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Factors Associated With E-Cigarette Usage and the Reasons for Initiation Among Malaysian Adolescents

Robert Lourdes TG, Abd Hamid HA, Mohd Yusoff MF, Rodzlan Hasani WS, Mat Rifin H, Saminathan TA, et al.

Asia Pac J Public Health, 2019 10;31(7_suppl):44S-52S.
PMID: 31522514 DOI: 10.1177/1010539519870663

Electronic cigarettes (e-cigarettes) are handheld devices that deliver an aerosol by heating a solution made up of propylene glycol and/or glycerol with or without flavoring agents and nicotine. This nationwide cross-sectional survey examined factors associated with e-cigarette usage and reasons for its initiation among 13 162 Malaysian adolescents. Data from TECMA (Tobacco and E-Cigarette Survey among Malaysian Adolescents) were used. Nine percent of adolescents had used e-cigarettes in the past month. Males (adjusted odds ratio [aOR] = 4.08; 95% confidence interval [CI] = 3.36-4.95), 16 to 19 year olds (aOR = 2.64; 95% CI = 2.13-3.26), Malays (aOR = 2.25; 95% CI = 1.79-2.83), Sabah and Sarawak Bumiputeras (aOR = 2.25; 95% CI = 1.61-3.15), and cigarette smokers (aOR = 13.16; 95% CI = 11.14-15.54) were more likely to use e-cigarettes. Three main reasons for e-cigarette initiation among adolescents were its taste and smell, experimentation, and popularity. Sale of e-cigarettes with or without nicotine to people aged younger than 18 years should be banned. Flavored e-cigarettes should also be banned since there is evidence suggesting increased appeal among the younger generation.
Cessation of e-cigarette use among adolescents and its associated factors

Saminathan TA, Rodzlan Hasani WS, Robert Lourdes TG, Mohd Yusoff MF, Ismail H, Akmal Abd Hamid H, et al.

Asia Pac J Public Health, 2019 10;31(7_suppl):53S-60S.
PMID: 31189348 DOI: 10.1177/1010539519854873

We assessed the prevalence of cessation of e-cigarette and its associated factors among adolescents in Malaysia. This study analyzed data from the Tobacco and E-Cigarette Survey among Malaysian Adolescent (TECMA) in 2016, a cross-sectional study with 2-stage stratification cluster sampling. A total of 14 832 school-going adolescents aged 10 to 19 years participated in this survey. A complex sampling design and multiple logistic regression analysis were applied. Nearly half of the adolescents (49.9%; 95% confidence interval [CI] = 44.9-55.0) who had ever used e-cigarette ceased the usage. Based on multivariate analysis, adolescents were more likely to quit e-cigarette because they could not afford the e-cigarette (adjusted odds ratio [aOR] = 2.39, 95% CI = 1.78-3.20), if they are aged 13 year and older (aOR = 1.80, 95% CI = 1.25-2.61), and those who claimed their e-cigarette does not contain nicotine (aOR = 1.35, 95% CI = 1.03-1.78). E-cigarette prevention efforts among adolescents could consider the cessation factors described in this study.
The prevalence of e-cigarette use among adults in Malaysia

Ab Rahman J, Mohd Yusoff MF, Nik Mohamed MH, Mahadir Naidu B, Lim KH, Tee GH, et al.

Asia Pac J Public Health, 2019 10;31(7_suppl):9S-21S.
PMID: 30880403 DOI: 10.1177/1010539519834735

Electronic cigarettes (e-cigarettes) are a new method for the consumption of nicotine. A nationwide survey among 4288 Malaysian adults was conducted in 2016 to measure the prevalence and to describe the population characteristics of e-cigarette users. A complex sampling design was used, and data were collected using a face-to-face questionnaire. The overall prevalence of current, ever, former, and dual users of e-cigarettes in Malaysia were 3.2% (95% confidence interval [CI] = 2.5-4.1), 11.9% (95% CI = 10.5-13.5), 8.6% (95% CI = 7.5-9.8), and 2.3% (95% CI = 1.8-3.1), respectively. The prevalence of all type of e-cigarette use was higher in urban than in rural areas. Current e-cigarette users were likely to be younger, males, and with higher education level. Among current e-cigarette users, 74% (95% CI = 64-82) also smoked conventional cigarettes (dual user). E-cigarette use is prevalent in Malaysia. It is common among younger adults, males, and cigarette smokers.
Fulltext A systematic review protocol on small/kiddie cigarette packaging size and its impact on smoking

Mat Rifin H, Rodzlan Hasani WS, Ling MYJ, Robert Lourdes TG, Saminathan TA, Ab Majid NL, et al.

Syst Rev, 2020 01 13;9(1):13.
PMID: 31931868 DOI: 10.1186/s13643-019-1263-6

BACKGROUND: Small/kiddie cigarette packs consist of less than 20 cigarette sticks. Kiddie packs were recently proposed to be reintroduced by the tobacco industry with an excuse to prevent consumers from buying illicit cigarettes. By reintroducing kiddie packs, cigarettes will inevitably be more affordable and this would appeal to lower-income consumers especially teens. In this systematic review, we aimed to identify the impact of kiddie packs on smoking, specifically on smoking initiation, the urge/tendency to buy cigarettes and attempts to reduce cigarette consumption.
METHODS: This systematic review will be based on the review of original articles on the impact of kiddie packs on smoking. There is no restriction on the publication dates. The Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Web of Science and Scopus will be searched to retrieve potential original articles. Additional records identified through other sources: Google Scholar, as well as Journal of Substance Use and Tobacco Control, are also to be searched. These will include original articles in any language which included all study designs (randomised controlled trials, quasi experimental and experimental studies, observational cross-sectional and cohort studies) comparing kiddie packs with regular cigarette packs. The primary outcomes of interest will be initiation of smoking and urge/tendency to buy cigarettes in the general population and attempts to reduce cigarette consumption among current smokers. Secondary outcomes will be the prevalence of smoking using kiddie packs among the current smokers.
DISCUSSION: This systematic review will provide evidence to support the impact of kiddie packs on smoking in terms of smoking initiation, smoking prevalence, urge/tendency to purchase cigarettes and attempts to reduce cigarette consumption. The findings from this review could be helpful to policymakers in regulating kiddie packs to control the consumption of tobacco.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018102325.
Fulltext Prevalence, Awareness, Treatment and Control of hypertension in the Malaysian population: findings from the National Health and Morbidity Survey 2006-2015

Ab Majid NL, Omar MA, Khoo YY, Mahadir Naidu B, Ling Miaw Yn J, Rodzlan Hasani WS, et al.

J Hum Hypertens, 2018 Sep;32(8-9):617-624.
PMID: 29899376 DOI: 10.1038/s41371-018-0082-x

Hypertension is strongly associated with chronic diseases such as myocardial infarction, stroke, heart failure, and renal failure. The objective of this study is to determine the trend of prevalence, awareness, treatment, and control of hypertension among Malaysian population since 2006 to 2015. The study used the data from National Health and Morbidity Survey (NHMS) 2006, 2011, and 2015. It was a cross-sectional with two-stage stratified random sampling throughout Malaysia for eligible respondents 18 years old and above. Respondents were interviewed face to face and blood pressure was recorded as the average reading from two electronic pressure monitoring measurements. Data was analyzed using the Complex sample module in SPSS Version 20. The prevalence of hypertension in Malaysia was 34.6% (95% CI: 33.9, 35.3) in 2006, 33.6% (95% CI: 32.6, 34.6) in 2011 and 35.3% (95% CI: 34.5, 36.3) in 2015. Awareness of hypertension in 2006, 2011, and 2015 was 35.6% (95% CI: 34.6, 36.6), 40.7% (95% CI: 39.3, 42.1), and 37.5% (95% CI: 36.1, 38.9) respectively. The trend of receiving treatment from 2006 to 2015 was 78.9% (95% CI: 77.5, 80.2) to 83.2% (95% CI: 81.3, 84.8). The control of hypertension increased significantly from 27.5% (95% CI: 25.9, 29.2) in 2006 to 37.4% (95% CI: 35.3, 39.5) in 2015. Despite higher proportions receiving treatment over time, the control of hypertension remained below 40% since NHMS 2006 until 2015. The strategies to further reduce the prevalence and increase awareness of hypertension should be enhanced particularly among the targeted age group to ensure early detection, treatment, and control thus preventing from long-term complications.
Fulltext Prevalence of metabolic syndrome and metabolic dysfunction-associated fatty liver disease in Malaysia 2023: study protocol for a community-based nationwide cross-sectional survey

Wan KS, Mat Rifin H, Mohd Yusoff MF, Yoga Ratnam KK, Chan WK, Mohamad M, et al.

BMJ Open, 2023 Oct 27;13(10):e074432.
PMID: 37890968 DOI: 10.1136/bmjopen-2023-074432

INTRODUCTION: Metabolic syndrome (MetS) is a cluster of cardio-metabolic dysfunctions characterised by increased fasting plasma glucose, waist circumference, blood pressure, triglycerides and reduction in high-density lipoprotein cholesterol. Meanwhile, metabolic dysfunction-associated fatty liver disease (MAFLD) is the new term for fatty liver associated with MetS. People with MetS or MAFLD have higher risks for adverse cardiovascular outcomes and mortalities. However, large-scale data on MetS and MAFLD prevalence in Malaysia is mainly unknown. This study aims to determine the prevalence of MetS and MAFLD among the general adult population in Malaysia.
METHODS AND ANALYSIS: This is a community-based nationwide cross-sectional study in Malaysia. The data collection period is from July 2023 until September 2023, with a planned sample size of 1296 participants. We use a two-stage proportionate stratified random sampling method to ensure national representativeness. The definition of MetS follows the Harmonised Joint Interim Statement in 2009. A diagnosis of MAFLD is made if a participant has fatty liver, defined as having a Fatty Liver Index ≥60 and has type 2 diabetes, a body mass index ≥23 kg/m2, or ≥2 metabolic risk abnormalities. Complex sample analysis will be conducted, and the disease prevalence will be reported with 95% CIs, unweighted counts and estimated populations.
ETHICS AND DISSEMINATION: The protocol has been approved by the Medical Research and Ethics Committee of the Ministry of Health Malaysia (NMRR ID-22-02845-GUT). The findings will be disseminated through a formal report, policy brief, scientific publications, conference presentations, social media, print media and stakeholder engagement activities.
Treatment intensification and therapeutic inertia of antihypertensive therapy among patients with type 2 diabetes and hypertension with uncontrolled blood pressure

Wan KS, Moy FM, Mohd Yusoff MF, Mustapha F, Ismail M, Mat Rifin H, et al.

Sci Rep, 2024 Jun 01;14(1):12625.
PMID: 38824234 DOI: 10.1038/s41598-024-63617-4

Treatment intensification is essential to ensure guideline targets are attained in diabetes patients. The failure to intensify treatment when the targets are not achieved is therapeutic inertia. This study aimed to determine the proportions and factors associated with treatment intensification and therapeutic inertia of antihypertensive therapy in type 2 diabetes patients with uncontrolled hypertension in Malaysia. A retrospective cohort analysis was conducted utilising registry data. Diabetes hypertensive patients with uncontrolled baseline systolic or diastolic blood pressure were included. Treatment intensification was the increase in the number of antihypertensive agents from the index treatment. Therapeutic inertia was the absence of treatment intensification when the second blood pressure reading was still uncontrolled. About 6956 patients were followed up over 2.5 ± 1.1 person-years. Treatment intensification was observed in 29.8% of patients, while 38.6% had therapeutic inertia. Chinese, Indian, and 'others' ethnic groups, retinopathy, more antihypertensive agents, and higher systolic blood pressure were associated with therapeutic inertia. Underweight, overweight patients and those with dyslipidaemia had lower risks for therapeutic inertia. The results indicate suboptimal quality of care in public health clinics in Malaysia. Further studies are needed to determine the underlying causes to formulate precise interventions to tackle the problem in Malaysia.
Smoking among Secondary School Students in Kota Tinggi, Johor, Malaysia--Findings from a Cross-Sectional Study

Lim HK, Teh HC, Lim LH, Lau JK, Kee CC, Ghazali SM, et al.

Asian Pac J Cancer Prev, 2015;16(11):4563-70.
PMID: 26107204

BACKGROUND: Smoking is a learnt behavior during adolescence and understanding the factor/s associated with smoking will assist in identifying suitable measures in combating the rising prevalence of smoking among adolescents. This research aimed to identify the factor/s associated with smoking among form four students in Kota Tinggi, Johor. Multistage sampling was used to select a representative sample of students in 2008 and data were collected using a self-administered validated questionnaire. This study revealed that the overall smoking prevalence was 19.0% with a significantly higher proportion of male smokers (35.8%) as compared to females (3.15%). Adolescents who were male (aOR 6.6, 95%CI 2.61-16.4), those who had peer/s who smoked (aOR 4.03, 95% CI 1.31-12.4), and those who studied in rural areas and Felda Settlements ( aOR 4.59, 95 CI 1.11-18.0; aOR 9.42, 95%CI 3.91-29.1) were more likely to smoke in the past one week. On the other hand, adolescents with better knowledge on the hazards of smoking and negative attitudes towards smoking were less likely to smoke (aOR 0.51, 95%CI 0.37-0.72; aOR 0.67, 95%CI 0.46-0.99). Future promotional and interventional programmes on smoking should be considered and the above identified risk factors integrated to reduce smoking prevalence among students of school-going ages in Kota Tinggi. Johor.
Cigarette Smoking Among Secondary School-Going Male Adolescents in Malaysia: Findings From the National Health and Morbidity Survey 2017

Ling MYJ, Rodzlan Hasani WS, Mohd Yusoff MF, Abd Hamid HA, Lim KH, Tee GH, et al.

Asia Pac J Public Health, 2019 11;31(8_suppl):80S-87S.
PMID: 31537102 DOI: 10.1177/1010539519874948

Smoking is a learned behavior during adolescence, and it is found predominantly among male adolescents in Malaysia. Our study aimed to investigate the prevalence and predictive factors of current cigarette smoking among school-going male adolescents in Malaysia. Data were derived from the National Health and Morbidity Survey: Adolescent Health Survey 2017, a cross-sectional study that utilized a 2-stage stratified cluster sampling to select a nationally representative sample of school-going adolescents in Malaysia (n = 27 497). Multiple logistic regression analysis was performed to identify factors associated with current cigarette smoking among male adolescents in Malaysia. Male adolescents aged 16 to 17 years (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.41-1.70), current illicit drug users (AOR = 8.14; 95% CI = 6.37-10.41), current alcohol users (AOR = 1.92; 95% CI = 1.65-2.23), those from rural schools (AOR = 1.60; 95% CI = 1.46-1.76), those whose parents were widowed/divorced/separated (AOR = 1.37; 95% CI = 1.21-1.55), and those whose parents/guardians were tobacco product users (AOR = 3.47; 95% CI = 2.33-5.16) were more likely to be current cigarette smokers. Tobacco control strategies should be aimed at both adolescents at risk and at promoting parental smoking cessation.
Fulltext Prevalence of chronic kidney disease and its associated factors in Malaysia; findings from a nationwide population-based cross-sectional study

Saminathan TA, Hooi LS, Mohd Yusoff MF, Ong LM, Bavanandan S, Rodzlan Hasani WS, et al.

BMC Nephrol, 2020 08 14;21(1):344.
PMID: 32795256 DOI: 10.1186/s12882-020-01966-8

BACKGROUND: The prevalence of chronic kidney disease (CKD) in Malaysia was 9.07% in 2011. We aim to determine the current CKD prevalence in Malaysia and its associated risk factors.
METHODS: A population-based study was conducted on a total of 890 respondents who were representative of the adult population in Malaysia, i.e., aged ≥18 years old. Respondents were randomly selected using a stratified cluster method. The estimated glomerular filtration rate (eGFR) was estimated from calibrated serum creatinine using the CKD-EPI equation. CKD was defined as eGFR
Prevalence and Factors Associated With Attempts to Quit and Smoking Cessation in Malaysia

Lim KH, Heng PP, Nik Mohamed MH, Teh CH, Mohd Yusoff MF, Ling JMY, et al.

Asia Pac J Public Health, 2019 10;31(7_suppl):22S-31S.
PMID: 31802718 DOI: 10.1177/1010539519874944

Smoking cessation significantly reduces risk of smoking-related diseases and mortality. This study aims to determine the prevalence and factors associated with attempts to quit and smoking cessation among adult current smokers in Malaysia. Data from the National E-Cigarette Survey 2016 were analyzed. Forty nine percent of current smokers had attempted to quit at least once in the past 12 months and 31.4% of the respondents were former smokers. Multivariable analysis revealed that current smokers with low nicotine addiction and aged below 45 years were more likely to attempt to quit smoking. Being married, older age group, and having tertiary education were significantly associated with smoking cessation. Only half of the current smokers ever attempted to quit smoking and only a third of smokers quit. Stronger tobacco control policies are needed in Malaysia to encourage more smokers to quit smoking. Improved access to cessation support for underprivileged smokers is also needed.
Prevalence and factors associated with physical inactivity among older adults in Malaysia: A cross-sectional study

Chan YY, Lim KK, Omar MA, Mohd Yusoff MF, Sooryanarayana R, Ahmad NA, et al.

Geriatr Gerontol Int, 2020 Dec;20 Suppl 2:49-56.
PMID: 33370865 DOI: 10.1111/ggi.13977

AIM: Physical inactivity in older adults is linked to increased risk of chronic diseases, disability and various poor health outcomes. As the aging population rises, the prevalence of diseases associated with aging also increases. Regular physical activity in older adults is important to improve overall health and promote healthy aging. This study aimed to determine the prevalence and factors associated with physical inactivity among older adults in Malaysia.

METHODS: This study was based on 3969 Malaysian older adults aged ≥60 years who completed the physical activity module in the National Health and Morbidity Survey 2018, a population-based cross-sectional survey. Physical activity was measured using the Global Physical Activity Questionnaire through a face-to-face interview. Participants were classified as physically active or inactive. Associations between physical inactivity, sociodemographic characteristics and a range of selected independent variables were examined using multivariable logistic regression.

RESULTS: Overall, three out of 10 (29.8%) Malaysian older adults were physically inactive. Results of multivariable analysis showed that older age group (≥80 years), of Bumiputera Sarawak ethnicity, unemployed/retirees/homemakers, functional limitation, diabetes mellitus and dementia were significantly associated with a higher risk of physical inactivity. Women, with secondary education level and good social support were less likely to be physically inactive.

CONCLUSIONS: The present study reported the status of physical inactivity among older adults in Malaysia. There is the need to design effective public health programs and interventions to promote active living and healthy aging among Malaysian older adults, particularly in those at-risk older population subgroups. Geriatr Gerontol Int 2020; 20: 49-56.
Fulltext Exposure to tobacco secondhand smoke and its associated factors among non-smoking adults in smoking-restricted and non-restricted areas: findings from a nationwide study in Malaysia

Lim KH, Teh CH, Nik Mohamed MH, Pan S, Ling MY, Mohd Yusoff MF, et al.

BMJ Open, 2018 01 08;8(1):e017203.
PMID: 29317411 DOI: 10.1136/bmjopen-2017-017203

OBJECTIVES: Secondhand smoke (SHS) has been associated with increased morbidity and mortality. Therefore, the aims of the paper are to assess SHS exposure among non-smoking adults in Malaysia attending various smoking-restricted and non-restricted public areas according to the Control of Tobacco Product Regulations (CTPR) as well as its relationship with various sociodemographic variables.
DESIGN: Data were extracted from a cross-sectional study, the Global Adults Tobacco Survey (GATS) 2011 which involved 3269 non-smokers in Malaysia. Data was obtained through face-to-face interviews using a validated pre-tested questionnaire. Factors associated with exposure to SHS were identified via multivariable analysis.
RESULTS: The study revealed that almost two-thirds of respondents were exposed to SHS in at least one public area in the past 1 month, with a significantly higher exposure among males (70.6%), those with higher educational attainment (81.4%) and higher income (quintile 1%-73.9%). Besides, the exposure to SHS was almost four times higher in non-restricted areas compared with restricted areas under the CTPR (81.9% vs 22.9). Multivariable analysis revealed that males and younger adults at non-restricted areas were more likely to be exposed to SHS while no significant associated factors of SHS exposure was observed in restricted areas.
CONCLUSIONS: The study revealed the prevalence of SHS exposure was higher among Malaysian adults. Although smoke-free laws offer protection to non-smokers from exposure to SHS, enforcement activities in restricted areas should be enhanced to ensure strict public abidance. In addition, legislation of restricted areas should also be extended to greatly reduce the SHS exposure among non-smokers in Malaysia.
Study name: Global Adults Tobacco Survey (GATS-2011)
Diagnostic accuracy of Cardiochek® PA point-of-care testing (POCT) analyser with a 3-in-1 lipid panel for epidemiological surveys

Robert Lourdes TG, Chong ZL, Saminathan TA, Abd Hamid HA, Mat Rifin H, Wan KS, et al.

Lipids Health Dis, 2024 Sep 12;23(1):297.
PMID: 39267137 DOI: 10.1186/s12944-024-02270-2

BACKGROUND: Point-of-care testing (POCT) is commonly used in epidemiological surveys due to its various advantages, such as portability and immediate test results. The CardioChek® PA analyser 3-in-1 lipid panel measures total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol. This study tested the reliability and diagnostic accuracy of the CardioChek® PA analyser using a 3-in-1 lipid panel.
METHODS: A cross-sectional study design with quota sampling was used. A total of 203 respondents aged 18 years and above from a research centre in the Ministry of Health, Malaysia, were recruited. Venous blood was sent to the laboratory and tested with Siemens Atellica CH, while a POCT analyser was used for capillary blood measurements. Intraclass coefficient correlation (ICC) analysis was employed to determine the agreement between capillary and venous blood parameters. The diagnostic performance of the evaluated tests was evaluated using STATA version 12.
RESULTS: The agreement between capillary and laboratory venous blood was moderate (0.64-0.67) for TC and HDL, good (0.75) for LDL and excellent (0.91) for TG). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were as follows: TC, 57.1%, 94.3%, 92.3% and 64.8%; TG, 76.0%, 100%, 100%, and 96.6%; HDL, 96.2%, 83.2%, 47.2% and 99.3%; and LDL, 81.0%, 100%, 100% and 68.3%, respectively.
CONCLUSIONS: The CardioChek® PA analyser showed acceptable diagnostic accuracy for screening high-risk individuals more often in places where laboratories are inaccessible. It could also be used in clinical settings where patients would benefit from swift treatment decisions.
Fulltext Small/Kiddie Cigarette Packaging Size and Its Impact on Smoking: A Systematic Review

Mat Rifin H, Jane Ling MY, Robert Lourdes TG, Saminathan TA, Rodzlan Hasani WS, Ab Majid NL, et al.

Int J Environ Res Public Health, 2022 Sep 23;19(19).
PMID: 36231349 DOI: 10.3390/ijerph191912051

Background: Small cigarette pack sizes contain less than 20 cigarette sticks in a pack. Smaller packs may suggest lower costs, increasing affordability among lower-income users, especially the younger generation, which could lead to tobacco-related diseases and economic costs, including human capital lost results from tobacco-attributable morbidity and mortality. This concern has caused many countries to ban the sale of single cigarette sticks or kiddie packs. However, small cigarette pack sizes were proposed recently to be reintroduced by the tobacco industry with an excuse to prevent consumers from buying illicit cigarettes. This would demean efforts in combating tobacco consumption based on the existing tobacco control policies to prevent minors from purchasing cigarettes. Given the competing influences of affordability and availability of tobacco on consumption and the dearth of evidence-based review on the impact of pack size on smoking, this systematic review was conducted to identify the link between kiddie packs and smoking specifically on the initiation of smoking, urge/tendency to buy cigarettes among the general population and attempt to reduce cigarette consumption and prevalence of smoking using kiddie packs among current smokers. Methods: We include all studies except for reviews, guidelines, conference papers, commentaries, editorials, or opinion pieces. A database search was conducted in PubMed, EMBASE, CENTRAL, Web of Science and Scopus on 27 November 2021. The results were presented in the form of narrative synthesis under four groups: initiation of smoking; urge/tendency to buy cigarettes; the prevalence of smoking, and attempt to reduce cigarette consumption. The literature search identified 1601 articles, of which 21 articles had met the inclusion criteria. The methodological quality of all included articles was determined using a validated 16-item quality assessment tool (QATSDD). The average quality score for all papers was 34.8%. Discussion: Given the diverse study settings of the articles and despite the challenges of the methodological quality of some articles, this review provides some evidence that kiddie packs may increase the urge/tendency to buy cigarettes and mixed evidence on the attempt to reduce cigarette consumption. This review also found some evidence that kiddie pack purchasing among teenage smokers was higher compared to adults. However, we are uncertain about the link between kiddie packs and smoking initiation. Nevertheless, since most studies were of low quality, further high-quality studies are needed to conclude about the impact of kiddie packs on smoking to assist the policymakers and stakeholders in formulating new policies and strengthening existing strategies related to the kiddie packs.

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