Introduction

In 1992 The Joint Commission introduced standards to make hospital buildings smoke-free, resulting in the nation's first industry-wide ban on smoking in the workplace.1 In addition to setting a national example, hospital indoor smoking bans have led to a number of positive developments. Providers are better prepared to promote smoking cessation with patients, taking advantage of "teachable moments" during hospitalization, as inpatients who smoke must abstain during their stay. 2 3 4 5 Research has demonstrated the positive impact of workplace bans on employee smoking behavior, with more restrictive smoke-free policies leading to greater smoking reduction and employee cessation.6 As important, fears that these restrictions would lead to reductions in employee morale, employee retention, or patient satisfaction have not been realized. 7

Now a new trend has emerged: the smoke-free hospital campus, with smoking prohibited outdoors, at entranceways, on grounds, and in parking areas.8 9 While these smoke-free hospital campus initiatives have been pursued voluntarily,10 11 12 as a part of local cooperative agreements 13 and in response to state, regional or local legislation 14 little is actually known about how many hospitals have adopted such policies, or what factors influenced their decisions to pursue a smoke-free campus. Qualitative data, describing the successes and challenges associated with policy adoption and implementation, may be used to inform diffusion efforts, and facilitate implementation. It is possible, for example, that many hospital decision makers are concerned about the dire economic consequences that purportedly accompany highly restrictive smoking policies. This myth has been actively promoted through tobacco industry sponsored research, despite a growing number of independent studies that demonstrate the opposite economic effect.15 Public health advocates could build upon such data to dispel common myths by employing marketing efforts that directly appeal to the economic self-interests of potential policy adopters. Ultimately, study data on the prevalence and challenges associated with adoption of smoke-free campus policies, and the clinical impact of those policies, could be used in conjunction with existing research to demonstrate the benefits of smoke-free policies and increase both consumer and professional demand for their adoption.

Numerous studies have examined the development,16 17 implementation, 18 19 and effects 20 21 of indoor smoke-free policies in healthcare settings. The rationale for these policies comes largely from the belief that smoke-free facilities project a healthy image in the community, protect smoke-sensitive patients, encourage smoking cessation, save on cleaning and maintenance costs, and improve productivity.22 In order to address how the proposed study will advance the knowledge of researchers and inform policy makers, opinion leaders, and the general public, the supporting research literature is presented in two sections. The first section reviews the well-established benefits of smoke-free environments to patients, hospital visitors and employees. The second section reviews the challenges commonly associated with the adoption of restrictive smoking policies and explores the notion that benefits associated with the adoption of such policies may also be reaped by the organization.

The Health Benefits of a Smoke-Free Hospital

A significant proportion of smoke-free environment research both contributed to and resulted from the adoption of a standard by The Joint Commission that required accredited institutions to ban smoking indoors. 23 As hospitals implemented policies to comply with the standard, researchers were able to take advantage of this unique opportunity to investigate the implementation process. By comparing hospitals at various stages of implementation, researchers described the experiences of hospitals and tracked the effects of hospital smoking bans. Contrary to some early predictions, this research revealed that very few patients violate indoor smoking prohibitions, and that tobacco abstinence during hospitalization is a predictor of cessation post discharge. 24 25 Considerable research has also demonstrated that hospital smoking bans can lead to a "teachable moment" for inpatient smoking cessation. 26 27 28 29

When physicians take advantage of this window of opportunity and provide brief smoking-cessation advice, their patients are more likely to quit than those who receive no counseling at all. 24 30 31 AMI patients, for example, who receive even brief smoking-cessation advice from their physicians, are more likely to quit than those who receive no counseling at all. 24 The smoking cessation literature clearly documents the effectiveness of a wide range of treatments, from brief clinician advice to specialistdelivered intensive programs, including pharmacotherapy. 32 These programs have been shown to be extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. 24 33 34 Despite the documented benefits of smoking cessation, and the documented efficacy of smoking cessation counseling, many hospitals fail to consistently provide smoking cessation counseling to hospital inpatients.35 36 As a matter of public policy, smoking cessation offers a significant economic benefit, as patients who quit eventually have significantly lower healthcare utilization than continuing smokers.34

Across many types of settings the adoption of indoor smoke-free workplaces has led to a significant increase in the employee cessation rate and a decline in cigarette consumption (reducing total consumption by up to 29% per employee).37 The medical services sector, however, has shown smaller than average declines in these areas.38 One reason for this lesser impact in medical facilities, supported by observations made in a case study of a smoke-free policy adopted by a large HMO, suggests that disappointing results may stem from employees' ability to smoke outdoors.39 Because hospitals typically have large campuses with safe or sheltered areas available, it may be necessary to ban smoking on hospital grounds in order to have a more significant impact on employee cessation. Research has demonstrated that more restrictive smoking bans prompt greater cessation rates. Facilities that are otherwise smoke-free but maintain designated smoking areas show decreases in amount smoked by employees but no increases in cessation,40 41 whereas totally smoke-free workplaces had approximately twice the effect on cigarette consumption and cessation as organizations that allowed smoking in some areas.37 Within the hospital setting, it is reasonable to assume that a campus-wide smoking ban would be more effective in its ability to impose smoking abstinence during a hospitalization, which may, in turn, facilitate long-term maintenance of abstinence. On the other hand, allowing patients to smoke outdoors on hospital grounds may undermine the impact of the hospital's no-smoking policy on patients' future smoking behavior.

With respect to clinical performance and quality, hospitals that seem to take smoking cessation the most seriously (e.g., prohibit physicians from writing exceptions to the no-smoking policy for their patients, document patient smoking history more consistently, employ more counseling methods and access more counseling resources) also appear to provide smoking cessation counseling to their patients with greater consistency. 42 The Centers for Disease Control and Prevention Task Force on Community Preventative Services strongly recommended the adoption of policies banning smoking in workplaces and public areas as a key strategy for reducing environmental tobacco smoke.43 Given the impact on patient, employee and visitor health, it is not surprising that some experts have also suggested that the Joint Commission adopt a smoke-free campus standard.44

Challenges and Organizational Benefits of a Smoke-Free Policy

While some scholars have debated the ethical implications of outdoor smoking bans,45 46 to our knowledge, no study has systematically evaluated the optimal means of implementing a hospital policy to maximize smoking reduction and cessation, addressed the perceived problems with employee morale or customer satisfaction, and examined factors that influence compliance. Indeed, few formal examinations of hospital outdoor smoke-free policies appear in the literature.47 48 Despite the lack of published data on such policies, many organizations across the country are considering the adoption of such policies, or have already implemented a smoke-free campus, including the Cleveland Clinic, Cincinnati area hospitals and 10 hospitals in the mid-Michigan area (Lansing, Flint, and Saginaw). In fact, the state of Arkansas recently passed legislation (effective October 1, 2005) prohibiting the use of all tobacco products in and on the grounds of all medical facilities within the state of Arkansas. 49 The Mayo Medical Center's indoor and outdoor smoking ban, likely the first such policy of its kind, appeared in the early 1990s. 50 51 A study reviewing the implementation of the Mayo smoke-free campus policy, cited a cessation rate of 22.5% among employees after implementation and a decrease in cigarette consumption among those who continued to smoke. Employees asked to rate the effect of the smoke-free policy generally found it to be positive. One-third of the smokers who quit attributed their cessation to the policy. Enforcement of the outdoor smoking ban, however, was reportedly ineffective. The study was not designed to determine what proportion of employee cessation was due to the indoor versus the outdoor smoking ban. Because of the longstanding Joint Commission standard for smoke-free indoor hospital environments, few, if any, hospitals today would be simultaneously implementing indoor and outdoor restrictions.19 Another study used an observational approach to evaluate an outdoor smoking ban in an Australian health care facility. Staff and visitors made up about 90% of all smokers observed on the grounds, and simply placing outdoor “no smoking” signs around the hospital had only a small effect on outdoor smoking.47 Unfortunately, little additional information was offered about the development of the hospital's smoke-free campus policy, its implementation, or enforcement methods.

Although there appear to be very few published studies that specifically address the impact of hospital smoke-free campus policies, there are a number of studies addressing workplace smoke-free policies in general, and hospital indoor smoking bans in particular. Following the Joint Commission's indoor smoking ban, a national survey of hospitals revealed that more than half of the hospitals included in the national survey had implemented smoke-free policies before the Joint Commission standard was implemented. Forty-three percent of hospitals implemented policies that exceeded the Joint Commission requirement, although only 2.7 % of the hospitals reported implementing an entirely smoke-free campus. 52 Variables that predicted a hospital exceeding the Joint Commission standard included: location in a non-tobacco growing state, location in a metropolitan statistical area (MSA), having fewer than 100 beds, having no dedicated psychiatry beds, being a children's hospital, and employee unionisation. Respondents identified very few "severe" barriers to policy implementation (lack of patient acceptance was cited most frequently, by 5% of respondents). Negative employee morale, lack of patient acceptance, and lack of visitor acceptance were each cited as moderate barriers by just over 20% of respondents. 53 While the Joint Commission requirement was predictably cited as one of the major factors influencing many hospitals to go smoke-free, concern for employee health was cited with nearly the same frequency. Hospitals that expressed this factor as a "very important influence" tended to provide more substantial cessation assistance to employees. Public image and fire safety were also cited as important considerations in the decision to adopt a smoke-free policy. 54 The study authors theorized that a "good public image would presumably help a hospital compete for 'customers', whereas fire safety might involve both an enhanced public image and lower costs. Given the product sold by hospitals health care services it is important for hospitals to promote healthy practices." 55 (p. 54)

Research on the impact of workplace smoking bans suggests that additional clinical and economic benefits may accompany more restrictive smoking policies. Cigarette smoking and secondhand smoke cost $92 billion in productivity losses annually, according to the U.S. Centers of Disease Control and Prevention.56 Smokers, on average, miss 6.16 days of work per year due to sickness compared to nonsmokers, who miss 3.86 days of work per year,57 and employees that smoke have almost twice as much lost production time per week than workers who do not smoke.58 Employees who smoke cost businesses more in increased health insurance premiums, lost productivity, and absenteeism, as well as additional recruitment and training costs resulting from premature retirement and deaths due to smoking.59 Within the hospital environment, nurses who smoke are perceived to take more breaks and spend less time with patients than those who do not smoke.60

Despite the significant benefits associated with workplace smoking bans and evidence supporting the advantages of more versus less restrictive bans, leaders are often reluctant to implement highly restrictive bans. Fears related to negative employee morale, lack of patient acceptance, and lack of visitor acceptance 19 are reinforced by the tobacco industry. A review of 97 hospitality industry studies found that methodologically flawed research was frequently sponsored by the tobacco industry and much more likely to conclude that smoke-free regulations had a negative impact. Conversely, all 21 of the studies assessed to be "well-designed" concluded that smoke-free policies had either a positive or neutral impact on revenue or jobs. 613 The tobacco industry has also championed preemptive state legislation that restricts local efforts to pass effective local smoke-free efforts and promoted policies that emphasize the use of ventilation systems as an alternative to smoke-free facilities. 62

The rate at which an innovation, such as the smoke-free hospital campus, is adopted within a population is, in large part, dependent upon how members of the population perceive it with respect to five basic characteristics:

1. Relative advantage (the degree to which an innovation is perceived as being better than the idea it supersedes)
2. Compatibility (the degree to which an innovation is perceived as consistent with the existing values, past experiences, and needs of potential adopters);
3. Complexity (the degree to which an innovation is perceived as relatively difficult to understand and use);
4. Trialability (the degree to which an innovation may be experimented with on a limited basis) and
5. Observability (the degree to which the results of an innovation are visible to others).63

These factors account for up to 87% of the variance in how likely an innovation is to be adopted, 64 and help to explain why some innovations diffuse very quickly, reaching widespread use in just a few years (i.e. the internet), while some innovative technologies, even those that far surpass older less effective methods, are slow to come into general use (i.e. the stethoscope).64 65 Unfortunately, most evidence-based practices in health care are developed and disseminated largely without attention to the perceived self-interests of the stakeholder groups that must adopt the innovation in order to enable the benefits of that innovation to reach the public.66 Given the characteristics associated with the diffusion of innovation, it is not surprising to see that educating hospital leadership about the benefits of more restrictive smoking policies and tobacco control programs plays an essential role in accelerating the adoption of smoke-free campus policies.67

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Note: This literature review was adpated from a Joint Commission research study of smoke-free hospital campuses. Special thanks to Amanda Holm and Ron Davis at the Henry Ford Health System for their assistance with development. The project, scheduled to begin in June 2007, will seek input from nearly all of America's hospitals. It is being funded by a grant from the Robert Wood Johnson Foundation's Substance Abuse Policy Research Program (SAPRP). (Read the News Release)

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