3.2.2. Thematic Framework Analysis
Eight themes were identified from the transcribed interview data; six a priori themes comprised: tobacco policy rhetoric and operational reality; tobacco use in residential units for looked-after children and young people; sourcing of tobacco by young people; staff attitudes towards addressing tobacco use by looked-after young people; strategies adopted to address tobacco use in residential units for looked-after children and young people; and tobacco-related staff development. Two further themes emerged: the use of electronic cigarette and new psychotropic substances (“legal highs”).
Theme 1: Tobacco policy rhetoric and operational reality
All participants reported awareness of the local authority’s smoke-free policy, and in contrast to the findings from the survey, also described adherence to the policy by staff and visitors. However, for the young people themselves, and in spite of the smoke-free policy which prohibits tobacco use by looked-after children and young people, designated smoking areas were reported to be provided in the gardens of all three units. This provision was believed by Managers and RCOs to minimize risks in terms of safeguarding young people, and reportedly reduced young people’s involvement in anti-social or criminogenic behaviours.
“If young people have to go off of site to smoke, that increases the risk. If we had young people constantly at the top of the driveway, you would get are undesirable people thinking that there is a group of young people stood there and would want to see what was going on. We have to balance their safety with trying to enforce no-smoking”.
Smoking by young people within the units was reported to be governed by a number of “local rules”, which included limiting the number of young people using the “smoking area” at any one time, and the “handing in” of tobacco and smoking paraphernalia overnight. The majority of young people were perceived to comply with these rules.
Theme 2: Tobacco use in residential units for looked-after children and young people
Participants reported that very few young people initiated smoking after entry to the units, and expressed that the majority had taken up smoking while living with birth parents or foster carers.
“Most of the young people smoke before they come here, there is only one in the last year or so, since I have been here that has started while they had been in the unit. I think the reason he started was because he had come from home and wanted to be socially accepted. He just wanted to be one of the boys I think”.
Tobacco use within residential units was identified by participants as problematic, complex, and frustrating. For example, smoking was perceived to create environmental and health and safety risks, not only to the smoker, but also the other young people and staff within the unit.
“You get children smoking in their rooms, falling out, passing and bribing cigarettes; you get them flicking lighters, burning things, stubbing fags out here, there, and everywhere. It’s a health and safety nightmare”!
Other participants commented that tobacco caused tensions between young people and residential carers that were considered intimidating and at times violent.
“One young person came here from a home where I used to work so I already knew him. He was a big lad and if he didn’t have his tobacco he would smash things up. I do think maybe at one point we did have permission from his mum to actually supply him with tobacco, if it got really, really bad”.
Participants voiced frustration in relation to tobacco’s impact on the running of the residential unit.
“It [smoking] is an issue, and has been previously. Young people use it as an excuse for not doing things, that the really should be doing. For example, we’ve had young people saying “I can’t go to school, without a cigarette”. So sometimes, it’s very cleverly used by young people to avoid doing things that they really need to be doing”.
Tobacco use was suggested by participants to be the basis for many peer-to-peer relationships within the units, and often the cause of turbulence within friendships. Young people were also described as using tobacco as a tool to control or manipulate other young people within the unit, residential carers, or family members.
“Smoking is used to cause disruption or issues within the unit. Most of them are smoking because they can and it’s a big thing to hit out at the world and adults around them with. It [addiction to tobacco] is used as an excuse… for example if a young person has ran out of tobacco, they will kick off claiming that another young person has stolen it—they’re just trying it on with their behaviour to get us on side… to give them tobacco or ask another young person to share theirs—not that we ever would”!
Participants reported that parents used tobacco as a means of controlling their child’s behaviour or to prevent engagement in criminogenic activity.
“She [Mother] is intimidated by her son, and so she gets worried because he gets aggressive without tobacco; even though she doesn’t live anywhere close to him. He becomes so abusive, that she puts some money in to his bank, to please him, and that’s how it continues”.
Theme 3: Sourcing of tobacco by looked-after young people
Participants described how young people living in the units sourced tobacco with relative ease within their local community. A number of sources were identified, from which young people could obtain tobacco, including: parental supply during contact visits, or occasionally through the post to the unit; socially though sharing or selling/purchasing tobacco between peers; proxy purchases by members of the general public; or direct purchasing from retailers willing to make under-age sales or from “fag houses” in the local community. Both managers and RCOs considered young people astute in their ability to identify sources of illicit tobacco within the community in relatively short periods of time after entering the units.
“The places that they [young people] know in town where they can go and get the under the counter stuff—they’ll know all about that... Some will just go outside on the road here begging cigarettes, or they’ll go in to town, outside of the pub—it’s very dangerous, but if they are addicted…”
Young people were reported to adopt a number of risky practices when they were without the means to purchase tobacco. These included: approaching members of the public, to whom they are not known, in a variety of locations, including public houses, to “cadge” cigarettes; smoking previously discarded cigarettes, retrieved from pavements or public ashtrays; and young females were reported to engage in inappropriate relationships with older males through which they were provided with tobacco. Participants claimed a small number of young people had provided sexual favors in return for cigarettes; such a practice was considered prevalent by participants in other local authorities across the region.
“A lot of the time its “well, I gave ‘em a shag, cause I wanted a fag!” It’s that casual. The young people don’t see anything wrong with that—just another commodity…”
Theme 4: Staff attitudes towards addressing tobacco use by looked-after young people
Participants believed smoking to be harmful. However, for some tobacco use was perceived to have a positive effect, particularly in assisting young people to overcome issues with, self-esteem, attachment, or negative pre-care experiences.
“If they [young people] have experienced any type of abuse in their family home, smoking is used as a coping mechanism, that really needs to be addressed, or if they have low self-confidence, or a lack of identity we need to address those issues, perhaps before we then move on to think about giving up smoking. Those needs are greater and smoking fills the void until those problems are resolved”.
Participants reported a perceived responsibility to encourage young people to address their tobacco use. While engagement by young people in discussions regarding smoking was reported, participants questioned the impact of their practice to discourage tobacco use among young people. Reasons for this related to beliefs that: anti-smoking messages lost meaning since they were repeated “ad nauseam”; making offers of treatment to smokers who were not sufficiently motivated to quit added to the stigma already experienced by young people; and that young people’s engagement with cessation services was a tokenistic gesture made as a means of placating and maintaining good relations with carers. Participants expressed pessimism in relation to young people successfully quitting smoking.
“I don’t think its (smoking) something that they are afraid of or uncomfortable discussing! They’ll agree with us, probably to stay on side, but when it comes down to it (attending the smoking cessation service) they always find reasons not to go—there is always something else they need to do. These young people find it very difficult to talk to people they don’t know”!
Theme 5: Strategies adopted to address tobacco use in residential units for looked-after children and young people
Participants reported confidence in their ability to advise and support young people in addressing smoking. A number of strategies were reportedly adopted by participants to reduce the use of tobacco within residential units. These included positive role modelling and highlighting to young people the negative aesthetic and monetary aspects of smoking. In one unit, temporary abstinence was reported to be incentivized, through the use of adventure type short-breaks for young people, during which smoking was not permitted. Participants considered confronting young people with the adverse health impacts of tobacco use to be ineffective.
“Because of the situations they’re [young people] in with their lives, not living with their families, being moved from place to place; I really don’t think that they give a monkeys’ about their future! Everything is day to day, talking to them about smoking causing cancer, maybe in 50 years’ time—I don’t think that they can see that far ahead”!
Members of residential staff who reported current smoking, claimed to take care not to reveal their own smoking behaviour to young people within the units. Discovery of staff smoking by young people was reported to have led to incidents of harassment of staff by young people. While some participants believed that the awareness of young people of staff smoking was positive, and promoted frank discussions, the majority considered it to counter positive image that residential carers were required to portray.
“…and it can be difficult for a smoker to say to a young person “you shouldn’t be doing this” “this is bad for your health”—I think that some staff that feel uncomfortable with that double standard”.
Participants provided accounts of interactions with social care professionals and health services in relation to smoking and suggested that interest and engagement with reducing smoking was varied. A need to improve the process of sharing information about young people’s smoking status was highlighted by participants. In particular, the importance of information relating to the young person’s dependence on tobacco was identified. This was felt to be particularly important during the “settling in phase” due to the young person encountering limited sources of tobacco and the potential psychological challenges related to a placement change, that may be confounded by nicotine withdrawal.
“Some social workers will tell you ”oh they don’t smoke that much!” and suddenly you find that most of their [young person]challenging behaviours are around the fact that haven’t got a cigarette—so they must smoke a fair amount, because their behaviour tells you they’re desperate”.
The statutory health assessment for looked-after children and young people provides an opportunity for addressing tobacco dependence. However, given the additional needs of residentially accommodated young people, participants described smoking as being overlooked, particularly in the context of wider health needs.
“During the health assessments, they’ll [specialist nurses for looked-after children and young people] ask “do you smoke?”, and if yes they just put a ‘Y’ in the box and then it’s on to the next bit...”
Links with local health services including smoking cessation teams were reported to be positive, with joint working and an understanding of the complexities of “being in care” being displayed by local smoking cessation advisors. Such attributes were suggested by participants to allow young people to engage with services, if they wish and on their own terms. A proactive approach to limiting young people’s access to tobacco was also adopted. Partnerships forged within the local community were believed by participants to be invaluable in addressing issues of underage, proxy, or illicit tobacco purchasing.
“We work really closely with the PCSOs [Police Community Support Officers]. We build relationships between them and the young people, so that they [PCSOs] can monitor our young people—if they see them in town. With it being a fairly small town, we get a lot of telephone calls from retailers as well saying that someone [from our unit] is trying to buy cigarettes… Friends of people who work here will ring in to say one of the young people is stopping passers-by in the street [to obtain cigarettes]. That’s a big thing, if you have a community reporting back to you, then it’s a fantastic network”!
Theme 7: Electronic cigarette use
Electronic cigarette use was discussed by participants across all three units. Concerns were expressed in relation to the safety of products, including the potential health implications and the media reported risk of fire. Other concerns related to the tensions that electronic cigarette use reportedly caused within the units.
“One of our smokers has one of those bloody vape things! I don’t agree with them at all, I think they are disgusting… there is not enough research into them. I think they are just as bad as cigarettes, if not more so. People use them more and they are flavored for god’s sake! They’re like Alco-pops used to be and they should be banned”!
Theme 8: New Psychotropic Substances (legal highs)
Defined by the UK Home Office’s expert panel review in October 2014, new psychotropic substances (NPS) are “psychoactive drugs, newly available in the UK, which are not prohibited by the United Nations Drug Conventions, but which may pose a public health threat comparable to those substances listed in those conventions. The key features are that NPS are psychoactive, in that they stimulate or suppress the nervous system, or cause dependence; have a comparable level of potential harm to internationally controlled drugs; and are newly available, rather than newly invented”. Legal highs were mentioned by participants from two units. Frustration was expressed by staff in being unable to remove the substances from LAC, given that possession of such substances is not illegal. Others highlighted the contribution of legal highs to tobacco-related adverse behaviours within the units and the impact on the capacity of the unit as a whole.
“(Young person) doesn’t only smoke tobacco, but legal highs also. It creates a massive issue for us and we do get the flips between being completely unconscious and his additional needs in terms of being monitored to really violent outbursts because he is coming down and really needing tobacco and that’s when he becomes violent—harassing people, and banging on doors to get people up because he knows that they have tobacco”.