Is inter-school variation in smoking uptake and cessation due to differences in pupil composition? A cohort study

The aims of this study were to determine if inter-school variation in smoking prevalence was due to differences in pupil composition or other school-level factors. A cohort of 13-14-year-olds (n = 7147) from 52 schools was followed-up 1 year later. Random effects logistic regression was used to examine school variation in smoking uptake and cessation, with and without adjustment for pupil composition. Inter-school variation in smoking prevalence is not caused by differences in pupil composition but is due to differences in the onset of smoking arising because of unmeasured school contextual or collective factors operating on pupils' decisions.     

The influence of school culture on smoking among pupils

School factors and not solely pupil composition probably cause variation in smoking prevalence amongst schools, but there are no theoretical models to explain why. In this paper we propose a hypothesis to explain schools' influence on pupils' smoking and test this using an existing cross-sectional survey of 23,282 pupils from 166 secondary schools in the West Midlands, UK. We hypothesise that school-level educational achievement scores would not be associated with smoking prevalence, but schools providing value-added education given the social background of pupils (authoritative schools) would provide effective support and control, have a relatively strong influence on pupils' lives and be associated with lower than average smoking prevalence. Schools providing value-denuded education (laissez-faire schools) would have a relatively weak influence on pupils' lives and be associated with higher than average smoking prevalence. The school achievement measures were the proportion of pupils achieving 5A-C General Certificates of Secondary Education (5A-Cs) grades and the proportion of half days lost to truancy. Value-added/denuded terms were created by regressing 5A-Cs and truancy on five markers of the social profile of pupils at the school. Authoritative schools achieved better than expected rates on both measures. Laissez-faire schools achieved worse than expected rates on both measures. All other schools were classed as indeterminate. Multilevel logistic regression was used to relate the risk of regular smoking to school culture in both achievement and authoritative/laissez-faire terms, both with and without adjustment for pupil-level risk factors for smoking. As predicted, schools' achievement measures were unrelated to pupils' smoking. The odds ratios (95% confidence intervals) for smoking in authoritative and laissez-faire schools relative to indeterminate schools were 0.80 (0.70-0.91) and 1.16 (1.07-1.27), respectively. Adjustment for pupil-level smoking risk factors had little effect. School culture is an independent risk factor for adolescent smoking. Schools providing effective support and control might protect pupils from smoking.     

Does school ethos explain the relationship between value-added education and teenage substance use? A cohort study

Previous studies found lower substance use in schools achieving better examination and truancy results than expected, given their pupil populations (high value-added schools). This study examines whether these findings are replicated in West Scotland and whether school ethos indicators focussing on pupils' perceptions of schooling (environment, involvement, engagement and teacher-pupil relations) mediate the associations. Teenagers from forty-one schools (S2, aged 13, n = 2268; S4, aged 15, n = 2096) previously surveyed in primary school (aged 11, n = 2482) were surveyed in the late 1990s. School value-added scores were derived from standardised residuals of two regression equations separately predicting from pupils' socio-demographic characteristics (1) proportions of pupils passing five Scottish Standard Grade Examinations, and (2) half-day truancy loss. Outcomes were current smoking, monthly drinking, ever illicit drug use. Random effects logistic regression models adjusted for potential pupil-level confounders were used to assess (1) associations between substance use and school-level value-added scores and (2) whether these associations were mediated by pupils' perceptions of schooling or other school-level factors (school roll, religious denomination and mean aggregated school-level ethos scores). Against expectations, value-added education was positively associated with smoking (Odds Ratios [95% confidence intervals] for one standard deviation increase in value-added scores were 1.28 [1.02-1.61] in S2 and 1.13 [1.00-1.27] in S4) and positively but weakly and non-significantly associated with drinking and drug use. Engagement and positive teacher-pupil relations were strongly and negatively associated with all substance use outcomes at both ages. Other school-level factors appeared weakly and largely non-significantly related to substance use. Value-added scores were unrelated to school ethos measures and no ethos measure mediated associations between value-added education and substance use. We conclude that substance use in Scotland is more likely in high value-added schools, among disengaged students and those with poorer student-teacher relationships. Understanding the underpinning mechanisms is a potentially important public health concern.     

Butt in, butt out: pupils' views on the extent to which staff could and should enforce smoking restrictions

Schools which enforce a no-smoking policy may experience lower rates of pupil smoking. Little is known, however, about how young people view such restrictions and it has been argued that smoking bans might actually encourage adolescent smoking. This paper presents pupils' views on the extent to which staff could, and should, enforce smoking restrictions. Twenty-five single-sex discussion groups were held with 13-year-old pupils who had been purposively selected from two Scottish secondary schools. Both schools served relatively deprived communities and ostensibly had no-smoking policies, but varied in their pupil smoking rates. The pupils' accounts suggested that staff enforcement could interrupt pupil smoking and discourage smoking on school premises, but did not affect whether or not they actually smoked. Pupils viewed staff efforts as ineffective and felt staff did not always have the authority or status needed to enforce a ban. Differences were found between the schools, but these did not explain the variation in their smoking profiles.     

Tobacco Point-of-Purchase marketing in school neighbourhoods and school smoking prevalence: a descriptive study

BACKGROUND: Point of Purchase (PoP) promotional and advertising activities are a sophisticated tobacco marketing strategy. This study describes tobacco PoP activities in school neighbourhoods and compares PoP activities in retail stores between schools with high and low smoking prevalence. METHODS: A cross-sectional study was conducted in 81 randomly selected schools across five provinces. Students in grades 10-11 completed a questionnaire on smoking. Observations were made in all retail stores located within a one-kilometre radius around the school. ANOVA tests were used to detect differences on PoP variables between high (> 20.6%) and low (< or = 20.6%) smoking prevalence schools, defined as percentage of students reporting at least a few puffs on > 2 days in the last 30 days. RESULTS: Approximately half of retail stores in each school neighbourhood exhibited tobacco PoP activities. Average school smoking prevalence was 20.99%. There were significant main effects on PoP variables between schools with high and low smoking prevalence, Wilk's lambda = 0.81, F (6,74) = 2.89, p < 0.01, eta2 = 0.19. Stores near schools with high smoking prevalence had significantly lower prices per cigarette (F (1,79) = 15.34, p < 0.01, eta2 = 0.16), more in-store promotions (F (1,79) = 6.73, p < 0.01, eta2 = 0.08), and fewer government-sponsored health warnings (F (1,79) = 6.26, p < 0.01, eta2 = 0.07) compared to schools with low smoking prevalence. CONCLUSION: Higher levels of PoP activities in stores located in the school neighbourhood are related to school smoking prevalence. Schools with low smoking prevalence had more stores that posted government health warning signs and higher cigarette prices. Legislation regulating PoP activities and health warnings in school neighbourhoods should be considered.     

Could the peer group explain school differences in pupil smoking rates? An exploratory study

Schools differ in the proportion of their pupils who smoke. Such differences transcend pupil intake characteristics and relate to the internal life of the school. Although adolescents' smoking behaviour has been associated with that of their peers, little consideration has been given to whether peer structures and processes contribute to school differences in pupil smoking rates. In two relatively deprived Scottish schools, one with a higher and one with a lower rate of pupil smoking, 13 and 15 year-olds were surveyed. Sociometric data and information on pupils' smoking behaviour and views were gathered. Twenty-five single-sex discussion groups were then held with a sub-sample of the 13 year-olds in order to explore in detail their views on smoking, smokers and fellow pupils. Findings showed that in the higher smoking school, pupils were more often in groups, smokers were identified as popular, and attitudes (especially among non-smoking females) were more pro-smoking. In the lower smoking school, by contrast, there were more isolates and dyads, there were no popular smokers and attitudes (especially among non-smoking females) were much less pro-smoking. Thus, evidence suggests peer group structures and related influences could be one explanation for school differences in smoking, and that the popularity of smokers together with the views of non-smoking females may be particularly important in creating such differences.     

Ifs,maybes and butts: factors influencing staff enforcement of pupil smoking restrictions

Levels of pupil smoking are reported to be associated with the extent to which school staff consistently enforce smoking restrictions. Little is known, however, about factors which might motivate or discourage staff from doing so. Following analysis of interviews conducted with 27 members of school personnel purposively selected from two Scottish secondary schools serving relatively deprived communities, this paper identifies various issues that hinder staff intervention when confronted with pupil smoking. Both schools had no-smoking policies. In each, staff assumed or understood that smoking within the buildings was forbidden, yet were unsure about how far the bans extended. While the risk of fire in the school buildings prompted staff to intervene when smoking was witnessed indoors, where this risk was absent, decisions were largely context dependent or motivated by personal and professional values. Concerns about staff-pupil relationships, attention to pupils' wider welfare, lack of authority and staff levels of discomfort were salient issues inhibiting intervention. Implications for smoking policies and their enforcement are discussed. The concept of the Health Promoting School is considered in the light of the findings and inherent tensions highlighted.     

School culture as an influencing factor on youth substance use

OBJECTIVE: To determine whether value-added education is associated with lower risk of substance use among adolescents: early initiation of alcohol use (regular monthly alcohol consumption in grade 7), heavy alcohol use (>10 units per week) and regular illicit drug use. DESIGN: Cross-sectional self-reported survey of alcohol and drug use. Analysis used two-level logistic modelling to relate schools providing value-added education with pupils' substance use. The value-added education measure was derived from educational and parenting theories proposing that schools providing appropriate support and control enhance pupil functioning. It was operationalised by comparing observed and expected examination success and truancy rates among schools. Expected examination success and truancy rates were based on schools' sociodemographic profiles. PARTICIPANTS: Data were collected across 15 West Midlands English school districts and included 25,789 pupils in grades 7, 9 and 11 from 166 UK secondary schools. RESULTS: Value-added education was associated with reduced risk of early alcohol initiation (OR (95% CI) 0.87 (0.78 to 0.95)) heavy alcohol consumption (OR 0.91 (0.85 to 0.96)) and illicit drug use (OR 0.90 (0.82 to 0.98)) after adjusting for gender, grade, ethnicity, housing tenure, eligibility for free school meal, drinking with parents and neighbourhood deprivation. CONCLUSIONS: The prevalence of substance use in school is influenced by the school culture. Understanding the mechanism through which the school can add value to the educational experience of pupils may lead to effective prevention programmes.     

Perceived smoking prevalence at school-level and children's smoking initiation: a multi-level analysis of a cross-sectional data in Taiwan

OBJECTIVES: Literature on the influence of smoking prevalence at school-level on the smoking initiation among elementary school children is scarce. The aim of the current study was to explore this in school clusters stratified according to student's perceived smoking prevalence in the school while adjusting for social impact of individual students. METHOD: The data was obtained from a survey administered to 13 elementary schools in Taoyuan County, a final sample of 1585 3rd and 4th grade students. Multi-level logistic regression analysis (MLRA) was used to examine the influence variable at school-level as well as individual socio-environment level had on smoking status of elementary schools students. RESULTS: Attending a school where the students reported a perception of high smoking prevalence had a greater effect on smoking behavior in boys than girls when compared with students attending a lower smoking prevalence school, after adjustment for student-level characteristics. CONCLUSIONS: Our study confirmed that a broader school environment with a high student perception of smoking prevalence is associated with children's smoking behavior in boys. The findings further indicate the need for enforcement of anti-smoking policies within schools with higher smoking rates to reduce visibility of smoking among school children.     

Peer Reviewed: 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.

Conclusions

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.     

长宁区1177名小学生吸烟影响因素及控烟对策探讨

目的　了解长宁区小学生吸烟情况及其影响因素 ,为探讨小学生控烟对策提供依据。方法　收集并分析 2 0 0 3年长宁区参加中国 /WHO控烟能力建设项目小学基线调查资料。结果　小学生尝试吸烟率为 8.0 % ,男生高于女生 (χ2 =9.70 ,P <0 .0 1 ) ;61 .3 %的小学生吸第 1支烟是因为好奇 ,吸第 1支烟的场所和香烟来源主要为家庭 (69.1 %和 42 .0 % ) ;父亲吸烟情况对孩子吸第 1支烟的影响无统计学意义 ;学生回忆学校开设的课程涉及控烟内容的比例较低 (思想品德 30 .8% ,自然 2 4 .8% ,语文、数学、外语等均 <1 0 .0 % )。结论　家庭、学校和社会对小学生吸烟都有着重要的影响。学校控烟工作较为薄弱 ,应采取综合措施对低龄儿童进行控烟干预。     

More than words? The status and impact of smoking policies in Scottish schools

The aim of this study was to investigate the current status of smoking policies in Scottish schools, and the relationship between policy status, enforcement of smoking restrictions and perceptions of smoking behaviour among pupils and teachers. A representative sample of 15-year-old school pupils from 77 Scottish secondary schools was surveyed in 1998 regarding their perceptions of smoking in several locations within and outside the school building. Two staff members from each school were also surveyed regarding school smoking policies for pupils and teachers, the nature of the school's smoking restrictions, and the extent to which the restrictions were enforced. The results showed that more schools had a written policy on teacher smoking than on pupil smoking. All schools in the sample banned smoking by pupils, but the majority allowed smoking by teachers in restricted areas. Irrespective of the type of policy or restrictions on smoking, pupils reported seeing smoking among both pupils and teachers on school premises in all of the sample schools. Whether or not a school had a written policy appeared to be unrelated to pupil smoking in the toilets or teacher smoking outdoors on school premises. However, pupils were less likely to be aware of pupils smoking outdoors and teachers smoking in the staff rooms in schools where there were written policies on pupil and teacher smoking, respectively. Consistent enforcement of a ban on pupil smoking was associated with lower levels of perceived smoking among pupils. Where a complete ban on teacher smoking existed, smoking among teachers was seen less often in the staff rooms, but more often in outside areas on school premises. The results have implications for the use of policy in promoting a healthy school environment.     

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.     

Senior student smoking at school, student characteristics, and smoking onset among junior students: a multilevel analysis

BACKGROUND: Current research on the etiology of tobacco use has largely focused on identifying the influential psychosocial characteristics of individual students; the influences of characteristics in the school environment are generally ignored. The purpose of this study was to simultaneously examine how school and individual student characteristics were related to smoking onset. METHOD: Multilevel logistic regression analysis was used to examine how the senior student smoking rate at a school and the psychosocial characteristics of students were able to differentiate tried-once smokers from experimental smokers in a sample of 4850 grade 9, 10, and 11 students from the School Smoking Profile (SSP) project. RESULTS: Each 1% increase in smoking rate among high school seniors increased the odds that a junior student was an experimental smoker vs. a tried-once smoker (OR 1.07, 95% CI 1.03-1.12). A significant contextual interaction was identified where the senior student smoking rate at a school moderates the negative influence of having close friends who smoke. Influential student characteristics were also identified. CONCLUSIONS: The smoking prevalence of older students at a school is directly related to smoking onset among younger students at that school. Prevention programs should target schools that put students at-risk.     

Factors related to adolescents' estimation of peer smoking prevalence

Although adolescents who overestimate peer smoking prevalence are more likely to smoke, little research has focused on the factors associated with why the majority of adolescents overestimate peer smoking rate. The purpose of this study was to examine demographic, social, environmental and behavioural characteristics related to overestimation of peer smoking prevalence among secondary school students. The current study analysed data collected in two Canadian studies that used the Tobacco Module of the School Health Action, Planning and Evaluation System, a school-based questionnaire. One study surveyed 23 458 students (Grades 9-13) in 29 schools during 2001-02, and the other surveyed 25 452 students in 39 schools in 2003. Results of multiple logistic regression indicate that grade, gender, close friends' smoking, seeing smoking at school, family members' smoking, smoking in the home and smoking status have a clear association with overestimation; school smoking rate and susceptibility to smoking show a tentative relationship and warrant further study. Other factors may also be important for prevalence estimation, and further research is needed to identify these factors. Since adolescents tend to overestimate peer smoking prevalence and perceived prevalence is in turn linked to smoking behaviour, interventions should focus on creating realistic perceptions of smoking prevalence.     

Individual and contextual determinants of perceived peer smoking prevalence among adolescents in six European cities

BackgroundYoung people perceiving a high peer smoking prevalence are more likely to initiate smoking. It is unclear which factors contribute to perceived peer smoking prevalence and if these factors vary according to education. This study aimed to assess the determinants of perceived smoking prevalence and assessed its variation at school and country-level.MethodsData of 10,283 14–17-year-old students in 50 secondary schools in six European cities were derived from the 2013 SILNE survey. The outcome was the perceived smoking prevalence score among peers at school (0–10 scale, 10 represented 100% smoking prevalence). Multilevel linear regression models estimated the associations of factors with perceived prevalence score and variance at school and country-levels. Analyses were also stratified by academic achievement of the adolescent and parental education.ResultsDeterminants of a higher perceived prevalence score were female sex, ever smoking, having friends who smoke, low academic achievement, low parental educational level, and higher actual prevalence of smoking in the school. The perceived prevalence score was not associated with school policies or with the availability of cigarettes near the school. Determinants were very similar across levels of academic achievement and parental education. Perceived prevalence scores substantially varied between schools and countries: 10% and 11% of total variance was related to schools and countries respectively.ConclusionAcross educational levels, perceptions of peer smoking are strongly determined by both individual characteristics and school and national contexts. Future studies should assess why perceived smoking prevalence varies between schools and countries and identify modifiable factors.     

Differences in students' smoking-related knowledge, attitudes, and behaviors among public, factory, and private secondary schools in Guangzhou, China

BACKGROUND: The prevalence of smoking among Chinese adolescents has dramatically increased in recent years. The purpose of this study was to examine the differences in smoking-related knowledge, attitudes, and behaviors among Chinese students in 3 types of secondary schools. METHODS: This cross-sectional study was conducted among 3,957 students of seventh, eighth, and ninth grades and 2,870 student parents from 3 public, 1 factory, and 2 general-paid private secondary schools at Guangzhou in 2004. Participants were asked to complete self-administered questionnaires about sociodemographic characteristics, smoking-related family and school environments, smoking-related knowledge and attitudes, and smoking behaviors. RESULTS: The average scores of students' smoking-related knowledge and attitudes (higher score, more against smoking) were highest in the factory school, followed by public schools and private schools. The differences among them were statistically significantly (P < .05). The lifetime smoking prevalence was also significantly different (P < .001) among 3 types of schools: 35.4% in private schools, 17.4% in public schools, and 13.2% in the factory school. The prevalence of students' weekly smoking was also higher in private schools (6.2%) than in public schools (4.9%) or the factory school (4.0%). Similar disparity was observed in the prevalence of daily smoking (3.9% private, 3.5% public, and 2.7% factory). However, differences in weekly and daily smoking were not statistically significant (P > .05). CONCLUSIONS: Compared with students in public and factory schools, those in general-paid private schools had poorer smoking-related knowledge, more supportive attitudes toward smoking, and more popular smoking behaviors. Therefore, more intensive smoking prevention programs should be implemented among them.     

What explains between-school differences in rates of sexual experience?

Background  

Schools have the potential to influence their pupils' behaviour through the school's social organisation and culture, as well as through the formal curriculum. This paper provides the first attempt to explain the differences between schools in rates of reported heterosexual sexual experience amongst 15 and 16 year olds. It first examined whether variations in rates of sexual experience remained after controlling for the known predictors of sexual activity. It then examined whether these residuals, or 'school effects', were attributable to processes within the school, or were more likely to reflect characteristics of the neighbourhood.     

A repeated cross-sectional study examining the school impact on child weight status

ObjectiveThe aim of this study is to examine whether there is a differential impact of primary schools upon children's weight status.MethodsA repeated cross-sectional study was undertaken using five years (2006/07–2010/11) of National Child Measurement Programme data, comprising 57,976 children (aged 4–5 (Reception) and 10–11 (Year 6) years) from 300 primary schools across Devon, England. Examining each year separately, the schools were ranked according to their observed and residual (having accounted for school and neighbourhood clustering and pupil ethnicity and socioeconomic status) school mean body mass index standard deviation score (BMI-SDS). Subtracting the Reception from the Year 6 mean residuals gave ‘value-added’ scores for each school which were also ranked. The rankings were compared within and across the years to assess consistency.ResultsAlthough pupil BMI-SDS was high, > 97% of the variation in BMI-SDS was attributable to environments other than the school. The ‘value-added’ by each school was only poorly correlated with the observed and residual pupil BMI-SDS; but none of the rankings were consistent across the five years.ConclusionThe inconsistency of the rankings and the small variation in BMI-SDS at the level of the school suggests that there is no systematic differential impact of primary schools upon pupil weight status.     

Nutrient-based standards for school lunches complement food-based standards and improve pupils' nutrient intake profile

Following concerns about the nutritional content of school lunches and the increased prevalence of overweight and obesity in the UK, changes to the standards of school meals were made. From September 2008, all primary schools in England were required, by law, to be fully compliant with the new food-based standards (FBS) and nutrient-based standards (NBS) for school lunches. The aim of the present survey was to evaluate the introduction of the NBS for school lunches on the nutritional profile of food and drink items provided by schools and chosen by pupils at lunchtime. A nationally representative sample of 6696 pupils from 136 primary schools in England aged 3-12 years and having school lunches was recruited. Data were collected on lunchtime food and drink provision at each school and on pupil food and drink choices at lunchtime. Caterers also provided planned menus, recipes and other cooking information. Compliance with both the FBS and NBS was then assessed. Results show that even when the FBS was met, many schools did not provide a school lunch that met the NBS as well. The average school lunch eaten was significantly lower in fat, saturated fat and Na in schools that met both the FBS and NBS for school lunches compared with schools that met only the FBS. Change in school lunch policy has contributed to improvements in pupils' choices and the nutritional profile of foods selected at lunchtime.