Now I don’t want to tread on the toes of my friends and colleagues on the Nicotine Science and Policy blog but, as it was National No Smoking Day on 14 March, I am going to reflect a little on smoking in the UK. It was first held in 1984, just after I had started my first job, and I was, I confess, a smoker. 34 years on what stands out most is not the money spent, the clothes damaged, accidental burns endured (smoking with a crash helmet on is not something I would do again) or the other risks associated with smoking tobacco. No, it’s the fact the world was very different.

I started work as a Counter Clerk for the Post Office and was given a key piece of equipment. A large glass ashtray, with ERII etched into its base. Staff smoked at the counter, customers smoked as they queued. We travelled on busses where the top deck was a smoke dense location, or in the smoking carriages of the Underground. These, especially in winter with the windows closed, could provide a glimpse into a circle of hell Dante forgot to describe. But that is, of course, with the benefit of hindsight. At the time it was normal. It was what people did. Inevitably it was matched by the scale of illness, premature death and misery associated with smoking.

Fast forward to 2018 and less than 16% of adults’ smoke in the UK, under half the number in 1984. This is a great public health gain. Yet within that success sit some real challenges. Those from better off backgrounds are most likely to have given up. The rate of decrease in smoking has slowed, even stalled in some populations. While many individuals are undoubtedly living longer, healthier lives our gains around smoking have done nothing to reduce the gradient of health inequalities.

As in so many areas it is easiest to reach and help those who are in the least need. This raises fundamental questions about how we approach at risk and vulnerable populations. How do we avoid leaving people behind? In the UK we are taking some steps forwards in this regard and Public Health England’s work in this area, supported by some enlightened local practitioners provides grounds for hope.

Because we do need to think about the fundamentals of this. In the last week in the UK we have had major stories in the media about the risks posed by excessive salt in food, too much sugar in our diet and micro plastics in our water. Issues about obesity are omni present. Alcohol problems are regular news fodder. None of these are trivial issues. All deserve responses from governmental and health agencies. They all generate conversation and provide marketing opportunities for some. Worryingly they all risk failing to engage the populations who could benefit the most.

All too often we develop approaches that fuel the sense that public health is something the state does to you. Something to make, often demanding lives, that little bit harder and, seemingly, less enjoyable. Before I upset too many people I know there are many excellent campaigns and local initiatives that focus on the positive but the majority of these operate at a micro level and the mood music at macro level often drowns these out. The tragic result is that attempts to improve population health are often helping to drive the alienation of communities from those agencies which seek to help them. Politicians often sense this at visceral level and become weary of engaging with health issues. This is an issue being explored within the Politics and Public Health; Friends or Enemies session at City Health 2018. It reflects a reality I recognise, one that can be professionally frustrating but more importantly hinders approaches that could help millions of people globally. We need to all think about the role we can play in reconnecting and creating the links between communities, politicians (and policy makers) and public health that allow us to realise the goals of improving health and societal wellbeing. To achieve these will require understanding, compassion, courage and the willingness to change existing practice. These pose serious and complex challenges, but it is necessary if we are to take people with us when we tackle the health challenges facing our cities. After all, helping people enjoy a better life is our objective and they should be our greatest resource.