A Survival Analysis of Factors Associated with Tobacco Initiation Among Adolescents in Zambia: Evidence from the 2021 Global Youth Tobacco Survey

A Survival Analysis of Factors Associated with Tobacco Initiation Among Adolescents in Zambia: Evidence from the 2021 Global Youth Tobacco Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Survival Analysis of Factors Associated with Tobacco Initiation Among Adolescents in Zambia: Evidence from the 2021 Global Youth Tobacco Survey Wingston Ng'ambi, Adoration Chigere, Cosmas Zyambo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8714350/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Introduction Tobacco use is a leading preventable cause of morbidity and mortality worldwide, with initiation often occurring during adolescence. Early uptake increases the risk of lifelong addiction and non-communicable diseases. In Zambia, evidence on age- and product-specific initiation, as well as regional and social determinants, remains limited, hindering targeted prevention strategies. Methods We analyzed data from the 2021 Zambia Global Youth Tobacco Survey (GYTS), a nationally representative, school-based survey of adolescents aged 11–17 years. Age at first use for cigarettes, hand-rolled cigarettes, shisha, electronic cigarettes, and smokeless tobacco was assessed. Cox proportional hazards regression models estimated the hazard of initiation, accounting for socio-demographic, household, school, and peer factors, as well as clustering by individual across multiple products. Weighted analyses ensured population-level representativeness. Results Overall, 16.0% of adolescents had initiated tobacco use, with the highest rates in Tobacco Growing Regions (22.2%) and lowest in Lusaka (10.9%). Product-specific initiation was highest for shisha, electronic cigarettes, and smokeless tobacco in high-risk regions. Early adolescence (11–12 years) represented the peak initiation window. Social exposures—including parental and peer smoking, teachers smoking at school, and ownership of tobacco-branded items—significantly increased initiation hazards. Prior experimentation and intention to use tobacco were also strong predictors, while awareness of tobacco harms slightly reduced initiation risk. Conclusion Tobacco initiation among Zambian adolescents is shaped by regional, product-specific, age, and social factors, with early adolescence and high-risk environments driving uptake. Findings highlight the need for targeted, multi-level interventions encompassing traditional and emerging tobacco products, supporting implementation of FCTC and MPOWER strategies, and informing Zambia’s adolescent-focused tobacco prevention policies. Adolescents Tobacco initiation Zambia Cox proportional hazards MPOWER/FCTC youth tobacco use tobacco control policy Figures Figure 1 INTRODUCTION Tobacco use remains one of the leading preventable causes of morbidity and mortality worldwide, responsible for over 8 million deaths annually, including direct tobacco-related illnesses and exposure to secondhand smoke 1 . Despite global progress in reducing prevalence through the implementation of the WHO Framework Convention on Tobacco Control (FCTC) 2 and MPOWER strategies, initiation of tobacco use often begins during adolescence, a period of heightened vulnerability to nicotine addiction and long-term health consequences 3 . Globally, an estimated 25% of adolescents experiment with tobacco before the age of 15, with considerable variation by region, product type, and socio-demographic factors 4 . Early initiation is a strong predictor of sustained tobacco use in adulthood and increases the lifetime risk of cardiovascular disease, cancer, and other chronic conditions 4 . These trends underscore the critical importance of monitoring age-specific initiation patterns and designing interventions that target youth before experimentation becomes habitual. In Africa, the landscape of adolescent tobacco use is complex, shaped by rapid urbanization, aggressive marketing of alternative tobacco products, and socio-cultural factors that normalize smoking in some communities 5 , 6 . While cigarette smoking remains the predominant form of tobacco use, the emergence of hand-rolled cigarettes, shisha, smokeless tobacco, and electronic nicotine delivery systems has diversified exposure pathways among African youth 7 . Regional surveys suggest that initiation often occurs earlier than reported in adult prevalence studies, with some countries documenting initiation as young as 11 years. However, data on initiation by product type and timing remain limited, impeding evidence-based policy planning, particularly in countries with high tobacco cultivation and low enforcement of age-of-sale restrictions 8 . In Zambia, national tobacco control efforts have advanced under the FCTC, yet gaps remain in understanding the dynamics of adolescent tobacco initiation across different products and regions 9 . Most existing data focus on prevalence rather than timing of initiation or the relative risks associated with social, household, and environmental exposures 10 . This limits the ability of policymakers to implement targeted prevention strategies in schools, homes, and communities where initiation is most likely to occur. To address these evidence gaps, this study aims to examine the age and determinants of tobacco product initiation among Zambian adolescents, using data from the 2021 Global Youth Tobacco Survey. The specific objectives are to: (1) estimate initiation rates for different tobacco products, including cigarettes, hand-rolled cigarettes, shisha, electronic cigarettes, and smokeless tobacco; (2) assess the influence of socio-demographic, household, and school-level factors on initiation; and (3) identify regional disparities in initiation to inform targeted, evidence-based interventions aligned with WHO MPOWER strategies and FCTC obligations. By generating detailed, product-specific initiation data, this study provides actionable insights to strengthen adolescent-focused tobacco control policies in Zambia 11 . METHODS Study Design and Data Source This study utilized a cross-sectional survival analytic approach applied to data from the 2021 Zambia Global Youth Tobacco Survey (GYTS) 12 , a core surveillance instrument under Article 20 of the WHO Framework Convention on Tobacco Control (FCTC), which mandates systematic monitoring of tobacco use and related determinants 2 , 13 – 15 . The GYTS provides standardized, policy-relevant indicators on youth tobacco use that directly support the MPOWER “Monitor” strategy, enabling countries to track emerging product use and initiation patterns among adolescents 15 . Although cross-sectional, the GYTS collects retrospective information on age at tobacco initiation, permitting time-to-event analyses that approximate initiation hazards across adolescence 16 . This analytic strategy strengthens the evidence base for primary prevention policies by identifying critical ages of vulnerability, thereby informing the timing of interventions such as school-based prevention, enforcement of age-of-sale laws, and restrictions on youth-oriented marketing. Sampling The 2021 Zambia GYTS employed a two-stage cluster sampling design to produce nationally representative estimates of school-going adolescents aged 11–17 years 12 . Schools were selected with probability proportional to enrollment size, followed by random selection of classes within sampled schools. This design aligns with WHO recommendations for youth tobacco surveillance and ensures comparability with other FCTC Parties. Sampling weights were applied to account for selection probabilities, differential non-response, and post-stratification, thereby supporting population-level inference consistent with FCTC reporting standards 12 . All analyses accounted for stratification and clustering, ensuring statistically valid estimates suitable for informing national tobacco control policy and international reporting obligations. Outcome Variables Primary outcomes were defined as time to initiation of specific tobacco product categories, operationalized as the reported age at first use 16 . Cigarette initiation—including hand-rolled cigarettes—was derived from CR6, reflecting products traditionally regulated under FCTC Articles 9 and 10 15 . Shisha (waterpipe) initiation (SR2) and smokeless tobacco initiation (SLR1) were included to capture non-cigarette products that are increasingly relevant in the context of regulatory loopholes and youth-targeted appeal. For electronic cigarettes, where direct age-at-initiation data were unavailable, a proxy initiation age was constructed using current age among adolescents reporting use in the past 30 days (ELR2). Each product type was treated as a distinct initiation event, enabling comparative assessment of product-specific risks that are directly relevant to product regulation, advertising bans (Article 13), and youth access restrictions (Article 16) 13 . Data Management Data management procedures prioritized epidemiological validity and policy interpretability 17 . Age-at-initiation responses were examined for internal consistency, and implausible or missing values were excluded from product-specific analyses. Adolescents who had not initiated use of a given product by the survey date were treated as right-censored, consistent with survival analytic conventions used in tobacco surveillance research. To support multi-product analysis, the dataset was reshaped into a person–product longitudinal structure, allowing individuals to contribute multiple observations across product types 18 . This approach reflects the real-world complexity of adolescent tobacco experimentation and supports policy-relevant comparisons across products subject to varying degrees of regulation. Data Analysis We employed Cox proportional hazards regression models to estimate hazard ratios (HRs) for tobacco product initiation, using age in years as the underlying time scale 18 . Product type was included as a key explanatory variable to quantify differential initiation risks, addressing a central policy concern under the FCTC regarding the substitution and proliferation of alternative tobacco and nicotine products among youth 15 . To account for correlated observations arising from multiple products per individual, robust standard errors clustered at the individual level were used. All models incorporated survey weights and design variables to ensure nationally representative estimates consistent with GYTS and MPOWER reporting standards. Proportional hazards assumptions were assessed using Schoenfeld residuals and graphical diagnostics. Findings are intended to inform evidence-based implementation and strengthening of MPOWER measures, particularly those related to monitoring, protecting youth, and enforcing comprehensive product regulation in Zambia. RESULTS Characteristics of the adolescents in 2021 in Zambia Table 1 summarizes the socio-demographic profile, tobacco-related exposures, and risk perceptions of adolescents across Zambia. Overall, the sample was dominated by mid-adolescents, with those aged 13–14 years comprising just over half of respondents (52%), followed by those aged 15–16 years (37%), while adolescents aged 17 years and older represented 11%. Females constituted the majority of the sample (57%), reflecting the underlying school enrolment patterns. Tobacco-related indicators showed concerning levels of early experimentation and exposure: nearly four in five adolescents (79%) reported ever trying cigarette smoking, 82% reported having tried shisha, and 21% reported use of hand-rolled cigarettes. Exposure to tobacco-promoting or permissive environments was substantial, with 25% reporting people smoking at school, 14% reporting teachers smoking at school, and 45% seeing tobacco use on television. While awareness of tobacco harms was relatively high—57% acknowledged that long-term tobacco use leads to cancer—intentions to use tobacco in the next five years remained notable at 13%, underscoring persistent vulnerability during adolescence. Marked regional disparities were observed across most tobacco-related indicators, many of which were statistically significant. Adolescents in the Tobacco Growing Regions consistently exhibited higher-risk profiles compared with Lusaka and the Rest of the Country (ROC). Ever trying cigarette smoking was highest in Lusaka (86%) and lowest in the Tobacco Regions (68%), with the difference highly significant (p < 0.001). Conversely, future intention to use tobacco increased sharply from Lusaka (9.3%) to ROC (14%) and was highest in the Tobacco Regions (18%) (p < 0.001). Parental or guardian smoking inside the home followed a similar gradient, rising from 12% in Lusaka to 19% in Tobacco Regions (p < 0.001). School environments also differed substantially: seeing teachers smoke at school ranged from 9.8% in Lusaka to 18% in Tobacco Regions (p < 0.001), and owning items branded with tobacco products was significantly more common in Tobacco Regions (14%) compared with Lusaka (9.0%) (p < 0.001). These statistically significant patterns point to structurally different risk environments by region. Table 1 Characteristics of adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey Characteristic Lusaka (n = 2,027) ROC (n = 2,500) Tobacco Regions (n = 1,972) Overall Sociodemographic Characteristics Age, years 11 53 (2.6%) 85 (3.4%) 127 (6.5%) 265 (4.1%) 12 176 (8.7%) 166 (6.7%) 115 (5.9%) 457 (7.1%) 13 389 (19%) 388 (16%) 299 (15%) 1,076 (17%) 14 498 (25%) 608 (25%) 483 (25%) 1,589 (25%) 15 432 (21%) 547 (22%) 384 (20%) 1,363 (21%) 16 289 (14%) 422 (17%) 316 (16%) 1,027 (16%) 17 182 (9.0%) 265 (11%) 231 (12%) 678 (11%) Sex Female 1,212 (60%) 1,302 (53%) 1,167 (61%) 3,681 (57%) Male 796 (40%) 1,169 (47%) 760 (39%) 2,725 (43%) Grade level Grade 7 731 (36%) 783 (32%) 757 (39%) 2,271 (35%) Grade 8 566 (28%) 855 (35%) 630 (33%) 2,051 (32%) Grade 9 708 (35%) 828 (34%) 545 (28%) 2,081 (33%) Wealth index Low 1,033 (51%) 1,351 (54%) 1,032 (53%) 3,416 (53%) Middle 361 (18%) 438 (18%) 338 (17%) 1,137 (18%) Rich 614 (31%) 693 (28%) 586 (30%) 1,893 (29%) Tobacco Use and Exposure Ever tried cigarette smoking 1,481 (86%) 1,536 (80%) 967 (68%) 3,984 (79%) Parent/guardian smokes in home 244 (12%) 412 (17%) 373 (19%) 1,029 (16%) Intention to use tobacco in next 5 years 187 (9.3%) 334 (14%) 344 (18%) 865 (13%) Friends smoke tobacco 434 (22%) 624 (25%) 551 (28%) 1,609 (25%) Use of handrolled cigarette 229 (11%) 533 (21%) 619 (31%) 1,381 (21%) Tried shisha 1,721 (86%) 2,052 (83%) 1,479 (76%) 5,252 (82%) Heard of electronic cigarette 479 (24%) 626 (26%) 630 (33%) 1,735 (27%) Own item with tobacco product 183 (9.0%) 314 (13%) 280 (14%) 777 (12%) School and Media Exposure Exposure to anti-tobacco media messages 1,286 (64%) 1,544 (62%) 1,192 (61%) 4,022 (62%) Taught about dangers of tobacco use 1,013 (51%) 1,134 (46%) 857 (44%) 3,004 (47%) Saw teachers smoking at school 198 (9.8%) 332 (13%) 357 (18%) 887 (14%) People smoke in school 514 (25%) 602 (24%) 528 (27%) 1,644 (25%) Teachers smoke at school 211 (10%) 350 (14%) 364 (18%) 925 (14%) See people using tobacco on TV 1,108 (55%) 1,057 (42%) 787 (40%) 2,952 (45%) See tobacco advertisement 429 (21%) 535 (21%) 405 (21%) 1,369 (21%) Knowledge and Attitudes Long tobacco use leads to cancer 1,246 (61%) 1,413 (57%) 1,064 (54%) 3,723 (57%) Long term tobacco use leads to drug use 847 (42%) 983 (39%) 734 (37%) 2,564 (39%) ROC = Rest of Country, TV= Television Tobacco use initiation rates in 2021 in Zambia Table 2 shows that the overall tobacco initiation rate among adolescents was 16.0% (95% CI: 15.6–16.4), indicating that roughly one in six adolescents had initiated tobacco use. Substantial heterogeneity was observed by region, with the highest initiation rate in Tobacco Growing Regions (22.2%; 95% CI: 21.3–23.0), followed by the Rest of the Country (ROC) at 15.2% (95% CI: 14.6–15.8), and the lowest rate in Lusaka (10.9%; 95% CI: 10.3–11.5). Initiation varied markedly by age, displaying a non-linear pattern: rates were highest among the youngest adolescents aged 11 years (33.1%; 95% CI: 30.5–35.6), declined through ages 13–15 (11.6–14.4%), and rose again among older adolescents aged 16 years (18.1%) and 17 years (22.1%), suggesting multiple windows of vulnerability during early and late adolescence. Males had a higher initiation rate than females (16.8% vs 14.9%), while differences by grade level were modest, ranging from 15.3% in Grade 7 to 16.0% in Grade 8. Initiation rates were markedly elevated among adolescents exposed to permissive social and school environments. Adolescents who reported use of hand-rolled cigarettes had an initiation rate of 44.2% (95% CI: 43.0–45.4), compared with only 8.4% among non-users. Similarly, initiation was substantially higher among those reporting teachers smoking at school (34.3%), seeing teachers smoke (34.8%), people smoking at school (23.9%), and friends who smoke tobacco (30.0%), compared with their unexposed counterparts. Household exposure also played a critical role: adolescents with a parent or guardian who smoked at home had an initiation rate of 31.2%, more than double that of those without such exposure (12.9%). Media and marketing influences were also evident, with higher initiation among those who saw tobacco advertisements (23.0%), heard of electronic cigarettes (26.9%), or owned tobacco-branded items (31.5%). Conversely, protective factors aligned with FCTC and MPOWER objectives were associated with lower initiation: adolescents who were taught about the dangers of tobacco use had lower initiation rates (13.6% vs 17.6%), and those without intentions to use tobacco in the next five years had substantially lower initiation (12.6% vs 37.0%). Collectively, these patterns underscore the strong influence of social exposure, marketing, and institutional environments on youth tobacco initiation, reinforcing the need for strengthened enforcement of smoke-free policies, comprehensive advertising bans, and school-based prevention strategies. Table 2 Tobacco use initiation rates amongst adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey Category Level Initiation Rate (%) 95% CI Person years Overall Overall 16.0 (15.6, 16.4) 32317 Region Lusaka 10.9 (10.3, 11.5) 10097 Tobacco Regions 22.2 (21.3, 23.0) 9796 ROC 15.2 (14.6, 15.8) 12424 Age (years) 11 33.1 (30.5, 35.6) 1325 12 15.0 (13.5, 16.4) 2285 13 11.6 (10.8, 12.5) 5380 14 13.2 (12.5, 13.9) 7945 15 14.4 (13.6, 15.3) 6815 16 18.1 (17.1, 19.2) 5135 17 22.1 (20.7, 23.5) 3390 Sex Female 14.9 (14.4, 15.4) 18346 Male 16.8 (16.1, 17.4) 13547 Grade Grade 7 15.3 (14.6, 16.0) 11312 Grade 8 16.0 (15.3, 16.8) 10192 Grade 9 15.9 (15.2, 16.6) 10341 Wealth Index Low 15.6 (15.0, 16.1) 17003 Middle 13.9 (13.0, 14.8) 5644 Rich 17.7 (17.0, 18.5) 9440 Use of Handrolled Cigarette No 8.4 (8.0, 8.7) 25453 Yes 44.2 (43.0, 45.4) 6864 Tried Shisha Yes 10.7 (10.4, 11.1) 26133 No 37.8 (36.6, 39.1) 5830 Heard of Electronic Cigarette No 11.2 (10.7, 11.6) 23025 Yes 26.9 (26.0, 27.9) 8634 People Smoke in School No 13.3 (12.9, 13.7) 24137 Yes 23.9 (23.0, 24.8) 8180 Teachers Smoke at School No 12.9 (12.5, 13.3) 27725 Yes 34.3 (32.9, 35.6) 4592 See People Using Tobacco on TV Yes 14.3 (13.7, 14.9) 14672 No 17.4 (16.8, 17.9) 17645 See Tobacco Advertisement No 14.1 (13.7, 14.5) 25512 Yes 23.0 (22.0, 24.0) 6805 Long Tobacco Use Leads to Cancer Yes 14.1 (13.6, 14.6) 18514 No 18.4 (17.8, 19.1) 13803 Long Term Tobacco Use Leads to Drug Use Yes 15.4 (14.7, 16.0) 12744 No 16.4 (15.9, 16.9) 19573 Own Item with Tobacco Product No 13.9 (13.5, 14.3) 28452 Yes 31.5 (30.0, 33.0) 3865 Ever Tried Cigarette Smoking Yes 3.1 (2.8, 3.3) 19826 No 47.7 (46.4, 49.1) 5387 Parent/Guardian Smokes in Home No 12.9 (12.5, 13.3) 26894 Yes 31.2 (29.9, 32.4) 5113 Intention to Use Tobacco in Next 5 Years No 12.6 (12.2, 13.0) 27649 Yes 37.0 (35.6, 38.5) 4293 Exposure to Anti-Tobacco Media Messages No 13.5 (12.8, 14.1) 12086 Yes 17.3 (16.7, 17.8) 20006 Taught About Dangers of Tobacco Use Yes 13.6 (13.1, 14.2) 14927 No 17.6 (17.0, 18.2) 16938 Saw Teachers Smoking at School No 12.9 (12.5, 13.3) 27725 Yes 34.8 (33.4, 36.2) 4410 Friends Smoke Tobacco No 11.2 (10.8, 11.6) 24037 Yes 30.0 (29.0, 31.0) 7998 ROC = Rest of Country, TV= Television Tobacco initiation rates by the product Table 3 reveals striking regional gradients in tobacco product initiation, with consistently higher rates observed in the Tobacco Growing Regions across all product types. Cigarette initiation was lowest in Lusaka (8.9%) and the Rest of the Country (ROC) (8.5%), but markedly higher in Tobacco Regions (13.3%), underscoring the heightened baseline risk in these areas. A similar pattern was evident for hand-rolled cigarettes, reflecting the close overlap between conventional and informal cigarette use. More pronounced disparities emerged for non-cigarette products: shisha initiation increased sharply from 14.0% in Lusaka to 18.9% in ROC, peaking at 28.9% in Tobacco Regions, while electronic cigarette initiation followed an almost identical trajectory (9.5%, 19.8%, and 28.1%, respectively). Smokeless tobacco initiation also displayed a strong regional gradient, rising from 13.2% in Lusaka to 20.4% in ROC and 27.3% in Tobacco Regions. Collectively, these patterns suggest a diversification of tobacco initiation beyond cigarettes, particularly in tobacco-growing areas, highlighting the convergence of social normalization, product availability, and regulatory gaps. The consistently elevated initiation of emerging and alternative products in Tobacco Regions reinforces the urgency of comprehensive, product-inclusive tobacco control strategies that extend beyond cigarettes, in line with WHO FCTC provisions and the MPOWER framework. Table 3 Tobacco use initiation rates by product amongst adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey Product Type Lusaka (n = 2019) ROC (n = 2486) Tobacco Regions (n = 1959) Cigarette 180 (8.9%) 212 (8.5%) 260 (13.3%) Hand-rolled 180 (8.9%) 212 (8.5%) 260 (13.3%) Shisha 283 (14%) 469 (18.9%) 566 (28.9%) Electronic 191 (9.5%) 490 (19.8%) 550 (28.1%) Smokeless 266 (13.2%) 507 (20.4%) 536 (27.3%) ROC = Rest of Country Rate ratios of tobacco use initiations amongst adolescents in 2021 in Zambia The Cox proportional hazards regression model for tobacco product initiation reveals several important patterns in both product-specific and individual-level predictors of initiation (see Fig. 1 ). Product type significantly influenced initiation, with hand-rolled cigarettes serving as the reference category (HR = 1.00). Compared with hand-rolled cigarettes, initiation hazards were slightly lower for shisha (HR = 0.88; 95% CI: 0.78–0.99, p = 0.041), electronic cigarettes (HR = 0.78; 95% CI: 0.69–0.88, p < 0.001), and smokeless tobacco (HR = 0.89; 95% CI: 0.78–1.00, p = 0.047), indicating a modestly delayed initiation for these products relative to hand-rolled cigarettes. Regionally, adolescents in the ROC and Tobacco Growing Regions had significantly lower hazards compared with Lusaka (ROC: HR = 0.78; 95% CI: 0.70–0.86, p < 0.001; Tobacco Regions: HR = 0.87; 95% CI: 0.78–0.96, p = 0.006), reflecting potential differences in the timing of initiation across settings despite higher overall prevalence in some rural areas. Age exhibited a strong inverse relationship with initiation hazard, with the youngest adolescents (11 years) having the highest risk (see Fig. 1 ). Compared with 11-year-olds, hazard ratios decreased sharply with age: 13 years (HR = 0.79), 14 years (HR = 0.77), 15 years (HR = 0.42), 16 years (HR = 0.26), and 17 years (HR = 0.17), all p < 0.05, highlighting early adolescence as the critical window for tobacco initiation. Social and household exposures also significantly increased hazard: having a parent or guardian who smokes (HR = 1.15; p = 0.002), friends who smoke (HR = 1.28; p < 0.001), seeing people smoke at school (HR = 1.19; p < 0.001), or prior use of hand-rolled cigarettes (HR = 1.67; p < 0.001) were all associated with elevated risk. Likewise, intention to use tobacco in the next five years (HR = 1.23; p < 0.001), being taught about tobacco dangers (HR = 1.14; p = 0.002), and hearing of electronic cigarettes (HR = 1.14; p = 0.002) were significant predictors. Protective factors were more nuanced (see Fig. 1 ). Awareness of long-term tobacco harms, such as the risk of cancer (HR = 0.92; p = 0.043), and prior experience with shisha (HR = 0.74; p < 0.001) were associated with slightly lower hazards, while sex, grade level, wealth index, exposure to anti-tobacco media messages, and ownership of tobacco-branded items did not show statistically significant effects in most cases. Overall, these findings underscore that early adolescence, peer and household influences, and prior experimentation with tobacco products are the strongest drivers of initiation, reinforcing the need for interventions aligned with WHO FCTC Articles 8, 12, 13, and 16 and MPOWER strategies targeting early prevention, smoke-free environments, and restrictions on access and promotion. DISCUSSION This study provides a comprehensive assessment of tobacco product initiation among Zambian adolescents, revealing several important findings. First, the overall initiation rate was 16.0%, with significant variation by region: Tobacco Growing Regions had the highest rates (22.2%), followed by the Rest of the Country (15.2%) and Lusaka (10.9%), highlighting substantial geographic disparities. Second, initiation patterns varied by product type, with shisha, electronic cigarettes, and smokeless tobacco exhibiting higher initiation in Tobacco Regions, whereas conventional and hand-rolled cigarettes showed more modest regional differences. Third, age emerged as a critical determinant, with the highest hazard of initiation occurring in early adolescence (11–12 years), and a sharp decline in initiation risk with increasing age, indicating early adolescence as a key window for preventive interventions. Fourth, social and environmental exposures significantly influenced initiation, including parental and peer smoking, observing people or teachers smoking at school, and ownership of tobacco-branded items, all of which were associated with increased initiation hazards. Fifth, prior experimentation and intention to use tobacco were strong predictors, with adolescents who had tried hand-rolled cigarettes or expressed intent to use tobacco in the next five years exhibiting markedly higher initiation hazards, underscoring the reinforcing effects of early experimentation on subsequent uptake. Collectively, these findings highlight the interplay of regional, social, and individual factors in shaping adolescent tobacco initiation and point to the need for targeted, evidence-based interventions to prevent early uptake. Our finding that tobacco initiation was highest in the Tobacco Growing Regions (22.2%) and lowest in Lusaka (10.9%) aligns with global evidence showing that adolescent tobacco use is often concentrated in areas of high product availability or cultural acceptance 19 . Studies in Kenya, South Africa, and Nigeria similarly report elevated initiation in rural or tobacco-producing regions compared with urban centers 20 . This regional pattern in Zambia underscores the need for context-specific interventions, including stricter enforcement of age-of-sale laws, community-based education programs, and targeted monitoring of youth exposure in high-risk areas. From a policy perspective, these findings reinforce FCTC Articles 8 and 16 by highlighting the importance of protecting adolescents from exposure and limiting youth access, while also supporting the MPOWER “Protect” and “Enforce” strategies 3 , 14 . Addressing these disparities contributes to SDG 3.4 (reducing premature mortality from non-communicable diseases) and aligns with Zambia’s National Health Strategy on reducing risk factors for chronic diseases 21 , 22 . In terms of product-specific initiation, non-cigarette products—shisha, electronic cigarettes, and smokeless tobacco—showed higher initiation rates in the Tobacco Regions, while conventional cigarettes and hand-rolled cigarettes were more evenly distributed across regions. This trend is consistent with global patterns in Europe, America, Africa and Asia, where the proliferation of alternative tobacco products has diversified adolescent exposure 23 – 26 . The findings underscore the need for comprehensive tobacco control policies that encompass all product types, reflecting FCTC Articles 9, 10, and 13 and supporting MPOWER’s “Monitor” and “Warn” pillars 15 . Policies should include the expansion of smoke-free regulations, advertising bans covering emerging products, and school-based education about the risks of all tobacco products, in alignment with the Africa CDC and regional youth health agendas 27 . The study also identified age as a critical determinant of initiation, with the highest hazard observed in early adolescence (11–12 years) and a sharp decline in older adolescents. This pattern is consistent with global evidence indicating that initiation commonly occurs in early adolescence, a period of heightened susceptibility to nicotine addiction 28 , 29 . These results emphasize the need for early, age-appropriate interventions, including school and community prevention programs, in order to pre-empt experimentation and prevent progression to regular use. Such interventions advance the MPOWER “Protect” and “Educate” strategies, support Zambia’s National Health Strategy goal of reducing early NCD risk behaviors, and contribute to SDG 3.4 by reducing long-term tobacco-related morbidity and mortality 21 . Social and environmental exposures were strongly associated with initiation, including parental and peer smoking, seeing teachers smoke at school, and observing people using tobacco in the community. These findings echo global literature highlighting the influence of social modeling on adolescent tobacco use 30 . From a policy perspective, they underscore the importance of multi-level interventions that address household, school, and community contexts, consistent with FCTC Articles 8, 12, and 16, and reinforce MPOWER strategies aimed at protecting youth from exposure to tobacco smoke and promoting supportive environments 15 . Implementing these interventions in high-risk communities can help shift social norms and reduce adolescent susceptibility to tobacco use 31 . Finally, prior experimentation and intention to use tobacco emerged as strong predictors of initiation. Adolescents who had tried hand-rolled cigarettes or expressed intent to use tobacco in the next five years exhibited substantially higher initiation hazards, corroborating evidence from other low- and middle-income settings where early experimentation is a strong precursor to habitual use 32 , 33 . These findings highlight the importance of early behavioral monitoring, school-based interventions, and enforcement of age-of-sale regulations, aligning with FCTC Articles 16 and 12 and MPOWER’s “Monitor” and “Warn” pillars 14 . By identifying adolescents at highest risk, targeted interventions can prevent progression to regular use, contributing to SDG 3.4 and supporting Zambia’s National Health Strategy objectives to reduce tobacco exposure among youth, as well as broader African efforts to curb adolescent tobacco initiation 21 . STRENGTHS AND LIMITATIONS A major strength of this study is the use of the 2021 Zambia GYTS, a nationally representative, school-based dataset that provides high-quality, standardized information on adolescent tobacco use across multiple products and regions. The large sample size and inclusion of diverse socio-demographic, environmental, and behavioral variables allowed for robust estimation of initiation rates and identification of key determinants using Cox proportional hazards models. Additionally, the study examined product-specific initiation, capturing emerging tobacco products such as shisha, electronic cigarettes, and smokeless tobacco, which are often underreported in traditional surveillance. These methodological strengths enhance the generalizability of findings and provide actionable evidence for policy, supporting the implementation of targeted interventions aligned with FCTC Articles 8, 12, 13, and 16, MPOWER strategies, and Zambia’s National Health Strategy priorities 15 , 21 , 22 . The ability to identify high-risk regions, age groups, and social contexts directly informs evidence-based decision-making for adolescent tobacco prevention programs and regulatory enforcement. Despite its strengths, the study has several limitations that may influence interpretation and policy application. First, the cross-sectional design limits causal inference, and initiation ages are based on self-reported, retrospective recall, which may introduce recall bias, particularly among older adolescents. Second, the GYTS survey excludes out-of-school adolescents, who may have different exposure and initiation patterns, potentially underestimating population-level risks. Third, electronic cigarette initiation was approximated using current use, which may misclassify true initiation timing. Despite these limitations, the study still provides critical policy-relevant insights, highlighting regions, products, and social exposures that require urgent attention 34 . Policymakers should interpret the findings within these constraints but can use the evidence to strengthen targeted interventions, reinforce school-based prevention programs, expand monitoring of emerging products, and guide enforcement of tobacco control legislation under the FCTC, MPOWER, and national health strategies 15 , 21 . Acknowledging these limitations also emphasizes the need for longitudinal surveillance and inclusion of out-of-school youth to fully capture the dynamics of adolescent tobacco initiation in Zambia and similar settings. CONCLUSION In conclusion, this study highlights that tobacco initiation among Zambian adolescents is influenced by a complex interplay of regional, product-specific, age-related, and social factors, with early adolescence and exposure to parental, peer, and school-based smoking representing critical windows of vulnerability. The highest initiation rates in Tobacco Growing Regions and for non-cigarette products such as shisha, electronic cigarettes, and smokeless tobacco underscore the need for comprehensive, multi-level interventions that address both traditional and emerging tobacco products. Policy implications are clear: targeted enforcement of age-of-sale laws, expansion of school- and community-based prevention programs, and broader regulation of all tobacco products are essential to curb early initiation, in alignment with FCTC Articles 8, 12, 13, and 16, MPOWER strategies, and Zambia’s National Health Strategy priorities 15 , 21 . Next steps should include longitudinal surveillance to monitor trends in initiation, inclusion of out-of-school youth to capture the full population at risk, and evaluation of interventions designed to reduce exposure to social and environmental risk factors. By translating these findings into actionable policies, Zambia and similar African settings can strengthen efforts to prevent early tobacco uptake, ultimately contributing to SDG 3.4 and the reduction of future tobacco-related disease burden. Declarations Competing interests None Ethical approval This study was conducted in accordance with internationally accepted ethical standards for research involving human participants. Access to the anonymized 2021 Global Youth Tobacco Survey (GYTS) dataset was obtained through the World Health Organization (WHO) NCD Microdata Repository. The GYTS data are fully de-identified prior to release, ensuring that no individual respondents can be identified. As the analysis involved secondary use of existing anonymized data and required no direct contact with participants, additional ethical approval or informed consent was not required. The study therefore posed minimal risk and complied with WHO data access and research ethics requirements. Consent to participate Not applicable. This manuscript does not involve human participants or individual-level data. Consent to publish Not applicable. Funding information We received no funding to conduct this analysis. Funding None Author Contribution WFN = Conceptualisation, preparing the paper and reviewing it. AC = Preparing the paper and reviewing it. CZ = Conceptualisation, preparing the paper and reviewing it. All authors reviewed and approved the final draft. Data Availability The datasets analysed during the current study were obtained from the Global Youth Tobacco Surveys and are publicly available. Access to the raw data can be requested from the World Health Organization (WHO) through the WHO NCD Microdata Repository or by contacting the WHO NCD Surveillance Team at [email protected] , subject to approval and relevant data-sharing agreements. The analytical code used in this study is available from the corresponding author upon reasonable request. References Ritchie H, Roser M, Smoking. Our World in Data https://ourworldindata.org/smoking (2023). Zaatari GS, Bazzi A. Impact of the WHO FCTC on non-cigarette tobacco products. Tob Control. 2019;28:s104. Lyle G, Hendrie D. Global smoking-related deaths averted due to MPOWER policies implemented at the highest level between 2007 and 2020. Glob Health. 2024;20:40. Londani M, Sewani-Rusike C, Ayo-Yusuf O, Oladimeji O. Patterns of tobacco use and related factors among adolescents in South Africa: Insight from the Global Youth Tobacco Survey. Tob Induc Dis 23, (2025). Kyule GN, Iddi S, Mohamed SF. Growing Tobacco Use Among Adolescents and Women in Kenya and Across Africa. APHRC Blog Article https://aphrc.org/blogarticle/the-alarming-rise-of-tobacco-use-among-adolescents-and-women-in-kenya-and-across-africa/ (2024). James P, Bah AJ, Kabba J, Kassim, said abasse, Dalinjong P. Prevalence and correlates of current tobacco use and non-user susceptibility to using tobacco products among school-going adolescents in 22 African countries: a secondary analysis of the 2013–2018 global youth tobacco surveys. Arch. Public Health 80, (2022). Agaku IT et al. Gender differences in use of cigarette and non-cigarette tobacco products among adolescents aged 13–15 years in 20 African countries. Tob Induc Dis 22, (2024). Cantrell J, et al. Patterns in first and daily cigarette initiation among youth and young adults from 2002 to 2015. PLoS ONE. 2018;13:e0200827. Silumbwe A, San Sebastian M, Zulu JM, Michelo C, Johansson K. Collaborative dynamics and shared motivation: exploring tobacco control policy development in Zambia. Health Policy Plan. 2024;39:i19–28. Odo DB, Ayo-Yusuf O, Dinku Y et al. Trends in the Prevalence and Factors Associated with Indoor Smoking in 24 Countries Party to the WHO FCTC: Implications for Equitable Policy Implementation. BMJ Glob Health 2025;10:E017110. Doi:10.1136/Bmjgh-2024-017110. Tembo D. The Economic Consequences of Tobacco Use Among Adolescents in Zambia . (2025). 10.13140/RG.2.2.16488.33283 Ministry of Health, Z. & World Health Organization Regional Office for Africa. Zambia 2021 Global Youth Tobacco Survey (GYTS) Country Report . https://www.afro.who.int/countries/zambia/publication/zambia-2021-global-youth-tobacco-survey-gyts-country-report (2024). Nagler RH, Viswanath K. Implementation and research priorities for FCTC Articles 13 and 16: tobacco advertising, promotion, and sponsorship and sales to and by minors. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2013;15:832–46. Craig L, Fong GT, Chung-Hall J, Puska P. Impact of the WHO FCTC on tobacco control: perspectives from stakeholders in 12 countries. Tob Control. 2019;28:s129–35. Paraje G, Flores Muñoz M, Finot J, Pruzzo L, Jha P. The effect of WHO FCTC ratification and the implementation of MPOWER measures: An analysis using ITSA with synthetic control groups. Tob Induc Dis 23, (2025). World Health Organization. Global Youth Tobacco Survey (GYTS). WHO Noncommunicable Disease Surveillance, Monitoring and Reporting https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/global-youth-tobacco-survey (2025). Ng’ambi WF. Muula AS. A Reproducible R Workflow to Preserve Variable and Value Labels in Stata, SPSS, and SAS Datasets for Transparent and Reproducible Health Research. Malawi Med J. 2025;37(3):13506. Available from: Https://Www.Mmj.Mw/?P = 13506 Kirkwood BR, Sterne JAC. Essential Medical Statistics. Oxford; Malden, MA: Blackwell Scientific Publications (Wiley–Blackwell); 2003. Sun J, et al. Cigarette access and purchase patterns among adolescent smokers aged 12–16 years in 140 countries/territories, Global Youth Tobacco Survey 2010–2018. J Glob Health. 2022;12:e04101. Belete H, et al. Tobacco smoking in Sub-Saharan Africa: A systematic review and meta-analysis. Drug Alcohol Rev. 2025;44:1079–91. World Health Organization. Regional Office for the Western Pacific. Sustainable Development Goals (SDGs): Goal 3. Target 3.4 : By 2030, By 2030, Reduce by One Third Premature Mortality from Non-Communicable Diseases through Prevention and Treatment and Promote Mental Health and Well Being [Poster] . http://iris.wpro.who.int/handle/10665.1/12876 (2016). Wallengren E, et al. Relevance of the Sustainable Development Goals (SDGs) to Adolescent Health Measurement: A Systematic Mapping of the SDG Framework and Global Adolescent Health Indicators. Adv Adolesc Health Meas Indic Recomm Glob Action Meas Adolesc Health. 2024;74:S47–55. Surdacka J, Matuszewska M, Lipiak A, Chawłowska E. Nicotine consumption in Poland: from traditional cigarettes to modern products - a scoping review. BMC Public Health. 2025;25:3346. Sutfin E, et al. First Tobacco Product Tried: Associations with Smoking Status and Demographics among College Students. Addict Behav. 2015;51:152–7. Berry KM, et al. Association of Electronic Cigarette Use With Subsequent Initiation of Tobacco Cigarettes in US Youths. JAMA Netw Open. 2019;2:e187794. Wang L et al. Use patterns of cigarettes and alternative tobacco products and socioeconomic correlates in Hong Kong secondary school students. Sci Rep 11, (2021). Kaleta D, Polanska K. The youth’s awareness of regulations banning e-cigarette advertising, promotion, sponsorship and their use in educational buildings. Tob Induc Dis 19, (2021). Atherton OE, Conger RD, Ferrer E, Robins RW. Risk and Protective Factors for Early Substance Use Initiation: A Longitudinal Study of Mexican-Origin Youth. J Res Adolesc Off J Soc Res Adolesc. 2016;26:864–79. Abdelrahman A, et al. Prevention of Alcohol, Tobacco, and Illicit Drug Use Among Youth: A Scoping Review of European School-Based Programs with Insights on Mental Health. Int J Environ Res Public Health. 2025;22:1569. Appiah F et al. Association between Teachers’ Outdoor Smoking Attitude and Smoking Initiation among in-School Adolescents in Albania: A Cross-Sectional Study. (2024). 10.21203/rs.3.rs-3951515/v1 Zyambo C, et al. School tobacco-related curriculum and behavioral factors associated with cigarette smoking among school-going adolescents in Zambia: Results from the 2011 GYTS study. Tob Induc Dis. 2022;20:42. Persoskie A, O’Brien EK. Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods. Prev Med Rep. 2022;28:101855. Sargent JD, Gabrielli J, Budney A, Soneji S, Wills TA. Adolescent smoking experimentation as a predictor of daily cigarette smoking. Drug Alcohol Depend. 2017;175:55–9. WHO Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco Use and Prevention Policies. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Mar, 2026 Reviews received at journal 11 Mar, 2026 Reviews received at journal 10 Mar, 2026 Reviews received at journal 09 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviewers agreed at journal 01 Mar, 2026 Reviewers invited by journal 16 Feb, 2026 Editor invited by journal 05 Feb, 2026 Editor assigned by journal 04 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8714350","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592436204,"identity":"069a1a73-220b-4afa-9e54-b90d5eb8ca5d","order_by":0,"name":"Wingston Ng'ambi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYDACZmQOY4OEHIg+8ICglgSEFmOwlgQcqhEAoYUhsQFZABswOM57+OXPHzZ5DNLtFz/d3GGRPj/s8EOgLXZyug04tBzmS7PmSUgrZpA5Uyyde0Yid+PtNAOglmRjswPYtZgd5jEzZkg4nNggkZMgndsG1DI7AaTlQOI2PFoMf0C0JP8Gakk3nJ3+gZAW4wc8YC3px0C2JMhL5+C3xR5oCzNPWlpim0QOmzXQL4YbpHMKDiQY4PaLZP8Z448/bGwS+yXSH9/O3VEnLz87ffOHDxV2cri0AAGbBJhk4DEAcw3AKg1wKgcB5g8Qmv0BmJJvwKt6FIyCUTAKRiAAAH57YSfaSeFIAAAAAElFTkSuQmCC","orcid":"","institution":"Health Economics and Policy Unit","correspondingAuthor":true,"prefix":"","firstName":"Wingston","middleName":"","lastName":"Ng'ambi","suffix":""},{"id":592436205,"identity":"b573408f-e5f3-40fa-8b7d-0d54075de2e8","order_by":1,"name":"Adoration Chigere","email":"","orcid":"","institution":"Department of Public Health and Family Medicine, University of Zambia","correspondingAuthor":false,"prefix":"","firstName":"Adoration","middleName":"","lastName":"Chigere","suffix":""},{"id":592436206,"identity":"164f1fd7-db0c-4779-a647-e8a42623b1d4","order_by":2,"name":"Cosmas Zyambo","email":"","orcid":"","institution":"Health Economics and Policy Unit","correspondingAuthor":false,"prefix":"","firstName":"Cosmas","middleName":"","lastName":"Zyambo","suffix":""}],"badges":[],"createdAt":"2026-01-27 21:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8714350/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8714350/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103260869,"identity":"a86365ad-fcce-4766-80b5-5029386edb79","added_by":"auto","created_at":"2026-02-23 18:05:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":461676,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRate ratios of tobacco use initiations amongst adolescents in 2021 in Zambia\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8714350/v1/7154d874e0f459be0139d598.png"},{"id":103505646,"identity":"9fb9f6a6-e1f4-4e80-8cb6-043d08abffe3","added_by":"auto","created_at":"2026-02-26 13:32:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2267128,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8714350/v1/de86c38d-728e-4a58-9fd5-30fea082683e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Survival Analysis of Factors Associated with Tobacco Initiation Among Adolescents in Zambia: Evidence from the 2021 Global Youth Tobacco Survey","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTobacco use remains one of the leading preventable causes of morbidity and mortality worldwide, responsible for over 8\u0026nbsp;million deaths annually, including direct tobacco-related illnesses and exposure to secondhand smoke\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Despite global progress in reducing prevalence through the implementation of the WHO Framework Convention on Tobacco Control (FCTC)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and MPOWER strategies, initiation of tobacco use often begins during adolescence, a period of heightened vulnerability to nicotine addiction and long-term health consequences\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Globally, an estimated 25% of adolescents experiment with tobacco before the age of 15, with considerable variation by region, product type, and socio-demographic factors\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Early initiation is a strong predictor of sustained tobacco use in adulthood and increases the lifetime risk of cardiovascular disease, cancer, and other chronic conditions\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. These trends underscore the critical importance of monitoring age-specific initiation patterns and designing interventions that target youth before experimentation becomes habitual.\u003c/p\u003e \u003cp\u003eIn Africa, the landscape of adolescent tobacco use is complex, shaped by rapid urbanization, aggressive marketing of alternative tobacco products, and socio-cultural factors that normalize smoking in some communities\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. While cigarette smoking remains the predominant form of tobacco use, the emergence of hand-rolled cigarettes, shisha, smokeless tobacco, and electronic nicotine delivery systems has diversified exposure pathways among African youth\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Regional surveys suggest that initiation often occurs earlier than reported in adult prevalence studies, with some countries documenting initiation as young as 11 years. However, data on initiation by product type and timing remain limited, impeding evidence-based policy planning, particularly in countries with high tobacco cultivation and low enforcement of age-of-sale restrictions\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn Zambia, national tobacco control efforts have advanced under the FCTC, yet gaps remain in understanding the dynamics of adolescent tobacco initiation across different products and regions\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Most existing data focus on prevalence rather than timing of initiation or the relative risks associated with social, household, and environmental exposures\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. This limits the ability of policymakers to implement targeted prevention strategies in schools, homes, and communities where initiation is most likely to occur. To address these evidence gaps, this study aims to examine the age and determinants of tobacco product initiation among Zambian adolescents, using data from the 2021 Global Youth Tobacco Survey. The specific objectives are to: (1) estimate initiation rates for different tobacco products, including cigarettes, hand-rolled cigarettes, shisha, electronic cigarettes, and smokeless tobacco; (2) assess the influence of socio-demographic, household, and school-level factors on initiation; and (3) identify regional disparities in initiation to inform targeted, evidence-based interventions aligned with WHO MPOWER strategies and FCTC obligations. By generating detailed, product-specific initiation data, this study provides actionable insights to strengthen adolescent-focused tobacco control policies in Zambia\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Data Source\u003c/h2\u003e \u003cp\u003eThis study utilized a cross-sectional survival analytic approach applied to data from the 2021 Zambia Global Youth Tobacco Survey (GYTS)\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, a core surveillance instrument under Article 20 of the WHO Framework Convention on Tobacco Control (FCTC), which mandates systematic monitoring of tobacco use and related determinants\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The GYTS provides standardized, policy-relevant indicators on youth tobacco use that directly support the MPOWER \u0026ldquo;Monitor\u0026rdquo; strategy, enabling countries to track emerging product use and initiation patterns among adolescents\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough cross-sectional, the GYTS collects retrospective information on age at tobacco initiation, permitting time-to-event analyses that approximate initiation hazards across adolescence\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. This analytic strategy strengthens the evidence base for primary prevention policies by identifying critical ages of vulnerability, thereby informing the timing of interventions such as school-based prevention, enforcement of age-of-sale laws, and restrictions on youth-oriented marketing.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eThe 2021 Zambia GYTS employed a two-stage cluster sampling design to produce nationally representative estimates of school-going adolescents aged 11\u0026ndash;17 years\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Schools were selected with probability proportional to enrollment size, followed by random selection of classes within sampled schools. This design aligns with WHO recommendations for youth tobacco surveillance and ensures comparability with other FCTC Parties.\u003c/p\u003e \u003cp\u003eSampling weights were applied to account for selection probabilities, differential non-response, and post-stratification, thereby supporting population-level inference consistent with FCTC reporting standards\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. All analyses accounted for stratification and clustering, ensuring statistically valid estimates suitable for informing national tobacco control policy and international reporting obligations.\u003c/p\u003e\n\u003ch3\u003eOutcome Variables\u003c/h3\u003e\n\u003cp\u003ePrimary outcomes were defined as time to initiation of specific tobacco product categories, operationalized as the reported age at first use\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Cigarette initiation\u0026mdash;including hand-rolled cigarettes\u0026mdash;was derived from CR6, reflecting products traditionally regulated under FCTC Articles 9 and 10\u003csup\u003e15\u003c/sup\u003e. Shisha (waterpipe) initiation (SR2) and smokeless tobacco initiation (SLR1) were included to capture non-cigarette products that are increasingly relevant in the context of regulatory loopholes and youth-targeted appeal.\u003c/p\u003e \u003cp\u003eFor electronic cigarettes, where direct age-at-initiation data were unavailable, a proxy initiation age was constructed using current age among adolescents reporting use in the past 30 days (ELR2). Each product type was treated as a distinct initiation event, enabling comparative assessment of product-specific risks that are directly relevant to product regulation, advertising bans (Article 13), and youth access restrictions (Article 16)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eData Management\u003c/h3\u003e\n\u003cp\u003eData management procedures prioritized epidemiological validity and policy interpretability\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Age-at-initiation responses were examined for internal consistency, and implausible or missing values were excluded from product-specific analyses. Adolescents who had not initiated use of a given product by the survey date were treated as right-censored, consistent with survival analytic conventions used in tobacco surveillance research. To support multi-product analysis, the dataset was reshaped into a person\u0026ndash;product longitudinal structure, allowing individuals to contribute multiple observations across product types\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This approach reflects the real-world complexity of adolescent tobacco experimentation and supports policy-relevant comparisons across products subject to varying degrees of regulation.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe employed Cox proportional hazards regression models to estimate hazard ratios (HRs) for tobacco product initiation, using age in years as the underlying time scale\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Product type was included as a key explanatory variable to quantify differential initiation risks, addressing a central policy concern under the FCTC regarding the substitution and proliferation of alternative tobacco and nicotine products among youth\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo account for correlated observations arising from multiple products per individual, robust standard errors clustered at the individual level were used. All models incorporated survey weights and design variables to ensure nationally representative estimates consistent with GYTS and MPOWER reporting standards. Proportional hazards assumptions were assessed using Schoenfeld residuals and graphical diagnostics. Findings are intended to inform evidence-based implementation and strengthening of MPOWER measures, particularly those related to monitoring, protecting youth, and enforcing comprehensive product regulation in Zambia.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the adolescents in 2021 in Zambia\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the socio-demographic profile, tobacco-related exposures, and risk perceptions of adolescents across Zambia. Overall, the sample was dominated by mid-adolescents, with those aged 13\u0026ndash;14 years comprising just over half of respondents (52%), followed by those aged 15\u0026ndash;16 years (37%), while adolescents aged 17 years and older represented 11%. Females constituted the majority of the sample (57%), reflecting the underlying school enrolment patterns. Tobacco-related indicators showed concerning levels of early experimentation and exposure: nearly four in five adolescents (79%) reported ever trying cigarette smoking, 82% reported having tried shisha, and 21% reported use of hand-rolled cigarettes. Exposure to tobacco-promoting or permissive environments was substantial, with 25% reporting people smoking at school, 14% reporting teachers smoking at school, and 45% seeing tobacco use on television. While awareness of tobacco harms was relatively high\u0026mdash;57% acknowledged that long-term tobacco use leads to cancer\u0026mdash;intentions to use tobacco in the next five years remained notable at 13%, underscoring persistent vulnerability during adolescence.\u003c/p\u003e \u003cp\u003eMarked regional disparities were observed across most tobacco-related indicators, many of which were statistically significant. Adolescents in the Tobacco Growing Regions consistently exhibited higher-risk profiles compared with Lusaka and the Rest of the Country (ROC). Ever trying cigarette smoking was highest in Lusaka (86%) and lowest in the Tobacco Regions (68%), with the difference highly significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, future intention to use tobacco increased sharply from Lusaka (9.3%) to ROC (14%) and was highest in the Tobacco Regions (18%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Parental or guardian smoking inside the home followed a similar gradient, rising from 12% in Lusaka to 19% in Tobacco Regions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). School environments also differed substantially: seeing teachers smoke at school ranged from 9.8% in Lusaka to 18% in Tobacco Regions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and owning items branded with tobacco products was significantly more common in Tobacco Regions (14%) compared with Lusaka (9.0%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These statistically significant patterns point to structurally different risk environments by region.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLusaka\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;2,027)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eROC\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;2,500)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco Regions\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1,972)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge, years\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e127 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e265 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e166 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e457 (7.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e389 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e388 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e299 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,076 (17%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e498 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e608 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e483 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,589 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e432 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e547 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e384 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,363 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e289 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e422 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e316 (16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,027 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e265 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e231 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e678 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,212 (60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,302 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,167 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,681 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e796 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,169 (47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e760 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,725 (43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrade level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e731 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e783 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e757 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,271 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e566 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e855 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e630 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,051 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e708 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e828 (34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e545 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,081 (33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWealth index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,033 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,351 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,032 (53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,416 (53%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e361 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e438 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e338 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,137 (18%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRich\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e614 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e693 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e586 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,893 (29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTobacco Use and Exposure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver tried cigarette smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,481 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,536 (80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e967 (68%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,984 (79%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParent/guardian smokes in home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e244 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e412 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e373 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,029 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntention to use tobacco in next 5 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e187 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e334 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e344 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e865 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFriends smoke tobacco\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e434 (22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e624 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e551 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,609 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUse of handrolled cigarette\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229 (11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e533 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e619 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,381 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTried shisha\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,721 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,052 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,479 (76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5,252 (82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeard of electronic cigarette\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e479 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e626 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e630 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,735 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOwn item with tobacco product\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e314 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e280 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e777 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSchool and Media Exposure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExposure to anti-tobacco media messages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,286 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,544 (62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,192 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4,022 (62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTaught about dangers of tobacco use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,013 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,134 (46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e857 (44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,004 (47%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSaw teachers smoking at school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e198 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e332 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e357 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e887 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeople smoke in school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e514 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e602 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e528 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,644 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTeachers smoke at school\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e350 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e364 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e925 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSee people using tobacco on TV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,108 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,057 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e787 (40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,952 (45%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSee tobacco advertisement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e429 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e535 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e405 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,369 (21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge and Attitudes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong tobacco use leads to cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,246 (61%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,413 (57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,064 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,723 (57%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLong term tobacco use leads to drug use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e847 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e983 (39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e734 (37%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,564 (39%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eROC\u0026thinsp;=\u0026thinsp;Rest of Country, TV= Television\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTobacco use initiation rates in 2021 in Zambia\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows that the overall tobacco initiation rate among adolescents was 16.0% (95% CI: 15.6\u0026ndash;16.4), indicating that roughly one in six adolescents had initiated tobacco use. Substantial heterogeneity was observed by region, with the highest initiation rate in Tobacco Growing Regions (22.2%; 95% CI: 21.3\u0026ndash;23.0), followed by the Rest of the Country (ROC) at 15.2% (95% CI: 14.6\u0026ndash;15.8), and the lowest rate in Lusaka (10.9%; 95% CI: 10.3\u0026ndash;11.5). Initiation varied markedly by age, displaying a non-linear pattern: rates were highest among the youngest adolescents aged 11 years (33.1%; 95% CI: 30.5\u0026ndash;35.6), declined through ages 13\u0026ndash;15 (11.6\u0026ndash;14.4%), and rose again among older adolescents aged 16 years (18.1%) and 17 years (22.1%), suggesting multiple windows of vulnerability during early and late adolescence. Males had a higher initiation rate than females (16.8% vs 14.9%), while differences by grade level were modest, ranging from 15.3% in Grade 7 to 16.0% in Grade 8.\u003c/p\u003e \u003cp\u003eInitiation rates were markedly elevated among adolescents exposed to permissive social and school environments. Adolescents who reported use of hand-rolled cigarettes had an initiation rate of 44.2% (95% CI: 43.0\u0026ndash;45.4), compared with only 8.4% among non-users. Similarly, initiation was substantially higher among those reporting teachers smoking at school (34.3%), seeing teachers smoke (34.8%), people smoking at school (23.9%), and friends who smoke tobacco (30.0%), compared with their unexposed counterparts. Household exposure also played a critical role: adolescents with a parent or guardian who smoked at home had an initiation rate of 31.2%, more than double that of those without such exposure (12.9%). Media and marketing influences were also evident, with higher initiation among those who saw tobacco advertisements (23.0%), heard of electronic cigarettes (26.9%), or owned tobacco-branded items (31.5%). Conversely, protective factors aligned with FCTC and MPOWER objectives were associated with lower initiation: adolescents who were taught about the dangers of tobacco use had lower initiation rates (13.6% vs 17.6%), and those without intentions to use tobacco in the next five years had substantially lower initiation (12.6% vs 37.0%). Collectively, these patterns underscore the strong influence of social exposure, marketing, and institutional environments on youth tobacco initiation, reinforcing the need for strengthened enforcement of smoke-free policies, comprehensive advertising bans, and school-based prevention strategies.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTobacco use initiation rates amongst adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInitiation Rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePerson years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOverall\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(15.6, 16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32317\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLusaka\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(10.3, 11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTobacco Regions\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(21.3, 23.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eROC\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(14.6, 15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12424\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e11\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(30.5, 35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1325\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e12\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.5, 16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2285\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e13\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(10.8, 12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5380\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e14\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.5, 13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7945\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e15\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.6, 15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6815\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e16\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(17.1, 19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e17\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(20.7, 23.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3390\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(14.4, 15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(16.1, 17.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13547\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGrade\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGrade 7\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(14.6, 16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11312\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGrade 8\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(15.3, 16.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eGrade 9\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(15.2, 16.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eWealth Index\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(15.0, 16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMiddle\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.0, 14.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRich\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(17.0, 18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9440\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eUse of Handrolled Cigarette\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(8.0, 8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25453\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(43.0, 45.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6864\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTried Shisha\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(10.4, 11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(36.6, 39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5830\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eHeard of Electronic Cigarette\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(10.7, 11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(26.0, 27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8634\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003ePeople Smoke in School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.9, 13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(23.0, 24.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTeachers Smoke at School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.5, 13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(32.9, 35.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4592\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSee People Using Tobacco on TV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.7, 14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(16.8, 17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSee Tobacco Advertisement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.7, 14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25512\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(22.0, 24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLong Tobacco Use Leads to Cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.6, 14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18514\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(17.8, 19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLong Term Tobacco Use Leads to Drug Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(14.7, 16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(15.9, 16.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19573\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eOwn Item with Tobacco Product\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.5, 14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(30.0, 33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEver Tried Cigarette Smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(2.8, 3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(46.4, 49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eParent/Guardian Smokes in Home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.5, 13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26894\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(29.9, 32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIntention to Use Tobacco in Next 5 Years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.2, 13.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27649\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(35.6, 38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eExposure to Anti-Tobacco Media Messages\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.8, 14.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(16.7, 17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTaught About Dangers of Tobacco Use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(13.1, 14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14927\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(17.0, 18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSaw Teachers Smoking at School\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(12.5, 13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(33.4, 36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFriends Smoke Tobacco\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(10.8, 11.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e(29.0, 31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eROC\u0026thinsp;=\u0026thinsp;Rest of Country, TV= Television\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTobacco initiation rates by the product\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reveals striking regional gradients in tobacco product initiation, with consistently higher rates observed in the Tobacco Growing Regions across all product types. Cigarette initiation was lowest in Lusaka (8.9%) and the Rest of the Country (ROC) (8.5%), but markedly higher in Tobacco Regions (13.3%), underscoring the heightened baseline risk in these areas. A similar pattern was evident for hand-rolled cigarettes, reflecting the close overlap between conventional and informal cigarette use. More pronounced disparities emerged for non-cigarette products: shisha initiation increased sharply from 14.0% in Lusaka to 18.9% in ROC, peaking at 28.9% in Tobacco Regions, while electronic cigarette initiation followed an almost identical trajectory (9.5%, 19.8%, and 28.1%, respectively). Smokeless tobacco initiation also displayed a strong regional gradient, rising from 13.2% in Lusaka to 20.4% in ROC and 27.3% in Tobacco Regions. Collectively, these patterns suggest a diversification of tobacco initiation beyond cigarettes, particularly in tobacco-growing areas, highlighting the convergence of social normalization, product availability, and regulatory gaps. The consistently elevated initiation of emerging and alternative products in Tobacco Regions reinforces the urgency of comprehensive, product-inclusive tobacco control strategies that extend beyond cigarettes, in line with WHO FCTC provisions and the MPOWER framework.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTobacco use initiation rates by product amongst adolescents interviewed for the 2021 Zambia Global Youth Tobacco Survey\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProduct Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLusaka (n\u0026thinsp;=\u0026thinsp;2019)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eROC (n\u0026thinsp;=\u0026thinsp;2486)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco Regions (n\u0026thinsp;=\u0026thinsp;1959)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCigarette\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e212 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e260 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHand-rolled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e212 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e260 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShisha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e283 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e469 (18.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e566 (28.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191 (9.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e490 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e550 (28.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmokeless\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e266 (13.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e507 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e536 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eROC\u0026thinsp;=\u0026thinsp;Rest of Country\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRate ratios of tobacco use initiations amongst adolescents in 2021 in Zambia\u003c/h2\u003e \u003cp\u003eThe Cox proportional hazards regression model for tobacco product initiation reveals several important patterns in both product-specific and individual-level predictors of initiation (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Product type significantly influenced initiation, with hand-rolled cigarettes serving as the reference category (HR\u0026thinsp;=\u0026thinsp;1.00). Compared with hand-rolled cigarettes, initiation hazards were slightly lower for shisha (HR\u0026thinsp;=\u0026thinsp;0.88; 95% CI: 0.78\u0026ndash;0.99, p\u0026thinsp;=\u0026thinsp;0.041), electronic cigarettes (HR\u0026thinsp;=\u0026thinsp;0.78; 95% CI: 0.69\u0026ndash;0.88, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and smokeless tobacco (HR\u0026thinsp;=\u0026thinsp;0.89; 95% CI: 0.78\u0026ndash;1.00, p\u0026thinsp;=\u0026thinsp;0.047), indicating a modestly delayed initiation for these products relative to hand-rolled cigarettes. Regionally, adolescents in the ROC and Tobacco Growing Regions had significantly lower hazards compared with Lusaka (ROC: HR\u0026thinsp;=\u0026thinsp;0.78; 95% CI: 0.70\u0026ndash;0.86, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Tobacco Regions: HR\u0026thinsp;=\u0026thinsp;0.87; 95% CI: 0.78\u0026ndash;0.96, p\u0026thinsp;=\u0026thinsp;0.006), reflecting potential differences in the timing of initiation across settings despite higher overall prevalence in some rural areas.\u003c/p\u003e \u003cp\u003eAge exhibited a strong inverse relationship with initiation hazard, with the youngest adolescents (11 years) having the highest risk (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Compared with 11-year-olds, hazard ratios decreased sharply with age: 13 years (HR\u0026thinsp;=\u0026thinsp;0.79), 14 years (HR\u0026thinsp;=\u0026thinsp;0.77), 15 years (HR\u0026thinsp;=\u0026thinsp;0.42), 16 years (HR\u0026thinsp;=\u0026thinsp;0.26), and 17 years (HR\u0026thinsp;=\u0026thinsp;0.17), all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, highlighting early adolescence as the critical window for tobacco initiation. Social and household exposures also significantly increased hazard: having a parent or guardian who smokes (HR\u0026thinsp;=\u0026thinsp;1.15; p\u0026thinsp;=\u0026thinsp;0.002), friends who smoke (HR\u0026thinsp;=\u0026thinsp;1.28; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), seeing people smoke at school (HR\u0026thinsp;=\u0026thinsp;1.19; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), or prior use of hand-rolled cigarettes (HR\u0026thinsp;=\u0026thinsp;1.67; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were all associated with elevated risk. Likewise, intention to use tobacco in the next five years (HR\u0026thinsp;=\u0026thinsp;1.23; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), being taught about tobacco dangers (HR\u0026thinsp;=\u0026thinsp;1.14; p\u0026thinsp;=\u0026thinsp;0.002), and hearing of electronic cigarettes (HR\u0026thinsp;=\u0026thinsp;1.14; p\u0026thinsp;=\u0026thinsp;0.002) were significant predictors.\u003c/p\u003e \u003cp\u003eProtective factors were more nuanced (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Awareness of long-term tobacco harms, such as the risk of cancer (HR\u0026thinsp;=\u0026thinsp;0.92; p\u0026thinsp;=\u0026thinsp;0.043), and prior experience with shisha (HR\u0026thinsp;=\u0026thinsp;0.74; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were associated with slightly lower hazards, while sex, grade level, wealth index, exposure to anti-tobacco media messages, and ownership of tobacco-branded items did not show statistically significant effects in most cases. Overall, these findings underscore that early adolescence, peer and household influences, and prior experimentation with tobacco products are the strongest drivers of initiation, reinforcing the need for interventions aligned with WHO FCTC Articles 8, 12, 13, and 16 and MPOWER strategies targeting early prevention, smoke-free environments, and restrictions on access and promotion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study provides a comprehensive assessment of tobacco product initiation among Zambian adolescents, revealing several important findings. First, the overall initiation rate was 16.0%, with significant variation by region: Tobacco Growing Regions had the highest rates (22.2%), followed by the Rest of the Country (15.2%) and Lusaka (10.9%), highlighting substantial geographic disparities. Second, initiation patterns varied by product type, with shisha, electronic cigarettes, and smokeless tobacco exhibiting higher initiation in Tobacco Regions, whereas conventional and hand-rolled cigarettes showed more modest regional differences. Third, age emerged as a critical determinant, with the highest hazard of initiation occurring in early adolescence (11\u0026ndash;12 years), and a sharp decline in initiation risk with increasing age, indicating early adolescence as a key window for preventive interventions. Fourth, social and environmental exposures significantly influenced initiation, including parental and peer smoking, observing people or teachers smoking at school, and ownership of tobacco-branded items, all of which were associated with increased initiation hazards. Fifth, prior experimentation and intention to use tobacco were strong predictors, with adolescents who had tried hand-rolled cigarettes or expressed intent to use tobacco in the next five years exhibiting markedly higher initiation hazards, underscoring the reinforcing effects of early experimentation on subsequent uptake. Collectively, these findings highlight the interplay of regional, social, and individual factors in shaping adolescent tobacco initiation and point to the need for targeted, evidence-based interventions to prevent early uptake.\u003c/p\u003e \u003cp\u003eOur finding that tobacco initiation was highest in the Tobacco Growing Regions (22.2%) and lowest in Lusaka (10.9%) aligns with global evidence showing that adolescent tobacco use is often concentrated in areas of high product availability or cultural acceptance\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Studies in Kenya, South Africa, and Nigeria similarly report elevated initiation in rural or tobacco-producing regions compared with urban centers\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This regional pattern in Zambia underscores the need for context-specific interventions, including stricter enforcement of age-of-sale laws, community-based education programs, and targeted monitoring of youth exposure in high-risk areas. From a policy perspective, these findings reinforce FCTC Articles 8 and 16 by highlighting the importance of protecting adolescents from exposure and limiting youth access, while also supporting the MPOWER \u0026ldquo;Protect\u0026rdquo; and \u0026ldquo;Enforce\u0026rdquo; strategies\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Addressing these disparities contributes to SDG 3.4 (reducing premature mortality from non-communicable diseases) and aligns with Zambia\u0026rsquo;s National Health Strategy on reducing risk factors for chronic diseases\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn terms of product-specific initiation, non-cigarette products\u0026mdash;shisha, electronic cigarettes, and smokeless tobacco\u0026mdash;showed higher initiation rates in the Tobacco Regions, while conventional cigarettes and hand-rolled cigarettes were more evenly distributed across regions. This trend is consistent with global patterns in Europe, America, Africa and Asia, where the proliferation of alternative tobacco products has diversified adolescent exposure\u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The findings underscore the need for comprehensive tobacco control policies that encompass all product types, reflecting FCTC Articles 9, 10, and 13 and supporting MPOWER\u0026rsquo;s \u0026ldquo;Monitor\u0026rdquo; and \u0026ldquo;Warn\u0026rdquo; pillars\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Policies should include the expansion of smoke-free regulations, advertising bans covering emerging products, and school-based education about the risks of all tobacco products, in alignment with the Africa CDC and regional youth health agendas\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe study also identified age as a critical determinant of initiation, with the highest hazard observed in early adolescence (11\u0026ndash;12 years) and a sharp decline in older adolescents. This pattern is consistent with global evidence indicating that initiation commonly occurs in early adolescence, a period of heightened susceptibility to nicotine addiction\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. These results emphasize the need for early, age-appropriate interventions, including school and community prevention programs, in order to pre-empt experimentation and prevent progression to regular use. Such interventions advance the MPOWER \u0026ldquo;Protect\u0026rdquo; and \u0026ldquo;Educate\u0026rdquo; strategies, support Zambia\u0026rsquo;s National Health Strategy goal of reducing early NCD risk behaviors, and contribute to SDG 3.4 by reducing long-term tobacco-related morbidity and mortality\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSocial and environmental exposures were strongly associated with initiation, including parental and peer smoking, seeing teachers smoke at school, and observing people using tobacco in the community. These findings echo global literature highlighting the influence of social modeling on adolescent tobacco use\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. From a policy perspective, they underscore the importance of multi-level interventions that address household, school, and community contexts, consistent with FCTC Articles 8, 12, and 16, and reinforce MPOWER strategies aimed at protecting youth from exposure to tobacco smoke and promoting supportive environments\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Implementing these interventions in high-risk communities can help shift social norms and reduce adolescent susceptibility to tobacco use\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFinally, prior experimentation and intention to use tobacco emerged as strong predictors of initiation. Adolescents who had tried hand-rolled cigarettes or expressed intent to use tobacco in the next five years exhibited substantially higher initiation hazards, corroborating evidence from other low- and middle-income settings where early experimentation is a strong precursor to habitual use\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. These findings highlight the importance of early behavioral monitoring, school-based interventions, and enforcement of age-of-sale regulations, aligning with FCTC Articles 16 and 12 and MPOWER\u0026rsquo;s \u0026ldquo;Monitor\u0026rdquo; and \u0026ldquo;Warn\u0026rdquo; pillars\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. By identifying adolescents at highest risk, targeted interventions can prevent progression to regular use, contributing to SDG 3.4 and supporting Zambia\u0026rsquo;s National Health Strategy objectives to reduce tobacco exposure among youth, as well as broader African efforts to curb adolescent tobacco initiation\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSTRENGTHS AND LIMITATIONS\u003c/h2\u003e \u003cp\u003eA major strength of this study is the use of the 2021 Zambia GYTS, a nationally representative, school-based dataset that provides high-quality, standardized information on adolescent tobacco use across multiple products and regions. The large sample size and inclusion of diverse socio-demographic, environmental, and behavioral variables allowed for robust estimation of initiation rates and identification of key determinants using Cox proportional hazards models. Additionally, the study examined product-specific initiation, capturing emerging tobacco products such as shisha, electronic cigarettes, and smokeless tobacco, which are often underreported in traditional surveillance. These methodological strengths enhance the generalizability of findings and provide actionable evidence for policy, supporting the implementation of targeted interventions aligned with FCTC Articles 8, 12, 13, and 16, MPOWER strategies, and Zambia\u0026rsquo;s National Health Strategy priorities\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The ability to identify high-risk regions, age groups, and social contexts directly informs evidence-based decision-making for adolescent tobacco prevention programs and regulatory enforcement.\u003c/p\u003e \u003cp\u003eDespite its strengths, the study has several limitations that may influence interpretation and policy application. First, the cross-sectional design limits causal inference, and initiation ages are based on self-reported, retrospective recall, which may introduce recall bias, particularly among older adolescents. Second, the GYTS survey excludes out-of-school adolescents, who may have different exposure and initiation patterns, potentially underestimating population-level risks. Third, electronic cigarette initiation was approximated using current use, which may misclassify true initiation timing. Despite these limitations, the study still provides critical policy-relevant insights, highlighting regions, products, and social exposures that require urgent attention\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Policymakers should interpret the findings within these constraints but can use the evidence to strengthen targeted interventions, reinforce school-based prevention programs, expand monitoring of emerging products, and guide enforcement of tobacco control legislation under the FCTC, MPOWER, and national health strategies\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Acknowledging these limitations also emphasizes the need for longitudinal surveillance and inclusion of out-of-school youth to fully capture the dynamics of adolescent tobacco initiation in Zambia and similar settings.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, this study highlights that tobacco initiation among Zambian adolescents is influenced by a complex interplay of regional, product-specific, age-related, and social factors, with early adolescence and exposure to parental, peer, and school-based smoking representing critical windows of vulnerability. The highest initiation rates in Tobacco Growing Regions and for non-cigarette products such as shisha, electronic cigarettes, and smokeless tobacco underscore the need for comprehensive, multi-level interventions that address both traditional and emerging tobacco products. Policy implications are clear: targeted enforcement of age-of-sale laws, expansion of school- and community-based prevention programs, and broader regulation of all tobacco products are essential to curb early initiation, in alignment with FCTC Articles 8, 12, 13, and 16, MPOWER strategies, and Zambia\u0026rsquo;s National Health Strategy priorities\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Next steps should include longitudinal surveillance to monitor trends in initiation, inclusion of out-of-school youth to capture the full population at risk, and evaluation of interventions designed to reduce exposure to social and environmental risk factors. By translating these findings into actionable policies, Zambia and similar African settings can strengthen efforts to prevent early tobacco uptake, ultimately contributing to SDG 3.4 and the reduction of future tobacco-related disease burden.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003eThis study was conducted in accordance with internationally accepted ethical standards for research involving human participants. Access to the anonymized 2021 Global Youth Tobacco Survey (GYTS) dataset was obtained through the World Health Organization (WHO) NCD Microdata Repository. The GYTS data are fully de-identified prior to release, ensuring that no individual respondents can be identified. As the analysis involved secondary use of existing anonymized data and required no direct contact with participants, additional ethical approval or informed consent was not required. The study therefore posed minimal risk and complied with WHO data access and research ethics requirements.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003eNot applicable. This manuscript does not involve human participants or individual-level data.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to publish\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eFunding information\u003c/h2\u003e \u003cp\u003eWe received no funding to conduct this analysis.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eWFN = Conceptualisation, preparing the paper and reviewing it. AC = Preparing the paper and reviewing it. CZ = Conceptualisation, preparing the paper and reviewing it. All authors reviewed and approved the final draft.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analysed during the current study were obtained from the Global Youth Tobacco Surveys and are publicly available. Access to the raw data can be requested from the World Health Organization (WHO) through the WHO NCD Microdata Repository or by contacting the WHO NCD Surveillance Team at [email protected], subject to approval and relevant data-sharing agreements. The analytical code used in this study is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRitchie H, Roser M, Smoking. \u003cem\u003eOur World in Data\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ourworldindata.org/smoking\u003c/span\u003e\u003cspan address=\"https://ourworldindata.org/smoking\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZaatari GS, Bazzi A. Impact of the WHO FCTC on non-cigarette tobacco products. 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Tob Induc Dis. 2022;20:42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersoskie A, O\u0026rsquo;Brien EK. Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods. Prev Med Rep. 2022;28:101855.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSargent JD, Gabrielli J, Budney A, Soneji S, Wills TA. Adolescent smoking experimentation as a predictor of daily cigarette smoking. Drug Alcohol Depend. 2017;175:55\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eWHO Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco Use and Prevention Policies. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Tobacco initiation, Zambia, Cox proportional hazards, MPOWER/FCTC, youth tobacco use, tobacco control policy","lastPublishedDoi":"10.21203/rs.3.rs-8714350/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8714350/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eTobacco use is a leading preventable cause of morbidity and mortality worldwide, with initiation often occurring during adolescence. Early uptake increases the risk of lifelong addiction and non-communicable diseases. In Zambia, evidence on age- and product-specific initiation, as well as regional and social determinants, remains limited, hindering targeted prevention strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe analyzed data from the 2021 Zambia Global Youth Tobacco Survey (GYTS), a nationally representative, school-based survey of adolescents aged 11\u0026ndash;17 years. Age at first use for cigarettes, hand-rolled cigarettes, shisha, electronic cigarettes, and smokeless tobacco was assessed. Cox proportional hazards regression models estimated the hazard of initiation, accounting for socio-demographic, household, school, and peer factors, as well as clustering by individual across multiple products. Weighted analyses ensured population-level representativeness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall, 16.0% of adolescents had initiated tobacco use, with the highest rates in Tobacco Growing Regions (22.2%) and lowest in Lusaka (10.9%). Product-specific initiation was highest for shisha, electronic cigarettes, and smokeless tobacco in high-risk regions. Early adolescence (11\u0026ndash;12 years) represented the peak initiation window. Social exposures\u0026mdash;including parental and peer smoking, teachers smoking at school, and ownership of tobacco-branded items\u0026mdash;significantly increased initiation hazards. Prior experimentation and intention to use tobacco were also strong predictors, while awareness of tobacco harms slightly reduced initiation risk.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTobacco initiation among Zambian adolescents is shaped by regional, product-specific, age, and social factors, with early adolescence and high-risk environments driving uptake. Findings highlight the need for targeted, multi-level interventions encompassing traditional and emerging tobacco products, supporting implementation of FCTC and MPOWER strategies, and informing Zambia\u0026rsquo;s adolescent-focused tobacco prevention policies.\u003c/p\u003e","manuscriptTitle":"A Survival Analysis of Factors Associated with Tobacco Initiation Among Adolescents in Zambia: Evidence from the 2021 Global Youth Tobacco Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-23 18:05:29","doi":"10.21203/rs.3.rs-8714350/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-22T19:51:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-11T20:45:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-10T13:56:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-09T18:12:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115052597876851196911588399288403492497","date":"2026-03-03T04:13:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27114510477738575218173414747184659133","date":"2026-03-02T15:27:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36296144995584267577541143721667865871","date":"2026-03-01T14:58:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173545182021493833898215565490043923013","date":"2026-03-01T14:44:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T00:55:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-05T15:31:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T05:28:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T05:27:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2026-01-27T21:09:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ac9db3c-98d6-41be-9974-bfd0db11c251","owner":[],"postedDate":"February 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T07:23:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-23 18:05:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8714350","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8714350","identity":"rs-8714350","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}