title: Socioeconomic inequalities in adolescent smoking across 35 countries: a multilevel analysis of the role of family, school and peers.
abstract: BACKGROUND
  Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment.
  
  
  METHODS
  Data were derived from the international WHO-collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking.
  
  
  RESULTS
  Across countries, adolescents from low affluent families had an increased risk of weekly smoking (OR(boys) 1.14, confidence interval (CI) 1.05-1.23; OR(girls) 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking.
  
  
  CONCLUSIONS
  The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour.
authors.affiliation: 1 Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Germany irene.moor@medizin.uni-halle.de.
authors.forename: Irene
authors.initials: I
authors.lastname: Moor
authors.affiliation: 1 Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Germany.
authors.forename: Katharina
authors.initials: K
authors.lastname: Rathmann
authors.affiliation: 2 Department of Developmental and Social Psychology, University of Padua, Italy.
authors.forename: Michela
authors.initials: M
authors.lastname: Lenzi
authors.affiliation: 1 Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Germany.
authors.forename: Timo-Kolja
authors.initials: TK
authors.lastname: Pförtner
authors.affiliation: 3 Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands 4 Alliance Smokefree Holland, The Hague, The Netherlands.
authors.forename: Gera E
authors.initials: GE
authors.lastname: Nagelhout
authors.affiliation: 5 Department of Interdisciplinary Social Sciences, Faculty of Social and Behavioural Sciences, Utrecht University, The Netherlands.
authors.forename: Margreet
authors.initials: M
authors.lastname: de Looze
authors.affiliation: 6 National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
authors.forename: Pernille
authors.initials: P
authors.lastname: Bendtsen
authors.affiliation: 3 Department of Health Promotion, Maastricht University (CAPHRI), Maastricht, The Netherlands 4 Alliance Smokefree Holland, The Hague, The Netherlands.
authors.forename: Marc
authors.initials: M
authors.lastname: Willemsen
authors.affiliation: 7 Department of Health Sciences, University of Jyväskylä, Finland.
authors.forename: Lasse
authors.initials: L
authors.lastname: Kannas
authors.affiliation: 8 Department of Public Health, AMC, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Anton E
authors.initials: AE
authors.lastname: Kunst
authors.affiliation: 1 Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Richter
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior / Q000523:psychology*; D005060:Europe / Q000453:epidemiology; D005190:Family / Q000523:psychology*; D005260:Female; D015438:Health Behavior; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D009656:North America / Q000453:epidemiology; D010290:Parents / Q000523:psychology; D010379:Peer Group; D012574:Schools; D012907:Smoking / Q000453:epidemiology* / Q000523:psychology; D012959:Socioeconomic Factors; D013334:Students / Q000523:psychology