Could the next generation be tobacco free?

Tobacco control expert Andrea Crossfield MBE considers the dramatic reductions in young people’s smoking in recent years, especially while adult smoking rates are falling more slowly and smoking-related health inequalities persist

Smoking is a childhood addiction. In England, almost two-thirds of smokers started before the age of 18,¹ so preventing uptake is key to long-term reduction of smoking prevalence and health inequalities. As the government acknowledges,² half the difference in life expectancy between the richest and the poorest is due to smoking, and while youth smoking has reduced considerably in recent years many hundreds of children still start smoking every day.³

The state of play

Around 207,000 children aged 11-15 begin smoking every year⁴ in the UK, and between a third and half become regular smokers* within two or three years.⁵ Of children aged 8-15, 4% reported in 2015 that they had ever smoked a cigarette⁶ with 1% reporting that they smoked regularly. Long term this last statistic is good news, with youth “ever-smokers” down from 19% in 2003. This fall by three quarters reflects changing social norms driven by tobacco policy and legislation.

During the last decade, governments have raised the age of sale, introduced graphic health warnings and proxy purchase regulations, removed cigarette vending machines and banned smoking in cars with children.

The 2007 smokefree law reduced children’s exposure to second-hand smoke, resulting in 11,000 fewer under 15s being admitted to hospital with respiratory infections.⁷

From May 2017, tobacco will be sold in standard packaging, maximising the impact of new larger graphic health warnings.

Sustained reductions in youth smoking are delivered by tackling adult smoking, as children who live with smokers are up to three times more likely to become smokers themselves than children of non-smoking households.⁸ The recent report⁹ from Action on Smoking and Health (ASH) about reductions in local stop smoking services in England is very concerning, especially coupled with deep cuts to mass media budgets to support quitting (down to a fifth of 2009 levels¹⁰), despite such campaigns being known to be cost effective.¹¹

Some people have concerns about electronic cigarettes and their potential to “gateway” young people into tobacco smoking. However, current evidence does not support this view,¹² with 2016 data from ASH¹³ indicating that regular use of e-cigarettes (once a month or more) was rare and largely among youth who currently or have previously smoked. Only 2% of respondents said they used electronic cigarettes more than once a month, including 1% who used them weekly. Surveys suggest some increasing experimentation with e-cigarettes, but smoking rates continue to fall and it’s important to note that it is illegal to sell e-cigarettes to under 18s. So what about the future?

Tobacco plan for England

A new national tobacco plan for England is due imminently, and promises comprehensive action to cut smoking rates, particularly for the most vulnerable and disadvantaged groups. This needs funding and support commensurate with the devastation wreaked by smoking on the lives of those addicted as young people.

All primary care professionals, including GPs, have daily opportunities to take just 30 seconds to deliver effective, very brief advice (http://elearning.ncsct.co.uk/vba-stage_1) to patients who smoke. This simple action can change not just one life, but a whole family’s life and support turning off the tap of new young smokers to deliver a tobacco-free generation.

Price rises are also crucial to reduce smoking, and young people are up to four times as price-sensitive as adults,¹⁴ so tax increases and action to tackle cheaper illegal tobacco are key.

A new area for action is smoking in films and entertainment media, with a clear relationship between exposure to smoking imagery in films and smoking uptake.15 Disappointingly, between 2007 and 2015 UK Film Tax Relief provided subsidies worth c£473m to c90 top-grossing UK or US-UK films containing tobacco imagery, with 97% of this granted to films suitable for teenagers in the UK.16 Subsidies should be removed and short anti-smoking advertisements shown before under-18 rated films containing smoking, or an 18 rating applied.

Andrea Crossfield is Chief Executive of Healthier Futures (formerly Tobacco Free Futures) in the UK. Previous roles have included Department of Health Regional Tobacco Policy Manager for the North West and Programme Director for SmokeFree Liverpool. She is actively involved in a range of national partnerships – including the Smokefree Action Coalition and Alcohol Health Alliance – and has a keen interest in public health advocacy and its role in securing evidenced-based comprehensive approaches to tackling public health agendas such as that advocated by the WHO Framework Convention on Tobacco Control.

*Regular smoking is defined as smoking at least one cigarette per week

References

1 Department of Health, Healthy Lives, Healthy People: A Tobacco Control Plan for England. Department of Health, 2011.2 Smoking: Written question – HL1194. 26 July 2016

3 Hopkinson NS, Lester-George A, Ormiston-Smith N, Cox A, Arnott D. Thorax, 2013. doi:10.1136/thoraxjnl-2013-204379

4 Hopkinson NS, Lester-George A, Ormiston-Smith N, Cox A, Arnott D. Thorax, 2013. doi:10.1136/thoraxjnl-2013-204379

5 Harm reduction in nicotine reduction. Helping people who can’t quit. A report of the Tobacco Advisory Group of the Royal College of Physicians, London, RCP, 2007

6 Health Survey for England, 2015. Publication date: December 14, 2016. ONS, Newport.

7 Smoke-free legislation and childhood hospitalisations for respiratory tract infections. Been JV1, Millett C2, Lee JT2, van Schayck CP3, Sheikh A4.

8 Leonardi-Bee J, Jere ML, Britton J. Thorax, 2011 doi:10.1136/thx.2010.153379

9 Cutting Down: The Reality of Budget Cuts to Local Tobacco Control, Action on Smoking and Health, ASH, London – November 2016 http://ash.org.uk/download/cutting-down-the-reality-of-budget-cuts-to-local-tobacco-control

10 Source: Hansard: Citation: HC Deb, 3 May 2016, cW and HC Deb, 3 April 2014, c799W

11 Atusingwize E, Lewis S, Langley T. Tobacco Control 2015: 24: 320-327

12 Bauld L, MacKintosh AM, Ford A, McNeill A. Nicotine Tob Res 2016; 18: 102-313 Use of electronic cigarettes among children in Great Britain, ASH, London – October 2016 http://ash.org.uk/download/use-of-electronic-cigarettes-among-children-in-great-britain/14 Hopkins, D et al. Am J Prev Med 2001; 20: 16-66