SWPHO BulletinContents. Too much, too young. Smoking and young people. in the South West. Key facts and figures

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1 O B S E R V A T O R Y South West Public Health Intelligence Team in the South West Children in the South West Series: Bulletin 4 Too much, too young Smoking and young people in the South West Authors: Dr Robert Mulliss, Public Health Intelligence Analyst, South West Public Health Observatory, Fiona Andrews, Regional Tobacco Policy Manager, South West Regional Public Health Group, Paul Brown, Deputy Director, South West Public Health Observatory and Dr Tanya Cross, Specialist Registrar, formerly at the South West Public Health Observatory. S O U T H W E S T P U B L I C H E A L T H March 2007 Key facts and figures 1 Introduction 2 Aim 2 Why children and smoking? 2 National and local policy context 2 The national picture 3 Smoking prevalence 3 Smoking and long-term health outcomes 3 The South West 4 Smoking prevalence among young people in the South West 4 Smoking habits 5 Wider determinants and factors influencing smoking in young people 5 Accessibility of cigarettes to young people 5 Marketing cigarettes to young people 6 Sibling and peer pressure 6 Smoking and socioeconomic inequality 7 Exposure to second-hand smoke 7 Going forward 8 Appendix A: Additional tables 9 Appendix B: Additional charts 12 Appendix C: Technical notes and definitions 14 References 15 SWPHO BulletinContents Key facts and figures Children first become aware of cigarettes from the age of 3 or 4 years and are most likely to first try a cigarette around the age of 9 (1). In the UK around 450 children each day start smoking, with 60% of adult smokers adopting the habit by the time they are aged 13 (2, 3). Around 50% of young people who continue to smoke will die from the habit in adulthood, many dying prematurely (1, 4). Estimates for the South West suggest that around 1,000 adults a year currently die prematurely from lung cancer and heart disease because of smoking (5). A number of factors are associated with an increased risk of smoking in young people: the marketing techniques of the tobacco industry; accessibility to tobacco products, low prices and peer pressure from friends and siblings; the smoking habits of parents and a number of factors associated with social and economic inequalities. South West Regional Public Health Group

2 It is estimated that a greater number of girls aged smoke in the South West compared to boys. Estimates indicate that between 26,200 and 30,600 young people aged in the South West smoke at least one cigarette a week. In the South West (and nationally) higher rates of smoking and exposure to second-hand smoke are associated with increased levels of deprivation. The extent of exposure is particularly marked in Torbay, Penwith and Kerrier, where it is estimated that 9 out of 10 (90%) of children with raised salivary cotinine levels (see technical notes) live in either deprivation quintiles 1 or 2 (most deprived). In the South West, a quarter (24%) of children with raised salivary cotinine levels live in affluent locations (quintiles 4 and 5), including South Gloucestershire, Cheltenham, Cotswold, North Wiltshire and East Dorset. Introduction Aim This bulletin is fourth in the Children in the South West series, which provides an overview of the health status of children and young people (aged 0 19 years) across the South West. The series is aimed at policy makers and practitioners in Local Authorities, Local Strategic Partnerships, Primary Care Trusts (PCTs), NHS Trusts, the South West Strategic Health Authority (NHS South West), Children s Trusts, regional bodies, academic institutes, the business community and voluntary sector. The bulletin: focuses on smoking in children and young people aged years; draws on a variety of data to describe the impact of smoking and exposure to second-hand smoke on the health and wellbeing of children; highlights estimated smoking prevalence in different age groups and across different geographical areas; provides estimates of the number of children exposed to second-hand smoke; examines the relationship between smoking, secondhand smoke and deprivation; considers the wider determinants and factors influencing smoking in young people such as marketing and accessibility of cigarettes, and influences on smoking uptake such as sibling and peer pressure and socioeconomic status; aims to assist in the planning, delivery and monitoring of relevant interventions and services to improve the wellbeing of children and young people in the South West. The series has been produced jointly by the South West Public Health Observatory (SWPHO) and Regional Public Health Group, in consultation with key partners across the region. Why children and smoking? The health consequences of both active and passive smoking are significant for children. An important determinant of the health of children in the short term and during their life course is whether they have been exposed to tobacco in utero, the extent to which they have been exposed to second-hand smoke and whether they then take up regular smoking themselves. Nicotine addiction can develop quickly in children and teenagers, who exhibit levels of dependence similar to those in adults. Office for National Statistics (ONS) figures suggest that over half of regular smokers aged stated that they would find it difficult to go without a cigarette for a week and 72% said that they would find it hard to quit the habit (27). Taking action to reduce or delay the uptake of smoking among children is a priority because most adult smokers start during their childhood or adolescence. Each day around 450 children in the UK start smoking. Most adult smokers adopted the habit by the time they were aged 16 (60% by the age of 13) and 82% started during their teenage years (6, 7), before they had the knowledge and experience to understand the severity of the health risks or the addictive nature of smoking. While the greatest short-term impact on disease trends will result from adult quit rates, taking action to prevent or reduce uptake in children and young people will facilitate a longer term reduction in smoking-related diseases. National and local policy context Smoking among children and young people is a priority for the government: the Smoking Kills White Paper on tobacco set a national target to decrease smoking in this group from 13% in 1996 to 9% by 2010 (8). In Choosing Health (9) the Government restated its concern about the number of children and young people who take up smoking and set out the need to strengthen action to tackle under-age smoking. Many components of the national and regional tobacco control strategies, such

3 as banning advertising, limiting point-of-sale materials, price increases and public education campaigns, are designed to address this. Proposals in Choosing Health include measures to protect children from exposure to second-hand smoke (as part of wider measures proposed to reduce smoking in public places), making smoke-free policies part of a supportive environment under the National Healthy Schools programme (from April 2005), and stronger action to tackle the sale of tobacco products to under-age young people. The South West Region Tobacco Control Strategy (10) reflects this national guidance by focusing on a programme of action with six key strands: working in partnership to inform and increase awareness of the health impacts of smoking; building NHS Stop Smoking services and strengthening local and regional action; reducing the supply and availability of tobacco products; reducing tobacco promotion; regulating tobacco products; reducing exposure to second-hand smoke. Many factors influence children s smoking (2), including the tendency for teenagers to smoke in imitation of adults. For this reason, a strong case has been made for addressing adult smoking as a cornerstone of youth smoking prevention strategies (11). Effective implementation of all the components of the tobacco control strategy not just those specifically targeted at young people is, therefore, crucial. The national picture Smoking prevalence In the 1960s and 70s, boys generally started smoking earlier and in greater numbers than girls. By the early 1980s, the proportions of girls and boys smoking regularly were equal. However, since 1993, girls are more likely to smoke than boys; in 2004, 10% of girls were regular smokers compared with 7% of boys (12). Between 1982 and 2004 smoking prevalence in the age group decreased by 1% in girls and 4% in boys. During the same period, the percentage of 15 year old girls smoking regularly remained static at 26%, while in boys the figure declined from 24% to 16% (4). Figure 1: Percentage of regular smokers aged in England in 2004 Percentage Boys Girls Age (years) Source: Centre for Social Research and the National Foundation for Educational Research Variations in smoking prevalence for young people within the age range are illustrated in Figure 1. This suggests that the percentage of young people who smoke regularly increases steadily from the age of 13, with smoking prevalence in girls higher than boys. Government targets set out in Smoking Kills (8) aim to reduce the percentage of regular smokers aged to 11% by 2005 and to 9% by The White Paper includes a number of measures to protect young people, both by making it less likely that they will start smoking and by helping them to stop. Estimates from other sources suggest that 10% of children aged are regular smokers, smoking at least one cigarette a week, with prevalence ranging from 1% in 11 year olds to 22% in 15 year olds (6, 7). The picture for cigarette consumption is slightly different. Despite a declining trend observed in the proportion of boys smoking regularly, figures for 1990 and 2000 suggest that cigarette consumption remains slightly higher in boys (50 to 55 cigarettes a week) compared with girls (45 to 49 cigarettes a week) (1, 4, 5). Smoking and long-term health outcomes Children who smoke increase their risk of dying prematurely from diseases such as cancer, chronic obstructive airway disease, coronary heart disease and stroke, and are two to six times more susceptible to coughs and increased phlegm, wheeziness, shortness of breath and adverse changes in blood cholesterol than those who do not smoke (13, 14). Earlier starters are at greater risk of developing lung cancer, with a person smoking 40 cigarettes a day for 40 years eight times more likely to develop lung cancer than a person smoking 20 cigarettes a day for 20 years (14). Starting to smoke at an early age also appears to adversely affect the brain and increases the likelihood of mental health disorders (14, 15).

4 Among young people the cost of cigarettes and short-term advantages (relief of stress, boredom and anxiety and the boosting of image and confidence) are often more salient concerns than the long-term health outcomes, which are viewed as being remote (16). Exposure to second-hand smoke may also impact upon health, with children at increased risk of developing a number of different health problems. The US Surgeon General s report published in 2006 included a comprehensive review of the evidence relating to the respiratory effects on children of exposure to second-hand smoke. The report concluded that children exposed to second-hand smoke are at increased risk of sudden infant death syndrome (SIDS), acute respiratory infections, ear problems and severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. The scientific evidence indicates that there is no risk-free level of exposure to second-hand smoke (3). The South West Smoking prevalence among young people in the South West Studies specific to young people in the South West suggest that, during the year 2000, 8% of girls aged years and 11% of boys the same age smoked regularly (17). These figures also show that, as children grow older, an increasing proportion of both genders takes up smoking, with 28% of girls and 25% of boys aged classed as regular smokers. Figure 2: Percentage of male pupils in Year 8 (12 13 years) and Year 10 (14 15 years) who reported having a cigarette during the last 7 days ( ) Estimates of smoking prevalence based on selfreporting in the Health Survey for England are lower than estimates based on analysis of salivary cotinine levels (see the technical notes and definitions in Appendix C). A possible reason for this is that parents, if present, could have influenced the young people s responses. Salivary cotinine studies tend to underestimate smoking prevalence among children who smoke infrequently but may capture children and young people exposed to second-hand smoke. Due to the different characteristics of these survey methods, both of which may provide useful information, we have calculated two sets of estimates for the numbers of regular smokers aged in the South West (by Local Authority area). These have been derived from national data, using the results of both self-reported and salivary cotinine studies. The self-reported estimates are based on 2004 data from the National Centre for Social Research and the National Foundation for Educational Research, and 2003 mid-year population estimates from the Office for National Statistics (ONS). The estimates based on salivary cotinine are derived from Health Survey for England Data (2002) and the ONS 2003 mid-year population estimates. Both sets of estimates are presented in Table A1 for males and Table A2 for females (Appendix A) and as charts in Appendix B. The estimates that have been generated from self-response figures suggest that as many as 11,165 boys and 15,042 girls who live in the South West may be regular smokers, according to the conventional definition for smoking in children of smoking at least one cigarette a week. Figure 3: Percentage of female pupils in Year 8 (12 13 years) and Year 10 (14 15 years) who reported having a cigarette during the last 7 days ( ) UK male year 10 South West male year 10 UK male year 8 South West male year UK female year 10 South West female year 10 UK female year 8 South West female year Pupils (%) 20 Pupils (%) Year Source: Schools Health Education Unit Year Source: Schools Health Education Unit

5 Estimates derived from salivary cotinine surveys indicate that as many as 15,086 boys and 15,517 girls may be regular smokers. The estimates for girls aged show greater similarity and may reflect the fact that older girls are more likely to smoke and more likely to admit to smoking regularly. A reluctance to admit to smoking regularly in younger children may account for the fact that the sets of estimates are most different in the youngest children (11 and 12 years). A comparison of the percentage of and year olds in the South West and the rest of England, who admitted smoking at least once in the seven days prior to a survey conducted by the Schools Health Education Unit, is shown in Figure 2 (males) and Figure 3 (females). Since 1987, irrespective of gender, trends in the South West have broadly mirrored those in the rest of England. However, since 1996 Year 10 males in the South West have generally smoked less than their counterparts nationally, with the percentage smoking regularly generally declining each year. Despite an increase in the percentage of girls smoking regularly (in both Years 8 and 10) between 1987 and 1997, there is evidence to suggest that, since the late 1990s, levels have begun to decrease (17). Smoking habits A comparison of the smoking habits of Year 8 and Year 10 pupils in the South West is shown in Table 1. The data reflect the findings of other studies, which have found that as children get older the proportion who claim they have never smoked decreases. Boys are more likely than girls to have never smoked, while the percentage who have smoked on one or two occasions is similar for both genders and age groups. The percentage of younger girls who smoke occasionally is comparable to that of older boys. Paradoxically, attitudes to quitting seem more polarised in girls. Whilst a greater proportion of girls state they want to quit, they are also more likely than boys to wish to continue with the habit. Wider determinants and factors influencing smoking among young people Accessibility of cigarettes to young people Since 1908 it has been illegal to sell tobacco products to anyone below the age of 16. Current legislation on the sale of tobacco to young people is included in the Children and Young Persons (Protection from Tobacco) Act Despite this legislation the results of a survey using volunteer children and conducted by Trading Standards Departments in England (18) suggest that cigarettes were sold to under-age children in 12% of premises where purchases were attempted and 13% of premises failed to display a warning sign. Another study suggested that, in 2000, 80% of regular smokers aged bought cigarettes from shops, with 79% perceiving it to be easy to access cigarettes this way. The same survey also found that 22% of regular smokers bought cigarettes from vending machines (6). Other studies suggest that between 1990 and 2000 the percentage of children purchasing cigarettes from shops and vending machines decreased by 6% and 15% respectively, with the purchase of cigarettes from other people increasing by 19% during the same period (18). Young people have little difficulty in accessing cigarettes and actively identify shops which take a relaxed view regarding buyer age (16). In more recent years, however, there has been an increase in children of school age reporting that they have been refused the sale of cigarettes (19). A comparison of the findings of another study relating to children in the South West (Table 2) indicates that for both and year old pupils, more than 80% of cigarettes smoked were obtained from either shops or friends (17). Approximately 60% of cigarettes smoked by year old pupils are obtained from friends with 21% Table 1: A comparison of the smoking habits of and year old pupils in the South West ( ) Smoking habit Year 8 (12 13 year olds) Males (%) Year 8 (12 13 year olds) Females (%) Year 10 (14 15 year olds) Males (%) Year 10 (14 15 year olds) Females (%) I have never smoked at all I have tried smoking once or twice I used to smoke, but I don t now I smoke occasionally (<1/week) Smoke regularly, like to give up Smoke, don t want to give it up Source: Schools Health Education Unit

6 Table 2: Comparison of the sources of last cigarette smoked by and year old pupils in the South West Source of last cigarette Year 8 (12 13 year old) pupils (%) Year 10 (14 15 year old) pupils (%) From shop From friends Given them Parent Stolen Vending machine Other relatives Someone bought them for me Garage Pub Off-licence Other Source: Schools Health Education Unit purchased from shops. The opposite trend occurs for year old pupils with around 59% of cigarettes being purchased from shops and approximately 28% being purchased from friends. Older girls are more likely to buy cigarettes from a shop than older boys. Younger pupils are more likely to steal or obtain them from relatives, while older children are more likely to obtain cigarettes from vending machines, parents, garages, pubs and offlicences. During 2006 the Government undertook a national consultation on under-age sale of tobacco (18). Responses were strongly supportive of this proposal and the raising of the minimum age for buying tobacco from 16 to 18 years of age will be effective from 1 October Bringing the legal age of the purchase of tobacco in line with that of alcohol will reinforce the dangers of smoking to young people, as well as helping retailers comply with the law. While there is little evidence that this will reduce prevalence among young people as a stand-alone measure, it may well contribute to a cultural shift in the acceptability of tobacco use when combined with other measures such as tobacco advertising bans. Marketing cigarettes to young people It is illegal to advertise tobacco products to children and young people under 16. Despite this, the tobacco industry has successfully targeted young people through the association of smoking with adulthood (4). A meta-analysis of nine cohort studies found a positive, consistent and specific relationship between exposure to tobacco advertising and the subsequent uptake of smoking among adolescents (20). Research has shown a positive association between awareness of tobacco advertising and becoming a smoker compared to nonsmoking peer groups (21). Young people take their role models from a wide range of sources, including advertising. Marketing strategies that associate cigarettes with rebellion, self expression, self confidence, independence, freedom, adult identity, masculinity for boys and femininity for girls powerfully reinforce traits that many young people aspire to. The most heavily advertised brands are those that are most commonly mentioned and remembered by teenagers and children. The sponsorship of sporting events has been a powerful way for the tobacco industry to target young people (4). About two-thirds of year olds were able to identify a sport connected with cigarette advertising. Boys whose favourite sport was motor-racing were twice as likely to become regular smokers than those who had no interest in the sport (22). A qualitative study conducted in 2000 (16) found that Lambert and Butler, Sovereign, and Benson and Hedges were the most commonly smoked brands, with consumption driven by price and availability (generally available in packs of 10). The consumption of a strong (high-tar) brand such as Benson and Hedges was seen as an image-enhancing activity by both sexes, especially boys, who were also more likely to be dismissive of light (low-tar) cigarettes. Sibling and peer pressure As Table 3 shows, the uptake of smoking can be a complex process, often involving environmental, sociodemographic, behavioural and individual factors. It is rarely due to a single distinct event. One of the most consistent factors is the influence of peers, family members and siblings (16). Research has also shown that children are three times more likely to smoke if other people at home or a close friend smokes (4). Table 3: Factors associated with the uptake of smoking Environmental Parental smoking Parental attitudes Sibling smoking Family environment/ parental attachment Peer smoking Peer attitudes and norms Sociodemographic Age Ethnicity Source: Effective Health Care Parental socioeconomic status Personal finance Behavioural/ Individual School performance Lifestyle Self-esteem Attitudes to smoking/ smokers Stress Health concerns

7 Evidence from the Schools Health Education Unit, which explores the relationship between the smoking habits of relatives and close friends and those of year old females (Table 4), suggests that smoking prevalence is highest when siblings and close friends are smokers. The children of parents who smoke are almost twice as likely to smoke, whereas children with close friends who smoke are seven times more likely to smoke than those with nonsmoking close friends. Table 4: The relationship of the smoking status of relatives or close friends to the smoking status of females aged in the UK Relationship to smoker % of year old girls who smoke Relative or friend = non-smoker Relative or friend = smoker Mum Dad Brother Sister Close friend 6 45 Source: Schools Health Education Unit Smoking and socioeconomic inequality The link between socioeconomic status and smoking or exposure to tobacco in children aged 4 15 years has been demonstrated through a number of studies (23, 24, 25). Increased levels of smoking in adults are often associated with poor housing, income deprivation, marital status and poor mental health. Figure 4: Percentage of children aged 4 15 with salivary cotinine of 15ng/ml or more by Index of Multiple Deprivation area quintile Percentage st (most deprived) 2nd 3rd 4th 5th (least deprived) Index of multiple deprivation quintile Boys Girls The extrapolation of these values to Local Authority areas in the South West is presented in Table A3 (Appendix A). Across the region around half of young people (aged 4 15) are estimated to live in deprivation quintiles 1 and 2 (most deprived) but in the Peninsula area this rises to 73%. Quintiles 1 or 2 represent 33% of all areas in the South West. Almost 20% of children with a raised salivary cotinine level live in the most deprived 20% of deprived areas (quintile 1). In Torbay, Bristol, Kerrier, Penwith and Plymouth over 47% of children exposed live within wards in the most deprived quintile. The extent of exposure is particularly marked in Torbay, Penwith and Kerrier, where 9 out of 10 (90%) of children live in either quintiles 1 or 2. It is important to note that children with raised salivary cotinine levels also live in more affluent areas that tend to be situated in the North, East and South East of the region. In several locations (Bath & North East Somerset, Cheltenham, Cotswold, South Gloucestershire, Stroud, Tewkesbury and East Dorset), over 20% of children exposed live in the most affluent 20% of wards. In Cotswold, Kennet, East Dorset, North Dorset and South Somerset more than 40% of children with a raised salivary cotinine level live in Quintile 4. Exposure to second-hand smoke Smoking near children is a cause of serious respiratory illness such as bronchitis and pneumonia. The children of parents who smoke are 72 times more likely to get serious chest infections (13, 26). In households where both parents smoke, children may receive a nicotine dosage equivalent to as many as 80 cigarettes a year (27). Bronchitis, pneumonia, asthma and other chronic respiratory illnesses are significantly more common in infants and children who have one or two smoking parents (3). Children with asthma from households with two or more smokers are five times as likely to be off school with breathing problems than their peers from non-smoking homes. Young adults who smoke more than double their chances of developing asthma symptoms (4). Source: Health Survey for England Drawing on data from the 2002 Health Survey for England, Figure 4 shows the relationship between salivary cotinine levels in children aged 4 15 and deprivation, (expressed in terms of their quintile of residence, as categorised by the Index of Multiple Deprivation). The percentage of children in England with raised salivary cotinine levels is highest in deprivation quintiles 1 and 2 (most deprived). In boys, the lowest percentage is associated with quintile 5, and in girls, the lowest percentages are associated with quintiles 3, 4 and 5.

8 Going forward This bulletin has highlighted that smoking is an important issue for the health of children in the South West. While the estimates presented here suggest that the South West is on course to meet the target of reducing the numbers of regular smokers aged to 9% by 2010, there are still substantial numbers of young people smoking about whom there must be real concern. Studies suggest that the majority of year olds who are regular smokers want to give up and are willing to seek help to do so. Currently NHS Stop Smoking services are targeted at adult smokers, who form the majority of their clients, but most services would also support children who seek help to quit. There is evidence to support the effectiveness of community-wide interventions based on social learning theory, social influences approaches, and school-based peer or social type interventions in preventing uptake of smoking in children and young people (29). There is also evidence indicating the effectiveness of increasing the price of cigarettes on reducing consumption and smoking prevalence in young people (29). Research also shows that mass media campaigns, in combination with other interventions, have been shown to reduce smoking prevalence (29). Other approaches, such as reducing supply and underage sales of tobacco to children, can lead to decreases in the numbers of outlets selling to young people, changes in smoking behaviour and ease of access to cigarettes (29). There is growing evidence of the impact of smoke-free public places interventions and legislation, (30, 31) with recent studies showing that young people living in towns with local restaurant smoking bans were much less likely to progress to established smoking than those living in towns with weaker regulations (32). Many factors influence young people s smoking. A wide range of strategies needs to be considered by policy makers and others involved in planning children s and young people s campaigns and services. While deprivation is strongly linked to smoking in young people, it is clear that large numbers of young people living in more affluent areas are also affected. These are important findings when it comes to considering appropriate interventions regionally and locally.

9 Appendix A: Additional tables Table A1: Estimates of the number of male smokers aged in Local Authority areas in the South West Local Authority area Age (years) Total SR SC SR SC SR SC SR SC SR SC Bath & North East Somerset < Bristol North Somerset < Swindon < Plymouth < Torbay < South Gloucestershire < Bournemouth < Poole < Gloucestershire ,287 1,516 Gloucester < Cheltenham <35 <35 < Cotswold <35 <35 < Forest of Dean <35 <35 < Stroud < Tewkesbury <35 <35 < Wiltshire ,001 1,356 Kennet <35 <35 < North Wiltshire < Salisbury < West Wiltshire < Cornwall ,118 1,510 Caradon <35 <35 < Carrick <35 <35 < Kerrier <35 <35 < North Cornwall <35 <35 < Penwith <35 <35 <35 < Restormel <35 <35 < Devon ,566 2,120 East Devon < Exeter <35 <35 < Mid Devon <35 <35 < North Devon <35 <35 < South Hams <35 <35 < Teignbridge < Torridge <35 <35 <35 < West Devon <35 <35 <35 < Dorset ,221 Christchurch <35 <35 <35 < East Dorset <35 <35 < North Dorset <35 <35 < Purbeck <35 <35 <35 < West Dorset <35 <35 < Weymouth & Portland <35 <35 <35 < Somerset ,200 1,624 Mendip < Sedgemoor < South Somerset < Taunton Deane < West Somerset <35 <35 <35 <35 <35 < South West 648 1,626 1,630 2,604 3,576 4,555 5,311 6,301 11,165 15,086 Note: County totals reflect total estimated values. The values in the total column for year olds assume that where a value of less than 35 is specified in any given column, it equals a value of 35. This is done as numbers under 35 are too small to be considered robust estimates. SR = Self response survey; SC = Salivary continine based survey Source: Derived from self-response data in the 2004 National Centre for Social Research and National Foundation for Educational Research survey, and salivary cotinine survey data from the 2002 Health Survey for England. Population data are taken from 2003 mid-year census population estimates.

10 Table A2: Estimates of the number of female smokers aged in Local Authority areas in the South West Age (years) * 15 Total Local Authority area SR SC SR SC SR SC SR SC SR SC Bath & North East Somerset < Bristol ,171 1,181 North Somerset < Swindon < Plymouth Torbay < South Gloucestershire Bournemouth < Poole < Gloucestershire ,751 1,808 Gloucester < Cheltenham <35 < Cotswold <35 <35 < Forest of Dean <35 <35 < Stroud <35 < Tewkesbury <35 <35 < Wiltshire ,369 1,428 Kennet <35 <35 < North Wiltshire < Salisbury < West Wiltshire < Cornwall ,504 1,555 Caradon <35 <35 < Carrick <35 <35 < Kerrier <35 < North Cornwall <35 <35 < Penwith <35 <35 <35 < Restormel <35 < Devon , ,119 2,189 East Devon < Exeter <35 < Mid Devon <35 <35 < North Devon <35 <35 < South Hams <35 <35 < Teignbridge < Torridge <35 <35 < West Devon <35 <35 <35 < Dorset ,155 1,202 Christchurch <35 <35 <35 <35 <35 < East Dorset <35 <35 < North Dorset <35 <35 < Purbeck <35 <35 <35 < West Dorset <35 < Weymouth & Portland <35 <35 < Somerset ,577 1,633 Mendip < Sedgemoor <35 < South Somerset < Taunton Deane <35 < West Somerset <35 <35 <35 <35 <35 < South West 923 1,541 1,844 2,773 4,307 4,307 7,968 6,896 15,042 15,517 Note: County totals reflect total estimated values. The values in the total column for year olds assume that where a value of less than 35 is specified in any given column, it equals a value of 35. This is done as numbers under 35 are too small to be considered robust estimates. SR = Self response survey; SC = Salivary continine based survey * The methodologies used resulted in identical estimates for 14-year-old females. Source: Derived from self-response data in the 2004 National Centre for Social Research and National Foundation for Educational Research survey, and salivary cotinine survey data from the 2002 Health Survey for England. Population data are taken from 2003 mid-year census population estimates. 10

11 Table A3: Estimated percentage of children aged 4 15 with a salivary cotinine level of 15ng/ml or more by quintile of deprivation in each Local Authority area in the South West IMD quintile 1 (most deprived) (least deprived) Local Authority area Bath & North East Somerset Bristol North Somerset Swindon Plymouth Torbay South Gloucestershire Bournemouth Poole Gloucestershire Gloucester Cheltenham Cotswold Forest of Dean Stroud Tewkesbury Wiltshire Kennet North Wiltshire Salisbury West Wiltshire Cornwall Caradon Carrick Kerrier North Cornwall Penwith Restormel Devon East Devon Exeter Mid Devon North Devon South Hams Teignbridge Torridge West Devon Dorset Christchurch East Dorset North Dorset Purbeck West Dorset Weymouth & Portland Somerset Mendip Sedgemoor South Somerset Taunton Deane West Somerset South West Source: Salivary cotinine survey data from the 2002 Health Survey for England. Population data are taken from 2003 mid-year census population estimates. % 11

12 Appendix B: Additional charts Figure B1: Estimated numbers of regular smokers aged in the South West, based on the results of a nationally conducted self-response survey, 2004 Bristol Plymouth South Gloucestershire North Somerset Swindon Bath & North East Somerset South Somerset Bournemouth Poole North Wiltshire Torbay Mendip Teignbridge West Wiltshire East Devon Gloucester Stroud Local Authority Sedgemoor Exeter Taunton Deane Salisbury Cheltenham Restormel West Dorset Kerrier North Devon Kennet Carrick South Hams Forest of Dean North Dorset Caradon North Cornwall East Dorset Tewkesbury Cotswold Mid Devon Weymouth & Portland Penwith Torridge West Devon Purbeck Christchurch West Somerset Females Males ,000 1,100 1,200 Numbers Source: Derived from self-response data in the 2004 National Centre for Social Research and National Foundation for Educational Research survey. Population data are taken from 2003 mid-year census population estimates. 12

13 Figure B2: Estimated numbers of regular smokers aged in the South West, based on the results of a salivary cotinine survey, 2002 Bristol Local Authority Plymouth South Gloucestershire North Somerset Swindon Bath & North East Somerset South Somerset Bournemouth North Wiltshire Poole Torbay Mendip Teignbridge West Wiltshire Gloucester East Devon Stroud Sedgemoor Taunton Deane Salisbury Exeter Cheltenham Restormel West Dorset Kerrier North Devon Kennet Carrick South Hams Forest of Dean North Cornwall Caradon North Dorset East Dorset Tewkesbury Cotswold Mid Devon Weymouth & Portland Penwith Torridge West Devon Purbeck Christchurch West Somerset Females Males ,000 1,100 1,200 Numbers Source: Derived from salivary cotinine survey data from the 2002 Health Survey for England. Population data are taken from 2003 mid-year census population estimates. 13

14 Appendix C: Technical notes and definitions Technical notes The self-reported set of estimates presented in Tables 1 and 2 are calculated by taking the percentage values for year old 2004 data presented by the National Centre for Social Research and the National Foundation for Educational Research and multiplying these with population data taken from 2003 mid-year population estimates from the Office for National Statistics (ONS). The estimates based on salivary cotinine surveys are derived by multiplying the percentage values from the Health Survey for England Data (2002) for year olds with a salivary cotinine level greater than 15ng/ml with the 2003 mid-year population estimates from the ONS. The estimate for the distribution of 4 15 year olds with a salivary cotinine level of 15ng/ml or more by deprivation has been derived by taking percentage estimates for salivary cotinine from the 2002 Health Survey for England and applying these to the population associated with each quintile of deprivation for each Local and Unitary authority areas in the South West. The distribution of young persons with salivary cotinine levels greater than 15ng/ml is shown as a percentage estimate. Definitions Cotinine: is the major metabolite of nicotine. Because it is metabolised and eliminated at a much lower rate than nicotine (cotinine has a half-life in the body of between 16 and 20 hours) it is used as an indicator of smoking status. A salivary cotinine level of 15ng/ml or more is considered to be a reliable cut-off point to indicate that an individual is a regular smoker. A value of less that 15ng/ml indicates that an individual has not smoked or inhaled in the last day or so, but does not preclude infrequent smoking. In this bulletin levels greater or equal to 15ng/ml are referred to as raised salivary cotinine levels. 14

15 References (1) ASH Fact sheet No. 2. Smoking statistics: illness and death. Available from: (2) Goddard E. Why children start smoking. London Social Surveys Division; 1990 (3) The health consequences of involuntary exposure to second-hand tobacco smoke. A report of the Surgeon General, United States Department of Health and Human Services (4) ASH Fact sheet No. 3. Young people and smoking. Available from: (5) Health and lifestyle in the South West: estimates of smoking attributable mortality from lung cancer and vascular disease. SWPHO; September Available from: (6) Department of Health. Smoking, drinking and drug use among young people in England in The Stationary Office; Available from: englandsmoking.pdf (7) Preventing the uptake of smoking in young people. Effective Health Care. 5(5). ISSN (8) Department of Health. Smoking Kills. A White Paper on tobacco. The Stationary Office; November 1998 (9) Choosing Health: Making Healthier Choices Easier. London: Department of Health; 2004 (10) Government Office for the South West. The South West Region Tobacco Control Strategy Available from: docs/166235/ (11) Hill D. Why we should tackle adult smoking first. Tob Control. 1999;8: (12) Smoking, drinking and drug use among young people in National Centre for Social Research; 2004 (13) Tobacco use and the health of young people. Centre for Disease Control and Prevention, US Department of Health and Human Services; May 2004 (14) Smoking and the Young. London: Royal College of Physicians; 1992 (15) Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA. 2000; 284: (16) Need a fag, need a fag. Smoking and young people, Cranborne, Dorset: Kay Scott Associates; July 2000 (17) Trends; young people and smoking. Schools Health Education Unit; 2003 (19) Boreham R, McManus S, eds. Smoking, drinking and drug use among young people in England in London: The Stationery Office; 2004 (20) Lovato C, Linn G, Stead LF, Best A. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. (Cochrane Review) In The Cochrane Library; Issue 3. Chichester: John Wiley & Sons Ltd; 2004 (21) Evans N, Farkas AJ, Gilpin EA, Berry C, Pierce JP. Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking. Journal of the National Cancer Institute. 1995;87: (22) Charlton A, White D, Kelly S. Boys smoking and cigarette-brand sponsored motor racing. The Lancet. 1997;350:1474 (23) Health Survey for England 1998 (24) Health Survey for England 2000 (25) Health Survey for England Volume 1: The Health of Children and Young People. (26) Jarvis M et al. Passive exposure to tobacco smoke: saliva cotinine concentrations in a representative population sample of non-smoking children. BMJ. 1985;291: (27) Smoking, drinking and drug use among teenagers in Volume 1: England. ONS;1989 (28) Statistics on activity undertaken to prevent the sale of tobacco products to children aged under 16 years in England, Trading Standards Department Bulletin 2002:16. August 2002 (29) Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking. Health Development Agency evidence briefing summary (30) Wakefield M, Forster J. Growing evidence for new benefits of clean indoor air laws: reduced adolescent smoking. Tob Control. 2005;14(5):292 3 (31) Wakefield M, Chaloupka FJ, Kaufman NJ et al. Effect of restrictions on smoking at home, at school and in public places on teenage smoking: cross sectional study. BMJ. 321:333 7 (32) Seigal M, Albers AB, Cheng DM, Biener L, Rigotti NA. Effect of local restaurant smoking regulations to progression to established smoking among youths. Tob Control. 2005;14(5): (18) Consultation on under-age sale of tobacco. Changing the age of sale and strengthening sanctions against retailers for under-age sale of tobacco. London: Department of Health; July

16 Related online resources 1. Other titles in the Children in the South West series: Bulletin 1: Stickin out... demographics and deprivation. Available from: Bulletin 2: Family misfortunes: the health of homeless families in the South West. Available from: 2. The national report Indications of Public Health in the English Regions: 5: Child Health, can be downloaded from and the South West regional summary of this report can be downloaded from 3. Other titles in the Indications series (on sexual health, ethnicity and health, lifestyles, and general health) can be downloaded from Bulletin 3: First in line for infection: a report by Health Protection Agency, South West. HPA South West; December Available from: SWPHO Bulletin Further information This bulletin is available online at: Author contact details: Dr Robert Mulliss Public Health Intelligence Analyst South West Public Health Observatory Grosvenor House 149 Whiteladies Road Clifton, Bristol BS8 2RA T: F: E: robert.mulliss@swpho.nhs.uk Fiona Andrews Regional Tobacco Policy Manager South West Regional Public Health Group Government Office for the South West 2 Rivergate, Temple Quay Bristol BS1 6EH T: F: E: fiona.andrews@gosw.gsi.gov.uk About the South West Public Health Observatory The South West Public Health Observatory (SWPHO) is part of a network of regional public health observatories in the UK (funded by the Department of Health) and Ireland. These were established in 2000 as outlined in the Government White Paper Saving lives: our healthier nation. Key tasks include: monitoring health and disease trends; identifying gaps in health information; adivsing on methods for health and health impact assessment; drawing together information from different sources; and carrying out projects on particular health issues. The SWPHO incorporates the National Drug Treatment Monitoring System South West (NDTMS- SW), and in April 2005 merged with the South West Cancer Intelligence Service (SWCIS). The SWPHO works in partnership with a wide range of agencies, networks and organisations regionally and nationally to provide a seamless public health intelligence service for the South West. For more information about the SWPHO and its partner organisations, please visit SWPHO is part of the UK & Ireland Association of Public Health Observatories. South West Public Health Observatory