With smoke-filled public rooms already fading into the past following the smooth introduction of smoke-free laws, it is easy to understand how the public health focus might shift away from tobacco use. But smoking must remain the number one concern for everyone who cares about inequalities in health and tackling poverty and social exclusion, argues Tonia Hagaman

In his report Securing Good Health for the Whole Population, Derek Wanless reported that 48 per cent of men in social class V (the poorest) died before the age of 70, compared with 22 per cent of men in social class 1. He estimated that half of this difference was accounted for by higher smoking rates among men in social class V.

It would be a catastrophic mistake to think one or two new pieces of legislation will win the war on tobacco. Maintaining investment in tobacco control at a national, regional and local level is vital.

The momentum is there, but smoking in some sections of society is still considered the norm. While adults may vocalise their right to engage in what is after all a legal activity, how many smoking parents would wish to see their children growing into an addiction that guarantees to kill half of all lifetime users?

Now is the time to drive forward change with a mature and adequately funded tobacco control programme for the future and with goals that are much more challenging than at present.

The tobacco industry continues to spend billions of dollars prioritising new markets and customers by investing in marketing, promotion, advertising and product-development worldwide, with sophisticated marketing techniques bypassing the UK's advertising laws.

Denormalising smoking

Californians are veterans of the tobacco war, having battled the tobacco companies for many years. When the Californian tobacco control model is discussed, it is often accompanied by assumptions that it is easier for California because it is richer or more homogenous as a population, but this is far from the truth.

A specific challenge the state faces is the diversity of its population. Disproportionately high levels of smoking and exposure to second-hand smoke are experienced by low-income Californians, black and minority ethnic communities, as well as by the state's lesbian, gay, bisexual and transgender community and active duty military personnel.

The California tobacco control programme has sought to change the broad social norms around using tobacco - to push tobacco use out of the charmed circle of normal, desirable practice to being an abnormal practice; in short, to denormalise smoking and other tobacco use.

It has achieved this via a policy development approach. Whereas individual behaviour change approaches have a limited impact at the personal level, policy change creates environments where it is easier to quit smoking, or not start at all. Policy change sustains social norm change.

Promising results

Evaluation results indicate that this approach is working in California: consumption has declined by around 60 per cent since the inception of the programme in 1989, and it is half the rate as compared with the rest of the US. Adult smoking prevalence had dropped to 14 per cent by 2005, a 38 per cent reduction since 1988.

Given declining resources, the programme has determined that each policy development effort must result in victory. Winning is everything. Therefore, the programme provides statewide leadership by funding local training programmes in community organising, legal technical assistance, and other areas critical for policy development success.

California has made an unflinching commitment to local tobacco control policy development in these priority areas. The programme has found that local communities are the incubator of tobacco control innovation. Many, if not most, successful tobacco control policies were tried, tested, and eventually succeeded at the local level.

We use a community planning framework called Communities of Excellence in Tobacco Control. At the heart of the framework is the idea that communities can achieve excellence in tobacco control by involving a motivated and diverse group of people to assess where their community is now and determine where it needs to go and how best to get there.

The model challenges the perception of tobacco use as normal or glamorous. It places all the emphasis on changing the core attitudes, values and mores of the community rather than the individual.

Sharing practice

The UK is now at a crucial junction in its tobacco control programme. Policy-makers must take heed not to slow down at this vital moment. We have excellent practice to share with one another at an international level, which we must do to ensure we win what is now a battle being fought at community level as well across national boundaries.