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} 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. ^{3 – 5} According to a survey conducted by the Global Youth Tobacco in Indonesia, prevalence of smoking among teenagers aged 13-15 years rose from 33.9% in 2014 to 38.3% in 2019, indicating a significant increase. This percentage is notably high when compared to global statistics. ⁶

Tragically, in 2016, 0.8% of girls and 1.2% of boys reported starting smoking at an early age when they were 5-9 years old. ⁷ Health data research in 2018 showed that 77.7% of novice smokers in Indonesia started smoking before the age of 19. ⁷ The results of research conducted by the 2018 Campaign for Tobacco Free Kids (CTFK) in 23 countries including Indonesia showed that the cigarette industry targeted children by advertising and promoting cigarette products in school environments. ⁸ This contrasts with government programs during the 2015-2019 period, namely reducing smoking initiation by 1% per year. ⁷

The age at which an individual begins smoking has been found to have a significant impact on their smoking habits in adulthood, as well as serving as an indicator of other problematic behaviors such as substance abuse, school disengagement, sexual risk-taking, and violent conduct. ⁹ The current body of literature does not provide any forecast regarding the onset of smoking initiation in individuals. The findings of an Indonesian ministry study show that higher taxes on tobacco products have a very significant impact on reducing tobacco consumption among teenagers, especially by reducing smoking initiation, as well as among individuals with low socioeconomic status. ⁷ However, alternative research posits that pricing strategies may not serve as a significant motivator for smokers to cease their habit, nor do they appear to act as a deterrent for young individuals who are considering initiating smoking. ¹⁰

Several research studies have investigated determinants that contribute to the initiation of smoking behavior globally. A study conducted with Jordanian students revealed that a decrease in availability of financial resources, an increase in educational attainment, and heightened awareness of the adverse health consequences of tobacco consumption were significant factors that contributed to reduction of smoking prevalence among the student population. ¹⁰ Likewise, in in Canada, a positive correlation was observed between the smoking behaviors of parents, siblings, and peers and the prevalence of smoking among university students. ¹ Furthermore, a research investigation into initiation of smoking behavior among young adults in the Korea observed that although education exhibited a negative correlation with smoking, exposure to smoking and tobacco use demonstrated a positive correlation with smoking behavior among this demographic. ¹¹ Despite extensive research on the determinants of smoking initiation, there remains a dearth of specific studies pertaining to developing countries in Southeast Asia, particularly Indonesia. Given the compelling evidence regarding determinants of tobacco smoking, the Indonesia-based investigation offers valuable perspectives on the factors that underlie tobacco smoking in the area and proposes policy interventions that emerging economies could implement to deter student smoking. ¹²

Teenagers in Indonesia may also find it easy to access cigarettes, which can be bought anywhere at affordable prices for teenagers in Indonesia. ¹³ 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. ¹² The results of this study are expected to particularly inform theory development in community nursing. Knowledge of tobacco smoking initiation factors can be used as material for health promotion, as well as protection and prevention of diseases caused by tobacco smoking. ¹⁴ The study findings can also provide additional information and overview of initiation factors of tobacco smoking in teenagers, and information for government to support development of health policies and programs aimed at preventing initiation of tobacco smoking in teenagers in Indonesia. Hence, the purpose of this study was determining predictors of tobacco smoking initiation among teenagers in Indonesia.

The predictor of initiation of tobacco smoking among teenagers in Indonesia is in accordance with the 2018 Basic Health Research which showed 77.7% of first-time smokers in Indonesia started smoking before the age of 19 years. ⁸ from ordering children under the age of 18 (eighteen) years to sell, buy, or consume tobacco products. Another policy that is quite effective in preventing the emergence of novice smokers is to implement a 100% non-smoking area policy. The Main Provisions of Non-Smoking Area Regulations in Indonesia are rooms or areas that are declared prohibited for smoking activities or for producing, selling, advertising, and/or promoting tobacco products in the applicable places. ¹⁷ Because there are already regulations and policies regarding this, the government can carry out more supervision regarding the policies that have been implemented to prevent the initiation of smoking in teenagers in Indonesia.

Age has been shown to have a significant relationship with smoking initiation among teenagers in Indonesia. The results of research on age showed that the older the teenager, the risk to start smoking increases. This is consistent with research conducted in Samoa at 2021 ¹⁸ and Korea at 2020 ¹⁹ that age increases problems in life and their use of smoking is a coping mechanism. For this reason, health education is needed about the dangers of smoking, especially for older teenagers. Research has showed that a person is at risk for smoking initiation if they have insufficient knowledge about tobacco-related problems. ²⁰ Another study also found that discussions within the family about the harmful effects of smoking had a negative relationship with the adoption of tobacco smoking among students. This health education aimed to prevent teenagers from initiating smoking. ²¹

Sex was found to have a significant relationship with smoking initiation in teenagers in Indonesia. The study’s results on gender showed that males were more at risk for initiating smoking. These results concur with studies in Africa, ²² Nigeria, ²³ Samoa, ¹⁸ and Korea. ¹⁹ Adolescent males in Indonesia were found to be more likely to initiate smoking because the prevalence of smoking among the male population in Indonesia was higher than that of females. According to the 2018 Basic Health Research, the dominant gender is male in smoking initiation. ⁸ Therefore, it is necessary to educate all genders about the dangers of smoking, especially male and female adolescents, which aims to prevent Indonesian youth from starting smoking. The study did not find a statistically significant correlation between receiving pocket money and smoking initiation among adolescents in Indonesia. This is in contrast to previous research conducted in Canada. ²⁴ While pocket money may not play a significant role in smoking initiation among adolescents in Indonesia, this should not be ignored because it has been identified as a causative factor for smoking initiation in other countries. Pocket money is not related to smoking initiation because smoking initiation in Indonesia is the low price of cigarettes. ⁷ The 2019 GYTS data shows that most teenagers buy cigarettes in shops, stalls, street vendors and convenience stores. The cheap price of cigarettes makes it easier for teenagers to buy them. Although Government Policy 109/2012 prohibits the sale of cigarettes to youths under 18 years of age, most admit that they have never been prevented from buying cigarettes based on their age. ²⁵ Policies are needed regarding the increase in cigarette prices and re-monitoring of shops, stalls, street vendors and small shops selling cigarettes. Thus, they do not sell cigarettes in retail if the buyer is not over 18 years. ²⁶

Research has demonstrated a noteworthy correlation between outdoor exposure to smoke in public areas and onset of smoking behavior among teenagers in Indonesia. According to research findings, adolescents who are exposed to secondhand smoke in public places outside closed spaces are found to have a higher risk of starting smoking. ²⁷ The findings of this study are consistent with previous studies conducted in Nigeria ²³ and Samoa ¹⁸ regarding adolescents who are accustomed to cigarette smoke and often start smoking. Researchers in Nigeria and Samoa demonstrated a positive correlation between external exposure and smoking initiation. ^{18 , 23} 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. There were already regulations in Indonesia prohibiting smoking indiscriminately, but supervision was still lacking. Hence, many people smoked haphazardly. ²⁸ Therefore, as community nurses, they provide education about smoking-free areas and the dangers of smoking, which aims to prevent young people from starting smoking. ²⁹

Anti-tobacco media has a significant relationship with smoking initiation among teenagers in Indonesia. According to research on anti-tobacco media, teenagers who had never seen anti-tobacco messages in the mass media were more at risk for smoking. ^{22 , 23 , 30} This was in line with Widyaningsih’s research that the mass media campaign against tobacco marketing had effectively reduced smoking initiation. ³¹ However, this result contrasted with a study in Samoa, where the media did not have any impact on cigarette consumption. ¹⁸ Teenagers in Indonesia already have adequate access to mass media and social media. ³² Many teenagers today use the telephone to communicate. Anti-smoking media messages on television, radio, internet, billboards, posters, newspapers, magazines, or films are easy for teenagers to access. ³³ Technology development has integrated the lives of children and teenagers with social and digital media on the internet. ³⁴ Children and adolescents who are still in their infancy are reported to be interested in trying new information or something, even if they see famous people or their idols smoking. ⁹ They can use social and digital media to educate themselves about the dangers of smoking to reduce smoking initiation. ³⁵

Parents who smoked had a significant relationship with smoking initiation in teenagers in Indonesia. This study was in line with research in Nigeria, ²³ Swedia, ²⁰ Samoa, ¹⁸ and Africa. ²² These results indicated that teenagers saw their parents as role models and prominent influencers. ³⁶ The influence of advertisements, cigarette advertisements that often appear on television which are packaged with gentlemen like men completely make teenagers or children feel attracted to be considered adults and even more so if the advertisement model is an idol. ³⁷ 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. ³⁸

Teachers who smoked had a significant relationship with smoking initiation in teenagers in Indonesia. The study’s results on teachers who smoked showed that teenagers who saw teachers smoking in the school area were more at risk for initiating smoking. ³⁸ According to a study in Beijing, China, there was a positive correlation between smoking and teachers who smoked. ³⁹ However, this result contrasted with a study in Samoa, where factors such as smoking among teachers were insignificant in smoking initiation. ¹⁸ Teenagers’ parents regarded teachers as role models. ⁴⁰ Hence, targeting teachers who smoke tobacco in school areas through various health interventions such as health education is likely to reduce smoking initiation in students or teenagers. ⁴¹

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. ²⁰ This was consistent with research in Samoa, ¹⁸ Nigeria, ²³ and Africa ²² 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, it is necessary to supervise teenagers and educate parents to reduce the initiation of smoking. ⁴²

Nevertheless, this study is not without its limitations. Initially, it should be noted that the data is reliant on self-reporting, which may result in either an overestimation or underestimation of the actual values. 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 our study. Further research efforts should aim to investigate the factors associated with the initiation of smoking among teenagers.

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. The findings highlight the need for interventions and policies targeted at reducing tobacco use among teenagers in Indonesia. Nurses and healthcare professionals can use these findings to develop effective smoking prevention and cessation programs for teenagers. Furthermore, policymakers can utilize these insights to design and implement health policies and initiatives to curb smoking behavior among Indonesian teenagers.

All authors edited and approved the final manuscript.

Not commissioned; externally peer reviewed.

This study was reviewed and approved by the Institutional Review Board of the Ministry of Health (LB.02.01/2/KE.315/2019 date approval: 7 August 2019). Participation was voluntary, and all respondents were provided with information about the research. This study complied with the ethical principles of the Declaration of Helsinki.

The data used in the study were collected by a reputable survey (Global Youth Tobacco Survey), and it is assumed that ethical considerations, including obtaining informed consent, were addressed during the original data collection process. The researchers adhered to any regulations, guidelines, or ethical standards set forth by the organization or authority that provided the data. Compliance with these standards may obviate the need for individual consent for secondary data analysis.