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Smoke Free PolicyAuthor: Nora O’Shea

Sponsor/Executive: Medical Director

Responsible committee: Clinical Governance & Patient Safety

Ratified by: Quality, Safety & Governance

Consultation & Approval:(Committee/Groups which signed off the policy, including date)

Clinical Governance & Patient Safety( 20th November 2017)

This document replaces: Version 8

Date ratified: 15th December 2017 (Electronically)

Date issued: 18th December 2017

Review date: 1st October 2018

Version: Version 9

Policy Number: P105

Purpose of the Policy: This policy has been developed to support theTrust commitment to become smoke free.

If developed in partnership with another agency, ratification details of the relevant agency

Policy in-line with national guidelines:

Care Quality Commission (CQC), Brief guide: Smoke free policies in mental health inpatient services (2017).NICE Guidance PHG48 Smoking Cessation – acute, maternity and mental health services (2013) NICE.Public Health England (2015). Smoking cessation in secure mental health settings: guidance for commissioners.

Signed on behalf of the Trust: …………………………………………………..Tracey Dowling, Chief Executive

Elizabeth House, Fulbourn Hospital, Fulbourn, Cambs, CB21 5EF Phone: 01223 726789.Version Control Page

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Version Date Author Comments

1.0 01/06/06 Dr Tom Dening, Medical Director

New policy.

2.0 01/06/08 Dr Tom Dening, Medical Director

Review point for policy.

3.0 17/12/10 Dr Tom Dening, Medical Director

Updates to reflect changes in legislation.

4.0 01/03/13 Tom Abell, Director of Performance & Information

Review point for policy.

4.1 05/06/14 Chess Denman, Medical Director

Minor amendment to scope of policy.

5 19/06/14 Kate Brown, Physiotherapy Team Lead

Expansion of policy to include information relating to:Scope of policy.Roles and responsibilities of staff in smoking cessation.E-cigarettes. Training.

6 31/12/15 Wendy Endersby, Smoke Free Trust Lead

Amendments and expansion of policy following review using NICE Self Assessment of PH48 and NICE PH45.

7 09/08/17 Babs Brafman-PriceSmoke Free Trust Lead

Amendments and expansion of policy in preparation for Trust becoming Smoke free.

8 03/11/2017 Babs Brafman-PriceSmoke Free Trust Lead

Minor amendment – Revised health advice in respect to e-cigarettes and vaping.

9 Nora O’sheaCPFT Wellbeing Coordinator

Amendments and expansion of policy to include, use of Eburns, Under 18 year olds.

Policy Circulation Information

Notification of policy release: All recipients;Staff Notice Board;Intranet;

Key words to be used in DtGP search. Smoking, vaping, NRT, Eburns, Nicotine Replacement Therapy, Smoke Free Trust

CQC Standards

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Other Quality Standards

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Contents

Section Page

1 Introduction 4

2 Background 4

3 Purpose 5

4 Scope 6

5 Definitions 6

6 Duties and responsibilities 7

6.1 The Trust Board and Chief Executive 7

6.2 Physical and Mental Health Strategic Group and Forums 7

6.3 Directorates 8

6.4 Professional Nurse Lead / Matrons 8

6.5 Managers 8

6.6 Staff 9

6.7 Level 2 Smoking cessation advisors. 10

6.8 Clinical staff 11

6.9 Pharmacy. 12

6.10 Responsibilities of Occupational Health Services 13

7 E-Cigarettes. 13

8 Support for staff who smoke. 13

9 Dissemination and implementation arrangements. 13

10 Smoking and human rights – Legislation and ethics 14

11 Smoke Free in the context of „blanket restriction‟ as regulated by the CQC

14

12 Managing patient breaches to this policy. 15

13 Visitors and contractors 15

14 Training 16

15 Review and Monitoring 16

16 References 16

17 Acknowledgements 17

Appendices

Appendix 1 18

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1. Introduction

Cambridgeshire and Peterborough NHS Foundation Trust are committed to enhancing the health and wellbeing of all its patients, employees, contractors and visitors. Through this policy it will support patients and staff to stop smoking and eliminate smoking in its buildings, grounds (owned and leased) and vehicles to create a Smoke free environment, thus reducing the harmful effects of second-hand smoke.

2. Background

2.1 The Health and Safety at Work Act 1974 places a duty on employers to: “…provide and maintain a safe working environment which is, so far as is reasonably practical, safe, without risks to health and adequate as regards facilities and arrangements for their welfare at work”.

2.2 The Health Act 2006 introduced a ban on smoking in enclosed public places, in places of work and in places that the public access to obtain goods and services, including the NHS with Mental Health facilities to be Smoke free by July 2008.

2.3 Following the 2010 Department of Health Public Health White Paper “Healthy Lives, Healthy People” the government produced a tobacco control plan for England (March, 2011), which sets out the government‟s key actions to reduce tobacco use over the next five years. These include:

Helping tobacco users to quit. Reducing exposure to second hand smoke. Stopping the promotion of tobacco. Effective regulation of tobacco products. Effective communications for tobacco control.

2.4 Public Health England data (2016) shows that the current overall smoking prevalence amongst Adults in England is 15.5%, in Cambridgeshire this is 15.1%. The highest Cambridgeshire prevalence is Fenland with 21.6%.

Smoking rates among adults with a common mental disorder such as depression and anxiety are almost twice as high compared to adults who are mentally well and three times higher for those with schizophrenia or bipolar disorder. In every area of mental health, even child and adolescent mental health services, perinatal psychiatry and older adult care, smoking rates are disproportionately high. It is estimated that people with a mental health or substance use problem buy approximately 42% of the tobacco sold in the UK. People with a mental illness tend to smoke more heavily and be more dependent on nicotine than those without a mental illness. They are just as likely to want to stop smoking but often lack confidence in their ability to quit and historically have not routinely been offered specialist support to quit.

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2.5 It is well known that smoking is a major contributor to many serious illnesses, including respiratory problems, vascular disease and various forms of cancer.

2.6 Second-hand smoke has also been shown to cause lung and heart disease in non-smokers, as well as many other illnesses and minor conditions, seen in those who smoke.

2.7 The National Institute for Health and Clinical Excellence, released guidelines PH48 „smoking cessation in secondary care: acute, maternity and mental health services‟ in November 2013, seeking to address the disparity in the management of nicotine dependent service users between different types of NHS services. The guidelines describe a framework for all Trusts to work to, to improve the quantity and quality of smoking cessation opportunities for people using mental health services, to protect service users and staff from harm caused by tobacco smoke, and to improve health outcomes

2.8 As a health and social care organisation, the Trust has a responsibility to promote health by reducing the exposure of patients, visitors and staff to tobacco smoke and its harmful effects. The Trust recognises that it also has a responsibility as an employer to reduce exposure to second hand smoke.

3. Purpose

The aim of the policy is to promote Health & Wellbeing for all through:

Protecting and improving the health and well being of patients, service users, staff, visitors and contractors by eliminating the health risks associated with passive smoking.

Promoting smoking cessation among employees, service users and patients.

Ensuring that all patients have adequate support to stop smoking, or abstain while using Trust services through appropriately trained staff; by supporting patients to quit, patients are potentially able to reduce prescribed medications and this will contribute to improved health status and less side- effects.

Providing advice and guidance for staff and managers in supporting nicotine dependent service users and patients, through comprehensive screening, and evidence based treatments.

Providing advice and guidance for staff and managers in services working with people who smoke in their own homes through a programme of providing “very brief advice” – ASK, RECORD, ADVISE, And ACT.

Setting an example to other employers and workforces, particularly in health-related localities; by arranging for Trust premises and vehicles to be„smoke-free‟ and by requiring staff not to smoke whilst on duty.

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Ensuring that the Trust meets legal obligations relating to smoke free hospital sites.

Protecting and improving the health and well being of staff by increasing knowledge and promoting healthy behaviours, i.e.: Smoking cessation support for staff will provide opportunities for improved health status, good role modelling and improved attendance at work.

4. Scope.

4.1 This policy applies to: all staff, including bank and agency workers; service users; visitors; volunteers; contractors; students; trainees and other persons visiting Trust owned and operated premises for any reason.

4.2 It should be read in conjunction with the Physical Health Assessment Policy, Health and Well Being Policy and The Nicotine Replacement Therapy Guideline.

4.3 It covers all Trust premises, including buildings and grounds, as well as extending to cars leased from the Trust during business usage and private cars parked on Trust owned or rented grounds.

4.4 The Trust will ensure that everyone entering its premises understands that smoking is not allowed in the buildings and grounds. Clear signs will be on display.

4.5 All meetings, courses and conferences held under the auspices of the Trust will be non-smoking.

4.6 The Trust Smoke free policy will be featured on all appropriate documentation, such as job and volunteer descriptions, job advertisements, induction packs, patient information and through websites.

5. Definitions.

5.1 “Smoking” refers to smoking tobacco or anything which contains tobacco, or smoking any other substance, and smoking includes being in possession of lit tobacco or of anything lit which contains tobacco, or being in possession of any other lit substance in a form in which it could be smoked.

5.2 Specialist smoking cessation or stop smoking services.

Locally commissioned smoking cessation or stop smoking services available to all staff and service users e.g. Camquit and Peterborough Stop Smoking Service.

5.3 Smoking Cessation Advisors.

„Level 2‟ Smoking Cessation Advisors are staff members trained by local specialist smoking cessation services to provide smoking cessation advice, and use motivational interviewing techniques to support behavioural change.

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All Level 2 Advisors will be registered with their local specialist smoking cessation service provider. Advisors will be expected to attend an annual update after accreditation in order to remain an accredited level 2 advisor.

5.4 E- Cigarettes / Electronic cigarettes/vapes battery powered electronic vapourising devices for consuming nicotine.

5.5 NRT - Nicotine Replacement Therapy, licensed forms of nicotine replacement medication e.g. Patches, gum, inhalators.

5.6 Smokalyzer - An easy to use hand-held and non-invasive monitor for the testing of patients to determine level of Carbon Monoxide (CO) in the blood, which is present in those who smoke.

6 Duties and Responsibilities.

6.1 The Trust Board and Chief Executive.

The Trust Board and Chief Executive Officer have a duty of care to protect the health of patients, staff and visitors and overall responsibility for all aspects of this policy in particular they will:

6.1.1 Ensure that staff, patients, visitors and contractors are made aware of the policy.

6.1.2 Provide resources to ensure effective implementation.

6.1.3 Comply fully with the policy and provide suitable role models for staff and patients.

6.1.4 Monitor compliance via the Trusts‟ physical and mental health strategic group.

6.1.5 Ensure that all jobs advertised will state that Cambridgeshire & Peterborough NHS Foundation Trust is a Smoke free Trust.

6.1.6 Ensure that all Service Level Agreements with other organisations contain the following clause „Cambridgeshire & Peterborough NHS Foundation Trust is a Smoke free Trust. Smoking is not allowed in all Trust buildings, grounds and all Trust vehicles‟.

6.2 Physical and Mental Health Strategic Group and Forums.

6.2.1 The Physical and Mental Health Strategic Group and forums will ensure that the Smoke free Trust project and Smoking Cessation is a regular agenda item and is used to provide advice and guidance in relation to smoking cessation knowledge and information.

6.2.2 This will provide an opportunity to feedback concerns relating to the Trust‟s

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adherence to and implementation of the Smoke Free Policy.

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6.2.3 The forums will provide an opportunity to share good practice in relation to smoking cessation.

6.2.4 Concerns raised at the Physical Health Forums will be fed back and discussed at the Physical and Mental Health Strategic group who may then choose to inform the Clinical Effectiveness, Audit and Research Group.

6.3 Directorates.

Directorate Clinical Leads and Heads of Nursing will hold ultimate responsibility for the implementation of this policy in their directorate, delegating implementation to individual Matrons/ Team Managers.

6.4 Professional Nurse Leads / Matrons.

Nursing leads and matrons will support teams and services in the implementation of this policy and monitoring compliance against the required practice.

6.5 Managers.

6.5.1 Will ensure a smoke free environment is maintained and all staff adhere to this Policy.

6.5.2 Ensure that smoking cessation training is promoted, completed, and translated into practice in the workplace.

6.5.3 Ensure that all services have at least one Level two trained smoking advisor (inpatient wards will have at least two and where necessary will work together to source appropriate advice during staff absence).

6.5.4 Ensure service users and staff are aware of no smoking options, smoking cessation pathways and options to quit.

6.5.5 Support staff wishing to access the Smoking Cessation Service by allowing them reasonable time to do so. Staff should be allowed time off to attend smoking cessation intervention training and to receive individual advice on quitting smoking.

6.5.6 Ensure adequate quantities of nicotine replacement therapies are available (where supplied).

6.5.7 Will not permit the facilitation of “smoking breaks”, purchasing tobacco for service users or other mechanisms of supporting smoking.

6.5.8 Ensure that patient information regarding the relationship between smoking and illness (both physical and mental) is available in patient areas.

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6.5.9 Ensure that information on smoking cessation and medication interactions is available in all clinical areas.

6.5.10 Inpatient managers will ensure that information on nicotine replacement therapies (NRT) and e-cigarettes is available to all inpatients.

6.5.11 Ensure „no smoking‟ signs placed in buildings are maintained in good order.

6.5.12 Ensure that information on the smoke free policy is readily available to staff, patients and visitors.

6.5.13 Ensure that carbon monoxide monitors (smokerlyzers) are available within services if appropriate.

6.5.14 Ensure that staff are fully supported in addressing policy breaches with patients and other staff.

6.5.15 Comply fully with the policy and provide a suitable role model for staff and patients.

6.6 Staff

6.6.1 All staff are required to follow this policy and should be aware of the important part they play as NHS workers to promote a no smoking environment.

6.6.2 Staff must not smoke any tobacco containing product .

Whilst on duty. During paid working hours. At any time where their uniform is visible and /or displaying their staff

badge. Whilst on duty on any other NHS premises or any other premises where

a service to patients is provided. In NHS owned vehicles or any vehicle leased or rented by the Trust, also

as a driver or passenger in privately owned vehicles/ privately leased vehicle whilst on Trust or making a journey whilst on duty especially when transporting work colleagues, patients and/ or equipment.

When representing the Trust in work time.

6.6.3 Staff who smoke tobacco should also consider the following:

Particles of cigarette smoke and ash can settle on hair and clothing and may be a particular health risk to children and babies who ingest the toxins.

Patients, visitors and colleagues should not have to experience being treated by / or working alongside staff that smell of cigarette smoke.

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Staff choosing to smoke in their own time outside the Trust premises must ensure smoke cannot be smelt on their person upon returning to the workplace.

6.6.4 Staff smokers who wish to stop smoking will be given information about the local smoking cessation services.

6.6.5 Where members of staff choose to smoke in their own time outside of the Trust premises (out of uniform and without displaying their ID badge) they are expected to have consideration for local neighbours adjacent to the Trust grounds. This includes avoiding smoking directly outside a neighbouring house and not discarding cigarette ends in gardens or on pavements or littering the neighbouring community (e.g. cigarette packet litter/ coffee cups/ sweets etc.).

6.6.6 It is strongly recommended that all staff complete the on-line “Very Brief Advice” training to support assessment of and delivery of support to patients who are identified as smokers upon admission into our services smokers.

6.7 Level 2 Smoking Cessation Advisors

6.7.1 Each clinical area must have at least three designated member(s) of staff who have completed level two training in smoking cessation, provided by the local NHS Smoking Cessation Services (inpatient wards are expected to have at least two).

6.7.2 Smoking cessation advisors will: Provide specialist advice, information on this policy and give behavioural

support to people who have stopping smoking. Support other staff to complete smoking assessment (within the physical

health assessment) in order to support and engage service users. Provide information on smoking cessation products, in conjunction with

medical and pharmacy staff. Provide information on the use of e-cigarettes. Promote smoking cessation through engaging service users and staff in

health promotion events, e.g. National No Smoking Day. Liaise with local NHS Smoking Cessation Services: Cambridge CAMQUIT

or Peterborough Stop Smoking Service. Attend twice yearly update training from the above services and feedback to

team/clinical area, including update on treatment techniques and products to support stopping smoking.

Ensure loaned smokerlyzers are kept safe and are submitted for calibration and checking by the smoking cessation service once a year.

Ensure that colleagues and service users are aware of the resources available to support stop smoking, how to access and use them, including smokalysers CPFT smoking cessation intranet webpage, leaflets, group material and referral opportunities.

Ensure patients who wish to stop smoking are referred to stop smoking services for ongoing support when required or in the case of inpatients, upon discharge into the community.

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Attend, feedback, and discuss smoking cessation at the Physical Health Forums.

6.7.3 A list of Smoking Cessation Advisors will be maintained on the Trust intranet.

6.7.4 The Trust will support the introduction of site specialist smoking cessation advisors to support the Smoke free Trust policy and the smoking cessation advisors as soon as this is practicable.

6.8 Clinical staff ( Community and Inpatient units)

6.8.1 All staff are required to adhere to the smoke free policy. Should be aware of the important part they play as NHS workers to promote a no smoking environment.

6.8.2 It is strongly recommended that all clinical staff complete online Very Brief Advice (VBA) smoking cessation training via the Trust e-academy.

6.8.3 All clinical staff will be responsible for asking patients about smoking behaviour and providing VBA on smoking cessation during every assessment. Repeated delivery of VBA by health professionals is a clinically effective smoking cessation intervention.

If VBA is not available via the e-academy please copy and paste the link below into a web browser to access e-learning on how to deliver very brief advice. http://www.ncsct.co.uk/publication_very-brief-advice.php.

6.8.4 Every employee should politely and respectfully advise staff colleagues, patients and visitors of the no smoking policy if they are seen acting in breach of it. However, only if they feel safe and confident to do so as they must not put their safety at risk. If staff feel unsafe when considering or attempting to ask those individuals to refrain from smoking due to the smoker‟s attitude/ and or behaviour then they should report the matter to their line manager.

6.8.5 Staff must not purchase tobacco products for patients in any setting (however, they may facilitate the purchase of e-cigarettes if requested).

6.8.6 Staff must not escort patients to smoke either on Trust property, or in the community, including during escorted leave. Where a patient refuses to comply the staff can ask that they refrain from smoking whilst out on escorted leave. The Trust encourages staff to use non compliance incidents as an opportunity to positively and proactively work with patients /service users to explore the benefits of abstaining from smoking, and products available to address their nicotine addiction.

6.8.7 Patients smoking status will continue to be monitored whilst they are on the caseload of the service and if appropriate the effect on other medication assessed and adjusted as required in the community this may mean liaising with the patients GP.

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6.8.8 Information relating to stop smoking will inform the care plan accordingly.

6.8.9 Community patients will be asked to refrain from smoking whilst Trust members of staff are visiting their homes. If a patient is smoking or starts to smoke during a visit, the member of staff will politely remind the patient of this policy, if the patient refuses to stop, the member of staff will advise the patient they are at liberty to leave if they do not stop. If the patient continues to smoke the member of staff will then advise the patient that they are leaving (the member of staff will ensure as far as practicable that the patient is safe). The incident will be recorded as soon as possible on the Datix incidence management system. Street Teams who work with homeless service users can request that those who smoke refrain from doing so during a meeting with a staff member, however if they continue to do so staff should be proactive in how they manage the situation using their own clinical judgement to address this .

6.8.10 Electronic cigarettes and vapes are permitted for use by inpatients in designated areas e.g. ward gardens.

6.8.11 Cigarettes and lighters are a prohibited item that should be removed and kept in safekeeping on admission.

6.8.12 All registered nurses working on in-patient wards are expected to familiarise themselves with the Protocol for the short-term administration of nicotine replacement therapy (see Trust NRT guideline).

6.8.13 Medical colleagues will manage on going prescribing of NRT.

6.8.14 Occupational therapists and Physiotherapists can provide advice and support regarding healthy lifestyles, including exercise and the development of new routines.

6.8.15 Dietetic staff will be available to offer guidance and advice on healthy eating and the impact that smoking cessation may have on appetite to patients who are quitting smoking.

6.8.16 When a service user is discharged from inpatient services, the discharge summary will reflect the smoking cessation care plan and be clearly communicated to the community service, and/or service user‟s GP, as appropriate, to ensure continuity of care.

6.9 Pharmacy

6.9.1 Pharmacy staff are strongly recommended to complete online smoking cessation VBA training.

6.9.2 Pharmacy staff are responsible for provision of smoking cessation products against a valid prescription, maintaining nicotine replacement therapy stock levels on wards and will respond to medicines information questions about such products, including:

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• Information about the range of smoking cessation products available.• General dosing and licensing information.• Advice to clinicians and service users about the impact of smoking habit

changes on existing drug treatments (as some medicines require dose adjustment when smoking habit changes).

•6.9.3 Tobacco smoke contains ingredients that induce the activity of certain liver enzymes

(particularly CYP1A2) that metabolise medications. This means that some medicines are affected when a patient stops smoking, which may lead to an increase in side-effects or the need to adjust doses. The medications that are most likely to be affected are listed below; patients taking these should be closely monitored if they stop smoking.

6.9.4 The enzyme-inducing ingredients are polycyclic aromatic hydrocarbons, which are present in tobacco smoke but not in e-cigarette vapour or in NRT products. Patients who only use these substitute products should be considered to have ‘stopped smoking’ for the purposes of this section.

6.9.5 Enzyme induction may take a week or more to normalise, so any changes would be expected to occur over this timescale. Patients who stop smoking for a few days during a brief inpatient admission may not be affected significantly.

Further information and advice can be obtained from CPFT pharmacy services.

6.9.6 Table1. Clinically significant interactions with cigarette smoking

Drug Clinical relevance EffectClozapine High Clozapine is metabolised principally by CYP1A2;

stopping smoking may increase plasma levels by c50% and lead to increased side-effects (e.g sedation, constipation, hypotension). Significant dose reduction may be needed. Plasma clozapine levels should be monitored.

Olanzapine High Olanzapine is metabolised by CYP1A2; stopping smoking may increase plasma levels and lead to increased side-effects (dizziness, sedation, hypotension). Dose reduction (e.g. by 25%) may be needed.

Theophylline/ aminophylline

High Theophylline /aminophylline are metabolised by CYP1A2; stopping smoking may increase plasma levels and produce adverse effects (e.g. vomiting, diarrhoea, palpitations). Dose reduction (e.g. by 25%) may be needed. Plasma theophylline levels should be monitored.

Erlotinib High These specialist drugs are less likely to be used on CPFT wards. Dose adjustment is needed if smoking status changes.

Riociguat High

Warfarin Moderate Warfarin is partially metabolised by CYP1A2; stopping smoking may increase INR. Monitor INR more frequently and adjust dose.

Chlorpromazine Moderate Stopping smoking may lead to increase in side-effects (e.g. dizziness, sedation, nausea).

Methadone, and possibly other opioids

Moderate Stopping smoking may lead to adverse effects (e.g. respiratory depression, sedation).

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6.11 Responsibilities of Occupational Health Services

Occupational Health will provide advice and support for staff. Those who wish to stop smoking will be helped to access individual or group support and nicotine replacement therapies as appropriate.

7. E- Cigarettes

7.1 Staff are not allowed to use e-cigarettes whilst on duty.

7.2 The Trust takes a positive view in the use of e-cigarettes as an effective harm minimisation strategy for people who smoke: e-cigarettes may help them move away from using harmful burnt tobacco towards a cleaner form of nicotine delivery, and can support cutting down and quitting altogether. E-cigarettes can be safely used alongside or instead of licenced pharmaceutical nicotine replacement therapy (NRT) e.g. patches , lozenges and sprays.

7.3 E-cigarettes used by patients in hospital will be permitted subject to the appropriate care planning, advice and with regard to the safe use and possession of devices. Whilst inpatients are responsible for providing their own e-cigarettes , it is recognised that some patients may not be in a position to obtain them. Therefore staff are permitted to facilitate the acquisition of these.

7.4 Inpatients will be permitted to use E-Cigarettes within ward gardens only. Chargers and liquid refills to be kept by ward staff for health and safety reasons, all E-Cigarettes will be charged in an allocated area under the supervision of staff.

7.5 E-burn will be given to patients on admission if they have not got their own NRT. One will be given every 24hours, on Trust agreement a maximum of 3 to an individual per admission. Allowing time for the purchase of the patients own E-cigarettes.

7.6 Each ward will hold a stock of E-burns for emergency admissions, purchased from the ward budget.

7.7 As E-cigarettes contain batteries they should be disposed of via the same methods as other batteries.

7.8 Community patients must refrain from smoking or using e-cigarettes whilst a member of staff is visiting.

7.9 Whilst it is not legal for under 18 year olds to purchase vaping products there are no restrictions on an under 18 to vape. The consent of parents should be obtained prior to allowing the use of any vape in line with the trust protocol.

8. Support for staff who smoke

8.1 The Trust recognises that smoking is an addiction and therefore adherence to the smoke free policy can be challenging for all smokers. The NHS Smoking

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Cessation Services will provide advice and support to those staff members who currently smoke. The Trust will encourage anyone eligible to take advantage of local smoking cessation programmes.

8.2 Support and guidance will also be available through the Occupational Health Services. Those who wish to stop smoking will be helped to access individual or group support and nicotine replacement therapies as appropriate.

8.3 Managers will be encouraged to support staff wishing to access the Smoking Cessation Service by allowing them reasonable time to do so. Staff should be allowed time off to attend smoking cessation intervention training and to receive individual advice on quitting smoking.

9. Dissemination and implementation arrangements

This document will be available to all staff via the Trust intranet and all staff will be notified via the staff briefing.Managers will ensure that all members of staff are briefed on its contents and on what it means for them.

10. Smoking and human rights

It is not an infringement of a service user‟s human rights for the Trust to be Smoke free. This argument has been legally tested and was upheld by the Court of Appeal in 2008 - after Rampton Hospital in Nottinghamshire went Smoke free.

The Court rejected the notion of an absolute right to smoke wherever one is living, as well as the argument that those responsible for the care of detained people are obliged to make arrangements to enable them to smoke. It concluded that in the interests of public health, strict restrictions on smoking and a complete ban, in appropriate circumstances, are justified and therefore patients can be prevented from smoking for health and security reasons.

The Court also noted that none of the various disturbing consequences of a smoke-free policy feared by the claimants, such as an increase in the prescription of sedative drugs, had actually materialised.

The Northern Ireland Human Rights Commission considered the issue of smoking and human rights in 1995 and found that "no treaty or other instrument defines a human right to smoke and the Commission does not accept the position, sometimes advanced by the tobacco lobby, that there is such a right." Article 1 of the UK Human Rights Act (1998) states that: "everyone's right to life shall be protected by law."

The Charter of Fundamental Rights of the European Union, signed in 2000, states that: "every worker has the right to working conditions which respect his or her health, safety and dignity."

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Article 8 of the Universal Declaration of Human Rights provides for the right to a private life. This is a referred to as a 'qualified right', meaning it does not override the protection of the health and freedom of others.

Tobacco smoke is a Class A carcinogen and exposure to second-hand smoke causes direct harm to non-smokers. Therefore, under the legislation the right to work or be treated in a hospital (or community centre) that has not been polluted by a Class A carcinogen outweighs any perceived right to smoke.

Under the Health Act 2006 the vast majority of the British public have legal protection from exposure to second-hand smoke in public places. Failing to afford people with a mental illness the same level of protection from exposure to second-hand smoke or encouragement to quit smoking as a result of the introduction of smoke-free places is discriminatory against this group.

11 Smoke Free in the context of „blanket restriction‟ as regulated by the CQC

The CQC is aware of the duties of mental health care providers to protect patients and staff and that hospitals are increasingly implementing comprehensive smoke-free policies and practice. They are also aware of the fact that the Court of Appeal has ruled that Smoke free policies do not infringe human rights.

As part of their inspections, the CQC inspectors will not challenge Smoke free policies and practice as unwarranted „blanket restriction‟. Instead, they will focus on whether such a ban is mitigated by adequate advice and support for smokers to stop or temporarily abstain from smoking with the assistance of behavioural support, and a range of stop smoking medicines and/or e-cigarettes. The inspectors will also consider whether alternative activities are in place and promoted, including regular access to outside areas.

12 Managing patient breaches to this policy

12.1 Given the severity of nicotine dependence suffered by many of our patients/ service users, it is anticipated that policy breaches will occur. Illicit smoking behaviour often occurs as a result of insufficiently managed nicotine dependence, and therefore the management of policy breaches are an opportunity to positively and proactively work with patients /service users to reduce distress caused by nicotine withdrawal.

12.2 Illicit smoking is a „challenging behaviour‟, which poses a risk of harm to the health and safety of staff and other patients /service users, and all staff should address any patients /service users smoking in areas where it is not permitted using the following protocols. If illicit smoking has been inside a Trust building, and/or resulted in potential second-hand smoke exposure to staff or patients/service users, a Datix (incident) form must be completed.

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12.3 Review the pre-admission smoking behaviour of the service user to establish their level of nicotine dependence. Consider whether current NRT prescription is adequately managing their dependence and ask the patient if they feel cravings. Medical staff to review NRT prescription if required.

12.4 Review the level of engagement in activities, encourage engagement in 1-1 and/or current ward-based group activities to distract from any cravings.

13 Visitors and contractors

13.1 The staff member inviting visitors and contractors on to Trust premises is responsible for making them aware of the Trust‟s smoke free policy.

13.2 If a member of staff observes a visitor smoking on the premises, they should politely make them aware of the Trust Smoke free policy and ask them to stop smoking, if possible suggesting a place off site where they can smoke.

13.3 If a member of staff observes a contractor smoking on Trust premises, they should make them aware of the policy and ask them to stop smoking. If they do not comply they should be reported to the Estates and Facilities Department.

14 Training

14.1 The Trust will ensure all members of staff are trained to provide them with the knowledge and skills to raise the issue of smoking with service users.

14.2 Clinical staff will receive Level 1 or Level 2 Smoking Cessation training dependent on the responsibilities placed upon them by this policy.

15 Review and Monitoring

15.1 The Trust will review the NICE PHG 48 - Self Assessment on a quarterly basis until full compliance has been obtained.

15.2 Incidents regarding smoking will be monitored via the Datix system on a monthly, quarterly and yearly basis. Trends and themes will be reported by The Patient Safety and Complaints team via the Quality, Safety and Governance Committee.

15.3 From time to time, an audit maybe undertaken by the Trust as part of its wider health and wellbeing programme or as a NICE requirement. The outcome of the audit and any resultant action plans will be reported to and monitored by the Clinical Executive.

16 References

16.1 Choosing Health White Paper (2010) Department of Health.

16.2 Healthy Lives, Healthy People: Our strategy for public health in England (2010) Department of Health.

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16.3 Healthy Lives, Healthy People: a tobacco control plan for England (2011) Department of Health.

16.4 NICE Guidance PHG45 Smoking: Harm Reduction, June 2013, NICE.

16.5 NICE Guidance PHG48 Smoking Cessation – acute, maternity and mental health services (2013) NICE.

16.6 NICE Guidance QS43 Smoking Cessation – supporting people to stop smoking (2013) NICE.

16.7 Care Quality Commission (CQC), Brief guide: Smoke free policies in mental health inpatient services (2017).

16.8 Public Health England (2016), E-cigarettes: an evidence update.

16.9 Public Health England (2015). Smoking cessation in secure mental health Settings: guidance for commissioners.

16.10 Towards a Smoke Free generation: a tobacco control plan for England (2017) Department of Health.

17 Acknowledgements

The Trust would like to acknowledge the support of the following Trusts in developing this policy:

South London and Maudsley, Addenbrookes Hospital, Hertfordshire Partnership Trust.

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Appendix1. Inpatient Smoke free Trust Patient Pathway

ReferralMember of CPFT inpatient staff makes referrer aware of Trust Smoke free policy and requests that referrer checks that patient is aware of Smokefree Trust policy and asks which option patient would like to follow whilst in ward:

Nicotine Replacement Therapy whilst inpatient Use of patient’s own supply of e-cigarettes in ward gardens Abstaining from smoking whilst on ward or Trust grounds – with limited availability to leave to

smoke

Member of staff then makes arrangements to support patient‟s NRT plan if required e.g. arranging prescription and ordering of NRT

Remind referrer to advise patient they will need to purchase and bring in a supply of e- cigarettes if this option is chosen

An E-burn will be offered to patients for emergency admission, 1 per every 24 hours with a maximum of 3 being given

AdmissionPatients smoking status reviewed upon admission and updated if required in the patients clinical records (RIO / Systmone).

Belongings searched as per admission process and all lighters and cigarettes/e-cigarettes kept in patient drawer. (Document on admission belongings check list)

Options for patients not smoking whilst on ward agreed with patient and documented within patients care plan. Advice, guidance and strategies offered to patients who would like to initiate a quit attempt with onward referral to CAMQUIT or Peterborough Stop Smoking Service as required. If required supplies of NRT facilitated as per protocolNicotine Replacement Therapy – Prescribed by Doctor – Supplied by Pharmacy – Administered by staffE-cigarette – As per individual ward risk assessment – put into patient drawer to be collected for leave off wardSmoking Cessation – Refer to smoking cessation link

Whilst on WardSmokefree Patients on psychiatric medication must be monitored for possible changes in condition (e.g. signs and symptoms or enhanced effects of medication) which may suggest a need for medication review. Doctors will adjust medication as required.

DischargeSmoking status must be considered as part of the patients discharge plan:

If the patient wishes to remain Smokefree after discharge.o Advise GP and other services as part of the discharge communication.o If patient agrees - refer to community stop smoking service.o Update patients clinical record (RIO / Systmone).

If the patient is on psychiatric medication which has been adjusted and wishes to return to smoking tobacco after discharge.

Advise GP and other health services as part of discharge communication

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Appendix 2Electronic Cigarette Procedure

1. Background

1.1 What are electronic cigarettes (e-cigarettes)? E-cigarettes are battery powered devices that deliver nicotine via inhaled vapour. Devices come in many shapes or forms, sometimes resembling cigarettes, but others resemble pens or gadgets. They commonly comprise a battery-powered heating element, a cartridge containing a solution principally of nicotine in propylene glycol or glycerine, water (frequently with flavouring), and an atomizer that when heated vaporises the solution in the cartridge enabling the nicotine to be inhaled (it should be noted however that some e-cigarettes do not contain nicotine). E-cigarettes can be disposable, rechargeable or refillable. E-liquids come in various different volumes, concentrations and flavourings. An estimated 2.8 million people in the general population in Great Britain currently use e-cigarettes, the vast majority of whom are smokers or recent ex-smokers. Recent reports from Public Health England (PHE) and the Royal College of Psychiatrists (RCP) have summarised the evidence on the impact of e-cigarettes on smoking in England. These reports concluded that e-cigarettes appeared to be effective when used by smokers as an aid to quitting smoking. E-cigarettes offer a much less harmful alternative to tobacco for dependent smokers.

1.2 Effects on Other Medicines

Electronic cigarettes do not effect prescribed medication in the same way as smoking can. Clozapine levels can double when a person stops smoking. Clozapine levels will be the same in a person using an electronic cigarette as in a non smoker. It is important to consider this if an individual switches from normal cigarettes to electronic cigarettes as this will affect their clozapine levels. Currently e-cigarettes cannot be prescribed as they are not licensed as medicines. E-cigarettes can be used safely in combination with NRT however the treatment plan must be carefully considered

1.3 E-cigarette use in mental health settings

The Care Quality Commission (CQC) recently published guidance on smoke free policies in mental health inpatient services where they clearly distinguished tobacco cigarettes from e-cigarettes. The guidance confirmed that blanket bans on tobacco cigarettes are justified but that blanket bans on e-cigarettes may not be. The guidance also highlighted the role of E-cigarettes in supporting smoke-free policies and referenced a briefing from the National Centre on Smoking Cessation and Training (NCSCT). The NCSCT briefing recognises that some people find e-cigarettes helpful for quitting, cutting down and/or managing temporary abstinence. Our policy reflects these documents too.

Section 2: Procedure for the use of Electronic Cigarettes2.1: E Cigarettes Products permitted within the TrustTo ensure the safe use of e-cigarettes within the Trust and to prevent excessive staff time to manage these risks, the range of e-cigarettes available for use has been restricted with different products available for use depending on the risks associated with the ward environment. Evidence from areas which have allowed an unrestricted range of products to be used is that this leads to the safe use of these devices being compromised, and increased staff time to manage these risks.The ward are required to have a general risk assessment, recorded on datix in relation to the management of E-burn/vapes.All e-cigarette users must have in place a risk assessment and care plan that details how the individual will be supported to use his/her device.Level 1 – areas assessed as high risk - Single use E-cigarettes onlyThe product which may be used in these areas is E Burn single use e cigarette. Single use (disposable) e-cigarettes do not require charging and provide a convenient means of using these products.

E-Burn may be used throughout the Trust in discrete areas such as gardens or hospital grounds, and external areas. They must NOT be used in bedrooms or communal indoor area. Users are expected to be considerate to those around them.

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E Burn has been designed specifically for use within inpatient and secure environments. Each device has a unique serial number so should it be necessary staff can record and trace ownership and tackle issues of bullying or theft.

E Burn Limited is a privately run business that does not supply through high street retail outlets. The aim is for the product to be affordable to those with limited income. The focus of the design is primarily about security. The clear body enables staff to see nothing is hidden inside and the semi rigid body makes it less likely to be used as a weapon.

Level 2 – areas assessed as lower risk – single use and rechargeable e-cigarettes Any e-cigarettes used must be CE marked. The procedure for safely charging these devices below must be followed. Improper handling of the batteries and chargers may present a risk of fire, explosion or chemical burn. Procedure for using rechargeable e-cigarettes:Rechargeable e-cigarettes must be charged by nursing staff and cannot be charged by patients.

Only use the batteries or charger which comes with the EC. To prevent batteries/chargers being mixed up each must be clearly labelled with the patient’s name.

In line with manufacturer instruction.

The individual instructions for the EC must be checked and followed.

When the charge is complete disconnect battery and remove charger from USB port – this is usually indicated by a light on the device. The charger may not switch off once charged and subsequently overheat.

Do not charge or use batteries which appear to be leaking, discoloured, rusty or deformed or otherwise appear abnormal

Batteries and chargers are to be stored in a cool dry place at normal room temperature. Do not leave in hot places such as direct sunlight

Keep away from any source of ignition such as flammable objects and liquids, sparks and electrical equipment and Oxygen cylinders.

Do not immerse batteries or chargers in water or otherwise get them wet

Do not disassemble, puncture, modify, throw, drop of cause any other unnecessary shocks to the batteries or chargers

A mains multi USB charger may be used to charge ECs - this must be CE marked and should be purchased via Integra. Multi chargers for use with a PC USB socket must not be used – only a single EC may be charged in a PC USB socket.

Wards to ensure that they have suitable supply of antibac wipes to ensure products cleaned, (Hygein)

.Other Types of Electronic Cigarettes and VapesA wide variety of e-cigarettes are available. The use of other devices including those which require the use of nicotine liquid which can be purchased in Vape shops to refill the device cannot be routinely supported Trust wide at the current time due to the risks of handling the liquid. If an individual wishes to use one of these

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devices and it can safely be supported within the ward environment then following a thorough risk assessment of the device and the individual a decision to support the use may be taken by the MDT. All of the precautions above regarding charging MUST be adhered to. These devices can only be used in outside areas. This is due to the variety of products available and risk of setting off fire alarms. 2.2: Supply of Electronic CigarettesElectronic cigarettes will be purchased by service user, relative/family member, or in some cases if the service users does not have the necessary leave to purchase an E-cig, then this purchase can me made by CPFT member..2.3: Lithium battery safety The risk of serious harm and even death from swallowing lithium batteries has been further evidenced in incidents from within the Trust and nationally. Staff are reminded that products such as watches, e-cigarettes, remote control handsets and many other small electric and electronic devices may contain these batteries. There is no blanket ban on such devices, but the risk of each patient’s access to them must be assessed on an individualised basis.2.4: Disposal of Electronic CigarettesElectronic cigarettes should be disposed of in the E-Burn bin provided. If no E-burn bin, then to be treated as a battery, to be placed in the battery disposal container.

Section 3: Frequently Asked Questions about Electronic cigarettesAre electronic cigarettes safer than ordinary cigarettes? As e-cigarettes do not contain tobacco and are not burnt, they do not result in the inhalation of cigarette smoke which contains about 4000 constituents, around 70 of which are known to cause cancer. E-cigarette vapour contains far fewer chemicals and those that are found have much lower levels than in cigarette smoke. E-cigarettes are therefore regarded by most experts as much safer delivery devices for nicotine. This does not mean that they are completely safe, but they are envisaged to be much less harmful than cigarettes. The RCP recently indicated that the hazard to health arising from e-cigarettes was unlikely to exceed 5% of the harm from smoking tobacco.How are e-cigarettes regulated? Since 20 May 2017 all e-cigarettes in England on the consumer market need to be compliant with new regulations introduced through the European Union tobacco products directive. These regulations include controls on content and packaging, such as child resistant/tamper proof packaging, must be protected against breakage and leakage and capable of being refilled without leakage, must deliver a consistent dose of nicotine under normal conditions, must contain a health warning, and tanks and cartridge sizes must be no more than 2ml in volume and nicotine strengths of liquids must be no more than 20mg/ml. Manufacturers can apply for a Medicines & Healthcare products Regulatory Agency (MHRA) licence for e-cigarettes which will allow them to be used for smoking cessation, and confers other benefits, such as enabling them to be prescribed, be advertised and make health claims in line with other medicinal products. An e-cigarette product, e-Voke, was licensed by the MHRA in 2015 but is yet to come to market.

Do e-cigarettes help smokers to stop?

There is evidence from a Cochrane review which assessed two randomised controlled trials that e-cigarettes may help some smokers to stop, corroborated by surveys and case reports. A large cross-sectional analysis of a representative sample of the English population found that those who used e-cigarettes in their quit attempts were more likely to report that they had stopped, than those who used a licensed nicotine replacement product over-the-counter or no cessation aid. More recent data from the same survey indicated that changes in prevalence of e-cigarette use in England have been positively associated with the success rates of quit attempts, and estimated that e-cigarettes may have contributed about 18,000 additional long-term ex-smokers in 2015. There is some evidence that the newer generation e-cigarette devices are more helpful for smoking cessation compared with some of the older disposable models8. This is likely to be due to improved efficiency of delivering nicotine in the newer devices. Two small pilots of e-cigarettes (first generation devices) with people with serious mental illness were positive regarding reduction/cessation of cigarette smoking, and without an exacerbation in psychopathology.

What concerns have been raised by e-cigarettes?

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E-cigarettes were first introduced onto the market in the UK in 2004 so there have been no long-term health studies. However a recent study examined levels of known toxins in urine of e-cigarette users who had used them exclusively for around 17 months and found much lower levels of these substances compared to cigarette smokers, and e-cigarette users had similar levels to a group of long term users of nicotine replacement therapy.There have been other concerns that:

1. E-cigarettes resemble ordinary cigarettes and therefore re-normalise smoking. The PHE and RCP reports found that there is currently no evidence to support this as smoking prevalence continues to decrease, both among adults and youth, in the UK and other countries such as US where e-cigarettes are prevalent;

2. Simply replacing some cigarettes with e-cigarettes may confer little benefit. Some dual use is inevitable, but the toxins study reported above, did indicate that e-cigarette users who also smoke did not have significantly lower levels of toxins, so an important message is that e-cigarette users need to give up smoking completely as soon as possible;

3. Some e-cigarettes are produced by the tobacco industry – this is indeed true. Whilst e-cigarettes were developed originally by a smoker wishing to stop smoking, and independent companies, the tobacco industry is increasingly involved in this area;

4. and they are not tightly regulated in terms of their content and delivery. From May 2017, all e-cigarettes on the UK market need to comply with an EU regulation on electronic cigarettes (see below).

5. There is a potential fire risk that these devices may present, for example if an incorrect charger is used or if the device is left charging for longer than recommended. It is important however to recognise that the fire risk from tobacco cigarettes is much higher and the fire risk caused by other commonly used devices such as mobile phones and MP3 players is similar.

6. E-cigarettes must not be used near naked flames or oxygen.

E-cigarette use in public places As stated above some people are concerned that the use of e-cigarettes will renormalize smoking, particularly if used in public places. Whilst many e-cigarettes differ in appearance to ordinary cigarettes, when users exhale, they do produce a vapour for which there is no evidence of harm from second-hand inhalation, but could be irritating to non-users in their immediate environment. A number of organisations published a discussion document about whether e-cigarettes should be permitted or prohibited in various premises and Public Health England produced guidance including key principles to guide policy making. We have referred to these documents as well as listened to patients view when reaching a decision about e-cigarette use in the Trust. As new evidence emerges we will adapt this policy accordingly.

Estates & Facilities e-cigarette alerts

Guidance issued by the Department of Health (June 2014) recommended that:1) All staff should be made aware of possible fire hazards with use/recharging of e-cigarettes;3) e-cigarettes should not be used in an oxygen rich environment; and3) Safety advice should be given to patients receiving therapies at home.

Additional guidance issued by the Department of Health (July 2014) suggested that a complete ban on recharging might not be a workable solution. Action required included

1) Reviewing the risk of withdrawing or discouraging re-chargeable e-cigarette use;2) Recording competing risks in the Risk Register;3) Assessing the opportunities for safe, supervised charging of devices by designated staff in

designated areas and where this was possible taking several subsequent steps to further reduce risk including only using batteries/chargers that came with the e-cigarette, disconnecting when charge is complete, storing batteries safely etc.

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Informational Advice:Nora O’ Shea (CPFT Wellbeing Coordinator)Stephen McNichol (Serco Health & Safety Advisor)Mark Garthwaite ( Fire Safety Manager)Individual Ward , Level 2 Smoke cessation Advisors.)www.healthypeterborough.org.uk www.cambridgeshire.gov.uk

References Action on Smoking and health (ASH). Use of electronic cigarettes (vapourisers) among adults in

Great Britain. May 2016. Available at:http://ash.org.uk/information-and-resources/fact-sheets/use-of-electronic-cigarettes-vapourisers-among-adults-in-great-britain/

McNeill A, Brose L.S., Calder R, Hitchman S.C., Hajek P, McRobbie H (2015). E-cigarettes: and evidence update, Public Health England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf

Royal College of Physicians. Nicotine without smoke. A report of the Tobacco Advisory Group of the Royal College of Physicians. London: Royal College of Physicians, 2016. Available at: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction- 0

Public Health England. E-cigarettes: a developing public health consensus. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534708/E-cigarettes_joint_consensus_statement_2016.pdf

Hartmann-Boyce J, McRobbie H, Bullen C, Begh R, Stead LF, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. NO: CD010216. DOI:10.1102/14651858. CD010216.pub3.

Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addition 2014 May 20 doi: 10.1111/add.12623.[Epub ahead of print]

Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. BMJ 2016 Sep 13;354:i4645. doi: 10.1136/bmj.i4645.

Hitchman SC, Brose LS, Brown J, Robson D, McNeill A. Associations Between E-Cigarette Type, Frequency of Use, and Quitting Smoking: Findings From a Longitudinal Online Panel Survey in Great Britain. Nicotine Tob Res. 2015;17: 1187–1194.

Caponetto P et al. Impact of an electronic cigarette on smoking reduction and cessation in schizophrenic smokers: a prospective 12-month pilot study. Int J Environ Res Public Health. 2013;10:446–618

Hickling LM, Perez=Iglesias R, McNeill A, Dawkins L, Moxham J, Ruffell T, Sendt K-V, Mcguire R. Electronic Cigarettes as a Harm-Reduction Strategy in People with Serious Mental Illness: A Pilot Clinical Trial. Poster, 2016.

ASH, ASH Wales, RSPH, TSI, UKCTAS< CIEH. Will you permit or prohibit electroniccigarette use on your premises? Five questions to ask before you decide. October 2015. Available at: http://ash.org.uk/information-and-resources/briefings/will-you-permit-or-prohibit-e-cigarette-use-on-your-premises/

Public Health England. Use of e-cigarettes in public places and workplaces Advice to inform evidence-based policy making. July 2016. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/534586/PHE-advice-on-use-of-e-cigarettes-in-public-places-and-workplaces.PDF

Department of Health. Estates and Facilities Alert. Ref: EFA/2014/002. Issued 16 June 2014. Department of Health. Estates and Facilities Alert. Ref: EFA/2014/002/(NI) Addendum. Issued 7 July

204 CQC. Brief guide: smoke free policies in mental health inpatient services. January 2017. Available at:

https://www.cqc.org.uk/sites/default/files/20170109_briefguide-smokefree.pdf

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National Centre on Smoking Cessation and Training: http://www.ncsct.co.uk/usr/pdf/Electronic%20cigarettes.%20A%20briefing%20for%20stop%20smoking%20services.pdf.

CPFT NHS Foundation Trust Smoke Free Policy