Publication
National survey of tobacco-related work with young people
8. Summary, discussion and conclusions
Summary
Are there strategies and approaches which underpin tobacco-related work with young people in Scotland?
Less than half of respondents reported organisational strategies relating to tobacco-related work with young people. Only 7% of respondents highlighted strategies relating specifically to this issue, although a further 41% felt it was incorporated in a broader based young person strategy. Nearly two-thirds of respondents (63%) were able to identify links in their work to broader national or local strategies, although smoking specific strategies did not predominate. Respondents' feedback indicated limited salience of an evidence base in informing practice in this area of work. There appears to be a reasonable level of inter-agency working, with only 2% of respondents not having contact with other agencies.
How are key areas of work addressed across Scotland?
The greatest levels of reported involvement were in the area of prevention and education (69% of respondents), followed by cessation (47%) and enforcement (23%). There were low levels of involvement in training provision (20% in-house and 10% for other agencies) and the development of support materials (14% for internal use and 9% for other agencies).
In relation to prevention and education, over half (59%) of those who worked in this area felt that their activities were targeted directly at those within the 10-20 year old age range. Activities tended to be generalised such as providing materials to users / clients and awareness raising.
Work incorporating youth smoking cessation was reported by less than half the respondents, and only half of these stated that they undertook activities targeted directly at the 10-20 year range (50 respondents). Providing smoking cessation materials to service users is the highest reported area of involvement (56% of those currently undertaking cessation work). Of the range of approaches described, structured support groups or classes were most frequently highlighted but only in around a quarter of activities. Importantly, only a small number of these focussed on young people, with ten youth specific cessation programmes reported across Scotland. Less structured general support, one-to-one interactions, and opportunistic approaches which might also make an appropriate contribution were also described but at lower levels.
Areas of planned new activity in relation to prevention and cessation appear to be in the youth work and FE/HE sectors, together with electronic based activities such as internet sites. Planned activity in youth cessation also focussed on school settings.
For enforcement activities, the majority of respondents are from trading standards departments, with a very small number scattered across other sectors. Enforcement and support of underage sales regulation is the most common activity, involving 54% of respondents. Relatively little new activity was planned, although respondents indicated a wish to undertake 'test purchasing' as part of enforcing underage sales regulation, currently halted pending results of the Lord Advocate's review.
In terms of training, only a minority (36%) had received some form of training, primarily those in health promotion and primary care. The main sources of training were local Health Promotion Departments (51% of training recipients) with Fast Forward, HEBS and ASH mentioned by much lower numbers. Tobacco awareness (38%) and smoking cessation (36%) form the bulk of training experienced.
In relation to provision of training, 20% of respondents stated that their organisation provided in-house training and 10% indicated that they provided training for other agencies. Main reported targets were youth workers, leaders and community educators (38%).
Development of support materials either for internal or external use was reported by 18% of respondents, mainly resource packs and leaflets/booklets.
What activities are undertaken among nationally based organisations?
Nationally based organisations who responded included national and UK tobacco-related agencies, agencies focusing on cancer, asthma or the well-being of young people, 'uniformed' organisations and agencies with a broader health remit. As with other agencies, the nationally based organisations' work with young people was most likely to include prevention/education activities (50%), followed by cessation (32%), enforcement (23%) and provision of training and materials (around 20%). A relatively large proportion indicated they were involved in campaigning and lobbying activities (around 30%).
In describing individual activities, only a few mentioned approaches which had a national spread. In general, localised activities were more commonly reported including local young people and youth leader training events.
What is the scope of tobacco-related work with young people across geographical areas of Scotland?
NHS Board areas were used as convenient geographical units. Prevention and education activity across the NHS Board areas was broadly similar to the national level of 69% reporting this kind of work, but relatively higher proportions reported preventive activities in Tayside, Fife, Lanarkshire and Dumfries and Galloway. Young people specific activities were proportionately higher in Argyll and Clyde, Lanarkshire, Forth Valley and Ayrshire and Arran.
Recording of cessation activities across the NHS Board areas tended to be closer to the national proportion of 47%. However, higher levels are apparent in Dumfries and Galloway, Grampian and Forth Valley. More positive ratios towards young people specific activities are observed in Highland, Argyll and Clyde, Ayrshire and Arran and Forth Valley.
In relation to enforcement, recorded involvement is relatively higher than the total proportion (23%) in Ayrshire and Arran, the Islands and Lothian. Provision of training was at a relatively low level overall but reporting of in-house training was relatively higher in Grampian and Dumfries and Galloway, and training for other agencies was higher in Dumfries and Galloway, the Islands and Forth Valley.
Development of materials for internal use was at a low level, but was more likely to be reported in Tayside and Ayrshire and Arran, largely reflecting activities in the youth sector. There was little geographical variation from the overall reporting of 9% involvement in developing materials for other agencies. There was no reporting of each of these activities respectively in four NHS Board areas.
Discussion
The survey identified a considerable range of tobacco-related work with young people across Scotland and across the various agencies contacted. It appears there is considerable interest in this issue, as reflected in the commitment to the study, and there are positive indications of innovative approaches and increased planned activity. However, it should be remembered that when viewed from the perspective of individual young people spread across the country, the spheres of influence are relatively low, and the survey suggests there will be local areas with no workers or activities with a tobacco-related interest and focus.
A very varied picture emerged across and within agency types. Health promotion departments, and to a slightly lesser extent, trading standards, were the only agency types that consistently claimed involvement in this area. Within primary care, youth work, SIPs, DATs and nationally based organisations, the picture was more varied. Involvement in tobacco-related work with young people was more ad hoc and appeared to reflect local organisational priorities together with the interests of individual workers, as well as inter-agency working and support, including more structured 'alliances'. Nationally based youth organisations with a broad reach across Scotland might be a useful target group (40% of potential respondents in this category reported that they were not involved in this work). Some responses from 'uniformed' organisations acknowledged that this was an area that they should address, in line with existing policies and initiatives relating to drugs and alcohol.
Variations in agency types included variations in relevant posts within organisations. Within primary care, respondents included school nurses, health visitors with a young person remit, Smoking Cessation Co-ordinators and Public Health Facilitators. Some SIPs employed Youth Health Workers, and one voluntary organisation included a Tobacco Issues Worker. In some areas, health promotion officers are seconded part-time to primary care settings to facilitate tobacco-related activities.
The picture described above is very fluid and likely to change. For example, responses indicated considerable movement within jobs, especially in the youth work sector. As workers move from post to post, skills and motivations will vary in relation to tobacco as well as other issues, as will the build up of links with other workers and agencies and client groups. New posts are also anticipated, in particular public health and smoking specific roles in LHCCs, which should enhance the scope in this area.
Focusing on the tobacco-related activities themselves, there was also considerable variation within and across the categories set in the study objectives (prevention/education, cessation, enforcement, training and support materials). It was apparent that these divisions were not always clear to respondents, and it should be borne in mind that to some extent the reporting suggests boundaries that are 'artificial' in the context of common practice. Thus, some respondents outlined the same or very similar activities in the prevention and the cessation sections, for example making leaflets and posters available, No Smoking Day events, health fairs and displays. Some respondents reported initiation of Proof of Age cards as a preventive rather than an enforcement activity. Training of workers could be recorded as an intervention or as a training activity. The development of a website could be undertaken by an organisation to make information available or could be seen as an intervention in itself, led by young people with the process enhancing their tobacco awareness and perhaps triggering cessation as well as providing other benefits. In addition, the two main settings of youth groups and schools, supported primarily by youth workers and primary care based workers respectively, might also be targeted by workers from both sectors describing activities in the 'opposite' sector, such as YES workers located in schools and health visitors working in youth settings. Similarly, trading standards officers not only worked with retailers, but also reported educational activities with young people themselves. Finally, as well as tobacco and smoking sometimes being set in the context of broader health and social issues, more specific fields included alcohol and drugs related interventions and lifestyle/decision-making approaches.
Thus there is considerable mix and overlap in tobacco-related activities. This is not necessarily a negative point, although it could also suggest limited recognition of tobacco as an issue and lack of structuring of activities. Arguably, there is a case for tobacco and smoking to be addressed within a broader holistic approach rather than in isolation. While often more challenging, this approach could be more actively recognised and supported. A 'holistic' approach was particularly reported in the youth work sectors where a number of respondents stressed the importance of responding to individual young people and their concerns at the time rather than imposing 'initiatives' - to "enable them to make informed decisions on a range of issues including, where requested, smoking" (Youth Worker). This made it difficult to plan or assess effectiveness in relation to one particular topic (and made it difficult to complete the questionnaire!). For example defining an activity as cessation would be "dependent on whether the Informal Social Education approach encourages a young person to stop smoking" (Youth Worker).
Perhaps the goal is to ensure that tobacco-related issues are on the agenda for those working with young people in all sectors, if not always at the forefront of day-to-day activity. Workers from different sectors may not need to be 'experts' but it is important that firstly, there are youth-appropriate specialist sources in an area and secondly, that good sign-posting is provided for workers and for young people themselves, whether it be for information or cessation support.
No Smoking Day appears to have a useful role in maintaining the place of tobacco 'on the agenda'. Over half the respondents across many agency types reported undertaking No Smoking Day activities including many youth workers. Many of these had attended related training sessions, often the only tobacco-related training they received. Reported activities tended to be limited to 'the day' but a sizable minority reported relatively longer-term interventions with a No Smoking Day Focus.
Linked with the merging of divisions between tobacco-related categories, it was also apparent that interventions ranged from clearly defined 'discrete' projects to something that was considered very much part of everyday work, with tobacco often being one of many issues addressed opportunistically. Thus, while some projects were sustained and longer-term, although commonly planned in months rather than years, others would be one-off and short-term, for example No Smoking Day, and some were unplanned and reactive to individual requests. Different parts of the spectrum might occur within one post or organisation so that a planned activity, perhaps with a clear protocol as would be required for a funding bid, might run in parallel with more general tobacco-related information and support provision and with work in other areas. Similarly, it appeared that many reported activities were perhaps more likely to have 'evolved' than be the outcome of specific planning, although individual structured projects were also highlighted.
Focussing on cessation interventions, it is important to note that among the activities reported, there were only ten examples of young people-specific group programmes or classes reported across Scotland. Other programmes were described, primarily in primary care, which were targeted at the general public or practice population but could potentially be accessed by young people. However, adult health services are often inappropriate for young people (eg. Community Learning Scotland 2000). In addition, the limited guidance and general discouragement of provision of NRT to those under 18 years brings the issue into focus, with only two respondents appearing to offer NRT to this age group. Within the context of cessation, others described one-to-one counselling and opportunistic responses to request for help, as well as information provision, workshops and discussion sessions, and broader positive lifestyle and coping advice. While increased provision of specific classes and programmes is desirable, it may be that more flexible and opportunistic approaches are also important, reflecting young smokers' 'on-off' acknowledgement of having a habit and their unfamiliarity with service provision. Some of these issues are addressed in the ASH Scotland small grants projects, some of which encourage consideration of quitting and preparation to join cessation services rather than actually providing cessation support.
It is also important to note that cessation support of any kind is relatively thinly spread. Only 98 respondents reported cessation work of any kind, suggesting limited availability of support with young people unlikely to travel far for help. In addition, only 27 respondents reported receiving training on cessation approaches, and these were not always young people focussed.
Cessation interventions were more commonly described as occurring in youth group settings but school-based intervention were also frequently reported, although there is no clear evidence that this is an optimal setting. However, it might be that New Community Schools with integrated provision of services and the ethos of addressing the needs of young people 'in the round' (New Community Schools) may increase effectiveness.
The limited extent of training is also important. Only a third of respondents had received any training in tobacco-related issues, primarily in health promotion and primary care, and this was more likely to be one-off seminars rather than formal training. Thus, many respondents, especially but not exclusively in youth work, relied on past experience and approaches used in relation to other issues when addressing tobacco-related work. Where an opportunistic approach is taken, responding to smoking as one of many issues potentially raised by young people, will there be sufficient knowledge and skills to respond appropriately, either directly or by referral to other services? Again, it may not be important that all workers are fully trained, but arguably, basic skills and knowledge should be widely disseminated and access to specialist advice and support should be available and clearly signposted.
Finally, although there was frequent mention of the importance of responding to young people and their declared needs, there was a very low level of reporting of formal needs assessment or consultation with young people.
Conclusions
- Tobacco-related work with young people was identified across Scotland and across different agency types. There is considerable interest in addressing this issue, and there are positive indications of increasing activity and innovative approaches. However, in terms of access for individual young people, provision is still relatively thinly spread.
- Cessation provision is particularly limited. Just under half of respondents reported any involvement in cessation (98), and only 10 youth specific programmes or classes were described. One-to-one and opportunistic advice and broader lifestyle approaches which may also have an appropriate role in youth cessation were reported in similarly small numbers.
- Only a third of respondents reported experiencing any kind of training in tobacco-related work, with many relying on 'picking it up' and past experience with other issues. While not all workers need to be 'experts', dissemination of basic knowledge could be enhanced, and it is also important that appropriate specialist services are available and are well 'sign-posted'.
- Enforcement activities are widespread, but many trading standards officers expressed a wish to employ test-purchasing by under-16s, suspended pending the Lord Advocate's decision on the matter.
- Finally, a considerable mix and overlap of approaches was apparent. For some workers and settings there was a lack of distinction between areas of work, particularly prevention and cessation, and it appeared that activities reported were not always discrete entities. Often this reflects a valuable holistic and flexible approach, but it might also indicate a limited priority in planning and structuring of tobacco-related activities.