“Social capital” has been defined as the sum of the resources, actual or virtual, that accrue to an individual or a group by virtue of possessing a durable network of more or less institutionalized relationships of mutual acquaintance and recognition.1 Others note that social capital is built on trust, norms and networks, which enable self-affirmation and development.2,3 Moreover, social capital has been seen as a sustaining resource for social action and a contributor to population health as interpersonal relationships among people have impacts on health.2 Social capital acts through the relationship system that ensures pro-social motivation, through information channels, as well as obligations/expectations and norms/sanctions.4,5 This is an effect that can be a community-level protective factor; for example, if an adolescent is connected to the community through a strong network of contacts, then he/she internalizes the community expectations, which fosters pro-social behavior.

Adolescence is a turbulent time of attitudinal and behavioral development, often marked by the experimentation with risky behaviors such as the use of tobacco products. In Romania, according to a survey made in 2014, the adolescent smoking is a prevalent behavior, and the prevalence of weekly smoking increases by age: in 13-year-olds 6% of girls and 8% of boys, while for the 15-year-olds, 17% of girls and 20% of boys smoked.6

The local community is the natural living space, where the socio-cultural conditions are identical. It is a social structure where the members of the community are in consistent interaction; they have mutual values, interests, experiences and common expectations. The feeling of belonging, cohesion are the forces that result in its members having an influence on each other. Although the local communities in the counties we have studied, preserve traditions and retain deep community values, the sense of belonging and cooperation among residents seems to be weakening.7

We have tried to evaluate how the adolescents could make use of the social capital of local communities as they navigate the transition to adulthood. More specifically, which of the variables of social capital factors are most related to smoking behavior.

The aim of our study was to identify and explore the risks or protective factors embedded in the social capital construct, based on the three dimensions: information, orientation and modeling (Fig. 1) as related to the adolescent tobacco use.

Figure 1.

The impact of social capital on adolescent smoking —framework of study.

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We hypothesized that community activity, smoking among classmates, and school performance (as a marker for motivation for performance) are variables with significant impact on adolescent smoking.

The main characteristics of the sample are presented in Table 1.

The majority of the students were aware that smoking is very dangerous (59.7%), while only 7.0% considered it harmless. Half of the respondents (52.0%) were included in the “very high” and “rather high” school performance categories, with a similar distribution found for the quality of the school. Community activity was reported to be very high (31.2%) or high (20.0%) by most respondents. More than one-third (37.0%) reported attending church each week, while 18.7% of them reported attending church less half as frequently. Two-thirds of the students were exposed to secondhand smoke at least once a week. Very high levels of smoking were registered for students’ classmates (28.2%) and in the community (26.5%), and 38.0% of the respondents claimed that the nearest neighbor had a rejecting attitude towards smoking.

Controlling for all other factors in the model, experimenting with smoking is mostly related to knowledge about smoking (Table 2). Those who thought smoking was harmless or slightly dangerous were more likely to having had lit a cigarette in their life (aOR: 2.36, 95%CI: 1.11-5.05; and aOR: 1.83, 95%CI: 1.35-2.49, respectively). Academic/school performance is also important, as students with poor (very low and rather low) results were more likely to have tried cigarettes (aOR: 1.73, 95%CI: 1.08-2.78; and aOR: 1.57, 95%CI: 1.02-2.40, respectively), as well as those who are prone to exposure to tobacco smoke in the home (aOR: 1.47; 95%CI: 1.03-2.10).

The strongest risk factor of adolescent smoking is the classmates’ (friends, peers) smoking behavior, suggesting that among adolescents in this study, smoking is a social environment-related activity. Independent of other factors, students who report a significant proportion of smokers among their classmates (more than a quarter) are 9 times more likely to smoke themselves than in other cases (aOR: 9.05; 95%CI: 4.10-20.00).

A second major factor is knowledge and attitude towards smoking. Those who consider smoking to be harmless are four times more likely to be smokers than those who consider this behavior very harmful (aOR: 4.28; 95%CI: 2.05-8.94). A third independent risk factor is related to the individual school performance: poor (very low and rather low) academic results increased adolescents’ odds of smoking (aOR: 3.22, 95%CI: 1.86-5.59; and aOR: 2.66, 95%CI: 1.60-4.41). A fourth factor is linked to social relationships, as smoking is strongly associated with intensive community activity; odds are significantly higher for smoking if they have an active social life (aOR: 2.54; 95%CI: 1.60-4.03). In the regression model, the perceived smoking rate in the respondent's community appears to be a stronger risk factor than smoking among family members (aOR: 2.50, 95%CI: 1.37-4.57; vs. aOR: 1.79, 95%CI: 1.06-3.01).

Variables such as regular church attendance and the prohibiting attitude of nearest neighbor proved to be protective factors for smoking. Respondents who attend church weekly were found to have less than half the odds of smoking as compared to those who rarely attend church (aOR: 0.45; 95%CI: 0.22-0.91). Also, if the nearest neighbor has a very negative (aOR: 0.48; 95%CI: 0.28-0.83) or rather negative (aOR: 0.44; 95%CI: 0.23-0.83) attitude towards adolescent smoking, it can be a protective factor.

According to the logistic regression analyses, the three components of our social capital model showed association with smoking behavior of the students. Considering “information” those who found smoking very dangerous, in case of “orientation” component those who had better school performance, and from the point of “modeling” the smokers among classmates, tobacco smoke exposure at home, and the negative attitude of the nearest neighbor can represent a protective factor of smoking in the community.

Factors that may be associated with adolescent smoking habits were examined on several dimensions. Our study measured several key individual and community indicators hypothesized to be associated with smoking behavior among adolescents, including those related to information, orientation and modeling factors. The results partly support our hypothesis that community activity, smoking among classmates and school performance (motivation for performance) have a high impact on the adolescent smoking.

We found associations between information measures and smoking: the prevalence of smoking is much higher among those who think that smoking is harmless or less harmful. Kaya and Ünalan14 draw the attention to the fact that the beliefs and perceptions of adolescents about smoking should be given as much consideration as the negative effects of cigarettes in planning smoking free messages. Hohman et al.15 assumed that, at the community level, communication comprising anti-smoking messages to which adolescents are receptive may have an important influence on young people's behavior. The importance of awareness is emphasized in other studies also,16,17 confirming that health information represents a protective factor for health behavior.

Adolescent socialization is a significant orientation factor in the development of smoking habits. The integration of the adolescent in his/her community, i.e. the social milieu of the behaviors and values in which the adolescent socializes, leaves its mark on the adolescent's behavior.1

Our results show that the school can be a protective factor only if it is highly rated, it offers quality education and there are clear values and rules that can be followed. As hypothesized, an elevated school performance, will help reduce smoking rates. Our results are congruent with those reported previously showing that school results and teenage smoking status (former or current smoker) are strongly associated.18

In the case of community activity, we focused on activities that appear at the level of the neighborhood: participation in community programs, neighborhood gatherings, joint celebrations, joint entertainment and play. Contrary to our hypothesis, the risk of the adolescent smoking is higher if these types of activities are present in the neighborhood and the adolescent takes part in them, suggesting that the level of community activity itself is not a protective factor against smoking. Similar results were obtained by Pförtner et al,19 confirming that friend-related social capital was significantly associated with a higher likelihood of daily smoking. The time spent with peers will benefit the adolescent provided that the activity has some kind of guidance, such as going to church, and it conveys information about the harmful consequences of smoking. Coleman's findings2 are comparable: social capital is determined by the sense of belonging and it manifests its effects on orientation and behavioral standards. When a community disseminates information through its channels, it attempts to regulate the adolescent behavior by setting clear standards and expectations, by applying sanctions for deviations from norms, and by monitoring how adolescents keep their commitments; these all have an impact on adolescent behavior and promote a healthy socialization.

This study demonstrates that the orientation factors strongly associated with adolescent smoking among Romanian adolescents are: good school results; adult smoking patterns (parents, neighbors); peer smoking patterns; and community activities that not only imply living and having fun together, but also anti-smoking communication. Another important role is played by how much adolescents attach to their home communities and by the type of information they are exposed to about the harmful effects of smoking.

Our findings related to the modeling factor confirm our hypothesis that smoking classmates highly impact teenagers’ behavior. It also suggests that, in general, smoking by friends and attitudes and smoking by adults in the neighborhood are strongly associated with adolescent smoking. Our analysis reveals the perception of adult neighbors’ attitudes toward smoking may serve as a protective factor; i.e., adolescents in neighborhood with a negative attitude towards smoking are less likely to smoke than those whose immediate living environment is permissive or even indifferent about smoking. These results are similar what has been reported by other authors.20–22

One of the limitations of our research is that we did not make a sharp distinction between the individual versus social nature of particular activities, nor did we try to separate activities between youngsters and adults. Certain components of our index, such as cultural activities (like listening to music or regularly going to the theatre) are associated with an increased risk of smoking, as these are social activities undertaken with friends, while activities spent in one's private sphere (like reading a book) are associated with a reduced risk of smoking.

Another limitation of our study is the sample's representativity for Transylvania region only (one of the three main historical regions of Romania), which may narrow the generalizability of our findings.

We should also mention that the validity and reliability of the complete questionnaire have not been checked yet. A potential source of bias is also the self-reported nature of the data; we cannot exclude that the students under-report smoking due to the social desirability or exaggerate the effect of the variable: the negative/prohibiting attitude of the nearest neighbor. In general, the main bias could be that even if teenagers want to appear “desiderable” it is a period of time when they do believe and follow the social norms of their counterparts.

Our results suggest that several social capital factors can play a major role in the adolescent smoking. Although some elements of the social capital do not constitute health risk factors themselves, all may be considered as risk or protective factors, depending on their mode of action and interaction. Our results demonstrate that the organization and development of the community activities aimed at prevention must strengthen the factors mentioned above —information, orientation, modeling— because, through them, the community's social capital will expand and reduce the likelihood of teenage smoking.

Carlos Álvarez-Dardet.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

All procedures performed in this study were in accordance with the 1964 Declaration of Helsinki and its later amendments. We previously obtained written permission from schools inspectorates, headmasters (school management) and parents for conducting the survey. All parents were informed about the purpose, benefits and risks of the study. Participation in the study was optional.

E. Albert-Lorincz designed and planned the study. B. Szabo contributed to the implementation; carried out the statistical analysis and data interpretation. A.I. Gasparik conceived and wrote the final version of the manuscript. E. Paulik was in charge of overall direction of the study. K. Foley supervised the project. All authors were involved in the critical review and have approved the final version of the manuscript for publication.

The research reported in this publication was supported by the Fogarty International Center and the National Cancer Institute of the National Institutes of Health under Award Number 1 R01 TW09280-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

None.