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

3 Specific issues facing NHS organisations, local authorities and care service providers

a. With respect to their obligations as an employer
b. With respect to their obligations to service users and clients
c. The importance of the health leadership role
d. The requirement to develop an appropriate organisational response, and the benefits of doing this in a timely and efficient manner
e. Whether or not to provide external smoking areas
f. Workers needs - shift / on call etc.
g. Patient safety
h. Adult care homes
i Psychiatric hospitals and psychiatric units
j Adult hospices
k. Domiciliary visits
l. Vehicles
m. Premises which are used by children / families e.g. nurseries, schools, youth clubs, leisure centres, parks and playgrounds etc.
n. Parks, grounds and working outdoors
o. Sheltered housing
p. Offender accommodation

a. With respect to their obligations as an employer

The new smoke-free law makes clear that the presence of second-hand smoke within a working environment (and this includes rest and welfare facilities) is no longer acceptable. In order to comply with the law, it is essential that all employers ensure that their premises and other indoor environments, where work is carried out on their behalf, are smoke-free. It is important to note that this includes vehicles (light and heavy goods vehicles), where they are being used as part of the employees' work.

Although the new smoke-free law governs smoking at work, some employers with responsibility for exempted premises (or parts of premises) will still have responsibilities for ensuring that their employees are protected from the effects of second-hand smoke, under health and safety legislation.

Under the requirements of The Management of Health and Safety at Work Regulations 1999 ⁹, employers should assess the risks to any employees who may be subjected to the effects of second-hand smoke, and take action as appropriate to control or minimise that risk.

Employers also have a specific requirement, under Regulation 25 ³ of The Workplace (Health Safety and Welfare) Regulations 1992 ¹⁰, to ensure that rest rooms and rest areas include suitable arrangements to protect non-smokers from discomfort caused by tobacco smoke

b. With respect to their obligations to service users and clients

The 2005 Act and 2006 Regulations in Scotland require owners and managers of relevant premises, visited by the general public, including places of entertainment and where food and beverages are served, to ensure that the premises are smoke-free.

c. The importance of the health leadership role

NHS organisations, local authorities and care service providers all provide services which protect, promote or treat people's health. In other words they have a vested interest in 'health'.
It is very important, therefore, that as public places and workplaces in Scotland become smoke- free that these types of organisation are in the vanguard, setting the pace and providing an example and leadership for others to follow.

d. The requirement to develop an appropriate organisational response, and the benefits of doing this in a timely and efficient manner

The implementation of the smoke-free law will result in many benefits for employers and service providers in Scotland. To maximise these benefits, organisations, their management teams, staff and client / patient groups need to be prepared, both for the changes in day to day practice and for the opportunities that will result.

e. Whether or not to provide external smoking areas

One of the most positive outcomes of the move to smoke-free status is that some smokers use the fact that they can no longer smoke at work as an incentive to quit smoking, while others reduce the number of cigarettes they smoke each day ¹¹.

However there is equally strong evidence that the provision of any smoking area for staff - including external smoking shelters, undermines this potential health gain ¹². In terms of health and wellbeing a smoking area does little to benefit either the staff or the organisation in the short or the long term.

The major point to be noted here is that there is no requirement within the legislation for employers to provide an external smoking shelter. If one is already in existence, then the move to smoke-free could be used as an opportunity to review whether or not it should continue to be made available to staff. If it is continued then care must be taken to ensure that its physical structure complies with the requirements of the legislation. (See Appendix 1 Section 1). Liaison on this issue with the local environmental health service, who will be enforcing the law, is advisable.

Employers should therefore think very carefully before erecting new external smoking shelters for staff, patients, clients etc. because they minimise the health benefits of going smoke-free, as outlined above. If it is felt that this option should be pursued, then again care should be taken to ensure that local planning laws and guidelines are followed and that the proposal complies with the new law, i.e. is not 'wholly or substantially enclosed' within the meaning of the legislation .

There is one context in which smoking shelters might be appropriate, and that is on a time-limited basis i.e. they could be maintained immediately prior to going smoke-free, or for a limited time after going smoke-free. At the same time a considerable emphasis is placed on encouraging and supporting smokers to quit the habit. The smoking shelter could even be used as a place in which cessation advice and guidance could be provided.

If external smoking areas are being maintained, or if staff or patients, visitors or clients need to leave the premises to smoke, then consideration should be given to the provision of external stubbing-out bins at entrances or exits to keep litter to a minimum.

Time-limited shelters should, of course, still not be 'wholly or substantially enclosed' within the meaning of the legislation

f. Workers needs - shift / on call etc.

The issue of risk that staff face on leaving the site in order to smoke a cigarette must be considered in relation to an employer's duty of care towards staff. In some circumstances this simply means stepping out of the building onto a busy public thoroughfare, for others it might entail a long walk to reach a lonely and isolated road. For members of staff who are working late into the evening or through the night, streets which are busy and safe during the day can become threatening at night.

Careful consideration needs to be given therefore to the matter of staff leaving the site in order to smoke. Some organisations insist that staff clock in and out when they do this - effectively they are smoking in their own time and at their own risk. Other organisations provide specific breaks or encourage staff to use existing breaks in order to smoke, but the issue of employees being away from their work for what could be many minutes at a time should be carefully considered. The European Working Time Directive ¹³ sets out expectations about workers' hours and break times and will be a factor in these considerations.

The health and safety of the employee needs to be a major concern. If they are putting themselves at risk by leaving the premises to smoke - be it in the middle of the day or the middle of the night, then the employee should be discouraged from this practice and instead encouraged to consider joining a smoking cessation programme.

Organisations may wish to consider outlining to staff appropriate approaches and support mechanisms should they be in a position of challenging someone who has refused a request to stop smoking in an enclosed and non-exempted area.

g. Patient safety

The safety of patients is of paramount importance to any agency with care or treatment responsibilities. The sight of patients clustered around an entrance to a hospital has been commonplace and everyone would acknowledge that it is not desirable practice.

The question is - what are the alternatives?

The best alternative is for patients to no longer need to exit the safety of the building to smoke a cigarette. Encouraging them to prepare for treatment by quitting the habit is the optimal solution, although less easy to achieve in the case of emergency admissions. This issue is addressed more fully in Section 6.

If they are admitted as smokers, then patients should be encouraged to make use of smoking cessation services while they are in hospital. A number of examples of good practice in terms of hospital based cessation services and the creation of good referral pathways from and to community based services are available and these demonstrate the potential positive impact that can be derived from the creation of such a service.

Finally, consideration should be given to providing patients who cannot or who choose not to stop smoking, with pharmacological aids to help them during their stay in hospital, so long as their use is not contra-indicated. Experiencing the effect that such aids have in reducing the symptoms of nicotine withdrawal might encourage them to consider trying to stop smoking at a later date.

h. Adult care homes

For organisations with residents for whom the premises are considered to be their home, an exemption applies under the legislation, such that arrangements can be made to designate specific rooms in which residents can smoke. See section 2 for the definition of 'designated room' used in the smoke-free legislation. These rooms must, under the terms of the exemption, be enclosed spaces i.e. not one end of a large room. They must also have some form of forced air ventilation that vents to the outside of the building (and not immediately beneath or next to a window). Ideally they would be separated from the corridor or connections to the rest of the building by a double door. Finally, they must be clearly marked as a room in which smoking is permitted. Ventilation systems may make the air appear cleaner, by diluting the larger particles found in tobacco smoke, but ventilation cannot protect people from the health risks associated with second-hand smoke.

Designated rooms where smoking is permitted are intended for the use of residents only, not for staff or visitors. The exemption for designated rooms in these premises was made in recognition that they are residential establishments.

Staff should not normally be required to work in these designated smoking rooms. If they have to enter them, then their time of exposure to second-hand smoke must be kept to a minimum. Staff with pre-existing conditions exacerbated by second-hand smoke e.g. asthma, should not be asked to enter them at all.

Effective tobacco and smoking policies, sensitively communicated, can help to encourage smokers to stop smoking, which brings health benefits at any age.

If it is not possible to provide a designated room for smoking in line with the legislation, then the building must be smoke-free. This ensures that residents and staff are protected from the dangers of second-hand smoke.

i. Psychiatric hospitals and psychiatric units

The principles which apply to adult care homes also apply to residential psychiatric hospitals and units ( i.e. residential care) for circumstances where it is possible to permit patients to smoke in designated rooms. Smoking prevalence can be higher among people with mental health problems and consideration must be given to the wide range of issues faced when implementing smoke-free policies in both residential and non-residential facilities for this care group.

Scottish Ministers are commited to reducing the health inequalities experienced by people with mental health problems, as for all others, including through a programme of targeted cessation, which may allow the exemption for designated rooms to be reviewed in due course. A specific national framework for mental health services is currently being developed by the Scottish Executive to augment the advice contained in this guidance.

This framework will deal more clearly with the specific challenges faced by mental health services and their users, particularly in relation to smoking cessation. For example, the framework will tackle the myth that stopping smoking exacerbates mental health problems and address concerns about medication issues, particularly in relation to NRT. The Scottish Executive has established a short-life expert group, with representatives of key interests, to oversee the development of the guidance. It is proposed that draft proposals will be developed and consulted on in Spring 2006, to enable the new framework to be finalised and launched in October 2006.

j. Adult hospices

For humanitarian reasons, adult hospices have been exempted from the smoke-free legislation. However, it is recommended that, wherever possible, smoking should be contained and tobacco smoke restricted to designated smoking rooms, as outlined above for adult care homes. Every effort should be made to ensure that exposure to second-hand smoke is kept to a minimum. Again, however, there is no obligation on management to allow smoking on these premises, if they do not wish to do so.

k. Domiciliary visits

Staff who visit / treat people in their homes are at risk if the person being treated is a smoker. Private houses are not covered by the Act. Several factors, therefore, need to be taken into consideration.

First, does your organisation know which of the homes visited by its staff are occupied by smokers? If not, it would be advisable to develop such a list. Once the situation relating to individual properties is ascertained, steps can be taken to reduce the exposure the staff might face.

Measures that can be taken include writing to all those who will be visited to ask them and those who may be with them, not to smoke during the visit, and ideally not to smoke for an hour or so before the visit is scheduled to take place.

Second, it is important to identify members of staff who have a pre-existing condition that is made worse by exposure to tobacco smoke, such as asthma, COPD and cardiovascular disease or who face additional risks e.g. due to pregnancy. Members of staff who have such conditions are at higher risk and particular care should be taken to prevent or minimise their exposure to tobacco smoke.

Third, no member of staff should be expected to make consecutive visits, or even a sequence of visits, to houses in which they are likely to be exposed to tobacco smoke. A better option is to alternate the visits, but this should not take the place of steps one and two.

l. Vehicles

As outlined in Appendix 1 Section 2, vehicles used primarily for business purposes fall within the scope of the smoke-free legislation. Cars are exempt under the legislation, as are other vehicles that are used primarily for private purposes. The ideal, however, is that all vehicles used by employees as part of their work should be considered to be an integral part of the workplace and therefore be smoke-free. This is particularly so when a private vehicle is being used to convey passengers on work related activity and the driver / owner, whether an employee or volunteer, is a smoker. The driver should not seek permission to smoke from the passenger(s), rather he or she must not smoke.

The use of private vehicles as a smoking 'shelter' while parked on land associated with the employer should be discouraged.

m. Premises which are used by children / families e.g. nurseries schools, youth clubs, leisure centres, parks and playgrounds etc.

Second-hand smoke is particularly harmful to the health of children and young people. ¹⁴ Under the legislation, typically all 'wholly or substantially enclosed' public premises used or visited by children either on their own (schools and youth clubs) or with their families or friends (leisure centres etc.) must be smoke-free.

Smoke-free policies may already be in place in these areas. However, local authorities and others will wish to consider the benefits of introducing smoke-free policies in external areas which children and young people frequent, like playgrounds and parks. This will help to de-normalise smoking further and discourage young people from being influenced by what they may see as an 'adult' activity. Scenes of parental smoking at the entrances to schools, for example, are to be discouraged.

n. Parks, grounds and working outdoors

In situations where work is undertaken outside buildings, for example outdoor areas such as gardens, parks, grounds, highways etc. the employer should give careful consideration to the appropriateness of having one set of requirements for those who work indoors and another for those who do not. In such circumstances, consideration should be given to the development of a comprehensive policy that covers tobacco use and extends to all employees, irrespective of their working environment.

In any workplace situation, the equitable treatment of employees is a matter of prime concern. Having different approaches for employees working within an office or manufacturing environment, which is different to those employed by the same organisation, but who are working outside, is inequitable. Good practice would indicate that a comprehensive, equitable approach is followed.

For the employee, those working outside may conclude that they are exempt from the organisation's tobacco policy, since their smoking isn't harming anyone else. Three points need to be made in response to that position.

First, they are doing themselves harm 'on the company time' as it were. Second, they may be seen by members of the public, other employees, patients or visitors, who will rightly ask why one group of individuals within an organisation are treated differently to others, and who might assume that the organisation has a lax approach to tobacco at work. Third, they may be in breach of the organisation's smoke-free policy.

o. Sheltered housing

There are many different types of sheltered housing accommodation. Local authorities are reminded that the communal areas of such accommodation are covered by the smoke-free legislation.

p. Offender accommodation

The situation in relation to offender accommodation in the community is perhaps slightly different to those other types of premises detailed above, primarily because, in most cases, residents of offender accommodation will be there under a court requirement and not voluntarily.

Nevertheless, offender accommodation is still covered by the smoke-free legislation and smoking is banned in these premises except for those areas that are captured by the residential / domestic accommodation exemption. In practice this means that in hostel accommodation, smoking will be prohibited in any public areas, but in private dorms smoking may be permitted. In the case of co-habited dorms, smoking should only be permitted if both or all residents are smokers. In all cases, staff exposure to second-hand smoke should be kept to a minimum

Other forms of offender accommodation such as supported flats are considered to be residential / domestic accommodation and are therefore exempt from the smoke-free legislation. Bed and breakfast type accommodation is covered by the rules relating to hotels and guest houses.

Consideration should be given to actively encouraging and supporting any residents who may wish to take the opportunity to try to stop smoking.