The student and school neighbourhood characteristics associated with smoking susceptibility, experimental and established smoking among secondary school students (grades 9 to 12) in Canada by Susan Kaai A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Doctor of Philosophy in Health Studies and Gerontology Waterloo, Ontario, Canada, 2013 © Susan Kaai 2013 AUTHOR'S DECLARATION I hereby declare that I am the sole author of this thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. ii Abstract Background: Lifetime smoking often commences as naïve experimentation during adolescence which frequently develops into a strong addictive habit that is difficult to break. Despite the evidence and acknowledgement of the harmful outcomes of smoking, youth smoking rates remain high in North America. Objective: The purpose of this dissertation was to examine which student- and school-level factors differentiated (1) susceptible never smokers from non-susceptible never smokers, (2) experimental smokers from never smokers, and (3) current smokers from experimental smokers among a nationally representative sample of Canadian students in grade 9-12. Methods: Student-level data from Canada’s nationally representative 2008-2009 Youth Smoking Survey (2008 YSS) were linked with school-level data from the 2006 Census, and one built environment characteristic, and examined using multi-level logistic regression analyses. The 2008 YSS was administered to 51,922 students from grades 6 to 12 in 10 provinces in Canada. The present study used only a subset from the students who were in grades 9 to 12 (n=29,296) from 133 secondary schools. The first study compared susceptible never smokers with non-susceptible never smokers and used a sub-sample of 15,982 never smokers. The second study that compared experimental smokers with never smokers used a sub-sample of 16,044 never smokers and 2,028 experimental smokers. The third study compared 3,412 current smokers with 2,028 experimental smokers. Results: Sixty-nine out of 133 secondary schools were located in urban areas. The mean number of tobacco retailers within a 1-km radius of each secondary school was 5.8 (range, 0-49). The mean household income was $56 424 (range, $30 784-$97 706). Within schools, the average prevalence rate for susceptible never smokers was 27.1% (range, 0%-58.3%), for experimental smokers was 6.2% (range, 0%-17.4%), and for current smokers was 11.6% (range, 0%-39.1%). Overall as hypothesized in these three studies, student-level and school-level characteristics were associated with smoking susceptibility among never smokers, experimental smoking and current smoking. The 2 likelihood of susceptibility among never smokers ( u0= 0.05 [0.01], P=0.0002), experimental 2 2 smoking ( u0= 0.23 [0.05], P<0.0001) and current훔 smoking ( u0= 0.13 [0.04], P<0.001) significantly훔 varied across schools. Among the three school neighbourhood훔 characteristics examined, two were significantly associated with smoking behaviour. This study identified that attending a iii school in an urban (AOR=0.62; 95% CI 0.46-0.82) setting or in a high socioeconomic status (SES) neighbourhood (AOR=0.88; 95% CI 0.79-0.98) was inversely associated with odds of a student being an experimental smoker versus a never smoker when adjusting for student-level characteristics. The number of tobacco retailers that were located within 1-km radius of each school was associated with the odds of a student being a current smoker (versus an experimental smoker) (AOR 1.03; 95% CI 1.01-1.05) and also associated with a student being a susceptible never smoker (versus a non- susceptible never smoker) (AOR 1.01; 95% CI 1.00-1.02). In sum, all the school neighbourhood factors examined exhibited moderate associations with the dependent variables. Several student-level intrapersonal (gender, grade, amount of pocket money, alcohol and marijuana use, attitudes and tobacco-related knowledge, self-esteem, perception of school rules, and perceived school connectedness) and social context (family members and friends who smoke, and smoking rules at home) characteristics were associated with smoking susceptibility, experimental smoking and current smoking. Students were more likely to be susceptible never smokers (vs. non-susceptible) if they were: in lower grades, reported low self-esteem, used alcohol or marijuana, had close friends who smoked, came from homes without a total ban on smoking, and held positive attitudes towards smoking. Students were more likely to be experimental smokers (vs. never smokers) if they were: in grades 10 or 11, reported low school connectedness, used alcohol or marijuana, believed that smoking can help people relax, received pocket money each week, and had a family member or close friend who smoked. Students were more likely to be current smokers (vs. experimental smokers) if they were: male, in higher grades, believed that smoking can help when they are bored, reported low school connectedness, used marijuana, had a sibling or close friend who smoked, and had no smoking bans at home. Conclusions: This study showed that the characteristics of the school a student attends may increase their likelihood of a student being in any of the smoking stages that were examined. The location of a school that is, being in an urban or a high SES neighbourhood was inversely associated with experimental smoking when adjusting for student characteristics. The number of tobacco retailers located within 1-km radius of each school was associated with the odds of a student being a current smoker and also associated with a never smoker being susceptible to smoking. Several student-level factors were associated with the three smoking stages. Understanding these factors will provide more insight to guide stakeholders interested in developing anti-tobacco strategies that are responsive to the risk and protective factors of adolescents in different smoking stages. iv Acknowledgements First, I really want to thank my first supervisor Dr. Sandra Bullock who opened the door for me to do my PhD studies at the University of Waterloo. Secondly, I am very grateful for my current supervisors Drs. Steve Manske and Scott Leatherdale for accepting to be my supervisors in the third year of my PhD studies in spite the fact that each of them already had students they were supervising. I am also indebted to their consistent support and patience throughout my studies. I am really thankful for the great support I received from Dr. Steve Brown. Special thanks to Drs. Mary Thompson, Steve Brown and Donna Murnaghan for accepting to be in my committee. I used secondary data from Canada’s 2008-2009 Youth Smoking Survey (YSS). The YSS is a product of the pan-Canadian capacity building project funded through a contribution agreement and contract between Health Canada and the Propel Centre for Population Health Impact from 2004 to 2011.The YSS consortium includes Canadian tobacco control researchers from all provinces and provided training opportunities for university students (like myself ) at all levels. I would like to acknowledge the Youth Smoking Survey (YSS) team for their great contribution without which my research would not be possible, specifically the schools, school boards, teachers, students, and researchers from Propel Centre for Population Health Impact. Special thanks to Robin Burkhalter, Drs. Tara Elton-Marshal and Rashid Ahmed. I would also like to acknowledge the financial support that I received for my PhD studies namely the University of Waterloo Graduate Entrance Scholarship, Senate Graduate Scholarship in Health Studies, University of Waterloo Graduate Scholarship, Presidential Graduate Scholarships, and the Ontario Graduate Scholarships. My PhD studies could not have been complete without the contribution of the faculty members from the School of Public Health and Health Systems and also the support of several wonderful people like Erin Hobin, Nour Schoueri, Mary Vu, Natasha Lane and Dana Zummach. I am glad that our paths crossed. I do not have words to express how grateful I am for the unrelenting support that I received from my husband, Sospeter and our children, Kimathi and Mutugi who labored alongside me during my doctoral studies. v Dedication This thesis is dedicated to my husband, Sospeter who challenged me to do a PhD. He consistently supported me throughout my studies including caring for our two boys in spite of doing his doctoral studies at the same time. I cannot forget my lovely children Kimathi and Mutugi who patiently put up with my absence when I had to burn the midnight candle and reassured me that all would be well. I also dedicate this thesis to my mother Pauline Jepketer and departed father Samuel Kiptanui who valued education and gave up a lot to educate me. And more importantly, I dedicate this thesis to the Almighty God who is my daily inspiration and hope. vi Table of Contents AUTHOR'S DECLARATION ............................................................................................................... ii Abstract ................................................................................................................................................. iii Acknowledgements ................................................................................................................................ v Dedication ............................................................................................................................................