Scottish Health Survey 2015 - volume 1: main report

5 Smoking

Linsay Gray and Alastair H Leyland

Summary

• Self-reported smoking levels for adults in 2015 have decreased significantly from 28% in 2003 to 21% in 2015.
• When adjusted for cotinine levels, prevalence among all adults for 2014/2015 was 25%.
• The mean number of cigarettes smoked per day by adults smokers decreased from 15.3 in 2003 to 12.6 in 2015.
• A significantly higher mean number of cigarettes were smoked by male smokers (13.9 per day) than female smokers (11.3).

• Levels of current e-cigarette usage among adults increased significantly from 5% in 2014 to 7% in 2015.
• Current e-cigarette usage was at comparable levels in 2015 for men (6%) and women (7%), but higher for those aged 25-64 (7-9%) than other age groups.
• Younger adults were much more likely to have ever tried e-cigarettes than older ones (22-26% of those aged 16-34, compared with 4-10% of those aged 65 and over).

• There was a significant decrease from 2014 to 2015 in the proportion of children who were exposed to second-hand smoke in the home (11% to 6%).
• There was also a significant decrease from 2014 to 2015 in the proportion of children who lived in accommodation where someone smoked inside (16% to 12%).

• The proportion of non-smokers aged 16 and over who said they'd been exposed to second-hand smoke in their own or other people's homes declined from 25% in 2003 to 12% in 2015 and was significantly higher in 2015 for women (14%) than men (11%).

5.1 Introduction

Nationally ^[1] and globally ^[2] , tobacco use is the leading cause of preventable poor health and premature mortality, each year killing around 6 million people and costing over half a trillion dollars worldwide ^[3] . In Scotland alone, tobacco use is associated with around 10,000 deaths (around a fifth of all deaths) ^[4] .

5.1.1 Policy background

Several of the Scottish Government's National Indicators are relevant to smoking ^[5] . In addition to the specific indicator to reduce the proportion of adults who are current smokers (measured using SHeS data), there are more general related indicators on, for example, reducing premature mortality and reducing emergency admissions to hospital ^[6] .

The Tobacco Control Strategy ^[7] lays out the Scottish Government's vision to create a 'tobacco-free generation' (defined as 'a smoking prevalence among the adult population of 5% or lower') by the year 2034. Actions arising from the strategy are structured around the themes of prevention, protection and cessation. Smoking cessation interventions, including pharmacotherapy, are among the most cost-effective health care interventions available ^[8] .

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill was passed at Stage 3 in March 2016. The Bill introduces the following provisions:

• the introduction of a minimum age of 18 for the sale of Nicotine Vapour Products ( NVPs).
• a prohibition on the sale of NVPs from vending machines.
• 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 ban on unauthorised sales of tobacco and NVPs by under 18s.
• the introduction of statutory smoke-free perimeters around buildings on NHS hospital sites.

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) ^[9] .

5.1.2 Reporting on smoking in the Scottish Health Survey ( SHeS)

Reliable data on smoking behaviour, cessation, 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 figures for prevalence of cigarette smoking (including adjustment for saliva cotinine), e-cigarette use and exposure to second-hand smoke.

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.

5.1.3 Comparability with other UK statistics

The Health Survey for England, Health Survey for Northern Ireland and Welsh Health Survey 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[10]. Smoking prevalence estimates from the UK-wide Integrated Household Survey for Scotland, Wales, England and Northern Ireland have been deemed to be fully comparable.

5.2 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

Questions on smoking have been included in SHeS since 1995. Some small changes were made to the questions in 2008 and 2012. These are outlined in the relevant annual reports ^[11,12] .

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 Definitions

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 the original self-reported cigarette smoking levels by including those with cotinine levels in their saliva above 12ng/ml in saliva, with this indicating 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 5.3 (showing figures both adjusted for saliva cotinine and unadjusted). This is as it was not possible to tell whether any raised cotinine levels among this group were due to the e-cigarettes and NRT products alone, or additionally to unreported smoking.

Children's exposure to second-hand smoke

Children's (age 0-15) exposure to second-hand smoke 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.

5.3 Cigarette Smoking Status

5.3.1 Trends in cigarette smoking status since 1995

Table 5.1 presents, for 1995 to 2015, the breakdown by sex for each of the self-reported cigarette smoking status groups for all adults aged 16 and over and the mean number of cigarettes smoked daily by adult smokers. Due to changes to the age range of the sample, data are presented for all adults aged 16 and over since 2003 along with data for individuals aged 16-64 from 1995.

The current smoking level for all adults aged 16 and over dropped significantly from 28% in 2003 to 21% in 2015. There was no significant change in the most recent time periods, with current smoking prevalence at levels ranging from 21-22% from 2013 to 2015. Figures for adults aged 16-64 showed a significant decline in current smoking levels from 35% in 1995 to 31% in 2003, with there then being a further significant decline to 23% in 2015.

The proportion of adults aged 16 and over who had never smoked, or had never smoked regularly increased from 50% in 2003 to 55% in 2011; since then, the figures have remained almost static at 54-55% (54% in 2015). The proportion of all adults identifying as ex-regular smokers increased significantly between 2003 (22%) and 2015 (25%). The trends in adult smoking status were similar for men and women.

There was a significant decrease over time in the mean number of cigarettes smoked per day for current adult smokers aged 16 and over, from 15.3 cigarettes in 2003 to 12.6 cigarettes in 2015. Mean figures for adults aged 16-64 suggest that this trend began earlier, with a decrease from 16.7 cigarettes in 1995 to 15.3 in 2003, with a subsequent significant decrease taking this to 12.3 in 2015. The decrease for adults aged 16 and over was seen for both male smokers (15.9 cigarettes per day in 2003 to 13.9 in 2015) and female smokers (14.7 cigarettes and 11.3 respectively).

Figure 5A, Table 5.1

5.3.2 Cigarette smoking status in 2015

Figure 5B, Figure 5C and Table 5.2 show the data on self-reported cigarette smoking status for all adults aged 16 and over in 2015 by age and sex. Just over one in five (21%) adults reported that they were current smokers in 2015, with no significant difference between men (22%) and women (20%). The rest comprised of 25% adults who used to smoke regularly and 54% who reported that they had either never smoked at all, or used to smoke, but not regularly. Men were significantly more likely than women to be ex-regular smokers (27% compared with 23%) and less likely to be never/never regular smokers (51% compared with 57%).

There were clear differences in cigarette smoking status by age in 2015, as noted in previous Scottish Health Survey reports ^[13] . Self-reported current smoking prevalence in 2015 was highest among those aged 25-54 (24-26%), lower among those aged 16-24 (21%) and those aged 55-74 (15-21%) and lowest among those aged 75 and over (8%). Similar patterns were seen for both sexes, with both having lowest current smoking prevalence among those aged 75 and over (9% for men, 8% for women).

The proportion of people identifying as ex-regular smokers in 2015 was lowest for the youngest age group (6% for those aged 16-24) and highest for the older adults (37-40% for those aged 65 and over). The youngest age group were most likely to have never smoked or have never smoked regularly (73% for those aged 16-24 compared with 48-54% of those aged 25 and over). These patterns generally held for both men and women, although a significantly higher proportion of women aged 75 and over than men in the same age group had never smoked or never smoked regularly (59% compared with 40%) and a lower proportion were ex-regular smokers (33% compared with 52% respectively).

The mean number of cigarettes smoked per day per adult smoker in 2015 is also shown in Table 5.2. The overall mean for all adults in 2015 was 12.6 cigarettes, but levels were significantly higher for male (13.9 cigarettes) than female smokers (11.3 cigarettes). Younger smokers smoked the fewest cigarettes on average per day (10.5-11.4 cigarettes for smokers aged 16-44) with higher average numbers for those aged 45-74 (between 13.8 and 15.5 cigarettes). The pattern of numbers of cigarettes consumed across age groups was similar for male and female smokers.

Figure 5B, Figure 5C, Table 5.2

5.3.3 Cotinine-adjusted cigarette smoking status in 2014/2015 (combined)

The calculation of cotinine-adjusted cigarette smoking status is discussed in Section 5.2.3. As the sample for this section (the sub-sample of participants who participated in the biological module and provided a valid saliva sample) is reduced relative to the entire survey sample, the figures presented here are based on data from both the 2014 and 2015 surveys combined and, as a result, differ to those presented in Table 5.2.

For both men and women aged 16 and over in 2014/2015, just over a fifth (22%) self-reported as current cigarette smokers. When adjusted for cotinine levels, prevalence rose to 25% for all adults (26% for men and 24% for women). The gap of three percentage points at a total level (four percentage points for men and two percentage points for women) between self-reported smoking status and the cotinine-adjusted smoking prevalence is consistent with previously reported SHeS findings (gaps of four, five and three percentage points respectively in 2012/2013) ^[14] .

Table 5.3

5.4 E-Cigarette Use

Figure 5D, Figure 5E and Table 5.4 show data on use of e-cigarettes among adults aged 16 and over separately for 2014 and 2015, by age and sex. In 2015, 7% of adults aged 16 and over were currently using e-cigarettes with a further 11% having previously used them and 83% never having used them. There was a significant increase from 2014 in the proportion of current users (7% in 2015 compared with 5% in 2014), no significant difference in the proportion having previously used e-cigarettes (11% compared with 10%), and a significant decrease in those having never used them (83% compared with 85%).

Usage patterns did not vary by sex in 2015, with there being no significant difference in the proportions that currently use (6% for men compared with 7% for women), previously used (12% compared with 10%) or never used e-cigarettes (82% compared with 83%). E-cigarette use in 2015 did vary with age. The prevalence of current use of e-cigarettes in 2015 was highest among the middle age groups (7-9% among those aged 25-64) and lower for the youngest (4% among individuals aged 16-24) and older adults (2-4% for those aged 65 and over). Similar patterns were seen for both men and women.

Past/current usage showed a strong association with age. Around a quarter of those aged 16-34 had ever tried or were currently using e-cigarettes (22-26%) compared with one in ten of those aged 65-74 (10%) and less than one in twenty of those aged 75 and over (4%). For those aged 45 and over, roughly half of those who had ever used e-cigarettes (4-18%) were still using them (2-9%). Of those aged 16-24 around a fifth of those who had ever used e-cigarettes (22%) were currently using them (4%).

Figure 5D, Figure 5E, Table 5.4

5.5 Trends In Exposure To Second-Hand Smoke

5.5.1 Non-smokers' exposure to second-hand smoke since 1998

Adult participants who self-reported as non-smoking have been asked since 1998 about their exposure to second-hand smoke in a range of public and private settings. As previously reported in SHeS ^[14] , exposure to second-hand smoke had fallen markedly since the introduction of the ban on smoking in public places in 2006. Questionnaire changes introduced in 2012 mean that some trends can no longer be reported across the series (see footnotes to Table 5.5; trend figures for the period up to 2011 are available in Table 5.6 of the 2011 report) ^[15] .

Table 5.5 gives non-smokers' self-reported exposure to smoke in a range of locations, since 1998 by sex. The 1998 survey includes adults aged 16-74 only, with the following discussion of trends concentrating primarily on the trend for all adults aged 16 and over from 2003.

The proportion of non-smokers aged 16 and over reporting being exposed to second-hand smoke in their own or other people's homes has dropped from 25% in 2003 to 12% in 2015, with data for those aged 16-74 suggesting this trend began earlier (declining from 33% in 1998 to 27% in 2003, and then to 13% in 2015). Non-smoking women were significantly more likely to have been exposed to second-hand smoke in their own or other people's home than non-smoking men in 2015 (14% compared with 11%).

Data on second-hand smoke exposure in any public place in 2015 is only comparable with data collected since 2012 due to changes in definitions (see footnotes to Table 5.5). Under the definition used in recent years, the percentage of adult non-smokers aged 16 and over exposed in any public place was 16% in 2015, with little change since 2012 (between 16% and 18%). Figures for men and women in 2015 were identical (both 16%).

Non-smokers' were asked to state their exposure to second-hand smoke in their or other people's homes, at work, outside buildings, in cars/vans and in other public places, with this data being collected from 2012 onwards. Whereas in each of 2012, 2013 and 2014 70% of non-smokers said they had not been exposed to smoke at any of these places, this rose significantly to 74% in 2015, with identical figures for both men and women (74% each).

Table 5.5

5.5.2 Children's exposure to second-hand smoke since 2012

The two measures of children's exposure to smoke at home - 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 aged 0-15 are exposed to smoke at home - are presented for 2012 to 2015 in Figure 5F and Table 5.6.

In 2015, 12% of children lived in accommodation in which someone smoked inside, with no statistically significant difference by sex (12% of boys and 11% of girls). The 2015 figure for all children represented a significant decrease on all previous survey years (19% in 2012, 16% in 2013 and 2014). The same pattern of statistically significant decreases was seen for both boys and girls.

A lower proportion of children (6%) was reported to be exposed to second-hand smoke in their home in 2015 than in 2012 (12%), and 2013 and 2014 (11% in both years). Again, there was a comparable pattern of a statistically significant decrease for both boys and girls. The data show that the target to reduce the percentage of children exposed to smoke at home to 6% by 2020 has been met by 2015. This figure (and the others in this section) will be examined in future years to assess whether this result is an outlier.

Figure 5F, Table 5.6

5.5.3 Saliva cotinine levels among self-reported cotinine validated non-smokers since 2003

The geometric mean ^[16] cotinine levels of non-smokers aged 16 and over since 2003 are presented by sex in Table 5.7. To be included here, self-reported non-smokers had to have a cotinine level below 12ng/ml (higher levels would suggest that these were smokers who misreported their behaviour in the interview). Geometric means have been used rather than arithmetic means as they take into account extreme values arising from the skewed distribution of data for non-smokers (the glossary at the end of this volume contains more details of these terms).

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 has occurred since, with non-smokers' mean cotinine levels reaching 0.09 ng/ml in 2014/2015. There were no significant differences between men and women, with both having a similar geometric mean cotinine level in 2015 (0.09 ng/ml for men compared with 0.08 ng/ml for women).

Table 5.7