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Summary and recommendations

Chapter 1 Why do some people become smokers and how can this be prevented?

The active drug in tobacco is nicotine. Nicotine is highly addictive, acting on the same parts of the brain as other psychoactive drugs such as heroin and alcohol. Addiction to nicotine can develop within weeks or months of starting to smoke. However, few young people are aware of nicotine's addictiveness and many young regular smokers do not think they are addicted. Whilst recognising that smoking is unhealthy, many young people think it has some benefits such as helping to cope with anxiety, controlling weight or creating a positive self-image and identity. Many other factors contribute to encouraging young people to start and continue smoking including: parental attitudes and behaviour; friends who smoke; and the availability, cost and perceived attractiveness of cigarettes. An effective smoking prevention strategy should therefore both reduce the availability of cigarettes and other tobacco products and discourage young people from wanting to smoke.

Chapter 2 Current patterns and trends in smoking by young people in Scotland

In Scotland in 2004, at age 13 about 5% of boys and 7% of girls are regular smokers. At 15, about 14% of boys and 24% of girls are regular smokers. In the last ten years, boys' smoking rates have fallen much more than girls'. Rates for boys are among the lowest in Europe, for girls among the highest. Smoking rates continue to rise through the late teens and early twenties. Among 16-24 year olds in 2003, 32% of men and 29% of women are regular smokers.

Substantially higher rates of smoking among 15 year olds are associated with: having a parent or elder sibling who smokes; living with a single or step parent; having lower levels of parental supervision and spending more nights out with friends; truanting, being excluded from school and juvenile offending.

Regular smoking is more common among disadvantaged young people, especially girls. The link with disadvantage becomes stronger with age. Smoking is less common among girls of South Asian origin, but data for other ethnic groups are lacking. Regular smoking is strongly associated with the use of alcohol and other drugs, especially cannabis. Among 13 year olds, 48% of smokers had used other drugs in the past month compared with 1% of never smokers. Among current smokers at age 23, the majority have used other drugs in the last year.

Chapter 3 Sources, availability and marketing of cigarettes to young people

Thirteen and 15 year olds in Scotland have little difficulty in buying cigarettes from shops, indicating a widespread disregard for the law of age of purchase at 16. Research shows that vigorous enforcement of age of purchase laws may help reduce youth smoking rates. Given that the harmfulness of tobacco is at least as great as that of alcohol, there is a strong case for raising the age of purchase of tobacco to 18. While raising the age of purchase of tobacco has not been shown to reduce youth smoking rates on its own, it may well do so as part of a comprehensive package of control measures including vigorous enforcement and a negative licensing scheme for persistent offenders. Raising the price of cigarettes through increasing taxes has been shown consistently to reduce youth smoking rates. This is arguably the most effective measure that can be taken to reduce smoking by young people.

Packets of ten cigarettes are particularly popular with teenage smokers. Smuggling of cigarettes currently accounts for a significant proportion of cigarettes in circulation, particularly in disadvantaged areas. There is good evidence that the marketing of cigarettes has been successful in encouraging young people to smoke. Whilst advertising and sponsorship have now been banned, opportunities still exist for other forms of marketing. Positive images of smoking are still found in the media including the youth media (eg magazines and films).

A series of recommendations are made aimed at making cigarettes less affordable, accessible and attractive to children and young people.

Chapter 4 Evidence for the effectiveness of smoking prevention programmes

Several major long-term, comprehensive American state-wide smoking prevention programmes appear to have contributed to declines in teenage smoking rates, although it was several years before the effects were seen. A small number of media campaigns have been shown to contribute to reducing youth smoking rates, as part of a wider smoking control strategy. They were intensive and long-lasting and used strong, carefully designed messages on TV, supported by other media. Some multi-stranded campaigns involving community action have been effective but the contribution of community action and its possibly effective elements have not been clearly identified.

Reviews of the evaluations of large numbers of mainly American school-based smoking and drug prevention programmes show that most are ineffective in reducing smoking rates. Some programmes using social influence methods, including peer-led approaches, reported positive short-term effects on smoking rates but it is unclear why these were effective and other similar programmes were not. A peer-supported preventive programme in South Wales is showing early promise.

Few programmes appear to have addressed the underlying factors associated with higher rates of smoking and other drug use by young people. Although rates of smoking and other drug use continue to rise after leaving school, few preventive programmes have focused on this older age group.

Chapter 5 The current policy context and smoking prevention initiatives in Scotland

The new legislation on smoking in public places has the potential to make a major contribution to smoking prevention by reducing young people's exposure to second hand smoke and reinforcing a negative image of smoking. Over the past eight years, there has been a series of anti-smoking adverts on Scottish TV that have achieved high viewer awareness and accurate recognition of the message but an unknown impact on smoking behaviour. Websites and other new technologies are beginning to be used to promote anti-smoking and other health messages but their impact is not known.

A major recent study has shown that most Scottish schools are providing education about drugs including tobacco but there is great inconsistency in the methods and materials used, the training of staff and the level of coordination within and between the primary and secondary school curricula. An anti-smoking campaign using community development principles did not achieve changes in attitudes or behaviour in the local community. A pilot programme of various different types of smoking cessation services for young people in Scotland did not prove to be effective in helping smokers quit. Both these initiatives offer useful lessons about how to proceed in the future.

By reducing the proportion of parents and other adults who smoke, action to increase smoking cessation among adults (eg cessation services, taxation and smoke-free environments) may in the long term make a major contribution to smoking prevention among young people.

Chapter 6 Implications of the research evidence and recent experience in Scotland for future preventive initiatives

There is good evidence that a comprehensive integrated approach to smoking prevention can reduce smoking rates among young people. A well-designed on-going, intensive, multi-stranded media campaign can contribute by conveying potent messages to large numbers of young people. Target audiences should include girls and young women in disadvantaged circumstances and young people in their late teens.

Given the equivocal research evidence and the inconsistency of drugs education in Scottish schools, there needs to be a careful reappraisal of how it is done. The Ambitious, Excellent Schools agenda and the Health Promoting Schools programme provide a framework within which a comprehensive new approach to drugs education including smoking prevention in schools can be developed. Further detailed work will be required to design its content and integration into the school curriculum as a whole. The message on tobacco should be uncompromising: never smoke. Effective support and management of pupils with behavioural or family problems is highly relevant to smoking prevention. Informing parents about tobacco, alcohol and other drugs and their responsibilities in this regard should also be an integral part of drugs education.

Given the large number of young people who start smoking or become heavier smokers once they leave school, universities and further education institutions should play a bigger part in discouraging young people from smoking (or misusing alcohol or other drugs).

Given the lack of impact of the only Scottish community development based initiative for smoking prevention and of a series of pilot smoking cessation services for young people, any plans for future initiatives of these types should take full account of what has been learned from these studies and should be fully evaluated. There is a need for innovative research studies that aim to identify ways to prevent children and young people in disadvantaged circumstances from starting to smoke.

In the long-term, increasing smoking cessation among adults who are or will be parents is likely to contribute to the prevention of smoking among young people. Where cessation is not attained, stopping smoking in the home may also contribute to the prevention of smoking among young people.

Recommendations

Targets

1. New separate targets should be set for boys and girls at both 13 and 15 as follows (See paragraph 2.24).

% regular smokers at these ages

2. The following new targets should be set for 16-24 year olds (See paragraph 2.25).

Research

3. Priority should be given to commissioning research that can provide a clearer understanding of current knowledge, attitudes and behaviour relating to the use of tobacco, alcohol and other drugs among 16-24 year olds. Regular surveys of 13 and 15 year olds should be continued (See paragraph 2.26).

4. All the new measures proposed in this report should, if implemented, be subject to rigorous evaluation to establish their impact and cost-effectiveness (See paragraph 2.27).

Reducing availability

The Scottish Executive should implement an integrated series of measures aimed at substantially reducing theavailability, affordability and attractiveness of cigarettes and other tobacco products to young people. It should:

5. ensure that much greater efforts are made to enforce the prevailing legal age of purchase. These should include: the use of proof of age; active test purchasing; prosecution with heavy fines and education of retailers and trading standard officers (See paragraph 3.6).

6. introduce a negative licensing scheme to enable vendors who repeatedly sell cigarettes to under-age customers to be prohibited from selling tobacco products (See paragraph 3.8).

7. amend the current offence of selling tobacco products to anyone under the age of 16 by raising the minimum age to 18. There should be a sufficient delay between amending the legislation and its implementation to prepare both customers and retailers for a smooth transition. Its impact should be carefully evaluated (See paragraph 3.13).

8. urge the UK Government annually to increase the price of tobacco products at a rate faster than inflation (See paragraph 3.16).

9. make representations to the UK Government to urge that health considerations are taken into account in the decision making process of EU policy concerning the taxation of tobacco products, as is required by the Framework Convention on Tobacco Control (See paragraph 3.17).

10. refer the issue of the sale of packs of ten cigarettes to the UK Government for consideration in the light of further research into its likely impact (See paragraph 3.22).

11. commission research to ascertain the extent to which young people in Scotland purchase cigarettes in packs of ten (See paragraph 3.22).

12. commission research to ascertain the current extent of use of smuggled or personally imported tobacco by young people (See paragraph 3.31).

13. ensure that Customs and Excise and the police in Scotland both put a high priority on activities aimed at reducing the influx of smuggled tobacco (See paragraph 3.31).

14. urge the UK Government to maintain and if necessary increase the investment in staff and equipment needed to control the influx of smuggled tobacco (See paragraph 3.31).

15. urge the UK Government to review the appropriateness of the current limits for the importation of cigarettes from other EU countries for personal use and the effectiveness of the controls thereof (See paragraph 3.31).

16. urge the UK Government to work collaboratively with the EC and other Member States to help develop a comprehensive international protocol on illicit tobacco as agreed at the first Conference of the Parties of the Framework Convention on Tobacco Control (See paragraph 3.31).

17. reinforce the UK Government's intention to require graphic photographs of smoking-related diseases to be displayed on cigarette packets (See paragraph 3.37).

18. together with the UK Government and other devolved administrations, look at ways to reduce positive images of smoking in the media and associated publicity materials, including reviewing any additional measures which might be taken to strengthen the ban on tobacco advertising and promotion introduced in 2002 (See paragraph 3.38).

19. prohibit the display of cigarettes at the point of sale, to be replaced by a simple list of the brands available and their prices (See paragraph 3.39).

Discouraging young people from smoking

The Scottish Executive should also implement an integrated series of measures aimed at discouraging young people from starting to smoke and encouraging and enabling young smokers to stop:

20. Building on previous work by Health Scotland and the Health Education Board for Scotland, an on-going, multi-stranded media campaign should be designed and implemented to discourage the uptake of smoking by young people of any age. One strand should have a strong focus on developing messages and using media that will have resonance with girls and young women in disadvantaged circumstances. Another should target young people in their late teens (See paragraph 6.2).

21. A comprehensive reassessment and reform of education on tobacco, alcohol and other drugs in Scottish schools should be carried out by a working group whose members bring expertise in drugs education research and delivery and in the design, integration and delivery of complex educational programmes across the curriculum. (See paragraph 6.5).

22. Given the importance of parents' influence upon whether or not their child will smoke, an integral part of drugs education in school should be to inform parents about tobacco, alcohol and other drugs and their responsibilities in this regard. This should mainly be done by sending parents clear, consistent information at regular points during their child's progress through school (See paragraph 6.6).

23. At the relevant stages, parents should be encouraged by midwives, health visitors, general practitioners and hospital doctors, nursery staff and teachers to create a smoke-free home and not smoke when their children are present. (See paragraph 6.6).

24. Embracing the concept of the Health Promoting School, all schools should develop an holistic approach to the health and well-being of their pupils. The aim should be to ensure that the school's ethos, policies, services and extra-curricular activities all foster the health and well-being of all the pupils. This should include having and strictly enforcing a school no-smoking policy covering everyone using the school grounds (See paragraph 6.7).

25. Given the association between smoking (and other drug use) and mental health problems, truancy and juvenile offending, all schools should have effective systems for the assessment, support and care for such pupils, including the ability to liaise effectively with social services where necessary (See paragraph 6.8).

26. Given the clear evidence that many young people start to smoke or progress from occasional to regular smoking (and drink heavily or use other drugs) once they leave school, Universities, Colleges of Further Education, student associations, the National Union of Students and other major training providers should be invited to explore how they could better enable students or trainees to avoid starting to smoke or misuse alcohol or other drugs. This could be developed within the framework of "The Health Promoting University" (See paragraph 6.9).

27. Research studies should be commissioned to test innovative, carefully designed ways of protecting and dissuading young people in disadvantaged areas from starting to smoke or becoming regular smokers (See paragraph 6.11).

28. All community-based youth organisations should be encouraged to adopt clear no-smoking policies and to use the opportunities open to them to reinforce the message about the addictiveness and harm to health of smoking (See paragraph 6.11).

29. In the light of the recent poor outcome of the pilot smoking cessation services for young people in Scotland we recommend that active consideration is given to developing other approaches within a carefully designed evaluation framework (See paragraph 6.12).

Making things happen

30. Given that implementation of the recommendations in this report would largely affect young people, a representative sample of young people should be consulted to seek their views on the recommendations (See paragraph 6.14).

31. The recommendations in this report should be used by the Scottish Executive as the basis for developing a fully resourced five year Action Plan, with built in performance measures subject to monitoring by the Scottish Ministerial Group for Tobacco Control (See paragraph 6.15).

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