Abstract
Introduction
Parents are essential stakeholders for policy implementation. However, data on parents’ support for e-cigarette- and tobacco-related policies is limited. This study examines parents’ support for five e-cigarette- and tobacco-related policies targeted to prevent youth initiation and exposure to industry marketing practices.
Methods
Data were from a 2018 nationally representative sample of US parents of 11- to 18-year-old middle and high school students. Weighted adjusted logistic regression models examined correlates of support for policy outcomes, controlling for demographics. Analyses were performed among the full sample (n = 2743) and among current tobacco users (n = 355).
Results
The majority of parents, including current tobacco users, supported tobacco control efforts to protect adolescents. More than 90% of all parents supported restrictions on e-cigarette marketing to youth and 75% supported a ban on flavored e-cigarette sales. Additionally, more than 80% of all parents supported increasing the age of tobacco product sale to 21, limiting tobacco retailer density near schools, and keeping tobacco products out of view where youth shop. Presence of strict home tobacco rules or reporting a high priority to prevent child’s e-cigarette use were significantly associated with higher odds of policy support. Results were similar among current tobacco users.
Conclusions
Parents are an important group of tobacco control stakeholders and should be utilized to garner support for tobacco control policies in the context of the recent growth in youth tobacco and e-cigarette use. Parents’ public support for tobacco control policies, particularly regulations on e-cigarette sales and marketing, can motivate advocates and policymakers to advance tobacco control policy agendas.
Implications
Youth tobacco and e-cigarette use in the United States has increased in recent years. Parents are important stakeholders to inform policy agendas and advance efforts to restrict youth access and exposure to tobacco products. This study provides evidence that parents of adolescents are highly supportive of youth-centered tobacco control policies, particularly those that restrict access to youth-targeted e-cigarette marketing and the sale of youth-appealing flavored e-cigarettes. Utilizing policy support to mobilize parents may be an important advocacy strategy to advance tobacco control policy agendas and curb rising rates of youth e-cigarette and tobacco use.
Introduction
Youth tobacco use has steadily declined in the United States over the last 20 years. However, recent data from the National Youth Tobacco Survey suggest an alarming trend reversal. During 2017–2018, past 30-day use of any tobacco product increased by 38% among high school students and 29% among middle school students.1 This increase was predominantly driven by the considerable, rapid uptake of electronic cigarettes (e-cigarettes)—such as the USB-shaped, high nicotine content device JUUL—among youth.2 From 2017–2018, e-cigarette use alone increased by 78% among high school students (from 11.7% to 20.8%) and 48% among middle school students (from 3.3% to 4.9%).1 E-cigarettes may appeal to adolescents for multiple reasons including product design, social media promotion, or flavor availability.3–8 Flavor is a particularly salient reason for youth e-cigarette use and the majority of current adolescent e-cigarette users use fruit, sweet, or mint-flavored e-cigarettes either exclusively or in combination with tobacco and other flavors.9 In addition to e-cigarettes, cigarettes, smokeless tobacco, and cigars are also frequently used by adolescents and concurrent use of multiple tobacco products is common.1,10
The use of any tobacco product during adolescence places youth at risk for developing nicotine dependence.11,12 Policies to reduce youth access to tobacco products and marketing are essential population-based strategies to prevent initiation and sustained use.11 For example, a growing number of localities in the United States have restricted the sale of flavored e-cigarettes,13 and the federal government recently issued pending guidance to restrict the sale of selected flavored e-cigarettes to adult only stores.14 Additionally, more than 450 cities, counties, and states recently raised the legal age to purchase tobacco to 21.15,16 Other viable policy strategies include reducing tobacco retail outlet density near youth-oriented areas, like schools,17,18 point-of-sale marketing restrictions to keep tobacco products in areas out of view to minors,19,20 and restrictions on youth-appealing e-cigarette advertising. Currently, there are limited regulations on e-cigarette marketing in the United States,21 and a growing body of evidence suggests that youth are heavily exposed to e-cigarette advertising in both traditional and social media platforms,22–24 which can increase intentions to use this product.23,24
Gauging public support for tobacco control policies is an important tool to motivate decisionmakers and inform agenda setting.25,26 Parents are an essential group of stakeholders for adolescent health and policy development and implementation. Parents play a critical role in monitoring adolescent tobacco use, educating youth about tobacco-related harms, and establishing tobacco use norms based on their own use behavior and rules regarding smoking or e-cigarette use at home.27–31 Importantly, parents can also influence the policy process. In the United States, parent advocacy groups have actively shaped policy issues relevant to protecting children, such as mandatory childhood vaccinations,32 gun control legislation,33 and efforts to strengthen drunk driving laws.34 They are also likely to be important actors in policy efforts to curb the epidemic rise of youth e-cigarette use,31 particularly grassroots citizen advocacy groups like Parents Against Vaping E-cigarettes (PAVe).35
Only a handful of studies have surveyed parents’ attitudes and support for tobacco product regulations in the United States. In general, these studies found that parents broadly favored policies that limit exposure to secondhand combustible tobacco smoke36,37 or increase product price through taxation.36–38 More recently, a nationally representative online survey of parents conducted in 2015 by C.S. Mott Children’s Hospital found that support for several e-cigarette policies was also high, with the majority of parents in favor of a ban on flavored e-cigarette sales and requiring e-cigarette marketing restrictions on social media sites.39 Among the general population, other studies suggest high levels of national support for raising the legal age of tobacco product sales to 2140–42 and restricting youth targeted e-cigarette marketing,43 with substantial but more limited levels of support for restricting flavored e-cigarette sales.43,44 Efforts to reduce tobacco outlet density near schools and keep tobacco products out of view in retail stores were also widely supported among a sample of New York City residents.45
As youth e-cigarette and tobacco product use continues to rise, regulatory actions are needed. The current study updates prior research and provides an estimate of parents’ support for five e-cigarette- and tobacco-related policies targeted to prevent youth initiation and exposure to tobacco industry marketing practices. These include banning the sale of candy and fruit flavored e-cigarettes, raising the legal age of tobacco product sales to 21, restricting e-cigarette marketing to adolescents, requiring tobacco products be kept out of view in stores where youth shop, and limiting the number of stores that sell tobacco products near schools. This research can inform advocates and policymakers on which policies have broad support from an important and understudied group of stakeholders. Additionally, we explore how parents’ own tobacco use, the presence of home tobacco rules, and factors related to monitoring their child’s tobacco use are associated with policy support. Results can identify advocacy and communication strategies to enhance parents’ support of policies to prevent adolescent tobacco use.
Methods
Study Sample
Data were collected October–November 2018 using the Ipsos KnowledgePanel, an online panel of English and Spanish speaking adults aged 18 and older that covers both the online and offline populations in the United States. The panel was recruited via address-based sampling, a probability-based random sampling method that provides statistically valid representation of the US population, including cell phone-only households. For those panelists without internet, Ipsos provided free Internet service and a web-enabled device. Panelists were eligible if they were the parent/guardian of at least one child between 11 and 18 years old currently enrolled in middle or high school. The purpose of the study was to examine awareness and knowledge of the popular e-cigarette JUUL among parents of adolescents and examine parents’ support for policy initiatives to address e-cigarette and tobacco use.
Approximately 7760 panelists were invited to participate, 4094 completed the survey (completion rate = 52.76%), and 3075 were eligible (qualification rate = 75.1%). The analytic sample for this study included parents of 11- to 18-year-old middle (grades 6–8) and high (grades 9–12) school students (n = 2885). Participants included in statistical analyses had no missing data for any outcome variable or covariate of interest (n = 2743). The number of dropped cases was around 6% of the sample and dropped cases did not significantly differ from cases retained in the analysis. For participants with multiple children in middle or high school, a rostering system was used to randomly select one child and parents were instructed to answer questions about e-cigarette use for only that child. Data were weighted to be nationally representative of parents of middle and high school aged children in the United States. Research was approved by the Advarra Institutional Review Board (Pro00030402).
Measures
Policy Support
Participants were asked the extent to which they supported five policies: (1) a ban on the sale of fruit, alcohol, or candy flavored e-cigarettes; (2) a policy which requires individuals to be 21 years old before they can buy tobacco products; (3) a policy to restrict marketing and advertising of e-cigarette products to adolescents; (4) a policy which requires that tobacco products, like e-cigarettes and cigarettes, be kept out of view in stores where adolescents shop; and (5) a policy that limits the number of stores that sell tobacco products near schools. Participants answered using a response scale ranging from (1) “strongly support” to (4) “strongly oppose.” Responses were dichotomized to support (strongly support/support) and oppose (strongly oppose/oppose). Each dichotomized measure was used as an outcome in the models.
Current Tobacco Use
Participants were defined as a current tobacco user if they currently smoked cigarettes, currently used e-cigarettes, or used both products. Current smokers were defined as those who smoked at least 100 cigarettes in their lifetime and smoked a cigarette on at least 1 of the past 30 days. Current e-cigarette users were defined as those who used an e-cigarette on at least 1 of the past 30 days.
Home Tobacco Rules
The presence of home tobacco rules was based on two items: “For tobacco products that are burned, such as cigarettes, cigars, pipes or hookah, which statement best describes the rules about smoking these products inside your home?” and similarly, “Now think about e-cigarettes (including JUUL)…”, with response options, “it is allowed anywhere and at any time inside my home,” “it is allowed in some places or at some times inside my home,” and “it is not allowed inside my home.” Those who responded, “it is not allowed inside my home” to both questions were defined as having strict rules that “restrict all use.” Those who responded with “it is allowed anywhere…” or “it is allowed in some places…” to either item were considered as having “limited or no rules.”
Priority to Prevent Child’s E-cigarette Use
Participants were asked, “How much of a priority is it to prevent your child from using e-cigarettes (including JUUL)?” with response options “very high priority,” “somewhat high priority,” “medium priority,” “somewhat low priority,” and “very low priority.” Responses were collapsed into three categories (high priority; medium priority; low priority).
Suspected Child E-cigarette Use
Suspected child e-cigarette use was measured with the following item, “As far as you know, has your child ever used e-cigarettes (including JUUL)? Would you say…,” with options “you know that she/he has,” “you strongly suspect she/he has,” “you don’t think she/he has,” “you are confident she/he has not,” and “don’t know.” The first two response options were collapsed into the category “suspect,” while “you are confident she/he has not” was treated as “does not suspect.” The other two options were combined to create a “don’t know” category. Treating the “you don’t think she/he has” and “don’t know” categories separately in the analyses did not result in many major differences.
Demographics
Demographic characteristics included participants’ age (25–34; 35–44; 45–54; 55+), race/ethnicity (non-Hispanic White; non-Hispanic Black; Hispanic; non-Hispanic other), education level (≤ high school; some college; ≥ bachelor’s degree), child school level (middle school; high school), and language in which the survey was taken (English; Spanish).
Data Analysis
All analyses were performed with post-stratification weights using SAS Enterprise Guide version 9.1. Weighted prevalence estimates for participant characteristics and support for each policy outcome are provided. Weighted Rao-Scott chi-square tests were used to assess bivariate associations between each policy support outcome and participant characteristics, and weighted adjusted logistic regression was used to examine the correlates of support for each policy outcome. Analyses were conducted among the full sample of all parents (n = 2743) and among current tobacco users only (n = 355). Given that current tobacco users are generally less supportive of tobacco control policies,40–42,44 these subgroup analyses allowed for assessment of variation in levels of support by demographic and family-level factors among tobacco users. All regression models controlled for age, race/ethnicity, education, and child school level. Tests of association were two sided (p < .05).
Results
Approximately 81% of parents in this study were between the ages of 35–54 and the majority identified as non-Hispanic White (56.8%) (Table 1). Slightly more than one third (37.2%) of parents had at least a bachelor’s degree and the majority (61.9%) had a child enrolled in high school. Overall, 12.6% of parents were current tobacco users with 7.8% exclusive cigarette smokers and 2.4% exclusive e-cigarette users.
Table 1.
Percentage of All Parents Supporting E-cigarette- and Tobacco-Related Policies Overall and by Various Characteristics (n = 2743)
| Policy support (strongly support/support) | ||||||
|---|---|---|---|---|---|---|
| Total | Ban on flavored e-cigarette sales | Restriction on e-cigarette marketing | Tobacco 21 | Tobacco products out of view to adolescents | Limits stores selling tobacco near schools | |
| Characteristic | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) |
| Overall | 2743 (100.0) | 2062 (75.2) | 2602 (94.3) | 2397 (86.8) | 2374 (86.6) | 2307 (83.8) |
| Age | ||||||
| 25–34 years | 254 (9.4) | 196 (78.7) | 240 (92.8) | 226 (88.6) | 223 (87.4) | 212 (85.9) |
| 35–44 years | 1101 (40.9) | 844 (74.4) | 1051 (94.5) | 957 (85.4) | 964 (86.7) | 924 (83.0) |
| 45–54 years | 1093 (39.8) | 803 (75.4) | 1035 (94.3) | 953 (87.1) | 938 (87.2) | 920 (83.8) |
| 55+ years | 295 (9.9) | 219 (74.5) | 276 (94.6) | 261 (89.8) | 249 (83.1) | 2251 (84.8) |
| Race/ethnicity | ||||||
| Non-Hispanic White | 1733 (56.8) | 1294 (74.5) | 1642 (94.3) | 1510 (86.2) | 1500 (87.2) | 1457 (83.4) |
| Non-Hispanic Black | 229 (11.2) | 183 (79.5) | 217 (94.0) | 203 (89.1) | 195 (83.7) | 194 (87.1) |
| Hispanic | 636 (23.2) | 480 (74.9) | 607 (94.9) | 553 (86.3) | 553 (86.2) | 531 (81.3) |
| Non-Hispanic other | 145 (8.8) | 105 (75.3) | 136 (92.9) | 131 (88.7) | 1126 (87.4) | 125 (88.7) |
| Education | ||||||
| High school or less | 569 (36.4) | 424 (74.9) | 539 (93.7) | 487 (85.3) | 491 (86.4) | 475 (83.2) |
| Some college | 913 (26.5) | 686 (74.7) | 869 (94.9) | 800 (87.8) | 795 (87.5) | 766 (83.8) |
| BA or above | 1261 (37.2) | 952 (75.9) | 1194 (94.4) | 1110 (87.5) | 1088 (86.3) | 1066 (84.4) |
| School level | ||||||
| Middle school | 1047 (38.1) | 790 (76.2) | 988 (93.4) | 917 (87.0) | 919 (86.9) | 893 (84.0) |
| High school | 1696 (61.9) | 1272 (74.6) | 1614 (94.8) | 1480 (86.6) | 1455 (86.5) | 1414 (83.6) |
| Survey language | ||||||
| English | 2459 (88.2) | 1849 (75.1) | 2330 (94.2) | 2153 (86.9) | 2126 (86.3) | 2070 (84.0) |
| Spanish | 284 (11.8) | 213 (76.4) | 272 (95.0) | 244 (86.3) | 248 (88.9) | 237 (82.2) |
| Current tobacco use | ||||||
| No | 2388 (87.4) | 1882 (78.3)*** | 2279 (94.8)* | 2128 (88.5)*** | 2112 (88.1)*** | 2054 (85.4)*** |
| Yes | 355 (12.6) | 180 (53.6)*** | 323 (90.9)* | 269 (75.3)*** | 262 (76.2)*** | 253 (72.7)*** |
| Home tobacco rules | ||||||
| Limited or no rules | 347 (12.7) | 175 (52.9)*** | 310 (89.2)** | 256 (71.9)*** | 252 (75.2)*** | 241 (70.8)*** |
| Restrict all use | 2396 (87.3) | 1887 (78.4)*** | 2292 (95.0)** | 2141 (89.0)*** | 2122 (88.3)*** | 2066 (85.7)*** |
| Priority to prevent child’s e-cigarette use | ||||||
| Low priority | 265 (10.2) | 151 (58.8)*** | 236 (87.6)*** | 199 (76.0)*** | 180 (65.9)*** | 171 (63.9)*** |
| Medium priority | 330 (11.7) | 196 (59.9)*** | 293 (86.0)*** | 257 (74.5)*** | 253 (77.0)*** | 237 (76.3)*** |
| High priority | 2148 (78.1) | 1715 (79.6)*** | 2073 (96.4)*** | 1941 (90.0)*** | 1941 (90.8)*** | 1899 (87.5)*** |
| Suspected child e-cigarette use | ||||||
| Does not suspect | 1952 (69.7) | 1487 (76.2)* | 1866 (95.1) | 1717 (87.8) | 1703 (87.2) | 1656 (84.5) |
| Don’t know | 561 (21.8) | 421 (75.8)* | 523 (93.3) | 482 (84.4) | 490 (87.5) | 471 (82.8) |
| Suspect | 230 (8.5) | 154 (65.8)* | 213 (90.6) | 198 (84.6) | 181 (79.9) | 180 (80.9) |
wt.%, weighted percent.
*p < .05; **p < .01; ***p < .001.
Table 1 presents weighted estimates of policy support among all parents. Support for each policy was high and estimates ranged from 75.2% of parents who supported a ban on flavored e-cigarettes to 94.3% that favored restrictions on marketing and advertising e-cigarette products to adolescents. In the bivariate analyses, current tobacco use was significantly associated with lower levels of policy support, while presence of strict home tobacco rules and high priority to prevent child’s e-cigarette use were significantly associated with greater levels of policy support. Suspected child e-cigarette use was only significantly associated with support for a ban on flavored e-cigarette sales, where parents who strongly suspected their child used e-cigarettes reported lower levels of support.
Table 2 presents weighted estimates of policy support among parents who were current tobacco users only. Overall, most parents who were current tobacco users were supportive of policies to restrict e-cigarette marketing to adolescents (90.9%), raise the age of tobacco sales to 21 (75.3%), keep tobacco products out of view of adolescents (76.2%), and limit tobacco outlets near schools (72.7%). A majority of current tobacco users (53.6%) supported a ban on flavored e-cigarette sales. In the bivariate analyses, presence of strict home tobacco rules and high priority to prevent child’s e-cigarette use were significantly associated with higher levels support for most policies. Child’s school level was significantly associated with support for a ban on flavored e-cigarette sales, where a higher proportion of current tobacco users who had a child in high school (58.7%) supported a ban compared with those with a child in middle school (43.8%). All other demographic variables and suspected child e-cigarette use were not significantly associated with policy support (Table 2).
Table 2.
Percentage of Current Tobacco Users Supporting E-cigarette- and Tobacco-Related Policies Overall and by Various Characteristics (n = 355)
| Policy support (strongly support/support) | ||||||
|---|---|---|---|---|---|---|
| Total | Ban on flavored e-cigarette sales | Restriction on e-cigarette marketing | Tobacco 21 | Tobacco products out of view to adolescents | Limits stores selling tobacco near schools | |
| Characteristic | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) | n (wt. %) |
| Overall | 355 (100.0) | 180 (53.6) | 323 (90.9) | 269 (75.3) | 262 (76.2) | 253 (72.7) |
| Age | ||||||
| 25–34 years | 30 (7.6) | 17 (53.6) | 27 (88.2) | 23 (77.4) | 25 (83.3) | 19 (65.7) |
| 35–44 years | 150 (45.4) | 85 (54.7) | 139 (88.5) | 118 (74.8) | 117 (77.3) | 107 (69.0) |
| 45–54 years | 133 (34.7) | 53 (47.7) | 119 (93.2) | 96 (74.5) | 90 (74.9) | 94 (77.2) |
| 55+ years | 42 (12.3) | 25 (65.8) | 38 (95.0) | 32 (78.0) | 30 (71.5) | 33 (78.4) |
| Race/ethnicity | ||||||
| Non-Hispanic White | 215 (56.9) | 103 (50.2) | 196 (91.3) | 154 (70.2) | 155 (75.2) | 152 (69.1) |
| Non-Hispanic Black | 34 (10.6) | 21 (66.0) | 31 (93.2) | 29 (90.0) | 25 (74.8) | 26 (85.9) |
| Hispanic | 82 (20.8) | 44 (52.1) | 75 (95.1) | 66 (83.0) | 61 (76.0) | 57 (73.0) |
| Non-Hispanic other | 24 (11.7) | 12 (61.3) | 21 (79.4) | 20 (72.7) | 21 (82.3) | 18 (77.9) |
| Education | ||||||
| High school or less | 78 (36.7) | 35 (51.4) | 73 (92.7) | 52 (71.1) | 58 (76.3) | 52 (71.0) |
| Some college | 119 (25.8) | 66 (58.5) | 111 (95.0) | 92 (78.0) | 91 (77.5) | 88 (75.6) |
| BA or above | 158 (37.5) | 79 (52.2) | 139 (86.4) | 125 (77.4) | 113 (75.1) | 113 (72.5) |
| School level | ||||||
| Middle school | 132 (34.8) | 64 (43.8)* | 118 (88.1) | 98 (68.6) | 103 (77.0) | 94 (63.6) |
| High school | 223 (65.2) | 116 (58.7)* | 205 (92.4) | 171 (78.8) | 159 (75.8) | 159 (77.6) |
| Survey language | ||||||
| English | 332 (90.3) | 172 (54.8) | 301 (90.0)*** | 251 (74.4) | 244 (76.0) | 238 (72.8) |
| Spanish | 23 (9.7) | 8 (42.4) | 22 (99.4)*** | 18 (83.7) | 18 (78.3) | 15 (72.3) |
| Home tobacco rules | ||||||
| Limited or no rules | 153 (42.1) | 49 (38.3)*** | 132 (88.8) | 102 (66.3)* | 90 (64.0)*** | 93 (64.8)* |
| Restrict all use | 202 (57.9) | 131 (64.7)*** | 191 (92.4) | 167 (81.8)* | 172 (85.0)*** | 160 (78.5)* |
| Priority to prevent child’s e-cigarette use | ||||||
| Low priority | 40 (11.4) | 10 (43.0)* | 35 (90.2)*** | 23 (63.2)** | 17 (53.3)* | 20 (60.8) |
| Medium priority | 53 (14.5) | 20 (36.1)* | 42 (69.0)*** | 33 (53.5)** | 33 (74.4)* | 30 (59.2) |
| High priority | 262 (74.1) | 150 (58.6)* | 246 (95.3)*** | 213 (81.4)** | 212 (80.0)* | 203 (77.2) |
| Suspected child e-cigarette use | ||||||
| Does not suspect | 202 (56.4) | 102 (50.8) | 191 (93.9) | 155 (76.9) | 156 (78.6) | 147 (73.9) |
| Don’t know | 89 (26.4) | 45 (58.2) | 76 (86.6) | 63 (68.1) | 66 (76.8) | 63 (69.5) |
| Suspect | 64 (17.2) | 33 (55.2) | 56 (87.9) | 51 (80.8) | 40 (67.3) | 43 (73.9) |
wt.% = weighted percent.
*p < .05; **p < .01; ***p < .001.
Table 3 presents the results for the weighted, adjusted logistic regression models among all parents. As expected, current tobacco use was significantly associated with lower odds of support for a ban on flavored e-cigarette sales (adjusted odds ratio [aOR] = 0.42; 95% confidence interval [CI] = 0.30–0.60), raising the age of sale to 21 (aOR = 0.56; 95% CI = 0.37–0.84), keeping tobacco products out of view to adolescents (aOR = 0.55; 95% CI = 0.36–0.83), and limiting stores selling tobacco near schools (aOR = 0.57; 95% CI = 0.37–0.86). Parents with strict home tobacco rules had higher odds of support for all policies compared to those with limited or no rules except for restricting e-cigarette marketing to adolescents. Parents who reported a high priority to prevent their child’s e-cigarette use had significantly greater odds of support for all five policies compared with those who reported a low priority to prevent use (all aORs above 2.50; p < .001). After controlling for other factors, parents who strongly suspected their child used an e-cigarette had significantly lower odds of support for restrictions on e-cigarette marketing to adolescents compared with those who did not suspect their child had ever used an e-cigarette (aOR = 0.46; 95% CI = 0.21–0.98). Demographic characteristics and child’s school level were not significantly associated with any policy outcome in the adjusted models for the full sample of parents.
Table 3.
Weighted Adjusted Logistic Regression Models of Policy Support among All Parentsa (n = 2743)
| Policy support (strongly support/support) | |||||
|---|---|---|---|---|---|
| Ban on flavored e-cigarette sales | Restriction on e-cigarette marketing | Tobacco 21 | Tobacco products out of view to adolescents | Limits stores selling tobacco near schools | |
| Characteristic | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) |
| Current tobacco use | |||||
| No | REF | REF | REF | REF | REF |
| Yes | 0.42 (0.30–0.60)*** | 0.79 (0.40–1.58) | 0.56 (0.37–0.84)** | 0.55 (0.36–0.83)** | 0.57 (0.37–0.86)** |
| Home tobacco rules | |||||
| Limited or no rules | REF | REF | REF | REF | REF |
| Restrict all use | 2.21 (1.55–3.16)*** | 1.64 (0.83–3.26) | 2.30 (1.53–3.47)*** | 1.70 (1.11–2.60)* | 1.77 (1.19–2.65)** |
| Priority to prevent child’s e-cigarette use | |||||
| Low priority | REF | REF | REF | REF | REF |
| Medium priority | 1.11 (0.67–1.82) | 0.91 (0.44–1.88) | 0.99 (0.58–1.69) | 1.84 (1.08–3.14)* | 2.00 (1.22–3.27)** |
| High priority | 2.78 (1.84–4.18)*** | 3.94 (2.19–7.10)*** | 2.90 (1.86–4.52)*** | 5.36 (3.50–8.21)*** | 4.22 (2.80–6.35)*** |
| Suspected child e-cigarette use | |||||
| Does not suspect | REF | REF | REF | REF | REF |
| Don’t know | 1.05 (0.76–1.45) | 0.67 (0.38–1.16) | 0.78 (0.53–1.16) | 1.01 (0.68–1.51) | 0.86 (0.59–1.25) |
| Suspect | 0.75 (0.48–1.17) | 0.46 (0.21–0.98)* | 0.95 (0.53–1.70) | 0.64 (0.39–1.05) | 0.89 (0.55–1.44) |
aOR, adjusted odds ratio; 95% CI, 95% confidence interval.
aAll models control for age, race/ethnicity, education, child school level, and language survey taken.
*p < .05; **p < .01; ***p < .001.
Table 4 presents the results from the weighted, adjusted logistic regression models among current tobacco users only. In the adjusted models, parents with strict home tobacco rules had higher odds of support for a ban on flavored e-cigarette sales (aOR = 2.66; 95% CI = 1.44–4.91) and keeping tobacco products out of view to adolescents (aOR = 3.09; 95% CI = 1.51–6.31) compared with parents with limited or no rules. Current tobacco users who reported a high priority to prevent their child’s e-cigarette use also had significantly higher odds of support for keeping tobacco products out of view to adolescents (aOR = 3.36; 95% CI = 1.28–8.80) compared with parents who reported a low priority to prevent use. Demographic characteristics were not significantly associated with policy support in the adjusted models among current tobacco users; however, current tobacco users with a child in high school versus middle school had greater odds of support to limit the number of stores selling tobacco near schools (aOR = 2.04; 95% CI = 1.01–4.11) and ban flavored e-cigarette sales (aOR = 1.94; 95% CI = 1.03–3.64).
Table 4.
Weighted Adjusted Logistic Regression Models of Policy Support among Current Tobacco Usersa (n = 355)
| Characteristic | Policy support (strongly support/support) | ||||
|---|---|---|---|---|---|
| Ban on flavored e-cigarette sales | Restriction on e-cigarette marketing | Tobacco 21 | Tobacco products out of view to adolescents | Limits stores selling tobacco near schools | |
| aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | |
| Home tobacco rules | |||||
| Limited or no rules | REF | REF | REF | REF | REF |
| Restrict all use | 2.66 (1.44–4.91)** | 1.32 (0.43–4.07) | 1.99 (0.98–4.04) | 3.09 (1.51–6.31)** | 1.73 (0.87–3.41) |
| Priority to prevent child’s e-cigarette use | |||||
| Low priority | REF | REF | REF | REF | REF |
| Medium priority | 0.61 (0.18–2.08) | 0.30 (0.06–1.42) | 0.59 (0.17–2.05) | 2.61 (0.80–8.57) | 0.96 (0.28–3.24) |
| High priority | 1.72 (0.64–4.66) | 2.50 (0.65–9.64) | 2.19 (0.84–5.75) | 3.36 (1.28–8.80)* | 2.03 (0.78–5.26) |
| Suspected child e-cigarette use | |||||
| Does not suspect | REF | REF | REF | REF | REF |
| Don’t know | 1.36 (0.62–2.98) | 0.54 (0.16–1.80) | 0.74 (0.35–1.57) | 0.90 (0.39–2.06) | 0.74 (0.32–1.68) |
| Suspect | 1.12 (0.50–2.49) | 0.48 (0.13–1.79) | 1.43 (0.53–3.80) | 0.56 (0.22–1.41) | 0.87 (0.37–2.07) |
aOR, adjusted odds ratio; 95% CI, 95% confidence interval.
aAll models control for age, race/ethnicity, education, child school level, and language survey taken.
*p < .05; **p < .01.
Conclusions
Parents are an important—and understudied—group of tobacco control stakeholders with documented influence on the policy making process.32,33 Results from the current study reveal that an overwhelming majority of parents supported tobacco control efforts to protect adolescents from exposure to tobacco products and marketing. Importantly, support remained high among parents who are current tobacco users and may be less favorable toward tobacco control efforts in general.40,41,43–45 More than 70% of parents who are tobacco users and more than 80% of all parents supported a policy to raise the legal age of tobacco sales to 21, limit tobacco retailers near schools, or keep tobacco products out of view of adolescents. These estimates are notably higher than the levels of support reported among US adults in past research40,41,44,45 which likely reflects the vested interest of parents to protect adolescents from tobacco use.29,36,37
This study also provides evidence of parents’ support for regulations on e-cigarette sales and marketing in the context of the rapid growth in youth e-cigarette use in the United States.1 We found that nearly all parents, regardless of tobacco use status, supported restrictions on youth-targeted e-cigarette marketing. These findings are consistent with the 2015 C.S. Mott Children’s Hospital poll which found a high level of support among parents for restricting e-cigarette marketing on social media.39 Our estimates of parents’ support also exceed those reported by Tan et al.,43 where 70% of US adults in 2014 agreed that marketing and advertising e-cigarettes to underage youth should not be allowed. While there is a growing body of evidence that exposure to e-cigarette advertising can increase the likelihood of e-cigarette use among young people,21–23 current regulation of e-cigarette marketing is limited, especially compared with cigarettes or other emerging tobacco products, like IQOS, a heat-not-burn tobacco product.21,46,47 Our data suggest that local and national policymakers should introduce comparable restrictions on youth-targeted e-cigarette marketing, and such measures would be met with broad support from both parents and the public.39,43
Flavored e-cigarettes also strongly appeal to youth4,9 and play a role in youth susceptibility to e-cigarette use and initiation.4,6,48 Our study demonstrates that three out of four parents in the United States support a ban on fruit, alcohol, or candy flavored e-cigarette sales. This finding is consistent with the results from the 2015 C.S. Mott poll which found that 64% of parents agreed that there should be a ban on candy- and fruit-flavored e-cigarettes39 and higher than the levels of support reported among the general population.43,44 Additionally, we observed that the majority of parents (53.6%) who are current tobacco users were in favor of a flavored e-cigarette ban, suggesting that this is a salient policy issue even among parents who use tobacco products. Although considerable efforts have been made in recent years to restrict flavored e-cigarette sales nationally and within local jurisdictions,13,14 these policies often face substantial political challenges and tobacco-industry funded opposition.49 The results from this study provide consistent and compelling evidence that parents favor efforts to ban flavored e-cigarette sales and can be important advocates in the policymaking process.25
This is one of the first studies to explore the influence of key family-level predictors of youth tobacco use on parents’ level of support for tobacco control policies.27–30 Overall, we found that suspecting one’s child of e-cigarette use was not significantly associated with increased support for most policies. This suggests that parents—who often underestimate their child’s tobacco use36—are just as likely to support tobacco control policies to protect youth regardless of whether they believe their child has used a product. One exception was the lower odds of support for e-cigarette marketing restrictions among parents who suspected their child ever used an e-cigarette. It is possible this group may consider marketing restrictions to be a less effective tool in preventing their child’s continued e-cigarette use, while, parents who suspect their child never tried an e-cigarette may be more supportive of marketing restrictions as a preventive measure to reduce future use. Regardless, it is important to note that 9 in 10 parents (90.6%) who did suspect their child ever used an e-cigarette supported marketing restrictions, suggesting this is a viable policy strategy among this group.
Not surprisingly, parents who report it is a high priority to prevent their child from using e-cigarettes and those who have strict rules against tobacco use at home had significantly greater odds of policy support. Perhaps more importantly, trends were similar for parents who are current tobacco users. Advocacy groups can leverage these findings to include parents in framing policy messages. Prior campaigns, like the FDA’s Real Cost, have been targeted toward youth who may be susceptible to e-cigarette use.50 However, campaigns aimed toward parents can inform and mobilize this group, as well. Strong messages can highlight parents’ influence on youth tobacco use in the home, including setting strict home-based tobacco rules, and empower parents to demand stronger tobacco control regulations in their community.31 Prevention programs can also actively recruit and involve parents to support ordinances that strengthen e-cigarette policies at the local level.
Limitations
This study is not without limitations. First, the policy support measure for banning flavored e-cigarettes did not include mint or menthol flavors, therefore findings are limited to fruit, alcohol, and candy-like flavors. Second, the survey design did not allow for oversampling of current tobacco users and we were unable to produce reliable estimates of differences among exclusive cigarette smokers, exclusive e-cigarette users, and dual users. Third, parents were not asked about suspected child’s use or priority to prevent child’s use of other tobacco products (eg, cigarettes, cigars, smokeless tobacco), limiting our ability to determine if policy support would vary by type of tobacco product. Nonetheless, this recent data collection from a large, nationally representative probability-based sample provides valuable and timely information to inform advocates and policymakers alike on policy support from a group of key stakeholders.
This study updates and expands the limited research on parents’ support for tobacco control policies in the context of the recent growth in youth tobacco and e-cigarette use.1,36–39 Our results provide evidence that parents are highly supportive of youth-centered tobacco control policies, particularly those that restrict access to youth-targeted e-cigarette marketing and the sale of youth-appealing flavored e-cigarettes. Mobilizing parents’ public support may be an important advocacy strategy to set policy agendas and advance efforts to prevent the growing rates of youth tobacco and e-cigarette use in the United States.
Acknowledgments
The authors would like to thank Elizabeth Hair and Lindsay Pitzer at Truth Initiative for assistance in designing this study.
Funding
This work was self-funded by Truth Initiative.
Declaration of Interests
None declared.
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