Chapter 6 234 There were no important differences in the proportion of smokers complying with the policy or having a positive verbal response according to whether those addressing wore a Smoke-Free Generation vest or not (79% vs 69%; and 41% vs 50%, respectively). In the log, observers noted that they felt that smokers more often responded positively when being addressed in a positive (friendly and calm, e.g. ‘Did you know that this is a smoke-free zone?’) rather than a negative (judgmental) manner (e.g. ‘You are not allowed to smoke here’). Furthermore, they noted that if one person was smoking in the smoke-free zone, this appeared to attract other smokers. Finally, observers felt that addressing employees was easier than addressing students and patients, and that addressing a single smoker was easier than addressing a group of smokers. Discussion In this study, addressing people who smoked inside a voluntary smoke-free zone often elicited a positive or neutral response and increased compliance with the smoke-free policy. Our findings are in line with previous research indicating that a positive approach towards smokers in a smoke-free zone more often results in a positive response15. Whereas fear of confrontation and aggression from smokers is a barrier perceived especially among healthcare staff11, our study indicates that this fear is often ungrounded. The fact that representatives of Erasmus MC, among whom where members of the board, addressed smokers may have contributed to the successful implementation of the smoke-free zone, and also might explain the guilty response among many smoking employees. Clear signage in the smoke-free zone likely contributed to smokers’ awareness of the social norm16, possibly explaining the high proportion of understanding verbal responses. Changing the social norm in a smoke-free zone is a fundamental part of the implementation. Compliance with social norms increases with the number of others expecting a person to comply with the norm17. Culture plays an important role in this process, and it is unclear to what degree our findings are generalizable to other locations. However, we would like to argue that in any situation where smoke-free zones are implemented, changing the social norm is an important step. Addressing smokers can contribute to this, despite cultural differences. Furthermore, the addressors quickly gained experience in addressing smokers, which might have
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