Education and indoor smoking among parents who smoke: the mediating role of perceived social norms of smoking

Second-hand smoke (SHS) exposure is a major cause of premature death and disease in children [1]. The main source of SHS exposure for young children is parental indoor smoking [1‐3]. Therefore, to protect children from SHS exposure, promoting smoke-free homes (e.g. setting voluntary rules to restrict indoor smoking at home) is the second-best option for parents who smoke, next to parental smoking cessation [4]. Younger children (e.g. aged less than 2 years) are particularly vulnerable due to their physiological features and the fact that they generally spend a lot of time with their parents [3].

The level of SHS exposure in children differs by parents’ socioeconomic status (SES) [5]. While overall prevalence of children’s SHS exposure has been significantly reduced in many developed countries [6, 7], the absence of smoke-free homes or indoor smoking behaviours among less-educated parents was 3.9 times higher than that among more-educated parents in Germany [8], 6.6 times higher in Japan [9], and 11.5 times higher in Denmark [10]. In Japan, the average prevalence of infants exposed to SHS decreased from 36.8% in 2001 to 14.4% in 2010 [9]. However, in both years, 51.5% and 28.1% of infants of less-educated parents were exposed to parental indoor smoking at home, respectively. Although evidence is scarce on the mechanisms between parental SES and indoor smoking behaviours, studies thus far have suggested that social norms of smoking play a key role in explaining SES inequality in smoking cessation [11, 12]. However, the role of these social factors in the link between parental SES and indoor smoking has not been studied.

We hypothesized that socioeconomic disparities in parental indoor smoking behaviours may arise from socioeconomic differences in individual perceptions of social norms of smoking. According to an integrated behavioural model, perceived social norms consist of descriptive and subjective norms [13]. A perceived descriptive norm is the perception of what most people do, whereas a perceived subjective norm characterizes perceived approval about performing a given behaviour by significant others, such as family and friends [13, 14]. Low-SES smokers are more likely to belong to a pro-smoking social context compared to high-SES smokers [12, 15]. If they perceive that many people around them are smoking, they may infer that smoking is common and tend to overestimate smoking prevalence (i.e. perceived descriptive norms). Subsequently, they may perceive that their significant others would approve of their smoking behaviours (i.e. perceived subjective norms) as smoking is common in their community [16]. Such a perceived acceptability of smoking predicts smoking behaviour [17], and is a vital mechanism for spreading smoking behaviour across close and distant social ties [18].

Moreover, these social norms of smoking may be affected by smoking behaviours of significant others and/or worksite smoking ban. Low-SES smokers are more likely to marry a smoker [11, 19], and mothers with a smoking partner are 7.7 times more likely to smoke indoors than mothers with a non-smoking partner [20]. Blue-collar workers are more likely to work at tobacco-friendly worksites compared with white-collar workers [21], and smoke-free workplaces reduce the prevalence of smoking among workers [22]. Therefore, having family members who smoke and/or working at tobacco-friendly worksites may be associated with indoor smoking behaviours via perceived social norms of smoking.

Emerging evidence suggest that smoke-free policies in public places and workplaces can effectively reduce tobacco use, SHS exposure, and protect child health [22‐24]. Although there are legal ‘recommendations’ regarding smoke-free public places, Japan has no national legislation for comprehensive smoke-free public places. Two prefectures have an ordinance preventing SHS in public places; however, it is not comprehensively mandated in these prefectures. For workplaces, owing to the Occupational Safety and Health Act in 2014, employers are obligated to prevent SHS exposure. Although, this measure was not in effect at the time of data collection for this study, some companies had already voluntarily created smoke-free workplaces. Therefore, we used a smoke-free workplace ban as a measurement of indoor smoking policy in this study.

Consequently, we tested the mediating role of perceived social norms of smoking (perceived descriptive norms and perceived subjective norms influenced by descriptive norms) on the associations between education and indoor smoking behaviours among parents who smoke.

This cross-sectional study was conducted using a self-administered online questionnaire through an online survey company, Macromill Inc., which is one of the largest online research panels in Japan (as of October 2014, over 2 million registered members across Japan). An online survey method is the best way to reach unique populations [25], as conventional resident registry-based random sampling has an unacceptably high cost to gather sufficient number of smoking mothers and fathers living with their young children. When compared the members of the online survey company to nationally representative populations, the distribution of main socio-demographic data (e.g. marital status, household income, and employment status) was similar [26], although the education level of participants in this study was a little higher than that of smoking parents included in the nationally representative survey [27]. Thus, the bias in this study introduced by our sampling was not expected to dramatically influence the results.

Participants were selected through convenience sampling: voluntary members of an online survey company, who met our inclusion criteria, were asked to participate. We recruited individuals who fulfilled the following inclusion criteria: (1) fathers aged 20–59 years and mothers aged 20–49 years, (2) current smokers (defined as persons who reported smoking at least 100 cigarettes in their lifetime and were currently smoking), and (3) living with one’s child who was aged 6 years or under. Considering the gender differences in the age people have children in Japan, we decided to use two different age ranges for fathers and mothers. The proportion of fathers aged 50 years or older having children in 2014 was 0.80%; however, the proportion among same-aged mothers was 0.005% [28]. We recruited fathers and mothers separately from a large sample. Although there is a possibility that some participants belong to the same couple by chance, it would not affect the results as we conducted stratified analyses by gender. We excluded individuals who were aged below 20 years (minimum legal age to smoke in Japan) since collecting information about an illegal activity was not allowed. Participants were paid through the online survey company in the form of ‘reward points’, which could be used for online shopping.

In September 2014, we collected data using a two-step process of participants screening, followed by administering the main survey (for a full description of our sampling framework, see Fig. 1). First, among the 921,326 male and 1,191,690 female panel members, 197,800 males and 194,667 females were randomly selected and received the screening survey via e-mail. Among those selected, 40,141 fathers and 30,054 mothers initially accessed the webpage and responded to the online screening questionnaire, which asked about their smoking status and the age of their children. Next, among those who met all inclusion criteria, 1120 fathers and 1120 mothers were randomly selected and invited to participate in the main survey. Then, 854 fathers and 853 mothers voluntarily accessed the webpage again and completed the online questionnaire. After excluding ineligible respondents (e.g. responded too quickly), the data from 822 fathers and 823 mothers (fathers’ response rate = 73.4%; mothers’ response rate = 73.5%) were analysed. These data cannot be made publicly available since it contains identifying information.

Table 1 shows the perceived descriptive characteristics of fathers and mothers. The mean age was 38.9 years (SD = 6.8) for fathers and 31.5 years (SD = 6.0) for mothers who smoked. The mean years of education were 14.5 years (SD = 2.1) for smoking fathers and 12.8 years (SD = 2.1) for smoking mothers. Most fathers (97.9%) were employed, while over half the mothers (53.2%) were unemployed. The prevalence of indoor smoking behaviours was much higher among mothers (64.0%) than fathers (35.9%). Most fathers (78.6%) did not live with smoking household members, while over half of the mothers (65.3%) lived with at least one smoking household member.

Binary logit regression analysis showed that, for both fathers and mothers who smoked, years of education was significantly negatively associated with indoor smoking behaviours, and the possible mediating variables were significantly positively associated with indoor smoking behaviours. For worksite smoking ban and indoor smoking behaviours, a significant negative association was found only among working fathers (Table 2).

Figures 2 and 3 show the standardized coefficients in the model among fathers and mothers. For fathers who smoked, years of education was negatively associated with perceived descriptive norms of smoking, whereas descriptive norms and following subjective norms were positively associated with indoor smoking behaviours. Household smoking was positively associated with each social norm of smoking, and mediated the association between education and indoor smoking behaviours. The indirect effect of education on indoor smoking via either perceived descriptive or subjective norms of smoking was significant (coef. = − 0.046; proportion of the total effect = 32.0%) (Table 3).

For mothers who smoked, both perceived descriptive and subjective norms of smoking mediated the association between education and indoor smoking behaviours. However, household smoking was neither significantly associated with social norms of smoking nor indoor smoking behaviours. The indirect effect of education on indoor smoking behaviours via either perceived descriptive or subjective norms of smoking was significant (coef. = − 0.080; proportion of the total effect = 51.9%) (Table 3).

Figures 4 and 5 show the standardized coefficients in the model among working fathers and mothers who smoked. For fathers, worksite smoking ban was positively associated with perceived descriptive norms of smoking, and the indirect effect of education on indoor smoking via worksite smoking ban and perceived descriptive norms of smoking was significant (coef. = − 0.009, 5.9%) (Table 3). For mothers, worksite smoking ban was positively associated with perceived subjective norms of smoking; however, the indirect effect via worksite smoking ban was not significant (Table 3).

For the above four models, WLSMV estimation showed acceptable model fit values, and the direct association between education and indoor smoking was not statistically significant.

Perceived social norms of smoking mediated the association between education and indoor smoking behaviours among parents who smoke. Further, only for fathers, household smoking status and worksite smoking ban mediated the association between education and indoor smoking via perceived norms of smoking. Social norms of smoking is suggested to be a mechanism between SES and smoking behaviours [34], and this study extended evidence that social norms explain the associations between education and indoor smoking behaviours among parents who smoke.

As hypothesized, perceived descriptive and subjective norms of smoking mediated the pathways between education and indoor smoking behaviours. According to a study that examined the person-to-person spread of smoking behaviours [18], smokers in interconnected groups (such as partners, siblings, and friends) shared social norms of smoking and changed their smoking behaviours (such as quitting smoking) together. As the prevalence of smoking is concentrated in lower-SES groups in Japan, smoking parents with less formal education may share an overestimation of smoking prevalence (perceived descriptive norm) and greater acceptability of smoking (perceived subjective norm) in their social networks. Therefore, they may tend to continue indoor smoking behaviours, while parents with more formal education are more likely to stop these behaviours due to social pressure [35]. This result suggests that overestimation and greater acceptability of smoking would be an acceptable explanation of such disparity in Japan.

The social norms of smoking were associated with environmental variables (worksite smoking and household smoking bans) among fathers who smoked, but not among mothers who smoked. As less-educated fathers are more likely to work in places without worksite smoking ban, they tend to have a greater acceptance of smoking (perceived subjective norms) through overestimating smoking prevalence (perceived descriptive norms), and leading to higher indoor smoking. Previous studies suggest that smoke-free policies lower the perceived acceptability of tobacco exposure, even among smokers [36], with decreased acceptability leading to a reduction in tobacco use [37]. In addition, the acceptability of smoking in a work unit is considered to impact worksite smoking policies on smoking cessation [38]. The present study suggested that smoking fathers may also increase the awareness of the need to prevent SHS exposure at home when they feel that smoking is not accepted in their workplaces; therefore, they are more likely to stop smoking at home even if they do not quit smoking. Similarly, for fathers who smoke, cohabiting with family members who smoke results in a consensus about what is acceptable, and may motivate them to engage in the same behaviours. Alternatively, however, as this was a cross-sectional study, an effect in the opposite direction may also be possible (e.g. individuals with similar smoking norms may tend to marry each other or work in similar places). Future studies should collect longitudinal data to identify more accurate causal pathways.

A unique finding of this study was the gender difference in the associations between social norms of smoking and environmental variables. A study in the United States found that women were twice as likely to report social pressure to quit smoking compared to men [35]. However, in this study, household smoking was not associated with perceived norms of smoking for mothers. One possible explanation is that mothers’ smoking norms may be influenced by friends’ behaviours, rather than families or colleagues. Alternatively, mothers’ smoking norms may be under more pressure from a much wider social context than those of fathers [39]. Traditional norms about female gender roles may cause pressure of not to smoke for women [40]. Simultaneously, because of tobacco marketing women have been exposed to an institutional gender norm that those who smoke are feminine, free, and stylish [41].

These findings provide new insights for effective interventions to narrow the educational disparities in parental indoor smoking behaviours. This study suggests that less- and more-educated smokers perceive social norms of smoking differently in their distinct social networks. This may be one of the reasons why less-educated smokers are less responsive to smoke-free legislation than more-educated smokers [42]. Therefore, it may be effective to modify perceived pro-smoking norms in less-educated fathers by encouraging smoking cessation for household members including grandparents and others who smoke, and by promoting workplace smoking ban especially for blue-collar workplaces or small companies where less-educated fathers tend to work [43].

This study has several limitations. First, since we employed a cross-sectional design, we cannot infer causality. Although educational attainment would not have changed over the time of interest, indoor smoking behaviour could influence household members’ smoking status. Second, selection bias might have existed due to the self-selection of participants in the online survey. As the participants had higher levels of education than nationally representative random samples, the association between education level and mediating variables might have been underestimated. However, as the distribution of main socio-demographic data among online survey panel members are similar to those found in nationally representative random samples, we believe that our data are generalizable to smoking parents with young children in Japan. Third, other critical and omitted variables might exist that may affect the mediating role of social norms of smoking such as peers’ smoking behaviours, and social norms of smoking at the community level (not perceived norms at the individual level) [44].

Despite these limitations, this study is the first to examine the multiple pathways between education and indoor smoking behaviour, using an SEM approach, among parents who smoke with young children. Our results aid in the understanding of the mechanisms in this relationship to a greater degree than would have been achieved by a general multiple regression analysis. Further, stratified analysis of fathers and mothers allowed for more accurate inferences about the gender specificity of the pathways.

In conclusion, this study provided evidence that parents who smoked with less formal education were more likely to perceive pro-smoking descriptive and subjective norms and these norms were significantly associated with their indoor smoking behaviours. In addition, for fathers who smoked, smoking among colleagues and household members had an indirect effect on indoor smoking behaviours via perceived norms of smoking. Discouraging pro-smoking norms in home and work social networks could help to reduce indoor smoking behaviours and narrow socioeconomic disparities in children’s SHS exposure.