Prohibiting smoking outside hospital buildings: consultation analysis

Section 2: No-Smoking Notices

Question 3: Do you support the proposal to set the wording and dimensions of no smoking notices as described above?

Context

It is proposed that the Regulations should prescribe two different types of notice warning people of the existence of the statutory no-smoking area. The Act stipulates that these notices must state that it is an offence to smoke in the no-smoking area outside a hospital building or knowingly permit smoking there.

The first type of notice would be placed at the entrance to hospital grounds and measure one metre square. The second type of notice would be A3 size and be placed at the entrances to hospital buildings. However, we will also encourage hospitals to display this size of notice at different strategic locations on or near hospital buildings. The grounds notices would include the wording:

• "It is an offence to smoke or knowingly permit smoking in the no-smoking area outside a hospital building".
• "No smoking areas extend up to 15 metres around affected buildings and include all areas under canopies or other overhangs on those buildings".
• "Penalties and fines apply".
• "If you observe someone smoking in the no-smoking area, a complaint may be made to a member of hospital staff".

Overview

Around two-thirds of respondents supported the proposal to set the wording and dimensions of no-smoking notices as described above (67%), Table A3. Individuals expressed slightly higher levels of support for the proposal than organisations.

Almost three-quarters of respondents who agreed with the proposal did not leave any wider commentary on the suggested wording or dimensions.

Where comments were provided, these can be grouped into generic comments or specific comments on the proposed wording and/or dimensions of notices.

In terms of the more general feedback, the main themes that emerged from the consultation responses were that:

• All notices must be clear, prominent and highly visible at entrances to hospital buildings and at key strategic locations to ensure that staff, visitors and patients are made fully aware of the no-smoking Regulations. Support was expressed for standardised wording across notices at NHS hospital sites to ensure consistency and to reinforce key messages.
• There is a strongly held perception that current no-smoking signage on hospital grounds are largely ignored, that smokers are not always challenged for smoking on hospital grounds, and/or that the smoke-free hospital grounds policy is not effectively enforced. The main feedback was that signage and better monitoring and enforcement (i.e. penalties and fines) were needed. Concerns were raised that if the perimeter was not policed (e.g. use of Enforcement Officers, CCTV) then notices would have no effect. A related point was that some respondents noted a potential conflict between the 15 metre perimeter and the smoke-free hospital grounds policy - it has the "potential to create confusion".
• There was equally strong feedback that signage on its own might not be sufficient to encourage people to respect smoke-free areas, or to achieve the Scottish Government's stated goal of reducing the use of tobacco. Suggestions included the need for: communications campaigns, media coverage, print materials, a freephone number to make complaints, public announcement systems, collaboration with key stakeholders to increase awareness of the Regulations in communities before people arrive at the hospital, and sign-posting to smoking cessation services.

"We therefore recommend that clear signage and communications highlighting Scotland's 'Quit Your Way' approach, and advertising the stop smoking support available to people for free on the NHS, be placed alongside no smoking signage at hospitals. Doing this would encourage staff, patients and visitors to use a visit to or stay at a hospital as a unique opportunity to start on the road to quitting smoking. It would also raise awareness of the comprehensive and effective stop smoking support already available to them for free through NHS Scotland".
ASH Scotland

"Case studies of smoke-free regulations and policies in other countries show that while visible signage is an important element to encourage people to respect smoke-free areas, successful implementation is hindered without: staff training on communicating the rationale to patients and visitors, clarity on enforcement responsibility, and how to compassionately draw attention to stop smoking services and offer support….By being required to add supplementary signs in addition to mandatory notices, hospitals are more likely to see greater compliance with these regulations".
Cancer Research UK

• There was a strong call for clear and comprehensive guidance to be provided to health boards/hospitals on roles and responsibilities regarding the implementation of the new Regulations and on the practicalities of enforcement. It was noted that all members of staff would need sufficient information, training and support regarding the new Regulations and what is expected of them (e.g. clear protocols).
• Some respondents raised concerns about the potential verbal abuse, confrontation, and/or aggressive behaviour staff might receive should they challenge someone smoking in a no-smoking area. It was further noted that staff might not feel "confident" or "safe" or feel "powerless" to take action - "opens up the possibility of criminalising staff who are aware of smoking within the 15 metre limit, but do not have the confidence, authority, or capacity to prevent it happening". A related point was that hospital staff are already "stretched" and the Regulations could place additional burden on hospital staff.

Many respondents went on to provide specific feedback regarding the proposed wording of no-smoking notices:

• Some felt that notices should contain "stronger" language to send a clear signal that smoking would not be tolerated on hospital grounds, and for the notices to be taken seriously.
• The signs could include details of enforement action, including more specific information on the penalties/fines that would be imposed. Some felt it would be important to send a clear message regarding on-the-spot fines and/or that legal action would be taken to aid compliance - "…not put off by the threat of penalties or fines. It would have to happen for it to be effective".
• Sign-posting to smoking cessation support services.
• Sign-posting to where designated smoking shelters or zones can be found.

Table 4 presents a summary of the main points raised regarding the proposed wording of notices.

Table 4: Feedback on Proposed Notice Wording

Proposed Wording on Notices: "It is an offence to smoke or knowingly permit smoking in the no-smoking area outside a hospital building".

Main Feedback: This could be clearer, more concise, or phrased differently to avoid any confusion and to ensure it is easily understood. A number of comments made specific reference to the term "knowingly permit smoking", and that this could be rephrased as it was perceived to be subjective. The notice could include additional wording such as "please respect our staff, patients and visitors by not smoking in this area/hospital grounds", how much smoking related illness costs the NHS, and the benefits of stopping smoking.

Proposed Wording on Notices: "No smoking areas extend up to 15 metres around affected buildings and include all areas under canopies or other overhangs on those buildings".

Main Feedback: There would need to be clarity provided on where no-smoking areas start and end. Many felt that the 15 metre perimeter would need to be defined in a way that is easily understood and marked visually in some way.

Proposed Wording on Notices: "Penalties and fines apply".

Main Feedback: This could be more exact, for example, including numbers or amounts (e.g. total maximum fine). On-the-spot fines could be considered.

Proposed Wording on Notices: "If you observe someone smoking in the no smoking area, a complaint may be made to a member of hospital staff."

Main Feedback: The term "hospital staff" was considered too generic (e.g. does it mean any member of staff, or just medical staff?). It might be better to specify reception, security staff, building managers or a specific point of contact during the day and in the evening (e.g. a specific team, office, or department). Details regarding where a complaint can be made should be clear to provide assurance to the public that appropriate action would be taken if a complaint is made. This could include details about the individual, a dedicated telephone number, email address, etc. A wider suggestion was that this could be addressed through the NHS Boards existing complaints procedure.

There were fewer comments made regarding the proposed dimensions of no-smoking notices. Where comments were made, most reported that notices should be at least the size of A3 or larger to be noticed and to increase compliance.

Less than one-third of respondents did not support the proposal to set the wording and dimensions of no-smoking notices as described at Question 3 (29%), Table A3. Third sector organisations and educational institutions were slightly more likely to oppose the proposals. The most common feedback was as follows:

• It was considered unfair that the onus was being placed on all hospital staff to enforce the Regulations. Specific concerns were raised about the inherent challenges of monitoring and enforcing the Regulations and/or staff not having the confidence or authority to take action and/or that it could leave staff vulnerable or subject to abuse. Most considered the proposal "inappropriate" and/or that staff would be "reluctant to intervene". A wider point made was that it could "impact on the therapeutic relationship of staff and patients" linked with mental health services.
• A common suggestion was that any queries and complaints should be made to a designated person or service responsible for monitoring infringement of the smoke-free area rather than any member of hospital staff (and appropriate training provided), or to an organisation charged with the "dispensation of legal sanctions against contraventions of the criminal law" (i.e. Police). Related points included calls for additional resources for Environmental Health Officers to undertake regular spot checks across hospital sites, or the need for security staff to patrol the no-smoking area.
• Similar points to those raised by respondents that supported the proposals outlined at Question 3, were also noted:
  • No-smoking notices should be informative, clear and concise - and not misleading (i.e. potential conflict with smoke-free hospital grounds policy).
  • Stronger language could be used (e.g. a signal that prosecution is likely).
  • Larger and/or more visual notices and signs that are more "hard-hitting" (e.g. notices could include information on the health risks of smoking, graphic images like those on cigarette packets).
  • The value of penalties and fines should be made clear on notices and be sufficient to deter smoking.
  • The 15 metres should be clearly marked out to aid understanding.
  • Sign-posting to designated smoking areas.
  • Sign-posting to smoking cessation services.

"In discussion with colleagues in NHS Boards, it has become apparent to us that the proposed wording may not make clear who is responsible for managing buildings. This is the case where hospital sites also cover areas of University research and teaching facilities. Those responsible for managing the buildings should be responsible for handling complaints - guidance and support will be required for sites to clarify this".
SPECTRUM - Shaping Public hEalth poliCies To pRevent ineqUalities and harM

"These signs will be misleading. They would need to set out the overall smoking policy on the grounds generally, including highlighting it is contrary to hospital policy to smoke anywhere in the grounds (except in designated smoking areas) where this is the case. The signs would suggest that it is acceptable to smoke in the grounds as long as someone is more than 15m from a building which is not necessarily the case where an NHS Board has a separate policy banning smoking from all hospital grounds".
Individual

There were a few comments that the proposed wording was either too "negative" "threatening" or "punitive" (in general but also for people with health issues or who might be anxious or stressed), that the notices were considered "discriminatory", or that tobacco was a legal product and people should be able to smoke anywhere.

"I do not believe that penalties and fines should apply, certainly if the person smoking is extremely upset or stressed. It is an overreaction and is likely to make a patient worse, rather than better….. Stress and anxiety are far worse, especially when trying to recover from an illness or surgery, than smoking is, at that time".
Individual

"People visiting hospitals, either for treatment or to visit loved ones who are ill, do not need to be confronted with this kind of threatening signage".
Individual