NO SMOKING AND SMOKE FREE ENVIRONMENT POLICY: IMPLEMENTATION UPDATE AND MANAGEMENT GUIDANCE

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1 AGENDA ITEM April 2012 NO SMOKING AND SMOKE FREE ENVIRONMENT POLICY: IMPLEMENTATION UPDATE AND MANAGEMENT GUIDANCE Report of Paper Prepared by Director of Public Health Head of HR Policy and Compliance Executive Summary Action on tobacco forms a key part of Cardiff and Vale University Health Board s drive towards becoming a practising public health organisation to improve the health of the population In March 2011, the Board approved the No Smoking and Smoke Free Environment Policy, with implementation in two phases. The first phase was the introduction of smoke free entrances that commenced in May 2011 with a view to moving to a full ban in November The ethos of the policy was, and remains, a cultural shift in the attitude towards smoking in health environments. A review of progress and staff views during August suggested that the organisation was not ready to move to a full ban in November Therefore in September 2011, the Board agreed to a further phase continuing the ban on smoking at entrances and allowing smoking to occur only in designated smoking shelters. The Board reaffirmed its intention to move to a full ban in No Smoking and Smoke-free Environment Page 1 of 17 Workforce and OD Committee

2 At the Board meeting on 6 March 2012, the UHB agreed the final phase of the policy on No Smoking Day, March 14 th This means that smoking is now banned on all grounds owned by the UHB for all staff and contractors, with only patients and visitors to smoke in designated shelters. In order to reinforce this message, detailed Guidance Notes have been produced which include a rationale for the ban; what this means for UHB staff; how managers and staff can make this work and; how we can help our staff who wish to stop smoking. Action / Decision Required The Workforce and OD Committee is asked to: NOTE progress with implementing the No Smoking and Smoke Free Environment Policy to date NOTE the Guidance for Managers on the implementation of the No Smoking and Smoke Free Environment Policy Link to Board Committee (s) Link to Standards for Health Services in Wales March 2011 Board Paper Draft No Smoking and Smoke Free Environment Policy discussed at Health and Safety Committee, 11 th January 2011 and Local Partnership Forum, 7 th February 2011 September 2011 Board Paper Local Partnership Forum, 30 th January 2012 Quality and Safety Committee February 2012 Board, 6 March Health Promotion, Protection and Improvement No Smoking and Smoke-free Environment Page 2 of 17 Workforce and OD Committee

3 Link to Public Health Agenda Link to UHB Strategic Direction and Corporate Objectives / Legislative and Regulatory Framework Link to Evidence Base Tobacco control forms a key priority for delivery of the Cardiff and Vale Local Public Health Strategic Framework and Target 2 of the Annual Quality Framework. The UHB has a statutory duty to protect and improve the health of the population. Tobacco control forms part of the health improvement component of the UHB operational plan. British Thoracic Society. (2005) Smoke Free Hospitals. London: The British Thoracic Society Cardiff and Vale University Health Board (2011). No Smoking and Smoke Free Environment Policy. Board paper for meeting 22 March 2011, agenda item 4.1 Fichtenberg, C. Glantz, S.(2002). Effect of smoke-free workplaces on smoking behaviour: systematic review. London: BMJ 2002; 325:188 Furlong, C. (2005). Pre-operative smoking cessation: A model to estimate short term health gain and reductions in length of stay. London: London Health Observatory. Kim,B. (2009) Workplace Smoking Ban policy and Smoking behaviour. Journal of Preventative Medicine Public Health 2009:42: pp McKee,M. Gilmore, A. (2003) Smoke free hospitals. London: BMJ 2003;326: National Institute for Health and Clinical Excellence. (2007) Workplace interventions to promote smoking cessation. London: NICE National Institute for Health and Clinical Excellence. (2007) Smoking Cessation No Smoking and Smoke-free Environment Page 3 of 17 Workforce and OD Committee

4 Services. London: NICE. FOR INFORMATION National Institute for Health and Clinical Excellence. (2008) Smoking Cessation Services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. PH10. London: NICE. Phillips, C. Bloodworth, A..(2009) Costs of smoking to the NHS in Wales. ASH Wales and BHF. Smedslund, G. Fisher, KJ. Boles SM. (2004) The effectiveness of workplace smoking cessation programmes: a meta-analysis of recent studies. Tobacco Control 13: Welsh Assembly Government. (2009) Our Healthy Future. Cardiff: Welsh Assembly Government. Welsh Assembly Government. (2010) Welsh Health Survey Cardiff: Welsh Assembly Government. Welsh Assembly Government. (2010) Annual Quality Framework Cardiff: Welsh Assembly Government. NO SMOKING AND SMOKE FREE ENVIRONMENT POLICY: IMPLEMENTATION UPDATE INTRODUCTION Cardiff and Vale University Health Board (UHB) has a statutory responsibility to improve the health of the population of Cardiff and Vale of Glamorgan, as well as to provide individual patient centred care for promotion, prevention, diagnosis, treatment and rehabilitation. No Smoking and Smoke-free Environment Page 4 of 17 Workforce and OD Committee

5 Reducing the prevalence of smoking and exposure to second-hand smoke is a key theme in the Public Health framework, Our Healthy Future. Action on tobacco forms a key priority for delivery of the Cardiff and Vale Local Public Health Strategic Framework and Target 2 of the Annual Quality Framework. The UHB has a statutory duty of care under the Health and Safety at Work Act 1974 to provide and maintain a safe working environment which is, so far as is reasonably practical, without risk to health and adequate as regards facilities and arrangement for their welfare at work. Finally, the Welsh Government Tobacco Control Action Plan proposes that the NHS should take on an exemplar action role to discourage smoking, including introducing smoke-free grounds. UHB POLICY DEVELOPMENT In March 2011, the UHB Board endorsed the proposal to introduce a No Smoking and Smoke Free Environment Policy across the UHB. Implementation of the policy was proposed to proceed in two phases: Phase 1 smoke free entrances (from May 2011) Phase 2 a comprehensive ban 1 across all UHB buildings, grounds and vehicles (from November 2011) A review of progress including staff views was undertaken in August That review indicated the organisation was not ready for a full ban. In particular, concerns for patients and relatives who smoke that are dealing with difficult situations needed to be considered. In September 2011, the Board reaffirmed its commitment to a full ban but agreed a further step to the policy by asking people to smoke only in designated shelters. MOVING TO A SMOKE FREE UHB The Board agreed the move to a final implementation of its policy on 6 March The Smoke Free Steering Group proposed no smoking day on March 14 th as the date for final implementation. No Smoking Day remains a nationally recognised quit date for many smokers, with over one million people pledging to quit smoking last year. In 2010, 28% of year olds either stopped smoking for one day or quit smoking 1 Excluding mental health inpatients for whom provision in dedicated smoking rooms may be made No Smoking and Smoke-free Environment Page 5 of 17 Workforce and OD Committee

6 altogether. Representatives from Cardiff and Vale UHB were available on the day to help smokers quit and provide helpful advice on all aspects of smoking cessation. The move to a Smoke Free UHB will now mean that staff will not be permitted to smoke under any circumstances on hospital grounds. Staff smoking on NHS premises and in uniform in visible smoking areas sends a contradictory message about the public health risks and health outcomes of smoking. The view is that NHS staff should act as role models for promoting healthy behaviours. Similarly, for contractors agreeing to carry out work on UHB property and grounds, the UHB will use the Contractual Agreement between both parties to specify that smoking is not permissible on hospital grounds. DESIGNATED SMOKING AREAS FOR PATIENTS/VISITORS During the discussions since March 2011, concerns were raised on the position of patients and relatives who are smokers. Patients dealing with difficult situations or resident in hospital for a longer period of time may find smoking off-site difficult to manage. The same is true for relatives and friends dealing with a particularly stressful situation, such as family illness or a recent bereavement. The UHB understands that these situations may increase the desire to smoke and that having to walk offsite may be considered difficult, particularly at UHW and UHL In recognition of these factors, it was agreed to retain the designated smoking areas for the sole use of patients and visitors. GUIDANCE FOR MANAGERS As part of the implementation of the No Smoking and Smoke Free Environment Policy, guidance has been produced for managers within the UHB which include a rationale for the ban; what this means for UHB staff; how managers and staff can make this work and; how we can help our staff who wish to stop smoking. The Guidance is attached as Appendix 1. The Guidance is based on the principle that creating a smoke free UHB is involves changing cultures and behaviours rather than disciplining staff in the first instance. No Smoking and Smoke-free Environment Page 6 of 17 Workforce and OD Committee

7 As part of the guidance for managers, staff are encouraged to become Clean Air Champions. This role approaching members of staff or the public who are smoking in our entrances, politely informing them of our new policy and explaining to them where they can use the smoking shelters. A set of draft Frequently Asked Questions are under consultation and these are attached as Appendix B. CONCLUSION Significant progress has been made in implementing the UHB s No Smoking and Smoke Free Environment Policy. Societal norms around cigarette smoking have changed radically in recent years and it is becoming less culturally acceptable in a number of settings. Welsh Government, in prioritising reducing smoking prevalence, is supporting NHS establishments to become smoke free and exemplars in promoting the no smoking message. The UHB agreed to the No Smoking and Smoke Free Environment Policy in March 2011 and reinforced commitment to a full ban on smoking in September By launching the final phase of the Action Plan on No Smoking Day, 14 th March 2012, the UHB is communicating a strong message that smoking is not acceptable on hospital grounds. Detailed Guidance Notes have been produced to assist managers in the implementation of the ban. Whilst the initial approach to dealing with staff who fail to adhere to the No Smoking Policy will be through Disciplinary Counselling, it is recognised that some staff may continue to smoke on the UHB sites and in these cases Disciplinary sanctions will be required. As part of the monitoring of the Policy, a report on the number of staff receiving Disciplinary Counselling/Warnings will be provided to the October meeting of the Workforce and OD Committee. As part of the monitoring process, the Managers Guidance Notes and the associated Frequently Asked Questions will be reviewed as the ban is implemented and in view of any staff failing to adhere to the policy. No Smoking and Smoke-free Environment Page 7 of 17 Workforce and OD Committee

8 RECOMMENDATION The Workforce and OD Committee is asked to: NOTE progress with implementing the No Smoking and Smoke Free Environment Policy to date; NOTE the Guidance for Managers on the implementation of the No Smoking and Smoke Free Environment Policy No Smoking and Smoke-free Environment Page 8 of 17 Workforce and OD Committee

9 IMPACT ASSESSMENT Health Improvement Workforce Education and Training Financial Reducing the prevalence and incidence of smoking improves the health of all the population Reducing the prevalence and incidence of smoking improves the health of our workforce and helps ensure our compliance with Health and Safety legislation. Brief Education for Smoking Cessation Training has been carried out within UHB Divisions. Dates for future sessions have been published and attendance confirmed. Plans to hold additional training sessions are already underway. The hospital in-house Smoking Cessation Service currently has a 15 hour post frozen which may need to be recruited into. This post is a Band 7 post equating to approximately 22, (including 20% on-costs). The total cost to the UHB of pharmacotherapies in in Cardiff and the Vale including nicotine replacement therapy (NRT) and the smoking cessation drugs bupropion and varenicline both in primary care was 681, and in secondary care was 23, The cost of Nicotine Replacement Therapy (NRT) for staff is estimated to be in the region of 5,075, based on approximately the number of UHB staff (14,000) who smoke (3,500) against the approximate number of staff who may access smoking cessation services (10%) - at a prescription cost to the UHB of Costs have been incurred for signage in UHB grounds, amounting to around 25,000. There may be a potential for saving as working days lost due to smoking related illness may reduce. No Smoking and Smoke-free Environment Page 9 of 17 Workforce and OD Committee

10 Legal Equality Environmental The Health and Safety at Work Act 1974 places a duty on employers to provide and maintain a safe working environment which is, so far as is reasonably practical, without risk to health and adequate as regards facilities and arrangements for their welfare at work. Under the 2007 legislation, employers need to take steps to minimise the risk for their employees of exposure to second-hand smoke within private dwellings. An Equality Impact Assessment (EQIA) has been completed as part of the development of the No Smoking and Smoke Free Environment Policy. Under the 2007 legislation, employers need to take steps to minimise the risk for their employees of exposure to second-hand smoke. Additionally, the UHB has a duty of care to all patients to ensure they are not susceptible to second hand smoke at any point whilst accessing services. Working in partnership with other agencies, the UHB recognises that the control of litter will be required if a full ban on smoking on UHB grounds is progressed. RISK ASSESSMENT Clinical/Service Financial The capacity of the hospital in-house smoking Cessation Service will need to be reviewed as the ban rolls out. This will be undertaken as part of the remit of the UHB s Smoke Free UHB Steering Group which is led by the Director of Public Health. If any barriers to implementing Phase 2 are not adequately addressed prior to starting, there is a risk of alienating patients and relatives who smoke, reducing their trust in the local NHS. No Smoking and Smoke-free Environment Page 10 of 17 Workforce and OD Committee

11 Reputational Acronyms and Abbreviations The UHB must be seen as a credible NHS organisation able to lead health improvement by example. AQF Annual Quality Framework PHT Public Health Team UHB University Health Board UHW University Hospital Wales CONSULTATION AND ENGAGEMENT A draft and final No Smoking and Smoke Free Environment Policy has been discussed at two Local Partnership Forums (January 2011 and January 2012), Health & Safety Committee (February 2011) and Quality and Safety Committee (February 2012). An internal, intranet staff on-line poll has taken place during 29 th January to Monday 7 th February A second online staff poll took place in August to identify any barriers to implementation of Phase 2. Several internal communication processes are planned or have already been used including utilising payslips, intranet e-bulletins and the staff magazine Vital Signs to further update staff. Support for the process has been gained from the Wales Medical Committee, Medical Advisory Group and the Cardiff Chest Physicians Group. On-going work is required to take forward the implementation of the Policy and monitor adherence. SOURCES OF INFORMATION British Thoracic Society. (2005) Smoke Free Hospitals. London: The British Thoracic Society Cardiff and Vale University Health Board (2011). No Smoking and Smoke Free Environment Policy. Board paper for meeting 22 March 2011, agenda item 4.1 Fichtenberg, C. Glantz, S.(2002). Effect of smoke-free workplaces on smoking behaviour: systematic review. London: BMJ 2002; 325:188 No Smoking and Smoke-free Environment Page 11 of 17 Workforce and OD Committee

12 Furlong, C. (2005). Pre-operative smoking cessation: A model to estimate short term health gain and reductions in length of stay. London: London Health Observatory. Kim,B. (2009) Workplace Smoking Ban policy and Smoking behaviour. Journal of Preventative Medicine Public Health 2009:42: pp McKee,M. Gilmore, A. (2003) Smoke free hospitals. London: BMJ 2003;326: National Institute for Health and Clinical Excellence. (2007) Workplace interventions to promote smoking cessation. London: NICE National Institute for Health and Clinical Excellence. (2007) Smoking Cessation Services. London: NICE. National Institute for Health and Clinical Excellence. (2008) Smoking Cessation Services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. PH10. London: NICE. Phillips, C. Bloodworth, A..(2009) Costs of smoking to the NHS in Wales. ASH Wales and BHF. Smedslund, G. Fisher, KJ. Boles SM. (2004) The effectiveness of workplace smoking cessation programmes: a meta-analysis of recent studies. Tobacco Control 13: Style, G. Capewell,S. (1998) No Smoking at Work: the effect of different types of workplace smoking restrictions on smoker s attitudes, behaviour and cessation interventions. Health Education Journal Volume 5:4: pp Welsh Assembly Government. (2009) Our Healthy Future. Cardiff: Welsh Assembly Government. Welsh Assembly Government. (2010) Welsh Health Survey Cardiff: Welsh Assembly Government. Welsh Assembly Government. (2010) Annual Quality Framework Cardiff: Welsh Assembly Government. No Smoking and Smoke-free Environment Page 12 of 17 Workforce and OD Committee

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18 APPENDIX B Frequently Asked Questions No Smoking and Smoke Free Environment Policy What is happening? As of Wednesday March , the UHB has banned smoking in hospital grounds in line with the Cardiff and Vale University Health Board s (UHB) No Smoking and Smoke Free Environment Policy. This means that a full no smoking ban is in operation and we are a smoke free organisation, so we will ask everyone, including all staff, not to smoke inside our buildings or outside on our property. However, the UHB recognises that distressed patients and relatives may find this difficult, so smoking shelters will remain for their use only. Why has smoking been banned on hospital grounds? In Wales, 24% of our population smoke and smoking costs NHS Wales an estimated 386 million a year. As a practising public health organisation, the UHB also has a legal duty to improve the health of the population of Cardiff and the Vale of Glamorgan. Encouraging people to stop smoking is the area of public health where the UHB can have the most positive impact on the health of the population of Cardiff and the Vale. However working to improve the health of the local population also means demonstrating our commitment to healthy living. People smoking on NHS premises, and particularly around the entrances undermines the UHB s commitment to healthy living, and give a very poor impression. It also has a health impact, as people passing the entrances are exposed to second-hand tobacco smoke and are therefore at risk from the proven harm caused by second-hand smoke. What exactly does this mean for UHB staff? Staff will not be able to smoke on hospital grounds, in their cars when parked within the boundaries of the hospital grounds, in other UHB buildings and premises, or in UHB vehicles. This will apply to all staff, regardless of whether they are in uniform or not, and regardless of whether they are on site as part of their working day or as a visitor or even patient. Smoking shelters will not be available for staff use at any time.

19 I don t work on a hospital site does this ban apply to me? Yes, the No Smoking and Smoke Free Environment Policy applies to all UHB premises, not just the main hospital sites. It also applies to staff working in the Community while they are on duty. My job is really stressful shouldn t I be given the same opportunities to smoke as distressed patients and visitors? As members of staff, we have a responsibility to promote healthy living and maintain a smoke free environment at all times. This means that there are no exceptions to the ban on staff smoking on UHB premises, regardless of what role you are in. However, the UHB recognises that many members of staff work in challenging or stressful environments and therefore provides a free, independent and fully confidential counselling service as well as stress resilience training and other courses through the Employee Wellbeing Service (telephone: ) Staff who would like to quit smoking can contact Stop Smoking Wales on for free advice and support and have recently facilitated a Stop Smoking Group at UHW. Can I take a break to leave the site and have a cigarette if I make sure I work the time back at the end of the day? No, there are no such things as cigarette breaks. Members of staff can go off site to smoke during their normal unpaid break(s) e.g. lunch etc. in the same way as they can for any other reason, but they cannot use their working time in this way. However, staff are reminded that it is offence to drop litter (including cigarette butts) and are asked to use appropriate bins for cigarette waste. Cardiff Council Litter Enforcement Officers are operating in the perimeter areas of the hospital sites and we remind all staff of their responsibility in clearing up litter. What about the safety implications for staff who work nights and want to leave site to smoke during their break? A member of staff can choose to leave a site during their unpaid break as long as they realise that they do so at their own risk. This applies whether they are leaving a site for a cigarette or for any other reason. I have heard that the beer garden at the Sports and Social Club is exempt from this ban. Is this true? The smoking ban does not include the beer garden at the Sports and Social Club at the current time, but this area is for Club patrons using the facilities at that time only and should not be treated as a designated smoking area for staff. What will happen if staff continue to smoke on UHB grounds? Creating a smoke free UHB means that we need to focus on changing the culture through the provision of help and support, rather than focusing on disciplining staff. However, if someone is reported smoking or caught smoking, the first step will be for them to be given Informal Counselling under the UHB Disciplinary Policy by their manager and they will be

20 signposted to the help, support, counselling and any other resources that are available. They will also be advised that if there is a repetition of the breach of the policy, formal disciplinary action will have to be considered. Is there help available for staff who want to stop smoking? If staff wish to stop smoking they can contact Stop Smoking Wales (SSW) on A Quit Smoking group has already been established to directly support UHB staff. On calling the freephone number please advise the operator that you are a staff member of the UHB. They will then book you into that group if it is convenient for you, or suggest alternative groups local to where you live. Staff members thinking of giving up smoking can also call Smokers Helpline Wales, who provide free and confidential advice to help young people and adults who want to give up smoking. To speak to a member of the team for general advice on stopping smoking and receive an information pack and details on additional support services, call between 9am and 7pm, Monday to Friday (including bank holidays) and 10am and 4pm on Saturdays and Sundays. The UHB also has a Smoking Cessation Service and recognises that employees may, as part of a planned programme, need to attend Smoking Cessation appointments. If you are required to attend these sessions, you are expected to make every effort to ensure that they are as close to the beginning or the end of the working period as possible or during periods when you are not scheduled to work. Where possible, you will be allowed to attend any pre-booked appointments, but it must be recognised there may be occasions when staff cannot be released from busy areas because of service pressures. How can I help make the smoking ban work? To ensure that the UHB is a credible and effective advocate for healthy living, all staff and managers have a responsibility to support the implementation of this policy and create a smoke-free UHB. If a member of staff feels comfortable challenging patients or visitors who are smoking, the suggested approach is: 1) Politely introduce yourself and explain that you work for the UHB 2) Explain that smoking is not permitted anywhere on the UHB site but explain that smoking shelters are available if patients or visitors are particularly distressed If you see another member of staff smoking: 1) Politely introduce yourself and explain that you also work for the UHB 2) Remind the individual(s) that they are no longer permitted to smoke anywhere on site, as this is now a smoke free UHB. 3) Ask them politely to extinguish their cigarette(s), and remind them that if you see them smoking on UHB grounds again, you are obligated to report them to their line manager but that you would prefer not to have to do this.

21 What is a Clean Air Champion? This role involves approaching members of staff or the public who are smoking in our entrances and politely informing them of our policy. Clean Air Champions are also eligible for Brief Intervention Training, which provides some simple tips on challenging smokers in a non-confrontational manner. Being a Clean Air Champion doesn t mean policing the entrances, but as part of your daily routine coming in and out of our sites, being alert and politely approaching people who are smoking in Clean Air Zones. Challenging smokers is difficult; but we are trying to create a culture where it s not appropriate to smoke outside our entrances, and the more people get involved, the easier this is. Details of the Clean Air Zone campaign, including information on how to register to become a Clean Air Champion and the UHB s Smoking Cessation Services can be found on the intranet site Will staff get into trouble if they challenge managers who are not complying with the policy? No. This is a UHB wide policy and is therefore applicable to everyone irrespective of grade. Any employee politely asking someone to stop smoking on UHB grounds will receive the full support of the Board. What if a challenge to a smoker results in violence or aggression? Although members of staff are asked to politely remind people that smoking on UHB grounds is not allowed, this should only be done if you feel confident to do so. Under no circumstances should a confrontational attitude be adopted or allowed to develop. If verbal or physical abuse occurs as a consequence of employees implementing the No Smoking and Smoke Free Environment Policy, the perpetrator (whether they are another member of staff, a patient or a visitor) will be dealt with in line with the UHB Management of Violence and Aggression (Personal Safety) Policy and the UHB Disciplinary Policy as appropriate. Where can I get further information? A copy of the No Smoking and Smoke Free Environment Policy and additional information on being a Smoke Free UHB including guidance for managers, details of the smoking cessation service and how to become a Clean Air Champion are available on the intranet.