- Email: [email protected]
Perceived parental reactions to substance use among adolescent vapers compared with tobacco smokers and non-users in Iceland
p u b l i c h e a l t h 1 6 4 ( 2 0 1 8 ) 1 1 5 e1 1 7
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Perceived parental reactions to substance use among adolescent vapers compared with tobacco smokers and non-users in Iceland A.L. Kristjansson a,b,*, J.P. Allegrante b,d,e, I.D. Sigfusdottir b,c,d a
Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, WV, 26505, USA b Icelandic Center for Social Research and Analysis, Reykjavik University, 101 Reykjavik, Iceland c Department of Psychology, Reykjavik University, 101 Reykjavik, Iceland d Department of Health and Behavior Studies, Teachers College, Columbia University, New York, 10027, NY, USA e Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, 10032, NY, USA
article info
abstract
Article history:
Objectives: The objective is to assess perceived parental reactions to cigarette smoking,
Received 30 April 2018
vaping, drunkenness, and marijuana use among cigarette smokers, vapers, and those who
Received in revised form
neither smoke nor vape (non-users).
23 July 2018
Study design: It is a population-based, cross-sectional, school survey with all accessible 13-
Accepted 9 August 2018
to 16-year-old students in Iceland (response rate: 84.1%). Methods: Data were analyzed in Mplus using multinomial logistic regression for categorical data with maximum likelihood and robust standard errors, adjusting for potential school
Keywords:
clustering.
Electronic cigarettes
Results: Across all four outcome categories and controlling for background factors, non-
Iceland
users were more likely than vapers and smokers to perceive their parental reactions to
Adolescents
substance use as negative (P < 0.01). Vapers were significantly more likely than smokers to
Primary prevention
perceive their parental reactions as negative toward all types of substance use (P < 0.01). Conclusions: Adolescent smokers, vapers, and non-users appear to form a sequential risk gradient toward perceived parental reactions to substance use, with smokers being least likely to perceive their parental reactions as negative and vapers thereafter; non-users are most likely to perceive their parental reactions toward substance use as negative. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, WV, 26505, USA. E-mail address: [email protected] (A.L. Kristjansson). https://doi.org/10.1016/j.puhe.2018.08.005 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
116
p u b l i c h e a l t h 1 6 4 ( 2 0 1 8 ) 1 1 5 e1 1 7
Introduction While the long-term physical harm of vaping remains unclear, it is generally considered a safer alternative to tobacco smoking,1 although vaping, especially for minors, is not entirely harmless.2 The tobacco control community has also highlighted notable differences in viewpoints on vaping based on the principles of primary prevention (i.e., prevention of initiation) and secondary prevention (i.e., smoking cessation, harm reduction).3,4 However, irrespective of different viewpoints about the physical harm of vaping and whether electronic cigarettes are applicable as harm reduction tools for current smokers, a more consistent literature has now established that adolescents who initiate vaping before any form of tobacco use are significantly more likely than never users to escalate into smoking.5 Vaping should, therefore, be discouraged among never smokers. From a primary prevention perspective, an important effort to curb the initiation of vaping by never smokers is to understand the level of environmental sanctions, or lack thereof, that contribute to the odds of vaping and other substance use. Few sanctions are more important than the ones provided by parents.6,7 Parents are at the center of most primary prevention efforts and programs,6 and their perceived disapproval of usage by children and adolescents is an important preventive mechanism.7 In this study, we investigated the relationship among perceived parental reactions to vaping, smoking, drunkenness, and marijuana use in a large sample of 13- to 16year-old never smokers, vapers, and cigarette smokers, in Iceland, which has been highlighted for its strong communitybased primary prevention efforts that have led in achieving some of the greatest reductions in adolescent substance use in all of Europe over a 20-year period.8 Iceland, currently, has the lowest or the second lowest rates of adolescent smoking and alcohol use in all of Europe.8
Methods Data from the 2018 population-based Youth in Iceland survey on substance use and risk, and protective factors were analyzed. The survey was administered to all 8th through to 10th grade students (aged 13e16 years) in Iceland, by the Icelandic Centre for Social Research and Analysis at Reykjavik University. Consistent with published protocols,9 data collection was conducted at the population level with all accessible students in all 135 schools in the country, using anonymous questionnaires, supervised by a contact agent in each school using procedures deemed exempt by the Icelandic authority overseeing the protection of human research subjects. Passive consent was used. A total of 10,651 students returned completed questionnaires (response rate: 84.1%). The current smoking status was determined by a combination of responses to four questions about lifetime and current (i.e., 30 day) vaping and smoking with 1 ¼ never (i.e., neither vaping or smoking ever in their lifetime), 2 ¼ vaping only (i.e., electronic cigarettes at least once during the last 30 days but no combustible cigarettes), and 3 ¼ smoking or dual use (combustible cigarettes or both vaping and smoking at
least once during last 30 days). For perceived parental reactions, participants were asked to indicate how their parents would react if they (a) ‘would smoke cigarettes’, (b) ‘would use electronic cigarettes or vape’, (c) ‘would become drunk’, and (d) ‘would use marijuana’. Responses ranged from 1 ¼ ‘very much against’ to 4 ¼ ‘almost would not care’. Control variables included gender, coded 1 ¼ girls (50.3%), 0 ¼ boys; grade, coded 1 ¼ 8th grade, 2 ¼ 9th grade, and 3 ¼ 10th grade; family structure, coded 1 ¼ lives with both parents (69.8%), 0 ¼ other forms; perceived family financial status, ranging from 1 ¼ ‘much better off’ to 7 ¼ ‘much worse off’; and a composite measure on the father and mother educational status ranging from 1 ¼ ‘college graduate’ to 5 ¼ ‘elementary school or less’. Analyses were conducted in Mplus using multinomial logistic regression for categorical data with maximum likelihood and robust standard errors, adjusting for potential school clustering (average cluster ¼ 59.9 students, intraclass correlation coefficient (ICC) ¼ 1.8%).
Results About 83% of the sample had neither tried vaping nor tobacco smoking, 3.2% were current smokers, and 13.6% were current vapers. Table 1 shows the results from the multinomial logistic regression models with vapers as a reference group. After controlling for confounding background variables, i.e. gender, grade, family structure, family financial status, and parental education, non-users were significantly more likely than vapers to report that their parents would react negatively to all four forms of substance use. Conversely, vapers were significantly more likely than cigarette smokers to report that their parents would react negatively to all forms of substance use.
Discussion These results indicate that even after controlling for a host of background variables, non-users were more likely to perceive their parental reactions to all forms of substance use as negative, compared with vapers, who subsequently were more likely than smokers to perceive their parental reactions as negative to all forms of substance use. These findings suggest a sequential risk gradient by the smoking status in perception to parental reactions to substance use. Previously, we found a similar risk gradient between the odds of eight
Table 1 e Odds ratios from multinomial logistic regression models with vapers as the reference category (control relationships not shown). Perceived parental reaction
Non-users (95% CI)
Cigarette smokers (95% CI)
To electronic cigarette use To cigarette smoking To drunkenness To marijuana use
0.32 (0.29e0.35)**
1.37 (1.19e1.59)**
0.61 (0.54e0.70)** 0.62 (0.54e0.72)** 0.60 (0.53e0.69)**
1.87 (1.55e2.25)** 1.52 (1.25e1.85)** 1.52 (1.27e1.83)**
CI, confidence interval. ** P < 0.01.
p u b l i c h e a l t h 1 6 4 ( 2 0 1 8 ) 1 1 5 e1 1 7
types of substance use and smoking status, with vapers consistently being in between non-users and smokers.10 Together with these findings, it appears that vapers are not only more likely to use other substances than non-smokers but are also more likely to perceive critical environmental sanctions for use, such as parental reactions, as less prevalent in their lives. Vaping may, therefore, represent a slippery slope toward other forms of substance use among mildly riskprone individuals who would otherwise not have considered smoking tobacco. Given that studies have now repeatedly shown a link between vaping and increased risk of escalation into smoking,5 our findings underscore the possible role of vaping as a behavioral slope toward the increased risk of substance use through less perceived parental sanctions to such use. Notwithstanding these findings however, for prevention practice, it is logical to underline that a clear distinction be made between the primary and secondary elements of vaping which may be helpful for smokers attempting to quit, while discouraged among never smokers, especially minors. Noteworthy study limitations are (a) the cross-sectional design that negates any causal interpretation and (b) the inability to separate smokers from dual users (i.e. those who smoke and vape) as nearly all smokers in our sample were also vapers. In conclusion, previous studies have shown vaping to be a possible slope toward tobacco smoking. Lower levels of perceived negative parental reactions to substance use may represent one mechanism that may explain why vapers are more likely than non-users to both use other substances and slide toward tobacco smoking.
Author statements Ethical approval Data collection procedures for this study were deemed ‘exempt’ by the National Bioethics Committee of Iceland that oversees the ethical review of studies with human subjects (Ref # VSNb2017020009/04.01).
Funding No specific funding was provided for this analysis.
117
Competing interests All authors declare no competing interests.
references
1. Pokhrel P, Fagan P, Kehl L, Herzog TA. Receptivity to ecigarette marketing, harm perceptions, and e-cigarette use. Am J Health Behav 2015;39:121e31. 2. Rubinstein MLDK, Benowitz NL, Ramo DE. Adolescent exposure to toxic volatile organic chemicals from ecigarettes. Pediatrics 2018;141:e20173557. 3. Glasser AMCL, Pearson JL, Abudayyeh H, Niaura RS, Abrams DB, Villanti AC. Overview of electronic nicotine delivery systems: a systematic review. Am J Prev Med 2017;52:e33e66. 4. Levy DTBR, Lindblom EN, Goniewicz ML, Meza R, Holford TR, Yuan Z, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobac Contr 2018;27:18e25. 5. Soneji SB-TJ, Wills TA, Leventhal AM, Unger JB, Gibson LA, Yang J, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr 2017;171:788e97. 6. Kristjansson AL, James JE, Allegrante JP, Sigfusdottir ID, Helgason AR. Adolescent substance use, parental monitoring, and leisure-time activities: 12-year outcomes of primary prevention in Iceland. Prev Med 2010;51:168e71. 7. Kristjansson AL, Sigfusdottir ID, James JE, Allegrante JP, Helgason AR. Perceived parental reactions and peer respect as predictors of adolescent cigarette smoking and alcohol use. Addict Behav 2010;35:256e9. 8. Kristjansson AL, Sigfusdottir ID, Thorlindsson T, Mann MJ, Sigfusson J, Allegrante JP. Population trends in smoking, alcohol use and primary prevention variables among adolescents in Iceland, 1997-2014. Addiction 2016;111:645e52. 9. Kristjansson AL, Sigfusson J, Sigfusdottir ID, Allegrante JP. Data collection procedures for school-based surveys among adolescents: the Youth in Europe study. J Sch Health 2013;83:662e7. 10. Kristjansson AL, Mann MJ, Sigfusdottir ID. Licit and illicit substance use by adolescent e-cigarette users compared with conventional cigarette smokers, dual users, and nonusers. J Adolesc Health 2015;57:562e4.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Perceived parental reactions to substance use among adolescent vapers compared with tobacco smokers and non-users in Iceland A.L. Kristjansson a,b,*, J.P. Allegrante b,d,e, I.D. Sigfusdottir b,c,d a
Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, WV, 26505, USA b Icelandic Center for Social Research and Analysis, Reykjavik University, 101 Reykjavik, Iceland c Department of Psychology, Reykjavik University, 101 Reykjavik, Iceland d Department of Health and Behavior Studies, Teachers College, Columbia University, New York, 10027, NY, USA e Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, 10032, NY, USA
article info
abstract
Article history:
Objectives: The objective is to assess perceived parental reactions to cigarette smoking,
Received 30 April 2018
vaping, drunkenness, and marijuana use among cigarette smokers, vapers, and those who
Received in revised form
neither smoke nor vape (non-users).
23 July 2018
Study design: It is a population-based, cross-sectional, school survey with all accessible 13-
Accepted 9 August 2018
to 16-year-old students in Iceland (response rate: 84.1%). Methods: Data were analyzed in Mplus using multinomial logistic regression for categorical data with maximum likelihood and robust standard errors, adjusting for potential school
Keywords:
clustering.
Electronic cigarettes
Results: Across all four outcome categories and controlling for background factors, non-
Iceland
users were more likely than vapers and smokers to perceive their parental reactions to
Adolescents
substance use as negative (P < 0.01). Vapers were significantly more likely than smokers to
Primary prevention
perceive their parental reactions as negative toward all types of substance use (P < 0.01). Conclusions: Adolescent smokers, vapers, and non-users appear to form a sequential risk gradient toward perceived parental reactions to substance use, with smokers being least likely to perceive their parental reactions as negative and vapers thereafter; non-users are most likely to perceive their parental reactions toward substance use as negative. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, WV, 26505, USA. E-mail address: [email protected] (A.L. Kristjansson). https://doi.org/10.1016/j.puhe.2018.08.005 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
116
p u b l i c h e a l t h 1 6 4 ( 2 0 1 8 ) 1 1 5 e1 1 7
Introduction While the long-term physical harm of vaping remains unclear, it is generally considered a safer alternative to tobacco smoking,1 although vaping, especially for minors, is not entirely harmless.2 The tobacco control community has also highlighted notable differences in viewpoints on vaping based on the principles of primary prevention (i.e., prevention of initiation) and secondary prevention (i.e., smoking cessation, harm reduction).3,4 However, irrespective of different viewpoints about the physical harm of vaping and whether electronic cigarettes are applicable as harm reduction tools for current smokers, a more consistent literature has now established that adolescents who initiate vaping before any form of tobacco use are significantly more likely than never users to escalate into smoking.5 Vaping should, therefore, be discouraged among never smokers. From a primary prevention perspective, an important effort to curb the initiation of vaping by never smokers is to understand the level of environmental sanctions, or lack thereof, that contribute to the odds of vaping and other substance use. Few sanctions are more important than the ones provided by parents.6,7 Parents are at the center of most primary prevention efforts and programs,6 and their perceived disapproval of usage by children and adolescents is an important preventive mechanism.7 In this study, we investigated the relationship among perceived parental reactions to vaping, smoking, drunkenness, and marijuana use in a large sample of 13- to 16year-old never smokers, vapers, and cigarette smokers, in Iceland, which has been highlighted for its strong communitybased primary prevention efforts that have led in achieving some of the greatest reductions in adolescent substance use in all of Europe over a 20-year period.8 Iceland, currently, has the lowest or the second lowest rates of adolescent smoking and alcohol use in all of Europe.8
Methods Data from the 2018 population-based Youth in Iceland survey on substance use and risk, and protective factors were analyzed. The survey was administered to all 8th through to 10th grade students (aged 13e16 years) in Iceland, by the Icelandic Centre for Social Research and Analysis at Reykjavik University. Consistent with published protocols,9 data collection was conducted at the population level with all accessible students in all 135 schools in the country, using anonymous questionnaires, supervised by a contact agent in each school using procedures deemed exempt by the Icelandic authority overseeing the protection of human research subjects. Passive consent was used. A total of 10,651 students returned completed questionnaires (response rate: 84.1%). The current smoking status was determined by a combination of responses to four questions about lifetime and current (i.e., 30 day) vaping and smoking with 1 ¼ never (i.e., neither vaping or smoking ever in their lifetime), 2 ¼ vaping only (i.e., electronic cigarettes at least once during the last 30 days but no combustible cigarettes), and 3 ¼ smoking or dual use (combustible cigarettes or both vaping and smoking at
least once during last 30 days). For perceived parental reactions, participants were asked to indicate how their parents would react if they (a) ‘would smoke cigarettes’, (b) ‘would use electronic cigarettes or vape’, (c) ‘would become drunk’, and (d) ‘would use marijuana’. Responses ranged from 1 ¼ ‘very much against’ to 4 ¼ ‘almost would not care’. Control variables included gender, coded 1 ¼ girls (50.3%), 0 ¼ boys; grade, coded 1 ¼ 8th grade, 2 ¼ 9th grade, and 3 ¼ 10th grade; family structure, coded 1 ¼ lives with both parents (69.8%), 0 ¼ other forms; perceived family financial status, ranging from 1 ¼ ‘much better off’ to 7 ¼ ‘much worse off’; and a composite measure on the father and mother educational status ranging from 1 ¼ ‘college graduate’ to 5 ¼ ‘elementary school or less’. Analyses were conducted in Mplus using multinomial logistic regression for categorical data with maximum likelihood and robust standard errors, adjusting for potential school clustering (average cluster ¼ 59.9 students, intraclass correlation coefficient (ICC) ¼ 1.8%).
Results About 83% of the sample had neither tried vaping nor tobacco smoking, 3.2% were current smokers, and 13.6% were current vapers. Table 1 shows the results from the multinomial logistic regression models with vapers as a reference group. After controlling for confounding background variables, i.e. gender, grade, family structure, family financial status, and parental education, non-users were significantly more likely than vapers to report that their parents would react negatively to all four forms of substance use. Conversely, vapers were significantly more likely than cigarette smokers to report that their parents would react negatively to all forms of substance use.
Discussion These results indicate that even after controlling for a host of background variables, non-users were more likely to perceive their parental reactions to all forms of substance use as negative, compared with vapers, who subsequently were more likely than smokers to perceive their parental reactions as negative to all forms of substance use. These findings suggest a sequential risk gradient by the smoking status in perception to parental reactions to substance use. Previously, we found a similar risk gradient between the odds of eight
Table 1 e Odds ratios from multinomial logistic regression models with vapers as the reference category (control relationships not shown). Perceived parental reaction
Non-users (95% CI)
Cigarette smokers (95% CI)
To electronic cigarette use To cigarette smoking To drunkenness To marijuana use
0.32 (0.29e0.35)**
1.37 (1.19e1.59)**
0.61 (0.54e0.70)** 0.62 (0.54e0.72)** 0.60 (0.53e0.69)**
1.87 (1.55e2.25)** 1.52 (1.25e1.85)** 1.52 (1.27e1.83)**
CI, confidence interval. ** P < 0.01.
p u b l i c h e a l t h 1 6 4 ( 2 0 1 8 ) 1 1 5 e1 1 7
types of substance use and smoking status, with vapers consistently being in between non-users and smokers.10 Together with these findings, it appears that vapers are not only more likely to use other substances than non-smokers but are also more likely to perceive critical environmental sanctions for use, such as parental reactions, as less prevalent in their lives. Vaping may, therefore, represent a slippery slope toward other forms of substance use among mildly riskprone individuals who would otherwise not have considered smoking tobacco. Given that studies have now repeatedly shown a link between vaping and increased risk of escalation into smoking,5 our findings underscore the possible role of vaping as a behavioral slope toward the increased risk of substance use through less perceived parental sanctions to such use. Notwithstanding these findings however, for prevention practice, it is logical to underline that a clear distinction be made between the primary and secondary elements of vaping which may be helpful for smokers attempting to quit, while discouraged among never smokers, especially minors. Noteworthy study limitations are (a) the cross-sectional design that negates any causal interpretation and (b) the inability to separate smokers from dual users (i.e. those who smoke and vape) as nearly all smokers in our sample were also vapers. In conclusion, previous studies have shown vaping to be a possible slope toward tobacco smoking. Lower levels of perceived negative parental reactions to substance use may represent one mechanism that may explain why vapers are more likely than non-users to both use other substances and slide toward tobacco smoking.
Author statements Ethical approval Data collection procedures for this study were deemed ‘exempt’ by the National Bioethics Committee of Iceland that oversees the ethical review of studies with human subjects (Ref # VSNb2017020009/04.01).
Funding No specific funding was provided for this analysis.
117
Competing interests All authors declare no competing interests.
references
1. Pokhrel P, Fagan P, Kehl L, Herzog TA. Receptivity to ecigarette marketing, harm perceptions, and e-cigarette use. Am J Health Behav 2015;39:121e31. 2. Rubinstein MLDK, Benowitz NL, Ramo DE. Adolescent exposure to toxic volatile organic chemicals from ecigarettes. Pediatrics 2018;141:e20173557. 3. Glasser AMCL, Pearson JL, Abudayyeh H, Niaura RS, Abrams DB, Villanti AC. Overview of electronic nicotine delivery systems: a systematic review. Am J Prev Med 2017;52:e33e66. 4. Levy DTBR, Lindblom EN, Goniewicz ML, Meza R, Holford TR, Yuan Z, et al. Potential deaths averted in USA by replacing cigarettes with e-cigarettes. Tobac Contr 2018;27:18e25. 5. Soneji SB-TJ, Wills TA, Leventhal AM, Unger JB, Gibson LA, Yang J, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr 2017;171:788e97. 6. Kristjansson AL, James JE, Allegrante JP, Sigfusdottir ID, Helgason AR. Adolescent substance use, parental monitoring, and leisure-time activities: 12-year outcomes of primary prevention in Iceland. Prev Med 2010;51:168e71. 7. Kristjansson AL, Sigfusdottir ID, James JE, Allegrante JP, Helgason AR. Perceived parental reactions and peer respect as predictors of adolescent cigarette smoking and alcohol use. Addict Behav 2010;35:256e9. 8. Kristjansson AL, Sigfusdottir ID, Thorlindsson T, Mann MJ, Sigfusson J, Allegrante JP. Population trends in smoking, alcohol use and primary prevention variables among adolescents in Iceland, 1997-2014. Addiction 2016;111:645e52. 9. Kristjansson AL, Sigfusson J, Sigfusdottir ID, Allegrante JP. Data collection procedures for school-based surveys among adolescents: the Youth in Europe study. J Sch Health 2013;83:662e7. 10. Kristjansson AL, Mann MJ, Sigfusdottir ID. Licit and illicit substance use by adolescent e-cigarette users compared with conventional cigarette smokers, dual users, and nonusers. J Adolesc Health 2015;57:562e4.