Published: 02/12/2004, Volume II4, No. 5934 Page 29

Elsie, an elderly woman from Eccles, explained it to me very clearly. 'Why should I give up smoking? I really do not want to live longer. My husband's dead, my kids have left home. I have nothing to live for.' Debilitated by a bad chest and affected by high blood pressure, she is no stranger to her GP. She has fun with the few friends who live locally; their experiences are similar.

Making difficult life changes is not high on their list of things to do.

Day-to-day getting by is. Smoking is a pleasure - one of an increasingly small number available to them. And the financial impacts of the prohibitive cost of cigarettes are felt acutely.

Her story is reassuringly and depressingly familiar. Quitting is rarely a priority for people living in the poorest areas of the city. There are other things on their minds, including poverty, crime and loneliness. My preoccupations as a primary care trust manager, like four-week quitter rates and lung cancer rates, are not often on their radar screens.

Tobacco is the nation's biggest killer. In Salford alone - a city of 215,000 people - 10 people die each week from related conditions. Many others struggle with long-term conditions, caused or exacerbated by smoking. Nationally, lung cancer kills more people than all other cancers put together. Heart disease and stroke destroy far too many lives. Individuals and families carry the emotional burden. There is a relentless association of poverty and smoking-related disease. And the NHS foots the bill.

Ultimately, we have to stop people from picking up cigarettes, putting them in their mouths, lighting them up and inhaling. Quite simple, really.

But people's lives are seldom simple.

Getting people to stop is really very hard. Some people struggle for years to stop. Others do not want to. There are few universal truths.

Taking people's cigarettes away will not get us far, so supporting individuals is crucial. Nationally, PCTs strive to meet cessation targets, and effort is encouraged.

There are several incentives - not least improving our star-ratings.

Achieving excellence in cessation services (as I would argue we have managed in Salford) is challenging, and should be developed.

There are plenty of influences on behaviour: the money in our pockets, the opportunities we have, the neighbourhood we live in, and the proximity of our families and friends. We need programmes of work to tackle these influences, and get other organisations to take their part. For example, community regeneration activities can have an important role in changing people's life experiences before they are asked to change their own behaviours. Elected council members can get smoking cessation on local agendas.

Last month's public health white paper underscores the importance of changing behaviours to increase life expectancy and reduce the burden of long-term conditions - especially for those communities that carry the burden of disease. Access to community and hospital-based services, smoke-free work places, and informing the public of the effects of smoking are crucial. NHS resources should be channelled accordingly.

And there are additional elements we must pursue. We have to integrate work designed to support individuals with efforts to improve community well-being. Controlling tobacco is central to our battle with poverty and the poor life chances associated with it. Conversely, efforts to promote equality are fundamental to reducing smoking.

The NHS has a clear and important role to play, and in partnership with local authorities we can have a real impact, but we have to act together. Otherwise, we will continue to fail people like Elsie, and reduce the opportunities they have.

David Woodhead is deputy director of public health at Salford primary care trust and Salford city council.