A survival analysis of factors associated with tobacco initiation among school-going adolescents in Zambia using the 2021 Global Youth Tobacco Survey

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 determinants remain 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 of tobacco initiation, 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 WHO FCTC and MPOWER strategies, and informing Zambia’s adolescent-focused tobacco prevention policies.