Intended for healthcare professionals

Rapid response to:


Legal smoking age in England should rise every year, review recommends

BMJ 2022; 377 doi: (Published 09 June 2022) Cite this as: BMJ 2022;377:o1432

Rapid Response:

The Javed Khan review - time to make smoking obsolete

Dear Editor

We welcome the publication of Javed Khan’s Independent Review into smoking and urge the Government to heed his call for immediate investment of £125 million in tobacco control to deliver its Smokefree 2030 ambition [1].

Up to two thirds of smokers die prematurely, losing on average 10 years of life [2]. Achieving the Smokefree 2030 ambition[3] of adult smoking rates of 5% or less, would at a stroke deliver the Levelling Up mission to extend healthy life expectancy by 5 years [4].

Targeted investment to tackle inequalities in smoking rates across society is desperately needed. Smoking is a far greater source of difference in life expectancy than socio-economic status, and these differences can only be eliminated if we achieve the Government’s goal of making smoking obsolete [5]. We agree with the Secretary of State for Health, that it is a “moral outrage” [6] that England’s richest people live on average up to a decade longer than the poorest. It is time for the Government to match words with deeds, outrage with action. That’s what the public wants too, with a substantial majority supporting a range of Government interventions, and only 6% thinking the Government is doing too much [7].

No time is to be lost, if current trends continue we will miss the target by 7 years, and around double that for the poorest communities [8]. Ministers have recognised the need to “floor it” on public health [9], but that requires fuel in the tank. The Tobacco Control budget has been cut by a third in real terms since 2015 [10], and additional investment is desperately needed, alongside tougher regulation. If the Government cannot find the necessary funding, then, as Khan says, it should ‘make the polluter pay’.

This was also the recommendation of the APPG on Smoking and Health, which urged the Government to strictly control the profitability of the tobacco transnationals [11]. Reducing net profit margins from around 50% to no more than 10%, in line with the average for other businesses[12], could release £700 million excess profits a year [13] which should be used to fund tobacco control and other Levelling Up measures.
Smoking is not a lifestyle choice, it is an addiction usually starting in childhood. Stopping smoking benefits hard-pressed families, reducing poverty by increasing disposable household income; creating jobs; increasing productivity; reducing NHS waiting lists; and improving health and wellbeing.

The £12 billion a year spent on tobacco [14] has greatest impact on poorer communities where smoking rates are highest, exacerbating the cost of living crisis. In addition to the £2.4 billion smoking costs the NHS; and £1.2 billion for social care; a further £13 billion accrues from lost productivity due to premature death, disease and disability [14]. The Government rightly wants to make smoking obsolete [3]. If this were achieved, it is estimated that UK jobs would increase by 500,000 as smokers spent their money on other goods and services [15]. The net benefit to public finances would be around £600 million for England alone [15].

Nationally around 14% of adults smoke but rates in social housing, where a third of smokers live, are double that [16]. Around 25% of people with depression and anxiety [17] and over 40% of those with severe mental illness smoke[18]. Smoking is the single biggest modifiable risk factor for cancer [19] and COPD, as well as for miscarriages, stillbirth, premature birth and birth anomalies [20]. Women in the most deprived group are five times more likely to smoke in pregnancy than the least deprived.

Every day the Government fails to act more than 200 people in England die from smoking [21] and 280 children under 16 have their first cigarette [22]. Two thirds of those smoking one cigarette will go on to become addicted, daily smokers[ 23], taking on average thirty attempts before they successfully quit [24].

The Health Disparities White Paper is due shortly, a fully-funded comprehensive Tobacco Control Plan to make smoking obsolete must follow swiftly on its heels.

Nicholas S. Hopkinson, chair, Action on Smoking and Health

Helen Stokes-Lampard, chair, Academy of Medical Royal Colleges

Jim McManus, president, Association of Directors of Public Health UK

Sarah Woolnough, chief executive, Asthma+Lung UK

Charmaine Griffiths, chief executive, British Heart Foundation

David Strain, chair, BMA Board of Science

Ian Walker, executive director, Cancer Research UK

Maggie Rae, president, Faculty of Public Health

Jennifer Dixon, chief executive, The Health Foundation

Gill Walton, chief executive, Royal College of Midwives

Eddie Morris, president, Royal College of Obstetricians and Gynaecologists.

Andrew Goddard, president, Royal College of Physicians

Adrian James, president, Royal College of Psychiatrists

Linda Bauld, director, SPECTRUM

Pat Cullen, general secretary & chief executive, Royal College of Nursing

Martin Marshall, president, Royal College of General Practitioners

Carol Black, chair, Centre for Ageing Better

1 Javed Khan review on Tobacco and Health Inequalities.
2 Banks E, Joshy G, Weber MF, et al. Tobacco smoking and all-cause mortality in a large Australian cohort study: findings from a mature epidemic with current low smoking prevalence. BMC Med 2015 Feb;13(38). [Accessed 7th June 2022]
3 Cabinet Office and Department of Health & Social Care. Advancing our health: prevention in the 2020s – consultation document. [Accessed 7th June 2022]
4 Office for National Statistics. What affects an area’s healthy life expectancy? [Accessed 7th June 2022].
5 Gruer L, Hart C L, Gordon D S, et al. Effect of tobacco smoking on survival of men and women by social position: a 28 year cohort study. BMJ 2009 Feb;338(b480). [Accessed 7th June 2022]
6 Wheeler C. Sajid Javid plots vaping revolution to help poor live longer. [Accessed 2nd June 2022].
7 Action on Smoking and Health. Public support in England for Government action on tobacco: Results extracted from the ASH Smokefree GB survey 2022. ASH. 2022.
8 Alarilla A, Brown K, Ahmad A, et al. Smoking prevalence projections for England, Scotland, Wales, and Norther Ireland, based on data to 2018/19. Cancer Research UK. 2020. [Accessed 7th June 2022]
9 Hill, J. O’Brien: Government must ‘floor it’ on public health prevention. [Accessed 7th June 2022]
10 The Health Foundation. Why greater investment in the public health grant should be a priority. [Accessed 7th June 2022]
11 APPG on Smoking and Health. Delivering a Smokefree 2030: The All Party Parliamentary Group on Smoking and Health recommendations for the Tobacco Control Plan 2021. 2021. [Accessed 7th June 2022]
12 Corporate Finance Institute. Profit Margin: Profit relative to revenue. [Accessed 7th June 2022]
13 Featherstone H. Keep Coughing Up: establishing a Smoke-free 2030 Fund. 2021. [Accessed 7th June]
14 Action on Smoking and Health. ASH ready reckoner 2022. [Accessed 2nd June 2022]. 15 Reed H. The economic impact of a smokefree United Kingdom: technical report. 2021. [Accessed 7th June]
16 Office for National Statistics. Adult smoking habits in the UK 2019. [Accessed 7th June 2022].
17 [dataset] GP Patient Survey (GPPS). 2016/17 GP Patient Survey.
18 [dataset] Health and Social Care Information Centre. Health and Social Care Information Centre 2014/2015 data, 2015. 2
19 Brown KF, et al..The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015. British Journal of Cancer. 2018. 118; 1130–1141. 2018.
20 Royal College of Physicians. Hiding in plain sight: treating tobacco dependency in the NHS. 2018.
21 NHS. Statistics on Smoking: England 2020. [Accessed 7th June 2022].
22 Calculated by the Cancer Research UK Statistical Information Team, using data from the Smoking, Drinking and Drug Use in Young People in England survey 2016 and 2018.
23 Birge M, Duffy S, Miler JA, Hajek P. What Proportion of People Who Try One Cigarette Become Daily Smokers? A Meta-Analysis of Representative Surveys. Nicotine Tob Res 2018 Nov;20(12). [Accessed 7th June 2022]
24 Chaiton M, Diemert L, Cohen JE, et al. Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open 2016

Competing interests: No competing interests

09 June 2022
Nicholas S Hopkinson
Professor of Respiratory Medicine
Helen Stokes-Lampard, Jim McManus, Sarah Woolnough, Charmaine Griffiths, David Strain, Ian Walker, Maggie Rae, Jennifer Dixon, Gill Walton, Eddie Morris, Andrew Goddard, Adrian James, Linda Bauld, Pat Cullen, Martin Marshall, Carol Black
National Heart and Lung Institute, Imperial College, Royal Brompton Hospital Campus, London UK