No smoker left behind: the next opportunity for tobacco control

Plane Sailing Director, Jane Coyne, reflects on the opportunity created by new tobacco legislation in the UK — and why the next phase of tobacco control must focus not only on preventing people from starting to smoke, but on finding and supporting the smokers our current system still struggles to reach.

The new tobacco legislation gives us an extraordinary opportunity. After spending much of my career working in tobacco, I genuinely believe we are entering one of the most exciting periods in tobacco control. But I also think we need to be brave enough to ask a difficult question - what about the smokers we aren’t seeing?

While we rightly focus on creating a generation that never starts smoking, millions of people still smoke today. And some of the people who most need our support are the people our current approaches find hardest to reach.

The hidden smoking population

Over the years, I've worked across maternity, acute services, public health and national tobacco programmes. One thing has become increasingly clear to me - smoking prevalence data doesn't always tell us enough about who isn't in the room. There is a hidden population we aren’t reaching.

If our model relies predominantly on smokers finding us, making a referral or attending a traditional appointment, we will inevitably leave people behind. And the people left behind are very often those experiencing the greatest inequalities.

People experiencing poverty, poor mental health, insecure housing or other challenges that make attending regular appointments much harder. People moving between maternity, hospitals, primary care, pharmacies, mental health and community services. And people who simply don't want to walk through the door of something called a stop smoking service.

If our model relies predominantly on people finding us, accepting a referral and attending an appointment, we will inevitably miss some of them. And those we miss may be the very people experiencing the greatest health inequalities.

What happens when we change the model

My own journey in tobacco transformation began in maternity. We knew smoking during pregnancy was causing significant harm and we knew women wanted healthy pregnancies and healthy babies, but simply telling pregnant women to stop smoking wasn't enough. So we started changing the system around them.

We made identification part of routine maternity care. We used carbon monoxide testing and opt-out referral pathways. We trained maternity staff to have better conversations, strengthened access to specialist support and treatment, used data to understand where women were disengaging and tested new approaches, including incentives.

Most importantly, we listened, learned and changed things when they weren't working. Over time, work that began locally contributed to something much bigger, helping to inform approaches that are now being delivered nationally.

And it taught me a lesson that I think is hugely relevant to where tobacco control goes next: If people aren't accessing the service, we need to stop asking how we change the person and start asking how we change the service.

Stop designing the experience around organisations

This could be one of our biggest opportunities. A person who wants to stop smoking doesn't care who commissions their support. They shouldn't need to understand whether their treatment is funded by a local authority, the NHS, an integrated care board or a national initiative. They shouldn't have to work out whether they belong in primary care, pharmacy, maternity, mental health or a community stop smoking service. And they certainly shouldn't have to start again every time they cross an organisational boundary.

We have some excellent services. But from the individual's perspective, they can still feel like separate parts of a system rather than one connected pathway.

The funding can sit in different places. The workforce can sit in different organisations. The governance can happen behind the scenes. But to the person trying to quit, it should feel like one service.

What if support followed the smoker?

Imagine a different model. Someone can be identified as smoking wherever they touch the system: at a maternity appointment, during a hospital admission, at their GP, in a pharmacy, through a mental health service or community organisation. Or they might be sitting at home at 10pm and decide that tomorrow is finally the day they want to stop.

Instead of asking: “Which service does this person belong to?”

We ask: “What support does this person need, and how do we get it to them?”

For one person, that might mean face-to-face support. For another, virtual appointments or digital support. It might involve a pharmacist, nicotine replacement therapy, vaping or another appropriate treatment. Someone else may need more intensive behavioural support.

And some people will need several attempts. That's okay.

What's important is that the system doesn't lose them.

Digital gives us a huge opportunity

Digital shouldn't replace good clinical care or good stop smoking practitioners. But it can help us reach people our traditional models haven't always reached. Support doesn't necessarily have to happen in a clinic between 9am and 5pm. Treatment doesn't always need to be collected from the building where the practitioner works. Follow-up doesn't always need to mean another face-to-face appointment. Data doesn't need to stop at organisational boundaries.

We now have the opportunity to create genuinely blended tobacco treatment pathways — combining digital, virtual, community and face-to-face support around the individual. And that could completely change our reach.

No smoker left behind

For me, this needs to be one of the ambitions sitting alongside the new legislation.

Stop the start. Create a smokefree generation. But leave no existing smoker behind.

That means actively finding our hidden smoking populations. It means understanding who isn't accessing our services, and why. It means making every contact with health and care an opportunity to offer support. It means designing services around people's lives rather than organisational structures. And it means being prepared to change models that may have worked well for some people but aren't reaching everyone.

Transformation at scale is possible

My experience in maternity has made me optimistic. I've been fortunate enough to be part of a journey that took an idea, tested it locally, learnt from it, built the pathways and infrastructure around it and ultimately helped create something that is now delivered nationally.

It didn't happen because we had a perfect model on day one. We tested, we learnt, we listened to women and practitioners, and we followed the data. We challenged ourselves when something wasn't working. And we kept asking how we could reach more people. That is exactly the mindset I think we need for the next phase of tobacco control.

At Plane Sailing, we bring that experience into our work with organisations looking at what comes next — pathway redesign, digital transformation, workforce, prevention, treatment, data and large-scale implementation. Because the legislation gives us the opportunity, now we need to redesign the system around it.

A smokefree generation shouldn't only mean fewer young people starting to smoke. It should also mean finding the person we've never reached, re-engaging the individual who has tried to quit many times before, making behavioural support and treatment easier to access, removing organisational boundaries, and building a system where wherever someone asks for help — or wherever we identify that they need it — the response is simple: we can help you here.

That's what no smoker left behind should mean.