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) (Fichtenberg and Glantz, 2002). The medical services sector, however, has shown smaller than average declines in these areas. (Farrelly, Evans, Sfekas, 1999). 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 (Mullooly et al., 1990). 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 the amount smoked by employees but no increases in cessation, (Chaloupka, 1992; Glasgow, Cummings, Hyland, 1997) whereas totally smoke-free workplaces had approximately twice the effect on cigarette consumption and cessation as organizations that allowed smoking in some areas (Fichtenberg and Glantz, 2002). 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 (Williams et al., 2005). 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 (CDC, 2000) 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 (Sciamanna et al., 2000).

Smoke free policies do decrease smoking rates, and the smoke-free campuses are no different. For example, Mayo Clinic reported a decrease from 17% to 12% employee smoking prevalence 2 years after the campus policy was implemented. The University of Michigan reported a decrease from 17% to 11% within 2 years, and Spectrum Health reported a drop from 16% to 9% 3 years after the policy was adopted.

• North Carolina Healthy Hospital Initiative

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• Fichtenberg CM and Glantz SA. Effect of smoke-free workplaces on smoking behaviour: systematic review. British Medical Journal. 2002;325:188-195.
• Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: results from a national survey. Tobacco Control 1999;8:272-277.
• Mullooly JP, Schuman KL, Stevens VJ, Glasgow RE, Vogt TM. Smoking behavior and attitudes of employees of a large HMO before and after a work site ban on cigarette smoking. Public Health Reports 1990;105:623-8.
• Chaloupka F. Clean indoor air laws, addiction and cigarette smoking. Applied Economics, 1992;24:193-205.
• Glasgow RE, Cummings KM, Hyland A. Relationship of worksite smoking policy to changes in employee tobacco use: findings from COMMIT. Tobacco Control 1997;6(suppl 2):S44-S48.
• Williams, SC, Morton DJ, Jay, KN, Koss RG, Schroeder SA and Loeb JM. Smoking cessation counseling in U.S. hospitals: a comparison of high and low performers. Journal of Clinical Outcomes Management, 2005; 12(7):345-352.
• Centers for Disease Control and Prevention. Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco cessation and reducing initiation in communities and health-care systems: a report on recommendations of theTask Force on Community Preventative Services. Morbidity and Mortality Weekly Report, 2000;49(No. RR-12):1-11.
• Sciamanna, CN, Stillman, FA, Hoch, JS, Butler, JH, Gass, KG, and Ford, DE. Opportunities for Improving Inpatient Smoking Cessation Programs: A Community Hospital Experience. Preventive Medicine 2000;30:496-503.
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