Commentary on Jackson et al.: The role of regional tobacco control in centralised nations

In nations with federal or decentralised governance structures, the role of subnational tobacco control is clear. Local and regional areas not only provide smoking cessation services, but implement significant tobacco control policies. For example, in the United States, local and state authorities enacted the first Tobacco 21 statutes [1]; in China, municipal governments introduced smoke-free laws [2]; and in South America, smoke-free legislation originated at the provincial tier in Argentina [3].

The same is not true of England, United Kingdom. Despite the introduction of elected regional mayors, England has undergone decades of funding cuts for local and regional tiers of government and has a highly centralised system of governance [4, 5]. It has also experienced sustained increases in regional economic inequality since the mid-2000s [6]. In relation to tobacco control, most legislative activity in England takes place at national government level. Local areas deliver smoking cessation services, enforcement of national policy and broader tobacco control measures that require no major new legislation. Regional programmes were previously funded by the national government to support local areas by providing expert advice, co-ordinating activity and enabling economies of scale [7]; however, this funding was withdrawn in the early 2010s, leaving regional programmes only where local areas banded together to pool resources [8].

This makes the results of Jackson et al.’s study on regional tobacco trends in England especially important [9]. Drawing on approximately 370 000 survey participants from 2006 to 2024, the authors modelled age-standardised smoking prevalence by region and social grade. When comparing areas with and without dedicated supra-local tobacco-control programmes, they found that prevalence fell in every region, but declined fastest in the North East, the only region that has maintained continuous regional tobacco control capacity, by 13.3 percentage points (95% CI = −15.3 to −11.3) against 9.3 percentage points (95% CI = −10.0 to −8.5) elsewhere.

The authors offer strong arguments that regional tobacco control played a role reducing smoking prevalence. During the same period, economic inequalities in England have widened [6], alcohol harms have increased in the North East [10], and yet smoking prevalence strongly bucked this trend.

How might regional tobacco control be reducing smoking prevalence? Prior research sheds some light on the possible mechanisms at play. Despite England's pronounced administrative centralisation, long-standing supra-local tobacco-control units have exercised a distinct role. Without independent legislative authority or substantial distributive budgets, these teams have spearheaded strategies against illicit trade [11], led mass-media cessation initiatives [12], brokered regional consensus on e-cigarettes [8] and developed multi-year strategic frameworks for local implementation [13]. This demonstrates the capacity of modest, expert regional infrastructure to shape the tobacco environment, even within a strongly centralised state [14].

Regional tobacco control may also have a role to play in ameliorating the economic gap between English regions. Tobacco use places a financial burden on households and communities, with most of the money spent on tobacco flowing directly out of local economies. Recent research has highlighted the substantial benefit to local economies in England when people who smoke quit and, therefore, stop spending money on tobacco, and that this gain is greater in lower income areas [15].

More research is needed to further understand the most effective components and contexts for regional tobacco control. The United Kingdom government has invested £70 million per annum in local smoking cessation services in 2024/2025 and 2025/2026 [16]. Although no money has gone directly to regional tiers of governance, under the conditions of the grant, local areas are able to use these allocations to jointly fund regional work [17], although the scale of recent investment into regional work is not yet clear. Ongoing evaluation is required to deepen understanding of the circumstances in which regional approaches strengthens local tobacco control.

Consistent research and investment in subnational, supra-local programmes, with an expert-led focus on tobacco control, could support nations with centralised governance structures to reduce inequalities in regional tobacco prevalence, inequalities in regional health and even inequalities in regional economies.

Nathan Davies: Conceptualization; writing—original draft. Tessa Langley: Conceptualization; writing—review and editing.

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