Table 2 Interview Quotes concerning aspects of smoke-free policy implementation

Challenges: Extent of policy

"Having ambiguities, (...) having exemptions – where do you draw the line? The approach we took is: the message is "no", because if the message is, ""Well, you can do it for these patients or these patients...", it becomes confusing and leads to misinterpretations." (1)

"We struggled whether we should include this [exemptions on a case-by-case basis in distressing situations]in the policy, in case that people start using this as an excuse to allow smoking... We decided to let people use common sense on that rather than saying "Yes, in a distressing situation"... It's very hard to measure what is a distressing situation." (2)

Challenges: Enforcement

"It [enforcement]is a real challenge. What we expect is every member of staff to play a part in it. (...) Obviously, they have to be careful, you know, there is the issue of violence and aggression (...) The biggest fear that our staff have is that of violence and aggression, of taking someone's habit away from them – how are they going to react?" (3)

"Now, what we know is that getting patients to stop smoking outside the main entrance has been a nightmare..." (4)

"We struggle at the entrance of A&E, and a little bit still in front of maternity..." (5)

Challenges: Litter/Smoking in adjacent public grounds

"This [litter]is a real dilemma- we took away the smoking areas that we have had, and we took away the bins, that's on the basis that if people aren't allowed to smoke they shouldn't have a place to put their fag ends – of course what people then do is drop them on the floor."(4)

"The litter problem has actually shifted from the Trust to the council, because patients are going outside [the premises]to smoke." (6)

"Smoking staff congregating in front of the premises doesn't make a good impression in terms of the Trust image... And also, it's a health and safety issue, if staff wander off and nobody knows where they are." (7)

Impacts

"You actually go outside and you can breathe fresh air (...) so I think it's a pleasurable environment for patients, I think that's the fundamental impact that it has had."(6)

"We find now you walk through the hospital grounds and it's quite rare to see anyone smoke."(8)

"I would say with confidence that a number of people [staff] have, as a result of the promotion we are doing, given up smoking, but we don't have specific figures on that."(9)

"I think that, when people go to the pre-assessment where (...) smoking status is recorded and smokers are told that they can't smoke whilst they are in here, this adds to their motivation to stop smoking."(5)