Objectives: Literature on the influence of smoking prevalence at school-level on the smoking initiation among elementary school children is scarce. The aim of the cut-rent study was to explore this in school clusters stratified according to student's perceived smoking prevalence in the school while adjusting for social impact of individual students. Method: The data was obtained from a survey administered to 13 elementary schools in Taoyuan County, a final sample of 1585 3rd and 4th grade students. Multi-level logistic regression analysis (MLRA) was used to examine the influence variable at school-level as well as individual socio-environment level had on smoking status of elementary schools students. Results: Attending a school where the students reported a perception of high smoking prevalence had a greater effect on smoking behavior in boys than girls when compared with students attending a lower smoking prevalence school, after adjustment for student-level characteristics. Conclusions: Our study confirmed that a broader school environment with a high student perception of smoking prevalence is associated with children's smoking behavior in boys. The findings further indicate the need for enforcement of anti-smoking policies within schools with higher smoking rates to reduce visibility of smoking among school children.
