2 Public health need and practice


Tobacco smoking remains the single greatest cause of preventable illness and early death in England, accounting for 79,100 deaths among adults aged 35 and over in 2011 (NHS Information Centre 2012). The effects of smoking are not limited to the smoker, but also have implications for those around them. Secondhand smoke is a human carcinogen and no safe level of exposure has been identified (US Surgeon General 2006).

Treating smoking-related illnesses cost the NHS in England an estimated £2.7 billion in 2006/07 (Callum et al. 2010). The overall financial burden to society has been estimated at £13.74 billion a year. This includes NHS costs (based on the figure above) and loss of productivity due to illness and early death (Nash and Featherstone 2010).

Although smoking prevalence has fallen sharply in the past 30 years, there is some evidence that this decline is levelling off. In 2010, 1 in 5 adults in England (20%) smoked cigarettes, with prevalence highest among those aged 20–24 and 25–34 (28% and 26% respectively) (NHS Information Centre 2012).

People from routine and manual occupational backgrounds are almost twice as likely to smoke as those from managerial or professional backgrounds (27% versus 13%) (NHS Information Centre 2012). Smoking is responsible for at least half of the excess risk of premature death faced by middle-aged men in manual occupations, compared to those in professional groups (Jha et al. 2006).

Smoking prevalence is particularly high among some groups. This includes: lesbian, gay, bisexual and transgendered people, those with mental health problems, people in prison and those who are homeless. For example, a recent survey of smoking prevalence among gay and bisexual men found that just over 35% smoked cigarettes, including 48% of those who were HIV-positive (Hickson et al. 2007).

There is less UK data available on lesbian women. But small surveys in the West Midlands indicate that 42% to 55% smoke – twice as many as the West Midlands average for women (Meads et al. 2007).

A third (33%) of people with mental health problems (McManus et al. 2010) and more than two-thirds (70%) of patients in psychiatric units smoke tobacco (Jochelson and Majrowski 2006). Recent studies show that people with mental health problems are just as likely to want to stop smoking as the general population – and are able to stop when offered evidence-based support. However, support is not always available (Jochelson and Majrowski 2006; Siru et al. 2009).

Children and young people

Exposure to secondhand smoke in the home affects an estimated 5 million children under the age of 16 (British Medical Association 2007). Children's vulnerability to tobacco smoke has been well documented. A UK report estimated that passive smoking caused 22,600 new cases of wheeze and asthma, 121,400 new cases of middle ear infection and 40 sudden infant deaths (Royal College of Physicians 2010).

The health of babies born into lower income households is disproportionately affected by secondhand smoke. In addition, as they are growing up in an environment where smoking is the norm, they are more likely to start smoking in adolescence (British Medical Association 2007; Royal College of Physicians 2010).

In England, the number of children admitted to hospital with asthma symptoms had been increasing on an annual basis up to 2007, when smoke-free legislation was introduced. It has been calculated that, in the first 3 years following implementation of the legislation, there were 6802 fewer admissions for asthma (Millett et al. 2013). Following this there has been a continuing annual reduction.

Legislation requiring all large shops and supermarkets to remove cigarette displays at the point-of-sale came into force in April 2012. The aim is to reduce the impact of tobacco marketing on children and young people and so reduce the likelihood of them taking up smoking. Newsagents and small stores will be able to display cigarettes until 2015.

Stopping smoking

About two-thirds (67%) of people who smoke say they would like to stop and three-quarters (75%) of them say they have tried to do so in the past. In 2008, about a quarter (26%) of all smokers had tried in the past year (Lader 2009). Most people attempt to stop without help, but only around 4% of those who stop without using behavioural or pharmacological therapy are successful for a year or longer (Hughes et al. 2004). This compares with about 15% at 1 year of those who stop with support from NHS stop smoking services (Ferguson et al. 2005).

People often try many times before they eventually succeed in stopping smoking. People who have recently tried and failed are more likely to try again – but they are also more likely to relapse than those who have not tried recently. Relapse is associated with:

  • nicotine dependence

  • exposure to smoking cues

  • craving

  • withdrawal symptoms

  • lack of help to stop (the latter could include medication, behavioural support or support from family and friends)

(Zhou et al. 2009).

Reducing cigarette consumption

In 2009, 57% of smokers in England reported that they would find it difficult to go without smoking for a day. People in routine and manual occupational groups were more likely to say they would find this difficult compared to those in managerial and professional occupations (61% and 50% respectively). This difference was less pronounced in people who smoked 20 or more a day (83% and 78%) (NHS Information Centre 2011).

People from routine and manual groups are more likely to cut down first, rather than stop 'abruptly' (Siahpush et al. 2010). They inhale more nicotine from cigarettes and are more dependent than more affluent people. To take in more nicotine they inhale more deeply and smoke more of the cigarette, which increases their exposure to the other toxins in tobacco smoke and, thus, increases their risk of smoking-related disease. As a result, they are likely to find it harder to stop smoking and so may need additional support (Jarvis 2010).

The harm associated with cigarette smoking is almost entirely caused by the toxins and carcinogens found in tobacco smoke – not the nicotine (Royal College of Physicians 2007). However, nicotine is the main addictive chemical that makes it difficult to stop smoking.

Medicinal products containing nicotine which aim to help people cut down, temporarily abstain or reduce the harm caused by smoking have been given marketing authorisation by the UK's Medicines and Healthcare products Regulatory Agency (MHRA). At the time of publication (June 2013), only nicotine replacement therapy (NRT) products were licensed by the MHRA. A number of other nicotine-containing products that are not tobacco-based, including electronic cigarettes, were being considered for regulation by the MHRA when this guidance was published.

The MHRA has since issued a decision that all nicotine-containing products should be regulated. Unlicensed products that are currently being marketed, such as electronic cigarettes, and products new to the market will need a medicines licence once the European Commission's revised Tobacco Products Directive comes into effect in the UK (this is expected to be in 2016). In the meantime, the UK government will encourage applications for medicines licences for nicotine-containing products and will make best use of the flexibilities within the existing framework to enable licensed products to be available. For further information, visit the MHRA website.

  • National Institute for Health and Care Excellence (NICE)