Young People & Tobacco Young People & Tobacco Training – day 2Training – day 2

Rebecca Campbell and Sarah Lindsay

SmokeFree Services

NHS Greater Glasgow & Clyde

E-mail: sarah.lindsay@ggc.scot.nhs.uk

rebecca.campbell@ggc.scot.nhs.uk

Mixed messages exercise

The Tobacco Industry

• “ Younger adult smokers are the only source of replacement smokers... If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle.“ R.J.Reynolds, 1984

• "attract young smokers to replace the older ones who were dying or quitting …I was part of a scam, selling an image to young boys. My job was to get half a million kids to smoke by 1995"

• "They (13 year olds) represent tomorrows business.“(James Johnson CEO, R.J. Reynolds Tobacco Company, 1994, in testimony before the House of Energy and Commerce Sun Committee on Health and Environment.)

• "If you are really and truly not going to sell to children, you are going to be out of business in 30 years"(Bennett LeBow, Tobacco CEO)

• DVD – ‘Breath of Fresh Air’

Cannabis

Intro

• Class B drug – reclassified 2009• Still illegal• Maximum sentence for possession up to 5 years

imprisonment or an unlimited fine or both• Maximum sentence possession with intent to

supply up to 14 years imprisonment or an unlimited fine or both

• Illegal to drive under the influence of cannabis – disqualification

• Traces in urine up to 1 month

What is it?• Cannabis – general name for products from

plant Cannabis sativa• Contains over 400 chemicals, 60 responsible

for its unique effects• Main ingredient: THC (delta-9-tetrahydrocannabinol)

• Responsible for ‘stoned’ feeling, changes in mood, thoughts, perceptions & motor skills

• Travels to cannabis receptors in brain - activated

What is it?

• Strength depends on how much THC• 3 main forms: Grass, resin & oilGrass:• Dried flowering tops, leaves & stems of

plant• THC levels depend on growing conditions,

genetics (THC 7-15%)• Head has highest conc’n, followed by

leaves, little or none in stems / seeds • Skunk

Resin:• Solid lump of compressed parts of plant• Mixed with ‘fillers’: glue, dyes, solvents, henna, pine resin,

tranquilisers, tar, wax, boot polish, milk powder, dried excrement

• THC 3-7%Oil:

• Most concentrated• THC extracted using filtering & purification• Rare in UK• THC 50%

What are the effects?

• ‘Stoned’: feeling of mild euphoria & relaxation

• Perceptions altered: time distortion, short term memory altered, focus increased

• Intense / altered senses: to music, food, films

• ‘Munchies’• Often preferred to alcohol – calm as

opposed to violent / confrontational / no hangover

How is it used?

How is it used?

• Around 75% rolled & smoked with tobacco• Water pipe / Bong• Pipe• Neat cannabis• Eaten• Hot knives

Stats• In Scotland 11% of people aged 16-59 reported

taking cannabis in the previous year, 33% ever (2007)

• Most commonly used illicit drug

Stats

• 9.5 million people estimated to have ever used cannabis (England & Wales)

• 2.3 million estimated to have used cannabis in the last year

• 1.3 million in the last month

Stats

• 13% of 15 year old boys and 10% of 15 year old girls reported using cannabis in the last month.

• 19% of all 15 y.o. in last year• 2% of 13 year old boys and 2% of 13 year old

girls reported using cannabis in the last month

• 4% of all 13 y.o. in last year

Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS) national report 2008.

Is it addictive?

• Depends on definition of addiction – in control or not?

• Study by Swift et al 2001 – 1/3 met criteria• Suffer withdrawals: restless, anxious, insomnia,

loss of appetite• Mostly smoked with tobacco• Cannabis 1st, tobacco addiction follows• Smoke cigarettes if can’t get cannabis• Often want to stop cigarettes but not cannabis• Difficult to distinguish dependence to tobacco from

cannabis

Health Effects?

• Difficult to determine unique effects as mainly used with tobacco BUT

• High in toxins & carcinogens• Smoked without a filter• Held in for longer, deeper in lungs• Inhalation of any form of smoke is

detrimental to health: Carbon monoxide & toxins

Health Effects?

• Chronic inflammatory changes• COPD• Expands airways in lungs temporarily but

allows irritants & toxins to enter• Affects blood pressure & heart rate• Increase BP when sitting, decreases when

standing up – dizziness / fainting• In pregnancy: similar to tobacco effects• Thought to affect fertility

Mental Health?

• Some evidence showing links - disagreements• Modest association with early / regular use &

onset of depression (more common in women than men)

• Links to schizophrenia / psychosis but probably predisposed. More likely to precipitate onset or heighten an existing condition.

• 1 in 10 have panic attacks, paranoia, confusion, hallucinations. Usually pass after drug wears off.

Gateway?• Most heroin & cocaine users began on

cannabis• No evidence that it physiologically leads

them to crave other drugs BUT• Cannabis users more likely to experiment• Social contacts make this easy• However, majority of regular cannabis users

do not go on to harder drugs

Medicinal?

• Tinctures used in 19th Century to treat: asthma, bronchitis, migraine, depression

• Modulates pain in certain conditions: nausea, glaucoma, MS, epilepsy, asthma, arthritis, stroke, chemo

• Sativex sublingual spray:prescription medicine. Available as unlicensed medication in UK for individual patients

Stopping

• Stopping smoking cannabis is less easy than it sounds;

• identification of a time/date when you intend to stop• writing down reasons for wanting to stop• discarding cannabis-related paraphernalia• informing trusted friends that you are stopping and why• getting rid of numbers of suppliers and/or getting rid of

any remaining drugs• having identified triggers (e.g. music, TV etc) prepare to

avoid those triggers

Stopping

• have a strategy for dealing with cravings.• Learn techniques to help you relax and feel calm when

feeling restless or craving• Be aware that sleep will be disrupted and dreams more

vivid; develop techniques for getting to sleep and staying relaxed

• Develop a plan for the day and the week and stick with it• Be aware of improvements in energy levels, memory and

concentration.• Remember and rehearse reasons why you are not using• Treat yourself for your achievements• Don’t play with the idea of “just a little bit, as a treat…”

Harm Reduction?

• Other ways of using cannabis – should we mention these?

• If abstinence not possible, eating is a common way to use

• Not suggesting it to clients• Effects take 1 – 2 hours, last longer• Amount usually put in a joint• Recipes on internet• Better is passes through water – less oil and

soot

Resources

• www.knowthescore.info or freephone

0800 587 587 9

• www.cannabishelp.org.uk

• www.talktofrank.com or freephone

0800 77 66 00 (formerly National Drugs Helpline)

• www.hit.org.uk - What’s the deal booklets

Cannabis scenarios activity

Prevention workshop plans

Sample Workshop Plans

General Smoking Info – primary age (50mins)

Learning outcome:• To develop general tobacco knowledge.• To be able to discuss reasons people may start

smoking and why it’s difficult to stop.• To identify some of the health effects related to

smoking • To identify some of the chemicals in cigarettes.

Session plan:• Introduction- interested in the health of young people. What kinds

of things keep you healthy? Some things we do have an effect on us when we are older.

• Prevention catch ball • Breathing exercise – ask YP to ly down for 60 seconds count how

many breaths. Do 10-20 sit ups – now count how many breaths. Is it higher or lower than before? Smokers feel like this all the time because their heart is working harder.

• Straw exercise – ask YP to breath in and out. Quite easy? Now ask them to breath through a straw and ask them if this is more difficult than normal.

• What’s in a cig? - Big cigarette and tar jar • CSI <Name of school> - Body mapping in style of a murder scene • Higher lower quiz (goodie bag for the winning team) • SmokeFree Services details for families wishing to quit

General Smoking Info – 10 to 13yrs (50mins)

Learning Outcomes• To be able to discuss current level of knowledge and

also feelings and emotions around smoking-why start/stop etc

• To identify the associated health risks• To understand the financial cost of smoking

Session plan:• Introduction-why is this important? Give general

information around mortality stats• “Smoky Bingo”• Breath of fresh air DVD • Mind Mapping• Four Whys • CSI <Name of school or group>

Older group / more challenging audience

• Input as part of a back to work scheme or apprenticeship.

• Balancing act for those who are smokers and those who are not.

• Information giving and training

YouthBuild:• Smoking and cannabis • 16-24 yr olds (most younger age) • 1 hour session• Numbers: 11 maximum

Session plan• Smoky bingo (warm up) / prevention catch ball • What’s in a cig?• Effects of smoking on the body• Tobacco companies – quotes and DVD, pictures of what will appear on the

packets – will this make an impact?• What’s in cannabis?• Methods of use – pros and cons • Scenarios re cannabis and tobacco > discussion of what you would say to

get people to quit • Benefits of quitting flip chart exercise • Carbon monoxide monitoring (and explain why)• NRT information • Smoking cessation services available in Greater Glasgow and Clyde (for

those 18 and over).• Youth led prevention pilot recruitment

Youth Club: • Smoking and Cannabis• 12-18 years old• Various numbers (young people dropping in

and out) Session Plan:• What in a cigarette? Using chemicals board• Show Tar Jar & Jar of Phlegm • Carbon Monoxide Monitor• PowerPoint pictures of the Graphic pictures of

cigarette packets • Effects on the body – using body mapping• Cannabis PowerPoint • NRT Samples

Cessation: the evidence, the way forward and 10 top tips

Pilot projects

• 8 across Scotland between 2002 and 2005• Aims were:

– “to identify acceptable and potentially effective approaches to help young smokers to quit”

– “to enhance the knowledge, skills and confidence of young people to support future attempts to quit smoking”

• Fell short of agreed benchmark for quit rate – aim – 15% at 12 months, reality – under 3% at 12 months

(http://www.uknscc.org/2006_UKNSCC/presentations/amanda_amos.html)

Key Challenges

• Recruitment

• Logistical constraint e.g.lack of time and space

• Dealing with fluctuating attendance

• Keeping sessions fun

Conclusions

• Limited reach and low validated long-term quit rate suggest limited impact….

• However, individual projects reported less tangible benefits e.g. increased confidence and self-esteem

• Unable to produce a definitive answer as to the relative effectiveness of different youth cessation programmes

Conclusions (2)

• Young people differ from adults and service providers need help to meet these needs

• Services must be flexible • Smoking cannot be addressed in isolation• NRT could be beneficial in attracting /

engaging young people but its relationship with quit rate is unclear

• The issue of cannabis use cannot be ignored

Recommendations

Key principle/values of smoking cessation services for young people

• Being client-centred• Demonstrating trustworthiness• Responding to needs timeously• Focusing on client empowerment• Adopting a whole person (holistic) approach• Being non-judgemental• Establishing ‘rolling’ programmes of activities (clients

will ‘dip’ in and out of ‘treatment’)• Good “youth working” skills

Final reporthttp://www.healthscotland.com/

documents/1395.aspx

Summary report (recommend reading)http://www.ashscotland.org.uk/ash/

4502.html

Local picture • Mixed local picture between different CH(C)Ps • Youth cessation/prevention service integrated within youth health

structure (Inverclyde)• Pilot youth cessation service operating within a youth health

service providing NRT and behavioural support (Glasgow North, East Renfrewshire)

• Pilot youth cessation / related youth and tobacco service in operation (Glasgow West, Glasgow East)

• Pilot Looked After and Accommodated youth cessation service in operation (Glasgow City CHCPs, soon to be extended)

• No youth cessation service, but integrated youth health service (Glasgow South West)

• No youth cessation service, but youth worker potentially able to provide support (East Dunbartonshire)

• No youth cessation service, no integrated youth health service, but cessation advisor given named responsibility (West Dunbartonshire)

• No youth cessation service, but cessation advisor given named responsibility (Renfrewshire)

• Role of pharmacies in all of these areas

Proposed way forward

• Position statement

• Training > capacity building

• Mentoring

• Pathway

Top tips 1)Grab every opportunity to plant the seed for

future quit attempt

2)Use any method of communication that the young person is happy with – text, phone, email etc

3)Smoking diaries work well with young people

4)Be realistic

5)Give practical tips

6)Relate to young person as an individual

7)Prepare the young person about what to expect

Resources

• Me and my NRT contract

• Client record sheet

• Dependency measures and HONC tool

Client Record Sheet

Week / Date

Smoke StatusS= smokerN= non-smoker

CO Reading

Treatment :P= patch, G gum, N=nasal spray, L=lozenge, I=InhalatorM=microtab

ProductET=nicoretteEL=nicotinellCQ=Nicquitin

Dose Patch16/24

Comments on Treatment/Progess

Client Name:

Address:

Tel No:

Date:

Group / 1:1 (please circle)

For Groups Start Date

Source of Referral:

D.O.B Age

Gender: male/female

Yeah, but…no BUTTS!

Week / Date

Smoke StatusS= smokerN= non-smoker

CO Reading

Treatment :P= patch, G gum, N=nasal spray, L=lozenge, I=InhalatorM=microtab

ProductET=nicoretteEL=nicotinellCQ=Nicquitin

Dose Patch16/24

Comments on Treatment

Relapse: Yes/No Re-attempt: Yes/No How many times attempted? _ _ _ _ .

Still Quit after 3 months: Yes/No Verified with CO monitor: Yes/No

Still Quit after 12 months: Yes/No Verified with CO monitor: Yes/No

Client Referred to other Service: Yes/No Which Service(s)? _ _ _ _ _ _ Total number of referrals _ _ _ _

Number of Stress Management Sessions Attended Other support used _ _ _ _ _ _ _

KeyCD= Cut DownSTQA= Short Term Quit AttemptRS= Regular SmokerOC= Occasional SmokerCW= Client WithdrawnUS= Unreported Status

Briefing Notes(on form completion)

• Clients names and contact details must be taken.

• Date of 1st meeting, this will be used in evaluation so it is important.

• Start date of the group. This important as groups need to follow a set time table.

• Just circle either 1:1 or group. We are testing a model so delivery setting is important. In the instances where individuals come with friends then circle 1:1 and state that they are ‘with a friend’

• Source of referral is an evaluation question and therefore needs to be filled in.• Age is also important for the evaluation and DOB is a minimum dataset question.• The grid is pretty self explanatory. CO readings will not be recorded until the second

meeting. The first meeting is about getting to know the client and there are a lot of forms to fill out.

• Treatment information to be filled out once treatment is started. The last column allows for notes on any kind of progress and advisors are to refer to key at the bottom of the page. Any movement

Briefing Notes(on form completion cont….)

• The sections at the bottom are evaluation questions and therefore it is imperative that these are completed. The time specific sections to be filled out at the correct times.

Dependence measures 5. Smoking History(a) How long have you been smoking at least one cigarette a week (Please

Specify)?(b) How many cigarettes/roll ups do you usually smoke per day? 10 or less 11 – 20

21 – 30

More than 30 (c) Which best describes the way you smoke your cigarettes?Smoke the full cigarette Go twos up with a friend Share with a group Few drags now and then (d) How soon after getting up do you smoke? Within 5 minutes 6-30 minutes 31-60 minutes After 60minutes (If 30 minutes and under skip to question j) (e) If later than 30 minutes do you feel like you could smoke earlier but

things stop you from doing so? (parents not knowing you smoke) Yes No

(f) Do you smoke as soon as you can (on the way to school or as soon as you get there)?Yes No

(g) Do you find it hard not smoking in places where you’re not supposed to(e.g. school, in the library, cinema and other public places)?

Yes No (h) Do you feel that you are smoking because you need instead of just for the sake of it?

Yes No (i) When you are at home do you ever make excuses so that you can pop out for a cigarette?

Yes No (j) What cigarette would you hate to give up most?First thing in the morning Any other (k) Do you smoke more frequently during the first few hours after waking than during the rest of the

day?Yes No (l) Do you smoke when you are so ill that you are in bed most of the day?Yes No (m) How easy or difficult would you find it to go without smoking for a whole day?Very Easy Fairly Easy Fairly Difficult Very Difficult (n) Have you ever tried to give up smoking?Yes No Why do think you smoke?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Working with young Working with young people on smoking – the people on smoking – the

practical issuespractical issues

Questions to consider

• Who?

• Where?

• When?

• How?

• What?

Who?

• Who is your audience?

• Are they are smokers or are some non-smokers?

• Age group?

• Gender?

Where?

• If doing a prevention workshop this may be decided for you

• School setting?

• Older young people?

• Cessation service provision? – venue they already know

• Pharmacy – experiences from each area?

When?

• Again if prevention workshop this is sometimes dictated, but if choice not last thing on a Friday!

• Time and place convenient for attendees

• School and other commitments

• Time of year

How?

• Partnership working

• If attendance optional, what will you do to pull people in?

• Group or individual? Pros and cons

PRO’S

• Economical in time and effort

• Sharing information and experience among peers is beneficial

• Groups can encourage and prompt new areas of discussion

• Members can feel supported & motivated by group

CONS

• Group size may be a problem

(too few, too many)

• Group dynamics

• Location, timing, staff issues

• Gender and age issues

• Confidentiality issues

RUNNING EFFECTIVE GROUPS

• Make smoking info part of a wider programme

• Vary activities e.g. paired, group, serious, fun etc

• Avoid lecturing and give pupils ownership- they should participate in decisions about activities, ground rules etc

What?

• Have clear aims and objectives

• Check what is expected of you

• Prevention and cessation are not separate

• Remember resources

Questions to consider

• Challenging behaviour?

• Mental health?

• Responding to other issues

MONITORING & EVALUATION

• FOR YP

• FOR STAFF

• FOR FUNDERS/EMPLOYER

MONITORING & EVALUATION

BALANCING ACT

GOOD QUALITATIVE & QUANTITATIVE

DATA

YP, THEIR ABILITIES & INTEREST

Resources

• Development of a board-wide tobacco resource library• Workshop session

– Tar jar– Big cig– Chemical and accessories board– Scary tongue – Lou-wheeze – Prevention catch ball– CSI resources for body mapping– Quiz (and prizes)

• One to one – Paperwork – CO monitor

Local tobacco contacts InverclydeSarah Grant01475 506 018Sarah.Grant@renver-pct.scot.nhs.ukWest GlasgowSarah Brady/Nicola Mathieson0141 314 6221Sarah.brady@ggc.scot.nhs.ukNicola.Mathieson@ggc.scot.nhs.ukNorth GlasgowJulie Gordon0141 531 8717julie.gordon@ggc.scot.nhs.ukEast GlasgowAndrew Scott0141 201 9826andrew.scott@ggc.scot.nhs.ukSouth West GlasgowDaniel Maher0141 276 4665daniel.maher@ggc.scot.nhs.uk

Local tobacco contacts (2)South East GlasgowAnn Duffy / Heather Bath0141 531 8306ann.duffy@ggc.scot.nhs.ukHeather.bath@ggc.scot.nhs.ukEast RenfrewshireHazel-Ann McWhirter0141 577 6118HazelAnn.McWhirter@eastrenfrewshire.gov.ukRenfrewshireDan Kershaw01505 821362daniel.kershaw@renver-pct.scot.nhs.ukEast DunbartonshireLesley Kellas0141 201 3441lesley.kellas@ggc.scot.nhs.ukWest DunbartonshireFiona McLean0141 435 7507Fiona.mclean@ggc.scot.nhs.uk

Prevention catch ball!

Preparing and presenting a session or model

Activity

• Work individually or in small groups / those in similar job / using training for similar purpose

• How are you going to put this training into action?

• Design a prevention workshop or cessation intervention – realistic to what you can do in the real world

• Present bit of session back to group – as you would deliver it

• Outline:– Who you are targeting (age, gender, number

of people)– Aims and purpose of workshop, intervention– Group or individual?– Format/session plan – topics covered?– Resources and icebreakers – Why choose the approach you did?– Challenges?

Each person to present part of session to group

Dice evaluation

1 How will you use this training in your day job?

2 What were the 3 best bits?

3 What were the 3 least useful bits?

4 Anything you wanted to cover that we didn’t?

5 Do you feel confident to be able to provide cessation support / prevention workshops to young people? If not, what else would you need to be able to do this?

6 Is there any part of the service you feel you need more information about?

Questions

• Questions?

• Thank you

www.nhsggc.org.uk/ www.nhsggc.org.uk/ smokefreeservicessmokefreeservices

0800 84 84 840800 84 84 84SmokelineSmokeline