Revisiting the continuum of resistance model in the digital age: a comparison of early and delayed respondents to the Norwegian counties public health survey.

BACKGROUND: The continuum of resistance model's premise is that delayed respondents to a survey are more similar to non-respondents than early respondents are. For decades, survey researchers have applied this model in attempts to evaluate and adjust for non-response bias. Despite a recent resurgence in the model's popularity, its value has only been assessed in one large online population health survey. METHODS: Respondents to the Norwegian Counties Public Health Survey in Hordaland, Norway, were divided into three groups: those who responded within 7 days of the initial email/SMS invitation (wave 1, n = 6950); those who responded after 8 to 14 days and 1 reminder (wave 2, n = 4950); and those who responded after 15 or more days and 2 reminders (wave 3, n = 4045). Logistic regression analyses were used to compare respondents' age, sex and educational level between waves, as well as the prevalence of poor general health, life dissatisfaction, mental distress, chronic health problems, weekly alcohol consumption, monthly binge drinking, daily smoking, physical activity, low social support and receipt of a disability pension. RESULTS: The overall response to the survey was 41.5%. Respondents in wave 1 were more likely to be older, female and more highly educated than those in waves 2 and 3. However, there were no substantial differences between waves for any health outcomes, with a maximal prevalence difference of 2.6% for weekly alcohol consumption (wave 1: 21.3%, wave 3: 18.7%). CONCLUSIONS: There appeared to be a mild continuum of resistance for demographic variables. However, this was not reflected in health and related outcomes, which were uniformly similar across waves. The continuum of resistance model is unlikely to be useful to adjust for nonresponse bias in large online surveys of population health.

How should recruitment to public health surveys be conducted? / Hvordan bør rekrutteringen til folkehelseundersøkelsene gjennomføres?

BACKGROUND: The aim of the public health survey in the Norwegian counties is to obtain information that is useful for public health work. In 2018, two parallel data collection processes were undertaken in Hordaland county. Both samples were drawn randomly from the National Population Register, but one of these was limited to users of the helsenorge.no website. The purpose of this article is to investigate the degree to which limiting users to the helsenorge.no website leads to selection bias beyond the selection that occurs through ordinary non-participation. MATERIAL AND METHOD: Services for Sensitive Data (TSD) was used in the data collection for the sample drawn from the National Population Register (n = 36 000), and the helsenorge.no platform was used in the data collection for the sample limited to users of helsenorge.no (n = 30 000). The response rate was 40.8 % and 41.5 %, respectively. RESULTS: For some outcome measures, the differences between the two datasets were modest (gender distribution, age, education and health habits). For variables that were more directly related to health, the differences were greater. In the helsenorge.no sample a higher proportion reported generally poorer health (29.4 vs. 24.0 %), mental health problems (13.6 vs. 11.6 %), disability pension (10.5 vs. 7.8 %) and long-term illness (13.3 vs. 9.3 %). Analyses of subgroups showed more pronounced differences in the proportion with generally poorer health and mental health problems between those with low education in the helsenorge.no sample and the corresponding group in the sample from the National Population Register. INTERPRETATION: Systematic and pronounced differences between the samples show that limiting recruitment to users of helsenorge.no's services results in further selection problems.

Supportive of a smoke-free campus but opposed to a 100% tobacco-free campus: Identification of predictors among university students, faculty, and staff.

Many universities are adopting campus tobacco policies, but little research has explored factors influencing the choice between the policy options of smoke-free versus 100% tobacco-free. Students, faculty, and staff at a U.S. state university participated in a web-based survey in 2013, approximately one year after adoption of a smoke-free policy. Respondents who expressed support for the policy were included in an analysis to examine their opinions regarding a 100% tobacco-free policy. The samples included 4138 students and 1582 faculty/staff. Bivariate analyses and multivariate logistic regression were used to identify predictors of opposition to a tobacco-free campus. Independent variables included strength of support for a smoke-free campus, past-month tobacco use (cigarettes, smokeless tobacco, e-cigarettes, non-cigarette combustible tobacco products), campus exposure to secondhand smoke, perceptions of tobacco-related behaviors and norms, and demographics. Of these supporters of a smoke-free campus, 14.3% of students and 10.2% of faculty/staff were opposed to a tobacco-free campus. In the multivariate analyses, in both samples, smokeless tobacco use predicted opposition while smoke-free policy support and female gender predicted support. In addition, among students, current or former cigarette smoking and non-cigarette combustible tobacco use predicted opposition; international student status and secondhand smoke exposure predicted support. Among faculty/staff, age over 55 predicted support. Future research should examine why current and former smokers might oppose policies restricting non-combustible tobacco products, even when they support smoke-free policies. In policy planning, campus administrators should communicate actual tobacco usage levels. International students who do not use tobacco may be a source of policy support.

Daily Smoking and Subjective Health Complaints in Adolescence.

INTRODUCTION: Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period. METHODS: Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (n total = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods. RESULTS: Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002-2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (-.963, n = 5, p < .01). CONCLUSIONS: As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints. IMPLICATIONS: This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.

The association between smoking and depression from adolescence to adulthood.

BACKGROUND AND AIMS: The association between depression and smoking is firmly established, but how the association develops remains unclear. The aim of this study was to examine development of the smoking-depression association from early adolescence to adulthood. DESIGN: Cross-sectional and longitudinal analyses of the smoking-depression association from adolescence to adulthood. SETTING: Hordaland, Norway. PARTICIPANTS: A cohort of adolescents (initially, 924 pupils) in the Norwegian Longitudinal Health Behaviour Study (NLHB) was followed over nine data collection waves from ages 13 to 30 years. MEASUREMENTS: Daily smoking and depressed mood were measured in each wave. FINDINGS: In the cross-sectional analyses, daily smoking and depression were significantly associated (P-value range from P < 0.01 to 0.04) in eight of nine waves. In the final longitudinal model, after controlling for the time-invariant effects of smoking and depression and of tertiary factors, the only significant paths were early adolescent smoking prediction of early adolescent depression (waves 1-2: ß = 0.07, P < 0.05; waves 2-3: ß = 0.12, P < 0.05) and vice versa (waves 1-2: ß = 0.10, P < 0.05; waves 2-3: ß = 0.08, P < 0.05). CONCLUSIONS: The inter-relationship between depression and smoking seems to be due to the reciprocal causal effects between smoking and depression that are established in early adolescence and maintained into adulthood.

Smoking during consecutive pregnancies among primiparous women in the population-based Norwegian Mother and Child Cohort Study.

INTRODUCTION: This study investigated changes in smoking behavior across pregnancies in a sample of 10,890 primiparous women participating in the prospective population-based Norwegian Mother and Child Cohort Study (MoBa) in order to identify risk factors that may inhibit smoking cessation and promote smoking during a woman's second pregnancy. METHODS: Registry information regarding smoking, age, marital status, parity, and year of birth was applied, in addition to questionnaire assessments of own and partner's smoking behavior, educational attainment, and symptoms of anxiety and depression at weeks 17 and 30 of gestation from both pregnancies. RESULTS: The vast majority did not smoke in either of the pregnancies, and more women quit smoking than relapsed to smoking in their second pregnancy. Among smokers in the first pregnancy, 30.9% quit smoking by their second pregnancy. Women living with a nonsmoking partner or a partner who quit between pregnancies were more likely to quit smoking, as were women smoking occasionally in their first pregnancy. Symptoms of psychological distress and increasing number of years between pregnancies were negatively associated with smoking cessation. Among women not smoking in their first pregnancy, 2.3% did smoke during their second. Living with a smoking partner, low educational attainment, symptoms of psychological distress, and increasing number of years between pregnancies were all associated with smoking during the second pregnancy. CONCLUSIONS: These findings, linking smoking behavior to changes taking place between pregnancies, offer new and additional insight into modifiable risk factors that may help facilitate more targeted smoking cessation interventions for women at the highest risk.

Late-onset smokers: how many, and associations with health behaviours and socioeconomic status.

AIMS: Adolescence is considered a critical phase for smoking initiation, while smoking initiation in adulthood has received less attention. In the present study, we investigated smoking initiation in early adulthood, with an additional focus on how socioeconomic status (SES) relates to late-onset smoking. METHODS: The Norwegian Longitudinal Health Behaviour Study followed a representative sample of adolescents (n=530) from age 13 (7th grade) to age 30 (years 1990-2007) through 9 waves of data collection. Information was collected on the adolescents' gender, smoking, alcohol use, cannabis use, physical activity, and SES. Those reporting to be smokers at age 30, but not at age 18, were defined as "late-onset smokers". RESULTS: At age 30, 21% were daily smokers, of which 45% met our definition of late-onset smoking. Participants with a low SES had a higher odds ratio for late-onset smoking (OR=3.42) and a lower odds ratio for quitting smoking (OR=0.40) after adjusting for confounders. CONCLUSIONS: Early adulthood is an additional critical phase for daily smoking initiation. The clear and consistent negative association between SES and late-onset smoking, as well as the positive association between SES and smoking cessation, contribute to the association between SES and smoking in the general adult population.

Adolescent smoking behavior and outcome expectancies.

Adolescent smoking behavior is assumed to be associated with smoking outcome expectancies. Results in this paper are based on data from the control group of two data collections among Norwegian secondary school students taken approximately 30 months apart (T1 and T2). The dimensionality of smoking outcome expectancies was the same at both time points, revealing three components ("Addicted", "Not harmful" and "Social"). After correction for attenuation, the Pearson's correlation between T1 and T2 was 0.41 for the total sumscore, indicating low to moderate relative stability. When examining smoking expectancy sumscore means by smoking habits at T1 and T2, never smokers were different from smokers on both occasions. Never smokers scored low on "Social" and "Not harmful", and high on "Addictive". All associations were statistically significant (p < 0.001). The "Social" dimension was the strongest predictor of smoking behavior at T1 and T2. One of the outcome expectancy sumscores ("Addictive") at T1 predicted smoking habits at T2 after controlling for smoking habits at T1 (p < 0.01). This predictor was significant also after entering outcome expectancy sumscores at T2 into the model (p < 0.05). These results indicate that outcome expectations other than the health-related ones should be paid attention to when planning new prevention programs.

Distal and proximal family predictors of adolescents' smoking initiation and development: a longitudinal latent curve model analysis.

BACKGROUND: Studies on adolescent smoking indicate that the smoking behaviours of their parents, siblings and friends are significant micro-level predictors. Parents' socioeconomic status (SES) is an important macro-level predictor. We examined the longitudinal relationships between these predictors and the initiation and development of adolescents' smoking behaviour in Norway. METHODS: We employed data from The Norwegian Longitudinal Health Behaviour Study (NLHB), in which participants were followed from the age of 13 to 30. We analysed data from the first 5 waves, covering the age span from 13 to 18, with latent curve modeling (LCM). RESULTS: Smoking rates increased from 3% to 31% from age 13 to age 18. Participants' smoking was strongly associated with their best friends' smoking. Parental SES, parents' smoking and older siblings' smoking predicted adolescents' initial level of smoking. Furthermore, the same variables predicted the development of smoking behaviour from age 13 to 18. Parents' and siblings' smoking behaviours acted as mediators of parents' SES on the smoking habits of adolescents. CONCLUSIONS: Parents' SES was significantly associated, directly and indirectly, with both smoking initiation and development. Parental and older siblings' smoking behaviours were positively associated with both initiation and development of smoking behaviour in adolescents. There were no significant gender differences in these associations.

Associations between adolescent socioeducational status and use of snus and smoking.

BACKGROUND: Findings from studies on the association between smoking and socioeconomic status are mixed. While adolescent smoking is reduced in many countries, use of smokeless tobacco seems to increase. Associations between socioeducational status and smoking as well as use of snus (smokeless tobacco), and to what extent these associations had changed significantly from 2004 to 2007 (a period of relatively abrupt changes in tobacco use in Norway), were examined. METHODS: Data from two national representative cross-sectional studies of Norwegian 16-20 year olds, where participants were asked questions allowing us to construct indicators of socioeducational status, was used. Information was also collected about the adolescents' smoking and use of snus, as well as their intentions with regard to future use of these products. RESULTS: Adolescents with a lower socioeducational status had much higher odds for smoking compared to those with higher socioeducational status (ORs ranged from 2.9 to 3.8). There was no similar association between socioeducational status and snus use (ORs ranged from 0.6 to 1.2). No support was found for a change in the socioeducational status-smoking/snus use association from 2004 to 2007. CONCLUSIONS: Adolescents' socioeducational status was associated with smoking for boys and girls, while there was no similar association with snus use. This may indicate that snus truly deviates from how smoking is distributed across social strata or that snus is at a much earlier stage in the social diffusion process.

Bar and restaurant workers' attitudes towards Norway's comprehensive smoking ban: a growth curve analysis.

BACKGROUND: Norway passed legislation banning smoking in restaurants, bars and other public spaces in 2004. This study tracks changes in hospitality workers' attitudes towards Norway's ban over three time points, using growth modelling analysis to examine predictors of attitude change. METHODS: Participants were a national sample of 1525 bar and restaurant workers. Surveys were conducted, by phone or internet, one month before the ban's implementation and at 4 and 12 months thereafter. Exploratory principal components analysis of nine survey items revealed one primary attitude component. A latent growth model was fitted to the data to examine trajectories of attitude change and individual differences in rate of change. RESULTS: Respondents supported the ban before implementation and increased support at 4 months (p=0.021) and again at 12 months (p=0.001). Concern for one's job followed a quadratic trend, increasing at 4 months and decreasing at 12 months (p<0.001). All demographic categories were associated with attitude increase; rate of increase was greater for females than males. Two within-person variables--change in smoking status and change in job concern--strongly predicted (p<0.001) respondents' deviations from their predicted group trajectories, explaining over 70% of residual between-person slope variance. CONCLUSIONS: Norway's hospitality workers increased their support of the ban over its first year. The strong influence of the within-person variables leads to two primary policy recommendations. First, support should be provided to assist cessation efforts and prevent relapse. Second, informational campaigns should inform hospitality workers about evidence that smoking bans are not economic threats to the industry.

Associations between schools' tobacco restrictions and adolescents' use of tobacco.

Schools are an important arena for smoking prevention. In many countries, smoking rates have been reduced among adolescents, but the use of smokeless tobacco is on the rise in some of these countries. We aimed to study the associations between schools' restrictions on smoking and snus and on the use of these tobacco products among students in upper secondary school. We employed data from a national representative study of 1444 Norwegian students, aged 16-20 years. Respondents were asked about their schools' restrictions on snus and smoking and own use of these products. We examined associations between restrictions and the use, controlling for age, gender, type of school and regional differences. We found clear consistent associations between schools' restrictions on tobacco use and less use of these products. More explicit pervasive restrictions were strongly associated with the prevalence of use. This first study on the associations between schools' restrictions on snus and the prevalence of snus use corroborate what has been found in many studies on smoking restrictions and smoking. Strict school tobacco policies may be an important tool if health authorities are interested in implementing measures to limit or reduce snus use among adolescents.

[Use of tobacco among Norwegian pupils in secondary school 1975-2005]. / Tobakksbruk blant norske ungdomsskoleelever 1975 - 2005.

BACKGROUND: The proportion of daily smokers in the adult Norwegian population is gradually decreasing. We have examined changes in smoking among secondary school students (1975 - 2005) and changes in snus use (smokeless tobacco) from 1985 through 2005. MATERIAL AND METHOD: The data stem from a series of nationwide surveys carried out by the Norwegian Directorate of Health every fifth year since 1975. The present analyses are based on samples of students born on the 6 th day of any month (n = 32669) in the period 1975 - 2005. RESULTS: The proportion of daily smokers among 15-year-olds was highest in 1975 (22.6 % among males and 28.4 % among females) and lowest in 2005 (8.5 % among males and 9.5 % among females). There were periods with no decrease during the 1980s and 1990s, and even an increase in smoking. From 2000 to 2005, the proportion of smokers decreased markedly irrespective of how smoking is defined - in all three grades - and for both sexes. The proportion of 15-year-old boys who used snus daily dropped markedly from 1985 to 1990, and increased steadily thereafter (7.9 % in 2005). INTERPRETATION: The marked decrease in smoking among secondary school students from 2000 to 2005 may result in that fewer of these students will ever start smoking.

[A study of adolescent smoking and use of snuff in 2004 and 2007]. / Røyking og snusbruk blant ungdommar i 2004 og 2007.

BACKGROUND: During the last decades, the proportion of smokers has declined and the use of snus has increased. We examined changes in 16 - 20-year-olds' use of tobacco products after introduction of stricter smoking regulations in 2004. MATERIAL AND METHODS: 16 - 20-year-olds' use of and attitudes towards tobacco-products were assessed in national surveys representative for the age-group (n 2004 =2400 and n 2007 =2415) in 2004 and 2007. We compared use of such products at the two measurement points and to what extent the decline in smoking and increase in snus. RESULTS: The same proportion of adolescents used snus or smoked in both surveys (28.8 %), but the distribution was markedly changed. In 2004, 22.5 % of the girls and 20.3 % of the boys smoked daily or every week; corresponding figures in 2007 were 17.3 % and 17.0 %. In 2004, 18.2 % of the boys used snus daily or every week and in 2007 the proportion had increased to 24.9 %. Among the girls, this figure tripled between the two surveys, from 2.4 % to 7.3 %. INTERPRETATION: A further reduction in smoking rates can be expected if we presume that the changes we found are stable. The increased use of snus calls for more knowledge about how this product affects health.

Changes in smoking among restaurant and bar employees following Norway's comprehensive smoking ban.

Norway implemented a nationwide ban on indoor smoking in June 2004. This study documents the smoking patterns of Norway's restaurant and bar workers before and after the ban, to determine changes in smoking prevalence and explore which individual and environmental characteristics were related to cessation. A national sample of food service workers was surveyed by telephone or Internet immediately before the ban and at 4 and 11 months post-implementation. Results showed that between baseline measurement and 4 months post-implementation, there were significant declines in prevalence of daily smoking (-3.6% points, p < 0.005), daily smoking at work (-6.2% points, p < 0.001), number of cigarettes smoked by continuing smokers (-1.55, p < 0.001) and number of cigarettes smoked at work by continuing smokers (-1.63, p < 0.001). No significant changes occurred in any of these variables between 4 and 11 months post-implementation. Logistic regression analysis revealed that only smokers' intentions at baseline to quit within 30 days predicted cessation at both follow-up time points. In addition, cessation at 4 months was predicted by lower daily cigarette consumption at baseline, whereas cessation at 11 months was predicted by baseline attitude toward ETS and exposure to ETS as measured at follow-up. In sum, Norway's smoking ban was accompanied by a reduction in smoking in the period immediately following the ban, and the reduction was maintained almost a year later. The finding that smoking cessation was consistently associated with smokers' intentions to quit within 30 days suggests that motivational and support programs could play a significant role in boosting cessation rates. It is recommended that targeted interventions be used to supplement the benefits of a comprehensive ban to achieve tobacco control objectives.

Smoking in relation to anxiety and depression: evidence from a large population survey: the HUNT study.

Smoking is reported to be associated with depression and anxiety. The present study (a) examines these associations taking comorbidity into account, (b) investigates possible confounders, (c) examines how former smokers compared to current and never-smokers in terms of anxiety and depression, and if anxiety and depression decline by time since cessation. Participants (66%) aged 20-89 years in a population-based health survey (N=60,814) were screened employing the HADS. (a) The association with smoking was strongest in comorbid anxiety depression, followed by anxiety, and only marginal in depression. Associations were stronger in females and younger participants. (b) Variables partly accounting for the association comprised somatic symptoms, socio-demographics, alcohol problems, and low physical activity. (c) Anxiety and depression were most common in current smokers, followed by quitters, and then never-smokers. No decline in anxiety or depression was found with time since cessation. Previous studies of associations between depression and smoking might have overestimated the association when ignoring comorbid anxiety.

Evaluation of the school-based smoking-prevention program "BE smokeFREE".

This article examines the impact of the school-based smoking-prevention program "BE smokeFREE" on adolescent smoking. A national representative sample of 99 schools (195 classes, 4,441 students) was used when the intervention started in November 1994. Schools were allocated to one of four groups: a comparison group (A) and three intervention groups (B, C, and D). Group B received the most comprehensive intervention. A baseline (autumn 1994) and three follow-up data collections (1995, 1996, and 1997) were conducted. There were no significant differences in smoking habits among the four groups at baseline. The smoking habits in the group that was involved in the most comprehensive intervention (group B) changed more favourably than those of students in the comparison schools over the three follow-up data collections. At the third follow-up, the proportion of students smoking weekly or more in the comparison group was 29.2%, compared with 19.6% in the model intervention group. The two less comprehensive interventions (no teacher in-service courses in group C, and no involvement of parents in group D) appeared to be less effective than the model intervention. Multilevel multiple logistic regression analyses, comparing changes in smoking habits between students in group B with those among students in the comparison schools, confirm the conclusion that the comprehensive intervention was the most effective. This school-based intervention, based on a social influence approach, proved to be effective at reducing smoking rates among participants.

Adolescent smoking and exposure to tobacco marketing under a tobacco advertising ban: findings from 2 Norwegian national samples.

OBJECTIVES: We examined the extent to which adolescents in Norway have been exposed to tobacco marketing despite an existing ban, and whether exposure is related to their current smoking or expectations they will smoke in the future. METHODS: Questionnaires were administered to nationally representative systematic samples of Norwegian youths aged 13 to 15 years in 1990 (n = 4282) and 1995 (n = 4065). RESULTS: About half in each cohort reported exposure to marketing. Youths reporting exposure were significantly more likely to be current smokers and to expect to be smokers at 20 years of age, after control for important social influence predictors. CONCLUSIONS: Adolescents' current smoking and future smoking expectations are linked to marketing exposure even in limited settings, suggesting the need for comprehensive controls to eliminate the function of marketing in promoting adolescent smoking.

[BE smokeFREE--evaluation of an intervention program for smoke-free schools]. / VAER røykFRI--evaluering av et tiltak for røykfrie skoler.

BACKGROUND: We present an evaluation of school-based intervention aiming at smoke-free schools (BE smokeFREE). The intervention programme was developed by the Norwegian Cancer Society. MATERIAL AND METHODS: A large-scale field experiment (initial n = 4,215) was carried out among lower secondary school students, starting in 8th (age 15) grade during the school year 1994/95. Schools were allocated to four groups: Control (A), a model intervention which included involvement of parents as well as courses for teachers (B), intervention identical to B but with no courses for teachers (C), and intervention identical to B but with no involvement of parents (D). Questionnaire surveys were administered four times (baseline and three follow-up surveys). A total of 19 school hours were used for the intervention, which took place in grades 8, 9, and 10. RESULTS: Changes in smoking frequency (daily, weekly, more seldom, non-smoker) and number of cigarettes smoked per week were used as end-point measures. Changes in smoking habits were markedly more favourable among students in model intervention schools than among students in control schools. INTERPRETATION: Carefully planned school-based intervention contributes to reduced smoking among adolescents.