“But it’s the least of their problems…”

Barriers to managing tobacco dependence in young people under 18 in QueenslandPresented by Rebecca Mounsey (Dovetail)

Dovetail / Insight: Centre for Alcohol and Other Drug Training and Workforce Development

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We acknowledge the Traditional Owners of the land on which this event takes place and pay respect to Elders past and present.

Who are we?

www.dovetail.org.au

www.dovetail.org.au

Dovetail Resources

The Project Team

Cameron Francis (Co-Investigator)

Team Leader Dovetail

Rebecca Mounsey (Chief Investigator)

Senior Social Worker Dovetail

Dr Hoiyan Karen Li (Coordinating Principal Investigator)

Advanced Clinical Educator, Psychologist Insight

Introduction

https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019-in-brief/summary

1998Ban sales to U18s

2006Bans: outdoor eating or drinking places

2010• Annual 12.5%

increase each year in price from 2013 to 2020

2012• All tobacco

products must be in plain packaging

Tobacco use in the previous 4 weeks

BackgroundHealth and non-health related harms experienced by young people under 18

Conflict and breakdown in

living environment

Acquisition related harms

e.g. taken advantage of, smoking used

butts/illegal tobacco, engaging in crime to

obtain cigarettes, trading sexual favours

Harms to school

engagement

MethodsHuman Research Ethics Approval for this project was granted by The Prince Charles Hospital HREC/2020/QPCH/62735

• Snowball recruitment method / 12 x semi structured phone interviews in 2020 / grounded theory approach

Participants • Different professional backgrounds and roles• Different work settings (community, in-patient, school etc.)• Tobacco treatment experience varied from no specific experience to

qualified Tobacco Treatment Specialist • From various locations across Queensland (city, regional, remote)• Some working with Aboriginal and Torres Strait Islander young people

Findings

https://www.youthaodtoolbox.org.au/framework-resilience-based-intervention

INTERNAL RESOURCES

EXTERNAL RESOURCES

• Social• Material• Services

• Skills• Abilities • Beliefs

Barriers• Smoking being a primary coping

mechanism / limited other strategies for coping

• Don’t see tobacco as a drug• Don’t recognize any short-term

negative consequences • Not motivated by long term health

harms • No or fluctuating motivation to change

to smoking behaviour• Don’t believe they have a real

addiction / don’t understand withdrawal

Findings

INTERNAL RESOURCES

• Skills• Abilities • Beliefs

They don't see the smokes as an issue, they might see the cannabis as an issue because it’s illegal and they don't want to get in trouble with cops, but they think “ah I’ll just stick with the smokes”

Some of them really do use it as a stress reliever and to calm themselves and they will report… that they're actually smoking from stress

The motivation ebbs and flows… like at times it’s a high priority and at other times, “I need cigarettes because I'm stressed”

External resources - social

BARRIERS• Lack of family support to quit • Complex psychosocial issues within the

home• Living with people who smoke• Workers unable to work with family

members

EXTERNAL RESOURCES

• Social• Material• Services

Findings

Our low socio-economic families like… their kid wants to quit smoking and that's good, but they're just trying to pay the rent and get food on the table and get their car fixed or get to appointments themselves, they've got so many other things happening

I can talk to the student and give the student education… but then they’re going back into a home environment with the parents who haven't received any of that education… I've had a student and I gave him education and he came back a couple of weeks later and said he wanted to quit. And so we've gone down the whole path of calling Quitline and getting nicotine replacement therapy for him… however, both his parents smoke inside the house… he’s got the smoke constantly around him.

External resources - material

BARRIERS

• Lack of autonomous access to material resources like money and transport

EXTERNAL RESOURCES

• Social• Material• Services

Findings

So that can be a bit tricky, getting a hold of them, so even if it's phone consult… they've either… missed the call or… they don't have credit to return a call

It's a problem helping kids because of their age, they’re not adults and they don’t necessarily have parents support, so that's always a deal breaker… they can't physically take them themselves anywhere, they can't pay for any other services or pay for pharmaceuticals

External resources - services

Barriers • Services often don’t meet young people’s needs

(time to build rapport / hours of operation)• Conflicting service priorities and agendas• Lack of training and no identified response or

routine screening for smoking in some workplaces

• Existing intervention- both behavioural and Nicotine Replacement Therapy (NRT) based interventions, are often not always suitable, accessible or appropriate for young people

Findings

EXTERNAL RESOURCES

• Social• Material• Services

External resources - services - behavioural interventions Barriers• Behavioural interventions are often adult centric• Not appropriate to some young people’s literacy

levels • Not developmentally or age appropriate • Use motivators sometimes not relevant or important

to young people • Don’t always consider cultural context and

environment• Cessation based interventions are not always

appropriate for young people not yet ready to quit smoking

Findings

EXTERNAL RESOURCES

• Social• Material• Services

behavioural interventions

In every other area of alcohol and drugs, there’s harm minimization, continue to use, but use more safely… with tobacco smoking, it's all stop

The stuff we get tends to be very generic across the age span… the big smoking brochure… I don't give out because they just look at you and go, “what?”… I don't feel we have enough material to really be able to get some information across in a very age appropriate way

External resources - services - Nicotine Replacement Therapy (NRT)

Barriers for community-based workers: • Lack of access to NRT (young people and

workers)• Lack of capacity to support the young person

to start/use NRT

Findings

EXTERNAL RESOURCES

• Social• Material• Services

Nicotine Replacement Therapy (NRT)

No one's there when it arrives in the mail, who's going to say “this is how you use it, hey, open the box, come on, stick one in your mouth right now”

They can't get the NRT, like that's usually the issue. If you've got someone who's young and they don't have money, how, how are they going to get it?... And is it going to be served to them? So if you're 16 and you go down to the chemist are they going to sell it to you at the counter? Or are they going to say, “you need to have an adult with you”

It’s getting the educational partners to understand that it is really addictive. We need to have some sort of management plan to assist them with their addiction and helping them to limit the symptoms of withdrawal or behaviour that comes with that… allowing them to have breaks, allowing them to have nicotine replacement therapy gum [but] gum is banned in a lot of school settings…

External resources - services - Nicotine Replacement Therapy (NRT)

Barriers for in-patient workers: • Fear of misuse leading to difficulties gaining a

prescription for NRT• Lack of access to a range of NRT product types

and strengths • Issues supporting NRT use post discharge

Findings

EXTERNAL RESOURCES

• Social• Material• Services

Nicotine Replacement Therapy (NRT)

People are really fearful about being able to prescribe nicotine replacement therapy… because they’re under 18… it's actually easier for them to access butts and cigarettes

It’s not that it's contraindicated but it says “caution” under 12 and that can be a barrier… they go, “oh, can't use it in kids under 12” and so they're not proceeding any further

I've seen a number of young people who are unable to access NRT because they're come under the care of the state and nobody knows who can go and buy the nicotine replacement therapy… and how they can continue it as well. So that's been really difficult

You don't have the same treatment options [as you do with adults]. I think that's probably where it falls down… so you don't have differences with the patches, you don’t have the different strengthen of NRT, you can't give them a whole stack of it to self medicate

There’s a view that it’s those challenging, higher risk sort of behaviours… scoffing everything down in one go. They're just seen as riskier and more unpredictable, impulsive and more dysregulated.

External resources - services - Nicotine Replacement Therapy (NRT)Barriers related to NRT products: • Immediate adverse reactions (e.g. rash from patches)

• Sprays contain alcohol• Other pharmaceutical options

contraindicated for young people under eighteen

• NRT products are not youth friendly (e.g. the taste, method of use)

• Products can be hard for young people to use correctly (e.g. forgetting to put patches on)

Findings

EXTERNAL RESOURCES

• Social• Material• Services

Nicotine Replacement Therapy (NRT)

Even if they say “oh yeah, I could use that” Then the next week when I see them it's “okay, so have you worn your patches this week?” and it's like, “oh yeah, but I just keep forgetting”

I put a patch on him just to see how he would go… and he instantly came out in a rash… so just being a really young, young person, his skin was still really quite sensitive and so patches were out of the scenario because of that reaction… and then that makes it really difficult because he didn't feel that he would be able to access and use the nicotine gum in the right way as well

And my other strategies are giving samples of the nicotine therapy when I've got them rather than just going “go out and get some” because I’m making sure that they know what to do with it, what it tastes like, how to use it properly. That's when I'll discover that they hate everything

Summary 1

Lack of helpful and meaningful internal and external resources create barriers for workers addressing tobacco dependence in young people under 18. These barriers can look different depending on the worker setting, environmental and cultural context.

2

Existing tobacco treatment and interventions are adult centric and mostly cessation based therefore inappropriate for use with pre-contemplative under 18s.

3

There is a need for under 18 specific treatment and intervention, including harm reduction options and intervention that supports minimising boththe health and non-health related harms.

Limitations

Some key youth sectors were not represented whilstothers were potentially overrepresented

Potential selection bias due to the project title targeting those only experiencing barriers or difficulties

A note on future research

Given the increase in young people using e-cigarettes in 2021, future research may need to include nicotine containing e-cigarettes

It is important the voices of young people are heard on this topic

Acknowledgements

A very big THANK YOU to the 12 clinicians who took time out of their day to participate in this study.

Thanks for listening! Questions?

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WWW.DOVETAIL.ORG.AU

Rebecca.mounsey@health.qld.gov.au

info@dovetail.org.au

(07) 3837 5621

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References • Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019: in brief. Drug Statistics series no. 33. PHE 271.

Canberra: AIHW; 2020.

• Guerin N, White V. ASSAD 2017 statistics & trends: Australian secondary students’ use of tobacco, alcohol, over-the-counter drugs, and illicit substances. Melbourne: Cancer Council Victoria; 2018.

• State of Queensland (Department of Health). The Health of Queenslanders 2020. Report of the Chief Health Officer Queensland. Brisbane: Queensland Government; 2020. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0019/1011286/cho-report-2020-full.pdf.

• McNeill AD. The development of dependence on smoking in children. Br J Addict. 1991;86(5):589-92. doi: 10.1111/j.1360-0443.1991.tb01813.x

• O'Loughlin J, DiFranza J, Tyndale RF, Meshefedjian G, McMillan-Davey E, Clarke PBS, et al. Nicotine-dependence symptoms are associated with smoking frequency in adolescents. American Journal of Preventive Medicine. 2003;25(3):219-25. doi: https://doi.org/10.1016/S0749-3797(03)00198-3

• Doubeni CA, Reed G, DiFranza JR. Early Course of Nicotine Dependence in Adolescent Smokers. Pediatrics. 2010;125(6):1127. doi: 10.1542/peds.2009-0238

• Sargent JD, DiFranza JR. Tobacco control for clinicians who treat adolescents. CA. 2003;53(2):102-23. doi: 10.3322/canjclin.53.2.102

• The Centre for Youth AOD Practice Development. Framework for resilience-based intervention. cited October 2021. Available from: https://www.youthaodtoolbox.org.au/framework-resilience-based-intervention