Data from national and state surveys indicate that approximately one-third of adolescent females have initiated the 3-shot HPV vaccine series (7–10). Because many potential vaccine recipients are under 18 years of age, most HPV vaccine acceptability studies have focused on the diverse factors that may influence parental acceptability (9, 11, 12), including demographic factors (11, 13), medical history variables (9, 14), parental knowledge and awareness about HPV and cancer (15–18), and other psychosocial or attitudinal beliefs (8, 9, 15–21). Despite the number of studies that have been conducted, few have examined how various health behaviors may be associated with vaccine acceptability. Patterns of associations among multiple health behaviors (e.g., tobacco use, physical activity, fruit and vegetable intake) have been widely studied, and there is empirical evidence to suggest that health-enhancing behaviors (such as healthy diet, physical activity) are commonly associated with one another, whereas health risk behaviors (smoking, alcohol use) tend to cluster together (22–24). Further, studies have reported that those who practice healthy lifestyle behaviors are not only more likely to accept personal immunization against disease (25), but may also be more willing to vaccinate their offspring (26).

Associations between vaccine uptake and other health behaviors, such as use of complementary and alternative medicine (CAM) services, however, appear to be more complex. Although adult CAM users may be more likely to obtain vaccinations (against influenza and pneumococcal infection) themselves (27), parental CAM use has been associated with poorer vaccine uptake among their children (28, 29). In light of the growing interest and awareness of CAM use among adults in the United States (30, 31), it is important to consider whether potential associations exist among such health behaviors and HPV vaccine acceptability.

With regard to behavioral correlates, vaccine acceptability was higher among physically active individuals and individuals not reporting CAM use, as hypothesized. These findings are consistent with prior research that suggests that health-promoting behaviors (e.g., physical activity and diet) tend to co-occur (22, 24) and may be associated with vaccine acceptability (25, 26). Likewise, the present findings support the notion that parental CAM use may be associated with poorer vaccine uptake among their children (28, 29). It has been reported that individuals who prefer CAM to conventional approaches are sometimes mistrustful of, or have had negative experiences with, conventional medical approaches and/or public health recommendations (31). Among parents who requested medical exemptions to required vaccinations for their children, the most common reasons for not vaccinating were concerns about vaccine safety (28). Recently published data on the post-licensure safety profile of the quadrivalent HPV vaccine should alleviate some parents’ safety concerns given that few serious adverse events have been associated with the vaccine (34). However, in light of declining incidence and mortality rates of cervical cancer in the U.S., there continues to be debate over whether even the slight risks of vaccination outweigh the possible long-term benefits (35), and the present findings may reflect ongoing parental consideration of these issues.

Contrary to our hypotheses, smokers reported greater acceptability of the HPV vaccine. It is possible that former and current smokers have a heightened awareness of cancer and/or the cancer-related risks of secondhand smoke (36–38), and therefore, they may be more willing to engage in behaviors that offer protection to their daughters. Smoking is also more prevalent in subgroups with lower educational attainment (39), and some prior studies have reported lower education to be associated with greater HPV vaccine acceptability (13). However, it should be noted that the association between smoking and vaccine acceptability remained significant even after education level was included in the model.

In addition to behavioral factors, the current analysis also included demographic, medical history, and attitudinal variables that have previously been reported to be associated with HPV vaccine acceptability. Surprisingly, although three behavioral factors were associated with HPV vaccine acceptability in the present study, not one of the demographic variables or medical history variables was associated with vaccine acceptability. Prior studies have also reported inconsistent findings with respect to demographic background and prior medical history (9, 14, 40), perhaps suggesting that personal health beliefs and behaviors may be more closely related to vaccine acceptability than one’s background or prior experiences. For example, with respect to health beliefs, participants who strongly agreed that cancer can be cured if it is caught early reported greater acceptability of the HPV vaccine. These findings suggest that the assessment of health behaviors and personal beliefs about cancer can help inform our understanding of individuals’ decisions regarding the uptake of cancer prevention strategies for their children.

Strengths of the current study include the use of a diverse national sample and standardized procedures. Although there have been a number of HPV vaccine acceptability studies conducted previously, few have included data from a national sample and thus, the present findings serve as an important barometer of public opinion. Additionally, the majority of prior studies were conducted before the vaccine’s approval for use by the FDA and the subsequent proliferation of vaccine marketing to both adults and children. However, the present findings should be considered in the context of several limitations to the present study. First, the study asked about willingness to vaccinate as opposed to assessing actual vaccine uptake rates. Second, study respondents may not have been the parents or legal guardians of the female children in the household. Third, given the manner in which the sample was selected and how the relevant questions were stated, it is acknowledged that although all study respondents had female children living in the household, some respondents had girls aged 11–12 and some did not. Therefore, for those respondents who did not have a child in that age group, the question to which they were responding was a hypothetical one; whereas for those respondents who did have a child in that age group, the question may have captured “actual” willingness rather than hypothetical willingness. Though our inability to distinguish between actual and hypothetical willingness in this study may limit how we can attribute these findings, the present findings may be informative with respect to actual behavior. Presumably, the respondents with girls aged 11–12 years (or older) will have described their actual willingness very well. Therefore, although a subgroup of respondents will have answered the item according to their hypothetical willingness to vaccinate a daughter, data from the current study may more closely approximate actual behavior than earlier studies, due to the fact that this sample was partially comprised of those who have already made their decisions and were reporting on their actual willingness to engage in this behavior. Finally, the study was limited to items included in the HINTS survey and did not contain other potential correlates, such as items regarding physician recommendations for HPV vaccination. Findings from a recent study suggest that only 50% of physicians always recommend the HPV vaccine for 11–12 year old girls (41), and therefore, the absence of a physician recommendation may be contributing to the fact that almost half of the study respondents were undecided or not willing to vaccinate an 11–12 year old daughter.