Editorials

Banning smoking in the workplace

Smoking bans work: so what is the government going to do about it?

Papers p 188

A teaching hospital not a million miles from where I work has, for some years, been considering beefing up its non-smoking policy. In the next year a new policy will come into force, which will remove dedicated smoking rooms and hopefully discourage smokers from lighting up around the entrances to buildings. Moving this far has not been easy. The hospital envisages in the next five years moving to a totally smoke free hospital of the kind which Fichtenberg and Glantz (p 188) claim leads some 15% of smokers to give up altogether and others to cut down.¹ Perhaps with these findings to hand it might manage it in less than five yearsor perhaps not.

The figures from the review¹ are startling and would make workplace smoking bans by far the most effective short term smoking cessation strategy, barring outright prohibition, available to any government. In the United Kingdom, smoking prevalence is stuck at around 27% of the adult population.² Comprehensive workplace bans could reduce it to 23%. Achieving this effect with tax rises would require a doubling of the price of cigarettes.³ The English national smoking cessation guidelines estimated that comprehensive general practitioner advice to stop, coupled with referral to smokers clinics and widespread use of medications such as nicotine replacement therapies, could reduce prevalence by perhaps 1% in a given year.⁴

Even as you read this, tobacco company researchers and lawyers are possibly seeking ways of picking holes in the review's findings. The studies that were considered did not randomly allocate some workplaces to be totally smoke free and others not to bewhich admittedly would have been somewhat difficult. The review omitted some studies that involved only partial smoking bans and others that did not report "desired" outcomes. However, overall the evidence is as persuasive as it could be, given the limitations of this kind of real world research. Indeed, governments have mounted major and very costly initiatives on flimsier evidence.

In 1999 the UK Health and Safety Executive drafted an approved code of practice on smoking in the workplace,⁵ which was endorsed by the health and safety commission in September 2000, and 155 members of parliament signed a motion in support of it in May 2001. The code of practice focuses on the rights of workers to protection from environmental tobacco smoke but stops short of outright smoking bans. However, at present even this limited initiative seems to have stalled.

One might imagine that the major stumbling block to more effective action is concern over public opinion. Perhaps the public has had enough of restrictions on its freedoms and pleasures. However, the evidence is that the public is very much behind greater restrictions on smoking. ^{6 7}

Perhaps it is the moral argument that is staying the hand of politicians. Smokers should have the right to enjoy a perfectly legal activity and should not be hounded into abstinence. Against this argument is the fact that the large majority of smokers actually want to stop and have tried in the past but failed.⁸ Indeed, each year some 30% of smokers attempt to stop.⁸ Workplace bans can be seen not so much as restricting smokers' freedoms but providing an environment which is more conducive to their regaining control over their behaviour. Add to this the fact that environmental tobacco smoke is estimated to be killing more than 1000 non-smokers in the United Kingdom each year,⁹ and the balance of the moral argument would seem to weigh heavily in favour of strictly enforced bans.

So where does this leave the teaching hospital trying to establish a strict no smoking policy? Certainly, it has the backing of the main professional bodies and other relevant agencies in their endorsement of the national smoking cessation guidelines.⁴ It would also have the strong backing of the public.⁶ However, in practice, it seems likely that central government will have to act to require such institutions to be smoke freenot because the managers are reluctant but so that employees, patients, and visitors know that the regulations are serious and nationally enforceable. If the government puts the wheels in motion now to require workplace smoking bans, our teaching hospital could well be smoke free in five years' time. If it does not, we can expect the sweet aroma of tobacco carcinogens to pervade the air for many more years.

Robert West, professor of health psychology. 

St George's Hospital Medical School, London SW17 0RE r.west{at}sghms.ac.uk

Acknowledgments

RW has undertaken paid consultancy for, received hospitality and travel funds from, and undertaken research for GlaxoSmithKline and Pharmacia, of smoking cessation products.