Smoking intervention for school children

• The adolescent years are extremely important in establishing an

individual’s lifetime smoking or non-smoking behaviour (“Smoking”, 2012)

• It is reported that around 40% of regular smokers began smoking before they were 16 (Office for

National Statistics, 2013).• There is evidence that a younger age of smoking initiation carries

additional risks of lung damage (Wiencke et al., 1999).• Those people who take up smoking before the age of 15 have double the

risk of lung cancer as those starting at the age of 20 or later, after taking into account the amount smoked (Peto et al, 2000).

• Previous interventions have focussed mainly on adult smokers (Stoptober, SmokeFree Quit Pack etc.)

Rationale

Prevalence• Around 207,000 children aged 11-15 start smoking every year• By the age of 15, 11% of children in England report being regular smokers.• However, due to self-reports, it is thought that this rate may be a lot higher

(as high as 21% in males and 19% in females)

(The NHS Information centre for health and social care, 2012)

• Opinion that smoking enhances attractiveness as a result of advertising (Bearden & Etzel, 1982)• Role models: parents (Kardia et al., 2003; Rossow & Rise, 1994; Fergusson et al, 2007), older siblings, peers, celebrities.

• Misconception that smoking helps to relieve stress (Hardy, 2013).• Cigarette packaging has been found to attract young people (Hastings,

Galopel-Morvan & Rey, 2008; Wakefield & Letcher , 2002; Wakefield, Germain &Durkin, 2008)

Why do children begin smoking?

Costs Benefits

Children smoking •Poorer health: more likely to be absent from school due to colds, bilious attacks, stomach upsets, influenza, headaches etc (Charlton & Blair, 1989)•Increased likelihood of lung disease and lung cancer in later life (Wiencke et al., 1999)•More likely to leave school early (Charlton, 1984).•Costs the NHS a lot of money

•Perceived as “cool”.•Perceived ability to cope with stress.

Children not smoking •Perceived social exclusion •Reduction of health risks•Individuals are more likely to continue not smoking throughout adulthood

COM-B Model

Capability

Motivation

Opportunity

Children might be taught to smoke by peers

Children are motivated to smoke by peers initially and then motivation might come from the addictive affects of nicotine.

Children have the opportunity to smoke if family members or older peers smoke, however it is illegal to provide cigarettes to children under 18.

Information can be provided for parents who smoke and warn them about the affects of allowing their children to smoke.

Children who smoke should be warned against trying to get other children to take up smoking.

BehaviourChildren should be taught about the negative affects of smoking and how addictive it can be. This should take some motivation away.

Leading to smoking behaviour

Leading to non-smoking behaviour

Theory of Planned Behaviour (Ajzen, 1985)

•Based on the idea that people behave in a way that they intend to behave.•A behavioural intention is made up of a persons attitudes, what they perceive to be the norm, and their perceived behavioural control over a situation.•Therefore if these aspectsof smoking are changed their behavioural intention (to smoke in the future) will alter.

The proposed intervention will therefore address these 3 aspects.

Stage 1: Teaching sessions• Sessions will involve children in discussing their views of smoking, their

knowledge of the harmful effects of smoking, and how prevalent they think smoking is in school.

• Older peers (non-smokers, smokers who have quit) will teach facts about smoking, showing children that smoking causes more harm than they might think and how difficult it is to quit smoking once started. • Involving older peers will be more effective than teacher-led sessions.• This stage will address all three components of the TPB model: the

behavioural attitude component will be addressed through children becoming more aware of the negative affects of smoking. Subjective norms will be addressed through the older peer explaining that smokers are a minority. The perceived behavioural control component will be

addressed by training children to say no to cigarettes.

Stage 2: Anti-smoking magazine• Children will be given an anti-smoking magazine to take home

which will remind them of the points raised in the group discussion.

• Pages will include smoking statistics, celebrities who are opposed to smoking and who have quit smoking, and real life stories.Stage 2 will address the behavioural attitude component again because physical images and data will show the effects of smoking. Subjective norms will also be addressed because celebrity role models will talk about their decisions not to smoke.

Stage 3: Parent information• Information letters will be sent to

parents of children in the intervention group.

• Parent modelling is considered one main mechanism of children's smoking initiation (Engels et al, 1997; Flay et al, 1994; Chassin et al., 1996; Distefan et al., 1998; Flay et al, 1998; Engels & Knibbe, 1990)

• According to Social Learning Theory (Bandura, 1977) modelled behaviour can be acquired through children’s memories of their parents’ past behaviour.

• Subjective norms will be addressed and there will be an impact on parents smoking in front of children.

How will we test the intervention’s effectiveness

• 1 school will take part in the prevention programme and another will not.• 5 year longitudinal study• Participants will be matched on gender, smoking status, number of smoking family

members.• Adapted- National Youth Tobacco Survey Questionnaire ( administered at T0 (start of year

7) and then once at the start and end of each academic year

• All students will be offered anonymous counselling to help them quit smoking if they so wish.

Year 7 Year 8 Year 9 Year 10

Year 11

% smokers 1 2 4 5 5

Behavioural attitude

Subjective norms

Perceived behavioural control

Year 7 Year 8 Year 9 Year 10

Year 11

% smokers 1 3 6 10 11

Behavioural attitude

Subjective norms

Perceived behavioural control

Results of school 1 (No intervention) Results of school 2 (Intervention)

Higher scores indicate a more negative attitude towards smoking (34), the belief that smoking is not the norm (27), and a greater perceived behavioural control over not staring to smoke (29).

References:Ajzen, I. (1985). From intentions to actions: A theory of planned behaviour. In J. Kuhl & J. Beckman (Eds.). Action Control: From Cognition to

Behaviour (pp.11-39). Heidelberg: Springer. Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall.Bearden, W.O., & Etzel, M.J. (1982) Reference group influence on product and brand purchase decisions. Journal of Consumer Research, 9,

183–94.Charlton, A. (1984). Children’s coughs related to parental smoking. British Medical Journal, 288, 1647-1649.Charlton, A., & Blair, V. (1989). Predicting the onset of smoking in boys and girls. Soc Sci Med, 29, 813-818.Chassin, L., Presson, C.C., Rose, J.S., & Sherman, S.J. (1996). The natural history of cigarette smoking from adolescence to adulthood:

demographic predictors of continuity and change. Health Psychology, 15, 478-484.Distefan, J.M., Gilpin, E.A., Choi, W.S., & Pierce, J.P. (1998). Parental influences predict adolescent smoking in the United States. Journal of

Adolescent Health, 22, 466-474.Engels, R.C.M.E., & Knibbe, R.A. (1999). Influences of parental and best friends’ smoking and drinking on adolescent use: a longitudinal study.

Journal of Applied Social Psychology, 29, 337-361Engels, R.C.M.E., Knibbe, R.A., Drop, M.J., & De Hann, Y.T. (1997). Homogeneity of cigarette smoking within peer groups: influence or

selection? Health Education and Behaviour, 24, 801-811.Fergusson, D.M., Horwood, L.J., Boden, J.M., Jenkin, G. (2007). Childhood social disadvantage and smoking in adulthood: results of a 25-year

longitudinal study. Addiction, 102, 475-482.Flay, B.R., Hu, F.B., & Richardson, J. (1998). Psychosocial predictors of different stages of cigarette smoking among high school students.

Preventive Medicine, 27, A9-A18.Flay, B.R., Hu, F.B., Siddiqui, O., Day, L.E., Hedeker, D., Patraitis, J., Richardson, J., & Sussman, S. (1994). Differential influence of parental smoking and

friends’ smoking on adolescent initiation and escalation of smoking. Journal of Health and Social Behaviour, 35, 248-265.General Lifestyle survey overview: A report on the 2011 general lifestyle survey. (2013). Office for National Statistics.Hardy, M. Nicotine relieves stress. Retrieved November 10, 2013, from http://stress.lovetoknow.com/Nicotine_Relieves_StressHastings G, Galopel-Morvan K, Rey JM. The plain truth about tobacco packaging. Tob Control 2008;17:361-362Kardia, S.L., Pomerleau, C.S., Rozek, L.S., & Marks, J.L. (2003). Association of parental smoking history with nicotine dependence, smoking rate,

and psychological cofactors in adult smokers. Addict Behav, 28, 1447-1452.Ling, P., Landman, A., & Glantz, S.A. (2002). It is time to abandon youth access tobacco programmes. Tobacco Control, 11, 3-6.National Youth Tobacco Survey 2012. Retrieved November 20, 2013, from http://cdc.gov/tobacco/data_statistics/surveys/nyts/Peto, R., Darby, S., Deo, H., Silcocks, P., Whitley, E., Doll, R. (2000). Smoking, smoking cessation, and lung cancer in the UK since 1950:

combination of national statistics with two case-control studies. BMJ, 321, 323-329.Rossow, T., & Rise, J. (1994). Concordance of parental and adolescent health behaviours. Soc Sci med, 38, 1299-1305.Smoking. (2012). Retrieved November 18, 2013, from http://www.cancerresearchuk.org/ cancer- info/cancerstats/types/lung/smoking/#source23Smoking, drinking and drug use among young people in England in 2011. (2012). The NHS Information Centre for Health and Social Care.Wakefield M.A., Germain, D., Durkin, S.J. (2008). How does increasingly plainer cigarette packaging influence adult smokers' perceptions about

brand image? An experimental study. Tob Control,17, 416-21 Wakefield, M.A., & Letcher, T. (2002) My pack is cuter than your pack. Tob Control,11,154-156. Wiencke, J.K., Thurston, S.W., Kelsey, K.T., Varkonyi, A., Wain, J.C., Mark, E.J., & Christiani, D.C. (1999). Early age at smoking initiation and

tobacco carcinogen DNA damage in the lung. J Natl Cancer Inst, 7, 614-9.