Major driver of health inequalities in your area of work

Smoking is the largest preventable cause of death and disability, and inequalities in health, in England. It is associated with almost every indicator of deprivation and marginalisation. For example, smoking is more common among:

• People with a mental health condition
• People with a physical long term condition
• People who are unemployed
• People with manual occupations
• People who are homeless
• People who live in rented housing
• People who receive income support
• People in prison
• People with no qualifications
• Single parents
• People who are divorced or separated
• Gay men and lesbians.

Target groups

Deprivation

Intervention

CLeaR

Description

CLeaR is an improvement tool for evidence-based tobacco control that every local health system can use, ideally in partnership with other organisations who are involved in tackling smoking. Local areas should assess themselves against the three CLeaR self-assessment products (‘deep-dives’) that are aligned with the Long Term Plan priority areas for smoking:

• Stopping smoking in acute settings and maternity
• Stopping smoking in mental health settings
• Stopping smoking during and after pregnancy

To implement the CLeaR self-assessments follow the guidance available on GOV.UK

What outcomes is it expected to lead to?

CLeaR deep dive self-assessment which uses a scoring system to help localities evaluate current efforts on specific tobacco control issues, identify areas of good practice, and highlight any gaps in local provision. Implementation of CLeaR is expected to lead to:

• A baseline against which local areas can identify gaps and monitor improvements over time
• Development of locally agreed plans to improve the support that is available to help people to stop smoking
• Improved leadership to oversee implementation of locally agreed improvement plans
• Improved collaboration among local partners to work together to reduce harm from smoking
• Improved compliance with relevant NICE guidance

This should inform local action planning to enable the health system to comply with NICE guidance on smoking, prepare for implementation of the specific commitments within the Long Term Plan, and deliver interventions to patients that will help to address the inequalities caused by smoking.

Evidence

The National Institute for Health and Care Excellence (NICE) use the best available evidence to develop recommendations to improve the health of communities. The CLeaR self-assessments are based on NICE guidance on tobacco control and stop smoking interventions. In particular, the CLeaR deep dives are based upon the following guidance:

Smoking: acute, maternity and mental health services (PH48)

Smoking: stopping in pregnancy and after childbirth (PH26)

Public Health England has published a Health Equity Report. The report provides an assessment of the Public Health Framework Indicator ‘Prevalence of smoking among persons aged 18 years and over’, examining inequalities by sex, ethnic group, religion, sexual orientation, socio-economic classification and deprivation.

Details of the impact of smoking on these 3 deep dive topic areas can be found here:

• RCP report on role of NHS in treating tobacco, “Hiding in plain sight”
• Mental Health and Smoking Action report, “Stolen Years”
• Smoking in Pregnancy Challenge Group, “Review of the challenge”

The CLeaR deep dive tools have been available since November 2017, Since that time, they have been widely used by localities as a mechanism for benchmarking existing activity and driving performance improvement. An analysis of regional adoption of the smoking and mental health deep dive across the East of England concluded that the process, “showed significant progress towards implementation (of Smokefree NHS)”.

Guidance for Commissioners

CLeaR local tobacco control assessment