Smoking is still a major challenge for clinicians, despite recent successes, argues Dr Kiran Patel, medical director of NHS England (West Midlands) and consultant cardiologist, Heart of England NHS Trust


You don’t have to think back too far to a time when you could walk into a public house, sit on a bus or in a restaurant in England and be forced to inhale the cigarette smoke exhaled by someone else wishing to enhance their own social experience by ‘lighting up’.

Fortunately, the smoking ban has made such behaviour obsolete and our children will never have to suffer the fate of non-smokers of the past. However, having seen substantial progress in legislation, tobacco control and smoking cessation, are we still right to be concerned about tobacco in society today?

I am sure most of us in the clinical world would answer such a question with a resounding ‘yes’.

Why? Well, simply put, smoking continues to be the most significant driver of health inequality in England despite substantial progress. It also necessitates a sustained effort from public health and clinicians in primary and secondary care to protect the public and our patients from avoidable harm. The crusade fighting for plain packaging has been launched and clinicians must be on their guard to support a drive to reduce uptake of the habit and, in habituated individuals, encourage cessation.

The latest report from NICE estimates that more than eight million people in England smoke tobacco and most started smoking before 19 years of age. Almost 13% of children under 16 years of age smoke regularly or occasionally. However, what is concerning is the range of smoking prevalence among children, which ranges from half the national prevalence rate in parts of London to almost 17% in parts of northeast England.

With an appreciation that health outcomes are largely attributable to social determinants, it would be entirely appropriate to support NICE to embark upon its initiative to define school-based interventions to guide local authorities and public health services on which interventions they should implement to protect our children from poor health outcomes. The interventions will also protect the public from health inequalities, and our taxpayers from avoidable public expenditure in future.

So, supporting initiatives to prevent smoking in childhood is not contentious. However, we must also develop an evidence base for parallel or aligned behaviours which are risk factors to tobacco use later in life.

The advent of electronic gadgets to support the behaviour of ‘vaping’ needs to be evaluated. Is ‘vaping’ an intervention that supports smoking cessation in those who are habituated? Is it harm-free in those who have no prior experience of smoking? Is smokeless tobacco use harm-free, particularly in communities such as ethnic minorities, which are prone to health inequality?

There is still some way to go in terms of answering these questions to inform an evidence base upon which organisations like NICE can guide us in future. However, tackling the smoking of tobacco in children is what one would call a ‘no brainer’ regardless of whether one represents patients, the public or the professions. Let us hope that we can succeed in ensuring the seeds of tobacco use are not sown in childhood.


The views expressed are those of the author and not NHS England or the Heart of England Trust.