The relationship between school policies and youth tobacco use

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

OBJECTIVE

This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation.

DESIGN

Qualitative semi-structured interviews.

SETTING

Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.

PARTICIPANTS

Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.

RESULTS

The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.

CONCLUSION

Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

From a teacher and school leader perspective: What happened with smoking rules and practices during a three-year smoking preventive intervention? - Findings from the X:IT II study

BACKGROUND

School-based smoking preventive interventions are most effective if they consist of multiple components; one of them being strict anti-smoking rules, i.e., no smoking by anyone at any location during school hours. However, there is a lack of in-depth knowledge about how smoking practices and rules about smoking actually change over time. Therefore, the purpose of this study was to examine how smoking practices changed during a three-year period in which a smoking preventive intervention with strict anti-smoking rules was implemented at schools.

METHODS

We used data from 46 Danish schools that were enrolled in the evaluation of the X:IT II study - a smoking preventive intervention with three main components: one of them being strict anti-smoking rules. We collected questionnaire data among school employees at four timepoints from the autumn of 2017 until April 2020. The questionnaire covered topics regarding students' and employees' tobacco patterns at the school, control with smoking, and aspects of the intervention delivery.

RESULTS

Over time, student smoking rules got stricter; from three out of four at baseline to almost all schools having rules about no student smoking during school hours three years later. Employee smoking rules also changed, although not as much as student rules. Overall, smoking at school grounds seemed to decline - however, student smoking at other locations increased, hence, violating the rule about no smoking during school hours. Enforcement of smoking rules also increased over time.

CONCLUSION

Although implementing and enforcing new rules in a school setting may be difficult, it seemed that most schools in the X:IT II study changed their rules and smoking practices for both students and employees over the three-year intervention period. It seemed, however, that students relocated their smoking to other places than the school or just outside school grounds. Implications of these findings are important to consider in future interventions, i.e., students leaving school during school hours to smoke and the physical separation between those who smoke and those who do not.

The Diffusion of Smoking: Association Between School Tobacco Policies and the Diffusion of Adolescent Smoking in 38 Schools in 6 Countries

Social network research has evidenced the role of peer effects in the adoption of behaviours. Little is known, however, about whether policies affect how behaviours are shared in a network. To contribute to this literature, we apply the concept of diffusion centrality to school tobacco policies and adolescent smoking. Diffusion centrality is a measure of centrality which refers to a person's ability to diffuse a given property-in our case, smoking-related behaviours. We hypothesized that stronger school tobacco policies are associated with less diffusion centrality of smoking on school premises and of smoking in general. A whole network study was carried out in 2013 and 2016 among adolescents (n = 18,805) in 38 schools located in six European cities. Overall, diffusion centrality of smoking in general and of smoking on school premises significantly decreased over time. Diffusion centrality of smoking significantly decreased both in schools where the policy strengthened or softened over time, but for diffusion of smoking on school premises, this decrease was only significant in schools where it strengthened. Finally, stronger school tobacco policies were associated with lower diffusion centrality of smoking on school premises and of smoking in general, though to a lesser extent. With such policies, smoking may, therefore, become less prevalent, less popular, and less clustered, thereby lowering the risk of it spreading within networks in, and even outside the school.

Facilitating conditions for staff's confidence to enforce school tobacco policies: qualitative analysis from seven European cities

Background

School staff members’ consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff’s confidence, indicating their perceived ability to cope with students’ negative responses, explains variations in staff’s STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff’s enforcement. 

Methods

Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3–4 staff members (senior management, teachers, supportive staff) in 3–4 schools (academic–vocational, high–low SES area) were interviewed. Transcripts were analyzed with thematic analysis.

Results

When staff felt confident in their ability to prevent, diminish, or handle students’ negative responses, they were more likely to address students on STP violations. The staff was more confident (1) when consistent policy enforcement within school and regarding the wider society ensured staff legitimacy for STPs enforcement, (2) when dialog and mutual familiarity with students allowed the staff to facilitate constructive interaction with STP violators, and (3) when organizational backup structures provided staff collegial support to overcome challenges in the enforcement. These conditions would support consistent enforcement, especially with persistent misbehavers and among the more uncertain staff members.

Conclusions

Our study stresses the need to implement strategies at multiple levels to strengthen staff’s confidence for STP enforcement. To support staff’s legitimacy for enforcement, we suggest reinforcing structures and practices that facilitate consistency in STP enforcement; to support staff’s ability for constructive interaction with STP violators, we suggest strengthening staff’s social and emotional learning; and to support staff’s experience of collegial support, we suggest reinforcing staff’s collective ability to cope with students’ negative responses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00362-7.

Self-Reported Sedative Drug Use Among Students Attending at University of Gondar, Gondar, Northwest, Ethiopia: A Cross-Sectional Study

Background

Medical students experience significant psychological stress and are therefore at higher risk of using sedatives. There are currently no studies describing the prevalence of sedative drug use among medical students in Ethiopia. This study aimed to assess the prevalence and associated factors of self-reported sedative drug use among medical students attending the College of Medicine and Health Science (CMHS) students at the University of Gondar (UoG).

Material and Methods

A prospective cross-sectional study was conducted from May to July 2018 in CMHS at UoG. Data were collected using a pre-tested self-administered standard questionnaire. Data were collected, entered into a computer using Epi Info 7 software, and analyzed using SPSS version 20. Frequency, mean, and standard deviation were used to describe descriptive statistics, and binary and multiple logistic regression analyses were used to assess the association between different variables and sedative drug use; P <0.05 was used to declare association.

Results

Of the 422 students who returned questionnaires, 26 (6.2%) participants were reported sedative drug use at some time since enrollment. Of these, 61.54% participants used antihistamine drugs. Smoking status (AOR (95% CI), 0.046 (0.009–0.241) P = 0.0001), stimulant use (AOR (95% CI), 0.220 (0.062–0.780) P = 0.019), sleeping hour (AOR (95% CI), 9.931 (4.155–14.785) P = 0.001) and sleep disorder (AOR (95% CI), 0.149 (0.033–0.680) P = 0.014) were significantly associated with sedative drug use.

Conclusion

Self-reported sedative drug use among medical students at the University of Gondar is relatively low, and antihistamines are the most commonly used drugs. Smoking, stimulant use, sleeping hour, and the presence of sleep disorders were associated with sedative drug use.

Are Danish vocational schools ready to implement "smoke-free school hours"? A qualitative study informed by the theory of organizational readiness for change

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.

Programme theory and realist evaluation of the 'Smoke-Free Vocational Schools' research and intervention project: a study protocol

INTRODUCTION

Smoke-free school hours (SFSHs) entails a smoking ban during school hours and might be an effective intervention to reduce the high smoking prevalence in vocational schools. For SFSH to be effective, the policy must be adequately implemented and enforced; this challenge for schools constitutes a research gap. The 'Smoke-Free Vocational Schools' research and intervention project has been developed to facilitate schools' implementation of SFSH. It is scheduled to run from 2018 to 2022, with SFSH being implemented in 11 Danish vocational schools. This study protocol describes the intervention project and evaluation design of the research and intervention project.

METHODS AND ANALYSIS

The intervention project aims to develop an evidence-based model for implementing SFSH in vocational schools and similar settings. The project is developed in a collaboration between research and practice. Two public health NGOs are responsible for delivering the intervention activities in schools, while the research partner evaluates what works, for whom, and under what circumstances. The intervention lasts one year per school, targeting different socioecological levels. During the first 6 months, activities are delivered to stimulate organisational readiness to implement SFSH. Then, SFSH is established, and during the next 6 months, activities are delivered to stimulate implementation of SFSH into routine practice. The epistemological foundation is realistic evaluation. The evaluation focuses on both implementation and outcomes. Process evaluation will determine the level of implementation and explore what hinders or enables SFSH becoming part of routine practice using qualitative and quantitative methods. Outcomes evaluation will quantitively assess the intervention's effectiveness, with the primary outcome measure being changes in smoking during school hours.

ETHICS AND DISSEMINATION

Informed consent will be obtained from study participants according to the General Data Protection Regulation (GDPR) and Danish data protection law. The study adheres to Danish ethics procedures. Study findings will be disseminated at conferences and further published in open-access peer-reviewed journals.

Differential patterns of e-cigarette and tobacco marketing exposures among youth: Associations with substance use and tobacco prevention strategies

BACKGROUND

This study identified patterns of tobacco marketing exposures among youth and examined their associations with substance use and tobacco prevention strategies.

METHODS

In Fall 2018, 2,058 middle and high school students (ages 11-18) in an Appalachian county completed a substance use and behavioral health surveillance survey. We conducted latent class analysis (LCA) to identify exposure classes based on responses to 14 tobacco marketing exposures. Multinomial logistic regression was then performed to determine associations between the latent classes with past 30-day substance use and tobacco prevention strategies (e.g., school policies, parental rules, prevention messages).

RESULTS

Four latent classes of marketing exposure were identified among middle school students: low exposure, television, social media, and high exposure. Multinomial logistic regression found significant associations between e-cigarette use with the social media and high exposure classes, while prescription drug use was associated with the social media class and alcohol use with the high exposure class. For high school students, five classes were identified: low exposure, social media, environmental, cigarettes, and high exposure. E-cigarette and prescription drug use were associated with the social media and high exposure classes. Cigarette use was associated with the social media class. School rules prohibiting e-cigarettes were associated with the television class for middle school students. Self-reported exposure to prevention messages about the harms of tobacco were associated with multiple exposure classes for both middle (television and social media) and high school (social media and cigarettes) students, suggesting that both pro- and anti-tobacco communications have become ubiquitous and may be saturating youth.

CONCLUSION

This study demonstrates the need for stricter tobacco marketing regulations and multi-level interventions beginning in early adolescence that focus on increasing media-based literacy for youth to better discern tobacco prevention messages from pro-tobacco communications.

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.

Implementing Prevention against Tobacco Dependence (PAD) "Toward the Tobacco-Free Schools, Neighborhoods, and Cities": Study Protocol

INTRODUCTION

Although tobacco consumption in Iran has decreased in recent years, in 2010, the exposure to cigarette smoke was the fifth leading risk factor for death in Iran. This article is presenting the protocol for the prevention against tobacco dependence (PAD) project, an initiative planned and implemented by the Iranian Anti-Tobacco Association (IATA) of Iran in the city of Varamin.

STUDY DESIGN

A prospective cohort study.

METHODS

This project is carried out based on a participatory community-oriented approach and an action research method. It includes four inter-related, prospective studies phases; pilot, tobacco-free school (TFS), tobacco-free neighborhood (TFN), and tobacco-free city (TFS). The measuring tools for each phase were designed primarily using CDC and WHO guidelines and preliminary details were identified. Each phase is a combination of different methods (including systematic observation, questionnaire, heuristic interview, and structured interview). The studies will examine twelve goals and meet 9 project objectives in a comprehensive evaluation of ongoing progress with TFS, TFN, and TFC.

DISCUSSION

This project seeks to achieve indicators of tobacco-free schools, neighborhoods, and cities through direct and indirect education of all the target groups in the community. Participation of stakeholders and supporters in problem-solving can increase the effectiveness and influence of the project. The outcomes of the first two phases will be expanded to the wider settings.

Study protocol of the X:IT II - a school-based smoking preventive intervention

BACKGROUND

The X:IT intervention, conducted in 2010 to 2013, showed overall smoking preventive effect. However, parts of the intervention appeared less appealing to children from families with lower socioeconomic backgrounds. Therefore, the intervention components were modified and an evaluation of the amended intervention X:IT II is needed to show the effect of this revised intervention and whether children from different social backgrounds benefits equally from the current intervention.

METHODS

Main intervention components are smoke free schools, a curricular component, and parental involvement (smoke free agreements and talks about tobacco). Components have been revised from the first version; 1) previously, schools should be smoke free on the school ground and were encouraged to hide smoking so that it wasn't visible to pupils from the school ground. Now they are encouraged to tighten the rules so that no pupils or teachers smoke during the school day, no matter where they are; 2) the specifically developed educational material (Up in Smoke) has been revised so that all materials are online and all texts has a ARI; 3) the parental involvement is now targeted multiple groups of parents, e.g. parents that are smokers, and parents of children that smoke. Language used is simpler and the website for parents presents very specific examples. X:IT is implemented in 46 Danish public schools from fall 2017 until summer 2020. Data is collected through electronic questionnaires to students and coordinators four times (fall 2017, spring/summer 2018, 2019 and 2020). Further, qualitative interviews and observations are conducted.

DISCUSSION

Prevalence of smoking among Danish adolescents is high compared to other Nordic countries and there is social inequality in smoking, leaving individuals from the lowest social backgrounds at higher risk. Although there has been an overall decline in smoking among Danish adolescents over the last decades, a recent levelling of this development indicates an urgent need for smoking prevention in Denmark. The X:IT intervention has the potential to prevent uptake of smoking among adolescents. However, there is a particular need for evaluating the effectiveness of the revised X:IT intervention, X:IT II, with focus on the effect across socioeconomic groups of adolescents.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN31292019 , date of registration 24/10/2017. Retrospectively registered.

Assessing the strength of secondary school tobacco policies of schools in the COMPASS study and the association to student smoking behaviours

OBJECTIVES

The school environment is an ideal setting to introduce policies to prevent smoking behaviour. However, there may be variability in the strength of school board and secondary school tobacco policies, which may affect student smoking behaviours. This study assessed the strength of a sample of school board and secondary school tobacco policies and examined the association with student smoking behaviours.

METHODS

Tobacco policies from school boards (n = 21/26) and secondary schools (n = 43/81) that participated in the COMPASS study during 2015-2016 were obtained online. A standardized instrument was used to assess the strength of school board and secondary school tobacco policies on four domains. Using the sample of students from schools with identified policies (n = 22,696), separate multilevel regression models examined the association between school policy scores and a student's susceptibility to smoking, ever smoking, current smoking, and perceived support of the school environment.

RESULTS

The mean school board tobacco policy score was 13.7/40 and the mean secondary school tobacco policy score was 11.3/40. Students were significantly less likely to report current smoking (OR 0.95, 95% CI 0.91-0.99) and more likely to report a supportive school environment (OR 1.06, 95% CI 1.04-1.08) with each four-unit (i.e., 10%) increase in school tobacco policy score.

CONCLUSIONS

The vast majority of school board and secondary school tobacco policies were missing components and therefore could not be considered comprehensive. Stronger school tobacco policies may help to reduce student current smoking behaviours.

School Policy, Administrator Perceptions, and Student E-cigarette Use

Objective

In this study, we investigated the relationship between school e-cigarette policy and e-cigarette use among students. Secondarily, we examined whether this relationship varied by administrator perceptions about e-cigarette use being "an issue."

Methods

Data were utilized from written school policies, a school tobacco surveillance study of 2755 students (N = 310,412), and administrator interviews in 54 Texas schools.

Results

When administrators perceived e-cigarettes as an issue, the odds of ever e-cigarette use, susceptibility to use e-cigarettes, and perceived peer use of e-cigarettes were 0.20-0.54 times lower for students attending schools that had an e-cigarette policy compared to those without a policy (p < .05).

Conclusion

The impact of school policies on student e-cigarette use behavior is positive if policies are strongly implemented.

School workers' knowledge, attitude and behaviour related to use of Toombak: a cross sectional study from Khartoum state, Sudan

BACKGROUND

Toombak is a form of smokeless tobacco (SLT) that is locally made and consumed in Sudan and contains several carcinogenic elements. Use of Toombak has been etiologically linked to various oral diseases including oral cancer. This study aimed to obtain baseline information about the Toombak use among Sudanese school workers, as well as their knowledge about Toombak related health hazards and attitude towards their role in Toombak control. In addition, this study assessed the availability and effectiveness of control policies and preventive practices in the schools.

METHODS

A cross-sectional school-based study using one-stage stratified random sampling procedure; four schools were selected randomly from each of seven localities. A total of 239 school workers' were recruited (census) from the selected schools in Khartoum State, Sudan.

RESULTS

Of the school workers, 63% (147) were ≤40 years, half were females and 79.2% (187) were teachers. A total of 9.6% (22) school workers confirmed ever use of Toombak and the percentage of daily users amounted to 64.7% (11). Moreover, 76.2% (16) of ever Toombak users were ≥40 years and all of them were males (p < 0.001). Most of the school workers reported good knowledge, positive attitude towards their role in Toombak control and good preventive practice. Female school workers were more likely to report positive attitude towards their role in Toombak control (p < 05), and to report good knowledge. Those reporting good preventive practice in schools reported good knowledge more than two times than their counterpart (p < 0.001). Age was the strongest predictor of ever Toombak use among school workers (p < .001).

CONCLUSIONS

The use of Toombak among school workers was associated with poor knowledge, negative attitude towards their role in Toombak control and poor preventive practice, Therefore, school workers use of Toombak may reduce their motivation and use of their potential in the prevention of a major health problem caused by Toombak use and affects their role model behaviour. On the other hand, school workers engagement with preventive practices in schools' was associated with good knowledge which in turn empowers their positive attitude towards their role in Toombak control.

Changing the Smoking Trajectory: Evaluating the Impact of School-Based Tobacco Interventions on Changes to Susceptibility to Future Smoking

School-based programs and policies can reduce student smoking rates. However, their impact on never-smoking students has not been investigated despite the clear transition between non-susceptible, susceptible, and ever tried smoking statuses. The objective of this paper was to examine the longitudinal student-level impact of six changes in school-based tobacco control programs and policies on student transitions in susceptibility to smoking over one year. Two multinomial logistic regression models identified the relative risk of a change in self-reported susceptibility to smoking or in trying a cigarette among never-smoking students in each of the six intervention schools compared to the relative risk among never-smoking students in control schools. Model 1 identified the relative risk of a change in smoking susceptibility status among baseline non-susceptible never smoking students, while Model 2 identified the relative risk of a change in smoking susceptibility status among baseline susceptible never smoking students. Students at some intervention schools were at increased risk of becoming susceptible to or trying a cigarette at one year follow-up. Intervention studies should examine changes to susceptibility to future smoking when evaluating impact to ensure that school-based tobacco control programs and policies do not negatively change the risk status of never-smoking students.

The Tobacco Control Network's Policy Readiness and Stage of Change Assessment: What the Results Suggest for Moving Tobacco Control Efforts Forward at the State and Territorial Levels

CONTEXT

The Tobacco Control Network (TCN) is comprised of the tobacco control programs in the health departments of states, territories, and the District of Columbia. During the assessment period, the TCN was managed by the Tobacco Technical Assistance Consortium at Emory University.

OBJECTIVE

To assess the readiness of state and territory tobacco control programs to work on evidence-based, promising policy and system change strategies aimed at preventing and reducing tobacco use and secondhand smoke exposure.

DESIGN

The Policy Readiness and Stage of Change Assessment was a Web-based survey fielded in September 2013, which was based on the Community Readiness Model.

SETTING

Fifty-nine comprehensive tobacco control programs.

PARTICIPANTS

State and territory tobacco control program managers and their internal and external partners.

INTERVENTION

The TCN's 2012 Policy Platform recommendations were used as the basis to assess state/territory readiness to adopt and implement evidence-based and promising tobacco control policy/system change strategies.

MAIN OUTCOME MEASURES

Sixteen tobacco control strategies were rated on: (1) implementation status, (2) readiness, (3) stage of change, and (4) the appropriate level of action for work on the strategy.

RESULTS

The 3 strategies with the highest readiness scores were as follows: (1) 100% smoke-free air in workplaces (64%), (2) tobacco-free schools (61%), and (3) $1.50 or less cigarette tax with funds to tobacco control (53%). The 3 strategies with lowest readiness scores were: 1) coupon redemption (17%), 2) tobacco mitigation fee (14%), and 3) disclosure or sunshine laws (8%).

CONCLUSION

Readiness to work on tobacco control strategies varied by region and strategy. Many states/territories are ready to work on strategies for which there is less evidence of a population-level impact for reducing tobacco use, but which contribute to denormalizing tobacco use. Working toward less impactful policies may build support, capacity, and policy success, laying an important foundation to achieve more impactful strategies.

Do stronger school smoking policies make a difference? Analysis of the health behaviour in school-aged children survey

Background: Associations of the strength of school smoking policies with cigarette, e-cigarette and cannabis use in Wales were examined. Methods: Nationally representative cross-sectional survey of pupils aged 11–16 years (N=7376) in Wales. Senior management team members from 67 schools completed questionnaires about school smoking policies, substance use education and tobacco cessation initiatives. Multi-level, logistic regression analyses investigated self-reported cigarette, e-cigarette and cannabis use, for all students and those aged 15–16 years. Results: Prevalence of current smoking, e-cigarette use and cannabis use in the past month were 5.3%, 11.5% and 2.9%, respectively. Of schools that provided details about smoking policies (66/67), 39.4% were strong (written policy applied to everyone in all locations), 43.9% were moderate (written policy not applied to everyone in all locations) and 16.7% had no written policy. There was no evidence of an association of school smoking policies with pupils’ tobacco or e-cigarette use. However, students from schools with a moderate policy [OR = 0.47; 95% (confidence interval) CI: 0.26–0.84] were less likely to have used cannabis in the past month compared to schools with no written policy. This trend was stronger for students aged 15–16 years (moderate policy: OR = 0.42; 95% CI: 0.22–0.80; strong policy: OR = 0.45; 95% CI: 0.23–0.87). Conclusions: School smoking policies may exert less influence on young people’s smoking behaviours than they did during times of higher adolescent smoking prevalence. Longitudinal studies are needed to examine the potential influence of school smoking policies on cannabis use and mechanisms explaining this association.

School Health Promotion Policies and Adolescent Risk Behaviors in Israel: A Multilevel Analysis

BACKGROUND

Health promotion policies targeting risk-taking behaviors are being implemented across schools in Israel. This study identified the most effective components of these policies influencing cigarette smoking and alcohol consumption among adolescents.

METHODS

Logistic hierarchical linear model (HLM) analysis of data for 5279 students in 95 Jewish public schools from the Health Behavior in School-Aged Children (HBSC) 2010-2011 survey in Israel enabled simultaneous estimation of the relationship between student- and school-level variables (health promotion policy) to alcohol consumption and smoking behavior. Principals of participating schools also were interviewed to ascertain their degree of adoption and implementation of a health promotion policy.

RESULTS

Most of the variance in adolescent risk behaviors is explained by student-level variables: negative perceptions of school, lack of parental support for school issues, and more time spent with friends. Among the school-level policy measures, parental participation in health promotion intervention programs was repeatedly associated with lower rates of risk behaviors, over and above student characteristics.

CONCLUSIONS

School health promotion policies should focus on parents' involvement in intervention programs and should seek to improve students' perceptions of school and their sense of well-being to promote resilience. Further research is needed to identify additional factors that may increase the effectiveness of school health promotion policies.

The Impact of Tobacco-Free School Policies on Youth Smoking Rates in Florida Public School Districts

BACKGROUND

Developing and implementing policies to curb and prevent youth tobacco use is of the utmost importance. In Florida, public school districts were authorized to develop tobacco-free school policies through an amendment to the Florida Clean Indoor Air Act in 2011. The purpose of this study is to determine the impact of tobacco-free school policies on smoking rates among youth in Florida.

METHODS

Analysis of covariance (ANCOVA) and a multiple regression analysis were used to determine whether the comprehensiveness and enforcement of tobacco-free school policies affect the youth smoking rates within Florida public school districts. The 2010 and 2014 youth smoking rates were calculated based on the Florida Youth Tobacco Survey results.

RESULTS

The 2010 youth smoking rate and the inclusion of the enforcement component with provision of cessation resources were statistically significant predictors of the 2014 youth smoking rate. However, the comprehensiveness level of a policy and the inclusion of an enforcement component were not statistically significant predictors.

CONCLUSIONS

The inclusion of an enforcement component with provision of cessation resources is important in efforts to reduce youth smoking rates. The content of the tobacco-free school policies seems to be less relevant to their effectiveness than the enforcement of the policies.

Correlates of gambling on high-school grounds

OBJECTIVE

This study examined adolescent gambling on school grounds (GS+) and how such behavior was associated with gambling-related attitudes. Further, we examined whether GS+ moderated associations between at-risk problem-gambling (ARPG) and gambling behaviors related to gambling partners.

METHOD

Participants were 1988 high-school students who completed survey materials. Demographic, perceptions, attitudes, and gambling variables were stratified by problem-gambling severity (ARPG versus recreational gambling) and GS+ status. Chi-square and adjusted logistic regression models were used to examine relationships among study variables.

RESULTS

Nearly 40% (39.58%) of students reported past-year GS+, with 12.91% of GS+ students, relative to 2.63% of those who did not report gambling on school grounds (GS-), meeting DSM-IV criteria for pathological gambling (p<0.0001). In comparison to GS- students, GS+ students were more likely to report poorer academic achievement and more permissive attitudes towards gambling behaviors. Weaker links in GS+ students, in comparison with GS-, students, were observed between problem-gambling severity and gambling with family members (interaction odds ratio (IOR)=0.60; 95% CI=0.39-0.92) and gambling with friends (IOR=0.21; 95% CI=0.11-0.39).

CONCLUSIONS

GS+ is common and associated with pathological gambling and more permissive attitudes towards gambling. The finding that GS+ (relative to GS-) youth show differences in how problem-gambling is related to gambling partners (friends and family) warrants further investigation regarding whether and how peer and familial interactions might be improved to diminish youth problem-gambling severity. The high frequency of GS+ and its relationship with ARPG highlights a need for school administrators and personnel to consider interventions that target school-based gambling.

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.

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.

Carrots and sticks: compliance provisions in state competitive food laws-examples for state and local implementation of the updated USDA standards

BACKGROUND

Competitive foods remain prevalent in schools even though the majority of states' laws have addressed this for several years. Whereas updated federal standards take effect during school year 2014-2015, aspects of competitive food regulation will remain relegated to the states and districts and concerns exist about compliance with the federal standards. This study examined compliance provisions codified into state law that focused on incentives, monetary penalties, or contracts which could provide examples for other jurisdictions.

METHODS

Codified statutory and administrative laws effective as of January 2013 for all 50 states and the District of Columbia were compiled using Boolean searches in Lexis-Nexis and Westlaw. All laws were analyzed by 2 study authors to determine the presence and components of relevant provisions.

RESULTS

Eighteen states' laws contained compliance mechanisms including financial and/or programmatic incentives (5 states), contract provisions (11 states), and monetary penalties for noncompliance (7 states). Five states' laws contained a combination of approaches.

CONCLUSIONS

Compliance measures help to strengthen competitive food laws by providing state agencies with an enforcement mechanism. Enforcing such provisions will help to create healthier school environments. This study will provide useful insight for governments at all levels as they implement competitive food laws.

Design of a school-based randomized trial to reduce smoking among 13 to 15-year olds, the X:IT study

BACKGROUND

Adolescent smoking is still highly prevalent in Denmark. One in four 13-year olds indicates that they have tried to smoke, and one in four 15-year olds answer that they smoke regularly. Smoking is more prevalent in socioeconomically disadvantaged populations in Denmark as well as in most Western countries. Previous school-based programs to prevent smoking have shown contrasting results internationally. In Denmark, previous programs have shown limited or no effect. This indicates a need for developing a well-designed, comprehensive, and multi-component intervention aimed at Danish schools with careful implementation and thorough evaluation.This paper describes X:IT, a study including 1) the development of a 3-year school-based multi-component intervention and 2) the randomized trial investigating the effect of the intervention. The study aims at reducing the prevalence of smoking among 13 to 15-year olds by 25%.

METHODS/DESIGN

The X:IT study is based on the Theory of Triadic Influences. The theory organizes factors influencing adolescent smoking into three streams: cultural environment, social situation, and personal factors. We added a fourth stream, the community aspects. The X:IT program comprises three main components: 1) smoke-free school premises, 2) parental involvement including smoke-free dialogues and smoke-free contracts between students and parents, and 3) a curricular component. The study encompasses process- and effect-evaluations as well as health economic analyses. Ninety-four schools in 17 municipalities were randomly allocated to the intervention (51 schools) or control (43 schools) group. At baseline in September 2010, 4,468 year 7 students were eligible of which 4,167 answered the baseline questionnaire (response rate = 93.3%).

DISCUSSION

The X:IT study is a large, randomized controlled trial evaluating the effect of an intervention, based on components proven to be efficient in other Nordic settings. The X:IT study directs students, their parents, and smoking prevention policies at the schools. These elements have proven to be effective tools in preventing smoking among adolescents. Program implementation is thoroughly evaluated to be able to add to the current knowledge of the importance of implementation. X:IT creates the basis for thorough effect and process evaluation, focusing on various social groups.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77415416.

Evaluation of school tobacco-free policies in a rural Northern Plains state

BACKGROUND

The Centers for Disease Control and Prevention (CDC) has called for tobacco-free school (TFS) policies. In South Dakota (SD), a rural state with a large American Indian population, collaboration between state agencies focused on development and dissemination of a model TFS policy in 2008. This study explored the current status of TFS policies in statewide SD school districts.

METHODS

Tobacco policies were requested from all SD school district administrators. A 26-point checklist based on CDC TFS policy guidelines was used to evaluate policies. Follow-up interviews were conducted with selected superintendents.

RESULTS

Policies were received from 144 of 217 districts (66% response). Participation was higher for public districts than tribal/Bureau of Indian Education (BIE) districts and nonpublic districts. The overall mean policy score was 11.6 (SD 5.1). Public school districts had the highest mean (12.3) followed by nonpublic (8.9) and tribal/BIE (7.5). In a subset of districts with a large American Indian population (>30%), policy scores were lower for those located on reservation or tribal lands compared with other locations. Barriers to policy development were identified as time and staff expertise.

CONCLUSIONS

There is a need to improve statewide TFS policies. A district report card with recommendations for improvement and a resource guide were developed and disseminated.

Smoking experimentation among elementary school students in China: influences from peers, families, and the school environment

The aim of this study was to investigate experimentation with smoking among primary school students in China. Data were acquired from a recent survey of 4,073 students in grades 4 to 6 (ages 9–12) in 11 primary schools of Ningbo City. The questions were adapted from the Global Youth Tobacco Survey (GYTS). Results suggest that although the Chinese Ministry of Education (MOE) encourages smoke-free schools, experimentation with cigarettes remains a serious problem among primary school students in China. Peers, family members, and the school environment play important roles in influencing smoking experimentation among students. Having a friend who smoked, seeing a family member smoke, and observing a teacher smoking on campus predicted a higher risk of experimentation with smoking; the exposure to anti-tobacco materials at school predicted a lower risk of experimentation with smoking. The evidence suggests that public health practitioners and policymakers should seek to ensure the implementation of smoke-free policies and that intervention should target young people, families, and communities to curb the commencement of smoking among children and adolescents in China.

The impact of school alcohol policy on student drinking

Although it is common for secondary schools to implement alcohol policies to reduce alcohol misuse, there has been little evaluation of the efficacy of these policies. The purpose of this study was to test the impact of the degree and type of alcohol policy enforcement in state representative samples of secondary students in Washington State, USA, and Victoria, Australia (n = 1848). Multivariate logistic regressions were used to examine the prospective association between student reports of school alcohol policy in Grade 8 and self-reported alcohol use in Grade 9, controlling for age, gender, state, family socio-economic status and Grade 8 alcohol use. The likelihood of students drinking on school grounds was increased when students perceived lax policy enforcement. Student perceptions of harm minimization alcohol messages, abstinence alcohol messages and counselling for alcohol policy violators predicted reduced likelihood of binge drinking. Students perceiving harm minimization messages and counselling for alcohol policy violators had a reduced likelihood of experiencing alcohol-related harms. Perceptions of harsh penalties were unrelated to drinking behaviour. These results suggest that perceived policy enforcement may lessen drinking at school 1 year later and that harm minimization messages and counselling approaches may also lessen harmful drinking behaviours as harm minimization advocates suggest.

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.

Systematic review of the effects of schools and school environment interventions on health: evidence mapping and synthesis

Background

In contrast to curriculum-based health education interventions in schools, the school environment approach promotes health by modifying schools' physical/social environment. This systematic review reports on the health effects of the school environment and processes by which these might occur. It includes theories, intervention outcome and process evaluations, quantitative studies and qualitative studies.

Research questions

Research question (RQ)1: What theories are used to inform school environment interventions or explain school-level health influences? What testable hypotheses are suggested? RQ2: What are the effects on student health/inequalities of school environment interventions addressing organisation/management; teaching/pastoral care/discipline; and the physical environment? What are the costs? RQ3: How feasible/acceptable and context dependent are such interventions? RQ4: What are the effects on student health/inequalities of school-level measures of organisation/management; teaching/pastoral care/discipline; and the physical environment? RQ5: Through what processes might such influences occur?

Data sources

A total of 16 databases were searched between 30 July 2010 and 23 September 2010 to identify relevant studies, including the British Educational Index, the Cumulative Index to Nursing and Allied Health Literature, the Health Management Information Consortium, EMBASE, MEDLINE and PsycINFO. In addition, references of included studies were checked and authors contacted.

Review methods

In stage 1, we mapped references concerning how the school environment affects health and consulted stakeholders to identify stage 2 priorities. In stage 2, we undertook five reviews corresponding to our RQs.

Results

Stage 1: A total of 82,775 references were retrieved and 1144 were descriptively mapped. Stage 2: A total of 24 theories were identified (RQ1). The human functioning and school organisation, social capital and social development theories were judged most useful. Ten outcome evaluations were included (RQ2). Four US randomised controlled trials (RCTs) and one UK quasi-experimental study examined interventions building school community/relationships. Studies reported benefits for some, but not all outcomes (e.g. aggression, conflict resolution, emotional health). Two US RCTs assessed interventions empowering students to contribute to modifying food/physical activity environments, reporting benefits for physical activity but not for diet. Three UK quasi-experimental evaluations examined playground improvements, reporting mixed findings, with benefits being greater for younger children and longer break times. Six process evaluations (RQ3) reported positively. One study suggested that implementation was facilitated when this built on existing ethos and when senior staff were supportive. We reviewed 42 multilevel studies, confining narrative synthesis to 10 that appropriately adjusted for confounders. Four UK/US reports suggested that schools with higher value-added attainment/attendance had lower rates of substance use and fighting. Three reports from different countries examined school policies on smoking/alcohol, with mixed results. One US study found that schools with more unobservable/unsupervised places reported increased substance use. Another US study reported that school size, age structure and staffing ratio did not correlate with student drinking. Twenty-one qualitative reports from different countries (RQ5) suggested that disengagement, lack of safety and lack of participation in decisions may predispose students to engage in health risks.

Limitations

We found no evidence regarding health inequalities or cost, and could not undertake meta-analysis.

Conclusions

There is non-definitive evidence for the feasibility and effectiveness of school environment interventions involving community/relationship building, empowering student participation in modifying schools' food/physical activity environments, and playground improvements. Multilevel studies suggest that schools that add value educationally may promote student health. Qualitative studies suggest pathways underlying these effects. This evidence lends broad support to theories of social development, social capital and human functioning and school organisation. Further trials to examine the effects of school environment modifications on student health are recommended.

Funding

The National Institute for Health Research Public Health Research programme.

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.

The effects of the school environment on student health: a systematic review of multi-level studies

Health outcomes vary between schools and it is theorised that this may be partly attributable to variation in the school environment. Existing systematic reviews have not drawn authoritative conclusions because of methodological limitations in the review or studies available. We identified 42 multi-level studies, ten of which were judged of sufficient quality to narratively synthesize. There was consistent evidence that schools with higher attainment and attendance than would be expected from student intake had lower rates of substance use. Findings on the influence of smoking/alcohol policies were mixed. Three studies examined the health effects variously associated with school campus area and observability, year structure, school size and pupil-to-teacher ratio with mixed findings. The studies reviewed support the potential influence of the school environment on student health.

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.

Salient latent constructs underlying smoking initiation and continuous use by student-smokers of Huazhong University of Science and Technology, China

The factor analysis model was used to parsimoniously reduce the number of variables that influence smoking among students to salient factors that cut across continents, race, and sociocultural settings among university students in China. Stratified random sampling and snowball techniques were employed to obtain the sample. A Likert-type questionnaire was used to collect data. The results revealed that of the 39 variables identified to influence smoking, 34 were retained and regrouped in terms of common features they share into 13 salient factors that accounted for 58% of variances in the original variables. The predominant hidden construct was influence by association. The other 12 factors were labeled and ordered as follows: emotional needs, family history, addiction, peer pressure, lack of full realization of the consequences of their action as regards the expense of smoking, social needs, advertisement, psychological needs, self-image, environmental factors, ineffective policies, and underestimation of health risks. Irrespective of regional demarcations, factors that influence smoking initiation and continuous use are same.

Individual and contextual factors associated to smoking on school premises

INTRODUCTION

Despite regulations, tobacco consumption in schools is still very common. The objective was to evaluate the relationship of personal, family, and school-level contextual factors with smoking on school premises.

METHODS

A representative survey was undertaken of students in the 4th year of secondary education in the Madrid region (Spain), including 79 schools and 3,622 individuals. The student questionnaire gathered information about personal and family variables. The contextual factors were type of school, perception of compliance with the law, smoking policy, existence of complaints against smoking, and undertaking of educational activities regarding smoking. Analysis was carried out in the smoking population (n = 1,179) using multilevel logistic regression models.

RESULTS

During the last 30 days, 50.6% of smokers had smoked on school premises. Having a father with a university education (in comparison with fathers who have not attained any educational level) reduces this probability (odds ratio [OR]: 0.43; 95% CI: 0.19-0.96), whereas smoking a larger number of cigarettes (p < .001), illicit drug consumption (p < .001), and low academic achievement (p = .052) increases it. The probability is reduced when there is no parental permission to smoke (OR: 0.66; 95% CI: 0.43-1.01) and is lower both in nonsubsidized private schools (OR: 0.29; 95% CI: 0.12-0.67) and in state subsidized private schools (OR: 0.17; 95% CI: 0.09-0.34) than in public schools.

CONCLUSIONS

A very low level of educational attainment by the father, smoking a higher number of cigarettes, as well as illicit drug consumption, low academic achievement, having parental permission to smoke, and attending public schools are all related to a higher probability of smoking on school premises.

Adolescent smoking: effect of school and community characteristics

BACKGROUND

A substantial challenge in addressing adolescent tobacco use is that smoking behaviors occur in complex environments that involve the school setting and larger community context.

PURPOSE

This study provides an integrated description of factors from the school and community environment that affect youth smoking and explains variation in individual smoking behaviors both within and across schools/communities.

METHODS

Data were collected from 82 randomly sampled secondary schools in five Canadian provinces (British Columbia, Manitoba, Ontario, Quebec, Newfoundland, and Labrador) during the 2003-2004 school year. Cross-sectional data were obtained from students; school administrators (school-based tobacco control policies and programs); and from observations in the community. In 2009, hierarchic logistic regression was used to model the role of individual, school, and community variables in predicting student smoking outcomes.

RESULTS

Students who attended a school with a focus on tobacco prevention (OR=0.87, 95% CI=0.81, 0.94) and stronger policies prohibiting tobacco use (OR=0.92, 95% CI=0.88, 0.97) were less likely to smoke than students who attended a school without these characteristics. A student was more likely to smoke if a greater number of students smoked on the school periphery (OR=1.25, 95% CI=1.07, 1.47). Within the community, price per cigarette (OR=0.91, 95% CI=0.84, 0.99) and immigrants (OR=0.99, 95% CI=0.98, 0.99) were inversely related to students' smoking status.

CONCLUSIONS

The results suggest that school and community characteristics account for variation in smoking levels across schools. Based on the current findings, the ideal school setting that supports low student smoking levels is located in a neighborhood where the cost of cigarettes is high, provides tobacco prevention education, and has a policy prohibiting smoking.

The influence of school policies on smoking prevalence among students in grades 5-9, Canada, 2004-2005

INTRODUCTION

School characteristics may account for some of the variation in smoking prevalence among schools. The purpose of this study was to investigate the relationships between characteristics of school tobacco policies and school smoking prevalence. We also examined the relationship between these characteristics and individual smoking status.

METHODS

Tobacco policy data were collected from schools in 10 Canadian provinces during the 2004-2005 school year. Written tobacco policies were collected from each school to examine policy intent, and school administrators were surveyed to assess policy enforcement. Students in grades 5 through 9 completed the Youth Smoking Survey to assess smoking behaviors and attitudes. We used negative binomial regression and multilevel logistic regression to predict the influence of school policies on smoking behavior at the school and student levels.

RESULTS

School policies that explicitly stated purpose and goals predicted lower prevalence of smoking at the school and individual levels. Policies that prohibited smoking on school grounds at all times predicted lower smoking prevalence at the school level but not at the individual level.

CONCLUSION

For maximum effectiveness, school smoking policies should clearly state a purpose and goals and should emphasize smoking prohibition. These policies can help reduce smoking prevalence among youths and are part of a comprehensive school approach to tobacco control.

The impact of school tobacco policies on student smoking in Washington State, United States and Victoria, Australia

This paper measures tobacco policies in statewide representative samples of secondary and mixed schools in Victoria, Australia and Washington, US (N = 3,466 students from 285 schools) and tests their association with student smoking. Results from confounder-adjusted random effects (multi-level) regression models revealed that the odds of student perception of peer smoking on school grounds are decreased in schools that have strict enforcement of policy (odds ratio (OR) = 0.45; 95% CI: 0.25 to 0.82; p = 0.009). There was no clear evidence in this study that a comprehensive smoking ban, harsh penalties, remedial penalties, harm minimization policy or abstinence policy impact on any of the smoking outcomes.

Evaluating the strength of school tobacco policies: the development of a practical rating system

BACKGROUND

School tobacco control policies vary widely in their strength, extensiveness, and enforcement. Currently, no standardized method exists to assess the comprehensiveness of school tobacco policies. The purpose of this study was to develop a new practical rating system for school tobacco policies, assess its reliability, and present preliminary validation data.

METHODS

This study presents the systematic development of a rating system to assess the strength of school tobacco policies. Based on the empirical literature and the expertise of an advisory panel consisting of educational leaders and tobacco control advocates and practitioners, a "gold standard" school tobacco policy was developed and guided the content of the 40-point rating system. The 4 domains of the School Tobacco Policy Index were: Tobacco-free environment (14 points), Enforcement (12 points), Prevention and treatment services (6 points), and Policy organization (8 points).

RESULTS

The Index was pilot-tested using 95 Missouri public school district tobacco policies and proved to be highly reliable among coders. The evaluated policies varied greatly between school districts, with the lowest total policy score of phi and the highest score of 21. School district policy scores were significantly related to a number of county-level tobacco policy characteristics, including support for a tobacco excise tax increase.

CONCLUSIONS

The Index is a user-friendly, practical tool for tobacco control professionals and educators, providing them with the ability to easily evaluate their own school policies. Their evaluation efforts will be useful in strengthening existing policies and developing new comprehensive policies to protect the health of students, staff, administrators, and visitors.