Health Promotion Journal of Australia, 2014, 25, 59–64 http://dx.doi.org/10.1071/HE13029
Tobacco Control
Protecting children from taking up smoking: parents’ views on what would help K. Marck A,F, M. Glover A,G, A. Kira A, J. McCool B, R. Scragg C, V. Nosa D and C. Bullen E A
Centre for Tobacco Control Research, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. B Social and Community Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. C Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. D Pacific Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. E NIHI, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. F Present address: Cancer Society Auckland Division, PO Box 1724, Auckland 1140, New Zealand. G Corresponding author. Email: [email protected]
Abstract Issue addressed: The present study investigated what factors the parents of children in low-income areas of Auckland, New Zealand, thought could help protect their children from smoking initiation. Methods: Participants in a large quasi-experimental trial that tested a community-, school- and family-based smoking-initiation intervention were asked in a questionnaire ‘What could we do to help you protect your children from smoke and taking up smoking?’ Free-text responses were divided into distinct meaning units and categorised independently by two of the researchers. Results: 1806 participants (70% of parents who returned the questionnaire) completed the question. The majority of respondents (80%) were either Pacific Island or Maori mothers and 25% were current smokers. Five main categories of suggested strategies for preventing smoking initiation were identified: building children’s knowledge of the ill-effects of smoking; denormalising smoking; reducing access to tobacco; building children’s resilience; and health promotion activities. The most common suggestion was to educate children about smoking. Conclusion: Building children’s knowledge of smoking risks was the main strategy parents proposed. There was some support for banning smoking in most public areas and for tougher moves to stop tobacco sales to minors. Few parents suggested innovative or radical strategies, such as banning the sale of tobacco, fining children for smoking or use of competitions. So what? To ensure reductions in smoking initiation for lower socioeconomic and Maori and Pacific Island people, further research should engage Maori, Pacific Island and lower socioeconomic parents in a process that elicits innovative thinking about culturally acceptable strategies.
Key words: child smoking initiation, health education, health promotion, parental attitudes. Received 25 March 2013, accepted 3 October 2013, published online 14 March 2014
Introduction The New Zealand (NZ) government has set an aspirational goal for the nation to be smokefree (5% or less smoking prevalence) by 2025.1 Protecting children from taking up tobacco smoking is one of the three objectives to achieve this goal, and to reduce the burden of smoking-related morbidity and mortality.2,3 Although the role of parents in protecting children from smoking uptake has been well studied, parent’s perceptions of what would help keep their children from starting to smoke is not known. Journal compilation Ó Australian Health Promotion Association 2014
Despite extensive tobacco-control efforts, NZ youth, particularly from low socioeconomic areas or of Maori (the indigenous people of NZ) ethnicity, commence smoking at a young age: almost 10% of 14–15 year olds smoke tobacco regularly.4 The prevalence is substantially higher among Maori and Pacific Island than European students (21%, 12% and 7% respectively) and there is a marked difference in smoking prevalence in students attending schools in low compared with high- socioeconomic communities (for females: 7% in high compared with 21% in low socioeconomic schools; for CSIRO Publishing
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males: 5.9% in high compared with 14% in low socioeconomic schools).4 Further, although smoking prevalence among all ethnic groups has reduced since 1999, the reduction has been substantially slower for Maori and Pacific Island than for European students (43% to 21%, 28.5% to 12% and 27% to 7% respectively). Parental smoking is one of the many factors associated with higher rates of adolescent smoking.5–7 Conversely, regardless of their smoking status, having parents with negative attitudes towards smoking is associated with lower smoking rates in adolescents.8,9 Further, practices such as banning smoking indoors and educating children about the dangers of smoking reduce the likelihood of adolescent smoking.10,11 Evidence suggests parents underestimate their capacity to influence children’s smoking behaviour. However, even simple measures such as not smoking inside the home can be protective as can more proximal factors such as increasing their beliefs about the health risks of smoking and expressing their desire for their children to be non-smokers.12 Similarly, our previous research13 suggests that parents who are aware of and talk about the tobacco industry can be protective against the influence of tobacco marketing in mainstream media. McCool et al.14 found that children who were exposed to clear antismoking expectations in their home were less likely to appraise tobacco imagery in film as positive. Positive appraisal of smoking imagery in films is associated with smoking uptake.14 Yet, the strategies parents tend to engage in, with the intention of preventing smoking uptake among their children, include teaching children refusal skills, promoting participation in sport, encouraging the wider whanau (family) to refrain from smoking, and more punitive (school- and community-based) measures such as school- and community-level negative consequences if found smoking.15 Parents also need support from the wider community to protect their children from smoking uptake.12,16 Parents, particularly mothers, value school smoking-prevention initiatives.17 Public support for a range of tobacco-control measures aimed at reducing harm to health from exposure to second-hand smoke and reducing uptake of smoking by children, such as smoking bans at playgrounds and keeping tobacco products out of sight,18 not selling tobacco in shops accessed by children18,19 and increasing tax on cigarettes and introducing tighter regulations on tobacco companies,19 are also key.
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family-based smoking-initiation-prevention intervention targeting 11–12 year olds in South Auckland, an urban area where the population has high smoking prevalence and is predominately of low socioeconomic status with a high proportion of Maori and Pacific peoples. The study is described in detail elsewhere.20 In brief, at baseline, during 2007–2009, each student was given a pack containing a cover letter, participant information sheet, consent form and parent questionnaire and envelope for returning their consent form and questionnaire to the child’s school or by free mail directly to our research centre. Parents were incentivised to return the questionnaire with entry into a prize draw for a family trip to a restaurant, the movies or a fun park.
Data collection The baseline questionnaire consisted of 19 questions. In order to allow parents to write in their own words what they thought could help them to protect their children from smoking, a free-text question was included (‘What could we do to help you protect your children from smoke and taking up smoking?’). Simple demographic and smoking-related data were collected. Smoking status was assessed by asking two questions; ‘have you ever smoked a cigarette’ and if the answer was yes, a follow-up question ‘how much do you smoke now?’ Details of the remaining questions in the questionnaire can be found in Glover et al.20
Data analysis All data were entered into a Microsoft Excel spreadsheet. Free-text responses were divided into distinct meaning units and categorised independently by two of the researchers (KM, MG) inductively. Discrepancies were discussed until consensus was reached.21 Ethnicity was prioritised according to NZ ethnicity-coding protocols,22 whereby participants listing more than one ethnicity had priority assigned to Maori, Pacific, Asian and European/Other ethnicity in that order.
Ethical approval Ethics approval for the study was obtained from the University of Auckland Human Participants Ethics Committee (Ref. 2006/416).
Results Participant characteristics
Understanding parents’ opinions of how children can be protected can assist tobacco-control-programme design and the development of key messages for parents. The aim of this study was therefore to investigate what factors the parents of children attending schools in low-income areas of urban Auckland, NZ, thought could help to protect their children from taking up smoking.
Of the total 4144 questionnaires distributed, 2839 (64%) were returned and 1805 (70%) of these had the relevant question completed. The majority of participants were either Pacific Island or Maori mothers and 25% were current smokers (Table 1). A similar proportion of never and ever smokers answered the question.
Method
Strategies for preventing smoking initiation
Keeping kids smokefree The parents were participants in the Keeping Kids Smokefree (KKS) 3-year quasi-experimental trial testing a community-, school- and
Five main categories of suggested strategies for preventing smoking initiation were identified. There were more suggestions relating to educating children about smoking and building knowledge than all the other categories combined.
Protecting children from smoking: parents’ views
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Table 1. Participant demographics Answered question (n = 1805) n % (of answered) Relationship with student Mother Father Both parents together Parent (not defined) Caregiver Other (e.g. grandparent, aunt, sibling) Missing Total Ethnicity Maori Pacific Island European/other Asian Missing Total Smoking status Never smoker Ever smoker Missing Total Smoking amount Not current smoker 1–10 cigarettes per day 11–20 cigarettes per day More than 20 cigarettes per day Missing Total
Did not answer question (n = 1034) n % (of not answered)
1201 331 15 31 23 160 44 1805
67 18 1 2 1 9 2
418 116 1 50 4 91 680 1034
40.4 11.2 0.1 4.8 0.4 8.8 66
494 778 168 310 55 1805
27.4 43.1 9.3 17.2 3
58 77 26 59 814 1034
5.6 7.4 2.5 5.7 78.7
862 877 57 1805
48 49 3
81 135 818 1034
8 13 79
390 277 131 30 49 877
47 33 16 4 6
27 82 24 2 0 135
19 59 17 1 0
Build children’s knowledge Building children’s knowledge via education was the most commonly suggested strategy for protecting children against tobacco uptake.
Information and knowledge is our best protection for our children. (Pacific Mother) Many comments suggested topics that could be covered, for example, the risks, and, the harmful and dangerous effects of smoking. Some parents thought children should be made aware of how easy it is to become addicted to smoking and how hard it is to give up.
Let them know how hard it is to quit. (Maori Mother) Parents also thought children should be taught about the financial cost of smoking and how they could better spend their money.
Delivering education Parents had ideas about how education could be delivered and by whom. School was considered to be an appropriate setting for health promotion to take place, for example in the form of seminars for
students and parents, workshops after school, activity programmes and training programmes.
Include my son in a training session on how to live in a smokefree home environment, workplace. Update him on your latest products available or training or events so he can participate. (Pacific Mother) Some parents thought it important to include education about the harms of smoking in the school curriculum. They suggested it could be covered within physical exercise classes, biology, health education and classes teaching about illnesses or the human body.
Have smoking issues incorporated into health education at intermediate level [age 11–12 years] if not already. (Maori Mother) A range of visual resources that could be used to deliver the message were also suggested, for instance, DVDs, videos, CDs, posters, TV and advertisements. Interactive experiences were suggested, such as science experiments using straws to breathe running up the stairs to emulate being a smoker, squeezing tar out of lungs, visiting patients in hospitals who have diseases caused by smoking and visiting family members with smoking related diseases.
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Show them films on people who have died from smoking/ the effects and what it does and how families are destroyed through losing family members from smoking. (Maori Mother) Some parents suggested that guest speakers should come and talk to the children such as ‘celebrity and sport’ ‘role models who don’t smoke’, someone kids look up to. One parent stated that children tend to pay more attention to role models. Also suggested were having nurses, government social workers and councillors as speakers, or have groups coming in to perform. Other suggestions on guest speakers were to have an ex-smoker and a current smoker talk about their experiences, such as how hard it is to stop smoking and the health implications for them. One parent suggested it would be a good idea to:
Invite special guests, celebrities, people suffering from health defects as a result of smoking. (Maori mother) Graphic photos of the damaged caused by smoking. (Maori Father) Denormalising smoking Another category of comments related to denormalising smoking. Several respondents articulated a desire to keep all ‘public places’ smokefree and specifically mentioned schools, churches, clubs, homes, parks, cars and shops.
Make most of the areas smokefree so that the smokers are forced not to smoke. (Pacific Mother) Some respondents stated that it is important to ‘stop advertising smoking’. These comments were associated with not showing people on television that smoke or act as if they’re smoking’ and not displaying cigarettes in dairies (convenience stores), supermarkets and gas stations.
Out of sight, out of mind. Remove smokes from sights in dairies, gas stations, etc. – Keep them under counter. Smoking areas should be out of sight to children. (Maori Mother) Parents made comments on how they could help their children. One common suggestion was ‘not smoking in the house or vehicles’. Other common suggestions included ‘keeping them [their children] away from smokers’ and ‘not smoke in front of them [children]’. There were also comments that parents needed to ‘set a good example’ and ‘be a good role model’. Suggestions included that parents needed to ‘be an [good] example and don’t smoke’ and for ‘parents to quit smoking’. Twenty-five parents suggested changing the social perception of smoking, for example, giving the message that smoking is not cool and creating a social stigma around smoking. Reduce access to tobacco products The second largest category of comments related to reducing access to tobacco products. Some parents suggested legislative changes to
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completely ban smoking. This was expressed in several ways, such as ‘stop manufacturing cigarettes’, ‘make smoking illegal’, and ‘lobby the government to stop sale of cigarette’. Tobacco sales to minors was a concern for a few parents and some suggested raising the ‘age limit for purchasing cigarettes’. There were also suggestions to impose ‘heavy penalties for people selling cigarettes to people underage’ and to impose ‘penalties for underage smoking’.
Random checks of dairies located close to schools of whether or not children are accessing cigarettes illegally. (Pacific Mother) Some respondents wanted an increase in the price of cigarettes to ‘$30’, ‘$150’ or making them ‘absurdly expensive’. There were also suggestions to limit the children’s pocket money and thereby ‘not giving them a chance to afford cigarettes’.
Prices should go up so people can’t afford to buy it. (Asian Mother) Further, some parents thought there needed to be adequate monitoring of locations students might smoke in, for example, in the toilets and by fence lines. They believed that children smoke during break times and they wanted tougher checks at school of children looking for smokes and lighters.
By having a strong monitor in school during break times when kids would try to smoke. (Asian Sister) Respondents thought schools could help by maintaining rules. Strict school policies in school about cigarette smoking were suggested. Rules should be enforced with use of random bag checks, have completely smokefree schools, and impose that students in school uniform should not be allowed to smoke.
Have strict rules about smoking. Have punishment for children caught with smokes in school. (Pacific Mother) Resilience Several parents suggested building children’s resilience to withstand temptation to smoke. Parents suggested that we ‘encourage them to take up more positive healthier past times [than smoking]’ and ‘keep children busy in creative pursuits’ and ‘sport’.
[Provide] more programmes or activities that kids would rather participate in than smoking. (Pacific Mother) Parents also suggested that children need to be taught skills to avoid taking up smoking and that children needed to know how to withstand peer pressure.
Peer pressures are greater at school. Children need to know it’s okay to say no. (Pacific Mother) There were also some suggestions of how spirituality and faith in God could help children abstain from smoking.
O le mea sili o le faamalosi faaleagag e mafai e tamaiti na inoino i mea e faaleagaga ai latou physically and spiritually
Protecting children from smoking: parents’ views
2 Corinthians 7 : 11. (Also important is encouraging the children spiritually, so that they become disgusted at things that damage physically and spiritually. 2 Corinthians 7 : 11) (Pacific mother) Health promotion Several parents commented on existing smokefree health promotion, with some suggesting that more health promotion needed to take place. Some thought that health promotion should continue ‘doing exactly what you are’ with the ‘educational initiatives/media exposure already in place’. However, many parents believed that antismoking programmes have no impact on children.
Honestly, as far as I am concerned no matter if I tried or someone else tried to stop kids from smoking. They’re only going to do it or at least give it a go. (Maori Mother) There were also comments relating to current television smoking advertisements. Most of those parents were positive about the ads, which were considered to be an ‘effective deterrent’ and a way of making children aware of ‘what happens if they take up smoking’. The ads were said to be useful for prompting family discussions about smoking. It was suggested that there should be more ads during ‘programmes mostly watched by children’. A range of other health promotion ideas were suggested: ‘cheap or free nicotine replacement therapy’; ‘competitions’; visual health warnings like on the packets in Australia; health and dental providers to encourage children not to smoke; and ethnicity-specific programmes.
Discussion Through this study we have gained information on how parents think children can be protected from smoking initiation and the main suggestions were building children’s knowledge, denormalising smoking, reducing access to tobacco products and increasing children’s resilience to withstand temptation. The NZ Framework for Reducing Smoking Initiation23 identified the need for an integrated and comprehensive programme of interventions across four realms of activity: (1) developing personal skills to resist tobacco use; (2) reducing the affordability and access by youth to tobacco products; (3) denormalising tobacco use by reducing prevalence of attitudes and behaviours that reinforce the use of tobacco products in NZ; and (4) supporting positive identity development by strengthening associations with key social and environmental factors that contribute to the formation of self-identities. The dominant strategy parents thought would help reduce smoking initiation among children was to educate them, albeit in creative and engaging ways, about the ill-effects of smoking. There is, however, no evidence that simply providing children with information prevents smoking uptake.24 The second largest category was denormalising tobacco use. Suggestions included calls for wider smoking bans in public spaces
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and reduced smoking visible to children, both by the parents themselves and their community. This aligns with the findings of nationally representative surveys showing wide public support in NZ for extending smoking bans, especially in children’s playgrounds and public parks.25 Other strategies proposed by parents concurred with the Framework’s objective to reduce child access to retail tobacco. About 10% of parents’ comments called for more radical measures, such as banning the manufacture and sale of tobacco, lifting the permitted age of purchase and increased monitoring of, and stiffer penalties for, retail sales to minors. Although some parents considered there was a need for further health-promotion interventions, many thought smokefree campaigns were ineffective in deterring children from smoking. Indeed, tobacco-control campaigns using mainstream media have been found to be less effective for Maori and Pacific Islanders.26 However, no parent mentioned the Maori-specific TV campaign nor did any participant suggest Maori-targeted health promotion. Furthermore, only a few parents suggested development of personal skills that would enable children to resist tobacco use (the Framework’s first objective). The parents’ most likely proposed strategies they were familiar with and had knowledge of, that is, past and current strategies deployed in NZ. There were only a few untried or innovative suggestions (such as banning the sale of tobacco, fining children for smoking, or use of competitions). This may reflect a ‘mere exposure effect’.27 A further possible explanation is that parents’ analysis of the problem is founded, albeit implicitly, on the learning and behavioural theories predominant in NZ society. For example, Bandura’s (1986) Social Learning Theory, which explains human functioning in terms of the ‘interactive determinants’ of behaviour, cognition and environment27 and highlights the role of instruction and observation of the actions and attitudes of significant others, is a paradigm that underpins the focus on denormalisation of smoking. Thus, adolescents who perceive smoking as acceptable and practised by others they consider influential are more likely to be accepting of, and to mimic, such behaviour.28 Smoking prevalence among Maori and Pacific Island people is static or declining at a far slower rate than European New Zealanders.29 Different interventions are desperately needed if NZ is to meet its goal of halving Maori and Pacific smoking prevalence by 2018. Further research needs to test the use of different paradigms to identify new strategies. For example, NZ has successfully stopped smoking among prisoners, not by using education, health promotion or by building skills to refuse tobacco, but by completely removing access to tobacco.30 Other policies being considered internationally that could delay initiation include the concept of a smokers’ licence31 or restricting sales to anyone born in a certain year, such as the year 2000, as Singapore has proposed.32 To ensure reductions in smoking initiation for lower socioeconomic and Maori and Pacific Island people, further research should engage Maori, Pacific Island and
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lower socioeconomic parents in a process that elicits innovative thinking about culturally acceptable ways to prevent smoking initiation and piloting innovative strategies. Education, no matter how innovative, may not work if smoking is the norm at home. We don’t have to expect parents to come up with the innovative solution, but in order to implement innovative strategies it helps to have community support. If we need to do something different and the parents are convinced that education is the best strategy, then are they going to support an innovative strategy if one was proposed?
Limitation and strengths A major strength of this study was the large sample size. However, response rate was low overall. A limitation is that the question, ‘what could we do...’ left room for varied interpretation of who ‘we’ was. Parents could have thought they were being asked what schools could do, which could explain the large emphasis on educating children about the risks of smoking. However, many of the suggestions for intervention strategies were ones that would need to be implemented by government or regional public health services, that is, broader than just schools, indicating that the interpretation of ‘we’ as the school was not universal across participants. The findings also have limited generalisability to the whole NZ population in that participants were largely Maori and Pacific mothers of low socioeconomic status. However, smoking is more prevalent among Maori and Pacific Islanders, and those of low socioeconomic status, so the focus on these populations is a strength of the study.
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www.publish.csiro.au/journals/hpja
Tobacco Control
Protecting children from taking up smoking: parents’ views on what would help K. Marck A,F, M. Glover A,G, A. Kira A, J. McCool B, R. Scragg C, V. Nosa D and C. Bullen E A
Centre for Tobacco Control Research, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. B Social and Community Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. C Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. D Pacific Health, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. E NIHI, School of Population Health, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand. F Present address: Cancer Society Auckland Division, PO Box 1724, Auckland 1140, New Zealand. G Corresponding author. Email: [email protected]
Abstract Issue addressed: The present study investigated what factors the parents of children in low-income areas of Auckland, New Zealand, thought could help protect their children from smoking initiation. Methods: Participants in a large quasi-experimental trial that tested a community-, school- and family-based smoking-initiation intervention were asked in a questionnaire ‘What could we do to help you protect your children from smoke and taking up smoking?’ Free-text responses were divided into distinct meaning units and categorised independently by two of the researchers. Results: 1806 participants (70% of parents who returned the questionnaire) completed the question. The majority of respondents (80%) were either Pacific Island or Maori mothers and 25% were current smokers. Five main categories of suggested strategies for preventing smoking initiation were identified: building children’s knowledge of the ill-effects of smoking; denormalising smoking; reducing access to tobacco; building children’s resilience; and health promotion activities. The most common suggestion was to educate children about smoking. Conclusion: Building children’s knowledge of smoking risks was the main strategy parents proposed. There was some support for banning smoking in most public areas and for tougher moves to stop tobacco sales to minors. Few parents suggested innovative or radical strategies, such as banning the sale of tobacco, fining children for smoking or use of competitions. So what? To ensure reductions in smoking initiation for lower socioeconomic and Maori and Pacific Island people, further research should engage Maori, Pacific Island and lower socioeconomic parents in a process that elicits innovative thinking about culturally acceptable strategies.
Key words: child smoking initiation, health education, health promotion, parental attitudes. Received 25 March 2013, accepted 3 October 2013, published online 14 March 2014
Introduction The New Zealand (NZ) government has set an aspirational goal for the nation to be smokefree (5% or less smoking prevalence) by 2025.1 Protecting children from taking up tobacco smoking is one of the three objectives to achieve this goal, and to reduce the burden of smoking-related morbidity and mortality.2,3 Although the role of parents in protecting children from smoking uptake has been well studied, parent’s perceptions of what would help keep their children from starting to smoke is not known. Journal compilation Ó Australian Health Promotion Association 2014
Despite extensive tobacco-control efforts, NZ youth, particularly from low socioeconomic areas or of Maori (the indigenous people of NZ) ethnicity, commence smoking at a young age: almost 10% of 14–15 year olds smoke tobacco regularly.4 The prevalence is substantially higher among Maori and Pacific Island than European students (21%, 12% and 7% respectively) and there is a marked difference in smoking prevalence in students attending schools in low compared with high- socioeconomic communities (for females: 7% in high compared with 21% in low socioeconomic schools; for CSIRO Publishing
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males: 5.9% in high compared with 14% in low socioeconomic schools).4 Further, although smoking prevalence among all ethnic groups has reduced since 1999, the reduction has been substantially slower for Maori and Pacific Island than for European students (43% to 21%, 28.5% to 12% and 27% to 7% respectively). Parental smoking is one of the many factors associated with higher rates of adolescent smoking.5–7 Conversely, regardless of their smoking status, having parents with negative attitudes towards smoking is associated with lower smoking rates in adolescents.8,9 Further, practices such as banning smoking indoors and educating children about the dangers of smoking reduce the likelihood of adolescent smoking.10,11 Evidence suggests parents underestimate their capacity to influence children’s smoking behaviour. However, even simple measures such as not smoking inside the home can be protective as can more proximal factors such as increasing their beliefs about the health risks of smoking and expressing their desire for their children to be non-smokers.12 Similarly, our previous research13 suggests that parents who are aware of and talk about the tobacco industry can be protective against the influence of tobacco marketing in mainstream media. McCool et al.14 found that children who were exposed to clear antismoking expectations in their home were less likely to appraise tobacco imagery in film as positive. Positive appraisal of smoking imagery in films is associated with smoking uptake.14 Yet, the strategies parents tend to engage in, with the intention of preventing smoking uptake among their children, include teaching children refusal skills, promoting participation in sport, encouraging the wider whanau (family) to refrain from smoking, and more punitive (school- and community-based) measures such as school- and community-level negative consequences if found smoking.15 Parents also need support from the wider community to protect their children from smoking uptake.12,16 Parents, particularly mothers, value school smoking-prevention initiatives.17 Public support for a range of tobacco-control measures aimed at reducing harm to health from exposure to second-hand smoke and reducing uptake of smoking by children, such as smoking bans at playgrounds and keeping tobacco products out of sight,18 not selling tobacco in shops accessed by children18,19 and increasing tax on cigarettes and introducing tighter regulations on tobacco companies,19 are also key.
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family-based smoking-initiation-prevention intervention targeting 11–12 year olds in South Auckland, an urban area where the population has high smoking prevalence and is predominately of low socioeconomic status with a high proportion of Maori and Pacific peoples. The study is described in detail elsewhere.20 In brief, at baseline, during 2007–2009, each student was given a pack containing a cover letter, participant information sheet, consent form and parent questionnaire and envelope for returning their consent form and questionnaire to the child’s school or by free mail directly to our research centre. Parents were incentivised to return the questionnaire with entry into a prize draw for a family trip to a restaurant, the movies or a fun park.
Data collection The baseline questionnaire consisted of 19 questions. In order to allow parents to write in their own words what they thought could help them to protect their children from smoking, a free-text question was included (‘What could we do to help you protect your children from smoke and taking up smoking?’). Simple demographic and smoking-related data were collected. Smoking status was assessed by asking two questions; ‘have you ever smoked a cigarette’ and if the answer was yes, a follow-up question ‘how much do you smoke now?’ Details of the remaining questions in the questionnaire can be found in Glover et al.20
Data analysis All data were entered into a Microsoft Excel spreadsheet. Free-text responses were divided into distinct meaning units and categorised independently by two of the researchers (KM, MG) inductively. Discrepancies were discussed until consensus was reached.21 Ethnicity was prioritised according to NZ ethnicity-coding protocols,22 whereby participants listing more than one ethnicity had priority assigned to Maori, Pacific, Asian and European/Other ethnicity in that order.
Ethical approval Ethics approval for the study was obtained from the University of Auckland Human Participants Ethics Committee (Ref. 2006/416).
Results Participant characteristics
Understanding parents’ opinions of how children can be protected can assist tobacco-control-programme design and the development of key messages for parents. The aim of this study was therefore to investigate what factors the parents of children attending schools in low-income areas of urban Auckland, NZ, thought could help to protect their children from taking up smoking.
Of the total 4144 questionnaires distributed, 2839 (64%) were returned and 1805 (70%) of these had the relevant question completed. The majority of participants were either Pacific Island or Maori mothers and 25% were current smokers (Table 1). A similar proportion of never and ever smokers answered the question.
Method
Strategies for preventing smoking initiation
Keeping kids smokefree The parents were participants in the Keeping Kids Smokefree (KKS) 3-year quasi-experimental trial testing a community-, school- and
Five main categories of suggested strategies for preventing smoking initiation were identified. There were more suggestions relating to educating children about smoking and building knowledge than all the other categories combined.
Protecting children from smoking: parents’ views
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Table 1. Participant demographics Answered question (n = 1805) n % (of answered) Relationship with student Mother Father Both parents together Parent (not defined) Caregiver Other (e.g. grandparent, aunt, sibling) Missing Total Ethnicity Maori Pacific Island European/other Asian Missing Total Smoking status Never smoker Ever smoker Missing Total Smoking amount Not current smoker 1–10 cigarettes per day 11–20 cigarettes per day More than 20 cigarettes per day Missing Total
Did not answer question (n = 1034) n % (of not answered)
1201 331 15 31 23 160 44 1805
67 18 1 2 1 9 2
418 116 1 50 4 91 680 1034
40.4 11.2 0.1 4.8 0.4 8.8 66
494 778 168 310 55 1805
27.4 43.1 9.3 17.2 3
58 77 26 59 814 1034
5.6 7.4 2.5 5.7 78.7
862 877 57 1805
48 49 3
81 135 818 1034
8 13 79
390 277 131 30 49 877
47 33 16 4 6
27 82 24 2 0 135
19 59 17 1 0
Build children’s knowledge Building children’s knowledge via education was the most commonly suggested strategy for protecting children against tobacco uptake.
Information and knowledge is our best protection for our children. (Pacific Mother) Many comments suggested topics that could be covered, for example, the risks, and, the harmful and dangerous effects of smoking. Some parents thought children should be made aware of how easy it is to become addicted to smoking and how hard it is to give up.
Let them know how hard it is to quit. (Maori Mother) Parents also thought children should be taught about the financial cost of smoking and how they could better spend their money.
Delivering education Parents had ideas about how education could be delivered and by whom. School was considered to be an appropriate setting for health promotion to take place, for example in the form of seminars for
students and parents, workshops after school, activity programmes and training programmes.
Include my son in a training session on how to live in a smokefree home environment, workplace. Update him on your latest products available or training or events so he can participate. (Pacific Mother) Some parents thought it important to include education about the harms of smoking in the school curriculum. They suggested it could be covered within physical exercise classes, biology, health education and classes teaching about illnesses or the human body.
Have smoking issues incorporated into health education at intermediate level [age 11–12 years] if not already. (Maori Mother) A range of visual resources that could be used to deliver the message were also suggested, for instance, DVDs, videos, CDs, posters, TV and advertisements. Interactive experiences were suggested, such as science experiments using straws to breathe running up the stairs to emulate being a smoker, squeezing tar out of lungs, visiting patients in hospitals who have diseases caused by smoking and visiting family members with smoking related diseases.
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Show them films on people who have died from smoking/ the effects and what it does and how families are destroyed through losing family members from smoking. (Maori Mother) Some parents suggested that guest speakers should come and talk to the children such as ‘celebrity and sport’ ‘role models who don’t smoke’, someone kids look up to. One parent stated that children tend to pay more attention to role models. Also suggested were having nurses, government social workers and councillors as speakers, or have groups coming in to perform. Other suggestions on guest speakers were to have an ex-smoker and a current smoker talk about their experiences, such as how hard it is to stop smoking and the health implications for them. One parent suggested it would be a good idea to:
Invite special guests, celebrities, people suffering from health defects as a result of smoking. (Maori mother) Graphic photos of the damaged caused by smoking. (Maori Father) Denormalising smoking Another category of comments related to denormalising smoking. Several respondents articulated a desire to keep all ‘public places’ smokefree and specifically mentioned schools, churches, clubs, homes, parks, cars and shops.
Make most of the areas smokefree so that the smokers are forced not to smoke. (Pacific Mother) Some respondents stated that it is important to ‘stop advertising smoking’. These comments were associated with not showing people on television that smoke or act as if they’re smoking’ and not displaying cigarettes in dairies (convenience stores), supermarkets and gas stations.
Out of sight, out of mind. Remove smokes from sights in dairies, gas stations, etc. – Keep them under counter. Smoking areas should be out of sight to children. (Maori Mother) Parents made comments on how they could help their children. One common suggestion was ‘not smoking in the house or vehicles’. Other common suggestions included ‘keeping them [their children] away from smokers’ and ‘not smoke in front of them [children]’. There were also comments that parents needed to ‘set a good example’ and ‘be a good role model’. Suggestions included that parents needed to ‘be an [good] example and don’t smoke’ and for ‘parents to quit smoking’. Twenty-five parents suggested changing the social perception of smoking, for example, giving the message that smoking is not cool and creating a social stigma around smoking. Reduce access to tobacco products The second largest category of comments related to reducing access to tobacco products. Some parents suggested legislative changes to
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completely ban smoking. This was expressed in several ways, such as ‘stop manufacturing cigarettes’, ‘make smoking illegal’, and ‘lobby the government to stop sale of cigarette’. Tobacco sales to minors was a concern for a few parents and some suggested raising the ‘age limit for purchasing cigarettes’. There were also suggestions to impose ‘heavy penalties for people selling cigarettes to people underage’ and to impose ‘penalties for underage smoking’.
Random checks of dairies located close to schools of whether or not children are accessing cigarettes illegally. (Pacific Mother) Some respondents wanted an increase in the price of cigarettes to ‘$30’, ‘$150’ or making them ‘absurdly expensive’. There were also suggestions to limit the children’s pocket money and thereby ‘not giving them a chance to afford cigarettes’.
Prices should go up so people can’t afford to buy it. (Asian Mother) Further, some parents thought there needed to be adequate monitoring of locations students might smoke in, for example, in the toilets and by fence lines. They believed that children smoke during break times and they wanted tougher checks at school of children looking for smokes and lighters.
By having a strong monitor in school during break times when kids would try to smoke. (Asian Sister) Respondents thought schools could help by maintaining rules. Strict school policies in school about cigarette smoking were suggested. Rules should be enforced with use of random bag checks, have completely smokefree schools, and impose that students in school uniform should not be allowed to smoke.
Have strict rules about smoking. Have punishment for children caught with smokes in school. (Pacific Mother) Resilience Several parents suggested building children’s resilience to withstand temptation to smoke. Parents suggested that we ‘encourage them to take up more positive healthier past times [than smoking]’ and ‘keep children busy in creative pursuits’ and ‘sport’.
[Provide] more programmes or activities that kids would rather participate in than smoking. (Pacific Mother) Parents also suggested that children need to be taught skills to avoid taking up smoking and that children needed to know how to withstand peer pressure.
Peer pressures are greater at school. Children need to know it’s okay to say no. (Pacific Mother) There were also some suggestions of how spirituality and faith in God could help children abstain from smoking.
O le mea sili o le faamalosi faaleagag e mafai e tamaiti na inoino i mea e faaleagaga ai latou physically and spiritually
Protecting children from smoking: parents’ views
2 Corinthians 7 : 11. (Also important is encouraging the children spiritually, so that they become disgusted at things that damage physically and spiritually. 2 Corinthians 7 : 11) (Pacific mother) Health promotion Several parents commented on existing smokefree health promotion, with some suggesting that more health promotion needed to take place. Some thought that health promotion should continue ‘doing exactly what you are’ with the ‘educational initiatives/media exposure already in place’. However, many parents believed that antismoking programmes have no impact on children.
Honestly, as far as I am concerned no matter if I tried or someone else tried to stop kids from smoking. They’re only going to do it or at least give it a go. (Maori Mother) There were also comments relating to current television smoking advertisements. Most of those parents were positive about the ads, which were considered to be an ‘effective deterrent’ and a way of making children aware of ‘what happens if they take up smoking’. The ads were said to be useful for prompting family discussions about smoking. It was suggested that there should be more ads during ‘programmes mostly watched by children’. A range of other health promotion ideas were suggested: ‘cheap or free nicotine replacement therapy’; ‘competitions’; visual health warnings like on the packets in Australia; health and dental providers to encourage children not to smoke; and ethnicity-specific programmes.
Discussion Through this study we have gained information on how parents think children can be protected from smoking initiation and the main suggestions were building children’s knowledge, denormalising smoking, reducing access to tobacco products and increasing children’s resilience to withstand temptation. The NZ Framework for Reducing Smoking Initiation23 identified the need for an integrated and comprehensive programme of interventions across four realms of activity: (1) developing personal skills to resist tobacco use; (2) reducing the affordability and access by youth to tobacco products; (3) denormalising tobacco use by reducing prevalence of attitudes and behaviours that reinforce the use of tobacco products in NZ; and (4) supporting positive identity development by strengthening associations with key social and environmental factors that contribute to the formation of self-identities. The dominant strategy parents thought would help reduce smoking initiation among children was to educate them, albeit in creative and engaging ways, about the ill-effects of smoking. There is, however, no evidence that simply providing children with information prevents smoking uptake.24 The second largest category was denormalising tobacco use. Suggestions included calls for wider smoking bans in public spaces
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and reduced smoking visible to children, both by the parents themselves and their community. This aligns with the findings of nationally representative surveys showing wide public support in NZ for extending smoking bans, especially in children’s playgrounds and public parks.25 Other strategies proposed by parents concurred with the Framework’s objective to reduce child access to retail tobacco. About 10% of parents’ comments called for more radical measures, such as banning the manufacture and sale of tobacco, lifting the permitted age of purchase and increased monitoring of, and stiffer penalties for, retail sales to minors. Although some parents considered there was a need for further health-promotion interventions, many thought smokefree campaigns were ineffective in deterring children from smoking. Indeed, tobacco-control campaigns using mainstream media have been found to be less effective for Maori and Pacific Islanders.26 However, no parent mentioned the Maori-specific TV campaign nor did any participant suggest Maori-targeted health promotion. Furthermore, only a few parents suggested development of personal skills that would enable children to resist tobacco use (the Framework’s first objective). The parents’ most likely proposed strategies they were familiar with and had knowledge of, that is, past and current strategies deployed in NZ. There were only a few untried or innovative suggestions (such as banning the sale of tobacco, fining children for smoking, or use of competitions). This may reflect a ‘mere exposure effect’.27 A further possible explanation is that parents’ analysis of the problem is founded, albeit implicitly, on the learning and behavioural theories predominant in NZ society. For example, Bandura’s (1986) Social Learning Theory, which explains human functioning in terms of the ‘interactive determinants’ of behaviour, cognition and environment27 and highlights the role of instruction and observation of the actions and attitudes of significant others, is a paradigm that underpins the focus on denormalisation of smoking. Thus, adolescents who perceive smoking as acceptable and practised by others they consider influential are more likely to be accepting of, and to mimic, such behaviour.28 Smoking prevalence among Maori and Pacific Island people is static or declining at a far slower rate than European New Zealanders.29 Different interventions are desperately needed if NZ is to meet its goal of halving Maori and Pacific smoking prevalence by 2018. Further research needs to test the use of different paradigms to identify new strategies. For example, NZ has successfully stopped smoking among prisoners, not by using education, health promotion or by building skills to refuse tobacco, but by completely removing access to tobacco.30 Other policies being considered internationally that could delay initiation include the concept of a smokers’ licence31 or restricting sales to anyone born in a certain year, such as the year 2000, as Singapore has proposed.32 To ensure reductions in smoking initiation for lower socioeconomic and Maori and Pacific Island people, further research should engage Maori, Pacific Island and
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lower socioeconomic parents in a process that elicits innovative thinking about culturally acceptable ways to prevent smoking initiation and piloting innovative strategies. Education, no matter how innovative, may not work if smoking is the norm at home. We don’t have to expect parents to come up with the innovative solution, but in order to implement innovative strategies it helps to have community support. If we need to do something different and the parents are convinced that education is the best strategy, then are they going to support an innovative strategy if one was proposed?
Limitation and strengths A major strength of this study was the large sample size. However, response rate was low overall. A limitation is that the question, ‘what could we do...’ left room for varied interpretation of who ‘we’ was. Parents could have thought they were being asked what schools could do, which could explain the large emphasis on educating children about the risks of smoking. However, many of the suggestions for intervention strategies were ones that would need to be implemented by government or regional public health services, that is, broader than just schools, indicating that the interpretation of ‘we’ as the school was not universal across participants. The findings also have limited generalisability to the whole NZ population in that participants were largely Maori and Pacific mothers of low socioeconomic status. However, smoking is more prevalent among Maori and Pacific Islanders, and those of low socioeconomic status, so the focus on these populations is a strength of the study.
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