Do as I say: parent smoking, antismoking socialization, and smoking onset among children

Adolescent alcohol and tobacco use: onset, persistence and trajectories of use across two samples

AIMS

We examined the alcohol-tobacco relationship using two prospective, ethnically diverse samples. Trajectories of alcohol and tobacco use are portrayed overall and by sex and ethnicity. Using prospective analyses, we examine directional influences between alcohol and tobacco use, and we characterize initiation versus persistence of drinking and smoking as a function of use of the other substance.

DESIGN, SETTING

Data were from the National Longitudinal Study of Adolescent Health (AddHealth) and the Adolescent Health Risk Study (AHRS). Follow-up intervals for AddHealth and AHRS were 1 and 5 years, respectively.

PARTICIPANTS

AddHealth respondents (n = 4831) were on average 14.8 years old (48% male, 23% black, 61% white) and AHRS respondents (n = 1814) were on average 16.7 years old (47% male, 44% black, 49% white).

MEASUREMENTS

Two alcohol consumption variables and two smoking variables were used: drinking frequency and heavy drinking frequency, and regular (current) smoking and daily number of cigarettes.

FINDINGS

Alcohol and tobacco use exhibited monotonic increases over adolescence and young adulthood. Men and white respondents reported more use than women and black respondents. Alcohol and tobacco were moderately associated at both times. Analyses revealed that prior alcohol use predicted tobacco use more strongly than the converse. Initiation of smoking was a function of prior drinking; to a lesser extent, initiation of drinking was a function of prior smoking. Persistence of smoking was a function of prior drinking and persistence of drinking was a function of prior smoking.

CONCLUSIONS

Provisional support exists for the claim that alcohol use predicts tobacco use more strongly than the converse. For both drinking and smoking, onset and persistence are predicted by prior use of the other substance, and these associations were robust across sex and ethnicity.

A pediatric, practice-based, randomized trial of drinking and smoking prevention and bicycle helmet, gun, and seatbelt safety promotion

OBJECTIVE

To prevent early adolescent health risk behaviors and to maintain or improve safety behaviors, we compared the effects of 2 interventions, delivered through pediatric primary care practices. The interventions, based on an office systems' approach, sought to prevent early drinking and smoking or to influence bicycle helmet use, gun storage, and seatbelt safety for children who were followed from fifth/sixth grades through eighth/ninth grades.

DESIGN

Settings and Participants. Twelve pediatric practices in New England were paired according to practice size and assigned randomly within pairs to deliver the multicomponent interventions, which built on pediatric primary care clinicians performing as counselors and role models during health supervision visits and other office encounters.

INTERVENTION

One intervention arm focused on alcohol and tobacco use. The other intervention arm focused on gun safety, bicycle helmet, and seatbelt use. Office systems provided infrastructure that supported the clinician's role. Clinician messages encouraged family communication and rule setting about the issues of the middle school years. The intervention was initiated during a health supervision visit and continued for 36 months. Both child and parent received quarterly newsletters to reinforce the clinician messages.

OUTCOME MEASURES

The primary outcomes were ever drinking alcohol, ever smoking, ever using smokeless tobacco, using a bicycle helmet in the previous year, using a seatbelt in the previous 30 days, and guns in the child's home in locked storage.

RESULTS

The pediatric practices recruited 85% (N = 3525) of the practices' fifth/sixth grade children and their responding parents. We obtained 36 months' follow-up data on 2183 child-parent pairs. Chart audit verified that the intervention was implemented. Additional data from interviews and surveys showed that parents, children, and pediatric clinicians found the intervention useful. Despite this, comparisons between the 2 study arms show no significant intervention effects in the prevention of alcohol and tobacco use or gun storage or seatbelt safety. There was a negative effect in the alcohol arm. Only bicycle helmet use showed a positive outcome.

CONCLUSION

With rigorous evaluation, 2 office interventions failed to produce desired outcomes. Coordinated multiple settings for prevention interventions are probably necessary.

Family processes for children in early elementary school as predictors of smoking initiation

OBJECTIVES

To assess the relationship between family processes measured when children are in early elementary school and initiation of cigarette smoking in early adolescence.

METHODS

The analysis sample of 810 children was drawn from a longitudinal study of students from a suburban school district in the Pacific Northwest. Predictor variables were assessed when children were in second or third grade, and smoking initiation was measured when the children were in sixth or seventh grade. Measures of family processes were entered separately into logistic regression models that included controls for household structure and income, parent smoking, and peer and child characteristics.

RESULTS

Measures of child attachment to parent and parent involvement with the child's school were significantly and negatively associated with smoking initiation. Among control variables, parent smoking, child grade level, and child antisocial behavior and depression were the strongest predictors of smoking initiation.

CONCLUSIONS

The results point to the importance of family bonding and parent supportiveness as protective factors and parent smoking and early childhood antisocial behavior and depression as risk factors for smoking initiation in pre- or early adolescence.

Does parental disapproval of smoking prevent adolescents from becoming established smokers?

OBJECTIVE

To evaluate the hypothesis that adolescents are less likely to smoke if their parents voice strong disapproval of smoking.

DESIGN AND SETTING

Three-wave school-based cohort study of rural Vermont adolescents attending 3 K-12 schools. We evaluate cross-sectional and longitudinal associations between perceived parental disapproval of smoking and the adoption of smoking behavior.

OUTCOME MEASURES

Students' perceptions of their parents' reaction to their own smoking was ascertained by asking the following question for mothers and fathers: "How do you think your mother (father) would react if you were smoking cigarettes and she (he) knew about it?" A response of "S/he would tell me to stop and be very upset" was considered to indicate strong parental disapproval. Outcome measures include a 6-level smoking index for cross-sectional analyses and, for a longitudinal analysis of 372 never smokers at baseline, being an established smoker (smoked > or =100 cigarettes lifetime and within the past 30 days) by survey 3.

RESULTS

The study samples for the cross-sectional analyses were 662 (baseline), 758 (year 2), and 730 (year 3). Students were equally distributed across grade (4th-11th grades) and gender. At baseline, most (65.9%) adolescents perceived both parents as disapproving of smoking, with 110 (16.6) perceiving 1 parent as disapproving, and 116 (17.5%) perceiving neither parent as disapproving. Perceived disapproval of smoking was inversely associated with adolescent smoking, grade in school, parental and sibling smoking, friend smoking, and ownership of tobacco promotional items. After controlling for confounding influences, adolescents who perceived strong parental disapproval of their smoking were less than half as likely to have higher smoking index levels compared with those who did not perceive strong parental disapproval. In the longitudinal sample of baseline never smokers, those who perceived strong disapproval in both parents at baseline were less than half as likely to become established smokers (adjusted odds ratio 0.4 [0.1, 1.0]). Those who perceived their parents becoming more lenient over time were significantly more likely to progress to established smokers. In all analyses, the effect of parental disapproval of smoking was stronger and more robust than the effect of parent smoking. In addition, the effect of parent disapproval was as strong for parents who smoked as it was for nonsmoking parents. An interaction analysis suggests that the peer smoking effect is attenuated when both parents strongly disapprove of smoking, suggesting that parent disapproval makes adolescents more resistant to the influence of peer smoking.

CONCLUSIONS

These findings contrast with the widespread notion that there is little parents can do to prevent their adolescents from becoming smokers. Instead, adolescents who perceive that both parents would respond negatively and be upset by their smoking are less likely to smoke. Interventions that enhance parental self-efficacy in conveying and enforcing no-smoking policies for their children could reduce adolescent smoking.

Cigarette use in adolescents: the Cardiovascular Health in Children and Youth Study

Tobacco is the leading cause of preventable death in the United States, and its use is increasing in adolescents. To determine the interventions needed to prevent the initiation of smoking, it is important to know the factors related to tobacco use by adolescents. In this study the following factors related to cigarette use were examined: age, gender, ethnicity, self-esteem, physical activity, parental smoking, and socioeconomic status. Participants were 1,207 youth completing a written survey for the Cardiovascular Health in Children and Youth Study (CHIC II). Participants ranged in age from 10 to 15 years, with a mean age of 12.2 years; 64.2% were White, 24.0% Black, 5.8% Hispanic, and 6.0% other races. White and Hispanic youth and youth of other races had significantly higher rates of smoking than did Black youth. Significant risk factors for smoking were: higher grade in school, White race, and for girls only, lower self-esteem. In White youth those in the lowest socioeconomic status were most likely to be current and experimental smokers. Smoking was as common in girls as in boys at these ages. Multivariate analysis showed that neither physical activity nor parental smoking were significant predictors of smoking behaviors. These results suggest that smoking prevention programs for adolescents should specifically target White and Hispanic youth and those from families with low socioeconomic status. In addition, these interventions should include ways to increase self-esteem in girls.

The social context of experimenting with cigarettes: American Indian "start stories"

Smoking rates among American Indians are higher than any other racial or ethnic group. Focus groups were conducted with 140 American Indian middle school students who were not living on reservations to explore the social context of smoking initiation. Most teens smoked their first cigarettes with friends, siblings or cousins, usually out of curiosity, or in response to peer encouragement. There was no indication of any link between smoking initiation and use of tobacco in traditional ceremonies. Overall, the social context for these teens was very similar to the social context of other teens in the United States.

Age-related differences in adolescent smokers' and nonsmokers' assessments of the relative addictiveness and health harmfulness of cigarettes, alcohol, and marijuana

The present work was undertaken to determine how general beliefs about various substances and substance use behaviors change during adolescence. Secondary analyses were carried out on the telephone interview responses of 1,200 adolescent smokers and nonsmokers between the ages of 12 and 17. The specific beliefs regarding which substances were hardest to stop using and which were the most harmful to one's health by smoking status and age were compared using Chi-squared analyses for univariate comparisons, and polytomous logistic regression for multivariate analyses. Results revealed that the youngest cohort believed that marijuana was the substance most difficult to stop using while the oldest cohort believed that cigarettes were the hardest to stop using. A similar pattern was observed regarding which substance was the most harmful to one's health. While smokers believed that cigarettes were both the hardest to stop using and the most harmful, nonsmokers were divided between cigarettes and marijuana as the hardest to stop using, and indicated that marijuana, rather than cigarettes, were most harmful. Results are discussed in terms of their implications for substance abuse prevention and the development of relative risk assessments.

Effectiveness of a cardiovascular health promotion education intervention on the attitudes of urban African American school-age children

African American children are at risk for high rates of morbidity and mortality associated with cardiovascular (CV) disease as they become adults, yet little is known about the effectiveness of CV risk-reduction interventions in African American children. This study explored the effectiveness of a concentrated CV health promotion educational program on health-related attitudes of 76 African American children enrolled in a mid-southern school system. The Children's Cardiovascular Health Promotion Attitude Scale was used to examine differences in attitude prior to and 2 weeks following a focused health education intervention. Results demonstrate that children have preconceived attitudes regarding practice of health behaviors and that these attitudes are modifiable with age and developmental level specific educational interventions. Findings indicate the need for health care providers to assume more active roles in reducing the risk of future CV disease and death in African Americans through health promotion education of individuals who influence the development of children's attitudes.

Stages in the development of adolescent smoking

Many researchers have conceptualized smoking uptake behavior in adolescence as progressing through a sequence of developmental stages. Multiple social, psychological, and biological factors influence this process, and may play different functions at different points in the progression, and play different roles for different people. The major objective of this paper is to review empirical studies of predictors of transitions in stages of smoking progression, and identify similarities and differences related to predictors of stages and transitions across studies. While a number of factors related to stage of progression replicated across studies, few variables uniquely predicted a particular stage or transition in smoking behavior. Subsequently, theoretical considerations related to stage conceptualization and measurement, inter-individual differences in intra-individual change, and the staged or continuous nature of smoking progression are discussed.

Smoking bans in the home and car: Do those who really need them have them?

BACKGROUND

This paper addresses the question of whether individuals who are most in need of household and car smoking bans, such as individuals with children living at home or who have many friends who smoke, are the ones who have them.

METHOD

A representative sample of 6985 California adults ages 18 and older participated in telephone interviews.

RESULTS

Overall, 76% of adults report having home smoking bans and 66% have car smoking bans. Being a smoker or African American, not having children in the home, having more friends who smoke, and lower household income were associated with lower prevalence of both home and car smoking bans (P < 0.01). In multivariate analyses, nonsmokers were 7.9 (95% CI = 3.56, 17.31) times more likely to have a home smoking ban when none of their friends were smokers compared to when most of their friends were smokers. Among smokers, there was an interaction between having children at home and the proportion of friends who smoke. Only 27 to 55% of smokers had home smoking bans unless most of their friends were smokers, then the odds of having a ban were 6.1 (95% CI = 2.76, 13.68) times higher for smokers with children (67% with home bans) than for smokers without children at home (25% with home bans).

CONCLUSIONS

Efforts to increase home and car smoking bans for nonsmokers who have friends who smoke and smokers with children living at home are needed.

Why can't we convince the young not to smoke?

Tobacco is the largest cause of preventable death and morbidity in the world. Significant progress has been made in national tobacco control programmes, followed by a significant reduction in smoking-associated diseases. However, other populations have taken up the habit and the worldwide surge in cigarette smoking by young people is particularly worrisome. Based on our own experience as well as reported data, we examined determinants of tobacco use, at the familial, peer and societal levels as well as various prevention strategies based on legislation, health promotion and society awareness. Reasons for failures include under-enforcement of legislation, uniform approach to diverse populations and too limited means. Recommendations for future actions should include integrated policies and health programmes. Most importantly, the society outlook on tobacco should be changed, making non-smoking the norm and the objective.

Tobacco use among Australian secondary students in 1996

OBJECTIVES

To estimate smoking prevalence among Australian secondary students in 1996 and to examine trends in smoking prevalence since 1984.

METHOD

A randomly selected representative sample of 434 secondary schools from across Australia participated in the study. At each school 80 randomly selected students completed a pencil-and-paper questionnaire anonymously. Data from 29,850 students aged between 12 and 17 years are reported.

RESULTS

Current smoking (smoking in the week before the survey) was 8% in boys and 7% in girls aged 12, and rose to a peak prevalence among 17 year olds of 28% for boys and 34% for girls. The mean number of cigarettes smoked per week among current smokers rose from 11 for boys and six for girls aged 12 to 37 for boys and 34 for girls aged 17. Comparisons across survey years showed that while fewer 12 to 15 year olds were current smokers in 1996 than in 1984, the proportion in 1996 was greater than that in 1987 or 1990. Among 16 and 17 year olds, the proportion of current smokers in 1996 was greater than that seen in 1987 or 1990. An aggregate measure of tobacco involvement suggested that involvement with tobacco had remained stable since 1993 among 12 to 15 year olds.

CONCLUSION

The decline in adolescent smoking seen in the late 1980s has stopped.

IMPLICATIONS

Extrapolating from this survey, we estimate that more than 276,000 12-17 year old students were current smokers in 1996. If they all continue to smoke, 138,000 would die prematurely.

The role of social networks and media receptivity in predicting age of smoking initiation: a proportional hazards model of risk and protective factors

The increasing prevalence of adolescent smoking demonstrates the need to identify factors associated with early smoking initiation. Previous studies have shown that smoking by social network members and receptivity to pro-tobacco marketing are associated with smoking among adolescents. It is not clear, however, whether these variables also are associated with the age of smoking initiation. Using data from 10,030 California adolescents, this study identified significant correlates of age of smoking initiation using bivariate methods and a multivariate proportional hazards model. Age of smoking initiation was earlier among those adolescents whose friends, siblings, or parents were smokers, and among those adolescents who had a favorite tobacco advertisement, had received tobacco promotional items, or would be willing to use tobacco promotional items. Results suggest that the smoking behavior of social network members and pro-tobacco media influences are important determinants of age of smoking initiation. Because early smoking initiation is associated with higher levels of addiction in adulthood, tobacco control programs should attempt to counter these influences.

Anti-tobacco socialization in homes of African-American and white parents, and smoking and nonsmoking parents

PURPOSE

To examine parental perceptions and behaviors with regard to teen smoking, comparing African-American and white parents, and those who did and did not smoke.

METHODS

Focus groups consisting of African-American and white parents who smoked provided initial in-depth information. A computer-assisted telephone survey of a biracial sample of 311 parents of children ages 8 to 17 years provided more generalizable information regarding parental beliefs and behaviors.

RESULTS

Nearly 50% of households either allowed teen smoking, had no ground rules, or had set restrictive rules but never communicated them to the children. Compared to white parents, African-American parents felt more empowered to affect their children's behaviors and were more likely to actively participate in anti-tobacco socialization within the home (all p values < 0.01). Among the African-American parents, 98% reported 18 years or older to be an appropriate age for teens to make up their own minds about using tobacco, whereas 26% of white parents thought 16 years to be an appropriate age (p < 0.001). Parents who smoked reported more frequent rule-making than those who did not smoke (p = 0.02), but were more likely to believe that childhood tobacco use is inevitable (p = 0.01).

CONCLUSIONS

Many parents are not engaged in antitobacco socialization in the home. Differences in the degree of parental participation may contribute to the variance in smoking prevalence between African-American and white children.

Does parental smoking cessation discourage adolescent smoking?

BACKGROUND

We examined the relationship of smoking cessation in parents to smoking and uptake and cessation by their adolescent children.

METHODS

We analyzed a cross-sectional sample of 4,502 adolescents, ages 15-17 years, who lived in two-parent households that were interviewed as part of the 1992-1993 Tobacco Supplement of the Current Population Survey, which questioned householders 15 years of age and older about their smoking history. Ever smokers reported smoking at least 100 cigarettes in their lifetime. Former smokers were ever smokers who had quit.

RESULTS

Multivariate analyses, adjusted for demographic characteristics of adolescents, as well as father's age, education, and family income, found that adolescents whose parents had quit smoking were almost one-third less likely to be ever smokers than those with a parent who still smoked. Furthermore, adolescent ever smokers whose parents quit smoking were twice as likely to quit as those who had a parent who still smoked. Parental quitting is most effective in reducing initiation if it occurs before the child reaches 9 years of age.

CONCLUSION

Encouraging parents to quit may be an effective method for reducing adolescent smoking, through decreased uptake and increased cessation. The earlier parents quit, the less likely their children will become smokers.

Nicotine dependency of a girl at the age of 18 months

This case report describes severe nicotine dependency developing at the age of 18 months. Familial, genetic, biological aspects of the case and the therapeutic strategy are discussed.

The Authoritative Parenting Index: predicting health risk behaviors among children and adolescents

Public health research demonstrates increasing interest in mobilizing parental influence to prevent health risk behaviors among children and adolescents. This research focuses on authoritative parenting, which previous studies suggest can prevent health risk behaviors among youth. To evaluate the reliability and validity of a new survey measure of authoritative parenting, data from studies of (1) substance use in a sample of 1,236 fourth- and sixth-grade students; (2) weapon carrying and interpersonal violence in a sample of 1,490 ninth- and tenth-grade students, and (3) anger, alienation, and conflict resolution in a sample of 224 seventh- and eighth-grade students were analyzed. The Authoritative Parenting Index had a factor structure consistent with a theoretical model of the construct; had acceptable reliability; showed grade, sex, and ethnic differences consistent with other studies; and identified parenting types that varied as hypothesized with multiple indicators of social competence and health risk behaviors among children and adolescents.