Exploring the perceived socio-cultural factors in the initiation of smokeless tobacco among adolescents: a qualitative systematic review.

BACKGROUND

Smokeless tobacco use remains highly prevalent among adolescents in many regions, driven by complex socio-cultural influences that extend beyond individual choice. Understanding the perceived social, cultural, and familial factors that contribute to initiation is essential for informing effective prevention strategies.

METHODS

A qualitative systematic review was conducted following JBI Methodology to identify and explore socio-cultural factors influencing smokeless tobacco initiation among adolescents. Electronic searches were performed in MEDLINE (Ovid), Scopus, Embase, CINAHL, PsycINFO, and Cochrane CENTRAL. Grey literature was identified through ProQuest Dissertations, OAIster, and Google Scholar. Studies published in English between January 2002 and March 2026 were eligible. Qualitative studies examining socio-cultural determinants of smokeless tobacco initiation were included, while studies focusing on cigarette smoking, alternative tobacco products, or cessation interventions were excluded. Two independent reviewers undertook study selection, data extraction, and critical appraisal using standardized JBI qualitative appraisal and data extraction tools. Data were synthesized through meta-aggregation of findings and categories, with interpretation informed by a socio-ecological framework, and the review was reported in accordance with PRISMA guidelines.

RESULTS

Fourteen studies met the inclusion criteria, yielding 42 findings that were grouped into eight categories and three synthesized findings. Key drivers of initiation included curiosity, perceived pleasure, low cost, easy availability, and beliefs regarding the relative harmlessness of smokeless tobacco products. Social influences such as familial role modelling, peer pressure, socio-cultural identity, and normalization of smokeless tobacco use further contributed to initiation among adolescents. These findings reflect influences operating across individual, interpersonal, and socio-cultural levels. Based on ConQual assessment, confidence in the synthesized findings ranged from low to moderate.

CONCLUSION

This review highlights the central role of socio-cultural environments in shaping smokeless tobacco initiation among adolescents. The findings underscore the need for comprehensive prevention strategies and policies that address intergenerational transmission, social normalization, and misconceptions surrounding smokeless tobacco. Targeting these broader societal influences is critical for reducing early initiation and long-term tobacco use.

TRIAL REGISTRATION: The review is prospectively registered in PROSPERO under the registration number: CRD42021240588.