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(Chest. 2004;125:429-434.)
© 2004 American College of Chest Physicians

Concordance Between Parental and Children’s Reports of Parental Smoking Prompts*

Rafael Laniado-Laborín, MD, MPH, FCCP; Jeanette I. Candelaria, MPH; Adriana Villaseñor, BS; Susan I. Woodruff, PhD and James F. Sallis, PhD

* From the Facultad de Medicina-Tijuana (Dr. Laniado-Laborín), Universidad Autónoma de Baja California, Mexico; and Graduate School of Public Health, Center for Behavioral and Community Health Studies (Dr. Laniado-Laborín, Ms. Candelaria, Ms. Villaseñor, and Dr. Woodruff), and Department of Psychology (Dr. Sallis), San Diego State University, San Diego, CA.

Correspondence to: Rafael Laniado-Laborín, MD, MPH, FCCP, San Diego State University, Graduate School of Public Health, Center for Behavioral and Community Health Studies, 9245 Sky Park Court, Suite 221, San Diego, CA 92123; e-mail: rafaellaniado{at}hotmail.com


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Study objectives: To describe the prevalence of parental prompting to smoke (eg, parent requests that their child light the parent’s cigarette in his/her own mouth) in a sample of families, and to assess the agreement between child and parent reports of the prompting behaviors.

Design, setting, and participants: A total of 3,624 adolescents from 10 middle/junior high schools completed baseline surveys. Parents identified as smokers in these surveys were contacted to complete a telephone survey. These analyses included 270 parent/child pairs. Fifty-one percent of parents were Latino American, 51% had the equivalent of a high-school diploma, 83% were employed when surveyed, and the median household monthly income was between $2,200 and $2,599.

Measurements and results: Students completed a paper-and-pencil survey assessing demographic characteristics, seven parental prompts to smoke, past month smoking, parental smoking, acculturation, and familism. A similar questionnaire was developed to collect information by telephone from smoking parents. Concordance between child- and parent-reported prompting was > 85% for five of seven prompts. However, the reported prevalence of six of the seven prompts was lower among parents than children. Thirty-two percent of mothers and 17% of fathers reported prompting their children to bring cigarettes to parents (the most common prompt). Students reported that 62% of their mothers and 54% of their fathers prompted them to bring their cigarettes, a substantial discrepancy in both cases.

Conclusions: Child-reported prompting prevalence was consistently higher than parents’ reports, with the biggest discrepancies between requests to clean ashtrays and bring cigarettes, the two most common prompts. In subsequent studies of parental prompting, it is advisable to collect data from both children and parents and to validate the accuracy of the sources.

Key Words: adolescents • culture • family • Latino Americans • parents • smoking


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Our previous research has suggested that Latino-American parents who smoke may engage in behaviors that inadvertently prompt their children to smoke.1 2 These prompting behaviors include, for example, parental requests for the child to light a cigarette in his or her own mouth and then give it to the parent, or even direct invitations to smoke with the parent.1 2 Influences to smoke from within the family may be especially strong for Latinos owing to the central role of the family in the culture.3 4 This is supported by a study5 involving 178 focus groups that found parental influences, other than parental smoking, to be important correlates of youth smoking. Latino youth reported they would likely receive harsh punishment from parents should they smoke, but reported a clear role of family members and parents in "recruiting" them into smoking by offering them their first cigarette, sending them to the store to buy cigarettes, and asking them to light cigarettes for them.5 Parental smoking itself is a consistent predictor of youth smoking reported in the literature,6 7 8 9 and the contribution of prompting to adolescent smoking over and beyond parental smoking status has not been explored. Prompting may encourage smoking among children by putting the child in contact with cigarettes, giving them direct access to cigarettes and the opportunity for experimentation, facilitating careful observation of how the parent lights the cigarette, exposing the child directly to cigarette smoke, and demonstrating the ease with which cigarettes can be purchased commercially. Even further, prompting may communicate parental acceptance of tobacco use by involving the child in the act of smoking, and encouraging rehearsal of smoking behaviors.10

Our previous study2 showed that these parental prompting behaviors are associated with increased smoking experimentation by their children. Although child reports of these parental behaviors are associated cross-sectionally with increased smoking experimentation by their children,2 there are no studies to our knowledge that describe prompting from the parents’ point of view. The objective of the present study was to report the prevalence of parental prompting as specified by middle school students and their smoking parent in a convenience sample of Latino families, and assess the concordance between child and parent reports of those parental prompting behaviors.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
The study was conducted in San Diego, CA, as part of a larger multiphase study. Students and parents were recruited from the Sweetwater Union High School District, which is a lower- to lower-middle-income area, with a high concentration of Latinos. The detailed methodology has been published elsewhere.10 The institutional review board that approved the human subjects’ protocol has a federal-wide assurance and follows regulations found in the Code of Federal Regulations (45CFR46) and the Belmont Report.

Formative Study
Parents from schools other than but similar to the study schools, who reported being smokers and who had seventh- or eighth-grade children were recruited with their children to convene in focus groups. Focus group participants provided input on student and parent survey development, especially measures of parental prompting to engage in tobacco-related behaviors. Students and parents each received a small monetary incentive for their participation. Afterwards, 41 smoking adults and 49 adolescents were recruited from the same schools for a test-retest reliability study. Students who participated received a soft drink certificate, and parents received a $10 grocery store certificate.

Concordance Study
All seventh- and eighth-grade students in the Sweetwater school district were invited to participate in a cross-sectional study. Active consent forms in both English and Spanish were sent home with the students. Only students with consent forms signed by their parents, and who then signed assent forms prior to taking the survey were included in the study. Smoking parents who had consented to participate in the study along with their child were contacted by telephone for interview. Students who completed the surveys received a pencil with the project logo. Parents received a $10 grocery certificate for completing the surveys.

Student Survey Measures of Parental Prompting
At school, students completed a paper-and-pencil survey that was developed based on that used in our previous studies, 1 2 3 and then refined, based on the focus groups conducted for this study. The seven parental prompts described below were measured as dichotomous variables, with response options being (1) "ever occurred" or (0) "never occurred." There was high test-retest agreement (1-week interval) for students’ reports of both mother-initiated and father-initiated prompts, ranging from 98 to 100% agreement.

  1. The parent (mother and/or father) asks the child to empty ashtrays. This prompt provides the child with direct access to partially smoked cigarettes.
  2. Parent asks the child to bring the parent his/her cigarettes. This prompt provides the child contact with cigarettes, and the opportunity to obtain cigarettes for experimentation.
  3. Parent gives the child gifts (ie, promotional gear) from the tobacco industry. This prompt aids the marketing efforts of the tobacco industry by using the child as a "billboard" and communicates parental acceptance of tobacco use.
  4. Parent asks the child to go and buy his/her cigarettes. This prompt provides contact with cigarettes and may demonstrate the ease with which cigarettes can be purchased commercially. It is illegal to sell cigarettes to minors in San Diego and neighboring Tijuana, Mexico. However, we suspected that there might still be prompting of children to buy cigarettes.
  5. Parent asks the child to light his/her cigarette with a match or lighter. This prompt exposes the child directly to cigarette smoke, involves the child in the act of smoking, and may facilitate careful observation of how the parent lights the cigarette.
  6. Parent asks the child to put the cigarette in the child’s own mouth, light it, and pass it to the parent. This prompt may lead the child to inhale cigarette smoke, may encourage the child to rehearse smoking behaviors, and may imply parental acceptance of the child smoking.
  7. Parent asks the child to smoke with the parent on occasion. This is the most direct prompt, and may demonstrate parental acceptance of the child smoking.

For the student survey, the primary smoking variable was past 30-day smoking, a dichotomous variable based on a quantitative item that asked about the number of cigarettes typically smoked per day during the past 30 days. Students who indicated they had not smoked in the past 30 days were classified as nonsmokers (coded as 0); those who reported any smoking were classified as past-month smokers (coded as a 1). An additional lifetime smoking variable, "ever smoked," was a dichotomous variable with never smokers (ie, those who had never tried smoking, not even a puff) coded as 0, and ever smokers coded as 1.

The student survey also assessed sociodemographic characteristics, including gender (1 = male, 2 = female) and ethnicity (1 = Latino, 0 = non-Latino). A language-based acculturation measure, for Latino participants only, was computed as a mean of responses to 10 items developed by Marín and colleagues.11 Scores ranged from 1 to 5, with higher scores indicating greater acculturation to US culture.11 A familism measure, used to describe shared core values and beliefs that place high value on family unity and cohesiveness,12 was based on five items. Four items were taken from an existing measure developed by Buriel and Rivera,13 and the present investigators developed an additional item. Response options ranged from 1 (strongly disagree) to 4 (strongly agree), with higher scores indicating higher familism. Responses were summed and divided by five to compute a mean score. More details regarding these measures are described elsewhere.10

Parent Survey Measures of Parental Prompting
A similar questionnaire was developed to collect information from smoking parents of the participating students on parental prompting behaviors, familism, and acculturation. To maximize parent participation, we collected the data by telephone. Data from those parents and their children were then matched for analysis. Students reported prompting information about both parents, but only one parent provided prompting data. Therefore, student/parent data were matched based on which parent completed the survey, such that if the mother completed the questionnaire, the child’s report of mother’s prompting was used. If the father completed the questionnaire, the child’s report of father’s prompting was used. There was high test-retest agreement for all seven prompts among parents, ranging from 87.8 to 100% agreement for adults.

Precautions To Reduce Variability due to Different Survey Formats
We took a number of precautions while collecting the data to minimize coverage and nonresponse differences between the data collection processes, to ensure that students responded to all appropriate questions on site, and that clarification of questions with parents on the phone was consistent with the method used to clarify questions with students at the school site. Furthermore, staff at the middle school sites monitored the students completing the surveys to reduce interaction during survey administration. Therefore, in spite of the difference in the survey formats, we believe that the data collection protocols helped to minimize variability.

Statistical Analysis
Descriptive statistics (eg, frequency distributions, means, SDs) were computed to describe the characteristics of the student and parent samples. Comparative statistics such as t tests and {chi}2 analysis were used to test differences between groups, such as parents and their children, and mothers and fathers, on several variables of interest. The primary analyses were focused on assessing agreement or concordance between the parents’ and child’s reports of parental prompts to smoke. Percentage agreement was calculated; however, because some agreement will occur by chance, a {kappa} statistic was computed to assess the level of agreement between parent and child for each prompt.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
Student Characteristics
A total of 3,624 students (35% of those targeted) participated in the study. Results showed that the group was comparable with the district student population on ethnicity. Analyses were conducted to assess the prompting differences among classrooms classified into three equal-sized groups based on low-, medium-, and high-participation rates. No association between participation rates and parental prompting levels was found. Additional details regarding recruitment and participation are reported elsewhere.10

There where 270 parent/child pairs. The average age of the children was 13.4 years (SD, 1.35), with a median age of 13 years; 56.7% were female, and 60% were Latino. The "ever-tried" smoking prevalence for the 270 adolescents was 38.5%, while their past 30-day smoking prevalence was 6.7%. The familism score for the students was 3.18 (SD, 0.44) on a scale of 1 to 4; non-white students had a higher familism score (Latinos, 3.23 [SD, 0.43], blacks, 3.25 [SD, 0.43], Asians, 3.43 [SD, 0.41]) than that of the white students (2.99 [SD, 0.39]; F = 4.26, p < 0.000). The average acculturation score for the Latino youth (n = 150) was 3.35 (SD, 0.71) on a scale of 1 to 5. There were no significant differences in prompts between female and male students.

Parent Characteristics
Forty percent of the smoking parents who had voluntarily provided a phone number on the parent consent form participated in the survey. The average age for the parents was 40 years (range, 23 to 62 years). Sixty-four percent of the smoking parents were female, and 51% were Latino. Fifty-seven percent were born in the United States, 33% were born in Mexico, and 10% were born elsewhere, predominantly in the Philippines. Sixty-nine percent were married or living with a partner. Fifty-one percent had a high school diploma or general education degree. Forty-two percent of the families had more than two children. Eighty-three percent of the smoking parents were employed at the time of the survey. The median household monthly income was between $2,200 and $2,599. The mean familism score for parents (on a 4-point scale, low to high) was 3.3 (SD, 0.46), and the mean acculturation score for Latino parents (5-point scale, low to high) was 2.6 (SD, 1.04), a significantly lower score than that of their children (t [130] = 11.86, p = 0.000). Sixty-six percent of the parents reported daily smoking, and 32% reported prompting their child with at least one of the prompts. Thirty-six percent of mothers and 23% of fathers reported any prompting ({chi}2 = 4.77, p = 0.029). Of the 723 participating parents who were identified as smokers by their child, 27% (n = 196) reported they were ineligible to participate because they were not smokers.

Concordance
Overall, concordance between students’ and their parents’ reports was high for five of the seven prompts (> 85%; Tables 1 , 2 ). Table 1 presents the prevalence of the seven prompting behaviors as reported by the children and their mothers. Table 2 presents the prevalence of the seven prompting behaviors as reported by the children and their fathers. The reported prevalence of six of the seven prompts was lower among parents than children. Among both mothers and fathers, the most prevalent prompt was asking the child to bring the cigarettes, followed by asking the child to empty and clean ashtrays, both of which were also the most prevalent prompts reported by children.


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  		Table 1. Concordance Between 187 Smoking Mothers’ and Children’s Reports of Mothers’ Prompting

 

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  		Table 2. Concordance Between 83 Smoking Fathers’ and Children’s Reports of Fathers’ Prompting

 
For six of the seven prompts, fathers reported less prompting than mothers. For only one prompt "bring cigarettes" was the difference statistically significant, with mothers reporting prompting children to bring the cigarettes more often than fathers (Tables 1 , 2) .

Children reported that fathers prompted less than mothers for only four of the seven prompts. Children’s reports indicate that fathers prompted more often than did mothers to light cigarettes with a match or lighter, light father’s cigarette in the child’s own mouth, and to smoke together. Although infrequent, mothers’ and fathers’ reports for requests to smoke with the parent were relatively highly correlated with childrens’ reports compared to some of the other prompts (Tables 1 , 2) .


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
A significant proportion of smoking parents reported behaviors that could inadvertently prompt their children to smoke, although rates were lower than those previously reported by adolescents.2 The most frequent prompt by either parent, as reported by both parent and child, was to ask their children to bring cigarettes to parents.

Concordance varied among the prompts. Concordance for emptying ashtrays was low, especially between the mothers and their children. Emptying and cleaning ashtrays gives the adolescent the opportunity to use partially smoked cigarettes, but parents may view it as simply one component of cleaning the house, which may explain the low concordance in the paired reports. The other prompt with low concordance was asking the child to bring the cigarettes for the parent to smoke. Although the prevalence for the remaining five prompts was much lower than those for "clean ashtrays" and "bring cigarettes," it is possible that they were more memorable to parents and, therefore, the agreement between child and adult responses was higher.

The discrepancy in prevalence between parent and child reports of parent prompting was often large. The consistently lower reported prevalence in prompting behaviors by the parents might be attributed either to an overestimation of parental prompting by the children or, by parental underreporting. Questions that arise are whether parents are motivated by their perceptions of what might be socially acceptable to minimize their smoking-related prompting, or whether some unintentional cognitive error could explain the discrepancy.

In studies involving multiple informants, reporting is often complicated by discordance between informants, with discordance casting doubt on one or another of the informants.14 15 16 Some suggest that wording or ambiguity may result in interpretation differences for a variety of informants.17 18 Informant errors and mistakes must be considered when evaluating the accuracy of reports.19 In addition, parental tendencies to over report positive and socially desirable parenting practices may also explain some of the discordance.16

The issue arises regarding how to interpret the discordance and how to determine which informant is more reliable. Achenbach and colleagues14 suggested that because different informants validly contribute different information, it is important to preserve their contributions, and Rutter20 described the need to develop instruments that take into account information from various sources and how each should be combined or weighed. Interpretation is further complicated in the present study because children completed a self-administered survey, but parents were interviewed. Such differences in methodology can add to the variability of responses and threaten the internal validity of a study, but we have no way of measuring what type of bias might have been introduced. Under the circumstances, however, it would have been impractical and costly to administer a paper-and-pencil questionnaire to parents. Additionally, a number of national surveys have incorporated both telephone and self-administered questionnaire approaches into their study designs to optimize survey design advantages.21

In our study, parental underreporting seems to be a more likely explanation, and it is possible that the interview method contributed to the underreporting. Most of our knowledge about smoking behavior relies on self-report, and validity, the extent to which a measure indicates what it is believed to measure, is of particular importance when studies rely on self-reports of sensitive behaviors. Indeed, the findings of studies are sometimes questioned because measures have not been validated. A case in point is the frequent suggestion that conclusions from research on cigarette smoking might be wrong because study participants intentionally provided incorrect information about their smoking.22 Quantitative and qualitative reviews of studies containing comparisons between self-report and biochemical measures have shown that the strongest evidence of underreporting of smoking comes from studies among adolescents or individuals where there is strong pressure to stop smoking.23 24 It has been suggested that it would be expected that underreporting of smoking would become increasingly frequent as smoking becomes less acceptable socially. Further, there is some evidence that social desirability is a particularly important factor operating in the way Latinos answer behavioral surveys. Prompting their children to smoke could be perceived as a socially undesirable behavior. Presenting oneself in a good light by claiming socially desirable traits is an image-management technique that is likely to be used by people that stress the presentation of a good face to outsiders, as is often the case with Latinos.12 Therefore, it is plausible that Latinos are more likely than non-Latino whites to answer questions about prompting their children to smoke in a way that responds to the demand characteristics of the situation.12 25 26


   Conclusions
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
Except for requests from fathers to smoke together, child-reported prompting prevalence was consistently higher than parents’ reports. The biggest discrepancies between parent and child reports were requests to clean ashtrays and bring cigarettes, the two most common prompts. Additional research is needed to validate the accuracy of the sources of prompting reports such as by using proxy measures by siblings or other household members regarding parental prompting. In subsequent studies of parental prompting of child smoking, it is advisable to collect data from both children and parents.


   Footnotes
 
This research was supported entirely by a grant from the University of California Tobacco-Related Disease Research Program, grant No. 7RT-0049. All research was conducted in the U.S.

Received for publication May 8, 2003. Accepted for publication September 9, 2003.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

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