Multilevel analysis of school anti-smoking education and current cigarette use among South African students

INTRODUCTION: South Africa (SA) implemented the Global Youth Tobacco Survey (GYTS) four times between 1999 and 2011. Data from the four surveys indicated that downward trends in cigarette use among students may have stalled. Understanding the effect of school anti-smoking education on current smoking among students within schools and variability across schools may provide important insights into policies aimed at preventing or reducing tobacco use among students. The objective was to assess the student- and school-level effects of students' exposure to school anti-smoking education on current cigarette use among the study population using the most recent wave of GYTS data in SA (2011). METHODS: An analytic sample of students 13-15 years of age was selected (n=3,068) from the SA GYTS 2011. A taxonomy of two-level logistic regression models was fit to assess the relationship of various tobacco use, control, and exposure predictor variables on current cigarette smoking among the study population. RESULTS: At the student-level in the full model, secondhand smoke (SHS) exposure, peer smoking, and ownership of a promotional item were significantly associated with higher risk of current smoking. At the school-level in the full model, average exposure to peer smoking was associated with significant increases in the prevalence of current cigarette use, while average family anti-smoking education was significantly associated with decreases in the outcome variable. School anti-smoking education was not a statistically significant predictor at the student- or school-levels. CONCLUSION: in this study, exposure to school anti-smoking education had no association with current cigarette smoking among the study population. Consistent with previous studies, having peers that smoked was highly associated with a student being a current smoker. Interestingly, at the school-level in the multilevel analysis, schools with higher rates of average family anti-smoking education had lower prevalence of current smoking. This finding has potential implications for tobacco control in SA, particularly if the school-level, family-centered protective effect can be operationalized as a prevention tool in the country's tobacco control program.