There is limited evidence on how to promote systems changes to reduce tobacco use that are recommended by the Public Health Serivce Guideline on Addressing Tobacco Dependence. Research is quite limited on methods for effectively promoting implementation of the PHS Guideline systems strategies. Evidence suggests that provider education on tobacco cessation alone has little effect on changing provider practice (Community Preventive Service Task Force, 2001). Until leadership is motivated to put new policies and systems in place that promote the treatment of tobacco use widespread changes in provider practices will be limited.

Momentum for smokefree hospital ground polices has increased across the U.S. and Canada There are more than 200 hospitals that have implemented such policies (American for Nonsmoker’s Rights, 2006) Reasons for this trend likely include: -passage of stronger clean indoor air laws; -growing concern about secondhand smoke; -strengthening of quality measures on addressing tobacco use among certain patients by the Joint Commission on Accreditation of Healthcare Organizations.

In August 2005, with the help of the University of Michigan Medical Center and the American Cancer Society, Upstate Medical University in Syracuse put a smokefree grounds policy into effect. New tobacco dependence treatment protocols were also adopted such as: -screening all patients for tobacco use at registration; -dedicating trained respiratory therapy staff to consult with tobacco using patients; -including nicotine replacement therapy as a standing order for tobacco dependent patients.

In May of 2005, the Director for the Seton Health Center for Smoking Cessation and the Director of Employee Health at St. Peter's Hospital in Albany, New York, met at a Grand Rounds and discussed their hospital's intention to become tobacco free facilities. Each expressed a similar response; the desire was there but the fear of nurses leaving to work elsewhere in order to smoke was the inhibiting factor. Both agreed that the best way to approach this would be to assess the level of interest in all hospitals in the area. This would level the playing field if all hospitals worked on this jointly. The hospitals in the area were invited to a meeting to discus this issue. 10 hospitals representatives attended and expressed a desire to go forward and by November of 2005, 19 hosptials had signed a letter of committment to become tobacco free facilties as of 1/1/07.

After the first meeting the Capital Region Health Care Tobacco Free Initiative(CRHCTFI) was formed. The group decided that top level buy-in was required before going forward. A subcommittee was formed and drafted a Letter of Commitment that was to sent to 25 hospital CEO's in the Capital District region of New York State. The Initiative met monthly.

There were agencies in the community that wanted to see this Initiative be successful: Department of Health Bureau of Tobacco Control, The Cessation Center (there are 19 of these across NYS), Americian Heart Association, American Cancer Society, Medical Society, and Tobacco Free Coaltion. These agencies stepped up and offered resources to expedite the process. The DOH granted Nicotine Replacement Strategies for employees of hospitals who make a quit attempt during this transition, and granted signage. The Tobacco Free Coalition brought in a consultant who provided a two day training on strategies for becoming tobacco free facilties. The Americian Cancer Society held two press conferences on the Great American Smoke Out. The first was to publically announce the 19 hospital commitment and the next was to announce a media campaine by the hospitals announcing the tobacco free status that was to begin in January of 2007. The Cessation Center conducted several full day train-the-trainer programs on smoking cessation. Those who attended were then equip to return to their hosptials and offer counseling assitance to employees who chose to make a quit attempt. The Medical Society held a pharmacotherapy training for physicians, and the American Heart Association submitted a supportive "letter to the editor."

A "letter of committment" was developed and it included some of the resources mentioned above. As letters were being returned, an email was sent out weekly providing updates. As the list of committed hospitals grew, some who may have been undecided became more and more compelled to participate.By August of 2005, 16 letters of committment from hospital CEO's were signed and returned.

The Initiative held monthly meetings and a representative from every hospital attended. At these meetings issues were discussed, strategies developed and guest speakers were invited periodically to educate on certain areas. Each hospital formed a tobacco free task force at their hospital and disseminated information discussed at the Initiative meetings.

5 TV stations, 4 radio stations attended the first press conference on the Great American Smokeout in November of 2005. Every newspaper throughout the region and many others in the state covered the story the following day. It was the first time in the country that a group of hospitals of this size joined together to become tobacco free without a mandate.

The Initiative members shared resources which save time and expense. For example, one hospital developed excellent posters announcing cessation programs that were being provided for employees. The graphic designed was offered to anyone who wanted to use it, they simple adjusted the text. Another developed an effective 30 employee insevice on how to courteously address those who violate the smoking policy. People shared their draft policies, table tents, etc. At the press conference on the Great American Smokeout in November of 2006, the hospitals shared the marketing expense of half page color ads that were placed in all newspapers throughout the region. In addition, they shared the expense of a mailing to all physicians in the regions that included materials for their office announcing the tobacco free status.

-All 19 hospitals stay on track. 3 became tobacco free in July 06, 14 in January and 2 hospitals in late spring.

-Follow-up and technical assistance is provided to hospitals on implementing the Public Health Service Guideline on Addressing Tobacco Dependence and JCA compliance with core measures.

-Statewide the percentage of smokers who received assistance with quitting from a health care provider increased from 38% in 2003 to 58% in 2006.

-Several other regional collaboratives in Upstate NY (Buffalo, Rochester, Utical, Souther tier) have been established- total of approximately 100 hospitals are tobacco free or are planning a start date in 2007.

-15 addiction treatment facilities in the Albany, NY area area have also committed to become tobacco free as of February 2007. Tobacco dependence treatment is being integrated into diagnosis and treatment planning at all levels of care.

-10 long term care facilities in the Capital Region form a similar initiative and plan on becoming tobacco free in June of 2007.

-The rate of smoking for employees in the Initiative drops from 6%-3%

Tobacco free hospital ground policies, which hospitals and other healthcare facilities are embracing across the country, may be important vehicles to advance the implementation of system level strategies in healthcare facilities recommended by the PHS Guidelines to reduce tobacco use.

Research is needed to test the hypothesis that smokefree grounds policies are correlated with the implementation of the PHS Guidelines.

This regional collaborative model was cost efficient due to the sharing of materials and support from stake holders in the community.