Background:
The use of alternative tobacco products (ATPs) has grown in popularity among Canadian youth. This study examined the association between a school-level characteristic (the senior student tobacco use rate) and the current use of manufactured cigarettes, little cigars or cigarillos, cigars, roll-your-own cigarettes, smokeless tobacco (SLT), and a hookah among junior students.

Methods:
This study used nationally representative Canadian data from 29,495 students in grades 9 to 12 as part of the 2010/2011 Youth Smoking Survey. For each ATP, we described rates of senior and junior tobacco use, calculated the variance attributed to school-level factors, and examined the association between the senior student (grades 11 and 12) tobacco use rate and the current use of each ATP among junior students (grades 9 and 10) while accounting for relevant student-level characteristics. SAS 9.3 was used for all analyses.

Results:
Over half of schools sampled had senior students that reported using each ATP. School-level differences accounted for between 14.1% and 29.7% of the variability in ATP current use among junior students. Each one percent increase in the number of senior students at a school that currently use manufactured cigarettes, SLT, or a hookah was significantly independently associated with an increased likelihood that a junior student at that school currently used manufactured cigarettes (OR 1.04, 95% CI 1.01 to 1.06), SLT (OR 1.14, 95% CI 1.06 to 1.24), or a hookah (OR 1.09, 95% CI 1.03 to 1.14).

Conclusions:
Characteristics of the school environment a junior student attends appear to play an important role in ATP use, and tobacco control programs and policies should be designed to ensure that they include strategies to curb the use of all tobacco products. Additional evidence is needed for the impact of comprehensive school-based tobacco control approaches.