Journal of Public Health Vol. 30, No. 1, pp. 2 7 doi:10.1093/pubmed/fdn004 Achieving a smoke-free hospital: reported enforcement of smoke-free regulations by NHS health care staff Mark Shipley, Robert Allcock Gateshead Health NHS Trust, Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK Address correspondence to Mark Shipley, E-mail: drmdshipley@hotmail.com ABSTRACT Background In December 2006, all UK NHS trusts introduced smoke-free regulations prohibiting smoking on all NHS sites. These rules are to be enforced by all NHS trust staff. We have investigated the implementation of these regulations by health care workers when they encounter smokers on a NHS hospital site. Methods Eighty-five medical and nursing staff working in acute medicine at the Queen Elizabeth Hospital, Gateshead, completed a questionnaire reporting their behavior when exposed to smokers on NHS hospital sites. Results Over 50% of medical and nursing staff reported that they would not challenge patients, staff or visitors smoking on NHS trust site. There was a trend for employees to be more likely to challenge patients than visitors, and to be more likely to challenge visitors than other staff. Fear of aggression was the most commonly reported reason for not challenging smokers. Conclusions Most medical and nursing staff report that they do not enforce NHS smoke-free regulations and do not challenge smokers on NHS sites. This is due to many real and perceived barriers including fear of aggression. Overcoming these barriers is an important area of research to guide successful implementation of future smoking policy. There may be scope for improvement through training in NHS policy and in non-confrontational communication skills. Keywords England, NHS, perceptions, regulations, smoking Introduction Smoking tobacco is the dominant modifiable cause of mortality and morbidity in the UK. Approximately 24% of the UK population continues to smoke cigarettes despite widespread knowledge of negative health effects. Smoking is implicated in 120 000 premature deaths in the UK every year. Most of these deaths are the result of ischemic heart disease, chronic obstructive pulmonary disease (COPD) and cancer. Exposure to passive smoking at home is implicated in up to 10 000 deaths every year. 1 Smokers exposed to passive smoking at home have a 25% increased risk of cancer and ischemic heart disease. 2 4 Six hundred and twenty-two admissions per 100 000 people occur as a result of COPD every year in the Gateshead Health NHS Trust, the 13th highest admission rate nationally. 5 An estimated 29% of residents in the North East of England smoke. 6 Smoking is the leading cause of preventable ill health in Gateshead. Workplace smoking is a cause of lost revenue to business in the UK and many employers have introduced smoking regulations to tackle this problem. Exposure to cigarette smoke in the work place is associated with morbidity in the work force including worsening of lung function 7 and workplace bans have resulted in reduced reporting of respiratory symptoms. 8 In 1993, US hospitals became smoke-free in accordance with the Joint Commission on Accreditation of Healthcare Organizations. 9 In 1996, 96% of accredited hospitals in the USA were compliant with this ban. 10 Some authors suggest that a smoking ban can increase quit rates and abstinence from smoking. 11 In July 2007, smoking tobacco was banned in all enclosed public places in the UK. In December 2006, all UK NHS sites became Smokefree. Until this point, patients, staff and visitors smoked in smoking rooms or outside hospital buildings. NHS employees now have the right to work in a smoke-free environment and all staff have a duty to support a NHS Mark Shipley, Specialist Registrar in Respiratory and General Medicine Robert Allcock, Consultant Respiratory Physician 2 # The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
REPORTED ENFORCEMENT OF SMOKE-FREE REGULATIONS BY NHS HEALTH CARE STAFF 3 trust s smoke-free status to ensure this environment exists, however, it remains commonplace for smoking on hospital sites to go unchallenged. Smoking was banned on Gateshead NHS trust sites on 1 October 2006. The effects of this ban are yet to be determined. Addressing the mismatch between policy and behavior requires innovative solutions. There is limited evidence to guide such approaches. No studies to date have examined difficulties in the enactment of smoke-free regulations on NHS sites. The aim of this first study is to assess the behavior of healthcare workers at a busy district general hospital NHS site in the North East of England in relation to implementation of smoke-free regulations. In particular, we investigated the factors that alter the likelihood of members of staff challenging people seen smoking. Methods Participants Study participants were full-time medical and nursing staff working in acute medicine at the Queen Elizabeth Hospital, Gateshead. Part time, agency and voluntary staff, medical and nursing students and non-nursing staff from professions allied to medicine were excluded. No staff declined to participate. Data collection M.S. visited acute medical wards at the Queen Elizabeth Hospital during a 3-day period during March 2007 (7 months after implementation of Gateshead NHS site Smoke-free initiative). A questionnaire was delivered to members of staff working during this time period on a convenience basis. A direct opportunistic approach was chosen to minimize response bias. Verbal consent was obtained and succinct introduction to the purpose of the study was given. Subjects were given the questionnaire and were asked to complete it and place it in an envelope or dispose of it. This was to ensure confidentiality was maintained. Respondents were asked whether they had challenged a patient, visitor or member of staff smoking on the hospital site and, if not, whether they would in future. Respondents were asked to offer reasons why they would not challenge staff, patients or visitors to stop smoking. Personal smoking history, job title and age were requested for each subject. People who had challenged smokers in the past were assumed to be likely to challenge smokers in future and therefore they were grouped together to identify planned future behavior. Data on those who had previously challenged smokers were included as a subgroup of those who reported that they would challenge smokers in future. Data analysis Qualitative and quantitative data from questionnaires was analysed and interpreted by M.S. The Chi-square test was used to analyse differences between reported behaviors of the subgroups when compared to the average of the study population. A P-value of,0.05 was accepted to identify key trends in the data. Results Eighty-five questionnaires were completed. Fifty-five (65%) females and 30 (35%) males were sampled. This comprised 49 (58%) medical staff and 36 (42%) nursing staff. Twelve (14%) were smokers, 12 (14%) were ex smokers, 61 (72%) had never smoked 41 (48%) of the respondents were aged between 25 and 34. Age and sex distribution of the sample approximated to workforce data supplied by Medical Staffing at the Queen Elizabeth Hospital, Gateshead. Respondents included all medical grades and both HealthCare Assistants and Qualified Nurses. Demographic data are summarized in Fig. 1. Fifty-one (60%) respondents reported awareness of other members of staff smoking on site. Seventy-nine (93%) of staff were aware of the implementation of the NHS smoke-free regulations implemented in December 2006 (Figs 2 and 3). Most respondents reported that they would not challenge smokers to stop smoking on the hospital site. Forty-five (53%) respondents would not challenge patients, 50 (59%) would not challenge visitors and 58 (68%) would not challenge staff. Throughout all groups, there was a trend Fig. 1 Age and sex demographics of participants.
4 JOURNAL OF PUBLIC HEALTH Fig. 2 Reported planned behavior by subgroup (F1, Foundation year one doctor; F2, Foundation year two doctor; SHO, Senior House Office; Reg, Registrar). Fig. 3 Statistical significance analysis using Chi-squared test of significance of reported behavior by subgroup: P-values shown. towards medical and nursing employees being more likely to have challenged patients over visitors over staff. Twenty-one (25%) of respondents had previously challenged patients, 11 (13%) had previously challenged visitors and 7 (8%) had previously challenged other members of staff. This information is shown in Fig. 4. There was a progressive trend towards medical staff being more likely to challenge patients, visitors and staff smoking when compared to nursing staff. This difference was not statistically significant. The differences identified between the reported behaviors of the subgroups did not reach statistical significance.
REPORTED ENFORCEMENT OF SMOKE-FREE REGULATIONS BY NHS HEALTH CARE STAFF 5 Fig. 4 Summary response data as percentage of sample. Eighteen (21%) study participants would challenge all three groups of smokers. The remaining respondents were asked to report why they did not challenge smokers. Eleven respondents did not offer a reason. Thirteen different reasons why staff would not challenge smokers on site were reported. These data are summarized in Fig. 5. Twenty-seven respondents reported fear of aggression as the reason why they would not challenge smokers on site. Twelve respondents reported that it was not their job to enforce smoke-free regulation. Discussion Main findings of this study This study highlights important challenges in the implementation of a smoke-free NHS in a district general hospital medical unit. Most medical and nursing staff does not enforce NHS policy. Most medical and nursing staff report that they would not challenge patients, staff and visitors to stop smoking on a hospital site. Almost 50% of study participants responded that they would challenge smokers to stop smoking in future, yet most of these had never challenged smokers before. Medical and nursing employees encounter people smoking on hospital site on a daily basis and therefore it seems unlikely that they had not had the opportunity to challenge smokers on site prior to the study period. It is possible that participating in the study inspired staff to challenge smokers in future. All groups had a higher number of participants who felt they would challenge a smoker if they encountered them in future when compared to those who had challenged smokers in the past. It appears people respond that they are prepared to challenge smokers to stop smoking yet do not follow through with that claim. There may be differences in the subgroups and their attitudes towards smoking on site. This is likely to be influenced by attitudes and experiences in my study population. Trust employees appear more likely to challenge patients than visitors or members of staff. This may because they feel it is extension of their role as a healthcare provider. There was no significant difference between the reported actions of medical and nursing staff. Members of staff appear to be the group of smokers least likely to be challenged. Many respondents felt that challenging smokers was not their job, and colleagues had the right to choose whether they smoked or not. Only one respondent raised the concern that challenging colleagues might impinge on their working relationships. Other reasons were offered as to why respondents do not challenge smokers on site. A proportion of employees were unaware of the trust policy or legality of challenging smokers. Some did not feel it was their job to enforce NHS smoke-free regulations. Although the majority of respondents were aware of the introduction of new NHS regulations, some are unclear as to how this regulation is to be implemented. Further staff training may increase action. Demonstration and dissemination of the benefits of a smoke-free workplace may increase the commitment to a smoke-free environment in those apathetic about the workplace smoking bans. A total of 60 385 NHS employees are subject to violence and verbal assault every year 12 and it is unsurprising that NHS employees are cautious of increasing the likelihood of being a victim of assault. Fear of confrontation and aggression from smokers appears to be a determinant to whether a member of staff challenges smokers. Further education in recognition, avoidance and management of aggression directed at members of staff may increase the proportion of smokers challenged by NHS medical and nursing staff. What is already known on this topic? Smoking is the dominant modifiable cause of mortality and morbidity in the UK. Successful implementation of smokefree regulations is central in reducing the burden of Tobacco related disease. Workplace smoking is associated with morbidity in the workforce and smoking bans have a positive effect on smoking related behavior. National bans on smoking in public places have decreased smoking rates. Some authors suggest a smoking ban can increase quit rates and abstinence from smoking. 11
6 JOURNAL OF PUBLIC HEALTH Fig. 5 Reasons given to justify not challenging smokers. What this study adds? This study has shown that implementation of NHS smoking regulations by NHS medical and nursing staff working at an acute medical unit in a District General Hospital is suboptimal. There is a trend towards medical and nursing staff reporting that they are more likely to challenge patients about smoking than visitors or other employees. Fear of confrontation and aggression is the most common reason for inaction. Limitations of this study This study is limited to staff working in acute medicine in a District General Hospital in Gateshead. This region has smoking rates above the national average and high admissions from smoking related illness. Subgroup size limits analysis of differences between subsets of data. Conclusions Most medical and nursing staff report that they do not enforce NHS smoke-free regulations and do not challenge smokers on NHS sites. This is due to many real and perceived barriers including fear of aggression. Overcoming these barriers is an important area of research to guide successful implementation of future smoking policy. There may be scope for improvement through training in NHS policy and in non-confrontational communication skills. Acknowledgements Thanks to Elizabeth Scott for proofreading the manuscript. R.A., Member of the British Thoracic Society Tobacco Committee. Funding No funding. References 1 Jamrozik K. Estimate of deaths attributable to passive smoking among UK adults: database analysis. BMJ, doi: 10.1136/ bmj.38370.496632.8f (2 March 2005, date last accessed). 2 Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ 1997;315:973 80. 3 Hackshaw AK, Morris JK, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ 1997;315:980 88. 4 US DHHS. National Institutes of Health, National Cancer Institute. National Cancer Institute. Health effects of exposure to environmental tobacco smoke: the report of the California Environmental Protection Agency. Smoking and Tobacco Control Monograph no. 10. (NIH Publication No 99 4645.). US Environmental Protection Agency. 1999.
REPORTED ENFORCEMENT OF SMOKE-FREE REGULATIONS BY NHS HEALTH CARE STAFF 7 5 COPD Medical Admissions in the UK: 2000/01 2001/02 Kings Fund, 2004 6 General Household Survey, ONS, 2001. 7 Skogstad M, Kjaerheim K, Fladseth G, Gjolstad M, Daae HL, Olsen R, Molander P, Ellingsen DG. Cross shift changes in lung function among bar and restaurant workers before and after implementation of a smoking ban. Occup Environ Med 2006;63:482 7. 8 Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L. Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin Pubs. Am J Respir Crit CareMed 2007;8:840 5. 9 US Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual For Hospitals. Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations, 1992. 10 Longo DR, Feldman MM, Kruse RL et al. Implementing smoking bans in American hospitals: results of a national survey. Tob Control 1998;7(Spring):47 55. 11 Longo DR, Johnson JC, Kruse RL et al. A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tob Control 2001;10(Autumn):267 72. 12 Tackling nuisance or disturbance behaviour on NHS healthcare premises: A paper for consultation. Department of Health Consultation. 10th July 2006.