NHS Tayside responds to complaints about smoking shelters

Late last year Smokers Justice presented a complaint to NHS Tayside about their smoking policy following this story.

Phil Johnson of Smokers Justice sent me this reply from NHS Tayside.

NHS Tayside, along with other Health Boards in Scotland, considers smoking to be the most serious threat to the health of the people of Tayside. In accordance with this view we believe that, as a public health organisation, it should contribute, in every way possible, to continuing the de-normalisation of smoking. A key component of this is NHS Tayside's policy which bans smoking in its grounds. Our own staff, visitors, other Health Boards and the Scottish Government has strongly supported our Smoking Policy.
[Links added]

In line with any other Policy, the smoking ban has to be enforced and our experience since 2006, (when the Policy was launched), has indicated that the employment of a Liaison Officer, along with support from NHS managers, is the most effective approach. The Courier and Advertiser is trained to persuade those NHS staff and visitors who smoke in our groundsto put out their cigarettes and signpost them to support services to help them quit smoking permanently. In the case of staff, he can also report smokers to their line managers for potential disciplinary action. Given the fact that our staff are viewed by the public as exemplars for health, then their behaviour can have a significant impact on the beliefs and attitudes of others. This is particularly important in the case of smoking.

I should stress that NHS Tayside staff who smoke are offered, and receive, considerable support from smoking cessation experts to quit smoking. Many of our staff have actually sought support to quit smoking as a result of our Policy.

We do have one smoking shelter in each hospital for in-patients to smoke. We decided not to have any others because our experience showed that this would dilute the message of our Policy. Also, when we tried to have more shelters pre-2006, staff and visitors saw this as an excuse to smoke anywhere they liked.

Therefore it is essential that we maintain the strength of our message within the Smoking Policy, which, along with other tobacco control initiatives, will eventually lead to a smoke-free Scotland. [Emphasis added]

Good luck with that one, NHS Tayside. The direction of travel has changed since anti-smoking rhetoric became an international government obsession, reflected in the smoking rate seen against anti-smoking government expenditure in Scotland:

Figures on tobacco control and smoking cessation expenditure obtained from FOI request from the Scottish Government, December 2012

Number of smokers taken from Scottish Household Survey reports

It is hard to find a way to say how unproductive tobacco control spending is on actual outcomes regarding smoking levels. And since we know so little about that, the figures on heart attacks and other health indicators are fairly meaningless as it remains as impossible as it ever was to measure either smoking levels or passive smoke exposure.

On the issue of smoking in hospitals, the casus belli in this case, read Smoking Scot, whose research and detailed accounts are worth pursuing.

I am very familiar with General Hospitals and their smoking shelters and I've had ample time to observe the dynamics of several shelters. During daylight hours the main users are hospital staff, able bodied patients and outpatients. During visiting hours those patients who need help with drips, catheters and such frequently enlist the help of family and friends - and they park themselves close to the entrance. There's nothing rebellious about this, the simple fact is the entrances to the shelters are not wide enough for a standard wheelchair and - in almost all cases I witnessed - we're talking about the aged or severely infirm, some with a terminal condition and all with something medical attached to them. Exposing them to rain, snow or extreme cold in a flimsy hospital gown is simply not an option for those who really care about them. Reality is so very far removed from the idealistic little vacuum of Simpson and McMahon.

After dark was a time of great poignancy when those without family had to make it to the entrance on their own. I spent a couple of evenings chatting to an aged widow (close to the entrance; even a hospital gets quiet after 21.00 hrs), who was remarkably candid about her condition and immediate future, despite having to wheel her drip which had her catheter reservoir dangling precariously on a hook. However they all had one thing in common, considerable personal dignity. None of us wanted to be in hospital yet those places, the entrance (after everyone had naffed off), or the shelters were great levelers. Met many very interesting people, got lots of tips and advice, even made a friend, and was delighted for him when he finally got what he wanted and passed over. And not one of them had any smoking related illness. Guts, bowels, breasts and brain cancers mainly.

Continue reading

Smoking Scot continues, discussing the perils of developing a culture of covert smoking, questioning who is demanding smoke-free health services, despairs at the myopic medical establishment view of smoking itself. The piece stands by itself but raises points that have been touched on this blog many times.

The main point is that actions enforcing the denormalisation agenda have no effect whatever on smoking rates, except perhaps to retard their decline. Like Sheila Duffy, NHS Tayside is living in a dream world if it believes the present trajectory will lead to a smoke-free Scotland.

Smoking liaison officer for NHS Tayside abused at work

I would not like to be in the shoes of anyone who is on the wrong end of abuse at work. But really, what is NHS Tayside doing, appointing somebody called a Smoking Liaison Officer to ensure that no one smokes on its sites in the face of reports that staff smoking on hospital sites is increasing?

Other hospitals have acknowledged that they can't prevent on-site smoking.

Workers who continue to smoke at work now risk committing the aggravated offence of being insolent to somebody who appears to have been appointed simply in order to ensure that they comply with a restriction on smoking in the open air, and to start disciplinary proceedings against any who refuse to do so.

Mr Marr added: ''Please note that the use of abusive language will not be tolerated, will be deemed as unacceptable behaviour, could be viewed as gross misconduct and will be addressed in accordance with the Dignity at Work Policy."

Where is any concern for the dignity of health care workers who like to smoke during the working day? Where were the unions when all this was being discussed? How does management get away with making such an inroad on terms and conditions of employment, imposed unilaterally?

All this could be avoided with the use of comfortable and well ventilated indoor smoking areas. But oh, no. We can't be seen to condone smoking. We prefer focus our resources on disciplining smokers.

Driving smoking down yet further in Scotland

First a graphic illustration (from Cancer Research UK):



And an interview with Michael Matheson (Scottish Health Minister) (available 6 more days from today). Sheila Duffy also participates. The Minister is questioned about the failure of the Scottish Government to meet its smoking targets. Both the Minister and Sheila Duffy point out in the interview the dramatic fall in smoking rates that has occurred since 1999. The graph (UK-wide) shows that there has actually been very little change in smoking rates since 2005.

Unusually for a BBC Scotland interview presenter Colin Kelly (sitting in for Kaye Adamson on Call Kaye) challenged the Minister and a couple of callers on their approach to smoking. Colin's fear is that if the Minister pushes too hard there will be a backlash against the smoking ban, which he likes. He is concerned about  individual liberty – to an extent – as well as costs. At 24.50 minutes into the clip he asks the Minister whether the only people who now smoke are in deprived pockets of Scotland who require help in many different areas of their lives – Matheson replies that they have a 'range of measures in place to try and help people who do wish to give up smoking'! The only problem he recognises in smokers is that they smoke.

The next stages of Scottish smoking cessation strategy seems to aim at the smokers in Scotland's most deprived communities. If Matheson is anything to go by, they won't get much of his personal attention because he already knows that all their health problems are smoking-related.

A recent initiative to persuade people not to smoke got off to a quiet start in Arbroath last weekend, where just 30 people signed up. The Courier reports the failure rates of smoking cessation programmes in the area, and state that NHS Tayside had the lowest success rate at 33 per cent (not mentioning that this figure was likely to have been a success rate at four weeks – very far from being a confirmed success story).  Professionals know that cold turkey is a very common quit method. Professional intervention seems quite over-rated, especially by those that provide it. Even if the reporters on the Courier are not reporting the full story it's good that they point out some of the failures of the smoking cessation service.

More here: again this relates to the UK, but is relevant. Of the whole NHS smoking cessation activity Chris Holmes points out that the 'real' smoking cessation rate has been about 6 per cent over the last few years. He says this:

Ladies and gentlemen, this programme was started by the Blair government in 2001.  It has been running for a decade, and boasting roundabout 50% success rates all along, with hundreds of thousands of smokers being duped into taking part with scandalous misinformation about actual outcomes, and yet the number of smokers in the UK today is: “similar to previous years”!

It's hard to resist the conclusion that the smoking rate has flattened out, and that no amount of NHS service delivery will make any difference in the future.

Edit, 21 August: You can access a permanent link to the Matheson discussion here.

Ring-fenced funding, smoking cessation, social marketing and slave labour

Further to this post, a planning document has come to light (h/tip Eddie) entitled The Application of Social Marketing to Behaviour Change in Tayside – A Progress Report. It gives a budget for two items regarding smoking cessation totalling £540,000 and two items on social marketing totalling £162,000.

I am struggling to get hold of what social marketing is really about. Here is a very quick explanation using the smoking example:


Gerard Hastings is an international pioneer on this issue, and loves working with authority at the highest level on interventions supporting the official view of desirable behaviour change. An anonymous commenter on this blog assures me that social marketing is about behaviour change according to people's aspirations, rather than according to the grandiose notions of public health. Perhaps I should have attended this conference?

For the time being, Hastings is the only authority I have consulted, and I've yet to be convinced that there is anything politically radical or right on, or democratic, about 'top down' programmes of behaviour change. Democracy is about being represented – not being managed.*

Social marketing as developed by NHS Tayside is about top-down management. It's about NHS Tayside deciding on a desirable behaviour change, be it handwashing or smoking cessation. I would be the last to claim that the budget here was very high, but still would contend that a handwashing policy in a health service doesn't require a social marketing toolkit. It's basic hygiene.

The smoking cessation programme, with a target of 360,000, has got 800 into its fold of which around half abstain for up to three months. Its target is 1,800 quitters, or 2 per cent, over two years. Nothing startling there in marketing terms, especially if the targets are for a three-month quit. But do we really need to ring-fence that money for a very small number of people to quit smoking? Over half a million pounds?

Reading on we discover that the supermarket vouchers paid out to people passing their carbon monoxide tests probably come from Asda, since Asda is listed among the  'partnerships'.

Asda – now where did that name come up recently? Another initiative to reduce health inequalities? Oh no, it was this:

Unemployed people ‘bullied’ into unpaid work at Tesco, Primark and other multinationals 

Unemployed people are being sent to work without pay in multinational corporations, including Tesco, Asda, Primark and Hilton Hotels, by Jobcentres and companies administering the government's welfare reforms. Some are working for up to six months while receiving unemployment benefit of £67.50 a week or less.

On another page, another company participates in the no-work-no-benefit charade – a registered charity this time:

March 2009 was my first claim. The placement was seven months after. [Before that] I was going to college [to learn English]. I paid £50 for it. Then when I went to the job centre they told me: “Now it's the New Deal. You're going to a placement”. I told them my English was not good but they said: “It doesn’t matter, you have to go. If you're not going, we’ll stop your money.” They told me they would stop my JSA [Job Seekers Allowance] so I stopped my English course.

The first [placement] was with the British Heart Foundation. I worked from 9 or 9.30am to 4.30pm with a half hour break. I did everything. I went for one week and the manager was so rude. One day she ate something and left so much mess in the kitchen. Then she says to me: “Karina, you wash up.” The first time I didn’t say anything. I was scared they would stop my money.

My point isn't to 'get at' Asda or the British Heart Foundation. It's to show how companies that participate in top-down initiatives supposedly to improve our health are capable of profiteering from government initiatives to get people off benefits. Again: 'Instead of being represented, we are now being managed. The governments in all the western countries manage us on behalf of the international system.'*

*with thanks to Tony Benn (reply to second question)

Scotland bribes smokers to quit: the efficacy of medication

NHS Tayside is extending its programme that offers money to people who use NHS services in order to attempt to stop smoking, on a postcode lottery basis. It targets its efforts towards those in deprived areas whose postcode indicates that they are probably heavy smokers, in order to try and close the 'health inequality' gap. 


The Courier explains. The scheme (which pays £12.50 a week in supermarket vouchers) has allegedly reached a quit rate of 50 per cent after four weeks. (Only five readers have left comments on this story, and they don't seem very happy about the outlay on the scheme.) This stupendously high quit rate (compared with what is normally achieved – see Michael Siegel's review of a recent study) apparently justifies the roll-out of the scheme, known as quit4u, from Dundee into neighbouring towns. 


Interesting that arch anti-smoker (and plain packaging advocate) Simon Chapman doesn't buy the line that NRT works, or that expenditure on it is justified.

The pharmaceutical industry has a clear commercial interest in eroding public and professional confidence in unassisted smoking cessation, yet easily implemented ideas, such as graphic health warnings, are more effective than nicotine replacement therapy. 

Is Chapman biting the hand that feeds him? It is not hard to find pharmaceutical links with the anti-smoking industry. Indeed health professionals were cautioned about this close relationship only a few weeks ago, by the World Health Organisation. Some of Chapman's anti-smoking colleagues are puzzled by his line of argument. Many have taken issue with him.  Not only does he not believe in smoking cessation treatments, he believes that pharmaceutical interests exaggerate the difficulties of smoking cessation, and that anti-smoking campaigning should not attempt to make out that people can't quit without help. Two years ago he published a major study that made the following points:

• - Research shows that two-thirds to three-quarters of ex-smokers stop unaided. In contrast, the increasing medicalisation of smoking cessation implies that cessation need be pharmacologically or professionally mediated.
• - Most published papers of smoking cessation interventions are studies or reviews of assisted cessation; very few describe the cessation impact of policies or campaigns in which cessation is not assisted at the individual level.
• - Many assisted cessation studies, but few if any unassisted cessation studies, are funded by pharmaceutical companies manufacturing cessation products.
• - Health authorities should emphasise the positive message that the most successful method used by most ex-smokers is unassisted cessation.

The message still hasn't got through to Tayside. 


I would love to know how Chapman expects the anti-smoking bandwagon to get pharmaceutical industry support if he goes about dissing the effects of nicotine replacement therapy. Does he expect to extort the money from the tobacco industry? Only time will tell.

Ballard not daunted by dismal quit rates in Tayside

A quit rate of one-third might not sound impressive, but Paul Ballard, deputy director of Public Health at NHS Tayside, isn't embarrassed about having spent nearly £4.5 million on trying to persuade/make/encourage/bribe people to give up. Because the cost of treating smoking related conditions is far greater than the cost of smoking cessation.

Well I think he should be embarrassed enough to order a review of NHS Tayside spending. One third is not a terribly promising success rate. I won't pretend to know what success rate is generally expected of medical preparations. But I would hazard an educated guess that we are not talking about a success rate of one-third really, we are talking about one-third of attempters managing to abstain from smoking for a four-week period. What use is that? Even Action on Smoking and Health (UK) knows that the long-term quit rate is abysmal (scroll down for this one). Scottish Government quit targets are expressed as a four-week term (see under smoking cessation services).

Paul Ballard's health board has effectively helped one-third of its attempting quitters to quit for four weeks. Whoopi-doo! Even after paying £½ million to some of his targets, this is the best he can manage. Has he realised that this expenditure is not reducing the cost of treating so-called smoking-related diseases? He's paying for both ineffective smoking cessation and the cost of treating smoking-related diseases.

Well done, Mr Ballard.

More about hospitals

Good news from NHS Grampian – a delay in its decision to implement its no- smoking policy for six months pending further consultations.

The threat of withholding treatment from smokers who breached NHS Grampian policy did not stop the Patients' Council spokeswoman from saying that she could 'not understand the delay'.

Another board member's view that 'the integrity of the board is at stake' if they fail to come up with an enforceable policy reflects the board's position that only a narrowly defined and very dogmatic interpretation of 'health promotion' will satisfy.

Freedom to Choose (Scotland) takes the view that the integrity of the board will take a leap if it listens to the problems detailed in the consultation executive summary (2009) – including the clear possibility that a doctrinaire anti-smoking policy will deter people from treatment – and abandons its dogmatic approach. In these economically-straitened times the prospect of spending up to £80K (Daily Mail, 3 August, p. 25) on destroying smoking shelters for no clear gain, only to have more people wandering off the site in their pyjamas, seems quite bizarre.

YET ANOTHER HOSPITAL STORY BROKE TODAY – Ninewells Hospital, Dundee, was reported in The Scotsman to have called in the environmental officers to 'fine people up to £50 for flouting its smoking policy'.

Of course, the environmental officers can apply fines for smoking only in enclosed or partially enclosed places. A phone call to Tayside Health Board quickly clarified that the enforcement officers had been called in to enforce the law – not the policy of no smoking in the grounds, which is not law.

For convenience I have added the link for Smoking, Health and Social Care Act (Scotland) 2005 to the side bar of the blog for easy reference.

And one more point:

the sign on the left must mean that prohibitions on smoking are banned, mustn't it ...?