Uruguayan secondary school students speak up about tobacco: results from focus group discussions in and around Montevideo

Abstract

This qualitative research study investigated intrapersonal, interpersonal, and environmental factors that shape young adolescent tobacco use behaviors in Uruguay. Focus groups were conducted in the summer of 2012 and fall of 2013 in four secondary schools in Montevideo, Uruguay, including two private schools and two public schools. A total of four focus groups were led in each school, composed of 4–6 students each, 16 focus groups in total. Data analysis utilized NVivo software and included deductive and inductive content analysis. Overwhelmingly, students reported that the onset of smoking occurred in the second year of secondary school. The primary intrapersonal factors that were found to be universal among respondents identified that smoking was a performance in groups, to garner attention from their peers. Students interviewed most often stated that the greatest interpersonal factors for smoking were to look older, as a rite of passage, and for group membership. Environmental factors cited most often indicate that they smoked during unsupervised time, either at night or around the short Uruguayan school day. Focus group interviews revealed that adolescents had easy access to cigarettes for purchase through small family owned grocery stores, even though laws exist preventing the sale of cigarettes to minors. Few differences were cited between strata related to cigarette use in adolescents. The differences that do exist are most apparent across gender, though there were a few observed differences when stratified by public and private school. Findings from this study indicate that key factors across ecological levels (intrapersonal, interpersonal, and environmental) should be taken into consideration when designing tobacco prevention programs for youth in Uruguay. A multiple-component approach which addresses risk factors at all of these levels, implemented in schools, may be particularly well-suited to this setting.

Introduction

In 2006, Uruguay became a world leader in tobacco control when it became the first middle-income country worldwide and the first country in Latin America to institute comprehensive anti-tobacco legislation (1). The government created a National Program for Tobacco Control, banning tobacco advertising, smoking in enclosed public spaces, the sale or distribution of e-cigarettes, increasing taxes on tobacco products, and requiring graphic warnings to cover 80% of cigarette packages (2,3). Among adults, male and female smoking prevalence dropped from 39.6% to 30.0% in 2005 and from 29.6% to 22.0% in 2012, respectively (4). These policies have been so effective that Philip Morris filed suit against the country in an attempt to fight these laws (5,6). This proved unsuccessful, however, and the World Bank’s International Centre for Settlement of Investment Disputes ruled in Uruguay’s favor in 2016 (7).

In addition to these positive changes for adults, adolescent smoking prevalence decreased by 8.0% from 2003 to 2009, a dramatic difference when compared with the 2.5% drop in Argentina over the same time period (2). By 2014, 26.4% of Uruguayan adolescents (ages 13–17) reported they had ever tried smoking cigarettes, 15.5% smoked in the past year, and 9.2% smoked in the past month (8). Past month smoking prevalence for Uruguayan adolescents now represents the median prevalence for Latin America, where the range is 4.3% in Panama to 20.5% in Ecuador (9). When compared to adolescents in the US, the prevalence of smoking remains high. For example, in 2014, 4.9% of US 12–17 year olds reported past month smoking, about half of that observed in Uruguay (10).

There is also a historical discrepancy in rates of smoking between genders in Uruguayan adolescents that are not matched in their peers in the US. In 2014, 8.5% of adolescent males and 9.8% of adolescent females in Uruguay smoked in the past month (8). While differences in smoking between males and females have narrowed since 2007 when 16.4% of males compared with 22.9% of females aged 13–15 reported past month cigarette use, females in Uruguay still report higher rates of smoking compared to their male counterparts (11). Though tobacco control regulation in Uruguay appears to be reducing adolescent cigarette use, additional strategies may be necessary to help Uruguay reach ‘the endgame’ of tobacco use, a state in which countries can begin planning not just for tobacco control, but for a tobacco free future (12). Further research on differences and similarities in risk factors for smoking among adolescent males and females holds the potential to inform tobacco prevention strategies, such as school-based programming. Such programs, when coupled with Uruguay’s regulatory momentum against tobacco, could lower adolescent smoking even further.

Secondary school students in Uruguay spend four to six hours a day, six days a week, in school. This represents a significant period of time for adolescents and one reason school-based interventions are reasonable to consider. Also, afterschool programming may be a helpful addition to any school-based program, given the amount of unsupervised time during these hours (13). In Uruguay, most students attend public schools, though wealthier parents may send their children to private schools. Examining differences between public and private school students can act as a proxy for socioeconomic status, which may mitigate adolescent smoking prevalence (14). Private schools have lengthier school days than public schools, as well as a greater number of activities offered outside of class. This could result in differential tobacco uptake, since unsupervised time could allow students in public schools to engage in risky behaviors more often, smoking included (15,16).

Research shows that school-based programs that are based on a social influences model, use multiple components, and employ interactive delivery methods can effectively reduce cigarette smoking among school-aged adolescents (17,18). To date, however, few school-based tobacco programs have been implemented in Uruguay or elsewhere in Latin America (19,20). At present, we are working to design, implement, and evaluate a school-based tobacco prevention program for Uruguay, called ¡Activate Ya!. However, little research exists on risk factors for adolescent cigarette smoking specific to Uruguay and in Latin America (21–25) which can be used to develop a grounded understanding of adolescent cigarette smoking and therefore appropriately construct such a program. An initial step in this process must therefore be to conduct etiologic research; qualitative studies are useful in this regard (26,27).

The purpose of this paper is to present the results of a qualitative needs assessment designed to inform the development of ¡Activate Ya!, a multiple component school-based intervention program to prevent the onset of smoking among adolescents recently created for use in this context. This intervention is a randomized, controlled trial in which half of participating schools will receive the intervention over the course of two years to evaluate the program’s efficacy in comparison with control schools. ¡Activate Ya! is funded by the National Institutes of Health in the US, as part of the TOBAC program (28).

Using a qualitative research design, we explored intrapersonal, interpersonal, and environmental factors that shape young adolescent (12–16 year olds) tobacco use behaviors in Uruguay. These types of factors have been found to be theoretically and empirically reliable predictors of adolescent tobacco initiation (17). Intrapersonal factors are those which are characteristics of an individual and include intrinsic reasons to use tobacco. Interpersonal factors are influenced by social situations, and include modeling by peers, family, and at school. Environmental factors are those that are found in an individual’s surroundings and include tobacco modeling in the movies, advertising and access to tobacco. In assessing these factors, we explored themes across school type (public and private) and gender (male and female).

Methods

Study design

This study is a qualitative case study by design. Focus groups were conducted as the first phase of ¡Activate Ya! to inform the development of this intervention and ensure the appropriateness of its conceptual model (26). Sixteen focus groups across four schools (two public and two private) were conducted in 2012 and 2013.

Recruitment and eligibility

Participants were Montevideo students enlisted in ‘ciclo básico’ 1 and 2 (1° and 2° cycles), or the equivalent of 7th and 8th grades in the US. Most students in these classes were aged 12–14, though there were students as old as 16. Students were recruited using flyers that were distributed in the study schools along with active consent forms. Participants received sandwiches and juice boxes for their attendance in the focus groups.

Active consent was provided by parents who completed forms granting permission for their children to participate in the study. In order to be eligible, students gave assent by either signing a written assent form or giving verbal assent. In addition, inclusion criteria included being aged 12 through 16 at the time of the interviews; being Montevideo residents; communicating in Spanish; and willing to share their opinion about adolescents and tobacco.

Data collection

Interviews were conducted via focus groups in four middle schools. Two of these schools were inner city private schools, while the other two schools were public schools located on opposite outskirts of the city. A convenience sample of schools was selected prior to implementation of the ¡Activate Ya! intervention study sample with the aim of generating insights from private and public school students on tobacco use. Interviews were conducted in the summer of 2012 in the private schools, and the fall of 2013 in the public schools. Each focus group session lasted approximately one hour. The interviews were audio recorded, and notes were taken concurrent with the interviews.

Following best practice guidelines (29), the aim was to conduct four focus groups per school with six participants each, stratified by gender and grade in order to create more homogenous groups and to allow for comparison across these factors (see Table 1). A total of 81 students participated in 15 focus groups conducted in four schools. Interviews took place outside of school time, which may have influenced students’ desire to participate. The other public school had an actual total enrollment lower than the target due to a teacher absence during one of the interview days.

Table 1.

Focus group participant enrollment by school, Montevideo, Uruguay, ¡Activate Ya! study, Summer 2012–Fall 2013.

	Private school (high SES)	Private school (middle SES)	Public school (middle SES)	Public school (low SES)
1° cycle	6 boys	5 boys	4 boys	6 boys
	6 girls	6 girls	4 girls	6 girls
2° cycle	6 boys	6 boys	0 boys	4 boys
	6 girls	6 girls	4 girls	6 girls
Total	24	23	12	22	81
	4 groups	4 groups	3 groups	4 groups	15 groups

Focus group guides

The focus groups were led by trained investigators utilizing a semi-structured interview guide to drive discussion. These guides focus on exploring modifiable risk factors of adolescent tobacco use. The guides were refined from the private school focus groups in 2012 to those for the public school focus groups in 2013, but the major discussion categories remained comparable. Questions and probes were informed by constructs from social cognitive theory (30), theory of reasoned action, and theory of planned behavior (31). The questions are open ended and developed to: (a) describe initiation and continued use of tobacco; (b) describe intrapersonal, interpersonal, and environmental factors that can both promote and dissuade smoking; and (c) identify smoking prevention strategies that would resonate with adolescents. In order to determine the factors for adolescent smoking, we asked students to tell us (a) reasons why adolescents smoke (intrapersonal factor); (b) who they smoke with, when they smoke, from whom they learned to smoke (interpersonal factors); and (c) where they get messages about smoking, and how they get access to cigarettes (environmental factors).

Data analysis

The data were analyzed using NVivo 10 QSR International software (32) for qualitative inductive analysis. For the current study, a constant comparison analysis was conducted. This has been an effective approach with NVivo software for qualitative analysis (33), involving three steps: first, chunking data into manageable units and coding; second, grouping these coded data into categories; and third, developing themes for these categories. This allows a researcher the ability to assess similarities and differences in themes across different groups (34). Datasets were then compiled in order to analyze the data based upon school type and gender.

Ethical considerations

The original study upon which this research is based was reviewed and approved by the Committee for the Protection of Human Subjects at the University of Texas Health Science Center School of Public Health in the US, and the Centro de Investigación de la Epidemia de Tabaquismo in Uruguay. Researchers were certified in the Protection of Human Subjects through the Collaborative Institutional Training Initiative before the project began.

Participant privacy and confidentiality were ensured through conducting interviews in closed rooms. The discussions were confidential, and audio files were stored in a password protected computer. No names of students or schools were included in the analysis of the data.

Results

The analysis of the themes discussed here were examined upon the basis of gender (male vs. female) and school type (private vs. public) Overall, few differences in themes between public and private school students were noted, although small differences did arise between male and female participants. Wherever disparities did emerge, they were reported within the appropriate theme.

Smoking initiation

Most students reported that adolescents begin smoking around age 13, or sometime in 2° cycle: ‘it’s normal to start in middle school’ (Males, High SES, Private School, 2° cycle). One focus group reported that a few students started smoking earlier, but that more begin to smoke in each subsequent year. They start ‘during the first year of middle school, generally … then more in second, and more in third … in fourth a lot’ (Females, High SES, Private School, 1° cycle). Those starting earlier were described to be less affluent or to have family problems. ‘Kids that have a milkman for a father, or who beg, they gather cigarette butts and go smoking. They’re small children, 8 years old’ (Females, High SES, Private School, 2° cycle). In another school, students stated that most often adolescents began to smoke at 14, 15, or even 17 and 18. But that ‘I know a few girls who smoke at 12’ (Males, Low SES, Public School, 1° cycle).

Smoking behavior

Participants described the frequency of tobacco consumption by individuals that smoke at 12 or 13 years of age as high. ‘The ones that smoke, smoke very frequently’ (Males, High SES, Private School, 2° cycle), explained one boy. Girls interviewed qualified that smoking frequency was determined by the method of smoking. They stated that ‘when they smoke together, they smoke more’ and ‘those who smoke start with a pack a week or less’ (Females, High SES, Private School, 1° cycle).

Both boys and girls reported that students their age most commonly smoke in groups ‘with friends’ (Males, Middle SES, Public School, 1° cycle). They state that smoking with friends exerts pressure to smoke. ‘If you have a person that does it just for attention, or because friends pressured him, he’s not going to smoke alone. Maybe he doesn’t even have cigarettes. He smokes because others gave them to him’ (Females, High SES, Private School, 2° cycle). Multiple interviews revealed that students believe individuals smoke more when they are in groups than if they were smoking alone. ‘I think that when they are in groups, they want to smoke a lot’ (Females, Middle SES, Private School, 1° cycle). These groups smoke in public places – most often in parks or on the street so that their members receive the ‘benefit’ of smoking: appearing older and receiving attention. ‘I think that group smoking is more a social thing … because you’re going to do it so people can see you’ (Males, High SES, Private School, 2° cycle).

After smoking at night (e.g. at previas, or parties), the second most cited event at which adolescents use cigarettes is ‘when they escape the school’ (Females, Low SES, Public School, 2° cycle). Most students report that peers smoke after school: ‘inside the school they can’t smoke, then when the bell rings and they go outside the school, the first thing they do is to take out a cigarette and start smoking. And you see them smoking at the school entrance, which is supposed to be prohibited’ (Males, High SES, Private School, 2° cycle). Not only does this occur on the streets, but also at home. Most adolescents live in homes where both parents work, and so the short school day provides them substantial unsupervised time in their houses. This allows students to smoke during the day, when parents are working and no one is home (Males, Middle SES, Private School, 1° cycle).

Intrapersonal risk factors

The most common reason adolescents gave for smoking was for attention, literally ‘to be seen’. One of the students stated that smoking is a ‘performance’ done in order to ‘accomplish’ a social objective (Females, High SES, Private School, 1° cycle). Students believe that the primary reason for smoking is done for popularity (Males, Middle SES, Public School, 1° cycle), to be ‘seen by others’ (Females, Middle SES, Private School, 1° cycle). Multiple interviews reveal the recurrent theme: ‘those who smoke do it to be seen’ (Males, Middle SES, Private School, 1° cycle) or ‘to call attention to themselves’ (Females, Low SES, Public School, 1° cycle).

Furthermore, boys speculated that when girls smoke, it is so that boys notice them. While boys said that other boys smoked in order to ‘look tough’, girls thought that other girls smoked in order to ‘look cute’. Both boys and girls in one focus group thought that another reason girls smoke is for weight loss, though two groups interviewed did not believe that this was a factor.

Many students believed that those who smoked did so in order to follow trends. They thought others did so in order to be part of a group, ‘they do it just because it’s the trend’ (Males, High SES, Private School, 2° cycle). More boys than girls mentioned that they believed smoking was done in order to be part of a group, ‘because it’s a custom’ (Males, Low SES, Public School, 2° cycle). Boys may be more susceptible to peer pressure than girls, as discussed in more depth later.

Interpersonal risk factors: peers

While both boys and girls reported peer modeling as a cause for smoking, it appears to develop differently for each gender. For females, smoking is done in order to emulate those who are important to them: ‘[you start smoking] when you see someone smoking … to increase the personal connection’ (Females, High SES, Private School, 2° cycle). Another group supported this statement, clarifying that principally smoking is learned from ‘friends … or a relative, like a cousin’ (Females, Low SES, Public School, 2° cycle). Boys, on the other hand, seem to be motivated more by older individuals, regardless of whether they have a relationship with these older students. They learn from ‘people on the street’ (Males, Middle SES, Private School, 1° cycle) in addition to friends.

Peer pressure as a motivator for smoking was a strong theme that arose in all focus group interviews. Students across all strata reported that friends can goad adolescents into smoking when they otherwise might not. However, pressure may be exerted in a different manner between genders. Boys expressed that friends are ‘sometimes the ones who smoke … can make you feel bad if you do not smoke … Friends will say, “Go on, smoke, smoke!”’ (Males, High SES, Private School, 1° cycle). Boys stated that their peers are vocal and use taunting tactics to pressure them into smoking. Girls, on the other hand, expressed a more subtle way in which their friends influence them to smoke. Rather than by force, girls will ‘offer a cigarette, and they don’t know how to say no’ (Females, High SES, Private School, 1° cycle).

Interpersonal risk factors: family

Problems in families are reported to be the single most contributing factor for adolescents to smoke alone. These include family dysfunction, parental separation or divorce, or domestic violence. ‘You do it to go against your parents, I know people who do it because of that’ (Females, Middle SES, Public School, 1° cycle). The reason for the behavior is not to socialize, like within the peer factors. ‘If you do it (smoke) alone, then you can also have problems in your family in the social aspect’ (Males, High SES, Private School, 2° cycle). Not only do these issues impact the manner in which adolescents smoke, but they also have an effect on the quantity smoked. One interviewee clarified that the quantity of cigarettes smoked ‘depends on the problems. If you have a very concerning situation at home you can smoke a pack a week maybe. A lot’ (Females, High SES, Private School, 1° cycle).

Interpersonal risk factors: school

Most interviews brought up an association between smokers and academically poor students. Students of high socioeconomic status all reported the perception of smokers to be ‘students that are not doing so well in school, the ones that don’t care about their studies or anything. The irresponsible ones’ (Males, High SES, Private School, 2° cycle). There was also one mention of causative influence: ‘I do poorly and then I smoke’ (Females, High SES, Private School, 1° cycle). It is important to mention that in discussions over this topic, adolescents reported tendencies; they do not believe that this is always the case. A middle socioeconomic status group exclusively stated that there was no relationship between grades and smoking. ‘Smokers aren’t always doing badly. You can be a person that does well at school’ (Females, Middle SES, Private School, 2° cycle).

Environmental factors

While all student groups stated that smoking in movies ‘may catch attention’ (Males, Middle SES, Private School, 1° cycle), girls appear to be more receptive to this messaging than boys. Girls overwhelmingly clarified: when people are shown smoking in movies, ‘you want to be like him and smoke’ (Females, Middle SES, Private School, 2° cycle). All girls who spoke of movies expressed interest in imitating smoking behavior of characters perceived as ‘cool’, while boys were more likely to state that although they noticed smokers in movies, ‘that doesn’t encourage you to smoke’ (Males, Middle SES, Private School, 2° cycle).

For students who want to smoke, obtaining cigarettes is not difficult. Since selling tobacco products to minors is illegal in Uruguay, commercial access to cigarettes should be a deterrent to minors who wish to smoke. The legal age to purchase cigarettes ‘is 18 and up. But there are small stores that can sell them to you anyway. As long as they make money, they’ll sell you alcohol, cigarettes…’ (Males, High SES, Private School, 2° cycle). It is so easy for students to buy their own cigarettes, that students are much more likely to purchase cigarettes than utilize another method of procurement. All focus groups described that small family run stores sell cigarettes to minors, and only one made mention of being turned away: ‘for example, the small store over here doesn’t sell them to me because I’m a minor’ (Males, Low SES, Public School, 2° cycle).

Discussion

Implications for intervention

Uruguay has been an important leader in tobacco control locally and globally, and smoking prevention efforts targeted at adolescents hold potential to further support Uruguay in reaching ‘the endgame,’ moving beyond tobacco control to a tobacco free future(12). Given the limited research on intrapersonal (i.e. reasons to use), interpersonal (i.e. peer, family, and social influences), and environmental (i.e. access to tobacco) domains that may influence tobacco use among young people in Uruguay, the current study aims to inform tobacco prevention efforts by exploring factors that shape tobacco use in young adolescents. Our findings suggest risk factors for adolescent tobacco use share similarities with risk factors identified for US (17,35) and other Latin American adolescent populations (21–25). This provides support for exploring tobacco intervention strategies that have been found to be effective in the US and elsewhere that could be translated and tailored for the Uruguayan context and implemented effectively elsewhere in Latin America.

Currently, school-based health education efforts are limited in Uruguay and elsewhere in Latin America for tobacco prevention or other risk factors (e.g. physical activity, nutrition) relevant to adolescents. In 2004, results of a school-based educational program showed that an intervention utilizing lectures, reading and discussion, increased knowledge about the dangers of smoking, but did not show efficacy in decreasing tobacco use. The authors state that this intervention could have benefited from a community approach over a longer timeframe (20). ¡Activate Ya! addresses these limitations, and utilizes an ecological approach.

Based on our findings, we developed ¡Activate Ya! to include two primary components specific to tobacco that can fit both within and outside of school context: (a) a 12 session curriculum implemented during open period (Espacio Curricular Abierto) in schools; and (b) a 12 session after-school program, called Espacio Adolescente. Both components seek to change interpersonal and environmental risk factors that support smoking by adolescents and intrapersonal factors that increase their susceptibility to smoking (17). ¡Actívate Ya! seeks to decrease opportunities to smoke; strengthen social norms against smoking by adolescents; and provide social support to encourage adolescents to avoid smoking. ¡Actívate Ya! will also reinforce negative consequences of smoking; clarify reasons why young people should not smoke and identify alternatives to reasons why some do; as well as boost adolescent self-efficacy to avoid smoking.

Uruguay’s Junta Nacional de Drogas y Observatorio Uruguayo de Drogas has found the average age of tobacco initiation to be low (age 13) for adolescents 12–17 years of age (8), consistent with student reports in focus groups. Our interviews revealed that those who smoked at a young age smoked often. This association between age and smoking experience is corroborated in the analysis of the Pelotas birth cohort in Brazil (36). In addition, respondents noted a positive association between age and increased frequency of smoking, consistent with analyses of smoking trends in the US (17). To address these issues, ¡Activate Ya! will be aimed at adolescents prior to initiation, which may be especially important for those of lower socioeconomic status attending public schools.

Unsupervised time, a factor identified in our focus groups as associated with smoking, has also been associated with risk taking behaviors in Brazil (22). In the current study, interviewees stated that the most common times adolescents smoked were during unsupervised times, like after school. In Brazil, poor parental supervision was found to be a contributing factor to adolescent tobacco use (22). Providing students with pro-social activities that discourage risky behaviors during otherwise unsupervised time after school is one potentially successful approach to filling this gap (15,16). ¡Activate Ya! has developed an after-school program, called Espacio Adolescente, to address this otherwise free time for students, providing structured activities that are engaging, active, and enjoyable for students. A pilot test (37) has shown that this aspect of the intervention is feasible, with high rates of recruitment and retention. Additional information regarding the impact of this part of ¡Activate Ya! will be available once the randomized trial is complete.

Smoking for attention and to look older/as a rite of passage were some of the predominant intrapersonal factors cited by respondents for smoking. These are similar to the factors of coolness and sophistication reported by Latino adolescents in the US (38). These factors are analogous, as they imply a positive reception by peers due to smoking. In these instances, smoking contributes to positive attitudes and beliefs (39) that encourage smoking uptake in adolescents. As part of its curriculum implementing during school time, ¡Activate Ya! will directly addresses these reasons for use and engage students in considering alternative ways to meet these developmental needs.

Participants in focus groups stated that they learned to smoke from peers, including their friends and those they observed on the street. This influence has also been documented in Brazil, where the time individuals spent with friends had a strong, dose response association with whether that individual smoked (22). ¡Activate Ya! utilizes a social influences model (17), allowing students to work together to reinforce positive behaviors and problem solve, one of the most dominant interactive strategies employed. This helps students re-evaluate what may be perceived as ‘mature behavior’, and allows them to gain attention from peers in a positive manner. ¡Activate Ya! further reinforces increasing individuals’ self-efficacy to resist cigarettes when offered through practice in group settings which should help stem experimentation and peer-pressure. Pressure exerted on students to smoke by their peers was reported to manifest differently across gender groups, however. This could be an element contributing to the finding in Barcelona that group influence impacted smoking to a greater degree in boys than girls (40). Opportunities to practice gender-specific refusal skills like these have also been added to this school-based curriculum.

Strengths and limitations

The focus group design allowed students to provide personal and observed examples of tobacco related behaviors and potential influences on these behaviors. Furthermore, the focus group design provides a case study specific to the culture of smoking in Uruguayan adolescents, aiding in the determination of whether perceptions differ from adolescents elsewhere. Finally, the students’ observations are balanced between gender and public and private schools, which enhance understanding across strata.

Clearances for researchers to work in the private schools were more expedient than those required for public schools, and therefore focus groups were conducted a year apart. However, the tobacco regulatory context did not change during this time frame. As there is limited history of school-based health education in Uruguay, it is unlikely that the analysis and reporting of data was influenced by the timing of the focus groups.

While the study offers valuable insight into adolescents’ perceptions about tobacco, it does have limited generalizability as a case study. The students sampled are from only four schools, and all reside within the surrounding neighborhoods of Montevideo. Moreover, this method is used for exploratory research, and therefore does not offer insight into causation. Finally, participants were volunteers, and their perceptions may not be reflective of the rest of the students at their school in their grade.

Conclusion

Future studies may build upon this research by utilizing a quantitative, longitudinal design that can better elucidate predictive factors of adolescent smoking in Uruguay. These findings can also be applied to current anti-tobacco regulation in Uruguay. While it is illegal to sell tobacco products to minors under the age of 18 years, few students note any difficulty in purchasing cigarettes. Our findings document key factors reported by Uruguayan adolescents that encourage tobacco use, including misconceptions about enhancing one’s appearance, maturity and social approval with tobacco; the ongoing power of peer influence as a motivator; and unsupervised time. Regulatory efforts alone may not suffice to fully curb adolescent tobacco use, and other ‘high touch’ strategies grounded in interpersonal influence approaches such as school and afterschool programming may be needed to further reduce tobacco use in Uruguay. Given Uruguay’s global leadership role in tobacco control, exploration of additional adolescent-focused strategies in addition to tobacco regulation holds promise for helping Uruguay reach ‘the endgame’ of tobacco use (12).