This summary contains the following sections of the full report:
- executive summary
- summary of recommendations
In 2019, the government set an objective for England to be smokefree by 2030, meaning only 5% of the population would smoke by then. Without achieving this objective, the government will simply not meet its manifesto commitment “to extend healthy life expectancy by five years by 2035”. It will also prevent the government from fulfilling its ambition to save more lives as part of a new 10-Year Cancer Plan.
My review found that without further action, England will miss the smokefree 2030 target by at least 7 years, and the poorest areas in society will not meet it until 2044. To have any chance of hitting the smokefree 2030 target, we need to accelerate the rate of decline of people who smoke, by 40%.
The Rt Hon Sajid Javid, Secretary of State for Health and Social Care said in speech on health reform on 8 March 2022:
Richer communities get healthier – and healthier communities get richer. Healthy people work more, learn more and earn more.
Figure 1 shows the prevalence of smoking in England, reducing from 19.8% in 2011 to 13.9% in 2019. The chart then shows the projected trend downwards to 2.5% in 2050.
Public support for government action to limit smoking has grown significantly in the last 10 years. Those who think the government is not doing enough to tackle smoking has risen from 29% in 2009 to 46% in 2022.
Figure 2 compares the responses from 18 to 24 year olds and everyone, to a question asking if they think that the government is doing enough to limit smoking. The responses are:
- too much: 4% of 18 to 24 year olds and 6% of everyone
- about right: 24% of 18 to 24 year olds and 30% of everyone
- not enough: 52% of 18 to 24 year olds and 46% of everyone
- don’t know: 20% of 18 to 24 year olds and 18% of everyone
These 4 recommendations are my critical ‘must dos’ for the government, around which all other interventions are based.
1. Increased investment
I have set out the case for comprehensive investment now of an additional £125 million per year in smokefree 2030 policies, to fund the easily accessible, high quality support that smokers need to help them quit. This includes investing an extra £70 million per year in stop smoking services, ringfenced for this purpose.
If the government cannot fund this themselves, they should ‘make the polluter pay’ and either introduce a tobacco industry levy, or generate additional corporation tax, with immediate effect.
2. Increase the age of sale
The government must stop young people starting to smoke, which is why I recommend increasing the age of sale from 18, by one year, every year until no one can buy a tobacco product in this country.
3. Promote vaping
The government must embrace the promotion of vaping as an effective tool to help people to quit smoking tobacco. We know vapes are not a ‘silver bullet’ nor are they totally risk-free, but the alternative is far worse.
4. Improve prevention in the NHS
Prevention must become part of the NHS’s DNA. To reduce the £2.4 billion that smoking costs the NHS every year, the NHS must deliver on its commitments in the Long Term Plan. It must do more, offering smokers advice and support to quit at every interaction they have with health services, whether that be through GPs, hospitals, psychiatrists, midwives, pharmacists, dentists or optometrists. The NHS should invest to save, committing resource for this purpose.
I have also made several other recommendations throughout my report, presenting a holistic response to the challenge of delivering smokefree 2030, and setting the country on the path to making smoking obsolete.
I have called on the government to introduce a tobacco license for retailers, to limit the availability of tobacco across the country. I have proposed a fundamental rethink of the way cigarette sticks and packets look, to reduce their appeal. A smokefree society should be the social norm, which is why there should be even more smokefree places (in hospitality and outdoor places where children congregate), where people cannot smoke.
Investing in a well-designed mass media campaign will help create this smokefree culture, while encouraging smokers to quit. Substantially raising the cost of duties (more than 30%) across all tobacco products will also encourage smokers to quit, by increasing the cost of smoking. Abolishing all duty free entry of tobacco products at our borders.
I am also asking the government to accelerate the path to prescribed vapes and provide free Swap to Stop packs in deprived communities. Alongside this they should do everything they possibly can to prevent children and young people from vaping, including by banning child friendly packaging and descriptions.
The government must do more to support the most deprived areas and groups who are disproportionately impacted by smoking. In particular, pregnant women and people with mental health conditions who show substantially higher negative health impacts of smoking. I am calling on integrated care systems (ICS) across the country to lead on meeting smoking cessation targets.
To achieve all of this, it will also be important to tackle illicit tobacco, which often sells tobacco cheaply and to underage young people.
The government must also invest in new research and data, including commissioning further research on smoking related health disparities.
My proposals are a plan for England. They are not simply a plan for this government, but successive governments too. As we make progress, we will need to refine our proposals, adjusting spend to match changing needs, responding to the evolving challenges and opportunities. So, I also propose the government introduces progress checkpoints in 2026, 2030 and 2035.
Summary of recommendations
Part 1. Invest in reaching smokefree 2030
Recommendation 1. Urgently invest £125 million per year in interventions to reach smokefree 2030, and make smoking obsolete, addressing the health disparities smoking creates (critical intervention). Within this, invest an increase of £70 million per year into stop smoking services, ringfenced for this purpose, distributed according to prevalence data.
Part 2. Stopping the start – reduce the number of people taking up smoking, particularly young people
Recommendation 2. Raise the age of sale of tobacco from 18, by one year, every year, until no one can buy a tobacco product in this country (critical intervention). This will create a smokefree generation.
Recommendation 3. Substantially raise the cost of tobacco duties (more than 30%) across all tobacco products, immediately. This includes increasing duty rates for cheaper tobacco products, such as hand rolled tobacco, so they are the same as standard cigarette packages. It also includes banning tobacco products at duty-free entry points.
Recommendation 4. Introduce a tobacco licence for retailers to limit where tobacco is available. The government should also ban online sales for all tobacco products, ban supermarkets from selling tobacco and freeze the tobacco market to stimulate innovation in tobacco-free alternatives.
Recommendation 5. Enhance local illicit tobacco enforcement by investing additional funding of £15 million per year to local trading standards. Give trading standards the power to close down retailers known to be selling illicit tobacco. Alternative tobacco products such as shisha need enhanced enforcement.
Recommendation 6. Reduce the appeal of smoking by radically rethinking how cigarette sticks and packets look, closing regulatory gaps and tackling portrayals of smoking in the media.
Recommendation 7. Increase smokefree places to de-normalise smoking and protect young people from second-hand smoke. Strengthen smokefree legislation in hospitality, hospital grounds and outdoor public spaces. Local authorities should make a significant proportion (70% or more) of new social housing tenancies and new developments smokefree.
Part 3. Quit for good – encouraging smokers to quit for good
Recommendation 8. Offer vaping as a substitute for smoking, alongside accurate information on the benefits of switching, including to healthcare professionals (critical intervention). The government should accelerate the path to prescribed vapes and provide free ‘Swap to Stop’ packs in deprived communities, while preventing young people’s uptake of vapes by banning child friendly cartoon packaging and descriptions.
Recommendation 9. Invest an additional £70 million per year into ‘stop smoking services’, ringfenced for this purpose. The government should commission an update to existing quality of service standards guidance and build the provision of good quality stop smoking support across the country. The government should also ensure that any national helpline complements existing local (and national) virtual offers of support. Employers should follow National Institute for Health and Care Excellence (NICE) guidance on stopping smoking to support their employees to quit.
Recommendation 10. Invest £15 million per year in a well-designed national mass media campaign, supported by targeted regional media. This should be nationwide, direct smokers to support and dismantle myths about smoking and vaping.
Part 4. System change – the critical role of the NHS, the importance of collaborative working and improving data and evidence
Recommendation 11. The NHS needs to prioritise prevention, with further action to stop people smoking, providing support and treatment across all its services, including primary care (critical intervention). First and foremost, the NHS must meet its existing commitments in the Long Term Plan. Healthcare professionals should use every ‘teachable moment’ to deliver ‘very brief advice’ on quitting, and this should form part of revised core training curriculums. The NHS should invest to save, committing resource for this purpose and incentivise its services to implement the NICE guidance on stopping smoking. All hospitals must integrate ‘opt-out’ smoking cessation interventions into routine care. Hospital trusts should report on progress towards implementing these measures in their annual reports and have a named lead. The NHS must ramp up its messaging on stopping smoking.
Recommendation 12. Invest £15 million per year to support pregnant women to quit smoking in all parts of the country. The NHS should provide treatment at every stage. The government needs to create a national funding pot for evidence-based financial incentives to support all pregnant women to quit. There should be a ‘stop smoking midwife’ in every maternity department to provide expert support and advice at the front line.
Recommendation 13. Tackle the issue of smoking and mental health. Disseminate accurate information that smoking does not reduce stress and anxiety, through public health campaigns and staff training. And make stopping smoking a key part of mental health treatment in acute and community mental health services and in primary care.
Recommendation 14. Invest £8 million to ensure regional and local prioritisation of stop smoking interventions through ICS leadership. ICS and directors of public health must set, and annually report against, clear targets to reduce smoking prevalence in their areas and commission services to allow that reduction to be achieved. The government should set up a support fund to which ICS can bid for funding to support regional collaboration and partnership.
Recommendation 15. Invest £2 million per year in new research and data. The government should invest in an innovation fund to support the commissioning of new research, data and monitoring of impact at all levels. This will provide improved and accessible information to identify effective evidence-based interventions that should be rolled out. The government must also commission further research on smoking related health disparities, particularly on ethnic disparities and young people.
Smoking kills and ruins lives. But it doesn’t have to be like that.
By commissioning this review, the government sent out a powerful message that the status quo is not acceptable. I have taken on that challenge and responded with recommendations that are as comprehensive as they are bold. Anything less would have been an abdication of my duty. We now need to make it as hard as possible to smoke, and as easy as possible to quit, leading to a smokefree generation.
The effects of policy changes linger for decades and have already shown how successful smoking cessation policies can be. We just need to look back to the initial reaction to the 2007 smoking ban in all English pubs and clubs. While there was much opposition at the time, we would never go back now. It has changed social norms. We now need to go further.
While we have had great success in reducing smoking rates, the rate of decline has now become a small trickle, year on year. If we do nothing different, smoking will cause over half a million more deaths by 2030. Alongside the emotional impact, this will also cost society many billions of pounds along the way.
The benefits of making smoking obsolete are a multitude – whether in population health, social or economic benefits. Recognising that the poorest, the least educated and least skilled, the underemployed suffer the most from smoking and its effects, the government’s levelling up ambitions can’t be fully delivered without tackling smoking.
The government now has the opportunity to make our country a place where cigarettes disappear from our shops. To make this a country where the tobacco industry won’t want to trade. To invest now to save lives, helping people to live longer with more fulfilling lives with higher standards, particularly for the disadvantaged communities who need it most. To help smokers quit, improving the chance of our children having smoke-free childhoods and improved life chances. To get more adults and children out of poverty. To deliver large productivity gains in the workforce. And to help our cherished NHS free up beds and resource, and help tackle waiting lists.
In this report I have set out 4 critical interventions, without which smokefree 2030 will not be met:
- The case for investment now: provide a minimum additional investment of £125 million per year to fund comprehensive smokefree interventions.
- Increase the age of sale for all tobacco products from 18, by one year, every year, so we achieve a smokefree generation in this country.
- Embrace the promotion of vaping as the most effective tool to help smokers quit.
- Prevention must become part of the NHS’s DNA.
These interventions are critical as they will lead to exponential gains in reducing health disparities. The supporting recommendations I have set out, present a holistic response to the challenge we face. Taken together, and if implemented in full, I believe these actions will get the government to its 2030 target and then lead to a smokefree generation. But to get there, there can be no short cuts, no quick fixes, no excuses.
So, I urge the government to seize this moment and commit to making smoking obsolete.
Dr Javed Khan OBE