Peer Pressure and Family Smoking Habits Influence Smoking Uptake in Teenage Boys Attending School: Multilevel Modeling of Survey Data

Introduction: Among young teens, about one in five smokes worldwide. Adolescents spend a considerable amount of their time in school, and the school environment is therefore important for child health practices and outcomes. Objectives: We aimed to investigate the impact on smoking behavior of the school environment and the personal characteristics of male teenage students attending schools in Pakistan, taking into account the survey sampling structure. Methods: A twostage cluster sampling with stratification was employed, and we interviewed 772 male secondary school students. We adopted random effect and generalizing estimating equation models. Results: Peer pressure in particular had a strong influence on adolescents smoking; those whose friends smoked were up to 6 times more likely to smoke. Family smoking was also significantly associated with adolescents smoking, but those students whose mother was educated were 50% less likely to smoke. The fitted random effect model indicated that the between school variability was significant (p-value < 0.01), indicating differences in smoking habits between schools. A random coefficient model showed that variability among schools was not significantly different for public and private schools. Conclusion: Public health campaigns for smoking cessation should target not only the individual but also the families of adolescents attending schools. Corresponding author.