1. Staff views on implementing an enforceable smoke-free hospital grounds policy Jenni Strachan, Dr Dermot Gorman, Dr Vittal Katikireddi and Martin Higgins

2. NHS Lothian’s staged approach to smoke-free grounds All NHS grounds smoke- free by March 2015. Painting of hatched areas. Increased ‘no smoking’ signs. Three month advertising campaign with local paper. Internal Communication.

3. Staff interviews Aim: To describe changes in NHS Lothian staff views regarding proposals for smoke-free NHS grounds prior to the Scottish Government deadline of March 2015. Method: Repeated in-depth semi-structured interviews with two overlapping groups of 10 NHS staff working in areas of RIE affected by second-hand smoke (SHS). Conducted: December 2013 & July 2014 Interview topics: Views on current tobacco policy, exposure to second-hand smoke (SHS), challenges and barriers to implementing ‘smoke-free’ and potential enforcement measures.

4. Smoking provides negative image on hospital grounds “They look pretty disadvantaged as a group…judging by the uniforms they are particularly domestic staff…here are people in uniform smoking, I think that sends a bad message.” (Respondent B,4) “Terrible image, sick patients in wheelchairs with drip stands up, can see they are unwell smoking, sends out completely the wrong message for healthy hospital premises.” (Respondent A,6)

5. Exposure to SHS amongst staff and patients is high “…I really don’t want to walk through clouds of smoke and stink of smoke…I don’t use the main entrance, I cut through the outpatient department.” (Respondent A,5) “You can smell it. When the windows are open you can smell it.” (Respondent B,8) “I go around seeing respiratory patients…I have had several patients complain about the smell coming up to first floor windows. All I can see when I look out is that smoking shelter which makes it more difficult for them [not to smoke].” (Respondent A,1)

6. The role of staff in enforcement of smoke- free policy “…you are not going to get a good reaction challenging strangers if you don’t have any authority to challenge them.” (Respondent A,5) “People would be more likely to take notice from someone from security.” (Respondent A,4) “I think it should be somebody other than healthcare professionals, we already have to deal with them as it is, I think it has to be somebody separate.” (Respondent A,1)

7. Barriers Staff ambivalence towards smoke-free policy “…you are always going to get the people who are in their last few weeks in life and it is a bit miserable what we are doing to them.” (Respondent A,6) “Sometimes I feel sorry for them because they come out with their drips and things, sitting there, I don’t have the heart to say to them because it might be their last weeks.” (Respondent B,5) “I think it’s unfair to try and force people, it’s very much a conflict, they are a vulnerable group of people, they are here because they are not well…I wouldn’t say cut a little slack but its understandable.” (Respondent B,4)

8. Pregnant women act as facilitators of policy by encouraging non-smoking and enforcement “My colleague went out and told them. She is very pregnant and she said this is not on. I have to be able to sit in my office and work with windows open because this room is stifling without smoke coming in the window and actually I think he realised he had overstepped the mark.” (Respondent B,7) “I mean I used to smoke but I am pregnant and I have to sit here and breathe in other people’s smoke when I chose not to smoke myself.” (Respondent A,2)

9. Pregnant women who smoke are victims of stigmatisation via staff disapproval “There is a lot of pregnant women out there smoking and I don’t think that’s right.” (Respondent A,3) “I think it gives a terrible impression to see women in their third trimester smoking. It gives an awful impression…we are dealing with foetal problems all the time and you know that it causes retardation.” (Respondent A,7)

10. E-cigarette use by patients and staff management “People are not allowed [to use e- cigarettes] in the wards but several patients have asked me if they can use [e-cigarettes] and I say I’m sorry and in many ways send them down to the front door…just encouraging them to smell the smoke, I did smoke once…it gives you the willing to [smoke cigarettes again].” Respondent B,4) “I ask people to move on with those as well…we don’t know what’s in them.” (Respondent B,7)

11. Conclusion Smoking on grounds gave a negative image of NHS with ‘disadvantaged groups’ being repeatedly highlighted. Nearly all staff were regularly affected by SHS and avoided using main entrances into work to reduce exposure. Staff also noted the negative impact SHS had on patients trying to stop smoking. Individual staff were generally unwilling to routinely enforce policy unless severely provoked e.g. –clinical areas being severely polluted –extreme rude/ inconsiderate behaviour All staff felt the policy should be enforced by designated persons, with staff feeling they lacked authority to do so.

12. Conclusion Some staff felt that disadvantaged groups were already being ‘unfairly’ penalised by having bad health and being in or having family in hospital. Approaches to smoke-free implementation needs to understand the potential for further stigmatisation and address it via training and specialist smoking cessation support. Pregnant women acted as both facilitators (encouraged enforcement and non-smoking) and victims of stigmatisation (heavily disapproved of by staff and RIE users). E-cigarette use was relatively low at time of interviews but staff are unsure how to deal with them.

13. Final Thoughts… What do we do about e-cigarettes? −Inclusion of e-cigarettes in smoke-free policy needs careful consideration and regular reviewing as evidence emerges. How do we enforce a policy without sanctions? −Consistency of policy implementation and management commitment both nationally and locally is required.

14. Thanks for listening Any questions? Jenni.Strachan@luht.scot.nhs.uk