F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.147006.4 Research Article Articles Predictors Of Tobacco Smoking Initiation Among Indonesian Teenagers: The 2019 Global Youth Tobacco Survey

[version 4; 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 Emergency Medical Services, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Al Ahsa, 31982, Saudi Arabia King Abdullah International Medical Research Center, Al Ahsa, 31982, Saudi Arabia ferry-e@fkp.unair.ac.id

No competing interests were disclosed.

 1 7 2026 2024 13 410 28 5 2026 Copyright: © 2026 Deva HS et al. 2026 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

This cross-sectional study used secondary data 2019 Indonesia Global Youth Tobacco Survey (GYTS) involving students grades 7–12. The GYTS questionnaire was used to assess tobacco related initiation and related factors, which served as the variables analyzed in this study. The analysis used descriptive, chi-square and logistic regression with the STATA application version 15.

 Results

In total, 9,655 adolescent respondents participated in this study. Multivariate analysis showed that smoking initiation was more likely among teenagers aged 13–15 years (AOR: 1.34, 95% CI: 1.08–1.66), those older than 15 years (AOR: 1.65, 95% CI: 1.25–2.17), males (AOR: 13.99, 95% CI: 11.11–17.63), those exposed to cigarette smoke in public places (AOR: 2.00, 95% CI: 1.74–2.29), those who had never seen anti-tobacco messages in mass media (AOR: 1.23, 95% CI: 1.02–1.48), those with smoking parents (AOR: 1.26, 95% CI: 1.08–1.46), those who saw teachers smoking at school (AOR: 1.42, 95% CI: 1.18–1.71), and those who accepted cigarette offers 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 3

This revised version has been updated in response to the reviewers’ comments. We clarified that the study used one wave of secondary data from the 2019 Indonesia Global Youth Tobacco Survey and revised the Abstract, Research Design, Population and Sample, Variables, Data Analysis, and Ethical Considerations sections for consistency. The Introduction was restructured to improve the logical flow from background and rationale, current evidence, research gap, study objective, and potential contribution. We updated national evidence using the 2023 Indonesia Health Survey and incorporated the RPJMN 2025–2029 policy context. The Methods section was revised to clarify the school-based and nationally representative design of GYTS, variable definitions, coding, and categorization, including smoking initiation, pocket money, secondhand smoke exposure, anti-tobacco media exposure, parents’ and teachers’ smoking, and friends’ cigarette offers. The Results section was revised to improve consistency between the variable definitions, tables, and narrative interpretation. The Discussion was strengthened by providing a clearer summary of key findings, deeper interpretation of age, gender, pocket money, secondhand smoke exposure, anti-tobacco media, parental, teacher, and peer influences, and updated policy implications. We also revised the limitations section and made grammatical, wording, formatting, and reference corrections throughout 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 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 Research design

This study utilized a cross-sectional design, based on secondary data sources obtained from the 2019 Indonesia Global Youth Tobacco Survey (GYTS). GYTS is school-based survey and 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 The 2019 Indonesia GYTS used a standardized two-stage cluster sampling design to obtain a nationally representative sample of students in grades 7–12. 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. The final study comprised a sample size of 9,655 participants.

 Variables

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. 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 selected from specific GYTS questions and grouped into 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.

Demographic variables; Gender was coded as a binary variable: female and male. Age, originally recorded as a continuous variable, was categorized into three groups: <13 years, 13–15 years, and >15 years, based on developmental stages and distribution in the dataset. Pocket money was grouped into four categories: “None,” “<1 USD,” “1–5 USD,” and “>5 USD” to reflect economic variability among respondents and maintain adequate sample sizes in each group. Environmental influences encompassed 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 0 days, 1–2 days, 3–4 days, 5–6 days, 7 days. 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.)?”, responses were categorized into “Yes” and “No”. 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 peer influence, “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.

 Data analysis

This study analyzed data from the 2019 round of GYTS conducted in Indonesia. analysis used the STATA version 15. Univariate analysis used to describe the variables, followed by bivariate analysis using chi square tests to determine relationships between variables. Multivariate logistic regression applied to determine which independent variable including between age, gender, allowance, exposure to smoke in public outdoor places, anti-tobacco media, parents’ smoking, teacher smoking and friend cigarette offers had the greatest influence, while controlling for the potential confounders. Each analysis received equal weighting to address the complexity of the GYTS data. Additionally, the “svyset” or survey estimation command was employed to accommodate the survey sampling method. 13

Ethical considerations

This study used secondary data from the Global Youth Tobacco Survey (GYTS), which is publicly available and fully anonymized. Therefore, no additional ethical approval was required for this analysis. The original GYTS data collection had obtained ethical clearance from relevant institutional review boards and was conducted in accordance with the 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 1-5 USD 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
Pocket money
 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 3154 32.67
 1-2 days 2616 27.09
 3-4 days 1200 12.43
 5-6 days 595 6.16
 7 days 2090 21.65
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’ cigarette offers’
 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
Pocket money 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 724 22.95 2430 77.05 Ref
 1-2 days 868 33.18 1,748 66.82 1.60 1.38-1.85 0.000
 3-4 days 513 42.75 687 57.25 2.05 1.71-2.46 0.000
 5-6 days 281 47.23 314 52.77 2.07 1.63-2.62 0.000
 7 days 1,141 54.59 949 45.41 2.41 2.06-2.82 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 <13 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

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 Nigeria 19 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 influencers 33 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 Africa 18 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.

 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. 38

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

 Acknowledgements

None.

 References Azagba S Baskerville NB Minaker L : A comparison of adolescent smoking initiation measures on predicting future smoking behavior. Prev. Med. Rep. 2015;2:174–177. 26844068 10.1016/j.pmedr.2015.02.015 PMC4721447 Cui Y Forget EL Zhu Y : The effects of cigarette price and the amount of pocket money on youth smoking initiation and intensity in Canada. Can. J. Public Health. 2018;110(1):93–102. 30168041 10.17269/s41997-018-0123-9 Asyary A Veruswati M : Smoking Behavior and Cigarette Expenditure in a Household: Evidence for Smoke-Free Houses Initiation in Indonesia. Int. J. Prev. Med. 2023;14(7):1–4. 10.17269/s41997-018-0123-9 GYTS: Gyts│Global Youth Tobacco Survey Lembar Informasi Indonesia 2019. 2019. Soerojo W Bigwanto M Susilo D : Fakta Tembakau Indonesia 2020: Data Empirik untuk Pengendalian Tembakau. Jakarta: Ikatan Ahli Kesehatan Masyarakat Indonesia;2020;200. Fithria F Adlim M Jannah SR : Indonesian adolescents’ perspectives on smoking habits: a qualitative study. BMC Public Health. 2021;21(82):1–8. 33413232 10.1186/s12889-020-10090-z World Health Organization (WHO) : Raising tobacco taxes and prices for a healthy and prosperous indonesia. World Heal Organ [Internet]. 2020:30. https://apps.who.int/iris/bitstream/handle/10665/336149/9789290227748-eng.pdf Riset Kesehatan Dasar (Riskesdas) : Laporan Riskesdas 2018 Nasional.pdf. Lembaga Penerbit Balitbangkes [Internet]. 2018;hal 156. Reference Source Ma C Xi B Li Z : Prevalence and trends in tobacco use among adolescents aged 13–15 years in 143 countries, 1999–2018: findings from the Global Youth Tobacco Surveys. Lancet Child Adolesc. Heal. 2021;5(4):245–255. 33545071 10.1016/S2352-4642(20)30390-4 Nagelhout GE Mons U Allwright S : Prevalence and predictors of smoking in “smoke-free” bars. Findings from the International Tobacco Control (ITC) Europe Surveys. Soc. Sci. Med. 2011;72(10):1643–1651. 21497973 10.1016/j.socscimed.2011.03.018 PMC4565519 Lee Y Lee K-S : Factors Related to Smoking Status Among Young Adults: An Analysis of Younger and Older Young Adults in Korea. J. Prev. Med. Public Health. 2019 Mar;52(2):92–100. 30971075 10.3961/jpmph.18.201 PMC6459759 Kumboyono K Hamid AYS Sahar J : Community response to the initiation of smoking in Indonesian early adolescents: a qualitative study. Int. J. Adolesc. Youth. 2020;25(1):210–220. 10.1080/02673843.2019.1608273 Kandebo SW : Svyset-Declare survey design for dataset. Aviat. Week Sp. Technol (New York). 2004;160(16):32–33. 10.4324/9781003279693-7 Maria DA Glavce CS Turcu S : Adolescents Caught Between the Temptation and the Habit of Smoking Study design. Cureus. 2025;17(4):4–12. 10.7759/cureus.83108 Mak YW Leung D Loke AY : The vulnerability to alcohol, tobacco, and drug use of adolescents in Hong Kong: a phenomenological study. BMC Pediatr. 2019;19:1–12. 10.1186/s12887-019-1678-1 Vrinten C Parnham JC Filippidis FT : Risk factors for adolescent smoking uptake: Analysis of prospective data from the UK Millennium Cohort Study. Tob. Induc. Dis. 2022;20:1–6. 36249346 10.18332/tid/152321 PMC9521183 Martini S Artanti KD Hargono A : Association between percentage of smokers and prevalence of smoking attributable morbidity in Indonesia: one decade after implementation of smoke-free area regulation. BMC Public Health. 2022;22(1):2202. 36443727 10.1186/s12889-022-14435-8 PMC9703741 Reference Source Veeranki SP John RM Ibrahim A : Age of smoking initiation among adolescents in Africa. Int. J. Public Health. 2016;62(1):63–72. 27572496 10.1007/s00038-016-0888-7 Odukoya OO Odeyemi KA : Determinants of Smoking Initiation and Susceptibility to Future Smoking among School-Going Adolescents in Lagos State, Nigeria. Asian Pacific J. Cancer Prev. 2013;14(3):1747–1753. 23679268 10.7314/APJCP.2013.14.3.1747 Kim E Park E Kim H : Sex Differences in Multilevel Factors of Smoking Experimentation and Age of Initiation in Korean Adolescents. J. Sch. Nurs. 2020;36(5):348–359. 30966858 10.1177/1059840519840805 Masood M Masood Y Md Sabri BA : Within-Family Discussion on Harmful Effects of Smoking and Intention to Initiate Smoking Among European Adolescents. J. Addict. Med. 2015;9(4):261–265. 26241085 10.1097/ADM.0000000000000127 Reference Source Nurhasana R Ratih SP Dartanto T : Public support for cigarette price increase in Indonesia. Tob. Control. 2022 May 1;31(3):483–486. 10.1136/tobaccocontrol-2019-055554 Reference Source Singh B Chand SS Chen H : Tobacco smoking initiation among students in Samoa and health concerns. PLoS One. 2021;16(10):e0258669. 34714847 10.1371/journal.pone.0258669 PMC8555831 Kuwabara Y Kinjo A Kim H : Secondhand Smoke Exposure and Smoking Prevalence Among Adolescents. JAMA Netw. Open. 2023 Oct;6(10):e2338166. 37862017 10.1001/jamanetworkopen.2023.38166 PMC10589809 Lagerweij NA Kuipers MAG Schreuders M : The visibility of smoking in Europe and its relationship with youth’s positive beliefs about smoking. Int. J. Public Health. 2019;64(9):1335–1344. 31486855 10.1007/s00038-019-01288-z PMC6868106 Evans WD Renaud J Blitstein J : Prevention Effects of an Anti-Tobacco Brand on Adolescent Smoking Initiation. Soc. Mark. Q. 2007;13(2):2–20. 10.1080/15245000701326368 Choi S Kim Y Lee J : Tobacco use among students aged 13-15 years in South Korea: The 2013 global youth Tobacco survey. J. Prev. Med. Public Health. 2017;50(1):60–65. 28173685 10.3961/jpmph.16.079 PMC5327682 Widyaningsih V Mashuri YA Nugroho SD : Sociodemographic predictors for smoking persistence among young males in Indonesia. J. Public Heal. Dev. 2022;20(3):175–183. 10.55131/jphd/2022/200314 Septiono W Kuipers MAG Ng N : Self-reported exposure of Indonesian adolescents to online and offline tobacco advertising, promotion and sponsorship (TAPS). Tob. Control. 2022 Jan 1;31(1):98–105. 10.1136/tobaccocontrol-2020-056080 Reference Source Carson KV Ameer F Sayehmiri K : Mass media interventions for preventing smoking in young people. Cochrane Database Syst. Rev. 2017 Jun;6(6):CD001006. 28574573 10.1002/14651858.CD001006.pub3 Judd TM Sloane EB Silva RJ : The digital hospital of the 21th century, and information systems management. Iadanza E , editor. Clinical Engineering Handbook. 2nd ed. Academic Press;2020; pp.530–542. 10.1016/B978-0-12-813467-2.00081-X Reference Source Raffetti E Landgren AJ Andersson F : Cortisol Concentration as Predictor of Tobacco Initiation in Adolescents: Results From a Population-Based Swedish Cohort. J. Adolesc. Health. 2021;68(4):758–764. 33039272 10.1016/j.jadohealth.2020.08.012 Chinwong S Saharatchataphong K Kachai C : Knowledge and attitude towards electronic cigarettes among university student smokers in Thailand. Tob. Induc. Dis. 2021;19(1):A102. 10.18332/tid/141040 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 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.

Efendi Ferry Universitas Airlangga, Indonesia

Competing interests: No competing interests were disclosed.

 26 5 2026

Dear Reviewer,

Thank you for your careful review and constructive comments. We have revised the manuscript accordingly and addressed each comment point-by-point below. 

Abstract

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

Respond: Thank you for the comment. We clarified in the Methods section that the GYTS questionnaire was used to collect information on students’ tobacco-related behaviors, exposures, and influencing factors, which served as the variables analyzed in this study.

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

Respond: We revised the sentence in the Results section of the Abstract to improve clarity by breaking it into two shorter sentences.

 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.

Respond: Thank you for the suggestion. We revised the Introduction to improve its structure. The revised section now presents the background, current evidence, research gap, study objective, and potential contribution more concisely.

Paragraph 1 (P1)

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. 

Respond: We have revised Paragraph 1 to make the key message clearer, namely that adolescent smoking initiation remains an important public health concern in Indonesia. The revised paragraph now focuses on the health consequences of tobacco use, the importance of early smoking initiation, and the current magnitude of smoking among adolescents in Indonesia.

Teen smoker’s data could be updated using the latest findings, for example The 2023 Health Survey of Indonesia (SKI 2023)

Respond: We have updated the paragraph using recent evidence from the 2023 Indonesia Health Survey. The revised paragraph now reports that Indonesia has approximately 70 million smokers, with 7.2% of them aged 10–18 years. We also added the distribution of smokers by age group, showing that the highest number of smokers was found among those aged 15–19 years, followed by those aged 10–14 years. This update strengthens the background and provides more current national evidence for the study.

“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.   Respond: We agree that the phrase “marketed without health warnings” did not directly explain accessibility to cigarette products. Therefore, we removed this phrase from the revised paragraph. The revised sentence now focuses on the wide availability and marketing of tobacco-related products, particularly through social media, as contextual factors that may increase adolescents’ exposure to tobacco products.

 P2

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

Respond: Thank you for this helpful comment, we have revised Paragraph 2 to improve the transition from the first paragraph. The revised paragraph now continues from the broader concern of adolescent smoking in Indonesia by further emphasizing the early onset of smoking among children and adolescents, as well as the broader policy and environmental factors that contribute to youth smoking initiation

Please kindly update the references in this paragraph using latest data

Respond: We have updated the paragraph using more recent evidence, including 2023 national data on smoking initiation among children and adolescents. We also added updated policy-related evidence, including the 2025–2029 RPJMN target, to reflect the current national tobacco control context.

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)

Respond: We agree that presenting small percentages alone may not fully convey the magnitude of the problem. Therefore, we revised the paragraph by replacing the previous percentage-based description with absolute numbers. The revised paragraph now reports that 2,060 children aged 4–9 years and 25,000 adolescents aged 10–14 years initiated smoking in 2023. This presentation provides a clearer and more tangible description of the public health concern.

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

Respond: We have revised the paragraph to include the most recent government program period by referring to the RPJMN 2025–2029 target. This update helps situate the study within the current national policy context and highlights the continued importance of strengthening tobacco control efforts, particularly in relation to youth smoking prevention.

 P3

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

Respond: Thank you for this suggestion. We have revised the sentence to improve clarity. The revised paragraph now explains that the age at which an individual begins smoking has a significant impact on smoking habits in adulthood and may also be associated with other risk behaviors, such as substance abuse, school disengagement, sexual risk-taking, and violent conduct.

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

Respond: We have revised the wording by removing the phrase “very significant” and using “significant” instead to make the sentence more appropriate for scientific writing.

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

Respond: We agree with the reviewer’s comment. Therefore, we removed the discussion on the correlation between price and smoking initiation, as price was not included as a variable in this study. The revised paragraph now focuses on factors more directly related to smoking initiation, including age at initiation, family influence, peer pressure, pocket money, access to information, perceived benefits of smoking, and sociodemographic characteristics

 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).

Respond: Thank you for the suggestion. The paragraph has been revised to better align with the Indonesian context and maintain consistency with the preceding discussion.

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. 

Respond: The paragraph has been revised to focus specifically on smoking initiation and to better align the discussion of previous studies with the objective of the present study

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

Respond: We appreciate this suggestion. The statement regarding the study contribution has been repositioned to the final paragraph to improve the flow and structure of the introduction

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.

Respond: The paragraph has been revised to further elaborate the existing evidence in Indonesia, identify limitations of previous studies, and clarify the knowledge gap addressed by the present study

 P5

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

Respond: We appreciate these valuable comments. To improve coherence and avoid redundancy in the introduction, the content of Paragraph 5 has been integrated into Paragraph 4.The statement has been removed to improve coherence and maintain the logical flow of the introduction

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

Respond: The repetitive statement regarding the study urgency has been removed to avoid redundancy

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. 

Respon: The revised section now provides a clearer explanation of previous evidence in Indonesia, the existing knowledge gap, and the added value of focusing specifically on smoking initiation among adolescents using nationally representative data

 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.

Respond: Thank you for pointing out this inconsistency. We have clarified that this study used only one wave of data, namely the 2019 Indonesia Global Youth Tobacco Survey. The Abstract and Methods sections have been revised accordingly to ensure consistency and avoid confusion

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

Respond: We have revised the Research Design section to clarify that the Global Youth Tobacco Survey is a school-based survey and part of the Global Tobacco Surveillance System. We also added information on the standardized survey design and national representativeness of the 2019 Indonesia GYTS, which helps readers interpret the validity and generalizability of the findings.

 Population and sample

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

Respond: Thank you for pointing this out. We have removed the redundant sentence in the Population and Sample section to avoid repetition and improve clarity. The remaining text now provides a concise description of the study population without duplication

 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

Respond: We removed the Data Collection section and created a new section titled Variables, as suggested.

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

Respond: The redundant explanation that independent variables were derived from GYTS questions has been deleted.

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.

Respond: For secondhand smoke exposure, we clarified that the variable was categorized into five groups: 0 days, 1–2 days, 3–4 days, 5–6 days, 7 days. This decision was based on sample size limitations and consistency with previous GYTS-based studies, though we also acknowledge it as a limitation in reflecting more nuanced exposure levels

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

Respond: We added detailed explanations of the grouping for other variables, including anti-tobacco messages, peer influence, and teacher/parent smoking, to ensure transparency

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

Respond: Regarding age, we elaborated that it was grouped into <13 years, 13–15 years, and >15 years, consistent with standard GYTS reporting. We acknowledged this categorization as a methodological consideration commonly used in GYTS analyses

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

Respond: We clarified how gender, age, pocket money, behavioral factors, and potential confounders were coded and treated in the analysis

“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. 

Respond: We removed the unnecessary statement about moving variable categorization from Results to Methods

“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?

Respond: The unclear statement on recoding has been rephrased

 Data analysis

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

Respond: Thank you for this valuable comment. We have clarified the number of survey waves included in our analysis. Specifically, the study used data from  2019 of the Global Youth Tobacco Survey (GYTS). This information has been explicitly stated in the revised manuscript (Methods – Data Analysis section)

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

Respond: We appreciate this observation. To avoid redundancy, we have streamlined the section by retaining the key point in the concluding 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

Respond: Thank you for highlighting this important point. We agree that additional ethical approval is not required for this study since it relies on anonymized secondary data from GYTS. To avoid any potential confusion, we have revised the section accordingly and removed references to the original GYTS ethical procedures.

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

Respond: Thank you for pointing this out. We have now moved the description of pocket money categorization into the  Methods section to ensure consistency with how age was reported

Please be consistent using the Rupiahs or USD

Respond: We appreciate this suggestion. To maintain consistency and readability for an international audience, we have revised all monetary values into  United States Dollar (USD) and provided the conversion rate at first mention in the  Methods section.

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

Respond: Thank you for this important clarification. We agree that the term “peer smoking” may be misleading. We have revised the terminology for accuracy and provided a clear operational definition in the  Methods section. Specifically, we replaced “peer smoking” with  “friends’ cigarette offers” to better reflect the survey question and avoid confusion with actual peer tobacco use prevalence

 Discussion

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

Respond: Thank you for this valuable suggestion. We have revised the Discussion section to provide a clearer and more in-depth interpretation of the findings. We also improved the writing quality by correcting grammatical errors, reducing repetitive statements, and making the sentences more concise and coherent throughout the section

P1

Please update the data with the latest

Respond: We appreciate this suggestion. We have updated the introduction of the discussion with the most recent available data.This ensures that our discussion is framed within the current global and national context of tobacco use among adolescents

Second sentence is unclear

Respond: Thank you for highlighting this. We have revised the second sentence to make the intended meaning clearer.

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

Respond: We agree with this observation. We have rewritten the first paragraph of the discussion so that it clearly summarizes the key results before expanding into interpretation

 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. 

Respond: Thank you for pointing this out. We agree that the original sentence may have been misleading and not fully aligned with the cited reference. We have revised the statement to more accurately reflect the literature, emphasizing developmental transitions rather than “problems

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. 

Respond: We appreciate this insightful feedback. We have revised the paragraph to ensure a logical connection between the finding (higher age associated with smoking) and its interpretation. The previous discussion on family communication has been removed, as it was not directly supported by the data. Instead, we now emphasize the importance of age-appropriate preventive interventions

 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. 

Respond: Thank you for this observation. We revised the sentence to avoid misleading causality and to elaborate further

Please update the data with the latest

Respond: We have updated the prevalence figures using the most recent national and WHO reports

“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

Respond: Thank you for this valuable comment. We agree that recommendations should align with the study findings. Accordingly, we have revised the statement to emphasize prioritizing adolescent boys, who showed a higher likelihood of smoking initiation, while maintaining inclusive prevention efforts for all adolescents to ensure broad public health impact. This revision improves the consistency between our results and recommendations

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

Respond: Thank you for this helpful suggestion. We have revised the manuscript by presenting the findings on pocket money in a separate paragraph to improve clarity and readability

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

Respond: We agree that the sentence was unclear and we have removed it to improve clarity and coherence of the discussion

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

Respond: We have revised the sentence to clearly present the findings from the Canadian 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

Respond: We agree that the sentence was repetitive and have removed it to improve conciseness and avoid redundancy in the discussion

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

Respond: We have revised the sentence to better align the policy discussion with the role of pocket money by explicitly linking cigarette affordability and retail availability to adolescents’ purchasing capacity

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

Respond: We have reviewed and updated the policy reference accordingly by incorporating Government Regulation No. 28/2024 to ensure accuracy and relevance

 P4

Some basic writing errors. Please kindly check

Respond: We appreciate this observation. The paragraph has been checked and the basic writing errors have been corrected

“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.

Respond:Thank you for this comment. The sentence has been revised and rephrased to improve clarity

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

Respond:We appreciate the reviewer’s note. The sentence has been removed to avoid redundancy and improve the conciseness of the discussion

“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?

Respond:We appreciate this insightful comment. We have revised the text by adding a brief explanation supported by literature to clarify the role of visibility and social normalization in outdoor 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. 

Respond:We have revised the manuscript to provide a more comprehensive discussion of smoke-free area policies in Indonesia by incorporating broader systemic challenges beyond enforcement, including governance complexity, decentralization, and policy inconsistencies

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?

Respond: We appreciate this comment. We have revised the statement to better align the role of community nurses with the study findings by emphasizing their contribution to reducing adolescents’ exposure to smoking and secondhand smoke, which is associated with smoking initiation

 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.

Respond: We appreciate this important observation. We have revised the statement to better reflect the broader media environment in Indonesia by acknowledging the widespread presence of tobacco-related content, including advertising and promotion, and its potential influence on adolescent smoking initiation

“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

Respond:We appreciate this insightful comment. We have revised the paragraph to improve clarity and ensure alignment with our findings by linking the discussion on media platforms to the role of media exposure in smoking initiation

 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. 

Repond:We appreciate this suggestion. The paragraphs have been combined into a single section to improve coherence and reduce redundancy

“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.

Respond: We acknowledge this point. The statement has been removed to ensure the paragraph remains focused on parental smoking and to enhance overall coherence

 P7

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

Respond: We have revised the sentence to clarify the relevance of this statement to our findings by explicitly explaining the role of teachers as social models and how their smoking behavior may influence adolescents’ smoking initiation

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?

Respond: Thank you for the suggestion. We have revised the manuscript to include a discussion on the implementation of smoke-free area policies in schools, highlighting gaps in enforcement as reflected by teacher smoking within school environments

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.

Respond: The manuscript has been updated to address the influence of adult smoking on adolescents and to highlight the importance of improving access to smoking cessation services for adults

 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

Respond: We have revised the recommendation to include peer group support and access to youth-friendly smoking cessation services as additional strategies to prevent smoking initiation among adolescents.

 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.

Respond: The statement has been revised to focus specifically on preventing smoking initiation among adolescents, in line with the scope of this study

“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

Respond: This point is well taken. The statement has been revised to broaden the implications to both adolescents and the general population, taking into account the continuity of smoking behavior from early initiation into adulthood

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