young people & tobacco training rebecca campbell and sarah lindsay smokefree services nhs...
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Young People & Tobacco Young People & Tobacco TrainingTraining
Rebecca Campbell and Sarah Lindsay
SmokeFree Services
NHS Greater Glasgow & Clyde
E-mail: [email protected]
Welcome!
• Housekeeping
• Informal training, lots of participation
• Smoky Bingo
• Introductions • Aims and ground rules
The course
• Journey from young people starting to smoke, to a successful quit attempt.
• Information on tobacco• Practicalities and techniques for
discussion / support for young people• A session plan / intervention designed by
you and practical presentation to each other.
Young people and smoking:the issues
• Smoking in Scotland
• Young people and smoking
• Smoking prevention action plan
• Tobacco and primary medical services bill
• Current work in NHS GGC
• Gaps to be filled
Smoking in Scotland
• NHS Greater Glasgow and Clyde – highest rates
• 34% of deaths in 35-69 yr olds due to smoking
• Island boards lowest, Shetland 15% and Orkney and WI 16%
• Age of purchase changed to 18 from 16
Tobacco & Young PeopleSmoking prevalence in Scotland
• 2008 SALSUS survey reported that 4% of 13 year olds were regular smokers, 4% occasional smokers
• 15% of 15 year olds were regular smokers (boys 14%, girls 16%), 6% occasional smokers
• This has dropped from 6% (13 yo) & 19% (15 yo) in 2004
• Encouragingly, no. of yp who have never tried smoking went up from 69% to 75% in 13 y.o’s & from 47% to 51% in 15 y.o.’s
Regular smokers among 13 & 15 yo in Scotland by age group & gender 1982-2004
Glasgow schools survey 2007• 9246 secondary school pupils (S1-S4) across 27
Glasgow city schools completed a health and wellbeing survey questionnaire.
• 9.7% smoking on at least some days (S1-S4)• 15.8% smoking on at least some days (S4)• One in 10 pupils in Glasgow was smoking on at
least some days with little variation across CHCPs for this indicator.
• Proportion of all school pupils who smoked on at least some days ranged from 5% at Bellahouston to 20% at Govan.
• Useful data on age of first puff, wanting to stop etc – worth having a look.
• Only Glasgow City
Smoking prevention action plan
• Scotland’s future is SmokeFree, 2008(http://www.scotland.gov.uk/Publications/2008/05/19144342/0)
• Aim: to discourage young people from taking up smoking by making cigarettes and other tobacco products less accessible, less attractive and less affordable to young people.
• Number of measures to further de-normalise smoking including:– Legislating to restrict the display of cigarettes and other
tobacco products at point of sale– Updating statutory controls on the sale of tobacco products,
with a view to introducing licensing and sanctions such as cautions and fixed penalty notices
– Consider the issues surrounding outlawing the sale of cigarettes in packs of 10 and further steps to reducing underage sales from vending machines
– Introducing a scheme for councils to more vigorously enforce tobacco sale laws
– Cracking down on smuggled and counterfeit cigarettes, in collaboration with Her Majesty’s Revenue and Customs
– Working with the UK Government and devolved administrations to consider using plain packaging for cigarettes
– Stepping up education in schools and other settlings to make clear the risks associated with smoking
Tobacco and primary medical services bill
• 3 major control measures – Ban on promotional displays in shops Register of tobacco retailers Ban on cigarette vending machines
Ban of promotional displays
Plan:• To restrict tobacco displays – the tobacco wall – in
shops and supermarkets. Why:• Young people’s smoking habits can be strongly
influenced by tobacco advertising, particularly in shops where it is advertised alongside other household products.
• Restricted media environment so point of sale advertising vital to tobacco companies
• Tobacco companies highlighted that point of sale bans will harm sales
• Evidence from Iceland and Canada shows that smoking prevalence has dropped since this scheme was introduced.
Register of tobacco retailers
• 82% of 15 year old and 47% of 13 year old smokers regularly buy their cigarettes from shops.
• Younger start, harder to quit • 2007, 31.5% shops tested sold tobacco to children• Very few shopkeepers are punished for breaking the law
by selling to children – between 2001 and 2007, only 17 retailers were prosecuted for selling tobacco to underage children.
• Trading standards officers will be able to enforce laws more effectively.
• Offenders fined, repeat offenders – rights to sell suspended
Ban on cigarette vending machines
• 10% of 13 and 15 years get cigarettes from vending machines
• No other age-restricted products available from unmonitored self service vending machines
Plain packaging law
Plan: tobacco firms to sell cigarettes in plain, unbranded packets with
legally mandated information with no logos, colours, and graphics on the packets.
Why?: Due to advertising ban, tobacco companies use elaborate
branding to distinguish them from their rivals. People would abandon more expensive brands like Malbora Strip cigs of their glamour, with less young people taking up the
habit!
What now? Queen’s speech, measure on hold
Older young people report Dec 08• In 2006, 28% of those aged16–24 in Scotland were regular
smokers – an estimated 166,000 young adults. The Scottish Government has set a target to reduce this rate to 22.9% by 2012.
• Young women generally have higher smoking rates than young men in the 16–19 age group. Male rates exceed female rates in the 20–24 age group.
• Half of young adult smokers in2006 were in employment (51%), with 30% not in education, employment or training, (NEET),16% in further or higher education (FE/HE) and 3% at school.
• Need prevent smoking from making up part of social identity.
• Watch this space – East Glasgow CHCP commissioning some local research on this issue.
Current work with NHS GGC• Schools programmes
• Training
• Cessation pilots and pharmacy service
• LAAC pilot
• Youth prevention pilot
• School smoking policies
• Second hand smoke lead and working group
• Ad hoc work in socially deprived areas
Gaps still to be filled from action plan
• Specific targeted work – young women in deprived areas (first pilot being delivered in Inverclyde) the unemployed, those in prison (potential work in Inverclyde), and those in HM Forces.
• Transition work with higher and further education institutions
• Work around the ethos of groups/organisations that young people have contact with, such as no smoking policies in schools etc.
• Working in partnership with parents to change their smoking behavior
• Working in partnership with Trading Standards to ensure test purchasing can take place
Influences on youth smoking
• Substantially higher rates of smoking among 15 year olds associated with:
- a parent or elder sibling who smokes
- living with a single or step parent
- lower levels of parental supervision & more nights out with friends
- Truanting, excluded from school, juvenile offending
• Regular smoking:- is more common among disadvantaged young people, especially girls- is less common among girls of South Asian origin, data from other ethnic groups lacking- strongly associated with use of alcohol & other drugs. E.g. Among 13 yo, 48% of smokers had used other drugs in the previous month compared to 1% of never smokers
Towards a Future Without Tobacco (2006) The Report of The Smoking Prevention Working Group
New evidence
• ‘Forever Cool’ - http://www.bma.org.uk/ap.nsf/content/forevercool
• Candy cigs for kids – 18 Aug 2008 by Cameron Hay, Paisley Daily Express
• Research commissioned locally – watch this space!
New evidence (2)• The school effect - What explains
between-school differences in rates of smoking? Henderson et al, BMC Public Health 2008, 8, 218
• SmokeFree school policies– Exist, but problem with implementation– Smokefree ethos to be promoted through
SmokeFree Me and SmokeFree Class – Youth-led approach required – rather than
imposed upon from above
Resource used with young people: understanding your Smoking
Curiouswanting to give it a go!
Preparing tostart. Buying
cigs and arranging to
meet friends.
Starting
Physically repeating.
Mentally repeating.
Maintaining. You continue
to smoke.
Againstsmoking andnot wanting
to do it!
You might know people that dropped off here.
Most people do not lapse back into the not wanting to stop until they are making a quit attempt.
The Four Whys"a cigarette for the beginner is a symbolic act. I am no longer my mother's child, I'm tough, I am an adventurer, I'm not square … As the force from the psychological symbolism subsides, the pharmacological effect takes over to sustain the habit“ Philip Morris
"hitting the youth can be more efficient even though the cost to reach them is higher, because they are willing to experiment, they have more influence over others in their age group than they will later in life, and they are far more loyal to their starting brand.“
"There is no doubt that peer group influence is the single most important factor in the decision by an adolescent to smoke …Serious efforts to learn to smoke occur between ages 12 and 13 in most case [sic] ….However intriguing smoking was at 11, 12 , or 13, by the age of 16 or 17 many regretted their use of cigarettes for health reasons and because they feel unable to stop smoking when they want to. By the age of 16, peer pressure to initiate others to smoking is gone."
What’s in tobacco?
• 4000 chemicals, 60 of which are known carcinogensNicotine: Addictive partCarbon Monoxide (CO): Poisonous gas, binds to haemoglobinTar: Thick, sticky Arsenic, cyanide, ammonia, acetone,
benzene, formaldehyde, cadmium, hydrogen cyanide etc
Carbon Monoxide monitoring
• Measures the amount of CO in the blood.
• Demo
• Pros and cons of use with young people
What is addiction?
Addiction
• Compulsive physiological and psychological need for a habit-forming substance
• Characterised by compulsive drug seeking & use - even in the face of negative health consequences
• Speed of effect following action
• More addictive than heroin & cocaine• Higher relapse rates• 7 seconds to reach the brain
• 10 puffs, 5 minutes = 200 ‘hits’ per day
Nicotine Addiction
AddictionRapid EffectAction
Blood
Brain
Nicotine Addiction
• What effect does nicotine have?
• Stimulates adrenal glands adrenalin
- increases heart rate, BP, breathing
- release glucose, suppresses insulin
SedativeStimulantNicotine
Nicotine Addiction• Acts on Acetylcholine receptors
- neurotransmitter (chemical messenger)
- rush of ACh, develop new receptors
- if not activated – cravings
• Release Dopamine
- ‘pleasure pathway’
- enjoyment & relaxation
• Tolerance
ADDICTION
The Nicotine Addiction CycleThe Nicotine Addiction Cycle
Emotional
Neurochemical Changes
Habit
Withdrawal symptoms quiz
NICOTINE WITHDRAWAL SYMPTOMS
0 20 40 60 80 100
anxiety
poor concentration
cravings
headache
sleep disturbed
wt gain
%
irritability
urges to smoke
GI upset
Restless
Ref.: U.S. Dept of Health and Human Services. The Health Consequences of Smoking., Nicotine Addiction. A report of the Surgeon General. DHSS publication No. 88-8404 1988
Ref.: U.S. Dept of Health and Human Services. The Health Consequences of Smoking., Nicotine Addiction. A report of the Surgeon General. DHSS publication No. 88-8404 1988
Increased appetite
depression
Pharmacological cessation aids
Nicotine replacement therapy (NRT) is a suitable aid to quitting for those smokers who feel they wish to have support to help them give up.
NRT or bupropion should generally only be prescribed as part of an abstinent-contingent treatment (ACT), in which the smoker makes a commitment to stop smoking on or before a particular date.
Until recently NRT has not been licensed for use in people under 18 years of age unless they have had the product prescribed by their GP. However, this has now changed so anyone above 12 years old can use NRT via local protocols.
Pharmacological cessation aids
NRT releases nicotine into the body thereby… (about half the amount they would get from cigarettes)
• Taking the edge off cravings and withdrawal symptoms, such as anxiety and irritability
• And doubling the chances of quitting
• BUT with young people:
- It may lead to increased addiction
- Assess dependence
- Assess motivation
- Extra ‘buzz’
- Combined with support
Me & My NRT Contract
• I understand that the product is a medicine and will be used by me and only me!
• I will speak to my adviser if I have any questions about my product or if am unsure about it.
• I will use the product as advised.• I agree to collect the product weekly from the Youth Health Service
on a Thursday evening.• I understand that if I do not follow this, my prescription will be
reviewed.
Signed (advisor) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signed (client) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Yeah, but…no BUTTS!
Nicotine Patches
• Stick on the skin• Release nicotine slowly
and steadily to protect against cravings and withdrawals
• Available in different strengths
• Use for 8-12 weeks• Gradually reduce the
strength
Nicotine Gum
• Gum, in different flavours• Chew and ‘park’ –
nicotine is absorbed when the gum is rested in the cheek
• Available in different strengths
• Use for 12 weeks• Gradually reduce the
number of pieces per day
Nicotine Lozenges
• Lozenges, available in different flavours, that dissolve in your mouth
• Nicotine is absorbed through the lining of the mouth
• Available in different strengths
• Use for 12 weeks• Gradually reduce the
number of lozenges per day
Nicotine inhalator
• A plastic tube that you inhale nicotine through. Replaceable nicotine cartridges fit inside the tube
• Helpful for those who miss the action of smoking
• Gradually reduce the number of cartridges over a 12 week period
Microtab
• Sublingual (under the tongue) tablet
• Flexible and discreet• May help people for
whom chewing gum is inappropriate
• Use for 12 weeks gradually reducing
Bupropion
• Bupropion (Zyban® GSK) is a prescription-only drug licensed for use in smoking cessation (with motivational support) in the UK.
• Not prescribed to under 18.• Bupropion is a low dose antidepressant.
Works on reward pathways in the brain.• Bad press on launch but has similar
safety profile to e.g. prozac. Not appropriate for all.
• Side effects: insomnia, dry mouth
Champix®
• Stop smoking aid: no nicotine
• Reduces cravings, reduces effects if you do smoke
• Must be prescribed
• Main side effect: nausea
• Not licensed for under 18
• Mostly 2 tablets per day
The Circle Game
Effects of Smoking on the Body
CSI Sidekix
What damage is smoking doing?
Stroke
Gum disease / tooth loss
Cancer of lips, tongue, throat, larynx, oesophagus
Narrowed arteries
CHD, heart attacks
COPD (bronchitis, emphysema)
Chest infections
Asthma
Lung Cancer
Stomach ulcers
Stomach cancer
Kidney cancer
Bladder cancer
Pancreatic cancer
Skin – healing, wrinkling
Osteoporosis
Impotence
Reduced fertility
Testicular cancer
Cervical cancer
Miscarriage
SIDS
Gangrene
PVD
Macular degeneration
Aesthetics
• Premature ageing
• Bad breath
• Clothes and hair smelling of smoke
• Sexual dysfunction i.e. impotence
• Body weight (Glasgow Uni study and central adiposity)
• Effect on sports performance
http://www.youtube.com/watch?v=DcJy5m36n4o
April software
• Upload photograph, young person can see the effects at any age up to 72
• Can play up – photo exact!
• Hard with large groups
• Doesn’t show effects on eyes and teeth – missed a trick!
• Gimmicky but grabs attention!
If you want a free alternative…1
SMOKER
NON-SMOKER
Source: http://www.roycastle.org/atyc/
Second hand smoke• Environmental Tobacco Smoke (ETS)• Secondhand smoke (SHS) means involuntarily inhaling
other people’s tobacco smoke. • Mainstream: Smoke that has been exhaled by the
smoker• Sidestream: Comes directly from the end of the cigarette • (this type is the most toxic)• 85% of second hand smoke is an invisible gas
• “Carcinogenic to humans” – WHO 2002• “Class A human carcinogen” – U.S. Environmental
Protection Agency 1993 (same group as asbestos & arsenic)
Health effects – children and young
people • Smoking ban = positive impact on health• Concern focussing now on children and infants high levels of
exposure within the home and car.• Smaller airways, faster breathing rates, immature immune
systems. • Infants inhale double the quantity of household dust compared
to adults, and so inhale more dust containing SHS particulates• Infants also have greater hand/ object /mouth contact, and so
absorb proportionately more SHS through ingestion, as well as through inhalation.
• Pre-term birth• Sudden infant death syndrome• Poorer respiratory function• New asthma in children under 5 • Middle ear disease• Higher risk of developing lung cancer as an adult. • UK data suggests that approximately 50% of all children in the
UK are exposed to SHS in the home.
Benefits of quitting
The health benefits start almost immediately….
After…
20mins
• Blood Pressure and Pulse return to normal
8hours
• Nicotine & CO levels in the blood are halved
• Oxygen levels return to normal
After….
24 hours
• CO is eliminated from the body
• Lungs begin to clear tar
48 hours
• Nicotine gone• Taste & smell begin
to improve
After…
72 hours
• Bronchial tubes begin to relax, breathing becomes easier
• Energy levels increase
2 – 12 weeks
• Circulation improves, making physical exertion easier
After…
3 – 9 months
• Coughs and breathing problems improve as lungs have room for up to 10% more Oxygen
1 year
• Risk of heart attack is halved
After…
10 years
• Risk of lung cancer is halved
15 years
• Risk of heart attack same as non-smoker
Medium to Long-Term• Stopping at any age increases life
expectancy as long as it is before the onset of serious disease
• Even with serious disease stopping will mean less strain and a better chance of fighting it
• After an MI, stopping will halve risk of 2nd • Stopping between 65 & 74yrs increases
life expectancy beyond 75
Activity and handout
What are the good things about smoking?
What are the bad things about smoking?
What are the bad things about giving up?
What are the good things about giving up?
Personal Change Journey activity
Behaviour Change
Behaviour Change
Why do people change behaviour?• A health scare
• To attract a partner
• To look & feel better
• A comment by another
• Money
Behaviour Change
‘Behaviour change is a complex process. It is often difficult to achieve and sustain. Health professionals realise that in their work to encourage healthy behaviours, they are competing against powerful influences. These involve social, psychological and environmental conditioning. Information is not enough in order for behaviour change to occur. The benefits of behaviour change must desired and perceived to be obtainable.’
Behaviour Change
“We believe that each person possesses a powerful potential for change. Your task…..is to release that potential , to facilitate the natural change processes already inherent in the individual. In this approach, the client is treated with great respect, and as an ally rather than an opponent.”
Miller & Rollnick, 1993
Cycle of change
PRE-CONTEMPLATIONCONTEMPLATION
READY TO CHANGE
ACTIONMAINTENANCE
RELAPSE
The Cycle of Change
Prochaska & Di Clemente’s cycle of change
• Precontemplation - not thinking about changing• Contemplation – thinking about changing behaviour• Preparation – deciding & preparing to change, but not
yet performing the new behaviour.• Action – Overt behaviour change• Maintenance – six months regular practice of a
behaviour• Relapse – normal occurrence in the stage of change
model
Understanding your smoking
Stages of smoking
AT WHAT STAGE ARE THE SMOKERS IN YOUR GROUP?
• Experimental – smokes irregularly and infrequently• Regular – smokes regularly and habitually• Addicted daily smoker – needs a cigarette quite
soon after waking
The standard test for assessing nicotine dependence is “FAGERSTROM TEST FOR NICOTINE DEPENDENCE” – but how relevant is this for young people?
HONC more relevant
What can you do?
For behaviour change to be successful, and acceptable to the client, it is important that:
• The client “finds” their own solutions to the problem, which fit their lifestyle, finances and family commitments.
• Spend time helping clients to draw up their own action plans.
• Be realistic
• Be supportive
• Remember – relapse is NOT failure, but a part of the quitting journey!
Initial questions you could ask a smoker
• Have you ever thought about smoking and your health?• What are your feelings about smoking?• Are you interested in trying to stop?• Would you like more information?• What might work for you?• What are the pros and cons of your smoking habit just
now?• Would you like support from the local stop smoking
services?• How important is it?• How confident do you feel?• It’s fine if you don’t want to discuss this now, I’ll leave you
this leaflet…
Listening Skills
• What makes a good listener?• Active listening: focus attention on speaker• More listening than talking• Empathy: the ability to share someone else's feelings or
experiences by imagining what it would be like to be in their situation
• Body Language: not distracted• Being quiet: giving time to talk, not interrupting
Active Listening
• Acknowledging: verbal / non-verbal
• Restating / paraphrasing: not repetition & not interpreting what you think the problem is
• Reflecting: reflects feelings, experiences or content
• Summarising / synthesising: bring together feelings & experiences, provide a focus
Questioning
• Vital in finding out information & helping the client look at the issue
• Open Questions: Who, what, why, where, when & how?
• Hypothetical: How do you think you would cope without a cigarette for a day?
• What do you think would help you in that situation? Etc
• But not like an interrogation. Helping them to explore the issue
Motivational Interviewing
• ‘a directive, client centred counselling style for eliciting behaviour change by helping clients to explore & resolve ambivalence.’
• Focused & goal directed• Motivation to change elicited from client not
imposed from without
Smoking Myths
• You could go out & get knocked down by a bus
- Smoking kills 6x more people in UK than RTAs, other accidents, poisoning and overdose, murder, suicide, and HIV infection combined
- 1 in 2 smokers will eventually be killed by their habit, losing on average 8 years
• I smoke lights so I’m doing less damage
-It is now illegal to refer to cigs as light or mild. They do exactly the same damage.
• I’m cutting down
• Motivational Interviewing Exercise
Practical work
• Situation cards exercise – how would you respond?
• Discuss in small group, feedback to main• Practical situations – work with a partner –
practice the sort of questions you would ask a smoker – use the situation card scenarios to help you.
Case study exercise – split into small groups, think about a young smoker you know, How many they smoke, how long they have smoked, type of smoker (social, heavily dependent etc), where they might be in cycle of change, their barriers to quitting, how they could get family/friends to help support quit attempt, appropriate questions, how you would take it forward etc
• Questions?