5.7 The home environment
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5.7.1 Smoking behaviour of parents
A number of studies report that parental tobacco use is linked with higher rates of adolescent initiation, escalation to regular smoking, and smoking into adulthood.7, 12, 62 This may be attributable to a number of factors, including children's modelling their behaviour, beliefs, expectations and attitudes on those of their parents, perceived parental approval of smoking, ready access to tobacco, and possibly some element of genetic predisposition4 (or the effects of maternal smoking during pregnancy – see Section 5.4.2 above). Some studies have suggested that parental influence appears to be stronger for younger children,63 whereas peer group behaviours have more influence during teenage years.4 One large study has suggested that parental, sibling and peer smoking behaviours have similar importance in influencing a child's smoking behaviour.64
The strength of the association between parental smoking and adolescent uptake varies across studies. Some research suggests that smoking prevalence is two or more times greater in young people living with one or more parents who smoke, compared to teenagers who live with non-smokers.10, 56, 65-67 A study from the USA has suggested that maternal smoking behaviour has more impact on smoking uptake than whether or not the father smokes.68 Other research has reported only a weak and inconsistent relationship between parental and adolescent smoking behaviour; a finding that could be due to methodological issues, or factors that moderate or confound measurement.11, 69, 70 In their review from 1995, Tyas and Pederson reported that about twice as many of the studies they reviewed showed a significant association between parental and adolescent smoking, as showed no significant association.44 Smoking patterns of step-parents may be as likely to influence smoking behaviour as behaviour of biological parents.71
Victorian research has found that in secondary school students aged between 12–17, of those living in a family in which neither parent smoked, 12% were current smokers; in families with one parent who smoked, 21% of adolescents were smokers, and in families where both parents smoked, 28% were current smokers.72 National data from New Zealand show broadly similar findings, concluding that parental smoking status is a major, independent predictor of smoking among 14–15 year old schoolchildren, especially those with Maori and Pacific backgrounds.73, 74
An interesting study from the USA has shown how even very young children (in this case, aged between two and six) emulate their parents' behaviour. Researchers asked the children to 'shop' at a store of miniature items, role-playing as adults. Overall, about one quarter of children 'purchased' cigarettes, but children whose parents smoked were four times more likely to select cigarettes than children of non-smokers. The authors observe that children's perceptions of smoking as normative behaviour may influence their decisions whether or not to smoke as they grow older.75
Quitting behaviour of parents also influences smoking in children. A large prospective study undertaken in the USA found that in households where both parents had quit smoking, daily smoking among children was reduced by about 40%. Smoking cessation by one parent reduced the likelihood of smoking among children by 25%.76
5.7.1.1 Parenting practices
Parenting practices also affect a child's likelihood of smoking. Teenagers, particularly younger ones,77 are less likely to take up smoking if they live in a home in which smoking is banned,7 even if the parents themselves smoke,73, 78, 79 and living in a smoke-free home may also increase the likelihood of quitting among adolescent smokers.80 Adolescents whose parents have rules about smoking, and take a strong anti-smoking stance, are also less likely to take up smoking, again even though the parents may be smokers themselves.4, 7, 79 Young people who think that their parents would react negatively were they to start smoking are only about half as likely to begin. Conversely, leniency in parental attitude to smoking correlates with increased likelihood of uptake of smoking.4
Children whose parents use an 'authoritative' style of parenting, defined as being responsive to their children's needs and opinions, while also setting limits for behaviour and monitoring compliance, are also less likely to become smokers.4 Children who feel supported by their parents, find it relatively easy to talk to their parents, and have a high sense of family belonging, are less likely to smoke.7 Adolescents whose parents have adopted an 'unengaged' parenting style, whereby the adolescent is more free to pursue his or her own wishes,62, 81 are most likely to smoke.
Degree of parental supervision is also connected with smoking behaviour during adolescence.1, 10, 44 Australian research has shown that teenagers who are regularly permitted to spend unsupervised evenings out with their friends are more likely to smoke.82
A range of studies have shown that growing up in an intact, two-parent family is protective against uptake of smoking in adolescents, and that children living in single-parent homes are more likely to smoke.44 Australian research has shown that adolescents whose parents have divorced are almost twice as likely to smoke as children in intact families, and to smoke on a daily basis.83 Living in an environment of marital discord is also a predictor of smoking behaviour among adolescents, as is being born to a teenage mother with a lower level of education, or to a mother with depressive illness.51 Other family factors such as having a mother who is not married, having a mother whose partner has been in trouble with the police, and living in a household with four or more children have been associated with a greater risk of adolescent smoking.25
5.7.2 Smoking behaviour of siblings
Many studies have found that living in a family with older brothers or sisters who smoke also influences adolescent uptake of smoking,1, 10, 11, 44, 64 some research suggesting that it may be a more important predictor of uptake of smoking than parental smoking status.11, 69, 84 As parental influences decline during adolescence, adolescent behaviour may be increasingly modelled on that of siblings.
Studies have consistently shown that adolescents with a sibling who smokes, especially of the same sex,84 are more likely to take up smoking, and to continue smoking into adulthood.69 Based on a national survey of American adolescents aged between 14–18, Wang et al84 found that the likelihood of a teenage boy taking up smoking was increased by two to threefold if his older brother smoked, the greatest influence occurring at about the ages of 16 and 17. Among teenage girls, the same study showed that having an older sister who smoked more than trebled the likelihood of smoking in the younger sibling, but that 15-year-old girls with an older sister who smoked were almost eight times as likely to smoke.84
5.7.3 Socioeconomic aspects of uptake
Smoking and disadvantage is discussed in detail in Chapter 9.
It is well-established that the prevalence of smoking is higher among groups with lower socioeconomic status (SES). The disparity in smoking rates between Australia's most and least advantaged populations has been apparent for many years (see Chapter 9, Section 9.2). Analysis of smoking prevalence over time in Australian males has shown that the gap in smoking prevalence between highest and lowest SES groups has increased because higher SES men have become much less likely to take up smoking. Among women, the difference between smoking prevalence in the highest and lowest SES groups has remained fairly static.85
An international review of the literature on socioeconomic status and health behaviours in adolescence (aged from 10–21) has found that most of the peer-reviewed published research since 1970[5] has concluded that lower SES in adolescence is associated with an increased likelihood of smoking, particularly during the early teenage years.86 The authors of this review observe that this may be because lower SES adolescents are modelling the behaviour and attitudes of lower SES adults, who are more likely to be smokers, and also because they may be more likely to experience stress and negative life events.86 It may also be that low parental SES acts as a barometer for other influences likely to affect youth smoking rates, such as local community factors (including prevailing beliefs and attitudes, smoking policies, availability of tobacco, and quality of health education) and a perceived lack of opportunity for advancement.87
Recent research from Scotland examining SES and smoking behaviour in young teenagers has found that students with a lower SES tended to have a greater amount of personal disposable income than children from higher SES households. This study also found that students from a higher SES background were more sensitive to pricing of tobacco products. West et al suggest that this may be because of differences in ease of access. Adolescents from more disadvantaged backgrounds are more likely to have family and friends who are smokers, and to have access to informal sources of tobacco. By contrast, teenagers in higher SES areas wanting to obtain cigarettes may be restricted to buying cigarettes at full retail price.88
Aside from family SES, studies have consistently shown that young people with more money are more likely to smoke.44, 73, 82, 87 Young teenagers commonly have access to money from a number of sources, including pocket money, lunch money, and borrowings from friends and family that allow them to buy cigarettes from retailers or via their social networks.89 Adolescents who have part-time jobs may be more likely to be developmentally precocious, seeking to emulate an adult lifestyle, or it could be that by being in a workplace that they are exposed to smoking behaviour of workmates.90
For discussion on how affordability of cigarettes affects uptake of smoking in children, see Section 5.12. Pricing policy as a means of tobacco control is discussed briefly in Section 5.30, and in greater detail in Chapter 13, Section 13.1 .
[5] The authors confined their review to studies on healthy adolescents in Western countries in order to reduce confounding influences.86
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