Smoking is one of the major causes of preventable and premature death in the England. Smoking is a main contributory factor to the gap in mortality and healthy life expectancy between the most and least advantaged. There has been action on this public health issue by the government to protect the children and old age people. Government effort to tackle the problem of smoking gives multiple results in health promotion in society like reducing the cancer deaths, reducing asthma, reducing coronary heart diseases etc. Government took a major step towards the issue smoking by publishing White paper. Smoking is also one of the primary causes of health equality in England. In this paper, the problem of smoking is addressed by discussing about public health and health promotion models approach towards smoking, epidemiology of smoking in England, international policies and strategies to control smoking, national and local policies and strategies implemented to reduce the prevalence of smoking in England and reviewing them and concluding with some suggestions and recommendations.

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Smoking was not a major public health problem in 19th century. Tobacco was introduced from North America in Europe at the end fifteenth century. In beginning, tobacco was used for the medicinal purposes, later it was burnt in pipes for the pleasure purpose in England, then in Europe which later spread in whole world (Doll, 1998). The introduction of mechanical cigarette rolling machine brought the transformation and then cigarette became the cheapest and convenient way of tobacco use. In first half of 20th century cigarettes were promoted through advertisements, public relation and sponsorships. Smoking was not considered a public health issue due to insufficient evidence to prove relation of smoking to lung cancer, coronary heart disease etc. Later in research studies prove that smoking causes lung cancer (Doll and Hill, 1950).
Globally 5.4 million people die each year from tobacco epidemic. The death toll is rising persistently and in two decades will reach 8 million a year. In the WHO European Region smoking prevalence is estimated at around 28.6% with a large gender difference – males account for 40% and females 18.2%. The difference between the proportions of men and women smoking has gradually reduced, although it has not disappeared completely. In 1982, 38 per cent of men and 33 per cent of women were smokers, compared with 27 per cent of men and 25 per cent of women in 2002(Office for National Statistics, 2004). Among young people aged 15 years, the prevalence of weekly smoking is on average 24%. About 8.5 million people still smoke in England today, and over 80,000 deaths a year are due to smoking in England alone. According to the Tobacco control database, years lost from death by smoking range from 12 – 20 years, and up to 21% of deaths are attributed to smoking. According to Office of National Statistics (March, 2009) smoking fell to its lowest recorded level in 2007 i.e. 21 per cent of the population aged 16 and over which were 22 percent in 2006, 28 percent in 1998 and 39 percent in 1980.
It has been found that smoking is prevalent in the working age groups. Those aged 20 to 24 and 25 to 34 reported the highest prevalence of cigarette smoking (32% and 26% respectively) while those aged 60 and over reported the lowest (12%). Current smokers smoked an average of 13.1 cigarettes a day. Prevalence of smoking amongst people in the routine and manual socio-economic group continues to be greater than amongst those in the managerial and professional group (26% and 15% respectively). Almost two thirds (65%) of current and ex-smokers who had smoked regularly at some point in their lives started smoking before they were 18.
Smoking is more prevalent in the ethnic minority groups. There has been huge difference between the ethnic groups in England. Bangladeshi (44percent), White Irish (39 percent), Black Caribbean (35 percent) men were the highest smokers where as Pakistani (25 percent) and Indian (23percent) men were smoking comparable to the general population and Chinese men smoked the least of 17 percent. Similar to men, White Irish and Black Caribbean women had the highest smoking rates (33 per cent and 25 per cent respectively), although only White Irish women had a rate higher than the general population (27 per cent). But unlike men, women in every other minority ethnic group were much less likely to smoke than women in the general population (Health Survey for England, 1999).
Smoking prevalence is a key indicator not just for smoking-related diseases but also for health inequalities. Smoking behaviour is strongly related to a person’s socio-economic class. Death rates from tobacco are two to three times higher among disadvantaged social groups. Smoking is significant contributor to the gap in health and life expectancy between the richest and the poorest. Smoking exhibits a strong social gradient and is the major cause of health inequalities in the United Kingdom accounting for two thirds of the difference in risk of premature death between social classes. Reducing the prevalence of smoking increases the life expectancy and also reduces the chances of various acute and chronic diseases. Smoking is responsible for various forms of cancers, coronary heart diseases and respiratory diseases like emphysema and bronchitis. It also increases the chances of tuberculosis infection. Reducing the smoking rate has a strong positive impact on local economy.
People from lower socio-economic classes are more likely to smoke than those from higher classes. For example, Bangladeshi men were over represented in the lowest socio-economic class (semi-routine or routine occupations), and these men also had the highest rates of smoking. Smoking is prevalent almost equally in both the sex in the high income group but in low income groups or manual working class the number of female smokers is considerably less (Health Survey for England, 1999). Smoking in pregnancy increases infant mortality by approximately 40%, and smoking prevalence is 1.5 times higher in routine and manual pregnant women than the population as a whole. Second hand smoke is responsible for the sudden infant death syndrome and also contributes to asthma or bronchitis in children. People in poorer social groups who smoke, start smoking at an earlier age: of those in managerial and professional households, 31% started smoking before they were 16, compared with 45% of those in routine and manual households.
The issue of smoking can be approached from all the models of health promotion. From medical model point of view the aim is to identify those at risk from disease. It can be done by screening the individual for the risk assessment e.g. measurement Forced Expiratory Volume (FEV). Behavioural change approach is aimed mainly to encourage individuals to take responsibility for their own health and choose healthier lifestyle. This can be done by individual advice and information about the impact of smoking on their family members .Educational model approach aims to increase the knowledge about healthy lifestyle which can be done by educating about the hazards of smoking and informing them about various methods to quit smoking e.g. Nicotine replacement Therapy (NRT) etc. Social model approach from aspect of health promotion is very important for dealing with smoking. It aims to address the inequalities in health based on class, race, gender, geography. This can be done by development of public health legislation like smoke free workplace, smoke free public places etc (Naidoo and Wills, 2009, p.67-77).
Smoking kills one-in-two of all lifelong users. At current rate of mortality and morbidity due to smoking approximately 10 million people will die out of which around 70% people will be from developing countries. World Health Organisation developed a first health treaty known as Framework Convention on Tobacco Control (FCTC) and adopted in May 2003 to control tobacco supply and consumption. At the World Health Assembly in May 2003 the Member States of the World Health Organization (WHO) including United Kingdom agreed on this public health treaty. The text of the WHO Framework Convention on Tobacco Control (FCTC) covers tobacco taxation, smoking prevention and treatment, illicit trade, advertising, sponsorship and promotion, and product regulation. The treaty requires signatory parties to implement comprehensive tobacco control programmes and strategies at the national, regional and local levels. The preamble of treaty mentions the need to protect public health, the unique nature of tobacco products and the harm that companies that produce them cause. The key measures included in the tobacco control strategy for England are reducing exposure to children from second-hand smoke through targeted campaigns highlighting the benefits of smoke-free homes and cars; to strengthen the NHS Stop Smoking Services and providing new routes to quitting for smokers unable to stop abruptly; to increase the investment to drive down tobacco smuggling; to sustain spending on marketing campaigns to encourage smokers to quit; to implement the retail display ban and ban on sale of tobacco from vending machines (Health Act, 2009).The key elements included in text of FCTC and in tobacco control policy of United Kingdom were very similar. These key elements have been discussed together from the international and national aspects.
Advertising is considered as the main reason for promotion of smoking. At international level, World Health Organisation tells the signatory countries to move towards a comprehensive ban within five years of the FCTC convention entering into force. It also contains provisions for countries that cannot implement a complete ban by requiring them to restrict tobacco advertising, promotion and sponsorship within the limits of their laws. It also requires the countries to look at the possibility of a protocol to provide a greater level of detail on cross-border advertising which can include the technical aspects of preventing or blocking advertising in areas such as satellite television and the internet. At national level, tobacco advertising is banned by law throughout the United Kingdom. The Tobacco Advertising and Promotion Act 2002 prohibit tobacco advertising on billboards, in print media, by direct mail and through sponsorship. The act has set of four regulations which ban advertising at point of sale, brand sharing, sponsorship, specialist tobacconist. A health warning equivalent to one third of the surface area of the advertisement must be included at counters.
Taxation and price rise of the tobacco product is one of the way which helps in reducing the prevalence of smoking among young people by increasing the cost of tobacco products. High tobacco tax, which is recommended by the World Bank, is recognised as a good health and economic policy. Increasing taxes on tobacco encourages people to give up smoking and raises revenue for the government thus reducing the need for taxes on jobs and investment. At international level, the FCTC guidelines tells that countries should consider public health objectives when implementing tax and price policies on tobacco products. At national level, the British government announced that it planned to increase tobacco tax by at least 5% a year in real terms (White Paper, 1998). This policy was dropped in 2001 and since then annual increase is around inflation rates which comes around 2.5% a year.
Tobacco smuggling is an international problem requiring a global response. It has been estimated that about one-third of all internationally traded cigarettes are smuggled (350 billion cigarettes per year), causing billions of pounds of lost government revenue (over £2 billion in the UK alone).Under the Article 15 of Framework Convention on Tobacco Control (May, 2003) agreed governments were required to monitor and collect data on cross border trade in tobacco products including illicit trade, to enact or strengthen legislation against illicit trade in tobacco, to destroy counterfeit and contraband tobacco, to adopt and implement measures to monitor and control the distribution of tobacco products and to adopt measures to enable the confiscation of proceeds derived from smuggling. The British Government launched a £200 million initiative to tackle tobacco smuggling which resulted in declining the illicit market share from a peak of 21% in 2000-1 to 15% by 2003-4. In the 2006 Budget, the Treasury announced plans to extend the campaign which included a target to reduce the size of the UK illicit tobacco market by 1,200 tonnes by 2007/08. In the 2008 Budget, the Chancellor announced that the recently created Borders Agency would take responsibility for developing a new comprehensive strategy to tackle tobacco smuggling.
Labelling of the cigarette and tobacco packet showing health warning alerts the customer about the potential health hazards of the product. According to FCTC guidelines, at least 30 percent of the display area on tobacco product packaging should display clear health warnings. These warnings can be in form of text, pictures or both. Labelling language should not be misleading and should not give false impression that the product is less harmful than others. Similar policy was implemented in United Kingdom by Tobacco Products Regulations (2002). In the UK, picture warnings on cigarette packs were introduced from October 2008. Pictorial warnings on other tobacco products will be required by October 2010. The Tobacco Products Directive also places maximum levels on the amount of tar, nicotine and carbon monoxide permitted in cigarettes and requires tobacco companies to disclose tobacco ingredients to national governments.
Financing of the national tobacco control programmes by the governments is a major step towards smoking and health promotion among the people, educating the illiterate people about the hazards of tobacco. According to World Health Organisation Framework Convention on Tobacco Control (2003), signatory countries are required to provide financial support to their national tobacco control programmes. The elements of the treaty reflect WHO and World Bank policies on a comprehensive plan to reduce global tobacco consumption. The text of the treaty requires the countries to promote treatment programmes to help people stop smoking and education to prevent people from starting, to prohibit sales of tobacco products to minors, and to limit public exposure to second-hand smoke.
In England, tobacco control activity is led by the Department of Health. The Department has six strands strategy to reduce smoking rates. This strategy is focused on: supporting smokers to quit; reducing exposure to second-hand smoke; running effective communications and education campaigns; reducing tobacco advertising, marketing and promotion; effectively regulating tobacco products; reducing the availability and supply of tobacco products.
The outcome of this six strand strategy is that the prevalence of smoking is reducing in general population but the rate is slower in the routine and manual group and smoking is major contributor of health inequality in England.
In 2008, Department of Health issued a consultation, a step towards a new national tobacco control strategy. It covers four main areas for controlling smoking. They are:
Reducing the smoking rates and health inequalities caused by smoking. Smoking prevalence is an indicator for health inequalities. Government policy is dedicated to tackle health inequality under a Public Service Agreement (PSA) to ensure that the gap in health inequalities in rich and poor should not widen. National Support Teams are made to support the local delivery of the Public Sector Agreement, working with local authorities like primary care trust. Local Strategic Partnerships need to be encouraged to adopt smoking prevalence as one of the targets in their Local Area Agreements. Local Strategic Partnerships should ensure that work is undertaken with their local public health agencies and government office for calculating smoking prevalence in their area and for determining the appropriate targets. Public Health professionals also need to work with their Local Strategic Partnership to help develop Local Area Agreement action plans. Targeting the Routine and Manual helps in targeting the largest group of smokers responsible for smoking related health inequality (Department of Health, 2009).
Protection of children and young people from smoking by reducing the affordability, reducing the availability to the children, reducing the attractiveness of the tobacco products and increasing awareness about harms of tobacco products. There is rise in the price of cigarettes and tobacco products each year by government which makes cigarette less affordable for young people. Government made strict laws for sale of cigarettes by vending machines and also by increasing the minimum age to 18 years for purchase of tobacco product. The advertising of the tobacco products is banned and tobacco products will be removed from display in 2011 from large retailers and completely removed by 2013. The government will continue to give advice on harms of smoking and tobacco through voluntary National Healthy Schools Programme.
Motivating and assisting smokers to quit smoking. Smoking cessation has been a key component of the government’s tobacco control policy. This includes NHS stop smoking services or primary care or using over the counter medication. The NHS Stop Smoking Services were launched in 1999-2000 in the Health Action Zones (HAZ) which are the areas of high deprivation. The services were rolled out to the rest of England in 2000/01. The Specialist stop smoking services providing behavioural support and pharmacotherapy have been established as standard NHS services throughout the United Kingdom. Most forms of Nicotine Replacement Therapies are also available on general sale. The importance of helping smokers to quit smoking is stressed in priorities guidance to the NHS and health professionals. Targets have been set for smoking cessation treatment and also for prevalence reductions in each Primary Care Trust. Expenditure on smoking cessation services has steadily increased since their creation in 2000, rising from £21.5 million to £74 million in 2008-09. The cost per quitter in 2008/09 was £219. The cost including hospital admissions, GP consultations and prescriptions, the treatment of disease caused by smoking is approximately £1.7 billion per year. The net ingredient cost of all pharmacological therapies to help people stop smoking was £61 million in 2007/08. This compares to £45m in 2006/07.
The government encourages people to quit smoking through its mass media campaigns like ‘Get Unhooked’ campaign. The funding of advertising campaigns in form of banners is supported by the government on large scale. Government funds various researches to give evidence on smoking cessation services, and to monitor and evaluate the above initiatives including options to reduce under-age sales, introduce ID cards for children, tougher penalties for retailers who sell to children, and a new code on the location of cigarette vending machines.
Reviewing the tobacco control policy in United Kingdom various policy gaps were identified and recommendations are suggested for the service gaps. Firstly, advertising policy of the tobacco products. Currently advertising at the point of sale is still permitted which is equivalent in size to one A5 sized advertisement and the health warning should be covering the one third area of the display or advertising. According to Health Act (2009) the tobacco products should be removed from the display in shops. But government will implement this law in 2011 for large retailers and 2013 for small retailers. It is recommended that government should implement the law about the advertising immediately so as to reduce the promotion and marketing of tobacco products which discourages the interest of the young age people.
Government is encouraging and funding various media campaigns like banner promotions, television and newspaper advertising campaigns to promote smoking cessation services and anti smoking campaigns. Government need to develop local campaigns which should target the ethnic groups by translating the banners in their language. The campaigns should involve the cultural or community leaders, celebrities etc so that the campaigns attract more public.
The age limit for buying a tobacco product has increased from 16 years to 18 years so that the cigarette and tobacco products are not easily available to young people. Government should licence all the tobacco retailers so as to improve the enforcement of the minimum age limit. Prohibit the sale of tobacco from vending machines.
Ensure all pregnant women are offered support from specialist stop smoking services as part of routine antenatal care. Train midwives to provide appropriate stop smoking advice and referrals to all pregnant smokers. Develop and evaluate new services and incentives to support the efforts of pregnant smokers to quit. Promote smoke free homes and cars through national and local campaigns.
Routine and Manual smokers should be approached through an integrated framework model to reduce smoking prevalence. All the Primary Care Trust service providers at the local stop smoking service should be trained and capable to deliver high quality services. The insights of the routine and manual smokers should be shared by health commissioner for development of future agreements. The service provider should try to gather and share tobacco related intelligence e.g. cheap and illicit tobacco. The local authorities should try coordinating and monitoring the local tobacco control alliance.
Government has encouraged various initiatives to reduce the prevalence of smoking in England. There has been support from the World Health Organisation and World Bank to promote anti tobacco campaigns. The new strategies and policies are needed to focus on the routine and manual worker groups which will help in reducing the smoking prevalance. The policies should be implemented properly at the local level. England has achieved the targets to reduce the smoking in public. But still there is a need for every individual smoker and non smoker to take an initiative to eradicate the unhealthiest lifestyle from their lives.