Smokeless tobacco (ST) is a global problem affecting more than 300 million people worldwide . ST is a type of tobacco that is not burned or smoked, but that is usually consumed by placing the product against the mucosal sites in the oral or nasal cavities, from which nicotine can be absorbed into the body . In the Eastern Mediterranean region (e.g., Saudi Arabia (KSA), Sudan and Yemen), locally produced ST products (e.g., Shammah, Toombak) are widely used . In KSA, however, data on the prevalence of Shammah use are still scarce.
In the period from 1994 to 2015, the age-standardized incidence rates (ASR) of oral cancer (OC) per 100,000 people in Saudi Arabia ranged from 1.5 in Hail region to 19.6 in Jazan region (highest rate) . A previous retrospective study (1976 to 1995) utilized the available data from the Tumor Registry data at King Faisal Specialist Hospital and Research Centre in Riyadh has identified that 35.4% of the nationally diagnosed cases with OC were from Jazan region . Jazan is a region in the southwest of KSA with a relatively small population of 1,365,110 people compared to the total population of 33,284,101 inhabitants in the KSA (i.e., 4% of the total population of KSA). Previous reviews have linked the high incidence of OC in this region with Shammah dipping [6, 7]. Shammah is a traditional type of ST made of mixture of tobacco, pepper, oils, lime, ash, coloring and flavoring materials . Shammah is placed (dipped) in the buccal vestibule (space between the internal cheeks’ tissue and teeth), labial vestibule (between the internal lip’s tissue and teeth), below and above the tongue. After few minutes of Shammah dipping, the user spits it out. Shammah.
In 2005, WHO has published a report of global data on the incidence of OC where the female population of KSA reported a higher ASR of OC (3.3 to 6.8 per 100,000 people) compared to the male population (≤ 3.2 per 100,000 people) . The reported findings were further illustrated in a study that collected data from patients visiting King Fahd Hospital and Prince Mohammed Bin Naser Hospital in Jazan region in the period from 2012 to 2016 . The study found that 57.5% of all OC cases were females and 42.5% were males. Which contrasts the findings reported from a previous case–control study with data limited to the OC cases diagnosed in 2014 at King Fahd Hospital in Jazan region. The diagnosed OC cases in the latter study were slightly higher among males; 18.74% in males and 14.58% in females .
Despite the high prevalence of Shammah usage in Jazan, the attention paid towards curbing Shammah use in terms of research, interventions, policy formulation and implementation are far from optimal . Moreover, no study has been conducted before to explore possible reasons of using Shammah in the Jazan region, including women.
In order to understand Shammah usage behavior, the related psychosocial factors must be identified. The focus on these determinants is related to their ability to be changed and because of their influence on behavior. Multiple psychosocial theories have explained the possible determinants of comparable health-risk behaviors (e.g., smoking). Based on the Reasoned Action Approach (RAA), individual’s attitude, subjective norm, perceived and actual behavioral control predict the intention to change behavior . Also, constructs from the Social Cognitive Theory (SCT), outcome expectancies and self-efficacy are significant determinants of behavior change . Outcome expectations refer to the belief that Shammah benefits or harms people’s health while self-efficacy refers to the people’s confidence in their ability to quit Shammah usage. The Integrated Change model (I-change model) considers the degree to which an individual knows about his behavior, the knowledge about the effect of using Shammah and its health threat, the beliefs about potential vulnerability to OC and the internal and external prompts as factors influencing an individual’s pre-motivational phase of behavior . These determinants refer to psychosocial factors in general and need to be explored in-depth to understand their relevance to understanding a specific behavior (e.g., Shammah use). The integration of these theories uncovers the aspects that are under-represented in each of these separate theories. Moreover, it brings a rich understanding of the possible psychosocial determinants related to using Shammah from different perspectives. The operationalization of the behavioral determinant attitude is different among these theories. For instance, in the RAA, attitude entails two dimensions: instrumental (cognitive) and experiential (affective). While in the SCT, the emotional aspect of attitude is not covered, and instead, attitude is operated by the outcome expectation that is a subjective estimate of the consequences of doing a particular behavior. Another example is self-efficacy; we draw on the evaluation guidance provided by both the SCT and the RAA to enable a thorough and complementary assessment specification of the individual belief about his ability to perform the healthy behavior.
Therefore, the objective of the present study was to gain in-depth information about the possible psychosocial determinants of Shammah usage behavior among adult Saudi current Shammah users. Knowledge and understanding of these determinants are expected to provide targeted information for the development of effective interventions for Shammah use prevention and cessation.