The relationship between school-based smoking policies and prevention programs on smoking behavior among grade 12 students in Prince Edward Island: a multilevel analysis.
ABSTRACT To examine how school-based smoking policies and prevention programs are associated with occasional and regular smoking among a cohort of grade 12 students in Prince Edward Island, Canada, between 1999 and 2001.
Data from the Tobacco Module of the School Health Action, Planning and Evaluation System (SHAPES) collected from 3,965 grade 12 students in 10 high schools were examined using multi-level regression analysis.
Attending a school with smoking prevention programming was associated with a decreased risk of being an occasional smoker (OR 0.42, 95% CI: 0.18, 0.97). School-based policies banning smoking on school property were associated with a small increased risk of occasional smoking (OR 1.06, 95% CI: 0.67, 1.68) among some students. The combination of both policies and programs was not associated with either occasional or regular smoking.
This preliminary evidence suggests that tailored school-based prevention programming may be effective at reducing smoking uptake; however, school smoking policies and the combination of programs and policies were relatively ineffective. These findings suggest that a new approach to school-based tobacco use prevention may be required.
- SourceAvailable from: Vesa Saaristo[Show abstract] [Hide abstract]
ABSTRACT: Finnish national data sets on schools (N = 496) and pupils (N = 74,143; 14–16 years) were used to study whether a systematic documenting policy for the violations of school smoking bans was associated with pupils’ smoking and their perceptions on the enforcement of smoking bans. Attending a school with a systematic documenting policy was associated with perceptions that smoking is prohibited and restrictions monitored, with lower levels of smoking in the vicinity of the school during the school day, but not with smoking prevalence. Findings suggest that a consistent documenting policy could be an effective tool for reducing pupils’ smoking in schools.Leadership and Policy in Schools 01/2014; 13(2).
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ABSTRACT: Public-health interventions informed by theory can be more effective but complex interventions often use insufficiently complex theories. We systematically reviewed theories of how school environments influence health. We included 37 reports drawing on 24 theories. Narrative synthesis summarised and categorised theories. We then produced an integrated theory of school environment influences on student health. This integrated theory could inform complex interventions such as health promoting schools programmes. Using systematic reviews to develop theories of change might be useful for other types of 'complex' public-health interventions addressing risks at the individual and community levels.Health & Place 10/2013; 24C:242-249. · 2.42 Impact Factor
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ABSTRACT: To report on the delivery of evidence-based smoking cessation treatments (EBSCTs) within a sample of 40 Ontario family health teams (FHTs).Canadian family physician Médecin de famille canadien. 07/2014; 60(7):e362-71.
The relationship between school-based smoking policies and prevention
programs on smoking behavior among grade 12 students in
Prince Edward Island: A multilevel analysis
Donna A. Murnaghana,b,⁎, Marja Sihvonenc, Scott T. Leatherdaled,e,f, Pertti Kekkic
aSchool of Nursing, University Prince Edward Island, Charlottetown, Prince Edward Island, Canada
bPrince Edward Island Health Research Institute, Charlottetown, Prince Edward Island, Canada
cDepartment of General Practice and Primary Health Care, Institute of Clinical Medicine, University of Helsinki, Finland
dDivision Preventive Oncology, Cancer Care Ontario, Toronto, ON, Canada
eDepartment of Public Health Sciences, University of Toronto, Toronto, ON, Canada
fDepartment Health Studies and Gerontology, University Waterloo, Waterloo, ON, Canada
Available online 18 January 2007
Purpose. To examine how school-based smoking policies and prevention programs are associated with occasional and regular smoking among
a cohort of grade 12 students in Prince Edward Island, Canada, between 1999 and 2001.
Methods. Data from the Tobacco Module of the School Health Action, Planning and Evaluation System (SHAPES) collected from 3,965 grade
12 students in 10 high schools were examined using multi-level regression analysis.
Results. Attending a school with smoking prevention programming was associated with a decreased risk of being an occasional smoker (OR
0.42, 95% CI: 0.18, 0.97). School-based policies banning smoking on school property were associated with a small increased risk of occasional
smoking (OR 1.06, 95% CI: 0.67, 1.68) among some students. The combination of both policies and programs was not associated with either
occasional or regular smoking.
Conclusion. This preliminary evidence suggests that tailored school-based prevention programming may be effective at reducing smoking
uptake; however, school smoking policies and the combination of programs and policies were relatively ineffective. These findings suggest that a
new approach to school-based tobacco use prevention may be required.
Crown Copyright © 2007 Published by Elsevier Inc. All rights reserved.
Keywords: School; Policy; Smoking prevention; Adolescents; Multilevel models
Cigarette smoking typically begins and escalates during
adolescence (CCS, 2005; Chen, 2003; Ellison et al., 1995) with
the majority of youth (70–75%) having tried smoking at least
once by the end of high school (Orlando et al., 2004; CDC,
2004). The Theory of Triadic Influence (TTI) (Flay et al., 1999;
Petraitis et al., 1995) suggests that youth smoking is influenced
by factors from three domains: intrapersonal factors (e.g.,
personality traits or self-esteem); socio-environmental factors
(e.g., friends and family members); and broader contextual
factors (e.g., school environment). A large body of research has
examined the intrapersonal and socio environmental domains
outlined in the TTI (e.g., USDHH, 1994; Tyas and Peterson,
1998); however, a relative paucity of research has examined
factors from the contextual domain (Aveyard et al., 2004a,b).
Within the existing literature, it appears that school-based
smoking policies have an impact on youth smoking (Kumar et
al., 2005; Distefan et al., 2000; Reitsma and Manske, 2004;
Pentz et al., 1997). For instance, strongly enforced school
policies are associated with lower rates of daily and non-daily
smoking (Trinidad et al., 2004; Wakefield et al., 2000; Moore
et al., 2001; Maes and Lievens, 2003). However, recent
Preventive Medicine 44 (2007) 317–322
⁎Corresponding author. Prince Edward Island Health Research Institute, 550
University Avenue, Charlottetown, Prince Edward Island, Canada C1A 4P3.
Fax: +1 902 566 0777.
E-mail address: email@example.com (D.A. Murnaghan).
0091-7435/$ - see front matter. Crown Copyright © 2007 Published by Elsevier Inc. All rights reserved.
research has also identified that some non-smoking students are
with a policy banning smoking on school property (Leatherdale
et al., 2005a,b). Additional research is required to better
understand how school smoking policies are associated with
Research examining the influence of school-based smoking
prevention programs on youth smoking appears to suggest that
such programs have had mixed success in reducing youth
smoking (Manske et al., 1997; Peterson et al., 2000; Sussman et
al., 2001; Hanewinkel and Aßhauer, 2004; Wiehe et al., 2005).
However, research has also identified that school-based
prevention programs can be effective when targeted to sub-
populations of high-risk youth (Cameron et al., 1999a) or when
tailored to the needs of smoking youth (Brown et al., 2002;
Sussman et al., 2001). Additional research examining the
impact school-based prevention programs have on youth
smoking behavior is required.
Between 1999 and 2001, Prince Edward Island introduced a
province-wide initiative to implement both school-based
policies banning smoking on school grounds and school-
based smoking prevention programming in all schools, phased
in over a three-year period. Considering that research has yet to
examine the individual and combined effects of both school
policies and programs on youth smoking behavior, the situation
in Prince Edward Island presents a unique natural experiment to
examine such associations. As such, this paper examines how
school smoking policies and school smoking prevention
programs are associated with occasional and regular smoking
among a cohort of grade 12 students in Prince Edward Island.
This cross-sectional, cohort study used self-reported data collected from all
10 English speaking secondary schools (grades 10–12) in the province of Prince
Edward Island from 1999 to 2001. The Tobacco Module of the School Health
Action, Planning and Evaluation System (SHAPES) (Cameron et al., 1999b)
was administered to students from all 10 schools each year resulting in data
being collectedfrom 13,131 students;the TobaccoModule asked about smoking
behavior, attitudes about smoking, and contextual influences on tobacco use.
Since anonymous data collection was required for the surveys, individual
student smoking behavior could not be tracked over the study period.
In 1999, none of the 10 schools in Prince Edward Island had school
smoking policies banning smoking on school property or were participating in
a provincially directed school-based smoking prevention program. In 2000,
four schools had introduced the new smoking policy, while six schools
implemented the new school-based smoking prevention programs (SWITCH
club and Kick the Nic smoking cessation programs). SWITCH was a student-
led program that designed and delivered targeted programs (both in and outside
class activities to inform students about tobacco use, using a variety of skits,
posters and quizzes). The Kick the Nic program was a ten-session facilitated
group cessation program offered on a voluntary basis to students in each
school. In 2001, all 10 schools had implemented both the smoking policies and
prevention programming. This natural experiment allowed us to examine how
the presence or absence of school smoking policy and/or prevention
programming were associated with smoking behavior in a provincially
representative sample of students. In order to reduce potential confounding,
data from the sample of grade 12 students (n=3,965) from each study year
were used for the analyses (n=1,179 in 1999, n=1,361 in 2000, n=1,425 in
2001). The study was approved by the University of Prince Edward Island
Research Ethics Board.
Never smokers were defined as students who reported that they had never
smoked or had only tried smoking once; occasional smokers reported that they
smoked less than weekly; and regular smokers reported that they smoked every
School smoking programs and policy was based on whether or not the
school was participating in the school-based prevention programming and/or if
the school had implemented the school smoking policy at the time of data
collection. School location was measured as urban or rural.
Student beliefs about school smoking policies were measured by asking: in
your school there is a clear set of rules about smoking for students to follow
(true/false); and if a student is caught breaking the smoking rules at your school
they get into trouble (true/false). Friend smoking behavior was measured by
asking students if they have one or more friends who smoke (none/1 or more
smoking friends). Gender was measured as either male or female.
Since students were located within schools [creating a 2-level nested
structure in which individual students (level-1) were nested within schools
(level-2)], multi-level logistic regression analyses were used to examine how
both school and student characteristics are associated with student smoking
behavior. The first model examined how school and student characteristics were
able to differentiate occasional smokers (1) from never smokers (0). The second
model examined how school and student characteristics were able to
differentiate regular smokers (1) from occasional smokers (0). All analyses
controlled for the waveof data collectionto adjust for potential differences in the
grade 12 students over time. Contextual interactions between the student
characteristics and school characteristics were examined; however, only
significant interactions are presented in the final models. Statistical analyses
were conducted using MLwiN Version 1.1 (Rasbash et al., 2001).
Descriptive characteristics of the grade 12 students' smoking
behaviors are presented in Table 1. Among the 3,965 grade 12
students, 2,087 (52.6%) were never smokers, 789 (19.9%) were
occasional smokers, and 1,089 (27.5%) were regular smokers.
The sample was 47.8% male and 52.2% female. Slightly more
females (22.5%) than males (17.0%) were occasional smokers,
regular smokers. Average age was 17.6 (SD 0.7) years. Overall,
regular smokers hadmore close friends whosmoke [3.7(SD1.4)
smoking friends] in comparison to occasional smokers [1.6
(SD1.5) smoking friends] and never smokers [1.0 (SD1.3)
School and student characteristics related to youth smoking
The relationships between school smoking policies and
programs, student beliefs about school smoking policies, and
318D.A. Murnaghan et al. / Preventive Medicine 44 (2007) 317–322
smoking status are presented in Table 2. Significant between-
school random variation in occasional smoking [σμ
(0.02), p<0.01] was found. The school a grade 12 student
attended was significantly related to his/her likelihood of
being an occasional smoker versus a never smoker. Sig-
nificant between-school random variation in regular smoking
grade 12 student attended was significantly related to his/her
likelihood of being a regular smoker versus an occasional
2=0.04 (0.01), p<0.01] was also found. The school a
Differentiating occasional smokers from never smokers
When compared to a student attending a school without the
smoking prevention programs, a student attending a school with
the smoking prevention programs was less likely to be an
occasional smoker (OR 0.42, 95% CI: 0.18, 0.97). A student
whobelievedthat thereareclear rules about smokingwas alsoat
a decreased risk for being an occasional smoker (OR 0.41, 95%
CI: 0.23, 0.74). Conversely, if a student had one or more close
friends who smoked, he/she was at increased risk for occasional
interaction between the presence of a smoking policy at a school
and student beliefs about smoking rules at school was identified
(Fig. 1). Attending a school with a smoking policy was not
associated with a decreased risk of occasional smoking among
students who believed that their school did not have clear rules
about smoking. However, students who believed that their
decreased risk for occasional smoking if they attended a school
without the school smoking policy.
Differentiating occasional smokers from regular smokers
Students who believed that students caught breaking the
school smoking rules got into trouble were at increased risk for
regular smoking (OR 1.48, 95% CI: 1.02, 2.15). Students were
close friends who smoked (OR 2.38, 95% CI: 2.17, 2.62).
Descriptive statistics for the sample of grade 12 students who are never smokers
(n=2,087), occasional smokers (n=789), and regular smokers (n=1,089) from
10 high schools in Prince Edward Island, Canada (1999–2001)
Number of close
Wave of data
Multi-level logistic regression of school-level smoking programs and policies and student-level beliefs about school programs and policies related to student smoking
behavior in sample of 3,965 grade 12 students in Prince Edward Island, Canada (1999–2001)
Parameters Adjusted odds ratioa(95% CI)
Occasional smoker vs.
never smoker (O vs. N)
Regular smoker vs.
occasional smoker (R vs. O)
School smoking programs and policies
No smoking programs or policy
Smoking program only
Smoking policy only
Smoking programs and policy
0.42 (0.18, 0.97)*
1.06 (0.67, 1.68)
0.83 (0.61, 1.12)
1.11 (0.80, 1.53)
0.79 (0.52, 1.19)
0.88 (0.65, 1.19)
At school there are a clear set of rules
about smoking for students to follow
Students caught breaking the smoking
rules at school get into trouble
Close friend smoking
No smoking friends
1 or more smoking friends
0.41 (0.23, 0.74)**
1.48 (1.02, 2.15)*
2.38 (2.17, 2.62)***
1.30 (1.21, 1.39)***
School smoking policy
At school there are a clear set of rules
about smoking for students to follow
2.69 (1.20, 6.03)*
<refer to Fig. 1>
Model 1: 1=occasional smoker (n=789), 0=never smoker (n=2,087).
Model 2: 1=regular smoker (n=1,089), 0=occasional smoker (n=789).
*p<0.05 **p<0.01 ***p<0.001.
aOdds ratios adjusted for all other variables in the table.
bControlling for gender, wave of data collection, and school location.
319D.A. Murnaghan et al. / Preventive Medicine 44 (2007) 317–322
Neither smoking policies nor school prevention programming
was associated with the likelihood of being a regular smoker.
Probability of occasional and regular smoking in schools
The probability of students being occasional smokers was
less for students attending schools with smoking prevention
programming (0.30, 95% CI: 0.18–0.97) compared to students
who were attending schools with policy only (0.52, 95% CI:
0.67–1.68) or attending schools with both policies and
programming present (0.45, 95% CI: 0.61–1.12). The prob-
ability of students being regular smokers was greater for those
attending schools with smoking prevention programming (0.53,
95% CI: 0.80–1.53) compared to students who were attending
schools with policy only (0.44, 95% CI: 0.52–1.19) or attending
schools with both policies and programming present (0.47, 95%
This study identified that (a) school-based smoking preven-
tion programming was associated with a decreased risk of being
an occasional smoker but not with the risk of being a regular
smoker, (b) that school policies banning smoking on school
property actually increased the risk of being an occasional
smoker among sub-populations of students, and (c) that the
combination of programs and policies was not associated with
either a decreased risk of being either an occasional or regular
smoker. In essence, these findings suggest that school-based
primary prevention initiatives may not be effective unless they
reach students prior to adopting advanced smoking behavior.
Influence of policies and programs on smoking
The relationship identified between attending a school with a
school-based smoking prevention program and students being
at decreased risk for occasional smoking is contrary to the bulk
of existing empirical evidence that programs have had mixed
success in preventing or decreasing youth smoking (Manske et
al., 1997; Peterson et al., 2000; Wiehe et al., 2005). However,
considering that the program within this study was designed by
students and tailored to the needs of the smoking population in
each school, our finding is consistent with Brown and
colleagues (2002) and Sussman et al. (2001) who identified
that programs tailored to the needs of smoking youth are
effective at reducing smoking uptake. Our data suggest that
programs deemed ineffective may want to evaluate their
outcomes among occasional smoking populations.
The finding that students attending a school with a policy
banning smoking on school property were not at decreased risk
for either occasional or regular smoking is also contrary to the
existing literature which suggests that school policies are
associated with lower rates of daily and non-daily smoking
(Pentz et al., 1989; Wakefield et al., 2000; Moore et al., 2001;
Maes and Lievens, 2003). This finding may suggest that more
other influences within schools such as peers, teachers, and
coaches may contribute to changes in smoking behavior.
However, our finding that sub-populations of students were
a school with such policies is consistent with the work of
Leatherdale and colleagues (2005a,b) who previously identified
a similar relationship for smoking susceptibility among non-
smoking youth. Considering that suchpolicies force studentsoff
school property to smoke, these findings may result from such
smoking areas being a social place (Mermelstein, 1999; Nichter
et al., 1997) and a place where peer pressure occurs (Chaissin et
al., 1984; Hu et al., 1984). Additional research is required to
better understand how school smoking policies, which may put
some students at greater risk for smoking, are associated with
smoking among different youth populations.
Findings from earlier studies suggest that the effectiveness of
policies and programs may be a function of the characteristics of
the school (Cameron et al., 1999a,b; Leatherdale et al., 2005a,b)
and may suggest targeting programs and policies to the schools
where they are most likely to be effective (Cameron et al.,
1999a). Research has addressed prevention programs that
change social norms (Wakefield et al., 2000; Gilpin et al.,
2001) and those that include parents, siblings, and peers as
important role models for motivating students to not smoke
(Trinidad et al., 2005; Nofziger and Lee, 2006; Tragesser et al.,
2006). Such multi-pronged approaches to prevention and
cessation might be important for success. Studying how these
approaches affect sub-populations within schools where no-
smoking policy and programs are present, may contribute to a
better understanding of the effectiveness of tobacco reduction
The findings from this study suggest that providing policy
and prevention initiatives for students who are regular smokers
may not be a wise investment of limited resources (Cameron et
al., 1999a; Murnaghan et al., submitted for publication); rather
resources for booster inoculations of prevention efforts may
have more impact when primarily targeted to students who are
at an early stage of initiation of smoking. Further, inclusion of
Fig. 1. Using the model estimates, the odds of a student being an occasional
smoker can be estimated as a function of whether or not the school has a policy
about smoking and beliefs about whether or not the school has clear rules about
smoking for students to follow. In the figure, the model-based odds ratios of a
student being an occasional smoker relative to a hypothetical student who does
not believe his/her school has clear rules about smoking at a hypothetical school
without a school smoking policy are presented. Model-based estimated odds
ratio for being an occasional smoker versus a never smoker as a function of
school smoking policy and beliefs about smoking rules at school in Prince
Edward Island (1999–2001).
320D.A. Murnaghan et al. / Preventive Medicine 44 (2007) 317–322
smoking cessation programs, in conjunction with policy and
prevention efforts, may be more effective in decreasing the
overall burden of tobacco (Martin et al., 1999).
This study provided a unique opportunity to explore the
influences of policies and programs under natural occurring
events; however, limitations were present because of this design.
The quasi-experimental, cross-sectional design prevents us from
determining causality. Longitudinal data would have allowed us
and the onset and progression of student smoking behavior. A
second limitation is the use of self report data means we cannot
is national generalizability. Although these data are provincially
representative for Prince Edward Island, the findings may not
necessarily reflect the situation in other Canadian jurisdictions.
policy and program enforcement was not available which may
have contributed to data results in some schools.
Despite tobacco reduction efforts in Prince Edward Island,
smoking rates among grade 12 students remained high. This
preliminary evidence suggests that tailored school-based
prevention programming may be effective at reducing smoking
uptake; however, school smoking policies and the combination
of programs and policies appear relatively ineffective among
more advanced smokers. This study provides evidence that
traditional approaches to implementation of primary preven-
tion policies and programs may require changes that address
different needs of sub-populations of youth (i.e., providing
cessation programs rather than prevention programs). Further
studies should consider this relationship using longitudinal
the Centre for Behavioral Research and Program Evaluation at
the University of Waterloo and the National Cancer Institute of
Canada. The authors acknowledge the support of Dr. Roy
Program Evaluation and Dr. Steve Brown and his team at the
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