Gaceta Sanitaria 37 (2023) 102336 Protocol Urban and social determinants of alcohol and tobacco consumption among adolescents in Madrid Maitane Berasalucea, Irene Martín-Turreroa, Roberto Valientea,b,c, Lucía Martínez-Manriquea,d, María Sandín-Vázqueza,e, Xisca Suredaa,f,g,h,∗ a Public Health and Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain b Centre for Research on Environment, Society and Health (CRESH), School of GeoSciences, University of Edinburgh, Edinburgh, United Kingdom c SPECTRUM Consortium, United Kingdom d Department of Preventive Medicine, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain e Department of Community Health and Social Sciences, Graduate School of Public Health & Health Policy, City University of New York, New York, United States of America f Department of Epidemiology & Biostatistics, Graduate School of Public Health & Health Policy, City University of New York, New York, United States of America g Tobacco Control Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain h CIBER de Enfermedades Respiratorias (CIBERES), Spain a r t i c l e i n f o Article history: Received 28 June 2023 Accepted 25 September 2023 Available online 25 November 2023 Keywords: Alcohol drinking Tobacco use Adolescent Urban health Social determinants of health a b s t r a c t Objective: This study aims to describe the accessibility to and promotion of alcohol and tobacco around secondary schools in Madrid and its distribution in relation with area-level socioeconomic deprivation; analyze the relationship between this exposure and individual consumption characteristics of students between 14 and 18 years old; and explore other facilitators of this consumption. Method: Mixed-methods study conducted in three phases: 1) we collected data on accessibility to and promotion of alcohol and tobacco in the environment using systematic social observation around 55 secondary schools; 2) we administered 2287 questionnaires among the students in these centers to gather information about characteristics and determinants of consumption; and 3) we conducted 20 semi-structured interviews and one discussion group to deepen in the results obtained in surveys and systematic social observation. We will use Geographic Information Systems to integrate and analyze the data from a spatial perspective. © 2023 SESPAS. Published by Elsevier Espan˜a, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Determinantes urbanos y sociales del consumo de alcohol y tabaco en adolescentes en Madrid Palabras clave: Consumo de alcohol Consumo de tabaco Adolescentes Salud urbana Determinantes sociales de la salud r e s u m e n Objetivo: Este estudio tiene como objetivo describir la accesibilidad y la promoción de alcohol y tabaco alrededor de los centros de ensen˜anza secundaria en Madrid y su distribución en relación con la privación socioeconómica del área; analizar la relación entre esta exposición y las características individuales de consumo en estudiantes de entre 14 y 18 an˜os; y explorar otros facilitadores del consumo. Método: Estudio de métodos mixtos en tres fases: 1) recogimos datos sobre accesibilidad y promoción de estas sustancias en el entorno mediante observación social sistemática alrededor de 55 centros de secundaria; 2) administramos 2287 cuestionarios a estudiantes de estos centros sobre características y determinantes de consumo; y 3) realizamos 20 entrevistas semiestructuradas y un grupo de discusión en estos centros para profundizar en los resultados obtenidos en las encuestas y la observación social sistemática. Utilizaremos Sistemas de Información Geográfica para integrar y analizar los datos desde una perspectiva espacial. © 2023 SESPAS. Publicado por Elsevier Espan˜a, S.L.U. Este es un artı´culo Open Access bajo la licencia s nIntroductionAdolescents and young people are especially vulnerable to alco- hol and tobacco consumption, affecting neurodevelopment during these stages.1,2 In addition to health consequences, it has been ∗ Corresponding author. E-mail address: francisca.sureda@uah.es (X. Sureda). 3 a t b g a https://doi.org/10.1016/j.gaceta.2023.102336 0213-9111/© 2023 SESPAS. Published by Elsevier Espan˜a, S.L.U. This is an open access ar nd/4.0/).CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). hown that alcohol and tobacco consumption also have a high eco- omic and social impact on the populations.3–5 In Spain, 70.5% and 0.7% of adolescents aged between 14 and 18-years old reported lcohol and tobacco use within the last year, respectively.6 In the last decade there has been increasing interest in how he urban, social, and cultural environments influence people’s ehaviors related to health, such as substance use.7 Evidence sug- ests that greater accessibility to alcohol and tobacco products nd higher exposure to their promotion may increase alcohol and ticle under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- M. Berasaluce, I. Martín-Turrero, R. Valiente et al. Gaceta Sanitaria 37 (2023) 102336 rrelati s t p T p t a P s ( t a H d i p a W n ( t o g t g b s wFigure 1. Chart illustrating the inte tobacco consumption among adults and adolescents.8–10 The expo- sure to alcohol and tobacco accessibility and promotion is not evenly distributed in the space and several inequalities have been described according to neighborhood sociodemographic depriva- tion, with greater exposure in the most deprived areas.11,12 Previous studies have characterized alcohol and tobacco envi- ronments around secondary schools in the city of Madrid. A recent study highlighted that 75% of tobacco outlets are located closer than 300 meters to a school.13 Another study found that in Madrid there is an average density of 26 alcohol outlets within buffers of 400 meters around schools, with a mean distance of 82 meters to the closest outlet.14 These results show a high exposure to alco- hol and tobacco around schools, and future studies should explore how this exposure may influence alcohol and tobacco consumption among adolescents. This study aims to describe the accessibility to and promotion of alcohol and tobacco around secondary schools in Madrid and its distribution in relation with area-level socioeconomic deprivation; analyze the relationship between this exposure and individual alco- hol and tobacco consumption among secondary school students between 14 and 18 years old in the city of Madrid; and explore other facilitators and barriers that may encourage or prevent alcohol and tobacco consumption among adolescents. Method Study design This is a cross-sectional mixed-methods study carried out in Madrid, Spain, in three phases (Fig. 1). In phase 1, we conducted a systematic social observation in 500-meters street network buffers around secondary schools to collect contextual data on alcohol and tobacco accessibility and promotion. In phase 2, we surveyed a sam- ple of secondary school students between 14 and 18-years about sociodemographic data and alcohol and tobacco consumption, and determinants of its consumption. In phase 3, we performed semi- o b o t 2onship of the methodologies used. tructured interviews and one discussion group with students in hese centers who have ever consumed alcohol or tobacco to com- lement the information gathered by the questionnaire in phase 2. ransversally, we will geocode all data obtained from these three hases to explore spatial patterns of the presence of alcohol and obacco elements in the environment and consumption among dolescents by using Geographic Information Systems (GIS). hase 1: systematic social observation around selected econdary schools All schools that taught secondary education in the city of Madrid n = 565) were classified into nine strata defined as the combina- ion of the tertiles of neighborhood socioeconomic status (SES) nd tertiles of alcohol and tobacco outlet density (i.e., SES High- igh Density; SES High-Medium Density; etc.). To account for eprivation, we used a validated predefined index, which includes ndicators based on unemployment, precarious employment, occu- ational class, educational level, and property value.15 We obtained lcohol and tobacco outlet locations from two public databases.16,17 e defined outlet density as the number of outlets within a street etwork buffer of 500 meters around schools, using ArcGIS 10.6 Esri, Redlands, CA, USA). We defined a “strata-balanced” strategy o contact and invite schools for participation to ensure a minimum f six centers within each strata. This may guarantee a minimum eographic variability of cases within each strata by including cen- ers from different neighborhoods throughout the city (and avoid eographic-location bias). Centers within each strata were ranked y their alcohol and tobacco outlet density value. In strata repre- enting high neighborhood outlet density, the contact of centers ith the highest densities were prioritized. In contrast, the contact f centers with the lowest densities were prioritized in low neigh- orhood outlet density strata. Centers in medium neighborhood utlet density strata were randomly ranked for contact prioritiza- ion. The response ratio was 12.42%. M. Berasaluce, I. Martín-Turrero, R. Valiente et al. d q c fi o ( P w 1 t fl ( r a S T t r i p w S s d s i S I a d c t g m 1 t a E g t e s c t g D b t o qFigure 2. Field collection map in a buffer of 500 meters by street network around the educational center. We used systematic social observation to gather data on alcohol and tobacco points of sale, promotion elements/banners and signs of consumption within a predefined street network buffer of 500 meters around schools that accepted to participate in the study. Data were collected between August and October 2021, exclud- ing school holiday weeks. An updated version of the OHCITIES questionnaire18,19 was used to record the alcohol items. We mod- ified an existing questionnaire used elsewhere to collect tobacco exposure.20–22 We provided theoretical-practical training to fieldworkers for data collection of alcohol and tobacco environments. We prepared maps of the buffer observation area around each secondary school (Fig. 2). Phase 2: individual data collection We conducted a survey among students between 14-18 years, enrolled in secondary schools in the city of Madrid between Febru- ary and April 2022. An initial sample size of 1,089 students was calculated, 363 participants for each socioeconomic level stratum (assuming power of 80% and losses of 20%). This would allow us to detect changes in alcohol and tobacco prevalence of 7% between different socioeconomic strata based on the results obtained in a previous study.23 Forty nine of the 55 centers involved in this study agreed to participate in the collection of individual consumption data, obtaining a total sample of 2287 students (with a loss of six centers in this phase, of which four were from strata representing high SES and high or medium alcohol and tobacco outlet density areas). The questionnaire included information related to sociode- mographic data, alcohol and tobacco consumption patterns and t w q s 3Gaceta Sanitaria 37 (2023) 102336 eterminants of their consumption. Alcohol and tobacco related uestions were based on the Survey on Drug Use in Secondary Edu- ation in Spain (ESTUDES).24 The questionnaires were provided and lled in paper format, except for seven centers that claimed for an nline format. In these cases, we used a free online survey tool www.surveymonkey.com). hase 3: Qualitative data collection A theorical, intentional, non-probabilistic purposive sampling as carried out.25 Inclusion criteria were being a student between 4 and 18 years of age and having ever consumed alcohol or obacco. We recruited informants through the dissemination of a yer in schools. We performed twenty semi-structured interviews six from schools located in high and medium SES neighborhood, espectively, and eight from low SES neighborhood schools) and discussion group (organized with five students from a medium ES neighborhood school) between April and September 2021. he topics covered in the interviews and discussion group tried o complement the information collected by the questionnaire in elation to alcohol and tobacco consumption patterns and factors nfluencing its consumption. Moreover, a section to explore health romotion strategies to prevent alcohol and tobacco consumption as included. tatistical and geographic analyses We will obtain prevalence ratios of consumption and con- umption patterns. We will carry out qualitative and thematic escriptive analysis using ATLAS-ti software26 and we will use equential explanatory method 27 to relate quantitative and qual- tative results. Transversally, we will use Geographic Information ystems to geocode exposure and consumption data. Geographic nformation Systems will allow us to create measurements to char- cterize alcohol and tobacco environment (i.e., outlet proximity and ensity, density and visibility of promotion elements and signs of onsumption) and analyze spatial inequalities in the alcohol and obacco accessibility, promotion and consumption among different eographies in the city of Madrid. We will use Poisson regression odels with multilevel robust variance, with the individual at level , the educational center at level 2 and the neighborhood at level 3 o assess associations between ecological data and individual char- cteristics. thical considerations This study was conducted according to the principles promul- ated by the Declaration of Helsinki and the Ethics Committee of he University of Alcalá (CEI/HU/2020/48, CEIP2021/5/128) granted thical approval. We informed participants and their legal repre- entatives about the study and we requested a written informed onsent from both parties, including also the permission to be con- acted in the future. Confidentiality and anonymity of all data is uaranteed. iscussion The quantitative measurement of environmental exposure may e subject to discrepancies in the definition of operational variables rying to address the complexities of reality, as well as depending n the quality of the data. Likewise, information collected through uestionnaires may be subject to reporting biases. To try to avoid hese limitations, we will carry out a quality control of the data and e will contrast the quantitative information from the individual uestionnaires with the semi-structured interviews and discus- ion group. The main strength of this project is the use of a mixed 11 1 1 1 1 1 1 1 1 2 2 2 2 2 2 sand Oaks: Sage; 1995. 26. ATLAS.ti. El Programa de Investigación y Análisis de Datos Cualitativos. Available at: https://atlasti.com/es. 27. Ivankova NV, Creswell JW, Stick SL. Using mixed-methods sequential explana- tory design: from theory to practice. Field Meth. 2006;18:3–20.M. Berasaluce, I. Martín-Turrero, R. Valiente et al. methodology that combines qualitative with quantitative and geo- graphic approaches. This will allow us to conduct an in-depth analysis of the relationships between the accessibility and promo- tion of alcohol and tobacco around schools and alcohol and tobacco consumption and its determinants in secondary school students. In addition, it will allow us to learn about other facilitators of the onset of alcohol and tobacco consumption in this population. Editor in charge Miguel Ángel Negrín Hernández. Authors contributions M. Berasaluce: writing original draft, methodology. I. Martín- Turrero: writing, review and editing, methodology. R. Valiente: conceptualization, writing, review and editing, methodology. L. Martínez-Manrique: review and editing, methodology. M. Sandín Vázquez: conceptualization, review and editing, methodology. X. Sureda: conceptualization, writing, review and editing, methodol- ogy, project administration, funding acquisition. Funding This study is funded by two projects of the Community de Madrid and the Universidad de Alcalá (CM/JIN/2019-021 and CM/JIN/2021-030) and by the Fondo de Investigaciones Sanitarias (PI19/01626). RV is a member of SPECTRUM a UK Prevention Research Partner- ship Consortium. UKPRP is an initiative funded by the UK Research and Innovation Councils, the Department of Health and Social Care (England) and the UK devolved administrations, and leading health research charities. Conflicts of interest None. Acknowledgments The authors would like to thank all the secondary schools and students that participated in this research project. We also thanks APLICA INVESTIGACIÓN Y TRASLACION S.COOP.MAD. for conduct- ing the field work. References 1. Guerri C, Pascual M. Mechanisms involved in the neurotoxic, cognitive, and neurobehavioral effects of alcohol consumption during adolescence. Alcohol. 2010;44:15–26. 2. Lydon DM, Wilson SJ, Child A, et al. 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