*Melinda Pènzes1, Pèter Balázs1, Kristie L. Foley2
Changes in smoking-related health knowledge and smoking status of Hungarian adolescents
1Institute of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
Head of Institute: prof. Károly Cseh, MD, PhD
2Department of Social Sciences and Health Policy, Wake Forest University, Winston-Salem, NC, USA
Head of Department: prof. Kristie L. Foley, PhD
Introduction. School-based anti-smoking programs often educate adolescents about the adverse health effects of smoking to enable them to make informed decisions about smoking.
Aim. Our study aimed to assess changes in smoking-related health knowledge and smoking status in two cohorts of adolescents.
Material and methods. A three-year prospective survey (from 2010 to 2012) with annual data collection was conducted in Hungary’s six metropolitan cities among randomly selected elementary (younger cohort) and secondary school (older cohort) students (N = 1,092; 54% females). Measures included a 14-item scale for smoking-related health knowledge and variables to assess demographics and self-reported smoking status.
Results. The prevalence of past month smoking increased by 8.8% in the younger cohort (p < 0.001) and 11.0% in the older cohort (p < 0.001). Throughout the study, 69.4% of the sample remained non-smoker, 12.8% remained smoker, 13.9% initiated smoking and 3.8% quit smoking. Smoking-related health knowledge changed significantly during three years with inconsistent positive and negative changes. Overall knowledge increased at a higher rate among students in the younger cohort. Those initiating smoking showed the lowest level of knowledge at the last wave of data collection.
Conclusions. To reduce smoking initiation and to promote quitting, comprehensive prevention strategies should be conducted, such as school-based programs that incorporate skill-building (not exclusively health education) and peer-focused anti-smoking programs.
The prevalence of adolescent smoking shows unfavorable trends in Hungary. Two-thirds of youth have tried cigarette by the age of 16 and 35-39% of them were current smokers (past 30 days) (1, 2). Education about the adverse health effects of smoking aimed to raise awareness of negative health consequences and prevent initiation is a cornerstone of many school-based tobacco prevention programs (3, 4). Schools provide an optimal social environment to influence adolescent smoking behavior because most children can be reached there and prevention fits well into educational and holistic school health promotion requirements (5, 6). In the past decades, numerous school-based tobacco and other drug prevention programs were implemented in Hungarian schools starting predominantly in the 5th class of elementary schools. However, little is known about the frequency, content and effectiveness of these interventions (7).
Recently, a nationwide study found decreasing yearly participation rates of 13-15 years old adolescents in school-based anti-smoking programs (8). A general review of Hungarian school-based drug prevention programs indicated that the interventions are methodologically heterogeneous, poorly designed, and non-professionally implemented and focused primarily on increasing health literacy of legal and illicit drug use (4, 7). Hungarian adolescents also report that anti-smoking interventions disproportionally overemphasized the adverse health consequences of smoking (9). However, there is little evidence to support the beneficial effects of this strategy on adolescents’ smoking behavior (4, 5). Seemingly, information-giving prevention programs may increase the awareness of adverse health effects of smoking, but have limited or no impact on the youth’s long term, smoking-related decisions (3, 4).
Our 3-year prospective study aimed to 1) assess changes of smoking status among Hungarian adolescents; and 2) explore differences in their smoking-related health knowledge over time.
MATERIAL AND METHODS
Participants and procedure
A 3-year prospective cohort study with yearly data collection started in the second half of the 2009-2010 school year in Hungary’s six metropolitan cities (Budapest, Debrecen, Győr, Miskolc, Pècs, Szeged). We used a cluster random sampling strategy, stratifying by number of students and school types of the settlements using annual data (2008) of the Public Education Information Office. Among 413 invited schools (elementary, vocational and high schools), 78 agreed to participate in the prospective survey. We invited 2,985 students to participate in the baseline survey. Parents were informed by a passive consent procedure; 418 refused participation, thus 2,567 students were informed both verbally and in writing about the voluntary nature of their participation of which 86.0% participated. Trained data collectors unknown to the students requested them to complete the self-administered questionnaire within one teaching hour. Data were entered anonymously, using a separate name-identifier linkage document. At baseline, randomly selected 6th (younger cohort) and 9th graders (older cohort) completed the survey (N = 2,208). Due to the prospective nature of the study, loss to follow-up occurred and 49.5% of baseline participants (N = 1,092) were successfully tracked over three years. The study was approved by the Institutional Review Board of Semmelweis University, Budapest (No.: 104/2009).
Demographic variables: gender (female/male), age in years and school grade were reported at each data collection waves (baseline or Time 1 = T1; follow-up 1 or Time 2 = T2; follow-up 2 or Time 3 = T3). Elementary school participants were 6th, 7th and 8th graders, while secondary school students were 9th, 10th and 11th graders at T1, T2 and T3, respectively.
Cigarette smoking status: Self-reported past 30 days smoking frequency. Participants who smoked ≥ 1 cigarette in the past month were regarded as current smokers (10). Smoking status were assessed from T1 to T3 and four categories were considered for analyzes (non-smokers, current smokers, students who initiated, and quitters).
Smoking-related health knowledge: fourteen, medically established health consequences of smoking were itemized (fig. 1) and respondents were requested to indicate those they think to be associated with smoking (11). We created a “knowledge scale for health consequences of smoking” (knowledge scale) by summing responses (maximum score: 14). Cronbach’s α-s, a measure of internal consistency of a scale, showed acceptable or good reliability (T1: 0.76; T2: 0.81; T3: 0.83).
Fig. 1. Changes in the knowledge of smoking-related adverse health consequences (N = 1,075).
*p < 0.001 (Cochran’s Q test)
#p ≤ 0.010 (McNemar’s test to test the difference between T1 and T3)
Descriptive statistics (Pearson’s chi-square test, mean and SD, Mann-Whitney U-test) were used to describe the sample. McNemar’s test and Cochran’s Q test with Bonferroni correction of p-value (for three comparisons, significant at p < 0.017) was applied to compare categorical variables of pairwise or overall survey waves. Two-way mixed ANOVA analyses with Tukey’s test were performed to identify changes in the mean value of knowledge scale at each survey time period. Data were analyzed using SPSS 22.0 and ROPstat 2.0 statistical program packages (12).
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