de Meer et al. BMC Public Health 2010, 10:615 http://www.biomedcentral.com/1471-2458/10/615 R E S E A R C H A R T I C L E Open Access Gender differences in the association between pre-adolescent smoking initiation and emotional or behavioural problems Gea de Meer1,2*, Matty R Crone3, Sijmen A Reijneveld2,3 Abstract Background: Emotional and behavioural problems are a risk factor for the initiation of smoking. In this study, we aimed to assess this relationship beyond clinical cut-off values of problem behaviour. Methods: Cross-sectional national survey among 9-13 year old children with data on smoking and Childhood Behaviour Checklist (CBCL) (N = 960). Relationships between smoking and tertiles of CBCL-scores were assessed. Results: Smoking was reported by 5.9% of the children (7.1% boys and 5.0% girls, P > 0.100). Relationships between smoking and problem behaviour were present in girls, but ot in boys. Among girls, smoking was associated with attention problems, thought problems, and delinquent behaviour. For attention problems and delinquent behaviour the associations were limited to the CBCL-scores in the uppermost 16% which agrees with the subclinical cut-off value. Conclusion: Pre-adolescent girls more frequently smoke if having attention problems, delinquent behaviour, or thought problems. Background Smoking-related diseases are the most common cause of death in Western societies and affluent countries [1]. Almost all adult smokers started smoking during adoles- cence [2]. Starting smoking at young age has been shown a risk factor for daily smoking and dependence [3]. There is a great amount of evidence for the co- occurrence of smoking initiation and emotional or behavioural problems [4-9]. Therefore, smoking pre- vention might benefit from targeting children with problem behaviour. So far, however, it is unclear if smoking prevention would benefit most from improve- ment of psychosocial health of all children, or from a targeted approach on children with more severe beha- vioural problems. Previous studies mostly relied on a dichotomous definition of problem behaviour like a clinical diagnosis [4-7], or the clinical or subclinical score on the Childhood Behaviour Checklist (CBCL), as reflected by respectively the uppermost 10% and * Correspondence: g.demeer@hvdfryslan.nl 1Municipal Health Service Fryslân, Leeuwarden, the Netherlands Full list of author information is available at the end of the article 15% scores in the population [8,9]. This, however, does not give information on CBCL-scores below the subcli- nical cut-off value. In this community-based study, we studied the relation- ship between smoking initiation and problem behaviour beyond subclinical cut-off values among pre-adolescent elementary school children. In addition, we searched for gender differences in the relationship between behaviour problems and the uptake smoking. Previous studies have shown that girls more frequently take up smoking in early adolescence [10,11]. Gender differences in the association with problem behaviour may play a role, as suggested by Rohde et al [12]. Therefore, we studied relationships between pre-adolescent problem behaviour and the uptake of smoking for boys and girls separately. Methods Study protocol The study was embedded in Preventive Child Healthcare (PCH) that provides health monitoring for all 0-19 year- old children according to Dutch public health legisla- tion. Parents and their children are invited for regular examination that includes monitoring of development © 2010 de Meer et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.