Under a cloud

Every year at least 12,000 people die in the UK because other people smoke cigarettes. Of these deaths, about 500 are due to other people smoking in the workplace. For many workers subjected to other people’s smoke, this situation is soon to change – but not for some health and social care practitioners.

In October, the government published its health bill, setting out plans to ban smoking in public places.(1) This would prevent those who work in public places being exposed to second-hand smoke, which is known to cause respiratory problems, lung cancer and heart disease.

But the health bill came with exemptions. One of these, most notably for health and social care practitioners, allows people  to continue smoking in public places that in effect serve as their home. Consequently, service users in care homes, psychiatric institutions and prisons would still be able to smoke even though these environments are also people’s workplaces.

This, combined with the fact that the law has no effect on people’s freedom to smoke in their own homes even if they are being visited by a worker, means that many health and social care practitioners will continue to find themselves working in smoky environments. Is this fair? Do practitioners mind? And what can be done to balance the rights of service users and workers?

In its report Smoking in Public Places, the House of Commons’ health committee concluded that care workers who visit patients in their own homes should be protected as far as possible from second-hand smoke.(2)

The MPs said it was the responsibility of employers to ensure clients were aware that they should not smoke during a visit and that care workers should have the right to refuse to enter a home or room where a patient is smoking.

But Nick Johnson, chief executive of the Social Care Association, says there is a problem with this stance. “If someone is on their knees socially, is it helpful for us to add to that burden by saying you’re not to smoke when our staff are there? What if the person has severe mental health problems or is an alcoholic – do we let them sink into total squalor? Some people say that all they’ve got is a fag and that they choose to smoke because it’s all they can do. It would be a churlish response to say we won’t come and care for you.”

Johnson agrees with the MPs, though, that negotiations over smoking should be the responsibility of the employer, not the individual practitioner. “I don’t think it’s the worker’s responsibility,” he says. “I know people who would say ‘if you don’t like it then bugger off.’ Workers who challenge a person might get thumped on the nose.”

In his view, few clients would be uncooperative and refuse to comply with a request to refrain from smoking while a care worker was present.

Although it is one thing to ask a service user not to smoke for an hour or so, it is quite another to suggest that they never do so. For clients who need a live-in care worker, this is a particular issue – they can hardly be expected never to smoke while the care worker is on the premises or to keep their windows open around the clock.

As a compromise, the client could decide to restrict their smoking to a designated room or area of their home, but the care worker would still need to be willing to work with a smoker. To this end, home care agencies would be well-advised to ensure that workers are aware, and have signed a document declaring their awareness, that the client is a smoker – a tactic that the Commission for Social Care Inspection has recently suggested to one provider.

An individual’s right to smoke in their private home may be a given, but what about the rights of everyone – workers and clients – in an institutional setting? The English Community Care Association (ECCA), which represents care home providers, carried out a poll to judge the feeling on smoking in care homes. More than three-quarters of the respondents thought smoking in care homes – which are some people’s homes and other people’s workplaces – should be banned. But ECCA chief executive Martin Green believes care homes should be excluded from the new smoking laws.

“We want it left as discretionary and as an issue for proprietors and managers in consultation with residents,” Green says. “The role of a residential care home is to provide a service to residents. Each case needs to be taken on its own merits so that it satisfies the need of the majority of residents.”

Many of the ECCA’s members have already taken steps to limit staff and non-smoking residents’ exposure to other people’s smoke. One solution has been to introduce a designated smoking room where only staff who have agreed to work in a smoking environment are required to enter. Larger homes may have the space for separate smoking and non-smoking lounges for residents, and in the future it may be that some homes become either smoking or non-smoking in their entirety.

The situation in psychiatric institutions, however, is more complicated. For a start, more people with mental health problems smoke than the general population, with an estimated 70 per cent of people in psychiatric institutions doing so. They also tend to smoke more cigarettes each day and inhale more deeply.

While giving up can be difficult for anyone, it can, for many reasons, be even more of a challenge for this group. People with mental health problems may enjoy smoking and see it as a release when they are feeling under stress; others might find that nicotine helps to alleviate their symptoms and medication side-effects. They may not want to stop smoking because they believe smoking prevents them from gaining weight (which is a side-effect of some psychiatric medications), or they may feel so negative about the future that they are not worried about maintaining their physical health. For people in psychiatric institutions, however, there is one overriding reason why they smoke: boredom.

Lucy Widenka, senior campaigns officer at mental health charity Rethink, says: “In certain psychiatric settings there’s not a lot of meaningful occupation. If you introduced a smoking ban you would have to give them something meaningful to do. Smoking is part of the culture of psychiatric institutions. Eventually there should be a smoking ban to protect everyone but at the moment it would be difficult to introduce in psychiatric institutions.”

Not everyone agrees there should be a time delay. The Royal College of Nursing believes that exempting psychiatric institutions from a ban would exacerbate existing health inequalities – already people with severe mental illness are likely to die 10 years younger than the average lifespan and are twice as likely to be obese and suffer from diabetes.

One trust has shown that a no-smoking policy in psychiatric settings can work – Norfolk and Waveney Mental Health Partnership NHS Trust, which in April 2004, banned smoking on its premises. When patients are first brought into the trust their smoking habit is treated as a clinical addiction and a plan for quitting is entered on their care records.

When Ireland introduced its smoking ban in March 2004, psychiatric hospitals and nursing homes were exempt from the conditions and, similarly, under the Scottish legislation which comes into force on 26 March, smoking will be allowed in designated rooms in these settings. The Westminster parliament is unlikely to do things differently and so the onus will fall on local authorities, health trusts and care providers to ensure a compromise is reached that satisfies everyone involved.

(1) Health Bill, House of Commons, 2005
(2) Smoking in Public Places, House of Commons health committee, 2005


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