A smoke-free Wales: Our long-term tobacco control strategy

The negative impacts of smoking on our health and wellbeing are well known. Smoking is the leading cause of preventable ill health and premature death in Wales.

The reasons why people take up smoking and continue to smoke are complex. Whilst around 13% of people in Wales are smokers, we know that those living in our more deprived communities are much more likely to smoke than those in the least deprived areas. The impact of tobacco use is a key component of the deeprooted health inequalities that Welsh Government want to tackle.

These deep-rooted inequalities have been put on display for all to see during COVID-19. The disproportionate impact of the pandemic on the less well off in Wales has highlighted the importance of tackling the causes of these health inequalities with a renewed urgency and heightened ambition. That’s why I am proud to introduce this bold and ambitious strategy for tobacco control in Wales, with a vision to create a smoke-free Wales by 2030.

To achieve this vision, we know we will need to be ambitious and introduce and deliver the meaningful changes that will support a smoke-free society. But we are not starting from scratch; we have already introduced many of the changes that we will need to build on. We have much to be proud of and through our collective efforts in Wales, smoking rates are at the lowest levels since records began – a fantastic achievement in itself. Our integrated smoking cessation service Help Me Quit, is supporting more and more people to quit smoking for good. We have taken significant steps to protect from the harmful effects of second-hand smoke and making smoke-free the norm in Wales by introducing bans on smoking in public places – first enclosed public and workplaces in 2007 and more recently in hospital grounds and places where children and young people spend their time, including school grounds and public playgrounds.

But we know we need to do more to strengthen our message that smoke-free is the norm, particularly to the next generation, and change how they and wider society view smoking. Our Programme for Government is built on the principle of fairness and a desire to eliminate inequality at all levels in society. This strategy sets out our vision for a smoke-free Wales and how we will work to achieve it. It focuses on reducing the inequalities in smoking, increasing the proportion of children and young people who have a smoke-free childhood, and ensuring that there is a whole-system approach to a smoke-free Wales. To support the strategy, and maintain the focus and pace of change needed, we will implement a series of two-year delivery plans, the first of which is published alongside this strategy.

We are committed to preventing ill health and supporting people to make healthier choices for their health and wellbeing – I therefore want us to be ambitious and to take all the actions we can to address the harms caused by tobacco. A smoke-free Wales is possible, but we must work together for the benefits of both current and future generations.

Lynne Neagle
Deputy Minister for Mental Health and Wellbeing

It is our ambition for Wales to be smoke-free Wales by 2030.

This means achieving a tobacco smoking prevalence rate in adults (age 16+) of 5% or less over the next 8 years. A smoking prevalence of 5% is understood to be the threshold at which the tobacco epidemic could become unsustainable (Moon G, & Barnett R, Pearce J, Thompson L, Twigg L. 2018. The tobacco endgame: The neglected role of place and environment. Health & Place).

Achieving a 5% prevalence rate has become the headline goal of the 'Tobacco Endgame' which are the actions necessary for a world free from tobacco smoking [^{Footnote 1}].  A number of countries worldwide have indicated their smoke-free ambitions to achieve a 5% prevalence rate including England, Scotland, Ireland, New Zealand, Canada, Finland and Sweden.

Reducing tobacco smoking prevalence to below 5% will be a key milestone in eradicating the harm caused by tobacco. It will not only improve lives by preventing smoking related illnesses and deaths, but it will support a healthier, more equal society for all.

This strategy establishes how we will tackle all aspects of smoking as we focus on achieving our ambition. It also sets out the 3 themes under which we will work as we drive forward the changes in smoking in Wales we need to see. These themes are:

• Theme 1: Reducing inequalities
• Theme 2: Future generations
• Theme 3: A whole-system approach for a smoke-free Wales

To support the delivery of this strategy, we will put in place a series of 2-year delivery plans, starting from 2022-2024 which will set out in detail the actions that we will undertake and support as we work towards a smoke-free Wales.

Smoking is extremely damaging to health. It is the cause of death for around half of all long-term smokers (Doll, R., et al, 2004 Mortality in relation to smoking: 50 years’ observations on male British doctors) and the World Health Organisation (WHO) estimates that tobacco kills more than 8 million people each year worldwide (World Health Organization. 2022. Tobacco Fact Sheet). In Wales, smoking is the leading cause of preventable death, and in 2018, around 5,600 deaths in people aged 35 and over were attributable to smoking (Public Health Wales. 2020. Smoking in Wales). Treating smoking related diseases also has major economic impacts, costing the NHS in Wales an estimated £302 million per year (Welsh Government. 2016. Explanatory Memorandum to the Public Health (Wales) Bill).

Smoking is also known to increase people’s risk of developing a wide range of illnesses, which can be fatal or cause irreversible long-term damage to health (NHS. 2018. What are the health risks of smoking?). These include cancers, respiratory diseases, and cardio-vascular diseases, including strokes, heart attacks and dementia. Smoking-related illnesses also lead to a large number of hospital admissions. In 2018/19, around 28,000 admissions in people aged 35 and over are estimated to be attributable to smoking, which represents around 4.6 percent of all admissions in this age group (Public Health Wales. 2020. Smoking in Wales).

Smoking doesn’t only harm the smoker. Exposure to second-hand smoke has been shown to cause significant harm, increasing non-smokers risks of developing smoking related diseases including lung cancer and cardio-vascular disease (DoH. Scientific Committee on Tobacco and Health (SCOTH). 2004. Secondhand Smoke: Review of the evidence since 1998).

Exposure to second-hand smoke is particularly harmful to children, leading to conditions including middle-ear disease, asthma and allergies (Royal College of Physicians London. 2010. Passive Smoking and Children). Smoking in pregnancy is known to have a range of impacts on the pregnancy and child in later life, including increased risk of miscarriage, premature birth and sudden infant death syndrome (SIDS) (Royal College of Obstetricians and Gynaecologists. 2021. Smoking and Pregnancy).

We have made significant progress in recent years in reducing the number of people smoking in Wales. In 2007, we introduced the ban on smoking in enclosed public and workspaces in Wales and in 2015, smoking was banned in cars carrying children. More recently, on 1 March 2021 hospital grounds, school grounds, outdoor areas of childcare settings and public playgrounds became smoke-free. These measures will strengthen our approach that smoke-free is the norm in our society and reduce exposure to harmful second-hand smoke. To support smokers to quit, we have the integrated Help Me Quit service, which offers smoking cessation support to all smokers in Wales and continues to support increasing numbers of people to quit smoking for good.

The World Health Organization’s Framework Convention on Tobacco Control (FCTC) is an international treaty focussed upon the health impacts of tobacco. The UK government has ratified and become a Party to the FCTC. The Welsh Government will continue to support the requirements of the FCTC in all areas of this strategy’s implementation, including taking proactive measures to protect health policy from the vested interests of the tobacco industry.

The Tobacco Control Action Plan which was published in 2012 (Welsh Government. 2012. Tobacco Control Action Plan for Wales), provided our strategic vision for tobacco control between 2012 and 2020. The action plan was supported by delivery plans, the most recent of which was the Tobacco Control Delivery Plan 2017-2020. This delivery plan detailed the actions required for a system-wide approach to tobacco control in Wales and the steps required to reduce the uptake and prevalence of smoking as well as exposure to second-hand smoke. Taken together, these actions have ensured there has been significant progress in tobacco control and the smoking prevalence in Wales has reduced to the lowest level since records began.

However, we know we have much more to do to prevent our children and young people from starting smoking and to support smokers to quit. Around 13% of adults in Wales are smokers (Welsh Government. 2022. National Survey for Wales) and as smoking patterns are not uniform across our society, smoking is a major cause of inequalities. Smoking rates are higher in some groups including amongst people living in socio-economically deprived areas, people in routine and manual occupations, people who are unemployed, people with mental health conditions, people from some ethnic backgrounds, and people from the LGBTQ+ community. Most adults who smoke had their first cigarette whilst they were a teenager, making smoking tobacco an addiction that starts in childhood for many smokers (ASH Wales. Smoking and young people. 2021).  Whilst 4% of adolescents aged 11-16 smoke at least weekly in Wales, this is also not evenly distributed, with adolescents from less affluent families twice as likely to be current smokers as those from more affluent families (SHRN. 2021. Student Health and Wellbeing in Wales: Report of the 2019/20 School Health Research Network Student Health and Wellbeing Survey).

We will need to work together to support the system and behavioural changes needed to achieve a smoke-free Wales. The progress that has been made in reducing smoking prevalence in Wales so far demonstrates the impact that co-ordinated tobacco control actions can have on the population. We will therefore work with a wide range of people, organisations and communities to ensure a community-led approach to tobacco control. We will also build upon the existing tobacco control legislation and structures in Wales, learn from the approaches used elsewhere (for example in taking forward our long-term strategy to prevent and reduce obesity Healthy Weight: Healthy Wales and in implementing the COVID Vaccination system in Wales), explore evidence-based and innovative ideas and monitor the impact of our actions to ensure that our work is agile and responsive.

A smoke-free Wales will support the well-being goals established by the Well-being of Future Generations Act 2015. In implementing and delivering our strategy, we will use the five ways of working to ensure we are tackling the challenges in a sustainable way.

Collaboration

We will work in collaboration with our key partners including NHS Wales, local authorities, Public Health Wales and third sector organisations to deliver our vision for a smoke-free Wales.

Integration

We will ensure that our work is integrated and has a whole of government approach and is strongly aligned with that of public bodies. In delivery of this strategy, we will support delivery of all 7 well-being goals as well as the government’s policy goals on areas such as addressing health inequalities, climate change and the protection of the environment.

Involvement

We will communicate with people throughout Wales to share our vision for a smokefree Wales and our progress towards reaching this aim. We will engage with individuals, organisations communities to develop solutions to meet this aim.

Long-term

We will consider the long-term work required to meet our ambition of a smoke-free Wales, and the long-term impacts of the actions proposed in this strategy.

Prevention

We will focus on prevention throughout our strategy and will continue to undertake work to denormalise smoking in Wales and support our message that smoke-free is the norm. We will aim to prevent children and young people from taking up smoking and will work to prevent ill health by offering smoking cessation support to people who do smoke.

It is our ambition for Wales to become smoke-free by 2030. All our actions will work towards and contribute to achieving this vision and in doing so we will:

• Tackle the engrained health inequalities associated with smoking and focus on those groups in our society where rates of smoking are the highest, who have a higher risk of taking up smoking, or who feel the health impacts of smoking the most. We will work in collaboration with these priority groups, taking a community-led approach to tobacco control.
• Focus on prevention by making smoke-free the norm across society.
• Aim to support a smoke-free generation by increasing our efforts to prevent the uptake of smoking in children and young people.
• Be clear and consistent in communications around our ambition for a smokefree Wales and encourage support and ownership from people, organisations and communities throughout Wales.
• Support more smokers to quit and target resources on evidence-based prevention and cessation interventions that are delivered consistently with continuous service improvement to provide the greatest benefit.
• Explore innovation in both prevention and cessation support that could help us to meet the target of a smoke-free Wales.
• Switch the emphasis in our policy approach to treat smoking as an addiction and not as a lifestyle choice.
• Use all available levers to support our ambition and align with wider strategies, delivery plans and the Well-being of Future Generations (Wales) Act 2015 to maximise our efforts and ensure that tobacco control is embedded in strategic planning at both local and national levels.

In order to meet this vision for a smoke-free Wales we will be driving forward work across our three key themes of Reducing Inequalities, Future Generations and a Whole-System Approach for a Smoke-Free Wales.

Despite progress in reducing smoking, we know that rates of smoking and use of other tobacco products in Wales vary between different groups of people. There is evidence that smoking rates are higher in certain groups, including people living in socio-economically deprived areas, people in routine and manual occupations, people who are unemployed, people with mental health conditions, people from some ethnic minority backgrounds and people from the LGBTQ+ community.

These disparities in smoking rates are causing a greater burden of smoking related diseases in these groups and in turn, contributing to inequalities and health inequalities. We have seen how a pandemic like COVID-19 has exposed these inequalities, affecting smokers and the communities where smoking prevalence is higher in a disproportionate way. We must increase the sophistication of our approach to drill down into these inequalities, and ensure we develop tailored approaches.

In order to do that, we will work in collaboration with these communities, to gather insights into the complex drivers for smoking behaviours and the barriers to accessing and using smoking cessation methods, which are crucial to supporting a smoke-free future for these groups.

By 2030 we will

• Focus on reducing the inequalities caused by smoking.
• Work with smokers to better understand what is stopping them from quitting and what support they need to overcome their barriers, and support smokers to become smoke-free.
• Reduce the uptake of smoking in Wales for those at highest risk of taking up smoking.
• Ensure appropriate smoking cessation support is available to all, with targeted support available for those groups with higher smoking prevalence. 

Smoking impacts on the lives of children and young people throughout their childhood. In Wales, 15% of pregnant people are recorded as smokers at their initial assessment, which is known to increase the risk of complications during pregnancy and beyond such as low birth weight, premature birth and stillbirth (Welsh Government. 2021. Maternity and birth statistics: 2021). We know that the majority of children do not smoke, however 4% of 11-16 years olds identify as current smokers, and this rises with age with 9% of 15-16 year olds currently smoking in Wales (SHRN. 2021. Student Health and Wellbeing in Wales: Report of the 2019/20 School Health Research Network Student Health and Wellbeing Survey). We also know that exposure to smoking in pregnancy, early childhood and adolescence, including in the home is not equally distributed across society. Children and young people from the most deprived areas are much more likely to be exposed to smoking throughout their childhood, including in the home (SHRN. 2021. Primary School Student Health and Wellbeing Survey 2021), increasing their harms from second-hand smoke and risk of taking up smoking themselves. This contributes to generational smoking patterns which worsen health inequalities.

Previous work on tobacco control in Wales has focused on supporting children and young people to understand the risks and harms of tobacco, and to make smoke-free the norm so that they are less likely to take up smoking in the first place. This has included smoking bans in places where children spend much of their time such as school grounds, outdoor areas of childcare settings and public playgrounds, as well as private cars when a child is present. Targeted support is offered to pregnant people to help them to quit smoking and adolescents in areas with the highest smoking prevalence are provided with a school based smoking prevention programme aimed at stopping them taking up smoking. However, we know that some children and young people continue to start smoking and so we need to do more to understand why children take up smoking (including the influence of vaping and cannabis on tobacco use) and ensure that all children and young people have a smoke-free childhood.

By 2030 we will

• Create an environment where smoke-free is the norm for all children and young people in Wales.
• Increase the proportion of smoke-free pregnancies in Wales, and promote a smoke-free preconception period.
• Promote a smoke-free childhood and aim to break generational smoking patterns to achieve a smoke-free generation.
• Make smoke-free the norm to deter social smoking amongst children and young people.
• Increase the proportion of teenagers and young people who remain smoke-free by reducing the uptake of smoking, whilst also discouraging the uptake of e-cigarettes or other nicotine products in teenagers and young people.
• Identify the groups of children and young people who are at higher risk of taking up smoking, and work with them to identify ways to help them to remain smoke-free.
• Identify priority groups of children and young people who have a higher prevalence of smoking, and work with them to understand their reasons for smoking, and provide evidence based targeted support to quit smoking.

To achieve our ambition of a smoke-free Wales, we must take a whole-system approach to tobacco control. This means all partners (including those designed to support joint working such as Area Planning Boards, Public Service Boards and Regional Partnership Boards) are working together in a collective effort to contribute to this shared vision in order to achieve change. Previous successful tobacco control measures have involved the whole system in Wales coming together and working towards an ambition, whether it be by supporting smoke-free places, our integrated Help Me Quit smoking cessation system or working with young people to prevent the uptake of smoking. The Tobacco Control Action Plan and the Tobacco Control Delivery Plan 2017-2020 outlined the whole system approach that is required to improve tobacco control and we will build on this work in this strategy by taking an integrated, joined-up approach and supporting our partners.

We recognise the significant progress we have already made on tobacco control so far, and the importance of supporting the ongoing actions being undertaken by a wide range of organisations, communities and individuals across Wales. However, we also recognise we cannot achieve our vision by doing more of the same. The success of this strategy will require us to support evidence-based interventions with continuous service improvement, to learn from good practice elsewhere, explore innovative approaches and dynamic solutions as well as to look for more opportunities at national and local levels to achieve a healthier, smoke-free future.

By 2030 we will

• Embed tobacco control principles across all policy areas, and use all available systems, levers and mechanisms to create a smoke-free Wales.
• Support collaboration by ensuring the actions of all partners are co-ordinated at a local, regional and national level, and together contribute towards a smoke-free Wales.
• Ensure consistent application of evidencebased tobacco control interventions across Wales with continuous service development and improvement.
• Explore innovative approaches and use of technologies to reduce smoking uptake and promote smoking cessation.
• Take further steps to protect people from the harms of second-hand smoke.
• Review the tobacco control enforcement and sanctions systems in Wales, including for illegal tobacco.

This strategy has set out our ambitious vision for a smoke-free Wales by 2030. To support its delivery and maintain our focus on our ambition, we will publish a series of 2-year delivery plans which will set out in detail the actions that we will undertake and support as we work towards a smoke-free Wales. These delivery plans will organise actions into priority areas which will cut across the 3 themes identified in the strategy of:

• Health inequalities
• Future generations
• A whole-system approach for a smoke-free Wales

By organising our actions into 2-year delivery plans, we will build and maintain momentum and a relentless focus on the areas that will support our ambition but also retain the flexibility to adapt to changing environments and priorities. Organising our actions in this way will also allow us to learn from and build upon previous plans and ensure there is coherence between the delivery plans. We will also be clear on the changes that each delivery plan will achieve as we make progress towards our ambition. Towards a Smoke-free Wales is the first in this series of delivery plans and will focus on actions that support denormalisation and making smoke-free the norm in Wales, promotion of best practice and integration from 2022-2024.

We will continuously monitor and evaluate our actions to ensure that we are making progress towards a smoke-free Wales. We will be transparent with our implementation of the strategy, publish annual progress reports and we will seek constructive feedback and input from a wide range of people, organisations and communities.

We will ensure that we use all available data sources and strengthen data collection systems so we accurately assess our progress across different areas of tobacco control, and ensure that this data feeds into the monitoring of each delivery plan, to inform all future delivery plans. Delivery of the strategy and the delivery plans will be the responsibility of the Tobacco Control Strategic Board. This board will have representation from our key partners on tobacco control and will have the right level of governance and challenge to provide leadership, assess evidence and make decisions which influence the direction of travel for delivery of the strategy and delivery plans. The board will also build in collaboration across the number of partners needed to make the systems changes that will support a smoke-free Wales. An implementation group will also be established with the remit of supporting, monitoring and implementing delivery of the delivery plans, as well as undertaking the engagement and collaboration needed. This group will report to the Tobacco Control Strategic Board.

We have made significant progress on tobacco control in Wales, but we must do more to minimise the harms caused by tobacco and support people to make healthier choices for their health and wellbeing. By working together and using a system-wide approach to tobacco control to maximise our efforts, we will do all we can to support achieving our vision of a smoke-free Wales.

Footnotes

1. Malone RE (2013). Tobacco endgames: what they are and are not, issues for tobacco control strategic planning, and a possible US scenario. Tob Control; 22(Suppl1): i42–4.
McDaniel PA, Smith EA, Malone RE (2016). Tob Control;25: 594–604.
Warner et al (2014) Impact of tobacco control on adult per capita cigarette consumption in the United States, 104 AM.J.PUBLIC HEALTH. 83, 83-89