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BMJ Open
An examination of the community-specific prevalence of
and factors associated with substance use and misuse
among Rural and Urban adolescents; cross-sectional
analysis in Bosnia and Herzegovina
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Journal:
Manuscript ID:
Article Type:
Date Submitted by the Author:
Zenic, Natasa; University of Split, Faculty of Kinesiology
Ostojic, Ljerka; University of Mostar, School of Medicine
Sisic, Nedim; University of Split, Faculty of Kinesiology
Peric, Mia; University of Split, Faculty of Kinesiology
Uljevic, Ognjen; University of Split, Faculty of Kinesiology
Sekulic, Damir; University of Split, Faculty of Kinesiology
Smoking and tobacco
Public health, Addiction, Sociology, Paediatrics
EPIDEMIOLOGY, Community child health < PAEDIATRICS, PUBLIC HEALTH
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Keywords:
21-Jul-2015
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Secondary Subject Heading:
Research
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Primary Subject
Heading:
bmjopen-2015-009446
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Complete List of Authors:
BMJ Open
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Page 1 of 27
BMJ Open
An examination of the community-specific prevalence of and factors associated with substance use
and misuse among Rural and Urban adolescents; cross-sectional analysis in Bosnia and
Herzegovina
Natasa Zenic; Faculty of Kinesiology; University of Split, Teslina 6, Split – 21000, Croatia
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Ljerka Ostojic; University of Mostar, Matice Hrvatske bb, Mostar – 63000, Bosnia and Herzegovina;
Academy of Medical Sciences of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina; Faculty
of Kinesiology; University of Split, Teslina 6, Split – 21000;
Nedim Sisic; Faculty of Kinesiology; University of Split, Teslina 6, Split – 21000, Croatia
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Mia Peric; Faculty of Kinesiology; University of Split, Teslina 6, Split – 21000, Croatia
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Ognjen Uljevic; Faculty of Kinesiology; University of Split, Teslina 6, Split – 21000, Croatia
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Damir Sekulic; Faculty of Kinesiology; University of Split, Teslina 6, Split – 21000, Croatia; University
Department of Health Care Studies, Split- 21000, Croatia
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Corresponding author: Professor Damir Sekulic; Faculty of Kinesiology; University of Split, Teslina 6,
Split – 21000, Croatia; Email: [email protected]
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Key words: community differences; substance abuse; physical exercise; puberty; prevention
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and misuse among Rural and Urban adolescents from Bosnia and Herzegovina
ABSTRACT
Objective
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The community of residence (i.e., urban vs. rural) is one of the known factors of influence on
substance-use-and-misuse (SUM). The aim of this study was to explore the community-specific
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prevalence of SUM and the associations that exist between scholastic, familial, sports, and
sociodemographic factors with SUM in adolescents from Bosnia-and-Herzegovina.
Methods
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In this cross-sectional study the participants were 957 17- to 18-year-old adolescents (485; 50.6%
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females) from Bosnia-and-Herzegovina (all ethnic Bosniaks). The independent variables were
sociodemographic-, academic-, sport-, and familial-factors. The dependent variables consisted of
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questions on cigarette smoking and alcohol consumption. Apart from descriptive statistics, we have
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calculated differences between groups of participants (gender, community). To determine the
associations between the independent variables and the dependent criteria (harmful drinking = HD,
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cigarette smoking = CS, and simultaneous smoking and harmful drinking = multiple SUM), logisticregressions were applied.
Results
The prevalence of SUM remains high, with 31% CS, and 42% boys and 27% girls involved in HD. In
urban-community, CS is more prevalent in girls (OR=2.05; 95%CI=1.27-3.35), while HD is more
prevalent in boys (OR=2.07; 95%CI=1.59-2.73). When data are broken out by both gender and
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community, HD is more prevalent in urban-boys (OR=1.97; 95%CI=1.31-2.95), cigarette smoking is
more frequent in rural boys (OR=1.61; 95%CI=1.04-2.39), and urban girls misuse substances to a
greater extent than rural girls (OR=1.70; 95%CI=1.16-2.51,OR=2.85; 95%CI=1.88-4.31,OR=2.78;
95%CI=1.67-4.61 for CS, HD, and multiple-SUM, respectively). Academic failure is strongly associated
with a higher likelihood of SUM. The associations between parental factors and SUM are more
evident in urban youth. Sports factors are specifically correlated to SUM for urban girls.
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Conclusions
Living in an urban-environment should be considered as a higher risk factor for SUM in girls. Parental
variables are more strongly associated with SUM among urban-youth. Specific indicators should be
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monitored in the prevention of SUM.
Strength and limitations of the study
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Because of the cross-sectional nature of the study we were not able to discuss the causality
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but only the association between studied variables
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Participants may lean to socially desirable answers, but since both cigarette smoking and
alcohol consumption are relatively common and socially accepted behaviors in the country
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probably decreased the possibility that participants did not respond honestly.
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This is one of the first studies to examine the community-specific context of SUM in
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adolescents from the wider territory of the former Yugoslavia, with the main intention to
determine those factors worth studying in forthcoming prospective investigations.
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This is one of the first studies to examine the problem of SUM and related factors among
European Muslim youth and results show specific prevalence and characteristic associations
between the studied factors.
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Funding
This research received no specific grant from any funding agency in the public, commercial or notfor-profit sectors
Conflict of interest
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Authors report no conflict of interest
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INTRODUCTION
With approximately 30% adolescents who smoke cigarettes and 34% who report harmful
alcohol consumption habits, Bosnia-and-Herzegovina has among the highest prevalence of use and
misuse (SUM) in adolescents in Europe [1, 2]. This is mostly explained not only by tradition and
heritage (i.e., growing tobacco has been a significant part of the economy for more than four
centuries) and social acceptance of alcohol consumption and cigarette smoking (i.e., smoking is
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allowed in public places and there is no strict regulation against drinking alcohol in public) but also by
post-war trauma, known political problems and a lack of a general and effective prevention policy [3
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The place of residence (i.e., community) is one factor that could directly or indirectly
influence SUM [5]. The investigations that examined the difference in SUM prevalence between
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adolescents living in urban and rural areas mostly found differences between individual communities
[6-9]. However, results were not consistent. Some studies found a lower likelihood of smoking [6],
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alcohol consumption [7], or smoking and alcohol consumption [10] among adolescents from rural
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communities. Other studies, however, found a higher prevalence of SUM in rural youth [8 9].
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As a result of high prevalence of SUM on the territory that was formerly Yugoslavia (including
Bosnia-and-Herzegovina) public-health authorities and academicians put special emphasize on
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evidencing factors potentially related to SUM in adolescence [3, 4]. But, studies conducted so far, are
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inconsistent with regard to associations that may exist between sports, sociodemographic, familial
and scholastic factors and among adolescents [1, 11]. One of the probable reasons for the variable
findings of the studies conducted thus far is the fact that none of the studies stratified participants
with regard to urban/rural communities. Namely, despite the growing efforts to explain the problem
of SUM, no attention has been given to examining the differences between rural and urban
adolescent SUM and the potential risk and protective factors in these locations. Also, practically all
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studies done so far examined ethnic Croats from Croatia and Bosnia-and-Herzegovina [1, 3, 11], while
there is an evident lack of studies that specifically investigated other ethnicities and religions.
The aim of this study was to explore the community-specific (i.e., urban/rural) associations
between scholastic, familial, sports, and sociodemographic factors and alcohol consumption and
cigarette smoking in adolescents from Bosnia-and-Herzegovina. Additionally, we have examined the
gender-specific and community-specific prevalence of SUM and associated factors in the study
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participants. In this study we have specifically investigated the problems among ethnic Bosniak
adolescents (Muslims by religion).
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METHODS
Participants
In this study, we examined 957 17- to 18-year-old adolescents from two Tuzla-Canton and
Zenica-Doboj-Canton (485 girls). At the time of testing, all of the participants were in their final year
of high school. For the purpose of the investigation we randomly selected one third of the high
schools in the Cantons, with half from each group. The testing took place during one morning school
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shift (school is organized into two shifts), and we attempted to test approximately 50% of the seniors
from the selected schools. Originally, the testing was intended to include more participants, but for
the purpose of this study, we selected only those children who declared themselves as traditionally
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(inherited) Muslim (religion will be discussed later in the paper). Ultimately, the sample studied in
this paper represented 6% of the high school students in the observed cantons.
Variables
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For the purpose of this study, we used an extensive, previously validated, self-administered
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questionnaire [1, 3, 4]. The independent variables observed were sociodemographic factors,
academic achievement factors, sports factors, and familial factors. The dependent variables
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consisted of questions on SUM. We asked children about their cigarette smoking and alcohol
consumption habits.
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Sociodemographic factors included age, gender, place of residence, financial situation (below
average, average, above average), and religion/ethnicity (responses included Bosniak-Muslim;
Bosniak-Other; Croatian-Catholic; Croatian-Other; Serbian-Orthodox; Serbian-Other; Other). Subjects
were grouped as rural and urban community residents according to the Bosnian and Herzegovinian
Agency for Statistics. [12]
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Academic achievement was determined using four questions on participants’ academic achievement
over the last academic year: (i) grade point average (a five-point scale ranging from excellent to
poor); (ii) behavioral grade (a five-point scale ranging from excellent to poor); (iii) unexcused school
absences (number of non-excused absences measured in teaching hours; a five-point scale ranging
from “less than 5 hours” to “20 hours or more”); and (iv) overall school absence (a four-point scale
ranging from “almost never” to “often”).
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Sports factors included questions on amount of time they have spent in sports (in years) and
their most significant competitive achievements in sports.
Apart from maternal and paternal educational level, and financial status of the family, the
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familial factors consisted of the following questions: (i) “How often do you have a conflict with your
parents?”; (ii) “How often are your parents absent from home, including for their work obligations?”;
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(iii) “How often do your parents ask you questions about your friends, scholastic achievements,
problems, and other personal issues?”; and (iv) “How would you rate how much your parents care
about you and your personal life?).
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Cigarette smoking was evaluated on a six-point scale (”Never smoked,” “Quit,” “Smoking
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from time to time, but not daily,” “Smoking fewer than 10 cigarettes per day,” “Smoking 10 to 20
cigarettes per day,” and “Smoking more than a pack of cigarettes per day”). The children were then
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grouped as “non-smokers” (Never smoked and Quit) and “smokers” (all remaining answers). Alcohol
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consumption was measured using the Alcohol Use Disorders Identification Test (AUDIT)
questionnaire, comprising ten items with the scores for each item ranging from 0 to 4. The
questionnaire defines a hypothetical range of 0 to 40. For the purpose of this study the results were
later divided into “harmful drinking” (scores of 11 and above) and “non-harmful drinking” (scores
below 11). Those participants who indicated both smoking and harmful alcohol drinking were
categorized as simultaneous SUM (multiple SUM).
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Testing and ethics
Testing was strictly anonymous, meaning that no personal data were collected. Prior to
testing, the design and aim of the study were explained to all participants and at least one parent for
each participant. Parental consent was obtained. Testing occurred in a classroom with groups of at
least 11 participants. Participants were informed that they could refuse to participate and that they
could leave some questions and/or the entire questionnaire unanswered and that returning the
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questionnaire will be considered their consent for participation in the study. When the testing was
completed, each participant placed the questionnaire in a closed box. The next day, the boxes were
opened by an investigator who had not tested the participants. The study was approved by the
corresponding author’s Institutional Ethical Board and Cantonal Ministries of Education.
Statistics
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We have calculated frequencies (i.e., counts) and percentages. Differences between the
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studied communities were tested by means of the Mann-Whitney test and independent samples ttest. To determine whether the observed communities and genders had different outcomes on a
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specific SUM measure, the odds ratio (OR) with 95% confidence interval (95% CI) was calculated. To
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determine independent variables associated with SUM, we calculated forward conditional logistic
regressions. The criteria were binomial SUM variables (smoking vs. non-smoking; harmful-drinking vs.
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non-harmful-drinking; multiple SUM vs. non-multiple SUM). Analyses were stratified by community.
Statistica version 12 (Statsfot, Tulsa, Ok, USA) was used for all analyses and statistical significance
was set at p < 0.05 (95%).
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RESULTS
Gender and community differences for SUM
The 29% boys and 32% girls smoke cigarettes, with no significant difference between genders
(OR = 1.12; 95%CI = 0.85-1.47). For urban-dwelling adolescents, smoking is more prevalent in girls
(OR = 2.05; 95% CI = 1.27-3.35). Smoking is more prevalent in urban-girls than in rural- girls (OR =
1.70; 95% CI = 1.16-2.51; 39% and 27% smokers for urban- and rural-girls, respectively). Rural-boys
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smoke more frequently than urban-boys (32% and 23% smokers for urban and rural boys,
respectively; OR = 1.61; 95%CI = 1.04-2.39) (Figure 1).
Boys are more likely to be involved in harmful drinking than girls (OR = 2.07; 95%CI = 1.59-
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2.73), with 42% boys and 27% girls who declared harmful drinking habits. Rural boys are evidently
more prone to harmful drinking than rural girls (OR = 2.81; 95% CI = 1.94-4.10; 38% and 18% harmful
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drinking for boys and girls, respectively) while the likelihood for harmful drinking is significantly
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greater for urban-boys than urban-girls (OR = 1.95; 95% CI = 1.25-3.03; 52% and 39% harmful
drinking for boys and girls, respectively). The harmful drinking is higher for urban boys than for rural
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boys (OR = 1.97; 95%CI = 1.31-2.95; 52% and 38% in urban- and rural-dwelling boys, respectively).
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Similarly, urban-girls drink alcohol to a greater extent than rural-girls (OR = 2.85; 95%CI = 1.88-4.31;
39% and 18% in urban- and rural-dwelling girls, respectively) (Figure 2).
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Multiple SUM is prevalent in 17% boys and 15% girls (OR = 1.16; 95%CI = 0.82-1.64), with
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significant differences in rural community between genders (OR = 1.95; 95%CI = 1.21-3.15; 17% and
10% for boys and girls, respectively). Urban girls are at higher risk for multiple-SUM (23%) than ruraldwelling-girls (10%) (OR = 2.78; 95%CI = 1.67-4.61) (Figure 3).
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When boys were compared between communities for independent variables, urban boys
reported more school absences (MW = 2.50; p = 0.01) (Table 1), longer involvement in sports (MW =
3.65; p = 0.01) (Table 2), higher levels of conflict with parents (MW = 3.07; p = 0.01), higher maternal
(MW = 4.92; p = 0.01) and paternal (MW = 5.17; p = 0.01) levels of education than rural boys.
Rural girls participate in sports for shorter periods (MW = 5.67; p = 0.01), and achieve lower
competitive results (MW = 6.55; p = 0.01) than urban girls. Maternal education (MW = 8.66; p = 0.01)
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and paternal education (MW = 5.48; p = 0.01) are higher in urban girls. Urban-dwelling girls reported
more frequent parental absences from home (MW = 3.80; p = 0.01), and higher levels of conflict with
parents (MW = 2.54 p = 0.01).
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The level of religiousness is higher among rural-dwelling adolescents for both boys
(26.95±8.45 and 30.42±7.63; for urban and rural boys, respectively; t-test=4.32, p < 0.01) and girls
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(26.01±7.36 and 32.02±6.42 for urban and rural girls, respectively; t-test=9.52, p < 0.01).
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A higher likelihood of cigarette smoking is evidenced in rural boys with lower behavioral
grades (OR = 2.66; 95% CI = 1.83-3.87) and who reported a poorer financial situation (OR = 0.29; 95%
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CI = 0.10-0.85). The logistic regression equation successfully classified 70% of participants (Table 1).
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Table 1
Forward conditional logistic regression results for the criteria cigarette smoking, harmful drinking and
multiple substance use and misuse (Multiple SUM) among rural and urban dwelling boys (OR – odds
ratio; CI – confidence interval).
Cigarette smoking
Harmful drinking
Rural
Urban
Rural
Urban
Rural
boys
boys
boys
boys
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boys
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
1.67
(1.02-2.73)
Grade point average
1.63
School absence
Behavioral grade
SCSRF
2.66
(1.83-3.87)
1.94
(1.38-2.73)
2.09
(1.38-3.19)
0.29
(0.10-0.85)
0.22
(0.06-0.83)
1.79
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Parental absence
1.74
(1.14-2.65)
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Financial status
(1.09-2.43)
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Unexcused absence
Multiple SUM
Urban
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1.91
(1.15-2.79)
(1.05-3.50)
0.96
0.94
(0.93-0.99)
(0.90-0.97)
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Lower behavioral grades (OR = 1.94; 95% CI = 1.38-2.73) together with lower levels of
religiousness (OR = 0.96; 95% CI = 0.93-0.99) contribute significantly to the prevalence of harmful
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alcohol drinking among rural boys, with 69% of rural boys successfully classified (Table 1).
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Harmful alcohol drinking is more frequent among urban boys who achieved a lower gradepoint average the preceding school year (OR = 1.67; 95% CI = 1.02-2.73), who were absent from
school more frequently (OR = 1.63; 95% CI = 1.09-2.43), and whose parents were frequently absent
from home, including because of job duties (OR = 1.79; 95% CI = 1.15-2.79). In total, 67.2% of the
subjects were successfully classified. (Table 1)
Multiple SUM is higher in rural boys with more unexcused school absences (OR = 1.74; 95%
CI = 1.14-2.65), lower behavioral grades (OR = 2.09; 95% CI = 1.38-3.19), poorer finances (OR = 0.22;
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95% CI = 0.06-0.830), and lower levels of religion (OR = 0.94; 95% CI = 0.90-0.97). At the final step,
the model successfully classified 85% of the participants. (Table 1)
A higher prevalence of multiple SUM among the urban boys was related to more frequent
parental absences from home (OR = 1.91; 95% CI = 1.05-3.50). The model successfully classified 84%
of the participants (Table 1).
The logistic regression calculated for cigarette smoking successfully classified 75.5% of rural
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girls. A higher prevalence of smoking is evidenced in those girls with low educational achievement
(OR = 1.41; 95% CI = 1.303-2.014), lower behavioral grades (OR = 6.65; 95% CI = 2.02-21.85), and
greater amounts of conflict with parents (OR = 1.52; 95% CI = 1.10-2.10) (Table 2).
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Table 2
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multiple substance use and misuse (Multiple SUM) among rural and urban dwelling girls (OR – odds
Cigarette smoking
Harmful drinking
Urban
Rural
Urban
Rural
Urban
Rural
girls
girls
girls
girls
girls
girls
OR
OR
(95%CI)
(95%CI)
2.53
(1.71-3.76)
1.41
(1.30-2.01)
2.31
(1.41-3.82)
(95%CI)
Behavioral grade
OR
OR
(95%CI)
(95%CI)
3.50
(2-23-5.15)
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2.06
(1.31-3.25)
6.65
4.14
(1.23-8.14)
(2.0221.85)
9.47
(2.02-44.12)
Financial status
Conflict with parents
OR
on
OR
(95%CI)
Unexcused absence
Parental absence
Multiple SUM
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Grade point average
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11.72
(4.18-32.83)
2.70
3.77
(1.77-4.15)
(2.01-7.07)
1.52
6.65
(1.10-2.10)
(3.06-14.47)
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Parental questioning
2.76
(1.67-4.58)
2.54
4.09
(1.11-6.14)
(1.79-9.23)
Sport achievement
0.52
(0.06-0.86)
3.11
(1.55-8.13)
SCSRF
0.85
(0.80-0.90)
Participation in sports
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Smoking in urban girls is associated with a lower grade point average (OR = 2.53; 95% CI =
1.71-3.76), more frequent parental absences (OR = 2.70; 95% CI = 1.77-4.15), frequent parental
questioning (OR = 2.76; 95% CI = 1.67-4.58), a lower level of religion (OR = 0.85; 95% CI = 0.80-0.90),
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and longer involvement in sports (OR = 2.54; 95%CI = 1.11-6.14) while being less successful (OR =
0.52; 95% CI = 0.06-0.86). In total, 87% of urban girls were successfully classified by logistic regression
calculation. (Table 2).
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When calculated for the harmful-alcohol-drinking criterion, the logistic regression was
successful for 81% of the rural girls. A higher prevalence of harmful drinking is evidenced for girls
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with a higher number of unexcused absences (OR = 2.06; 95% CI = 1.31-1.3.25). (Table 2)
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A higher prevalence of harmful alcohol drinking among urban girls is associated with lower
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scholastic achievement by means of grade point average (OR = 2.31; 95% CI = 1.41-3.82), longer
involvement in sports (OR = 4.09; 95% CI = 1.79-9.23), and high competitive achievement (OR = 3.11;
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95% CI = 1.55-8.13), better finances (OR = 9.47; 95% CI = 2.02-44.12) and higher levels of conflict with
parents (OR = 6.65; 95% CI = 3.06-14.47), with 88% of girls successfully classified (Table 2).
The logistic regression revealed a higher prevalence of multiple SUM in rural girls who had
more unexcused school absences (OR = 4.14; 95% CI = 1.23-8.14), with 82% of the girls being
successfully classified (Table 2)
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Multiple SUM in urban girls is more prevalent for girls with lower grade point averages (OR =
3.50; 95% CI = 2.23-5.15) and better finances (OR = 11.72; 95% CI = 4.18-32.83) and whose parents
are more frequently absent from home (OR = 3.77; 95% CI = 2.01-7.07). The model successfully
classified 85% of urban girls. (Table 2)
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DISCUSSION
With regard to the main study aim, there are several significant findings. In general, data
showed higher SUM in urban adolescents, and this is particularly evident for girls. Second, academic
achievement is the factor most significantly associated with SUM in both communities while the
association between parental factors and SUM is more evidenced in urban youth. Finally, sportfactors were associated with SUM only in urban girls. Prior to discussing those findings we will
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provide a discussion of the community-specific prevalence in SUM.
The overall prevalence of the SUM in studied adolescents is consistent with previous studies
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on the subject, which found consumption of cigarettes and alcohol to be alarming [3, 4]. Briefly, with
30% of adolescents smoking and 35% involved in harmful drinking, Bosnia-and-Herzegovina has
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among the highest frequencies of SUM in adolescents in Europe [2]. As a result, findings on the
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differences between urban and rural communities with regard to SUM are particularly important.
The higher prevalence of SUM in urban- than in rural-dwelling girls is almost certainly related to the
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overall sociocultural influence of the urban community on youth behavior. In general, Bosnia-and-
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Herzegovina is a traditional country where gender roles are (relatively) defined [3 13]. A number of
studies have shown that adherence to traditionalism and female-gender-role has been linked to
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lower SUM [14, 15]. However, in urban centers traditionalism is not so apparent [1]. Consequently, it
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is clear that cigarette smoking is more prevalent in urban than in rural girls. With regard to alcohol,
another issue deserves attention. Namely, girls’ alcohol drinking is socially accepted only in night
clubs and bars. Because such places are mainly located within urban centers, it logically increases
alcohol consumption in urban girls. Boys from rural communities misuse cigarettes to a greater
extent than their urban-dwelling peers. The cigarette smoking likely may be generally more accepted
and viewed as a cultural norm in rural areas than in urban ones, to the point where rural parents may
not perceive boys’ smoking as a disturbing issue [16]. However, it is also possible that a lack of other
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free-time activities (i.e., sports, extracurricular activities, etc.) together with social acceptance of
smoking has resulted in higher cigarette smoking among rural boys . One of the unique findings of
this study is that urban girls smoke more frequently than urban boys. In explaining this finding, we
must highlight that contrary to alcohol drinking, cigarette smoking in Bosnia-and-Herzegovina is a
socially acceptable behavior for girls. This is particularly true in urban centers, where girls frequently
present their “non-traditionalism” and emancipation by smoking. Together with the previously
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discussed difference between urban- and rural-dwelling girls in SUM (i.e., urban girls misuse
substances to a greater extent than rural girls), living in an urban environment should be considered
a factor of “increased risk” for SUM in girls.
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In a recent investigation the authors reported different associations between parental factors
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and SUM for urban and rural Latin American (Latino) youth [16]. With regard to gender, our findings
on the stronger influence of parental variables on SUM habits in girls are consistent with that study.
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On the other hand we have found there to be stronger parental influence on SUM in urban boys, and
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this is in contrast with the findings reported for Latino youth, where the authors found a stronger
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association between parental factors and SUM for rural children [16]. In explaining this inconsistency,
we must highlight that our respected colleagues observed 14- to 18-year-olds while we have studied
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17- to 18-year-olds. Parental monitoring generally decreases with age, and urban youth are more
likely to continue their education at the college level [3]. Therefore, it is reasonable to expect that
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parents of urban boys are more involved in their personal lives than is the case for their rural peers.
The level of religiousness was found to be specifically associated with SUM (i.e., urban girls for
cigarette smoking and rural boys for harmful drinking). In both cases, a lower likelihood of misusing
substances is evidenced for more religious subjects. Religiousness has already been studied with
regard to its potential protective effects against substance misuse in adolescents. However, findings
have not been consistent. The results from a US study [17] show that religiousness reduces the odds
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of tobacco use among adolescents. Conversely, a Mexican study found that adolescents with lower
church attendance and those who place a lower importance on religion are less likely to consume
cigarettes [18]. Although there is some recent evidence that Muslim adolescents have significantly
lower rates of substance misuse than Christians (all Middle Eastern youth) [19], this study is one of
the first that specifically reported on the association between Islamic religiousness and substance
misuse in adolescents. Academic achievement is one of the factors consistently found to be
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associated with SUM in adolescents [3, 4]. Therefore, our findings on the negative association
between most of the educational variables and smoking and drinking support previous findings.
However, this is one of the rare studies that defined the association between academic achievement
and SUM simultaneously for urban and rural communities, and the results are consistent with other
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results recently presented [16]. This is particularly important because of necessary future studies. To
determine the true cause-effect relationship that exists between consumption of substances and
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academic achievement in children, prospective studies are needed.
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Studies frequently examined potential association between sport (i.e. physical exercising)
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and cigarette smoking [4 11 20]. This investigation extends previous knowledge of associations
between sport factors and SUM by emphasizing the specific multivariate association of poor
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competitive achievement and long participation with a higher likelihood of smoking in urban girls. It
is possible that those girls who smoke cannot meet the physical demands of sports competition,
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which consequently results in poor performance (regardless of the long participation in sports).
Additionally, it is possible that those girls who did not have high achievement in sports despite being
in a sport for a prolonged period started to smoke. For a more detailed analysis, a prospective study
on the problem is needed. The negative association between competitive achievement and alcohol
consumption in girls did not surprise us. Namely, studies have frequently reported high alcohol
consumption among athletes and sport-fans [21-24]. In girls, this is mostly explained by (i) post-
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sports gatherings, (ii) frequent out-of-home situations, and (iii) lower levels of traditionalism in those
girls involved in sports [1, 25, 26]. We are convinced that all these factors to some extent lead to the
association between competitive results and alcohol consumption in urban girls. Those girls who
achieve higher competitive results are (ii) more frequently absent from home (because of sports
competitions). The competitive successes are regularly followed by (i) gatherings where alcohol is
consumed for “relaxation”. Finally (iii), in traditional countries (such as Bosnia-and-Herzegovina),
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girls’ participation in sports and alcohol drinking are both more common in more “liberal” families
[3]. The fact that an association between sport factors and alcohol consumption is found solely in
urban girls is a logical reflection of the clear differences between urban and rural girls in regard to
sports (rural girls participate in sports less frequently; see Results).
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Specific sociocultural characteristics in Bosnia-and-Herzegovina seem to be the most
important factors influencing the alarmingly high prevalence of SUM in adolescents of both genders.
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Although alcohol consumption is higher in boys, the social acceptance of girls’ smoking, together
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with the relatively low price of cigarettes (a pack rarely costs more than 3 USD) and a lack of strict
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regulation against selling tobacco products to minors, are probably the most important factors that
boost cigarette smoking in urban girls. Although for the last couple of years extensive efforts have
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been made to explain SUM patterns and correlates of such behavior in the territory of the former
Yugoslavia, this is one of the first studies that has specifically focused on explaining these issues while
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taking into consideration both one specific ethnicity (i.e., Bosniak Muslims) and the influence of
community (i.e., urban- and rural-dwelling adolescents). Although in general urban youth consume
substances more often than their rural peers, the difference in cigarette smoking (smoking is higher
in rural- than in urban-dwelling boys) led us to the conclusion that rural areas are moving away from
being the protective communities they were once thought to be and are seeing an increase in
deviant behaviors once viewed as exclusively urban occurrences. Prevention efforts aimed at
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reducing adolescent SUM may have lesser or greater efficacy depending on the targeted
protective/risk factor and community group. Therefore, some specific factors of influence should be
noted. First, academic achievement seems to be systematically related to SUM in both genders and
both communities that were studied. Therefore, special attention should be placed on those children
who perform poorly in school. More precisely, behavioral variables and absence from school, as
specific indices of scholastic performance should be monitored. Next, sports factors are
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characteristically related to SUM solely among urban girls, while the highest SUM is found in those
girls who participate in sports for a prolonged period while being less successful. Third, parental
variables are more strongly associated with SUM in girls and in urban boys, so these variables are not
of particular interest when developing preventive campaigns against SUM for rural boys. The true
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cause-effect relationship for all observed factors should be more precisely investigated through
prospective studies. In doing so, a culturally specific and community-specific approach is needed.
Acknowledgements
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Special thanks go to Cantonal Ministries of Education who supported and approved the
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investigation. Authors are particularly grateful to all children who voluntarily participated in the
study.
Contributors
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NZ designed the study, performed statistical analysis and discussed data. LO collected the
data, drafted the manuscript and discussed the results; NS collected the data and overviewed the
previous research;; MP overviewed the previous researches; OU participated in the study design and
drafted the manuscript; DS did preliminary statistical procedures and discussed the data All authors
have read and approved the final version.
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Ethics approval
The Ethical Boards of University of Split, Faculty of Kinesiology, Split, Croatia and Univesity of
Mostar, School of Medicine, Mostar, Bosnia and Herzegovina approved the Investigation.
Additionally, the study was approved by Cantonal Ministries of Education.
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REFERENCES
1. Sekulic D, Ostojic M, Ostojic Z, Hajdarevic B, Ostojic L. Substance abuse prevalence and its relation
to scholastic achievement and sport factors: an analysis among adolescents of the
Herzegovina-Neretva Canton in Bosnia and Herzegovina. BMC Public Health 2012;12:274 doi:
10.1186/1471-2458-12-274[published Online First: 5 Apr 2012]|.
2. ESPAD report. http://www.espad.org/Uploads/ESPAD_reports/2011/FULL%20REPORT%20%20Supplement%20to%20The%202011%20ESPAD%20Report%20-%20WEB.pdf.
3. Cerkez I, Culjak Z, Zenic N, Sekulic D, Kondric M. Harmful Alcohol Drinking Among Adolescents: The
Influence of Sport Participation, Religiosity, and Parental Factors. J Child Adoles Subst
2015;24:94-101 doi: Doi 10.1080/1067828x.2013.764372[published Online First: 13 Jan
2015]|.
4. Sekulic D, Ostojic M, Vasilj M, Coric S, Zenic N. Gender-specific predictors of cigarette smoking in
adolescents: an analysis of sport participation, parental factors and religiosity as
protective/risk factors. J Subst Use 2014;19:89-94 doi: Doi
10.3109/14659891.2012.734544[published Online First: 12 Dec 2012]|.
5. Singh A, Sahoo N. Urban-rural differentials in the factors associated with exposure to second-hand
smoke in India. BMJ Open 2013;3:e003542 doi: 10.1136/bmjopen-2013-003542[published
Online First: 25 Nov 2013]|.
6. Peer N, Bradshaw D, Laubscher R, Steyn N, Steyn K. Urban-rural and gender differences in tobacco
and alcohol use, diet and physical activity among young black South Africans between 1998
and 2003. Global Health Act 2013;6:1-10 doi: DOI 10.3402/gha.v6i0.19216[published Online
First: 29 Jan 2013]|.
7. McDermott MJ, Drescher CF, Smitherman TA, et al. Prevalence and Sociodemographic Correlates
of Lifetime Substance Use Among a Rural and Diverse Sample of Adolescents. Subst Abus.
2013;34:371-80 doi: Doi 10.1080/08897077.2013.776000[published Online First: 25 Oct
2013]|.
8. Donath C, Grassel E, Baier D, Pfeiffer C, Bleich S, Hillemacher T. Predictors of binge drinking in
adolescents: ultimate and distal factors - a representative study. BMC Public Health
2012;12:263 doi: 10.1186/1471-2458-12-263[published Online First: 2 Apr 2012]|.
9. Sygit K, Kolltaj W, Wojtyta A, Sygit M, Bojar I, Owoc A. Engagement in risky behaviours by 15-19year-olds from Polish urban and rural areas. Ann Agr Env Med 2011;18:404-09
10. Gutierrez JP, Atienzo EE. Socioeconomic status, urbanicity and risk behaviors in Mexican youth:
an analysis of three cross-sectional surveys. BMC Public Health 2011;11:900 doi:
10.1186/1471-2458-11-900[published Online First: 30 Nov 2011]|.
11. Modric T, Zenic N, Sekulic D. Substance use and misuse among 17- to 18-year-old Croatian
adolescents: correlation with scholastic variables and sport factors. Subst Use Misuse
2011;46(10):1328-34 doi: 10.3109/10826084.2011.579677[published Online First: 11 Jul
2011]|.
12. Agency for Statistics of Bosnia and Hercegovina. http://www.bhas.ba/.
13. Vasilj I, Pilav A, Maslov B, Polasek O. Cardiovascular risk factors research in Bosnia and
Herzegovina. Coll Antropol 2009;33 Suppl 2:185-8
14. Kulis S, Marsiglia FF, Hurdle D. Gender Identity, Ethnicity, Acculturation, and Drug Use: Exploring
Differences among Adolescents in the Southwest. J Community Psychol 2003;31:167-88 doi:
10.1002/jcop.10041[published Online First: 4 Feb 2003]|.
15. Wahl AM, Eitle TM. Gender, acculturation and alcohol use among Latina/o adolescents: a multiethnic comparison. J Immigr Minor Health 2010;12:153-65 doi: 10.1007/s10903-008-91796[published Online First: 19 Sep 2008]|.
16. Zhen-Duan J, Taylor MJ. The Use of an Ecodevelopmental Approach to Examining Substance Use
Among Rural and Urban Latino/a Youth: Peer, Parental, and School Influences. J Ethn Subst
Abuse 2014;13:104-25
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Fo
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on
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
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28
29
30
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Page 22 of 27
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17. Kiesner J, Poulin F, Dishion TJ. Adolescent Substance Use with Friends: Moderating and Mediating
Effects of Parental Monitoring and Peer Activity Contexts. Merrill Palmer Q 2010;56:529-56
18. Bachman JG, O'Malley PM, Johnston LD, Schulenberg JE, Wallace JM. Racial/ethnic differences in
the relationship between parental education and substance use among U.S. 8th-, 10th-, and
12th-grade students: findings from the Monitoring the Future project. J Stud Alcohol Drugs
2011;72(2):279-85
19. Badr LK, Taha A, Dee V. Substance abuse In Middle Eastern adolescents living in two different
countries: spiritual, cultural, family and personal factors. J Relig Health 2014;53:1060-74 doi:
10.1007/s10943-013-9694-1[published Online First: 23 Mar 2013]|.
20. Hedman L, Andersson M, Stridsman C, Ronmark E. Evaluation of a tobacco prevention
programme among teenagers in Sweden. BMJ Open 2015;5(5):e007673 doi:
10.1136/bmjopen-2015-007673[published Online First: 14 May 2015]|.
21. Sekulic D, Bjelanovic L, Pehar M, Pelivan K, Zenic N. Substance use and misuse and potential
doping behaviour in rugby union players. Res Sports Med 2014;22:226-39 doi:
10.1080/15438627.2014.915839[published Online First: 20 Jun 2014]|.
22. Martens MP, Dams-O'Connor K, Duffy-Paiement C, Gibson JT. Perceived alcohol use among
friends and alcohol consumption among college athletes. Psychol Addict Behav.
2006;20(2):178-84
23. Barry AE, Howell SM, Riplinger A, Piazza-Gardner AK. Alcohol use among college athletes: do
intercollegiate, club, or intramural student athletes drink differently? Subst Use Misuse
2015;50(3):302-7 doi: 10.3109/10826084.2014.977398[published Online First: 10 Nov
2014]|.
24. Kingsland M, Wiggers J, Wolfenden L. Interventions in sports settings to reduce alcohol
consumption and alcohol-related harm: a systematic review protocol. BMJ Open
2012;2(2):e000645 doi: 10.1136/bmjopen-2011-000645[published Online First: 6 Apr 2012]|.
25. Zenic N, Peric M, Zubcevic NG, Ostojic Z, Ostojic L. Comparative analysis of substance use in
ballet, dance sport, and synchronized swimming: results of a longitudinal study. Med Probl
Perform Art 2010;25:75-81
26. Kondric M, Sekulic D, Petroczi A, Ostojic L, Rodek J, Ostojic Z. Is there a danger for myopia in antidoping education? Comparative analysis of substance use and misuse in Olympic racket
sports calls for a broader approach. Subst Abuse Treat Prev Policy 2011;6:27 doi:
10.1186/1747-597X-6-27[published Online First: 11 Oct 2011]|.
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Data sharing statement:
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Data files can be accessed via the Dryad data repository at http://datadryad.org/ with the
doi:10.5061/dryad.7rg48
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Figure legends:
Figure 1: Prevalence of cigarette smoking with odds ratio between and within genders. Percentage of
reported frequency for boys and girls with n = 472 and n = 485, respectively, being the 100%.
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Figure 2: Prevalence of harmful alcohol drinking with odds ratio between and within genders.
Percentage of reported frequency for boys and girls with n = 472 and n = 485, respectively, being the
100%.
Figure 3: Prevalence of multiple substance use and misuse (simultaneous harmful drinking and
cigarette smoking) with odds ratio between and within genders. Percentage of reported frequency
for boys and girls with n = 472 and n = 485, respectively, being the 100%.
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50%
OR = 2.05
95%CI = 1.27-3.35
Prevalence of smoking (%)
45%
OR = 1.12
95%CI = 0.85-1.47
40%
OR = 1.26
95%CI = 0.89-1.78
35%
30%
25%
20%
15%
10%
5%
0%
OR = 1.70
95%CI = 1.16-2.51
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OR = 1.61
95%CI = 1.04-2.39
TOTAL
BOYS
29%
GIRLS
32%
URBAN
RURAL
23%
32%
39%
27%
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100%.
Prevalence of harmful drinking (%)
65%
OR = 1.95
95%CI = 1.25-3.03
OR = 2.07
95%CI = 1.59-2.73
55%
OR = 2.81
95%CI = 1.94-4.10
45%
35%
25%
15%
5%
TOTAL
BOYS
42%
GIRLS
27%
OR = 1.97
95%CI = 1.31-2.95
OR = 2.85
95%CI = 1.88-4.31
URBAN
RURAL
52%
38%
39%
18%
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30%
Prevalence of multiple SUM (%)
OR = 1.43
95%CI = 0.82-2.50
25%
OR = 1.16
95%CI = 0.82-1.64
OR = 1.95
95%CI = 1.21-3.15
20%
15%
10%
5%
TOTAL
BOYS
17%
GIRLS
15%
OR = 1.00
95%CI = 0.58-1.71
OR = 2.78
95%CI = 1.67-4.61
URBAN
RURAL
16%
17%
23%
10%
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Journal:
Manuscript ID
Article Type:
Ostojic, Ljerka; University of Mostar, School of Medicine
Sekulic, Damir; University of Split, Faculty of Kinesiology
Smoking and tobacco
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Keywords:
27-Aug-2015
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Research
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Primary Subject
Heading:
bmjopen-2015-009446.R1
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Herzegovina
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Department of Health Care Studies, Split- 21000, Croatia
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ABSTRACT
Objective
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Methods
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In this cross-sectional study which was completed during November and December 2014, the
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participants were 957 17- to 18-year-old adolescents (485; 50.6% females) from Bosnia-andHerzegovina. The independent variables were sociodemographic-, academic-, sport-, and familial-
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factors. The dependent variables consisted of questions on cigarette smoking and alcohol
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consumption. We have calculated differences between groups of participants (gender, community),
while the logistic-regressions were applied to define associations between the independent and
dependent variables.
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Results
In urban-community, cigarette-smoking is more prevalent in girls (OR=2.05; 95%CI=1.27-3.35), while
harmful-drinking is more prevalent in boys (OR=2.07; 95%CI=1.59-2.73). When data are broken out
by both gender and community, harmful-drinking is more prevalent in urban-boys (OR=1.97;
95%CI=1.31-2.95), cigarette-smoking is more frequent in rural boys (OR=1.61; 95%CI=1.04-2.39), and
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urban girls misuse substances to a greater extent than rural girls (OR=1.70; 95%CI=1.162.51,OR=2.85; 95%CI=1.88-4.31,OR=2.78; 95%CI=1.67-4.61 for cigarette-smoking, harmful-drinking,
and simultaneous smoking-drinking, respectively). Academic failure is strongly associated with a
higher likelihood of SUM. The associations between parental factors and SUM are more evident in
urban youth. Sports factors are specifically correlated to SUM for urban girls.
Conclusions
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Living in an urban-environment should be considered as a higher risk factor for SUM in girls. Most
probably because of the higher parental-involvement in children’ personal lives in urban
communities (i.e. college-plans for example) parental variables are more strongly associated with
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SUM among urban-youth, Specific indicators should be monitored in the prevention of SUM.
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Participants may lean to socially desirable answers, but knowing that both cigarette smoking
and alcohol consumption are relatively common and socially accepted behaviors in the
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country decreased the possibility that participants did not respond honestly.
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Academic achievement was self-reported and therefore may not be absolutely reliable and
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accurate presentation of scholastic variables, but the testing was done at the beginning of
the school year so we believe that it was correctly reported. This is one of the first studies to
examine the community-specific context of SUM in adolescents from the wider territory of
the former Yugoslavia, with the main intention to determine those factors worth studying in
forthcoming prospective investigations.
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•
Funding
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INTRODUCTION
Cigarette smoking and alcohol drinking are the most common types of substance use and
misuse (SUM) among adolescents ([1]. Daily smoking rates in European countries range mostly from
10% to 20%. More specifically, among the countries with the lowest daily smoking prevalence in
adolescence are Sweden (5% and 14%), UK (10% and 17%), and Switzerland (13% and 13.0% for boys
and girls, respectively). The highest daily-smoking-rates among adolescents are reported for Hungary
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(17% and 19%), Belgium (17% and 19%), Bosnia and Herzegovina (25% and 15%), and Austria (20%
and 25% for boys and girls respectively) [1-4]. Additionally, with approximately 30% of adolescents
who self-reported harmful-alcohol-drinking, Bosnia and Herzegovina is clearly one of the European
countries with the highest prevalence of SUM in Europe ([1 4 5]
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These disturbing figures areon adolescent SUM are mostly explained not only by tradition
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and heritage (i.e., growing tobacco has been a significant part of the economy in Bosnia and
Herzegovina for more than three centuries) and social acceptance of alcohol consumption and
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cigarette smoking (i.e., smoking is allowed in public places and there is no strict regulation against
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drinking alcohol in public) but also by post-war trauma, known political problems and a lack of a
general and effective prevention policy [3 5].
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influence SUM [6 7]. The investigations that examined the difference in SUM prevalence between
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evidencing factors potentially related to SUM in adolescence [3 5]. But, studies conducted so far, are
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and scholastic factors and among adolescents [1 13]. One of the probable reasons for the variable
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studies done so far examined ethnic Croats from Croatia and Bosnia-and-Herzegovina [1 5 13], while
The aim of this cross-sectional study was to explore the community-specific (i.e., urban/rural)
associations between scholastic, familial, sports, and sociodemographic factors and alcohol
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consumption and cigarette smoking in adolescents from Bosnia-and-Herzegovina. Additionally, we
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have examined the gender-specific and community-specific prevalence of SUM and associated
factors in the study participants. In this study we have specifically investigated the problems among
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ethnic Bosniak adolescents (Muslims by religion).
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METHODS
Participants
In this cross-sectional study, we examined 957 17- to 18-year-old adolescents from two
Tuzla-Canton and Zenica-Doboj-Canton (485 girls). At the time of testing, all of the participants were
in their final year of high school. For the purpose of the investigation we randomly selected one third
of the high schools in the Cantons, with half from each group. The testing took place during one
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morning school shift (school is organized into two shifts), and we attempted to test approximately
50% of the seniors from the selected schools. Originally, the testing was intended to include more
participants, but for the purpose of this study, we selected only those children who declared
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themselves as traditionally (inherited) Muslim (religion will be discussed later in the paper).
Ultimately, the sample studied in this paper represented 6% of the high school students in the
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observed cantons. The sample is described in the Table 1
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Table 1
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Sample characteristics, break-down for gender and community
Tuzla Canton
Boys
Girls
90
110
225
176
315
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Urban
Rural
Total
Zenica Doboj Canton
Boys
Girls
44
94
113
105
157
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Variables
questionnaire [1]. The independent variables observed were sociodemographic factors, academic
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achievement factors, sports factors, and familial factors. The dependent variables consisted of
questions on SUM. We asked children about their cigarette smoking and alcohol consumption habits.
average, average, above average), religion/ethnicity (responses included Bosniak-Muslim; BosniakOther; Croatian-Catholic; Croatian-Other; Serbian-Orthodox; Serbian-Other; Other) and strength of
religious beliefs as measured by Santa Clara Strength of Religious Faith (SCSRF) [14 15],. All
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participants who reported place of residence of less than 10.000 inhabitants were grouped as “ruraldwelling” while those who reported place of residence of more than 10.000 inhabitants were
classified as “urban-dwelling”. The population was defined according to Bosnian and Herzegovinian
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their most significant competitive achievements in sports .
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Testing and ethics
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Study was completed during November and December 2014. Testing was strictly anonymous,
meaning that no personal data were collected. Prior to testing, the design and aim of the study were
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explained to all participants and at least one parent for each participant. Parental consent was
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obtained. Testing occurred in a classroom with groups of at least 11 participants. Participants were
informed that they could refuse to participate and that they could leave some questions and/or the
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entire questionnaire unanswered and that returning the questionnaire will be considered their
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consent for participation in the study. When the testing was completed, each participant placed the
questionnaire in a closed box. The next day, the boxes were opened by an investigator who had not
tested the participants. The study was approved by the corresponding author’s Institutional Ethical
Board and Cantonal Ministries of Education.
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Statistics
determine independent variables associated with SUM, we calculated forward conditional stepwise
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logistic regressions. The criteria were binomial SUM variables (smoking vs. non-smoking; harmfuldrinking vs. non-harmful-drinking; multiple SUM vs. non-multiple SUM). Analyses were stratified by
community. Statistica version 12 (Statsfot, Tulsa, Ok, USA) was used for all analyses and statistical
significance was set at p < 0.05 (95%).
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RESULTS
The 29% boys and 32% girls smoke cigarettes, with no significant difference between
genders. For urban-dwelling adolescents, smoking is more prevalent in girls while moking is more
prevalent in urban-girls than in rural- girls. Rural-boys smoke more frequently than urban-boys
(Figure 1).
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Boys are more likely to be involved in harmful drinking than, with 42% boys and 27% girls
who declared harmful drinking habits. Rural boys are evidently more prone to harmful drinking than
rural girls while the likelihood for harmful drinking is significantly greater for urban-boys than urban-
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girls. The harmful drinking is higher for urban boys than for rural boys and urban girls than for rural
girls (Figure 2).
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Multiple SUM is prevalent in 17% boys and 15% girls, with significantly higher likelihood of
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multiple SUM for boys but only for rural-dwelling adolescents.. Urban girls are at higher risk for
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multiple-SUM (23%) than rural-dwelling-girls (10%) (Figure 3).
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parents (MW = 2.54 p = 0.01).
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Table 2
multiple substance use and misuse (Multiple SUM) among rural and urban dwelling boys (OR – odds
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Cigarette smoking
Urban
boys
Rural
boys
OR
OR
(95%CI)
(95%CI)
Harmful drinking
Urban
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OR
OR
OR
OR
(95%CI)
(95%CI)
(95%CI)
(95%CI)
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1.63
(1.09-2.43)
1.74
(1.14-2.65)
2.66
1.94
2.09
(1.83-3.87)
(1.38-2.73)
(1.38-3.19)
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SCSRF
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Unexcused absence
Parental absence
Rural
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(1.02-2.73)
School absence
Financial status
Multiple SUM
Urban
boys
1.67
Grade point average
Behavioral grade
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0.29
(0.10-0.85)
1.79
(1.15-2.79)
0.22
(0.06-0.83)
1.91
(1.05-3.50)
0.96
(0.93-0.99)
0.94
(0.90-0.97)
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Table 3
multiple substance use and misuse (Multiple SUM) among rural and urban dwelling girls (OR – odds
Cigarette smoking
Grade point average
Harmful drinking
Multiple SUM
Urban
Rural
Urban
Rural
Urban
Rural
girls
girls
girls
girls
girls
girls
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
2.53
(1.71-3.76)
1.41
(1.30-2.01)
2.31
(1.41-3.82)
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Unexcused absence
Behavioral grade
3.50
(2-23-5.15)
2.06
4.14
(1.31-3.25)
(1.23-8.14)
6.65
(2.02-
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21.85)
Financial status
Parental absence
2.70
1.52
(1.10-2.10)
2.54
(4.18-32.83)
3.77
(2.01-7.07)
6.65
(3.06-14.47)
4.09
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(2.02-44.12)
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(1.11-6.14)
(1.79-9.23)
Sport achievement
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(0.06-0.86)
3.11
(1.55-8.13)
SCSRF
0.85
(0.80-0.90)
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DISCUSSION
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on the subject, which found consumption of cigarettes and alcohol to be alarming [3 5] As a result,
findings on the differences between urban and rural communities with regard to SUM are
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particularly important. The higher prevalence of SUM in urban- than in rural-dwelling girls is almost
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certainly related to the overall sociocultural influence of the urban community on youth behavior. In
general, Bosnia-and-Herzegovina is a traditional country where gender roles are (relatively) defined
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[5 17]. A number of studies have shown that adherence to traditionalism and female-gender-role has
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been linked to lower SUM [18 19]. However, in urban centers traditionalism is not so apparent [1].
Consequently, it is clear that cigarette smoking is more prevalent in urban than in rural girls. With
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regard to alcohol, another issue deserves attention. Namely, girls’ alcohol drinking is socially
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accepted only in night clubs and bars. Because such places are mainly located within urban centers, it
logically increases alcohol consumption in urban girls. Boys from rural communities misuse
cigarettes to a greater extent than their urban-dwelling peers. The cigarette smoking likely may be
generally more accepted and viewed as a cultural norm in rural areas than in urban ones, to the point
where rural parents may not perceive boys’ smoking as a disturbing issue [20]. However, it is also
possible that a lack of other free-time activities (i.e., sports, extracurricular activities, etc.) together
with social acceptance of smoking has resulted in higher cigarette smoking among rural boys. One of
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the unique findings of this study is that urban girls smoke more frequently than urban boys. In
explaining this finding, we must highlight that contrary to alcohol drinking, cigarette smoking in
Bosnia-and-Herzegovina is a socially acceptable behavior for girls. This is particularly true in urban
centers, where girls frequently present their “non-traditionalism” and emancipation by smoking.
Together with the previously discussed difference between urban- and rural-dwelling girls in SUM
(i.e., urban girls misuse substances to a greater extent than rural girls), living in an urban
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environment should be considered a factor of “increased risk” for SUM in girls.
Parental/familial factors have generally been found to be a protective factor against SUM in
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adolescence, [21 22]. In a recent investigation the authors reported different associations between
parental factors and SUM for urban and rural Latin American (Latino) youth [20]. With regard to
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gender, our findings on the stronger influence of parental variables on SUM habits in girls are
consistent with that study. On the other hand we have found there to be stronger parental influence
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on SUM in urban boys, and this is in contrast with the findings reported for Latino youth, where the
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authors found a stronger association between parental factors and SUM for rural children [20]. In
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explaining this inconsistency, we must highlight that our respected colleagues observed 14- to 18year-olds while we have studied 17- to 18-year-olds. Parental monitoring generally decreases with
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age, and urban youth are more likely to continue their education at the college level [5]. Therefore, it
is reasonable to expect that parents of urban boys are more involved in their personal lives than is
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the case for their rural peers. The level of religiousness was found to be specifically associated with
SUM (i.e., urban girls for cigarette smoking and rural boys for harmful drinking). In both cases, a
lower likelihood of misusing substances is evidenced for more religious subjects. The level of
religiousness (i.e. commitment to religious beliefs, traditions and norms) has already been studied
with regard to its potential protective effects against substance misuse in adolescents. However,
findings have not been consistent. The results from a US study [23] show that religiousness reduces
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the odds of tobacco use among adolescents. Conversely, a Mexican study found that adolescents
with lower church attendance and those who place a lower importance on religion are less likely to
consume cigarettes [24]. Although there is some recent evidence that Muslim adolescents have
significantly lower rates of substance misuse than Christians (all Middle Eastern youth) [25], this
study is one of the first that specifically reported on the association between Islamic religiousness
and substance misuse in adolescents. Academic achievement is one of the factors consistently found
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to be associated with SUM in adolescents [3 5]. Therefore, our findings on the negative association
While this study was cross-sectional, and we were not able to define the true cause-effect
relationships between academic achievement and SUM (i.e. it is not clear did adolescents started to
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abuse substances and then failed educationally or vice-versa) some pathways are intuitively obvious.
Namely, it is almost certain that SUM (harmful drinking and multiple SUM; see Results) actually let to
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more unexcused absences. However, this is one of the rare studies that defined the association
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between academic achievement and SUM simultaneously for urban and rural communities, and the
results are consistent with other results recently presented [20].
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consumption among athletes and sport-fans [27-30]. In girls, this is mostly explained by (i) postsports gatherings, (ii) frequent out-of-home situations, and (iii) lower levels of traditionalism in those
girls involved in sports [1 31 32]. We are convinced that all these factors to some extent lead to the
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Following conclusions can be made. In general urban youth consume substances more often
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than their rural peers. But, smoking prevalence which is higher in rural- than in urban-dwelling boys,
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led us to the conclusion that rural areas are moving away from being the protective communities
they were once thought to be and are seeing an increase in deviant behaviors once viewed as
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exclusively urban occurrences. Some specific factors of influence on SUM should be noted. First,
academic achievement seems to be systematically related to SUM in both genders and both
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communities that were studied. Therefore, special attention should be placed on those children who
perform poorly in school. Also, sports factors are characteristically related to SUM solely among
urban girls, while the highest SUM is found in those girls who participate in sports for a prolonged
period while being less successful. The true cause-effect relationship for all observed factors should
be more precisely investigated through prospective studies. In doing so, a culturally specific and
community-specific approach is needed.
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Acknowledgements
Special thanks go to Cantonal Ministries of Education, Science, Culture and Sport who
supported and approved the investigation. Authors are particularly grateful to all children who
voluntarily participated in the study.
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Contributors
data, drafted the manuscript and discussed the results; NS collected the data and overviewed the
previous research; MP overviewed the previous researches; OU participated in the study design and
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drafted the manuscript; DS did preliminary statistical procedures and discussed the data All authors
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have read and approved the final version.
No, there are no competing interests.
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Competing interest:
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No additional data are available.
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Data sharing statement:
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Ethics approval
The Ethical Boards of University of Split, Faculty of Kinesiology, Split, Croatia and Univesity of
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REFERENCES
1. Sekulic D, Ostojic M, Ostojic Z, Hajdarevic B, Ostojic L. Substance abuse prevalence and its
relation to scholastic achievement and sport factors: an analysis among adolescents of the
Herzegovina-Neretva Canton in Bosnia and Herzegovina. BMC Public Health 2012;12:274
doi: 10.1186/1471-2458-12-274[published Online First: 5 Apr 2012]|.
2. Hublet A, De Bacquer D, Valimaa R, et al. Smoking trends among adolescents from 1990 to
2002 in ten European countries and Canada. BMC public health 2006;6:280 doi:
3. Sekulic D, Ostojic M, Vasilj M, Coric S, Zenic N. Gender-specific predictors of cigarette
smoking in adolescents: an analysis of sport participation, parental factors and religiosity
as protective/risk factors. J Subst Use 2014;19:89-94 doi: Doi
rp
Fo
4. ESPAD report.
http://www.espad.org/Uploads/ESPAD_reports/2011/FULL%20REPORT%20%20Supplement%20to%20The%202011%20ESPAD%20Report%20-%20WEB.pdf.
ee
5. Cerkez I, Culjak Z, Zenic N, Sekulic D, Kondric M. Harmful Alcohol Drinking Among
Adolescents: The Influence of Sport Participation, Religiosity, and Parental Factors. J Child
Adoles Subst 2015;24:94-101 doi: Doi 10.1080/1067828x.2013.764372[published Online
First: 13 Jan 2015]|.
ev
rr
6. Singh A, Sahoo N. Urban-rural differentials in the factors associated with exposure to
second-hand smoke in India. BMJ Open 2013;3:e003542 doi: 10.1136/bmjopen-2013003542[published Online First: 25 Nov 2013]|.
ie
7. Pawlowska B, Zygo M, Potembska E, Kapka-Skrzypczak L, Dreher P, Kedzierski Z.
Psychoactive substances use experience and addiction or risk of addiction among by
Polish adolescents living in rural and urban areas. Ann Agric Environl Med 2014;21(4):77682 doi: 10.5604/12321966.1129932[published Online First: 14 Apr]|.
w
on
8. Peer N, Bradshaw D, Laubscher R, Steyn N, Steyn K. Urban-rural and gender differences in
tobacco and alcohol use, diet and physical activity among young black South Africans
between 1998 and 2003. Global Health Act 2013;6:1-10 doi: DOI
10.3402/gha.v6i0.19216[published Online First: 29 Jan 2013]|.
ly
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
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31
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43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Page 22 of 31
9. McDermott MJ, Drescher CF, Smitherman TA, et al. Prevalence and Sociodemographic
Correlates of Lifetime Substance Use Among a Rural and Diverse Sample of Adolescents.
Subst Abus. 2013;34:371-80 doi: Doi 10.1080/08897077.2013.776000[published Online
First: 25 Oct 2013]|.
10. Donath C, Grassel E, Baier D, Pfeiffer C, Bleich S, Hillemacher T. Predictors of binge
drinking in adolescents: ultimate and distal factors - a representative study. BMC Public
Health 2012;12:263 doi: 10.1186/1471-2458-12-263[published Online First: 2 Apr 2012]|.
11. Sygit K, Kolltaj W, Wojtyta A, Sygit M, Bojar I, Owoc A. Engagement in risky behaviours by
15-19-year-olds from Polish urban and rural areas. Ann Agr Env Med 2011;18:404-09
22
Page 23 of 31
BMJ Open
12. Gutierrez JP, Atienzo EE. Socioeconomic status, urbanicity and risk behaviors in Mexican
youth: an analysis of three cross-sectional surveys. BMC Public Health 2011;11:900 doi:
2011]|.
14. Zenic N, Stipic M, Sekulic D. Religiousness as a factor of hesitation against doping behavior
in college-age athletes. J Relig Health 2013;52(2):386-96 doi: 10.1007/s10943-011-9480x[published Online First: 02 Nov 2011]|.
rp
Fo
15. Cavar M, Sekulic D, Culjak Z. Complex interaction of religiousness with other factors in
relation to substance use and misuse among female athletes. . J Relig Health
2012;51(2):381-9 doi: 10.1007/s10943-010-9360-9[published Online First: 03 Oct 2010]|.
ee
18. Kulis S, Marsiglia FF, Hurdle D. Gender Identity, Ethnicity, Acculturation, and Drug Use:
Exploring Differences among Adolescents in the Southwest. J Community Psychol
2003;31:167-88 doi: 10.1002/jcop.10041[published Online First: 4 Feb 2003]|.
rr
19. Wahl AM, Eitle TM. Gender, acculturation and alcohol use among Latina/o adolescents: a
multi-ethnic comparison. J Immigr Minor Health 2010;12:153-65 doi: 10.1007/s10903008-9179-6[published Online First: 19 Sep 2008]|.
ev
20. Zhen-Duan J, Taylor MJ. The Use of an Ecodevelopmental Approach to Examining
Substance Use Among Rural and Urban Latino/a Youth: Peer, Parental, and School
Influences. J Ethn Subst Abuse 2014;13:104-25
w
ie
21. Branstetter SA, Furman W. Buffering Effect of Parental Monitoring Knowledge and ParentAdolescent Relationships on Consequences of Adolescent Substance Use. Journal of child
and family studies 2013;22(2):192-98 doi: 10.1007/s10826-012-9568-2[published Online
First: Epub Date]|.
on
22. Mason WA, Haggerty KP, Fleming AP, Casey-Goldstein M. Family Intervention to Prevent
Depression and Substance Use Among Adolescents of Depressed Parents. J Child Fam Stud
2012;21(6):891-905.
ly
1
2
3
4
5
6
7
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17
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41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
23. Kiesner J, Poulin F, Dishion TJ. Adolescent Substance Use with Friends: Moderating and
Mediating Effects of Parental Monitoring and Peer Activity Contexts. Merrill Palmer Q
2010;56:529-56
24. Bachman JG, O'Malley PM, Johnston LD, Schulenberg JE, Wallace JM. Racial/ethnic
differences in the relationship between parental education and substance use among U.S.
8th-, 10th-, and 12th-grade students: findings from the Monitoring the Future project. J
Stud Alcohol Drugs 2011;72(2):279-85
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BMJ Open
25. Badr LK, Taha A, Dee V. Substance abuse In Middle Eastern adolescents living in two
different countries: spiritual, cultural, family and personal factors. J Relig Health
2014;53:1060-74 doi: 10.1007/s10943-013-9694-1[published Online First: 23 Mar 2013]|.
27. Sekulic D, Bjelanovic L, Pehar M, Pelivan K, Zenic N. Substance use and misuse and
potential doping behaviour in rugby union players. Res Sports Med 2014;22:226-39 doi:
28. Martens MP, Dams-O'Connor K, Duffy-Paiement C, Gibson JT. Perceived alcohol use
among friends and alcohol consumption among college athletes. Psychol Addict Behav.
2006;20(2):178-84
rp
Fo
29. Barry AE, Howell SM, Riplinger A, Piazza-Gardner AK. Alcohol use among college athletes:
do intercollegiate, club, or intramural student athletes drink differently? Subst Use Misuse
2014]|.
ee
2012;2(2):e000645 doi: 10.1136/bmjopen-2011-000645[published Online First: 6 Apr
2012]|.
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rr
31. Zenic N, Peric M, Zubcevic NG, Ostojic Z, Ostojic L. Comparative analysis of substance use
in ballet, dance sport, and synchronized swimming: results of a longitudinal study. Med
Probl Perform Art 2010;25:75-81
ie
32. Kondric M, Sekulic D, Petroczi A, Ostojic L, Rodek J, Ostojic Z. Is there a danger for myopia
in anti-doping education? Comparative analysis of substance use and misuse in Olympic
racket sports calls for a broader approach. Subst Abuse Treat Prev Policy 2011;6:27 doi:
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Figure legends:
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100%.
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Figure 2: Prevalence of harmful alcohol drinking with odds ratio between and within genders. Percentage of
245x143mm (300 x 300 DPI)
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Figure 3: Prevalence of multiple substance use and misuse (simultaneous harmful drinking and cigarette
smoking) with odds ratio between and within genders. Percentage of reported frequency for boys and girls
with n = 472 and n = 485, respectively, being the 100%.
245x143mm (300 x 300 DPI)
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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies
Section/Topic
Title and abstract
Item
#
1
Introduction
Recommendation
Reported on page #
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(a) Indicate the study’s design with a commonly used term in the title or the abstract
Pages 1 and 2
(b) Provide in the abstract an informative and balanced summary of what was done and what was found
Page 2 and 3
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Background/rationale
2
Explain the scientific background and rationale for the investigation being reported
Objectives
3
State specific objectives, including any prespecified hypotheses
Study design
4
Present key elements of study design early in the paper
Page 6
Setting
5
Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection
Page 8 and 9
Participants
6
(a) Give the eligibility criteria, and the sources and methods of selection of participants
Page 7
Variables
7
Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if
Data sources/
8*
For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
Bias
9
Describe any efforts to address potential sources of bias
Study size
10
Explain how the study size was arrived at
Quantitative variables
11
Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and
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Methods
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applicable
measurement
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comparability of assessment methods if there is more than one group
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Statistical methods
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(b) Describe any methods used to examine subgroups and interactions
Page 10
(c) Explain how missing data were addressed
Page 10
(d) If applicable, describe analytical methods taking account of sampling strategy
NA
(e) Describe any sensitivity analyses
NA
Results
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Participants
13*
(a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
Page 11 and Figures
confirmed eligible, included in the study, completing follow-up, and analysed
Descriptive data
14*
(b) Give reasons for non-participation at each stage
NA
(c) Consider use of a flow diagram
NA
(a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential
confounders
Page 7
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(b) Indicate number of participants with missing data for each variable of interest
Page 7 and Figures
Outcome data
15*
Report numbers of outcome events or summary measures
NA
Main results
16
(a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence
interval). Make clear which confounders were adjusted for and why they were included
NA
(b) Report category boundaries when continuous variables were categorized
NA
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period
NA
Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses
Page 12 and 14
Other analyses
17
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Discussion
Key results
18
Summarise key results with reference to study objectives
Limitations
19
Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and
magnitude of any potential bias
Page 3 and 4
Interpretation
20
Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from
similar studies, and other relevant evidence
Page 11-15
Generalisability
21
Discuss the generalisability (external validity) of the study results
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22
Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
Other information
Funding
which the present article is based
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NA
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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Journal:
Manuscript ID
Article Type:
bmjopen-2015-009446.R2
Research
13-Oct-2015
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Primary Subject
Heading:
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Keywords:
Smoking and tobacco
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Ostojic, Ljerka; University of Mostar, School of Medicine; University of
Split, Faculty of Kinesiology
Pojskic, Haris; Mid Sweden University, Department for Health Sciences
Sekulic, Damir; University of Split, Faculty of Kinesiology; University of
Split, University Department of Health Care Studies
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Herzegovina
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Haris Pojskic; Mid Sweden University, Department for Health Sciences
Östersund - 83125, Sweden
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Department of Health Care Studies, Split - 21000, Croatia
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ABSTRACT
Objective
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Methods
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In this cross-sectional study which was completed during November and December 2014, the
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participants were 957 17- to 18-year-old adolescents (485; 50.6% females) from Bosnia-andHerzegovina. The independent variables were sociodemographic-, academic-, sport-, and familial-
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factors. The dependent variables consisted of questions on cigarette smoking and alcohol
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consumption. We have calculated differences between groups of participants (gender, community),
while the logistic-regressions were applied to define associations between the independent and
dependent variables.
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Results
In urban-community, cigarette-smoking is more prevalent in girls (OR=2.05; 95%CI=1.27-3.35), while
harmful-drinking is more prevalent in boys (OR=2.07; 95%CI=1.59-2.73). When data are broken out
by both gender and community, harmful-drinking is more prevalent in urban-boys (OR=1.97;
95%CI=1.31-2.95), cigarette-smoking is more frequent in rural boys (OR=1.61; 95%CI=1.04-2.39), and
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urban girls misuse substances to a greater extent than rural girls (OR=1.70; 95%CI=1.162.51,OR=2.85; 95%CI=1.88-4.31,OR=2.78; 95%CI=1.67-4.61 for cigarette-smoking, harmful-drinking,
and simultaneous smoking-drinking, respectively). Academic failure is strongly associated with a
higher likelihood of SUM. The associations between parental factors and SUM are more evident in
urban youth. Sports factors are specifically correlated to SUM for urban girls.
Conclusions
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Living in an urban-environment should be considered as a higher risk factor for SUM in girls. Most
probably because of the higher parental-involvement in children’ personal lives in urban
communities (i.e. college-plans for example) parental variables are more strongly associated with
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SUM among urban-youth, Specific indicators should be monitored in the prevention of SUM.
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Participants may lean to socially desirable answers, but knowing that both cigarette smoking
and alcohol consumption are relatively common and socially accepted behaviors in the
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country decreased the possibility that participants did not respond honestly.
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Academic achievement was self-reported and therefore may not be absolutely reliable and
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accurate presentation of scholastic variables, but the testing was done at the beginning of
the school year so we believe that it was correctly reported.
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This is one of the first studies to examine the community-specific context of SUM in
adolescents from the wider territory of the former Yugoslavia, with the main intention to
determine those factors worth studying in forthcoming prospective investigations.
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Funding
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INTRODUCTION
Cigarette smoking and alcohol drinking are the most common types of substance use and
misuse (SUM) among adolescents ([1]. Daily smoking rates in European countries range mostly from
10% to 20%. More specifically, among the countries with the lowest daily smoking prevalence in
adolescence are Sweden (5% and 14%), UK (10% and 17%), and Switzerland (13% and 13.0% for boys
and girls, respectively). The highest daily-smoking-rates among adolescents are reported for Hungary
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(17% and 19%), Belgium (17% and 19%), Bosnia and Herzegovina (25% and 15%), and Austria (20%
and 25% for boys and girls respectively) [1-4]. Additionally, with approximately 30% of adolescents
who self-reported harmful-alcohol-drinking, Bosnia and Herzegovina is clearly one of the European
countries with the highest prevalence of SUM in Europe ([1 4 5]
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These disturbing figures areon adolescent SUM are mostly explained not only by tradition
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and heritage (i.e., growing tobacco has been a significant part of the economy in Bosnia and
Herzegovina for more than three centuries) and social acceptance of alcohol consumption and
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cigarette smoking (i.e., smoking is allowed in public places and there is no strict regulation against
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drinking alcohol in public) but also by post-war trauma, known political problems and a lack of a
general and effective prevention policy [3 5].
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influence SUM [6 7]. The investigations that examined the difference in SUM prevalence between
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evidencing factors potentially related to SUM in adolescence [3 5]. But, studies conducted so far, are
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and scholastic factors and among adolescents [1 13]. One of the probable reasons for the variable
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studies done so far examined ethnic Croats from Croatia and Bosnia-and-Herzegovina [1 5 13], while
The aim of this cross-sectional study was to explore the community-specific (i.e., urban/rural)
associations between scholastic, familial, sports, and sociodemographic factors and alcohol
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consumption and cigarette smoking in adolescents from Bosnia-and-Herzegovina. Additionally, we
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have examined the gender-specific and community-specific prevalence of SUM and associated
factors in the study participants. In this study we have specifically investigated the problems among
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ethnic Bosniak adolescents (Muslims by religion).
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METHODS
Participants
In this cross-sectional study, we examined 957 17- to 18-year-old adolescents from two
Tuzla-Canton and Zenica-Doboj-Canton (485 girls). At the time of testing, all of the participants were
in their final year of high school. For the purpose of the investigation we randomly selected one third
of the high schools in the Cantons, with half from each group. The testing took place during one
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morning school shift (school is organized into two shifts), and we attempted to test approximately
50% of the seniors from the selected schools. Originally, the testing was intended to include more
participants, but for the purpose of this study, we selected only those children who declared
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themselves as traditionally (inherited) Muslim (religion will be discussed later in the paper).
Ultimately, the sample studied in this paper represented 6% of the high school students in the
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observed cantons. The sample is described in the Table 1
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Table 1
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Sample characteristics, break-down for gender and community
Tuzla Canton
Boys
Girls
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110
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Urban
Rural
Total
Zenica Doboj Canton
Boys
Girls
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105
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Variables
questionnaire [1]. The independent variables observed were sociodemographic factors, academic
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achievement factors, sports factors, and familial factors. The dependent variables consisted of
questions on SUM. We asked children about their cigarette smoking and alcohol consumption habits.
average, average, above average), religion/ethnicity (responses included Bosniak-Muslim; BosniakOther; Croatian-Catholic; Croatian-Other; Serbian-Orthodox; Serbian-Other; Other) and strength of
religious beliefs as measured by Santa Clara Strength of Religious Faith (SCSRF) [14 15],. All
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participants who reported place of residence of less than 10.000 inhabitants were grouped as “ruraldwelling” while those who reported place of residence of more than 10.000 inhabitants were
classified as “urban-dwelling”. The population was defined according to Bosnian and Herzegovinian
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their most significant competitive achievements in sports .
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Testing and ethics
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Study was completed during November and December 2014. Testing was strictly anonymous,
meaning that no personal data were collected. Prior to testing, the design and aim of the study were
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explained to all participants and at least one parent for each participant. Parental consent was
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obtained. Testing occurred in a classroom with groups of at least 11 participants. Participants were
informed that they could refuse to participate and that they could leave some questions and/or the
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entire questionnaire unanswered and that returning the questionnaire will be considered their
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consent for participation in the study. When the testing was completed, each participant placed the
questionnaire in a closed box. The next day, the boxes were opened by an investigator who had not
tested the participants. The study was approved by the corresponding author’s Institutional Ethical
Board and Cantonal Ministries of Education.
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Statistics
determine independent variables associated with SUM, we calculated forward conditional stepwise
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logistic regressions. The criteria were binomial SUM variables (smoking vs. non-smoking; harmfuldrinking vs. non-harmful-drinking; multiple SUM vs. non-multiple SUM). Analyses were stratified by
community. Statistica version 12 (Statsfot, Tulsa, Ok, USA) was used for all analyses and statistical
significance was set at p < 0.05 (95%).
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RESULTS
The 29% boys and 32% girls smoke cigarettes, with no significant difference between
genders. For urban-dwelling adolescents, smoking is more prevalent in girls while moking is more
prevalent in urban-girls than in rural- girls. Rural-boys smoke more frequently than urban-boys
(Figure 1).
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Boys are more likely to be involved in harmful drinking than, with 42% boys and 27% girls
who declared harmful drinking habits. Rural boys are evidently more prone to harmful drinking than
rural girls while the likelihood for harmful drinking is significantly greater for urban-boys than urban-
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girls. The harmful drinking is higher for urban boys than for rural boys and urban girls than for rural
girls (Figure 2).
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Multiple SUM is prevalent in 17% boys and 15% girls, with significantly higher likelihood of
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multiple SUM for boys but only for rural-dwelling adolescents.. Urban girls are at higher risk for
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multiple-SUM (23%) than rural-dwelling-girls (10%) (Figure 3).
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parents (MW = 2.54 p = 0.01).
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Table 2
Stepwise forward conditional logistic regression results for the criteria cigarette smoking, harmful
drinking and multiple substance use and misuse (Multiple SUM) among rural and urban dwelling boys
(OR – odds ratio; CI – confidence interval).
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Cigarette smoking
Urban
boys
Rural
boys
OR
OR
(95%CI)
(95%CI)
Harmful drinking
Urban
boys
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OR
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OR
OR
(95%CI)
(95%CI)
(95%CI)
(95%CI)
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1.63
(1.09-2.43)
1.74
(1.14-2.65)
2.66
1.94
2.09
(1.83-3.87)
(1.38-2.73)
(1.38-3.19)
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SCSRF
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Unexcused absence
Parental absence
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(1.02-2.73)
School absence
Financial status
Multiple SUM
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boys
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Grade point average
Behavioral grade
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0.29
(0.10-0.85)
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(1.15-2.79)
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(0.06-0.83)
1.91
(1.05-3.50)
0.96
(0.93-0.99)
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(0.90-0.97)
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Table 3
Stepwise forward conditional logistic regression results for the criteria cigarette smoking, harmful
drinking and multiple substance use and misuse (Multiple SUM) among rural and urban dwelling girls
(OR – odds ratio; CI – confidence interval).
Cigarette smoking
Grade point average
Harmful drinking
Multiple SUM
Urban
Rural
Urban
Rural
Urban
Rural
girls
girls
girls
girls
girls
girls
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(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
OR
(95%CI)
2.53
(1.71-3.76)
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(1.30-2.01)
2.31
(1.41-3.82)
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Unexcused absence
Behavioral grade
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(2-23-5.15)
2.06
4.14
(1.31-3.25)
(1.23-8.14)
6.65
(2.02-
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Financial status
Parental absence
2.70
1.52
(1.10-2.10)
2.54
(4.18-32.83)
3.77
(2.01-7.07)
6.65
(3.06-14.47)
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(2.02-44.12)
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(1.77-4.15)
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(1.11-6.14)
(1.79-9.23)
Sport achievement
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(0.06-0.86)
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(1.55-8.13)
SCSRF
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(0.80-0.90)
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DISCUSSION
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on the subject, which found consumption of cigarettes and alcohol to be alarming [3 5] As a result,
findings on the differences between urban and rural communities with regard to SUM are
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particularly important. The higher prevalence of SUM in urban- than in rural-dwelling girls is almost
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certainly related to the overall sociocultural influence of the urban community on youth behavior. In
general, Bosnia-and-Herzegovina is a traditional country where gender roles are (relatively) defined
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[5 17]. A number of studies have shown that adherence to traditionalism and female-gender-role has
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been linked to lower SUM [18 19]. However, in urban centers traditionalism is not so apparent [1].
Consequently, it is clear that cigarette smoking is more prevalent in urban than in rural girls. With
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regard to alcohol, another issue deserves attention. Namely, girls’ alcohol drinking is socially
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accepted only in night clubs and bars. Because such places are mainly located within urban centers, it
logically increases alcohol consumption in urban girls. Boys from rural communities misuse
cigarettes to a greater extent than their urban-dwelling peers. The cigarette smoking likely may be
generally more accepted and viewed as a cultural norm in rural areas than in urban ones, to the point
where rural parents may not perceive boys’ smoking as a disturbing issue [20]. However, it is also
possible that a lack of other free-time activities (i.e., sports, extracurricular activities, etc.) together
with social acceptance of smoking has resulted in higher cigarette smoking among rural boys. One of
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the unique findings of this study is that urban girls smoke more frequently than urban boys. In
explaining this finding, we must highlight that contrary to alcohol drinking, cigarette smoking in
Bosnia-and-Herzegovina is a socially acceptable behavior for girls. This is particularly true in urban
centers, where girls frequently present their “non-traditionalism” and emancipation by smoking.
Together with the previously discussed difference between urban- and rural-dwelling girls in SUM
(i.e., urban girls misuse substances to a greater extent than rural girls), living in an urban
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environment should be considered a factor of “increased risk” for SUM in girls.
Parental/familial factors have generally been found to be a protective factor against SUM in
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adolescence, [21 22]. In a recent investigation the authors reported different associations between
parental factors and SUM for urban and rural Latin American (Latino) youth [20]. With regard to
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gender, our findings on the stronger influence of parental variables on SUM habits in girls are
consistent with that study. On the other hand we have found there to be stronger parental influence
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on SUM in urban boys, and this is in contrast with the findings reported for Latino youth, where the
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authors found a stronger association between parental factors and SUM for rural children [20]. In
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explaining this inconsistency, we must highlight that our respected colleagues observed 14- to 18year-olds while we have studied 17- to 18-year-olds. Parental monitoring generally decreases with
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age, and urban youth are more likely to continue their education at the college level [5]. Therefore, it
is reasonable to expect that parents of urban boys are more involved in their personal lives than is
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the case for their rural peers. The level of religiousness was found to be specifically associated with
SUM (i.e., urban girls for cigarette smoking and rural boys for harmful drinking). In both cases, a
lower likelihood of misusing substances is evidenced for more religious subjects. The level of
religiousness (i.e. commitment to religious beliefs, traditions and norms) has already been studied
with regard to its potential protective effects against substance misuse in adolescents. However,
findings have not been consistent. The results from a US study [23] show that religiousness reduces
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the odds of tobacco use among adolescents. Conversely, a Mexican study found that adolescents
with lower church attendance and those who place a lower importance on religion are less likely to
consume cigarettes [24]. Although there is some recent evidence that Muslim adolescents have
significantly lower rates of substance misuse than Christians (all Middle Eastern youth) [25], this
study is one of the first that specifically reported on the association between Islamic religiousness
and substance misuse in adolescents. Academic achievement is one of the factors consistently found
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to be associated with SUM in adolescents [3 5]. Therefore, our findings on the negative association
While this study was cross-sectional, and we were not able to define the true cause-effect
relationships between academic achievement and SUM (i.e. it is not clear did adolescents start to
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abuse substances and then failed educationally or vice-versa) some pathways are intuitively obvious.
Namely, it is almost certain that SUM (harmful drinking and multiple SUM; see Results) actually led to
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more unexcused absences. However, this is one of the rare studies that defined the association
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between academic achievement and SUM simultaneously for urban and rural communities, and the
results are consistent with other results recently presented [20].
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consumption among athletes and sport-fans [27-30]. In girls, this is mostly explained by (i) postsports gatherings, (ii) frequent out-of-home situations, and (iii) lower levels of traditionalism in those
girls involved in sports [1 31 32]. We are convinced that all these factors to some extent lead to the
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Following conclusions can be made. In general urban youth consume substances more often
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than their rural peers. But, smoking prevalence which is higher in rural- than in urban-dwelling boys,
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led us to the conclusion that rural areas are moving away from being the protective communities
they were once thought to be and are seeing an increase in deviant behaviors once viewed as
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exclusively urban occurrences. Some specific factors of influence on SUM should be noted. First,
academic achievement seems to be systematically related to SUM in both genders and both
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communities that were studied. Therefore, special attention should be placed on those children who
perform poorly in school. Also, sports factors are characteristically related to SUM solely among
urban girls, while the highest SUM is found in those girls who participate in sports for a prolonged
period while being less successful. The true cause-effect relationship for all observed factors should
be more precisely investigated through prospective studies. In doing so, a culturally specific and
community-specific approach is needed.
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Acknowledgements
Special thanks go to Cantonal Ministries of Education, Science, Culture and Sport who
supported and approved the investigation. Authors are particularly grateful to all children who
voluntarily participated in the study.
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Contributors
data, drafted the manuscript and discussed the results; NS and HP collected the data and overviewed
the previous research; MP overviewed the previous researches; OU participated in the study design
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and drafted the manuscript; DS did preliminary statistical procedures and discussed the data. All
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authors have read and approved the final version.
No, there are no competing interests
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Competing interest
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No additional data are available
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Data sharing statement
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Ethics approval
The Ethical Boards of University of Split, Faculty of Kinesiology, Split, Croatia and University of
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REFERENCES
1. Sekulic D, Ostojic M, Ostojic Z, Hajdarevic B, Ostojic L. Substance abuse prevalence and its
relation to scholastic achievement and sport factors: an analysis among adolescents of the
Herzegovina-Neretva Canton in Bosnia and Herzegovina. BMC Public Health 2012;12:274
doi: 10.1186/1471-2458-12-274[published Online First: 5 Apr 2012]|.
2. Hublet A, De Bacquer D, Valimaa R, et al. Smoking trends among adolescents from 1990 to
2002 in ten European countries and Canada. BMC public health 2006;6:280 doi:
3. Sekulic D, Ostojic M, Vasilj M, Coric S, Zenic N. Gender-specific predictors of cigarette
smoking in adolescents: an analysis of sport participation, parental factors and religiosity
as protective/risk factors. J Subst Use 2014;19:89-94 doi: Doi
rp
Fo
4. ESPAD report.
http://www.espad.org/Uploads/ESPAD_reports/2011/FULL%20REPORT%20%20Supplement%20to%20The%202011%20ESPAD%20Report%20-%20WEB.pdf.
ee
5. Cerkez I, Culjak Z, Zenic N, Sekulic D, Kondric M. Harmful Alcohol Drinking Among
Adolescents: The Influence of Sport Participation, Religiosity, and Parental Factors. J Child
Adoles Subst 2015;24:94-101 doi: Doi 10.1080/1067828x.2013.764372[published Online
First: 13 Jan 2015]|.
ev
rr
6. Singh A, Sahoo N. Urban-rural differentials in the factors associated with exposure to
second-hand smoke in India. BMJ Open 2013;3:e003542 doi: 10.1136/bmjopen-2013003542[published Online First: 25 Nov 2013]|.
ie
7. Pawlowska B, Zygo M, Potembska E, Kapka-Skrzypczak L, Dreher P, Kedzierski Z.
Psychoactive substances use experience and addiction or risk of addiction among by
Polish adolescents living in rural and urban areas. Ann Agric Environl Med 2014;21(4):77682 doi: 10.5604/12321966.1129932[published Online First: 14 Apr]|.
w
on
8. Peer N, Bradshaw D, Laubscher R, Steyn N, Steyn K. Urban-rural and gender differences in
tobacco and alcohol use, diet and physical activity among young black South Africans
between 1998 and 2003. Global Health Act 2013;6:1-10 doi: DOI
10.3402/gha.v6i0.19216[published Online First: 29 Jan 2013]|.
ly
1
2
3
4
5
6
7
8
9
10
11
12
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14
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16
17
18
19
20
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43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
Page 22 of 30
9. McDermott MJ, Drescher CF, Smitherman TA, et al. Prevalence and Sociodemographic
Correlates of Lifetime Substance Use Among a Rural and Diverse Sample of Adolescents.
Subst Abus. 2013;34:371-80 doi: Doi 10.1080/08897077.2013.776000[published Online
First: 25 Oct 2013]|.
10. Donath C, Grassel E, Baier D, Pfeiffer C, Bleich S, Hillemacher T. Predictors of binge
drinking in adolescents: ultimate and distal factors - a representative study. BMC Public
Health 2012;12:263 doi: 10.1186/1471-2458-12-263[published Online First: 2 Apr 2012]|.
11. Sygit K, Kolltaj W, Wojtyta A, Sygit M, Bojar I, Owoc A. Engagement in risky behaviours by
15-19-year-olds from Polish urban and rural areas. Ann Agr Env Med 2011;18:404-09
22
Page 23 of 30
BMJ Open
12. Gutierrez JP, Atienzo EE. Socioeconomic status, urbanicity and risk behaviors in Mexican
youth: an analysis of three cross-sectional surveys. BMC Public Health 2011;11:900 doi:
2011]|.
14. Zenic N, Stipic M, Sekulic D. Religiousness as a factor of hesitation against doping behavior
in college-age athletes. J Relig Health 2013;52(2):386-96 doi: 10.1007/s10943-011-9480x[published Online First: 02 Nov 2011]|.
rp
Fo
15. Cavar M, Sekulic D, Culjak Z. Complex interaction of religiousness with other factors in
relation to substance use and misuse among female athletes. . J Relig Health
2012;51(2):381-9 doi: 10.1007/s10943-010-9360-9[published Online First: 03 Oct 2010]|.
ee
18. Kulis S, Marsiglia FF, Hurdle D. Gender Identity, Ethnicity, Acculturation, and Drug Use:
Exploring Differences among Adolescents in the Southwest. J Community Psychol
2003;31:167-88 doi: 10.1002/jcop.10041[published Online First: 4 Feb 2003]|.
rr
19. Wahl AM, Eitle TM. Gender, acculturation and alcohol use among Latina/o adolescents: a
multi-ethnic comparison. J Immigr Minor Health 2010;12:153-65 doi: 10.1007/s10903008-9179-6[published Online First: 19 Sep 2008]|.
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20. Zhen-Duan J, Taylor MJ. The Use of an Ecodevelopmental Approach to Examining
Substance Use Among Rural and Urban Latino/a Youth: Peer, Parental, and School
Influences. J Ethn Subst Abuse 2014;13:104-25
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21. Branstetter SA, Furman W. Buffering Effect of Parental Monitoring Knowledge and ParentAdolescent Relationships on Consequences of Adolescent Substance Use. Journal of child
and family studies 2013;22(2):192-98 doi: 10.1007/s10826-012-9568-2[published Online
First: Epub Date]|.
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22. Mason WA, Haggerty KP, Fleming AP, Casey-Goldstein M. Family Intervention to Prevent
Depression and Substance Use Among Adolescents of Depressed Parents. J Child Fam Stud
2012;21(6):891-905.
ly
1
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47
48
49
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51
52
53
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55
56
57
58
59
60
23. Kiesner J, Poulin F, Dishion TJ. Adolescent Substance Use with Friends: Moderating and
Mediating Effects of Parental Monitoring and Peer Activity Contexts. Merrill Palmer Q
2010;56:529-56
24. Bachman JG, O'Malley PM, Johnston LD, Schulenberg JE, Wallace JM. Racial/ethnic
differences in the relationship between parental education and substance use among U.S.
8th-, 10th-, and 12th-grade students: findings from the Monitoring the Future project. J
Stud Alcohol Drugs 2011;72(2):279-85
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25. Badr LK, Taha A, Dee V. Substance abuse In Middle Eastern adolescents living in two
different countries: spiritual, cultural, family and personal factors. J Relig Health
2014;53:1060-74 doi: 10.1007/s10943-013-9694-1[published Online First: 23 Mar 2013]|.
27. Sekulic D, Bjelanovic L, Pehar M, Pelivan K, Zenic N. Substance use and misuse and
potential doping behaviour in rugby union players. Res Sports Med 2014;22:226-39 doi:
28. Martens MP, Dams-O'Connor K, Duffy-Paiement C, Gibson JT. Perceived alcohol use
among friends and alcohol consumption among college athletes. Psychol Addict Behav.
2006;20(2):178-84
rp
Fo
29. Barry AE, Howell SM, Riplinger A, Piazza-Gardner AK. Alcohol use among college athletes:
do intercollegiate, club, or intramural student athletes drink differently? Subst Use Misuse
2014]|.
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2012;2(2):e000645 doi: 10.1136/bmjopen-2011-000645[published Online First: 6 Apr
2012]|.
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31. Zenic N, Peric M, Zubcevic NG, Ostojic Z, Ostojic L. Comparative analysis of substance use
in ballet, dance sport, and synchronized swimming: results of a longitudinal study. Med
Probl Perform Art 2010;25:75-81
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32. Kondric M, Sekulic D, Petroczi A, Ostojic L, Rodek J, Ostojic Z. Is there a danger for myopia
in anti-doping education? Comparative analysis of substance use and misuse in Olympic
racket sports calls for a broader approach. Subst Abuse Treat Prev Policy 2011;6:27 doi:
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Figure legends:
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100%.
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117x69mm (300 x 300 DPI)
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Figure 2: Prevalence of harmful alcohol drinking with odds ratio between and within genders. Percentage of
117x68mm (300 x 300 DPI)
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Figure 3: Prevalence of multiple substance use and misuse (simultaneous harmful drinking and cigarette
smoking) with odds ratio between and within genders. Percentage of reported frequency for boys and girls
with n = 472 and n = 485, respectively, being the 100%.
146x85mm (300 x 300 DPI)
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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies
Section/Topic
Title and abstract
Item
#
1
Introduction
Recommendation
Reported on page #
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(a) Indicate the study’s design with a commonly used term in the title or the abstract
Pages 1 and 2
(b) Provide in the abstract an informative and balanced summary of what was done and what was found
Page 2 and 3
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Background/rationale
2
Explain the scientific background and rationale for the investigation being reported
Objectives
3
State specific objectives, including any prespecified hypotheses
Study design
4
Present key elements of study design early in the paper
Page 6
Setting
5
Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data
collection
Page 8 and 9
Participants
6
(a) Give the eligibility criteria, and the sources and methods of selection of participants
Page 7
Variables
7
Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if
Data sources/
8*
For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe
Bias
9
Describe any efforts to address potential sources of bias
Study size
10
Explain how the study size was arrived at
Quantitative variables
11
Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and
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Methods
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applicable
measurement
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comparability of assessment methods if there is more than one group
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Statistical methods
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(a) Describe all statistical methods, including those used to control for confounding
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(b) Describe any methods used to examine subgroups and interactions
Page 10
(c) Explain how missing data were addressed
Page 10
(d) If applicable, describe analytical methods taking account of sampling strategy
NA
(e) Describe any sensitivity analyses
NA
Results
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Participants
13*
(a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,
Page 11 and Figures
confirmed eligible, included in the study, completing follow-up, and analysed
Descriptive data
14*
(b) Give reasons for non-participation at each stage
NA
(c) Consider use of a flow diagram
NA
(a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential
confounders
Page 7
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(b) Indicate number of participants with missing data for each variable of interest
Page 7 and Figures
Outcome data
15*
Report numbers of outcome events or summary measures
NA
Main results
16
(a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence
interval). Make clear which confounders were adjusted for and why they were included
NA
(b) Report category boundaries when continuous variables were categorized
NA
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period
NA
Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses
Page 12 and 14
Other analyses
17
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Discussion
Key results
18
Summarise key results with reference to study objectives
Limitations
19
Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and
magnitude of any potential bias
Page 3 and 4
Interpretation
20
Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from
similar studies, and other relevant evidence
Page 11-15
Generalisability
21
Discuss the generalisability (external validity) of the study results
Page 19
22
Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on
Other information
Funding
which the present article is based
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NA
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE
checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at
http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
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Examination of the community-specific
prevalence of and factors associated with
substance use and misuse among Rural and
Urban adolescents: a cross-sectional analysis
in Bosnia and Herzegovina
Natasa Zenic, Ljerka Ostojic, Nedim Sisic, Haris Pojskic, Mia Peric, Ognjen
Uljevic and Damir Sekulic
BMJ Open 2015 5:
doi: 10.1136/bmjopen-2015-009446
Updated information and services can be found at:
http://bmjopen.bmj.com/content/5/11/e009446
These include:
References
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