2 Public health need and practice
Smoking remains the main cause of preventable morbidity and premature death in England, leading to an estimated annual average of 86,500 deaths between 1998 and 2002 (Twigg et al. 2004). It is the primary reason for the gap in healthy life expectancy between rich and poor. Among men, smoking is responsible for over half the excess risk of premature death between the social classes (Jarvis and Wardle 1999).
A wide range of diseases and conditions are caused by cigarette smoking, including cancers, respiratory diseases, coronary heart and other circulatory diseases, stomach and duodenal ulcers, erectile dysfunction and infertility, osteoporosis, cataracts, age-related macular degeneration and periodontitis (US Department of Health and Human Services 2004). Following surgery, smoking contributes to lower survival rates, delayed wound healing and post-operative respiratory complications (US Department of Health and Human Services 2004).
Women who smoke during pregnancy have a substantially higher risk of spontaneous abortion (miscarriage) than those who do not smoke. Smoking can also cause complications in pregnancy and labour, including ectopic pregnancy, bleeding during pregnancy, premature detachment of the placenta and premature rupture of the membranes (British Medical Association 2004).
The health risks for babies are substantial. Those born to women who smoke are on average 200–250g lighter than babies born to mothers who do not smoke (British Medical Association 2004); the more cigarettes smoked, the greater the probable reduction in birth weight. This can increase the risk of death and disease in childhood: smoking in pregnancy increases infant mortality by about 40% (DH 2007) and more than a quarter of the risk of sudden unexpected death in infancy is attributable to smoking (British Medical Association 2004).
Breathing secondhand smoke ('passive smoking') can affect the health of people who do not smoke. For example, it can exacerbate respiratory symptoms and trigger asthma attacks. Longer term, it increases the risk of lung cancer, respiratory illnesses (especially asthma), heart disease and stroke (International Agency for Research on Cancer 2002; Scientific Committee on Tobacco and Health 2004; US Environmental Protection Agency 1993). Exposure to secondhand smoke in pregnancy can reduce fetal growth and increase the risk of preterm birth (British Medical Association 2004).
Smoking is estimated to cost the NHS £1.5 billion a year (Parrott et al. 1998). This estimate does not include other costs to government such as payment of sickness or invalidity benefits. Nor does it include the costs to industry or to individuals who smoke.
In England about 24% of people aged 16 and over in 2006 smoked (Lader 2007). Although smoking prevalence has dropped sharply since the 1970s, the decline has been much slower in the last decade. Recent estimates suggest that it is dropping by 0.4% a year (Jarvis 2003).
The government target to reduce smoking prevalence among manual working groups to 26% or less by 2010 will be challenging (HM Treasury 2004). In England in 2005 about 29% of those in routine or manual occupations smoked (Goddard 2006).
Smoking prevalence is also high among some minority ethnic groups (Erens et al. 2000). Among all groups, it is age-related. For example, among pregnant women smoking prevalence is highest for those under 35 (Penn and Owen 2002; Sproston and Primatesta 2004); and 45% of mothers aged under 20 smoke during their pregnancy (DH 2007). Among adults aged 16 and over, smoking prevalence for men was highest among those aged 20–34 (43% for both 20–24 year olds and 25–34 year olds) and for women highest among those aged 25–34 (29%) (Lader 2007).
This guidance is aimed at those working in the NHS, local authorities, other public sector organisations, and the community, voluntary and private sectors who have a direct or indirect role or responsibility for smoking cessation.
 From 2001, the classification system used to describe social class based on occupation was replaced by the National Statistics Socio-economic Classification (NS-SEC). 'Manual' households are now described as 'routine and manual' households: the phrase 'routine and manual' is now used for PSA targets.