DOI:10.31557/APJCP.2019.20.10.3029
Intergenerational Transfer of Tobacco Use Behaviour
RESEARCH ARTICLE
Editorial Process: Submission:06/05/2019 Acceptance:09/15/2019
Intergenerational Transfer of Tobacco Use Behaviour from
Parent to Child: A Case Control Study
Chandrashekar Janakiram*, Vinita Sanjeevan, Joe Joseph
Abstract
Background: Parental influence may be a strong modifiable risk factor in the initiation of Tobacco habits
among young adults. Parenting style may modify the risk of initiation of Tobacco use. Objective: To examine the
intergenerational transfer of Tobacco habits amongst the urban and tribal populations in Kerala. Methodology: A
hospital based unmatched case control study was undertaken in urban and tribal health centres in Kerala, India. 239
cases (19-30 years of age using any form of Tobacco, 64.10% males) and 256 controls (35.90% males) were enrolled.
Parental Tobacco exposure ascertainment was done by conducting in depth interviews using a validated structured
questionnaire, parent bonding instrument and life grid technique. Multiple logistic regressions were performed. Results:
The odds of a case initiating the habit of Tobacco use was nearly four times more when the parent was a Tobacco
user [adjusted OR 4.26 (95% CI 2.39 – 7.58)] as opposed to controls. Among other covariates examined, low parental
bonding with subject (especially father- warmth/care) was a strong risk factor for Tobacco usage [OR 2.17 (95% 1.11
– 4.23)]. The cases had nearly four times the probability of Tobacco uptake compared to controls if the mothers had
no formal schooling [adjusted OR of 3.93 (95% CI, 2.12 – 7.26)]. Conclusion: Parental use of Tobacco influences the
uptake of Tobacco habits in their children, with the father’s parenting (low paternal warmth) being a strong risk factor.
Keywords: Intergenerational- case control- smoking- smokeless Tobacco
Asian Pac J Cancer Prev, 20 (10), 3029-3035
Introduction
The initiation of Tobacco use in young adults is
influenced by cultural and social factors (Conrad et
al., 1992). Significant among these are parent to child
transmission, pressure from peers and perceived benefits
of smoking (Talip et al., 2016). It is very unlikely that
an individual will initiate the use of Tobacco if the habit
doesn’t start during adolescence (Tyas and Pederson,
1998) During this period, the intergenerational (parent to
child) transfer of habits is an important contributor for the
initiation of Tobacco use. The Social Learning theory by
Bandura emphasizes that people with whom one regularly
associates, delimits the types of behaviour that one will
repeatedly observe and hence learn, which explains
reasons for intergenerational transfer and influences from
peers (Johnston et al., 2012; Subramaniam et al., 2015).
In rural Indian communities, family members often
seek help from children to purchase chewable Tobacco
products from stores (Kakde et al., 2012). This trigger in
early formative years, may be responsible for the child to
perceive Tobacco use as acceptable. Additionally, when
parents (either both or single) themselves are Tobacco
users, attempts to impose restriction in their children may
not be effective due to credibility issues (Holdsworth
and Robinson, 2013). Casual mentions of Tobacco in
the household may further, trigger curiosity (Bantle and
Haisken-DeNew, 2002).
Parenting style has a modifying effect on the transfer
of Tobacco habits between generations. Culture serves as a
guiding framework to parents while rearing their children
(Londhe, 2015). The strong protective or formal parenting
style in Indian society differs from the western culture of
fostering independence.
The intergenerational transfer of the Tobacco habit
has been studied in developed countries (Bantle and
Haisken-DeNew, 2002; El-Amin et al., 2015; Escario
and Wilkinson, 2015; Gilman et al., 2009; Göhlmann et
al., 2010; Leonardi-Bee et al., 2011; Mahabee-Gittens et
al., 2012; Mays et al., 2014; Melchior et al., 2010; Vuolo
and Staff, 2013; White et al., 2000) but scarcely reported
in southeast Asian countries (Madathil et al., 2015),
where smokeless Tobacco (SLT) consumption is high.
We designed this study to assess if the parental Tobacco
use behaviour is a risk factor for initiation of Tobacco use
among their children Additionally, we aimed to understand
the effect of parenting style on the transfer of such
behaviours. We chose to look at Tobacco use irrespective
of the form it is consumed in (smoked/smokeless), as the
risk posed with its use and transfer across generations
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita University, Kerala, India. *For Correspondence:
sekarcandra@gmail.com
Asian Pacific Journal of Cancer Prevention, Vol 20
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Chandrashekar Janakiram et al
remains unchanged.
Materials and Methods
Study design
We designed this hospital-based case-control study
to compare the exposure distribution (parental Tobacco
use) between groups of Tobacco users and non-users as
given in Figure 1.
Study Setting
We identified two healthcare facilities for this study;
an urban centre (Cochin) and a tribal centre (Kalpetta)
Kerala, India.
Case and Control Selection
1. Individuals visiting the health centre as bystanders
of patients (individuals accompanying the patient to the
health facility and not requiring consultation or treatment
themselves on the concerned day) were identified. These
individuals were interviewed for their Tobacco usage
status and were classified as:
A. Cases if they used any form of Tobacco; chewing
or smoking or both.
B. Controls if they had never used any form of Tobacco
in their lifetime
2. Participants were aged between 19 – 30 years.
3. All participants were required to be continuous
life residents of the concerned area (urban/tribal) and
should have been raised by their parents until 18 years of
age. [Continuous life residents are those who are born,
reared and living in the same area except for a few weeks
(holidays) in the year].
The study was approved by institutional ethics
board of Amrita Institute of Medical Sciences
(Ref/011/TPRC/2016). A written informed consent
was obtained from all volunteering participants. This
research was conducted in full accordance with the World
Medical Association Declaration of Helsinki. The data
collection period extended from May 2016 to October
2017. The research instrument was pilot tested in 2016
and modifications were made accordingly.
Data Collection
Data collection was done in two stages;
Figure 1. Case Control Design
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Asian Pacific Journal of Cancer Prevention, Vol 20
1. Identification of cases and controls by trained
research assistants.
2. Investigator (VS) ascertained the parental Tobacco
history using the research instrument, facilitated further
using life grid technique.
To avoid selection bias and ascertainment bias, the
investigator (VS) was blinded for Tobacco status of the
case and control.
Exposure Ascertainment
To ascertain the parental Tobacco exposure, we
administered a structured validated questionnaire to
interviewees’ (cases and controls) uniformly. The content
validity of the questionnaire was done by three experts
in the field of psychology using Content Validity Index
(CVI). CVI score was found to be 0.95. Information
such as parent’s demographics, their Tobacco use
behaviour (frequency, duration etc.), educational status,
socioeconomic status was collected.
Life grid technique
We employed the life grid technique to facilitate recall
of parental Tobacco history from cases and controls. This
technique works on the principle that recalled information
on certain social circumstances when cross-referenced
with the information sought for the study, provides a
useful degree of accuracy, minimizing recall bias. Besides
controlling recall bias, the process of going through the
participants’ life events in the form of a life grid, helped
us establish a positive rapport with the participants, which
in turn allowed easier elicitation of sensitive information
(Berney and Blane, 1997; Blane, 1996).
Parent bonding instrument (PBI)
We used PBI, a validated and reliable scale to measure
fundamental parental styles as perceived by the cases
and controls about their parents which was categorised
as; ‘warmth/support/care’ and ‘protection/control/
demandingness’. The measure was retrospective, meaning
that the participants completed the measure for how they
remembered their parental role towards them during
their first 16 years. The measure was to be completed
for either parents separately. This 25-item questionnaire
consisted of questions related to caring (12 questions) and
warmth attitudes (13 questions). Each item was scored
DOI:10.31557/APJCP.2019.20.10.3029
Intergenerational Transfer of Tobacco Use Behaviour
to generate a care and protection score for each of the
parent. Predefined cut off scores enabled classification of
the parenting style as high or low caregiving and high or
low levels of controlling. The cut-off score for ‘care’ was
24 and 27 for fathers and mothers respectively. Scoring
above the cut-off value deemed the parent as high care
giving while scores below as low care giving. Cut-off
scores for the ‘control’ was 12.5 and 13.5 for fathers and
mothers respectively. Scores above these cut-off were
deemed as high levels of controlling (Parker et al., 1979).
Sample size estimation
Using estimates from previous studies, prevalence of
smoking Tobacco (0.18 control and 0.12 cases)(Melchior
et al., 2010) and chewing Tobacco (0.28 control and
0.61 cases)(Madathil et al., 2015) were obtained and we
estimated a sample size of 418 (209 each for cases and
controls) with power 80% and alpha error of 0.5. The
final sample size was rounded to 250 each for cases and
control to cover attrition and other covariates.
Statistical analysis
The data was processed using Statistical Package
for Social Sciences (SPSS, IBM Version 20). Initially,
a series of bivariate analysis were carried out, followed
by a stratified analysis of selected variables. Multivariate
logistic regression models were used to estimate the odds
ratios and the associated 95% confidence intervals (CI).
Results
Descriptive characteristics of cases and controls are
given in Table 1. Since, it was an unmatched case–control
study, there were variations in the distribution of cases
and controls in terms of characteristics. A total of 495
participants; 239 cases and 256 controls were enrolled
in this study with 49.6% of the participants belonging to
the tribal setting. The participants were aged between 19
and 30 years (57.77% females and mean age ± standard
deviation of 23.16 ± 3.53 years). 63.83% participants had
an ‘up to high school’ level of education and 70.9% of the
participants were not employed. 84.51% and 54.68% of
cases and controls respectively had Tobacco user parents.
(Table 2). Among the 113 cases in the urban area 97.34%
used the smoked form, while in the tribal area all 126
(100%) cases used the smokeless form of Tobacco.
Stratified analysis given in table 2 showed that when
parents were smokers, cases were three times more
likely to smoke as opposed to controls [odds ratios 2.79
(95% CI, 1.85 – 4.19)]. When parents were users of
Table 1. Characteristics of the Population
Variables
Cases (n)
%
Controls (n)
%
Total N (%)
Odds ratio [CI 95%]
19 – 24 years
151
45.07
184
54.92
335 (67.67)
0.67
25 – 30 years
88
55
72
45
160 (32.52)
[0.46 – 0.98]
Age
Gender
Male
134
64.11
75
35.88
209 (42.22)
3.08
Female
105
36.71
181
63.28
286 (57.77)
[2.12 – 4.46]
Urban
113
46.12
132
53.87
245 (49.50)
0.84
Tribal
126
50.4
124
49.6
250 (50.50)
[0.59 – 1.19]
Hinduism
200
50.63
195
49.36
395 (79.79)
1.6
Others
39
39
61
61
100 (20.20)
[1.02 – 2.51]
Unmarried
144
46.75
164
53.24
308 (62.22)
0.85
Married
95
50.8
92
49.19
187 (37.77)
[0.59 – 1.22]
Up to high school
164
51.89
152
48.1
316 (63.83)
1.49
Diploma and higher
75
41.89
104
58.1
179 (36.16)
[1.03 – 2.16]
Unemployed
150
42.73
201
57.26
351 (70.90)
0.46
Employed
89
61.8
55
38.19
144 (29.09)
[0.31 – 0.68]
Location
Religion
Marital status
Educational status
Occupation
Fathers education
Up to high school
227
51.12
217
48.87
444 (89.69)
3.4
Diploma and higher
12
23.52
39
76.47
51 (10.30)
[1.73 – 6.66]
Illiterate
96
65.75
50
34.24
146 (29.49)
2.76
Educated
143
40.97
206
59.02
349 (70.50)
[1.84 – 4.13]
Mothers education
Asian Pacific Journal of Cancer Prevention, Vol 20
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Chandrashekar Janakiram et al
Table 2. Distribution of Exposure - Parents’ Tobacco Use Status among Cases and Controls
Parents Tobacco use
Cases (Tobacco))
Controls
Total
Odds Ratio
n
%
n
%
N
%
(95% CI)
202
59.06
140
40.93
342
100
4.52 [2.94 – 6.94]
Non-user parent
37
24.18
116
75.81
153
100
1
Total
239
48.28
256
51.71
495
100
User parent
Cases (smokers)
Controls
Total
Odds Ratio
n
%
n
%
N
%
(95% CI)
Smoker parents
69
56.55
53
43.44
122
100
2.79 (1.85 – 4.19)
Non-user parents
146
39.89
313
85.51
366
100
Total
215
37
366
62.99
581
100
5
0.03
143
96.62
148
100
Non-user parent
Chewer parent
146
31.8
313
68.19
459
100
Total
151
24.87
456
75.12
607
100
Both form parent
0
0
3
100
3
100
Non-user parent
146
31.8
313
68.19
459
100
146
31.6
316
68.39
462
100
Total
Cases (chewers)
Chewer parents
Controls
Total
0.07 (0.03 – 0.18)
0.7 (0.07 – 6.92) *
Odds Ratio
n
%
n
%
N
%
(95% CI)
238
62.46
143
37.53
381
100
34.72 (19.87-60.67)
Non-user parents
15
4.57
313
95.42
328
100
Total
253
35.68
456
64.31
709
100
Smoker parent
1
1.85
53
98.14
54
100
Non-user parent
15
4.57
313
95.42
328
100
Total
16
4.18
366
95.81
382
100
Both form parent
4
7.01
53
92.98
57
100
Non-user parent
15
4.57
313
95.42
328
100
Total
19
4.93
366
95.06
385
100
0.39 (0.05 – 3.04)
1.57 (0.50 – 4.92)
* Yates correction performed
smokeless Tobacco the likelihood of a cases using it
increases exponentially to 35 times as much as controls
of smokeless Tobacco user parents [OR 34.72 (95% CI,
19.87 – 60.67)]. However, we found that it was unlikely
that participants picked up the habit of smoking, if their
parents were users of smokeless Tobacco when compared
to controls [OR 0.07 (95% CI, 0.03 – 0.18)].
The multivariate model provided in table 3,
showed that cases were four times more likely to use
Tobacco compared to controls if their parents had a
history of Tobacco use (adjusted odds ratio of 4.26
(95% 2.39 – 7.58)). The cases had a nearly four times
probability of Tobacco uptake compared to controls if the
mothers had no formal schooling [adjusted OR of 3.93
(95% CI, 2.12 – 7.26)]. The cases whose fathers exhibited
low warmth towards them were at nearly two times risk
of taking up Tobacco use habit compared to controls OR
2.17 (95% CI, 1.11 – 4.23). Males had a nine times risk
[adjusted OR 9.39 (95% CI, 4.64 – 18.99) of taking up
the habit as compared to females.
Discussion
We found a strong association between parental
Tobacco use and the uptake of the same among their
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children. Cases are likely to smoke or chew nearly four
times more when their parents had a history of Tobacco
use as opposed to controls. This intergenerational
transfer has been studied in western societies (Madathil
et al., 2015; Mahabee-Gittens et al., 2012; Vandewater
et al., 2014; Vuolo and Staff, 2013; White et al., 2000)
and similar strong associations have been found. The
findings of our study show the risk of transfer of smoking
habits from a parent to a smoker case to be nearly three
times when compared to a control [OR 2.79 (95%CI
1.85 – 4.19. Our findings were consistent with previous
studies by Vandewater et al., (2014), Melchoir et al.,
(2010), and Diwedi et al., (2016) that presented odds
of child’s smoking given a parent was smoker as 2.91
(1.60 – 5.31), 1.96 (1.30 – 2.79) and 3.47 (2.17-5.53)
respectively. The risk of intergenerational transfer
increases exponentially to 35 times for smokeless Tobacco,
if cases had parental history of smokeless Tobacco use
as compared to controls. This may be attributed to the
fact that all cases from tribal areas were using smokeless
Tobacco which is an accepted social norm as compared
to mainland urban areas (Janakiram et al., 2016; Valsan
et al., 2016). However, it was unlikely to find a smoker
case when parents were Tobacco chewers, highlighting a
form-specific transfer of Tobacco use behaviour between
DOI:10.31557/APJCP.2019.20.10.3029
Intergenerational Transfer of Tobacco Use Behaviour
Table 3. Multivariate Analysis
Variable
Reference
Lower
Upper
Lower
Upper
Age
19 - 24 years
0.67
0.46
0.98
0.9
0.52
1.53
Gender
Male
3.08
2.12
4.46
9.39
4.64
18.99
Location
Tribal
0.84
0.59
1.19
0.58
0.26
1.3
Religion
Hinduism
1.6
1.02
2.51
1.14
0.59
2.21
Marital status
Un-Married
0.85
0.59
1.22
0.85
0.46
1.55
Education
Up to High school
1.49
1.03
2.16
1.53
0.83
2.84
Occupation
Un-Employed
0.46
0.31
0.68
0.99
0.57
1.73
Father education
Up to High school
3.4
1.73
6.66
2.01
0.83
4.87
Unadjusted
Odds Ratio
95% Confidence
Interval
Odds Ratio
95% Confidence
Interval
Mothers education
Illiterate
2.76
1.84
4.13
3.93
2.12
7.26
Fathers occupation
Un-Employed
1.82
1.01
3.28
1.23
0.56
2.71
Mothers occupation
Un-Employed
0.77
0.54
1.1
1.47
0.89
2.42
Fathers warmth
High Warmth
3.16
1.94
5.17
2.17
1.11
4.23
Mothers warmth
Low Warmth
0.8
0.5
1.26
0.52
0.27
1.00
Fathers protection
High Protection
1.68
1.11
2.54
1.03
0.46
2.30
Mothers protection
High Protection
2.4
1.55
3.71
2.19
0.99
4.86
Parents Tobacco use
User
4.52
2.94
6.94
4.26
2.39
7.58
generations.
These findings reaffirm the concept of social learning
theory that children mould their behaviour using their
parental behaviour as example. Children observe parents at
close quarters, and habits practiced by them are oftentimes
perceived as appropriate. Whereas, direct stimulus for
Tobacco initiation may be from sources like peers, stress,
boredom etc; the trigger may arise from the deep-rooted
internalisation of the parent’s behaviour. This is reaffirmed
by the description of stages of smoking among adolescents
by Mayhew et al., (2000). Males had a nine times
risk of taking up the habit as compared to females. In
India, Tobacco use is predominantly a male behaviour,
particularly the smoked form. These findings are coherent
to cultural effect in India wherein prevalence of smoking
Tobacco is high in males in contrast to smokeless Tobacco
in females (Bhawna, 2013).
When the paternal care attitude is high, the likelihood
of the cases taking up the habit is reduced. This study was
suggestive that father’s care could provide a protective
influence on the cases and hence prevent the initiation
of Tobacco use. This finding is consistent with other
studies. In a study by Gittens et al., (2009) it has been
shown that increased parental monitoring is associated
with decreased odds of smoking initiation (33%) while
decreased parental monitoring is associated with increased
odds of smoking in children (55%). So also, in a critical
review of literature on the psychosocial factors related
to adolescent smoking, Tyas et al., (1998) report that an
authoritative positive parenting style is associated with
lower levels of adolescent smoking and that low parental
concern increases the risk of uptake of smoking among
boys. It has been shown from results of this study that the
child attempts to imitate the parent of the same gender.
Parental warmth has been associated with decrease in
externalizing behaviours such as alcohol consumption and
increase in self-esteem of the adolescent (Rosenberg and
Wilcox, 2006). This finding has been seen consistently
across all ethnic groups (Hoskins, 2014). Madathil et
al., (2015) concluded maternal strictness was associated
with decreased Tobacco uptake by the child. Though
our study findings are distinct from the previous study,
it is of substantial significance, as unlike the traditional
concept of mother’s central role in the rearing of a child;
our study results highlight the father’s role in the process
of parenting.
Mother’s education had a significant role to play in
the initiation of Tobacco habits by the child. A study on
the parental education and family status’s association
with children’s cigarette smoking concluded that higher
education of the mothers significantly lowered the
frequency of current experimentation and decision about
future smoking among children (Zaloudíková et al., 2012).
This is relevant as it has been proven that the mother’s
education has a crucial role to determining the health
behaviours of a family (Tyas and Pederson, 1998).
Strengths and limitations
This study has several strengths and some limitations.
Cases and controls were selected from the same study
base, comparable areas and participation was complete,
thus reducing the likelihood of selection bias. The
bystanders of patients who had visited for other reasons
(non-Tobacco) were enrolled, thereby decreasing bias
as the researchers had no access to the participant’s
medical history, hence no knowledge of the Tobacco
status prior to enrolment. Recall bias was controlled to
a large extent using the life grid technique, which also
proved to be beneficial in overcoming information bias.
Blinding the principal investigator to the outcome helped
overcome interviewer’s bias. However, bias arising from
non-response of participants and diagnostic suspicion bias
Asian Pacific Journal of Cancer Prevention, Vol 20
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Chandrashekar Janakiram et al
could not be controlled.
Limitations in the form of confounders like peer
pressure also need to be mentioned here. It was beyond
the scope of this study to adjust for this and hence was not
chosen to be included in the study question. It is necessary,
here to mention that parental transmission is not the only
factor influencing a child’s inclination to explore Tobacco,
several other factors have an interplay in this, however,
parents are a constant element in a child’s life, unlike peers
who may change over years.
Policy implications
Adolescent population is one group that may easily
succumb to the use of Tobacco. The argument for
Tobacco use prevention among adolescents is based on
the observation that if Tobacco use does not start during
adolescence, it is unlikely ever to occur.
Hence, public health programs have aggressively
targeted this population (Tyas and Pederson, 1998).
Most of the efforts have been directed at young adults in
an individualistic approach. We propose here, the need
to focus on families rather than individuals. There is a
need to advocate for Tobacco-free homes campaigns
at schools. There is evidence that engaging parents in
such school-based anti-Tobacco campaigns make them
more effective (Murray et al., 1985). Second and thirdhand smoking harms have been projected extensively to
curb Tobacco use among parents. Important though this
approach is, there is also a need to educate parents on the
possibility of their child initiating Tobacco, merely by
mirroring parental Tobacco use behaviour. This knowledge
gives parents the opportunity to make corrections to
their own Tobacco use behaviour, in turn ensuring a
Tobacco-free home. One needs to focus on the finding that
adequate care or support from the parent may defer the
child from picking up the habit, reinforcing the benefits
of right parenting.
Mothers are believed to be primary caregivers.
Maternal education is considered to be related to health
behaviours in a household (Tyas and Pederson, 1998).
Hence, equipping women with knowledge is mandated.
Finally, our study has shown a strong tendency for
male offspring to take up the habit. Here it is noteworthy
that this trend is soon changing, and efforts must be
targeted at both genders.
In conclusion, a child’s Tobacco initiation is strongly
associated with the parent’s Tobacco use behaviour.
However, father’s warmth towards his child and the
mother’s educational status both, have a modifying effect
on the uptake of this behaviour. Overall the transfer of
Tobacco habits across one generation, particularly among
the male child was high when parents used Tobacco, and
this calls for concerted efforts in making parents take
responsibility for their actions and child health.
Acknowledgements
Dr. Sanjeev Vasudevan, Medical officer, AmritaKripa
Charitable Hospital, Kalpetta, Kerala.
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Asian Pacific Journal of Cancer Prevention, Vol 20
Declaration
Ethics approval and consent to participate. The study
was approved by institutional ethics board of Amrita
Institute of Medical Sciences (Ref/011/TPRC/2016).
A written informed consent was obtained from all
volunteering participants. This research was conducted
in full accordance with the World Medical Association
Declaration of Helsinki.
Funding
The authors did not receive any specific funding for
this work.
Competing interests
The authors declare no conflict of interest. The
abstract of this manuscript was presented at the 17th World
Conference on Tobacco or Health.
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