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: [email protected]
A B S T R AC T
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
2
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 function7 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
# The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
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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
3
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
J O U R NA L O F P U B L I C H E A LT H
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.
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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
5
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 year12 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
J O U R NA L O F P U B L I C H E A LT H
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.
Acknowledgements
Thanks to Elizabeth Scott for proofreading the manuscript.
R.A., Member of the British Thoracic Society Tobacco
Committee.
Funding
No funding.
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.
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