INTRODUCTION

Although age-standardized global smoking prevalence has declined over recent decades, substantial regional disparities persist, and the absolute burden of tobacco-attributable disease remains high in low- and middle-income countries, particularly in Southeast Asia¹. Forecasts predict the increment in the absolute number of global cardiovascular (CVD) deaths attributable to tobacco to approximately 3.267 million by 2045, and disability-adjusted life-years (DALYs) lost annually are projected to potentially increase to 75.755 million by 2045². Smoking has a devastating impact on Malaysia, causing a significant number of premature deaths and disabilities, an estimated 20000 Malaysians die each year due to smoking-related illnesses². On the other hand, the economic cost is substantial, with approximately MYR 2.9 billion (1000 Malaysian Ringgit about US$250) or 16.5% of the national health expenditure, allocated to treat cardiopulmonary diseases and lung cancer that are directly linked to tobacco use³. Despite two decades of implementing various anti-tobacco policies consistent with the WHO Framework Convention on Tobacco Control (FCTC) which include smoke-free regulations, pricing strategies, advertising restrictions, and packaging mandates, the prevalence of tobacco use in Malaysian adults has remained stagnant at around one-fifth⁴. While FCTC-endorsed measures are well-established as effective when comprehensively implemented and rigorously enforced, variations in implementation fidelity, enforcement capacity, sociocultural norms, and ongoing tobacco industry interference may influence their population-level impact in Malaysia. In addition to these structural considerations, the highly addictive nature of nicotine remains a critical factor sustaining tobacco use and impeding successful cessation.

This persistent challenge is largely attributed to the highly addictive nature of nicotine, leading to significant dependence among users, which subsequently impedes successful cessation efforts⁵. Studies in Malaysia have consistently reported low sustained quit rates, often attributed to strong nicotine withdrawal symptoms, persistent socio-behavioral influences, and continued exposure to environmental smoking cues^5,6. The persistence of such cues may reflect gaps in the enforcement of smoke-free regulations, contextual sociocultural acceptance of smoking in certain settings, and adaptive marketing strategies by the tobacco industry. These interrelated factors collectively contribute to cycles of dependence and relapse, thereby attenuating the full potential impact of broader public health interventions. Nicotine dependence is a primary driver of sustained tobacco use and a significant barrier to successful cessation globally, and Malaysia is no exception. The pharmacological effects of nicotine lead to a strong physical and psychological dependence, shaping an individual’s smoking behavior into a compulsive habit often resistant to change. This dependence manifests as intense cravings, withdrawal symptoms including irritability, anxiety, difficulty concentrating, and depressed mood, which in turn manifests upon cessation attempts⁷.

A number of published tobacco-related studies have recognized ‘time to first cigarette upon waking up’ (TTFC) as a robust and widely used behavioral marker for assessing the severity of nicotine dependence⁸. This single-item measure is included in the instrument of the Fagerström test for nicotine dependence (FTND), which is indicative of physiological dependence due to its direct correlation with overnight nicotine withdrawal and the subsequent urgency to alleviate these symptoms⁸. A shorter TTFC, such as smoking the first cigarette 30 minutes of waking consistently, predicts higher levels of nicotine metabolites, a greater exposure to carcinogens, and increased difficulty in achieving and maintaining long-term abstinence. Furthermore, individuals with a shorter TTFC often exhibit more severe withdrawal symptoms and are at a higher risk of relapse during cessation attempts, irrespective of the total number of cigarettes smoked daily⁹. Taken together, this evidence supports the use of TTFC as an important clinical and research indicator for identifying highly dependent smokers and informing cessation strategies.

The smokers’ profile, tobacco consumption habits, patterns, and behavior are among the well-recognized determinants of nicotine dependence¹⁰. Therefore, understanding and addressing the multifaceted nature of nicotine dependence, encompassing its behavioral, physiological, and contextual dimensions, is critical to improving smoking cessation outcomes and reducing the persistently stagnant prevalence of tobacco use among Malaysian adults¹⁰. Nevertheless, because of variations in sociocultural background, norms, population characteristics, national laws, and control measures, these predictors may be region-specific³. As such, findings from other countries may not be directly generalizable to the Malaysian context. Therefore, a thorough investigation of the determinants of nicotine dependence, as measured by TTFC, within the Malaysian community is imperative. Understanding how individual-level dependence interacts with broader structural and contextual factors may provide complementary evidence to strengthen implementation strategies, enhance targeted cessation support, and optimize the impact of existing national tobacco control policies.

Research on TTFC has been extensively conducted across numerous countries worldwide, especially in high-income regions like United States⁹, Europe¹¹, and China¹². However, most of these studies have emphasized its clinical and biological implications, with comparatively limited attention to its application as a public health stratification tool. A notable gap remains in its comprehensive examination from a community or public health perspective. Although smokers with high nicotine dependence often demonstrate lower cessation success, identifying individuals with TTFC ≤30 minutes provides actionable information beyond prognosis alone. TTFC-based stratification may guide the intensity, modality, and allocation of cessation support. For instance, smokers with shorter TTFC may benefit from early initiation of combination nicotine replacement therapy, higher pharmacotherapy dosing, extended treatment duration, proactive follow-up, and more intensive behavioral counselling. At the population level, TTFC can help identify communities with a high concentration of heavily dependent smokers who may require resource prioritization, targeted outreach, or specialized cessation services.

In Malaysia, most local studies have been small-scale surveys focusing on factors associated with smoking initiation, with limited exploration of nicotine dependence severity at the population level. Individual-level associations, therefore, remain insufficiently established, particularly regarding how TTFC prevalence and its associated factors vary across Malaysia’s diverse sociocultural settings. Moreover, the potential utility of TTFC as a simple, cost-efficient screening indicator within primary care and community health programs remains underexplored. Understanding the sociodemographic and behavioral determinants of TTFC ≤30 minutes could inform differentiated cessation pathways, enhance risk stratification at primary care, optimize resource allocation, and strengthen tobacco control strategies tailored to the Malaysian context. This study aimed to determine the prevalence and associated sociodemographic and behavioral factors of TTFC within 30 minutes upon waking up, among Malaysian smokers.

METHODS

RESULTS

DISCUSSION

This is the first local study to evaluate nicotine dependence based on the recognized item of TTFC, among the current smoking adult population in Malaysia, employing the most recent nationally representative sample. The measure of TTFC is factored as a core item in the FTND, and Heaviness of Smoking Index (HSI), which are the widely used global instruments⁹. The binary outcomes were investigated in the present study (TTFC within 30 minutes or more than 30 minutes), given that smoking the first cigarette within 30 minutes of waking up has been widely considered by the literature as a strong indicator of nicotine dependence⁹. Among existing smokers in Malaysia, the prevalence of TTFC within 30 minutes of waking was 29.2%. Among all items of FTND, TTFC demonstrated the strongest predictive validity related to cessation outcomes^8,9. The TTFC prevalence, hence, indicates smoking dependence, in which regions or populations with a higher proportion of smokers reporting TTFC within 30 minutes typically have a more severely nicotine-dependent smoking population¹⁵. Our prevalence was lower compared to United States (59.5%)¹⁶ and Korea (53.9%)¹⁷, but higher than China (12.8%)¹² though the Chinese study did not represent the entire adult smoking population.

The discrepancies in prevalence of TTFC within 30 minutes might be due to the variations in sociocultural-norms and even smoking behavior across nations, as well as the disparities in the survey methodology. In our study, the GATS specifically recruited adults aged ≥15 years as a compliance to the standardized component of the WHO’s Global Tobacco Surveillance System (GTSS). Conversely, the Korean study focused exclusively on middle-aged male current smokers¹⁷, while the Chinese study targeted the elderly population¹² rendering the global burden of TTFC difficult to compare directly. While our analysis focuses specifically on the 2023 GATS Malaysia dataset, the 2011 GATS Malaysia Fact Sheet provides a valuable historical baseline for comparison. The 2011 report indicated that almost half of all current daily smokers had their first cigarette within 30 minutes of waking¹⁸. By contrast, our current 2023 analysis shows that this proportion has been reduced to less than one-third. This comparison suggests a significant downward trend in nicotine dependence levels over the past 12 years, likely reflecting the positive impact of cumulative cessation support and tobacco control policies in Malaysia. Our finding also indicated a favorable pattern of increases in quit attempts. The percentage of Malaysian smokers who reported quitting smoking grew from 24.0% in 2012 to 50.6% in 2020¹⁹. Additionally, the number of smokers registered under the mQuit program, which was developed under the National Strategic Plan on Tobacco Control in order to strengthen cessation services in Malaysia, had drastically increased from 7757 (2015) to 28167 (2020)²⁰. These longitudinal observations, when paired with our current 2023 findings, underscore the importance of sustained cessation services in reducing high-dependence smoking patterns.

Past literature has identified individual sociodemographic, economic and occupational factors as the primary determinants of nicotine dependence²¹. The present study highlights smoking behavioral cues that significantly determined TTFC upon waking among the current smokers nationwide, including age of smoking initiation, quit attempt in the past, perception of quitting difficulty, and apprehension about negative health impacts of smoking.

The odds of consuming the first cigarette within 30 minutes of waking up were 1.6 times significantly higher among those who initiated smoking aged <18 years. The underlying mechanism for this heightened dependence among early initiators is largely attributed to the developing brain during adolescence. Adolescents’ brains are still developing significantly, especially in areas linked to decision-making, reward, and impulse control. Therefore, nicotine exposure during this critical period can lead to profound and rapid neuroadaptations in the brain’s reward pathways, specifically by influencing the dopamine and nicotinic acetylcholine receptors (nAChRs), increasing the susceptibility to addiction and decreasing the ability to control cravings²². Consequently, the earlier exposure to tobacco products predisposes the brain for stronger dependence, implying that the withdrawal symptoms of intense cravings upon waking after a period of abstinence due to an overnight sleep, become more severe and immediate²². Studies in Japan²³ and the European Union²⁴ consistently show that early smoking initiation is associated with higher FTND scores and lower cessation rates. These scenarios indicate the universal nature of nicotine’s impact on the developing brain, regardless of geographical location. The substantial association between early initiation and severe dependence contributes to a significant public health burden. Consequently, delaying smoking initiation through a combined public health intervention, such as an impactful school health educational program, and stricter enforcement of the relevant regulation on the legal age for tobacco purchase, are among the crucial measures to reduce overall nicotine dependence and combat smoking habits during pre-adulthood.

In the present study, current smokers without a previous quit attempt in the past 12 months were significantly more likely to report TTFC within 30 minutes of waking, a commonly used indicator of higher nicotine dependence. Nevertheless, this significant pattern of association was not observed in quit intention in the next 12 months. The relationship between nicotine dependence, quit attempts, and quit intentions is complex and bidirectional. While the absence of recent quit attempts in our analysis was associated with earlier TTFC, this does not imply a simple linear pathway whereby stronger dependence uniformly prevents quit attempts. Highly dependent smokers may make repeated but unsuccessful quit attempts, whereas others may refrain from attempting to quit due to low self-efficacy, anticipated withdrawal symptoms, or reduced perceived behavioral control. Conversely, repeated failed attempts may undermine confidence and reduce subsequent motivation to quit, as described in the Theory of Planned Behavior²⁵.

While both past quit attempts and future quit intentions are relevant, they represent conceptually distinct constructs: past quit attempts reflect enacted behavior, whereas quit intentions reflect motivational readiness that may or may not translate into action. However, intentions to quit in the future, while also linked to dependence, may be influenced by ambivalence, social desirability, and perceived behavioral control, and therefore do not consistently predict an actual quit attempt²⁶. Within the constraints of the WHO standardized GATS instrument, aligned with MPOWER indicators, past 12-month quit attempts and intention to quit in the next 12 months are measured as dichotomous indicators. While these standardized measures enhance comparability across countries, they do not capture the frequency, duration, intensity, or context of quit attempts, nor the strength or immediacy of quit intentions. The concept that a lack of quit attempts is linked to increased nicotine addiction, reinforcing the addiction cycle and hindering self-efficacy for quitting, may partially explain the observed association in this population, although alternative pathways are plausible. This phenomenon is grounded in the understanding of operant conditioning and social cognitive theory. Repeated exposure to nicotine without interruption or challenge (quit attempts) provides continuous positive reinforcement for smoking behavior, strengthening the neural pathways associated with tobacco-seeking and tobacco-taking²⁷.

This finding also highlights that intentions are an important intermediate step toward quitting, but do not guarantee a successful or even initiated quit attempt. Thus, behavioral interventions in cessation support play a crucial role in supporting smokers who remain ambivalent or have low self-perceived control, helping them move towards action. A meta-analysis on behavioral interventions for tobacco cessation in low- and middle-income countries has emphasized techniques like motivational interviewing help individuals explore their personal reasons for quitting, weigh the pros and cons, and develop a sense of confidence in their ability to succeed. By tailoring the intervention to the individual’s specific stage of change and their unique circumstances, these approaches help to crystallize a smoker’s intent to quit into a concrete plan, such as setting a quit date and preparing for potential challenges²⁸. Such stage-matched and self-efficacy enhancing interventions may help bridge the gap between passive contemplation and active quit attempts, particularly among smokers with higher levels of dependence who face greater physiological and psychological barriers to cessation.

The present study revealed that smokers with a self-perceived difficulty in quitting was a significant psychological factor of nicotine dependence. This association can be understood via several interconnected psychological and physiological mechanisms. The self-perceived difficulty in quitting is a measure of self-efficacy, which indicates the smokers’ belief in their own ability to succeed at quitting²⁹. Low self-efficacy in quitting smoking is a powerful predictor of relapse and is often a reflection of past failed attempts, which can lead to a sense of hopelessness and a perception that the addiction is insurmountable^28,30. The psychological aspect of self-perceived difficulty in quitting, or barriers, is directly intertwined with this physiological drive. Smokers who feel they have little control over their addiction are more likely to succumb to the intense morning cravings. This behavior, in turn, reinforces their belief that quitting is difficult or impossible, creating a vicious cycle⁹. The act of reaching for a cigarette within 30 minutes of waking is not only a habit, but more likely a rapid response to a powerful physiological craving, which is fueled by a psychological state of perceived helplessness³¹. Therefore, a shorter TTFC is a behavioral manifestation of both high physiological dependence and the psychological conviction that quitting is an impossible task¹⁵. Additionally, the Theory of Planned Behavior (TPB) posits that an individual’s perception may influence specific behavioral participation. The TPB proposes that a person’s desire to engage in a behavior will be stronger if they have a more positive attitude, a more favorable subjective norm or perception, and a larger sense of behavioral control²⁵. This theoretical framework provides a robust explanation for the link between cognitive beliefs and actual actions across a wide range of domains, especially in health behaviors. Therefore, recognizing self-perceived difficulty in quitting as an important determinant, cessation interventions should concentrate on an educational approach in par with boosting smokers’ confidence in their capacity to quit in order to increase their self-efficacy. Depending on the person’s stage of transformation, special techniques including group support groups, cognitive behavioral therapy (CBT), and motivational interviewing have been proven as effective tools³².

In our study, individuals who did not have an apprehension about the adverse health outcomes were two times significantly more likely to smoke the first cigarette within 30 minutes of waking up. Similar findings were found in an Indian study that nicotine dependence and health risk apprehension are intertwined, with higher levels of nicotine dependence often linked to lower awareness of health risks associated with smoking, especially the extra cardiopulmonary disease such as stroke and reproductive health effects (infertility, low birth weight, genital cancer)³³. The phenomenon is best explained by numerous social-cognitive theories of health behavior, especially the Health Belief Model and Protection Motivation Theory which propose that deliberative and reflective cognitions motivate action³⁴. One cognition associated with risk is worry, which is an anticipatory negative emotion experienced when thinking about possible future events. Worry about health consequences has been reported to be associated with motivation or intention to quit smoking, in a population study in England³⁵, which explains individuals who downplay the health risks associated with smoking may exhibit higher levels of nicotine dependence. Therefore, targeting the behavioral mechanism that drives nicotine dependence is crucial for the application of the behavioral modification approach in the comprehensive nicotine cessation support among existing smokers.

The behavioral component plays a major role in determining nicotine dependence, which predicts the likelihood of successful quitting. From a public health perspective, cessation strategies should consider individual behavioral triggers and perceptions identified in empirical findings. While comprehensive tobacco control policies aligned with the WHO FCTC framework, including tobacco taxation, restricting points of sale, enforcing advertising bans, and reducing environmental smoking cues, are fundamental in reducing tobacco use at the population level, individual-level behavioral mechanisms should not be overlooked, particularly among current smokers attempting cessation. Structural interventions reduce exposure and normalize cessation; however, highly dependent smokers may still require targeted behavioral support to address cue-induced cravings and perceived difficulty in quitting. By understanding the specific cognitive and behavioral processes associated with higher dependence, public health initiatives can complement policy measures with targeted, evidence-based behavioral interventions³⁶. Public health programs that educate individuals to recognize and manage cue-induced cravings through cognitive-behavioral techniques delivered via quit lines, digital applications, or community health interventions, are essential for achieving sustained and long-term abstinence³⁵, especially when integrated within supportive regulatory environments.

CONCLUSIONS

This study revealed that less than one-third of Malaysian current smokers reported consuming their first cigarette within 30 minutes of waking. Subpopulations with specific behavioral cues, including those who initiated smoking before the age of 18 years, smokers without previous quit attempt, those who perceived quitting as difficult, and those who are not worried about the adverse health outcomes, were significantly associated with TTFC. This finding implies that nicotine dependence among individual smokers with lower self-efficacy must be critically addressed through impactful behavior-based interventions. Although comprehensive tobacco control efforts should address the entire population, the identified high-risk smoking subgroups may benefit from more focused and tailored behavioral interventions. These findings provide important evidence to inform the refinement of anti-tobacco initiatives targeting smokers with indicators of stronger nicotine dependence.