The challenges of getting youth cessation services right

Inroads into reducing adult smoking have been made in many countries, but there is little evidence of such positive progress in reducing adolescent smoking. In Scotland, for example, although prevalence of smoking among 15-year-old boys declined between 1994 and 2004, girls' smoking remained static [1, 2]. Most early efforts aimed at reducing youth smoking focused on preventing smoking initiation, but these had mixed success. In recent years, therefore, more attention has been paid to helping young smokers to stop. For example, the UK government's White Paper, Smoking Kills, emphasized the need to help adolescent smokers to quit and identified them as a priority group for National Health Service (NHS) stop smoking services. However, given the much larger evidence base for adult cessation and that evidence-based treatment was not widely available for adult smokers, most attention was placed rightly on adult smokers [3]. In 2005/6, only 3% of clients of the English NHS stop smoking services who set a quit date were under 18 years [4]. Research on adolescent smoking cessation is still in its infancy, and it is not yet clear how best to help adolescent smokers to stop. Most early research was carried out in the United States [5, 6], and demonstrated little success. This led to a number of qualitative research studies with young smokers which have explored the barriers to quitting and what they believe will best help them to stop. These have been carried out in various countries, including the United states, Canada, the United Kingdom ([e.g. [7-10]) and in the United Kingdom with both 11–15-year-olds [11] and older teenagers [12]. In this issue of Addiction a new study with adolescent smokers in Wales is published [13], making another useful addition to the field. Although these studies have employed different qualitative methods and techniques, some of their findings are remarkably similar and have started to generate important insights about how best to offer support to young smokers. Where the studies agree is that the existing cessation services are not attractive to adolescents, who find it difficult to imagine what these services involve, and some therefore view these negatively or as irrelevant. They also acknowledge that recruiting and encouraging young people to use cessation services may be challenging. Several studies have found that young people report being interested in quitting and having tried to quit on their own [9, 11]. However, young people's motivation is rather labile and they have mixed views about the importance of quitting within their own lives, and often feel that, compared to adults, they are still in control of their smoking and could quit if they wanted to without help [12]. The studies indicate that adolescent smokers require a more flexible provision of support. Where the studies differ with their conclusions is the way in which such services should be delivered, including who delivers them, in which settings and the type of support that is offered. The Welsh study suggests that friends and family members could be engaged more with the quitting process (although it seems that the young people were encouraged specifically to think of friends and family who had tried to quit and what helped them). Family doctors and teachers were not envisaged to be helpful, and drop-in services outside school were requested. However, other studies have found that the school is a useful setting when support is provided appropriately, because children are a captive audience [11]. Like some other studies, the new study found that nicotine replacement therapy (NRT) was viewed positively [11, 13], but others were less enthusiastic [12]. Perhaps these contradictory findings should not be surprising. Our work in Scotland [12] demonstrated that adolescent smoking ranges from intermittent non-addicted smoking to the highly dependent, so a much greater variety of measures and approaches may be required to support young smokers which will be dependent upon experiences of support from their immediate environment. The Welsh study concluded that provision of support for young smokers needs to be tailored more appropriately to adolescents' views and experiences. In taking this work forward, it will be necessary to balance what treatment and support people say they want with what works. The findings from a recent major pilot programme on youth cessation projects, funded by NHS Health Scotland and Action on Smoking and Health (ASH) Scotland, lend support to the importance of tailoring [14]. Most of these eight pilot projects found recruitment to be more difficult than expected, with considerable time and effort needed to be given to attracting young smokers and developing programmes that were flexible and acceptable. Although the evaluation of this initiative also re-emphasized the complex methodological issues involved in measuring cessation effectiveness with young smokers [14-16], the results showed that providing more tailored services does not translate to successful quitting. Reducing smoking among youth still has a long way to go, and further research is needed to enhance cessation in young smokers. We agree with the authors of this new study when they conclude that it is important to embed youth interventions, both prevention and cessation, within wider tobacco control strategy. England is the last country in the United Kingdom to introduce comprehensive smoke-free public places and those interacting with young people should maximize the opportunities this presents to encourage youth to quit. In addition, a new law in England and Wales raising the age of purchasing cigarettes to 18 might help (Scotland is likely to introduce similar legislation). However, further measures, including banning cigarette vending machines, eliminating tobacco marketing, implementing regular above inflation tax increases and supporting education and media campaigns, are needed [2].