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Smoking in children and young people

Summary

Smoking is the single biggest cause of the difference in life expectancy between the richest and poorest in England and is a major public health concern. Nationally some 80% of people who smoke started as teenagers and it can be presumed that this will be the same for smokers who live in South Gloucestershire. Breathing other people’s cigarette smoke, also known as passive smoking, has far reaching impacts on children’s health, often starting in the womb and continuing into adult life. Passive smoking is a cause of respiratory disease, cot death, middle ear infections and asthma in children. Infants and children are particularly vulnerable to the health effects of second hand smoke with most of their exposure coming from parents within the home.

Nationally an estimated 12.71% of 15 year olds are regular or occasional smokers. Estimated smoking prevalence ‘age 15 years indicator’ based on answers to the ‘What About YOUth’ (WAY) survey was released for the first time into the public domain, 2014/15. This showed that 9% of 15 year olds in South Gloucestershire were current smokers, lower than the South West average (9.8%) but higher than England average (8.2%).  The same survey showed that 6.8% were regular smokers, higher than both the South West average (6.3%) and the England average (5.5%). Local trend data is not available, but nationally there has been a decline in young people smoking over the last decade.

Local smoking prevalence in Year 10 students (aged 14 to 15), based on the South Gloucestershire 2014/15 health and wellbeing online pupil survey (OPS), is 9.3% (regular and occasional smokers).  The results of this survey mirrors national indicators in that smoking prevalence increases with age. In year 10, girls have a higher (regular and occasional) smoking prevalence, 14.6%, than boys, 4.2%.

Year 10 smoking prevalence is significantly higher in those who are entitled to Free School Meals; 1 in 10 pupils who do not receive free school meals classified as a smoker compared to 3 in 10 pupils receiving free school meals.  Higher rates of smoking were found in schools in the geographical areas of Pathway and Filton. Of those who smoke, 48% said they would like to stop and 17% wanted help to stop. Of the pupils surveyed, 12% of the secondary and further education felt they wanted to know more about smoking and 9% felt they need to know more about smoking.

ASSIST, a smoking prevention intervention in schools aimed to reduce adolescent smoking prevalence, is commissioned in South Gloucestershire Council. Health Visitors work with families to refer parents and establish smoke free homes. South Gloucestershire’s Stop Smoking Service provided 21 Nicotine Replacement Therapy (NRT) prescriptions to under 18’s in 2014/15, 1.7% of all NRT prescriptions.

Recommendation for consideration

Action is required to re-establish the local tobacco alliance network; repeat the online pupil survey; review the evidence on Assist; explore additional suitable and cost effective smoking prevention interventions; support the Health in Schools programme; develop centrally led support through the trained stop smoking advisor within the Young People’s Drug and Alcohol Service team; develop capacity across professionals, including school nurses and school staff, in smoking cessation and tobacco control; and to promote Smokefree campaign to reduce exposure to second hand smoke.

Authors: Kathryn Kavanagh, Programme Lead, South Gloucestershire Council; Sarah Godsell, Partnership Officer, South Gloucestershire Council

Who is at risk and why?

It is well evidenced that uptake of smoking at a young age has the greatest harm because early uptake is associated with subsequent heavier smoking, higher levels of dependency, a lower chance of quitting, and higher mortality (ASH – Passive smoking and children. Royal College of Physicians, London, 2010).

Child and adolescent smoking causes serious risks to short and long term respiratory 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 (Smoking and the Young. Royal College of Physicians, 1992). Smoking impairs lung growth and can cause lung function decline which may lead to an increased risk of chronic obstructive lung disease later in life.

Children are also at risk from the effects of passive smoking. Parental smoking is the main determinant of exposure in non-smoking children. Although levels of exposure in the home have declined in the UK in recent years, children living in the poorest households have the highest levels of exposure as measured by cotinine, a marker for nicotine. In addition it is documented that bronchitis, pneumonia, asthma and sudden infant death syndrome (cot death) are significantly more common in infants and children who have one or two smoking parents. (Royal College of Physicians, 2005).

Estimated figures are that 2 million children in UK are routinely exposed to second-hand smoke (Royal College of Physicians, 2010).  In the UK, it is estimated that between 1,600 and 5,400 new cases of asthma occur every year as a result of parental smoking.  Another major study has shown that passive smoking has a negative effect on the respiratory systems of children of all ages. As well as impacting on children’s health parental smoking can cause damage to family finances and wellbeing, it also has a strong influence on the likelihood of their children becoming smokers (BMA Board of Science, Breaking the cycle of Children’s exposure to tobacco smoke, 2007).

Need identifies that whilst the proportion of young people starting to smoke is falling, there are still some young people who are more exposed to adult smoking behaviour and are therefore more likely to start smoking themselves.

The charity Action on Smoking and Health (ASH) is undertaking regular YouGov surveys of 2,000 young people aged 11-18. The latest survey concluded that the proportion of 11-18 year olds who had ever tried an electronic cigarette increased from 5% in 2013 to 8% in 2014 (ASH, 2014). Other surveys give higher estimates. Moore et al (2015) report from two nationally representative Welsh datasets that, overall, 12.3% of secondary school students (11-16) reported ever using e-cigarettes. However only 1.5% reported regular e-cigarette use.

Current services and assets in relation to need

A number of programmes locally are aimed at stopping children and young people taking up smoking and helping them to quit.

  • DECIPHer-IMPACT: ASSIST, a smoking prevention intervention aimed to reduce adolescent smoking prevalence, is commissioned in South Gloucestershire. There is currently capacity to support a limited number of schools identified as having higher smoking prevalence (OPS 2014). The intervention has been running since 2011 and has worked with 3140 pupils in year 8 and 573 year 8s have been trained as peer educators and supported to have informal conversations with other year 8 students about the risks of smoking and the benefits of being smoke-free. An additional asset of the DECIPHer-ASSIST intervention is the conversations the peer supports have with family members and in particular those who are smokers.
  • South Gloucestershire Tobacco Control team deliver mass media campaigns that de-normalise smoking. Of particular relevance is Stoptober which also raised awareness of the new smoke free cars legislation Oct 2015. In support of this a lesson plan and presentation has been developed and made available to all schools with year 6 and 7 pupils.
  • Following an audit of returned Health Visitor pink forms (recording smoking status in the home, completed at the primary (newborn) visit which usually happens when the baby is around two weeks old), data was used to assess the consistency of this process. Findings suggested that not all pink forms were completed or returned (53%). A set of proposals were put forward:
    • for a smoke free homes intervention;
    • training for HV’s in how to refer clients at the point of contact to the Stop Smoking Service, via Quit Manager;
    • how to raise the issue of smoke free homes/ what to say to families.
    • establish contact with households and offer specialist smoking cessation support to influential adults.
  • Following an evidence review for cannabis & tobacco duel use a trained smoking adviser within the YPDAS team is heading up a joint working group to plan a brief intervention package for multiple substance use.

Data from the Stop Smoking Service last complete Nicotine Replacement Therapy (NRT) monitoring sheet identifies 1,261 prescriptions for NRT in 2014/15 with 21 prescriptions to under 18s, equal to 1.7% of NRT prescriptions. The data relates to 12 individuals. 18 of the 21 prescriptions were for 2 products, with 39 products were prescribed in total. Patches were the most common (20/39), followed by the inhalator (12/39). If ONS statistics of 11-15 year olds smoking are extrapolated for the whole of the South Gloucestershire 11-15 age group, there would be approximately 300 young people wanting support to stop. With only 12 individuals seeking support, wither young people do not know they can seek support or services are not currently supporting young people to stop smoking.

In 2014/15, 29 14-18 year olds set a quit date with South Gloucestershire Stop Smoking Services:

  • 62% female, 38% Male
  • 31% success rate with under 18’s. This is in contrast to a 53% quit rate across the whole service
  • 22 used NRT, 4 used Champix, 3 were not recorded

The level of need in the population

Public Health England wants to see a tobacco-free generation by 2025. The target for young people is to reduce regular and occasional smoking among 15 year olds to 9 per cent by 2020 and 2per cent by 2025.  Despite a continuing decline in smoking rates there are around 90,000 regular smokers aged between 11 and 15.

The Smokefree South West Regional Tobacco Plan identified a regional objective to halve the number of adults in the South West who allow smoking in their home by 2015 from the current 20% to 10%.

South Gloucestershire Council Strategy 2012 – 2016 seeks to reduce the prevalence of smoking in both adults and children through targeted interventions focused on priority neighbourhoods. Another of its objectives; “for children have the best possible start in life” will also be determined by work to reduce smoking prevalence in the overall population.

The health status of children and young people in relation to smoking has been ascertained from the first Online Pupil Survey (OPS) in South Gloucestershire, with data from 6,151 children and young people in schools and educational settings across the local authority. The survey was conducted in October 2014 to March 2015 in order to find out how children and young people in South Gloucestershire behave and what they really think about a range of health-related issues. These pupils came from 59 schools, colleges and other settings across South Gloucestershire, including nearly all the secondary schools, the majority of primary schools and South Gloucestershire and Stroud FE College.

In 2014/15, key local findings from the OPS on young people’s smoking behaviours in the health and wellbeing indicate:

  • 6.5% of 11 – 15 years olds smoke at least once
  • 3.5% of 11 – 15 years olds are regular smokers (defined as those who smoke at least one cigarette a week)
  • The proportion of young people who smoke weekly increases with age; from less than 1% of 11 year olds to 5.6% of 15 year olds.
  • Of those pupils reporting they smoke regularly, the average number of cigarettes smoked a week was:
    • Year 8 = 4.5
    • Year 10 = 8.1
    • Year 12 = 6.2

Year 10s classed as entitled to Free School Meals (FSM) show a significantly higher prevalence of smoking than Year 10s not entitled to FSM. It is therefore acceptable to say that for every 1 year 10 pupil that DOES NOT receive free school meals that smokes most days, you would expect 3 year 10 pupils that are in in receipt of free school meal to be of the same smoking status. As demonstrated by the graph below.

chart showing proportion of year 10 that smoke most days by fire school meal status

There is a slight increase in the prevalence of smokers who identified themselves as children in care compared to those not in care, although these numbers are very small and cannot be generalised.

There is no significant difference in the number of girls and boys who report being regular smokers (OPS 2014/15) across all ages. However year 10, girls have a higher (regular & occasional) smoking prevalence 14.6%, then year 10 boys, 4.2%

Projected service use and outcomes in first 5 years and 5-10 years

Public Health England are due to publish the new Strategy leading to a smoke free generation by 2025. We will be guided by their targets to reduce the number of young people who smoke.

Repeating the health and wellbeing online pupil survey (OPS 2014) bi annually will begin to provide trend data regarding smoking prevalence and attitudes towards smoking.  It will highlight areas of highest smoking prevalence and number of cigarettes smoked.  It’s intended to include a question to capture how young people are accessing cigarettes.

There is capacity to benchmark South Gloucestershire data against two other local authorities that run the same OPS survey.

Evidence of what works

Smoking cessation services for young people

A review was recently requested to explore the evidence of effectiveness for smoking cessation interventions tailored for young people, particularly those delivered in schools.

The evidence identified was intended to inform a scoping project to develop a pilot intervention for students in schools where there is evidence (OPS 2014) of pupils seeking help to stop smoking.

The review aimed to address the following questions:

  • How effective are smoking cessation interventions for young people, delivered either within or outside of the school setting?
  • Does it make a difference who leads the intervention (school nurses/teachers/external agencies)?
  • The review identified a range of high-level studies, largely systematic reviews and
  • RCTs, with one cost-effectiveness study.
  • The secondary studies were based on low-moderate quality studies, which is also reflected in the primary studies identified. The cost-effectiveness study appears to be reliable.
  • No evidence was identified to determine whether it makes a difference who delivers the intervention.

The full evidence review can be accessed here.

NICE guidelines: There are a range of NICE guidelines to support decision making processes in developing tobacco control linked to preventing children from becoming smoking.  Of the peer led interventions, Assist – A Stop Smoking in Schools Trial is listed in the NICE recommendations. It is licensed to run in South Gloucestershire until December 2016.

The programme works by following the same steps, which were implemented in the original trial of this successful intervention in order to replicate the results. Large scale evaluation was carried out as part of the trial which determined which elements need to be included in the programme in order to achieve a similar effect. If this evidence based programme is replicated in its entirety, then the translation of the successful results should be seen in many localities.

Reducing Smoking in Adolescents: Cost-Effectiveness Results From the Cluster Randomized ASSIST (A Stop Smoking In Schools Trial)

However, it is widely recognised that there is no one intervention that will prevent children and young people from starting smoking.  Activities should instead take a more comprehensive approach and seek to bring together work with both adults and children; these are more likely to act synergistically, ‘activities targeting young people in schools may also have an effect on parents’ smoking habits. Likewise, if parents are encouraged and supported to quit smoking, this will affect their children’s attitudes and behaviour in relation to smoking.’ (NICE, 2010).

Further reviews of evidence are contained in the reference section.

User views (on need, services / assets and gaps)

Of the 1671 secondary and FE aged pupils answering the following question in the OPS 2014 – ‘Is there anything that you feel you need to know more about?’, on average:

  • 12% feel they need to know more about smoking

Of the 3249 primary aged pupils answering the following question in the OPS 2014 – ‘Is there anything that you feel you need to know more about?’, on average:

  • 9% feel they need to know more about smoking

Of the 2006 secondary and FE aged pupils answering the following question in the OPS 2014:  ‘How helpful is the information and advice you get in school on the following things listed below?’

Smoking

No help at all / not enough help: 25%

Just about enough help: 22%

Most of the help I need / all of the help I need: 53%

Equalities

The information presented within this chapter provides evidence of needs in respect of diverse groups.  Consideration of these needs has resulted in the identification of priority issues to be addressed within South Gloucestershire as follows:-

  • Local smoking prevalence in Year 10 students (aged 14 to 15), based on the South Gloucestershire 2014/15 health and wellbeing online pupil survey (OPS), is 9.3% (regular and occasional smokers). The results of this survey mirrors national indicators in that smoking prevalence increases with age. In year 10, girls have a higher (regular and occasional) smoking prevalence, 14.6%, than boys, 4.2%.
  • Year 10 smoking prevalence is significantly higher in those who are entitled to Free School Meals; 1 in 10 pupils who do not receive free school meals classified as a smoker compared to 3 in 10 pupils receiving free school meals.
  • Higher rates of smoking were found in schools in the geographical areas of Patchway and Filton.

Unmet needs and service gaps

Local provision of advice and support to young people who want to stop smoking is currently under resourced and will be taken up by the new South Gloucestershire Tobacco Control Alliance.

Recommendations for consideration by commissioners

  • To re-establish a local tobacco alliance network and work across existing partnerships to protect young people from the harms of smoking and second hand smoke.
  • Strengthen partnerships with Trading Standards to raise awareness of underage sales and intelligence gathering.
  • To continue to commission the Health and Wellbeing online pupil survey in 2016/17 so that data sets can be collected and trends compared with 2014/15 survey data. In addition to discuss including a question on e-cigarettes, exposure to second hand smoke and where young people who smoke access tobacco.
  • To review the evidence on school smoking prevention interventions to inform the next stage in delivering appropriate and cost effective services
  • To review the evidence on the Assist smoking prevention programme before renewing the licence, due to expire Dec 2016
  • To support and promote the Health in Schools programme which takes an integrated approach to addressing health and wellbeing issues in schools, including tobacco education and facilitates healthier behaviour change through its silver and gold awards.
  • To develop centrally led support through a trained stop smoking advisor within Young People’s Drug and Alcohol Service team.
  • To develop capacity across professionals, including training for school nurses and appropriate school staff, in smoking cessation and tobacco control interventions.
  • To continue to promote Smokefree campaigns aimed at reducing the harm to children and young people of second hand smoke.
  • To work to reduce the number smokers within the group of children and young people falling into the FSM.
  • To further explore literature and data from Gloucestershire and Wiltshire OPS on children in care and smoking prevalence.
  • Audit how many school nurses trained in smoking cessation and further develop the core offer to schools to include advice and support on tobacco use/smoking cessation.
  • Continue to reinforce the proposals from the Health Visitor ‘pink form’ review 2012 – 2014 to promote smoke free homes, collect data on the number of smokers in homes and seek to support those wanting support to stop smoking.

Recommendations for needs assessment work

To further analyse and interpret the current OPS data sets

Further information gathering on current service provision / access to SSS services in communities, schools and Family and Young People Support team (formally YISS and FISS).

References

Action on Smoking and Health, 2015.  Fact Sheet on Young People and Smoking. London: ASH.

Action on Smoking and Health, 2014. Use of electronic cigarettes in Great Britain. London: ASH.

BMA Board of Science, 2007. Breaking the cycle of children’s exposure to tobacco smoke. London.

Department of Health, 2004. Secondhand smoke: Review of evidence since 1998. London: Scientific Committee on Tobacco and Health (SCOTH).

Department of Health, 2011. Tobacco Control Plan. London: DH.

Health and Social Care Information Centre, 2014. Statistics on Smoking in England, 2014b. Leeds: HSCIC.

Health and Social Care Information Centre, 2014.  Smoking, drinking and drug use among young people in England in 2013. Leeds: HSCIC.

Health and Social Care Information Centre, 2015.  Health and Wellbeing of 15 year olds in England: Smoking Prevalence – Findings from the What About YOUth? Survey 2014. Ipsos MORI.

Moore, G. Hewitt, G. Evans, J. Littlecott, H. J. Holliday, J. Ahmed, N. Moore, L. Murphy, S. and Fletcher, A., 2015. Electronic-cigarette use among young people in Wales: evidence from two cross-sectional surveys. BMJ Open, 2015; Apr 15;5 (4).

National Child and Maternal Health Intelligence Network, 2015. Young People’s Profiles – South Gloucestershire

National Institute of Care and Health Excellence, 2010.  School-based interventions to prevent the uptake of smoking among children. London: NICE.

National Institute of Care and Health Excellence, 2008.  Preventing the uptake of Smoking by Children and Young People. London: NICE

Public Health England, 2015. Health Matters: Smoking and Quitting in England. London: PHE

Royal College of Physicians, 2010. Passive smoking and children. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: RCP.

Royal College of Physicians, 2005. Going smoke-free. The medical case for clean air in the home, at work and in public places. A report on passive smoking by the Tobacco Advisory Group of the Royal College of Physicians. London: RCP.

Foster and Brown Research Ltd, 2015. Online pupil survey (OPS) 2014/15. South Gloucestershire Council.