Asia-Pacific Journal of Public Health

Supplement to 22(3) 175 S180S

2010 APJPH
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DOI: 10.1177/1010539510372835
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Adolescent Tobacco Use and
Health in Southeast Asia
Nabilla Al-Sadat
1
, A. Y. Misau
1
, Z. Zarihah
2
,
Dahlui Maznah
1
, and Tin Tin Su
1
Abstract
The use of tobacco by adolescents is a major public health concern worldwide. There are
1.2 billion smokers globally, of which more than 50% are young people. The Southeast Asian
countries have about 600 million tobacco smokers within the global burden of tobacco users.
Most smokers begin at early stage of life and persist through adulthood. Malaysia alone has about
5 million smokers, 20% of whom are younger than 18 years old. Many factors are implicated
in the continuous rising trend of tobacco use among adolescents in Southeast Asia. A triad of
family, environmental, and individual factors synergistically acts to motivate adolescents toward
smoking. This article discusses the current trends of tobacco use and implications of increasing
rise in adolescent smoking in the Southeast Asia region.
Keywords
adolescents, cigarette smoking, Malaysia, Southeast Asia, tobacco use
Introduction
The use of tobacco by adolescents remains a major public health concern worldwide. There are
1.2 billion smokers globally, of which more than 50% are young people. Southeast Asia, like
most other delineated regions of the world, is made up of culturally, economically, socially, and
politically diverse countries: Malaysia, Laos, Philippines, Cambodia, Singapore, Myanmar,
Brunei, Vietnam, Indonesia, and Thailand. There are nearly 600 million tobacco users within the
Southeast Asian countries, with the region contributing to about 50% of the global burden of
tobacco users. Malaysia alone has about 5 million smokers, 20% of whom are younger than
18 years old.
1
Many factors are implicated in the prevalence of tobacco use in Southeast Asia. Among youth
smokers, a triad of family, environmental, and individual factors synergistically acts to motivate
adolescents to smoke. Documented factors include experimentation and peer pressure, easy
access and/or lack of restrictive laws, family smoking, cultural norms, stress and psychological
factors, smoking within school environments, and involvement with other high-risk behaviors.
1
University of Malaya, Kuala Lumpur, Malaysia
2
Ministry of Health, Kuala Lumpur, Malaysia
Corresponding Author:
Nabilla Al-Sadat, Centre for Population Health, Department of Social and Preventive Medicine, Faculty of Medicine,
University of Malaya, Kuala Lumpur 50603, Malaysia
Email: nabilla@ummc.edu.my
176S Asia-Pacic Journal of Public Health Supplement to 22(3)
The aim of this review is to discuss tobacco use among both young people and adults in
Southeast Asia and its implications for the health of this population.
Prevalence of Tobacco Use in Southeast Asia
There are variations in trends of tobacco use among the Southeast Asian countries, which
largely reflects cultural differences, values, and norms toward use of tobacco and tobacco-
related products in these societies. In Malaysia, Thailand, and Vietnam, tobacco use appears to
be on a gradual decline, whereas in Indonesia there is a rising trend. Youths use of tobacco,
which mirrors the future burden, also shows remarkable variations. In the year 2002, about 30%
of adolescents were smoking tobacco in Malaysia
2
compared with less than 25% in 2006.
3
The
prevalence of smoking among adolescents in Vietnam was also found to be 31.6% in 2001
4

compared with 25% in 2008.
5
However, in Indonesia, adolescent smoking rose from 68% in
2001 to 78% in 2004 and significant increases have been sustained through 2006.
6
However,
although it may appear to be a decline in the rate of young people who smoke in Southeast Asia
over the years, the absolute number is still on the rise, as the population of adolescents expands.
The current 4.5 billion population of all developing countries is projected to increase to
7.5 billion by the year 2015. In addition to the projected population explosion, there is waning
political will to fund tobacco control programs across developing countries. The decline does
not therefore directly translate into a success in controlling tobacco use among youth, but rather
indicates a slower rate of progression. Indonesias current low taxation policy on tobacco par-
tially accounts for persistently high smoking prevalence rates compared with other Southeast
Asian countries. This also corroborates the finding of a study in 2004 that concluded that
easy affordability and accessibility
7
are enabling factors for smoking among Indonesian
adolescents.
Determinants of Tobacco Consumption in Young People
It is of no surprise that the reasons why young people in developing countries initiate smoking
are similar to those in developed countries. Some of the factors similarly reported are urban com-
munity disorganization, poverty, and personal factors such as emotional and psychosocial prob-
lems,
8
lack of school involvement, academic failure and dropping out, antisocial behavior, young
pregnancy and parenthood, family dissociation, homelessness, stress, lack of cohesion and
supervision, familial use of cigarettes, alcohol, and other drugs. However, in developing coun-
tries such as Malaysia, curiosity, peer pressure, and feeling more matured have been shown to be
the key factors responsible for initiation of smoking among youths.
9,10
Ignorance of the health risks associated with smoking appears to be the significant determi-
nant of smoking among adolescents in Indonesia, where a majority of the adolescents are unaware
of the health risk of smoking whereas others believed health effects will only manifest if ciga-
rettes are smoked for a certain period of time.
7
However, it has been shown that other enabling
factors like repetitive easy access to cigarettes, weak legislation that restrict access, and lack of
restriction at school and in public places all contribute to the high rate of adolescents smoking
in Indonesia.
7,10
In Thailand, significant predisposing factors for adolescent smoking have been
shown to be having close friends smoking and having smoking siblings.
11,12
Many studies have
correlated adolescent smoking with the parents smoking status,
13,14
but the role of family in the
control of adolescent smoking behavior has been poorly investigated.
2
Despite the fact that in both Malaysia and Thailand evidence has consistently suggested that
male adolescents are much more likely to report smoking behaviors than female adolescents,
15

recent studies have shown that there is a continuous rise in female in Malaysia.
16
The increase in
Al-Sadat et al. 177S
smoking rates among young people will have devastating effects on the future generations of the
countries. The tobacco industry is well aware of the trend of smoking among adolescents and
is using this advantage to promote smoking among young people. It cannot be stressed enough
that is timely to intervene now while rates of tobacco use are still relatively lower than predicted
future rates.
Burden of Ill Health Caused by Tobacco in Southeast Asia
Evidence of the harmful effects of tobacco has existed for centuries, at first in relation to oral
cancer and then to vascular diseases and lung cancer;
17
however, even though smoking is often
initiated early in life, its most obvious health consequences are not seen until later stages in life,
when they manifest as various chronic problems in adulthood through old age. Because of late
onset of symptoms, most smokers are oblivious of the harmful effects of cigarette smoking.
18

One of the obvious implications of tobacco use is addiction or dependence, which is a state of
drug-seeking behavior. It is well established that multiple nicotinic receptors reside in the central
nervous system that are stimulated on nicotine intake; hence cigarette smokers have higher levels
of brain nicotine receptors than do nonsmokers.
19
Another implication of serious consequences of tobacco use is the link between smoking
and cancer. This relationship has been re-enforced in many studies across Southeast Asia.
20
In
the International Correlation With Disease in the Asian Pacific report it was quoted that
Comparison of WHO data for smoking in the Asian Pacific countries and their incidence rates
gives a clear pointer to the importance of smoking, and particularly the numbers of cigarettes
consumed, in terms of lung cancer, a positive correlation of r = .56, P < .005 was reported.
21
Another implication is the influence of cigarette smoking on other respiratory illnesses.
Smoking cigarettes is a known risk factor for chronic obstructive pulmonary disease (COPD),
asthma, interstitial lung diseases, respiratory tract infections, and pulmonary tuberculosis.
22-24

The prevalence of COPD has been on the rise in Southeast Asia as has been shown in a 10-year
comparison between 1990 and 2000. Smoking is the most important risk factor for COPD in
Southeast Asia, which therefore makes smoking indirectly responsible for the increased disabil-
ity life adjusted years (DALY) and the mortality due to COPD in the region.
Smoking in adolescence is associated with other high-risk behaviors leading to premature
deaths. Current statistics shows smoking-related diseases kill 1 in 10 adults, and if the current
trend continues, smoking-related diseases will kill 1 in 6 adults by the year 2030 globally.
25
The
vast majority of these adults would have started smoking during their adolescent life. The total
annual tobacco deaths in the year 2000 in developed countries was 2 million with a projection of
3 million deaths by 2030, and 2 million in the developing countries with a projection of 7 million
deaths by 2030. Acute smoking-related problems that adolescents and also adults may encounter
include the following: irritability, restlessness, sleep disturbance, increased appetite, anxiety,
difficulty in concentrating, depressed mood, and craving for more cigarettes.
Active adolescent smokers are more likely to have reduced rate of lung growth, be less
physically fit, more likely to experience shortness of breath, coughing spells, phlegm produc-
tion, wheezing, and overall diminished physical health. Adolescent smokers tend to move to
marijuana, alcohol, and hard drugs as well as being engaged in risky life behaviors.
26
They are
more often absent from school and are poor academic achievers with low aspirations.
27
Another concern is that active adolescent smokers are more likely to have low self-esteem,
which predisposes to suicide ideations. Psychologically they have poor social skills, difficulty
coping with stress, high stress levels, and they tend to have infertility problems because of
decreased sperm counts or erectile dysfunctions.
28
Smoking adolescent pregnant mothers tends
to deliver babies with low birth weight or have abortion.
29
178S Asia-Pacic Journal of Public Health Supplement to 22(3)
Tobacco Control Policies in Southeast Asia
Tobacco smoking is one of the social problems governments attempt to mitigate by creating
public policy initiatives. Many such policies are being implemented in the Southeast Asian coun-
tries. All the countries in Southeast Asia except for Indonesia have adopted the plan to operation-
alize the Framework Convention on Tobacco Control (FCTC) created during the Hong Kong
summit.
30
This plan is the first regional effort with targets and indicators and also encompasses
guides to avoid conflict of interest with the major tobacco industries. Subsequently, most of the
countries in Southeast Asia and especially those in the Western Pacific region are recording slow
but steady declining rates of smoking prevalence. In Malaysia, the Ministry of Health has pro-
jected tobacco will not be a major public health problem by the year 2020. Also, Hong Kong has
had a declining rate of smoking from 23% in 1992 to 14% in 2005 and further 12% in 2008.
30
Success achieved in lowering smoking prevalence in the Western Pacific region is linked to
enforcement of the ban on tobacco advertisements in some countries and taxation policies. It has
also been shown that continuous increase in tobacco taxes and prices can lead to a reduced demand
in smoking, as shown by a study in Malaysia.
31
Other measures are banning sports sponsorship by
tobacco companies and legislation restricting smoking in public places. There are, however, few
adolescent-specific policies in most of the Southeast Asian countries. Overall decline in smoking
prevalence will be misleading if it is assumed that adolescents smoking rates are declining as
well. Persons younger than 18 years are restricted from purchasing cigarettes in most Southeast
Asian countries, but adherence to the law is rare.
Corporate organizations, particularly the tobacco industry, relentlessly target the adolescent
age group through direct and indirect marketing and promotions. Although the industry also
promotes youth smoking prevention programs through schools and civic groups in several of
the regions member states and areas (including Australia, Guam, Japan, Laos PDR, Malaysia,
Papua New Guinea, the Philippines, and Vietnam), most of these prevention programs are
shown to be ineffective and, in some cases, counterproductive in preventing tobacco use.
Conclusion
Tobacco smoking remains a source of public health concern in Southeast Asia despite some suc-
cess in achieving a gradual decline in prevalence rates among countries in the region. More
vigorous target-oriented goals are needed to address rising trends of smoking among girls and
young smokers in general. Global governance is a prerequisite and pressure on the regional
countries to uphold the World Health Organization framework convention on tobacco control, is
required to strengthen the regional effort in containing this serious public health problem.
Another recommendation is to ensure that surveillance of the tobacco industry is upheld at a
regional level. Strong political will is needed to tame the increasing intensity of tobacco marketing
to consolidate and sustain any success in anti-smoking campaigns. More comprehensive and
aggressive enforcement of the domestic tobacco control laws such as smoke-free public places,
bans on tobacco advertising and sponsorship, prohibition of sales to and by minors, plus intensi-
fication of anti-tobacco promotion and advocacy, is required at a regional level.
The public health community must recognize that tobacco use is a global problem that needs
international collaboration as well as regional consolidation. We as public health practitioners need
to consolidate our actions toward active, evidence-based interventions. It is also envisaged that a
double-pronged strategy in health promotion (using both upstream and downstream policies) is
needed to effectively curb the lethal public health problem of tobacco.
Al-Sadat et al. 179S
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of
this article.
Funding
The author(s) received no financial support for the research and/or authorship of this article.
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