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

Key points

• 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 were 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.
• Regular smoking is less common among girls of South Asian origin, but data for other ethnic groups are lacking.
• Regular smoking is strongly associated with use of alcohol and other drugs. In particular, cannabis is typically smoked with tobacco. 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.
• A school's ethos and policies may have an influence on smoking rates.

2.1 In this chapter, we first look at current patterns and trends in smoking among young people in Scotland. We then consider a range of factors which are strongly associated with higher or lower smoking rates.

2.2 There have been a series of regular, large cross sectional surveys of 13 and 15 year olds in Scotland which give a clear idea of the proportion of young people who smoke regularly at these ages (Figure 1). In these surveys, regular smoking is defined as smoking one or more cigarettes each week ⁶.

2.3 Between 1998 and 2004 the prevalence of regular smoking among 13 year olds has decreased from 9% to 5% among boys and from 11% to 7% among girls ¹⁰. Among 15 year old boys, the prevalence of regular smoking has decreased from 30% in 1996 to 15% in 2000 and has since remained around that level. The drop among 15 year old girls over the same period (from 30% in 1996 to 24% in 2000) was smaller and not statistically significant: prevalence has remained at 24% since 2000.

Figure 2.1. Regular smokers among 13 and 15 year olds in Scotland by age group and gender 1982- 2004

Source: ONS 1982-1998; NCSR 2000; SALSUS 2002 and 2004

Comparisons with other countries in Europe.

2.4 The Health Behaviour of School Children ( HBSC) ¹¹ and the European School Survey Project on Alcohol and Drugs ( ESPAD) ¹² are two large well-conducted international studies which provide comparisons between Scotland and other European and North American countries. The prevalence of regular smoking in the UK is higher among girls than in most European countries but, among boys, UK smoking rates are among the lowest in Europe (Figures 2.3 and 2.4). Scotland and Wales are two of only four European countries where smoking among boys has declined since 1998. On the other hand, in only Greenland and Scotland is the average onset of both weekly and daily smoking earlier among girls than boys.

Fig 2.2: Percentage of 15 year old boys who are weekly smokers ¹³

Fig 2.3: Percentage of 15 year old girls who are weekly smokers ¹³

2.5 In Edinburgh, over 4000 children who were 12 in 1998 (the vast majority of 12 year olds in the city at that time) have been followed up every year since then ¹⁴ . Figure 2.4 shows the proportion who were smoking at least once a week at each age. As with the cross-sectional studies, it shows that by the age of 15, girls are smoking more than boys. However, the gap has narrowed somewhat by the time they are 17

Figure 2.4. Edinburgh study of youth transitions and crime: weekly smoking by sex and age (ref 13)

2.6 In the West of Scotland, a representative sample of almost 1000 young people who were 15 in 1987 has been followed up periodically since then. Figure 2.5 shows that the proportion who smoked at least weekly continued to rise until the mid twenties. The proportion who smoked at least ten cigarettes a day was less than 5% at age 15 but rose rapidly to over 20% by 18 and continued to rise further until the mid 20s ¹⁵. The continuing high prevalence of smoking in this age group is confirmed by the 2003 Scottish Health Survey. In a representative sample of over 900 16-24 year olds, 32% of men and 29% of women were current smokers; 19% of the men and 16% of the women smoked more than ten cigarettes a day .

Figure 2.5. MRC Twenty-07 study: weekly and heavy smoking by the 15 year old cohort from 1987 (ref 15)

2.7 The late teens and early twenties is thus a period when many young people start to smoke and many smokers become regular heavy smokers. This is a crucial period of transition from school to higher education or the work environment and greater independence from parents. The role of the cigarette as a perceived reliever of stress, and a tool for socialising and bonding with one's peers may all have potency for many young people trying to respond to new everyday pressures, establish their own identity and cope with the uncertainties of the future.

2.8 The direction of travel is not always towards smoking. Significant numbers of young people stop smoking, some for good, others for variable periods of time. In the MRC Twenty-07 study, 2% of the sample had been smoking at age 15 but had stopped at age 18; 6% were smokers at 18 but had stopped by 23; and 8% were smokers at 23 but had stopped by age 30 ¹⁵ .

Factors strongly associated with smoking by young people

Parents or elder siblings who smoke

2.9 Teenagers are more likely to smoke if their parents or siblings do. SALSUS found that 71% of 13 year old regular smokers and 62% of 15 year old regular smokers had at least one parent who was a daily smoker, compared with only 37% of non-smoking 13 year olds and 36% of non-smoking 15 year olds ¹⁰. Higher smoking rates were also found among pupils who had at least one sibling who smoked. Having an elder sibling who smoked was found to be strongly and significantly correlated with smoking in all 31 European countries providing data for ESPAD¹².

Living with a single parent or a step parent

2.10 The proportion of pupils who smoked is lowest among those living with both natural parents. Among 13 year olds living with both natural parents, 4% of pupils reported smoking regularly compared with 10% of pupils living with one parent and a step parent and 10% of pupils living with a step parent ¹⁰. Living with a single parent or a step parent was strongly and significantly correlated with smoking in 25 of 29 reporting countries in Europe ¹².

Low levels of parental supervision and more evenings out with friends

2.11 Both 13 year old and 15 year old regular smokers are less likely to be closely supervised by their parents than non-smokers . In SALSUS, 79% of 13 year olds who were regular smokers reported that their mothers had lower than average levels of knowledge about what they were doing compared with 42% of non-smokers of this age ¹⁰. Among 15 year olds, 62% of regular smokers and 47% of non-smokers reported lower than average levels of maternal knowledge about their behaviour. At both 13 and 15, boys and girls who were regular smokers were more likely to spend more evenings out than non-smokers and to have less structured leisure time activities ¹⁰. In 30 of 31 reporting countries in Europe, "adolescents used substantially and significantly more tobacco, alcohol and cannabis when their parents did not know where they spent their Saturday nights" ¹².

Friends who smoke

2.12 SALSUS also found that regular smokers were much more likely than non-smokers to have friends who smoked. Forty-six percent of 15 year olds and 38% of 13 year olds who were regular smokers reported that "all or almost all" of their friends smoked compared with only 4% of 15 year old and 2% of 13 year old non-smokers ¹⁰. The importance of friends and their wider peer group for smoking has been underlined by studies of the relationships between individuals, for example at school. Scottish research has confirmed work from elsewhere that starting to smoke and moving on to heavier smoking typically involves individuals both selecting and being influenced by the group or groups they associate with ¹⁶, ¹⁷. The popularity of smokers can vary between schools and this in turn can influence the behaviour of others ¹⁸. Friends who smoke continue to be an important factor in the late teens, by which time parental and sibling influences have waned ¹⁹. During this time of transition, smoking is often perceived as a means of maintaining and enhancing sociability in new social, educational and occupational spheres ²⁰.

Gender differences

2.13 As shown above, more girls than boys in Scotland are regular smokers by their mid-teens, although these differences appear to narrow and disappear in the late teens and early twenties. It is increasingly recognised that the factors which influence starting and continuing to smoke are different for boys and girls. A study of Scottish 11 and 13 year olds found that popular or "top" girls were often smokers whereas for boys smoking conflicted with their wish to be fit ²¹. Among 15-16 year olds, some girls saw smoking as part of their rejection of the traditional "good girl" identity ²². While both boys and girls who smoke highlight the importance of smoking in their social relationships and dealing with negative feelings, they differ in the way this is expressed. For girls, smoking could be seen as helping when they are upset whereas for boys it is a means of dealing with anger and frustration. Girls are also much more likely to see smoking in relation to their appearance, on the one hand as a means of weight control and enhancing their sexual attractiveness; on the other, a dislike of their bodies and clothes smelling of smoke ²³. These differences point to the need to design prevention campaigns in ways that address the differing attitudes of males and females.

Truancy and exclusion from school

2.14 SALSUS found that among regular smokers about three-quarters had truanted in the past year compared with 29% of 13 year olds and 39% of 15 year olds who did not smoke ¹⁰. Regular smokers are also more likely to report they have been excluded since starting secondary school: 28% of 13 year olds and 32% of 15 year olds who were regular smokers had been excluded from school compared with only 6% of 13 year olds and 9% of 15 year olds who were non-smokers ¹⁰. In every one of 32 reporting countries in Europe there was a strong and significant correlation between truancy and use of tobacco, alcohol and other drugs ¹² .

Juvenile offending

2.15 The Edinburgh transitions study found large and statistically significant correlations between regular smoking and self-reported delinquency (covering a wide range of illegal and anti-social acts) at all ages from 12 to 17. Regular smokers reported on average between three and four times as many delinquent acts as occasional or non-smokers ¹⁴.

Socio-economic disadvantage

2.16 Among girls, regular smoking is significantly more common in Scotland among those from more disadvantaged areas or whose parents have lower socio-economic status ¹⁰. The link with family affluence is less clear cut for boys (Figure 2.6). However, both boys and girls whose parents were in manual occupations were about twice as likely to be regular smokers as those whose parents were in non-manual occupations ⁹. Between 2002 and 2004 there was a drop in smoking levels among both 13 and 15 year old boys from "higher affluence" families. During the same period there was no change among boys from lower affluence families or among girls in general ⁹. These differences may at least in part be explained by the much higher proportion of adults and hence parents who smoke in disadvantaged areas. However, there is also evidence that heavier smoking is more likely to develop among the more disadvantaged. Among 15 year olds, the differences between those of higher and lower economic status were more marked among daily than weekly smokers and much more marked among those smoking more than ten cigarettes a day ²⁴. This may be part of the explanation why young people from lower socio-economic backgrounds find it harder to quit than their more affluent counterparts.

Figure 2.6 Relationship between smoking and family affluence by gender among Scottish 15 year olds ¹⁰

Ethnic minorities

2.17 Scotland's population is becoming increasingly diverse, with significant numbers of immigrants having settled here over the last 50 years and a rapid new influx in the last five years of asylum seekers and refugees and, since 2005, of people from the new accession states of the European community. However, each distinct group remains relatively small and there is thus very little reliable information about the smoking behaviour of young people in any one group.

2.18 Even with a sample size of over 23,000, in the SALSUS survey of 2002, South Asians were the only ethnic group large enough to allow comparisons to be made with white pupils. Girls of South Asian ethnicity were significantly less likely to be regular smokers than white girls. Levels of smoking reported by boys of South Asian origin were not significantly different from those of white boys ⁶.

2.19 Some useful insights into ethnic differences which may have relevance to Scotland are provided by a large survey of 13 and 15 year olds in England ²⁵. White and mixed ethnicity pupils were more likely than black or South Asian pupils to report being a regular smoker. Around one in ten white pupils (12% girls and 8% boys) and mixed ethnicity pupils (11% girls and 8% boys) were regular smokers compared with one in twenty black pupils (7% girls and 4% boys). The same proportion of South Asian boys as black boys were regular smokers (4%) although South Asian girls were less likely than other girls to smoke (3%).

The use of tobacco, alcohol and other drugs

2.20 Smoking tobacco is highly correlated with regular use of alcohol and other substances. SALSUS, 2002, found that among regular smokers aged 13, 48% had used drugs in the past month, compared with only 1% of never smokers ⁶. At age 15, 61% of regular smokers had used drugs in the past month compared with only 3% of never smokers. At age 13, 59% of regular smokers were already weekly drinkers, compared with only 18% of those who had never smoked. At age 15, 71% of regular smokers were weekly drinkers compared with only 10% of never smokers.

2.21 The Edinburgh transitions study has shown that smoking most commonly starts around the same age as drinking and drug use but there are also many young people who start smoking before they start drinking or taking other drugs and vice-versa ¹⁴.

2.22 Cannabis use is particularly linked to smoking tobacco because cannabis is usually smoked mixed with tobacco. Typically, a first time cannabis smoker will already have tried cigarettes but some cannabis users may have their first experience of tobacco this way and may indeed then become addicted to tobacco as a result ²⁶ .

2.23 The association between smoking tobacco and the use of other drugs persists into the later teens and early twenties. Using data from the MRC Twenty-07 study Figures 2.7 and 2.8 show that the majority of current smokers at ages 18 and 23 also drank above the recommended limits or used other drugs, with the proportion that do so apparently rising with age ¹⁵. By age 23, almost one in ten of the sample were smoking, drinking and using other drugs.

Influence of the school

2.24 Studies which have compared secondary schools in the West of Scotland have found that the smoking levels can be very different even when the communities from which the pupils are drawn are apparently similar ^{18, 19, 27} . There is evidence from these studies that a number of factors may contribute to this "low smoking school effect" including:

• The enforcement of a school smoking policy
• The creation of a positive school ethos with good communication, teamwork and pupil involvement
• "More advanced" health education and health promotion policies.

Figure 2.7 Combination of current smoking, drinking over recommended levels and last year drugs at age 18¹⁵.

Figure 2.8 Combination of current smoking, drinking over recommended levels and drug use in the last year at age 23 [%s do not add up to 100 due to rounding]¹⁵

Recommendations for targets, regular surveys and more research

Children

2.25 The targets for smoking rates set out in A Breath of Fresh Air for Scotland were: Reduce smoking among young people (aged 12-15) from 14% to 12% between 1995 and 2005 and to 11% by 2010 ².

The current surveys of school-children sample only those who are around 13 and 15 and consequently an accurate figure for 12-15 year olds cannot be given. In addition, there are big differences in the smoking rates of girls and boys at these ages. We therefore recommend that new separate targets are set for boys and girls at both 13 and 15 as shown below. We suggest a greater proportionate drop for girls as we think the aim should be to reduce smoking rates for girls towards those of boys and that therefore there should be a greater focus on preventing smoking among girls. The targets for 2010 are based on the extrapolation of current trends. Those for 2015 and beyond are aspirational, reflecting the desired direction of travel. They assume that the proposed recommendations in this report will be implemented and effective.

% regular smokers at these ages

Adults

2.26 The targets for adults in A Breath of Fresh Air were: Reduce smoking among adults (16-64) from an average of 35% to 33% between 1995 and 2005 and to 31% by 2010. This has since been modified to be 22% of all adults over 16 by 2010 ².

This target does not allow for the rates among young adults to be followed. As large numbers of people start to smoke or become regular smokers aged 16-24, we think it is essential that there is a separate target for this age group to concentrate minds on preventing the uptake of smoking in this group. We therefore recommend that new targets for 16-24 year olds are created as follows:

The target for 2010 reflects the current downward trend of adult smokers as a whole. The targets for 2015 onwards are aspirational and assume that the recommendations in this report will be implemented and effective.

2.27 In the light of the relative lack of information about smoking and the misuse of alcohol and other drugs by young people in the 16-24 age group, we recommend that this should be a priority area for new research. The aim should be to establish a clearer understanding of the current knowledge, attitudes and behaviour of this group to provide a firmer foundation for prevention initiatives. To enable comparisons to be made between surveys, the same age groups should be surveyed at the same time of year wherever possible. Regular surveys of 13 and 15 year old schoolchildren should continue to provide accurate information about smoking and other related behaviour.

2.28 Later in this report, a series of new measures are proposed. We recommend that, if implemented, they are all subject to rigorous evaluation to establish their impact and cost effectiveness.

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