Last updated October 2014
Several aspects of the home environment can potentially relate to smoking uptake, including whether or not parents or siblings themselves smoke, parenting practices and style of parenting, 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 (cross-sectional and longitudinal) have found that parental tobacco use is linked with higher rates of child and adolescent smoking initiation,1 escalation to regular smoking and smoking into adulthood.1,2,3,4,5 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, ready access to tobacco, and possibly some element of genetic predisposition8,9 (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
A recent systematic review of international literature examined the magnitude of the effects of contact with other smokers, particularly those in the family, as a strong determinant of risk of smoking uptake among children and adolescents (aged 2 to 19 years).1 Researchers conducted meta-analyses based on 58 studies reported between 2000 and 2009, concluding that the relative odds of uptake of smoking in children were increased significantly if at least one parent smoked, with the effects of maternal smoking greater than smoking by the father. If both parents smoked, the risk of their children becoming smokers almost tripled. Sibling smoking more than doubled the risk of an adolescent smoking, and smoking by any household member also significantly increased the odds of smoking uptake. Investigators estimated that approximately 17 000 children and young people in England and Wales take up smoking by the age of 15 each year as a result of exposure to smoking by other household members.1
A recent Australian study examined the influence of parents, siblings and peers on pre- and early-teen smoking through an online survey among 7314 years 6 and 8 students.5 Analyses controlled for clustered data at school/community levels, as well as known correlates of smoking such as alcohol use, sensation seeking, academic performance and commitment to school. 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.5
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.12 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.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.13,14,15,16, 17 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 Results of recent research and a systematic literature review have confirmed 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.20,21,22 In a 1995 review, Tyas and Pederson reported that 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
Evidence also suggests that the developmental trajectory of parental smoking from adolescence to adulthood has a unique effect on adolescent smoking.25 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.25
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.26 National data from New Zealand show broadly similar findings, concluding that parental smoking status is a major, independent predictor of smoking among schoolchildren aged 14–15 years, especially those with Māori and Pacific Islands backgrounds.27,28
Some recent 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.29 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.29 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.30
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%.31
18.104.22.168 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.2,8,32 Young people who think that their parents would react negatively were they to start smoking are only around half as likely to begin; conversely, leniency in parental attitudes to smoking correlates with increased likelihood of smoking uptake.32
Degree of parental supervision is also connected with smoking behaviour during adolescence.15,23,33 Australian research has shown that teenagers who are regularly permitted to spend unsupervised evenings out with their friends are more likely to smoke.34
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.4,33,35
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 describes a school-based group randomised controlled intervention trial conducted in Perth among 1201 parents of children aged 10–11 years, assessing the impact of self-help drug education materials designed to encourage parent–child discussions about smoking and drinking.36 Short-term outcomes associated with the 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) included enhanced frequency and content of tobacco- and alcohol-related discussions and higher parent–child engagement during such discussions.36
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.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, as children in intact families.37 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.38 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.39
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,11,21,23,33 some research suggesting that it may be a more important predictor of uptake of smoking than parental smoking status.20,21,40 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.41
Studies have shown consistently that adolescents with a smoking sibling, especially of the same sex,40 are more likely to take up smoking, and to continue smoking into adulthood.20 Based on a national survey of American adolescents aged 14–18 years, Wang et al40 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.40
A study examined pooled cross-sectional data of smoking participation among more than 122 000 young people aged 15–24 years from 90 000 households involved in US population surveys between 1992 and 1999.42 Investigators 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.42 They did not find that older siblings had more influence than younger ones. The authors describe significant consequences for public policy towards youth smoking based on asymmetric peer effects (i.e. where a sibling's smoking has a quantitatively different influence than a sibling not smoking); for example, an information campaign with a constant intensity of anti-smoking messages will have a larger deterrent effect on youth smoking than an on-and-off campaign with the same total number of messages.
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.43 This was based on data analysis from paired biological siblings in a study involving almost 9000 young people aged 12–16 years. 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.43
5.7.3 Home smoking policies
Research indicates that bans on smoking in the home influence smoking behaviours, acceptance of smoking, susceptibility to smoking, smoking beliefs, and motivation to quit smoking,44–46 with partial or no bans on smoking in the home increasing the likelihood of adolescent and young adult smoking.44,47
Teenagers, particularly younger ones,48 are less likely to take up smoking if they live in a home in which smoking is banned,46 even if the parents themselves smoke. 32,46 Living in a smokefree home may also increase the likelihood of quitting among adolescent smokers.49
There is evidence from Victorian 50 and US research51 that home smoking bans inhibit or delay smoking initiation and experimentation in adolescents and may stop teenagers from ever smoking. Children living in a non-smoking home are less likely to smoke, even if their parents and friends are smokers,45,47,50,52 while US research has found that the majority of adolescents living in homes with smoking bans have not tried smoking, while those living in homes where smoking is allowed are much more likely to have tried smoking.44,45 A US study among over 4000 students aged 14–19 years found that those who lived in homes with smoking bans were less likely to have seen a parent smoke, to have friends who smoke, to try smoking, to smoke daily, to give in to peer pressure to smoke, and to be susceptible to smoking.45
Australian research50 drawing on 2002 data from a statewide survey of 4125 Victorian secondary school students aged 12–17 years examined the association between home smoking bans and stage of smoking uptake among adolescents. In a classroom survey, students were asked their own and their parents' smoking status, their likelihood of smoking in a year, and how many of their five closest friends smoked (to assess peer smoking).50 Logistic regression analyses controlling for parental smoking and smoking among friends indicated that students living in homes with a total smoking ban were least likely to be susceptible to smoking or to have tried smoking. While the effect of home bans was strongest when neither parent smoked, results suggested that home smoking bans reduced the likelihood of an adolescent experimenting with tobacco regardless of peer smoking behaviour.50 Bans were not associated with a reduction in adolescent daily smoking when friends' smoking was included in analyses.
A US study assessing perceptions of smoking prevalence and attitudes about the social acceptability of smoking among young people aged 12–17 years found a household smoking ban to be associated with two factors influencing the likelihood of smoking initiation: a lower perceived prevalence of adult smoking in the community and more negative attitudes about the social acceptability of smoking.52 This was observed even among youth reporting parental smoking and lack of perceived parental disapproval of youth tobacco use, both of which encourage adolescent smoking initiation.52 More recent (2009) US research among over 4000 high school students aged 14–19 years found that those living in households with a partial or full smoking ban were more likely to have less favourable attitudes toward smoking and were less likely to be exposed to secondhand smoke in vehicles, at home, and among family and friends. 45
Evidence from a cross-sectional study examining stages of uptake and smoking prevalence among more than 17 000 US high school students aged 14–17 years51 indicates that even when parents smoked, those adolescents who smoked and lived in homes with greater restrictions on smoking (both total or partial home bans) were significantly more likely to be in an earlier stage of smoking uptake and report a significantly lower rate of current smoking. Home smoking restrictions were found to have a greater effect than bans in public places on both adolescent smoking initiation and prevalence.51 Analyses of cross-sectional US population survey data indicate that the likelihood of ever having smoked, being a current smoker, and smoking more than five cigarettes per day was significantly reduced among adolescents (15–18 years) and young adults (19–24 years) living in parental households with strict no-smoking policies, compared with those in households where smoking was permitted anywhere, after controlling for smoking status of other household members.44
A study in Finland provides evidence that home smoking bans are associated with a reduced risk of adolescent smoking, even when parents smoke:47 in homes where both parents smoked with partial or no smoking bans, young people aged 12–18 years were two to three times more likely to smoke daily. Factors strongly associated with homes that did not have a complete smoking ban included adolescents living in non-intact families, lower parental educational level, parental smoking and permissive parental attitudes towards youth smoking.47
A literature review to evaluate population-level government policies in Australia, New Zealand, Britain and the US, associated with evidence on increasing the prevalence of smokefree homes, concluded there is some relationship between relatively comprehensive tobacco-control programs aimed at reducing the prevalence of smoking in the total population and lower prevalence levels of smoking in homes.53
Recent US research found that the presence of home smoking bans was strongly associated with the presence of a smoker in the household and also with the age of children in the household; the vast majority of non-smoking households (94%) had a smoking ban, compared with 56% of smoking households, while parents of young people aged 6–17 years were much less likely to have a no-smoking policy than those with children aged 0–5 years.54
There is also evidence from a range of studies that the presence, introduction and retention of smokefree homes increase with increasing socio-economic status (SES).54,55 For example, findings from the International Tobacco Control Four Country Survey in Australia, Canada, the US and the UK, involving nationally representative samples of nearly 6000 current and former adult smokers, indicated that smokers with high SES were more likely than low-SES smokers to both have and to introduce a total ban on smoking in the home, while continuing smokers with high SES were less likely than low SES smokers to remove a total ban.55
Young people from homes with a parental smoking ban are much more likely to move into smokefree accommodation when they leave home (controlling for a range of factors including smoking status, parental education level, gender and age).56
The association between home smoking bans and inhibition of smoking among adolescents has been attributed to a range of factors. Standards set in the home may influence smoking norms for adolescents who live there, through for example reducing exposure to (visible) smoking behaviours of significant others such as parents and friends and possibly counteracting the influence these behaviours may have on them; thus, the adolescent is less likely to initiate smoking or to believe smoking is a desirable behaviour.45,50,52 Household smoking bans have been described as a potentially powerful aspect of 'anti-tobacco socialisation'44 through which adolescents are given an unequivocal message that smoking is not acceptable.46 In addition, parental home smoking and subsequent child exposure to environmental tobacco smoke may increase tolerance for tobacco smoke and reduce a potential deterrent to teenagers taking up active smoking.46
5.7.4 Socio-economic 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 socio-economic 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 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.57
According to a review of the international literature on SES and health behaviours in adolescents (aged 10–21 years), most of the peer-reviewed published research between 1970 and 2007 concluded that lower SES in adolescence is associated with an increased likelihood of smoking, particularly during the early teenage years.57 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.57 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.58 Reduced investment in and accessibility of effective smoking cessation programs may also be a factor.5
A longitudinal study among Finnish youth followed from ages 13 to 28 years (1978 to 1993) examined the effects of parental and own SES on the changes in smoking status from adolescence to adulthood.59 Own SES (particularly education) at ages 21 and 28 was strongly related to smoking, while social mobility (the difference between parental and own education) was not significantly associated with smoking. Researchers attributed the association of smoking and own SES variables to factors not covered in the study. Parental SES was significantly associated with participant smoking only at ages 15 and 16 when children of blue collar workers smoked more than children of white collar or farm workers; researchers concluded that the data could not establish a causal chain from parental SES to own SES (because the majority of students started smoking before own SES could be measured), and that low parental SES (where smoking is more prevalent) does not necessarily mean that adolescents from that group would follow a similar life course.59
Research from Scotland examining SES and smoking behaviour in young teenagers found that students with a lower SES tended to have a greater amount of personal disposable income than children from higher SES households.60 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.60
Aside from family SES, studies have consistently shown that young people with more money are more likely to smoke.23,27,34 61 Young teenagers commonly have access to money from a number of sources, including pocket money, lunch money and borrowings from friends and family, which allows them to buy cigarettes from retailers or via their social networks.62 There is also evidence of a relationship between working for pay and adolescent tobacco use such as smoking uptake, including a positive association between smoking behaviours and the amount of time young people spend working for pay. Such associations may be attributed to several factors: adolescents who have part-time jobs may be more likely to be developmentally precocious, or seeking to emulate an adult lifestyle (through work and through tobacco use), or work could be a risk factor for smoking via exposure to workmates' smoking behaviour in the workplace.63 For young student workers, smoking may serve as an excuse for a break from work duties, wages may provide access to commercial sources of cigarettes, or smoking may occur in order to deal with the pressure of balancing work and study.63
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 5.22, and in greater detail in Chapter 13, Section 13.1.4.