The influence of school smoking policies on student tobacco use

Adolescent Health and Parents' and Teachers' Beliefs about Smoking: A Cross-Sectional Study

BACKGROUND

The acquisition of healthy lifestyle habits by adolescents is largely influenced by close interpersonal relationships including their parents and teachers.

METHODS

A cross-sectional survey regarding tobacco use was conducted among 304 parents and 41 teachers of secondary school adolescents (12-17 years of age) enrolled in the first, second, and third grades of compulsory secondary education at the largest high school in Sueca, Valencia, Spain.

RESULTS

The prevalence of smoking was 36.2% among parents (occasional smokers 75.4%) and 19.5% among teachers (occasional smokers 62.5%). Most parents (89.8%) did not believe that their child smoked and 95.7% viewed it negatively if they did. Also, 75.2% of parents agreed that tobacco consumption encourages adolescents to use cannabis or other drugs. Friends who smoke and additives added to cigarettes were considered very influential factors for starting smoking. Most teachers (90.2%) reported having given a recommendation to their students to quit smoking. Cannabis and cigarette smoking were rated as harmful to health. Most respondents believed that cigarette smoking may favor the consumption of cannabis.

CONCLUSIONS

The use of e-cigarettes was also considered a risk factor for starting smoking. It would be advantageous incorporating parents and teachers as role models in multidisciplinary interventions addressing smoking behavior in secondary school students.

Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study

School tobacco policies are often poorly implemented, which may explain their limited effectiveness. Further, constructs to measure implementation outcomes of school tobacco policies are missing. The Smoke-Free Vocational Schools intervention was designed to stimulate the implementation of a comprehensive school tobacco policy into routine practice. This study (1) developed implementation fidelity outcomes measures for the school tobacco policy and (2) examined associations between intervention activities and implementation fidelity at two time points. We applied a repeated cross-sectional survey study design across seven schools: the first time point was >5 months after the policy was established and the second time point > 14 months after policy establishment. The dependent/outcome variables were four binary fidelity domains as well as a total score across domains. A total of six intervention activities were measured among either students (e.g., new school-break facilities) or staff/managers (e.g., a joint workshop before policy implementation). Associations were analyzed separately for students and staff/managers using generalized linear mixed models, adjusted for confounders. A total of n = 2674 students and n = 871 staff/managers participated. The total implementation fidelity scores increased over time among both students and staff/managers. Three intervention activities were consistently associated with the total implementation fidelity score, including: new school-break facilities (B_T1 = 0.08, 95% CI = 0.03; 0.12; B_T2 = 0.07, 95% CI = 0.04-0.50), the joint workshop before policy implementation (B_T1 = 0.13, 95% CI = 0.02; 0.25; B_T2 = 0.13, 95% CI = 0.004; 0.24), and internalization of fixed procedures for enforcement (B_T1 = 0.19, 95% CI = 0.13-0.26; B_T2 = 0.16, 95% CI = 0.13-0.26). These findings can be applied by schools and other actors in practice. The developed implementation fidelity outcomes measures can be applied in future research on school tobacco policies.

Campus Policy on Tobacco Prohibition and Tobacco Use among Youth in Sub-Saharan Africa: An Investigation Based on the Perspectives of School Personnel

Background

Schools in sub-Saharan Africa respond to the widespread use of tobacco among youth with the tobacco-prohibition policies. This study empirically examined the impact of the strength of campus tobacco-prohibition policies on tobacco use among youth across 20 sub-Saharancountries.

Methods

This study used data from the Global School Personnel Survey across 20 sub-Saharan countries during 2005–2011. Respondents comprised 7,365 school personnel (valid sample size) from Cameroon, Central African Republic, Congo, Eritrea, Ghana, Guinea-Bissau, Lesotho, Malawi, Mauritania, Mauritius, Namibia, Niger, Rwanda, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, and Uganda. Considering the potential endogeneity-estimation bias occurring in the normal ordinary least square estimation, instrumental variable estimation was used to ensure the regression results were reliable.

Results

The interaction term “tobacco-prohibition policy × policy-enforcement strength” was found to negatively predict perceived seriousness of tobacco use among youth (−0.0053, 95% CI [-0.0101, -0.0005]; p<0.05), which indicated that when campus tobacco-prohibition policy and enforcement were both sufficiently strict, the extent to which school personnel felt concerned or anxious about tobacco use among youth in the 20 countries was lowest. A series of identification tests using instrumental variable estimation demonstrated that these regression results were reliable and without endogeneity-estimation bias.

Conclusion

This study confirms the effectiveness of the interaction of tobacco-prohibition policy and policy-enforcement strength for alleviating the seriousness of tobacco use among youth in underdeveloped areas. A series of important policy implications are discussed to prevent fast development of tobacco use in this area.

School policies and smoking intention in a Swiss sample of adolescents

The majority of today's adult smokers took up the habit during adolescence. The school community and the rules it imposes are important factors that can influence adolescents' smoking intention and behaviour. Research on the effect of school tobacco policies on adolescents' smoking concludes with mixed results. Our study aims to look at the influence of these policies on the intention to smoke and to know if this relation is mediated by individual and environmental factors. The study includes information on social norms, attitude towards smoking and smoking intention from 4515 students of 32 Ticino middle schools and on the tobacco policy implemented in this school. Linear regression indicates a marginal impact of school policy on intention to smoke. Schools that strongly enforce tobacco policy obtain an increase in their students' intention to smoke, while schools that implement assistance programmes to overcome tobacco use decrease intention to smoke. Mediation models show that the influence of some of tobacco policy dimensions on the intention to smoke is mediated by personal attitudes towards smoking, beliefs about health consequences of smoking and perceived peers smoking. Increasing visibility of tobacco policies and having tobacco prevention programmes have stronger positive effects on smoking intention than other policy dimensions, but only through the mediation of individual and environmental factors.

School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

Smoking susceptibility among non-smoking school-going adolescents in Malaysia: findings from a national school-based survey

OBJECTIVE

The identification of susceptible non-smoking adolescents is an essential step in reducing smoking initiation among adolescents. The aim of this study was to examine the prevalence and factors associated with smoking susceptibility among non-smoking school-going adolescents in Malaysia.

DESIGN

Cross-sectional study.

SETTING

Primary and secondary schools in Malaysia.

PARTICIPANTS

11 246 non-smoking school-going adolescents.

OUTCOME MEASURES

The prevalence and factors associated with smoking susceptibility among non-smoking school-going adolescents in Malaysia.

RESULTS

Approximately 14% of non-smokers were susceptible to smoking, and the prevalence of susceptibility was significantly higher among males, ever-smokers and e-cigarette users. The odds of susceptibility to smoking were higher among males, e-cigarette users, those aged 12 years and under and those who had ever smoked or tried cigarettes. Students from schools with educational programmes on the health effects of second-hand smoke (SHS) and who perceived smoking to be harmful were less likely to be susceptible to smoking.

CONCLUSION

Smoking susceptibility is prevalent among school-going adolescents. A comprehensive approach that enhances or reinforces health education programmes on the adverse health effects of smoking and SHS among school children, that considers multiple factors and that involves all stakeholders is urgently needed to reduce the prevalence of smoking susceptibility among vulnerable subgroups, as identified from the present findings.

Results of outdoor smoking bans at secondary schools on adolescents smoking behaviour: a quasi-experimental study

BACKGROUND

Research on the effectiveness of school smoking policies on adolescents' smoking behaviour remain inconclusive. This study evaluates the results of an outdoor school ground smoking ban at secondary schools on adolescents smoking behaviour, taking individual characteristics into account.

METHODS

Data on 2684 adolescents from 18 Dutch secondary schools (nine with and nine without an outdoor smoking ban) were obtained at two moments. Associations between outdoor school ground smoking bans, individual characteristics, and smoking prevalence and frequency were measured. Multilevel logistic regression analyses were used. At schools with a ban implementation fidelity was checked.

RESULTS

Although smoking prevalence and frequency appeared to make a slower increase at schools with an outdoor smoking ban compared with schools without an outdoor smoking ban, the differences were not significant. Differences between schools in the prevalence of smoking behaviour of students could mainly be explained by individual characteristics. Smoking prevalence and frequency were higher among adolescents with a positive attitude towards smoking and when significant others were more positive about smoking. Smoking prevalence and frequency were significantly lower when adolescents perceived it as easy not to smoke. Implementation fidelity was good at schools with a ban.

CONCLUSIONS

No short-term effects were found of an outdoor smoking ban. A longer follow-up time than 6 months is needed. In addition, future research should investigate effectiveness in relation to the enforcement of the ban, comprehensiveness of the ban and when it is prohibited to leave school grounds, as smoking behavior might be transferred off school grounds.

Effectiveness of a complex intervention on smoking in adolescents: A cluster-randomized controlled trial

Tobacco smoking is a major preventable cause of death, and a significant public health problem worldwide. Most smokers begin in adolescence, age at which they are more susceptible to nicotine addiction. The prevalence of smoking in adolescence is considerable. Therefore, it would be convenient to incorporate smoking prevention programs in the school environment. It is necessary to provide evidence of its effectiveness. The primary objective of the study was to evaluate the effectiveness of a teacher-delivered school-based intervention on the initiation of smoking in adolescents (ITACA smoking prevention education program). A multi-center cluster randomized trial was designed. Twenty-two secondary schools from Spain were enrolled in 2 successive cohorts, from 2010 to 2011. The intervention consisted in the application of the ITACA smoking prevention education program. A 4-year cognitive-behavioral intervention that is based on the social-influences model and is integrated into schools' regular curricular activities. A total of 1055 students were surveyed before the intervention (age: 12-13 years-old), and at the third year of the intervention (age: 14-15 years-old) of a 4-year education program. The outcome measures were daily and weekly use of cigarettes, and initiation of smoking. There was no evidence that the intervention impacted the incidence of regular smoking (OR = 1.08; 95% CI: 0.50-2.33) or the initiation of smoking (OR = 1.09; 95% CI: 0.56-1.72). This trial provides evidence supporting the non-effectiveness of a complex educational smoking prevention program at 3 years after the intervention.

TRIAL REGISTRATION NUMBER

Current Controlled Trials: NCT01602796.

Analyzing Multilevel Factors Underlying Adolescent Smoking Behaviors: The Roles of Friendship Network, Family Relations, and School Environment

BACKGROUND

This study investigates the extent to which friendship network, family relations, and school context are related to adolescent cigarette smoking. Friendship network is measured in terms of delinquent peers; family relations in terms of parental supervision; and school environment in terms of objective (eg, antismoking policy) and subjective (eg, school attachment) characteristics.

METHODS

Findings are based on the secondary analysis of the health behavior in school-aged children, 2009-2010. Two-level hierarchical generalized linear models are estimated using hierarchical linear modeling 7.

RESULTS

At the student level, ties to delinquent friends is significantly related to higher odds of smoking, while greater parental supervision is associated with lower odds. At the school level, antismoking policy and curriculum independently lower smoking behavior. Better within-class peer relations, greater school attachment, and higher academic performance are also negatively related to smoking. Last, the positive association between delinquent friends and smoking is weaker in schools with a formally enacted antismoking policy. However, this association is stronger in schools with better peer relations.

CONCLUSIONS

Adolescent smoking behavior is embedded in a broader ecological setting. This research reveals that a proper understanding of it requires comprehensive analysis that incorporates factors measured at individual (student) and contextual (school) levels.

Impact of an Outdoor Smoking Ban at Secondary Schools on Cigarettes, E-Cigarettes and Water Pipe Use among Adolescents: An 18-Month Follow-Up

The effectiveness of outdoor smoking bans on smoking behavior among adolescents remains inconclusive. This study evaluates the long-term impact of outdoor school ground smoking bans among adolescents at secondary schools on the use of conventional cigarettes, e-cigarettes (with/without nicotine) and water pipes. Outdoor smoking bans at 19 Dutch secondary schools were evaluated using a quasi-experimental design. Data on 7733 adolescents were obtained at baseline, and at 6 and 18-month follow-up. The impact of outdoor smoking bans on ‘ever use of conventional cigarettes’, ‘smoking onset’, ‘ever use of e-cigarette with nicotine’, ‘e-cigarette without nicotine’, and ‘water pipe’ was measured. Multilevel logistic regression analysis was used. At schools with a ban, implementation fidelity was checked. At schools where a ban was implemented, at 18-month follow-up more adolescents had started smoking compared to the control condition. No effect of implementation of the ban was found for smoking prevalence, e-cigarettes with/without nicotine, and water pipe use. Implementation fidelity was sufficient. No long-term effects were found of an outdoor smoking ban, except for smoking onset. The ban might cause a reversal effect when schools encounter difficulties with its enforcement or when adolescents still see others smoking. Additional research is required with a longer follow-up than 18 months.

Tobacco use patterns, knowledge, attitudes towards tobacco and availability of tobacco control training among school personnel from a rural area in Poland

Background

Tobacco-free school environment as well as non-smoking teachers and school personnel provide positive role models for children and young people. In Poland, smoking should be banned in colleges, schools, educational establishments and educational care facilities. However, for the existing law to be effective, awareness of all people in school curriculum and enforcement of the law are crucial. The aim of the study was to evaluate tobacco use patterns, knowledge and attitudes towards tobacco as well as availability of tobacco control training among school personnel in a rural area in Poland. Moreover, compliance with tobacco control policies and their enforcement were assessed.

Methods

The study was carried out in Piotrkowski district between November 2014 and May 2015 in accordance with the Global School Personnel Survey (GSPS) methodology. Sixty schools participated in the survey (92% of the schools from the region) with involvement of 1044 teachers and 500 non-teaching staff (the response rate – 83.1%). The multivariate linear regression analyses were applied to study factors linked to the need for anti-tobacco training dedicated to the youth and teachers’ knowledge as well as activities to educate the students about tobacco use and its prevention.

Results

About 24% of the school personnel were current and 9% were ex-smokers. Significantly more teachers than the non-teaching staff indicated that the schools had a policy prohibiting tobacco use among students. In addition, 6% of the study participants indicated everyday violations of the tobacco control policy by the school personnel. More than 80% of the teaching personnel indicated the need for training dedicated to the youth to prevent their tobacco use. In the multivariate linear regression model, longer duration of working experience predicted higher levels of knowledge and more activities performed to teach the youth about tobacco use and its prevention. The smokers comparing to the non–smokers perceived the need for anti- tobacco training among the youth less strongly.

Conclusions

In order to make it possible for the inhabitants of Piotrkowski district to work and learn in tobacco smoke free environment there is an urgent need for taking actions aiming at increasing effectiveness of enforcing applicable tobacco control regulations in educational units. The necessity for systematic training dedicated to the youth to prevent their tobacco use, including accurate preparation of teachers, also needs to be highlighted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12971-016-0110-y) contains supplementary material, which is available to authorized users.

National and State Attitudes of US Adults Toward Tobacco-Free School Grounds, 2009-2010

Introduction

Schools are an important environment for addressing tobacco use among youth. Tobacco-free school policies can help reduce the social acceptability of tobacco use and prevent tobacco initiation among youth. This study assessed attitudes toward tobacco-free school grounds among US adults.

Methods

Data came from the 2009–2010 National Adult Tobacco Survey, a telephone survey of adults aged 18 or older in the 50 US states and District of Columbia. Respondents were considered to have a favorable attitude toward tobacco-free school grounds if they reported tobacco use should be completely banned on school grounds, including fields and parking lots, and at all school events. Data were assessed using descriptive statistics and multivariable logistic regression, overall and by tobacco use status. Correlates were sex, age, race/ethnicity, education, marital status, income, sexual orientation, US region, and whether respondent lived with any children aged 17 years or younger.

Results

Nationally, 86.1% of adults had a favorable attitude toward tobacco-free school grounds, with larger percentages among nontobacco users (91.9%) than current users (76.1%). State prevalence ranged from 80.0% (Kentucky) to 90.9% (Washington). Overall odds of favorable attitudes were higher among nontobacco users (referent, current users), women (referent, men), and adults aged 25 or older (referent, aged 18–24); odds were lower among residents of the South (referent, West) and lesbian, gay, bisexual, or transgender adults (referent, heterosexual or straight).

Conclusion

Nearly 9 in 10 US adults have a favorable attitude toward tobacco-free school grounds, but attitudes vary across states and subpopulations. Opportunities exist to educate the public about the benefits of tobacco-free school grounds, which might help reduce tobacco use among youth.

Longitudinal effects of school drug policies on student marijuana use in Washington State and Victoria, Australia

OBJECTIVES

We examined the longitudinal effect of schools' drug policies on student marijuana use.

METHODS

We used data from the International Youth Development Study, which surveyed state-representative samples of students from Victoria, Australia, and Washington State. In wave 1 (2002), students in grades 7 and 9 (n = 3264) and a school administrator from each participating school (n = 188) reported on school drug policies. In wave 2 (2003), students reported on their marijuana use. We assessed associations between student-reported and administrator-reported policy and student self-reported marijuana use 1 year later.

RESULTS

Likelihood of student marijuana use was higher in schools in which administrators reported using out-of-school suspension and students reported low policy enforcement. Student marijuana use was less likely where students reported receiving abstinence messages at school and students violating school policy were counseled about the dangers of marijuana use.

CONCLUSIONS

Schools may reduce student marijuana use by delivering abstinence messages, enforcing nonuse policies, and adopting a remedial approach to policy violations rather than use of suspensions.

Strategies for an effective tobacco harm reduction policy in Indonesia

Tobacco consumption is a major causative agent for various deadly diseases such as coronary artery disease and cancer. It is the largest avoidable health risk in the world, causing more problems than alcohol, drug use, high blood pressure, excess body weight or high cholesterol. As countries like Indonesia prepare to develop national policy guidelines for tobacco harm reduction, the scientific community can help by providing continuous ideas and a forum for sharing and distributing information, drafting guidelines, reviewing best practices, raising funds, and establishing partnerships. We propose several strategies for reducing tobacco consumption, including advertisement interference, cigarette pricing policy, adolescent smoking prevention policy, support for smoking cessation therapy, special informed consent for smokers, smoking prohibition in public spaces, career incentives, economic incentives, and advertisement incentives. We hope that these strategies would assist people to avoid starting smoking or in smoking cessation.

School policies for preventing smoking among young people

BACKGROUND

School tobacco policies (STPs) might prove to be a promising strategy to prevent smoking initiation among adolescents, as there is evidence that the school environment can influence young people to smoke. STPs are cheap, relatively easy to implement and have a wide reach, but it is not clear whether this approach is effective in preventing smoking uptake.

OBJECTIVES

To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools.

SEARCH METHODS

We searched seven electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and ERIC. We also searched the grey literature and ongoing trials resources. The most recent search was performed in May 2014.

SELECTION CRITERIA

We included cluster-randomised controlled trials (c-RCTs) in which primary and secondary schools were randomised to receive different levels of smoking policy or no intervention. Non-randomised controlled trials, interrupted time series and controlled before-after studies would also have been eligible. Cross-sectional studies were not formally included but we describe their findings and use them to generate hypotheses to inform future research.

DATA COLLECTION AND ANALYSIS

We independently assessed studies for inclusion in the review, and present a narrative synthesis, as the studies are too limited in quality to undertake a formal meta-analysis.

MAIN RESULTS

We found only one study which was eligible for inclusion in the review. It was judged to be at high risk of bias. The study compared two 'middle schools' from two different regions in China. The experimental conditions included the introduction of a tobacco policy, environmental changes, and communication activities, while the control condition was no intervention. After a year's follow-up the study found no differences in smoking prevalence between intervention and control schools. We also described 24 observational studies, the results of which we considered for hypothesis generation. In these, policy exposure was mainly described using face-to-face interviews with school staff members, and the outcome evaluation was performed using self-administered questionnaires. Most studies reported no differences in students' smoking prevalence between schools with formal STPs when compared with schools without policies. In the majority of studies in schools with highly enforced policies, smoking bans extended to outdoor spaces, involving teachers and including sanctions for transgressions, with assistance to quit for smokers plus support by prevention programmes, there was no significant difference in smoking prevalence when compared to schools adopting weaker or no policies.

AUTHORS' CONCLUSIONS

Despite a comprehensive literature search, and rigorous evaluation of studies, we found no evidence to support STPs. The absence of reliable evidence for the effectiveness of STPs is a concern in public health. We need well-designed randomised controlled trials or quasi-experimental studies to evaluate the effectiveness of school tobacco policies.

Multilevel analysis of the impact of school-level tobacco policies on adolescent smoking: the case of Michigan

BACKGROUND

In efforts to curb and prevent youth smoking, school tobacco policies have become an important and effective strategy. This study explores the degrees and types of tobacco-free school policy (TFSP) enforcement that are associated with adolescent smoking.

METHODS

A multilevel analysis was performed using 983 students who are nested in 14 schools. The individual-level data are drawn from the 2009 Michigan Youth Risk Behavior Survey. The school-level data are drawn from the 2008 School Health Profiles survey.

RESULTS

Two factors are associated with lower adolescent smoking: greater punishment for TFSP violation and more tobacco control communication efforts. By contrast, the factors associated with higher adolescent smoking are designation of a tobacco-free school zone and school-level smoking.

CONCLUSIONS

This study theoretically and methodologically guides researchers to test TFSP effectiveness in other states. Three strategic implications emerge: (1) schools should provide a consistent antismoking message in smoke-free environments; (2) schools should integrate TFSP into a comprehensive tobacco control initiative, including community-wide tobacco control programs and messages; and (3) the way a specific TFSP is promoted and communicated could determine how effective it is.

An evaluation of public school district tobacco policies in St. Louis County, Missouri

BACKGROUND

One way to address tobacco use by youth is for primary and secondary schools to adopt and implement comprehensive tobacco policies. The purpose of this study was to evaluate the comprehensiveness of tobacco policies in St. Louis County, Missouri public school districts.

METHODS

We evaluated the strength of tobacco policies from all 23 public school districts located in the county using the Center for Tobacco Policy Research's School Tobacco Policy Index, a standardized tool for rating school tobacco policies.

RESULTS

The districts averaged a score of 24.4 of 40 possible points on the Index. Policies scored highest on the Tobacco-Free Environment domain and lowest on the Enforcement domain. Policies averaged about half of the total possible points for the Prevention and Treatment Services and Policy Organization domains.

CONCLUSION

Despite more than a decade of efforts by the Centers for Disease Control and Prevention to improve school tobacco policies, this study shows that policies in St. Louis County districts have yet to meet the standard of comprehensiveness. It is recommended that schools adopt policies that are comprehensive and that address all domains of the School Tobacco Policy Index.

Predictors of nicotine dependence symptoms among never-smoking adolescents: a longitudinal analysis from the Nicotine Dependence in Teens Study

BACKGROUND

Recent cross-sectional studies suggest some adolescents who have never smoked cigarettes experience nicotine dependence (ND) symptoms and that exposure to second-hand smoke, social exposure to smoking, and alcohol use are plausible correlates. The aim of this study was to replicate and extend these findings by investigating possible predictors of ND symptoms longitudinally.

METHOD

Participants included 847 secondary school students who had never smoked cigarettes enrolled in the Nicotine Dependence in Teens Study. Adolescents completed self-report questionnaires measuring smoking status, ND symptoms, and risk factors for ND in smokers (i.e., socio-demographic indicators, social exposure to smoking, psychosocial indicators, and substance use) in 20 survey cycles from 7 to 11th grade. Generalized estimating equations, which account for repeated measures within individuals, were used to test the predictors of ND symptoms.

RESULTS

Consistent with previous research, 7.8% of never-smokers across all cycles endorsed at least one ND symptom. Younger age (p ≤ .001), country of birth (p ≤ .05), peer smoking (p ≤ .001), teacher smoking (p ≤ .05), depression (p ≤ .05), stress (p ≤ .001), lower self-esteem (p ≤ .05), impulsivity (p ≤ .05), and alcohol use (p ≤ .001) predicted greater ND symptoms in multivariable modeling.

CONCLUSIONS

Replicating previous cross-sectional findings, peer smoking and alcohol use predicted ND symptoms among never-smoking adolescents. Extending these findings, previous predictors only observed among ever-smokers, including socio-demographic and psychosocial indicators, also predicted ND symptoms. This longitudinal investigation demonstrated the temporal relation of the predictors preceding ND symptoms. Future research should consider longer prospective studies with younger children to capture early onset of ND symptoms and with longer follow-up to detect eventual smoking uptake.

Effect of a smoking ban and school-based prevention and control policies on adolescent smoking in Spain: a multilevel analysis

We evaluated the impact of a smoking ban in schools and of school-based smoking prevention and control policies on adolescent smoking. Annual surveys carried out between 2001 and 2005 that were representative of students in the 4th year of secondary education in the Madrid region, with 203 schools and 9127 students participating. The student questionnaire gathered information about personal and family variables. The contextual factors were: the periods before (years 2001-2002) and after the law; and through a survey of school management boards: compliance with the law, policy reflected in the school regulations, existence of complaints against smoking, and undertaking of educational activities regarding smoking. Multilevel logistic regression models were constructed with two dependent variables: current smoking and the proportion giving up smoking. Smoking declined in 2003, the first year after the law came into force (Odds ratio: 0.80; CI 95%: 0.66-0.96), and this decline was maintained in 2005. By contrast, smoking increased in those schools that did not undertake educational programmes regarding smoking (Odds ratio: 1.34; CI 95%: 1.13-1.59), and in those that received complaints about smoking (Odds ratio: 1.12; CI 95%: 0.96-1.29). This association is partly due to the effect of the increase in giving up smoking. The inclusion of contextual variables into the model with the individual factors reduces the variability of smoking between schools by 32.6%. In summary, the coming into force of a law banning smoking in schools, and the implementing of educational policies for the prevention and control of smoking are related to a lower risk of adolescent smoking.

School and community predictors of smoking: a longitudinal study of Canadian high schools

OBJECTIVES

We identified the most effective mix of school-based policies, programs, and regional environments associated with low school smoking rates in a cohort of Canadian high schools over time.

METHODS

We collected a comprehensive set of student, school, and community data from a national cohort of 51 high schools in 2004 and 2007. Hierarchical linear modeling was used to predict school and community characteristics associated with school smoking prevalence.

RESULTS

Between 2004 and 2007, smoking prevalence decreased from 13.3% to 10.7% in cohort schools. Predictors of lower school smoking prevalence included both school characteristics related to prevention programming and community characteristics, including higher cigarette prices, a greater proportion of immigrants, higher education levels, and lower median household income.

CONCLUSIONS

Effective approaches to reduce adolescent smoking will require interventions that focus on multiple factors. In particular, prevention programming and high pricing for cigarettes sold near schools may contribute to lower school smoking rates, and these factors are amenable to change. A sustained focus on smoking prevention is needed to maintain low levels of adolescent smoking.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Using Photovoice to assess and promote environmental approaches to tobacco control in AAPI communities

Asian American and Pacific Islander (AAPI) communities face enormous health disparities, with tobacco use contributing to high rates of cancer and heart disease. There is growing interest nationwide on the influence of environmental factors on tobacco use. AAPI communities have been found to have higher exposures to tobacco company marketing compared to the general population. The authors describe the use of Photovoice (a qualitative needs assessment technique) to empower AAPI youth to identify and understand environmental characteristics associated with tobacco use in four AAPI communities in California and Washington. Of the six major environmental themes identified from the photos, three themes were found across all four communities. Debrief sessions with youth and community leaders underscore the relevance of Photovoice for identifying community needs and motivating community organization for change. Despite some logistical challenges, Photovoice exemplifies the power and potential of this community-based methodology to capture how the environment influences youth on tobacco use.

Community-level determinants of tobacco use disparities in lesbian, gay, and bisexual youth: results from a population-based study

OBJECTIVE

To determine whether characteristics of the social environment surrounding lesbian, gay, and bisexual (LGB) youth contribute to their rates of tobacco use after controlling for established community-level risk factors.

DESIGN

Cross-sectional.

SETTING

Population-based study of youth.

PARTICIPANTS

A total of 31,852 eleventh-grade students (1413 LGB individuals [4.44%]) in Oregon completed the Oregon Healthy Teens survey in 2006-2008.

MAIN EXPOSURES

We created a composite index of the social environment in 34 Oregon counties. This measure included the proportion of same-sex couples, the presence of gay-straight alliances in schools, and school policies (nondiscrimination and antibullying) that specifically protected LGB students.

MAIN OUTCOME MEASURES

Any tobacco use in the past 30 days.

RESULTS

A more supportive social environment for LGB youth was significantly associated with reduced tobacco use (odds ratio, 0.92; 95% confidence interval, 0.90-0.94). This effect remained robust after controlling for sociodemographic variables and multiple community-level risk factors for tobacco use, including median county-level income, exposure to cigarette advertisements, exposure to teacher and peer smoking in schools, and school smoking rules.

CONCLUSION

This study documents an association between an objective measure of the social environment and sexual orientation-related disparities in tobacco use. These results highlight the need for structural-level interventions that reduce smoking behaviors in LGB youth.

Associations between schools' tobacco restrictions and adolescents' use of tobacco

Schools are an important arena for smoking prevention. In many countries, smoking rates have been reduced among adolescents, but the use of smokeless tobacco is on the rise in some of these countries. We aimed to study the associations between schools' restrictions on smoking and snus and on the use of these tobacco products among students in upper secondary school. We employed data from a national representative study of 1444 Norwegian students, aged 16-20 years. Respondents were asked about their schools' restrictions on snus and smoking and own use of these products. We examined associations between restrictions and the use, controlling for age, gender, type of school and regional differences. We found clear consistent associations between schools' restrictions on tobacco use and less use of these products. More explicit pervasive restrictions were strongly associated with the prevalence of use. This first study on the associations between schools' restrictions on snus and the prevalence of snus use corroborate what has been found in many studies on smoking restrictions and smoking. Strict school tobacco policies may be an important tool if health authorities are interested in implementing measures to limit or reduce snus use among adolescents.

Changes in the SF-8 scores among healthy non-smoking school teachers after the enforcement of a smoke-free school policy: a comparison by passive smoke status

Background

The effects of the enforcement of a smoke-free workplace policy on health-related quality of life (HRQOL) among a healthy population are poorly understood. The present study was undertaken to examine the effects of the enforcement of a smoke-free school policy on HRQOL among healthy non-smoking schoolteachers with respect to their exposure to passive smoke.

Methods

Two self-reported questionnaire surveys were conducted, the first before and the second after the enforcement of a total smoke-free public school policy in Nara City. A total of 1534 teachers were invited from 62 schools, and their HRQOL was assessed using six domains extracted from the Medical Outcomes Survey Short Form-8 questionnaire (SF-8): general health perception (GH), role functioning-physical (RP), vitality (VT), social functioning (SF), mental health (MH), and role functioning-emotional (RE). The participants were divided into two groups according to their exposure to environmental tobacco smoke (ETS) at baseline: participants not exposed to ETS at school (non-smokers), and participants exposed to ETS at school (passive smokers). Changes in each SF-8 score were evaluated using paired t-tests for each group, and their inter-group differences were evaluated using multiple linear regression analyses adjusted for sex, age, school type, managerial position, and attitude towards a smoke-free policy.

Results

After ineligible subjects were excluded, 689 teachers were included in the analyses. The number of non-smokers and passive smokers was 447 and 242, respectively. Significant changes in SF-8 scores were observed for MH (0.9; 95% confidence interval [CI], 0.2-1.5) and RE (0.7; 95% CI, 0.0-1.3) in non-smokers, and GH (2.2; 95% CI, 1.2-3.1), VT (1.8; 95% CI, 0.9-2.7), SF (2.7; 95% CI, 1.6-3.8), MH (2.0; 95% CI, 1.0-2.9), and RE (2.0; 95% CI, 1.2-2.8) in passive smokers. In the multiple linear regression analyses, the net changes in the category scores of GH (1.8; 95% CI, 0.7-2.9), VT (1.4, 95% CI, 0.3-2.5), SF (2.5; 95% CI, 1.1-3.9), MH (1.2; 95% CI, 0.1-2.4) and RE (1.6; 95% CI, 0.5-2.7) in passive smokers significantly exceeded those in non-smokers.

Conclusions

A smoke-free school policy would improve the HRQOL of healthy non-smoking teachers who are exposed to ETS.

School smoking policy characteristics and individual perceptions of the school tobacco context: are they linked to students' smoking status?

The purpose of this study was to explore individual- and school-level policy characteristics on student smoking behavior using an ecological perspective. Participants were 24,213 (51% female) Grade 10–11 students from 81 schools in five Canadian provinces. Data were collected using student self-report surveys, written policies collected from schools, interviews with school administrators, and school property observations to assess multiple dimensions of the school tobacco policy. The multi-level modeling results revealed that the school a student attended was associated with his/her smoking behavior. Individual-level variables that were associated with student smoking included lower school connectedness, a greater number of family and friends who smoked, higher perceptions of student smoking prevalence, lower perceptions of student smoking frequency, and stronger perceptions of the school tobacco context. School-level variables associated with student smoking included weaker policy intention indicating prohibition and assistance to overcome tobacco addiction, weaker policy implementation involving strategies for enforcement, and a higher number of students smoking on school property. These findings suggest that the school environment is important to tobacco control strategies, and that various policy dimensions have unique relationships to student smoking. School tobacco policies should be part of a comprehensive approach to adolescent tobacco use.

Perceived enforcement of school tobacco policy and adolescents' cigarette smoking

OBJECTIVES

School tobacco use policies are part of a comprehensive strategy for preventing or reducing adolescent cigarette smoking. This study examines the relationship between perceived tobacco policy enforcement at the school level and smoking behaviors among students.

METHODS

21,281 middle and high school students of 255 schools participated in the 2006 Oregon Health Teens Survey. Multilevel logistic regression was conducted, using a school-level policy enforcement measure based on aggregated student reports, and individual-level characteristics (e.g., age, gender, cigarette smoking before age 12, personal beliefs about smoking) as predictors of past-30-day cigarette smoking behaviors (e.g., any smoking, daily smoking, heavy episodic smoking, smoking on school property).

RESULTS

Higher levels of perceived enforcement of anti-smoking policy at the school level were inversely associated with the prevalence of past-30-day smoking behaviors, independent of individual-level predictors.

CONCLUSIONS

Stricter enforcement of school policies against tobacco use may help prevent or reduce adolescents' cigarette smoking on and outside of school property.

The impact of social influence on adolescent intention to smoke: combining types and referents of influence

OBJECTIVES

Theory and research suggest that the intention to smoke is the main determinant of smoking initiation and emphasizes the role of cognitive and social factors on the prediction of the intention to smoke. However, extended models such as the I-Change and results from published studies reveal inconsistencies regarding the impact of social influence on the intention to smoke. Possible explanations for this may be the definition and measurement of the constructs that have been used.

DESIGN AND METHODS

The current study was designed with two main goals: (i) to test a measurement model for social influence, combining different types of social influence (subjective norms, perceived behaviour, and direct pressure) with various referents of influence (parents, siblings, peers, and teachers); (ii) to investigate the impact of social influence on adolescent intention to smoke, controlling for smoking behaviour. LISREL was used to test these models. The sample includes 3,064 Portuguese adolescents, with a mean age of 13.5 years, at the beginning of the seventh school grade.

RESULTS

The hypothesized measurement model of social influence was supported by results and explained 29% of the variance of the intention to smoke. A more extended model, including attitude and self-efficacy, explained 55% of the variance of the intention to smoke. Perceived behaviour of peers, parental norms, and perceived behaviour of parents were the social influence factors with impact on adolescent intention to smoke.

CONCLUSIONS

Results suggest that different referents exert their influence through distinct types of social influence and recommend further work on the definition and measurement of social influence.

Social-cognitive and school factors in initiation of smoking among adolescents: a prospective cohort study

AIMS

The aim of the present study was to examine the association between social-cognitive factors, school factors, and smoking initiation among adolescents who had never smoked.

METHODS

The study was based on longitudinal data on Danish adolescents attending randomly selected public schools. Adolescents enrolled in grade 7 (mean age, 13 years) who had never smoked (n = 912) were followed up for 6 months after baseline. Those who had still never smoked were followed up again 18 months after baseline, in grade 8 (n = 442). Social-cognitive factors were examined with five measures: self-efficacy, social influence (norms), social influence (behavior), social influence (pressure), and attitude. We used multilevel analyses to estimate the associations between social-cognitive factors at baseline and smoking initiation as well as the random effects of school, school class, and gender group in the school class.

RESULTS

At the first follow-up, we found significant associations between attitude, father's smoking, best friend's smoking, and smoking initiation. At the second follow-up, we found a significant association with pressure to smoke from friends. Of the school factors, gender group in the school class showed an effect at both first and second follow-up.

CONCLUSION

Our results suggest that father's smoking, best friend's smoking, attitude, and pressure to smoke from friends affect smoking initiation. The results for school factors suggest an effect of classmates of the same gender, which has not previously been examined longitudinally.