Trends in smoking initiation, sex, and regional differences: a repeat cross-sectional study in the European Union between 1940 and 2019

Introduction: In the European Union (EU), one in five young people aged 15 to 24 currently smokes, with more than half establishing regular smoking by the age of 18. Information on the long-term historical trends of smoking initiation across the EU remains scarce. This study sought to examine trends in initiation rates of regular smoking in the EU over the last 80 years. Methods: We analyzed data from representative, repeat cross-sectional surveys of EU residents aged 15 and older (n = 108,856) collected across four waves of the Special Eurobarometer survey: 77.1 (2012), 82.4 (2014), 87.1 (2017), and 93.2 (2020). Using a reconstructed approach based on each participant's age, smoking status, and age at regular smoking onset for each calendar year, we estimated age-specific initiation rates (for ages 10-24) and age-group-specific rates (for age-group 10-17, 18-24, and 10-24) by sex, region, and country for each calendar decade from 1940 to 2019. Results: EU-overall initiation rates among those aged 10-24 have significantly declined compared to the peak period: for males, from 5.7% (95% CI = 5.6-5.9%) in the 1970s to 3.2% (95% CI = 3.0-3.3%) in the 2010s and for females from 3.9% (95% CI = 3.7-4.0%) in the 1990s to 2.4% (95% CI = 2.3-2.5%) in the 2010s. The decline was more pronounced in young adults aged 18-24 than legal minors aged 10-17, with the minors' rates surpassing those of young adults during the 2010s. Sex and regional disparities have narrowed over the study period, while the rates among legal minors have remained stagnant in Southern Europe since 1980 and have an upward trend in Eastern Europe. Conclusions: The downward trend in youth smoking initiation reflects progress in tobacco control within the EU. However, despite the ban on tobacco sales to minors, an unacceptably high number of youths still began smoking regularly before the age of 18. Our results suggest that enforcing stricter EU-wide tobacco control policy focus on minors and introducing smoke-free generation initiatives, such as the Tobacco 21 law, could potentially reduce future tobacco use by limiting minors' access to tobacco products.