Today, around two hundred people will die from smoking in Britain alone. This is often compared to a plane of smokers crashing down everyday. This makes for a powerful metaphor, but it needs updating. Because where these planes fall, and who the passengers are, is not evenly distributed. As the Marmot review update reveals, our poorest and most socially disadvantaged communities have suffered the most from austerity, and tobacco-related disease contributes to extensive morbidity and mortality within these areas. The passengers on these planes also share some similarities: most often they are lower paid and facing what can be described as severe and multiple health and social comorbidities, with little or no support. Covid-19 will have exacerbated these circumstances. The metaphor should be that a plane crashes down on poorer towns and communities every day, taking money, resources, and family members.  

A new Tobacco Control Plan for England will be released in Summer 2021. A central focus of this will be reducing the smoking prevalence rate to <5% by 2030. The current smoking prevalence rate in England is around 14.5%. If we consider the daily circumstances of many smokers, it brings into sharp focus just how little time there is to achieve an overall 9% reduction. But smoking prevalence among adults presenting with a serious mental illness, homelessness, or substance dependence is up to four times higher. This requires all those who are in a position to help to consider, what can we do to help smokers with these additional needs to quit? 

These populations are not insignificant small groups who don’t deserve our attention, and they don’t just deserve our attention once all other smokers have quit. I last wrote about this a year ago, but there have been some developments in the evidence base, and I share my recommendations on how we can all work together for a smoke free future based upon these updates:

Break the myth that smoking is good for stress and improves mood 

We need to stop the false binary between mental and physical health as applied to smoking. There is a real risk of leaving behind those smokers who are perceived as needing to smoke for their mental wellbeing.  The most recent Cochrane review of the literature, shows mental health does not worsen as a result of quitting smoking, and in fact wellbeing as measured by stress, quality of life, and positive affect is improved. An earlier systematic review also highlighted improvements in mental health in those with a psychiatric disorder and the effect sizes were equal or larger than those of antidepressant treatments.  

Offer support wherever smokers access public services

Making every contact count is essential. Smoking cessation support needs to be provided quickly at a place that the person is already accessing and is familiar with. There are several studies which have embedded support within services, and as large cuts to local authority stop smoking services continue, this is an adaption that needs to be accelerated. Take a look at your own service – what else could you be doing? 

Make harm reduction alternatives available and free

There is growing evidence for the role of tobacco harm reduction in helping people quit smoking. A recent Cochrane review suggests that e-cigarettes are effective in helping people to stop smoking over and above behavioural support and licensed nicotine replacement therapy. Nicotine levels in e-cigarettes can be varied to address higher nicotine dependence in some groups; for instance, a small study has shown that for adults with schizophrenia, use of a high concentration nicotine e-cigarette improved quit rates compared with a lower concentration. There is growing evidence that adult smokers accessing homeless services prefer e-cigarettes over other cessation methods.

Offer people choice

One size does not fit all, so the first offer should not be the only offer available. E-cigarettes, while popular, are not a panacea, and do not suit everyone; equally, traditional methods may meet resistance from smokers who have tried them in the past. Don’t be afraid to combine nicotine products as this can improve quit rates. Also remember, offering something is always better than nothing. 

Routinely screen for smoking 

You need to screen so you can then offer support. In addition, we need to ensure we do not leave smokers behind; we do this by ensuring we have accurate baseline data to measure the progress we make in addressing smoking rates. We must all start screening for smoking, documenting it and sharing our data where possible. 

Sharon Cox, Senior Research Fellow, University College London

Twitter: @Sharon_ACox

Competing interests: none declared.