Australian Health Promotion Association

Marewa Glover, Anette Kira, Sandar Min, Robert Scragg, Vili Nosa, Judith McCool and Chris Bullen

Introduction: Tobacco, alcohol and marijuana, in that order, are popular drugs widely used in New Zealand and elsewhere.1,2.Twenty-one per cent of New Zealanders aged over 15 years are smokers, of whom Māori
(the indigenous people of New Zealand) and Pacific Island people, (comprising15% and 7% of the national population respectively3) have substantially higher smoking prevalences (45% and 31% respectively), than European (21%) and Asian (12%) New Zealanders.4 Deaths and morbidity attributable to tobacco smoking far exceed those from other preventable causes combined, such as alcohol, illegal drugs, obesity or unsafe sex.5 Smoking has been estimated to contribute to almost 10% of the health inequality between Māori and non-Māori New Zealanders.6,7 Despite this, smokers under-estimate their personal risk from smoking.8-10

Although both smokers’ and non-smokers’ perceptions of the risk of smoking have been well researched, relatively few studies have examined people’s perception of the risk of smoking in comparison with other preventable health risks. Calman et al.11 asked teachers to rank the relative importance of teaching particular health topics, such as cigarette smoking, food and exercise, alcohol, sex and illegal drugs. Teachers of 10-12 year olds ranked smoking as the sixth most important topic, less important than food and nutrition, but more important than alcohol, drugs or sex. In a study by Krewski and colleagues,12 smoking was found to be rated as more risky (to health) than obesity, violence or (unprotected) sex. Participants in another study perceived that avoiding cigarettes was more likely to prevent cancer than reducing alcohol consumption or avoiding being overweight.8 However, when Borland13 asked Australian smokers to select the riskiest behaviour from a list of six items, smoking being the item that was the most likely to cause death, and five others all of which had a substantially lower mortality risk than smoking, only about a third of those surveyed selected smoking.

Parents’ beliefs about health risks affect their advice and expectations of smoking behaviours with their children. Knowledge of the harms associated with smoking contributes to promoting smoke-free expectations to children.14 The more parents are aware of smoking health risks, the more likely they are to communicate anti-smoking messages to their children.15 Qualitative research with Māori, Pacific Island and other New Zealand parents found that they perceived many other hazards, such as illegal drugs, alcohol and sex, to be more important to discuss with their children than smoking.16

Both ranking and rating are commonly used to obtain value data from participants. For items that are likely to have low discriminability, rating may be more suitable, as ranking may inaccurately result in a difference. However, if there are likely to be differences between the items, ranking is regarded as being more suitable.17.In tobacco control, research rating is more commonly used. We found only one study that asked participants to rank smoking against other health risks (Calman et al, 1985). We were unable to identify other research that has investigated how parents rank smoking in comparison to other preventable health risks. Other than Glover et al.,16 previous research has not focused on a New Zealand context or considered attitude differences by ethnicity. Research that investigated how parental values affect the risk of children becoming smokers has predominantly been based on reports from the children18-20 and only a few use parent samples.21,22.Because of this lack of research into parents’ perception of the comparative risk of smoking, and also of the association between parental attitudes and perception of smoking and their influence on adolescent uptake of smoking, this study aimed to investigate how parents of pre-adolescent children rank cigarette smoking in comparison with other risks to health. We also sought to compare the ranking between different ethnic groups.

Issue addressed: Despite the established risks associated with smoking, 21% of New Zealand adults smoke. Prevalence among Māori (indigenous) and Pacific Island New Zealanders is disproportionately high. Prevention of smoking initiation is a key component of tobacco control. Keeping Kids Smokefree – a quasi-experimental trial − aimed to do this by changing parental smoking behaviour and attitudes. However, little is known about parents’ attitudes to smoking in comparison with other concerns.
Method: Parents of 4,144 children attending five urban schools in a high smoking prevalence population in Auckland, New Zealand, were asked to rank seven concerns on a paper-based questionnaire, including smoking, alcohol and bullying, from most to least serious.
Results: Methamphetamine and other illicit ‘hard’ drugs were ranked as most serious followed by marijuana smoking, alcohol drinking, bullying, cigarette smoking, sex and obesity. Never smokers ranked cigarette smoking as more serious than current or ex-smokers.
Conclusion: Parents’ under-estimation of the serious nature of tobacco smoking relative to other drugs could partly explain low participation rates in parent-focused smoking initiation prevention programs.
So what? This study contributes to more effective smoking prevention by providing insight into how pre-adolescents’ parents rank smoking in comparison to other health concerns. If parents perceive bullying, alcohol and illegal drugs to be a greater threat to their child than tobacco smoking, they may be less inclined to focus attention on preventing their children from taking up smoking. The parents themselves may also be less likely to quit smoking.

Health Promotion Journal of Australia 2011; 22: 223-7