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Objective: Implementation fidelity is a key dimension in process evaluation but has been scarcely studied. Reptes is a selective alcohol and cannabis use prevention program performed in vulnerable young people (16-21 years) from different educational and leisure settings. The study aimed to describe the components of this program, its implementation fidelity, and satisfaction among participants and facilitators., Method: A descriptive cross-sectional study was conducted. Implementation fidelity was assessed in terms of adherence, dose, participant responsiveness, and quality of the intervention through self-reports completed by 15 facilitators and self-administered questionnaires by 99 youth from the 15 groups completing the program., Results: 70.7% of the groups performed 30 of the 43 planned activities with high use of various teaching methods, except for Information and Communication Technology resources. Fidelity implementation was above 70%. 2/3 groups completed an acceptable intervention and 1/3 completed a qualified intervention. Satisfaction was higher than 7., Conclusions: Our results show high implementation fidelity and satisfaction compared with those from similar studies., (Copyright © 2023 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To analyze the patterns of alcohol and cannabis consumption, and their associated factors, in young people aged 16 and 21 in a context of vulnerability., Method: Cross-sectional study based on a pre-test questionnaire from an evaluation study, administered to a convenience sample of 365 young people from Social Guarantee Programs (SGP), or who attended activities of community entities from disadvantaged neighborhoods in Barcelona. Dependent variables were experimental, regular, and problematic alcohol and cannabis consumption, while independent variables were impulsivity, sensation seeking, expectations, and beliefs regarding drug use, social skills, and contextual variables. Associations were established using multivariate logistic regression models., Results: The prevalence of intensive alcohol consumption (24.2% for binge drinking and 33.3% for binge drinking) and experimental (51.1%) and problematic cannabis use (12.9%) was higher in SGP students than entity youth. Likewise, they presented higher scores on the impulsivity scales, sensation seeking, expectations and beliefs favorable to alcohol consumption. In general, the prevalence of experimental alcohol consumption was higher in girls than in boys. Regular binge drinking was associated with intense sensations seeking (adjusted odds ratio [aOR]: 1.06; 95% confidence interval [95%CI]: 1.01-1.12), while attending SGP was associated with problematic cannabis use (aOR: 2.73; 95%CI: 1.26-5.89). Positive expectations to alcohol and cannabis use were associated with problematic substance use., Conclusion: Individual risk, linked to the higher risk trajectories of SGP students, is associated with a higher problematic consumption of alcohol and cannabis than in young people from community entities exposed to an environmental risk of high frequency of consumption., (Copyright © 2020 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: We aimed to analyse the prevalence of having multiple lifestyle risk behaviours (LRB) and the potential relationship between excess weight (including overweight and obesity) and cumulative multiple LRB among adolescents in Barcelona, Spain., Methods: A cross-sectional study was performed among a representative sample of 3,114 secondary school students in Barcelona. Height and weight were objectively measured and excess weight was defined in accordance with World Health Organization criteria. Information on screen time, breakfast, physical activity and sleep duration was obtained through a self-administered questionnaire., Results: More than 80% of the students had at least two LRBs. In compulsory schooling, the adjusted prevalence ratio (aPR) of excess weight increased with a higher number of reported LRBs (four LRBs: aPR=1.56; 95% confidence interval: 1.19-2.05)., Conclusions: These results highlight the importance of a multiple-behaviour approach in preventive programmes aimed at reducing adolescent obesity., (Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

The prevention of childhood obesity is one of the greatest public health challenges of modern times. This has triggered the generation of a wealth of scientific evidence, culminating in a body of knowledge concerning the essential components of campaigns implemented in the school setting. In this regard, a growing trend towards the evaluation of research results in terms of effectiveness has become apparent, while the fieldwork itself very rarely comes under the spotlight. By considering the implementation process description of a multicomponent campaign designed to prevent childhood obesity in boys and girls in the 3 rd year of primary education in Spain (9-10 years of age), the aim of this paper is to influence the elements of this process by considering important aspects pertaining to its implementation, such as its plausibility and feasibility in the particular context., (Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Breakfast is considered the most important meal of the day in an equilibrated diet. Skipping breakfast has been associated with overweight. This study aimed to describe overweight and obesity among high school students in Barcelona and to analyze their association with eating habits and sedentary behaviors., Material and Methods: A cross-sectional study was performed in 2008 on a representative sample of high-school students in Barcelona (Spain). Overweight and obesity were defined using Body Mass Index (BMI), which was calculated from objective measurements. The prevalences of overweight and obesity were determined, and their association with eating habits, sedentary behaviors, and physical activity was analyzed using logistic regression models., Results: A total of 3,089 students were analyzed (52% girls). The prevalence of overweight was 26.1% in boys (6.2% obese) and 20.6% in girls (3.7% obese). In both sexes, overweight was associated with being younger, having breakfast less often, being on a diet, and with a lower frequency of unhealthy food intake. Being on a diet and a lower unhealthy food intake were related to obesity in both sexes. Among boys, obesity was also associated with sedentary behaviors., Conclusions: The results show that overweight and obesity are a serious public health problem and confirm the importance of breakfast to prevent overweight. Moreover, these results allow us to expand our knowledge on the factors associated with overweight and obesity in order to improve current school preventive programs., (Copyright © 2014 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

The percentage of failure and relapse in the treatment of obesity is high. Where possible, the preferred strategy for preventing obesity is to modify eating habits and lifestyles. This article aims to provide a framework for evidence on the most effective interventions for addressing childhood obesity, both from a prevention point of view, as well as reducing it, when it is already established. After a review of the scientific literature, the issues that must be considered both in the universal and selective prevention of childhood obesity are presented. Also, in light of the controversy over the tools for measuring and controlling the problem, some clarification is provided on the criteria. Finally, the approach to the prevention of overweight and obesity with a community perspective is separated, with two short protocols being offered with diagrams of the basic procedure to follow., (Copyright © 2014 Elsevier España, S.L.U. All rights reserved.)

Objective: To determine the prevalence of risky alcohol consumption and associated risk factors among adolescents living in Central Catalonia (Spain) during the 2011-2012 academic year, depending on their area of residence., Method: A cross-sectional study was carried out in a sample of 1268 10th grade students (4th grade of secondary education) in Central Catalonia., Results: Risky alcohol consumption was higher among adolescents in rural areas than in urban areas (59.6% versus 49.8%). Associated risk factors were drunkenness in siblings and friends, having positive expectations of alcohol consumption, and buying alcohol. Not living with both parents and poorer academic achievement were associated risk factors in rural areas, while higher socioeconomic status was a risk factor in urban areas., Conclusions: Risky alcohol consumption was much higher among adolescents living in rural areas. The main associated factor was alcohol consumption among family and friends., (Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objective: To identify and describe studies on social inequalities in child and adolescent health conducted in Spain with special emphasis on social determinants., Methods: In July 2012, we conducted a systematic review in the PubMed, MEDES, SCOPUS and COCHRANE databases. We included studies on social inequalities in child and adolescent health in Spain published between 2000 and 2012. A total of 2147 abstracts were reviewed by two researchers and 80 manuscripts were fully reviewed by three researchers. Risk of bias was assessed. Seventy-two articles were finally included., Results: A total of 83% of the studies were cross-sectional and the most frequently studied age group consisted of 13-15-year-olds. More than 20 individual or group determinants were identified. The most frequently analyzed determinants were the most advantaged educational level and occupation of the mother or the father. In 38% of the studies analyzing education and occupation, there was no definition of the determinant. Social inequalities were detected in dental health with all determinants and in all age groups (9% of studies with a high risk of bias). Social inequalities were also detected in obesity, physical activity and mental health with some determinants. Specific data were missing for younger children. No social inequalities were found in the use of health services, excluding dental care. Few studies analyzed immigration and 42% of them had a high risk of bias., Conclusion: Wide diversity was found in the measurement of social determinants, with a lack of studies in preschoolers and of studies with longitudinal designs. The results of this study confirm social inequalities in some aspects of health., (Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objectives: Smoking is a preventable cause of early death and the habit starts in adolescence. The aim of this study was to describe tobacco consumption in secondary school students in 2008 and trends in the last 20 years in Barcelona., Material and Methods: We analyzed the trend in tobacco consumption by comparing data from 8 surveys carried out between 1987 and 2008 in the 8th (2nd year of Compulsory Secondary Education), 10th (4th year of Compulsory Secondary Education) and 12th (2nd year of Compulsory Secondary Education) years of secondary school. The FRESC questionnaire was used. Data on regular and daily consumption and associated factors in 2008 were gathered and compared with those corresponding to the previous studies. Percentages of annual change were calculated with Joinpoint regression and data were stratified by sex and year of education., Results: In 2008, 6.1% of boys and 4.5% of girls in the 8th year, 15.8% and 20.4% of those in the 10th year, respectively, and 26.1% and 33.1% of those in the 12th year, respectively, were regular smokers. A strong association was noted between regular smoking and cannabis consumption in three school years, as well as with having friends who were smokers and poor school performance. At 15-16 years old, the average annual decrease from 1996 to 2008 was 6.8% in girls and 6.1% in boys., Conclusions: Adolescent smoking has been decreasing in the last few years in Barcelona. There is a strong association between tobacco use and cannabis consumption., (Copyright © 2013 SESPAS. Published by Elsevier Espana. All rights reserved.)

Objective: To analyse information on adolescent use of tobacco in Spain from different school surveys., Design: Data on daily smoking prevalence by sex at the end of compulsory education is extracted and figures are compared, analysing trends., Setting: The five representative studies on adolescents in Spain are reviewed: The National Survey on Drug Use in Secondary School Children (Encuesta estatal sobre uso de drogas en estudiantes de secundaria (ESTUDES); Survey of Health Behaviour in School-aged Children (HBSC-ECERS); Surveillance System of Risk Factors Associated With Non-Transmittable diseases in the Young Population (Sistema de Vigilancia de Factores de Riesgo Asociados a Enfermedades No Transmisibles dirigido a población Juvenil)(SIVFRENT-J); Study of Risk Factors in Secondary School Children (Estudio de factores de riesgo en estudiantes de secundaria) (FRESC); Surveillance Study of Health Behaviour in Adolescents (Estudio de Monitorización de las Conductas de Salud de los Adolescentes) (EMCSAT)., Results: The prevalence of daily smokers varies among studies, in boys from 8.5 to 13.3% and in girls from 12.7 to 16.4%. Although some series show variations, the trend from 1993 to 2008 is downwards. With data from recent years, weighted annual declines in smoking prevalence in adolescence can be estimated to be 6.47% for boys and 6.96% for girls., Conclusions: There is a decreasing pattern in adolescent daily smoking prevalence in Spain from the different existing studies, which provide consistent data, although surveillance must be kept due to fluctuations. This is in agreement with tobacco sales statistics and health surveys in the adult population. However, the pace of change should be more rapid and constant., (© 2010 Elsevier España, S.L. All rights reserved.)

Introduction: In the last few years, health surveys and epidemiological studies on smoking have introduced questions on environmental tobacco smoke (ETS) exposure. However, a standardized questionnaire is lacking., Methods: Between January and May 2008, we reviewed surveys containing items on ETS exposure carried out in Spain by public administrations, scientific societies and research institutes. The wording of the questions was reviewed and classified according to the study type, target population, geographical setting and place of exposure., Results: We identified 27 surveys that included questions on passive smoking. Most were health surveys (81.5%) and were aimed at the general population (70.4%). The most frequent geographical setting consisted of autonomous regions (48.1%) and the most common place of exposure was the home (88.9%), Discussion: The results show wide variability in the questions used. Questionnaire items on ETS exposure should be homogenized to allow comparison of the results of surveys., (Copyright © 2010 SESPAS. Published by Elsevier Espana. All rights reserved.)

Evaluation of public health interventions usually focus on the quality of design and research methods, and less on the quality of the intervention or process evaluation. In process evaluation of school-based interventions, key issues are how completely the intervention is carried out and adherence to the protocol. In addition, exploration of intermediate variables, such as those that influence (and often predict) preventable behavior, is highly useful. This article describes the basic concepts in this topic, using examples of the effectiveness of some preventive interventions carried out in schools. The interventions discussed were mainly quasi-experimental studies, based on data from programs promoted by public health teams in the city of Barcelona. Data from process evaluation of preventive programs in secondary schools that underwent formal assessment of their effectiveness is provided. The examples are drawn from preventive programs of HIV infection or unprotected sexual intercourse (PRESSEC program) and drug consumption prevention (the PASE, PASE.bcn and x kpts programs). These examples show why the intervention process influences the impact of the programs and their results. Thorough planning of process evaluation is essential to obtain valid indicators that will identify, in the effectiveness evaluation of the intervention, the most efficacious strategies to obtain positive outcomes., (Copyright © 2011 Sociedad Española de Salud Pública y Administración Sanitaria. Published by Elsevier Espana. All rights reserved.)

In the last few years, interest has markedly increased in evaluating health programs, especially their social utility and economic efficiency. However, consensus on key issues in evaluation, such as terminology, goals and methods is still a long way off. In this context, we review the main definitions and classifications of evaluation applied to public health programs and policies. We describe the main evaluation designs and their components, focusing on outcome evaluation. Threats to the internal validity of the results of weak evaluation designs are also discussed. The characteristics of public health interventions that limit evaluation with traditional designs are also analyzed. These limitations include the complexity of interventions, usually with multiple components, and the difficulty of forming an equivalent control group with no intervention, especially through random assignment. Finally, a two-step approach to evaluation through weak designs, which takes into account adequacy and plausibility, is described. Adequacy consists of the observation of a change in the selected indicators after the intervention, and would be sufficient to take decisions under certain conditions; at other times, plausibility would need to be analyzed, defined as attribution of the results to the program or intervention., (Copyright © 2011 Sociedad Española de Salud Pública y Administración Sanitaria. Published by Elsevier Espana. All rights reserved.)

Objective: To assess the optimal cut-point for salivary cotinine concentration to identify smoking status in the adult population of Barcelona., Methods: We performed a cross-sectional study of a representative sample (n=1,117) of the adult population (>16 years) in Barcelona (2004-2005). This study gathered information on active and passive smoking by means of a questionnaire and a saliva sample for cotinine determination. We analyzed sensitivity and specificity according to sex, age, smoking status (daily and occasional), and exposure to second-hand smoke at home. ROC curves and the area under the curve were calculated., Results: The prevalence of smokers (daily and occasional) was 27.8% (95% CI: 25.2-30.4%). The optimal cut-point to discriminate smoking status was 9.2 ng/ml (sensitivity=88.7% and specificity=89.0%). The area under the ROC curve was 0.952. The optimal cut-point was 12.2 ng/ml in men and 7.6 ng/ml in women. The optimal cut-point was higher at ages with a greater prevalence of smoking. Daily smokers had a higher cut-point than occasional smokers., Conclusions: The optimal cut-point to discriminate smoking status in the adult population is 9.2 ng/ml, with sensitivities and specificities around 90%. The cut-point was higher in men and in younger people. The cut-point increases with higher prevalence of daily smokers.

Background and Objective: The objective of this study was to assess the exposure to environmental tobacco smoke (ETS) by means of the concentration of salivary cotinine in a sample of adolescent students, and its relationship with active and passive tobacco consumption., Methods: A cross-sectional survey was conducted in 92 secondary education and high school pupils (16-20 years). Salivary samples were collected and salivary cotinine was measured by gas chromatography/mass spectrometry. Salivary cotinine medians and interquartile ranges were calculated. Significant statistical differences were detected with the non parametric test for medians., Results: The median of salivary cotinine concentration in current smokers was 91.5 ng/ml (RI: 62.4-125); in former smokers 7.9 ng/ml (RI: 5.1-15.5) and in never smokers 1.9 ng/ml (RI: 0-3.6). In smokers of more than 10 cigarettes per day, the result was 98.3 ng/ml (RI:63.4-142.9). Among non-smokers (never-smoker and ex-smokers), the median of salivary cotinine in non-smokers living with smokers was 3.3 ng/ml (RI: 0-8.6) versus 2.9 ng/ml (RI: 1.1-6.9) in those living with non-smokers., Conclusions: The salivary cotinine concentration increases with the intensity of tobacco consumption and the perception of passive exposure to tobacco smoke.

Objective: To analyze the efficiency of a school-based smoking prevention program in Barcelona (PASE.bcn program)., Methods: A cost-benefit analysis was performed. As costs we included those corresponding to the design and implementation of the program. As benefits we considered healthcare costs and the productivity losses avoided. This study was conducted from a societal perspective, and the estimations of costs and benefits related to 2005., Results: Assuming an effectiveness of 1%, the PASE.bcn program would achieve a total benefit of 1,558,311.46euro. The healthcare benefits per prevented smoker were 1997.57euro, and the indirect benefits per prevented smoker were 21,260.80euro. Given the total cost of the school-based program (68,526.03euro), the cost-benefit ratio was 22.74., Conclusions: From a societal perspective, the benefits of school-based tobacco prevention programs, in terms of healthcare costs and productivity losses avoided, are far greater than the costs. These results support universal application of this type of intervention.

Objectives: To describe the circumstances of initial use of Cannabis, as well as the reasons for consumption, reported effects and expectations related to cannabis use, among adolescents in Barcelona., Methods: A cross-sectional survey was conducted in a sample of pupils in the third year of compulsory secondary education in 2005. The questionnaire was confidential and self-completed. Data were gathered from 2,043 secondary school pupils from 47 schools in Barcelona., Results: A total of 37.5% of students reported cannabis consumption at some time, and 10.0% of these students had used cannabis in the previous month. Cannabis use was more common in public schools than in subsidized or private schools (p < 0.001). More than half the adolescents (60.3%) smoked cannabis for the first time in parks or on the street. Most (88.4%) of the adolescents obtained cannabis from a classmate or friend and 92.3% did so without paying for it. The main reason for initial consumption was curiosity, and reasons for continuing use were a desire to feel better and to forget problems. The most frequently reported effects were memory loss, sadness and difficulties in studying or working. Cannabis use was positively related to the expectation that the drug induces relaxation and aids social and sexual relations, and negatively to the beliefs that the drug can impair intellect and behavior and has negative effects on health., Conclusions: Cannabis was easily accessible to secondary school pupils and 9 out of 10 obtained the drug from a classmate or friend without paying for it. Two out of 3 adolescents reported negative effects as a consequence of cannabis use. Knowledge of expectations could help to explain and prevent cannabis consumption during adolescence.

Objective: To compare the utility of two multivariate analytic methods, case-control (CC) analysis and nested case-control (NCC) analysis in a cohort, to identify the factors associated with the onset of cannabis use., Methods: A longitudinal cohort study of a sample of secondary school students (n = 1,056) in the first year of secondary school was carried out. Participating students were followed-up annually until the fourth year of secondary school. In the CC analysis, students in the fourth year who reported having consumed cannabis at some time were considered cases and those who had never consumed cannabis were considered controls. Logistic regression (LR) models were estimated. In the NCC analysis, cases in each year of follow-up were compared with a random sample of controls at risk in the same year and conditional LR models were estimated., Results: In the CC analysis, 6 variables in boys and 9 variables in girls in bivariate models and 3 variables in boys and 4variables in girls in multivariate models were identified. In the NCC analysis, 17 variables in univariate models and 4 in multivariate models were obtained in both boys and girls. The estimators of the CC analysis showed an average of 1.2-fold more variability., Conclusions: A higher number of factors associated with cannabis use were identified in the NCC analysis and the estimators were more precise. NCC could be a more efficient option than CC analysis.

Objective: To determine the factors associated with the onset of cannabis use through a systematic review of cohort studies., Methods: An internet-based search was performed using several keywords and their combinations. Original studies with longitudinal design and the onset of cannabis use as dependent variable, as well as review studies were included, published between January 1980 and May 2004. Methodology quality of the studies was assessed independently by two reviewers, according to pre-established criteria, in order to classify studies in high, mid or low quality. Agreement between reviewers was assessed through kappa coefficient., Results: A total of 32 relevant studies were identified, of which 13 were of higher quality. Selection bias for the inclusion of consumers at the baseline measurement and lack or insufficient adjustment for confounders were the causes of exclusion. The factors of great evidence related to the onset of cannabis use were masculine sex, consumption of tobacco or alcohol, having a problematic relationship with parents, and cannabis consumption by friends., Conclusion: Results highlight the importance of different individual, family and environmental factors on the onset of cannabis use. These must be considered to properly arrange intervention programs focusing on primary prevention among teenagers.

Background and Objective: To estimate the excess lung cancer mortality risk associated with environmental tobacco (ETS) smoke exposure among hospitality workers. The estimation was done using objective measures in several hospitality settings in Barcelona., Method: Vapour phase nicotine was measured in several hospitality settings. These measurements were used to estimate the excess lung cancer mortality risk associated with ETS exposure for a 40 year working life, using the formula developed by Repace and Lowrey., Results: Excess lung cancer mortality risk associated with ETS exposure was higher than 145 deaths per 100,000 workers in all places studied, except for cafeterias in hospitals, where excess lung cancer mortality risk was 22 per 100,000. In discoteques, for comparison, excess lung cancer mortality risk is 1,733 deaths per 100,000 workers., Conclusion: Hospitality workers are exposed to ETS levels related to a very high excess lung cancer mortality risk. These data confirm that ETS control measures are needed to protect hospital workers.

Objectives: To describe levels of exposure to environmental tobacco smoke (ETS) in various public places in Barcelona (Spain)., Material and Method: Vapor-phase nicotine was measured with passive samplers containing a sodium bisulfate treated filter with a 37 mm diameter. The places sampled were primary and secondary schools, hospitals, primary care centers, train stations, subways, universities, airports, restaurants and discotheques., Results: Primary and secondary schools and health centers had the lowest levels of ETS exposure, with mean concentrations of less than 1 microg/m3. The mean values found in transport and universities were 2.16 microg/m3 in train stations, 3.30 microg/m3 in subways, 4.30 microg/m3 in airports and 4.97 microg/m3 in universities. The highest concentrations were found in restaurants and discotheques, with mean values of 12.36 microg/m3 in restaurants and 130.65 microg/m3 in discotheques. All samples taken from primary and secondary schools, airports, subways, restaurants and discotheques contained ETS. Likewise, 90% of the samples taken from train stations and 96% of those from universities contained ETS. Seventy-nine percent of the samples from hospitals and 58% of those from primary care centers contained ETS., Conclusions: The results confirm that passive smoking is an important public health problem in Spain and that greater efforts are needed to enforce smoke-free policies in public spaces and workplaces.

Objective: To analyze the predictors of smoking onset among schoolchildren., Methods: A cohort study of 1056 children starting in first year secondary school at 44 schools in Barcelona was carried out. Participating children were invited to answer a lifestyle questionnaire every year for 4 years. Each questionnaire carried a personal code to allow the 4 questionnaires to be matched. Matching questionnaires were found for 729 children, 70% of the initial sample., Results: Over the study period, the prevalence of regular smokers increased from 1.7% to 22% among boys and from 1.6% to 38.2% among girls. The predictors of smoking onset among boys were scoring high on the pro-smoking attitudes index (odds ratio [OR]=1.2; 95% confidence interval [CI], 1.1-1.3), intention to smoke in the future (OR=2.2; 95% CI, 1.0-4.9), low self-efficacy in resisting pressures to smoke (OR=0.98; 95% CI, 0.96-0.99), having siblings that smoke (OR=2.5; 95% CI, 1.2-5.4), and spending some free time in bars (OR=2.4; CI, 1.1-4.9). Among girls, the predictors were having low self-esteem (OR=0.94; 95% CI, 0.88-0.99), scoring low on the anti-tobacco attitudes index (OR=0.92; 95% CI, 0.88-0.97), having siblings who smoke (OR=2.5; 95% CI, 1.2-5.5), spending some free time in discotheques (OR=4.5; 95% CI, 1.9-11.8), and living in high socioeconomic-status neighborhoods (OR=3.1; 95% CI, 1.4-10.9)., Conclusions: The results show the importance of cognitive variables as well as a variety of environmental variables, particularly the pattern of free time use and the influence of sibling models. Prevention programs must take into account smoking onset risk factors as a whole.

Objective: To describe the factors asssociated with smoking and intention to smoke among a representative sample of first-grade pupils of secondary education (12-13 years old) in Barcelona., Subjects and Methods: 37 secondary schools were randomly selected to evaluate the impact of a European-wide smoking prevention program (European Smoking prevention Frame Approach, ESFA project). In these schools, 1041 pupils of first grade of secondary education responded to a questionnaire designed at the University of Maastricht to study life-style attitudes and behaviours, mainly smoking., Results: 9.8% of boys and 12.6% of girls declared to smoke either regulary or ocasionally. Among the no-smokers, 61.4% of the boys and 73.3% of the girls reported to have the intention to smoke in the future. Among the boys, factors associated with smoking included social norms (odds ratio [OR] = 2.5; 95% confidence interval [CI]: 1.2-5.2), smoking by siblings (OR = 2.4; 95% CI, 1.1-5.2), attitudes against smoking (OR = 0.3; 95% CI, 0.1-0.6), practicing some sports in the leisure time (OR = 0.3; 95% CI, 0.1-0.7) and having more available pocket money (OR = 3.2; 95% CI, 1.5-6.8). Intention to smoke was only related to attitudes (OR = 0.3; 95% CI, 0.2-0.5). Among girls, smoking was associated to perceived pressure to smoke (OR = 2.5; 95% CI, 1.2-5.0), consumption by friends (OR = 6.0; 95% CI, 2.4-15.4) and attitudes against smoking (OR = 0.2; 95% CI, 0.1-0.4), while intention was only associated to attitudes (OR = 0.4; 95% CI, 0.2-0.6) and hanging out in the street in the leisure time (OR = 2.2; 95% CI, 0.3-3.5)., Conclusions: The results stress the need to deal simultaneoulsy with the different factors associated to smoking initiation and attitude shaping, including cognitive factors, environmental factors, and patterns of leisure time utilization.