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3 days ago · MPs to vote on legislation to create first smokefree generation, ... smoking is the UK’s single biggest preventable killer and costs the NHS and economy an estimated £17 billion a year - far ...
- Foreword
- Executive summary
- 1. The case for change
- 2. Action already underway
- 3. Smoking - stopping the start
- 4. Supporting people to quit smoking
- 5. Youth vaping
- 6. Enforcement
- 7. Next steps
Smoking damages and cuts short lives in extraordinary numbers. From increasing stillbirths, through asthma in children, to dementia, stroke and heart failure in old age, it causes disability and death throughout the life course. It drives many cancers, especially lung cancer which is the most common cause of cancer deaths in both women and men in the UK. It causes and accelerates heart disease, the biggest single cause of deaths overall. Large numbers of people are confined to their homes by heart failure or chronic obstructive pulmonary disease caused by smoking, unable even to climb the stairs. Non-smokers, including children and pregnant women are exposed to the risks of second-hand passive smoking. The NHS has a huge burden of smoking-related disease to attend to, along with all its other work.
Data over the last 5 years shows most smokers want to quit, but cannot due to an addiction to nicotine that started in their teenage years. Over 80% of smokers started before they turned 20, many as children. They have had their choices taken away by addiction, and their lives will be harmed and cut short by an addiction they do not want.
One of the tools to help people addicted to nicotine to stop smoking is vaping - and because the harms of smoking are so great, it is safer to vape than smoke, but vapes are not risk free. So, if you smoke, swap to vaping, if you don’t smoke, don’t vape. Marketing vapes to children is utterly unacceptable. Some are now clearly trying to addict children including with colours, flavours, cartoons and other marketing methods aiming to tempt children towards addiction.
The government has made clear they wish to create a smokefree generation unaffected by the extraordinary harms of addiction-driven smoking, and tackle youth vaping. This Command Paper lays out a route to prevent addiction to smoking before it starts, to support smokers to quit and to stop vapes being marketed to children.
Professor Sir Chris Whitty, Chief Medical Officer for England
Smoking kills, places a huge burden on the NHS and costs the economy billions every year in lost productivity. We need to do more to protect our children and grandchildren from the many health problems it causes, including cancer and cardiovascular disease, and to help them live longer, healthier lives. We know that most smokers start in their youth and are then addicted for life. Vaping can be an effective tool in helping smokers to quit, but we have seen a recent and highly concerning surge in the number of children vaping
Tobacco is the single most important entirely preventable cause of ill health, disability and death in this country, responsible for 64,000 deaths in England a year. No other consumer product kills up to two-thirds of its users. The independent review in 2022 found that, if we do not act, nearly half a million more people will die from smoking by 2030.
… when used exactly as recommended by the manufacturer, cigarettes are the one legal consumer product that will kill most users…
The Khan review: making smoking obsolete (2022)
Smoking causes harm throughout people’s lives. It is a major risk factor for poor maternal and infant outcomes, significantly increasing the chance of stillbirth and can trigger asthma in children. It leads to people needing care and support on average a decade earlier than they would have otherwise, often while still of working age. Smokers lose an average of ten years of life expectancy, or around one year for every 4 smoking years.
Smoking causes around 1 in 4 of all UK cancer deaths and is responsible for the great majority of lung cancer cases. Smoking is also a major cause of premature heart disease, stroke and heart failure and increases the risk of dementia in the elderly. Non-smokers are exposed to second-hand smoke (passive smoking) which means that through no choice of their own many come to harm - in particular children, pregnant women, and their babies.
The tobacco epidemic is one of the biggest public health threats the world has ever faced… All forms of tobacco use are harmful, and there is no safe level of exposure to tobacco.
Overview
This chapter sets out the case for taking further action to finish the job on preventing people becoming addicted to smoking, while also addressing the more recent challenge of youth vaping. Tobacco, and especially cigarette smoking, is the single biggest entirely preventable cause of ill health, death and disability in this country. Stopping people from ever starting smoking, as well as supporting current smokers to quit, will improve public health and reduce disparities, reduce the burden on the NHS and the social care system, and provide substantial benefits to the workforce and the economy.
Smoking prevalence and age of initiation
The government is committed to reducing the harms of smoking and has a strong history of taking bold and comprehensive action on tobacco control. Smoking rates in the UK are now the lowest on record, at 12.9% (around 6.4 million people) and 12.7% smoke in England. Smoking prevalence is a third of its height in 1974, and has fallen by more than a third over the last decade. We have successfully seen smoking rates decline in all ages since the 1970s, with the largest reduction among 18 to 24 year olds: 25% of this group smoked in 2011 compared with 11.6% in 2022. Legislation has been an important driver of this decline - including raising the age of sale for smoking from 16 to 18, which reduced prevalence in this age group by 30%. The great majority of initiation of cigarette use continues to be in the teenage years. 83% of smokers start before the age of 20. People who start smoking under the age of 18 have higher levels of nicotine dependence compared to those starting over 21 and are less likely to make a quit attempt and successfully quit.
The impact of smoking on public health
Figure 1 shows that tobacco is the single leading preventable cause of mortality, leading to 64,000 deaths in England each year and harming nearly every organ of the body. Smoking is causing a hidden national health crisis. Estimates suggest there have been as many - if not more - deaths from smoking as from COVID-19 since the start of the pandemic. Up to two-thirds of smokers die of smoking, and those who start smoking as a young adult lose an average of 10 years of life expectancy. Figure 1: Age-standardised mortality attributed to risk factors, England, 2019 Source: Global Burden of Disease Study 2019 Smoking causes around 1 in 4 of all UK cancer deaths. Lung cancer is the most common cause of cancer deaths in the UK, and most people who are diagnosed with this condition die within a year. Of the estimated 54,500 total new lung cancer cases in the UK in 2023, 43,000 were preventable. Tobacco is responsible for just over 70% of all lung cancer cases, or equivalent to over 39,300 cases. Smoking also contributes significantly to cancers of the mouth, throat, oesophagus, stomach, bowel, pancreas and bladder. Lung health in general is also severely impaired by smoking, leading to disabilities, including the 9 out of 10 cases of chronic obstructive pulmonary disease (COPD) thought to be caused by smoking. Smoking, including passive smoking, can increase the risk of asthma in children and adults. Smoking substantially increases the risk of cardiovascular disease (CVD) - heart attacks and strokes - one of the most common causes of mortality in the UK. Between 2017 and 2019, around 28,000 deaths from heart disease were attributable to smoking. Smoking increases the rates of stroke by around 12% for every 5 cigarettes a day. Smoking is also a significant risk for poor pregnancy-associated health outcomes. Women who smoked during pregnancy were 2.6 times more likely to give birth prematurely. These babies were more likely to have a lower birth weight and were 4.1 times more likely to be small-for-date babies. Smoking increases the risk of birth defects which can result in poorer health outcomes later in life. In areas with the highest smoking rates, in high income countries, up to 20% of stillbirths may be caused by smoking. Smoking is closely associated with poor mental health and wellbeing. People with mental health conditions die 10 to 20 years earlier with smoking contributing significantly to this. Smokers are also 1.6 times more at risk of dementia, including Alzheimer’s and vascular dementia, and 14% of dementia cases can be attributed to smoking internationally.
Overview
A comprehensive approach to tobacco control has been critical to the success in reducing smoking rates including a history of legislation, funding to local stop smoking services, NHS tobacco dependence treatment services and impactful anti-smoking campaigns.
Tobacco legislation
Legislative action has made long-lasting change, particularly legislation to discourage young people from taking up smoking. Figure 8 shows a consistent decrease in smoking rates alongside the legislation which has supported this. Figure 8: Smoking prevalence mapped against key interventions from 1982 to 2021 Source: Smoking, drinking and drug use among young people in England, 2021 In 2007, the legal age of sale for tobacco products was raised from 16 to 18. This change was shown to reduce smoking among children with a similar impact among different socioeconomic groups. This helped reduce youth smoking rates in children aged 11 to 15 from 9% in 2005, to less than 1.1% in 2021. In 2008, the first time data was collected after the change in the law, 39% of pupils who smoked said they found it difficult to buy cigarettes from shops, an increase of 15 percentage points from 2006. More recent changes include the introduction of standardised packaging in 2016 and prohibiting the sale of menthol flavoured cigarettes and hand rolling tobacco, which came into force in May 2020, as international evidence shows that many young people start smoking by using menthol cigarettes.
System wide action and funding
Last year alone, the government provided £35 million to deliver on the NHS Long Term Plan’s commitments on smoking. This funding will mean that all inpatients admitted to hospital who smoke will be offered NHS-funded tobacco treatment services. As part of the plan, all pregnant smokers will receive specialist opt-out support as part of a new maternity-led pathway. Routine carbon monoxide testing, which is used to identify smokers at booking and refer them into support to quit, has resulted in more pregnant smokers being identified and referred into stop smoking services. In June 2023, the government announced a new national targeted lung cancer screening programme designed to catch cancer sooner. Smoking causes just over 70% of lung cancer cases, so people aged 55 to 74 with a history of smoking will be assessed and invited for screenings and directed to smoking cessation services. In August 2023, the government launched a consultation on introducing mandatory cigarette pack inserts with positive messages and information to help people to quit.
Overview
There is no more addictive product that is legally sold in our shops than tobacco, which is why ‘stopping the start’ of addiction is vital. Three-quarters of smokers would never have started if they had the choice again. It is much easier never to start than to have to quit. The great majority of smokers start as teenagers - 83% before the age of 20. Drawing on the 2022 independent review recommendations, the government will bring forward new legislative proposals to raise the age of sale indefinitely. The government wants to continue the current downward trajectory and get smoking rates to 0%. There is no safe age to smoke.
Legislating to create a smokefree generation
The government will bring forward legislation making it an offence to sell tobacco products to anyone born on or after 1 January 2009. In effect, the law will stop children turning 14 or younger this year from ever legally being sold tobacco products - raising the smoking age by a year each year until it applies to the whole population. This will ensure children and young people do not become addicted in the first place. As is the case with current age of sale legislation, the emphasis will be on those who sell tobacco products - the government has never and will not criminalise smoking. Furthermore, the phased approach means that anyone who can legally be sold cigarettes now will not be prevented from doing so in the future. These changes will be brought in following an implementation period, alongside ongoing support for current smokers to quit.
Context
The Children and Young Persons (Sale of Tobacco etc) Order 2007 increased the legal age of sale for tobacco products from 16 to 18 years old in England and Wales. There have been calls in recent years to go further. The independent review recommended the government raise the age of sale by one year each year to stop people from ever starting to smoke and create the first smokefree generation. As noted in Chapter 1, New Zealand became the first country in the world to prohibit the sale of tobacco to anyone born after a specified date, as part of a broader set of policies announced under its Smokefree Aotearoa 2025 Action Plan. Such action is supported by most people in this country. 71% of adults in Great Britain support raising the legal smoking age by one year each year.
Overview
Quitting smoking is the best thing a smoker can do for their health. It has been estimated that someone who quits before turning 30 could add 10 years to their life. So, alongside taking bold action to stop the start, the government is also taking new action to support current smokers to quit - building on the existing infrastructure of funding and support we have in place through the NHS and local authorities across England. The government is investing: an additional £70 million per year to support local authority-led stop smoking services (SSS) - more than doubling current spend from £68 million per year (to a total of £138 million) and supporting around 360,000 people to set a quit date each year an additional £5 million this year and then £15 million per year after to fund new national anti-smoking campaigns - a substantial uplift on current spend up to £45 million over 2 years to roll out our new national ‘Swap to Stop’ scheme - supporting 1 million smokers to swap cigarettes for vapes up to £10 million over 2 years to provide evidence-based financial incentives to support all pregnant smokers to quit
Local stop smoking services
SSS were established across England in 2000 to enable smokers to access a combination of behavioural support from a trained advisor, as well as medicines or stop smoking products for up to 12 weeks. Local authorities report spending £68 million in 2021 to 2022 on commissioning SSS. SSS are an effective and cost-effective way of supporting smokers to quit, increasing the chances of quitting threefold, compared to willpower alone, and since inception have delivered over 5 million successful quits. Stop smoking products and medicines (provided by SSS) can double the likelihood of quitting compared to willpower alone, but are most effective when combined with behavioural support. SSS are also effective in reaching high-prevalence groups, with the official statistics NHS Stop Smoking Services in England showing that 55% of clients in 2022 to 2023 were recorded as routine and manual workers, long-term unemployed/never worked, unpaid home carers or those who are sick or disabled and unable to work. However, the number of smokers seeking help to quit from SSS has declined by nearly 80% since their peak in 2012. Figure 10 shows the number of people accessing stop smoking services between the years 2000 to 2001 and 2022 to 2023 who set a quit date and managed to quit smoking successfully. Figure 10: Number of people using SSS who set a quit date and quit successfully Source: Statistics on stop smoking services in England While some of this decline reflects the success of SSS in helping people quit smoking, there has also been a drop in the availability and accessibility of these services. Additionally, there has been a decrease in referrals to SSS from healthcare professionals, and a decrease in public awareness regarding the availability of this support. This is why the government is also funding an awareness raising campaign which will direct smokers to quit support. The decline in the number of smokers accessing SSS highlights the need for continued investment in these crucial services. The latest data suggests that there were over 176,000 quit attempts with the support of a SSS in 2022 to 2023. To help reach the Smokefree 2030 ambition, the government is committing additional funding of £70 million per year to SSS. This will more than double the current local authority spend on SSS of £68 million per year to a total of £138 million, and also meet the independent review recommendation for increased investment. In total the funding will aim to support around 360,000 people to quit with 198,000 successful quits (measured as 4-week quits). As the independent review made clear, well-funded SSS are highly cost-effective and play a pivotal role in improving healthy life expectancy and narrowing the gap in health disparities. This additional funding will ensure there is a universal and comprehensive offer across local authorities in England, while providing additional weighted funding to local authorities with the highest smoking rates to level up the communities who need it most and address health disparities. This increased investment will directly impact on the availability and quality of support offered, and the number of quits achieved in those areas that need it most. The methodology for allocating indicative funding to local authorities is published alongside this paper. Funding will be used to help bring all services in line with quality standards that are set out by National Centre for Smoking Cessation and Training guidance. It will support a core specialist team of advisors into local SSS, and a range of other trained professionals (for example, nurses and pharmacy staff) to engage with specific smoking populations that typically do not access SSS without being targeted and directed to stop smoking support. This will also support delivery of the ‘Swap to Stop’ scheme as detailed later in the chapter. It is important to recognise that the remaining smokers are likely to be the most entrenched smokers and may find it harder to quit having experienced a number of unsuccessful quit attempts. Helping these individuals successfully quit is essential, even if it may require a higher cost per smoker. After all, these services were established with the goal of supporting all smokers in their journey to quit, whoever and wherever they are.
Awareness raising campaigns
There is strong evidence that national campaigns are effective in supporting smokers to quit and they deliver a strong return on investment and impact at scale. In particular, awareness raising campaigns play a role in dismantling common misperceptions among the public. For example, 4 in 10 smokers incorrectly believe vaping is as dangerous as smoking cigarettes. They can be targeted at current smokers, so they can make well informed choices about quitting tools. The annual Stoptober campaign alone has driven more than 2.3 million quit attempts between its inception in 2012 and the latest evaluation in 2020. Evidence from evaluations of Stoptober campaigns showed that in 2020, the campaign generated quit attempts among 12.3% of smokers and recent ex-smokers. The Stoptober campaign emphasises that if a smoker can quit for 28 days, they are 5 times more likely to quit permanently. The independent review recommended that the government invest £15 million to fund a nationwide, all year stop-smoking campaign. The government will invest an initial £5 million right now, and £15 million each year after, on campaigns to highlight the harms of smoking and signpost people to support. We will take a national approach, but this will be amplified in local areas with higher smoking rates and targeted at demographics most likely to start smoking or be current smokers. Combined with the increase in availability and quality of other support, this is a wide reaching, high impact proposal. It is also supported by the public: 69% of adults in England support further investment in campaigns on smoking.
Overview
The government is committed to having the biggest impact possible in reducing youth vaping. The government is also conscious of the potential impact that new policies may have on adult smokers looking to quit and the associated health benefits, as vaping is substantially less harmful than smoking and can be an effective tool in supporting adult smokers to quit. Ensuring vapes can continue to be made available to current adult smokers is vital to tackle smoking. The government is therefore consulting on a set of proposals to reduce youth vaping, ensuring we get the balance right between protecting our children and supporting adult smokers to quit. There has been a recent and highly concerning surge in the number of children vaping and the evidence shows that vaping products are regularly promoted in a way that appeals to children, through flavours and descriptions, cheap convenient products and in-store marketing - despite the risks of nicotine addiction. Alongside the findings from the call for evidence, the government has drawn on the latest public health evidence both in the UK and internationally, what we know has worked in reducing youth smoking, and extensive learning from stakeholders. The government is also responding to recommendations made in the independent review to tackle youth vaping. The proposals the government is looking at include: restricting vape flavours regulating vape packaging and product presentation regulating point of sale displays restricting the sale of disposable vapes introducing an age restriction for non-nicotine vapes exploring further restrictions for other nicotine consumer products such as nicotine pouches preventing industry giving out free samples of vapes to children These actions would complement each other, forming a suite of measures that will work together to reduce the various ways that vapes appeal to children, with the aim of reducing youth vaping and the potential for children to be exposed to the risks.
Restricting vape flavours
Our call for evidence showed us that children are attracted to the fruit and sweet flavours of vapes, both in their taste and smell, as well as how they are described. So, restricting flavours has the potential to significantly reduce youth vaping. So, the government is considering new legislation to regulate the flavours of vapes and their descriptions. To avoid unintended consequences on youth and adult smoking rates, the scope of restrictions will need to be carefully considered. The options for how the government will seek to do this will be detailed in a consultation later this month.
Context
Vape liquids (e-liquids), sometimes known as vape juice, is typically composed of nicotine, propylene glycol and/or glycerine, and flavourings. The TRPR currently restricts certain ingredients including colourings, caffeine, and taurine. However, it does not restrict any combinations of flavours or flavour types. There are a vast and diverse variety of flavours on the UK market including: tobacco (imitating cigarettes), menthol and mint, fruit flavours (for example, strawberry, blueberry and mango), dessert and sweet flavours (for example, bubblegum, cotton candy, caramel or cheesecake), tobacco blends (combining tobacco with vanilla, caramel or nuts), and custom mixes (vape liquid mixed by users to suit their personal preferences). The attractive wording (descriptor names) can also entice children to try vaping, such as ‘fiery flavoured strawberry’ and ‘berry blast’: sweet flavours that children may be familiar with.
Overview
A strong approach to enforcement is vital if the smokefree generation policy is to have real impact. Underage and illicit sale of tobacco, and more recently vapes, is undermining the work the government is doing to regulate the industry and protect public health. The sale of illicit products frequently targets children and young people in disadvantaged communities, widening health disparities. The impact of the illicit trade is often the greatest in the most deprived areas of the country. Tobacco smuggling also costs over £2.8 billion in lost tax and duty revenue each year. This deprives the UK of vital money that could be used to fund essential public services - instead putting it in the hands of criminals. In this chapter, we set out additional steps that the government will take to clamp down on those irresponsibly selling tobacco products and vapes to underage people and preventing illicit products from being sold. This includes: providing £30 million additional funding per year (from April 2024) to support enforcement agencies such as trading standards, Border Force and HMRC to implement and enforce the law (including enforcement of underage sales) and tackle illicit trade HMRC and Border Force publishing an updated Illicit Tobacco Strategy, which will: set out plans to target illegal activity at all stages of the supply chain to stamp out opportunities for criminals in light of the new rules establish a multi-agency Illicit Tobacco Taskforce, led by HMRC and Border Force, to oversee future evolution of our illicit tobacco strategy introducing new powers for local authorities to issue on-the-spot fines (fixed penalty notices) to enforce age of sale legislation of tobacco products, as well as vapes enhancing online age verification to stop underage sales of tobacco products and vapes online
Background
Underage sales Despite long standing restrictions on the legal age of sale and the well-known harm of tobacco products, underage sales remain an issue. In 2019 to 2020, of the councils who undertook test purchasing, 50% reported that cigarettes or tobacco products were sold to people who were underage in at least one premise. Similarly in 2022 to 2023, National Trading Standards identified that 27% of the 1,000 vape test purchases carried out with retailers resulted in an illegal sale. Illicit trade The estimated size of the illicit market was 17.7% of all tobacco trade in 2021 to 2022. The government has acted in recent years to deter illicit trade of tobacco products through publishing its national strategy, introducing harsher penalties to deter and punish those selling illicit tobacco and launching the Tobacco Operational Intelligence Coordination Centre (TOICC), a multi-disciplinary and multi-agency team which identifies tactical opportunities to counter organised criminal groups’ activities. The UK was one of the first countries to implement the Tobacco Track and Trace System for tracking cigarettes and hand-rolling tobacco from manufacture to retail, to deter illicit sales, which will be rolled out to other tobacco products in 2024. In 2018, we joined the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) Protocol to Eliminate Illicit Trade in Tobacco Products (The Protocol), which represents a significant move towards a new global standard in tobacco control. Project CeCe led by HMRC has been hugely successful, resulting in more than £7 million worth of illegal tobacco products being removed from sale in its first year Illicit vapes on the UK market is a rising concern and the government is applying lessons from our approach in tackling illicit tobacco. In April 2023, the government announced £3 million of investment to a new illicit vapes enforcement unit, led by National Trading Standards, building on existing work by trading standards officers across the country. They identified that 2.1 million illicit vapes were seized across England by trading standards in 2022 to 2023. These vapes often contain unknown ingredients, higher levels of nicotine and are often made easily available through markets that target children.
Investment in enforcement capacity
In light of our action to prohibit the sale of tobacco products for future generations, we must ensure our actions keep pace with criminals who adapt quickly to new controls. When the government makes legitimate smoking less attractive, illegal supply can serve as a dangerous alternative. We must ensure one harm does not replace another. The government will provide £30 million additional funding per year to support enforcement agencies such as trading standards, Border Force and HMRC to implement and enforce the law (including enforcement of underage sales) and tackle illicit trade. The additional funding will help boost enforcement capacity across the country. HMRC and Border Force will also publish an updated Illicit Tobacco Strategy which will set out our plans to be at the forefront of tackling illegal activity and opportunities that criminals might seek to exploit. To support this strategy, the government will establish an Illicit Tobacco Taskforce. The taskforce will combine the operational, investigative and intelligence expertise of various agencies, to enhance our ability to detect and disrupt organised criminals. These actions build on the recommendations of the independent review, which proposed additional funding for local trading standards and partners to gather and develop intelligence, and deliver enforcement activity.
Through this paper, the government has outlined new legislative proposals to stop future generations from starting to smoke and tackle the rise in youth vaping. The paper also outlines an ambitious package of additional measures to support the implementation of our legislative proposals and sustain action to support current smokers to quit.
Later this month, the government will bring forward a consultation on the smokefree generation policy detailed in this paper and its scope, as well as on measures to tackle youth vaping by reducing the appeal and availability of vapes to children. Following this consultation, the government intends to bring forward legislation as soon as the parliamentary timetable allows.
Health policy is a devolved matter in Scotland, Wales and Northern Ireland. However, the UK government is committed to working closely with the devolved administrations as we develop these proposals with a view to aligning policy approaches wherever this would improve outcomes - continuing ongoing collective action to tackle the harms caused by smoking and youth vaping across all parts of the UK.
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The NHS Smokefree Pledge is a clear and visible way for NHS organisations to show their commitment to help smokers quit and provide smokefree environments. It was relaunched in 2022 to support the Government's ambition for England to be smokefree by 2030 and the NHS Long Term Plan. Download the Pledge Briefing, sign the Pledge, and publicise your commitment.
Dec 28, 2023 · The NHS is launching a new smokefree campaign to encourage 5.3 million smokers in England to make a quit attempt this January for their health and to prevent young people from starting. The campaign features former England goalkeeper David James and other ex-smokers who share their stories of how smoking influenced their lives and how they quit.
