Introduction

Secondhand smoke (SHS) exposure remains a major public health concern globally, being responsible for over 1.3 million deaths and millions of disabilities every year1. Exposure to SHS increases the risk of several diseases, including cardiovascular diseases2, chronic obstructive pulmonary disease3, hypertension4, type 2 diabetes5, stroke, and several types of cancer6. Moreover, never-smokers exposed to SHS have a higher risk of all-cause mortality (18%), cardiovascular diseases (23%)2, and cancer (16%)7. Globally, SHS exposure was also responsible for 2 million deaths due to stroke8, more than 130,000 cancer-related deaths, and more than 3 million cancer-related disability-adjusted life years (DALYs)9.

Children and adolescents are especially vulnerable to the health consequences of SHS, including increased risks of respiratory infections10, middle ear disease6, and other adverse effects11. In 2019, SHS was responsible for approximately 7% of lower respiratory tract infection-related mortality and DALYs among children younger than 5 years12. In addition, exposure to SHS increases the likelihood of susceptibility to tobacco use13, tobacco use initiation14, and nicotine dependence15 among adolescents.

The Gulf Cooperation Council (GCC) is a political and economic cooperation entity whose member countries include Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE). The six GCC members have a similar culture and history and a high economic status. All the GCC countries had ratified the Framework Convention on Tobacco Control (FCTC) by 200616. However, the region still suffers from the burden of smoking and SHS exposure. The prevalence of tobacco smoking among people aged 15 years and older in 2020 was estimated to range from 10.6% in Oman to 22.3% in Kuwait17. The high prevalence of tobacco smoking is also reflected in the burden of several tobacco-related diseases18,19,20,21; for example, 16% of cancer cases in the GCC countries (22.8% among men and 2.8% among women) are attributable to smoking22. In addition to the detrimental health consequences of SHS, the GCC countries are also impacted by its economic costs, which were calculated at approximately USD 7.1 billion in 2016 based on purchasing power parity23.

The prevalence of SHS exposure among youth in the GCC countries is a significant topic due to its potential impact on the health of current and future generations. However, data on SHS exposure among adolescents in the region are limited. A few studies have reported concerning rates of SHS exposure among youth in the GCC countries24. However, these studies were mostly limited to the subnational level, with small sample sizes25,26. In addition, GCC countries have undergone rapid socioeconomic transformation in recent decades, which has significantly influenced smoking behaviors and SHS exposure16,27. This modernization has led to changes in lifestyle and social norms, potentially increasing susceptibility to tobacco use, especially among youth. Cultural practices unique to the region, such as the social acceptance of waterpipe smoking, further complicate tobacco control efforts. Waterpipe use is often perceived as less harmful and more socially acceptable than cigarette smoking28, contributing to increased SHS exposure in social settings29. Moreover, gender roles and expectations in GCC societies play a critical role in shaping smoking patterns and SHS exposure21,30.

The objective of this paper was to analyze SHS exposure patterns among adolescents (12–16 years) across the six GCC countries by synthesizing data from the most recent Global Youth Tobacco Survey (GYTS) conducted in each nation. Beyond prevalence data, we conducted an in-depth examination of predictors associated with SHS exposure in different settings (home, public places, and schools) and provided gender-specific insights into exposure patterns. Examining exposure prevalence, associated factors, and gender differences in this region can highlight priority areas for intervention and policy to protect youth from tobacco-related harms. This paper provides a comprehensive analysis of SHS exposure at home, in public places, and at school among adolescents in the GCC countries.

Methods

Data source

The data for this analysis came from the Global Youth Tobacco Survey (GYTS), a school-based survey of boys and girls students aged 12–16 years31. The GYTS uses a standardized methodology to monitor youth tobacco use, attitudes, exposure to SHS, cessation, media messages, access and availability, and other tobacco control indicators across countries. The GYTS is a recurring survey conducted every 4 years. For this analysis, the most recent available GYTS data from each GCC country were utilized, with surveys conducted from 2010 to 2018 (Table 1).

Table 1 Sample characteristics and key exposures among adolescents in GCC countries (unweighted)*.
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For each participating GCC country, the GYTS used a comprehensive, national sampling strategy to representatively survey students in grades associated with ages 13–15 years. A two-stage cluster sample design was employed to produce nationally representative samples of students. The first stage consisted of selecting schools with probabilities proportional to student enrollment size. The second stage involved randomly selecting classrooms from each chosen school. All students in the selected classes were eligible to participate in the survey. The GYTS was administered during regular class periods, with students recording their responses on computer-scannable answer sheets.

Survey measures

The main outcomes examined in this analysis were exposure to SHS at home, in public places, and at school. The questions assessed exposures within the past 7 days. Students were considered exposed to SHS at home if they reported people smoking in their presence at home on 1 or more days in the past 7 days. Exposure in public places was defined as people smoking around them in places other than home on 1 or more days in the past week. Public places included both indoor and outdoor places. Finally, students were considered exposed to SHS at school if they reported observing people smoking in school on 1 or more days in the past week.

Additional collected variables included demographics such as age, sex, grade level, parental smoking status, having friends who smoke, beliefs about the harms of SHS, exposure to tobacco advertising, and exposure to anti-smoking media messages.

Data analysis

All analyses were conducted using Stata/MP 18 software, accounting for the complex survey design and sampling weights from the GYTS. To account for the complex survey design, primary sampling units were defined based on the original strata and clusters within each country dataset. The sampling weights provided for each country were incorporated using the svyset command in Stata for weighted analyses and to obtain appropriate variance estimates. All analyses applied sub-population survey commands (svy) in Stata to handle the clustering, stratification, and sampling weights. In the present analyses, a complete case approach was followed, where only cases with full information on all variables of interest were included in the final analytical sample.

Descriptive statistics were calculated to summarize the sample characteristics across the GCC countries. These included frequency distributions of demographic factors (age, sex, grade level), social exposures (parental smoking, friend smoking), beliefs about SHS harms, exposure to tobacco advertising and promotion, and exposure to anti-smoking media messages. The prevalence of SHS exposure at home, in public places (combined indoor and outdoor), and at school was estimated for the overall sample and stratified by sex using survey proportion commands with 95% confidence intervals.

Multivariable logistic regression models were used to examine factors associated with each SHS exposure outcome (home, public, school). The models included country, age, sex, parental smoking, friend smoking, beliefs about harms, anti-smoking media exposure, and tobacco advertising exposure as independent variables. These variables were selected based on the literature and theoretical background.32,33,34 The reported adjusted odds ratios were adjusted for all the mentioned independent variables. Multicollinearity was assessed using variance inflation factor. Adjusted odds ratios and 95% confidence intervals were calculated from the regression models.

Results

Sample characteristics

A total of 17,220 students participated in the GYTS across the six GCC countries. The sample included adolescents aged 12–16 years old, with approximately half being males and half female. Table 1 shows the distribution of key demographic and exposure characteristics among the sample of adolescents surveyed. The sample size and distribution by country ranged from 2071 in Qatar (12% of the total) to 4259 in the UAE (24.7% of the total). Regarding age, there was an approximately equal distribution of students aged 13 years (21.7%), 14 years (26.9%), and 15 years (26.1%), with a lower percentage aged ≤ 12 years (9.3%) or ≥ 16 years (15.9%). The sample was nearly evenly split by sex, with 47.7% males and 52.3% females. Regarding parental smoking, around one-quarter of the overall sample reported having a parent who smokes, ranging from 14.4% in Oman to 35.8% in Kuwait. Around 30% indicated that their friends smoke. Regarding beliefs, 39% did not think SHS is harmful, ranging from 33.7% in Oman to 43.5% in Qatar. The majority (80.8%) reported exposure to tobacco advertising or promotion, with almost 95% being exposed in Saudi Arabia and the lowest percentage being exposed (73%) in Qatar. Just over half (58.8%) had seen or heard anti-smoking media messages, ranging from 46.3% in Qatar to 71.4% in Saudi Arabia.

Prevalence of SHS exposure

Table 2 presents the prevalence of SHS exposure at home, in public places, and at school among adolescents in the GCC countries, including overall estimates and those stratified by gender. Overall, exposure at home ranged from 12.7% in Oman to 39.4% in Kuwait. Exposure was generally higher among girls compared to boys in most countries, with the biggest gender disparity observed in Qatar (26.6% for girls vs 20.7% for boys).

Table 2 Secondhand smoke (SHS) exposure by gender and country in the GCC countries.
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In public places, exposure was common, with almost half reporting exposure to SHS, and the prevalence ranged from 40.8% in Saudi Arabia to 65.9% in Kuwait. Boys reported higher exposure than girls in all countries except Qatar, with the largest relative differences observed in the UAE (63.1% for boys vs 51.0% for girls) and Saudi Arabia (43.9% for boys vs 37.6% for girls).

Approximately one-third of respondents reported exposure at school in most countries, with the prevalence ranging from 20.69% in Oman to 36.7% in Kuwait. In all countries, exposure at school was substantially higher among boys compared to girls. For example, in Qatar, 44.44% of boys reported exposure versus only 16.66% of girls.

Factors associated with SHS exposure

In adjusted analyses using multivariable logistic regression models, exposure at home was significantly associated with older age, male sex, parental smoking, friend smoking, and a lack of belief in the harms of SHS (Table 3). Adolescents aged 16 years or older had 1.37 times higher odds of home exposure compared to those aged ≤ 13 years. Females had 1.4 times higher odds of exposure at home than males. Parental smoking had the strongest association, with 6.5 times higher odds of SHS exposure for those who have one or more parents smoking, while friend smoking and a lack of belief in the harms were associated with approximately 1.9- and 1.4-times higher odds, respectively. In public places, exposure was associated with older age (14–15 years), parental smoking, friend smoking, and tobacco advertising exposure. Friend smoking and tobacco advertising had the strongest effects, with 2.2 times higher odds of SHS exposure. Exposure at school was associated with male sex, friend smoking, and tobacco advertising exposure. Girls had 64% lower odds of exposure than boys, and exposure to tobacco advertising was associated with 1.46 times higher odds.

Table 3 Factors associated with secondhand smoke exposure at home, in public places, and at school in GCC countries.
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Discussion

This study revealed high rates of SHS exposure among adolescents across the GCC countries, with over half reporting exposure in public places. Exposure at home varied widely from 13% in Oman to 39% in Kuwait. While prior national studies in Saudi Arabia and Kuwait reported a similarly high prevalence, this is the first multi-country investigation synthesizing data across the region to provide a comprehensive overview of SHS exposure. The levels documented in our study indicate that GCC youth are facing dangerously high SHS exposure, especially in public places.

In line with other research24,35, we found that older adolescents generally reported higher exposure at home and in public places compared to younger students, although exposure in public places was not statistically significant among 16 years and older group. This may reflect more time spent outside the home with greater access to public venues. Boys also generally reported higher exposure than girls, which could be related to social norms around smoking and gender-specific exposure risks that require further exploration. For example, girls in the region are often more likely to remain home, which could lead to greater exposure to SHS from parents or other adult relatives smoking inside the home. In contrast, boys may have more freedom to spend time outside the home in public places where smoking is common, as reflected by their higher exposure to SHS in public places in most countries.

As expected, having a parent who smokes was the strongest predictor of SHS exposure at home, increasing the odds of SHS exposure more than sixfold. Similarly, Al-Zalabani et al.25 found that adolescents having one or both parents who smoke had 5 times higher odds of SHS exposure in Saudi Arabia. Although some patterns in the gender differences in SHS exposure were observed, they varied between countries and the place of exposure. This highlights the need for further investigation of the gender-related determinants of SHS exposure in the cultural context of the GCC region.

In public places, friend smoking and tobacco advertising increased the odds of exposure, suggesting that these are key interpersonal and environmental risk factors. Smoke-free policies limiting advertising and restricting smoking in public venues could help reduce exposure among youth. At school, boys and those exposed to advertising had higher odds of SHS exposure. As schools are meant to be smoke-free, this indicates inadequate policy enforcement. Tobacco control initiatives should prioritize stronger implementation of smoke-free regulations and educational campaigns to denormalize smoking on school grounds. According to their guidance to schools, the World Health Organization asserts that nicotine- and tobacco-free policies can prevent young people from smoking, protect youth from SHS, reduce cigarette litter, and reduce cleaning costs36.

The findings have important implications for policy and practice. First, the high prevalence of exposure in public places highlights the need for comprehensive smoke-free policies that prohibit smoking in all indoor public spaces, including restaurants, cafes, and other gathering places frequented by youth37. Governments should prioritize the implementation and enforcement of such policies to create safer environments for adolescents16,38. Second, the strong association between parental smoking and adolescent SHS exposure at home underscores the importance of promoting smoke-free homes39. Public health campaigns should educate parents about the harms of SHS and encourage them to establish household smoking rules. Healthcare providers can also play a role by counseling parents who smoke to quit smoking or avoid smoking around their children27. Third, the findings highlight the importance of school-based interventions. While schools are meant to be smoke-free, the observed prevalence of exposure at school indicates a need for stronger enforcement of smoking bans on school grounds. Schools can also incorporate education about the harms of SHS into their health curricula to empower students to protect themselves and advocate for smoke-free environments.

While our findings underscore the need for comprehensive tobacco control policies, it is important to acknowledge the cultural and social barriers that might hinder implementing such measures in GCC countries. The social acceptability of smoking in certain contexts, particularly among men, and the widespread use of waterpipes pose unique challenges to tobacco control efforts targeting indoor household SHS exposure40. Cultural norms in the region may lead to disparities in tobacco control efforts; for instance, the stigmatization of female tobacco use could result in unequal dissemination of tobacco control information between genders13. Moreover, the interpretation and implementation of tobacco control measures vary across GCC countries, potentially explaining differences in SHS exposure prevalence. For instance, while all GCC countries have ratified the WHO Framework Convention on Tobacco Control, the extent of smoke-free policies and their enforcement varies between countries16. Meanwhile, the high prevalence of SHS exposure in schools across all countries suggests a common challenge in enforcing smoke-free policies in educational settings. The collectivistic nature of Arab societies, which values conformity, may amplify the influence of peer smoking on tobacco use initiation among nonsmoking youth13,40. This cultural context, combined with our findings, underscores the importance of implementing and enforcing comprehensive smoke-free policies in public spaces to safeguard youth from SHS exposure. Future research should explore these country-specific policy landscapes and cultural factors to inform more targeted and culturally sensitive tobacco control strategies in the GCC region.

Study strengths and limitations

This study has several notable strengths. It provides the first comprehensive analysis of SHS exposure patterns among adolescents across the GCC nations. It utilized data from the GYTS, which is a well-established and standardized survey methodology that allows for cross-country comparisons. The use of a standardized definition of exposure also facilitated comparisons between countries. Moreover, the GYTS sampling strategy ensured that the findings were generalizable to the population of adolescents in this age group within each country. Finally, the study assessed SHS exposure in multiple settings, including homes, public places, and schools. This allowed for a better understanding of settings where adolescents are most at risk of exposure and can inform setting-specific interventions.

Despite these strengths, the study also has some limitations. First, the cross-sectional design precluded causal inferences about the directionality of associations. Longitudinal studies are needed to establish temporal relationships. Second, the reliance on self-reported data may also have introduced biases. The respondents may have underreported SHS exposure due to social desirability bias, particularly due to strong cultural norms against smoking. Third, while the study adjusted for important covariates, residual confounding by unmeasured factors, such as socioeconomic status, parental education, or regional differences within countries, may have occurred. Future studies could consider multilevel models that account for clustering at the school or regional level to better disentangle individual and contextual influences on SHS exposure.

Conclusion

This study provides a comprehensive assessment of SHS exposure among adolescents in the GCC countries, revealing a high prevalence of exposure across multiple settings. Male sex, parental smoking, friend smoking, and exposure to tobacco advertising were significant risk factors for SHS exposure in various settings. These findings highlight the need for comprehensive tobacco control policies and targeted interventions to protect adolescents from SHS in the GCC region. Smoke-free laws covering all public places and workplaces should be enacted and enforced. Educational initiatives are needed to promote smoke-free homes and denormalize social smoking. Finally, schools must implement and enforce smoke-free campus policies.