Journal of Nursing Management, 1999, 7, 349–354

Implementing smoking policies within Trusts: nurses’ perceptionsand views of effectiveness and implications

C. ANDERSON bsc (hons), msc1, S. SENGUPTA bsc (hons), msc2 andJ. COLEMAN bsc (hons), rgn, dip palliative care3

1Health Promotion Specialist and 2Research and Development OBcer, Gateshead and South Tyneside Health PromotionService (South Tyneside Health Care Trust), Tyne and Wear and 3Vascular Nurse Specialist, Queen Elizabeth’s Hospital,Gateshead Health Trust, Gateshead, UK

Correspondence anderson c., sengupta s. & coleman j. (1999) Journal of Nursing Management 7,S. Sengupta 349–354Gateshead and South Tyneside Implementing smoking policies within Trusts: nurses’ perceptions and views ofHealth Promotion Service effectiveness and implicationsHospital DriveEast View Aim This study set out to explore nurses’ views and perceptions of their hospital Trust’sHebburn

smoking policy, and the eCects that it has had on both staC and patients.Tyne and Wear NE31 2TH

Background Although soliciting and considering the views and perceptions of staC duringUKsmoking policy development increases the likelihood of eCective implementation, suchactivity does not appear to be routinely undertaken within the NHS.Methods Semistructured interviews were conducted with seven surgical nurses workingwithin one district general hospital in the UK.Results While all of the subjects acknowledged the value of there being a smoking policy,they felt that their Trust’s policy placed nurses in a powerless and vulnerable position,with little support available to help eCectively address the problems that smoking raisedfor them and their patients.Conclusions NHS Trusts that wish to develop and implement eCective smoking policiesshould engage their staC throughout the process, and not underestimate the positivecontribution that they all can make.

Accepted for publication: 1 June 1999

Introduction health of staC, patients and visitors, but also as necessarypart of the exemplar role that the health service has to

The recent Report of the Scientific Committee on Tobacco play with regards to tackling the wider problem ofand Health has underlined the continuing threat that smoking throughout the UK. Our Healthier Nation hassmoking poses, with it accounting for approximately one reiterated the importance of this type of activity, and infifth of all deaths in the United Kingdom (UK) (DoH particular has highlighted the role that nurses are expected1998a). The Health of the Nation recommended that the to play (DoH 1998b).whole of the Health Service work towards creating anenvironment that was ‘virtually smoke free’ as rapidly as

Literature reviewpossible (DoH 1992a). The importance of achieving thisgoal was reinforced by the Health at Work in the NHS Action on Smoking and Health (ASH) have identified sixinitiative that was launched in the same year (HEA 1992). principal benefits of introducing an eCective smoking

policy within workplaces (1994):Not only was this considered essential to protecting the

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1 Improved staC morale policy, with little consideration having been given to theadverse eCects that such a role could have on the nurse–2 Improved eBciency and productivity

3 Reduced absenteeism patient relationship (Philpot 1994).Batterley and Moore (1991) have suggested that clarity4 Reduced cleaning costs

5 Reduced ventilation and air conditioning costs is vital with regards to responsibilities for implementation,monitoring and censure. Indeed, while the importance of6 A possible reduction in fire and life insurance

premiums. staC support and enthusiasm to eCective policy implemen-tation has been stressed (Berry 1992), hospital staC haveLongo et al. (1996) stated that the introduction of

adequate smoking policies within hospitals serves a often been found to have had an acutely low awarenessof their organizations’ smoking policies (Batten 1988).number of public health functions, as they can protect

non-smokers from passive smoking; promote smoking With reference to the specific health-promoting role ofnurses, lack of time and knowledge have been identifiedcessation (or at least reduced consumption); and generally

set a positive example. In fact it has been suggested that as limiting their ability to eCectively put health promotioninto practice on hospital wards (Latter et al. 1993). Indeed,the best demonstration that any hospital can make of its

commitment to health is for it to forbid smoking within limited knowledge of smoking cessation techniques hasbeen found to inhibit both the ability and the willingnessits premises (Batten 1992). The rationale is that by doing

so not only does the hospital and its staC declare an of nurses to act as health promoters (Faulkner & Ward1983).unequivocal opposition to smoking within hospitals, but

they also help reinforce a wider message that tobacco is While the above demonstrate the variety of materialavailable to inform the development and implementationdangerous to health.

However, while there is a considerable weight of evi- of eCective smoking policies, little evidence was found toindicate that NHS Trusts are actually paying any genuinedence linking smoking with ill health and premature

death, there is growing support for the argument that the attention to them.It has long been accepted that soliciting the views andhabit of smoking can have a positive eCect on the well-

being of many smokers, in terms of its providing them considering the opinions of staC during the developmentof proposed policies increases the likelihood of eCectivewith pleasure, comfort and relaxation (Skrabanek 1992).

In addition, it has been argued that while the acknowl- implementation (DoH 1992b). However, little researchhas been undertaken to investigate the views and percep-edged dangers of smoking justify promoting the benefits

of not smoking, they do not provide justification for tions of NHS staC with regards to this particular type ofhealth promotion strategy.constraining individual liberty and restricting the right to

choose—after all smoking is not illegal (TiCany 1992).Certainly a strong case has been made for health pro-

Aimsmotion practice to abide by ‘an ethic of enabling orempowerment’ (Yeo 1993), with the facilitation of The aims of this study were to explore the views and

perceptions that nursing staC working within one generalinformed choice held to be a key goal (DeAbreu 1995).Smoking policies within hospitals have been the cause hospital held about their Trust’s smoking policy, and the

eCects that it had had on both staC and patients. Theof much heated debate, with many tensions related moreto the manner in which policies have been developed and essence of the smoking policy in question was that:

$ StaC were not permitted to smoke within the hospitalimplemented rather than to the idea of smoking restric-tions itself (although TiCany [1992] has suggested that except in a designated area at break times

$ Patients were not permitted to smoke within thesuch restrictions may merely encourage illicit and poten-tially hazardous smoking). One example of this with hospital, except in designated areas at the discretion of a

ward managerregards to policy development is that in many cases itappears that little consideration has been given to the $ Visitors were not permitted to smoke within the

hospital.addictive nature of tobacco, with many policies implicitlyassuming that smokers can and should be able to quit The study’s specific objectives were to:

$ Ascertain subjects’ awareness of the smoking policy,their habit at will (Paxton 1992). Conversely, Batten(1990) found that the most successfully implemented its purpose and how it was interpreted across the Trust

$ Establish whether subjects’ perceived the smokingsmoking policies included such initiatives as developingsupport programmes for smokers wishing to quit. Another policy to either help or hinder patient well-being

$ Ascertain problems perceived by subjects in relationexample with regards to policy implementation is thatnursing staC are often expected to ‘police’ the smoking to the smoking policy

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Implementing smoking policies in Trusts

$ Ascertain subjects’ perceptions of their role in main- completely banned you just end up with morepatients from these wards at the back door.taining the smoking policy

$ Identify subjects’ suggestions for improving the smok- When probed about smoking facilities for staC, a smokingroom referred to as the ‘sin bin’ was the only facilitying policy.mentioned. While all wards generally took a tough stanceon staC contravening the policy, it was felt rare for staCto be tempted to smoke during day shifts; it was more ofMethodsa temptation during night shifts, especially for those

This study was based on qualitative data collected fromworking on wards some distance from the ‘sin bin’.

in-depth semistructured interviews of a sample of nursesWhen the question of whether the smoking policy either

employed within one surgical directorate (n=7). Surgicalhelped or hindered patient well-being was broached, all

nurses were selected for three reasons, any one of whichsubjects stated that it could do both. It was felt that the

may have influenced their views of the smoking policy.policy could help in limiting postoperative complications

Firstly, they care for both short-stay and longer-stayamong all patients; and could be of assistance to smokers

patients; secondly, they often treat patients who have hadwho wanted to quit. However, it was also acknowledged

no ‘preparation time’ before entering a no-smokingthat the current arrangements could negatively aCect the

environment (e.g. road traBc accident victims); andmental well-being of patients who smoke, especially as

thirdly, the recovery of the types of patients that theysmoking is both an addiction and for many individuals

care for (i.e. patients in need of surgery) can be adverselyactually perceived as a way of helping themselves to cope

eCected by exposure to tobacco smoke (Philpot 1994).with stressful situations, e.g.

Following a successful pilot study, the main studyI can see that there are places in which its appro-

interview schedule was developed. The schedule’s ques-priate (the policy), but when you’re stressed you

tions were based on the study’s objectives, with interviewssmoke more … they’re going to want something

timed so that subjects would not be away from theirthat they’ve had for years to help them through.

work for more than 30 min (as recommended by BellIn addition, a number of subjects highlighted the

1993).detrimental eCect of patients contravening the smoking

A brief questionnaire was circulated to all nursing staCpolicy on patients who did not (e.g. staC having to search

to ascertain their willingness to participate. Seven nursesfor patients who had ‘sneaked oC’ for an illicit cigarette

were then approached to participate in the study: fourmeans that less time may be available to care for others

non-smokers, two ex-smokers and one smoker. The sub-on the ward).

jects were all aged between 26 and 59 years: six femalesWith regards to problems perceived by subjects in

and one male.relation to the smoking policy, a number of key issues

All subjects were assured that their individual responseswere identified. It was felt that it was unfair that nurses

would be held confidentially and that only anonymizedseemed to be expected to act as the sole enforcers of the

responses would be reported. At the end of the study,policy, especially as doing so often had a negative eCect

key findings were fed back to all subjects.on their relationships with patients, and in many instancesexposed them to aggression from smokers on the wards.Dangers associated with clandestine smoking by patients

Resultswere also highlighted, e.g.

… I ended up following the smell of smoke to findAll seven of the nurses approached readily agreed toparticipate in the study, and during their interviews a little old lady putting her cigarette into a bin

which contained paper towels. How the place didn’tappeared happy to talk openly about the issues underinvestigation. go up is beyond me!

In addition, the possible detrimental eCects on patientsAll of the subjects were aware of their Trust’s smokingpolicy and shared a broadly accurate understanding of it. who wish to smoke while abiding by the policy were

noted, e.g. elderly patients venturing out of the hospitalWith regards to the purpose of the policy, subjects clearlyidentified promoting health and/or risk management. to smoke, even in poor weather conditions.

When asked about their role in maintaining the smokingHowever, variations in how the policy was interpretedon diCerent wards were apparent, with some wards policy, subjects stated that an important part of their job

was to act as an advocate for their patients, providingadopting a very firm stance while others preferred a moreflexible attitude with regards to patients, e.g. them with advice and support: ‘Our job is to help them

to quit and to encourage them—can’t force them.’On some wards it’s completely banned, but if it’s

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C. Anderson, S. Sengupta and J. Coleman

However, they generally felt that they lacked both the (Batten 1988), this probably reflects the higher level ofnecessary health promotion training (e.g. of smoking publicity aCorded to such initiatives nowadays. However,cessation techniques) and resources (e.g. nicotine patches) the subjects did not possess a high level of awareness ofto provide actual substantive help. They also repeated the the policy’s specifics. Following further investigation, itfact that they were expected to act as sole policy enforcers, was discovered that their Trust’s smoking policy docu-a role sometimes at odds with that of patients’ advocate. ment was actually very diBcult to obtain; and so it was

Finally, when asked for suggestions for how to improve understandable that staC were unlikely to know whatthe smoking policy, the following were proposed: was actually detailed within it.$ Subjects felt that greater provision for patients who The flexible approach to policy enforcement was con-smoke had to be made, whether it be in terms of sistent with guidelines set out by the Trust. While suchdesignated smoking facilities within easy reach of all an approach can allow staC the freedom to act respon-wards; or support systems similar to those available to sively to diCerent situations, it also increases the possibil-patients with other addictive disorders (e.g. heroin ity of judgements being made on the basis of personaladdiction) opinions and not sound health promotion principles.$ Subjects felt that all other staC working in the Trust Although few thoughts about the policy’s eCect on staChad to share in the responsibility for and be more active were voiced, this may have been a consequence of onlyin enforcing the smoking policy one smoker having been interviewed. However, the fact$ Subjects felt that more training should be provided to that the designated staC smoking room was referred tostaC with regards to how to help and cope with patients as the ‘sin bin’ may have been indicative of the limitedwho smoke arrangements generally made for staC smokers across$ Subjects felt that future policy development could the Trust.benefit from input from patients; and that soliciting All of the subjects were aware of the dilemmas pre-patient views on the current policy and existing arrange- sented by the existence of the smoking policy for patientments would be desirable. well-being. While they understood the need for the policy,

they appreciated the range of diBculties that patients mayface as a result of it. While this dichotomy was often aDiscussionsource of confusion and frustration, the fact that all of

The Northern and Yorkshire Regional Task Force onthe subjects were aware of it demonstrated their realistic

Tobacco Control recently recommended that ‘all NHSgrasp of the issues.

establishments have smoking policies by the year 1999’An additional source of frustration for subjects con-(1998). While such an achievement would undoubtedly

cerned their perceived requirement to act as sole enforcersconstitute a positive advance, in order for them to beof the policy. Not only did this suggest that patients wereeCective they will have to be appropriately developed andnot being provided with consistent information regardingimplemented.the policy from all Trust staC, but that nurses wereWhen viewing the results of this study, due consider-expected to take sole responsibility for the policy’s eCec-ation must be made of its limitations, particularly thetiveness. Indeed the fact that subjects felt that their rolerelatively small size of the sample involved. While inter-as patients’ advocates was being compromised as a resultviewing more nurses would have been desirable, lowof having to enforce the policy may have actually limitedstaBng levels meant that there were few opportunitiestheir ability to be eCective health promoters on the ward.for directorate staC to be spared from their work in orderHowever, subjects were also readily willing to acknowl-to be questioned. While the generalizability of the findingsedge and identify their own shortcomings (e.g. lack ofmay have been compromised by the small sample sizesmoking cessation skills).and also the sample composition (all from one specialty;

It appears that at the heart of the subjects’ responsespredominantly female; predominantly non-smokers), thewas the implication that the Trust’s approach to tacklingfact that most of the results were corroborated by evidencesmoking placed nurses in the position of being bothidentified in the literature review suggest that they arepowerless and vulnerable, with few facilities (e.g. suBcientnevertheless valid. However, it also suggests that littledesignated smoking areas) or systems (e.g. counsellingprogress (if any) has been made in improving smokingservices) in place to help them eCectively address thepolicy development and implementation within the par-problems that smoking raised for them and the patientsticular Trust under investigation.in their care. Their suggestions for how this situationWhile the high level of awareness of the smoking policy

amongst the subjects appears to contradict earlier work could be remedied not only reflected this, but mirrored

352 © 1999 Blackwell Science Ltd, Journal of Nursing Management, 7, 349–354

Implementing smoking policies in Trusts

recent recommendations for eCective smoking policies in group to introduce a genuinely more eCective Trust-wide policy.the NHS proposed by ASH (Walker 1998).

Soliciting the views and considering the opinions ofstaC is neither an easy endeavour nor one that should beembarked upon lightly. It is nonetheless an importantRecommendationsactivity that should be encouraged across the NHS. The

When considered in addition to the established evidencepositive contribution that nurses can make to successful

identified in the literature review, the findings of thissmoking policies should not be underestimated, and their

study (despite its limitations) suggest a number of rec-participation will be crucial to achieving Our Healthier

ommendations for eCective smoking policy developmentNation’s aspiration for NHS Trusts to become ‘places

and implementation that NHS Trusts across the UK couldwhich actively improve everyone’s health’ (DoH 1998).

benefit from considering:$ NHS Trusts should ensure an evidence-basedapproach to smoking policy development and

Acknowledgementsimplementation$ NHS Trusts should facilitate a constructive dialogue The authors would like to express their gratitude towith all staC with which to inform smoking policy Darren Archer, Vicky Cave, Tracey Cowper, Judy Loggie,development and implementation Pam McLauchlan, Sue Milner, Kris Mitchell, Sharon$ NHS Trusts should take steps to provide patients Pearson, Debbie Philips, Amanda Potts, Gill Walton andwith the opportunity to input into and comment on policy Penny Williams for all the advice and support that theydevelopment and implementation provided throughout the study; Andrea Blackburn, Maeve$ NHS Trusts should take steps to ensure that developed English, Evelyn McCluskey, Gillian Reavley, Eileensmoking policies are leavened with a realistic awareness Westthorp and Pat Wilson for their administrative andof the range of diBculties and dilemmas that can arise clerical support; and Senga Bond, Glenda Cook, Margaretfrom policy implementation Dobson and Anne Scott for commenting on drafts of$ NHS Trust smoking policies should ensure the this article.adequate provision of appropriate facilities and support Most especially, we would like to thank all those nursessystems for smokers within their premises who so generously contributed their time and thoughts$ NHS Trusts should ensure that smoking policy to this study.implementation and enforcement is not the responsibility Parts of this work were carried out by C. Anderson to(nor perceived as the responsibility) of any one group contribute to a Masters of Science in Health Promotionof staC from the University of Northumbria at Newcastle.$ NHS Trusts should seek to provide those staC with a Parts of this work were presented as a poster at thespecific role as defined within the smoking policy with 6th Annual Forum of the Association for Public Health,the appropriate training (and the necessary time to under- Lancaster 1998 and at the 1st UK Health Promotiontake that training) so as to ensure eCective implementation Research Conference, Edinburgh 1998; and orally at theand enforcement. 7th International Health Promoting Hospitals Conference,

Swansea 1999.

Conclusion

The introduction of smoking policies within many NHS ReferencesTrusts has been both long awaited and laudable. However,

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