Smoking is a major contributor to heart disease and mortality, making it one of the most avoidable causes of death on the globe [1]. Cardiovascular disorders, emphysema, bronchitis, lung and oral cavity cancer, are among the illnesses linked to tobacco use [2]. While not entirely safe, nicotine is the addictive component in tobacco that causes the least amount of harm when compared to the other active elements [3]. There is strong proof regarding the risks associated with smoking and the positive health advantages of quitting [4].   One in four deaths from Cardiovascular Disease (CVD) are caused by smoking, which is also one of the main causes of CVD. Data from the World Health Organization indicate that 10% of all CVDs are caused by smoking. Around 6 million deaths worldwide are attributed to tobacco use each year; in the US, nearly 500,000 of these deaths can be ascribed to smoking, with secondhand smoke exposure accounting for 10% of these fatalities [5].   People can avoid cardiovascular disease and mortality by giving up smoking. Quitting smoking also helps people who already have heart problems, quitting smoking has been shown to reduce mortality in both the general population and myocardial infarction patients [6]. Also stopping smoking lowers the risk of recurrent episodes in CHD patients by 50% [7]. CVD risk decreases after smoking cessation. In some clinical research there is no distinguish between former smoker and who never smoked before [8].   Regular tobacco use was found to be a strong predictor of both APUDs and MUDs in all age groups studied in 2016. Age-related increases in showed PUDs and decreases in expected MUDs were seen. There was a 3-day difference in PUDs comparing nonsmokers and regular's smokers among adults 45-54 and 55-64 years old. In young people (18-24 years old), there was a 4.3-day variation in MUDs [9]. In 2013 a study that measured the variations in indirect expense between present and previous smokers as a result of their lower job efficiency. The research's results were Regardless of the duration elapsed after quitting, the sum of all annual indirect expenditures of those who still smoke was much higher than those of previous smokers [10]. A study published to assess anxiety and depression by using the Hospital Anxiety and Depression Scale at week 24, with a lower score indicating better mental health (range, 0-21) and the result show smoking cessation was associated with lower scores for both anxiety (-0.40 points; 95% confidence interval, -0.58 to -0.22 points) and depression (-0.47 points; 95% confidence interval, -0.61 to -0.33 points) [11].   With the greatest impact size for incident PAD, overall smoking indicators demonstrated links with three main atherosclerotic illnesses. For PAD and CHD, the danger of smoking lasted up to 30 years and 20 years, respectively. These results underscore the need of smoking prevention and early cessation and suggest that public declarations recognizing the detrimental effects of smoking on general cardiovascular health must take PAD into consideration [12]. By addressing limitations in previous research, such as small sample sizes, inconsistent methodologies and lack of cultural context, this study seeks to provide region-specific, comprehensive and reliable insights. The findings will guide the development of effective smoking cessation programs and public health strategies tailored to the Saudi population.   Objectives This study aims to investigate the impact of smoking and smoking cessation on the quality of life among individuals diagnosed with Cardiovascular Diseases (CVDs) compared to those without CVDs in Saudi Arabia.

Study Design and Setting Based on an established questionnaire that the WHO constructed, this study was a cross-sectional questionnaire survey. The study’s conducted to patients who smoke and smoking cessation and they were previously diagnosed with cardiovascular diseases.   Sample Size In order to determine the lowest possible number of responders required to constitute a representative sample for everyone in the population, calculations for sample sizes were made. The Raosoft sample size calculator was used to calculate the sample size. The sample size that was determined was 384, with an indicator percentage of 0.50, a margin of error of 5 percent and a range of trust (CI) of 95 percent.   Inclusion and Exclusion Criteria The inclusion criteria for this study are adults aged 18 years or older, current smokers or individuals who have quit smoking within the past 6 months, participants diagnosed with Cardiovascular Disease (CVD), participants without a diagnosis of CVD, residents of Saudi Arabia and able to provide informed consent. Exclusion Criteria include severe cognitive impairment or mental incapacity, acute illness significantly affecting quality of life, serious non-CVD related conditions (e.g., advanced cancer), inability to communicate effectively in the study language and pregnant or breastfeeding women.   Method for Data Collection, Instrument and Score System The World Health Organization Quality of Life Brief version (WHOQoL-BREF) was used to assess quality of life. It is a self-reported questionnaire with 26 questions, each of which represents one area of life that is thought to contribute to a person's quality of life. Twenty-four measures assess four major domains: physical health (7 items), psychological health (6 items), social interactions (9 items) and the environment (8 items). Two additional items assess the sense of quality of life and general health. Thus, 24 items make up the four WHOQoL domains (physical, psychological, social and environmental).   The WHOQoL-BREF uses a 5-point scale (1 to 5), with a maximum score of 100 indicating no limits or impairments. Greater scores suggest greater self-perceived quality of life.   The questionnaire was developed based on the WHO quality of life scale-brief, which was evaluated by an expert.   Scoring System The WHOQOL-Brief is a shortened version of the WHOQOL-100 quality of life assessment, containing 26 items. It produces scores across four domains, as well as two individual items measuring the person's overall perception of their quality of life and health. The domain scores are scaled positively, with higher scores indicating a better quality of life. Three of the items need to be reverse-scored. To transform the raw scores into a standardized 0-100 scale, the formula is:   This converts the lowest and highest possible scores to 0 and 100 respectively, with scores in between representing the percentage of the total possible score achieved. This standardized 0-100 scoring allows for comparison across different WHOQOL-100 datasets. As an example, a raw score of 15 on the "Pain and Discomfort" facet would be transformed as:   Pilot Test The questionnaire was distributed and filled by 20 individuals to test the accessibility and clarity of the questionnaire. The pilot test data excluded from the final data of the study.   Analyzes and Entry Method On a computer, collected data was input using the Microsoft Excel (2024) Windows software. After then, the data was moved to version 29 of the Statistical Package for Social Science Software (SPSS). to be examined statistically. In this study, both descriptive statistics and the chi-square tests were used.

Table 1 displays various demographic parameters of the participants with a total number of (574). Mean age is 35.8 years and standard deviation is 13.8, suggesting a broad age distribution; 27% of the sample is 24 and under or 45 and over. Overall, there is a large gender disparity in gender representation at this museum, with 73.9% being male. About 29.8% of participants report chronic heart disorders that could have public health implications within this demographic. There is a lot of smoking status balance, about 38 percent are actively smoking and a lot of people who quit or not smoke behaviors too. It seems educational qualifications are among the biggest in the system, with more than half having a bachelor’s degree or above. The majority in which are employed and indicative of prevailing socio-economic conditions, moreover a large part of whom are in the lower income brackets.   As shown in Figure 1, This survey with a total sample size of 574 respondents offers helpful info from the participants’ perceptions. Results show that most of them perceived their quality of life positively. For instance, 37.6% (216 respondents) said it was "Good," and 27.0% (155 respondents) said it was "Excellent." A noteworthy number of respondents, 28.6% (164), represented their quality of life as 'normal'. On the other hand, 33 respondents rated their quality of life as "Bad" (5.7%) and 6 (1.0%) rated the quality of life as "Very Bad". About 64.6% of respondents indicate a positive attitude towards the quality of their life whereas 6.7% are negative about it.   Table 2 presents data of a comprehensive overview of the parameters regarding the World Health Organization Quality of Life (WHOQOL)-BREF with responses from a large group of 574 respondents. A presumption of a positive self-assessment was found in a significant majority of respondents, approximately 64.6%, when rating their overall quality of life as 'Good' or 'Excellent'. Additionally, they were quite pleased with their health with a huge 55.1 percent reporting satisfaction. While a lot of respondents were experiencing some degree of physical pain (33.6% reporting needing a moderate amount of pain to carry out their everyday tasks, with 21.3% saying that they have none), that does not seem to be a huge obstacle in the life of many respondents. These also strung with an interesting point of view to mental wellbeing as 62.5 percent felt they live their lives to a great extent in a meaningful way, suggesting a real strong sense of purpose among the participants.   Table 1: Sociodemographic Characteristics of Participants (n = 574) Parameter No. Percent Age (Mean:35.8, STD:13.8) 24 or less 155 27.0 25 to 30 108 18.8 31 to 44 151 26.3 45 or more 160 27.9 Gender Female 150 26.1 Male 424 73.9 Do you suffer from any heart disorders or diseases? No 403 70.2 Yes 171 29.8 Are you a smoker or a former smoker? None of the above 216 37.6 Smoker 217 37.8 Quit smoking 141 24.6 Nationality Saudi 565 98.4 Non-Saudi 9 1.6 Educational level Middle school or less 17 3.0 High school 237 41.3 Bachelor’s degree or more 313 54.5 Non-educated 7 1.2 Job status Student 132 23.0 Employed 295 51.4 Non-Employed 69 12.0 Freelance 19 3.3 Retired 59 10.3 Marital status Single 236 41.1 Married 318 55.4 Divorced 15 2.6 Widowed 5 .9 Residential region Northern region 9 1.6 Southern region 166 28.9 Central region 163 28.4 Eastern region 103 17.9 Western region 133 23.2 Monthly income Less than 1000 SAR 123 21.4 1000-5000 SAR 143 24.9 up to 10,000 SAR 138 24.0 up to 15,000 SAR 56 9.8 more than 15,000 SAR 114 19.9       Figure 1: Illustrates How Participants Rate Their Quality of Life   As shown in Figure 2, based upon a sample of 574 respondents, this survey measures satisfaction with daily living activities. Finds that 28.2% (162 respondents) were 'Satisfied', the biggest proportion 47.2% (271 respondents) indicated they were 'Neither satisfied nor dissatisfied', implying neutrality. At the other end, 20.9% (120 respondents) were dissatisfied, while a smaller 3.7% (21 respondents) answered "Very Dissatisfied." By and large, 28.2% of respondents said they were satisfied, compared with 24.6% that said they were dissatisfied. A high rate of neutral responses might reflect either mixed experience or lack of knowledge of daily living performance.   As shown in Table 3, the data presented sheds some light on the different dimensions of WHOQOL – BREF (the World Health Organization Quality of Life), providing answers from a sample of 574 participants.     Figure 2: Illustrates Satisfaction with Ability to Perform Daily Living Activities Among Participants   Table 2: Parameters related to World Health Organization Quality of Life (WHOQOL) – BREF (n = 574) Parameter No. Percent How would you rate your quality of life? Very bad 6 1.0 Bad 33 5.7 Normal 164 28.6 Good 216 37.6 Excellent 155 27.0 How satisfied are you with your health? Very satisfied 137 23.9 Satisfied with it 179 31.2 Fairly so 153 26.7 Unsatisfied in some ways 94 16.4 Very dissatisfied 11 1.9   Table 2: Continue Parameter No. Percent To what extent do you feel that physical pain prevents you from doing what you need to do? Extremely 15 2.6 Very much 51 8.9 A moderate amount 193 33.6 A little 193 33.6 Not at all 122 21.3 How much do you need any medical treatment to function in your daily life? Extremely 15 2.6 Very much 34 5.9 A moderate amount 124 21.6 A little 175 30.5 Not at all 226 39.4 How much do you enjoy life? Extremely 83 14.5 Very much 216 37.6 A moderate amount 216 37.6 A little 49 8.5 Not at all 10 1.7 To what extent do you feel your life to be meaningful? Extremely 166 28.9 Very much 193 33.6 A moderate amount 152 26.5 A little 52 9.1 Not at all 11 1.9 How well are you able to concentrate? Extremely 102 17.8 Very much 175 30.5 A moderate amount 218 38.0 A little 66 11.5 Not at all 13 2.3 How safe do you feel in your daily life? Extremely 192 33.4 Very much 197 34.3 A moderate amount 130 22.6 A little 42 7.3 Not at all 13 2.3 How healthy is your physical environment? Extremely 88 15.3 Very much 167 29.1 A moderate amount 214 37.3 A little 77 13.4 Not at all 28 4.9 Do you have enough energy for everyday life? Completely 97 16.9 Mostly 177 30.8 Moderately 227 39.5 A little 60 10.5 Not at all 13 2.3 Are you able to accept your bodily appearance? Completely 154 26.8 Mostly 210 36.6 Moderately 147 25.6 A little 51 8.9 Not at all 12 2.1 Have you enough money to meet your needs? Completely 119 20.7 Mostly 114 19.9 Moderately 219 38.2 A little 91 15.9 Not at all 31 5.4 How available to you is the information that you need in your day-to-day life? Completely 124 21.6 Mostly 186 32.4 Moderately 198 34.5 A little 50 8.7 Not at all 16 2.8 To what extent do you have the opportunity for leisure activities? Completely 75 13.1 Mostly 110 19.2 Moderately 214 37.3 A little 144 25.1 Not at all 31 5.4 How well are you able to get around? Very good 151 26.3 Good 174 30.3 Neither poor nor good 168 29.3 Poor 63 11.0 Very poor 18 3.1   Table 3: Participants’ World Health Organization Quality of Life (WHOQOL) – BREF (n = 574) Parameter No. Percent How satisfied are you with you sleep? Satisfied 159 27.7 Neither satisfied nor dissatisfied 243 42.3 Dissatisfied 137 23.9 Very dissatisfied 35 6.1 How satisfied are you with your ability to perform your daily living activities? Satisfied 162 28.2 Neither satisfied nor dissatisfied 271 47.2 Dissatisfied 120 20.9 Very dissatisfied 21 3.7 How satisfied are you with your capacity for work? Satisfied 212 36.9 Neither satisfied nor dissatisfied 259 45.1 Dissatisfied 78 13.6 Very dissatisfied 25 4.4 How satisfied are you with yourself? Satisfied 268 46.7 Neither satisfied nor dissatisfied 226 39.4 Dissatisfied 65 11.3 Very dissatisfied 15 2.6 How satisfied are you with your personal relationships? Satisfied 236 41.1 Neither satisfied nor dissatisfied 223 38.9 Dissatisfied 93 16.2 Very dissatisfied 22 3.8 How satisfied are you with your sex life? Satisfied 206 35.9 Neither satisfied nor dissatisfied 215 37.5 Dissatisfied 100 17.4 Very dissatisfied 53 9.2 How satisfied are you with the support you get from your friends? Satisfied 198 34.5 Neither satisfied nor dissatisfied 234 40.8 Dissatisfied 107 18.6 Very dissatisfied 35 6.1 How satisfied are you with the conditions of your living place? Satisfied 249 43.4 Neither satisfied nor dissatisfied 216 37.6 Dissatisfied 86 15.0 Very dissatisfied 23 4.0 How satisfied are you with your access to health services? Satisfied 214 37.3 Neither satisfied nor dissatisfied 218 38.0 Dissatisfied 114 19.9 Very dissatisfied 28 4.9 How satisfied are you with your transport? Satisfied 256 44.6 Neither satisfied nor dissatisfied 226 39.4 Dissatisfied 71 12.4 Very dissatisfied 21 3.7 How often do you have negative feelings such as blue mood, despair, anxiety, depression? Very satisfied 34 5.9 Satisfied 64 11.1 Neither satisfied nor dissatisfied 172 30.0 Dissatisfied 157 27.4 Very dissatisfied 147 25.6   Table 4: Shows Total WHOQOL-Brief Score Results Frequency Percent Very good quality of life 84 14.6 Good quality of life 385 67.1 Moderate quality of life 96 16.7 Poor quality of life 9 1.6 Total 574 100.0   A surprising thing to note is that in fact a large percentage of people indicated dissatisfaction with several parameters in particular, sleep, daily living activity and emotional wellbeing. For instance, although 27.7% reported satisfaction with sleep quality, this amounted to 30% who were dissatisfied or very dissatisfied with their sleep quality, suggesting that follow up investigation an area worth exploring. Similarly, only 28.2 percent were satisfied with the ability to perform daily activities. These are shown to raise some concerns, however notwithstanding, a rather higher satisfaction rate is recorded in personal relationships (41.1%) as 41.1 had them deemed satisfied. In fact, only 53% were positive or not that happy with the feeling of negative emotions.   Table 4 presents the data relevant to quality of life according to the WHOQOL-Brief instrument in a sample of 574 respondents. 67.1% reported a "Good quality of life," an encouraging indicator of overall wellbeing in the population studied. Moreover, although the 'Very good quality of life' category is much smaller with just 14.6%, it nevertheless adds positively to the total picture. On the other hand, 16.7% said their quality of life was "Moderate" and only 1.6% said their quality of life was "Poor"; this implies that adverse living conditions are not very common in the case of the cohort.   Table 5 shows that quality of life according to WHO has statistically significant relation to smoking (p value = 0.001), nationality (p value = 0.041), educational level (p value = 0.006), job status (p value = 0.003) and monthly income (p value = 0.001). It also shows statistically insignificant relation to suffering from heart disorders, gender, age, marital status and residential area. Participants who are nonsmokers, holding bachelor’s degree or higher and those with a monthly income over 15000 SAR were found to have better quality of life than others.

The purpose of the present study was to determine how smoking and smoking cessation affected the quality of life of those with Cardiovascular Diseases (CVDs) as compared to those without CVDs, in Saudi Arabia. Contributing to the growing literature on the negative association of smoking with health-related quality of life (HRQoL) for patients with cardiovascular conditions, the findings of this study. These findings show smoking is significantly related to lower quality of life scores in physical and especially in the psychological domains, an finding consistent with previous evidence showing similar trends in populations that are very diverse.   Taira et al. [13] found in a study that patients with established coronary disease who quit smoking had reduction in risk of myocardial infarction and enhancement of quality-of-life post intervention. Similar to the findings of the present study, participants who were non-smoker, reported higher quality of life scores than those that were smokers.   Table 5: Relation Between WHO Quality of Life and Sociodemographic Characteristics Parameters WHO quality of life Total (N = 574) P value* Moderate or poor quality of life Very good or good quality of life Do you suffer from any heart disorders or diseases? No 66 337 403 0.068 62.9% 71.9% 70.2% Yes 39 132 171 37.1% 28.1% 29.8% Are you a smoker or a former smoker? None of the above 25 191 216 0.001 23.8% 40.7% 37.6% Smoker 55 162 217 52.4% 34.5% 37.8% Quit smoking 25 116 141 23.8% 24.7% 24.6% Gender Female 30 120 150 0.529 28.6% 25.6% 26.1% Male 75 349 424 71.4% 74.4% 73.9% Age 24 or less 33 122 155 0.242 31.4% 26.0% 27.0% 25 to 30 22 86 108 21.0% 18.3% 18.8% 31 to 44 29 122 151 27.6% 26.0% 26.3% 45 or more 21 139 160 20.0% 29.6% 27.9% Nationality Saudi 101 464 565 0.041 96.2% 98.9% 98.4% Non-Saudi 4 5 9 3.8% 1.1% 1.6% Educational level Middle school or less 6 11 17 0.006 5.7% 2.3% 3.0% High school 55 182 237 52.4% 38.8% 41.3% Bachelor’s degree or more 42 271 313 40.0% 57.8% 54.5% Non-educated 2 5 7 1.9% 1.1% 1.2% Job status Student 19 113 132 0.003 18.1% 24.1% 23.0% Employed 60 235 295 57.1% 50.1% 51.4% Non-Employed 21 48 69 20.0% 10.2% 12.0% Freelance 1 18 19 1.0% 3.8% 3.3% Retired 4 55 59 3.8% 11.7% 10.3% Marital status Single 50 186 236 0.147 47.6% 39.7% 41.1% Married 49 269 318 46.7% 57.4% 55.4% Divorced 4 11 15 3.8% 2.3% 2.6% Widowed 2 3 5 1.9% 0.6% 0.9% Residential area Northern region 2 7 9 0.588 1.9% 1.5% 1.6% Southern region 31 135 166 29.5% 28.8% 28.9% Central region 35 128 163 33.3% 27.3% 28.4% Eastern region 14 89 103 13.3% 19.0% 17.9% Western region 23 110 133 21.9% 23.5% 23.2% Monthly income Less than 1000 SAR 35 88 123 0.001 33.3% 18.8% 21.4% 1000-5000 SAR 25 118 143 23.8% 25.2% 24.9% up to 10,000 SAR 27 111 138 25.7% 23.7% 24.0% up to 15,000 SAR 10 46 56 9.5% 9.8% 9.8% more than 15,000 SAR 8 106 114 7.6% 22.6% 19.9%   The evidence provides us with details that indicate that the improvement of the health of the smoker through the act of stopping smoking goes far beyond the immediate and even leads to improvement of patients’ both general well-being and their satisfaction of life as a whole. Smedt et al.'s study [14] further suggests that HRQoL outcomes improve rather rapidly after smoking cessation supporting the idea that timely interventions can have a big impact in quality of life.   Furthermore, these results are in line with Holahan et al. [15] who found that smoking status is related closely to physical health related quality of life, especially in middle aged and older woman. That implies the damage caused from smoking to quality of life is not circumscribed to a particular segment of society, but is felt by nearly everyone. Combining these facts with the demographics of the current study's profile, a substantial portion of younger adults, the importance of tailored smoking cessation programs that are tailored to different age groups and cultural contexts is even more important.   In addition, the study points to educational attainment and socioeconomic status as determinants of CVD patients’ quality of life. Higher educated and higher income participants reported better quality of life scores consistent with previous research that has found a relationship between socioeconomic factors and health outcomes [16]. For example, research by Goettler et al. [16] showed that socioeconomic status is a determinant of smoking cessation rates among patients with coronary heart disease, perhaps making it more difficult for those with lower socioeconomic status to quit smoking and improve their quality of life.   Moreover the findings of the current study regarding psychological domain of quality of life are crucial. Consistent with the literature that reports the associations between smoking and psychiatric morbidity, particularly depression and anxiety, a considerable proportion of participants were dissatisfied with emotional well being. Rodrigues et al. [17] study highlights that non cardiovascular comorbidities, especially depressive disorders, have a greater impact on quality of life than the cardiovascular diseases themselves. This suggests that there needs to be a comprehensive approach involving smoking cessation and mental health support for patients with CVD.   Although, the present study have limitations. The cross-sectional design precludes us from determining causality between smoking, smoking removal and quality of life. Furthermore, use of self reported measures may be subject to bias due to the fact that participants may underreport their smoking status and overestimate their quality of life. Longitudinal studies in future are needed to determine long term effects of smoking cessation on CVD patients’ quality of life.

This paired study offers important information on the impact of smoking and smoking cessation on the quality of life of patients with cardiovascular diseases. This underscores the great need for effective stepped smoking cessation interventions customized to the sociocultural and socioeconomic contexts of patients. Addressing smoking as a modifiable risk factor, healthcare providers can dramatically improve the quality of life of those with cardiovascular conditions to better quality of life. Future research is needed to continue to delineate the intricate interrelationship between smoking, quality of life and cardiovascular health to use as the basis for public health approaches designed to limit the burden of smoking related morbidity and mortality.   Limitations   Informed Consent: Written informed consent was obtained from all individual participants included in the study Data and Materials Availability: All data associated with this study are present in the paper   Acknowledgement We thank the participants who all contributed samples to the study.   Conflicts of Interest The authors declare that there are no conflicts of interest. Funding The study did not receive any external funding.   Ethical Statement An informed consent was obtained from each participant after explaining the study in full and clarifying that participation is voluntary. Data collected were securely saved and used for research purposes only.