Prohibiting smoking outside hospital buildings: consultation analysis

Section 4: Nicotine Vapour Products on Hospital Grounds

Question 7: Do you support the proposal that the use of NVPs should be allowed as an alternative to smoking on hospital grounds but not within the no-smoking area outside hospital buildings?

Context

In addition to questions relating to the specifics of the 2016 Act, the Scottish Government sought views on proposals to ask NHS boards to amend their smoking policies to permit the use of NVPs, including electronic cigarettes, on hospital grounds but outwith the proposed no-smoking area.

The intention of the new offences is to eliminate smoking around buildings where continued smoking causes most inconvenience and harm. However, NHS Scotland already has a policy in place which asks people not to smoke anywhere on hospital grounds. The aim of the new offence is not only to move smoking away from the building but to remove smoking completely from hospital grounds. Allowing smokers to vape on hospital grounds could reduce the 'need' to smoke there for many people.

There is now a consensus statement on the use of NVPs that has been drawn up by a range of signatories including public health professionals - such as the Chief Medical Officer for Scotland, academics - the universities of Edinburgh and Stirling, health lobbying groups - such as ASH Scotland and Cancer Research UK, and many others. It states that, based on current evidence, vaping e-cigarettes is less harmful than smoking tobacco. Although "not risk free", these devices pose "a much lower risk than tobacco" and are useful to public health as a potential route towards stopping smoking.

Given the potential of NVPs in harm reduction and as a means to help people quit tobacco products, to ban their use on hospital grounds would be contrary to the ethos of the consensus statement. In addition, permitting use of a less harmful device for those smokers who may struggle to cope without nicotine during potentially stressful visits to hospital would be in line with the NHS's compassionate approach: that it appreciates smoking is, for some people, a difficult habit to break but advises people to seek support to quit.

Therefore, it is proposed that NHS boards should be asked to amend their smoking policies to permit the use of NVPs as an alternative to smoking on hospital grounds but only beyond the no-smoking area outside hospital buildings.

Overview

There were mixed views provided to Question 7 - some 48% supported the proposal and 45% did not, Table A7.

As mentioned, almost half of respondents supported the proposal that the use of NVPs should be allowed as an alternative to smoking on hospital grounds but not within the no-smoking area outside hospital buildings:

• Highest levels of support were expressed by other organisations (60%), NHS (50%), and third sector organisations (50%).
• Lower levels of support were expressed by educational institutions (33%) and other public sector bodies (20%).

The vast majority of these respondents did not provide any wider feedback or comments on the Scottish Government proposal.

Where comments were made, the main message was that vaping e-cigarettes "should be treated in the same way as tobacco" throughout hospital sites in Scotland - for consistency in messaging and communications about the no-smoking perimeter, and for ease of enforcement.

"This will limit the potential for misinterpretation of the regulations governing the no-smoking perimeter on NHS Scotland hospital when it comes to communicating them to patients, staff and visitors…. Prohibiting vaping within the no-smoking zone on the same basis as smoking, but not banning it entirely from hospital grounds, strikes the right balance between protecting the health of patients at the hospital, whilst respecting that some people who are using e-cigarettes are doing so to quit smoking altogether".
Asthma UK British Lung Foundation Partnership

Secondly, while some of these respondents also noted that vaping e-cigarettes is less harmful than smoking tobacco - others caveated their "yes" response and/or raised points of concern:

• Many noted that the long-term effects of vaping e-cigarettes (e.g. secondary exposure) were "not yet known" - some further noted that if the proposal was agreed it would need to be regularly reviewed and that Scottish Ministers be guided by the scientific evidence base.
• Others noted that some people exposed to the flavoured vapour from NVPs can experience breathing irritations (e.g. asthmatics) - and wider comments around the "plume of smoke" being "just as bad as smoking tobacco".
• That using NVPs emulates the actions of smoking, and could normalise the behaviour among children and young people.
• A few mentioned that there should be separate vaping areas on hospital grounds from areas where smoking tobacco products is permitted.

"That is the current policy in most of NHS Lothian and we have no problems with/complaints about NVP use on our grounds. We would propose that a 'sunset clause' be added, enabling detailed study of the present situation and review in 2023/4. This would enable the current consensus statement to be reviewed, the literature updated and ongoing surveys of patients, staff and relatives regarding how to optimise utilisation of quit your way services and trial smoke free work time, building on the experience of those countries that are already trialling this".
NHS Lothian

"Our policy is that e-cigarettes and other NVP products should be treated in exactly the same way as tobacco smoking. They are not harm free and as such they should not be encouraged within a healthcare facility. While there is not yet the same body of evidence against secondary exposure to vapour as is established for passive tobacco smoking, there are still challenges for some people e.g. asthmatics. In the same way as tobacco they should not be used in enclosed spaces. A pragmatic approach would therefore be to enforce the same rules for vaping as for tobacco smoking and ensure this activity is kept well away from entrances and anywhere that would expose young people to this activity. There should also be information visible and available on "Thinking of Quitting?" and "where to obtain smoking cessation support locally, including at community pharmacies".
Royal Pharmaceutical Society

Thirdly, some respondents that supported the proposal considered vaping as a good option for people who are trying to stop smoking cigarettes (i.e. an effective smoking cessation tool), and could support longer-term behaviour change.

45% of respondents did not support the proposal that the use of NVPs should be allowed as an alternative to smoking on hospital grounds so long as this was ouwith the no-smoking area outside hospital buildings, Table A7. This was highest amongst educational institutions and some third sector organisations.

The main feedback from this cohort of respondents echoed some of the caveats or points of concern raised by respondents who supported the proposal regarding NVPs. Namely that:

• There is insufficient research into the impact on health and longitudinal data/evidence that vaping is less harmful than tobacco products.
• Exposure to the flavoured vapour from NVPs is unpleasant, can be harmful to health (e.g. people with respiratory problems), and is not "risk free".
• NVPs should be included in the existing smoke-free hospital grounds policy. For example, most but not all of these respondents felt that NVPs and tobacco products should be treated in the same way throughout NHS Scotland premises and subject to the same restrictions. Wider feedback noted that e-cigarettes are not currently regulated as a tobacco product or a medicine in the UK and/or they can mimic the look of smoking, which might make it harder for others not to smoke. The same approach was also considered important for clarity and consistency of message, to limit the potential for misinterpretation of the Regulations, and for ease of public understanding.
• There could be some flexibility applied and reasonable adjustments made in implementing the proposal for certain groups (e.g. psychiatric patients), including some recogition of the role that NVPs play in smoking cessation.

"Not enough evidence on the consequences of vaping, I think we need to treat it the same as smoking and not authorise".
NHS Grampian

"Emerging cases of hospitalisations (and deaths) suggest that NVPs may not be as "safe" as originally thought. I think they should not be allowed until further research can prove whether or not they are indeed safe".
Individual

"There is a clear need to be unambiguous regarding both no-smoking regulations and smoke-free policies throughout hospital grounds. These need to be consistent, easily understood, easily communicable, and straight-forward if they are to be effectively implemented. For this reason, ASH Scotland does not support the proposal….. and we strongly recommend that the use of tobacco and NVPs be treated the same throughout NHS Scotland hospital premises, both in relation to the no-smoking perimeter around hospital buildings, and under policies applying across hospital grounds.

"… we support the approach to NVPs set out on the NHS Scotland Smoke Free Grounds website. This states that e-cigarettes are not allowed in NHS buildings, or on the majority of NHS grounds, 'because they are not currently regulated as a tobacco product or a medicine in the UK, and we can only recommend the products that are known to be safe and effective. E-cigarettes can also mimic the look of smoking, which may make it harder for others not to smoke'. To give both policy and regulations the best chance of success, ASH Scotland strongly recommends taking a thought-out approach that foregrounds stakeholder engagement and feedback, effective communications with patients and visitors, staff support, and prioritises the stop smoking support options known to be safe and effective, and available without charge from the NHS".
ASH Scotland

"The intended objective of working towards smoke-free grounds around hospitals is likely to be compromised by permitting persons to use NVPs. Additionally, the health effects of NVPs are not yet fully understood".
Individual

A few respondents made specific reference to the part of the proposition that there should be a ban on the use of NVPs within the no-smoking area outside hospital buildings, as illustrated by the quotes below.

"NVPs should be allowed on hospital grounds but we do not support a ban on the use of NVPs within the no-smoking area outside hospital buildings. Without exception, NVPs can be classified as harm reduction products. They are widely credited with helping millions of smokers who wish to quit smoking to switch from a potentially harmful product (combustible tobacco) to a product (e-cigarettes) that is said by Publish Health England to be "95 per cent less harmful" than traditional cigarettes. What sense, therefore, does it make to prohibit within the statutory no-smoking area the use of a product that some smokers are using to quit smoking? Likewise, what good will it do to threaten to fine or penalise someone who is using an NVP, almost certainly in an attempt to stop smoking?"
Freedom Organisation for the Right to Enjoy Smoking Tobacco (FOREST).

"…the Scottish Government should encourage and support health boards to develop solutions that sufficiently distinguish smoking and vaping. Policies should support people attempting to quit smoking to vape (including supporting dual users to quit smoking), while limiting exposure of non-NVP users to vapour. We believe that functionally treating NVP use as the same as smoking could result in people who use NVPs gathering in the same location as people who use tobacco cigarettes (it is not unrealistic to assume that people who smoke will continue to not adhere to NHS Scotland's existing non-statutory smoking policy). For NVP users, this could prove detrimental to both their quit attempt and expose them to the health harms of ETS. "The proposal could also functionally prevent some NVP users from using NVPs as part of their quit attempt - particularly those who cannot go outside - which could prove detrimental.

"We believe that functionally treating NVP use as the same as smoking does not reflect the evidence base and sends out an inaccurate message about the relative harms of NVPs. While the long-term effects of e-cigarettes are unknown, the long-term harms of tobacco are indisputable, and e-cigarettes represent an opportunity for harm reduction. The evidence so far indicates e-cigarettes are less harmful than tobacco smoking and can be an effective quitting tool".
Cancer Research UK

"Not allowing NVPs within the proposed 15m no smoking perimeter puts NVPs into the same category of harm as smoking tobacco. It is recognised that NVPs are less harmful than smoking, there is no good evidence that vapour emitted from NVPs causes harm, and encouraging smokers to switch to NVPs is a harm reduction approach….This is particularly relevant for mental health in-patients where the use of NVPs is a viable alternative for patients addicted to tobacco. A 15m perimeter means that these products could not be used within the secure garden used by patients and reduces the options available to health professionals to help this vulnerable group of patients to manage their smoking whilst in hospital".
Individual

"While the use of NVPs is supported as part a programme to reduce and cease smoking, there is no evidence that use of NVPs alone and not part of such a programme is safe. There are reports from the United States and the UK of significant lung disease associated with the use of NVPs. While this has not reached the stage of a proven case, we do not consider it appropriate to recommend use of these agents allowing exposure to the general public when their safety is unproven. We would emphasise that all current communications state that neither smoking nor use of NVPs are allowed within the no-smoking areas. Hence there is a consistency of messages and because there are good reasons for not allowing NVPs in hospitals e.g. safety issues, even if they are less harmful than smoking".
Royal College of Physicians and Surgeons of Glasgow

NHS Health Scotland noted in its submission that "e-cigarettes have polarised the public health community across the globe", and in part related this to the different lenses in which NVPs are perceived - a "harm reduction lens" and a "do no harm lens" (as is reflected in the responses to this consultation question). NHS Health Scotland recommended further meaningful stakeholder engagement, including with signatories to the consensus statement, as outlined below.

"Given that both perspectives are consistent with the consensus statement, we do not agree that to ban the use of e-cigarettes on hospital grounds would be contrary to the ethos of the consensus statement. It should also be noted that the consensus statement is based on a review of the evidence undertaken over two years ago. A number of studies have been published since then, including the first longitudinal studies, and therefore a review of the best available evidence would be beneficial. We are aware that a number of signatories to the consensus statement have altered their view since 2017 as a result of the emerging evidence. Therefore re-engaging with the signatories would be an important part of seeking to establish a renewed consensus around the place of e-cigarettes in public health.

"We would suggest that the issue of the place of e-cigarettes in public health in Scotland would lend itself well to a process of deliberative democracy akin to the Citizens' Jury on realistic medicine held by the Chief Medical Officer last year. Taking this approach would align with the Scottish Government's commitments around human rights, including the National Performance Framework outcome on human rights. It would enable staff, patients and visitors - smokers and non-smokers alike - to engage in the discussion.

"We know from work undertaken in 2018 that while the current policies on vaping on NHS grounds are variable, the majority of NHS Boards do not allow the use of e-cigarettes. We also know from this work that the majority of Boards were in support of direction from the centre on this matter and supported the need for consistency across the country.

"Consistency of approach would be beneficial for members of the public visiting hospitals as well as providing the sought-after national position on the place of e-cigarettes in public health.

"The standpoint taken by NHS Scotland on whether or not to permit vaping on hospital grounds will have ramifications across the rest of the country. While it may not be the intent, permitting their use in this context could be seen as promoting their use more broadly even though the active promotion of vaping is not being directly expressed by NHS Health Scotland.

"In summary therefore, it is our view that this question cannot be answered without meaningful stakeholder engagement and a review of the best available evidence. NHS Health Scotland, and from April of this year, Public Health Scotland, can support the Scottish Government in this regard".
NHS Health Scotland