The Ontario ban on smoking on school property: perceived impact on smoking

The effect of school smoke-free policies on smoking stigmatization: A European comparison study among adolescents

The increasing denormalization of smoking by tobacco control policies and a normative smoke-free climate may shift power towards adolescent non-smokers. It is unclear, however, how common stigmatization of smokers is among adolescents or how stigmatization relates to the denormalization of smoking in their school and social environment. This paper aims to measure (1) whether stigmatization among European adolescents varies according to smoking status and socioeconomic position (SES), and (2) whether stigmatization is greater in school environments in which smoking is denormalized (i.e. those with low smoking rates and strong school tobacco policies). Data on 12,991 adolescents were collected in 55 schools in seven European countries (SILNE R-survey, 2016/17). We applied Stuber’s adapted scale of perceived stereotyping and discrimination towards smokers to smoking status and five variables indicating a power shift towards non-smokers: the school’s tobacco control policy (STP) score, the percentage of adolescents in the school who smoke, parents’ level of education, students’ academic performance, and the percentage of their friends who smoke. Multilevel regressions were applied to the global score for perceived stigmatization. Discrimination against smokers and stereotyping of smokers were frequently reported. Smokers reported less ‘perceived stigmatization of smoking’ than non-smokers (Beta = -0.146, p < 0.001). High-SES students reported stereotyping and discrimination more frequently than lower-SES students. The perception of stigmatization was lower among students whose academic performance was poor (Beta = -0.070, p < 0.001) and among those who had friends who smoked (Beta = -0.141, p < 0.001). Stigmatization was lower in schools with greater exposure to smoking and was not associated with the school’s STP score. Perceived stigmatization of smoking is common among European adolescents. Smokers themselves, however, perceive stigmatization less often than non-smokers. Strong school tobacco policies do not increase stigmatization, but a social environment that is permissive of smoking decreases perceived stigmatization.

Why Secondary Schools Do Not Implement Far-Reaching Smoke-Free Policies: Exploring Deep Core, Policy Core, and Secondary Beliefs of School Staff in the Netherlands

Background

Secondary schools that implement smoke-free policies are confronted with students who start smoking outside their premises. One solution is to complement smoke-free policies with prohibitions for all students to leave the school area during school hours, technically making school hours a smoke-free period. However, there are strikingly few Dutch secondary schools that implement this approach. This study explores why staff members in the Netherlands decide not to implement smoke-free school hours for all students.

Method

We interviewed 13 staff members, with different functions, from four secondary schools. The analysis was informed by the Advocacy Coalition Framework (ACF) to delve into the values, rationales, and assumptions of staff with the aim to identify deep core, policy core, and secondary beliefs.

Results

We identified six beliefs. Two deep core beliefs are that schools should provide adolescents the freedom to learn how to responsibly use their personal autonomy and that schools should only interfere if adolescents endanger or bother others. Three policy core beliefs identified included the following: that smoking is not a pressing issue for schools to deal with; that schools should demarcate their jurisdiction to intervene in adolescents’ lives in time, space, and precise risk behavior; and that implementing smoke-free school hours would interfere with maintaining positive student-staff relationships. One secondary belief identified was that smoke-free school hours would be impossible to enforce consistently.

Conclusion

This paper was the first to demonstrate the many beliefs explaining why schools refrain from voluntary implementing far-reaching smoke-free policies.

Understanding school staff members' enforcement of school tobacco policies to achieve tobacco-free school: a realist review

BACKGROUND

School tobacco policies (STPs) that aim to achieve a tobacco-free environment require consistent enforcement by school staff. However, little is known about why staff choose whether or not to enforce STPs. Therefore, we investigated staff members' responses to STPs that determine enforcement. Furthermore, we examined how these responses depend on contextual factors at the individual, interpersonal, school, implementation, and national levels.

METHODS

We performed a realist review (RR), which synthesizes existing primary evidence into a programme theory demonstrating key causal pathways through Context-Mechanism-Outcome configurations (CMOs). These CMOs link contextual factors to outcomes (i.e. staff enforcement) by explaining the underlying generative mechanisms (i.e. staff members' cognitive, psychosocial, and behavioural responses). A systematic literature search for the period 2000-2016 was performed using Academic Search Premier, PsycInfo, and MEDLINE. Forty English-language articles were identified for the synthesis.

RESULTS

Our programme theory demonstrated three CMOs: when contextual factors make staff members experience STP enforcement as part of their professional role and duties, it may lead to staff members showing responsibility for STP enforcement (CMO1); when contextual factors make staff members feel their contribution is leading to positive outcomes, it may lead to staff members showing motivation to enforce STPs (CMO2), and when contextual factors make staff members feel that they are able to deal with students' responses, it may lead to staff members showing confidence in STP enforcement (CMO3). Moreover, the programme theory provided more precise insights into what contextual factors contribute to triggering the individual mechanisms and the consequent outcomes.

CONCLUSIONS

By applying a realist approach, we have been able to detect three CMOs explaining staff members' STP enforcement. The findings provide useful insights explaining how stakeholders can support staff members' STP enforcement and consequently improve the impact of STPs on adolescent smoking.

Legislative smoking bans for reducing secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans and restrictions affecting populations. The minimum standard was having a ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. We included randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before and after studies, interrupted-time series as defined by the Cochrane Effective Practice and Organization of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Correlates of multiple chronic disease behavioral risk factors in Canadian children and adolescents

The authors assessed individual, social, and school correlates of multiple chronic disease behavioral risk factors (physical inactivity, sedentary behavior, tobacco smoking, alcohol drinking, and high body mass index) in a representative sample of Canadian youth aged 10-15 years (mean = 12.5 years) attending public schools. Cross-sectional data (n = 1,747) from cycle 4 (2000-2001) of the National Longitudinal Survey of Children and Youth were used. Ordinal regression models were constructed to investigate associations between selected covariates and multiple behavioral risk-factor levels (0/1, 2, 3, or 4/5 risk factors). Older age (odds ratio (OR) = 1.95, 95% confidence interval (CI): 1.21, 3.13), caregiver smoking (OR = 1.49, 95% CI: 1.09, 2.03), reporting that most/all of one's peers smoked (OR = 7.31, 95% CI: 4.00, 13.35) or drank alcohol (OR = 3.77, 95% CI: 2.18, 6.53), and living in a lone-parent family (OR = 1.94, 95% CI: 1.31, 2.88) increased the likelihood of having multiple behavioral risk factors. Youth with high self-esteem (OR = 0.92, 95% CI: 0.85, 0.99) and youth from families with postsecondary education (OR = 0.58, 95% CI: 0.41, 0.82) were less likely to have a higher number of risk factors. Although several individual and social characteristics were associated with multiple behavioral risk factors, no school-related correlates emerged. These variables should be considered when planning prevention programs.

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.

What are the effects of tobacco policies on vulnerable populations? A better practices review

BACKGROUND

While comprehensive tobacco policies have reduced the prevalence of smoking in Canada, some groups remain vulnerable to tobacco use and display high rates of smoking. This article reviews three types of tobacco policies--tax and price, smoking location restrictions and sales restrictions--and examines the consequences for Aboriginal people, youth and low-income people.

METHODS

A better practices review model was used to assess the strength of studies published between 1990 and 2004 that examined the effects of these tobacco policies on the three vulnerable populations of interest. A total of 72 studies were assessed and 42 judged medium or high strength. A gender-based and diversity analysis was applied to assess the differential impacts on females and males and/or diverse characteristics within these populations. Intended and unintended consequences were examined.

FINDINGS

Few studies assessed the potential or differential effects of tobacco policies on the three selected populations. In these, it was difficult to disentangle the effects of each policy in a comprehensive tobacco control environment, and there is need for improved indicators and greater attention to sex and gender analysis.

CONCLUSIONS

Research is required to measure the intended and unintended impacts of tobacco policies on populations vulnerable to tobacco use. There are problems in assessing these studies that could be resolved with more precise indicator development. An equity-based framework for assessing the effects of tobacco policies is needed that is conceptually linked to health determinants and inequities. The article concludes with a set of recommendations for research, evaluation, policy and ethics arising from this review.

Associations between health promoting schools' policies and indicators of oral health in Brazil

No detailed analyses have been undertaken on the effects of Health Promoting Schools on oral health status. The objective of this study was to assess whether the oral health of 12-year-old children in supportive schools, where health promoting policies had been developed, was better than that of children in non-supportive schools. A sample of 1823 12-year-old children in 33 public (government-funded) schools were selected in deprived areas of Curitiba, Brazil. Principal component analysis, multiple regression, meta-analysis and meta-regression were used in the data analysis. Schools with a comprehensive curriculum were more likely to have a higher percentage of caries-free children (beta = 6.27, p = 0.02) and fewer children with dental trauma (beta = -5.04, p = 0.02). The commitment towards health and safety at school was strongly associated with dental trauma, as 9.7% fewer children had dental trauma (p = 0.00) in schools that demonstrated a commitment towards health and safety. At the school level, mother's education and family income were independently associated with children's caries experience and dental trauma, respectively. Children in supportive schools had better oral health than those in non-supportive schools. Our results suggest that some benefit can be obtained for the improvement of the oral health of children living in deprived areas if they attend supportive schools.

Symptoms of nicotine dependence and other predictors of student smoking at school: implications for school smoking policy

Students who violate school smoking policies present a difficult health and disciplinary issue for school officials. Professionals know little about the characteristics of students who smoke at school. In a prospective study of 679 students in two cities in central Massachusetts, researchers examined how nicotine dependence contributes to the problem of smoking at school. After three years of follow up, smoking at school was reported by 10.3% of students. Among subjects who admitted to smoking at school, 63% reported that symptoms of nicotine dependence preceded their smoking at school. After adjusting for other variables, student smokers with symptoms of nicotine dependence were nine times more likely to report smoking in school (OR 9.1, 95% CI 2.9-28.5) than were student smokers without symptoms. Smoking at school was more common among daily smokers and those who paid for their own cigarettes. Age, gender, race, and parental smoking status were not significantly associated with students' reports of smoking at school. These data suggest nicotine dependence as an important contributor to the problem of smoking at school, but not the only reason why students violate school smoking policies. Disciplinary action against students caught violating school smoking policies should be supplemented with an offer of treatment for nicotine dependence.

Smoking visibility, perceived acceptability, and frequency in various locations among youth and adults

OBJECTIVES

This study tests whether there is an association between high visibility of smoking, perceived acceptability of smoking, and where youth smoke.

METHODS

Surveys of 9,762 students in grades 8-10 and 1,586 parents in 15 Minnesota communities asked about the frequency of and opinions of adult and youth smoking in various indoor and outdoor public places. Chi-square analysis and ANOVAs compared smokers and nonsmokers.

RESULTS

More smoking than nonsmoking youth reported often seeing adults and teens smoking in all locations. Forty-two percent of students often noticed adults and 35% often noticed teens smoking outdoors, also the most frequent location where teens report smoking. Students perceived adult and teen smoking as more acceptable in restaurants, recreation centers, and outdoor gathering places. More student smokers than nonsmokers believe that smoking is acceptable for both adults and teens. Of the parent sample, 52% often observed adults and 36% often observed youth smoking outdoors. Nonsmoking parents observed adult and teen smoking more often than parents who smoke.

CONCLUSIONS

The data support an association between the frequency that youth observe smoking in various locations and the perception that smoking is socially acceptable by smoking status. Policies that restrict smoking in various locations will reduce both visibility and perceived acceptability of smoking in those locations.

Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour

The main aim of this article is to assess the relationship between the structural and (health) policy variables of the school and characteristics of the individual on the risk and health behaviour of adolescents. Individual and school level effects on seven health-related behaviours are simultaneously estimated, using multilevel modelling. The data are from the Flemish health behaviour in school-aged children study in Belgium. Data are used from 29 Flemish schools in which students (N=3225), school administrators (N=29) and teachers (N=1132) were surveyed with anonymous written questions. The analysis confirms previous findings concerning individual level effects. Although differences between schools in risk and health behaviour were found to originate mainly from differences in pupil characteristics, substantial variation between schools remained with regard to regular smoking, drinking habits and tooth brushing after controlling for individual effects. A wide range of school structure and policy variables were taken into account, but only few of them were found to influence the health and risk behaviour of young people. Moreover, the study could not detect an effect of health promotion policy at school. The analysis therefore only partially confirms the hypothesis that the school has an impact on the health behaviour of young people. The findings demonstrate the need for a more thorough examination of the paths by which schools can influence the health behaviour of their pupils.

In conversation: high school students talk to students about tobacco use and prevention strategies

The purpose of this multi-site qualitative study is to explore how adolescents talk about tobacco use. Sixty-six students in four high schools became co-researchers and led focus group interviews with 205 fellow students. From the interviews, the authors develop a story line that reports how adolescents begin smoking, how smoking becomes a pervasive influence, how attitudes form about smoking, what it means to be a smoker, and, ultimately, student suggestions for tobacco use prevention. Embedded within this story line are complex questions and contradictions. We explore whether peers really are influential, if the media is important, whether smoking is a matter of personal choice, if schools actually promote tobacco use, and whether adolescents can quit smoking.

Factors influencing implementation of the legislated smoking ban on school property in Ontario

BACKGROUND

Implementation of legislation in Ontario, Canada, that banned smoking on school property gave rise to perceptions of problems in some schools. A telephone survey was conducted to assess these problems. This analysis identifies risk or protective factors in the school environment associated with administrators' reports of problems.

METHODS

Survey data were obtained from key informants in 213 high schools. Multiple logistic regression was used to identify school-related characteristics associated with: (1) major problems in implementing the ban and (2) recommendations that schools return to designated smoking areas.

RESULTS

A protective factor against both outcomes was having a school no-smoking policy prior to the ban. Also protective against major problems was a perceived decrease in student smoking during the school day. The identification of safety risks to students who leave school property to smoke was a strong risk factor for both outcomes. Beliefs that the ban was not effective and opposition to it from teachers/staff were associated with desires for its repeal.

CONCLUSIONS

In implementing legislated school smoking bans, attention should be given to informing teachers and gaining their support. Strategies for dealing with potential safety risks to students who leave school property to smoke should also be devised.

The Ontario ban on smoking on school property: issues and challenges in enforcement

We document implementation and enforcement activities undertaken by high schools and health units with regard to the 1994 ban on smoking on school property in Ontario. Telephone interviews were conducted in the early summer of 1996 with 213 high school administrators and 38 tobacco enforcement personnel in health units. While some schools are unclear about enforcement responsibility, most are making efforts to enforce the ban, including warning and suspending students. Some school administrators (30%) suggest the reinstitution of designated smoking areas on school property. One quarter of health units had not made enforcement visits in schools in the 1995-96 school year and a minority accounted for most of the warnings and tickets issued to students. While most tobacco enforcement officers perceive that schools support the ban, they report some problems in obtaining cooperation in enforcement. However, only 11% suggest returning to designated smoking areas on school property.

The Ontario ban on smoking on school property: issues and challenges in enforcement

We document implementation and enforcement activities undertaken by high schools and health units with regard to the 1994 ban on smoking on school property in Ontario. Telephone interviews were conducted in the early summer of 1996 with 213 high school administrators and 38 tobacco enforcement personnel in health units. While some schools are unclear about enforcement responsibility, most are making efforts to enforce the ban, including warning and suspending students. Some school administrators (30%) suggest the reinstitution of designated smoking areas on school property. One quarter of health units had not made enforcement visits in schools in the 1995-96 school year and a minority accounted for most of the warnings and tickets issued to students. While most tobacco enforcement officers perceive that schools support the ban, they report some problems in obtaining cooperation in enforcement. However, only 11% suggest returning to designated smoking areas on school property.