Tobacco Use and Self-Reported Perceptions of Health Risks among 7,213 Adolescents Living in Sicily (Italy): A Cross-Sectional Survey-Based Study

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.