The London Health Observatory is the lead Public Health Observatory on tobacco for the Association of Public Health Observatories (APHO). This introduction gives a brief background to resources on smoking and health, and policies to address the harm. It includes both UK-wide and London data and resources.

(Information for these smoking and ill health sections draws mainly on resources on the useful ASH website at www.ash.org.uk).

Nationally, one fifth of all UK deaths (112,000 per year) are caused by smoking. One in two regular smokers is killed by tobacco, half dying before the age of 70 (losing an average of 21 years of life) and half in later life (but still an average of eight years earlier than their non-smoking peers). The London data on smoking related harm can be found in the health profile for London at: http://www.apho.org.uk/resource/item.aspx?RID=50156

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. Taking up smoking in adolescence greatly raises the risk of lung cancer - those who start before age 15 have double the number of cell mutations compared with those who start after the age of 20. Cigarette smokers have two to three times the risk of a heart attack, compared with non-smokers. Smoking also increases the risk of:

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Breathing other people's smoke causes both short and long term health problems. Immediate effects include eye irritation, cough, dizziness and nausea. Longer term exposure raises the risk of death from lung cancer by 20-30%, and risk of death from coronary heart disease by 50-60%. Smoking both during and after pregnancy causes one in three 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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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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The use of smokeless tobacco in the UK tends to be confined largely to the South Asian community. Smokeless tobacco, which may be chewed alone or with betel quid/paan, has a significant detrimental impact on the oral cavity (the inside of the mouth between the teeth and the soft palate). 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 (lining of the mouth) 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. These 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, eg in Tower Hamlets.

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Water pipes, also known as hookahs, narghiles, shisha or hubble-bubble pipes, deliver tobacco smoke, often flavoured with fruit and other flavourings, through a reservoir of water. Smoking a water pipe is often a shared social experience. They are used primarily by UK’s Middle Eastern and eastern Mediterranean communities, although the prevalence of use is not well researched. The health impacts are likely to be similar to those of cigarette smoke, since the water does not alter the composition of the smoke. In fact, exposure to smoke can be considerably greater – possibly the equivalent of 100 cigarettes at a smoking session. Secondhand smoke from water pipes can also pose serious health risks.

Water pipes are covered by legislation prohibiting smoking in public places.

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As smoking is the biggest single preventable cause of ill-health and premature death, stopping smoking is the most important way of reducing mortality, morbidity, and health inequalities. It is seldom "too late" to stop smoking. Within 15-20 years of stopping smoking, the risk of lung cancer reduces to 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 to about half that of a continuing smoker within a year or so. Encouraging cessation among adults is also important in reducing smoking role models for children.

There are benefits for the health service. An estimate by the London Health Observatory found that, if surgeons and outpatient teams worked with smoking cessation colleagues to help patients quit, there could be as many as 5,300 fewer post-operative complications in London per year.

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Smoking accounts for a significant proportion of inequalities in expectation of life at birth the UK, contributing particularly to CHD, other cardiovascular and respiratory diseases, and many cancers. The health impact by socio-economic status has been estimated for the London Health Inequalities Forecast. This found that 37% of the difference in life expectancy at birth in males and 30% of the difference in females between the ‘London Spearhead Group’ and all local authorities was accounted for by mortality attributable to smoking.

Note: Spearhead authorities are in the fifth of English local authorities with the worst health and deprivation indicators- of which there are 70 in England and 11 in London.

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There are 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 10 million adults in Great Britain smoke cigarettes – 23% of men and 21% of women. There has been a steady decline in smoking since the early 1970s, largely through established smokers quitting. More than 83% of smokers take up the habit as teenagers. Smoking is highest among those aged 20-34, of whom 33% of men and 28% of women smoke. Smoking prevalence gradually declines with age, through quitting or dying; the lowest smoking rate is among people aged 60 and over, of whom 12% smoke. About one in seven of Britain's 15 year-olds – 12% of boys and 19% 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 18.

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The Health Survey for England published in 2004 found that across England Bangladeshi men were 43% more likely (a rate ratio of 1.43) to smoke than the general population after accounting for age. Other groups with rates above the general population for men were Irish men (30% more likely), Pakistani men (8% more likely) and black Caribbean men (2% more likely). Chinese men and Indian men were less likely than the general male population in England to smoke (81% and 78% as likely as the general population, respectively). Smoking is less common among women in most minority ethnic groups compared to the general female population, when age was taken into account. Compared to the general female population, Bangladeshi women were 11% as likely, Pakistani women 19% as likely, Indian women 23% as likely and Chinese women 32% as likely to smoke. However, Irish women were 11% more likely to smoke, and black Caribbean women 8% more likely.

The gap between the smoking rate of the general population and that of minority groups in each sex closed between the survey conducted in 1999 and that conducted in 2004. This was true of groups with rates above that of the general population (Bangladeshi men, Irish men, Black Caribbean men and Irish women, where the rate ratio has fallen) and those with rates below the general population (Chinese men, Indian men, Bangladeshi women, Pakistani women, Indian women and Chinese women, where the rate ratio has risen). Two groups have both moved from a smoking rate below that of the general population of their sex to one above. Pakistani men were 90% as likely to smoke as the general male population in 1999 and 8% more likely in 2004. Black Caribbean women were 85% as likely to smoke in 1999 and 8% more likely in 2004 compared to the general female population.

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Since 1982 the Department of Health has commissioned regular surveys of smoking among secondary schoolchildren aged 11-15. The 2007 survey revealed a significant drop in the overall prevalence of regular smoking (at least one cigarette a week) from 9% in 2006 to 6% in 2007. This is the lowest rate since surveys began in 1982.There is a sharp increase in prevalence of smoking with age: 1% of 11-year-olds smoke regularly compared with 15% of 15-year-olds.

• As in previous years, overall girls are more likely to be regular smokers than boys –eight percent compared with five percent;
• The proportion of 11-15 year olds who had tried smoking at least once (33%) represents a long term decline since 1982 when 53% had tried smoking.
• Young people classified as regular smokers smoked an average of 44.1 cigarettes a week, approximately six a day.

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There is little reliable information on smoking prevalence in adults or children at a local level. Estimates have been produced and form part of the community health profiles for every local authority in England.

London’s health and health care partners have commissioned a boost of the health survey for England which provides more detailed local information.

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The Government’s smoking target for England in the 2007 Public Service Agreement on promoting health and wellbeing (from the Comprehensive Spending Review) is to reduce overall adult smoking (aged 16+) to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less. In 2006 the actual rates were 22% for all adults, and 29% for those in routine and manual occupations. At the current rate of decline, it appears that the target for the overall population is likely to be reached or exceeded while that for smoking amongst manual groups is less certain.

Smoking is recognised as being an important contributor to achieving cross government objectives on:

• Inequalities in life expectancy
• Inequalities in infant mortality
• Coronary heart disease (Coronary Heart Disease NSF – Standards 2, 3, 4) and stroke
• Diabetes (Diabetes NSF – Standard 4)
• Cancers (Cancer Reform Strategy – Chapter 2)

A target from the 1998 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 has been achieved in England. However, reduced smoking rates must be sustained and improved upon.

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The Government’s programme on tobacco is made up of six strands:

• help for smokers to quit through NHS stop-smoking services, national quit-lines & stop-smoking aids on NHS prescription;
• mass media communication and education campaigns;
• comprehensive bans on tobacco advertising, promotion and sponsorship;
• protection for people from harm from secondhand smoke through the smokefree legislation;
• regulation of tobacco products through pack-warnings – including graphic images, information on packs, age of sale raised from 16 to 18 years and restricting under-age sales; and tougher sanctions against retailers who break the law;
• reducing consumption through increased price, by action to tackle smuggling and action on tax / duty rates.

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Stop-smoking advice is delivered in a number of settings by trained advisors in England. This work is part of the Government’s strategy to reduce health inequalities and funding is targeted at the 'Spearhead Group' - the most deprived local authority areas in England. It is supported by evidence-based aids to quitting (principally nicotine replacement therapy, bupropion and varenicline). These initiatives are supported by media stop-smoking campaigns.

The NHS commissioned an evaluation which found that this work did make a modest but significant contribution to reducing socio-economic inequalities in smoking rates. The rate of quitting one year after treatment was four times that for willpower alone (at 15% of those who had quit for four weeks, the indicator used to monitor the programme). The Healthcare Commission (now the care quality commission) found that more deprived PCTs were more likely to perform well. However, a report from the LHO found that NHS stop smoking services have not been as successful in attracting black and minority ethnic clients.

London’s smokers referred to or offered smoking cessation advice are reported on in the London PCTs' public health quarterly performance reports, produced by the LHO.

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Smoking was banned in enclosed public places and workplaces in England in July 2007, following implementation of earlier legislation in Wales, Scotland and Northern Ireland. Compliance in England is monitored. Since July 2008, the English legislation also applies to mental health facilities.

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From October 2008, picture warnings will be added to tobacco packs in the UK, as part of a continuing programme to strengthen warnings.

From October 2007, sales to people aged under 18 years were banned in England and Wales, with enforcement by trading standards officers.

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There is active debate on the merits of introducing a smoking harm reduction strategy. The intention is to shift smokers away from harmful inhalation of tobacco and regulate nicotine replacement strategies appropriately. Recent research in this area can be found at: http://jpubhealth.oxfordjournals.org/cgi/content/full/31/1/3.

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• Ash Essential Information Series
• London Health Inequalities Forecast
• Scientific Committee on Tobacco and Health
• National Library for Health – Public Health Specialist Library – Tobacco use

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• Links to Government documents and related policies
• Smoking-related behaviour and attitudes – a report on research using the National Statistics Omnibus Survey produced on behalf of the Information Centre for Health and Social Care (covers Great Britain)
• General Household Survey (covers Great Britain)

The two sources above both cover smoking prevalence in Great Britain. Jarvis 2003 (below) considers how the two surveys relate to each other and concludes that their similarity in sample and findings means that they can usefully complement each other. Data on adults in the "Cigarette smoking – who smokes" section above draws mainly on the General Household Survey.

The sources above exclude Northern Ireland. Comparable data for all parts of the island of Ireland can be found through Ireland and Northern Ireland’s Public Health Observatory (INIsPHO) Online data

• Jarvis MJ Monitoring cigarette smoking prevalence in Britain in a timely fashion. Addiction 2003; 98:1569-1574
• Health survey for England 2004: health of ethnic minorities
• Health survey for England 1999: the health of minority ethnic groups
• Peto R, Lopez AD, Boreham J, Thun M. Mortality from smoking in developed countries 1950-2000 (2nd edition: updated June 2006)
• Community health profiles (providing estimates of numbers of people who smoke)

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• HM Treasury Public Service Agreements
• Smoking kills white paper
• Cancer reform strategy
• Diabetes NSF
• Coronary Heart Disease NSF / Stroke strategy
• Smoking treatment services in England: implementation and outcomes
• No ifs no buts: improving services for tobacco control. Healthcare Commission 2007
• 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
• Smoking and public health (compendium of material)
• 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)
• Guidance on smoking 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
• Bull J, Mulvihill C, Quigley R. Prevention of low birth weight: Assessing the effectiveness of smoking cessation and nutritional interventions. London: HDA, 2003.
• Cochrane Tobacco Addiction Group reviews on smoking cessation
• Reviews of evidence for community-level interventions (A resource from the CDC)
• Targeting smokers from disadvantaged groups (information from ASH)
• 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.

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• ASH - Action on Smoking and Health
• Net Doctor
• Department of Health
• Quit
• Asian Quitline

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