JSNA topic report : healthy lifestyles - smoking and tobacco control

Smoking is one of the leading causes of preventable illness and early death (source: Smoking and tobacco: applying All Our Health, Office for Health Improvement & Disparities).

It is also the biggest cause of health inequalities in the United Kingdom (UK), accounting for half the difference in life expectancy between the most and least deprived in society (source: Health inequalities and smoking, ASH).

There is clear evidence that smoking:

• increases the risk of developing more than 50 serious health conditions, some may be fatal, and others can cause irreversible long-term damage to your health
• damages the lungs, leading to conditions such as chronic obstructive pulmonary disease (COPD) and pneumonia.
• causes about 70% of lung cancers and increases the risk of many other types of cancers.
• damages the heart and blood circulation, increasing the risk of developing conditions such as coronary heart disease and stroke.
• can worsen or prolong the symptoms of respiratory conditions such as asthma or respiratory tract infections like the common cold

Source: 'What are the health risks of smoking?, NHS website'

Approximately 64,000 people are killed by smoking each year but around twice as many people as have died from coronavirus (COVID-19) in the last 12 months (source: ASH ready reckoner). In 2019/20 there were estimated to be 506,100 hospital admissions attributable to smoking in England (source: Smoking and tobacco: applying All Our Health, Office for Health Improvement & Disparities). There were also 74,600 deaths attributable to smoking, which is an increase of 3% compared to 2018.

Achieving the Government’s Smokefree 2030 ambition for smoking prevalence to be less than 5% is an essential step towards reducing inequalities and increasing healthy life years. For every smoker who dies, another 30 are suffering serious smoking-related diseases. On average, smokers have difficulty carrying out everyday tasks like dressing, eating and walking across a room, seven years earlier compared to people who have never smoked (source: The cost of smoking to the social care system, ASH).

Smokers need care support ten years earlier than people who have never smoked (source: The cost of smoking to the social care system, ASH).

Over the last 10 years the price of tobacco has increased by 100% (source: Statistics on Smoking, England 2020, NHS Digital), pushing thousands of smokers into poverty and some are now reaching for cheaper illegal tobacco.

It is estimated that treating smoking related disease costs the National Health Service (NHS) £2.4 billion a year, with the wider economic costs reaching over £17.4 billion a year. This significantly exceeds the £10 billion per year generated from tobacco duties (taxes).

In Buckinghamshire, smoking costs the economy £43.96 million a year, with £22.72 million of this for healthcare and £8.61 million for social care. Helping the most disadvantaged smokers to quit will return thousands of pounds to family budgets. If smoking was obsolete in England, over £11.4 billion would go back into communities' and families' pockets and one million less children would be living in poverty.

Source: ASH ready reckoner

This section summarises key data for England, data for Buckinghamshire is presented in a subsequent section. It is important to note that not all data at the England level can be replicated at a local level, therefore having this national context is important.

In England, an estimated 5.8 million adults are currently smokers, which is around 13% of the population (source: Local Tobacco Control Profiles).

Although there has been a continuing decline in the number of adult smokers since 1972, smoking rates remain higher in certain groups such as those with mental health conditions or those living in the most deprived areas. Most smokers say they want to quit, but without support 80% of quit attempts end in relapse within 12 months (source: 'Attempts to quit smoking and relapse', Zhou et al).

The Wider Impacts of Covid Tool uses the latest opinions and lifestyles survey data, and this showed that 37.9% of smokers nationally (during March and September 2020) rated themselves as having very high anxiety. This is an increase from 28.3% in 2019. Life satisfaction for smokers also decreased between 2019 (18.7% of smokers) to 2020 (12.6% of smokers). One positive was that smokers intending to quit in the next three months increased during 2020 at 21.2% (up from 20% in 2019). Intent to quit was higher for females (25.8%) than males (17%).

Smoking rates among children under 16 have fallen to the lowest recorded levels since 1982, yet unfortunately an estimated 207,000 children start smoking every year in the United Kingdom (UK) (source: Young people and smoking, ASH).

Once someone starts smoking, it is difficult to stop. Two out of every 3 people who try smoking go on to become daily smokers (source:'What Proportion of People Who Try One Cigarette Become Daily Smokers? A Meta-Analysis of Representative Surveys') . The latest national survey of secondary school pupils in 2021 (mostly aged 11 to 15) found that 12% of pupils had ever smoked (decrease from 16% in 2018).

Only 1% were regular smokers (defined as smoking at least one cigarette a week), which is a reduction from 2% in 2018. However, current e-cigarette use has increased to 9% in 2021 from only 6% in 2018 (source: Smoking, Drinking and Drug Use among Young People in England, NHS Digital).

There are many risk factors associated with youth smoking including whether a parent, carer or sibling smokes. Higher deprivation, higher levels of truancy and substance misuse are all associated with higher rates of youth smoking (source: Wider impacts of COVID-19, Public Health England).

Smoking prevalence is higher in men, with 15.5% (around 3.7 million) of men in the UK saying they smoked cigarettes compared with 12.1% of women (around 3 million) in 2020 (source:ONS). These differences may relate to a combination of physiological, cultural, and behavioural factors.

Around one third of adult tobacco consumption is by people with a current mental health condition, with their smoking rates more than double that of the general population (source: Smoking prevalence in the UK and the impact of data collection,changes: 2020, ONS).

The more severe the mental health condition, the higher the rate of smoking, smoking dependence, and the chance of relapse. People with mental health conditions die 10 to 20 years earlier, and the biggest preventable factor in this is smoking (source: Action on Smoking and Health, ASH).

For symptoms of anxiety and depression, stopping smoking is as effective as taking antidepressants (source:'Change in mental health after smoking cessation,' BMJ). Just 6 weeks after quitting, people start feeling happier as well as healthier (source: 'Smoking cessation for improving mental health,'Cochrane Database of Systematic Reviews).

Smoking in pregnancy is a leading cause of health inequality for mothers and babies. It increases the risk of stillbirth, miscarriage, and sudden infant death syndrome (source: Smoking, pregnancy and fertility, ASH).

The Government’s target for smoking in pregnancy is 6% by 2022 (source: 'Tobacco control plan delivery plan', Department for Health and Social Care).

In 2021 to 2022, 9.1% of mothers were smokers at the time of delivery in England (source: 'Statistics on Women's Smoking Status at Time of Delivery', NHS Digital).

Stopping smoking is one of the most beneficial things a pregnant woman can do for her own health and to improve the health and development of her baby (source: 'Stop smoking in pregnancy,' NHS).

Children of parents who smoke are 4 times as likely to take up smoking themselves (source: GOV.UK).

In 2019, the percentage of adults who smoked was higher than average in Mixed (19.5%) and White (14.4%) ethnic groups (source: 'Cigarette smoking among adults', GOV.UK). Prevalence was lower than average in the Chinese (6.7%), Asian (8.3%) and Black (9.7%) ethnic groups. Smokers from minority ethnic groups are as motivated to quit smoking as the overall UK population.

In 2019, the percentage of adults who smoked was higher than average in Mixed (19.5%) and White (14.4%) ethnic groups (source: 'Tobacco and Ethnic Minorities, ASH'). Prevalence was lower than average in the Chinese (6.7%), Asian (8.3%) and Black (9.7%) ethnic groups. Smokers from minority ethnic groups are as motivated to quit smoking as the overall UK population (source: 'Tobacco and Ethnic Minorities, ASH').

Further research needs to be completed to understand the effects of shisha and chewed tobacco (e.g., paan), especially for people from ethnic minority backgrounds. It is already well known that shisha, paan and khat are linked to increased risk of cavities and oral cancer (source: 'Tobacco and Ethnic Minorities, ASH').

Smoking rates are higher among more deprived groups. Those in routine and manual occupations are 2.5 times more likely to smoke than people in other occupations (source: Adult smoking habits in the UK: 2019, ONS).

There is also a socio-economic gradient for quit rates seen across all smokers, with rates lower among those in lower socio-economic groups. Reasons for this may include a lack of social support or stress. People living in social housing are also 3 times as likely to be smokers than those who have a mortgage.

Source: 'Adult smoking habits in the UK', ONS.

The negative outcomes that come with smoking are not felt equally across communities; there are huge differences in smoking rates across the country. At its most extreme, smoking prevalence is 4.5 times higher in Burnley compared to Exeter (source: 'Tobacco and Ethnic Minorities, ASH').

While smokers from more deprived communities are as likely to want to quit and to try to quit as people who are less deprived, more deprived individuals are less likely to succeed (source: 'Stop smoking services and health inequalities,' NCSCT).

The United Kingdom is facing a cost-of-living crisis (as of October 2022) that will hit the most deprived hardest, yet it is often those who cannot afford to smoke who spend the most on their smoking addiction. In Bolton alone, smokers spend over £67 million a year on tobacco and nearly all this money goes straight out of the local economy as tobacco industry profits or tax (source:'Adult smoking habits in the UK, ONS)

Illegal (or illicit) tobacco is any illegal activity related to the manufacturer, distribution and sale of tobacco products including the smuggling and counterfeiting of cigarettes. Illicit tobacco undermines the work that the Government is doing to regulate the tobacco industry and protect public health. More than 1 in 2 smokers who have ever bought illegal tobacco are from the most deprived groups, compared to around 1 in 20 from the least deprived (source:'Making smoking obsolete,' The Khan Review).

In 2019 to 2020 the estimated size of the illegal market was 16.6% of all tobacco trade (source: Corporate report: Outputs for March 2019 to April 2020,' GOV.UK).

An e-cigarette (or vape) is a device that allows you to inhale nicotine in a vapour rather than smoke. E-cigarettes do not burn tobacco and do not produce tar or carbon monoxide, two of the most damaging elements in tobacco smoke. E-cigarette products continue to be the most popular and effective smoking cessation aid used by people trying to quit smoking (source: 'South East of England Position Statement on Electronic Cigarettes,' ADPH).

In 2020, 27.2% of people used a vaping product in a quit attempt in the previous 12 months (source: 'Research and analysis: Vaping in England,' GOV.UK). 3.6 million people were current vapers in 2021, with 65% of these being ex-smokers (source: 'Use of e-cigarettes (vapes) among adults in Great Britain,' ASH).

We know E-Cigarettes are not a 'silver bullet' nor are they totally risk free, but the alternative is far worse. They are an important risk reduction tool to help people quit smoking cigarettes (source: 'Electronic cigarettes for smoking cessation,' Cochrane Database of Systematic Reviews).

Stop Smoking Services across the country are starting to offer the tools as free quit aids (source: 'Incorporating e-cigarettes into your Stop Smoking Service: Making the case and addressing concerns,' NCSCT).

Concerns that when young people use e-cigarettes that this creates a pathway into smoking have not materialised in the UK to date. Smoking rates in young people have declined significantly since 2010 when e-cigarette use started to expand rapidly. E-Cigarette use among young people aged 11 to 18 years has remained concentrated among young people who are existing smokers, with young people who have never smoked trying but rarely sustaining e-cigarette use (source: 'Use of e-cigarettes among young people in Great Britain, ASH). Use among young people is stable, but continued vigilance is needed. E-cigarette regulations should be strengthened nationally to further protect children and young people.

There is good international evidence that exposure to media campaigns significantly reduces the number of people smoking, through encouraging people to make quit attempts (source:'Adult smoking habits in the UK, ONS).

Nearly three quarters (70%) of the public (18 years old and over) support increasing campaigns on tobacco. However, budgets for marketing campaigns to encourage smokers to quit have dropped from £23 million to £2 million in 10 years (source:'Adult smoking habits in the UK, ONS).

Stoptober is an annual national campaign aimed at encouraging smokers to quit during the month of October. Since 2012, the campaign has driven over 2.3 million quit attempts.

The NHS Long Term Plan (LTP) sets out new commitments for action that the NHS will take to improve prevention. This includes provision of tobacco dependence treatment to all hospital inpatients, pregnant smokers, and those with long-term mental health conditions. However, roll out was due to start in 2020/2021 but was delayed by COVID-19. Full roll out must be completed by 2023/24. The NHS must also ensure that all smokers in primary care, whether inpatient or outpatient, are given advice to quit directly by their clinician or health professional.

A nationwide survey in 2021 showed that smoking rates increased during the first COVID-19 lockdown. Key reasons reported included being bored (43%) or the Covid-19 pandemic making people more anxious (42%).

Nationally, Stop Smoking Services had to adjust their delivery model, by offering remote support for those wishing to quit. Gradually services are starting to return to face-to-face appointments. The proportion of young adults (18- to 24-year-olds) who have smoked rose during the COVID-19 pandemic, from a quarter to a third (source: 'Moderators of changes in smoking, drinking and quitting behaviour associated with the first COVID-19 lockdown in England,' SSA).

The Tobacco Control Plan for England in 2018 set out the vision of a smoke free generation, defining this as smoking rates of 5% or below by 2030. This is an essential step towards reducing inequalities and increasing healthy life years, but it is likely to be missed unless the rate of decline in smokers increases rapidly. A Smokefree 2030 will only be achieved by motivating more smokers to make a quit attempt using the most effective quitting aids, while reducing the number of children and young adults who start smoking each year.