INTRODUCTION
Tobacco use remains a paramount concern in the realm of global public health1,2, contributing to over 8 million deaths annually worldwide3. Of these, more than 7 million are directly attributable to tobacco use, while approximately 1.3 million deaths result from exposure to secondhand smoke4. In 2020, 22.3% of the global population consumed tobacco, including 36.7% of males and 7.8% of females5. Approximately 80% of the world’s 1.3 billion tobacco users reside in low- and middle-income countries3. In South-East Asia, around 4.1 million deaths occur annually due to tobacco use6. As per the WHO-STEPS Survey (2019) conducted by Nepal Health Research Council (NHRC), 3.8 million adults or currently, 28.9% of adults aged 15–69 years used smoked or smokeless tobacco products7. Tobacco products can be consumed through various forms such as smoking, chewing, snuffing, and ingestion8,9. In Nepal, tobacco is used in both smoked and smokeless forms, especially in the Terai region, where bidis, cigarettes, hookahs, and chillums, along with smokeless tobacco products like khaini, gutkha, and zarda are prevalent10. It is a leading risk factor for non-communicable diseases (NCDs), such as coronary heart disease, stroke, chronic obstructive pulmonary disease (COPD), lung cancer and cardiovascular disease (CVD)-related fatalities1,10,11. Annually, 27100 premature deaths are attributed to tobacco-related diseases in Nepal12.
As per the World Health Organization (WHO)13, adolescents are the individuals within the age group of 10–19 years. In Nepal, adolescents constitute 20.15% of the total population, with 9.98% in the age group of 10–14 years and 10.17% in the age group of 15–19 years14. The global data set indicates that at least 38 million adolescents (25 million boys and 13 million girls) aged 13–15 years are current users of some form of tobacco5. Moreover, globally, at least 1 in 10 adolescents aged 13–15 years uses tobacco15. In 2024, 19.0% of US middle and high school students (5.28 million students) in which 1 of every 19 middle school students (5.4%) and 1 of every 10 high school students (10.1%) reported ever having used any tobacco product16. The South-East Asia Region leads with 11 million adolescent tobacco users aged 13–15 years, or 30% of the global total17. More than 19 million adolescent tobacco users, or 51% of the global total, reside in lower middle-income countries17. On average, nearly 10% of adolescents globally, 13% of boys and 7% of girls aged 13–15 years use one or more types of tobacco products17. The vast majority of people using tobacco today began doing so when they were adolescents.
Tobacco use remains a significant public health issue among adolescents in Nepal, with prevalence showing a rising trend over the years and across the regions. Early studies reported prevalence of current users of tobacco was 10.2% of adolescents (cigarette smoking: 9.4%, smokeless products: 6.5%, and both forms: 5.7%) in western Nepal18, 19.7% in Dharan19, 25.3% in Kalaiya (boys 31% and girls 14.4%)20. In Birgunj, it was 15.6%21. Subsequent studies highlighted rates of 19.6% in Kaski22, in Nawalpur, tobacco use prevalence was 11.6%23, while in Kalimati, Kathmandu 15–20% of higher secondary students used tobacco9, 22.8% in Syangja district24, and 31.7% in Budhanilkantha25. More recently, the prevalence reached 20.6% in Tokha Municipality, Kathmandu, Nepal26, and 23.3% in Jumla, with higher rates among males (31.9%) compared to females (7.2%)27. Additionally, WHO-STEPS Survey, 2019 by the NHRC reported a national prevalence of 28.9%7. These figures underscore the growing burden of tobacco use among adolescents.
Although countries like Bangladesh, Nepal, Bhutan, and Sri Lanka have tobacco control laws and policies, tobacco consumption among youth remains prevalent, and the issue is growing28. Moreover, as per the tobacco control Act in 2011, the use of tobacco products is banned in public places, and the purchase is restricted for individuals under 18 years in Nepal28. Despite the implementation of tobacco control laws and policies, there has been no notable decrease in tobacco users between 2013 and 2019 in Nepal7. There is rising prevalence of tobacco use among adolescents worldwide, including in Nepal3. Furthermore, the various studies conducted over the years and across the regions also revealed a rising trend of prevalence of tobacco use among adolescents in Nepal from 10.2% to 31.7%18,25. Teenagers make snap decisions and engage in risk-taking behaviors such as using tobacco, abusing drugs, being violent, having sex beginning from middle adolescence (aged 14–15 years) and onwards29. Additionally, late adolescents were more likely to use tobacco than those in early and middle adolescence, as this period is often associated with increased susceptibility to risk-taking behaviors19,30. This study therefore focused on the specific age groups of late adolescents (15–19 years). Even though numerous students from various terai and hilly regions are enrolled in grades 11 and 12 of various schools and colleges in Nepalgunj submetropolitan city, no specific study on tobacco use has been done in Nepalgunj to date. Thus, this study has attempted to explore the prevalence of tobacco use and the factors associated with adolescent secondary school students in Nepalgunj, Banke District, Nepal.
METHODS
Study design, area, population and sample
A school-based cross-sectional study was conducted in Nepalgunj, Banke District, Nepal, located in Lumbini Province, from April to May 2023. According to the records of the Education Development and Coordination Unit, Banke (2024), Nepalgunj comprises a total of 24 secondary schools (grades 1–12), including 7 government schools and 17 private schools. The target population consisted of all adolescents enrolled in grades 11 and 12 in these secondary schools. Two government schools and two private schools were selected using convenience sampling. Moreover, as indicated by the list of students available from the school administration, the sampling unit comprised students in the late-adolescence age groups (16–17 years) and (18–19 years) enrolled in grades 11 and 12 in these schools. Subsequently, simple random sampling was employed to recruit adolescent students from the selected schools and were approached with a self-administered structured questionnaire adapted from the Global Youth Tobacco Survey (GYTS) for data collection (Supplementary file). The sample size was estimated using the formula31:
where Z = 1.96 at 95% confidence interval (CI). From a similar study in Dharan, Eastern Nepal conducted among adolescents, prevalence of ever use of any tobacco product was 19.7%18, so we set p=0.197 and the margin of error (e) at 5%. This gave n=243, but assuming a non-respondent rate of 5%, the final sample size was 256.
A total of 256 questionnaires were thus distributed to students in four selected schools and 252 questionnaires were filled in and submitted to the investigator, but four students did not submit a questionnaire. Among 252 responses, two questionnaires were partly filled in; thus, they were excluded. Finally, for a greater representation of the targeted population in our study, we included a total of 250 adolescent students in the analysis, comprising 106 from government schools and 144 from private schools.
Variables
Tobacco ever use was taken as the dependent variable. Ever user was regarded an adolescent who had used any form of tobacco (either smoked or chewed) at least once up to the data collection time. A never user was an adolescent who had never used any form of tobacco. Explanatory variables considered (factors associated with tobacco ever use) were: age, gender, type of school, grade, ethnicity, religion, type of family, living status (living alone, with friends, or family), father’s education level, mother’s education level, father’s occupation, mother’s occupation, knowledge regarding the adverse effects of tobacco, personal use of tobacco and by others (father, mother, other family members, friends).
Statistical analysis
Th collected raw data were initially assessed to ensure completeness and consistency. Subsequently, the data were coded, entered, and analyzed using the Statistical Package for Social Science (SPSS version 23.0). Frequencies and percentages were employed for descriptive statistics. Initially, for categorical variables, bivariate analyses using chi-squared (χ²) test or Fisher’s exact test, as appropriate, were conducted to examine the association between the dependent variable (tobacco ever use: ‘no’=0 and ‘yes’=1) and each explanatory variable. These analyses identified significant variables for potential inclusion in a binary logistic regression model. The results are reported as odds ratios (ORs) with corresponding 95% confidence interval (CI). The goodness of fit for the binary logistic regression model was evaluated using the Hosmer-Lemeshow test32. A small discrepancy between the predicted and observed values, for the Pearson’s chi-squared value with a high p-value (>0.05) suggests that the model is well-fitted to the data. Similarly, for the test of model adequacy, log likelihood ratio test (LRT), Omnibus test, and the Nagelkerke R2 test were employed with 5% level of significance33. The Omnibus test was applied to assess the overall significance of the model (more details in the Supplementary file). If p<0.05, the overall model coefficients were considered significant at the 5% level. The Nagelkerke R2 was computed to assess the proportion of variation in the dependent variable explained by the independent variables33. The iterated weighted least square method was implemented to solve maximum likelihood equations32. Variance inflation factors (VIFs) were used to determine whether acceptable multicollinearity exists between the explanatory variables.
RESULTS
Table 1 presents the sociodemographic characteristics of the respondents. Among the 250 students included in the study, the majority 90 (30.4%) were aged 18 years. Of the total respondents, 144 (57.5%) attended private schools, while 106 (42.4%) were enrolled in government schools. The participants comprised nearly equal numbers of males (50.8%) and females (49.2%). Of the respondents, 131 (52.4%) were in grade 12 and 119 (47.6) in grade 11. Only 2.8% were Muslims, and 90.4% were Hindus. Brahman/Chhetri accounted for 126 (50.4%) of the total respondents; 34 (53.6%) of the respondents were part of a joint family, and 176 (70.4%) of the respondents lived with family. The fathers of 222 (88.8%) of respondents were literate, while the mothers of 61.6% of respondents were literate. In terms of occupation, half of the respondents’ mothers 125 (50.0%) were housemakers, while 81 (32.4%) of the respondents’ fathers were employed in agriculture.
Table 1
Sociodemographic characteristics of adolescent students in Nepalgunj sub-metropolitan city, Banke, Nepal, April – May 2023 (N=250)
Prevalence of ever use of tobacco
The prevalence of ever used tobacco among the adolescents was 103 (41.2%). Among the various tobacco products, 40 adolescents (38.8%) reported using pan masala, gutkha or parag, 37 (35.9%) used cigarettes or bidis, and 9 (8.7%) consumed other tobacco products such as surti or khaini.
Table 2 shows that nearly half of the respondents 48 (46.6%) were former tobacco users, 11 (10.7%) were regular users, and 10 (9.7%) were experimental users. Among the adolescents who used tobacco, 51 (49.5%) got their products from friends. More than three-fourths of respondents, 84 (81.5%), were not denied tobacco sales by the shopkeepers due to their age. Furthermore, the desire for experience led 56 (54.4%) adolescents to use tobacco products. Similarly, 23 (22.3%) were influenced by peer pressure, while only 3.9% used tobacco for enjoyment. The results also indicate that 82 (79.6%) of tobacco users attempted to quit. The vast majority of respondents 244 (97.6%) were aware of the negative consequences of tobacco use, while only 2.4% were unaware of them.
Table 2
Tobacco consumption by adolescent students in Nepalgunj sub-metropolitan city, Banke, Nepal, April – May 2023 (N=250)
Bivariate analysis
Table 3 demonstrates that gender and age (p<0.01) are statistically significantly related in to ever using tobacco, as are the type of school and grade (p<0.05). Education level and occupation of parents show no association with ever use of tobacco among adolescent students (p>0.05). Additionally, the adverse effects of tobacco use are significantly linked to the ever use of tobacco among adolescent students. Furthermore, tobacco use by the father, or other family members (excluding the mother), or by friends, has a significant association with adolescents’ tobacco use (p<0.01).
Table 3
Association between sociodemographic characteristics and ever use of tobacco among adolescent students in Nepalgunj sub-metropolitan city, Banke, Nepal, April – May 2023 (N=250)
| Variables | Ever use of tobacco | Pearson chi-squared or Fisher’s exact test value (p-value) | |
|---|---|---|---|
| Yes n (%) | No n (%) | ||
| Gender | |||
| Male | 73 (57.5) | 54 (42.5) | 28.24 (0.00**) |
| Female | 30 (24.4) | 93 (75.6) | |
| Age (years) | |||
| 16–17 | 35 (29.2) | 85 (70.8) | 13.79 (0.00**) |
| 18–19 | 68 (52.3) | 62 (47.7) | |
| Religion | |||
| Hindu | 94 (41.6) | 132 (58.4) | 0.96 (0.811) |
| Muslim | 2 (28.6) | 5 (71.4) | |
| Buddhist | 4 (50.0) | 4 (50.0) | |
| Christian | 3 (33.3) | 6 (66.7) | |
| Ethnicity | |||
| Brahmin/Chhetri | 50 (39.7) | 76 (60.3) | 1.24 (0.871) |
| Janajati | 19 (41.3) | 27 (58.7) | |
| Madhesi | 22 (47.8) | 24 (52.2) | |
| Dalit | 9 (36.0) | 16 (64.0) | |
| Other | 3 (42.9) | 4 (57.1) | |
| Type of family | |||
| Nuclear | 44 (37.9) | 72 (62.1) | 0.95 (0.329) |
| Joint | 59 (44.0) | 75 (56.0) | |
| Living status | |||
| Alone | 18 (51.4) | 17 (48.6) | 1.80 (0.406) |
| With friends | 16 (41.0) | 23 (59.0) | |
| With family | 69 (38.2) | 107 (60.8) | |
| Type of school | |||
| Government | 53 (50.0) | 53 (50.0) | 5.88 (0.015*) |
| Private | 50 (34.7) | 94 (65.3) | |
| Grade | |||
| 11 | 41 (34.5) | 78 (65.5) | 4.26 (0.039*) |
| 12 | 62 (47.3) | 69 (52.7) | |
| Father’s education level | |||
| Illiterate | 8 (28.6) | 20 (71.4) | 2.07 (0.150) |
| Literate | 95 (42.8) | 127 (57.2) | |
| Mother’s education level | |||
| Illiterate | 43 (44.8) | 53 (55.2) | 0.83 (0.362) |
| Literate | 60 (39.0) | 94 (61.0) | |
| Father’s occupation | |||
| Business | 32 (54.2) | 27 (45.8) | 6.63 (0.156) |
| Job | 17 (44.7) | 21 (55.3) | |
| Agriculture | 29 (35.8) | 52 (64.2) | |
| Daily wages | 11 (36.7) | 19 (63.3) | |
| Foreign employment | 14 (33.3) | 28 (66.7) | |
| Mother’s occupation | |||
| House maker | 50 (40.0) | 75 (60.0) | 5.80 (0.214) |
| Business | 13 (52.0) | 12 (48.0) | |
| Job | 6 (40.0) | 9 (60.0) | |
| Agriculture | 28 (36.4) | 49 (63.6) | |
| Foreign employment | 6 (75.0) | 2 (25.0) | |
| Knowledge of adverse effects of tobacco | |||
| Yes | 102 (41.8) | 142 (58.2) | 5.27 (0.023*) |
| No | 1 (16.7) | 5 (83.3) | |
| Father uses tobacco | |||
| Yes | 72 (48.6) | 76 (51.4) | 8.30 (0.004**) |
| No | 31 (30.4) | 71 (69.6) | |
| Mother uses tobacco | |||
| Yes | 6 (55.2) | 13 (44.8) | 2.64 (0.104) |
| No | 87 (39.4) | 134 (60.6) | |
| Any other family member uses tobacco | |||
| Yes | 39 (58.2) | 28 (41.8) | 10.93 (0.001**) |
| No | 64 (35.0) | 147 (58.8) | |
| Friends use tobacco | |||
| Yes | 78 (73.6) | 28 (26.4) | 17.67 (0.000**) |
| No | 25 (17.4) | 119 (82.6) | |
Fitted model for tobacco use
The results in Table 4 show that male adolescent students are 3.61 times more likely to use tobacco products compared to female students (AOR=3.61; 95% CI: 1.29–4.25, p=0.018). Adolescents aged 16–17 years are 2.28 times more likely to have ever used tobacco than those aged 18–19 years (AOR=2.28; 95% CI: 1.18–4.40, p=0.013). In addition, adolescent students from government schools are 57% less likely to use tobacco products compared to those from private schools (AOR=0.43; 95% CI.: 0.22–0.82, p=0.012). Similarly, adolescents with knowledge of the adverse effects of tobacco use are 32.9% less likely to have ever used tobacco than those without such knowledge (AOR=0.67; 95% CI: 0.18–0.71, p=0.021). The odds of using tobacco are 3.69 times higher for adolescents with family members who smoke compared to those whose family members do not smoke (AOR=3.69; 95% CI: 1.18–4.75, p=0.007). Similarly, adolescents with friends who smoke are 4.09 times more likely to use tobacco than those whose friends do not smoke (AOR=4.09; 95% CI: 2.04–6.19, p=0.001).
Table 4
Binary multiple logistic regression model for ever use of tobacco among adolescent students in Nepalgunj sub-metropolitan city, Banke, Nepal, April – May 2023 (N=250)
| Variables | Categories | p* | AOR | 95% CI | |
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Gender | Male | 0.018 | 3.61 | 1.29 | 4.25 |
| Female ® | 1 | ||||
| Age (years) | 16–17 | 0.013 | 2.28 | 1.18 | 4.40 |
| 18–19 ® | 1 | ||||
| Type of school | Government | 0.012 | 0.43 | 0.22 | 0.82 |
| Private ® | 1 | ||||
| Knowledge of adverse effects of tobacco | Yes | 0.021 | 0.67 | 0.18 | 0.71 |
| No ® | 1 | ||||
| Smoking by family members | Yes | 0.007 | 3.69 | 1.18 | 4.75 |
| No ® | 1 | ||||
| Smoking by friends | Yes | 0.001 | 4.09 | 2.04 | 6.19 |
| No ® | 1 | ||||
| Constant | 0.001 | 7.40 | |||
DISCUSSION
This study provides significant insight into the high prevalence (41.2%) of tobacco use among school adolescents aged 16–19 years, which is significantly influenced by demographic, familial, social and peer-related factors.
This prevalence stands in stark contrast to previous studies conducted across Nepal: 25.3% in Kalaiya20, 15.6% in Birgunj21, 19.6% in Kaski22, 15–20% in Kalimati, Kathmandu9, 22.8% in Syangja24, 31.7% in Budhanilkantha25, 20.6% in Tokha Municipality, Kathmandu26, and 23.3% in Jumla27. Similarly, studies in other countries reported that 19.0% of middle and high school students used tobacco in the US in 202416, 30.6% in Bhubaneswar, India34, and 1.8% in Iraq30. This difference may be attributed to variations in the study populations. Furthermore, this study exclusively focused on late adolescents aged 16–19 years, specifically students from grades 11 and 12, as this age group represents a transitional phase from adolescence to early adulthood, a period often associated with increased susceptibility to risk-taking behaviors, such as tobacco use.
This study identified demographic, familial, and social factors significantly associated with the ever use of tobacco, including gender, age, type of school, knowledge of the adverse effects of tobacco use, tobacco use by family members or by friends. These findings are consistent with the results of numerous studies in the literature. Specifically, age and gender have been identified as significant determinants by other studies18-20,23, as have the type of school attended19,35, the influence of tobacco use by family members12,35,36 or by friends35. These findings collectively highlight the multifactorial nature of tobacco use behavior among adolescents, influenced by a combination of demographic, familial, and social factors.
The current study revealed that male adolescent students are more likely to use tobacco products compared to female students. This finding aligns with the study conducted in Budhanilkantha municipality of Kathmandu, Nepal25, and the finding of GYTS 2011, Nepal28. This is supported by the studies conducted in the Gaindakot municipality of Nawalpur district, Nepal, in which male adolescents were more likely to use tobacco products than female adolescents23. This finding was also in line with the study conducted in Kalaiya, Nepal, in which the male students were likely to ever use tobacco than the female students20. This result was supported by the study in Iraq in which male adolescents were twice more likely to be tobacco users than female students30. This might be because males have been reported to be more involved in risky behaviors than females5. The difference might be caused by alcohol being consumed more by males than by females as a means of stress relief and for recreational purposes.
Our study revealed that adolescents aged 16–17 years were more likely to have ever used tobacco compared to those aged 18–19 years. In contrast, studies conducted in Dharan, Eastern Nepal19, Gaindakot municipality of Nawalpur district23, and Iraq30, indicated that late adolescents were more likely to use tobacco than their early and middle adolescent counterparts. The observed discrepancy may be attributed to factors such as peer pressure, experimentation, and imitation of others, which were identified as primary reasons for initiating tobacco use in our study.
Additionally, this study found that adolescent students attending government schools were less likely to use tobacco products compared to their counterparts in private schools. This finding aligns with research conducted in Syangja, Nepal, which reported higher tobacco consumption among students in non-government schools compared to those in government schools24. However, a study in Dharan, Eastern Nepal, showed that students in government schools were more likely to have ever used tobacco than those in private schools19. This variation may be explained by socioeconomic differences and the contrasting school environments in the respective study settings.
In our study, adolescents who were aware of the harmful effects of tobacco use were less likely to have ever used tobacco compared to those who lacked such knowledge. This finding is consistent with research conducted in Western Nepal18 and Budhanilkantha municipality of Kathmandu, Nepal25. It may be advantageous to incorporate education on the health risks of tobacco use into the curricula of schools and colleges.
The present study showed that the students with family members who used tobacco were higher than those with no family history of tobacco. This finding aligns with research conducted in Bhubaneswar, India, which demonstrated the role of tobacco use by family members34, and in Iraq by parents or siblings30; however, a study in Kalaiya, Nepal, indicated that for students whose family members used tobacco20, the association was significantly higher compared to the findings of our study.
We found that adolescents with friends who smoke are more likely to use tobacco compared to those whose friends do not engage in smoking. This is consistent with findings from the studies in Bhubaneswar, India, where tobacco use among peers34, and in Ibadan, Nigeria, where close friends who smoked increased the odds of tobacco use37. A study in Iraq, also revealed that having friends who smoked was substantially correlated with tobacco use30. This may be attributed to the significant association between friends’ tobacco consumption and the influence of peer pressure on tobacco use20.
Limitations
Our study has some limitations, including a focus on a specific age group of adolescent students enrolled in grades 11 and 12, convenience sampling to select schools, and the research was conducted only in Nepalgunj sub-metropolitan city, Banke District, Nepal, which may impact the generalizability of the findings. A cross-sectional study design was adopted, which does not allow for causal attribution. Furthermore, data were acquired using a self-administered questionnaire, which may have introduced reporting bias. Despite these limitations, our findings might be crucial for designing targeted interventions to address tobacco use in Nepal and in similar contexts.
CONCLUSIONS
The study revealed a notably high prevalence of tobacco use among adolescents. The alarming rise in tobacco use among adolescent students in Nepal is significantly influenced by demographic, familial, and social factors such as gender, age, type of school, knowledge of the adverse effects of tobacco use, tobacco use by family members or by friends. These findings underscore the critical need for targeted interventions, including school-based education on the harmful effects of tobacco, family-focused programs, and peer resistance programs to reduce tobacco use among youth. These initiatives should take into account gender differences, age-related susceptibility, the influence of peers, family, and knowledge. It is essential that policymakers, educators, and health authorities work collaboratively to implement evidence-based strategies that protect the health and well-being of adolescent students and foster a tobacco-free future.
