Abstract
BACKGROUND: Tobacco smoking is a leading cause of morbidity and mortality worldwide, responsible for about 61,300 deaths annually in Italy. In addition to tobacco cigarettes, the use of electronic cigarettes (e-cigs) and heated tobacco products (HTPs) has increased among young people, raising public health concerns. This study aimed to investigate smoking habits, exposure to passive smoke, and awareness of health risks among Italian university students. METHODS: A multicentre observational survey was carried out by 8 Italian Universities to promote smoke-free lifestyles among students. All students were sent an anonymous online questionnaire via email regarding their smoking habits, their exposure to second-hand smoke, and their knowledge of, and opinions on, smoking. Descriptive statistics and multinomial logistic regression models were applied to assess associations between tobacco and nicotine use with sex and areas of study. RESULTS: A total of 20,644 students from different study areas were included in the study: 62.3% did not smoke, 9.9% were former smokers, 14.4% were smokers of tobacco cigarettes exclusively, 6.5% of e-cigs or HTPs, and 6.9% were dual smokers (total smokers 27.8%). Smoking prevalence was highest among Law (35.9%) and Economics (33.7%) students, and lowest among Medicine and Sciences and Technology students (22%). Males were more likely to smoke tobacco or to be dual users, while females reported higher e-cig use; most smokers consumed fewer than 10 cigarettes/day with mild nicotine dependence. Among e-cig/HTP users, over 60% started as an alternative to cigarettes, but 22% started or resumed tobacco smoking after using them and 22% had never smoked tobacco cigarettes before. Passive smoke exposure was common: 26.5% lived with smokers and 58.9% reported peer exposure. While nearly all students recognized the harms of both active and passive tobacco smoking, only 60% considered passive exposure to e-cigs/HTPs as dangerous. About 70% were favourable to stricter enforcement of university smoking bans. Conclusions: Traditional cigarettes remain the most used product among Italian university students, but e-cigs and HTPs are increasingly widespread and socially accepted, even among never smokers. Awareness of the risks of alternative products is limited, and passive exposure remains underestimated. These findings underline the importance of targeted educational campaigns and stronger enforcement of smoke-free policies in academic settings. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-026-26840-4.