A methodological and substantive review of the evidence that schools cause pupils to smoke
Introduction
This review summarises evidence from observational studies that some schools not operating specific interventions appear to inhibit smoking whilst other schools with equivalent pupils appear to promote smoking. Two types of observational studies are included. Ecological studies measure smoking prevalence at the school-level and relate this to school characteristics or aggregated pupil characteristics. Multilevel studies validly relate school-level characteristics to the pupil-level outcome of smoking.
An epidemiological framework for assessing causality from observational studies is described by Hennekens and Buring (1987). In this framework, there should be evidence that association is not due to chance, bias, or confounding. Associations that are strong, credible, consistent across studies, where cause precedes effect, and a where a dose–response relationship exists support causality. In particular, we examine confounding by pupil characteristics as the main threat to the validity of observed associations. If pupil characteristics explain inter-school smoking variation, this implies adolescent risk factors for smoking that are not of the schools’ making, such as parental smoking, are common amongst pupils in some schools but not others. School-level characteristics include, for example, tobacco control policies and school culture. Macintyre, Ellaway, and Cummins (2002) describe differences in pupil characteristics between schools as compositional characteristics, and school-level characteristics as contextual and collective characteristics.
To date, school-based anti-smoking interventions have had very limited success (Peterson, Kealey, Mann, Marek, & Sarason, 2000) If school-level contextual/collective factors influence pupils’ smoking, this could generate new school smoking prevention programmes. The search for the attributes of schools and schooling that influence pupils’ smoking is the first stage of this development.
Section snippets
Data sources
To conduct this review, we searched Medline, Embase, Psychlit, the British Education Index (BEI), ERIC (an educational database), and the Science and Social Science Citation databases using index terms and text words, and searched our own library of papers. In Medline, we used the index terms ‘culture’ (exploded), ‘institutional management teams’ (exploded), ‘smoking’ (exploded) and text words either ‘college’ or ‘school’. In Embase, we used index terms organisation (exploded), sociology
Does smoking prevalence vary by school?
Five UK studies reported on variation between schools (Table 1) Smoking prevalence increases rapidly as adolescents move through the secondary school (ages 11–16 years), which influences measures of variation between schools. To provide a common index of variation, we calculated a ‘school effect’ odds ratio (OR). This OR is the odds of smoking in a school one standard deviation above the average school divided by the odds of smoking in a school with average smoking prevalence, calculated from
Conclusion
This review has documented that smoking prevalence varies markedly between schools, but what is the evidence that this is caused by school factors? For the most part, where associations have been significant, chance does not provide an adequate explanation of inter-school smoking prevalence variation. Selection bias is unlikely because most studies used appropriate sampling and it cannot explain variation per se. Information bias is more possible. Particularly, for example, in schools with
References (41)
- et al.
Variations between schools and regions in smoking prevalence among British schoolchildren—implications for health education
Public Health
(1985) - et al.
Variability in cigarette smoking within and between adolescent friendship cliques
Addictive Behaviors
(1994) - et al.
A survey of cigarette smoking among middle school students in 1988
Public Health
(1990) - et al.
Place effects on healthHow can we conceptualise, operationalise and measure them?
Social Science and Medicine
(2002) - et al.
The smoking habits of 16-year-olds in the National Child Development Study
Public Health
(1978) - et al.
The relationship between students’ sense of their school as a community and their involvement in problem behaviors
American Journal of Public Health
(1997) Why are school-based, youth-centred smoking interventions not as effective as we hoped? Some ideas for research
International Journal of Health Promotion & Education
(2000)- et al.
Smoking prevalence among 16–19 year-olds related to smoking policies in sixth forms and further education
Health Education Journal
(1994) - et al.
School structural and policy variables associated with student smoking
Tobacco Control
(1994) - et al.
Why children start smoking cigarettesPredictors of onset
British Journal of Addiction
(1992)
Confounding in epidemiological studiesWhy “independent” effects may not be all they seem
British Medical Journal
The association between teacher attitudes, behavioral intentions, and smoking and the prevalence of smoking among seventh-grade students
Adolescence
The contribution of influence and selection to adolescent peer group homogeneityThe case of adolescent cigarette smoking
Journal of Personality & Social Psychology
School and neighborhood characteristics associated with school rates of alcohol, cigarette, and marijuana use
Journal of Health & Social Behavior
Smoking prevalence among 15–16 year olds in Doncaster, England
Journal of Public Health Medicine
Variations in adolescents’ smoking and alcohol behaviour between Swedish schools—an ecological analysis
Drugs: Education, Prevention and Policy
Epidemiology in medicine.
Indications for measures to be taken in childhood to prevent chronic respiratory disease
Millbank Memorial Quarterly
Children's purchases of single cigarettesEvidence for drug pushing?
British Journal of Addiction
Schools and smokingSchool features and variations in cigarette smoking by children and teachers
British Journal of Educational Psychology
Cited by (117)
Smoke-free school policies in Europe: Challenges for the future
2020, Preventive MedicineReintegrating contexts into quantitative intersectional analyses of health inequalities
2019, Health and PlaceThe association between smoke-free school policies and adolescents’ anti-smoking beliefs: Moderation by family smoking norms
2019, Drug and Alcohol DependenceCitation Excerpt :The injunctive and descriptive norms were combined into an overall family smoking norms score that ranged from 0 to 8 and was dichotomised by using a median split (0–6 and 7–8), representing individuals with relatively permissive and prohibitive family smoking norms, respectively. Age (in years), gender (male vs female), city, parents’ migration background (0, 1, or 2 parents not from country of residence), mother’s educational level and father’s educational level (low, middle, high or unknown) were measured as potential confounders (Aveyard et al., 2004). The education level of parents was assigned country-specific categories that were later standardized into low-, middle- and high-education.
Role theory of schools and adolescent health
2019, The Lancet Child and Adolescent HealthCitation Excerpt :Mental health and behavioural problems have a profound effect on student engagement and educational attainment.2 Conversely, schools have an equally substantial effect on students' health, with great variation existing between schools in terms of rates of violence, and use of tobacco, alcohol, and other drugs: differences that reflect school characteristics rather than merely differences between the students entering schools.3–5 A range of theories have been suggested for the health benefits observed in students, including avoidance of health risks associated with early entry into labour markets, sexual activity, or criminality;6 education of young people about how to promote their physical and mental health;7 and enhanced provision of nurturing social environments, with growing evidence that interventions that modify the school environment also improve student mental and physical health across a range of outcomes.8–10
A Web-Based Gamification Program to Improve Nutrition Literacy in Families of 3- to 5-Year-Old Children: The Nutriscience Project
2019, Journal of Nutrition Education and Behavior