Linsay Gray and Alastair H Leyland
- Smoking prevalence was highest among adults aged 25-34 (24%) and lowest among those aged 75 and over (6%) in 2017.
- The percentage of adults who had never smoked regularly or at all increased from 50% in 2003 to 56% in 2017; the figure for ex-regular smoking increased from 22% to 26%.
- Younger adult smokers (aged 16-44) smoked fewer cigarettes per day on average (between 9.6 and 11.4 cigarettes) than those aged 45 and over (between 13.8 and 14.3 cigarettes).
- There was a clear deprivation gradient in the numbers of cigarettes smoked (13.4 in the most deprived areas compared to 8.6 in the least deprived areas).
- Current cigarette smoking prevalence corrected for cotinine levels was 31% for men and 22% for women in 2016/2017.
- 50% of adult non-smokers living in the most deprived areas had detectable salivary cotinine (suggesting exposure to second hand smoke), compared with 13% of those living in the least deprived areas.
- In 2017, 48% of cotinine-validated, self-reported non-smoking adults said they were not exposed to smoke in any of the places they were asked about (at their own / other’s home, at work, in cars/vans, outside buildings, or in public places).
- In 2017, current e-cigarettes use among adults was 7%, the same level as in 2015 and 2016 and a significant increase from 5% since 2014.
- The proportion of adults that had ever used e-cigarettes increased from 15% in 2014 to 19% in 2017.
Nationally and globally, tobacco use is the leading cause of premature mortality and preventable poor health. Tobacco use is associated with stillbirths and infant deaths, childhood respiratory diseases, and communicable as well as non-communicable diseases in adulthood. Each year tobacco use costs over half a trillion dollars worldwide and kills around seven million people. More than six million of the deaths are caused by direct tobacco use while more than 890,000 are the consequence of non-smokers being exposed to second-hand smoke. In Scotland alone, tobacco use is associated with around 10,000 deaths each year (around a fifth of all deaths).
5.1.1 Policy background
Tobacco control policies have led to significant declines in adult smoking levels in Scotland in recent decades. One of the Scottish Government's National Outcomes is the overall strategic objective for health: We are healthy and active. This is supported by a number of National Indicators that are relevant to smoking which are monitored using data from the Scottish Health Survey (SHeS). In addition to the new Health Risk Behaviour indicator which includes current smokers, there are more general related indicators including healthy life expectancy and premature mortality.
In 2013 the Scottish Government set out its ambition to create a 'tobacco-free generation' (defined as 'a smoking prevalence among the adult population of 5% or lower') by the year 2034.
Since 2013 a number of key actions have been set for local authorities and partners including full implementation of smoke-free policies for local authority grounds. Working with COSLA, NHS Health Scotland published guidance in January 2018 to facilitate such action. The NHS Local Delivery Plan (LDP) Standards require NHS Boards to sustain and embed successful smoking quits at twelve weeks post quit, in the 40% most deprived SIMD areas (60% in the Island Boards). Smoking rates in these SIMD areas are significantly higher than in more affluent SIMD areas. The targeting of these areas through LDP Standards has been recognised by organisations such as Cancer Research UK as having a positive effect in health equalities. Smoking cessation interventions, including pharmacotherapy, are among the most cost-effective health care interventions available.
In 2018, the Scottish Government published its 'Tobacco Control Action Plan' which sets out a five year plan of interventions and policies to help reduce the use of and associated harms from using tobacco in Scotland. The action plan continues the Scottish Government's focus on achieving the 'tobacco-free generation' ambition. The actions include raising awareness through campaigns, encouraging healthier behaviour in schools, universities, workplaces and healthcare settings, improving cessation services and regulations on smoking in prisons, the advertisement of e-cigarettes and restrictions on heated tobacco products. The Scottish Prison Service has set the target for all prisons in Scotland to be smoke-free by the end of 2018.
The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 was commenced on 1 April 2017. The Act includes provisions to regulate:
- the introduction of a minimum age of 18 for the sale of Nicotine Vapour Products (NVPs) – including electronic cigarettes.
- a ban on the purchase of NVPs on behalf of an under 18 – 'proxy purchase'.
- the introduction of mandatory registration for the sale of NVPs.
- bans on certain forms of domestic advertising and promotion of NVPs.
- the introduction of an age verification policy for sales of tobacco and NVPs by under 18s ('Challenge 25').
- a prohibition on the sale of NVPs from vending machines.
- a ban on unauthorised sales of tobacco and NVPs by under 18s.
- the introduction of statutory smoke-free perimeters around buildings on NHS hospital sites.
Regulation on most of these provisions came into force in 2017.
The most recent primary legislation on smoking passed by the Scottish Parliament is the Smoking Prohibition (Children in Motor Vehicles) (Scotland) Act 2016 which deems as an offence smoking in cars in a public place in the presence of children.
All across the UK new regulations came into force on 21 May 2017 making it an offence to sell cigarettes in any pack containing less than 20 cigarettes, and ensuring all cigarettes are sold in standardised brand-neutral packs.
One set of these new regulations also restricted the strength, availability and access to electronic cigarettes – banning cross-border advertising and promotion on, TV, radio, online, by e-mail and in print media. Further restrictions on advertising and promoting electronic cigarettes in Scotland are planned for 2019.
5.1.2 Reporting on smoking in the Scottish Health Survey (SHeS)
Reliable data on smoking behaviour, cessation, Nicotine replacement therapy (NRT) use and exposure to second-hand smoke are vital to effective monitoring of trends relevant to the various targets in place. This chapter presents prevalence of adult cigarette smoking and e-cigarette use. Figures for smoking prevalence based on self-report are provided alongside prevalence rates using saliva cotinine adjustment. Trends in cigarette smoking prevalence by deprivation are also shown. Exposure to second-hand smoke among adults and children is also examined. For adults second-hand smoke exposure was identified through the analysis of cotinine in saliva samples and for children via self-reported information.
The area deprivation data are presented in Scottish Index of Multiple Deprivation (SIMD) quintiles. Readers should refer to the Glossary at the end of this Volume for a detailed description of SIMD.
The area deprivation trend data have been age-standardised using 2016 mid-year household population estimates applied to each year 2008 to 2017 separately. This enables comparisons across years to be made without estimates being affected by changes to the age composition of the population. However figures may differ slightly from previously published figures using different mid-year population estimates. The closest SIMD rating was used for each year of the data: 2017 data uses the 2016 ranking (as does 2016) whereas the 2012 data uses the 2012 ranking (as does 2010-2015) and the 2008 and 2009 data uses the 2009 ranking.
Supplementary tables are also available on the Scottish Government SHeS website.
5.1.3 Comparability with other UK statistics
The Health Survey for England, Health Survey for Northern Ireland and the National Survey for Wales provide estimates of smoking prevalence in the other home nations within the UK. The surveys are conducted separately and have different sampling methodologies, so smoking prevalence estimates across the surveys are only partially comparable. Smoking prevalence estimates from the UK-wide Integrated Household Survey for Scotland, Wales, England and Northern Ireland have been deemed to be fully comparable.
5.1.4 Adolescent smoking in Scotland
Smoking rates for 13 and 15 year olds are available from The Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS). This survey is conducted on a biennial basis, targeting secondary school pupils in local authority and independent schools.
5.2 Methods and Definitions
5.2.1 Methods of collecting data on smoking behaviour
Adults aged 20 and over were asked about their smoking behaviour during the face to face interview. For those aged 16 and 17, information was collected in a self-completion questionnaire offering more privacy and reducing the likelihood of concealing behaviour in front of other household members. At the interviewer's discretion those aged 18 and 19 could answer the questions either face to face or via the self-completion booklet.
5.2.2 Questions on smoking behaviour
The current questions in the survey focus on:
- 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
- past smoking behaviour
- quit attempts and desire to give up smoking
- medical advice on giving up smoking
- NRT use
- e-cigarette use (including as part of a quit attempt)
While the self-completion questions were largely similar to those asked in the face to face interview, the self-completion questionnaire did exclude questions on: past smoking behaviour, desire to give up smoking and medical advice to stop smoking.
5.2.3 Questions on e-cigarette use
From 2014, SHeS has gathered information on the use of e-cigarettes among the Scottish adult population, in response to their increased availability and high profile. The questions ask whether participants have ever used an e-cigarette as well as whether they are currently using an e-cigarette.
5.2.4 Methods of collecting data on exposure to second-hand smoke
Participants on SHeS were asked whether they are regularly exposed to other people's tobacco smoke from a list of pre-defined spaces including:
- At own home
- At work
- In other people's homes
- In cars, vans etc
- Outside of buildings (e.g. pubs, shops, hospitals)
- In other public places
They were then asked whether this bothered them at all.
In addition to the self-reported measure a subsample of participants were asked to provide a saliva sample which was analysed for cotinine. This analysis identified non-smokers who were exposed to a level of cotinine that indicated that they were exposed to second-hand smoke.
Cigarette smoking status
Information on cigar and pipe use is collected in the survey but as prevalence is low these are not considered in the definition of current smoking. Smoking status categories reported here are:
- current cigarette smoker
- ex-regular cigarette smoker
- never regular cigarette smoker
- never smoked cigarettes at all
Cotinine adjusted smoking status
The saliva cotinine adjustment adjusts original self-reported cigarette smoking levels by including those with cotinine levels in their saliva above 12ng/ml; this indicates that the individual is using nicotine either from tobacco, e-cigarettes or NRT. For self-reported non-smokers this therefore indicates exposure beyond what would be expected from contact with second-hand cigarette smoke and hence suggests misreporting of smoking behaviour in the main interview.
Those who stated that they used either e-cigarettes or NRT products but did not currently smoke were excluded from the calculation of smoking prevalence estimates in Table 5.5 (showing figures both adjusted for saliva cotinine and unadjusted). This was because it was not possible to tell whether any raised cotinine levels among this group were due to e-cigarettes and NRT products alone, or additionally to unreported smoking.
Exposure to second-hand smoke
Exposure to second-hand smoke for children is measured in two ways in the survey:
- whether there is someone who regularly smokes inside the accommodation where the child lives, and
- parents' and older children's (aged 13-15) reports of whether children are exposed to smoke at home.
In addition exposure to second-hand smoke for adults is also measured in two ways:
- Self-reported information about whether they have been exposed to second-hand smoke in a number of places including in their own home, someone else's home, work or outside of buildings
- Analysis of cotinine levels in saliva (see above).
5.3 Cigarette Smoking Status
5.3.1 Trends in cigarette smoking status since 2003
Current smoking prevalence for adults fell significantly from 28% in 2003 to 21% in 2013; subsequently, the figures had remained relatively stable at 21-22% until 2016 before dropping significantly again to 18% in 2017 (see Figure 5A). This fall is in line with the Adult Smoking Habits in the UK for 2017 conducted by Office of National Statistics which also suggests a substantial recent drop in smoking in Scotland. Similar patterns were found for women and men whereby smoking prevalence had fallen between 2016 and 2017 (23% to 20% for men and 20% to 16% for women) however this reduction was only significant among women.
The percentage of adults who had never smoked regularly or had never smoked at all increased from 50% in 2003 to 55% in 2011. There has been no significant change in the time period since, with the proportion of adults who had never smoked ranging from 54-56% between 2012 and 2017. The percentage of all adults reporting that they were ex-regular smokers increased overall between 2003 (22%) and 2017 (26%). The trends in those reporting that they had never smoked or were ex-regular smokers were similar for men and women.
There has been a significant drop over time in the mean number of cigarettes smoked per day by current adult smokers from 15.3 in 2003 to 12.3 in 2017. A similar pattern was found for both men and women, as can be seen in Figure 5B (from 15.9 in 2003 to 13.2 in 2017 for men and from 14.7 in 2003 to 11.4 in 2017 for women).
Figures 5A and 5B, Table 5.1
5.3.2 Cigarette smoking status in 2017, by age and sex
Overall, 18% of adults were current cigarette smokers in 2017, 26% reported that they were ex-regular smokers and 56% said they had never smoked regularly or at all.
Men were more likely than women to identify as current smokers (20% and 16% respectively). Men were also significantly more likely than women to report being an ex-regular cigarette smoker (28% of men compared with 24% of women). Correspondingly, men were significantly less likely than women to have reported never smoking or never being a regular smoker (52% and 60% respectively).
There were significant differences in smoking prevalence by age group in 2017, as seen in previous years. Smoking prevalence was highest among adults aged 25-64 (19-24%, 24% among those aged 25-34), lower among those aged 16-24 (17%) and those aged 65-74 (14%), and lowest among those aged 75 and over (6%). Similar patterns for men and women were observed for smoking prevalence by age.
As in previous years, the percentage of people in 2017 who reported that they were ex-regular smokers was smallest among the youngest age group (7% for those aged 16-24) and largest among the older adults (34-37% for those aged 65 and over). Correspondingly, those in the youngest age group were most likely to report never smoking regularly or at all (76% for those aged 16-24 compared with 49-60% of those aged 25 and over). These patterns held generally for both men and women, although, in the oldest age group, a far lower percentage of women were ex-regular smokers than men (23% compared with 50%). Similarly, a far higher percentage of women than men were never regular cigarette smokers or never smoked at all in the oldest age group (72% compared with 42%).
The mean number of cigarettes smoked per day was higher for male smokers (13.2 cigarettes) than for female smokers (11.4 cigarettes). For all adults and women, the highest mean number of cigarettes smoked per day was among the 45-54 age group (14.3 and 13.4 cigarettes, respectively); for men, the highest mean was among those aged 55-64 (16.6 cigarettes).
Of all adult smokers, the younger age groups (aged 16-44) smoked fewer cigarettes per day on average (between 9.6 and 11.4 cigarettes) than those aged 45 -74 (between 13.8 and 14.3 cigarettes) in 2017.
5.3.3 Cigarette smoking status (age-standardised) since 2003, by area deprivation and sex
Adults living in more deprived areas were more likely to smoke than those in less deprived areas in 2017. Smoking prevalence was 27% among those in the most deprived areas with step-decreases across the intermediate quintiles to 9% among those in the least deprived areas. The gradient was similar for men (30% in the most deprived areas compared with 10% in the least deprived areas) and women (25% in the most deprived areas compared with 9% in the least deprived areas).
In 2017, there was a clear gradient by area deprivation in the numbers of cigarettes smoked with a mean of 13.4 cigarettes smoked per day among smokers in the most deprived area and 8.6 cigarettes smoked among those in the least deprived area. The gradient was more pronounced among male smokers, with an average of 15.0 cigarettes smoked daily per current smoker living in the most deprived areas compared with 9.5 cigarettes smoked among those living in the least deprived areas. The pattern for women was less clear, with 12.0 cigarettes smoked daily per current smoker in the most deprived area and 7.7 in the least deprived areas and the highest prevalence among the middle quintile (12.3 cigarettes).
Taking the time period 2003 to 2017 as a whole, the deprivation gradients in current smoking prevalence and numbers of cigarettes smoked were significant overall for all adults, as well as separately for men and women; these gradients were consistent across the time period. The gap between smoking prevalence in the most deprived and least deprived areas has narrowed, from 28 percentage points in 2003 (45% in most deprived and 17% in least deprived) to 18 percentage points in 2017 (27% in most deprived and 9% in least deprived); however rates remain around 3 times higher in the most deprived areas. Table 5.3
5.4 Exposure to Second Hand Smoke
5.4.1 Children's exposure to second-hand smoke since 2012
In 2017, 10% of children were living in a home in which someone regularly smoked indoors; the figure was the same for boys and girls. There have been significant falls between 2012 and 2017 in the percentage of children living in accommodation in which someone regularly smoked inside (19% in 2012, 16% in 2013 and 2014, 12% in 2015 and 11% in 2016), with similar patterns for both boys and girls.
A lower percentage of children (6%; 5% for boys and 6% for girls) were reported to have been exposed to second-hand smoke in their home in 2017 than in 2012 (12% for both boys and girls; see Figure 5C).
The data indicate that the target to reduce the percentage of children exposed to smoke at home to 6% by 2020 was met in 2015 and 2017 (the 1% point increase in 2016 was non-significant). These figures (and the others in this section) will continue to be examined in future years to assess adherence to the target. Figure 5C, Table 5.4
5.5 Cotinine-Adjusted Cigarette Smoking Status
5.5.1 Cotinine-adjusted smoking status, 2016/2017 combined, by age and sex
Just over a fifth (22%) of adults self-reported as current cigarette smokers in 2016/2017. When corrected for cotinine levels, current cigarette smoking prevalence increased for all adults to 26% (24% to 31% for men and 19% to 22% for women) for those years. The gap of five percentage points for adults (six percentage points for men and three percentage points for women) between self-reported smoking status and cotinine-adjusted smoking prevalence is higher than previously reported SHeS findings (gaps of three, four and two percentage points respectively in 2014/2015).
The difference between self-reported smoking status and the cotinine-adjusted smoking prevalence for adults aged 16 and over did not vary significantly with age. Table 5.5
5.6 Exposure to Second Hand Smoke Among Non-Smokers
5.6.1 Saliva cotinine levels among non-smokers since 2003
Adult non-smokers' geometric mean cotinine levels reduced significantly from 0.40 ng/ml in 2003 to 0.11 ng/ml in 2008/2009. A further small, but significant decrease had occurred since, with non-smokers' mean cotinine levels reaching 0.08 ng/ml in 2016/2017. There were no differences between men and women in geometric mean cotinine trend or levels in 2016/2017.
The percentage of non-smokers aged 16 and over with detectable salivary cotinine fell dramatically from 85% in 2003 to 24% in 2016/2017 combined. The largest fall was between 2003 and 2008/2009 combined, a drop of 47 percentage points; the percentage remained level in 2010/2011 combined and subsequently fell again by 13 percentage points to 25% in 2014/2015 combined. Levels and patterns were similar for men and women at each time point after 2003.
5.6.2 Saliva cotinine levels among non-smokers in 2016/2017 combined, by age and sex
Adult non-smokers' geometric mean cotinine levels were slightly higher for those aged 16-44 (0.09 ng/ml) compared with those aged 45 and older (0.07 ng/ml) in 2016/2017 combined; this was the case for both men and women.
The percentage of adult non-smokers with detectable salivary cotinine was higher among younger adults than older (29% of those aged 16-44 compared with 17% of those aged 65 and older). This pattern was reflected in men, where detectable salivary cotinine decreased with age (34% among those aged 16-24 to 17% among those aged 65 and over). For women, detectable cotinine remained stable among those aged 16-64 (25%), only decreasing to 17% in those aged 65 and above.
5.6.3 Saliva cotinine levels among cotinine-validated self-reported non-smokers in 2014-2017 combined (age-standardised), by area deprivation and sex
The age-standardised geometric mean saliva cotinine level for non-smokers living in the most deprived area quintile was more than double the level for those living in the least deprived quintile (0.14 ng/ml compared with 0.06 ng/ml). This pattern was true for both male and female non-smokers.
The age-standardised percentage of adult non-smokers with detectable salivary cotinine living in the most deprived area, at 50%, was more than three times that of non-smokers living in the least deprived area (13%). A similar pattern was found among both men and women.
5.6.4 Places self-reported cotinine-validated non-smokers are exposed to second hand smoke in 2014-2017 combined, by age and sex
Nearly half of cotinine-validated self-reported non-smoking adults with a detectable saliva cotinine level (48%) reported not being exposed to smoke in any of the places they were asked about (at their own / other's home, at work, in cars / vans, outside buildings, or in public places). Patterns in exposure to second-hand smoke were similar for non-smoking men and women.
Nearly a quarter (23%) of non-smoking adults with detectable cotinine levels were exposed to second-hand smoke in their own home and 18% were exposed in someone else's home. These figures were similar for non-smoking men and women (24% and 21% in their own home and 15% and 20% in someone else's home, respectively).
Of all non-smoking adults with detectable cotinine levels, 6% reported exposure at work and a similar proportion (8%) reported exposure in cars / vans. Of the public places asked about, reported exposure was greatest outside buildings (e.g. pubs, shops, hospitals) with one in five (20%) reporting this. Similar patterns were found for men and women.
There were some variations in non-smokers' exposure to second-hand smoke by age in 2014-2017 combined, with exposure generally greater among younger non-smokers with detectable cotinine levels. Of those aged 16-44, 40% were not exposed in any of the listed places compared with 61% of those aged 64 and over; these percentages were similar for men and women.
Age-related differences in exposure to second-hand smoke among non-smokers with detectable cotinine levels were apparent among most of the specific locations with 9% aged 16-44 exposed to second-hand smoke while at work compared with 1% of those aged 64 and over. Such differences in exposure to second-hand smoke were also seen in other people's homes (22% of those aged 16-44 compared with 10% of those aged 64 and over); outside buildings (e.g. pubs, shops, hospitals: 27% and 11%, respectively), in other public places (18% and 2%, respectively) and in cars / vans (11% and 2%, respectively). Exposure to second-hand smoke in the non-smoking respondent's own home was an exception, with percentages of 22-23% across the three age groupings. Table 5.9
5.7 Household Smoking Rules
5.7.1 Household smoking rules in 2017, by age and sex
In 2017, nearly two thirds (64%) of adults lived in households in which smoking was only permitted in outdoor areas. For 12%, smoking was permitted indoors but only in certain areas or rooms; while 5% of adults lived in a household with no restrictions placed on smoking indoors. For the remaining 19%, smoking was not allowed indoors or outdoors. The figures were similar for men and women.
Household smoking rules varied somewhat by age. For instance, those aged 16-44 were least likely to live in homes with no restrictions on smoking (2-4%% compared with 7-9% for other age groups) in 2017. Correspondingly, those in the 16-44 age group were also most likely to live in homes where smoking was not permitted indoors or outdoors (20-25% compared with 14-18% for other age groups). Those aged 16 to 24 were most likely to live in homes where people can only smoke in certain areas or rooms (18% compared with 8-14% for other age groups) in 2017. These patterns were broadly similar for men and women. Table 5.10
5.7.2 Household smoking rules (age-standardised) in 2017, by area deprivation and sex
Household smoking rules were associated significantly with deprivation in 2017. Those in the least deprived two quintiles were least likely to live in homes with no restrictions on smoking (2% for both compared with 13% for the most deprived quintile). Correspondingly, people in the least two deprived quintiles were also most likely to live in homes where smoking was not permitted indoors or outdoors (21-29% compared with 12-17% for other quintiles).
Those in the least deprived quintile were least likely to live in homes where people can only smoke in certain areas or rooms (age-standardised figure of 5% compared with 8-19% for other quintiles). Those in the most deprived quintile were least likely to live in homes where people can only smoke in outdoor areas (e.g. gardens/balconies; 56% compared with 63-68% for other quintiles). Figure 5D, Table 5.11
5.8 Trends in E-Cigarette Use Since 2014, by Age and Sex
In 2017, current e-cigarettes use among adults was 7%. A separate 11% had previously used e-cigarettes (with a total of 19% ever using them). Four fifths (81%) had never used e-cigarettes.
The proportion of current e-cigarette users had not changed from 2015, but was significantly higher than in 2014 (5% in 2014 compared with 7% in 2015, 2016 and 2017). The proportion of people that had previously used e-cigarettes has fluctuated between 10-12% since 2014 (10% in 2014 and 11% in 2017). Fewer adults reported never having used e-cigarettes in 2017 (81%) than in 2014 (85%).
Men and women were equally likely to be current users of e-cigarettes (7% for both men and women) in 2017. However, men were more likely to have previously used e-cigarettes than women (13% compared with 10%) and women were more likely than men to have never used e-cigarettes (83% compared with 80%).
As in previous years, e-cigarette use in 2017 varied significantly with age. The prevalence of e-cigarette use in 2017 was highest among the middle age groups (8-11% among those aged 25-64) and lower for the youngest (5% among those aged 16-24) and older adults (1-6% for those aged 65 and over). A similar age-related pattern was seen for both men and women.
Combined past and current usage – ever use – was also associated with younger age in 2017, with lower use among older adults. Of those aged 16-54, 20-26% had ever used e-cigarettes compared with 18% of those aged 54-65, 11% of those aged 65-74 and 2% of those aged 75 and over. For adults aged 45-74, around half of those who had ever used e-cigarettes (11-20%) were still using them (6-11%). Around a fifth of adults aged 16-24 who had ever used e-cigarettes were currently using them in 2017 (5% were current users compared with 23% that reported having ever used e-cigarettes).
Age-related patterns in e-cigarette use have not changed over time. Table 5.12