2 Public health need and practice
The cost of smoking is high. Between 1998 and 2002 it was responsible for an estimated 86,500 premature deaths in England each year, including 35,800 from cancer, 28,200 from circulatory disease and 20,700 from respiratory disease. It is also responsible for a range of other diseases and conditions, including impotence and infertility (Twigg, Moon and Walker 2004).
Smoking has been identified as the primary reason for the gap in life expectancy between rich and poor. Among men, it is responsible for more than half the difference in the risk of premature death between the social classes (Jarvis and Wardle 2006).
Children who smoke become addicted to nicotine very quickly. They also tend to continue the habit into adulthood. Around two-thirds of people who have smoked took up the habit before the age of 18 (The Information Centre 2006). Because the risk of disease is related to the length of time a person has smoked, people who take up smoking before the age of 18 face a greater-than-average risk of developing lung cancer or heart disease (Royal College of Physicians 1992).
Children and young people who smoke are two to six times more susceptible to coughs, increased phlegm and wheezing than their non-smoking peers (Royal College of Physicians 1992). The habit can impair the growth of their lungs and is also a cause of asthma-related symptoms in childhood and adolescence (Muller 2007).
In recent years, little progress has been made to reduce the number of children aged 11–15 who take up smoking. Between 1982 and 1998 the proportion who smoked regularly fluctuated between 8% and 13%. Since 1999, rates have remained steady at between 9% and 10%. In 2006 in England, 9% of 11–15 year olds said they smoked regularly – equivalent to more than a quarter of a million young people. Among young people aged 16–19, 26% smoked regularly – equivalent to nearly three quarters of a million young adults (Office for National Statistics 2006; The Information Centre 2007).
Up to age 13, boys and girls are equally likely to smoke on a regular basis. However, from age 14 girls take the lead: 14% of girls aged 14 and 25% of girls aged 15 smoke regularly (compared with 10% and 16% of boys, respectively) (The Information Centre 2007).
The highest prevalence of smoking is among people aged 20–24 (37% of men and 30% of women) accounting for more than one million young adults (The Information Centre 2006).
Children and young people usually get cigarettes from friends, family and shops, especially small corner shops. However, they also buy from adults who sell them from home and from others involved in organised criminal activities.
In a 2004 survey of more than 9000 pupils in 313 schools across England, 66% of children aged 11–15 who smoked had bought cigarettes from a shop. Just over half (52%) said they had been refused a purchase at least once. Sixty three per cent of children and young people who smoked were also likely to have been given cigarettes by friends (58%) or by siblings (13%).
Environmental, sociodemographic, behavioural and individual factors are all associated with the uptake of smoking. Having a parent or sibling who smokes is particularly strongly associated with uptake (Goddard 1992; Stead et al. 1996).
Tobacco use in adolescence is associated with many behaviours that can adversely affect health, including the misuse of alcohol or other drugs (The Information Centre 2007). For example, young people aged 11-15 who have recently smoked tobacco, drunk alcohol or used cannabis, volatile substances or class A drugs are likely to have used one of the other substances as well; the strongest relationship is between recent cannabis use and cigarettes (The Information Centre 2006).
Regular smoking is also more prevalent among adolescents who have truanted or been excluded from school compared with those who have not (The Information Centre 2007).
The treatment of smoking-related diseases costs the NHS an estimated £1.5 billion a year (Parrott et al. 1998). In addition, smoking costs industry around £5 billion each year in terms of lost productivity, higher rates of absenteeism among people who smoke and fire damage (Parrott et al. 2000).
It also costs families, especially the poorest, a great deal. In 1996, 55% of lone parents on income support (approximately 0.5 million) spent £357 million on cigarettes (smoking five packs of cigarettes a week on average at £2.50 per pack) (Dorset and Marsh 1998). In 2007, an estimated 858,000 lone parents were on income support. If the same percentage continued to smoke at the same rate as in 1996 (with cigarettes now costing £6 per pack) it is estimated that they would have spent a total of £736 million on cigarettes in 2007.
The following policies and legislation are relevant when attempting to prevent children and young people from taking up smoking.
The Children and Young Persons (protection from tobacco) Act 1991 updated the original 1933 law which made it illegal to sell cigarettes to young people under the age of 16. In 1991, the law was amended to ban the sale of any tobacco product to those under the age of 16 and to make it illegal to sell single cigarettes. Local authorities are obliged, once a year, to consider whether or not they should introduce a local enforcement programme. From October 2007, the age of legal purchase was increased from 16 to 18 years (Children and Young People [sale of tobacco etc.] Order 2007). Apart from warnings about the legal age of purchase (required on premises where tobacco is sold), the other provisions of the 1991 act remain the same.
The tobacco white paper 'Smoking kills' (DH 1998) set out a number of steps to help protect children and young people from smoking:
minimal tobacco advertising in shops
tough enforcement on under-age sales
proof-of-age card requirement.
The Criminal Justice and Immigration Bill became an act of parliament in May 2008 and will come into force in April 2009. It includes banning orders for retailers who persistently sell cigarettes to young people under the age of 18).
There is no statutory obligation on local authorities to carry out an enforcement campaign. However, the Local Government Association, Local Authorities' Coordinators of Regulatory Services (LACORS) and government all agree that local authorities should assess the need for such a campaign. Where it is introduced, they recommend it should be run in accordance with best practice. In April 2006, LACORS published a practical guide, 'The LACORS practical guide to test purchasing', for organisations undertaking test purchases with young people on all age-restricted products.
When the legal age for buying tobacco was changed in 2007, the DH issued a toolkit to help retailers fulfill their legal obligations.
In May 2008, the government initiated a consultation in England on its proposals for new tobacco controls, including measures to reduce children and young people's access to tobacco and to protect them from secondhand smoke. The proposals included: removing branding and logos from all tobacco packaging; restricting the display of tobacco products in shops; banning the advertising of smoking paraphernalia, such as cigarette papers; and banning cigarette vending machines. The document also proposes that cigarettes should be sold in packs of 20 as a minimum (because most children and young people can only afford packs of 10).
In October 2011, the sale of tobacco was banned in vending machines in England.