Prohibiting smoking outside hospital buildings: consultation analysis

Section 1: No-Smoking Area

Question 1: Do you support the proposal that the distance from hospital buildings which will form the perimeter of the no-smoking areas outside a hospital building should be 15 metres?

Context

The Scottish Government does not believe it would be practical to introduce a statutory ban on smoking covering the entire extent of NHS hospital grounds. Such a ban could be hard to enforce as many hospitals cover large areas of land, and it is considered to be a disproportionate response to the problem of smoking being visible and potentially harmful where it is most undesirable - around buildings and near building entrances and windows.

The policy memorandum for the 2016 Act highlights that there is evidence from studies of second-hand smoke in outdoor environments which suggest that smoke-drift from outside can lead to levels of second-hand smoke inside building entrances and windows which may be high enough to warrant concern for people inside a building. The highest risk from smoke-drift will depend on the environment, but it is reasonable to expect that a no-smoking perimeter of 10 metres could provide adequate protection while a perimeter of 15 metres would reduce risk significantly.

During the Bill process, Scottish Ministers indicated that the perimeter of no-smoking areas would ideally be 10-15 metres from hospital buildings. This focuses on the busiest areas where the majority of patients, visitors and staff pass through and where the bulk of non-compliance with the current administrative ban takes place. Ministers also committed to consult with health boards on the distance of the perimeter to be applied across all NHS hospital sites, and a distance of 15 metres is proposed.

Overview

A clear majority of respondents agreed that the perimeter of the no-smoking area should be 15 metres from hospital buildings (72%), Table A1.

Organisations noted stronger levels of agreement with the proposal than individuals. There was relatively little variation in responses across most organisation types. That being said, while the majority of third sector organisations supported the proposal, a relatively high proportion did not (25%).^[11]

Many of the respondents that were in favour of setting the perimeter at 15 metres considered the proposed distance "necessary", "justified" and/or "sufficient" to significantly reduce health risks for patients, visitors and staff.

There was wide reference made to areas around hospital buildings where smoking is most prevalent (e.g. at or near entrances, windows, vents), and that this was considered harmful and presented a public health risk to anyone entering or leaving hospital buildings.

There was strong reference made to exposure to second-hand smoke and smoke drifting indoors, including some reference to the existing evidence base. It was frequently noted that smokers often congregate at or near hospital entrances, and this was considered to be "obtrusive", "unpleasant" and/or "harmful" for patients, visitors and staff, and in particular for those with ill-health, those recovering from illness, people with asthma, children, pregnant women, etc. Others mentioned wider issues such as increased litter around hospital entrances and buildings.

"Given the health risks associated with smoking no one attending a place of treatment for ill health should be exposed to other risk factors".
Individual

"It creates litter, there are wheelchairs being used that should be for emergency cases and smoke travels up to the postnatal ward creating obvious dangers".
Individual

Wider points made included that the 15 metre perimeter would send a clear message that NHS Scotland hospitals were "health promoting health environments", and would support the "de-normalisation" of smoking. A further comment was that the implementation of smoke-free environments could contribute to a reduction in smoking rates across the population.

However, many respondents in support of the 15 metre perimeter went onto report that they would prefer the no-smoking area to extend beyond this distance.^[12] Where suggestions were made, this ranged from 20 to 50+ metres. A related point was that there might be instances when the perimeter might need to be extended if, for example, it ends at a hazard (e.g. a road).

Further, some questioned whether smoking should be allowed anywhere on hospital grounds (i.e. a statutory ban). Here, a variety of comments were made, including that: allowing smoking anywhere near a hospital building sends the wrong message; it gives the impression of "NHS tolerance of the habit"; the 15 metre perimeter would still allow people to smoke on hospital grounds (i.e. signals that it is acceptable behaviour); and/or a statutory ban across all hospital grounds could be easier to understand and implement. Some NHS bodies also noted that allowing smoking anywhere on hospital grounds was contradictory to the smoke-free hospital grounds policy - the general view was that this sends out "mixed messages", could add "confusion", and/or that it goes against the NHS leading the way and being an exemplar of health promotion.

"NHS Grampian has a number of sites with numerous buildings and walkways. It would be easier to enforce the legislation if it covered the whole grounds and not just 15 metres, and easier to explain to staff and the public."
NHS Grampian

"….if hospital grounds remain "smoke free"....there could be situations where offenders are 16m away and therefore cannot get a fixed penalty notice by Officers, however, are still in contravention of hospital policy".
Renfrewshire Council

Some respondents raised concerns that, despite implementation guidance from NHS Scotland, the existing smoke-free hospital grounds policy had not stopped smoking on hospital sites. There was broad reference to challenges/difficulties in encouraging people to completely respect the smoke-free hospital grounds policy.

"I am fed up reporting this to security who tell me they are powerless to do anything".
Individual

"Having approached numerous people over the years to point out they should not be smoking on hospital premises, I have only been ignored or taken some backlash for asking politely for them to move or not smoke".
Individual

Based on their current experience at hospital sites, many respondents touched on the importance of monitoring the effectiveness and enforcement of the perimeter of the no-smoking areas outside a hospital building - it would need to be "better policed". The main message was that the agreed perimeter would need to be enforced and strictly adhered to - "otherwise people will continue to smoke...beyond the 15 metre line".

Concerns were widely raised about the practicalities of effective enforcement, and a common view was that this could be challenging. Related points were that:

• It could be difficult for individuals to gauge the exact extent of the 15 metre no-smoking area. It was suggested that this was "vague" and/or that clear demarcation, markings and boundaries would be required to ensure that there was no dubiety - "everyone has a different perception of what 15 metres looks like". A wider suggestion was that a "real-world object that measures approximately 15 metres could be used to explain what is meant by a perimeter of that size".
• Signage on its own was considered insufficient to increase awareness and achieve the behaviour or culture shift required around tobacco use - "current no-smoking signs outside hospitals are blatantly ignored".
• Penalties/fines could be considered for those who continue to flout the ban.

A small minority of respondents that supported the 15 metre perimeter were supportive of designated smoking shelters or areas. There was recognition that smoking was an "addiction" and a difficult habit to break, of peoples' freedom to choice to smoke, and/or that it might be easier to implement the 15 metre perimeter if there were designated spaces for people to smoke. But there were strong calls for careful consideration of the location of any designated smoking shelters (i.e. not near entrances or windows). A wider point raised was that smoking restrictions could have the potential to "marginalise people who smoke" if "not implemented with care".

These points are reflected in the quotes below.

"They're going to smoke anyway, so I think there should be an allocated (covered/sheltered) space that they can go to that won't cause a health issue for everyone else."
Individual

"Although depending on how this is implemented, visitors may still need to walk through the "fog" of smoke as they approach the building, so preferably, if setting up designated areas, these are not on the paths en route to the door".
Individual

Another challenge identified was the perceived lack of clarity around who would be responsible for monitoring the perimeter's implementation. Specific concerns were raised around hospital staff receiving abuse from people who smoke.

"A major concern from staff was the enforcement of this legislation as the burden appears to fall on clinical staff although avoided by most for fear of verbal aggression and abuse."
NHS Highland

There were wider comments that the Scottish Government could work in partnership with others (e.g. local government) to implement the legislation, and that there would need to be additional resources and support for the NHS to apply regulatory sanctions and to make it work in practice.

Around one-quarter of respondents did not support the proposal that the distance from hospital buildings which will form the perimeter of the no-smoking areas outside a hospital building should be 15 metres (26%), Table A1.

Individuals were more likely to oppose the proposal than organisations.

There were some similarities in the feedback from respondents that did not support the proposal with those that did. Firstly, a relatively large proportion of these respondents also felt that the perimeter should be greater than 15 metres (e.g. 20 to 30 metres were suggested), or that there should be no smoking on hospital grounds at all (e.g. including car parks, bus stands).

"I am not exposed to passive smoking anywhere….except from if I go to a hospital, this has to change".
Individual

Other common views provided by those who did not support the proposed 15 metre perimeter were that:

• It would be difficult to police its implementation and concerns were raised about how it would be resourced. Some felt that it would be easier to enforce a complete ban on smoking on all hospital grounds.
• It would be complicated to explain and for the public to understand. It might also be necessary to use different units of distance (e.g. yards, feet).
• It would send a message that it is acceptable to smoke on hospital grounds regardless of the fact that it presents a significant public health risk. Also it could be seen as misleading given the smoke-free hospital grounds policy.
• Some people might react with hostility or aggression if they were challenged about smoking in a no-smoking area, and staff might feel threatened.

Other common themes that emerged from the feedback of respondents that did not support the proposed 15 metre perimeter can be grouped as follows:

• It was perceived to be restrictive, and lacked compassion for those who want to smoke/who are addicted to nicotine/who smoke as a coping mechanism. Individuals have a right to choose to smoke.
• Being denied permission to smoke could be stressful for patients, visitors and staff. Particular reference was made to individuals with mobility issues or those who were grieving, and/or that there might require to be some exemptions (e.g. vulnerable patients, psychiatric patients).
• A few respondents felt that the perimeter should be less than 15 metres (e.g. 5 or 10 metres were proposed).

"For disabled and infirm people this distance will cause unfair distress at a time that's already stressful".
Individual

"This should not be the case for psychiatric hospitals due to the need to manage patients who may present an element of risk of absconding".
Mental Health Network Greater Glasgow

Amongst those that opposed the 15m perimeter, there was support for designated smoking rooms/shelters on hospital grounds. Most agreed that these should be located away from the entrances of hospital buildings, although there were some concerns raised about how disabled people, those with mobility issues, older people and the infirm could easily access these areas. A few individuals did suggest designated smoking rooms inside hospital buildings.

Question 2: Do you support the proposal that the perimeter should be measured from the outside wall of a building and include all land or area under any canopy or overhang even where those extend beyond 15 metres?

Context

There will be two situations where the actual perimeter could be greater than or less than 15 metres. The no-smoking area can only cover hospital grounds. So at any point where hospital grounds do not extend to 15 metres the no-smoking area perimeter will match the distance to which the hospital grounds extend.

Hospital buildings are of various age, design and construction. The Scottish Government also want to make sure smoking is not allowed anywhere under canopies or overhangs. Many hospital buildings have incorporated walkways, canopies and other covered structures designed to provide protection from the elements. These structures may extend beyond the 15 metre distance. Some hospitals have reported incidents where people have gathered under canopies and other structures to smoke. This creates an obstruction and air-quality hazard.

To prevent instances such as this, the proposal is that the no-smoking area should include all the land and areas beneath such canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building.

Overview

The majority of respondents agreed that the perimeter of the no-smoking area should be measured from the outside wall of a building, and include all the land and areas beneath canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building (72%), Table A2.

Organisations noted stronger levels of agreement with the proposal than individuals. The distribution of responses was very similar to Question 1.

Question 2 received fewer open-ended comments than the previous question, with some respondents cross-referencing to the point(s) they made at Question 1. The main feedback from these respondents was that the actual perimeter should be greater than 15 metres and/or that the ban on smoking should cover all hospital grounds.

These points aside, there was strong support that smoking under canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building, should not be allowed, and that these should be smoke-free areas.

Such an approach was generally considered vital to ensure that smoking on hospital grounds was undertaken at a safe distance from others entering, leaving or moving between hospital buildings - even if this meant it is beyond the proposed 15 metres. A common view was that people tend to congregate under canopies, overhangs and entrance ways to smoke, and that these "semi-enclosed" areas are often used as "impromptu smoking shelters". It was further noted that the proposal could help reduce exposure to second-hand smoke "which is likely to be exacerbated in more enclosed spaces".

"…in the process of engaging with patients (to inform consultation response) we observed many smokers utilising sheltered areas with an overhang to smoke".
Mental Health Network Greater Glasgow

It was also noted by some respondents that adopting this proposal would ensure that outdoor Environmental Tobacco Smoke (ETS) around hospital buildings does not reach levels that pose a health hazard to hospital patients, staff and visitors.

Here, there was wider reference to research that shows when people smoke in "semi-enclosed" spaces, levels of ETS can exceed hazardous levels as defined by the World Health Organization (WHO), and presents a public health risk. Further, when outdoor ETS can reach high levels where tall buildings are close together it was reported that this creates a "canyon" where cigarette smoke can become concentrated.

Some respondents, however, suggested that the actual perimeter distance should be measured from the point where any canopies or overhangs end.

"At least 15 metres beyond the furthest point of cover canopy. Not 15 metres beyond the outside wall this would defeat the purpose on some hospital grounds".
Individual

"I think it should be measured from the end of the canopy or overhang as that is still effectively "indoors" since it is covered with little air circulation".
Individual

"This should be from the exterior doors and walls - it is essential that internal courtyards, gardens canopies, etc. are classed as being inside the building and that the 15m starts from the outer edge of any canopy. We are very concerned that buildings with secure therapeutic courtyards, gardens, etc will no longer be smoke free if the definition is not the outer wall of the building and outer edge of any canopy".
NHS Lothian

A number of similar points were raised to those noted by respondents in Question 1, namely that:

• Managing the implementation of the perimeter of the no-smoking area that includes all the land and areas beneath canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building might be more difficult than a statutory ban on smoking covering the entire extent of NHS hospital grounds.
• It would also be difficult or challenging to explain this proposal to staff, visitors and patients, and for people to be clear on the distance/boundaries.
• There would need to be clear signage, and all no-smoking areas would need to be clearly demarcated and lines displayed (including on the ground) to highlight restricted areas to avoid any confusion or dubiety among patients, visitors and staff alike.

"For Royal Infirmary of Edinburgh in particular, the public may not be aware that the bus hub would probably be included in the 15 metres away from the hospital building - currently people do smoke at the bus hub, although not inside the bus-shelters".
Individual

Wider points raised, but to a lesser extent, included:

• Concerns about littering around semi-enclosed areas within hospital grounds.
• Questions were raised around how enforcement action would be resourced. Enforcement action was considered key to ensuring people did not smoke near hospital buildings.
• There was some reference to prohibiting smoking near bus stops/shelters/ hubs, car parks, and children's play areas.
• Consideration could be given to creating designated smoking areas/shelters in adherence to the proposed 15 metre perimeter.

One-quarter of respondents did not agree that the perimeter of the no-smoking area should be measured from the outside wall of a building, and include all the land and areas beneath canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building (25%), Table A2. Individuals and third sector organisations^[13] were more likely to note disagreement with the proposal.

The main feedback from these respondents echoed points raised in Question 1, and by those that supported the proposal that the perimeter of the no-smoking area should be measured from the outside wall of a building, and include all the land and areas beneath canopies or overhangs, even where they measure more than 15 metres from the side of the hospital building.

The most common points raised included a combination of the following points: that there should be no smoking at all in hospital grounds, or the actual perimeter should be greater than 15 metres, or it should at least be measured from the point where any canopies or overhangs end.

Further, some respondents felt that the proposal was too "punitive" against smokers. The most common feedback from these respondents was that canopies and overhangs provide shelter for smokers from the elements. These (and other respondents) felt that there could be accessible smoking shelters or smoking zones on hospital grounds.

"Completely unnecessary and deeply uncaring to patients who may be unable to walk."
Individual

"There should be a covered "smoking zone" open on at least 3 sides created a distance away from the normal traffic route and hospital entrances".
Individual

A couple of specific comments were made about canopies or overhangs which were 50%+ open to the elements, as reflected in the quote below.

"If the canopy or overhang extends beyond 15 metres, and the area beneath it is over 50 per cent open to the elements (and therefore not an enclosed space) we do not accept that patients, some of whom may be infirm or elderly, should be forced to move even further from the hospital building if they wish to smoke. In the absence of a proper smoking shelter, we believe it is cruel and petty to deny them even a small degree of shelter under a canopy or overhang that extends beyond 15 metres from the hospital buildings".
Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST)

Wider points, but raised to a much lesser extent were:

• Concerns around the practicalities and resourcing of enforcement, and that some people would continue to smoke in semi-enclosed areas or just beyond the 15 metre line.
• It was considered that 15 metres (and longer if extending the area to include overhangs should that extend beyond 15 metres) was too great a distance for some patients to walk. A few suggested exemptions could be considered for vulnerable patients and/or specific types of hospital (e.g. hospices used for palliative care).