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Literature review on family influence on smoking behaviour among adolescents

Wong, On-na, Anna; 王安娜 Wong, O. A. [王安娜]. (2013). Literature review on family influence on smoking behaviour among adolescents. (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR. Retrieved from http://dx.doi.org/10.5353/th_b5098934 2013

http://hdl.handle.net/10722/193848

The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

Abstract of project entitled

“LITERATURE REVIEW ON FAMILY INFLUENCES ON SMOKING BEHAVIOR AMONG ADOLESCENTS”

Submitted by Wong On Na Anna for the degree of Master of Public Health at The University of Hong Kong August 2013

Background:

Smoking has long been one of the principal causes for

morbidity and mortality and is ranked as the third leading cause for preventable health deaths in the world, posting serious threat to public health. Most smokers start smoking during adolescence. Adolescence describes teenagers aged 13-19 years old which can be considered as the transitional period from childhood to adulthood, about 88% of adult smokers who smoke daily started their smoking behavior by age of 18 years old and 68.2% of smokers started smoking below age of 20 in Hong Kong. Therefore, there is an urgent need to direct the public health effort towards the prevention of smoking in adolescents. It has been found that family has important influences on smoking behavior among adolescents. Objective:

The objective of this review is to examine the effect of family

influences on adolescents smoking behavior, particularly the association of parenting style, parental smoking and adolescent smoking behavior. Methods:

The online databases PsycINFO, Medline and EMBASE were

searched by using keywords “adolescents smoking” or “youth smoking” and 1

“family influence” or “parental influence”. The last search was done on 10th August, 2013. Total 13 English articles, of which 10 were cross-sectional studies and 3 were longitudinal studies, were included in this review. Results:

Literature showed authoritative parenting style could reduce the

risk of smoking among adolescents; all studies showed authoritative parenting style, disapproval to smoke with higher level of parental monitoring could reduce risk of regular smoking behavior among adolescents. On the other hand, results from articles examining the association of parental smoking and smoking behavior among their children were almost homogenous. Adolescents who lived with smoking parents were more likely to initiate the smoking behavior compared to those with non-smoking family members. Meanwhile, studies showed adolescents from single-parent families were more likely to smoke when compared with those came from complete family. A negative association between single parent and daily smoking was observed among the adolescents. Conclusion: Future campaigns on smoking prevention should increase the involvement of family members, encourage parents to quit smoking and act as role model to their children; parents are suggested to practice authoritative parenting which will increase the acceptance of adolescents to their rules and suggestions and thus, avoid them from smoking. On the other hand, adolescents from single-parents are more likely to attain smoking and should increase awareness. More local researches, with randomized control trial studies, are needed in the future to examine family influences that fit the situation in Hong Kong. The aim of campaign is to further decrease smoking prevalence in adolescents.

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LITERATURE REVIEW ON FAMILY INFLUENCE ON SMOKING BEHAVIOR AMONG ADOLESCENTS By

WONG ON NA ANNA (UID: 2008085587)

A project submitted in partial fulfillment of the requirements for the Degree of Master of Public Health at The University of Hong Kong August 2013 3

Declaration

I declare that the project and the research work thereof represents my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications.

Signed ___________________________ (Wong On Na Anna) 1

Acknowledgements

The project would not have been possible without support from many people. I would like to take opportunity to express the gratitude to my project advisor Dr. Lin Yang of the School of Public Health for her invaluable advice, support, guidance and suggestion on the selection of the project topic.

Deepest gratitude also gives to all the teachers, staffs and classmates of the School of Public Health who provide useful suggestions to the project.

Finally, I would like to express my love and gratitude to my beloved family and friends, for their support and understanding throughout my studies.

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Contents

Declaration ……………………………………………….……………..1 Acknowledgements …………………………………………………….,2 Table of Contents …………………………………………..…………...3 Lists of Illustrations/Tables/Figures …………...………………………..4 Abbreviations …………………………………………………………...5 Chapter 1: Introduction 1.1 Background ……………………………………………………6 1.2 Adolescents Smoking Behavior in HK ……………………..…6 1.3 Family Influence ………………………………………………7 1.4 Objective …………………………………………………..…..8 Chapter 2: Methods 2.1 Search Strategy ………………………………………………10 2.2 Inclusion & Exclusion Criteria ……...……………………….10

Chapter 3: Results 3.1 Study Characteristics ………………………………………...12 3.2 Parental Smoking ..……….…………………………………..13 3.3 Parenting Style ..……….……………………………...….......14 3.4 Single Parent Family ..……….…………………………...…..15 Chapter 4: Discussion 4.1 Family Influence ………………………………………...…...20 4.2 Parental Smoking ………………………………………...…..21 4.3 Parenting Style …………………………………………..…...22 4.4 Single-Parent Family …………………………………..…….23 4.5 Limitations ……..………………………………………..…...23 4.6 Implication ……………………………………………..….....24 Chapter 5: Conclusion …………………………………………….…26 References ……………………………………………………………..28

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Illustrations Figures Figure1 - Flow Chart of selection process for the studies …...................11

Tables Table 1 - Summary table of Studies …………………………………….16

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Abbreviations

AOR

Adjusted Odd Ratio

C.I

Confidence Interval

COPD

Chronic Obstructive Pulmonary Disease

DH

Department of Health

HK

Hong Kong

n

Sample size

OR

Odd Ratio

p

p-value

RR

Risk Ratio

SHS

Second hand smoking

TCO

Tobacco Control Office

UK

United Kingdom

U.S.

United States

y.o.

Years old

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Chapter 1: Introduction 1.1 Background

Smoking has long been one of the principal causes for morbidity and mortality. It acts as the main contributor to cancer, e.g. lung cancer which is the top three killers in Hong Kong. [1] It also associated with many diseases like chronic obstructive pulmonary disease (COPD), heart diseases, stroke, asthma, etc. Smokers are also at higher risk to develop pneumonia or lower-respiratory tract infections. [1] There are studies in UK showed that preventing from smoking can reduce one third of deaths among cancers and one sixth of other causes of deaths. [2] Smoking not only harms the smokers, second hard smoking (SHS) is another important and concerning problem. There are reports showing SHS can be more harmful than the mainstream smoke, the purified chemicals contains more than 250 known to be harmful substances and more than 60 are carcinogens. [3] Smoking is therefore the third leading cause for preventable health deaths in the world. The harm done by smoking is obvious and concerning. It has posted a serious public health problem and with the urgent need to control the smoking rate and provide a smoking-free environment to the public for better health.

According to the survey done by the U.S. Department of Health and Human Services in 2012, smoking behavior is mostly initiated primarily during adolescence. Adolescence describes the teenagers from 13-19 years old which can be considered as the transitional period from childhood to adulthood. In fact, about 88% of adult smokers who smoke daily started their smoking behavior by age of 18 years old. [4] It is therefore one of the most effective and important ways to control the tobacco behavior in long term.

1.2 Adolescents smoking behavior in Hong Kong

Nowadays, with advertising effect in movies and bring by celebrities, it helps to build up a cool image for smoking behavior. Therefore, smoking among 6

adolescents has been increased and popularized. Adolescence is period that transited from infancy to adulthood. At the stage, the mental development is not yet mature; some people may fail when adjusting to the changes during adolescence, become easily addicted to the tobacco. [4] According to the statistics from Tobacco Control Office (TCO) and the Department of Health (DH), the prevalence of current smokers (aged 15 and above) was 11.1% in 2010. [5] The rate is relatively lower in Hong Kong when compared to western countries; tobacco use was about 19.5% in U.S. and the rate for adolescent smoking is about 18% globally. [6] Meanwhile, the percentage of daily cigarette smokers started smoking under age of 20 was 68.2% in 2010. [5] That is over half of smokers started smoking during their adolescence, below age of 20. It has been noted that the younger the person starts smoking, the longer time and more cigarettes consumed, the more harm will do to the body. There is a need to direct the public health effort towards the prevention of smoking in adolescents.

1.3 Family influence

There are 3 main factors that influence the smoking behavior among the adolescents, which are the individual characteristics, peer influences and family factors. Most researches and reviews have already been done on peer influences, while family factors are also important and are modifiable. Moreover, individual characteristic is somehow built up by the parenting style and education, with good education and role modeling, [7] risk of adolescent smoking behavior will be reduced. Parental behavior is no doubt a significant determinant for smoking behavior among adolescent.

Parents are the primary role models for the adolescents; children used to follow what their parents do. [7] There is an increased interest in family based intervention to study the influence of parenting style and family factors on adolescents smoking behavior. There are 2 main dimensions in parenting: one is parental acceptance which includes warmth, attachment, and nurturance; and the behavior control that includes discipline and monitoring. [7] Both parental acceptance 7

and behavior control can used in prediction of a variety of problem behavior among adolescents, including smoking behavior. [7] These two dimensions can be concluded in describing 4 parenting styles which are authoritarian (with low level of acceptance and high level of control); authoritative (high level of acceptance and control); indulgent (high level of acceptance and low level of control) and disengaged (low level of acceptance and low level of control). [7] Among these four parenting styles, disengaged has showed its greatest influences on problem behavior, including smoking behavior. [8] The lack of the affective bonding to the parents and supervision, and monitoring leads to bad communication which discourages the adolescents to comply and attend the good behaviors.

Apart from parenting styles, parental smoking is associated with higher risk of smoking initiation among the adolescents. [9] Adolescents are more likely to start smoking if both of their parent smoke, when compared to those parents both is non-smokers. [11, 21] It has also been noted that frequency of smoking among adolescents increased when there are smokers in the family since parents are the primary role models for the adolescents. [17, 21] Therefore, to reduce the risks of smoking among the adolescents, parents have played an important role. They are encouraged to stop or, at least reduce smoking and act as good role models.

1.4 Objectives

Two recent review papers studied the effect of family influence on adolescents smoking behavior. They were “Family influence on adolescent smoking” by Avenevoli and Merikangas (2003) [9] and “Family-based programmes for preventing smoking by children and adolescents (Review)” by Tomas et al (2008) [8]. For the most recent review in 2008, it only included search performed till November 2007 using studies with control group, and excluded those if the randomized allocation to intervention and control groups was not stated. The review focus on the influence of parenting behavior, parental or family members smoking behavior, family interaction or communication on smoking behavior of adolescents. Since there is no review paper currently studying results 8

of all types of studies published from 2008 till now, this review paper will include all types of articles published from 2008 to now. The objective of the review paper is to examine the importance of family influences on adolescents smoking behavior, if there is any association between parenting style, parental smoking and adolescent smoking behavior. To understand the family influences on adolescents smoking behavior, articles were chosen based on the following questions:

1.

Does the parental smoking initiate the smoking behavior among adolescents?

2.

Do parenting styles, parental smoking behavior, or family interaction; reduce the risk of smoking behavior in adolescents?

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Chapter 2: Methods 2.1 Search Strategy

Online database PsycINFO, Medline and EMBASE were searched by using the keywords “family influence” or “parental influence”, and “adolescent smoking” or “youth smoking”. The last search was done on 10th August, 2013.

2.2 Inclusion and Exclusion Criteria

Only research articles published from 2008 were included, because a previous paper, “Family-based programmes for preventing smoking by children and adolescents (Review)” [8] had comprehensively reviewed the studies performed before November 2007 on family influence of adolescents smoking behavior. To increase the specificity of the review, articles discussing the effects of other factors on adolescents smoking behavior: peer influences, genetic factors, school policies, social influences, gender; articles comparing effects between different countries or cultures; and articles studying the maternal smoking during pregnancy were all excluded.

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Figure1. Flow Chart of selection process for the studies

781 free full text were found in the preparatory keywords search from 3 databases. Keywords: “Adolescent smoking” or “youth smoking” and “family influence” or “parental influence”

555 studies were excluded after title and abstract 226 full text articles were examined 176 studies were excluded because not published from 2008-2013 50 full text articles were examined

35 studies of peer influence, social influence, school influence, gender, maternal smoking during pregnancy, genetic factors, difference between countries and culture were excluded

15 full text articles were examined

2 studies were excluded because of dead link *

13 articles were included in the review paper

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Chapter 3: Results 3.1 Study characteristics

Among the 13 reviewed articles, ten of them were cross sectional studies (Abrams et al., 2009 [11]; Baker and Rice., 2008 [12]; Wong et al., 2008 [13]; Balazs and Piko., 2012 [14]; Camenga et al., 2012 [15]; Golden et al., 2012 [16]; Hinds et al., 2012 [17]; Ho et al., 2012 [18]; Hrafn Jonsson et al., 2012 [19]; Shenassa and Wen., 2012 [20]); three were longitudinal studies (Chang et al., 2011 [21]; Bernat et al., 2012 [22]; Mahabee-Gittens et al., 2013 [23]). Studies were from U.S., Europe, New Zealand and Asia. Seven studies were done in U.S. (Baker and Rice.,2008 [12]; Bernat et al., 2012 [22]; Camenga et al., 2012 [15]; Golden et al., 2012 [16]; Hinds et al., 2012 [17]; Shenassa and Wen.,2012 [20]; Mahabee-Gittens et al., 2013 [23]); one in New Zealand (Wong et al., 2008 [13]); one in England (Abrams et al.,2009 [11]); one in Iceland (Hrafn Jonsson et al.,2012 [19]); one in Hungary (Balazs and Piko., 2012 [14]); one in Taiwan(Chang et al.,2011 [21]); one was local study that carried out in Hong Kong(Ho et al.,2012 [18]). Data collection was by questionnaires and telephone interview, with self-reported smoking status, one study used salvia cotinine concentration for verification of the self-reported smoking status (Hrafn Jonsson et al., 2012 [19]). Studies focused on family influence of different factors, including parenting style, parental smoking status, and single parent families.

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3.2 Parental Smoking

For articles examining the association of parental smoking status and smoking behavior of adolescents, results were almost homogenous, indicating that active parental smoking increased risk of smoking behavior of the children (Wong et al., 2008 [13]; Abrams et al., 2009 [11]; Chang et al., 2011 [21]; Bernat et al., 2012 [14]; Camenga et al., 2012 [22]; Hinds et al., 2012 [17]; Ho et al., 2012 [18]); except the study done by Baker and Rice shows no significant association among these 2 factors which may due to the small sample size (sample size=297), ethnicity ( Arab Yemeni) selected and culture difference of the Arab in the study. [12]

Adolescents were more likely to initiate the smoking behavior if they lived with parents who smoked when compared to those lived with non-smoking family members, and those without second hard smoking exposure at home (AOR =1.5, 95%C.I.=1.23-1.83, p