Background: Geographical inequalities in smoking persist across the UK. This study quantifies the potential benefits of stronger tobacco control policies in North West (NW) England.

Methods: We used a validated microsimulation model to compare five policy scenarios over 50 years: baseline trends; increasing the minimum age of tobacco access to 21 (MinAge21); a 30% increase in tobacco duty (TaxUP); enhanced smoking cessation services (ServicesUP); and combining TaxUP and ServicesUP (Combined).

Results: By 2030, smoking prevalence is projected to decrease to 10.1% (95% UI: 9.9%–10.2%) under baseline trends; 10.0% (95% UI: 9.5%–10.1%) with MinAge21; 9.5% (95% UI: 9.4%–9.6%) with ServicesUP; 8.6% (95% UI: 8.5%–8.7%) with TaxUP, and best, 8.1% (95% UI: 8.0%–8.2%) with Combined.

All policies would reduce the current NW/UK smoking prevalence gap of 1.5%, potentially reaching zero by 2047 with Combined or TaxUP.

By 2072, compared to baseline trends, all policies could reduce morbidity: approximately 25,000 (95% UI: 21,000–31,000) fewer disease cases with Combined; ~24,000 (95% UI: 20,000–29,000) with TaxUP; ~9,300 (95% UI: 7,300–14,000) with MinAge21, and ~2,900 (95% UI: 2,300–3,800) with ServicesUP.

All policies would reduce absolute inequalities between affluent and deprived groups, generate cost savings, and add quality-adjusted life years, especially Combined and TaxUP scenarios.

Conclusions: Geographical and socio-economic inequalities in smoking prevalence persist in NW England. Our policy simulations suggest that stronger tobacco control policies (notably increased tax and enhanced smoking cessation services) could substantially reduce smoking prevalence, minimise inequalities, and generate substantial cost savings in NW England.