Assessing the Relationship between Tobacco Control School Policies and Adolescent Smoking in Israel : A Multilevel Analysis

Cigarette smoking is one of the most dangerous behaviors affecting health. The World Health Organization (WHO) has stated that tobacco smoking is the second most common cause of death and is the fourth most dangerous risk factor for disease worldwide. Health promotion policies can help reduce health-related risk behaviors and policies targeting risk behaviors have been gradually implemented across schools in Israel. This study identified the most effective school health promotion policy components and their association with risk behaviors, specifically tobacco smoking among adolescents. Data from the random-sample Israeli 2011/12 Health Behavior in School-Aged Children (HBSC) survey was analyzed. This included interviews with 5,279 students in 95 Jewish public schools. In addition, 100 principals from the participating schools were interviewed to measure the extent of implementation of health promotion policies in their schools. A logistic hierarchical linear model (HLM) analysis was performed to simultaneously estimate the relationship between individual and school level factors with tobacco smoking. Most variance in adolescent smoking was explained by student level variables including negative perceptions of school, lack of parental support for school issues, and time spent with friends. Among the school level measures, parental participation in health promotion intervention programs proved to be associated with lower rates of Adolescents Tobacco Smoking, over and above student characteristics. School health promotion policies should focus on parents’ participation in intervention programs and should seek to improve students’ perceptions of school and their sense of well-being to promote resilience. Central Bringing Excellence in Open Access   Tesler et al. (2017) Email: J Addict Med Ther 5(1): 1028 (2017) 2/5 A very significant factor contributing to a healthful environment at school is the establishment of a properly structured school health promotion policy under the guidance of the school principal [9,13]. The principal’s perceptions, management, and policies can directly affect the development and design of a viable health-behavior culture to be adopted by students and teachers alike. Numerous studies have found a correlation between health-promotion policies and positive changes among students for a variety of risk behaviors [14-16]. For example, studies have shown that enforcement of rules and implementation of intervention programs regarding tobacco smoking cessation significantly decreases student smoking rates [17,18]. Given these prior findings, this study attempts to examine the correlation between individual level (e.g. parental support in school matters, student perceptions of school and social involvement) and school level (e.g. school health policy) factors on risk behaviors among adolescents in Israel, with important implications for health promotion policies and interventions. The goal of this study is to understand which factors at the student level (e.g., parental support on issues related to school, perceptions of the school and of the student, and social involvement), and school health promotion policy level (e.g., agenda setting, school rules, intervention, student involvement, and parental involvement), are associated with tobacco smoking. It was hypothesized that higher levels among the student level characteristics are associated with lower tobacco smoking. It was also hypothesized that increased levels of health promotion policies are associated with lower tobacco smoking. MATERIALS AND METHODS The current study is part of the multinational project Health Behavior in School-Aged Children (HBSC), undertaken under the auspices of the World Health Organization (WHO). The HBSC is a school-based survey of adolescent health, behaviors and psychosocial determinants, carried out internationally every four years, using a methodological protocol standardized across countries [19]. This anonymous, self-administered in class includes questions on risk behaviors, school perception, parental support, and social connectedness [19]. This study was based on the Israeli data from the 2011 HBSC-WHO cross-national survey of children in 6th, 8th, 10th and 12th grade. It included 5,279 students in 225 classrooms from 95 Jewish schools. The class level response rate was 94.5% with a 99% response rate of children enrolled in participating classes. Our study in 2011-2012 also included a survey of the principals of the sampled schools to ascertain the degree of adoption and implementation of a health promotion policy. Of the 160 principals surveyed, 100 principals’ responses were included in the study, after excluding those who were not from public secular or religious schools, lacked time or lacked interest in completing the survey. The Israeli HBSC research protocol received approval from the research ethics committees of both the Israeli Ministry of Education and Bar-Ilan University and this study was approved by the ethics of Ariel University. Data were collected with anonymous self-report questionnaires distributed in the classroom. Using the lists of classes and schools obtained from the Israeli Ministry of Education, a random stratified two-stage cluster sample was obtained. The sample unit was a classroom, stratified by region, type of school and grade level with a maximum of two classrooms within each sampled school allowed. For the first time since the implementation of the WHO HBSC project in the early 1980s, to our knowledge, school principals were surveyed. A questionnaire was administered by the research team to the principals of schools in which the students were sampled. Interview topics for the principals included commitment to health promotion in the school, the existence of school policies for regulation and enforcement of tobacco use, implementation of intervention programs, and participation of students, parents and teachers in health promotion activities.