Tobacco Use and Awareness of Health-Related Risks among 7,213 Adolescents living in Sicily (Italy): A Cross-Sectional Survey-Based Study

Tobacco Use and Awareness of Health-Related Risks among 7,213 Adolescents living in Sicily (Italy): A Cross-Sectional Survey-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tobacco Use and Awareness of Health-Related Risks among 7,213 Adolescents living in Sicily (Italy): A Cross-Sectional Survey-Based Study Martina Coppini, Monica Bazzano, Giulia Marcon, Giuseppe Seminara, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8444619/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Tobacco use, including electronic nicotine delivery systems (ENDS), is increasingly prevalent among adolescents, often accompanied by misconceptions regarding associated health risks. Reliable epidemiological data are essential to inform prevention strategies, particularly in regions where evidence remains limited. A cross-sectional, observational survey was conducted among 7,213 students aged 11–19 years attending 48 middle and high schools in Sicily (Italy). Data were collected using an anonymous, self-administered questionnaire assessing tobacco behaviors, vaping habits, and awareness of systemic and oral health risks related. Associations and response patterns among selected variables were explored using Multiple Correspondence Analysis (MCA). Most participants reported not currently using (82.8%); however, experimentation with tobacco cigarettes (28.6%), e-cigarettes (27%), or both was common (42.5%). Nearly half of students using e-cigarettes perceived vaping as less harmful than conventional smoking (48%). Gender differences were observed for e-cigarette use, with a higher prevalence among females (p-value = 0.019). MCA highlighted distinct behavioral and perceptual profiles, identifying e-cigarette use as a pattern associated with inconsistent or underestimated risk perception, especially in the absence of family- or school-based education. Although awareness of smoking-related health risks was generally high, knowledge alone appeared insufficient to prevent experimentation. These findings underscore the need for structured, age-appropriate school-based prevention programs and provide a descriptive foundation for future longitudinal and intervention studies. tobacco consumption electronic nicotine delivery systems ENDS smoking awareness survey survey and questionnaires adolescents vaping electronic cigarettes e-cigarettes Multiple Correspondence Analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Tobacco consumption represents the primary cause of cancer mortality worldwide and is associated with nearly two-thirds of all lung cancer cases [1]. Tobacco causes approximately 7 million deaths worldwide each year, with 6 million resulting from direct consumption and 1.2 million from exposure to secondhand smoke [2]. In addition to being the leading cause of lung cancer, tobacco consumption also contributes to the development of several other types of cancer, including those of the oral cavity, esophagus, larynx, and pancreas. Smoking is a leading cause of preventable cancers, linked to multiple cancer sites through numerous carcinogens in tobacco and combustion products, with a risk that increases according to both dose and duration of use [3, 4]. Since their introduction in the mid-2000s, the consumption and purchase of tobacco products have increasingly shifted toward alternative nicotine delivery systems, raising public health concerns due to their growing popularity. Electronic cigarettes (e-cigarettes) are innovative, battery-operated devices engineered to administer nicotine via aerosolization, providing a smoke-free alternative to conventional tobacco use [5]. The use of e-cigarettes has grown over the past decade. A 2019 review of surveys on e-cigarette use in Europe found that, among both adults and young people, current use ranged from 0.2% to 27%, ever-use from 5.5% to 56.6%, and daily use from 1% to 2.9% [6]. E-cigarette vapor contains many of the same toxins as conventional cigarettes, such as formaldehyde, cadmium, and lead, though generally at lower levels. Nonetheless, their short- and long-term health effects remain unclear, and marketing often creates the misleading suggestion that they are safer than traditional cigarettes [7]. The packaging and marketing strategies adopted for electronic cigarettes (e-cigs), including electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs), have garnered substantial interest and are increasingly prevalent among the youth population[8]. Adolescent susceptibility to e-cigarette use is influenced by intrapersonal factors such as age, interpersonal dynamics including family or peer conflicts, and contextual factors like community structures and regulations, while product features and marketing, including flavors, lack of age restrictions, and appeals to social or sexual identity, further increase their attractiveness [9]. However, the health impacts of these devices on both users and the broader public are still poorly understood [10]. Widespread prevalence, especially among young people, underscores the need for awareness campaigns to warn of the risks and understand the potential harm [8]. The null hypothesis of this study is that vaping is widely used among adolescents and is perceived as less harmful than conventional tobacco smoking. The present study aims to investigate tobacco consumption habits and awareness of related health risks within a study population of middle and high school students in Sicily. 2. Materials and Methods 2.1. Study description The present study was designed as a cross-sectional, survey-based observational study. The study population consisted of 7,213 adolescents attending middle and high schools across Sicily, Italy, ranging between 11 and 19 years old. The sample represents a convenience population recruited within an educational prevention initiative and does not constitute a probabilistic or population-based sample. Data were collected through a structured, anonymous, self-administered online questionnaire accessed via a QR code. Prior to questionnaire submission, all students viewed a standardized educational video addressing general information on tobacco use and vaping. The questionnaire included mandatory demographic items and 19 closed-ended questions exploring smoking behaviors, motivations for initiation, frequency and intensity of use, perceptions of risk, family and school-based education, and exposure to passive smoking (Table 1 ). The study protocol was approved by the University Hospital “P. Giaccone” of Palermo Institutional Local Ethics Committee (#4/2023); within an educational project, a questionnaire with multiple responses on the topic was administered in 48 middle and high Sicilian schools. Participation was voluntary and anonymous. All data collected was processed in compliance with legislative order N. 196/03 and the European Regulation N. 2016/679 on the processing and protection of personal data. The educational video focused on key topics such as the harmful components found in cigarettes, the dangers of vaping, the distinction between first, second, and third hand smoke, and the health risks associated with tobacco use. To better engage the younger audience, the content incorporated elements inspired by social media formats commonly used by adolescents, such as TikTok. The use of video as an educational tool in this study offered several advantages, particularly for younger individuals who might have limited prior knowledge of the subject. It provided a standardized form of communication, ensuring that all participants received uniform information regardless of their age, gender, or socio-economic background. This approach was intended to reduce variability in baseline knowledge and to limit potential bias arising from misinterpretation of either the educational content or the questionnaire, thereby supporting the overall consistency and validity of the collected responses. No selection or categorization of students was carried out based on age or gender; therefore, the observed distribution of participants across these variables reflects the natural composition of the surveyed school population. 2.2. Questionnaire description The questionnaire consisted of a structured set of items designed to assess multiple domains related to tobacco use and risk awareness. Specifically, it included questions on smoking behaviors (Item #1-2-3-4-5), perceived clarity of the educational video (Item #6), awareness of smoking-related health risks (Item #7-8-9-10), frequency of dental appointments (Item #11), awareness of health risks associated with svaping (Item #12), awareness of passive smoking risks (Item #13–14), knowledge of first-, second-, and third-hand smoke (Item #15), smoking habits within the family environment (Item #16–17), and school-based education on smoking risks and prevention (Item #18–19). Table 1 English version of the online questionnaire. ITEM # Questionnaire and Answers ITEM #1 What do you smoke? □ I don't smoke, □ Tobacco cigarette, □ E-cigarette □ Both (tobacco and e-cigarette) ITEM #2 If you smoke, at what age did you start smoking? □ Between 10–12, □ Between 13–15, □ Between 16–18 □ After 18 ITEM #3 If you smoke, what made you start smoking? □ I don't smoke, □ For fun or as a game, □ Out of boredom □ To be like other friends □ Because my parents and/or siblings smoke ITEM #4 How often do you smoke now? □ Never, □ Every day, □ Occasionally □ Only in the evening when I go out with friends ITEM #5 How many cigarettes do you smoke per day? □ I don't smoke, □ A couple, □ Fewer than 5 □ Between 5 and 10 □ More than 10 ITEM #6 Was the video you just watched interesting to you? □ Yes, □ Yes, but it wasn’t clear, □ No ITEM #7 Are you aware of the health risks associated with smoking? □ Yes, I learned about them by watching the video, □ Yes, I already knew about them, □ No ITEM #8 Do you think smoking is dangerous for your health? □ Yes, very dangerous, □ Yes, but not very dangerous, □ No ITEM #9 Do you think smoking is dangerous for your oral health (tongue, cheeks, gums)? □ Yes, very dangerous, □ Yes, but not very dangerous, □ No ITEM #10 Do you think smoking is dangerous for your dental health (teeth)? □ Yes, very dangerous, □ Yes, but not very dangerous, □ No ITEM #11 Do you go to the dentist at least twice a year for prevention? □ Yes □ No ITEM #12 Do you think vaping is less dangerous than smoking tobacco cigarettes? □ Yes □ No □ I don't know ITEM #13 Have you been exposed to secondhand smoke in the past month? □ Yes □ No □ I don't know ITEM #14 Do you know how harmful secondhand smoke is? □ Yes, I learned about it by watching the video □ Yes, I already knew about it □ No ITEM #15 Do you know the difference between first-hand, second-hand, and third-hand smoke exposure? □ Yes, I learned about it by watching the video □ Yes, I already knew about it □ No ITEM #16 Can guests smoke in your home? □ Yes, wherever they want □ Yes, only in certain rooms/on the balcony □ No ITEM #17 Has your family talked about the risks related to smoking? □ Yes □ No □ I don't know ITEM #18 Do you think schools should provide information about the risks of smoking and alternatives to smoking? □ Yes □ I think it's important, but not necessary □ No ITEM #19 Have you been taught at school about the risks of smoking? □ Yes, I learned about them by watching the video □ Yes, they talked about it on other occasions □ No □ I don't know 2.3. Preliminary Analysis All collected variables were categorical and were summarized using absolute frequencies and percentages, stratified by gender (female vs. male) and by age groups. In line with the exploratory nature of the study and its educational context, no a priori sampling procedure or power calculation was performed. Descriptive analyses focused on the distribution of current smoking status, age at smoking initiation, and perceived risks related to both tobacco smoking and vaping. Selected items were recoded or aggregated to improve interpretability and to capture broader constructs, such as overall perceived risk of smoking. Further analysis focused on a subset of questionnaire variables selected a priori for their relevance to smoking behavior, risk perception, and exposure to preventive education. These included the following original variables: current smoking status (non-smoker, tobacco cigarette smoker, e-cigarette user, dual user); smoking frequency; self-reported reasons for smoking initiation; number of cigarettes smoked per day; perceived harmfulness of vaping compared with conventional cigarettes; family discussion of smoking-related risks; school-based education on smoking risks. In addition, two derived variables were constructed for exploratory purposes: Overall risk perception, defined as the sum of three ordinal items assessing perceived danger of smoking for (i) general health, (ii) oral soft tissues (tongue, cheeks, gums), and (iii) dental health. Each item was coded on a three-level ordinal scale (0 = “No”, 1 = “Yes, but not very dangerous”, 2 = “Yes, very dangerous”), yielding a composite score ranging from 0 to 6. Maximum perceived risk category, defined as the highest health domain for which the respondent selected “Yes, very dangerous”, based on the following predefined hierarchy: general health < oral health < dental health. 2.4. Statistical Analysis Multiple Correspondence Analysis (MCA) was applied as an exploratory multivariate technique to explore associations and latent structures among selected categorical variables related to smoking behavior, vaping, education, and risk perception. MCA was chosen because of its suitability for nominal and ordinal categorical data and its ability to represent complex response patterns in a reduced-dimensional space [11–14]. The analysis was exploratory and intended to generate hypotheses rather than to support inferential or causal claims. All analyses were conducted using the R software [15]. Interpretation of the MCA dimensions was based on the relative contribution of variables to each axis (η²) and on the positioning of categories in the factorial space. The quality and relevance of categories were assessed using standard MCA diagnostics, including category coordinates, squared cosine values (cos²), v.test statistics, and contribution indices. Detailed numerical results are reported in the Supplementary Material. 3. Results 3.1. Demographic, smoking patterns and gender features The survey was completed by 7,213 students (49% males, 49% females, and 2% other) with a mean age of 14.3 ± 2 years. Regarding smoking habits, 5,973 declared that they did not smoke (82.8%). Among smokers, most smoked both electronic and conventional cigarettes (42.5%), followed by tobacco cigarettes (28.6%) and electronic cigarettes (27%). The remaining adolescents did not specify what they smoked (1.9%). The age at which students begin smoking varies individually, but the highest incidence consistently occurs between 13 and 15 years of age, with 62% of e-cigarette users, 58% of conventional cigarette smokers, and 57% of both users reporting initiation during this period. The majority consumed between 1 and 5 cigarettes per day. Alarmingly, approximately 8% reported smoking more than 10 cigarettes daily, indicating the onset of a potential addiction pattern even at a young age. Regarding gender-based differences, a statistically significant disparity was observed only in the use of e-cigarettes, with a higher prevalence among females (p-value = 0.019). No significant differences were found between males and females in the use of conventional cigarettes or both use (Fig. 1 ). Among those who admitted smoking, the behavior was mostly occasional. The most frequently cited reasons for smoking included curiosity ("fun and games", 7,5%), boredom (4,8%), or peer influence (2.4%) (Table 2 ). Table 2 Smoking habits among students. ITEM #3 If you smoke, what made you start smoking? N (%) I do not smoke 5,329 (73,88%) Fun and games 541 (7,50%) Be like friends 153 (2,12%) Parents and/or siblinds smoke 175 (2,43%) Out of boredom 349 (4,84%) Not Responding 666 (9,23%) The students' responses suggest some confusion in the definition of a smoker, as individuals who report smoking 'occasionally' subsequently identify themselves as non-smokers. One of the most alarming findings was related to perceptions of vaping. Among students who smoke e-cigarettes or both, the largest percentage believes that vaping is less dangerous than smoking tobacco cigarettes (48% and 43%, respectively); while smokers of tobacco cigarettes seem to be aware of the danger of vaping (51%) (Table 3 ). Table 3 Perception of danger of vaping among students. ITEM #12 Do you think vaping is less dangerous than smoking tobacco cigarettes? ITEM #1 What do you smoke? Nothing Both (tobacco and electric) Tobacco cigarette Electric cigarette Total No 2511 (42%) 177 (34%) 180 (51%) 114 (34%) 2982 (41%) Yes 1498 (25%) 227 (43%) 102 (29%) 162 (48%) 1989 (28%) I do not know 1964 (33%) 123 (23%) 73 (21%) 59 (18%) 2219 (31%) Total 5973 (100%) 527 (100%) 355 (100%) 335 (100%) 7190 (100%) Regarding the knowledge of the difference between first-, second-, and third-hand smoke, only 21% were familiar with these concepts before the video, 55% learned about them during the video, and 24% remained unaware. Almost half of the students stated that smoking-related risks had never been openly discussed within their family. Most students agreed on the importance of school-based health education on this topic. Although many students recognized the school’s role in tobacco prevention, a considerable number reported never having received formal education on the health consequences of smoking, pointing to the need for more structured and widespread school programs. Notably, all students were aware of the systemic and oral health risks associated with smoking, which makes the persistence of the habit particularly concerning. 3.2. Multiple Correspondence Analysis Six dimensions were retained based on eigenvalues and the cumulative proportion of explained variance, which together accounted for 44.5% of the total inertia, a level considered acceptable for complex survey data. Additional details about the MCA framework are available in the Supplementary Material. The first dimension (14.7% of explained variance) primarily captured current smoking behavior , clearly distinguishing non-smokers from occasional and daily smokers, as well as separating tobacco cigarette users, e-cigarette users, and dual users according to smoking frequency, intensity, and motivations for initiation. This axis represents the behavioral core of tobacco and nicotine use. The second dimension (7.1%) reflected global perceived health risk , contrasting respondents who consistently perceived smoking as highly dangerous with those who minimized or denied health risks. This dimension was largely independent of actual smoking behavior, highlighting a cognitive-perceptual component. The third dimension (6.6%) represented risk–behavior coherence , separating individuals whose smoking intensity was consistent with low perceived risk from those displaying discordant profiles, such as heavy smokers reporting high awareness or light users expressing limited concern. The remaining dimensions (Dimensions 4–6; 6.1%, 5.6%, and 4.4%, respectively) provided more nuanced refinements of risk perception and information exposure. In particular, Dimension 6 isolated respondents according to educational exposure , distinguishing students who reported receiving information on smoking risks at school or within the family from those consistently selecting “I do not know”. Overall, the MCA highlighted that smoking behavior, perceived risk, and educational background constitute partially independent yet interconnected dimensions shaping adolescents’ smoking-related profiles. The analysis was exploratory and intended to generate hypotheses rather than to infer causal relationships. Concerning the electronic cigarette, it emerges as a particularly complex element in the MCA results, both in terms of behaviour and risk perception. From a behavioural perspective, the category "electric cigarette" shows a strong positive coordinate on Dimension 1 (coord = 1.862), which represents current smoking behaviour. This confirms that vaping is often part of students’ broader tobacco use patterns. Additionally, it is positively associated with Dimension 3 (coord = 1.538, contrib = 6.4%), a dimension that captures the inconsistency between actual smoking and perceived health risks. The contribution to Dimension 4 (4.1%) further reinforces its link to how individuals subjectively rationalize or internalize risk, independently of their actual behaviour. These results suggest that electronic cigarettes are frequently used in combination with traditional smoking, and that users tend to minimize or rationalize the potential dangers, displaying at times inconsistent or ambivalent behaviours. These patterns are visually illustrated in Figs. 2 – 4 which display the distribution of respondents across the main MCA dimensions. All individual factor maps highlight distinct yet complementary patterns across the examined dimensions. In Fig. 2 , individuals cluster, according to smoking status, with non-smokers positioned on the negative side of Dimension 1 and smokers, particularly tobacco and dual users, distributed on the positive side. Electronic cigarette users occupy an intermediate and more dispersed position, indicating heterogeneity in both behavior and associated perceptions. In Fig. 3 , individuals are primarily differentiated by overall risk perception, with higher perceived risk categories grouped on the positive side of Dimension 2 and lower or absent risk perception on the negative side, largely independent of smoking behavior. Finally, in Fig. 4 , the Dim5–Dim6 projection reveals a weaker but interpretable separation related to educational exposure: respondents reporting school-based education on smoking risks tend to cluster distinctly from those indicating uncertainty or lack of information. 4. Discussion The indiscriminate use of electronic cigarettes, often without sufficient awareness of their potential health risks, represents an increasingly urgent public health concern [8]. This phenomenon has spread with alarming speed: the e-cigarette industry has rapidly evolved into a multibillion-dollar global market, positioning itself as a popular alternative to traditional tobacco products. Initially targeting current and former smokers seeking a less harmful alternative, e-cigarettes have gained widespread popularity among adolescents and young adults, reshaping patterns of nicotine consumption [16]. Until 2021, vaping was rare among European youth and adults who had never smoked (< 0.8%), but over the past three years the emergence of disposable nicotine delivery devices containing high concentrations of nicotine salts (≤ 20 mg/ml in the EU), which are inexpensive, easily concealable, and convenient to use, has been associated with a rapid increase in use among young people [17, 18]. Data from the Global Burden of Disease Study indicate that 82.6% of tobacco users initiate use between 14 and 25 years of age, with the likelihood of developing dependence decreasing substantially thereafter. Consequently, adolescents and young adults constitute the population at highest risk, as ongoing neurodevelopment, social influences, and peer-related pressures render them particularly vulnerable to nicotine addiction (21). Young people tend to be more impulsive and inclined toward risky behaviors. Many view e-cigarettes as safer and easier to hide than traditional cigarettes [19]. Moreover, social media marketing strongly promotes vaping among adolescents, and retail displays near checkout counters and youth-oriented products reinforce the perception of e-cigarettes as common and socially accepted [20, 21]. Proponents of e-cigarettes argue that, since they involve no combustion, they are safer than traditional cigarettes. Consequently, e-cigarettes have been proposed as a potential aid for smoking cessation among current smokers [22]. Nevertheless, Etter and Bullen reported that 81% of those patients who were daily e-cig users continued vaping after 1 year [23]. Also, among Italian e-cigarette users, those who restart smoking after using e-cigarettes outnumber those who stop smoking after using e-cigarettes [24]. Despite limited evidence regarding their long-term health effects, e-cigarettes are widely accessible in retail and online markets, supported by aggressive advertising. In 2016, 4.3% of U.S. middle school students and 11.3% of high school students used e-cigarettes. In the UK, ever-use among 11–16-year-olds ranged from 7% to 18%, while regular use ranged from 1% to 3%. Notably, nearly one-third of U.S. adolescents believe e-cigarettes are less harmful than conventional cigarettes [25–27]. In Italy, while the prevalence of current smokers among adolescents remained stable at around 20%, vaping rose sharply: from 0% in 2010 to 7.4% in 2014 and 17.5% in 2018 [28]. To the best of our knowledge, to date, very few studies have examined this public health concern in Italy, particularly among the adolescent population[24, 28, 29]. The present study aims to investigate for the first time this issue in a study population of 7,213 students living in Sicily (south Italy) from both middle and high schools. In our study, although most students declared they did not smoke, many reported experimenting with cigarettes or e-cigarettes between 13 and 15 years of age, with troubling misconceptions about the safety of vaping and notable gaps in basic smoking-related awareness. These results highlight the urgency of implementing reinforced and structured educational programs in schools to correct misunderstandings and address early smoking initiation. Indeed, although anti-smoking campaigns have traditionally been introduced in high school, our findings indicate that the average age of smoking initiation has significantly decreased, underscoring the need to implement structured prevention programs starting as early as middle school. A study performed on students enrolled in healthcare assistance programs, comparing first-year and final-year cohorts, reported a significant reduction in smoking habits over the course of university training [29]. Moreover, regarding gender differences, our findings performed on 7,213 Sicilian adolescents suggest a possible shift in the traditional smoking patterns reported in the literature. In the context of electronic cigarette use, girls in our study appeared more inclined to vape compared with boys, a trend that contrasts with previously published Italian data. For example, a study conducted in 2020 among Italian healthcare students reported similar smoking frequencies between genders (38.9% males vs. 33.4% females)[29]. In line with our findings, a recent ISTAT (Istituto Nazionale di Statistica – National Statistics Institute) report shows that the gender gap in smoking prevalence has significantly narrowed over time (from 10.2% in 2013 to 7.1% in 2023), primarily due to a marked reduction in smoking among men, while rates among women have remained largely stable [30]. This apparent trend reversal may indicate a changing sociocultural dynamic in the uptake of e-cigarettes among younger generations, warranting further investigation. However, in our study, this shift in gender patterns was observed exclusively for electronic cigarettes, which showed higher prevalence among females, whereas the use of conventional tobacco cigarettes remained more common among males. Notably, 2% of respondents did not identify exclusively as male or female, reflecting the presence of gender-diverse adolescents within the surveyed population. Although this subgroup is numerically small, its inclusion highlights the need for sensitivity toward gender diversity when interpreting health-related behaviors in youth. This study reveals substantial confusion among adolescents regarding what it means to “smoke”. Students' self-classification of smoking status shows notable inconsistency: individuals reporting occasional smoking occasionally subsequently identified themselves as non-smokers. This discrepancy suggests that the concept of being a “smoker” is subjectively interpreted, potentially influenced by social norms, underestimation of occasional behaviors, or stigma avoidance. Uncertainty persists among students regarding the relative harms of vaping versus smoking, reflecting either a lack of knowledge or conflicting information. Consistent with previous literature, the high initiation rates observed between 13 and 15 years of age underscore adolescence as a critical period for tobacco and nicotine exposure, corroborating evidence that early experimentation increases the likelihood of long-term dependence. Although most smokers consumed only a few cigarettes per day, the finding that approximately 8% smoked more than ten cigarettes daily is concerning, suggesting the emergence of addictive patterns even at a young age. E-cigarettes occupy a behavioral and perceptual grey area : they are frequently used by students who also smoke traditional cigarettes and are perceived as a safer alternative, partly due to insufficient education on their risks. The customizable nature of e-liquids, particularly their flavors, increases their appeal and represents a growing public health concern among youth, especially women [31, 32]. Although the short- and long-term effects of e-cigarettes are not yet fully understood, recent studies have reported that alterations in the salivary composition of smokers appear to be associated with an increased risk of developing conditions such as type 2 diabetes, hypertension, cardiovascular and renal diseases, as well as promoting tumorigenesis and impairing oral immune function. In contrast, analyses of e-liquids after use have not revealed any significant molecular or compositional changes (26,27). However, the levels of nicotine delivered through ENDS are comparable to, or even higher than, those of traditional cigarettes, with similar systemic retention. Moreover, individuals who use these devices tend to smoke more frequently, often even in indoor environments, further exacerbating exposure [8]. Regarding the oral health status, recent studies reported an increased risk of periodontitis, dental caries, and tooth and prosthesis discoloration associated with vape use [33–35]. Additionally, salivary metabolite alterations have been identified in e-cig users, particularly with elevated levels of metabolites associated with inflammation, xenobiotic metabolism, and biomass-burning pathways [36]. In the present study, regarding perceptions of vaping risk, a concerning underestimation of it emerges, with nearly half of e-cigarette users believing vaping to be harmless, highlighting persistent misinformation and inadequate education. Despite widespread awareness of health risks, the perseverance of even occasional smoking underscores that knowledge alone is insufficient, emphasizing the urgent need for comprehensive, school-based programs that correct misconceptions and target both traditional and electronic smoking [37]. Recent evidence suggests that the most effective strategies for promoting health awareness among adolescents focus on three elements: fostering a school-wide health ethic, creating a supportive health-promoting environment, and integrating health education into the formal curriculum [38]. Schools thus represent strategic settings for early interventions, particularly when programs are supported by family and community involvement; however, further rigorous research is needed to ensure that these interventions are evidence-based and truly effective [39]. 5. Limitations This study had limitations that should be considered. First, the study population may not fully represent the broader adolescent population, as it refers to limited geographical and institutional context; moreover, since it is consisted entirely of Sicilian participants, the findings may not be generalizable. Variations in socioeconomic status, cultural attitudes, and access to vaping products may further limit the applicability of the results to other populations. Nonetheless, the large number of students interviewed across 48 schools and the inclusion of adolescents with diverse backgrounds within the region enhance the internal validity and robustness of the observed patterns. Second, since the survey involved young people, responses may be subject to bias, as adolescents may not have taken all the questions seriously or may have provided inaccurate answers. Additionally, the study relies solely on self-reported data, which may not always accurately capture actual behaviors, particularly when dealing with sensitive activities like smoking or vaping. The occasional nature of smoking reported by most students, coupled with the apparent confusion in self-classification as smokers, indicates that social norms and subjective interpretations may influence both behavior and reporting, complicating the identification of at-risk individuals. However, the anonymity of the questionnaire likely reduced bias, helping students provide more honest and uninfluenced responses. Finally, a further limitation could be the potential influence of the educational video, as exposure to the video before completing the survey may have affected students’ responses and awareness, potentially biasing the results regarding knowledge and attitudes. At the same time, using a standardized educational tool ensured that all participants received uniform information, reducing variability due to differences in prior knowledge and improving comparability across responses. 6. Conclusion The study reveals a concerning prevalence of smoking among Sicilian adolescents, many of whom experiment with both tobacco and e-cigarettes. Although some awareness exists regarding tobacco consumption-related health risks, the perception that vaping is safer or more dangerous, reflecting a significant concern, as it may lead to increased experimentation and addiction among adolescents. These findings underscore the urgent need for targeted, age-appropriate educational strategies that distinguish vaping from traditional smoking, both in terms of behavioral patterns and risk communication. Intervening during adolescence is particularly crucial: disrupting the adoption of these harmful habits at an early stage can substantially reduce the likelihood of long-term health consequences and chronic disease in adulthood. Ultimately, strengthening preventive efforts in schools and communities may play a pivotal role in mitigating the future burden of tobacco- and vaping-related pathologies. Future research should consider longitudinal study designs, probabilistic sampling strategies, and multilevel modeling approaches to account for school-level clustering and to better assess temporal relationships and potential determinants of smoking and vaping behaviors. Abbreviations ENDS: electronic nicotine delivery systems MCA: Multiple Correspondence Analysis E-cigs: electronic cigarettes Declarations Ethics approval and consent to participate The study protocol adhered to the ethical guidelines specified in the 1964 Declaration of Helsinki and its subsequent amendments, or comparable ethical standards. To ensure compliance, approval for the study and necessary permissions were obtained from the school management boards and the Sicilian Regional Department of Education and Professional Training. The Ethical Local Committee of the University Hospital of Palermo also approved it (#4/2023). Informed consent to participate was obtained from all participants or, in the case of minors under the age of 16, from their parents or legal guardians. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare no conflicts of interest. Funding This research received no external funding. Authors' contributions Conceptualization, G.C.; methodology, G.M., M.B., M.C., G.L.M., F.B., G.S., R.M., and D.M., validation, G.C. and G.M.; formal analysis, G.M. and M.C; investigation, M.B., F.B., G.L.M., G.S., M.C. and D.M.; resources, M.C., G.L.M., G.S., F.B. and D.M.; data curation, M.C. and G.M.; writing—original draft preparation, M.C., G.S. and M.B.; writing—review and editing, G.C., G.M. and R.M.; visualization, G.C. and G.M..; supervision, G.C.; project administration, G.C.); funding acquisition, G.C. All authors have read and agreed to the published version of the manuscript. Acknowledgements We express our gratitude to the Rotary District 2110 Sicily-Malta for their involvement and direct invitation to the district Rotarian dental prevention project named “Quit smoking. Choose health, including your oral health. Smetti di fumare. Scegli la salute anche quella orale”. 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Effective health promoting school for better health of children and adolescents: indicators for success. BMC Public Health [Internet]. 2019 Aug 13 [cited 2025 Nov 2];19(1):1088. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6691553/ Gardner LA, Rowe AL, Newton NC, Egan L, Hunter E, Devine EK, et al. A Systematic Review and Meta-analysis of School-Based Preventive Interventions Targeting E-Cigarette Use Among Adolescents. Prev Sci [Internet]. 2024 Oct 1 [cited 2025 Nov 17];25(7):1104–21. Available from: https://pubmed.ncbi.nlm.nih.gov/39325296/ Additional Declarations No competing interests reported. Supplementary Files SupplementSmokingHabitsandAwarenessofSmoking.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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11:57:34","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":100126,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/07b5c3b9e4b59843f053d31c.html"},{"id":100399929,"identity":"77c4f7bb-edfa-4c3b-b957-211e25a8c27e","added_by":"auto","created_at":"2026-01-16 11:57:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173516,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of smoking status and product type by gender.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/a15b368a3c948dd6db8b7860.png"},{"id":100400309,"identity":"54d6ca47-1a63-4806-914c-ac2d1d3046ca","added_by":"auto","created_at":"2026-01-16 11:58:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":293953,"visible":true,"origin":"","legend":"\u003cp\u003eMCA projection of individuals onto axes 1 and 3, coloured by \u003cem\u003eWhat do you smoke?,\u003c/em\u003e with group confidence ellipses\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/80c020fcf4b7cae883676584.png"},{"id":100399734,"identity":"d21b1efc-921a-4ddb-b412-b72add3d9334","added_by":"auto","created_at":"2026-01-16 11:57:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":257368,"visible":true,"origin":"","legend":"\u003cp\u003eMCA projection of individuals onto axes 2 and 4, coloured by \u003cem\u003eOverall risk perception,\u003c/em\u003e with group confidence ellipses\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/51d3b1c05e0c2c44d6c0f1e0.png"},{"id":100399460,"identity":"d2082d6e-14f9-4eea-9f86-64d96b46c0c5","added_by":"auto","created_at":"2026-01-16 11:57:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":254009,"visible":true,"origin":"","legend":"\u003cp\u003eMCA projection of individuals onto axes 5 and 6, coloured by \u003cem\u003eHave you been taught at school about the risks of smoking?,\u003c/em\u003e with group confidence ellipses\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/4eab1b582393c85a3f21eb73.png"},{"id":102962692,"identity":"bf42f7a4-22bd-4d48-a296-2a3822159cdb","added_by":"auto","created_at":"2026-02-19 04:10:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2255511,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/4193b48b-4583-4938-aab0-f3c4ba033014.pdf"},{"id":100399521,"identity":"54a91491-a20b-45cd-92b5-da1e31a8bfe6","added_by":"auto","created_at":"2026-01-16 11:57:10","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":31493,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementSmokingHabitsandAwarenessofSmoking.docx","url":"https://assets-eu.researchsquare.com/files/rs-8444619/v1/ec28875aed1457c473d32e79.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tobacco Use and Awareness of Health-Related Risks among 7,213 Adolescents living in Sicily (Italy): A Cross-Sectional Survey-Based Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eTobacco consumption represents the primary cause of cancer mortality worldwide and is associated with nearly two-thirds of all lung cancer cases [1]. Tobacco causes approximately 7\u0026nbsp;million deaths worldwide each year, with 6\u0026nbsp;million resulting from direct consumption and 1.2\u0026nbsp;million from exposure to secondhand smoke [2].\u003c/p\u003e \u003cp\u003eIn addition to being the leading cause of lung cancer, tobacco consumption also contributes to the development of several other types of cancer, including those of the oral cavity, esophagus, larynx, and pancreas. Smoking is a leading cause of preventable cancers, linked to multiple cancer sites through numerous carcinogens in tobacco and combustion products, with a risk that increases according to both dose and duration of use [3, 4].\u003c/p\u003e \u003cp\u003eSince their introduction in the mid-2000s, the consumption and purchase of tobacco products have increasingly shifted toward alternative nicotine delivery systems, raising public health concerns due to their growing popularity. Electronic cigarettes (e-cigarettes) are innovative, battery-operated devices engineered to administer nicotine via aerosolization, providing a smoke-free alternative to conventional tobacco use [5].\u003c/p\u003e \u003cp\u003eThe use of e-cigarettes has grown over the past decade. A 2019 review of surveys on e-cigarette use in Europe found that, among both adults and young people, current use ranged from 0.2% to 27%, ever-use from 5.5% to 56.6%, and daily use from 1% to 2.9% [6].\u003c/p\u003e \u003cp\u003eE-cigarette vapor contains many of the same toxins as conventional cigarettes, such as formaldehyde, cadmium, and lead, though generally at lower levels. Nonetheless, their short- and long-term health effects remain unclear, and marketing often creates the misleading suggestion that they are safer than traditional cigarettes [7].\u003c/p\u003e \u003cp\u003eThe packaging and marketing strategies adopted for electronic cigarettes (e-cigs), including electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs), have garnered substantial interest and are increasingly prevalent among the youth population[8].\u003c/p\u003e \u003cp\u003eAdolescent susceptibility to e-cigarette use is influenced by intrapersonal factors such as age, interpersonal dynamics including family or peer conflicts, and contextual factors like community structures and regulations, while product features and marketing, including flavors, lack of age restrictions, and appeals to social or sexual identity, further increase their attractiveness [9].\u003c/p\u003e \u003cp\u003eHowever, the health impacts of these devices on both users and the broader public are still poorly understood [10].\u003c/p\u003e \u003cp\u003eWidespread prevalence, especially among young people, underscores the need for awareness campaigns to warn of the risks and understand the potential harm [8].\u003c/p\u003e \u003cp\u003eThe null hypothesis of this study is that vaping is widely used among adolescents and is perceived as less harmful than conventional tobacco smoking.\u003c/p\u003e \u003cp\u003eThe present study aims to investigate tobacco consumption habits and awareness of related health risks within a study population of middle and high school students in Sicily.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study description\u003c/h2\u003e \u003cp\u003eThe present study was designed as a cross-sectional, survey-based observational study. The study population consisted of 7,213 adolescents attending middle and high schools across Sicily, Italy, ranging between 11 and 19 years old. The sample represents a convenience population recruited within an educational prevention initiative and does not constitute a probabilistic or population-based sample.\u003c/p\u003e \u003cp\u003eData were collected through a structured, anonymous, self-administered online questionnaire accessed via a QR code. Prior to questionnaire submission, all students viewed a standardized educational video addressing general information on tobacco use and vaping. The questionnaire included mandatory demographic items and 19 closed-ended questions exploring smoking behaviors, motivations for initiation, frequency and intensity of use, perceptions of risk, family and school-based education, and exposure to passive smoking (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The study protocol was approved by the University Hospital \u0026ldquo;P. Giaccone\u0026rdquo; of Palermo Institutional Local Ethics Committee (#4/2023); within an educational project, a questionnaire with multiple responses on the topic was administered in 48 middle and high Sicilian schools. Participation was voluntary and anonymous. All data collected was processed in compliance with legislative order N. 196/03 and the European Regulation N. 2016/679 on the processing and protection of personal data.\u003c/p\u003e \u003cp\u003eThe educational video focused on key topics such as the harmful components found in cigarettes, the dangers of vaping, the distinction between first, second, and third hand smoke, and the health risks associated with tobacco use. To better engage the younger audience, the content incorporated elements inspired by social media formats commonly used by adolescents, such as TikTok.\u003c/p\u003e \u003cp\u003eThe use of video as an educational tool in this study offered several advantages, particularly for younger individuals who might have limited prior knowledge of the subject. It provided a standardized form of communication, ensuring that all participants received uniform information regardless of their age, gender, or socio-economic background. This approach was intended to reduce variability in baseline knowledge and to limit potential bias arising from misinterpretation of either the educational content or the questionnaire, thereby supporting the overall consistency and validity of the collected responses.\u003c/p\u003e \u003cp\u003eNo selection or categorization of students was carried out based on age or gender; therefore, the observed distribution of participants across these variables reflects the natural composition of the surveyed school population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Questionnaire description\u003c/h2\u003e \u003cp\u003eThe questionnaire consisted of a structured set of items designed to assess multiple domains related to tobacco use and risk awareness. Specifically, it included questions on smoking behaviors (Item #1-2-3-4-5), perceived clarity of the educational video (Item #6), awareness of smoking-related health risks (Item #7-8-9-10), frequency of dental appointments (Item #11), awareness of health risks associated with svaping (Item #12), awareness of passive smoking risks (Item #13\u0026ndash;14), knowledge of first-, second-, and third-hand smoke (Item #15), smoking habits within the family environment (Item #16\u0026ndash;17), and school-based education on smoking risks and prevention (Item #18\u0026ndash;19).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEnglish version of the online questionnaire.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITEM #\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuestionnaire and Answers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWhat do you smoke?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ I don't smoke, □ Tobacco cigarette, □ E-cigarette □ Both (tobacco and e-cigarette)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIf you smoke, at what age did you start smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Between 10\u0026ndash;12, □ Between 13\u0026ndash;15, □ Between 16\u0026ndash;18 □ After 18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIf you smoke, what made you start smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ I don't smoke, □ For fun or as a game, □ Out of boredom □ To be like other friends\u003c/p\u003e \u003cp\u003e□ Because my parents and/or siblings smoke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHow often do you smoke now?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Never, □ Every day, □ Occasionally □ Only in the evening when I go out with friends\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHow many cigarettes do you smoke per day?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ I don't smoke, □ A couple, □ Fewer than 5 □ Between 5 and 10 □ More than 10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eWas the video you just watched interesting to you?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, □ Yes, but it wasn\u0026rsquo;t clear, □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAre you aware of the health risks associated with smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, I learned about them by watching the video, □ Yes, I already knew about them,\u003c/p\u003e \u003cp\u003e□ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you think smoking is dangerous for your health?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, very dangerous, □ Yes, but not very dangerous, □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you think smoking is dangerous for your oral health (tongue, cheeks, gums)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, very dangerous, □ Yes, but not very dangerous, □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you think smoking is dangerous for your dental health (teeth)?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, very dangerous, □ Yes, but not very dangerous, □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you go to the dentist at least twice a year for prevention?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you think vaping is less dangerous than smoking tobacco cigarettes?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes □ No □ I don't know\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHave you been exposed to secondhand smoke in the past month?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes □ No □ I don't know\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you know how harmful secondhand smoke is?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, I learned about it by watching the video □ Yes, I already knew about it □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you know the difference between first-hand, second-hand, and third-hand smoke exposure?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, I learned about it by watching the video □ Yes, I already knew about it □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCan guests smoke in your home?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e□\u003c/b\u003e Yes, wherever they want □ Yes, only in certain rooms/on the balcony □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHas your family talked about the risks related to smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes □ No □ I don't know\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDo you think schools should provide information about the risks of smoking and alternatives to smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes □ I think it's important, but not necessary □ No\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eHave you been taught at school about the risks of smoking?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e□ Yes, I learned about them by watching the video □ Yes, they talked about it on other occasions □ No □ I don't know\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Preliminary Analysis\u003c/h2\u003e \u003cp\u003eAll collected variables were categorical and were summarized using absolute frequencies and percentages, stratified by gender (female \u003cem\u003evs.\u003c/em\u003e male) and by age groups. In line with the exploratory nature of the study and its educational context, no a priori sampling procedure or power calculation was performed.\u003c/p\u003e \u003cp\u003eDescriptive analyses focused on the distribution of current smoking status, age at smoking initiation, and perceived risks related to both tobacco smoking and vaping.\u003c/p\u003e \u003cp\u003eSelected items were recoded or aggregated to improve interpretability and to capture broader constructs, such as overall perceived risk of smoking.\u003c/p\u003e \u003cp\u003eFurther analysis focused on a subset of questionnaire variables selected a priori for their relevance to smoking behavior, risk perception, and exposure to preventive education. These included the following original variables: current smoking status (non-smoker, tobacco cigarette smoker, e-cigarette user, dual user); smoking frequency; self-reported reasons for smoking initiation; number of cigarettes smoked per day; perceived harmfulness of vaping compared with conventional cigarettes; family discussion of smoking-related risks; school-based education on smoking risks.\u003c/p\u003e \u003cp\u003eIn addition, two derived variables were constructed for exploratory purposes:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOverall risk perception, defined as the sum of three ordinal items assessing perceived danger of smoking for (i) general health, (ii) oral soft tissues (tongue, cheeks, gums), and (iii) dental health. Each item was coded on a three-level ordinal scale (0 = \u0026ldquo;No\u0026rdquo;, 1 = \u0026ldquo;Yes, but not very dangerous\u0026rdquo;, 2 = \u0026ldquo;Yes, very dangerous\u0026rdquo;), yielding a composite score ranging from 0 to 6.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMaximum perceived risk category, defined as the highest health domain for which the respondent selected \u0026ldquo;Yes, very dangerous\u0026rdquo;, based on the following predefined hierarchy: general health\u0026thinsp;\u0026lt;\u0026thinsp;oral health\u0026thinsp;\u0026lt;\u0026thinsp;dental health.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Statistical Analysis\u003c/h2\u003e \u003cp\u003eMultiple Correspondence Analysis (MCA) was applied as an exploratory multivariate technique to explore associations and latent structures among selected categorical variables related to smoking behavior, vaping, education, and risk perception. MCA was chosen because of its suitability for nominal and ordinal categorical data and its ability to represent complex response patterns in a reduced-dimensional space [11\u0026ndash;14]. The analysis was exploratory and intended to generate hypotheses rather than to support inferential or causal claims. All analyses were conducted using the R software [15].\u003c/p\u003e \u003cp\u003eInterpretation of the MCA dimensions was based on the relative contribution of variables to each axis (η\u0026sup2;) and on the positioning of categories in the factorial space. The quality and relevance of categories were assessed using standard MCA diagnostics, including category coordinates, squared cosine values (cos\u0026sup2;), v.test statistics, and contribution indices. Detailed numerical results are reported in the Supplementary Material.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Demographic, smoking patterns and gender features\u003c/h2\u003e \u003cp\u003eThe survey was completed by 7,213 students (49% males, 49% females, and 2% other) with a mean age of 14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2 years. Regarding smoking habits, 5,973 declared that they did not smoke (82.8%).\u003c/p\u003e \u003cp\u003eAmong smokers, most smoked both electronic and conventional cigarettes (42.5%), followed by tobacco cigarettes (28.6%) and electronic cigarettes (27%). The remaining adolescents did not specify what they smoked (1.9%).\u003c/p\u003e \u003cp\u003eThe age at which students begin smoking varies individually, but the highest incidence consistently occurs between 13 and 15 years of age, with 62% of e-cigarette users, 58% of conventional cigarette smokers, and 57% of both users reporting initiation during this period.\u003c/p\u003e \u003cp\u003eThe majority consumed between 1 and 5 cigarettes per day. Alarmingly, approximately 8% reported smoking more than 10 cigarettes daily, indicating the onset of a potential addiction pattern even at a young age.\u003c/p\u003e \u003cp\u003eRegarding gender-based differences, a statistically significant disparity was observed only in the use of e-cigarettes, with a higher prevalence among females (p-value\u0026thinsp;=\u0026thinsp;0.019). No significant differences were found between males and females in the use of conventional cigarettes or both use (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmong those who admitted smoking, the behavior was mostly occasional. The most frequently cited reasons for smoking included curiosity (\"fun and games\", 7,5%), boredom (4,8%), or peer influence (2.4%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSmoking habits among students.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITEM #3 If you smoke, what made you start smoking?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not smoke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5,329 (73,88%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFun and games\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e541 (7,50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBe like friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (2,12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParents and/or siblinds smoke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (2,43%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOut of boredom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e349 (4,84%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Responding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e666 (9,23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe students' responses suggest some confusion in the definition of a smoker, as individuals who report smoking 'occasionally' subsequently identify themselves as non-smokers.\u003c/p\u003e \u003cp\u003eOne of the most alarming findings was related to perceptions of vaping. Among students who smoke e-cigarettes or both, the largest percentage believes that vaping is less dangerous than smoking tobacco cigarettes (48% and 43%, respectively); while smokers of tobacco cigarettes seem to be aware of the danger of vaping (51%) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerception of danger of vaping among students.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eITEM #12 Do you think vaping is less dangerous than smoking tobacco cigarettes?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eITEM #1 What do you smoke?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNothing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBoth (tobacco and electric)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTobacco cigarette\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eElectric cigarette\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2511\u003c/p\u003e \u003cp\u003e(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e177\u003c/p\u003e \u003cp\u003e(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e180\u003c/p\u003e \u003cp\u003e(51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e114\u003c/p\u003e \u003cp\u003e(34%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2982\u003c/p\u003e \u003cp\u003e(41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1498\u003c/p\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e227\u003c/p\u003e \u003cp\u003e(43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e102\u003c/p\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e162\u003c/p\u003e \u003cp\u003e(48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1989\u003c/p\u003e \u003cp\u003e(28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1964\u003c/p\u003e \u003cp\u003e(33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e123\u003c/p\u003e \u003cp\u003e(23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003cp\u003e(21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59\u003c/p\u003e \u003cp\u003e(18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2219\u003c/p\u003e \u003cp\u003e(31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5973\u003c/p\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e527\u003c/p\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e355\u003c/p\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e335\u003c/p\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7190\u003c/p\u003e \u003cp\u003e(100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding the knowledge of the difference between first-, second-, and third-hand smoke, only 21% were familiar with these concepts before the video, 55% learned about them during the video, and 24% remained unaware.\u003c/p\u003e \u003cp\u003eAlmost half of the students stated that smoking-related risks had never been openly discussed within their family.\u003c/p\u003e \u003cp\u003eMost students agreed on the importance of school-based health education on this topic. Although many students recognized the school\u0026rsquo;s role in tobacco prevention, a considerable number reported never having received formal education on the health consequences of smoking, pointing to the need for more structured and widespread school programs.\u003c/p\u003e \u003cp\u003eNotably, all students were aware of the systemic and oral health risks associated with smoking, which makes the persistence of the habit particularly concerning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Multiple Correspondence Analysis\u003c/h2\u003e \u003cp\u003eSix dimensions were retained based on eigenvalues and the cumulative proportion of explained variance, which together accounted for 44.5% of the total inertia, a level considered acceptable for complex survey data. Additional details about the MCA framework are available in the Supplementary Material.\u003c/p\u003e \u003cp\u003eThe first dimension (14.7% of explained variance) primarily captured \u003cb\u003ecurrent smoking behavior\u003c/b\u003e, clearly distinguishing non-smokers from occasional and daily smokers, as well as separating tobacco cigarette users, e-cigarette users, and dual users according to smoking frequency, intensity, and motivations for initiation. This axis represents the behavioral core of tobacco and nicotine use.\u003c/p\u003e \u003cp\u003eThe second dimension (7.1%) reflected \u003cb\u003eglobal perceived health risk\u003c/b\u003e, contrasting respondents who consistently perceived smoking as highly dangerous with those who minimized or denied health risks. This dimension was largely independent of actual smoking behavior, highlighting a cognitive-perceptual component.\u003c/p\u003e \u003cp\u003eThe third dimension (6.6%) represented \u003cb\u003erisk\u0026ndash;behavior coherence\u003c/b\u003e, separating individuals whose smoking intensity was consistent with low perceived risk from those displaying discordant profiles, such as heavy smokers reporting high awareness or light users expressing limited concern.\u003c/p\u003e \u003cp\u003eThe remaining dimensions (Dimensions 4\u0026ndash;6; 6.1%, 5.6%, and 4.4%, respectively) provided more nuanced refinements of risk perception and information exposure. In particular, Dimension 6 isolated respondents according to \u003cb\u003eeducational exposure\u003c/b\u003e, distinguishing students who reported receiving information on smoking risks at school or within the family from those consistently selecting \u0026ldquo;I do not know\u0026rdquo;.\u003c/p\u003e \u003cp\u003eOverall, the MCA highlighted that smoking behavior, perceived risk, and educational background constitute partially independent yet interconnected dimensions shaping adolescents\u0026rsquo; smoking-related profiles. The analysis was exploratory and intended to generate hypotheses rather than to infer causal relationships.\u003c/p\u003e \u003cp\u003eConcerning the electronic cigarette, it emerges as a particularly complex element in the MCA results, both in terms of behaviour and risk perception. From a behavioural perspective, the category \"electric cigarette\" shows a strong positive coordinate on Dimension 1 (coord\u0026thinsp;=\u0026thinsp;1.862), which represents current smoking behaviour. This confirms that vaping is often part of students\u0026rsquo; broader tobacco use patterns. Additionally, it is positively associated with Dimension 3 (coord\u0026thinsp;=\u0026thinsp;1.538, contrib\u0026thinsp;=\u0026thinsp;6.4%), a dimension that captures the inconsistency between actual smoking and perceived health risks. The contribution to Dimension 4 (4.1%) further reinforces its link to how individuals subjectively rationalize or internalize risk, independently of their actual behaviour. These results suggest that electronic cigarettes are frequently used in combination with traditional smoking, and that users tend to minimize or rationalize the potential dangers, displaying at times inconsistent or ambivalent behaviours.\u003c/p\u003e \u003cp\u003eThese patterns are visually illustrated in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e which display the distribution of respondents across the main MCA dimensions. All individual factor maps highlight distinct yet complementary patterns across the examined dimensions. In Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, individuals cluster, according to smoking status, with non-smokers positioned on the negative side of Dimension 1 and smokers, particularly tobacco and dual users, distributed on the positive side. Electronic cigarette users occupy an intermediate and more dispersed position, indicating heterogeneity in both behavior and associated perceptions. In Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, individuals are primarily differentiated by overall risk perception, with higher perceived risk categories grouped on the positive side of Dimension 2 and lower or absent risk perception on the negative side, largely independent of smoking behavior. Finally, in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the Dim5\u0026ndash;Dim6 projection reveals a weaker but interpretable separation related to educational exposure: respondents reporting school-based education on smoking risks tend to cluster distinctly from those indicating uncertainty or lack of information.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe indiscriminate use of electronic cigarettes, often without sufficient awareness of their potential health risks, represents an increasingly urgent public health concern [8].\u003c/p\u003e \u003cp\u003eThis phenomenon has spread with alarming speed: the e-cigarette industry has rapidly evolved into a multibillion-dollar global market, positioning itself as a popular alternative to traditional tobacco products. Initially targeting current and former smokers seeking a less harmful alternative, e-cigarettes have gained widespread popularity among adolescents and young adults, reshaping patterns of nicotine consumption [16].\u003c/p\u003e \u003cp\u003eUntil 2021, vaping was rare among European youth and adults who had never smoked (\u0026lt;\u0026thinsp;0.8%), but over the past three years the emergence of disposable nicotine delivery devices containing high concentrations of nicotine salts (\u0026le;\u0026thinsp;20 mg/ml in the EU), which are inexpensive, easily concealable, and convenient to use, has been associated with a rapid increase in use among young people [17, 18].\u003c/p\u003e \u003cp\u003eData from the Global Burden of Disease Study indicate that 82.6% of tobacco users initiate use between 14 and 25 years of age, with the likelihood of developing dependence decreasing substantially thereafter. Consequently, adolescents and young adults constitute the population at highest risk, as ongoing neurodevelopment, social influences, and peer-related pressures render them particularly vulnerable to nicotine addiction (21).\u003c/p\u003e \u003cp\u003eYoung people tend to be more impulsive and inclined toward risky behaviors. Many view e-cigarettes as safer and easier to hide than traditional cigarettes [19]. Moreover, social media marketing strongly promotes vaping among adolescents, and retail displays near checkout counters and youth-oriented products reinforce the perception of e-cigarettes as common and socially accepted [20, 21].\u003c/p\u003e \u003cp\u003eProponents of e-cigarettes argue that, since they involve no combustion, they are safer than traditional cigarettes. Consequently, e-cigarettes have been proposed as a potential aid for smoking cessation among current smokers [22]. Nevertheless, Etter and Bullen reported that 81% of those patients who were daily e-cig users continued vaping after 1 year [23]. Also, among Italian e-cigarette users, those who restart smoking after using e-cigarettes outnumber those who stop smoking after using e-cigarettes [24].\u003c/p\u003e \u003cp\u003eDespite limited evidence regarding their long-term health effects, e-cigarettes are widely accessible in retail and online markets, supported by aggressive advertising. In 2016, 4.3% of U.S. middle school students and 11.3% of high school students used e-cigarettes. In the UK, ever-use among 11\u0026ndash;16-year-olds ranged from 7% to 18%, while regular use ranged from 1% to 3%. Notably, nearly one-third of U.S. adolescents believe e-cigarettes are less harmful than conventional cigarettes [25\u0026ndash;27].\u003c/p\u003e \u003cp\u003eIn Italy, while the prevalence of current smokers among adolescents remained stable at around 20%, vaping rose sharply: from 0% in 2010 to 7.4% in 2014 and 17.5% in 2018 [28].\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, to date, very few studies have examined this public health concern in Italy, particularly among the adolescent population[24, 28, 29]. The present study aims to investigate for the first time this issue in a study population of 7,213 students living in Sicily (south Italy) from both middle and high schools.\u003c/p\u003e \u003cp\u003eIn our study, although most students declared they did not smoke, many reported experimenting with cigarettes or e-cigarettes between 13 and 15 years of age, with troubling misconceptions about the safety of vaping and notable gaps in basic smoking-related awareness. These results highlight the urgency of implementing reinforced and structured educational programs in schools to correct misunderstandings and address early smoking initiation.\u003c/p\u003e \u003cp\u003eIndeed, although anti-smoking campaigns have traditionally been introduced in high school, our findings indicate that the average age of smoking initiation has significantly decreased, underscoring the need to implement structured prevention programs starting as early as middle school.\u003c/p\u003e \u003cp\u003eA study performed on students enrolled in healthcare assistance programs, comparing first-year and final-year cohorts, reported a significant reduction in smoking habits over the course of university training [29].\u003c/p\u003e \u003cp\u003eMoreover, regarding gender differences, our findings performed on 7,213 Sicilian adolescents suggest a possible shift in the traditional smoking patterns reported in the literature. In the context of electronic cigarette use, girls in our study appeared more inclined to vape compared with boys, a trend that contrasts with previously published Italian data. For example, a study conducted in 2020 among Italian healthcare students reported similar smoking frequencies between genders (38.9% males vs. 33.4% females)[29].\u003c/p\u003e \u003cp\u003eIn line with our findings, a recent ISTAT (Istituto Nazionale di Statistica \u0026ndash; National Statistics Institute) report shows that the gender gap in smoking prevalence has significantly narrowed over time (from 10.2% in 2013 to 7.1% in 2023), primarily due to a marked reduction in smoking among men, while rates among women have remained largely stable [30].\u003c/p\u003e \u003cp\u003eThis apparent trend reversal may indicate a changing sociocultural dynamic in the uptake of e-cigarettes among younger generations, warranting further investigation.\u003c/p\u003e \u003cp\u003eHowever, in our study, this shift in gender patterns was observed exclusively for electronic cigarettes, which showed higher prevalence among females, whereas the use of conventional tobacco cigarettes remained more common among males.\u003c/p\u003e \u003cp\u003eNotably, 2% of respondents did not identify exclusively as male or female, reflecting the presence of gender-diverse adolescents within the surveyed population. Although this subgroup is numerically small, its inclusion highlights the need for sensitivity toward gender diversity when interpreting health-related behaviors in youth.\u003c/p\u003e \u003cp\u003eThis study reveals substantial confusion among adolescents regarding what it means to \u0026ldquo;smoke\u0026rdquo;. Students' self-classification of smoking status shows notable inconsistency: individuals reporting occasional smoking occasionally subsequently identified themselves as non-smokers. This discrepancy suggests that the concept of being a \u0026ldquo;smoker\u0026rdquo; is subjectively interpreted, potentially influenced by social norms, underestimation of occasional behaviors, or stigma avoidance.\u003c/p\u003e \u003cp\u003eUncertainty persists among students regarding the relative harms of vaping versus smoking, reflecting either a lack of knowledge or conflicting information.\u003c/p\u003e \u003cp\u003eConsistent with previous literature, the high initiation rates observed between 13 and 15 years of age underscore adolescence as a critical period for tobacco and nicotine exposure, corroborating evidence that early experimentation increases the likelihood of long-term dependence. Although most smokers consumed only a few cigarettes per day, the finding that approximately 8% smoked more than ten cigarettes daily is concerning, suggesting the emergence of addictive patterns even at a young age.\u003c/p\u003e \u003cp\u003eE-cigarettes occupy a behavioral and perceptual \u003cem\u003egrey area\u003c/em\u003e: they are frequently used by students who also smoke traditional cigarettes and are perceived as a safer alternative, partly due to insufficient education on their risks. The customizable nature of e-liquids, particularly their flavors, increases their appeal and represents a growing public health concern among youth, especially women [31, 32].\u003c/p\u003e \u003cp\u003eAlthough the short- and long-term effects of e-cigarettes are not yet fully understood, recent studies have reported that alterations in the salivary composition of smokers appear to be associated with an increased risk of developing conditions such as type 2 diabetes, hypertension, cardiovascular and renal diseases, as well as promoting tumorigenesis and impairing oral immune function. In contrast, analyses of e-liquids after use have not revealed any significant molecular or compositional changes (26,27). However, the levels of nicotine delivered through ENDS are comparable to, or even higher than, those of traditional cigarettes, with similar systemic retention. Moreover, individuals who use these devices tend to smoke more frequently, often even in indoor environments, further exacerbating exposure [8].\u003c/p\u003e \u003cp\u003eRegarding the oral health status, recent studies reported an increased risk of periodontitis, dental caries, and tooth and prosthesis discoloration associated with vape use [33\u0026ndash;35].\u003c/p\u003e \u003cp\u003eAdditionally, salivary metabolite alterations have been identified in e-cig users, particularly with elevated levels of metabolites associated with inflammation, xenobiotic metabolism, and biomass-burning pathways [36].\u003c/p\u003e \u003cp\u003eIn the present study, regarding perceptions of vaping risk, a concerning underestimation of it emerges, with nearly half of e-cigarette users believing vaping to be harmless, highlighting persistent misinformation and inadequate education.\u003c/p\u003e \u003cp\u003eDespite widespread awareness of health risks, the perseverance of even occasional smoking underscores that knowledge alone is insufficient, emphasizing the urgent need for comprehensive, school-based programs that correct misconceptions and target both traditional and electronic smoking [37].\u003c/p\u003e \u003cp\u003eRecent evidence suggests that the most effective strategies for promoting health awareness among adolescents focus on three elements: fostering a school-wide health ethic, creating a supportive health-promoting environment, and integrating health education into the formal curriculum [38].\u003c/p\u003e \u003cp\u003eSchools thus represent strategic settings for early interventions, particularly when programs are supported by family and community involvement; however, further rigorous research is needed to ensure that these interventions are evidence-based and truly effective [39].\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study had limitations that should be considered. First, the study population may not fully represent the broader adolescent population, as it refers to limited geographical and institutional context; moreover, since it is consisted entirely of Sicilian participants, the findings may not be generalizable. Variations in socioeconomic status, cultural attitudes, and access to vaping products may further limit the applicability of the results to other populations. Nonetheless, the large number of students interviewed across 48 schools and the inclusion of adolescents with diverse backgrounds within the region enhance the internal validity and robustness of the observed patterns.\u003c/p\u003e \u003cp\u003eSecond, since the survey involved young people, responses may be subject to bias, as adolescents may not have taken all the questions seriously or may have provided inaccurate answers.\u003c/p\u003e \u003cp\u003eAdditionally, the study relies solely on self-reported data, which may not always accurately capture actual behaviors, particularly when dealing with sensitive activities like smoking or vaping. The occasional nature of smoking reported by most students, coupled with the apparent confusion in self-classification as smokers, indicates that social norms and subjective interpretations may influence both behavior and reporting, complicating the identification of at-risk individuals. However, the anonymity of the questionnaire likely reduced bias, helping students provide more honest and uninfluenced responses.\u003c/p\u003e \u003cp\u003eFinally, a further limitation could be the potential influence of the educational video, as exposure to the video before completing the survey may have affected students\u0026rsquo; responses and awareness, potentially biasing the results regarding knowledge and attitudes. At the same time, using a standardized educational tool ensured that all participants received uniform information, reducing variability due to differences in prior knowledge and improving comparability across responses.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe study reveals a concerning prevalence of smoking among Sicilian adolescents, many of whom experiment with both tobacco and e-cigarettes. Although some awareness exists regarding tobacco consumption-related health risks, the perception that vaping is safer or more dangerous, reflecting a significant concern, as it may lead to increased experimentation and addiction among adolescents.\u003c/p\u003e \u003cp\u003eThese findings underscore the urgent need for targeted, age-appropriate educational strategies that distinguish vaping from traditional smoking, both in terms of behavioral patterns and risk communication. Intervening during adolescence is particularly crucial: disrupting the adoption of these harmful habits at an early stage can substantially reduce the likelihood of long-term health consequences and chronic disease in adulthood.\u003c/p\u003e \u003cp\u003eUltimately, strengthening preventive efforts in schools and communities may play a pivotal role in mitigating the future burden of tobacco- and vaping-related pathologies.\u003c/p\u003e \u003cp\u003eFuture research should consider longitudinal study designs, probabilistic sampling strategies, and multilevel modeling approaches to account for school-level clustering and to better assess temporal relationships and potential determinants of smoking and vaping behaviors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eENDS: electronic nicotine delivery systems\u003c/p\u003e\n\u003cp\u003eMCA: Multiple Correspondence Analysis\u003c/p\u003e\n\u003cp\u003eE-cigs: electronic cigarettes\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol adhered to the ethical guidelines specified in the 1964 Declaration of Helsinki and its subsequent amendments, or comparable ethical standards. To ensure compliance, approval for the study and necessary permissions were obtained from the school management boards and the Sicilian Regional Department of Education and Professional Training. The Ethical Local Committee of the University Hospital of Palermo also approved it (#4/2023). Informed consent to participate was obtained from all participants or, in the case of minors under the age of 16, from their parents or legal guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, G.C.; methodology, G.M., M.B., M.C., G.L.M., F.B., G.S., R.M., and D.M., validation, G.C. and G.M.; formal analysis, G.M. and M.C; investigation, M.B., F.B., G.L.M., G.S., M.C. and D.M.; resources, M.C., G.L.M., G.S., F.B. and D.M.; data curation, M.C. and G.M.; writing\u0026mdash;original draft preparation, M.C., G.S. and M.B.; writing\u0026mdash;review and editing, G.C., G.M. and R.M.; visualization, G.C. and G.M..; supervision, G.C.; project administration, G.C.); funding acquisition, G.C. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe express our gratitude to the Rotary District 2110 Sicily-Malta for their involvement and direct invitation to the district Rotarian dental prevention project named \u0026ldquo;Quit smoking. Choose health, including your oral health. Smetti di fumare. Scegli la salute anche quella orale\u0026rdquo;. Special thanks to the school headmasters of the participating schools for their readiness to conduct the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSiegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin [Internet]. 2022 Jan [cited 2025 Sep 9];72(1):7\u0026ndash;33. Available from: https://pubmed.ncbi.nlm.nih.gov/35020204/\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien B, Knight-West O, Walker N, Parag V, Bullen C. 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BMJ Open [Internet]. 2015 [cited 2025 Sep 9];5(9). Available from: https://pubmed.ncbi.nlm.nih.gov/26362665/\u003c/li\u003e\n\u003cli\u003ePerikleous EP, Steiropoulos P, Paraskakis E, Constantinidis TC, Nena E. E-cigarette use among adolescents: An overview of the literature and future perspectives. Front Public Health [Internet]. 2018 Mar 1 [cited 2025 Sep 9];6:309275. Available from: www.frontiersin.org\u003c/li\u003e\n\u003cli\u003eHartmann-Boyce J, McRobbie H, Lindson N, Bullen C, Begh R, Theodoulou A, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews [Internet]. 2021 Apr 29 [cited 2025 Sep 9];2021(4). Available from: https://pubmed.ncbi.nlm.nih.gov/33913154/\u003c/li\u003e\n\u003cli\u003eEtter JF, Bullen C. A longitudinal study of electronic cigarette users. Addictive Behaviors [Internet]. 2014 Feb [cited 2025 Dec 7];39(2):491\u0026ndash;4. 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Available from: https://pubmed.ncbi.nlm.nih.gov/39325296/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tobacco consumption, electronic nicotine delivery systems, ENDS, smoking, awareness, survey, survey and questionnaires, adolescents, vaping, electronic cigarettes, e-cigarettes, Multiple Correspondence Analysis","lastPublishedDoi":"10.21203/rs.3.rs-8444619/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8444619/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTobacco use, including electronic nicotine delivery systems (ENDS), is increasingly prevalent among adolescents, often accompanied by misconceptions regarding associated health risks. Reliable epidemiological data are essential to inform prevention strategies, particularly in regions where evidence remains limited. A cross-sectional, observational survey was conducted among 7,213 students aged 11\u0026ndash;19 years attending 48 middle and high schools in Sicily (Italy). Data were collected using an anonymous, self-administered questionnaire assessing tobacco behaviors, vaping habits, and awareness of systemic and oral health risks related. Associations and response patterns among selected variables were explored using Multiple Correspondence Analysis (MCA). Most participants reported not currently using (82.8%); however, experimentation with tobacco cigarettes (28.6%), e-cigarettes (27%), or both was common (42.5%). Nearly half of students using e-cigarettes perceived vaping as less harmful than conventional smoking (48%). Gender differences were observed for e-cigarette use, with a higher prevalence among females (p-value\u0026thinsp;=\u0026thinsp;0.019). MCA highlighted distinct behavioral and perceptual profiles, identifying e-cigarette use as a pattern associated with inconsistent or underestimated risk perception, especially in the absence of family- or school-based education. Although awareness of smoking-related health risks was generally high, knowledge alone appeared insufficient to prevent experimentation. These findings underscore the need for structured, age-appropriate school-based prevention programs and provide a descriptive foundation for future longitudinal and intervention studies.\u003c/p\u003e","manuscriptTitle":"Tobacco Use and Awareness of Health-Related Risks among 7,213 Adolescents living in Sicily (Italy): A Cross-Sectional Survey-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 08:49:05","doi":"10.21203/rs.3.rs-8444619/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6c0babba-8913-405f-8277-08c2cb9cd257","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-17T02:54:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 08:49:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8444619","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8444619","identity":"rs-8444619","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}