Prevalence and factors associated with tobacco and nicotine product use among adolescents in the Democratic Republic of the Congo: evidence from a cross-sectional national household survey

A 2024 national cross-sectional survey in the Democratic Republic of the Congo revealed that 11.87% of adolescents currently use tobacco or nicotine products, with usage significantly influenced by gender, parental status, household education, and exposure to public smoking, thereby highlighting the urgent need for strengthened regulatory policies to curb accessibility and appeal.

The Gist

Imagine the Democratic Republic of the Congo (DRC) as a massive, bustling city where nearly 6 out of every 10 people are teenagers. In this city, there is a hidden "trap" set by tobacco companies, designed to catch young people before they even reach adulthood. This study is like a team of detectives who went door-to-door in this city to count exactly how many teenagers have fallen into that trap and why.

Here is what they found, broken down into simple stories:

The Big Picture: How Many Kids Are Caught?

Think of the 27.5 million teenagers in the DRC as a giant stadium. The researchers found that about 12 out of every 100 people in that stadium are currently using some kind of tobacco or nicotine product. That's roughly 3.3 million young people.

• The Main Culprit: The most common trap is the traditional cigarette (both the factory-made kind and the ones rolled by hand). About 8 out of 100 teens are smoking these.
• The Side Traps: About 6 out of 100 are using smokeless tobacco (like chewing tobacco or snuff).
• The New Traps: Very few kids are using the "new tech" traps like electronic cigarettes or heated tobacco products yet (less than 1 out of 100), but the door is open for them.

Who is Most Likely to Fall Into the Trap?

The study looked at the "weather conditions" that make it more likely for a teen to start smoking. Here are the patterns they found:

• Gender: Being a boy is like walking into a storm with an open umbrella. Boys are significantly more likely to use tobacco than girls.
• School is a Shield: Think of school as a protective force field. Teens who are currently in school are less likely to smoke. Those who have dropped out or never started school are much more exposed to the "smoke."
• Family Structure: It's a bit surprising, but teens living in households with a male head were more likely to smoke than those with a female head. The researchers suggest this might be because smoking is more common among men, so these teens see it happening at home more often.
• The "Both Parents Alive" Shield: Teens who have lost one or both parents were actually less likely to smoke in this specific study. The authors note this is an interesting finding, though they don't fully explain why, other than suggesting different social dynamics might be at play.
• The "Public Smoke" Effect: If a teen sees people smoking in public places (like markets or parks), it's like seeing a billboard advertising the product. This exposure makes them much more likely to try it themselves.
• Money: Having pocket money is like having the key to the candy store. Teens with more spending money are more likely to buy tobacco.

What the Study Did (The Detective Work)

Unlike previous studies that only looked at kids inside school buildings in just two big cities, this team went everywhere. They visited 4,675 homes across the whole country, including rural villages and urban neighborhoods. They asked kids aged 10 to 17 directly, ensuring they didn't miss the kids who aren't in school (who are often the most vulnerable).

The Solution: How to Close the Trap

The researchers suggest that to stop the trap from catching more kids, the government needs to change the rules of the game:

1. Raise the Price: Make tobacco so expensive that it's hard for kids to afford. They suggest raising taxes so that taxes make up at least 75% of the price (currently, they are only about 39%).
2. Ban "Single Sticks": Right now, kids can buy just one cigarette stick at a time. The study says this is like selling a single bullet instead of a whole box; it makes it too easy for poor kids to try it. They need to ban selling single sticks or tiny packs.
3. Ban Flavors: Stop selling tobacco that tastes like candy or fruit, which is like putting a cherry on top of a poison pill to make it look tasty.
4. Keep Schools Smoke-Free: Ban selling tobacco near schools and playgrounds.

The Bottom Line

This study is a wake-up call. It shows that in the DRC, tobacco use among teenagers is a widespread problem, especially for boys and those out of school. The "rules of the road" for tobacco need to be tightened to make it harder for young people to get their hands on these products before they get hooked.

Technical Summary

1. Problem Statement and Context

• Public Health Crisis: Tobacco use causes over 8 million deaths annually globally. Adolescents are a critical target group for initiation, with low- and middle-income countries (LMICs) seeing prevalence rates between 11–13%.
• The DRC Context: Approximately 58% of the Democratic Republic of the Congo (DRC) population is under 19 years old. Despite ratifying the WHO Framework Convention on Tobacco Control (FCTC) in 2005 and adopting Law No. 18/035 in 2018, implementation is poor. Regulatory gaps exist regarding single-stick sales, flavored products, and emerging nicotine products (e-cigarettes, heated tobacco).
• Data Gap: The last available data (2008 Global Youth Tobacco Survey) was limited to two urban areas (Kinshasa and Lubumbashi), covered only school-going adolescents aged 13–15, and excluded emerging products. There was no national data on out-of-school youth or modern nicotine products.

2. Methodology

• Study Design: A nationally representative, cross-sectional household survey conducted between March and May 2024.
• Target Population: Adolescents aged 10–17 years.
• Sampling Strategy:
  • Frame: Based on the National Health Information System, stratified by six historical provinces.
  • Selection: Multistage, stratified cluster sampling. 16 provinces were selected, followed by 48 health zones (HZs), 144 health areas (HAs), and finally 144 enumeration areas (EAs).
  • Sample Size: Calculated to detect a 25% prevalence (based on prior urban data) with a 95% confidence level, design effect of 1.5, and 10% non-response adjustment. The target minimum was 4,323; the final analyzed sample was 4,675 adolescents.
• Data Collection:
  • Face-to-face interviews using SurveyCTO on tablets.
  • Two questionnaires: Household (demographics, SES) and Adolescent (tobacco/nicotine use, exposure, knowledge).
  • Languages: French, Lingala, Swahili, Tshiluba, and Kikongo.
  • Ethics: Approved by the National Health Ethics Committee of the DRC; verbal consent/assent obtained due to cultural sensitivities.
• Statistical Analysis:
  • Software: STATA version 18.
  • Methods: Survey-weighted descriptive statistics and logistic regression to calculate Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CI).
  • Framework: Socio-ecological framework (individual, household, environmental factors).

3. Key Contributions

• First National Estimate: Provides the first comprehensive, nationally representative data on tobacco and nicotine use in the DRC, covering the 10–17 age range.
• Inclusion of Out-of-School Youth: Unlike previous school-based surveys, this study includes the ~11.5% of adolescents who are not in school, a group often at higher risk.
• Emerging Products: Captures data on heated tobacco products (HTP), electronic cigarettes, and nicotine pouches, which were previously unmeasured in the DRC.
• Multilevel Analysis: Identifies specific individual, household, and environmental factors associated with use, moving beyond simple prevalence rates.

4. Key Results

Prevalence Estimates

• Any Tobacco/Nicotine Product (Current Use): 11.87% (95% CI: 6.93–19.58). This represents approximately 3.27 million adolescents.
• Tobacco Products Only: 11.85% (95% CI: 6.92–19.55).
• Nicotine-Only Products: 0.60% (95% CI: 0.10–3.40).
• Breakdown by Product Type (Current Use):
  • Smoked Tobacco: 7.98% (Driven by manufactured cigarettes at 6.65% and roll-your-own at 3.31%).
  • Smokeless Tobacco: 5.86%.
  • Shisha: 1.37%.
  • Heated Tobacco Products (HTP): 0.11% (exclusively among boys).
  • Electronic Cigarettes: 0.04%.
  • Nicotine Pouches: 0.56%.
• Ever Use: 18.53% for any product; 18.39% for tobacco; 0.8% for nicotine-only products.

Demographic Disparities

• Gender: Boys had significantly higher prevalence than girls for all categories (e.g., 16.15% vs. 7.09% for any product; 12.44% vs. 3.00% for smoked tobacco).
• Age: Prevalence increased with age (10–12: 8.94% vs. 16–17: 18.94%).
• Schooling: Out-of-school adolescents had higher usage rates (16.38%) compared to in-school peers (11.24%).
• Residence: Urban areas showed higher prevalence (16.98%) than rural areas (10.58%).

Factors Associated with Use (Logistic Regression)

• Protective Factors:
  • School Attendance: In-school adolescents were less likely to use tobacco (aOR = 0.57).
  • Parental Status: Having both parents alive was protective; losing one or both parents increased risk (aOR = 0.49 for having both alive vs. orphaned).
  • Female-Headed Households: Living in a female-headed household was protective compared to male-headed households.
• Risk Factors:
  • Gender: Boys were significantly more likely to use tobacco (aOR = 2.47) and smoked tobacco (aOR = 4.65).
  • Household Head Education: Having a head with secondary education or higher increased odds of use (aOR = 1.74).
  • Environmental Exposure: Exposure to tobacco smoking in public places was a strong predictor (aOR = 3.97).
  • Household Head Gender: Male-headed households increased odds (aOR = 1.35).

5. Significance and Policy Implications

• High Burden: The study reveals a high burden of tobacco use among DRC adolescents, with nearly 12% currently using products and over 18% having tried them.
• Policy Recommendations: The authors advocate for evidence-based interventions to reduce accessibility and appeal:
  • Taxation: Increase excise taxes to at least 75% of the retail price (currently ~38.7%) to deter youth.
  • Sales Bans: Prohibit the sale of single cigarette sticks and small packets to prevent affordability for low-income youth and ensure health warnings are visible.
  • Flavor Bans: Ban flavored products and emerging nicotine products.
  • Point of Sale: Ban sales near schools and playgrounds; ban point-of-sale displays.
  • Comprehensive Laws: Strengthen smoke-free laws and enforcement of existing regulations.
• Future Research: Calls for longitudinal studies to track initiation and transition to regular use, and regular surveillance to monitor emerging products.

Conclusion: This study fills a critical data void in the DRC, highlighting that tobacco use is a significant public health threat to adolescents, driven by gender, lack of school attendance, and environmental exposure. Immediate policy strengthening is required to prevent a future generation of tobacco-related morbidity and mortality.