Smoking
In UK surveys, the following definitions of smoking prevalence in children are used:
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Regular smokers – usually smoke at least one cigarette a week;
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Occasional smokers – usually smoke less than one cigarette a week;
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Current smokers – all regular and occasional smokers.
There is some evidence that young people who smoke may under-report their usual smoking behaviour (National Statistics and NHS Information Centre 2006). This survey of 11-15 year olds did not measure initiation ages as such but identified the length of time respondents had been regular cigarette smokers (figure 1 below). 61% had been smoking for more than one year, 16% for 6-12 months, 10% for 3-6 months and 13% for less than three months. The data on smoking prevalence and initiation age show that young people are a major sector of the tobacco market. Most smokers start before they are 18 years old and virtually all do by the age of 25, making this group a key target for tobacco industry marketing as well as tobacco control.
Risk factors associated with youth smoking:
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Parental smoking
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Peer influence from older siblings and friends
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Low socio-economic status
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Female – the creation of an adult social identity; peer valued as ‘cool’, ‘popular’
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Low parental education
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Living in a single parent household
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Poor academic performance
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Participation in risk taking activities
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Exposure to tobacco marketing activities
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Television and films
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Mental illness.
Source: National Statistics and NHS Information Centre (2006)
Tobacco marketing in all its forms is a central influence on the initiation and continuance of youth smoking. In particular, evocative tobacco brands appeal to young people. The entertainment media are full of images that normalise smoking, making it appear both more common and acceptable than it really is. In this way, it influences how young people perceive and attribute meaning to their own and others smoking. It also reinforces the idea that cigarettes have social and cultural significance (BMA 2008).
Different forms of tobacco marketing:
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Sponsorship of sport and the arts
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Point-of-sale: promotional material in shops such as branded gantries, clocks, signage, staff clothing and product display
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Merchandising: giving away or discounting low cost items such as T-shirts, baseball hats and key rings
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Loyalty schemes: promotional mail and coupons designed to encourage continued purchase
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Free samples: the distribution of free products
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Brand stretching: non-tobacco products with tobacco branding such as Marlboro Classic Clothes
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Pack designed to communicate brand image and to add value
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Internet sites: websites promoting tobacco companies, cigarette brands or smoking
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Product placement: paid-for placement of cigarette brands in films or television
Source: Based on MacFadyen et al (2001)
Parental attitudes to smoking have been established as a major risk factor for smoking initiation, with permissive attitudes towards smoking increasing the risk. In England, 10% of children who smoke regularly report that they have been given cigarettes by their parents. Children of parents who smoke are nearly three times more likely to smoke than those who come from non-smoking homes.
Smokers who begin to smoke at a young age are less likely to give up than those who start later in life. One study has shown that those who start before the age of 16 are more than twice as likely to continue smoking than those who begin later in life (Khuder et al 1999).
Figure 1 – Length of time as a regular smoker (aged 11 to 15) in England, 1988 to 2006
Source: Information Centre for Health and Social Care 2007
Nicotine replacement therapy (NRT) is now licensed for use for young people over the age of 12 years. Recent research raises questions as to whether NRT will be effective in this regard (Platt et al 2006, Grimshaw et al 2006). Grimshaw et al (op cit) reviewing adolescent cessation programmes including 15 trials involving more than 3,500 smokers under the age of 20, concluded that more evidence is needed to elucidate effective measures to support young people to stop smoking. Amos et al (2006) found that many young people often express a desire to give up, but that their views are characterised by ambivalence. Many see quitting as a project for the future rather than short term.
Whilst the evidence base for policy and practice in relation to substance misuse focuses on the misuse of drugs there is little in the way of an evidence base with respect to alcohol. This is as much a response to social attitudes with a general acceptance of sensible alcohol use as opposed to a concern for abstinence. The acceptance of links to social exclusion also means that alcohol misuse is increasingly seen as an integral part of the larger youth agenda and in conjunction with vulnerable groups such as the homeless, care leavers and youth offenders. There is little in the way of an evidence base in respect to alcohol misuse amongst adolescents as such.
Alcohol use
Nationally, alcohol use overall amongst 11-15 year olds appears to have fallen but use amongst 11-13 year olds is increasing. An overall fall in prevalence has also been accompanied with an increase in consumption. Those who do consume alcohol are doing so more regularly and consuming higher levels of alcohol. These higher levels of alcohol consumption are associated with high risk behaviours including unprotected sex and offending (Home Office 2008).
Alcohol use is disproportionately concentrated in areas of high deprivation. In the most deprived areas, alcohol related death rates amongst women are three times higher than those women in the least deprived areas, for men they are five times higher (ibid).
The health consequences of increased consumption at an early age is manifest in the increase in liver cirrhosis in the 25-34 year old age group. Early initiation before the age of 14 is strongly associated with dependency in later life.
A recent study (Viner and Taylor 2007) of 11,622 subjects from the 1970 British Birth Cohort Study, surveyed at aged 16 years (1986) and aged 30 years (2000) showed that binge drinking was reported in 17.7% of the cohort. It was associated with increased risk of drug/alcohol dependence, excessive regular consumption, illicit drug use, psychiatric morbidity, homelessness, convictions, school exclusions, lack of qualifications and lower adult social class. In short, adolescent binge drinking was a risk behaviour associated with significant later adversity and social exclusion and may contribute to the development of health and social inequalities during the transition from adolescence to adulthood.
Attitudes and behaviours related to drinking and smoking from KCC commissioned survey of children and young people in Kent
Only 1% of children (7-11 years) thought it was healthy to be around people who smoked and 1% thought it was healthy to smoke.
Most young people felt that smoking caused health problems (93% of the 11-16s and 95% of the post 16s agreed or strongly agreed) and that getting drunk could be dangerous (84% of the 11-16s and 85% of the post 16s agreed or strongly agreed). However as figure 2 illustrates, a small minority of young people, in particular the post 16s, reported that they regularly (most days or once or twice a week) drank alcohol and slightly smaller proportions said that they smoked and got drunk.
Figure 2 – The percentage of young people (11-19 years) who regularly (most days or once or twice a week) smoke, drink and get drunk
These findings suggest levels of underage drinking have reduced over the past year in Kent. The proportion of 11-16 year olds who said that they drank alcohol, has decreased by four percentage points and the proportion of post 16s who said that they drank alcohol has also decreased.
The Smoking, Drinking and Drugs survey of children and young people in England in 2008[1] indicates that 6% of 11-15 year olds smoked regularly (at least once a week). This is similar to the proportion of 11-16s in the Kent survey who reported that they smoked regularly (7%). Just under a fifth (18%) of young people participating in the Smoking, Drinking and Drugs survey said they had drunk alcohol in the last week, compared to 11% of 11-16s in the Kent survey who indicated that they did drink alcohol most days or once or twice a week. Although the questions are measuring slightly different behaviours, they can be broadly compared and suggest that a slightly lower proportion of young people in Kent get drunk regularly.
What characteristics are young people who have healthy attitudes and behaviours related to drinking and smoking likely to have?
Further analysis (multilevel modelling) was undertaken to explore which groups of young people scored higher and lower than average on the measure of healthy attitudes and behaviours related to drinking and smoking when other measurable factors were taken into account[2]. The findings (see figure 3) showed that there was a stronger association between a higher score on the healthy attitudes related to drinking and smoking measure and:
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Being of Asian British, Black British, dual heritage/mixed or any other ethnic origin;
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Having a statement of SEN;
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Being gifted and talented;
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Attending a grammar school;
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Attending a school with an above average percentage of pupils with statements of SEN.
The findings showed that there was a stronger association between a lower score on the healthy attitudes related to drinking and smoking measure and:
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Being year 8 and above;
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Attending a special school/PRU (pupil referral unit);
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Attending a boys’ school (compared to attending a mixed school);
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Being recognised for school action or school action plus on the register of SEN;
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Being eligible for free school meals.
In this case, attending a grammar school is associated with higher scores on this measure whereas attending boys’ schools has lower scores of association. This association of grammar schools mitigates the lower scores association of boys’ schools. This suggests boys who are from mixed grammar schools will tend to have higher scores on healthy attitudes related to drinking and smoking compared to those from boys’ grammar schools. Those from boys’ grammar schools will tend to have similar scores to those from mixed secondary modern schools and those from boys’ grammar schools will tend to have higher scores compared to those from boys’ secondary modern schools.
Figure 3 – Young people (11-19 years) scoring above and below average on the healthy attitudes relating to drinking and smoking[3]
Illicit Drug Use
A recent survey for Kent suggests that 82% of young people report that they have never used drugs.
Nationally drug use has fallen among 11-15 year olds from 29% in 2001 to 24% in 2006 (Fuller E (ed) et al 2007).
Cannabis is the most common drug used by young people. There is a small casual relationship between cannabis use and psychosis (Hunt et al 2006) and evidence that heavy use of cannabis can exacerbate other social and emotional problems that young people face (Melrose et al 2006).
Nationally there has been no change in 11-15 year olds reported use of Class A drugs. Reported use has remained at 4% since 2001, with around 1% reporting use of heroin and 1.9% reporting use of cocaine (Fuller et al 2007). Cocaine use has marginally risen and this reflects a Europe-wide concern about the increased supply and use of the drug (EMCDM 2007). Where traditionally cocaine was seen as the drug of choice for the wealthy there is now concern that its use is increasing amongst disadvantaged and vulnerable groups of young people. The health consequences of cocaine when sniffed, include cardiovascular, neurological and psychiatric problems. Its use alongside alcohol, common in recreational settings, results in significant toxicity issues as well as risky sexual practice. Sharing sniffing equipment can lead to the transmission of blood borne viruses.
Class A drug use amongst 16-24 year olds remains stable at 8% (British Crime Survey 2005-6).
The use of volatile substances has also remained at 4% over this period (Reitox 2007) which is of particular concern given that its use is more common in younger age groups and use of volatile substances contribute to more deaths than any other drug and results in 2.2% of all deaths of young people in 2002. There is evidence that those who use volatile substances are amongst the most vulnerable in society, with many experiencing emotional problems as a result of trauma, abuse and neglect (DH 2005).
Frequent use of any drug under the age of 15 is concentrated amongst a very small minority. These frequent users of drugs often also exhibit ‘concurrent or preceding psychological and social disorders’, often come from families experiencing problems, socially excluded groups, those young people who are not engaged with school, those with ADHD, conduct disorders and other psychological disorders.
These young people are more likely to become adult drug and alcohol service users as adults, with a quarter of drug users having initiated drug and volatile substance misuse by the time they are 13, one third by the time they are 14 and 37% by the age of 15 (Analysis of Kent DAAT NDTMU 2007).
Co-propensity to display multiple risk behaviours
The close correlation between substance misuse and unplanned teenage pregnancy has been highlighted in many studies, as risk taking behaviour in one may easily lead to experimentation in the other. Use of substances may lead young people to intimate sexual contacts, having unprotected sex, having sex with someone they don’t know or becoming a victim of a sexual act (Independent Advisory Group on Sexual Health & HIV 2007).
Half of all 11-15 year olds who use alcohol at least once a week reported criminal or disorderly behaviour. Alcohol use amongst young people in public places also generates fears in the wider public of crime and disorder.
Drug and alcohol use amongst vulnerable young people
Drug and alcohol use is concentrated amongst groups of vulnerable young people. These vulnerable groups include looked after young people, young offenders, young people who are not in mainstream school, young people who are truanting, children of substance misusing parents, refugees and asylum seekers, young homeless people and young people who are sexually exploited (in Kent, a decision was taken to focus preventative resources on the former six vulnerable groups).
Looked after young people are more likely to use drugs, alcohol and to smoke as well. They are more likely to commence usage at an early age, use more and use more frequently. 10% of looked after children report heroin and crack cocaine use (Ward et al 2003).
Young people who have been temporarily or permanently excluded from school have a greater risk of misusing substances; they are more likely to commence usage at an earlier stage (NCCDP Fact sheet 5).
Young offenders have disproportionately higher levels of drug and alcohol use compared to the general population of young people (Hammersely et al 2003).
Patel et al (2004) research with refugees and asylum seekers found that one third reported lifetime use of an illegal drug and 4% knew about drug and alcohol services (Coomber 2004).
Within these vulnerable groups young women are identified as having particular complex and serious drug use issues (Coomber 2004).
[1] For further details on survey please see: http://www.ic.nhs.uk/pubs/sdd08fullreport
[2] It is worth noting that some of the different SEN variables included in this model are closely correlated and this may affect some of the findings relating to SEN status at pupil level and school level
[3] Being of Gypsy/Roma/Traveller origin is included in the analysis as it is important that this variable is controlled for, along with others. However, although being from this ethic group emerged as significant it is not reported in the commentary because the result may be significant due to the small sample size.
