F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.147006.3 Research Article Articles Predictors Of Tobacco Smoking Initiation Among Indonesian Teenagers: The 2019 Global Youth Tobacco Survey

[version 3; peer review: 1 approved with reservations, 2 not approved]

 Deva Hani Salsabila Conceptualization Formal Analysis Methodology Project Administration Software Visualization Writing – Original Draft Preparation Writing – Review & Editing 1 Efendi Ferry Conceptualization Data Curation Formal Analysis Methodology Supervision Validation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-7988-9196 a 1 2 Asmoro Candra Panji Conceptualization Methodology Supervision Writing – Original Draft Preparation Writing – Review & Editing 1 Aditya Ronal Surya Methodology Visualization Writing – Review & Editing 3 McKenna Lisa Supervision Validation Writing – Review & Editing https://orcid.org/0000-0002-0437-6449 2 Alruwaili Abdullah Saleh Validation Writing – Review & Editing https://orcid.org/0000-0001-5803-1414 4 5 Faculty of Nursing, Universitas Airlangga, Surabaya, East Java, Indonesia School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia Department of Public Health, Universitas Negeri Malang, Malang, East Java, Indonesia King Abdullah International Medical Research Center, Al Ahsa, 31982, Saudi Arabia Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, 31982, Saudi Arabia ferry-e@fkp.unair.ac.id

No competing interests were disclosed.

 6 3 2025 2024 13 410 4 3 2025 Copyright: © 2025 Deva HS et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction

We examined the predictors of tobacco smoking initiation considering factors such as age, gender, pocket money, exposure to smoke in public outdoor places, anti-tobacco media, smoking parents, smoking teachers, and smoking friends among adolescents in Indonesia.

 Methods

Using data from the 2014–2019 National Youth Tobacco Survey grades 7–12, data from 9,655 teenagers were analyzed. The research used the Global Youth Tobacco Survey (GYTS) questionnaire. The analysis used univariate, chi-square and logistic regression with the STATA application version 15.

 Results

In total, 9655 adolescent respondents participated. Multivariate tests indicated that teenagers aged 13-15 years (AOR: 1.34, 95% CI: 1.08-1.66) and teenagers aged> 15 years (AOR: 1.65, 95% CI: 1.25-2.17), teenagers who were male (AOR: 13.99, 95% CI: 11.11-17.63), teenagers who were exposed to cigarette smoke in public places outside the room (AOR: 2.00, 95% CI: 1.74-2.29), teenagers who had never seen anti-tobacco messages in the mass media (AOR: 1.23, 95% CI: 1.02-1.48), Teenagers who had parents who smoke (AOR: 1.26, 95% CI: 1.08-1.46), teenagers who saw teachers smoking in the school area (AOR: 1.42, 95% CI: 1.18-1.71), and teenagers who accepted offers of cigarettes from friends (AOR: 15.11, 95% CI: 10.33-22.11).

 Conclusion

The initiation of tobacco smoking among teenagers in Indonesia can be predicted by various factors such as age, gender, exposure to smoke in outdoor public places, exposure to anti-tobacco media, and influence of parents, teachers, and friends.

 Indonesia Initiation Smoking Tobacco use The author(s) declared that no grants were involved in supporting this work. Amendments from Version 2

In this revised version, we have made several key improvements. In the Introduction, we updated the section to include the latest adult tobacco use prevalence statistics in Indonesia and provided a demographic breakdown of tobacco consumption. In the Methods section, we explicitly stated that this study is a secondary analysis of the 2019 GYTS dataset, elaborated on the variable selection process, and clarified the categorization of key variables, particularly exposure to secondhand smoke and teacher smoking visibility. In the Results section, we refined ambiguous wording in key findings and provided a clearer rationale for variable classifications. Finally, in the Discussion and Conclusion, we added a statement on the limitations of the cross-sectional design and its inability to establish causality. We also expanded the discussion on self-reporting bias, particularly regarding potential underreporting among younger adolescents and female respondents. These revisions enhance the clarity and rigor of the manuscript.

 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 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 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. 1 The most commonly used tobacco product in Indonesia is the kretek, a clove-flavoured cigarette. 2 Other tobacco products, such as electronic nicotine delivery systems and heated tobacco products, have also seen rapid market growth since their legalization in 2018. 3 These products are widely available and often marketed without health warnings, making them easily accessible. 3 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

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.

 Methods Research design

The present investigation employed a cross-sectional research design, utilizing secondary data sources obtained from the 2019 Indonesia Global Youth Tobacco Survey (GYTS). The Global Youth Tobacco Survey (GYTS) is a component of the Global Tobacco Surveillance System (GTSS) that serves as a worldwide benchmark for the methodical monitoring of tobacco consumption (both inhalation and chewing) among young individuals, as well as the tracking of tobacco control metrics. 9 This study conducted a secondary analysis of the existing dataset, with no primary data collection. The selection of variables was guided by their relevance to smoking initiation, and the specific GYTS survey questions used in this study are detailed in the subsequent sections.

 Population and sample

This survey was given to a total of 9,992 students in grades 7-12 spread throughout Indonesia, yielding a total response rate of 91.0%. The methodology employed by GYTS conforms to a global standard and involves a two-stage sample design. The present study employed a purposive sampling method, whereby participants were selected based on specific inclusion criteria. Specifically, the sample consisted of students in grades 7-12 who had completed the survey. The final study comprised a sample size of 9,655 participants.

 Data collection

First, the researcher downloaded the dataset needed in the study from the Global Youth Tobacco Survey (GYTS) in 2019. Then downloaded it on the website https://nccd.cdc.gov/GTSSDataSurveyResources/Ancillary/DataReports.aspx?CAID=2. after being downloaded, the respondent data recruited based on the inclusion criteria were grade 7-12 students who had completed the survey. Then, data cleaning was carried out to re-check the data for the possibility of missing data, which was found to be as many as 225 data elements. Then, we identified variables to determine the final variables to be used in the study. The selection of variables was guided by their theoretical and empirical relevance to smoking initiation as suggested in the literature. The variables were grouped into independent and dependent variables based on prior research and public health frameworks related to tobacco use. We specifically included demographic factors (age, gender, pocket money), environmental influences (exposure to smoke in public outdoor places, anti-tobacco media exposure, and smoking behavior of parents, teachers, and friends), and behavioral factors that are commonly associated with smoking initiation.

The dependent variable, smoking initiation, was defined using the GYTS question: “Have you ever tried smoking, even one or two puffs?” Respondents who answered “Yes” were classified as having initiated smoking, while those who answered “No” were considered non-smokers. We explicitly defined the term “smoking initiation” as “having ever tried smoking, even one or two puffs” to ensure consistency in classification. Independent variables were also derived from specific GYTS survey questions. Exposure to secondhand smoke was assessed through the question: “During the past 7 days, on how many days were you exposed to tobacco smoke in public places?” Responses were categorized into “Never” and “1-7 days to align with prior research on youth smoking behavior and to maintain statistical power. While a more detailed categorization (e.g., 1-3 days, 4-7 days) was considered, it was not used due to potential sample size limitations in each subgroup.” Anti-tobacco media exposure was measured using the question: “During the past 30 days, have you seen or heard any anti-tobacco messages in the media (TV, radio, internet, billboards, etc.)?” The influence of parents, teachers, and friends was determined using questions such as “Do any of your parents smoke?”, “Do you often see teachers smoking in school?”, and “Have any of your friends ever offered you a cigarette?”

To identify the variables, a recoding process was carried out, in which the variables contained in the dataset were categorized into variables in accordance with the research without changing the original data and were given new code names. To improve clarity, we moved the categorization of variables from the Results section to the Methods section, ensuring that readers could understand variable classifications before analyzing the findings.

 Data analysis

We used multivariate logistic regression to measure the association between age, gender, allowance, exposure to smoke in public outdoor places, anti-tobacco media, parents’ smoking, teacher smoking and peer smoking, while controlling for the previously mentioned potential confounders. In analyzing data from the four survey rounds, each round received equal weighting. This weighting was applied to address the complexity of the GYTS data. Additionally, the “svyset” or survey estimation command was employed to accommodate the survey sampling method. 15 The analysis used the STATA 15 16 application and carried out using univariate analysis to enable description of the variables, then bivariate analysis was carried out using chi square tests to determine relationships between variables. Multivariate analysis using logistic regression analysis testing which aimed to determine which independent variable had the greatest influence.

 Ethical considerations

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.

 Results Univariate analysis results

Based on Table 1, from the total data of 9655 teenagers, the age of teenagers was categorized into 3 levels, namely <13 years, 13-15 years, and >15 years. Most were in the category of 13-15 years (n=4965, 51.43%). Most teenagers were women, as many as 5429 (56.23%). Pocket money was categorized into 4 levels, namely no pocket money, pocket money <1 USD, pocket money 1-5 USD, and pocket money >5 USD, with most teenagers in the Rp.11,000-50,000 category (n=4876, 50.50%). A total of 6,501 teenagers (67.33%) reported being exposed to cigarette smoke in public outside the room. Teenagers who reported seeing anti-tobacco messages on mass media such as television, radio, internet, billboards, posters, newspapers, magazines, or films were 7567 (78.37%). Most teenagers do not have smoking parents, 5546 (57.44%), less than half of teenagers who often see teachers smoking in the school environment are 4533 (46.95%). Among all surveyed teenagers, 89.56% (n=8647) reported refusing offers to smoke from their friends. The number of teenagers who said they had never tried or experimented with smoking was 6128 (63.47%).

Characteristics of Respondents in Teen Tobacco Survey (GYTS Indonesia 2019) (n=9655).
Variable Frequency (n) Percentage (%)
Age
 <13 Years 1572 16.28
 13-15 Years 4965 51.43
 >15 Years 3118 32.29
Gender
 Female 5429 56.23
 Male 4226 43.77
Allowance
 None 474 4.91
 <1 USD 2002 20.74
 1-5 USD 4876 50.50
 >5 USD 2303 23.85
Exposure to smoke in public outdoors places
 0 day (Never seen) 3154 32.67
 1-7 day (Seen) 6501 67.33
Anti-tobacco media
 Yes 7567 78.37
 No 2088 21.63
Parents’ smoking
 No 5546 57.44
 Yes 4109 42.56
Teachers’ smoking
 Never seen 5122 53.05
 See often 4533 46.95
Friends’ smoking
 No 8647 89.56
 Yes 1008 10.44
Smoking initiation in teenagers
 No 6128 63.47
 Yes 3527 36.53
TOTAL 9655 100%

Table 2 indicates that based on the results of bivariate analysis there were 7 independent variables that showed significant results on initiation of tobacco smoking in teenagers (p-value<0.05). These included: age (p-value=0.0053), gender (p-value=0.0000), smoke exposure in open public places (p-value=0.0000), anti-tobacco media (p-value=0.0029), parents who smoked (p-value=0.0108), teachers who smoked (p-value=0.0000), and friends who smoked (p-value=0.000). Meanwhile, the allowance variable (p-value=0.2636) did not show significant results on the dependent variable with p-value>0.05.

Bivariate and multivariate analysis result of predictors of tobacco smoking initiation (n=9655).
Variable Dependent
Independent Smoking initiation in teenagers
Yes No Bivariate analysis Multivariate analysis
N % N % p-value X 2 AOR 95% CI p-value
Age 0.0053 30.62
 <13 Years 521 33.77 1051 66.23 Ref
 13-15 Years 1815 38.46 3150 61.54 1.34 1.08-1.66 0.008
 >15 Years 1191 42.31 1927 57.69 1.65 1.25-2.17 0.000
Gender 0.0000 3196.64
 Female 643 11.47 4786 88.53 Ref
 Male 2884 67.52 1342 32.48 13.99 11.11-17.63 0.000
Allowance 0.2636 8.16
 None 185 41.55 289 58.45
 <1 USD 720 39.32 1282 60.68
 1-5 USD 1825 39.2 3051 60.8
 >5 USD 797 36.25 1506 63.75
Exposure to smoke in public places outdoors 0.0000 389.03
 0 day (Never seen) 724 24.59 2430 75.41 Ref
 1-7 day (Seen) 2803 45.43 3698 54.57 2.00 1.74-2.29 0.000
Anti-tobacco media 0.0029 14.51
 Yes 2689 37.63 4878 62.37 Ref
 No 838 42.2 1250 57.8 1.23 1.02-1.48 0.028
Parents’ smoking 0.0108 17.69
 No 1929 36.84 3617 63.16 Ref
 Yes 1598 41.06 2511 58.94 1.26 1.08-1.46 0.004
Teachers’ smoking 0.0000 236.36
 Never seen 1526 31.72 3596 68.28 Ref
 See often 2001 47.03 2532 52.97 1.42 1.18-1.71 0.000
Smoking friends 0.0000 1488.92
 No 2593 31.96 6054 68.04 Ref
 Yes 934 93.48 74 6.52 15.11 10.33-22.11 0.000

Notes: CI (Confidence Interval), AOR (Adjusted Odds Ratio).

Based on Table 2 also indicates that based on the results of multivariate analysis there were 7 independent variables that showed significant results on initiation of tobacco smoking in teenagers (p-value <0.05). Teenagers who were >15 years old were 1.65 times more likely to start smoking than those who were 15 and 13–15 years old. Teenage males were 13.99 times more likely to start smoking than teenage girls. Teenagers who were exposed to secondhand smoke outside in crowded areas were twice as likely to start smoking. Teenagers were 1.23 times more likely to start smoking if they had never encountered anti-tobacco messaging in the media. Teenagers who had smoking parents were 1.26 times more likely to start smoking. Teenagers were 1.42 times more likely to start smoking if they observed instructors smoking in the schoolyard. Accepting cigarettes from friends increased a teenager’s chance of starting to smoke by 15.11 times.

 Discussion

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. 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. 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.

 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 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.

 Data availability

The data underlying the results presented in the study are available from the https://extranet.who.int/ncdsmicrodata/index.php/catalog/926 by submitting an application.

Extended data

FigShare: Checklist for Predictors of tobacco smoking initiation among indonesian teenagers: the 2019 global youth tobacco survey, https://doi.org/10.6084/m9.figshare.25512025.v1. 43

Data are available under the terms of the Creative Commons Attribution International License (CC BY 4.0).

 Acknowledgements

None.

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Lancet Public Health. 2019;6(7):e472–e481. 10.1016/S2468-2667(21)00102-X Lee J Kong G Kassas B : Predictors of vaping marijuana initiation among US adolescents: Results from the Population Assessment of Tobacco and Health (PATH) study Wave 3 (2015–2016) and Wave 4 (2016–2018). Drug Alcohol Depend. 2021;226(July):108905. 34304122 10.1016/j.drugalcdep.2021.108905 Cheng X Guo X Jin C : Social determinants of smoking among school adolescents in Beijing, China. Tob. Induc. Dis. 2022;20:1–9. 10.18332/tid/152202 Nazlıcan E Ersoy Ö Akbaba M : Social factors should not be underestimated in smoking behaviour among adolescents: A patriarchal experience from senior high school students in Turkey. Tob. Induc. Dis. 2018;16(3):3. Duke JC Macmonegle AJ Nonnemaker JM : Impact of The Real Cost Media Campaign. Am. J. Prev. Med. 2019;57(5):645–651. 31443954 10.1016/j.amepre.2019.06.011 Zhu B Liu S Program L : Cigarette Smoking and Its Risk Factors among Elementary School Students in Beijing. Am. J. Public Health. 1996;86(3):368–375. 8604762 10.2105/AJPH.86.3.368 PMC1380518 Efendi F : Strobe checklist. figshare.[Dataset].2024. 10.6084/m9.figshare.25512025.v1 10.5256/f1000research.178930.r376716 Reviewer response for version 3 Melinda Gea 1 Referee https://orcid.org/0000-0001-7908-9287 Center for Indonesia's Strategic Development Initiatives, Jakarta, Indonesia

Competing interests: No competing interests were disclosed.

 26 5 2025 Copyright: © 2025 Melinda G 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

Thank you for this important work. 

In general, I have concern regarding

1. The outdated data or resources cited;

2. The coherence and cohesion of the sentences;

3. The consistency and clarity in the method section;

4. The depth of analysis;

5. Mistyping in many parts of the document and the clarity of language used.

I will explain in detail below.

Abstract

1. Methods part: "The research used the GYTS questionnaire. Use questionnaire for what purpose?

2. Results part: second sentence is not clear and too long. Please kindly revise the sentence.

Introduction

Please revise all paragraphs in this section and follow the guideline for introduction that includes rationale or background in the first paragraph, then explore what is already known in the topic of interest, proceed to the research gap, then close the section with objective and potential contribution. It would be helpful to make each paragraph concise and avoid repeating the same materials or key messages.

Paragraph 1 (P1)

1. This paragraph explains a diverse topic but it is not clear what the key message is. Please try to maintain that each paragraph has 1-2 key messages. 

2. Teen smokers data could be updated using the latest findings, for example The 2023 Health Survey of Indonesia (SKI 2023)

3. “These products are widely available and often marketed without health warnings, making them easily accessible.” Please kindly clarify how often marketed without health warnings has correlation with accessibility to cigarette products. I would suggest removing the part mentioning health warnings.  

P2

In my opinion, bridging from first to second paragraph does not come naturally

Please kindly update the references in this paragraph using latest data

I do agree that youth smoking is concerning. However, would it be relevant to mention the proportion since it’s significantly small (0,8% and 1,2%)? Maybe you can use another data or expressing this percentage in real value (for example 1 million children or so)

I would suggest using the recent government program since they have announced the new national program for the period of 2025 to 2029.

 P3

Second sentence needs clarity, I could not understand what it aims to deliver

In scientific writing,‘very significant’ is redundant. I would suggest to simply mention ‘significant’

I do not think it is necessary to explain the correlation between price and smoking initiation since price is not one of variables included in this study

 P4

The writer focused on explaining the determinants of smoking on a global level, while previous paragraphs have explained the condition in Indonesia. Usually the introduction section explains the condition in the broader level in the early part of it (first paragraph).

The previous studies mentioned in this part demonstrate the determinants of smoking prevalence and tobacco consumption while this study focuses on smoking initiation. I would recommend sticking with study on smoking initiation. 

The last sentence could be on the last paragraph as it elaborates on potential contribution

For the gap of the study, please elaborate more on what studies have been done in Indonesia, what are the weakness, what are the gap of knowledge you try to fill.

 P5

The first sentence pops out of nowhere, it does not correlate with other sentences before or after this sentence. Consider deleting this part. 

Second sentence is repetition from third paragraph, elaborating on the urgency of this study

Please explain more about the novelty of this study, why this work can add value to the recent body of knowledge, and what are the added values. I believe study on smoking determinants in Indonesia has been done before, even though this study tries to focus on smoking initiation, but since the variable is derived from GYTS questionnaire, it is somehow quite similar with other studies that use another term for students who have ever tried or consumed tobacco products. 

 Methods

I found some inconsistencies and some parts need improvement on clarity

Research design

In the abstract, the writer stated that data from GYTS 2014 to 2019 has been used. In the method section, you mentioned only one wave of survey. Please kindly clarify the discrepancy.

I suggest the writer should explain how GYTS took the data (school-based survey) and its representativeness because it will affect the validity of the data and how the result can be interpreted.

 Population and sample

Sentence 4 mentioning the grade of students has been repeated the information on first sentence

 Data collection

As this study uses secondary data, I do not think this section is necessary. In addition, there are many repetitions here and there in this section. Otherwise, you could make new section for the variables

Independent variables were also derived from specific GYTS survey questions. → I suggest deleting this part because as secondary analysis, the reader has understood it.

Grouping for the secondhand exposure (and I think some others as well), I acknowledge that the sample number might be the limitation to separate it into three or more categories. However, I am also worried about the extreme differences between never and 1-7 days (everyday), because maybe some people only get the exposure some days. Please kindly clarify this assumption.

The writer does not explain the grouping for other variables such as anti-tobacco messages. 

I recognize some studies using GYTS have concern with treatment on the age variable. Please kindly elaborate on this issue, as well.

I noticed that the writer does not declare the treatment for some variables, such as gender, age, and pocket money. Also for the behavioural factors and confounding factors. There is no sufficient information provided.

“To improve clarity, we moved the categorization of variables from the Results section to the Methods section, ensuring that readers could understand variable classifications before analyzing the findings.” → No need to declare it since it is a necessity to declare variables used in the analysis in the method section. 

“To identify the variables, a recoding process was carried out, in which the variables contained in the dataset were categorized into variables in accordance with the research without changing the original data and were given new code names.” → I could not understand this part. Do you mind clarifying this part?

 Data analysis

Another question about how many wave of surveys the research team include in this study

The first and last sentence is quite similar. Please reduce the repetition and I would suggest putting it on the last sentence.

 Ethical consideration

In my opinion, secondary analysis does not require you to declare the ethical consideration because you do not take any primary data with humans. Furthermore, it may lead to confusion to put the ethics from GYTS on your study as reader may assume you conduct the survey.

 Results

The age of teenagers was categorized into 3 levels, namely <13 years, 13-15 years, and >15 years and similar information about pocket money categorization should be in the method section

Please be consistent using the Rupiahs or USD

The term ‘peer smoking’ leads to confusion. First, the writer does not declare this term and what variable this stands for in the method section. Second, it is not common to use this term for addressing friends who offer the students a cigarette. Usually this term is used referring to tobacco consumption among students’ peers or friends. 

 Discussion

In general, I would suggest deeper analysis and please be careful with basic writing or grammar errors. Making the sentences more concise and clear also would be highly recommended.

P1

Please update the data with the latest

Second sentence is unclear

I could not understand the key message of this paragraph in general. The first paragraph should sum up the results

 P2

Age increases problems in life?? Please kindly recheck the reference. I agree that as we get older, we face more complicated tasks or have bigger responsibilities, but this sentence is kinda misleading. 

For this reason, health education is needed about the dangers of smoking, especially for older teenagers… - until the last sentence. It is kinda difficult to imagine the relationship between the findings of higher age and the importance of health education. These sentences discuss deeper into family discussion as well and I do not think that is suitable for this finding. 

 P3

“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.” → This sentence is confusing. Yes, the male smokers in Indonesia are soaring high, but I do not think it is a good reason to explain and mention the causality related to the findings that the boys that are more likely to initiate smoking. The young smokers will somehow become adult smokers in the future. So, please kindly elaborate more. 

Please update the data with the latest

“Therefore, it is necessary to educate all genders about the dangers of smoking, especially male and female adolescents, …” → I agree that this is important but you can not give this recommendation while you findings reflected that boys are more likely to initiate smoking

Findings of pocket money should be in the new paragraph and discussed separately. It will be easier to digest for the readers. 

“Pocket money is not related to smoking initiation because smoking initiation in Indonesia is the low price of cigarettes.” → the sentence is unclear

“This is in contrast to previous research conducted in Canada.” → please explain findings from this study

“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.” → repeated information

Sentences discussing the places to buy cigarettes do not have direct correlation with pocket money. 

Government Policy 109/2012 → I think this policy has been updated with 28/2024. Please kindly check

P4 

Some basic writing errors. Please kindly check

“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.” → this sentence is unclear for me. Please kindly rephrase.

“Researchers in Nigeria and Samoa demonstrated a positive correlation between external exposure and smoking initiation.” → repetition of previous sentence

“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. “ → why only in outdoor space? I think the exposure from indoors also will bring the same impact. So, what is the significant factor from outdoor exposure that differentiate it from other settings?

“There were already regulations in Indonesia prohibiting smoking indiscriminately, …” → please dig deeper on the topic of smoke free areas in Indonesia. It has more problems beyond the supervision. 

I do not think recommendations regarding the role of community nurse in this paragraph are related to the findings. Why providing education on smoke free areas may impact on smoking initiation among adolescents?

 P5

“Anti-smoking media messages on television, radio, internet, billboards, posters, newspapers, magazines, or films are easy for teenagers to access.” → I am unsure about this since there is a big loophole in our TAPS policy. I would say advertisements of tobacco products are much more pervasive compared to the anti-tobacco messages.

“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.” → how does this information support your findings? In addition, the last sentence (sentence after this part) contradicts it. 

 P6

I suggest this paragraph and the next one discussing teacher smoking should be written as one paragraph only. I found many repetitions between P6 and P7. 

“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.” → this paragraph focuses on discussing parent smoking, please stick to it.

P7

“Teenagers’ parents regarded teachers as role models.” → I could grasp the idea why this information mattered to the findings of teacher smoking. 

Besides recommendations that have been mentioned about intervention for teachers, please discuss the implementation of smoke free areas in the school. I believe school should be a smoke free area, thus seeing teachers smoking in the school area means lack of enforcement?

From P6 and P7, I think it is also important to discuss that the status of smoking in the adult population may bring influence to youth smoking, thus access to smoking cessation service for adults is equally important to curb youth smoking.  

P8

“Therefore, it is necessary to supervise teenagers and educate parents to reduce the initiation of smoking.” → other than this recommendation, I would incline to peer group support among adolescents and access to smoking cessation service for youth.

Conclusion

“The findings highlight the need for interventions and policies targeted at reducing tobacco use among teenagers in Indonesia.” → since this paper focuses on smoking initiation, I would suggest the recommendation focuses on how to prevent the initiation itself.

“Nurses and healthcare professionals can use these findings to develop effective smoking prevention and cessation programs for teenagers.” → maybe for the general population as well since it is like a vicious cycle.

Is the work clearly and accurately presented and does it cite the current literature?

No

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No source data required

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

tobacco control advocacy focuses on tax increase policy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

 10.5256/f1000research.175543.r354568 Reviewer response for version 2 Leinberger-Jabari Andrea 1 Referee https://orcid.org/0000-0003-2014-9032 Public Health Research Center, New York University Abu Dhabi, Abu Dhabi,, United Arab Emirates

Competing interests: No competing interests were disclosed.

 21 1 2025 Copyright: © 2025 Leinberger-Jabari A 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

I reviewed a revision to the original article submission. I can see that the authors have made several minor corrections to the original article; however, there are still several revisions that are needed for clarity. 

A general note, I believe that the manuscript should be reviewed to assist with language flow.

Introduction:

The authors do not clearly state current tobacco use prevalence statistics for the country of Indonesia. Are there other forms of tobacco that are used there and what is the breakdown of their use across demographics?

Methods:

The authors still do not clarify that this is a secondary analysis of an existing dataset, and so this is a little confusing to the reader. "Then, we identified variables to determine the final variables to be used in the study. " The authors could expand on this statement to provide a rationale for the variables selected from the original dataset. Additionally it would be helpful to know what the questions were from the GYTS that they used for their variables in the model. Independent variables are described briefly, but the dependent variable is not clearly mentioned. Did the authors control for other forms of tobacco use? Why or why not, please justify. The authors throughout the article refer to smoking "initiation" as the main outcome variable, although they do not clearly state this in the methods. What is meant by "initiation"? Do you mean ever tried smoking or does this refer to teenagers who smoke occasionally/daily? This is an important distinction that should be made clear. Also, the authors chose to categorize several variables, and only described them in the results; please include the category distinctions in the methods section.

Results:

Please provide a rationale for categorizing some of the variables as follows:

Exposure to smoke in public outdoor places (never vs 1-7 days) - could you have used more categories?

Teacher smoking - what is meant by "see often"? Is more information on that available?

"Almost all of the teenagers who refused offers to smoke from their friends were 8647 teenagers (89.56%)." - consider re-phrasing as this is not clear what is meant.

Discussion and conclusion:

The authors could add a statement in the limitations that this is a cross-sectional analysis and therefore they cannot infer any causation. They could also expand the discussion on the implications of self-reported data, could this influence possible underreporting in specific groups (<13 year olds, girls)?

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

Tobacco use behaviors

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.161139.r278564 Reviewer response for version 1 Septiono Wahyu 1 Referee https://orcid.org/0000-0003-1376-976X Universitas Indonesia, Depok, West Java, Indonesia

Competing interests: No competing interests were disclosed.

 13 6 2024 Copyright: © 2024 Septiono W 2024 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation reject

General comment

Please consult a proofreader.

INTRODUCTION

1. "Indonesia currently exhibits the highest prevalence of smoking globally, indicating a potential upward trend." please specify the latest prevalence.

2. "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." Are 600 only adolescents or all age? Better to specify only adolescents to show the relevancy with the title

3. "...teenagers aged 13-15 years rose from 33.9% in 2014 to 38.3% in 2019, indicating a significant increase." please put the reference

4. "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." while this may seem to be very low, I suggest authors to emphasize a shocking worldwide video from Indonesia about toddler smoker which may show that cases of smoking among that age may be undereported https://www.youtube.com/watch?v=x4c_wI6kQyE&t=2s&ab_channel=OnDemandNews

5. "This contrasts with government programs during the 2015-2019 period, namely reducing smoking initiation by 1% per year." This seems quite old. Perhaps the latest program will be better.

6. "Several research studies have investigated determinants that contribute to the initiation of smoking behavior globally." In paragraph 4, I think it is more accurate if authors can cite systematic review studies. 

METHODS

1. The author wrote, "The present investigation employed a cross-sectional research design, utilizing secondary data sources obtained from the 2019 Indonesia Global Youth Tobacco Survey (GYTS)." I suggest rephrasing this as the study did not collect primary data but used secondary data. Referring to this study as using a cross-sectional design might be misleading. For example: "The study used secondary data from the 2019 Indonesia Global Youth Tobacco Survey (GYTS), in which data from GYTS was collected through a cross-sectional study design." And please additional information about the GYTS: 1) study population, 2) sampling method, 3) number of sample, etc.

2. I don't believe that "Data Collection" is the appropriate subheading for this study. See the reason at number 1 above.

3. The study did not clearly explain the variables included. For example, it is unclear which survey questions corresponded to the variables and how they were measured. Readers need to know the original instrument and understand how the authors converted these variables for analysis in the study.

4. the term "multivariate logistic regression" is incorrect for such analysis. See: reference 1.

5. The data analysis section did not thoroughly explain the steps taken for the analysis. Additionally, it is unclear why the authors applied weighting. Weighting can be used for several reasons, such as adjusting for over-sampling of a particular group in the population or accounting for non-response.

6. Authors stated that "Multivariate analysis using logistic regression analysis testing which aimed to determine which independent variable had the greatest influence." However, using regression to determine which variable had the greatest influence seems less feasible. While regression can provide insights into the relationships between variables and the dependent variable, determining which variable has the greatest influence requires careful consideration of the context, scale, potential multicollinearity, and the limitations of regression analysis. This should be performed under Dominance analysis if authors aim to determine the greatest influence. Dominance analysis provides understanding the relative importance of predictor variables in a regression model. It provides a nuanced view that takes into account multicollinearity and the combined effects of predictors, offering a clear ranking of variables based on their contributions to the explained variance in the dependent variable.

Results

1. "Most teenagers were women.." While many women might enjoy being referred to as teenagers, this is not the correct usage in English.

2. Why did the authors include the categorization in the results section? This should be in the methods section. Please refer to my previous comment!

3. There's no need to split the analysis into two tables.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

No

Is the study design appropriate and is the work technically sound?

No

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

statistics, tobacco control, data science, public health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References : Distinction Between Two Statistical Terms: Multivariable and Multivariate Logistic Regression. Nicotine & Tobacco Research .2021;23(8) : 10.1093/ntr/ntaa055 1446-1447 10.1093/ntr/ntaa055