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Smoke gets in your eyes ... and every other part of your body

Jennifer Percival
RN RM RHV
Counsellor, Trainer, Author

Most nurses are aware that smoking is the greatest single preventable cause of disease and premature death in the UK. What is not comprehensively understood is that breathing in secondhand smoke (SHS), also known as passive smoke or environmental tobacco smoke, puts nonsmokers at risk of developing the same diseases as smokers. It may be an inconvenient truth, but there is hard scientific data that show that almost every organ in the human body is affected by inhaling tobacco smoke, your own or someone else's.

Why is secondhand smoke so harmful?
Smoke contains tar, carbon monoxide and over 4,000 chemicals, 70 of which are known carcinogens. It can reduce lung function, exacerbate respiratory problems, trigger asthma attacks, reduce coronary blood flow, irritate eyes, and cause headaches, coughs, sore throats, dizziness and nausea in nonsmokers.(1)
Exposure to SHS increases blood platelet activity, causing the blood to thicken and become more likely to clot. The tobacco smoke also affects cells lining the coronary arteries, contributing to the narrowing of the arteries. This reduction in blood flow may lead to a heart attack. A small study concluded that even half an hour of exposure to SHS can reduce coronary blood flow.(2)

Is the public aware of the dangers?
Polls show that many people still underestimate the health risks. To address this issue, Cancer Research UK has run a TV and poster campaign called Smoke is Poison (see Resources).
Despite the fact that some still "pooh-pooh" the idea that their smoke can be harmful to other people, the negative health effects are extremely well documented. A major review by the government-appointed Scientific Committee on Tobacco and Health (SCOTH) in 1998 concluded that secondhand smoke is a cause of lung cancer and ischaemic heart disease in adult nonsmokers, and a cause of respiratory disease, cot death, middle ear disease and asthma attacks in children.(1) A further review in 2004 stated that there is no safe level of exposure to secondhand smoke.(3) SHS has now been shown to cause the deaths of over 10,000 people in the UK every year.(4) SCOTH recommended that the government took action to protect nonsmokers.

Are nurses at risk?
The whole of the NHS became smoke-free on 1 January 2007, but staff working in the community may remain at risk from exposure to SHS. Although no one is suggesting that people are prevented from smoking in their homes, it is reasonable to expect that they refrain from active smoking while a community worker is in attendance. SHS isn't a nuisance, it is a health hazard. With the media attention and changes in the law, now is the perfect time to ask all if they'd mind going outside to protect nonsmokers.
The RCN guide, Protecting Community Staff From Exposure to Second-Hand Smoke, is available on the RCN website (see Resources). It encourages dialogue between healthcare workers and patients about ways in which staff can be protected from SHS - without compromising patient care.

Is the surgery environment smoke-free?
Nothing is worse than having to walk through a group of smokers huddled outside an entrance. To keep your surgery and its environment smoke-free put a sign up saying "Smoke-Free Zone - Please Refrain From Smoking Within 10 Metres of this Area". Do not provide litter bins, they support continued smoking and will be used as ashtrays. A new smoke alarm can be purchased from Bedfont, which shouts out "Please do not smoke in this area". If anyone is seen smoking, simply redirect them to the nearest place where smoking is allowed.

When will the new law come into force?
A law to ban smoking in virtually all workplaces in England (separate measures apply to Wales and Northern Ireland) will be implemented in 2007. Scotland enacted legislation in March 2006. Wales will follow on 2 April and Northern Ireland goes smoke-free on 30 April. The Department of Health has published regulations that set out some of the details of the Health Act 2006. They cover the definition of an enclosed area, enforcement authorities and signage.
Employers, managers and those in charge of smoke-free premises and vehicles will need to:

  • Display "no smoking" signs.
  • Take reasonable steps to ensure that staff, customers/members and visitors are aware that premises and vehicles are legally required to be smoke-free.
  • Ensure that no one smokes in these places

Exemptions
There are some exemptions to the ban, specifically for hospices providing palliative care, mental health units that provide long-term residential accommodation, prisons and offshore installations. In such establishments it will be possible for the person in charge of the premises to permit smoking in specified bedrooms or other rooms that are to be used only for smoking.

What stops a ban from working?
In order for a new law to work it has to be enforced. If people can flout the law without consequence, it will very soon become meaningless. In South African hospitals there is officially a ban on smoking, but as it is not regulated patients and visitors and staff feel free to continue smoking. In Singapore the law intended to limit (and) confine smoking to a single location where practical, "to minimise (a patron's) exposure to second-hand smoke", is ignored by most restaurant owners as they're concerned about losing business. In contrast, Hong Kong introduced a total ban on smoking in enclosed public places and have found it much easier to enforce the law.

How will the UK smoke-free legislation be enforced? 
The government's intention is to create a supportive environment where people are encouraged to comply with the new legislation. Experience in other countries that have already implemented smoke-free legislation, shows that compliance builds very quickly after implementation.
Although there is provision to fine people contravening the new law, the general approach to enforcement will be nonconfrontational. Efforts will be focused on raising awareness to ensure compliance through education, advice and support.

What about smokers' rights?
It's important to be clear that nowhere in the new legislation are the rights of smokers being denied. The only thing that is being changed is where people smoke in order to protect those around them from harm.

Will the ban cause a slump in business?
In countries where the ban has been in place for some time there is overwhelming public support for the move. In Ireland, all workplaces, including public houses, went smoke-free in March 2004. Today, 98% of the Irish public believes that workplaces are healthier since the introduction of the smoke-free workplace law, and 93% of people think the introduction of the law was a good idea, including 80% of smokers. Forecasts of a disastrous slump in pub trade have not been borne out.(4)
A study in Scotland looked at the air quality in bars and clubs pre and post the ban and found a marked difference.(5) Smoke-free legislation was associated with significant early improvements in symptoms, spirometry measurements, and systemic inflammation of bar workers. Asthmatic bar workers also had reduced airway inflammation and improved quality of life.
 
Do bans help people stop smoking?
In New York City, smoking prevalence dropped from 22% in 2002 to 19% in 2003, a year after the introduction of the smoking ban and other tobacco control measures - equivalent to 100,000 fewer New Yorkers smoking.
The government predicts about 600,000 people in England and Wales will give up smoking as a result of the law change.

Advocating for the rights of children
Nurses can act as advocates for those children whose parents smoke indoors. Children exposed to SHS are at increased risk of sudden infant death syndrome (SIDS), respiratory infections, ear problems and asthma.

Conclusion
The health risks from SHS exposure are now well documented and there is no risk-free level of exposure to SHS. The detrimental health impact of people's exposure to SHS will be significantly reduced as a result of the smoke-free legislation. Smoke-free laws protect everyone's right to breathe clean air without harming personal liberties or business trade and will help many smokers give up.

  • As of 1 January all surgeries in the UK have to be smoke-free by law.
  • Individual practice managers can decide if the ban extends to the grounds of the surgery.
  • In any case, it would be appropriate to put a sign up at the entrance to say "No smoking zone - please refrain from lighting up in this area". 
  • Do not provide litter bins as they will be used as ashtrays and will support continued smoking. 

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References

  1. Scientific Committee on Tobacco and Health (SCOTH). Second-hand smoke: review of evidence since 1998. Update of evidence on health effects of secondhand smoke. London: DH; 2004.
  2. Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001;286:436-41.
  3. Jamrozik K. Estimates of deaths attributable to passive smoking among UK adults: database analysis. BMJ 2005;330:812-7.
  4. Tobacco Control. Smoke-free workplaces in Ireland. A one year review. Available from: http://www.smokefreeengland.co.uk/files/1_year_report_ireland.pdf
  5. Menzies D, Nair A, Williamson PA, et al. Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places. JAMA 2006;296:1742-8.


Resources

Action on Smoking and Health (ASH)
W: www.ash.org.uk

Smoke is Poison
W: www.smokeispoison.com

Protecting community staff from exposure to second-hand smoke
W:http://www.rcn.org.uk/publications/pdf/protecting_community_staff_smoke.pdf

Smoke-free England
W: www.smokefreeengland.co.uk