Association of Exposure to Smoke in Households with Childhood Anxiety and Depression in the United States: A Secondary Analysis from a National Dataset

Abstract

Background: Tobacco smoke exposure in the home remains common among U.S. families and has been increasingly associated with adverse mental health outcomes, including anxiety and depression, among children and adolescents. Rising rates of youth anxiety and depression, coupled with evidence that secondhand smoke and related psychosocial stressors may disrupt emotional development, underscore the importance of examining household smoking exposures as a modifiable risk factor for youth mental health. This study examines associations between exposure to smoke in households and the likelihood of caregiver-reported anxiety and depression in US children and adolescents aged 6–17 years, using data from the 2022–2023 National Survey of Children’s Health (NSCH). Methods: A retrospective analysis of NSCH data for two age cohorts, children (6–11 years) and adolescents (12–17 years), for the years 2022–2023 was conducted. Descriptive statistics were generated for the selected sample by frequencies and counts for each of the dependent and independent variables, followed by binary logistic regressions for each measured mental health variable based on current diagnosis, severity levels (not severe, mild, moderate, severe) and household tobacco use. Results: This study found significant associations between parental smoking and increased odds of caregiver-reported anxiety and depression in both children and adolescents. Specifically, children living with parents who smoke had 1.55 times the odds of severe anxiety, while adolescents had 1.38 times the odds of currently experiencing anxiety and 1.31 times the odds of currently experiencing depression. Smoking inside the household was not significantly associated with caregiver-reported anxiety or depression. These findings suggest that parental smoking serves as a marker for broader psychosocial and environmental stressors that contribute to youth mental health outcomes. Conclusions: Parental smoking is a significant, modifiable risk factor for anxiety and depression among US children and adolescents. These results emphasize the need for targeted, evidence-based interventions to reduce parental smoking, improve awareness of associated mental health risks, and address social determinants of health. Policies promoting smoke-free households, integrated cessation support, and culturally tailored education programs are essential to mitigate the impact of parental smoking on child and adolescent mental health.

1. Introduction

In the United States (US), tobacco use remains the leading preventable cause of disease and death for adults, with children and adolescents facing substantial risks from exposure to tobacco smoke in the home environment [1]. Approximately 20.2% of US parents with children at home reported smoking cigarettes in recent years [2]. Beyond its well-established physical health effects, household smoke exposure has been increasingly linked to adverse mental health outcomes among youth. Research demonstrates that secondhand smoke (SHS) exposure is associated with higher risks of anxiety and depression in children and adolescents [3]. Additionally, exposure to parental smoking in early life may disrupt neurodevelopmental pathways responsible for emotional regulation, increasing vulnerability to anxiety and depression that often persist into adolescence and adulthood [4]. Furthermore, it has been reported that children growing up in households with smokers are also exposed to a complex combination of psychosocial stressors, including parental mental health challenges, financial strain, and household instability, which may further exacerbate mental health challenges [4].

Rates of childhood and adolescent anxiety and depression in the US have been increasing steadily, with approximately 9.4–9.8% of children aged 3–17 years reported to be diagnosed with anxiety, and around 20.9% of adolescents aged 12–17 years reported experiencing a major depressive episode [5]. The COVID-19 pandemic further amplified these trends, with meta-analytic estimates showing about 20.5% of youth experiencing clinically elevated levels of anxiety, and 25.2% experiencing elevated levels of depressive symptoms during the pandemic [6]. Environmental exposures, including exposure to secondhand tobacco smoke, have been shown to contribute to youth mental health challenges [4]. Combined with environmental stressors such as financial strain, parental social determinants of health, including socioeconomic status, education, mental health, and awareness of the health risks associated with smoking, are key factors influencing household smoking behaviors [7,8]. Lower parental education levels and limited health literacy are associated with increased likelihood of smoking and indoor tobacco use, which in turn increases children’s exposure to SHS and increases their risk of developing anxiety and depression [9]. Similarly, households experiencing financial strain or parental psychological distress often experience higher prevalence of smoking and greater indoor smoke exposure [10]. These social and environmental factors interact with biological vulnerabilities that increase children’s susceptibility to emotional dysregulation and internalizing symptoms, highlighting the critical need to address both parental behavior and social determinants in efforts to protect child mental health [11].

Despite growing evidence linking secondhand smoke exposure to adverse mental health outcomes in youth, several important gaps remain in the literature. Prior studies have often relied on older datasets, focused on limited age ranges, or examined physical and behavioral outcomes rather than anxiety and depression specifically. In addition, few nationally representative studies have simultaneously examined household smoking exposure in the context of parental social determinants of health, such as education, financial strain, and caregiver mental health, which may confound or modify associations with youth mental health outcomes. Accordingly, this study aims to examine the association between exposure to household tobacco smoke and symptoms of anxiety and depression among U.S. children and adolescents aged 6–17 years using nationally representative data.

2. Methods

The National Survey of Children’s Health (NSCH) is a household survey whose goal is to estimate healthcare needs of children and their families at a state level [12,13]. It aims to measure the physical well-being, mental well-being, and socioeconomic factors affecting children ages 0–17 in the United States. Both the screener survey and the age-based survey are completed by the parent or legal guardian of the selected child. For the purpose of this study, the ages 6 through 11 years old and 12 through 17 years old were used in the compiled dataset from the surveys taken between July 2022 and January 2023, with an overall response rate of 39.1%. This age group was selected due to the evidence of higher risk of developing anxiety and depression in US adolescents and children when exposed to tobacco [4,14,15]. This paper was considered as exempt research by the Florida Atlantic University IRB (IRB#2505164) based on the Declaration of Helsinki requirements as it consists of secondary data analysis from a public database. This study consisted of a retrospective analysis of data from a national database and was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. A completed STROBE checklist has been included as Supplementary Material (Supplementary File S1).

2.1. Dependent Variables

Dependent variables were measured based on survey questions asking the parent or legal guardian of the randomly selected child if the child has ever been diagnosed with any of the specific selection of two mental health disorders, anxiety and depression. Questions focused on (1) presence of condition in the past 12 months; “In the last year has the child ever been diagnosed with anxiety or depression?”; (2) current diagnosis of illnesses if applicable; “If yes, does this child currently have the condition?”; and (3) severity of the condition if applicable: “If yes, is it: mild, moderate, or severe?”. Diagnoses are thus caregiver-reported reports of having been told by a healthcare provider, without clinical verification or standardized diagnostic assessment.

For the dependent variables, the answers were coded as follows: “yes” = 1, “no” = 2, and logical skip and all other responses = systems missing. For depression and anxiety variables measuring severity, the scale was recoded into a new binary variable: “not severe” = 1 if the parents responded “mild” or “moderate”, and “severe” = 2 if the parents responded “severe.” The severity variable was dichotomized into “severe” versus “not severe” due to small cell sizes in the more granular severity categories, which limited statistical stability and model convergence. Severity categories include caregiver-perceived severity rather than clinically defined severity.

2.2. Independent Variables

Independent variables were selected based on survey questions that were reflective of tobacco use inside the household as well as having parents as smokers per household. The survey questions included: (1) “Does anyone living in your household use cigarettes, cigars, or pipe tobacco?” (2) “If yes, does anyone smoke inside your home,” and a third question on the type of substance used, “Does anyone vape or use E-cigarettes inside your home?”. The binary response (Yes/No) for each of those questions was coded as “yes” = 1 and “no” = 2 for the purpose of the analysis.

2.3. Data Analysis

Data analysis was carried out with IBM SPSS Statistics (version 30). First, we selected responses for children aged 6–11 years old and adolescents aged 12–17 years old, inclusive. Summary statistics were generated for the selected sample by frequencies and counts for each of the dependent and independent variables for the 2022–2023 timeframe. Binary logistic regression models were conducted for both caregiver-reported depression and anxiety variables based on severity level (severe vs./not severe), in relation to household tobacco use and in-home smoking. Regression analysis controlled for parental mental and emotional health (5-Likert scale ranging from Excellent–Poor) and ability to pay for child’s medical or healthcare bills as covariates.

3. Results

3.1. Sample Characteristics and Smoke Exposure

Our analysis included data from a total of 68,000 participant responses in the 2023–2024 survey year, of which the childhood subgroup comprised 30,575 responses and the adolescence subgroup comprised the remaining 37,425 responses.

Table 1. Frequency of Household Tobacco, Vape, and E-Cigarette Use Stratified by Child and Adolescent Age Groups.

Tables Tobacco Use Variables	Childhood Ages 6–11 Years (N = 30,575)		Adolescence Ages 12–17 Years (N = 37,425)
	Count	Percent	Count	Percent
Anyone in household use tobacco -Smokes tobacco inside home	3429	11.2	4657	12.4
	359	1.2	710	1.9
Anyone in household use vapes/e-cigarettes	1277	4.2	1897	5.1

summarizes the distribution of household smoke exposure by age group and is further stratified by the exposure type within each age group. Adolescents tended to have slightly higher rates of exposure to smoke regardless of exposure type, with 12.4% (n = 4657) of parents of adolescent responses indicating at least one member of the household smoking tobacco products (11.2% [n = 3429] in the childhood subgroup) and 1.9% (n = 710) of parents of adolescent responses endorsing tobacco smoking specifically inside of the home (1.2% [n = 359] in the childhood subgroup). Additionally, adolescents had more vape/e-cigarette exposure, with 5.1% (n = 1897) of adolescent parents in our sample reporting at least one member of the household uses vapes or e-cigarettes compared to 4.2% (n = 1277) in the childhood subgroup.

3.2. Mental Health Variables

Prevalence of mental health issues, specifically caregiver-reported depression and anxiety, varied widely across the childhood and adolescence subgroups. 22.8% (n = 8521) of parents of adolescents reported that their child has a history of anxiety, while 13.6% (n = 5105) reported a history of depression. In contrast, 12.7% (n = 3871) of parents of children aged between 6–11 reported a history of childhood anxiety and 2.7% (n = 839) reported a history of childhood depression. Furthermore, of those participants reporting child or adolescent depression, the largest share of responses for assessment of severity levels of depression in both age subgroups were classified as the “mild severity” classification on a scale of mild, moderate, and severe. Specifically, for children, 1.4% (n = 419) of parental responses indicated mild depression severity as did 5.0% (n = 1863) of adolescent parental responses. However, for anxiety, the largest share of responses for severity classification differed between the two subgroups, with 9.2% (n = 3426) of parents of adolescents predominantly classifying their adolescent’s anxiety level as “moderate” and 6.0% (n = 1833) of parents of children predominantly classifying their child’s anxiety level as “mild” (

Table 2. Sample Mental Health Reported Issues in Childhood and Adolescence.

Mental Health Variables	Childhood Age 6–11 Years (N = 30,575)		Adolescence Ages 12–17 Years (N = 37,425)
	Count	Percent	Count	Percent
Anxiety	3871	12.7	8521	22.8
-Anxiety currently	3501	11.5	7467	20.0
-Mild anxiety	1833	6.0	3231	8.6
-Moderate anxiety	1404	4.6	3426	9.2
-Severe anxiety	247	0.8	770	2.1
Depression	839	2.7	5105	13.6
-Depression currently	708	2.3	4041	10.8
-Mild depression	419	1.4	1863	5.0
-Moderate depression	245	0.8	1740	4.7
-Severe depression	42	0.1	416	1.1

).

3.3. Regression Analysis

A series of binary logistic regression analyses was conducted to examine the associations between household smoking status and smoking inside the household with current caregiver-reported anxiety and depression, as well as with the severity levels of these mental health conditions, among children (ages 6–11) (

Table 3. Binary Logistic Regression of Mental Health Current Status and Severity Level and Each of Parental Smoking Status and Inside Household Tobacco Use in Children Aged 6–11 years old.

Household Smoking Status	Severe Anxiety			Severe Depression			Currently Have Anxiety			Currently Have Depression
	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Yes	1.552	1.114–2.162	0.009 *	1.334	0.654–2.722	0.429	1.338	0.910–1.967	0.138	1.545	0.907–2.632	0.109
Smoking Tobacco Inside Household	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Yes	1.632	0.749–3.557	0.217	0.357	0.044–2.898	0.335	1.016	0.344–3.001	0.976	2.120	0.463–9.714	0.333

* Significance is set at p < 0.05.

) and adolescents (ages 12–17) (

Table 4. Binary Logistic Regression of Mental Health Current Status and Severity Level and Each of Parental Smoking Status and Inside Household Tobacco Use in Adolescents Aged 12–17.

Household Smoking Status	Severe Anxiety			Severe Depression			Currently Have Anxiety			Currently Have Depression
	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Yes	1.208	0.995–1.467	0.056	1.119	0.870–1.440	0.382	1.382	1.113–1.716	0.003 *	1.313	1.085–1.590	0.005 *
Smoking Tobacco Inside Household	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.	OR	95%	Sig.
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Yes	1.313	0.855–2.016	0.214	1.349	0.796–2.286	0.266	1.153	0.672–1.979	0.605	1.306	0.816–2.093	0.266

* Significance is set at p < 0.05.

). Parental mental and emotional health and ability to pay for the child’s medical or healthcare bills were controlled for as covariates.

3.4. Household Smoking Status in the 6–11-Year-Old Children Age Group

When compared to children living in a non-smoking household, children who lived with parents who smoke had 1.5 times the odds of being diagnosed with severe anxiety (p = 0.009; 95% CI (1.114–2.162)). No significant associations were observed between household smoking status and current mental health diagnosis (current anxiety or depression status).

3.5. Household Smoking Status in the 12–17-Year-Old Adolescent Age Group

When compared to adolescents living in a non-smoking household, adolescents who lived with parents who smoke had 1.4 times the odds of currently experiencing anxiety (p = 0.003; 95% CI (1.113–1.716)), and 1.3 times the odds of a current diagnosis of depression (p = 0.005; 95% CI (1.085–1.590)).

3.6. Smoking Inside Household in Both the 6–11-Year-Old Children and 12–17-Year-Old Adolescent Age Group

No significant associations were observed between smoking inside the household and current mental health diagnosis (current anxiety and/or depression) for both age groups.

4. Discussion

Using data from the NSCH, prominent links were identified between the presence of smokers within a household and rates of anxiety and depression in children and adolescents. This study identified significant associations between the presence of parental smoking in the household and higher odds of caregiver-reported anxiety and depression among both children (ages 6–11) and adolescents (ages 12–17). While associations were statistically significant, the observed odds ratios were modest and should be interpreted cautiously with respect to clinical impact at the individual level, while still being relevant at the population level. However, these findings are consistent with recent U.S. evidence showing that parental smoking or youth exposure to tobacco smoke is linked to elevated risk of anxiety and depression among young people [16,17]. For example, one U.S. nationally representative study found that children and adolescents with confirmed tobacco smoke exposure had significantly higher odds of neuropsychiatric comorbidities, including anxiety and depression, compared to those without such exposure [17]. Furthermore, exposure to parental smoking and second-hand smoke in childhood was found to be significantly associated with poorer mental health outcomes later in life, hinting at both short-term and enduring effects of early household tobacco exposure [16]. Our findings extend this work by demonstrating that parental smoking, independent of smoking inside the household, is a significant predictor of anxiety and depression in both children and adolescents.

This study also highlighted that smoking inside the household was not significantly associated with caregiver-reported anxiety or depression, suggesting that parental smoking may reflect broader psychosocial risk factors rather than direct secondhand smoke exposure alone. These findings are consistent with previous research showing that parental smoking is associated with increased risk of depressive and anxious symptoms in adolescents, largely through familial stress, disrupted caregiving, and modeling of maladaptive coping behaviors [4]. Parental stress, mental health challenges, and social determinants such as low income and limited educational attainment likely mediate these effects [9,18]. Children living with parents who smoke are more likely to come from lower-income households or have parents with lower educational attainment. Moreover, parents who smoke may use tobacco to manage their own stress, anxiety, or depression, which can indirectly impact their children’s emotional well-being. These findings are consistent with prior work showing that lower socioeconomic status and parental stress increase the risk of youth anxiety and depression [9,18]. Furthermore, prior research has demonstrated that environmental exposures, including parental smoking, increase the risk of developing anxiety and depression by contributing to heightened levels of household stress, inconsistent caregiving, and reduced parental emotional availability [19,20]. Our study’s results are consistent with these findings, emphasizing that parental smoking serves as a marker of these broader environmental and psychosocial stressors.

The findings of this study, when considered alongside the prior literature, suggest several potential implications for interventions aimed at reducing parental smoking and supporting youth mental health. Evidence from existing research indicates that programs such as the Community Engaged and Advocating for a Smoke Free Environment (CEASE) initiative, pediatrician-delivered counseling, and school-based education programs have been effective in increasing parental awareness of tobacco-related risks and reducing smoking behaviors, which may in turn support child and adolescent mental well-being [21,22,23]. Culturally tailored interventions may be particularly important for reaching diverse populations and families with lower health literacy, and prior studies suggest that integrating mental health support into smoking cessation programs could help address shared psychosocial risk factors linked to both parental smoking and youth anxiety and depression [24].

At the policy level, existing evidence highlights the potential role of public health policies in reducing parental smoking and limiting children’s exposure to associated environmental and psychosocial risks [25]. Although smoke-free air laws in public spaces have been associated with population-level health improvements, the home remains a primary setting for children’s exposure to parental smoking [26]. Prior research suggests that expanding access to cessation resources, strengthening smoke-free housing policies, and providing support for parental mental health may help reduce household-level risk factors for youth anxiety and depression [25]. Even in multiunit housing with smoke-free regulations, indirect exposure through shared ventilation systems has been documented, underscoring the need for comprehensive approaches that combine policy, education, cessation support, and community outreach [27].

Limitations

Several limitations should be considered when interpreting the findings of this study. First, all mental health outcomes were based on caregiver-reported information, including reports of provider-diagnosed anxiety and depression as well as perceived severity. Proxy reporting is a recognized limitation for internalizing conditions, for which caregiver–child agreement is often modest, particularly during adolescence. Caregiver reports may reflect parental awareness of diagnoses, perceptions of symptom burden, or caregivers’ own stress or mental health rather than children’s subjective emotional experiences. As a result, the prevalence and severity of anxiety and depression in this study may be misclassified, and associations should be interpreted as reflecting caregiver-reported mental health status rather than clinically confirmed psychiatric conditions. Second, the NSCH does not include standardized diagnostic assessments or clinical verification. Reports of anxiety and depression represent caregiver-reported recall of having been told by a healthcare provider that the child had these conditions and may not align with DSM-defined disorders. Similarly, severity categories (mild, moderate, severe) are caregiver-defined and may vary in interpretation across respondents. Consequently, the findings should not be interpreted as estimates of clinically diagnosed disorders or validated symptom severity, but rather as indicators of perceived mental health burden within households. Third, severity was dichotomized into “severe” versus “not severe” due to small cell sizes in the more granular categories, which limited statistical stability and model convergence. While this approach improved analytic feasibility, it reduced dimensional nuance and combined heterogeneous presentations (mild and moderate symptoms), potentially obscuring clinically meaningful differences in symptom severity. Therefore, results related to severity should be interpreted cautiously and understood as identifying higher perceived symptom burden rather than precise gradations of clinical severity. Fourth, despite adjustment for parental mental and emotional health and ability to pay for medical care, residual confounding remains a concern. Key sociodemographic variables—including parental education, household income, and race/ethnicity—were not included due to data limitations and concerns regarding model stability. These factors are strongly associated with both parental smoking behaviors and child mental health outcomes and may partially explain the observed associations. Additionally, the dataset does not capture adolescent self-smoking behaviors or detailed information on smoking by non-parent household members, which may further confound results. Fifth, the cross-sectional design of the NSCH precludes causal inference or assessment of temporality. Although parental smoking was associated with higher odds of caregiver-reported anxiety and depression, the directionality of these associations cannot be established. It is possible that shared psychosocial stressors—such as financial strain, parental psychological distress, or household instability—contribute to both parental smoking and child mental health outcomes, or that children’s mental health challenges increase parental stress and tobacco use. Accordingly, findings should be interpreted as associative rather than causal. Finally, although parental smoking was examined as a potentially modifiable exposure, it is important to avoid stigmatizing interpretations. Parental smoking often occurs within broader structural and contextual constraints, including socioeconomic disadvantage, limited access to cessation resources, chronic stress, and mental health challenges. In this context, parental smoking should be understood as a marker of broader environmental and psychosocial risk rather than an isolated behavior. Interventions aimed at reducing smoking-related harms to children should therefore emphasize supportive, non-punitive, and structurally informed approaches that address underlying social determinants of health.

5. Conclusions

This study emphasizes the need to address child and adolescent exposure to parental smoking in US households. Although smoking inside the household was not independently associated with these mental health outcomes, parental smoking serves as a marker of broader psychosocial and environmental stressors that increase risk for anxiety and depression. While some interventions and policies exist, there is a need for a more comprehensive approach that integrates parental smoking cessation, mental health support, and culturally tailored education to reach high-risk groups and reduce the long-term burden of anxiety and depression among youth.