Smoking prevalence and emerging tobacco product use among Saudi adolescents: a systematic review.

Objectives: To synthesize updated prevalence findings on tobacco and emerging nicotine product use, such as e-cigarettes, among Saudi adolescents based on evidence published since 2018 and to summarize reported sociodemographic and behavioral factors associated with use. Methods: A systematic review was conducted following the PRISMA 2020 guidelines. We searched PubMed, Embase, Scopus, and Web of Science for observational studies published between March 2018 and February 2026. This timeframe was chosen to update the review, which included studies published up to March 2018, and to incorporate evidence generated during the healthcare reforms introduced under Saudi Vision 2030. Study selection and data extraction were conducted using predefined eligibility criteria and standardized extraction forms. Eligible studies included Saudi adolescents aged 10-19 years reporting prevalence rates of cigarette smoking, waterpipe use, electronic cigarettes, or other nicotine products. The risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for cross-sectional studies. A narrative synthesis was performed. Results: Twelve studies reporting the prevalence of smoking among adolescents in Saudi Arabia were included. The prevalence of current cigarette smoking ranged from 2.8% in nationally representative surveys to 40.8% in male-only regional samples. Most mixed-gender, school-based studies reported current smoking prevalence between 8 and 23%, while ever-smoking prevalence exceeded 40% in some male-only studies. Emerging tobacco products were widely used, with e-cigarette prevalence ranging from 3 to 20.6%, and shisha use reported as high as 29%. Patterns of dual and poly-tobacco use, particularly involving e-cigarettes and hookah, were common. Across studies, males consistently demonstrated higher smoking prevalence than females. Peer smoking and family smoking were the factors most consistently associated with tobacco use across studies. Conclusion: Tobacco use among Saudi adolescents remains prevalent and varies across regions, with reported use of electronic cigarettes and dual-use patterns. Tailored prevention strategies are needed to address smoking behaviors in Saudi adolescents. National studies should be conducted to better estimate tobacco products use and other addictive behaviors among youth, guiding future prevention efforts. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD420261320020, identifier (CRD420261320020).