Smoking around hospitals: Time to call time

There are few upsides to a global pandemic, but maintaining some of the benefits of improved air quality on respiratory health during lockdown might be one of them.

Given the risks of Covid-19 to smokers, and the annoyance to hospital neighbours of displaced smoking, might this be a good opportunity to distil key messages on stopping smoking around hospital estates*?

We know that:

• Being a hospital patient, carer or staff member is rarely stress free, and smoking brings temporary relief to keen smokers
• Tying a message to a brick and throwing it at a smoker with a message tied to it saying ‘stop’ doesn’t work

What can we learn from pandemic and post-pandemic lessons?

1. People might not like rules, but unambiguous rules help. Lockdown in the UK ‘worked’ to protect the NHS and save lives.
2. In the UK, re-opening restaurants with government backed price reductions and the ‘eat out to help out’ slogan ‘helped’ in the short term. Incentives and social marketing sometimes ‘works’.
3. Kindness ‘works’ –and as a therapeutic measure, with no unexpected adverse side effects.

What do we need to avoid?

1. Displacing smoking a few yards down the street into someone else’s backyard
2. Asking workers with the least clout – often security colleagues – to be the sole ‘enforcers’

So what does this mean in practice and how do we test it?

Smoking, although a known killer is not yet illegal. Smoking rooms in hospitals set a bad example, Displacing smoking is bad for neighbourly relationships and the use of outside nearby spaces such as parks make them less attractive to patients and visitors. Reports of vaping as an entry drug for young people suggest that this is not a great solution either.

On the more positive side, almost every trial of interventions to stop smoking shows a bit of an effect, which is important at a population level.

So:

• basic community health measures before, during and after hospital appointments and with communities living around hospitals – if adequately resourced and with nicotine patches on offer -are not going to do any harm if sensitively delivered, and may be helpful.
• Low paid hospital workers and drivers are the most likely to smoke around hospitals, Enrolling in evidence-based quit smoking programmes for hospital employees and volunteer, ambulance service and taxi drivers irrespective of r contract status could be incentivised.
• Clinical staff and hospital neighbours could be offered fun training from actors on bystander interventions when they see a smoker (just as already exists for safeguarding). This could mean that everyone from the CEO to the Chair of the Trust Board could get a sense of the real challenges faced by colleagues who are asked to enforce no smoking norms around hospitals.
• As clinical staff are expensive but people still trust doctors more than estate agents and politicians, medical students and others trained by the actors and wearing scrubs (for this purpose only) to initiate an empatheric conversation with individuals about what might ‘work’ or at least help for them.
• Patients, visitors and staff often make a connection with a particular staff member – whether a health care assistant, a doctor, nurse or volunteer. These people (already not under-worked) could play a similar role.

Finally, incentives can sometimes work, though not when they are tied to sanctions rather than rewards. At a time when restaurants and gyms are struggling, post-Covid, a feasibility trial might well make use of local contacts for a range of rewards for carers of inpatients, who want to try different ways of diverting themselves from reaching for a ciggy.

The Australians have shown us that the steady drip drip drip of water on stone over a long period had an effect on smoking legislation and smoking behaviour over time. Covid has shown us that we can move faster. Sacred cows – a l’abbatoir!

*https://www.nice.org.uk/guidance/ng92