It's a public health problem that spans the globe.
It kills close to 6 million people a year.
Teenagers are at risk.
It's not the latest epidemic or chronic disease.
It's the cigarette.
A new report from the Centers for Disease Control looks at rates of smoking among 13- to 15-year-olds (most smokers start in adolescence) and how they feel about it, with a nod to the kinds of measures that work to cut rates of teen smoking.
Worldwide, about 10 percent of the youngest teens smoke, according to the report, which analyzed data on more than 170,000 young teens in 61 countries. But in some countries, numbers are significantly higher, especially among boys.
In Timor-Leste, the study found, 61 percent of early teen boys smoke cigarettes. And of course it's not just boys. In Bulgaria, 29 percent of the girls smoke.
Most kids who smoke say they want to stop. The survey asked kids in 51 of the countries if they wanted to stop smoking; in 40 countries, more than half of them said yes. Rates of wanting to quite ranged from 32.1 percent in Uruguay to 90.2 percent in the Philippines.
"I think what this story is about, at least for me, is that it tells us there are too many kids that are smoking globally and the majority of them want to quit," says Indu Ahluwalia, the Global Tobacco Control Branch Chief at the CDC's Office on Smoking and Health in Atlanta, and one of the study's co-authors.
The new study used data from the Global Youth Tobacco Survey, a World Health Organization program that periodically asks a nationally representative sample of school kids about their recent tobacco-smoking behaviors.
Overall, the CDC reported, nearly 15 percent of boys and 7.5 percent of girls in the 13- to 15-year-old age group had smoked at least once in the previous 30 days.
The spread from country to country was large even within regions of the globe. Just 5.5 percent of young teens in Mozambique smoke, compared to about 16 percent in Zimbabwe and more than 25 percent in the Seychelles. In Jordan, some 23 percent of kids (and nearly 33 percent of boys) smoke, compared to nine percent in Pakistan.
Why do the numbers vary so much in different places?
The study didn't ask kids why they chose to smoke, but a country's commitment to tobacco control is a major factor, Ahluwalia says. Of the 61 countries considered in the report, 59 have ratified an international treaty called the WHO's Framework Convention on Tobacco Control, which recommends evidence-based measures for reducing numbers of young people who smoke. But some places have implemented those measures more fully than others.
Among the strategies known to make a dent in youth smoking rates, according to WHO, are taxes that make cigarettes more expensive, bans on ads and vending machines, policies that make public places smoke-free, and mandated warnings on cigarette packaging that show the gruesome consequences of smoking.
These strategies can make a big dent if they're executed well, found a study published this year by Canadian researchers. Raising cigarette prices by 10 percent, for example, leads to a reduction in demand by four percent in high-income countries, and even more in low- and middle-income countries, according to WHO estimates. And tobacco use drops by up to 16 percent when countries ban tobacco ads. Eighty percent of the world's smokers live in low- and middle-income countries.
"When countries strongly implement these policies, the rates of tobacco use go down," says Mark Hurley, head of Indonesia programs with the Campaign for Tobacco-Free Kids, a non-profit organization in Washington, D.C., who was not involved in the recent studies. "The report underscores the urgency of the global tobacco crisis and clearly demonstrates that tobacco use by youth is a major public health problem around the world."
Still, social norms are powerful, especially among teenagers. And many kids continue to think that smoking is cool, especially when anti-tobacco policies are weak.
In Indonesia, where Hurley spends a lot of time, kids see advertising banners that promote cheap cigarettes right outside the gates of their schools. Sales of single cigarettes are also allowed, Hurley says, making it easier for young people to buy them for just 10 cents each.
The vast majority of adult smokers start the habit during their teenage years, and evidence suggests that the adolescent brain is particularly vulnerable to nicotine addiction. As regulations grow stronger in developed countries like the United States, Hurley says that tobacco companies are increasingly targeting young people in countries that haven't enforced strict tobacco control policies and are often less able to deal with the health burdens of tobacco.
But when aggressive ad campaigns associate tobacco with values like adventure and independence — a strategy evident in many low- and middle-income countries, Hurley says, young people get easily hooked.
Tobacco companies "are actively interested in getting youth addicted to their products," he says. "These are their future customers."
Emily Sohn is a freelance journalist in Minneapolis who writes regularly about health and science for Nature, the Washington Post, bioGraphic, Hakai and others. More at www.tidepoolsinc.com. On Twitter: @tidepoolsinc