School-Level Disadvantage Moderates Individual-Level Tobacco Cessation Failure

Background: Over half of adolescent smokers desire to quit, but the majority fail. Most adolescent cessation programming conventionally focuses on individual-level factors and mainly highlight successful outcomes. While understanding factors that lead to successful individual smoking cessation outcomes is necessary in adolescents, it is also essential to determine factors and conditions that contribute to treatment, or cessation, failure. The present study posits that adolescents' proximal environments-such as schools-may influence cessation treatment outcomes. Purpose/Objective: The purpose of this study is two-fold: a) Determine the individual level (Level 1) predictors of tobacco cessation failure in adolescents, b) Determine how the school environment level (Level 2) moderates the influence of level 1 predictors of tobacco cessation failure. Methods: Using aggregated data from multi-year (1998-2010) school based cessation trials (Not on Tobacco (N-O-T)in 5 states, we created a socio-spatial database comprising of linked individual-level and school-level data. By applying a tobacco-specific socio-ecological framework and Hierarchical Linear Modeling, the present study examined the interplay of individual level (n=8,855) and school level (n=807) factors associated with cessation treatment failure among adolescent cigarette smokers. Treatment (participation in N-O-T) was deemed as failing to meet its primary goals if participants continued to smoke cigarettes, measured 3-months post baseline. Results: At the individual level, greater self-efficacy predicted a higher likelihood of cessation success and nicotine dependence predicted a greater likelihood of failure. Ten percent of the variation in individual tobacco cessation failure was attributable to school-level variables. Adolescent smokers were more likely to experience failed treatment in a) school districts with large percentages of the population having less than high school education and b) schools with a higher ratio of students to teachers. Moreover, ...