The path to a smoke-free England by 2030BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m518 (Published 17 February 2020) Cite this as: BMJ 2020;368:m518
- Nicholas S Hopkinson, reader in respiratory medicine
Smoking is on course to kill around one billion people in the 21st century1 and is the leading preventable cause of morbidity and mortality. The adult smoking rate in England is now 14.4%, down from 19.3% five years ago, but this still represents six million smokers.2 Smoking is an important driver of health inequality; more than 25% of routine and manual workers smoke, compared with 10% in the professional and managerial group. The UK government’s prevention green paper3 set out an ambition for England to be smoke free by 2030, defined in its 2017 tobacco control plan as a smoking rate below 5%. The equivalent target for Scotland is 2034.
The UK has made important progress in tackling the tobacco epidemic4 through policies such as taxation to reduce the affordability of tobacco products and the introduction of standardised packaging and display bans,5 as well as by advancing smoke-free legislation, most recently a ban on smoking in cars with children present.6 The health secretary has acknowledged that the smoke-free 2030 ambition “is extremely challenging” and will require “bold action,”3 so it is important to consider what additional strategies are needed.
The scale and pace of many tobacco control activities depends on adequate funding. This has been limited by cuts both to public health funding and to local authority budgets more broadly. A key proposal therefore is to hold the tobacco industry, which makes about £1.5bn (€1.8bn; $1.9bn) a year profits in the UK, responsible for the harm that it causes by introducing a “polluter pays” levy from tobacco companies that will feed into a smoke-free 2030 fund.37
The levy would be based on powers already established in the National Health Service Act 2006 along the lines of the Pharmaceutical Price Regulation Scheme (PPRS). The PPRS addresses market failure in drug pricing by raising money from drug companies and is administered by the Department of Health and Social Care. The tobacco industry levy would raise around £300m a year, a figure based on restoring funding for tobacco control to the level present before 2010 and the amount recommended per capita by the US Centers for Disease Control.7
The smoke-free 2030 fund would support comprehensive media campaigns, local, regional and national tobacco control, trading standards enforcement, and the restoration of the universal provision of effective, evidence based treatment for tobacco dependence. Money would be raised from companies in proportion to their contribution to the combustible tobacco market and the fund administered without any industry input to ensure that the government maintains its obligation under the Framework Convention on Tobacco Control not to allow the tobacco industry any role in the setting or implementing policy.89 The US Food and Drug Administration user fee regime,10 which raises money from the tobacco industry, is a helpful precedent.
Beyond ensuring a secure source of funding, what else needs to be done? Preventing children from taking up smoking is essential to deliver a smoke-free future and reduce the risk of future ill health.1112 Increasing the age of sale from 16 to 18 in 2007 was associated with a fall in child smoking.13 A further increase from 18 to 21 would drive additional reductions, particularly as adolescence is a high risk time for the development of addiction and people are less likely to start smoking once they are in their 20s. In the US, “tobacco 21” policies have been shown to contribute to a greater decline in youth smoking 14 and are now implemented in all states. Introducing the requirement for a licence to sell tobacco products, which could be removed if retailers breach such rules, is also a sensible step to reduce children’s access to tobacco products.5
Tough controls on advertising mean that pack inserts and cigarettes themselves are the last available platforms on which the tobacco industry can promote its products. Work in Canada supports mandating pack inserts that include affirmative messages about quitting and links to smoking cessation services.15 Likewise, a requirement for “dissuasive cigarettes,” which are in unappealing colours or carry health messages on the cigarette paper should be introduced.15
For clinicians, the key priority is to ensure that all patients have access to timely and effective treatment for tobacco dependence16 and plans to deliver the Ottawa model of comprehensive hospital initiated smoking cessation programmes17 across the NHS should be accelerated and extended to primary care. The doubling of quit attempts by smokers in Greater Manchester following properly funded media campaigns at a time when quit attempts stood still in the rest of England is a useful reminder that in tobacco control the more we do, the better the result.456812131415
The political promise has been made, and a smoke-free 2030 is essential if the government is to deliver its manifesto commitment to increase healthy life expectancy by five years by 2035. With political will and engagement across the health and social care system it is also achievable.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I am chair of Action on Smoking and Health and medical director of the British Lung Foundation.
Provenance and peer review: Not commissioned, externally peer reviewed.