Prohibiting smoking outside hospital buildings: consultation analysis

Introduction

About This Report

This report presents the main findings from an analysis of responses to the Scottish Government consultation on Prohibiting Smoking Outside Hospital Buildings. The consultation was open from 8^th October 2019 to 17^th January 2020.

Background

The Scottish Government is committed to raising a tobacco-free generation by 2034 and to reduce the prevalence of smoking to 5% or less by that same year.^[5] Indeed, "a Scotland where we reduce the use of and harm from alcohol, tobacco and other drugs" is identified as one of six Public Health Priorities for Scotland.^[6]

While smoking rates have significantly declined with fewer people taking up the habit, and the proportion of ex-smokers outnumbering the number of smokers for the first time in 2013, there is still more that needs done to achieve the 2034 target. Indeed, smoking tobacco products continues to be one of the greatest threats to public health in Scotland and remains the most significant cause of preventable disease in the country. It results in up to 100,000 hospitalisations each year and more than 9,000 premature deaths. One in four of all deaths in Scotland are attributable to tobacco.^[7]

The NHS should be an exemplar of health promotion and support people in their efforts to stop smoking - accessible and open places which promote good health and lifestyle choices. The introduction of offences for smoking in enclosed public spaces in 2006, including inside hospital buildings, is a notable success. Despite NHS Scotland subsequently adopting a smoke-free hospital grounds policy across all of its hospital sites in 2015, people smoking on hospital grounds continues to be a nuisance and poses a potential health risk to patients, visitors and staff. While the smoke-free grounds policy has had some impact, smoking on hospital grounds continues to be the subject of many complaints to health boards and to government.

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 amended sections of the Smoking, Health and Social Care (Scotland) Act 2005 to allow offences to be introduced in respect of smoking around hospital buildings. The 2005 Act now provides for the introduction of formal no-smoking areas outside hospital buildings and for offences of allowing smoking in these areas and of smoking in these areas.

The primary aim of introducing a formal no-smoking area around hospital buildings is to support the de-normalisation of smoking and to help reduce the use of tobacco across the population. It also aims to prevent or reduce exposure to second-hand smoke outside and inside hospital buildings to improve and protect public health.

The Act gives Ministers the powers to make secondary legislation ("Regulations") to finalise the details before these provisions can be brought into force.

The Scottish Government has worked with health boards and other stakeholders to develop practical proposals for an effective set of regulations that will persuade people to respect others and not smoke around hospital buildings. The purpose of this consultation was to seek views on the three matters which remain to be determined:

1. The distance from hospital buildings which will form the perimeter of the no-smoking areas outside a hospital building, and how the perimeter around the building is determined in so far as whether the perimeter ends the specified distance from a wall or from any part of the building structure or otherwise.

2. The manner of display, form and content of no-smoking notices.

3. Whether there are any exceptions required for specific hospitals or specific buildings, or specific areas of land which should not be considered hospital grounds or part of the no-smoking areas respectively under the definitions in the Act.

The consultation also sought views on the use of Nicotine Vapour Products (NVPs) - including electronic cigarettes - around hospital buildings, a question not raised at the time of the 2005 Act.^[8] Current evidence shows that the use of NVPs is less harmful than smoking and the proportion of smokers who are also using NVPs is growing. This presents an opportunity to consider if the smoking policies of health boards should now allow vaping on hospital grounds to eliminate the continued flouting of NHS policies aimed at preventing smoking anywhere on hospital grounds. Many NHS Boards allow vaping but some do not. There is a need for consistency, a Scotland-wide approach, and clear guidance to health boards on whether the use of NVPs on hospital grounds should be allowed as an alternative for smokers visiting or working in hospitals.

The findings from this consultation will be used by Ministers to finalise the detail of the Regulations, and for these provisions to be laid in the Scottish Parliament.

Analysis Methodology

The Scottish Government provided EKOS Ltd access to all responses via Citizen Space. A few responses were not submitted through this route, and did not always follow the consultation structure (e.g. letter response to the Scottish Government), or answer the individual consultation questions. Where this was the case, the Scottish Government manually inputted the responses into Citizen Space for inclusion in the overall analysis.^[9]

Quantitative (closed questions) and qualitative (open-ended, free text questions) responses were exported into Microsoft Excel for subsequent analysis. All closed questions have been presented in table format in Appendix A, and qualitative responses have been sorted and analysed to identify common themes. The analysis identifies common themes and issues as opposed to reporting on every point raised.

Profile of Respondents

A total of 586 responses were received to the consultation. During the data "cleaning" phase, 27 responses were either combined or removed for the following reasons:

• Duplicate responses (i.e. the same individual responded twice and submitted identical responses). In these cases multiple responses from the same individual were merged into one response.^[10]
• Responses that did not include a name or an email with an identifiable name.
• Responses that included a percieved made-up name and/or email address that meant responses could not be clearly or easily attributed. These were classed as invalid.

The consultation received a total of 559 valid responses, of which the vast majority were from individuals (Table 2). Based on a review of the open-ended responses and/or email addresses, many of the individuals that responded to the consultation worked in the health sector in Scotland.

Table 2: Profile of Consultation Respondents

	Number	Percentage
Individuals	513	92%
Organisations	46	8%
Total	559	100%

The consultation attracted responses from a diverse range of organisations. NHS bodies represented almost half of all organisation responses (e.g. NHS Boards, hospitals and health and social care partnerships), Table 3. Further, three NHS responses included the feedback and views gathered through their own consultation process which involved staff and/or patients. This was followed by third sector organisations (e.g. health improvement organisations/charities as well as smokers' rights bodies). Other public sector bodies were represented by local government and a related membership body. Educational institutions comprised medical professionals' institutions and a health research consortium.

Table 3: Organisation Type

	Number	Percentage
National Health Services	21	46%
Third Sector	9	20%
Other	6	13%
Other Public Sector Body	5	11%
Educational Institution	5	11%
Total	46	100%

Note: 'Other' organisations included unions, advocacy and trade associations.
Percentages have been rounded, therefore totals might not equal 100%.

Consultation Limitations

Respondents to any consultation are self-selecting. Smoking is also a sensitive and emotive topic matter. As is to be expected, the consultation attracted responses from those who strongly supported the proposals as well as some who did not. There did not appear to be any campaigning responses.

Report Structure

The remainder of the report has been structured in line with the consultation document which consisted of eight questions:

• Section 1 covers Questions 1 and 2, and is related to the regulations concerning the perimeter of no-smoking areas.
• Section 2 covers Question 3 on no-smoking notices.
• Section 3 covers responses to Questions 4, 5, and 6 which are related to any exceptions required for specific hospitals or specific buildings, or specific areas of land which should not be considered hospital grounds or part of the no-smoking areas.
• Section 4 covers responses to Question 7 concerning the use of NVPs.
• Section 5 covers responses to Question 8 on equalities.

Additional information is contained within the Appendices.