Symptoms of Nicotine Dependence and Other Predictors of Student Smoking at School: Implications for School Smoking Policy zyx Elpidoforos S. Soteriades, Joseph zyxwvu R. DiFranza, Judith A. Savageau, Michael Nicolaou ABSTRACT: zyxwvutsrqponm Students who violate school smoking policies present a difficult health and ~1i.scipIinary issue for school ojficials. Professionals know little about the characteristics zyxwvutsrq of students who smoke at school. zyxwvut In a prospective study of 679 students in two cities in central Massachusetts, researchers examined how nicotine dependence contributes to the problem of smoking at school. After three years ojjollow up, smoking at school was reported by 10.3% ofstudmts. Among subjects who admitted to smoking at school, 63% reported that symptoms of' nicotine dependence preceded their smoking at school. After adjusting for other variables, student smokers with symptoms of nicotine dependence were nine times more likely to report smoking in school (OR 9.1,95% CI 2.9 - 28.5) than were student smokers without symptoms. Smoking at school was more common among daily smokers and those who paid for their own cigarettes. Age, gender, race, and parental smoking status were not signijicantly associated wiith students' reports of smoking at school. These data suggest nicotine dependence as an important contributor to the problem of smoking at school, but not the only reason why students violate school smoking policies. Disciplinary action against students caught violating school smoking policies should he supplemented zyxwvutsrq with an offer Sf treatmenr.fhr nicotine dependence. zyxwvut (J zyxwvutsrqpo Sch Health. 2003;73(4): 154-158) ith 3 I % of high school seniors reporting tobacco use W within the previous 30 days, adolescent smoking represents a serious problem.' Since four of five persons who use tobacco begin smoking before they reach adult- hood, tobacco prevention and cessation efforts have focused on school-aged children and adolescents.* Several studies indicate that tough enforcement of school smoking policies discourages youth from smoking.'-'" A perennial problem facing school staff involves how to enforce school smoking policies. Students who smoke at school jeopardize not only their health, but the health of others through envi- ronmental tobacco smoke and role modeling of a harmful behavior. Several agencies, including the Centers for Disease Control and Prevention and the National School Boards Association, published guidelines regarding school-based programs and policies to prevent tobacco use.6 I' Policies banning smoking at school or on school property are wide- spread,l* l4 but how to best deal with infractions remains uncertain.'s.lb Should violations be treated as a simple disci- plinary action," or should medical treatment for addiction be rendered?','**" Is smoking at school an expression of defiance, or a need to satisfy the urges of addiction? This study examined the relationship between symptoms of nicotine dependence and student smoking at school, and Elpidoforos S. Soteriades, MD, MSc, Doctoral Student, Harvard School of Public Health, Dept. of Environmental Health, 665 Huntington Ave., Boston, MA 021 zyxwvutsrqpo 15; (.sros56@aol.com); Joseph R. DiFranza, MD. Professor, Dept. of' Family Medicine and Community Health, University of' Mussuchusetis Medical Centcr, 55 Lake Ave., Worcester, MA 01655; (DiFranzJ@ummhc.org);Judith A. Savageau, MPH, Biostatisticinn, Dept. of Fanzily Medicine and Community Health, University of Massac~husetts Medical Center, 55 Lake Ave., Worcester, MA 01655; (.ludith.Savageau~uniassmed.edu); and Michael Nicolaou, MD, PhD, Resident in Surgery, Henry Ford Hospital. Dept. zyxwvutsr of Surgery, K8, 2799 West Grand Blvd., Detroit, MI 48202; (michalisn@ureach.com). This study was funded by grant number CA77067-03,from the National Canwi- Institute. The opinions expressed in this paper are those ojthe authors and do not necessarily represent the ojficial views of the National Cancet- Institute. Additional funding was provided by an educational grant (#03496) from the Robert Wood Johnson Foundation and the Massachusetts Dept. of Public Health (Health Protection Fund). This arti- cle was submitted July 26,2002, and revised and accepted for publication Januury 13,2003. explored personal and social characteristics of students who smoke at school. METHODS To study onset of the first symptoms of nicotine depen- dence in adolescents, a cohort of seventh-grade students was enrolled in a three-year longitudinal study.*' The study was conducted in two small industrial cities in central Massachusetts with populations of 38,000 and 41,000 in 1990, and per capita income below the state average. The following factors contributed to selection of these cities: their large and ethnically diverse student bodies, coopera- tion of school administrators, and smoking rates compara- ble to the national average. All schools in these communities had policies which prohibited use of all tobacco products on school property. There were 900 seventh-grade students in the seven public schools in these two cities when the study began in January 1998. With approval of the institutional review board, parents of all seventh graders were given the opportunity to withdraw their child from participating. Subjects A cohort of 679 seventh-grade students, with parental consent to participate, were enrolled in the longitudinal study starting in January 1998. They were interviewed indi- vidually at school, three times each year, over a period of three years. Considerations of statistical power and antici- pated attrition indicated a need for an initial sample size of 650. Random number assignments were used to recruit subjects. However, the initial 6-50 interviews were completed ahead of schedule allowing the sample size to be expanded. Subjects were told the study was confidential and concerned tobacco. Reports of tobacco use prior to initiation of the study did not preclude students from participating. The sample was 51% male, with a mean initial age of 13.1 years (range 12-15). Students identified themselves as follows: 68% non-Hispanic White; 20% Hispanic; -5% Asian; 4% Black; 0.6% Native American; and 2.5% Unspecified. Students who reported use of any tobacco product prior to initiation of the study were classified as student smokers. 154 Journal of School Health April 2003, Vol. 73, No. 4