The relationship between peer relations, self-rated health, and smoking behavior in secondary vocational schools

Nursing Open. 2019;1–11.   | 1 wileyonlinelibrary.com/journal/nop2 Received:27July2018 | Revised:1October2018 | Accepted:16October2018 DOI:10.1002/nop2.260 RESEARCH ARTICLE The relationship between peer relations, self‐rated health and smoking behaviour in secondary vocational schools Hanna Aho1,2,3 | Anna‐Maija Koivisto1 | Eija Paavilainen1 | Katja Joronen1 ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium, providedtheoriginalworkisproperlycited. ©2019TheAuthors.Nursing OpenpublishedbyJohnWiley&SonsLtd. 1FacultyofSocialScience,Health Sciences,UniversityofTampere,Tampere, Finland 2DepartmentofMusclosceletal Diseases,TampereUniversityHospital, Tampere,Finland 3TampereUniversityofAppliedSciences, Tampere,Finland Correspondence HannaAho,UniversityofTampere,Tampere, Finland. Email:[email protected] Funding information Thisresearchprojectwasfundedby theJuhoVainioFoundation(Grant number201810080).Foundationhad noinvolvementinthestudydesign,data collection,dataanalysis,decisiontopublish, orthepreparationofthemanuscript. Abstract Aims: Toexaminetheassociationbetweenpeerrelations,self‐ratedhealthandsmok‐ ingbehaviourinvocationalschoolsetting. Background: Smokinginadolescencecauseshealthandsocioeconomicinequalityin adulthood.Thereisevidencethatsmokersarephysicallylessactive,haveloweraca‐ demicaspirationsandperceivepoorerhealththannon‐smokers. Method: Thestudywasconductedinspring2013andinvolved34,776vocational studentswhotookpartintheSchoolHealthPromotionStudyinFinland.Theasso‐ ciationsbetweenadolescentsmokinghabitsand peer relationsandsmokers’self‐ ratedhealthwerestudiedadjustingfortherespondents’age,parentaleducationand familytype. Results: Asubstantialproportionoftherespondents,37%ofthegirlsand36%ofthe boys,reportedsmokingdaily,15%ofthegirlsand14%boyssmokedoccasionally withafurther15%ofthegirlsand13%oftheboysstatingthattheywereex‐smok‐ ers.Ofthegirls,33%and38%oftheboyswerenon‐smokers.Adjustedmultinomial regressionrevealedthathavingaclosefriendorfriendspredictedsmokingamong girlsandboys.Additionally,theadjustedmodelindicatedthatbeingabullyand/ora bully+bully‐victimwasassociatedwithsmokingbehaviourinboysonly.Boysand girlswhoratedtheirhealthasmoderateorpoorweremoreoftendailysmokers;in girls,thiswasalsothecaseinoccasionalsmokers. Conclusion: Smokingpreventionaimedatvocationalschoolsshouldtakeintoconsid‐ erationthenormsandexpectationsrelatedtopeerrelationswhichstronglyinfluence adolescents’smokinghabits. KEYWORDS adolescenthealth,bullying,healthpromotion,inequalitiesofhealth,schoolhealth,school nursing,smoking 1 | INTRODUCTION Smoking among adolescents is a major public health concern as smokingposesmanyhealthriskssuchassubstanceuse(O'Loughlin, Dugas,O'Loughlin,Karp,&Sylvestre,2014)andlowerlevelofphysi‐ calactivity(Kauranen,2013)leadingtohealthinequalitiesinadult‐ hood(WorldHealthOrganization,2015).Furthermore,adolescents whosmokehavebeenassociatedwithnegativebehaviours,suchas 2 | AHO et Al. truancy (Vaughn, Maynard, Salas‐Wright, Perron, & Abdon, 2013) andbullying(Luk,Wang,&Simons‐Morton,2012).Morethanfour out of every five U.S adult smokers have begun smoking before 18yearsofageandsmokerswhostartsmokingatayoungageare morelikelytosmokeasadults(AmericanLungAssociation,2016). High school students who are acquainted with peers and family memberswhoaresmokershavebeenfoundtoreportmorepositive symptomsfromtheirinitialsmokingexperience(Okoli,Richardson, &Johnson,2008).Therefore,althoughpreventionofintergenera‐ tionaltransmissionisimportant, also peerrelationshipsandsocial relationshipsshouldbeaccountedforwhileplanningresearchinto waystocurbadolescentsmoking. Therelationshipsbetweenpeerrelationstoadolescentsmok‐ ing are complex. Peer relationships at school and perceptions of belongingness can mitigate the effects of risk factors linked tosubstanceuse.Friendshipshavebeenfoundtobeprotective againstsubstanceuse,aswellasmediatingtherelationshipbe‐ tween social self‐control (Forster, Grigsby, Bunyan, Unger, & Valente, 2015; Tang & Loke, 2012). Thus, social bonding with friendsandclassmatesishighlyrecommendable,anditispeerse‐ lectionandinfluencethathavefoundtoprecedeadolescentand youngadultsmoking(Jonesetal.,2013;Seo&Huang,2012).It hasbeendemonstratedthatadolescentswithfriendswhosmoke arelikelytosmokethemselvesortotakeupsmokingovertime (Simons‐Morton&Farhat,2010). In Finland, after 9‐year compulsory elementary school, there are two separate types of secondary schools. After the compul‐ soryschooling,55%ofschool‐leaversofFinlandchoosetocontinue intotheacademicallyorienteduppersecondaryschool,whichpre‐ paresstudentsforgraduateeducation.About39%willchoosevo‐ cational schoolingandtrainingthat is aimingtoimprovetheskills oftheworkforceandpreparestudentsforspecificvocations.The largestfieldsaretechnologyandtransport,businessandadminis‐ trationandhealthandsocialservicesleadingtoprofessionssuchas carmechanic,carpenter,salespersonnel,practicalnurse,thatiscare assistant,hairdresserordentallaboratoryassistant.Allstudypro‐ grammesinvocationalqualificationstakethreeyears(120credits) to complete. In the initial vocational upper secondary level, there are 52 vocational qualifications, and in all programmes, there is a compulsory minimum of six‐month period of on‐the‐job learning. (MinistryofEducation&Culture,Finland,2016). According to Belgian research, students in vocational schools have a significant lower sense of belonging than students in ac‐ ademic high school (Van Houtte & Van Maele, 2012). Studying requiresmoreindependenceonbehalfofthestudent;he/sheisre‐ sponsibleforhowwellorbadlytheymakeprogressontheroadto becomingaskilledprofessional.Smokingratesamongadolescents’ studyingfordifferentvocationsaremuchhigherthanamonghigh schoolstudents.Itwasestimatedin2013thatabout36%ofthose Finnishadolescentslearningaspecifictradeinvocationalschoolsare smokingdaily,comparedwithonly8%oftheirpreviousclassmates thatcontinuedtotheacademicallyfocuseduppersecondaryschool after ninth grade. This relationship has been noted also in other Western countries (Huisman, Werfhorst, & Monshouwer, 2012; Ingholtetal.,2015;Lee,Goldstein,Klein,Ranney,&Carver,2012; Loukas,Murphy,&Gottlieb,2008).Furthermore,academicachieve‐ mentandsmokingbehaviourexhibitanassociation,thatisindivid‐ uals with lower levels of academic achievement seem to be more likelytosmokecigarettes(Andersenetal.,2015).Astudyconducted Why is this research needed? • Tobaccosmokingisapreventablecauseonhealthine‐ qualityandprematuredeath.Youthsstudyingforblue‐ collar trades in vocational schools smoke significantly morethanthoseyouthswhohaveselectedacademically orientateduppersecondaryschool,thatishighschool. • Thereareveryfewgoodqualitystudiesconductedon smokingamongvocationalstudents. What are the key findings? • Tobaccosmokingisdisproportionatelyprevalentamong vocationalstudents. • Friendships are related to smoking among vocational schoolstudents. • Bulliesand/orbullieswhoarealsobullyingvictimsare morefrequentlysmokersthanstudentswhodonotpar‐ ticipateinbullyingbehaviouramongboysonly. • Adolescents that ratetheir healthas moderateor bad aremorelikelysmokers. • Relationship between peer relations and adolescents’ smokingiscomplexalsoinvocationalschools; further researchwithmultiplemethodswillbeneededtoclarify thisassociation. How should the findings be used to influence policy/practice/research/education? • Enhancingschoolactivityinschoolpremisesaimingso‐ cial bonding to all schoolmates and connectedness to school might have a great impact of creating healthy studyenvironment. • Bothcommunityandschoolnursesarewellpositionedto provideeducationandsupportatreducingsmokingand topromotemethodsforeffectivesmokingcessation. • Strategies to reduce socioeconomic inequalities in smokingshouldinvolveaspectsofpeerrelationships. Impact statement Smokinginadolescenceleadstohealthinequalityinadult‐ hood.Accordingtothisstudy,healthinequalityisevident muchearlier,alreadyinadolescence.Schoolhealthnurses andcommunityhealthnurseshaveanuniqueopportunity topromoteeffectivelyhealthystudyenvironmentsbytak‐ ingaccountofpeerrelationsatschool. | 3 AHO et Al. amongvocationalschoolinFinlandfoundsomestudentsbelieving thatsmokingenhancestheirsocialstandingandprojectsanimage ofaskilledprofessional(Kauranen,2013).Blue‐collarworkersalso smokesignificantlymorethantheirwhite‐collarcounterparts.Since vocationaltraininghasperiodsofon‐the‐joblearning,thestudents maymimicthebehaviouroftheirworkmates/instructors(Bonevski, Paul,Walsh,Bryant,&Lecathelinais,2011).Tutorsareconsideredas authoritieswhoseviewsandexamplearegenerallynotopposed(Kiri &Catherine,2018). 1.1 | Background Smokingisamultifacetedbehaviourinfluencedbyseveralfactors, andundoubtedly,theschoolenvironmentexertsacriticalinfluence onadolescentwell‐being.Thetheoryoftriadicinfluence(TTI)(Flay &Petraitis,1994;Flay,Petraitis,&Hu,1999)suggeststhatadoles‐ cents’smokingbehaviourisinfluencedbyintrapersonalfactorsand contextual features but also by socio‐environmental aspects such asfriendsandfamily;learning,bondingandnormativebeliefs.Peer relations andsocial belonging have a major influence on the ado‐ lescent'sschoolperception,thatistheso‐calledschoolconnection; thesefactorshavebeenshowntoaffecteducationalambitions,for exampledecreasingtruancyanddropoutrates(Crosnoe&Johnson, 2011;Seo&Huang,2012). 1.1.1 | Peer relations Classmates have been shown to be important to allow vocational students to become engaged with their school (Elffers, Oort, & Karsten,2012)Alackofpeerrelationshasbeenshowntoresultin school dropout(Havik,Bru,&Ertesvåg,2015).Bullying behaviour exerts a significant detrimental impact on adolescent well‐being; for instance, it is responsible for truancy and dropout, even sui‐ cide(Haviketal.,2015;Kellyetal.,2015).Previously,bullyinghas beenshowntobemoreprevalentamongmiddleschooladolescents thanolderstudentsbutitdoespersistalsointhefinalschoolyears (Azagba,2016;Radliff,Wheaton,Robinson,&Morris,2012).There isresearchevidenceindicatingthatbullyingisrelatedtosmoking behaviour(Azagba,2016;Klein,Cornell,&Konold,2012;Luketal., 2012;Niemeläetal.,2011;Radliffetal.,2012).Studiesconducted in Australia and the USA among middle and high school students found that both bullies and bullies that have been bullied them‐ selvesreportedthegreatestlevelsofsubstancemisuseandsmok‐ ingwhilebullyingvictimsandstudentsnotinvolvedinbullyingwere lesslikelytoabusesubstances(Kellyetal.,2015;Radliffetal.,2012) Furthermore,thosebulliedduringchildhoodweremorelikelytobe regularsmokersbytheageof18(Niemeläetal.,2011). 1.1.2 | Self‐rated perceived health Adolescent students’ well‐being is related to their subjective so‐ cialstatus (Zorotovich,Johnson,&Linn,2016),butthesocialsta‐ tusgainedbysmokingdoesnotseemtocorrelatewithperceived orself‐ratedhealth(Hansen,Lindström,&Rosvall,2015).Dailyand occasional smokers have reported more physical and psychologi‐ calcomplaintsandlowerqualityoflifethanneversmokers(Dube, Thompson,Homa,&Zack,2013;Hansenetal.,2015;Wang,Ho,Lo, Lai,&Lam,2012).Previously,earlysmokinginitiatorshavereported poorerhealththanlaterinitiatorsandthispoorerself‐ratedhealth remainsevenaftersmokingcessationamongboyswhostartedto smokeatanearlyage(Hansenetal.,2015). 2 | AIMS Therearestudiesconductedinprimaryandsecondaryschoolsex‐ amining the association between peer relations with smoking but fewerstudieshaveinvestigatedpeerrelationsrelatedtoadolescent smoking in the vocational school setting, even though there has beenatraditionallyhighprevalenceofvocationalschoolstudents whoaresmokers.Furthermore,smokers’self‐ratedhealthhasnot previouslybeenstudiedinthissetting.Inthisstudy,wewillexamine whether:(a)peerrelations;and(b)self‐ratedhealthareassociated withadolescents’daily,occasionalandformersmokingbehaviourin avocationalschoolsetting. 3 | DESIGN ThiswasasecondarydataanalysisusingthedataofSchoolHealth Promotion Study carried by Institution of National Health and WelfareinFinland.Thedatawereanalysedwithmultinomialregres‐ sion,cross‐sectionaldesign. 3.1 | Participants The target group for this study consisted of 1st (57%) and 2nd (43%) grade students in vocational schools in Finland in 2013. A totalof34,776studentsfromall419vocationalschoolsinFinland completed the questionnaire. The response rate of biennial study wasnotabletocountreliablyasthenumberofstudentswasnot inquiredfromtheinstitutesbutfromstatisticsthatcouldonlygive the total number of adolescents studying in vocational schools. However,thisstudywasnotconductedforstudentsintheirthird year. Furthermore, vocational training is based on long practical trainingperiodsandthatwasnotconsideredwhenconductingthe SHPstudy.Respondentsthatwereoutofschoolthedayofthestudy werenotcontactedafterwards.However,inthissecondaryanaly‐ sis,therateofmissingvalueswasquitelow(between0.3%–2.3%), with one exception: missing values for parents’ education were somewhathigher(mothers’education3.6%andfathers’education 4.7%)andquestionwhetherbeenbullied12.5%.Vocationaltraining canbestartedaftertheninthgradeofelementaryschool,butitis alsopossibletostartlater.Forthisreason,agedistributionwithin the1stand2ndgradesmayvary.Therespondentswereagedbe‐ tween14–20(Mean=17.6,SD0.90).Overhalf(55.6%)weremales 4 | AHO et Al. TABLE 1 Samplestatisticsofselectedvariables Variables Girls Boys pN %N% Currentsmokinghabit Daily 5,613 37.2 6,522 35.6 <0.001 Weeklyorlessthanweekly 2,249 14.9 2,311 12.6 Ihavequitsmoking 2,254 15.0 2,543 13.9 Non‐smoking 4,955 32.9 6,948 37.9 Areyouexperiencingdifficultiesingettingalongwithschoolmates Notatall 10,795 56.4 9,370 61.1 <0.001 Ratherlittle 5,978 31.2 4,431 28.9 Rathermuch 1,753 9.2 1,082 7.1 Verymuch 629 3.3 451 2.9 Atthemoment,doyouhaveaclosefriendwithwhomyoucantalkconfidentiallyaboutalmosteverythingconcerningyourself? Idonothaveanyclosefriends 736 4.8 1,844 9.8 <0.001 Ihaveoneclosefriend 3,203 21.0 3,797 20.2 Ihavetwoclosefriends 4,183 27.4 3,755 19.9 Ihaveseveralclosefriends 7,166 46.9 9,441 50.1 Howoftenhaveyoubeenbulliedatschoolduringthissemester? Severaltimesaweek 209 1.4 557 2.9 <0.001 Aboutonceaweek 273 1.8 525 2.7 Rarely 2,170 14.1 3,159 16.4 Notatall 12,757 82.8 15,035 78.0 Howoftenhaveyouparticipatedinbullyingotherpupilsduringthissemester? Severaltimesaweek 87 0.6 478 2.5 <0.001 Aboutonceaweek 148 1.0 524 2.7 Rarely 1,876 12.2 4,112 21.4 Notatall 13,295 86.3 14,144 73.4 Bullyingindicator Bulliedbully 80 0.5 492 2.6 <0.001 Bully 154 1.0 510 2.7 Victim 401 2.6 582 3.0 Notbulliednotbully 14,746 95.9 17,644 91.8 Self‐ratedhealth Moderateorpoor 4,064 26.5 3,251 17.0 <0.001 Fairlygoodorgood 11,286 73.5 15,837 83.0 Respondentsage 14 26 0.2 13 0.1 <0.001 15−16 3,674 23.7 5,217 27.1 17−18 9,750 63.4 12,747 66.3 Familytype Intact 6,847 45.0 10,359 55.2 <0.001 Co‐parenting/dualresidence 662 4.3 1,491 7.9 Singleparent 2,364 15.5 3,127 16.7 Stepfamily 1,437 9.4 1,712 9.1 Othertype 3,914 25.7 2,080 11.1 (Continues) | 5 AHO et Al. (N=19,336)and44.4%females(N=15,440).Toaccountforpoten‐ tialgenderdifferences,separateanalyseswereconductedforboys andgirls.SamplestatisticsofselectedvariablesareshowninTable1. 3.2 | Data collection DatafromtheSchoolHealthPromotionStudy(SHP)conductedbythe NationalInstituteforHealthandWelfareinFinlandwereusedinthis study.SHPisanationwidesurveyofadolescents’healthandwell‐being andisconductedeveryotheryearinMarch–April.Thetargetgroupfor thisstudyconsistedof1stand2ndgradestudentsinvocationalschools in Finland in 2013. A total of 34,776 students from 419 vocational schoolsanonymouslyandvoluntarilycompletedaclassroom‐adminis‐ teredquestionnaireofcomprehensivemeasuresoftheirhealthandwell‐ beingundertheirteacher'ssupervision.Thequestionnairecanbefound onlineathttp://www.thl.fi/fi/web/thlfi‐en/research‐and‐expertwork/ population‐studies/school‐healthpromotion‐study 3.3 | Ethical considerations The study was approved by the Institute for Health and Welfare InstitutionalReviewBoardinFinland.Allstudentsweregivenade‐ tailedexplanationofthestudybytheresearchteam,andvoluntary participationtothestudywasconsideredastheinformedconsent according to local regulations. Respondents anonymously com‐ pletedontheirownaclassroom‐administeredquestionnaireunder theirteacher's supervision,which mostlikelyaddedtheresponse rateofthestudy.Participantswereinformedoftheirrighttowith‐ drawatanyphaseofthestudy. 3.4 | Measures Adolescent smokingbehaviourwasoriginallyassessedbytwoques‐ tions:(a)Howmanycigarettes,pipefulsandcigarshaveyousmoked altogether(none,onlyone,about2–50andover50)?(b)Whichof thefollowingalternativesbestdescribesyourcurrentsmokinghab‐ its?(Ismokeonceadayormoreoften,Ismokeonceaweekormore often,butnoteveryday,Ismokelessoftenthanonceaweek,Ihave quitsmoking,IhavesmokedtotalofonlyonetimeandIhavenever smoked).Theseadolescentsmokingvariableswerecombinedinto onevariablewithresponsecategories:dailysmokers(Ismokeoncea dayormoreoften),occasionalsmokers(Ismokeonceaweekorless often),thosewhohadquitsmoking(Ihavequitsmoking)andnon‐ smokers(Ihavesmokedatotalofonlyonetimeorneversmoked). Atotalof846respondentshadinconsistentresponsessuchasthey claimedtobenon‐smokersintheirresponsetothefirstquestionbut claimedtosmokeonadailybasisinthesecondquestion.Allthose 846respondentswereexcludedfromtheanalysis. Peer relationsweremeasuredbytwoquestions.Firstrespon‐ dentswereaskediftheyareexperiencingdifficultiesingettingalong withtheirschoolmateswith4‐pointscaleresponsecategoriesvary‐ ingfrom(1)not at allto(4)very much.Thisscalewasdichotomized into not at all/rather little and very much/rather much. Secondly, respondentswereaskedifastudenthadaclosefriendwithwhom the respondent could talk confidentially about almost everything concerningher/him.Responsecategorieswereasfollows:“Idonot haveanyclosefriends”;“Ihaveoneclosefriend”;“Ihavetwoclose friends”;and“Ihaveseveralclosefriends.”Thismeasurewasdichot‐ omizedas“havingatleastoneclosefriend”and“nothavinganyclose friends.”Next,therespondentwasaskedofhowoftentheyhadbeen bulliedatschoolduringthisschoolsemester.Theresponsecategory wasasfollows:“severaltimesaweek”;“aboutonceaweek”;“rarely”; and“notatall.”Studentswhorespondedthattheyhadbeenbullied weekly(severaltimesaweek/aboutonceaweek)wereconsidered asbeingbulliedatschoolandtherestofrespondentsasnotbullied atschool.Lastquestionthatmeasuredstudents’peerrelationswas howoftenyouhaveparticipatedinbullyingotherpupilsduringthis semesterwithresponsecategories:“severaltimesaweek”;“about once a week”; “rarely”; and “not at all.” Respondents that bullied otherpupilsonaweeklybasiswereconsideredasbullies. Variables Girls Boys pN %N% Mother'seducationlevel Comprehensiveschoolorprimaryschoolornoeducation 2,321 15.4 2,655 14.4 <0.001 Uppersecondaryschoolorvocationaleducation 6,550 43.5 7,617 41.2 Occupationalstudiesinadditiontouppersecondaryschoolorvocational education 3,166 21.0 3,917 21.2 University,universityofappliedsciencesofotherhighereducation 3,028 20.1 4,279 23.2 Father'seducationlevel Comprehensiveschoolorprimaryschoolornoeducation 3,419 23.0 3,761 20.6 <0.001 Uppersecondaryschoolorvocationaleducation 6,953 46.8 8,151 44.6 Occupationalstudiesinadditiontouppersecondaryschoolorvocational education 2,248 15.1 2,933 16.0 University,universityofappliedsciencesofotherhighereducation 2,243 15.1 3,450 18.9 TABLE 1 (Continued) 6 | AHO et Al. TABLE 2 Cross‐tabulation Girls’ smoking Boys’ smoking Smokes daily Occasionally Has quit smoking Non‐smoker p Smokes daily occasionally Has quit smoking Non‐smoker pN %N%N%N%N%N%N%N% Difficultieswithmates Ratherlittleor notatall 5,028 37.3 2,017 15.0 2,027 15.0 4,419 32.8 0.140 5,656 35.3 2,035 12.7 2,237 14.0 6,088 38.0 0.879 Ratherorvery much 540 36.6 218 14.8 219 14.8 499 33.8 808 37.8 254 11.9 282 13.2 794 37.1 Havingaclosefriend Ihaveafriendor friends 5,362 37.7 2,143 15.1 2,118 14.9 4,611 32.4 <0.001 5,862 36.1 2,115 13.0 2,278 14.0 5,964 36.8 <0.001 Don'thaveany friends 192 27.4 78 11.1 123 17.5 308 43.9 464 27.5 154 9.1 212 12.6 857 50.8 Bulliedatschool Severaltimesa week 92 47.7 15 7.8 33 17.1 53 27.5 0.003 226 46.8 52 10.8 58 12.0 147 30.4 <0.001 Weekly 110 41.8 32 12.2 31 11.8 90 34.2 164 37.5 53 12.1 56 12.8 164 37.5 Rarely 797 37.6 334 15.7 337 15.9 654 30.8 1,079 35.8 389 12.9 397 13.2 1,147 38.1 Notatall 4,608 37.0 1,860 14.9 1,849 14.8 4,150 33.3 5,039 35.1 1,806 12.6 2,027 14.1 5,474 38.2 Participatedinbullying Severaltimesa week 43 56.6 810.5 911.8 16 21.1 <0.001 218 52.9 48 11.7 52 12.6 94 22.8 <0.001 Weekly 70 50.4 22 15.8 19 13.7 28 20.1 187 43.7 63 14.7 55 12.9 123 28.7 Rarely 876 47.6 311 16.9 263 14.3 392 21.3 1,708 43.6 561 14.3 557 14.2 1,088 27.8 Notatall 4,614 35.5 1,903 14.7 1,955 15.1 4,512 34.8 4,382 32.4 1,630 12.1 1,872 13.9 5,625 41.6 Bullyingstatus Bulliedbully 41 63.1 46.2 69.2 14 21.5 <0.001 185 47.9 49 12.7 46 11.9 106 27.5 <0.001 Bully 72 48.3 26 17.4 21 14.1 30 20.1 220 48.5 62 13.7 61 13.4 111 24.4 Victim 161 41.2 43 11.0 58 14.8 129 33.0 203 38.4 55 10.4 68 12.9 203 38.4 Notbulliednot bully 5,324 36.9 2,165 15.0 2,157 15.0 4,769 33.1 5,881 34.9 2,130 12.6 2,357 14.0 6,499 38.5 Self‐ratedhealth Moderateorbad 1,914 48.0 555 13.9 503 12.6 1,018 25.5 <0.001 1,383 44.7 346 11.2 379 12.2 987 31.9 <0.001 Verygoodor good 3,661 33.3 1,688 15.3 1,738 15.8 3,912 35.6 5,068 33.7 1,940 12.9 2,138 14.2 5,890 39.2 | 7 AHO et Al. Theassociationbetweenbullyingwithadolescents’smokingwas exploredbyclarifyingthebullying status. Measurements of being bulliedandbeingabullywerecombinedtocreateabullying status toclarifythecomplexnatureofbullyingwithanewmeasurement: (a)bulliedbull;,(b)bullynotbullied;(c)bulliednotbully;and(d)not bulliednotbully. IntheSelf‐rated perceived health, therespondentevaluatedher/ hishealth.Responseswere“good”;“rathergood”;“moderate”;and “poor.”Measurementsweredichotomizedasself‐reportedhealthas being“good/rathergood”and”moderate/poor.”. 3.5 | Data analysis Cross‐tabulationandchi‐squaredtestswereperformedforcategori‐ cal variables to establish the proportion of students who smoked daily,thosewhosmokedoccasionally,thosewhohadquitsmoking andfinallythosestudentswhowerenon‐smokersonvariouspeer relationsfactorsaswellaswiththeadolescents’perceivedhealth (Table2).Adjusted(i.e.multivariateanalysis)(Table3)multinomial logistic regression analyses were then performed to examine and evaluatetheassociationsbetweensmokingandpeerrelationsand perceivedhealthfactors.Adolescentsmokingwassetasadepend‐ entvariableandpeerrelationsfactorsandperceivedhealthfactor as independent variables. Adolescents’ age, mothers’ and fathers’ education and family type were set as covariates (Aho, Koivisto, Paavilainen,&Joronen,2017;Wellmanetal.,2016).Dailysmokers, occasionalsmokersandthosewhohadquitsmokingwerecompared with non‐smokers,who were used asthe referencegroup.Toac‐ countforpotentialgenderdifferences,separateanalyseswerecon‐ ductedforgirlsandboys. ThestatisticalanalyseswereconductedusingIBM(Armonk,NY) SPSSstatistics23.Resultsfromthemultinomialregressionanalyses arepresentedasoddsratio(ORs)andtheir95%confidenceintervals. Thelevelofstatisticalsignificancewassetatp<0.001duetothe largenumberofrespondents. 4 | RESULTS 4.1 | Adolescent smoking prevalence AsshowninTable1,37%ofgirlsweredailysmokersand36%of boys.Girlswerealsooccasionalsmokers(15%)slightlymoreoften than boys (13%). Almost equal numbers, 15% of girls and 14% of boys,saidtheyhadquitsmoking.Everythirdgirl(33%)andalmost fouroutofevery10boys(38%)reportedbeingnon‐smokers. 4.2 | Bivariate associations between peer relations and adolescent smoking compared with non‐ smokers InTable2,wepresentthecross‐tabulationandchi‐squaretestsof smoking behaviour according to the peer relations variables and self‐rated health variable. Difficulties with schoolmates were not associated with smoking in either girls or boys. Instead, having a closefriendorfriendswassignificantlyassociatedwithsmokingin bothgenders.Isolates,thatisadolescentswithoutafriendinwhom they could confide, were less frequently daily smokers and were moreoftennon‐smokers. Beingavictimofbullyingatschoolwassignificantlyassociated withsmokinginboysbutnotingirls.Participationofbullyingbe‐ haviour was associated with smoking behaviour in both genders. Bullying status was significantly associated with smoking in both genders,andbulliesweremorefrequentlydailysmokersthantheir classmateswhodidnotparticipateinbullyingbehaviour. Self‐ratedhealthwassignificantlyassociatedwithsmokingbe‐ haviouringirlsandboys.Adolescentswhoassessedtheirhealthas moderateorpoorweremoreoftendailysmokersthantheircounter‐ partswhoratedtheirhealthasfollows:fairlygoodorgood. 4.3 | Multivariate associations between the peer relations variables, self‐perceived health and smoking behaviour Multivariateassociationsbetweenthepeerrelationsandadolescent smoking and perceivedhealth, for girls and boysrespectively, are presentedasORs,andestimatesareadjustedfortheageofthere‐ spondent,parent'seducationlevelandfamilytype(Table3).Even after adjustment for these socio‐demographic characteristics and havingaclosefriendandbullyingstatus,difficultieswithmateswere notassociatedwithsmokingbehaviourineithergender.However, havingaclosefriendorfriendsaddedtotheoddsofgirl'sdailysmok‐ ingandoccasionalsmokingandtoboys’dailysmoking,occasional smokingandformersmoking. Adjustedmodelofbullyingbehaviourwasnotassociatedwith smokingin girls. Boys who bullied others and werebullying vic‐ timsthemselves(bulliedbully)weresignificantlymoreoftendaily smokers. In addition, bullies who were not themselves bullied (bully–not bullied) were significantly more often daily and occa‐ sionalsmokers.Beingavictim(bullied–notbully)wasnotassoci‐ atedwithsmoking. Adjusted(Table3)multivariateregressionanalysisrevealedthat thosegirlswhoratedtheirhealthasmoderateorbadsmokeddaily and occasionally significantly more often than their non‐smoking classmates. Boys who assessed their health as moderate or poor weresignificantlymoreoftendailysmokers. 5 | DISCUSSION InthisnationallyrepresentativesampleofFinnish14‐to20‐year‐old vocationalschoolstudents,peerrelationsandself‐ratedhealthwere associatedwithsmokingbehaviourinbothgirlsandboysstudying inuppersecondaryvocationalschools.Aftercontrollingforthere‐ spondentsage,familytypeandparentseducationlevel,thisstudy identified:(a)havingafriendorfriendsbutnotnecessarilyaclass mateincreasedtheoddsforgirls’andboys’smokingeitherdailyor 8 | AHO et Al. TABLE 3 Adjustedoddratios(and95%confidenceintervals)inthemultinomiallogisticregressionofsmokingonpeer‐relatedissues Girls’ smoking Boys’ smoking Smokes daily Smokes occasionally Has quit smoking Smokes daily Smokes occasionally Has quit smoking OR 95% CI pOR 95% CI pOR 95% CI pOR 95% CI pOR 95% CI pOR 95% CI p Difficultieswithmates Hasdifficulties 0.89 0.77−1.02 0.081 0.98 0.82−1.16 0.785 0.95 0.79–1.13 0.532 1.02 0.91−1.14 0.704 0.98 0.84−1.14 0.772 0.95 0.82−1.11 0.538 Nodifficulties withmates 1 1 1 1 1 1 Havingaclosefriend Don'thave friends 0.44 0.36−0.53 <0.001 0.53 0.41−0.67 <0.001 0.85 0.79−1.06 0.139 0.45 0.40−0.52 <0.001 0.49 0.41−0.59 <0.001 0.63 0.54−0.75 <0.001 Hasafriendor friends 1 1 1 1 1 1 Bullyingstatus Bulliedbully 2.41 1.26−4.64 0.008 0.69 0.23−2.14 0.525 0.81 0.29−2.30 0.695 2.11 1.62−2.75 <0.001 1.60 1.09−2.30 0.017 1.22 0.83−1.80 0.319 Bully 2.00 1.27−3.14 0.003 1.92 1.12.3.29 0.018 1.57 0.88−2.78 0.126 2.23 1.74−2.86 <0.001 1.89 1.36−2.62 <0.001 1.63 1.17−2.27 0.004 Victim 0.98 0.76−1.25 0.852 0.72 0.50−1.02 0.066 0.99 0.72−1.36 0.934 1.03 0.84−1.27 0.778 0.85 0.62−1.16 0.311 0.96 0.72−1.28 0.786 Notbulliednot bully 1 1 1 1 1 1 Perceivedhealth Moderateorbad 1.95 1.78−2.14 <0.001 1.28 1.13−1.44 <0.001 1.06 0.94−1.21 0.326 1.59 1.44−1.75 <0.001 1.10 0.95−1.26 0.196 1.05 0.92−1.20 0.478 Goodorvery good 1 1 1 1 1 1 Note.Adjustedforage,familytype,mothers’educationandfathers’education Boldvaluesindicatep > 0.001 | 9 AHO et Al. occasionallyaswellasbeinganex‐smoker;(b)difficultiesinrelations with classmates were not associated with smoking behaviour; (c) beingabullyincreasedtheoddsforsmokingdailyandoccasionally andbeingabully‐victimincreasedtheoddsfordailysmokingonlyin boys;andd)poorerself‐ratedhealthwasassociatedwithsmoking behaviourinbothgirlsandboys. A literature review reported that isolates, that is adolescents withoutclosefriend(s),weremorelikelytosmokethantheircoun‐ terpartswithabetterpeernetworkstructure(Seo&Huang,2012). Thisdiffersfromthefindingspresentedhere.Inthisstudy,having atleast one closefriendwasassociated withhigherodds of daily smoking in girls and boys and additionally in girls with occasional smoking.Inthisstudy,thesmokingstatusofafriendwasnotinves‐ tigatedbutaccordingtopreviousresearchfriendswhosmoke,peer influenceandcrowdaffiliation(lähteet)increaseadolescentsmoking andalso might explain someof the highratesofsmoking adoles‐ centsinuppervocationalschools.However,somesocialpsychology theoriesmightexplainwhyadolescentssmokewithfriendsandwhy smokingismore commoninsurroundingswheresmoking ismore ubiquitous.Thesetheorieshypothesizethatpeoplecanbecatego‐ rizedasbelongingtogroups,andtheymakesocialcomparisonwith membersoftheirowngroup—aprocesscalledsocialidentification (Tajfel,1981).Smokersidentifythemselvesaspartofthe“smokers group,”andintheirsocialcomparisons,theymakeadistinctionbe‐ tweenusandthem;thatisbetweensmokersandnon‐smokers.It ispossiblethatthefearoflosingsocialstatus,beingexcludedfrom agroupofpeoplewithsimilarvaluesandattitudeswilleventually become apart oftheirself‐identity.This may prevent established smokersfromquittingsmokingeventhoughtheirawarenessofthe disadvantagesofsmokingisobvious.Furthermore,educationalcam‐ paignswhichhopereducesmokingbyhighlightingthefactthatitis an abnormal habit might increase the gap between the groups of smokersandnon‐smokers;inthiscase,thesecampaignsevidently causemoreharmthanbenefit. Arecent studyofDanish vocational schoolstudentsindicated thatsmokingplaysasignificantroleinsocialinteractionsandmaking newrelationshipsacrosseducationalprogrammes,inotherwords, for example students from the painting programme or hairdress‐ ing can meet students from the carpentering and plumbing pro‐ grammes.Inthatstudy,thevocationalschoolcontextenhancedthe likelihoodofsmoking;studentstookupsmokingasawayofestab‐ lishingsocialrelationshipswithpeers,andnon‐smokingcouldlead to exclusion from relationships forged around an ashtray (Ingholt etal.,2015).Surprisingly,wedidnotfindanyassociationbetween difficultieswithschoolmatesandsmokingbehaviour.Thismayindi‐ catethatsmokingisseenawaytofitinandconductsocialrelations. (Osgood,Feinberg,Wallace,&Moody,2014;Suh,Shi,&Brashears, 2017) Instead, itispossible thatdifficulties with schoolmatescan leadtowithdrawalfromthegroupofclassmates. Inthisstudyaftercontrollingforrespondentsage,familytype and parents’ education bullying was related only with smoking in boys;bothbeingabullyandbeingabullywhohasalsobeenabul‐ lyingvictimwereassociatedwithsmoking.Anunanticipatedfinding was that among girls either participating in bullying behaviour or beingavictimwasnotassociatedwithsmoking.Infact,bullyingwas notverywidespreadinvocationalschools.Ontheotherhand,itis possiblethatstudentsunderreportedbullying.Anotherexplanation fortheseresultsisthatdifferentaspectsofpeerrelationsotherthan bullyingmayincreasetheoddsofsmokingbehaviourinuppervoca‐ tionalschool.Smokingmaybemoreprevalentwithpopularstudents andbullyingisnotconsideredasdesirablebehaviour,andbeinga bullyisnotasuccessfulwaytoseekthepositiveattentionofpopular students. We found that smokers evaluated their health as poorer than theirnon‐smokingclassmates.Ourresearchdidnotcovertheage started experimenting with smoking but earlier studies have re‐ porteddailyandoccasionalsmokerstoexperiencemorehealthcom‐ plaintsandtohavealowerqualityoflifethanquitters,respectively (Dubeetal.,2013;Hansenetal.,2015;Tianetal.,2016;Wanget al.,2012).Previously,ithasbeenfoundthatstudentsreportpoorer subjectivehealthiftheyhadinitiatedsmokingbeforetheageof14 thanlaterstarters.Establishedsmokersarebroadlyawareofthead‐ dictivenatureofcigarettesandthehealthconsequencesofcigarette smokingcauses,evenmoresothantheirnon‐smokingcounterparts. However,smokersunderestimatetheaddictivepotencyofnicotine and assure themselves that they will be able to quit before their healthbecomescompromised.(Twigg&Byrne,2015)Furthermore, alongitudinalstudyhasshownthatadolescentswithmorethansix smokingfriendsreportincreasingperceptionsofbenefitsofsmok‐ ingovertime(Morrell,Song,&Halpern‐Felsher,2010).Studentsin vocational school invariably rate peer relations as being more im‐ portantthantheirhealth;however,addictionmaycomeassurprise. 5.1 | Limitations Althoughthesize,demographiccoverageandlong‐termstability oftheSHPareimpressive,therearelimitationsthatgiveriseto caution.First,thecross‐sectionaldesignpreventsusfromdeter‐ miningcausality.Longitudinaldatawouldhaveallowedustoex‐ aminetemporalrelationshipsbetweenvariablesandtheonsetand progression ofstudents’smoking behaviour.A secondlimitation istheusageofself‐reportdata;wecannotignorethepossibility of under‐ or over‐reporting of problematic behaviours (Brener, Billy,&Grady,2003). Nevertheless,littledata wereavailableon peer relations and smoking behaviour outside of the self‐report paradigm. However,self‐reportshavebeenshown to bereliable whenconductedunderoptimizedmeasurementconditions,ensur‐ inganonymityandwhenusingavarietyofquestions(Breneretal., 2003;Caraballo,Giovino,&Pechacek,2004).Ourapproachcould haveunderestimatedtheprevalenceofbullying,becausebullying hasbeenassociatedwithtruancy(Haviketal.,2015)andstudents whoareoftenabsentfromschoolmaynothavebeenincludedin thesurvey.Additionally,totalof12.5%ortherespondentsleftthe question of whether they had been bullied or not, unanswered. Last,despitethemanyadvantagesofsecondarydata,researchers arelimitedtothedatacollectedduringtheoriginaldatacollection.