In November 2002, Alan Milburn said, in a public speech that "Smoking is a public health disaster." He went on to outline the measure the government has and will be taking, and what it expected of the NHS in supporting the 70% of smokers who want to quit.

Nationally, 19% of deaths (120,000 per year) are caused by smoking. One in two regular smokers is killed by tobacco, half dying in middle-age (losing an average of 20 years of life) and half in later life (but still an average of eight years earlier than their non-smoking peers). Smoking Causes:

As coronary heart disease is so common, most deaths caused by smoking are due to coronary heart disease.

Compared with non-smokers, smokers who smoke between 1 and 14 cigarettes a day have eight times the risk of dying from lung cancer and those who smoke more than 25 cigarettes a day have 25 times this risk. Cigarette smokers have two to three times the risk of a heart attack, compared with non-smokers. Smoking also increases the risk of:

Half of all regular smokers die prematurely because of tobacco use, losing an average of 14 years of life.

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Breathing other people's smoke causes over a thousand deaths each year in this country from heart disease and a few hundred deaths from lung cancer. Smoking during or after pregnancy causes one in two cot deaths (Sudden Infant Death Syndrome). Infants whose parents smoke have four times the risk of being admitted to hospital with a respiratory infection before their first birthday. Parental smoking increases the risk of middle ear infections in childhood.

For people who already have asthma or coronary heart disease, other people's smoke can precipitate severe symptoms.

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There are large differences in smoking prevalence and consumption in the UK, varying by age, sex, social class, employment status, and ethnicity. People in deprived circumstances are not only more likely to take up smoking but generally start younger, smoke more heavily and are less likely to quit smoking , each of which increases the risk of smoking-related disease. About 12 million adults in the UK smoke cigarettes - 28% of men and 26% of women. There has been a large fall over past decades through established smokers quitting but almost as many young people are taking up smoking as previously.

More than 80% of smokers take up the habit as teenagers: about 450 children in the UK start smoking every day. Smoking is highest among those aged 20-34, of whom 37% of men and women. Smoking prevalence gradually declines with age, through quitting or dying; the lowest smoking rate is among people aged 60 and over, of whom 17% smoke. About one fifth of Britain's 15 year-olds - 19% of boys and 25% of girls - are regular smokers (at least one cigarette per week), despite the fact that it is illegal to sell cigarettes to children aged under 16.

Men and women in manual socio-economic groups are more likely to smoke than people in non-manual occupations. 21% of men and 18% of women in the professional and managerial groups smoke compared with 35% of men and 31% of women in routine and manual groups.

There are 2.9 million London residents who are members of black and minority ethnic groups. The Health Survey for England published in 2000 found that 27% of men were current smokers, 31% used to smoke regularly and 42% had never smoked regularly. The age-adjusted risk ratio for being a current smoker was 1.26 for black Caribbean men, 1.43 for Irish men and 1.57 for Bangladeshi men, compared with the general population. Chinese (0.62), Indian (0.78) and Pakistani men (0.90) were less likely than the general male population to smoke. Although smoking prevalence among women was the same (27%) in the general population, the picture was very different among ethnic groups. Irish women were the only group reported who were more likely to smoke than average (age-adjusted risk ratio 1.16), with slightly fewer smokers among black Caribbean women (0.85) and very few among other women (Bangladeshi 0.07, Pakistani 0.14, Indian 0.19+, and Chinese 0.31).

The Department of Health commissioned a questionnaire survey of just under 10,000 pupils in 321 schools in England in the 2002 Autumn term. The survey is the most recent in a series that began in 1982.

The government set a target in the Smoking Kills White Paper to reduce the prevalence of smoking among young people aged 11-15 from a baseline of 13% in 1996 to 11% by 2005 and nine percent or less by 2010.

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Smoking is the principal proximal cause of health inequalities in the UK, particularly for CHD, other cardiovascular and respiratory diseases, and cancers. Adult men of working age in social class V are three times as likely to die of lung cancer as men in social class I. Women in social class V are almost twice as likely to die of lung cancer as women in social class I.

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Smoking cessation is the most important lifestyle factor in reducing mortality, morbidity, and health inequalities over the next 20 years. It is seldom "too late" to stop smoking. Within 15-20 years of stopping smoking, the risk of lung cancer is almost the same as the risk for people who have never smoked. The reduction in risk for CHD is particularly rapid, with the risk falling within a year or so. Encouraging cessation among adults is also important in reducing smoking role models for children.

Community based services supporting smoking cessation in each health authority area in England and Wales, particularly for low-income groups and Black and minority ethnic groups, were mapped in 2000. Although all the NHS services are available to any smoker who wishes to quit, most services had identified as their priority target groups people living on a low income, pregnant women, young people, and heavily dependent smokers.

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Restricting smoking in public places is another important target. Reducing exposure to secondhand smoke not only reduces deaths, disease and disability caused by such exposure but also, like decreasing smoking prevalence, reduces the perception among young people that smoking is a normal adult habit.

Ventilation is not the answer. Only 15% of secondhand smoke is particles, which are cleared by filters. The remaining 85% is gaseous: to clear this requires so many changes of air per hour that customers or employees would notice a pronounced draught. It would also use very large amounts of electricity and be very expensive.

In 2001, SmokeFree London commissioned a survey of 10,000 Londoners' behaviours and attitudes regarding smoking. It provided a picture of Londoners' smoking habits and their views about smoking, including cessation attempts, exposure to secondhand smoke, attitudes to smoking in public places and to those who sell cigarettes to children, experience of buying smuggled cigarettes and knowledge of the risks associated with tobacco and of the services available to help smokers quit.

An analysis for London as a whole and for the local authority areas was published and distributed October 2001 (SmokeFree London: Survey report ); the results for all London were also published in May 2002 (Attitudes to smoking in the capital ) as a volume in the Tobacco in London series of publications.

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The 1998 White Paper, Smoking Kills, promoted (for the first time by a UK government) a comprehensive tobacco control strategy. This included:

Department of Health guidance, initially to Health Action zones, then to all health authorities (and now primary care trusts, PCTs) was to develop a three tier cessation service, comprising brief interventions, 'intermediate' level 1:1 interventions, and specialist cessation services, including clinics. The Acheson report on inequalities also recommended policies to improve living standards for those on low incomes; providing nicotine replacement therapy on prescription as a cessation aid; and support for cessation as ways of encouraging smokers to quit and to remain ex-smokers. View Report On The Case For Clinicians To Support Smoking Cessation in the Reports & References Section.

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A series of National Service Frameworks and similar documents refer to reducing smoking prevalence amongst:

The NHS is required to contribute to the national inequalities targets by delivering a one percentage point reduction per year in the proportion of women continuing to smoke throughout pregnancy, focussing especially on smokers from disadvantaged groups.

The 2003 - 2006 Priorities and Planning Framework requires PCTs to:

Issues of secondhand smoke exposure and the right of employees to smokefree workplaces are gaining prominence. A draft Approved Code of Practice for employers to protect their staff from secondhand smoke has been widely supported by trades unions, environmental health officers, and health professionals but its passage through government has been delayed repeatedly, due to concern about bureaucracy for businesses. The tobacco industry has actively obfuscated the arguments about the hazards of secondhand smoke and has promoted ventilation as the answer in the hospitality industry, despite evidence of its lack of effectiveness in protecting staff or the public from tobacco smoke's toxic chemicals.

In April 2003, a joint conference organised by ASH (Action on Smoking and Health), the TUC, and the Chartered Institute of Environmental Health on protecting employees from secondhand smoke in the workplace was held. In July 2003, the Chief Medical Officer for England included a chapter on secondhand smoke in his 2002 Annual Report. He called for comprehensive workplace smoking bans to reduce smoking prevalence as well as to protect people from secondhand smoke. The same week, British Medical Association called for legislation to require smoke-free public places; a National Opinion Poll found a majority of the public in favour of banning smoking even in pubs; and a television campaign was launched to warn parents of the dangers to children and infants of secondhand smoke.

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Cigar and pipe smoking increase the risk of oral cancers. Early studies found much lower risks of other health consequences than were shown for cigarette smoking. This resulted in many cigarette smokers switching to smoking cigars or pipes. More recent studies have shown substantial risks of lung and other cancers and circulatory diseases in cigar and pipe smokers. This is probably because former cigarette smokers continue to inhale when they change from cigarettes to smoking other products.

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Smoking tobacco, which is chewed alone or with betel quid/paan, has a significant detrimental impact on the oral cavity. It has been recognised that the areca nut, an active ingredient in betel quid / paan, causes oral submucous fibrosis. This is a debilitating, non-reversible and pre-cancerous disease characterised by a stiffening of the oral mucosa and development of fibrous material that restricts mouth opening. The use of smokeless tobacco is known to induce wrinkled changes in the oral mucosa, so-called "snuff dipper's pouches" that occur beneath the lip that can lead to severe gum recession and bone loss. Serious changes can occur in people who have used smokeless tobacco for only a short period of time, and though stopping can alleviate the wrinkling, damage to gums and bone is permanent.

There have been a number of investigations into the implications of smokeless tobacco on South Asian populations in the UK, the majority of which show that betel chewing is prevalent in many areas.

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• Evidence-Based Information About The Treatment Of Tobacco Dependence
• Smoking Treatment Services in England: Implementation and Outcomes
• HDA Collaborating Centre: Tobacco Control
• HDA Collaborating Centre: Smoking Cessation
• British Heart Foundation Statistics
• Twigg L, Moon G, Walker S. The Smoking Epidemic. London: Health Development Agency, 2004.
• Links to Government documents and related policies
• Key facts on tobacco
• Department of Health summary on Tobacco in 2004 White Paper Choosing Health
• Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking (full report)
• Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking (summary)
• HDA Evidence Base - publications on effective actions
• HDA guidance on cessation
• Guidance for PCTs on planning smoking cessation services
• Answers to service providers' questions about smoking cessation
• Guidance for dental teams on helping smokers quit
• Guidance on helping smokers with mental health problems
• Guidance on helping professionals who work with homeless smokers
• Reducing smoking in pregnancy
• Bull J, Mulvihill C, Quigley R. Prevention of low birth weight: Assessing the effectiveness of smoking cessation and nutritional interventions. London: HDA, 2003.
• Promoting young people's health
• Cochrane Tobacco Addiction Group reviews on smoking cessation
• Reviews of evidence for community-level interventions
• Links to reviews of published evidence
• Targeting smokers from disadvantaged groups
• Health Survey for England 2003: Risk factors for cardiovascular disease

• ASH - Action on Smoking and Health
• Net Doctor
• Department of Health
• BMA Tobacco Control Resource Centre
• Centre for Tobacco Control Research
• Quit
• UCL's Smokers' Clinic
• Asian Quitline

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Date	Title	Format	View
30 Nov 2007	Commissioning for equity. Are London's stop smoking services equitable? A review of age, gender, ethnic group and area based deprivation data: a progress report
1 Oct 2007	Monitoring the impact of the English smokefree legislation using routine data
11 Sep 2007	Monitoring the impact of English smokefree legislation using routine data
11 Sep 2007	Smokefree conference 2007: Edinburgh statement
23 May 2006	Stop before the op: a briefing on the short term benefits of preoperative smoking cessation in London
18 Apr 2006	An Explanation of Availability of Data on Smoking Quit Rates by Socio-economic Group and Ethnicity
Sep 2005	Preoperative smoking cessation: a model to estimate potential short term health gain and reductions in length of stay
13 Jun 2005	Smoking, Drinking and Drug Use Among Young People in England, 2002
13 Jun 2005	The Smoking Epidemic in England - Health Development Agency Report
16 May 2005	Smoking Cessation - The National Evaluation of the English Treatment Services
16 May 2005	Tobacco Resources - Links to Useful Information
9 May 2005	Improving Health Care Outcomes by Helping People to Stop Smoking
7 Apr 2005	Smoking Cessation and its Effects on Outcomes of Surgical Interventions
17 Feb 2005	Choosing health. A briefing on tobacco in London
18 Mar 2004	Tobacco in London: The Preventable Burden [data tables for local authorities]
18 Mar 2004	Tobacco in London: The Preventable Burden [data tables for parliamentary constituency]
18 Mar 2004	Tobacco in London: The Preventable Burden [data tables for SHAs and PCTs]
18 Mar 2004	Tobacco in London: The Preventable Burden [Executive summary]
18 Mar 2004	Tobacco in London: The Preventable Burden [Press Release]
18 Mar 2004	Tobacco in London: the preventable burden. Full report
27 Nov 2003	Presentation: Women and Tobacco
26 Nov 2003	Smoking and Mental Health
26 Nov 2003	Smoking Cessation and Exposure to Secondhand Smoke Among Members of Black and Minority Ethnic Groups in London
26 Nov 2003	Tobacco in London: Attitudes to Smoking in the Capital
26 Nov 2003	Tobacco in London: Facts and Issues

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1. Peto R, Lopez AD, Breham J, Thun M, Heath C, Jr. Mortality from smoking in developed countries, 1950 - 2000, indirect estimates from national vital statistics. Oxford: Oxford University Press, 1994.
2. Prescott-Clarke P, Primatesta P. Health Survey for England, 1996. London: TSO, 1997
3. Richardson K. Smoking, Low Income and health Inequalities: Thematic Discussion Document. Report for Action on Smoking and Health and the Health Development Agency, May 2001.
4. Department of Health. Health Survey for England. London: TSO, 2000.
5. Jarvis M, Wardle J, Social patterning of individual health behaviours: the case of cigarette smoking. In Marmot M, Wilkinson R, eds. Social determinants of health. Oxford: Oxford University Press, 1999.
6. Peto R. The Archie Cochrane lecture, September 2001, Society for Social medicine conference, Oxford.
7. US Surgeon General. Preventing Tobacco Use among Young People. A report of the Surgeon General. Atlanta: CDC, 1994.
8. Crosier A. A rapid mapping study of smoking projects and services targeted at people living on Law income and/or minority ethnic groups. Report to the health Development Agency, February 2001.
9. UK Department of Health. Report of the Scientific Committee on Tobacco and Health. London: TSO, 1998.
10. British Medical Association Board of Science and Education & Tobacco Control Resource Centre. Towards smoke-free public places. London: BMA, 2002.
11. Rapace J. Can ventilation control second hand smoke in the hospitality industry? Bowie, MD: Rapace Associates, 2000.
12. BMRB Social Research. SmokeFree London: Survey Report. October 2001.
13. Williams B, Williams J, Owen L, Crosier A. Attitudes to smoking in the capital. London: SmokeFree London and Health of Londoners Programme, 2002.
14. Department of Health. Smoking Kills. A white Paper on tobacco. London: TSO, 1998
15. Tobacco Policy Unit, Department of Health, April 2000
16. Department of Health. Priorities and Planning Framework 2003-2006:Improvement,Expansion and Reform:The Next 3 Years. London: the Stationery Office, 2002.
17. Action on Smoking and Health / Chartered Institute of Environmental Health / Trades Union congress. Don't Choke on Smoke Conference, April 2003. Summary and transcript available from ASH.
18. Sandford A, Dehlavi N. The tobacco industry, ETS and the hospitality trade. A chronology of tobacco industry obfuscation. London: Action on Smoking and Health, 2003
19. Department of Health. Smoking, drinking and drug use among young people in England, 2002. London: TSO, 2003.

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