Introduction Tobacco smoking is especially high among males in the Kingdom of Saudi Arabia (KSA). In 2019, 27.5% of males ages 15+ reported smoking. Despite a minimum age requirement of 18 years, data indicate that 6.8% of youth ages 13-15 currently smoke tobacco products. To reduce youth smoking, countries have raised the minimum purchase age to 21, also referred to as Tobacco 21. Except for Kuwait, no other Middle Eastern country has done so. We develop a tobacco smoking simulation model to project the potential impact of a national Tobacco 21 policy in Saudi Arabia.

Methods We used data from three nationally representative health surveys in Saudi Arabia to develop the KSA Tobacco Control Policy (TCP) model, estimating smoking initiation and cessation rates for males, as smoking rates are low among females. A national Tobacco 21 policy was operationalized as a 34% (15%-53%) reduction to smoking initiation for ages 18-20. Economic impact was evaluated using the 2024 KSA value of a statistical life which ranges from $1.65 million to $5.15 million USD.

Results Under a status quo scenario, tobacco smoking prevalence in males would decrease to 10.2% by 2100. Implementation of Tobacco 21 in 2026 would decrease smoking prevalence to 9.4% (8.9%, 9.8%) by 2100. While modest, these reductions would eventually translate into nearly 5000 (2200, 7800) premature deaths averted with up to 155000 (69000, 241000) life years gained from 2026-2100, respectively. The total expected economic benefit ranges from $1.67 to $5.19 billion USD, equivalent to 6.25 to 19.45 billion SAR.

Discussion Timely implementation would support the KSA in its goals to reduce non-communicable disease and death; however, even under best-case conditions, a Tobacco 21 alone would not achieve the Vision 2030 smoking prevalence target of 9%. Additional policies that substantially increase smoking cessation are needed.

What is already known on this topic The leading causes of death in Saudi Arabia are all linked to tobacco smoking. Tobacco 21 policies have been pursued by numerous governments to reduce youth smoking, but such policies are lacking in Middle Eastern nations.

What this study adds A nationwide Tobacco 21 policy in Saudi Arabia would reduce smoking initiation, smoking prevalence, and smoking-related mortality. Overall smoking prevalence among males ages 15+ would decline, and nearly 5000 premature deaths would be averted with up to 155,000 life years gained from 2026-2100, valued at 6.25 to 19.45 billion SAR.

How this study might affect research, practice or policy This study quantified for the first time the potential long-term benefits of a Tobacco 21 policy in Saudi Arabia for the male population. A Tobacco 21 policy would benefit future generations of young people by reducing their risk for heart disease, stroke, and cancer, currently the leading causes of death in the nation. However, additional efforts are needed in addition to Tobacco 21 policies to achieve tobacco smoking reduction goals.

The authors have declared no competing interest.

This study was supported by the Saudi Public Health Authority and World Bank. Financing for the analysis was provided by the Saudi Public Health Authority and the Health, Nutrition and Population Reimbursable Advisory Services Program between the World Bank and the Ministry of Finance in Saudi Arabia (P179873). Findings, interpretations, and conclusions expressed in this work are those of the authors, and do not necessarily reflect the views of The Saudi Public Health Authority or the World Bank, their Boards of Directors, or the governments they represent.

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This study involves secondary analyses of de-identified survey data that were obtained by request to the Saudi Arabia Public Health Authority. No data was collected as part of this study.

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rmezabccrc.ca, majabripha.gov.sa, azalabanitaibahu.edu.sa, ssmonshiuqu.edu.sa, aayakoubmoh.gov.sa, fmdhaherpha.gov.sa, mhamzaworldbank.org, Wfbalawipha.gov.sa, ralsukaitworldbank.org, mashahinpha.gov.sa, vcetinkayaworldbank.org, tmghaithpha.gov.sa

Data produced in the present study are available upon reasonable request to the authors. All model R code, input data, and smoking and mortality estimates will be made publicly available online upon publication in a peer-reviewed journal.