Exposure, access, susceptibility to and use of nicotine and tobacco products among 10-16 year-olds: National cross-sectional survey of 14,232 in-school and out-of-school children in Pakistan.

IntroductionTobacco and newer nicotine products pose significant risks to children. Data is needed on tobacco and nicotine use among children in Pakistan, given the evolving market and lack of regular surveillance.MethodsWe conducted a cross-sectional survey of 10-16-year-olds in Pakistan. Using a multistage stratified random sampling strategy, we planned to recruit 9,000 school children from 180 schools and 4,320 out-of-school children from 72 enumeration blocks. We gathered data on their tobacco/nicotine use, exposure, access, and susceptibility. Descriptive analyses were performed to estimate frequencies and usage patterns.ResultsBetween December 2023 and May 2024, 14,232 children were surveyed; one-third were out-of-school, with one-third girls. Overall, 9.1% (95%CI:8.5-9.6) of boys and 7.1% (95%CI:6.3-7.7) of girls reported using nicotine and/or tobacco products. Their use did not differ between school-going (8.3%; 95%CI:7.7-8.9) and out-of-school (8.5%; 95%CI:7.7-9.2) children. Reported use of e-cigarettes (boys=4.3%; girls=3.2%) and nicotine pouches (boys=3.4%; girls=2.7%) appeared higher than smoking (boys=2.1%; girls=0.7%) and smokeless tobacco use (boys=2.7%; girls=2.0%), though no statistical comparisons were conducted. More children stated that they would accept cigarettes (27%) and nicotine pouches (23.4%) than smokeless tobacco (18.5%) and electronic cigarettes (16.7%) when offered by a friend. A significant proportion could access tobacco shops near their schools (55.4%) and homes (43.1%); and 33.3% indicated they could buy these easily.ConclusionsIn Pakistan, more children reported using e-cigarettes and nicotine pouches than smoking cigarettes, although these differences were not tested for statistical significance. Nonetheless, the observed prevalence underscores the need to regulate these products.ImplicationsThe findings underscore the need for targeted regulatory actions to address youth use of tobacco and nicotine products in Pakistan. Comprehensive policies should consider restrictions on sales near schools, enforcement of smoke-free laws, and public awareness campaigns to prevent youth uptake and continued use of tobacco and nicotine products. Future research should build on these findings by exploring the social and behavioural drivers of children's nicotine use and evaluating interventions aimed at curbing product accessibility and appeal. This study sets a benchmark for future surveillance efforts and policy evaluations in Pakistan and similar settings.