The European Journal of Public Health Advance Access originally published online on April 26, 2006
The European Journal of Public Health 2006 16(6):617-626; doi:10.1093/eurpub/ckl054
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Health inequalities |
Influence of parental education, childhood adversities, and current living conditions on daily smoking in early adulthood
Laura Kestilä1, Seppo Koskinen1, Tuija Martelin1, Ossi Rahkonen2, Tiina Pensola3, Sami Pirkola4,5, Kristiina Patja6 and Arpo Aromaa1
1 Department of Health and Functional Capacity, National Public Health Institute (KTL), Helsinki, Finland
2 Department of Public Health, University of Helsinki, Helsinki, Finland
3 Rehabilitation Foundation, Helsinki, Finland
4 Department of Mental Health and Alcohol Research, National Public Health Institute (KTL), Helsinki, Finland
5 STAKES, Helsinki, Finland
6 Department of Epidemiology and Health Promotion, National Public Health Institute (KTL), Helsinki, Finland
Correspondence: Laura Kestilä, M.Soc.Sci, Department of Health and Functional Capacity, National Public Health Institute (KTL), Mannerheimintie 166, FI-00300 Helsinki, Finland, tel +358 9 4744 8795, fax +358 9 4744 8924, e-mail: laura.kestila{at}ktl.fi
Received November 24, 2005, accepted March 1, 2006
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Abstract |
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Aims: To assess the association of parental education, childhood living conditions and adversities with daily smoking in early adulthood and to analyse the effect of the respondent's own education, main economic activity, and current family structure on these associations. Methods: The study is based on a representative two-stage cluster sample (N = 1894, participation rate 79%) of young adults aged 18–29, in 2000, in Finland. The outcome measure is daily smoking. Results: Parental smoking and the respondent's own education had the strongest effects on daily smoking. If both parents of the respondent were smokers, then the respondent was most likely to be a smoker too (for men OR (odds ratio) = 3.01, for women OR = 2.41 after all adjustments). Young adults in the lowest educational category had a much higher risk of daily smoking than those in the highest category (OR = 5.88 for women, 4.48 for men). For women parental divorce (OR = 2.31) and current family structure also determined daily smoking. Parental education had a strong gradient in daily smoking and the effect appeared to be mediated largely by the respondent's own educational level. Conclusions: Childhood living conditions are strong determinants of daily smoking. Much of their influence seems to be mediated through current living conditions, which are also determined by childhood conditions. Determinants of smoking behaviour are developed throughout the life course. The findings stress the importance of the respondent's education and parental smoking as determinants of smoking behaviour. Our results support the notion that intervention on smoking initiation and cessation should be considered throughout the life course. Parental involvement in fostering non-smoking would be important.
Keywords: childhood adversities, daily smoking, education, life course, parental smoking
Smoking is the most common preventable cause of premature morbidity and mortality.1 The majority of smokers start smoking as teenagers2 and deepen the dependency during early adulthood maintaining their smoking behaviour before they possibly succeed in quitting in middle age.3 In Finland, 80% of adolescents experiment with cigarettes and one-third maintain smoking through their teens.4 Development of tobacco dependency from situational social bonding to physiological and psychological dependency syndrome is a long process,5 and smoking behaviour has been reported to be influenced by both genetic and environmental factors.6,7 Smoking initiation, maintenance, and cessation have been shown to have strong social gradients with both childhood and adulthood socio-economic circumstances.8–10
Numerous risk factors for daily smoking have emerged from epidemiological research: studies often report age, sex, socio-economic8–13 and marital-status-related14 socio-demographic characteristics, and adverse life events. Low socio-economic status in adulthood, but also childhood primary environment; parental low socio-economic status,15–18 parental divorce, and childhood adversities,19 have been found to be associated with smoking in adolescence and adulthood. Smoking in the social environment, parental smoking,20–23 especially a smoking mother,24,25 peer smoking,2,7 and smoking siblings26 have been found to predict smoking, although results on the determinants are partly inconsistent.27 However, the role of stressful childhood experiences and their relation with later determinants of smoking is complex and needs more comprehensive research.27
Familial and early life influences, in particular, have been reported as determinants of smoking initiation and adolescent smoking behaviour. Young adults are at the age of adopting and maintaining persistent patterns of behaviours. Familial and early life influences on the risk of persistent smoking may differ from those found to influence smoking initiation.28 The effect of early social environment on adult health and health behaviour is either independent or mediated through social conditions during upbringing, educational achievement, entry into work, and adult living conditions and lifestyle, for example.29–33 Furthermore, the effect may be modified by subsequent life course factors. Unhealthy behaviour, such as regular smoking, is seen from the life course perspective34,35 as an important pathway by which poor adult health and health inequalities emerge.36–38 Very few studies have been able to combine detailed individual level data on various childhood living conditions and adversities with information on current living conditions. In order to reduce smoking and its harmful effects it is essential to understand the determinants of prolonged smoking in early adulthood.
This study assesses the contribution of various childhood indicators and current living conditions on daily smoking in early adulthood. The specific aims are (i) to assess the influence of parental education, and childhood living conditions and adversities on daily smoking in early adulthood and (ii) to assess how the respondent's own education, main economic activity, and current family structure mediate these associations.
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Participants
This study is based on a nationally representative sample of 1894 young adults in Finland aged 18–29 years. The data were collected in 2000–01 as part of the Health 2000 Survey, using two-stage cluster sampling.39 The 15 largest and 65 other health centre districts selected using systematic PPS sampling (sampling with probabilities proportional to size) where the primary sampling units, and in the second stage persons, were randomly selected from these districts. The information was obtained through standardized structured computer-aided interviews (CAPI) and self-administered questionnaires. The participation rate was high: 79% participated in the phases of the survey on which this study is based. Questions concerning childhood adversities were asked in the questionnaire, which was answered by 85% of the participants. Thus, the analyses comprising childhood adversities were carried out on 68% of the sample.
Measures
Outcome measure
Self-reported smoking status was derived from four questions: ‘Have you ever smoked?’, ‘Have you ever smoked regularly (i.e. daily for at least 1 year)?’, ‘When did you last smoke?’ and ‘Have you smoked at least 100 times?’. On the basis of this information five categories, used also in previous studies,40 were constructed (table 1). Daily smokers were defined as respondents smoking regularly for at least one year, most recently today or yesterday, and at least 100 times. Daily smokers are compared with all other groups in the logistic models. The estimated age at which daily smoking began was calculated by subtracting the reported number of years of daily smoking from the respondent's age. Cigarette consumption was based on the question ‘How much on average do you smoke daily or smoked before you gave up smoking daily?’.
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Childhood living conditions
Parental education was based on the participant's response concerning his/her mother's and father's basic and vocational education (table 2). The parent with the higher educational level was chosen to indicate parental education. Family structure was based on the question ‘when starting school (i.e. when you were
7 years old), did you live...?’ with four possible response alternatives ‘at home with both your parents’, ‘with only one parent’, ‘with relatives such as grandparents’, and ‘in an orphanage or other institution’. Participants reporting the last two alternatives were combined. Having siblings was based on an open-ended question ‘how many siblings do you have/have you had (including stepsisters and stepbrothers, both dead and living)?’ The categories ‘one or more’ and ‘none’ were constructed.
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Childhood adversities were based on the question ‘when you think about your growth years, i.e. before you were aged 16, did you...?’. Eleven adversities were described (table 2). In general, the pair-wise correlations between different childhood adversities were <0.4. Parental smoking was based on the question ‘did your parent(s) smoke when you were between 13 and 15 years old?’ with four response alternatives ‘no, neither of the parents smoked’, ‘yes, both parents smoked’, ‘only mother smoked’, and ‘only father smoked’. Parents were considered here as those the respondent lived with (also stepfather or stepmother). In case the parental smoking status varied over time, respondents were asked to answer the question according to the predominant situation.
Current living conditions
The respondent's own education was based on the highest completed level. Because many respondents were still studying (21%), the measure for students was based on the expected level of education assuming the person would complete ongoing studies, and if it was higher than already completed previous education. Four categories were constructed (table 2): ‘only primary school’, ‘lower or upper secondary or lowest tertiary’, ‘lower degree level tertiary’ and ‘higher degree level tertiary or higher’. The respondent's main economic activity was categorized as ‘full time or part-time employed’, ‘student’, ‘unemployed or laid off’, and ‘other’.
The current family structure was constructed by using variables describing marital status, household structure, and number of children. The measure was categorized as ‘married and a child/children’, ‘married, no children’, ‘cohabiting and a child/children’, ‘cohabiting, no children’, ‘living with own parents’, ‘living with other(s) than a partner or parents’, and ‘living alone’. If the person belonged to more than one category, the highest one in the list was chosen. The category ‘living with other(s)’ was very small among men, and among women it included mostly single mothers (72%). In addition, women were categorized as being currently pregnant or not according to their own reports.
Statistical analysis
First, we present the distribution of smoking status, and among current daily smokers, cigarette consumption and the estimated age of starting daily smoking, together with the prevalence of different childhood living conditions and current living conditions by gender, and the prevalence of daily smoking according to the number of childhood adversities. The significance of the difference between genders is presented for all variables (Chi-square). To be able to assess the impact of the cumulation of childhood adversities on current daily smoking, the sum of the 11 childhood adversities was calculated, the sum was divided in five categories (table 3) and their association with the outcome measure was tested.
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Second, the associations between daily smoking and childhood as well as current determinants were analysed using logistic regression. Owing to significant interactions between gender and the explanatory factors, the results are presented separately for women and men. Items that were not significantly associated with daily smoking in either gender were removed from further analyses, except parents' mental health and alcohol problems, which were kept in the analyses owing to close significant associations. Interactions between age and all explanatory factors were examined. Childhood determinants were incorporated in the model sequentially in order to assess pathways between them.
Finally, we adjusted for the effect of the respondent's own education, current family structure, and primary economic activity. Results are presented in terms of odds ratios (ORs), together with 95% confidence intervals (95% CIs). The data were weighted to take into account the sampling design and non-response.39 All analyses were performed using STATA software.
Logistic models 0 and 1 were carried out first, using all data available (n = 1505), and second, using the population that also answered the questions on childhood adversities (n = 1282) in the questionnaire . The results were similar; however, we present the models based on the smaller population to ensure a valid comparison of the successive models.
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Daily smoking in early adulthood
Daily smoking was significantly more common among men than among women (P < 0.001); 36% of men and 24% of women smoked daily, but there was no clear gender difference in occasional smoking (table 1). The proportion of non-smokers (P < 0.001) among women was higher than that among men. Men smoked substantially more than women: among daily smokers almost one-third of men, but only one-tenth of women smoked more than 20 cigarettes per day, whereas lighter smoking (1–9 cigarettes per day) was more common among women. The majority of women and men (
80%) had started daily smoking before the age of 19. However, in our data there were 80 persons who had not yet reached this age and had never smoked.
Variation in daily smoking by childhood living conditions and current living conditions
The more childhood adversities the respondents reported, the more likely they were to smoke daily (table 3). Among women the relationship between daily smoking and the number of reported childhood adversities was very strong (P = 0.000). 39.5% of the respondents did not report any of the asked adversities.
After adjusting for age, parental education had a strong negative association with daily smoking in both genders: the lower the parental education, the higher the prevalence of daily smoking (tables 4 and 5, Model 0). Associations remained when childhood family structure was incorporated (Model I) but attenuated somewhat when childhood adversities were included in the model (Model II). Further, including parental smoking in the model reduced the associations slightly among women (Model III). After adjusting for the respondent's own education (Model IV) associations disappeared among both men and women.
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Daily smoking was more common among respondents who had lived with only one parent in childhood than among those who had lived with two parents (Model 0), particularly among women in the younger age group (interaction AGE*ChFS, P = 0.013). The association remained after adjusting for parental education (Model I) but lost its significance after all childhood adversities were included in the model (Model II). When each adversity was added separately to Model I, parents' divorce among both genders and long-term financial problems within the family among women reduced the associations the most (no data shown). Having siblings was not associated with daily smoking.
After controlling for age, parental divorce showed significant associations with daily smoking in both genders (Model 0). In addition, regular parental unemployment among men, and among women, long-term financial problems within the family, mother's alcohol and mental health problems, and serious conflicts within the family were associated with daily smoking. All associations for women except parental divorce (OR = 2.66) lost their statistical significance after controlling for all childhood conditions (Model II). The association between parents' divorce and daily smoking among women remained statistically significant, when all indicators relating to current living conditions were controlled for (Model VII). Serious illness or disability of a parent, the respondent's own serious or long-term illness, and bullying at school were not statistically significant determinants of daily smoking and they were removed from further analyses. However, alcohol and mental health problems of both parents were kept in the further analyses because of the close significant associations.
Daily smoking varied strongly according to parental smoking in both genders (tables 4 and 5, Model 0). The respondents whose both parents smoked were most likely to be daily smokers themselves (for women OR = 3.74, for men OR = 3.27). This group differed markedly from the other groups even when all other factors were controlled for(Models VI–VII). Furthermore, men whose fathers or mothers smoked, and women whose mothers smoked were also more likely to be daily smokers than those whose parents did not smoke (Model 0). Including all other variables in the model at the same time attenuated the associations particularly among women (Models VI–VII).
Large differences in daily smoking were found according to the respondent's own education: the lower the education, the higher the prevalence of daily smoking (Model 0). This strong association attenuated but remained significant when all childhood conditions (Model IV) and furthermore, primary economic activity and current family structure were adjusted for (Model VI). Among men, respondents with lower-degree level tertiary and lowest tertiary education (OR = 6.94 and 9.45, respectively), differed significantly from the reference group only in the older age group.
Among unemployed and laid-off women (OR = 2.33), daily smoking was more common than for other primary economic activity groups in the age-adjusted model (Model 0), but this difference was significant only in the older age group (interaction AGE*MA, P = 0.046). The proportion of daily smokers was lower among students than in other groups (for women OR = 0.51 and for men OR = 0.68), but these associations disappeared when childhood conditions and the respondent's own education were controlled for (Model V).
Current family structure was an important determinant of daily smoking, in particular among women. In the age-adjusted model (Model 0) for women cohabiters with children (OR = 4.20), women living alone (OR = 2.79) or living with other(s) (OR = 7.75) smoked more often than married women with children. These associations remained significant also in the fully adjusted model (Model VII). In addition, daily smoking was significantly less common among married men if they did not have children than if they had children, also after all adjustments (Model VI).
In separate analyses, we found that a higher proportion of persons having children smoked daily than did those without children (no data shown). However, this association held true only for those aged 18–24. Cohabitants differed from married people in this respect as well; only cohabitants with children differed significantly from those without children, whereas among married respondents there was no clear difference.
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Discussion |
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We examined both childhood living conditions and current circumstances as determinants of daily smoking. Our results showed that parental smoking and the individual's own education were the strongest determinants of current daily smoking in early adulthood. In women, also parental divorce, current family structure and current primary activity were associated with current daily smoking. Parental education had a strong gradient in daily smoking and affected it through different paths. First, lower parental education increased the risk of childhood adversities and parental smoking. The effect of parental education was also mediated through the respondent's own education, which was strongly associated with daily smoking.
The prevalence of current daily smoking in early adulthood is determined by the incidence of smoking initiation, maintenance, and quit rate during adolescence. Initiation, maintenance, and cessation of smoking are modulated by environmental factors such as childhood experiences. Moreover, smoking behaviour has been shown to be connected with personality traits, distribution, and structure of nicotine receptors and other genetically determined factors.6,7 Several twin and adoption studies have reported that genetic factors explain 50% of the variance in the population for both smoking initiation and smoking persistence.6,28,41 Parental smoking appears to predispose children to become daily smokers.21 This can be due to at least three mechanisms; first, biological vulnerability to tobacco (genetic factors and exposure to nicotine in utero and during childhood) may influence both initiation and maintenance of tobacco use. Second, ‘social heredity’ and modelling (in which offspring imitate their parents' behaviour) may influence initiation through adolescent's own perceptions of smoking. Third, tolerant attitudes towards smoking in the respondent's upbringing may influence the empowerment of young person with capabilities to resist smoking and continuing the habit.
Previous results concerning a dose–response association with respect to parental smoking are contradictory.21,27 According to our results, the risk of being a daily smoker in early adulthood was the greatest among respondents whose both parents smoked. This finding is compatible with both biological and social inheritance of smoking. Parental attitudes toward smoking and their reactions to initiation may play an important role in maintaining smoking through the teenage years.
Living with one parent was an important determinant of daily smoking. It was partially explained by parent's divorce,19 and the fact that those from single parent families had lower parental education and more childhood adversities. Living with one parent has previously been found to be associated with poorer health and higher mortality.30,32
In general, women seemed to be more susceptible to the childhood living conditions determining current daily smoking. Corresponding results have been reported before.17 In particular, the mother's role was significant for women: mother's alcohol and mental health problems determined women's daily smoking in the age-adjusted model. The previously reported effect of maternal smoking on girls' smoking,24,25 was also found in this study. Health behaviour traits in offspring may depend more on mother's than on father's health behaviour.
Current family structure was an important determinant of daily smoking among women. Daily smoking was least prevalent in married women. This has also been observed in earlier studies, which connect the finding with the effect of having children.12,14 According to our results, however, having children was not consistently associated with daily smoking. In the age group 18–24 daily smoking was more common among those who had children compared with those not having children, controlling for own education. In Finland, young women with early childbirths are more likely to be smokers as their educational level is lower and the probability of being a single mother higher.42 In the age group 25–29, having children did not increase the risk of smoking but neither did children protect from smoking. Thus, it seems that early family formation is linked with other factors, for example lower education and predisposing to daily smoking, in addition to those controlled for in our analyses.
Daily smoking is a complex behaviour and dependency syndrome affected by various factors, many of which we were not able to analyse, including the peer groups, youth cultures and the school contexts. These factors strongly influence the initiation and maintenance of smoking.2,7 In addition, we have to consider the possible effect of smoking related selection: smoking itself may affect the respondents' educational tracks43,44 and other living conditions, which in turn influences daily smoking in early adulthood.
Methodological considerations
This study was based on a nationally representative sample with a high participation rate (79%). Particular strengths of this study include the breadth of indicators of living conditions in childhood and in adulthood. However, the size of our data only allowed us to report on strong associations. In addition, reporting childhood conditions and adversities sets out some methodological issues.32,33 For instance, we could only approximate the age at which the respondents had been exposed to adversities during childhood. The environmental effects on smoking may depend on the age at which they were experienced. Furthermore, it is possible that current living conditions to some extent affect the retrospective perceptions of childhood conditions and problems (‘negative affectivity’), although good test–retest reliability has been reported.45 A clearly larger proportion of women than men reported childhood adversities. The difference was particularly marked in the case of items open to interpretation (e.g. conflicts within the family). We suggest that women are more prone to report them and may also be more sensitive to these problems in childhood.
Self-reported daily smoking can be regarded as a valid measure.46,47 In this study we analysed the determinants of daily smoking at the age of 18–29, not paying attention on occasional or former smoking. Thus, the results refer to more or less persistent smoking, which has trajectories to future smoking and health as well. It is possible that similar factors affect both initiation of smoking and maintenance; however, we were not able to examine this here with reliable measures.
Our measure of own education could not take into account that some subjects may have only temporarily finished their education. However, regarding smoking habits, those who later continue their education may resemble those who already have a higher level of education. It is, therefore, possible that the effect of own education would have been even stronger than we reported if we had been able to anticipate the final level of education of all participants.
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Conclusions |
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The individual's own education and parental smoking are particularly strong determinants of daily smoking in early adulthood, with an obvious dose–response effect. Childhood living conditions and parental education seem to have a strong influence on daily smoking, largely mediated through current living conditions. This finding emphasizes that smoking behaviour is shaped throughout the life course. Childhood environment is an important determinant of smoking in early adulthood and in order to prevent later health difficulties living conditions of the families should be improved. Parental involvement in non-smoking would be important. The results suggest that interventions against smoking should take place throughout the life course.
Key points
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Acknowledgments |
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We are indebted to the Yrjö Jahnsson Foundation (#4880) and to the doctoral programme ‘Population, Health and Living Conditions’ for funding the study. O.R. is supported by the Academy of Finland (#45664 and #210435).
Conflict of interest: None declared.
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 M. Leinsalu, M. Tekkel, and A. E. Kunst Social determinants of ever initiating smoking differ from those of quitting: a cross-sectional study in Estonia Eur J Public Health, December 1, 2007; 17(6): 572 - 578. [Abstract] [Full Text] [PDF]
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