The challenge of teenage smoking

VOL: 100, ISSUE: 06, PAGE NO: 52

Samantha Andrews, RGN, BA, DipHE, is a smoking cessation specialist for Hull and East Riding Smoking Cessation Service, and a freelance trainer for the health education consultancy, Jennifer Percival and Associates

Smoking cessation services for adults are now well established in England and have proven to be effective and successful. From April to June 2003, a total of 64,700 people set a stop date and at four weeks 33,900 (52 per cent) had successfully given up smoking (Department of Health, 2003a).

Smoking cessation services for adults are now well established in England and have proven to be effective and successful. From April to June 2003, a total of 64,700 people set a stop date and at four weeks 33,900 (52 per cent) had successfully given up smoking (Department of Health, 2003a).

However, the decline in smoking seen in adults is not matched by trends observed in young people. NHS smoking cessation services established in 1999-2000 have generally focused on adult smokers because the impact of deaths and morbidity due to smoking-related disease in the adult population is substantial.

However, young people experience health problems associated with smoking and find it difficult to give up. These potential adult smokers of the future present a challenge to the NHS. Unlike adult smoking cessation services, which are based on sound evidence about what works and how to structure services and support, no such base exists to provide services for young smokers.

A Health Education Authority seminar report, published in 1999, suggests it is unlikely that adult services would be suitable for young smokers. It says there is no good evidence about what type of smoking cessation interventions work with this age group (Foulds, 1999).

Facts about young smokers
In Britain about 450 young people are said to start smoking every day (Royal College of Physicians, 1992). The overall trend in the prevalence of smoking in 11-15-year-olds has fluctuated since it was first recorded in 1982. There have been lows of eight per cent in 1988 and highs of 13 per cent in 1984 and 1996. Since 2000, the rate has been consistent at 10 per cent.

Girls have smoked more than boys since 1986 and this persisted in 2002, when 11 per cent of girls and nine per cent of boys reported smoking regularly (at least one cigarette a week) (Action on Smoking and Health, 2003).

Health risks of teenage smoking
The earlier that children become regular smokers (and continue the habit into adulthood), the greater the risk they have of dying prematurely. Although clinical problems are rarely seen before middle age, there is evidence that negative effects begin soon after smoking is started. These effects are increased by the length and intensity of exposure (Royal College of Physicians, 1992).

Young people who smoke are more susceptible to coughs and increased phlegm, wheeziness and shortness of breath than those who do not (Royal College of Physicians, 1992). Smoking can lead to an increase in respiratory problems for young people with asthma (Royal College of Physicians, 1992).

Young people who smoke are further compromised by reduced school attendance due to illness and an increase in admissions to hospital. There is evidence that those who smoke are three times more likely to have time off school (ASH, 2003).

Although the risks to health of smoking are often difficult for young people to appreciate, the desire to stop smoking is still strong. A survey on attitudes to smoking (Schools Health Education Unit, 2003) found that about 70-75 per cent of young people who smoke want to give up. This is comparable with the rate for adults (Department of Health, 2003b).

Nicotine addiction and young people

Many young people underestimate the addictive nature of smoking. They believe they are in control and can discontinue it whenever they want. It is often their intention not to be lifelong smokers and that at some point they will stop.

Personal goalposts are identified for stopping, such as 'when I leave school' or 'when I go to university'. However, studies have shown that children's intake of nicotine is comparable with adult smokers (Royal College of Physicians, 1992). They inhale nicotine doses that are substantial enough to have pharmacological effects.

The effect of addiction is reflected in young people's perception of their dependence; the longer a young person smokes, the greater the perceived difficulty in stopping (Foulds, 1999).

Barriers to smoking cessation
Smoking is an incredibly complex behaviour involving elements of addiction, habit and dependence. It is a common misconception that smoking is just about addiction to nicotine. It is possible, for example, for a smoker to experience a craving that has nothing to do with physiological dependence but stems from an association of habit.

For example, a young smoker may experience a severe craving first thing in the morning when nicotine levels are at their lowest (having not smoked overnight) but the craving they experience when meeting friends outside the school gates may have little to do with physiological need but arise because of the situation. This behavioural component of smoking is particularly important to address in young smokers.

Unlike adults, who often have a history of numerous attempts to stop smoking, young people tend to have much less experience of trying to stop. Relapse, which is often seen in a negative light, can in fact be a positive experience. Exploring the relapse situation provides a building block for the next attempt at stopping.

Relapse should trigger an exploration of what worked well, what helped or hindered the attempt to stop smoking, what the trigger was for the relapse, and what can be learnt from the situation and could be done differently next time.

It is recognised that it can take between three and seven attempts for a smoker to successfully give up smoking (Miller and Rollnick, 1991).

Adults are often familiar with this process when they ask for support to stop. They have a wealth of experience that can be harnessed by cessation support services to help them successfully give up smoking. However, young people lack this experience.

They may present for support without having tried to stop before or, if they have, it may have been a short-lived and negative experience. Building confidence and self-esteem as well as valuing previous attempts should all be part of the process of supporting a young client.

Initiatives to help young people stop smoking
The provision of smoking cessation support for young people in England varies widely. Some NHS smoking cessation services offer support to young smokers as part of their adult service provision. Other areas have specialist services or workers for young people.

The lack of evidence about what works in helping young people to give up, and the uncertainty as to whether services should be directed at young people at all (Hill, 1999), mean that wide variations exist in the type of support offered.

The CHUCKIT project in Hull and East Yorkshire is just one example of how young smokers can be offered specialist smoking cessation support. A branch of the adult smoking cessation service, CHUCKIT provides one-to-one support for smokers under 18 years of age. This support is tailored to the needs of young people and, as a result, differs from the adult service (Box 1).

This support is facilitated by a network of NHS and non-NHS professional support workers. These people already deal with young clients and work in a range of roles such as youth workers, school nurses, learning mentors, drug workers, and health development workers.

They undergo free training in smoking cessation skills, and are given resources and a named specialist to support and mentor them in their work with young smokers. Health education activities are essential to the CHUCKIT service. Planting seeds through educational activities can prompt referrals to the helpline.

CHUCKIT is still in its infancy. It has taken 18 months to build the infrastructure, and its effectiveness in reducing smoking prevalence is not yet known. One difficulty for services trying to cater for the needs of young smokers is the pressure to meet national smoking cessation targets.

This often means the needs of young people cannot be met and where provision does exist, success is measured by the number of people who give up smoking and not by the number who are enabled to make a connection with services about their smoking and its effect.

Conclusion
Statistics on smoking among young people suggest cause for concern, and the rising rates among young girls are particularly worrying. Tackling smoking cessation in this age group is a challenge. Young people require different support systems than those of adults to help them stop smoking.

There is a lack of evidence about what is effective in helping young people to stop. However, it is clear that many want to quit smoking.

The sooner health services engage with them and offer support, the sooner they can help them through the journey of giving up. This will decrease their lifelong exposure to smoke and so reduce their risks of smoking-related disease and death.

Raising awareness about the effects of smoking needs to be a proactive and consistent part of a young person's education both in and out of the school environment. There should be an understanding of the difficulties of giving up smoking among young people and appropriate smoking cessation support must be sensitive to the needs of this unique group.