In July the Government published its new Tobacco Control Plan: Towards a smoke-free generation. It envisages a future in which the prevalence of smoking could be reduced to 5 per cent or less – a smoke-free generation.
A key theme is an increased emphasis on the role of the NHS in tackling tobacco use. In terms of specific policy, the Plan includes a government commitment to “support the implementation of smoke-free policies across all hospitals in England”, aiming for a smoke-free NHS estate by 2020.
Renewed commitment to this policy puts it under the spotlight, but it is crucial that its merits be evaluated not on its own, but as part of a broader framework seeking to achieve the Plan’s ambitious targets.
What is the harm?
Accounting for 27 per cent of lung cancer deaths, 35 per cent of respiratory deaths, and 13 per cent of all circulatory disease deaths, the impact of smoking on the health service is readily discernible. In addition, smokers are 38 per cent more likely to die from surgery than non-smokers.
A smoker’s visit to an NHS site often serves to underscore the harmful effects of tobacco use, but it is exactly this that can make NHS sites conducive to smoking cessation. The increased tangibility of risk can encourage quit attempts. Plus advice from clinicians is, as the Plan argues, “one of the most effective ways of triggering a quit attempt”.
In promoting this mindset, the Plan picks up a thread already present in NICE guidance, Very Brief Advice training, and Making Every Contact Count. The smoke-free estates policy can serve to unify these strands, providing the necessary backdrop, as well as give renewed impetus to encourage more smokers to quit.
Prohibiting smoking on NHS estates is not a means to punish those who smoke, but instead underlines that they are places where the harms caused by tobacco are recognised and challenged, and where efforts to quit are fully supported.
How should it be done?
For smoke-free policies to be fully effective, the referral processes and cessation support they seek to bolster must be firmly in place. For those who aim to quit, cessation must be seen as a treatment; referrals to smoking cessation services must be embedded in care pathways.
Effective implementation requires strong leadership and staff buy-in. Duncan Selbie, Chief Executive of Public Health England, has written of how Medway NHS Foundation Trust, before the introduction of their smoke-free estates policy, offered staff free Nicotine Replacement Therapy (NRT). Helping staff to quit is an important part of the process identified by NICE, and it can help to bring staff on board – encouraging the ‘smoke-free champions’ that Selbie describes.
A comprehensive approach in line with NICE guidance is particularly crucial in mental health trusts. To complement its smoke-free policy, South London and Maudsley NHS Foundation Trust (SLaM) has ensured that all patients who smoke are supported, whether temporarily abstaining or starting a quit attempt.
Patients are offered NRT within 30 minutes of admission, as well as longer-term behavioural support to manage withdrawal symptoms. Those trying to quit can be referred to a specialist tobacco cessation adviser. E-cigarettes can also be used in specified areas on the site.
With this framework in place, SLaM’s smoke-free policy has not only encouraged patients to reduce their tobacco use, but has also seen the rate of physical assaults at the trust – both between patients and towards staff – drop by 39 per cent.
At what cost?
Under current financial conditions, policies like smoke-free estates may seem extracurricular. But, as the Five Year Forward View argues, preventative measures must be central to any efforts to reduce costs.
In London alone, it has been estimated that savings of around £2.6 million a year could be made if between 8 per cent and 17 per cent of smokers quit before having surgery.
The Welsh Government, which has since mandated smoke-free hospital grounds, has estimated that supporting smokers to quit before having surgery could save as much as £2.3 million every year. (These savings are derived from ‘bed days’ saved and the reduced cost of treating post-operative complications.)
Meanwhile, the Plan charts the cost of smoking to the economy as exceeding £11 billion per year, of which £2.5 billion was borne by the NHS. It has also been estimated that smoking increases the cost burden of social care to local authorities by a further £760 million.
What do the public think?
Public support for a ban on smoking in hospital grounds has grown in recent years. ASH’s Smoke-free Great Britain surveys, conducted by YouGov, show in that England agreement with the proposal stood at 62 per cent in 2011,1 rising to 69 per cent in 2014.2 In 2017, 72 per cent agreed, with only 15 per cent against the idea.3 Support for this measure is particularly pronounced in the north east, where rates of smoking-related illness and death are at their highest in England.
Rolling out smoke-free NHS estates is not about making an example of smokers.
Instead – as the Plan makes clear – it is about enabling the NHS to lead by example. By creating an environment in which smoking cessation is fully supported, the NHS’s attempts to promote health and wellbeing can be strengthened.
It can also help to bolster the efforts of those who want to quit, at a time when the benefits of doing so are at their most stark.
1. ASH and YouGov, Smoke-free Survey 2011. All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 10,238 adults in England. Fieldwork was undertaken 3-15 March 2011. The survey was carried out online. The figures have been weighted and are representative of all adults in England (aged 18+).
2. ASH and YouGov, Smoke-free Survey 2014. All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 10,112 adults in England. Fieldwork was undertaken 5-14 March 2014. The survey was carried out online. The figures have been weighted and are representative of all adults in England (aged 18+).
3. ASH and YouGov, Smoke-free Survey 2017. The survey was carried out online by YouGov for ASH; the total sample size was 10,488 adults in England. Fieldwork was undertaken between 16 February 2017 and 19 March 2017. The figures have been weighted and are representative of all adults in England (aged 18+).
Euan Holmes is a Policy and Campaigns Assistant at Action on Smoking and Health.
Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Holmes, E (2017) "Win win: how smoke-free policies can benefit both the NHS and its patients". Nuffield Trust comment. www.nuffieldtrust.org.uk/news-item/win-win-how-smoke-free-policies-can-benefit-both-the-nhs-and-its-patients