School-Based Tobacco Control and Smoking in Adolescents: Evidence from Multilevel Analyses

Since 2015, universal comprehensive school-based tobacco control programs have been provided in all primary and secondary schools in Korea. This study explored the association of school-level tobacco control with adolescent smoking, and the interactions to investigate whether gender moderates the impact of school tobacco control programs and school-level norms. Both school- and individual-level data were drawn from the 2015 School-Based Tobacco Prevention Program Survey. Multilevel logistic regression analyses were performed using data from 4631 students (ages 10-18 years) who were nested in 62 secondary schools in Seoul, Korea. Students who participated in more prevention programs were less likely to smoke (OR = 0.47, 95% CI 0.30-0.74). The effect of the programs was significantly moderated by gender. For boys, exposure to a greater number of programs decreased the risk of smoking (OR = 0.32, 95% CI 0.18-0.57) but not for girls. At the school level, the school norm regarding tobacco control regulations was negatively associated with smoking (OR = 0.28, 95% CI 0.11-0.76), and its effect was significant for girls only (OR = 0.35, 95% CI 0.17-0.76). This study highlights how the school environment is associated with adolescent smoking behavior, and the effects of programs and norms are different by gender. The findings suggest the need to develop strategies to enhance school-based tobacco control programs and the school norm considering gender differences.