Smoke-free Scotland - Guidance on smoking policies for the NHS, local authorities and care service providers

Appendix 3 Practical guidance on preparing to become smoke-free

The smoothest, most straightforward and sustainable way to capture the opportunities and potential of the legislation (both at the organisational and individual level) is to be proactive and to plan ahead.

This section describes eight stages, with policy development at the heart of these, which can be taken now to make the move to full compliance and the creation of a health enhancing environment as straightforward and problem free as possible. The diagram shows these stages in schematic form, with a more detailed explanation following.

The latter part of the section considers issues specific to the types of organisation for whom this guidance has been written.

The major stages in the development of a comprehensive approach to tobacco

Adapted from 'Tobacco at work - guidelines for local authorities. Achieving the best outcomes' ³

Stage 1 Review the current situation

Many NHS organisations, local authorities and care service providers will already have well established approaches to tobacco in place. Some, but perhaps not all, will have moved the organisation to smoke-free or almost smoke-free status. For these organisations there is no need to reinvent the wheel, rather review and evaluate how close the current position is to the approach that needs to be in place in order to comply fully with the legislation, identify any gaps and then put in place measures to close the gaps e.g. ensuring that signage is of the appropriate size and in the correct position.

For those organisations that have yet to formally tackle the issue of tobacco at work, it is still important to review the current situation, as it is common for such organisations to have an informal approach in place. The problem with this is that while it may seem to work well enough on a day to day basis, when a problem occurs, or when external requirements change, as is happening with the implementation of the law, the starting position is unclear. Reviewing what has been done informally, and then using the strong elements of that as a foundation, on which to build a comprehensive formal approach, centred on a clear and robust policy, is by far the best solution.

Stage 2 Gain the support of the senior management team and the elected members / board members

This step is an essential prerequisite for all workplace health and wellbeing processes. Employees need to know that the organisation they work for is fully committed to their health, safety and wellbeing. This is reinforced by the public or open support of the senior management team, which in turn gives added significance to the actions of the working group. Ideally a member of the senior management team should be asked to monitor the development and implementation of the policy. Meetings of the senior management team should receive regular reports on the developmental process.

For many public and private sector organisations the most senior decision making body is the Board ( NHS and private sector organisations) or the elected members (local authorities). These groups also have a vitally important role to play in the development of a comprehensive approach to tobacco. All those who serve on one of these groups should be briefed at the outset and those with an interest in the organisation's HR function should be invited to be active participants in the review and consultation procedures. Once the process of development has been completed, members of these senior decision-making bodies should be asked to affirm their support for the measures being introduced, when the approach is implemented.

Stage 3 Establish a working group and make links with the Scottish Centre for Healthy Working Lives (now incorporating Scotland's Health at Work) and other NHS services

Setting up a working group, to take forward the development and implementation of a comprehensive approach to tobacco, has a number of advantages over giving this responsibility to just one person. These advantages include:

• It is an indicator of the organisation's commitment to the process, especially so if the working group reports to the senior management team
• It provides a forum in which a variety of professional viewpoints can be shared and discussed
• By including smokers and non smokers in the working group the needs of smokers can be easily identified, smokers will have more confidence in the process and having a smokers perspective in the working group can shorten the time of the developmental process.
• The group can become an advocacy body within the organisation, raising awareness of the need for a comprehensive approach and the measures that will be implemented
• Different members of the group can be tasked with different actions, thus speeding up the process (as opposed to one person doing them all).

Stage 4 Consult and communicate with staff

Consultation and communication are essential features in the development of a sustainable approach to tobacco at work. A number of methods can be used to both consult with and communicate with staff.

In terms of consultation any of the following tools might be used:

• Team briefings / meetings - issues can be raised and feedback invited. It is important that, if employees put forward views and opinions, they receive feedback on why or why not their views were acted on, once decisions have been taken.
• Staff meetings - the traditional way of communicating a message, but care needs to be taken to ensure that one or two employees don't derail the process. Contentious issues can often be better dealt with in smaller groups.

In terms of communication, in addition to the above (with the exception of self-completion questionnaires) the intranet, the organisations staff newsletter, notice boards and leaflets / posters can all be used to convey information about the new approach to tobacco.

Stage 5 Develop or refine the policy

The question might be asked, 'Why bother with a policy when the law is so clear in its requirements?' The answer is that a formal policy provides a number of benefits to the organisation. These include;

• It is a clear, unambiguous written statement to which all can refer, and which leads to a consistent approach across the organisation - equally important for small as well as large organisations
• It legitimises action being taken on the broader range of issues associated with a comprehensive approach
• It enables managers and others with responsibility for ensuring that the policy is adhered to, to clearly know what is required of them
• As Section 7 demonstrated, the use of tobacco has significant negative effects for the user and for the organisations in which they work. A comprehensive tobacco policy will address issues such as support for those who are trying to stop smoking, and it is in encouraging and helping smokers to quit the habit that the real health and organisational benefits will be seen.

A note on 'comprehensive' policies

The term 'comprehensive policy' has been used several times already in this guidance, but what does the term mean?

A comprehensive tobacco policy is one that tackles in a positive way the wide range of issues associated with tobacco at work. It is not confined to a narrow focus on where people can and cannot smoke and what will happen to them if they do. Rather it provides information on a wide range of workplace related tobacco issues, including, for example, the provision of support to those trying to stop smoking, the creation of links with the local providers of NHS cessation advice and support, the taking, or not taking, of breaks away from the building which employees can use to smoke a cigarette, and the way in which managers and others are expected to enforce the policy. For organisations who provide domiciliary visits, the policy should also address the issue of client smoking.

A typical workplace tobacco policy should be clearly and succinctly written and would consist of the following elements:

• Rationale - The reasons behind the approach being adopted
• Statement of Intent - A clear statement setting out the organisation's parameters, rules and procedures for dealing with the issue of tobacco
• Background Information - Key data and facts about the company / organisation's previous position on tobacco, the legal obligations it is now under, plus information on the dangers of smoking
• The Objectives (of the Policy) e.g.
• To comply with The Smoking, Health and Social Care (Scotland) Act 2005
• To ensure that there is minimal exposure of employees to tobacco smoke whilst on the organisation's premises or while engaged in the organisation's business
• To ensure that the health and wellbeing of employees is protected and enhanced
• To provide a consistent approach to break entitlements for smokers and non-smokers
• Application of the policy - Clearly state that the policy applies to all employees, sub- contractors, residents, clients and visitors
• Smoking Provision - Clearly indicate precisely where (if at all) smoking will be permitted on the organisation's site(s). This should only be for long stay patients / clients and then only in designated smoking areas.
• Exemptions to smoke-free areas - Outline where these will be established, who can use them (patients / residents, not staff and visitors), how they will be separated from the rest of the building and how tobacco smoke will be prevented from reaching the rest of the building
• Employee welfare / Cessation support - Outline how cessation support will be available to staff - either internally or externally, and how this can be accessed
• Failure to Comply - Indicate the process for dealing with staff who breach the policy
• Effective date, monitoring and review - To be legally binding a policy must have a date of implementation. Formal reviews of the policy should take place at least every two years, although for a new policy, an initial review after twelve months is recommended.

If your organisation is tackling the issue of policy development for the first time, then the following sources of advice and information may be helpful:

The ASH Scotland website: http://www.ashscotland.org.uk

Tobacco Information Scotland: http://www.tobaccoinscotland.org.uk

The Scottish Centre for Healthy Working Lives: http://www.healthyworkinglives.com

The Advisory, Conciliation and Arbitration Service Advisory booklet - Health and Employment (2001) http://www.acas.org.uk

Stage 6 Prepare to implement the policy / approach

Once the policy / approach has been finalised and given corporate approval, steps need to be taken to ensure that everyone associated with the organisation is familiar with it and the requirements it places on them.

All staff should be informed of the new policy / approach - this includes those who may work at a distance from the centre of the organisation, as well as those who work during the evenings and nights. Ideally they will be given something in writing, which explains the new situation, as well as receiving an oral briefing from a manager. Information about the new approach should, as a matter of course, be included on the organisations web site etc. Managers should understand their duties in relation to enforcing the policy among clients / members of the public as well as staff.

All existing clients and patients should be informed of the new situation by receiving something in writing and a clear oral explanation from someone from the organisation who is known to them.

All prospective patients and clients should receive a letter indicating the organisation's approach to tobacco several weeks in advance of their admittance - receiving it only a short time before does not enable them to amend their own smoking behaviour, in the light of the information they will have received.

Any materials / correspondence with patients and clients must contain information on the importance of smoking cessation for them; how they can access smoking cessation and support, both prior to and during their stay in the establishment and where they can receive follow up support should they return to their own homes.

Each of the above actions is enhanced when the organisation is able to publicise its new approach. Good PR can be obtained when organisations show to the general public the actions they are taking to promote the health and wellbeing of their staff, client and patient and user groups. For those organisations who are able to, the issuing of a press release creates a positive level of background awareness and reduces, to some extent, the likelihood of a person being surprised when they arrive, either as a client / patient or visitor, that they can no longer smoke while on the premises.

Other means of raising awareness include the use of signs and posters. Signs are a very important tool to indicate to people where they cannot smoke and are required as part of the legislation. Large signs at the entrance to sites, which are branded with the organisation's logo (always a good thing regardless of the size of the sign), establish very quickly that the organisation is committed to the process of going smoke-free. The important thing about signs is that they should be clear, readable and appropriately placed i.e. within people's line of sight. The mandatory requirements for signage in the smoke-free legislation are outlined in Section 2.

In the lead up to the day of the launch of the new policy posters can be a useful way of keeping the issue in the forefront of people's minds. Count down posters, posters with important health and wellbeing messages can positively reinforce the message that this organisation is taking a big step forward, in terms of health and wellbeing, and that people should be prepared for it.

Of key importance is the inclusion on such posters of information on where help and support to quit smoking can be obtained. This is a period of time when many staff will be actively considering this option. Helping them to take action is an important means of improving their health and over the longer term the health of the organisation. To be effective however, posters need to be widely - not sparingly - used. One poster hidden among many will not be effective. Posters which are changed frequently and which are prominently positioned in many locations will contribute to a raised level of awareness.

Stage 7 Launch the policy / approach

Once the approach / policy has been developed and agreed it needs to be launched. The date of the launch should be known in advance and as the previous section has indicated, measures put in place to ensure that everyone, who should know, does know that from the specified date the organisation will be adhering to the new position. Mandatory requirements must be implemented on or by 26th March 2006.

Having a clear launch date, often accompanied by some activities to support it - health fair, competitions etc. gets things off to a positive start. The alternative is to have a low key implementation with little awareness raising and associated activities. The risk associated with this approach is that the opportunity to promote the organisation's positive stance on health and wellbeing is lost, and that the opportunity for people to change their behaviour, so far as tobacco is concerned, might also be significantly diminished. Levels of resentment might also increase, as staff could feel that the new approach has been surreptitiously introduced.

Stage 8 Monitor, review and evaluate the process

An essential element of any organisational activity which focuses on staff health and wellbeing, and which also involves patients, visitors and clients, is the assessment of the short and long term outcomes, e.g. the impact on staff, resistance to the approach, the ease with which managers are able to enforce the approach and so on.

Responsibility for monitoring, reviewing and evaluating the process can be left with the working group, or it could be taken over by others, such as representatives of the human resources department. The key issue is that regardless of who is ultimately responsible for it, the process actively engages with the groups who are affected.

Key issues that need to be addressed include:

• How well is the approach working?
• Are there are any problem areas - frequent breaches of the policy / approach, issues of poor or inconsistent enforcement, poor communication with staff, patients or service users etc.? If there are problem areas what can be done to improve the situation?
• How do staff feel about the approach, do the staff continue to support it, if not why not?
• How do other stakeholder groups feel about the approach?
• Are there any elements of the approach that need to be amended in some way?

Once the evidence has been collected and reviewed, measures can be put in place to strengthen those areas that have been revealed to be weak. Under no circumstances does this mean moving away from a strong position on tobacco use and the need to be smoke-free, rather it may be that key groups need to be reminded of the rationale for the approach, managers might need to be trained, so that they are better able to enforce the approach etc.

While review should be a constant process, the commonly held position is that a formal review should be undertaken within twelve months of the approach being implemented and thereafter at two yearly intervals.

A note on enforcing the new policy

If the situation that has occurred in other countries that have gone smoke-free is repeated in Scotland, then the encouraging point to note at the outset is that enforcement should not be a major issue. This is especially so where there is a high level of public support for the measures, which research indicates that there is in Scotland ²²

Nevertheless people affected by the policy / approach need to be aware that it is underpinned by enforcement measures. Despite this it would be remarkable if these were not called into use at some time.

Within an organisation enforcement of a policy usually lies with managers. It is vitally important that if this is the case then they are aware of the implications of the policy themselves and are trained and / or supported as they seek to perform their enforcement role. Managers and staff need to be reminded of the terms of the smoke-free legislation and that it is a criminal offence to fail to comply.

Key steps in this process are:

a. Prior to the launch of the policy -

• Clear links should be established between the tobacco policy and other HR policies such as the Disciplinary Policy and the Health and Safety Policy
• All managers are briefed on the policy and have an opportunity to discuss the issue of enforcement and their role
• All managers receive training on the specifics of enforcement - how to raise the issue with a member of staff suspected of breaching the policy; collecting evidence; making a record of the discussions with the individuals concerned etc.
• All staff is made aware of their responsibilities and of the consequences of being in breach of the policy.

b. Around the launch of the policy

• While all the positive messages about the improvement to the working / living environment and people's health and wellbeing are promoted widely and positively, reference should still be made to enforcement measures i.e. the issue remains alive.
• Anyone found to be smoking in breach of the policy at this time should be warned about their future action and the workforce as a whole might be made aware (in an anonomised form) that x people have been warned and more significant action will follow for anyone found in breach of the policy from a predetermined date.

c. Collecting evidence of a breach and the Human Rights Act

• The European Convention for the Protection of Human Rights and Fundamental Freedoms contains a number of Articles, which have implications for employment practice. The Human Rights Act states that: "it is unlawful for a public authority, including a court or tribunal to act in a way that is incompatible with a Convention Right."
• An employer would have to be mindful of how evidence was collected to verify that a breach of a workplace smoking policy was taking place. If, for example, the employer installed a video camera to monitor a designated non-smoking area, in which employees were smoking, and dismissed an employee on the grounds that he / she had been videotaped smoking in the non-smoking area, an Employment Tribunal would have to decide if the evidence had been collected in a way that was compatible with the employee's Human Rights.

d. Cessation support

• Someone found to be in repeated breach of the smoke-free policy is likely to end up passing through the full measure of the disciplinary process. The process could, however, be put on hold, pending their successful completion of a smoking cessation course.

It might therefore be advantageous to have established links with local providers of NHS cessation services, prior to the policy being implemented, and also to have in place a mechanism that enables the employer to contact the cessation service, in order to verify that a) the individual has participated in the course and b) completed it successfully.

The employee should be informed when the cessation option is proposed that this information will be sought.