A new report from the Royal College of Physicians (RCP) examines the effects of smoking that are increasingly concentrated among people already living in poverty, poor health and with social exclusion. It calls on the UK government to adopt opt-out treatment models across all NHS services.
The report examines the structural factors that contribute to smoking inequality, including the social determinants of health and the substantial influence of the tobacco industry. It reviews trends in smoking behaviour across numerous indicators of social disadvantage and protected characteristics, setting out over 30 recommendations for change.
While national and regional differences in smoking prevalence across the UK have narrowed significantly over the past decade, substantial differences remain between the most and the least advantaged areas. For example, smoking prevalence in Blackpool, one of the most deprived towns in the UK, is almost 20%, while in affluent Woking, only 4% of people smoke.
There is an estimated ‘hidden population’ of around 1.9 million adults in England who have a smoking prevalence of between 58% and 66%, representing over 1 million additional people who smoke, skewing official UK prevalence estimates. The report examines policy options to reduce the gap in smoking-related inequality and identifies ways in which the government can limit the financial cost of smoking to people and society by realising a ‘smoke-free dividend’.
The RCP is calling on the government to reduce smoking inequalities and realise the ‘smoke-free dividend’ by:
- Introducing opt-out smoking cessation services into all NHS settings.
- Weighting national tobacco policy towards high prevalence groups to close the tobacco-related health inequalities gap, with a national tobacco control plan in England to provide a clear strategy and targets to achieve this policy objective.
- Strengthening regulation of the pricing, retail availability and marketing of tobacco products, with price increases for tobacco coupled with support to stop smoking to avoid widening disparities in people who continue to smoke.
- Investing in better data collation that captures ‘hidden populations’ to enable targeted action.
- Adopting a coherent cross-government policy approach to address cross-risk factors from high-risk consumption of tobacco, alcohol and unhealthy foods.
People experiencing disadvantage are often motivated to quit smoking and make repeated quit attempts, but social stressors reduce their chances of success. When treatment is offered routinely across NHS settings, rather than relying on self-referral, it reaches those who need it most, with the highest quit rates in the most deprived communities.
Smoking continues to represent a significant cost to the UK. In 2024, premature deaths caused by smoking resulted in approximately £1.35 billion in lost productivity across the UK. Reduced employment levels for people who smoke, compared to those who do not, account for around £8.9 billion of productivity losses for the UK each year.
Download the full report and executive summary below.
Led by the RCP special adviser on tobacco, Professor Sanjay Agrawal, the report was developed with members of the RCP Tobacco Advisory Group and approved by RCP Council.