Trends in health-related economic inactivity by smoking status in England, 2013-2025: a population-based analysis.

Background: Rising levels of economic inactivity due to long-term illness in the UK have important public health and socioeconomic implications. Smoking is a leading risk factor for many chronic conditions that impair work capacity and is strongly associated with socioeconomic disadvantage. We examined trends in health-related economic inactivity among working-age adults in England by smoking status from 2013 to 2025. Methods: We analysed data from 173,248 adults aged 18-64 y in the Smoking Toolkit Study, a nationally representative monthly survey. Health-related economic inactivity was defined as not being in paid work due to long-term illness or disability. Logistic regression modelled time trends adjusted for age and gender, overall, by smoking status (current, former, never), and by duration of abstinence among former smokers. Findings: Health-related economic inactivity more than doubled between 2013 and 2025 (2.5% [2.3-2.7%] to 5.5% [5.1-5.9%]; prevalence ratio = 2.21 [1.96-2.49]). Prevalence was consistently highest-and absolute increases over time were largest-among current smokers; reaching 11.3% [9.9-12.7%] in 2025, compared with 5.8% [5.0-6.6%] in former smokers and 3.3% [2.9-3.7%] in never smokers. This equates to ∼700,000 current smokers not in work due to ill health or disability in 2025, up from ∼390,000 in 2013. Among former smokers, inactivity declined with longer abstinence. Interpretation: Smoking is strongly associated with health-related economic inactivity, with absolute disparities widening over time. In early 2025, one in nine working-age adults in England who smoked was not in work due to long-term illness or disability. Reducing smoking prevalence and addressing its social determinants may contribute to tackling rising inactivity and improving labour market participation. Funding: Cancer Research UK.