Smoking initiation is earlier in low-income countries, but more prevalent in high-income countries

A macroeconomic study confirms that the prevalence of adolescent smoking initiation increases with country income. The age at which young people start smoking is significantly earlier in low-income countries than in high-income countries, particularly for girls.

A team of Chinese researchers analyzed the smoking initiation behaviors of adolescents from 147 countries, using data from the Global Youth Tobacco Surveys (GYTS) conducted by the World Health Organization (WHO). This new analysis focused on linking adolescent smoking behaviors with the income level of countries and regions, and by gender.[1]The Chinese study was based on data collected in schools between 1999 and 2018 from 456,634 adolescents aged 12 to 16.

Age of first cigarette earlier in low-income countries

The results indicate that 12.2 % of boys and 6.7 % of girls experienced a first cigarette, which is consistent with a other analysis of the same data on 143 countries, indicating a respective prevalence of 11.3 % and 6.1 % for cigarettes alone. This prevalence of experimentation differs significantly according to the income level of the countries: it is low in low-income countries (8 % for boys, 3 % for girls), increases with the income level and is highest in high-income countries (15.6 % for boys, 10.1 % for girls), particularly in the Europe region (17.4 % and 10.7 %). Analysis by quantiles according to national per capita income allows us to observe that this prevalence of experimentation increases from quantile Q1 to Q4, but then decreases in quantile Q5. The prevalence for boys is higher than that of girls in all quantiles, except in Q4.

The average age of first cigarette smoking is generally 12 years for boys and 11.9 years for girls, with significant variation. Initiation to smoking is actually earlier for girls in low-income countries (10.7 years, compared to 11.8 years for boys) than in middle-income countries (12.3 years) or high-income countries (12.4 years).

Adolescents who become smokers generally try their first cigarette early. This first cigarette is generally smoked between the ages of 12 and 15, but 16.1% of girls and 13.2% of boys smoked it at age 7 or younger, and more than a quarter of them tried it between ages 8 and 11. While 35.5% of girls in high-income countries (compared to 41.8% of boys) try their first cigarette at age 12 or younger, this is the case for 58.1% of girls (compared to 46.6% of boys) in low-income countries. The Eastern Mediterranean, African, and Southeast Asian regions are the most affected by this phenomenon of early experimentation among girls. It is two years earlier on average.

Sustained prevention measures to be focused on the 10-13 age group

The study also confirms that the period between the ages of 10 and 13 constitutes a crucial moment for smoking initiation, both for the age at which first cigarettes are smoked (on average between 10.5 and 12.5 years) and for the onset of smoking. It also corroborates the link between the age of the first cigarette and subsequent smoking.

The authors of this macroeconomic study conclude the need to develop prevention programs "continuous and intensive" of smoking initiation targeted at specific populations, particularly girls in low-income countries, and at the 10-13 age group in all regions and especially in Europe. They recommend mobilizing proven methods of tobacco control, in particular increasing the price of tobacco products, this price being a determining factor for girls at the time of initiation and for boys during the onset of smoking. Raising the legal age for tobacco sales is also recommended, as it allows for delaying the time of smoking initiation.

However, the study only focused on cigarette consumption, which remains the main form of tobacco consumed, and did not look at other tobacco and nicotine products, which have been on the rise in recent years. The study also has limitations in that it relies on self-reported responses and only reports on the behavior of school-aged adolescents, as actual consumption may be even higher in any country.

Keywords: Initiation, first cigarette, low- and middle-income countries, GYTS

MF