Prevalence and trend of smokeless tobacco use and its associated factors among adolescents aged 12–16 years in 138 countries/territories, 1999–2019

In this study, the prevalence of current smokeless tobacco use was 4.4% among adolescents aged 12–16 years based on the latest data from 138 countries in 2010–2019. The prevalence was higher among boys than girls, among adolescents aged 15–16 years than those aged 12–14 years, and highest in the South-East Asian region but lowest in the Western Pacific region. Although the prevalence of smokeless tobacco use decreased in 57 of 100 countries, the prevalence increased or remained unchanged in 43 countries. Cigarette smoking, other tobacco product use, tobacco advertisement exposure, being offered free tobacco products, and not being taught about dangers of smoking were positively associated with smokeless tobacco use among adolescents.

The prevalence of current smokeless tobacco use varied largely between countries and WHO regions, with the lowest in Tokelau (0.0%) and highest in Kiribati (51.6%), and the lowest in the Western Pacific region (2.0%) and highest in the South-East Asian region (6.1%). However, Cahn et al. found that the prevalence of current smokeless tobacco use among youth aged 13–15 years was lowest in the European region (2.0%) and highest in the African region (7.45%) based on the GYTS data from 2007 to 2016 [8], which is different from our finding. It has been shown that smokeless tobacco is the dominant form of tobacco consumption in South-East Asia where over 80% of smokeless tobacco users live [6, 31]. The high social acceptance, low price, and easy availability make smokeless tobacco accessible and affordable among adolescents in this region [19]. The Western Pacific region is the only WHO region to achieve a 100% ratification rate for the FCTC [19] and most countries in this region have banned smokeless tobacco products [10], which may account for the low prevalence in this region. Our findings highlight the importance of strengthening implementation policy on smokeless tobacco control, especially in countries from the South-East Asian region.

Among 100 included countries, the prevalence of current smokeless tobacco use decreased in 57 and increased or leveled off in 43 countries from 1999 to 2019. We also found that the greatest decrease was observed in Timor-Leste (absolute change/5 years was − 42.9%) and the greatest increase was in Zimbabwe (21.8%). Our understanding is that no previous study has assessed the global secular trend of smokeless tobacco use among adolescents. In our study, the decreased trend in most countries might reflect the transition from using traditional tobacco products to using emerging tobacco products such as e-cigarettes and hookah [2,3,4], and effective implementation of smokeless tobacco control strategies and measures in those countries [21]. However, there were still 43 countries showing an increased or unchanged trend in the prevalence of smokeless tobacco use. This might be due to cigarette product restriction in some countries that shifts adolescents toward smokeless tobacco as an alternative for nicotine dependence [1]. Other factors might include sale of smokeless tobacco products to minors [20], weak enforcement and regulation, management difficulties in diverse products, marketing and sponsoring, lower taxes and prices, and deep-rooted social acceptance [9, 19, 21]. These findings suggest that demand-reduction measures for smokeless tobacco are necessary in countries with static or increased prevalence, such as bans on sale to minors, tax or price increases, pictorial warnings on packaging, and tailor-made education [20].

We found the prevalence of smokeless tobacco use was nearly five times as high among cigarette smokers and nearly seven times as high among other tobacco product users compared with their counterparts. Although our cross-sectional design limits our ability to draw causal inference from our findings, previous studies have found an increased likelihood of cigarette smoking and multiple tobacco use among exclusive smokeless tobacco users, but switching from smoke products to only smokeless tobacco use was less investigated [25, 26]. In addition, adolescents who used multiple tobacco products at the same time had a higher likelihood of developing nicotine addiction and continuing to use tobacco during adulthood [11, 16]. These findings highlight that timely prevention or intervention of smokeless tobacco use at an early age likely has important public health implications for reducing the prevalence of multiple tobacco use.

Adolescents exposed to tobacco-related advertising and sponsorship were more likely to start using smokeless tobacco. According to Article 13 Guidelines of the FCTC, all forms of tobacco advertising, promotion, and sponsorship should be prohibited. Despite the early achievements by some countries since implementing these proposals, more effort is needed to reduce tobacco-related marketing exposure among adolescents [20]. Notably, adolescents who had been taught about dangers of smoking in class were less likely to use smokeless tobacco, which underlines the importance of anti-tobacco activities that disseminate information about dangers of smoking to prevent youth smoking [32]. The prevalence among adolescents was higher in low- and lower-middle-income countries, which was shown previously [18]. This might be a result of smokeless tobacco products being more readily available and affordable to adolescents, and limited resources invested in smokeless tobacco control, in these countries [18]. The aforementioned findings highlight the importance of banning tobacco advertising and creating a smoke-free environment to protect youth — with more attention needed to address smokeless tobacco use among youth in low and lower-middle-income countries.

Strengths of this study were the use of the latest global data to assess the prevalence of smokeless tobacco use among adolescents and we are the first to determine secular trends in the prevalence. Moreover, data were from the global surveillance instrument with the same sampling frame and standardized questions, which allow direct comparisons across countries. However, several limitations should be considered. First, information on smokeless tobacco use was self-reported, and recall bias might influence the results. However, a previous study reported a good test-retest reliability of the GYTS questionnaire [33]. Second, the GYTS data do not provide information on smokeless tobacco use by different types, which should be considered in future surveys. Third, current smokeless tobacco use was defined based on response to whether or not the participants used smokeless tobacco products during the past 30 days, rather than based on the use intensity or frequency, making it difficult to distinguish between experimental and regular users. Fourth, as our study only included adolescents aged 12–16 years in school, our findings might have limited generalizability to adolescents of other age groups and those out of school. Fifth, the regional generalizability of the results was limited given that in some regions, such as Europe, data were missing for a great number of countries that might influence the findings. Sixth, we used data from a wide range of survey years (2010–2019) to estimate the prevalence of current smokeless tobacco use, which might influence the pooled prevalence. However, 81.2% (112/138) of included countries conducted the surveys in 2013–2018. The pooled prevalence based on 112 countries in 2013–2018 was 4.5% (95% CI 3.9–5.1), which was largely similar to the pooled prevalence based on 138 countries in 2010–2019 (4.4%, 95% CI 4.0–4.9). Seventh, only 100 out of 138 countries provided sufficient data for a trend analysis between 1999 and 2018. Eighth, no causal inference can be made between associated factors and smokeless tobacco use due to the cross-sectional design.

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