Dear Editor,

Youth e-cigarette use is a public health epidemic, prompting health professionals to investigate prevention/intervention efforts. The Social Ecological Model proposes that interventions addressing multiple levels of influence are essential to changing behavior1. The current study examined parental influences (current smoking behaviors and parenting style) as they relate to their knowledge, beliefs and behaviors surrounding teen e-cigarette use.

Odds for youth smoking increases with the number of parents who smoke2 and e-cigarette using parents are often unaware of health risks and view e-cigarettes as a safer alternative than conventional cigarettes3. Parental anti-smoking expectations are associated with lower likelihood that their child will smoke and non-e-cigarette smoking youth are more likely to have parents who view e-cigarettes negatively4,5.

Positive parent–child relationships are associated with lower levels of youth smoking6, while spending less family time together is associated with higher levels7. An authoritative parenting style and open communication between parent–child are considered protective factors2.

Data were collected electronically from a convenience sample of parents/guardians (N=116) of middle and high school students in a selected Midwestern school district during Fall 2019 (IRB Approval Number: IRB-2019-512). Demographics of the sample population are included in Table 1. Guided by studies of teen alcohol use8, scales were developed to measure parent knowledge, beliefs and behaviors surrounding e-cigarettes. All items were rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Sum scores were created for each scale by summing the item-level scores. The knowledge scale consisted of six items: electronic cigarettes contain nicotine; electronic cigarettes are just as addictive as traditional cigarettes; the smoke from electronic cigarettes is just water; electronic cigarette vapor contains harmful chemicals; electronic cigarettes may harm teen brain development; and electronic cigarettes are risk free. Possible scores ranged from 6 to 30. The beliefs scale consisted of six items: I believe that if my child’s friends use electronic cigarettes, then my child is more likely to use them as well; I believe that teens can get access to electronic cigarettes very easily; I believe that teens who use electronic cigarettes suffer negative health consequences; I believe that schools could do more to prevent electronic cigarette use among teens in our community; using electronic cigarettes, rather than traditional cigarettes, are a safe alternative for teens; and I believe that teens use electronic cigarettes to get the same ‘buzz’ that they get from traditional cigarettes. Possible scores ranged from 6 to 30. The behavior scale consisted of two items: I talk to my child about the dangers of electronic cigarettes; and I enforce clear rules with my child about not using electronic cigarettes. Possible scores ranged from 2 to 10. Relationships were examined between scores on knowledge, beliefs and behavior scales, and parents’ personal tobacco use or family pro-social behaviors (eating family dinners, number of hours spent with children, and children’s participation in extracurricular activities).

Table 1

Demographic characteristics of participants (N=116)

Relation to child
Other primary caregiver22
Black or African American11
Native American11
Marital status
Education level
High school1110
Some college or Associate’s degree2925
Bachelor’s degree3530
Graduate school4035
Children’s participation in extracurricular activities
Adult household cigarette use status
Adult household e-cigarette use status

Parents who smoke had significantly lower knowledge scores (mean: 25.00, SD: 3.21) and behavior scores (mean: 8.29, SD: 1.49) compared to non-smokers [mean: 27.04, SD: 2.79; t(114)=2.53, p=0.013, d=0.68, two-tailed], [mean: 9.31, SD: 1.15; t(114)=3.00, p=0.003, d=0.76, two-tailed], respectively.

A significant, positive correlation was found between number of days a family ate together weekly and scores on the behavior scale [r(114)=0.24, p=0.01, two-tailed]. A significant, positive correlation existed between number of hours spent together weekly and scores on the behavior scale [r(114)=0.22, p=0.02, two-tailed]. Parents whose children did not participate in extracurricular activities had significantly lower knowledge scores (mean: 24.00, SD: 3.88) compared to parents whose children did participate [mean: 26.99, SD: 2.72; t(114)=-2.31, p=0.023, d=0.89, two-tailed].

Parental smoking behaviors were correlated with significantly lower knowledge and behavior scores, indicating that parents who smoke cigarettes possess inaccurate information and take less action with their children to prevent or stop e-cigarette use. Targeted educational interventions for smoking parents surrounding e-cigarette dangers exist.

Pro-social parent behaviors were significantly, positively correlated with behavior scores. The majority of parents in this study enforce clear expectations and have open discussions with their children about the dangers of e-cigarettes. Promoting pro-social parenting behaviors, encouraging open parent–child communication, and providing expectations surrounding e-cigarette use should be critical components of interventions.