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Waterpipe and cigarette smoking linked to heart attacks at younger age in Saudi Arabians

Smokers suffer from bigger heart attacks and have more complications

Risk Factors and Prevention
Acute Coronary Syndromes

Riyadh, Saudi Arabia 7 March 2019: Waterpipe and cigarette smoking are associated with heart attacks at a younger age in Saudi Arabians, reports a study presented at the 30th Annual Conference of the Saudi Heart Association (SHA 30). Smokers have more complications and worse outcomes.

SHA 30 takes place from 7 to 9 March in Riyadh. Joint scientific sessions are being held by the European Society of Cardiology (ESC) and SHA as part of the ESC Global Activities programme.1

Study author Dr Farhan A.W. Khan, of King Abdullah Medical City, Mecca, Saudi Arabia, said: “In addition to cigarette smoking, water pipe smoking – also called hookah and shisha – is very common in the Middle East due to social trends and the misconception that it is less harmful than cigarettes. More than one in ten Saudi Arabians smoke, starting at an average age of 19, while 9% of smokers start before age 15.”2

All types of smoked tobacco, including water pipe, increase the risk of cardiovascular disease.3 This study examined levels of cigarette and waterpipe smoking and outcomes in 1,554 heart attack patients presenting to King Abdullah Medical City between 2015 and 2018.

The average age at the time of heart attack was 54 years for smokers and 60 years for non-smokers – a statistically significant difference – despite diabetes mellitus and hypertension being less frequent in smokers. Smokers were more likely to have multiple arteries affected and more likely to have bigger, severe heart attacks in the form of ST-elevation myocardial infarction. Complications of heart attack, including pulmonary oedema and cardiac arrest, were more common in smokers. Smokers had a trend towards higher in-hospital mortality (4.0% versus 2.4%). More than one-third (38%) of heart attack patients were current smokers.

Smokers were predominantly men (98%). Regarding ethnicity, 50% of Arab patients and 35% of South Asian heart attack patients were smokers. More than half (51%) of patients living in Mecca were smokers, while 30% of patients on pilgrimage were smokers.

Dr Khan said: “Like studies from Western countries, our data suggest that smokers have heart attacks at a significantly younger age than non-smokers. Moreover, smokers have heart attacks even without other risk factors including diabetes and hypertension, and they have poorer outcomes.”

He continued: “There is limited awareness in the Middle East about the harmful effects of smoking, and particularly about the health risks of water pipe smoking. Tobacco products are reasonably cheap compared to the average income in Saudi Arabia. Young people in Saudi Arabia are particularly at risk of starting and continuing to smoke and there is also a growing trend in young females.”

The Saudi Ministry of Health started a national tobacco control programme in 2002 and smoking is banned in most public places.2 Tobacco packages must have health warnings and selling tobacco products to minors is prohibited. Dr Khan said more efforts are needed to enforce smoking bans and there should be higher taxes on tobacco products. Doctors and nurses should ask about smoking at each encounter, give advice to help smokers kick the habit, and refer smokers to dedicated cessation programmes. After a heart attack, smokers should be referred to cardiac rehabilitation programmes with smoking cessation services.

Dr Khan said: “Campaigns are needed to raise awareness about the harmful effects of waterpipe and cigarette smoking, particularly in young people so that they never take up the habit. People of all ages can improve their health and reduce their risk of heart problems if they quit smoking.”

Dr Fayez Bokhari, head of the Scientific Committee of SHA 30, said: “Saudi Arabia has made great progress in tobacco prevention including a ban on all forms of smoking advertising, a ban on smoking in public places and new added taxes on tobacco products; this is in addition to active educational campaigns. Despite all these efforts, smoking is still a major health problem with a huge burden to the economy. Data from The Ministry of Health of Saudi Arabia indicates that smoking kills 71 men and 21 women every week in Saudi Arabia along with 4,545 million Saudi Riyals in tobacco related-costs to the government.”4

Professor Marco Roffi, course director of the ESC programme at SHA 30, said: “Smoking can be lethal not only because of heart attacks but also stroke and cancer. Smoking is particularly dangerous in association with diabetes, a condition with high prevalence in the Middle East. The ESC prevention guidelines recommend no exposure to tobacco in any form.3 People who stop smoking generally halve their risk of cardiovascular disease. ESC advice to reduce smoking includes higher taxes and prices on all tobacco products, banning smoking in public places, and prohibiting sales of tobacco products to adolescents.”



Notes to editor

Authors: ESC Press Office
Tel: +33 (0)4 8987 2499

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References and notes

1ESC in Arabia.

2Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, et al. Tobacco consumption in the Kingdom of Saudi Arabia, 2013: findings from a national survey. BMC Public Health. 2015;15:611. doi: 10.1186/s12889-015-1902-3.

3Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016;37:2315–2381. doi:10.1093/eurheartj/ehw106.


About the European Society of Cardiology

The European Society of Cardiology brings together health care professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Global Activities

ESC Global Activities are extending the ESC mission beyond European borders. ESC Global Affairs is a programme of international ESC educational courses built around a global network of international partnerships.