It only takes two cigarettes a week for a child to show signs of nicotine addiction

It only takes two cigarettes a week for a child to show signs of nicotine addiction and around 80 per cent of adult smokers pick up the habit during childhood. Every hour, 13 people die from a smoking-related disease. And of every 1,000 young people who carry on smoking, half will die prematurely due to smoking.


It doesn't take a genius to work out that, if you are a health provider serious about stamping out smoking, it's best to start early, very early. Yet surprisingly, only one primary care trust in the country has set up and developed a smoking cessation course exclusively for children - Knowsley PCT in Merseyside.



In the short space of five years, the scheme has proved so successful that funding has more than doubled - from ?42k to ?90k. And while originally funding was secured from special short-term pots of cash - the health action zone in 1999 and the neighbourhood renewal fund in 2001 - the scheme now has mainstream financial backing from the PCT and the drug and alcohol action team. But how did it all start?


Knowsley is a deprived area of Liverpool with a high number of child smokers - 13.7 per cent compared to the national average of 10 per cent. Most of these start to smoke at the age of 11. Liz Gaulton, assistant director of public health at Knowsley PCT, explains: 'At the time, there was a national push on adult smoking cessation services. Many school nurses in Knowsley felt that there were a lot of children who were smoking yet there was no support given to them to quit.'


This concern was duplicated across the borough and PCT, with both determined to work on the issue together. The project began in 2000 with a team of three senior smoking cessation advisers - supervised by a senior school nurse. In 2001, extra funding secured two additional advisers. There is no standardised training for smoking cessation advisers, let alone a qualification for those working exclusively with children. Although the advisers in the Knowsley team all had experience of working with children and young people, they had to learn as they went along.


The first port of call was to get all 11 secondary schools in Knowsley on board. The advisers approached the school heads direct as well as youth club providers. Not all the schools were enthusiastic about the scheme but slowly the doors began to open and today all are participating.


Although Knowsley PCT had a good relationship with Healthy schools, which helped open doors for them, Ms Gaulton adds: 'With hindsight, it would have been better to have gone to a more senior level - perhaps to have had the director of education on board first. That's a lesson learnt.'


The advisers gave presentations at school assemblies and in youth clubs to make the young people aware of the service they offered. Not many pupils stay on until sixth form in Knowsley so the target age group was 11 to 16. After school quit clubs are open to 16- and 18-year-olds but so too are adult services. At the start of the project in 2000, Knowsley had asked the charity Shared Learning in Action (SLA) - which already had a great deal of experience in this area of health prevention - for help. SLA gave the team a two-day training course, which focused on how to get their message across in a classroom environment.















Through this process, it became clear that the resources available for adult quit groups were inadequate for their purposes. So the team worked with SLA, and the children and young people who were trying to quit, to develop resources. Ms Gaulton explains: 'Adult resources talked about dying early from heart disease and cancer but that isn't relevant if you're 13-years-old - it's years off. We had to go for more immediate issues - such as cost, the effect on your skin, and on taste, as well as the fact that it would damage your health in the long term.


'Also a lot of the images in the existing material were very white middle class. While Knowsley is a predominantly white area it is also a very deprived area, so we developed language and images in the resources that were specific to local children. The resources are quite culturally sensitive. They talk in a 'scouse' way - without being derogatory - in a terminology that the kids are used to. And the pictures [used] in booklets were developed by the children because they were images they could identify with. So that was quite a long process.' A manual for advisers was also published.


The next step was to standardise the programme so that it was ready for assessment - so that Knowsley PCT could prove it worked and, more importantly, to secure more funding. SLA, the team and the children defined the programme as a course of six core sessions - running through a standard set of activities with a follow-up additional four or five top-up sessions if requested.



But how does it actually work? Ms Gaulton explains: 'The children are invited to attend a support group - of no more than 10 - which runs as a closed group. They are told they can come along to learn about the dangers of smoking and to help cut down or help quit. In some cases, you can have someone who comes along with a friend who doesn't particularly want to quit or perhaps a friend who doesn't smoke.



'If somebody is having great difficulty with that then they can be seen one-to-one but it usually runs on a mutual support basis. We do carbon monoxide readings through a tube which the children blow into. We know that our quit rates are right because that's what the kids tell us but we also know through the carbon monoxide readings. They quite like doing the carbon monoxide readings because it's very immediate.'



The course explores the origins of smoking, what motivates them to smoke and what might motivate them to quit. But it is based on an empowerment model - which means it aims to increase the children's confidence. As Sue Occleston, director of SLA, argues: 'Rather than giving kids information, we actually did the training for them in participatory courses. Rather than telling them facts about smoking, we find out what they know already and build on that - it's about building self esteem.



'We ask them why they think they smoke and ask them what might make children more likely to smoke. It's about acknowledging that young people have their own thoughts and ideas about how they are going to solve a problem. You give them support in making decisions, building their confidence and raising their self-esteem.'



Many might be surprised to learn that the scheme steers clear of nicotine replacement therapy - it's all based on will power. Confidence building also has additional benefits to the most immediate aim of giving up smoking. As Ms Occleston argues: 'The relationship the smoking cessation advisers have with the children is really important. It's about caring and supporting and listening. It's a real self-esteem builder for a young person to have an adult sit down to listen to them and take them seriously.'



The scheme works because the children have chosen to be there and the good relationships built up with the advisers cements this. 'Although in some cases teaching staff and GPs refer pupils to the scheme, most is through self-referral,' says Ms Gaulton. 'There's a little box somewhere in school so they fill in a slip with their details and stick it in - nothing goes home at all. [Then] they are handed a brown envelope by their class teacher or mentor telling them when the group meets and to attend.'



In January last year, Liverpool John Moores University published the results of its evaluation of the scheme. It found that, after six weeks, 29 per cent of smokers had quit and a further 56 per cent had reduced the amount they smoked. It praised the scheme for the 'valuable information' it provided on young smokers. For example, the scheme established that friends and peer pressure were the most influential factors on young people to start smoking. Parents and siblings were not as influential.



The report also recommended that the scheme be expanded - particularly for those who had to drop out because of other school commitments. And it reinforced the idea that this is a worthwhile project and that there is a definite need to tackle smoking among young people. The Knowsley team is constantly looking to improve its service so has commissioned John Moores University to carry out further evaluation of the scheme over a longer period.



'This will look at quit rates over 12 months to see if kids who've quit, stay quit,' says Ms Gaulton. 'So one of our longer term aims is, "does this work in the long term and can we sell this to other areas of policy?". We need to know it's not a short-term fix. Another aim is around the high number of females who smoke compared to males that smoke. But, although we know the highest number is females, girls are better at attending the groups than boys, I think because girls are probably happier doing things in groups and have fewer hang-ups over coming forward for help. So we need to be better at targeting boys.'



Knowsley PCT is extending its work to include primary schools, targeting children aged between nine and 11. While it is very rare to find children smoking in this age group - the PCT believes it could benefit from smoking prevention work. Advisers hold sessions with the children, discussing the dangers and issues around smoking.



Another area that Knowsley plans to include is smoking cessation for young people with learning difficulties. Some preliminary work has already been done on this but it will need new resource material. Ms Occleston predicts too that more visual aids may be needed - particularly if reading skills are not that well developed - and more games may be incorporated as people with learning difficulties often have shorter concentration spans. More one-to-one work will probably also be required.



While further evaluation studies are being carried out, neighbouring St Helen's PCT has already implemented a scheme based on the Knowsley model. Liverpool John Moores University's evaluation report states: 'There is a need to tackle smoking among young people, from both a national and local direction and cessation programmes which specifically target young people appear to be reducing the number of smokers in this population.'



In July 2003, Knowsley won the Health and Social Care Award for Children and Young People for its pioneering work. One of the reasons Knowsley won was the fact that the work could be 'replicated'.
In fact, the award comprised ?15,000 to be used to provide training for other health providers. While it's never too late to give up, it also seems you're never too young to start the quitting process.



by Katie Coyne

Public Health News