Published: 24/02/2005, Volume II5, No. 5944 Page 14 15

Politicians have been promising to rid hospitals of smoking for over a decade, but with the public health white paper pledged to deliver a smoke-free NHS by the end of next year good intentions are no longer enough. Jeremy Davies reports that help may be at hand

As long ago as 1992 the Conservative government issued guidance stating that the NHS should create a virtually smoke-free environment for staff, patients and visitors.

Twelve years on, guidance issued by the Health Development Agency has brought the anti-smoking agenda into sharp focus again, challenging trusts to implement more effective policies and thus enable the government to meet its target, set in the public health white paper, of a smoke-free NHS by the end of 2006.

But while few NHS managers would argue against the principle of making the NHS smoke-free, the HDA's own research suggests trusts may have their work cut out to turn the concept into a reality.

A random survey of 80 hospitals, conducted as background to the guidance published last month, found that the vast majority of hospitals already had policies on smoking, but that these varied considerably in scope and were often not being implemented effectively.

Ten per cent of hospitals claimed to be completely smoke-free, which by the HDA's definition means smoking is not allowed anywhere on the hospital premises, including the grounds. But more in-depth research showed that in fact these policies had been allowed to lapse, or that smoking was being permitted in designated smoking shelters or elsewhere outside the buildings.

The remaining 90 per cent of hospitals in the survey were operating partial bans - for example, allowing smoking in dedicated smoking rooms or shelters, or outside the hospital entrance. Partial bans often granted exceptions: for example, for bereaved relatives, long-stay patients and mental health patients; and more than a quarter of hospitals allowed smoking by staff.

One in ten of the hospitals operating partial bans had tried but failed to enforce a total ban, and although 70 per cent of hospitals surveyed thought the NHS should be totally smoke-free within two years, only 11 per cent thought this a very realistic prospect.

The HDA guidance focuses mainly on how to make NHS buildings smoke-free, but NHS chief executive Sir Nigel Crisp has said that including hospital grounds in smokefree policies 'may be considered the ultimate standard to which all trusts might aspire in the near future'; and the HDA lists reasons why completely smoke-free hospitals are a good idea (see box below).

Many trusts are making this their goal (see case study opposite, right), but even those ahead of the game admit that banning smoking altogether can be quite a struggle.

Mary Richings, smoke-free hospital project lead at University Hospitals Coventry and Warwickshire trust, was part of the team that produced the HDA guidance. But she says her trust - which launched itself as smokefree in April 2004 - has yet to achieve that nirvana-like state.

'We still get people smoking at hospital entrances, despite all the signs and information We have provided, ' she says. 'We tried installing audible alarms in the entrance area, but people just ignore them. And We have even tried to recruit an anti-smoking officer.' The aim is to recruit someone to patrol the grounds and encourage anyone smoking to abide by the trust rules. But there have been no applicants to date.

The good news is that enforcement problems tend to involve only a small minority of smokers on site.

Although, stresses Linda Caine, head of commissioning at Norwich primary care trust - the first in the country to go smoke-free, in January 2003 - it is not all plain-sailing.

'We have an ongoing issue about whether staff should be able to go off site for a cigarette, and we do allow them to smoke in their cars in the car park if necessary. But from our own experience and what I've seen of others, there tends to be an unjustified fear from the top to the bottom of NHS organisations that smokers deprived of the right to smoke will get aggressive and stressed. In fact, almost without exception people are very accepting if you consult and implement policies properly.' 'Staff who smoke often take the opportunity presented by a new workplace policy to make a quit attempt, ' adds Jane Sunter, public health development manager working on tobacco control for North, South and Central Manchester PCTs. 'On the whole, people are incredibly enthusiastic, whether they smoke or not.' A programme of smokingcessation support for nurses, due to be launched later this year by the Royal College of Nursing and Department of Health, could offer further support for staff to kick the habit, although only qualified nurses, not nursing support staff, will qualify.

Engaging clinicians in antismoking initiatives can prove one of the biggest challenges, says Ms Caine.

'Over the last four years it has been a big learning process to get all our hospital clinicians to fully grasp the impact of smoking on patient populations and engage with patients on the subject, ' she says.

'GPs and nurses have taken it on board, but some of the hospital doctors have been much more reluctant to talk to patients about stopping - even though there is good evidence that doing so can drastically reduce morbidity and post-operative complications.' Trusts are already some way down the road towards being smoke-free, says the HDA guidance, which identifies five key steps that trusts should focus on (see box below).

Organisations could still face implementation problems with some patient groups, however. Ms Sunter cites mental health inpatients and patients requiring home visits as cases in point: 'There are likely to be areas for negotiation in any smoke-free policy - in mental health facilities sectioned patients may not be allowed to go outside, for example. We need to protect staff, so we might look at providing enclosed spaces and specified smoking times.

'Home visits also need to be thought about, so that patients are encouraged not to smoke when staff visit them. We are making it clear that we would totally back staff who refused to visit where the patient refused to not smoke, and would either find another staff member to do the work or ask the patient to come to us instead.' Enforcing policies that encompass all patient groups may rely, then, on a wider cultural shift against smoking - something which many in the NHS believe would accelerate if the Department of Health were to legislate to ban it in all enclosed public places.

Earlier this month the British Medical Association called again on health secretary John Reid to 'play fair and protect everyone from exposure to second-hand smoke at work', as it published a report detailing the benefits of antismoking legislation in other countries. It highlights that lung cancer rates in California have fallen six times faster than in other US states since smoke-free laws were introduced in 1998; evidence from Norway suggests designated smoking areas and ventilation systems are ineffective; and cigarette sales fell by almost 16 per cent in the first six months of Ireland's ban.

On a practical level, NHS bodies in some areas are already finding greater public acceptance thanks to pioneering local anti-smoking coalitions, says Mike Donnelly, Smoke Free Wirral project officer at Birkenhead and Wallasey PCT.

'Here we are able to set our smoke-free NHS policy in the context of a bigger strategy involving the borough council and local businesses, as well as benefiting from the publicity already gained by the Smoke Free Liverpool bid. All the polls suggest this is what people want, and local initiatives like this will hopefully persuade the government to pass tougher laws.' Legislation alone would never be sufficient to make smoke-free workplaces a reality, warns Rachel Harrison, senior policy and research officer at Action on Smoking and Health Scotland. A bill going through the Scottish Parliament could ban smoking in all NHS buildings and most other public places from April 2006, but ASH still aims to publish guidance for the NHS in Scotland this April once it has collated the results of an ongoing audit of existing antismoking policies.

'We did an audit in the mid-'90s and found that even where policies were in place they were not necessarily working very well, ' she says.

'Legislation can force organisations' hands, but what's important is learning about best practice of how to make policies stick.'

www. hda. nhs. uk


Tobacco smoke pollution kills more than 1,000 smokers a year.

To avoid litigation under the Health and Safety at Work Act 1974 employers have a duty to maintain a safe working environment, which could include protecting against passive smoking.

To help smokers quit, improve their health and thus cut health demands.

To reduce postoperative complications, shown to be higher among smokers.

To reduce costs such as cleaning and extended bed-days.

Staff who smoke take more days off sick and longer breaks.

The majority (84 per cent) of patients want smoke-free hospitals.

Source: Health Development Agency


1 Commit to the policy

Identify a champion responsible for implementing the policy.

Secure visible senior commitment.

Set up a working party.

Identify human and financial resources.

Consider the pros and cons of including grounds in the policy.

2 Create the policy

Consult with all parties.

Anticipate and deal with common challenges.

Seek board approval.

Ensure adequate 'lead-in' period.

3 Cessation support

NHS Stop Smoking Services should be widely advertised.

Offer staff training in smoking cessation.

Ensure smoking-cessation medications are on hospital formulary.

4 Communication

Advertise a firm date for implementation.

Communicate policy internally and externally.

Inform ancillary services.

Ensure employee ownership of policy, especially at management level.

5 Consolidate the policy

Introduce the policy.

Enforce the policy with regular written and verbal communication.

Deal with violent or abusive patients.

Ensure a rigorous monitoring protocol.

Review the policy regularly.


Plymouth Hospitals trust is nearly six months into a three-year smoke-free strategy, which it launched in September 2004.

In the first year, patients, staff and visitors can smoke in the grounds, but only in designated smoking shelters; and smokingcessation services are being made available to patients and staff.

From September 2005 staff and patient smoking rooms will be withdrawn, and from September 2006 staff will be able to access smoking-cessation services and counselling in work time. From September 2007 the smoking shelters will be removed.

Lesley Thomas, tobacco control project manager at Plymouth teaching PCT - who is co-ordinating smokefree strategies across the district - says phasing in the policy makes sense for the trust because going smoke-free will coincide with completion of a major new building, which has been designed to be smoke-free, on site.

'Although We have done a lot of consultation and marketing, it was also felt that it would be less onerous for people, rather than just imposing a ban, ' she says, adding that 137 people at the hospital have already made use of smoking-cessation services, with a quit rate of around 70 per cent for staff.