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Saetta S, Frohlich KL, Le Dref G, Kivits J, Minary L. The (De)normalisation of Smoking Among Apprentices: Plurality of Settings, Norms and Vulnerability Levels. QUALITATIVE HEALTH RESEARCH 2024; 34:473-486. [PMID: 37173861 DOI: 10.1177/10497323231166796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
When it comes to smoking, apprentices are considered a 'vulnerable' population. They have been the subject of targeted approaches based on the assumption of common characteristics. In contrast to most public health studies, that assume homogeneity of vulnerable groups, this article, based on Lahire's 'theory of the plural individual', aims to examine inter- and intra-individual variability in relation to tobacco exposure. It is based on a secondary analysis of 30 interviews with apprentices in France on the stigma attached to their use in their different living environments. Our study confirms that the family and the Centre de Formation des Apprentis, as a whole, encourage smoking. It also provides a better understanding of the mechanisms by which inequalities are perpetuated (permissive rules, loans and gifts of cigarettes, spillover effects, lack of incentives to quit). Nevertheless, it allows us to observe that, in some families and in some companies, smoking is denormalised, even stigmatised. Several apprentice profiles emerge: those who are protected from tobacco and seem to be able to quit easily; those who are permanently confronted with it and for whom it is difficult to consider quitting or reducing; and those who are confronted with a plurality of norms, who seem ambivalent and whose consumption varies significantly. These results will allow us to adapt the interventions according to the profile of the apprentices and by including their entourage. In particular, it will be necessary to propose a 'go-to' approach that goes beyond the school setting and involves the family and the workplace.
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Affiliation(s)
- Sébastien Saetta
- ENSEIS Recherche, ENSEIS, Villeurbanne, France
- UMR 5283 Centre Max Weber, Lyon, France
- EA4360 APEMAC, University of Lorraine, Nancy, France
| | - Katherine L Frohlich
- School of Public Health, University of Montréal, Montréal, QC, Canada
- CReSP, University of Montréal, Montréal, QC, Canada
| | | | - Joëlle Kivits
- EA4360 APEMAC, University of Lorraine, Nancy, France
- Université Paris Cité, Inserm, ECEVE, F-75010 Paris, France
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Kjeld SG, Homberg T, Andersen S. Relationship between smoking and mental health in educational settings with high smoking rates: a cohort study among Danish youth. Scand J Public Health 2024:14034948241227305. [PMID: 38342989 DOI: 10.1177/14034948241227305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
BACKGROUND Smoking and poor mental health in youth represent important public health priorities. This study aimed to (i) compare tobacco-related behaviors and mental health in two educational settings with high smoking rates: vocational education and training (VET) schools and preparatory basic education (PBE) schools, and (ii) examine associations between smoking at school start and mental health 5 months later. METHODS Data were obtained from baseline (N = 1843) and follow-up (N = 1039) assessments conducted as part of a school-based trial in two rounds (baseline in August 2018 and August 2019). Students' characteristics were presented by adjusted prevalences. Logistic regression analyses assessed associations between smoking and measures of mental health: school-related well-being, overall loneliness, and stress. RESULTS More PBE students than VET students reported daily smoking (40% vs. 27%), nicotine dependence, perceived benefits of smoking (e.g., stress reduction: 41% vs. 33%), low smoking-related self-efficacy (e.g., ability to resist smoking if offered by a friend: 20% vs. 32%), school-related loneliness, and low school connectedness (25% vs. 11%). Daily smokers at VET and PBE schools had lower odds of school-related loneliness (AOR = 0.51, 95% CI: 0.35-0.74) and higher odds of stress (AOR = 2.75, 95% CI: 2.00-3.80). Smoking was associated with better classmate relations in VET schools but not in PBE schools. CONCLUSIONS Our study suggested that students in PBE schools constitute a more vulnerable group in terms of smoking and mental health compared with students in VET schools. Smoking seemed to prevent loneliness in school but was associated with heightened stress levels.
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Affiliation(s)
- Simone G Kjeld
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Ponsford R, Melendez-Torres GJ, Miners A, Falconer J, Bonell C. Whole-school interventions promoting student commitment to school to prevent substance use and violence, and improve educational attainment: a systematic review. PUBLIC HEALTH RESEARCH 2024; 12:1-290. [PMID: 38356404 DOI: 10.3310/dwtr3299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Background Whole-school interventions modify the school environment to promote health. A subset of these interventions promotes student commitment to school to prevent substance (tobacco, alcohol, other drugs) use and/or violence. A previous review identified the theory of human functioning and school organisation as a comprehensive theory of such interventions, and found evidence that these interventions reduce substance use and/or violence. Objectives The objectives were to search for, appraise and synthesise evidence to address the following questions: (1) What whole-school interventions promoting student commitment to school to prevent substance use and/or violence have been evaluated, what intervention subtypes are apparent and how closely do these align with the theory of human functioning and school organisation? (2) What factors relating to setting, population and intervention affect implementation? (3) What are the effects on student substance use, violence and educational attainment? (4) What is the cost-effectiveness of such interventions? (5) Are intervention effects mediated by student commitment to school or moderated by setting or population? Data sources A total of 56 information sources were searched (in January 2020), then an updated search of 48 of these was carried out (in May 2021). Reference lists were also searched and experts were contacted. Review methods Eligible studies were process/outcome evaluations of whole-school interventions to reduce student violence or substance use among students aged 5-18 years attending schools, via actions aligning with the theory of human functioning and school organisation: modifying teaching to increase engagement, enhancing student-staff relationships, revising school policies, encouraging volunteering or increasing parental involvement. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised qualitatively. Outcome and economic data were synthesised narratively; outcome data were meta-analysed. Results Searches retrieved 63 eligible reports on 27 studies of 22 interventions. We identified four intervention subtypes focused on student participation in school-wide decisions, improving staff-student relationships, increasing engagement in learning and involving parents. The theories of change of most intervention subtypes aligned closely with the theory of human functioning and school organisation, and informed refinement of an intervention theory of change. Theories of change for interventions increasing learning engagement did not align with this theory, aiming instead to increase school commitment primarily via social skills curricula. Factors influencing the implementation included whether or not interventions were tailorable, workable and well explained. Interventions with action groups comprising staff/students, etc. and providing local data were well implemented. Implementation was also affected by whether or not schools accepted the need for change and staff had the resources for delivery. Meta-analyses suggest small, but significant, intervention effects in preventing violence victimisation and perpetration, and substance use. There was sparse and inconsistent evidence of moderation and some evidence of mediation by student commitment to school. Two economic evaluations suggested that there is the potential for the interventions to be cost-effective. Limitations The quality of the studies was variable and the economic synthesis was limited to two studies. Conclusions Whole-school interventions aiming to promote student commitment to school share similar theories of change and factors affecting implementation. They have the potential to contribute to preventing violence and substance use among young people. Future trials should aim to optimise intervention effectiveness by better theorisation, and assess implementation and effect moderators and mediators. Study registration This study is registered as PROSPERO CRD42019154334. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/151/05) and is published in full in Public Health Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Ruth Ponsford
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jane Falconer
- Library & Archives Service, London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Bonell
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
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Kjeld SG, Thygesen LC, Danielsen D, Jensen MP, Krølner RF, Pisinger C, Andersen S. Do school-based smoking preventive interventions have unintended effects? Post hoc analysis of the Focus cluster randomised controlled trial. BMJ Open 2024; 14:e070176. [PMID: 38191253 PMCID: PMC10806711 DOI: 10.1136/bmjopen-2022-070176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/27/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Public health interventions are designed to improve specific health-related outcomes; however, they may also produce negative side effects, such as substitution use, psychological or social harms. Knowledge about the unintended effects of school-based smoking preventive interventions is sparse. Hence, this study examined these potential unintended effects of the smoking-reducing intervention, Focus, among students in the vocational education and training setting. DESIGN Cluster randomised controlled trial stratified by school type with 5 months follow-up. SETTING AND PARTICIPANTS Across Denmark, eight schools were randomised to the intervention group (n=844 students, response proportion 76%) and six schools to the control group (n=815 students, response proportion 75%). This study focused solely on students who smoked at baseline (N=491). INTERVENTIONS The intervention was developed systematically based on theory and a thoroughly mixed-methods needs assessment. Intervention components included a comprehensive school tobacco policy (smoke-free school hours) supported by a 3-day course for school staff and launched by an edutainment session for students; class-based lessons and a quit-and-win competition; and individual telephone smoking cessation support. OUTCOMES Alternative tobacco and nicotine products (regular use of smokeless tobacco, hookah and e-cigarettes), regular cannabis use, boredom and loneliness at school, stress and perceived stigmatisation among smokers. RESULTS We found no statistically significant unintended effects of the intervention. Nonetheless, insignificant findings indicated that students in the intervention group were less likely to be bored during school hours (OR 0.59, 95% CI 0.32 to 1.10) and experience stress (OR 0.62, 95% CI 0.35 to 1.10), but more likely to report feeling stigmatised compared with the control group (OR 1.55, 95% CI 0.71 to 3.40). CONCLUSIONS Overall, findings suggested no unintended effects of the Focus trial with respect to substitution use, psychological, nor group or social harms. Future research is encouraged to report potential harmful outcomes of smoking preventive interventions, and interventions should be aware of the possible stigmatisation of smokers. TRIAL REGISTRATION NUMBER ISRCTN16455577.
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Affiliation(s)
- Simone G Kjeld
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Lau C Thygesen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Dina Danielsen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Marie P Jensen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Rikke F Krølner
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
| | - Charlotta Pisinger
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
- Center for Clinical Research and Prevention, Frederiksberg University Hospital, Frederiksberg, Denmark
- Tryg Foundation, Virum, Denmark
| | - Susan Andersen
- University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark
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Danielsen D, Jensen TS, Kjeld SG, Bast LS, Andersen S. Context matters in smoking prevention: evaluating smoke-free school hours in Danish vocational schools. Health Promot Int 2023; 38:7143326. [PMID: 37099679 PMCID: PMC10132565 DOI: 10.1093/heapro/daad030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Youth is a crucial period for smoking preventive interventions. School-based interventions targeting the policy level and the sociocultural processes of smoking show promising effects in reducing smoking uptake and prevalence. This study presents findings from the qualitative process evaluation of a smoking preventive intervention, Focus, in the vocational school (VET) setting. Specifically, the study focused on contextual factors affecting the implementation of smoke-free school hours (SFSH). Participant observations and focus groups were conducted in four VETs during the implementation period October-December 2018. The data encompass participant observation field notes (n = 21 school days), student focus groups (n = 8) (aged 16-20), teacher focus groups (n = 5) and semi-structured individual interviews with VET leaders (n = 3). The study found that SFSH was not clearly communicated to students due to the educational structure and chaotic rhythm of the school days, ambivalent attitudes among teachers toward enforcement of smoking rules and lack of clear managerial support. The interplay of these factors counteracted the implementation of SFSH in the VET context. The presented contextual factors are important when interpreting the effectiveness of the Focus intervention and for informing future preventive efforts aiming to reduce smoking among youth in high risk of smoking cigarettes.
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Affiliation(s)
- Dina Danielsen
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Kobenhavn 1455, Denmark
| | - Tina S Jensen
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Kobenhavn 1455, Denmark
| | - Simone G Kjeld
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Kobenhavn 1455, Denmark
| | - Lotus S Bast
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Kobenhavn 1455, Denmark
| | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, Kobenhavn 1455, Denmark
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Kjeld SG, Thygesen LC, Danielsen D, Jakobsen GS, Jensen MP, Holmberg T, Bast LS, Lund L, Pisinger C, Andersen S. Effectiveness of the multi-component intervention 'Focus' on reducing smoking among students in the vocational education setting: a cluster randomized controlled trial. BMC Public Health 2023; 23:419. [PMID: 36864450 PMCID: PMC9979485 DOI: 10.1186/s12889-023-15331-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 02/27/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Social inequality in smoking remains an important public health issue. Upper secondary schools offering vocational education and training (VET) comprise more students from lower socioeconomic backgrounds and have higher smoking prevalence than general high schools. This study examined the effects of a school-based multi-component intervention on students' smoking. METHODS A cluster randomized controlled trial. Eligible participants were schools offering VET basic courses or preparatory basic education in Denmark, and their students. Schools were stratified by subject area and eight schools were randomly allocated to intervention (1,160 invited students; 844 analyzed) and six schools to control (1,093 invited students; 815 analyzed). The intervention program comprised smoke-free school hours, class-based activities, and access to smoking cessation support. The control group was encouraged to continue with normal practice. Primary outcomes were daily cigarette consumption and daily smoking status at student level. Secondary outcomes were determinants expected to impact smoking behavior. Outcomes were assessed in students at five-month follow-up. Analyses were by intention-to-treat and per protocol (i.e., whether the intervention was delivered as intended), adjusted for covariates measured at baseline. Moreover, subgroup analyses defined by school type, gender, age, and smoking status at baseline were performed. Multilevel regression models were used to account for the cluster design. Missing data were imputed using multiple imputations. Participants and the research team were not blinded to allocation. RESULTS Intention-to-treat analyses showed no intervention effect on daily cigarette consumption and daily smoking. Pre-planned subgroup analyses showed statistically significant reduction in daily smoking among girls compared with their counterparts in the control group (OR = 0.39, 95% CI: 0.16, 0.98). Per-protocol analysis suggested that schools with full intervention had higher benefits compared with the control group (daily smoking: OR = 0.44, 95% CI: 0.19, 1.02), while no marked differences were seen among schools with partial intervention. CONCLUSION This study was among the first to test whether a complex, multicomponent intervention could reduce smoking in schools with high smoking risk. Results showed no overall effects. There is a great need to develop programs for this target group and it is important that they are fully implemented if an effect is to be achieved. TRIAL REGISTRATION https://www.isrctn.com/ISRCTN16455577 , date of registration 14/06/2018.
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Affiliation(s)
- Simone G Kjeld
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark.
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Dina Danielsen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Gitte S Jakobsen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Marie P Jensen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Lotus S Bast
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Lisbeth Lund
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
| | - Charlotta Pisinger
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Copenhagen, Denmark
- Faculty of Health Sciences, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Danish Heart Foundation, Copenhagen, Denmark
| | - Susan Andersen
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, Denmark
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Hjort AV, Kuipers MAG, Stage M, Pisinger C, Klinker CD. Intervention Activities Associated with the Implementation of a Comprehensive School Tobacco Policy at Danish Vocational Schools: A Repeated Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12489. [PMID: 36231788 PMCID: PMC9565121 DOI: 10.3390/ijerph191912489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
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 (BT1 = 0.08, 95% CI = 0.03; 0.12; BT2 = 0.07, 95% CI = 0.04-0.50), the joint workshop before policy implementation (BT1 = 0.13, 95% CI = 0.02; 0.25; BT2 = 0.13, 95% CI = 0.004; 0.24), and internalization of fixed procedures for enforcement (BT1 = 0.19, 95% CI = 0.13-0.26; BT2 = 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.
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Affiliation(s)
- Anneke Vang Hjort
- Health Promotion Research, Steno Diabetes Center Copenhagen—Copenhagen University Hospital, 2730 Herlev, Denmark
- National Institute of Public Health, University of Southern Denmark, 5230 Odense, Denmark
| | - Mirte A. G. Kuipers
- Department of Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Health Behaviors & Chronic Diseases, Amsterdam Public Health Research Institute, 1081 BT Amsterdam, The Netherlands
| | - Maria Stage
- The Danish Cancer Society, 2100 Copenhagen, Denmark
| | - Charlotta Pisinger
- Center for Clinical Research and Prevention, Capital Region, 2000 Frederiksberg, Denmark
- The Danish Heart Foundation, 1120 Copenhagen, Denmark
| | - Charlotte Demant Klinker
- Health Promotion Research, Steno Diabetes Center Copenhagen—Copenhagen University Hospital, 2730 Herlev, Denmark
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Hjort AV, Schreuders M, Rasmussen KH, Klinker CD. Are Danish vocational schools ready to implement "smoke-free school hours"? A qualitative study informed by the theory of organizational readiness for change. Implement Sci Commun 2021; 2:40. [PMID: 33836841 PMCID: PMC8033695 DOI: 10.1186/s43058-021-00140-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The smoking prevalence is high among students enrolled in vocational education and training, which is considered a lower level of education. The school tobacco policy regarding smoke-free school hours stipulates that students and staff are not allowed to smoke during school hours-inside or outside school premises-and it might be an effective intervention for reducing smoking in vocational schools. For school tobacco policies to be effective, they must be appropriately implemented. A primary predictor for successful implementation is organizational readiness for change. This study seeks to identify and understand the barriers to and facilitators for developing organizational readiness to implement smoke-free school hours in Danish vocational schools. METHODS Semi-structured interviews and focus groups were carried out with managers and teachers (n = 22 participants) from six vocational schools. The interview guides were informed by "A theory of organizational readiness for change" developed by Weiner, which was also used as a framework to analyze the data. RESULTS We identified 13 facilitators and barriers. Nine factors acted as facilitators, including the following: believing that health promotion is a school role and duty; believing that society and workplaces are becoming more smoke-free, and believing that smoke-free school hours is a beneficial strategy to achieve fewer educational interruptions. Additional facilitators include establishing clear rules for sanctioning and enforcement, developing a joint understanding about smoke-free school hours, developing skills to deal with student responses to smoke-free school hours, establishing social alternatives to smoking, offering smoking cessation help, and mandating smoke-free school hours by law. Four organizational norms, practices, or discourses acted as barriers: believing that smoke-free school hours violate personal freedom, believing that students have more important problems than smoking, believing that it is difficult to administer the level of enforcement, and believing that the enforcement of smoke-free school hours negatively influences student-teacher relations. DISCUSSION Our results suggest that developing organizational readiness before adopting a comprehensive tobacco policy such as smoke-free school hours is important for successful implementation. Further research should investigate how to strengthen the facilitators for and counter the barriers to developing readiness for implementing smoke-free school hours.
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Affiliation(s)
- Anneke Vang Hjort
- Health Promotion Research, Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820, Gentofte, Denmark.,National Institute of Public Health, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen, Denmark
| | - Michael Schreuders
- Department of Public Administration & Sociology, Erasmus School of Behavioral and Social Studies, Erasmus University Rotterdam, 3000, Rotterdam, DR, The Netherlands
| | | | - Charlotte Demant Klinker
- Health Promotion Research, Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, 2820, Gentofte, Denmark.
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van den Toren SJ, van Grieken A, de Kroon MLA, Mulder WC, Vanneste YTM, Raat H. Young adults' self-sufficiency in daily life: the relationship with contextual factors and health indicators. BMC Psychol 2020; 8:89. [PMID: 32859267 PMCID: PMC7456010 DOI: 10.1186/s40359-020-00434-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023] Open
Abstract
Background Certain factors, such as depressive symptoms and binge drinking, may be linked to young adults’ ability to attain an acceptable level of functioning on specific life-domains (i.e. self-sufficiency). We studied the association of contextual factors and health indicators with self-sufficiency in young adults. Methods We used both baseline (n = 755) and 6-months follow-up (n = 200) self-reported questionnaire data of intermediate vocational education students (16–26 years). The questionnaire included the adapted Dutch self-sufficiency matrix (SSM-D), which addresses self-sufficiency regarding 11 life-domains (e.g. finances and housing). The questionnaire also included potentially associated contextual factors (e.g. socio-demographic characteristics) and health indicators (e.g. sickness absence from school). Ordinal (overall self-sufficiency: self-sufficient on 11, 10, 9 or ≤ 8 life-domains), and logistic (self-sufficiency per life-domain: self-sufficient yes/no) regression models were applied. Results The studied population was 18.6 years on average (SD 2.04), and 73.6% were female. Cannabis use was associated with a lower overall self-sufficiency category at baseline (OR = 0.57, 95% CI = 0.33–0.99), as were an increase in sick days (OR = 0.94, 95% CI = 0.91–0.98) and an increase on the scale of depressive symptoms (OR = 0.87, 95% CI = 0.85–0.89). An increase in sick days and an increase on the scale of depressive symptoms were associated with lower odds of being self-sufficient on three and ten life-domains, respectively (p < 0.05). An increase on the scale of depressive symptoms was associated with a lower overall self-sufficiency category 6-months post-baseline (OR = 0.90, 95% CI = 0.86–0.93). Conclusions Our findings underline the importance of addressing self-sufficiency, sickness absence, and depressive symptoms, preferably before the transition from adolescence to young adulthood has begun.
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Affiliation(s)
- Suzanne J van den Toren
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Amy van Grieken
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands
| | - Marlou L A de Kroon
- Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | - Wico C Mulder
- Dutch Center for Youth Health (NCJ), Utrecht, the Netherlands
| | | | - Hein Raat
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
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Chyderiotis S, Benmarhnia T, Spilka S, Beck F, Andler R, Legleye S, Menvielle G. Why do apprentices smoke much more than high school students? Understanding educational disparities in smoking with a Oaxaca-blinder decomposition analysis. BMC Public Health 2020; 20:924. [PMID: 32532252 PMCID: PMC7291761 DOI: 10.1186/s12889-020-09050-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/04/2020] [Indexed: 12/04/2022] Open
Abstract
Background Educational disparities in daily smoking begin during adolescence and can lead to educational disparities in health among adults. In particular, vocational students including apprentices have higher daily smoking rates compared to non-vocational students. This study aimed to identify the determinants of the gap in daily smoking between French apprentices and high school students aged 17 in 2008 and in 2017. Methods We used data from a cross-sectional repeated survey representative of all French adolescents aged 17 in 2008 and 2017. We conducted a non-linear extension of the Oaxaca-Blinder decomposition technique and included the following variables: sociodemographic and familial characteristics, parental smoking, cannabis and alcohol use, suicidal attempt, grade repetition and money received. Results Daily smoking was about two times higher among French apprentices compared to high school students in 2008. This gap did not decrease between 2008 and 2017. Differences in measured characteristics between the two groups explained this gap partly, from 28.6 to 51.2%. Cannabis and alcohol use, money received and parental smoking contributed the most to the daily smoking gap. Conclusions Prevention programs could target cannabis and alcohol use as well as parental smoking to help decrease educational disparities in smoking status among French adolescents.
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Affiliation(s)
- Sandra Chyderiotis
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, CESP, 92541, Villejuif, France. .,Observatoire français des drogues et des toxicomanies (OFDT), 69, rue de Varenne, 75007, Paris, France.
| | - Tarik Benmarhnia
- Department of Family Medicine and Public Health, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA.,Scripps Institution of Oceanography, University of California, San Diego, CA, USA
| | - Stanislas Spilka
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, CESP, 92541, Villejuif, France.,Observatoire français des drogues et des toxicomanies (OFDT), 69, rue de Varenne, 75007, Paris, France
| | - François Beck
- Institut national de la statistique et des études économiques, 88, avenue Verdier, CS 70058, 92541, Montrouge Cedex, France
| | - Raphaël Andler
- Santé Publique France, 12, rue du Val d'Osne, 94415, Saint-Maurice Cedex, France
| | - Stéphane Legleye
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, CESP, 92541, Villejuif, France.,Institut national de la statistique et des études économiques, 88, avenue Verdier, CS 70058, 92541, Montrouge Cedex, France
| | - Gwenn Menvielle
- Department of Social Epidemiology, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, 75012, Paris, France
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11
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Klinker CD, Aaby A, Ringgaard LW, Hjort AV, Hawkins M, Maindal HT. Health Literacy is Associated with Health Behaviors in Students from Vocational Education and Training Schools: A Danish Population-Based Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020671. [PMID: 31968667 PMCID: PMC7014204 DOI: 10.3390/ijerph17020671] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/17/2020] [Accepted: 01/19/2020] [Indexed: 01/16/2023]
Abstract
Health literacy has been identified as an important and changeable intermediary determinant of health equity. Vocational education and training (VET) schools are a relevant setting for health behavior interventions seeking to diminish health inequities because many VET students come from low socio-economic status backgrounds. This study examines VET students’ health literacy and its association with health behavior based on a cross-sectional survey among 6119 students from 58 VET schools in Denmark in 2019. Two scales from the Health Literacy Questionnaire was used to assess domains of health literacy. Data were analyzed using Anova and logistic regression. The study population consisted of 43.4% female, and mean age was 24.2 years (range 15.8–64.0). The health literacy domain ‘Actively managing my health’ mean was 2.51, SD 0.66, and ‘Appraisal of health information’ mean was 2.37, SD 0.65. For both domains, being female, older age, attending the VET educational program Care-health-pedagogy, and higher self-rated health were associated with higher scale scores. In the adjusted analyses, lower scale scores were associated with less frequent breakfast, daily smoking, high-risk alcohol behavior and moderate-to-low physical activity. Our results show that low health literacy is associated with unhealthy behaviors in this population. Our results support and inform health literacy research and practice in educational institutions and services.
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Affiliation(s)
- Charlotte Demant Klinker
- Steno Diabetes Center Copenhagen, Health Promotion, Niels Steensens vej 6, 2820 Gentofte, Denmark
- Correspondence: ; Tel.: +45-30-91-29-68
| | - Anna Aaby
- Department of Public Health, Bartholins Alle 2, Aarhus University, 8000 Aarhus, Denmark
| | - Lene Winther Ringgaard
- Steno Diabetes Center Copenhagen, Health Promotion, Niels Steensens vej 6, 2820 Gentofte, Denmark
| | - Anneke Vang Hjort
- Steno Diabetes Center Copenhagen, Health Promotion, Niels Steensens vej 6, 2820 Gentofte, Denmark
| | - Melanie Hawkins
- School of Health and Social Development, Deakin University, Geelong, VIC 3220, Australia
| | - Helle Terkildsen Maindal
- Steno Diabetes Center Copenhagen, Health Promotion, Niels Steensens vej 6, 2820 Gentofte, Denmark
- Department of Public Health, Bartholins Alle 2, Aarhus University, 8000 Aarhus, Denmark
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12
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Heinze C, Hjort AV, Elsborg P, Maindal HT, Klinker CD. Smoke-free-school-hours at vocational education and training schools in Denmark: attitudes among managers and teaching staff - a national cross-sectional study. BMC Public Health 2019; 19:813. [PMID: 31234822 PMCID: PMC6591894 DOI: 10.1186/s12889-019-7188-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tobacco is the main cause of non-communicable disease and premature death globally. Implementing restrictive school tobacco policies such as smoke-free-school-hours (SFSH) may have the potential to reduce smoking among Vocational Education and Training (VET) school students. To be effective, school tobacco policies that largely involve strict and consistent enforcement by both managers and teaching teaching staff must be implemented. This study investigated the attitudes towards the implementation of SFSH among the managers and teaching staff at Danish VET schools. METHODS The analyses were based on cross-sectional survey data collected with an online survey among managers and teaching staff at Danish VET schools. The data was collected from March to June 2017. RESULTS Managers and teaching staff (n = 571) from 71 out of 87 Danish VET schools (81.6%) took part in the survey. In the adjusted analysis, teaching staff were twice as likely as managers to have a favourable attitude towards SFSH. Furthermore, being female and of increasing age correlated with having a favourable attitude. A trend towards schools in favour of SFSH having more health promotion facilities, policy and practice, was identified. CONCLUSION AND IMPLICATIONS Existing health promotion facilities and activities at the schools were associated with a favorable attitude among the management towards implementing SFSH. Thus, implementing other health promotion activities and policies might be an important first step to establish readiness to implement SFSH.
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Affiliation(s)
- Clara Heinze
- Health Promotion, Steno Diabetes Center Copenhagen, Niels Steensens vej 6, 2820, Gentofte, Denmark.
| | - Anneke Vang Hjort
- Health Promotion, Steno Diabetes Center Copenhagen, Niels Steensens vej 6, 2820, Gentofte, Denmark
| | - Peter Elsborg
- Health Promotion, Steno Diabetes Center Copenhagen, Niels Steensens vej 6, 2820, Gentofte, Denmark
| | - Helle Terkildsen Maindal
- Health Promotion, Steno Diabetes Center Copenhagen, Niels Steensens vej 6, 2820, Gentofte, Denmark.,Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Charlotte Demant Klinker
- Health Promotion, Steno Diabetes Center Copenhagen, Niels Steensens vej 6, 2820, Gentofte, Denmark
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13
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Adolescent Smoking in Secondary Schools that Have Implemented Smoke-Free Policies: In-Depth Exploration of Shared Smoking Patterns. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16122100. [PMID: 31200563 PMCID: PMC6616619 DOI: 10.3390/ijerph16122100] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/31/2019] [Accepted: 06/12/2019] [Indexed: 11/24/2022]
Abstract
Large numbers of adolescents smoke during school hours, despite the implementation of smoke-free school policies (SFSPs). Studies about SFSPs predominantly analyse smoking as individual behaviour, yet there is increasing recognition that smoking should be understood as social behaviour. We explored shared smoking patterns specifying where, when, and with whom, and social meanings about why groups of adolescents smoke in two Dutch schools that have implemented SFSPs. Surveys among adolescents were held to obtain contextual information about the schools. Four focus group discussions and fourteen individual interviews were held with adolescents to identify shared smoking patterns in each school. Two shared patterns were identified at a school where 17% of students smoked daily: Dependent smoking and Rebellious smoking. Both built on pro-smoking norms and underscored the benefits of smoking. Three shared patterns were identified at a school where 3% of students smoked daily: Social bonding smoking, Low-profile smoking and Smoking-friendly event smoking. These built on anti-smoking norms and helped smokers cope with negative social judgements related to smoking. We conclude that adolescent smoking during school hours is embedded in diverse shared smoking patterns. Future studies should develop more understanding about how to deal with adolescents’ shared smoking patterns that decrease the effectiveness of tobacco policies.
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14
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Stjernqvist NW, Sabinsky M, Morgan A, Trolle E, Thyregod C, Maindal HT, Bonde AH, Tetens I. Building school-based social capital through 'We Act - Together for Health' - a quasi-experimental study. BMC Public Health 2018; 18:1141. [PMID: 30257663 PMCID: PMC6158853 DOI: 10.1186/s12889-018-6026-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 09/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Social capital has been found to be positively associated with various health and well-being outcomes amongst children. Less is known about how social capital may be generated and specifically in relation to children in the school setting. Drawing on the social cohesion approach and the democratic health educational methodology IVAC (Investigation - Vision - Action - Change) the aim of this study was to examine the effect of the Health Promoting School intervention 'We Act - Together for Health' on children's cognitive social capital. METHOD A quasi-experimental controlled pre- and post-intervention study design was conducted with 548 participants (mean age 11.7 years). Cognitive social capital was measured as: horizontal social capital (trust and support in pupils); vertical social capital (trust and support in teachers); and a sense of belonging in the school using questions derived from the Health Behaviour in School Children study. A series of multilevel ordinal logistic regression analyses was performed for each outcome to estimate the effect of the intervention. RESULT The analyses showed no overall significant effect from the intervention on horizontal social capital or vertical social capital at the six-month follow-up. A negative effect was found on the sense of belonging in the school. Gender and grade appeared to be important for horizontal social capital, while grade was important for sense of belonging in the school. The results are discussed in relation to We Act's implementation process, our conceptual framework and methodological issues and can be used to direct future research in the field. CONCLUSION The study finds that child participation in health education can affect the children's sense of belonging in the school, though without sufficient management support, this may have a negative effect. With low implementation fidelity regarding the Action and Change dimension of the intervention at both the school and class level, and with measurement issues regarding the concept of social capital, more research is needed to establish a firm conclusion on the importance of the children's active participation as a source for cognitive social capital creation in the school setting. TRIAL REGISTRATION https://www.isrctn.com/ISRCTN85203017.
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Affiliation(s)
- Nanna W. Stjernqvist
- Division for Risk Assessment and Nutrition, National Food Institute, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
- Diabetes Prevention Research, Steno Diabetes Center Copenhagen, 2820 Gentofte, Denmark
| | - Marianne Sabinsky
- Division for Diet, Disease Prevention and Toxicology, National Food Institute, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - Antony Morgan
- Public Health, Glasgow Caledonian University in London, 40 Fashion Street, Spitalfields, London, E1 6PX UK
| | - Ellen Trolle
- Division for Risk Assessment and Nutrition, National Food Institute, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - Camilla Thyregod
- Department of Applied Mathematics and Computer Science, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Helle T. Maindal
- Diabetes Prevention Research, Steno Diabetes Center Copenhagen, 2820 Gentofte, Denmark
- Present address: Department of Public Health - Department of Health Services Research, Aarhus University, 8000 Aarhus, Denmark
| | - Ane H. Bonde
- Diabetes Prevention Research, Steno Diabetes Center Copenhagen, 2820 Gentofte, Denmark
| | - Inge Tetens
- Division for Diet, Disease Prevention and Toxicology, National Food Institute, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
- Present address: Department of Nutrition, Exercise and Sports, Vitality - Centre for Good Older Lives, University of Copenhagen, 1958 Frederiksberg C, Denmark
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15
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Andersen S, Rod MH, Holmberg T, Ingholt L, Ersbøll AK, Tolstrup JS. Effectiveness of the settings-based intervention Shaping the Social on preventing dropout from vocational education: a Danish non-randomized controlled trial. BMC Psychol 2018; 6:45. [PMID: 30208956 PMCID: PMC6134754 DOI: 10.1186/s40359-018-0258-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 09/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lack of formal education is an important social determinant of health inequality and represents a public health problem. School dropout is particularly common in vocational education; however few prevention programs targeting dropout in the vocational school setting have been evaluated. The purpose of the present study was to test the effect on school dropout of a settings-based intervention program (named Shaping the Social) that targeted the school organization in order to create social and supportive learning environments. METHODS A non-randomized controlled design including four large intervention schools and six matched-control schools was used. The target population was students in technical and agricultural vocational education, which is provided to students from age 16. Students were enrolled at school start. Register-based data (n = 10,190) was used to assess the effect on school dropout during a 2-year period. Odds ratios (OR) and 95% confidence intervals (CI) were calculated in logistic regression models, adjusting for age, sex, ethnicity, parental income, prior school dropout and type of basic course. Student survey (n = 2396) at 10-week follow-up was used to examine wellbeing at school (four subscales: school connectedness, student support, teacher relatedness, and valuing the profession) which was the hypothesized proximal intervention effect. As a secondary aim, we examined how the student wellbeing factors were associated with school dropout, independently of the intervention, and we explored whether the student wellbeing factors were potential mediators. RESULTS The present study showed an intervention effect on school dropout with dropout rates lower in intervention schools (36%) than control schools (40%) (OR = 0.86, 95% CI: 0.74, 0.99). We had no attrition on the dropout outcome. School connectedness mediated the intervention effect; no significant mediation effects were found for student support, teacher relatedness, and valuing the profession. Independently of the intervention, each student wellbeing factor prevented dropout. CONCLUSIONS Findings from this study suggest that a comprehensive, multicomponent school-based intervention could prevent dropout from vocational education by promoting school connectedness; nevertheless, the dropout rate remained high. Our results point to the need to explore how to further improve the wellbeing at school among young people in vocational education. TRIALS REGISTRATION ISRCTN, ISRCTN57822968 . Registered 16 January 2013 (retrospective registered).
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Affiliation(s)
- Susan Andersen
- Centre for Intervention Research in Health Promotion and Disease, National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen K, Denmark.
| | - Morten Hulvej Rod
- National Research Centre for Disadvantaged Children and Youth, Kronprinsesse Sofies Vej 35, Frederiksberg, Denmark
| | - Teresa Holmberg
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen, Denmark
| | - Liselotte Ingholt
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen, Denmark
| | - Annette Kjær Ersbøll
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen, Denmark
| | - Janne Schurmann Tolstrup
- National Institute of Public Health, University of Southern Denmark, Studiestræde 6, DK-1455, Copenhagen, Denmark
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16
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Tolstrup JS, Pisinger VSC, Egan KK, Christensen AI. Trends in smoking and smokeless tobacco use among Danish Adolescents, 1997-2014. Tob Prev Cessat 2018; 4:10. [PMID: 32411838 PMCID: PMC7205043 DOI: 10.18332/tpc/86331] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 01/23/2023]
Abstract
INTRODUCTION High rates of smoking among adolescents remain a public health concern. This study investigates smoking behavior and use of smokeless tobacco among Danish high-school students and assesses how smoking and use of smokeless tobacco cluster in schools and school classes. We estimate the trend in cigarette smoking from 1997 to 2014. METHODS We used data on 70 243 students, from 3 214 school classes in 119 high schools, who participated in the Danish National Youth Study from 2014. We had information on 87% of all Danish high schools and 85% of eligible students. We also used data from 1997 on 26 644 high-school students from a similar data set to assess the chronological trend in smoking. We calculated prevalences and intraclass correlation coefficients (ICCs) to estimate between-school and between-school class clustering in smoking and use of smokeless tobacco. RESULTS In all, 14% of boys and 11% of girls were daily smokers. A large fraction of the variation in smoking and the use of smokeless tobacco was attributable to the school and school-class level (ICC of 0.19, 0.12, 0.16 and 0.27, for daily smoking, waterpipe smoking, use of electronic cigarettes and snuff/chewing tobacco, respectively). Daily smoking decreased from 15% in 1997 to 12% in 2014, while more students were occasional smokers in 2014 than in 1997 (30% vs 18%). CONCLUSIONS The prevalence of smoking was high among Danish high-school students and had changed little since 1997. The school and class environment accounted for a large part of the variation in smoking behavior.
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Affiliation(s)
- Janne S Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Veronica S C Pisinger
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Kia K Egan
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Anne I Christensen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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17
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Jarlstrup NS, Juel K, Pisinger CH, Grønbæk M, Holm S, Andersen S. International Approaches to Tobacco Use Cessation Programs and Policy in Adolescents and Young Adults: Denmark. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0187-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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