Guidance

Tobacco commissioning support: principles and indicators

Updated 4 October 2018

1. Introduction

1.1 The Tobacco Control Plan

In July 2017, the government published its Tobacco Control Plan for England, to pave the way for a smokefree generation. The comprehensive plan sets out the following national ambitions for achievement by the end of 2022.

1. To reduce smoking prevalence among adults in England from 15.5% to 12% or less.
2. To reduce the prevalence of 15 year olds who regularly smoke from 8% to 3% or less.
3. To reduce the prevalence of smoking in pregnancy from 10.7% to 6% or less.
4. To reduce the inequality gap in smoking prevalence between those in routine and manual occupations and the general population.

The UK is a world leader in tobacco control, but smoking remains our biggest preventable killer. In England alone, 78,000 people a year - or 200 per day - die from smoking. In addition to the human cost, smoking costs the economy £14.7 billion per year, £2.5 billion of which falls to the NHS.

Since publication of the last Tobacco Control Plan, smoking prevalence among adults in England has dropped from 20.2% to 14.9% - the lowest level since records began.

The new plan sets out the ambition for a further reduction in smoking rates, down to 12% by the end of 2022, as the first step toward a generation of non-smokers, which will be achieved when smoking prevalence is at 5% or below.

The plan prioritises reducing the rates of smoking in pregnancy, as well as addressing the huge variation in harm across the country, which disproportionally falls on the more disadvantaged communities. In 2015, there were almost 3 times as many smokers among the lowest earners in comparison to the highest earners.

The plan calls for targeting prevention and local action to address the variation in smoking rates in our society, educate people about the risks and support them to quit for good.

In June 2018, the government published Tobacco control plan: delivery plan 2017 to 2022. The delivery plan makes it clear that helping smokers to quit is the job of the whole health and care system.

1.2 The benefits of having a comprehensive approach to tobacco control

Comprehensive tobacco control interventions, implemented at a local level and part of a strategic partnership approach, reduce smoking prevalence and have been proved effective in reducing social and health inequalities. Having a comprehensive approach to tobacco control can help with the following things.

Cut costs to local business, healthcare and public services

Action on Smoking and Health estimates that in England each year smoking costs society £12.6 billion in terms of output lost from early deaths, smoking breaks, sick days, provision of NHS treatment, provision of social care, household fires, and smoking litter.

Support the NHS sustainability and transformation agenda

Smoking is a leading cause of preventable illness and tackling it presents a major opportunity to make services across the entire health and care system more sustainable.

Protect children from harm

The Office of National Statistics found that two thirds of smokers say they began smoking before the age of 18, when it’s legal to purchase cigarettes, and 9 out of 10 began before the age of 19. Children exposed to secondhand smoke are at much greater risk of cot death, meningitis, lung infections and ear disease - see ‘Passive smoking and children’, a report by the Tobacco Advisory Group of the Royal College of Physicians, published March 2010.

Boost the disposable income of the poorest people in your local area

Two adult smokers with a 20-a-day habit are likely to spend over £6,000 per year on cigarettes. According to ASH, workers in routine and manual jobs are twice as likely to smoke as those in managerial and professional roles and poorer smokers spend 5 times as much of their weekly household budget on smoking as richer smokers.

Improve population health indicators

Reducing smoking rates will have an effect on core indicators included in 3 out of the 4 public health domains identified in the Public Health Outcomes Framework. Examples of indicators which would be positively affected include:

• sickness absence
• the number of children in poverty
• numbers of low birth-weight babies
• pregnant women smoking at time of delivery
• smoking prevalence rates in adults and children
• infant mortality and all cause preventable mortality
• mortality from cardiovascular disease
• mortality from cancer
• mortality from respiratory disease
• preventable sight loss

1.3 Local systems

You need to have effective local systems to move the tobacco control agenda forward. So it’s vital to make sure that all partner agencies involved in local tobacco control activity have an opportunity to contribute to the needs assessment process and assessing any further action that might be needed.

Formal strategic partnerships for tobacco control should involve all the relevant stakeholders and agencies (such as acute health, mental health, public health, regulatory services, employment, social care, children’s services, fire and rescue service and criminal justice). The aim of the partnership is to develop an integrated and comprehensive system for preventing smoking uptake, supporting smokers to stop, reducing the harm and inequalities caused by smoking and advocating for a tobacco-free generation.

Sustainability and transformation plans and integrated care systems should identify the role of tobacco control in reducing health inequalities and improving sustainability. Local partners can identify the potential return on investment for funding tobacco control interventions, including any economies of scale from commissioning services between more than one local authority. - see the NICE tobacco return on investment tool.

1.4 Aim of this guidance

PHE supports local authorities to deliver locally-appropriate interventions and services to improve the public’s health, by providing data, guidance and evidence. This guidance, along with the data packs that are sent directly to local authorities, supports local needs assessment processes and commissioning of tobacco control interventions. It also introduces a model from behaviour change theory, to support commissioners to do a systematic analysis of their available commissioning options.

Local authorities and their partners are also encouraged to adopt CLeaR, an evidence-based improvement model which can assist in evaluating the effectiveness of local action addressing harm from tobacco.

2. Commissioning comprehensive local tobacco control interventions

2.1 Statement of principle

Local authority public health commissioners work closely with all relevant partners to commission high quality, evidence-led comprehensive tobacco control interventions.

2.2 What we mean by ‘evidence-led’

Tobacco control is an area of public health that has a very strong and consistent evidence base. If recommended interventions are delivered, the evidence indicates clearly that they will save lives and reduce chronic ill-health and disability, providing net savings to the local and national economy within a few years.

The main drivers of reduction in smoking prevalence are decreasing uptake and increasing cessation. By far the biggest impact on smoking prevalence in any one year comes from increasing cessation simply because the numbers affected are so much greater. So it is more cost effective to focus resources on smoking cessation. An added advantage of this is that many interventions that promote cessation, such as raising the cost of smoking, also serve to reduce smoking uptake.

The evidence comes from large numbers of population-level and clinical studies. They demonstrate that, for smoking cessation to happen, smokers need to have the capability, opportunity and motivation to change. All three of these need to be in place. This broad principle has been captured by the COM-B model of behaviour.

Figure 1 shows the COM-B model applied to smoking cessation in a given population or sub-population (for example, low income smokers, smokers with mental health problems or pregnant smokers).

Capability refers to smokers’ ability to stop if they try. This depends on their level of addiction to cigarettes. Most smokers are addicted to some degree, so treating the addiction will improve their chances of success. Some smokers are much more heavily addicted than others and it is essential that these people have access to specialist support.

Motivation refers to smokers’ desire to try to stop now rather than at some other time or never. Creating a sense of immediacy and hope are important in prompting quit attempts. Examples include:

• social marketing via mass media, social media and other platforms – these are leading factors in motivating a person to quit, working by reminding them about quitting, the best ways to do it, and prompting a quit attempt
• minimising access to cheap tobacco – this supports one of the main influences for quitting: the financial cost
• brief advice from a healthcare professional – this is still one of the most important triggers to quitting, especially if it involves the offer of support

Opportunity refers to reducing triggers to smoke, making smoking seem less normal and making quitting seem like the kind of thing everyone is doing. Setting up and enforcing smoking bans in key locations can play a role in this, as can ensuring compliance with bans on marketing and promotion.

Figure 1: The COM-B model of behaviour change applied to reducing smoking prevalence

The COM-B model of behaviour change applied to reducing smoking prevalence

There is a high level of interaction between these elements, emphasising the need for comprehensive local tobacco control action plans. Improving smokers’ ability to stop can increase their motivation to try, as can decreasing smoking triggers in their environment and increasing public visibility of quitting.

The most effective tobacco control strategy is one in which all the elements are working together. This means, for example, linking up social marketing campaigns prompting quitting with brief advice from health professionals offering support. An integrated strategy requires multi-agency working with a clear and coherent vision as to the local objectives and how the different elements of the strategy will combine to achieve these.

2.3 What will you see locally if you are meeting the principle?

Effective integrated commissioning of interventions that achieve positive outcomes for individuals, families and communities by:

• having well-functioning partnerships between local authority-led public health, the NHS (clinical commissioning groups (CCGs) and NHS England regional teams), acute health services, mental health services and adult social care, regulatory services, children’s services and criminal justice agencies
• commissioning transparently, based on assessed need
• bringing partner agencies and service providers together into cost-effective delivery systems
• involving service users and local communities, including through Healthwatch

All smokers are offered cessation support suited to their needs and preferences.

Tobacco control is a prominent action within strategies aimed at addressing health and social inequalities.

2.4 Questions to check if you are following evidence and best practice

Embedding in local systems

Do tobacco control needs assessments, the local authority commissioning strategy, CCG commissioning strategy, the joint health and wellbeing strategy and sustainability and transformation plans (STPs) show an explicit link between evidence of need and service planning?

Are there suitable mechanisms in place within the local public health structure to ensure the impact of tobacco use is reported to the health and wellbeing board and STP delivery boards?

Have the people responsible for commissioning tobacco control and stop smoking services established partnership arrangements with CCGs, local clinical networks, the local maternity system, NHS England regional teams, regulatory services and criminal justice agencies?

Has the role of tobacco control in supporting the NHS sustainability and transformation agenda been formally explored?

Have such strategic partnerships undertaken a self-assessment to enable you to:

• evaluate your local action on tobacco
• ensure that local activity follows the latest evidence-based practice
• identify priority areas for development

Have strategic partner organisations acknowledged their responsibilities to protect their tobacco control policies from the vested interests of the tobacco industry under Article 5.3 of the World Health Organization’s (WHO) Framework Convention on Tobacco Control, by signing the Local Government Declaration on Tobacco Control?

Is there a clearly accessible process for smokers to express their preferences for how they want to stop smoking and the type of support they are willing to engage with?

Needs assessment

Needs assessment involves not just assessing whether smokers in particular sub-groups would benefit from cessation support, but also what kind of support, if any, they are willing to engage with.

Does the local needs assessment include a comprehensive section on tobacco control that addresses smoking-related harm and health inequalities, and acknowledges the impact of tobacco control activity across the Public Health Outcomes Framework and NHS Outcomes Framework?

Is there a shared understanding of the local level of demand and need, based on a range of local and national data across a range of public services?

Is local data on tobacco control interventions provided within hospitals, primary health care and other settings collected and analysed to inform needs assessment?

Does analysis of tobacco-related hospital admissions inform the targeting of local interventions?

Do commissioners own and analyse local stop smoking service treatment data to assess quality, including specific breakdown by gender, age, postcode, condition, route of referral and treatment outcome, so that treatment provision can be aligned with need?

Does the needs assessment incorporate a methodology such as asset-based community development to take into account the availability and potential for development of existing community support networks and other local assets?

Have you identified:

• gaps in the delivery of brief interventions across all partner agencies
• the equity of access to stop smoking services for populations with a higher prevalence of smoking (such as routine and manual workforce, teenage pregnant women, people with mental health problems, prison populations and lesbian, gay, bisexual and transgender (LGBT) people)
• the impact of tobacco control and stop smoking interventions on hospital admissions, length of stay and social care activity

Resources and investment

Is investment equal to the level of identified need and sufficient for a range of prevention, harm reduction and stop smoking service activities?

Can commissioners identify the total level of local investment by all partners who contribute to delivering services?

Have the partners identified the potential return on investment for funding tobacco control interventions and does this include any economies of scale that could be achieved by commissioning with other local authorities? See the NICE return on investment tool.

Effective commissioning

Do interventions commissioned for tobacco control and tackling smoking-related harm take an evidence-based approach based on NICE guidance and National Centre for Smoking Cessation and Training (NCSCT) commissioning recommendations?

Are reliable cost-effectiveness data tools used to inform commissioning decisions and ensure that investment in tobacco control is based on an understanding of expenditure, performance and effectiveness?

Do contracts for commissioned services specify performance indicators and are these regularly monitored and reviewed?

Are interventions and services geographically and culturally appropriate to the people for whom they are designed?

Is there sufficient tobacco control commissioning capacity and expertise?

Are arrangements in place to enable commissioning with regional partners?

Does formal evaluation of the range of tobacco control interventions feature in the commissioning strategy?

3. Supporting people to stop smoking

3.1 Statement of principle

Targeted stop smoking services, as an integral part of any comprehensive tobacco control strategy, provide evidence-based support tailored to the needs and preferences of smokers.

3.2 Local stop smoking services

Stop smoking services are an important component of cost-effective tobacco control strategies at local and national level. Targeted, high quality stop smoking services are essential to the reduction of health inequalities in local populations. For many years, smokers in England have been offered a highly effective universal service. In recent years, some local authorities have been looking at new ways of providing this service, often in response to budget constraints.

It is important to ensure that resources are appropriately targeted, and that commissioning decisions are based on the evidence of what works and avoid selectively disadvantaging the local population.

All health and social care services play a role in identifying smokers and referring them to stop smoking services. For smokers who are not ready, willing or able to stop in one step, harm reduction interventions can support them in becoming smokefree over the longer term.

3.3 The need for tailored quitting support within a comprehensive strategy

The probability of one-year success of an unaided quit attempt is typically less than 5%. That is a main reason why smoking prevalence is falling very slowly despite the fact that a third of smokers try to stop every year.

Failure to quit attempts is also why prevalence is declining more slowly in people with greater social disadvantage. In the recent past there has been no difference in the rate at which more disadvantaged smokers try to stop. It is their chances of success that are lower - see the BMJ research paper on the social gradient in smoking cessation.

Smokers who get expert support from stop smoking services are up to 4 times as likely to quit successfully as those who try to quit unaided according to the National Centre for Smoking Cessation and Training. So support for smoking cessation is a crucial part of tobacco control at national and local level, and essential for reducing health inequalities caused by smoking. As noted in Chapter 1, it is important to link stop smoking support with other components of the local tobacco control strategy so that:

• smokers are motivated to try to stop and use effective methods to do so
• increasing ability to stop increases motivation to stop
• stopping smoking becomes more visible in the community (see figure 2)

Figure 2: The role of stop-smoking support in a comprehensive strategy

Making sure that cessation support is available helps to: (1) tackle cigarette addiction, (2) which increases cessation rates and (3), can motivate others to quit, and (4) to use cessation support. Increased successful quitting in the community reshapes the social environment (5) making quitting normative and potentially helping to motivate others to quit (6).

3.4 Smoking cessation within integrated lifestyle services

There is a pressing need for broader lifestyle advice and support, with issues such as healthy weight and physical activity becoming more prominent. This has led some local authorities to commission lifestyle services and to incorporate stop smoking support into these.

Broadly, 2 different models for integrating services have emerged and it is important to distinguish between them. One involves an umbrella organisation, which directs people to specific treatment programmes, such as stop smoking support with evidence based behavioural support and pharmacotherapy. The other provides a more generic multi-behaviour change intervention, that may include smoking.

It is essential that commissioning decisions take account of the large body of evidence on the effectiveness and cost-effectiveness of different approaches. The NCSCT has reviewed this literature and provided recommendations. It concludes that smoking cessation is most effective and cost-effective when provided as a single intervention, rather than as part of multi-component integrated lifestyle interventions. The evidence associated with different components and models for providing stop smoking interventions is summarised in this PHE models of delivery guidance.

3.5 Harm reduction and the role of e-cigarettes in supporting smokers to quit

The best thing a smoker can do is to stop smoking now, completely and for good. However not all smokers are ready, willing or able to stop in one step and NICE tobacco harm reduction guidance PH45 sets out a series of approaches that support smokers to quit in the longer term, while reiterating that abrupt quitting is the best option.

1. Stopping smoking and using one or more licensed nicotine-containing products as long as needed to prevent relapse.
2. Cutting down prior to stopping smoking with or without the help of licensed nicotine-containing products.
3. Smoking reduction with or without the help of licensed nicotine-containing products.
4. Temporary abstinence from smoking with or without the help of licensed nicotine-containing products.

NICE guidance on tobacco harm reduction is currently under review and will be updated to include recommendations on consumer and licensed e-cigarettes.

There is growing evidence that harm reduction approaches may play a role in complementing conventional cessation-focused strategies. In the context of tobacco control in the UK, harm reduction involves:

• advising smokers who are not ready to quit that they should try to reduce their smoking with the aid of a nicotine substitute
• recognising that smokers who have stopped smoking with the aid of a nicotine substitute may need to continue to use that substitute for months or years to prevent relapse to smoking

Stop smoking services provide highly cost-effective interventions to help people stop smoking and any investment in harm reduction should not detract from providing them. Harm reduction interventions are intended to support and extend the reach and impact of existing services.

Although existing evidence is not clear regarding the health benefits of smoking reduction alone, people who reduce the amount they smoke are more likely to stop smoking eventually, particularly if they are using licensed nicotine-containing products.

An estimated 2.9 million adults in Britain currently use e-cigarettes (vape). Over time, the proportion of vapers who smoke tobacco has fallen and the proportion who are ex-smokers has risen, while regular e-cigarette use among people who have never smoked has remained negligible at 0.3%, according to ASH’s report on ‘Use of e-cigarettes among adults in Great Britain, 2018’. The latest data from Action on Smoking and Health shows that 1.7 million vapers – over half of the total – have managed to stop smoking completely - and ONS figures suggest that more than 900,000 people have given up both smoking and vaping. This suggests that for many smokers, dual use (vaping while continuing to smoke) may be a stage in their journey to becoming smokefree and, ultimately, nicotine free.

Leading UK health and public health organisations including the Royal College of General Practitioners, the British Medical Association and Cancer Research UK now agree that although they are not risk free, e-cigarettes are far less harmful than smoking. Based on an assessment of the available international peer-reviewed evidence, Public Health England and the Royal College of Physicians estimate the risk reduction to be at least 95%. In 2018 so far, 3 major US reports (National Academies of Sciences, Engineering and Medicine, American Cancer Society and the US Annual Review of Public Health) have found that e-cigarettes are substantially less harmful than smoking.

The UK has some of the strictest regulation for e-cigarettes in the world. Under the Tobacco and Related Products Regulations 2016, e-cigarette products are subject to minimum standards of quality and safety, as well as packaging and labelling requirements to provide consumers with the information they need to make informed choices. All e-cigarette products must be notified by manufacturers to the UK Medicines and Healthcare products Regulatory Agency (MHRA), with detailed information including the listing of all ingredients.

E-cigarettes are now the most commonly used stop smoking aid in England, according to Smoking in England data. Evidence for their effectiveness from research trials is currently limited but suggests that it is broadly similar to prescribed stop smoking medicines and more effective than licensed nicotine products if these are used without any professional support. Smokers who combine e-cigarettes with support from stop smoking services in England have some of the highest quit rates. In the financial year 2017 to 2018, around two thirds of smokers who did this quit smoking successfully according to NHS Digital figures.

E-cigarettes cannot be prescribed to smokers as part of stop smoking interventions, as there are currently no medicinally licensed products available on the market. However some services provide e-cigarette starter packs, increasing footfall and improving quit rates. Clear advice on the benefits and risks should be included in optimal self-support, and stop smoking services should welcome smokers who want to use an e-cigarette to help them quit.

NICE guidance NG92 ‘Stop smoking interventions and services’ recommends that health and social care professionals provide the following advice to smokers who are using, or interested in using, an e-cigarette for quitting. The guidance says that:

• although these products are not licensed medicines, they are regulated by the Tobacco and Related Products Regulations 2016
• many people have found them helpful to quit smoking cigarettes
• people using e-cigarettes should stop smoking tobacco completely, because any smoking is harmful
• the evidence suggests that e cigarettes are substantially less harmful to health than smoking but are not risk free
• the evidence in this area is still developing, including evidence on the long-term health impact

Further guidance is available from the National Centre for Smoking Cessation and Training (NCSCT).

3.6 What you will see if you are meeting the principle

In line with NICE guidance, service providers should treat at least 5% of their local smoking population and see the following indicators in their area:

Stop smoking services achieve exhaled carbon monoxide (CO) validated success rates comparable to areas with similar smoker profiles and within the nationally prescribed range.

Stop smoking support is routinely offered, and made easily accessible, to vulnerable populations and those identified as at risk in the needs assessment.

All licensed stop smoking medications are available as first-line treatment options, especially dual form nicotine replacement therapy (NRT) (for example, nicotine transdermal patch plus a faster acting product), and varenicline.

People who are using or want to use e-cigarettes to stop smoking receive advice and behavioural support from their local stop smoking service.

Services are independently audited and improvement plans are implemented where required.

There are clear and efficient referral pathways embedded throughout health and social care services and these are routinely used to promote stop smoking services.

Services are promoted locally through mass media channels to raise awareness of the support available for people who want to stop smoking.

There is simple, easy-to-use online information for smokers to get information about the stop smoking support available in their area, the benefits of using each of the options, the commitment required for each and how to access them.

The role of stop smoking support in the local tobacco control strategy is clearly set out, quantifying how it is expected to contribute to reducing overall smoking prevalence and in different sub-populations.

All required monitoring data is reported to NHS Digital through the quarterly reporting system.

Smokers who are not ready, willing, or able to stop in one step are advised and supported to use a licensed nicotine-containing product or an e-cigarette to help them reduce their smoking with a view to stopping in the future.

Ex-smokers who feel they need to continue to use a nicotine substitute long term to avoid relapse to smoking are encouraged to do so.

3.7 Questions to check if you are following evidence and best practice

Is there a clear specification of how stop smoking support integrates with other parts of the local tobacco control strategy to increase the capability, motivation and opportunity of smokers to quit?

Is service design and delivery informed by the latest evidence, summarised in the NCSCT service delivery and monitoring guidance?

Has an equity impact and gap analysis been carried out and do commissioning priorities reflect it?

Have all stop smoking practitioners been trained to NCSCT standards?

Are all licensed stop smoking medicines offered as first-line interventions, including dual form NRT and varenicline?

Is stop smoking support offered to smokers who want to use e-cigarettes in their quit attempt?

Have priority sub-populations been identified and do those in greatest need of specialist support (such as smokers with mental health problems, pregnant smokers and those from disadvantaged backgrounds) have good access to it?

Are 4-week quit outcomes collected as specified in the NCSCT service and delivery guidance validated biochemically by measuring exhaled carbon monoxide and is the full data set submitted quarterly to NHS Digital?

Does the commissioner own all the monitoring data and have the capacity to undertake independent audits and performance monitoring when they need to?

Are stop smoking service providers subject to annual independent audit?

Are stop smoking services commissioned to promote available stop smoking interventions, to the public and to health professionals, including use of appropriate referral pathways?

Does the local tobacco control strategy include a clear specification of how harm reduction approaches will be used to complement stop-smoking support?

Are smokers who are not ready to try to quit advised to use a licensed nicotine product or an e-cigarette to reduce their smoking, with a view to quitting at a later date?

Are ex-smokers encouraged to use a nicotine substitute for as long as they feel they need them to prevent relapse to smoking?

4. Supporting pregnant smokers and those with infants to stop smoking

4.1 Statement of principle

All women who smoke and are pregnant, planning a pregnancy and have an infant should be referred for help to stop smoking.

4.2 Reducing smoking in pregnancy is an urgent priority

Smoking during pregnancy causes up to 2,200 premature births, 5,000 miscarriages and 300 perinatal deaths every year in the UK. It also increases the risks of stillbirth and of the child developing respiratory disease; attention and hyperactivity difficulties; learning difficulties; problems of the ear, nose and throat; obesity; and diabetes.

Addressing smoking in pregnancy should be a focus for all localities as this impacts on a range of issues related to health, inequalities and child development. NICE has produced guidance on how best to support women to stop smoking in pregnancy.

Although rates have declined over the last decade, 10.8% of women in England were recorded as smoking at the time of delivery in 2017 to 2018, which represents the second consecutive year with no progress. This NHS digital data translates into over 64,000 babies born to smoking mothers each year.

There are significant demographic differences and inequalities related to this issue. For instance, pregnant mothers under the age of 20 are 6 times as likely to smoke as mothers aged 35 or over. Those in routine and manual occupations are more than 4 times as likely as those in managerial and professional occupations to smoke throughout pregnancy (29% and 7% respectively). Infants born to smokers are much more likely to become smokers themselves, which further perpetuates health inequalities.

Treating mothers and their babies (0 to 12 months) who have problems caused by smoking during pregnancy is estimated to cost the NHS between £20 million and £87.5 million each year according to a Public Health Research Consortium report.

4.3 Support is needed for pregnant smokers

Motivation to stop smoking is very high in pregnancy and by the time pregnant smokers come into contact with healthcare services, many of those who can stop by themselves will have done so. Using the COM-B model, there needs to be a much greater emphasis on capability and opportunity. This may be expected to boost motivation to try to stop and to persist with quit attempts in the face of difficulties.

Pregnant women who continue to smoke should receive the highest quality stop smoking support available based on evidence-based principles set out in NICE and NCSCT guidance. The healthcare system should support broader strategies to address this issue, creating a social environment in which smoking during pregnancy is not normal, but quitting is. This requires repeated offers of support for quitting, delivered in a way that inspires hope rather than making people feel guilty.

Relapse to smoking soon after the baby is born is very common, but can be reduced by appropriate interventions from healthcare professionals working with new mothers. This kind of support should form part of a comprehensive programme commissioned by local authorities and embedded within the local maternity system.

4.4 What you will see if you are meeting the principle

Smoking is addressed by all healthcare professionals working with pregnant women throughout their pregnancy.

All pregnant women are screened for carbon monoxide (CO) at their booking appointment, and at subsequent antenatal appointments. If elevated CO levels are identified (indicating smoking) a referral is made to a specially trained pregnancy stop smoking advisor for support to stop.

Robust, opt-out referral pathways are in place between the healthcare professional (HCP) who raises the issue of smoking with the pregnant woman and the stop smoking service or person trained to provide the intervention. This will include feedback mechanisms to ensure the referring HCP is aware of the outcome.

Partners and family members who smoke are also offered support to stop smoking and information is provided on the risks associated with secondhand smoke.

4.5 Questions to check if you are following evidence and best practice

Is NICE guidance (PH26) appropriately implemented across systems in your local area?

Do service specifications for local midwifery services include requirements for smoking to be addressed?

Do these specifications include routine CO screening at booking appointments and other appointments?

Are there appropriate performance indicators in place to monitor this activity, and are there systems in place to address poor performance?

Are individuals who smoke provided with appropriate and consistent messages around smoking, the risks of continuation and the importance of cessation, as well as the risks associated with secondhand smoke?

Are there appropriate opt-out referral pathways in place, to make sure that women with elevated CO levels have swift access to specialist support to stop smoking?

Are there effective feedback mechanisms to the referrer that provide information and details for future follow-up?

Are all healthcare professionals who meet with pregnant women trained in very brief advice for smoking in pregnancyenabling them to raise the issue of smoking and refer to specialist services?

Are staff providing stop smoking interventions appropriately trained and does the training meet NCSCT standards?

Are stop smoking interventions provided on an ongoing basis and is information on and access to stop smoking medications made available?

Is smoking status a mandatory data item collected at booking, including recording of the CO reading?

Is smoking status at time of delivery (SATOD) monitored regularly within and across the locality?

Does the system for SATOD data collection include the option of ‘not known?’ If there is, are there plans to remove this and make sure there is more accurate and informative data collection?

Is there a local multi-agency partnership in place with appropriate local leadership to address the issue of smoking in pregnancy? Is there a strategy?

Is system-wide action to address smoking in pregnancy clearly specified within the local maternity system?

Are contract specifications reviewed regularly? Is there a process for monitoring delivery and outcomes?

Has the local authority undertaken a CLeaR deep dive review on smoking in pregnancy, involving all relevant partners?

5. Smokefree homes and cars

5.1 Statement of principle

Enclosed smokefree places or settings create an environment in which smoking is less normal and protect the health of non-smoking children and adults.

5.2 Enclosed smokefree environments protect non-smokers and promote quitting

Millions of children in the UK are still exposed to secondhand smoke that puts them at increased risk of respiratory problems, meningitis and sudden unexplained infant death, according to a Royal College of Physicians report ‘Passive smoking and children’ published in 2010. Each year this results in over 300,000 GP visits and around 9,500 hospital admissions in the UK and costs the NHS more than £23.6 million.

Exposure to secondhand smoke in confined spaces such as a car is particularly hazardous. Legislation introduced in October 2015 means it is now prohibited to smoke in a vehicle with someone under the age of 18 present. As there is no safe level of exposure to tobacco smoke, it is important that other vulnerable groups such as older adults are also protected.

Reducing the visibility of smoking can be expected to make smoking less normative, helping to support smokers who are in the process of quitting and motivating other smokers to try to quit. This is an important contribution to a comprehensive local approach to tobacco control.

Figure 3: Promoting smokefree homes and cars to promote successful quitting

Smokefree homes and cars reduces visibility of smoking for the family and promotes a wider non-smoking norm (1), which should trigger more quitting behaviour (2) and also provide greater motivation to quit (3) which should also promote more quitting behaviour (4).

5.3 What you will see if you are meeting the principle?

Frontline health and social care workers routinely ask service users if they are ever exposed to tobacco smoke in an enclosed environment.

Frontline health and social care workers provide expert advice on how to make homes and cars smokefree.

Local policies and plans are in place to increase enclosed smokefree spaces, supporting smokers to create and maintain smokefree homes and cars..

Local partners are in a position to educate the public on compliance with smokefree legislation, including the prohibition of smoking in a vehicle with someone under the age of 18 present.

5.4 Questions to check if you are following evidence and best practice?

Have early years partners undertaken an assessment of their capacity to deliver brief interventions, advice about smoking cessation, and secondhand smoke interventions?

Do frontline health and social care workers monitor and record smoking status?

Are there measures of exposure to secondhand smoke for vulnerable groups, especially children?

Is there access to a freely available and evidence-based stop smoking service? There are further questions in Section 2: Supporting people to stop smoking.

Have smoking cessation advisors and frontline health and social care workers completed the NCSCT module for very brief advice on secondhand smoke?

Does advice on secondhand smoke extend to cars, with and without under-18s present, and other enclosed environments?

Do you have evidence that brief interventions on secondhand smoke are being delivered?

Do you have evidence that commitments to smokefree homes and cars are being adopted and maintained?

6. Preventing young people from taking up smoking

6.1 Statement of principle

Positive influences in the school, home and local community prevent young people from taking up smoking.

6.2 Reducing smoking uptake involves creating non-smoking communities

Evidence suggests that a strong anti-smoking ethos in schools, families and the wider community is important in preventing smoking uptake. ONS figures show that the majority of smokers start while in their teenage years with very few new smokers beginning after the age of 20.

Many factors contribute to an increased likelihood of young people starting to smoke. School-based programmes have been found to have some effect in reducing smoking uptake but may be limited if they are based on educational approaches alone. Promoting a non-smoking community and reducing access to tobacco for under-18 year olds are important to youth prevention.

The tobacco control plan for England makes it clear that one of the most effective ways to reduce the number of young people smoking is to reduce the number of adults who smoke. Continuing to encourage adult smokers to quit must therefore remain an important part of reducing prevalence amongst the young, and achieving a smokefree generation.”

There is a separate commissioning support pack for young people’s drug, alcohol and tobacco use that should be read alongside the principles and questions in this guidance.

6.3 What you will see locally if you are meeting the principle

Every learning institution has a clear anti-smoking ethos that applies to everyone who comes into contact with the institution.

Educational content implemented in learning environments ensures that young people understand the short and long-term health, and the economic and societal consequences of tobacco use. This can be achieved within the school curriculum.

Targeted peer mentoring programmes are implemented in areas of greater need.

A reduction in the availability and affordability of tobacco for young people see Section 12: Tackling cheap and illicit tobacco.

6.4 Questions to check if you are following evidence and best practice

Does tobacco prevention work in schools follow the NICE evidence base by promoting a non-smoking community?

Do schools have a clear anti-smoking ethos that is backed by a clear policy on tobacco?

Do schools include tobacco education as part of the curriculum?

Has consideration been given to using peer-led smoking prevention programmes?

Are frontline workers in schools and youth settings trained to discuss smoking with young people?

Do you monitor compliance with retail legislation for tobacco?

Is training and information offered to retailers to maintain or strengthen compliance with point of sales legislation?

Is your monitoring and enforcement of point of sale legislation intelligence-led?

Are systems in place to identify and report sales of illicit tobacco locally? Further prompts are provided in Section 12: Tackling cheap and illicit tobacco.

7. Primary care

7.1 Statement of principle

Primary care remains a main source of evidence-based advice and support about smoking and action must be properly integrated with other tobacco control activities.

7.2 The continuing role for primary care

According to NICE, approximately 90% of patient interaction with the healthcare system in England is with primary care services. Smoking is responsible for many fatalities from cancer, respiratory and circulatory disease but there are also many non-fatal diseases which are intensified as a result of smoking. So it’s likely that a higher proportion of smokers will present to primary care services, many of whom will have illnesses caused or aggravated by smoking.

The majority of smokers want to quit and around a third make a quit attempt each year. However success rates are low, as most use the least effective quitting methods. There is a significant opportunity to direct smokers motivated to quit to more effective methods of cessation, for their individual benefit and to support the sustainability of services.

7.3 What will you see locally if you are meeting the principle?

GPs identifying smokers, delivering very brief advice and following up, where appropriate, with a referral into stop smoking services, in accordance with NICE guidance NG92 ‘Stop smoking interventions and services’.

GPs offering advice on using nicotine-containing products on general sale, including NRT and e cigarettes, in accordance with NICE guidance NG92.

All evidence-based support options are available to smokers through primary care and smokers are clear about what they involve and the benefits of each.

There are effective referral routes into specialist stop-smoking support.

As part of the NHS Health Check for adults aged 40 to 74, all smokers are given advice and offered a referral to their local stop smoking service.

Patients who decline support are advised to reduce their smoking with the aid of a licensed nicotine product or, if they prefer, an e-cigarette.

All GPs have completed the NCSCT ‘Very brief advice on smoking’ online training module.

7.4 Questions to check if you are following the evidence and best practice

Is the smoking status of all patients known?

Are records routinely updated to ensure that the smoking status of all patients is accurate?

Are all patients who smoke offered very brief advice on stopping smoking?

Are patients who smoke offered advice on using nicotine-containing products on general sale, including NRT and e cigarettes?

Is there access to a freely available and evidence-based stop smoking service for everyone who smokes or uses tobacco in any other form? Further prompts are provided in Section 2: Supporting people to stop smoking.

Have any barriers to accessing stop smoking support been identified?

Is referral to a stop smoking service made where support is required?

Is referral recorded on the patient’s records and is the outcome of the intervention recorded?

Have all in-house stop smoking practitioners been trained to NCSCT standards?

8. Secondary care

8.1 Statement of principle

Smokers attending secondary care are usually in most urgent need of encouragement and support to stop and should routinely be offered support. Inpatients should be treated for their tobacco dependency and offered quit support that continues after discharge.

8.2 Smoking cessation support should be integral to secondary care

Stopping smoking at any time has considerable health benefits for people who smoke and those around them. For people using secondary care services, there are additional advantages. These include shorter hospital stays, lower drug doses, fewer complications, higher survival rates, better wound healing, decreased infections, and fewer re-admissions after surgery, according to the British Thoracic Society’s report ‘The case for change’,.

Secondary care providers have a duty of care to protect the health of people who use or work in their services and to promote healthy behaviour among them. This duty of care includes providing effective support to stop or abstain from smoking while using or working in secondary care services (NICE guidance PH48).

8.3 What you will see if you are meeting the principle

Smokers who attend secondary care settings are offered advice and support to stop.

All hospitals have an onsite stop smoking service that provides intensive behavioural support and pharmacotherapy as an integral component of secondary care.

Integrated care pathways exist that allow for a seamless transition of care between primary and secondary settings.

Stop smoking medicines are available on hospital formularies and available to support people experiencing nicotine withdrawal when in hospital.

There are no designated smoking areas or smoking breaks allowed by staff for anyone using secondary care services.

All secondary care estates are designated completely smokefree and the policy is clearly communicated to all patients, staff and visitors.

Policies on e-cigarette use make a clear distinction between smoking and vaping, and support smokers to quit smoking and stay smokefree while managing identified risks.

Local tobacco control strategies include secondary care as a main point of contact for smokers.

8.4 Questions to check if you are following evidence and best practice

Do local tobacco control strategies include secondary care? Do these strategies employ contractual levers such as the Preventing ill health by risky behaviours – alcohol and tobacco CQUIN?

Is information on the smoking policies and available stop smoking support provided to patients before they enter secondary care?

Is there a mandatory training programme for all frontline healthcare staff to know and use very brief stop smoking advice and, where possible, train in motivational interviewing for behavioural change, to Make Every Contact Count (MECC)?

Do health and social care practitioners in all acute, maternity, public health and mental health services – including community services, drug and alcohol services, outpatient and pre-admission clinics – identify people who smoke and offer help to stop?

Are people who are not willing or able to stop completely provided access to harm reduction strategies and pharmacotherapies to support them?

Do hospital staff routinely provide information and advice for carers, family and other household members and hospital visitors on the services available to help them stop smoking?

Are all stop smoking medicines available as first-line treatment for people who are in hospital?

Are referral systems in place that provide a prompt for action (including the referral of people to stop smoking support) and that ensure smoking status is consistent in all patient records? Are these records stored in a way that helps them to be easily accessed and audited?

Do directors, senior managers and clinical leads provide leadership on stop smoking support?

Do all secondary care sites have smokefree grounds or do they have a plan to achieve this status within the next 6 months?

Are policies on e-cigarette use consistent with PHE advice?

Do secondary care providers act as examples of best practice?

Are staff provided with support to stop smoking?

Has the local authority undertaken a CLeaR deep dive review of smoking in acute settings with all relevant partners?

9. Mental health

9.1 Statement of principle

A comprehensive tobacco control strategy provides high quality evidence-based interventions to people who need it most.

9.2 Smoking and mental health problems

People with a mental health condition die on average 10 to 20 years earlier than the general population. A joint report by the Royal College of Physicians and the Royal College of Psychiatrists estimates that a third of all cigarettes smoked in England are smoked by people with a mental health condition. Smoking among this population has changed little, if at all, over the past 20 years and in 2014 to 2015, smoking prevalence among people with a serious mental illness was 40.5% according to the Local Tobacco Control Profiles.

People with a mental health condition are just as likely to want to stop smoking as those without, but are more likely to be addicted to smoking and more likely to think it will be difficult to stop smoking.

There is an urgent need to address the widening inequalities which remain from high smoking rates among this population. If these inequalities are going to be reduced, it’s essential that smokers in mental health services are routinely identified and offered evidence-based support, which is based on NICE guidance PH48.

9.3 What will you see locally if you are meeting the principle?

NICE guidance relating to smoking cessation and tobacco control is implemented fully in all aspects of care for individuals with a mental health condition.

People with a mental health condition are provided with the same, or better, opportunities to access smoking cessation support services as the general population.

These services provide outcomes that are comparable to those experienced by the general population.

Effective links between primary and secondary care provision, resulting in integrated tobacco dependence treatment pathways.

Providers of mental health services have an excellent understanding of what they need to do in relation to smoking cessation and smokefree environments.

Smokefree signage and application of policy is clear and consistent throughout the estate, with high levels of compliance.

Policies on e-cigarette use make a clear distinction between smoking and vaping, and support smokers to quit smoking and stay smokefree while managing identified risks.

Those people who do not want or are unable to stop smoking in one step are offered other strategies to reduce the harm of tobacco, as outlined in NICE guidance PH45.

9.4 Questions to check if you are following evidence and best practice

Has NICE guidance PH48, which supports mental health trusts’ implementation of smokefree policies, been followed and have staff and patients had an opportunity to voice and overcome their concerns?

Has consultation with appropriate stakeholders, including service user groups, influenced the design of services?

Do you understand enough about the needs of people with a mental health condition who smoke to ensure that services are appropriately commissioned?

Do senior clinicians support and champion the process of identification, referral, intervention and follow-up?

Do all staff in mental health settings receive training on brief interventions for smoking cessation, and medical and nursing staff receive more extensive training in smoking cessation?

Are smokefree mental health units an integral part of a health-promoting culture, providing alternative, meaningful activity during the day?

Are policies on e-cigarette use consistent with PHE advice?

Do specialist cessation services for people with a mental health condition achieve results comparable with the best services nationally?

Are users of mental health services able to access stop smoking medications?

Are outcomes monitored in such a way as to ensure that they reduce health inequalities?

Has the NHS trust undertaken a CLeaR deep dive review of smoking in mental health settings with all relevant partners?

10. Offender health

10.1 Statement of principle

A comprehensive tobacco control strategy provides high quality evidence-based support to those people who need it most.

10.2 Offenders tend to have poor physical and mental health and high smoking rates

Nationally around 80% of prisoners smoke compared with 15.5% in the general population, with similar levels recorded across the offender journey in police custody and community supervision where data is available. See ‘Healthcare issues of detainees in police custody in London, UK’.

This high rate of smoking causes health problems to the smokers themselves and to non-smokers who are exposed to their tobacco smoke. The offender population has a high prevalence of poor mental health and substance misuse according to ‘Substance misuse among prisoners in England and Wales’, and offenders are predominantly from disadvantaged backgrounds (see ‘Health indicators in a prison population: Asking prisoners’, all of which are associated with high smoking prevalence. Offenders who smoke and those exposed to this smoke experience a marked increase in health inequalities.

In September 2015, the Prisons Minister announced the roll-out of smokefree prisons across England and Wales. Three years later in September 2018, the last few prisons in England joined the rest of the estate in providing custody within entirely smokefree environments.

The smokefree prisons estate provides the opportunity for around 200,000 people each year to experience life free of smoke. For many of these, this will be their first ever opportunity to do so. Healthcare and prison staff across the estate have received evidence-based training to support smokers to quit. Nicotine replacement is available on prescription and electronic cigarettes are available to buy in the prison canteen.

NHS England published the healthcare service specification ‘Minimum offer for stop smoking services and support in custody’. All prisons are expected to meet this minimum service offer. It supports the work programme to reduce smoking in prisons and is aimed at standardising the approach and quality of smoking cessation services delivered in prisons. This document defines standards for training, interventions and pharmacological support for smoking cessation to be adhered to by stop smoking services in all prisons.

10.3 What you will see if you are meeting the principle

NICE guidance relating to smoking cessation and tobacco control is implemented fully in all aspects of care for those within the justice system.

People in prison, custody or under community supervision are provided with the same, or better, opportunities to access stop smoking support services as the general population.

People in prison, custody or under community supervision report that the services provided are accessible, suitable and address their specific needs.

Nicotine-containing products including e-cigarettes are available and offered to smokers entering custody for the first time and their availability is maintained through the offender pathway.

Staff working within the criminal justice system have a full understanding of what services they are required to deliver.

People who do not want to or are unable to stop smoking in one step should be offered other strategies to reduce the harm of tobacco, as outlined in NICE guidance PH45.

10.4 Questions to check if you are following evidence and best practice

Do NHS England Health and Justice and local authority commissioners work together to ensure that there are robust arrangements in place to support people who need smoking cessation services as they move between custody and the community?

Has NICE public health guidance been followed?

Has consultation with appropriate stakeholders, including groups representing offenders, influenced the design of services?

Are the needs of people in prison, custody or under community supervision sufficiently well understood to ensure that services are appropriately commissioned?

Do governors, senior management and senior clinicians support and champion the process?

Do all staff in prison, custodial and community settings receive training on brief interventions for smoking cessation, with medical and nursing staff receiving more extensive training? This should also include training staff in prison settings, in particular health providers, listeners and peer supporters.

Are the stop smoking services delivered in line with the ‘Minimum offer for stop smoking services and support in custody’ document?

Do specialist cessation services for people in prison, custody or under community supervision achieve results comparable with the best services nationally?

Are outcomes monitored to ensure that they reduce health inequalities?

Do services achieve the desired outcomes?

Are those people who do not want to or are unable to stop smoking in one step offered other strategies to reduce the harm of tobacco, as outlined in NICE guidance PH45?

Are stop smoking services in the community linked to prison-based services to provide post-release support?

11. Workplace interventions

11.1 Statement of principle

Interventions delivered in workplaces will encourage more people to access support to stop smoking, reduce absenteeism and increase productivity.

11.2 Workplaces can be important settings for promoting smoking cessation

Smoking has a significant impact on business productivity. It is estimated that smoking breaks and smoking-related sick days cost businesses in England around £6.8 billion a year. Reducing levels of smoking among employees will help reduce illnesses and conditions such as cardiovascular and respiratory disease, which are important causes of sickness absence. This will result in improved productivity and a reduced burden on employers and employees.

The workplace has several advantages as a setting for smoking cessation interventions, including:

• large numbers of people can be reached (including groups which may not normally consult health professionals, such as young men)
• the potential to provide peer group support
• a non-smoking working environment encourages people who smoke to quit (see NICE guideline PH5 and NICE quality standard QS82)

11.3 What you will see if you are meeting the principle

A widely accessible stop smoking service available to all employees.

Employers supporting employees through quit attempts allowing them time off to attend stop smoking services.

Where demand is identified, stop smoking clinics delivered on site in workplaces.

Smokefree working environments and comprehensive smokefree policies are consistently enforced.

Policies on e-cigarette use make a clear distinction between smoking and vaping, and support smokers to quit smoking and stay smokefree while managing identified risks.

11.4 Questions to check if you are following the evidence and best practice

Is support for smoking cessation established in local workplace wellbeing initiatives?

Is there communication between the stop smoking service and local employers?

Have barriers to accessing stop smoking support from the workplace been identified?

Are employees routinely provided with information on local stop smoking support services? Are staff allowed time off to attend stop smoking services?

Do larger employers in the area allow the local stop smoking services to attend events to offer very brief advice?

Are public sector smoking policies an exemplar to other local employers?

Does your policy facilitate the use of licensed nicotine replacement therapy in the workplace?

Is your policy on e-cigarette use consistent with PHE advice?

Are all employees protected from secondhand smoke in their workplace, including those who provide home visits, or visit other workplaces?

Is your smokefree policy regularly reviewed and updated if necessary?

12. Tackling cheap and illicit tobacco

12.1 Statement of principle

The local authority has established partnership arrangements with other local authorities and external partners which focus on reducing the demand for and the supply of illicit tobacco.

12.2 Illicit tobacco is a problem which needs local action

The illicit tobacco market is in long-term decline but remains a problem in some communities. It undermines tobacco control measures, including taxation and age of sale regulations. This can lead to children starting a lethal addiction and encouraging smokers to smoke more than if they were paying full price. Criminal activity in the illicit trade tends to target smokers in deprived areas, further increasing health inequalities.

Effective approaches are co-ordinated across some large geographical areas where health and enforcement partners collaborate to reduce the demand for and the supply of illicit tobacco. Evidence-based social marketing and public relations campaigns have raised awareness of the issue in these areas, helped to generate intelligence and have provided the facts on illicit tobacco by countering the misinformation circulated by the tobacco industry.

12.3 What you will see if you are meeting the principle

Full engagement between public health, police regional intelligence units, trading standards, licensing and Her Majesty’s Revenue & Customs to improve the intelligence base.

Active intelligence-led enforcement in the locality, accompanied by communications to build support in the local community and encourage people to report perpetrators of illicit tobacco crime.

A greater awareness and understanding of the impact of illicit tobacco among partner organisations and the general public.

Clear data and intelligence on the levels of demand for illicit tobacco which helps to target priority communities.

Increased reporting of illicit tobacco by the general public.

12.4 Questions to check if you are following the evidence and best practice

Have local or regional measures been established to assess the impact of activity, including quantity of information received from the public, seizures and enforcement activity, and increased partnership working between agencies?

Have local or regional evaluation surveys been conducted to measure the impact of activity? Do these include the establishment of a baseline?

Is there a safe, anonymous intelligence-sharing resource available for the public and partner agencies to use?

Is there a dedicated budget for illicit tobacco enforcement activity and social marketing activity?

Is there collaboration on illicit tobacco between local areas within the region?

Has a public opinion and stakeholder survey been carried out on illicit tobacco?

Do the local trading standards authorities and police forces recognise tackling illicit tobacco as a strategic priority within broader tobacco control work?

Is there a local or regional policy in place on the WHO Framework Convention on Tobacco Control Article 5.3, to protect policies from the vested interests of the tobacco industry?

13. Smokefree outdoor spaces

13.1 Statement of principle

Where smokefree outdoor places are introduced, this should happen within an evidence based approach to tobacco control and with rigorous evaluation.

13.2 There is mixed evidence on the benefits of outdoor smokefree spaces

The health impacts of outdoor secondhand smoke are contested. Exposure to secondhand smoke outdoors can be high in some conditions (a high density of smokers, enclosed outdoor locations, low wind and close proximity to smokers).

There is very limited UK research available about the effectiveness of smokefree outdoors as they are less widely adopted here than internationally. Evidence from other countries suggests that levels of support can vary considerably according to type of place and respondent’s personal characteristics.

Attitudes towards smokefree outdoor places do not necessarily translate into behaviour change. Compliance can be low, even when a policy is mandatory. There is some evidence for positive effects on behaviour where some reductions in smoking prevalence have been seen in student populations following the introduction of a smokefree campus.

There should be a clear distinction between smoking and vaping. E-cigarettes can be helpful for abstinence from smoking and could be encouraged in places where smoking is prohibited.

More evidence is needed. If local smokefree outdoor policies are implemented, rigorous, peer reviewed evaluations will help to develop this.

13.3 What you will see locally if you are meeting the principle

Local policies and plans on smokefree outdoor places have clear intended outcomes and rigorous evaluation in place to see if these outcomes are met.

Where smokefree outdoor spaces are introduced they are within a wider tobacco control strategy.

There is a clear distinction between policies on smoking and vaping.

13.4 Questions to check if you are following evidence and best practice

Is your smokefree outdoor policy based on the best available evidence?

Do you have clear outcomes for your smokefree outdoor policy and an evaluation plan in place to assess if these are met?

Is there a clear distinction between smoking and vaping in your outdoor smokefree policy?

14. CLeaR model for tobacco control

CLeaR is an evidence-based improvement model that supports local action to reduce the use of tobacco. The model is designed for use by local authorities, tobacco alliances and NHS partners. The CLeaR model offers:

1. A free-to-access self-assessment tool that can assist in evaluating the effectiveness of local action addressing harm from tobacco - a major aspect of any health and wellbeing strategy.
2. An opportunity to bring local partners together to discuss the range of local tobacco control efforts and reinforce efforts and priorities.
3. A voluntary peer assessment process, which provides independent challenge to self-assessments and access to a recognised quality mark.
4. A chance to benchmark work on tobacco over time and against others.

CLeaR was updated in November 2017 to make it more relevant to all partners working in tobacco control. As part of the work, a series of “deep dive” tools were developed. These tools follow the same design as the generic CLeaR improvement tool but, rather than cover the breadth of tobacco control, they focus on specific issues. They currently cover:

• smoking in pregnancy
• smoking in acute settings
• smoking in mental health settings

A fourth deep dive tool, looking at tackling illegal tobacco, is currently in development. These deep dives can help localities to focus on topics of particular challenge, and will support broader NHS efforts on the smokefree agenda, as well as compliance with the requirements of CQUIN.

A guide to the CLeaR process, along with the self-assessment tool and deep dive tools, can be found online.