Smokefree hospital grounds:

1. Smokefree hospital grounds: NHS patient, staff, and visitor perceptions of smoking on hospital grounds Sarah Franklin, Scott Crosby, Alina Serafin, Andrew Furber, & Bridgette Bewick

2. Acknowledgements • Funding for this project was provided by NHS Wakefield Public Health (now Wakefield Council). • We thank other members of the project team for their contributions – specifically we thank Diane Lee, Rashesh Mehta and Becky Edlin.

3. Smokefree hospitals • National smoking ban inside hospitals • Adhered to • No smoking policy around hospital grounds • Concerns– relocation to entrances and grounds • Posited that widening policies might facilitate culture shift

4. Social norms approach • Addressing misperceptions of the norm • Celebrating the positive • Participatory process Messages included in a social norms campaign present information about actual (healthy) norms of a population back to that population.

5. Smokefree hospitals September 2012 – December 2012

6. What were people doing? • Asked staff, patients, and visitors • 1,000 surveys distributed, 940 completed: • Before the campaign 10th Sept - 18th Sept 2012 (n=481) • After the campaign 17th Dec - 21st Dec 2012 (n=459) • Paper surveys were distributed using convenience sampling in and around the hospital buildings and grounds • Incentive of £1 charity donation given for each survey completed

7. What were people doing? • Own behaviour and attitudes? • Behaviour and attitudes of others? • Anything else?

8. What did people think and do? • Over 90% reported not smoking in hospital entrance • 96% patients • 99% staff • 96% visitors • Perception was that 50% to 70% did not smoke in hospital entrance • 50% patients • 71% staff • 51% visitors Relatively consistent support for smokefree entrances

9. What did people think and do? • Over 85% reported not smoking on hospital grounds • 88% patients • 99% staff • 87% visitors • Perception was that 40% to 55% did not smoke on hospital grounds • 41% patients • 55% staff • 40% visitors Less consistent support for smokefree grounds

10. What did people ‘say’? • Optional free text response • 306 provided text (out of the 940) • n=62 patients • n=155 staff • n=83 visitors • Thematic analysis • n=272 represented by five themes

11. What did people ‘say’? • Smoking is a dirty problem (26%) • Smoking as a harmful and dirty habit that impacts upon non-smokers • “patients who smoke then enter wards are an infection risk” • “ I think it is disguising that people are continuing to smoke”

12. What did people ‘say’? • Smokers are free to do as they wish (4%) • Individuals have the freedom to choose how to behave • “everyone has a choice and if they choose to smoke they should be allowed” • “ It is 100% legal to smoke outside”

13. What did people ‘say’? • The poor smoker (20%) • Acknowledged that although people should not smoke there are some who continue to do so; utterances attempted to explain why some people continue to smoke. • “I respect how difficult it is for smokers ... In a hospital some people may be experiencing a great deal of stress and need a cigarette” • “ Expecting patients to go off site to smoke is both unrealistic and unsafe”

14. What did people ‘say’? • Smoke in our space: the battleground (65%) • Smoker and non-smokers share one environment. Smoke and smoking behaviours of others encroach into the space of others. • “It’s very unpleasant, when leaving the main entrance, to be met with a face full of second hand smoke” • “ I feel an allocated area should be provided so not to affect the non-smokers. Also , it looks better when approaching the entrance if it’s not surrounded by people smoking”

15. What did people ‘say’? • No smoking please (26%) • People shouldn’t smoke and there should be an outright ban or policy on no smoking. • “Fine smokers immediately, no excuses” • “ No smoking should be compulsory and penalties imposed”

16. Conclusions (part 1) • Underestimation of the proportion who kept the entrance smokefree • Support relatively unanimous for smokefree entrances • Underestimation of the proportion who kept the grounds smokefree • Less consistent support for smokefree grounds

17. Conclusions (part 2) • Hospital users have complex narratives around how they make sense of smoking within a place that attempts to promote a ‘smoke free’ environment. • Most participants acknowledge that smoking is unhealthy and socially unacceptable. • Understanding of smokers’ actions vary • Expressions of how to manage smoking in public spaces vary.

18. What did we do? • Promote the message ‘99% of hospital patient, staff and visitors keep our hospital entrance free from cigarette smoke’ • Saturate the key messages in high footfall locations around the hospital, ensuring we reach all target audiences • Use of innovative mediums that the target audiences may not have seen in the hospital setting before • Adhere to restrictions from building owners re. placement of messages

19. What did this look like? http://social-norms.org.uk/project/pinderfields-hospital/ (0.00 to 01.10 mins)

20. Branding

21. Media Media used Banners, pharmacy bags, dinner tray mats, window stickers, wobblers, badges, staff payslips, counter top posters, staff newsletter, parking bollard wraps, café barrier, balloons, napkins, flyers

22. Thanks ... questions? Smokefree hospital grounds: NHS patient, staff, and visitor perceptions of smoking on hospital grounds School of Medicine, Leeds Institute of Health Sciences Charles Thackrah Building b.m.bewick@leeds.ac.uk

23. References Publications under review Franklin, S., Crosby, S., Lee, D., Mehta, R., Edlin, B., and Bewick, B.M. (submitted). The impact of a social norms approach on reducing levels of misperceptions around smokefree hospital entrances amongst patients, staff, and visitors of a NHS hospital. Serafin, A., Franklin, S., Mehta, R., Crosby, S., Lee, D., Edlin, B. and Bewick, B.M. (revisions submitted). NHS patients, staff, and visitor viewpoints of smoking within a hospitals’ ground: a qualitative study. Other resources Haines, M.P., Perkins, H.W., Rice, R.M. and Barker, G. (2005). A guide to marketing social norms for health promotion in schools and communities. National Social Norms Resource Center. (www.socialnorm.org) McAlaney, J., Bewick, B.M. and Bauerle, J. (2010). Social Norms Guidebook: A guide to implementing the social norms approach in the UK. University of Bradford, University of Leeds, Department of Health: West Yorkshire, UK. McAlaney, J., Bewick, B.M., Hughes, C. (2010). The international development of the ‘Social Norms’ approach to drug education and prevention. Drugs: Education, Prevention and Policy.