Individual and Neighborhood Socioeconomic Status Effects on Adolescent Smoking: A Multilevel Cohort-Sequential Latent Growth Analysis

Objectives. We examined the prospective effects of parental education (as a proxy for individual socioeconomic status [SES]) and neighborhood SES on adolescent smoking trajectories and whether the prospective effects of individual SES varied across neighborhood SES.Methods. The study included 3635 randomly recruited adolescents from 5 age cohorts (12–16 years) assessed semiannually for 3 years in the Minnesota Adolescent Community Cohort study. We employed a cohort–sequential latent growth model to examine smoking from age 12 to 18 years with predictors.Results. Lower individual SES predicted increased levels of smoking over time. Whereas neighborhood SES had no direct effect, the interaction between individual and neighborhood SES was significant. Among higher and lower neighborhood SES, lower individual SES predicted increased levels of smoking; however, the magnitude of association between lower individual SES and higher smoking levels was significantly greater for higher neighborhood SES.Conclusions. We found evidence for differential effects of individual SES on adolescent smoking for higher and lower neighborhood SES. The group differences underscore social conditions as fundamental causes of disease and development of interventions and policies to address inequality in the resources.There is increasing evidence that the neighborhoods in which people live influence health through such mechanisms as the availability and accessibility of health services and other infrastructure, the prevalence of attitudes toward health and health-related behaviors, stress levels, and social capital.1In addition, research suggests that there are persistent and definite patterns of youth smoking across communities defined by geographical areas and groups defined by gender, race, education level, occupation income, and marital status.2 These findings substantiate the prospect of environmental influences at the neighborhood level on youth smoking, including both as a direct effect as well as the moderating or conditioning effects of such contexts. To better understand individual behaviors and outcomes, it may be beneficial to analyze not only the characteristics of individuals but also those of the social groups to which they belong.3 Health behaviors, including youth smoking, are typically studied at the individual level, ignoring the social context that shapes and constrains these behaviors.4 Even after controlling for numerous individual-level characteristics across multiple studies, significant unexplained variability in smoking remains.5Wilcox has defined neighborhood as a geographic space (although geographic boundaries can be imprecise and variable) in which individuals, their proximal contexts (e.g., families and peer groups), and their physical structures (e.g., stores, churches, farms, schools, hospitals, playgrounds, businesses, billboards, roads) are embedded, resulting in a larger, more distal context that has aggregate social and cultural characteristics of its own.5 Darling and Steinberg describe the possible mechanism of how context influences outcomes; individuals in a neighborhood share resources and a common sense of identity.6There is an increasing amount of empirical evidence that neighborhood variables may shape the distribution of health-related behaviors of its residents directly, independent of individual variables. A recent literature review on the effect of neighborhood social factors on smoking among adults reported an inverse relationship between neighborhood-level socioeconomic status (SES) and smoking in 4 of 5 studies.7Research on the contextual effects of neighborhood SES on adolescent smoking has produced mixed results.8–12 However, the majority of studies report an increase in smoking among youths residing in affluent neighborhoods. Ennett et al., for example, report higher rates of lifetime cigarette use in schools located in neighborhoods that have greater social advantages.13 The study used neighborhood attachment, neighborhood safety, population mobility, population density, and neighborhood drug activity as measures of neighborhood social advantages. Consistent with this finding, MacBride et al. report lower rates of smoking among adolescents residing in poor neighborhoods.11 Another single study conformed to patterns found in adulthood indicating increased smoking among adolescents residing in disadvantaged neighborhoods.12 Higher scores on such census variables as poverty rate, percentage of residents receiving public assistance, percentage of woman-headed families, unemployment rate, and percentage with less than a high school diploma were used to define neighborhoods as disadvantaged. These studies emphasize the need to investigate the role of contextual effects further and include individual-level indicators of SES.A review of the literature examining the association between adolescent smoking and individual SES reveals that adolescents do not consistently show the reciprocal SES and smoking relationship seen with adults. Instead, studies have found the associations to adhere to a “traditional” (i.e., consistent with adult literature), null, or even reversed pattern.14One major drawback of the prior studies is the lack of examination of cross-level interaction between neighborhood SES and individual SES. A handful of studies have examined how community effects interacted with individual SES, and only 1 study examined the effect of a cross-level interaction between individual and neighborhood SES on smoking.15 Using longitudinal data from the Taiwan Social Change Survey conducted in 1990, 1995, and 2000, the authors examined the association between both neighborhood-level and individual-level SES on smoking behavior among 5883 individuals older than 20 years living in 434 neighborhoods. They found evidence for an interaction between neighborhood education and individual SES, with higher neighborhood education having a positive effect on smoking for lower SES women but a negative effect on smoking for higher SES women.15We addressed numerous gaps in the existing literature, including a lack of consistent data on the effect of individual SES on adolescent smoking, the effect of neighborhood SES on adolescent smoking, and the possible moderating effect of neighborhood SES on the relation between individual SES and adolescent smoking progression over time.     

Effects of a Saliva Pipeline Procedure on Adolescent Self-Reported Smoking Behavior and Youth Smoking Prevention Outcomes

Background. Two strategies to resolve the problem of under- or overreporting of tobaccouse among adolescents have been utilized: (a) objective measures for validating self-reports and (b) procedures for improving validity of self-reports, such as the pipeline procedure. The objectives of this article are to investigate the hypothesis that reporting biases may be related to intervention status and to examine what effect such biases would have on interpretation of treatment effects. Method. A two-by-two factorial design was used, with the first factor a pipeline manipulation consisting of pipeline versus control condition, and the second factor treatment status, consisting of treatment versus reference schools. Within each of the schools, half of the 9th-grade classrooms were randomly assigned to a pipeline condition and half served as controls. Analysis was conducted with school as the unit of analysis. Results. The main effect for pipeline condition and the significant interaction between treatment and pipeline conditions were not significant. However, the pipeline manipulation did have an effect on the difference detected between treatment and reference schools; 4.3% difference between treatment and reference schools in the control condition versus 9.9% difference in the pipeline condition, both in the direction of a treatment effect. Using saliva thiocyanate as an objective measure of smoking status suggested differential false negative reporting where students in the reference community falsely claimed to be nonsmokers more frequently than in the treatment community (10.04% versus 5.96%). Conclusions. The reporting bias assessed by the pipeline procedure alone appears to have masked treatment outcome effects. Adjusting the smoking-dependent variable for false negatives seems to have increased the treatment outcome effects even further. This result is contrary to the expectation that the treatment community would experience greater demand pressures to underreport their smoking behavior. Further investigation to address response biases in intervention studies is warranted.     

The Linkage Approach Applied to a School-Based Smoking Prevention Program in the Netherlands

ABSTRACT: Effective diffusion strategies are necessary to enhance use of innovative health promotion programs. One strategy uses the linkage approach to innovation-development and diffusion planning. The linkage approach enhances collaboration among three systems: resource system (university-based researchers), linkage system (district health educators), and user system (teachers). This article illustrates how the linkage approach was applied in a smoking prevention research project. Identification of the linkage system and the collaborative process between the resource system and linkage system are described. Results from a process evaluation indicated the linkage approach was feasible in a school-based smoking prevention project.     

Long-Term Follow-Up Effects of a School-Based Drug Abuse Prevention Program on Adolescent Risky Driving

This study examined long-term follow-up data from a large-scale randomized trial to determine the extent to which participation in a school-based drug abuse prevention program during junior high school led to less risky driving among high school students. Self-report data collected from students in the 7th, 10th, and 12th grades were matched by name to students' department of motor vehicles (DMV) records at the end of high school. The DMV data included the total number of violations on students' driving records as well as the number of "points" that indicate the frequency and severity of the violations. A series of logistic regression analyses revealed that males were more likely to have violations and points on their driving records than females, and regular alcohol users were more likely to have violations and points than those who did not use alcohol regularly. Controlling for gender and alcohol use, students who received the drug prevention program during junior high school were less likely to have violations and points on their driving records relative to control group participants that did not receive the prevention program. Findings indicated that antidrinking attitudes mediated the effect of the intervention on driving violations, but not points. These results support the hypothesis that the behavioral effects of competence-enhancement prevention programs can extend to risk behaviors beyond the initial focus of intervention, such as risky driving.     

When Intraclass Correlation Coefficients Go Awry: A Case Study From a School-Based Smoking Prevention Study in South Africa

Objectives. We conducted a group randomized trial of 2 South African school-based smoking prevention programs and examined possible sources and implications of why our actual intraclass correlation coefficients (ICCs) were significantly higher than the ICC of 0.02 used to compute initial sample size requirements.Methods. Thirty-six South African high schools were randomly assigned to 1 of 3 experimental groups. On 3 occasions, students completed questionnaires on tobacco and drug use attitudes and behaviors. We used mixed-effects models to partition individual and school-level variance components, with and without covariate adjustment.Results. For 30-day smoking, unadjusted ICCs ranged from 0.12 to 0.17 across the 3 time points. For lifetime smoking, ICCs ranged from 0.18 to 0.22; for other drug use variables, 0.02 to 0.10; and for psychosocial variables, 0.09 to 0.23. Covariate adjustment substantially reduced most ICCs.Conclusions. The unadjusted ICCs we observed for smoking behaviors were considerably higher than those previously reported. This effectively reduced our sample size by a factor of 17. Future studies that anticipate significant cluster-level racial homogeneity may consider using higher-value ICCs in sample-size calculations to ensure adequate statistical power.It is common when one is conducting public health interventions to randomize and then intervene with intact social groups, such as schools, churches, or worksites, rather than individuals. Appropriate analysis of such group- or cluster-randomized trials must account for the statistical similarity of participants within these larger units.^1,2 Individuals within clusters may enter the study with greater similarity than individuals randomly selected from the general population and they may also respond to an intervention in a dependent manner. Failure to account for either source of similarity violates the basic premise of participant nonindependence assumed in traditional statistical approaches and can result in inflated type I error.^1,2 Such within-group similarity is typically captured by the intraclass correlation coefficient (ICC).The following metaphor may help conceptualize how an ICC can affect sample size. A zero ICC occurs when 2 completely unrelated individuals are randomly selected from the general population. In this case, each person contributes a full independent observation. If, however, siblings from the same household were selected, because of their shared environment and genetics, depending on the degree of similarity, this would result in slightly less than 2 independent observations. If nonidentical twins were selected, they would contribute an even lower degree of independent observation; identical twins, even less. In the extreme case, if Siamese twins were recruited, they would begin to approach the contribution of a single individual. In most cluster-randomized studies, the degree of nonindependence within a group is low, but its impact on overall statistical power can still be great because of the variance inflation formulae used to adjust for the ICC.If the ICC is known before conducting a trial, sample size requirements can be adjusted upward to account for the reduction in true sample size and statistical power, decreasing the chances of type II error. As noted by Murray et al.,³ however, it is often difficult to obtain a reliable ICC estimate that is entirely applicable to one''s proposed study. Archival ICC estimates are often derived from samples, measures, contexts, or study designs that differ from the one proposed, limiting their utility. Whereas overestimation of the ICC can lead to an overpowered study and, therefore, inefficient use of resources, underestimation of the ICC can lead to an underpowered study (i.e., type II error).We recently conducted a group randomized trial of 2 school-based smoking prevention programs designed for South African youths from 2004 to 2008. In computing our a priori sample-size requirements, we used ICC estimates drawn from published school-based smoking prevention studies, all of which were conducted in the United States. Prior ICCs were predominantly in the range of 0.02 to 0.04,⁴ and our sample size was computed accordingly. However, when the study was completed and we examined the actual ICC it turned out to be significantly higher than we had anticipated. As a result, many of our outcomes that would have been statistically significant with the ICC that was originally projected turned out to be null. We felt it would be useful to publish and explain these ICCs to assist other investigators.     

Motivational Interviewing as a Component of a School-Based Obesity Prevention Program for Adolescent Girls

Over the past decade, motivational interviewing has been used by health professionals to promote health behavior changes and help individuals increase their motivation or “readiness” to change. This paper describes a preliminary study that evaluated the feasibility of motivational interviewing as a component of New Moves, a school-based obesity prevention program. New Moves is a program for inactive adolescent high school girls who are overweight or at risk of becoming overweight due to low levels of physical activity. Throughout the 18-week pilot study, 41 girls, age 16 to 18 years, participated in an all-girls physical education class that focused on increasing physical activity, healthful eating, and social support. Individual sessions, using motivational interviewing techniques, were also conducted with 20 of the girls to develop goals and actions related to eating and physical activity. Among the 20 girls, 81% completed all seven of the individual sessions, and girls set a goal 100% of the time. Motivational interviewing offers a promising component of school-based obesity-prevention programs and was found to be feasible to implement in school settings and acceptable to the adolescents.     

Component Analysis of a School-Based Substance Use Prevention Program in Spain: Contributions of Problem Solving and Social Skills Training Content

The objective of the present research was to examine the contribution of two intervention components, social skills training and problem solving training, to alcohol- and drug-related outcomes in a school-based substance use prevention program. Participants included 341 Spanish students from age 12 to 15 who received the prevention program Saluda in one of four experimental conditions: full program, social skills condition, problem solving condition, and a wait-list control group. Students completed self-report surveys at the pretest, posttest and 12-month follow-up assessments. Compared to the wait-list control group, the three intervention conditions produced reductions in alcohol use and intentions to use other substances. The intervention effect size for alcohol use was greatest in magnitude for the full program with all components. Problem-solving skills measured at the follow-up were strongest in the condition that received the full program with all components. We discuss the implications of these findings, including the advantages and disadvantages of implementing tailored interventions to students by selecting intervention components after a skills-based needs assessment.     

A Longitudinal Analysis of Adolescent Smoking and its Correlates

ABSTRACT: When designing effective programs, it is important to identify factors associated with tobacco use at particular stages of adolescence, as well as factors associated with changes in tobacco use. This study examined cross-sectional correlates of smoking during early adolescence and during late adolescence in a longitudinal sample to compare the pattern of prediction of smoking at both stages. Changes in predictor variables related to changes in smoking also were examined. Results showed intentions to smoke was the strongest predictor of smoking during both early adolescence and during late adolescence; however, it was a much stronger predictor for the late adolescent stage. In addition, intentions to smoke was the strongest predictor of changes in smoking. However, the pattern of prediction at the two grade levels showed some differences as did predictors of changes in smoking. Implications for designing smoking prevention and cessation programs are addressed.     

Project FLAVOR: 1-Year Outcomes of a Multicultural, School-Based Smoking Prevention Curriculum for Adolescents

To evaluate a multicultural smoking prevention curriculum, 16 schools were randomized to receive the multicultural curriculum or a standard curriculum and program effects on 1-year smoking initiation among 1430 never smokers were assessed. Hispanic boys who received the multicultural curriculum were less likely to initiate smoking than were those who received the standard curriculum; effects were insignificant among other groups. The prevention effect among Hispanic boys is encouraging, but additional research is needed to improve prevention effects among other groups.     

某证券营业部控烟法规实施前后吸烟状况调查与分析

通过对武汉市某证券营业部在《武汉市公共场所禁止吸烟规定》（以下简称《规定》）颁布实施前后一周股民的吸烟状况调查，发现实施后股民对吸烟危害健康以及公共场所禁烟与城市文明形象关系的认识有所提高，９０％以上的人拥护《规定》；实施前后现场吸烟人次的比较说明经济处罚不是执法的首要措施，而加强管理则是保证法规实施的关键。     

Patterns of Change in Adolescent Smoking Behavior and Results of a One Year Follow-up of a Smoking Prevention Program*

A smoking prevention program for adolescents conducted in two public middle schools focused on resisting peer pressure to smoke and understanding the intent of commercial cigarette advertising. One class in each school participated in the program group and one served as a control group. The program consisted of eight sessions and was conducted by first-year medical students. Data on smoking behavior and related information were obtained from self-administered questionnaires at baseline, at the conclusion of the program, and one year later. One year after the program was concluded, the proportion of non-smokers was higher among those who had participated in the program than among the controls. This suggests that routine implementation of smoking prevention programs in conventional school settings may be productive in reducing the prevalence of cigarette smoking.     

Peer Smoking, Other Peer Attributes, and Adolescent Cigarette Smoking: A Social Network Analysis

Peer attributes other than smoking have received little attention in the research on adolescent smoking, even though the developmental literature suggests the importance of multiple dimensions of adolescent friendships and peer relations. Social network analysis was used to measure the structure of peer relations (i.e., indicators of having friends, friendship quality, and status among peers) and peer smoking (i.e., friend and school smoking). We used three-level hierarchical growth models to examine the contribution of each time-varying peer variable to individual trajectories of smoking from age 11 to 17 while controlling for the other variables, and we tested interactions between the peer structure and peer smoking variables. Data were collected over five waves of assessment from a longitudinal sample of 6,579 students in three school districts. Findings suggest a greater complexity in the peer context of smoking than previously recognized.     

Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery

Objectives. We compared completion rates for adolescent immunization series administered at school-based health centers (SBHCs) to completion rates for series administered at community health centers (CHCs) within a single integrated delivery system.Methods. We performed a retrospective analysis of data from an immunization registry for patients aged 12–18 years. Patients were assigned to either an SBHC or a CHC during the study interval based on utilization. We used bivariate analysis to compare immunization series completion rates between the 2 groups and multivariate analysis to compare risk factors for underimmunization. We performed subanalyses by ages 12–15 years versus ages 16–18 years for human papillomavirus (HPV) and for the combination of HPV; tetanus, diptheria, and pertussis (Tdap); and tetravalent meningococcus virus.Results. SBHC users had significantly higher completion rates (P < .001) for hepatitis B, Tdap, inactivated poliovirus, varicella, measles/mumps/rubella, and HPV for ages 16–18 years, and for the combination of HPV, Tdap, and MCV4 for ages 16–18 years. CHC users had higher completion rates for tetanus and diphtheria.Conclusions. SBHCs had higher completion rates than did CHCs for immunization series among those aged 12–18 years, despite serving a population with limited insurance coverage.Immunizations have been a cornerstone of pediatric preventive care for decades, especially for infectious disease prevention in infants and young children. New vaccine developments have made it possible to administer vaccines against specific preventable diseases in children and adolescents, such as the tetravalent meningococcus virus (MCV4) vaccine and the human papillomavirus (HPV) vaccine, and to boost resistance to tetanus, diptheria, and pertussis (the Tdap vaccine). Recommended vaccines include single-dose regimens and multidose series. It is crucial to deliver these vaccines either before existing immunity wanes or before the risk of exposure.^1,2Immunizing children and adolescents presents challenges within our current system of health care delivery. This is true for all immunizations but particularly so for the administration of multidose vaccine series. Numerous authors have identified systemic, parental, and patient barriers to vaccine administration.^3–8 School-based health centers (SBHCs), primary care clinics located in schools, have been shown to improve rates of child and adolescent immunization.^9,10 SBHCs are an optimal model for delivery of adolescent primary care around the country, and many SBHCs currently deliver immunizations.¹¹ However, little is known about the success of this model in completing vaccine series.In a retrospective analysis, we examined immunization series completion rates of children and adolescents aged 12 to 18 years within an integrated health care system that delivered care via both SBHCs and community health centers (CHCs). We compared the completion rates of patients who received care primarily through SBHCs with the completion rates of patients who received care primarily through CHCs.     

Disposable Income With Tobacco Smoking Among Young Adolescents: A Multilevel Analysis

PurposePrior studies examining the connection between disposable income and adolescent smoking often yielded mixed results, partly due to the lack of consideration for contextual variables. In the present study, we sought to broaden understanding of disposable income on adolescent smoking behaviors via both absolute and relative perspectives in the school context.MethodsWe obtained data from the 2010 Global Youth Tobacco Survey (GYTS) in Taiwan. Information concerning sociodemographics, disposable income, smoking history, and contextual smoking exposure (e.g., school) were assessed via self-report. Recent-onset smokers were defined as those who had their first cigarette within two years of the survey. Complex survey and multilevel analyses were carried out to estimate association.ResultsAdolescents with higher monthly disposable income were 2～5 times more likely to start smoking and become regular smokers. Having the least disposable income in a class appeared linked with increased risk of tobacco initiation by 40% (95% confidence interval [CI]: 2%–91%). Pupils’ odds to start smoking were lowered to .70 when the majority of schoolmates had low disposable income (95% CI: .51–.99).ConclusionsAdolescent risk of smoking initiation may be differentially affected by individual- and contextual-level absolute and relative disposable income. Future research is needed to delineate possible mechanisms underlying unfavorable health behaviors associated with disposable incomes in early adolescence.