Young People in Liverpool: Synthetic Estimates of Smoking Prevalence

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2 Young People in Liverpool: Synthetic Estimates of Smoking Prevalence Introduction Smoking continues to be a major public health concern in England and is one of the main causes of disease and death (Department of Health, 2010). In October 2007 the law on selling tobacco products in England and Wales was updated and the minimum age for the sale of such products increased from 16 to 18 years (HM Government, 2007) but young people aged less than 18 continue to smoke in the UK. According to the latest results from the Smoking, Drinking and Drug Use among Young People in England survey (National Centre for Social Research, 2010), which collects data on 11 to 15 year olds, 29% of boys and 30% of girls surveyed had tried smoking at least once in their lives, with the likelihood of smoking increasing with age. Girls were significantly more likely than boys to be regular smokers (categorised as smoking at least one cigarette per week); 7% and 5% respectively, while older pupils were significantly more likely to smoke regularly than their younger counterparts. Consequently, while only 0.5% of 11 year olds reported being regular smokers, this proportion had increased considerably to 15% by the age of 15. Experimental smoking in childhood increases the likelihood of smoking in adolescence and those who smoke before the age of 16 are twice as likely to continue smoking as those who start smoking when they are older (British Medical Association, 2007). Furthermore, those who start smoking at an early age are likely to smoke more heavily than those who start smoking later, and also find it harder to quit (British Medical association, 2007). Consequently, preventing children from smoking is an important public health priority. However, smoking does not affect all groups of society equally, with higher prevalence being observed among those of lower socioeconomic status. There is evidence from the USA to show that the effect of socioeconomic status on smoking accumulates over the lifespan. More specifically, analysis of data from a prospective study reported a significant association between lower socioeconomic status in childhood and the likelihood of smoking initiation, while both childhood and adult socioeconomic status was significantly associated with becoming a regular smoker and being less likely to quit (Gilman et al., 2003). 2

3 The aim of the current piece of work is to estimate the prevalence of smoking among those aged 15 and 16 years across Liverpool. Data to support the current research are taken from a survey of school children conducted in the North West of England during Methodology In March and April 2009, an anonymous cross-sectional self-completed school survey was conducted to investigate smoking and drinking patterns of young people who live in the North West region. The survey was conducted in 21 of 22 North West Trading Standard (local authority) areas and consisted of closed questions including demographic data (age, sex, postcode of residence) and information on alcohol consumption and smoking behaviour. Both school and student participation was voluntary. School staff delivered surveys to students in years 10 and 11 (ages 14 to 17) within normal school hours. Sampling ceased when 133 public and private schools (21% of the North West total of 620) had participated. A total of 13,903 surveys were completed; the sample was then restricted to those aged 15 or 16 for analysis (N = 11,879). Survey respondents were asked to provide a single answer, from a list of categories, that best described their current smoking behaviour; these categories were aggregated in order to derive a dichotomous indicator. Students were recorded as a current smoker if they classified themselves as any of the following: 1) I only smoke when drinking alcohol, 2) I smoke less than five per day, 3) I smoke six to ten per day, 4) I smoke 11 to 20 per day, or 5) I smoke more than 20 per day. Students were recorded as a current non-smoker if they classified themselves as any of the following: 1) I have never tried smoking, 2) I have tried smoking but did not like it, or 3) I used to smoke but have given up. In order to calculate a level of deprivation for each respondent, postcode of residence was mapped to Lower Super Output area (LSOA), with all LSOAs in England having an Index of Multiple Deprivation value. Where an individual s postcode was unavailable (N = 3,166; 26.7%), school postcode was used as a proxy. The Index of Multiple Deprivation value for each student was then categorised as follows 1) below or equal to 10, 2) 11 to 20, 3) 21 to 30, 4) 31 to 40 and 5) greater than 40, with category one being the most affluent areas and category five the poorest. 3

4 Data were restricted to Merseyside and a backwards stepwise binary logistic regression model was used to identify the relationship between smoking status and three variables: gender, age and deprivation quintile (N = 1,994). The results of this analysis showed that age was not significantly associated with whether or not the survey respondent was a current smoker, while gender (P<0.01) and deprivation quintile (P<0.05) were (Table 1). Consequently, when estimating the prevalence of smoking among people aged 15 and 16 in each Middle Super Output Area (MSOA) of Liverpool by applying the modelled effects to the population structure of individual MSOAs, only the effects of gender and deprivation quintile were considered. Population weighted MSOA level deprivation scores were derived by summing LSOA level data. Table 1: Logistic regression analysis for the effect of age, gender and deprivation on smoking status among 15 and 16 year olds in Merseyside Variable Exp (B) 95% confidence interval P value for the exp (B) Gender Female Reference Male <0.001 Deprivation quintile (most affluent) 1 Reference NS NS NS (poorest) <0.001 Age was not significantly associated with smoking status. NS = not significant. Results The estimated prevalence of smoking among males and females aged 15 and 16 years by MSOA is shown in Table 2. See Figure 1 for details of the location of each MSOA. In total, an estimated 8.1% of males and 12.7% of females in Liverpool aged 15 and 16 smoke. 4

5 Table 2: Estimated prevalence (percentage) of smoking among 15 and 16 year olds in Liverpool, by Middle Super Output Area MSOA code Estimated prevalence (percentage) of smoking Males Females

6 Table 2: Estimated prevalence (percentage) of smoking among 15 and 16 year olds in Liverpool, by Middle Super Output Area (table continued from previous page) MSOA code Estimated prevalence of smoking as a percentage Males Females Liverpool

7 "Crown copyright. All rights reserved. NWPHO/DH (licence ). February 2010." Figure 1: Location of Middle Super Output Areas in Liverpool Discussion Here we provide estimates for smoking prevalence for males and females aged 15 to 16 years in Liverpool by Middle Super Output Area (MSOA). The areas with the highest estimated smoking prevalence are MSOAs 002, 003, 013, 033, 048 and 052; an estimated 9.7% of boys and 15.1% of girls aged 15 and 16 who live in these areas smoke. 7

8 In total, an estimated 8.1% of males and 12.7% of females in Liverpool aged 15 and 16 smoke. These figures for Liverpool are encouraging in light of recent estimates for England suggesting that 15% of 15 year olds smoke regularly (National Centre for Social Research, 2010), although care should be taken when making comparisons due to differences in the definition of what constitutes smoking. Furthermore, previous research using the 2007 Trading Standards survey reported that 22.5% of people aged 15 and 16 in the North West were current smokers (Atkinson et al., 2009). The Trading Standards survey used to derive the estimates presented here was school based and 15 and 16 year olds not in school were therefore not surveyed; the actual smoking prevalence among all young people in Liverpool could be slightly different if the smoking behaviour of those not in contact with schools differed systematically from those who were included in the survey. For males aged 15 and 16, the proportion who were current smokers ranged from 7.6% to 9.7%, while for females the prevalence estimates ranged from 12.0% to 15.1%. This gender difference was is unsurprising in light of the body of evidence to show higher rates of smoking among young females in the UK. When controlling for the effects of a variety of other factors, it has been reported that, among those aged 11 to 15, the odds of a girl being a regular smoker are 2.35 times the odds of boys (National Centre for Social Research, 2010). While smoking among those aged 11 to 19 has fallen in recent years (Office for National Statistics, 2008; National Centre for Social Research, 2010) the estimates presented here demonstrate that a proportion of young people aged 15 and 16 in Liverpool continue to smoke. For many people, smoking initiation occurs during school years, and rates continue to rise until people reach their mid-twenties (Office for National Statistics, 2008). Consequently, schools (including pupil referral centres, further education colleges, city technical colleges and so on) are institutions where smoking prevention work occurs. In light of this, the National Institute for Health and Clinical Excellence (NICE) produced guidance on school based interventions to prevent the uptake of smoking among children and young people. Their five recommendations are as follows: The smoking policy should support both prevention and stop smoking activities and should apply to everyone using the premises (including the grounds). 8

9 Information on smoking should be integrated into the curriculum. For example, classroom discussions could be relevant when teaching biology, chemistry, citizenship and maths. Anti-smoking activities should be delivered as part of personal, social, health and economic (PHSE) and other activities related to Healthy Schools or Healthy Further Education status. Anti-smoking activities should aim to develop decision-making skills and include strategies for enhancing self-esteem. Parents and carers should be encouraged to get involved and students could be trained to lead some of these programmes. All staff involved in smoking prevention should be trained to do so. Educational establishments should work in partnership with outside agencies to design, deliver, monitor and evaluate smoking prevention activities. (National Institute for Health and Clinical Excellence, 2010). People who start smoking at an early age are more likely to smoke for a longer time and are more likely to die from a smoking related disease than people who start smoking later in life (British Medical Association, 2007). According to the most recent General Lifestyle Survey, 42% of men and 37% of women who had ever been a regular smoker had started to smoke before the aged of 16 (Office for National Statistics, 2011). Consequently, prevention of smoking initiation continues to be a priority. The findings presented here demonstrate the need to continue to focus upon strategies to prevent and reduce smoking among school aged children living in Liverpool. Acknowledgements Thanks go to Ian Jarman for his support with the statistical analysis, Sacha Wyke and Karen Murphy for creating and checking the population data, to Neil Potter for producing Figure 1, to Martin Chandler, Adam Marr, Charlie Gibbons and Dave Seddon for proof reading the report and to Lee Tisdall for designing its cover. 9

10 References Atkinson A, Bellis M, Hughes K, Hughes S, Smallthwaite L (2009). Smoking behaviour in North West schoolchildren: a study of fifteen and sixteen year olds. Liverpool: Centre for Public Health. British Medical Association (2007). Breaking the cycle of children s exposure to tobacco smoke. London: British Medical Association. Department of Health (2010). Healthy lives, healthy people: Transparency in Outcomes. Proposals for a Public Health Outcomes Framework. A consultation document. London: Department of Health. Gilman SE, Abrams DB and Buka SL (2003). Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation. Journal of Epidemiology and Community Health, 57, HM Government (2007). Children and Young Persons (Sale of Tobacco etc.) Order National Institute for Health and Clinical Excellence (2010). School-based interventions to prevent the uptake of smoking among children and young people. London: National Institute for Health and Clinical Excellence. National Centre for Social Research (2010). Smoking, drinking and drug use among young people in England in London: National Centre for Social Research. Office for National Statistics (2008). General household survey. Smoking and drinking among adults, Newport: Office for National Statistics. Office for National Statistics (2011). Smoking and drinking among adults, Newport: Office for National Statistics. 10

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