Making Canadian Healthcare Facilities 100% Smoke ...

Ideas at Work

Making Canadian Healthcare Facilities 100% Smoke-Free: A National Trend Emerges

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Dan Parle, Shannon Parker and Dan Steeves

hen the Calgary Health Region, the Mental Health Centre in Penetanguishene and Capital Health in Nova Scotia declared their sites 100% smoke-free

(both buildings and grounds) in May of 2002, May of 2003 and May of 2003 respectively, the change was considered radical and foolish by some. Since then, the move to 100% smoke-free healthcare facilities has become a national trend in Canada, with many facilities following suit and many others planning to make the change. In this article, the authors reflect on what they have learned in these three jurisdictions and offer some advice for healthcare facilities preparing to implement smoke-free property policies. Tobacco use is the single largest cause of preventable disease and death in Canada resulting in more thin 45,000 deaths annually (Health Canada 2005a). To address this alarming reality, many Canadian health facilities are implementing smokefree property policies. Evidence indicates smoking restrictions are related to smoking behaviour, with fewer people smoking in areas with strong smoking policies in effect (US Department of Health Services 2000; Longo et al. 2001; Fichtenberg and Glantz 2002). The most comprehensive policies, such as smoke-free healthcare properties, are related to a reduction in the number of smokers and a decrease in the amount of cigarettes consumed (Health Canada 2005b; US Department of Health Services 2000; Longo et al. 2001; Moskowitz et al. 2000; Hieronimus

1992). This "de-normalizing" of tobacco use is an important part of the national tobacco strategy. Healthcare organizations, working to optimize health and well-being, are the logical choice to show leadership in this area. Besides health leadership, there are compelling health and safety, ethical and resource issues that have led many health care facilities to go 100% smoke-free. These issues have already been outlined in detail in this publication (Parle et al. 2004). Additionally, there are growing concerns about future liability for healthcare sites that sanction an activity known to be harmful and frequently fatal. Hospitals have a "business interest" in health and may be held more accountable for the negative health effects of smoking on their patients and staff if they permit the activity. Ignorance is not a plausible excuse. Small wonder then that the healthcare facilities that lead the smoke-free property trend find themselves deluged with requests for assistance as other facilities struggle with the intractable issues surrounding tobacco use. A recent national telehealth and web conference on the subject ("Clearing the Air - the Case for 100 Percent Smoke-Free Hospitals," June 21, 2005, organized by the Mental Health Centre Penetanguishene) attracted more than 60 participants and 45 requests for videotapes of the presentation. Clearly there is interest in this subject. It is also clear that smoking in healthcare facilities remains a controversial and polarizing issue. Below, the authors take a look at progress in

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Making Canadian Healthcare Facilities 100% Smoke-Free Dan Parle, Shannon Parker and Dan Steeves

making Canadian healthcare facilities 100% smoke-free in three regions of the country and share what they have learned. CALGARY: CANADIAN FORERUNNER The Calgary Health Region (the CHR) is one of the largest integrated health regions in Canada, covering a geographical area of39,264 square kilometres, serving 1,144,678 people and employing 23,000 staff (Calgary Health Region 2005). On May 31,2002, the CHR became the first Canadian health organization to enact a policy prohibiting smoking on all regional property, including all outdoor spaces. The CHR's Tobacco Reduction Policy was implemented as part of a regional commitment to promoting healthy choices and providing supportive environments for patients, volunteers, staff, physicians and visitors.

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As with any successful project it is imperative to develop a multifaceted implementation plan. Through extensive and repeated consultation with all levels of the organization, the Tobacco Reduction Policy implementation team developed a comprehensive plan including communication strategies, employee skill development, staff and patient cessation supports and site preparation (Calgary Health Region 2003).

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Challenges Enforcement continues to be a perceived challenge among staff. This has been, and continues to be, addressed through multiple strategies involving bold, direct and precise communications, development of enforcement protocols, staff skill development and creative collaborations between all program areas. For example, the CHR has utilized large signs that state: "No smoking on grounds and parking lots." Compliance visibly improved after these signs were placed at the property and facility entranceways (Calgary Health Region 2003). The CHR does not have 100% compliance, nor is it expected. One of the challenges of enforcement may be attribmed to many individuals tying the success or failure of the policy directly to full compliance. To mitigate this thinking and broaden the general understanding of success, short-term goals should be established and communicated throughout the planning and implementation phases. During the Tobacco Reduction Policy implementation process it was evident that conventional communication channels are not sufficient when attempting to spread information throughout a large, dynamic organization. In order to garner widespread support and understanding, efforts must be directed towards supporting management and positioning the policy as: 1) consistent with the role of all staff and 2) easily integrated with the work that is already done. It is also critical to continuously assess whether information is reaching the frontline staff (Calgary Health Region 2003).

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Knowledge Sharing To support the implementation of comprehensive smokefree property policies across Canada, the CHR hosted the "Shifting the Norm: Implementing a Smoke-Free Property Policy" workshop in 2004. Registration at this successful event was capped at 56 individuals from British Columbia, Alberta, Manitoba and Ontario, representing health facilities, addiction centres, Health Canada, Alberta Cancer Board and the Alberta Alcohol and Drug Abuse Commission. The "Clearing the Air: Implementing a Smoke-Free Property Policy" compact disc resource was recently released. This resource includes a 1O-minute video highlighting key strategies required to effectively implement a smoke-free property policy. The video and attached resources can be accessed at www. calgaryhealthregion.ca/hecomml

tobacco.

WESTERN CANADA The number of smoke-free health properties in Western Canada is steadily increasing. The Northern Lights Health Region, David Thompson Health Region, Capital Health Region and Palliser Health Region in Alberta have implemented policies or have committed to doing so by December 31, 2006. As well, three health regions in Manitoba - Winnipeg Regional Health Authority, Brandon Regional Health Authority and South Eastman Health - have implemented or are in the process of implementing smoke-free property policies. In Saskatchewan, Saskatoon Regional Health Authority is smokefree and numerous others are moving towards implementation. The same can be said in British Columbia with the Interior Health Authority, Vancouver Island Health Authority and Northern Health Authority in the planning or action phases of policy implementation. CAPITAL HEALTH DISTRICT AND THE EAST COAST The Capital Health District is one of nine health districts in Nova Scotia. Its service area consists of the Halifax Regional Municipality and the western portion of Hants County in Nova Scotia. Capital Health provides core health services to 395,000 residents, or 40% of the population of Nova Scotia, and tertiary and quaternary acute care services to residents of Atlantic Canada. The district has over 8,500 employees spread over 10 different healthcare sites in both urban and rural envlfonments. The Capital Health District recognizes the overwhelming evidence that clearly demonstrates the harm to health, family and finances caused by tobacco use and second-hand smoke. In sincere efforts to lessen that harm and to model healthier life choices, the district implemented a 100% smoke-free environment that benefits patients, volunteers, visitors and staff. As of January 1, 2003, the Capital Health District closed all inpatient and staff smoking rooms, including those in

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Dan Parle, Shannon Parker and Dan Steeves Making Canadian Healthcare Facilities 100% Smoke-Free

their Detoxification Unit and Addiction Services. At that time

advocates and staff from Addiction Services was formed to

inpatient psychiatric units and tWo of four long-term residential care facilities requested and were granted an exemption from the policy. Ventilated smoke rooms for patients only remained in these areas.

oversee policy communication and implementation as well as to address concerns from staff, consumers and families. Specialized nicotine withdrawal protocols were developed and staff received training regarding nicotine patch, gum and inhaler. Addiction Prevention and Treatment Services provided psychiatric inpatient staff with an overview of tobacco as an addiction and offered education on how to address tobacco use

On May 1, 2003, all health care service sites' grounds were made smoke-free. Tobacco use was no longer permitted on the grounds of any site or in any vehicle parked on the grounds. On September 1, 2004, the East Coast Forensic Hospital (a facility specializing in forensic psychiatry) chose to forgo its exemption from the policy and closed its inpatient smoking rooms and implemented a 100% tobacco-free policy. All inpatient psychiatric units within the Capital Health District closed their smoke rooms and implemented a 100% tobaccofree policy on January 14, 2005. Now (with the exception of tWo of four long-term residential facilities) the Capital Health District is 100% smoke-free. Tobacco use is not permitted in any building or on the grounds of the healthcare sites including vehicles parked on the grounds. Champions Successful policy implementation can be attributed to a core group of "champions" who researched best practices, consulted extensively with stakeholders, chose appropriate timelines and made creative communication of the policy a top priority. Senior Management at Capital Health was committed to the policy being implemented and despite some strong reaction in the media, their message remained consistent and their support never wavered. Addiction Prevention and Treatment Services within Capital Health played a key role in designing and delivering an effective employee smoking cessation program prior to policy implementation. This program has now expanded to include the public. Nicotine replacement therapy is available at no cost to those who take part in the programming. Unique consideration and planning took place as the psychiatric inpatient units adopted the policy. A committee of mental healthcare professionals, psychiatrists, nurses, consumer

among the chronically mentally ill. Tobacco intervention support groups specific to the needs of the chronically mentally ill were also developed. These groups are offered weekly in all our mental health sites. Nicotine replacement therapy is available at no cost to those accessing the group. Staff, managers and patients have all reported how remarkably uneventful this policy implementation has gone throughout the district. Many of the pre-policy concerns and fears did not come to fruition. Capital Health attributes this to effective planning, realistic timefrarnes and a dedication to proper communication though a wide variety of means. Challenges remain and Capital Health encourages maintaining the policy development and implementation committee long term to address the challenges as they arise. Coping With Challenges Capital Health's smoke-free committee has had to find creative ways to cope with the litter caused by tobacco use on the city sidewalks outside its health care sites. They have worked with its securiry personnel to take a "policy education" approach first with those using tobacco on site then move to greater consequences for those who continue to disregard the policy. The committee leading the mental health policy has been coping with a traditional psychiatric dogma that the mentally ill population has a "need to smoke." They have required strong leadership from our site managers to circumvent subtle acts of policy sabotage by a small percentage of staff. However, when examined, the Capital Health District's 100% smoke-free policy implementation has been effective in achieving its goals of eliminating patient and staff exposure to second-hand smoke and providing a positive health message to the community. Now that the policy has been in place for tWo and a half years in some locations, it has become an afterthought in many employees' day-to-day operations.

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Making Canadian Healthcare Facilities 100% Smoke-Free Dan Parle, Shannon Parker and Dan Steeves

Not Alone

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The Capital Health District is not alone on the East Coast in its efforts to reduce the harm caused by tobacco. In July of 2005, the Cape Breton District Health Authority implemented a 100% smoke-free policy, which extends to healthcare buildings (including inpatient psychiatric units), grounds and vehicles on the grounds. Capital Health and Addiction Prevention and Treatment Services are dedicated to sharing their learning, policy evaluation and helping advocate for 100% smoke-free environments. Readers are invited to visit their website at www.cdha.nshealth.ca.Click on Services, then click on Addictions. ONTARIO WITH AN EMPHASIS ON MENTAL HEALTH SERVICES The Mental Health Centre Penetanguishene (MHCP) is a complex 292-bed hospital offering a broad range of tertiary, aCUteand forensic programs on an inpatient and outpatient basis. The reasons behind its decision to become 100% smoke-free and its implementation efforts have already been described in this publication (Parle et al. 2004). Since MHCP went 100% smoke-

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free over two years ago, at least four other Ontario general hospitals have followed suit: the Credit Valley Hospital in Mississauga, the Cambridge Memorial Hospital, Woodstock General Hospital and Joseph Brant Memorial Hospital, in Burlington. Significantly, all four facilities operate acute inpatient psychiatric programs in some form. Many other Ontario healthcare , sites are planning for the change. As this trend comes to more hospitals, it is often the psychiatric programs where both staff and patients are the most resismental illness are estimated to smoke at rates ranging from 41% to as high as 85% (Lasser et al. 2000; Evins et al. 2004) compared to about 20% of the general Canadian population over the age of 15 (Health Canada 2005). People with schizophrenia are estimated to be nicotine-dependent at a rate of between 65 and 90% (Lasser et al. 2000). While it is wrong to assume that all patients who smoke will oppose a 100% smoke..free policy, a majority of patients on any psychiatric ward will be affected, and staff are wary of the effort it will take to implement the policy. Clinicians express concern that conflict over smoking policy will harm their therapeutic relationship with their patients.

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Particularly Exploited In fact, a strong case can be made that the mentally ill should be given special emphasis for smoking cessation programs since high addiction rates indicate they are, as a group, particularly exploited by Big Tobacco,with a resulting high financial and health cost. One study estimated that people with a diagnosable mental illness comprise 45% of the total tobacco market in the United States. The authors quote internal documents from the tobacco

tant. The concern is understandable - North Americans with H:

Staff also often express concerns about a possible increase in oUt-of-control behaviour among psychiatric patients who are not allowed to smoke. Many experienced mental health clinicians suggest that the mentally ill find it more difficult to quit smoking or even impossible. Some even believe that smoking somehow alleviates the symptoms of mental illness. The scientific literature does not support any of these assertions. Nevertheless, because of these concerns, some facilities that have gone 100% smoke-free have offered special dispensations to their psychiatric wards to allow limited smoking.

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industry showing that R.J. Reynolds has conducted marketing studies targeting psychologically vulnerable consumers (Lasser et al. 2000). Nevertheless, concerns about the effects of smoking bans on psychiatric patients remain a significant barrier for many hospitals considering a 100% smoke-free policy. Canada has at least two examples of psychiatric hospitals that do not allow smoking in their buildings or on their grounds: MHCP and the East Coast Forensic Hospital in Dartmouth, Nova Scotia. At MHCp, the policy remains controversial, although there is growing acceptance that the change is permanent after the passage of over two years. On programs where patients are confined to the wards unless they leave with an escort, the policy has been received more positively and has been easier to enforce. On programs where patients come and go quickly and/or have privileges to leave the hospital for work or recreation, enforcement has been more problematic. Despite the best effom of clinical staff and security, MHCP patients regularly break the policy in secluded areas of the hospital grounds. This should n01 be surprising. The Mayo Clinic, a renowned cancer hospital ir the United States that went 100% smoke-free 15 years ago, sti! reports smoking policy violations.

Dan Parle, Shannon Parker and Dan Steeves Making Canadian Healthcare Facilities 100% Smoke-Free

An acute psychiatric ward is probably one of the most difficult healthcare sites to implement a 100% smoke-free policy. Why? There is a constant rurnover of patients who stay a short period of time, there is a high nicotine addiction rate among the patients and, given our society's historic high tolerance of smoking, they expect to smoke when they arrive. Does this mean Canadian hospitals should continue to facilitate smoking on their acute psychiatric wards? The answer, at least from MHCP's Smoke-Free Task Force, is an emphatic no. With a committed staff, a good nicotine addiction protocol on admission and availability of Nicotine Replacement Therapy (NRT) and other smoking cessation aids, acute psychiatric patients should be able to adjust and benefit from the policy. As well, all of the health and safety, resource, ethical and liability reasons for taking health care facilities 100% smoke-free apply equally to psychiatric hospitals and wards. ADVICE ON GOING 1 00%

SMOKE-FREE

The following advice on going 100% smoke-free is based on available scientific literature, MHCP's own research and

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practical experience after more than two years: Be strong and committed when you make the change. Your success depends on it. Spend as much effort securing "buy-in" from your staff and training them to offer effective smoking cessation programs as you do preparing your public and patients for the change. Frame the change as a clinical goal. You are not turning your staff into the "smoke police"; you are helping them address an important health issue - nicotine addiction - with their clients.

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Be familiar with and use the scientific literature on smoking cessation and nicotine addiction - it's on your side! You can't win an emotional debate about smoking. Put more of your clinical and administrative resources into the areas where experience indicates the change will be most problematic. Acute psychiatric wards are one example.

i I. Consider doing an empirical evaluation of the effects of the change and start well before the implementation. While it will take some effort, it is simply good, evidence-based management to do so. MHCPis currently preparing its empirical evaluation for submission to a scientific journal. The data and analysis have already been useful to MHCP and others. Celebrate your 100% smoke-free status with your staff, patients and community. You will be demonstrating strong healthcare leadership with effects that will extend well beyond your facility.

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