Predictors Of Tobacco Smoking Initiation Among Indonesian Teenagers: The 2019 Global Youth Tobacco Survey

Introduction

The adverse health effects linked to tobacco have been thoroughly documented. Nevertheless, cigarette smoking remains the primary contributor to untimely and preventable deaths worldwide.^1,2 Smoking initiation in teenagers is an important problem to be addressed because the younger the age at starting smoking, the stronger the smoking habit and the more difficult it is to quit smoking.³ Indonesia currently exhibits the highest prevalence of smoking globally, indicating a potential upward trend. Consequently, a significant number of Indonesian individuals, amounting to over 660 daily or exceeding 240,000 annually, succumb to ailments associated with tobacco consumption, with a particular emphasis on the adolescent demographic.^4,5 Based on the 2023 Indonesia Health Survey, there are 70 million smokers in Indonesia, with 7.2% of them aged 10–18 years. The age group with the highest number of smokers is 15–19 years (56.5%), followed by the 10–14 year age group (18.4%). Additionally, national data in 2021 indicate that approximately 60.5% of adult men and 3.3% of adult women in Indonesia smoke, making it one of the highest smoking rates among males globally.² The most commonly used tobacco product in Indonesia is the kretek, a clove-flavored cigarette. Other tobacco products, such as electronic nicotine delivery systems and heated tobacco products, have also seen rapid market growth since their legalization in 2018.⁵ These products are widely available and often marketed particularly in social media, making them easily accessible particularly in social media. Tobacco use also varies by demographic factors, including gender, age, socioeconomic status, and geographic location, similar to those in rural areas compared to urban regions.^4,6

More concerningly, Indonesia faced a severe child smoking epidemic, with 2,060 children aged 4-9 years old, and 25,000 early adolescents aged 10-14 initiating smoking in 2023 alone.⁷ This crisis is exacerbated by deliberate tobacco industry targeting in youth, as evidenced by a Campaign for Tobacco Free Kids (CTFK) study across 23 countries (including Indonesia) showed that the cigarette industry targeted children by advertising and promoting cigarette products in school environments.⁸ Compounding this issue, Indonesia remains the only country in Asia not signed to the WHO Framework Convention on Tobacco Control (FCTC), allowing tobacco marketing to remain pervasive and minimally regulated. While national data shows progress in reducing youth smoking prevalence (from 9.1% in 2013 to 7.4% in 2023), surpassing the RPJMN 2025-2029 target of 8.7%, this masks deeper systemic failures: aggressive industry tactics, easy access to cigarettes, and weak local policy enforcement—particularly in regions with high prevalence.^9,10

The age at which an individual begins smoking have a significant impact on their smoking habits in adulthood, and is also associated with other problematic behaviors such as substance abuse, school disengagement, sexual risk-taking, and violent conduct.⁹ A study in Indonesia highlighted that some elementary school students were already smoking, with the average age of initiation around 10 years old, often influenced by family members who also smoked. Other influential factors identified include peer pressure, pocket money, access to information through the internet and printed media, beliefs about the perceived benefits of smoking, and sociodemographic characteristics.^11,12 In addition, some studies note that families who smoke often lack awareness of the health and economic consequences of smoking.³

Previous studies in Indonesia have largely focused on smoking prevalence, tobacco consumption, or current smoking behavior among adolescents, with limited attention to smoking initiation specifically. Existing evidence has identified several associated factors, such as peer influence, parental smoking, and sociodemographic characteristics; however, these studies often examined selected determinants rather than a broader range of predictive factors related to smoking initiation. To address this gap, the present study examines predictors of smoking initiation among Indonesian adolescents using nationally representative data from the 2019 Indonesia Global Youth Tobacco Survey. A broad range of variables were included, covering demographic factors (age, gender, and pocket money), environmental influences (exposure to secondhand smoke in public places, anti-tobacco media exposure, and smoking behavior of parents, teachers, and peers), as well as behavioral factors commonly associated with smoking initiation. By focusing specifically on smoking initiation rather than general smoking behavior, this study provides a broader understanding of early smoking uptake in the Indonesian context and helps identify opportunities for early prevention before smoking behaviors become established, thereby informing prevention-focused tobacco control strategies.

Methods

Results

Discussion

This study identified several key findings. First, the prevalence of cigarette use among Indonesian adolescents remains high compared to regional averages. Second, smoking initiation was most common between the ages of 13–15 years. Third, factors such as male gender, higher pocket money, and exposure to friends’ cigarette offers were significantly associated with smoking behavior. These findings underscore the urgent need for targeted interventions addressing both individual and social influences on youth smoking. According to the latest WHO report (2021), tobacco use among adolescents remains a significant public health challenge, with prevalence rates showing only a modest decline over the past decade. This study found that smoking initiation often begins during early adolescence, highlighting the critical need for prevention strategies targeting this age group.

The findings indicate a significant association between age and smoking initiation among adolescents in Indonesia, with those over the age of 15 being 1.6 times more likely to start smoking compared to those under the age of 13. This suggests that the risk of smoking initiation increases with age. Older adolescents frequently encounter increasing academic pressures and complex social demands during this developmental stage.¹⁴ Such developmental and psychosocial challenges have been associated with greater susceptibility to health-risk and risk-taking behaviors among adolescents.¹⁵ Smoking initiation is one such behavior and is further influenced by social environmental factors, particularly peer smoking exposure.¹⁶ Moreover, adolescents who begin smoking at an earlier age are at greater risk of developing nicotine dependence and are less likely to successfully quit compared to those who initiate smoking in adulthood.¹⁷ These findings highlight the importance of targeted prevention strategies, particularly for adolescents aged 15 and older. Health education and intervention programs should prioritize the provision of social support and the enhancement of life satisfaction to reduce the risk of smoking initiation.

Sex was found to have a significant relationship with smoking initiation in teenagers in Indonesia. The findings indicated that males adolescents were more at risk of initiating smoking, which aligns with studies from Africa,¹⁸ Nigeria,¹⁹ Samoa,¹⁸ and Korea.²⁰ This increased risk may be attributed a higher likelihood of forming friendships with peers who smoke, greater susceptibility to peer pressure, environmental influences, and more positive perceptions of smoking among boys. Additionally, nicotine is thought to have a more potent rewarding effect in adolescent males, contributing to higher initiation rates.^18,19,21 While, the young smokers will somehow become adult smokers in the future.¹⁸ The higher prevalence of smoking among Indonesian males further supports this pattern. According to the 2023 Indonesian Family Health Survey, males continue to dominate in smoking initiation rates compared to females. This finding highlights the need for gender-responsive smoking prevention strategies. Health promotion efforts should prioritize adolescent boys, who were found to have a higher likelihood of smoking initiation, by addressing peer influence, reshaping favorable perceptions of smoking, and creating environments that discourage tobacco use. At the same time, preventive education should remain inclusive of all adolescents to ensure broad public health impact. This study did not find a statistically significant correlation between receiving pocket money and smoking initiation among adolescents in Indonesia. This finding in contrast with a previous study conducted in Canada. Meanwhile, a qualitative study highlights that the widespread availably of loose cigarettes encourage adolescents to purchase tobacco products more frequently often spending at least half of their weekly allowance on them.¹⁸ This suggests that the ease of access enables adolescents to use a portion of their allowance to purchase tobacco products. Although Government Policy 28/2024 prohibits the sale of cigarettes to youths under 18 years of age, most adolescents reported that they have never been prevented from purchasing cigarettes due to their age.¹⁸ Therefore, stronger policies are needed, including increasing cigarette prices and strengthening the monitoring of shops, stalls, street vendors, and small retailers. These vendors should be prohibited from selling cigarettes—especially single sticks—to buyers under the age of 18. Such measures may limit adolescents’ ability to use their pocket money to purchase tobacco products.²²

Research has demonstrated a noteworthy correlation between outdoor exposure to smoke in public areas and initiation smoking among teenagers in Indonesia. The finding indicates that exposure to smoke in public area was significantly associated with the likelihood of initiation to smoking among adolescents. Consistent with studies conducted in Nigeria¹⁹ and Samoa,²³ which highlight that adolescents who are regularly exposed to cigarette smoke are more likely to start smoking. Additionally, exposure to secondhand smoke has been found to increase the risk of smoking initiation.²⁴ Adolescents who are exposed to individuals who smoke in outdoor public areas, including playgrounds, roadsides, building entrances, parks, beaches, and sports fields, show a higher likelihood of initiating smoking behavior due to their high curiosity. and want to imitate what they have seen. The study found that the visibility of smoking in indoor spaces such as friends’ and own homes was associated with more positive beliefs about smoking, but this association was largely explained by the smoking behaviour of friends and parents; in contrast, visibility of smoking in outdoor/public spaces was still related to more positive beliefs even after adjusting for these personal role models, suggesting an additional influence of public exposure.²⁵ Although regulations prohibiting indiscriminate smoking are in place in Indonesia, enforcement remains insufficient due to various factors, including complex bureaucratic structures, unclear lines of responsibility, decentralization, and inconsistencies in regional policies.^22,24 As a result, public smoking continues to occur widely and without effective control.²⁶ This highlights the need for stronger policy enforcement and the active involvement of community nurses in prevention efforts, particularly in reducing adolescents’ exposure to smoking and secondhand smoke, which is associated with smoking initiation.

The finding highlight that exposure to anti-tobacco media has a significant relationship with smoking initiation among teenagers in Indonesia. Teenagers who had never seen anti-tobacco messages in the mass media were more at risk for smoking. This is consistent with previous studies showing that adolescents exposed to point-of-sale tobacco advertisements or promotions were more likely to consider quitting smoking, and that mass media campaigns against tobacco marketing have been effective in reducing smoking initiation.^27,28 In Indonesia, adolescents generally have sufficient access to both mass media and social media, making anti-smoking messages readily available.^29,30 However, tobacco-related content remains widely accessible, and tobacco advertising and promotion are pervasive across various media platforms. Studies have shown that adolescents frequently exposed to tobacco-related content on platforms such as TikTok, Instagram, and YouTube are more likely to initiate e-cigarette use.^28,30 With the increasing integration of digital technology into the daily lives of children and adolescents, social and digital media platforms present both risks and opportunities. In line with our findings on the role of media exposure in smoking initiation, these platforms can be strategically utilized to disseminate educational content about the dangers of smoking and support efforts to prevent smoking initiation among youth.³¹ This highlight that the government should strengthen anti-tobacco media campaigns on social and mass media platforms, regulate online tobacco content, and collaborate with digital platforms to limit youth exposure to pro-tobacco messages.

The findings highlight that influence from parents and teachers who smoked had a significant relationship with smoking initiation in teenagers in Indonesia, in line with research in Nigeria,¹⁹ Swedia,³² Samoa,²³ and Africa.¹⁹ Which indicated that teenagers saw their parents as role models and prominent influencers³³ and also that teenagers who saw teachers smoking in the school area were more at risk for initiating smoking.³⁴ Targeting parents who smoke tobacco through various health interventions such as health education is suggested to be likely to reduce smoking initiation in their children.³⁴ According to a study in Beijing, China, there was a positive correlation between smoking and teachers who smoked.³⁵ However, this result contrasted with a study in Samoa, where factors such as smoking among teachers were insignificant in smoking initiation.²³ Teenagers’ parents regarded teachers as role models.³⁶ Accordingly, teachers’ smoking behavior in school environments may influence adolescents through social modeling, potentially increasing the likelihood of smoking initiation. Therefore, interventions targeting teachers’ smoking behavior in school settings may help reduce smoking initiation among students.³⁷ Indonesia has established laws and regional regulations to create smoke-free areas (SFAs), including schools, to protect individuals from the harmful effects of smoking. However, the implementation of these policies remains inconsistent, as evidenced by the continued presence of teachers smoking within school environments, indicating gaps in enforcement. Strengthening the implementation of smoke-free area policies in schools, alongside improving access to smoking cessation services for adults, may help reduce adolescents’ exposure to smoking and limit the normalization of tobacco use, thereby creating an environment that discourages smoking initiation.

Friends who smoked had a significant relationship with smoking initiation in teenagers in Indonesia. The results indicated that teenagers who accepted cigarette offers from friends were more at risk of initiating smoking. Research in Swedia suggested that the influence of smoking friends on boys and girls in the sample was in line with a theory that emphasizes the power of peer modeling in developing health behaviors among teenagers.³² This was consistent with research in Samoa,²³ Nigeria,¹⁹ and Africa¹⁸ that curiosity and peer pressure are the most contributing factors to the formation of the intention to smoke. This is in line with Indonesia where most teenagers are starting to dare to try cigarettes because they see other friends smoking. Therefore, in addition to parental supervision and education, it is essential to promote peer group support programs and improve access to youth-friendly smoking cessation services to help prevent and reduce smoking initiation among adolescents.

Nevertheless, this study is not without its limitations. First, as a cross-sectional analysis, this study can only assess associations between factors and smoking initiation but cannot establish causality; longitudinal studies are needed to confirm the temporal relationships between these variables and smoking initiation in adolescents. Additionally, this study relies on self-reported data, which may introduce response biases. Adolescents, particularly those under 13 years old and female respondents, may be more likely to underreport smoking behaviors due to social desirability bias or fear of judgment, potentially leading to an underestimation of smoking prevalence among these subgroups. Future research should consider using biochemical verification methods, such as cotinine tests, to validate self-reported smoking status. Furthermore, several factors related to smoking initiation, including the type of cigarette product used, frequency, age of onset, and motivation for smoking initiation, were not examined in this study. Further research efforts should aim to investigate these factors to provide a more comprehensive understanding of adolescent smoking initiation.

Conclusion

In conclusion, this study sheds light on predictors of tobacco smoking initiation among teenagers in Indonesia. The results suggest that several factors play a significant role in the initiation of smoking behavior, including age, gender, exposure to smoke in outdoor public places, exposure to anti-tobacco media, influence of parents, teachers, and friends. These findings highlight the urgent need for interventions and policies that specifically focus on preventing the initiation of smoking among adolescents, such as stricter enforcement of smoke-free areas, school-based prevention programs, and strengthening anti-tobacco media campaigns targeting youth. Nurses and healthcare professionals can utilize these insights to design and implement effective smoking prevention strategies and cessation support not only for teenagers but also for the general population, given that early initiation often leads to sustained smoking behavior into adulthood, creating a vicious cycle. Furthermore, policymakers can utilize these insights to design and implement health policies and initiatives to curb smoking behavior among Indonesian teenagers.

Authors’ contributions

All authors edited and approved the final manuscript.

Provenance and peer review

Not commissioned; externally peer reviewed.

Ethics and inform consent statement

This study used publicly available and anonymized secondary data from the 2019 Indonesia GYTS. Therefore, no additional ethical approval was required for this secondary analysis.