Introduction: Tobacco initiation during adolescence remains a critical contributor to India’s cardiovascular and oral-disease burden. With early initiation often occurring between 12–16 years, understanding determinants of first use across the school-to-work transition is essential for prevention. This prospective study evaluated sociodemographic, behavioral, and psychosocial predictors of smokeless tobacco and paan initiation among adolescents in India. Methods: A cohort of 2,412 students (mean age 16.2 ± 1.1 years; 53% female) from 12 secondary schools in western India, a was followed prospectively for 18 months as they transitioned to employment or higher education. Baseline variables included peer and parental use, perceived harm, marketing exposure, stress, and impulsivity. New initiation of smokeless tobacco or paan was recorded at 6-, 12-, and 18-month intervals, with salivary cotinine validation in a 10% random subsample. Cox proportional hazards models identified independent predictors (p < 0.05). Results: At 18 months, 17.4% (95% CI 15.6–19.2) reported new use of tobacco or paan; rural participants showed significantly higher initiation (21.3% vs 13.1% urban, p < 0.01). The median age at first use was 14.6 years (IQR 13–16). Males were nearly 2.5 times more likely to initiate than females (HR 2.5, 95% CI 1.8–3.3). Independent predictors included peer use (HR 2.7, 1.9–3.6), exposure to tobacco/paan marketing (HR 1.9, 1.4–2.5), low perceived harm (HR 1.6, 1.2–2.1), and parental use (HR 1.5, 1.1–2.0). Rural residence independently predicted initiation (HR 1.8, 1.3–2.4) after adjustment for socioeconomic status. High school connectedness (HR 0.7, 0.5–0.9) and accurate awareness of oral health risks (HR 0.8, 0.6–1.0) were protective. Population-attributable fraction estimates suggested that eliminating peer and marketing exposure could prevent approximately 42% of new initiations. Conclusions: Adolescent initiation of smokeless tobacco and paan in India predominantly occurs between 12–16 years, with highest risk among rural males influenced by peer behavior, family modeling, and aggressive marketing. Strengthening early adolescent interventions, enforcing point-of-sale restrictions in rural areas, and incorporating peer-led and digital harm-perception modules into school-exit programs could substantially reduce future tobacco uptake and its cardiometabolic consequences.
Mehta et al. (Tue,) studied this question.