A new report from the Royal College of Physicians (RCP) sets out the unequal and devastating health and economic impact of smoking in the UK, shaped by poverty, poor housing, employment insecurity and industry practices. The report calls on government to introduce opt out tobacco dependency treatment across all NHS services as a matter of public health and economic urgency.
In 2026, smoking remains the biggest avoidable cause of death and disability in the UK, but its impact is far from equal. Smoking rates and harms are increasingly concentrated among people experiencing poverty, unemployment, mental health conditions, insecure housing and social exclusion.
Place based inequalities remain stark. In Blackpool, one of the UK’s most deprived towns, nearly one in five people smoke, a rate almost five times higher than in affluent Woking, where only 4% of the population smokes.
In its new report, Smoking, health and social justice, the RCP is calling on government to introduce opt out tobacco dependency treatment services across every NHS setting, including emergency departments, primary care, outpatient services and neighbourhood health services. Under this approach, everyone who smokes and has contact with the NHS would be automatically referred to quit support unless they choose not to participate.
Evidence cited in the report from existing NHS opt out inpatient programmes shows that when barriers to access are removed, the greatest number of successful quit attempts come from the least advantaged communities, delivering both health and economic benefits.
The report also lays bare the huge scale of smoking’s damage to the UK economy and workforce, including:
- reduced employment levels among people who smoke due to smoking related ill health, accounting for around £8.9 billion in productivity losses each year
- people who smoke earning around 9% less than non smokers, contributing to approximately £11 billion in annual earnings losses, with premature deaths – particularly among experienced workers aged over 45 – resulting in a further £1.35 billion in lost productivity in 2024 alone
- a potential £10.9 billion ‘smoke free dividend’ for the UK economy if smoking were eliminated, lifting many families out of poverty and creating an estimated 135,000 jobs.
The report highlights serious gaps in data and visibility. People experiencing homelessness or entering prison are more than six times more likely to smoke than the national average. With around 1.9 million adults without stable addresses, the RCP warns that real smoking prevalence is likely to be significantly higher than official figures suggest. While many people facing disadvantage are motivated to quit, wider social and economic stressors significantly reduce their chances of success.
To tackle smoking related health inequalities, the RCP is calling on UK government and system leaders to:
- introduce opt out smoking cessation services across all NHS settings
- rebalance national tobacco control policy towards high prevalence and underserved groups
- strengthen regulation of the pricing, retail availability and marketing of tobacco products
- invest in better data collection to capture ‘hidden populations’ and enable targeted action
- adopt a coherent cross government approach to counter how health harming industries shape the availability, affordability and appeal of tobacco, alcohol, food and gambling products.
Professor Sanjay Agrawal, RCP special adviser on tobacco, said:
‘Over the past 30 years, smoking has claimed roughly three million lives in the UK and continues to place a huge and entirely avoidable burden on the economy. But its impacts are increasingly concentrated among people already living in poverty, poor health and social exclusion. Both the health and economic costs of smoking fall most heavily on the people and communities who can least afford them.
‘Put simply: smoking reinforces persistent cycles of disadvantage and inequality. Addressing it is a matter of public and economic urgency.
‘Opt out smoking cessation pathways reduce inequality by removing the barriers that prevent people from accessing treatment, particularly in more deprived areas where smoking rates are highest and awareness of support is lowest. NHS inpatient data already show that when support is offered as standard, the greatest quit success is seen among the least advantaged groups, delivering both health and economic returns. Opt out reaches the people our current system consistently fails.’
A 2025 survey of RCP members found that smoking continues to drive a significant proportion of avoidable ill health seen by clinicians: 53% of respondents said at least half of their average caseload consisted of patients whose conditions have been caused or exacerbated by smoking.
Professor Mumtaz Patel, RCP president, said:
‘In 2026, smoking remains the UK’s biggest avoidable cause of death and disability, and it remains disproportionately high in the most disadvantaged communities.
‘The health effects of tobacco place an enormous and entirely preventable strain on the NHS. The government has taken an important step forward with the Tobacco and Vapes Act, which will help create the first smoke free generation and deliver long term gains for public health.
‘But we must also act now to help the millions of people already addicted to tobacco who desperately need support. Too many are still being missed.
‘The gap in smoking rates between the most and least advantaged communities is closing far too slowly. In Blackpool, nearly one in five adults still smoke, while in Woking it is closer to one in 25. These stark differences translate directly into higher demand on local NHS services and worse outcomes for patients and staff alike. This is not acceptable. We already know what works – what we need now is decisive action to scale proven interventions and relieve pressure on the health service.’