The burden of tobacco use remains a significant global public health challenge, causing over 8 million deaths annually, primarily in low- and middle-income countries (1). In Saudi Arabia, the prevalence of current smoking among adults was approximately 12% in 2013 (2). By 2018, data from the Saudi Food and Drug Authority (SFDA) indicated an increased prevalence of smoking, with 21% of adults reporting current smoking (3). In 2019, the Global Adult Tobacco Survey (GATS) revealed that the prevalence of tobacco use among adults aged 15 years and above in Saudi Arabia reached 19%, with a higher prevalence among men (30%) than among women (4%). The survey also revealed that the average age of daily smoking initiation is 18 years (4). These factors position tobacco control as a critical public health priority in Saudi Arabia, particularly given that smoking is responsible for an estimated 70,000 deaths annually (5).

Youth is considered the largest segment of the population in Saudi Arabia (6). Maintaining a healthy status for youth is essential to reduce the risk of many preventable chronic diseases, particularly those related to tobacco use, such as hypertension, cardiovascular diseases, and cancers (7). In Saudi Arabia, the prevalence of hypertension is greater than that in other Arab countries (8), and there is a specific increasing trend of cardiovascular disease among youth (9). In addition, the tobacco industry has historically employed aggressive marketing strategies targeting adolescents, referring to them as “replacement smokers” (10, 11). In Saudi Arabia, approximately 15% of adolescents reported using tobacco in 2010 (12). A systematic review of studies published between 2007 and 2018 revealed that the prevalence of tobacco smoking among adolescents in Saudi Arabia ranged from 12.7 to 39.6% (13). These data indicate a wide range of prevalence rates attributable to various sampling methodologies employed across the included studies.

Furthermore, several studies have demonstrated similar variations in cigarette smoking prevalence according to region and sex (2, 12–14). One 2025 article revealed that the prevalence of youth who had ever used e-cigarettes in Saudi Arabia was 14.2% (15). Despite the implementation of educational programs and anti-tobacco campaigns, younger individuals continue to use tobacco (16).

The Saudi Ministry of Health (MOH) launched a national tobacco control program following Saudi Arabia’s ratification of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in 2005 (5, 17). Efforts to combat smoking began in the early 2000s. In 2009, the Gulf Cooperation Council (GCC) Standardization Organization (GSO) introduced a technical regulation that included provisions for limits on cigarette emissions, such as tar, nicotine, and carbon monoxide (18). This was followed in 2011 by GSO regulations mandating labeling requirements for tobacco product packaging (19). That same year, the MOH established specialized tobacco cessation clinics to support individuals seeking to quit smoking (12). Between 2012 and 2022, the government adopted more aggressive measures to control tobacco use (20). In 2015, Royal Decree No. 56 introduced the Anti-Smoking Law, a comprehensive framework for tobacco control in Saudi Arabia. The law imposed restrictions on smoking in public places, limited tobacco advertising, promotion, and sponsorship, and set requirements for health warnings on tobacco packaging (21). Additional measures followed, including a substantial 100% increase in tobacco taxes, an expansion of the smoking ban to include public establishments and restaurants, and the implementation of penalties for violations of smoking regulations.

Furthermore, the MOH ensures better access to high-quality treatment and preventive services; thus, it has collaborated with the Ministries of Education, Transportation, Interior Affairs, and the SFDA. The MOH has also launched several anti-smoking campaigns through mass media and social media platforms, aiming to raise awareness about the dangers of smoking (20). To support individuals who wish to quit, various smoking cessation services, including free treatment programs and the “937” Smoking Cessation Help Service hotline, have been established for citizens, residents, and visitors in the Kingdom of Saudi Arabia (22). In 2018, the SFDA issued a circular to tobacco product importers, mandating compliance with plain packaging regulations for tobacco products (20). By 2019, these services were made widely accessible through a network of 274 hospital-based clinics, 321 primary healthcare centers, 890 fixed smoking cessation clinics, 100 mobile cessation clinics, 283 home care services, and 14 specialized hospitals (12).

Although Saudi Arabia was recognized by the World Health Organization (WHO) in 2018 as one of 23 “best practice” countries for its exemplary efforts in providing effective tobacco dependence treatment (23), systematically tracking cigarette smoking prevalence since the implementation of these regulations has remained critically important. Despite increasing concerns about adolescent smoking in Saudi Arabia, comprehensive national-level evidence to fully understand its prevalence and associated factors is lacking.

Monitoring smoking trends over time is essential for informing public health policies and designing effective interventions, enabling the development of targeted strategies to prevent smoking initiation and reduce overall prevalence. Furthermore, these insights are crucial for optimizing resource allocation to address tobacco-related health challenges. The lack of a nationally representative tobacco survey in the past has limited the ability to analyze trends over time. Saudi Arabia conducted two waves of the Global Youth Tobacco Survey (GYTS), a nationally representative survey, in 2007 and 2010; however, these surveys were undertaken prior to the ratification of the FCTC (24). The recent administration of the GYTS by the Saudi MOH in 2022 presents an opportunity to assess tobacco trends in Saudi Arabia and examine whether tobacco-related health risks have changed over time. Such analyses could provide a better estimate of the current and future health burden of tobacco use, including its contribution to chronic diseases and its economic impact on the healthcare system. Therefore, this study investigated trends in tobacco use among youth in Saudi Arabia from 2007 to 2022 and evaluated whether the determinants of tobacco use and control have evolved over time.

This study employed an observational, cross-sectional design. GYTS data, which are nationally representative, were utilized. The GYTS is a cross-sectional, school-based survey of grade 1–3 intermediate school students (typically aged 13–15 years). In Saudi Arabia, the GYTS was conducted in 2007, 2010, and 2022. Three waves of the GYTS were included in this study. GYTS data from two waves (2007 and 2010) are publicly available,¹ whereas 2022 GYTS data were obtained with permission from the Ministry of Health in Saudi Arabia (IRB log No: 23–106 M).

The GYTS, a component of the Global Tobacco Surveillance System (GTSS), is a global standard for systematically monitoring youth tobacco use and tracking key indicators of tobacco control. The survey uses a standard core questionnaire, sample design, and data collection protocol. The questionnaire is self-administered via scannable paper-based bubble sheets. The questionnaire covers the following topics: tobacco use, cessation, second-hand smoke (SHS), pro- and anti-tobacco advertising and promotion, access to and availability of tobacco products, and knowledge and attitudes regarding tobacco use. Demographic data, including age, sex, income, and residency, were also collected.

The GYTS employs a global standardized methodology that incorporates a two-stage sample design, where schools are selected with probability proportional to their enrollment size. The classes within the selected schools were chosen randomly, and all the students in the selected classes were eligible to participate in the survey. A two-stage cluster sample design was used to produce a representative sample of the students.

School Level—The first-stage sampling frame included all schools with 1st–3rd-grade intermediate classes of 40 or more students (mainly aged 13–15 years). Schools were selected with a probability proportional to the school enrollment size.

Class Level—The second sampling stage involved systematic, equal-probability sampling (with a random start) of classes from each participating school. All classes in the selected schools were included in the sampling frame. All the students in the selected classes were eligible to participate in the survey.

The GYTS was conducted by the Saudi Arabia MOH in 2007, 2010, and 2022. All GYTS waves were included in this study. Male and female students aged 13–15 years were considered.

Various personal characteristics, including demographic, intra- and interpersonal, environmental, and social factors, were analyzed. Additionally, variables related to tobacco control policies, which included smoke-free policies, restrictions on tobacco advertisements, awareness-raising initiatives, and measures to prevent minors from accessing tobacco, among others, were examined. Appendix 1 presents the key questions considered in the study.

Variables similar across the three studies were integrated into a single dataset for analysis. During data management and cleaning, some variables were recoded to standardize them across the 3 years, aiming to simplify the analysis and interpretation. Subsequently, descriptive and linear regression analyses were performed to determine the rate of change over time (independent variable) while controlling for confounding factors, including age, sex, and grade level. The dependent variables across the analyses were categorized into the following domains: (A) tobacco prevalence; (B) age of smoking initiation; (C) exposure to second-hand smoke; (D) exposure to marketing activities; (E) tobacco-related attitudes, perceptions, and knowledge; and (F) intention to quit smoking (Appendix 1). Detailed information is provided regarding the chosen variables within each domain. The analyses were conducted using IBM SPSS Statistics 27 software.

The data from GYTS surveys conducted in 2007 (n = 2,574), 2010 (n = 1,797), and 2022 (n = 5,610) were analyzed. As presented in Table 1, the age distribution across surveys showed slight variation, with the 2022 survey having a greater proportion of 13-year-olds (34.4%) than the 2007 (26.7%) and 2010 (31.7%) surveys. The sex distribution remained relatively balanced across all three surveys, with male participation ranging from 46.9 to 50.9%. Most of the participants were enrolled in the 1st–3rd intermediate grades, with the 2nd intermediate grade consistently representing the largest proportion of students (37.1–40.3%).

The analysis of tobacco use behaviors revealed several significant trends between 2007 and 2022 (Table 2). The prevalence of current tobacco product use significantly decreased by 6.5% (B = −0.44, p = 0.030), declining from 15.9% in 2007 to 9.4% in 2022. Similarly, the use of other tobacco products demonstrated a significant reduction of 4.4% (B = −0.293, p = 0.003), dropping from 11.9 to 7.5% over the study period. Sex-specific analysis revealed that boys experienced a significant decrease in ever-smoking cigarettes, with a 9.6% decrease (B = −0.657, p = 0.048), resulting in a decline in prevalence from 35.8% in 2007 to 26.2% in 2022. Girls showed no significant trend in ever smoking cigarettes; however, the prevalence increased slightly, albeit not significantly, rising by 5.2% from 16.1% in 2007 to 21.2% in 2022 (B = 0.376, p = 0.172). Current cigarette smoking rates notably decreased across both genders, dropping by 3.8 percentage points from 6.7% in 2007 to 2.9% in 2022. The intention to initiate smoking among never smokers decreased substantially from 19.2% in 2007 to 7.9% in 2022, a change of 11.3 percentage points. Although findings related to the age of smoking initiation were not significant, they showed concerning trends, with an increase in early initiation (Table 2). The proportion of students who started smoking cigarettes at the age of 7 or younger increased by 8%, from 9.1% in 2007 to 17.1% in 2022. Similar patterns were observed for shisha use, with substantial proportions initiating use at young ages across all survey years.

Exposure to second-hand smoke tended to decrease across all measured indicators (Table 3). The percentage of students living in homes where others smoke decreased by 9.8%, from 27.9% in 2007 to 18.1% in 2022. Notably, the percentage of boys with one or more parents who smoked significantly decreased by 10.5% from 25.9 to 15.4% (B = −0.702, p = 0.006). Exposure to smoke outside the home also decreased by 9.7%, from 38.2 to 28.5%, over the study period. Moreover, exposure to tobacco marketing activities such as advertisements and promotions showed a declining trend, with the percentage of students who reported seeing tobacco use in the media decreasing by 35.7%, from 83.8 to 48.1% (Table 3).

Perceptions of smoking showed significant changes among girls (Table 4). There was a 6.8% decrease in those who thought that smokers were attractive (B = −0.676, p = 0.028), whereas there was a 6.4% increase in those who believed that smoking helped people feel more comfortable (B = 0.55, p = 0.033). The proportion of students taught about the dangers of smoking in class decreased by 21.4%, from 58.8% in 2007 to 37.4% in 2022, whereas exposure to anti-smoking media messages declined by 18.4%, from 61.8 to 43.4%. Further subanalysis of intentions to quit smoking among current tobacco users revealed a significant declining trend among girls, with their quit intention decreasing by 13.5%, from 65.7 to 52.2% (B = −0.895, p = 0.010). Compared with girls, boys had a higher but declining quit intention rate of 17.4%, decreasing from 77.1 to 59.7% (Table 4).

This study has several limitations. First, the use of secondary data from the GYTS may impact reliability, as inconsistencies in survey administration and variations in sampling methods may have existed across the years. Second, relying on self-reported data may imply the possibility of recall and social desirability biases, which could influence the accuracy of the reported prevalence of tobacco use and related behaviors. Third, owing to the cross-sectional nature of the study design, establishing temporal relationships between variables was not possible. Incorporating longitudinal follow-up data could help in assessing changes in tobacco trends and enhance the development of causal relationships. Fourth, the study analysis focused on adolescents aged 13–15 years, which limits the generalizability of the findings to other age groups, such as young adults. Thus, expanding the age range of participants to include young adults would enhance the generalizability of the findings and help in capturing tobacco use beyond the cohort of 13–15 years. Finally, variations in the implementation of tobacco control policies over time may not be fully captured by the study design, limiting the ability to attribute changes in tobacco use directly to specific interventions.