2 Public health need and practice

Smoking is the main cause of preventable morbidity and premature death in England. In 2007, it is estimated that 82,900 adults aged 35 and over died as a result of smoking. This translates into nearly two in ten deaths in England of people aged 35 and over (The Information Centre 2008).

In England, the long-term decline in adult smoking is reflected in the behaviour of young people. Among those aged 16–19, smoking fell from 40% in 1974 to 21% in 2007 (Robinson and Lader 2008). Regular smoking among young people aged 11–15 (defined in this group as smoking one or more cigarettes a week) shows an overall decline from 11% in 1982 to 10% in 2000, with a further decline to 6% in 2007 (Fuller 2008).

The earlier children become regular smokers, the greater their risk of developing life-threatening conditions, such as lung cancer or heart disease, if they continue smoking into adulthood. Those who start smoking before the age of 16 are twice as likely to continue to smoke as those who begin later in life – and are more likely to be heavier smokers (Muller 2007).

However, the process of becoming a regular smoker is not always constant – children and young people may stop and start the habit on a number of occasions before they come to identify themselves as someone who smokes (Goddard 1990).

Factors linked to smoking

Children and young people start to smoke and then continue for a number of reasons. These may be connected to their personal or social circumstances or to wider society.

Personal factors include age, gender, socioeconomic status, educational attainment and mental health.

Regular and experimental smoking increases with age. According to the latest national data, only 1% of children aged 11 regularly smoke. This increases to 4% at age 13 and to 15% by the time they are 15. At this age more than half (55%) have tried smoking (Fuller 2008).

Smoking rates continue to rise among young people until they are in their mid-20s; smoking prevalence is highest among this age group. General Household Survey data indicate that about one in five young people aged 16–19 smoke and that this rises to about three in ten of those aged 20–24 (Goddard 2008).

At 13, girls are more likely than boys to smoke on a regular basis, but by the early 20s, young men overtake young women (Fuller 2008; Goddard 2008).

Children and young people are more likely to smoke if they have:

  • used alcohol or drugs (Goddard 1992)

  • poor educational attainment or are 'disengaged' from school (Morgan et al. 2006)

  • mental or emotional health problems (Office for National Statistics 2005).

Social circumstances, such as being surrounded by peers and family members who smoke, can also affect whether or not young people will take up smoking. For example, smoking among young people is strongly associated with living with one or more people who smoke. In 2006, 25% of young people aged 11–15 who reported living with three or more people who smoked were themselves smoking on a regular basis. This compares with 4% of young people who did not live with someone who smoked.

Parents who smoked were perceived by their children to have a more lenient attitude towards their children smoking. The children of these parents were less likely to think that they would try to make them stop, compared with those who were not living with parents who smoke (Fuller 2007).

Many young people see smoking as the norm because they mistakenly believe it is more prevalent than it really is. When asked how many of their friends smoke, they consistently overestimate the figure. For example, in a 2006 sample in which an estimated 29% of young people aged 15 smoked, their non-smoking peers estimated that the prevalence of smoking was 63%. Those who regularly smoked put the figure at 93% (Fuller 2007).

A range of factors in wider society also influences whether or not children and young people take up smoking. These include:

  • tobacco price and availability

  • restrictions on smoking in public places

  • tobacco industry advertising, including point-of-sale, and other promotional tactics such as product placement (for example, in films)

    (DiFranza et al. 2006; Emery et al. 2001; Hastings 2003; Pierce et al. 2005).

National context: policy

The 'Smoking kills' white paper (DH 1998) set targets to reduce the number of children aged 11–15 who were regularly smoking. The targets were: to reduce the total smoking from 13% (in 1996) to 11% by 2005 and to 9% by 2010 (DH 1998).

'Smoking kills' recognised the fact that adult smoking and other societal factors affect whether or not children and young people take up smoking. It outlined plans to increase the real price of tobacco, combat smuggling and ban tobacco advertising, promotion and sponsorship. In addition, it set out the need to publicise the dangers of tobacco use more widely and to provide help to quit smoking through the NHS. It also urged local authorities to increase compliance with exisiting laws on under-age tobacco sales.

Legislation to make public places smokefree came into force in July 2007 – and was a significant step towards protecting children and young people from the harm caused by tobacco. In October 2007, the legal age for tobacco sales was increased from 16 to 18 years.

The Health Act 2009 will remove tobacco displays in shops and ban tobacco sales from vending machines (displays in all shops will be removed by October 2013 – the date for banning vending sales is yet to be announced). In addition, a new government tobacco control strategy was announced by the Secretary of State for Health on 1 February 2010. This sets out three objectives: 'to stop the inflow of young people recruited as smokers; to motivate and assist every smoker to quit; and to protect families and communities from tobacco-related harm'. The strategy aims to halve the proportion of people who smoke – from 21% to 10% – by 2020 (DH 2010).

National context: schools and further education colleges

All secondary schools include information to deter tobacco use as part of the science curriculum. Some include it as part of personal, social, health and economic (PSHE) education. Schools that have (or are working towards) National Healthy School Status (NHSS) or Healthy Schools enhanced status may be involved in additional anti-tobacco activities.

In particular, schools that sign up to the enhancement model will use a range of data and work with a range of partner organisations (including those from the voluntary sector) to help children and young people who want to quit smoking.

Further education colleges may become involved in the Healthy Further Education Programme. This encourages a 'whole college' approach to health and wellbeing and involves tackling a range of health issues including smoking.

In 2009, the Secretary of State for the Department for Children, Schools and Families announced that PSHE education should become a statutory part of the national curriculum at primary and secondary level in September 2011.  This was subject to parliament passing the Children, Schools and Families Bill (2009) which was put before Parliament in November 2009.

  • National Institute for Health and Care Excellence (NICE)