Smoking tobacco continues to be the single biggest cause of preventable mortality – with nearly 80 000 preventable deaths estimated to be caused by smoking in England alone in 2017 (NHS Digital, 2019). It is also a major driver of health inequality, accounting for around half of the difference in life expectancy between the richest and poorest in the UK (Scottish Government, 2013; Department of Health and Social Care, 2017). Smoking is a behaviour that is mainly started in adolescence; 77% of 16–24 year old smokers in 2014 had started smoking before the age of 18 (Department of Health and Social Care, 2017), and so preventing uptake of smoking by young people is a key mechanism to reducing adult health inequality and preventable mortality.
The latest UK Tobacco Control Plan, ‘Towards a smoke free generation’ (Department of Health and Social Care, 2017) has four key objectives, to be achieved by 2022:
- Reduce the number of 15 year olds who regularly smoke from 8% to 3% or less
- Reduce smoking among adults in England from 15.5% to 12% or less
- Reduce the inequality gap in smoking prevalence, between those in routine and manual occupations and the general population
- Reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less.
Nurses who work with children, adolescents and their families have a key role to play in supporting the achievement of a smoke free generation. They can help:
- Children to not start smoking by providing high-quality, evidence-based health promotion programmes, activity and messaging
- Children and adolescents not to continue smoking (whether they have experimented or become regular smokers) by providing evidence-based messaging, very brief advice and referral or evidence-based smoking cessation intervention
- Parents and carers in stopping smoking, or stopping it in the house or car, or around children, by ensuring that every intervention with parents/carers who are known to smoke includes health promotion messaging, very brief advice and referral or recommendation to adult local, regional or national Stop Smoking Services
- Those who become pregnant during adolescence by providing clear, evidence-based information, very brief advice and referral to a local Stop Smoking in Pregnancy Service.
Prevention of smoking uptake
Children become addicted to tobacco and smoking within 4 weeks of starting smoking (DiFranza, 2000), and often start smoking because they have been exposed to adults smoking in their lives, ‘normalising’ the behaviour. Children who live with parents or siblings who smoke are up to three times more likely to start smoking themselves (Leonardi-Bee et al, 2011). Approximately 200 000 children start smoking in the UK each year (Hopkinson et al, 2013), many of whom will become addicted and will go on to become adult smokers. A total of 40% of adult smokers in 2011 stated they had started smoking regularly before the age of 16 years old, around two thirds before 18 years old, and over 80% by the age of 20 years old (Department of Health and Social Care, 2017). Preventing uptake of smoking requires a holistic, concentrated and focused approach across agencies.
‘Children become addicted to tobacco and smoking within 4 weeks…and often start smoking because they have been exposed to adults smoking in their lives, ‘normalising’ the behaviour. Children who live with parents or siblings who smoke are up to three times more likely to start smoking themselves’
School nurses can undertake a very brief advice session with a smoker, following the Ask, Advice, Act steps.
‘…nurses can support reducing access to tobacco and smoking products by working with local communities or local Trading Standards, among others, to embed and implement proof of age programmes…’
There is limited evidence of long-term impact for any intervention with the exception of:
- Mass media campaigns
- Reducing access to tobacco and smoking products
- The ASSIST school/peer-based programme.
While it is not possible for any individual or nursing team to change the price of tobacco or smoking products locally, or to instigate national or regional mass media campaigns, nurses can support reducing access to tobacco and smoking products by working with local communities or local Trading Standards, among others, to embed and implement proof of age programmes and to encourage local community vendors not to sell tobacco or smoking products to those who are underage. They can also get involved with any local Tobacco Control Alliance (if there is one, the details will be available from the Local Authority Tobacco Control lead).
Nurses can ensure they take all opportunities to talk to children, young people and parents about tobacco use, ensuring that messaging to children and young people is consistent. This may include messages such as ‘the best thing you can do if you have never tried smoking is to keep avoiding it’ and ‘if you have experimented once or twice, the best thing you can do is not do it any further’. Looking at the reasons why children feel they may be tempted to try, and helping them to model avoidance can be helpful. For example, a child may feel pressured by others to smoke and benefit from practice saying no to the offer.
In addition, nurses have a duty to continue to provide evidence-based advice to the children and families they serve. Nurses can make sure they are providing accurate information by undertaking the free courses available from the National Centre for Smoking Cessation Training (NCSCT, 2021).
Smoking cessation
All nurses should be able to undertake a very brief advice session with a smoker, leading to a referral or a recommendation to a qualified stop smoking adviser. In the UK, a qualified stop smoking adviser is someone who has completed the NCSCT practitioner training and who can be identified via the practitioner register at https://www.ncsct.co.uk/practitioners.php.
The advice should consist of a number of steps, Ask, Advise, Act.
Ask
This step aims to assess current and past smoking behaviour, and includes questions such as ‘are you ever smoking or using nicotine or tobacco at all currently?’, ‘have you ever?’, ‘when was the last time you smoked, even a puff?’
Advise
This step includes explaining that the best thing for the person's health, wealth and wellbeing is to stop smoking as soon as possible. There are really effective methods available via the NHS, for free, to maximise chances of stopping smoking for good. The nurse can help them access the most effective method of stopping smoking.
Act
Make the referral for the person to the Local Stop Smoking Service, if available. If possible, arrange to follow up with them to find out how they have got on, and provide support while they continue through the programme. Most programmes last for 6–12 weeks and provide a combination of behavioural support and evidence based medicine (Nicotine Replacement Therapy, Varenicline or Bupropion). Programmes are usually abstinence based, predicated on setting a quit date, the date on which the person plans never to smoke again, not even a puff. ‘Success’ is measured at 4 weeks subsequent to the quit date and is described as either 4-week quit, not quit or lost to follow up. A 4-week quitter is defined as someone who reports abstinence (not even a puff) between weeks two and four from the target quit date, verified by an expired air CO concentration of less than 10 parts per million (NCSCT, 2014). Relapse curves have been well established over years of rigorous research in smoking cessation, meaning that a biochemically validated 4-week quit outcome can be used to predict long-term abstinence (even given the relatively short follow up period of 2–4 weeks).
Vaping
Vaping is a term used for the use of electronic cigarettes, devices that simulate tobacco smoking, but where a harmless, often flavoured, vapour is inhaled, rather than smoke. Around 16% of 11–18 year olds have ever tried vaping (NHS, 2017; Action on Smoking and Health, 2019). There is evidence that young people who vape before they have ever smoked are significantly (up to five times) more likely to go on to smoke (Khouja et al, 2020).
Electronic cigarettes containing nicotine are helpful, alongside behavioural support, in helping people stop smoking (Hartmann-Boyce et al, 2020), but should not be used by those who have never, or do not, smoke.
Conclusion
Nurses who work with children, young people and their families have a unique role to play in supporting people to not smoke, or to quit, by providing clear, evidence-based advice, information and intervention. Tobacco Control is a primary function of public health nurses, who have a duty to remain up to date with both the appropriate content, context and methods of intervention. This can be easily managed through the use of credible sources of training and information, such as those provided by NCSCT.
‘Nurses who work with children, young people and their families have a unique role to play in supporting people to not smoke, or to quit, by providing clear, evidence-based advice, information and intervention’