Young People & Tobacco Training – day 2

1. Young People & Tobacco Training – 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

2. Mixed messages exercise

3. 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"

4. "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’

11. Cannabis

12. Intro • Class B drug – reclassified2009 • 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

13. 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

14. What is it? • Strength depends on how much THC • 3 main forms: Grass, resin & oil Grass: • 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

15. 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%

16. 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

17. How is it used?

18. How is it used? • Around 75% rolled & smoked with tobacco • Water pipe / Bong • Pipe • Neat cannabis • Eaten • Hot knives

19. Stats • In Scotland 11% of people aged 16-59 reported taking cannabis in the previous year, 33% ever (2007) • Most commonly used illicit drug

20. 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

21. 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.

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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

28. 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

29. 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…”

30. 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

31. 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

32. Cannabis scenarios activity

33. Prevention workshop plans

34. 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.

35. 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

36. 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

37. 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>

38. 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

39. 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

40. 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

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

42. 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)

43. Key Challenges • Recruitment • Logistical constraint e.g.lack of time and space • Dealing with fluctuating attendance • Keeping sessions fun

44. 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

45. 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

46. 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

47. Final report http://www.healthscotland.com/documents/1395.aspx Summary report (recommend reading) http://www.ashscotland.org.uk/ash/4502.html

48. 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

49. Proposed way forward • Position statement • Training > capacity building • Mentoring • Pathway

50. 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