Developing a system-wide tobacco control programme
ASH has developed a series of resources designed to assist areas aiming to collaborate on tobacco control at a supra-local level.
We are proposing models of tobacco control that focus on evidence-based activities which are best enacted at scale in order to drive down rates of smoking further and faster. They are not designed to replace or duplicate activity at a local authority level but instead should add value to current work.
These resources include:
- “Creating conditions for success" poster
- Directors of Public Health briefing paper
- Local authority mapping template
- Budget calculations template
- Paper to an Integrated Care Board (ICB) board
- "Making the case” slide set
- Supporting spreadsheet
- "Building the strategy” slide set
- “Fresh programme overview” slide set.
More than a quarter of all deaths in the UK in the last 50 years were due to smoking. As smoking is the leading cause in the difference in life expectancy between the most and least deprived in society, reducing it is key to tackling health inequalities. There is a national target to achieve a Smokefree 2030, where smoking prevalence is below 5% across all demographic groups. A representative survey for ASH found that 74% of the public support this ambition. The policy action required to achieve a Smokefree 2030 was set out in the independent Khan review in 2022.
Unfortunately, current modelling suggests that the Smokefree 2030 target is likely to be missed by 9 years. Furthermore, cuts to the public health grant have resulted in a greater than 40% reduction in spending on tobacco control and stop smoking services. Many key recommendations in the Khan review were not adopted into national policy in the government’s recent announcement on tobacco control.
Many recommendations in the Khan review can be delivered through a collective approach at Integrated Care System (ICS) or wider regional level. This collective action provides an opportunity for areas to make progress towards a smokefree 2030 beyond that achievable at a local level. For ICSs, reducing smoking prevalence is key to tackling health inequalities through the Core20PLUS5 approach.
Regional programmes have demonstrated success in reducing smoking prevalence faster than areas without regional programmes. The first of these programmes, Fresh (Making Smoking History) in the North East, has been running since 2005 and has achieved a reduction in adult smoking prevalence from 29%, at the time of the programme’s launch, to 15.3% in 2019. Meanwhile Greater Manchester’s strong investment in mass media campaigns has been associated with a higher rate of quite attempts. Newer programmes now also exist in London and Humber and North Yorkshire. These programmes employ a variety of funding models including:
- Pooled local authority funding (London)
- A combination of local authority funding matched by ICB health inequalities funding (Fresh (Making Smoking History))
- ICB health inequalities money only (Humber and North Yorkshire).
In 2022, ASH released a report Delivering a Smokefree 2030: The role of supra-local tobacco control which outlined interventions best delivered on regional, or sub-regional levels and factors associated with success of such programmes.
To get started, the “Creating Conditions for Success” poster outlines the pathway to a system-wide tobacco control programme (using ICB health inequalities funding), including the building blocks for success, stages of development and stakeholders to consider.
Setting up a programme will require a dedicated and suitably senior individual to drive progress, apply for funding, and bring stakeholders on board. Ideally this will be a public health professional situated within, or working in close relationship with, an ICB (if planning to apply for ICB health inequalities funding) with strong links to local authorities.
Local Directors of Public Health (DsPH) will be key drivers of any regional programme, acting as champions and leaders to bring together different agencies to take a partnership approach to tobacco control. The “Directors of Public Health briefing” can help to make the case to DsPH and bring them into the planning process.
Choose a geography
The introduction of ICSs and ICBs presents an opportunity for collaboration across the system. These resources are therefore primarily designed to take advantage of ICB health inequalities funding using the Core20PLUS5 framework at an ICS level, but they can also be translated to wider regional collaboration.
One consideration when choosing a geography to collaborate across, would be media boundaries. If collaboration was to be at a level that aligned with media boundaries, this would achieve the best value from pooled funding for mass media campaigns. Other relevant geographies to think about include trading standards groupings, Association of Directors of Public Health (ADPH) networks, HM Revenue and Customs (HMRC) and policing boundaries. For some places the role of Combined Authorities will also be important.
Understand existing activity
A regional programme should not replace, nor duplicate, activity done at a local level - it should have a dedicated programme of work. Therefore, when planning a programme, it is important to understand existing tobacco control activity across the places within the region or ICS. The “Local authority mapping template” can be used to facilitate discussions with local authority tobacco control leads and trading standards officers to achieve this.
Progress within the region on the NHS Long Term Plan (LTP) should also be mapped. This can be through the LTP dashboard or through discussion with those coordinating the LTP within the ICB or trusts.
This mapping will help in the early stages of a programme to establish roles and responsibilities across the agencies working in partnership.
Making the case and applying for funding
You will need to identify a funding source and secure the funding for the programme. Our suggested funding source is the ICB health inequalities funding, which uses the Core20PLUS5 approach. However, joint funding with local authorities or pooled local authority funding could also be considered.
It is important to note that activity at system level is not intended to replace the delivery at place in either the NHS or local authorities. Supporting smokers to stop and other place-based activity remain important parts of a comprehensive approach to addressing smoking.
Once a funding source has been identified, the “budget calculations template” can assist in calculating the level of funding that may be required and broadly how it could be prioritised. In the first year of the programme, lower levels of funding might be considered as it will take time for the full programme to become established. This template is adaptable and the current parameters intended to be guide rather than a fixed requirement.
The “Paper to an ICB board” can be localised to help make the case to an ICB board for directing some of its health inequalities money towards a tobacco control programme, if this is the chosen funding source.
In addition, there is a “making the case” slide set, which can also be personalised to outline the need for supra-local collaboration on tobacco control to wider stakeholders.
The “supporting spreadsheet” will help you identify and calculate key statistics for your area (where the area aligns with a group of local authority boundaries) to allow the “making the case” slide deck and the “Paper to an ICB board” to be adapted for your area. The “budget calculations template” will also help to inform the “Paper to an ICB board”.
Agree on a hosting organisation
A host organisation will be needed to employ staff to run the programme. Possible organisations include:
- The ICB
- An NHS trust within the ICB
- A local authority.
Developing the programme
To help develop the programme’s strategy, we have a “building the strategy” slide set, which outlines effective interventions for reducing smoking. We recommend that a regional programme focuses on those activities that are best delivered at scale, such as action on illicit tobacco and mass media campaigns and marketing. However, local contexts may vary and there may be identified gaps or regional priorities that should be included. The aim of these resources is not to be prescriptive but to provide guidance.
We have included two case studies within the resources. The “Fresh programme overview” slides outline the approach of the longest running regional tobacco control in the UK, which has demonstrated its effectiveness over 18 years. Meanwhile the newly established Humber and North Yorkshire programme’s proposed strategy is included within the “building the strategy” slide set. This programme was developed in collaboration with ASH and shows how the ASH pillars of regional working can be adapted locally to produce a new programme.
We would like to thank Fresh-Balance in the North East, Make Smoking History in Greater Manchester, and programmes in London and Humber and North Yorkshire for their input into the development of these resources.