Background Smoking remains common in England, with 20% of adults smoking in 2012, little changed from 21% in 2007. Smoking is more than twice as common among the most disadvantaged socioeconomic group compared to the most affluent and is a major contributor to inequalities in smoking-related mortality. The UK has comprehensive smoking policies according to the Tobacco Control Scale (TSC; score of 74 out of 100): public information campaigns; on-pack health warnings; plain packaging; ad bans; cessation; price; and smoke-free areas. However, there remains room for improvement. We aim to evaluate the cumulative effect on smoking prevalence of all TSC components, stratified by deprivation of area of residence in England.
Methods We modelled the decline in smoking prevalence that might result from maximising each component of the TSC. Effect sizes and socioeconomic gradients for all seven types of smoking policy in the UK setting were adapted from systematic reviews, primary studies and other modelling studies. Smoking prevalence in England stratified by socioeconomic circumstance, age, and gender has been published by the Office for National Statistics.
We used the previously-validated IMPACT Food Policy model to link predicted changes in smoking prevalence to changes in premature coronary heart disease (CHD) mortality for ages 35–74. Health outcomes with a time horizon of 2015–2025 were stratified by quintiles of lower layer super output areas ranked by their score on the Index of Multiple Deprivation for England. Inequality in CHD mortality was assessed using the Slope Index of Inequality.
A model was built in R software, and uncertainty was assessed using probabilistic sensitivity analysis.
Results Improving all smoking policies to achieve a maximum score of 100 on the TSC might reduce smoking prevalence in England by approximately 3% (95% CI: 1%–4%) in absolute terms, or by approximately 15% in relative terms (7%–21%). The most disadvantaged quintile would benefit more, with absolute reductions of about 5% (2%–7%). A 20% price increase via an excise tax would be responsible for about half (42%–57%) of the overall reduction.
There would be some 3300 fewer premature CHD deaths (2200–4700), or about 2% fewer (1.4%–2.9%). The most disadvantaged quintile would benefit more, reducing the slope index of inequality for premature CHD mortality by approximately 260 deaths (170–540), or about 4% (3%–9%).
Conclusion Further, feasible improvements in tobacco control policy in England could substantially improve population health AND reduce health-related inequalities. The health benefits would extend beyond CHD, most notably slowly reducing respiratory diseases and diverse cancers.
- tobacco control
- noncommunicable diseases