Determinants and Sequelae of Smoking: Prevalence, Incidence, and Cessation Among Male Adults in Abu Dhabi, United Arab Emirates. A Retrospective Cohort Study

Determinants and Sequelae of Smoking: Prevalence, Incidence, and Cessation Among Male Adults in Abu Dhabi, United Arab Emirates. 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A Retrospective Cohort Study Latifa Baynouna AlKetbi, Fatima Ali AlKetbi, Nico Nagelkerke, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4743493/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Sep, 2025 Read the published version in BMC Public Health → Version 1 posted 12 You are reading this latest preprint version Abstract Objectives The study aimed to determine the prevalence and the cumulative risk of smoking among national male adults in Abu Dhabi, and to assess the determinants of starting, quitting, maintaining cessation, and continuing smoking among them. Methods This retrospective cohort study has an average follow-up period of 9 years. The study population was national males aged 18 years and above. Data was initially collected from the medical electronic records of individuals who participated in a comprehensive screening program (Weqaya) performed in Abu Dhabi ambulatory healthcare services in 2011–2013. Results The prevalence of smoking among male adults was 21%. The cumulative risk of smoking was 45%, with the highest risk observed in adults aged 30–39. Young age and lower cholesterol level were the main determinants of starting smoking. The predictors of quitting smoking were younger age, lower systolic blood pressure, higher cholesterol, lower high-density lipoprotein (HDL), lower glomerular filtration rate (GFR), and vitamin D level. History of acute coronary syndrome (ACS) was a determinant for maintaining smoking cessation. Continuing smoking is associated with a higher risk of developing diabetes mellitus (DM), stroke, acute coronary syndrome (ACS), psychiatric illness, non-alcoholic fatty liver disease (NAFLD), and peripheral artery disease (PAD), while smoking cessation is associated with a reduced risk of those conditions. Conclusions The study confirms smoking's health burden in Abu Dhabi and its association with various health risks. Cohort study smoking tobacco prevalence Figures Figure 1 Figure 2 Introduction Tobacco use has been long recognized as a major public health problem, exerting a profound impact on the health of individuals and communities worldwide. The pervasive presence of tobacco products and the habitual and addictive nature of smoking have contributed to a global health crisis with far-reaching consequences for both physical and mental well-being. It is important to understand and address the health impact of tobacco use, considering its strong association with a group of diseases and its role as a leading preventable cause of morbidity and mortality. The adverse health effects of tobacco are diverse and affect multiple organ systems. The well-documented association of smoking with cardiovascular diseases, respiratory disorders, various cancers as well as reproductive health proves that the impact of tobacco on human health is extremely detrimental. As we grapple with the complexities of modern healthcare, studying the uptake and effects of tobacco usage becomes a necessity for developing effective preventive measures, interventions, and policies that can mitigate the burden of tobacco-related diseases. For the past decades, multiple policies have been implemented for this purpose, from smoking-free areas to smoking cessation campaigns and educational programs across the country. Controlling tobacco use is a main public health concern. Therefore, researchers, policymakers, and healthcare professionals should collaborate to develop targeted strategies for smoking prevention, cessation, and public health initiatives. In doing so, we move closer to building a healthier future free from tobacco-related diseases and mortality. This paper aims to give an overview of the prevalence of tobacco use in the Abu Dhabi region, to study the main determinants/ predictors of smoking behavior, and to investigate the major health outcomes of smoking behavior. Materials and methods This retrospective cohort study was conducted between September 2010 and July 2023. The study included national males aged 18 years and above who participated in a comprehensive screening program (Weqaya) performed in ambulatory healthcare services and primary care clinics in Abu Dhabi and Al Ain city between 2010 and 2013. Weqaya means prevention in Arabic. The Weqaya Screening Program is a population-level intervention developed by the Department of Health - Abu Dhabi, which aims to reduce the risks of cardiovascular diseases through early detection of risk factors, health education, and tailored personal health programs ( 1 ). UAE National adults over 18 years old are eligible for the Weqaya Screening Program. The screening includes the collection of information on demographic characteristics and self-reported indicators such as smoking status, preexisting cardiovascular disease (angina, heart attack, transient ischemic attack, stroke, or other circulatory disorder), and a family history of premature cardiovascular disease. It also involves obtaining anthropometric measures like height, weight, hip and waist circumference, Body Mass Index (BMI), and systolic and diastolic blood pressure (DBP), as well as hematological parameters in particular random glucose, glycosylated hemoglobin (HbA1c), total blood cholesterol, and random HDL cholesterol. ( 1 ) The participants’ follow-up data were collected from their electronic medical records in the Cerner system, which records every citizen's medical consumption. SPSS v29 software was used to analyze the data through crosstabulation, logistic regression, and Chi-square tests. All types of smoking were included (tobacco, cigarette, shisha, and pipe). The variables included in the analysis at screening were age at screening, smoking status at screening, SBP, DBP, BMI, HbA1c, cholesterol level, HDL, GFR, Vitamin D level, DM, prediabetes, stroke, ACS, and PAD. At the end of the follow-up, the variables collected were smoking status, psychiatric illness, NAFLD, Chronic Kidney Diseases, smoking uptake and cessation, cancer, and death. The average follow-up period was 9.2 years, with a range of 1–12. The primary outcome was the prevalence of smoking among UAE Nationals. The secondary outcome measures included cumulative risk of smoking in different age groups, determinants of smoking behaviors, particularly starting, quitting, and maintaining cessation, and association of smoking with other health conditions, including diabetes mellitus (DM), acute coronary syndrome (ACS), stroke, psychiatric illness, and non-alcoholic fatty liver disease (NAFLD). Results Prevalence of smoking A total of 8259 adults who participated in Weqaya screening program between 2011 and 2013 were included initially in the study. The Smoking statuses of 862 participants were not available/documented. Out of the total participants, 4037 were females, of whom only 19 of them reported being active smokers at the time of screening. Of the 3360 male participants, 826 were active smokers, 309 were ex-smokers, and 2225 were non-smokers at the time of screening. Considering the small number of female smokers at screening, female participants were excluded from the study. Male participants were followed up for an average of 9.2 years; 12.5% (277/2225) of the nonsmokers became new (incident) smokers, and 88% (1948/2225) remained nonsmokers (never smoked). On the other hand, 59% (489/826) of baseline smokers did quit smoking during follow-up, while 41% (337/826) continued smoking. This suggests that more than 50% of adult smokers quit smoking over time. Out of the total ex-smokers at screening (309), 70% (217) maintained their status as ex-smokers, whereas 30% (92) relapsed and began smoking during follow-up years. The prevalence of smoking among male adults at the end of the follow-up period, based on the number of new smokers, smokers who continued smoking, and relapsed ex-smokers, was estimated to be around 21%. (Figure 1) Characteristics of study participants Table 1 summarizes the characteristics of study participants, including age, BMI, and health conditions such as DM, dyslipidemia, hypertension, and chronic kidney disease. Cumulative risk of smoking The overall cumulative risk of (ever) smoking in males is 45%, i.e., 45% of all males in this cohort took up smoking at some point in time. Figure 2 represents the cumulative risk of smoking in relation to age. The cumulative risk of smoking is higher in young adults compared to older age groups. Adults aged 30-39 at the time of screening had the highest cumulative risk of smoking (54%), followed by adults 50-59 years and 40-49 years of age, with a risk of 52% and 47%, respectively. However, older age groups >70 have the lowest risk of smoking (26%). Determinants of smoking behavior Table 2 shows the two major determinants of starting smoking: age, with younger people being more at risk (B= -0.016, p-value 0.01, 95% CI 0.974-0.995) and lower total cholesterol levels (B= -0.272, p-value 0.00, 95% CI 0.659-0.881). With regards to determinants of quitting smoking, younger age (B= -0.25, p-value 0.00, 95% CI 0.964-0.989), lower systolic blood pressure (SBP) (B= -0.011, p-value 0.01, 95% CI 0.980-0.997), higher cholesterol level (B= 0.121, p-value 0.02, 95% CI 1.018-1.251), lower HDL (B= -0.418, p-value 0.04, 95% CI 0.445-0.973), lower GFR (B= -0.009, p-value 0.04, 95% CI 0.982-1.000), and lower vitamin D level (B= -0.008, p-value 0.04, 95% CI 0.985-1.000) were identified as significant determinants of quitting smoking (Table 2). On the other hand, having a history of AC) (B= 1.232, p-value 0.02, 95% CI 1.305-9.005) was the only significant indicator of maintaining smoking cessation (Table 2). As for the sequelae of smoking, this study identified associations between smoking and multiple health conditions, including DM, ACS, stroke, psychiatric illness, NAFLD, and PAD (Table 3). Adults who continue smoking are at three times higher risk of developing stroke (B= 1.148, p-value 0.01, OR 3.153, 95% CI 1.315-7.564) compared to nonsmokers, and their risk of developing ACS (B= 0.782, p-value 0.00, OR 2.186, 95% CI 1.361-3.509) or psychiatric illness, (B= 0.827, p-value 0.00, OR 2.285, 95% CI 1.444-3.617) is twice as high as among non-smokers. In addition, continuing smoking was associated with increased risk of having DM, NAFLD, and PAD (B= 0.434, p-value 0.03, OR 1.544, 95% CI 1.055-2.259) (B= 0.407, p-value 0.02, OR 1.502, 95% CI 1.058-2.134) and (B= 0.799, p-value 0.09, OR 2.224, 95% CI 0.867-5.704) respectively. This study also confirms that quitting smoking is linked with a reduced risk of developing DM (OR 0.584, p-value 0.01, 95% CI 0.277-0.843), stroke (OR 0.114, p-value 0.05, 95% CI 0.014-0.960), psychiatric illness (OR 0.337, p-value 0.00, 95% CI 0.165-0.691), NAFLD (OR 0.508, p-value 0.01, 95% CI 0.313-0.825), and PAD (OR 0.246, p-value 0.09, 95% CI 0.047-1.281) (Table 3). The incidence of stroke events among the participants who continued smoking was 2.7% compared to only 1.17% among the non-smokers. Similarly, adults who continued smoking had a higher incidence of ACS events (8.9 %) compared with nonsmokers (6.6%). Discussion This is the first, largest, and longest cohort study in the UAE to report smoking incidence, prevalence, and its determinants and sequelae. Previous cross-sectional studies reported a similar smoking prevalence of 21.6%( 2 ) to 24.3%( 3 ) compared to 21% in this study, and the highest prevalence reported was in the younger age group ( 2 ). A very low smoking prevalence among females (0.8%) confirmed findings from prior studies ( 3 ). However, as female smoking is known to be culturally, traditionally, and socially unacceptable in the region, females may underreport their smoking behavior. In view of the tremendous efforts ( 4 ) that the government has made over the last ten years to limit smoking, additional measures appear to be needed to reduce smoking among young adults. This study’s findings, especially the determinants we identified for quitting, maintaining, and relapsing, will definitely help in tailoring such efforts. Regarding starting smoking, age is one of the main predictors of smoking behavior. The available data shows that young male adults have the highest rates of smoking compared to other age groups. Curiosity was reported as the trigger to start smoking (39%) ( 5 ) among adolescents and young adults who are often keen to explore new experiences, including smoking. This possibility underlines the need to study the social determinants of smoking, about which we unfortunately had no data. Our study found that young age and having lower cholesterol levels are the main significant determinants of starting smoking, suggesting that young, fit adults are more likely to start tobacco smoking. Additionally, among cohort participants who did quit smoking, age was determinant of quitting smoking as well. This needs further studies in the UAE context, as this finding might be attributed to young adults being more flexible for change or having higher exposure to social factors such as health information sources and family pressure. There exists published evidence on the relationship -in other populations- between smoking and other health parameters, including blood pressure, cholesterol level, vitamin D, and renal function. Worth noting that lower blood pressure was associated with quitting smoking in this study. Although a study reported that current smokers have lower adjusted SBP, DBP, and MAP than nonsmokers ( 6 ), other studies have reported the opposite ( 7 ). Therefore, lower blood pressure levels may indicate higher or lower smoking intensity that can only be confirmed with future studies. As well, higher blood pressure may suggest association with other factors such as stress ( 8 ). Smoking being used as stress reliever was reported ( 9 ) and this may be a barrier for quitting. This could be an area targeted in smoking cessation programs. Another significant factor for quitting smoking was lower vitamin D level. Lower serum levels of 25-hydroxyvitamin D (vitamin D) have been linked to active smoking. A Chinese study found that serum vitamin D concentration in current smokers was 3.85 nmol/L lower than in nonsmokers ( 10 ). Vitamin D was found to be associated with higher metabolic risk ( 11 ), and quitting decisions may reflect patients' perception of being at higher health risk that may not be captured by this study. Vitamin D was also noted to be an independent risk factor for ACS ( 12 ). Adults with higher cholesterol levels were more likely to quite in this cohort An explanation can be that active smoking can affect lipoprotein levels’ causing higher median triglycerides and low-density lipoprotein cholesterol (LDL-C) levels and significantly lower high-density lipoprotein cholesterol (HDL-C) levels compared to non-smokers ( 13 ). This could be perceived as health risk and a motivation to quit. The same can be said regarding the association with lower eGFR. The effect of cigarette smoking on renal function has been investigated in previous studies. Several longitudinal studies showed an increased risk of reduced GFR ( 14 ) or end stage renal disease (ESRD) ( 15 ) with smoking. Nevertheless, smoking-related kidney damage may manifest as glomerular hyperfiltration, i.e. higher eGFR among continuing smokers than quitters, suggesting early stages or renal deterioration in the long term ( 16 ). This is an extremely important finding as the prevalence of CKD is high in Abu Dhabi, with a prevalence of 8% in this cohort and 9.22% in 2011–2013 in another study ( 17 ). This highlights the urgency to target smoking as one of the interventions to decrease CKD high prevalence. A supporting finding from this study is that young adults who develop the health-related consequences of smoking, such as higher cholesterol, lower HDL, lower GFR, and vitamin D levels, are more likely to quit smoking. This may well reflect the education they received about the harmful effects of smoking and the frequent counseling that patients with cardiovascular and other disorders get from their physicians. Smokers tend to quit when they become aware of the risks of smoking for themselves, and the chance of successful quitting increases with counseling ( 18 ). Perception of risk seems to be determinantal in behavior change as the only determinate of maintaining smoking cessation in this study was history of ACS. Our study contributes to the growing body of knowledge on the impact of smoking on an individual’s health. Our data showed that male adults who continue smoking have a threefold higher risk of developing stroke than nonsmokers, consistent with a meta-analysis conducted in 2019 reporting an increased risk of stroke among smokers, with a pooled odds ratio (OR) of 1.61 ( 19 ). This association underscores the vascular consequences of tobacco use, emphasizing the need for targeted interventions to mitigate this heightened risk. Similarly, is a well-recognized risk factor for the development of ACS ( 20 ). Psychiatric illnesses, on the other hand, are 3.2 times higher among current smoking ( 21 ), a result resembling our study, an association that may reflect the use of smoking in mitigating psychiatric symptoms rather than an etiological role of smoking in psychiatric disorders. Reviewing past literature on the association between NAFLD and smoking, a Japanese study reported that current smokers had a higher prevalence of NAFLD compared to non-smokers (52.5% compared to 33.0%) and that current smoking was significantly associated with NAFLD (OR 1.31) ( 22 ). Similarly, our study found that continuing smoking is associated with an increased risk of developing NAFLD (OR 1.502). The underlying mechanism of smoking related NAFLD has been investigated in several animal model studies. According to Yuan et al ., cigarette smoke stimulates lipid synthesis and fat accumulation in mice hepatocytes by modulating the activity of 5'-AMP-activated protein kinase (AMPK) and sterol response element binding protein-1 (SREBP-1) ( 23 ). Azzalini et al . reported that smoking induces oxidative stress and hepatocellular apoptosis in obese rats ( 24 ). With regards to the association with diabetes, smoking is a well-known risk factor for the development of diabetes, as found by this study, with an odds ratio of 1.5. A Korean cohort study reported that smoking increases the risk of incident diabetes and mortality ( 25 ). Another Chinese study involving nearly 50,000 men who were followed for an average of 5.4 years reported that adults who smoked more than 20 cigarettes per day had a hazard ratio of incident T2D of 1.25, while those with a ≥ 40 pack-year history of smoking had a hazard ratio of incident T2D of 1.28 ( 26 ). Similarly, the link between smoking and PAD has been investigated in multiple studies. A study based on the Gulf COAST registry reported that patients with PAD are more likely to be prior smokers ( 27 ). According to the Global Reduction of Atherothrombosis for Continued Health (REACH) Registry, 22% of patients with clinically evident PAD are current smokers but do not report relative risks ( 28 ). Nicotine causes endothelial dysfunction, smooth muscle cell remodeling, oxidative stress, and chronic inflammation, leading to vasoconstriction and the development of PAD ( 29 ). Our study, however, showed that PAD had only a marginally significant association with smoking (p value = 0.09). The results of our study should be interpreted in the light of several limitations. First, female participants were excluded. Second, the type and timing of smoking weren’t recorded for most of the participants. Third, social determinants were not studied. Finally, our study lacked data on the amount of smoking, the number of packs per day, etc. Nevertheless, its strengths are its large sample size, population, and representativeness. It is the first study to assess the important determinants of smoking incidence and cessation and provides key insights into the associations of smoking with other comorbidities in the UAE. In the clinical setting, health professionals can utilize this information by incorporating smoking history assessments during preventive care visits, providing personalized counseling that highlights specific health threats related to smoking, and tailoring smoking cessation strategies based on identified risks and determinants. Conclusion In this large population-based cohort study, the cross-sectional prevalence of smoking among male adults in Abu Dhabi was 21% in 2011-13. The overall cumulative prevalence of smoking over the follow-up period was 45% among males. Important starting, quitting, and/or relapse determinants were identified and will inform clinical and public health decisions. An important finding is that smoking cessation has substantial benefits in preventing multiple comorbidities and should be encouraged whenever possible. Further studies are needed to assess the socio-economic determinants of smoking in the UAE. Such studies may suggest novel strategies to discourage smoking as health information alone seems to be insufficiently effective in part of this population. Abbreviations UAE United Arab Emirates DM Diabetes Mellitus ACS Acute Coronary Syndrome CKD Chronic Kidney Disease PAD Peripheral Artery Disease NAFLD Non Alcoholic Fatty Liver Disease Declarations Ethics approval and consent to participate Ethical clearance was obtained from the institutional Review Board (IRB). This study was approved by the Ambulatory Health Services Ethical Committee in the region. The study was performed according to the ethical guidelines in the Declaration of Helsinki. Consent for publication Not applicable. Informed consent All the participants have provided written informed consent. Participation was voluntary. The information was anonymous and confidential. Availability of data and materials The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding received. Authors’ contributions Conceptualization: LBA, FAA, NN, AAA, AMA, SA. Data Curation: FAA, AAA, SA, AH, AA, MGA, MA, EM, RA, HA, NA, FS, TF, BA. Formal analysis: LA, FAA, AAA, AMA, SA. Methodology: LA, FAA, NN, AAA, AMA, SA. Writing and editing: FAA, AAA, AMA, SA. Review of the manuscript: LA, NN, AMA. Acknowledgements Not applicable. Authors’ information 1 Department of Family Medicine, Ambulatory Healthcare Services, Abu Dhabi Health Services Company, Al Ain, United Arab Emirates. 2 Department of Epidemiology, United Arab Emirates University, Al Ain, United Arab Emirates. References Hajat, C., Harrison, O., & Al Siksek, Z. (2012). Weqaya: a population-wide cardiovascular screening program in Abu Dhabi, United Arab Emirates. American journal of public health , 102 (5), 909–914. https://doi.org/10.2105/AJPH.2011.300290 Aden B, Karrar S, Shafey O, Al Hosni F. Cigarette, Water-pipe, and Medwakh Smoking Prevalence Among Applicants to Abu Dhabi's Pre-marital Screening Program, 2011. Int J Prev Med . 2013;4(11):1290-1295. Al-Houqani M, Ali R, Hajat C. Tobacco smoking using Midwakh is an emerging health problem--evidence from a large cross-sectional survey in the United Arab Emirates. PLoS One . 2012;7(6):e39189. doi:10.1371/journal.pone.0039189 Razzak HA, Harbi A, Ahli S. Tobacco Smoking Prevalence, Health Risk, and Cessation in the UAE. Oman Med J . 2020;35(4):e165. Published 2020 Jul 31. doi:10.5001/omj.2020.107 İçmeli ÖS, Türker H, Gündoğuş B, Çiftci M, Aka Aktürk Ü. Behaviours and opinions of adolescent students on smoking. Adolesan öğrencilerin sigara içme ile ilgili davranışları ve görüşleri. Tuberk Toraks. 2016;64(3):217-222. doi:10.5578/tt.20925 Li G, Wang H, Wang K, et al. The association between smoking and blood pressure in men: a cross-sectional study. BMC Public Health. 2017;17(1):797. Published 2017 Oct 10. doi:10.1186/s12889-017-4802-x Sultana R, Nessa A, Yeasmin F, Nasreen S, Khanam A. Study on Blood Pressure in Male Cigarette Smokers. Mymensingh Med J. 2019;28(3):582-585. Chamik T, Viswanathan B, Gedeon J, Bovet P. Associations between psychological stress and smoking, drinking, obesity, and high blood pressure in an upper middle-income country in the African region. Stress Health. 2018;34(1):93-101. doi:10.1002/smi.2766 Siahpush M, Borland R, Scollo M. Smoking and financial stress. Tob Control. 2003;12(1):60-66. doi:10.1136/tc.12.1.60 Jiang CQ, Chan YH, Xu L, et al. Smoking and serum vitamin D in older Chinese people: cross-sectional analysis based on the Guangzhou Biobank Cohort Study. BMJ Open. 2016;6(6):e010946. Published 2016 Jun 23. doi:10.1136/bmjopen-2015-010946 Hsu S, Hoofnagle AN, Gupta DK, et al. Race, Ancestry, and Vitamin D Metabolism: The Multi-Ethnic Study of Atherosclerosis. J Clin Endocrinol Metab. 2020;105(12):e4337-e4350. doi:10.1210/clinem/dgaa612 AlKetbi L, Nagelkerke N, Humaid A et al. Cardiovascular disease risk score derivation and validation in Abu Dhabi, United Arab Emirates. Retrospective Cohort Study. medrxiv. Published online March 24, 2024. doi:https://doi.org/10.1101/2024.03.19.24304561 Nakamura M, Yamamoto Y, Imaoka W, et al. Relationships between Smoking Status, Cardiovascular Risk Factors, and Lipoproteins in a Large Japanese Population. J Atheroscler Thromb. 2021;28(9):942-953. doi:10.5551/jat.56838 Yamagata K, Ishida K, Sairenchi T, et al. Risk factors for chronic kidney disease in a community-based population: a 10-year follow-up study. Kidney Int. 2007;71(2):159-166. doi:10.1038/sj.ki.5002017 Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med. 1996;334(1):13-18. doi:10.1056/NEJM199601043340103 Maeda I, Hayashi T, Sato KK, et al. Cigarette smoking and the association with glomerular hyperfiltration and proteinuria in healthy middle-aged men. Clin J Am Soc Nephrol. 2011;6(10):2462-2469. doi:10.2215/CJN.00700111 Hemaid A, Al Mansoori M, Al Marzooqi N, et al. Prevalence, Incidence and Associated Risk Factors for Chronic Kidney Disease in Abu Dhabi: A Retrospective Cohort Study. 2024. World Health Organization. Tobacco. World Health Organization. Published July 31, 2023. https://www.who.int/news-room/fact-sheets/detail/tobacco Pan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke: A meta-analysis. Medicine (Baltimore). 2019;98(12):e14872. doi:10.1097/MD.0000000000014872 Hu G, Zhou M, Liu J, et al. Smoking and Provision of Smoking Cessation Interventions among Inpatients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project. Glob Heart. 2020;15(1):72. Published 2020 Oct 23. doi:10.5334/gh.784 Asharani PV, Ling Seet VA, Abdin E, et al. Smoking and Mental Illness: Prevalence, Patterns and Correlates of Smoking and Smoking Cessation among Psychiatric Patients. Int J Environ Res Public Health. 2020;17(15):5571. Published 2020 Aug 1. doi:10.3390/ijerph17155571 Takenaka H, Fujita T, Masuda A, Yano Y, Watanabe A, Kodama Y. Non-Alcoholic Fatty Liver Disease Is Strongly Associated with Smoking Status and Is Improved by Smoking Cessation in Japanese Males: A Retrospective Study. Kobe J Med Sci. 2020;66(3):E102-E112. Published 2020 Nov 17. Yuan H, Shyy JY, Martins-Green M. Second-hand smoke stimulates lipid accumulation in the liver by modulating AMPK and SREBP-1. J Hepatol. 2009;51(3):535-547. doi:10.1016/j.jhep.2009.03.026 Azzalini L, Ferrer E, Ramalho LN, et al. Cigarette smoking exacerbates nonalcoholic fatty liver disease in obese rats. Hepatology. 2010;51(5):1567-1576. doi:10.1002/hep.23516 Jee SH, Foong AW, Hur NW, Samet JM. Smoking and risk for diabetes incidence and mortality in Korean men and women. Diabetes Care. 2010;33(12):2567-2572. doi:10.2337/dc10-0261 Shi L, Shu XO, Li H, et al. Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men. PLoS One . 2013;8(11):e77919. Published 2013 Nov 4. doi:10.1371/journal.pone.0077919 Al-Zakwani I, Al Siyabi E, Alrawahi N, et al. Association between Peripheral Artery Disease and Major Adverse Cardiovascular Events in Patients with Acute Coronary Syndrome: Findings from the Gulf COAST Registry. Med Princ Pract . 2019;28(5):410-417. doi:10.1159/000497790 Cacoub PP, Abola MT, Baumgartner I, et al. Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry. Atherosclerosis . 2009;204(2):e86-e92. doi:10.1016/j.atherosclerosis.2008.10.023 Benowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. Trends Cardiovasc Med . 2016;26(6):515-523. doi:10.1016/j.tcm.2016.03.001 Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 24 Sep, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 26 May, 2025 Reviews received at journal 26 May, 2025 Reviewers agreed at journal 12 May, 2025 Reviews received at journal 29 Apr, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers agreed at journal 15 Apr, 2025 Reviewers invited by journal 05 Sep, 2024 Editor invited by journal 24 Jul, 2024 Editor assigned by journal 17 Jul, 2024 Submission checks completed at journal 17 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4743493","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336158469,"identity":"194cfbbe-9c1d-4089-9de4-f3a2c6e7cdf3","order_by":0,"name":"Latifa Baynouna AlKetbi","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Latifa","middleName":"Baynouna","lastName":"AlKetbi","suffix":""},{"id":336158470,"identity":"614aff2a-ff85-4de7-b665-cffe3bb93ee9","order_by":1,"name":"Fatima Ali AlKetbi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYBAC9gY2BgbGBgk5BgYeIrXwHABqOdggYUyyFobEBuK1sB9LfPxxh0X6/Pbegx8YamyI0MKTdtjg4BmJ3A1nziVLMBxLI6zFniG9TeJgG1CLRI6BBAPbYSJs4X/e/gOoJV1+/hvjHwz//hOhRSLtGANQSwLDDR4zCca2A8RoeZYscfaMhOGGMzlmFol9ycQ4LM3wQ+WOOnn59jPGNz58syOsBRUkkKphFIyCUTAKRgF2AABZ+zom15xhWgAAAABJRU5ErkJggg==","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":true,"prefix":"","firstName":"Fatima","middleName":"Ali","lastName":"AlKetbi","suffix":""},{"id":336158471,"identity":"41bbed68-3f0f-4df5-854e-75f5bbc548b7","order_by":2,"name":"Nico Nagelkerke","email":"","orcid":"","institution":"United Arab Emirates University","correspondingAuthor":false,"prefix":"","firstName":"Nico","middleName":"","lastName":"Nagelkerke","suffix":""},{"id":336158472,"identity":"0df20954-67be-42f0-864a-a9f1e3a4d961","order_by":3,"name":"Alreem Abdulla 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Services","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Humaid","suffix":""},{"id":336158476,"identity":"87d13f7b-d482-4bd8-b1c0-8b082347824e","order_by":7,"name":"AlYazia AlAzeezi","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"AlYazia","middleName":"","lastName":"AlAzeezi","suffix":""},{"id":336158477,"identity":"31f4a7bb-cd71-4cd1-b15b-e51d8a59c205","order_by":8,"name":"Muna Galal AlDobaee","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Muna","middleName":"Galal","lastName":"AlDobaee","suffix":""},{"id":336158478,"identity":"8dee3986-ae76-46ab-843e-18b006f9a357","order_by":9,"name":"Mohammed AlMansoori","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"AlMansoori","suffix":""},{"id":336158479,"identity":"35850504-4020-4aea-a09c-83d0ee6cc924","order_by":10,"name":"Esraa Mahmoud","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Esraa","middleName":"","lastName":"Mahmoud","suffix":""},{"id":336158480,"identity":"13ba196c-12c6-43f3-b7db-7b05cd28ba14","order_by":11,"name":"Rudina AlKetbi","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Rudina","middleName":"","lastName":"AlKetbi","suffix":""},{"id":336158481,"identity":"d2e39f4a-8d83-4a44-b07d-33ee5e789b84","order_by":12,"name":"Hamda Aleissaee","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Hamda","middleName":"","lastName":"Aleissaee","suffix":""},{"id":336158482,"identity":"c9055105-b01b-47d5-8cb2-ab0bdbdb0642","order_by":13,"name":"Noura AlAlawi","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Noura","middleName":"","lastName":"AlAlawi","suffix":""},{"id":336158483,"identity":"8757a51d-95cc-4ca7-a021-9c128a612d37","order_by":14,"name":"Fatima Shuaib","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Fatima","middleName":"","lastName":"Shuaib","suffix":""},{"id":336158484,"identity":"aa10f97d-e66c-4820-bb03-da95024404b5","order_by":15,"name":"Toqa Fahmawee","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Toqa","middleName":"","lastName":"Fahmawee","suffix":""},{"id":336158485,"identity":"30aa9f23-3850-4422-8531-7453d2cc8034","order_by":16,"name":"Basil AlHashaikeh","email":"","orcid":"","institution":"Ambulatory Healthcare Services","correspondingAuthor":false,"prefix":"","firstName":"Basil","middleName":"","lastName":"AlHashaikeh","suffix":""}],"badges":[],"createdAt":"2024-07-15 14:14:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4743493/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4743493/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-23826-6","type":"published","date":"2025-09-24T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62657009,"identity":"c6675213-41a2-4ab1-b244-cfafa64094ca","added_by":"auto","created_at":"2024-08-17 02:05:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45462,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFlow Diagram of study population and smoking status of participants\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4743493/v1/bb35d9e9bfb5b318c95445fa.png"},{"id":62657007,"identity":"3d232843-c4e0-438d-94c9-35cf2670c1ae","added_by":"auto","created_at":"2024-08-17 02:05:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16104,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCumulative risk of smoking per age group\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4743493/v1/f4775bbefdb0946075f7b9b5.png"},{"id":92430452,"identity":"bc0fca3b-4a95-4420-8f56-5cb101173ddd","added_by":"auto","created_at":"2025-09-29 16:04:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":608165,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4743493/v1/1c2ef33f-411f-448f-b427-638b95cc3749.pdf"},{"id":62657008,"identity":"e1a47ea1-439b-49f6-b943-0075121e7a90","added_by":"auto","created_at":"2024-08-17 02:05:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":422526,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4743493/v1/a0b4df0258c90dc8ab62f2e7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determinants and Sequelae of Smoking: Prevalence, Incidence, and Cessation Among Male Adults in Abu Dhabi, United Arab Emirates. A Retrospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTobacco use has been long recognized as a major public health problem, exerting a profound impact on the health of individuals and communities worldwide. The pervasive presence of tobacco products and the habitual and addictive nature of smoking have contributed to a global health crisis with far-reaching consequences for both physical and mental well-being. It is important to understand and address the health impact of tobacco use, considering its strong association with a group of diseases and its role as a leading preventable cause of morbidity and mortality.\u003c/p\u003e \u003cp\u003eThe adverse health effects of tobacco are diverse and affect multiple organ systems. The well-documented association of smoking with cardiovascular diseases, respiratory disorders, various cancers as well as reproductive health proves that the impact of tobacco on human health is extremely detrimental. As we grapple with the complexities of modern healthcare, studying the uptake and effects of tobacco usage becomes a necessity for developing effective preventive measures, interventions, and policies that can mitigate the burden of tobacco-related diseases.\u003c/p\u003e \u003cp\u003eFor the past decades, multiple policies have been implemented for this purpose, from smoking-free areas to smoking cessation campaigns and educational programs across the country. Controlling tobacco use is a main public health concern. Therefore, researchers, policymakers, and healthcare professionals should collaborate to develop targeted strategies for smoking prevention, cessation, and public health initiatives. In doing so, we move closer to building a healthier future free from tobacco-related diseases and mortality.\u003c/p\u003e \u003cp\u003eThis paper aims to give an overview of the prevalence of tobacco use in the Abu Dhabi region, to study the main determinants/ predictors of smoking behavior, and to investigate the major health outcomes of smoking behavior.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis retrospective cohort study was conducted between September 2010 and July 2023. The study included national males aged 18 years and above who participated in a comprehensive screening program (Weqaya) performed in ambulatory healthcare services and primary care clinics in Abu Dhabi and Al Ain city between 2010 and 2013.\u003c/p\u003e \u003cp\u003eWeqaya means prevention in Arabic. The Weqaya Screening Program is a population-level intervention developed by the Department of Health - Abu Dhabi, which aims to reduce the risks of cardiovascular diseases through early detection of risk factors, health education, and tailored personal health programs (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). UAE National adults over 18 years old are eligible for the Weqaya Screening Program. The screening includes the collection of information on demographic characteristics and self-reported indicators such as smoking status, preexisting cardiovascular disease (angina, heart attack, transient ischemic attack, stroke, or other circulatory disorder), and a family history of premature cardiovascular disease. It also involves obtaining anthropometric measures like height, weight, hip and waist circumference, Body Mass Index (BMI), and systolic and diastolic blood pressure (DBP), as well as hematological parameters in particular random glucose, glycosylated hemoglobin (HbA1c), total blood cholesterol, and random HDL cholesterol. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; follow-up data were collected from their electronic medical records in the Cerner system, which records every citizen's medical consumption. SPSS v29 software was used to analyze the data through crosstabulation, logistic regression, and Chi-square tests. All types of smoking were included (tobacco, cigarette, shisha, and pipe). The variables included in the analysis at screening were age at screening, smoking status at screening, SBP, DBP, BMI, HbA1c, cholesterol level, HDL, GFR, Vitamin D level, DM, prediabetes, stroke, ACS, and PAD. At the end of the follow-up, the variables collected were smoking status, psychiatric illness, NAFLD, Chronic Kidney Diseases, smoking uptake and cessation, cancer, and death. The average follow-up period was 9.2 years, with a range of 1\u0026ndash;12.\u003c/p\u003e \u003cp\u003eThe primary outcome was the prevalence of smoking among UAE Nationals. The secondary outcome measures included cumulative risk of smoking in different age groups, determinants of smoking behaviors, particularly starting, quitting, and maintaining cessation, and association of smoking with other health conditions, including diabetes mellitus (DM), acute coronary syndrome (ACS), stroke, psychiatric illness, and non-alcoholic fatty liver disease (NAFLD).\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003ePrevalence of smoking\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA total of 8259 adults who participated in Weqaya screening program between 2011 and 2013 were included initially in the study. The Smoking statuses of 862 participants were not available/documented. Out of the total participants, 4037 were females, of whom only 19 of them reported being active smokers at the time of screening. Of the 3360 male participants, 826 were active smokers, 309 were ex-smokers, and 2225 were non-smokers at the time of screening. Considering the small number of female smokers at screening, female participants were excluded from the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMale participants were followed up for an average of 9.2 years; 12.5% (277/2225) of the nonsmokers became new (incident) smokers, and 88% (1948/2225) remained nonsmokers (never smoked). \u0026nbsp; On the other hand, 59% (489/826) of baseline smokers did quit smoking during follow-up, while 41% (337/826) continued smoking. This suggests that more than 50% of adult smokers quit smoking over time. \u0026nbsp;Out of the total ex-smokers at screening \u0026nbsp;(309), 70% (217) maintained their status as ex-smokers, whereas 30% (92) relapsed and began smoking during follow-up years. The prevalence of smoking among male adults at the end of the follow-up period, based on the number of new smokers, smokers who continued smoking, and relapsed ex-smokers, was estimated to be around 21%. (Figure 1)\u003c/p\u003e\n\u003ch2\u003eCharacteristics of study participants\u003c/h2\u003e\n\u003cp\u003eTable 1 summarizes the characteristics of study participants, including age, BMI, and health conditions such as DM, dyslipidemia, hypertension, and chronic kidney disease.\u003c/p\u003e\n\u003ch2\u003eCumulative risk of smoking\u003c/h2\u003e\n\u003cp\u003eThe overall cumulative risk of (ever) smoking in males is 45%, i.e., 45% of all males in this cohort took up smoking at some point in time. Figure 2 represents the cumulative risk of smoking in relation to age. The cumulative risk of smoking is higher in young adults compared to older age groups. Adults aged 30-39 at the time of screening had the highest cumulative risk of smoking (54%), followed by adults 50-59 years and 40-49 years of age, with a risk of 52% and 47%, respectively. However, older age groups \u0026gt;70 have the lowest risk of smoking (26%).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDeterminants of smoking behavior\u003c/h2\u003e\n\u003cp\u003eTable 2 shows the two major determinants of starting smoking: age, with younger people being more at risk (B= -0.016, p-value 0.01, 95% CI 0.974-0.995) and lower total cholesterol levels (B= -0.272, p-value 0.00, 95% CI 0.659-0.881).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith regards to determinants of quitting smoking, younger age (B= -0.25, p-value 0.00, 95% CI 0.964-0.989), lower systolic blood pressure (SBP) (B= -0.011, p-value 0.01, 95% CI 0.980-0.997), higher cholesterol level (B= 0.121, p-value 0.02, 95% CI 1.018-1.251), lower HDL (B= -0.418, p-value 0.04, 95% CI 0.445-0.973), lower GFR (B= -0.009, p-value 0.04, 95% CI 0.982-1.000), and lower vitamin D level (B= -0.008, p-value 0.04, 95% CI 0.985-1.000) were identified as significant determinants of quitting smoking (Table 2). On the other hand, having a history of AC) (B= 1.232, p-value 0.02, 95% CI 1.305-9.005) was the only significant indicator of maintaining smoking cessation (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs for the sequelae of smoking, this study identified associations between smoking and multiple health conditions, including DM, ACS, stroke, psychiatric illness, NAFLD, and PAD (Table 3). Adults who continue smoking are at three times higher risk of developing stroke (B= 1.148, p-value 0.01, OR 3.153, 95% CI 1.315-7.564) compared to nonsmokers, and their risk of developing ACS (B= 0.782, p-value 0.00, OR 2.186, 95% CI 1.361-3.509) or psychiatric illness, (B= 0.827, p-value 0.00, OR 2.285, 95% CI 1.444-3.617) is twice as high as among non-smokers. In addition, continuing smoking was associated with increased risk of having DM, NAFLD, and PAD (B= 0.434, p-value 0.03, OR 1.544, 95% CI 1.055-2.259) (B= 0.407, p-value 0.02, OR 1.502, 95% CI 1.058-2.134) and (B= 0.799, p-value 0.09, OR 2.224, 95% CI 0.867-5.704) respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study also confirms that quitting smoking is linked with a reduced risk of developing DM (OR 0.584, p-value 0.01, 95% CI 0.277-0.843), stroke (OR 0.114, p-value 0.05, 95% CI 0.014-0.960), psychiatric illness (OR 0.337, p-value 0.00, 95% CI 0.165-0.691), NAFLD (OR 0.508, p-value 0.01, 95% CI 0.313-0.825), and PAD (OR 0.246, p-value 0.09, 95% CI 0.047-1.281) (Table 3). The incidence of stroke events among the participants who continued smoking was 2.7% \u0026nbsp;compared to only 1.17% among the non-smokers. Similarly, adults who continued smoking had a higher incidence of ACS events (8.9 %) compared with nonsmokers (6.6%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first, largest, and longest cohort study in the UAE to report smoking incidence, prevalence, and its determinants and sequelae. Previous cross-sectional studies reported a similar smoking prevalence of 21.6%(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to 24.3%(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) compared to 21% in this study, and the highest prevalence reported was in the younger age group (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A very low smoking prevalence among females (0.8%) confirmed findings from prior studies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, as female smoking is known to be culturally, traditionally, and socially unacceptable in the region, females may underreport their smoking behavior.\u003c/p\u003e \u003cp\u003eIn view of the tremendous efforts (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) that the government has made over the last ten years to limit smoking, additional measures appear to be needed to reduce smoking among young adults. This study\u0026rsquo;s findings, especially the determinants we identified for quitting, maintaining, and relapsing, will definitely help in tailoring such efforts.\u003c/p\u003e \u003cp\u003eRegarding starting smoking, age is one of the main predictors of smoking behavior. The available data shows that young male adults have the highest rates of smoking compared to other age groups. Curiosity was reported as the trigger to start smoking (39%) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) among adolescents and young adults who are often keen to explore new experiences, including smoking. This possibility underlines the need to study the social determinants of smoking, about which we unfortunately had no data. Our study found that young age and having lower cholesterol levels are the main significant determinants of starting smoking, suggesting that young, fit adults are more likely to start tobacco smoking.\u003c/p\u003e \u003cp\u003eAdditionally, among cohort participants who did quit smoking, age was determinant of quitting smoking as well. This needs further studies in the UAE context, as this finding might be attributed to young adults being more flexible for change or having higher exposure to social factors such as health information sources and family pressure.\u003c/p\u003e \u003cp\u003eThere exists published evidence on the relationship -in other populations- between smoking and other health parameters, including blood pressure, cholesterol level, vitamin D, and renal function. Worth noting that lower blood pressure was associated with quitting smoking in this study. Although a study reported that current smokers have lower adjusted SBP, DBP, and MAP than nonsmokers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), other studies have reported the opposite (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Therefore, lower blood pressure levels may indicate higher or lower smoking intensity that can only be confirmed with future studies. As well, higher blood pressure may suggest association with other factors such as stress (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Smoking being used as stress reliever was reported (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and this may be a barrier for quitting. This could be an area targeted in smoking cessation programs.\u003c/p\u003e \u003cp\u003eAnother significant factor for quitting smoking was lower vitamin D level. Lower serum levels of 25-hydroxyvitamin D (vitamin D) have been linked to active smoking. A Chinese study found that serum vitamin D concentration in current smokers was 3.85 nmol/L lower than in nonsmokers (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Vitamin D was found to be associated with higher metabolic risk (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and quitting decisions may reflect patients' perception of being at higher health risk that may not be captured by this study. Vitamin D was also noted to be an independent risk factor for ACS (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAdults with higher cholesterol levels were more likely to quite in this cohort An explanation can be that active smoking can affect lipoprotein levels\u0026rsquo; causing higher median triglycerides and low-density lipoprotein cholesterol (LDL-C) levels and significantly lower high-density lipoprotein cholesterol (HDL-C) levels compared to non-smokers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This could be perceived as health risk and a motivation to quit.\u003c/p\u003e \u003cp\u003eThe same can be said regarding the association with lower eGFR. The effect of cigarette smoking on renal function has been investigated in previous studies. Several longitudinal studies showed an increased risk of reduced GFR (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) or end stage renal disease (ESRD) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) with smoking. Nevertheless, smoking-related kidney damage may manifest as glomerular hyperfiltration, i.e. higher eGFR among continuing smokers than quitters, suggesting early stages or renal deterioration in the long term (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This is an extremely important finding as the prevalence of CKD is high in Abu Dhabi, with a prevalence of 8% in this cohort and 9.22% in 2011\u0026ndash;2013 in another study (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This highlights the urgency to target smoking as one of the interventions to decrease CKD high prevalence.\u003c/p\u003e \u003cp\u003eA supporting finding from this study is that young adults who develop the health-related consequences of smoking, such as higher cholesterol, lower HDL, lower GFR, and vitamin D levels, are more likely to quit smoking. This may well reflect the education they received about the harmful effects of smoking and the frequent counseling that patients with cardiovascular and other disorders get from their physicians. Smokers tend to quit when they become aware of the risks of smoking for themselves, and the chance of successful quitting increases with counseling (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Perception of risk seems to be determinantal in behavior change as the only determinate of maintaining smoking cessation in this study was history of ACS.\u003c/p\u003e \u003cp\u003eOur study contributes to the growing body of knowledge on the impact of smoking on an individual\u0026rsquo;s health. Our data showed that male adults who continue smoking have a threefold higher risk of developing stroke than nonsmokers, consistent with a meta-analysis conducted in 2019 reporting an increased risk of stroke among smokers, with a pooled odds ratio (OR) of 1.61 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This association underscores the vascular consequences of tobacco use, emphasizing the need for targeted interventions to mitigate this heightened risk.\u003c/p\u003e \u003cp\u003eSimilarly, is a well-recognized risk factor for the development of ACS (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Psychiatric illnesses, on the other hand, are 3.2 times higher among current smoking (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), a result resembling our study, an association that may reflect the use of smoking in mitigating psychiatric symptoms rather than an etiological role of smoking in psychiatric disorders.\u003c/p\u003e \u003cp\u003eReviewing past literature on the association between NAFLD and smoking, a Japanese study reported that current smokers had a higher prevalence of NAFLD compared to non-smokers (52.5% compared to 33.0%) and that current smoking was significantly associated with NAFLD (OR 1.31) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similarly, our study found that continuing smoking is associated with an increased risk of developing NAFLD (OR 1.502). The underlying mechanism of smoking related NAFLD has been investigated in several animal model studies. According to Yuan \u003cem\u003eet al\u003c/em\u003e., cigarette smoke stimulates lipid synthesis and fat accumulation in mice hepatocytes by modulating the activity of 5'-AMP-activated protein kinase (AMPK) and sterol response element binding protein-1 (SREBP-1) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Azzalini \u003cem\u003eet al\u003c/em\u003e. reported that smoking induces oxidative stress and hepatocellular apoptosis in obese rats (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith regards to the association with diabetes, smoking is a well-known risk factor for the development of diabetes, as found by this study, with an odds ratio of 1.5. A Korean cohort study reported that smoking increases the risk of incident diabetes and mortality (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Another Chinese study involving nearly 50,000 men who were followed for an average of 5.4 years reported that adults who smoked more than 20 cigarettes per day had a hazard ratio of incident T2D of 1.25, while those with a\u0026thinsp;\u0026ge;\u0026thinsp;40 pack-year history of smoking had a hazard ratio of incident T2D of 1.28 (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Similarly, the link between smoking and PAD has been investigated in multiple studies. A study based on the Gulf COAST registry reported that patients with PAD are more likely to be prior smokers (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). According to the Global Reduction of Atherothrombosis for Continued Health (REACH) Registry, 22% of patients with clinically evident PAD are current smokers but do not report relative risks (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Nicotine causes endothelial dysfunction, smooth muscle cell remodeling, oxidative stress, and chronic inflammation, leading to vasoconstriction and the development of PAD (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Our study, however, showed that PAD had only a marginally significant association with smoking (p value\u0026thinsp;=\u0026thinsp;0.09).\u003c/p\u003e \u003cp\u003eThe results of our study should be interpreted in the light of several limitations. First, female participants were excluded. Second, the type and timing of smoking weren\u0026rsquo;t recorded for most of the participants. Third, social determinants were not studied. Finally, our study lacked data on the amount of smoking, the number of packs per day, etc. Nevertheless, its strengths are its large sample size, population, and representativeness. It is the first study to assess the important determinants of smoking incidence and cessation and provides key insights into the associations of smoking with other comorbidities in the UAE.\u003c/p\u003e \u003cp\u003eIn the clinical setting, health professionals can utilize this information by incorporating smoking history assessments during preventive care visits, providing personalized counseling that highlights specific health threats related to smoking, and tailoring smoking cessation strategies based on identified risks and determinants.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this large population-based cohort study, the cross-sectional prevalence of smoking among male adults in Abu Dhabi was 21% in 2011-13. The overall cumulative prevalence of smoking over the follow-up period was 45% among males. Important starting, quitting, and/or relapse determinants were identified and will inform clinical and public health decisions. An important finding is that smoking cessation has substantial benefits in preventing multiple comorbidities and should be encouraged whenever possible. Further studies are needed to assess the socio-economic determinants of smoking in the UAE. Such studies may suggest novel strategies to discourage smoking as health information alone seems to be insufficiently effective in part of this population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eUAE United Arab Emirates \u003c/p\u003e\n\u003cp\u003eDM Diabetes Mellitus \u003c/p\u003e\n\u003cp\u003eACS Acute Coronary Syndrome \u003c/p\u003e\n\u003cp\u003eCKD Chronic Kidney Disease \u003c/p\u003e\n\u003cp\u003ePAD Peripheral Artery Disease \u003c/p\u003e\n\u003cp\u003eNAFLD Non Alcoholic Fatty Liver Disease \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the institutional Review Board (IRB). This study was approved by the Ambulatory Health Services Ethical Committee in the region. The study was performed according to the ethical guidelines in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed consent\u003c/p\u003e\n\u003cp\u003eAll the participants have provided written informed consent. Participation was voluntary. The information was anonymous and confidential.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNo funding received.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions\u003c/p\u003e\n\u003cp\u003eConceptualization: LBA, FAA, NN, AAA, AMA, SA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Curation: FAA, AAA, SA, AH, AA, MGA, MA, EM, RA, HA, NA, FS, TF, BA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFormal analysis: LA, FAA, AAA, AMA, SA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethodology: LA, FAA, NN, AAA, AMA, SA. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting and editing: FAA, AAA, AMA, SA.\u003c/p\u003e\n\u003cp\u003eReview of the manuscript: LA, NN, AMA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; information\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Department of Family Medicine, Ambulatory Healthcare Services, Abu Dhabi Health Services Company, Al Ain, United Arab Emirates.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Department of Epidemiology, United Arab Emirates University, Al Ain, United Arab Emirates.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHajat, C., Harrison, O., \u0026amp; Al Siksek, Z. (2012). Weqaya: a population-wide cardiovascular screening program in Abu Dhabi, United Arab Emirates. \u003cem\u003eAmerican journal of public health\u003c/em\u003e, \u003cem\u003e102\u003c/em\u003e(5), 909\u0026ndash;914. https://doi.org/10.2105/AJPH.2011.300290\u003c/li\u003e\n \u003cli\u003eAden B, Karrar S, Shafey O, Al Hosni F. Cigarette, Water-pipe, and Medwakh Smoking Prevalence Among Applicants to Abu Dhabi\u0026apos;s Pre-marital Screening Program, 2011. \u003cem\u003eInt J Prev Med\u003c/em\u003e. 2013;4(11):1290-1295.\u003c/li\u003e\n \u003cli\u003eAl-Houqani M, Ali R, Hajat C. Tobacco smoking using Midwakh is an emerging health problem--evidence from a large cross-sectional survey in the United Arab Emirates. \u003cem\u003ePLoS One\u003c/em\u003e. 2012;7(6):e39189. doi:10.1371/journal.pone.0039189\u003c/li\u003e\n \u003cli\u003eRazzak HA, Harbi A, Ahli S. Tobacco Smoking Prevalence, Health Risk, and Cessation in the UAE. \u003cem\u003eOman Med J\u003c/em\u003e. 2020;35(4):e165. Published 2020 Jul 31. doi:10.5001/omj.2020.107\u003c/li\u003e\n \u003cli\u003eİ\u0026ccedil;meli \u0026Ouml;S, T\u0026uuml;rker H, G\u0026uuml;ndoğuş B, \u0026Ccedil;iftci M, Aka Akt\u0026uuml;rk \u0026Uuml;. Behaviours and opinions of adolescent students on smoking. Adolesan \u0026ouml;ğrencilerin sigara i\u0026ccedil;me ile ilgili davranışları ve g\u0026ouml;r\u0026uuml;şleri.\u0026nbsp;Tuberk Toraks. 2016;64(3):217-222. doi:10.5578/tt.20925\u003c/li\u003e\n \u003cli\u003eLi G, Wang H, Wang K, et al. The association between smoking and blood pressure in men: a cross-sectional study.\u0026nbsp;BMC Public Health. 2017;17(1):797. Published 2017 Oct 10. doi:10.1186/s12889-017-4802-x\u003c/li\u003e\n \u003cli\u003eSultana R, Nessa A, Yeasmin F, Nasreen S, Khanam A. Study on Blood Pressure in Male Cigarette Smokers.\u0026nbsp;Mymensingh Med J. 2019;28(3):582-585.\u003c/li\u003e\n \u003cli\u003eChamik T, Viswanathan B, Gedeon J, Bovet P. Associations between psychological stress and smoking, drinking, obesity, and high blood pressure in an upper middle-income country in the African region.\u0026nbsp;Stress Health. 2018;34(1):93-101. doi:10.1002/smi.2766\u003c/li\u003e\n \u003cli\u003eSiahpush M, Borland R, Scollo M. Smoking and financial stress.\u0026nbsp;Tob Control. 2003;12(1):60-66. doi:10.1136/tc.12.1.60\u003c/li\u003e\n \u003cli\u003eJiang CQ, Chan YH, Xu L, et al. Smoking and serum vitamin D in older Chinese people: cross-sectional analysis based on the Guangzhou Biobank Cohort Study.\u0026nbsp;BMJ Open. 2016;6(6):e010946. Published 2016 Jun 23. doi:10.1136/bmjopen-2015-010946\u003c/li\u003e\n \u003cli\u003eHsu S, Hoofnagle AN, Gupta DK, et al. Race, Ancestry, and Vitamin D Metabolism: The Multi-Ethnic Study of Atherosclerosis.\u0026nbsp;J Clin Endocrinol Metab. 2020;105(12):e4337-e4350. doi:10.1210/clinem/dgaa612\u003c/li\u003e\n \u003cli\u003eAlKetbi L, Nagelkerke N, Humaid A et al. Cardiovascular disease risk score derivation and validation in Abu Dhabi, United Arab Emirates. Retrospective Cohort Study.\u0026nbsp;medrxiv. Published online March 24, 2024. doi:https://doi.org/10.1101/2024.03.19.24304561\u003c/li\u003e\n \u003cli\u003eNakamura M, Yamamoto Y, Imaoka W, et al. Relationships between Smoking Status, Cardiovascular Risk Factors, and Lipoproteins in a Large Japanese Population.\u0026nbsp;J Atheroscler Thromb. 2021;28(9):942-953. doi:10.5551/jat.56838\u003c/li\u003e\n \u003cli\u003eYamagata K, Ishida K, Sairenchi T, et al. Risk factors for chronic kidney disease in a community-based population: a 10-year follow-up study.\u0026nbsp;Kidney Int. 2007;71(2):159-166. doi:10.1038/sj.ki.5002017\u003c/li\u003e\n \u003cli\u003eKlag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men.\u0026nbsp;N Engl J Med. 1996;334(1):13-18. doi:10.1056/NEJM199601043340103\u003c/li\u003e\n \u003cli\u003eMaeda I, Hayashi T, Sato KK, et al. Cigarette smoking and the association with glomerular hyperfiltration and proteinuria in healthy middle-aged men.\u0026nbsp;Clin J Am Soc Nephrol. 2011;6(10):2462-2469. doi:10.2215/CJN.00700111\u003c/li\u003e\n \u003cli\u003eHemaid A, Al Mansoori M, Al Marzooqi N, et al. Prevalence, Incidence and Associated Risk Factors for Chronic Kidney Disease in Abu Dhabi: A Retrospective Cohort Study. 2024.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Tobacco. World Health Organization. Published July 31, 2023. https://www.who.int/news-room/fact-sheets/detail/tobacco\u003c/li\u003e\n \u003cli\u003ePan B, Jin X, Jun L, Qiu S, Zheng Q, Pan M. The relationship between smoking and stroke: A meta-analysis.\u0026nbsp;Medicine (Baltimore). 2019;98(12):e14872. doi:10.1097/MD.0000000000014872\u003c/li\u003e\n \u003cli\u003eHu G, Zhou M, Liu J, et al. Smoking and Provision of Smoking Cessation Interventions among Inpatients with Acute Coronary Syndrome in China: Findings from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project.\u0026nbsp;Glob Heart. 2020;15(1):72. Published 2020 Oct 23. doi:10.5334/gh.784\u003c/li\u003e\n \u003cli\u003eAsharani PV, Ling Seet VA, Abdin E, et al. Smoking and Mental Illness: Prevalence, Patterns and Correlates of Smoking and Smoking Cessation among Psychiatric Patients.\u0026nbsp;Int J Environ Res Public Health. 2020;17(15):5571. Published 2020 Aug 1. doi:10.3390/ijerph17155571\u003c/li\u003e\n \u003cli\u003eTakenaka H, Fujita T, Masuda A, Yano Y, Watanabe A, Kodama Y. Non-Alcoholic Fatty Liver Disease Is Strongly Associated with Smoking Status and Is Improved by Smoking Cessation in Japanese Males: A Retrospective Study.\u0026nbsp;Kobe J Med Sci. 2020;66(3):E102-E112. Published 2020 Nov 17.\u003c/li\u003e\n \u003cli\u003eYuan H, Shyy JY, Martins-Green M. Second-hand smoke stimulates lipid accumulation in the liver by modulating AMPK and SREBP-1.\u0026nbsp;J Hepatol. 2009;51(3):535-547. doi:10.1016/j.jhep.2009.03.026\u003c/li\u003e\n \u003cli\u003eAzzalini L, Ferrer E, Ramalho LN, et al. Cigarette smoking exacerbates nonalcoholic fatty liver disease in obese rats.\u0026nbsp;Hepatology. 2010;51(5):1567-1576. doi:10.1002/hep.23516\u003c/li\u003e\n \u003cli\u003eJee SH, Foong AW, Hur NW, Samet JM. Smoking and risk for diabetes incidence and mortality in Korean men and women.\u0026nbsp;Diabetes Care. 2010;33(12):2567-2572. doi:10.2337/dc10-0261\u003c/li\u003e\n \u003cli\u003eShi L, Shu XO, Li H, et al. Physical activity, smoking, and alcohol consumption in association with incidence of type 2 diabetes among middle-aged and elderly Chinese men. \u003cem\u003ePLoS One\u003c/em\u003e. 2013;8(11):e77919. Published 2013 Nov 4. doi:10.1371/journal.pone.0077919\u003c/li\u003e\n \u003cli\u003eAl-Zakwani I, Al Siyabi E, Alrawahi N, et al. Association between Peripheral Artery Disease and Major Adverse Cardiovascular Events in Patients with Acute Coronary Syndrome: Findings from the Gulf COAST Registry. \u003cem\u003eMed Princ Pract\u003c/em\u003e. 2019;28(5):410-417. doi:10.1159/000497790\u003c/li\u003e\n \u003cli\u003eCacoub PP, Abola MT, Baumgartner I, et al. Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry. \u003cem\u003eAtherosclerosis\u003c/em\u003e. 2009;204(2):e86-e92. doi:10.1016/j.atherosclerosis.2008.10.023\u003c/li\u003e\n \u003cli\u003eBenowitz NL, Burbank AD. Cardiovascular toxicity of nicotine: Implications for electronic cigarette use. \u003cem\u003eTrends Cardiovasc Med\u003c/em\u003e. 2016;26(6):515-523. doi:10.1016/j.tcm.2016.03.001\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cohort study, smoking, tobacco, prevalence","lastPublishedDoi":"10.21203/rs.3.rs-4743493/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4743493/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe study aimed to determine the prevalence and the cumulative risk of smoking among national male adults in Abu Dhabi, and to assess the determinants of starting, quitting, maintaining cessation, and continuing smoking among them.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study has an average follow-up period of 9 years. The study population was national males aged 18 years and above. Data was initially collected from the medical electronic records of individuals who participated in a comprehensive screening program (Weqaya) performed in Abu Dhabi ambulatory healthcare services in 2011\u0026ndash;2013.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe prevalence of smoking among male adults was 21%. The cumulative risk of smoking was 45%, with the highest risk observed in adults aged 30\u0026ndash;39. Young age and lower cholesterol level were the main determinants of starting smoking. The predictors of quitting smoking were younger age, lower systolic blood pressure, higher cholesterol, lower high-density lipoprotein (HDL), lower glomerular filtration rate (GFR), and vitamin D level. History of acute coronary syndrome (ACS) was a determinant for maintaining smoking cessation. Continuing smoking is associated with a higher risk of developing diabetes mellitus (DM), stroke, acute coronary syndrome (ACS), psychiatric illness, non-alcoholic fatty liver disease (NAFLD), and peripheral artery disease (PAD), while smoking cessation is associated with a reduced risk of those conditions.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study confirms smoking's health burden in Abu Dhabi and its association with various health risks.\u003c/p\u003e","manuscriptTitle":"Determinants and Sequelae of Smoking: Prevalence, Incidence, and Cessation Among Male Adults in Abu Dhabi, United Arab Emirates. A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-17 02:05:33","doi":"10.21203/rs.3.rs-4743493/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-26T17:59:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-26T17:30:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251148650858863227303100614375613285322","date":"2025-05-12T06:53:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-29T09:10:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334863863759325491206341090497654251686","date":"2025-04-21T07:25:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319746652238626701530126032367645367317","date":"2025-04-17T09:09:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177885093657083764960869717950389097765","date":"2025-04-15T04:19:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-05T18:17:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-24T10:29:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-17T11:58:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-17T11:57:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-07-15T14:11:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d098cd33-87d0-4802-8f9a-c576f79fad79","owner":[],"postedDate":"August 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T16:00:00+00:00","versionOfRecord":{"articleIdentity":"rs-4743493","link":"https://doi.org/10.1186/s12889-025-23826-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-09-24 15:57:23","publishedOnDateReadable":"September 24th, 2025"},"versionCreatedAt":"2024-08-17 02:05:33","video":"","vorDoi":"10.1186/s12889-025-23826-6","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23826-6","workflowStages":[]},"version":"v1","identity":"rs-4743493","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4743493","identity":"rs-4743493","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}