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Link between perceived smoking behaviour at school and students smoking status: a large survey among Italian adolescents
p u b l i c h e a l t h 1 5 1 ( 2 0 1 7 ) 1 6 9 e1 7 6
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Original Research
Link between perceived smoking behaviour at school and students smoking status: a large survey among Italian adolescents I. Backhaus a,*, V. D'Egidio a, D. Grassucci b, M. Gelardini b, C. Ardizzone b, G. La Torre a a
Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy b Skuola Network Srl, Via Taranto 21, 00182 Rome, Italy
article info
abstract
Article history:
Objectives: To investigate a possible link between sociodemographic factors, the perception
Received 27 February 2017
of smoking habits at school and smoking status of Italian adolescents attending secondary
Received in revised form
school.
15 May 2017
Study design: The study was a cross-sectional study.
Accepted 7 July 2017
Methods: An anonymous online survey was employed to gather information on age, gender,
Available online 6 September 2017
smoking status and to examine the perception of smoking behaviour on the school premises. Chi-squared and KruskaleWallis tests were performed for the univariate analysis
Keywords:
and logistic and multinomial regressions for the multivariate analysis.
Adolescent
Results: The statistical analyses included 1889 students. Univariate analysis showed sig-
Perception
nificant differences concerning knowledge between smoker and non-smoker concerning
School
the harmfulness of smoking (P < 0.001). According to the multivariate analysis smokers had
Tobacco smoking
a higher perception of teacher, principal or janitor smoking at school (odds ratio: 1.54 [95%
Behaviour
confidence interval 1.26e1.89]). Students older than 19 years most often begin smoking
Knowledge
because their friends smoke compared with younger students (adjusted odds ratio: 1.18 [95% confidence interval 0.48e2.89]). Conclusion: School environment and behaviour of role models play a crucial part in student smoking. To prevent and reduce youth tobacco smoking, not merely the presence of preventive measures is important but greater attention needs to be placed on the enforcement of smoking policies. © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Smoking poses an important threat to the current and future health of the European youth population and with about six
million deaths annually, the tobacco epidemic is one of the greatest public health challenges.1 Unfortunately, it is during adolescence when nicotine addiction is most likely to develop2 and the earlier in life adolescents try a cigarette, the
* Corresponding author. E-mail address: [email protected] (I. Backhaus). http://dx.doi.org/10.1016/j.puhe.2017.07.004 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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more likely they are to become daily or regular smokers.3 Besides, nicotine addiction, cigarette smoking by youth comes along with several serious health consequences such as respiratory effects and risk of cardiovascular disease in adulthood.4 Even with a long history of smoking control reforms and substantial efforts to reduce the smoking prevalence in Italy, including the introduction of an anti-smoking law (Sirchia Law) that prohibits smoking in all enclosed public premises, public transport, libraries, bars, and so forth,5 the smoking prevalence among young people in Italy remains at 20%, far above the European average (14%).6 These developments indicate the need for a more rigorous understanding about the dynamics that influence adolescents smoking. In particular, because a healthy population may result in substantial benefit in terms of public health, productivity and social development. An adolescent's perception about smoking by peers and role models can play an important role in smoking initiation and continuation. In fact, positive associations to smoking, including the perception of smoking of role models (e.g. teachers and friends) smoking and social acceptability, has been suggested as predictors for adolescents' intention to smoke.7 Negative association to smoking, on the other hand, such as undesirable effects on one's physical appearance, the perception of lower social acceptability and believing that second-hand smoke can cause harm to others have been closely linked to smokers' intention to quit.8 Adolescent smoking should be of particular interest from both a research and a policy perspective since it has important implications for lifetime. Given that most adolescents attend school, the school environment represents a vital arena in which learning takes place. The school environment therefore plays a significant role in shaping the smoking behaviour of an adolescent. The correlations of adolescent smoking with exposure to peer smoking and to school personnel smoking has been documented in some countries.9 However, until now, little is known about how Italian students perceive smoking at school in relation to their smoking behaviour. Consequently, the present study was carried out to assess the relation between sociodemographic factors (age and gender), tobacco smoking status and the perception of tobacco use at school of peers, janitors, teachers or principals among Italian educated adolescents.
Methods Study design and setting This cross-sectional study took place in Italy in November 2016. It was performed in accordance with the STROBE statement10 and was a self-completed anonymous online survey developed by Skuola.net. Skuola.net is an Italian internet forum for middle, high school and university students to share notes, advices, doubts, news and perspectives.
Participants The present study included students aged 14 years and older. All students participated voluntarily.
Data collection Data collection was carried out using an online survey. The survey collected data on demographic figures and student tobacco smoking status, and consisted of three sections: Attitude towards smoking (reason to start smoking); Knowledge (e.g. about health consequences, smoking ban at school, preventive interventions); Smoking behaviour of schoolmates at school. Smoking status was assessed by asking the students: do you smoke (yes/no/little). Students who responded ‘yes’ or ‘little’ were classified as smokers in the analysis and students who responded ‘no’ were named non-smokers. The students' perception of teachers smoking and pupils smoking measured using questions such as ‘Do any of your teachers smoke at the garden or courtyard?’ (Yes, without any problems; Yes, but hiding; No, the ban is respected), ‘Has your school organized preventive interventions?’ (Yes; No; Yes, but I did not participate) or ‘Do students smoke in the restrooms’ (Yes, but hiding; Yes, but they receive warning; No, the ban is respected) were asked. The survey included also a question to explore the reasons why students started to smoke: Why did you start to smoke? The students were able to choose between: because I like it, because my parents smoke, all my friends smoke and others.
Statistical analysis The statistical analyses included descriptive statistics, univariate analyses, multinomial and multivariate analyses. Qualitative variables such as gender and smoking habits are described as frequencies and percentages. They were recoded into dummies if needed and separate code numbers were assigned to each category of each variable. Male and female were for instance coded into ‘0’ and ‘1’. A coding manual for each variable can be found in the supplemental materials (see supplement Table 5. Coding manual). Missing data were also reported for each survey item and were not included in the analysis. Baseline characteristics are presented as absolute numbers N (%). Univariate analysis was carried out including the chi-squared test or the Fisher's exact-test where applicable and KruskaleWallis tests. Three age groups were considered for the analyses: 14e16, 17e19, >19 years. A multivariate logistic regression was performed to study the relation between qualitative independent variables (gender, age group, smoking habits) and dependent variables (knowledge, attitude, behaviour). Odds ratio (AOR) and 95% confidence intervals (CIs) were calculated for all the categories. The goodness-of-fit for the logistic regression model was assessed with Hosmer and Lemeshow's test. Participants with missing values for one or more of the variables were excluded from the analysis. A logistic regression analysis was conducted including knowledge score, which was composed of answers concerning students' knowledge about the existence of a smoking ban, health consequences, disciplinary measures or sanctioning for students who smoked at school and preventive
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intervention organized at school. For each question students answered with either ‘yes’, ‘yes, and I fear the consequences’ or ‘yes, but I did not participate’ one point was given, resulting in a maximum of four points. For the analysis, knowledge score was then categorized in either low knowledge score (0e2) or high knowledge score (3e4). A multinomial analysis was carried out to explore the motivation of students to start smoking and to gauge the difference between age group, gender and smoking habit. Modalities included: because my parents smoke, because all my friends smoke, because I like it and other reasons. As a reference category ‘because I like it’ was chosen. Results of the multivariate analyses were presented as adjusted odds ratio (AOR) and 95% CI. Statistical significance level was set at P < 0.05. All statistical analyses were performed with Statistical Package for Social Sciences (SPSS) version 24.0 for Windows (SPSS Inc. Chicago, Illinois, USA).
Results A total of 1889 students were included in the analysis. Table 1 provides details of the descriptive statistics and sample characteristics.
Characteristics of participants and smoking status Of 1889 students, 44% were males and 56% were females. Most students were between 17 and 19 years of age (847; 44.8%), followed by students aged 14e16 years (773; 40.9%). Overall, 621 (32.9%) students reported that they were smokers, of those more females were smokers (58.5%) than males (41.5%). A total of 19.6% of students reported that they started to smoke because they like it, 4.1% because their friends smoked, and only 1.9% because their parents smoked.
Students' perception of smoking behaviour A total of 39.8% of the students reported that they had witnessed other students smoking outdoors either in the garden or courtyard without any problems. Another 40.5% reported that students were hiding while smoking on the school premises. A percentage of 62% of the students perceived that students where smoking in the restrooms, however many perceived that students were hiding while doing so (44.5%). Smoking in the hallway instead was not common with 87% reported that students were not smoking in the hallways. A total of 57.3% stated that teachers, janitors or the principal smoke on the school premises (courtyard or garden).
Students' knowledge Only 40.8% of the students, half of the students, seemed to be aware about punishments for smoking at school, whereas the other half did not. About 60% of students were not aware of preventive intervention organized by the school. Circa 86% of students knew about the existence of a smoking ban at school. Table 1 reports the descriptive statistics.
Table 1 e Descriptive characteristics of participants. Variable Age group in years (0 missing)
Modalities
14e16 17e19 >19 Gender (1 missing) Male Female Smokers Male Female Do you smoke? No (1 missing) Yes A little Why did you start to Because I like it smoke? (3 missing) Because my parents smoke All my friends smoke Other Do you know that It do not think it smoking is is harmful harmful? Yes, but I do not (1 missing) care Yes, and I fear the consequences No Has your school organized Yes meetings/lessons Yes, but I did not against smoking? participate (2 missing) Did you know that No smoking is Yes prohibited at school, also in garden and courtyard? (2 missing) No, they do not At your school, are people smoking in smoke Yes, without any the garden or problems courtyard? (4 missing) Yes, but hiding Do students smoke No, they do not in the hallway? smoke (2 missing) Yes, without any problems Yes, but with warning Are people at you No, they do not school smoking in smoke the restrooms? Yes and without (2 missing) warning Yes, but hiding Do teachers/ No, they do not principal/janitors smoke smoke in the Yes, without any garden/courtyard problems Yes, but hiding at your school? (2 missing) Has your school ever No sanctioned Yes, with fines students who Yes, with smoked at school? disciplinary (4 missing) measures I do not know
Number of Percentage answers 773 847 269 831 1057 258 363 1267 391 230 370 36
40.9 44.8 14.2 44.0 56.0 41.5 58.5 67.1 20.7 12.2 19.6 1.9
77
4.1
1403 137
74.4 7.3
398
21.1
1353
71.7
1167 554 166
61.8 29.4 8.8
256 1631
13.6 86.4
372
19.7
750
39.8
763 1641
40.5 87.0
98
5.2
148
7.8
714
37.8
333
17.6
840 806
44.5 42.7
705
37.4
376
19.9
396 350 419
21.0 18.6 22.2
720
38.2
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Univariate analysis
Gender
Table 2 shows the univariate analysis for gender, age categories and smoking habit. Results indicate differences among gender, age group and smoker versus non-smoker students.
Females are more informed about preventive intervention for smoking in school (AOR: 1.33; 95% CI: 1.10e1.61), and they perceive less smoking habits in different locations in the school.
Gender Age Of the students in this study, male students witnessed more often that pupils smoke in either the bathroom (21.2%), garden or courtyard (46.7%) without any problems compared with female students. No significant differences concerning knowledge on harmful consequences, meetings or lessons against smoking and smoking ban could be detected.
Age Overall, younger students (14e16 years old) were significantly more aware of health consequences of smoking (75.9%) than older students were (>19 years old; 59.9%). The percentage of students who did not know about preventive intervention was highest among the age group 17e19 years (66.2%). Moreover, students aged between 14 and 16 (25.1%) years seemed to be more aware of disciplinary measures taken for students smoking at school. An interesting finding is that students' perception of teachers smoking in either the garden or courtyard was rarer among the older students (33.8%) compared with students aged 14e16 aged (38.6%).
Smoking status Table 2 shows a significant difference between smokers and non-smokers. Significant differences were found concerning knowledge about the harmfulness of smoking between smoker and non-smoker. Among those students who identified themselves as smokers, 11% believed that smoking was not harmful, and about 44% did not care about harmful consequences. Whereas of non-smoker 84.5% stated to fear the harmful consequences of smoking. Overall, smokers were also less aware of preventive intervention organized at school (61.2%) compared with non-smokers (31.5%) and about the existence of a smoking ban at school. Smokers also were exposed more frequently to teachers, janitors or principals smoking at school (41.3%) than non-smokers (35.4%). Besides, students who smoke, stated more often that people are able to smoke in the hallways without any problems.
Knowledge score The univariate analysis concerning knowledge score demonstrates that younger students, females and non-smokers have a higher knowledge regarding the existence of a smoking ban, harmful consequences of smoking, e.t.c. (Table 2).
The univariate analysis, shows that older students know less about the health consequences of smoking (AOR: 0.174; 95% CI: 0.11e0.27) and students aged 17e19 had less knowledge about preventive interventions organized by the school (AOR: 0.794; 95% CI: 0.64e0.98). Moreover, students aged 17e19 compared with 14e16 years know less about disciplinary measures taken at school (AOR: 0.79; 95% CI: 0.62e1). Students older than 19 years perceive less often if schoolmates smoke in the garden or courtyard of the school (AOR: 0.41; 95% CI: 0.30e0.57) and bathroom (AOR: 0.67; 95%; 95% CI: 0.51e0.88), but more often if they smoke in the hallways (AOR: 1.59; 95% CI: 1.09e2.31). Instead, students aged 17e19 perceive less often whether schoolmates smoke in the hallways (AOR: 0.70 CI: 0.51e0.95). No differences were shown regarding the perception of teachers', principals' or janitors' smoking habit.
Smoking status Results of the analysis concerning smoking habit (yes or no) and students' knowledge about health consequences differed significantly between the two groups. Smoker students knew less about the consequences smoking has on health (AOR: 0.54; 95% CI: 0.37e0.77) and smoker students did not know about the smoking ban (AOR: 0.41; 95% CI: 0.31e0.54). Smokers are at risk of perceiving that teachers, principals or janitors smoke on the school premises (AOR: 1.54; 95% CI: 1.26e1.89).
Knowledge score A separate multivariate analysis regarding knowledge score displays that students who have a higher knowledge score, perceive less often whether pupils smoke on the school premises.
Multinomial analysis In the multinomial analysis, only smokers were considered. The multinomial analysis shows that younger students are more prone to start smoking because their parents or friends do in comparison to students aged over 19 years who start due to other reasons (AOR: 0.38; 95% CI: 0.23e0.74; Table 4.). Besides, the analysis reveals that males compared with females are more likely to begin smoking because their parents (AOR: 2.82; 95% CI: 1.34e5.93) and friends (AOR: 3.19; 95% CI: 1.71e5.91) smoke than because they like to smoke.
Multivariate logistic regression Multivariate logistic regression analysis was conducted to explore the relation between dependent variables (attitude, knowledge, behaviours) and independent ones (gender, smoking habits, age). Data are presented in Table 3.
Discussion The present study investigated the relationship between sociodemographic factors, smoking status of Italian educated
Table 2 e Univariate analysis of age groups, gender, smoking habit and knowledge score. Questionnaire items
Age group (years) 14e16
Attitude Why did you start to smoke?
Knowledge Do you know that smoking is harmful?
Do students smoke in the hallway?
Do people smoke in the restrooms at your school? Do teachers, principals or janitors smoke in the garden or courtyard at your school? Has your school ever sanctioned students who smoked at school?
Knowledge Score Low Score High Score
>19
P-value
Male
Female
Smoking habit P-value
No
Yes
P-value
Because I like it Because my parents smoke All my friends smoke Other
108 8 36 620
(14%) (1.0%) (4.7%) (80.3%)
211 23 27 584
(25.0%) (2.7%) (3.2%) (69.1%)
51 5 14 199
(19.0%) (1.9%) (5.2%) (74.0%)
<0.001a
159 22 56 603
(19.2%) (2.7%) (5.5%) (72.2%)
211 14 31 800
(20.0%) (1.3%) (2.9%) (75.8%)
0.005a
52 2 24 1186
(4.1%) (0.2%) (1.9%) (93.8%)
318 34 53 1402
(51.2%) (5.5%) (8.5%) (74.4%)
<0.001a
I do not think it is harmful Yes, but I do not care Yes, and I fear the consequences No Yes Yes, but I did not participate No, I did not know Yes, I knew
33 153 587 471 247 55 107 666
(4.3%) (19.7%) (75.9%) (60.9%) (32.0%) (7.1%) (13.8%) (86.2)
43 198 605 560 235 51 87 758
(5.1%) (23.4%) (71.5%) (66.2%) (27.8%) (6.0%) (10.3%) (89.7%)
61 47 161 136 72 60 62 207
(22.7%) (17.5%) (59.9%) (50.7%) (26.9%) (22.4%) (23%) (77%)
<0.001a
49 187 595 547 221 62 119 712
(5.9%) (22.5) (71.6%) (65.9%) (26.6%) (7.5%) (14.3%) (85.7%)
88 211 758 619 333 104 136 919
(8.3%) (20.0%) (71.7%) (58.6%) (31.5%) (9.8%) (12.9%) (87.1%)
0.074a
69 128 1069 787 399 80 128 1139
(5.5%) (10.1%) (84.4%) (62.2%) (31.5%) (86.3%) (10.1%) (89.9%)
68 270 283 380 155 86 128 491
(11.0%) (43.5 %) (45.6%) (61.2%) (25.0%) (13.8%) (20.7%) (79.3%)
<0.001a
No, they do not smoke Yes, without any problems Yes, but hiding No, they do not smoke Yes, without any problems Yes, but with warning No, they do not smoke Yes and without warning Yes, but hiding No, they do not smoke Yes, without any problems Yes, but hiding No Yes, with fines Yes, with disciplinary measures I do not know
127 346 300 666 43 63 262 141 370 339 298 136 133 110 194 336
(16.4%) (44.8%) (38.8%) (86.3%) (5.6%) (8.2%) (33.9%) (18.2%) (47.9%) (43.9%) (38.6%) (17.6%) (17.2%) (14.2%) (25.1%) (43.5%)
158 316 369 758 33 55 324 136 385 337 316 192 209 196 172 268
(18.7%) (37.5%) (43.8%) (89.9%) (3.9%) (6.5%) (38.3%) (16.1%) (46.6%) (39.9%) (37.4%) (22.7%) (24.7%) (23.2%) (20.4%) (31.7%)
87 88 94 217 22 30 128 56 85 130 91 48 54 44 53 116
(32.3%) (32.7%) (34.9%) (80.7%) (8.2%) (11.2%) (47.6%) (20.8%) (31.6%) (48.3%) (33.8%) (17.8%) (20.2%) (16.5%) (19.9%) (43.4%)
<0.001a
144 387 289 683 62 84 263 175 392 329 329 172 211 171 169 278
(17.4%) (46.7%) (35.9%) (82.4%) (7.5%) (10.1%) (31.7%) (21.1%) (47.2%) (39.6%) (39.6%) (20.7%) (25.5%) (20.6%) (20.4%) (33.5%)
228 362 465 957 36 64 451 158 447 477 375 204 184 179 250 442
(21.6%) (34.3%) (44.1%) (90.5%) (3.4%) (6.1%) (42.7%) (15.0%) (42.3%) (45.2%) (35.5%) (19.3%) (17.4%) (17.0%) (23.7%) (41.9%)
<0.001a
251 493 523 1109 45 112 494 214 559 583 449 235 251 196 297 520
(19.8%) (38.9%) (41.3%) (87.6%) (3.6%) (8.8%) (39.0%) (16.9%) (44.1%) (46.0%) (35.4%) (18.5%) (19.9%) (15.5%) (23.5%) (41.1%)
121 257 240 532 53 36 220 119 281 223 256 141 145 154 122 200
(19.6%) (41.6%) (38.8%) (85.7%) (8.5%) (5.8%) (35.5%) (19.2%) (45.3%) (36.0%) (41.3%) (22.7%) (23.3%) (24.8%) (19.6%) (32.2%)
0e2 3e4
400 (37.8%) 373 (44.9%)
163 (15.4%) 106 (12.8%)
0.001a
566 (53.5%) 491 (46.5%)
0.008b
495 (46.8%) 352 (42.4%)
<0.001a
<0.001a
0.004a
<0.001a
0.026a
<0.001a
491 (59.1%) 340 (40.9%)
0.005a
0.368a
<0.001a
<0.001a
0.052a
<0.001a
679 (64.2%) 588 (70.8%)
378 (35.8%) 243 (29.2%)
<0.001a
<0.001a
0.504a
<0.001a
0.254a
<0.001a
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Has your school organized meetings/lessons against smoking? Did you know that smoking is prohibited at school, also in garden and courtyard? Do people smoke in the garden or courtyard at your school?
17e19
Gender
<0.001a
<0.001a
Table Legend: Chi-square and KruskaleWallis tests were performed for the univariate analysis. a P-values of Chi square. b P-values for KruskaleWallis.
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Table 3 e Multivariate logistic regression analysis. Questionnaire items
Age groups (years) 17e19 vs 14e16a
Has your school ever sanctioned students who smoked at school? Do you know that smoking is harmful? Has your school organized meetings or lessons against smoking? Did you know that smoking is prohibited at school, also in garden and courtyard? Do people smoke in the garden or courtyard at your school? Do students smoke in the hallway? Do people smoke in the restrooms at your school? Do teachers, principal or janitors smoke in the garden or courtyard at your school?
>19 vs 14e16a
Gender
Smoking habits
Female vs Malesa
Yes vs Noa
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
Yes/noa
0.79 (0.62e1.00)
0.74 (0.53e1.05)
1.23 (0.99e1.54)
0.83 (0.65e1.06)
Yes/noa Yes/noa
0.93 (0.58e1.49) 0.79 (0.65e0.98)
0.17 (0.11e0.28) 1.46 (1.10e1.94)
0.81 (0.55e1.17) 1.33 (1.10e1.61)
0.54 (0.37e0.77) 1.04 (0.85e1.27)
Yes/noa
1.69 (1.24e2.30)
0.62 (0.44e0,90)
1.24 (0.95e1.63)
0.41 (0.31e0.54)
Yes/noa
0.84 (0.64e1.08)
0.41 (0.30e0.57)
0.80 (0.63e1.01)
1.12 (0.87e1.43)
Yes/noa Yes/noa
0.70 (0.51e0.95) 0.95 (0.79e1.15)
1.59 (1.09e2.31) 0.67 (0.51e0.88)
0.46 (0.35e0.61) 0.66 (0.56e0.79)
1.24 (0.93e1.65) 1.52 (1.25e1.84)
Yes/noa
1.10 (0.90e1.34)
0.78 (0.59e1.04)
0.80 (0.66e0.96)
1.54 (1.26e1.89)
CI ¼ confidence interval; OR ¼ odds ratio. a Reference group.
adolescents and their perception of smoking behaviour at school. To date, a limited number of studies have focused on the relation between student's perception of schoolmates and teachers' smoking habit at school. Data were collected from a relatively large sample among Italian adolescents aged 14 years and older through an online survey. The majority of students reported that other students or employees of the school smoke on the school premises. This suggests a degree of acceptance in Italian schools concerning smoking in schools, which in turn could influence pupil's beliefs and attitudes towards smoking. These finding are particularly worrisome from a public health perspective, bearing in mind that Italy has implemented an anti-smoking law already in 2003 banning smoking from education facilities. Furthermore, the data of the multivariate analysis revealed that older students (>19 years) surveyed were less aware about the unhealthy effects of smoking. Interestingly, although students aged 19 years and older were more aware of preventive interventions that were organized at school, many
students stated they did not participate. The poor knowledge about health consequences might either be due to ineffective teaching about the risk of smoking, a mistaken belief about the addictive nature of smoking or the general tendency of adolescents to downplay risks.11,12 Even if literature about whether prevention programs and sanctions are effective is controversial, earlier research showed that the prevalence of daily smoking in schools is lower when a policy prohibiting pupils or teachers to smoke on the school premises is adopted (9.5%; 95% CI: 6.1e12.9) compared with schools with no policy (30.1%; 95% CI: 23.6e 36.6). A recent review however concluded that schools with smoking bans, sanctions for transgressions and prevention programs, did not show a significant difference in smoking prevalence compared with schools with weaker or no policies.13 Nevertheless, unlike Moore et al (2001), we believe that not merely the presence of an anti-smoking policy may affect students smoking habit, but rather the consistency with which schools enforce policy measures can play an important role in the effectiveness of a policy.14 Research has shown that
Table 4 e Multinomial model to assess reason to smoke and age, gender and smoking habit differences. Why did you start to smokea
Variables
Because my parents smokea >19*/14e16 >19*/17e19 Gender Male*/female 2 log likelihood intercept only 127.995 2 log likelihood final 81.656 Log Likelihood Ratio Test (Chi square) 46.340 (P < 0.001) McFadden R2 0.035 Age
* Comparison/reference group. CI ¼ confidence interval; AOR ¼ odds ratio. a Reference: because I like it.
All my friends smoke othera
Othera
AOR
95% CI
AOR
95% CI
AOR
95% CI
0.83 1.17 2.82
0.24e2.93 0.38e3.60 1.34e5.93
1.18 0.57 3.19
0.48e2.89 0.24e1.39 1.71e5.91
0.38 0.47 0.92
0.23e0.74 0.30e0.75 0.64e1.32
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conspicuous actions taken by the school in response to policy violations are most likely what influences students' behaviour than the ban or policy itself.15 The univariate analysis showed that non-smokers are significantly more aware about the smoking ban, organization of preventive interventions and sanctions. Furthermore, knowledge about health consequences of smoking was significantly different between smokers and non-smokers. A similar finding was shown by Naing et al.16 (2004) who found out that the agreement on the harmfulness of smoking was greater among non-smoking students. Perhaps with the inclusion of tobacco prevention programs and a mandatory participation of students' in such programs, more awareness could be created. Another important finding arising from both the univariate and multivariate model is a possible association between teachers and peers smoking on the school premises and students smoking habits. Smokers reported more frequently that teachers and peers were smoking in the school environment. This is in line with a study conducted in Denmark, stating that adolescents' perceived exposure to teachers smoking outdoors on the school premises was significantly associated with daily smoking.17 Schools that allow teachers to smoke on the school premises may deliver the wrong message that smoking is an accepted and normal behaviour.18 Previous studies discovered a positive association between witnessing teacher smoking and student smoking.9,17 This stresses the importance for the task teachers might have as role models in school.19 A systematic review presented that the school was the main setting for smoking initiation for boys.20 Furthermore, according to the social cognitive theory, adolescents shape their behaviour based on people who they consider worthy,16 and therefore adolescents who observe role models smoking have a higher probability of smoking uptake.17 Thus, schools should focus on tackling students witnessing teachers who smoke and should emphasize policies, which prohibit teachers from smoking on the school premises. This could help to reduce the number of students smoking. Moreover, the behaviour of peers might play a vital role in determining smoking behaviour as shown from the multinomial analysis. In fact, peers are often the most common source of the first cigarette and the person with whom the first cigarette is smoked. Studies have proposed that initiating tobacco smoking might be a means by which youngsters use to enter friendship groups or be accepted.20 This is in line with studies that examined the interactions between friends' smoking habit and other network characteristics.21,22 Rostila et al.22 (2013), for example, suggest that having a large percentage of smokers in one's social network is by far the greatest risk factor for daily smoking. Moreover, similar to teachers, peers who smoke represent an environment in which smoking is viewed as favourable. As stated earlier, this is in line with the social learning theory of behaviour Social Learning and Personality Development which states that children are more likely to model their own behaviour on actions of people they regard as worthy, similar to themselves and models of their own sex.23 As so many, this study also comes with several strengths and limitations. A key strength is the large sample of Italian students of diverse age groups, who participated voluntarily in
175
the survey. Nevertheless, the study has important limitations that should be taken into account. A significant methodological problem concerns the truthfulness of answers on this topic. Second, not all participants answered to all the items included in the questionnaire (e.g. some skipped items). Hence, there were some missing data. Moreover, the study relies on self-reported data of students smoking status and their perception of teachers and students smoking on the school premises. Reporting bias can therefore not be excluded. In fact, evidence depicts that people are likely to project their own behaviour onto others and smokers, for instance, are more likely to be aware of others who smoke. Besides, we were not yet able to make a comparison between different geographical locations as the survey did not include a question about the city of residence. Finally, the survey method did not allow to evaluate the relationship between smoking exposure and smoking status since the evaluation of biomarkers (cotinine) through blood, urinary or hair samples was impossible. Conclusively, the present study demonstrates significant associations between students' smoking habit and students' perception of smoking behaviour at school. It stretches the important role that peers, teachers and a smoke-free school environment have in influencing an adolescent's smoking behaviour. The findings may serve as food for thought for upcoming school-based tobacco control strategies, particularly in countries with ‘liberal’ smoking policies. An important target for intervention should be adolescents' reference persons, given that they often learn and copy behaviours and attitudes from others. In addition, information about the smoking ban, possible sanctioning for smoking at school and health consequences have to be communicated more clearly, and there is a need not only to enforce smoking policies but also to apply them in a stricter manner. Besides, the results of the present study provide important information on smoking behaviour of school-aged adolescents and may serve as a basis for more tailored school-based preventive interventions in Italy. Furthermore, it indicates the laissez-faire style of adopting and implementing anti-smoking policies at school and gives important indication for policy makers at the supraregional level.
Author statements Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
Funding None declared.
Competing interests None declared.
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references 14. 1. WHO. Tobacco. WHO; 2016. http://www.who.int/mediacentre/ factsheets/fs339/en/. [Accessed 25 November 2016]. 2. Kessler DA, Witt AM, Barnett PS, Zeller MR, Natanblut SL, Wilkenfeld JP, et al. The Food and Drug Administration's regulation of tobacco products. N Engl J Med 1996;335:988e94. http://dx.doi.org/10.1056/NEJM199609263351321. 3. Institute of Medicine (US) Committee on Preventing Nicotine Addiction in Children and Youths. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington (DC): National Academies Press (US); 1994. 4. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Preventing tobacco use among youth and young adults: a report of the surgeon general. Atlanta (GA): Centers for Disease Control and Prevention (US); 2012. 5. Sirchia G. La legge italiana per la tutela dei non fumatori dal fumo passivo. 2010. 6. OECD, EU. Health at a glance: Europe 2016. Paris: Organisation for Economic Co-operation and Development; 2016. 7. Wiium N, Breivik K, Wold B. The relationship between smoker role models and intentions to smoke among adolescents. J Youth Adolesc 2006;35:549e60. http://dx.doi.org/10.1007/ s10964-006-9065-2. 8. Savvides ECG, Christophi CA, Paisi M, Pampaka D, Kinnunen T, Connolly GN. Factors associated with intent to quit tobacco use in Cyprus adolescents. Prev Med 2014;60:83e7. http://dx.doi.org/10.1016/j.ypmed.2013.12.016. 9. Roohafza H, Heidari K, Omidi R, Alinia T, Sadeghi M, Mohammad-Shafiee G, et al. Adolescent perception on school environment and smoking behavior: analysis of Isfahan tobacco use prevention program. Int J Prev Med 2014;5:S139e45. 10. Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Epidemiol Camb Mass 2007;18:805e35. http:// dx.doi.org/10.1097/EDE.0b013e3181577511. 11. Gough B, Fry G, Grogan S, Conner M. Why do young adult smokers continue to smoke despite the health risks? A focus group study. Psychol Health 2009;24:203e20. http://dx.doi.org/ 10.1080/08870440701670570. 12. Weinstein ND. Accuracy of smokers' risk perceptions. Ann Behav Med Publ Soc Behav Med 1998;20:135e40. 13. Coppo A, Galanti MR, Giordano L, Buscemi D, Bremberg S, Faggiano F. School policies for preventing smoking among
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young people. Cochrane Database Syst Rev 2014, CD009990. http://dx.doi.org/10.1002/14651858.CD009990.pub2. Moore L, Roberts C, Tudor-Smith C. School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tob Control 2001;10:117e23. http://dx.doi.org/10.1136/tc.10.2.117. Evans-Whipp TJ, Bond L, Ukoumunne OC, Toumbourou JW, Catalano RF. The impact of school tobacco policies on student smoking in Washington State, United States and Victoria, Australia. Int J Environ Res Public Health 2010;7:698e710. http:// dx.doi.org/10.3390/ijerph7030698. Naing NN, Ahmad Z, Musa R, Hamid FRA, Ghazali H, Bakar MHA. Factors related to smoking habits of male adolescents. Tob Induc Dis 2004;2:13. http://dx.doi.org/10.1186/ 1617-9625-2-13. Poulsen L, Osler M, Roberts C, Due P, Damsgaard M, Holstein B. Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark. Tob Control 2002;11:246e51. http://dx.doi.org/10.1136/tc.11.3.246. Piontek D, Buehler A, Rudolph U, Metz K, Kroeger C, Gradl S, et al. Social contexts in adolescent smoking: does school policy matter? Health Educ Res 2008;23:1029e38. http:// dx.doi.org/10.1093/her/cym063. Galaif ER, Sussman S, Bundek N. The relations of school staff smokers' attitudes about modeling smoking behavior in students and their receptivity to no-smoking policy. J Drug Educ 1996;26:313e22. Okoli C, Greaves L, Fagyas V. Sex differences in smoking initiation among children and adolescents. Public Health 2013;127:3e10. http://dx.doi.org/10.1016/j.puhe.2012.09.015. Muttarak R, Gallus S, Franchi M, Faggiano F, Pacifici R, Colombo P, et al. Why do smokers start? Eur J Cancer Prev Off J Eur Cancer Prev Organ ECP 2013;22:181e6. http://dx.doi.org/ 10.1097/CEJ.0b013e32835645fa. € Rostila M, Almquist YB, Ostberg V, Edling C, Rydgren J. Social network characteristics and daily smoking among young adults in Sweden. Int J Environ Res Public Health 2013;10:6517e33. http://dx.doi.org/10.3390/ijerph10126517. Bandura A, Walters RH. Social learning and personality development. 1963.
Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.puhe.2017.07.004.
Available online at www.sciencedirect.com
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Original Research
Link between perceived smoking behaviour at school and students smoking status: a large survey among Italian adolescents I. Backhaus a,*, V. D'Egidio a, D. Grassucci b, M. Gelardini b, C. Ardizzone b, G. La Torre a a
Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy b Skuola Network Srl, Via Taranto 21, 00182 Rome, Italy
article info
abstract
Article history:
Objectives: To investigate a possible link between sociodemographic factors, the perception
Received 27 February 2017
of smoking habits at school and smoking status of Italian adolescents attending secondary
Received in revised form
school.
15 May 2017
Study design: The study was a cross-sectional study.
Accepted 7 July 2017
Methods: An anonymous online survey was employed to gather information on age, gender,
Available online 6 September 2017
smoking status and to examine the perception of smoking behaviour on the school premises. Chi-squared and KruskaleWallis tests were performed for the univariate analysis
Keywords:
and logistic and multinomial regressions for the multivariate analysis.
Adolescent
Results: The statistical analyses included 1889 students. Univariate analysis showed sig-
Perception
nificant differences concerning knowledge between smoker and non-smoker concerning
School
the harmfulness of smoking (P < 0.001). According to the multivariate analysis smokers had
Tobacco smoking
a higher perception of teacher, principal or janitor smoking at school (odds ratio: 1.54 [95%
Behaviour
confidence interval 1.26e1.89]). Students older than 19 years most often begin smoking
Knowledge
because their friends smoke compared with younger students (adjusted odds ratio: 1.18 [95% confidence interval 0.48e2.89]). Conclusion: School environment and behaviour of role models play a crucial part in student smoking. To prevent and reduce youth tobacco smoking, not merely the presence of preventive measures is important but greater attention needs to be placed on the enforcement of smoking policies. © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Smoking poses an important threat to the current and future health of the European youth population and with about six
million deaths annually, the tobacco epidemic is one of the greatest public health challenges.1 Unfortunately, it is during adolescence when nicotine addiction is most likely to develop2 and the earlier in life adolescents try a cigarette, the
* Corresponding author. E-mail address: [email protected] (I. Backhaus). http://dx.doi.org/10.1016/j.puhe.2017.07.004 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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more likely they are to become daily or regular smokers.3 Besides, nicotine addiction, cigarette smoking by youth comes along with several serious health consequences such as respiratory effects and risk of cardiovascular disease in adulthood.4 Even with a long history of smoking control reforms and substantial efforts to reduce the smoking prevalence in Italy, including the introduction of an anti-smoking law (Sirchia Law) that prohibits smoking in all enclosed public premises, public transport, libraries, bars, and so forth,5 the smoking prevalence among young people in Italy remains at 20%, far above the European average (14%).6 These developments indicate the need for a more rigorous understanding about the dynamics that influence adolescents smoking. In particular, because a healthy population may result in substantial benefit in terms of public health, productivity and social development. An adolescent's perception about smoking by peers and role models can play an important role in smoking initiation and continuation. In fact, positive associations to smoking, including the perception of smoking of role models (e.g. teachers and friends) smoking and social acceptability, has been suggested as predictors for adolescents' intention to smoke.7 Negative association to smoking, on the other hand, such as undesirable effects on one's physical appearance, the perception of lower social acceptability and believing that second-hand smoke can cause harm to others have been closely linked to smokers' intention to quit.8 Adolescent smoking should be of particular interest from both a research and a policy perspective since it has important implications for lifetime. Given that most adolescents attend school, the school environment represents a vital arena in which learning takes place. The school environment therefore plays a significant role in shaping the smoking behaviour of an adolescent. The correlations of adolescent smoking with exposure to peer smoking and to school personnel smoking has been documented in some countries.9 However, until now, little is known about how Italian students perceive smoking at school in relation to their smoking behaviour. Consequently, the present study was carried out to assess the relation between sociodemographic factors (age and gender), tobacco smoking status and the perception of tobacco use at school of peers, janitors, teachers or principals among Italian educated adolescents.
Methods Study design and setting This cross-sectional study took place in Italy in November 2016. It was performed in accordance with the STROBE statement10 and was a self-completed anonymous online survey developed by Skuola.net. Skuola.net is an Italian internet forum for middle, high school and university students to share notes, advices, doubts, news and perspectives.
Participants The present study included students aged 14 years and older. All students participated voluntarily.
Data collection Data collection was carried out using an online survey. The survey collected data on demographic figures and student tobacco smoking status, and consisted of three sections: Attitude towards smoking (reason to start smoking); Knowledge (e.g. about health consequences, smoking ban at school, preventive interventions); Smoking behaviour of schoolmates at school. Smoking status was assessed by asking the students: do you smoke (yes/no/little). Students who responded ‘yes’ or ‘little’ were classified as smokers in the analysis and students who responded ‘no’ were named non-smokers. The students' perception of teachers smoking and pupils smoking measured using questions such as ‘Do any of your teachers smoke at the garden or courtyard?’ (Yes, without any problems; Yes, but hiding; No, the ban is respected), ‘Has your school organized preventive interventions?’ (Yes; No; Yes, but I did not participate) or ‘Do students smoke in the restrooms’ (Yes, but hiding; Yes, but they receive warning; No, the ban is respected) were asked. The survey included also a question to explore the reasons why students started to smoke: Why did you start to smoke? The students were able to choose between: because I like it, because my parents smoke, all my friends smoke and others.
Statistical analysis The statistical analyses included descriptive statistics, univariate analyses, multinomial and multivariate analyses. Qualitative variables such as gender and smoking habits are described as frequencies and percentages. They were recoded into dummies if needed and separate code numbers were assigned to each category of each variable. Male and female were for instance coded into ‘0’ and ‘1’. A coding manual for each variable can be found in the supplemental materials (see supplement Table 5. Coding manual). Missing data were also reported for each survey item and were not included in the analysis. Baseline characteristics are presented as absolute numbers N (%). Univariate analysis was carried out including the chi-squared test or the Fisher's exact-test where applicable and KruskaleWallis tests. Three age groups were considered for the analyses: 14e16, 17e19, >19 years. A multivariate logistic regression was performed to study the relation between qualitative independent variables (gender, age group, smoking habits) and dependent variables (knowledge, attitude, behaviour). Odds ratio (AOR) and 95% confidence intervals (CIs) were calculated for all the categories. The goodness-of-fit for the logistic regression model was assessed with Hosmer and Lemeshow's test. Participants with missing values for one or more of the variables were excluded from the analysis. A logistic regression analysis was conducted including knowledge score, which was composed of answers concerning students' knowledge about the existence of a smoking ban, health consequences, disciplinary measures or sanctioning for students who smoked at school and preventive
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intervention organized at school. For each question students answered with either ‘yes’, ‘yes, and I fear the consequences’ or ‘yes, but I did not participate’ one point was given, resulting in a maximum of four points. For the analysis, knowledge score was then categorized in either low knowledge score (0e2) or high knowledge score (3e4). A multinomial analysis was carried out to explore the motivation of students to start smoking and to gauge the difference between age group, gender and smoking habit. Modalities included: because my parents smoke, because all my friends smoke, because I like it and other reasons. As a reference category ‘because I like it’ was chosen. Results of the multivariate analyses were presented as adjusted odds ratio (AOR) and 95% CI. Statistical significance level was set at P < 0.05. All statistical analyses were performed with Statistical Package for Social Sciences (SPSS) version 24.0 for Windows (SPSS Inc. Chicago, Illinois, USA).
Results A total of 1889 students were included in the analysis. Table 1 provides details of the descriptive statistics and sample characteristics.
Characteristics of participants and smoking status Of 1889 students, 44% were males and 56% were females. Most students were between 17 and 19 years of age (847; 44.8%), followed by students aged 14e16 years (773; 40.9%). Overall, 621 (32.9%) students reported that they were smokers, of those more females were smokers (58.5%) than males (41.5%). A total of 19.6% of students reported that they started to smoke because they like it, 4.1% because their friends smoked, and only 1.9% because their parents smoked.
Students' perception of smoking behaviour A total of 39.8% of the students reported that they had witnessed other students smoking outdoors either in the garden or courtyard without any problems. Another 40.5% reported that students were hiding while smoking on the school premises. A percentage of 62% of the students perceived that students where smoking in the restrooms, however many perceived that students were hiding while doing so (44.5%). Smoking in the hallway instead was not common with 87% reported that students were not smoking in the hallways. A total of 57.3% stated that teachers, janitors or the principal smoke on the school premises (courtyard or garden).
Students' knowledge Only 40.8% of the students, half of the students, seemed to be aware about punishments for smoking at school, whereas the other half did not. About 60% of students were not aware of preventive intervention organized by the school. Circa 86% of students knew about the existence of a smoking ban at school. Table 1 reports the descriptive statistics.
Table 1 e Descriptive characteristics of participants. Variable Age group in years (0 missing)
Modalities
14e16 17e19 >19 Gender (1 missing) Male Female Smokers Male Female Do you smoke? No (1 missing) Yes A little Why did you start to Because I like it smoke? (3 missing) Because my parents smoke All my friends smoke Other Do you know that It do not think it smoking is is harmful harmful? Yes, but I do not (1 missing) care Yes, and I fear the consequences No Has your school organized Yes meetings/lessons Yes, but I did not against smoking? participate (2 missing) Did you know that No smoking is Yes prohibited at school, also in garden and courtyard? (2 missing) No, they do not At your school, are people smoking in smoke Yes, without any the garden or problems courtyard? (4 missing) Yes, but hiding Do students smoke No, they do not in the hallway? smoke (2 missing) Yes, without any problems Yes, but with warning Are people at you No, they do not school smoking in smoke the restrooms? Yes and without (2 missing) warning Yes, but hiding Do teachers/ No, they do not principal/janitors smoke smoke in the Yes, without any garden/courtyard problems Yes, but hiding at your school? (2 missing) Has your school ever No sanctioned Yes, with fines students who Yes, with smoked at school? disciplinary (4 missing) measures I do not know
Number of Percentage answers 773 847 269 831 1057 258 363 1267 391 230 370 36
40.9 44.8 14.2 44.0 56.0 41.5 58.5 67.1 20.7 12.2 19.6 1.9
77
4.1
1403 137
74.4 7.3
398
21.1
1353
71.7
1167 554 166
61.8 29.4 8.8
256 1631
13.6 86.4
372
19.7
750
39.8
763 1641
40.5 87.0
98
5.2
148
7.8
714
37.8
333
17.6
840 806
44.5 42.7
705
37.4
376
19.9
396 350 419
21.0 18.6 22.2
720
38.2
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Univariate analysis
Gender
Table 2 shows the univariate analysis for gender, age categories and smoking habit. Results indicate differences among gender, age group and smoker versus non-smoker students.
Females are more informed about preventive intervention for smoking in school (AOR: 1.33; 95% CI: 1.10e1.61), and they perceive less smoking habits in different locations in the school.
Gender Age Of the students in this study, male students witnessed more often that pupils smoke in either the bathroom (21.2%), garden or courtyard (46.7%) without any problems compared with female students. No significant differences concerning knowledge on harmful consequences, meetings or lessons against smoking and smoking ban could be detected.
Age Overall, younger students (14e16 years old) were significantly more aware of health consequences of smoking (75.9%) than older students were (>19 years old; 59.9%). The percentage of students who did not know about preventive intervention was highest among the age group 17e19 years (66.2%). Moreover, students aged between 14 and 16 (25.1%) years seemed to be more aware of disciplinary measures taken for students smoking at school. An interesting finding is that students' perception of teachers smoking in either the garden or courtyard was rarer among the older students (33.8%) compared with students aged 14e16 aged (38.6%).
Smoking status Table 2 shows a significant difference between smokers and non-smokers. Significant differences were found concerning knowledge about the harmfulness of smoking between smoker and non-smoker. Among those students who identified themselves as smokers, 11% believed that smoking was not harmful, and about 44% did not care about harmful consequences. Whereas of non-smoker 84.5% stated to fear the harmful consequences of smoking. Overall, smokers were also less aware of preventive intervention organized at school (61.2%) compared with non-smokers (31.5%) and about the existence of a smoking ban at school. Smokers also were exposed more frequently to teachers, janitors or principals smoking at school (41.3%) than non-smokers (35.4%). Besides, students who smoke, stated more often that people are able to smoke in the hallways without any problems.
Knowledge score The univariate analysis concerning knowledge score demonstrates that younger students, females and non-smokers have a higher knowledge regarding the existence of a smoking ban, harmful consequences of smoking, e.t.c. (Table 2).
The univariate analysis, shows that older students know less about the health consequences of smoking (AOR: 0.174; 95% CI: 0.11e0.27) and students aged 17e19 had less knowledge about preventive interventions organized by the school (AOR: 0.794; 95% CI: 0.64e0.98). Moreover, students aged 17e19 compared with 14e16 years know less about disciplinary measures taken at school (AOR: 0.79; 95% CI: 0.62e1). Students older than 19 years perceive less often if schoolmates smoke in the garden or courtyard of the school (AOR: 0.41; 95% CI: 0.30e0.57) and bathroom (AOR: 0.67; 95%; 95% CI: 0.51e0.88), but more often if they smoke in the hallways (AOR: 1.59; 95% CI: 1.09e2.31). Instead, students aged 17e19 perceive less often whether schoolmates smoke in the hallways (AOR: 0.70 CI: 0.51e0.95). No differences were shown regarding the perception of teachers', principals' or janitors' smoking habit.
Smoking status Results of the analysis concerning smoking habit (yes or no) and students' knowledge about health consequences differed significantly between the two groups. Smoker students knew less about the consequences smoking has on health (AOR: 0.54; 95% CI: 0.37e0.77) and smoker students did not know about the smoking ban (AOR: 0.41; 95% CI: 0.31e0.54). Smokers are at risk of perceiving that teachers, principals or janitors smoke on the school premises (AOR: 1.54; 95% CI: 1.26e1.89).
Knowledge score A separate multivariate analysis regarding knowledge score displays that students who have a higher knowledge score, perceive less often whether pupils smoke on the school premises.
Multinomial analysis In the multinomial analysis, only smokers were considered. The multinomial analysis shows that younger students are more prone to start smoking because their parents or friends do in comparison to students aged over 19 years who start due to other reasons (AOR: 0.38; 95% CI: 0.23e0.74; Table 4.). Besides, the analysis reveals that males compared with females are more likely to begin smoking because their parents (AOR: 2.82; 95% CI: 1.34e5.93) and friends (AOR: 3.19; 95% CI: 1.71e5.91) smoke than because they like to smoke.
Multivariate logistic regression Multivariate logistic regression analysis was conducted to explore the relation between dependent variables (attitude, knowledge, behaviours) and independent ones (gender, smoking habits, age). Data are presented in Table 3.
Discussion The present study investigated the relationship between sociodemographic factors, smoking status of Italian educated
Table 2 e Univariate analysis of age groups, gender, smoking habit and knowledge score. Questionnaire items
Age group (years) 14e16
Attitude Why did you start to smoke?
Knowledge Do you know that smoking is harmful?
Do students smoke in the hallway?
Do people smoke in the restrooms at your school? Do teachers, principals or janitors smoke in the garden or courtyard at your school? Has your school ever sanctioned students who smoked at school?
Knowledge Score Low Score High Score
>19
P-value
Male
Female
Smoking habit P-value
No
Yes
P-value
Because I like it Because my parents smoke All my friends smoke Other
108 8 36 620
(14%) (1.0%) (4.7%) (80.3%)
211 23 27 584
(25.0%) (2.7%) (3.2%) (69.1%)
51 5 14 199
(19.0%) (1.9%) (5.2%) (74.0%)
<0.001a
159 22 56 603
(19.2%) (2.7%) (5.5%) (72.2%)
211 14 31 800
(20.0%) (1.3%) (2.9%) (75.8%)
0.005a
52 2 24 1186
(4.1%) (0.2%) (1.9%) (93.8%)
318 34 53 1402
(51.2%) (5.5%) (8.5%) (74.4%)
<0.001a
I do not think it is harmful Yes, but I do not care Yes, and I fear the consequences No Yes Yes, but I did not participate No, I did not know Yes, I knew
33 153 587 471 247 55 107 666
(4.3%) (19.7%) (75.9%) (60.9%) (32.0%) (7.1%) (13.8%) (86.2)
43 198 605 560 235 51 87 758
(5.1%) (23.4%) (71.5%) (66.2%) (27.8%) (6.0%) (10.3%) (89.7%)
61 47 161 136 72 60 62 207
(22.7%) (17.5%) (59.9%) (50.7%) (26.9%) (22.4%) (23%) (77%)
<0.001a
49 187 595 547 221 62 119 712
(5.9%) (22.5) (71.6%) (65.9%) (26.6%) (7.5%) (14.3%) (85.7%)
88 211 758 619 333 104 136 919
(8.3%) (20.0%) (71.7%) (58.6%) (31.5%) (9.8%) (12.9%) (87.1%)
0.074a
69 128 1069 787 399 80 128 1139
(5.5%) (10.1%) (84.4%) (62.2%) (31.5%) (86.3%) (10.1%) (89.9%)
68 270 283 380 155 86 128 491
(11.0%) (43.5 %) (45.6%) (61.2%) (25.0%) (13.8%) (20.7%) (79.3%)
<0.001a
No, they do not smoke Yes, without any problems Yes, but hiding No, they do not smoke Yes, without any problems Yes, but with warning No, they do not smoke Yes and without warning Yes, but hiding No, they do not smoke Yes, without any problems Yes, but hiding No Yes, with fines Yes, with disciplinary measures I do not know
127 346 300 666 43 63 262 141 370 339 298 136 133 110 194 336
(16.4%) (44.8%) (38.8%) (86.3%) (5.6%) (8.2%) (33.9%) (18.2%) (47.9%) (43.9%) (38.6%) (17.6%) (17.2%) (14.2%) (25.1%) (43.5%)
158 316 369 758 33 55 324 136 385 337 316 192 209 196 172 268
(18.7%) (37.5%) (43.8%) (89.9%) (3.9%) (6.5%) (38.3%) (16.1%) (46.6%) (39.9%) (37.4%) (22.7%) (24.7%) (23.2%) (20.4%) (31.7%)
87 88 94 217 22 30 128 56 85 130 91 48 54 44 53 116
(32.3%) (32.7%) (34.9%) (80.7%) (8.2%) (11.2%) (47.6%) (20.8%) (31.6%) (48.3%) (33.8%) (17.8%) (20.2%) (16.5%) (19.9%) (43.4%)
<0.001a
144 387 289 683 62 84 263 175 392 329 329 172 211 171 169 278
(17.4%) (46.7%) (35.9%) (82.4%) (7.5%) (10.1%) (31.7%) (21.1%) (47.2%) (39.6%) (39.6%) (20.7%) (25.5%) (20.6%) (20.4%) (33.5%)
228 362 465 957 36 64 451 158 447 477 375 204 184 179 250 442
(21.6%) (34.3%) (44.1%) (90.5%) (3.4%) (6.1%) (42.7%) (15.0%) (42.3%) (45.2%) (35.5%) (19.3%) (17.4%) (17.0%) (23.7%) (41.9%)
<0.001a
251 493 523 1109 45 112 494 214 559 583 449 235 251 196 297 520
(19.8%) (38.9%) (41.3%) (87.6%) (3.6%) (8.8%) (39.0%) (16.9%) (44.1%) (46.0%) (35.4%) (18.5%) (19.9%) (15.5%) (23.5%) (41.1%)
121 257 240 532 53 36 220 119 281 223 256 141 145 154 122 200
(19.6%) (41.6%) (38.8%) (85.7%) (8.5%) (5.8%) (35.5%) (19.2%) (45.3%) (36.0%) (41.3%) (22.7%) (23.3%) (24.8%) (19.6%) (32.2%)
0e2 3e4
400 (37.8%) 373 (44.9%)
163 (15.4%) 106 (12.8%)
0.001a
566 (53.5%) 491 (46.5%)
0.008b
495 (46.8%) 352 (42.4%)
<0.001a
<0.001a
0.004a
<0.001a
0.026a
<0.001a
491 (59.1%) 340 (40.9%)
0.005a
0.368a
<0.001a
<0.001a
0.052a
<0.001a
679 (64.2%) 588 (70.8%)
378 (35.8%) 243 (29.2%)
<0.001a
<0.001a
0.504a
<0.001a
0.254a
<0.001a
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Has your school organized meetings/lessons against smoking? Did you know that smoking is prohibited at school, also in garden and courtyard? Do people smoke in the garden or courtyard at your school?
17e19
Gender
<0.001a
<0.001a
Table Legend: Chi-square and KruskaleWallis tests were performed for the univariate analysis. a P-values of Chi square. b P-values for KruskaleWallis.
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174
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Table 3 e Multivariate logistic regression analysis. Questionnaire items
Age groups (years) 17e19 vs 14e16a
Has your school ever sanctioned students who smoked at school? Do you know that smoking is harmful? Has your school organized meetings or lessons against smoking? Did you know that smoking is prohibited at school, also in garden and courtyard? Do people smoke in the garden or courtyard at your school? Do students smoke in the hallway? Do people smoke in the restrooms at your school? Do teachers, principal or janitors smoke in the garden or courtyard at your school?
>19 vs 14e16a
Gender
Smoking habits
Female vs Malesa
Yes vs Noa
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
Yes/noa
0.79 (0.62e1.00)
0.74 (0.53e1.05)
1.23 (0.99e1.54)
0.83 (0.65e1.06)
Yes/noa Yes/noa
0.93 (0.58e1.49) 0.79 (0.65e0.98)
0.17 (0.11e0.28) 1.46 (1.10e1.94)
0.81 (0.55e1.17) 1.33 (1.10e1.61)
0.54 (0.37e0.77) 1.04 (0.85e1.27)
Yes/noa
1.69 (1.24e2.30)
0.62 (0.44e0,90)
1.24 (0.95e1.63)
0.41 (0.31e0.54)
Yes/noa
0.84 (0.64e1.08)
0.41 (0.30e0.57)
0.80 (0.63e1.01)
1.12 (0.87e1.43)
Yes/noa Yes/noa
0.70 (0.51e0.95) 0.95 (0.79e1.15)
1.59 (1.09e2.31) 0.67 (0.51e0.88)
0.46 (0.35e0.61) 0.66 (0.56e0.79)
1.24 (0.93e1.65) 1.52 (1.25e1.84)
Yes/noa
1.10 (0.90e1.34)
0.78 (0.59e1.04)
0.80 (0.66e0.96)
1.54 (1.26e1.89)
CI ¼ confidence interval; OR ¼ odds ratio. a Reference group.
adolescents and their perception of smoking behaviour at school. To date, a limited number of studies have focused on the relation between student's perception of schoolmates and teachers' smoking habit at school. Data were collected from a relatively large sample among Italian adolescents aged 14 years and older through an online survey. The majority of students reported that other students or employees of the school smoke on the school premises. This suggests a degree of acceptance in Italian schools concerning smoking in schools, which in turn could influence pupil's beliefs and attitudes towards smoking. These finding are particularly worrisome from a public health perspective, bearing in mind that Italy has implemented an anti-smoking law already in 2003 banning smoking from education facilities. Furthermore, the data of the multivariate analysis revealed that older students (>19 years) surveyed were less aware about the unhealthy effects of smoking. Interestingly, although students aged 19 years and older were more aware of preventive interventions that were organized at school, many
students stated they did not participate. The poor knowledge about health consequences might either be due to ineffective teaching about the risk of smoking, a mistaken belief about the addictive nature of smoking or the general tendency of adolescents to downplay risks.11,12 Even if literature about whether prevention programs and sanctions are effective is controversial, earlier research showed that the prevalence of daily smoking in schools is lower when a policy prohibiting pupils or teachers to smoke on the school premises is adopted (9.5%; 95% CI: 6.1e12.9) compared with schools with no policy (30.1%; 95% CI: 23.6e 36.6). A recent review however concluded that schools with smoking bans, sanctions for transgressions and prevention programs, did not show a significant difference in smoking prevalence compared with schools with weaker or no policies.13 Nevertheless, unlike Moore et al (2001), we believe that not merely the presence of an anti-smoking policy may affect students smoking habit, but rather the consistency with which schools enforce policy measures can play an important role in the effectiveness of a policy.14 Research has shown that
Table 4 e Multinomial model to assess reason to smoke and age, gender and smoking habit differences. Why did you start to smokea
Variables
Because my parents smokea >19*/14e16 >19*/17e19 Gender Male*/female 2 log likelihood intercept only 127.995 2 log likelihood final 81.656 Log Likelihood Ratio Test (Chi square) 46.340 (P < 0.001) McFadden R2 0.035 Age
* Comparison/reference group. CI ¼ confidence interval; AOR ¼ odds ratio. a Reference: because I like it.
All my friends smoke othera
Othera
AOR
95% CI
AOR
95% CI
AOR
95% CI
0.83 1.17 2.82
0.24e2.93 0.38e3.60 1.34e5.93
1.18 0.57 3.19
0.48e2.89 0.24e1.39 1.71e5.91
0.38 0.47 0.92
0.23e0.74 0.30e0.75 0.64e1.32
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conspicuous actions taken by the school in response to policy violations are most likely what influences students' behaviour than the ban or policy itself.15 The univariate analysis showed that non-smokers are significantly more aware about the smoking ban, organization of preventive interventions and sanctions. Furthermore, knowledge about health consequences of smoking was significantly different between smokers and non-smokers. A similar finding was shown by Naing et al.16 (2004) who found out that the agreement on the harmfulness of smoking was greater among non-smoking students. Perhaps with the inclusion of tobacco prevention programs and a mandatory participation of students' in such programs, more awareness could be created. Another important finding arising from both the univariate and multivariate model is a possible association between teachers and peers smoking on the school premises and students smoking habits. Smokers reported more frequently that teachers and peers were smoking in the school environment. This is in line with a study conducted in Denmark, stating that adolescents' perceived exposure to teachers smoking outdoors on the school premises was significantly associated with daily smoking.17 Schools that allow teachers to smoke on the school premises may deliver the wrong message that smoking is an accepted and normal behaviour.18 Previous studies discovered a positive association between witnessing teacher smoking and student smoking.9,17 This stresses the importance for the task teachers might have as role models in school.19 A systematic review presented that the school was the main setting for smoking initiation for boys.20 Furthermore, according to the social cognitive theory, adolescents shape their behaviour based on people who they consider worthy,16 and therefore adolescents who observe role models smoking have a higher probability of smoking uptake.17 Thus, schools should focus on tackling students witnessing teachers who smoke and should emphasize policies, which prohibit teachers from smoking on the school premises. This could help to reduce the number of students smoking. Moreover, the behaviour of peers might play a vital role in determining smoking behaviour as shown from the multinomial analysis. In fact, peers are often the most common source of the first cigarette and the person with whom the first cigarette is smoked. Studies have proposed that initiating tobacco smoking might be a means by which youngsters use to enter friendship groups or be accepted.20 This is in line with studies that examined the interactions between friends' smoking habit and other network characteristics.21,22 Rostila et al.22 (2013), for example, suggest that having a large percentage of smokers in one's social network is by far the greatest risk factor for daily smoking. Moreover, similar to teachers, peers who smoke represent an environment in which smoking is viewed as favourable. As stated earlier, this is in line with the social learning theory of behaviour Social Learning and Personality Development which states that children are more likely to model their own behaviour on actions of people they regard as worthy, similar to themselves and models of their own sex.23 As so many, this study also comes with several strengths and limitations. A key strength is the large sample of Italian students of diverse age groups, who participated voluntarily in
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the survey. Nevertheless, the study has important limitations that should be taken into account. A significant methodological problem concerns the truthfulness of answers on this topic. Second, not all participants answered to all the items included in the questionnaire (e.g. some skipped items). Hence, there were some missing data. Moreover, the study relies on self-reported data of students smoking status and their perception of teachers and students smoking on the school premises. Reporting bias can therefore not be excluded. In fact, evidence depicts that people are likely to project their own behaviour onto others and smokers, for instance, are more likely to be aware of others who smoke. Besides, we were not yet able to make a comparison between different geographical locations as the survey did not include a question about the city of residence. Finally, the survey method did not allow to evaluate the relationship between smoking exposure and smoking status since the evaluation of biomarkers (cotinine) through blood, urinary or hair samples was impossible. Conclusively, the present study demonstrates significant associations between students' smoking habit and students' perception of smoking behaviour at school. It stretches the important role that peers, teachers and a smoke-free school environment have in influencing an adolescent's smoking behaviour. The findings may serve as food for thought for upcoming school-based tobacco control strategies, particularly in countries with ‘liberal’ smoking policies. An important target for intervention should be adolescents' reference persons, given that they often learn and copy behaviours and attitudes from others. In addition, information about the smoking ban, possible sanctioning for smoking at school and health consequences have to be communicated more clearly, and there is a need not only to enforce smoking policies but also to apply them in a stricter manner. Besides, the results of the present study provide important information on smoking behaviour of school-aged adolescents and may serve as a basis for more tailored school-based preventive interventions in Italy. Furthermore, it indicates the laissez-faire style of adopting and implementing anti-smoking policies at school and gives important indication for policy makers at the supraregional level.
Author statements Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.
Funding None declared.
Competing interests None declared.
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Appendix A. Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.puhe.2017.07.004.