Albert-L˝orincz Eniko , Edit Paulik , Bela Szabo , Kristie Foley , Andrea Ildiko Gasparik three counties in Romania Adolescent smoking and the social capital of local communitiesin

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Original article

Adolescent smoking and the social capital of local communities in three counties in Romania

Eniko Albert-L ˝orincz

^a

, Edit Paulik

^b

, Bela Szabo

^a

, Kristie Foley

^c

, Andrea Ildiko Gasparik

^d,^∗

aUniversityBabes-Bolyai,FacultyofSociologyandSocialWork,Cluj,Romania

bUniversityofSzeged,DepartmentofPublicHealth,Szeged,Hungary

cWakeForestUniversitySchoolofMedicine,DivisionofPublicHealthSciences,NorthCarolina,USA

dUniversityofMedicineandPharmacy,Tirgu,Mures,,Romania

a r t i c l e i n f o

Articlehistory:

Received26January2018 Accepted7May2018 Availableonline11August2018

Keywords:

Smoking Adolescent Socialcapital Community

a b s t r a c t

Objective:Toidentifytheeffectofsocialcapitalonadolescentsmoking.

Method:Astratifiedrandomsampleof13137thand8thgradestudentsfromthreecountiesinTransyl- vania,Romania,completedaself-administeredquestionnaireonsmoking-relatedknowledge,attitudes andbehaviours.Theimpactofsocialcapitalwasmeasured(personalandcommunityactivities,school achievementsandsmoking-relatedknowledge).Multivariatemultinomiallogisticregressionmodels wereusedtomeasuretheassociationbetweensocialparticipationandsmoking.

Results:Experimentingwithsmokingwasmostlyrelatedtoknowledgeaboutsmoking,academicperfor- manceandsecond-handtobaccosmokeexposureathome.Thestrongestriskfactorofadolescentsmoking wasthesmokingbehaviourofclassmates:thosewhoreportedasignificantproportionofsmokersamong theirclassmateswereninetimesmorelikelytosmokethemselvesthaninothercases(adjustedodds ratio[aOR]:9.05).Thosewhoconsideredsmokingtobeharmlesswere4timesmorelikelytobesmokers thanthosewhoconsideredthisbehaviourtobedangerous(aOR:4.28).Pooracademicresultsincreased adolescents’smoking(aOR:3.22and2.66).Theoddsweresignificantlyhigherforsmoking,iftheyhad anactivesociallife(aOR:2.54).Regularchurchattendanceprovedtobeaprotectivefactor(aOR:0.45).

Conclusions:Severalsocialcapitalfactorscanplayaroleinadolescentsmoking.Theorganizationand thedevelopmentofcommunityactivitiesaimedatpreventionmuststrengthenthefactorsrelatedtothe community’ssocialcapitaltoreducethelikelihoodofteenagesmoking.

Elconsumodetabacoenadolescentesyelcapitalsocialdelascomunidades socialesentrescondadosdeRumania

Palabrasclave:

Fumar Adolescente Capitalsocial Comunidad

re s um e n

Objetivo:Evaluarelefectodelcapitalsocialsobreelconsumodetabacoenadolescentes.

Método:Elestudioserealizóenungrupoaleatorizadoyestratificadocompuestopor1313estudiantes deséptimoyoctavogradodetresmunicipiosenTransilvania(Rumanía).Losparticipantescontestaron uncuestionarioautocumplimentadoenrelaciónconelconsumodetabacoysobreactitudesycom- portamientosrespectoaeste.Elimpactodelcapitalsocial,entendidocomoactividadespersonalesy comunitarias,asícomoeldesarrolloacadémicoylainformaciónsobreelconsumodetabaco,fueron algunasdelasmedidas.

Resultados:Experimentarconelhábitodefumarserelacionaprincipalmenteconelconocimientosobre dichaadicción,elrendimientoacadémicoylaexposiciónalconsumodetabacoenelhogar.Elmayor riesgoparaelconsumosederivadelainteracciónconcompa˜nerosdeclasequeincurrenenelcon- sumodetabaco.Entalcaso,laprobabilidaddeconsumoaumentanueveveces(oddsratioajustada [ORa]:9,05).Quienesconsideraronquefumaresinofensivotuvieroncuatrovecesmásprobabilidades deserfumadoresquequienesconsideraronestecomportamientocomopeligroso(ORa:4,28).Encuanto alos/lasestudiantesconbajorendimientoacadémicoseobservaunmayorincrementodelconsumo (ORa:3,22y2,66).Almismotiempo,dichopatróntambiénseobservaentreaquellos/asconunentorno socialactivo(ORa:2,54).Laasistenciaalaiglesiademaneraregularesunfactorprotector(ORa:0,45).

∗ Correspondingauthor.

E-mailaddress:ildikogasparik@gmail.com(A.I.Gasparik).

https://doi.org/10.1016/j.gaceta.2018.05.009

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Conclusiones:Diferentesaspectosrelacionadosconelcapitalsocialseasocianalconsumodetabacoen adolescentes.Laorganizacióndeactividadesyeldesarrollocomunitariodeberántenerencuentaestos aspectosparaprevenirelconsumodetabaco.Hayqueprestarespecialatenciónalaclasesocialconelfin dereducirlasprobabilidadesdeconsumoenadolescentes.

Introduction

“Socialcapital”hasbeendefinedasthesumoftheresources, actualorvirtual,thataccruetoanindividualoragroupbyvirtue ofpossessingadurablenetworkofmoreorlessinstitutionalized relationshipsofmutualacquaintanceandrecognition.¹Othersnote thatsocial capitalis builtontrust, normsandnetworks, which enable self-affirmation and development.^2,3 Moreover, social capitalhasbeen seenas a sustainingresource for social action and a contributor to population health as interpersonal rela- tionshipsamongpeoplehave impactsonhealth.² Social capital acts through the relationship system that ensures pro-social motivation, through information channels, as well as obliga- tions/expectationsandnorms/sanctions.^4,5 Thisisan effectthat canbeacommunity-levelprotectivefactor;forexample,ifanado- lescentisconnectedtothecommunitythroughastrongnetwork ofcontacts,thenhe/sheinternalizesthecommunityexpectations, whichfosterspro-socialbehavior.

Adolescenceisa turbulenttimeofattitudinalandbehavioral development,often marked by the experimentationwith risky behaviorssuchastheuseoftobaccoproducts.InRomania,accord- ingtoasurveymadein2014,theadolescentsmokingisaprevalent behavior,andtheprevalenceofweeklysmokingincreasesbyage:

in13-year-olds6%ofgirlsand8%ofboys,whileforthe15-year-olds, 17%ofgirlsand20%ofboyssmoked.⁶

Thelocalcommunityisthenaturallivingspace,wherethesocio- culturalconditionsareidentical.Itisasocialstructurewherethe membersofthecommunityareinconsistentinteraction;theyhave mutualvalues,interests,experiencesandcommonexpectations.

Thefeelingofbelonging,cohesionaretheforcesthatresultinits membershavinganinfluenceoneachother.Althoughthelocal communitiesinthecountieswehavestudied,preservetraditions andretain deepcommunity values, thesenseofbelonging and cooperationamongresidentsseemstobeweakening.⁷

Wehavetriedtoevaluatehowtheadolescentscouldmakeuseof thesocialcapitaloflocalcommunitiesastheynavigatethetransi- tiontoadulthood.Morespecifically,whichofthevariablesofsocial capitalfactorsaremostrelatedtosmokingbehavior.

Theaimofourstudywastoidentifyandexploretherisksor protectivefactorsembeddedinthesocialcapitalconstruct,based onthethreedimensions:information,orientationandmodeling (Fig.1)asrelatedtotheadolescenttobaccouse.

We hypothesized that community activity, smoking among classmates,andschoolperformance(asamarkerformotivationfor performance)arevariableswithsignificantimpactonadolescent smoking.

Theconceptualframeworkofthestudy

Our study is built on the Bourdieu and Wacquant’s social capitaltheory,¹aswellasontheCulturalCapital,andCommunity Empowerment Frameworks and the Information-Motivation- BehavioralSkillsModel.^8–10Thelattermodeldescribeshowthe developmentofmotivation,informationandbehavioralskillsleads tochangesinbehavior.⁹WhileintheCulturalCapitalFramework model the individuals’ socio-cultural environment affects their

attitudes,values,andaspirations,¹⁰theCommunityEmpowerment Framework¹¹showstherecursiverelationshipbetweenthepolicy interventionandtheindividualbehavioringeneratingcommunity empowerment.Thesemodelsexplainhowinterventionsaimingat behaviorchangecanbeeffective.Ourstudydoesnotexaminethe effectivenessofanintervention,butitinvestigatestheimpactof theenvironmentwhereadolescentsliveandact,focusingonthe role of social participation and networks, among the various approachesofsocialcapital.

Webelievethatbehaviorchangemayalsooccurifproperbeha- viormodelsandvaluesarepresentinadolescents’livesandthey aremotivatedenoughtoembracethem.

Theframeworkofthestudywasdevelopedbasedonthepre- viously described models, but witha broaderinterpretation of concepts.Weproposethreemaindriversofsocialcapital(information,orientationandmodeling)whichshapetherelationship betweensocialcapitalandadolescentsmoking(Fig.1).

Information refers to the knowledge concerning a healthy lifestyle, which in case of anti-tobaccocommunication, can be acquired within the local community. Orientation is a much broader concept than the enhancement of motivation. It is related tothepersonality(identity,axiological orientation),the socio-cultural situation, (e.g. the family’s financial situation), the developmental stage of the settlement and the school. It indicatesthe involvement in the community life, and it facili- tatesthemodificationoftheadolescent’sbehavioralso,according to the pro-social norms. And finally, in addition to providing cues for pro-social behavior and skills, modeling also con- tributestoself-determinationanddevelopmentofinterpersonal skills.

Methods

Studydesignandsampling

A cross-sectional, questionnaire-based survey was adminis- teredtostudentsinthreeRomaniancounties(Mures,,Harghitaand Covasna)inMarch2014.Arandom,stratified,multistagesampling procedurewasemployed,basedonenrollmentrecordsfromthe county schoolinspectorates.First,36 stratawereformedbased onbackgroundvariablessuchascounty,settlementsize,teaching languageandgrade.

Intotal,studentsfrom36schoolsin26settlementsweresam- pled. Across the schools, 72 classrooms of 7th and 8th grade students(13-15years-old)weresampledyieldingatotalof1,313 respondents; 74 respondents were excludedfrom the analyses becauseofmissingdata.Morethanhalf(57%)studiedintheRoma- nianlanguageand43%intheHungarianlanguage.

Allproceduresperformedinthisstudywereinaccordancewith the1964DeclarationofHelsinkianditslateramendments.Wepre- viouslyobtainedwrittenpermissionfromschools’inspectorates, headmasters(schoolmanagement)andparentsforconductingthe survey.Allparentswereinformedaboutthepurpose,benefitsand risksofthestudy.Participationinthestudywasoptional.Asthe analysedunitwastheclassinallcases,alltheconsentingstudents, regardlessofgender,filledinthequestionnaire.

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E.Albert-L ˝orinczetal./GacSanit.2019;33(6):547–553

Empowerment outputs - Health culture - Values and healthy behavioral models - Positive experiences of life and community control

Empowerment outcomes - Improved health behavior - Less addiction to cigarette - More quitting cigarette

Drivers of social capital Outputs Outcomes

Information Orientation

Modeling

Figure1. Theimpactofsocialcapitalonadolescentsmoking—frameworkofstudy.

Measures

The self-administered questionnaire included both standar- dized questions from published sources, as well as questions developedbytheresearchteam.^12,13Afterthepilottest,theques- tionnairewascalibratedsothatallstudentscouldrespondtoall questionswithin anaveragecompletiontime of40-45minutes.

Thesurveycontained61questions,generating210variablesfor analysis.

Variables

Demographic variables included the gender and the age.

Students were classified into three groups according to their self-reportedsmokingstatus:neversmokers,experimentersand smokers. Experimenters were defined as those who had lit a cigaretteonlyonceintheirwholelife.

ThecomponentsofthemodelshowninFigure1weredescribed usingthefollowingvariables:

1)Information

Theknowledgeaboutsmoking wasmeasuredwithanindex consistingofthreequestions:howdangerousyouconsidersmok- ingtobe,how easy orhard do youfindquittingsmoking, and howharmfulissmokingingeneral.Meanresponsesweredivided intothefollowingcategories:lessthan3points,“smokingisharmless”;between3.0-3.9points,“smokingisratherdangerous”;and 4points,“smokingisverydangerous”.

2)Orientation

Schoolresults—aswellasvalueachievements,motivationfor performance—operationalizedasrespondents’satisfaction with theirschoolperformance,wasmeasuredona1to10scale.Adis- tinctvariablewasdevelopedtodeterminetheleveloftheschool, takingintoaccounttheschool’saverage“capacityexam”score.

Acommunityactivityindexwasconstructedfromfourques- tions:“Arethereneighborhoodgatheringsinyourresidentialarea?

Doyoucelebrate,haveagoodtimetogetherwithyourneighbors?

Doyouhavefun,ordoyouplaywithyourneighbors?Howoften do youparticipate incommunity programs?”.Thevariablewas calculatedbasedontheaverageofthestandardizedvaluesofthe fourquestions,whichwasdividedintofourcategoricalquartiles.

Churchattendancewasmeasuredbyfourlevelsoffrequency.

3)Modeling

Exposuretotobaccosmokingathomewasmeasuredbythe respondentreportabouthowoftenhe/sheisincontactwithothers’

smokinginthehome.

Smokerclassmateswascalculatedastheaveragebyclassfor respondentestimatesofhowmanyclassmatessmoke.Fromthis, theshare(percentage)ofsmokerswascalculatedinrelationtothe numberofpupilsperclass,convertedintofourcategories:veryhigh (25%),high(17-25%),low(10-17%),andverylowrate(<10%).

Smokinginthecommunitywasestimatedbyhavingrespon- dentsusea0-10scaletoindicatehowmanyoutoftenadultssmoke regularlyintheirareaofresidence(neighborhood).Thevalueswere dividedintofourcategoricalquartiles:veryhigh,high,lowandvery lowrate.

Four attitudes of the nearest neighbor towards smoking categorieswerecreatedfromanswerstothequestion:“Towhat extent would your nearest neighbor oppose if theyknew that yousmoke?”.Categorieswere:verynegative,prohibiting;rather negative,prohibiting;permissive;indifferent.

Statisticalanalysis

Bothdescriptiveandinferentialmethodswereusedtodescribe thebasiccharacteristicsofthesampleandanswerourresearch questions.Simplefrequencydistributionswereinspectedtocha- racterizethesampleandbackgroundvariables.Theeffectofthe backgroundvariablesontobaccotrialorsmokingwasexamined usingmultivariatemultinomiallogisticregressionanalyses,after excluding the partialeffects and multicollinearity. The cluster- ingeffectofclassroomswascontrolledthroughlogisticregression methods.

Thedependentvariablewithinthemultinomialregressionmo- delswasthesmokingstatusoftherespondents,withneversmok- ersas thereference category.Independentvariables introduced in themodel were basic demographic characteristics (age and gender),andvariablesfromtheorientation-information-modeling framework.Wecalculatedtheadjustedoddsratio(aOR)and95%

confidenceinterval(95%CI)foreachvariable,andp<0.05wascon- sideredtobestatisticallysignificant.IBMSPSSversion23wasused forstatisticalanalysis.

Results

ThemaincharacteristicsofthesamplearepresentedinTable1.

Themajorityofthestudentswereawarethatsmokingisvery dangerous(59.7%), whileonly7.0%consideredit harmless.Half oftherespondents(52.0%)wereincludedinthe“veryhigh”and

“ratherhigh”schoolperformance categories,witha similardis- tributionfoundforthequalityoftheschool.Communityactivity was reportedto be very high(31.2%) or high(20.0%) by most respondents. More than one-third (37.0%) reported attending churcheachweek,while18.7%ofthemreportedattendingchurch lesshalfasfrequently.Two-thirdsofthestudentswereexposed

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Table1

Characteristicsoftherespondents(N=1313).

Characteristics N %

Sex

Male 650 49.5

Female 663 50.5

Age(years)

13 483 36.8

14 647 49.3

15 183 13.9

Smokingbehavior

Smokers 224 17.1

Experimenters 412 31.4

Neversmokers 677 51.5

Knowledgeabouttheconsequencesofsmoking

Smokingisharmless 92 7.0

Smokingisratherdangerous 437 33.3

Smokingisverydangerous 784 59.7

Schoolresults

Verylow 228 17.4

Ratherlow 390 29.7

Ratherhigh 333 25.4

Veryhigh 349 26.6

Missing 13 1.0

Schoollevel

Verylow 275 20.9

Ratherlow 331 25.2

Ratherhigh 364 27.7

Veryhigh 343 26.1

Communityactivity

Veryhigh 410 31.2

Ratherhigh 263 20.0

Ratherlow 282 21.5

Verylow 358 27.3

Churchattendance

Weekly 486 37.0

Severaltimesamonth 332 25.3

Morethanonceinhalfayear 223 17.0

Lessthanonceeverysixmonths 246 18.7

Missing 26 2.0

Exposuretotobaccosmokingathome

Frequently(6-7days/week) 430 32.7

Occasionally(1-5days/week) 261 19.9

Never 568 43.3

Missing 54 4.1

Smokerclassmates

Veryhighrate 370 28.2

Highrate 303 23.1

Lowrate 357 27.2

Verylowrate 283 21.6

Smokinginthecommunity

Veryhighrate 348 26.5

Highrate 356 27.1

Lowrate 351 26.7

Verylowrate 242 18.4

Missing 16 1.2

Theattitudeofthenearestneighbor

Verynegative,prohibiting 291 22.2

Rathernegative,prohibiting 207 15.8

Permissive 297 22.6

Indifferent 505 38.5

Missing 13 1.0

tosecondhandsmokeatleastoncea week.Veryhighlevelsof smokingwereregisteredforstudents’classmates(28.2%)andin thecommunity(26.5%),and38.0%oftherespondentsclaimedthat thenearestneighborhadarejectingattitudetowardssmoking.

Controlling for all other factors in the model, experiment- ingwithsmokingismostlyrelatedtoknowledgeaboutsmoking (Table2).Thosewhothoughtsmokingwasharmlessor slightly

dangerousweremorelikelytohavinghadlitacigaretteintheir life(aOR:2.36,95%CI:1.11-5.05;andaOR:1.83,95%CI:1.35-2.49, respectively).Academic/schoolperformanceisalsoimportant,as studentswithpoor(verylowandratherlow)resultsweremore likelytohave triedcigarettes(aOR: 1.73,95%CI:1.08-2.78; and aOR:1.57,95%CI:1.02-2.40,respectively),aswellasthosewhoare pronetoexposuretotobaccosmokeinthehome(aOR:1.47;95%CI:

1.03-2.10).

Thestrongest risk factorof adolescent smokingis theclass- mates’(friends,peers)smokingbehavior,suggestingthatamong adolescentsinthisstudy,smokingisasocialenvironment-related activity.Independentofotherfactors,studentswhoreportasigni- ficantproportionofsmokersamongtheirclassmates(morethana quarter)are9timesmorelikelytosmokethemselvesthaninother cases(aOR:9.05;95%CI:4.10-20.00).

Asecondmajorfactorisknowledgeandattitudetowardssmok- ing.Thosewhoconsidersmokingtobeharmlessarefourtimes morelikelytobesmokersthanthosewhoconsiderthisbehavior veryharmful(aOR:4.28;95%CI:2.05-8.94).Athirdindependent riskfactorisrelatedtotheindividualschoolperformance:poor (verylowandratherlow)academicresultsincreasedadolescents’

oddsofsmoking(aOR:3.22,95%CI:1.86-5.59;andaOR:2.66,95%CI:

1.60-4.41).Afourthfactorislinkedtosocialrelationships,assmok- ingisstronglyassociatedwithintensivecommunityactivity;odds aresignificantlyhigherforsmokingiftheyhaveanactivesocial life(aOR:2.54;95%CI:1.60-4.03).Intheregressionmodel,theper- ceivedsmokingrateintherespondent’scommunityappearstobe astrongerriskfactorthansmokingamongfamilymembers(aOR:

2.50,95%CI:1.37-4.57;vs.aOR:1.79,95%CI:1.06-3.01).

Variablessuchasregularchurchattendanceandtheprohibit- ingattitudeofnearestneighbor provedtobeprotectivefactors forsmoking.Respondentswhoattendchurchweeklywerefound tohavelessthanhalftheoddsofsmokingascomparedtothose whorarelyattendchurch(aOR:0.45;95%CI:0.22-0.91).Also,ifthe nearestneighborhasaverynegative(aOR:0.48;95%CI:0.28-0.83) orrathernegative(aOR:0.44;95%CI:0.23-0.83)attitudetowards adolescentsmoking,itcanbeaprotectivefactor.

Accordingtothelogisticregressionanalyses,thethreecompo- nentsofoursocialcapitalmodelshowedassociationwithsmoking behavior of the students. Considering “information” those who foundsmokingverydangerous,incaseof“orientation”component thosewhohadbetterschoolperformance,andfromthepointof

“modeling”thesmokersamongclassmates,tobaccosmokeexpo- sureathome,andthenegativeattitudeofthenearestneighborcan representaprotectivefactorofsmokinginthecommunity.

Discussion

Factorsthatmaybeassociatedwithadolescentsmokinghabits were examined on several dimensions. Our study measured severalkeyindividualandcommunityindicatorshypothesizedto beassociatedwithsmokingbehavioramongadolescents,includ- ingthoserelatedtoinformation,orientationandmodelingfactors.

Theresultspartlysupportourhypothesisthatcommunityactivity, smokingamongclassmatesandschoolperformance(motivation forperformance)haveahighimpactontheadolescentsmoking.

We found associations between information measures and smoking:theprevalenceofsmokingismuchhigheramongthose who think that smokingis harmless or less harmful.Kaya and Ünalan¹⁴drawtheattentiontothefactthatthebeliefsandper- ceptionsofadolescentsaboutsmokingshouldbegivenasmuch consideration as the negative effects of cigarettes in planning smoking free messages. Hohman et al.¹⁵ assumed that, at the communitylevel,communicationcomprisinganti-smokingmes- sagestowhichadolescentsarereceptivemayhaveanimportant

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Table2

Factorsinfluencingtobaccosmoking(multinomiallogisticregressionmodels).

Multivariate

Experimentersvs.neversmokers Smokersvs.neversmokers

aOR 95%CI aOR 95%CI

Age(years)

13 0.77 0.45-1.32 0.92 0.46-1.87

14 0.71 0.50-1.01 0.82 0.51-1.32

15 Ref. Ref.

Gender

Male 0.99 0.72-1.38 1.21 0.79-1.86

Female Ref. Ref.

Knowledgeabouttheconsequencesofsmoking

Smokingisharmless 2.36^a 1.11-5.05 4.28^c 2.05-8.94

Smokingisratherdangerous 1.83^c 1.35-2.49 3.22^c 2.17-4.76

Smokingisverydangerous Ref. Ref.

Schoolperformance

Verylow 1.73^a 1.08-2.78 3.22^c 1.86-5.59

Ratherlow 1.57* 1.02-2.40 2.66^c 1.60-4.41

Ratherhigh 1.80^b 1.19-2.72 1.32 0.77-2.26

Veryhigh Ref. Ref.

Schoollevel

Verylow 1.03 0.54-1.95 1.73 0.81-3.67

Ratherlow 0.75 0.41-1.37 0.79 0.43-1.47

Ratherhigh 0.92 0.53-1.59 1.15 0.66-2.02

Veryhigh Ref. Ref.

Communityactivity

Veryhigh 1.36 0.90-2.04 2.54^c 1.60-4.03

Ratherhigh 1.14 0.76-1.73 2.14^b 1.26-3.61

Ratherlow 1.22 0.86-1.74 2.42^b 1.32-4.45

Verylow Ref. Ref.

Churchattendance

Weekly 0.67 0.41-1.08 0.45^a 0.22-0.91

Severaltimesamonth 0.79 0.50-1.25 0.95 0.51-1.77

Morethanonceinhalfayear 0.72 0.42-1.23 0.76 0.45-1.31

Rarely Ref. Ref.

Exposuretotobaccosmokingathome

Frequently(6-7days/week) 1.47^a 1.03-2.10 1.22 0.68-2.20

Occasionally(1-5days/week) 1.10 0.75-1.62 1.79^a 1.06-3.01

Never Ref. Ref.

Smokerclassmates

Veryhighrate 1.75 0.94-3.26 9.05^c 4.10-20.00

Highrate 1.12 0.62-2.02 3.34^b 1.44-7.34

Lowrate 1.05 0.54-2.04 0.99 0.38-2.55

Verylowrate Ref. Ref.

Smokinginthecommunity

Veryhighrate 1.11 0.72-1.73 2.50^b 1.37-4.57

Highrate 1.19 0.79-1.78 1.25 0.74-2.12

Lowrate 1.33 0.87-2.05 1.12 0.60-2.08

Verylowrate Ref. Ref.

Theattitudeofthenearestneighbor

Verynegative,prohibiting 0.92 0.59-1.46 0.48^b 0.28-0.83

Rathernegative,prohibiting 1.06 0.72-1.58 0.44^a 0.23-0.83

Permissive 1.31 0.88-1.96 1.00 0.62-1.63

Indifferent Ref. Ref.

aOR:adjustedoddsratio;95%CI;95%confidenceinterval;Ref.:referencevalue.

ap<0.05.

bp<0.01.

c p<0.001.

influenceonyoungpeople’sbehavior.Theimportanceofawareness is emphasizedin otherstudiesalso,^16,17 confirmingthat health informationrepresentsaprotectivefactorforhealthbehavior.

Adolescentsocializationisasignificantorientationfactorinthe developmentofsmokinghabits.Theintegrationoftheadolescent inhis/hercommunity,i.e.thesocialmilieuofthebehaviorsand valuesinwhichtheadolescentsocializes,leavesitsmarkonthe adolescent’sbehavior.¹

Our results show that the school can be a protective factor only if it is highly rated, it offers quality educa- tion and there are clear values and rules that can be fol- lowed. As hypothesized, an elevated school performance, will help reduce smoking rates. Our results are congruent with those reported previously showing that school results and teenagesmokingstatus(formerorcurrentsmoker)arestrongly associated.¹⁸

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Inthecaseofcommunityactivity,wefocusedonactivitiesthat appearattheleveloftheneighborhood:participationincommu- nityprograms,neighborhoodgatherings,jointcelebrations,joint entertainmentandplay.Contrarytoourhypothesis,theriskofthe adolescentsmokingishigherifthesetypesofactivitiesarepresent intheneighborhoodandtheadolescenttakespartinthem,sug- gestingthatthelevelofcommunityactivityitselfisnotaprotective factoragainstsmoking.SimilarresultswereobtainedbyPförtner etal,¹⁹ confirmingthat friend-relatedsocialcapital wassignifi- cantlyassociatedwithahigherlikelihoodofdailysmoking.The timespentwithpeerswillbenefittheadolescentprovided that theactivityhassomekindofguidance,suchasgoingtochurch, and it conveysinformation about theharmful consequences of smoking. Coleman’s findings² are comparable: social capital is determinedbythesenseofbelonginganditmanifestsitseffects onorientationandbehavioralstandards.Whenacommunitydis- seminatesinformationthroughitschannels,itattemptstoregulate theadolescentbehavior bysetting clearstandardsandexpecta- tions, byapplyingsanctions for deviations fromnorms,and by monitoringhow adolescentskeep theircommitments;theseall havean impactonadolescent behavior and promote a healthy socialization.

Thisstudydemonstratesthattheorientationfactorsstrongly associatedwithadolescentsmokingamongRomanianadolescents are:goodschoolresults;adultsmokingpatterns(parents,neigh- bors);peersmokingpatterns;andcommunityactivitiesthatnot onlyimplylivingandhavingfuntogether,butalsoanti-smoking communication.Anotherimportantroleisplayedbyhowmuch adolescentsattachtotheirhomecommunitiesand bythe type ofinformationtheyareexposed toabouttheharmfuleffects of smoking.

Ourfindingsrelatedtothemodelingfactorconfirmourhypo- thesisthatsmokingclassmateshighlyimpactteenagers’behavior.

Italsosuggeststhat,ingeneral,smokingbyfriendsandattitudes andsmokingbyadultsintheneighborhoodarestronglyassoci- atedwithadolescentsmoking.Ouranalysisrevealstheperception ofadultneighbors’attitudestowardsmokingmayserveasapro- tectivefactor;i.e., adolescentsinneighborhood witha negative attitudetowardssmokingarelesslikelytosmokethanthosewhose immediatelivingenvironment ispermissive oreven indifferent aboutsmoking.Theseresultsaresimilarwhathasbeenreported byotherauthors.^20–22

Oneofthelimitationsofourresearchisthatwedidnotmake asharpdistinctionbetweentheindividualversussocialnatureof particularactivities,nordidwetrytoseparateactivitiesbetween youngstersandadults.Certaincomponentsofourindex,suchas culturalactivities(likelisteningtomusicorregularlygoingtothe theatre)areassociatedwithanincreasedriskofsmoking,asthese aresocialactivitiesundertakenwithfriends,whileactivitiesspent inone’sprivatesphere(likereadingabook)areassociatedwitha reducedriskofsmoking.

Anotherlimitationofourstudyisthesample’srepresentati- vityforTransylvaniaregiononly(oneofthethreemainhistori- calregionsofRomania),whichmaynarrowthegeneralizabilityof ourfindings.

We should also mention that the validity and reliability of the complete questionnaire have not been checked yet. A potential source of bias is also the self-reported nature of the data; we cannot exclude that the students under-report smoking due to thesocial desirability or exaggeratethe effect of the variable: the negative/prohibiting attitude of the nearest neighbor. In general, the main bias could be that even if teenagers want to appear “desiderable” it is a period of time when they do believe and follow the social norms of their counterparts.

Conclusions

Ourresultssuggestthatseveralsocialcapitalfactorscanplay amajorroleintheadolescentsmoking.Althoughsomeelements ofthesocial capital do notconstitutehealth risk factorsthem- selves,allmaybeconsideredasriskorprotectivefactors,depending ontheirmodeofactionandinteraction.Ourresultsdemonstrate thattheorganizationanddevelopmentofthecommunityactivities aimedatpreventionmuststrengthenthefactorsmentionedabove

—information,orientation,modeling—because,throughthem,the community’ssocialcapitalwillexpandandreducethelikelihood ofteenagesmoking.

Whatisknownaboutthetopic?

Socioculturalenvironmenthasanimpactonattitudes,va- luesandbehaviors.Socialcapitalrulesbehaviorthroughsafe humanrelationships,informationchannels,dutyandnorms.

This is a combination of effects that one turns to account dependingonhowshe/heisconnectedtothecommunity.

Whatdoesthisstudyaddtotheliterature?

We have developed amodel exhibiting the relationship betweencommunitycapitalandadolescentsmoking.Conse- quently,preventionshouldemphasizetheorientation,which meansvalues,attitudes,healthawareness,community/social life;themodeling(pro-socialbehaviormodels,interpersonal skills, self-determination),as well asthe information trans- ferconcerningtheeffectsofsmoking.Apolicyintervention, influencing adolescents’ behaviour serves the community empowerment.

Editorincharge CarlosÁlvarez-Dardet.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthorsgua- ranteethe accuracy,transparency and honestyof thedata and informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.

Declaration

Allproceduresperformedinthisstudywereinaccordancewith the1964DeclarationofHelsinkianditslateramendments.Wepre- viouslyobtainedwrittenpermissionfromschools inspectorates, headmasters(schoolmanagement)andparentsforconductingthe survey.Allparentswereinformedaboutthepurpose,benefitsand risksofthestudy.Participationinthestudywasoptional.

Authorshipcontributions

E.Albert-Lorinczdesignedandplannedthestudy.B.Szabocon- tributedtotheimplementation;carriedoutthestatisticalanalysis anddatainterpretation.A.I.Gasparikconceivedandwrotethefinal versionofthemanuscript.E.Paulikwasinchargeofoveralldirec- tionofthestudy.K.Foleysupervisedtheproject.Allauthorswere involvedinthecriticalreviewandhaveapprovedthefinalversion ofthemanuscriptforpublication.

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Funding

The researchreported in this publication was supportedby theFogartyInternationalCenterandtheNationalCancerInstitute oftheNationalInstitutesofHealthunderAwardNumber1R01 TW09280-01.Thecontentissolelytheresponsibilityoftheauthors anddoesnotnecessarilyrepresenttheofficialviewsoftheNational InstitutesofHealth.

Conflictsofinterest None.

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