Pou abha i Lang oudi, Ashkan e al.
A icle — Published Ve sion
Age o obacco smoking ini ia ion among I anian adul s based on
Na ional and Subna ional da a om he 2021 STEPS su ey: Sho i le:
Tobacco Smoking Onse Age in I an
Scien i ic Repo s
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among I anian adul s based on Na ional and Subna ional da a om he 2021 STEPS su ey: Sho
i le: Tobacco Smoking Onse Age in I an, Scien i ic Repo s, ISSN 2045-2322, Sp inge Na u e,
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Age o obacco smoking ini ia ion
among I anian adul s based on
Na ional and Subna ional da a
om he 2021 STEPS su ey
Sho i le: Tobacco Smoking Onse Age in I an
Ashkan Pou abha i Lang oudi 1,8, Yose Fa zi1,8, Golaleh Almasi1,
Zah a Shok i Va niab 1, Mohsen Abbasi-Kange a i1, Nega Rezaei1, Ali Goles ani1,
Nase Ahmadi1, Nazila Rezaei1, E an Ghasemi1, Sina Azadnaja abad 1,
Ma yam Nasse inejad1,2, Mohammad-Mahdi Rashidi1, Ameneh Kazemi1, Moein Yoose i1,3,
Elmi a Fo ou an Meh 1, Rosa Haghshenas1, Saha Saeedi Moghaddam 1,4,
Ami ali Hajebi1, Saha Mohammadi Fa eh1, Mana Moghimi1, Azadeh Momen Nia Rankohi1,
Massomeh A sa i5, Shi in Djalalinia6 & Fa shad Fa zad a 1,7
Tobacco smoking is a signi ican global public heal h challenge, esponsible o 8 million dea hs
annually. This s udy aimed o analyze he age o smoking ini ia ion and i s sociodemog aphic
de e minan s among I anian adul s, based on da a om he 2021 STEPwise app oach o su eillance
(STEPS) su ey, o in o m a ge ed public heal h in e en ions. The analysis o 27,874 adul s e ealed
ha he a e age ini ia ion ages o ciga e e and hookah smoking we e 22.2 yea s and 24.9 yea s,
espec i ely. Men ypically began smoking ea lie han women, wi h a e age ages o 21.9 yea s o
males and 27.7 yea s o emales. No signi ican di e ences we e obse ed in smoking ini ia ion
ages be ween u al and u ban a eas. Educa ion le el and ma i al s a us we e also in luen ial, wi h
he younges ini ia o s ha ing 7–12 yea s o educa ion and being single. This s udy highligh s he
signi ican oles o gende , educa ion, and u ban- u al di e ences in smoking ini ia ion in I an. The
indings unde sco e he need o a ge ed public heal h s a egies con o ming o he WHO’s MPOWER
ini ia i es and he F amewo k Con en ion on Tobacco Con ol (FCTC). Inc eased in es men in public
heal h, ocusing on educa ion and p e en i e measu es, is c ucial o educe ea ly smoking ini ia ion
and i s associa ed heal h isks, ul ima ely suppo ing b oade heal h policy goals.
Keywo ds Age o onse , Tobacco Smoking, Tobacco Use, Ciga e e smoking, Smoking Wa e pipes, I an
Abb e ia ions
NCD Noncommunicable disease
WHO Wo ld Heal h O ganiza ion
CDC Cen e s o Disease Con ol and P e en ion
CI Con idence in e al
OR Odds a io
FCTC F amewo k Con en ion on Tobacco Con ol
1Non-Communicable Diseases Resea ch Cen e , Endoc inology and Me abolism Popula ion Sciences Ins i u e,
Teh an Uni e si y o Medical Sciences, Teh an, I an. 2Cen e o Li e Cou se Heal h Resea ch, Facul y o
Medicine, Uni e si y o Oulu, Oulu, Finland. 3Depa men o Ma hema ics and S a is ics, Memo ial Uni e si y o
New oundland, S . John’s, NL, Canada. 4Kiel Ins i u e o he Wo ld Economy, Kiel, Ge many. 5NCD Managemen
O ice, Minis y o Heal h and Medical Educa ion, Teh an, IR, I an. 6De elopmen o Resea ch and Technology
Cen e , Depu y o Resea ch and Technology, Minis y o Heal h and Medical Educa ion, Teh an, I an. 7Endoc inology
and Me abolism Resea ch Cen e , Endoc inology and Me abolism Clinical Sciences Ins i u e, Teh an Uni e si y o
Medical Sciences, Teh an, I an. 8Ashkan Pou abha i Lang oudi and Yose Fa zi con ibu ed equally as i s au ho s.
email: [email p o ec ed]
OPEN
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Tobacco smoking, he mos signi ican beha io al isk ac o o noncommunicable diseases (NCDs), accoun s
o app oxima ely 8million dea hs globally each yea 1,2. The widesp ead p e alence o ciga e e smoking,
ollowed by hookah smoking, unde sco es he u gen need o comp ehensi e obacco con ol measu es3,4. The
age a which indi iduals begin smoking is c i ically associa ed wi h long- e m ad e se ou comes, including an
inc eased isk o de eloping ch onic diseases, acing educa ional challenges, engaging in subs ance abuse, and
encoun e ing psychosocial issues5. Mo eo e , smoking ini ia ion a a young age signi ican ly inc eases he isk o
lung cance , he eby educing li e expec ancy by a leas a decade compa ed o ha o nonsmoke s6,7.
Add essing obacco use equi es a mul i ace ed app oach, encompassing global s a egies and legal ac s
such as he Wo ld Heal h O ganiza ion’s (WHO’s) F amewo k Con en ion on Tobacco Con ol (FCTC) and
he MPOWER measu es8. These s a egies aim o moni o obacco use, p o ec people om obacco smoke,
help people qui obacco, wa n people abou he dange s o obacco, en o ce ad e ising bans, and aise obacco
axes. They ep esen a conce ed e o o cu ail obacco use h ough comp ehensi e policy and public heal h
ini ia i es8.
Despi e he global push o s ingen obacco con ol, I an encoun e s unique hu dles in mi iga ing
obacco use among i s popula ion. The p e alence o obacco consump ion ac oss all age g oups in I an was
app oxima ely 14.01% in 2021, wi h p ojec ions om he WHO sugges ing a po en ial dec ease o 12.8% by
2025, con ingen upon he pe sis ence o cu en con ol s a egies4,9. This highligh s he c i ical need o an
in-dep h unde s anding o smoking beha io s, pa icula ly he age o ini ia ion, as a ounda ional elemen o
e ec i e public heal h s a egies.
E en sligh a ia ions in he age o smoking ini ia ion can signi ican ly impac mo ali y isk se e al decades
la e , highligh ing he p o ound long- e m consequences o ea ly obacco use. Ea ly ini ia ion is no ably linked
o highe le els o nico ine dependence and an inc eased likelihood o escala ing obacco consump ion,
whe eas indi iduals who begin smoking a an olde age end o exhibi lowe consump ion in ensi y10. The
ini ia ion age o smoking may be in luenced by he s eng h and na u e o an i-smoking e o s, as well as
sociodemog aphic ac o s such as educa ion le el, employmen s a us, and social en i onmen 11,12. In Spain,
lowe socioeconomic s a us, including ac o s like lowe educa ion le els and unemploymen , has been linked
o highe smoking a es, unde sco ing signi ican socioeconomic dispa i ies in obacco use11. Simila ly, in he
Uni ed S a es and Canada, social in luences, alcohol and d ug use, and s ess con ibu e o smoking ini ia ion
among young adul s, wi h a ge ed p e en ion p og ams p o ing e ec i e when ocused on coun e -ma ke ing
and eshaping social no ms13. E ec i e policies ha e he po en ial o delay o al oge he p e en he ini ia ion o
smoking12. Con e sely, in he absence o such in e en ions, he e is a isk ha indi iduals may begin smoking
a inc easingly younge ages, posing addi ional challenges o public heal h in he u u e14.
Howe e , he e is a no able gap in he li e a u e ega ding he speci ic pa e ns o smoking ini ia ion wi hin
he I anian con ex , especially conside ing he la es da a. P e ious s udies, including he STEPwise app oach o
ch onic disease isk ac o su eillance (STEPS) conduc ed in 2016, ha e p o ided aluable insigh s ye ha e le
c ucial ques ions unanswe ed abou he cu en s a e and ends in smoking ini ia ion age8,15. This knowledge
gap is especially pe inen o in o ming policymaking and designing a ge ed in e en ions aimed a educing
obacco use among he I anian populace.
The p ima y aim o his s udy is o examine he age o smoking ini ia ion among I anian adul s and iden i y
key sociodemog aphic ac o s associa ed wi h smoking beha io s. U ilizing da a om he 2021 STEPS su ey,
we seek o add ess gaps in he li e a u e and suppo he de elopmen o a ge ed public heal h policies aimed a
educing obacco use in I an.
Ma e ials and me hods
S udy o e iew and design
The STEPS is a s anda dized and uni ied moni o ing su ey es ablished by he WHO o collec , assess, and
dis ibu e c i ical da a om pa icipa ing na ions16,17. Fo his s udy, we u ilized da a om he 2021 I anian
STEPS s udy, he eigh h ound o a na ional c oss-sec ional su ey on NCD isk ac o s. The su ey collec ed
da a h ough a h ee-pa p ocess: s anda dized ques ionnai es, physical measu emen s, and labo a o y es s,
ollowing WHO guidelines. Da a collec o s, ained in su ey me hods, ollowed WHO guidelines o ensu e
uni o mi y and eliabili y o sel - epo ed in o ma ion ac oss pa icipan s. The comple e epo o he p o ocol
o I an STEPS 2021 is eadily accessible, p o iding comp ehensi e de ails o he s udy18.
S udy popula ion
The s udy popula ion included I anian indi iduals aged 18 and olde esiding in I an a he ime o da a
collec ion. A clus e andom selec ion me hod was employed o selec pa icipan s om all 31 I anian p o inces,
encompassing bo h u ban and u al a eas. To ensu e ep esen a i e co e age o I anians aged 18 and olde ac oss
all p o inces, a o al o 3176 da a collec ion clus e s we e es ablished. The inal da a collec ion in ol ed 28,821
indi iduals; howe e , 947 pa icipan s declined o pa icipa e o we e unable o be en olled.
Va iables
Smoking age o onse was e alua ed using he STEPS ques ionnai e, as ecommended by he Wo ld Heal h
O ganiza ion (WHO) o na ional STEPS su eys. Fo each ype o p oduc , we que ied pa icipan s abou hei
cu en use and age a ini ia ion. Pa icipan s we e asked, ‘Ha e you e e used any obacco p oduc s, such as
ciga e es, ciga s, hookah, pipes, smokeless obacco, o elec onic ciga e es?’ and hen hey chose he ype o
obacco p oduc s hey used. The STEPS su ey collec ed da a on a ious obacco p oduc s, including ciga e es,
hookah, e-ciga e es, and smokeless obacco; howe e , due o limi ed da a on less commonly used p oduc s,
his s udy p ima ily ocuses on ciga e e and hookah use, he mos p e alen o ms in I an. Pa icipan s we e
also asked, ‘A wha age did you i s s a smoking ciga e es, hookahs, pipes, smokeless obacco, o elec onic
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ciga e es?’ Sociodemog aphic a iables included age, esiden ial a ea (u ban o u al), educa ional a ainmen
(0, 1–7, 7–12, and 12 + yea s), ma i al s a us (single, ma ied, di o ced/sepa a ed, and widowed), employmen
s a us (public sec o employee, public sec o labo e , p i a e sec o employee, p i a e sec o labo e , sel -
employed, unpaid wo k, e i ed, unemployed due o disabili y, unemployed seeking job, and unemployed no
seeking wo k). To de i e he weal h index, ques ions ega ding he asse s o he household o each pa icipan
we e u ilized, and p incipal componen analysis (PCA) was pe o med o de i e he weal h index o each
pa icipan and subsequen ly di ided in o quan iles.
The obacco-age o onse a iables included di e en o ms o smoking, namely, ciga e e smoking and
hookah use. Wi hin his s udy, we calcula ed he a e age age a smoking ini ia ion ac oss six age g oups—18–24,
25–34, 35–44, 45–54, 55–64, 65–74, and 75+— o all he de ined smoking ca ego ies.
S a is ical analysis
Da a weigh ing was applied o ensu e ep esen a i eness by add essing non- esponse a es and demog aphic
dispa i ies h ough a ou -s age p ocedu e. This included adjus men s o (1) gene al non- esponse, which
conside ed he o e all esponse a e o co ec o po en ial biases om pa icipan s who did no comple e he
su ey, (2) phase-speci ic non- esponse a each su ey s ep (ques ionnai es, physical, and lab measu emen s),
accoun ing o indi iduals who pa icipa ed in some pa s o he su ey bu no o he s, (3) demog aphic
weigh ing o e lec he dis ibu ion o age, sex, and a ea, and (4) a comp ehensi e adjus men ha combined
hese ac o s o op imize he alidi y o he analysis, ensu ing he sample’s ep esen a i eness o he I anian
popula ion’s demog aphic s uc u e. Addi ionally, clus e sampling was conduc ed ac oss 31 p o inces o
accoun o popula ion dis ibu ion, p o iding a balanced ep esen a ion o u ban and u al a eas in I an.
De ailed weigh ing equa ions and me hodology speci ics a e desc ibed in he I an STEPS p o ocol, o e ing
insigh in o handling complex su ey da a ac oss la ge, di e se popula ions18.
Ou desc ip i e analysis ocused exclusi ely on cu en smoke s, excluding indi iduals who had qui smoking
p io o he su ey o concen a e on ac i e consump ion pa e ns. We epo ed he mean age a smoking
ini ia ion among cu en obacco use s along wi h he co esponding 95% con idence in e als (CIs). The CI
was used o compa e he da a and de e mine he s a is ical signi icance o di e ences. All essen ial da a analyses
and isualiza ions, including he map in Fig.1, we e pe o med using he R s a is ical package ( 3.4.3, h p : / / w
w w . - p o j e c . o g , RRID: SCR_001905).
E hical conside a ion
This s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki, and all me hods we e pe o med
in line wi h he guidelines and egula ions se o h by he e hical commi ee o Teh an Uni e si y o Medical
Sciences unde e hical code IR.TUMS.NIHR.REC.1398.006. The p o ec ion o pa icipan s’ da a was ensu ed
by all au ho s. The s a is ical modeling used in he analysis does no in ol e any indi idual-le el da a, and he
esul s a e solely de i ed om s a is ical models. Pa icipan s p o ided in o med consen o he o iginal su ey,
I an STEPS 2021.
Resul s
The s udy analyzed da a om 27,874 pa icipan s, comp ising 44.77% males and 55.23% emales. The baseline
cha ac e is ics o he sample included in his s udy a e p esen ed in Supplemen a y Table S1. We obse ed
ha he mean age a ciga e e smoking ini ia ion was 22.18 yea s (95% CI: 21.81–22.55), wi h males ini ia ing
smoking ea lie (mean age 21.92 yea s, 95% CI: 21.55–22.29) han emales (mean age 27.73 yea s, 95% CI:
25.57–29.88). Hookah smoking ini ia ion p esen ed a simila gende dispa i y, commencing on a e age a 24.89
yea s (95% CI: 24.23–25.55), wi h males beginning a 23.95 yea s (95% CI: 23.08–24.82) and emales beginning
a 26.06 yea s (95% CI: 25.07–27.05). In iguingly, compa ed wi h women, men aged 18 o 44 yea s-ini ia ed
hookah smoking a a younge age, which was e e sed in pa icipan s o e 45 yea s, whe e women had a lowe
mean ini ia ion age. (Table1)
Educa ion le el signi ican ly in luenced smoking ini ia ion, wi h indi iduals holding 7–12 yea s o schooling
s a ing ciga e e smoking a he younges mean age o 20.96 yea s (95% CI: 20.41–21.52). Among hose who
smoked om hookah, hose wi h mo e han 12 yea s o educa ion had he lowes mean age, a 22.53 yea s
(95% CI: 21.78–23.28) o bo h sexes, 23.51 yea s (22.31–24.71) o emales and 22.02 yea s (21.08–22.97) o
males. (Table1) Ma i al s a us u he impac ed smoking onse , wi h single indi iduals beginning a he ea lies
o bo h ciga e es (mean age 19.71 yea s, 95% CI: 19.00- 20.43) and hookah (mean age 19.05 yea s, 95% CI:
18.48–19.63), con as ing wi h widows who had he highes ini ia ion ages (30.29 yea s, 25.76–34.82 o ciga e e
smoke s and 32.19 yea s; 28.33–36.04 o hookah smoke s) (Table2).
Ou analysis demons a ed ha he mean age a ciga e e smoking ini ia ion did no signi ican ly di e
be ween u al and u ban esiden s, wi h a e ages o 21.95 yea s (21.2–22.69) o bo h sexes in u al a eas and
22.26 yea s (21.84–22.69) o bo h sexes in u ban a eas. Wi hin hese g oups, u al emales s a ed smoking a
a mean age o 25.52 yea s (20.85–30.19), while u ban emales began smoking a 28.13 yea s (25.73–30.52). Fo
males, he mean ini ia ion age was 21.84 yea s (21.09–22.6) in u al se ings and 21.95 yea s (21.53–22.37) in
u ban se ings, indica ing ha men in u ban a eas end o s a smoking a a younge age han women. The e
was no no able di e ence in he a e age age o hookah smoking ini ia ion be ween u al a eas (24.53 yea s;
23.42–25.64) and u ban a eas (22.26 yea s; 21.84–22.69) (Table1).
Addi ionally, ciga e e smoke s who we e unemployed and no seeking wo k s a ed smoking a he lowes
mean age (19.75 yea s, 17.48–22.03), while hose wi h unpaid wo k had he highes mean age a ciga e e
smoking onse (25.54 yea s, 23.57–27.5). The e we e no signi ican di e ences in he mean age a ciga e e
smoking ini ia ion ac oss all i e weal h indices, wi h ages anging om 19.14 yea s (17.23–21.05) o 22.63
yea s (21.8–23.46). The job si ua ion e lec ed hose unemployed indi iduals seeking wo k had he ea lies mean
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Va iable
Ca ego y Mean age onse o ciga e e smoking (95%CI*) Mean age onse o hookah smoking (95%CI)
Sex Bo h Female Male Bo h Female Male
Age g oups
18–24 17.25 (16.65–17.85) 18.46 (17.78–19.14) 17.2 (16.58–17.82) 17.37 (16.94–17.8) 18.08 (17.06–19.1) 17.11 (16.67–17.55)
25–34 19.55 (18.99–20.12) 22.93 (17.01–28.84) 19.42 (18.9–19.95) 20.8 (20.3–21.3) 22.15 (21.32–22.98) 19.93 (19.34–20.51)
35–44 21.94 (21.36–22.53) 27.24 (23.48–31.01) 21.72 (21.14–22.3) 26.08 (25.09–27.06) 26.38 (24.79–27.98) 25.84 (24.61–27.07)
45–54 22.25 (21.53–22.97) 28.47 (23.28–33.66) 22.01 (21.29–22.72) 31.61 (29.82–33.39) 30.56 (28.22–32.89) 33.02 (30.28–35.76)
55–64 22.92 (22.05–23.8) 29.9 (25.57–34.22) 22.51 (21.64–23.39) 33.1 (30.04–36.16) 31.1 (27.41–34.79) 36.97 (31.71–42.22)
65–74 25.24 (23.63–26.84) 27.21 (21.67–32.75) 25.13 (23.47–26.8) 32.2 (26.63–37.77) 29.15 (22.88–35.41) 38.63 (28–49.26)
75+ 28.38 (24.11–32.65) 31.83 (21.91–41.74) 27.98 (23.37–32.58) 36.48 (27.25–45.71) 34.45 (25.7–43.19) 37.6 (24.14–51.05)
A ea o esidency u al 21.95 (21.2–22.69) 25.52 (20.85–30.19) 21.84 (21.09–22.6) 24.53 (23.42–25.64) 25.94 (24.16–27.72) 23.34 (22–24.69)
u ban 22.26 (21.84–22.69) 28.13 (25.73–30.52) 21.95 (21.53–22.37) 25.02 (24.21–25.82) 26.1 (24.91–27.3) 24.16 (23.08–25.24)
Yea s o educa ion
0 23.88 (22.29–25.48) 28.84 (24.87–32.82) 23.13 (21.44–24.83) 27.23 (24.6–29.85) 26.84 (23.87–29.8) 28.69 (23.14–34.24)
1–7 22.04 (21.27–22.81) 27.51 (22.48–32.54) 21.86 (21.1–22.63) 28.33 (26.61–30.05) 28.08 (26.11–30.06) 28.73 (25.54–31.93)
7–12 20.96 (20.41–21.52) 26.91 (21.65–32.18) 20.87 (20.31–21.43) 24.84 (23.63–26.05) 26.43 (24.46–28.41) 24.08 (22.56–25.59)
12+ 22.82 (22.23–23.4) 27.21 (23.8–30.63) 22.56 (21.98–23.15) 22.53 (21.78–23.28) 23.51 (22.31–24.71) 22.02 (21.08–22.97)
To al 22.18 (21.81–22.55) 27.73 (25.57–29.88) 21.92 (21.55–22.29) 24.89 (24.23–25.55) 26.06 (25.07–27.05) 23.95 (23.08–24.82)
Table 1. Mean onse age o smoking by age g oups, a ea o esidency and yea s o educa ion. * CI: Con idence
in e al.
Fig. 1. Geog aphic dis ibu ion o ea ly onse age o ciga e e smoking in I an. C ea ed using he R s a is ical
package ( e sion 3.4.3, h p://www. -p ojec .o g).
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onse age o hookah smoking (19.08 yea s, 17.93–20.23), while e i ees s a ed a an olde age (41.36 yea s, CI
34.43–48.3). (Table2) The analysis showed no subs an ial a ia ion in smoking ini ia ion ac oss weal h indices,
wi h a ela i ely na ow ange ac oss di e en quin iles (Table2).
The dis ibu ion o he a e age age o ciga e e smoking ini ia ion in I an e ealed highe a es o ea ly
ciga e e smoking ini ia ion in he no hwes and pa s o he sou hwes and midwes , as illus a ed in Fig.1.
Pa icipan s om Ku dis an P o ince had he lowes mean age o ciga e e smoking onse (18.68 yea s; 16.93–
20.42), while pa icipan s om Goles an P o ince had he highes (25.71 yea s; 23.02–28.4). In mos p o inces,
he mean age a ciga e e smoking ini ia ion was lowe o males han o emales. Rega ding hookah smoking,
pa icipan s om Kho asan, Sou h P o ince, had he lowes a e age age a hookah smoking ini ia ion (19.26
yea s, 17.04–21.49), while pa icipan s om Kho asan, Raza i P o ince, had he highes a e age age (26.04
yea s, 24.3–27.78). The lowes mean age o onse o hookah smoking in emales was 17.77 yea s (15.23–20.3)
in Albo z, and he highes was 34.36 yea s (23.94–44.78) in Kho asan, No h. The lowes mean age a hookah
smoking ini ia ion in males was 17.52 yea s (15.54–19.49) in Gilan, and he highes was 26.05 yea s (14.12–
37.99) in Albo z (Supplemen a y Table S2).
Discussion
This s udy in es iga ed he ini ia ion age o smoking p oduc s using a na ional and subna ional ep esen a i e
sample in I an, a low- o middle-income coun y. The main indings e ealed ha he mean age o onse o
ciga e e smoking (22.18 yea s) was lowe han ha o hookah smoking (24.89 yea s), wi h males gene ally
s a ing o smoke a a younge age han emales (21.92 s. 27.73 yea s, espec i ely). No ably, single indi iduals
exhibi ed he lowes a e age age a ciga e e smoking ini ia ion. Among hookah smoke s, hose wi h mo e han
12 yea s o educa ion had he lowes mean ini ia ion age. Fu he mo e, ou analysis e ealed nonsigni ican
di e ences in he mean ini ia ion age be ween u al (21.95 yea s) and u ban a eas (22.26 yea s).
O e ime, he age o smoking ini ia ion in I an has shown a iabili y, which e lec s shi s in social no ms
and he impac o public heal h in e en ions. A 2007 su ey on NCD isk ac o s epo ed an a e age ini ia ion
age o 20.5 yea s, wi h men s a ing a 20.4 yea s and women a 24.2 yea s19. Subsequen da a om he STEPS
su eys be ween 2000 and 2011 also demons a ed luc ua ions in ini ia ion ages, culmina ing in highe epo ed
ages in 2016 o 23.3 yea s o e all, 21.9 o men, and 25.5 o women20,21. Despi e hese yea - o-yea a ia ions,
he o e all end ac oss he his o ical da a om p e ious STEPS su eys sugges s a s abiliza ion in he age a
which indi iduals begin smoking, indica ing ha changes, while p esen , do no signi ican ly al e he gene al
onse age o e ime. Addi ionally, a egional s udy by Hamzeh e al., conduc ed be ween 2014 and 2017 in
wes e n I an, e ealed a mean age o 20.3 yea s o men and 25.19 yea s o women5, which aligns wi h ou
indings, pa icula ly in e ms o gende dispa i ies. Mo ing beyond egional compa isons, ou esul s also di e
signi ican ly om Eu opean pa e ns. Fo ins ance, a s udy conduc ed in Eu ope in 2012 epo ed an a e age
ini ia ion age o 17.6 yea s o smoke s, wi h men s a ing sligh ly younge han women22. Fu he mo e, a 2008
s udy highligh ed ha o e 80% o Eu opean women began smoking a he age o 20, a e aging an ini ia ion age
Va iable
Ca ego y Mean age onse o ciga e e smoking (95%CI*) Mean age onse o hookah smoking (95%CI)
Sex Bo h Female Male Bo h Female Male
Ma iage
s a us
Single 19.71 (19–20.43) 22.43 (18.23–26.63) 19.55 (18.85–20.26) 19.05 (18.48–19.63) 20.53 (18.9–22.15) 18.64 (18.08–19.21)
Ma ied 22.27 (21.87–22.67) 28.38 (25.46–31.3) 22.11 (21.71–22.51) 26.18 (25.36–27) 26.06 (24.92–27.2) 26.28 (25.12–27.44)
Di o ced/sep a e wi h pa ne 25.16 (22.03–28.29) 25.24 (19.03–31.44) 25.14 (21.55–28.73) 26 (22.89–29.11) 26.19 (23.34–29.05) 25.29 (15.33–35.25)
Widow 26.77 (23.42–30.13) 30.29 (25.76–34.82) 22.34 (18.5–26.18) 32.19 (28.33–36.04) 31.48 (27.49–35.47) 43.92 (38.08–49.75)
Job
si ua ion
Public sec o employee 22.86 (20.99–24.73) 34.52 (28.28–40.76) 22.55 (20.69–24.4) 23.05 (21.07–25.04) 27.82 (23.16–32.49) 22.22 (20.17–24.27)
Public sec o labo 19.8 (17.75–21.84) N/A 19.8 (17.75–21.84) 25.59 (21.92–29.26) 24 (24–24) 25.77 (21.71–29.82)
P i a e Sec o Employee 22.09 (20.69–23.5) 23.02 (21.17–24.86) 22.05 (20.57–23.52) 25.84 (23.33–28.34) 24.23 (21.31–27.15) 26.45 (23.2–29.69)
P i a e Sec o labo 21.2 (20.06–22.33) N/A 21.2 (20.06–22.33) 24.16 (21.58–26.73) 24.63 (16.94–32.31) 24.11 (21.38–26.84)
F eelance job o sel -employed 21.75 (21.29–22.22) 27.7 (22.01–33.4) 21.69 (21.23–22.16) 23.4 (22.44–24.36) 24.59 (20.89–28.29) 23.27 (22.29–24.25)
Unpaid wo k 25.54 (23.57–27.5) 27.71 (25.19–30.23) 20.65 (18.58–22.72) 25.6 (24.56–26.63) 26.32 (25.21–27.42) 18.48 (17.24–19.72)
Re i ed 23.94 (22.74–25.13) 45.71 (17.37–74.06) 23.87 (22.68–25.06) 41.36 (34.43–48.3) 42.74 (31.08–54.39) 41.28 (33.94–48.61)
Unemployed due o disabili y 23.47 (20.51–26.43) N/A 23.47 (20.51–26.43) 29.29 (20.42–38.15) 29.77 (10.39–49.14) 29.09 (19.41–38.76)
Unemployed seeke job 20.04 (18.91–21.17) 21.52 (16.67–26.37) 20 (18.84–21.15) 19.08 (17.93–20.23) 20.05 (17.21–22.9) 18.94 (17.7–20.18)
Unemployed No seeking wo k 19.75 (17.48–22.03) N/A 19.75 (17.48–22.03) 24.24 (19.09–29.39) 21.31 (18.69–23.93) 28.07 (17.16–38.97)
No Decla ed 19.14 (17.23–21.05) 31.94 (26.58–37.3)
Weal h
index /
Na ional
1 22.47 (21.61–23.32) 28.51 (24.19–32.82) 22.13 (21.27–22.98) 24.53 (23.16–25.91) 26.44 (24.53–28.35) 21.89 (20.14–23.64)
2 22.03 (21.21–22.85) 26.76 (22.4–31.11) 21.73 (20.91–22.55) 25.2 (23.47–26.94) 26.24 (24.03–28.45) 23.98 (21.29–26.67)
3 21.99 (21.24–22.75) 28.29 (22.1–34.49) 21.81 (21.06–22.56) 26.48 (24.88–28.07) 26.97 (24.72–29.22) 26.08 (23.86–28.31)
4 21.89 (20.95–22.82) 29.58 (21.22–37.94) 21.75 (20.82–22.68) 24.4 (23.08–25.72) 26.33 (23.76–28.89) 23.44 (21.96–24.93)
5 22.63 (21.8–23.46) 27.49 (23.67–31.3) 22.27 (21.45–23.1) 24.36 (22.77–25.95) 24.24 (21.27–27.22) 24.39 (22.52–26.26)
Table 2. Mean onse age o smoking by ma iage s a us and weal h index job si ua ion. *CI: Con idence
in e al. *N/A: No a ailable da a.
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o 18.2 yea s23. These igu es a e subs an ially lowe han hose obse ed in ou I anian coho , whe e he mean
age a which smoke s s a ed smoking ciga e es was no ably g ea e .
Ini ia ing smoking a a young age has been consis en ly associa ed wi h a g ea e isk o subsequen egula
and hea y smoking la e in li e24. In luen ial ac o s o ini ia ing smoking include he in luence o iends (79%),
pa en al smoking (21%), and a liking o he as e o smell o obacco (19%)22. Al hough smoking adi ionally
ca ies a s igma, especially among I anian women, his end is shi ing as smoking becomes a symbol o gende
equali y and pe sonal eedom25. This shi con ibu es o he g ea e p opensi y o men o s a smoking a an
ea lie age han women, which signi ican ly impac s he p e alence o smoking- ela ed diseases, such as lung
cance 6.
Fu he mo e, i is commonly belie ed ha indi iduals wi h lowe incomes a e mo e esponsi e o changes
in obacco p ices, which could in luence hei smoking beha io s26. Con a y o his expec a ion, ou s udy
e ealed ha he mean age a ciga e e smoking ini ia ion was consis en ac oss all weal h indices. This
consis ency sugges s ha economic s a us does no signi ican ly impac he onse o smoking, possibly due o he
ela i e a o dabili y and widesp ead a ailabili y o ciga e es in I an, which makes hem accessible i espec i e o
economic s a us, indica ing a nonlinea ela ionship be ween weal h and smoking27,28. Addi ionally, Meysamie
e al. obse ed no signi ican di e ences in smoking ini ia ion be ween u ban and u al a eas19, consis en wi h
ou indings. Howe e , con as ing s udies om o he egions sugges ha u ban esiden s a e mo e likely o be
smoke s, a end a ibu ed o he s ess ul en i onmen s and g ea e social accep ance ound in u ban se ings29.
Fo ins ance, a s udy om Ge many demons a ed ha u ban dwelle s (bo h men and women) end o s a
smoking a younge ages and a e mo e likely o be hea y smoke s han hei u al coun e pa s, highligh ing he
need o a ge ed public heal h s a egies in u ban a eas30.
This s udy e ealed ha he mean age o smoking ini ia ion in I an and i s wes e n p o inces (Ilam,
Ke manshah, and Khuzes an) was gene ally g ea e han ha in ou neighbo ing coun y, I aq, whe e he a e age
ini ia ion age is 19.1 yea s, excep o he p o ince o Ku dis an31. This disc epancy wa an s u he in es iga ion,
especially wi h espec o I aqi Ku dis an, due o i s close geog aphical p oximi y. In con as , Tu key epo ed
a lowe a e age ini ia ion age o 18.1 yea s, sugges ing ea lie exposu e o smoking han I an and i s adjacen
p o ince, Wes Aze baijan32. Simila ly, o he eas , A ghanis an has a mean smoking ini ia ion age o 18.8 yea s,
which is lowe han ha in I an and i s eas e n p o inces, such as Kho asan Raza i, Kho asan Sou h, Sis an
and Baluchis an33. Howe e , Pakis an has a mean age o smoking ini ia ion compa able o ha o I an and i s
p o inces Sis an and Baluchis an, likely e lec ing sha ed cul u al and socioeconomic cha ac e is ics34. Mo ing
no h, A menia, Aze baijan, and Tu kmenis an epo ed lowe mean ages o smoking ini ia ion (18.1 yea s,
18.7 yea s, and 21.3 yea s, espec i ely) han I an and i s neighbo ing p o inces35–37. In e es ingly, acco ding
o Heyda i’s analysis o WHO epo s, I an was anked i s in implemen ing he MPOWER package in he
Eas e n Medi e anean egion be ween 2011 and 201938. This obus implemen a ion migh help explain why he
smoking ini ia ion age in I an is g ea e han ha in mos neighbo ing coun ies.
The age o hookah smoking ini ia ion a ied based on he s udy’s age ange; o example, in Sy ia, he e was a
signi ican di e ence in he ini ia ion age be ween uni e si y s uden s (mean age 22) and ca é smoke s (mean age
30)3. In ou s udy, hookah smoking ini ia ion was ound o occu a a la e age han ciga e e smoking, consis en
wi h he ends obse ed in he STEPS 2016 da a39. I has been ound ha hookah smoking is associa ed wi h
a g ea e han wo old inc ease in he likelihood o subsequen ciga e e smoking40. In I an, women mos ly use
hookah as a o m o en e ainmen , socializing, and o ming in ima e ela ionships41. Sighaldeh e al.‘s s udy
indica ed ha he a e age age o onse o hookah smoking among emale hookah smoke s in Teh an, I an, was
16.5 yea s41. This age is conside ably younge han wha was obse ed in ou s udy. These di e gen esul s
emphasize he impo ance o conside ing di e en s udy popula ions and con ex s when examining obacco
ini ia ion pa e ns. As a esul o inco ec pe cep ions abou hookah smoking, such as being less ha m ul han
ciga e es and being easie o s op, hookah smoking is likely o become mo e p e alen among adolescen s,
especially hose in high school20. As educa ion le el plays a key ole in p edic ing smoking, he smoking a e
dec eases wi h highe educa ion le els39. Bahei aeia e al.‘s s udy42 epo ed ha hookah smoking is mos
p e alen among I anian women wi h uni e si y educa ions. Ou s udy also e ealed ha women wi h he
highes le el o educa ion had he lowes a e age age a hookah smoking ini ia ion. This sugges s a po en ial
associa ion be ween educa ional a ainmen and hookah smoking ini ia ion age, especially among women.
These indings unde sco e he need o obus obacco con ol s a egies ailo ed o add ess he nuances o
obacco use ac oss di e en egions and popula ions wi hin I an. Since he a i ica ion o he global obacco
con ol con en ion on Oc obe 6, 2005, I an has ac i ely implemen ed MPOWER s a egies such as p omo ing
obacco- ee zones, en o cing ad e ising es ic ions, and ele a ing obacco axes43. These ini ia i es align wi h
he FCTC, which ad oca es o comp ehensi e measu es o p o ec he popula ion om obacco smoke, o e
cessa ion p og ams, and educa e people on obacco dange s44. Despi e hese e o s, challenges pe sis in he
o m o high smoking a es among you h, he p e alence o smuggled and o eign ciga e es, inadequa e public
awa eness, and limi ed en o cemen o exis ing obacco con ol policies45. Add essing hese challenges will
equi e enhanced educa ional p og ams ha accu a ely con ey he isks o smoking and he bene i s o cessa ion,
ailo ed o di e se demog aphic needs. Mo eo e , i is c ucial o he go e nmen o p io i ize unding o public
heal h ini ia i es aimed a u he educing smoking p e alence.
Looking ahead, I an’s commi men o he Uni e sal Heal h Co e age (UHC), Sus ainable De elopmen Goals
(SDGs), and WHO’s heal h objec i es is pi o al46. The la es esul s om he STEPS 2021 su ey indica e some
p og ess; howe e , o achie e hese in e na ional heal h a ge s, I an mus in ensi y i s e o s o ully implemen
bo h MPOWER s a egy and FCTC legal amewo k. Inc easing obacco axes and in eg a ing obacco cessa ion
p og ams in o b oade heal h co e age amewo ks a e essen ial s eps owa d his goal44,46.
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S eng hs and limi a ions
This s udy’s p ima y s eng h is i s la ge, ep esen a i e sample achie ed h ough weigh ed clus e sampling,
enhancing he gene alizabili y and s a is ical obus ness o he indings. Ou adhe ence o he WHO’s
s anda dized STEPS su ey p o ocols u he ensu e he eliabili y o ou da a. Howe e , he s udy’s c oss-
sec ional design limi s causali y in e ence be ween smoking ini ia ion age and heal h ou comes. Po en ial ecall
bias due o he sel - epo ed na u e o he da a collec ion and he omission o newe obacco p oduc s such as
apes and e-ciga e es a e no able limi a ions. Addi ionally, egional a ia ions in cul u al and socioeconomic
ac o s ha may a ec smoking beha io s ha e no been ex ensi ely explo ed. Fu u e s udies should in es iga e
addi ional sociodemog aphic ac o s and al e na i e obacco p oduc s, like e-ciga e es, o be e unde s and
eme ging ends in smoking. Longi udinal esea ch is also ecommended o e alua e he long- e m e ec s o
cu en an i-smoking policies and in e en ions on smoking ini ia ion and cessa ion in I an.
Conclusion
In conclusion, his s udy unde sco es ea ly smoking ini ia ion in I an, pa icula ly among men, unemployed
indi iduals, and educa ed indi iduals. The indings highligh he necessi y o a ge ed obacco con ol s a egies.
Despi e hese ad ancemen s, cu en ends sugges ha I an migh no mee he UHC and SDG a ge s ela ed
o noncommunicable diseases wi hou in ensi ied e o s. Adhe ing o he WHO’s MPOWER ini ia i es and
he FCTC could enhance hese s a egies. Tailo ed educa ional p og ams and inc eased obacco axes a e
ecommended o educe smoking a es e ec i ely. P io i izing hese in e en ions is c ucial o I an o p og ess
owa d achie ing i s heal h- ela ed SDGs.
Da a a ailabili y
The da ase s used and analyzed du ing he cu en s udy a e a ailable om he co esponding au ho upon
easonable eques .
Recei ed: 14 May 2024; Accep ed: 13 Janua y 2025
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Acknowledgemen s
The au ho s exp ess hei p o ound g a i ude o he Na ional Ins i u e o Heal h Resea ch o I.R. I an and he
Teh an Uni e si y o Medical Sciences o hei gene ous inancial suppo o he I an STEPS Su ey 2021.
Addi ionally, hea el hanks a e ex ended o e e y pa icipan who con ibu ed hei ime and insigh s o his
su ey, as well as o he dedica ed esea che s and s udy in es iga o s whose i eless e o s a a ious s ages o
he su ey’s execu ion and he dissemina ion o i s indings ha e been in aluable.
Au ho con ibu ions
APL: W i ing - o iginal d a /Concep ualiza ion/Fo mal analysis/Visualiza ion, YF: Fo mal Analysis/Me hodol-
ogy/Da a cu a ion, GA: Fo mal Analysis/Me hodology, ZSV: Supe ision/W i ing - o iginal d a , MAK, NGR:
Concep ualiza ion/Re iew & edi ing, AG, NR, EG, SA, MN, MMR: Me hodology/Da a cu a ion, AK, MY, EFM,
RH, SSM: Me hodology APL, ZSV, YF, ZSV, MAK, NGR, AG, AH, SMF, MM, AMR, MA, FF: Re iew & edi ing.
FF, NGR, NR: In es iga ion/Resou ces/P ojec adminis a ion. All he au ho s ha e ead and app o ed he inal
manusc ip .
Funding
This s udy was suppo ed by I.R. I an’s Na ional Ins i u e o Heal h Resea ch, Teh an Uni e si y o Medical
Sciences, I an (g an no. 241/M/9839).
Decla a ions
Compe ing in e es s
The au ho s decla e no compe ing in e es s.
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