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The influence of family structures on adolescent smoking among multicultural adolescents in Hawaii

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The influence of family structures on adolescent smoking among multicultural adolescents in Hawaii

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Content THE INFLUENCE OF FAMILY STRUCTURES ON ADOLESCENT SMOKING
AMONG MULTICULTURAL ADOLESCENTS IN HAWAII
by
Yajun Du
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTERS OF SCIENCE
(APPLIED BIOSTATISTICS & EPIDEMIOLOGY)
December 2005
Copyright 2005 Yajun Du
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UMI Number: 1435078
Copyright 2005 by
Du, Yajun
All rights reserved.
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ACKNOWLEDGEMENTS
I would like to thank Dr. Wendy Mack for serving as chairman, Dr. Paula
Healani Palmer, and Dr. C. Anderson Johnson for their guidance and support as
committee members.
Thanks also go to Dr. Steven Cen for guiding me through the beginning of this
project and to Kari-Lyn Kobayakawa, Megan Chang and other USC TTURC
researchers for all they have done for me through my studies at USC.
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS II
LIST OF TABLES IV
LIST OF FIGURES V
ABSTRACT VI
I. INTRODUCTION 1
II. MATERIALS AND METHODS 7
2.1. Study Sample 7
2.2. Procedure 9
2.3. Measures 10
2.3.1. Smoking Status 10
2.3.2. Family Structure 1 1
2.3.3. Demographic Variables and Parent’s Smoking Status 12
2.3.3.1. Age 12
2.3.3.2. Ethnicity/Race 12
2.3.3.3. Parent’s Educational Level 13
2.3.3.4. Parent’s Employment 13
2.3.3.5. Mother’s Smoking Status 14
2.3.3.6. Father’s Smoking Status 14
2.3.3.7. Economic Status 14
2.4. Statistical Analyses 14
III. RESULTS 17
3.1. Demographic Characteristics of the Sample 17
3.2. Prevalence of Smoking 21
3.3. Univariate Logistic Regression Analyses of Associations with Ever Smoking 26
3.4. Multivariate Logistic Regression Analyses of Associations with Ever Smoking 29
IV . DISCUSSION 32
REFERENCES 36
iii
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LIST OF TABLES
Table 1: Demographic Characteristics and Parental Smoking Status by Family
Structure 18
Table 2: Demographic Characteristics and Parental Smoking Status by Personal
Smoking Status 20
Table 3: Gender-Specific Prevalence of Ever Smoking, by Demographics, Parental
Smoking, and Family Structure 22
Table 4: Unadjusted Logistic Regression of Ever Smoking by Gender 27
Table 5: Adjusted Logistic Regression for Association between Family Structure and
Smoking among Female Adolescents 29
Table 6: Adjusted Logistic Regression for Association between Family Structure and
Smoking among Male Adolescents 30
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LIST OF FIGURES
Figure 1: Profile for the Hawaii Study 9
Figure 2: Prevalence of Ever, 30-Day and Established Smoking 21
Figure 3: Prevalence of Ever Smoking by Family Structure and Gender 23
Figure 4: Prevalence of Ever Smoking by Age and Gender 24
Figure 5: Prevalence of Ever Smoking by Age and Family Structure 25
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ABSTRACT
Objective. Smoking is associated with a variety of negative health outcomes, and is
the most preventable cause of disease and premature death in the U.S. This study
examined whether the prevalence o f smoking among single-, step-, and non-parent
families is higher than that of intact families in multicultural adolescents, after
controlling for gender, age, parent education, parent employment, economic status,
mother's smoking status, father's smoking status, and ethnicity. Methods. Analyses
used data from the USC Transdisciplinary Tobacco Use Research Center (TTURC)
Hawaii Project. A representative sample of 7th graders from Hawaii completed in-
class questionnaires. The final sample included 819 students from intact, single
parent, step-, and non-parent families. Results. Parent’s education, parent
employment, economic status, mother's smoking, father's smoking and ethnicity each
significantly varied by family structure. Age, parent education, economic status,
mother's smoking, father's smoking, ethnicity and family structure were associated
with adolescent smoking. In both males and females, certain non-intact family
structures were positively associated with smoking with adjustment for confounders.
Adolescents from single parent, step-, and non-parent families were more likely to
smoke than those from intact families. A significant interaction between living in a
stepfamily and gender indicated that the positive association between a stepfamily
structure and smoking was stronger in males than in females. Conclusions. These
findings suggest that family structure is a significant risk factor for smoking during
adolescence among multicultural students.
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Chapter I
I. INTRODUCTION
Smoking is associated with a variety of negative health outcomes such as
cancer, heart and lung disease (Hays and Dale 1998) and is the most preventable
cause of disease and premature death in the United States. An estimated 400, 000
Americans die each year as a result of cigarette smoking and smoking-related
illness (McGinnis and Foege 1993; Mokdad, Marks et al. 2004). Additionally, as
a result of tobacco use, related health care and lost productivity in the United
States is estimated to cost a total of $100 billion each year (ACS 2000).
Adolescence is clearly a critical period for the onset of cigarette smoking.
Most smokers initiate smoking during adolescence (USDHHS 1994) and
continue smoking for many years (Pierce and Gilpin 1996). In the United States
everyday, approximately 4,400 youths between the ages of 12-17 smoke their
first cigarette. An estimated 13.3% of middle school students and 28.8% of high
school students were current smokers in 2002 (CDC 2003). More than one -third
of high school students smoke at least once a month and 17% smoke a cigarette
almost everyday (USDHHS 1998). Among adult smokers, the statistics are even
bleaker, with 89% beginning to smoke at or before age 18 and 71% smoking
daily by age 18 (USDHHS 1994). Thus, six thousand American adolescents will
smoke their first cigarette and three thousand of their peers will progress to
smoking at least one cigarette a day (CDC 1998). Almost two out of three
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adolescents will have tried smoking by the twelfth grade (CDC 1998; CDC
1998), and once they have started, nearly one of three adolescents will move on a
to a frequent pattern of regular smoking (USDHHS 1994).
Research strongly suggests that adolescent smoking is associated with a
variety of other social and personal problems. In particular, smoking appears to
be associated with the development of juvenile delinquency, including heavy
substance abuse (Golub and Johnson 1998), display of violent behaviors
(Bemburg 1999; Bjamason, Davidaviciene et al. 2003), and engaging in early
sexual activity (Dorius, Heaton et al. 1993). However, a causal relationship has
not been demonstrated.
Since it is evident that adolescent smoking is influenced by a complex
range of factors, smoking prevention is a difficult task and no single approach is
likely to be successful on its own (Reid, McNeill et al. 1995; Tyas and Pederson
1998). Thus, prevention of cigarette smoking during adolescence remains one of
the most important public health challenges (Elders, C.L. et al. 1994; USDHHS
1994).
Just as adolescents may begin smoking by modeling the behavior of
peers, smoking may also be modeled after the behavior of parents. Not
surprisingly, parents play an important role in the growth and development of
children. The influence of parents on children has been a primary focus of
research. Recent studies have definitively confirmed the critical role that parents
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play in determining their children’s participation in, and emulation of, healthy or
unhealthy behaviors. Researchers have also posited a variety of mechanisms by
which family members, particularly parents, can influence youth smoking. For
instance, an adolescent observing his or her parents smoking for relaxation may
be consciously or unconsciously motivated to smoke for similar rewards
(Jackson, Heniriksen et al. 1997). In addition, studies have revealed that family
structure has an impact on the choices children make regarding the adoption of
unhealthy or risky behaviors. Research has also shown that the presence of one or
both parents, and the type of behaviors they exhibit can have a profound
influence on a child’s well being (Miller 1997).
Numerous studies have examined the influence of family on adolescent
smoking. In general, parenting and family factors have played a rather minor role
in these studies, with the greater emphasis having been placed on peer and social
influences as well as on larger, socially contextual factors such as cigarette
advertising. Recently, however, there has been a shift in emphasis, and an
increased interest in family-based interventions both to deter adolescent
substance abuse in general and to prevent adolescent cigarette smoking
specifically (Ennett, Bauman et al. 2001). The vast majority of research on family
influence on smoking among adolescents examines the relative contribution of
parents in the onset of smoking.
Divorce in the United States has dramatically increased since the 1960s
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and the negative, long-term effects of divorce on children, particularly during
adolescence, have been a topic of frequent investigation. Findings from these
studies continue to suggest that adolescents from divorced families experience
poorer mental health than those from intact families. These studies also report
more smoking and other drug use among adolescents from divorced families.
Additionally, it has been noted that adolescents from non-intact families tend
both to smoke and to begin the habit at an earlier age. Studies have also shown
that adolescents who lived in a stepfamily during their formative years, are more
likely to use tobacco, alcohol and other illegal drugs by the age of 18(Nicholson,
Ferguesson et al. 1999). Similarly, single-parent households, or households with a
mother and a stepfather present, have been shown to pose a risk for substance use
(Gfellner 1994).
From 1970 to 1996, the percentage of children in the United States under
age 18 who were living with two parents, decreased steadily from 85 percent to
68 percent. The percentage stabilized during the late 1990s, remaining at 68
percent in 2003. Since 1970, the percentage of children living in mother-only
families has increased from 1 1 percent to 23 percent in 2002, and the statistic
remained constant in 2003. During the same time period, the percentage of
children living in father-only families increased from 1 percent to 5 percent. The
percent living without either parent (with other relatives or with non-relatives)
stayed fairly constant at about 3 to 4 percent (Halle 2002).
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The Asian American and Pacific Islander (AAPI) population comprises
the fastest growing ethnic minority in the US, having grown from 1.5 million in
1970, to 3.5 million in 1980, and to over 7 million in 1990 (McKenney and
Bennett 1994). According to the U.S. Census Bureau, in 2002, 12.5 million
AAPIs lived in the United States, comprising 4.4 percent of the civilian, non
institutionalized population (Reeves and Bennett 2003). These statistics are
significant in relation to racial and ethnic differences in the prevalence of
smoking. For instance, Whites and Hispanics are more likely than African
Americans to be smokers throughout adolescence (CDC 1998) and the former
also appear to initiate smoking habits earlier (Griesler and Kandel 1998). Asian
youths tend to exhibit lower rates of smoking than Whites and Hispanics but not
African Americans (Epstein, Botvin et al. 1998; Chen, Unger et al. 1999).
Research has shown that people from different AAPI subgroups show
different smoking patterns. The ethnic composition of Hawaii’s population is
unique. According to the 2000 census (total population: 1,211,537), 239,655
persons living in Hawaii reported a Native Hawaiian ethnicity, and only 503,868
individuals were of Asian ancestry (HSDB., Hawaii State of Department of
Business et al. 2002). Maskarine’s study showed that smoking rates generally
decreased during 1975-2001 in Hawaii (Maskarine, Dhakal et al. 2005). Among
males in the Hawaiian population, 20.5% of Japanese, 28.9% of Hawaiian, 30.3%
of Filipino, 21.1% of Chinese, 21.5% of Caucasian, and 29.1% of others reported
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smoking currently. Among females in the Hawaiian population, 11.2% of
Japanese, 27.6% of Hawaiian, 16.8% of Filipino, 10.2% of Chinese, 20.5% of
Caucasian, and 22.7% of others reported the same. Moreover, among the Asian
American population in California, the ethnic subgroup with the highest smoking
rate was Filipino, with a smoking rate of 18.9%, while the subgroup with the
lowest rate was Chinese (11.0%). The smoking rates for other Asian American
subgroups in California were: Japanese (16.2%), Korean (17.3%), other Asian
(16.2%) (Chen and Unger 1999).
While many studies have shown that children who live in non-intact families
are more likely to smoke, no previous studies have attempted to examine the
effects of different family structures on adolescent smoking in multicultural
households. Thus the first purpose of this study is to examine whether the
prevalence of smoking among single parent families, step-parent families and
non-parent families are higher than that of intact families in the ethnic
populations. The second purpose of this study is to explore the risk and protective
factors regarding adolescent smoking among different family structures in
multicultural populations.
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Chapter II
II. MATERIALS AND METHODS
2.1. Study Sample
Data on adolescent smoking patterns were obtained from a 2004 Hawaii
survey, which was a baseline survey for a longitudinal school-based smoking
prevention program in Hawaii conducted in the fall of 2003 and spring of 2004.
This survey was part of the University of Southern California Transdisciplinary
Tobacco Use Research Center (TTURC), which is one of seven such centers
funded by the National Cancer Institute, National Institute on Drug Abuse, and
National Institute on Alcohol and Alcoholism.
The study population was a sample of 7th graders from six schools on the
Big Island of Hawaii. The schools were selected for their high native Hawaiian
representation, and all students in targeted grades were invited to participate. The
schools were first ranked by student population size, ethnic makeup and their
location on the island. The largest student populations with ethnic diversity and
no single ethnicity reaching larger than 30% of the school’s population was
ranked highest. Health resources coordinators from the Hawaii Department of
Education served as liaisons and recruited the top three schools on each side of
their respective jurisdictions. Health and Physical Education classes were chosen
as the locations to conduct the survey since all 7th graders were required to
complete those courses allowing the study team to survey all 7th graders. One
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school declined to have both health and P.E. classes participate, only the health
classes were surveyed in this school allowing for only half of the student
population to participate.
A total of 1154 students were invited to participate, among which 93
students declined to participate, 9 students were lost because they moved to other
places, and 179 provided missing data. At the final count, 873 of 1154 submitted
letters of consent to participate in the study. Of these 873 consenting students, 54
students were absent during the day of the survey. Therefore, this study ultimately
reported the results from 819 students, accounting for 71.0%(819/1154) of those
invited to participate, and 93.8%(819/873) of those who consented to survey
(Figure 1).
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Invited
Subjects
(N=l 154)
1r
V ^ r ^ r v
Declined Moved Consented Missing data
(n=93) (n=9) (n=873) (n=179)
f r
Surveyed
(n=819)
Absent
(n=54)
Figure 1: Profile for the Hawaii Study
2.2. Procedure
Survey procedures were designed to protect student anonymity and allow
for voluntary participation; parental consents were also required. Each student
was given a parental consent form that explained the contents and purpose of the
questionnaire in general terms and stated that participation by the students was
voluntary. Students were asked to return the signed consent form. Parents were
called by the school staff and reminded to send the consent form back to school
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with their children. If a parent refused permission, that child was not given a
survey. Students were also given an assent form explaining the purpose of the
study; they were informed that all answers would be kept strictly confidential,
and that any and all participation was voluntary. If any student chose not to sign
the letter of assent or did not choose to participate, they were not given a survey.
Data collection took place in the classroom under examination conditions. A
trained data collector, not previously acquainted with the students, collected the
data during a single class period, administered to all sampled students attending
the school on the day of the survey. Those students absent because of sickness or
other reasons were not surveyed.
The questionnaires included a 118-item paper-and-pencil survey on the
smoking and related health behaviors of students, their friends and family, and
questions on their relationships with peers and family, their school experience,
and their socioeconomic circumstances. The questionnaire was pilot tested before
it was formally used in data collection. Each student’s survey was identified only
by a unique code, not with the student’s name or any other identifying
information.
2.3. Measures
2.3.1. Smoking Status
Three variables were used to assess smoking behavior: Ever smoker, 30-Day
smoker, Established smoker.
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2.3.1.1. Ever Smoker: the following question was asked about cigarette
smoking: Have you ever tried cigarette smoking, even a few puffs?
Those who responded “No” and “Yes” to the question were
respectively coded as “Never smokers” and “Ever smokers”.
2.3.1.2. 30-Day smoker: a subject was classified as a 30-Day smoker if he/she
smoked at least one day during the past 30 days based on their response
to the question: “ Think about the last 30 days, on how many of these
days did you smoke cigarettes?”
2.3.1.3. Established smoker: a subject was classified as an established smoker
if he/she gave a positive response to the question: “Have you smoked at
least 100 cigarettes in your life?”
2.3.2. Family Structure
Family structure was defined on the basis of the students’ responses to a
set of questions about “Which of these people live with you in your home?” -
mother, stepmother, father, stepfather, sister(s), brother(s), cousin(s), aunts,
uncles. In each case, the respondent checked a box indicating “Yes” (I live with
this person) or “No” (I don’t live with this person). Based on these responses, the
family structure measure was dummy coded into four nominal variables:
2.3.2.1. Intact families: Respondents lived with biological mother and
biological father (This was used as the referent category in statistical analyses).
2.3.2.2. Single parent families: Respondents lived with their one
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biological parent, but not both, and they did not live with a stepparent.
2.3.2.3. Stepfamilies: Respondents lived with a biological parent and a
step-parent.
2.3.2.4. Non-parent families: Respondents lived with an aunt or uncle, and
they did not live with a parent or stepparent.
2.3.2.5. Step parent(s) only families: Respondents lived with step
parent(s) only, and they did not live with biological parent(s).
2.3.3. Demographic Variables and Parent’s Smoking Status
In order to control for confounding, the following demographic variables
(age, gender, ethnicity, parent’s education, parent’s employment, and economic
status), and parent’s smoking status were included in the analyses as covariates.
2.3.3.1. Age
According to students’ report, the students’ age was recoded as quartile
categorical variables (11.4-12.3, 12.3-12.6, 12.6-12.9, 12.9-14.7 years).
2.3.3.2. Ethnicity/Race
Students were asked to categorize their ethnicity (Including: White, Part-
Hawaiian, Native-Hawaiian, Japanese, Chinese, Filipino, Marshallese, Samoan,
Guamanian/Chamorro, Hispanic, and Portuguese). For each ethnicity, the
respondent indicated “Yes” or “No”. Based on their responses, subjects were
classified into six ethnic categories:
Pure White
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Pure Asian (Chinese, Japanese, Filipino, Korean etc.)
Pure Pacific Islander (Native-Hawaiian, Marshallese, Samoan, or
Guamanian/ Chamorro)
Multiethnic/Mixed (More than two ethnicities)
Pure Latino (Hispanic, Portuguese)
Unknown
2.3.3.3. Parent’s Educational Level
Parent’s educational levels were defined as: didn’t go to high school or
didn’t graduate from high school, high school graduate, college graduate, don’t
know. Based on the responses, subjects were classified into two categories of
parental education:
Less than high school (Both father and mother are less than high school)
High school graduate or higher degree (At least one parent is a high
school graduate or has a higher degree)
2.3.3.4. Parent’s Employment
The students were asked, “What is mother’s and father’s job”, including:
Her/his job is (fill in), she/he isn’t working right now, she/he doesn’t work
outside the home, don’t know. According to the responses, the subjects were
classified into categories of parental employment: employed (At least one parent
employed) and unemployed (Both mother and father unemployed).
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2.3.3.5. Mother’s Smoking Status
To take into account the possible influence of parental smoking, the
students were asked how many cigarettes their mother smoked on an average day.
Responses were: “none”, “1-5 cigarettes per day”, “6-10 cigarettes per day”, “11-
20 cigarettes per day”, “more than 20 cigarettes per day”, “I don’t know”.
2.3.3.6. Father’s Smoking Status
Father’s smoking status was asked in the same way as that for mother’s
smoking status.
2.3.3.7. Economic Status
Because there was no question in the survey about income, the following
questions relative to economic status were used as income proxy measures: “How
many rooms does your house or apartment have (Count every room EXCEPT the
kitchen, bathrooms and closets)?” This is a widely accepted proxy measure of
income and has been validated as such. The students choose from 7 responses
options ranging from “1 room” to “7 or more rooms”. The second question was
“How many people live in your home where you spend most of your time
(including you)?” Students chose from 6 response options ranging from “2
people” to “7 or more”. Economic status was calculated by dividing the number
of rooms by the number of people living in the household.
2.4. Statistical Analyses
Frequencies were calculated for demographic characteristics (including
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gender, age, ethnicity, parents’ education, employment status, and household
economic status) and parents’ smoking status, by family structure and by
student’s smoking status. Chi-square tests were used to test the differences
between each of the above variables by family structures and by student’s
smoking status.
The prevalence of smoking was calculated by gender, levels of smoking,
family structure, age, and combinations of these.
Unconditional univariate logistic regression was performed to examine
the associations between adolescent smoking and family structure, demographic
characteristics, and parental smoking status.
Unconditional multivariate logistic regression was also performed to
examine the association between adolescent smoking and family structure among
females and males respectively, considering demographic characteristics (gender,
age, ethnicity, parents’ education, parents’ employment, and household economic
status variables), and parents’ smoking status, as potential confounders. If any of
the potential confounders contributed a 15% or more change on the odds ratios
(ORs) for family structures, it was kept in the model. Otherwise, the variable was
excluded. The final models presented for each gender are based on multivariate
logistic regression analyses.
Likelihood ratio tests were used to test interaction terms; interactions
were developed and added into the models between family structure and each of
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the confounders (by females, males respectively). In a combined (females and
males) multivariate model, gender interactions with family structure were tested.
Likelihood ratio tests with p<0.05 were considered statistically significant
interactions.
All analyses were conducted using the Stata statistical package (Version
8.0).
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Chapter III
III. RESULTS
3.1. Demographic Characteristics of the Sample
Of the 819 students surveyed, the sample contained similar numbers of
females and males (50.6% male). The average age was 12.6±0.4 (mean±SD)
years.
Because 12 of 819 surveyed students did not report their family structure,
demographic characteristics by family structure include 807 students. Table 1
provides demographic information and parental smoking status by family
structures at baseline.
58.9% of students were from an intact family, 15.6% were from a single
parent family, 11.9% were from a stepfamily, 13.6% were from a non-parent
family, and 0.0% were from step parent(s) only family.
Gender and age did not statistically significantly vary by family structure
(p>0.05). Parent education, parent employment, economic status, mother
smoking status, father smoking status, and ethnicity statistically significantly
varied by family structure (p<0.05).
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Table 1: Demographic Characteristics and Parental Smoking Status by Family
Structure
Level
Intact Family
(N=475)
Single parent
Family
(N=126)
Step Family
(N=96)
Non Parent
Family
(N=110)
Total (N=807)
P value
n % n % n % n % n %
Gender
Female
Male
219
256
46.1
53.9
62
64
49.2
50.8
54
42
56.3
43.8
62
44
58.5
41.5
397
406
49.4
50.6
0.06
11.4- 12.3 119 26.4 31 25.8 20 21.5 26 25.5 196 25.6 0.89
Age (Year)
12.3- 12.6 112 24.8 27 22.5 28 30.1 22 21.6 189 24.6
12.6- 12.9 117 25.9 31 25.8 22 23.7 24 23.5 194 25.3
12.9- 14.7 103 22.8 31 25.8 23 24.7 30 29.4 188 24.5
High School
Parent
Education
Graduate and
above
358 93.7 77 84.6 62 88.6 55 73.3 66 10.7 <0.0001
Less than
High School
24 6.3 14 15.4 8 11.4 20 26.7 552 89.3
Parent
Employed 373 81.4 83 72.8 77 82.8 67 72 600 79.2 0.05
Employment
Unemployed 85 18.6 31 27.2 16 17.2 26 28 158 20.8
Economic
<1 127 26.7 37 29.4 43 44.8 54 49.1 261 32.3 <0.0001
Status
(room/family
>=1 348 73.3 89 70.6 53 55.2 56 50.9 546 67.7
member)
Mother No 387 85.4 80 76.9 69 75 50 58.8 586 79.8 <0.0001
Smoke
Yes 66 14.6 24 23.1 23 25 35 41.2 148 20.2
Father N o 359 81.2 62 68.9 53 64.6 55 64.7 529 75.7 <0.0001
Smoke Yes 83 18.8 28 31.1 29 35.4 30 35.3 170 24.3
White 45 9.5 9 7.1 11 11.7 6 5.5 71 8.8 <0.0001
Mixed 298 62.7 94 74.6 74 78.7 82 74.6 548 68.1
Asian 108 22.7 14 11.1 6 6.4 8 7.3 136 16.9
Ethnicity
Pacific
Islander
13 2.7 5 4 2 2.1 8 7.3 28 3.5
Latino 7 1.5 4 3.2 1 1.1 3 2.7 15 1.9
Unknown 4 0.8 0 0 0 0 3 2.7 7 0.9
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22 of 819 surveyed students did not report their smoking status, and so
demographic characteristics by smoking status include 797 students. Table 2
provides demographic information by smoking status at baseline.
In general, 10.9% of students reported that both parents did not graduate
from high school, while 89.1% reported that at least one parent graduated from
high school or college. 20.1% of students reported that both parents were
unemployed. 32.4% of students lived in less than one room for per family
member. Among these students who reported their smoking status, 8.8% were
White, 69.1% were mixed (multiethnic), 16.6% were Asian, 3.4% were Pacific
Islander, 1.6% were Latino, and 0.5% did not know their ethnicities. 59.4% of
students were from an intact family, 15.5% were from a single parent family,
12.1% were from a stepfamily and 13.0% were from a non-parent family.
Maternal and paternal smoking rates were 20.27% and 24.7%, respectively.
Student’ s smoking status was not statistically significantly associated with
gender, or parent employment (P>0.05). Student’s smoking status was
statistically significantly associated with age, parent education, economic status,
mother smoking, father smoking, ethnicity, and family structure (P<0.05).
19
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Table 2: Demographic Characteristics and Parental Smoking Status by Personal
Smoking Status
Non-smoker Smoker Total
(N=599) (N=198) (N=797)
Factor Level n % n % n % P value
Gender Female 285 47.7 105 53.0 390 49.0 0.19
Male 313 52.3 93 47.0 406 51.0
11.4, 12.3 161 28.2 35 18.6 196 25.8 0.01
Age 12.3, 12.6 142 24.9 46 24.5 188 24.8
(Year) 12.6, 12.9 146 25.6 47 25.0 193 25.4
12.9, 14.7 122 21.4 60 31.9 182 24.0
High school
Parent Education Graduate and above
Less than High
414 90.8 134 84.3 548 89.1 0.02
School 42 9.2 25 15.7 67 10.9
Parent Employed 457 80.3 143 78.6 600 79.9 0.61
Employment Unemployed 112 19.7 39 21.4 151 20.1
Economic Status <1 177 29.6 81 40.9 258 32.4 0.003
(Room/family
member) >=1 422 70.5 117 59.1 539 67.6
No 473 84.0 117 66.1 590 79.7 <0.0001
Mother Smoke Yes 90 16.0 60 33.9 150 20.3
No 427 78.9 103 63.2 530 75.3 <0.0001
Father Smoke Yes 114 21.1 60 36.8 174 24.7
White 60 10.0 10 5.1 70 8.8 0.001
Mixed 394 65.9 155 78.7 549 69.1
Ethnicity Asian 114 19.1 18 9.1 132 16.6
Pacific Islander 16 2.7 11 5.6 27 3.4
Latino 10 1.7 3 1.5 13 1.6
Unknown 4 0.7 0 0.0 4 0.5
Intact family 389 65.8 77 39.7 466 59.4 <0.0001
Family Structure Single parent family 80 13.5 42 21.7 122 15.5
Step family 58 9.8 37 19.1 95 12.1
N o parent family 64 10.8 38 19.6 102 13.0
20
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3.2. Prevalence of Smoking
The overall prevalence of ever smoking was 24.8%, 30-Day smoking was
7.8%, and of established smoking was 1.5% (Figure 1).
30.0
0 5
| 20.0
O
E
C O
CD
U
J 10.0
< 5
S
w
Q .
o .o
Ever Smoking 30-Day Smoking Established Smoking
Figure 2: Prevalence of Ever, 30-Day and Established Smoking
Because the prevalence of 30-Day smoking and established smoking were
only 7.8% and 1.5% respectively at this age, they could not provide sufficient
power for detection of any associations with family structures. Therefore, only
ever smoking status was used for further analyses. The detailed prevalence rates
of ever smoking by gender, family structure, age, and combinations of these are
shown in Table 3, and Figures 2- 4.
21
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Table 3: Gender-Specific Prevalence of Ever Smoking, by Demographics,
Parental Smoking, and Family Structure
Factor Level
Gender
Female Male
Total
11.4, 12.3 21.4 14.3 17.9
12.3, 12.6 28.9 20.0 24.5
Age 12.6, 12.9 25.8 23.0 24.4
(Year) 12.9, 14.7 31.5 34.4 33.0
Parent Education
High School
Graduate and above 25.6 23.4 24.5
Less than High
School 38.5 35.7 37.3
Parent Employed 26.1 21.7 23.8
Employment Unemployed 25.0 26.9 25.8
Economic Status <1 35.2 27.0 31.4
(Room/family
member) >=1 22.2 21.3 21.7
N o 18.5 21.0 19.8
Mother Smoke Yes 48.2 30.4 40.0
No 20.6 18.5 19.4
Father Smoke Yes 36.5 32.6 34.5
White 9.7 18.0 14.3
Mixed 30.5 25.9 28.2
Ethnicity Asian 11.1 15.4 13.6
Pacific Islander 53.9 28.6 40.7
Latino 25.0 20.0 23.1
Intact family 16.8 16.3 16.5
Family Structure Single parent family 39.0 30.2 34.4
Step family 33.3 46.3 39.0
N o parent family 44.1 28.6 37.3
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
50.0
40.0
30.0
o
E
<0
< 4 —
o
I D
S 20.0
10.0
■ Intact families
□ Stepfamilies
■ Single parent families
□ Non-parent families
Female
Gender
Figure 3: Prevalence of Ever Smoking by Family Structure and Gender
23
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♦ —Male — ■— Female
40.0
o) 30.0
c
o
W 20.0
o
a >
u
c
0 )
( Q
>
22
10.0
Q .
0.0
11.4 12.3- 12 .6- 12.9-
Age Group
Figure 4: Prevalence of Ever Smoking by Age and Gender
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
—♦— Intact fam ilies Single parent fam ilies
Stepfam ilies - x — Non-parent fam ilies
80.0
£ 60.0
U)
c
!2
o
W 40.0
o
o
o
c
0 )
re
>
o
u
20.0
a.
0.0
12.3- 11.4- 12 .6- 12.9-
Age Group
Figure 5: Prevalence of Ever Smoking by Age and Family Structure
Smoking prevalence for females was slightly higher than for males (Table 2).
Prevalence of smoking increased with age in both males and females (Table 3).
Before age 12.9 years old, the smoking prevalence for females was higher than
that of males. However, after 12.9 years old, the smoking prevalence for males
was higher than that of females (Table 3, Figure 3).
Table 3 also showed that lower educational level of the parent was
associated with a higher prevalence of smoking for their children. The prevalence
of smoking among adolescents whose mother or father smoked was much higher
25
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than those whose mother or father did not smoke. Adolescents living in homes
with less than 1 room per family member had a higher smoking prevalence than
those in homes with at least one room per family member. Among different
ethnicities, Asian and Pacific Islander adolescents had the lowest and highest
smoking prevalence respectively.
In Table 3, smoking prevalence was 16.5% students living in intact
families, 34.4% in single parent families, 39.0% in stepfamilies, and 37.3% in
non-parent families. After stratifying by age and family structures, it is apparent
that smoking prevalence among students living in an intact family was lower than
all other family structures at all age levels (Figure 4).
3.3. Univariate Logistic Regression Analyses of Associations with Ever Smoking
The results of univariate analyses of demographic characteristics, parent
education, parent employment, parent smoking status, and family structure
variables are shown in Table 4.
26
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Table 4: Unadjusted Logistic Regression of Ever Smoking by Gender
Female Male
P-value or P-value or
Factor Level
Odds Ratio 95% Cl (P-trend) Odds Ratio 95% Cl (P-trend)
11.4, 12.3 1 - -0.19 1 - -0.001
Age (Year) 12.3, 12.6 1.5 (0.8, 2.9) 0.23 1.5 (0.7, 3.2) 0.3
12.6, 12.9 1.3 (0.7, 2.5) 0.48 1.8 (0.9, 3.7) 0.12
12.9, 14.7 1.7 (0.9, 3.3) 0.12 3.1 (1.6, 6.4) 0.002
Economic Status <1 1 - 1 -
(Room/family
member) >=1 0.5 (0.3, 0.8) 0.006 0.7 (0.5, 1.2) 0.22
White 1 - 1 -
Mixed 3.2 (1-1, 9.3) 0.035 1.8 (0.8, 4.2) 0.18
Ethnicity Asian 0.9 (0.2, 3.5) 0.89 0.9 (0.3, 2.6) 0.9
Pacific Islander 8.5 (1.9,38.3) 0.006 2.1 (0.5, 8.5) 0.32
Latino 2.4 (0.4, 16.3) 0.37 1.3 (0.1, 13.3) 0.83
High School
Graduate and
Parent Education above
Less than High
1 — 1 —
School 1.8 (0.9, 3.7) 0.09 1.8 (0.8, 4.1) 0.15
High School
Parent Education in Graduate and
Intact Family above
Less than High
1 — 1 —
School 2.1 (1.1,4.0) 0.03 2.5 (1.3, 4.7) 0.004
Employed 1 - 1 -
Parent Employment Unemployed 0.9 (0.5, 1.7) 0.84 1.3 (0.7, 2.4) 0.36
Mother Smoke Yes 4.1 (2.4, 7.0) <0.0001 1.6 (0.9, 2.9) 0.09
Yes 2.2 (1.3, 3.8) 0.004 2.1 (1.3, 3.6) 0.01
Intact family 1 - 1 -
Single parent
Family Structure family 3 (1.6, 5.7) 0.001 2.2 (1.2, 4.1) 0.02
Step family 2.4 (1.2, 4.6) 0.01 4.4 (2.2, 8.7) <0.0001
No parent family 3.7 (2.0, 7.0) <0.0001 2 (1.0, 4.3) 0.07
27
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Most comparisons indicated significant association with smoking in both
males and females. Age was positively associated with smoking. Relative to the
lowest quartile (11.4-12.3 years) females older than 12.9 were 1.7 times as likely
to smoke (95% CI=0.9, 3.3) and males older than 12.9 were 3.1 times as likely to
smoke (95% CI=1.6, 6.4). The trend in smoking prevalence with age was
significant in males (p=0.001), but was not apparent in females (p=0.19). For
both genders, adolescents in better economic status (at least one room per family
member) were less likely to smoke than those of worse economic status (less one
room per family member, p=0.006 for females, p=0.22 for males). Compared to
whites, adolescents were more likely to smoke if their ethnicities were Mixed
(multicultural), Pacific Islander, and Latino, and were less likely to smoke if their
ethnicity was Asian. These ethnic differences were statistically significant only in
females (Mixed, Asian ethnicities versus white).
Among parenting variables, a lower parent education level was positively
but non-significantly associated with adolescent smoking. However, if students
only from intact families were kept in the analyses, a lower parent education level
was positively and significantly associated with adolescent smoking for both
genders (p=0.03 for females, and p=0.004 for males).
Parents’ smoking was highly positively associated with adolescent
smoking. Parents’ employment was not associated with adolescent smoking.
Adolescents from single parent, step, or non-parent families were far more likely
28
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to smoke than those from an intact family.
3.4. Multivariate Logistic Regression Analyses of Associations with Ever
Smoking
Several independent variables were retained in the final multivariate
logistic regression models. However, the final gender-specific model covariates
differed for males and females.
The final multivariate logistic regression model for female adolescents is
shown in Table 5.
Table 5: Adjusted Logistic Regression for Association between Family Structure
and Smoking among Female Adolescents
Factor Level Odds Ratio 95% Cl
P-value or
(P-trend)
White 1.0 -
Mixed 2.6 (0.6, 11.5) 0.23
Ethnicity Asian 0.8 (0.1, 5.1) 0.84
Pacific Islander 5.8 (0.8, 43.4) 0.08
Latino 5.6 (0.6, 50.8) 0.13
Mother Smoke Yes 2.5 (1.3,4.8) 0.01
Father Smoke Yes 1.5 (0.8, 2.8) 0.22
Intact family 1.0 -
Single parent
Family structure family 3.5 (1.6, 7.9) 0.003
Step family 1.4 (0.6, 3.3) 0.40
N o parent family 2.2 (1.0, 4.8) 0.06
Among female adolescents, family structures were positively associated
with smoking with adjustment for ethnicity and parental smoking. Compared to
those in an intact family, female adolescents who were from single parent, step
and non-parent families were more likely to have smoked, with odds ratios of 3.5
29
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(95% CI=1.6, 7.9, p=0.003), 1.4 (95% CI=0.6, 3.3, p=0.40), 2.2 (95% CI=1.0,
4.8, p=0.06) respectively. Ethnicity, mother’s smoking status and father’s
smoking status were included in the model because they were confounding
factors of the association between adolescent smoking and family structure.
The final multivariate logistic regression model for male adolescents is
shown in Table 6.
Table 6: Adjusted Logistic Regression for Association between Family Structure
and Smoking among Male Adolescents
Factor Level Odds Ratio 95% Cl
P-value or
(P-trend)
11.4- 12.3 1.0 - (0.005)
Age 12.3- 12.6 1.5 (0.6, 4.1) 0.41
12.6- 12.9 1.8 (0.7, 4.4) 0.20
12.9- 14.7 3.6 (1.5, 8.9) 0.005
High School
Parent Education Graduate and above 1.0 -
Less than High
School 0.7 (0.2, 2.1) 0.50
Father Smokes Yes 1.9 (1.0, 3.8) 0.07
Intact family 1.0 -
Family Structure Single parent family 2.6 (1.1, 6.2) 0.04
Step family 5.1 (2.1, 12.2) <0.0001
No parent family 1.4 (0.4, 4.8) 0.57
Among male adolescents, family structures were also positively
associated with smoking. Compared to male adolescents from intact families,
male adolescents who were from single parent, step and non-parent families were
more likely to have smoked, with odds ratios of 2.6 (95% CI=T.l, 6.2, p=0.04),
5.1 (95% CI=2.1, 12.2, p<0.0001), and 1.4 (95% CI=0.4, 4.8, p=0.57)
respectively. Age, parental education, and father’s smoking status were included
30
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because they were confounding factors for the association between adolescent
smoking and family structure.
No significant interactions were found between family structures with
any of the confounding factors for both females, males in the final logistic
regression models (P>0.05).
After age, ethnicity, mother’s smoking status, father’s smoking status,
and parental education were controlled in the combined multivariate model
(males and females), the interactions between family structures with gender were
tested.
Interactions of single parent family with gender and non-parent family
with gender were not statistically significant (LRT chi2=1.24, p=0.27; LRT
chi2=1.43, p=0.23, respectively). However, the stepfamily with gender
interaction was statistically significant (LRT chi2=3.87, p=0.049). Compared to
adolescents from an intact family, female adolescents who were from step family
were more likely to smoke, with odds ratio of 1.4 (95% CI=0.54, 3.4, p=0.51);
whereas, male adolescents who were from a step family were more likely to
smoke, with odds ratio of 3.3 (95% CI=1.0, 11.4, p=0.05).
31
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Chapter IV
IV. DISCUSSION
Although the relation between family structures and smoking in
adolescence is well documented in Europe (Bjamason, Davidaviciene et al.
2003), there have been few studies in the United States, especially those of
multicultural adolescents. In a sample comprised of intact, single parent, step-,
and non-parent families among multicultural students in Hawaii, we examined
the relationships among family structure, ethnicity, parental characteristic, and
adolescent smoking.
In this Hawaiian sample, 13.0% of students were in a non-parent family.
This may be particular to Polynesia where children often are raised in an ohana-
extended family. The overall prevalence of smoking was 24.8%. The prevalence
of smoking for females was slightly higher than males, but there was no
significant difference between genders.
The main hypothesis of this study was supported, in that the prevalence of
smoking in single parent, step-, and non-parent families were higher than in an
intact family. These differences were statistically significant. In univariate
analyses, the odds ratios of ever smoking were significantly elevated for
adolescents living in a non-intact family compared to adolescents living in an
intact family.
Age, socioeconomic status, parent’s education, parental smoking, and
32
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ethnicity were additional risk factors for adolescent smoking. In multivariate
analyses, ethnicity and the mother’s smoking habits were confounding factors
with regards to the family structure for females, whereas in males age was a
confounding factor with regards to smoking associations with family structure.
No significant interactions were found between variables (including
family structure by ethnicity) for the final logistic regression models (for both
males and females). In a model that combined genders, there was a statistically
significant interaction between gender and stepfamily structure in multivariate
analyses after controlling for other confounders. The interaction finding indicated
that the positive association between smoking and living in a step-parent family
was stronger in male adolescents than in female adolescents. This finding is
inconsistent with previous studies. There is evidence that adolescent girls have a
stronger and negative reaction to a parent’s remarriage than boys, particularly in
mother-custody families (Vuchinich, Hethrington et al. 1991; Hethrington,
Bridges et al. 1998). Remarriage has been associated with increased drug use by
adolescent girls and reduced use in adolescent boys (R.H., Su et al. 1990). It may
be that our contrasting results are due to the different population studied, the
different outcome.
Our findings therefore suggest that certain types of family structures are
significant risk factors for smoking during adolescence among multicultural
students. This research is particularly important for adolescents due to the high
33
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prevalence of smoking in non-intact family structures among multicultural
adolescents. On the other hand, protective factors were revealed for adolescent
smoking, including younger age, higher economic status, higher parent
educational level, Asian ethnicity, and having non-smoking parents. The findings
of this study may be instructive to adolescent smoking prevention in the future.
The results have important theoretical implications, since parent modeling
is considered a critical factor when children initiate smoking (Distefan, Gilpin et
al. 1998; Engles and Knibbe 1999). Behavior theory suggests that parental
problems and behaviors exert important and sometimes enduring influences on
children (Hoffman 1995). The possible effects of parental separation may be to
loosen family ties or control. Parental divorce or living with a stepparent, or a
non-parent may be associated with decreased family attachment and less adult
supervision. This may result in a higher likelihood of associating with smoking
peers, which is associated with initiation of smoking (Wang, Fitzhugh et al.
1995).
Limitations of this study need to be acknowledged. The study was based
on adolescents’ self-reporting on their own smoking behavior as well as of their
family structures, and thus may suffer from possible measurement biases. First,
when students were asked to report their own smoking behavior, the possibility of
under- or over-reporting exists due to social pressures (McKennel 1980).
However, self-administered questionnaires are often used to measure smoking
34
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behavior among adolescents and have been found to be as valid and reliable as a
more objective method such as biochemical verification for smoking (Perez-
Stable, Benowitz et al. 1995; Rebagliato 2002). Second, the relatively small
sample size and subsequent low prevalence of certain smoking variables hindered
analyses. Usually, 30-day smoking is the definition of regular smoking in
childhood and adolescence used in smoking research; however, the small number
of subjects reporting 30-Day smoking precluded analysis of this variable as the
outcome for this study. Therefore, future studies should gain sufficient sample
sizes to examine if associations with this more standard variable of recent
smoking vary within different ethnic populations. Furthermore, we could not
examine the role of nicotine dependence in the persistence of smoking. Because
of the structure of the questionnaire, we were not able to differentiate who was
the parent in the analyses (the person with whom the student lived or the
biological parent). Finally, these cross-sectional data only report associations
from an epidemiological perspective and cannot offer an explanation as to why
family structure may effect differences in smoking patterns. Longitudinal data
may provide more insight into family structures and subsequent initiation of
smoking in adolescents. Clearly, more research needs to be conducted to
understand the social, environmental, and intrapersonal forces with regards to
smoking among multicultural adolescents. Mediation analyses should also be
evaluated in future research.
35
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Asset Metadata

Creator Du, Yajun (author)

Core Title The influence of family structures on adolescent smoking among multicultural adolescents in Hawaii

Degree Master of Science

Degree Program Applied Biostatistics and Epidemiology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, public health,OAI-PMH Harvest

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-50388

Unique identifier UC11338177

Identifier 1435078.pdf (filename),usctheses-c16-50388 (legacy record id)

Legacy Identifier 1435078.pdf

Dmrecord 50388

Document Type Thesis

Rights Du, Yajun

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA