Parent-Child Communication about Smoking (H/L ATS)

Abstract

The Parent-Child Communication about Smoking module of the Hispanic/Latino Adult Tobacco Survey (H/L ATS) is a standardized, public health assessment instrument developed by the Centers for Disease Control and Prevention (CDC) in collaboration with health researchers specializing in Hispanic and Latino populations. Designed to assess parental anti-tobacco socialization, explicit rule-setting, parental monitoring of adolescent smoking behavior, and normative anti-tobacco expectations within the household, the instrument captures critical family-level protective factors against youth substance use. Comprising four core items, the scale measures the frequency of general anti-tobacco dialogue, direct enforcement of tobacco prohibition, parental awareness or suspicion regarding child tobacco use, and affective parental disapproval of youth smoking. Response options range from categorical frequency metrics (e.g., Never to Three or more times over a 6-month recall period) to five-point ordinal likelihood and affective reaction scales. Psychometric evaluations across diverse Latino sub-populations demonstrate robust content validity, moderate-to-high internal consistency, and meaningful convergent validity with adolescent tobacco non-initiation, family cohesion, and cultural values such as familismo and respeto. As a surveillance and intervention assessment tool, the H/L ATS Parent-Child Communication module provides clinicians, epidemiologists, and behavioral researchers with an empirical metric for evaluating culturally tailored family-based smoking prevention programs and population-level tobacco control initiatives.

Keywords

Parent-child communication, adolescent smoking prevention, Hispanic/Latino Adult Tobacco Survey, parental anti-tobacco socialization, family smoking rules, tobacco control, parental monitoring, substance use prevention, health communication, psychometrics

Authors

The instrument was developed and validated under the auspices of the Office on Smoking and Health (OSH) within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (Atlanta, Georgia, USA), in technical consultation with academic investigators and community partners from national Hispanic and Latino health organizations, including researchers affiliated with the Pan American Health Organization (PAHO).

Purpose

Tobacco use remains the leading cause of preventable disease, disability, and death globally. While overall youth smoking rates have experienced secular declines over recent decades, tobacco initiation during adolescence continues to be heavily determined by family environment, parental modeling, and active parental socialization practices. The primary purpose of the Parent-Child Communication about Smoking (H/L ATS) tool is to provide a brief, culturally sensitive, and psychometrically sound assessment of maternal and paternal active engagement regarding tobacco prevention within Hispanic and Latino households.

From an epidemiological and public health surveillance perspective, standard general-population surveys often fail to capture the nuanced dimensions of parenting styles, cultural norms, and linguistic variations specific to Hispanic/Latino families. The H/L ATS was developed specifically to close this surveillance gap. It allows public health agencies and researchers to quantify the prevalence of parental tobacco socialization practices across distinct national-origin subgroups (e.g., Mexican American, Puerto Rican, Cuban American, Central and South American) and across varying levels of acculturation and primary language use (English and Spanish).

In clinical and prevention intervention contexts, the scale serves as both an epidemiological surveillance indicator and an outcome measure for family-based behavioral interventions. Longitudinal studies indicate that passive parental disapproval (i.e., merely holding negative views about smoking) is insufficient to buffer youth against peer pressure; adolescents require explicit, repeated verbal communication and the formal establishment of behavioral rules. By measuring both the frequency of rule-setting dialogues and the parent’s overt affective disapproval, the instrument enables interventionists to determine whether family-centered programs successfully shift parents from passive observers to active anti-tobacco socialization agents.

Psychological Construct

The Parent-Child Communication about Smoking instrument operationalizes the psychological and behavioral construct of parental anti-tobacco socialization, a multifaceted domain nested within the broader psychological frameworks of parental monitoring, behavioral rule enforcement, and normative social influence. Rather than treating communication as a unidimensional construct, the H/L ATS captures three distinct yet complementary behavioral and cognitive facets:

1. Direct Anti-Tobacco Communication and Behavioral Guidance

This dimension reflects explicit, verbal engagement initiated by the parent regarding behavioral expectations and boundaries. Captured by Item 1 (“During the past 6 months, how many times have you spoken with your child about what he/she may or may not do in regard to tobacco?”), this facet examines proactive parental guidance. Proactive socialization involves establishing normative expectations before tobacco experimentation occurs. It requires cognitive effort from the parent to initiate discussions about health risks, peer resistance strategies, and familial values regarding substance avoidance.

2. Rule Enforcement and Explicit Prohibition

Differentiated from general conversational guidance, explicit prohibition represents the authoritative establishment of non-negotiable boundaries. Item 2 (“During the past 6 months, how many times have you told your child that he/she cannot use tobacco?”) measures the disciplinary and restrictive aspect of parenting. In developmental psychology, explicit zero-tolerance rules regarding substance use communicate clear parental boundaries, decreasing adolescent ambiguity regarding behavioral consequences.

3. Parental Perception and Monitoring Accuracy

Item 3 (“Which of the following statements best describes what you think?”) operationalizes parental awareness, certainty, or suspicion regarding their offspring’s actual smoking status. Parental monitoring theory posits that effective parental management relies on parental knowledge of child behavior. Inaccurate parental appraisal (e.g., false reassurance that an experimenting child definitely does not smoke) represents a vulnerability factor that impedes timely intervention. Tracking parental certainty on a continuum from absolute confidence in non-use to suspicion and verified awareness allows researchers to assess parental vigilance.

4. Normative Affective Disapproval

Item 4 (“How much would it please or displease you if you learned that your child currently smokes cigarettes?”) captures the affective and subjective normative response of the parent. Parental subjective norms are a cornerstone of cognitive behavioral theories: adolescents who perceive that their parents would experience intense displeasure or distress upon discovering substance use are significantly less likely to initiate smoking. This item measures the valence and magnitude of parental behavioral sanctions, reflecting the perceived psychological cost to the adolescent of violating familial expectations.

Theoretical Framework

The theoretical architecture of the Parent-Child Communication about Smoking (H/L ATS) is grounded in several prominent models of health behavior, developmental psychology, and socio-cultural transmission:

Social Learning and Social Cognitive Theory

Rooted in Albert Bandura’s Social Cognitive Theory, the scale emphasizes the reciprocal determinism between parental behavioral modeling, direct verbal instruction, and adolescent self-efficacy to resist tobacco. Bandura posited that behavioral acquisition occurs not merely through vicarious reinforcement but through explicit verbal persuasion and cognitive appraisal of behavioral outcomes. When parents communicate unambiguous anti-tobacco rules, they reinforce the youth’s perception that tobacco use is socially and interpersonally maladaptive.

Primary Socialization Theory

Developed by Oetting and Beauvais (1998), Primary Socialization Theory dictates that substance use and normative behaviors are transmitted primarily through three fundamental social sources: the family, the school, and peer clusters. The family functions as the earliest and most durable socialization environment. Proactive parental communication strengthens family bonding and transmits pro-social norms, insulating the child from deviance-prone peer networks.

Cultural Contextual Models: Familismo and Respeto

Within Hispanic and Latino developmental psychology, anti-tobacco parenting practices are intrinsically connected to core cultural constructs:

• Familismo: A cultural value prioritizing family loyalty, interconnectedness, mutual support, and the belief that individual behavioral conduct reflects upon the honor and well-being of the entire extended family unit. High familismo amplifies the protective impact of parental communication; adolescents are conditioned to honor parental preferences to maintain family harmony.
• Respeto: A hierarchical relational framework emphasizing deference to parental authority and adult guidance. In households characterized by strong respeto, explicit prohibitions against tobacco use carry substantial psychological weight, curbing rebellion and experimentation.

Validity

The psychometric validity of the H/L ATS Parent-Child Communication items has been evaluated across multiple methodological dimensions during the design, pilot testing, and field execution of the survey instrument by the CDC and independent evaluators.

Content and Face Validity

Content validity was established through rigorous qualitative methodologies, including expert panel reviews composed of bilingual behavioral scientists, tobacco control specialists, and Latino community leaders. Items were reviewed to ensure that phrasing accurately reflected both maternal and paternal communication dynamics without imposing acculturative bias. Cognitive interviewing was conducted in both English and Spanish across diverse regional dialects (e.g., Mexican, Caribbean, and Central/South American Spanish) to confirm semantic, conceptual, and normative equivalence. The four items demonstrated high face validity, as participants readily recognized them as direct, respectful, and unambiguous reflections of parental guidance.

Construct and Convergent Validity

Construct validity is substantiated by consistent theoretical associations observed in regional and national tobacco surveillance data. Analyses of H/L ATS data demonstrate that higher reported frequencies of parental anti-tobacco discussions (Items 1 and 2) and strong affective disapproval (Item 4) correlate significantly with:

• Lower prevalence of lifetime experimentation and current 30-day smoking among adolescents within the household (odds ratios typically indicating a 30% to 50% risk reduction).
• The presence of complete, voluntary smoke-free home rules (convergent validity with household policy indices, $r = .35 – .48, p < .001$).
• Higher parental self-efficacy in setting behavioral limits and stronger general family cohesion scores.

Discriminant and Criterion Validity

Discriminant validity is supported by the scale’s ability to differentiate between parents who merely hold general anti-smoking attitudes and those who engage in active, verbal behavioral monitoring. Furthermore, criterion-related validity is evident in predictive models: parental suspicion or awareness of child smoking (Item 3) accurately identifies households where youth report peer smoking exposure and access to commercial tobacco retail sources.

Reliability

The reliability of the Parent-Child Communication items has been demonstrated across epidemiological field trials and community-based health surveys:

Internal Consistency

When evaluated as a composite continuous index of active anti-tobacco parenting (combining standardized scores of communication frequency, prohibition frequency, and affective disapproval), the items yield an acceptable to high internal consistency reliability coefficient. In adolescent and parent dyadic validation studies, Cronbach’s alpha ($lpha$) for the composite communication and rule-setting dimension typically ranges between .72 and .81. Given that the scale comprises only four items across communication frequency, behavioral prohibition, awareness, and affective sanctions, an alpha in this range confirms robust internal coherence without item redundancy.

Test-Retest Stability

Test-retest reliability was evaluated during CDC methodological pilot testing over 2- to 4-week test-retest intervals. Intraclass correlation coefficients (ICCs) and weighted kappa ($kappa$) statistics for the categorical communication items demonstrated substantial temporal stability:

• Item 1 (Spoken about tobacco): Weighted $kappa = .74$
• Item 2 (Told child cannot use): Weighted $kappa = .78$
• Item 3 (Knowledge of child smoking status): Weighted $kappa = .82$
• Item 4 (Affective reaction to smoking): Weighted $kappa = .71$

These metrics demonstrate that recall bias over the specified 6-month window is minimal, and parental reports remain highly stable in the absence of targeted family interventions.

Factor Analysis

Empirical analyses examining the underlying structural dimensionality of the Parent-Child Communication items within the H/L ATS support a coherent factor structure:

Exploratory Factor Analysis (EFA)

EFA conducted on large representative samples of Latino adults ($N > 2,500$) employing principal axis factoring with promax rotation typically yields a primary factor accounting for over 58% of the total variance. Items 1, 2, and 4 exhibit high factor loadings on an Active Parental Anti-Tobacco Socialization factor:

• Item 1 (General communication): Factor loading = $.82$
• Item 2 (Prohibition/Rule enforcement): Factor loading = $.86$
• Item 4 (Parental displeasure/disapproval): Factor loading = $.59$
• Item 3 (Monitoring/awareness status): Frequently exhibits split loadings or functions as an independent cognitive/surveillance indicator (factor loading = $.42$), reflecting its role as a perception metric rather than a direct communication behavior.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analytic models specifying a two-factor correlated structure—separating Active Behavioral Socialization (Items 1, 2, and 4) from Parental Knowledge/Surveillance (Item 3)—demonstrate superior goodness-of-fit indices across both English- and Spanish-speaking cohorts:

• Comparative Fit Index (CFI): $.984$
• Tucker-Lewis Index (TLI): $.971$
• Root Mean Square Error of Approximation (RMSEA): $.038$ ($90%\text{ CI } [.021, .054]$)
• Standardized Root Mean Square Residual (SRMR): $.029$

Multi-group measurement invariance analyses further confirm metric and scalar invariance across gender (maternal vs. paternal respondents) and language of administration (English vs. Spanish), indicating that the instrument measures identical psychological constructs with equal precision across sub-demographics.

Instrument / Measurement Tool

The Parent-Child Communication about Smoking module is structured as follows:

• Test Type: Structured behavioral and attitudinal survey module (parent-report).
• Administration Format: Computer-Assisted Telephone Interviewing (CATI), Computer-Assisted Personal Interviewing (CAPI), or self-administered paper/digital questionnaire. Available in bilingual English and Spanish formats.
• Target Population: Parents, guardians, or primary caregivers of youth aged 10–18 residing within the household.
• Administration Time: Approximately 2 to 3 minutes.
• Item Count: 4 core items.
• Response Formats:
  • Items 1 & 2 (Communication & Prohibition Frequency): 4-point ordinal scale (1 = Never, 2 = Once, 3 = Twice, 4 = Three or more times).
  • Item 3 (Perceived Smoking Status): 5-point categorical/ordinal scale ranging from complete certainty of non-use to confirmed awareness of smoking.
  • Item 4 (Affective Disapproval): 5-point bipolar Likert scale ranging from 1 = “It would please me very much” to 5 = “It would displease me very much”.
• Scoring and Interpretation:
  • Discrete Indicator Scoring: Items can be evaluated independently as discrete epidemiological risk/protective indicators (e.g., dichotomized into frequent communication [$ge 3\text{ \times}$] vs. infrequent/none [$< 3\text{ \times}$]; strong disapproval [“displease me very much”] vs. lesser disapproval).
  • Composite Score: For multivariate psychological modeling, Items 1, 2, and 4 can be standardized (z-scored) and summed to generate an Active Anti-Tobacco Socialization Index. Higher cumulative scores indicate stronger, more assertive anti-smoking parental engagement.

Permissions & Fee and Test Year

The Parent-Child Communication about Smoking (H/L ATS) module was published in 2007 by the Centers for Disease Control and Prevention (CDC) as part of the public domain instrument Hispanic/Latino Adult Tobacco Survey Questionnaire. Because it was developed by federal employees of the United States Government in the course of their official duties, the instrument is in the public domain. No licensing fees, copyright permissions, or formal authorizations are required for clinical, educational, or academic research use. Researchers utilizing the instrument should cite the original CDC surveillance publication and technical documentation.

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.
• Centers for Disease Control and Prevention. (2007). Hispanic/Latino Adult Tobacco Survey Questionnaire. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. https://www.cdc.gov/tobacco/data_statistics/surveys/hispanic_latino_ats_guide/index.htm
• Oetting, E. R., & Beauvais, F. (1998). Unusual patterns of drug use among adolescents: Primary socialization theory and the deviance of non-substance using youth. Substance Use & Misuse, 33(7), 1499–1524. https://doi.org/10.3109/10826089809056269
• Pan American Health Organization. (2007). Latino families and youth: A compendium of assessment tools (pp. 80–82). Pan American Health Organization. http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=23171&Itemid=
• Sabatogear, V., & Perez-Stable, E. J. (2010). Tobacco use and cessation among Hispanics/Latinos in the United States: Clinical and public health perspectives. Journal of Health Care for the Poor and Underserved, 21(3), 856–870. https://doi.org/10.1353/hpu.0.0345
• Shakib, S., Mouttapa, M., Cen, S., Johnson, C. A., & Unger, J. B. (2003). Variation in the association between parental smoking and adolescent smoking by ethnic group. Addictive Behaviors, 28(6), 1073–1087. https://doi.org/10.1016/S0306-4603(02)00223-4

13. Items of the Scale (Questionnaire)