In the UK, 94,000 people die from a smoking-related disease every year. Huge geographic and socioeconomic variation in smoking means health, life expectancy and economic inequality. Tackling smoking head-on remains a crucial step to meeting Government targets to extend healthy life expectancy and level up. However, the latest ILC-UK research highlights the need for greater Government ambition in health improvement measures. Even if all smoking was banned tomorrow, the beneficial impact might not be felt for 40 years. Improving healthy life expectancy means addressing the interconnected risk factors associated with smoking, such as mental illness, drug abuse, obesity, poor housing, and deprivation. With differences of up to 15 years in health expectancy between the healthiest and least healthy areas, there is much scope to level up – the Government’s policies just need to be bolder.

1. Levelling up:
The great health challenge
Professor Les Mayhew, ILC
Professor Andrew Cairns, Heriot Watt University
Dr Mei Chan, Lane, Clark & Peacock
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2. What levelling up means for health
• A key aim of the Government’s Levelling Up agenda is narrowing
the gap in healthy life expectancy (HLE) between local areas by
2030, and increasing HLE by five years, for all, by 2035.
• The Government plans to tackle the core drivers of health
inequalities and a white paper in England is planned for this year.
• There will be a strong focus on prevention and on health disparities
by ethnicity, socioeconomic background and geographical region,
with special attention to communities with a high prevalence of
behavioural risk factors, such as smoking or poor diet.
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3. Where are we now?
• Since 2001, life expectancy has increased by more years than healthy
life expectancy – we are spending more time in ill health.
• This is partly due to an ageing population and negative health
behaviours such as smoking, but also the success of the NHS in
keeping people alive if they have existing health conditions.
• Making sure we increase the time we have in good health not only
increases individuals’ wellbeing and life satisfaction, it will save
health costs and bring much wider benefits to society.
• Areas where people have the best health are economically more
productive – addressing poor health is key to levelling up.
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4. So, where do we start?
• Many of the risk factors for poor health are interrelated - e.g.
smoking, mental illness, obesity, poor housing, deprivation –
and there is no silver bullet.
• But we can start somewhere. As the greatest behavioural risk
factor, we started looking at the impact of smoking cessation
and how it links with geographical inequalities in health.
• There is much work still to be done on smoking cessation and
scope for improvement.
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5. The research question
• What is the impact of smoking on life expectancy, health and
economic productivity, and how does this vary by local area?
• How much would smoking cessation contribute towards the
government’s target to increase HLE by 5 years by 2035?
• What would the impact be on both HLE and life expectancy in
different parts of the UK?
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6. How smoking policy has evolved
• Policies to reduce smoking prevalence have been broadly
successful - among men, it has fallen from over 80% in 1950 to
15% today.
• There’s been a long line of initiatives since 1976 including:
• A smoking ban on public transport
• Bans on advertising tobacco products
• Health warnings on packaging
• Above-inflation rises in tobacco duties
• A ban on smoking indoors and in cars with child passengers
• A ban on tobacco vending machines
• But we can still improve this.
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7. The geography of smoking and health
Smoking versus HLE at age 22 by local
authority
HLE versus life expectancy by local
authority
image goes here
60
70
80
90
100
110
120
130
140
150
30 35 40 45 50 55 60
ONS
Smoking
Index
Remaining health at age 22 (years)
20
25
30
35
40
45
50
55
60
65
70
50 52 54 56 58 60 62 64 66 68 70
Life
and
health
expectancy
at
age
22
Age
Life expectancy at age 22
Healthy male life expectancy at age 22
The geography of smoking is strongly correlated
(R2=0.6) with the geography of HLE. On the ONS
Smoking Index, Richmond-upon-Thames ranks best
in England and the worst are Blackpool and
Kingston-upon-Hull.
This chart shows the gap between health and life
expectancy by local authority. The local areas that
have the highest life expectancy also have fewer
years in poor health.
14yrs
17yrs
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8. Mapping lung cancer mortality in
England
Males deaths per 100,000 Female deaths per 100,000
Smoking is by far the most important risk factor in deaths from lung cancer, as well as other causes of
death such as heart disease. If we compare the geographical pattern of deaths from lung cancer in
England, we would find a strong correlation with the geographical distribution of smoking. It is also
similar to the pattern for deaths from heart disease, although other risk factors may also apply.

9. Smoking impacts health across the life course
Health expectancy by age for smokers and people
who have never smoked
Difference in health expectancy by age for smokers
and never-smokers
0
5
10
15
20
25
30
35
40
45
50
10 20 30 40 50 60 70 80 90 100
Health
expectancy
(years)
Age
All persons
All smokers
All never-smokers
Q
0
1
2
3
4
5
6
7
10 20 30 40 50 60 70 80 90 100
Difference
in
health
expectancy
(years)
Age
All versus smokers
Non-smokers versus smokers
The impacts of smoking on health can be felt across
the life course. The health of someone who has never
smoked at biological age 40 is the same as that of a
34 year-old smoker.
The gap in health expectancy is greatest between
non-smokers and never-smokers and is highest in
young adults measuring about 6 years. The gap
closes with age as remaining years of life decline.
9
P
HLE gap

10. Smoking contributes to disability and affects
men more than women
Difference in health expectancies HLE and DFLE Gender differences in health expectancy
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
10 20 30 40 50 60 70 80 90 100
Difference
in
health
expectancy
(years)
Age
DFLE non-smoker versus smoker
HLE non smoker versus smoker
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
10 20 30 40 50 60 70 80 90 100
Difference
in
health
expectancy
(years)
Age
Women
Men
Smoking also contributes to disability. A 20 year-old
smoker could expect to spend 5 years less free of
disability than a comparable non-smoker. However, the
impact of smoking on disability-free life expectancy
(DFLE) is slightly lower than on health.
Smoking particularly affects men. Women’s health
appears to be less impacted by smoking than
men‘s, probably because they smoke less over the
life course. But it is still significant and is harmful to
children and in pregnancy.
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11. Smoking costs not just health, but the
economy
Age DFLE (years)
Difference
(years) WLE (years)
Difference
(years) Activity rate %
Difference
(%)
Never smoked
Current/ex-
smoker
Never
smoked
Current/ex-
smoker
Never
smoked
Current/ex-
smoker
20 47.7 42.7 5.0 42.2 39.7 2.5 61.1 74.1 -13.0
30 39 34.3 4.7 33.9 31.0 2.8 94.8 91.2 3.6
40 30.3 26.1 4.3 24.3 21.9 2.4 95.2 89.7 5.5
50 22.1 18.7 3.5 14.9 13.1 1.7 94.1 86.9 7.2
60 14.8 12.3 2.5 6.1 5.1 1.0 72.5 67.8 4.7
70 8.8 7.2 1.6 1.6 1.0 0.6 19.9 12.3 7.7
Male never-smokers enjoy 5 more years of DFLE at the age of 20 than current/ex-smokers, and 2.5 more years of
working life expectancy (WLE). They are also more likely to be economically active at every age except 20 and enjoy 3.5
more years of DFLE at the age of 50, and 1.7 more years of WLE. They are 7.2% more likely to be economically active
than current/ex-smokers at age 50. If all men were never-smokers, then GDP would be £11.5bn higher (see Up in smoke,
2021). The same applies to women, though the direct economic impacts are slightly less (£7.6bn).
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12. Reaching the Government’s target
• Despite big falls in smoking prevalence over the last decades, we are not out of
the woods and there is huge geographic and socioeconomic variation in
smoking, affecting health, life expectancy and economic productivity.
• Although people who have never smoked stand to gain six years of health
expectancy at age 20, the impact of smoking cessation will not be immediate.
• Around 40% of the adult population are current or ex-smokers, meaning that
potential advancement is somewhat less - only around 2.5 years.
• It also depends on the ages at which cessation occurs as just stopping smoking
may not reverse previous damage to health.
• Even if all smoking ceased tomorrow, the whole process could take 40 years to
work, and so other health improvement measures are also needed to achieve
the Government’s targets.
• But this is not an argument for doing nothing, because we saw that in areas
most at risk, the potential for improvement is the highest.
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13. What happens next?
• In 2019, the UK Government set the ambition for England to be
smoke-free by 2030.
• A ‘Tobacco Control Plan for England’ is due to be published in
2022.
• Our results suggest there are gaps in our understanding in terms of
what is achievable over the timescale.
• The Government will need to be ambitious in its measures to
deliver its target.
• More research is needed on what to focus on and which other
health behaviours could help us reach the target sooner.
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