Published: 04/03/2004, Volume II4, No. 5895 Page 12 13

It is an uncomfortable fact, but it sits at the heart of the Wanless report. For all the shock media campaigns, the helplines, the Nicotine patches, the heart-rending testimonies of lung cancer victims and the political commitment, the decline in the numbers of smokers in the UK has stalled.

There are currently 13 million smokers: 27 per cent of the population.And as Mr Wanless makes clear, the figure has remained virtually 'stable' throughout the 1990s.

Put simply, if Mr Wanless's long-term vision of multi-billion pound savings in healthcare expenditure is to be realised, the numbers of smokers must drop - and drop significantly.

The government's pledge to reduce smoking prevalence to 24 per cent of the population by 2010 'does not represent substantial progress', he says. And meeting target levels set out in his 'fully engaged scenario' requires a fundamental shift.

He highlights the success of previous anti-smoking campaigns, the benefits of banning smoking in public places as well as the need to take action on smuggling to make tax increases on cigarettes bite.

But he is particularly vexed with the government's current smoking-cessation targets - especially those handed down through the priorities and planning framework to primary care trusts.

The most notorious, it seems, is the target for 800,000 smokers to quit at the four-week stage by 2006.

Given that the targets were being devised back in 2002 when then health secretary Alan Milburn was proclaiming to the Faculty of Public Health that smoking was 'a public health disaster', Mr Wanless is not impressed.

'It was not clear how the targets were arrived at and how they contribute to overall objectives, ' he says.

Only 30-40 per cent of smokers 'truly abstinent at four weeks are likely to be abstinent at one year'.

'Therefore as an outcome it is a poor representative indicator of true long-term cessation.'

Privately, many PCTs have being saying the same thing for a long time, frustrated that pressures to hit the target have diverted them from the more effective business of succeeding in getting people - particularly those living in the poorest communities - to succeed in stopping smoking in the long term. But it now looks as though the Treasury-sponsored words of Mr Wanless will force the government to act.

Nottingham City primary care trust tobacco control strategic manager Alison Challenger says:

'There is a tremendous amount of work that we are doing that doesn't get recognised in the targets: the work that we do with low-income families or pregnant women.

'I am not against targets - I think they are useful and they have focused people's attention. But with this emphasis on throughput I think there have been occasions where the quality of the service people can provide has been threatened.'

Cancer Research UK professor of health psychology Robert West says that the report is likely to make uncomfortable reading for the government. And particularly when it has given PCTs£138m to hit its own widely disparaged target.

'I think although the language is moderate, Mr Wanless has rightly savaged the target. It is encouraged PCTs to drag in thousands of people with little idea of whether they want to really quit smoking or not. That is not effective, ' he argues 'The Wanless report pushes all the right buttons because it shows the government could be doing things now at relatively little cost simply to improve the targets.'

London Health Observatory director Dr Bobbie Jacobson says:

'I know there are criticisms, but you have to look at what went before. There were no targets on smoking cessation - none at all and I think the government should be applauded for taking a first step.

'The point Mr Wanless makes is that there cannot be just a single approach to reducing smoking.

There has to be co-ordination.'

In the words of Mr Wanless himself: 'Smoking-cessation services alone are essentially an individual intervention that cannot be expected to deliver significant falls in prevalence.

They are part of a much broader strategy that is required to influence smoking behaviour across the general population, with a commitment from right across government, not just from the Department of Health.' l Smoking cessation:

what Wanless says lThere is only patchy evidence on how best to make the service work.

lHealth Development Agency guidance on cessation services has not always reached the front line.

lManagement information is very poor.At a national level there are long time lags before smoking prevalence data becomes available.

At local level it is not clear who is smoking, who wants to give up and their motivations for doing so.

lFour-week targets on giving up smoking are a poor indication of long-term success.