Youth participation in tobacco control: From symbolic engagement to Shared governance

Abstract

Youth-led interventions are increasingly recognized as vital in advancing global tobacco control, yet their ethical and strategic dimensions remain underexplored. Building on the study by Karki et al., which demonstrated that youth-led awareness and advocacy interventions can positively influence adolescents’ attitudes toward tobacco products in Nepal, this letter highlights two key considerations. First, youth participation must move beyond symbolic engagement toward genuine power-sharing within decision-making structures, ensuring that adolescents are treated as co-governors rather than temporary campaigners. Second, attitudinal change should be situated within broader structural dynamics, particularly the influence of the tobacco industry. Without enforceable reforms such as taxation, advertising restrictions, plain packaging, and protection from industry interference, youth empowerment risks being undermined. We argue for an integrated approach that combines empowerment, governance, and structural reform to transform short-term attitudinal shifts into sustained intergenerational public health gains.

Dear Editor,

Karki and colleagues provide valuable evidence that youth-led awareness and advocacy interventions can positively influence adolescents’ attitudes toward tobacco products in Nepal. ¹ Their study contributes to the growing recognition that young people are not merely passive recipients of health policy but potential co-architects of public health change. We commend this contribution while highlighting two points that extend the ethical and strategic implications of their findings.

First, the notion of “youth-led” warrants careful scrutiny. Participation may range from tokenistic consultation to genuine power-sharing. ² In many contexts, programs described as “youth-led” remain adult-initiated, externally funded, and temporally limited. The ethical challenge is not merely to involve youth in message delivery but to embed their voices within institutional decision-making—such as municipal health boards, school policy councils, or national tobacco control taskforces. Such an approach transforms participation from symbolic engagement into intergenerational governance, consistent with recent calls to center adolescents in health governance. ³

Second, the effectiveness of attitudinal change must be considered alongside the structural power of the tobacco industry. Adolescents may adopt critical perspectives, yet their agency can be undermined by pervasive marketing, digital promotion of novel nicotine products, and policy gaps. The World Health Organization’s 2023 report on the Framework Convention on Tobacco Control emphasizes that youth advocacy is essential but insufficient unless reinforced by taxation, plain packaging, and protection from industry interference. ⁴ The normative imperative, therefore, is to pair empowerment with enforceable structural reforms that shield young advocates from systemic forces.

In sum, Karki et al. advance understanding of youth-led tobacco interventions. To maximize both ethical legitimacy and public health impact, future efforts should move from youth as campaigners to youth as co-governors of health policy, while ensuring their advocacy is supported by robust structural tobacco control measures. This integrated vision—empowerment plus governance plus structure—can transform short-term attitudinal shifts into sustained intergenerational public health gains.

Nathkapach K. Rattanapitoon FMC Medical Center, FMC Medical Center, Nakhon Ratchasima, Thailand Chutharat Thanchonnang Faculty of Public Health, Mahidol University, Nakhon Sawan, Thailand Jun Norkaew Faculty of Public Health, Vongchavalitkul University, Nakhon Ratchasima, Thailand Schawanya K. Rattanapitoon FMC Medical Center, FMC Medical Center, Nakhon Ratchasima, Thailand