The role of health literacy in the association between academic performance and substance use.

BACKGROUND: To address social inequalities in adolescent substance use and consequent disparities in health, it is important to identify the mechanisms of the association between substance use and academic performance. We study the role of health literacy (HL) in the association between academic performance and weekly smoking, monthly alcohol use and cannabis ever-use among adolescents in Europe. METHODS: SILNE-R school survey data, which was collected in 2016-17 with paper-and-pencil-method from Hanover (GE), Amersfoort (NL) and Tampere (FI), were used (N = 5088, age 13-19). Health Literacy for School-aged Children instrument was used to assess students' HL. Logistic regression analyzed the association of substance use with academic performance and HL, separately and in the same model. Linear and multinomial logistic regression analyzed the association between academic performance and HL. RESULTS: Poor academic performance compared with high was associated with smoking [odds ratio (OR) 3.94, 95% confidence interval (CI) 2.83-5.49], alcohol use (OR: 2.94, 95% CI: 2.34-3.68) and cannabis use (OR: 2.56, 95% CI: 1.89-3.48). Poor HL was also associated with each substance use (with ORs of 2.32, 1.85 and 1.29). HL was positively associated with academic performance (ß = 1.04, 95% CI: 0.89-1.20). The associations between academic performance and substance use were only slightly attenuated after controlling for HL. CONCLUSIONS: Academic performance and HL were both determinants of substance use, confirming their role in tackling the disparities in substance use. However, HL did not demonstrably mediate the association between academic performance and substance use. A wider set of factors needs to be tackled to address emerging social inequalities in adolescent substance use.

Electronic cigarette use among 14- to 17-year-olds in Europe.

BACKGROUND: Studies comparing adolescent e-cigarette use in different countries are scarce. We study students' e-cigarette and conventional cigarette ever-use, their social correlates and e-liquid use in seven EU countries. METHODS: SILNE-R data (N=12 167, response rate 79.4%) of 14-17-year-olds from Amersfoort (NL), Coimbra (PT), Dublin (IR), Hanover (GE), Latina (IT), Namur (BE) and Tampere (FI) were used. E-cigarette and conventional cigarette ever-use, dual-use, type of e-liquid and social correlates were measured with a school survey and analyzed with cross-tabulations and multinomial logistic regression. RESULTS: About 34% had tried e-cigarettes, but the variation was large between the cities (Latina 50%; Hanover 23%). Of e-cigarette ever-users, 37% had used nicotine e-liquid, 43% exclusively non-nicotine liquid and 20% did not know the content. Nicotine e-liquid was more prevalent among monthly e-cigarette users and weekly smoking e-cigarette users. The social correlates were mainly the same for exclusive e-cigarette ever-use, exclusive conventional cigarette ever-use and dual-use. Boys had greater odds for exclusive e-cigarette and dual-use compared to girls. Of social correlates, low academic achievement and parental smoking were positively associated with all categories of use, but parental education and immigrant background were not. The strongest association was found between peer smoking (most/all best friends smoke) and dual-use (OR 34.29). CONCLUSIONS: Students' e-cigarette ever-use varies greatly between EU countries. E-cigarettes seem not to be a substitute for conventional cigarettes but more a complementary product. Tobacco control policies might also prevent e-cigarette use but specific regulations on e-cigarettes are needed to prevent nicotine addiction originating from them.

Nicotine matters in predicting subsequent smoking after e-cigarette experimentation: A longitudinal study among Finnish adolescents.

BACKGROUND: Several studies indicate an association between e-cigarette use and subsequent smoking among youth. However, most previous studies lack measures of the nicotine content of e-liquid and have not usually measured regular smoking. METHODS: We tested the association between e-cigarette use, with and without nicotine, and subsequent daily use of conventional cigarettes and nicotine e-cigarettes among study population of 3474 students. A survey was conducted in lower secondary schools of the Helsinki metropolitan area, Finland, with 15 - 16-year-olds in 2014 (baseline) and in upper secondary schools in 2016 when the cohort was 17 - 18-year-olds (follow-up). Firth logistic regression and generalized linear mixed models (GLMM) were used. RESULTS: Of students, 25% had experimented with nicotine e-cigarettes at baseline and 40% at follow-up. Among baseline never-smokers, experimentation with or use of nicotine e-cigarettes predicted the uptake of daily smoking at follow-up (AOR 2.92; 95% CI 1.09-7.85), but baseline experimentation with non-nicotine e-cigarettes did not when compared with the non-e-cigarette experimenters. Nicotine e-cigarette experimentation at baseline predicted daily nicotine e-cigarette use at follow-up (AOR 2.96; 95% CI 1.22-7.22). Non-nicotine e-cigarette experimentation at baseline did not predict statistically significantly daily nicotine e-cigarette use at follow-up (AOR 3.13; 95% CI 0.98-10.02). The small number of cases may have diminished the statistical significance. CONCLUSIONS: The findings suggest that experimentation with nicotine e-cigarettes serves as a gateway to subsequent use of conventional cigarettes as well as nicotine e-cigarettes. Our results support the actions to limit youths' access to e-cigarettes in order to prevent nicotine addiction.

Low schoolwork engagement and schoolwork difficulties predict smoking in adolescence?

Background: Low academic achievement has been associated with smoking but factors behind this association are poorly known. Such factors could include schoolwork disengagement and schoolwork difficulties. To assess the extent to which they contribute to the explanation of how health inequalities emerge, we study in a longitudinal design whether these have an independent effect on smoking or whether their effect is mediated through academic achievement. Methods: Longitudinal data were collected in the Helsinki metropolitan area, Finland in 2011 and 2014. Participants were seventh-graders (12 - 13 years, N=9497). In the follow-up, 6534 students reported their smoking status in the ninth grade (15 - 16 years). Smoking, schoolwork behavioural engagement, i.e. participation in academic activities, and disengagement, schoolwork difficulties and cognitive competence were self-reported by adolescents. Academic achievement was obtained from the Finnish national application register on upper secondary education. A mediation analysis was executed with bootstrapped confidence intervals. Results: Higher schoolwork behavioural engagement and cognitive competence in the seventh grade predicted that adolescents were more likely not to smoke in the ninth grade (all P<0.001) while higher schoolwork disengagement and schoolwork difficulties predicted adolescents' smoking (all P<0.001). The effects were mediated through academic achievement. Conclusions: Students' behavioural disengagement with schoolwork and schoolwork difficulties are risks for smoking initiation. Their effect is mediated through poor school achievement. As smoking often continues in adulthood and poor school performance typically leads to lower education, schoolwork disengagement and difficulties in adolescence constitute potential pathways to inequalities in health.

A Longitudinal Study of Predictors for Adolescent Electronic Cigarette Experimentation and Comparison with Conventional Smoking.

Little is known of the predictors of electronic cigarette (e-cigarette) use among adolescents, even though the use is increasing. We studied here the predictors for e-cigarette experimentation (tried and tried more than twice) and compared them with predictors for conventional smoking. A baseline school survey was conducted in the Helsinki metropolitan area, Finland, in 2011 for seventh graders (12 to 13-year-olds). Response rate was 73%. The same students were followed up in 2014 (9th grade, 15 to 16-year-olds), N = 5742. Generalized linear mixed models controlling for school clustering were used. In the follow-up, 43.3% of boys and 25.6% of girls had tried e-cigarettes and 21.9% and 8.1% correspondingly more than twice. The strongest predictors for both genders were conventional smoking, drunkenness and energy drink use. Furthermore, poor academic achievement predicted e-cigarette experimentation for both genders, and for boys, participation in team sports was a predictor. The predictors for experimenting and for experimenting more than twice were very similar, except for boys' participation in team sports. They were also similar compared to the predictors of conventional smoking but the associations were weaker. To conclude, smoking and other addictive behaviors predict adolescents' experimentation with e-cigarettes. Family's socioeconomic background had little significance.

Changes in Electronic Cigarette Use from 2013 to 2015 and Reasons for Use among Finnish Adolescents.

Electronic cigarettes are quite a new potential source of nicotine addiction among youth. More research is needed, particularly on e-liquid use and socioeconomic factors as potential determinants. We studied changes from 2013 to 2015 in adolescent e-cigarette awareness and ever-use, types of e-liquids, and determinants in Finland. In 2015, we studied weekly use and reasons for ever-use. Data were from two national surveys of 12-18-year-old Finns (2013, n = 3535, response rate 38%; 2015, n = 6698, 41%). Descriptive statistics and logistic regression analysis were used. Awareness and ever-use of e-cigarettes increased significantly from 2013 to 2015 in all age and gender groups. Ever-use increased from 17.4% to 25%, with half having tried nicotine e-liquids. In 2015, weekly use was rare (1.5%). Daily cigarette smoking was the strongest determinant (OR 51.75; 95% CI 38.18-70.14) for e-cigarette ever-use, as for e-cigarette weekly use, but smoking experimentation and ever-use of snus (Swedish type moist snuff) and waterpipes alongside parental smoking and poor academic achievement also increased the odds for ever-use. The most common reason behind e-cigarette ever-use was the desire to try something new. To conclude, adolescent e-cigarette ever-use is increasing, and also among never-smokers. Tobacco-related factors are stronger determinants for e-cigarette use than socioeconomic factors.

Occurrence of violence among 12-18-year-old adolescents in 1999 and 2009 in Finland.

We examined whether the occurrence of violence changed among Finnish adolescents between 1999 and 2009. The study was based on the nationwide Adolescent Health and Lifestyle Survey from samples of 12- to 18-year-olds. The number of respondents was 8136 in 1999 and 5516 in 2009. The proportion of adolescents reporting violence was 7.9% in 1999 and 6.2% in 2009 (P < 0.000). In both of the study years, the violence occurrence rate varied by age and sex, with boys reporting higher rates in all age groups. The results did not support our hypothesis of a general increase in violence among adolescents.

Cyberbullying among Finnish adolescents--a population-based study.

BACKGROUND: Cyberbullying, threatening or harassing another via the internet or mobile phones, does not cause physically harm and thus the consequences are less visible. Little research has been performed on the occurrence of cyberbullying among adolescents or the perception of its seriousness. Only a few population-based studies have been published, none of which included research on the witnessing of cyberbullying. Here, we examined exposure to cyberbullying during the last year, and its frequency and perceived seriousness among 12 to 18-year-old adolescents in Finland. We studied four dimensions of cyberbullying: being a victim, bully, or both victim and bully of cyberbullying, and witnessing the cyberbullying of friends. METHODS: Self-administered questionnaires, including four questions on cyberbullying, were mailed to a representative sample of 12-, 14-, 16-, and 18-year-old Finns in 2009 (the Adolescent Health and Lifestyle Survey). The respondents could answer via the internet or paper questionnaire. RESULTS: The number of respondents was 5516 and the response rate was 56%. Girls more often than boys reported experiencing at least one dimension of cyberbullying during the last year. The proportion was highest among 14-year-olds and lowest among 18-year-olds of both sexes. Among girls, the most commonly encountered dimension was witnessing the cyberbullying of friends (16%); and being a victim was slightly more common than being a bully (11% vs. 9%). Among boys, an equal proportion, approximately 10%, had been a victim, a bully, or had witnessed cyberbullying. The proportion of bully-victims was 4%. Serious and disruptive cyberbullying was experienced by 2% of respondents and weekly cyberbullying by 1%; only 0.5% of respondents had been bullied weekly and considered bullying serious and disruptive. CONCLUSIONS: Adolescents are commonly exposed to cyberbullying, but it is rarely frequent or considered serious or disruptive. Cyberbullying exposure differed between sexes, such that girls more often than boys witness cyberbullying of friends and boys more often act as the bully than girls. In future studies, the witnessing of cyberbullying and its consequences should be taken into account.