Social Science & Medicine 119 (2014) 81e87

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Social Science & Medicine

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Social capital and adolescent smoking in schools and communities: A

cross-classified multilevel analysis
Bart De Clercq a, *, Timo-Kolja Pfoertner b, Frank J. Elgar c, Anne Hublet a, Lea Maes a
a
Ghent University e Faculty of Medicine and Health Sciences, Department of Public Health, Academical Hospital, K3-4, De Pintelaan, 185,
B-9000 Gent, Belgium
b
Institute of Medical Sociology, Martin Luther University, Halle (Saale), Germany
c
Institute for Health and Social Policy and Douglas Institute, McGill University, Montreal, Quebec, Canada

a r t i c l e i n f o a b s t r a c t

Article history: We sought to determine whether social capital at the individual-, school- and community-level can
Received 8 April 2014 explain variance in adolescent smoking and accounts for social inequalities in smoking. We collected
Received in revised form data as part of the 2005/6 Health Behavior in School-aged Children survey, a nationally representative
12 August 2014
survey of the health and well-being of high school pupils in Belgium (Flanders). Social capital was
Accepted 14 August 2014
Available online 15 August 2014
assessed by structural and cognitive components of family social capital, a four-factor school social
capital scale and a cognitive community social capital scale. We fitted non-hierarchical multilevel models
to the data, with 8453 adolescents nested within a cross-classification of 167 schools and 570 com-
Keywords:
Adolescence
munities. Significant variation in adolescent regular smoking was found between schools, but not be-
Smoking tween communities. Only structural family social capital and cognitive school social capital variables
Social capital negatively related to regular smoking. No interactions between socio-economic status and social capital
Inequalities variables were found. Our findings suggest that previously observed community-level associations with
Cross-classified multilevel models adolescent smoking may be a consequence of unmeasured confounding. Distinguishing nested contexts
of social capital is important because their associations with smoking differ.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction The association between social capital and adult smoking is well
documented (Chuang and Chuang, 2008) including the “miniatur-
Tobacco smoking, the largest single cause of avoidable death in ization of community” phenomenon (Lindstrom, 2003), but evi-
the EU (European Commission, 2013), inversely relates to socio- dence in adolescent populations remains sparse. Few studies have
economic status in adult (Winkleby et al., 1992) and adolescent examined a link between both individual- (Curran, 2007;
populations (Blane et al., 1996). Prevention interventions are Lundborg, 2005; Morgan and Haglund, 2009) or contextual social
needed at an early stage because such health-risk behaviors are capital (Aslund and Nilsson, 2013; Henderson et al., 2008;
typically established during adolescence and young adulthood Takakura, 2011; Thorlindsson et al., 2012) and adolescent smok-
(Centers for Disease Control and Prevention, 2008). The last twenty ing, and more specifically in the context of families (Curran, 2007),
years have witnessed an explosion of interest in place effects on schools (Henderson et al., 2008; Takakura, 2011), and communities
health (Diez Roux, 1998; Macintyre et al., 2002). This research has (Aslund and Nilsson, 2013; Thorlindsson et al., 2012). The definition
found between-school and between-neighborhood variance in and measurement of social capital are important to understand (a)
adolescent smoking (Aveyard et al., 2005; Henderson et al., 2008; the heterogeneous findings across studies, and (b) the differential
Kelly et al., 2011; Lovato et al., 2010). However, differences in the impact of various components of social capital on health. Social
associations of social contextual factors with the prevalence of capital has been broadly defined as the resources that individuals
smoking remain unclear (Galea et al., 2004). The goal of this study access through their social networks (Kawachi and Berkman, 2001).
was to explore the social context of adolescent smoking. A first distinction in the conceptualization and measurement of
social capital is commonly drawn between “structural” and
“cognitive” components of social capital (Harpham et al., 2002). The
structural component reflects behavioral manifestations of
* Corresponding author.
E-mail address: [email protected] (B. De Clercq). network connections: network social capital refers to network

http://dx.doi.org/10.1016/j.socscimed.2014.08.018
0277-9536/© 2014 Elsevier Ltd. All rights reserved.
82 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87

membership, family social capital refers to parentechild and areas). The data were collected in the Flemish 2005e2006 Health
parenteschool interactions, school social capital consists of Behavior in School-aged Children (HBSC) survey. Self-completion
childeschool interactions, and childeneighborhood interactions questionnaires were administered in school classrooms with re-
are labeled as community social capital. Within these networks lie quirements in terms of sampling, questionnaire items and survey
subjective aspects of social capital, such as perceptions of trust and administration being set out in a standardized research protocol
reciprocity. These subjective elements of social capital are referred (for more details of the international used methodology and survey
to as cognitive components. Almost orthogonal to the distinction design, see Currie et al. (2009) and Roberts et al. (2007)). In Flan-
between structural and cognitive social capital, most conceptuali- ders, pupils from the 1st year (12 year) to the 6th year (18 year)
zations can be decomposed into “horizontal” and “vertical” com- secondary school were questioned. A random sample of schools
ponents (Islam et al., 2006). Horizontal social capital reflects ties was drawn from the official school list of Flanders, keeping into
that exist among individuals or groups of equals or near-equals, and account the size of the school (schools were weighted by the
vertical (linking) social capital refers to interactions across explicit, number of pupils in the school so that every pupil has the same
formal or institutionalized power or authority gradients in society chance to be in the sample). In total 336 schools were asked to
such as relationships between pupils and teachers (Szreter and participate and 167 agreed (49.7%). Within the schools, 2e3 classes
Woolcock, 2004). Additional distinctions have been drawn within were selected to participate keeping into account the distribution
horizontal social capital, namely “bonding” social capital (strong of gender and the different educational levels in Flanders (general,
ties within homogenous groups such as family members and technical and vocational). The response on pupil level was 98.2%.
friends) and “bridging” social capital (weaker ties within hetero- Passive informed consent was asked to the parents. The study was
geneous groups such as neighbors and school personnel, and approved by the ethics review committee of the University Hospital
formal or informal social participation) (Putnam, 2000). A third of Ghent (project EC UZG2005/383).
distinction concerns the level of analysis e whether social capital is
treated as an individual attribute or as a collective resource 2.2. Measures
(Kawachi, 2006). The proliferation of multilevel techniques in
public health research is consistent with the notion that social 2.2.1. Smoking
capital influences health across multiple nested contexts (Duncan Smoking frequency was measured with the following question:
et al., 1996, 1998). Smoking among adolescents, for instance, “How often do you smoke tobacco at present?” (1 ¼ every day,
might not only be shaped by where they live, but also be an 2 ¼ at least once a week but not every day, 3 ¼ less than once a
interface of simultaneous influences of the family, school, and week, 4 ¼ never). Adolescents who smoked at least once a week
community contexts (De Clercq et al., 2012; Morrow, 1999). A were considered regular smokers (Richter and Leppin, 2007).
limitation of traditional multilevel models is the requirement that
pupils are nested within schools, and schools in their turn, are 2.2.2. Parental and peer smoking
nested within communities. This rigid classification rarely corre- Many studies show that parental smoking and peer smoking are
sponds to actual populations, in which pupils from several neigh- important predictors of adolescent smoking (Kelly et al., 2011). This
borhoods attend the same school or schools serve multiple was measured with the following question: “Does one of the
communities. Ignoring the cross-classification within a population following people smoke?”, with separate response options for fa-
causes underestimation of the standard error of estimates. To our ther, mother, and best friend (1 ¼ every day, 2 ¼ occasionally,
knowledge, no previous research has examined the multilevel as- 3 ¼ never, 4 ¼ don't know, 5 ¼ don't have or see this person).
sociation between multiple levels of social capital and smoking Persons who smoked at least occasionally were considered as
allowing for a non-nested data structure. smokers.
Influenced by theory on income inequality and social network
integration (Wilkinson,1996), prior research has proposed the concept 2.2.3. Socio-economic covariates
of social capital as an explanatory pathway in social inequalities in The Family Affluence Scale (FAS) is a composite indicator of self-
adult (Kawachi et al., 1997) and adolescent (Waterson et al., 2004) reported socio-economic status comprising four items that address
health. Regarding inequalities in adolescent smoking, only two studies family assets or conditions that indicate material wealth (Currie
have examined the role of individual (Evans and Kutcher, 2011) and et al., 2008): ‘Does your family own a car, van or truck? (0 ¼ no;
contextual (Thorlindsson et al., 2012) social capital. These studies 1 ¼ yes one; 2 ¼ yes two or more); Do you have your own bedroom
found that community social capital buffered the negative relation for yourself? (0 ¼ no; 1 ¼ yes); During the past 12 months, how
between socio-economic status and smoking. Previous research also many times did you travel away on holiday with your family?
found that high levels of neighborhood or community social capital (0 ¼ not at all, 1 ¼ once, 2 ¼ twice, 3 ¼ more than twice); How many
might weaken (flatten) the social gradient in adolescent health computers does your family own?’ (0 ¼ none, 1 ¼ one, 2 ¼ two,
(Aminzadeh et al., 2013; De Clercq et al., 2012; Vyncke et al., 2013). 3 ¼ more than two). Responses are summed on a 1 to 10 scale with
The objectives of this study were to (1) estimate the amount of higher scores indicating greater affluence. In addition, adolescents'
variance in adolescent smoking that can be attributed to individual- current education was also used as an indicator of socio-economic
, school- and community-level factors, (2) evaluate the importance status (coded as 1 ¼ general, 2 ¼ technical, 3 ¼ vocational) (Richter
of social capital at the individual-, school- and community-level for and Leppin, 2007).
explaining variance in smoking, and (3) investigate whether dif-
ferences in individual-, school- or community-level social capital 2.2.4. Structural social capital
account for social inequalities in adolescent smoking. Network social capital was measured by participation in clubs or
organizations: “Are you involved in any of these kinds of clubs or
2. Methods organizations?” A sum score was calculated from the following
response categories: sports club, voluntary service, political orga-
2.1. Study participants nization, cultural organization, religious group, youth club, other
club (0 ¼ no, 1 ¼ yes) (De Clercq et al., 2012). Family social capital
The sample consisted of 8453 adolescents nested within a cross- was measured with two separate questions: “How often do you
classification of 167 schools and 570 communities (postal code have breakfast with your mother or father?”; “How often do you
 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87 83

have dinner with your mother or father?” (each coded from Table 1
1 ¼ never to 6 ¼ every day). According to Coleman (Coleman, 1990), Rotated pattern matrix of cognitive social capital items in 8453 adolescents, the
Flemish Health Behavior in School-Aged Children (HBSC) survey, 2005e2006.
communication between family members is critically important in
the formation of basic rules and norms. Family items Factor

1
2.2.5. Cognitive social capital
When I have problems in school, my 0.80
We selected 14 survey questions reflecting cognitive school parents are willing to help me
social capital. Because some of these items could reflect both hor- My parent are willing to come to 0.72
izontal and vertical components of social capital an exploratory school to talk with the teachers
My parents encourage me to do well at 0.76
factor analysis was conducted using Mplus 7.11 to determine a
school
parsimonious set of factors in the data (Muthe
n and Muthe
n,
My parents are interested in what is 0.76
1998e2012). An oblique rotation of factors was performed allow- happening with me in school
ing factors to covary. The plot of eigenvalues suggested a four-factor My parents are willing to help me with 0.63
solution (Table 1): Horizontal (three items, related to fellow pupils), my homework
Eigenvalue 3.14
Vertical (four items, related to teachers), Trust (three items,
Factor determinacy 0.93
reflecting an aspect of trust within the school), and Participation
School items 1 2 3 4
(four items, reflecting involvement in decision making processes
within the school) (each coded from 1 ¼ strongly disagree to Horizontal Trust Vertical Participation
5 ¼ strongly agree). Values below 0.05 on the Root Mean Square My classmates like to be together 0.58 0.02 0.02 0.09
Error of Approximation (RMSEA) and a value of 0.90 or greater on Most classmates are friendly and 0.84 0.00 0.00 0.02
the Comparative Fit Index (CFI) were considered as indicative of a helpful
My classmates accept me as I am 0.65 0.05 0.03 0.03
good fit. With the criteria, the 14 item four-factor model showed
Pupils are involved in organizing 0.28 0.00 0.05 0.33
good fit to the data (c2(df¼41) ¼ 598.34, P < 0.01; CFI ¼ 0.99; school activities
RMSEA ¼ 0.03). Good internal consistency was found in each Pupils are involved in making school 0.03 0.02 0.03 0.52
subscale (Table 1). Alternative factor solutions were considered regulations
(results not shown) and evaluated on the basis of their efficiency Pupils have a say in which kind of 0.02 0.13 0.05 0.56
activities they do
using Akaike's Information Criterion (AIC) and the more conser- Pupils have a say in how class time is 0.00 0.02 0.03 0.63
vative Bayesian information criterion (BIC) (Burnham and used
Anderson, 2002). Compared to other factor solutions, the four- Our school is a nice place 0.00 0.68 0.11 0.08
factor model showed the lowest AIC and BIC values and therefore I feel home at school 0.00 0.90 0.07 0.01
I feel safe at school 0.05 0.60 0.09 0.01
best fit to the data. Family social capital consisted of a 5-item scale.
The teachers treat us fairly 0.02 0.03 0.72 0.02
Example items are “My parent are willing to come to school to talk If necessary, I get extra help 0.00 0.02 0.69 0.01
with the teachers; My parents encourage me to do well at school” The teachers are interested in who I 0.02 0.02 0.62 0.11
(coded from 1 ¼ strongly disagree to 5 ¼ strongly agree). As in am
previous work (De Clercq et al., 2012), community social capital is Most teachers are friendly 0.00 0.09 0.69 0.04
Eigenvalue 4.63 1.57 1.38 1.07
measured using a 5-item scale. Example items are “You can trust Factor determinacy 0.90 0.92 0.90 0.81
people around here; I could ask for help or a favor from neighbours”
Community items 1
(coded from 1 ¼ strongly disagree to 5 ¼ strongly agree). Both
scales are one-dimensional and showed high factor determinacy People say ‘hello’ and often stop to talk 0.63
supporting good internal reliability. Because all social capital in- to each other in the street
It is safe for younger children to play 0.58
dicators were originally measured on the basis of individual re- outside during the day
sponses, they automatically represent the individual dimension of You can trust people around here 0.73
social capital. The collective dimension, on the contrary, was There are good places to spend your 0.54
measured on the basis of aggregated individual indicators or scales free time
I could ask for help or a favor from 0.55
(school- or neighborhood-level mean scores).
neighbors
Eigenvalue 2.39
2.3. Statistical analysis Factor determinacy 0.87

Note. Coefficients represent factor loadings.

Given the complexity of cross-classified models, it is advisable to Bold coefficients represent factor loadings. Italics refer to information criteria
carry out preliminary analysis using standard multilevel models, (Eigenvalue and Factor determinancy).
leaving out each of the cross-classified factors in turn (Hox, 2010).
We first used a 2-level random intercept model, with adolescents as socio-economic variables (family affluence and adolescent educa-
level-1 units and communities as level-2 units. In a second model, tion). Model 4 accounted for parental and peer smoking behavior.
schools were used as the level-2 units. We found statistically sig- In a next step, all individual-level social capital variables were
nificant variance for each of these models, so we used the cross- entered simultaneously (model 5). This model estimated the
classified model to assess whether these variances at each level contribution of individual-level structural (network and family)
were independent. Additionally, a 3-level model was fitted to and cognitive (network, family, school and community) social
compare the overall efficiency of the hierarchical multilevel models capital to smoking frequency. In order to distinguish between
(2-level and 3-level) versus the non-hierarchical model (cross- purely contextual social capital associations with adolescent
classified). Then we proceeded to sequentially estimate a series of smoking and compositional associations (Diez Roux, 1998), further
logit models. First, a variance partition coefficient (VPC) was models consecutively entered contextual-level social capital vari-
calculated to estimate the proportion of the variance of the ables on the condition that significant contextual-level variability
outcome between schools and communities (Goldstein et al., was observed. Finally, (cross-level) interactions with socio-
2002). Model 2 included socio-demographic variables (gender economic status indicators were computed for all social capital
and age). Model 3 was the same as model 2, but with additional variables.
84 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87

We applied Bayesian inference to estimate the parameters, as showed an overestimation of the community-level variance
maximum likelihood based methods (Goldstein and Rasbash, 1996) (s2m0 ¼ 0:271 ¼ 0.271, P < 0.01 compared to s2m0 ¼ 0:033, not sig-
are inefficient in the context of cross-classified models (Browne, nificant in the cross-classified model) and a rather similar school-
2012). We used Markov Chain Monte Carlo (MCMC) simulation level variance (s2v0 ¼ 1:519¼1.519, P < 0.01 compared to
procedures in MLwiN 2.26 (Rasbash et al., 2009). Little is known s2v0 ¼ 1:526, P < 0.01 in the cross-classified model). Results from
about the model parameters a priori, and so our prior distributions the 3-level model showed an underestimation of the school-level
are required to express this lack of knowledge. We used Metropolis variance (s2v0 ¼ 1:387, P < 0.01 compared to s2v0 ¼ 1:526, P < 0.01
Hastings sampling with non-informative improper uniform priors in the cross-classified model) and a correct estimation of the
for the fixed effects and weakly informative uniform priors (derived community-level variance (s2m0 ¼ 0:032, not significant compared
from the iterative generalized least squares [IGLS] algorithm to s2m0 ¼ 0:033, not significant in the cross-classified model).
(Goldstein and Rasbash, 1996)) for the between-school and Overall, MCMC diagnostics from the cross-classified model showed
between-community variances. The Raftery-Lewis diagnostic was that keeping in the neighborhood cluster-set was inefficient.
used to monitor the length of the MCMC chain required for Therefore, further modeling was reduced to the usual 2-level
convergence after a burn-in of 5000 simulations. Variance com- model.
ponents estimates are reported with their standard errors (SEs) and Table 4 presents the regression coefficient estimates from the
p-values. Model coefficient estimates were converted into odds sequential multilevel models. Variance partition calculations indi-
ratios (ORs) with 95% credible intervals (CIs). We used the Deviance cated that about one third of the variability in regular smoking was
Information Criterion (DIC) to test the improvement of fit for each attributable to contextual factors, and thus school related differ-
model (Browne, 2012). A formal description of the cross- ences (r ¼ 32%) since between community differences were
classification procedure can be found elsewhere (Rasbash and negligible. Controlling for socio-demographic differences (model
Goldstein, 1994). 2), model 3 showed no association between family affluence and
regular smoking. However, strong educational differences in reg-
3. Results ular smoking were found: compared to pupils in general education
both technical (OR ¼ 1.737; 95% CI ¼ 1.411, 2.138) and vocational
Table 2 shows the descriptive characteristics of the sample. (OR ¼ 3.651; 95% CI ¼ 2.920, 4.565) pupils reported higher odds for
Respondents (n ¼ 8453) were secondary school pupils between 12 regular smoking. The school-level variance (i.e. the random inter-
and 18 years old (Mean ¼ 15 years) and both boys and girls were cept) was reduced by 59% after adjusting for individual socio-
proportionally distributed in the overall sample. About one third of demographic characteristics (model 2) and additionally by
their fathers, mothers, and peers were smokers, and 17.7% were another 50% after adjusting for individual socio-economic variables
regular smokers themselves. Table 3 presents the variance com- (model 3), which means that individual socio-demographic and
ponents estimates from the different multilevel models. The cross- socio-economic parameters accounted for 80% of the variability
classified model shows that the between school variance in regular between schools. As expected, both parental and peer smoking
smoking was different from 0 at the 0.01 significance level were strongly and positively related to adolescent regular smoking
ðs2v0 ¼ 1:526Þ and the between community variance was not sig- and explained about two third of the remaining school variance
nificant ðs2m0 ¼ 0:033Þ. Results from the 2-level models clearly (model 4). These variables acted as covariates in the subsequent
models to control for compositional differences. Model 5 included
all individual-level social capital variables rendering the between-
Table 2 school variance nonsignificant. Only structural family social capi-
Descriptive characteristics of 8453 adolescents, the Flemish Health Behavior in
tal and cognitive school social capital variables (vertical, horizontal
School-Aged Children (HBSC) survey, 2005e2006.
and trust dimension) significantly related to regular smoking.
Socio-demographics Vertical school social capital inversely related to regular smoking
Gender
(OR ¼ 0.764; 95% CI ¼ 0.678, 0.861), while horizontal school social
Boy % 49.2
Girl % 50.8 capital positively related to regular smoking (OR ¼ 1.189; 95%
Age mean (SD), range ¼ 12e18 15.2 (1.90) CI ¼ 1.076, 1.314). Since the between-school variance turned
Socio-economics nonsignificant after controlling for model 5, no further models
Family affluence mean (SD), range ¼ 1e10 6.55 (1.76) including school-level variables were developed. Finally, in-
Education
General % 50.5
teractions with socio-economic status indicators were tested for all
Technical % 28.4 social capital variables, but none were significant (results not
Vocational % 21.1 shown).
Parental & peer smoking
Father smokes % 33.2
Mother smokes % 27.5
Best friend smokes % 33.1
Structural social capital
Network social capital mean (SD), range ¼ 0e7 1.12 (0.98) Table 3
Family social capital Variance components estimates for the multilevel models in 8453 adolescents, the
Breakfast with parents mean (SD), range ¼ 1e6 3.57 (1.78) Flemish Health Behavior in School-Aged Children (HBSC) survey, 2005e2006.
Dinner with parents mean (SD), range ¼ 1e6 5.16 (1.25)
Cognitive social capital Non-hierarchical Hierarchical models
Family social capital mean (SD), range ¼ 1e5 4.16 (0.72) model
School social capital
Cross-classified 2-Level 3-Level
Horizontal mean (SD), range ¼ 1e5 3.84 (0.81)
Vertical mean (SD), range ¼ 1e5 3.54 (0.72) School-level variance s2v0 1.526 (0.236)* 1.519 (0.237)* 1.387 (0.174)
Trust mean (SD), range ¼ 1e5 3.34 (0.89) *
Participation mean (SD), range ¼ 1e5 2.81 (0.75) Neighborhood-level 0.033 (0.025)n.s. 0.271 (0.050)* 0.032
Community social capital mean (SD), range ¼ 1e5 3.75 (0.62) variance s2m0 (0.033)n.s.
Regular smoking % 17.7
Note. Figures in parentheses represent standard errors (SE).
Note. SD ¼ standard deviation. *P < 0.01.
 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87 85

Table 4
Fixed and random parameters of the multilevel smoking model in 8453 adolescents, the Flemish Health Behavior in School-Aged Children (HBSC) survey, 2005e2006.

Model 1 Model 2 Model 3 Model 4 Model 5

b (SE) b (SE) b (SE) b (SE) b (SE)

Fixed parameters
Constant 1.884 (0.102)* 1.881 (0.083)* 2.325 (0.095)* 3.740 (0.109)* 3.728 (0.113)*
Individual-level
Socio-demographics
Girl 0.083 (0.070) 0.090 (0.073) 0.148 (0.079) 0.149 (0.081)
Age 0.436 (0.026)* 0.406 (0.025)* 0.328 (0.025)* 0.310 (0.026)*
Socio-economics
Family affluence 0.030 (0.019) 0.017 (0.022) 0.004 (0.023)
Education (ref: general)
Technical 0.552 (0.106)* 0.321 (0.106)* 0.236 (0.105)*
Vocational 1.295 (0.114)* 0.900 (0.111)* 0.811 (0.108)*
Parental & peer smoking
Father smokes 0.311 (0.078)* 0.284 (0.083)*
Mother smokes 0.752 (0.079)* 0.688 (0.082)*
Best friend smokes 2.442 (0.082)* 2.392 (0.087)*
Structural social capital
Network social capital 0.010 (0.039)
Family social capital
Breakfast with parents 0.098 (0.025)*
Dinner with parents 0.113 (0.032)*
Cognitive social capital
Family social capital 0.060 (0.053)
School social capital
Horizontal 0.173 (0.051)*
Vertical 0.269 (0.061)*
Trust 0.218 (0.054)*
Participation 0.043 (0.058)
Community social capital 0.004 (0.065)
School-level
e e e
Random parameters
s2v0 (school) 1.519 (0.237)* 0.621 (0.110)* 0.310 (0.068)* 0.106 (0.044)* 0.044 (0.031)
DIC 6913.671 6705.187 6283.572 4812.891 4420.155

Note. Figures in parentheses represent standard errors (SE); *P < 0.05.

4. Discussion minor importance for the prediction of smoking patterns is in line

with other research. As in our study, Richter and Leppin (Richter
The cross-classified model showed significant variation in and Leppin, 2007) found that especially pupils' educational level
adolescent regular smoking between schools, but not between had a major impact on regular smoking. Furthermore, Huisman
communities. Traditional hierarchical two-level (Aslund and et al. (Huisman et al., 2012) found that adolescents' social back-
Nilsson, 2013; Thorlindsson et al., 2012) and three-level studies ground effects on daily smoking were almost fully explained by
(Kelly et al., 2011) came to different conclusions since all found educational enrollment. Thus, in accordance with our finding, the
significant community-level variability in adolescent smoking. relevance of educational tracking for adolescent smoking seems to
Sources of these mixed findings could be the different study support the homogenizing effects within schools in adolescent risk
context of Flemish, Icelandic (Thorlindsson et al., 2012), Swedish behavior (Richter et al., 2009). On individual level, our findings are
(Aslund and Nilsson, 2013) or Australian (Kelly et al., 2011) ado- in line with studies on the positive role of social capital for
lescents, and also the size of the neighborhood cluster scale that adolescent health (McPherson et al., 2013) as well as hypotheses on
differed considerably between studies. However, it is plausible that the dark side of social capital (Portes, 1998). We found that it was
observed community-level associations with adolescent smoking not so much the emotional embeddedness (cognitive social capital)
may be a consequence of unmeasured confounding. Results from within the family, but social relations (structural social capital) that,
our 2-level models clearly showed an overestimation of the according to Due et al. (Due et al., 2003), involve the ‘paren-
community-level variance and a slight underestimation of the techildeschool triad’. In accordance with our findings on structural
school-level variance. Such evidence suggests that 2-level studies family social capital, research has shown that having meals with
may overestimate the contribution of the community environment parents is a fundamental aspect of family live that offers the op-
if they disregard other contexts potentially relevant to the popu- portunity of socialization that include learning of healthy behaviors
lation and outcome under study. Results from the 3-level model (Coleman, 1990; Ja€rvelaid, 2004). Whereas horizontal ties between
showed an underestimation of the school-level variance. Further- pupils increased the likelihood of regular smoking, adolescents'
more, ignoring the cross-classification effect underestimated the trust towards schools and their relation to teachers (vertical social
standard error of the estimates. In sum, these findings support the capital) decreased the likelihood of regular smoking. Similar
need for a cross-classified multilevel approach. studies reported that negative perceptions about the school envi-
Differences in adolescent regular smoking behavior were mostly ronment and about teachers support act as fundamental de-
explained by individual characteristics. Accordingly, previous terminants of health compromising behaviors (McLellan et al.,
research has shown that interschool variance in daily smoking is 1999).
mainly attributed to differences in the composition of schools Especially on school level, vertical social capital represents the
(Aveyard et al., 2005). The finding that family affluence is only of overall cohesion between pupils and teachers at school and
86 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87

teachers' opportunity to interact with pupils and to control their schools are connected in various ways that are difficult to measure.
behavior directly. Our final model was subjected to some additional Other analytic approaches such as fixed-effects analyses and
simulation analysis and we found a truly contextual association (i.e. instrumental variable (IV) estimation are needed to address the
schools with higher levels of vertical social capital had lower rates endogeneity of social capital (Kawachi et al., 2013). Fourth, the
of daily smoking) from the moment we discarded school- substantial meaning of the cognitive family social capital scale may
eneighborhood combinations that were only applicable for a be more relevant for academic achievement, rather than health,
maximum of five adolescents (results not shown). The finding was since two items uniquely refer to school performance (Coleman,
quite robust since it could be replicated in both 2-level and cross- 1988). Lastly, the present study conceptualized social capital
classified models using the standard IGLS algorithm (Goldstein mainly as an ecological resource. This “communitarian perspective”
and Rasbash, 1996) as well as Bayesian procedures (Browne, shifted the focus of public health research on social capital away
2012). Such evidence points out specific issues of cross- from an analytical focus on social networks and ties (Moore et al.,
classification analytic structures besides general multilevel prob- 2005). The distinction between social capital as an ecological
lems such as the ecological fallacy (Robinson, 1950), the modifiable resource and social networks as an individual level attribute
areal unit problem (MAUP) (Openshaw, 1984), and endogeneity already runs through the early public health literature on social
(Kawachi and Subramanian, 2007). To our knowledge, no previous capital, as researchers focused on place effects (Diez Roux, 1998;
study has investigated the contextual association of different forms Macintyre et al., 2002) and began to use multilevel analysis
of social capital with adolescent smoking. Takakura (2011) only (Duncan et al., 1996, 1998). Future studies should measure more
analyses the relation between social trust and prevalence of structural properties of social capital as for example the density of
smoking and found inconclusive results as school-level trust was adolescents' networks (both at school and in the neighborhood),
negatively associated with smoking only for girls. Furthermore, number of friends, parents' social network, structural components
similar findings are only available for school-related outcomes of parenteschool interactions (e.g. parental participation in advi-
(Goddard, 2003) and aspects of adolescents' well-being (Ellonen sory organization), etc. However, this was not possible in the pre-
et al., 2008). Thus, further research is needed to identify support sent study due to lack of data. Further research is also needed to
findings on the association of different forms of school social capital develop an integrated model that identifies the mechanisms that
with smoking and inequalities in smoking. underlie various forms of social capital in their impacts on
In this context, no interactions between socio-economic status adolescent smoking.
and individual-, school- or community-level social capital variables
were found indicating that social capital could not explain social
inequalities in adolescent regular smoking behavior. These results 5. Conclusion
are supported by our findings to the homogenizing effects of
educational tracking on smoking, but are in contrast with tradi- Our findings emphasize the importance of school as a social
tional single-level (Evans and Kutcher, 2011) and 2-level context for adolescent regular smoking. A common line of argu-
(Thorlindsson et al., 2012) neighborhood studies. mentation supports this view (Takakura, 2011): schools are (i) the
places where adolescents spend most of their daytime, and thus (ii)
4.1. Strengths and limitations the main place where they interact with their friends and teachers,
which (iii) shapes both their social relations and behavioral pat-
Among the strengths of this study was its comprehensive terns, and moreover (iv) relatively stronger than larger environ-
assessment of different forms of social capital on multiple levels of ments such as neighborhoods. Therefore, it is plausible that school
analysis. The use of an appropriate statistical method that allowed can be an important source of social capital and a useful unit of
modeling and testing of the cross-classification in neighborhoods analysis to study social capital for pupils. Moreover, previously
and schools strengthened our conclusions. The adopted method- observed community-level associations with adolescent smoking
ology gives more accurate estimates of standard errors for the may be a consequence of unmeasured confounding. Distinguishing
estimated coefficients and shows how random variance is distrib- between types of social capital is critical because their associations
uted among different levels and how it decreases when adding with health are different.
different sets of level-specific variables of interest.
Some limitations in this study warrant comment. Communities
were operationalized as postal code areas, but smaller levels of Funding
aggregation or spatial scales using physical distances between
residents might have tapped between community variability in This work was supported by the Flemish government.
adolescent smoking (Takagi, 2013). Moreover, the research design
of the study (i.e. sampling at school-level) is biased against com-
munity effects because the sample consisted of 8453 adolescents The HBSC study
from 167 schools and 570 communities. Such a design undermines
community-level statistical power in that there were on average 51 HBSC is an international study carried out in collaboration with
cases in each school but only 15 cases in each community, which WHO Europe. The International Coordinator of the 2005e6 survey
would present stronger within-school correlation than within- was Professor Candace Currie from the University of Edinburgh and
community correlation. Third, the problem of endogeneity the Data Bank Manager was Dr. Oddrun Samdal from the University
(Kawachi and Subramanian, 2007) in the context of the present of Bergen. The 2005e6 survey was conducted by Principal In-
dataset was discussed extensively elsewhere (De Clercq et al., vestigators in 41 countries. For details, see http://www.hbsc.org.
2012). Also in cross-classified multilevel models the econo-
metrical partition of variance between contexts is somewhat arti-
ficial. The community where adolescents lived, is likely to Appendix A. Supplementary data
determine the supply of schools to which they can attend. The types
of schools that are available are likely to determine the types of Supplementary data related to this article can be found at http://
families that move into the local area. Thus, neighborhoods and dx.doi.org/10.1016/j.socscimed.2014.08.018.
 B. De Clercq et al. / Social Science & Medicine 119 (2014) 81e87 87

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