INTRODUCTION

Tobacco use poses a serious threat to public health. According to the World Health Organization (WHO), it causes over 8 million deaths globally each year¹. For this reason, tobacco control has been established as a specific target within the Sustainable Development Goals – specifically Goal 3, ‘Good health and well-being’ – and is considered a global development priority². Although the global smoking rate among people aged over 15 years declined from 22.7% in 2007 to 17.5% in 2019, according to recent WHO reports, it remains a significant concern³. In Latin America and the Caribbean (LAC), 70% of smokers begin smoking before the age of 18 years⁴. This is particularly relevant in adolescents, who are more vulnerable to peer pressure and experimentation, and for whom early tobacco use can impair lung growth and brain development, increase susceptibility to respiratory diseases and reduce physical performance and endurance^5,6. This underscores the need for effective prevention strategies.

Several studies have identified factors associated with cigarette use^7-9. Psychological risk factors include depression, anxiety, poor academic performance, feelings of rejection, and underdeveloped social skills⁷. At the family level, risk factors include low emotional attachment, overprotective or rigid parenting, and poor communication⁷. Parental absence, limited involvement in family decisions, and frequent conflict have also been implicated⁹. The family environment is therefore critical to early smoking initiation^7-9. Empirical evidence from the region supports these mechanisms. A study in Chile found that adolescents exposed to smokers at home were up to 70% more likely to experiment with tobacco⁸, while, in Cuba, those with family members who smoke were about twice as likely to have ever smoked¹⁰. This vulnerability is further amplified in permissive households, where low risk perception and the normalization of smoking promote earlier tobacco experimentation¹¹. Given that youth smoking remains a persistent public health problem, with rates reaching up to 20% in some countries in the region, further research and evidence-informed approaches that consider the family unit are needed to guide future prevention efforts¹².

Consistent with these regional findings, global evidence also highlights the strong influence of household smoking behavior on adolescent tobacco consumption. A meta-analysis of 58 studies confirmed that parental and sibling smoking significantly increase the risk of smoking uptake among adolescents¹³. Despite this, there is limited evidence exploring the association between exposure to tobacco smoke at home and smoking intentions among never-smoking adolescents in LAC. The Global Youth Tobacco Survey (GYTS)¹⁴ applied in several countries across the region, offers data on household exposure and smoking intentions in adolescents, creating an opportunity to examine this association in greater depth. The GYTS is a school-based survey with an internationally standardized methodology targeting adolescents aged 13–15 years, with the objective of monitoring tobacco use and assessing related attitudes, knowledge, and behaviors¹⁴.

This study aims to examine the association between exposure to tobacco smoke at home and the intention to smoke among never-smoking adolescents in LAC. We aim to understand how the family environment shapes perceptions and attitudes toward tobacco use in this vulnerable population. The findings may contribute to the existing evidence base and support future efforts to design context-appropriate strategies to prevent early tobacco initiation and its long-term health consequences.

METHODS

Participants

The Global Youth Tobacco Survey included all secondary students present in the selected classrooms who provided informed consent¹⁴. After applying the eligibility criteria and excluding records with missing data on key variables, the final analytical sample comprised 36662 adolescents from 27 Latin American and Caribbean countries (Figure 1).

Figure 1

Flowchart of the selection of adolescents aged 13–15 years included in the study, a cross-sectional analysis of the Global Youth Tobacco Survey (GYTS), Latin America and the Caribbean, 2013-2021 (N=36662)

RESULTS

We analyzed data from 36662 adolescents across 27 Latin American and Caribbean (LAC) countries. Of the total sample, 53.4% were female and 46.6% were male. The age distribution was as follows: 36.5% were aged 13 years, 36.7% were 14 years, and 26.8% were 15 years. Overall, 18.5% of adolescents reported exposure to tobacco smoke in their homes. In addition, 13.0% expressed an intention to smoke in the future (Table 1).

The prevalence of smoking intention was highest among male adolescents (14.1%). It increased with age, reaching 15.7% among those aged 15 years, 12.5% those aged 14 years, and 11.5% those aged 13 years. Adolescents not exposed to household tobacco smoke reported a slightly higher prevalence of smoking intention (13.2%) than those who were exposed (12.2%) (Table 2).

The overall prevalence of household exposure to tobacco smoke was 18.5%. Some countries reported relatively low rates, including Peru (7.1%) and Honduras (9.0%), while others showed higher levels, particularly Uruguay (28.9%), Suriname (28.2%), and Chile (27.9%) (Figure 2).

Figure 2

Prevalence of exposure to secondhand smoke at home among adolescents aged 13–15 years, by country, a cross-sectional analysis of the Global Youth Tobacco Survey (GYTS), Latin America and the Caribbean, 2013-2021 (N=36662)

The prevalence of smoking intention among adolescents in the 27 countries varies widely, with a global average of 13.02%. Costa Rica reported the lowest prevalence (4.5%; 95% CI: 3.2–6.3), while El Salvador exhibited the highest rate (40.3%; 95% CI: 36.1–44.8) (Figure 3).

Figure 3

Prevalence of smoking intention among adolescents aged 13–15 years, by country, a cross-sectional analysis of the Global Youth Tobacco Survey (GYTS), Latin America and the Caribbean, 2013-2021 (N=36662)

In the analysis of the association between household exposure to tobacco smoke and smoking intention among adolescents from 26 LAC countries, no statistically significant association was identified (APR=0.91; 95% CI: 0.69–1.19; p=0.487). However, a significant association was observed in Chile (APR=1.78; 95% CI: 1.33–2.37; p<0.001), Barbados (APR=1.98; 95% CI: 1.16–3.40; p=0.014), the Dominican Republic (APR=1.96; 95% CI: 1.21–3.17; p=0.010), Saint Lucia (APR=1.82; 95% CI: 1.05–3.18; p=0.035), Panama (APR=1.58; 95% CI: 1.12–2.23; p=0.012), and Uruguay (APR=1.77; 95% CI: 1.27–2.46; p=0.002). In these countries, exposure to tobacco smoke at home was significantly associated with a higher intention to smoke among adolescents (Table 3).

DISCUSSION

This study assessed the association between household tobacco smoke exposure and smoking intention among never smokers in Latin American and Caribbean countries. Although no significant association was found at the regional level, country-specific analyses showed a relationship in Chile, Barbados, the Dominican Republic, Saint Lucia, Panama, and Uruguay, suggesting that the influence of the home environment varies according to sociocultural factors, regulations, and smoking patterns.

All countries analyzed have ratified the WHO Framework Convention on Tobacco Control (FCTC), which establishes the MPOWER package (monitoring, protection, cessation support, warnings, advertising bans, and tax increases)^16,17. However, uneven implementation could explain part of the observed heterogeneity. Progress has been stronger in the non-Spanish-speaking Caribbean, South America, and North America, but weaker in Central America and the Spanish-speaking Caribbean¹⁷.

Uruguay illustrates these gaps: 10% of adolescents aged 13–15 years smoke, 41.5% report exposure in enclosed public places¹⁸, and 52.6% of those who bought cigarettes access loose cigarettes, an illegal practice in the country¹⁹. Nearly half see tobacco advertisements at points of sale, and most are exposed through media¹⁸. These figures highlight deficiencies in protection, advertising bans, and access control. Countries such as the United Kingdom and France have strengthened protection through laws banning smoking in vehicles with minors, demonstrating that targeted regulations in private settings can complement public smoke-free laws^20,21.

In Barbados, weak enforcement of tobacco control policies, including weak advertising bans with unknown levels of compliance, has likely contributed to the continued normalization of smoking and the persistence of relatively high youth smoking rates, despite the country’s ratification of the FCTC²². In contrast, Mexico has integrated tobacco control into public health and child protection strategies through national campaigns and legal restrictions that promote smoke-free environments, including homes, thereby reinforcing norms that protect minors from tobacco exposure²³.

Peru and Honduras reported the lowest household exposure, reflecting progress linked to national tobacco control policies^24-28. In Peru, this decline coincides with the progressive enforcement of Law No. 28705 and its amendments, including stricter smoke-free regulations, advertising bans, and health warnings, as well as awareness campaigns on secondhand smoke harms^24-26. In Honduras, reforms introduced through Decree No. 12-2011 and the Special Law for Tobacco Control strengthened restrictions on smoking in enclosed public spaces, advertising prohibitions, and sales limitations to minors^27,28. The country also achieved a high MPOWER score in 2023, indicating broad population protection through smoke-free regulations²⁹. In contrast, Chile, Suriname, and Uruguay had the highest exposure, despite ratifying the FCTC, pointing to enforcement gaps^18,30. While over 100 countries have implemented at least one MPOWER measure at the highest level, only Brazil and Turkey have achieved full compliance³¹. Marketing tactics, including appealing packaging and point-of-sale visibility, continue to affect adolescents despite legal restrictions^32,33. Taxation also varies across the region, with high-tax countries not necessarily showing lower exposure due to illicit sales and single-cigarette availability³⁴.

The intention to smoke among adolescents in El Salvador (40.3%) is substantially higher than in Costa Rica (4.5%), reflecting a considerable disparity in the predisposition to tobacco use. In El Salvador, most adolescent smokers consume an average of less than one cigarette per day, and over 70% start before the age of 14 years, indicating early initiation as a key driver³⁵. In contrast, in Costa Rica, shows lower smoking intention, likely linked to stronger family and school-based prevention efforts: most adolescents discuss smoking risks at home, and over half receive information on tobacco harms at school, which may contribute to delaying or preventing initiation³⁶.

The observed association between household exposure to tobacco smoke and smoking intention in certain LAC countries reinforces the notion that the family environment plays a decisive role in shaping adolescents’ attitudes and behaviors toward tobacco use. Exposure at home may influence smoking intention through social and psychological mechanisms such as modeling, normalization, and reduced risk perception. Adolescents who frequently witness smoking within the household are more likely to perceive it as acceptable and develop curiosity or positive expectancies toward tobacco use^8,10,11,13. In addition, permissive family dynamics, marked by limited communication, inconsistent supervision, and low perceived harm, may increase susceptibility to experimentation^10,11. These findings highlight the importance of the home as a key setting for prevention and underscore the need for further research to confirm these mechanisms and inform evidence-based public policies.

CONCLUSIONS

At the regional level, no statistically significant relationship was identified between exposure to tobacco smoke at home and the intention to smoke among adolescents from LAC. However, country-specific analysis showed this relationship in Chile, Barbados, the Dominican Republic, Saint Lucia, Panama, and Uruguay. This suggests that the influence of the family environment on tobacco initiation is not homogeneous across the region and may be shaped by sociocultural factors, local regulations, and household consumption patterns. Longitudinal studies are recommended to assess directionality and explore modulating contextual factors. Confounding variables not included in this analysis should be considered. These findings may help inform future research and support the design of context-sensitive strategies to reduce adolescent exposure to tobacco smoke, while acknowledging that evidence from cross-sectional studies is insufficient to establish causal relationships.