5.7 Family and the home environment

5.7.1 Smoking behaviour of parents

Children of parents who smoke are more likely to take up smoking themselves.^1-56 Figure 5.7.1 shows smoking status among secondary school students in 2022–23 in Victoria according to parental smoking status, with the likelihood of having ever smoked and having smoked in the past month higher among students who have at least one parent who smokes.

Smoking may be transmitted from one generation to the next via number of factors, see Figure 5.7.2, including;

• children modelling their behaviour, beliefs, expectations and attitudes on those of their parents,⁷
• perceived parental approval, and/or permissiveness of adolescent smoking,
• access to tobacco in the household, and
• possibly some element of genetic predisposition^8,9 (or the effects of maternal smoking during pregnancy—see Section 5.3.2).

A 2011 systematic review and meta-analysis of 58 studies found that children were significantly more likely to take up smoking if exposed to smoking behaviour within their household. The risk was highest when both parents smoked—2.7 times more likely—followed by maternal smoking at 2.2 times more likely, paternal smoking at 1.7 times more likely, sibling smoking at 2.3 times more likely, and smoking by any household member at 1.9 times more likely. 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.¹⁰ Further research has also provided evidence that maternal smoking (including pre- and post-natal) influences smoking behaviours of adolescent daughters more than sons.¹¹ An Australian online survey of students 11–13 years also found the effect of maternal smoking stronger than that of paternal smoking.¹² The risk of intergenerational transmission of smoking has been found to be greatest if the adolescent child had parents whose smoking trajectory had an early onset, steep acceleration, was at high levels and persisted over time. These effects were regardless of current parental smoking or education level.¹³

National data from New Zealand show 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.^14,15 A 2023 New Zealand study using data from the Youth Insights Survey (2016 and 2018) of Year 10 students (14-15 years), investigated factors that help protect adolescents with caregivers who smoke from taking up smoking themselves.¹⁶ The study found that among those with a smoking caregiver; attending more affluent schools, not being exposed to smoking at home or in cars in the past week, having parents that would be upset if they were caught smoking, and having high self-esteem were protective factors.¹⁶

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.¹⁷ 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.¹⁷ 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 parents who did not smoke. 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.¹⁸

Research has also shown that smoking patterns of step-parents may be just as likely to influence smoking behaviour as behaviour of biological parents.¹⁹

5.7.1.1 Quitting

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%.²⁰

5.7.1.2 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 smoke themselves.^2,8,21 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.^21,22

Degree of parental supervision is also connected with smoking behaviour during adolescence.^23-26 Australian research has shown that teenagers who are regularly permitted to spend unsupervised evenings out with their friends are more likely to smoke.²⁷ 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.²²

In terms of parenting style, 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 less likely to take up smoking.^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.^4,25,28

Parental attachment, i.e. the nature of the relational bond between parents and children, is a strong predictor of smoking in adolescents.²⁹ 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.³⁰

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.²⁴ 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.³¹ A 2021 systematic review concluded that parental separation is associated with an increased likelihood of smoking in adolescents, especially in females. The review also looked at this effect by country, however the data on Australia found that the odds of parental separation being associated with smoking for adolescents was only slightly higher and not statistically significant.³² Living in an environment of marital discord, however, is 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.³³ 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.³⁴

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 person who smoked in the household.  Almost all the parents (91.5%) believed their child was less likely, or much less likely, than other children to take up smoking before the age of 18 years. Of parents who reported having a person who smoked 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.³⁵

5.7.2 Smoking behaviour of siblings

While research in this area can be 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,³⁶ many studies have nonetheless found that living in a family with older brothers or sisters who smoke influences adolescent uptake of smoking,^{1,24,25,37,38} with some research suggesting that it may be a more important predictor of uptake of smoking than parental smoking status.^38-40 As parental influences decline during adolescence, adolescent behaviour may be increasingly modelled on that of siblings, and the effects of siblings’ smoking have been shown to be as strong as the effects of smoking by close friends.⁴¹ A 2011 systematic review and meta-analysis of 58 studies found that having a sibling smoking within the home environment increased the risk of taking up smoking by 2.3 times.¹ Research has also shown that smoking by older siblings influences progression to higher levels of tobacco use, such as daily smoking^41,42 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,¹² and found that while both parents’ smoking status was a significant predictor, sibling and peer smoking were found to be more influential.¹² Other research has found that the probability an adolescent has smoked and used other substances such as alcohol and cannabis in the past year was markedly higher if an older sibling engaged in the corresponding behaviour when at the same age.³⁶

5.7.3 Smoking behaviour of grandparents

A 2017 systematic review⁴³ 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, researchers identified three overarching themes. Firstly, many parents reported limiting their children’s contact with grandparents who smoked, largely due to the grandparents’ noncompliance with suggested household smoking bans. Secondly, when grandparents were receptive to smoking bans, this often motivated them to quit smoking or at least restrict their smoking to outdoors while grandchildren were present. Lastly, grandparents who continued to smoke were seen as negative role models, contributing in some cases to smoking uptake among grandchildren.⁴³

Norwegian research published in 2023 examined how grandparents influence the intergenerational transmission of risky health behaviours, focusing specifically on smoking. The study found smoking by maternal grandparents during the parent’s upbringing was associated with a lower likelihood that the grandchild would smoke in adulthood, which may reflect shifting social attitudes and increased health awareness, or an aversion to smoking developed through exposure to its harms. No comparable effect was observed for paternal grandparents. The authors note, however, that while grandparents exert some influence, the parents’ smoking remains a stronger determinant of smoking behaviour in their children.⁴⁴

5.7.4 Socio-economic aspects of uptake

Smoking and disadvantage is discussed in detail in Chapter 9 and InDepth 9A.

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. These gaps have narrowed over time 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, however, 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.⁴⁵ (see Section 9.2.4).

Higher smoking prevalence among lower SES adolescence in earlier years may be partly due to lower SES adolescents modelling the behaviour and attitudes of lower SES adults, who are more likely to smoke.⁴⁶ 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.⁴⁷ As well as an increased likelihood of experiencing stress and negative life events.⁴⁶

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.⁴⁸ The 2017 data showing disparities in smoking between the most and least disadvantaged 12–15 year olds⁴⁵ also came in the wake of an absence of ongoing government investment in mass media campaigns.⁴⁹

The likelihood of having a smokefree home—which can deter uptake among children—increases alongside socio-economic status (SES) (see Section 9.2.5).^50,51 Findings from the International Tobacco Control Four Country Survey in Australia, Canada, the US and the UK indicated that high SES persons who smoke were more likely than low SES persons who smoke to either have, or to introduce, a total ban on smoking within the home. High SES persons who smoke were also more likely than low SES persons who smoke to uphold a household smoking ban while continuing to smoke themselves.⁵¹ An Australian study analysed data from the 2001–2019 HILDA  study to investigate smoking initiation among adolescents (aged 15–18 years) living in social housing. Adolescents in social housing had a 1.80 times greater risk (95% CI: 0.95, 2.66) of smoking five years later compared to adolescents living in privately rented or owned housing, after adjusting for household income, household smoking and other relevant factors.⁵²

Studies have consistently shown that young people with access to discretionary spending money are more likely to smoke.^14,24,27,53  Research from New Zealand has shown that while parents monitor young people’s use of large amounts of money, they 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.⁵⁴  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.⁵⁵ By contrast, young people in higher SES areas looking to purchase tobacco may be restricted by the full retail price.⁵⁵

For discussion on how affordability of cigarettes affects uptake of smoking in children, see Section 5.12 along with a discussion of pricing policy as a means of tobacco control, and in greater detail in Chapter 13, Section 13.4.

5.7.5 Family- and home-based interventions to reduce smoking uptake

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.⁵⁶ Parents often underestimate the likelihood of their child participating in risky behaviours, including smoking. In one US study⁵⁶, almost two-thirds of parents (64.5%) of adolescents aged 12–17 years 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.^56,57 Parents were more likely to be aware of tobacco use when their child was male, reported being a current tobacco user, achieved lower school grades, had relatives who used tobacco, or had tobacco available in the home.⁵⁶

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.⁴¹ 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.⁵⁸ 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.⁵⁹ 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.⁵⁹  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.⁶⁰

5.7.5.1 Home smoking bans

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.^61-63 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 taking up smoking themselves.^61,64 Both Australian⁶⁵  and international^61,62,64-67 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 smoked and has been shown to have a greater effect on young people than smoking bans in public places.⁶⁶

In homes with smoking bans, young people were less likely to have seen a parent smoke.⁶² 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.^62,65,67 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.⁶⁷ Household smoking bans have thus been described as a potentially powerful aspect of ‘anti-tobacco socialisation’⁶¹ through which young people are given an unequivocal message that smoking is not acceptable.⁶³

A 2017 systematic review⁶⁹ 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.⁶⁹

5.7.5.2 Effectiveness of family-based interventions/programs

The 2012 Report of the Surgeon General on Preventing Tobacco Use Among Youth and Young Adults⁴¹ 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.’⁴¹ 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.⁴¹

An updated 2017 Cochrane review⁶⁸ 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 persons who had never smoked, 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.⁶⁸ However, a 2017 systematic review⁶⁹ notes that frequent communication about smoking may undermine prevention efforts; the authors suggest talking too often about smoking may undermine autonomy and psychological freedom, reducing the adolescent’s motivation to not smoke.⁶⁹

A 2024 systematic review and meta-analysis of 27 studies demonstrated that smoking prevention interventions involving parents were moderately effective in delaying the onset of smoking among children and adolescents. Children and adolescents who took part in these family-based smoking prevention programs were about 16% less likely to start smoking than the control group.⁷⁰

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.⁶⁰ 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.⁶⁰

While parental smoking itself is a significant predictor of smoking uptake, one interesting US study implemented a home-based program with parents who smoked.⁷¹ 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’.⁷¹ 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.⁷¹ 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.⁶⁹

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,^39,72 siblings may be another ally for tobacco-control efforts within the family setting.⁷³ See Section 5.7.2 for more on smoking behaviour of siblings.

5.7.5.3 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 5.7.1), or as an element of school-based programs, see Section 5.29 School-based interventions.

Related reading