Going tobacco-free, tall order for health-care facilities

"To be tobacco-free, a facility must prohibit tobacco and smoking in buildings and on campus grounds it owns and leases. It must be enforced 24-7 and prohibit smoking or tobacco for all people," explained assistant nursing professor Heidi Mennenga from South Dakota State University.

That's a tall order, particularly when it comes to enforcement, she admitted. "From a hospital perspective, I can see that being difficult. Is it my job as a staff nurse or is that security's responsibility? And what are the consequences?"

Through a one-year, approximately $50,000 grant from the South Dakota Department of Health, Mennenga and a research team surveyed South Dakota health-care facilities to examine their tobacco policies. The goal is to encourage facilities to develop and/or improve those policies.

"We wanted to work more with health-care facilities on tobacco evidence-based interventions," said Kiley Hump, administrator of the S. D. Department of Health's Office of Chronic Disease Prevention and Health Promotion. "If they ask about tobacco use, do they then give tobacco users advice and referrals to services that will help them quit? If so, how do they do that?"

She pointed out that the South Dakota QuitLine offers a comprehensive range of free tobacco cessation services.

Recognizing strengths, weaknesses

The health-care facilities surveyed included clinics, hospitals, Women, Infants and Children (WIC) and family planning centers, mental health and substance abuse treatment facilities and cancer centers. Each was asked to provide a tobacco-free or smoke-free policy and answer additional questions regarding tobacco use assessment and referral procedures for patients, Mennenga explained.

Of the 420 facilities that were invited to participate, 348 provided copies of their tobacco- or smoke-free policy that two research team members evaluated in four general areas utilizing a policy review tool. They looked for a strong, comprehensive policy that was clearly communicated to those who work at or visit the facility. Then they evaluated how complete the tobacco ban was, including what specific products were prohibited, such as chewing tobacco.

In addition, the reviewers considered whether the issue of enforcement was addressed for employees and volunteers, patients and clients, visitors and contractors/vendors -- along with disciplinary actions for noncompliance. Lastly, they reviewers looked at whether tobacco users were encouraged to quit and then offered guidance on how to do so.

Mennenga shared some summary statistics from the evaluations. Scores ranged from 3 percent to 90 percent. Hospital, clinics and cancer treatment were among the facilities with more comprehensive policies, all scoring above 60 percent. Overall, mental health and substance abuse treatment facilities averaged a 30 percent for comprehensiveness, which mirrors the national trend, she noted.

The researchers found that 77 percent of the facilities had electronic health record systems that prompted them to assess patients' tobacco use. "Among those facilities without electronic health records, only 45 percent had a tobacco cessation section in their intake process," research associate Jennifer Kerkvliet said.

In addition, the researchers looked at two emerging topics that were not scored -- electronic cigarettes and third-hand smoke. "People are accustomed to not smoking in public places, but there are so many misperceptions about E-cigarettes," Mennenga said.

When it came to electronic cigarettes, 56.6 percent prohibited them, according to Kerkvliet. "That was encouraging."

Only 25.3 percent of the facility policies addressed third-hand smoke, which Mennenga described as "the smell and residue left on surfaces, including a smoker's hands, hair and clothing, that can cause potentially harmful effects."

Looking ahead

The researchers have also helped the S.D. Department of Health develop a model tobacco-free policy for health-care institutions that is available at www.goodandhealthysd.org/healthcare/practice-guidelines/.

"We're happy with the two-pronged assessment that addresses, not just buildings and grounds, but also looks at the referral side," Hump said.

Next, the researchers will give each facility feedback on how to improve its policy. The final step will be to conduct interviews at select facilities, representing low, mid and high evaluation scores. "We want to identify barriers and facilitators to developing and implementing tobacco-free policies," Mennenga said.

The researchers hope that their work will result in more health-care facilities developing comprehensive tobacco-free policies and providing tobacco users who want to quit with assistance.