“Fresh Air” for the NHS by Emma Hadley

It is easy to assume those who work for the NHS, particularly frontline staff, would live a healthy lifestyle due to being well educated on lifestyle choices that positively and negatively impact on their health, or, that exposure to the outcomes of these choices could be enough of a deterrent to pursuing unhealthy habits. But like any other person, we too have our flaws, our weaknesses, and our needs – one of mine is chocolate, something I could not do a nightshift as a hospital doctor without. A habit that is still prevalent in the NHS workforce, despite its well-known risks, is smoking tobacco. If a colleague says to you that they are going for “fresh air”, often this is code for “I am going for a cigarette break”. It can seem odd that those in a position of responsibility to improve the health of the nation, including providing primary and secondary preventative advice, continue to smoke tobacco. I have seen this paradox play out many times at work, the first when I was an Foundation Doctor on an orthopaedic ward round when the consultant stopped the round to go get some “fresh air” having just explained to a patient his fractured bone would take longer to heal if he continued to smoke.

According to the report Hiding in Plain Sight: Treating Tobacco Dependency in the NHS, published June 2018, 73,000 NHS employers smoke, which costs the NHS approximately £206 million each year – £101 million from sickness absence, £99 million from smoking breaks (“fresh air”) and £6 million in sickness treatment, around £2,800 per smoker per year. So why do we smoke? According to a BMJ article on Why People Smoke, whilst smoking was previously considered to be a socially learned habit and a personal choice, it is now widely recognised to be a manifestation of nicotine addiction, with nicotine being labelled a stimulant drug with some of the positive and re-enforcing side effects including relieving anxiety, improved mood and improved attention – things that could be perceived as beneficial for a tough day at work. But why do people start smoking in the first place?  Largely, these will be influenced by social, economic, cultural, commercial, and environmental factors – the Social Determinants of Health. For example, we know that there are higher rates of smoking  tobacco in more deprived areas; according to the Nuffield Trust in 2019, 16.9% of people aged 18 and over in the most deprived areas were smokers compared with 9.1% of people in the least deprived areas. Sadly, smoking tobacco perpetuates a vicious cycle of illness and deprivation and according to Action on Smoking and Health (ASH), smoking is known to be the largest driver of health inequalities in England.

Perhaps there are some additional factors at play in the NHS that contribute to staff smoking – working nightshifts, reduced access to food overnight, camaraderie between work colleagues and that our jobs can be mentally and emotionally challenging? NHS Digital produce monthly NHS sickness absence rate data which shows that anxiety, stress, depression and other psychiatric illnesses are consistently the most reported reason for NHS staff sickness absence, accounting for 25.1% of all absences reported in October 2021, which equates to 571,200 full time equivalent days of work lost. Given some of the previously listed positive side effects, perhaps there is a link between the rates of mental ill health of our staff and smoking.

Is it a problem that NHS staff smoke? I think the answer to this is best articulated by the positive impacts quitting could have on the individual, patients and NHS organisations. To mention just a few, the risks of smoking are well known with the NHS citing it be one of the biggest causes of death and illness in the UK. For the individual, to quit smoking would reduce the risk of developing one of at least 50 serious health conditions including cancer.  For the patient, the Boorman Report 2009 showed that better staff health and wellbeing is associated with improve patient outcomes and organisational performance. One factor that may be implicated in this association could be that staff who live healthy lifestyles, may be more likely to act as ambassadors, championing this way of life. We must also not forget the risk of passive smoking on NHS sites. For NHS organisations, the economic impact of staff smoking has already been outlined.

To help staff stop smoking, we need to continue to develop a workplace culture that cares for the physical health and mental wellbeing of our staff, with tangible actions that prove leaders and organisations are fulfilling the NHS People Promise, keeping staff safe and healthy.  Root causes of why staff smoke need to be identified and eliminated.  Support given to those trying to quit, such as staff specific smoking cessation offers including nicotine replacement therapy and behavioural support. Creation of smoke-free environments that prevent the risk of smoking relapses occurring but also reduce the risk of passive smoking. And education on the risks of smoking and promotion of why and how to quit.

Today is National No Smoking Day 2022, an annual health awareness day in the UK, intended to help smokers quit. This year’s theme is ‘Don’t give up on giving up. Every time you try to stop smoking, you’re a step closer to success.’ This year, the voices of healthcare professionals are being used as ambassadors to drive home this message and that #TodayIsTheDay to quit. The NHS Smoke-free Pledge, which was created in 2018 to provide a platform for organisations to show their promise to help smokers quit and provide the smoke-free environment to do this, is being re-launched this week. To date, it has been signed by 25 Clinical Commissioning Groups (out of 106) and 49 Trusts (out of 219).  So, to all my colleagues out there who smoke, today is your day to quit smoking and the NHS is here to support you. And to NHS leaders and organisations, please join us in pledging to make our NHS air nicotine-free and truly fresh for all our staff, patients and the general public.

Dr Emma Hadley

Dr Emma Hadley is a Geriatric and General Medical Registrar, working across Kent, Surrey and Sussex Deanery. Having undertaken leadership roles within local NHS trusts and participation in local quality improvement projects, Emma applied to the Faculty of Medical Leadership and Management (FMLM) National Medical Directors Clinical Fellow Scheme to continue to develop her leadership and management skills as well as to gain a deeper understanding and appreciation of change management within the NHS at a national level. Emma has a particular interest in the wellbeing and morale of the workforce, which has been at the centre of many of her previous QI projects and Emma feels incredibly privileged to have been placed within the Health Inequalities Team at NHS England. Emma hopes that she can bring both her medical and clinical leadership skills to the team, her holistic approach to addressing tasks and her passion for contributing to positive change, now with a new health inequalities lens.  Emma hopes to be an ambassador for the Health Inequalities Team, networking within NHSEI and liaising with the FMLM fellows across other organisations to align the health inequalities work being done nationally.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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