Adolescents’ perceptions of tobacco and electronic cigarette prevention: six school-based cohorts (2010/11–2023/24)

Abstract

Background: Adolescent tobacco use remains a major public health concern (World Health Organization, 2024). In recent years, electronic cigarettes have become a frequent pathway to nicotine initiation, posing new challenges for traditional school-based tobacco prevention strategies. Methods: A repeated cross-sectional observational study was conducted with 5,658 students aged 11 to 18 years from secondary schools in Burgos (Spain), corresponding to six academic cohorts between 2010 and 2023. The study was carried out within the framework of a universal school-based prevention program targeting tobacco and electronic cigarette use, delivered during the first year of compulsory secondary education. Following the intervention, students voluntarily and anonymously completed an evaluation questionnaire. Trends in experimentation across cohorts and associations between self-reported program participation and psychosocial and program evaluation variables were examined using logistic regression models and interpreted as observational associations without causal attribution. Results: Experimentation with conventional cigarettes showed a marked decline in the earlier cohorts and a subsequent stabilization in more recent years. Electronic cigarette use was assessed from 2021 onwards, with relevant prevalence levels observed in the most recent cohorts. In the subsample with detailed consumption data (n = 2,206), electronic cigarettes were the most commonly used product in the past 30 days (10.4%), followed by conventional cigarettes (7.2%). Social exposure to tobacco use was high, with more than 80% of students reporting at least one smoker in their immediate environment. In bivariate regression analyses, self-reported participation in the program was associated with experimentation with electronic cigarettes (OR = 0.66; p = 0.006), although this association did not remain significant after adjustment for age, gender, school type, and social exposure. By contrast, program participation showed consistent associations with indicators of program evaluation, including positive appraisal of the sessions (AOR = 5.25; 95% CI: 3.85–7.16) and discussion of program content within the family (OR = 1.92; p < 0.001). Conclusions: In this repeated cross-sectional series, adolescent use patterns were characterized by the increasing prominence of electronic cigarettes. Self-reported program participation was associated with indicators of engagement and appraisal, which should be interpreted within the limits of the observational design. Overall, the findings highlight the relevance of prevention approaches that