essay about smoking inside the school

Essay on Smoking

500 words essay on  smoking.

One of the most common problems we are facing in today’s world which is killing people is smoking. A lot of people pick up this habit because of stress , personal issues and more. In fact, some even begin showing it off. When someone smokes a cigarette, they not only hurt themselves but everyone around them. It has many ill-effects on the human body which we will go through in the essay on smoking.

Ill-Effects of Smoking

Tobacco can have a disastrous impact on our health. Nonetheless, people consume it daily for a long period of time till it’s too late. Nearly one billion people in the whole world smoke. It is a shocking figure as that 1 billion puts millions of people at risk along with themselves.

Cigarettes have a major impact on the lungs. Around a third of all cancer cases happen due to smoking. For instance, it can affect breathing and causes shortness of breath and coughing. Further, it also increases the risk of respiratory tract infection which ultimately reduces the quality of life.

In addition to these serious health consequences, smoking impacts the well-being of a person as well. It alters the sense of smell and taste. Further, it also reduces the ability to perform physical exercises.

It also hampers your physical appearances like giving yellow teeth and aged skin. You also get a greater risk of depression or anxiety . Smoking also affects our relationship with our family, friends and colleagues.

Most importantly, it is also an expensive habit. In other words, it entails heavy financial costs. Even though some people don’t have money to get by, they waste it on cigarettes because of their addiction.

How to Quit Smoking?

There are many ways through which one can quit smoking. The first one is preparing for the day when you will quit. It is not easy to quit a habit abruptly, so set a date to give yourself time to prepare mentally.

Further, you can also use NRTs for your nicotine dependence. They can reduce your craving and withdrawal symptoms. NRTs like skin patches, chewing gums, lozenges, nasal spray and inhalers can help greatly.

Moreover, you can also consider non-nicotine medications. They require a prescription so it is essential to talk to your doctor to get access to it. Most importantly, seek behavioural support. To tackle your dependence on nicotine, it is essential to get counselling services, self-materials or more to get through this phase.

One can also try alternative therapies if they want to try them. There is no harm in trying as long as you are determined to quit smoking. For instance, filters, smoking deterrents, e-cigarettes, acupuncture, cold laser therapy, yoga and more can work for some people.

Always remember that you cannot quit smoking instantly as it will be bad for you as well. Try cutting down on it and then slowly and steadily give it up altogether.

Get the huge list of more than 500 Essay Topics and Ideas

Conclusion of the Essay on Smoking

Thus, if anyone is a slave to cigarettes, it is essential for them to understand that it is never too late to stop smoking. With the help and a good action plan, anyone can quit it for good. Moreover, the benefits will be evident within a few days of quitting.

FAQ of Essay on Smoking

Question 1: What are the effects of smoking?

Answer 1: Smoking has major effects like cancer, heart disease, stroke, lung diseases, diabetes, and more. It also increases the risk for tuberculosis, certain eye diseases, and problems with the immune system .

Question 2: Why should we avoid smoking?

Answer 2: We must avoid smoking as it can lengthen your life expectancy. Moreover, by not smoking, you decrease your risk of disease which includes lung cancer, throat cancer, heart disease, high blood pressure, and more.

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Article Contents

Introduction, conflict of interest statement.

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The impact of school smoking policies and student perceptions of enforcement on school smoking prevalence and location of smoking

• Article contents
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C. Y. Lovato, C. M. Sabiston, V. Hadd, C. I. J. Nykiforuk, H. S. Campbell, The impact of school smoking policies and student perceptions of enforcement on school smoking prevalence and location of smoking, Health Education Research , Volume 22, Issue 6, December 2007, Pages 782–793, https://doi.org/10.1093/her/cyl102

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The purpose of this study was to comprehensively assess the impact of school tobacco policy intention, implementation and students' perceptions of policy enforcement on smoking rates and location of tobacco use during the school day. Data were obtained from all students in Grades 10–11 ( n = 22 318) in 81 randomly selected schools from five Canadian provinces. Policy intention was assessed by coding written school tobacco policies. School administrators most familiar with the tobacco policy completed a survey to assess policy implementation. Results revealed policy intention and implementation subscales did not significantly predict school smoking prevalence but resulted in moderate prediction of tobacco use on school property ( R 2 = 0.21–0.27). Students' perceptions of policy enforcement significantly predicted school smoking prevalence ( R 2 = 0.36) and location of tobacco use ( R 2 = 0.23–0.63). The research findings emphasize: (i) the need to consider both written policy intention and actual policy implementation and (ii) the existence of a policy is not effective in controlling tobacco use unless the policy is implemented and is perceived to be strongly enforced.

School-based strategies are a key element in adolescent tobacco control because school environments are established systems in which adolescent behavior can be targeted and in which social behaviors are reinforced [ 1 , 2]. School tobacco policies are critical to a comprehensive adolescent tobacco control program, yet research to date shows inconsistencies in the way policies are measured and evaluated. Furthermore, little is known about the most effective strategies linking characteristics of school tobacco policies to adolescent tobacco use.

There has been an increased interest and emphasis on tobacco policies and their impact on youth tobacco use. Studies have shown that school tobacco policies are effective only if they are strongly enforced [ 3 , 4 ]. A comprehensive review of the effects of school policies on youth smoking rates shows inconclusive findings [ 4–11 ]. Some of the ambiguity in strength of relations between policies and smoking behavior is likely a result of the differences in dates when the research was conducted (spanning the 17 years from 1989 to 2006), geography (i.e. Australia, Canada, Scotland and the United States), definitions of smoking behavior used as the outcome variable (i.e. current smoker, daily smoker, occasional smoker, susceptible smoker), sample size, operationalization of tobacco policies (i.e. intention, implementation, enforcement) and conceptualization of tobacco policy strength (i.e. students' versus teachers' perceptions of the policies and/or coded written policies). Based on these observations, it is important to identify consistencies in the way school policies are examined and to determine the relationships among policy intentions, implementation, enforcement and smoking behaviors during adolescence.

Policies that prohibit tobacco use vary in their target application, location of application and timing of enforcement. It is understood that strong policy intention and implementation should include emphases on comprehensiveness, prevention, cessation, punishment, consistency of enforcement, strength and visibility [ 3 , 11–13 ]. The difficulty in exploring distinctions between strength of policy intention and implementation lies in the assessment of written policies with inherent intention to curtail smoking behaviors, and in exploring school informants' strategies to implement written policies. The application of these assessments to research and practice is of value to understanding policy impact.

A written policy can be viewed as a statement of intent addressing tobacco control in the school environment. The application of the written policy is not actualized in practice until the policy is implemented at the school. Furthermore, this actualization may not impact the school environment unless compliance is ensured through enforcement. This level of distinction is often overlooked in policy reviews, yet the use of consistent definitions of policy intention and implementation is critical to the examination of policy content, enforcement and effectiveness. One method of ensuring consistency of policy evaluation is to employ coding rubrics that capture the complexities of both policy intention and implementation. For example, a comprehensive coding rubric for written tobacco policies has been developed to include the main factors critical to strong policies [ 13 ]. The coding system includes five main components: developing, overseeing and communicating the policy, purpose and goals, tobacco-free environments (including prohibition, strength and characteristics of enforcement), tobacco use prevention education and assistance to overcome tobacco addictions. Despite some initial testing of the rubric [ 13 ] it has seen limited use. More importantly, the different roles that school policy components play in influencing adolescent smoking behaviors remains elusive.

In addition to the lack of consistent evaluation strategies associated with written tobacco policies, the other main limitations in research linking policies and smoking behavior include: (i) the dependence on adolescents' perceptions of the strength of school policies; (ii) limited assessments of the consistency between policy intention and implementation and (iii) unclear conceptual links between the tobacco policy variables and youth smoking classifications. Specifically, in research linking tobacco policies and smoking behavior, it is not necessarily that tobacco policies will directly impact whether an individual is a daily or an occasional smoker, or whether they have ever tried a cigarette, but rather they will impact how the school environment contributes to shaping these behaviors. School-based policies should, at minimum, impact the frequency and location of smoking behavior that occurs around and at school. Efforts should be focused on characteristics of smoking behavior that are likely to be influenced, both directly and indirectly, by school-based tobacco policies.

The purpose of this paper is to (i) describe an approach for assessing school smoking policies, (ii) examine differences between school written policy (intention) and reported implementation; (iii) examine characteristics of school written (indention) policies and reported implementation as predictors of school smoking prevalence, as well as smoking prevalence at school, on and off school property and (iv) examine students' perceptions of policy enforcement as predictors of school smoking prevalence.

Participants

Following ethics approvals from the University and Secondary School Districts, a multi-site cross-sectional study was conducted in 81 randomly selected secondary schools from British Columbia, Manitoba, Newfoundland, Ontario and Quebec. The five provinces represent a reasonable geographical balance and have smoking rates that span the range of Canada's overall smoking rate for youth aged 15–19 years (15–24%) [ 14 ].

Following a passive parental consent approach, all students in Grades 10 and 11 ( n = 22 318) within the 81 sampled schools were asked to complete a questionnaire about their smoking attitudes and behavior. From each school, a senior school administrator with extensive knowledge of the tobacco policy was recruited to complete a questionnaire about the implementation of the school smoking policy (i.e. survey on school smoking policies). In the final sample, administrators included principals (50%), vice principals (47.4%), assistant vice principals (1.3%) and teachers (1.3%). Written tobacco policies were also collected from each school and each corresponding school district board for assessment of policy intention.

Data sources and measures

Written school tobacco policies (intention).

To assess policy intention, school policies were collected from administrators, official policy documents or web pages. In the event that schools did not have a written policy, the district policy was obtained since it was the school's official tobacco control document. To assess the strength of policy, the hard copies were coded by two trained researchers using a theoretical and conceptually derived rating scheme [ 13 ]. Modifications to the existing rubric were made to reflect the Canadian context and recent theoretical findings [ 3 , 15 , 16 ]. Several Canadian experts on policy evaluation and implementation were also consulted during this process. Modifications to Stephens and English rubric [ 13 ] involved creating separate subscales for prohibition, strength and characteristics of enforcement instead of using the broader category of ‘tobacco-free environments’. The final rating system was composed of seven policy components that were derived from a number of items: developing, overseeing and communicating the policy; purpose and goals; prohibition; strength of enforcement; characteristics of enforcement; tobacco use prevention education and assistance to overcome tobacco addictions (see Table I for sample items). Two trained researchers used the rating system as a directed assessment instrument to code to the policies. The coders read through the school and district written policies and rated each policy components from ‘poor’ to ‘outstanding’ using a combination of Likert scale and dichotomous response sets. When rating discrepancies occurred, they were discussed until consensus was established.

Sample questions from the policy intention and implementation subscales

School tobacco policy implementation

To assess the implementation of school tobacco policies, it was necessary to develop a structured survey that supported the main policy rubric informing this study. Development of the survey incorporated school health questionnaires [ 17 , 18 ] and guidelines from prominent policy research [ 3 , 13 ]. The survey was pilot tested by three school administrators (not included in our sample) before it was finalized to a total of 41 items (survey can be obtained from first author).

The resulting survey of school smoking policies was completed by school administrators who were knowledgeable about tobacco policies. The responses were coded using the same protocol and scoring system was described for the written school policies (see Table I ). Similar procedures were used to ensure comparability between written policies (intention) and the structured interviews (implementation). The final rating system for policy implementation included an additional subscale for consistency of enforcement.

Student smoking and perceptions of policy enforcement

Student smoking behaviors were assessed using the tobacco module of the School Health Action, Planning and Evaluation System (SHAPES) [ 19 ] which is a research-supported machine readable survey designed to collect perceptions related to multiple characteristics of youth tobacco use [ 19 ]. For this study, questions pertaining to frequency and quantity of tobacco consumption were used to define smoking behavior. A smoker was defined as an adolescent who had smoked at least a few puffs of a cigarette on ≥2 days in the last month. The individual data were used to create two dependent variables. First, a composite score assessing smoking status, which was then converted into a school prevalence rate by adding the number of smokers at each of the schools represented, divided by the total students at the school. Second, prevalence of smokers who smoke at school both on and off the property (location of smoking behavior) was calculated. Prevalence of smoking behavior location was calculated as a ratio of smokers indicating they smoked on and/or off school property divided by the total number of smokers at each school.

Items from SHAPES were also used to create five independent variables related to student perceptions of policy enforcement at the school: (i) perception regarding the percentage of students who smoke (10-point Likert scale ranging from 0–10% to 91–100%); (ii) whether there are punishments for smoking on school property (percentage of students reporting ‘true’ and ‘usually true’); (iii) existence of a clear set of tobacco use rules at school (percentage of students reporting ‘true’ and ‘usually true’); (iv) strong sanctions for breaking the tobacco rules (percentage of students reporting ‘true’ and ‘usually true’) and (v) whether students smoke where they are not allowed (four-point Likert scale ranging from none to a lot).

Data analyses

Prior to main analyses, it was important to assess the validity of the instruments used to code the policies. Nine completed surveys assessing both policy intention and implementation were randomly selected and given to six experts in the field of tobacco policy who were asked to rank order them in terms of strength, and to include rationale for their decisions. This rank ordering was compared with the strength of scores generated from the developed rating system as coded by the trained researchers. The survey and the rater's rankings elicited the same policy strength scores 83.4% of the time.

Following the validation of the policy measures, the psychometrics of the policy scale scores and aggregated data from SHAPES (i.e. smoking behaviors and students' perceptions of policy enforcement) were examined. Descriptive analyses were conducted to examine correlations, means and standard deviations (SDs). t -tests were conducted to examine significant mean differences and between policy intention and implementation. The main analyses involved independent multiple linear regressions conducted to examine (i) policy implementation (reported by school administrators), (ii) policy intention (from written policies) and (iii) students' perceptions of policy enforcement, as predictors of school smoking prevalence and smoking behaviors occurring on and off school property during the school day. No simultaneous models including intention, implementation and perceptions of enforcement were conducted due to the limited power resulting from the small sample size. Since there were no theoretical or conceptual reasons to expect differences among the predictors, all policy subscales were entered in step one. For all analyses, the significance level was set at 0.05. Given the number of predictors and sample size, we recognize the possibility of inflated Type I errors. However, the exploratory nature of this study begins to address an existing gap in the literature. It was desirable to use this approach to identify the majority of factors that may influence school smoking rates.

The majority of schools (80%) had their own tobacco policy, with the remaining schools reporting use of the district policy (see Table II ). The policy intention subscales for tobacco use prevention education and assistance to overcome tobacco addiction were indiscriminant across the schools and were not included in the main regression analyses.

Means and SDs for the policy data

The relationships among smoking prevalence and school-based tobacco control policies are presented in Table III . Very few of the policy implementation subscales were related to policy intention. The majority of students' perceptions of policy enforcement items was significantly correlated with the intention and implementation subscales. None of the policy intention and implementation subscales was related to smoking prevalence. However, student perceptions regarding the percentage of smokers attending the school were related to school smoking prevalence. There were many significant relationships among policy intention, implementation and students' perceptions of school tobacco policy enforcement and smoking prevalence (at school) on and off school property.

Correlations among the policy subscales and smoking prevalence

1, school smoking prevalence; 2, off school property smoking prevalence; 3, on school property smoking prevalence; 4–10, policy intention subscales (4, developing, overseeing and communicating policy; 5, purpose and goal; 6, prohibition; 7, strength; 8, characteristics; 9, tobacco use prevention education; 10, assistance to overcome tobacco addiction); 11–17, policy implementation subscales (11, developing, overseeing and communicating policy; 12, purpose and goal; 13, prohibition; 14, strength; 15, characteristics; 16, consistency; 17, tobacco use prevention education; 18, assistance to overcome tobacco addiction); 18, perception of smoking where not allowed; 19, perception of smoking prevalence; 20, prevalence perception that students can be fined; 21, prevalence perception of clear set of rules; 22, prevalence perception consequences of breaking rules.

P < 0.05.

Differences between intention and implementation subscales

To explore the differences in intention and implementation subscales, a number of t -tests were conducted using a Bonferroni technique to protect against Type 1 errors. Implementation subscales were significantly higher than intention subscales: developing, overseeing and communicating policy, t (1, 76) = 22.50, P < 0.001; prohibition, t (1, 76) = 12.79, P < 0.001; strength of enforcement, t (1, 76) = 9.64, P < 0.001; characteristics of enforcement, t (1, 76) = 9.31, P < 0.001; tobacco use and prevention education, t (1, 76) = 3.04, P < 0.001 and assistance to overcome tobacco addiction, t (1, 76) = 10.82, P < 0.001. The subscales for purpose and goals were not significantly different. Policy implementation had an additional subscale (consistency of enforcement) that was not included in comparative analyses.

Predictors of school smoking prevalence and location of smoking behavior

School smoking prevalence.

To examine policy intention and implementation as predictors of school smoking prevalence, a multiple regression was planned. However, the correlations among both policy implementation and intention showed little, if any, relationships and no further analyses were conducted. The model predicting school smoking prevalence from students' perceptions of school policy was significant, F (5, 72) = 7.86, P < 0.001, R 2 = 0.36, with perception of smokers emerging as an independent predictor (see Table IV ).

Regression analyses predicting school smoking prevalence from perceptions of policy enforcement

Smoking location: at school, on school property

To test the hypothesis that schools with weaker policy intention and implementation would have more smokers using tobacco at school, separate regressions were conducted with location of smoking as the dependent variable (see Table V ). For policy intention, the model was significant, F (5, 70) = 5.17, P < 0.05. The policy intention subscales accounted for 27% of the variance in on school property tobacco use, with prohibition, strength and purpose and goals emerging as significant individual predictors. For policy implementation, the model was also significant, F (8, 69) = 2.28, P < 0.05, R 2 = 0.21. The individual significant predictors included prohibition, consistency of enforcement and tobacco use prevention education. Finally, the model examining adolescents' perceptions of policy enforcement predicting smoking on school property was also significant, F (5, 72) = 22.72, P < 0.001, R 2 = 0.62. The significant independent predictors in the model included perceptions that students can be fined, breaking the rules leads to consequences and prevalence of smokers at school.

Regression analyses predicting tobacco use on school property from policy intention (Model 1), policy implementation (Model 2) and perceptions of policy enforcement (Model 3)

Smoking location: at school, off school property

Regressions were also conducted with smoking on school property as the dependent variable (see Table VI ). The first regression included all policy intention subscales as predictors of smoking at school but off property. The model was not significant, F (5, 70) = 0.190, P > 0.05, R 2 = 0.01. The second regression included the policy implementation subscales as predictors of smoking off school property. The model was not significant, F (8, 69) = 1.85, P = 0.09, R 2 = 0.17. Finally, the model exploring adolescents' perceptions of policy enforcement as predictors of smoking off school property was tested. In this model, adolescents' perceptions of more students smoking where they are not allowed and greater perception of smokers at the school were significant independent predictors in the model, F (5, 72) = 4.11, P < 0.001, R 2 = 0.23.

Regression analyses predicting tobacco use off school property from policy intention (Model 1), policy implementation (Model 2) and perceptions of policy enforcement (Model 3)

The coding scheme developed in this study was used to explore school written tobacco policy intention and administrator-reported policy implementation in secondary schools across Canada. Results revealed few of the school policy implementation subscales were related to written policies (intention) and none of the policy subscales was correlated to smoking prevalence. However, there were many significant relationships among policy intention, implementation and students' perceptions of school tobacco policy enforcement and smoking prevalence at school (both on and off school property). Several moderate predictive models exploring characteristics of adolescent smoking behaviors were observed.

Comparing the strength of the policies, implementation scores were significantly higher than intention for all but one subscale (i.e. purpose/goals). In particular, it is encouraging to note that strength and characteristics of enforcement were higher than the intention subscales since tobacco policies have maximum benefit only when they are strongly enforced [ 3 , 4 ]. The differences may be due to the length of time that the written policy has been in place at the school. However, it may also be that administrators were more optimistic in their reporting of implementation; thus this finding should be interpreted with caution. This result highlights the need to assess both policy intention and implementation.

School smoking prevalence was not significantly related to policy intention or implementation. This suggests that school policies do not have direct consistent effects on smoking prevalence. A number of researchers have noted similar relationships among school tobacco use policies and adolescent smoking prevalence [i.e. 5, 8–11]. Conceptually, it is not surprising that a school policy alone fails to impact school smoking prevalence unless part of a comprehensive tobacco control program. The synergistic impact of tobacco control policies, prevention and cessation programs and other forms of tobacco control approaches in the school (such as health education curriculum and anti-smoking campaigns and promotions) are likely to be most influential and require further investigation for the impact on school smoking.

Students' perceptions of policy enforcement were moderately linked to smoking prevalence. In the predictive model, a perception that there were a higher number of smokers at school was the strongest predictor of smoking prevalence. This finding is supported in research using social cognitive frameworks, where observational learning is a strong predictor of behavior [ 20 , 21 ]. These types of modeled behaviors should be considered when policies are developed and enforced. Furthermore, teacher and staff smoking prevalence were not explored in this study but have the potential to impact student smoking through modeling mechanisms and should be included in future studies. There are reports to suggest that teacher smoking during school hours is associated with adolescent smoking [ 22 ]. If schools can reduce the visibility of tobacco use, both by students and teachers, it will likely have positive effects on controlling the prevalence of adolescent smoking behaviors. This is a potent area for developing awareness and influencing behavior.

None of the school policy intention or implementation subscales significantly predicted smoking prevalence off school property. This finding was expected since school policies likely have more influence on smoking behaviors exhibited on school property. Alternatively, schools with written policies (intention) describing low prohibition, greater strength of enforcement and clearly established purpose and goals had higher smoking rates on school property. For administrator-reported implementation, low prohibition, greater consistency of enforcement and the absence of tobacco use prevention education were related to high smoking rates on school property. These results suggest that further work is needed to decipher the complex interrelationships among prohibition, enforcement, prevention education and school environment when examining smoking on school property. For example, if schools have designated smoking areas (i.e. smoking pit), the higher strength and consistency of enforcement of tobacco policies may be propagating tobacco use on school property but limiting smoking to specific areas. In this case, further research is needed to examine smoking on school property and the possible covariance associated with designated smoking areas. Additionally, students' knowledge and understanding of their school policy is unknown and may interact with smoking behavior. It would be beneficial to assess students' recall and recognition of school-based tobacco policies and to control for these effects when examining smoking behavior.

Students' perceptions of policy enforcement were strongly predictive of smoking on school property. Specifically, in schools where punishment was not perceived a consequence of smoking, there were more students smoking on school grounds. This finding is consistent with previous research [ 5 , 7 ] and highlights the importance of communicating the consequences of breaking the tobacco policy rules. We also found that schools where adolescents' perceived more student smokers had high smoking rates on school property. This finding may again illustrate the power of observational learning and highlights the importance of reducing the visibility and awareness of adolescent smoking behaviors at school.

There are a number of limitations associated with this study. First, the coding rubrics and surveys developed for this project need to be further tested for their reliability and validity. Also, confirmatory factor analyses are needed to examine the factor structure of tobacco policies. The cross-sectional design and relatively small sample of schools in this study preclude more advanced analyses and limit the power to detect statistical results. Future research should explore the longitudinal relationships among tobacco policies and characteristics of smoking behaviors during adolescence.

Despite its limitations, this study makes important contributions to research on school tobacco policies. The conceptualization of policies as intention and implementation, coupled with the development of a coding paradigm used to assess policies, begins to address the need for consistent definition and evaluation of tobacco policies. A cost-effective and practical approach to measure policy implementation reliably is a challenge. Developing student items for cross-validation with administrator reports may be one approach to addressing this challenge. Future studies should continue to move beyond simple classification of smokers and non-smokers and examine conceptually plausible relationships between policy and different smoking behaviors. There are many more opportunities for intervention when we consider location and timing of tobacco use among student smokers at school. In conclusion, exploring the differences between policy intention and implementation highlights the need to further examine inconsistencies in the way tobacco policies are written and the strategies used to implement them. As practitioners, it is important to focus on bridging this gap to ensure consistent and clearly communicated tobacco use prohibition strategies.

None declared.

This research was supported by a Canadian Institutes of Health Research grant no. 62748. We are pleased to acknowledge the contribution of Helen Hsu and Jane Shen who assisted in reviewing the literature. Technical assistance was also provided by Tamiza Abji and Sarah Lockman. Above all, we thank the high school administrators and students who completed the surveys. The research presented in this article is part of a larger study which along with school-based smoking policies is examining the relationship between adolescent tobacco use, school-based programs and factors in the community environment.

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School smoking bans reduce teen smoking

An international study of junior high- and high school-aged students who attended schools where smoking was banned were less likely to smoke than those where smoking was permitted, according to a study led by researchers at Harvard T.H. Chan School of Public Health. Smoking bans also were found more effective in preventing students from smoking than just classroom-based tobacco education in the study, which did not include U.S. schools.

Researchers, led by Israel Agaku of the Harvard T.H. Chan School of Public Health’s Center for Global Tobacco Control , compared data gathered from 2005 to 2011 on students, ages 13 to 15, in 43 nations. In countries with moderate-to-strongly enforced smoke-free-school policies, kids were 41% less likely to smoke than kids in countries with poorly enforced or no smoke-free-school policies.

Olubode Olufajo, research fellow in the School’ s Department of Epidemiology , was a co-author.

Read a Globe and Mail January 13, 2015 article about the study: Tobacco bans in school linked to lower smoking levels

Read the  study  in the European Journal of Public Health .

E-cigarettes in Europe used mostly by the young, current smokers, would-be quitters

Teens who use smokeless tobacco often smoke

Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools

Affiliations.

• 1 National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
• 2 Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
• 3 Center for Clinical Research and Prevention, Bispebjerg-Frederiksberg University Hospital, Copenhagen, Denmark.
• PMID: 34131598
• PMCID: PMC8171329
• DOI: 10.18332/tpc/133934

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating 1 a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)] 2 , a course for school staff in short motivational conversations 3 , school class-based teaching material 4 , an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students' acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

Keywords: adolescents; alternative high school; intervention studies; school tobacco policies; social environment; tobacco prevention.

© 2021 Jakobsen G. S. et al.

ORIGINAL RESEARCH article

School smoking policies and health science students' use of cigarettes, shisha, and dipping tombak in sudan.

• Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland

The relationship between school smoking policies and students' tobacco use is ambiguous, and little is known about the effect of these policies in low- and middle-income countries. This study was designed to assess the effects of schools' smoking policies and the exposure to residential smoking on cigarette smoking and the use of different kinds of tobacco products by Health Science students. Self-reports of cigarette smoking, use of shisha (smoking of fruits-mixed tobacco using a bowl and a connected hose); dipping tombak (local smokeless tobacco that users usually place inside oral cavity in the groove behind the lower lip), and tobacco use on school premises are analyzed. A cross-sectional survey was carried out using a modified self-report questionnaire, originally developed by WHO, among a representative sample of 1,590 third-year HSS from 25 schools drawn from 13 universities, using a multi-stages sampling technique. The response rate was 100% for schools and 68% for students. A multilevel analysis was performed by nesting student-level in school-level variables. Results from the adjusted models revealed that, when students reported awareness of smoking restriction, they were more likely to be current smokers (OR = 2.91; 95% CI: 1.68–5.02; p = 0.021) and shisha users (OR = 2.17; 95% CI: 1.54–3.06; p = 0.021). Results from additional analysis performed among tobacco users only, showed increased risk of smokers and tombak dippers who smoked or dipped on school premises (OR = 2.38; 95% CI: 1.34–4.25; p = 0.003, OR = 2.60; 95% CI: 1.22–5.56; p = 0.013, respectively). Current smokers (OR = 3.12; 95% CI: 1.98–4.92; p = ≤ 0.001), ever smokers (OR = 1.66; 95% CI: 1.31–2.10; p = ≤ 0.001) and shisha users (OR = 1.73; 95% CI: 1.36–2.21; p = ≤ 0.001) were exposed to residential smoking on one or more days during the previous 7 days. High percentages of those who used any kind of tobacco products reported being aware of school smoking policies, indicating no clear evidence that school smoking policies had an effect on use of any of the mentioned tobacco products. The lack of compliance with school policies shows the need for further policy enforcement and sustainability, taking into account the effect of residential smoking and social influences.

Introduction

Tobacco use is one of the greatest challenges to public health, with steadily increasing consumption and a rapidly growing epidemic in the low- and middle-income countries ( 1 ). It has been well documented with overwhelming scientific evidence that trends of tobacco product use are increasing for some sub-groups within the global population, and its effect on health is undeniable. The available data demonstrate that about one quarter of the world's adult population currently smokes, and several million people become fatally addicted every year ( 2 – 4 ). Most documented successes in reducing tobacco use have occurred in developed countries by effective tobacco control policies ( 5 , 6 ). In contrast, most of the developing countries require more efforts to reach a comparable level. Despite the evidence, some policy-makers in low-income countries have failed to regard tobacco use as a health priority and do not fully appreciate the essential influence of public policies related to tobacco control ( 7 ). This lack of understanding is one partial explanation for the near absence of adequate prevention measures in these countries ( 8 ).

The problem is particularly challenging in Africa, which presents a great risk in tobacco use. Cigarettes are becoming increasingly affordable, and there are limited strategies to combat the increasing trends in use of shisha ( 1 , 9 ), use of smokeless tobacco ( 10 ), and their harmful effects on future morbidity and mortality ( 1 , 11 ). This shift to developing settings is partly because of the global tobacco industry fierce marketing strategies and partly due to lack of adequate tobacco control measures ( 7 , 12 , 13 ). In Sudan, as one example of a sub-Saharan African country, smoking cigarettes, shisha use, and tombak dipping are widely spread among adolescents and young adults ( 14 , 15 ).

Schools are particularly important and considered to be the best places where students' tobacco use can be targeted. Schools represent a key environment where prevention and control strategies can be implemented ( 16 , 17 ). Anti-smoking policies can reduce the prevalence of smoking by promoting prevention, restriction, cessation, and by preventing students from using tobacco on school premises and protecting non-smokers ( 18 – 20 ). Well-known statements document that smoking behavior is mainly recognized and established at or before the age of 18 ( 21 ). Consequently, smoking prevention programs have been focused on adolescents, mainly within school settings. Other researchers have suggested that college students might be an important audience in initiation and in the development of regular smoking ( 22 ), whatever the age of the students. In addition to schools, a better understanding of the main factors that affect students' tobacco habits in other environments would be useful for policy formulation in tobacco control programs. For instance, exposure to smoking in students' neighborhoods and residential areas can have an important role in their tobacco use ( 23 ).

Regardless of the methodological issues or the heterogeneity of exposure definitions in observational studies, various researchers have evaluated the effectiveness of school tobacco policies ( 20 , 24 ). Some of them revealed a significant association between student smoking on school premises and weak policy ( 25 ). Others concluded that perceptions of students' smoking on the school premises also varied according to enforcement of smoking restrictions ( 20 , 26 ).

These policies are particularly important in Health Science students' schools, where students are trained and seeking careers in the health professions. Ideally, they will be role models for patients. The extent to which they effectively guide tobacco users may largely depend on their own tobacco use behavior ( 27 ). In Africa, doctors are regarded as the most likely persons from whom advice about tobacco use would be accepted by both users and non-users. Very brief advice from the doctor yields positive 1-year quit rates ( 28 ).

Within a multilevel context, the study reported here was designed to examine the effects of university policies and residential smoking on smoking and the use of different kinds of tobacco products by students studying in the Health Science disciplines of medicine, dentistry, nursing, and pharmacy. Third-year students were asked to self-report their use of cigarettes, tombak dipping, and shisha, as well as their awareness of school policies that banned or restricted use of tobacco products, and their exposure to smoking in places where they live.

The current study used cross sectional collection of data as part of the Global Tobacco Surveillance System (GTSS) 2007. Full details of the surveys can be found elsewhere ( Centers for Disease Control and Prevention (CDC) 2006 ) ( 29 ). Newer data, targeting the same student population, can not be obtained because the conditions of the country have changed, Sudan split into two countries.

A multi-stage cluster sampling design was used in the first part of the sampling technique . The first stage : from a total number of 39 public and private universities, 13 universities were selected based upon having a school of medicine, dentistry, nursing, or pharmacy, or any combination of these four schools (one university might have one or more Health Science schools). The rest, 26 universities, were eliminated because they did not meet the selection criteria. The second stage : all Health Science schools ( N = 29) were drawn from the 13 universities. Four of the 29 Health Science schools were eliminated because they were new and did not have a third class at the time of the survey. Thus, the final sample became 25 schools (Medicine 10; Dentistry 6; Nursing 4; and Pharmacy 5). The third year classes in the 25 schools were selected purposively. All students who were enrolled and present in these classes, regardless of their age, were eligible to participate in the study.

The Health Science schools had a 100% school response rate. All third-year students were eligible and invited to complete the survey, with a 67% student response rate from dental schools; 64% from medical schools; 83% from nursing schools; and 71% from schools of pharmacy. On the day of the survey, students who had left the classroom (21 students) or those who were absent for any other reasons were not followed up. From the 2,344 registered eligible students, 1,590 students responded, giving an overall response rate of 68%.

The survey was an anonymous, modified self-reported questionnaire originally developed by the Tobacco Free Initiative and the World Health Organization (WHO) in collaboration with the US Centers for Disease Control and Prevention (CDC). The questionnaire used was originally in English, and later translated into Arabic by an expert team from the Sudan Ministry of Health (SMOH).

The Sudanese research coordinators, including the author of this study, trained the data collectors from the Ministry of Health, and supervised the data collection. The survey was first piloted among 50 non-Health Science students to determine clarity of questions and to ensure feasibility of administration and the accuracy of translation. After incorporating the corrections, the process resulted in removing, adding or changing some questions, resulting in a final set of 44 questions. These were then back-translated into English, by an independent professional person who was not part of the first translation or study, to check for validity and to avoid bias and/or misunderstanding. The questionnaires were distributed during regular lectures and class sessions. Completion time was about 40–45 min.

Ethical Approval

Permission to conduct the study was sought from the Ministry of High Education and the Ministry of Health Research Ethics Board, the university authorities' board, and the Dean of each school. The entry point for conducting the student survey for each school was through a designated faculty member to identify the student subject pool. Informed consent was obtained for all eligible students and for each student. This process involved explaining the purpose of the research, and why they had been selected. Their consents were obtained verbally; no written permission was required of individuals at the age of 18 and above, for those who were younger than age 18, parental consents were obtained. Participation was voluntary and confidential, with the option of declining without penalty or loss of benefits to which the student would be otherwise entitled.

Definitions of Variables and Outcome Measures

The selected questions for this study included demographic characteristics, questions related to school policy and use of three types of tobacco products (cigarettes, shisha and tombak), and a final question related to smoking in places where students live.

Tobacco Products

Cigarettes are the most common type of tobacco used throughout the world. Although cigarettes come in a variety of strengths and styles, the questions on the survey did not differentiate type of cigarettes smoked.

Tombak is a loose, moist form of smokeless tobacco. The plant is of the species Nicotiana Rustica and/or glauca , with a high content of nicotine. Soute /saΩt/ is another local name for tombak. The leaves are ground for maturation for up to 1 year for uniform drying and storage for aging ( 30 ). Then they are mixed with “ Atrun or Natrun ,” which is a kind of raw alkaline material, consisting of naturally occurring chemical substances, including sodium bicarbonate. The ingredients are then mixed with water and rubbed by hand for blending and constantly tested with the tips of the fingers in a process called “ Tatmeer / ta:tæm.i r /.” The final product “tombak” will be ready for dipping after many hours (up to 1-day) of being sealed in an airtight container. tæm tiǝr tiǝr tiǝr Tombak is highly addictive because of its high nicotine content. Its use results in serious health problems that are related to several forms of oral cancer ( 10 ). The dip in Sudan is named suffa /sǝ’f’fǝ/, which is a small moist lump/ball that is made by rolling a small amount of tombak repeatedly on the palm using the thumb, index, and middle fingers of the other hand in a circular manner. Suffa is usually placed in the lower labial groove between the lower lip and the gum ( usual site of cancer in Sudan ), or under the tongue or upper lip.

Shisha is another name for “oriental water-pipe” that is well known and popular in the Middle East and North Africa. Shisha is an instrument used for smoking, consisting of a head, body, water bowl, and rubber-pipe (hose). The smoking involves heating the fruit-flavored tobacco, usually with charcoal, cooled down by passing through the water chamber at the bottom of shisha prior to inhalation. Users believe that shisha is safer than cigarettes because the smoke passes through water before inhalation ( 9 ). Shisha use is becoming increasingly popular in Sudan among young people sitting for hours at Internet cafes. Its use is also increasing among young girls and women in some beauty centers and hair styling saloons (unpublished document, SMOH, 2007).

Tobacco Use Variables

Ever tobacco user included anyone who tried any kind of tobacco products, those who had smoked, dipped tombak, or used shisha at least one time, during the course of her/his life. Each question in these categories was treated independently. The question was “ Have you ever tried or experimented with cigarette smoking/shisha/tombak dipping, even if it was one puff/dip or two? ” Responses were “Never”/“Yes.”

Current smoking question was “ During the past 30 days, on how many days did you smoke cigarettes ?” Students were classified as “current smokers” if they reported smoking on any day of the previous month. Questions about current use of other kinds of tobacco ( shisha and tombak ) were not available in the survey therefore were not measured.

School Smoking Policy Variables

For ease of use, the term “school” was used in the text and the tables to refer to all colleges; faculties; and school under study (Dental schools, Colleges of Medicine, Nursing schools, and Faculties of Pharmacy).

Smoking on school premises

Smoking on schools' premises question was “ Have you smoked cigarettes on school premises during the last 1-year?” Responses were “Not-smoked”/“smoked.”

Dipping on schools' premises question was “ Have you dipped tombak on school premises during the last 1-year?” Responses were “Not-dipped”/“dipped.”

Two additional variables were created from the above two questions, included only the users (the current smokers and tombak dippers) who responded to the questions; and only those who reported “Yes” they had smoked or dipped on school premises were counted.

Smokers who smoked on school premises included both current and ever smokers who smoked during the prior 1-year.

Current smoking on school premises includes only current smokers who smoked on school premises during the prior 1-year.

Ever dippers on school premises includes only those who dipped tombak for the first time on school premises during prior 1-year. The variables about school policy were based on the responses to two questions; the answers were further categorized for purpose of the analysis.

Policy banning smoking

(PBS) “Does your school have an official policy banning smoking in school buildings and clinics?” Responses were “No official policy”/“exists in either of them”/“exists in both.”

Smoking restriction

Which of the following best describes your school's official smoking policy for public places or common areas “lobbies, restrooms & dining areas”? Responses were “No official policy”/“complete restriction”/“partial restriction.”

Complete restriction: Smoking not allowed in any of the mentioned places.

Partial restriction: Smoking is allowed in one of the mentioned places.

Residential Smoking Variable

The residential smoking question was “ Has anyone smoked in your presence in places where you live, on one or more days during the last 7-days ?” “No” = 0 days, “Yes” = 1–7 days. The terms of “residential smoking” and “smoking where student lives” are used interchangeably throughout this paper.

Data Analyses

Pearson's χ 2 test was performed to examine the descriptive analysis for frequencies, differences in proportion, and associations between variables. Statistical significance is reported two sided: p < 0.05. IBM SPSS Statistics version 23.0 was used for the preliminary analysis.

Due to the hierarchical and the tiered nature of the data, multilevel logistic regression was used to examine the relationship between school policy and residential smoking ( exposure ) and the use of tobacco by students ( outcome ). The dataset was assumed to have a two-level data structure, where individual cases (students) are nested in a higher-level group (schools). The individual-level of students' behavior related to tobacco use ( smoking cigarettes, dipping tombak, shisha, and “smoking and dipping” on school premises ) was nested at a higher-level group (25 schools) that simultaneously included policy and residential smoking in the multivariate model with the students as the unit of analysis.

Before conducting the analysis, the outcome tobacco variables were dichotomized. The data were exported to Statistical Package for Stata' gllamm (Generalized Linear Latent and Mixed Stata/SE 14.0) for multilevel logistic regression to fit random-intercept logistic models and to determine the strength of the hypothesized relationships between school policy and student tobacco behavior. A null model was first fitted and included only a random intercept to estimate the variations in the use of tobacco across schools (this model is not presented in the tables). A subsequent unadjusted model was separately fitted for each smoking policy in relation to tobacco use outcomes. A final adjusted model was fitted, adjusted for age and sex, with school level as a random effect. Student reporting about smoking on school premises was analyzed separately. The odds ratios for the fixed part of the models were estimated using 95% confidence intervals. To estimate the differences between schools, the school level variance (SE) were also measured.

Descriptive Analysis

Tables 1 , 2 provide a summary of the numbers and percentages arranged by tobacco use. Students' reporting about schools' smoking policies are presented as policy banning smoking and restriction, together with exposure to residential smoking. Sample sizes differ slightly among the analyses due to differences in the patterns of missing data.

Table 1 . Percentage of tobacco users by age, sex, type of school, school smoking policies, and residential smoking.

Table 2 . Percentages of students' awareness of school smoking policies as well as residential smoking by basic demographic characteristics and school type.

The 1,590 participants included more females (66%) than male students, the majority were between the ages of 19 to 24 years. Overall prevalence of ever smoking was 40.3%, more among males than females. Ever smoking, increased with age and varied between schools (ranging from 30 to 48%). The pattern was similar for shisha use. Overall prevalence of shisha use was 33.8%, dippers (16.2%) and current smokers (8.3%), more among male students. Strikingly, 10.5% of all students smoked on school premises. They were also more male students, older, and from dental schools. Those who reported that a policy existed and that smoking was restricted were more likely to smoke on school premises ( Table 1 ).

Most of ever smokers (52%), shisha users (44%), dippers (21%), and 15% of current smokers were exposed to residential smoking on any days of the previous 1 week ( Table 1 ). That means 40% of all participants were exposed to smoking where they live; more than half were male students (55%) and older (42%) ( Table 2 ).

As shown in Table 2 , more than half the students reported the non-existence of school smoking policy (54%), and there were no big differences in the percentages between schools. As reported, more nursing students than the rest reported that smoking was completely restricted in public places and common areas (39%).

Multi-Level Analysis

School smoking policy.

As indicated in Table 3 , the existence of policy was significantly associated with ever smoking and shisha use after adjusting for age and sex. Odds ratios declined but remained significant compared to non-smokers, with small reduction of school variance. Partial smoking restriction was significantly associated with increased risk of current-smoking (Adjusted OR (A-OR) 2.91), and shisha use (A-OR 2.17), with small reduction of school level variance. School policy and smoking restrictions appeared to be unrelated to dipping behavior.

Table 3 . Odds ratios (95% confidence intervals) for tobacco use by school smoking policies and exposure to residential smoking in unadjusted and adjusted models; adjusted for age, sex, and school level as random effects.

A third model was fit and further adjusted for school types and residential smoking as confounders in addition to age and sex. The adjusted odds ratio remained almost the same when adjusted for school types, but when adjusted for residential smoking, the odds ratio decreased and the results lost their significances. The results of this analysis were not presented in the tables. This may underestimate the importance of school factors influencing students' tobacco use ( 31 ).

Exposure to Residential Smoking

In the adjusted model, exposure to smoking during the last 7-days was significantly associated with increased risk of ever smoking (A-OR 1.66), current smoking (A-OR 3.12), and shisha use (A-OR 1.73), and marginally ( P -value 0.06) related to dipping tombak ( Table 3 ).

Smoking on School Premises

The results shown in Table 4 are consistent with the previous results of the multi-level analysis. The awareness of an official policy did not appear to stop students from dipping or smoking on school premises, when the students reported the existence of policies, the risk increased for tobacco use (A-OR 2.38, for current smoking and 2.60 for ever dipping) . Regarding smoking restriction, it was significant only with complete restriction.

Table 4 . Odds ratios (95% confidence intervals) for tobacco use on school premises during the prior 1–year by school smoking policies and exposure to residential smoking among smokers and tombak dippers; adjusted for age, sex, and school level as random effects.

The present study reveals new information about the pattern of tobacco use among Sudanese university students and its association with school anti-smoking policies. The study makes an important contribution to what is known about the tobacco habits of youth by including tombak dipping and shisha use in addition to cigarette smoking. No known study to date has been published in which the researcher compared these three types of tobacco use among youth or has considered the effect of school smoking policy on dipping tombak and/or using shisha and the effect of residential smoking on using different kinds of tobacco products.

Current smoking was observed in 8.3% of the Health Sciences students, compared to 13.7% among university students in Sudan in a study conducted in 2016 ( 32 ). Another study conducted in 2013 among 302 Sudanese Health Professional students from private schools ( 33 ) showed the prevalence of current smoking and ever smoking to be 9.6 and 26%, respectively, and 34.5% were exposed to residential smoking (compared to 40.8% of the present sample). Comparing the findings of current smoking from the three studies shows no significant reduction among current smoking in terms of policy measures, and strategic efforts to prohibit smoking among students during the period in between the three studies (2007, 2013, and 2016) do not appear to have been effective.

Regarding the students' reports about school policy, the results demonstrate a considerable diversity between schools. The kinds of tobacco product used were quite different among students. More than half of all students reported the non-existence of school policy (54%). Most of the tobacco users were aware of the existence of policy and the restriction of smoking in common areas and in school buildings. It would seem that tobacco users are more aware of school smoking policies than non-users, even though they may choose to ignore the policies.

With additional analysis, the awareness of existence of school policies diminished and lost its significant results except for shisha users. On the other hand, awareness of smoking restriction was significantly and reversely associated with increasing risk of current smokers and with shisha users. This implies either the policy was not well-enforced ( 26 ), or there was a lack of student commitment to school policy ( 34 ).

With respect to the shisha use category, shisha users were more aware of the policy existence and the restricted areas. That might be because it is inconvenient to use shisha inside a school compared to cigarette smoking and dipping. The size of the shisha, the strong smell of fruit-flavored tobacco, and the fact that shisha is usually smoked in groups ( 35 ) would collectively hinder the use of shisha inside the school. In addition, there is lack of literature about policy concerning shisha use ( 36 ). In contrast, the “dip” can be hidden behind the lips and remain hidden for several minutes ( 14 ), which makes it easier for dippers to dip inside schools. Unlike smoking cigarettes or using shisha, dippers were more aware of smoking and restriction zones only if they reported being dual users ( 37 ).

With regard to smoking on school premises, 31.8% of all smokers and 21.8% of dippers have smoked or dipped on school premises ( Table 4 , footnote). Specifically, more than half of the current smokers (59.2%) have smoked inside the school they attend ( Table 4 , footnote). Results of multi-level analysis showed that despite knowing the existence of a non-smoking policy, students continued to smoke and dip on school premises, meaning that the awareness of the policy had no effect on their smoking or dipping, or they knew that it was not vigorously enforced.

Students' reports about their school policy is quite ambiguous. Their responses varied greatly, despite the fact that they may be in the same schools ( 31 , 38 ). Awareness of the policy and enforcement are essential to help ensure compliance ( 39 ). Various researchers have shown that the relationship between school policies and students' -smoking are mixed ( 20 , 40 ). Some indicate a weak-to moderate relationship between policies and student smoking, while other studies indicate no effects ( 41 ). Other researchers suggest that changing a school environment represents a broader yet appropriate and effective factor in prevention and protection ( 26 , 42 ).

More than half of ever smokers and 44% of shisha users; at least on 1 day of the previous week, were exposed to smoking in places where they are living, more among older male students (55%). Those exposed to residential smoking were more susceptible to start smoking, and they were more than three times at risk to be current smokers and twice as likely to be shisha users ( 14 ). Exposure to residential smoking did not affect a student's risk of dipping tombak, and it was also not found to be related to smoking on school premises. Most researchers who examined smoking among young revealed that ever smokers initiated their smoking early in adolescence ( 43 , 44 ), raising a question of the possibility of exposure to residential smoking perhaps some time before getting into their current university. Therefore, it made it crucial, in the present study, to consider the exposure to residential smoking as one of the main factors behind starting to use cigarettes when students were already adults. Accordingly, this finding itself is an indicator of many other unmeasured influences on student tobacco use. Further research in the low- and middle-income countries is needed to explore other factors, possibly imitating friends ( 45 ) or socio-economic background ( 46 ), or exposure to smoking in places other than the places where they live.

Tombak dipping is a normative behavior among Sudanese. The product is cheap, easily available, and widely used. Some smokers have adopted it as an alternative to smoking tobacco ( 14 ). Results of the present study indicated that tombak is less used among Health Science students (16%) compared to the 45% prevalence of tombak among the adult population ( 47 ). This might be explained in that tombak is less prestigious among young university students and is less accepted, especially among females.

Strengths and Limitations

This study makes an important contribution to researches about school tobacco policies in Africa. The findings could be taken as a baseline for school policies in Sudan and other Sub-Saharan countries targeting the same group, although it was carried out in a country which is now two separate countries. Several factors may cause different students in different schools in different countries to experience the effect of tobacco use in different ways, but a baseline is important for the future researchers to measure the effect of changes over time. One of the most important strengths of the present study is that the researcher considered different kinds of tobacco products, and similarly assessed use of those products. By understanding the use of varied tobacco products and their associations with school policy, the results can be used to target future policy programs that address use of different kinds of tobacco products in the developing world and in establishing a school-based tobacco policy. Another important strength of the present study was the use of a standardized questionnaire for data collection; it was based on the international core questionnaire. The original questionnaire was translated by expert persons, piloted, and back-translated by an independent professional person who was not part of the first translation or the study to minimize bias and misunderstanding. More questions were also asked about local tobacco products. The overall response rate of school was 100%, and 68% for students, yet non-response bias might have affected the results. Some researchers have found that non-respondents are more likely to be smokers than respondents ( 48 ), the author does not expect that non-response rate (32%) of the students had a major role on influencing the results of this study.

The most important limitations of this study included its cross-sectional design ( 49 ); therefore, a causal relationship cannot be determined. For instance, from the findings obtained in this study, the direction of causality of the association between tobacco use by students and their attitudes toward anti-smoking policy was not clear. Longitudinal studies are required to make the direction of this kind of causality clear. The data for this study were only collected from third year Health Sciences Students; therefore, it cannot be assumed that the sample is representative of other students at the same age at other universities or in other academic disciplines of study. Other measures, such as school written policies from the schools, to validate the students' reports were not available. More information would be valuable in supporting the findings, since the official written policy and the students' perception of policy might be different. The data used in the present study were collected in 2007. To conduct another study; targeting the same study population would not be easy because the country has subsequently divided into two countries. However, findings from data collected among some Health Science students in the northern part of Sudan in 2013 and 2016 ( 32 , 33 ), showed that situation about tobacco use is worse than in 2007.

Conclusions

Despite the limitations, the results of this study provide important information as research about use of tobacco products continues. The present study was designed to examine the relationship between tobacco control activities and tobacco use prevalence among young adults, confirming the importance of continuous review of policies and prevention programs. Although school policies banning or restricting tobacco use seemed to be largely ignored, no specific elements with significant effects were found in the school context that would lead to specific suggestions for improvement of the policies. Yet, strategies for tobacco control must be extended to cover school, societal, and individual levels. From a research perspective, the high prevalence of tobacco use by the study population calls into question what other factors in the environment, including cultural norms, seem to promote smoking and result in such a high percentage of future health professional being tobacco users.

Recommendations

Based on the findings from this study, opportunities for schools to have a significant role in preventing tobacco use should be pursued. Further work is needed with emphasis on students' tobacco use attitudes and behavior for every form of tobacco product. More attention should be given to enforcement of school smoking policies, to help dissuade smoking initiation. Future researchers who use the questionnaire from this study in school settings should include a random sample of students from preparatory to finalist classes, representing a wider life span and geographical representation than in the present study. Researchers studying tobacco use and prevention should examine all major kinds of tobacco products, as the results here indicated that use of different types of tobacco is associated with different individual characteristics and environmental contexts. Different stages in a student's life should also be considered, including the socio-cultural background of the student, the school environment, residential and neighborhoods' smoking, and financial accessibility that might have effect on a student's initiating or continuing use of any kind of tobacco product.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

SE conceived the study, collected the data, conducted the analysis, drafted, and finalized the manuscript.

The data collection for this study was financially supported by the WHO and Centers for Disease Control and Prevention (CDC), USA and Khartoum Ministry of Health. Part of the author's salary was been paid by grants from the Competitive Research Fund of Tampere University Hospital (9P041), the Doctoral Programs in Public Health, and University of Tampere, during the conduct of the study.

Conflict of Interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

I am grateful to the Federal and Khartoum State Ministries of Health for their contribution to the successful implementation of the study fieldwork. My sincere thanks to my supervisor Prof. Arja Rimpela for her support and advice. I also wish to thank my former colleague Bright Nwaru, who assisted me with data management.

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Keywords: school smoking policy, residential smoking, tobacco, smoking, tombak, shisha, water-pipe

Citation: El Amin SET (2019) School Smoking Policies and Health Science Students' Use of Cigarettes, Shisha, and Dipping Tombak in Sudan. Front. Public Health 7:290. doi: 10.3389/fpubh.2019.00290

Received: 23 May 2019; Accepted: 25 September 2019; Published: 11 October 2019.

Reviewed by:

Copyright © 2019 El Amin. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Salma El Tayeb El Amin, salmozy@gmail.com ; salma.elamin@tuni.fi

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

235 Smoking Essay Topics & Examples

Looking for smoking essay topics? Being one of the most serious psychological and social issues, smoking is definitely worth writing about.

🏆 Best Smoking Essay Examples & Topic Ideas

🥇 good titles for smoking essay, 👍 best titles for research paper about smoking, ⭐ simple & easy health essay titles, 💡 interesting topics to write about health, ❓ essay questions about smoking.

In your essay about smoking, you might want to focus on its causes and effects or discuss why smoking is a dangerous habit. Other options are to talk about smoking prevention or to concentrate on the reasons why it is so difficult to stop smoking. Here we’ve gathered a range of catchy titles for research papers about smoking together with smoking essay examples. Get inspired with us!

Smoking is a well-known source of harm yet popular regardless, and so smoking essays should cover various aspects of the topic to identify the reasons behind the trend.

You will want to discuss the causes and effects of smoking and how they contributed to the persistent refusal of large parts of the population to abandon the habit, even if they are aware of the dangers of cigarettes. You should provide examples of how one may become addicted to tobacco and give the rationales for smokers.

You should also discuss the various consequences of cigarette use, such as lung cancer, and identify their relationship with the habit. By discussing both sides of the issue, you will be able to write an excellent essay.

Reasons why one may begin smoking, are among the most prominent smoking essay topics. It is not easy to begin to enjoy the habit, as the act of smoke inhalation can be difficult to control due to a lack of experience and unfamiliarity with the concept.

As such, people have to be convinced that the habit deserves consideration by various ideas or influences. The notion that “smoking is cool” among teenagers can contribute to the adoption of the trait, as can peer pressure.

If you can find polls and statistics on the primary factors that lead people to tweet, they will be helpful to your point. Factual data will identify the importance of each cause clearly, although you should be careful about bias.

The harmful effects of tobacco have been researched considerably more, with a large body of medical studies investigating the issue available to anyone.

Lung cancer is the foremost issue in the public mind because of the general worry associated with the condition and its often incurable nature, but smoking can lead to other severe illnesses.

Heart conditions remain a prominent consideration due to their lethal effects, and strokes or asthma deserve significant consideration, as well. Overall, smoking has few to no beneficial health effects but puts the user at risk of a variety of concerns.

As such, people should eventually quit once their health declines, but their refusal to do so deserves a separate investigation and can provide many interesting smoking essay titles.

One of the most prominent reasons why a person would continue smoking despite all the evidence of its dangers and the informational campaigns carried out to inform consumers is nicotine addiction.

The substance is capable of causing dependency, a trait that has led to numerous discussions of the lawfulness of the current state of cigarettes.

It is also among the most dangerous aspects of smoking, a fact you should mention.

Lastly, you can discuss the topics of alternatives to smoking in your smoking essay bodies, such as e-cigarettes, hookahs, and vapes, all of which still contain nicotine and can, therefore, lead to considerable harm. You may also want to discuss safe cigarette avoidance options and their issues.

Here are some additional tips for your essay:

• Dependency is not the sole factor in cigarette consumption, and many make the choice that you should respect consciously.
• Cite the latest medical research titles, as some past claims have been debunked and are no longer valid.
• Mortality is not the sole indicator of the issues associated with smoking, and you should take chronic conditions into consideration.

Find smoking essay samples and other useful paper samples on IvyPanda, where we have a collection of professionally written materials!

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• Smoking as a Predictor of Underachievement By comparing two groups smoking and non-smoking adolescents through a parametric t-test, it is possible to examine this assumption and draw conclusions based on the resulting p-value.
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• Smoking Prevalence in Bankstown, Australia The secondary objective of the project was to gather and analyze a sufficient amount of auxiliary scholarly sources on smoking cessation initiatives and smoking prevalence in Australia.
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• Health Promotion and Smoking Cessation I will also complete a wide range of activities in an attempt to support the agency’s goals. As well, new studies will be conducted in order to support the proposed programs.
• Maternal Mental Health and Prenatal Smoking It was important to determine the variables that may lead to postpartum relapse or a relapse during the period of pregnancy. It is important to note that the findings are also consistent with the popular […]
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• Smoking and Cancer in the United States In this research study, data on tobacco smoking and cancer prevalence in the United States was used to determine whether cancer in the United States is related to tobacco smoking tobacco.
• Marketing Plan: Creating a Smoking Cessation Program for Newton Healthcare Center The fourth objective is to integrate a smoking cessation program that covers the diagnosis of smoking, counseling of smokers, and patient care system to help the smokers quit their smoking habits. The comprehensive healthcare needs […]
• Smoking Among the Youth Population Between 12-25 Years I will use the theory to strengthen the group’s beliefs and ideas about smoking. I will inform the group about the relationship between smoking and human health.
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• Health Campaign: Smoking in the USA and How to Reduce It That is why, the government is oriented to complete such objectives associated with the tobacco use within the nation as the reduction of tobacco use by adults and adolescents, reduction of initiation of tobacco use […]
• Smoking Differentials Across Social Classes The author inferred her affirmations from the participant’s words and therefore came to the right conclusion; that low income workers had the least justification for smoking and therefore took on a passive approach to their […]
• Cigarette Smoking Side Effects Nicotine is a highly venomous and addictive substance absorbed through the mucous membrane in the mouth as well as alveoli in the lungs.
• Long-Term Effects of Smoking The difference between passive smoking and active smoking lies in the fact that, the former involves the exposure of people to environmental tobacco smoke while the latter involves people who smoke directly.
• Smoking Cessation Program Evaluation in Dubai The most important program of this campaign is the Quit and Win campaign, which is a unique idea, launched by the DHCC and is in the form of an open contest.
• Preterm Birth and Maternal Smoking in Pregnancy The major finding of the discussed research is that both preterm birth and maternal smoking during pregnancy contribute, although independently, to the aortic narrowing of adolescents.
• Enforcement of Michigan’s Non-Smoking Law This paper is aimed at identifying a plan and strategy for the enforcement of the Michigan non-smoking law that has recently been signed by the governor of this state.
• Smoking Cessation for Patients With Cardio Disorders It highlights the key role of nurses in the success of such programs and the importance of their awareness and initiative in determining prognosis.
• Legalizing Electronic Vaping as the Means of Curbing the Rates of Smoking However, due to significantly less harmful effects that vaping produces on health and physical development, I can be considered a legitimate solution to reducing the levels of smoking, which is why it needs to be […]
• Self-Efficacy and Smoking Urges in Homeless Individuals Pinsker et al.point out that the levels of self-efficacy and the severity of smoking urges change significantly during the smoking cessation treatment.
• “Cigarette Smoking: An Overview” by Ellen Bailey and Nancy Sprague The authors of the article mentioned above have presented a fair argument about the effects of cigarette smoking and debate on banning the production and use of tobacco in America.
• “The Smoking Plant” Project: Artist Statement It is the case when the art is used to pass the important message to the observer. The live cigarette may symbolize the smokers while the plant is used to denote those who do not […]
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Smoking in Schools

There is an increasing recognition of the need to restrict smoking in the workplace for employee well-being, medical, legal and financial reasons. This includes recognition of the health effects of passive smoking, and of the need to manage the risk of liability from diseases caused by smoking, as well as encouraging smoking cessation as part of employee health promotion in the workplace.

The secondary objectives of the School’s smoking policy are to protect learners and non-smokers from exposure to second-hand smoke, to enhance the air quality of the work environment for all, and to comply with all relevant legislation in this regard.

Employees who do smoke are therefore expected to respect the health rights of learners and all non-smokers, as well as the preferences of non-smokers while at work, and on the School’s premises.

ISASA member schools are not required to make use of this policy; it is provided by way of example. As a Pro Forma (standardised draft) document, this policy should also be appropriately and properly customised by the user to suit their requirements.

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• Open access
• Published: 29 March 2016

Schools as smoke-free zones? Barriers and facilitators to the adoption of outdoor school ground smoking bans at secondary schools

• A.D. Rozema 1 ,
• J.J.P. Mathijssen 1 ,
• M.W.J. Jansen 2 , 3 &
• J.A.M. van Oers 1 , 4  

Tobacco Induced Diseases volume  14 , Article number:  10 ( 2016 ) Cite this article

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Whereas smoking bans inside secondary school buildings are relatively widespread, a smoking ban for the outdoor school grounds is less common. Therefore, this study investigates why many secondary schools fail to adopt an outdoor school ground smoking ban. The aim is to elucidate the perceived barriers and facilitators of stakeholders at schools without an outdoor school ground smoking ban.

Qualitative data were obtained from 60 respondents of 15 secondary schools. Semi-structured interviews were held with various key stakeholders and a thematic approach was used for analysis of the transcripts.

The perceived barriers and facilitators of the stakeholders fell into four categories: 1) socio-political characteristics (legislation and social norm), 2) school characteristics (policy, decision process, enforcement, resources, workforce conditions, communication and collaboration), 3) individual characteristics (support, knowledge, and target group), and 4) smoking ban characteristics (environmental factors, guideline recommendations, outcome expectations, and evidence).

Conclusions

These findings highlight the importance of legislation for outdoor smoking bans. Moreover, collaboration, communication and involving stakeholders during an early stage of the process should be stimulated, as this might increase adoption. These results can be applied in future studies on outdoor tobacco control policies; moreover, they may facilitate tobacco control initiatives leading to more smoke-free environments to further protect youth from the harmful effects of tobacco.

Tobacco use is a leading cause of morbidity and mortality worldwide. Despite the implementation of various tobacco control interventions (e.g. increased taxation, mass media campaigns, or smoke-free laws for indoor public places and workplaces) the prevalence of tobacco use remains problematic [ 1 ]. Given that the onset of smoking generally takes place during adolescence and results in increased tobacco involvement in adult life [ 2 ], tobacco control policies should focus on the prevention of smoking behavior of adolescents. A recent study showed that smoke-free environments have the potential to improve population health [ 3 ]. Moreover, smoke-free environments may not only reduce teenage smoking, but also exposure to second-hand smoke [ 4 – 6 ]. Therefore, implementing smoking bans seems promising to reduce and prevent tobacco use among adolescents.

Due to mandatory attendance, secondary schools are a potential setting for implementing smoking bans to prevent tobacco use among adolescents. Moreover, schools can play a key role in tobacco interventions as adolescence is a critical time for acquiring new patterns such as smoking initiation [ 7 ]. In fact, smoking rates among adolescents are a reason for concern. For example, in the Netherlands 31 % of the adolescents are experimenters, 16 % have smoked in the past 4 weeks and 9 % are daily smokers [ 8 ]. In addition, in one study, 45 % of the smoking adolescents stated that school is the place where their smoking behavior most often takes place [ 9 ]. Although studies stress the importance of protecting the developing brain from exposure to tobacco products during adolescence [ 10 , 11 ], only a few countries (i.e., Belgium, Finland, Australia, New Zealand, five provinces in Canada, and two states in the USA) have banned smoking at secondary school outdoor areas as well as the indoor areas [ 12 ].

In the present study, the definition of outdoor school ground smoking bans is based on three guidelines: i) the ban applies to the whole site (i.e., everywhere), ii) the ban applies to everyone, including students, staff and visitors, and iii) the ban should be displayed, e.g. in the school regulations and/or by signs [ 13 ]. A lack of legislation for a smoking ban on schools grounds (e.g. in the Netherlands) might explain the low percentage of such smoking bans, as schools are not obliged to implement the ban. Currently, in the Netherlands about 52 % of the secondary schools lack adoption and implementation of the smoking ban [ 14 ]. Although the number of studies on adoption of more general prevention programs and tobacco prevention programs using curricula at secondary schools is growing [ 15 – 19 ], few have explored the adoption process of smoke-free policies at secondary schools. Thus, the question arises what stops secondary schools from adopting an outdoor school ground smoking ban.

Several models have been developed to improve our understanding of the innovation process, such as adopting and implementing an outdoor school ground smoking ban [ 20 – 23 ]. According to Fleuren et al. [ 21 ] the transition from the dissemination stage (i.e., people reading or hearing about the innovation) to the adoption stage (i.e., people acquiring and processing information and making decisions about the innovation) can be influenced by various determinants, divided into related categories [ 21 , 24 ].

The present study explores which barriers and facilitators might affect adoption of an outdoor school ground smoking ban at secondary schools. This is important for two reasons. First, given that smoke-free environments internationally are increasingly important for improving general population health [ 3 ], identifying the barriers and facilitators can help in enacting smoke-free environments in school settings. In fact, a recent study emphasized the urgency for research on the adoption of tobacco control programs at schools, to more effectively facilitate tobacco prevention initiatives by policymakers and health professionals [ 25 ]. Second, to our knowledge, few studies have examined the adoption process of outdoor tobacco control policies in a school setting. The main aim of this study is to elucidate the adoption process of an outdoor school ground smoking ban by identifying the perceived barriers and facilitators of various stakeholders in secondary schools.

Qualitative methods are an effective way to explore the experiences and views of people with different roles in organizations [ 26 ]. Therefore, semi-structured interviews were held with key stakeholders in secondary schools to identify and elucidate the adoption process of an outdoor school ground smoking ban.

Participants

The study took place in three Public Health Services regions in the northern, middle and southern part of the Netherlands, as these regions have a wide range of demographic characteristics (i.e., urbanization and ethnicity) and schools varying in their characteristics (i.e., education types and school size) (Table  1 ). In total, 31 secondary schools (with students aged 12–18 years) were contacted, 16 refused to participate and 15 participated. In most cases lack of time was the reason for non-participation. At these 15 schools, 60 stakeholders participated who differed in function, gender and smoking status (Table  2 ). Five types of stakeholders were interviewed, who are directly affected when implementing an outdoor school ground smoking ban: directors, non-teaching staff, teaching staff, parents and students.

The study was approved by the Psychological Ethics Committee of Tilburg University and informed consent was obtained from all participants included in the study. This study was conducted in collaboration with three of the 25 Public Health Services in the Netherlands in 2014. These services deliver screening and health promotion to meet the health needs of (amongst others) school populations. Three interviewers were employed by these Public Health Services and were trained and instructed by the first author (ADR) in data collection and interview techniques. The interviewers carried out the recruitment of the schools and the interviews with the stakeholders in their region. Secondary schools in the three regions were contacted by the interviewers and only schools without an outdoor school ground smoking ban were included. Moreover, variation in school size, urbanization and education type of the schools were taken into account during selection of the schools. Thereafter, in consultation with the school director, relevant stakeholders were selected within the school and asked to participate in the study, with a minimum of two and a maximum of five stakeholders at each school. This led to 60 interviewees in total. During selection of the stakeholders, their function and smoking status were taken into account.

Semi-structured interviews were conducted to explore the perceived barriers and facilitators of stakeholders with respect to a smoking ban in outdoor school grounds. Demographic variables were noted, i.e., function, age, smoking status, school size, percentage of smokers in school, education types, represented ethnicity at the school, and current smoking policy. Examples of questions during the interviews were: ‘What are the barriers to implement an outdoor school ground smoking ban?’ and ‘How easily could an outdoor school ground smoking ban be established?’. Data were recorded on a digital audio recorder and interviews were transcribed verbatim. The average duration of an interview was 34 (range 13–61) min.

Transcripts were analyzed using thematic analysis [ 27 ]. The coding was conducted by the first author. To establish the inter-rater reliability, all other authors coded 33 % of all transcripts separately and the codes were compared and discussed until consensus was reached. Thereafter, codes were revised and divided into general themes. Subsequently, any overlap between themes was reduced by creating overarching themes which conveyed the core essence of the themes. When the overarching themes were formed, discussions were held with all authors to verify the appropriateness and correctness of the themes. The framework of Fleuren et al. [ 21 ] was useful for this, as it represents the stages of innovation (e.g. dissemination and adoption) and the related categories of determinants. Therefore, the overarching themes were integrated in these four related categories of determinants. For the purpose of this study, the four categories (socio-political context, organization, the user and the innovation) formulated by Fleuren et al. [ 21 ] were further specified into socio-political, school, individual and smoking ban characteristics, and the overarching themes were divided into these four categories. An additional analysis was conducted to explore the different views held by the stakeholders (i.e., which stakeholders perceive which barriers or facilitators). Furthermore, member checks (i.e., sending stakeholders a summary of their interview and asking them to confirm that this accurately reflects their statements) were conducted with all stakeholders for interpretive validation [ 28 ]. Data were analyzed using the software package Atlas-Ti 7.

A total of 16 overarching themes of perceived barriers and facilitators were identified for an outdoor school ground smoking ban, divided into four related categories, i.e., socio-political characteristics, school characteristics, individual characteristics and smoking ban characteristics (Figure  1 ). The results show that the perceived barriers and facilitators were often two sides of the same coin (e.g., lack of support as a barrier, and the need for support as a facilitator). However, workforce conditions, knowledge, target group and outcome expectations were only identified as perceived barriers, whereas social norm, communication, collaboration and evidence of the effectiveness of the smoking ban, were only identified as facilitators. The category ‘school characteristics’ included the highest number of perceived barriers and facilitators.

Perceived barriers and facilitators to the adoption of a smoking ban divided into four categories

Category 1: Socio-political characteristics

In the category socio-political characteristics, legislation was reported as a barrier (i.e., lack of legislation) and as a facilitator (i.e., need for legislation). For example, stakeholders reported that i) enacting legislation for outdoor school ground smoking bans at secondary schools, ii) stricter legislation for tobacco use of adolescents, and iii) government guidelines on outdoor school ground smoking bans, would facilitate adoption. Moreover, lacking this type of legislation and lacking legislation for public areas around secondary schools, hinders adoption. Furthermore, according to stakeholders, the social norm for outdoor smoking bans should be strengthened (e.g., by mass media) as this is seen as a facilitator: i.e. when outdoor smoking bans are accepted as normal and considered appropriate in society, this will enhance adoption.

Category 2: School characteristics

In this category, 7 overarching themes of perceived barriers and facilitators were distinguished. As a first theme, policy is mentioned by stakeholders as both a barrier and a facilitator. Other priorities of the school (e.g., bullying, nutrition), a laissez-faire culture (i.e., low interference with the activities of students) and a policy which prohibits students leaving the school ground during school time (i.e., blocking the possibility to smoke causes problems among smokers), function as barriers. Conversely, a policy which prohibits leaving the school ground is also mentioned as a facilitator, as enforcement might then be easier. A tailored, stepwise and comprehensive implementation approach is seen as a facilitator. In addition, a well-chosen moment for implementation is also considered a facilitator, e.g., the start of a new school year.

Second, the decision process at secondary schools is considered as both a barrier and a facilitator. For example, a negative attitude of decision-makers towards an outdoor school ground smoking ban is seen as a barrier. Similarly, stakeholders did not expect a smoking ban to be adopted when the decision-makers themselves were smokers. Furthermore, not only a bottom-up decision approach but also a top-down decision approach is considered a facilitator. Nevertheless, stakeholders more frequently referred to a bottom-up approach than to a top-down approach.

Third, enforcement is mentioned as both a barrier and a facilitator. For example, stakeholders mentioned enforcement as a barrier because, due to additional pressures on staff etc., difficulties were expected with the enforcement of the ban.

Only the actual enforcement prevents us from implementing the smoking ban, just the enforcement. That’s the only problem ( Director, smoker, #31 ).

Furthermore, some stakeholders mentioned that ratification of the director and strict enforcement by all staff members would facilitate the adoption of the smoking ban.

Fourth, the availability of resources is considered both a barrier and a facilitator. A lack of resources, e.g. finances (e.g., to make/place signs, etc.), staff and time, were reported as barriers to adopt the smoking ban.

Implementing the smoking ban would take up far too much of our time. People forget that we’re a school, focusing on the education of students. This takes all our time and attention, together with all the other things that we have to do. So I, as a director, don’t want to invest any time at all on it. (Director, non-smoker, #59)

On the other hand, sufficient finances and time were mentioned as facilitators. For example, receiving adequate funding for implementation would be a facilitator.

Fifth, the working conditions are considered a barrier; for example, there is insufficient staff to deal with an increase in workload due to a new task (e.g., enforcement of the ban). Furthermore, the employment terms of smoking personnel must be taken into account, e.g., personnel must have the opportunity to smoke during the breaks (i.e. their private time).

Sixth, communication is mentioned as a facilitator. For example, information and education provided by schools or external organizations are reported as facilitators. Stakeholders would like to start projects or workshops which increase awareness of the harmful effects of smoking and underpin implementing an outdoor school ground smoking ban.

We’d like to receive information from the local Public Health Services. They should inform staff, parents and students about the legislation, the harmful effects of smoking and how to deal with it by implementing an outdoor school ground smoking ban. Then we’ll be able to continue moving forward to an outdoor school ground smoking ban. (Teacher, non-smoker, #32)

Finally, collaboration is mentioned as a facilitator, not only within the school (e.g., collaboration within the school resulting in a cohesive team) but also with other schools (e.g., collaborating with other schools by sharing experiences/best practices) and with other external organizations (e.g., receiving counseling and implementation instructions).

Category 3: Individual characteristics

In the category ‘individual characteristics’ three themes of perceived barriers and facilitators were identified. Firstly, support was both reported as a barrier (i.e., lack of support of smoking staff, smoking students and parents) and as a facilitator (i.e., need for support of smoking staff, smoking students, parents and residents). Without support for an outdoor school ground smoking ban, stakeholders do not foresee adoption.

I’ve said it many times: I think it’ll be tough confronting the smoking staff - the smoking ban will provoke resistance from the smoking staff. (Teacher, non-smoker, #19)

On the other hand, support will facilitate adoption. Secondly, lack of knowledge about the concept and about implementation are mentioned as barriers. Lastly, an ‘inappropriate’ target group is considered a barrier: e.g. if a school has students with severe problems, stakeholders expect aggression and rebelliousness when adopting an outdoor smoking ban.

Category 4: Outdoor school ground smoking ban characteristics

Four themes were identified in the category of the smoking ban itself (i.e., what makes it difficult to adopt and what would simplify adoption). First, some environmental factors are impediments and some underpin adoption of an outdoor school ground smoking ban. For example, a large school ground and/or no clear demarcation of the school premises hinders enforcement and thus adoption. Moreover, an outdoor school ground smoking ban is irrelevant when a school does not have its own premises. Changing the school ground area (e.g., new construction, placing signs, removing ashtrays, etc.) and a vignette (i.e., an acknowledgment of a smoke-free school) are considered as facilitators in the category of environmental factors.

Second, according to stakeholders, guideline recommendations for an outdoor school ground smoking ban should be more flexible. For example, the guideline ‘Smoking is prohibited for everyone’ should not apply to staff or visitors who smoke. An exception must be made for adults, e.g., a place out of sight from the students but on the school grounds.

When implementing the smoking ban, I think we should allow pupils aged 16 to 18 to smoke only with permission from their parents or only allow everyone who’s older than 18 years to smoke on the school grounds, because I think teachers shouldn’t be deprived of smoking. (Pupil, smoker, #52)

Thirdly, a variety of negative outcome expectations are often reported by stakeholders as a barrier. For example, non-compliance of students and turbulence in the school (i.e., a smoking ban will cause conflicts). Moreover, stakeholders expect smokers to disappear from sight when leaving the school ground to smoke a cigarette, which may increase the risk of truancy and use of drugs, and/or may cause nuisance in the neighborhood. These negative outcome expectations may prevent adoption.

If an outdoor school ground smoking ban is implemented, then students will smoke their cigarettes outside the school premises, which will increase littering in the neighborhood. That’s one of the biggest obstacles: the cigarette butts and students making a mess. (Parent, smoker, #10)

Furthermore, a negative image of the school is mentioned as an outcome expectation: stakeholders expect smokers will smoke outside the school entrance when they are prohibited from smoking on the school premises; this may give a negative impression to people entering the school. Finally, evidence based on research demonstrating the effectiveness of the outdoor smoking ban on tobacco use of adolescents is considered a facilitator.

Differences between stakeholders

All five types of stakeholders differed in their views regarding barriers and facilitators. Directors and parents valued outcome expectations as a barrier, while non-teaching and teaching staff and students also mentioned lack of support as a barrier. Directors and students valued collaboration as a facilitator; non-teaching and teaching staff reported communications as a facilitator; and parents mentioned legislation as a main facilitator. Smokers reported lack of support, workforce conditions and outcome expectations as barriers, and collaboration and communication as facilitators.

Until now, there is a lack of research on the adoption process of outdoor tobacco control policies in school settings, based on identifying the perceived barriers and facilitators [ 15 – 19 , 25 ]. The present study provides insight into the perceived barriers and facilitators of stakeholders at secondary schools that affect the adoption of outdoor school ground smoking bans. Several barriers and facilitators were identified, divided into four categories: socio-political characteristics, school characteristics, individual characteristics, and characteristics of the smoking ban. Changes that positively affect adoption are needed, as a smoke-free environment in secondary schools seems promising to improve the general health of adolescents and may reduce teenage smoking and exposure to second-hand smoke [ 4 – 6 ].

Closer analysis of the different views of stakeholders reveals interesting insights. First, no substantial differences were found between the reported barriers and facilitators of non-teaching staff and teaching staff. Second, all main users of an outdoor school ground smoking ban (i.e., non-teaching staff, teaching staff and students) mentioned lack of support as a barrier. Third, negative outcome expectations were mentioned by directors (i.e. the stakeholders responsible for school policies). Fourth, smokers reported lack of support, workforce conditions and negative outcome expectations as barriers, since the smoking ban might threaten their own smoking behavior. Also, according to the smokers, communication and collaboration would facilitate adoption. Results show that the differences between the stakeholders should be taken into account when aiming to enhance adoption.

According to all stakeholders, there is a need for stricter legislation in the socio-political category. Enacting legislation depends on public acceptance of the outdoor smoking ban. For example, Diepeveen et al. [ 29 ] reported that public acceptance of government interventions is the highest for low intrusive interventions and when they target behavior of others, rather than the participants’ own behavior. In the context of an outdoor school ground smoking ban, the extent of public acceptance will probably be high because, in the present study, the stakeholders themselves (i.e., the targets) stated their preference for legislation. Moreover, Jaine et al. [ 30 ] reported that the support of adolescents for outdoor smoking bans increased from 51 % in 2009 to 59 % in 2011 and that, based on these results, the government should enact legislation. However, Widome et al. [ 31 ] report that public support alone is not enough for enacting legislation, but that multiple factors determine public health policy decisions. Nevertheless, in some countries (such as Belgium, Finland, Australia, and some states in Canada and the USA), legislation for an outdoor school ground smoking ban has already been implemented [ 12 ].

Results of the present study also suggest that collaboration and communication (not only information/education provided by the school or external organizations, but also mass media in the socio-political category) might increase adoption. Indeed, meetings with key stakeholders, educational presentations and media outreach is associated with tobacco policy change [ 32 ]. In line with our results, another study showed that shared decision-making (e.g., community participation and collaboration) enhances adoption of smoking bans [ 18 ]. These findings emphasize the importance of the involvement of several relevant stakeholders or parties at an early stage, resulting in community ownership which, in turn, establishes sustainability of an innovation [ 33 ]. In other words, in the context of secondary schools, collaboration, communication and involving stakeholders during the process might be essential to increase adoption of an outdoor school ground smoking ban.

Lack of knowledge on the individual category might influence the adoption process. However, a distinction must be made between lack of knowledge about the concept (i.e., knowledge about what an outdoor school ground smoking ban implies) and lack of knowledge about implementation, as knowledge about the concept is a precondition for adoption. That is, without knowledge about the concept, stakeholders of secondary schools will not acquire and process information and make decisions about the smoking ban. Apparently, in the present study some schools were not sufficiently informed about the concept and therefore not yet in the dissemination stage (i.e. people read/heard about a smoking ban), which is an essential stage before the adoption stage [ 21 ].

Furthermore, the results of this study show that several factors in the smoking ban category played a role in the adoption process. Flexibility of the guidelines (i.e., not everyone has to adhere/staff and visitors should be condoned) is needed to enhance the adoption rate, according to the stakeholders. Similar to our results, Durlak & DuPre [ 18 ] showed that adaptation plays an important role in innovations. It appears that users of an innovation often replicate some parts and modify other parts and that some degree of innovation adaptation is unavoidable [ 34 ]. However, adaptations can influence outcomes both positively and negatively [ 18 ]. For example, adaptation might improve non-smoking behavior among students, in other cases it might undermine the credibility of the ban if smoking staff is excused, since teachers are recognized as role models and this influences the smoking behavior of adolescents [ 35 ]. Future research should address the outcomes and effectiveness of an outdoor school ground smoking ban when there is some degree of adaptation of the smoking ban, since the literature showed mixed results [ 36 , 37 ]. Additionally, the level of support of smoking staff should be measured both when restricting teachers smoking and when condoning them, as even after implementation of a smoking ban the level of support often remains low among smoking staff [ 38 ], and condoning them might increase support.

Some limitations should be considered when interpreting the results. First, differences between the various schools were not revealed with respect to the perceived barriers and facilitators (e.g., schools differing in size, education level). However, because an earlier study showed that adoption of a tobacco-free policy did not differ substantially between different types of schools [ 32 ], the differences between schools are probably small. A second limitation is that only Dutch secondary schools with Dutch representatives were included. Future research should address non-Dutch schools with reference to cultural diversity and international comparison. Although these limitations are relevant, we did include a large and diverse group of schools and stakeholders which led to maximal exploration of the barriers and facilitators. Overall, the wide variation and the richness of the data contribute to the generalizability of our findings [ 39 ] and offer new insight into the processes of adoption of an outdoor smoking ban in a school setting.

The findings highlight the importance of legislation for outdoor smoking bans in a school setting. Policymakers are advised to develop and implement legislation, as this may help normalize outdoor smoking bans in school settings. Furthermore, school-wide promotions, media messages and meetings with key stakeholders are important components for adoption. Collaboration, communication and involving stakeholders at an early stage of the process should be stimulated, as this might be essential to increase adoption. In general, the findings of this study can be used in future subsequent adoption studies of outdoor tobacco control policies. However, most importantly, the findings of this study can facilitate tobacco control initiatives which, in turn, might result in more smoke-free environments and additional protection of youth from the harmful effects of tobacco.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all participants, including consent to publish.

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Acknowledgments

The authors thank Rick Boesten, Paula Dijkema, Wilco Schilthuis and Marian Levens for the collection of data in the three regions. This study was funded by the Netherlands Organization for Health Research and Development (ZonMw) and the National Institute for Public Health and the Environment (RIVM).

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ADR instructed the interviewers of the Regional Public Health Services who collected the data. ADR did the analysis and drafted the manuscript. JJPM, MWJ and JAMO participated in the analysis and interpretation of the findings and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

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Rozema, A., Mathijssen, J., Jansen, M. et al. Schools as smoke-free zones? Barriers and facilitators to the adoption of outdoor school ground smoking bans at secondary schools. Tob. Induced Dis. 14 , 10 (2016). https://doi.org/10.1186/s12971-016-0076-9

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Cigarette smoking and reasons for leaving school among school dropouts in South Africa

• Rachana Desai   ORCID: orcid.org/0000-0001-8754-1093 1 , 3 ,
• Liesbeth A. G. Mercken 2 ,
• Robert A. C. Ruiter 3 ,
• Jan Schepers 4 &
• Priscilla S. Reddy 1 , 5  

BMC Public Health volume  19 , Article number:  130 ( 2019 ) Cite this article

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School dropouts are at heightened risk of tobacco use compared to in-school learners. School dropouts are described as those not currently enrolled in school for the academic year, have not completed their schooling, and are between 13 and 20 years old. This paper examines the relationship between reasons for leaving school and past month cigarette smoking, taking into account gender differences.

Multiple logistic regression was used to analyse survey data ( n  = 4185). Geographical location was also incorporated into the analysis as effect moderators.

Although no significant main effects between reasons for leaving school and tobacco use were found, results showed that those who leave school early smoke more. When examining interaction effects with gender, leaving school due to ‘not being able to pay for school fees’ was significantly associated with smoking, but only among girls residing in urban areas (OR = 0.327, p  = .023) .

Conclusions

More research is needed to understand why learners leave school and their subsequent tobacco use. This knowledge will help researchers identify and target those students that are at risk for dropping out of school and using tobacco.

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Tobacco use remains the largest preventable cause of premature deaths, accounting for over 6 million deaths each year, worldwide [ 1 ]. In addition to the death that smoking causes, tobacco use is a risk factor for a range of disease and disability, such as lung cancer, stroke, heart disease, and chronic respiratory disease [ 2 , 3 ]. According to the latest data from the WHO, the average global tobacco smoking among populations aged 15 years and older was 21% [ 1 ]. Moreover, South Africans aged 15 years and older reported past month tobacco smoking as high as 31.4% [ 4 ]. Globally, cigarette smoking is common among adolescents [ 5 ]. According to the Global Youth Tobacco Surveillance results, the prevalence of past month cigarette smoking among adolescents aged 13–15 years ranged from a low of 3.8% in Uganda to a high of 17.9% in Namibia [ 6 ]. In South Africa, the Global Youth Tobacco Survey (13–15 years) and Youth Risk Behavior Survey (13–20 years) reported adolescent past month cigarette smoking as high as 12.7 and 17.6% respectively [ 7 , 8 ]. Adolescents are also more likely to initiate cigarette use between the ages of 12–14 years [ 7 , 8 , 9 ]. Therefore, it appears that adolescents in South Africa are at heightened risk for tobacco use.

Most tobacco smoking studies in South Africa have focused on adolescents attending school. Those who have never enrolled in school or students leaving before attaining their high school diploma are often overlooked [ 10 ]. Globally, data at the end of the 2013 school year showed 124 million children and adolescents either never started school or dropped out, with nearly half living in sub-Saharan Africa [ 11 ]. In South Africa, an estimated 4% dropped out of primary school (age 13 years and below) and 12% dropped out in high school (from age 15 years old) at the end of the 2014 school year [ 12 , 13 ]. The literature suggests that school dropouts reported cigarette smoking as high as 58% in the U.S and 22.6% in a small South African urban area [ 10 , 14 , 15 ]. School dropouts are more likely to take up tobacco smoking, as they are not guided by school-based interventions and the supervision and mentoring of teachers and peers [ 10 , 16 , 17 , 18 ]. Therefore, school dropouts may be more vulnerable to developing tobacco-related diseases and disability than their school-going counterparts.

Reasons to stay out of school are often complex and multifaceted [ 19 ]. A number of studies conducted in high-income countries identified various reasons related to school dropout such as low academic performance [ 20 , 21 , 22 , 23 , 24 ], single-headed families [ 20 , 21 , 22 , 23 , 24 ], low socioeconomic status [ 10 , 23 , 24 ], and substance use and abuse [ 10 ]. In South Africa, reasons for dropping out of school have also been attributed to boredom [ 14 , 25 ], bullying [ 21 ], illness [ 26 ], community violence [ 23 ] family support (pregnancy, getting someone pregnant or seeking employment to support the family) [ 14 , 23 ], and school-related issues (disciplinary consequences, poor academic performance, disliking school, and conflict with teachers) [ 14 , 23 ]. These studies suggest that there are various reasons contributing to school dropout.

Drug and tobacco use among adolescents has usually been associated with school dropout, the risk of leaving school, and poor educational outcomes [ 10 , 27 , 28 , 29 ]. Compared to in-school learners, school dropouts reported significantly higher rates of cigarette smoking [ 14 , 21 ]. To our knowledge, only two studies have investigated the relationship between reasons for leaving school and risky behaviour, namely crime and substance use [ 30 , 31 , 32 ]. These studies found that those who leave school to be with their friends, or dropout due to poor school performance, were more likely to engage in substance use, smoking and delinquency than those who leave school for family-related reasons [ 30 , 31 , 32 ]. Previous studies have focused on substance use in general, encompassing the use of tobacco, inhalants, hallucinogens, and alcohol. There has been limited focus on understanding the relationship between the various reasons for leaving school and cigarette smoking specifically. Understanding these differences can inform programme developers to formulate differential cessation programmes for school dropouts or those at risk for dropping out.

Gender differences may be found when examining the relationship between reasons for leaving school and cigarette smoking. Studies have shown that boys smoke more than girls, globally as well as in South Africa [ 1 , 33 ]. Reasons for leaving school are also known to vary across gender. A review of the literature concluded that boys often drop out of school due to disciplinary problems, low academic achievement [ 34 ], or to seek employment to contribute towards the family income [ 14 , 22 ]. Girls are more likely to leave school due to pregnancy and caretaking responsibilities [ 14 , 22 ]. A South African study reported that girls were more likely to drop out of school due to bullying [ 21 ]. Therefore, based on the literature, we also expect gender differences in the relationship between reasons for leaving school and cigarette smoking.

The goal of this study was to investigate the association between various reasons for leaving school and cigarette smoking, taking into account possible gender differences. The knowledge gained in this study can contribute towards understanding the profile of school dropouts at risk for tobacco use in South Africa.

Study design

Data collection took place between 2010 and 2011 and followed a cross-sectional design. Four of the nine provinces (Kwazulu Natal, Western Cape, Mpumalanga, and Gauteng) in South Africa were selected using non-probability sampling. The various language and racial groups (black African, White, Indian, Coloured, Other) of South Africa are represented by these provinces. In this study, participants were school dropouts who met the criteria of not currently being enrolled in school for the entire academic year, have not completed their schooling, and are between 13 and 20 years old. School dropouts are considered to be a “hidden population” with no existing register or national database for locating them. Therefore, respondent driven sampling (RDS) was an appropriate method for recruiting school dropouts [ 35 ].

A stratified cluster sample design was used to select schools ( n  = 85) as a starting point for recruiting the initial school dropouts or “seeds.” Lists of school dropouts from the schools were obtained. Those on the list who met the criteria were contacted and formed the initial seeds. The goal was 20 “seeds” per school site. If schools were unable to provide lists of school dropouts, survey administrators recruited seeds directly from the community, such as approaching young people in the community who appeared to meet the initial criteria.

Each seed was required to identify up to three school dropouts to participate in the study. These participants formed the “first phase” of sampling and were themselves asked to identify and refer a further three school dropouts, and so on. Up to four phases of recruitment were conducted (Fig.  1 ) (four phases of recruitment depicted in Additional file  1 ) [ 36 ]. A coupon system was used to keep track of the RDS recruitment chain. Each respondent received three coupons and invitation cards to recruit three other school dropouts to participate in the survey. The coupons were designed to tear off so the recruiter could keep the left half of the coupon, and the potential recruit the right half. The potential recruit was required to arrive at the survey site with their half of the coupon to complete a survey if interested. As proof of recruitment, the recruiter also returned to the survey site (in a local community hall or school) with their half of the coupon to collect monetary incentives for each participant they successfully recruited into the survey [ 37 ]. Each participant completed a self-administered questionnaire in one of the five languages (English, Afrikaans, isiZulu, Xhosa, and Sesotho). The questionnaire designed for this study was initially designed in English and translated into four languages, namely Afrikaans, isiZulu, Xhosa, and Sesotho (see Additional file  2 ). To check for consistency and correct translation, the survey was back translated from these languages to English. The self-administered questionnaire measured a range of socio-demographic characteristics and risk behaviour. All measures used in the current study are stated below.

Respondent Driven Sampling for Out-of-School Youth-A Graphical Illustration of Two Sampling Phases

Past month cigarette smoking

Cigarette smoking in the past month was the main outcome variable. Participants were asked to pick a statement that best described their cigarette smoking patterns in the past 30 days. For the statistical analysis, the participants were then recoded as non-smokers (smoked 0 days) and smokers (smoked 1–30 days).

Demographics

Demographic characteristics of the participants were provided by stating the province (1 = Gauteng, 2 = Kwazulu Natal, 3 = Mpumalanga and 4 = Western Cape), the area that they reside in (1 = rural, 2 = urban, 3 = peri-urban), gender (1 = boy, 2 = girl), and their age. The racial categories defined by the Department of Labour were used to classify participant’s race (1 = black African, 2 = Coloured, 3 = Indian, 4 = White, 5 = Other). Racial categories allow investigation of ongoing health disparities that have endured post-Apartheid and were not used with the intention of reifying social constructions developed during the Apartheid era [ 38 ].

The timing of the dropout

Participants were asked to indicate the last grade they were in before leaving school (grade 7–12).

Reasons for leaving school

Eight items were used to measure reasons for leaving school (0 = No, 1 = Yes). Seven items represented each a different specific reason to leave school (i.e., no reason for leaving school, being pregnant or made someone pregnant, not enough money to pay school fees, working to support the family, had to help with looking after the house and siblings, the school was too far, and difficulties with school work, teachers or the learners) and one item represented other reasons not mentioned. Participants were allowed to select more than one reason. Each reason was treated as a dichotomy in the analysis.

Statistical analysis was conducted using IBM SPSS version 24. Descriptive statistics were used to describe the sample. Gender was cross-tabulated against study measures. A Spearman’s correlation analysis was used to assess the association between study measures. The strengths for the Spearman’s correlation were classified as weak (.1 ≤ r ≤ .3), moderate (.3 ≤ r ≤ .5), or strong (r ≥ .5) [ 39 ]. The prevalence past month tobacco use was examined against demographic variables, reasons for leaving school, and timing of the dropout. A Chi-square analysis of equal proportions was used to determine significant differences between categories. A pairwise check of overlapping confidence intervals was conducted to determine significant differences within categories. Logistic regression analysis was used to investigate the association between reasons for leaving school, covariates, and cigarette smoking. Moreover, the moderating effect of gender was examined in the model a . In the case of significant interactions, simple effects analyses were conducted to further examine the nature of the interaction [ 40 ]. All estimates were considered to be statistically significant at the 5% level of significance ( p  < .05).

Socio-demographic profile of the participants

Of the total 4432 respondents who completed the survey, 137 respondents did not answer the tobacco smoking question and a further 110 respondents did not indicate a reason for leaving school. Therefore the final sample was 4185. As seen in Table  1 , respondents most common reasons for dropping out of school were: no reason for leaving (boys = 20.8%, girls = 18.9%), they were pregnant or made someone pregnant (boys = 17.8%, girls = 19.8%), and they did not have enough money to pay school fees (boys = 18.1%, girls = 18.8%). More than half (58%) were boys and the majority classified themselves as black African (72.5%). The mean age was 17.4 years (SD = 1.6) and 20% had left school in grade 10 (age 16 onwards). Less than half (46.1%) resided in rural areas and 27.7% resided in the Western Cape. In addition, bivariate correlation analysis was used to assess associations between study measures (see Additional File  3 ). At the p  = .05 level of significance, the correlation coefficients were mostly weak and non-significant.

Prevalence of past month tobacco smoking

Overall, the prevalence of past month tobacco smoking among school dropouts was 50.2%. As shown in Table  2 , boys (61.6%, [95% CI: 59.6–63.5]) had a significantly higher prevalence of past month cigarette smoking than girls (33.9%, [95% CI: 31.6–36.2]). Those residing in Western Cape (69.5%, [95% CI: 66.7–72.1]) significantly smoked more than those living outside the Western Cape. Participants living in urban areas (56.8%, [95% CI: 53.9–59.8]) also smoked more than those in rural areas (44.4%, [95% CI: 42–46.8]). The prevalence of tobacco smoking was high among those who left school in grade eight (56.8%, [95% CI: 53–60.4]) and grade nine (58.2%, [95% CI: 54.5–61.9]) compared to those leaving school later (Table 2 ).

Development of the logistic regression model

The relationship between past month smoking and reasons for leaving school, moderated by gender was investigated. Covariates that were significantly associated with the smoking variable were included in the model. Further, it was found that the gender x reasons for leaving school interaction terms were non-significant (p’s > .05). Since the various provinces and areas showed significant differences on the smoking variable, these variables were included in a four-way interaction model: gender x reasons for leaving x province x area. The model was reduced by removing higher order terms based on non-significant omnibus tests, followed by eliminating lower order non-significant terms. In line with our original hypotheses, the terms reasons for leaving school and reasons for leaving x gender were kept in the models, irrespective of their significance.

Reasons for leaving school and cigarette smoking

The final model shown in Table  3 , revealed a significant three-way interaction of gender x not having enough money to pay for school fees x area. Simple effects analysis, shown in Table  4 , revealed a significant two-way interaction of gender with “not enough money to pay for school fees” in urban areas as opposed to rural and peri-urban areas (OR = 0.297, p  = .016, [95% CI: 0.110–0.800]). To investigate this significant two-way interaction in depth, separate analysis for boys and girls were performed. Results showed that leaving school due to not having enough money to pay for school fees was associated with less cigarette smoking, but only among girls living in urban areas (OR = 0.327, p  = .023, [95% CI: 0.158–0.872]). The final model, as shown in Table 3 , further implied the following significant two-way interactions: The effect of being pregnant or made someone pregnant in urban areas (OR = 0.542, p  = .011, [95% CI: 0.338–0.867]) is different compared to that effect in rural areas (OR = 1.810,[95% CI: 0.614–5.336]). The effect of “other” reasons for leaving in Mpumalanga (OR = 3.761) is different ( p  = .00, [95% CI: 1.858–7.616]) from that effect in Gauteng (OR = 0.82, [95% CI: 0.252–2.671]). Further simple effects analysis revealed non-significant effects. b

The results of this study confirm that cigarette smoking was common among school dropouts in this sample. Past month cigarette smoking was reported by 50.4% of the respondents with boys smoking twice as much compared to girls. Earlier studies also confirm that school dropouts exceeded the rate of cigarette smoking compared to in-school learners who reported 17.6 and 13.6% according to two national studies [ 7 , 8 ]. In comparison to in-school learners who reported 25% smoking in the Western Cape province, cigarette smoking among school dropouts is as high as 69.5% in the Western Cape and 56.8% in the urban areas. Those leaving school in grade 8 and 9 appeared to smoke more than those leaving school later. In contrast, in-school learners appear to smoke more in the later grades compared to those in grades 9 and lower [ 8 ]. These findings are worrying, particularly the fact that school dropouts are at higher risk for tobacco-related morbidity and mortality, posing a serious public health threat [ 10 , 16 , 17 , 18 ].

This paper investigated the relationship between various reasons for leaving school and cigarette smoking. Surprisingly, no significant main effects were found between the reasons for leaving school and subsequent cigarette smoking. The few studies conducted among school dropouts have either focused on substance use in general [ 30 ] or problem behaviour [ 31 ] as a function of reasons for leaving school. Some of our findings are in line with Aloise-Younge 2002, who found that substance use did not differ among adolescents who left school due to problems with teachers or poor school performance. Aloise-Younge 2002 only found significant effects between reasons for leaving and substance use when ethnic differences were taken into account [ 30 ]. Moreover, Jarjoura (1996) found that dropping out for school-related reasons (poor grades and problems with teachers) was more strongly related to delinquency, but only among adolescents from higher income households [ 31 ].

The present study was the first study that focused solely on the relationship between reasons for leaving school and cigarette smoking. The lack of significant relationships between both concepts may be accounted for by the lack of a standardised measure used for cigarette smoking. Given that the legal age for tobacco use in South Africa is 18, participants in this study were underage and may have also underreported their cigarette smoking behaviour. Studies have furthermore shown that tobacco use in the form of waterpipe, snuff, pipes, cigars, and cigarillos are increasing in popularity among adolescents in South Africa, which were not considered in this study [ 41 ]. On the other side of the comparison, the South African literature cited reasons for leaving school such as bullying [ 21 ], boredom [ 25 ] illness [ 26 ], and community violence [ 23 ], which were also not incorporated into this study. Future studies may find it useful to consider a qualitative approach to understanding the reasons for leaving school and the impact on tobacco use among school dropouts.

The second aim of this paper was to investigate the relationship between reasons for leaving and cigarette smoking, taking into account possible gender differences. Surprisingly, no significant effects were found, only when gender differences were considered. Therefore, we examined how reasons for leaving school differed by geographical location, as well as gender. Contrary to our expectations, we found that leaving school for not having enough money to pay for school fees was associated with less cigarette smoking, but only among girls living in urban areas. A qualitative study confirm our findings and indicated that physical (poor living conditions, inability to meet school costs), social (unemployment among caregivers and single headed families) and psychological (feelings of disempowerment and despair) poverty is a contributing factor to why adolescents leave school in three poor and marginalised urban communities in South Africa [ 23 ]. This is not surprising, given that more than two out of every five youth live below the poverty line in South Africa [ 42 ]. Moreover, the HIV/AIDS pandemic has severely affected the poor communities in South Africa [ 43 ]. School expenses cannot be met due to reduced income, possibly from the illness of the highest income recipient in the household, and an increased expenditure of health services, and funerals [ 43 , 44 ]. In many households affected by HIV and AIDS, girls tend to be the first to be taken out of school and the first to take on increased family responsibilities, including caring for an ailing guardian [ 44 ]. Boys may be more likely to seek employment to contribute towards the family income [ 22 ]. Consequently, boys may be able to afford purchasing cigarettes compared to girls who leave for the same reason.

The present study is not without its limitations [ 45 ]. Respondent driven sampling was conducted in four of the nine provinces of South Africa and therefore the results cannot be generalised to the entire population. However, bias that the non-random choice of seeds may have introduced is overcome through the sufficient number of phases of peer recruitment, which stabilises the composition of the sample, thereby becoming independent of the seeds from which recruitment began [ 37 ]. Data in this survey are also based on self-report and are therefore subject to the limitations of self-report bias. Although extensive literature exists on the correlates of friend and family smoking, we unfortunately did not have information on friend smoking, and a large amount of missing or unknown data was found on parent/guardian smoking. Finally, causal relationships could not be addressed due to the cross-sectional nature of the study. These limitations notwithstanding, this study provides valuable insight into the associations of cigarette smoking among school dropouts. To better elucidate causal mechanisms, future longitudinal and national studies will be needed.

The present study was the first study to examine the relationship between reasons for leaving school and cigarette smoking. This study found a significant effect between reasons for leaving school and cigarette smoking when demographic factors were incorporated into the analysis, in particular, gender and geographic location. Future research should closely explore the various reasons for dropping out of school and tobacco use in South Africa not considered in this study, possibly using qualitative methods to target the correct reasons for leaving.

This knowledge will help researchers identify and target those students that are at risk for dropping out of school and tobacco smoking. Such findings will inform the recommendations made for future research efforts, as well as the development of specific policies and interventions pertaining to tobacco use among high-risk school dropouts.

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Acknowledgements

We would like to acknowledge the scholarship of the Foundation Study Fund for South African students in the Netherlands. Opinions expressed and conclusions arrived at are those of the authors and are not necessarily to be attributed to the funder. We also thank the participants, data collectors, and translators for their participation and assistance in the project.

Author contributions

RD conceived the study, participated in its design and coordination, statistical analysis and interpretation and drafted the original and final manuscript. LM and RR supervised RD, made substantial contributions to conception and design, analysis and interpretation of data, and have been involved in revising the manuscript. JS participated in the data analysis, interpretation of the data and reviewing the manuscript. PR was the principal investigator of the study, grant holder of the project, participated in the conceptualisation, design, data collection and coordination of the project, supervised RD and contributed towards reviewing the manuscript. All authors read and approved the final manuscript.

a Similar analyses were conducted that tested the moderating effect of timing of the dropout, however, these analyses did not result in significant outcomes. b Similar analyses were done for the timing of dropout but did not result in significant outcomes.

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The datasets generated and analysed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request.

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Desai, R., Mercken, L.A.G., Ruiter, R.A.C. et al. Cigarette smoking and reasons for leaving school among school dropouts in South Africa. BMC Public Health 19 , 130 (2019). https://doi.org/10.1186/s12889-019-6454-5

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Are you wondering how to write your next persuasive essay about smoking?

Smoking has been one of the most controversial topics in our society for years. It is associated with many health risks and can be seen as a danger to both individuals and communities.

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• 1. What You Need To Know About Persuasive Essay
• 2. Persuasive Essay Examples About Smoking
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• 4. Tips for Writing a Persuasive Essay About Smoking

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A persuasive essay is a type of writing that aims to convince its readers to take a certain stance or action. It often uses logical arguments and evidence to back up its argument in order to persuade readers.

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Persuasive Essay Examples About Smoking

Smoking is one of the leading causes of preventable death in the world. It leads to adverse health effects, including lung cancer, heart disease, and damage to the respiratory tract. However, the number of people who smoke cigarettes has been on the rise globally.

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Check out some more persuasive essay examples on various other topics.

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An argumentative essay is a type of essay that uses facts and logical arguments to back up a point. It is similar to a persuasive essay but differs in that it utilizes more evidence than emotion.

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Select a particular perspective on the issue that you can use to form your argument. When talking about smoking, you can focus on any aspect such as the health risks, economic costs, or environmental impact.

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Teenage Smoking Essay: Writing Guide & Smoking Essay Topics

Smoking can be viewed as one of the trendy habits. Numerous teenagers try it since they think that it is cool or can help them socialize. Often students start smoking due to stress or mental illnesses. But is it okay?

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An argumentative essay on teenage smoking should give the reader a rational discussion of a specific issue. The ideas are expected to be well-structured and solidified with valid evidence.

Below, you can find the most useful tips for writing an argumentative teen smoking essay. Don’t hesitate to use them!

• Catch the reader’s attention. In the introduction, explain the significance and relatability of the chosen issue. Provide general background and make the reader continue exploring your essay through attention-grabbing elements (impressive statistics, personal stories, etc.).
• Express your position clearly. Compose a concise thesis statement , so the reader can quickly get your position. Be as precise as possible! For example, your thesis might look like this: Teenage smoking leads to poor health, psychological and social issues.
• The most vivid adverse ramification of teenage smoking is the development of health problems like heart or lung diseases and cancer.
• Another disruptive effect of smoking at a young age is the risk of psychological disorders such as anxiety or depression.
• The last negative consequence of teenage smoking is the conflict with social norms.
• Support your arguments. Your ideas will become stronger if you support them with proof from other sources. But be careful here! Use only reliable sources (academic journals, scholarly articles, books, etc.).
• Finish your essay dynamically. In your essay conclusion, restate your thesis statement and synthesize all of your arguments. Motivate your readers on further investigation of your topic. To make your paper even more impressive, finish it with the final memorable thought that would be stuck in your readers’ minds.

📈 Cause and Effect Essay on Smoking

A cause and effect of the teenage smoking essay should answer two questions:

• Why do teenagers smoke? (Causes).
• What are the consequences of teenage smoking? (Effects).

How to create an excellent cause and effect paper? You can start by checking successful teen smoking essay examples . Then, learn some useful tips here:

• Get an idea. The first step of creating a causes effects of teenage smoking essay is brainstorming topics. Think of the common reasons for teens smoking and analyze the possible outcomes. Here are some ideas for you:
• Outline your paper. This step helps structure your ideas properly. Create a well-organized plan and add there all the proof and examples. Make sure that everything is logical, and start writing your teenage smoking essay.
• Form a clear thesis. In your thesis statement, state your position and introduce the chosen cause and effect of smoking. Here is an example of the thesis for this type of smoking among teenagers essay: Caused by peer pressure, smoking negatively affects teenagers’ health and appearance.
• The key cause of teenage nicotine addiction is peer pressure and the fear of becoming an outsider among the friends-smokers.
• One of the detrimental effects of cigarettes on teenagers is health problems.
• Another adverse consequence of teenage smoking is negative changes in appearance .
• Polish your piece of writing. After you finished your first draft, revise and edit your essay. Ensure the absence of grammar and punctuation mistakes and double-check if your paper is coherent.

🚭 Persuasive Essay on Smoking

A persuasive essay about teenage smoking resembles an argumentative one but has a different purpose. Here, you have to convince your reader in your opinion, using evidence and facts. Moreover, in some papers, you have to call your reader to action. For example, to quit or ban smoking . So, see how to do so:

• Grab the reader’s attention. To do so, you should know your audience and their preferences. Start your smoking essay by proving to the reader your credibility and the significance of your topic. For example, if you are writing about smoking students, introduce the shocking statistics at the beginning of your paper and convince them to stop smoking.
• Show your empathy. An emotional appeal is a powerful tool for gaining the readers’ trust and influencing their opinions. Demonstrate that you understand their emotions and, at the same time, convince them to change their beliefs. To make it more clear, see an example: Although smoking might help teenagers be on the same wavelength as their friends, nicotine has a detrimental effect on health and leads to cancer development.
• Include rhetoric questions. This is a useful persuasive trick that makes readers change their minds. For instance, in your smoking essay, you may ask this question: Smoking helps me to relieve stress, but will I be able to overcome lung cancer later?
• Highlight your position. In a persuasive essay, you should be incredibly convincing. So, don’t be afraid of exaggeration or even repeating yourself. These tricks may help you to deliver your message to the reader more quickly and effectively.

You have a lot of ways of creating fantastic teen smoking essays. You should just turn around and gather material. Sometimes it lies near your foot.

To smoke or not to smoke? – This is the question! You should decide what is for you: To be yourself or follow the fashion! It is not difficult to do!

🔥 Smoking Essay Topics

Do you know what the critical secret of a successful essay is? A well-chosen topic!

If you find something you are passionate about, your essay writing process will be much easier. So, take a look at our smoking essay topics. Select one of them or use some to come up with your idea.

• Smoking among teenagers : an exaggerated problem or a real threat to the generation?
• The influence of nicotine on teenagers’ brain activity.
• How smoking parents develop smoking habits in their children.
• Vaping : a healthier alternative to regular cigarettes or just another dangerous teenagers’ passion?
• Is smoking still a problem among teenagers today – an essay to highlight the issue of cigarette addiction.
• The danger of smoking for immature teenagers’ organisms.
• If smoking in public places was banned, teenagers would be predisposed to cigarettes less.
• Social problems caused by teenage smoking.
• The role of parents in dealing with teenage cigarette addiction.
• Useful tips to stop smoking .
• Why teenagers are influenced by peer pressure , and how to overcome it.
• Teenage smoking: a matter of real nicotine addiction or a case of psychological processes inside immature minds?
• The danger of smoking and second-hand smoke .
• Is e-cigarette a threat or solution?
• Analyze the connection between vaping and dental health.
• Is it necessary to ban cigarette manufacturers?
• Is it possible to prevent teenagers from smoking using anti-smoking posters ?
• What are the best ways to persuade young adults to stop smoking?
• Discuss the possibility of the global ban on tobacco and its potential outcomes.
• Pros and cons of anti-smoking adverts.
• Explore the connection between smoking cessation and depression .
• Describe the link between smoking and heart disease.
• Explain how smoking cessation can improve teenagers’ life.
• How to reduce smoking among youth.
• What are the different types of cigarette smokers?
• Analyze the challenges of each stage of smoking cessation and how to overcome them.
• Is smoking an effective method of weight control?
• Discuss the impact of smoke on health of primary and secondary smokers.
• Do you support the idea of lowering the smoking age in the USA ?
• Effect of tobacco use on our body.
• Explore the efficiency of the acupuncture method for smoking cessation.
• Will the complete prohibition of smoking in cities help to preserve teenagers’ health?
• Examine how smoking in movies influences teenagers’ desire to start smoking.
• Are nicotine replacement medications necessary for successful smoking cessation?
• Reasons to prohibit tobacco products and cigarettes.
• Describe the reasons that prevent teenagers from smoking cessation .
• Analyze the public image of smoking in the USA.
• Discuss the issues connected with the smoking ban.
• Antismoking ads and their influence on youth smoking prevalence.
• What factors determine the success of anti-smoking persuasive campaigns among teenagers?
• Explore the impact of smoking on teenagers’ physical and mental health.
• What can you do to motivate your teenage friend to quit smoking?
• Why do teenagers start smoking?
• Analyze the rates of tobacco smoking among adolescents.
• Compare the peculiarities of smoking cessation methods and motivation for teenagers and adolescents.
• Examine whether raising cigarette pricing is an effective way to lower smoking rates.

Teenage Smoking Essay Prompts

Here are some writing prompts that you can use for your smoking essay: 

• What does the data on smoking in different countries say? Compare the age limitations for smoking, attitude to smoking in America and Europe, for example. Where the situation is worst, whether the government tries to fight against this, etc.
• The distribution of cigarettes and other types of tobacco. Is it okay that tobacco machines are available all over the world (especially in Europe)? Any child can buy a cigarette and start smoking. You could investigate this problem in your teen smoking essays.
• Opinion essay: present your ideas and attitude to smoking. Explain whether you like to see people smoking around you, or you cannot stand when people are gazing at you while you are smoking.
• How does media influence teens’ decision-making? When teenagers see their favorite characters getting pleasure from smoking, they may want to try it. Is it a reason to start? In what other ways does mass media affect the problem?

Effects of Teenage Smoking Essay Prompt

Smoking among teenagers is a serious problem that has long-term consequences for their physical and mental health. In your essay, you can dwell on the following ideas:

• Analyze the health consequences of tobacco use among young people. In your paper, you can study how tobacco affects youths’ health. Focus on the most widespread problems, such as heart and lung diseases, cancer risk, and others.
• Estimate the role of smoking in promoting antisocial behavior among teenagers . Does smoking really encourage aggression and vandalism among teenagers? Use psychological theories and recent research findings to prove your point.
• Explain why teenage smoking is associated with an increased risk of suicidal thoughts and urges. To prove your point, you may discuss how nicotine causes depression and neurotransmitter imbalances. Make sure to illustrate your essay with relevant studies and statistical data.
• Investigate the economic and social consequences of smoking among young people. Besides high cigarette prices, you can consider lost productivity and healthcare costs. Additionally, write about social issues, such as stigmatization and reduced life opportunities.

Smoking in School Essay Prompt

Despite the implementation of smoke-free policies, a large percentage of teenagers start smoking during their school years. You can write an essay advocating for more effective initiatives to address not only students’ access to cigarettes but also the core causes of teen smoking.

Check out some more ideas for your “Smoking in School” essay:

• Explain why educators should prohibit smoking on school grounds. Smoking is a dangerous habit that damages students’ health and the overall school environment. Even secondhand smoke exposure has harmful consequences. Your essay could provide evidence that proves the effectiveness of smoke-free policies in reducing teenage smoking rates and improving general well-being.
• Analyze the effectiveness of school smoking policies in your educational institution. What smoking policies are accepted in your school? Do students comply with them? What disciplinary measures are used? Use student surveys and disciplinary records to prove the effectiveness or ineffectiveness of current policies.
• Describe the issue of smoking in schools in your country. Answer the questions: how widespread is this problem? How does it manifest itself? What causes smoking in schools, and how do schools fight it?
• Investigate the role of schools in reducing youth smoking. How can schools prevent and reduce smoking among students? Are their programs and campaigns effective? What can families and communities do to support schools in their efforts? Study these questions in your essay.

Peer Pressure Smoking Essay Prompt

Peer pressure is a common reason why teenagers start smoking. Friends, romantic attachments, or other social circles — all have significant effects on teens’ smoking intentions and possible tobacco addiction.

Here are some practical ideas that can help you highlight the role of peer pressure in teenage smoking :

• Analyze why adolescents tend to be powerful in influencing their friends to start smoking. Peer pressure often impacts teenagers’ decisions more than parents’ disapproval. To explain this phenomenon, you can examine theories like social contagion and recent studies on peer dynamics.
• Provide your own experience of resisting peer pressure to smoke. Have you ever faced peer pressure inducing you to smoke? What helped you to withstand? Try to share some advice for students in a similar situation.
• Investigate how social media can amplify peer pressure through online portrayals of smoking as glamorous. We recommend studying images, videos, advertisements, and influencers that depict smoking as stylish and sophisticated. What can be done to prevent smoking glamorization on social media?
• Estimate the role of peers in normalizing smoking behavior. Peer influence is more than just direct pressure. Your essay could explain how factors like observational learning and group identity induce teenagers to smoke.

Causes of Smoking Essay Prompt

There are many reasons why people start smoking, ranging from simple curiosity to complicated social and psychological factors, including anxiety, low self-esteem, and domestic violence.

Check out several ideas for an essay about the causes of smoking:

• Analyze tobacco or e-cigarette ads that emphasize weight control benefits and explain how these ads encourage teenagers to smoke. Your paper may discuss how tobacco and e-cigarette companies make use of teenagers’ insecurities and social norms regarding body image. Include studies that prove the impact of advertising on youths’ behavior.
• Explore why the rising popularity of fashionable electronic “vaping” devices is one of the key causes of teen smoking. Why is vaping so popular among teenagers? How does it appeal to youths’ preferences and lifestyles? What role do sleek design and social media influence play in the devices’ popularity? Answer the questions in your paper.
• Describe your or your friend’s experience that forced you to try cigarettes. Have you or your friend ever tried smoking? Share your story in your essay. Reflect on the circumstances and emotions involved. What conclusions did you make from the experience?

Smoking Is Bad for Health Essay Prompt

Cigarette smoking impacts nearly every organ in the body, causes a variety of diseases, and worsens smokers’ overall health.

In your essay, you can expand on the following ideas to show the severe consequences of smoking on human well-being:

• Analyze why cigarette smoking is the leading cause of preventable death in the United States. Here, you can examine factors like addiction and chronic diseases cigarettes provoke. Add statistical data and emphasize the preventable nature of smoking-related illnesses and deaths.
• Examine passive smoking as a serious threat to health, especially for children, pregnant women, and people with chronic diseases. Your essay could analyze research and case studies proving that secondhand smoke is as dangerous to human health as smoking itself. Underline its harm to vulnerable populations, such as children, pregnant women, and people with chronic diseases.
• Investigate the impact of cigarettes on mental health, including their contribution to the development of depression and anxiety. In this paper, you can examine nicotine’s effect on neurotransmitters involved in mood regulation, such as dopamine and serotonin. Support your point with evidence from peer-reviewed studies.
• Research the possible diseases that smoking can provoke, including cancer, cardiovascular diseases, and respiratory illnesses. How does smoking contribute to the development and progress of these diseases? Use epidemiological data and medical research to answer this question.

Is Smoking Still a Problem Among Teenagers: Argumentative Essay Prompt

According to the CDC, in 2023, 1 out of every 100 middle school students and nearly 2 out of every 100 high school students had smoked cigarettes in the past 30 days . Public health experts are especially concerned about e-cigarettes since flavorings in tobacco products can make cigarettes more appealing to teenagers.

To evaluate the current situation with smoking among teens, dwell on the following ideas in your essay:

• Analyze your country’s or world’s statistics on teen smoking in recent decades. Do you see any changes? Why did they happen? What do these changes mean in terms of public health? Examine these questions in your essay.
• Describe your own observations of teenagers’ smoking habits. Contrast what you witnessed in the past with the current situation. Do you think teenagers’ smoking habits changed? What makes you think so? Provide real-life examples to back up your opinion.
• Examine data on e-cigarette use among teenagers. Your essay could compare ordinary cigarette smoking and e-cigarette use trends among teenagers. Which type prevails, and why? What impact does it have on teenagers’ health? What can be done to lower smoking and vaping rates among teenagers?

Thanks for reading till the end! Make sure to leave your opinion about the article below. Send it to your friends who may need our tips.

You might also be interested in:

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• How to Write an Argumentative Essay Step by Step: Virginia Kearney, Owlcation, Education
• Teen Smoking Essay: Bartleby
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• Definition and Examples of Cause and Effect in Essays: Richard Nordquist, ThoughtCo
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Student Attitudes Toward Tobacco Use and Tobacco Policies on College Campuses

Elizabeth k. do.

1 Department of Health Behavior & Policy, Virginia Commonwealth University, Box 980430, Richmond, VA 23298-0430, USA

2 Cancer Prevention and Control, VCU Massey Cancer Center, Richmond, VA, USA

Westley L. Fallavollita

Brianna bonat.

3 Division of Epidemiology, Department of Family Health and Population Sciences, Virginia Commonwealth University, Richmond, VA, USA

Kendall Fugate-Laus

Brianna c. rossi, bernard f. fuemmeler.

We utilized a mixed methods approach to assess student attitudes towards tobacco use and campus tobacco policies. Interviews (N = 21), focus groups (N = 2 groups, 4–5 participants each), and an online survey (N = 636) were conducted among a sample of students attending a 4-year, urban, public university in the Mid-Atlantic region of the United States. In interviews and focus groups, students expressed skepticism about a tobacco-free campus policy due to perceived violations of personal rights and challenges with enforcement. Of the sample surveyed, 9.2% and 20.6% had used cigarettes or e-cigarettes within the past 30 days. The majority of students agreed that colleges have a responsibility to adopt tobacco-free policies that reduce the risk of tobacco addiction (62.4%) and ensure smoke-free air to breathe (81.5%). However, more than half (56.3%) also indicated that a policy allowing for designated smoking areas for cigarettes was best for campus, which runs counter to a comprehensive tobacco-free policy. Academic year, gender, and race/ethnicity were significant factors associated with support for tobacco-free policies. Current smokers and vapers were less likely to support tobacco-free policies that reduce the risk of tobacco addiction (OR = 0.3, 95% CI 0.1, 0.7 for smokers; OR = 0.3, 95% CI 0.1, 0.6 for vapers), but not policies that ensure smoke-free air to breathe. E-cigarettes pose a unique obstacle to tobacco-free policies, as students perceived e-cigarettes to be less harmful than cigarettes. To implement a tobacco-free campus policy, students suggested educational campaigns that focus on the potential health benefits of a tobacco-free campus.

Introduction

The number of colleges and universities with smoke-free or tobacco-free campus policies has tripled since 2012 [ 1 , 2 ]. As of October 2019, at least 2469 campuses have adopted smoke-free policies, which prohibit smoking in all indoor and outdoor areas. Of these campuses, 2044 are also tobacco-free, which prohibit smoking and smokeless tobacco product use in all indoor and outdoor areas [ 1 ]. The adoption of tobacco-free campus policies have been associated with: reductions in tobacco use, secondhand smoke exposure, and litter from tobacco products (“Tobacco-Free Policies” [ 3 ], as well as improvements in cardiovascular health and respiratory symptoms among non-smokers [ 4 ]), less cigarette use and increased successful quit attempts among smokers [ 5 ], and overall reductions in negative long-term health effects of tobacco use among students [ 6 ].

Despite the potential benefits, some policies may not be effective if there is not a clear understanding of institutional culture related to tobacco use prior to and through the implementation process. An important population of interest in determining the culture within institutions are young adults (aged 18 to 25 years), who constitute the majority of college-aged students, are the youngest legal targets of the tobacco industry [ 7 ], and are vulnerable to peer influence and perceived social norms [ 8 ], shaped in part by tobacco company presence on campus. Tobacco companies often attempt to integrate tobacco use into college activities, including promotions at bars and retail outlets around campus and presence at campus social events targeted towards young adults [ 7 , 9 , 10 ]. Colleges and universities where tobacco use is seen as highly prevalent and socially normative may experience opposition by students and discourage college administration from adopting tobacco-free policies [ 11 , 12 ].

Thus, understanding students’ attitudes towards tobacco policies can be useful for identifying implementation and enforcement stages of a tobacco-free campus policy, as well as informing strategies that ensure success [ 13 ]. Initiatives that allow students to voice their opinions can help administrators create a “comprehensive rationale” to remedy student opposition and communicate about tobacco-free policies in a more effective way [ 14 , 15 ]. Remedying student opposition is important for the adoption process, as student support for tobacco-free campus policies is a predictor of compliance [ 16 ]. Determining factors that influence support for tobacco-free policies can be used to help inform education and outreach strategies for the successful implementation of a tobacco-free campus policy [ 17 ].

The goal of this study was to better understand students’ attitudes towards tobacco use and the implementation of a tobacco-free campus policy. First, qualitative research was conducted using interviews and focus groups. Then, a campus-wide survey of students examined tobacco use, and attitudes towards smoking, peer tobacco use, and tobacco-free campus policies. Binomial logistic regression models were used to predict support for tobacco-free campus policies, differentiating between support for policies that reduce addiction risk and ensure smoke-free air. Themes from interviews and focus groups were used to contextualize findings.

Overall Study Design and Rationale

A mixed methods approach, inclusive of qualitative interviews, focus groups, and a survey, was used to identify and understand student attitudes towards tobacco-free campus policies. Given that quantitative and qualitative methods have different biases and weaknesses, a mixed methodology allows for a stronger design by offsetting the weaknesses of each individual method. After data were collected and analyzed from each method, interpretations were made from the data using a convergent, parallel process.

Participant Eligibility and Consent Processes

Participants were students enrolled at Virginia Commonwealth University (VCU), a diverse, urban, public research university located in the central region of Virginia. To be eligible, students had to be currently enrolled at VCU and 18 years of age or older. The research methods and procedures were approved by the VCU Institutional Review Board as exempt, and participants were not required to provide consent.

Procedures and Measures

Qualitative interviews.

Second-year graduate students from the VCU Brandcenter, trained in qualitative interviewing methodologies, conducted “man-on-the-street” interviews on campus. These interviews yielded raw, unscripted reactions to smoking and vaping on campus and a proposed tobacco-free campus policy prohibiting the use of all tobacco products, including the use of electronic nicotine products such as electronic cigarettes (e-cigarettes). Interviews lasted less than 10 min and occurred during the day, in efforts to interview students traveling between classes. Interviews were conducted in February 2019.

Focus Groups

Participants for focus groups were recruited via word-of-mouth, e-mail list serves, and posted flyers. Focus groups were conducted in private rooms of a library on campus. Participants received a catered meal for their time and participation. Each focus group lasted between 60 and 75 min and was facilitated by a second-year graduate student from the VCU Brandcenter and at least one other member of the research team (e.g. a research assistant and/or a faculty member to assist with notetaking). A semi-structured, focus group discussion guide was developed prior to conducting focus groups. Within each focus group, participants were asked to comment on their smoking habits and history (e.g. “how often do you use tobacco products?”, “what forms of tobacco do you use?”, “where do you normally use tobacco products?”), perceptions of smoking and vaping on and off campus (e.g. “are there specific locations where smoking should be allowed?”, “is it okay to vape both indoors and outdoors?”, “do you feel that you should ask permission to [smoke or vape] in certain locations?”), and strategies for implementing and enforcing tobacco-free campus policy policies (e.g. “do you think that implementing a tobacco-free policy at this university could be successful—why or why not?”, “how would a tobacco-free policy affect your on-campus experience?”, “what do you think would be a fair way to enforce tobacco-free policies on campus?”). Focus groups were conducted in February 2019.

Quantitative Survey

Due to e-mail privacy policies at the university, researchers on this project were not allowed access to student e-mail addresses. Instead, the study team contracted with The Survey and Evaluation Research Laboratory in the Center for Public Policy of the L. Douglas Wilder School of Government and Public Affairs at VCU to distribute the survey via email. A disproportionate stratified random sampling design was used to select a subset of students that were representative of the VCU student population. No e-mail addresses or other personally identifying information were shared with the research group, though demographic information was collected within the survey (e.g. age, year in college, gender, and race/ethnicity). A total of 3920 survey invitations were sent to current students aged 18 years or older in March 2019. The response rate was 16.2%, equivalent to 636 responses.

Self-Reported Tobacco Use

Students were asked if they had ever tried any tobacco product. Those who had tried any tobacco product were also asked if they had ever tried cigarettes, and if so, whether they now smoke every day, some days, or not at all. Respondents who smoked every day or some days were asked on how many days during the past 30 they had smoked cigarettes. Those who smoked one or more cigarettes in the past 30 days were classified as “current smokers.” Those who had ever tried any tobacco product were also asked how many days during the past 30 they had used electronic nicotine products. Those who used electronic nicotine products on one or more of the past 30 days were classified as “current vapers.” This method for assessing tobacco is consistent with large-scale studies of young adult populations [ 18 – 21 ].

Peer Tobacco Use

Students were asked, “How many of your friends smoke cigarettes?” with possible responses: “None,” “A few,” “Most of them,” or “All of them.” Students similarly indicated how many of their friends vape [ 22 ]. Responses were dichotomized (No = none, Yes = a few/most of them/all of them).

Perceptions of Friends’ Disapproval of Smoking

Students were asked, “How much would your friends try and stop you from smoking cigarettes?” and “How much would your friends try and stop you from vaping?” Respondents answered using a four-point Likert scale including “Not at all,” “Not much,” “Some,” and “A lot” [ 22 ]. Responses were dichotomized (No = not at all/not much, Yes = some/a lot).

Disapproval of Peer Smoking

Students were asked, “How much would you try to stop your friends from smoking cigarettes?” and “How much would you try to stop your friends from vaping?” Respondents answered using a four-point Likert scale including: “Not at all,” “Not much,” “Some,” and “A lot.” Responses were dichotomized (No = not at all/not much, Yes = some/a lot).

Opinion on the Best Tobacco-Policy for Campus

Students were asked which tobacco policy would be best for campus. Policy options were “Prohibit use indoors and outdoors at all times,” “Prohibit use indoors; Allow use outdoors in specific locations only,” “Prohibit use indoors; Allow use outdoors everywhere,” and “Allow use indoors and outdoors everywhere.” Respondents chose separate policies for cigarettes and e-cigarettes. Responses were coded into three categories: prohibition policy, designated smoking area policy, and other policy. These measures were obtained from the Georgia Tobacco-Free Colleges and Universities Toolkit [ 23 ].

Support for Tobacco-Free Campus Policies

Students indicated their agreement with two statements: “Colleges have a responsibility to reduce the risk of tobacco addiction by adopting policies that discourage tobacco product use” and “Colleges have a responsibility to adopt policies that ensure people have smoke-free air to breathe.” Respondents answered using a five-point Likert scale including “Strongly agree,” “Somewhat agree, “Neutral,” “Somewhat disagree,” and “Strongly disagree.” Responses were dichotomized (Don’t agree = neutral/somewhat disagree/strongly disagree, Agree = somewhat agree/strongly agree). These measures were obtained from the Georgia Tobacco-Free Colleges and Universities Toolkit [ 23 ].

Data Analysis

Qualitative data analysis.

Feedback from qualitative interviews was summarized into main points by graduate students from the VCU Brand-center. Focus groups were audio-recorded using digital voice recorders and transcribed into a text file by two public health graduate students (BB and BR). Transcripts were read multiple times and checked for accuracy against audio recordings by research assistants and a research faculty member. Transcripts were independently coded by research members (EKD, WLF, BB, KFL and BR) and inductive codes were generated from the data through an iterative coding process. Independently coded transcripts were reviewed for concordance by the entire team, who resolved any coding discrepancies and reached final consensus. Data management and analysis were supported by ATLAS.ti 7 (ATLAS.ti Scientific Software Development GmbH, Berlin) [ 24 ]. Data analysis and interpretation were conducted using constant comparison and thematic summarization.

Quantitative Data Analysis

Descriptive statistics are reported as frequency counts and percentages. Binomial logistic regression was used to predict support for tobacco-free campus policies. Analyses were conducted using SAS 9.4 (SAS Institute; Cary, NC).

Twenty-one man-on-the-street interviews were completed. Interviews included nine non-smokers, six smokers, and six smokers/vapers. Generally, campus tobacco use was not a pressing issue for students. Non-smokers felt unaffected, while tobacco users stated they would continue to smoke or vape on a tobacco-free campus. The majority of smokers expressed a desire to quit, and some considered e-cigarettes to be a cessation tool. E-cigarettes were perceived to be less harmful than cigarettes, and e-cigarette aerosol less bothersome than cigarette smoke.

Participant Characteristics

Nine students were interviewed across two focus groups. The first focus group had five students: four smokers and one non-smoker, of which three were graduate students and two were undergraduates. The second focus group had four students: all non-smokers and undergraduates.

Major Themes Identified

The focus group discussion guide explored participant’s tobacco use, attitudes towards tobacco use, attitudes towards a tobacco-free campus policy, and suggestions for adopting and implementing a tobacco-free campus policy. The goal was to understand the contextual factors influencing attitudes towards the implementation of a tobacco-free campus policy. Major themes are highlighted, with sample quotations provided to illustrate themes.

Theme 1: Tobacco Use is More Likely in Certain Times and Settings

Participants indicated they were more likely to use tobacco products when they were on their own, “in the morning,” “around meal times,” and “before or after class.” Tobacco use often occurred as a reaction to feelings of sadness, boredom, or impulsiveness. Students reported smoking more often around peers that smoke, at parties, and at bars. Some smokers limited their tobacco use around family members to avoid disapproval. Graduate student smokers reported reductions of their tobacco use, compared to their undergraduate years, due to the perception that they should “know better.”

Theme 2: The Locations Where Smoking and Vaping are Socially Acceptable are Different

Smoking was acceptable outdoors, including on campus, because “the great outdoors belong to everyone” and bystanders have the option to “move away.” Smoking was also acceptable in private indoor spaces with the permission of the host, and in certain public indoor spaces, such as bars. Vaping indoors was more acceptable than smoking indoors, and was reported inside campus buildings, such as dorms and the library. E-cigarette vapor was more acceptable indoors because it did not have “an offensive smell” and was perceived to be less harmful than cigarette smoke.

Theme 3: Using Tobacco Products is a Personal Choice

Across both focus groups, tobacco use was described as a personal choice. Smokers described their choice to use tobacco within the context of personal rights (“it’s my body”), addiction (“can’t just have one cigarette”), and indifference to health risks (“you only live once”). Students were not comfortable infringing on freedom of personal choice (by telling others to stop) or with policies that limit personal freedom.

Theme 4: A Tobacco-Free Campus Policy May Not Curb Tobacco Use on Campus by Itself

Participants were skeptical that a tobacco-free policy would reduce tobacco use on campus. Reasons included unclear campus boundaries, nearby tobacco retail outlets, and the university’s inability to enforce such a policy on a sprawling, urban campus. Smokers indicated they would continue to smoke on campus under a tobacco-free campus policy. One participant noted, “Nothing is going to stop me from smoking a cigarette.” Reasons for non-compliance included the inconvenience of leaving campus (“I am not going to walk four blocks just to smoke off campus”) and the university’s inability to enforce such a policy (“I would just walk away. They are not going to chase after people”).

Theme 5: Tobacco-Free Campus Policy Awareness Campaigns and Messages Should Focus on Health Benefits, and Not be Punitive for Those Who Use Tobacco

Focus groups agreed that students should be educated on any new policy, with a focus on the health benefits of a tobacco-free campus. Communication about the policy should be “positive” and “optimistic” with a focus on themes such as “clean air” and “health.” Students felt that cessation services should be publicized, but not in a way that stigmatized smokers. Ticketing violators was a contentious issue: smokers expressed they could avoid being caught, and non-smokers did not approve of tickets.

As shown in Table 1 , 62.9% were ages 18–22 and 26.8% were ages 23–29. Most were undergraduates (77.7%), female (67.2%), and White (61.9%).

Survey participant characteristics and results

Tobacco Use

Of the sample, 9.2% and 20.6% were smokers and vapers, respectively. Regarding peer tobacco use, 59.5% had at least one friend who smoked cigarettes and 73.3% had at least one friend who used e-cigarettes.

Tobacco Attitudes

Regarding disapproval of peer smoking, 78.7% and 60.4% indicated that they would try to stop their friends from smoking cigarettes or vaping, respectively. Similarly, 68.4% and 46.5% have friends who would try to stop them from smoking cigarettes or vaping.

Opinion on the Best Tobacco Policy for Campus

Students reported the best tobacco policy for their campus would limit tobacco use: 28.0% selected a “prohibition policy” for cigarettes and 56.3% a “designated smoking area policy,” while 21.2% selected a “prohibition policy” for e-cigarettes and 44.4% a “designated smoking area policy.”

The majority supported tobacco-free policies on college campuses: 62.4% agreed “Colleges have a responsibility to reduce the risk of tobacco addiction by adopting policies that discourage tobacco product use,” and 81.5% agreed “Colleges have a responsibility to adopt policies that ensure people have smoke-free air to breathe.”

Factors Associated with Support for Tobacco-Free Policies

Academic year, gender, and race/ethnicity were significant factors influencing support for tobacco-free campus policies, as shown under Model 1 on Table 2 . Graduate students were more likely than freshman to support policies that reduce addiction risk (OR = 2.0, 95% CI 1.1, 3.6) and policies that ensure smoke-free air (OR = 2.8, 95% CI 1.3, 6.3). Females were more likely than males to support policies that reduce addiction risk (OR = 1.6, 95% CI 1.1, 2.4). Compared to White students, Asian (OR = 2.6, 95% CI 1.0, 6.3) and Black/African American (OR = 3.1, 95% CI 1.3, 7.7) students were more likely to support policies that ensure smoke-free air, and Asian students were also more likely to support polices that reduce addiction risk (OR = 2.1, 95% CI 1.1, 3.9). These factors became non-significant after adjusting for tobacco use, as shown under Model 2 on Table 2 . Smokers and vapers, as defined by past 30-day use, were both less likely than non-smokers and non-vapers to support tobacco-free policies that reduce addiction risk (OR = 0.3, 95% CI 0.1, 0.7 for smokers; OR = 0.3, 95% CI 0.1, 0.6 for vapers), but not policies that ensure smoke-free air. After controlling for tobacco attitudes, as shown under Model 3 on Table 2 , vapers were less likely than non-vapers to support tobacco-free campus policies that reduce addiction risk (OR = 0.2, 95% CI 0.1, 0.7). Students that would try to stop their friends from smoking were more likely to support policies that ensure smoke-free air (OR = 4.2, 95% CI 1.1, 15.9).

Predictors of support for tobacco-free campus policies

Bold values are statistically significant ( p ≤ 0.05)

The purpose of this study was to provide an assessment of student attitudes towards tobacco use and tobacco-free policies on campus, using a mixed methods approach. Through this research, we identified factors influencing support for tobacco-free campus policies (e.g. gender, race/ethnicity, year in school, current use, and attitudes towards smoking and vaping). Students provided insight into potential challenges/barriers to the implementation and enforcement stages of a tobacco-free campus policy, and suggestions for how to best frame messaging and communication for the implementation of a tobacco-free campus policy. Results highlight the importance of incorporating student perspectives into planning for the implementation of a tobacco-free campus policy.

Recent studies suggest that most students support tobacco-free campus policies [ 1 , 25 – 27 ]. Similarly, our results demonstrate that a majority of students support tobacco-free policies that “ensure smoke-free air to breathe” (81.5%) and “reduce the risk of tobacco addiction” (62.4%). While the majority of students support tobacco-free policies, when asked to choose the best policy for the campus, 56.3% selected a policy that allows for “designated smoking areas.” The finding that students generally support both tobacco-free campus policies and designated smoking areas, which run counter to a comprehensive tobacco-free campus policy, appears to reflect the attitudes held by focus group participants that tobacco use is a personal choice, and to interfere with this choice would impede the personal freedoms of smokers.

Previous studies have found that student opposition to tobacco-free campus policies is associated with the perception that tobacco-free policies violate smoker’s rights [ 15 , 17 , 28 ]. Added to this, non-smokers may be disinclined to infringe on the perceived rights of smokers [ 15 , 28 ]. Both smokers and non-smokers within our focus groups agreed that smokers have a right to choose when and where to smoke in most environments. In this context, smokers have a right to smoke on campus because, according to students, it is a shared and public space, and having designated smoking areas helps preserve the rights of tobacco users. However, to better understand the student preference for designated smoking areas, despite personal support for tobacco-free campus policies, further research is needed.

From our research, support for tobacco-free campus policies differ according to demographic characteristics. Female students were significantly more likely than male students, and Asian students were significantly more likely than White students, to agree with tobacco-free policies that reduce addiction risk. Black and Asian students were significantly more likely than White students to agree with tobacco-free policies that ensure smoke-free air. Similar findings are found in the existing literature, which demonstrates that a majority of students support smoke-free campus policies [ 25 ], and that female students are more likely than male students [ 29 ], and Asian, Black and Hispanic students are more likely than White students, to support tobacco-free campus policies [ 17 , 30 ].

Support for tobacco-free campus policies also differs by academic year. In focus groups, graduate smokers expressed that they were expected to “know better” than to smoke, while undergraduate smokers could “blend into a crowd.” From survey data, graduate students were more likely than undergraduates to agree with tobacco-free campus policies that reduce the risk of addiction and ensure smoke-free air to breathe, which aligns with the demonstrated association between non-compliance with tobacco-free campus policies and age [ 16 ]. In part, these associations may be influenced by tobacco industry marketing that specifically targets new college students [ 9 ] and the increase of e-cigarette use by adolescents and young adults [ 20 ]. However, further research is needed.

Attitudes towards tobacco-free campus policies are also influenced by current use of tobacco products. Previous studies have reported significantly higher levels of support for smoke-free campus policies among non-smokers and never-smokers [ 17 , 25 ], and significantly lower levels of support among former smokers and current smokers [ 17 , 29 , 31 ]. This is consistent with our second model, where current smokers had significantly lower levels of support for tobacco-free campus policies that reduce the risk of addiction. However, in final regression models, smokers and vapers were not less likely than non-smokers and vapers to agree with such policies. This aligns with previous studies, where most students, including tobacco users, believe college campuses should be smoke-free environments [ 12 , 17 ]. Smokers in our focus groups contextualized this belief by emphasizing “respect for others,” especially in “public spaces” and “private property.” Therefore, one way to “counter-frame” arguments against tobacco-free campus policies is to emphasize the rights of non-smokers to smoke-free air [ 15 ].

The prevalence of e-cigarettes may have important implications for effective communication around tobacco-free campus policies—especially those that emphasize smoke-free air. Mirroring national trends among college students (ACHA [ 32 ], e-cigarette use was more prevalent than cigarette use in our sample, with one in five students vaping in the last 30 days. Within focus groups, students reported an increased prevalence of vaping in dorm rooms and the library. In the final models controlling for individual and peer attitudes towards smoking and vaping, students who vape were less likely to support tobacco-free campus policies that reduce “the risk of addiction.” One explanation is that students who vape did not equate e-cigarette vapor with smoke and did not perceive policies that promote smoke-free air as a threat to their ability to vape on campus [ 29 ]. Another explanation is that students who vape did not feel e-cigarette addiction can be curtailed by a campus smoking policy. As one student explained, “I am addicted to nicotine. A regulation is not going to change or alter that.” While there have been many interventions to reduce smoking on college campuses [ 33 , 34 ], e-cigarettes are a newer product and there may be less knowledge about e-cigarette cessation services. This is consistent with our focus groups, where students were unaware of campus cessation services in general. Finally, for some students, vaping was considered a healthier alternative to cigarettes, and even a cessation tool: “Smoked for a while, trying to quit smoking. Hence, the vape.” This sentiment is consistent with previous studies [ 35 , 36 ], suggesting that communication about tobacco-free policies should specifically address e-cigarettes and e-cigarette cessation services.

Study Limitations and Strengths

Results from this study have to be considered within the context of certain limitations. Formative research was conducted in small groups, potentially limiting generalizability to other populations. However, inferences were consistent between interviews, focus groups, and survey data. Additionally, due to the requirement of retaining participants’ anonymity by the IRB, data from interviews and focus groups cannot be directly linked to surveys, which were disseminated through an email campaign. As a result of this limitation, information on non-respondents could not be assessed. Additionally, because findings are pulled from a diverse, urban, four-year public institution that is located in a state with one of the nation’s highest tobacco-producing rates, the results of this study might not generalize to other universities with different student populations.

Despite these study limitations, this study provides insight into student perspectives related to what factors influence support for tobacco-free policies and how best to implement these policies on campus. Given that the primary method of examining student attitudes towards tobacco-free campus policies has been through campus surveys [ 25 , 33 ], our study contributes to the existing literature by incorporating a mixed-methods design, inclusive of qualitative interviews and focus groups to inform survey data.

Future Research Directions

Results from interviews, focus groups, and surveys were shared with university administration in the form of a report. On July 1, 2019, VCU implemented a tobacco policy prohibiting the use of all tobacco products (including cigarettes, cigars, smokeless tobacco, hookah, and e-cigarettes) outside of designated smoking areas [ 37 ]. Future research will focus on student perspectives related to the effectiveness of the adopted tobacco-free policy in reducing secondhand smoke exposure and tobacco use on campus. Follow-up studies could investigate the rate of compliance with the policy and the effectiveness of how it is being implemented and enforced. Potential methodologies include an analysis of campus newspapers [ 27 ] and geospatial analysis of reported tobacco use [ 38 ].

Student support for tobacco-free policies differed depending on the student’s academic year, use of tobacco or e-cigarettes, peer tobacco use, and attitudes towards smoking and vaping. In general, students were more likely to support tobacco-free campus policies that ensure smoke-free air to breathe, as opposed to tobacco-free campus policies that reduce the risk of addiction. Students felt that adopting a tobacco-free policy is unlikely to influence individual tobacco use behaviors, due to challenges involved with policy enforcement within an urban campus setting and existing social norms regarding the acceptability of smoking and vaping. However, students provided information on how best to implement tobacco-free policies university campuses. Students emphasized focusing messages on the potential health benefits of implementing a tobacco-free policy to de-normalize smoking and vaping on campus.

Acknowledgements

The authors would like to thank all of the students who participated in this research, as well as the student volunteers from the VCU Brandcenter (Evanne Allen, Miguel Atkins, Mykala Daniel, Nanda Golden, Anna Kim, Chorong Kim, Hadley Mathews, and Beka Tesfaye) for their assistance with conducting the man-onthe-street interviews and focus groups, Dr. Caley Cantrell, who helped to identify student volunteers to help us with this project, Lisa Joyner, the Director of the Wellness Resource Center at VCU, who helped us to identify participants for the focus groups, and Jason Burkett from the Survey Evaluation and Research Laboratory of the L. Wilder School at VCU, who assisted with collecting the survey data for this research project. The authors would also like to thank Erica Sheldon Heath, Amy Nyman, Amelia Jazwa, and Saiza Jivani from the Georgia State University School of Public Health, who assisted with survey measure design, and Bidisha Sinha from ACS-TFGCI for her assistance in coordinating efforts.

Funding This research was funded with a grant awarded to the research group by the American Cancer Society’s (ACS) Tobacco Free Generation Campus Initiative (TFGCI), supported by the CVS Health Foundation. Additional support for this research was provided by funding from NIH-NCI Cancer Center Support Grant P30 CA016059. Study data were collected and managed using REDCap electronic data capture tools hosted at Virginia Commonwealth University (Award Number UL1TR000058).

Conflict of interest The authors declare that they have no conflict of interest.

Research Involving Human Participants All procedures performed involving human participants were in accordance with the ethical standards of the institutional research board at Virginia Commonwealth University. This study was approved as exempt.

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Up, Up and Not OK: Letting Go of Balloons Could Soon Be Illegal in Florida

In an effort to curb microplastics and marine pollution, state lawmakers voted to ban intentional releases.

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By Cara Buckley

Balloons released in the sky don’t go to heaven. They often end up in oceans and waterways, where they’re 32 times more likely to kill seabirds than other types of plastic debris. Despite this, humans like to release them en masse, be it to celebrate a loved one’s life or a wedding, or to reveal the gender of a baby.

The practice is on the verge of becoming illegal in Florida, where the legislature has joined a growing number of states to ban the intentional release of balloons outdoors. The Florida ban is expected to be signed by Gov. Ron DeSantis and would take effect July 1.

Florida is at the forefront of a dizzying and contentious array of statewide bans, outlawing lab grown meat , certain books from school libraries and classrooms, and most abortions after six weeks . But the balloon ban is rare for garnering widespread bipartisan support. It was championed by environmentalists and sponsored by two Republican lawmakers from the Tampa Bay area, Linda Chaney, a state representative and Nick DiCeglie, a state senator.

“Balloons contribute to the increase in microplastic pollution which is harmful to every living thing including humans, polluting our air and drinking water,” Ms. Chaney wrote in an email.

“My hope is that this bill changes the culture, making people more aware of litter in general, including balloons,” she said.

Ms. Chaney said she first heard about the perils of balloon debris in 2020. Aquatic animals often mistake balloons for jellyfish and feel full after eating them, essentially starving from the inside out. Ribbons affixed to balloons entangle turtles and manatees. Balloons also pose a threat to land animals. In her research, Ms. Chaney learned about a pregnant cow that died after ingesting a balloon while grazing. The unborn calf died too.

The bill closes a loophole in an existing Florida law that allowed for the outdoor release of up to nine balloons per person in any 24-hour period, a provision that critics say didn’t achieve the goal of reducing marine trash.

The new legislation makes it clear that balloons can pose an environmental hazard, supporters say. It equates intentionally releasing a balloon filled with a gas lighter than air with littering, a noncriminal offense that carries a fine of $150. The ban also applies to outdoor releases of any balloons described by manufacturers as biodegradable.

The ban does not restrict the sale of balloons by party suppliers or manufacturers; they could still be used indoors or as decorations outdoors if properly secured.

Balloons released by a government agency or for government sanctioned scientific purposes would be exempt from the new law. Hot air balloons recovered after launch or balloons released by children aged 6 and younger would also be exempt.

The bill counts among its supporters the Florida Retail Association as well as the Coalition for Responsible Celebration, a trade association for balloon distributors and party stores, which in a statement said it recognized “the importance of promoting responsible balloon usage and ensuring safe access to these joy-inspiring products.”

The legislation marks a win for environmentalists hamstrung by Florida legislation known as the “ban on bans,” which prohibits counties and local municipalities from regulating single use plastics and plastic bags.

Jon Paul “J. P.” Brooker, director of Florida conservation for the nonprofit group Ocean Conservancy, said that increased concern about the health of beaches, a major driver of tourism, helped conservationists and lawmakers find common ground.

“Florida is its beaches,” Mr. Brooker said, “People are not going to flock by millions to them if they’re trashed and there’s dead animals and plastic and trash all over.”

Mr. Brooker said while it remains to be seen how vigorously police will enforce the ban, the fact that they will be able to issue tickets was a good thing. “More than anything,” he added,” it gives us in the environmental community an opportunity to educate the public as to why it’s bad.”

Public sentiment in Florida against balloon releases has been growing. Earlier this year, the city of Miami Beach adopted an ordinance banning party balloons from public marinas, marine facilities, parks and public beaches. This followed the arrest of two people in 2022 who were filmed popping balloons aboard a chartered yacht and letting the remnants fall into Biscayne Bay.

The balloon release ban follows another environmental win in the state. For more than 30 years, Mr. Brooker said cigarettes were the number one form of trash found on the state’s beaches. Then in 2022, the state passed a law allowing local governments to restrict cigarette smoking and vaping on public beaches and parks. More than 50 counties and municipalities, accounting for more than 500 miles of the state’s 1,350 miles of coastline, have since outlawed smoking and vaping on beaches, Mr. Brooker said.

“This isn’t just the bailiwick of progressives, and it’s certainly not something that draws the enmity of conservatives,” Mr. Brooker said. “It’s all Floridians banding together to protect Florida’s beaches that are the backbone of our economy and the underpinning of our cultural identity.”

According to Emma Haydocy, Florida policy manager for the Surfrider Foundation, seven other states have cracked down on outdoor balloon releases. And just last week, lawmakers in North Carolina filed their version of the Florida legislation.

In lieu of releasing balloons, conservationists are urging people to instead plant a tree or toss flower petals into the water.

“There are so many other ways of celebrating that are not detrimental,” Ms. Haydocy said.

Cara Buckley is a reporter on the climate team at The Times who focuses on people working toward climate solutions. More about Cara Buckley

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