|Year : 2017 | Volume
| Issue : 5 | Page : 12-17
Youth tobacco use in South-East Asia: Implications for tobacco epidemic and options for its control in the region
Manju Rani1, Thaksaphon Thamarangsi2, Naveen Agarwal3
1 Regional Advisor, (NCD and Tobacco Surveillance), World Health Organization, Regional Office for South-East Asia Region, New Delhi, India
2 Director, Noncommunicable Diseases and Environmental Health, World Health Organization, Regional Office for South-East Asia Region, New Delhi, India
3 Surveillance Management Associate, World Health Organization, Regional Office for South-East Asia Region, New Delhi, India
|Date of Web Publication||15-Sep-2017|
Regional Advisor (NCD and Tobacco Surveillance), World Health Organization, Regional Office for South-East Asia Region, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Nearly half of all male population and two in every five females in the WHO South-East Asia Region (SEAR) consume some form of tobacco. Preventing initiation among adolescents is critical for overall tobacco control. We assessed the trends in youth tobacco use and policies in SEAR. Data are used from school-based youth (Global Youth Tobacco Survey and global school student-based health survey) and adult (Global Adult Tobacco Survey, STEPS) tobacco surveys and the WHO Framework of Convention of Tobacco Control (FCTC) implementation database. More than 10% of 13–15-year-old adolescent students reported tobacco use in 8 out of 11 countries. The prevalence of smokeless tobacco exceeded that of cigarettes except in Indonesia, Thailand, and Timor-Leste. No consistent declining trends in tobacco use were observed in any of the countries with 3 or more data points. More than half of all daily smokers aged 20–34 years initiated “daily” smoking before 20 years of age. 19% (Bangladesh) to 55% (Timor-Leste) of 13–17-year old students tried their first cigarette before their 14th birthday. Majority of adolescent students in most of the SEAR countries reported purchasing their cigarettes from store/shop/vendor and as single sticks, with few exceptions and purchased them as “single” cigarette. There is a limited change in affordability of cigarettes in SEAR over time. Tobacco use remains high among youth in SEAR. Efforts should be strengthened to fully implement/enforce recommended policy measures (legal minimum age, fiscal measures to reduce tobacco affordability; prohibiting sale of single cigarettes, etc.) and to explore new measures (e.g., tobacco-free generation).
Keywords: Cigarettes, smokeless tobacco, surveillance, tobacco, trends, youth
|How to cite this article:|
Rani M, Thamarangsi T, Agarwal N. Youth tobacco use in South-East Asia: Implications for tobacco epidemic and options for its control in the region. Indian J Public Health 2017;61, Suppl S1:12-7
|How to cite this URL:|
Rani M, Thamarangsi T, Agarwal N. Youth tobacco use in South-East Asia: Implications for tobacco epidemic and options for its control in the region. Indian J Public Health [serial online] 2017 [cited 2020 Feb 17];61, Suppl S1:12-7. Available from: http://www.ijph.in/text.asp?2017/61/5/12/214907
| Introduction|| |
Tobacco continues to be a leading preventable cause of death worldwide and in South-East Asia Region (SEAR). Given its public health importance, one of the global goals for prevention and control of noncommunicable diseases is 30% relative reduction in the prevalence of current tobacco use by 2025 compared to baseline levels in 2010. Implementation of tobacco control measures figures prominently in the new sustainable development goals (SDGs). The WHO SEAR with more than one-fourth of world's population (26%) has among the top tobacco-consuming and tobacco-producing countries in the world. Embedded in the sociocultural practices, nearly half of all male population and two in every five females in SEAR consume some form of tobacco (smoked or smokeless). The region has 250 million tobacco smokers and a nearly equal number of smokeless tobacco users. In addition, the number of smokeless tobacco users seems to be growing, a cause of concern in many SEAR countries.,
The global evidence suggests that most of the current adult tobacco users initiate tobacco use during adolescence, which is continued into the adulthood. As per the global estimates, nearly 9 out of 10 smokers start before 18 years of age and 98% start smoking by age of 26 years. About 3 out of 4 adolescent smokers become adult smokers. The higher sensitivity and vulnerability of children and adolescents to nicotine addiction implies that the earlier the smokers start smoking, the more likely they are to become addicted. Recognizing the difficulty in forcing existing users to quit, preventing initiation of tobacco use among adolescents has become critical to inform any policies and measures to stem the overall tobacco epidemic.
Using data from different sources, this paper reviews the current status and trends in youth tobacco use and in the policy measures put in place to control it in SEAR. It also discusses the potential options to prevent future generations from initiating the tobacco use.
The study context
The WHO SEAR comprises 11 countries with a total population of about 1.9 billion or about 26% of the total global population. Adolescents (10–19 years) constitute an important sociodemographic group in the WHO SEAR accounting for almost one-fifth or 18.8% (362.2 million individuals) of the total regional population. Of this, 13–17-year-old adolescents comprise 181 million or nearly one-tenth (9.4%) of the total regional population. It is a culturally, religiously, and economically diverse region. While India and Nepal have predominantly Hindu populations, Bangladesh, Indonesia, and Maldives are predominantly Muslim countries and Myanmar, Sri Lanka, and Thailand have a large proportion of populations that practice Buddhism.
| Data and Methods|| |
The data on youth tobacco use come from nationwide school-based youth tobacco prevalence surveys conducted as part of the Global Youth Tobacco Surveys (GYTS) initiative or integrated youth risk factor surveys implemented as part of global school student-based health survey (GSHS) initiative among middle to high school students aged 13–15 years (GYTS) or 13–17 years of age (GSHS).,
In addition, data on age at initiation are presented from the household Adult Tobacco Prevalence Surveys (done as part of Global Adult Tobacco Prevalence surveys initiative (Global Adult Tobacco Survey) among 15+ population or as integrated noncommunicable disease (NCD) risk factor surveys (STEP surveys) done among population of 18–69 years of age.,
Both these surveys included a follow-up question “how old were you when you first started smoking daily” to the respondents who reported daily tobacco smoking.
Data are also used from the WHO FCTC (WHO Framework of Convention for Tobacco Control) implementation database and other qualitative policy databases collected by the WHO from members state to assess the trends and current status of implementation of selected tobacco control policies.
Conceptually reduction in tobacco use among adolescents may result from:
- Reduction in supply (article 16 of FCTC): Reduced availability of single cigarettes and from vendor sales, reduced availability of promotional products, reduced access (from stricter implementation of minimum age laws for tobacco purchase)
- Reduction in demand: Reduced affordability of tobacco through increased prices (article 6 of FCTC), nonprice demand reduction measures such as pictorial health warning, reduced exposure to people smoking article 8, 11, 12, and 13 of FCTC)
- Reduction in other risk factors that predispose adolescents to overall substance use (e.g., bullying at school, family environment, mental health issues, etc.).
This paper reviews the current status of selected policy options only along the first two bullet points but does not go in depth for policies under bullet point 3.
| Results|| |
Trends in tobacco use among adolescents
Tobacco use prevalence among adolescents in South-East Asia Region
[Figure 1] shows the trends in tobacco use among 13–15-year-old students as reported in anonymously administered GYTS surveys. More than 10% of 13–15-year-old school-going adolescents reported tobacco use in 8 out of 11 countries in the WHO SEAR [Figure 1]. The prevalence exceeded 20% in Bhutan, Nepal, and Timor-Leste. Only in Bangladesh and Sri Lanka, the prevalence was <10% [Figure 1]. The Democratic Republic of Korea (DPRK) has no comparable data available, but it reports no tobacco use among adolescents aged 16 years and younger, the minimum legal age for selling tobacco products in the country.
|Figure 1: Trends in tobacco use among 13–15-year-old students in the WHO South-East Asia.|
Click here to view
Cigarette use is common; exceeding 10% in Bhutan, Thailand, and Timor-Leste, the prevalence of smokeless tobacco is higher than that of cigarettes in most of the countries in SEAR with the exception of Indonesia, Thailand, and Timor-Leste [Figure 1].
No consistent declining trends in tobacco use (either smokeless or smoked) were observed in any of the countries where at least 3 data points were available, though a sudden drop in overall tobacco use was observed in Sri Lanka in 2015 compared to previous 3 rounds in 2003–2011, mainly due to decline in smokeless tobacco use [Figure 1]. In some countries, a substantial increase (e.g., Nepal and Bhutan) was observed from one round to another for smokeless products, while a substantial drop was observed in Sri Lanka and Thailand which needs to be investigated further.
Age at initiation of daily tobacco smoking in South-East Asia Region
The mean age for initiating daily smoking among 20–34-year-old current daily smokers ranged from 17 years in Nepal to 18.9 years in Bhutan. More than half of all current daily smokers aged 20–34 years of age in all countries initiated daily smoking before their 20th birthday, with such proportion exceeding 75% in Indonesia, Nepal, and Thailand [Table 1]. The lower proportion reported in Bhutan (58%) and Timor-Leste (54%) needs investigation as this is not consistent with very high youth tobacco use reported from these countries as shown in [Table 1].
|Table 1: Age of initiation of “daily” smoking among 20-34-year-old current daily smokers and percentage of 13-17-year-old students who first tried a cigarette before 14 years of age|
Click here to view
Another source of information on early initiation of smoking in the WHO SEAR comes from nationwide school-based surveys of 13–17-year-old students implemented as part of the Global School Health Student-based surveys (GSHS). [Table 1] shows percentage of students of 13–17 years who tried a cigarette before the age of 14 years among those who ever smoked.
Consistent with the data presented on age at initiation of daily smoking among 20–34-year-old population, a very high proportion of students who ever tried cigarettes, tried their first cigarette very early before turning 14 years of age, ranging from almost one in four students in Bangladesh to more than half of all ever-smokers in Timor-Leste.
Current status and trend in selected policies
The minimum age of legal access
The article 16 of the WHO FCTC aims at restricting access and supply of tobacco to adolescents and requires parties to adopt and implement measures to prohibit sales of tobacco products to and by minors as well as other measures limiting the access of underage persons to tobacco products.
All the countries in SEAR have specified legal minimum age for tobacco sales. As of 2016, DPRK and Timor-Leste have the lowest minimum legal age at 16 and 17 years, respectively, while Sri Lanka has the highest legal minimum age of 21 years. Thailand became as a close second with raising of minimum legal age to 20 years (from 18 years previously) in their new tobacco products control act (article 26) passed in 2017. The remaining countries have 18 years of age as the legal minimum age for tobacco sales.
Enforcing the minimum age of legal access and patterns of tobacco purchase by adolescents
The percentage of adolescents who got their cigarettes by purchasing them from a store, shop, or vendor in the last 30 days varied greatly across countries in the WHO SEAR, ranging from just 20% in Sri Lanka to over 80% in Bangladesh [Table 2]. A specific question “during the past 30 days, did anyone refuse to sell you cigarettes because of your age?” was included in GYTS survey to assess enforcement of minimum legal age for purchasing tobacco. Similarly, while only 14% of students were refused from buying cigarettes in Bangladesh because of their age being less than minimum legal age for tobacco purchase, more than 60% of students were refused on the same grounds in Sri Lanka [Table 2]. This reflects the variation in the enforcement of legal minimum age for purchasing tobacco in the Region. Finally, in many countries such as Bangladesh, Indonesia, Myanmar, and Sri Lanka, majority of adolescents are purchasing cigarettes mainly as individual sticks, which perhaps make them more affordable. Only in Thailand, only 20% reported buying them as individual sticks [Table 2].
|Table 2: Patterns of purchasing cigarettes among current smokers (13-15 years) and refusal because of being underage, Global Youth Tobacco Surveys in World Health Organization South-East Asia Region|
Click here to view
Sale of single cigarettes
Single cigarette market neutralizes four important tobacco control strategies: protecting minors, pictorial warning, and support quitting and effective taxation., An easy affordability of loose cigarettes is an enabling factor for student and minors which perhaps make them more affordable to them. The article 16 (sales to and by minors) of the World Health Organization (WHO) Framework Convention on Tobacco Control states that countries “shall endeavor” to prohibit sale of single stick and “kiddie packs” (soft packs of 10 cigarettes) as it makes them more affordable for minors.
As of 2016, Bangladesh, Maldives, Indonesia, and Sri Lanka do not prohibit single sticks sale, but some SEAR countries have made good progress with Thailand and Timor-Leste passing legislations to prohibit sale of cigarettes as individual sticks in 2017 and 2016, respectively. In addition, 11 states and union territories in India have issued orders/notifications banning the sale of loose cigarettes under section-7 of COTPA, 2003 in 2016.
However, the survey data as presented in [Table 2] show that majority of adolescents in many SEAR countries such as Bangladesh, Indonesia, Myanmar, and Sri Lanka are purchasing cigarettes mainly as individual sticks [Table 2].
Trends in tobacco prices and affordability
While the WHO FCTC recommends raising taxes to more than 75% of the retail price and is considered to be most powerful and most cost-effective tobacco control intervention, only three countries in SEAR (Bangladesh, Sri Lanka, and Thailand) met the goal of 75% tax rate of retail price as of 2016. More importantly, the tax increases in most of the SEAR countries have not been sufficient to impact affordability of tobacco products in most of the countries as measured by price of the pack divided by the GDP per capita [Table 3]. The affordability of the tobacco products was estimated by dividing reported price of 20-cigarettes pack of most sold brand in 2014 in GTCR survey and GDP per capita as reported in World Bank WDI indicator database. Higher the percentage of GDP required to buy 100 packs of 20-cigarettes each, higher is the unaffordability.
|Table 3: Change in relative affordability of most sold brand of cigarettes (percentage of GDP per capita required to purchase 100 packs [of 20 cigarettes each] of most sold brand of cigarettes) between 2007 and 2014 (GTCR data)|
Click here to view
Status of youth tobacco use surveillance
Adolescent tobacco use is included as an indicator in global monitoring framework for NCDs (WHO 2014), but only one country in the region (Indonesia) has included smoking prevalence among children <18 years as one of the key indicators to assess the performance of district mayors as part of its National Medium-Term Development Plans (RPJMN) for 2015–2019. Youth tobacco surveillance in SEAR is mainly undertaken as part of GYTS initiative funded by the CDC (USA) in the form of school-based surveys. All the countries in SEAR have implemented at least three rounds of such surveys, and some have done even 4–5 rounds over last 15 years (e.g., Myanmar and Sri Lanka). However, the surveillance remains ad hoc and highly donor dependent and the current methodology excludes out of school youth in most of the member states in SEAR.
| Discussion|| |
The WHO Global Action Plan for the Prevention and Control of NCD has set an ambitious target of 30% relative reduction in the prevalence of current tobacco use by 2025 compared to baseline levels in 2010. The new SDGs also call for strengthening the implementation of the WHO FCTC in all countries, as appropriate, and is recognized as one of the “means of implementation” to reach the overall health goal (SDG 3) and the mortality reduction target on NCDs. Given the high use and early initiation of tobacco use among adolescents in SEAR as in many other Regions, the region's long-term success in achieving the SDG and global NCD targets will depend to some extent controlling the tobacco use among adolescents.
The evidence from the WHO SEAR suggests very high use of tobacco among adolescents and perhaps underestimates the actual prevalence. The actual prevalence may be higher if out of school youth are included. In addition, the proportion reporting initiation of tobacco use before age of 20 years may actually be higher, if the question would have elicited when the current daily smokers actually start smoking, rather than the daily smoking, as most smoker start smoking occasionally, and then become daily smokers. The data presented do not show any signs of declining tobacco use among adolescents, or increase in age of initiation among adolescent in most of the SEAR countries with few exceptions.
The factors increasing youth tobacco initiation may vary across countries, but some commonly documented factors include others smoking in their presence, tobacco use by parents or peers; exposure to tobacco advertising; acceptability of tobacco use among peers or in social norms advertised in movies or tobacco commercials; having depression, anxiety, or stress;, and higher accessibility and lower prices of tobacco products.,
Cultural taboos or resistance explain to some extent low tobacco use among female population. This suggests promoting tobacco-free society as a norm will go a long way in reducing tobacco use. Most of the policy measures, hence, should aim at changing social norms around tobacco use (or make it look bad) or make it increasingly difficult for adolescents to use tobacco (e.g., by making it too unaffordable or restricting the supply).
The review of policy data showed that SEAR countries are yet to fully implement and/or enforce regulations to reduce the affordability and accessibility of tobacco products, including taxation, sale of single cigarettes or loose tobacco products, and the minimum legal age for tobacco sales.
The data presented in [Table 1] clearly show that most adolescent and adult tobacco users initiate tobacco use very early. One of the options to reduce early tobacco use initiation and progression to regular tobacco use may be to increase the minimal legal age to 21 years from the current 18 years in-effect in most of the SEAR countries., In the past 2 years, new evidence has emerged that suggests that minimal legal age laws are effective, enjoy very high levels of public support and have minimal economic impact on revenues in the short term. Limiting youth access to cigarettes by increasing the legal purchase age to 21 years is expected to reduce adult smoking prevalence in the long term by having a larger drop in youth smoking prevalence, but this will require high-level advocacy efforts including mobilizing public support for raising the tobacco sale age to 21 years by increasing public awareness about the susceptibility and rapid addiction of youth to nicotine.
In addition to increasing the minimum legal age to purchase tobacco, more concerted efforts are needed to enforce these underage laws. The data presented in [Figure 1] and [Table 2] clearly demonstrate that the underage laws are not well enforced in SEAR countries and adolescents have rather easy access to tobacco from shops and stores, etc., Greater attention to enforcing and monitoring retailer compliance with all tobacco regulations will be important for tobacco underage laws to be effective in reducing youth access to tobacco products.
Many advocates are also pushing for tobacco-free generation, which aims at completing restricting the sale of tobacco to people born after a certain date. Feasibility and applicability of this concept may also be explored in countries in SEAR.
The evidence supporting the negative impact of increased prices or unaffordability especially on youth tobacco use is well established both within SEAR countries and outside.,, Tobacco pricing is crucial to address the youth tobacco epidemic, as adolescents are particularly sensitive to tobacco pricing. The good news is that there is still sufficient room in most of SEAR countries to implement appropriate fiscal measures, especially raising taxes to increase prices of tobacco products.
Member states must institutionalize youth tobacco surveillance preferably as part of integrated risk factor surveys and should ensure inclusion of out of school youth which comprises substantial proportion in some countries such as Bangladesh and India. Finally, these regulations and the surveillance measures must include all tobacco products including smoked tobacco products other than cigarettes and smokeless tobacco products (whose use outpaces the smoked tobacco products use in many countries in SEAR). The adolescent tobacco use should be included as a key indicator of overall development as well as of progress toward to control of NCD diseases and mortality.
| Conclusion|| |
The youth tobacco use remains high with early age of initiation in most of the SEAR countries with no consistent signs of decline over the last 10–15 years. The recommended policy measures are not yet fully implemented/enforced in any of the member states. Efforts should be strengthened to fully implement these policy measures and exploration of new measures (e.g., tobacco-free generation).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sinha DN, Palipudi KM, Jones CK, Khadka BB, Silva PD, Mumthaz M, et al.
Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region. Indian J Cancer 2014;51 Suppl 1:S50-3.
Sinha DN, Rizwan SA, Aryal KK, Karki KB, Zaman MM, Gupta PC. Trends of Smokeless Tobacco use among Adults (Aged 15-49 Years) in Bangladesh, India and Nepal. Asian Pac J Cancer Prev 2015;16:6561-8.
Centers for Disease Control and Prevention (US). Changing Landscape for Tobacco Control: Current Status and Future Directions, National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, Atlanta, Georgia; 2014.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2015 Revision, DVD Edition; 2015.
Central Bureau of Statistics. 2013 Adult Tobacco Survey. Democratic People's Republic of Korea, PyongPyang; 2013.
World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003.
Hall MG, Fleischer NL, Reynales-Shigematsu LM, Arillo-Santillán E, Thrasher JF. Increasing availability and consumption of single cigarettes: Trends and implications for smoking cessation from the ITC Mexico Survey. Tob Control 2015;24 Suppl 3:iii64-iii70.
Lal P, Kumar R, Ray S, Sharma N, Bhattarcharya B, Mishra D, et al.
The single cigarette economy in India – A back of the envelope survey to estimate its magnitude. Asian Pac J Cancer Prev 2015;16:5579-82.
World Health Organization, Regional Office for South-East Asia. Mental Health Status of Adolescents in South-East Asia: Evidence for Action. New Delhi: World Health Organization, Regional Office for South-East Asia; 2017.
Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: National Academies Press (US); 23 July, 2015. Summary. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310401/
. [Last accessed on 2017 Jul 10].
Winickoff JP, McMillen R, Tanski S, Wlson K, Gottlieb M, Crane R. Public support for raising the age of sale for tobacco to 21 in the United States. Tob Control 2016;25:284-8.
Berrick AJ The tobacco-free generation proposal Tobacco Control 2013;22:i22-i6.
Kengganpanich M, Termsirikulchai L, Benjakul S. The impact of cigarette tax increase on smoking behavior of daily smokers. J Med Assoc Thai 2009;92 Suppl 7:S46-53.
Joseph RA, Chaloupka FJ. The influence of prices on youth tobacco use in India. Nicotine Tob Res 2014;16 Suppl 1:S24-9.
Kostova D, Andes L, Erguder T, Yurekli A, Keskinkiliç B, Polat S, et al.
Cigarette prices and smoking prevalence after a tobacco tax increase – Turkey, 2008 and 2012. MMWR Morb Mortal Wkly Rep 2014 30;63:457-61.
25 World Bank. World Development Indicators. Washington: World Bank; 2016.
[Table 1], [Table 2], [Table 3]