Int. J. Environ. Res. Public Health 2013, 10, 3868-3885; doi:10.

3390/ijerph10093868
OPEN ACCESS

International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article

Family Process and Peer Influences on Substance Use by

Adolescents
Alice Yuen Loke * and Yim-wah Mak

School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China;
E-Mail: hsywmak@polyu.edu.hk

* Author to whom correspondence should be addressed; E-Mail: alice.yuen.loke@polyu.edu.hk;

Tel.: +852-2766-6386; Fax: +852-2364-9663.

Received: 24 May 2013; in revised form: 6 August 2013 / Accepted: 15 August 2013 /
Published: 27 August 2013

Abstract: This study explores the association of family process and peer influences with
risk behaviors of adolescents. A total of 805 students were recruited from secondary
schools. The results showed that adolescents who have parents who are ―authoritarian‖
(OR = 1.856) were more likely to smoke. Adolescents who have conflicts with their
parents (OR = 1.423) were more likely to drink. Those who have parents who
are ―permissive‖ were less likely to drink (OR = 0.885). Having friends who smoked
(OR = 5.446) or drank (OR = 1.894), and friends‘ invitation to smoke (OR = 10.455) or
drink (OR = 11.825) were the dominant contributors to adolescent smoking and drinking.
Interventions are needed that recognize the strength of the parent-child relationship, as well
as strengthen family functioning through improved interpersonal, parenting, and
monitoring skills.

Keywords: family structure; family process; parental style; substance use; adolescents

1. Introduction

Young people are vulnerable of many behaviors that put their health at risk such as experimenting
with smoking cigarettes, taking illegal drugs, and drinking alcohol [1]. A Hong Kong population-based
survey reported that adolescents start to experiment with behaviors that are risky to their health when
they are as young as 10 [2]. It was reported that among children aged 11–14 who had experimented
Int. J. Environ. Res. Public Health 2013, 10 3869

with smoking cigarettes, 22.1% of them had smoked their first cigarette at the age of 10 or younger,
and 60% had done so between the ages of 11–14. Among the 5% of children aged 11–14 who had
drunk alcohol, about one-third had their first drink at the age of 10 or younger, and 44.3% between the
ages of 11 and 14. Among children aged 11–14, 0.2% reported that they had taken illicit drugs in the
30 days preceding the survey.
The healthy development of adolescents assures a healthy society in the future. Behavior practiced by
adolescents that puts their health at risk will extend into adulthood, rendering them vulnerable in
adulthood to preventable morbidities and mortalities. The family process plays a key role in socializing
and shaping children to enable them to adjust to the demands of their social environment [3]. Adolescent
perceptions of what goes on in their family can make them vulnerable to behavior that is harmful to their
health. Public health professionals are increasingly recognizing the major role that families play in a
range of social and psychological problems affecting adolescent behaviors and health.

1.1. Family Process and the Impact on Adolescents

There is evidence showing that the family process plays a key role in inducing social and behavioral
problems among youths or in protecting them from such problems. Family warmth and connectedness
serve as a protective factor against many of the risky behaviors engaged in by adolescents [3].
Although childbirth comes naturally to most married couples, this is not the case with parenting
skills. The family—in particular the parents—is responsible for setting an example in terms of
health-promoting behaviors, and for providing protection against the uptake of behaviors harmful to
health. Parents serve as role models for their children in imparting important health-related knowledge
and appropriate behavior, as gatekeepers to both opportunities and barriers, and as the major source of
reinforcement of behavior in most children [4,5].
The structure of the family affects the development of children. The children of divorced parents
have been found to be twice as likely as children from intact families to display a lower level of
conduct and delinquent behavior [6]. Adolescents who do not live with two parents are more likely to
smoke cigarettes, and use marijuana and other illicit drugs. Studies have reported that adolescents from
intact families (two birth parents) are less likely to be regular drinkers [7] and smokers [8] than those
from either reconstituted or single parent families.
Studies have shown the relationship between the family process and behaviors by adolescents that
put their health at risk. The family process has multiple characteristics, including: family
connectedness, the satisfaction of family roles, and family conflicts. A study investigating the
relationship between the influence of the family and behaviors among adolescents that put their health
at risk reported that family connectedness was significantly inversely associated with alcohol and drug
use [9]. The satisfaction of family roles, with positive mother-adolescent communication and quality
father-adolescent communication, was associated with lower levels of problem behavior among
adolescents [10]. Getting into conflicts with one‘s parents also increases the likelihood that a young
person will engage in risky health behavior. A cross-sectional study revealed that higher levels of
parent-adolescent conflict (from the perspectives of both children and parents) are generally related to
more behavioral problems among adolescents [11].
Int. J. Environ. Res. Public Health 2013, 10 3870

Parental warmth and support, and consistent and moderate discipline can inhibit behavioral problems
in children [12]. Supportive parenting and positive perceptions of the quality of the parent-child
relationship were also related to a reduction in behavioral problems among adolescents [13]. Parenting
patterns are classified as: warm-directive, indulgent, authoritarian, and neglectful. Adolescents who
perceived their parents as authoritative (high control, low support) and neglectful (low support and low
control) were three times more likely than those who perceived their parents as warm-directive to
report that they engaged in moderate or heavy alcohol use, substance use (2.75 times), and smoking
(25% vs. 16.6%) [14].
A study that explored parental monitoring and negotiated unsupervised time found that adolescents
with parental monitoring when compared with those without monitoring from their parents were less
likely to drink (OR = 0.63), smoke (OR = 0.99), and take illicit drugs (OR = 0.73) [15].
The adolescents who have more unsupervised time from their parents were more likely than those with
less unsupervised time from their parents to drink (OR = 1.85), smoke (OR = 1.35), and take illicit
drugs (OR = 1.77). Another study showed that young adolescents who characterized their parents as
neglectful were more likely to have tried smoking (OR = 4.27), drinking (OR = 1.99), and illicit drugs
(OR = 3.34) than adolescents with warm and directive (authoritative) parents [16]. Parents‘ perception
of their own parental style also revealed similar phenomenon. The study showed that parents‘ own
report of high level of support and monitoring of their adolescents were associated with adolescents‘
less involvement in smoking and drug taking [17].

1.2. Peer Influence and the Risk Behavior of Adolescents

Adolescents have a moderate to strong influence impact on their peers‘ risk behavior [18].
Adolescents are susceptible to peer influence in that it has been observed that they are more likely to
engage in risk taking in groups than alone. Adolescents, with their limited degree of self-reliance,
which interferes with their ability to act independently of the influence of their peers, may be more
easily swayed towards engaging in risky behavior [19]. Impulse control or sensation seeking by
adolescents also plays an important role in the degree to which they might engage in risk taking
behavior [20]. The results of a study that examined risk taking and decision making supported the idea
that adolescents are more inclined than those of other age groups to engage in risky behavior and make
risky decisions, and that peer influence plays an important role in explaining such behavior during
adolescence [21].
A study involving 1,969 adolescents showed that a friend‘s cigarette smoking, alcohol drinking, and
drug use activities, significantly predicts an adolescent‘s risk activities over a one-year period [22].
Peer influence is an outcome of peer selection processes and socialization [23]. Adolescents tend to
affiliate and develop friendships with peers who shares common attitudes and characteristics
contributing to homogeneity of peer group [24–26]. A study has reported that school-aged children
with smoking parents were less likely to consider that smoking is harmful to health (67.7%), and had
more peers who smoked (30.3%) [27].
Peer influence is also one of the top reasons given by adolescents for why someone their age would
pick up smoking. Adolescents do offer cigarettes to their peers and that smoking is typically initiated
in the context of peer groups [28]. ‗Cigarette offer by peers‘ was a common reason given by
Int. J. Environ. Res. Public Health 2013, 10 3871

adolescents for their picking up of their first cigarette (43.3%) [24]. Adolescents also tend to pick up
their cigarettes when they were ‗wanting acceptance from friends‘ (36%) [29].
A study has reported that adolescents who have a smoking peer are four times more likely to smoke
than those who do not [27]. It was concluded that peers may also play a crucial role in the development
of adolescents by influencing how they interpret information on risk behaviors and shaping their
normative beliefs. A study found that having a friend who discourages a teen from engaging in
particular types of behavior may also protect adolescents from engaging in risky activities [22].
Public health professionals are increasingly recognizing the key role that families and peers play in
a range of social and behavioral problems affecting young adolescents. To address youth problems in
the community, such as substance use, preventative action must be taken—for example, looking into
adolescent perceptions of the family process and the peers that surround them, and identifying the
issues that put adolescents in a vulnerable position.
This study was conducted to examine the family process of adolescents and the influence of their
peers, and how both factors relate to the issue of substance use by adolescents. A better understanding
of the family process responsible for behaviors by adolescents that are harmful to their health will
provide the information needed to design appropriate interventions for families that are aimed at
supporting these families and responding to the needs of those with at-risk adolescents.

2. Methods

The aim of this study was to explore the influence of family structure, the family process, parenting
style, and the influence of friends on substance use by adolescents. This is a cross-sectional survey that
employed a self-developed questionnaire. The study was conducted in a district in Hong Kong
populated mostly by families of a lower socio-economic class, where a high prevalence of risky
behaviors among adolescents has been reported.

2.1. Subject Recruitment

Secondary school principals in the Sham Shui Po District were approached for permission to
conduct the survey in their schools. Prior to the survey, adolescents of the participating schools were
given an information sheet and a refusal form to bring home to their parents. The information sheet
provided to the parents clearly stated the purposes of the survey, and those parents who did not want
their children to complete the questionnaire were asked to return the refusal form.
Five secondary schools (including one all-boys school) in the district accepted the invitation to
participate in the survey. Two classes (Forms 1–6) were randomly selected from each school. The
participating students completed the survey in a regular classroom setting on an agreed-upon date and
time that did not interfere with their school schedule. A member of the research team distributed and
collected the questionnaires.

2.2. Questionnaires

The questionnaire consisted of questions on the students‘ perception of the family process;
substance use (smoking, drinking alcohol, and using drugs), their parents‘ and friends‘ smoking
Int. J. Environ. Res. Public Health 2013, 10 3872

behavior and their acceptance of smoking, the demographic characteristics of the adolescents, and their
family structure (if they live with both parents or with a single parent).
The family process was examined from different perspectives, including family structure, family
process (family activities, family conflicts), parental style (the interaction of support and control), and
satisfaction with the fulfillment of the roles played by one‘s parents and oneself [30]. The question on
family structure asked if an adolescent was living with both birth parents or was from a single parent
family. Family process was measured by the scales for ―family activities‖ (six items), ―conflicts with
parents‖ (five items) and ―parental support and control‖ (six items) adopted and modified from
Sweeting et al. [31] and Glendinning et al. [8], respectively. Family activities refer to time spent in
shared family activities, which include spending time together to ―watch television‖, ―play indoor
games‖, ―eat dinner‖, ―exercise‖, ―shopping‖, and ―visit relatives‖. Family conflicts refer to arguments
over everyday matters, which include ―school works‖, ―cleaning own room‖, ―how money is spent‖,
―help in house chores‖, and ―choice of friends‖. These two aspects were measured in terms of
frequency. The items related to parental support and control include ―cannot get on well‖, ―expect too
much of me‖, and ―disappointed in me‖ for parental support; and ―strong view about my appearance‖,
―disapproval of some of my friends‖, and ―want to know where I go in the evenings‖ for parental
control. The parental support and control items were rated on a five-point Likert scale from ―0-strongly
disagree‖ to ―5-strongly agree‖. The questions on satisfaction with the fulfillment of the roles of
parents and self were statements asking the respondents to indicate their satisfaction with each parent
and with themselves using a five-point Likert scale ranging from ―never‖ to ―almost always‖.
The questions on the adolescents‘ substance use behaviors: smoking, drinking alcohol, and using
illicit drugs, were adopted from various studies [32–34]. With regard to smoking and drinking alcohol,
the students were categorized into never/ever tried/occasional/regular smokers; and never/ever
tried/and occasional drinkers. Items on the adolescents‘ illegal drug use, the smoking behavior of their
family members and peers, and their family members‘ and peers‘ acceptance of smoking, were rated in
terms of yes and no responses.
The developed questionnaire was translated into Chinese, and the content validity was assessed by a
panel of three experts. All of the experts agreed that the items were relevant, given a Content Validity
Index of 1.

2.3. Ethical Considerations

Ethical approval was obtained from the Human Subjects Research Ethics Committee of the
University prior to the study. Permission to conduct the survey was also obtained from the principals
of the schools attended by the participants. An information sheet explaining the aims of the study and a
refusal form were sent to the parents. Students who returned the refusal forms were excluded from the
study; all of the others completed the questionnaire in class. No risk in participating in this study was
anticipated. The participants were ensured of confidentiality and anonymity, and assured that all data
collected would be used solely for research purposes.
Int. J. Environ. Res. Public Health 2013, 10 3873

2.4. Data Analysis

All of the data were analyzed using the Statistical Package for the Social Sciences (SPSS) version
17 (SPSS Inc., Chicago, IL, USA). Descriptive statistics such as frequencies and percentages were
used for the demographic data. The dependent variables, smoking status and drinking status, were
dichotomized into ―non-smoker‖ and ―smoker‖ (including students who had ever tried smoking,
smoked occasionally, and regular smokers); and ―non-drinker‖ and ―drinkers‖ (including students who
had tried drinking alcohol, drank occasionally, and regular drinkers). Chi-square tests were used to
compare the adolescents who had and had not engaged in substance use (smoking and drinking) with
reference to family structure, family process, parental style, satisfaction with the roles of parents and
self, the smoking behavior of family members, and the influence of friends.
A composite score was computed for the overall scale and for each of the subscales for measuring
family process (family activities time, conflicts with parents, parental support and control). T-tests
were employed to examine the relationship between the characteristics of the family process and the
substance use (smoking and drinking) of the adolescents.
The composite scores of the scales for parental support (mean = 7.89, SD = 2.48) and control
(mean = 3.53, SD = 2.28) were further divided into three groups representing a relatively high,
moderate and low level of family support and control as perceived by the adolescents. Parental support
is desirable, with the three statements were negatively stated, the Likert scale scores for ―never‖ was
given a score of 4 and ―seldom‖ was given a score of 3, and almost always a score of 0, etc. The higher
the score, the higher level of parental support there was. One would expect that only those parents who
―never or seldom‖ cannot get on well, expect too much or disappointed in adolescents to be considered
supportive (score 9 or higher, reported of at least ―seldom‖ doing so in all 3 behaviors.
The parents who were considered ―sometimes‖ (score of 2) or ―often‖ (score of 1) showing
disapproval all three statements were considered non-supportive (score 6 or less). The middle range
would be those who are moderate of parental support (score 7–8).
While on the other hand, the three statements on parental control are undesirable. The higher the
score, the higher level of parental control there was. The parents who were considered as ―often‖ doing
so (score of 3) in one and ―sometimes‖ (score of 2) in other two behaviors, would be considered of
highly control (score 7 or higher). The parents who score of 4 or less (at least 2 statements being
considered as seldom doing so) would put parents considered of being less controlling. The middle
range would be those who are moderate of parental control (score 5–6). The three support and control
categories were regrouped to produce five distinct types of parenting styles, namely ―neglectful‖ (low
support and low control)‖; ―authoritarian‖ (low support but high control); permissive (high support but
low control); ―warm-directive‖ (high support and high control); and ―moderate‖ (moderate support and
control) [14].
The two subscales measuring ―family activity time‖ (mean = 11.53, SD = 4.314) and ―conflict with
parents‖ (mean = 5.90, SD = 3.748) were re-coded into two groups: frequent activity time with family‖
(score ≥ 12) and ―little activity time with family‖ (score ≤ 11); and ―have conflicts with parents‖
(score ≥ 11) and ―not in conflict with parents‖ (score ≤ 10) in the binary logistic regression analysis.
Logistic regression was used to identify the factors contributing to the substance use of adolescents.
Int. J. Environ. Res. Public Health 2013, 10 3874

3. Results

A total of 835 questionnaires were collected in the five schools. Only a few students, 2–4 students
from each school returned their parents‘ signed refusal forms and did not complete the questionnaires.
A total of 30 cases were excluded due to incompleteness; as a result, 805 cases were included in the
analysis for this study.
Table 1 shows the demographic characteristics of the respondents. There were more boys than girls
in this study (73.4% vs. 26.6%). A majority of the adolescents had never smoked (91.1%), 4.5% had
tried smoking, 1.7% smoke occasionally, and 2.7% were regular smokers. More adolescents had drunk
alcohol (25.3%), with 30.7% of them drinking occasionally. Less than 1% of adolescents (n = 8)
reported ever having used illegal drugs. Nearly 80% of the adolescents lived with both parents and had
siblings. Adolescents from single parent families comprised 17.4% of the respondents.

Table 1. Demographic Characteristics of the Adolescents in the Study (n = 805).

Demographic characteristics N %
Gender
Male 591 73.4
Female 214 26.6
Age groups
11–15 394 48.9
16–18 411 51.1
Substance use status
Smoking
Never smoke 733 91.1
Has tried smoking 36 4.5
Smoke occasionally 14 1.7
Regular smoker 22 2.7
Drinking alcohol
Never drink 330 40.9
Has tried drinking 228 25.3
Drink occasionally 247 30.7
Illegal drug use
Has tried illegal drugs 8 <1.0
Family structure
Lives with both parents 641 79.6
Lives with a single parent 140 17.4
Has siblings 635 78.9
Lives with siblings (among those with siblings) 575 90.6
Smoking status of
Father 359 44.6
Mother 45 5.6
Sibling 63 7.8
Friend(s) 169 22.9
Int. J. Environ. Res. Public Health 2013, 10 3875

Table 1. Cont.
Demographic characteristics N %
Smoking status of
Father 359 44.6
Mother 45 5.6
Sibling 63 7.8
Friend(s) 169 22.9
Satisfaction with role fulfillment
of father 413 51.7
of mother 507 63.2
of self as a child 361 45.1
Parenting styles
Moderate (moderate support and control) 350 43.2
Permissive (high support and low control) 310 38.5
Neglectful (low support and low control) 88 10.9
Authoritarian (low support and high control) 52 6.5
Warm-directive (high support and high control) 5 0.6

Nearly half of the respondents had a father who smoked (44.6%), while a respective 5.6% and 7.8%
of the adolescents had a mother and sibling(s) who smoked. About a quarter (22.9%) of the
adolescents had at least one friend who smoked. More adolescents were satisfied with their mother‘s
role fulfillment (51.7%) than with their father‘s (43.2%) and their own role fulfillment as a child
(45.1%).
The calculation of the composite scores for family support and control showed that most of the
parents (43.2%) were moderate in their support and control of their children, 38.5% were permissive,
10.9% were ―neglectful‖, 6.5% were ―authoritarian‖, and only 0.6% were ―warm and directive‖ in
their style of parenting (Table 1).
Table 2 shows the comparison between adolescents who do and do not use substances, smoke, and
drink, with reference to the smoking behaviors of family members, family structure, satisfaction with
the roles of one‘s parents and oneself, and the influence of friends. Those defined as smokers are those
who had ever tried smoking or who smoke occasionally or regularly, and those defined as drinkers are
those who had ever tried drinking. No comparisons were made for drug use since less than 1% of
adolescents admitted to having tried illicit drugs.
The comparison between smoking and non-smoking adolescents showed that more smokers than
non-smokers have a father who smokes (62.5% vs. 42.9%, p = 0.002), a mother who smokes (22.2%
vs. 4.0%, p ≤ 0.001), and siblings who smoke (25.0% vs. 6.1%, p = 0.001). Fewer smokers than
non-smokers were living with both parents (62.5% vs. 81.0%, p ≤ 0.001) and perceived that their
family objected to their smoking (72.2% vs. 84.9%, p ≤ 0.003). The smokers were less likely than the
non-smokers to be satisfied with the role fulfillment of their father (29.1% vs. 53.2%, p ≤ 0.001),
mother (47.2% vs. 64.2%, p = 0.003), and their own self as a child (23.6% vs. 46.6%, p ≤ 0.001). More
of the smokers than the non-smokers had friends who smoke (66.6% vs. 16.4%), and would accept a
friend‘s offer to smoke (48.6% vs. 4.0%), but had fewer friends who object to smoking (33.3% vs.
63.9%), all with p ≤ 0.001 (Table 2).
Int. J. Environ. Res. Public Health 2013, 10 3876

Table 2. Comparison of smoking behaviors of family members, family structure, satisfaction of roles, and friends‘ factors between
adolescents with and without risk behaviors (n = 805).
Non-smoker Daily Smoker Chi-square Test Non-drinker Drinker Chi-square Test
n % n % n % n %
Total 733 91.1 72 8.9 χ2
p 330 40.9 475 59.0 χ2 p
Smoking behavior of family members
Father smokes (yes) 314 42.9 45 62.5 10.06 0.002 * 126 38.1 231 48.6 7.75 0.005 *
Mother smokes (yes) 29 4.0 16 22.2 41.21 ≤0.001 ** 10 3.0 34 7.1 6.22 0.013 *
Siblings smoke (yes) 45 6.1 18 25.0 29.77 ≤0.001 ** 10 3.0 53 11.2 17.85 ≤0.001 **
Family structure
Lives with both parents 594 81.0 45 62.5 13.8 ≤0.001 ** 273 82.7 368 77.5 3.31 0.068
Lives with a single parent 116 15.8 24 33.3 14.51 ≤0.001 ** 44 13.3 96 20.2 6.28 0.012 *
Lives with siblings (yes) 532 72.6 56 77.8 0.74 0.389 241 73.0 344 72.4 0.27 0.603
Family objects to smoking 623 84.9 52 72.2 9.07 ≤0.003 * - - - - - -
Satisfaction with role fulfillment
of father (yes) 390 53.2 21 29.1 15.1 ≤0.001 ** 179 54.2 232 48.8 2.66 0.103
of mother (yes) 471 64.2 34 47.2 8.59 0.003 * 214 64.8 291 61.3 1.70 0.193
of self as child (yes) 342 46.6 17 23.6 14.5 ≤0.001 ** 159 48.1 200 42.1 3.74 0.053
Friends’ factors
Have friends who 120 16.4 48 66.6 96.82 ≤0.001 ** 36 10.9 133 28.0 30.46 ≤0.001 **
smoke/drink
Will accept friend‘s 30 4.0 35 48.6 172.68 ≤0.001 ** 57 17.3 343 72.2 222.63 ≤0.001 **
invitation to smoke/drink
Friend objects to 469 63.9 24 33.3 31.85 ≤0.001 ** 211 64.9 283 59.0 5.47 0.019 *
smoking/drinking
* p ≤ 0.05, ** p ≤0.001.
Int. J. Environ. Res. Public Health 2013, 10 3877

The comparison between drinkers and non-drinking adolescents showed that more of the drinking
than non-drinking and smoking adolescents have a father (48.6% vs. 38.1%, p = 0.005), mother (7.1%
vs. 3.0%, p ≤ 0.013), and siblings (11.2% vs. 3.0%, p ≤ 0.001) who drink. More of the drinkers than
non-drinkers were living with a single parent (20.2% vs. 13.3%, p = 0.012). Fewer drinkers than
non-drinkers were satisfied with the role fulfillment of their father (48.8% vs. 54.2%), mother (61.3%
vs. 64.8%), and their own self as a child (42.1% vs. 48.1%), but there were no statistically significant
differences. More of the drinkers than non-drinkers had friends who drink (28.0% vs. 10.9%, p ≤ 0.001),
and would accept a friend‘s offer to drink (72.7% vs. 17.3%, p ≤ 0.001), but fewer had friends who
object to drinking (59.0% vs. 64.9%, p = 0.019) (Table 2).
A comparison was made of the family process (family activities, conflicts with parents, and parental
support and control) of adolescents who smoke/drink and those who do not (Table 3). The results show
that when compared with non-smokers, smokers have a lower mean score for ―time spent with
parents‖ (mean = 9.06 vs. 11.78, p ≤ 0.001) and a higher mean score for ―conflict with parents‖
(mean = 7.24 vs. 5.77, p = 0.002). The smokers, in comparison with those who do not smoke, also
tended to think that their parents were providing them with less support (mean = 6.81 vs.
7.99, p ≤ 0.001) and exerting more control (mean = 4.32 vs. 3.45, p = 0.002). With regard to the
comparison between drinkers and non-drinkers, the former have a higher mean score for ―conflict with
parents‖ (mean = 6.30 vs. 5.29, p ≤ 0.001). The drinkers, when compared with those who do not drink,
also tended to think that their parents provide less support (mean = 7.58 vs. 8.33, p ≤ 0.001) and exert
more control (mean = 3.83 vs. 3.09, p ≤ 0.001).

Table 3. Comparison of family process between adolescents with and without health risk
behaviors (n = 805).
Non-smokers Smokers t-test Non-drinkers Drinkers t-test
Family process n = 733 n = 72 t value n = 330 n = 475 t value
Mean (SD) Mean (SD) (p value) Mean (SD) Mean (SD) (p value)
Family activities (time
5.12 1.40
spent with parents 11.78(4.24) 9.06(4.30) 11.78 (4.38) 11.35 (4.26)
(p ≤ 0.001) ** (p = 0.162)
(6 items) a
Conflicts with parents −3.19 −3.79
5.77 (3.66) 7.24 (4.33) 5.29 (3.57) 6.30 (3.77)
(5 items) b (p = 0.002) * (p ≤ 0.001) **
Parenting style 1.18 −0.019
11.44 (2.17) 11.13 (2.05) 11.42 (2.25) 11.42 (2.11)
(6 items) c (p = 0.238) (p = 0.985)
parental support 3.90 4.26
7.99(2.41) 6.81(2.84) 8.33(2.47) 7.58 (2.43)
(3 items) d (p ≤ 0.001) ** (p ≤ 0.001) **
parental control −3.10 −4.52
3.45 (2.24) 4.32 (2.54) 3.09 (2.38) 3.83 (2.16)
(3 items) d (p = 0.002) * (p ≤ 0.001) **
a
Composite score ranges from 0–24; b Composite score ranges from 0–20; c Composite score ranges from
0–24; d Composite score ranges from 0–12. ** p ≤ 0.001; * p ≤ 0.05.

Factors Contributing to Substance Use by Adolescents

Factors that contribute to substance use among the adolescents in this survey were identified using
logistic regression. All statistically significantly differences between the users and non-users of
substances were included in the analysis. The logistic regression analyses were carried out in two steps
Int. J. Environ. Res. Public Health 2013, 10 3878

for each type of substance use (smoking or drinking). The first set of analyses was conducted by
inputting all family-related factors. The second step in the analyses was then done by adding the
variables relating to friends.
Table 4 shows that when only family-related factors were analyzed, the factors contributing to
adolescent smoking were: having a mother who smokes (OR = 4.633, 95% CI = 1.87–11.49, p ≤ 0.001),
having a sibling who smokes (OR = 3.16, 95% CI = 1.51–6.64, p = 0.0012), and having parents who are
―authoritarian‖ (OR = 1.856, 95% CI = 1.185–2.905, p = 0.007). Adolescents were less likely to smoke if
they were satisfied with their father‘s fulfillment of his role (OR = 0.478, 95% CI = 0.23–0.99,
p = 0.048), and satisfied with their own self (OR = 0.410, 95% CI = 0.185–0.905, p ≤ 0.027).
When friends‘ factors were added in the second step, only the factors relating to siblings who
smoke (OR = 2.61, 95% CI = 1.118–6.09, p = 0.027) and satisfaction with oneself (OR = 0.274,
95% CI = 0.121–0.624, p = 0.002) remained. Having friends who smoked (OR = 5.446,
95% CI = 2.608–11.374, p ≤ 0.001), and friends who invite one to smoke appeared to be the dominant
contributors to adolescent smoking with OR = 10.455, 95% CI = 4.434–24.649, p ≤ 0.001).

Table 4. Logistic regression analysis # of risk behaviors of adolescents (smoking cigarettes

& drinking).
Factors contributing to smoking Odds ratio 95% CI p value
Only family factors are considered
Mother smokes 4.633 1.869–11.485 ≤0.001 **
Sibling smokes 3.160 1.505–6.635 0.002 *
Satisfaction with father 0.478 0.230–0.995 0.048 *
Satisfaction with self 0.410 0.185–0.905 0.027 *
Authoritarian parenting 1.856 1.185–2.905 0.007 *
Friends’ components are added
Sibling smokes 2.610 1.118–6.094 0.027 *
Satisfaction with self 0.274 0.121–0.624 0.002 *
Friends smoke 5.446 2.608–11.374 ≤0.001 **
Friend‘s invitation to smoke 10.455 4.434–24.649 ≤0.001 **
Factors contributing to drinking Odds ratio 95% CI p value
Only family factors are considered
Sibling drinks 4.531 2.174–9.444 ≤0.001 **
Permissive parenting 0.885 0.786–0.996 0.042 *
Conflicts with parents 1.423 1.004–2.018 0.048 *
When friends’ components are added
Sibling drinks 3.607 1.510–8.617 0.004 *
Conflicts with parents 1.529 1.010–2.313 0.045 *
Friends drink 1.894 1.083–3.311 0.025 *
Friend‘s invitation to drink 11.825 7.715–18.126 ≤0.001 **
#
Method = Forward LR; * p ≤ 0.05; ** p ≤ 0.001.

When only family-related factors were analyzed, the factors contributing to adolescent drinking
were: having a sibling who drinks (OR = 4.53, 95% CI = 2.174–9.444, p ≤ 0.001) and having conflicts
with one‘s parents (OR = 1.423, 95% CI = 1.004–2.018, p = 0.048). Those who have parents who are
Int. J. Environ. Res. Public Health 2013, 10 3879

―permissive‖ were less likely to drink (OR = 0.885, 95% CI = 0.786–0.996, p = 0.042). When friends‘
factors were added in the second step, both the factors of having siblings who drink (OR = 3.607,
95% CI = 1.51–8.62, p = 0.004) and conflicts with parents (OR = 1.529, 95% CI = 1.01–2.31,
p = 0.045) remained significant. Having friends who drank (OR = 1.894, 95% CI = 1.083–3.311,
p = 0.025), and having been invited by friends to drink appeared to be the dominant contributors to
adolescent drinking with OR = 11.825, 95% CI = 7.715–18.126, p ≤ 0.001) (Table 4).

4. Discussion

A higher proportion of male students (73.4%) than female students were recruited in this survey due
to the participation of one all-boys school, and the gender distribution does not represent the normal
distribution in the territory. The prevalence of smoking fathers (44.6%) and mothers (5.6%) in
this survey was higher than the prevalence of smoking males (19.9%) and females (3.0%) in
Hong Kong [35]. With the participants coming from the Sham Shui Po District of Hong Kong,
a district populated by less affluent families, this could reflect the significance association between
socio-economic status (SES) and smoking behaviors [36].
The reported prevalence of smoking among the adolescents in this survey (2.7%) is very close to
that reported for adolescents in Hong Kong (2.5%) in 2010 [35], indicating that the sample was
representative of this population in Hong Kong. This prevalence was relatively low when compared to
those found in Western countries, such as 18.1% in the United States [37] and 25% in the United
Kingdom [38].
At 56%, the prevalence of those in this study under the age of 18 who had ever tried to drink
alcohol is alarming, indicating that the use of alcohol in social activities is finding increasing
acceptance among teens. This poses a risk of adolescents progressing to becoming binge drinkers,
which could impact on their physical and psychological well-being. Parents and healthcare
professionals should be cautioned about the rise of such activities and of the need to be aware of the
need to closely monitor the drinking behaviors of youth.
It has long been recognized that family plays an important role in the psychological well-being and
health risk behaviors of adolescents [10,39]. A wide range of family factors including family structure,
family process, parenting styles, and the smoking habits of family members, have been shown to be
associated with adolescent smoking and drinking [40,41]. Although the findings in the present study
show that the smoking habits of fathers, mothers, and siblings were all linked to the acquisition by
adolescents of these behaviors that are potentially harmful to their health, maternal and sibling
smoking had a greater impact on adolescent smoking and drinking than paternal smoking.
Both maternal and sibling smoking were identified as predictors of adolescent smoking (OR = 4.63
and 3.16, respectively), a finding consistent with other studies [42]. Our results show that having
siblings who smoke is a more influential factor in adolescent smoking than having parents who smoke,
as its effect remained significant with regard to both smoking and drinking behaviors even after the
inclusion in the analyses of factors related to friends. Similar findings have been observed in
other studies [43].
Recent research suggests that family structure is associated with behavior by adolescents that puts
their health at risk. The results of this study show that adolescents in single-parent households were more
Int. J. Environ. Res. Public Health 2013, 10 3880

likely to smoke and drink than those who live with both parents. This is possibly due to reduced parental
contact, such as the absence of a father [44] or to economic hardship resulting from the need to live on
the income of just one parent [45] inducing stress in the adolescents. However, this effect was moderated
when other family processes such as parental support and control, and conflict with parents, were taken
into account. This suggests that other factors may have a greater bearing on behavior by adolescents that
is harmful to their health, consistent with the findings of other studies [40,46].
The parenting process in terms of parent-child relations and parenting styles is closely related to
adolescent psychological well-being and problem behavior. The results of this study show that those
adolescents who spend more time engaged in activities with their parents are at a lower risk of
behaving in ways that are harmful to their health, while a poor parent-child relationship as indicated by
frequent parent-child conflicts puts adolescents at a greater risk of engaging in substance abuse. These
findings are supported by other studies [10,11,41].
Parenting style is an important factor influencing the psychosocial development of adolescents,
their use of substances, and delinquency [47]. The results of this study are consistent with those of
previous studies that found that parental support and control affect the uptake of behavior by
adolescents that puts their health at risk [41,48,49]. A nationwide study in the United States has found
that both too much and too little parental control contribute to adolescent delinquency [49]. While it
was thought that authoritarian parenting impacts on adolescents regardless of ethnic background,
a study among Latino found that increases in parental control, because of their tradition and culture
norm, function positively for Latino families and protects adolescents against problem behaviors [50].
This study among Chinese, found that authoritarian (low support and high control) and permissive
(high support and low control) parenting were contributors to drinking and smoking by adolescents.
Parents who are nurturing and supportive could enhance feelings of self-esteem and security in their
children; however, without appropriate monitoring or control, supportive parenting could also be
ineffective. An appropriate level of support and control on the part of parents could improve
parent-child relations, causing parents to be more successful in guiding adolescents to engage in
positive health behavior.
A large number of studies have documented that peers play an important role in the development of
adolescent risk behavior. Our findings support the notion that the influence of friends is highly predictive
of whether or not an adolescent will engage in smoking and drinking. These results are supported by
previous studies [21,39]. In this study, non-smoking adolescents had friends who objected to smoking,
suggesting that the influence of friends could either promote or deter risky behavior, as has been found in
other studies [22,33]. The pressure to gain acceptance among friends by smoking is common among
adolescents. Understanding the influence of peers could enable practitioners to design appropriate
measures to prevent the development of risky behavior among youth.
Substance use could compromise one‘s health. Although the cumulative negative effects of
smoking and drinking are slow, and signs and symptoms may not be apparent in adolescents, early
intervention is desirable to prevent engagement in risky behaviors.
Int. J. Environ. Res. Public Health 2013, 10 3881

Limitations of the Study

There are several limitations to this study. First, the study‘s population was not representative of the
gender distribution in Hong Kong. Participants were drawn from a less affluent district with families of
low socio-economic status, making the findings not generalizable. Second, the cross-sectional nature
of the study limits our ability to make causal inferences on the assessed variables. Third, the analyses
that were conducted were based on self-reported data, making response bias a possibility.

5. Conclusions

Using tobacco and drinking alcohol are leading causes of many preventable diseases. Family
processes and the influence of friends will influence engagement in such behavior during adolescence,
making adolescents susceptible to health risks later in life.
Familial influences are seen as important factors in the development of adolescents. Children look
up to their parents as role models; therefore, smoking on the part of parents and siblings will be
regarded by children as acceptable behavior, which they are likely to emulate. The ready availability of
cigarettes at home also encourages teenagers to try smoking, which could lead to the development of
this risky behavior. Parents and siblings, being the first persons that children interact with, exert
immense influence on children‘s behaviors by acting as role models. Recognizing the negative role
that they may play on the development of behavior among their children or younger siblings that could
be harmful to their health, family members who smoke should be encouraged to quit.
Besides serving as role models, parents also provide support and control to guide their children in
the course of their development. The quality of the parent-child relationship is another factor
influencing the development of risky behavior. A poor parent-child relationship, as reflected by less
time spent in activities together and increased conflict with parents, is a factor contributing to
engagement in risky behavior. Parenting with warmth, love, care, acceptance, respect, reason, and the
appropriate level of monitoring will encourage positive psychosocial development in children. Neither
an authoritarian (low support but high control) nor a permissive (high support but low control)
parenting style is seen as ideal, as shown in this study. High support without an appropriate level of
control or vice versa could contribute to engagement in risky behavior by adolescents, such as smoking
and drinking.
As adolescents begin to socialize with friends, the role of peers becomes important. Friends of
smokers are far more likely to transition to tobacco use/drinking than friends of non-smokers/non-
drinkers. In this study, the smoking and drinking habits of friends were important predictors of the
uptake by adolescents of such behaviors. Having a friend who smokes will increase the odds that an
adolescent will smoke by 5.45 times, rising to 10.46 times when the adolescent is invited by a friend to
smoke. Having a friend who drinks will increase the odds that an adolescent will drink by 1.89 times,
increasing to 11.825 times when invited by a friend to drink.
In this study, the smoking status of family members, parent-child conflicts, parenting styles, and the
influence of friends were all found to correlate with the development of smoking and drinking among
adolescents. This information is valuable for planning programs for the prevention and cessation of
risky behavior among adolescents.
Int. J. Environ. Res. Public Health 2013, 10 3882

Community-Based Family-Centered Interventions

Families should be supported in a respectful approach that views the family as central to the well-
being of adolescents. Any intervention needs to recognize the strength of the parent-child relationship
and to build on this strength to establish warmth and support in families. It needs to provide a range of
activities designed to strengthen family functioning by improving interpersonal relations, parenting,
and monitoring skills. Family-centered interventions should also include counseling, communication
skills, and information on enhancing parenting abilities; advocating for families; and connecting
families with the support services that they need to achieve a nurturing and stable family environment.
Healthy families also facilitate communication between parents and children and have a good
influence on an adolescent‘s selection of friends, both of which will greatly influence an adolescent‘s
choice of health behaviors. In order to reduce the incidence and prevalence of behaviors risky to health
among adolescents, communities should make an effort to enhance those factors that are protective
of families with adolescents. The result will be beneficial for the health of adolescents, families, and
the community.

Conflicts of Interest

The authors declare no conflict of interest.

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