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

Key points

• 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 have been a series of anti-smoking adverts on Scottish TV that have achieved high viewer awareness and accurate recognition of the message. Websites and other new technologies are beginning to be used to promote anti-smoking and other health messages.
• A major recent review has shown that most schools are providing drug education but there is great inconsistency in the methods and materials used, training of staff and coordination within and between the primary and secondary school curricula.
• The Ambitious, Excellent Schools agenda and the Health Promoting Schools programme provide a framework for addressing smoking prevention .
• A pilot programme of smoking cessation services for young people in Scotland did not prove to be effective in helping smokers quit.
• 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.

The wider environment: prohibition of smoking in enclosed public places

5.1 On March 26, 2006 legislation prohibiting smoking in wholly or substantially enclosed public places came into effect in Scotland ⁹³. The early signs are that the ban is being very largely observed. As a result, deaths due to passive smoking will be prevented. There may be other benefits. The occasions when children and young people will be exposed to second-hand smoke should be greatly reduced. The opportunities for young people to observe other people smoking in leisure or work situations will diminish. Furthermore, there is emerging evidence from New York and Ireland that banning smoking in public places enables substantial numbers of people to stop smoking. As many of these quitters will be parents, and the children of non-smokers are less likely than those of non-smokers to become smokers themselves, the new legislation may well prove to have a powerful preventive effect. Evaluation of the impact of the ban in Scotland should enable some of these issues to be addressed ⁹⁴.

Smoking in the home

5.2 The next challenge will be to find ways of reducing children's exposure to smoking in the home. Success in this domain may not only protect children from the physical effects of cigarette smoke but also make it less likely that they will be influenced by their parents' or other adults' behaviour in the home. Qualitative research linked to the evaluation of the new legislation is currently taking place and is likely to shed further light on this.

Media

TV

5.3 From 1998-2003, the Health Education Board of Scotland and, from 2003 to the present, NHS Health Scotland, have conducted a number of anti-smoking media campaigns centred on TV adverts but supplemented by promotional material such as a CD, a website and posters. They have all involved developmental research with the target audience which has been defined in each case according to gender, age and whether they are non-smokers or smokers. Thus, the targeted viewers for successive adverts are shown in Table 5.1. In the light of our findings that many people only start to smoke in their late teens and twenties, it is notable that this age group has not been targeted.

Table 5.1 TV anti-smoking advertising campaigns in Scotland

5.4 All the adverts achieved moderate to very high viewer awareness. When asked prompted questions, a high proportion of the viewer sample appeared to think that the advert would have an effect on viewers' attitudes towards smoking. However, the research was not designed to be able to demonstrate an effect on smoking behaviour.

Websites

5.5 Young Scot is an organisation dedicated to providing information and support for 12-26 year olds in Scotland. Its website, www.youngscot.org.uk has a major section on health - Health: Feeling Good - funded by NHS Health Scotland. This includes a number of entries about the effects of smoking on your health, how much it costs to smoke and how to give up.

5.6 Healthbits is a web-based initiative developed by Youth Media and NHS Health Scotland. It is designed for use on University and Further Education networks (see www.healthbits.co.uk). It uses ten second pop-up adverts to encourage students to click through to related web pages. It has included a number of ads to help smokers quit but has not yet focused on smoking prevention.

Education

Drug education in schools

5.7 Drug education in schools has been strongly promoted by the Scottish Office and the Scottish Executive since the early 1990s. Tobacco is generally included in the range of drugs covered. Whilst some central guidance has been given, exactly what is taught and how it is taught also depends upon the local authority, the school board, the head teacher and the teaching staff. Such an arrangement inevitably produces considerable scope for variation in content, mode and timing of delivery and educational value. Typically, however, many schools opt for a staged approach, introducing new concepts, information and skills at appropriate ages (See box).

A staged approach to education on smoking in schools

9-11 yrs - health effects of smoking, what's in tobacco smoke, addiction; why young people choose to smoke, global tobacco - growing and producing;

11-13 yrs - booster sessions covering components covered in primary school, short term and long term health effects - smoking related diseases, peer pressure, glamorisation of smoking, the tobacco industry (controls, taxation, environmental impact, etc),

13-15 yrs - tobacco advertising and the media, role models in the media, peer pressure, stopping smoking support.

5.8 A large and detailed evaluation of the effectiveness of drugs education in Scottish schools has recently been carried out by the Institute for Social Marketing on behalf of the Scottish Executive. It considers how drugs education is currently delivered, assesses the most effective best practice of drug delivery and considers the views of young people on its value and impact on them. The report is due to be published soon.

Health Promoting Schools

5.9 Our National Health: A Plan for Action, A Plan for change⁹⁵ included a commitment by the Executive that all Scottish schools would become health promoting schools by 2007. Following this, the Scottish Health Promoting School's Unit ( SHPSU) was established to support schools in achieving this target. The Unit's main role is to champion, facilitate and support the implementation of the health promoting school concept throughout Scotland. A key focus is to provide strategic and practical support to partner organisations, councils, schools, NHS health boards, community planning partnership integration managers and other stakeholders as they work together to achieve the National Priorities for education and health in schools.

5.10 The SHPSU is supporting a whole school approach to promoting the physical, social, spiritual, mental and emotional well-being of all pupils and staff. This ensures not only that health education is integral to the curriculum but also that the school ethos, policies, services and extra-curricular activities foster mental, physical and social well-being and healthy development. Efforts to prevent smoking and the misuse of alcohol and other drugs should be part of the curriculum but also reflected in the school's ethos, policies, services and extra-curricular activities.

Future policy

5.11 In 2004, the Scottish Executive launched Ambitious, Excellent Schools ( AES) ⁹⁶, a comprehensive modernisation agenda for Scotland's schools. This sets out a wide ranging plan for action to ensure that "all our young people are safe, nurtured, healthy, achieving, active, respected, responsible and included". The aim is to enable all children and young people to have access to positive learning environments and opportunities to develop their knowledge, skills, ambition, confidence and self-esteem to the fullest potential. As a part of the agenda, A Curriculum for Excellence (CfE) sets out the action for change ⁹⁷. The four capacities of CfE encompass aspirations for all children and young people which are that they should be

• successful learners,
• confident individuals,
• responsible citizens and
• effective contributors.

Health education, including drugs education, will be firmly embedded within these four areas. Exactly how this will be done will be the subject of further work.

Universities, other institutions of further education and training establishments

5.12 In Chapter 2, we showed that many young people only start using tobacco, alcohol or other drugs in a hazardous way once they have left school. A growing proportion of school-leavers now spend several years at Universities or Further Education Colleges and thousands others receive training in other establishments such as the Armed Forces, the Police and the Civil Service. The combination of new freedoms, greater stresses, peer pressures and more disposable income may all tip the balance for many in favour of smoking, excessive drinking and use of other drugs. To our knowledge, such institutions either provide no information to students or trainees about the potential hazards of tobacco, alcohol and other drugs or it is done in a very low-key way - a few lines in a freshers' week manual for example, or a leaflet in a student health centre. The National Union of Students actively promotes No Smoking Day but the focus is on helping existing smokers to stop. Advice and support for students who smoke is available from a number of other sources which are readily found on the Internet. However, we think that more attention should be paid to preventing school leavers and students from starting to smoke.

Community-based initiatives

See para 4.17

Smoking cessation services for young people

5.13 There is increasing interest in providing smoking cessation services for young people, but relatively little research evidence on which to base such services. In 2002 NHS Health Scotland and ASH Scotland funded the first major UK programme of pilot cessation projects for young people. These aimed to engage with young smokers (12-24 years) who wanted to quit smoking, and identify acceptable and potentially effective approaches to help them quit. The eight projects were funded for three years, took place in a range of settings ( NHS, community, education, prison, internet) and focused on different groups (pregnant women, students, pupils, offenders) ⁹⁸.

5.14 The projects all experienced difficulty in attracting and retaining clients, with more time and effort having to be put into recruitment than had been expected. Most participants reported making some change to their smoking. However, from a total of 470 young people using the services, only 11 (2.4%) were confirmed quitters with carbon monoxide validation at both 3 and 12 months.

5.15 Participation in the pilots was seen by the project staff as offering wider benefits to the young people involved, such as increased confidence and self esteem. Key learning points were identified concerning the challenges of engaging and working with young people on their smoking which would be relevant to smoking prevention as well as cessation interventions and programmes. Indeed given the diversity of participants' understanding of smoking, dependence, addiction and cessation, projects had to provide considerably more information and education on smoking-related issues than is required in adult cessation services.

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