DOI: 10.1590/1516-3180.2017.

0154220717 ORIGINAL ARTICLE

Smoking among adolescents is associated with their own

characteristics and with parental smoking: cross-sectional study
Rafaela Campos Cuissi de AndradeI, Aline Duarte FerreiraII, Dionei RamosIII, Ercy Mara Cipulo RamosIII,
Catarina Covolo ScarabottoloIV, Bruna Thamyres Ciccotti SaraivaIV, Luis Alberto GobboV, Diego Giulliano Destro ChristofaroV
This study was developed in the city of Londrina (PR), Brazil

MSc. Physiotherapist, Department of

I ABSTRACT
Physiotherapy, School of Technology and BACKGROUND: This study aimed to analyze the association between smoking during adolescence and
Sciences, Universidade Estadual Paulista Julio the characteristics of smoking and alcohol consumption among their parents.
de Mesquita Filho (UNESP), Presidente Prudente DESIGN AND SETTING: Cross-sectional study in Londrina (PR), Brazil.
(SP), Brazil. METHODS: The subjects comprised 1,231 adolescents aged 14-17 years. The adolescents and their par-
II
MSc. Professor, Department of Physical ents answered a self-report questionnaire that asked for sociodemographic information and data on
Education, Universidade do Oeste Paulista smoking and alcohol consumption. Multiple logistic regression models were used to analyze associations
(UNOESTE), Presidente Prudente (SP), Brazil. between smoking among adolescents and their characteristics (age, sex, period of the day for attending
Professor, Department of Physiotherapy,
III
school, alcohol consumption and socioeconomic level) and their parents’ characteristics (smoking, alcohol
Universidade Estadual Paulista Julio de Mesquita consumption, age and education level), adjusted according to the adolescents’ characteristics (sex, age
Filho (UNESP), School of Technology and
and socioeconomic level).
Sciences, Presidente Prudente (SP), Brazil.
RESULTS: The prevalence of smoking among adolescents was 3.4% (95% confidence interval, CI: 2.4-4.4).
IV
Master’s Student, Department of Physical
Adolescents whose mothers or fathers were smokers were 2.0 and 2.5 times more likely to be smokers,
Education, Universidade Estadual Paulista
Julio de Mesquita Filho (UNESP), Instituto de respectively. The prevalence of smoking among adolescents with a smoking mother was 7.1% (95% CI:
Biociências Campus de Rio Claro, Rio Claro (SP), 2.6-10.7) and a smoking father, 5.4% (95% CI: 1.6-8.5). There were significant associations between smok-
Brazil. ing adolescents and age [5.2% (95% CI: 3.3-6.6)], studying at night [9.6% (95% CI: 4.0-15.5)] and alcohol
V
Professor, Department of Physical Education, consumption [69.0% (95% CI: 55.0-83.0)]. It was observed that the number of alcoholic beverage doses
School of Technology and Sciences, consumed was higher among smoking adolescents (P = 0.001).
Universidade Estadual Paulista Paulista Julio de CONCLUSION: Adolescent smoking was associated with smoking by their parents, regardless of the gen-
Mesquita Filho (UNESP), Presidente Prudente der of the parents or adolescents. Age, alcohol consumption and studying at night are characteristics of
(SP), Brazil. adolescents that can contribute towards smoking.

KEY WORDS:
Adolescent.
Smoking.
INTRODUCTION
Parents.
Smoking is considered to be a behavior that puts health at risk.1 Several studies have demon-
strated a strong relationship between smoking and various types of diseases in the adult popu-
lation, such as carotid calcification2 and other cardiovascular problems, like stroke.3 However,
this type of behavior has been detected not only among adults, but also in young populations.
In a study conducted in Saudi Arabia, Al-Zalabani and Kasim4 observed that the prevalence of
smoking was around 15% among the young people who they evaluated.
Adolescent smoking is increasing in poorer countries. Smoking in adulthood may start during
adolescence, which demonstrates the importance of studies addressing this issue.5 Tavares et al.6
and Barreto et al.7 highlighted that adolescence is a period of great exposure and vulnerability
to consumption of substances such as tobacco and alcohol, with frequent experimentation by
adolescents. Consequently, determining the factors that could cause this type of behavior among
adolescents is important. Another aspect that has been investigated is whether adolescents’ house-
hold environment might contribute to such behavior.
In a study on adolescents aged 13-18 years, Vázquez-Rodríguez et al.8 reported that paren-
tal smoking was associated with smoking among their children. Similar results were observed
in some studies in which adolescent smoking was more prevalent among those whose parents
were smokers.9,10 Tondowski et al.9 showed that approximately 45% of adolescents who reported
frequent tobacco use had fathers or mothers who smoked. In addition, it has been shown that
smoking during adolescence may be linked both to use of illicit drugs such as marijuana and to
use of licit drugs such as alcohol.11-15

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 ORIGINAL ARTICLE | Andrade RCC, Ferreira AD, Ramos D, Ramos EMC, Scarabottolo CC, Saraiva BTC, Gobbo LA, Christofaro DGD

The majority of previous studies have only examined parental The adolescents took the consent form home for their par-
smoking as a risk factor. However, other lifestyle variables such as ents to sign and thus authorize the adolescent to participate in the
alcohol consumption and sociodemographic characteristics such study. Along with this consent form, they also took the parents’
as the parents’ ages and educational levels, also need to be con- questionnaire with them, so that their parents could answer this
sidered. One of the hypotheses is that the parents’ characteristics instrument at home. The parents’ questionnaire contained questions
other than smoking may also be associated with smoking among about their lifestyle habits (among them smoking and alcohol con-
adolescents. Moreover, it needs to be emphasized that the charac- sumption) and sociodemographic variables (sex, age and schooling
teristics of the adolescents themselves should also be considered level). In total, 1,202 mothers and 871 fathers answered the ques-
in order to eliminate possible confounding factors, since late ado- tionnaire. Subsequently, the adolescents were evaluated at school.
lescence16 and being male17 tend to be more associated with smok-
ing, and socioeconomic level may also be associated, depending Smoking and alcohol
on the characteristics of each country.18 Smoking status was ascertained through analysis of participants’
Studies that investigate lifestyle habits between parents and smoking behavior.19 If individuals replied that they had smoked
children can contribute towards health promotion actions, if these cigarettes within the previous 30 days, they were considered to
relationships are observed in the family environment. Therefore, the be smokers. The number of cigarettes that these individuals con-
aim of the present study was to analyze the association between sumed in a typical week was also established.
smoking during adolescence and the lifestyle characteristics (smok- Alcohol consumption was obtained through questions based
ing and alcohol consumption) of parents or family members who on the questionnaire of the Brazilian Center for Psychotropic Drugs
live with adolescents. (CEBRID),20 which assesses the frequency and quantity of alcoholic
drinks consumed. Adolescents and parents or family members who
METHODS reported consumption of more than 1-2 doses (each dose corre-
sponded to 250 ml of beer or 40 ml of distilled beverages in this
Sample study) on more than 1-2 days a week were classified as high consum-
The sample of this study formed part of a larger study that looked ers. The cutoff points used in this study were adapted from Moreira
at risk factors for health among adolescents at public schools in et al.21 These instruments demonstrate good reproducibility values:
the city of Londrina (PR), Brazil, and among their parents. To kappa = 0.81 for smoking and kappa = 0.83 for alcohol consumption.
contact the adolescents, the Londrina Department of Education
was first contacted in order to explain the objectives of the study. Anthropometric variables
Subsequently, the Department identified the six largest public The adolescents were measured wearing light clothing and no
schools in the central region, which receive adolescents from dif- shoes. Weight was measured using a portable scale (Plenna; preci-
ferent areas of the city (north, south, east, west and central areas). sion of 0.100 kg) with a capacity of 150 kg. Height was measured
Subsequently, the researchers contacted the principals of the using a portable stadiometer (Sanny; precision of 0.1 cm) with a
schools that were invited to participate in the study to explain scale in centimeters. The anthropometric characteristics of the
the objectives of the study. After authorization from the schools’ adolescents were evaluated by two previously trained evaluators.
directors, contact was made with all classes of students aged The procedures were applied in accordance with the recommenda-
14-17 years in these schools. tions of Gordon et al.22 To assess the participants’ nutritional status,
To calculate the sample, the prevalence of smoking among the body mass index (BMI) was calculated as the ratio between the
adolescents was taken to be 15%,4 and a tolerable error of 3% and weight and height squared. The adolescents’ nutritional status was
power of 80% were used. Since the sample was selected through classified in accordance with the values proposed by Cole et al.23
clusters, a design correction of 1.5 was used. To anticipate possible Overweight among the parents was determined based on the cut-
losses from the sample, 10% was added to the sample calculation. off points of the World Health Organization, and adults with BMI
Thus, the minimum sample required was 870 adolescents. In the greater than or equal to 25 kg/m2 were classified as overweight.24
end, the study included 1231 adolescents (716 girls and 515 boys)
aged 14-17 years. Sociodemographic variables
Adolescents and their parents or family members who agreed to The parents’ educational level was evaluated as the number of years
participate in the study signed a free and informed written consent of study reported over the course of their lives. Parental schooling
form. This study was approved by the Research Ethics Committee was divided into terciles, such that lower education level was con-
of the institution responsible for this study (procedural number: sidered to be up to 8 years of study; medium education level, from
0.181.0.268.000-10; register number: 367.801). 8 to 12 years; and higher education level, more than 12 years.

562 Sao Paulo Med J. 2017; 135(6):561-7

 Smoking among adolescents is associated with their own characteristics and with parental smoking: cross-sectional study | ORIGINAL ARTICLE

Parental age was determined as the difference between the date the adolescents’ sex and socioeconomic status would be inserted as
of data collection and birth date. Subsequently, age was divided adjustment variables. This was done to ascertain whether the possible
into terciles. associations between smoking and the variables analyzed would be
To define the families’ economic class, the 2011 Brazilian eco- independent of these confounding factors.
nomic classification criteria of the Brazilian Market Research The significance level used for all analyses was P ≤ 5%. The con-
Association (ABEP) were used.25 Householders’ education level fidence interval (CI) used was 95%. The analyses were performed
and the presence and quantity of certain rooms, assets and domes- using the Statistical Package for the Social Sciences (SPSS) soft-
tic employees in the homes analyzed were considered (color TV, ware, version 15.0.
VCR or DVD player, radio, number of bathrooms, car, washing
machine, housemaids, refrigerator and freezer). At the end of this RESULTS
instrument, a scoring system is provided in which the individual The prevalence of smoking in the sample of this study was
is classified according to economic strata, such that higher scores 3.4% (95% CI: 2.4-4.4), which was equivalent to 42 adolescents.
represent higher economic strata. The average number of cigarettes smoked by the adolescents
interviewed was 0.29 per month with no difference between boys
Statistical analysis and girls (P = 0.351). The prevalence of smoking among the moth-
The data characterizing the sample were presented as means ers was 12.1% (95% CI: 10.5-14.2) and among the fathers, 17.9%
and standard deviations stratified according to smoking status (95% CI: 15.3-20.4). Smoking mothers consumed more alcohol
(smoker or nonsmoker). Analysis on the association between the than did mothers who did not smoke. Fathers who smoked pre-
dependent variable (smoking adolescents) and the independent sented lower weight, lower BMI and higher alcohol consump-
variables was performed using the chi-square test. tion than did fathers who did not smoke. Mothers and fathers
Subsequently, two multivariate models were created and were with fewer years of schooling were more likely to be smokers.
analyzed through binary logistic regression. The association between The prevalence of smoking was higher among fathers and moth-
smoking adolescents and their own characteristics (sex, age, period of ers of medium socioeconomic status. Table 1 presents informa-
the day for attending school, day or night, socioeconomic status and tion regarding sample characterization. It can be seen that the
alcohol consumption) was analyzed. The association between smok- highest average of alcoholic beverages consumed in doses were
ing adolescents and the characteristics of their mothers and fathers higher among smoking adolescents.
was analyzed. In the first model, unadjusted smoking among adoles- Table 2 shows the significant associations between smoking among
cents was analyzed in relation to their mothers and fathers’ smoking, adolescents and later adolescence, studying at night and alcohol con-
alcohol consumption, age and education level. In the second model, sumption. Older adolescents (16-17 years) presented higher levels of
which was adjusted according to the adolescents’ characteristics, the smoking behavior (5.2%; 95% CI: 3.45-6.82) than younger adolescents
sociodemographic variables of the adolescents that might be poten- (1.6%; 95% CI: 0.56-2.61) (P = 0.002). The adolescents who studied
tial confounders were considered (sex, age and socioeconomic status). in the evenings presented higher prevalence of smoking (9.6%; 95%
Although only the adolescents’ ages presented P values lower than CI: 4.0-15.5) than those who studied during the day (3.2%; 95% CI:
0.200, it was decided that, in analyzing the association with smoking, 1.94-3.91). Smoking adolescents presented higher frequency of alcohol

Table 1. Characteristics of the sample according to smoking status

Adolescents Mothers Fathers
Mean (SD) Mean (SD) Mean (SD)
Nonsmoker Smoker P-value Nonsmoker Smoker P-value Nonsmoker Smoker P-value
Age (years) 15.53 (1.06) 16.2 (0.9) 0.001 43.2 (7.0) 43.6 (8.1) 0.532 45.9 (7.4) 44.8 (7.5) 0.098
Weight (kg) 21.5 (13.0) 62.9 (13.0) 0.155 68.1 (12.8) 66.7 (12.7) 0.205 82.8 (14.2) 78.5 (14.6) 0.001
Height (cm) 166.61 (9.1) 169.1 (8.6) 0.085 161.3 (6.4) 161.3 (6.3) 0.991 173.0 (6.9) 173.4 (7.4) 0.568
Alcohol (doses) 0.42 (0.1) 2.0 (0.2) 0.001 0.4 (0.1) 1.1 (0.3) ≤ 0.001 1.21 (1.1) 2.13 (1.6) 0.001
Body mass index (kg/m2) 21.5 (3.8) 21.9 (4.0) 0.518 26.1 (4.7) 25.6 (4.5) 0.158 27.6 (4.09) 26.1 (4.38) 0.001
Education level (years) 10.5 (1.0) 11.2 (0.9) 0.001 8.3 (3.8) 7.3 (3.4) 0.002 8.0 (3.5) 6.6 (3.4) ≤ 0.001
Socioeconomic level (%)
High 39.0 38.1 40.2 29.5 44.3 30.1
Medium 55.4 57.1 0.988 54.7 60.1 0.003 52.4 64.1 0.001
Low 5.6 4.8 5.1 9.4 3.4 5.8
Nutritional status (%)
Normal weight 96.8 95.6 87.1 88.0 72.5 86.2
0.496 0.682 ≤ 0.001
Overweight 3.2 4.4 12.9 12.0 27.5 13.8
SD = standard deviation.

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 ORIGINAL ARTICLE | Andrade RCC, Ferreira AD, Ramos D, Ramos EMC, Scarabottolo CC, Saraiva BTC, Gobbo LA, Christofaro DGD

consumption: among the 42 adolescents who smoked, 29 (69.0%; among adolescents between those with older mothers and those with
95% CI: 55.0-83.0) consumed alcohol and 7.0% of them (95% CI: younger mothers, or between those with mothers with lower edu-
0.65-14.95) consumed alcohol with a frequency of four times a week. cation levels and those with mothers with higher education levels.
Table 3 shows the associations between adolescents who smoked The prevalence of smoking among adolescents with smoking
and mothers or female guardians who smoked. Adolescents whose fathers was 5.4% (95% CI: 1.6-8.5). Smoking among fathers was
mothers were smokers were twice as likely to have this habit. The prev- also associated with smoking among adolescents: teens whose
alence of smoking among adolescents with smoking mothers was fathers smoked were 2.5 times more likely to be smokers (Table 4).
7.1% (95% CI: 2.6-10.7), compared with 2.3% (95% CI: 1.85-3.86) Table 5 presents information on the relationship between smok-
among adolescents with non-smoking mothers. In both the raw and ing among adolescents and the smoking habits of both of their
adjusted analyses on the variables relating to the adolescents, asso- parents. There were no associations between adolescent smoking
ciations between smoking adolescents and alcohol consumption and both parents smoking.
could be seen. There were no significant differences in smoking levels
DISCUSSION
Table 2. Association between adolescents’ smoking habits and their The prevalence of smoking adolescents in this study can be con-
characteristics sidered low (3.4%) in comparison with other studies.4,26 In a
95% confidence recent study, Figueiredo et al.16 observed that the prevalence of
Characteristics Odds ratio P-value
interval
smoking in a sample of adolescents aged from 12 to 17 years
Age
was 5.7%, considering several Brazilian cities. Their findings
14-15 years 1.00 1.00 1.00
16-17 years 3.26 1.54-6.88 0.002 were similar to those of the present study and their prevalence
Sex can also be considered low. One reason for this low prevalence
Male 1.00 1.00 1.00 appears to be related to restrictions on tobacco advertising on the
Female 0.71 0.38-1.31 0.277 television and to laws prohibiting tobacco use in public places,
Period of attending school
along with increased prices for cigarettes and increased activity
Daytime 1.00 1.00 1.00
of smoking cessation programs, as shown by Levy et al.27
Night 3.21 1.49-6.92 0.003
Socioeconomic level There were no significant differences in the nutritional status
High 1.00 1.00 1.00 of adolescent smokers and nonsmokers in this study. This same
Medium 1.05 0.55-2.01 0.868 relationship was observed for the mothers, but smoking fathers
Low 0.87 0.19-3.90 0.865 presented lower weight and prevalence of overweight than did
Alcohol consumption nonsmoking fathers. Adolescents are at an early stage of life, at
No 1.00 1.00 1.00
which they have probably not yet established a pattern for nutri-
Yes 6.81 3.59-12.90 0.001
tional status or smoking habits. Considering the difference in
the nutritional status among their fathers, one of the reasons for
Table 3. Association between smoking among adolescents and
characteristics of their mothers this that can be considered is nicotine levels, which cause several
Adjusted using
changes to appetite and metabolic rate, thus giving rise to differ-
Mothers’ ences between smokers and nonsmokers.28 For both fathers and
Crude P-value adolescents’ P-value
characteristics
characteristics* mothers, those with higher average schooling levels presented
Smoking lower tobacco consumption than did parents with lower schooling
No 1.00 1.00
levels, possibly because parents with higher education levels have
Yes 2.44 (1.17-5.11) 0.017 2.37 (1.23-5.00) 0.022
more knowledge about the harm that cigarette smoking can cause.
Alcohol consumption
No 1.00 1.00 This study found that adolescents whose mothers or fathers
Yes 1.90 (1.00-3.60) 0.049 1.91 (1.00-3.66) 0.049 smoked were about 2.0 and 2.5 times as likely, respectively, to have
Age the same kind of behavior, even after various adjustments for poten-
≤ 40 years 1.00 1.00 tial confounders. It was observed that the habit of smoking among
41-46 years 1.32 (0.63-2.79) 0.455 1.22 (0.57-2.59) 0.727 parents was associated with their children’s habits, independent
≥ 47 years 1.27 (0.58-2.78) 0.925 1.37 (0.62-3.03) 0.659
of the abovementioned variables. In a study on young Canadians,
Educational level
Low 1.00 1.00
O’Loughlin et al.29 also observed that parental smoking was associ-
Medium 0.82 (0.36-1.86) 0.645 0.83 (0.35-1.94) 0.729 ated with the onset of smoking during their children’s adolescence,
High 1.10 (0.48-2.48) 0.818 1.08 (0.47-2.50) 0.759 regardless of parental schooling levels. Similar relationships have
*Adjusted according to the adolescents’ sex, socioeconomic level and age. been observed in other studies.9,10

564 Sao Paulo Med J. 2017; 135(6):561-7

 Smoking among adolescents is associated with their own characteristics and with parental smoking: cross-sectional study | ORIGINAL ARTICLE

The fact is that teens tend to replicate their parents’ habits. In a Additionally, adolescents who went to school in the evenings
recent meta-analysis, Laird et al.30 observed that adolescents with were about three times more likely to have a smoking habit than
physically active parents were more likely to be physically active. their peers who attended school during the day. This corroborated
However, this replication of habits does not seem to occur for the findings of Farias Junior et al.35 who observed that young people
healthy habits alone, and a similar relationship regarding smoking who attended classes in the evenings presented a greater chance of
habits is observed between adolescents and their parents. One of being smokers. This relationship was also observed among almost
the hypotheses for this is that these young people may have felt 3,000 adolescents in northern Brazil.36 Among the reasons that
more freedom to experiment with smoking because of the exam- could explain this relationship, the first is that adolescents who
ple seen in their homes. study in the evenings have a higher average age than the adoles-
Having a father and/or mother who smokes seems to repre- cents who study during the day.
sent a permissive attitude for adolescents, based on their parents’ Another characteristic of the adolescents attending school in
behavior, thus producing an image that smoking is acceptable and the evenings is that they tend to work during the day, which aids
possibly contributing towards a process of initiation of smoking. independence and brings the possibility of buying cigarettes with
Nonetheless, in our sample, contrary to expectations, there was their own income. The association between adolescents working
no association between smoking among adolescents and both par- and smoking has also been reported in another study.37 A further
ents being smokers. One of the possible reasons for this finding factor to be considered as a hypothesis, but which was not analyzed
is that the prevalence of occurrences of both parents smoking at in this study, is that at night, several bars and nightclubs, which
home was low: only 4.4%. are often close to where schools are located, are open. This may
An association was observed between mothers who had the contribute towards this type of behavior among young people who
behavior of consuming alcohol and smoking among adolescents. attend these places.
One of the possible reasons for this is the strong relationship
between smoking and alcohol. Elicker et al. showed that 39.2% Table 4. Association between smoking among adolescents and
of the adolescents in Porto Velho (RO), Brazil, consumed alcohol characteristics of their fathers
Adjusted using
for the first time at home.31 This may be one of the reasons, since Fathers’
Crude P-value adolescents’ P-value
alcohol consumption at parties or family meetings would not be characteristics
characteristics*
characterized as a risk factor for health, but as a normal attitude Smoking
that could be related to smoking. Perhaps parents who are per- No 1.00 1.00
missive regarding alcohol use may also be permissive regarding Yes 2.51 (1.04-6.05) 0.039 2.58 (1.06-6.28) 0.029
to smoking among young people. Alcohol consumption
No 1.00 1.00
Among the characteristics of adolescent smoking, there were
Yes 2.40 (0.88-6.55) 0.085 2.37 (0.86-6.47) 0.095
associations with age (being older), alcohol consumption and the
Age
period of the day in which adolescents attended school (night). ≤ 43 years 1.00 1.00
Khuder et al.32 found that older adolescents were about six times 44-47 years 0.98 (0.35-2.70) 0.978 0.87 (0.31-2.41) 0.665
more likely to be smokers than younger adolescents. One reason ≥ 48 years 0.57 (0.20-1.56) 0.275 0.46 (0.16-1.28) 0.137
for this relationship is the transformation that adolescents expe- Educational level
Low 1.00 1.00
rience during this stage of life. This is a period in which social
Medium 0.64 (0.64-2.07) 0.465 0.77 (0.23-2.58) 0.725
relationships are important, and this could contribute towards
High 1.20 (0.41-3.55) 0.736 1.33 (0.45-3.95) 0.398
starting some types of behavior such as smoking, with the aim
*Adjusted according to the adolescents’ sex, socioeconomic level and age.
of achieving acceptance in social groups. Several studies have
reported the strong influence that friends have on smoking hab- Table 5. Association between smoking among adolescents and
its among adolescents.10,33 smoking among parents
Regarding alcohol consumption, those who consumed alco- Adjusted using
Both parents’
holic beverages were six times more likely to be smokers. Several Crude P-value adolescents’ P-value
characteristics
studies have demonstrated significant relationships between smok- characteristics*
Smoking
ing and alcohol consumption among adolescents.13-15 Among the
Neither 1.00 1.00
substances found in large quantities in cigarettes, nicotine acts in
Mother or
many areas of the brain. It has been hypothesized that neuronal 1.74 (0.65-4.66) 0.267 1.70 (0.62-4.58) 0.299
father
nicotinic acetylcholine receptors act in a specific brain area that Both parents 2.72 (0.59-12.55) 0.198 2.99 (0.62-14.01) 0.165
also causes higher propensity towards alcohol use.34 *Adjusted according to the adolescents’ sex, socioeconomic level and age.

Sao Paulo Med J. 2017; 135(6):561-7 565

 ORIGINAL ARTICLE | Andrade RCC, Ferreira AD, Ramos D, Ramos EMC, Scarabottolo CC, Saraiva BTC, Gobbo LA, Christofaro DGD

The practical application for the present study is that it serves 4. Al-Zalabani A, Kasim K. Prevalence and predictors of adolescents’
as a reminder to different healthcare agencies regarding the impor- cigarette smoking in Madinah, Saudi Arabia: a school-based cross-
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