How can we help young people avoid smoking? Evidence considered by NICE

1. How can we help young people avoid smoking?Evidence considered by NICE Andrew Hoy Analyst Centre for Public Health Excellence (CPHE)

2. In this presentation • Overview of NICE • A comprehensive tobacco control policy • Mass-media and point-of-sales measures to prevent the uptake of smoking by children and young people (PH14) • School-based interventions to prevent the uptake of smoking among children and young people (PH23) • Smoking cessation services in primary care, pharmacies, local authorities and workplaces (PH10) What evidence did NICE consider when developing guidance on young people and smoking?

3. (1) Overview of NICE The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health

4. NICE guidance • Public health – guidance on the promotion of good health and the prevention of ill health – for those working in the NHS, local authorities and the wider public, private and voluntary sectors • Health technologies / Interventional procedures – guidance on the use of new and existing medicines, treatments and procedures within the NHS • Clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS

5. Public Health Audiences • The NHS • Local government • Education • Private and voluntary sectors • Other arms of government • Employers

6. Centre for Public Health Excellence • Produces guidance according to two different processes: • Intervention guidance – PH14, PH23 • Programme guidance – PH10

7. Types of evidence

8. Reviewing evidence • Review(s) of effectiveness • assess quality • assess strength of evidence • assess applicability • Economic appraisal • review of evidence of cost effectiveness • analysis of cost effectiveness from NHS and public sector perspective • Quality Adjusted Life Year is main measure (QALY)

9. Where does NICE guidance apply? • Clinical guidelines and technology appraisal guidance applies to England and Wales • Interventional procedures guidance applies to England, Wales and Scotland • Public health guidance applies to England – but can be applied in Wales if agreed by Welsh Assembly

10. (2) A Comprehensive Tobacco Control Policy • Considers price • Protects people from tobacco smoke • Warns people (including mass media, health warnings, education etc) • Bans all forms of promotion • Helps smokers to quit • Monitors and evaluates programmes WHO: Report on the Global Tobacco Epidemic 2009 http://www.who.int/tobacco/mpower/2009/en/index.html

11. NICE Public Health guidance on smoking – past and future • Brief intervention and referral of smokers (PH1) • Workplace interventions to promote smoking cessation (PH5) • Preventing uptake of smoking in children and young people (PH14) [age of purchase and mass media] • School based interventions to prevent smoking (PH23) • Smoking cessation services (PH10) • Quitting smoking in pregnancy and following childbirth [June 2010]

12. (3) Mass-media and point-of-sales measures to prevent the uptake of smoking by children and young people (PH14)

13. Mass Media Interventions - Evidence • There is evidence that mass-media campaigns can prevent the uptake of smoking and also influence knowledge, attitudes and intentions of children and young people • Factors that influence effectiveness include message source, content, format, frequency and duration • Research recommendations, however, around the use of new media, and socioeconomic differences

14. Mass media campaigns - Recommendations • Mass media campaigns targeting young people should: • be informed by research that identifies and understands the target audiences • consider groups have higher than average or rising rates of smoking • be developed in partnership with: national, regional and local government and non-governmental organisations, the NHS, children and young people, media professionals, healthcare professionals, public relations agencies and local anti-tobacco activists • should not be developed in conjunction with the tobacco industry

15. Mass media campaigns - Effective messages (1) • Are based on strategic research and qualitative pre- and post-testing with the target audiences that: • elicit a strong, negative emotional reaction (for example, loss, disgust, fear) while providing sources of further information and support • portray tobacco as a deadly product, not just as a drug that is inappropriate for children and young people • use personal testimonials that children and young people can relate to • are presented by celebrities to whom children and young people can relate

16. Mass media campaigns - Effective Message (2) • empower children and young people to refuse offers of cigarettes • include graphic images portraying the detrimental effect on health as well as appearance (for example, on skin and teeth) • repeat the messages in a number of ways and regularly update them to keep audience attention The evidence is that young people, like adults, react well to frank descriptions of risk if they are also told about how to get help

17. Point of Sale Interventions - Evidence • Sales restrictions to under-age smokers do influence the number of sales • However, the evidence suggests that the effectiveness of point of sale restrictions is blunted by the fact that children in the earlier stages of smoking are more likely to get their cigarettes from friends and family (“social sources”) • A research recommendation on “unofficial sources” - how many of them, and who are they?

18. Point of Sale Interventions – Evidence (2) • Factors that have been shown to influence the success of these interventions include: • active enforcement • interventions driven by tobacco control bodies • requesting age / proof of ID The demographics of the target audience and the vendor / store clerk also impact on success

19. Point of Sale Interventions - Recommendations • National authorities • Support better enforcement of existing legislation by: • Working to make illegal tobacco sales a higher priority for local authorities • encouraging and providing local authorities with support • encouraging national organisations and local authorities to provide education and training programmes for trading standards officers • working with government agencies and national organisations to ensure retailers and others, such as publicans, are aware of legislation on under-age tobacco sales • ensuring magistrates are aware of the potential damage that smoking can do to children and young people; and the range of measures available to deter retailers

20. Point of Sale Interventions – Recommendations (2) • Ensure enforcement efforts are sustained over a number of years Local authorities / trading standards • Ensure retailers are aware of legislation • Make it as difficult as possible for young people under 18 to get tobacco products • Give practical advice on how to avoid illegal sales via vending machines • Work with other agencies to identify areas where under-age tobacco sales are a particular problem

21. Point of Sale Interventions – Recommendations (3) • Work with the Local Better Regulation Office to improve inspection and enforcement activities related to illegal tobacco sales. • Assess whether an advocacy campaign is needed to support enforcement. Any such campaign should be run in accordance with best practice and provide a clear, published statement on how to deal with under-age sales • Actively discourage use of enforcement and related campaigns developed by the tobacco industry. • Ensure efforts to reduce illegal tobacco sales by retailers are sustained

22. (4) School-based interventions to prevent the uptake of smoking among children and young people (PH23)

23. School based programmes – Evidence • Not much UK-based research, and evidence difficult to interpret and compare against back-drop of wider changes in tobacco control • Programmes judged to be cost-effective on the basis of delay to smoking, not impact on actual smoking rates • Evidence suggests that there was a “dose-response” effect • One provocative high quality UK study on peer-led interventions – and conflicting evidence overseas • Research recommendations emphasised the need for UK based research, including of peer-based programmes

24. School based programmes – Recommendations • Whole school approaches: Develop a whole-school or organisation-wide smokefree policy: • include smoking prevention activities • ensure the policy forms part of wider health strategies • widely publicise the policy • ensure the policy also supports smoking cessation Adult-led interventions: Deliver smoking prevention interventions as part of PSHE / drugs education and activities related to Healthy Schools or Healthy Further Education status

25. School based programmes – Recommendations (2) Peer-led interventions: Consider offering evidence-based, peer-led interventions aimed at preventing the uptake of smoking such as the ASSIST (A Stop Smoking in School Trial) programme Training: Provide training for all staff involved in prevention work, and work in partnership to design, deliver, monitor and evaluate smoking prevention training and interventions Local and regional coordinated approach: Ensure prevention interventions are part of a local tobacco control strategy, and are linked to regional and national tobacco control strategies. Ensure the interventions are integrated into the curriculum, PSHE education and work associated with Healthy Further Education and Healthy Schools status

26. (5) Smoking cessation services in primary care, pharmacies, local authorities and workplaces (PH10)

27. Smoking cessation services - Evidence • Originally not in the scope of this guidance to examine young people and Nicotine Replacement Therapy • However: • new licensing provisions were released for NRT relating to those aged 12 and older • an associated Technology Appraisal that NICE was doing at the same time on NRT • However, the Programme Development Group was aware of the lack of evidence of effective smoking cessation interventions for young people

28. Smoking cessation services - Recommendations • Because of lack of evidence, the recommendation suggests professional judgement to assess whether to offer NRT on a case-by-case basis • But the young person needs to be motivated – to “show a strong commitment” • This was IDE - “Inference Derived from Evidence” - which our committees are asked to do in the absence of direct evidence

29. (6) Conclusions and observations • A great deal of research in general which NICE can help make in-roads into smoking • Cautions: • Sometimes lack of UK-based research • Evidence can be difficult to interpret against a constantly changing back-drop Still, more than enough evidence to how the overwhelming cost-effectiveness of these types of measures – when the cost (in lives and money) of not doing them is considered

30. (7) Further information about NICE and tobacco guidance • http://www.nice.org.uk • The pieces of guidance discussed in this presentation can be found at: • http://www.nice.org.uk/ph14 • http://www.nice.org.uk/ph23 • http://www.nice.org.uk/ph10

31. Further Information about NICE Public Health Process and Methods Methods and process manuals available at: http://www.nice.org.uk/aboutnice/howwework/how_we_work.jsp