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The Scottish Health Survey: Volume 1: Main Report

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Chapter 4 Smoking

4 SMOKING

Louise Marryat

SUMMARY

  • In 2010, 25% of all adults aged 16 and over were current smokers. Smoking rates were almost identical between men (26%) and women (25%), although female smokers smoked fewer cigarettes per day than male smokers (13.1 compared with 14.8, respectively).
  • Rates of smoking among adults aged 16-64 declined between 1995 and 2010, from 35% to 28%. However, smoking prevalence has not significantly changed since 2008.
  • Over the same period, the proportion of adults aged 16-64 who say they have never smoked regularly has increased, from 49% in 1995 to 54% in 2010.
  • The sharp decrease in non-smokers' exposure to second-hand smoke seen in the decade between 1998 and 2008 was maintained in 2010. Non-smokers' exposure to second-hand smoke in the home has fallen from 18% in 1998 for both sexes to 9% for men and 8% for women in 2010.
  • As seen in previous years, exposure to second-hand smoke varies with age. For example, the proportion of male non-smokers who said they were never exposed to other people's smoke at home, work or in public places, rose from 48% of those aged 16-24, to 71% of those aged 25-34 before rising more gradually to 94% of men aged 75 or older. A similar pattern was apparent for female non-smokers.
  • Overall, 40% of all smokers had made one or two attempts to quit smoking, and a further 38% had made three or more attempts to quit. A fifth (21%) of adult smokers had made no attempt to quit.
  • The majority of smokers - 69% - would like to quit smoking.
  • Women were more likely than men to want to quit smoking (72% versus 67%) and were more likely to have made three or more attempts to quit (42% versus 36%).
  • Smokers' attempts to quit, and their desire to stop smoking, did not vary by area deprivation.
  • Desire to quit was unrelated to the number of cigarettes smoked per day. However, people who smoke fewer than 10 cigarettes per day were less likely to have made an attempt to quit than people smoking more than this.

4.1 INTRODUCTION

Smoking remains one of Scotland's most significant public health concerns. It has been estimated that around 13,500 deaths a year are attributable to smoking - around a quarter of all deaths in Scotland. [1] Smoking is implicated as a factor in cancer, coronary heart disease and stroke. The substantial public health concern about smoking in Scotland is underlined by its inclusion as one of the Scottish Government's National Performance Framework national indicators, which is measured by the Scottish Household Survey: [2]

Reduce the percentage of the adult population who smoke to 22% by 2010

The introductions to the smoking chapters in the 2008 and 2009 Reports [3], [4] provided a comprehensive overview of the recent policy context and outlined a number of actions being taken by the Government and NHS to help support smokers to quit, and to discourage people from starting to smoke. These included:

  • The introduction of a ban on smoking in public places in 2006
  • The raising of the legal age for buying tobacco from 16 to 18 in 2007
  • The publication of the action plan Scotland's Future is Smoke-Free in 2008
  • The Tobacco and Primary Medical Services (Scotland) Act 2010, which introduced new measures specifically designed to reduce the attractiveness and availability of tobacco to those aged under 18.

In March 2011, due in part to ongoing legal challenges, plans to ban the display of tobacco products in shops from October 2011 were amended when the Scottish Government announced that the ban would be implemented in large stores in April 2012, and in April 2015 for smaller stores. [5]

The SNP administration elected in May 2011 outlined plans in their manifesto to develop a new tobacco control strategy for Scotland, to replace the previous strategy which has now ended. In March 2011 the English Department of Health published its Healthy Lives, Healthy People: Tobacco Control Plan for England.[6] Although primarily focusing on policy in England, some of its provisions will impact Scotland, including a consultation in 2011 on the introduction of plain packaging for tobacco products.

The above policy actions to reduce the attractiveness of smoking are complimented by a programme of support to assist existing smokers who want to quit. For example, one of Scotland's HEAT targets [7] for the NHS focuses specifically on smoking cessation:

Through Smoking Cessation Services, support 8% of each board's smoking population to successfully quit over the period 2008/09-2010/11

According to the most recent figures from NHS Scotland's Information Services Division, [8] there were 79,672 quit attempts using NHS Smoking Cessation services in 2010, compared with 74,038 recorded in 2009. Of these, 31,456 (39%) were still smokefree (self-reported) one month after their quit date. Women were more likely than men to access cessation services (59% and 41%, respectively). From April 2011 this HEAT target has been reframed to achieve 80,000 successful quits over the three years to March 2014, of which 48,000 are expected to be within the 40% most deprived SIMD areas within each board. [9]

This chapter will present the prevalence of smoking in adults aged 16 and over, non-smokers' second-hand smoke exposure, and current smokers' history of quit attempts and their desire to quit. Trends will also be presented by comparing data across the 1995, 1998, 2003, 2008, 2009 and 2010 Scottish Health Surveys. Quit attempts are explored by the Scottish Index of Multiple Deprivation ( SIMD) and the number of cigarettes smoked. More detailed socio-demographic analysis of smoking by National Statistics Socio-economic classification, household income and Scottish Index of Multiple Deprivation, will be presented in the 2011 report.

4.2 METHODS

4.2.1 Smoking questions in the 2010 Scottish Health Survey

The survey has included questions on smoking since 1995. Some small changes were introduced to the questionnaire in 2008, as outlined in the 2008 Report. This information is not repeated here. Instead, it outlines the main measures and definitions used in this chapter.

Information about cigarette smoking was collected from adults aged 16 and 17 by means of a self-completion questionnaire which offered them the privacy to answer without disclosing their smoking behaviour in front of other household members. For adults aged 20 and over it was collected as part of the main interview. Those aged 18 and 19, at the interviewers' discretion, could answer the questions in the self-completion booklet or the main interview.

For young adults, the smoking questions in the self-completion questionnaire focus upon:

  • current smoking status
  • frequency and pattern of current smoking
  • the number of cigarettes smoked by current smokers
  • ex-smokers' previous smoking history
  • exposure to second-hand smoke.

The self-completion and main interview questions are mostly similar. However the main interview also asked about past smoking behaviour, desire to give-up smoking and medical advice to stop smoking.

The question about non-smokers' exposure to second-hand smoke covers a range of domestic and public places, including some locations covered by the 2006 smoking ban (such as pubs). In previous reports, people who were not exposed to smoke in any of the places asked about were described as never being exposed to second-hand smoke. This is not wholly accurate as they might have been exposed to smoke in a location that was not asked about. The tables and text below have been amended to reflect this.

4.2.2 Cotinine

The Scottish Health Survey has tested people's cotinine levels in every year it has been conducted. Cotinine is a derivative of nicotine and is an objective measure of smoking. Levels above a certain threshold indicate that someone has smoked recently while levels below the threshold are a measure of exposure to second-hand smoke. All those aged 16 years and over who were visited by the nurse were asked to provide a saliva sample in order to measure cotinine levels.

The measurement of cotinine levels in the Scottish Health Survey series provides an objective cross-check on self-reports of smoking behaviour, which are known to under-estimate prevalence. Inaccuracies in reporting arise in part from difficulties participants may experience in providing quantitative summaries of variable behaviour patterns, but in some cases arise from a desire to conceal the truth from other people, such as household members who may be present during the interview. This study is the only data source in Scotland which can provide a validated measure of self-reported smoking in this way.

The smoking chapter in the 2009 report presented the survey's measures of cotinine taken in 2008 and 2009. The 2011 report will repeat this analysis using the combined 2010 and 2011 data.

4.2.3 Definitions

The tables reported in this chapter use the following classifications of smoking status:

  • Current smoking status: current smokers, ex-regular smokers, ex-occasional smokers and never smoked at all.
  • Number of cigarettes smoked by current smokers: under 10 cigarettes per day, 10 to fewer than 20 cigarettes per day, 20 or more cigarettes per day. The mean number of cigarettes smoked is also used.

4.3 TRENDS IN SMOKING PREVALENCE

Table 4.1 shows the smoking rates for adults aged 16-64 from 1995 to 2010, and for adults aged 16 and over from 2003 to 2010. The prevalence of smoking in adults aged 16-64 fell from 35% in 1995 to 28% in 2010, though rates have been broadly similar since 2008. This decline was apparent for both sexes. The smoking rate in men aged 16-64 was highest in 1998 (36%) and was 29% in 2010. Women's smoking was highest in 1995 (36%) and was 28% in 2010. All age groups saw a fall in smoking rates across this period.

The mean number of cigarettes smoked per day by smokers aged 16-64 has also declined, from 16.7 in 1995 to 13.9 in 2010. The decline was greater among men (from 18.1 cigarettes per day in 1995 to 14.6 in 2010) than women (15.4 and 13.3, respectively).

The decreasing proportion of adults aged 16-64 who smoke is largely accounted for by a corresponding increase in the proportion who have never smoked regularly, or at all, from 49% in 1995 to 54% in 2010. In contrast, the proportion each year who were ex-regular smokers has been very similar (17%-18%).

The pattern among all adults aged 16 and over since 2003 is broadly similar to the longer-run trend for adults aged 16-64: 28% of adults aged 16 and over were smokers in 2003 compared with 26% in 2008 and 25% in both 2009 and 2010. The figures declined from 29% in 2003 to 26% in 2010 among men, and from 28% to 25% among women, respectively. The 2010 Scottish Household Survey smoking estimate was 24%, [10] which means that the target to reduce smoking prevalence to 22% by 2010 mentioned in the introduction, was not met.

The mean number of cigarettes smoked per day by smokers also saw a decline between 2003 and 2010 (from 15.3 to 13.9). Similar proportions of adults aged 16 and over were ex-regular smokers in the 2003-2010 period (22%-23%), while the proportion that had never smoked regularly or at all was 50% in 2003 and 52% in 2010. Table 4.1

4.4 SMOKING PREVALENCE IN 2010

Table 4.1 also shows that, in 2010, there was little difference between men and women's current smoking rates (26% versus 25%). However, there were notable variations by age. Smoking prevalence was 27%-31% in adults aged 16-54, and declined steadily after that to 16% for those aged 65-74 and 11% for those aged 75 and over. The same overall pattern of declining prevalence in the older age groups was true for both sexes. However, as Table 4.1 and Figures 4A and 4B show, women's smoking rates remained at a similar level up to the 55-64 age group, whereas the pattern for men showed an increase between the two youngest groups followed by a steady decline thereafter. Figures 4A and 4B also show how the proportion of people who were ex-smokers increased notably with age, especially among men. Table 4.1, Figure 4A, Figure 4B

Figure 4A

Figure 4B

Table 4.1 includes figures for the mean number of cigarettes smoked by current smokers. Male smokers smoked slightly more cigarettes than women: 14.8 per day compared with 13.1 per day, respectively. Smokers aged 45-64 smoked the highest number of cigarettes per day (16.0-16.3) while the lowest numbers were smoked by those aged 16-34 (9.9-12.2) and 75 and over (12.1). The numbers of cigarettes smoked by women followed the same pattern across the age groups as for all adults, whereas the number of cigarettes smoked by male smokers was very similar for those aged 35 and over (16.4-17.0). Table 4.1

4.5 TRENDS IN EXPOSURE TO SECOND-HAND SMOKE

Exposure to second-hand smoke in all settings has fallen substantially since the introduction of the ban on smoking in public places in 2006. Table 4.2 shows the figures for non-smokers aged 16-74 from 1998 onwards (and for non-smokers aged 16 and over from 2003). These show that exposure to second-hand smoke in the home has fallen from 33% in 1998 to 20% in 2008, and 18% in 2010. In addition, non-smokers' exposure to smoke in any public place fell from 50% in 1998 to 7% in 2008, and has remained at 7% since then. Furthermore, the proportions of non-smokers aged 16-74 who are not exposed to other people's smoke in any of the places asked about more than doubled since 1998, from 36% in 1998 to 74% in 2008, and 75% in both 2009 and 2010. The separate figures for men and women were very similar to those for all non-smokers, as were the total figures for non-smokers aged 16-74 and those aged 16 and over. Table 4.2

4.6 EXPOSURE TO SECOND-HAND SMOKE IN 2010

Looking now in more detail at the figures in 2010, Table 4.2 shows that 8% of non-smoking men and women were exposed to second-hand smoke in their own home, and 10% of men and 12% of women said they were exposed to second-hand smoke in other people's homes.

In addition, 5% of men and 2% of women who did not smoke were exposed to second-hand smoke at work. Just 1% of men and less than 1% of women reported being exposed to second hand smoke in pubs, while less than 1% of men and women reported exposure to second-hand smoke on public transport.

Table 4.2 and Figure 4C illustrate the considerable differences in non-smokers' overall exposure to second-hand smoke by age. From the age of 35, at least three-quarters of non-smokers report never being exposed to second-hand smoke at home, work, or in public places, and this figure increases to over 9 in 10 in the oldest age group. In contrast, only around half of non-smokers aged 16-24 are never exposed to second-hand smoke in these places. The most common places in which non-smokers aged 16-24 were exposed to second-hand smoke were their own home (19% of men and women), other people's homes (23% of men and 34% of women), or other public places (24% of men and 19% of women). Presumably, the other public places mentioned are not those currently covered by the smoking ban, as the proportions reporting exposure in places like pubs or public transport were very low (around 2% in the youngest age group). Young non-smoking men were more likely to be exposed to other people's smoke at work than young women (8% versus 4%). Table 4.2

Figure 4C

4.7 SMOKERS' QUIT ATTEMPTS AND DESIRE TO STOP SMOKING

4.7.1 Quit attempts and desire to stop smoking, by age and sex

This section focuses on smokers. Table 4.3 presents the number of attempts smokers in 2010 said they had made to quit smoking, and the proportions who said they would like to stop smoking. A fifth (21%) of smokers had made no attempts to quit smoking, 40% had made one or two attempts, and a further 39% had made three or more attempts to quit. The majority of smokers (69%) said they would like to quit smoking.

Similar proportions of men and women smokers had made no attempt to quit smoking (23% and 19%, respectively), or had made one or two attempts to quit (41% and 39%, respectively). However, women smokers were more likely than men to have made three or more attempts to quit (42% and 36%, respectively).

Table 4.3, and Figure 4D, show the differences in the number of attempts to quit smoking by age. As smoking prevalence is lower in those aged 65-74 and 75 and over, these age groups have been combined in the table and chart. Smokers aged 18-24 were the most likely to have made no attempt to quit (34%), this fell gradually to 14% of smokers aged 55-64, before rising again to 24% of the 65 and over age group. Younger smokers were also the least likely to have made as many as three or more attempts to quit (21% compared with 48% of smokers aged 45-64). These patterns are likely to reflect an association between the total length of time someone has smoked and their number of quit attempts, rather than an association between being a particular age and wanting to stop smoking. As smoking tends to be a habit that people develop when they are young, older smokers are likely to have smoked for much longer periods than younger smokers. The separate figures for men and women smokers followed similar patterns, though the sample sizes are relatively small for some of the sex-specific age groups. Table 4.3, Figure 4D

Figure 4D

The introduction cited figures from ISD that showed women were more likely than men to have accessed NHS smoking cessation services in 2010 (59% versus 41%). Table 4.3 shows that women smokers were more likely than men to express a desire to stop smoking (72% versus 67%). However, the difference between men and women's desire to quit was smaller than the difference between men and women's rate of accessing services. This might suggest that the gender difference in accessing services is only partly due to men and women having different levels of motivation to quit. Based on these two sets of data, it appears that women who want to quit are more likely to access services than men who want to quit.

Again, there were differences by age which will, in part, reflect differences in the longevity of people's smoking behaviour. Around three-quarters (75%-78%) of smokers aged 25-54 want to quit smoking. The corresponding figures for smokers aged 16-24 and 55-64 were lower, at 64%, while only 47% of smokers aged 65 and over want to quit. The fact that the lowest proportion of smokers who want to quit were in the oldest age group is interesting. This group has the lowest prevalence of smoking in the population ( Table 4.1 shows that 16% of those aged 65-74 and 11% of those aged 75 and over were current smokers in 2010). In addition, the proportions in this group who were ex-regular smokers were the highest of all age groups (39%-42%). This could mean that the remaining smokers aged 65 and over comprise a group whose smoking behaviour is more entrenched than is the case for younger age groups, or it could be that smokers in this age group who give up are more determined to quit and are therefore more successful than younger people. For example, older smokers are more likely to have the impetus of an episode of ill-health to motivate them to quit. Whichever is the case, these figures suggest that older smokers are a group that might be useful to target, even though the majority of smokers are aged under 65.

The patterns for men and women were virtually identical, though a higher proportion of women smokers aged 18-24 reported wanting to quit than men (73% versus 55%). However, the sample sizes for these two groups were relatively small so these estimates have very wide confidence intervals. The difference between them was marginally insignificant which suggests that more years of data should be combined before drawing firm conclusions about young men and women's levels of motivations to quit smoking. Table 4.3

4.7.2 Quit attempts and desire to stop smoking by SIMD

Table 4.4 presents the figures about quit attempts and desire to stop smoking by the Scottish Index of Multiple Deprivation. Two measures of SIMD are being used throughout this report. The first, which uses quintiles, enables comparisons to be drawn between the most and least deprived 20% of areas and the intermediate quintiles. The second contrasts the most deprived 15% of areas with the rest of Scotland (described in the tables as the "85% least deprived areas"). To ensure that the comparisons presented in this section are not confounded by the different age profiles of the sub-groups, the data have been age-standardised (age-standardisation is also described in the Glossary).

The 2008 smoking chapter 3 illustrated how smoking rates are strongly associated with area deprivation. Around four in ten adults in the most deprived quintile were current smokers compared with just one in six in the least deprived quintile. For this reason, smoking cessation activities are largely targeted at smokers in more deprived areas. As noted in the introduction, the new NHSHEAT target for successful quit attempts stipulates that over half the number that should be achieved is expected to be within the 40% most deprived SIMD areas within each health board.

Despite these differences in the prevalence of smoking by area deprivation, Table 4.4 shows that smokers' attempts to quit, and their desire to stop smoking, were very similar across the deprivation quintiles, and that the figures in the 15% most deprived areas were almost identical to those in the rest of Scotland. For example, 65% of smokers in the most deprived 15% of areas want to quit smoking compared with 66% of smokers in the rest of Scotland. The higher prevalence of smoking in more deprived areas does not, therefore, appear to be related to different levels of willingness to quit, or in the propensity to attempt quitting. Table 4.4

4.7.3 Quit attempts and desire to stop smoking, by daily cigarette consumption

Table 4.5 explores the association between the number of cigarettes smoked by current smokers and their propensity to try quitting, and their desire to quit. The number of cigarettes smoked was grouped as follows: fewer than 10, 10 to fewer than 20, and 20 or more. The figures were age-standardised to control for differences in the age profile of these three groups. People who smoked fewer than 10 cigarettes per day were less likely to have attempted to quit smoking than smokers of 10 or more (29% in the <10 group had made no attempts compared with 19% in the 10 to <20 group, and 17% in the 20 or more group). People smoking 10 or more cigarettes were also more likely to have made one or two attempts than those who smoked fewer than 10. However, similar proportions in all three groups had made three or more quit attempts (36%-40%).

Smokers' desire to quit did not vary by the number of cigarettes they smoked. The proportion who wanted to quit was almost identical (66%-67%) in all three groups. These figures suggest that while smokers' stated desire to quit does not appear to be related to their level of cigarette consumption, people who smoke 10 or more cigarettes per day had been more successful in translating their desire to quit into an actual attempt (albeit a failed one). Table 4.5