Tobacco smoking remains the single greatest cause of preventable illness and premature death in England. It is also the largest single cause of inequalities in health and accounts for about half of the difference in life expectancy between the lowest and highest income groups. Deaths caused by smoking are 2 to 3 times higher in low income than in wealthier groups (Jarvis and Wardle 2005). Smoking prevalence is particularly high among people with mental health problems, and has changed little in this group in the past 20 years (Royal College of Physicians 2013). Most of the reduction in life expectancy among people with serious mental illness is attributable to smoking (Royal College of Physicians 2013).
Smoking causes a range of diseases including cancer, cardiovascular disease and respiratory diseases. It causes many other debilitating conditions such as age-related macular degeneration, gastric ulcers, impotence and osteoporosis. Further, it can cause complications in pregnancy, including increased risk of miscarriage, premature birth and low birthweight. It is also associated with lower survival rates, delayed wound healing, increased infections, prolonged hospital stays and repeated admissions after surgery (Delgado-Rodriguez et al. 2003; Theadom et al. 2006).
In England in 2011, an estimated 79,100 adults aged 35 and over died as a result of smoking, accounting for 18% of all deaths. An estimated 462,900 hospital admissions of people from the same age group were attributable to smoking, accounting for 5% of all admissions (Health and Social Care Information Centre 2013).
There is no risk-free level of exposure to secondhand smoke (US Surgeon General 2006) and breathing it in can have both immediate and long-term health consequences. In the short term, it can exacerbate respiratory symptoms and trigger asthma attacks. In the longer term, it can increase the risk of smoking-related diseases (Royal College of Physicians 2005; Scientific Committee on Tobacco and Health 2004).
People with medical conditions (such as respiratory illnesses), pregnant women and children are particularly vulnerable to secondhand smoke. A UK report on children estimated that passive smoking caused 22,600 new cases of wheeze and asthma, 121,400 new cases of middle ear infection and 40 cases of sudden infant death each year. These consequences were strongly associated with maternal smoking (Royal College of Physicians 2010).
Treating smoking-related illnesses cost the NHS an estimated £2.7 billion in 2006 (Callum et al. 2010). The overall financial burden of all smoking to society has been estimated at £13.74 billion a year. This includes both NHS costs and loss of productivity because of illness and early death, as well as other factors (Nash and Featherstone 2010).
Treating smoking-related illnesses in people with mental health problems has been estimated to cost the NHS £720 million a year in primary and secondary care. Given that smoking can reduce their effect, smoking increases psychotropic drug costs in the UK by up to £40 million (Royal College of Physicians 2013).
The strong association between smoking and both physical and mental ill-health means that many people who use secondary care services are smokers. When smokers use these services, it presents a valuable opportunity to use interventions of proven effectiveness and cost effectiveness to initiate and support stop smoking attempts or other strategies to reduce harm.
Although the prevalence of cigarette smoking has fallen markedly in the last 30 years, 1 in 5 adults aged 16 or over in England (20%) still smoked in 2010. On average, they smoked just under 13 cigarettes a day. Smoking prevalence remains higher in certain groups as follows.
A third (33%) of people with mental health problems (McManus et al. 2010; Royal College of Physicians 2013) and more than two-thirds (70%) of people in psychiatric units smoke tobacco (Jochelson and Majrowski 2006). Smoking is also common among young people with mental health problems. According to the child and adolescent mental health survey of Great Britain (2004), young people aged 11–16 years with an emotional, hyperkinetic or conduct disorder were much more likely to be smokers (19%, 15% and 30% respectively) than other young people (6%) (Green et al. 2005).
Recent studies show that people with mental health problems are just as likely to want to stop as the general population – and are able to stop when offered evidence-based support (Jochelson and Majrowski 2006; Siru et al. 2009; Royal College of Physicians 2013). However, research also shows that effective stop smoking treatment is not always offered to them (Ratschen et al. 2009a).
In addition, there is a lack of support for smokefree policies among healthcare staff working in mental health. Staff are reported to lack specific knowledge about the influence of smoking – and cessation activities – on a person's mental health (McNeill 2004; McNally et al. 2006; Ratschen et al. 2009a).
A survey also showed that more than a third of doctors in an NHS mental health trust were unaware that the dosage of some antipsychotic medications may need to be reduced when a person stops smoking (Ratschen et al. 2009a).
People in routine and manual occupations are about twice as likely to smoke as those in managerial or professional occupations (27% compared with 13%) (Health and Social Care Information Centre 2013).
Many teenage women smoke during pregnancy. According to the Infant Feeding Survey 2010, women aged 20 and younger were 6 times more likely than those aged 35 and over to have smoked throughout pregnancy (35% compared with 6%). Pregnant women from routine and manual occupations are much more likely to smoke and to have done so through pregnancy than those from professional and managerial occupations (20% compared with 4%) (McAndrew et al. 2012).
Overall, more than a quarter (26%) of mothers in England smoked before pregnancy. More than half (55%) gave up at some stage before the birth. Although most women who had stopped before or during pregnancy were still not smoking shortly after the birth, nearly a third (31%) were smoking again less than a year later (McAndrew et al. 2012). Because of the stigma attached to smoking in pregnancy, there is likely to be a significant under-reporting by pregnant women who smoke.
The 2011 white paper Healthy lives, healthy people sets out a comprehensive list of tobacco control objectives for England. This includes:
reducing smoking during pregnancy
reducing smoking among people with mental health problems
reducing the health effects of secondhand smoke
promoting quitting smoking through providers of secondary care.
The Health Act introduced in England in July 2007 made it illegal to smoke in enclosed, or substantially enclosed, public places or workplaces, including work vehicles. Mental health units were given a temporary exemption until July 2008 (HM Government 2006).
Benefits of smokefree legislation have included a fall in hospital admissions for heart attacks (Sims et al. 2010). In addition, an estimated 6802 fewer children were admitted to hospital in England with asthma symptoms in the first 3 years following its implementation. This is a reversal of what was a steady annual increase (Millett et al. 2013).
Many NHS secondary care settings have smokefree policies that apply to their grounds (as well as to enclosed areas). However, there have been problems with compliance and enforcement (Ratschen et al. 2009b; Shipley and Allcock 2008).