5.27 Family and home-based interventions to reduce smoking uptake

Last updated: October 2022

Suggested citation: Hanley-Jones, S, Letcher, T and Wood L. 5.27 Family and home-based interventions to reduce smoking uptake. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from https://www.tobaccoinaustralia.org.au/chapter-5-uptake/5-27-parent-family-home-targeted-interventions

 

Parents can play an important part in preventing tobacco use among young people; however they are often unaware of their children’s use of tobacco products.1 Parents often underestimate the likelihood of their child participating in risky behaviours, including smoking. In a US study1 determining the prevalence of, and factors associated with, parent unawareness of tobacco/nicotine use among adolescents aged 12 to 17 years, almost two-thirds of parents (64.5%) were unaware of their child’s tobacco use. Parents were more so unaware of their child’s use of tobacco-related products if they were using e-cigarettes or non-cigarette tobacco products, compared to cigarettes.1, 2 Parents were more likely to be aware of tobacco use when their child was male, reported being a current tobacco user, earned lower school grades, had relatives who used tobacco, or had tobacco available in the home.1

In the 2012 Report of the Surgeon General on Preventing Tobacco Use Among Youth and Young Adults, parental disapproval was a major reason young people did not use tobacco, or other drugs.3 Qualitative research undertaken in Australia found that while parents often felt that their opinions had little influence, young people participating in the same study cited parental disapproval of smoking as a barrier to smoking uptake.4 A large-scale empirical study in Sweden similarly found that the majority of adolescents were in support of strong parental intervention to help them refrain from tobacco use, but preferred this not to be done in a punitive manner.5 More specifically, of the 4500 adolescents surveyed in 2006, almost all strongly supported parental action including trying to persuade them not to smoke (94%), not smoking themselves (87%) and not allowing their children to smoke at home (86%). This support was evident across both smoking and non-smoking adolescents.5

A parent’s own smoking behaviour is a powerful influence on the likelihood of adolescent smoking uptake,6-8 as is a complete tobacco ban within the household.6, 9-11 Other aspects of parenting have also emerged as significant contributors to adolescent smoking, such as parenting style, parental attachment and perceived family support. For instance, a parenting style that combines both demanding and responsive management of children’s behaviour, i.e. authoritative parenting, has been shown to reduce smoking uptake, while more permissive home policies are associated with increased likelihood of experimentation.12, 13 (See also Sections 5.7.1 and 5.7.1.2.) Parental attachment, i.e. the nature of the relational bond between parents and children, is a strong predictor of smoking in adolescents.11 Perceived family support, described as a variation in the amount of parental responsiveness and warmth, has been shown to reduce the risk of smoking uptake during adolescents’ transition from early to late adolescence. A 2021 study of 11–15-year-old adolescents from 42 countries found higher family support was associated with a lower risk of smoking.14

While parents have the main responsibility for educating their children about smoking, a multipronged approach, including school and society more generally, will have a greater effect.15 However, this section will focus on programs that attempt to educate parents on the kinds of communication and parenting styles that have been associated with reduced uptake of smoking.

5.27.1 Effectiveness of family-based interventions/programs

The 2012 Report of the Surgeon General on Preventing Tobacco Use Among Youth and Young Adults3 analysed two systematic Cochrane reviews on family interventions for preventing tobacco use in adolescents and found the most successful interventions had one or more of the following characteristics:

‘1. Targeted high-risk adolescents with selective interventions;

2. Combined skills training among youth with homework assignments for parents on parenting;

3. Focused specifically on the family, with skills training for the family that included more sessions or included time with the families to learn together;

4. Provided longer periods to train the staff in the intervention methods;

5. Conducted checks on the fidelity of implementation or on quality;

6. Used interventions for skills training among families that were based on behavior change theory; and

7. Stressed active parental involvement and parenting skills and developed social competencies and self-regulation among youth.’3 P.727

Most of the interventions were part of school-based programs whereby the parents were sent material or homework assignments to complete with their children at home. The analysis concluded that well-executed family interventions with sufficient dosage may be helpful in preventing smoking among adolescents.3

An updated 2017 Cochrane review16 of family-based programs for preventing smoking among children and adolescents judged the evidence for these strategies to be of moderate quality with an overall uncertainty in the result. Evidence from nine family-based intervention studies showed significantly reduced uptake of smoking for baseline never smokers, compared with no intervention. The authors estimated that the benefit of standalone family-based interventions was a reduction in new smoking behaviour of 16­­–32%.  For combined interventions of family and school, compared to school only interventions, there was evidence of benefit from two studies, with an estimated benefit of 4–25% reduction in new smoking. The review concluded that key characteristics of effective high-intensity interventions included: authoritative parenting, frequent contacts with general practitioners, particularly for new mothers, motivating parents and families to engage in services, telephone facilitators supporting parents and their children working together, positive parenting and family support and strengthening their skills. For combined family plus school based interventions effective components also included strategies for effective communication and freedom to choose and makes one’s own decisions.16

A 2017 systematic review examining smoking-specific parenting strategies and their effectiveness in preventing children and adolescents from smoking uptake found a complete household smoking ban to be effective. Partial bans, however, were not effective. Keeping cigarettes out of the home, i.e. reducing availability, was effective in more than half the reviewed studies. Constructive and respectful communication about smoking showed a preventative effect in two studies, however other studies looking at the quality of communication found no effects. No support was found for the effectiveness of non-smoking agreements. Frequent communication about smoking was found to undermine prevention efforts; the authors suggest talking too often about smoking may undermine autonomy and psychological freedom, reducing the adolescent’s motivation to be a non-smoker.

In addition to tobacco-specific family-based interventions, smoking is sometimes incorporated into broader programs targeting a number of adolescent risk behaviours. An Australian example of this was a Perth-based randomised controlled trial to assess the impact of a home-based intervention designed to encourage parent–child communication about tobacco and alcohol.17 Parents (n=1201) of children aged 10–11 years were recruited from 20 primary schools, and those in the intervention group were provided with information sheets, parenting tips and activities to help parents talk with their child about issues related to smoking cigarettes and drinking alcohol. Parents in the intervention group were more likely to have engaged their child in discussions and to have addressed topics identified in the provided materials as being protective of children’s involvement in tobacco and alcohol.17

While parental smoking itself is a significant predictor of smoking uptake, one interesting US study implemented a home-based program with parents who smoked.18 The program was framed around an ‘anti-smoking socialisation approach’, which focuses on influencing the development of children’s cognitive and behavioural norms against smoking. As articulated by the researchers, although parents who smoke model smoking behaviour, this does not ‘preclude a parent from eliminating a child’s exposure to passive smoke, talking to a child about smoking, making cigarettes inaccessible, monitoring the smoking behaviour of children and their friends, and making clear the disciplinary consequences of smoking’.18, p57 In the follow-up evaluation three years after the intervention, those in the intervention group were significantly less likely to have begun smoking, with the odds of smoking twice as high among the control group compared with the intervention group, despite the fact that children in both groups had parents who smoked.18  A 2017 systematic review found that, in studies considering parental smoking as a moderating effect of smoking-specific parenting on adolescent smoking onset, most studies did not find different effects for smoking versus non-smoking parents. However, the studies that did report a moderation effect showed that smoking-specific parenting strategies were more effective when they were applied by non-smoking parents compared to smoking parents.19

While family-based interventions often focus on parents, having a sibling who smokes is also a significant predictor of smoking uptake. Given research indicating that older teenagers often hope that their younger siblings do not experiment with smoking,20, 21 siblings may be another ally for tobacco-control efforts within the family setting.22 See Section 5.7.2 for more on smoking behaviour of siblings.

5.27.2 Australian resources for parents/carers on smoking prevention

In Australia, the role of families or parents in discouraging smoking has not been overtly addressed in many discrete programs, but is more likely to be incorporated into broader information for parents (see examples in Table 5.25.1), or as an element of school-based programs, see Section, 5.29 School-based interventions.

Table 5.27.1
Home/parent-based programs and strategies to reduce smoking in Australian youth

Resource

Description

Weblink

VIC Gov: Smoking and vaping; Advice for parents

Webpage resource for parents focussing on the facts and health risks of smoking and vaping, including state laws, and where to get help.

https://www.vic.gov.au/smoking-and-vaping-advice-parents

Raising Children: Alcohol, smoking and other drug use: how to help teenagers

Webpage resource for parents, including information on ‘what is safe’, ‘warning signs’, ‘how to communicate’, ‘where to get help’

https://raisingchildren.net.au/teens/healthy-lifestyle/alcohol-other-drugs/alcohol-other-drug-use-how-to-help

Alcohol and Drug Foundation: Parenting; Preventing and delaying AOD uptake by young people;

Webpage resource, including full report and video, focusing on strategies to prevent and delay alcohol and drug use by 12-17 year-olds.

https://adf.org.au/talking-about-drugs/parenting/preventing-aod-uptake/

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated April 2022)

 

References

1. King JL, Merten JW, and Nicksic NE. Parents are unaware of their youths' Tobacco use: Results from the Population Assessment of Tobacco and Health Study. Journal of School Health, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32367532

2. Wu TS and Chaffee BW. Parental awareness of youth Tobacco use and the role of household Tobacco rules in use prevention. Pediatrics, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33020248

3. U.S. Department of Health and Human Services. Preventing Tobacco use among youth and young adults: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK99237/pdf/Bookshelf_NBK99237.pdf.

4. Eureka Strategic Research, Youth tobacco prevention research project. Undertaken for the Australian government department of health and ageing.  Canberra: Department of Health and Ageing; 2005. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-pub-tobacco-literature-cnt.htm.

5. Nilsson M, Weinehall L, Bergstrom E, Stenlund H, and Janlert U. Adolescent's perceptions and expectations of parental action on children's smoking and snus use; national cross sectional data from three decades. BMC Public Health, 2009; 9(1):74. Available from: http://www.biomedcentral.com/content/pdf/1471-2458-9-74.pdf

6. Scragg R, Laugesen M, and Robinson E. Parental smoking and related behaviours influence adolescent tobacco smoking: Results from the 2001 New Zealand national survey of 4th form students. The New Zealand Medical Journal, 2003; 116:U707. Available from: https://researchspace.auckland.ac.nz/handle/2292/4691

7. Bricker J, Leroux B, Peterson A, Kealey K, Sarason I, et al. Nine-year prospective relationship between parental smoking cessation and children's daily smoking. Addiction, 2003; 98(5):585-93. Available from: http://www.blackwell-synergy.com/doi/full/10.1046/j.1360-0443.2003.00343.x

8. Bricker J, Otten R, Liu J, and Peterson A. Parents who quit smoking and their adult children's smoking cessation: A 20-year follow-up study. Addiction, 2009; 104(6):1036–42. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720994/

9. Thomas RE, Baker P, and Lorenzetti D. Family-based programmes for preventing smoking by children and adolescents. Cochrane Database of Systematic Reviews 2007; (1): CD004493. Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004493/frame.html

10. Bricker J, Peterson J, Sarason I, Andersen M, and Rajan K. Changes in the influence of parents' and close friends' smoking on adolescent smoking transitions. Addictive behaviors, 2007; 32:740-57. Available from: http://www.sciencedirect.com/science/article/pii/S0306460306002000

11. Song HY and Yang SJ. Factors associated with smoking behaviors in out-of-school youth: Based on an ecological model. International Journal of Environmental Research and Public Health, 2021; 18(12). Available from: https://www.ncbi.nlm.nih.gov/pubmed/34204696

12. Proescholdbell R, Chassin R, and MacKinnon D. Home smoking restrictions and adolescent smoking. Nicotine and Tobacco Research, 2000; 2(2):159–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11072454

13. Jackson C, Henriksen L, and Foshee V. The authoritative parenting index: Predicting health risk behaviors among children and adolescents. Health Education & Behavior, 1998; 25:319-37. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9615242

14. Zaborskis A, Kavaliauskiene A, Eriksson C, Klemera E, Dimitrova E, et al. Family support as smoking prevention during transition from early to late adolescence: A study in 42 countries. International Journal of Environmental Research and Public Health, 2021; 18(23). Available from: https://www.ncbi.nlm.nih.gov/pubmed/34886464

15. Small SP, Kushner KE, and Neufeld A. Smoking prevention among youth: A multipronged approach involving parents, schools, and society. Canadian Journal of Nursing Research, 2013; 45(3):116–35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24236375

16. Trivedi D. Cochrane review summary: Family-based programmes for preventing smoking by children and adolescents. Primary Health Care Research & Development, 2017; 18(4):303–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28294096

17. Beatty S, Cross D, and Shaw T. The impact of a parent-directed intervention on parent-child communication about tobacco and alcohol. Drug and Alcohol Review, 2008; 31:1–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19378443

18. Jackson C and Dickinson D. Enabling parents who smoke to prevent their children from initiating smoking: Results from a 3-year intervention evaluation. Archives of Pediatric Adolescent Medicine, 2006; 160:56-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16389212

19. Hiemstra M, de Leeuw RN, Engels RC, and Otten R. What parents can do to keep their children from smoking: A systematic review on smoking-specific parenting strategies and smoking onset. Addictive Behaviors, 2017; 70:107–28. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28237717

20. Avenevoli S and Merikangas K. Familial influences on adolescent smoking. Addiction, 2003; 91(suppl.1):1–20. Available from: https://pubmed.ncbi.nlm.nih.gov/12752359/

21. de Vries H, Candel M, Engels R, and Mercken L. Challenges to the peer influence paradigm: Results for 12-13 year olds from six European countries from the European smoking prevention framework approach study. Tobacco Control, 2006; 15(2):83–9. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/2/83

22. Bricker JB, Peterson AV Jr, Anderson M, Leroux B, Bharat Rajan K, et al. Close friends', parents', and older siblings' smoking: Reevaluating their influence on childen's smoking. Nicotine & Tobacco Research, 2006; 8:217-26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16766414