Smoking is the single greatest cause of avoidable illness and preventable death. Smoking kills more than 120,000 people each year in the UK: that is about one in every five deaths (Callum 1995). Smoking is also the principal cause of the inequalities in death rates between rich and poor (Jarvis and Wardle 1999). About half of all smokers will be eventually killed by their habit (Peto 1994).
Most people who die from a smoking related disease die from either cancer, chronic obstructive lung disease (bronchitis and emphysema) or coronary heart disease. Smoking also causes a number of other serious conditions such as low birth weight and ‘cot death’ (SIDS). No other single avoidable factor causes such a high proportion of deaths, hospital admissions or consultations with general practitioners (Department of Health 1998).
Tackling smoking among young people
Reducing smoking among young people is a key policy goal for tobacco control. Over 80% of those who ever smoke daily, start before the age of 18. If young people could be dissuaded from taking up smoking, then the problem would be largely solved. However, there is much debate about the best way of tackling smoking among young people (McNeill and Charlton 2003).
Smoking and children’s health
Children who smoke are two to six times more susceptible to coughs and increased phlegm, wheeziness and shortness of breath than those who do not smoke. One study revealed that children who smoke are three times more likely to have time off school. The earlier children become regular smokers and persist in the habit as adults, the greater the risk of dying prematurely. A recent US study found that smoking during the teenage years causes permanent genetic changes in the lungs and forever increases the risk of lung cancer, even if the smoker subsequently stops (McNeill and Charlton 2003).
Children are also more susceptible to the effects of tobacco smoke pollution (also known as passive smoking) and cotinine levels found in the saliva of children whose parents smoke indicate that in households where both parents smoke, the children receive a nicotine equivalent of smoking 80 cigarettes a year. Bronchitis, pneumonia, asthma and other chronic respiratory illnesses are significantly more common in infants and children who have one or two smoking parents. Children of parents who smoke during the child’s early life run a higher risk of cancer in adulthood and the larger the number of smokers in a household, the greater the cancer risk to non-smokers in the family.
Children whose parents smoke are subject to disadvantage from the very beginning of life. Smoking during pregnancy increases the risk of several serious problems including miscarriage, preterm birth and low weight at birth. Low birth weight causes grave health and developmental problems for the baby (Department of Health 1998).
Trends in youth smoking
Despite a reduction in the overall prevalence of smoking in the UK over the past 30 years there has been little change in smoking rates among young people. Regular surveys of smoking prevalence among 11-15 year old secondary school students began in 1982. In every year the survey has been carried out, the proportion smoking regularly has been the same or higher among girls than among boys: in 2002, 11% of girls and 9% of boys smoked regularly. There is a sharp increase in prevalence with age: in 2002, 1% of 11 year olds were regular smokers, compared with 23% of those aged 15 (Department of Health 2003).
Social inequalities and smoking among young people
Children from less advantaged social backgrounds are somewhat more likely to start smoking than children from more affluent backgrounds, but the difference is not great. However, by their 30s, half of the better off young people have stopped smoking while three quarters of those in the lowest income group carry on (Jarvis and Wardle 1999).
Why do young people take up smoking?
The routes into smoking are complex but involve both environmental and personal factors. Environmental factors include the tobacco industry’s activities to market smoking as desirable and fashionable, the portrayal of smoking in the media, the price and availability of cigarettes. Personal factors include the influence of family and friends, the young person’s social background, their personality and the influence of the school they attend (Crosier et al 2003).
Marketing of smoking in the media
Several studies have demonstrated that the portrayal of smoking in films influences young people’s attitudes to smoking. Every year the tobacco industry spends billions of pounds worldwide advertising and promoting tobacco products. A report by the US Surgeon General concluded that tobacco advertising increases consumption by encouraging children or young adults to experiment with tobacco and thereby slip into regular use and by creating an environment in which tobacco use is seen as familiar and acceptable. As a result, the warnings about its health are undermined (US Department of Health and Human Sciences 1989). Endorsement of smoking by celebrities, sponsorship of sporting events and product placement of cigarette brands in films have been found to be particularly effective means of influencing young people’s perceptions and smoking behaviour (ASH 2004a).
Family smoking behaviour
Perhaps the single most important predictor of a young person’s smoking status is the smoking status of the family in which the child lives. Children who live with two parents who both smoke are nearly three times as likely to become smokers themselves as those whose parents do not smoke (McNeill and Charlton 2003). This has led to the call from a number of experts to focus efforts on adults as the principal means of tackling the uptake of smoking among young people (Hill 1999).
Low academic achievement, rebelliousness, alienation from school, the perception that tobacco use is the norm and the belief that smoking confers future advantages in social life also predict onset. Smoking may be used by teenage girls as self-medication for depression and anxiety. A lack of skills to resist offers and low self-esteem are also predictive of smoking. The influence of peers, the desire to bond with a group and the likelihood of exposure of smokers in school tutor groups, have all been shown to increase the uptake of smoking.
A number of studies have examined the factors that appear to protect children from becoming smokers. Autonomy, self-regulation, problem-solving, family characteristics and community characteristics and the availability of opportunities at major like transition points – have all been found to protect young people from taking up smoking. Active participation in sports is also known to predict non-smoking status in young people (McNeill and Charlton 2003).
The policy context
The Government’s policy on smoking was set out in the white paper, Smoking Kills (Department of Health 1998). This detailed a comprehensive strategy to tackle smoking among adults and to help prevent the uptake of smoking among children. Specific measures included:
· Minimal tobacco advertising in shops
· Tough enforcement on under age sales
· Proof of age card
· Strong rules on siting of cigarette vending machines
· Ending all tobacco advertising
· Changing attitudes to smoking through mass media campaigns
· Offering NHS help to smokers who want to quit, and nicotine replacement therapy to reduce nicotine addiction – free of charge to those least able to afford it
The Tobacco Advertising and Promotion Act 2002 banned press, billboard and most internet advertising of tobacco products and the promotion of smoking through free distribution of tobacco products, coupons and mailshots in the UK. Through regulations it will place restrictions on point of sale advertising. It will also bring an end to the promotion of tobacco products through the sponsorship of sporting and other events and will control brandsharing.
The following statement from the anti-tobacco charity ASH identifies the problem of a youth focussed strategy.
‘At first sight it seems obvious to try to stop young people starting to smoke in the first place. However this is not at all easy. Focussing on young people can easily make smoking seem to be something for adults… and hence more attractive to young people. The result of youth anti-smoking and prevention initiatives have been very mixed and unclear to say the least. Tobacco companies always favour youth smoking prevention initiatives – an obvious reason for alarm and caution..’ (ASH 2004b)
As young people’s smoking is strongly related to that of adults, reducing adult smoking prevalence may be the best way to prevent the uptake of smoking among young people. However, delaying the onset of smoking in children may reduce the likelihood of becoming addicted, of smoking heavily later in life, and of future substance use disorders. Early understanding of the health risks of smoking might increase the inclination of smokers to stop and help to protect them against the ploys of the tobacco industry. It also reduces the risk of the immediate and future health problems which become established in young smokers. Addiction can develop quickly in young smokers (McNeill and Charlton 2003).
Price of cigarettes
Price increases are regarded as a key lever in reducing overall prevalence of cigarette smoking in all segments of the population. The price of tobacco is a one of the most important factors affecting tobacco consumption. Increasing levels of tax on cigarettes reduces consumption because people respond to the price signal by giving up, cutting down or never starting. However, this policy can be undermined by the illegal importation of tobacco which is sold at reduced rates on the black market. Most commentators believe that the impact of price on young people’s smoking is at least as important as it is on adults – although it is unlikely to account for the very first attempts at smoking, as most young smokers get their cigarettes from friends and relatives.
The HBSC survey
The Health Behaviour in School-Aged Children (HBSC): WHO Collaborative Cross-National Study was conducted in 35 countries across Europe and North America during 2001/2. It was the sixth such survey of over 162,000 young people, and it covered self-reported health and well-being, healthy eating, physical activity, smoking, alcohol consumption, accident prevention and bullying, within the contexts of peer relations, school environment, family and socio-economic status.
The findings presented here are taken from the HBSC survey conducted in England in 2002. The survey involved responses from a total of 6,425 secondary school children in Years 7, 9 and 11. The study involved the use of self completion questionnaires administered in the classroom.
A measure of smoking frequency was obtained by asking young people:
‘How often do you smoke tobacco at present?’
Sixteen percent of respondents to the HBSC survey were smokers, that is people who smoke ‘sometimes, but not as often as once a week’ or more regularly.
Overall, just over half (54%) of respondents had ‘never tried’ smoking. A further 18% had ‘only ever tried smoking once’ and 10% ‘used to smoke sometimes, but never smoke tobacco now’. Thus 82% of respondents were defined as ‘non smokers’. Of those 16% who were smokers, the majority, 9% smoked ‘every day’. Only 4% of respondents smoked ‘sometimes, but not as often as once a week’ or ‘at least once a week, but not every day’.
Smoking by age and sex
Smoking was strongly associated with the age of respondents. Very few (3%) Year 7 students smoked, compared to 16% of Year 9 students and 31% Year 11 students. Overall, girls (19%) were more likely to smoke than boys (14%). The higher smoking rates among girls were evident from Year 9 onwards.
Smoking behaviour was strongly associated with levels of support within the family. The more positive the students’ perceptions of the support they received from their parents, the less likely they were to smoke. Only 12% of respondents who said they found it easy to talk to their mother and father smoked, compared to 34% and 28% respectively of respondents who said they found it ‘very difficult’ to talk to their mother and father. Similarly, only 10% of students with a ‘high’ or ‘very high’ sense of family belonging smoked, compared to 29% of those with a low sense of family belonging. And respondents who felt their parents ‘never help’ were much more likely to smoke (33% smoked) than those who felt their parents ‘almost always help’ (13% smoked). Nearly three in ten (29%) of respondents with a low sense of family belonging smoked compared to 7% of those with a very high sense of family belonging.
Involvement at school
A number of variables that explored the idea of ‘self determination at school’ were associated with levels of smoking. For instance, smoking rates were lower among respondents who reported a greater sense of involvement in decision making at school (11%) than those who did not feel involved (25%).
Fewer respondents who participated in school clubs at least once per week smoked (11%) than those who were not involved with a school club or who attended less frequently than once per week (20%). There were fewer respondents who smoked who felt able to get extra help if needed (13%) than those felt they could not get extra help (29%), and respondents who felt their parents helped if there was a problem at school were less likely to smoke (15%) than those who felt their parents would not help (28%).
Rspondents who felt there was a strong sense of belonging at the school were less likely to be smokers (14%) than those who did not (25%). Respondents who felt they could not get extra help at school when they needed it were more likely to be smokers (29%) than those who felt they could get help (13%).
There was no significant difference in smoking prevalence by the family affluence scale. However, a difference was found by perceived family wealth. Twenty four percent of respondents who perceived their family to be ‘not well off’ smoked, compared to 17% of those who felt their families were ‘average’ and 15% of those who felt their families were ‘well off’.
A sense of belonging
As with involvement at school, respondents who reported a stronger sense of involvement, belonging and personal control in their neighbourhood were less likely to smoke. For instance among those with a high sense of neigbourhood control only 12% smoked, whereas the proportion of smokers rose to 18% among those with a low sense of neighbourhood control. Similarly, for students with a medium or high level of involvement with neighbourhood clubs and organisations only 13% smoked, compared to 22% among those with no involvement.
Among those with a low sense of neighbourhood belonging 25% smoked compared with 14% who felt a high sense of belonging. Meanwhile, among those who said they rarely or never feel safe in their local area the proportion of smokers was 27%. This compares with 15% of respondents who smoked who siad they always feel safe. This pattern was most marked among respondents in Years 9 and 11.
Most experts now agree that teenage smoking rates are unlikely to decline in the absence of a fall in adult rates (HDA 2001). This is because of the aspirational values attached by young people to smoking as a mark of adulthood. It is argued that quitting by adults (especially by parents) will reduce the likelihood of children taking up smoking.
The components of a local strategy to reduce smoking prevalence include:
· Reducing smoking in public places and especially in workplaces
· The development and nurturing of evidence based smoking cessation services
· National media campaigns to educate and remind people of the benefits of quitting
· Media advocacy as a component of a social marketing approach
· Reducing sales of cigarettes to children
· Encouraging the introduction of smoking policies in schools
· Ensuring that campaigns are inclusive and targeted to reach poor smokers and smokers from minority ethnic groups as well as the rest of the general population (HDA 2001).
The ASH website contains the most extensive database of information on all aspects of smoking – including young people and smoking, and links to all relevant websites. www.ash.org.uk
The Department of Health’s website www.doh.gov.uk/tobacco contains useful links to Government documents and related policies.
The Health Development Agency’s website www.hda.nhs.uk contains important guidance on the development and implementation of policies to tackle smoking prevalence.
http://www.hda.nhs.uk/evidence/ HDA Evidence Base provides direct access to publications on effective actions to reduce alcohol misuse
www.hbsc.org.uk find out more about the HBSC study from this website.
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