State adoption of 100% smoke-free acute non federal hospital campus policies.

Abstract

To assess the number and percentage of acute care hospitals in the U.S. that have adopted smoke-free hospital campus (SFHC) policies, researchers conducted an assessment from January 2008 to May 2008 of available data on SFHC policy adoption in each state. Slightly more than one third (34.4%) of acute care, non-Federal hospitals had adopted such policies, with wide variation of policy adoption between states.

Full text

Page 1

Int. J. Environ. Res. Public Health 2009, 6, 2793-2799; doi:10.3390/ijerph6112793

International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
State Adoption of 100% Smoke-Free Acute Non Federal
Hospital Campus Policies
Adam O. Goldstein 1,*, Julea Steiner 1, Anna McCullough 1, Kathryn D. Kramer 1 and Melva
Fager Okun 2

1 University of North Carolina, Department of Family Medicine/Chapel Hill, NC 27599, USA;
E-Mails: jsteiner@med.unc.edu (J.S.); annamc@unc.edu (A.M.); kdkramer@med.unc.edu (K.D.K.)
2 Prevention Partners of North Carolina/Chapel Hill, NC 27514, USA;
E-Mail: melva@ncpreventionpartners.org
* Author to whom correspondence should be addressed; E-Mail: aog@med.unc.edu;
Tel.: +1-919-966-4090; Fax: +1-919-966-9435.
Received: 21 September 2009 / Accepted: 6 November 2009 / Published: 10 November 2009

Abstract: To assess the number and percentage of acute care hospitals in the U.S. that
have adopted smoke-free hospital campus (SFHC) policies, researchers conducted an
assessment from January 2008 to May 2008 of available data on SFHC policy adoption in
each state. Slightly more than one third (34.4%) of acute care, non-Federal hospitals had
adopted such policies, with wide variation of policy adoption between states.
Keywords: tobacco; hospital; policy; policy diffusion; smoke-free; tobacco-free; hospital
campus; secondhand smoke; smoking; cessation

1. Introduction

To achieve broad public health objectives related to tobacco use among adults in the U.S., increased
implementation of strategies that augment tobacco cessation and eliminate secondhand smoke
exposure are needed [1,2]. When the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) required all accredited U.S. hospitals to prohibit smoking within their buildings, increased
rates of smoking cessation occurred among employees [3], and the positive impacts of indoor
OPEN ACCESS

Page 2

Int. J. Environ. Res. Public Health 2009, 6


2794
smoke-free policies in hospitals on employee quit rates are well documented [4,5]. Efforts to increase
cessation rates among hospital employees and patients and to increase availability of and access to
cessation services have coincided with an increasing number of hospitals adopting SFHC or
tobacco-free hospital campus (TFHC) policies. SFHC policies prohibit the use of cigarettes, pipes or
cigars inside any hospital buildings or structures and also in all outdoor areas on the hospital campus.
Tobacco free policies include all smoked tobacco products in addition to smokeless tobacco. SFHC
policies offer greater protection from secondhand smoke exposure to patients, employees, volunteers
and visitors by eliminating exposure to smoking on hospital campuses. Tobacco free policies add the
element of deterring smokers from switching to smokeless. As no uniform method currently exists for
collecting and disseminating data on U.S. hospitals that have adopted SFHC policies, researchers
conducted a small-scale assessment from January 2008 to May 2008 to ascertain, retrieve and verify
SFHC policy adoption. This protocol initially included a review of all state hospital association web
sites for any information within the state about adoption of SFHC policies. Researchers attempted
contact with a specific staff person within the state hospital association to discuss any tracking or
verification mechanism. A second step involved contacting at least one tobacco control organization in
each state to determine if any other organization outside of the state hospital association might track
SFHC policy adoption in that state. Contacts in the state hospital or tobacco control organization
confirmed whether data collection on SFHC policy adoption occurred within the state, who collected
such data, which hospitals had adopted such policies or whether no systematic source existed for the
collection of such data.
In cases where no information existed, researchers conducted systematic Internet searches using
search terms of “tobacco free hospital campus” and “smoke free hospital campus”. Researchers
confirmed the number of SFHC policy adoptions in these states by reviewing documentation generated
from these searches, examining hospital web sites or by direct contact with hospital staff. Researchers
also utilized a similar Internet verification procedure for states that had reports of five or less 100%
SFHC policy adoption (n = 12).
Information about the total number of hospitals in the state came from data provided by the
American Hospital Association, with updates by states, as needed, if more reliable information was
available. For the purposes of this survey, only hospitals classified as acute care or community
hospitals were included, and hospitals classified as psychiatric, long-term care and Federal
were excluded.
Fifteen state hospital associations indicated they had data on the number of SFHCs in their state.
Information for an additional twenty states came primarily through a source other than the hospital
association (e.g., tobacco control group). For sixteen states, information on the status of SFHCs was
not available from any state organization.

2. Results and Discussion

Data show that a little more than one third (34.4%) of U.S. acute care hospitals have adopted 100%
SFHC policies. The data also indicate wide variation in the number of SFHC policy adoptions by state
(Table 1). In twenty seven states, less than 25% of hospitals have adopted 100% SFHC policies. In

Page 3

Int. J. Environ. Res. Public Health 2009, 6


2795
only seven states (Arkansas, Wisconsin, Indiana, Ohio, Michigan, North Carolina and Iowa) have 75%
or more of acute care hospitals adopted 100% SFHC policies.
Research on adoption of 100% smoke-free campus wide policies in schools and workplaces has
shown that, if enforced, these policies decrease tobacco consumption [7,8]. While research
documenting the successes or effectiveness of SFHC or TFHC policies on employees, patients, or
visitors to U.S. hospitals is quite limited, the potential positive health effects are substantial [9]. This
data systematically shows the extent of SFHC policy adoption in U.S. acute care hospitals.
Limitation to this data exist, including the fact that no uniform source exists for the retrieval of
information documenting the existence of 100% SFHC or TFHC policies in states. A recent survey of
hospitals seeking such data estimated a slightly higher number of hospitals in the U.S. as having SFHC
policies (45% compared to 34% reported here), but that estimate was based on a sample response rate
of only 43% and total reports of slightly less than one half the number of SFHC policies reported in
our study. Further, no data was available for several states with too few responses [10]. To overcome
these problems, we obtained data from multiple sources and relied on documentation from at least one
source, focusing on records of policy adoption. Alternatively, our study did not collect secondary data
on hospital characteristics, a factor that does help explain reasons associated with policy adoption [10].
Since our data were collected from organizations in addition to individual hospitals, it is likely that our
data underestimate the number of hospitals that have adopted 100% SFHC or TFHC policies. For
instance we discovered hospitals that had passed 100% SFHC polices, even when a state contact had
indicated no such policies existed. On the other hand, overestimation of the extent of policy adoption
could also occur when using self-report data alone, including having exceptions to such policies [10].
A strength of our methods is that they allow for repeated, rapid and efficient examination of SFHC
policy adoption over time. Information regarding policy compliance for all of these policy adoptions in
states is important but not currently available. A final limitation is that we limited data collection to
hospitals designated as acute care; thus this data cannot verify the number of federal or psychiatric
hospitals that have adopted 100% SFHC or TFHC policies.
Though an effective strategy, few states have pushed for or achieved universal 100% SFHC policies
to date. Despite limited state activity, the SFHC movement is spreading across the U.S. with the rapid
adoption of SFHC policies in several states. A similar process has occurred in Canada [11]. In most
states, the process of policy adoption is occurring through grassroots activism and local leadership. For
instance, in Michigan, the SFHC effort began with a statewide coalition encouraging SFHCs and
increased smoking cessation programs in local communities and inpatient settings. Since 2000, the
Michigan Department of Community Health has provided an annual grant to help increase smoke-free
hospital campuses. In Wisconsin, the state hospital association encouraged all hospitals in 2006 to
adopt 100% SFHC policies. In Arkansas a statewide law (passed in October, 2005) required all
Arkansas hospital campuses, except psychiatric hospitals, to implement 100% SFHC policies, not
including smokeless tobacco products [12].
In North Carolina, one organization has collected data on the passage of TFHC policies in the state
for the last three years, allowing examination of the annual rate of TFHC policy adoption in one
state [6]. North Carolina hospitals chose to develop and implement campus policies that address the
use of all tobacco products, not just cigarettes.

Page 4

Int. J. Environ. Res. Public Health 2009, 6


2796
Data from North Carolina show rapid passage of 100% TFHC policies statewide in a short period of
time. In 2006, the North Carolina Hospital Association (NCHA) and NC Prevention Partners (NCPP),
with support from The Duke Endowment, created the Healthy Hospital Initiative to assist all North
Carolina hospitals in adopting 100% TFHC policies and also to provide comprehensive cessation
support to hospitals [6]. Of the state’s acute care hospitals, 102 passed TFHC policies from 2005 to
2008 (Figure 1). As of May 2008, another 13 had announced policies scheduled for implementation
in 2009.
In North Carolina, prior to the 2006 inception of the Healthy Hospital Initiative, only 11% of North
Carolina hospitals had adopted 100% SFHC policies. The goal of the Healthy Hospital Initiative was
to have 100% of North Carolina’s hospitals adopt 100% TFHC policies by June 2009, a goal that was
recently achieved. Strategies utilized by the Initiative include use of statewide opinion leaders,
technical assistance, public education, model policies, peer networks of hospital administrators and
personnel, and frequent dissemination of policy successes. Dissemination activities include a website
(http://www.healthyhospital.org/) where information about the rate of policy adoption statewide is
posted. Hospitals in other states can follow North Carolina in adopting “tobacco-free” versus “smoke-
free” campus wide policies to assure that employees do not switch from using cigarettes or other
smoke products to smokeless tobacco products. Benefits of these policies are immediate (decreased
exposure to secondhand smoke for patients, visitors and staff) and sustained (reductions in employee
and staff tobacco use) [13].
Table 1. Percent of acute-care 100% smoke free hospital campuses by state, as of May, 2008.
State Total SFHC %
75% or greater
Arkansas
Wisconsin
Indiana
Ohio
Michigan
North Carolina
Iowa
85
124
127
170
146
122
116
85
124
120
149
124
102
94
100.0%
100.0%
94.5%
87.6%
84.9%
83.6%
81.0%
50%–74%
Kansas
Maryland
Delaware
Vermont
New York
Hawaii
Alaska
131
50
94
34
4
9
117
14
12
71.8%
68.0%
66.7%
64.3%
57.6%
56.0%
54.5%
6
14
203
25
22
25%–49%
Virginia
Massachusetts
Oklahoma
Pennsylvania
Oregon
Maine
Nebraska
Mississippi
Rhode Island
Colorado
87
79
131
182
58
37
87
94
11
71
37
30
49
67
19
11
25
27
3
19
42.5%
38.0%
37.4%
36.8%
32.8%
29.7%
28.7%
28.7%
27.3%
26.8%

Page 5

Int. J. Environ. Res. Public Health 2009, 6


2797
Table 1. Cont.
Less than 24%
West Virginia
Arizona
Kentucky
Montana
Idaho
Tennessee
Georgia
Districtof Columbia
Wyoming
Missouri
South Carolina
New Hampshire
California
New Jersey
Minnesota
Illinois
Florida
Alabama
Louisiana
Nevada
South Dakota
Connecticut
New Mexico
Texas
Washington
North Dakota
Utah
Total
57
67
105
54
39
135
172
11
24
119
63
28
357
80
133
191
229
109
128
49
52
36
37
415
86
40
43
5037
14
16
25
12
8
27
32
2
4
19
9
4
50
11
17
24
28
11
11
3
3
2
2
22
4
1
1
24.6%
23.9%
23.8%
22.2%
20.5%
20.0%
18.6%
18.2%
16.7%
16.0%
14.3%
14.3%
14.0%
13.8%
12.8%
12.6%
12.2%
10.1%
8.6%
6.1%
5.8%
5.6%
5.4%
5.3%
4.7%
2.5%
2.3%
34.4% 1731
Figure 1. Cumulative adoption of TFHC policies in North Carolina acute care hospitals
(Jan 2003–May 2008).
28
15
49
91
102
13
0
10
20
30
40
50
60
70
80
90
100
110
120
130
200320042005200620072008
Number
Year
ANNOUNCED
ADOPTED

To facilitate the sharing of policy successes across states, the JCAHO recently launched
WikiHealthCare (http://wikihealthcare.jointcommission.org), a collaborative forum for health care

Page 6

Int. J. Environ. Res. Public Health 2009, 6


2798
professionals to discuss issues including smoking cessation and SFHC policies. Resources provided by
the JCAHO Wiki and the NC Healthy Hospital Initiative can foster the successful replication of state
models of policy diffusion in hospitals and health care systems nationwide.

3. Conclusions

This data, combined with another recent study, shows that the spread of 100% SFHC policies across
the U.S. is rapidly occurring [10]. In some states, such as Rhode Island, leaders have announced that
all acute care hospitals in the state will implement 100% SFHC policies by the end of 2009. The
adoption of SFHC and TFHC policies will better link new tobacco dependence treatment strategies
with health care system interventions [14].

Acknowledgements

Abby C. Rosenthal, Centers for Disease Control and Prevention, Office on Smoking and Health.

References and Notes

1. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon
General; Department of Health and Human Services, Centers for Disease Control and Prevention,
Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and
Health Promotion, Office on Smoking and Health: Atlanta, GA, USA, 2006.
2. Rock, V.J.; Malarcher, A; Kahende, J.W.; Asman, K.; Husten, C.; Caraballo, R. Office on
Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion,
CDC. Cigarette smoking among adults—United States. MMWR 2006, 56, 1157-1161.
3. Longo, D.R.; Feldman, M.M.; Kruse, R.L.; Brownson, R.C.; Petroski, G.F.; Hewett, J.E.
Implementing smoking bans in American hospitals: results of a national survey. Tob. Control
1998, 7, 47-55.
4. Longo, D.R.; Brownson, R.C.; Johnson, J.C.; Hewett, J.E.; Kruse, R.L.; Novotny, T.E.; Logan,
R.A. Hospital smoking bans and employee smoking behavior: results of a national survey. JAMA
1996, 275, 1252-1257.
5. Longo, D.R.; Johnson, J.C.; Kruse, R.L.; Brownson, R.C.; Hewett, J.E.; A prospective
investigation of the impact of smoking bans on tobacco cessation and relapse. Tob. Control 2001,
10, 267-272.
6. NC Prevention Partners. Hospitals with 100% tobacco-free campus wide policies [document on
the Internet]. Chapel Hill: The Institute; 2008 [cited 2009 October 10]. Available online:
http://www.ncpreventionpartners.org/dnn/LinkClick.aspx?fileticket=ilk2FbNAz9k%3d&tabid=73
(accessed October 10, 2009).
7. Trinidad, D.R.; Gilpin, E.A.; Pierce, J.P. Compliance and support for smoke-free school policies.
Health Educ. Res. 2005, 20, 466-475.

Page 7

Int. J. Environ. Res. Public Health 2009, 6


2799
8. Osinubi O.Y.; Sinha S.; Rovner E.; Perez-Lugo, M.; Jain, N.J.; Demissie, K.; Goldman, M.
Efficacy of tobacco dependence treatment in the context of a “smoke-free grounds” worksite
policy: a case study. Am. J. Ind. Med. 2004, 46, 180-187.
9. Lin, D.; Stahl, D.C.; Ikle, D.; Grannis, F.W. Employee attitudes and smoking behavior at the City
of Hope National Medical Center smoke-free campus. J. Natl. Compr. Canc. Netw. 2006, 4,
535-542.
10. Williams, S.C.; Hafner, J.M.; Morton, D.J.; Holm, A.L.; Milberger, S.M.; Koss, R.G.; Loeb, J.M.
The adoption of smoke-free hospital campuses in the United States. Tob. Control 2009; August
online edition. Available online: http://tobaccocontrol.bmj.com/cgi/content/abstract/
tc.2009.030494v1 (accessed October 26, 2009).
11. Parle, D.; Parker, S.; Steeves, D. Making Canadian healthcare facilities 100% smoke-free: a
national trend emerges. Healthc. Q. 2005, 8, 53-72.
12. An Act to Prohibit the Use of Tobacco Products in and on the Grounds of All Medical Facilities in
Arkansas, Arkansas Code Title 20-27-704. Available online: http://www.tobacco-facts.net/
usa-tobacco-policy/arkansas (accessed October 25, 2009).
13. Viera, A.J.; Goldstein, A.O.; Steiner, J.B.; Ripley-Moffitt, C.; Kramer, K.D. Influence of a
tobacco hospital campus policy on smoking status of hospital employees. Amer. J. Health Promot.
2009 (in press).
14. Fiore, M.C.; Jaen, C.R.; Baker, T.B.; Bailey, W.C.; Benowitz, N.L.; Curry, S.J.; Dorfman, S.F.;
Froelicher, E.S.; Goldstein, M.G.; Healton, C.G. et al. Treating Tobacco Use and Dependence:
2008 Update; Department of Health and Human Services. Public Health Service: Rockville, MD,
USA, May 2008.
© 2009 by the authors; licensee Molecular Diversity Preservation International, Basel, Switzerland.
This article is an open-access article distributed under the terms and conditions of the Creative
Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).