J Adv Nurs. 2023;00:1–17.  | 1wileyonlinelibrary.com/journal/jan Received: 23 September 2022  | Revised: 9 February 2023  | Accepted: 16 March 2023 DOI: 10.1111/jan.15665 O R I G I N A L R E S E A R C H : E M P I R I C A L R E S E A R C H - Q U A N T I T A T I V E Transitions in smoking status in nursing students: A prospective longitudinal study Kenza Laroussy1,2,3  | Yolanda Castellano1,2,4  | Marcela Fu1,2,3  | Antoni Baena1,2,5  | Ariadna Feliu1,2,4  | Armando Peruga1,2,6  | Mercè Margalef1,2  | Jon Aldazabal1,2  | Olena Tigova1,2,3  | Jordi Galimany3  | Montserrat Puig3  | Carmen Moreno3  | Albert Bueno7  | Antonio López8  | Judith Roca9  | Judith Saura1,2,3  | Esteve Fernández1,2,10  | Cristina Martínez1,2,3 1WHO Collaborating Centre for Tobacco Control, Institut Català d'Oncologia- ICO, Av. Granvia de L'Hospitalet 199- 203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain 2Tobacco Control Research Group, Institut d'Investigació Biomèdica de Bellvitge- IDIBELL, Av. Granvia de L'Hospitalet 199- 203, L'Hospitalet de Llobregat, 08908, Barcelona, Spain 3Department of Public Health, Mental Health and Maternal and Child Health Nursing, School of the Medicine and Health Sciences, University of Barcelona, C. Feixa llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain 4Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain 5Department of e- Health, Faculty of Health Sciences, Universitat Oberta de Catalunya, Rambla de Poblenou 156, 08018, Barcelona, Spain 6Faculty of Medicine, Center for Epidemiology and Health Policy, Clínica Alemana, Universidad del Desarrollo, Región Metropolitana, Lo Barnechea, Chile 7Nursing Care Management, EAP Roses, Institut Català de Salut, Crta Mas Oliva no. 23, Roses, 17480, Alt Empordà, Spain 8Nursing Care Management, EAP Valls Urbano, c/ Vallvera no. 8, 43800, Tarragona, Spain 9Department of Nursing and Physiotherapy, University of Lleida, C/Montserrat Roig 2, 25198, Lleida, Spain 10Department of Clincial Science, School of the Medicine and Health Sciences, University of Barcelona, C. Feixa llarga s/n, L'Hospitalet del Llobregat, 08907, Barcelona, Spain Correspondence Cristina Martínez, Tobacco Control Unit, Institut Català d'Oncologia- ICO, Av. Granvia de L'Hospitalet 199- 203, L'Hospitalet de Llobregat, Barcelona 08908, Spain. Email: cmartinez@iconcologia.net Funding information Campus Ciències de la Salut de Bellvitge, Universitat de Barcelona; Consell de Col·legis d'Infermeres i Infermers en Catalunya; Government of Catalonia, Grant/Award Number: 2021SGR906 Abstract Aim: To describe transitions in smoking status and their determining factors among nursing students between baseline (2015– 2016) and follow- up (2018– 2019). Design: Observational prospective longitudinal study of 4381 nursing students in Catalonia (Spain). Methods: We examined transitions in smoking status from: (i) current smokers to re- cent quitters, (ii) never smokers to new smokers and (iii) former smokers to quitters who relapsed. We fitted logistic regression models to assess the predictors of quitting smoking. Results: The proportion of current smokers decreased from 29.7% at baseline to 23.6% at follow- up, with a cumulative incidence rate of quitting of 28.3% during fol- low- up. Nondaily smokers were more likely to quit than daily smokers. Of those who This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd. 2  |    LAROUSSY et al. 1  |  BACKGROUND Young college students (18– 24 years- old) are susceptible to being exposed to high- risk behaviors, such as tobacco use, which can lead from experimentation to regular consumption, this time being a cru- cial period of consolidation of tobacco behaviors (Berg et al., 2020; Cooke et al., 2016; Sutfin et al., 2022). Furthermore, emerging to- bacco and nicotine products have altered college students' tobacco behaviors, leading to an increased prevalence of alternative tobacco product and polytobacco use among this group (American College Health Association, 2022; Haardörfer et al., 2016). According to recent data, nearly 33% of college students are current users of a tobacco or nicotine product, including cigarettes, cigar/cigarillo/little cigar, electronic nicotine systems (ENDS) such as electronic cigarettes (e- cigarettes), water pipes (also known as hookah or shisha), heated tobacco products (HTPs) and smokeless tobacco (American College Health Association, 2022). Tobacco ini- tiation occurs frequently between the ages of 14 and 25 through combustible products such as manufactured (MF) and roll- your- own (RYO) cigarettes, which are still the most common gateway to tobacco addiction among young people (Reitsma et al., 2021). However, in recent years, increasing use of alternative tobacco prod- ucts such as e- cigarettes and water pipes has been observed among college students (American College Health Association, 2022). Furthermore, concurrent use of multiple tobacco products (polyto- bacco use) is increasing, while single tobacco product use is decreas- ing (Haardörfer et al., 2016). Several known factors influence tobacco use among college stu- dents, either by increasing the probability of initiating and maintaining consumption or by hindering tobacco cessation. In this regard, being male, older, having a peer and/or family smoker, being exposed to sec- ondhand smoke (SHS) and having high scores of depression, anxiety and/or stress are all associated with a greater likelihood of being a to- bacco user (Berg et al., 2020; Cooke et al., 2016; Creamer et al., 2018). Moreover, the use of alternative tobacco products predicts cigarette initiation, as well as the inverse associated exits (Creamer et al., 2018; Sutfin et al., 2022). Furthermore, high nicotine dependence, high per- ceived addiction and low self- efficacy to quit are significant barriers to stopping smoking (Pardavila- Belio et al., 2019). The current evidence has widely demonstrated the prevalence and changes in tobacco use and its predictors among college stu- dents globally. Nevertheless, there is a scarcity of longitudinal studies that have focused on different college fields, such as health science degrees, even though they have a key role in tobacco con- trol. This is especially true for nursing students, who in the future will be role models and will be expected to perform smoking preven- tion and cessation interventions. Although previous studies among Spanish nursing students have reported changes in tobacco use prevalence and smoking status (Ordás et al., 2015), the predictors of smoking status changes have not been addressed. Furthermore, cohort studies that encompass the use of different tobacco prod- ucts, e- cigarettes and cannabis among this group are uncommon in Europe. Thus, we analyzed data from the “Study of Tobacco Consumption in Nursing Students of the Universities of Catalonia were never smokers at baseline, 4.6% were smokers at follow- up, and 23.2% of for- mer smokers at baseline had relapsed at follow- up. Conclusions: Nondaily smokers were more likely to have quit smoking at follow- up among this cohort of nursing students. The early implementation of a comprehensive tobacco control program that includes tobacco- free campus policies, tobacco preven- tion interventions and cessation support during college years may decrease tobacco use among nursing students. Impact: Nursing students' tobacco use is concerning, as they are the future work- force of nurses who have a key role in tobacco product use prevention and cessation. During college years, nursing students have a greater likelihood of experimenting with several smoking status changes as well as to consolidate smoking behaviors. This is the first longitudinal study to highlight the factors associated with quitting smoking among a cohort of Spanish nursing students. Being a nondaily smoker at baseline predicted quitting at follow- up. Our findings support the early implementation of a comprehensive tobacco control program that includes tobacco- free campus policies, tobacco prevention interventions and tobacco cessation support during college years to decrease tobacco product use prevalence among nursing students. Reporting Method: We have adhered to STROBE guidelines. No Patient or Public Contribution. This observational study has not been registered. K E Y W O R D S longitudinal studies, nursing students, smoking, smoking cessation, tobacco use, young adult 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  3LAROUSSY et al. (ECTEC),” a cohort study initiated in the academic year 2015– 2016 (Martínez et al., 2019) to describe transitions in smoking status and their determining factors among nursing students between baseline (2015– 2016) and follow- up (2018– 2019). 2  |  METHODS 2.1  |  Design We employed an observational prospective longitudinal study de- sign to follow a cohort of nursing students from all nursing schools in Catalonia (Spain) between the academic years 2015– 2016 and 2018– 2019. 2.2  |  Participants and recruitment At baseline, we have instructed all nursing students from all nurs- ing schools of Catalonia (Spain) to complete a paper- and- pencil questionnaire during class time at their nursing schools. All partici- pants gave written informed consent to take part in the baseline study and, optionally, they provided their email account addresses and permission to be contacted in follow- up studies. Details of the cross- sectional baseline survey are available (Martínez et al., 2019). Atfollow- up, we included all participants who answered the baseline questionnaire, provided informed consent to be followed up, and had valid contact information. In 2018, we invited the par- ticipants by email to fill in an online follow- up questionnaire. For this study, we included the participants that completed the baseline and follow- up questions regarding their smoking status. 2.3  |  Instrument and outcome measures At baseline, we used a self- administered questionnaire that ex- plored: (i) the use of tobacco products, e- cigarettes and cannabis, (ii) knowledge, attitudes and formal training about tobacco control and (iii) compliance with tobacco- free policies. The baseline paper- and- pencil questionnaire was based on the Global Health Professional Survey (GHPS). At follow- up, we used an online survey based on the baseline questionnaire that was launched through the LimeSurvey platform. The follow- up questionnaire included 11 questions re- garding sociodemographic characteristics and 19 about the use of tobacco products, e- cigarettes and cannabis (7 for all participants, 8 for those who were current smokers and 4 for former smokers). Prior to administration, the follow- up questionnaire was piloted, first with 20 collaborating researchers from different areas and then with 50 study participants (see details in Laroussy et al., 2022). In the baseline and follow- up surveys, we asked about the par- ticipants' use of different tobacco products (MF and RYO cigarettes, cigars/cigarillos/little cigars and water pipes), e- cigarettes, HTPs and cannabis, through the question: Of the following statements, indi- cate which one best describes your behavior with respect to (name of the product). A total of seven questions were formulated, one for each product. The possible answers were: I currently smoke every day (at least once a day), I currently smoke nondaily (not every day), I don't smoke now, but I used to smoke every day (at least once a day), I don't smoke now, but I used to smoke nondaily (not every day) and I have never smoked. Then, we classified participants into three categories according to the current Centers for Disease Control and Prevention and Diagnostic and Statistical Manual of Mental Disorders Fifth Edition definitions of smoking behaviors: (i) current smoker, a person who uses combustible tobacco products (MF and/or RYO cigarettes) at the moment of the survey or had quit less than 6 months ago; (ii) former smoker, a person who had smoked MF and/or RYO cigarettes and had remained abstinent for at least 6 months and (iii) never smoker, a person who has never smoked MF and/or RYO cigarettes. Among current smokers, we differentiate between a daily smoker (a person who smokes every day) and a nondaily smoker (a person who smokes regularly but not every day, whatever the quantity or the frequency). Current smokers were asked about their age of initiation (clas- sified into <17 or ≥17); the reason/s why they initiated smoking (because my friends/classmates smoked, because one of my family mem- bers smoked, because my teachers smoked, to experiment with new ex- periences, because it is trendy, to feel older, to meet people or to flirt, and other); the reason/s why they currently smoke (for weight control, for reducing stress/relaxing, for socializing, because my friend/family smokes, because it is trendy, for pleasure, because I could not quit, and other); the number of cigarettes smoked per day (CPD) or per week (classified into <10, 10– 19, or ≥20); how long it takes to smoke their first cigarette from the moment they wake up (5 min or less, between 6 and 30 min, between 31 and 60 min or more than 60 min); if they have seriously tried to quit smoking in the last year (yes or no), the number of quit attempts of at least 24 h in the last year (1 or ≥2) and if they have the intention to quit or cut back their consumption in the following year (yes or no). We used the data of the number of CPD and time to first cigarette (TFC) to calculate the heaviness of smok- ing index (HSI) using the following scoring for CPD: <10 = 1 point (p), 10– 19 = 2 p, or ≥20 = 3 p and TFC: 5 min or less = 3 p, between 6 and 30 min = 2 p, between 31 and 60 min = 1 p or more than 60 min = 0 p. We have summed the scores from both variables to obtain a score between 0 and 6; and considered an HSI from 0 to 2 as low nicotine dependence, 3– 4 as medium and 5– 6 as high (Chabrol et al., 2005). Former smokers were asked about their age of initiation (clas- sified into <17 or ≥17); their age of cessation (classified into <19 or ≥19); the reason/s why they quit smoking (to protect my health, on the advice of a health professional, to set an example, under pressure from family or friends, to save money, because it is important for my role as a nurse, or other reasons); and if they used any treatment during the quitting process (nicotine gum, lozenges, mouth spray or patches, prescription drugs [bupropion, varenicline or others], professional support [doctor, nurse, psychologist or others], acupuncture/home- opathy/hypnosis, others or they have not used any treatment). 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 4  |    LAROUSSY et al. The main dependent variable was transition in smoking status. Smoking transitions were defined according to the changes in to- bacco use between baseline and follow- up: (i) participants who were current smokers at baseline and transitioned to former smokers at follow- up were classified as recent quitters; (ii) participants who were never smokers at baseline and transitioned to current smokers at follow- up were classified as new smokers; (iii) participants who were former smokers at baseline and transitioned to current smokers at follow- up were classified as quitters who relapsed. Participants who had not changed their smoking status were defined as continued as smokers, continued as never smokers and continued as former smokers. At baseline, we collected sociodemographic characteristics such as sex, age (classified into ≤19 years, 20– 24 years or ≥25 years), year in nursing school (first, second, third or fourth year), place of birth (Catalonia or outside of Catalonia), location of nursing school (Barcelona or outside of Barcelona) and type of nursing school (pub- lic, private with public funding or private). At follow- up, we explored whether they had finished the nursing degree (yes or no); occupa- tion at follow- up (nursing student, nurse or other); for those who were still in nursing school, their year in nursing school (second, third or fourth); for those who were working as nurses, we asked their work area (hospital, primary care or other) and the type of institution (public, private with public funding or private); if they were living with family or were independent, their monthly income (≤1500€, 1501€– 3000€ or ≥3001€) and their marital status (single, married/ cohabiting, divorced or widowed). In addition, we also used the char- acteristics related to the pattern of tobacco use among current and former smokers at baseline as independent variables. 2.4  |  Validity, reliability and rigor of the instrument The content validity of the instrument of measurement used in this study (questionnaire) was strengthened by different pilot tests con- ducted before the baseline study and before the follow- up study. All details about the procedure of data collection and the charac- teristics of the survey have been described earlier and are explained elsewhere (Laroussy et al., 2022). To ensure reliability, a rigorous quality analysis of the data was conducted. In this step, we excluded invalid surveys as well as partic- ipants with incomplete information. The number of excluded invalid surveys is detailed in Section 3. 2.5  |  Data analysis For bivariate analysis, we used a Chi- square test for qualitative variables. In addition, to analyze the predictors of quitting, we per- formed logistic regression models to obtain both crude and adjusted odds ratios (aORs), and their 95% confidence interval (CI). The full- adjusted models only included the following independent variables: sex, baseline age and baseline smoking status. The variables smoking for reducing stress/relaxing, number of CPD, HSI and thinking about cutting back consumption were excluded from the model due to their association with the baseline smoking status (number of CPD and HSI) or their small sample size (smoking for reducing stress/re- laxing and thinking about cutting back consumption). Predictors of initiating smoking or relapsing were not assessed due to the small sample sizes in both subgroups. Furthermore, we calculated the cu- mulative rates of quitting, starting and relapsing, stratified by oc- cupation at follow- up, to compare the participants who were still nursing students with those who had graduated and were working as nurses at follow- up. Significance was set at p < .05. All statistical analyses were performed using IBM SPSS statistics version 25. 2.6  |  Ethical considerations The study protocol was approved by the Ethics Committee of the Hospital Universitari de Bellvitge (PR239/18). Written informed consent was obtained from all participants at both baseline and follow- up. 3  |  RESULTS 3.1  |  Description of the sample From the overall 4381 participants of the baseline study, we iden- tified 3440 (78.5%) people who were eligible for follow- up (who agreed to participate in the follow- up and provided their email ad- dress). Of them, 1252 (28.6%) participated in the follow- up. For the current analysis, we excluded 103 participants who did not complete the key questions in the follow- up survey and 64 participants whose response could not be linked to their response for the baseline sur- vey. Thus, we studied 1085 participants (24.8%) with complete in- formation at baseline and follow- up. Overall, 89.4% of the followed participants were female and 49.0% were aged 20– 24. Comparing the three age groups, the pro- portion of women was higher among participants ≤19 years old, and the proportion of men was higher among those ≥25 years old (both p < .01). Regarding their occupation at follow- up, 408 were still nurs- ing students and 647 had graduated. Among nursing students, we observed a higher proportion of females in the second or third year of school and a higher proportion of males in the fourth year (both p < .05) (Table S1). 3.2  |  Changes in smoking status Figure 1 presents the main smoking transitions that nursing students experienced during the follow- up period. The prevalence of current smokers decreased significantly between baseline (29.7%, 95% CI 27.2– 32.2) and follow- up (23.6%, 95% CI 21.1– 26.2). Consequently, there was an increased prevalence of former smokers (from 13.1%, 95% CI 11.3– 14.9, to 19.4%, 95% CI 17.1– 21.8). Among smokers, the 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  5LAROUSSY et al. percentage of nondaily smokers was high at both baseline (38.0%) and follow- up (36.4%). The proportion of never smokers showed al- most no change between baseline and follow- up (Table 1). Current smoking (daily and nondaily together) and former smok- ing increased by age group at follow- up (p < .001) with no differences by year in nursing school. Current smoking at follow- up was more common among students who were born in Catalonia compared with those who born outside of Catalonia (25.3%, 16.5%, respec- tively, p < .05), those who were enrolled in universities in Barcelona compared with those from universities outside of Barcelona (25.7%, 15.4%, respectively, p < .05), in private nursing schools with public funding compared with those from public or private schools (32.6%, 17.5%, 26.2%, respectively, p < .001), those who were indepen- dent when compared with those living with their families (27.7%, 21.4%, p < .001) and those who had a marital status other than sin- gles (28.1%, 22.0, p < .001). Former smoking at follow- up was more frequent among participants who were born outside of Catalonia than those who were born in Catalonia (24.5%, 18.1%, respectively p < .05), those who were independent, compared with those who were living with their family (24.7%, 17.2%, respectively, p < .001) and with another marital status, compared with those who were sin- gle (31.7%, 16.5%, respectively, p < .001). Among current smokers, the proportion of nondaily smokers was higher among younger participants, whereas the proportion of daily smokers was higher among older ones (p < .001). Daily smoking was more common among independent students and among those with another marital status, compared with those who were living with their families and with those who were single (both p < .002). Nondaily smoking was more frequent among students who were living with their families and were single, compared with those who were independent and had another marital status (both p < .002). In contrast to participants' tobacco use pattern at baseline, most male smokers at follow- up initiated smoking at ≥17 year- old, whereas most females initiated at <17 year- old (p = .008). Regarding the type of product, tobacco users mostly used combustible tobacco (MF cig- arettes 66.4% and RYO cigarettes 47.0% at baseline, increasing to 79.7% and 57.1% at follow- up, respectively, Table 2). The proportion of RYO cigarette and water pipe users was higher among the young- est participants, whereas the proportion of MF cigarette users was higher among the oldest participants (p < .05). The use of alternative products increased: water pipes from 10.0% to 16.1%, e- cigarettes from 0.4% to 1.6% and cannabis from 11.5% to 15.0%. While the use of HTPs was negligible at baseline, it had increased at follow- up, and it was higher in men (6.7%) than in women (1.3%) (p < .05). At follow- up, the number of consumed CPD and nicotine dependence increased by age group at follow- up (p ≤ .001). A greater proportion of males than females reported quit attempts in the last year (48.1% vs. 27.6%, p < .05). Finally, the proportion of smokers who had the intention to quit at follow- up increased by age group (≤19 year- old: 71.4%, 20– 24 year- old: 82.4% and ≥ 25 year- old: 100%, p = .002). 3.3  |  Predictors of smoking transition As shown in Table 3, the cumulative incidence of quitting was 28.3% at follow- up. The only predictor of quitting was being a nondaily smoker compared to a daily smoker (aOR = 3.86, 95% CI 2.19– 6.82). The proportion of recent quitters who reported smoking for reduc- ing stress or relaxing at baseline was lower than those who con- tinued smoking at follow- up (p < .006). As well, the proportion of recent quitters was higher among participants who, at baseline, had a low cigarette consumption (<10 CPD), compared with those who consumed ≥10 CPD (p < .001), those who had low nicotine depend- ence, compared with those who had medium and high dependence (p = .036) and those who had no intention to cut back consumption, compared with those who had this intention (p = .026). There were no differences in the factors linked to quitting at follow- up between participants who were still students and those who had graduated. F I G U R E 1  Smoking status transitions among the cohort of nursing students between baseline (2015– 16) and follow- up (2018– 19). *These participants reported being never smokers at baseline and former smokers at follow- up. Thus, we concluded that they both started smoking and quit smoking between baseline and follow- up. Current smoker at follow-up Former smoker at follow-up Never smoker at follow-up Current smoker at baseline Continued as current smoker (n=198) Recent quitter (n=78) - Former smoker at baseline Quitter who relapsed (n=29) Continued as former smoker (n=96) - Never smoker at baseline New smoker (n=29) New smoker and recent quitter* (n=58) Continued as never smoker (n=597) *These participants reported being never smokers at baseline and former smokers at follow-up. Thus, we concluded that they both started smoking and quit smoking between baseline and follow-up. 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 6  |    LAROUSSY et al. TA B L E 1  Tobacco use of the followed participants according to sociodemographic characteristics at baseline (2015– 2016) and follow- up (2018– 2019). Current smokers p- valuea Non smokers p- valueb All Daily smokers Nondaily smokers Never smokers Former smokers n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Overall 256 23.6 (21.1– 26.2) 163 15.0 (13.0– 17.2) 93 8.6 (7.0– 10.3) 619 57.0 (54.1– 60.0) 210 19.4 (17.1– 21.8) Characteristics at baseline Sex .396 .293 Male 30 26.1 (18.7– 34.6) 17 14.8 (9.2– 22.1) 13 11.3 (6.5– 18.0) 58 50.4 (41.4– 59.5) 27 23.5 (16.5– 31.8) Female 226 23.3 (20.7– 26.0) 146 15.1 (12.9– 17.4) 80 8.2 (6.6– 10.1) 561 57.8 (54.7– 60.9) 183 18.9 (16.5– 21.4) Age <.001 <.001 ≤19 years 79 19.6 (15.9– 23.6) 40 9.9 (7.3– 13.1) 39 9.7 (7.1– 12.8) 260 64.3 (59.6– 68.9) 65 16.1 (12.8– 19.9) 20– 24 years 135 25.6 (22.0– 29.5) 88 16.7 (13.7– 20.1) 47 8.9 (6.7– 11.6) 298 56.5 (52.3– 60.7) 94 17.9 (14.7– 21.3) ≥25 years 39 26.9 (20.2– 34.5) 34 23.4 (17.1– 30.8) 5 3.5 (1.3– 7.4) 57 39.3 (31.6– 47.4) 49 33.8 (26.5– 41.8) Year in nursing school .733 .862 First 90 23.4 (19.4– 27.9) 55 14.3 (11.1– 18.1) 35 9.1 (6.5– 12.3) 220 57.3 (52.3– 62.2) 74 19.3 (15.6– 23.4) Second 60 21.4 (16.9– 26.5) 37 13.2 (9.6– 17.6) 23 8.2 (5.4– 11.9) 165 58.9 (53.1– 64.6) 55 19.7 (15.3– 24.6) Third 57 27.2 (21.5– 33.4) 39 18.6 (13.8– 24.2) 18 8.6 (5.3– 12.9) 116 55.2 (48.5– 61.9) 37 17.6 (12.9– 23.2) Fourth 44 23.9 (18.2– 30.5) 30 16.3 (11.5– 22.1) 14 7.6 (4.4– 12.1) 102 55.4 (48.2– 62.5) 38 20.7 (15.3– 26.9) Place of birth .399 .011 Catalonia 218 25.3 (22.5– 28.3) 142 16.5 (14.1– 19.1) 76 8.8 (7.1– 10.9) 487 56.6 (53.3– 59.9) 155 18.1 (15.6– 20.7) Outside of Catalonia 33 16.5 (11.9– 22.1) 19 9.5 (6.0– 14.1) 14 7.0 (4.1– 11.2) 118 59.0 (52.1– 65.6) 49 24.5 (18.9– 30.8) Location of nursing school .528 .006 Barcelona 222 25.7 (22.9– 28.7) 143 16.6 (14.2– 19.1) 79 9.1 (7.4– 11.2) 479 55.4 (52.1– 58.7) 163 18.9 (16.4– 21.6) Outside of Barcelona 34 15.4 (11.1– 20.6) 20 9.0 (5.8– 13.4) 14 6.4 (3.7– 10.1) 140 63.3 (56.9– 69.5) 47 21.3 (16.3– 27.0) Type of nursing school .275 <.001 Public 82 17.5 (14.3– 21.1) 48 10.2 (7.7– 13.2) 34 7.3 (5.2– 9.9) 298 63.5 (59.1– 67.8) 89 19.0 (15.6– 22.7) Private with public funding 66 32.6 (26.4– 39.2) 47 23.2 (17.8– 29.3) 19 9.4 (5.9– 13.9) 102 50.2 (43.4– 57.1) 35 17.2 (12.5– 22.9) Private 108 26.2 (22.1– 30.5) 68 16.5 (13.1– 20.3) 40 9.7 (7.1– 12.8) 219 53.0 (48.2– 57.8) 86 20.8 (17.1– 24.9) Characteristics at follow- up Has finished degree .575 .853 Yes 149 23.0 (19.9– 26.4) 97 15.0 (12.4– 17.9) 52 8.0 (6.1– 10.3) 373 57.7 (53.8– 61.4) 125 19.3 (16.4– 22.5) No 107 24.4 (20.6– 28.6) 66 15.1 (12.0– 18.6) 41 9.3 (6.9– 12.4) 246 56.2 (51.5– 60.8) 85 19.4 (15.9– 23.3) Occupation .395 .078 Nursing student 94 23.0 (19.2– 27.3) 60 14.7 (11.5– 18.4) 34 8.3 (5.9– 11.3) 236 57.8 (53.0– 62.6) 78 19.2 (15.5– 23.1) Nurse 149 23.0 (19.9– 26.4) 97 15.0 (12.4– 17.9) 52 8.0 (6.1– 10.3) 373 57.7 (53.8– 61.4) 125 19.3 (16.4– 22.5) Other 13 43.3 (26.9– 61.0) 6 20.0 (8.8– 36.7) 7 23.3 (11.1– 40.4) 10 33.3 (18.6– 51.1) 7 23.4 (11.1– 40.4) Year in nursing school (students) .300 .925 Second or third 22 21.8 (14.6– 30.6) 12 11.9 (6.7– 19.2) 10 9.9 (5.2– 16.9) 60 59.4 (49.7– 68.6) 19 18.8 (12.1– 27.3) Fourth 72 23.5 (19.0– 28.4) 48 15.7 (11.9– 20.0) 24 7.8 (5.2– 11.2) 176 57.3 (51.7– 62.8) 59 19.2 (15.1– 23.9) Work area (nurses) .152 .501 Hospital 111 24.2 (20.5– 28.3) 77 16.8 (13.6– 20.4) 34 7.4 (5.3– 10.1) 259 56.6 (52.0– 61.0) 88 19.2 (15.8– 23.0) Other 24 20.9 (14.2– 29.0) 13 11.3 (6.5– 18.0) 11 9.6 (5.2– 15.9) 82 62.6 (53.5– 71.1) 19 16.5 (10.6– 24.1) Type of institution they work in (nurses) .808 .645 Public 70 24.8 (20.1– 30.1) 46 16.3 (12.4– 21.0) 24 8.5 (5.7– 12.2) 163 57.8 (52.0– 63.5) 49 17.4 (13.3– 22.1) Other 65 22.3 (17.8– 27.4) 44 15.1 (11.4– 19.6) 21 7.2 (4.7– 10.6) 168 57.7 (52.0– 63.3) 58 20.0 (15.7– 24.8) 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  7LAROUSSY et al. TA B L E 1  Tobacco use of the followed participants according to sociodemographic characteristics at baseline (2015– 2016) and follow- up (2018– 2019). Current smokers p- valuea Non smokers p- valueb All Daily smokers Nondaily smokers Never smokers Former smokers n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Overall 256 23.6 (21.1– 26.2) 163 15.0 (13.0– 17.2) 93 8.6 (7.0– 10.3) 619 57.0 (54.1– 60.0) 210 19.4 (17.1– 21.8) Characteristics at baseline Sex .396 .293 Male 30 26.1 (18.7– 34.6) 17 14.8 (9.2– 22.1) 13 11.3 (6.5– 18.0) 58 50.4 (41.4– 59.5) 27 23.5 (16.5– 31.8) Female 226 23.3 (20.7– 26.0) 146 15.1 (12.9– 17.4) 80 8.2 (6.6– 10.1) 561 57.8 (54.7– 60.9) 183 18.9 (16.5– 21.4) Age <.001 <.001 ≤19 years 79 19.6 (15.9– 23.6) 40 9.9 (7.3– 13.1) 39 9.7 (7.1– 12.8) 260 64.3 (59.6– 68.9) 65 16.1 (12.8– 19.9) 20– 24 years 135 25.6 (22.0– 29.5) 88 16.7 (13.7– 20.1) 47 8.9 (6.7– 11.6) 298 56.5 (52.3– 60.7) 94 17.9 (14.7– 21.3) ≥25 years 39 26.9 (20.2– 34.5) 34 23.4 (17.1– 30.8) 5 3.5 (1.3– 7.4) 57 39.3 (31.6– 47.4) 49 33.8 (26.5– 41.8) Year in nursing school .733 .862 First 90 23.4 (19.4– 27.9) 55 14.3 (11.1– 18.1) 35 9.1 (6.5– 12.3) 220 57.3 (52.3– 62.2) 74 19.3 (15.6– 23.4) Second 60 21.4 (16.9– 26.5) 37 13.2 (9.6– 17.6) 23 8.2 (5.4– 11.9) 165 58.9 (53.1– 64.6) 55 19.7 (15.3– 24.6) Third 57 27.2 (21.5– 33.4) 39 18.6 (13.8– 24.2) 18 8.6 (5.3– 12.9) 116 55.2 (48.5– 61.9) 37 17.6 (12.9– 23.2) Fourth 44 23.9 (18.2– 30.5) 30 16.3 (11.5– 22.1) 14 7.6 (4.4– 12.1) 102 55.4 (48.2– 62.5) 38 20.7 (15.3– 26.9) Place of birth .399 .011 Catalonia 218 25.3 (22.5– 28.3) 142 16.5 (14.1– 19.1) 76 8.8 (7.1– 10.9) 487 56.6 (53.3– 59.9) 155 18.1 (15.6– 20.7) Outside of Catalonia 33 16.5 (11.9– 22.1) 19 9.5 (6.0– 14.1) 14 7.0 (4.1– 11.2) 118 59.0 (52.1– 65.6) 49 24.5 (18.9– 30.8) Location of nursing school .528 .006 Barcelona 222 25.7 (22.9– 28.7) 143 16.6 (14.2– 19.1) 79 9.1 (7.4– 11.2) 479 55.4 (52.1– 58.7) 163 18.9 (16.4– 21.6) Outside of Barcelona 34 15.4 (11.1– 20.6) 20 9.0 (5.8– 13.4) 14 6.4 (3.7– 10.1) 140 63.3 (56.9– 69.5) 47 21.3 (16.3– 27.0) Type of nursing school .275 <.001 Public 82 17.5 (14.3– 21.1) 48 10.2 (7.7– 13.2) 34 7.3 (5.2– 9.9) 298 63.5 (59.1– 67.8) 89 19.0 (15.6– 22.7) Private with public funding 66 32.6 (26.4– 39.2) 47 23.2 (17.8– 29.3) 19 9.4 (5.9– 13.9) 102 50.2 (43.4– 57.1) 35 17.2 (12.5– 22.9) Private 108 26.2 (22.1– 30.5) 68 16.5 (13.1– 20.3) 40 9.7 (7.1– 12.8) 219 53.0 (48.2– 57.8) 86 20.8 (17.1– 24.9) Characteristics at follow- up Has finished degree .575 .853 Yes 149 23.0 (19.9– 26.4) 97 15.0 (12.4– 17.9) 52 8.0 (6.1– 10.3) 373 57.7 (53.8– 61.4) 125 19.3 (16.4– 22.5) No 107 24.4 (20.6– 28.6) 66 15.1 (12.0– 18.6) 41 9.3 (6.9– 12.4) 246 56.2 (51.5– 60.8) 85 19.4 (15.9– 23.3) Occupation .395 .078 Nursing student 94 23.0 (19.2– 27.3) 60 14.7 (11.5– 18.4) 34 8.3 (5.9– 11.3) 236 57.8 (53.0– 62.6) 78 19.2 (15.5– 23.1) Nurse 149 23.0 (19.9– 26.4) 97 15.0 (12.4– 17.9) 52 8.0 (6.1– 10.3) 373 57.7 (53.8– 61.4) 125 19.3 (16.4– 22.5) Other 13 43.3 (26.9– 61.0) 6 20.0 (8.8– 36.7) 7 23.3 (11.1– 40.4) 10 33.3 (18.6– 51.1) 7 23.4 (11.1– 40.4) Year in nursing school (students) .300 .925 Second or third 22 21.8 (14.6– 30.6) 12 11.9 (6.7– 19.2) 10 9.9 (5.2– 16.9) 60 59.4 (49.7– 68.6) 19 18.8 (12.1– 27.3) Fourth 72 23.5 (19.0– 28.4) 48 15.7 (11.9– 20.0) 24 7.8 (5.2– 11.2) 176 57.3 (51.7– 62.8) 59 19.2 (15.1– 23.9) Work area (nurses) .152 .501 Hospital 111 24.2 (20.5– 28.3) 77 16.8 (13.6– 20.4) 34 7.4 (5.3– 10.1) 259 56.6 (52.0– 61.0) 88 19.2 (15.8– 23.0) Other 24 20.9 (14.2– 29.0) 13 11.3 (6.5– 18.0) 11 9.6 (5.2– 15.9) 82 62.6 (53.5– 71.1) 19 16.5 (10.6– 24.1) Type of institution they work in (nurses) .808 .645 Public 70 24.8 (20.1– 30.1) 46 16.3 (12.4– 21.0) 24 8.5 (5.7– 12.2) 163 57.8 (52.0– 63.5) 49 17.4 (13.3– 22.1) Other 65 22.3 (17.8– 27.4) 44 15.1 (11.4– 19.6) 21 7.2 (4.7– 10.6) 168 57.7 (52.0– 63.3) 58 20.0 (15.7– 24.8) 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 8  |    LAROUSSY et al. Current smokers p- valuea Non smokers p- valueb All Daily smokers Nondaily smokers Never smokers Former smokers n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Living .002 <.001 With family 148 21.4 (18.5– 24.6) 83 12.0 (9.7– 14.6) 65 9.4 (7.4– 11.7) 425 61.4 (57.7– 65.0) 119 17.2 (14.5– 20.1) Independent 92 27.7 (23.1– 32.7) 70 21.1 (17.0– 25.7) 22 6.6 (4.3– 9.7) 158 47.6 (42.3– 53.0) 82 24.7 (20.3– 29.5) Monthly income .188 .659 ≤1500€ 68 24.5 (19.7– 29.8) 50 18.0 (13.8– 22.8) 18 6.5 (4.0– 9.8) 157 56.4 (50.6– 62.2) 53 19.1 (14.8– 24.0) 1501€– 3000€ 72 20.9 (16.8– 25.4) 46 13.3 (10.1– 17.2) 26 7.6 (5.1– 10.7) 198 57.4 (52.1– 62.5) 75 21.7 (17.6– 26.3) ≥3001€ 57 25.9 (20.5– 32.0) 34 15.4 (11.1– 20.7) 23 10.5 (6.9– 15.0) 121 55.0 (48.4– 61.5) 42 19.1 (14.3– 24.7) Does not know/Does not answer 59 24.4 (19.3– 30.1) 33 13.7 (9.8– 18.4) 26 10.7 (7.3– 15.1) 143 59.1 (52.8– 65.1) 40 16.5 (12.3– 21.6) Marital status .002 <.001 Single 175 22.0 (19.2– 25) 101 12.7 (10.5– 15.1) 74 9.3 (7.4– 11.5) 490 61.5 (58.1– 64.9) 131 16.5 (14.0– 19.2) Other 63 28.1 (22.5– 34.3) 50 22.3 (17.2– 28.1) 13 5.8 (3.3– 9.4) 90 40.2 (33.9– 46.7) 71 31.7 (25.9– 38.0) Note: Significant values are highlighted in bold. Abbreviation: CI, confidence interval. aChi- square test (daily vs. nondaily smokers). bChi- square test (current smokers vs. never smokers vs. former smokers). TA B L E 1 (Continued) Among never smokers at baseline, the cumulative incidence of smoking initiation at follow- up was 4.6% (Table 4). There were no sig- nificant differences in baseline characteristics among new smokers. The small number of new smokers (n = 29) prevented further analysis through logistic regression modelling. Stratified analysis by occupa- tion at follow- up showed no significant differences. Most new smok- ers used MF cigarettes exclusively (48.3%) or used both MF and RYO cigarettes (34.5%). The overall prevalence of water pipe and canna- bis use among this group was 27.6% and 24.1%, respectively. Among former smokers at baseline, the cumulative incidence of relapse was 23.2% at follow- up (Table 5). There were no dif- ferences regarding the baseline characteristics. Due to the small number of quitters who relapsed (n = 29), we could not perform lo- gistic regression modelling. Most quitters who relapsed consumed MF (44.8%) or both MF and RYO cigarettes (37.9%). The overall prevalence of water pipe and cannabis use was 20.7% and 13.8%, respectively. 4  |  DISCUSSION In our longitudinal study among nursing students in Catalonia, sev- eral changes in tobacco use patterns occurred between the base- line and the 3- year follow- up. The overall prevalence of current smokers decreased, and the overall prevalence of former smokers increased. Among current smokers at baseline, more than a quar- ter of them were recent quitters at follow- up. Being a nondaily smoker at baseline was a predictor of quitting at follow- up. Among never smokers at baseline, 4.6% were new smokers at follow- up. Finally, among former smokers at baseline, 23.2% had relapsed at follow- up. Our results regarding predictors of quitting smoking are con- sistent with previous findings in the literature among college stu- dents (Pardavila- Belio et al., 2019; Wetter et al., 2004). Being a nondaily smoker was the strongest predictor of quitting at fol- low- up, which is in line with what Wetter et al., have found in their study. The fact that nondaily smokers had a higher probability of quitting could be associated with their low nicotine depen- dence, a well- known predictor of quitting among college students (Pardavila- Belio et al., 2019). However, a lower level of addiction and frequency of use has also been linked to continuing smoking because of psychosocial factors rather than a physical addiction (Fernández et al., 2015). In fact, nondaily college smokers have an important heterogeneity regarding their behavioral and psychoso- cial factors, presenting relevant differences in their frequency and quantity of use, social smoking and perceived addiction (Romero et al., 2014). As such, analyzing these factors among subgroups of nondaily users could provide further information about the spe- cific factors that influence them to quit smoking. Notwithstanding that nondaily use was more prevalent among the youngest partic- ipants, age and sex were not associated with quitting smoking in this cohort of nursing students. Accordingly, Pardavila- Belio et al. found age and sex had no influence on the probability of quitting among a cohort of Spanish college students. In contrast, in another longitudinal study among U.S. college students, Buu et al. found males more likely to be both continuing smoking and quitting re- cently than females; however, they compared both groups with those who continued being never smokers rather than compare 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  9LAROUSSY et al. both groups (continued as smokers vs. recent quitters) with each other as we have done. Also, the fact that Berg et al. (2020)in- cluded all tobacco products in the definition of smoker, including e- cigarettes, water pipes, chewing tobacco and more (in addition to cigarettes), may explain these differences. Likewise, those who have included the year of university as a potential predictor of tobacco use have described an increased probability of using to- bacco among first year students, which points out that the first years of college may be a pivotal period in preventing tobacco ini- tiation (Sutfin et al., 2022). Finally, it must be mentioned that a potential factor associated with quitting among nursing students could be having a higher tobacco- related knowledge since they might have received training about this topic during their univer- sity education. Nonetheless, it seems that higher tobacco- related knowledge received during academic years is not associated with lower tobacco use among health students (Han et al., 2011). The 3- year quitting rate obtained was three times higher than the 4- year rate reported in longitudinal research conducted among Spanish college students (Gutiérrez- Bedmar et al., 2009) but was similar to the 6 and 27- month rate reported in college smokers en- rolled in smoking cessation programs (Joo et al., 2020; Pardavila- Belio et al., 2019). Since no smoking cessation programs were carried out among the cohort of our study, the striking cessation rate may be related to the participants' role as nursing students. We hypothesize that this role might have influenced their aware- ness of social norms and of the acceptability (or rather lack of ac- ceptability) of smoking and, consequently, it might have increased their odds of quitting (Alamar & Glantz, 2006). Furthermore, we have observed that a high proportion of participants lost to follow- up were current smokers at baseline, compared to never smokers, which could disguise the actual incidence of quitting (Laroussy et al., 2022). Smoking initiation rates in our nursing student cohort are in concordance with a longitudinal study among Spanish college stu- dents (Gutiérrez- Bedmar et al., 2009). It is noteworthy to mention that this initiation rate may be underestimated because we only examined the initiation of MF and RYO cigarette consumption. Furthermore, there may be a response bias regarding lower rates of participation among new smokers. Perhaps nursing students who smoked anticipated being judged by the researchers and therefore were more reluctant to participate, a phenomenon that has been re- ported in studies conducted among health professionals (Zhang & Jose Duaso, 2021). In addition, we observed that MF cigarettes were the main type of product involved in tobacco initiation and relapse in this cohort, which is in line with other studies (Buu et al., 2020; Joo et al., 2020). Nevertheless, the overall prevalence of other products such as e- cigarettes, water pipes and cannabis increased between baseline and follow- up, although it was lower than that re- ported in other studies (Buu et al., 2020). This fact suggests that the decreasing trend of cigarette initiation and increasing use of al- ternative tobacco products among college students might have also been reflected among nursing students (American College Health Association, 2022). Generally, rates and predictors of smoking status transitions among this cohort of nursing students were similar to those re- ported among other college students, despite being an important group regarding their role in tobacco control. This fact indicates that similar factors could be influencing their tobacco behaviors, at Current smokers p- valuea Non smokers p- valueb All Daily smokers Nondaily smokers Never smokers Former smokers n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Living .002 <.001 With family 148 21.4 (18.5– 24.6) 83 12.0 (9.7– 14.6) 65 9.4 (7.4– 11.7) 425 61.4 (57.7– 65.0) 119 17.2 (14.5– 20.1) Independent 92 27.7 (23.1– 32.7) 70 21.1 (17.0– 25.7) 22 6.6 (4.3– 9.7) 158 47.6 (42.3– 53.0) 82 24.7 (20.3– 29.5) Monthly income .188 .659 ≤1500€ 68 24.5 (19.7– 29.8) 50 18.0 (13.8– 22.8) 18 6.5 (4.0– 9.8) 157 56.4 (50.6– 62.2) 53 19.1 (14.8– 24.0) 1501€– 3000€ 72 20.9 (16.8– 25.4) 46 13.3 (10.1– 17.2) 26 7.6 (5.1– 10.7) 198 57.4 (52.1– 62.5) 75 21.7 (17.6– 26.3) ≥3001€ 57 25.9 (20.5– 32.0) 34 15.4 (11.1– 20.7) 23 10.5 (6.9– 15.0) 121 55.0 (48.4– 61.5) 42 19.1 (14.3– 24.7) Does not know/Does not answer 59 24.4 (19.3– 30.1) 33 13.7 (9.8– 18.4) 26 10.7 (7.3– 15.1) 143 59.1 (52.8– 65.1) 40 16.5 (12.3– 21.6) Marital status .002 <.001 Single 175 22.0 (19.2– 25) 101 12.7 (10.5– 15.1) 74 9.3 (7.4– 11.5) 490 61.5 (58.1– 64.9) 131 16.5 (14.0– 19.2) Other 63 28.1 (22.5– 34.3) 50 22.3 (17.2– 28.1) 13 5.8 (3.3– 9.4) 90 40.2 (33.9– 46.7) 71 31.7 (25.9– 38.0) Note: Significant values are highlighted in bold. Abbreviation: CI, confidence interval. aChi- square test (daily vs. nondaily smokers). bChi- square test (current smokers vs. never smokers vs. former smokers). 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 10  |    LAROUSSY et al. TA B L E 2  Tobacco use pattern among current smokers at follow- up (2018– 2019). All Sex p- valuea Baseline age group (years) p- valueb Male Female ≤19 20– 24 ≥ 25 n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Overall 256 100 30 100 226 100 79 100 135 100 39 100 Age of initiation .008 .820 <17 years 125 57.1 (50.5– 63.5) 9 33.3 (17.9– 52.1) 116 60.4 (53.4– 67.1) 34 54.0 (41.7– 65.9) 70 58.8 (49.9– 67.4) 20 57.1 (40.7– 72.4) ≥17 years 94 42.9 (36.5– 49.5) 18 66.7 (47.9– 82.1) 76 39.6 (32.9– 46.6) 29 46.0 (34.1– 58.3) 49 41.2 (32.6– 50.1) 15 42.9 (27.6– 59.3) Pattern of smoking .391 .001 Daily 163 63.7 (57.7– 69.4) 17 58.6 (40.6– 75.0) 146 66.7 (60.2– 72.7) 40 53.3 (42.1– 64.3) 88 67.2 (58.8– 74.8) 34 87.2 (74.2– 94.9) Nondaily 93 36.3 (30.6– 42.3) 12 41.4 (25.0– 59.4) 73 33.3 (27.3– 39.8) 35 46.7 (35.7– 57.9) 43 32.8 (25.2– 41.2) 5 12.8 (5.1– 25.8) Type of tobacco product consumed Manufactured cigarettes 204 79.7 (74.4– 84.3) 22 73.3 (55.9– 86.5) 182 80.5 (75.0– 85.3) .357 54 68.4 (57.6– 77.8) 114 84.4 (77.6– 89.8) 34 87.2 (74.2– 94.9) .008 Roll- your- own cigarettes 145 57.1 (50.9– 63.1) 18 60.0 (42.2– 76.0) 127 56.7 (50.2– 63.1) .731 55 69.6 (58.9– 78.9) 70 52.6 (44.2– 61.0) 19 48.7 (33.6– 64.0) .026 Cigars, cigarillos, little cigars 5 2.0 (0.8– 4.3) 1 3.3 (0.4– 14.5) 4 1.8 (0.6– 4.2) .567 3 3.8 (1.1– 9.8) 2 1.5 (0.3– 4.7) - - - .321 Electronic cigarettes 4 1.6 (0.5– 3.7) 1 3.3 (0.4– 14.5) 3 1.3 (0.4– 3.5) .410 1 1.3 (0.1– 5.8) 3 2.3 (0.6– 5.9) - - - .589 Water pipes 41 16.1 (12.0– 21.0) 8 26.7 (13.5– 44.1) 33 14.7 (10.6– 19.8) .095 21 26.6 (17.8– 37.0) 19 14.3 (9.1– 21) 1 2.6 (0.3– 11.4) .003 IQOS 5 2.0 (0.8– 4.3) 2 6.7 (1.4– 19.7) 3 1.3 (0.4– 3.5) .049 2 2.5 (0.5– 7.9) 3 2.3 (0.6– 5.9) - - - .619 Cannabis 38 15.0 (11.0– 19.7) 5 16.7 (6.7– 32.7) 33 14.7 (10.6– 19.8) .780 15 19.0 (11.5– 28.7) 21 15.8 (10.4– 22.7) 1 2.6 (0.3– 11.4) .054 Number of cigarettes per day .659 <.001 <10 170 68.5 (62.6– 74.1) 21 72.4 (54.6– 86.0) 149 68.0 (61.7– 73.9) 61 81.3 (71.4– 88.9) 90 68.7 (60.4– 76.2) 16 41.0 (26.7– 56.6) 10– 19 59 23.8 (18.8– 29.4) 7 24.1 (11.5– 41.6) 52 23.7 (18.5– 29.7) 9 12.0 (6.1– 20.8) 33 25.2 (18.4– 33.1) 17 43.6 (28.9– 59.1) ≥20 19 7.7 (4.8– 11.5) 1 3.4 (0.4– 15.0) 18 8.2 (5.1– 12.4) 5 6.7 (2.6– 14.0) 8 6.1 (2.9– 11.2) 6 15.4 (6.7– 29) Heaviness of smoking index .776 .001 Low (0– 2) 182 83.9 (78.5– 88.3) 23 88.5 (72.3– 96.6) 159 83.2 (77.5– 88.0) 56 90.3 (81.1– 95.9) 102 86.4 (79.4– 91.7) 22 62.9 (46.3– 77.3) Medium and high (3– 6) 35 16.1 (11.7– 21.5) 3 11.5 (3.4– 27.7) 32 16.8 (12.0– 22.5) 6 9.7 (4.1– 18.9) 16 13.6 (8.3– 20.6) 13 37.1 (22.7– 53.7) Quit attempts in the last year .029 .093 Yes 66 30.1 (24.4– 36.4) 13 48.1 (30.3– 66.4) 53 27.6 (21.6– 34.2) 13 20.6 (12.1– 31.8) 43 36.1 (27.9– 45.0) 10 28.6 (15.7– 44.8) No 153 69.9 (63.6– 75.6) 14 51.9 (33.6– 69.7) 139 72.4 (65.8– 78.4) 50 79.4 (68.2– 87.9) 76 63.9 (55.0– 72.1) 25 71.4 (55.2– 84.3) Number of quit attempts .144 .764 1 24 36.4 (25.5– 48.4) 7 53.8 (28.3– 77.9) 17 32.1 (20.7– 45.3) 4 30.8 (11.4– 57.7) 17 39.5 (26.0– 54.4) 3 30.0 (9.3– 60.6) ≥2 42 63.6 (51.6– 74.5) 6 46.2 (22.1– 71.7) 36 67.9 (54.7– 79.3) 9 69.2 (42.3– 88.6) 26 60.5 (45.6– 74.0) 7 70.0 (39.4– 90.7) Are you seriously thinking about quitting now? .620 .002 Yes 179 81.7 (76.2– 86.4) 23 85.2 (68.5– 94.8) 156 81.3 (75.3– 86.3) 45 71.4 (59.5– 81.4) 98 82.4 (74.8– 88.4) 35 100 - No 40 18.3 (13.6– 23.8) 4 14.8 (5.2– 31.5) 36 18.8 (13.7– 24.7) 18 28.6 (18.6– 40.5) 21 17.6 (11.6– 25.2) - - - Are you thinking about cutting back consumption? .911 .064 Yes 140 63.9 (57.4– 70.1) 17 63.0 (44.2– 79.1) 123 64.1 (57.1– 70.6) 34 54.0 (41.7– 65.9) 78 65.5 (56.7– 73.6) 27 77.1 (61.5– 88.6) No 79 36.1 (29.9– 42.6) 10 37.0 (20.9– 55.8) 69 35.9 (29.4– 42.9) 29 46.0 (34.1– 58.3) 41 34.5 (26.4– 43.3) 8 22.9 (11.4– 38.5) Note: Significant values are highlighted in bold. Abbreviation: CI, confidence interval. aChi- square test (male vs. female). bChi- square test (≤19 vs. 20– 24 vs. ≥25). 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  11LAROUSSY et al. TA B L E 2  Tobacco use pattern among current smokers at follow- up (2018– 2019). All Sex p- valuea Baseline age group (years) p- valueb Male Female ≤19 20– 24 ≥ 25 n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI n % 95% CI Overall 256 100 30 100 226 100 79 100 135 100 39 100 Age of initiation .008 .820 <17 years 125 57.1 (50.5– 63.5) 9 33.3 (17.9– 52.1) 116 60.4 (53.4– 67.1) 34 54.0 (41.7– 65.9) 70 58.8 (49.9– 67.4) 20 57.1 (40.7– 72.4) ≥17 years 94 42.9 (36.5– 49.5) 18 66.7 (47.9– 82.1) 76 39.6 (32.9– 46.6) 29 46.0 (34.1– 58.3) 49 41.2 (32.6– 50.1) 15 42.9 (27.6– 59.3) Pattern of smoking .391 .001 Daily 163 63.7 (57.7– 69.4) 17 58.6 (40.6– 75.0) 146 66.7 (60.2– 72.7) 40 53.3 (42.1– 64.3) 88 67.2 (58.8– 74.8) 34 87.2 (74.2– 94.9) Nondaily 93 36.3 (30.6– 42.3) 12 41.4 (25.0– 59.4) 73 33.3 (27.3– 39.8) 35 46.7 (35.7– 57.9) 43 32.8 (25.2– 41.2) 5 12.8 (5.1– 25.8) Type of tobacco product consumed Manufactured cigarettes 204 79.7 (74.4– 84.3) 22 73.3 (55.9– 86.5) 182 80.5 (75.0– 85.3) .357 54 68.4 (57.6– 77.8) 114 84.4 (77.6– 89.8) 34 87.2 (74.2– 94.9) .008 Roll- your- own cigarettes 145 57.1 (50.9– 63.1) 18 60.0 (42.2– 76.0) 127 56.7 (50.2– 63.1) .731 55 69.6 (58.9– 78.9) 70 52.6 (44.2– 61.0) 19 48.7 (33.6– 64.0) .026 Cigars, cigarillos, little cigars 5 2.0 (0.8– 4.3) 1 3.3 (0.4– 14.5) 4 1.8 (0.6– 4.2) .567 3 3.8 (1.1– 9.8) 2 1.5 (0.3– 4.7) - - - .321 Electronic cigarettes 4 1.6 (0.5– 3.7) 1 3.3 (0.4– 14.5) 3 1.3 (0.4– 3.5) .410 1 1.3 (0.1– 5.8) 3 2.3 (0.6– 5.9) - - - .589 Water pipes 41 16.1 (12.0– 21.0) 8 26.7 (13.5– 44.1) 33 14.7 (10.6– 19.8) .095 21 26.6 (17.8– 37.0) 19 14.3 (9.1– 21) 1 2.6 (0.3– 11.4) .003 IQOS 5 2.0 (0.8– 4.3) 2 6.7 (1.4– 19.7) 3 1.3 (0.4– 3.5) .049 2 2.5 (0.5– 7.9) 3 2.3 (0.6– 5.9) - - - .619 Cannabis 38 15.0 (11.0– 19.7) 5 16.7 (6.7– 32.7) 33 14.7 (10.6– 19.8) .780 15 19.0 (11.5– 28.7) 21 15.8 (10.4– 22.7) 1 2.6 (0.3– 11.4) .054 Number of cigarettes per day .659 <.001 <10 170 68.5 (62.6– 74.1) 21 72.4 (54.6– 86.0) 149 68.0 (61.7– 73.9) 61 81.3 (71.4– 88.9) 90 68.7 (60.4– 76.2) 16 41.0 (26.7– 56.6) 10– 19 59 23.8 (18.8– 29.4) 7 24.1 (11.5– 41.6) 52 23.7 (18.5– 29.7) 9 12.0 (6.1– 20.8) 33 25.2 (18.4– 33.1) 17 43.6 (28.9– 59.1) ≥20 19 7.7 (4.8– 11.5) 1 3.4 (0.4– 15.0) 18 8.2 (5.1– 12.4) 5 6.7 (2.6– 14.0) 8 6.1 (2.9– 11.2) 6 15.4 (6.7– 29) Heaviness of smoking index .776 .001 Low (0– 2) 182 83.9 (78.5– 88.3) 23 88.5 (72.3– 96.6) 159 83.2 (77.5– 88.0) 56 90.3 (81.1– 95.9) 102 86.4 (79.4– 91.7) 22 62.9 (46.3– 77.3) Medium and high (3– 6) 35 16.1 (11.7– 21.5) 3 11.5 (3.4– 27.7) 32 16.8 (12.0– 22.5) 6 9.7 (4.1– 18.9) 16 13.6 (8.3– 20.6) 13 37.1 (22.7– 53.7) Quit attempts in the last year .029 .093 Yes 66 30.1 (24.4– 36.4) 13 48.1 (30.3– 66.4) 53 27.6 (21.6– 34.2) 13 20.6 (12.1– 31.8) 43 36.1 (27.9– 45.0) 10 28.6 (15.7– 44.8) No 153 69.9 (63.6– 75.6) 14 51.9 (33.6– 69.7) 139 72.4 (65.8– 78.4) 50 79.4 (68.2– 87.9) 76 63.9 (55.0– 72.1) 25 71.4 (55.2– 84.3) Number of quit attempts .144 .764 1 24 36.4 (25.5– 48.4) 7 53.8 (28.3– 77.9) 17 32.1 (20.7– 45.3) 4 30.8 (11.4– 57.7) 17 39.5 (26.0– 54.4) 3 30.0 (9.3– 60.6) ≥2 42 63.6 (51.6– 74.5) 6 46.2 (22.1– 71.7) 36 67.9 (54.7– 79.3) 9 69.2 (42.3– 88.6) 26 60.5 (45.6– 74.0) 7 70.0 (39.4– 90.7) Are you seriously thinking about quitting now? .620 .002 Yes 179 81.7 (76.2– 86.4) 23 85.2 (68.5– 94.8) 156 81.3 (75.3– 86.3) 45 71.4 (59.5– 81.4) 98 82.4 (74.8– 88.4) 35 100 - No 40 18.3 (13.6– 23.8) 4 14.8 (5.2– 31.5) 36 18.8 (13.7– 24.7) 18 28.6 (18.6– 40.5) 21 17.6 (11.6– 25.2) - - - Are you thinking about cutting back consumption? .911 .064 Yes 140 63.9 (57.4– 70.1) 17 63.0 (44.2– 79.1) 123 64.1 (57.1– 70.6) 34 54.0 (41.7– 65.9) 78 65.5 (56.7– 73.6) 27 77.1 (61.5– 88.6) No 79 36.1 (29.9– 42.6) 10 37.0 (20.9– 55.8) 69 35.9 (29.4– 42.9) 29 46.0 (34.1– 58.3) 41 34.5 (26.4– 43.3) 8 22.9 (11.4– 38.5) Note: Significant values are highlighted in bold. Abbreviation: CI, confidence interval. aChi- square test (male vs. female). bChi- square test (≤19 vs. 20– 24 vs. ≥25). 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 12  |    LAROUSSY et al. TA B L E 3  Predictors of smoking cessation in a cohort of nursing students according to baseline characteristics and smoking status. Recent quittersa n % p- value Adjusted ORb and 95% CI Overall 78 28.3 Sex .212 Male 13 37.1 1.38 (0.63– 3.05) Female 65 27.0 1.00 Age groupc .191 1.01 (0.96– 1.08) ≤19 years 30 34.1 20– 24 years 32 23.4 ≥25 years 15 31.3 Year in nursing school .906 First 28 28.3 Second 21 31.3 Third 15 25.4 Fourth 13 27.7 Place of birth .146 Catalonia 61 26.3 Outside of Catalonia 14 37.8 Location of nursing school .075 Barcelona 62 26.3 Outside of Barcelona 16 40.0 Type of nursing school .201 Public 29 31.9 Private with public funding 13 19.7 Private 36 30.3 Age of initiation .614 <17 years 49 26.8 ≥17 years 27 29.7 Reason why they initiated smoking Having peer/family smoker 48 26.7 .421 Other 53 27.5 .653 Reason why they currently smoke For reducing stress/relaxing 32 21.5 .006 For pleasure 51 26.6 .314 Other 34 25.4 .301 Baseline smoking status <.001 Nondaily smoker 48 45.3 3.86 (2.19– 6.82) Daily smoker 30 17.6 1.00 Type of product used .222 Only manufactured and/or roll- your- own cigarettes 59 30.4 Manufactured and/or roll- your- own cigarettes + other/s 19 23.2 Number of cigarettes per day <.001 <10 48 41.4 10– 19 16 18.2 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  13LAROUSSY et al. the same time highlighting the need to intervene massively among college students to reduce tobacco product consumption and their negative consequences. The university setting could be a perfect time to prevent tobacco use initiation and to reinforce the observed quitting trends through targeted strategies for college students. The current evidence recommends the use of comprehensive tobacco control programs to address multiple components, such as policy, education and cessation programs (Centers for Disease Control and Prevention, 2014). The implementation of these comprehen- sive tobacco control programs has proven successful in decreas- ing the prevalence of tobacco use and SHS exposure among U.S. young adults (Centers for Disease Control and Prevention, 2014). The American Nonsmokers' Rights Foundation developed a Comprehensive Tobacco Control Program (CTCP) model, designed for college students, that encompasses several factors that influence tobacco behaviors in this population. It includes (i) the implemen- tation of tobacco- free campus policies, (ii) restriction of tobacco sales, advertising, and promotion, (iii) tobacco prevention interven- tions and (iv) tobacco cessation programs (American Nonsmokers' Rights Foundation, 2008). The implementation of this program in nursing universities may be effective in encouraging smoking ces- sation among nursing students and in reinforcing the already ob- served decrease in smoking. We consider that tobacco- free campus policies should also ban the use of alternative tobacco and nicotine products since they frequently contain nicotine. As well, tobacco prevention interventions should be offered to first year students, since first year' students are the most likely to use tobacco products. Moreover, the use of online methods, such as social media, univer- sity virtual campus platforms and text messages, in tobacco pre- vention and cessation programs may increase their effectiveness (Berg et al., 2014; Müssener et al., 2016). Finally, monitoring tobacco product use among nursing students could help to customize the last cited intervention for specific groups and products according to its predictors of initiation or cessation. More research is needed to evaluate the implementation of these strategies on nursing students in Spain. 4.1  |  Limitations and strengths The main limitation of this study is the potential bias due to at- trition of the cohort of participants. In this regard, participants lost to follow- up were more likely to be male, aged ˃20 years, and current smokers at baseline (Laroussy et al., 2022). Furthermore, even with the large number of participants at baseline, the small number of participants at follow- up made it difficult to analyse pre- dictors of all smoking status transitions. Despite the wide range of tobacco and nicotine products explored, we only included MF and RYO cigarettes in the definition of smoker, because these are the main products consumed in Spain. This decision may have re- duced the number of participants identified as smokers. As previ- ously explained, due to the voluntary nature of the participation in the follow- up, some selection bias is possible, as those agree- ing to be followed up could be the participants with greater health Recent quittersa n % p- value Adjusted ORb and 95% CI ≥20 14 19.4 Heaviness of smoking index .036 Low (0– 2) 62 32.0 Medium and high (3– 6) 16 19.5 Number of quit attempts in the last year .557 0 57 27.8 1 10 33.3 ≥2 7 21.2 Are you seriously thinking about quitting now? .823 Yes 11 29.7 No 64 27.9 Are you thinking about cutting back consumption? .026 Yes 34 22.5 No 41 34.7 Note: Significant values are highlighted in bold. Abbreviations: CI, confidence interval; OR, odds ratio. aCompared with “continued as smokers” (n = 198). bOR adjusted for sex, baseline age and baseline smoking status. cContinuous variable. TA B L E 3  (Continued) 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 14  |    LAROUSSY et al. awareness and greater likelihood of being nonsmokers. This fact might have accounted for the low prevalence of new smokers at follow- up. A notable limitation of this work is the fact that we were not able to assess all quitting predictors that have been described in the literature. The most relevant absences are: social environ- ment, perceived addiction and self- efficacy to quitting smoking. However, we have included several individual and contextual vari- ables that are important for studying transitions in smoking among college students such as sex, age and several characteristics that describe baseline smoking status (frequency of use, type of to- bacco product, number of CPD, HSI and more). This study is, to the best of our knowledge, the first longitudinal research in Europe that has addressed the transitions in smoking status and its predic- tors among nursing students. Finally, data were collected through a self- report questionnaire and, therefore, are vulnerable to recall bias regarding smoking status. TA B L E 4  Baseline characteristics of the participants who had started to smoke at follow- up. New smokersa p- valuen % Overall 29 4.6 Sex .911 Male 3 4.9 Female 26 4.6 Age groupb .176 ≤19 years 15 5.7 20– 24 years 13 4.3 ≥25 years - - Year in nursing school .625 First 13 5.8 Second 5 3.1 Third 6 5.1 Fourth 4 3.9 Place of birth .087 Catalonia 27 5.4 Outside of Catalonia 2 1.7 Location of nursing school .523 Barcelona 24 4.9 Outside of Barcelona 5 3.6 Type of nursing school .737 Public 12 4.0 Private with public funding 5 4.8 Private 12 5.4 aCompared with “continued as never smokers” (n = 597). bContinuous variable. TA B L E 5  Baseline characteristics of the participants who had relapsed at follow- up. Quitters who relapseda p- valuen % Overall 29 23.2 Sex .168 Male 5 38.5 Female 24 21.4 Age groupb .409 ≤19 years 6 21.4 20– 24 years 17 28.3 ≥25 years 6 16.7 Year in nursing school .703 First 6 16.7 Second 9 28.1 Third 7 25.9 Fourth 6 24.0 Place of birth .618 Catalonia 20 22.2 Outside of Catalonia 8 26.7 Location of nursing school .523 Barcelona 24 24.5 Outside of Barcelona 5 18.5 .515 Type of nursing school Public 8 16.7 Private with public funding 8 33.3 Private 13 24.5 Age of initiation .317 <17 years 22 26.8 ≥17 years 7 18.4 Age of cessation .561 <19 years 10 20.4 ≥19 years 17 25.0 Reason why they quitted smoking To protect my health 23 23.0 .895 To save money 9 26.5 .687 Other 13 22.4 .701 Use of any treatment to quit smoking 1.000 Yes 1 20.0 No 28 24.1 aCompared with “continued as former smokers” (n = 96). bContinuous variable. 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on W iley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License     |  15LAROUSSY et al. 5  |  CONCLUSIONS Smoking nondaily (either MF or RYO cigarettes) was the main pre- dictor of quitting in a cohort of Spanish nursing students in the Catalonia region. Less than 5% of participants had started smoking at follow- up and just under a quarter of former smokers had relapsed. Early implementation of a comprehensive tobacco control program that includes tobacco- free campus policies, restriction of tobacco sales, advertising, and promotion, tobacco prevention interventions and tobacco cessation programs may be effective in decreasing to- bacco product use prevalence among nursing students. The use of online tools and monitoring tobacco product use may increase its effectiveness. AUTHOR CONTRIBUTIONS Kenza Laroussy, Esteve Fernández and Cristina Martinez: Conceptualization, Investigation, Methodology, Writing— Original Draft. Yolanda Castellano: Formal analysis and Data curation. Marcela Fu: Validation. Antoni Baena and Jon Aldazabal: Software. Ariadna Feliu: Writing— Review and Editing. Mercè Margalef: Project administration. Olena Tigova: Visualization and Writing— Review and Editing. Jordi Galimany: Supervision. Montserrat Puig: Supervision. Carmen Moreno: Resources and Funding acquisition. Albert Bueno: Supervision. Antonio López: Supervision. Judith Roca: Writing— Review and Editing. All authors have agreed on the final version and meet at least one of the following criteria (recom- mended by the ICMJE [http://www.icmje.org/recom menda tions/]): Substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; Drafting the article or revising it critically for important intellectual content. ACKNO WLE DG E MENTS The authors would like to thank the participants for contributing to the study, the deans and faculty of the participating university schools in Catalonia for facilitating the fieldwork, Alba Sanchez for collaborating in the fieldwork and Susan Frekko for editing the English. FUNDING INFORMATION This work was partially supported by the Consell de Col·legis d'Infermeres i Infermers de Catalunya (CCIC) and a REDICE18 fel- lowship from the University of Barcelona. The Tobacco Control Unit was funded by the Government of Catalonia (Directorate of Research and Universities grant 2021SGR906). CONFLIC T OF INTERE S T S TATEMENT No conflict of interest has been declared by the author(s). PEER RE VIE W The peer review history for this article is available at https:// www.webof scien ce.com/api/gatew ay/wos/peer- revie w/10.1111/ jan.15665. DATA AVAIL ABILIT Y S TATEMENT Data available on request from the corresponding author. At this moment, we have decided not to do it since most of the analysis have not been performed by the research team. Nonetheless, if the editor or reviewers want to browse our database, we can provide an encrypted and protected access through an online file. ORCID Kenza Laroussy https://orcid.org/0000-0002-8920-4039 Yolanda Castellano https://orcid.org/0000-0003-4452-305X Marcela Fu https://orcid.org/0000-0002-4962-0927 Antoni Baena https://orcid.org/0000-0001-9221-8784 Ariadna Feliu https://orcid.org/0000-0002-0033-9026 Armando Peruga https://orcid.org/0000-0002-1138-3292 Mercè Margalef https://orcid.org/0000-0001-8427-1403 Jon Aldazabal https://orcid.org/0000-0002-1641-2275 Olena Tigova https://orcid.org/0000-0002-4002-116X Jordi Galimany https://orcid.org/0000-0002-2538-3787 Montserrat Puig https://orcid.org/0000-0002-3893-4488 Carmen Moreno https://orcid.org/0000-0001-8771-5129 Albert Bueno https://orcid.org/0000-0002-8374-0690 Antonio López https://orcid.org/0000-0002-0417-3764 Judith Roca https://orcid.org/0000-0002-0645-1668 Judith Saura https://orcid.org/0000-0003-3700-0293 Esteve Fernández https://orcid.org/0000-0003-4239-723X Cristina Martínez https://orcid.org/0000-0002-0108-3288 T WIT TER Kenza Laroussy @KenzaLaroussy Esteve Fernández @StvFdz Cristina Martínez @CrisMarMar R E FE R E N C E S Alamar, B., & Glantz, S. 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Journal of Advanced Nursing, 77(7), 2957– 2970. https://doi. org/10.1111/jan.14783 SUPPORTING INFORMATION Additional supporting information can be found online in the Supporting Information section at the end of this article. How to cite this article: Laroussy, K., Castellano, Y., Fu, M., Baena, A., Feliu, A., Peruga, A., Margalef, M., Aldazabal, J., Tigova, O., Galimany, J., Puig, M., Moreno, C., Bueno, A., López, A., Roca, J., Saura, J., Fernández, E., & Martínez, C. (2023). Transitions in smoking status in nursing students: A prospective longitudinal study. Journal of Advanced Nursing, 00, 1–17. https://doi.org/10.1111/jan.15665 13652648, 0, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1111/jan.15665 by Readcube (Labtiva Inc.), W iley Online Library on [31/05/2023]. 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