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Smoke-free law: everyone has a role to play

Paul Hooper
MCEIH
West Midlands Regional Tobacco Policy Manager
Department of Health
Project Manager
Tobacco Control Collaborating Centre

Reducing smoking prevalence is a key element of many government strategies to improve health. The white paper, Choosing Health: Making Healthier Choices Easier, promised new action to tackle tobacco and reduce the 106,000 deaths in the UK caused by smoking every year (86,500 in England).(1,2)
The Department of Health has a "six-strand-strategy" to tackle smoking recognising that while local stop-smoking services can contribute to a reduction in smoking prevalence (and help reduce inequalities in health) on their own they cannot hope to achieve the 2010 public service target of 21% prevalence of adult smokers.(3,4)
This year England, Wales and Northern Ireland will see a major cultural change - one that has already occurred in Scotland and many other countries. By the summer virtually all workplaces and public places in the United Kingdom will be smoke-free (see Box 1).

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This is great news for people who don't smoke, especially those who are currently exposed to secondhand smoke at work or at leisure. Secondhand smoke is known to cause illness and even death in nonsmokers and will often aggravate conditions, such as asthma.(5) Perhaps surprisingly, the new law is also good news for the majority of smokers - 73% of smokers say they would like to quit and many will be encouraged to do so as a result of restrictions on smoking at work and in public.(6)
Practice nurses, health visitors, school nurses and others who have direct contact with smokers should see the introduction of the new law as an opportunity to encourage people to go smoke-free themselves. However, there will be occasions when you may have to deal with counterarguments. This may be used as part of the assessment of a smoker's readiness to stop.(7)
It might be tempting to suggest that if someone is not ready to stop there is no point in confrontation. But in my experience a person who is preparing to stop will put forward arguments for smoking (or against quitting) to give themselves an excuse for carrying on. By being able to deal with difficult questions in a professional way practitioners will not only boost their own confidence, but will also increase the likelihood of a smoker making a successful quit attempt sooner rather than later.(8)

Dealing with awkward issues
Most of us are familiar with the common "Yes, but …" arguments put forward by smokers to justify continuing to smoke.
Typical points (and some suggested responses) are:

  • "I had a relative who died of cancer and she never smoked a cigarette in her life." Smoking does not cause all cancers, but it is linked to one in three. Lung cancer kills more people than any other type of cancer and around nine out of 10 of these deaths are caused by smoking.(9)
  • "I keep pretty fit so smoking won't harm me." It is well known that smoking kills. What is less well known is the effect that smoking can have on people's ability to live life to the full - to be fit and physically active. For example, carbon monoxide in tobacco smoke binds with haemoglobin in the blood which means that there is less oxygen delivered to the body. At this point a smokerlyser carbon monoxide test could be introduced to tip the balance towards making a quit attempt.(10)
  • "The tax from my smoking keeps the NHS afloat." While it is true to say that smokers do contribute extra tax, indeed it is a recognised measure for reducing prevalence, it is not earmarked for spending on the NHS. If people stopped buying cigarettes tax would be paid on other things. It is hardly a reason for an individual to keep smoking!(11)

There are of course many more examples.(12)

Smoke-free is good for health
Tobacco smoke contains over 4,000 chemicals in the form of particles and gases. It contains many dangerous poisons, as illustrated by last year's Cancer Research UK campaign advertisement.(13) It is no surprise that smoking and/or breathing secondhand smoke is bad for health - indeed it would be a surprise if it wasn't.
Smoke-free legislation is an inevitable response to years of campaigning by health organisations for the protection of people's health at work and in public places. In particular, smoke-free laws:

  • Reduce the risks to health from secondhand smoke.
  • Recognise a person's right to be protected from the harm of secondhand smoke and to breathe smokefree air.
  • Help people trying to give up smoking by providing supportive smoke-free environments.
  • lWill ultimately save thousands of premature deaths by reducing exposure to hazardous secondhand smoke and overall smoking rates.

A European report detailing evidence gathered to assist European and other national policymakers reinforces the need for countries to go smoke-free (see Box 2).(14) As health professionals we have no need to apologise for supporting a law that will have such positive outcomes.

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Not everyone is convinced
Although smoke-free legislation offers a great opportunity to improve public health, not everyone fully supports the idea. At a recent social gathering I was shocked to be challenged by a nonsmoking health researcher who was vehemently suggesting that the right of smokers to do what they wanted (ie, smoke indoors) was more important than the protection of the health of bar workers. I have lost count of the number of times it has been suggested that if bar workers "didn't like the smoke they should get a job somewhere else".
Less surprisingly, we have already seen resistance from the tobacco industry and business proprietors who are worried about profits rather than health, and, based on experience in other countries, we can expect further action as laws are brought into force.(15) These arguments tend to get "recycled" by smokers when consulting health advisers.

New issues for nurses
So what are the "new" arguments connected with the smoke-free law that we might encounter from smokers and what could the response be:

  • "Secondhand smoke isn't as risky as the health lobby makes out." A typical response of the tobacco industry. The government's scientific committee says that secondhand smoke causes a range of illnesses in nonsmokers, such as lung cancer and heart disease.(16)
  • "Government doesn't have the right to tell businesses what to do." Businesses do not have the right to endanger the health and lives of their     employees and customers. Government is obliged to protect public health and safety, as it does when it regulates drinking and driving, implements seatbelt laws, or sets environmental pollution standards.
  • "The law is about forcing smokers to stop." Nobody is being forced to stop smoking. The law is about protecting people from a known hazard. Smokers are still welcome inside premises, but their hazardous smoke is not. If people want to stop smoking there is plenty of support available.(17)
  • "Nobody really wants the law." Yes they do! As awareness of the health risks of secondhand smoke has grown, demand for smoke-free public places has dramatically increased. There is overwhelming public support for new legislation to end smoking in the workplace.(18)
  • "Why can't we have more smoke-free areas and ventilation instead?" They don't work. A total of 85% of tobacco smoke is gaseous and cannot be seen. Smoke drifts and ventilation would need to be of tornado strength to remove hazardous substances.(19)
  • "I'll stop smoking if you stop driving your car." The two issues should not be linked. Car pollution is definitely a problem but our society makes allowances because of the car's redeeming uses and controls emissions where possible.
  • "Limiting the freedom to smoke is an infringement of smokers' rights." Health rights are a more important freedom than the "freedom" to indulge in a self-indulgent addictive habit that harms others. Freedom of choice is no longer the best choice when it endangers other people.(20) It is important to respect and protect the rights and freedoms of children, people with asthma, angina, chest problems, pregnant women and the four out of five people in society who are nonsmokers.

Top tips to tackle awkward arguments
It is not possible to predict every eventuality, but here are some useful general points to remember:

  • You should assert yourself at every occasion. By not challenging a false argument you may prevent someone making a quit attempt.
  • Don't be drawn into attempts to frame the issue as smokers versus nonsmokers. It is the smoke that is the issue, not the smoker.
  • Always have a confident and supportive attitude towards smokers and avoid victim blaming.
  • lAvoid debating pseudoscience and obscure statistical details. Use statements such as: "There is no controversy about the fact that smoking is the largest preventable cause of death and disease.'"
  • Get familiar with what is happening and what help is available (see Resources).

Conclusion
Smoke-free legislation is primarily aimed at protecting everyone from a known hazard. It will enable some people, such as asthmatics, who are currently unable to visit smoky premises to enjoy a normal life and it will also be a trigger for many smokers to make quit attempts. By being aware of the issues and being prepared to defend this public health measure nurses will help to implement a much-needed law and support many more smokers to quit for good.

Resources

No Smoking Day
W: www.nosmokingday.org.uk/smokers/helplines.htm

Smokefree
W: www.smokefreeengland.co.uk
Information about the new legislation in England
Smoke Free England Information Line
T: 0800 169 169 7
Telephone help and advice for businesses

Go Smokefree
W: www.gosmokefree.co.uk

Help for people wanting to quit in England
NHS Smoking Helpline
T: 0800 169 0 169
Telephone helpline for smokers. Professionals can also order resources from here

Smokefree action
W: www.smokefreeaction.org.uk
Resources for campaigning for smoke-free environments supported by a coalition of health organisations

Tobacco information Scotland
W: www.tobaccoinscotland.org.uk
Smoking and tobacco-related information in Scotland

References

  1. Department of Health. Choosing health: making healthy choices easier. London: DH; 2004.
  2. Twigg L, Moon G, Walker S. The smoking epidemic in England. London: Health Development Agency; 2004.
  3. Department of Health. Tobacco.
    Available from:
    http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Tobacco...
  4. Department for Work and Pensions.
    Available from:
    http://www.dwp.gov.uk/ofa/indicators/indicator-24.asp
  5. Action on Smoking and Health. Secondhand smoke. Factsheet No. 8. London: ASH; 2006. Available from: http://www.ash.org.uk
  6. National Statistics. Smoking.
    Available from:
    http://www.statistics.gov.uk/CCI/nugget.asp?ID=313&Pos=&ColRank=1&Rank=326
  7. 7. Raw M, McNeill A, West R. Smoking cessation
    guidelines for health professionals. Thorax 1998;53:S1-19.
  8. National Heart, Lung, and Blood Institute. Nurses help your patient stop smoking. Maryland: NHLBI; 1993. Available from:
    http://www.nhlbi.nih.gov/health/prof/lung/other/nurssmok.txt
  9. Cancer Research UK. UK cancer incidence statistics. Available from:
    http://info.cancerresearchuk.org/cancerstats/incidence/?a=5441
  10. Carbon monoxide monitoring.
    Available from: http://www.ebme.co.uk/arts/smoke/index.htm
  11. ASH. Budget 2005. Tobacco tax submission. Available from: http://www.ash.org.uk/
  12. Hooper P, Farren C. Tobacco control advocacy: framing the debate. A resource pack. Warwick: South West Government Office and Tobacco Control Collaborating Centre; 2005.
  13. Cancer Research UK. Smoke is poison. Available from:
    http://info.cancerresearchuk.org/healthyliving/smokeispoison/
  14. The Smokefree Partnership. Lifting the smokescreen - 10 reasons for a smoke-free Europe. Brussels; Smokefree Partnership; 2006.
  15. Harrison R, Hurst J. The unwelcome guest - how Scotland invited the tobacco industry to smoke outside. Edinburgh: ASH; 2005.
    Available from: http://www.ashscotland.org.uk/ash/files/The%20Unwelcome
    %20Guest.pdf
  16. Scientific Committee on Tobacco and Health (SCOTH). Update of evidence of health effects of secondhand smoke. London: Department of Health; 2004
  17. NHS. Smokefree. Available from: http://www.gosmokefree.co.uk
  18. Smokefree Action Coalition. YouGov Opinion Poll Smokefree Legislation. London: SAC; 2005
  19. Repace J. A killer on the loose. An ASH special investigation into the threat of passive smoking to the UK workforce. London: ASH; 2003.
  20. BMA. Behind the smokescreen: the myths and the facts. Available from: http://www.bma.org.uk/ap.nsf/Content/smokescreen~Choice