Approximately 6.9 million adults smoke in the UK, which equates to about 14.1% of the population, a figure that decreased from 14.7% in 2018 to 14.1% in 2019 (Office for National Statistics, 2020). The highest proportion of adult smokers was recorded in Northern Ireland with 15.6% and the lowest was in England at 13.9%; the figure was 15.5% in Wales and 15.4% in Scotland. The figures in each nation varied depending on a range of factors, including socioeconomic background.
The NHS has made a commitment to create a smoke-free society in the UK (NHS England and NHS Improvement, 2019; NHS Health Scotland, 2015; NHS Wales and Public Health Wales, 2019). To make this happen, England (NHS England and NHS Improvement, 2019) and Scotland (Scottish Government, 2013; NHS Health Scotland, 2015) have developed long-term strategies, while Wales has both medium- and long-term strategies (Welsh Government and NHS Wales, 2017; NHS Wales and Public Health Wales, 2018a; 2018b). Northern Ireland has chosen a similar approach to Wales (NHS Wales and Public Health Wales, 2018a; 2018b), focusing not only on NHS sites but also more widely on government and other public spaces and premises (Department of Health, Social Services and Public Safety, 2012; Public Health Agency, 2015; Department of Health (Northern Ireland) 2020).
The plan for England was that all NHS trusts should have smoke-free sites by 2020 and, although this has largely been achieved, its has been with varying success. In addition, all patients who smoke, regardless of the reason for their admission, will be offered smoking cessation support by 2023-2024, with many trusts already putting such initiatives in place (NHS England, 2017; NHS England and NHS Improvement, 2019).
Wales aims to denormalise smoking, offering smoking cessation services, including targeting certain groups, such as former prisoners and people with mental health issues, and ensuring that all public buildings, including government premises and NHS sites, are smoke-free (Welsh Government and NHS Wales, 2017; NHS Wales and Public Health Wales 2018a; 2018b; Public Health (Wales) Act, 2017).
Scotland is focusing on smoke-free sites across health and social care and access to smoking cessation services within hospitals, including nicotine replacement products being available (Scottish Government, 2013; NHS Health Scotland, 2015).
Northern Ireland highlights the need for smoke-free school gates and Gaelic Athletic Association touchlines, as well as NHS sites, and has based its guidance on the Monitor, Protect, Offer, Warn, Enforce and Raise (MPOWER) model developed by the World Health Organization (Scottish Government, 2013; NHS Health Scotland, 2015; World Health Organization, 2008).
Each of the four UK nations has considered how to facilitate smoke-free NHS sites, although understandably there will be differences based on the populations they are supporting. We also need to remember that tobacco smoking is an addiction and, as such, it is not a predetermined choice (NHS England and NHS Improvement, 2019).
Engagement
It is also necessary to consider whether some trusts and health boards are simply installing signage and making token gestures to ostensibly comply with their nation's policies on promoting smoke-free environments. Without engaging with strategies, such as supportive enforcement, why would smokers not continue to smoke on site, especially when their addiction is coupled with the uncertainty and stress that being a patient or visitor on an NHS site can engender.
‘Signage cannot be relied upon alone to implement positive and effective change, but needs to be supported with other elements’
Having smoke-free signage without proper follow-up, such as employing staff or recruiting volunteers to challenge and educate those who smoke, places the onus on patients, their visitors and staff to adhere unquestionably to this guidance.
Strategies such as those adopted at Medway NHS Foundation Trust (2016), (Public Health England (PHE), 2017) are good examples of how to ensure more collaborative and successful outcomes. The Trust has introduced five policies to enable sustained smoke-free sites. These involve:
The Trust places emphasis on the use of trained volunteers to highlight that the site is smoke free, while educating people about smoking cessation services, which has enabled progressive change. Enforcement of such smoke-free boundaries, supported with the positive element of education, can help denormalise smoking rather than stigmatise smokers (Welsh Government and NHS Wales, 2017).
Other key components to the enablement of smoke-free sites is the availability of nicotine-replacement products in hospital shops. This could perhaps be taken further by considering the benefits of having these products available across the full 24-hour window, for example through vending machines (Medway NHS Foundation Trust, 2016; PHE, 2017).
Smoke-free environments
It can be argued that Wales is leading the way among the UK nations: it has some of the most comprehensive policies of the four and Part 4 of the Public Health (Wales) Act (2017) is dedicated to tobacco and nicotine products, focusing on contemporary issues such as the sale of such products. Across the UK as a whole, many health and social care organisations have had some success in implementing smoke-free environments. However, there are inconsistencies in the measures taken, with sites that have still not yet fully implemented smoke-free status.
For example, signage cannot be relied upon alone to implement positive and effective change, but needs to be supported and nurtured with some of the other elements already mentioned. Neither can we treat this as a redundant issue, nor remain apathetic to its contribution towards future public health. Staff could perhaps also lead this positive change and make sure that, whether sites are smoke free or not, they personally do not smoke on site.
We should, however, remember that many trusts, health boards and the staff involved in enabling smoke-free sites are making huge inroads into the denormalisation of smoking. Most of those involved are likely agree that the work to reduce the exposure of everyone to primary and secondary tobacco smoke has not finished. Therefore, variations around signage, including more signage or larger signage, is not the only solution needed, because if done without other measures, it can be viewed as only a symbolic gesture.