School smoking bans: do they help/do they harm?

INTRODUCTION AND AIMS: The international evidence about the effectiveness of school smoking bans on youth smoking initiation is equivocal. The purpose of the present study was to examine the association between school smoking bans and smoking initiation as a health outcome as well as academic achievement as an educational outcome, taking into account socio-economic status. DESIGN AND METHODS: This multi-level study was based on a cross-sectional self-reported anonymous data from 12,990 students who participated in the 2002 Student Drug Use Survey in the Atlantic Provinces. The main outcomes were having smoked a first whole cigarette in the year prior to the survey, and academic performance. The main independent variable at the individual- and school-levels was a school rule against smoking on school property or at school events, as reported by students. RESULTS: Smoking initiation was predicted by individual-level demographic factors and by the contextual factor of attending a school with a high prevalence of established smoking, but failed to be predicted by a school smoking ban. The academic performance of students who indicated there was no school smoking ban was found to worsen as an increasing proportion of the student body indicated that such a rule existed. Lower socio-economic status was found to be an independent predictor of smoking initiation and poorer academic performance. DISCUSSION AND CONCLUSIONS: A school ban against smoking, in addition to not being clearly effective, might also not be entirely benign. School smoking policy should be monitored as to educational outcomes and the impact of policy on groups vulnerable to smoking.

From attention-deficit/hyperactivity disorder to medical stimulant use to the diversion of prescribed stimulants to non-medical stimulant use: connecting the dots.

AIMS: To describe the connections among the likelihood of attention deficit/hyperactivity disorder (ADHD), medical and non-medical methylphenidate and amphetamine use and the diversion of prescribed methylphenidate in the general adolescent population. DESIGN: Cross-sectional self-reported anonymous data from the 2002 Student Drug Use Survey in the Atlantic Provinces. SETTING: The Atlantic provinces of Canada. PARTICIPANTS: A total of 12,990 students participated. MEASUREMENTS: The outcomes were a positive ADHD screening test, medical and non-medical use of methylphenidate, medical and non-medical use of amphetamine and the giving and selling of methylphenidate medication by students with a prescription. The Ontario Child Health Study Hyperactivity Scale was used to screen for ADHD. FINDINGS: The prevalence of a positive ADHD screening test was 6% with no significant gender difference. The prevalence of medical and non-medical methylphenidate use and medical and non-medical amphetamine use was 2.0%, 6.6%, 1.2% and 8.7%, respectively. A positive ADHD screening test was independently predictive of these four patterns of use. About 26% of students with prescribed methylphenidate gave or sold some of their medication. Students in a class where at least one student had given or sold some of their prescribed pills had a 1.52-fold increased risk of non-medical methylphenidate use than their counterparts in classes where no giving or selling had taken place. CONCLUSIONS: Connections were demonstrated at the population level between ADHD, medical methylphenidate use, the diversion of prescribed methylphenidate and the non-medical use of methylphenidate. The appropriate assessment and management of ADHD are essential to minimize both the risk of diversion and of substance use associated with unrecognized or untreated ADHD.

Adolescent passengers of drunk drivers: a multi-level exploration into the inequities of risk and safety.

AIMS: This study determined the individual-, neighbourhood- and provincial-level effects of rural residence, socio-economic status (SES), substance use and driving behaviours on adolescents' riding with a drunk driver (RDD). DESIGN: Multi-level study based on cross-sectional self-reported anonymous data from the Student Drug Use Survey in the Atlantic Provinces (SDUSAP) and Census Canada data, merged on the postal code of participating schools. The sample design of the SDUSAP was a single-stage cluster sample of randomly selected classes stratified by grade and region. SETTING: The Atlantic provinces of Canada. PARTICIPANTS: A total of 12 990 students in junior and senior high schools, with an average age of 15 years, participated in the 2002 SDUSAP. MEASUREMENTS: The outcome variable was past-year RDD. The main individual-level independent variables were SES, rural residence, substance use and driving behaviours. The school-neighbourhood independent variables were the prevalence of heavy episodic drinking, driving under the influence of alcohol, driver's licence, highest level of educational attainment and low income. FINDINGS: The prevalence of RDD was 23.3% in 2002. Among students in grades 9-12, lower family SES, rural residence, substance use and driving under the influence were found to be independent individual-level risk factors for RDD; having a driver's licence was found to be protective. At the provincial and school-neighbourhood levels, a high prevalence of driving under the influence of alcohol and low educational attainment were found to be independent risk factors for RDD after taking into account individual characteristics. CONCLUSIONS: This study provides evidence that inequities exist in the options for adolescents to be ensured of passenger safety, and that interventions aimed at decreasing the extent to which adolescents engage in riding with a drunk driver should be based on conceptual approaches that recognize ecological factors as well as individual-level susceptibility.

Online health promotion, early identification of difficulties, and help seeking in young people.

OBJECTIVE: To examine the use and impact of a dedicated health information Web site for adolescents. METHOD: Five hundred fifty-eight (27.2%) of all students in grades 7 through 12 from 4 schools logged onto the Web site; 1775 (86.4%) of all students in these grades completed a year-end health survey, with 455 (81.5%) of the students who used the Web site completing the survey. Dependent variables were help seeking and satisfaction ratings plus visits to specific Web site sections. Predictor variables were demographic characteristics, mental health, and psychosocial difficulties assessed at years' end. RESULTS: Students logged on >11,000 times during the year. Female students, students wanting professional help, those scoring higher on depressive vulnerability measures, and students reporting more severe mood problems were related to logging on frequently over longer periods of time, as well as viewing information sheets, posting and viewing questions and answers, and completing the symptom screen. Students accessing the Web site from 1 to 7 A.M. reported higher levels of distress than did students who accessed the Web site at other times of the day. Visits to the Web site were positively associated with visits to school health centers and guidance counselors and referrals to a health professional. CONCLUSIONS: Results are consistent with a health-needs model of utilization of this Internet-based health resource. A school-based health information Web site holds significant promise for health promotion and early self-identification for emotional problems.

The South Oaks Gambling Screen-revised Adolescent (SOGS-RA) revisited: a cut-point analysis.

The lack of a criterion validity gold standard defining adolescent pathological gambling represents a major limitation of the adolescent gambling literature. The present study employed Receiver Operating Characteristic curve analysis (ROC) to examine the performance of the South Oaks Gambling Screen-Revised Adolescent (SOGS-RA) recommended cut-point of 4 against two-proxy gold standards: self-identified need for, or receipt of, help for gambling. Logistic regression analysis examined the correlates of self-identified need for help with gambling. The sample was comprised of 12990 adolescents from Atlantic Canada whose average age was 15 years and 50% of whom were male. The SOGS-RA performed as well or better with these proxy gold standards than with proxies used in previous studies. We concluded that the proxy gold standards based on self-identified need for or receipt of help represent a pragmatic solution to the lack of an adolescent-specific definition of problem or pathological gambling. Students in grade seven and SOGS-RA scores of 4 or greater were independent predictors of self-identifying a need for help.

Examining school health center utilization as a function of mood disturbance and mental health difficulties.

PURPOSE: We examined the presence and severity of mood disturbance and mental health difficulties as predictors of students' utilization of school health centers. METHODS: Mood disturbance and mental health difficulties were assessed through surveys completed at year end. Visits to school health centers were tracked prospectively over the year. RESULTS: Twenty-three percent of students with mental health difficulties visited the school health centers. Students reporting mood disturbance and difficulties were more likely to use school health centers and to use them more frequently than were students without such difficulties. More than half of all visitors were judged by health clinic staff to be experiencing impairment in functioning and reported difficulties, which typically lasted more than 6 months duration. CONCLUSIONS: Although the presence of mental health difficulties increases the probability of students' visiting school health centers, the majority of students with such difficulties do not avail themselves of this resource. Optimizing the effectiveness of school-based health services depends on understanding the interplay between availability and utilization of school-based services for students with mental health difficulties.

Unmet need for the treatment of depression in Atlantic Canada.

OBJECTIVE: Most people with depression do not receive treatment, even though effective interventions are available. Population-based data can assist health service planners to improve access to mental health services. This study aimed to examine the determinants of untreated depression in Canada's Atlantic provinces. METHOD: This study used data from the Canadian Community Health Survey Cycle 1.1. Logistic regression models explored the prevalence of depression and associated patterns of mental health service use among population subgroups. RESULTS: Of the respondents, 7.3% experienced major depression in the previous year, as measured by the Composite International Diagnostic Interview Short Form. Individuals with the following characteristics were at increased risk for depression: female sex; widowed, separated, or divorced marital status; low income; and 2 or more comorbid medical conditions. Only 40% of respondents with probable depression reported any consultation about their condition with a general practitioner or mental health specialist. Less than one-quarter of Atlantic Canadians with depression reported receiving levels of care consistent with practice guidelines. Vulnerable groups, including older individuals, people with low levels of education, and those living in rural areas, were significantly less likely to receive treatment in either primary or specialty care. CONCLUSIONS: These findings suggest inequitable access to services and the need to target interventions to at-risk populations by raising awareness among the public and health care providers. Health systems in the Atlantic region must work toward achieving consistent longitudinal care for a larger proportion of individuals suffering from depression by studying the underlying factors for service use among underserved groups.

Validity of a 12-item version of the CES-D used in the National Longitudinal Study of Children and Youth.

This validation study assessed the degree of confidence that can be placed on inferences from depressive symptoms among adolescents, based on a 12-item version of the Centre for Epidemiological Studies Depression scale (CES-D). This short version of the scale had been developed for application in the National Longitudinal Study of Children and Youth and we refer to it as the CES-D-12-NLSCY. The major data source for the present validation study was a 2002/2003 survey of 12,990 students in junior and senior high school in the Atlantic provinces of Canada. Receiver operating characteristic curve analyses for two different proxy gold standards yielded adequate areas under the curve (AUCs) of .84 and .80, allowing us to establish cut points for three categories of depressive symptoms in the general adolescent population: Minimal (CES-D-12-NLSCY total score 0 to 11), Somewhat Elevated (total score 12 to 20) and Very Elevated (total score 21 to 36). The CES-D-12-NLSCY was found to have acceptable internal consistency (Cronbach=s alpha .85). All but one of the 12 items of the CES-D-12-NLSCY were found to have acceptable discrimination ability. The prevalence of Minimal, Somewhat and Very Elevated depressive symptoms in the adolescent student population of the Atlantic provinces was estimated to be 72.3, 19.5 and 5.5 percent, respectively. A further 2.6 percent of students who responded to fewer than 11 items of the scale were classified as Indeterminate with regards to depressive symptom category. The major threat to the accuracy of the CES-D-12-NLSCY is its lack of inquiry about irritability, which is a key symptom of depression in youth.

Concordance between the SOGS-RA and the DSM-IV criteria for pathological gambling among youth.

This study assessed the possible differences in the classification of adolescent gamblers when using the South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA; K. C. Winters, R. D. Stinchfield, & J. Fulkerson, 1993) versus a clinical interview that was based on Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) criteria for pathological gambling. A total of 631 adolescents ages 15-17 years participated in the two phases of the study. Results revealed that of the 93 adolescents who had been screened as problem gamblers according to the SOGS-RA, only 7 could be clinically confirmed as pathological gamblers according to the criteria used at present to define pathological gambling. The need to clarify the construct of pathological gambling among youth is discussed.

Motor vehicle collision risk and driving under the influence of cannabis: evidence from adolescents in Atlantic Canada.

OBJECTIVE: Employing a sample of 6087 senior students in Atlantic Canada, this paper examines the relationship between driving under the influence of cannabis (DUIC) and motor vehicle collision (MVC) risk. A series of models were analyzed adjusting for demographic characteristics, driver experience, and substance use. METHODS: Participants were drawn from the 2002/2003 Student Drug Use Survey in the Atlantic Provinces, an anonymous cross-sectional survey of adolescent students in the Atlantic provinces of Canada. Logistic regression techniques were employed in the analysis of unadjusted and adjusted models. RESULTS: Among senior students, the prevalence of DUIC in the past year was 15.1% while the prevalence of MVCs was 8.1%. The predictors of DUIC were gender, driver experience, use of a fake ID, and driving under the influence of alcohol (DUIA). The predictors of MVC were gender, driver experience, DUIC, and DUIA. CONCLUSIONS: These findings extend our knowledge of DUIC as a socio-legal and public health issue with implications on road safety. Effort must be placed on educating new drivers about cannabis use in the context of driving.

Gender differences in the association between substance use and elevated depressive symptoms in a general adolescent population.

AIMS: This study explores gender differences in the association between substance use and elevated depressive symptoms in the general adolescent population. DESIGN: Cross-sectional self-reported anonymous survey, the 2002/2003 Student Drug Use Survey in the Atlantic Provinces. The sample design was a single-stage cluster sample of randomly selected classes stratified by grade and region. SETTING: The four Atlantic provinces of Canada. PARTICIPANTS: A total of 12 771 students in junior and senior high schools of the public school systems, representing a response rate of about 97%. The average age of participants was 15.2 years. MEASUREMENTS: The measure of elevated depressive symptoms was a 12-item version of the CES-D with three categories of depression risk validated in a companion study. FINDINGS: The prevalence of very elevated depressive symptoms was 8.6% in females and 2.6% in males. Alcohol use and cigarette smoking were found to be independent predictors of elevated depressive symptoms in females, but not males; cannabis use was found to be an independent predictor of elevated depressive symptoms in both males and females. Age was found to have a curvilinear relationship with elevated depressive symptoms in females but not in males. The adolescent's academic performance and province of residence were found to be independent risk factors of elevated depressive symptoms among both males and females. About 10.3% of adolescents considered to be potential candidates for needing help reported having received help because they felt depressed. CONCLUSIONS: The association between depression risk and age, alcohol use, cigarette smoking and cannabis use in the general adolescent population is not straightforward and may differ according to gender. There is unmet need for help for depression among adolescents.

An assessment of the validity and reliability of the SOGS-RA.

The present is a validation study seeking to determine the degree of confidence that can be placed on inferences about problem gambling among adolescents in the Atlantic provinces, based on their South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA) scores. The major source of data was a 1998 survey of 13,549 students in junior and high school of the public school systems of the 4 Atlantic provinces of Canada. The SOGS-RA was found to have adequate stability and internal consistency reliability. Statistically significant gender differences were demonstrated relative to endorsement and construct validity. Regarding the latter, this study shows that the existing cut-point of the SOGS-RA score for problem gambling identifies as problem gamblers, markedly different proportions of male than female daily gamblers. Regarding construct validity in relation to the Atlantic Alcohol and Drug Risk Continua, this study suggests that while statistically highly significant, the association between problem gambling and substance-related problems may be of low clinical significance. Regarding criterion validity, there is an urgent need to perform the types of enquiry that will allow clarification about how adolescent problem gambling is conceptualized, by adults versus adolescents, by males versus females, and from a clinical versus a public or population health perspective.