Part Four
Smoking and Young People
Introduction
4.1 One meeting was devoted to the topic of smoking and young people. The purpose was to review understanding of the factors influencing young people to smoke and to inform wider thinking on this issue. The Committee noted the importance of stopping young people from experimenting with smoking, given the intensely addictive properties of nicotine.
The Health of the Nation
4.2 The Health of the Nation White Paper10 recognised the importance of reducing the prevalence of smoking in young people. The White Paper included a specific target to reduce the proportion of 11 to 15 year olds who are regular smokers (defined as smoking at least one cigarette a week) from about 8% in 1988 to less than 6% in 1994. Disappointingly, the 1994 target was not met (see para. 1.19). The prevalence of smoking in this group has risen to 13%, and failure to make any impact here contrasts with the continued steady progress in reducing adult smoking prevalence and tobacco consumption.
Australian Experience
4.3 The Australian Quit Evaluation Studies number 8, 1994-199556 concluded that smoking among young people is not declining and there are worrying signs that smoking is re-emerging as a signifier of the rejection of authority. Research into the attitudes of young smokers to quitting revealed two strong themes: young people do not believe that smoking is currently doing them any harm and young smokers intend to quit eventually but put off the decision.
A Smoking Target for Young People
4.4 There may be an advantage in reducing the age range of any future targets among young people by focusing on discrete age groups. It is known that nearly all 10 to 11 year olds do not smoke, but by age 15 years about 30% have become smokers. The main change in attitude and behaviour occurs around age 13, with some variation between the sexes. A clearer focus on prevalence in 14 and 15 year olds (Years 10 and 11 of the National Curriculum) might offer a more precise indicator of the success of efforts to reduce smoking in young people. It will be useful to continue to document prevalence changes in smoking in younger age groups in order to provide early warning of any significant changes which might occur. Members considered that, in the future, gender related smoking prevalence for young people should be monitored for age groups 11, 12 - 13 and 14 - 15.
4.5 While the prevalence of regular smoking is an important indicator, information on the proportion of young people who used to smoke but have given up, those who have tried smoking without taking it up regularly and those who have never smoked is also relevant. Useful data are provided in an Exeter Schools Health Education Unit Publication “Young People in 1996”.57 This book, published in July 1997, reported that a quarter of 14 - 15 year old boys and almost a third of the girls, smoked at least one cigarette during the previous week. 20% of the 14 - 15 year olds were able to buy cigarettes from a shop. Within the 14 - 15 year age range, of girls and boys who consider themselves “regular “smokers, only about 6% say that they do not want to give up.
Children's Smoking, Taxes and Tobacco Industry Income
4.6 1994 OPCS figures62 on tax and industry revenue from children's (illegal ie under 16 years of age) smoking were illuminating. In England the total tobacco tax revenue to Treasury from young people was just under £104m (the industry received nearly £29m). Treasury revenue from under age smoking in Scotland was nearly £11 million, in Wales it was over £5 million and in Northern Ireland treasury income was over £4.5 million. Except in Scotland, under aged girls contributed more to treasury revenue than under aged boys. In England and Wales in 1996 there were 140 prosecutions for tobacco sales to minors, with findings of guilt in 119.63
Factors Influencing Young People to Smoke
Parents and siblings
4.7 An OPCS enquiry,64 commissioned by the Department of Health, showed that young people whose parents smoke are twice as likely to smoke as children of non-smoking parents. It also showed that young people who perceive no parental disapproval are seven times more likely to smoke than young people who perceive strong parental disapproval; that young people with a sibling who smokes are up to four times more likely to be regular smokers than those whose siblings do not smoke; and that the effect of peer smoking is more pronounced with increasing age. A Royal College of Physicians working party report showed that the prevalence of smoking among young people is higher in those living with a single parent and is higher still if the lone parent is a smoker.65 It should be said that little is known about the relative contribution of family influences and hereditary factors to susceptibility to smoking.
Young People and Price
4.8 It is clear that price plays a definite role in cigarette consumption. Smoking trends in 15 year olds mirror price changes, indicating that they are responsive to price.66
Young People and Nicotine Addiction
4.9 Studies of teenagers have shown that pharmacological motives become important very early in the smoking career. By the time daily smoking is established, within only a few months of starting, children take in as much nicotine per cigarette as do dependent adult smokers.67 Children as young as age 14-15 report experiencing nicotine withdrawal effects, and perceive that stopping smoking will be hard to achieve successfully.68 These observations confirm the US Food and Drug Administration's view of cigarette smoking as a “paediatric disease”.69
Young People and Cigarette Advertising
4.10 The Committee received evidence from Mr P Haynes, (see para. 3.5), suggesting that key advertising messages exploit the emerging independence of young people. Cigarettes are used as a fashion accessory and appeal to young women. Other influences on young people include the linking of sporting heroes and smoking through sports sponsorship, the use of cigarettes by popular characters in television programmes and cigarette promotions. Research suggests that young people are aware of the most heavily advertised cigarette brands.70 Mr Haynes suggested that the key objective of the advertisers is to expand the market, using various strategies to persuade young people to smoke more.
4.11 Sports sponsorship is acknowledged by the tobacco industry to be valuable advertising. A Tobacco Industry journal in 1994 described the Formula One car as “The most powerful advertising space in the world”.71 In a letter to the Lancet of 15th November 1997, Professor Anne Charlton and colleagues have described a cohort study carried out in 22 secondary schools in England in 1994 and 1995. Boys whose favourite television sport was motor racing had a 12.8% risk of becoming regular smokers compared to 7.0% of boys who did not follow motor racing. The Committee was concerned at the link between the onset of regular smoking in boys and their preference for watching motor racing sponsored by specific brands of cigarettes.
4.12 The Department of Health's Smee Report 199272 examined the effect of year-to-year variations in advertising expenditure within countries and concluded that advertising influenced tobacco consumption. The Smee report also reviewed the effect of advertising bans in other countries. Norway and Finland have complete bans on advertising which were estimated to have reduced cigarette consumption by 9% and 7% respectively. Bans in Canada, Australia and New Zealand resulted in reductions less than in Norway and Finland.
4.13 Although other factors may have been involved, the advertising ban in Norway in 1975 appears to have led to a substantial reduction in smoking among school students and adult males.69 Between 1973 - 1994 female smoking prevalence in the age group 16 - 24 years fell from about 44% to about 28%. For males of the same age group it fell from more than 45% to 30%. Since 1975, when the advertising ban was introduced in Norway prevalence among male daily smokers aged 13 - 15 fell from 15% to 9% in 1990. For girls the fall was from 17% to just below 10%.74 The ultimate effect of an advertising ban depends to a certain extent on prior restrictions on smoking.
4.14 The committee noted that a paper published in the Journal of the American Medical Association75 in 1994 concluded that: “The tobacco advertising campaigns targeting women, which were launched in 1967, were associated with a major increase in smoking uptake that was specific to females younger than the legal age for purchasing cigarettes”.
4.15 The long term effect of banning advertising and promotion in Australia and New Zealand, Canada, Norway and Finland and in any other parts of the world instituting a ban, is being watched with interest. Data from New Zealand76 show that there had not been a decrease in smoking prevalence in those aged 15 years and over between 1991 and 1995. There was a period of marked decline from 1984 to 1990. Among 15-19 year olds smoking prevalence peaked in the first quarter of 1991 and declined in the second half of the year. These changes were thought to be consistent with the heavy tobacco advertising in 1990, the advertising ban from December 1990, and the effect of the 17% cigarette price rise in July 1991. It was concluded in “Tobacco Statistics 1996”76 that smoking reduced as and when Government intervened, by legislation, taxation, health promotion programmes or publicity campaigns. This document also shows that smoking prevalence amongst Maori people is about double that in Europeans.
4.16 In February 1997, Mrs Christine Godfrey, Health Economist from the University of York, gave a presentation to the Committee on the effects of cigarette advertising on the young. Econometric studies could never provide conclusive evidence of causality ie a direct link between advertising and tobacco consumption. It was therefore necessary to make a judgement on the balance of probabilities, considering all available evidence, not least the marketing intentions and expenditure of tobacco companies.77 The dramatic increase in the brand share of the product following the launch of the Joe Camel character in the US demonstrated that marketing activities are directed at placing brands in different sectors of the market. Research has looked at young people's recognition and susceptibility to cigarette advertising or marketing techniques. Susceptible young people go on to become smokers, but it is not clear whether susceptibility pre- or post-dates awareness of advertising.78 Media advertising is only part of the industry's wider marketing activities and should not be considered in isolation from sponsorship, competitions and other types of sales promotion.79 Evidence from the General Household Survey1 shows that young people are more likely to smoke heavily promoted brands than older smokers. Current regulations clearly do not protect children from advertising messages. Advertising could also reinforce smoking behaviour, hinder quitting efforts, constrain media coverage of anti-smoking messages and legitimise the smoking habit. The balance of evidence from different types of studies (econometric, experimental and observational), together with examination of the marketing activities of tobacco companies, indicates that advertising influences consumption and that restrictions on advertising and other marketing activities will lead to a reduction in children's smoking.
4.17 The Committee recognised the difficulty in obtaining conclusive evidence on advertising and total tobacco consumption but, having looked at the available evidence, was of the unanimous view that tobaco advertising and promotion influence the uptake of smoking by young people. Based on firm medical evidence of the health effects of active smoking and exposure to ETS, open advertising and promotion of tobacco products could no longer be justified.
4.18 In March 1997, the American Liggett Group Inc., agreed to a legal settlement with 22 US states. As part of the settlement the company undertakes “to scrupulously avoid any and all advertising that would appeal to children and adolescents”. The company will hand over a quarter of its pre-tax profits for the next 25 years to a fund for litigants, and will give warnings on cigarette packs that smoking is addictive. It will be noted that this is the first time that a tobacco company has admitted that cigarette smoking is addictive and causes lung cancer, heart disease and emphysema.
4.19 A proposed settlement with the tobacco industry in America was announced in June, 1997. (The full text of the settlement is available on the internet.80) US tobacco companies have agreed to pay $368.5bn (£230bn) over 25 years, in a settlement with the Attorneys General from forty states, in return for limitations on future litigation. The deal proposes that teenage smoking should fall by 30% in five years and 60% in ten years with penalties against the tobacco companies if these targets are not met. The proposals, which have yet to be endorsed by the President and approved by Congress, will also ban billboard advertising, store displays, sports promotion and the use of human and cartoon images.
Recent Department of Health Funded Research about Smoking and Young People
4.20 A study on protective factors in adolescent smoking was carried out for the Department of Health.81 The authors concluded that certain factors operate as protective influences against smoking and are not necessarily the inverse of risk factors. Parental influence was seen to decrease during adolescence as peer influence increased. The importance of self-image or social identity was central.
4.21 The study recommended that interventions should have a family and community component as well as a school component; clear and consistent messages should be promulgated from trusted sources of similar age and from role models in sports and media. There should be promotion of the non-smoking image, stricter monitoring of illegal tobacco sales and better dissemination of existing information on the health effects of cigarette smoking.
4.22 The Exeter Schools' data61 show the higher percentages of smoking girls than boys in the older age groups (years 9, 10 and 11). This is confirmed by information form ONS,13 reporting a statistically significant increase among 15 year old boys from 19% in 1993 to 26% in 1994. Although there was also an increase in smoking among girls of this age, from 26% to 30%, it was not statistically significant. Social representation and social identity are important factors with respect to smoking and young people; social representation defines the special features of a social group and social identity relates to an individual's persistent sense of self and of sharing significant characteristics with others.
4.23 A quantitative/behavioural study on “Why do young girls smoke?” was commissioned by the Department of Health.78 The authors concluded that young adolescent girls smoked more cigarettes than boys. Living in single parent families or step families was a risk factor compared with living with both parents, as was the presence in the home of smokers. Peer influences were of considerable importance: having a best friend who smoked was identified as a significant risk factor for smoking. Intentions to smoke were predictive of future smoking behaviour six months later. Adolescents were aware of the health risks associated with smoking and of the addictive nature of smoking. Sensation seeking and non conformist aspects of adolescent identity appeared to be important determinants of smoking. The culture of the particular school influenced smoking prevalence over and above social background factors.
4.24 The authors made recommendations for interventions and indicated that school interventions alone were insufficient to deal with the problem of smoking in young people. Other measures necessary to achieve any substantial change included effective non smoking policies in all public institutions, a ban on all forms of tobacco promotion, and fiscal measures to increase the price of tobacco products above inflation and above increases in disposable income. Specific recommendations for health education programmes should have a shifting focus throughout the school curriculum to tie in with the developmental changes in young people as they mature. Adequate training of teachers was necessary and health education should have a more prominent place in the National Curriculum.
Conclusions
4.25 Targeting of young people by tobacco companies is of particular relevance because of the now acknowledged addictive nature of tobacco.
4.26 Price, advertising and promotion influence cigarette consumption among young people.
4.27 Interventions to prevent smoking in young people should form part of concerted action involving all agencies including home, school, community and Government.
Recommendations
4.28 Young people, in particular, should be protected by a ban on all forms of tobacco advertising and promotion.
4.29 The real price of tobacco products should continue to be increased each year to discourage young people from smoking.
4.30 Changes in smoking prevalence in younger age groups should be monitored.
4.31 Educating young people about tobacco addiction and its effects on health should remain an important part of the school curriculum.
4.32 Young people themselves should be involved in looking at constructive ways of reducing initiation of smoking.
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