Factors that mediate the relationships between household socio-economic status and childhood Attention Deficit Hyperactivity Disorder (ADHD) in children and adolescents: A systematic review.

BACKGROUND: ADHD is one of the most prevalent mental health disorders among children and adolescents. Household socio-economic status (SES) in early childhood is inversely related to ADHD later in childhood or adolescence. We conducted a systematic review to examine psychological, social and behavioural factors that mediate these relationships (PROSPERO Registration number: CRD42020182832). METHODS AND FINDINGS: We searched Medline, EMBASE, PsychINFo, and Web of Science from inception until May 2020. Both authors independently reviewed abstracts and identified papers for inclusion. We sought primary observational studies (cohort, cross-sectional and case control studies) of general population-based samples of children and adolescents aged 18 and under that investigated potential mediators of the relationships between SES and ADHD. Studies based upon non-general population-based samples, twins or biochemical/physiological changes were excluded. Direct and indirect effects derived from standard validated mediation analysis were extracted for potential mediators. We assessed risk of bias using a modified NIH tool and synthesised quantitative data without meta-analysis according to the (SWiM) protocol because of heterogeneity between included studies. Family adversity, paternal and maternal ADHD symptoms, Home Learning Environment, breastfeeding duration and a combined fine motor and language score at age 2 may lie on the SES-ADHD pathway. Evidence concerning the influence of maternal depression/anxiety and adverse parenting was inconsistent across studies. There was no evidence that mother's health-related behaviour, family characteristics, child's consumption of fizzy drinks or other developmental characteristics at birth/during infancy lie on the SES-ADHD pathway. Publication bias may have been introduced by our decision not to search grey literature, not to approach study authors and limit the search to the English language. CONCLUSIONS: Evidence for mediation of the SES-ADHD pathway in childhood/adolescence is under-researched. Maternal mental health, family adversity, parenting and health-related behaviours warrant further research based on longitudinal data and employing the most advanced mediation analysis methods.

Does school ethos explain the relationship between value-added education and teenage substance use? A cohort study.

Previous studies found lower substance use in schools achieving better examination and truancy results than expected, given their pupil populations (high value-added schools). This study examines whether these findings are replicated in West Scotland and whether school ethos indicators focussing on pupils' perceptions of schooling (environment, involvement, engagement and teacher-pupil relations) mediate the associations. Teenagers from forty-one schools (S2, aged 13, n = 2268; S4, aged 15, n = 2096) previously surveyed in primary school (aged 11, n = 2482) were surveyed in the late 1990s. School value-added scores were derived from standardised residuals of two regression equations separately predicting from pupils' socio-demographic characteristics (1) proportions of pupils passing five Scottish Standard Grade Examinations, and (2) half-day truancy loss. Outcomes were current smoking, monthly drinking, ever illicit drug use. Random effects logistic regression models adjusted for potential pupil-level confounders were used to assess (1) associations between substance use and school-level value-added scores and (2) whether these associations were mediated by pupils' perceptions of schooling or other school-level factors (school roll, religious denomination and mean aggregated school-level ethos scores). Against expectations, value-added education was positively associated with smoking (Odds Ratios [95% confidence intervals] for one standard deviation increase in value-added scores were 1.28 [1.02-1.61] in S2 and 1.13 [1.00-1.27] in S4) and positively but weakly and non-significantly associated with drinking and drug use. Engagement and positive teacher-pupil relations were strongly and negatively associated with all substance use outcomes at both ages. Other school-level factors appeared weakly and largely non-significantly related to substance use. Value-added scores were unrelated to school ethos measures and no ethos measure mediated associations between value-added education and substance use. We conclude that substance use in Scotland is more likely in high value-added schools, among disengaged students and those with poorer student-teacher relationships. Understanding the underpinning mechanisms is a potentially important public health concern.

Preventing the link between SES and high-risk behaviors: "value-added" education, drug use and delinquency in high-risk, urban schools.

We examined whether schools achieving better than expected educational outcomes for their students influence the risk of drug use and delinquency among urban, racial/ethnic minority youth. Adolescents (n = 2,621), who were primarily African American and Hispanic and enrolled in Chicago public schools (n = 61), completed surveys in 6th (aged 12) and 8th (aged 14) grades. Value-added education was derived from standardized residuals of regression equations predicting school-level academic achievement and attendance from students' sociodemographic profiles and defined as having higher academic achievement and attendance than that expected given the sociodemographic profile of the schools' student composition. Multilevel logistic regression estimated the effects of value-added education on students' drug use and delinquency. After considering initial risk behavior, value-added education was associated with lower incidence of alcohol, cigarette and marijuana use; stealing; and participating in a group-against-group fight. Significant beneficial effects of value-added education remained for cigarette and marijuana use, stealing and participating in a group-against-group fight after adjustment for individual- and school-level covariates. Alcohol use (past month and heavy episodic) showed marginally significant trends in the hypothesized direction after these adjustments. Inner-city schools may break the links between social disadvantage, drug use and delinquency. Identifying the processes related to value-added education in order to improve school environments is warranted given the high costs associated with individual-level interventions.

Psychosocial factors associated with the prescription of generic drugs.

OBJECTIVE: To evaluate factors associated with "Generic drug prescription" (GDP) behaviour in Spain using the ASE (Attitude, Social Influence, Self-Efficacy) Model. METHODS: General Practitioners were sent a validated and anonymous questionnaire measuring the ASE and Motivation variables for GDP and their generic drug prescription percentage. Most (n=486; 61.98%) responded to this cross-sectional survey. The mean scores and the 95% confidence intervals (95% CI) were calculated. A binary logistic regression was used to identify the variables that best predict GDP behaviour. RESULTS: The main advantages and motivations for GDP were "saving money" and "protecting professional ethics". The greatest social influences were "doctors' personal preferences" and "authorities' pressure". GDP accounted for a scarce 15% of the total prescription. ASE and Motivation items were the best predictors: they explain 25% of being a 'high prescriber'. The highest prescribers were paediatricians (OR=5.07), workers in rural settings (OR=3.68) and professionals with high Motivation (OR=1.17) and Attitude (OR=1.11) scores. CONCLUSIONS: GDP percentage is very low compared with other countries. Interventions to modify the Attitudes of Primary Care doctors towards generic drugs should be implemented. Better informed patients, longer doctor appointment times and more varied dosage forms of generic drugs would also facilitate improvements in GDP.

Trial protocol and preliminary results for a cluster randomised trial of behavioural support versus brief advice for smoking cessation in adolescents.

BACKGROUND: Many young people report they want to stop smoking and have tried to do so, but most of their quit attempts fail. For adult smokers, there is strong evidence that group behavioural support enhances quit rates. However, it is uncertain whether group behavioural support enhances abstinence in young smokers trying to quit. FINDINGS: A cluster randomised trial for young people trying to stop smoking to compare the efficacy of a school-based 9 week intensive group behavioural support course versus a school-based 7 week brief advice only course. Participants were assessed for evidence of tobacco addiction and nicotine replacement therapy (NRT) was used if it was deemed appropriate by the therapist. Both types of course aimed to recruit approximately one hundred participants from approximately ten schools.The primary outcome was successful quitting at 4 weeks after quit day judged according to the Russell standard. Had the trial been completed, abstinence at 6 months after quit day and the relationships between successful quit attempts and 1) psychological assessments of dependence prior to quitting 2) salivary cotinine concentration prior to quitting and 3) sociodemographic characteristics would also have been assessed. The proportion of participants who stopped smoking in each arm of the trial were compared using Chi square tests.The trial was stopped shortly after it had started because funding to support the therapists running the stop smoking group behavioural support programme was withdrawn. Only three stop smoking courses were completed (two group support courses and one brief advice pharmacotherapy course). Seventeen participants in total entered the trial. At the end of the courses, one participant (10%) attending the group support programme had stopped smoking and no participant attending the brief advice programme had stopped smoking. DISCUSSION: The trial was stopped so we were unable to determine whether group support helped more young people to stop smoking than brief advice. Engagement and recruitment of participants proved much more difficult than had been anticipated. Fifteen of the seventeen participants reported that quitting smoking was either pretty important or very important to them. Thus, the stop smoking success rate could, nevertheless, be considered disappointing. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25181936.

How ratings vary by staff group in multi-source feedback assessment of junior doctors.

CONTEXT: UK doctors-in-training undergo assessments of their professional behaviours. From an analysis of multi-source feedback (MSF) data, we report how ratings of junior doctors (Foundation Programme [FP] doctors and senior house officers [SHOs]) differed by staff group. METHODS: The MSF data were collected in 2003 and 2005 in hospitals in the West Midlands. Using a single-sided Team Assessment of Behaviour form, 1928 assessors evaluated 226 FP doctors and SHOs in four domains: professional relationship with patients; communication; team-working, and accessibility. The distribution of 'concerns' across the professional groups was explored using a random effects logistic regression model. RESULTS: On average, each trainee received nine assessment forms from a range of staff, most commonly nurses. Although concerns were identified for the minority, ratings varied by staff group. Peers (other FP doctors or SHOs) and administrators or managers were four and three times, respectively, less likely to indicate concern. By contrast, consultants and sisters (senior nurses) were more likely to give concern ratings. CONCLUSIONS: Guidance on the selection of assessors in any MSF process should take into account findings that rating behaviour varies by staff group.

Mediated, moderated and direct effects of country of residence, age, and gender on the cognitive and social determinants of adolescent smoking in Spain and the UK: a cross-sectional study.

BACKGROUND: European trans-national adolescent smoking prevention interventions based on social influences approaches have had limited success. The attitudes-social influences-efficacy (ASE) model is a social cognition model that states smoking behaviour is determined by smoking intention which, in turn, is predicted by seven ASE determinants; disadvantages, advantages, social acceptance, social norms, modelling, perceived pressure, self-efficacy. Distal factors such as country of residence, age and gender are external to the model. The ASE model is, thus, closely related to the Theory of Planned Behaviour. This study assessed the utility of the ASE model using cross-sectional data from Spanish and UK adolescents. METHODS: In 1997, questionnaires were simultaneously administered to Spanish (n = 3716) and UK adolescents (n = 3715) who were considered at high risk of smoking. Participants' age, gender, smoking intentions and ASE determinant scores were identified and linear regression analysis was used to examine the mediated, moderated and direct effects of country of residence, age and gender on participants' smoking intentions. RESULTS: All UK participants were aged 12 or 13 and most Spanish participants were aged between 12 and 14 (range 12-16 years). Amongst 12 and 13 year olds, regular smoking was more common in Spain. Almost half the participants were female (47.2% in Spain; 49.9% in the UK). Gender did not vary significantly according to age. The distribution of ASE determinant scores varied by country and predicted intention. The influence of each ASE determinant on intention was moderated by country. Country had a large direct influence on intention (1.72 points on a 7 point scale) but the effects of age and gender were mediated by the ASE determinants. The findings suggest resisting peer pressure interventions could potentially influence smoking amongst UK adolescents but not Spanish adolescents. Interventions that promote self-efficacy, on the other hand, would possibly have a greater influence on smoking amongst Spanish adolescents. CONCLUSION: The ASE model may not capture important cultural factors related to adolescent smoking and the relative contribution of particular ASE determinants to adolescent smoking intentions may differ between countries. Future European trans-national adolescent smoking prevention programmes may benefit from greater understanding of country-level cultural norms.

Psychosocial and behavioural determinants of the implementation of Pharmaceutical Care in Spain.

OBJECTIVE: We aimed to gain greater understanding of the implementation of the Pharmaceutical Care (PhC) initiative in Spain. Our investigation was underpinned by Prochaska and Di Clemente's stages of change model. We also used the A.S.E. (Attitude, Social influence and self-Efficacy) Model to identify the psychosocial determinants of this professional behaviour. SETTING: Spanish community pharmacists. METHOD: A validated questionnaire was sent to all community pharmacists registered on a national database and 1,977 (10.3%) responded. The questionnaire assessed stage of change regarding the implementation of PhC and the psychosocial determinants of this professional behaviour. Data were analyzed using descriptive statistics. Kruskal-Wallis and Mann-Whitney U tests were used to compare psychosocial determinants according to stage of change. The profile of community pharmacists who had implemented PhC was identified through logistic regression analysis. MAIN OUTCOME MEASURES: attitude, social influence, self-efficacy, motivations, needs and stages of change to perform PhC. RESULTS: Some respondents (n = 228; 11.8%) had adopted PhC, and were, thus, in the action or maintenance stage. The mean A.S.E. determinants scores increased significantly by stage i.e. from "precontemplation" to "action": attitude (0.28 vs. 0.99), social influence of people (2.61 vs. 3.07), and self-efficacy (2.74 vs. 3.61). Conversely, most needs were highlighted by precontemplators (3.66 vs. 347.). Variables significantly associated with the probability of implementing PhC were: having undertaken appropriate training (OR: 13.92; CI 95%: 5.37-36.08); self-efficacy (OR: 3.19; CI 95%: 2.38-4.28), having assistant pharmacists (OR: 1.70; CI 95%: 1.02-2.80) and positive attitude (OR: 1.03; CI 95%: 1.01-1.04). The A.S.E. determinants were the best predictors of PhC implementation according to the regression model. CONCLUSION: The implementation of PhC among Spanish community pharmacists appears to be relatively low. Strategies to move pharmacists should be adapted to stage: focussed on emphasizing advantages at initial stages and facilitating training courses, guidelines and communication to professionals at intermediate and advanced stages.

Value-added education and smoking uptake in schools: a cohort study.

AIM: To show that schools achieving higher examination pass and lower truancy rates than expected, given that their pupil populations (high value-added schools) are associated with a lower incidence of smoking among pupils (13-14 years). DESIGN: Value-added scores for schools were derived from standardized residuals of two regression equations predicting separately the proportion of pupils passing high school diplomas and the half-days lost to truancy from the socio-economic and ethnic profiles of pupils. The risk of regular smoking at 1- and 2-year follow-up was examined in relation to the value-added score in a cohort of 8352 UK pupils. Random-effects logistic regression was used to adjust for baseline smoking status and other adolescent smoking risk factors. SETTING: A total of 52 schools, West Midlands, UK. PARTICIPANTS: Year 9 pupils aged 13-14 years (n = 8352) were followed-up after 1 year (n = 7444; 89.1% of original cohort) and 2 years (n = 6819; 84.6% of original cohort excluding pupils from two schools that dropped out). MEASUREMENTS: Regular smoking (at least one cigarette per week). FINDINGS: Schools with high value-added scores occurred throughout the socio-demographic spectrum. The odds ratio (95% confidence interval) for regular smoking for a 1 standard deviation increase in the value-added measure was 0.85 (0.73-0.99) at 1-year and 0.80 (0.71-0.91) at 2-year follow-ups. Baseline smoking status did not moderate this. CONCLUSIONS: Schools with high value-added scores are associated with lower incidence of smoking. Some schools appear to break the strong link between deprivation and smoking. Understanding the mechanisms could be of great public health significance.

School culture as an influencing factor on youth substance use.

OBJECTIVE: To determine whether value-added education is associated with lower risk of substance use among adolescents: early initiation of alcohol use (regular monthly alcohol consumption in grade 7), heavy alcohol use (>10 units per week) and regular illicit drug use. DESIGN: Cross-sectional self-reported survey of alcohol and drug use. Analysis used two-level logistic modelling to relate schools providing value-added education with pupils' substance use. The value-added education measure was derived from educational and parenting theories proposing that schools providing appropriate support and control enhance pupil functioning. It was operationalised by comparing observed and expected examination success and truancy rates among schools. Expected examination success and truancy rates were based on schools' sociodemographic profiles. PARTICIPANTS: Data were collected across 15 West Midlands English school districts and included 25,789 pupils in grades 7, 9 and 11 from 166 UK secondary schools. RESULTS: Value-added education was associated with reduced risk of early alcohol initiation (OR (95% CI) 0.87 (0.78 to 0.95)) heavy alcohol consumption (OR 0.91 (0.85 to 0.96)) and illicit drug use (OR 0.90 (0.82 to 0.98)) after adjusting for gender, grade, ethnicity, housing tenure, eligibility for free school meal, drinking with parents and neighbourhood deprivation. CONCLUSIONS: The prevalence of substance use in school is influenced by the school culture. Understanding the mechanism through which the school can add value to the educational experience of pupils may lead to effective prevention programmes.

A preliminary investigation into factors influencing limiting long-standing illness among UK university graduates: a retrospective cohort study.

Two competing hypotheses underpinned an investigation into limiting long-standing illness (LLI) among UK graduates. Hypothesis 1 proposed childhood social class (CSC) influences LLI independently of educational attainment and adult income. Hypothesis 2 proposed typical middle-class graduates would have lower LLI prevalence than typical and atypical working-class and atypical middle-class graduates. Working/middleclass refers to childhood circumstances. Atypical/typical refers to full-time employment duration before attending university. Graduates (1985; N = 5093 and 1990; N = 8147) were followed up in 1996. Logistic regression was used to examine LLI in 1996 by CSC only and CSC, atypical graduate status and their interaction, adjusting for age and adult income. Hypothesis 1 was not confirmed. Hypothesis 2 was partially confirmed. Typical middle-class graduates had a lower LLI prevalence than typical working-class and atypical middle-class graduates. These results support the idea that opportunities for good human functioning are culturally determined and affect health.

Sexual health care training needs of general practitioner trainers: a regional survey.

OBJECTIVES: The National Strategy for Sexual Health and HIV aims to facilitate improved patient access to sexual health care, primarily in general practice. This study aimed to identify sexual health care provision in general practitioner (GP) training practices and highlight training and resource implications of the strategy for GPs and prospective GPs. METHODS: Data were gathered from interviews with five key representatives (all of whom had a special interest in GP training and/or sexual health care) and a self-completed questionnaire survey of all 374 GP trainers in the West Midlands region. The questionnaire was developed from the interviews and comprised three sections: sample characteristics; current practice; and 30 statements to elicit attitudes, knowledge and training implications. The questionnaire was mailed out in March 2002 with two re-mailings at 2-week intervals. RESULTS: Most GP trainers (79%; n=295) returned completed questionnaires. Most respondents were already offering some 'Level 1 services' or were prepared to including cervical screening (100%; n=295), sexual history taking (95%; n=271), sexually transmitted infection (STI) testing (74%; n=217), HIV testing (68%; n=198) and contraceptive services (71%; n=208). However, most (86%; n=251) needed further information on the Strategy detail and its implications. Training needs in sexual history taking, STI testing and HIV testing were also highlighted. Most GP trainers (62%; n=181) believed GP registrars were relatively unprepared for sexual health care and proposed improved training and assessment. Appropriate nurse training should also be provided. CONCLUSION: Although 82% (n=242) of respondents would implement the Strategy if properly resourced, considerable training and support needs were identified.

Is inter-school variation in smoking uptake and cessation due to differences in pupil composition? A cohort study.

The aims of this study were to determine if inter-school variation in smoking prevalence was due to differences in pupil composition or other school-level factors. A cohort of 13-14-year-olds (n = 7147) from 52 schools was followed-up 1 year later. Random effects logistic regression was used to examine school variation in smoking uptake and cessation, with and without adjustment for pupil composition. Inter-school variation in smoking prevalence is not caused by differences in pupil composition but is due to differences in the onset of smoking arising because of unmeasured school contextual or collective factors operating on pupils' decisions.

A methodological and substantive review of the evidence that schools cause pupils to smoke.

The objectives of this review were to examine whether smoking prevalence varies between schools independently of health promotion programmes and pupil composition, to show which school characteristics are responsible for this variation, and to examine the methodological adequacy of such studies. Searches for published studies were performed on medical, educational and social science databases, relevant articles' reference lists, and citation searches. Any study was included that described inter-school variation in smoking prevalence, or related such variation to school characteristics. A model relating pupil smoking to school, neighbourhood, and pupil characteristics unlikely and likely to be influenced by school was used to examine the adequacy of control of confounding by pupil composition. Data from studies were combined qualitatively considering methodological adequacy to examine the relation of smoking prevalence to school characteristics. Theoretical frameworks underpinning the choice of school characteristics and postulated relationships between these characteristics and smoking prevalence were described. There were large variations in smoking prevalence between ostensibly similar schools. Evidence that pupil composition did not cause this was weak, because all studies had methodological problems, including under control of relevant pupil compositional factors and over control of factors likely to represent the mechanism through which schools influence pupils' smoking. There was little evidence that elements of tobacco control policy other than bans and enforcement deterred smoking. Academic practice and school ethos were related to smoking. Academically selective schools did not influence smoking, once pupil composition was controlled. There was one study on neighbourhood influences, which were unrelated to smoking. Studies frequently offered little or no theoretical justification for associating school characteristics with smoking. Some aspects of school influence pupils' smoking, probably independently of pupil composition. However, under-control and over-control of confounding and lack of theoretical underpinning precludes definitive conclusions on how particular school characteristics influence pupils' smoking.

The influence of school culture on smoking among pupils.

School factors and not solely pupil composition probably cause variation in smoking prevalence amongst schools, but there are no theoretical models to explain why. In this paper we propose a hypothesis to explain schools' influence on pupils' smoking and test this using an existing cross-sectional survey of 23,282 pupils from 166 secondary schools in the West Midlands, UK. We hypothesise that school-level educational achievement scores would not be associated with smoking prevalence, but schools providing value-added education given the social background of pupils (authoritative schools) would provide effective support and control, have a relatively strong influence on pupils' lives and be associated with lower than average smoking prevalence. Schools providing value-denuded education (laissez-faire schools) would have a relatively weak influence on pupils' lives and be associated with higher than average smoking prevalence. The school achievement measures were the proportion of pupils achieving 5A-C General Certificates of Secondary Education (5A-Cs) grades and the proportion of half days lost to truancy. Value-added/denuded terms were created by regressing 5A-Cs and truancy on five markers of the social profile of pupils at the school. Authoritative schools achieved better than expected rates on both measures. Laissez-faire schools achieved worse than expected rates on both measures. All other schools were classed as indeterminate. Multilevel logistic regression was used to relate the risk of regular smoking to school culture in both achievement and authoritative/laissez-faire terms, both with and without adjustment for pupil-level risk factors for smoking. As predicted, schools' achievement measures were unrelated to pupils' smoking. The odds ratios (95% confidence intervals) for smoking in authoritative and laissez-faire schools relative to indeterminate schools were 0.80 (0.70-0.91) and 1.16 (1.07-1.27), respectively. Adjustment for pupil-level smoking risk factors had little effect. School culture is an independent risk factor for adolescent smoking. Schools providing effective support and control might protect pupils from smoking.

What determines future smoking intentions of 12- to 13-year-old UK African-Caribbean, Indian, Pakistani and white young people?

It is important to know when designing adolescent smoking interventions how ethnicity and gender influence intention. This paper reports an investigation into how ethnicity influences the smoking intentions of disadvantaged UK African-Caribbean (n = 275), Indian (n = 397), Pakistani (n = 687) and white (n = 1792) 12-13 year olds. The Attitudes-Social influences-Efficacy (ASE) model underpinned the study. It states that ASE determinants (advantages, disadvantages, social acceptance, social norms, modelling, perceived pressure and self-efficacy) directly influence behavioural intention. External factors (country, ethnicity and gender) indirectly influence intention by influencing ASE determinants. ASE determinant scores and future smoking intentions were measured. Linear regression analyses showed that smoking intention varied by ethnicity and gender. Differences in ASE scores largely explained these variations. Ethnicity and gender did not modify the predictive effects of equivalent ASE determinant scores on intention. Being a white boy had a small independent direct influence on intention, which was ascribed to affective beliefs underpinning fitness and sporting prowess. Otherwise, ethnicity had no independent direct effects on intention. Culturally appropriate interventions that aim to change cognitions underpinning ASE determinants and, thus, ASE scores would, consequently, be expected to be equally effective amongst disadvantaged UK African-Caribbean, Indian, Pakistani and white adolescents.

A new theory of health promoting schools based on human functioning, school organisation and pedagogic practice.

This paper outlines a novel explanatory frame for understanding how schools may intervene in order to promote pupils' health. The new theory is synthesised from an Aristotelian interpretation of human functioning and a theory of cultural transmission. In keeping with recent influential theoretical developments, it is proposed that health has its roots in human functioning. It follows from this concept that the promotion of pupils' health is facilitated by the promotion of pupil functioning and the primary mechanisms through which schools promote pupil functioning and, hence, health, are through the influences of school organisation, curriculum development and pedagogic practice on pupil development. According to the new theory, good human functioning is dependent on the realisation of a number of identified essential human capacities and the meeting of identified fundamental human needs. Two essential capacities, the capacity for practical reasoning and the capacity for affiliation with other humans, plan and organise the other essential capacities. The realisation of these two capacities should, it is argued, be the primary focus of health promoting schools. Additionally, health promoting schools should ensure that fundamental human needs concerning non-useful pain and information about the body are met. A number of testable hypotheses are generated from the new theory. Comparisons with existing interpretations of health promoting schools indicate there are similarities in the actions schools should take to promote health. However, the new theory can, uniquely, be used to predict which pupils will enjoy the best health at school and in adulthood. Additionally, according to the new theory, schools do not need designated health education classes or teaching staff with specialist health education roles in order to be health promoting. It is concluded that the new theory may have a number of advantages over existing theories at both the policy and intervention levels.

The risk of smoking in relation to engagement with a school-based smoking intervention.

Health promotion interventions cannot work if people do not engage with them. The aim of this study was to examine whether disengagement from an adolescent smoking prevention and cessation intervention was an independent risk factor for regular smoking 1 and 2 years later. The data were taken from a cluster randomised controlled trial, in the West Midlands, UK, based on the transtheoretical or stages of change model. In this trial, 8,352 13-14-year old school pupils enrolled, and the data in this report were based on the 7,413 and 6,782 pupils present at 1 and 2 years follow-ups, respectively. The intervention group undertook three sessions using an interactive computer programme. At the end of the programme, pupils recorded their responses to it. Pupils were classed as engaged if they thought the intervention was both useful and interesting; all others were classed as disengaged. Random effects logistic regression related the number of times engaged to regular smoking at 1 and 2 years follow-up, adjusted for school absences and 11 potential confounders. The majority of pupils were engaged by the intervention. For participants using the intervention three times but not engaging once, the odds ratios (95% confidence intervals) for smoking at 1 and 2 years relative to the controls were 1.83 (1.41-2.39) and 1.70 (1.38-2.11). For those engaging three times, they were 0.79 (0.60-1.03) and 0.96 (0.75-1.21). There was no interaction with baseline intention to smoke, classified by stage of change, but there was a borderline significant interaction with baseline smoking status, with disengagement acting as a stronger risk factor among baseline never-smokers. We conclude that disengagement from interventions is a risk factor for smoking independently of experimentation with cigarettes. The best explanation is that disengagement from school, an established risk factor for smoking, generalises to disengagement from didactic school-based health promotion programmes.