Several aspects of the home environment can relate to smoking uptake, including whether or not parents or siblings smoke, parenting practices, policies relating to smoking in the home, and the socio-economic status of the family. These are discussed in turn in the sections below.
5.7.1 Smoking behaviour of parents
Many studies have found that parental tobacco use is linked with higher rates of child and adolescent smoking initiation,1 progression to regular smoking, and smoking into adulthood.1-5 Parental tobacco use and perceived parental approval of smoking have also been associated with adolescents’ intentions to smoke.6 These associations may be attributable to a number of factors, including children modelling their behaviour, beliefs, expectations and attitudes on those of their parents,7 perceived parental approval of smoking, access to tobacco, and possibly some element of genetic predisposition 8, 9 (or the effects of maternal smoking during pregnancy— see Section 5.3.2 ).
Research on the relative effects of parents and peers on youth smoking is inconsistent.5 Some studies have suggested that parental influence appears to be stronger for younger children,10 whereas peer group behaviours have more influence during teenage years. 8 One large study has suggested that parental, sibling and peer smoking behaviours have similar importance in influencing a child’s smoking behaviour.11 Similarly, a 2016 systematic review of Asian adolescents found both familial and peer factors predominantly influence adolescent smoking initiation.12
The strength and nature 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 with teenagers who live with non-smokers. 13-17 Other research suggests that if both parents smoked, the risk of their children becoming smokers almost triples while sibling smoking more than doubles the risk of an adolescent smoking.1 Research among high school students across six European countries has suggested that maternal smoking behaviour has more impact on adolescent smoking behaviour than whether or not the father smokes.18 Further research has supported this finding, and also provided evidence that maternal smoking (including pre- and post-natal) influences smoking behaviours of adolescent daughters more than sons.1, 19 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.20-22 In a 1995 review, about twice as many of the studies reviewed showed a significant association between parental and adolescent smoking compared with those that showed no significant association. 23 Smoking patterns of step-parents may be as likely to influence smoking behaviour as behaviour of biological parents.24
An Australian study examined the influence of parents, siblings and peers on pre- and early-teen smoking through an online survey among students aged 11–13 years.25 Child smoking was explained by individual-level influences: both parents’ smoking status was a significant predictor, with the effect of maternal smoking stronger than that of paternal smoking. Sibling and peer smoking were more influential than parental smoking, with these differences largely accounting for the substantial smoking variation across schools and communities. Results suggested that pre- and early-teen smoking was more related to participant characteristics and their proximal influences than school and community traits. 25
Other Australian researchers examined the long-term effects of childhood smoking experimentation and exposure to parental smoking on adult smoking risk using data from a 2004–05 follow-up of young people aged 9–15 years through the 1985 Australian Schools Health and Fitness Survey.26 They found that any childhood smoking experimentation increased the risk of being a smoker 20 years later, especially among experimenters aged 14–15 years who had smoked more than 10 cigarettes. Parental smoking was associated with adult current smoking risk but not with childhood smoking experimentation.26
Evidence also suggests that the developmental trajectory of parental smoking from adolescence to adulthood has a unique effect on adolescent smoking.27 A multigenerational longitudinal study in the US found that the risk of smoking among adolescents was greatest if they had parents whose smoking had early onset, accelerated rapidly, was at high levels and persisted over time. These effects were regardless of current parental smoking or education level.27
Victorian research found that in secondary school students aged 12–17 years, of those living in a family in which neither parent smoked, 12% were current smokers; in families with one parent who smoked, 21% were current smokers; and in families where both parents smoked, 28% were current smokers.28 National data from New Zealand show broadly similar findings, concluding that parental smoking status is a major, independent predictor of smoking among school children aged 14–15 years, especially those with Māori and Pacific Islands backgrounds.29, 30
Research from the Netherlands has demonstrated that parental smoking may influence the way in which young children (aged 4–7 years) interact with peers during play: those who reported at least one smoking parent were more likely to initiate pretend smoking.31 Investigators suggested this demonstrates that parental smoking can increase vulnerability to smoking in children and also probably indirectly in children’s friends, with the modelling processes already visible at a young age. 31 Similarly, US research has also shown how even very young children (in this case, aged 2–6 years) 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 regarding whether or not to smoke as they grow older.32
Quitting behaviour of parents also influences smoking in children. A large prospective study undertaken in the US 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%.33
126.96.36.199 Parenting practices
Parenting practices both in regard to smoking and more generally also affect a child’s likelihood of smoking. Adolescents whose parents have rules about smoking and take a strong anti-smoking stance are less likely to take up smoking, even though the parents may be smokers themselves.2, 8, 34 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 attitudes to smoking correlates with increased likelihood of smoking uptake.12, 34
Degree of parental supervision is also connected with smoking behaviour during adolescence.15, 23, 35, 36 Australian research has shown that teenagers who are regularly permitted to spend unsupervised evenings out with their friends are more likely to smoke. 37 A systematic review of Asian adolescents found low parental monitoring and having no discussion on smoking in the home to be associated with increased likelihood of initiation of smoking.12
Children whose parents use an ‘authoritative’ style of parenting, defined as being responsive to their children’s needs and opinions, while also setting clear limits and expectations for behaviour and monitoring compliance, are also less likely to become smokers. 8, 9 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. 2 Adolescents whose parents have adopted an ‘unengaged’ parenting style, whereby the adolescent is more free to pursue his or her own wishes, are most likely to smoke. 4, 35, 38
Along with parenting style and family management techniques, features such as the nature and content of parent–child communication have been identified as one of the major groups of parenting factors associated with adolescent substance use initiation, including tobacco. Australian research found that a home-based intervention (comprising self-help information and activity sheets describing parenting tips and the links between parenting behaviours and the likelihood of child substance use, i.e. the role of behavioural modelling and family rules, limits and expectations) led to enhanced frequency and content of tobacco- and alcohol-related discussions and higher parent–child engagement during such discussions.39
A range of studies have shown that growing up in a two-parent family is protective against uptake of smoking in adolescents, and that children living in single-parent homes are more likely to smoke.23 Evidence from a longitudinal Australian study indicates that adolescents whose parents have divorced are almost twice as likely to smoke, and to smoke on a daily basis.40 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. 41 A range of 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 also been associated with a greater risk of adolescent smoking.42
Research into parental optimism for risk of future tobacco use found most parents believed their child to be at a lower risk than the general population of taking up smoking, even when the child’s risk was greater due to there being a smoker in the household. Almost all the parents (91.5%) believed their child was less likely, or much less likely, than other children to become a smoker before the age of 18 years. Of parents who reported having a smoker in the household, most (70.4%) still believed their child would not start smoking before the age of 18 years, despite research showing parental smoking vastly increases the likelihood of the child also taking up smoking. 43
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,11, 21, 23, 35 with some research suggesting that it may be a more important predictor of uptake of smoking than parental smoking status.20, 21, 44 As parental influences decline during adolescence, adolescent behaviour may be increasingly modelled on that of siblings. For example, a longitudinal study that followed Canadian students (all never smokers at baseline) throughout high school found that sibling smoking was an independent determinant of smoking initiation as well as of the onset of daily smoking, while parental smoking was associated only with smoking uptake.45
Studies have shown consistently that adolescents with a smoking sibling, especially of the same sex,44 are more likely to take up smoking, and to continue smoking into adulthood.20 A national survey of American adolescents44 found that the likelihood of boys aged 15–18 years taking up smoking was increased three- to fourfold if their older brothers smoked, the greatest influence occurring at around the ages of 16 and 17. The same study showed that for teenage girls, while having an older sister who smoked more than trebled the likelihood of smoking in the younger sibling, those aged 15 with an older sister who smoked were almost eight times as likely to smoke.44
A US study in the 1990s46 estimated that a young person’s probability of smoking was increased by 7.6% for each additional smoking sibling in the household and reduced by 3.5% for each non-smoking sibling, concluding that the pro-smoking influence of a smoking sibling has more than double the deterrent effect of a non-smoking sibling.46 They did not find that older siblings had more influence than younger ones. The probability an adolescent has smoked and used other substances such as alcohol and cannabis in the past year has been found to be markedly higher if an older sibling engaged in the corresponding behaviour when at the same age.47 The investigators also note that research in this area is difficult as it is challenging to successfully control for the range of shared characteristics affecting siblings, such as common family backgrounds, neighbourhoods, schools, and genes, which could potentially account for most of the observed correlations.47
5.7.3 Smoking behaviour of grandparents
A systematic review examining the influence grandparents have over their grandchildren’s long-term cancer risk among developed countries, including 16 studies on tobacco consumption, found strong evidence suggesting grandparents who smoked had an adverse impact upon their grandchildren’s health. In the tobacco studies reviewed by the researchers they found, ‘grandparents smoked around grandchildren, did not comply with parents’ wishes regarding secondhand smoke, and role modelled negative behaviours which led to grandchildren taking up smoking’ (page 20). However, there were also instances where the introduction of grandchildren provided the grandparents with an incentive to quit smoking, or limit smoking to outside of the house while the grandchildren were present.48
5.7.4 Home smoking policies
Having a ban on smoking in the home has been shown to influence a young person’s susceptibility to smoking, as well as acceptance of smoking, smoking beliefs, smoking behaviours, and motivation to quit smoking.49-51 However, having a partial ban or no ban at all on smoking in the home has been shown to increase the likelihood of young people being exposed to environmental tobacco smoke, as well as increase their tolerance, increase their chances of having tried smoking, and increase the likelihood of the young person becoming a smoker themselves.49, 52 Both Australian53 and international49, 50, 52-55 research has shown home smoking restrictions are effective at inhibiting and/or delaying smoking initiation, experimentation and prevalence in young people. This was found to be true even if parents and friends were smokers and has been shown to have a greater effect on young people than smoking bans in public places.54
In homes with smoking bans, young people were less likely to have seen a parent smoke.50 Reducing exposure to (visible) smoking behaviours of significant others such as parents and friends means the young person is less likely to see smoking as a desirable behaviour. 50, 53, 55 Research assessing perceptions of smoking prevalence and attitudes about the social acceptability of smoking found household smoking bans to be associated with a lower perceived prevalence of adult smoking in the community and more negative attitudes about the social acceptability of smoking, these two factors decrease the likelihood of smoking initiation among young people.55 Household smoking bans have thus been described as a potentially powerful aspect of ‘anti-tobacco socialisation’49 through which young people are given an unequivocal message that smoking is not acceptable.51
5.7.5 Socio-economic aspects of uptake
Smoking and disadvantage is discussed in detail in Chapter 9.
In Australia, the prevalence of smoking has traditionally been higher among young people with lower socio-economic status (SES). In the late 1990s and early 2000s, there was a clear social gradient in smoking, with higher smoking rates among the most disadvantaged Australian school students. In recent years, however, these gaps have narrowed among older students, and in 2017 there was no difference in current smoking between the most and least disadvantaged 16 and 17-year-olds. Among younger students, despite a convergence in smoking rates in 2014, in 2017 12–15 year olds living in areas with relatively greater socioeconomic disadvantage were significantly more likely to report current smoking than those who lived in relatively less disadvantaged areas.56 (see Section 9.2.4).
Higher smoking prevalence among lower SES adolescence may be partly due to lower SES adolescents modelling the behaviour and attitudes of lower SES adults, who are more likely to be smokers.57 Disadvantaged children are also more likely to be exposed to other influences that can affect 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.58 As well as an increased likelihood of experiencing stress and negative life events. 57
Research has shown that during a period of low tobacco-control funding and activity in Australia (1992-1996), including minimal mass media anti-smoking advertising, smoking prevalence increased among young people aged 12 to 15 years old, with the greatest increase among the lowest SES group. While in periods of high tobacco-control activity, such as 1987-1990 and 1997-2005, smoking prevalence decreased consistently across all SES groups.59 The most recent data showing disparities in smoking between the most and least disadvantaged 12–15 year olds56 has also come in the wake of an absence of ongoing government investment in mass media campaigns.60
The likelihood of having a smokefree home—which can deter uptake among children—increases alongside socio-economic status (SES) (see Section 9.2.5). 61, 62 Findings from the International Tobacco Control Four Country Survey in Australia, Canada, the US and the UK indicated that high SES smokers were more likely than low SES smokers to either have, or to introduce, a total ban on smoking within the home. High SES smokers were also more likely than low SES smokers to uphold a household smoking ban while continuing to be a smoker themselves.62
Studies have consistently shown that young people with access to discretionary spending money are more likely to smoke.23, 29, 37, 63 Research from New Zealand has shown that while parents monitor young people’s use of large amounts of money, young people experienced freedom in spending small amounts. Young people commonly have access to money from a number of sources, including pocket money, lunch money and borrowing from friends and family, that allow them to buy cigarettes from retailers or via their social networks.64 Research from Scotland found that students from low SES backgrounds had greater access to cheaper informal sources of tobacco, either through family and friends or via the illicit market.65 By contrast, young people in higher SES areas looking to purchase tobacco may be restricted by the full retail price.65
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 (4).
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