Mary E Black: New Year’s resolution—a smoke-free NHS

maryeblack copyMy doctor father used to regularly set his trousers on fire. Born in 1924, he started smoking cigarettes as a teenager. He died of a smoking related cancer in 2003. My doctor grandfather served in the Royal Army Medical Corps in the first world war and died, when my father was 14, of smoking related cancer (and possibly some damage from mustard gas). I never met him.

My father tried but failed to stop his tobacco use. As public and medical attitudes to tobacco changed, he reduced his tobacco consumption. He almost broke the habit at home and when caught out would stuff his still smouldering pipe in his pocket. I perfected my darning skills aged 10 fixing singed holes in his tweedy jacket. At work was the worst, as there was no ban on smoking and no pressure on him to cut back.

When my father practised medicine doctors used to prescribe cigarettes, and doctors and nurses were used in tobacco advertising campaigns. You could smoke in the Department of Health, smoke in hospital corridors, and ward coffee rooms—you could even smoke on NHS hospital wards. Have you seen the genial 1950s Doctor Turner seeing patients in a fug of smoke in BBC1’s excellent series Call the Midwife? I can go one better: in the early 1980s I was taught what was then known as venereology by a charming doctor who would put down his fag, don gloves, do a pelvic exam, take off the gloves, and finish the cigarette while his patient put her underwear back on.


This would all be unthinkable now. Attitudes changed, fought every step of the way by the tobacco industry. We know that tobacco use is addictive, but also that it’s a learnt and socially mediated behaviour.

A kind of misguided sympathy keeps the last vestiges of tobacco acceptability alive in the NHS. We falter before ill patients in pyjamas dragging their IV fluid stands out onto the winter street in front of a hospital to have a fag, we pass with no comment past colleagues clustered around the emergency department exit having a communal smoke—some staff even smoke with patients at the exits of mental health units or in the last few remaining smoking shelters. And everywhere there’s the evidence of cigarette butts crunching underfoot along NHS paths and garden areas.

I too used to thoughtfully wheel ill folks out on hospital balconies so that they could have a fag. I believe now that staff should focus their efforts on making sure every smoker (and that is one in six people admitted to the NHS and half of all admitted to mental health facilities) gets nicotine replacement therapy and stop smoking advice in the first critical hours. By actually doing this, I have seen many recalcitrant older smokers stop, including my own mother-in-law.

Working with the UN as a doctor during the Bosnian war in the 1990s, I would stop at checkpoints to have a cigarette with the local commanders to show solidarity and help get my convoys through. It might have been a bit harder, but I could have made the same bond with a cup of tea or a greeting in their language, and some of my co-workers did just that.

And finally, till six years ago I used to smoke a cigarette annually with my best friend in Belgrade, who lost her son in tragic circumstances. I stopped doing that and stick to coffee. We are still friends and I am still able to share that anniversary with her.

cigaretteNone of my justifications for colluding with tobacco use still hold water. Tolerating tobacco smoking on NHS premises is a form of collusion. Staff who smoke in NHS uniforms are sending a very clear pro-tobacco signal. Health staff who smoke with patients are empathising in a harmful way. Colleagues who smoke deserve all our support to kick the habit at work. A campaign to make the NHS smoke free was launched in 2006. Ten years on, the job is not done yet—here is the latest call to change that.

A tobacco-free NHS means:

• No smoking anywhere in NHS buildings or grounds

• Stop smoking support offered on site or with referrals to local services

• Every frontline professional discussing smoking with their patients

The NHS is not yet smoke free. But it’s time that it was. If this had happened years ago then perhaps I would not be able to darn so well. Perhaps my father would still be alive.

Mary E Black is head of digital strategy at Public Health England. She is on Twitter @DrMaryBlack

Competing interests: I have no relevant interests to declare.

  • danbc

    I agree, but I’m still a little bit uncomfortable when we apply this to MH hospitals. Imagine I’m living in the community and am a confirmed smoker. And now imagine that you have to detain me under section of the MH Act, deprive me of my liberty and force me to take treatment against my will. How does give you the power to stop me from smoking? If I have capacity to make a choice then I have capacity to make an unwise choice. Smoking is by definition a very unwise choice to make.

    I think, to persuade me, people need to remind me of the numbers of people who go into MH hospitals as non-smokers and who come out as smokers. That’s a severe harm caused to those people. And also that banning smoking means hospitals have to do better on activities – occupational therapists have a key role to play here. And also that perhaps people don’t have capacity to chose to continue an addiction. And also that people with mental illness die on average 20 years earlier than the general population, and that smoking is one of the causes of that, and (as you say) smoking is very much more common in people with mental illness.

    I’d think it would be useful if health staff could say in simple language why they don’t want people to smoke. “Tobacco smoke makes your anti-psychotic medication less effective, and so we need to give you a higher dose if you keep smoking, and so you suffer worse side effects”. “Smoking means your wound will heal more slowly, and you’re more at risk of getting infection.”

    Finally: one small worry I have is that if there is a smoking bunker smokers will tend to use it and not smoke in the rest of the grounds, but if you remove the bunkers smokers will then smoke anywhere in the ground. This means that all staff now have some responsibility for stopping smoking, and I’m wary about dumping that onto an already overworked workforce. Especially because people smoking in hospital grounds are already under stress and more likely to respond in unacceptably aggressive ways. I think (although I have no evidence for this and accept I could be wrong) that smoking bunkers could be part of a phased approach, allowing trusts to provide targeted stop smoking info and advice about cessation, while hiding smoking away from the rest of the public.

  • kbrendel

    Response posted on behalf of Mary Black:

    Thanks for writing about this. It is really important we discuss this topic and also not assume this wicked issue is insoluble. All of the issues raised about why we cannot do this come up all the time in practice and all of them have answers. Some trusts have managed to deal with them and some have left them in the ‘too difficult box” and have not bothered to look at the evidence.

    Mental health admissions is a tricky one. I would say that if admitted into hospital as a heavy drug or alcohol user they get medical and other support to stop. Why should tobacco use be treated differently? Mental health act detentions – often cited as the last case where it is just too hard. Also that violence will increase against staff. Not sure really if this is true as I am getting widely varying information on this, and would say that some trusts have succeeded so it cannot be impossible.

    My own experience with smoking shelters is that they are horribly messy and require cleaning, are a pretty poor advert on NHS premises, and are usually avoided. Stop smoking signs on them are usually defaced or torn down. Not sure also what signal it sends to have staff in uniform smoking alongside patients and visitors. They cost money to maintain and generally annoy lots of folks.

    People as you say do tend to try and smoke anywhere they can. That leaves cigarette butts all over the place. That is unless there is a concerted effort to actually ask people to stop – and believe me when asked politely most people will. Lots of trusts have managed to do this. Some have not bothered. Remember that airlines have refused to let you smoke for years and most airports do not have smoking areas – so anyone going on a long distance flight is already prepared before they enter it. It is a social convention – there are some areas now where people would NEVER think of smoking and that has changed over time. I cannot really understand why the NHS is not one of them yet. Yes I do think we have a responsibility to ask people not to smoke, all of us. If someone lit up in front of you on the tube, or on a plane, or in a restaurant you can be quite sure people would say something. So why is that so difficult really?

    Using “stress” as the reason is to my mind a bit of a cop out. I am concerned that we do not support staff and patients with better options than lighting up. Cigarettes kill.

    If any reader is interested in this area, do try and pick an NHS trust that has addressed this and which has clear and practical stories of how they have tackled all the tricky areas.

    One final point, and I do apologise for asking this but I must. The pro-tobacco lobby is adept at engaging in this debate with various advocates. Can I suggest if you, or indeed anyone else, posts on this topic that you declare any conflict of interest, which might be funding or affiliation with a tobacco related business, or lobbying group. We should make this the norm for any tobacco cessation related posts, even those framed in a helpful and thoughtful way, as yours is!