Joint Commission: Smoke-free campuses will be the norm soon—ideas abound for execution and enforcement

A report by The Joint Commission makes a bold prediction: The majority of U.S. hospitals will have smoke-free campuses by the end of the year.

The study, The Adoption of Smoke-Free Hospital Campuses in the United States, was published in August in the British journal Tobacco Control. The report discusses the growing trend among hospitals to expand indoor smoking bans to their entire property.

Standard EC.02.01.03 already prohibits smoking in all buildings except for patients under certain circumstances.

The Joint Commission gave no indication about expanding that standard to encompass entire campuses.

“Conceptually, the adoption of a smoke-free campus policy exceeds the expectation laid out in The Joint Commission’s standards related to smoking,” says Scott Williams, PsyD, the study’s lead author and associate director of The Joint Commission’s division of quality measurement and research.

But if a hospital’s no-smoking policy affects the whole campus, the facility must live up to its word. “The expectation is that the hospital complies with the standard and implements the policies that it has defined,” says Williams.

The Joint Commission’s report defines “smoke-free” as no smoking allowed on indoor and outdoor properties owned or leased by the hospital, with no designated smoking areas on those properties.

Hospitals follow social trends

The major findings of the study? Nonprofit and nonteaching hospitals were more likely to implement smoke-free policies campuswide, and when they did, they were more likely to provide employees with smoking cessation help.

Some states have a much greater percentage of hospitals establishing smoke-free campus policies, but the study wasn’t designed to account for the discrepancies. Williams says that could have to do with individual legislation varying from state to state, as well as statewide nonprofit organizations (e.g., North Carolina Prevention Partners) championing the issue.

The smoke-free campus trend fits in with state laws banning smoking on state-owned property as well as public spaces (e.g., restaurants and bars), says Jessica Ronan Jackson, communications director at the Maryland Hospital Association.

Although it might take some transition time for patients and employees who smoke to adjust to a smoke-free campus, more hospitals are adopting the policies for good reason.

“Getting the administration on board with a smoke-free policy is obviously a key,” Jackson says. “But it’s kind of an easy sell, especially with hospitals, because of their missions.”

State toolkits provide ideas for you

Several state hospital associations, including those of Maryland and Kansas, have taken it upon themselves to aggregate information on hospitals going smoke-free.

Their Web sites include best practices for the following:

• Writing and implementing smoke-free policies
• Developing templates on press releases, employee notifications, and letters to patients and visitors
• Designing enforcement strategies

(See “Online smoke-free resources” on p. 4 for information on how to access these state resources.)

Jackson, who compiled the Maryland Hospital Association’s toolkit, strove to provide a variety of choices so hospitals could benefit from the past experiences of those who’ve already designed their policies.

Acknowledging that one size does not fit all, some of the example policies posted are less stringent than others, and there are many examples of press releases and letters to employees that basically say the same thing in different ways.

Creating, planning, and going forth with a successful smoke-free campus policy involves a multidisciplinary team that might include physicians, nurses, administrators, employee health representatives, and media relations leaders.

If a team determines that a smoke-free campus is the best option, but has a hard time getting administration buy-in, The Joint Commission’s report might give the initiative the final nudge it needs.

“I think that the study helps to change the question from, ‘Does our hospital want to lead the way and set a healthy example by adopting a smoke-free campus policy?’ into ‘Do we want to be the last hospital in our community to allow smoking on hospital property?’ ” Williams says. “From my perspective, that is a powerful shift in thinking.”

Enforcement doesn’t have to be hard-nosed

The toolkits offer many ideas for enforcement when people violate the policy, such as giving nicotine gum to offending patients.

Many hospitals hand out cards explaining the policy to patients, making it easier for busy or shy employees to say, “Put out that cigarette; here’s the official rules,” Jackson says.

One hospital puts a unique spin on the matter: On the back of the card is a coupon redeemable for a free soda at the cafeteria, turning a negative (“Sorry, you can’t smoke …”) into a positive (“… but we’ll give you a drink to help you get by”).

The one common denominator of all successful smoke-free campus policies is the idea that certain employees will become the enforcers, Jackson says. That might seem like a difficult goal, but when one considers that nonsmokers outnumber smokers by four or five to one—and cigarette smoke annoys most of them—it becomes easier to imagine.

Neighbors at times bear the brunt

One hitch to smoke-free campus policies is that smokers will inevitably go somewhere else to light up.

A.O. Fox Hospital in Oneonta, NY, changed its smoke-free campus policy because smokers learned to go out on city-owned sidewalks surrounding the campus for cigarette breaks. That not only violated the spirit of the policy, it irritated passers-by, says Carrie Post, RN, BSN, director of employee health and emergency management coordinator at the hospital.

“We [still] have a smoke-free campus,” Post says. “Except you can’t call it that, because there is a smoking area for employees and it’s closed in. It’s worked very well. It can’t be seen by the public, you don’t have to walk behind them and inhale their smoke, but they do get to smoke.” (See “Surveyors zoom in on testing and a locked egress door” on p. 8. to learn about Post’s hospital’s recent Joint Commission visit.)

Variations on this story have been repeated across the country, with neighbors of smoke-free hospitals getting testy with employees and patients who cross streets on the perimeter of the campus to smoke near private business properties or residences.

Some hospitals have dealt with this issue by sending letters from the CEO to property owners explaining the smoke-free campus policy, says Jackson.