Parent smoker role conflict and planning to quit smoking: a cross-sectional study

Tobacco smoke exposure (TSE) endangers the health of infants and children and leads to increased risk of asthma, other respiratory diseases, otitis media, cognitive dysfunction, neurobehavioral disorders, and sudden infant death syndrome [1–3]. Tobacco smoke has “sticky” properties and very small particulate matter that prevent smokers from completely protecting others in close proximity from its harms [4]. Parental smoking is associated with parental morbidity and mortality, increased risk of house fires, diversion of income, and greater likelihood of children’s tobacco addiction [5]. In these ways, smoking cigarettes attenuates parents’ performance of the protective function that is a defining characteristic of the parental role [6].

The child health care setting provides unique teachable moments to motivate parents to quit smoking as a result of the number of contacts a parent has with his or her child’s healthcare provider and the strong link between TSE and chronic and acute childhood illness [5, 7–9]. The child’s wellness visit may be the only opportunity for many parents to access physician assisted smoking cessation resources due to the steadily increasing rate of uninsured adults [7]. Child healthcare clinicians, through the schedule of primary care visits, are often in a position to intervene with parental smokers in a repeated and consistent manner over the course of many years [5]. For parents who lack a primary care provider, their child’s doctor may be a key access point for pharmacological advice and treatment for tobacco addiction [10, 11].

Having parents’ smoking addressed in child healthcare visits by their children’s clinicians may prompt parents to experience conflict between their parent and smoker identities. Identity, especially identity in relation to others with in a social group, is developed through processes of reflection and categorization; identity may contain several different roles, including the role of parent and the role of smoker [12]. The role of ‘parent’ evokes the parents’ own expectations of their actions and behavior as well as the expectations of others within society as a whole. Role conflict is particularly apparent in smoking parents because the roles of parent and smoker can have incompatible behavioral standards and social expectations. Role conflict, as defined by tension among identities, has been identified as a major force in the motivational process [13, 14]. The discomfort associated with role conflict might enhance motivation to quit smoking. To our knowledge, this idea has not been examined previously.

To explore the extent and nature of conflicts that may occur between the parental role and smoking, we measured the role conflict experienced by parents who smoked at baseline from data collected in a randomized controlled trial of tobacco cessation service delivery at child healthcare visits. We assessed the parent and child characteristics associated with the parent/smoker role conflict variable. We were particularly interested in testing the hypothesis that parent/smoker role conflict was associated with a parent’s intention to quit smoking in the next month. We chose this variable because planning to quit smoking within the next 30 days is the most advanced “stage of change” prior to action in the transtheoretical model of change [15]and has been an independent predictor of smoking cessation in longitudinal studies [16].

Twenty practices were recruited from Pediatric Research in Office Settings (PROS), the practice-based research network of the American Academy of Pediatrics. Practices were randomized with 10 to the intervention arm and 10 to the control arm. The study participants were smoking parents who accompanied a child to an office visit. Eligibility criteria specified that participants be a parent or legal guardian of the child, over age 18, and English speaking, as well as having reported: “smoked a cigarette, even a puff, in the past 7 days.” The data for this analysis was collected as part of a larger study testing a pediatric-office based tobacco control program for families called CEASE (Clinical Effort Against Secondhand Smoke Exposure). The program includes training and materials to support the establishment of smoke-free home and car rules and smoking cessation, including connecting smoking parents to free cessation services and pre-printed nicotine replacement therapy prescription pads. The study protocol was approved by the Institutional Review Boards of the American Academy of Pediatrics and Massachusetts General Hospital.

Twenty-nine percent of parents (n = 563) said that they experienced parent/smoker conflict. In bivariate analyses (Table 1), parents who experienced parent/smoker role conflict were more likely to be older, non-Hispanic white, smoke more heavily, made a recent quit attempt, planned to quit in the next month, accompanied a child over 5 years old, visited the pediatrician because their child was sick, and received assistance for smoking cessation during that visit (p < 0.05). Parental gender, education, and child’s health insurance were not associated with parent/smoker role conflict.

In this study, 29% of parents who smoked and were visiting a pediatrician with their child reported experiencing role conflict, as measured by the statement, “Being a smoker gets in the way of being a parent.” Parents who reported this conflict were more likely to be planning to quit smoking in the near future, and the association persisted even after an analysis adjusting for other factors associated with planning to quit.

Overall, we found that 43% of parents reported that they seriously planned to quit smoking within the next 30 days, and 46% had attempted to quit smoking within the previous 3 months. Compared with studies of stages of change in other populations, this percentage is high: about 20% of smokers typically qualify for the preparation level of readiness to quit [18]. Enhanced readiness to quit suggests an even greater opportunity for pediatric healthcare providers to influence smokers compared to adult healthcare providers or smoking cessation programs for the general population. Having a recent quit attempt had the strongest association with planning to quit smoking within the next 30 days [aOR 2.63(95% CI 2.14-3.23)]. Being a nondaily smoker was also associated with readiness to quit. This finding is consistent with a study of light smokers in which nondaily smokers differed from daily smokers in having more recent and planned quit attempts [19].

In addition, receipt of cessation assistance for tobacco dependence from the child healthcare provider was associated with planning to quit smoking in the next 30 days. However, because all data for the current study were gathered after the child healthcare visit, it is impossible to say whether assistance may have increased the likelihood of being ready to quit or whether being ready to quit may have elicited assistance from clinicians able to provide it.

Few studies about the distribution of smokers by stage of change find that age is associated with readiness to quit [20]. This study’s concentration of parents may skew the impact of age on our findings and account for the association with older parents. Jarvis [21] reported that among women, there was a linear increase in the odds of cessation with each additional child, and this effect was marginally present in men, as well. It is likely age 25 is associated with a higher number of children in our study population. We could not examine the interaction of number of children and intention to quit because we did not collect data on the number of children per family unit. Cessation may have been preceded by intention to quit within the next 30 days, as reflected in our data.

We explored the question of parent/smoker role conflict out of our ultimate interest in tailoring interventions for parents accompanying children to child healthcare visits. Women and men often designate “parent” as their most important identity or role [22].We speculated that the hierarchical position of the parental versus smoker role could invoke protective instincts to increase readiness to quit smoking. Theories of motivational intervention support the concept that when adults are confronted with a discrepancy between their perceived versus desired roles (smoking parent versus non-smoking parent), their motivation can be increased through a brief motivational moment. Physicians can emphasize the behaviors that lead to such a discrepancy and the potential solutions to resolve it. Increased motivation prompted by role conflict is consistent with predictions of self-discrepancy theory, which states that people compare themselves to internalized standards and are motivated to reduce the gap in order to remove discrepancy in self-guides. Sick visit type, planning to quit in the next 30 days, allowing smoking within the home, and receiving assistance for tobacco dependence were all associated with experiencing conflict. These findings are associative but might suggest possible parent/smoker role mechanisms that could be utilized in future studies to enhance motivation to quit.

Interventions that increase parent/smoker role conflict might increase motivation to quit among parents who smoke. Physicians can utilize the child’s visit to initiate brief motivational moments with parents to both emphasize these conflicts and also provide an action-oriented approach to resolve them. However, not all types of motivation to quit are equally associated with successful cessation. A recent report in which motivation to quit was deconstructed into desire, duty and intention found that duty was negatively associated with success, unless it resulted in the smoker desiring to quit [23]. Duty was measured by response to the statement, “I ought to stop smoking,” as opposed to “I want to stop smoking” and “I intend to quit smoking.” Future qualitative work is needed to understand what the parent/smoker role question means to parents and how it might influence their tobacco use.