4.2% of females, while the use of smokeless tobacco stood at 2.4%10. These figures highlight the continued public health burden and reinforce the importance of sustained, evidence-based control efforts.

The KSA has implemented a range of tobacco-control measures—including smoke-free laws, advertising bans, age restrictions, and pictorial health warnings—but enforcement remains inconsistent11. On the fiscal side, a 100% selective excise tax and a 100% import duty were imposed on all tobacco products in 2017, followed by the general 15% value-added tax (VAT) in 202012. Following the excise tax, cigarette import volumes declined by 27.4% between 2013 and 2019, and the price elasticity of demand for cigarettes was estimated at − 0.93, indicating a substantial reduction in consumption in response to rising prices7. Despite these efforts, the national target of achieving a 30% relative reduction in tobacco use among individuals aged 15 years and older by 2025 has yet to be reached13. To reduce tobacco use and its health burden, integrated strategies that promote both cessation and prevention—alongside public education, taxation, smoke-free policies, and regulatory frameworks—are essential components of effective tobacco control11,14.

Numerous studies have investigated tobacco use in the KSA15,16,17. Bassiony15 conducted a comprehensive review of the literature on the epidemiology, consumption patterns, trade, control measures, prevention strategies, and treatment approaches related to tobacco smoking in the KSA. Qattan et al.16 examined the socioeconomic determinants of smoking behaviour, while Monshi et al.17 explored factors influencing the intention to quit smoking among tobacco users. While these studies have contributed valuable insights, they have largely focused on smoked tobacco products. The increasing prevalence of smokeless tobacco use, which is a growing health concern, was not comprehensively addressed in previous analyses.

In the light of these gaps, there is a need to provide an update on these trends in the context of sustained government efforts to reduce the consumption of tobacco products. Therefore, the aim of this study was to examine socioeconomic and demographic correlates of smoked and smokeless tobacco use in a nationally representative sample. These findings could help highlight specific disparities in the prevalence and correlates of smoking that represent a challenge for smoking prevention initiatives, thereby identifying new targets for effective policies.

Materials and methods

Study setting

This study was carried out in the KSA, the largest country in the Middle East, covering an area of approximately 2.15 million km2 and home to a population of about 35.3 million18. Globally recognized as a leading oil producer and exporter, the KSA is also home to some of the most significant Islamic heritage sites19. The country’s economy is largely dependent on oil revenues, which fund the majority of public sectors, including healthcare20. As classified by the World Bank, the KSA is a high-income country with a high Human Development Index21.

Data

This study used self-weighted data derived from the National Health Survey (NHS) conducted in 2021 by the General Authority for Statistics (GaStat) of the KSA22. The NHS is a large cross-sectional survey conducted to collect data from adults aged 15 years and above, addressing questions regarding health status (including tobacco use, physical activity, and nutrition), healthcare needs, and health behaviours of the population of the KSA, among other related topics22. The tobacco use section of the 2021 NHS covered questions on ever- and current-smoking status, type and frequency of tobacco products consumed, consumption of smokeless tobacco products, and age of smoking initiation. Data were collected through face-to-face interviews.

The survey questionnaire was developed by health statistics experts at GaStat, incorporating international guidelines, standards, and definitions provided by the WHO throughout the design process. The NHS employed a stratified, two-stage sampling design—a specific type of multi-stage sampling—to ensure national representativeness across all 13 administrative regions of the KSA. In the first stage, enumeration areas were selected from the Saudi Census frame using probability proportional to size sampling. In the second stage, individuals were randomly selected from each enumeration area using simple random sampling. Sampling weights were calculated to adjust for non-response and to align the sample with population distributions through post-stratification. The analysis was limited to respondents with complete data on all variables of interest, resulting in a final sample of 1530 respondents.

Measurements

Outcome variables

Two outcome variables were used for this study. The first variable was related to current smokeless tobacco use, which was assessed using self-reported responses to the question: “Do you currently use any type of smokeless tobacco? (including chewing, sniffing, and moist tobacco)”. The second variable is related to current smoked tobacco use, which was based on self-responses to the question: “Do you currently smoke any type of smoked tobacco? (including cigarettes, hand-rolled tobacco, Bidi cigarettes, cigars, smoking pipes, and hookahs)”. Both outcome variables were binary in nature and were dichotomized as 1 for “yes” and 0 for “no” for logistic regression analyses.

Explanatory variables

The explanatory variables included gender, age, marital status, educational level, work status, nationality, monthly income, and region. These variables were selected based on previous studies23,24 and variables available in the dataset. Gender was assigned a value of 1 for men and 0 for women. The age variable was divided into six categories: 15–24 (reference category), 25–34, 35–44, 45–54, 55–64, and ≥ 65 years. Marital status was also captured as a binary variable, with a value of 1 given for married respondents and 0 for unmarried respondents (including never been married, divorced, and widowed). Educational level was grouped as follows: primary school or below (reference category), intermediate school, high school, and higher education. Work status was assigned a value of 1 for those indicating they were employed and 0 for those indicating they were unemployed (including those responding as unemployed, those enrolled in education or training, and those dedicated to the work of the house). Nationality was given a value of 1 if the respondent was Saudi and 0 if non-Saudi. Monthly income [in Saudi Riyal (SR); 1 SR = USD 0.27] was grouped into six categories: less than SR 3000 (reference category), SR 3000 to < 6000, SR 6000 to < 12,000, SR 12,000 to < 20,000, SR 20,000 to ˂30,000, and ≥ SR 30,000. Region was grouped into 13 administrative regions: Riyadh (reference category), Al-Baha, Al-Jouf, Aseer, Eastern Province, Hail, Jazan, Madinah, Makkah, Najran, Northern Borders, Qassim, and Tabuk.

Statistical analysis

Frequencies and proportions were calculated to describe the distribution and prevalence of the current use of smoked and smokeless tobacco within the population. Bivariate associations between independent variables and current smoked and smokeless tobacco use were examined using the Chi-square (χ2) test. Additionally, a binary logistic regression model was developed to identify factors associated with current smoked and smokeless tobacco use. The enter-variable selection method was used in building the regression model. To account for the multi-stage sampling design used during the survey, the complex sample design module in SPSS was used. A multicollinearity test was performed to detect collinear variables that could affect the reliability of the regression slopes. A variance inflation factor (VIF) analysis was performed, which indicated no significant multicollinearity among the independent variables, as the VIF score for each variable was below the commonly accepted threshold of 525. Data analyses were carried out using the Statistical Package for Social Sciences version 27 (IBM SPSS 27).

Results

Descriptive statistics

The study included a diverse sample of 1530 adults. The population was predominantly male and composed largely of young and middle-aged adults, with a substantial proportion under the age of 45. Most participants were Saudi nationals, and nearly three-quarters were currently married. In terms of education, the majority had completed secondary school or attained higher education. Just over half of the respondents were employed at the time of the survey. Regarding tobacco use, 15.6% of participants reported currently using smoked tobacco, while 8.6% reported using smokeless tobacco. Table 1 shows the full characteristics of the sample.

Table 1 Descriptive statistics of the sample (N = 1530).
Full size table

Prevalence of current smoked and smokeless tobacco use

Table 2 presents the results of the bivariate analysis for the prevalence of smoked and smokeless tobacco use with respect to the socioeconomic characteristics of study participants. Gender differences were detected in the prevalence of current smoked tobacco use. In particular, a significantly higher proportion of men (22.99%) reported that they smoked tobacco compared to women (1.52%). The proportion of current smokers was also significantly higher among participants in the age groups of 25–34 (18.57%) and 35–44 (19.24%) years compared to those of other ages. The proportion of current tobacco smoking was also significantly higher among individuals who were married (16.73%), employed (22.17%), and earning 12,000–20,000 SR monthly (28.57%). There were significant regional differences for smoked tobacco use. For instance, a significantly high proportion among participants from Al-Baha (26.79%) and the Eastern Province (20.6%) reported smoked tobacco use. Meanwhile, there was no significant association between current tobacco smoking and the educational level or nationality of the participants.

Table 2 Bivariate analysis of the prevalence of current smoked and smokeless tobacco use with socioeconomic characteristics of the population.
Full size table

Table 2 also shows that a significantly higher proportion of men reported using smokeless tobacco (12.34%) compared to the proportion of women reporting the same (1.33%). Moreover, the proportion of individuals who reported smokeless tobacco use was significantly higher among individuals who were aged 55–64 years (13.24%), employed (11.68%), and earning 12,000 to 20,000 SR monthly (15.93%). There were no significant associations found between smokeless tobacco use and region, marital status, educational level, or nationality of the respondents.

Correlates of smoked and smokeless tobacco use

Smoked tobacco use

Table 3 shows the correlates of smoked and smokeless tobacco use among study participants. These associations represent both the unadjusted and adjusted odds ratio between smoked and smokeless tobacco use and socioeconomic characteristics. There was a statistically significant association between smoked tobacco use and gender of the respondent both in the unadjusted and adjusted models, indicating a reliable association. Specifically, after controlling for confounders, men were found to be over 14 times more likely [adjusted odds ratio (AOR) = 14.8, 95% CI = 7.03–31.5] to use smoked tobacco compared to women. Meanwhile, wide confidence intervals are observed for this predictor [gender] due to the relatively small proportion of the females in the sample, reflected in greater variability. After adjusting for other variables, age was significantly associated with smoked tobacco use, with individuals aged 25–34 years (AOR = 4.31, 95% CI = 2.00-9.29), 35–44 years (AOR = 4.11, 95% CI = 1.84–9.14), 45–54 years (AOR = 3.15, 95% CI = 1.32–7.48), and 55–64 years (AOR = 3.67, 95% CI = 1.33–10.1) being more likely to report smoked tobacco use compared to those aged 15–24 years.

After adjusting for other variables, the odds of smoked tobacco use were significantly lower among individuals who were married (AOR = 0.50, 95% CI = 0.32–1.19) and those with a higher education (AOR = 0.48, 95% CI = 0.25–0.90) compared to their corresponding counterparts. By contrast, individuals earning 3000 to 6000 SR (AOR = 1.96, 95% CI = 1.21–3.18) and 12,000 to 20,000 (AOR = 2.50, 95% CI = 1.39–4.51) were more likely to use smoked tobacco compared to those earning lower than SR 3000 monthly. Quite similarly, regional differences were observed for smoked tobacco use. The odds of smoked tobacco use were significantly higher at Al-Baha (AOR = 1.91, CI = 1.01–3.61), while for regions such as Hail (AOR = 0.38, CI = 0.16–0.90), Jazan (AOR = 0.43, CI = 0.20–0.90) and Najran (AOR = 0.07, CI = 0.01–0.56) the odds of smoked tobacco use were significantly lower than for Riyadh. With respect to employment status, the odds of using smoked tobacco were significantly higher among employed individuals in the unadjusted model. However, after introducing control variables, this statistically significant association was no longer found, indicating that the observation made in the unadjusted model was spurious and driven by other factors.

Smokeless tobacco use

Table 3 also shows that smokeless tobacco use was significantly associated with the gender of the respondent. For instance, the odds of smokeless tobacco use were significantly higher among men than among women in both the unadjusted [unadjusted odds ratio (UOR) = 10.4, 95% CI = 5.46–19.8] and adjusted (AOR = 8.00, 95% CI = 3.53–18.1) models, suggesting that the association is robust. Similarly, smokeless tobacco use was significantly associated with age, with individuals aged 25–34 years (AOR = 3.26, 95% CI = 1.32–8.01), 35–44 years (AOR = 2.83, 95% CI = 1.10–7.23), and 55–64 years (AOR = 3.71, 95% CI = 1.16–11.7) being more likely to report smokeless tobacco use compared to their counterparts. Conversely, the odds of smokeless tobacco use were significantly lower among individuals who were married (AOR = 0.47, 95% CI = 0.24–0.92) and those with a higher education level (AOR = 0.40, 95% CI = 0.17–0.90) compared to their counterparts. Notably, the odds of smokeless tobacco use were significantly higher among individuals with a monthly income of 6000 to 12,000 SR (AOR = 1.92, 95% CI = 1.07–3.37) and 12,000 to 20,000 SR (AOR = 3.18, 95% CI = 1.50–6.73) compared to those earning < 3000 SR. For regions, the odds of smokeless tobacco use were significantly low among participants from the Jazan region (AOR = 0.23, CI = 0.06–0.80) compared to Riyadh.

Table 3 Correlates of smoked and smokeless tobacco use among study participants.
Full size table

Discussion

This study provides an update on the patterns and correlates of smoked and smokeless tobacco use among the Saudi adult population according to the most recent 2021 NHS data. Among the 1,530 respondents, 15.6% reported current use of smoked tobacco, while 8.6% reported current use of smokeless tobacco products. This finding indicates a notable increase in the prevalence based on the Saudi Health Information Survey conducted in 20139. A relatively high prevalence of smokeless tobacco use can be attributed to several factors in Saudi Arabia. Smokeless tobacco use, particularly traditional form such as “Shammah” is relatively high in Saudi Arabia due to a combination of factors including cultural practices, social influences, and perceived lower health risks compared to smoking26,27,28.

Evidence from the 2019 nationally representative Global Adults Tobacco Survey (GATS) indicated that a substantial majority (82.4%) of tobacco users in Saudi Arabia expressed a desire to quit17. However, the observed increase in tobacco use prevalence between 2013 and 2021 suggests that this intention has not been fully translated into behaviour change. This trend may undermine government initiatives such as the 2015 anti-smoking law, enacted in alignment with the WHO Framework Convention on Tobacco Control (FCTC), which aims to reduce tobacco consumption nationwide29. Prior research suggests that rising tobacco use during this period may be partially explained by disparities in risk perception, particularly among individuals with lower income and educational attainment30. While the government has introduced measures such as increased taxation on tobacco products and restrictions on indoor smoking to encourage cessation17, additional efforts are needed. In particular, expanding public awareness of smoking cessation clinics—especially in low-income settings—may be key to reducing tobacco use and its associated health burden.

There are different forms of tobacco products available in the KSA, including cigarettes, and waterpipes, as new products have emerged in recent years10. Findings of this study indicate that most tobacco users still use smoked tobacco. This finding corroborates the results of other studies31,32,33,34. Despite evidence that some smoked tobacco users also use smokeless tobacco products35,36, the prevalence of smokeless tobacco is generally low among tobacco users in both developed37 and developing countries38, which was also evident in the present study.

Gender differences in tobacco use were evident, with significantly higher rates of both current smoked and smokeless tobacco use among men compared to women. After adjusting for potential confounders, men were approximately 14 times more likely to report smoked tobacco use and 8 times more likely to report smokeless tobacco use. These findings align with previous research showing that tobacco use is consistently more prevalent among male adults in both developed and developing countries38,39,40,41. Several cultural and behavioural factors have been proposed to explain these disparities, including differences in nicotine sensitivity, traditional gender roles, and societal expectations regarding tobacco use42. Moreover, cultural norms and social factors contribute to gender disparities in tobacco use observed in this study. While smoking prevalence is generally low among Saudi women compared to men, there is a growing trend of tobacco use among young women, with cultural perceptions playing a crucial role in uptake of both smoked and smokeless tobacco use. Some of the cultural factors commonly influencing the use of tobacco in Saudi Arabia are social acceptance of male smoking, the influence of Western culture, and the role of family and peers43,44.

Tobacco smoking and smokeless tobacco use were both significantly higher among people aged 25–64 years compared to those aged 15–24 years. The highest prevalence of smoked and smokeless tobacco use was among individuals aged 25–34 years and 35–44 years, respectively. A plausible reason for high tobacco use rates among individuals in these age groups could be related to increased stress in this period of life, as individuals transition from early adulthood to more established life stages, including professional pressures, relationships, and potentially starting families. Tobacco can sometimes be used as a coping mechanism for these stressors45. In some cultures, including in Saudi Arabia, tobacco smoking is seen as a more acceptable habit among adults in their late twenties to thirties, and certain milestones such as promotions or celebrating major events may be associated with smoking46.

Conversely, the prevalence of smoked tobacco use was found to be relatively low among married respondents compared to that of their non-married counterparts. Studies in developed and developing countries present mixed findings related to these trends. For instance, Ramsey et al.47 found that the prevalence of tobacco smoking was significantly higher among non-married individuals, whereas Fotouhi et al.48 found that tobacco smoking was significantly higher among married individuals compared to non-married individuals.

In addition, this study shows that the odds of smoked and smokeless tobacco use were significantly higher among respondents with relatively lower monthly incomes of 3000 to < 6000, 6000 to 12,000, and 12,000 to < 20,000 SR compared to their higher-income counterparts. Consistent with this finding, there is an established correlation between low-income status and tobacco use49. The use of tobacco among low- and middle-income earners can lead to a diversion of limited resources from essential needs, leading to a cycle of poverty. As a result, tobacco control policies, particularly significant increases in tobacco taxes, can help break the cyclical relationship between tobacco use and poverty.

There were regional differences observed for tobacco smoking. For instance, after adjusting for potential confounders it was observed that the odds of smokeless tobacco use were significantly higher among participants residing in Al-Baha region compared to Riyadh. Some previous studies have attributed high rates of tobacco use in Al-Baha than in other districts to the young age of smoking initiation and demographic and social influences such as having household members and friends who smoke50. On the other hand, it was observed that smoked tobacco use was significantly low among participants in Aseer, Hail, Jazan and Najran compared to those in Riyadh. The most plausible explanation for this finding is that these regions are found in the southern part and are known for their more conservative cultural values and strong community cohesion, which may discourage tobacco use, especially in public or among younger individuals51. These regions are also more rural and semi urban compared to Riyadh. It was also found that individuals residing at Jazan were less likely to report smokeless tobacco use compared to those residing in Riyadh since Riyadh is a highly urbanized area with wide product availability.

This study’s main strength is the use of timely national survey data to re-assess the prevalence and correlates of current tobacco use in the KSA population. The findings offer valuable insights that can inform the design of targeted and evidence-based tobacco control interventions. However, several limitations should be acknowledged. First, the cross-sectional nature of the data limits the ability to draw causal inferences between sociodemographic factors and current smoked and smokeless tobacco use. Second, the analysis was constrained by the use of secondary data, which restricted the variables that could be examined. Lastly, there is a possibility of underreporting tobacco use, particularly among female respondents, due to social desirability bias.

Conclusion

This study provides the most recent national evidence on the prevalence and social determinants of smoked and smokeless tobacco use among adults in Saudi Arabia. Variations in tobacco use were observed based on gender, age, marital status, education, employment status, income and region of residence. Despite ongoing tobacco control efforts, tobacco use remains prevalent, particularly among men, individuals aged 25–44 years, and those with lower- to middle-range income. These disparities suggest that current policies are not equitably reaching or impacting all population groups. The protective effects of higher education and marital status highlight the role of social and structural factors in shaping health behaviours. Addressing the patterns of tobacco use in Saudi Arabia requires more targeted, equity-oriented interventions—especially among socioeconomically disadvantaged and high-risk populations. Policies that encourage cessation support, regulatory measures, and community engagement should therefore be strengthened and tailored to the needs of disadvantaged population groups.