According to WHO, tobacco is the single largest preventable risk factor for various diseases including premature deaths and disability around the world. It kills nearly six million people each year of which more than five million are users and ex-users and more than 600,000 are nonsmokers exposed to second-hand smoke [1] . Tobacco products are the only legally available products that can kill up to one half of their regular users if consumed as recommended by the manufacturer [2] . In Nepal, tobacco use is more common among men (52%) than women (13%). Of the men using tobacco, 30% smoke cigarette while 38% consumed other forms of tobacco. Among women, 9 percent smoke cigarette and 6 percent consumed other forms of tobacco [3] . Prevalence of smoking among adult females in Nepal is one of the highest in the WHO South-East Asia Region [4] .

The population of Nepal has increased to 26,621,000 with the annual growth rate of 1.4% [5] . As a consequence of a high growth rate, majority of population of the country is fairly young. There are several factors that increase the risk of youth smoking. Availability, accessibility and affordability, pressure from peer or siblings; having a lower self-image than peers, perceiving that tobacco use is normal or “cool” and parental smoking are important risk factors associated with youth smoking [6] [7] . Advertising and promotional activities are considered to influence key risk factors for tobacco use among adolescents [8] .

The U.S. Food and Drug Administration’s 1995 review of available tobacco industry documents highlighted that cigarette manufacturers know that young people are vital for their market, so they need to develop advertising and other promotional activities that appeal to young people [9] . Tobacco marketing capitalizes upon issues that are of great importance to adolescents because of which it is likely that adolescents are influenced to smoke cigarettes [10] and the presence of tobacco use in young is more serious problem as they may be exposed for longer periods.

Studies reflect that media can play role in both increasing and decreasing the exposure of tobacco among the different at risk group. On one hand, media can shape and reflect social values about smoking, can provide new information about smoking directly to audiences, can act as the source of observational learning by providing models which teenagers may seek to emulate; exposure to media messages about smoking also provides direct reinforcement for smoking or not smoking. On the other hand, the media promote interpersonal discussion about smoking, can influence “intervening” behaviors that may make teenage smoking less likely; and antismoking media messages can also set the agenda for other change at the community, state or national level [11] .

The Tobacco Product Control and Regulatory Bill, 2010 was approved by Nepal’s legislature on April, 2011. Major features of this law include a complete ban on smoking in public places, workplaces and public transportation; cover 75% of cigarette and other tobacco product packaging space with pictorial health warning; health tax on tobacco product and total ban on tobacco advertisement, promotion and sponsorship in any form [12] . Though there is a ban on most forms of tobacco advertising, it is unclear whether some types of promotional practices are prohibited as the law does not provide a definition of “tobacco advertising and promotion [13] . It is unclear whether paid placement of tobacco products in TV, film and other media is encompassed by the ban [14] .

In Nepal, studies about tobacco use, its correlates and media role among college students in Nepal are inadequate. Moreover, the previous studies including Global Youth Tobacco Surveillance (GYTS), Nepal have not explored these factors. There is a need of information at multiple levels on the relationship of media exposure and tobacco/cigarette smoking to address the escalating use of tobacco among adolescents.

There are separate roles for entertainment media and tobacco marketing on adolescents’ smoking [16] . DuRant et al. [17] examined the content of tobacco and alcohol use behaviors on television and found out that a high percentage (26%) of MTV videos portrayed tobacco use. The same study found that, given the influence of modeling and imitation in young people, videos that portrayed alcohol and tobacco use depicted the lead performer as most often the one observed to be smoking or drinking. A study done in 2010 in India [18] showed that smoking was more common among men who watched television daily compared to those who never watched television and among those who attended the cinema monthly compared to those who did not. Similar finding was obtained from this study where significant association (p < 0.01) was found between time of watching television in a day and smoking behavior. Frequently watching movies in cinema halls and watching television for more hours indirectly expose adolescents in smoking promoting contents that shape their attitudes and

^*p < 0.05, ^**p < 0.01.

Nagelkerke R² = 0.355, −2 log-likelihhood = 99.294, Chi-square = 44.274; Reference category for independent variable: Poor receptivity to cigarette advertisement; Adjusted for: sex (male, female) and use of other forms of tobacco (yes, no); ^*p < 0.01, ^**p = 0.524.

Numbers in the parenthesis indicate percentage of row total.

affect their smoking status though the contents might have been targeted for older adults. A study done in 2006 among youths in grades 10 and 12, demonstrated that during the 4 months leading up to survey administration, each additional viewing of a tobacco company parent-targeted advertisement was, on average, associated with lower perceived harm of smoking, stronger approval of smoking, stronger intentions to smoke in the future, and greater likelihood of having smoked in the past 30 days [19] .

Results from a study done to examine whether identifying with a smoker film character increases implicit association of the self with smoking provided the evidence that exposure to smoking in movies is causally related to changes in smoking related thoughts, that identification with protagonists is an important feature of narrative influence and implicit measures may predict the deliberate behavior [20] . In India, nearly 38% of the tobacco incidents in Indian films are filmed with leading actors who are powerful role models for youth to start smoking and perceive smoking as associated with celebration and fun as depicted in the films [21] . A study in Zambia found positive association between youth smoking and seeing actors smoking in media though negative association was found for variables like possessing item with cigarette brand logo and seeing advertisement on billboards [22] . A study done in 2008 showed that after rigorous covariate control, exposure to films and music are associated with smoking [23] .

Giplin in 2007 has found that odds of initiating smoking increased by 46% for youth who were moderately receptive to advertising and by 84% in youth who were highly receptive to advertising [15] . Similarly, a study done among teenagers and young adults demonstrated strong influence of receptivity to advertising on both susceptibility to smoking, experimenting and regular smoking after adjusting for other important variables like exposure to smoking from friends and family [24] . Strong influence of receptivity to advertising on both current smoking (OR = 71.416) and ever smoking (OR = 9.582) was demonstrated by present study as well. However there is need of information on dose response relationship in order to determine whether the relationship between two variables is causal.

Results after administering the statements that reflects smoking provoking role of media showed that majority of respondents agree upon the view that media promote smoking among adolescents. According to McCool’s media interpretation model, attitudes are mediated by exposure to film, which contribute to the perception of smoking prevalence, permissiveness toward smokers and smoking imagery, and enhances smoking intention. Smoking imagery in film may play a role in the development of smoking intentions through inflating the perception of smoking prevalence and presenting socially attractive images [25] .

This study is based on the self-reported exposure as well as view of adolescent students towards media and its role on promoting cigarette smoking among individuals of their age. Findings from this study show that different forms of media including cinema, music, magazines, television, games and music sponsorship are found to be important predictors for smoking status of college students in urban Nepal. Thus both entertainment media and tobacco marketing require equal emphasis from policy standpoint. Formulation of strict policies as well as monitoring the activities of media regarding promotion of harmful behavior including cigarette smoking regularly can be beneficial to lead adolescents towards a healthy life. The study has included adolescent students from Kathmandu, the capital city of Nepal, it represents only students in urban Nepal which is one of its limitations. So, further research on large scale on this area is required for significant policy implication.

We are highly indebted to Dr B. D. Chataut; Principal of CIST College and former Directorate General of Health at Ministry of Health, Nepal for his encouragement throughout the research project. We are heartily thankful to all the colleges that gave permission for study. We acknowledge all the students who participated in the study. We would like to thank the data enumerators: Mr. Madhav KC and Mr. Saurav Chandra Acharya. The authors acknowledge University Grants Commission (UGC), Nepal for providing fund to conduct this study.

The authors declare that they have no competing interests.