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Erschienen in: BMC Medicine 1/2022

Open Access 01.12.2022 | Research article

Sex and macroeconomic differences and trends in early attempts at cigarette smoking among adolescents: findings from 147 countries

verfasst von: Huaqing Liu, Qi Qi, Ying Duan, Chuanwei Ma, Chengchao Zhou

Erschienen in: BMC Medicine | Ausgabe 1/2022

Abstract

Background

Most tobacco users initiate smoking during adolescence. Little is known about the global prevalence and trends in early cigarette smoking among adolescents. This study aimed to evaluate the prevalence of early attempts at cigarette smoking and its change trends among young adolescents.

Methods

We used data from the Global Youth Tobacco Surveys on adolescents aged 12–16 years, comprising 456,634 participants from 147 countries between 2006 and 2018, to estimate the prevalence of early attempts at cigarette smoking and age distribution at attempt by sex, country income, purchasing power parity (PPP) per capita, and WHO region. We assessed the average annual rate of reduction (AARR) in the prevalence of attempts at cigarette smoking before 12 years of age in 70 countries that had data from three or more surveys completed between 1999 and 2018.

Results

The average prevalence of early attempts at cigarette smoking was 12.2% (95% CI: 10.9–13.5) for boys and 6.7% (95% CI: 5.8–7.6) for girls, with the highest prevalence of 17.4% for boys and 10.7% for girls in the European region. Along with the growth of the national economy, the prevalence of early attempts at cigarette smoking gradually increased in both sexes. A total of 22.9% and 30% of countries had a negative change in AARR for boys and for girls, respectively. The countries with an upward prevalence were mainly located in the Eastern Mediterranean, Southeast Asia, and African regions. The age distribution at first cigarette smoked did not differ substantially between sexes. Notably, the age at first cigarette smoked of 10.7 years for girls was significantly earlier than that of 11.8 years for boys in low-income countries. Among cigarette-smoking adolescents, the average percentage of girls reporting smoking their first cigarette at an age <12 years was 55.7% in Q1 for PPP quintiles, 46.5% in Q2, 40.3% in Q3, 38.4% in Q4, and 34.6% in Q5, and the corresponding prevalence for boys was 46.0% in Q1, 42.8% in Q2, 42.9% in Q3, 43.5% in Q4, and 41.1% in Q5.

Conclusions

The global prevalence of early attempts at cigarette smoking among adolescents was substantial, with differences by sex and macroeconomic situation, and our findings stress that interventions and policies targeting the first smoking experience are required to prevent the initiation of tobacco use among early adolescents, especially girls in low-income countries.
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Abkürzungen
AARR
Average annual rate of reduction
CI
Confidence intervals
FCTC
Framework Convention on Tobacco Control
GYTS
Global Youth Tobacco Surveys
PPP
Purchasing power parity
WHO
World Health Organization

Background

Tobacco use is a leading preventable risk factor for noncommunicable chronic diseases and premature death worldwide, resulting in more than eight million deaths each year and 170.9 million disability-adjusted life-years lost [1]. In 2019, more than one billion individuals worldwide were tobacco users. Therefore, preventing tobacco use is critical for tobacco control and ending the tobacco epidemic.
Most tobacco users initiate smoking during adolescence [24]. Hence, tobacco use is referred to as a “paediatric disease” [5, 6]. A recent study in 2019 estimated that 82.6% of tobacco users aged 20–54 years initiated smoking between ages 14 and 25, and 18.5% of tobacco users began smoking regularly by age 15 [7]. In Africa, 9.6% of adolescents in Cote d’Ivoire initiated smoking at ages 12 or 13, and 2.66% of adolescents in Mali initiated smoking at 7 years or younger [8]. In European countries, among regular smokers aged 15–39 years, the average initiation age of regular smoking was 16.6 years, and 68.1% of participants began smoking regularly before the age of 18 years [4]. Behavioral and biological studies have indicated that young individuals are particularly vulnerable to addiction and that most adult tobacco users regret starting smoking. Notably, younger individuals who initiate tobacco use are more likely to become regular and heavy tobacco users [9, 10], less likely to make successful quit attempts [11, 12], and more likely to experience tobacco-related mortality [13]. If people do not become regular tobacco users by the age of 25, they are much less likely to become tobacco users [5].
Early initiation of tobacco use during adolescence might be a critical point to control the tobacco epidemic. Tobacco addiction, as the early initiation of tobacco use, is associated with an increased risk for later nicotine dependence [14]. Therefore, preventing early tobacco-smoking initiation during adolescence could be an effective strategy to reduce the number of new tobacco users and is particularly critical in controlling tobacco use [3, 15]. However, to date, little is known about the prevalence and trends in the early initiation of cigarette use in adolescents worldwide.
In addition, the age at first tobacco use could reflect health aspects of a population. Along with the prevalence or incidence of tobacco use, the age at first smoking attempt could be regarded as a predictor of the health impact from tobacco-induced diseases, the economic impact from tobacco-attributable direct medical expenses, and lost earnings from loss of productivity [16]. Moreover, evaluation of the age at first smoking attempt could have social implications and help formulate locally relevant, targeted public health policy to reduce early initiation of tobacco use. Information on changes in early attempts at cigarette smoking may provide valuable insight into the effectiveness of adolescent-targeted prevention measures on tobacco use.
Our study was designed to evaluate the prevalence and trends in early attempts at cigarette smoking among adolescents and to further assess the age at first attempt among smoking adolescents. The results provide important insights into developing targeted intervention programs or policies to control the early initiation of tobacco use in adolescents from a public health and global perspective.

Methods

Study design and participants

Data were obtained from the Global Youth Tobacco Survey (GYTS), a nationally representative school-based survey of young adolescents, to collect comprehensive tobacco use and initiation information and enhance countries’ capacity to implement and evaluate tobacco prevention and control programs. The GYTS uses a consistent and standardized sample design, “core questionnaire,” and a data collection protocol to generate comparable data across countries. A two-stage sample design was used to select schools with a probability proportional to enrolment size and randomly select classes within selected schools in all countries [17]. Each student in the selected classes was eligible to participate in the GYTS. A standardized set of survey questions (i.e., core questionnaire) was used through anonymous, confidential, and self-administered surveys in all countries. The methodology of the GYTS is described in more detail on the websites of the World Health Organization (WHO) and the US Centers for Disease Control and Prevention. The country datasets are publicly available and comply with the corresponding national ethical board review.
This study included a total of 147 countries or territories that reported a nationally representative sample, after excluding surveys for which the unweighted sample of cigarette users was less than 100 or there was no data on the age at first smoking attempt. Finally, 456,634 young adolescents aged 12–16 years were analyzed. The most recent survey was used to analyze the prevalence of early attempts at cigarette smoking (i.e., trying the first cigarette before 12 years of age) if a country had conducted two or more surveys. Data from 70 countries that had three or more surveys completed between 1999 and 2018 were selected to evaluate the time trends in the prevalence of early attempts at cigarette smoking.

Procedures

Age at first attempt at cigarette smoking was defined by the question “How old were you when you first tried a cigarette?” in the questionnaire. The responses included “I have never tried smoking a cigarette,” “7 years old or younger,” “8-9 years old,” “10-11 years old,” “12-13 years old,” “14-15 years old,” and “16 years old or older.” We calculated the mean estimates of the age at first cigarette smoked after recoding the responses as follows: “7 years old or younger” was coded as “6.5 years,” “8-9 years old” as “8.5 years,” “10-11 years old” as “10.5 years,” “12-13 years old” as “12.5 years,” “14-15 years old” as “14.5 years,” and “16 years old or older” as “16 years.” Age was defined by the question “How old are you?” The responses were “11 years old or younger,” “12 years old,” “13 years old,” “14 years old,” “15 years old,” “16 years old,” and “17 years old or older.” Our study limited the analysis to adolescents from 12 to 16 years old because these ages have a specific and clear definition in most countries. Boys and girls were included in the study. Regions were categorized into Africa, America, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific, according to the WHO [18]. Country income was categorized into four levels for analysis (i.e., low income, lower-middle income, upper-middle income, and high income) according to World Bank Analytical classifications based on the gross national income per capita for the corresponding most recent GYTS year [19]. Data on PPP per capita were obtained from the World Bank and Index Mundi [20] according to the corresponding most recent survey year of the GYTS. In this study, we classified the PPP/capita into five categories according to its integral quintiles, namely, Q1: $600–$3299, Q2: $3300–7999, Q3: $8000–13,699, Q4: $13,700–23,999, and Q5: $≥24,000. FCTC ratification status was defined based on the year that a country had ratified the WHO FCTC and the year that the GYTS survey was carried out.

Statistical analysis

Statistical analyses were conducted using Stata v16.0. The unweighted national sample size and the number of smokers were calculated, and then the samples were weighted computed using primary sampling units, sampling weights, and strata based on the methodology of the GYTS in each country. The weighted prevalence of early attempts at cigarette smoking and the age distribution at first smoking attempt by sex were calculated for each country. We further estimated the average prevalence and 95% confidence intervals (CI) for all countries or each subgroup by country income, PPP/capita, and WHO region. The median age at first cigarette smoked for boys and girls was estimated for each country, and the mean estimate and 95% CI by country income level, PPP/capita, and WHO region were calculated. Nonoverlapping 95% CI were considered statistically significant differences according to sex, country income level, PPP/capita, and WHO region, which is a conservative estimation of the differences. Linear regression was used to assess linear trends across quintiles of the country’s PPP/capita with the mean age at first cigarette smoked, and it was also used to calculate the average annual rate of reduction (AARR) in the prevalence of early attempts at cigarette smoking before 12 years of age. The equation of AARR was created by the United Nations International Children’s Emergency Fund [21]. The age range for the first cigarette smoked was assessed using the 10th–90th percentile of the age for boys and girls.

Results

Table 1. presents the characteristics of the study participants. A total of 456,634 adolescents aged 12–16 years from 147 countries across six WHO regions (Africa: 36; America: 27; Southeast Asia: 10; Europe: 34; Eastern Mediterranean: 20; and Western Pacific: 20) were analyzed in this study, with sample sizes ranging from 442 in the Cook Islands to 13,274 in the Russian Federation.
Table 1
Characteristics of Global Youth Tobacco Survey
 
Survey year
Number of study participants
Boys (%)
Girls (%)
Number of study participants initiating smoking
African region (n=36)
Algeria
2013
5164
45.8
54.2
903
Botswana
2008
1944
43.1
56.9
390
Burundi
2008
1440
45.8
54.2
192
Cabo Verde
2007
1612
45.3
54.7
180
Cameroon
2014
2306
54.5
45.5
324
Chad
2008
1471
67.0
33
163
Comoros
2007
1146
43.8
56.2
285
Congo
2009
1634
52.3
47.7
206
Côte d'Ivoire
2009
2826
55.0
45
724
Equatorial Guinea
2008
1989
47.2
52.8
277
Eritrea
2006
6896
57.7
42.3
184
Eswatini
2009
1807
43.4
56.6
174
Gabon
2014
1149
42.1
57.9
273
Gambia
2017
9339
41.4
58.6
1297
Ghana
2017
5080
47.5
52.5
294
Guinea
2008
1956
57.3
42.7
235
Kenya
2013
1666
45.5
54.5
198
Lesotho
2008
1990
39.3
60.7
221
Madagascar
2018
2112
44.0
56
476
Mali
2008
2964
53.7
46.3
622
Mauritania
2018
3065
44.9
55.1
427
Mauritius
2016
3874
46.3
53.7
1037
Mozambique
2013
4048
47.3
52.7
217
Namibia
2008
1609
43.9
56.1
294
Niger
2009
1737
48.1
51.9
169
Rwanda
2008
1322
46.1
53.9
153
Sao Tome and Principe
2010
5478
45.1
54.9
387
Senegal
2007
2227
51.0
49
287
Seychelles
2015
2313
46.7
53.3
818
Sierra Leone
2017
4440
43.3
56.7
342
South Africa
2011
5855
44.0
56
1687
Togo
2013
4135
55.5
44.5
523
Uganda
2018
2845
42.5
57.5
328
United Republic of Tanzania
2016
3465
46.6
53.4
132
Zambia
2011
2368
46.9
53.1
237
Zimbabwe
2014
5206
43.8
56.2
622
Region of the Americas(n=27)
Antigua and Barbuda
2017
1934
50.4
49.6
248
Argentina
2018
1386
55.6
44.4
508
Bahamas
2013
1247
47.0
53
217
Barbados
2013
1646
50.2
49.8
339
Belize
2014
1674
43.1
56.9
382
Bolivia (Plurinational State of)
2018
4430
51.5
48.5
1091
Costa Rica
2013
2769
48.4
51.6
575
Cuba
2018
3971
49.1
50.9
864
Dominica
2009
1275
43.0
57
368
Dominican Republic
2016
1202
44.8
55.2
153
Ecuador
2016
5000
50.4
49.6
1312
El Salvador
2015
2923
47.4
52.6
846
Grenada
2016
1971
48.1
51.9
415
Guatemala
2015
3864
51.2
48.8
1265
Guyana
2015
1472
43.1
56.9
216
Honduras
2016
3281
47.4
52.6
554
Jamaica
2017
1346
44.9
55.1
433
Nicaragua
2014
3917
44.4
55.6
1158
Panama
2017
2505
49.1
50.9
245
Paraguay
2014
6365
49.8
50.2
751
Peru
2014
3420
48.2
51.8
865
Saint Lucia
2017
1442
47.5
52.5
270
Saint Vincent and the Grenadines
2011
1338
52.8
47.2
381
Suriname
2016
1749
46.8
53.2
499
Trinidad and Tobago
2017
3430
42.8
57.2
756
Uruguay
2014
4548
46.9
53.1
950
Venezuela (Bolivarian Republic of)
2010
2196
50.9
49.1
194
Southeast Asia region(n=10)
Bangladesh
2013
3189
43.1
56.9
142
Bhutan
2013
1909
42.3
57.7
472
India
2009
10982
48.6
51.4
535
Indonesia
2014
5725
46.7
53.3
1464
Maldives
2011
2076
50.9
49.1
310
Myanmar
2011
2353
45.7
54.3
314
Nepal
2011
2322
47.8
52.2
205
Sri Lanka
2011
4620
45.9
54.1
286
Thailand
2015
1824
45.3
54.7
462
Timor-Leste
2013
1662
50.8
49.2
601
European region(n=34)
     
Albania
2015
4410
47.8
52.2
1308
Armenia
2009
3161
44.4
55.6
567
Azerbaijan
2016
2139
50.1
49.9
177
Belarus
2015
2911
49.8
50.2
910
Bosnia and Herzegovina
2013
10163
50.3
49.7
3511
Bulgaria
2015
3922
47.2
52.8
1921
Croatia
2016
3173
51.4
48.6
1461
Cyprus
2011
1022
48.9
51.1
320
Czech Republic
2016
3874
49.3
50.7
1837
Estonia
2007
2946
49.2
50.8
2264
Finland
2012
4930
49.4
50.6
1949
Georgia
2017
1263
49.4
50.6
294
Greece
2013
4501
50.6
49.4
1292
Hungary
2008
3434
50.7
49.3
1960
Italy
2014
1714
52.0
48
813
Kazakhstan
2014
2023
52.8
47.2
160
Kyrgyzstan
2014
4168
44.9
55.1
731
Latvia
2014
4195
49.5
50.5
2294
Lithuania
2014
3306
48.6
51.4
1980
Malta
2017
1229
55.3
44.7
199
Montenegro
2014
3868
51.0
49
1164
North Macedonia
2016
4841
49.9
50.1
1083
Poland
2016
4922
47.8
52.2
2222
Portugal
2013
10484
46.5
53.5
2639
Republic of Moldova
2013
3794
49.3
50.7
1159
Romania
2017
5232
48.4
51.6
1302
Russian Federation
2004
13274
48.5
51.5
6595
San Marino
2014
608
49.5
50.5
166
Serbia
2017
3737
49.5
50.5
1400
Slovakia
2016
3897
49.8
50.2
1818
Slovenia
2017
2405
46.2
53.8
688
Turkey
2012
4562
51.2
48.8
1379
Ukraine
2017
3940
49.3
50.7
1097
Uzbekistan
2008
1805
43.8
56.2
151
Eastern Mediterranean region(n=20)
Afghanistan
2017
1382
52.6
47.4
176
Bahrain
2015
3208
48.5
51.5
611
Djibouti
2013
1498
52.3
47.7
180
Egypt
2014
2219
58.1
41.9
331
Iran (Islamic Republic of)
2007
1597
54.8
45.2
290
Iraq
2014
1516
61.1
38.9
280
Jordan
2014
2020
54.2
45.8
504
Kuwait
2016
2319
45.3
54.7
641
Lebanon
2011
2087
47.9
52.1
521
Libya
2010
1722
50.5
49.5
177
Morocco
2016
3662
48.8
51.2
299
Oman
2016
1968
45.6
54.4
172
Pakistan
2013
7494
44.7
55.3
556
Qatar
2018
1940
49.4
50.6
373
Saudi Arabia
2010
2187
46.8
53.2
459
Sudan
2009
1420
43.2
56.8
103
Syrian Arab Republic
2010
1547
39.4
60.6
269
Tunisia
2017
2347
43.8
56.2
507
United Arab Emirates
2013
3979
44.3
55.7
888
Yemen
2014
1766
52.0
48
378
Western Pacific region(n=20)
     
Brunei Darussalam
2013
1410
48.9
51.1
290
Cook Islands
2016
442
48.4
51.6
205
Fiji
2016
2981
44.9
55.1
537
Kiribati
2009
1263
41.6
58.4
402
Lao People's Democratic Republic
2016
5412
46.7
53.3
744
Malaysia
2009
3019
50.3
49.7
812
Marshall Islands
2016
2038
43.6
56.4
470
Micronesia (Federated States of)
2013
3286
45.8
54.2
1330
Mongolia
2014
6947
45.8
54.2
1311
New Zealand
2008
1377
59.6
40.4
481
Northern Mariana Islands
2014
2080
51.5
48.5
788
Palau
2017
1032
49.5
50.5
630
Papua New Guinea
2016
1661
48.8
51.2
540
Philippines
2015
7602
43.9
56.1
1986
Republic of Korea
2013
4059
45.5
54.5
540
Samoa
2017
1413
36.7
63.3
226
Tonga
2010
1854
43.6
56.4
739
Tuvalu
2018
588
45.1
54.9
127
Vanuatu
2017
1516
39.1
60.9
318
Viet Nam
2014
3482
48.2
51.8
283
 Total
 -
456 634
47.9
52.1
105 209
Figure 1 presents the prevalence of early attempts at first cigarette smoking for boys and girls at the country level. Seventy-nine (54.1%) countries had a prevalence of early attempts at first cigarette smoking ≥ 10% for boys, with prevalence exceeding 20% in Estonia, Lithuania, the Russian Federation, Timor-Leste, Latvia, Palau, the Cook Islands, the Republic of Moldova, Bosnia and Herzegovina, Hungary, Indonesia, Micronesia, the Czech Republic, New Zealand, Slovakia, Ukraine, and Tonga, and 23 (15.8%) countries had a prevalence of early attempts at first cigarette smoking ≥ 10% for girls, with prevalence exceeding 20% in Estonia, Lithuania, the Cook Islands, Latvia, Palau, Montenegro, and Hungary. There was a high prevalence of early attempts at first cigarette smoking for girls relative to boys in Montenegro, Maldives, and Antigua and Barbuda.
Table 2 shows the prevalence of early attempts at first cigarette smoking among young adolescents according to the WHO regions, income groups, PPP/capita, and FCTC ratification status. The mean prevalence of early attempts at first cigarette smoking was 12.2% (95% CI: 10.9–13.5) for boys and 6.7% (95% CI: 5.8–7.6) for girls, with a significant difference. The difference applied widely to most WHO regions, income groups, and PPP/capita. There were variations in the prevalence of early attempts at first cigarette smoking across WHO regions, with the highest prevalence of 17.4% for boys and 10.7% for girls in the European region, which was higher than that in Africa, the Eastern Mediterranean region, and the Americas (9.1%, 9.7%, and 10.8% for boys and 4.3%, 6.3%, and 4.6% for girls, respectively). The prevalence of early attempts at cigarette smoking was 8.0% in low-income countries, 11.5% in lower-middle-income countries, 12.0% in upper-middle-income countries, and 15.6% in high-income countries for boys, and the corresponding prevalence for girls was 3.4%, 5.2%, 7.0%, and 10.1%, respectively. With increasing PPP/capita, the prevalence of early attempts at cigarette smoking increased from Q1 to Q4 but decreased in the highest quintile (Q5) for both sexes. The highest prevalence was observed in the Q4 group in terms of PPP/capita. The prevalence for boys was higher than that for girls in the other PPP/capita categories (i.e., Q1, Q2, Q3, and Q5), except for the Q4 group of PPP/capita, in which no significant sex difference was observed. However, there was no significant difference in the prevalence of early attempts at cigarette smoking by FCTC ratification status.
Table 2
Prevalence of early attempts at first cigarette smoking among adolescents
 
Number of countries
Boys
Girls
Total
147
12.2 (10.9–13.5)
6.7 (5.8–7.6)
WHO region
 African region
36
9.1 (7.9–10.3)
4.3 (3.6–5.0)
  Region of the Americas
27
9.7 (8.2–11.2)
6.3 (5.4–7.3)
 Southeast Asia region
10
12.2 (5.1–19.3)
4.0 (1.8–6.2)
 European region
34
17.3 (13.6–21.0)
10.5 (7.8–13.2)
 Eastern Mediterranean region
20
10.8 (8.9–12.6)
4.6 (3.8–5.5)
 Western Pacific region
20
13.6 (9.7–17.5)
8.5 (5.1–11.9)
PPP per capita, $
 Q1 600–3299
30
9.5 (6.9–12.2)
4.2 (3.1–5.2)
 Q2 3300–7999
29
9.1 (7.5–10.7)
4.6 (3.5–5.7)
 Q3 8000–13,699
29
14.0 (11.0–17.0)
7.2 (5.5–9.0)
 Q4 13,700–23,999
29
15.4 (11.4–19.4)
10.1 (6.9–13.3)
 Q5 ≥24,000
30
12.8 (10.2–15.5)
7.4 (5.4–9.4)
World Bank income group
 Low income
23
8.0 (6.4–9.6)
3.4 (2.6–4.1)
 Lower-middle income
42
11.5 (9.3–13.7)
5.2 (4.2–6.2)
 Upper-middle income
47
12.0 (10.2–13.7)
7.0 (5.7–8.2)
 High income
34
15.5 (11.8–19.2)
9.9 (7.2–12.6)
FCTC ratification status
 Not ratified
10
12.2 (5.0–19.5)
5.9 (2.0–9.8)
 Ratified
137
12.2 (10.9–13.5)
6.8 (5.8–7.7)
PPP purchasing power parity
The mean age at first cigarette smoked was 12.0 years (95% CI: 11.9–12.2) for boys and 11.9 years (95% CI: 11.6–12.1) for girls. The age window at first cigarette smoked was between 10.5 and 12.5 years for both genders (Table 3). In low-income countries, the age at first cigarette smoked among girls, 10.7 years old (95% CI: 10.0–11.4), was significantly earlier than that for boys, 11.8 years old (95% CI: 11.4–12.2). Additionally, the age at first cigarette smoked was earlier for girls in low-income countries than for girls in upper-middle-income and high-income countries, with 12.3 years old (95% CI: 12.0–12.6) and 12.4 years old (95% CI: 12.2–12.7), respectively. Girls tried smoking for the first time at a younger age than boys in the lower PPP quintiles (Q1). However, no significant sex differences were observed in the other PPP/capita categories (Q2–Q5). With increasing PPP/capita, the age at first cigarette smoked increased gradually in girls (p for trend < 0.001) but not in boys (p for trend = 0.334) (Table 3). Girls tried cigarette smoking 0.6 years, 0.6 years, and 1.0 years earlier than boys in the African, Eastern Mediterranean, and Southeast Asian regions, respectively, and the corresponding age window at first cigarette smoked was reduced to 8.5–12.5 years from 10.5 to 12.5 years.
Table 3
Trends in early attempts at cigarette smoking among adolescents
 
Mean age at first cigarette smoked/years
Age window at first cigarette smoked (10th–90th percentile; years)
Boysa
Girlsa
Boys
Girls
Total
12.0 (11.9–12.2)
11.9 (11.6–12.1)
10.5–12.5
10.5–12.5
WHO region
 African region
11.7 (11.4–12.1)
11.1 (10.5–11.6)
10.5–12.5
8.5–12.5
 Region of the Americas
12.1 (11.8–12.4)
12.2 (11.8–12.6)
10.5–12.5
10.5–12.5
 Southeast Asia region
11.9 (11.2–12.6)
10.9 (9.8–12.0)
10.5–12.5
8.5–12.5
 European region
11.8 (11.5–12.2)
12.4 (12.0–12.8)
10.5–12.5
10.5–13.7
 Eastern Mediterranean region
12.2 (11.9–12.5)
11.6 (10.8–12.4)
10.5–12.5
8.7–12.5
 Western Pacific region
12.5 (12.0–13.0)
12.7 (12.2–13.2)
10.5–14.5
10.7–14.5
Country income
 Low income
11.8 (11.4–12.2)
10.7 (10.0–11.4)
10.5–12.5
8.5–12.5
 Lower-middle income
12.0 (11.6–12.3)
11.7 (11.2–12.2)
10.5–12.5
10.5–12.5
 Upper-middle income
12.2 (12.0–12.5)
12.3 (12.0–12.6)
10.5–12.5
10.5–12.5
 High income
12.0 (11.9–12.2)
12.4 (12.2–12.7)
10.5–12.5
11.3–12.5
PPP/capita, $
 Q1 600–3299
11.8 (11.4–12.2)
10.8 (10.2–11.4)
10.5–12.5
8.5–12.5
 Q2 3300–7999
12.2 (11.9–12.6)
11.8 (11.1–12.5)
10.5–12.5
10.5–14.5
 Q3 8000–13,699
11.9 (11.4–12.3)
12.1 (11.7–12.5)
10.5–12.5
10.5–12.5
 Q4 13,700–23,999
12.1 (11.8–12.4)
12.1 (11.7–12.5)
10.5–12.5
10.5–12.5
 Q5 ≥24,000
12.1 (11.8–12.4)
12.5 (12.2–12.8)
10.5–12.5
12.5–12.5
β (95% CI)
0.05 (−0.06, 0.16)
0.36 (0.21, 0.52)
-
-
P
0.334
<0.001
-
-
FCTC ratification status
 Not ratified
12.3 (11.8–12.8)
11.7 (10.3–13.1)
10.7–12.5
8.5–14.3
 Ratified
12.0 (11.8–12.2)
11.9 (11.6–12.1)
10.5–12.5
10.5–12.5
Linear regression was used to assess the linear trend across quintiles of country’s PPP/capita with mean age at first cigarette smoked
PPP purchasing power parity, β linear regression coefficient
aData are mean (95% CI)
Figure 2 shows the age distribution at first cigarette smoked among smoking adolescent boys and girls according to country income, PPP, and WHO region. Of cigarette-smoking adolescents, 16.0% reported trying cigarette smoking at age ≤7 years, 10.5% at 8–9 years, 16.6% at 10–11 years, 29.6% at 12–13 years, 24.4% at 14–15 years, and 2.9% at 16 years for girls, and 13.2%, 11.4%, 18.7%, 30.7%, 22.7%, and 3.3% for boys, respectively. For girls, the average percentage reporting smoking their first cigarette at an age <12 years was 58.1% in low-income countries, 47.3% in lower-middle-income countries, 36.8% in upper-middle-income countries, and 35.5% in high-income countries. For PPP quintiles, the corresponding percentages were 55.7% in Q1, 46.5% in Q2, 40.3% in Q3, 38.4% in Q4, and 34.6% in Q5. For boys, the average percentage reporting smoking their first cigarette at an age <12 years was 46.6% in low-income countries, 45.3% in lower-middle-income countries, 40.5% in upper-middle-income countries, and 41.8% in high-income countries. For PPP quintiles, the average percentage was 46.0% in Q1, 42.8% in Q2, 42.9% in Q3, 43.5% in Q4, and 41.1% in Q5. More than 30% of smoking adolescents reported smoking their first cigarette at an age <12 years in all six regions, and one in two young girls tried smoking a cigarette before 12 years of age in the African region (53.9%) and Southeast Asian region (54.0%).
Figure 3 shows the changes in AARR in the prevalence of first cigarette smoked before 12 years of age at the national level. For boys, 77.1% (54/70) of countries had a positive change in AARR prevalence, ranging from 0.6% in Morocco to 15.6% in the Republic of Korea, while 22.9% (16/70) had a negative change in AARR, ranging from −0.4% in the United Arab Emirates to −15.1% in Timor-Leste, among which 50% (8/16) came from the Eastern Mediterranean region, 25% (4/16) came from the Southeast Asia region and 18.8% (3/16) came from the African region. For girls, 70% (49/70) of countries had a positive change in AARR in the prevalence of attempts at cigarette smoking before 12 years of age, ranging from 0.1% in Lebanon to 23.1% in Bangladesh, while 30% of countries (21/70) had a negative change in AARR, ranging from −0.2% in the Maldives to −11.1% in the Syrian Arab Republic, among which 38.1% (8/21) came from the Eastern Mediterranean region, 23.8% (5/21) came from the Southeast Asia region, and 23.8% (5/21) came from the African region.

Discussion

Our study estimated the prevalence of early attempts at cigarette smoking among adolescents aged 12–16 years in 146 countries. One in eight adolescent boys and one in fifteen girls had smoked their first cigarette before they were 12 years old. Our findings indicated that the global prevalence of early attempts at cigarette smoking among adolescents was substantial. This is similar to the findings of a recent study [22] on the prevalence of cigarette smoking, which was 11.3% in boys and 6.1% in girls, and the prevalence in boys was approximately twice as high as that in girls. Moreover, one-quarter of smoking adolescents tried their first cigarette before 12 years of age. As matters stand, most tobacco users begin smoking during adolescence [24, 8], and smoking adolescents begin smoking at an earlier age. Tobacco users with higher nicotine dependence begin smoking earlier in life [23]. Moreover, age at first cigarette smoking experience is significantly associated with smoking status in the future [24, 25]. Notably, a 1-year delay in first smoking experience results in a 25% reduction in the probability of future smoking among adolescents [26]. The evidence highlights the vital importance and unique opportunity to prevent the initiation of tobacco use in early adolescence.
In this study, the prevalence was high in all six WHO regions, which is similar to the prevalence of cigarette smoking among adolescents [22], indicating that the prevention of early smoking attempts should be strengthened throughout all regions, especially in the European region, because the highest prevalence in early cigarette smoking was found for both sexes in the region. Although the prevalence of first cigarette smoked before 12 years of age declined over time in most countries, 1/3 of the countries, which are mainly located in the Eastern Mediterranean, Southeast Asia, and African regions, experienced an increase, especially for girls. Our findings also strengthen the necessity of continued and intensive actions to further control the early initiation of tobacco use in young adolescents, especially in these regions.
Our study indicated that the age distribution at first cigarette smoked did not differ substantially between sexes, although there was a sex difference in cigarette use among adolescents [22]. Conversely, young girls tended to try cigarette smoking earlier in the African, Southeast Asia, and Eastern Mediterranean regions, and the corresponding age window at first cigarette smoked was 2 years earlier than that in other regions. This result is consistent with the change in the AARR of early attempts at cigarette smoking, and the increase was mainly found in these regions. This evidence indicates an urgent need for policies and intervention programs targeting young girls in these regions. Tobacco use varies by sex and region [27] and is perhaps related to racial and social culture [2830]. Further studies are needed to explore cultural and social mores that may prevent early attempts at cigarette smoking among young girls in these regions and help address risk factors for tobacco use initiation in early adolescence.
The fact that most smoking adolescents aged 12–16 years tried smoking a cigarette during the age window between 10 and 13 years old, assuming that 10–11 years old means 10.5 and 12–13 means 12.5 in this study, indicates that this age period is the crucial window during which young adolescents develop into tobacco users. This finding stresses that protecting adolescents from exposure to smoking during this crucial age window may be vital to controlling tobacco use among young adolescents. Most countries set their legal purchase age for tobacco at 16 or 18 years globally, which is an extensively adopted national policy curbing the initiation of tobacco use among children and adolescents. However, it is worth considering that there was still an abundance of young adolescents who smoked cigarettes. Moreover, our study did not observe that ratifying the WHO FCTC influenced early attempts at cigarette smoking among young adolescents. FCTC ratification status may not reflect the actual implementation and enforcement of the regulatory measures at the country level. There is still no common metric for publicly assessing FCTC implementation, which needs more attention in future studies. More studies are needed to investigate how tobacco products can be accessed or exposed in early adolescence. Many smoking adolescents or youths obtained their first cigarette from peers in China [31, 32] and the Czech Republic [33]. Increasing the minimum age of purchase of tobacco products may support the decrease in the number of smoking young adults [34, 35], who are associated with increased risk of early adolescents’ access or exposure to tobacco use as peers [3638].
To our knowledge, this study is the first to investigate the relationship between national economic development and early attempts at cigarette smoking among adolescents. With the increase in national income level, the prevalence of early attempts at cigarette smoking gradually increased in both sexes. The association also applies to PPP/capita, and the prevalence gradually increased from Q1 to Q4 but decreased for Q5. With the development of the economy, the supply of cigarette products in a country increases. A recent study reported that national income levels were associated with the prevalence of cigarette use in adolescents [22]. As an index reflecting individuals’ tobacco purchasing power and national economic capacity for tobacco control, national macroeconomic development could be associated with the early initiation of tobacco use. Moreover, the risk of adolescents’ tobacco-smoking initiation is differentially affected by individuals’ disposable income [39]. Exposure to high cigarette prices is related to reducing the initiation of cigarette smoking among youth [40, 41]. At the individual level, the economy is an important factor influencing the early initiation of tobacco use.
It is remarkable that among smoking adolescents, young girls tried cigarette smoking earlier than young boys in low-income countries and lower PPP/capita categories. Our findings indicate that the age at first cigarette smoked among young girls is closely related to the national macroeconomy and purchasing power. Young girls are a socially vulnerable group who try smoking cigarettes in low-income countries. This suggests a need to raise awareness about early attempts at cigarette smoking and the need for developing intervention programs to reduce the early initiation of tobacco use in girls from a low level of national economic development. Unfortunately, the prevalence of cigarette smoking has increased along with increasing country income among girls aged 13–15 years [22] and women aged 15–49 years [42]. This indicates major issues in reducing the high prevalence of cigarette smoking in high-income countries and highlights how to prevent the early initiation of cigarette smoking in low-income countries. Decreasing the affordability of tobacco products is one of the most effective measures for preventing early initiation of tobacco use, especially among young individuals, because they are particularly sensitive to price changes [41, 43]. Interestingly, young women are more price-responsive to cigarette smoking initiation, but young men are more price-sensitive to cigarette prevalence and consumption [41]. Therefore, accompanied by the development of the national economy, expanding and strengthening fiscal policy to reduce the affordability of tobacco products is an essential component to prevent young adolescents, especially girls, from starting to smoke cigarettes.
Our study has several limitations. First, cigarette smoking and age at first cigarette smoked were self-rated via one question, and the response was categorical data, not continuous variables, such as specific age, which might be inclined to some recall or response bias. In addition, this study estimated only the age at first cigarette smoked and did not include other tobacco products, which comprise an increasing proportion of tobacco use among young adolescents [22], although smoking cigarettes is the most common form of tobacco use worldwide. Second, the GYTS on the age at first cigarette smoked among young adolescents are conducted in schools; therefore, our results might not apply to all adolescents. Moreover, as smoking is often associated with socioeconomic status, adolescents from lower socioeconomic status are likely to start smoking at a younger age and are less likely to have a school education. In light of this, the results presented in this study might underestimate age at first cigarette smoked, particularly in low-income countries or countries without free education. Third, the GYTS is a cross-sectional survey; therefore, causal inferences cannot be established. Furthermore, the study did not evaluate confounders. Further studies are needed to assess the association between exposure to environmental tobacco use, access to tobacco products, tobacco advertisements, and the initiation of cigarette smoking.

Conclusions

Cigarette smoking often begins with the first cigarette smoked and repeated experimentation before adolescents become regular smokers. It is important to target the early stage to prevent smoking. Our findings highlight the need to adopt continued and intensive actions to reduce early attempts at cigarette smoking in young adolescents; the age range of 10–13 years is a critical age window to change the tobacco epidemic among adolescents. Young girls tend to try smoking cigarettes earlier in low-income countries, such as those in Africa, Southeast Asia, and the Eastern Mediterranean.

Acknowledgements

We thank the US Centers for Disease Control and Prevention for sharing GYTS data. We also thank the country survey coordinators for sharing data.

Declarations

The country datasets in the GYTS are publicly available, comply with the corresponding national ethical board review, and exempt under the ethical board review of the corresponding author’s institution.
Not applicable.

Competing interests

The authors declare that they have no competing interests.
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Metadaten
Titel
Sex and macroeconomic differences and trends in early attempts at cigarette smoking among adolescents: findings from 147 countries
verfasst von
Huaqing Liu
Qi Qi
Ying Duan
Chuanwei Ma
Chengchao Zhou
Publikationsdatum
01.12.2022
Verlag
BioMed Central
Erschienen in
BMC Medicine / Ausgabe 1/2022
Elektronische ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-022-02512-z

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