1. WHO IS THE SMOKER AT THE HOSPITAL FRONT DOOR? Dr Jiliu Pan (FY2 doctor) Dr Rob Fowler (retired consultant respiratory physician) 11 June 2015 First steps to tackling the most visible challenge to smokefree hospitals.

2. WHY FRONT DOOR SMOKERS? It’s obvious! Harm to patients, visitors, staff passing by A challenge to the positive messages of a smokefree environment Close to maternity unit

3. QUEEN’S HOSPITAL MAIN ENTRANCE

4. NICE (2013) – SMOKEFREE Recommendation 11: Develop smokefree policies involve + train staff removal of smoking shelters facilitate compliance and support staff Recommendation 12: Communicate the smokefree policy clear + positive messages on smokefree environment information on access to stop smoking support ensure staff do not smoke

5. BUT… Difference between policy and outcome

6. WHAT DO WE KNOW? County Galway audit (2014):  48% of smokers non-compliant, 1 year after smokefree policy Sabido et al. (2006): inpatients more likely to be compliant if:  They believe current illness related to smoking  mild withdrawal symptoms  confidence in post-discharge abstinence

7. QUESTIONS Who are the smokers at the hospital front door? Why do they continue to smoke? What can we do to stop smoking at the front door?

8. … WE ASKED THE SMOKERS Interviewed 50 smokers outside the hospital main entrance Questionnaire designed to encourage open answers Included specific questions and subjective level of cooperation All interviewees offered a referral to stop smoking services

9. RESULTS: Not everyone wanted to be approached about their smoking…

10. RESULTS: Most smokers were visitors Some outpatients Small minority were inpatients or staff

11. WHO IS THE FRONT-DOOR SMOKER? A heterogeneous group, mostly visitors A majority will be cooperative with requests to stop smoking At least some will be uncooperative or even confrontational A sizeable proportion are patients

12. WHY DO THEY CONTINUE TO SMOKE? Only 23% knew of the Trust’s new smokefree policy 72% of smokers would choose to smoke away from the maternity department  But only 50% were aware maternity is right next to the front door Common response: point at other smokers + “but they are smoking here”

13. RESULTS Figure 3

14. HOW CAN WE STOP THEM SMOKING? More, better and clearer signs Signs are not enough, need physical presence (from security) Clarify the smokefree perimeter ?a designated area for those that cannot stop smoking - ACCORDING TO THE SMOKERS

15. WHAT ELSE DID THEY TELL US? bins designed to facilitate smoking removal would give consistent message Figure 4

16. Figure 5

17. Figure 6

18. CONCLUSIONS Front door smokers are a heterogeneous group Good quality signs and an unambiguous perimeter are needed Static signs are not enough – we need PEOPLE to ENFORCE We should promote and make available NRT to visitors

19. THANK YOU Any questions? Contacts:  jiliu.pan@gmail.comjiliu.pan@gmail.com  robert.fowler@nhs.netrobert.fowler@nhs.net

20. REFERENCES 1. NICE (2013): Smoking cessation in secondary care: acute, maternity and mental health services. 2. Evans, David S; Faney, Maria; McHugh, Laura;O'Byrne, Irene; Goggin, Deirdre: "Audit of Galway University Hospitals tobacco free campus policy:final report prepared on behalf of the Tobacco Free Campus Audit Group", Health Service Executive Galway 2014. 3. Sabido M, Sunyer J, Masuet C, Masip J: Hospitalized smokers: Compliance with a nonsmoking policy and its predictors. Prev Med 2006, 43(2):113-6.