England has achieved a consistent decline in smoking prevalence through comprehensive activity at national, regional and local levels with adult smoking rates falling from around 45% in 1974 to 14.4% in 2019. However, smoking still kills around 78,000 people a year. Differences in smoking rates are the leading cause of health inequalities between rich and poor and expenditure on tobacco is pushing households into poverty. Comprehensive local action is needed to achieve the Government’s ambition for England to be smokefree by 2030 and narrow the gap in health inequalities between the richest and poorest.
This roadmap sets out the resources available for local tobacco control alliances to deliver comprehensive evidence based activity to support prevalence reduction and work towards a smokefree generation.
If you have any questions regarding this resource, would like contact details for the local authority case studies featured in it or have any other questions on tobacco control alliances and partnerships, don’t hesitate to get in touch by e-mailing:
Comprehensive tobacco control is a coordinated, multiagency approach to reducing smoking prevalence and the harm from tobacco. There are six internationally recognised strands of tobacco control work, the World Health Organization sets these out in the MPower framework:
These reflect the six strands set out by the World Bank framework for tobacco control, which formed the basis of the 2011 Tobacco Control Plan for England, Healthy Lives Healthy People, these are:
Tobacco control is most effective when localities are able to consider and act on all of these components. The North East regional tobacco control office, Fresh, has based activity on, and added to, the World Bank six strand approach, while Greater Manchester has based its strategy on the MPower framework.
Alliances are local partnerships working to reduce smoking rates and tackle health inequalities, they typically include a wide range of members from inside and outside local authorities.
They can operate across local authority, STP, ICS, regional or other footprints.
These example Terms of Reference should give you an idea of the scope of Alliance work and membership:
A broad range of partners is key to being able to deliver on each of the six elements of comprehensive tobacco control and alliances function best when there are a range of multi-agency partners around the table who can contribute to this agenda.
The first step for establishing an alliance is therefore to identify the local partners you want to get involved:
Building relationships is key to establishing an Alliance (see ‘Suggested membership‘ above). These short briefings should help you engage with colleagues in:
Establishing face-to-face meetings to bring these partners together initially can be a useful first step for engaging partners within an alliance.
Building these relationships and getting partners involved in alliance activity is a key way to ensure tobacco becomes a priority across local authorities and partner organisations and creates advocates for tobacco control activity outside of public health teams.
Using national hooks such as the Saving Babies’ Lives Care Bundle, or key media opportunities like Stoptober can be a good time to bring new partners to the table.
Partners may also engage through other networks such as Local Maternity Systems that link into and provide updates to the Alliance. For more on this see ‘Issue focused collaboration’ (below).
When trying to engage new partners or make the case for tobacco control with elected members, there are a range of data orientated tools and resources that you may find helpful.
Local authority level data:
Regional level data:
Check out the ‘Local data’ box (above) for local statistics to help you make the case for tobacco control and ASH’s Local Toolkit for further resources and materials.
Getting buy-in to a local alliance from senior leaders both within and outside a local authority can help ensure there’s broad membership and be key to an alliance’s success.
Establishing links into Health and Wellbeing Boards and Health Scrutiny Committees and making tobacco a priority area to report on will give this agenda momentum and ensure senior colleagues are receiving regular updates on activity. Identifying these reporting channels should also ensure the alliance is reporting into NHS structures, such as ICS prevention boards.
Across broader footprints, having tobacco as a priority within STP/ICS prevention strategies will be key to ensuring smokers in the NHS are getting the support and treatment they need in line with the commitments set out in the NHS Long Term Plan.
Engaging senior leaders can also increase accountability. Having elected members chairing alliance meetings makes them partially accountable for alliance activity and helps ensure there’s someone in the room that can hold others accountable for their activity.
See more on accountability under ‘Governance: running your alliance’ (below).
Directors of Public Health (DPHs) are key stakeholders and establishing their relationship or role within an alliance can be a key determinant of its success.
DPHs have a strategic role in relation to health inequalities and working to quantify and illustrate the impact of tobacco control upon local health inequalities will help present a strong case for their involvement.
Check out the Health Inequalities Resource Pack to help you make this case.
Engaging councillors in your local alliance is often an effective way of raising and maintaining the profile of tobacco control across the council or wider regional partnership.
Having an elected member as Chair of the alliance will help provide strategic leadership and accountability.
These Councillor briefings set out the evidence-base on tobacco control issues such as illicit trade, local costs of smoking and smoking related litter and point towards actions the council can take to reduce smoking related harms. These can be used to engage a range of councillors in the work of an alliance depending on their priorities and interests.
Research by ASH and Cancer Research UK has found that political support for tobacco control in local authorities can mitigate – though not remove – the threat of budget cuts.
Smokers see their GP a third more than non-smokers, making the support smokers are offered in primary care very important.
As commissioners, CCGs are key partners to ensuring smokers receive evidence based support in both primary and secondary care.
Leaders within CCGs can help ensure that treating tobacco dependence is embedded in contracts and activity monitored.
Ideally, all alliances should have a CCG representative but if this isn’t possible, ensuring that the alliance has a named contact to report into and liaise with at the CCG is crucial.
Primary Care Networks are also increasingly important. Pooling primary care resources and capacity across these footprints should create scope for broader engagement on public health. Engaging PCNs prior to introduction of the Health Inequalities specification in 2021/22 should help ensure PCNs build smoking cessation into this activity.
NHS Trusts are key delivery partners. The Tobacco Control Plan sets the ambition for all Trusts in England to be smokefree by April 2020, through comprehensive implementation of “tobacco dependence treatment pathways” in line with NICE Guidance PH48.
This will help ensure successful roll-out of The NHS Long Term Plan commitments on smoking, which should help making treating tobacco dependency a priority for NHS colleagues. While full LTP funding won’t be in place until 2023/24 all partners should be making progress ahead of this deadline.
Clinical champions for are important for driving forwards this agenda. As well as individual clinicians, post-holders such as ‘Maternity Safety Champions’ can be useful contacts for this.
Having Alliance representation from local acute or mental health trusts and maternity teams enables collaboration and helps ensure colleagues see tobacco control as an ‘NHS issue’.
It’s important for local areas to have a local ambition for tobacco control, articulated in a vision or strategy.
In areas such as the North East where they have a regional ambition, all localities have individually committed and signed-up to this ambition.
In areas where there aren’t regional tobacco control structures, local authorities should use their local data and experience to articulate local strategies and prevalence reduction targets.
Considering timing when developing your strategy is important. If you are establishing an alliance and want to engage new partners in writing the strategy or are looking for partners’ input with an update, thinking about how this fits into broader council and organisational timeframes will be important for engagement.
There is real variety in how local authorities set out their strategies and how they collaborate to produce these; below are some local and regional examples.
N.B. Lancashire’s strategy links to an old ADPH position on e-cigarettes, an updated version is available here.
ASH and Fresh have published a strategic guide for local areas, The End of Smoking, highlighting where local strategies should focus and setting out the three key components for local prevalence reduction:
Local plans should include activity in each of these areas to ensure appropriate support is reaching all smokers in your local population, and not just those engaging with formal services.
For an overview of prevalence reduction and how it works, check out this video from Professor Robert West at University College London.
Further strategic guidance
In addition to longer term visions and strategic goals, effective alliances should have action plans setting out the activity which will take place over shorter time frames, eg. this quarter, in the next two quarters or this year.
Action plans can take different forms but consolidating actions which will deliver against the strategic vision and incorporate evidence based activity across the six key strands of tobacco control is important to ensuring Alliances are taking a comprehensive approach to tobacco control.
Giving Alliance partners ownership of actions can be a key way to ensure their engagement, especially if they’re asked to provide updates on activity at meetings with senior leadership presence.
The frequency of alliance meetings varies as does whether alliances meet physically or via virtual networks. Sending out dates well in advance can help with engagement.
Ensuring meetings are held, even when some partners aren’t able to attend can keep-up momentum and ensure that people expect to be invited.
Alliances should be a supportive environment. Part of the role of an Alliance is to enable partners to work through challenges together and progress activity through action focused meetings.
Ideally, alliances should regularly meet face-to-face. However, virtual networks can be effective through teleconferences with actions, minutes and reporting.
Alliances where actions are not regularly reported on, shared and updated can lose momentum – this may be more likely with a virtual alliance where partners commitments to joining meetings are lower.
Buckinghamshire have been working to re-establish their alliance through workshop style meetings and engaging partners using the ‘Rose, Thorn, Bud’, design approach.
Background: Within Buckinghamshire the local Tobacco Control Alliance ceased over 3 years ago. The first workshop held was to launch the new Buckinghamshire Tobacco Control Strategy and re-establish an alliance. This was an exciting opportunity to bring a wide range of partners together.
Aims: The aim of the workshop was to introduce the new Strategy and give an overview of the wider picture, to bring together the supporting action plan and to share information on the most recent tobacco control issues. 14 delegates attended from over 10 different local organisations. 100% of participants agreed that they found the meeting useful.
Rose, Thorn, Bud approach: This process asks participants to look at something from three different perspectives:
This can be a good way of getting partners involved and encouraging participants to look at issues from different perspectives.
The second Buckinghamshire Tobacco Control Alliance meeting featured four different presentations, one from each ‘Area of Action’ within the Strategy, covering topics from supporting smokers to quit to illicit tobacco.
Participants were actively engaged in the presentations by using the ‘Rose, Thorn, Bud’ approach to feedback for each presentation, which was then discussed as a group. The benefits of this method ensured participants were engaged throughout, and it was a useful way to gather a large number of ideas for consideration.
Internal communication: Communication between alliance members is key to keeping the alliance working cohesively; sharing resources from meetings but also updates from other work relevant to tobacco control between meetings is useful. Publicising alliance activity within councils and partner organisations is a good way to engage senior leadership and ensure they see tobacco control as a priority area and the alliance as active and effective.
Public communication: Understand your local communications, what you have and what you have access to. Use these tools and your partners to help communicate effectively with members of the public e.g. newsletters, social media (Twitter, Facebook). This can be especially important on issues such as illicit tobacco or the introduction of new smokefree spaces.
Media and PR: Media hooks such as the PHE Stoptober campaign provide key set piece opportunities for engagement and activity involving all partners. These campaigns provide further opportunity for collaboration with NHS, STP/ICS communications teams and ensure that they’re aware of local priorities for tobacco control. If partners comms teams are engaged in these campaigns, they’re more likely to publicise and engage with further tobacco control activity.
Shout about successes! These can be specific successes for the alliance or broader local successes such as declines in prevalence. This is important for highlighting the importance of local tobacco control activity and is a good way to engage local leaders.
Tap into your partners networks. Alliance partners such as police forces often have large followings among members of the public and can be a great way of getting your message out. Housing providers also have direct routes into the communities and homes you need to reach.
Develop an alliance brand. Colour schemes, logos, strap lines, means that public and professionals can recognise what this is about. Links to strategy and vision and tying this in. For example, Barnsley uses a ‘Making Smoking History’ message and brand, while seven north east localities share the Fresh Smokefree North East branding.
Benefits of pooling budgets: Tobacco control delivered on regional footprints is evidence based and effective. Pooling budgets to fund public education campaigns can deliver better value for money and reach a greater audience than trying to deliver these campaigns in individual local authorities.
West Yorkshire collaborates on illicit tobacco work. They’ve effectively coordinated activity to run the Keep it Out campaign, reducing demand, increasing and sharing intelligence as well as best practice approaches to enforcement.
The regional tobacco control programme Fresh, in the north east, oversaw a media campaign on the 16 cancers caused by smoking in February 2016, reaching approximately 333,000 people via TV, radio, print and online. 90% of total campaign recall came from TV advertising, compared to 4% on Facebook and 1% online, despite relatively high online budgets. Of those who saw the campaign:
The 16 Cancers health harms campaign was run again in June 2019, across the North of England. This was funded by the NHS North of England Cancer Alliances as a way to support cancer prevention.
The main campaign channel was regional ITV advertising encouraging smokers to visit the Quit 16 website for tips to quit, contact details for local stop smoking services and videos of real people’s stories. Additional digital advertising was funded by PHE.
Partners were encouraged to support and uplift the campaign to maximise awareness. This was co-ordinated by NHS England. A communications tool kit developed by Fresh and NHS England was shared widely with NHS Trusts, CCGs, PHE, cancer alliances, local authorities and other relevant partners in the North of England. This was an effective collaboration at scale.
This illustrates the additional value that can come from pooling budgets and delivering media work on larger footprints.
While alliance formats will vary, establishing where your alliance sits within reporting structures is key to ensuring it delivers on actions and has a direct route to report on progress.
Accountability is also important for improving engagement of partners. Ensuring minutes and records of meetings are circulated and kept up-to-date will help to ensure actions are delivered and partners know what they’re expected to report on at subsequent meetings.
Good governance should also include evaluating new activity or projects. This can demonstrate effectiveness, helping with sustainability, giving you a basis for reporting leaders and add to the evidence base around effective tobacco control interventions.
Having terms of reference, a strategy/action plan which set out targets and a clear framework for reporting against these are key components to effectively governing your alliance. Check out our Monitoring and Evaluation section to see how areas are doing this.
Depending on the footprint of your alliance the organisations and boards it reports into will vary.
Different structures your alliance may want to report into include:
It’s important to establish a flow of communication into these structures so they know what the Alliance is trying to achieve, who you’re accountable to and broader sharing of tobacco control activity and successes.
Tobacco Control Alliances should focus on a comprehensive programme of activity.
Localities often also collaborate with partners on specific tobacco related issues such as smoking in pregnancy, this can ensure there’s focused ongoing work around high priority groups.
These issue focused groups should feed into an Alliance and provide regular updates at meetings.
Having these separate groups working on priority areas, can also help keep attendance at Alliance meetings focused to those who’ll most directly benefit from this collaboration.
Alliances must monitor their activity against both strategies and action plans. This is important for demonstrating progress and can also highlight if new partners need to be engaged, new targets set and workplans updated.
Monitoring activity also gives a reason to report to senior strategic boards on progress and puts tobacco control on their agendas.
Examples of approaches include:
The CLeaR self and peer assessments provide a framework for local authorities to assess how they’re delivering against different tobacco control priorities. It focuses on three key elements:
CLeaR can be used by alliances at many different stages. While establishing new alliances it can be a useful tool for engaging partners, assessing where action is happening and where further activity is needed, it can also be used by more established alliances to reinvigorate particular activity or identify new priorities.
CLeaR Deep Dives are also excellent ways of reviewing activity in key areas. The four deep dives focus on:
For support with CLeaR contact CLeaRTobaccoTeam@phe.gov.uk
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Provides the latest news, evidence updates and event information including commentary on data releases relating to smoking in pregnancy. Co-ordinated by the Smoking in Pregnancy Challenge Group.
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