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Official websites use. Share sensitive information only on official, secure websites. This is an open access article distributed in accordance with the Creative Commons Attribution 4. Albania has one of the highest smoking prevalence in Europe especially among the youth. There is a lack of evidence in Albania, as well as in most of Eastern Europe and middle-income countries, regarding the effect of price on smoking experimentation. The study aims to assess the effect of price and tobacco control policies on youth smoking experimentation in Albania. We constructed a pseudo-longitudinal dataset and estimated a split-population model to assess the hazard of smoking experimentation. Peer and parent smoking are also important determinants for smoking experimentation. Introducing penalties for smokers and legal entities violating smoke-free policies implemented in is also associated with a lower hazard of smoking experimentation. Price is a significant predictor of smoking experimentation among teenagers in Albania for both males and females. A combination of increasing taxes and strengthening the rule of law to control tobacco use in public spaces, in addition to public awareness campaigns targeting both youth and smoking parents, could help to significantly reduce the probability of smoking experimentation. Taxes that lead to higher prices are associated with lower consumption and lower hazard of smoking experimentation. Although there are previous studies that examine smoking experimentation among youth, few examine the specific contexts of newer democracies and post-socialist countries under transition characterised by weak law enforcement as is the case of Albania, a country with one of the highest smoking prevalences in Europe. This research finds that consistent, with other contexts, higher price is associated with a lower hazard of smoking experimentation among youth in Albania. Females seem to be more price responsive than their male counterparts. Smoke-free policies have reduced smoking experimentation among youth. Increasing taxes on tobacco products that lead to higher prices could help to prevent the youth population in Albania from smoking experimentation and eventual initiation or at least delay them, while banning smoking in public spaces by implementing comprehensive legislation with strict monetary penalties could reinforce its protective effect towards this vulnerable group of population. There is substantial evidence that for some and even many young people, the first few cigarettes are enough to trigger a vulnerability to nicotine dependence. Taxes on tobacco are associated with lower hazards of smoking experimentation and onset, 8—17 especially among youth. Younger smokers also typically have lower levels of smoking addiction because of shorter smoking histories. Research also shows that non-price tobacco control policies negatively affect tobacco experimentation and initiation. Peer relationships are important factors in youth smoking. Indeed, studies have been limited only to a few sociodemographic characteristics, 32 33 thus the effects of prices and other tobacco control instruments have not been adequately assessed. Consequently, this research explores the main predictors for smoking experimentation among Albanian youth, with focus on both price and non-price tobacco control policies. Albania is a Southern European emerging post-communist economy with a population of 2. Tobacco use in Albania is especially high among youth and males 34 and this is a major public health and economic concern 35 35 as Accordingly, mitigating youth smoking should be a priority for policymakers. Excise tax increases on cigarettes that lead to price increases are instrumental for reducing tobacco consumption in Albania. Changes in excise taxes in Albania have been associated with increasing prices over the last 25 years; however, cigarettes remain affordable as Gross Domestic Product GDP per capita has also grown at a similar pace. Figure 1 illustrates the trend of the real retail price of cigarettes, excise tax and GDP. Albania, — In addition, the Government of Albania introduced several tobacco control policies during the early post-socialist transition all characterised by weak law enforcement, among others: a law that banned some tobacco advertisement on TV, radio, print media and billboards in , and the law implemented in that prohibits all types of advertising, promotion, and sponsorship of tobacco on radio, TV, and print media; and establishes a minimum age for tobacco sale. The Law No. This law included several measures such as nearly doubling the maximum fines. In , the Law No. Survival analysis addresses the issue of incomplete information from individuals who may not have experimented with smoking before the end of the data collection. Standard survival models implicitly assume that all individuals under observation will eventually experience the event of interest smoking experimentation. To relax this assumption, and to treat right censoring, like previous research 15 17 29 32 40 44 48 we use a discrete-time split population survival model to analyse the impact of price policies on smoking experimentation. The split population model is a discrete-time proportional hazard cloglog model, with an additional restriction that supposes a proportion of the population never fails ie, experiments with smoking and estimates the hazard rate for the remainder of the population that has a positive probability of smoking experimentation. However, we use also standard cloglog discrete hazard survival model as a sensitivity analysis. One key assumption of survival models, known as non-informative censoring, is that survival and censoring are independent. To deal with this limitation, as reported elsewhere, 50 we excluded younger respondents who are less likely to have experimented with smoking and more likely to be censored and focused on individuals aged 15—17 years at interview. We organised the data in a pseudo-longitudinal format to analyse the effects of tobacco policies from to The dependent variable is first smoking experimentation. The age of first experimentation with smoking in all GYTS was provided in 2-year intervals such as 8—9 years old, 10—11 years old, etc. We randomly selected between the upper and the lower age of the interval if it was not higher than the current age during the interview year. Unfortunately, like all GYTS and most health surveys, no survey questions indicate when respondents become regular smokers. The hazard of smoking experimentation is modelled as a function of cigarette prices, non-price tobacco control policies, gender, parental smoking behaviour and peer smoking behaviour. Our key variable of interest is the price of a cigarette pack. An advantage of using mean price, instead of price by brand declared by the respondents, is that it rules out endogeneity between price and consumption, one of the major concerns to disentangle the effect of price as it can lead to biased estimates. By interacting the price variable with gender, we can estimate the impact of cigarette prices on smoking experimentation by gender. In this study, we use respondent-indicated sex as a proxy of gender. We include two dichotomous indicators to capture the implementation of the two regulatory acts of and To control for income growth, we include a GDP per capita measure for each year. We control for demographics including gender, and contextual factors including peer smoking habits and parental smoking behaviour see online supplemental table A1. The main concern about these variables is endogeneity. Similarly, we argue that it is difficult for a young person to influence greatly the smoking behaviour of a parent who likely initiated many years before the child was born. We assume that individuals are first exposed to the risk of smoking experimentation at the age of nine. It is generally not recommended to include a measure of calendar time in duration models. We control for different forms of duration dependence in every model see the online supplemental table A2. The split population model is estimated through the spsurv command. The number of individuals observed in the four waves is The number of experimenters is females and males. Just over The average age those reporting smoking is The average age of smoking experimentation is Table 1 reports the estimates of the hazard of smoking experimentation from the split population and cloglog model. Model 1 is our baseline model, while model 2 presents the estimates of the sensitivity to the cigarette price by gender. The estimates were exponentiated and values below 1 are interpreted to reduce the hazard of smoking by the distance to 1, while those above 1 increase the hazard of smoking experimentation by the amount over 1. For the sake of interpretability, HRs are shown. SEs are in parentheses. Errors are clustered at the individual level in the cloglog hazard model. Spsurv command did not allow clustering of SEs. We control for duration dependence in both models. Various robustness checks are presented in the online supplemental appendix. For every 1 Albanian Lek increase in the price of cigarettes, smoking experimentation is expected to decrease by 1. Price is a negative predictor of smoking for both males and females see Model 2. This effect is also likely partially explained by a possible time-lagged effect of the tobacco control policies. On the other hand, GDP per capita has also a statistically significant impact on the experimentation with smoking. Due to the potential endogeneity concerns highlighted above, we are cautious not to overinterpret the effect size of the peers and family smoking coefficients. We find a high correlation between the hazard of smoking experimentation in youth and both peer and parental smoking behaviour. Even when we use different variables to measure peer and family smoking patterns, the association remains strong. These variables are impactful but further research is needed to disentangle their effects on smoking experimentation. Various tests were conducted to check the robustness of the results see online supplemental tables A2—A4. The main results are robust to different specifications. We first include in the regression only price, then add the control variables one by one to see if the effect of any control variable would influence the size of our focus variables. Results show the robustness of the price and policies effect. Given the potential endogeneity of the peer and parental control variables, we employ different variables to measure the importance of the family and peer smoking behaviour. The correlation of peers and family smoking with youth experimentation behaviour remains significant, and the main results did not change, confirming the robustness of the baseline estimates. Different time dependences, up to the fourth polynomial degree, are tested. All estimates were also performed by a standard discrete-time hazard cloglog survival model, which generated similar results, confirming the robustness of our main results. The results are in line with some studies which show that female youth are more sensitive to price increase eg, in terms of initiation , 15 21 22 thus are in contrast with other studies which observe that higher cigarette prices decrease the probability of smoking initiation among males but have no impact on female smoking initiation as compared with males. Tobacco control policies have a positive role in reducing smoking experimentation in Albania. Similar to findings from other researchers, 17 19 40 we found that smoke-free policies have a significant negative effect on smoking experimentation. Peer and family smoking appear to have substantial effects on youth smoking experimentation. These findings are similar to other research, adding to evidence that tobacco use may be transmitted intergenerationally. The study has several limitations. We note that this is a limitation of our study, but also emphasise that estimating these effects is not the aim of our analyses and we include them instead as controls. We acknowledge that, even though we try to mitigate informative censoring and endogeneity issues, we cannot rule out the possibility that our analysis may still face these issues. However, despite these limitations the study captures most tobacco experimentation predictors and provides strong evidence supporting tobacco control policies—including excise taxation—in Albania. Finally, we use experimentation and not initiation of regular smoking as the dependent variable. It is a related but different query to identify and understand the variables that drive initiation. If the data had existed, we would have examined this important relationship. But one might reasonably argue that we would expect an even larger effect of price on initiation because it costs more to be a regular smoker than an experimenter. Thus, the fact that this research finds a strong relationship between price and experimentation suggests that future research should try to examine initiation more closely if the data become available to explore this hypothesis. This research contributes to the scarce existing literature in Eastern Europe and low and middle income countries LMICs on youth smoking experimentation with a focus on price. The research finds that price is a key predictor of youth smoking experimentation in Albania. These findings suggest strongly that further tax increases that lead to price increases are likely to contribute to a greater decline in smoking rates and decrease smoking experimentation among youth. Even if an excise tax increase results only in a delay of smoking experimentation rather than permanent abstinence, it is still likely to have positive health effects because those individuals are less likely to become regular smokers over their lifetimes. We also find that smoke-free laws help to reduce smoking initiation. Furthermore, the findings show that income, measured through real GDP per capita, have a significant impact on smoking experimentation. This implies that it is crucial to consider GDP income growth when designing tobacco taxation so that higher tobacco excise can mitigate the positive effect of higher income. Contributors: DI, EZ and EM conceptualised and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. EM led and managed the methodology and all analyses undertaken. EZ and IG contributed with data collection and the literature review. CMG-L and JD reviewed and revised the manuscript for important input content at both the initial and revision stages. EM acts as guarantor. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. The study represents the views of the authors and not necessarily those of the funder. Supplemental material: This content has been supplied by the author s. Any opinions or recommendations discussed are solely those of the author s and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Tob Control. Find articles by Elvina Merkaj. Find articles by Edvin Zhllima. Find articles by Drini Imami. Find articles by Irena Gjika. Find articles by Jeffrey Drope. Re-use permitted under CC BY. Published by BMJ. Open in a new tab. X caosomatik. Provenance and peer review: Not commissioned; externally peer reviewed. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. 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