Memorandum by the Royal College of Physicians
of Edinburgh (SP32)
The Royal College of Physicians of Edinburgh
welcomes the proposals to ban smoking in most public places but,
given the strength of scientific evidence on the dangers of second-hand
smoke, the College cannot support the wider exemptions and slower
timetable proposed for licensed premises. The College is particularly
concerned about the exclusion of some licensed premises serving
restricted food items, proposals to permit smoking at the bar
and the longer lead time for licensed premises. In addition, it
should be clear that any exempted premises should have designated
smoking areas only, looking forward to a future when no-one will
be exposed to the dangers of passive smoke in a public building
or at their place of work. The scientific evidence is now irrefutable
that second-hand smoke damages health, and a total ban in public
places will support the denormalising of this life threatening
This evidence is offered by the Royal College
of Physicians of Edinburgh. The College has over 10,000 Fellows
and Members across the world and, indeed, has more Fellows and
Members in England than in any other country. Our main objectives
are to improve the standards of medical practice and health, largely
through standard-setting and education of doctors through out
their careers. A previous President of the College, Sir John Crofton,
was instrumental in the foundation of ASH Scotland and the College
continues to be a partner in the Scottish Coalition on Tobacco
(SCOT), which has been actively involved in the successful legislation
in Scotland which will ban smoking in public places from March
2006. The College is also a strong supporter of colleagues in
the Royal College of Physicians of London and their work on the
dangers of smoking and passive smoking.
The definition used within the Scottish Bill
has been amended to smoking rather than smoking tobacco, given
the enforcement problems that could arise from distinguishing
claims of smoking herbal cigarettes from tobacco-based products.
The College recommends that the definition is changed in the proposed
Bill for England to focus on smoking any substance.
The definition of "enclosed" as used
in the Scottish Bill is more rigorous at 50% enclosure rather
than the 70% proposed for England. This provides for semi-enclosed
structures eg station platforms in large urban stations, and would
capture most open fronted bars, entrances and restaurants where
walls can be removed onto adjacent pavement terraces. The 70%
level could result in a higher number of disputes over semi-enclosed
premises and would obstruct enforcement.
The College considers it helpful to provide
for future amendments by regulation, including the power to include
other premises within the definition of an enclosed space. The
example cited within the proposed Bill of sports stadia is particularly
relevant, given the combined risk to health from second-hand smoke
and fire where large numbers of people gather. The opportunity
to encourage a smoke-free environment should not be missed, given
the number of families and young people who use such stadia, and
the College would encourage the inclusion of stadia within the
scope of the Bill or regulations.
The issue about smoking in doorways will be
critical to enforcement with employers and retailers seeking to
maintain a smoke-free environment at their entrances and avoid
a "smoking ghetto" on the pavements and car parks. This
will also be of particular help to hospitals and other health
premises and assist managers to enforce a total ban on all NHS
property (including car parks). The College encourages the inclusion
of doorways within the definition or regulations to support enforcement.
The College cannot agree to the restricted exclusion
of licensed premises where food is being served or for private
clubs. There is no logic within such proposals if other retailers
are bound by the ban, and it is discriminatory to continue to
expose workers in the pub and club trades to second-hand smoke,
particularly as workers in the hospitality trade have the highest
exposure to second-hand smoke of any occupation (1). They are
thus at the highest risk to the hazards with a 50% increased risk
of lung cancer (2). The exposure of hospitality workers to dangerous
components of second-hand smoke falls dramatically following banning
smoking (3). In San Francisco, the respiratory health of bar workers
improved significantly following banning smoking in bars, whether
or not these workers stop smoking themselves (4).
The proposed ban on smoking at the bar is insufficient
to protect staff, will complicate enforcement and do much to damage
the denormalising of smoking which the majority now support, including
the over 70% of smokers who have indicated a wish to stop smoking
(5). Ventilation systems do not effectively remove the pollutants
in second-hand smoke (6), thus, smoking anywhere in the premises
will result in hazard permeating to those in the bar, including
staff. Furthermore, staff will need to enter the smoking rooms
to serve and/or clear and will thus be exposed to risk. Enforcement
will be particularly difficult even for responsible bar owners.
The College accepts that any premises serving
non-exempted food at any time will be covered by the ban at all
times, and that this will limit those premises that fall outside
the Bill. However, this is unsatisfactory and will be difficult
to enforce. Taking the power to amend the definition of exempted
foods will add to the confusion as lists change. Exempting any
premises that serve food adds to the complication of enforcement
by giving responsibilities to Food Standards Officers in addition
to Environmental Health and Trading Standards Officers.
There is no justification for a longer lead
time for the restrictions proposed for licensed premises, which
are themselves inadequate with exemptions of some bars where food
is not being served.
The College understands the need for exemptions
where the premises are in effect the individual's home, and that
this will include private houses and certain residential homes.
However, those working in these environments need to be protected
against the hazards of tobacco smoke. Thus, it is critical that
communal residential premises are not wholly exempted from the
Bill, and that there are designated smoking areas only within
these premises as appropriate to the level of need among residents.
There was considerable debate in Scotland over
the issue for psychiatric hospitals and units, particularly with
the reduction in residential care and the integration of psychiatric
units within general hospital buildings and community health centres.
Other supportive measures to encourage smoking cessation among
psychiatric patients should be provided and promoted to ensure
that all non-residential facilities can also be made smoke-free.
The College is not in favour of exempting all psychiatric patients
from a ban that will capture all other groups of in-patients.
However, it may be necessary on humanitarian
grounds to provide, for a limited time, very restricted smoking
facilities within in-patient environments. Examples include facilities
for elderly patients whose discharge may be significantly delayed.
The College is strongly opposed to the inclusion
of private clubs within the exemption list because of the risk
to staff employed in such premises, the lost opportunity to contribute
to denormalising of smoking, and the potential to avoid the ban
by licensed premises not currently offering admission by membership.
The College believes that the risk of increasing
the numbers of private clubs that permit smoking will also increase
health inequalities if the proposed Bill is not amended. It is
critical that all public buildings become non-smoking to support
smoking cessation activities by community health workers and those
individuals who have expressed a wish to stop but struggle to
achieve it. The Department of Health must support the implementation
of this important public health measure with training for all
healthcare workers in smoking cessation and easier access to smoking
cessation services for all current smokers.
The definition of a place where a self-employed
person is working should not include a taxi or private hire coach.
The College also has concerns about permitting smoking in a vehicle
if, although only occupied by one person at a time, that vehicle
may be shared between staff.
The College believes that the main aims of this
legislation are to protect staff from second-hand smoke and to
encourage smoking cessation for improved public health. The timetable
should reflect the earliest possible introduction date, and the
College sees no justification for allowing licensed premises an
additional 12 months. Setting a "go live" date that
encourages early adoption seems reasonable.
1. Wortley P M, Caraballo R S, Pedersen L L,
Pechacek T F; Exposure to Secondhand Smoke in the Workplace: Serum
Cotinine by Occupation; J Occup Environ Med 2002, 44, 503-9.
2. Siegel M; Involuntary Smoking in the Restaurant
Workplace: a review of employee's exposure and health effects;
JAMA 1993 274 90-3.
3. Repace J; Respirable Particles and Carcinogens
in the Air of Delaware Hospitality Venues before and after a smoking
ban; J Occup Environ Med 2004 46 887-905.
4. Eisner M D, Smith A K, Planc P D Bartenders'
Respiratory Health after Establishment of Smoke-free Bars and
Taverns; JAMA 1998 280 1909-14.
5. Smoking-related Behaviours and Attitudes 2002.
Office of National Statistics 2003.
6. Action on Smoking and Health: A Killer on
the Loose. An Action on Smoking and Health Special Investigation
into the Threats of Passive Smoking to the UK Workforce; ASH 2003.