From policy to practice: creating a smokefree generation

In 2019, the Government published Advancing Our Health: Prevention in the 2020s announcing the ambition for England to become ‘smokefree’ by 2030 (achieved when 5% or less of the population smoke) (Department of Health and Social Care (DHSC), 2019). In 2022, the Khan review, an independent review into the Government's current tobacco control polices, was published, which outlined four critical recommendations to achieve a smokefree England by 2030. One of the recommendations included in the Khan report was the need for ‘stopping the start’, including raising the age of the sale of tobacco by one year, every year (Office for Health Improvement and Disparities (OHID), 2022a).

In October 2023, the DHSC published a policy paper called Stopping the Start: Our new plan to create a smokefree generation in which the Government set out its intention to create the first ‘smokefree generation’ by phasing out the sale of tobacco by bringing forward legislation that would make it an offence to sell tobacco products to anyone born on or after 1 January 2009 (DHSC, 2023a). The policy paper also announced further support for current smokers to quit (including increased funding for stop-smoking services and funding for anti-smoking campaigns), plans to consult on measures to reduce the appeal of vapes to children (for example, restricting vape flavours and regulating vape packaging to make them less appealing to children), and increased funding to strengthen enforcement.

Following the publication of the policy paper, the government launched its consultation ‘Creating a smokefree generation and tackling youth vaping’ (DHSC, 2023b), to gather evidence on how best to implement the measures set out in the command paper. The consultation closed on 6 December 2023, and the Government now intends to introduce the Tobacco and Vapes Bill in this Parliamentary session (DHSC, 2023c), which will introduce legislation to implement the measures set out in the command paper.

Positive responses to the new smokefree generation policy have been published by numerous organisations, including the Faculty of Occupational Medicine (FOM) which states that it:

‘… strongly supports measures to reduce the number of young people taking up smoking and helping existing smokers to quit.’

FOM, 2023

Additionally, many organisations have welcomed the new proposed legislation, including the Royal College of Physicians (RCP), which stated that this:

‘… prevention first approach will pay dividends for future generations as we look to improve public health, reduce demand on the NHS, tackle health inequalities and create a more prosperous society.’

RCP, 2023

What does the evidence tell us?

There has been significant progress in the reduction of smoking rates. In England, 12.7% of people currently smoke, which is lower than in 2021 and the lowest out of the four UK countries (Office for National Statistics (ONS), 2023a). However, this means that 5.3 million people in England still smoke, with the highest prevalence in people aged between 24 and 34 (ONS, 2023a). Furthermore, as the DHSC policy paper Major Conditions Strategy: Case for change and our strategic framework highlights, smoking is the biggest single cause of preventable illness and death in adults in England (DHSC, 2023d). Smoking is the largest cause of cancer in the UK, with 3 in 20 (15%) of cases attributed to smoking (Cancer Research UK, 2023). Additionally, smoking contributes a wide range of ill-health or health concerns throughout the life course, including cardiovascular and respiratory disease, adverse outcomes following surgery, osteoporosis and complications in pregnancy and labour, and people who smoke are 50% more likely to develop cognitive impairment than people who do not (National Institute for Health and Care Excellence (NICE), 2023a). Smoking contributes to increasing health inequalities, with 33.1% of smoking adults living in the most deprived areas of England, an increase from 29.5% in 2017 (ONS, 2023b).

The cost of smoking to society is estimated to be £17 billion for England each year (Action on Smoking and Health (ASH), 2023a). As smokers need health and social care younger than non-smokers, current figures indicate smoking costs the NHS £2.4 billion and social care £1.2 billion (ASH, 2023a).

The evidence base for the impact of vaping is still emerging. Vaping is less harmful than smoking as vapes do not contain tobacco, and they are used to support people to quit smoking (OHID, 2022b), contributing to an estimated 50 000 to 70 000 additional quits per year (Beard et al, 2020). However, due to nicotine content and the unknown long-term harms, vaping carries the risk of harm and addiction for children. Current figures indicate that, in 2023, 20.5% of children have tried vaping, up from 15.8% in 2022, and 13.9% in 2020 (ASH, 2023b).

What does this mean for practice and impact?

Nurses working in any setting can have an impact on helping someone to quit smoking. As the single largest safety critical profession in the health and care system, nurses can have a wide-reaching and demonstrable impact. The implementation of any national policy or strategy is a challenge; however, there are mechanisms being put in place to try to make the desired impact. Funding, totalling £138 million per year, over the financial years of 2024-25 through to 2028-29, has been made available to local authorities for stop-smoking services (DHSC, 2023a). This is welcome investment, as stop-smoking services have been in need of support, and they are an evidence-based intervention, known to help many quit smoking. The DHSC is aiming to help 360 000 people to set a quit date each year, with 198 000 successful quits (measured as 4-week quits), due to this funding increase. Nurses are a core part of stop-smoking services and, smokers are more likely to engage with the service if they have been referred by a health professional. The funding is hoped to improve local authority capacity and referral pathways for stop-smoking services, and nurses in all settings are ideally placed to support an increase in referrals to these services.

Additionally, led by local authorities, up to £45 million over 2 years has been made available for a new national ‘swap to stop’ scheme, the first of its kind in the world. This scheme aims to support 1 million smokers to swap cigarettes for vapes, and smokers will be provided with a free vape starter kit alongside behavioural support to help them quit (DHSC, 2023a). Successful pilots have been carried out and local authorities are now being invited to take part in the swap to stop scheme and design one that suits their requirements, including deciding which populations to prioritise.

A rollout of a financial incentives scheme for all pregnant smokers by the end of 2024 has been announced. This will build on the recently updated best practice guidance for supporting pregnant smokers to quit, Saving Babies Lives Version 3 (NHS England, 2023). Nationally, around 9% of pregnant women currently smoke, which is higher than the intended 6% target set out in the tobacco control plan for England, which was supposed to be met at the end of 2022 (Nuffield Trust, 2023).

Financial incentives schemes have a precedent for helping to increase the number of women quitting. For example, the Greater Manchester maternity-led specialist smokefree pregnancy programme, which started in 2018, has helped support more than 3500 smoke-free pregnancies (Greater Manchester Integrated Care Partnership, 2022). Incentives are now also recommended by NICE (2023b). The new initiatives will offer vouchers of up to £400, which will be issued at specific points during the quitting journey, alongside behavioural support (DHSC, 2023a) and subject to confirmed smoking abstinence via carbon monoxide testing. With a national platform, midwives and nurses who care for pregnant women will be able to support many more smokers to quit, helping to decrease the risks of stillbirths, miscarriages, and neonatal complications.

The Government's Stopping the start: our new plan to create a smokefree generation policy proposals offer England an opportunity to significantly reduce the huge harm that smoking and tobacco places on individuals, families and communities (DHSC, 2023a). The nursing profession should use its professional voice to show support for these proposals, while also using our trusted positions in society to support more people to access evidence-based cessation support, while also taking action to reduce youth vaping. Table 1 provides a list of useful websites that will support you in your development and practice in relation to this critical public health issue.