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Health Development Agency
Guidance for smokefree hospital trusts

Health Development Agency
Guidance for smokefree hospital trusts
Ann McNeill
University College London
Lesley Owen
Health Development Agency
Endorsed by NHS Employers

Acknowledgements
We are grateful to Linda Caine, Modernisation Lead, Norwich Primary Care Trust, for her very
important contributions to this guidance document.
We would also like to thank the Norfolk and Waveney Mental Health Partnership NHS Trust
for providing the policy templates.
We are very grateful to the three hospital trusts that provided the case studies and the 80
hospitals that took part in the survey of current practice regarding smokefree policies.
Special thanks are also due to Mary Richings, Nurse Adviser, University Hospitals Coventry and
Warwickshire NHS Trust. We are grateful to Department of Health and Health Development
Agency colleagues who commented on drafts.
We also thank members of the Tobacco Advisory Group of the Royal College of Physicians
and the British Thoracic Society Tobacco Committee for helpful comments.
Copies of this publication are available to download from the
HDA website (www.hda.nhs.uk/evidence)
Health Development Agency
Holborn Gate
330 High Holborn
London WC1V 7BA
Email: [email address]
ISBN 1-84279-315-2
© Health Development Agency 2005
About the Health Development Agency
The Health Development Agency (www.hda.nhs.uk) is the national authority and information
resource on what works to improve people’s health and reduce health inequalities in England.
It gathers evidence and produces advice for policy makers, professionals and practitioners,
working alongside them to get evidence into practice.
ii
Guidance for smokefree hospital trusts

Foreword
The recent white paper, Choosing Health, announced that the NHS will be smokefree by the end of 2006.
Even with the recent progress in reducing prevalence, smoking remains the largest single cause of death
and disease in England. The harm caused by secondhand smoke is now well established. The NHS, as the
foremost health promoting and treatment organisation in the UK and largest employer in Europe, will
underscore these dangers and demonstrate strong leadership by becoming smokefree.
This guidance, drawing on lessons learned from successful case studies, surveys and consultation with
hospital trusts, takes you through the steps needed to implement smokefree policies. Consultation will
be important to ensure all staff and patients abide by the policy and understand why it is required.
Communication with patients and carers will be important to ensure they are aware of the policy and can
prepare for it. The widespread availability of cost-effective treatment for stopping smoking must be an
integral part of smokefree policies and the guidance explains how to work with the NHS Stop Smoking
Services in your area.
This guidance is about where people smoke, not whether they do so, although I hope that many people
may use smokefree policies to make attempts to quit and in so doing improve their chances of living longer
and healthier lives.
In the white paper, Choosing Health, the government stated its belief that the NHS can and will become
an exemplar for public and private sector employers. Swift movement to a smokefree NHS will be a clear
demonstration of that aim; and this document will help you to deliver that aim.
Sir Nigel Crisp
Chief Executive of the NHS
Guidance for smokefree hospital trusts
iii

Contents
Acknowledgements
ii
Foreword
iii
Introduction
2
Background
2
Why become smokefree?
2
What is meant by a smokefree NHS?
3
How to introduce a smokefree policy in hospitals
4
Step 1 – Commit to the policy
4
Step 2 – Create the policy
7
Step 3 – Ensure NHS stop smoking support is widely available
10
and accessible
Step 4 – Communicate the policy
11
Step 5 – Consolidate the policy
12
References
13
Annex 1 – Previous guidance and implementation
14
Annex 2 – Rationale for smokefree grounds as well as buildings
15
Annex 3 – Policy template
16
Annex 4 – Guidance to staff template
18
Annex 5 – Contacts
20
Annex 6 – Resources
21
Guidance for smokefree hospital trusts
1

Introduction
Background
Why become smokefree?
In the 1990s the NHS was advised to adopt policies on
Since the 1990s knowledge of the dangers of secondhand
smoking that allowed for limited, ‘necessary’ provision for
smoke has continued to accumulate and it is now well
smokers – but interpretation of this guidance has varied
established that secondhand smoke causes a wide range of
greatly. A recent survey has shown that there is still
diseases including lung cancer, coronary vascular disease
considerable and unacceptable exposure of staff, patients
and chronic respiratory problems.3 Indeed, in 2002 the
and visitors to secondhand smoke (see also Annex 1).1
World Health Organization’s International Agency for
Secondhand smoke is a proven carcinogen2 and apart from
Research on Cancer classified secondhand smoke as a
cancer causes a range of diseases including heart disease
carcinogen.2 Given these health risks it is important that
and respiratory infections.3 In addition, there is evidence
the NHS becomes smokefree to protect staff and patients
that patients who continue to smoke while in hospital are
from the dangers of exposure to secondhand smoke.11
at an increased risk of complications and delayed recovery.4
Evidence has also emerged of a greater risk of
The time has now come for the NHS to become smokefree.
perioperative complications, delays in wound healing and
The recently published white paper on public health,
increased rates of wound infection and postoperative
Choosing Health, stated that the NHS will be smokefree by
pulmonary complications for smokers, resulting in delayed
the end of 2006.5 This is a measure which the Chief
recovery, greater treatment costs and prolonged hospital
Medical Officer has recommended in his recent annual
stays.4 Stopping smoking reduces the risks of surgical
reports6, 7 and which receives widespread public support.8
complications for smokers and increases the availability of
hospital beds. It is therefore important that hospitals
The white paper noted that the Health Development
should actively encourage and help smokers to stop.
Agency (HDA) would shortly be publishing guidance for
NHS organisations on the provision of smokefree buildings
Support for smokers who wish to stop is now widely
to protect staff, patients and others from the health risks
available. Since 1998 a network of NHS Stop Smoking
of secondhand smoke. This guidance sets out these steps,
Services has been established across England, offering
building on previous guidance,9, 10 and drawing on the
evidence-based advice and support for smokers wishing
findings of the recent survey of smoking policies across
to stop. The services include the provision of proven
NHS hospitals as well as examples of good practice.1
medications – nicotine replacement therapy (NRT) or
Box 1 defines what is meant here by a smokefree NHS.
bupropion. The services also offer specialist intensive
support that can quadruple the chances of a smoker’s
quit attempt succeeding.12 Some of these services are
Box 1
based in hospitals; those that are not have formal links
Smokefree means that smoking is not permitted
with hospitals in their area. All smokers, be they
anywhere within hospital buildings. No exceptions will
employees, patients or visitors to the NHS, anywhere in
be made for staff or visitors. For long-stay mental health
the country, can be referred to these services to receive
patients in an acute psychiatric state or terminally ill
the best help to stop smoking.
patients exceptions may be made on a case-by-case
basis. However, no blanket exceptions will be allowed
The recent public health white paper states clearly that
for particular categories of patients.
the NHS should be smokefree by the end of 2006
(see Box 2).
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Guidance for smokefree hospital trusts

However, some NHS trusts have decided to include
Box 2 Selected excerpts from the white paper
grounds as well as buildings in their smokefree policies
on public health5
and this may be considered the ultimate standard to
which all trusts might aspire to in the near future.
‘NHS organisations should take action to eliminate
Smoking just outside the entrance to hospital buildings
secondhand smoke from all their buildings and
can give a very poor impression, as well as a cloud of
provide comprehensive support for smokers who want
smoke for patients, staff and visitors to walk through.
to give up’
Resources spent on clearing smoking litter, or building
and maintaining smoking shelters, can be much better
‘By the end of 2006 ... the NHS will be smokefree’
spent on providing treatment and support for smokers to
stop. The reasons why some trusts may decide to opt for
‘The HDA will shortly publish guidance for NHS
smokefree grounds as well as buildings are explained
organisations on the provision of smokefree buildings
further in Annex 2.
to protect staff, patients and others from the health
risks of secondhand smoke’
The remainder of the guidance sets out the steps needed
for NHS trusts to become smokefree as defined in Box 1,
but it also refers to the small additional steps needed to
This is a measure which receives widespread public
achieve the ‘gold standard’ of smokefree grounds as well
support. A recent survey (April/May 2004) of British adults
as buildings.
conducted by MORI for Action on Smoking and Health
(ASH) found that 96% of respondents were in favour of
a law making NHS hospitals and clinics smokefree, with
84% strongly supporting this.8
A survey of hospitals carried out by the HDA at the end
of 2003 found that there is still considerable and
unacceptable exposure of staff, patients and visitors to
secondhand smoke.1 The survey also highlighted the
difficulties encountered by some hospitals trying to
implement smokefree policies (see also Annex 1).
A more detailed rationale for why hospitals should
become smokefree can be found in the HDA
document, The case for a completely smokefree NHS
in England.4
This document aims to support hospitals to become
smokefree by providing guidance on how to overcome
the difficulties involved. The guidance is based on the
learning from the survey, three detailed case studies and
consultations with individuals who have been involved in
implementing smokefree policies.
What is meant by a smokefree NHS?
By smokefree it is meant that smoking is not permitted
anywhere within the hospital, so smoking rooms are not
allowed (see Box 1). There are no exceptions for staff or
visitors although exceptions can be made for individual
patients on a case-by-case basis. Exemptions are
explained further on p8 and in the policy template on p16.
Guidance for smokefree hospital trusts
3

How to introduce a smokefree policy in hospitals
The five main steps needed to implement a smokefree
STEP 1 – COMMIT TO THE POLICY
policy in hospital trusts are set out in Box 3. The first
four steps need not take long to implement given that it
is now a requirement to go smokefree. However, gaining
Identify a champion who will be responsible for
commitment to the policy from all those involved and
implementing the policy
engaging a working party to collaborate effectively can
take more time. In addition, it will be essential to the
There is a need to identify a champion who will act as
success of the policy that when it is introduced cessation
the driving force behind the smokefree policy. The key
support is made widely accessible, including the need
attributes are enthusiasm and commitment to the policy.
for smoking cessation medications to be put on the
The champion also needs to have sufficient seniority
hospital formulary. Another key factor will be identifying
within the hospital or trust to ensure that the necessary
clearly how the policy will be enforced and monitored.
time is put aside to discuss the policy at board meetings
These steps are discussed in more detail in the following
and ensure that the policy is promoted and acted on. The
sections and draw on a survey,1 case studies and
champion needs the authority to set up a working party
interviews carried out by the Health Development
with broad representation to steer the policy through
Agency (HDA).
implementation and must act decisively in the face of any
Box 3: Five steps to implementing smokefree trusts
• Offer training in smoking cessation to healthcare
staff
STEP 1 – COMMIT TO THE POLICY
• Ensure smoking cessation medications are on the
• Identify a champion who will be responsible for
hospital formulary
implementing the policy
• Secure visible senior commitment
STEP 4 – COMMUNICATE THE POLICY
• Set up a working party
• Adopt and advertise a firm date for implementing the
• Identify financial and human resources
policy
• Consider the pros and cons of including grounds as well
• Communicate policy requirements internally and
as buildings in the policy
externally
• Inform ancillary services
STEP 2 – CREATE THE POLICY
• Ensure employee ownership of policy, especially at
• Draft the policy
management level
• Consult with all staff and representative patient groups
• Anticipate and deal with common challenges
STEP 5 – CONSOLIDATE THE POLICY
• Finalise policy and seek board approval
• Introduce the policy
• Ensure adequate timescale for implementing the policy
• Enforce the policy via written and verbal
with ‘lead-in’ period
communication on a regular basis
• Deal with violent or abusive patients or visitors
STEP 3 – ENSURE CESSATION SUPPORT IS WIDELY
• Ensure a rigorous monitoring protocol whereby all
AVAILABLE AND ACCESSIBLE
staff are responsible for implementation
• Local NHS Stop Smoking Services should be widely
• Review the policy regularly
advertised
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Guidance for smokefree hospital trusts

problems. This cannot be done by an external person,
representatives, operational services, buildings or estate
who would not know the relevant people or systems to
managers and health promotion. It is useful to be able
see that the policy is successfully implemented. This role
draw on the experiences of smokers when implementing
will take up a significant amount of time.
the policy – they should be invited to join the working
party. If they are reluctant, a union representative can
One option is for a local respiratory physician to take on
bring the views of smokers to the group. Feedback from
this role. They have direct experience of the damage
occupational health representatives about queries or
smoking can do and will be aware of the help available
concerns from smokers can also be informative.
for people wanting to stop. Another option is to have the
human resources director as champion as he or she will
It helps to have someone involved who has implemented a
have links with external contractors as well as easy
smoking policy before, perhaps from a primary care trust
communication with all internal staff. The HR director also
or neighbouring hospital. They can report on their
has direct control of changes such as those needed to job
experiences in the run-up to the implementation of
descriptions, contracts, advertisements, disciplinary actions
the policy and this can help to allay fears. Although
etc. Alternatively a senior member of the health and safety
insuperable problems are often foreseen, they rarely
department could also act as champion.
become a reality. Annex 5 gives contact names of people
willing to offer advice, support and further information.
In some cases the next step – ‘Secure visible senior
commitment’ – may be needed before a suitably senior
The working party should meet on a regular basis both
champion can be found. However, if a suitable champion
before and after implementation and it may be necessary
exists this person can play an important role in securing
to meet fortnightly in the month leading up to policy
the commitment of senior colleagues.
implementation. Sometimes, to avoid wasting people’s
time on issues that are not of direct concern to them,
Secure visible senior commitment
subgroups of the working party can be set up – for
example, a staff group, an estates group and a patient’s
It is vitally important to ensure board-level approval and
group – and these can meet more regularly and report
prioritisation of the policy. This will help ensure that
back to the working party. Meetings should be kept
financial and human resources are devoted to the policy
short, avoid busy clinic times and planned well ahead to
and that it is taken seriously by all employees. The clear
secure dates in people’s diaries. Email can also be used to
commitment to a smokefree NHS by the end of 2006 in the
communicate between meetings.
public health white paper will mean that achieving the
successful implementation of this policy should be a priority
The working party will also need to ensure continuity of
for all NHS boards. It helps if the chief executive and chair of
the policy if the champion leaves (see also ’Identify a
the trust are seen to be taking an active interest in the
champion’).
successful implementation of the policy.
Securing trade union representation
Set up a working party
It is particularly important to include union representatives
on the working party. Most national health professional
A working party can help to draft the policy, ensure
trade unions are supportive of smokefree workplaces
adequate consultation across various professional and
including, the TUC, Unison and the RCN.13 It helps if this
patient groups, and help with troubleshooting prior to
fact can be brought to the attention of local trade union
and during the early stages of implementation. It can also
representatives as they are not always aware of or follow
ensure the policy is equitable and that smoking cessation
the line of their national organisations.
treatment is accessible to all who need it, and assist in
the monitoring and review of the policy’s success.
Securing clinician representation
One case study highlighted the difficulties of involving
The working party should have broad representation,
clinicians in the implementation of the smokefree policy
including members from health and safety, clinical,
as, despite repeated requests, no clinician attended
nursing, pharmacy and smoking cessation staff,
working party meetings. This appeared to reflect the
human resources, trade unions, service users/patient
perception that this is a complex area and/or an
Guidance for smokefree hospital trusts
5

unpopular policy that could create extra work for them,
The HDA’s survey1 indicated that just over half (53%) of
or a lack of interest in the topic and its importance.
hospital trusts felt that they did not have the capacity to
devote resources and staff to the development and
However, it is very difficult to make the policy work if
implementation of the policy and only just over one in 10
clinicians do not engage with the process. In this
had a specific budget for policy development and
particular case study members of the working party were
implementation. Awareness and usage of external
asked to attend a clinicians’ meeting and present the
resources was relatively low, although just over a quarter
reasons for the policy and discuss issues concerning its
were aware that they could get support from NHS Stop
implementation. Once the clinicians appreciated that the
Smoking Services.
policy was going ahead (countdown signs displaying the
date of implementation helped to bring this message
In one case study, funding was initially allocated but
home), more than one representative then became
then withdrawn as the budget was diverted to other –
actively involved and helped to ensure the policy was
apparently more pressing – needs. This jeopardised the
promoted to medical staff and its implementation
implementation of the policy until funding could be
supported. Having a clinician as a champion for the policy
secured from elsewhere. Although securing funds can be
can also motivate other medical staff to get involved.
difficult, some money is essential for adequate policy
implementation. When requesting resources it is
Securing pharmacy representation
important to highlight that any financial outlay to support
Pharmacy involvement is also crucial, especially for
the policy will easily be recouped by savings on accidental
ensuring the accessibility of stop-smoking treatments.
fires and cleaning within a very short time of
This is relevant particularly in a mental health institution
implementation. Bed occupancy and other complications
where there are some important interactions between
may be reduced if patients are not smoking. If staff stop
antipsychotic medication and stopping smoking.
smoking, there should also be a reduction in absenteeism.
Pharmacists can lend specific expertise to this area.14
Consider pros and cons of including grounds as
Given that smoking cessation treatment is being made
well as buildings in the policy
more accessible, the pharmacy budget will need to cover
greater demand for medication. However, the National
As mentioned in Annex 2, there are several reasons why
Institute for Clinical Excellence (NICE) has concluded that
NHS trusts should consider including grounds as well as
both nicotine replacement therapy (NRT) and bupropion
buildings in the smokefree policy. For example, some sites
are extremely cost-effective drugs15 and therefore both
consider it easier to extend the policy to grounds as well
should be made available on the hospital formulary.
as buildings to avoid the problem of deciding where
Pharmacists can assist with securing supplies with the
smokers can smoke outside. When only buildings are
support of the trust board.
included in the policy, difficult questions arise such as
whether smokers should be allowed to smoke just outside
Identify financial and human resources
entrances or whether a smokefree zone should be
designated outside the entrance, for example banning
Funding is needed for outlays such as designing and
smoking within five metres of the entrance. In one case
producing signage, posters, countdown signs, increased
study patients complained about smoke drifting in
smoking cessation staffing and pharmacotherapy support,
through the windows of a cancer ward.
staff and patient consultation events, training costs and
locum cover when attending training. There are also
A decision also has to be made as to whether resources
‘intangibles’ that need to be taken into account such as
deployed on smoking shelters in the grounds or clearing
the time needed to write to all contractors who share
smoking litter would be better spent ensuring treatment is
the site (such as ambulance drivers, taxi drivers etc),
readily available and accessible throughout the trust. In
attendance at meetings to publicise the policy,
addition, allowing patients to smoke in the grounds
troubleshooting and problem solving, and answering
means that their continued smoking will hinder and delay
queries and comments concerning the policy. The
their recovery (see ‘Why become smokefree?’, p2).
funding involved need not be great – about £5,000,
depending on the size of the trust or hospital.
6
Guidance for smokefree hospital trusts

stopping or advice on how to manage withdrawal
STEP 2 – CREATE THE POLICY
symptoms when abstaining.
Draft the policy
Where exceptions are made, every effort should be made
to minimise exposure of staff and other patients to smoke.
The smokefree policy should be framed within the context
Smoking in these circumstances should occur out of sight
of health and safety regulations with the aim of protecting
of other patients, staff and visitors and there should be an
and improving the health of staff, patients, visitors and
agreed protocol for risk management. In one case study,
contractors. The policy should apply to all staff working
smoking was permitted in an enclosed courtyard that was
within the trust regardless of their grade or professional
mainly out of sight of others. All exemptions should be
background. It should be integrated with other relevant
regularly reviewed by a senior member of staff. In addition,
policies such as the Working Time Directive and
all members of staff should know where smokers can
disciplinary procedures for failing to comply with the
go to smoke, or, if the grounds are also to be made
policy. In some policies smoking at work after a smokefree
smokefree, the nearest exit from the hospital grounds.
policy has been implemented is treated the same as any
other form of drug misuse at work and classified as gross
It must be stated clearly in the draft policy how it will
professional misconduct. Tenders and contracts should
be enforced. Preferably, enforcement should be the
stipulate adherence to the policy as a contractual
responsibility of all staff – everyone should be aware of how
condition. The policy should apply to anyone entering or
to deal with infringements. Managers have a responsibility
using the buildings (and grounds, if applicable) and staff
to deliver the organisation’s policies irrespective of their
while on duty. Annex 4 provides a model smokefree policy
personal views and to support their junior staff on the same
that can be adapted according to the local situation.
basis. Specific training may be appropriate. Non-compliance
with the policy by staff should result in the initiation of
The policy should be equitable and transparent throughout
disciplinary procedures in a similar way to non-compliance
the hospital. It should not be concerned with whether
with other hospital policies.
people smoke but about where people smoke and the
effect it has on others. It is concerned with the preventable
Giving responsibility to all staff can, however, mean that
presence of carcinogenic substances in the locality of health
no-one is directly responsible for the enforcement of the
sites. However, because smoking damages health and
policy. It can therefore be helpful to designate an
delays recovery, every opportunity should be taken to advise
overarching responsibility for enforcement to a particular
smokers of the health risks of smoking and encourage them
staff group, which should report to the working party
to make an attempt to stop. In addition, the policy should
at regular intervals as part of the monitoring process of
apply to staff entering homes with a smoking environment
the policy. In one case study, security staff hold overall
while on duty. Patients should be asked, in writing, not to
responsibility for ensuring the policy is enforced. If
smoke when staff are present and staff should not be
smokefree grounds are included in the policy security
forced to enter patients’ homes where people are smoking.
staff can be particularly helpful at entrances and exits to
In one trust where this policy was implemented compliance
the trust, and car park attendants can also be responsible
was almost 100 per cent.
for ensuring smoking does not take place in the grounds.
Wherever possible, enforcement of the policy should be
The policy should allow for flexibility in exceptional
educational and supportive. However, patients who
circumstances, such as a terminally ill patient or a patient
persistently offend (three or more times) should be
with mental health problems in an acute psychiatric state.
referred to a stop-smoking adviser.
The nurse or doctor in charge of a ward or unit should be
able to make an exception for a patient where this has
Consult with all staff and representative
been agreed as part of their care plan. For all exceptions
patient groups
there should be demonstrable evidence that smoking
cessation has been fully considered as part of the patient
Once a draft of the policy has been agreed by the
pathway. For example, over time all patients in long-stay
working party, it should be widely circulated to all
institutions should be offered an appointment with a
employees, trade unions, contractors, staff and partner
specialist stop-smoking adviser who can offer support for
organisations for comment by an agreed date. It should
Guidance for smokefree hospital trusts
7

be made clear that the policy is a decision of the board
Nevertheless, it should also be acknowledged that
but that consultation is helpful to identify potential
smoking cessation is about disease prevention and that
problem areas and to assist with implementation. The
clinical institutions have a duty of care to staff and
draft policy should also be circulated to users and carers
patients for both physical and mental health. Stop-
for comment by an agreed date. In addition, members of
smoking support must be brought to the attention of,
the working party can present the policy at various multi-
and made accessible to, both staff and patients.
disciplinary meetings and address any concerns arising
The occupational health department should be on
about implementation.
standby to provide advice and support to staff members
who smoke.
Anticipate and deal with common challenges
Blanket exemptions
Staff and patients’ rights
In one case study, during a consultation on a draft
The issue of staff and patients’ rights to smoke comes up
smokefree policy, clinicians requested blanket exemptions
repeatedly when implementing a smokefree policy. It has
for whole wards and wings where there were long-stay
been argued that banning smoking leads to inhumane
patients. In this example, blanket exemptions were ruled
treatment of smokers. This can be a particular issue when
out but the policy allowed for case-by-case assessments
the health institution is the home for long-stay patients,
(as described in ‘Draft the policy’, p7 ) as part of the
but such patients should be reviewed on a case-by-case
individual care plans of all patients. Where an exception
basis (see section on ‘Empowering smokers with mental
is made, minimising staff exposure to smoke would
health problems...’, p9). In relation to staff, under health
normally mean that smoking is only permitted outdoors,
and safety guidelines no organisation should be
where staff and other patients are not in close proximity
endangering its employees by allowing the inhalation of
to the smoker. Ideally, this would be out of sight of other
carcinogens.
patients, visitors and staff, who may be engaged in a
cessation programme.
Some staff report smoking on hospital premises to signal
that they are taking a break but are unable to leave their
Hospital shops
station because of staffing shortages. One case study
Guidance issued by the NHS in 1992 indicated that
dealt with this by identifying the staffing shortages,
hospitals should not sell cigarettes except to long-stay
taking steps to fill the gaps and ensuring staff had their
patients.16 Given the availability of nicotine replacement
entitled breaks. Night staff may also comment that they
therapy (NRT), any sale of cigarettes is no longer
cannot go out of the buildings to smoke because of the
appropriate. Shops should also not sell lighters or other
dangers of doing so. Improved lighting and security
tobacco products, but instead consider selling those NRT
systems have helped to allay concerns about safety. In
products that are available over the counter. In addition,
one case study where the policy required the grounds to
they should promote NHS Stop Smoking Services and
be smokefree as well as the buildings, staff were allowed
other effective routes to quitting. The HDA survey1
to smoke in their own vehicles as a compromise. More
indicated that only 8% of hospitals offered NRT products
importantly, however, night staff should be provided with
in the hospital shop and 11% were still selling cigarettes.
appropriate leisure facilities for their breaks to promote
alternatives to smoking.
In one case study, it was discovered that the hospital
shop was sustained by its cigarette sales. Initially, there
The smokefree policy should be seen in the same light as
was resistance to the proposal that the shop should stop
policies on alcohol and illicit drugs. Those addicted to
selling tobacco. However, as continuing to sell tobacco
alcohol and illicit drugs are not allowed to bring them
would undermine the smokefree policy, options for the
onto hospital premises but are instead offered treatment
future of the shop were considered. These included a
for their addictions. Most smokers are dependent on
subsidy, allowing a chain to take over the shop (although
nicotine and support should be offered to both staff
there was concern that most chains sold tobacco), selling
and patients. Nicotine replacement therapies can be
NRT over the counter, or closing the shop. In the event,
kept as stock items on wards and used by those not
the shop continued to remain viable even though it no
interested in quitting to assist in the control of
longer sold tobacco and smoking paraphernalia.
withdrawal symptoms.
8
Guidance for smokefree hospital trusts

Concerns raised about crossing busy roads to purchase
institutions as a short-term interim step towards going
cigarettes if they were no longer available from hospital
completely smokefree but made the smoking rooms
shops can be addressed with the positioning of ‘older
unattractive by restricting them to two patients at any
people’ signs on neighbouring roads. This was
time, having no televisions or radios, and providing only
successfully achieved in one case study.
basic seating.
Jointly owned premises
Smoking shelters
Some of the buildings on hospital sites are managed by
Some hospitals have built shelters in the grounds where
other organisations or jointly managed by a number of
staff, patients and visitors are allowed to smoke. These can
trusts. In one case study a social club was jointly owned,
be costly (for one trust the cost was an alleged £60,000),17
leading to discussions about whether it should be forced
unsightly and undermine policies designed to protect
to come under the smokefree policy. There were also
health. Rather than spend budgets on building shelters it
concerns that it was mostly frequented by smokers and it
is much more preferable to invest in advice and support
could be forced to close if it was made smokefree and
for smokers and provide nicotine replacement therapy for
people no longer used it. In this case the decision was made
those smokers unwilling or unable to stop and who need
that it should go smokefree so as not to undermine the
help with controlling withdrawal symptoms.
policy.
Finalise policy and seek board approval
Empowering smokers with mental health problems
to make quit attempts
Once the consultation period is complete the working
The smokefree policy can be seen as supportive of
party should discuss the comments and decide whether
patients with mental health problems in that both their
any changes are needed to the policy. Approval of the
physical and mental health are being addressed by health
board should then be sought for the final policy. Once
professionals.14 Many mental health patients who smoke
agreed, the final policy should be widely circulated in the
say they have never received advice to stop from a
same way as the draft.
health professional. A smokefree policy can support
these patients if it is coupled with advice and support
Ensure adequate timescale for introducing the
for stopping.
policy with ‘lead-in’ period
The introduction of a policy can highlight the lack of social
The timescale needed to implement a smokefree policy
activities that are available on hospital sites for patients,
can take a few months because of the need for adequate
many of whom cite boredom as an important factor in
consultation, informing the relevant people, changing
their continued smoking. Leisure activities can then be
contracts, preparing signage etc. In one case study the
created or publicised.
start of the policy was postponed for three months for
these reasons. Time should also be allowed for the
In one case study, nursing staff identified that smoking
provision and display of ‘countdown’ signs for the three
rooms were useful as they knew where their patients
months leading to the date the policy becomes live,
were – in this particular hospital they could check up on
ensuring all staff, patients and visitors are made aware of
them as the smoking room had glass windows. This is a
the start of the smokefree measures.
tacit encouragement to smoke on the premises and
highlights a number of issues: a shortage of social
Consideration should be given to an appropriate ‘lead-in’
activities, availability of ‘social rooms’ for patients, and
period for the policy. This could be for the first three
potential staff shortages. The smoking room was closed
months after the policy becomes live, during which staff
and the other issues addressed by providing non-smoking
not complying with the policy are not formally disciplined
social rooms, a wider range of leisure activities and
but instead are interviewed by their line manager and
rectifying staff shortages.
referred to occupational health for support and advice as
appropriate. If an individual continues to infringe the
Case studies have demonstrated that it is possible for
policy after the lead-in period then the manager should
NHS mental health care trusts to go smokefree. One such
be able to invoke disciplinary procedures as a means of
trust maintained a few smoking rooms in long-stay
encouraging adherence to the policy.
Guidance for smokefree hospital trusts
9

Offer training in smoking cessation to
STEP 3 – ENSURE NHS STOP SMOKING SUPPORT
healthcare staff
IS WIDELY AVAILABLE AND ACCESSIBLE
Training should be provided for all health professionals
Local NHS Stop Smoking Services should be
on how to give opportunistic stop-smoking advice to
widely advertised
smokers. This training will also ensure that they are made
aware of the support available to smokers from the local
It is incumbent on those working within the NHS to
NHS Stop Smoking Services. The coordinator of these
recognise the importance of encouraging their patients
services should be able to provide the training.
who smoke to stop. A close relationship should be forged
with the local NHS Stop Smoking Services and patients
In one case study, stop-smoking training was deemed to be
and staff should be made aware of these services.
a low priority by the clinical staff, who did not believe it
The services should be widely advertised through pre-
should be made mandatory for all staff. Given that stopping
admission literature as well as no smoking signs and
smoking is the most important step most smokers can take
posters throughout the hospital.
to improve their health, encouraging smokers to stop
should be a priority for all health professionals. Training
It is important to ensure that smoking status is recorded
in opportunistic advice to stop smoking takes half a day.
when patients register so that all smokers can be readily
A database of training courses can be found on the
identifiable on admission and throughout their stay in the
HDA website.19
hospital. This is to ensure help and support can be
offered.
Ensure smoking cessation medications are on
the hospital formulary
Some NHS Stop Smoking Services are hospital based (39%
of hospitals in the HDA’s survey1 indicated that this was
As proven smoking cessation treatments, nicotine
the case), others have a stop-smoking adviser employed
replacement therapy (NRT) and bupropion should also
by the hospital (29% of hospitals in the survey). Sixty one
be made widely accessible throughout the hospital – so
per cent of hospitals referred people to primary care trust
both need to be available on the hospital formulary. In
stop-smoking services. Patients can self-refer or be
addition to supplying patients who are receiving intensive
referred by health professionals, who therefore need only
support through the hospital system, patients unwilling or
to raise the issue of smoking, advise their patients to stop
unable to receive such support can be prescribed NRT or
and refer smokers to the services for support in doing so.
bupropion. The National Institute for Clinical Excellence
Some provision of specialist support will need to be
(NICE) has identified both these treatments as very cost
offered on-site as some staff may not be able and willing
effective.15 NRT, in particular, can be supplied to smokers
to travel to other sites for support.
who do not wish to stop, to help them with withdrawal
symptoms during their stay in hospital.
Some hospitals in the US that have implemented
smokefree environments in the grounds as well as the
The HDA survey1 found that although 40% had NRT on
buildings offer all patients and family members a pack
the hospital formulary, NRT was available on prescription
that contains an explanation of the policy, a map showing
in only 10% of hospitals and in only 8% were patients
where they can smoke, a brief summary of treatment
offered NRT. Only 6% of the hospitals surveyed stocked
options. They also offer a small pack of nicotine
NRT on their wards.
replacement therapy to aid withdrawal and educational
materials about smoking.18
Demand for stop-smoking services can be high when a
smokefree policy is implemented – planning ahead helps
to ensure demand can be met.
10
Guidance for smokefree hospital trusts

people that the smokefree policy will be taken seriously
STEP 4 – COMMUNICATE THE POLICY
and emphasises the reasons for introducing it.
Adopt and advertise a firm date for
Where grounds are included in the policy, all ashtrays and
implementing the policy
bins for extinguishing cigarettes at entrances and exits to
trust buildings should be removed.
The date the policy will take effect should be widely
advertised. Countdown signs advertising the date of
Inform ancillary services
implementation of the smokefree policy should be placed
prominently near the hospital entrances and will help to
It is important to ensure that all staff are made aware of
ensure that people are made aware of the forthcoming
the policy, including ancillary staff such as ambulance
policy. The date should be chosen carefully. Dates such
drivers or volunteer car drivers.
as New Year’s Day or No Smoking Day (the second
Wednesday of March) will find many smokers making
Ensure employee ownership of policy, especially
attempts to quit at the same time. When advertising the
at management level
policy it can be helpful to briefly explain again the key
reasons and the benefits for staff, patients and the trust.
Communications around the policy should make it clear
that the policy is the responsibility of all staff, not just the
Communicate policy requirements internally
board. In other words, all managers should be made
and externally
aware that it is their responsibility to ensure that their
staff adhere to the policy and be made aware how to
It is important to ensure that all staff, patients, visitors
deal with infringements (see Step 5).
and contractors are made aware of the implementation
date and reminded of the policy when on trust premises.
In addition to countdown signs, no smoking signs should
be placed in every ward, corridor and stairwell around the
hospital premises to advertise the policy. The size of
signage needs careful consideration: if too small, the
policy could be deemed insignificant and not important;
too large and it comes across like an order or ‘shouting’.
Signage also needs to be appropriate to the environment
in which it is to be used. Both countdown and no
smoking signs should give contact details for the local
NHS Stop Smoking Service.
The policy on smoking should also be advertised on hospital
intranet systems and in all correspondence with patients.
Letters sent out in advance of hospital treatment should
highlight the policy on smoking but also advise patients to
stop, giving details of local NHS Stop Smoking Services.
All job advertisements, job descriptions, contracts etc
should mention the smokefree policy. Briefing sessions
should also be held for patients and staff when the policy
is being introduced. In one case study information about
the forthcoming policy was put on payslips.
It can be a good idea for board members, in particular
the chair and chief executive of the trust, to tour smoking
rooms and talk to staff and patients. This helps to inform
Guidance for smokefree hospital trusts
11

STEP 5 – CONSOLIDATE THE POLICY
Introduce the policy
When the policy is launched, publicity should be obtained
in the local press.
Enforce the policy via written and verbal
communication on a regular basis
It is important that the policy has teeth and is enforced
from day one. All staff should observe the policy and ensure
that others (staff, patients and visitors) also adhere to it.
However, overall enforcement, particularly for patients and
visitors, should be designated to one staff group, such as
security staff. This staff group should nominate a
representative who should report to the working party at
regular intervals on the success of the policy.
Deal with violent and abusive patients or visitors
If a patient or visitor becomes angry or violent, the
standard NHS procedures and policies for aggressive
behaviour should be invoked. A ‘zero tolerance’ policy
applies to the NHS for violence and abuse and this area
should not be an exception. However, most smokers do
appreciate that smoking in hospitals is inappropriate.
Ensure a rigorous monitoring protocol whereby
all staff are responsible for implementation
A monitoring protocol should be drawn up to identify
problems and suggest improvements. Monitoring should
involve identifying breaches of the policy as well as
positive outcomes such as the number of staff trained in
smoking cessation, staff and patient numbers seeking
support with stopping etc. Monitoring should be assigned
to ward managers or hospital matrons, as well as those
assigned overall responsibility for enforcement. They
should collect information on a monthly basis.
Review the policy regularly
It is suggested that the working party meets quarterly for
the first year to examine the implementation of the policy
and then on an annual basis. A formal review of the
policy should be carried out by the champion of the
policy after six months, with support from the working
party, and yearly thereafter.
12
Guidance for smokefree hospital trusts

References
1
Health Development Agency (unpublished). Current
11 McKee, M., Gilmore, A. and Novotny, T. E. (2003). Smoke
tobacco control arrangements in NHS hospitals. London:
free hospitals. An achievable objective bringing benefits for
Health Development Agency.
patients and staff. British Medical Journal 326: 941-2.
2
World Health Organization International Agency for
12 West, R., McNeill, A. and Raw, M. (2003). Meeting
Research on Cancer (2004). Tobacco smoke and involuntary
Department of Health smoking cessation targets:
smoking. IARC Monographs on the Evaluation of
recommendations for primary care trusts. London:
Carcinogenic Risks to Humans 83. Summary available at:
Health Development Agency.
www.iarc.fr
13 See ASH website for more information on support by trade
3
Scientific Committee on Tobacco and Health (2004).
unions. www.ash.org.uk
Secondhand smoke: review of evidence since 1998. Update
of evidence on health effects of secondhand smoke.
14 McNeill, A. (2004). Smoking and patients with mental
London: Department of Health. Available at:
health problems. London: Health Development Agency.
www.advisorybodies.doh.gov.uk/scoth/PDFS/
scothnov2004.pdf
15 National Institute for Clinical Excellence (2002). Nicotine
replacement therapy (NRT) and bupropion for smoking
4
Health Development Agency (2004). The case for a
cessation. Technology Appraisal Guidance No. 39. London:
completely smokefree NHS in England. London: Health
National Institute for Clinical Excellence.
Development Agency.
16 NHS Executive. Health Service Guidelines (92) 41.
5
Department of Health (2004). Choosing health. Making
London: Health Service Executive.
healthy choices easier. London: Stationery Office.
17 Hospital trust defends smoking shelters. BBC News.
6
Department of Health (2004). Annual report of the Chief
February 2003. Available at:
Medical Officer 2003. London: Department of Health.
http://news.bbc.co.uk/1/hi/england/2793689.stm
www.dh.gov.uk/cmo
18 Suggestions for talking with patients and their families
7
Department of Health (2003). Annual report of the Chief
about our smoke-free environment smoking policy.
Medical Officer 2002. London: Department of Health.
In: Implementing a Smoke-free Environment CD-Rom.
www.dh.gov.uk/cmo
Michigan: University of Michigan Health System.
www.med.umich.edu/mfit/tobacco
8
MORI/ASH omnibus poll (2004). Smoking in public places.
Details at: www.mori.com/polls/2004/ash.shtml
19 Health Development Agency (2003) Smoking cessation
in England: courses 2003. London: HDA.
9
Seymour, L. (2000). Tobacco control policies within the
www.hda.nhs.uk/documents/smoking_cessation_courses.pdf
NHS: case studies of effective practice.
London: Health Development Agency. Available at:
20 Health Education Authority/Department of Health (1992).
www.hda.nhs.uk/documents/tobac_controlpol.pdf
Creating effective smoking policies in the NHS. London:
Health Education Authority.
10 Seymour, L. (1999). Been there, done that. Revisiting
tobacco control policies in the NHS.
21 Department of Health (1998). Smoking Kills. A White Paper
London: Health Development Agency. Available at:
on Tobacco. London: Stationery Office.
www.hda.nhs.uk/documents/beentheredonethat.pdf
Guidance for smokefree hospital trusts
13

Annex 1 – Previous guidance and implementation
In 1992, the government indicated that the NHS should
4% in maternity. Partial bans frequently granted
create a virtually smokefree environment for staff,
exceptions, the most common being for bereaved
patients and visitors.16,20 In particular, the sale of tobacco
relatives (65%), long-stay patients (51%) and mental
on NHS premises, except for long-stay patients who
health patients (42%). In addition, 32% allowed smoking
smoked, was to cease by 31 December 1992, and by 31
by theatre staff, 26% by nursing staff and 24% by
May 1993 the NHS was to be smokefree ‘except for
consultants.
limited necessary provision of separate smoking rooms’.
By 1998, it appeared that although virtually all hospitals
The survey indicated that of hospitals currently operating
had policies on smoking, not all were properly in
a partial ban, 10% had tried implementing a complete
operation.21
ban. The survey and further research indicated that the
two main reasons for failure of these bans were inability
A survey carried out by the Health Development Agency
to enforce the policy and a need to control smokers and
(HDA) in November/December 2003 of a random sample
where they smoked.
of 80 hospitals* confirmed that the vast majority of NHS
hospitals had policies on smoking, with 10% reporting to
Twenty nine per cent of the hospitals with partial bans
be completely smokefree.1 The definition used in this
were planning to introduce a complete ban on smoking.
survey for a completely smokefree policy was that no
Overall, although 70% of the hospitals thought the NHS
exceptions were allowed whatsoever and smoking was
should be totally smokefree in the next two years, only
not permitted anywhere on hospital premises, including
11% thought this a very realistic prospect.
buildings and grounds. However, further research of a
sub-sample of the hospitals claiming to be completely
smokefree found that this was not the case. Respondents
in this sub-sample either reported that their hospitals had
endeavoured to implement a completely smokefree policy
but that the policy had lapsed due to inadequate
implementation and enforcement, or that smoking was
allowed either in shelters or outside the buildings.
The remaining 90% of the hospitals sampled were
operating partial bans. For these hospitals, smoking was
most frequently allowed in dedicated smoking rooms
(63%), and/or in dedicated smoking shelters (61%),
and/or outside the hospital entrance (60%). The most
common location for smoking rooms was on the wards
(22%), or in or near the canteen/restaurant (19%),
although 8% located them in theatre, 4% in A&E and
* 138 people were interviewed across a random sample of 80
hospitals stratified to include a spread of hospitals across the
country. Nine further in-depth interviews were conducted covering
hospitals with different policy programmes and different levels
of implementation. All interviews were carried out between
6 November and 10 December 2003.
14
Guidance for smokefree hospital trusts

Annex 2 – Rationale for smokefree grounds
as well as buildings
RATIONALE FOR SMOKEFREE GROUNDS AS WELL AS BUILDINGS
A strong message is communicated about the dangers of smoking
Having smokefree grounds as well as buildings means a strong message is communicated about the
established dangers of smoking and secondhand smoke.
Duty of care
People smoking at the entrance to NHS trusts gives a very poor impression and also means that those
entering and leaving the buildings have to pass through tobacco smoke. Smoking cessation is about
disease prevention and clinical institutions have a duty of care to staff and patients for both physical and
mental health.
Allowing patients to smoke while in hospital puts them at increased risk of complications and delays
their recovery.
Support for smokers to quit
Completely smokefree hospitals and grounds create a smokefree environment for people trying to stop
smoking and remove triggers that cause many to smoke or relapse to smoking. The availability of a
national network of specialist NHS Stop Smoking Services means that support is easily accessible for
patients and staff wishing to stop smoking.
Resources can be better spent elsewhere
Building and maintaining smoking shelters and clearing smoking litter uses considerable resources.
Money spent on these is much better spent on profiling and providing treatment and support for
smokers wanting to stop.
Smoke travels
If smoking is allowed at entrances and outside buildings, the smoke will drift in through doors and
windows thereby continuing to be a health hazard. In addition, patients dislike the smell of cigarette
smoke on staff if employee smoking is allowed on-site, and this can weaken patients’ attempts to stop
as well as undermining the smoking policy.
Fire risks
When smoking is allowed anywhere on the premises an additional risk of fires breaking out remains.
Guidance for smokefree hospital trusts
15

Annex 3 – Policy template*
SMOKEFREE POLICY
adopted concerning smoking at all [name] NHS Trust
premises (buildings and grounds).
Introduction
General principles and scope
The public health white paper, Choosing Health, makes a
clear commitment to a smokefree NHS by the end of
The aim of this Policy is to:
2006.
• Protect and improve the health of staff
Section 2(2) of the Health and Safety at Work Act 1974
• Protect and improve the health of patients, visitors and
places a duty on employers to:
contractors
• Protect both smokers and non-smokers from the
‘…provide and maintain a safe working environment
danger to their health of exposure to secondhand
which is, so far as is reasonably practical, safe, without
smoke
risks to health and adequate as regards facilities and
• Set an example to other employers and workforces,
arrangements for their welfare at work.’
particularly in health-related locations.
Several EU directives relating to health and safety in the
...by arranging for Trust buildings (properties and
workplace have come into force since 1 January 1993.
vehicles) to be ‘smokefree’ and by requiring staff not to
These include the Management of Health and Safety at
smoke while on duty.
Work Regulations 1999 which, under General Principles
of Prevention, include:
This Policy is part of a range of policies that together
comprise the [NAME] Trust Health and Safety Policy.
• Avoiding risks
• Combating risks at source
Work areas
• Replacing the dangerous by the non-dangerous or the
less dangerous
This Policy will apply to all staff, patients, visitors,
• Giving collective protective measures priority over
contractors and other persons, who enter the [name]
individual protective measures.
Trust owned or rented buildings (or grounds) for any
purpose whatsoever. (Although the Policy extends to cars
Secondhand smoke – breathing other people’s tobacco
leased from the [NAME] Trust during business usage, it
smoke – has now been shown to cause lung cancer and
does not apply to the interior of cars owned privately and
heart disease in non-smokers, as well as many other
not being used for business purposes or during business
illnesses and minor conditions.
hours.)
The employer acknowledges that breathing other
(The policy can be extended to protect staff from
people’s smoke is both a public health hazard and a
exposure to smoke when making home visits.)
welfare issue. Therefore, the following Policy has been
Introduction and implementation of the Policy
* Adapted from smokefree policies implemented at Norwich Primary
Care Trust and Norfolk Mental Health Care Trust (NMHCT). This policy
The Policy was agreed by the Trust Board at its meeting
can be adapted for Trusts implementing either smokefree buildings
on [date]. Its formal adoption will commence on [date].
policies or smokefree buildings and grounds with additional
wording required for grounds being provided in italics.
From that date, staff will not be permitted to smoke
16
Guidance for smokefree hospital trusts

while they are on duty, (irrespective of their location),
smoke and the effect this has on patients, visitors,
except in accordance with the previous paragraph.
smoking and non-smoking colleagues and other
members of the wider health community. It is also
There will be a ‘lead-in’ period between [DATE] and [DATE].
concerned with the presence of preventable carcinogenic
During this period, staff who do not comply with the
substances in the locality of health sites.
Policy will be interviewed by their line manager and
referred to occupational health, for support and advice as
[NAME] Trust sincerely encourages its employees to refrain
appropriate. Should an individual or group of individuals
from smoking outside the times and circumstances set
continue to infringe this Policy after the lead-in period
out in this policy, both in their own interests and as
the manager may invoke disciplinary procedures as a
representatives of a major public body, whose purpose is
means of encouraging adherence to the Policy.
to improve health. However, this falls outside the scope
of this Policy.
Responsibility for implementing this Policy rests with
the chief executive. Day-to-day responsibility for
Exceptions
implementation lies with directors and managers.
The Trust Board recognises that some patients have
The occupational health department will provide advice
circumstances that will require staff to make an
and support for staff. Those who wish to stop smoking
assessment as to whether special arrangements need to
will be helped to access individual or group support and
be made so that the patient will be permitted to smoke
nicotine replacement therapies as appropriate.
on a Trust site. Such circumstance might include
detention under the Mental Health Act or the inability of
To ensure that everyone entering [name] Trust sites
a patient to give informed consent for help with smoking
understands that smoking is not allowed in the buildings
cessation. Permission to grant an exception will rest with
(and grounds), clear signs will be on display. Staff will be
the nurse in charge of the ward or unit and be formally
reminded of how the Policy relates to their use of
recorded.
vehicles. (Smoking at entrances and exits by staff,
patients or visitors will not be tolerated.)
In all cases where an exception has been made there
should be demonstrable evidence that smoking cessation
Tenders and contracts with the [NAME] Trust will stipulate
has been fully considered as part of the patient pathway,
adherence to this Policy as a contractual condition.
in conjunction with the patient and/or their relatives.
Existing contracts will be modified as soon as possible.
Where an exception is made, every effort must be made
Patients will be advised of the new Policy on admission to
to minimise staff exposure to smoke. This would normally
[NAME] Trust premises. GP practices will also be informed
mean that smoking would only be permitted outdoors
of the Policy. Existing patients will also be addressed
where staff and other patients would not be in close
through a series of information sessions, with the
proximity to the smoker. Ideally, this would also be out of
support of stop-smoking specialists and counselling as
sight of other patients, visitors and staff, who may be
appropriate.
engaged in a stop-smoking programme.
Job advertisements will include reference to the non-
smoking policy and indicate that the adherence will be
contractual.
Training will be offered to staff in advising patients,
visitors etc of the policy, as requested.
Secondhand smoke
This policy recognises that secondhand smoke adversely
affects the health of all employees. It is not concerned
with whether anyone smokes but with where they
Guidance for smokefree hospital trusts
17

Annex 4 – Guidance to staff template*
SMOKEFREE POLICY
3 Staff who are finding it difficult to adjust to the Policy
should be a) invited to discuss the issues with their
GUIDANCE TO STAFF
manager, and b) referred to occupational health for
support and, if they wish, referral to medications.
The Smokefree Policy applies to staff, patients, residents,
visitors and contractors. The following guidance points
4 After [DATE] staff will be expected to comply with the
are intended to give all staff key phrases and references
Policy. Failure to do so will result in disciplinary
to enable them to implement the Policy effectively.
procedures. Managers will need to establish their own
monitoring arrangements to see that the Policy is
General
being followed. Evaluation will be carried out during,
and at the end of, the first six months.
1 Smoking is the biggest single cause of ill health and
premature death in the country. The Trust is doing
5 If individual staff challenge their manager on their right
everything it can to promote the no smoking message.
to smoke, the manager should refer to these points:
2 As an NHS employer, the Trust has a duty to its staff
• This is a Trust Policy relating to health and safety
and patients to protect them from the health hazard
and is based on the same principles as policies
that smoking represents.
relating to dangerous machinery, toxic substances
etc
Staff
• An employee cannot challenge the employer’s right
to introduce healthier and safer working practices
1 The Policy applies to all staff, without exception.
• The Policy is concerned with where someone
It has been drawn up following staff and patient
smokes. (A smoker may use their break to go off-
consultation, and has been endorsed by the Trust
site or to their private vehicle to smoke.)
Board.
6 If staff need to go ‘off-site’ to smoke during their
2 Staff cannot smoke in buildings (or grounds) owned by
break, the following applies:
the Trust, (or in leased cars belonging to the Trust) or
when they are on Trust duty. During the lead-in
• Under the Working Time Directive, where staff work
period, from [DATE] to [DATE], if you see a member of
for longer than six hours they are entitled to a break
staff smoking, in contravention of the Policy, it is
of a minimum of 20 minutes. Within the Trust all
suggested that you:
staff should be encouraged to take a break
• In most health and social care workplaces, breaks
• Remind the person of the Policy
are taken in a manner consistent with maintaining
• Make a simple diary note
minimum staffing levels. Managers need to plan
• Report the incident to the person’s line manager.
effectively for staff who leave the premises on
breaks for any reason. In relation to smoking ‘off-
site’, managers will need to liaise with their human
resources manager/adviser to assess the impact on
* Adapted from smokefree policies implemented at Norwich Primary
Care Trust and Norfolk Mental Health Care Trust (NMHCT). This policy
staffing levels and the expected/required availability
can be adapted for Trusts implementing either smokefree buildings
of staff.
policies or smokefree buildings and grounds with additional
wording required for grounds being provided in italics.
18
Guidance for smokefree hospital trusts

7 Under no circumstances should a confrontational
2 Visitors who are distressed for any reason should be
attitude be adopted or allowed to develop. All staff
comforted, but the Policy still stands.
who experience difficulties with the application of the
Policy should seek support from their line manager in
3 Contractors who contravene the Policy should be
the first instance.
reported to the person responsible for monitoring the
conduct of contractors on site.
Patients
4 Visitors and Contractors may wish for advice on
1 This Policy applies to all patients, but there may be
stopping smoking and should be given the local NHS
some exceptions. (See Smokefree Policy and paragraph
Stop Smoking Service [NAME] on [TEL].
3 below)
You have the full support of your Trust in the delivery of
2 Polite signage and reminders are usually sufficient to
this Policy. We would like you to feel confident about
deter smoking, but patients should also be informed at
your role and the contribution you are making to improve
pre-admission or on admission.
the health of staff and patients. If you would like further
guidance or support, please contact your line manager or
A similar rationale applies as for staff:
the Trust’s physical health nurse on [TEL].
• This is a Trust Policy relating to health and safety
and is based on the same principles as policies
relating to dangerous machinery, toxic substances
etc.
• The Trust has a duty to its patients to protect them
from the health hazard that smoking represents
• Nicotine replacement therapy (NRT) is available on
prescription and over the counter.
(Patients who are not detained under the Mental Health
Act and who choose to discharge themselves because of
the Policy may do so.)
If a patient becomes angry or violent, the standard Trust
policy for aggressive behaviour is to be invoked.
3 Where there is an exception, permission to smoke in a
designated outdoor area away from others can only be
given by the relevant ward or unit nurse, clinician or
senior manager. Permission to smoke should be seen
as part of the clinical pathway and be discussed by the
clinician, the patient/client and appropriate relatives in
that light and documented. This allowance should
not be extended to staff who work with those
patients/clients.
Visitors and contractors
1 This Policy applies to all visitors and contractors,
irrespective of their circumstances.
Guidance for smokefree hospital trusts
19

Annex 5 – Contacts
LINDA CAINE
Modernisation Lead, Norwich Primary Care Trust
Manager, Norfolk Stop Smoking Service
Email: [email address]
MARY RICHINGS
Nurse Adviser, University Hospitals Coventry and Warwickshire NHS Trust
Tel: 02476 538999
Email: [email address]
NO SMOKING DAY (INFORMATION AND TIPS ON QUITTING)
www.nosmokingday.org.uk
ROY CASTLE LUNG CANCER FOUNDATION/THE NATIONAL CLEAN AIR AWARD
www.roycastle.org
www.cleanairaward.org.uk/business_levels.htm
SMOKING HELPLINES
NHS Smoking helplines:
England and Wales – 0800 169 0169
Scotland and Northern Ireland – 0800 848484
NHS Pregnancy Smoking Helpline – 0800 169 9169
Quitline – 0800 002200
Support is also available in the following languages:
Quitline NHS
Bengali
0800 002244
0800 169 0885
Gujarati
0800 002255
0800 169 0884
Hindi
0800 002266
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20
Guidance for smokefree hospital trusts

Annex 6 – Resources
ACHIEVING SMOKE FREEDOM TOOLKIT
www.cieh.org/research/smokefree
HOMELESSNESS, SMOKING AND HEALTH
www.hda.nhs.uk/documents/homelessness_smoking.pdf
MEETING DEPARTMENT OF HEALTH SMOKING CESSATION TARGETS: RECOMMENDATIONS FOR PRIMARY CARE TRUSTS
www.hda.nhs.uk/documents/smoking_cessation_targets_part1.pdf
MEETING DEPARTMENT OF HEALTH SMOKING CESSATION TARGETS: RECOMMENDATIONS FOR SERVICE PROVIDERS
www.hda.nhs.uk/documents/smoking_cessation_targets_part2.pdf
PERCEPTIONS OF SMOKING CESSATION PRODUCTS AND SERVICES AMONG LOW INCOME SMOKERS
www.hda.nhs.uk/documents/perceptions_smoking_cessation.pdf
PREVENTION OF LOW BIRTH WEIGHT: ASSESSING THE EFFECTIVENESS OF SMOKING CESSATION AND NUTRITIONAL
INTERVENTIONS (EVIDENCE BRIEFING)
www.hda.nhs.uk/documents/low_birth_weight_evidence_briefing.pdf
PREVENTION OF LOW BIRTH WEIGHT: ASSESSING THE EFFECTIVENESS OF SMOKING CESSATION AND NUTRITIONAL
INTERVENTIONS (EVIDENCE BRIEFING SUMMARY)
www.hda.nhs.uk/documents/low_birth_weight_summary.pdf
SMOKING AND PATIENTS WITH MENTAL HEALTH PROBLEMS
www.hda.nhs.uk/documents/smoking_mentalhealth.pdf
SMOKING AND PUBLIC HEALTH: A REVIEW OF REVIEWS OF INTERVENTIONS TO INCREASE SMOKING CESSATION, REDUCE
SMOKING INITIATION AND PREVENT FURTHER UPTAKE OF SMOKING (EVIDENCE BRIEFING)
www.hda.nhs.uk/documents/smoking_evidence_briefing.pdf
SMOKING AND PUBLIC HEALTH: A REVIEW OF REVIEWS OF INTERVENTIONS TO INCREASE SMOKING CESSATION, REDUCE
SMOKING INITIATION AND PREVENT FURTHER UPTAKE OF SMOKING (EVIDENCE BRIEFING SUMMARY)
www.hda.nhs.uk/documents/smoking_eb_summary.pdf
STANDARD FOR TRAINING IN SMOKING CESSATION TREATMENTS
www.hda.nhs.uk/documents/smoking_cessation_treatments.pdf
STATISTICAL BULLETIN: STATISTICS ON NHS STOP SMOKING SERVICES IN ENGLAND, APRIL TO JUNE 2004
www.publications.doh.gov.uk/public/smokingcessationaprjun04.htm
THE CASE FOR A COMPLETELY SMOKEFREE NHS IN ENGLAND
London: Health Development Agency
Guidance for smokefree hospital trusts
21

Notes

Health Development Agency
Holborn Gate
330 High Holborn
London WC1V 7BA
Tel: +44 (0)20 7430 0850
Fax: +44 (0)20 7061 3390
URL: www.hda.nhs.uk
email: [email address]
ISBN: 1-84279-315-2
© Health Development Agency 2005
Guidance for smokefree hospital trusts
The recent white paper, Choosing health: making healthy
choices easier, announced that the NHS will be smokefree by
the end of 2006. This guidance document provides the rationale
for why the NHS should become smokefree, defines what is
meant by smokefree and sets out the steps needed for NHS
trusts to become smokefree. It is based on the learning from a
survey of hospitals carried out by the HDA at the end of 2003,
three detailed case studies and consultations with individuals
who have been involved in implementing smokefree policies.
The document should be read in conjunction with the HDA
briefing paper, The case for a completely smokefree NHS in
England. This briefing paper sets out the case for a completely
smokefree policy across the NHS and counters objections from
those who say it cannot be done.