Tackling Tobacco Use

Action on Smoking and Health (ASH) identifies that smoking is the biggest cause of death and disease that you can control. About half of all life-long smokers will die early, losing on average about 10 years of life. Most smoking-related deaths arise from one of three types of disease: lung cancer, chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD). Tobacco kills more than 8 million people each year, including an estimated 1.3 million non-smokers who are exposed to second-hand smoke (Source: WHO). Whilst smoking rates have fallen, there are still around 6 million people in the UK (11.9% of adults) who smoke (Source: ASH).

Smoking is the leading cause of health inequalities and accounts for half of the difference in life expectancy between the most and least affluent communities in England. Smoking is associated with most indicators of disadvantage. While smoking prevalence at England level continues to decline each year, the gap in prevalence between the most and least deprived has increased. This means that prevalence is reducing more slowly in more deprived communities than in our more affluent communities (Source: Department for Health and Social Care (DHSC)).

There is also a strong link between cigarette smoking and socio-economic group. In 2023, 20.2% of adults in the UK in routine and manual occupations smoked, compared with 7.9% in managerial and professional occupations (Source: ASH).

Smoking during pregnancy remains the leading factor in poor birth outcomes, including stillbirth and infant (especially neonatal) deaths. Stopping smoking before or during pregnancy will reduce these risks to the child’s health and development. (Source: Royal College of Paediatrics and Child Health (RCPCH)).

In children, second hand smoke exposure can cause respiratory infections, ear infections, and asthma attacks. In babies, second hand smoke can cause sudden infant death syndrome (SIDS). Children who are exposed to second hand smoke are at an increased risk for acute respiratory infections such as pneumonia and bronchitis, middle ear disease, more frequent and severe asthma, respiratory symptoms, and slowed lung growth (Source: Centers for Disease Control (CDC)).

Research has shown that children with parents who smoke are about three times more likely to start smoking themselves. Children are also more likely to smoke if they have brothers, sisters or friends who smoke (Source: ASH).

Beyond its health impacts, smoking imposes a significant drain on economic productivity and generates substantial costs for public services, households and wider society, costs that far exceed the revenue raised through tobacco taxes (Reed, 2025). These impacts are felt most acutely in disadvantaged communities, where smoking prevalence remains high and contributes significantly to health inequalities (Source: Office for National Statistics (ONS, 2023)). The burden of smoking related illness and premature death continues to fall disproportionately on those in lower socio-economic groups, reinforcing the gap in healthy life expectancy across the UK (Source: ASH, 2019).

The NHS 10-Year Plan sets out a bold ambition to create the first smoke-free generation in the UK, building on existing pledges and going further to address the harms of tobacco and vaping. Central to the plan is the Tobacco and Vapes Bill, which will prohibit tobacco sales to anyone born in or after 2009 and introduce stricter regulations on vaping products to protect children. The plan also commits to expanding community-based cessation services, integrating opt-out support in routine hospital care, and launching digital tools like ‘Health Coach’ to empower individuals to quit. These measures are expected to significantly reduce smoking related illness, narrow health inequalities, and deliver major savings to the NHS and wider economy.

Core20PLUS5 is a national NHS England and NHS Improvement approach to support the reduction of health inequalities (HI) at both the National and System level. The framework will help to focus targeted support and action on specific population cohorts (the 20% most deprived communities as identified by Indices of Multiple Deprivation (IMD) and Integrated Care System (ICS) plus population groups who experience poorer-than-average access to health care/treatment, experience and/or outcomes which would benefit from a tailored health care approach).  The approach defines and identifies ‘5’ focus clinical areas requiring accelerated improvement (Maternity, Serious Mental Illness (SMI), Chronic Respiratory Disease, Early Cancer Diagnosis, Hypertension).  Smoking is independently associated with every indicator of disadvantage (Source: ASH).  We all have a role to play in tackling Health Inequalities, and we are aiming to go beyond Core20PLUS5 in Lincolnshire to reduce Health Inequalities in all areas of our system.

The Department of Health and Social Care Tobacco Control Plan for England 2017–2022 – Towards a Smokefree Generation outlined the government’s ambition to reduce smoking prevalence amongst 15 year olds, adults, pregnant women and those in routine and manual occupations. The release of the revised Tobacco Control Plan for England is awaited. The Tobacco and Vapes Bill operationalises and extends the ambitions of the Tobacco Control Plan. Whilst the Tobacco Control Plan (2017-2022) was the last formal strategy document, the new legislation and policy paper (Stopping the Start) effectively replaced its function and set a new direction for tobacco control in England.

The ‘Better Births’ report sets out a five-year plan for transforming maternity services implemented by Local Maternity Systems supported by NHS resource packs.

NHS England, Saving Babies’ Lives A care bundle for reducing stillbirth, and the follow up in 2019, Saving Babies’ Lives Version Two, looks to reduce the number of women smoking during pregnancy.  Smoking is a key factor linked to pre-term birth, low birth weight, still birth and sudden infant death syndrome (SIDS).

The WHO Framework Convention on Tobacco Control (WHO FCTC) and its guidelines provide the foundation for countries to implement and manage tobacco control. To help make this a reality, WHO introduced the MPOWER measures. These measures are intended to assist in the country-level implementation of effective interventions to reduce the demand for tobacco, contained in the WHO FCTC.

Action on Smoking and Health (ASH) have published factsheets relating to the use of vapes (e-cigarettes) among young people in Great Britain.

NICE has reviewed, updated and published their guidance – Preventing uptake, promoting quitting and treating dependence [NG209] which covers support to stop smoking and help reduce people’s harm from smoking.

Public Health data shows that whilst Lincolnshire’s smoking prevalence average continues to fall, the rate of decline is slower than in other parts of the country. Young people’s uptake of smoking remains stable and on a par with the national average however there are groups where smoking prevalence is higher than the national average such as adults in ‘routine and manual occupations’. Smoking at the time of delivery (SATOD) and smokers with long term mental health conditions are of particular concern, although both areas are improving. (Source: DHSC)

Pregnancy

Lincolnshire has one of the higher SATOD rates, above the national and regional average (Source: DHSE). Although the regional and national SATOD rates are decreasing, Lincolnshire’s rate is falling more rapidly, helping to close the gap. In 2023/24 Lincolnshire ICB had the highest SATOD rate in England at 12.1%. By the first three quarters of 2024/25, this had dropped to 8.7%, a 3.4 percentage point decrease. Over the same period, the Midlands regional rate fell by 1.7 percentage points and the national rate by 1.3 percentage points. Lincolnshire now ranks fifth worst nationally, showing slight improvement in rank.

As smoking prevalence has declined nationally, rates of smoking have become increasingly concentrated among disadvantaged communities and groups. There are big variations in maternal smoking rates, depending on age, geography, socio-economic status, and ethnicity. Women from disadvantaged backgrounds are more likely to smoke before pregnancy; less likely to quit in pregnancy and, among those who quit, more likely to resume after childbirth. It was also found that mothers in ‘routine and manual occupations’ were the most likely to have smoked before or during pregnancy compared to mothers in managerial and professional occupations. Pregnant women are also more likely to smoke if they are less educated, live in a community with high smoking rates, single or have a partner that smokes (Source: ASH).

Mental Health

A decrease in smoking rates has been seen among adults with a long-term mental health condition, but prevalence remains substantially higher than the general population. This is true for Lincolnshire. Smoking rates among people with a mental health condition are significantly higher than in the general population and there is a strong association between smoking and mental health conditions. This association becomes stronger relative to the severity of the mental health condition, with the highest levels of smoking found in psychiatric in-patients. It is estimated that around 30% of smokers in the UK have a mental health condition, and more than 40% of adults with a serious mental illness smoke (Source: ASH).

In addition, people with long-term mental health conditions smoke significantly more, have increased levels of nicotine dependency, and are therefore at even greater risk of smoking-related harm (Source: ASH).

Partly a result of high smoking rates, people with a long-term mental health condition have high mortality rates compared to the general population. Therefore, quitting smoking is particularly important for this group since smoking is the single largest contributor to their 10-20 year reduced life expectancy (Source: ASH).

LGBTQ++

While specific data is not available for Lincolnshire, lesbian, gay and bisexual people are more likely to smoke than heterosexual people. Rates are particularly high for LGB women and bisexual men, with the inequality particularly pronounced when compared with heterosexual women and men (Source: ASH).

Ethnic Minorities

Tobacco causes health problems for people of all ethnicities. Smoking cigarettes is the most common way of using tobacco in the UK. Black, Asian, and Chinese people are less likely to smoke than white people. People with mixed ethnicity are slightly more likely to smoke than white people. Over time, smoking is slowly becoming less common in people of all ethnicities. Ethnic minorities living in Britain have a higher risk of some diseases, such as cancer and cardiovascular disease, that can be caused by smoking than white Britons. If no-one used tobacco products, society would be more equal as well as healthier (Source: ASH).

Homeless Community

Nationally, smoking is significantly more prevalent among people experiencing homelessness compared to the general population. In 2014, around 77% of individuals without stable housing were smokers, compared to just 17% of the general population (Source: Homeless Link 2022). Moreover, the intensity of tobacco use is greater among this group. A report found that many people experiencing homelessness smoked more than 20 cigarettes a day, whereas the average in the general population was about 11 per day (Source: Groundswell 2016).

This widespread and heavy smoking contributes to serious health disparities. Individuals experiencing homelessness are three times more likely to die from chronic lower respiratory diseases, which are mainly caused by smoking. Additionally, 80% of this population face an increased risk of lung cancer due to tobacco use. The average age of death among people experiencing homelessness is approximately 30 years lower than that of the general population (Source: ASH).

While there is a strong national understanding of the link between homelessness and smoking, there is limited data and awareness regarding the prevalence of smoking specifically among the homeless population in Lincolnshire.

Young People

In 2023, 11% of 11–15-year-olds had tried smoking, 3% currently smoked and 1% smoked regularly. This equates to around 400,000 11- to 15-year-olds in England who have tried smoking and 120,000 who currently smoke. Children whose parents smoke are about three times more likely to start smoking themselves, and they are more likely to smoke if they have siblings or friends who smoke. The number of 11- to 15-year-olds who smoke has halved in the past ten years, this change could be attributed to new legislation such as banning cigarette displays in shops and requiring plain packaging (source: ASH). Emerging evidence suggests that young people who vape have a significantly higher probability of taking up smoking tobacco. A recent study found that among adolescents in the millennium cohort, the predicted probability of smoking was 1% among those who had never used e-cigarettes, compared to 33% among current e-cigarette users. Highlighting a concerning link between vaping and future smoking uptake (Source: Mongilio et al., 2025)  

In support of the government’s ambition to create a smokefree generation, an additional £70 million per year has been allocated from 2024/25 onwards to reinforce local authority-led stop smoking services. (Source: DHSC) This funding nearly doubles previous investments and is part of a broader public health strategy that includes legislative measures such as the Tobacco and Vapes Bill, which aims to reduce smoking initiation and regulate vape marketing. Funding allocations are determined based on smoking prevalence data from 2021 to 2023, ensuring resources are directed to areas with the highest need. In 2024/25, Lincolnshire received £1,076,632 and in 2025/26 is set to receive £1,140,181. This funding is ring-fenced for public health activities and must meet the specific grant criteria. This initiative empowers local authorities to enhance local stop smoking services and reduce health inequalities. (Source: ASH)

Across Lincolnshire, a multi-tiered strategy is being implemented to reduce smoking prevalence, address health inequalities, and support individuals to quit. This co-ordinated approach spans healthcare settings, enforcement, education and public engagement, ensuring that interventions are not only evidence based, but also tailored to the local context. The key components of Lincolnshire’s tobacco control efforts include:

Supporting Behaviour Change through One You Lincolnshire

One You Lincolnshire is a countywide integrated lifestyle service offering a 12-week stop smoking programme that combines behavioural support with medication. Delivered by specialist advisors in collaboration with subcontractors located in GP surgeries and pharmacies, the service has adapted since the COVID-19 pandemic to a hybrid model of telephone and online sessions. This flexible delivery has received positive feedback from clients and continues to operate post-pandemic, in 2024/25 One You Lincolnshire were able to help 2892 people to quit smoking (Source: Local Data).

Expanding Access through System Level Investment

The Integrated Care System (ICS), comprising the Integrated Care Board (ICB) and Integrated Care Partnership (ICP), has committed funding from the national Health Inequalities budget to establish in-house tobacco treatment services across all hospital trusts. This investment aims to ensure a consistent, system-wide approach to reducing tobacco-related harm.

Helping Expectant Mothers through Maternity Services

In line with the NHS 10-Year Plan and the Saving Babies’ Lives: Version 3 care bundle, the United Lincolnshire Hospitals NHS Trust is actively supporting pregnant individuals to quit smoking. The Trust participates in the Local Maternity and Neonatal Equity and Equality strategy, aligning with key goals such as reducing stillbirths, neonatal deaths, maternal deaths, and brain injuries etc.
Maternity Voice Partnerships have been engaged in co-producing tobacco dependency treatment services to ensure that interventions are responsive to service users’ needs and grounded in local lived experiences.
A National smoke-free incentive scheme is being tested and could be implemented soon in Lincolnshire hospitals. The scheme supports a pregnant/postnatal woman plus 1 nominated ‘significant other’ (e.g. a friend or family member) to quit smoking together. With monetary incentives to encourage the quit up to the value of £100 ‘Love2shop’ vouchers.

Addressing Inequalities through Mental Health Services

The Lincolnshire Partnership Foundation NHS Trust (LPFT), which provides mental health services across the county, has signed the NHS Smoke Free Pledge. This public commitment underlines the Trust’s dedication to implementing the NICE guidance on smoking cessation across healthcare settings.

Key pledges include:

• Treating tobacco dependency among both patients and staff, as outlined in the national Tobacco Control Plan for England.
• Ensuring access to appropriate smoking cessation medication in line with NICE recommendations for secondary care. This includes Harm Reduction support for those not entirely prepared to quit.
• Implementing and maintaining smoke-free environments across all Trust premises and vehicles, with limited exceptions for e-cigarettes under exceptional circumstances.
• Delivering consistent and clear messaging about the harms of smoking, with clinical staff expected to offer Very Brief Advice (VBA) and undergo relevant online training.
• Collaborating with local authorities and stakeholders to reduce smoking prevalence and related health inequalities.
• Safeguarding tobacco control initiatives from commercial tobacco industry influence.
• Supporting national policy and action on smoking cessation (Source: Smoke-free policy).

Enforcing the Law and Disrupting Illicit Trade

Tobacco control in Lincolnshire is supported by a multi-agency partnership involving the fire service, police, public health, trading standards, the NHS, and Lincolnshire County Council’s commissioned stop smoking service. Trading Standards officers lead efforts to reduce the availability of illegal and unsafe tobacco products through an intelligence-led enforcement strategy. Their activities include multi-agency raids, closure orders, prosecutions, and providing regulatory advice to businesses.
Police intelligence in certain areas of Lincolnshire has identified direct links between the illicit tobacco trade and other forms of serious crime, including drug trafficking, human trafficking, sex trafficking, modern slavery, and antisocial behaviour. In parallel, Trading Standards continues to deliver programmes aimed at preventing underage sales of tobacco. These include test purchasing operations, market surveillance, and education for local businesses.

Educating and Protecting Young People

Lincolnshire County Council Trading Standard’s Specialist Tobacco Control Officers offer a comprehensive tobacco and vaping education programme aimed at informing and protecting young people, particularly those considered vulnerable. Two interactive workshops ‘Tobacco and Young People’ and ‘Vaping: Have a BLAST?’ are delivered free of charge to schools, colleges, and pupil referral units as 50-minute sessions. These can be tailored for individual classes, year groups, or school-wide assemblies, offering accessible and engaging education without the need for formal qualifications.

For those needing more structured support, a Smoking and Vaping Awareness course is also available. Delivered over four guided learning hours, the course includes key content on health risks, passive smoking, quitting benefits, illicit tobacco and vape products, and legal considerations. It concludes with a multiple-choice assessment and is targeted at groups identified as high risk.

To support these interventions, schools can access free educational resource kits including visual aids such as tar jars and Clem’s Phlegm (COPD).

Together, these initiatives aim to empower young people across Lincolnshire to make informed, health-conscious choices and reduce the likelihood of smoking or vaping uptake, there are plans to develop online communications for the aforementioned programmes in the future.

Raising Awareness

Public-facing tobacco control activities raise awareness of the fire risks associated with cigarette smoking and the dangers of using illegal, unregulated tobacco products. These efforts are part of a broader national and local strategy to reduce smoking prevalence and related harms through education, enforcement, and support.

This JSNA includes information from the ICS, Lincolnshire ICB, Maternity Services and Trading Standards, and Lincolnshire Fire and Rescue.

Identified Gaps and Unmet Needs 

Key Population Groups with Unmet Needs:

• Deprived Communities: 
  Smoking prevalence increases significantly in more deprived areas across England (Source: ONS). These communities also face compounded health inequalities such as poor healthcare access, lower income, and higher unemployment (Source: NHS England). 

• Routine and Manual Workers: 
  Smoking rates are consistently higher among individuals in routine and manual jobs (Source: ASH). In Lincolnshire, prevalence in this group exceeds both national and regional averages. 

• Pregnant Women: 
  Lincolnshire continues to report high rates of smoking at the time of delivery, above both national and regional levels. (Source: DHSC) 

• Adults with Severe Mental Illness (SMI): 
  Around 40.1% of individuals with a severe mental illness in Lincolnshire smoke – above the general population average for Lincolnshire (14.2%) and matching the regional rate. (Source: DHSC)

• Homeless Populations: 
  Nationally, 77% of people experiencing homelessness smoke (Source: ASH; homeless link). There is limited local data available in Lincolnshire.

• Ethnic Minority Populations: 
  Particularly high smoking rates are reported among Eastern European populations, often due to cultural norms (Source: Health Inequalities Lincolnshire). 

• Gypsy, Roma and Irish Traveller (GRT) Communities: 
  These communities have the highest reported smoking rates among all ethnic groups (Source: Office for Health Improvement and Disparities). 

Health Inequalities and Responses 

Core Inequalities Identified:

• Socioeconomic deprivation 

• Employment type 

• Pregnancy 

• Mental health status 

• Ethnicity 

• Housing status (e.g. homelessness) 

Local Actions to Address Inequalities 

Lincolnshire’s response aligns with the Core20Plus5 model, which targets the most deprived 20% of the population and key vulnerable groups. 

Key Interventions: 

• Targeted Campaigns: Delivered through One You Lincolnshire in wards with the highest smoking rates. 

• Maternity Services: Use of CO-monitoring and opt-out referrals for smoking cessation support during pregnancy (Source: NHS). 

• Integrated Mental Health Support: Smoking cessation services are being embedded into mental health support pathways to enable dual recovery (Source: LPFT NHS). 

Additional Gaps and Evidence 

Unaddressed or Underexplored Areas:

• Homeless Populations: There is little local information on smoking cessation support for homeless individuals, although national efforts aim to reduce rough sleeping (Source: Gov.uk) 

• Ethnic Minorities (White-Other / Eastern European): Engagement with health services (e.g. vaccinations) has been low in this group due to language barriers and cultural differences. Smoking rates are high, but targeted interventions remain limited (Source: NHS). 

• Gypsy, Roma, and Irish Traveller Communities (GRT): While national data exists, there is little up-to-date or local data specifically about smoking prevalence or tailored interventions in Lincolnshire (Source: NHS). 

Plans to Address These Gaps 

Current and Planned Responses:

• Homeless Populations:  Although direct smoking cessation work is unclear, efforts to reduce rough sleeping may help indirectly. More specific actions are needed. 

• Ethnic Minority Groups:  The ICB has acknowledged service uptake issues among White-Other communities and plans to improve engagement. This will include addressing language barriers, which should help improve smoking cessation outcomes. 

• GRT Communities: No clear local plans or recent evidence exist. This gap is acknowledged, and further investigation is needed.

Addressing the Three National Shifts 

• Hospital to Community: Lincolnshire is expanding its community-based stop smoking services, moving beyond hospital-triggered interventions. Community pharmacies, social prescribers, and neighbourhood hubs now play a growing role in prevention and support.  

• Analogue to Digital: Adoption of digital tools such as the MyQuit App and integration with GP systems for referral and tracking. However, gaps remain in digital reach in rural Lincolnshire.   

• Treatment to Prevention: Shifting towards prevention-first by embedding smoking cessation within other lifestyle support (weight management, mental health) and making opt-out models standard in maternity and primary care following NICE guidelines.  

Gaps in Evidence and Planned Action 

Current Evidence Gaps:

• Despite national data on smoking prevalence, there remain significant gaps in localised, disaggregated evidence, particularly relating to vulnerable groups such as people experiencing homelessness and ethnically diverse communities. Addressing these gaps is essential for developing equitable and effective tobacco control strategies.  

Planned Steps to Address Gaps: 

• Partnering with Voluntary and Community Sector (VCS) groups to collect insights that reflect lived experience and local context. 

• Community engagement events to explore cultural, structural, and social drivers of smoking behaviours. 

• Research to fill knowledge gaps about smoking prevalence and habits across under-represented groups in Lincolnshire. 

The ILS has been independently evaluated and found to outperform national benchmarks in each of its four pathways. A full cost-effectiveness evaluation has also been undertaken and found that the ILS is cost effective and conservative estimates of its return on investment ratio are 4.26 to 1. If the ILS doesn’t continue beyond its current contract, this would be expected to see a loss of overall health benefit to the population and an increase in demand on NHS and adult social care services.

The Smokefree Generation Funding enables local services to: expand outreach and engagement, offer tailored quit support, and address inequalities and smoking rates. These enhancements are essential to doubling quits. As the funding must meet grant criteria and report on outcomes, including quit rates, this ensures the investment translates into measurable progress towards the Smokefree Generation goal.

• Continue to improve smoking rates in Lincolnshire, with a focus on high-prevalence groups in line with:
  • The NHS 10-Year Plan, which commits to offering NHS funded tobacco treatment services to all inpatients, pregnant women, and people with mental health needs.
  • Core20plus, targeting the most deprived 20% of the population and five clinical priorities, where smoking is a shared risk factor.
• Successfully address and tackle gaps and unmet needs in groups such as:
  • Pregnant women (via saving babies lives version 3) and participation in national smoke-free pregnancy incentive schemes.
  • Routine and Manual Workers – consider implemented smoking cessation interventions tailored to their unique needs.
  • People with a Serious Mental Illness (SMI) (via delivery of NHS smoke-free pledge by Lincolnshire Partnership NHS Foundation Trust).
  • Homeless Populations, Eastern European, and Gypsy Roma Traveller (GRT) communities, by improving outreach data collection and cultural relevant interventions.
• Strengthen data and intelligence gathering, especially:
  • On homeless populations and underrepresented ethnic groups, where local data is limited.
  • Partnering with voluntary and community sector (VCS) organisations and conducting community engagement events.
• Improve system-wide coordination and governance:
  • Oversight by Lincolnshire’s Integrated Care System (ICS) to align services across primary care hospitals, maternity, and mental health settings.
  • Shared performance tracking through dynamic dashboards and regular JSNA content refreshes.
• Expand digital and community-based support:
  • Wider use of digital tools (e.g. MyQuit app) while addressing rural digital exclusion.
• Deliver education and enforcement aligned with:
  • NICE guidance.
  • The upcoming Tobacco and Vapes Bill.
  • Local multi-agency efforts to enforce illicit tobacco laws and deliver youth education workshops (e.g. ‘Have a BLAST’).