Abstract
Tobacco use often begins in adolescence and it is a major driver of preventable diseases, with tobacco outlet availability around school environments in urban settings identified as a key factor influencing adolescent smoking. This study aimed to examine the association between tobacco outlet density (TOD) around schools and adolescent smoking in Madrid, Spain. We conducted a cross-sectional multilevel design with 2,198 students aged 14-18 from 49 secondary schools in the city of Madrid in 2022. Tobacco outlets around schools were identified by Systematic Social Observation. The TOD within 500m street network buffers around each school was calculated as outlet counts using Geographic Information Systems. Outcomes were defined as: ever smoking cigarettes, ever using e-cigarettes, and dual use of both. Multilevel Logistic Regression models were used to assess associations between TOD and smoking, adjusted for age, sex, nationality, weekly pocket money, parent smoking status, and school-area-level socioeconomic status (SES). Overall, 32.3% and 40.3% adolescents smoked cigarettes and e-cigarettes, respectively. Among smokers, 46.5% were dual users. The average TOD around schools was 16.2 (sd = 16.9). No association was found between TOD and adolescent smoking (OR = 1.00, 95% CI 0.99-1.01). However, smoking was more likely among 16-18 year old adolescents compared to 14-15 year olds (OR = 2.05, 95% CI 1.59-2.63), females (OR = 1.57, 95% CI 1.28-1.92), those with higher pocket money (OR = 1.69, 95% CI 1.38-2.08), and those with parents who smoke (OR = 1.64, 95% CI 1.33-2.01). Those of non-Spanish nationality had lower odds of smoking (OR = 0.72, 95% CI 0.55-0.95), while school-level SES was not associated. We found no association between TOD and adolescent smoking. TOD in Madrid is high, suggesting a threshold effect whereby additional outlets may not influence smoking. High TOD may also affect smoking through other mechanisms, such as advertising, which warrants further study.
Key messages
• Continued monitoring of tobacco outlet density around schools in urban settings is important for preventing smoking initiation among adolescents.
• Assessing adolescent tobacco use is key to identifying and addressing inequalities in exposure to tobacco products in urban settings.