Atencion Primaria 53 (2021) 102043 Atención Primaria www.elsevier.es/ap ORIGINAL ARTICLE Future intentions and beliefs about roll-your-own cigarettes in adolescents Eva Codinach-Danésa,b,c , Nuria Obradors-Riald,∗ , Jacobo Mendioroz-Peñaa , Joan R. Villalbíe,f,g,h , Marina Bosque-Prousi , Albert Espeltd,h a Health Promotion in Rural Areas Research Group, Gerència Territorial de la Catalunya Central, Catalan Health Institute, Sant Fruitós de Bages, Spain b Centre d’Atenció Primària Sant Quirze de Besora, Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Sant Quirze de Besora, Spain c Unitat de Suport a la Recerca de la Catalunya Central, Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Sant Fruitós de Bages, Spain d Facultat de Ciències de la Salut de Manresa, Universitat de Vic Universitat Central de Catalunya (UVicUCC), Manresa, Spain e Agència de Salut Pública de Barcelona, Barcelona, Spain f Department de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain g Institut d’Investigació Biomèdica Sant Pau, Barcelona, Spain h Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain i Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain Received 14 September 2020; accepted 18 November 2020 Available online 7 April 2021 KEYWORDS Abstract Roll-your-own Objective: To determine the predisposition to use roll-your-own (RYO) cigarettes and the beliefs cigarettes; about RYO cigarettes of all the students of 3◦ ---4◦ of ESO during the years 2016---17 and 2018---19. Manufactured A cross-sectional study. cigarettes; Setting: Bisaura High School from Sant Quirze de Besora. Primary Health Care in the Catalan Beliefs; Health Institute, Catalunya, Spain. Adolescents; Participants: 111 3rd and 4th of ESO (14---16 years). Smoking intention Main measurements: Dependent variables used were future intentions of smoking and beliefs regarding RYO cigarettes. Independent variables were sex, course and ever smoked. The preva- lence of the different dependent variables was described and compared according to the different independent variables with Pearson’s Khi-square test. Results: 26.6% of the adolescents intended to smoke in the future of which 17.4% intended to smoke RYO cigarettes and 13.8% manufactured cigarettes (MC). Around 30% of adolescents express at least one wrong belief regarding RYO cigarettes. For example, the 26.7% believed ∗ Corresponding author. E-mail address: nobradors@umanresa.cat (N. Obradors-Rial). https://doi.org/10.1016/j.aprim.2021.102043 0212-6567/© 2021 The Author(s). Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). E. Codinach-Danés, N. Obradors-Rial, J. Mendioroz-Peña et al. that smoking RYO cigarettes generated less addiction than MC and the 32.1% that was less harmful. Those who had smoked at some time in their life had a greater intention to smoke in the future (54.5%), to smoke MC (27.3%) and RYO cigarettes (40.9%) than those who had never smoked (7.7%, 4.6% and 1.5% respectively) (p < 0.005). Some misconceptions differed depending on whether adolescents had ever smoked in life, sex and course. The boys believed that smoking RYO cigarettes was more natural than smoking MC (p < 0.005). Conclusions: Educational activities to improve the information that young people have regard- ing RYO cigarettes are needed. © 2021 The Author(s). Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PALABRAS CLAVE Intenciones de futuro y creencias sobre el tabaco de liar en población adolescente Tabaco de liar; Resumen Tabaco Objetivo: Conocer la predisposición a usar tabaco de liar (TL) y las creencias sobre TL de todos manufacturado; los alumnos de 3◦ -4◦ de ESO durante los cursos 2016-17 y 2018-19. Estudio tansversal. Creencias; Emplazamiento: Institut Bisaura. Sant Quirze de Besora. Atención Primaria de Salud. Instituto Adolescentes; Catalan de la Salud, Catalunya, España. Intención de fumar Participantes: 111 adolescentes de 3◦ y 4◦ de ESO (14-16 años). Mediciones principales: Variables dependientes: intenciones futuras de fumar y creencias con respecto al TL. Variables independientes: sexo, curso y haber fumado o no en la vida. Se describió la prevalencia de las variables dependientes y se comparó según las distintas variables independientes con la prueba de Chi cuadrado de Pearson. Resultados: El 26,6% de los adolescentes manifestaron intención de fumar en el futuro, y de ellos, el 17,4% tenían intención de fumar TL y 13.8% tabaco manufacturado (TM). Alrededor del 30% de los adolescentes expresaron al menos una creencia errónea con respecto al TL. Concretamente, el 26,7% creía que fumar TL generaba menor adicción que fumar TM y el 32,1% creía que era menos perjudicial. Los que habían fumado alguna vez en la vida tenían mayor intención de fumar en el futuro (54,5%), de fumar TM (27,3%) y TL (40,9%) que los que no habían fumado nunca (7,7%, 4,6% y 1,5%, respectivamente) (p < 0,005). Algunas creencias erróneas difirieron según si los adolescentes habían fumado alguna vez en la vida, el sexo y el curso. Los chicos creían que fumar TL era más natural que fumar TM (p < 0,005). Conclusiones: Son necesarias actividades educativas para mejorar la información que tienen los jóvenes con respecto al TL. © 2021 El Autor(s). Publicado por Elsevier España, S.L.U. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction it is estimated that by 2020 there will be a decrease in MC smokers, whereas RYO consumers will increase.3 Tobacco consumption remains a major public health prob- On the one hand, RYO consumption growth can be lem, being one of the leading causes of illness and death explained by several economic reasons, as well as tobacco in developed countries.1,2 Although in 2004 tobacco con- industry business strategies to attract new customers. For sumption started to decline, in 2016 was the second most that matter, RYO has a lower price than MC,8 which makes used drug in Spain after alcohol and 8.8% of secondary some smokers choose this option instead of making an school students between 14 to 18 years consumed daily.2 attempt to quit smoking.9 Moreover, some RYO smokers state Among smokers, especially among young people, the pro- it tastes better.10,11 On the other hand, RYO consumption portion of people who use roll-your-own (RYO) cigarettes has increase could also be explained by false beliefs about it. grown.3,4 In general, students start smoking manufactured Many young people think that smoking RYO is less addictive, cigarettes (MC) at an early age, concretely at 14.1 years so they believe they have more personal control over its and as the years go by they start smoking RYO.5 In Catalo- consumption.8 In fact, they also believethat is less harm- nia, the percentage of smokers who use RYO daily increased ful and has less additives than MC.7,12---17 However, there are from 4.6% among men and 1.7% among women in 2006 to comparative studies that show that smoking RYO is more 29.6% and 22.6% respectively, in 2015.6 Also in Barcelona, damaging to health than smoking MC, with RYO having higher the prevalence of smokers who use RYO increased from 0.4% concentrations of nicotine, tar and carbon monoxide18---21 in 2004---05 to 3.7% in 2011---12.7 With these consumer trends, and even more tobacco-specific nitrosamines (TSNAs).13 2 Atencion Primaria 53 (2021) 102043 Given the few existing studies on adolescent RYO smoking Other variables to describe the sample were smoking fre- in Spain, the aim of the study is to know the predisposition quency and number of cigarettes smoked per day (not having to use RYO and RYO beliefs on 3◦ ---4◦ ESO students during the smoked, having smoked a cigarette a day or less, having 2016---17 and 2018---19 school years. smoked 2 or more cigarettes a day), both compared to the last 30 days. Methods Statistical analysis Study design The prevalence of each of the dependent variables accord- A Cross-sectional study during the 2016---17 and 2018---19 ing to the independent variables was compared using school years was carried out. All students in 3rd and 4th relative frequencies and Pearson Chi-square test through year of Educación Secundaria Obligatoria (ESO, equivalent STATA 15.0 statistical software. In all statistical tests a sig- to 9---10th grades) from the Bisaura High School in Sant nificance level of 5% was considered. Quirze de Besora, a town in Central Catalonia (14---16 years) participated in the study, with a total of 111 participants. Smoking habits in the last 30 days (consumption frequency Results and daily smoked cigarettes), future intentions of smok- ing and beliefs about RYO cigarettes were collected using A total of 111 students participated in the study (100% of the a self-administered questionnaire with the same questions students of 3rd and 4th of ESO). 51.4% of them were girls and that were used in the didactic unit: ‘‘Fumar? Jo No m’hi 56.8% were enrolled 3rd ESO. 40.5% of surveyed teens had Embolico!8 Data collection was in two occasions: May 2017 smoked at some time in their life, of these, 34.9% did so and December 2018. The questionnaire was answered dur- every day. 41.9% of users smoked 2 or more cigarettes a day ing school hours with the presence of the person responsible and 39.5% did not smoke during the past 30 days (Table 1). for the study, who provided instructions to complete the 26.6% of adolescents reported that would smoke in the questionnaire and answered questions. The questionnaire future, 13.8% that would smoke MC and 17.4% RYO (Fig. 2). was administered during school hours. Although participa- No statistically significant differences were found by sex or tion in the study was voluntary, all students answered the course. Instead, teens who had smoked at least once in their questionnaire (Fig. 1). life had higher proportions of intent tobacco consumption in This study is part of a training program called ‘‘Classes the future (54.5% vs. 7.7%), MC consumption (27.3% vs. 4.6%) sense fum’’ framed within the curriculum of ESO. Schools and RYO consumption (40.9% vs. 1.5%) than those who had that decide to participate in this training program give never smoked (p < 0.005) (Table 2). their consent so that all their students can participate. Regarding beliefs, 26.7%, 32.1% and 26.4% believed that The Helsinki Declaration of 1964 and subsequent revisions, RYO cigarettes produced less addiction, was less harmful and the professional ethics codes were followed during the to health and it was easier to quit smoking compared to study. Also, the Spanish law on data confidentiality (Reg- MC, respectively. Furthermore, 58.1% believed that MC had ulation (EU) 2016/679 of the European Parliament and of more chemical additives and 73.6% believed that RYO and the Council of 27 April 2016, on the protection of natural MC were not equally harmful (Fig. 2). No statistically signifi- persons with regard to the processing of personal data and cant differences by sex or course were found, except in the on the free movement of such data, and repealing Direc- belief that RYO was less damaging than MC, where 42% of tive 95/46/EC (General Data Protection Regulation), and the boys thought it was less harmful, compared to 23.2% of girls Organic Law 3/2018, of 5 December on the Protection of Per- (p < .005). In the stratified analyzes according to whether sonal Data and Guarantee of Digital Rights). The school staff they had ever smoked in their life or not, statistically signif- informed the parents of the teenagers about the aims of the icant differences were found in some beliefs. Among those study and obtained their collaboration. who smoked, 37.2% believed that RYO is less addictive than MC, and 38.6% believed that quitting RYO is easier than MC, compared to 19.4% and 17.7% of whom had never smoked Study variables (Table 2). The dependent variables were future smoking intentions and beliefs regarding the RYO cigarettes. Future intentions Discussion were studied by asking whether they intended to smoke in the future and if so, whether they would smoke MC or The main results of the study show that 26.6% of surveyed RYO. Beliefs about RYO cigarettes were studied through the teens intend to smoke in the future, concretely, 17.4% degree of agreement for each of the following statements: believe they will smoke RYO. About 30% of teens express ‘smoking RYO ‘‘hooks’’ less than smoking MC’, ‘smoking RYO at least one favorable misconception regarding RYO. The is less harmful than MC because it is more natural’, ‘RYO and most reported one was that MC and RYO have nicotine MC have nicotine and other harmful components and there- and other components harmful to health, but they are not fore are equally harmful’, ‘MC has more chemical additives equally harmful (73.6% of adolescents) and that the MC has than RYO’ and ‘it’s easier to quit smoking for people who more chemical additives than RYO (58.1% of adolescents). smoke RYO rather than the ones who smoke MC’. Both future intentions and beliefs are statistically signifi- The main independent variables were sex, the school cant when associated with having smoked at least once in year and having smoked at least once in their lifetime. their lifetime, being those who have ever smoked in their 3 E. Codinach-Danés, N. Obradors-Rial, J. Mendioroz-Peña et al. 111 3rd and 4th of ESO (14-16 years) adolescents were studied in the Bisaura High School from Sant Quirze de Besora, a town in Central Catalonia during the 2016-17 and 2018-19 school years 3rd of ESO: 63 (22 boys and 30 girls) 4th of ESO: 48 (21 boys and 27 girls) • Future intentions of smoking • Beliefs about RYO cigarettes Collected using a self-administered questionnaire Data collection was in two occasions: • May 2017 • December 2018 Figure 1 General outline of the study. Table 1 Bisaura High School student characteristics (Sant Quirze), 2016---19. Boy Girl Total p Value n % n % n % % Course 0.367 3rd 33 61.1 30 52.6 63 56.8 4th 21 38.9 27 47.4 48 43.2 Having smoked in their lifetime 0.263 Yes 19 35.2 26 45.6 45 40.5 No 35 64.8 31 54.4 66 59.5 Frequency of usea 0.377 Every day 7 38.9 8 32.0 15 34.9 One or more times a week or less 6 33.3 5 20.0 11 25.6 than once a week I have not smoked for the last 30 5 27.8 12 48.0 17 39.5 days Daily smoked cigarettes* 0.282 2 or more cigarettes a day 8 44.4 10 40.0 18 41.9 A cigarette day or less (just a few 5 27.8 3 12.0 8 18.6 puffs) I have not smoked for the last 30 5 27.8 12 48.0 17 39.5 days a last 30 days. 4 Table 2 Dependent variables (future intentions and beliefs about RYO) by sex, school year and according to whether they had ever smoked in life. Sex Course Smoke Male Female p Value 3rd 4th p Value Have smoked Not have smoked p Value n % n % n % n % n % n % Future intentions regarding smoking I think I will smoke in 0.633 0.828 <0.001 the future (when I’m Atencion Primaria 53 (2021) 102043 older) Yes 13 24.5 16 28.6 29 46.8 13 27.7 24 54.5 5 7.7 No 40 75.5 40 71.4 46 74.2 34 72.3 20 45.5 60 92.3 I think I will smoke MC 0.202 0.41 0.001 cigarettes in the future 5 Yes 5 9.4 10 17.9 10 16.1 5 10.6 12 27.3 3 4.6 No 48 90.6 46 82.1 52 83.9 42 89.4 32 72.7 62 95.4 I think I will smoke 0.7 0.922 <0.001 RYO cigarettes in the future Yes 10 18.9 9 16.1 11 17.7 8 17 18 40.9 1 1.5 No 43 81.1 47 83.9 51 82.3 39 83 26 59.1 64 98.5 Beliefs about RYO tobacco Smoking RYO 0.082 0.906 0.042 cigarettes ‘‘hooks’’ less than smoking MC Yes 17 34.7 11 19.6 16 27.1 12 26.1 16 37.2 12 19.4 No 32 65.3 45 80.4 43 72.9 34 73.9 27 62.8 50 80.6 Table 2 (Continued) Sex Course Smoke Male Female p Value 3rd 4th p Value Have smoked Not have smoked p Value n % n % n % n % n % n % RYO tobacco also 0.039 0.385 0.708 E. Codinach-Danés, N. Obradors-Rial, J. Mendioroz-Peña et al. ‘‘hooks’’, but its less damaging for your health than MC cigarettes because it’s more natural Yes 21 42 13 23.2 21 35.6 13 27.7 15 34.1 19 30.6 No 29 58 43 76.8 38 64.4 34 72.3 29 65.9 43 69.4 MC tobacco and RYO 0.927 0.854 0.288 tobacco carry nicotine and other harmful components for your 6 health, and therefore are equally harmful Yes 37 74 41 73.2 43 72.9 35 74.5 30 68.2 48 77.4 No 13 26 15 26.8 16 27.1 12 25.5 14 31.8 14 22.6 MC tobacco has more 0.315 0.492 0.682 chemical additives than RYO tobacco Yes 31 63.3 30 53.6 36 61 25 54.3 26 60.5 35 56.5 No 18 36.7 26 46.4 2.3 39 21 45.7 17 39.5 27 43.5 People who smoke RYO 0.927 0.05 0.016 find it easier to quit when they want to in comparison to the ones who smoke MC Yes 13 26 15 26.8 20 33.9 8 17 17 38.6 11 17.7 No 37 74 41 73.2 39 66.1 39 83 27 61.4 51 82.3 Atencion Primaria 53 (2021) 102043 73.6% 58.1% 32.1% 26.6% 26.7% 26.4% 17.4% 13.8% I think I will smoke in I think I will smoke MC I think I will smoke Smoking RYO RYO tobacco also MC tobacco and RYO MC tobacco has more People who smoke the future (when I’m cigarettes in the RYO cigarettes in the cigarettes “hooks” “hooks”, but its less tobacco carry nicotine chemical additives RYO find it easier to older) future future less than smoking MC damaging for your and other harmful than RYO tobacco quit when they want health than MC components for your to in comparison to cigarettes because it’s health, but they are the ones who smoke more natural not equally harmful MC Figure 2 Bisaura High School student future intentions and beliefs about RYO of the (Sant Quirze), 2016---19. life the ones with greater intention to smoke in the future major risk factor to consider and therefore, they should play and greater percentage of erroneous beliefs. a major role in smoking prevention programs.24 Behavioral Despite the decreasing trend in smoking, a large num- interventions may reduce the proportion that nonsmoking ber of young people continue with this habit and there are adolescents try,25 but some authors suggest that there is no teenagers who start this harmful and addictive consumption evidence that educational interventions have any influence very early.1,22 The results of this study show that 40.5% of in prevalence nor incidence of smoking.26 the surveyed students have smoked at least once in their Although there are some examples of programs with life. Of these, 34.9% do it every day and 41.9% smoke 2 these objectives, such as ‘‘Smokeless class’’,8 which has cigarettes or more a day. Some of these results agree with shown to reduce false beliefs in teenagers after its those obtained in the last ESTUDES survey,5 which docu- evaluation,27 there is a need to continue strengthening, mented that 40.7% of respondents had smoked at least once designing and evaluating prevention programs to prevent in their life. Among young people, the proportion of peo- the onset of tobacco consumption during adolescence and ple who use roll-your-own cigarettes (RYO) has grown.3,4 In correct false beliefs about RYO. Moreover, a change in the our study we found that 26.6% of the respondents intend taxation of the tobacco would be desirable to correct the to smoke in the future, mainly RYO. Intention to smoke in current price of the RYO, which is very low.7,13,28,29 the future has been identified as an important predictor of The main limitation of this study is its cross-sectional smoking behavior in adolescents over time, which means its design, which does not allow to establish causal effects. identification can be useful for understanding the smoker’s Another is its sample, specifically in some categories: the dynamics in adolescence.22 results may not be representative of all Catalan adolescents. There is a significant proportion of young people with Larger studies are needed to confirm the results obtained. false beliefs regarding RYO and its properties. Specifically, To gain statistical power, two grades were studied, analyzing more than 20% of young respondents believe that smoking students between 14 and 16 years, considering the fact that RYO ‘‘hooks’’ less, that is less damaging than MC and it in this period adolescents start using.5 We do not believe is easier for RYO smokers to quit than those who smoke that the academic environment can exert counter pressure MC. Therefore, our study shows that a large percentage when declaring the actual consumption of substances; ques- of young people have false beliefs about RYO, in line with tions about substance use, consumer beliefs and intentions other studies carried out so far.8,12---17,23 We have seen, for were self-declared and there are indications that the use of example, that many young people perceive the consump- self-reported questionnaires is a reliable method for mea- tion of RYO as a less harmful way to smoke compared to the suring substance use in adolescents.30 use of MC and they believe to have better personal control Even though demystification of false beliefs about RYO over consumption.8 However, studies show that are equally among adolescents is very important, future interventions harmful or than smoking RYO is even worse than smoking should also focus on applying proactive programs in ado- MC.13---16 We also found significant proportions of surveyed lescents. Different strategies have proven to be effective students who believe that RYO cigarettes ‘‘hook’’ less than in reducing tobacco consumption, passively reducing expo- MC, and that RYO is less harmful because it is more nat- sure to tobacco, or on promoting tobacco cessation, some ural, in line with other authors.12,14---17 Furthermore, they of them are: increasing the price of tobacco products, edu- believe that MC contains more chemical additives than RYO cation through the media, tobacco industry restrictions, use and that RYO smokers find it easier to quit when they want restrictions, access restrictions for underage and community to.9 education among others.31 In line with other studies, we found that the fact of having smoked in life is significantly related to smoking intentions in the future,24 with the intention to smoke MC or RYO in Conclusions the future, as well as the belief that smoking RYO hooks less than MC and that is easier to quit smoking it. Therefore, The main conclusions can be summarized in the existence experimenting with tobacco consumption in adolescence is a of a significant percentage of young people who intend to 7 E. Codinach-Danés, N. Obradors-Rial, J. Mendioroz-Peña et al. smoke in the future and have erroneous beliefs about RYO. Conflict of interests There is therefore the need to continue working on activities with an educational and tobacco preventive approach. The None declared. information that young people have regarding RYO needs to be improved to correct their misconceptions about RYO, generating a critical analysis process to help prevent future Acknowledgments consumption of both RYO and tobacco in general. The authors would like to thank all students and teach- ers of the High School Bisaura from Sant Quirze de Besora, whom facilitated the researchers to conduct the study. We also would like to thank M. Rosa Cirera Guàrdia and Helena What is known on the topic González-Casals for their help in the various tasks involved in the management of the project. This paper is part of the • Among smokers, especially among young people, the doctoral dissertation of Eva Codinach-Danés, at the Univer- proportion of people who use rolling tobacco has sitat de Vic --- Universitat Central de Catalunya. grown. • The increase can be explained by false beliefs about References rolling cigarettes. • There are currently few studies on adolescent popu- 1. Gutiérrez-Abejón E, Rejas-Gutiérrez J, Criado-Espegel lation that smokes rolling cigarettes in our country. P, Campo-Ortega EP, Breñas-Villalón MT, Martín-Sobrino N. Smoking impact on mortality in Spain in 2012. What this study contributes Med Clin (Barc). 2015;145:520---5, http://dx.doi.org/10. 1016/j.medcli.2015.03.013. 2. Plan Nacional Sobre Drogas. 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