Nursing a grudge against smokers

In September 2006, the Ohio District Court of Appeals upheld a local court decision that a mother and former nurse with a 20-a-day habit should lose custody of her six-year-old son to her former husband because she smokes. The court cited various health reports which link secondhand smoke to respiratory illnesses, in justification. In a 3-0 ruling, the judges wrote that a parent who smokes was a ‘factor to consider when making custody determinations’ (1).

Although the UK hasn’t emulated the USA in this regard yet, many here consider parents who smoke to be child abusers. Secondhand smoke, or passive smoking, has assumed enormous importance here, and illiberal tendencies are developing which suggest that the UK will not be far behind America in taking authoritarian measures against smokers. In the run-up to the national smoking ban indoors in public places, which begins in July 2007, the UK government’s White Paper Choosing Health has made a commitment to make government departments and the National Health Service (NHS) smoke-free by the end of 2006.

Some organisations have pursued this goal with vigour, and well-ahead of the deadline. It’s becoming common for councils and NHS organisations, for example, to tell tenants and patients that they mustn’t smoke in their homes if expecting a home visit from council or NHS staff, because a smoky environment is now considered an unsafe one. Some organisations have banned staff from having cigarette breaks or from smoking in or near their premises, car parks or vehicles. Sutton Council has even tried, albeit unsuccessfully to date, to ban employees from smoking in their own cars while driving to and from work. And all of this is done in the name of protecting people from the effects of secondhand smoke.

While initiatives like these might seem laudable, caring and even progressive to many, even if a bit ham-fisted, I think they are actually coercive, manipulative, moralistic, intolerant and anti-social. Sadly, my professional organisation, the Royal College of Nursing (RCN), has been at the forefront of pushing through these measures. Following its perceived successful campaign for the ban on smoking in enclosed public spaces, and in response to nurses’ concern that those of us who work in the community would not be covered by the smoke-free NHS plan, it has now published a ‘best practice guide’ for staff and managers.

Protecting Community Staff From Exposure to Second-Hand Smoke contains information and advice to help members protect themselves from secondhand smoke (2). Through exposure, nurses have reported symptoms like watery eyes, runny nose, dry cough and, in some cases, difficulty in breathing. The guide’s purported aim is to encourage dialogue between heathcare workers and patients about ways in which staff could be protected from their smoke without compromising patient care. Nurses felt it outside their role to ask clients not to smoke in their own homes, preferring their managers and employers to address the issue for them instead. The RCN’s tobacco policy adviser believes that ‘smoke-free working should be a right, not a privilege’.

The RCN’s guide suggests that because there is no law to protect staff working in a client’s home, employers and employees have traditionally relied on the understanding and goodwill of the client. Presumably now believing these qualities can no longer be relied upon, the RCN is encouraging managers to formalise relationships with patients by producing written contracts which outline the responsibilities of the service and patients. In return for nurses’ pre-booking visits, for example, patients will be expected to provide them with a smoke-free space to work in and not smoke during the appointment or for an hour beforehand.

Patients are to be informed that the nurse might leave if they do not adhere to the contract. While nurses can take a flexible approach, there is also the option of asking a patient to attend a clinic instead of having a home visit, or the nurses can turn to their managers for support in trying to change a patient’s behaviour.

Attached to the guidance are examples of ‘smoke-free environment policies’ from a variety of NHS Trusts around the UK. Some trusts are citing the 1974 Health and Safety at Work Act and the 2004 White Paper Choosing Health: Making Healthy Choices Easier to justify the policies. Many are taking the opportunity to advise staff that they mustn’t be seen smoking in public wearing a uniform and that selling tobacco products is prohibited on NHS premises.

The RCN considers Dorset Healthcare NHS Trust’s policy ‘an excellent example’. This stipulates that staff, contractors and visitors are not allowed to smoke in any part of the Trust’s premises or grounds, including car parks (including in their own vehicles), corridors, doorways and entrances, gardens, offices, rest rooms, restaurants, toilets, any shelters, garden sheds, or other similar structures that have previously been designated as smoking areas, even those areas immediately outside Trust grounds or premises.

The guide cites the findings of the government’s Scientific Committee on Tobacco and Health (SCOTH), which claimed that secondhand smoke can cause heart disease, stroke and lung cancer in adults – even though these findings are disputed (3). It also reports that secondhand smoke ‘causes somewhere between 1,000 and 16,000 deaths a year’. The irony of all of this is that, in an era of evidence-based healthcare and policies, there is no evidence that polices like these have any kind of positive effect. The studies quoted generally involved the non-smoking partners of smokers – people exposed to smoke over decades. Even among these people, the absolute increase in the risk of disease was tiny. For nurses and council workers popping in to see clients, the risk must be minute (see, for example, We have ways of making you stop smoking, by Dr Michael Fitzpatrick).

The RCN guide is also manipulative and guilt-inducing, implying that people who continue to smoke are selfishly putting their nurses’ health at risk. An information leaflet called Taking Care of the Nurse Who Takes Care of You has been produced to help reinforce the point.

All of this contributes to the commonly-held belief that working can seriously damage your health. Many in the public sector, for example, already believe they experience very high levels of ‘stress’ (nurses being the worst affected, apparently) and some have developed a tendency to blame others for this. Dealing with the real causes and problems – a high workload with insufficient resources – is presumably too difficult. It’s much easier to target people they can exercise some control over instead, with the added bonus of managerial support.

The RCN guide also wants a smoking ban imposed in mental healthcare settings on the grounds that anything else would perpetuate the health inequalities suffered by this client group. One Trust suggests that, based on legal advice, it is confident that a ban on service-users smoking does not contravene their right to respect for a private life under Article 8 of the European Convention on Human Rights, unless they could show that being denied their smoking habit would lead to deterioration in their mental health. How is this to happen? Dorset NHS Trust provides an answer:

‘The key to the successful implementation of this policy is an adequate supply of appropriate support and practical advice for service users who are smokers supplied through the SmokeStop Service.’

Acknowledging that conflict can arise with some service-users ‘who have generalised difficulties with relationships’, they advise that ‘discussion of the reasons for the arrangements and the firm and fair application of it can be used therapeutically with them’. The ‘use of cigarettes to reward approved behaviour or as a therapeutic aid is not appropriate’, however.

The only form of support mentioned for people who smoke is support to help them stop. There is no acknowledgement of the fact that some people enjoy smoking and want to continue to smoke, some no doubt in defiance of the intolerant climate that has developed around smoking. Neither is there a mention of making provision for staff who smoke. Presumably they don’t have the human rights that non-smokers have? There is also no mention of the fact that lung cancer only manages to get four per cent of the national cancer research budget. Maybe lung cancer sufferers deserve their fate because they brought it upon themselves?

Coercive anti-smoking policies are worthless in terms of encouraging people to stop smoking, but are fantastic in contributing to the political and moral climate that treats smokers as pariahs. Do we really want professional organisations and trades unions demonstrating that they care for their members at the expense of patient care or service provision? All of this places unnecessary barriers between staff and clients – even between colleagues. Instead of a panoply of guidance, leaflets and regulations, whatever happened to simply asking people to put the cigarette out if you don’t like it?

Brid Hehir is a nurse and the lead for patient and public involvement in Camden PCT, London. She writes in a personal capacity.

(1) Ex-wife smokes, so man can keep child, CantonRep.com, 26 September 2006

(2) Protecting community staff from exposure to second-hand smoke, Royal College of Nursing

(3) Report of the Scientific Committee on Tobacco and Health, March 1998