Outdoor Smoking Ban in Public Places

Many studies have shown that smoking causes various health problems to both the smokers and the people who are close by. Cigarette smoking is a major cause of many preventable diseases, leads to premature deaths and accounts for a big proportion of many health inequalities. The World Health Organization (WHO) has estimated that smoking accounts for 6 million deaths worldwide annually and causes a significant amount of economic damage. Due to the health hazards that come with smoking, many people believe that smoking should be banned in public places. Many countries and territories have banned smoking in enclosed public places. These include office buildings, shopping malls, supermarkets, banks, schools, cinemas, among many others. Smoking bans refer to public policies that prohibit tobacco smoking in workplaces and other public places. Among these policies are criminal laws and occupational safety and health regulations. A very significant factor driving the introduction of smoking bans in many public places has been the protection of the health of the public, particularly children. A good example of a public space that has banned public smoking is the hospital.

In the United States, tobacco is one of the major causes of death and disease and accounts for approximately 434000 deaths every year (HSE, 2016). Second-hand smoke has also been proven to contribute to this toll annually. Due to this, many hospitals have implemented policies stating that their premises are smoke-free. The staff, patients, their families and friends are prohibited from smoking on hospital grounds. Over the past twenty years, the policies that ban smoking in hospitals have become more common as a commitment towards health inspires many hospitals. Today, more than eighty per cent of all hospitals, clinics, and other health systems have smoke-free campuses. Hospitals are one of the major employers in many countries, employing more than 5 million individuals annually. Some states have passed laws prohibiting smoking within a certain distance from hospitals and other healthcare facilities. Some hospitals have gone as far as keeping all smokers from hospitals. This has spurred debates, with some people claiming this act is unfair. One of the objectives of banning smoking on hospital campuses is to set a clear example of good health-promoting practices since hospitals are places meant to promote healthy living.

Effects of the policy

The outdoor smoking ban in hospitals has had a great impact on various hospital sectors and hospital stakeholders. Evidence suggests that a smoking ban in public places promotes a decrease in the consumption of tobacco. This is due to the reduction of smoking opportunities. A report carried out in 2011 by the International Agency for Research on Cancer showed that there is sufficient evidence that the implementation of the smoking ban in hospitals decreases respiratory symptoms in workers (HSE, 2016). The report also suggested a reduction in hospital admissions for cardiac arrests and other heart diseases.

One major sector that has been greatly affected by the smoking ban is the mental health unit facilities. Mental health and smoking have always gone hand in hand (Nesnera, 2013). With smoking banned from mental health facilities, many patients have claimed that they feel like prisoners. This is because smoking helps to keep them busy and relaxed. Banning smoking in mental facilities is meant to facilitate the recovery of the patients, but research has suggested otherwise. There have been concerns that banning smoking in mental health facilities will distract the patients from treatment and cause them to leave the facilities prematurely or even fail to seek further help. For instance, for patients with schizophrenia, not smoking reduces their recovery rate due to the increased metabolism. Many mental patients have established smoking as a routine for a long time, as it is a stress reliever. Banning smoking in these areas is very difficult for these patients, and this has seen many of them refusing treatments in many hospitals.

The smoking ban in hospitals has also impacted the tobacco industry. The industry has claimed that the smoke-free laws have led to a decrease in business, with an accompanying 20 per cent reduction in employment (Creswel, 2015). However, further research suggests that the smoking ban in public places has no major, significant economic impact on the tobacco industry.

Ethical principle

The main principle that underpins the smoking ban in hospitals is the nonmaleficence principle. The principle means ‘to not harm, benefit only’ (Cresnel, 2015). In the clinical setting, harm is the patient's condition that worsens. This principle opposes the beneficence principle, and it is the duty of doctors to avoid any treatment that may be harmful or that which acts against the best interests of the patients. The principle calls for physicians to protect their patients from harm incurred by second-hand smoking. The difference between the nonmaleficence and beneficence principles hinges on intended action. Non-maleficence obliges smokers not to inflict evil or harm, whereas beneficence implies a duty to prevent evil and to promote good.

The principle of justice is also relevant to hospital smoking bans. The principle calls on doctors and other health workers to address all forms of social health disadvantage, especially those caused by public smoking. Policies to protect patients and other health workers from smoking in hospitals help to address injustices caused by second-hand smoking. Justice should be the primary focus of public health activity.

Policy brief for outdoor smoking ban in hospitals

This policy brief provides an overview of the literature on smoking ban in hospitals. A current debate in the literature is whether such policies have had an impact on the reduction of health-related complications caused by smoking in hospitals. Annually, 440000 deaths in the United States are smoking-related. Second-hand smoke kills approximately 38000 nonsmoking Americans every year (HSE, 2016). Many hospitals will benefit from working and living in smoke-free environments, and once comprehensive smoke-free policies are adopted, the health benefits will be immediate. Banning smoking in hospitals will significantly reduce the risk of cancer and chronic diseases, as well as improve surgical outcomes and enhance recovery (Adda, 2014). Today, several hospitals have gone so far as to restrict their workers from smoking on the hospital campuses, including in the set-aside smoking zones. This has been an area of great concern as many people who are affected by this policy feel that it is unfair.

Opponents of the smoking ban in hospitals argue against it for several reasons. Firstly, they argue that when passive smokers go to places where people are smoking, it is a choice they make to make to breathe in other people’s smoke. They also argue that smoking is a matter of freedom of choice and people have a right to smoke as they wish. Smoking is not against the law, so individuals should smoke anywhere they feel like. Another argument against banning smoking in hospitals and other public places is the negative economic impact on bars and restaurants, as it would drive them out of business.

Challenges faced in the implementation n of the policy

One challenge facing the successful implementation of smoking bans in hospitals is the failure to plan ahead for enforcement and maintenance of the smoking ban policy. Successful implementation of the policy depends upon the approach used. Many hospitals and other health facilities fail to promote the policy as part of a comprehensive approach to health and awareness and incorporate the smoke-free policy into their overall planning. Failure to approach the policy adoption and enforcement process as a chance to make a positive impact on the health of the employees is a challenge that may hinder the successful implementation of the policy.

Another challenge is encountered when collaborating with other organizations and local government entities in the hospital’s community. Many hospitals, when implementing the smoke-free policy in their organizations, forget to consider the policy used by other organizations. When the policy is similar to that of other healthcare organizations, it is much easier for everyone to comply so that no one will be at a competitive advantage. Implementing the smoking ban policy at different times and locations from other organizations can confuse the staff, patients, and other visitors.

Another challenge that may need to be addressed is the uneven implementation of the smoking ban in hospitals. Inconsistent enforcement of the policy may make the employees feel as if they are the target of the smoke-free policy. This should be addressed, as many employees feel there is an unequal and unfair implementation of the system, which tends to undermine effective enforcement. When enforcing the smoking ban policy in hospitals, many organizations do not involve their employees, which tends to make them feel that they are being left out.

Several areas also frequently present special challenges to smoke-free policy implementation and enforcement. For instance, one common challenge is in the area outside the emergency department. This area requires the policymakers to be compassionate and non-confrontational. Some hospitals opt to hold back on enforcing the policy when a distraught family member or a loved one is seen smoking on the premises.

The hospital parking lot is another frequently problematic area. This area presents some interesting challenges. One is differentiating between what will be permitted on hospital grounds and what will be allowed in personal vehicles. Another is deciding if the policy will allow people to smoke in their cars while parked on hospital property, and if so, will the employees be allowed to do this also?

One of the main challenges facing the smoking ban in hospitals is protests from patients suffering from mental health. Many patients in these facilities find it too difficult to quit smoking, and a smoke-free policy will present a hardship not only to them but for the employees caring for them. The patients claim that the ban violates the common law to smoke outdoors. They also argue that there is a common law right to autonomy, which actually allows people to do what they like. Many other obstacles are encountered when implementing the smoke-free policy in mental facilities since most patients have ‘smoke breaks’ to keep them busy. When enforcing the policy in these institutions, the mental health patients should be involved and help them develop a plan that involves quitting.

Primary options available

i) Training all the hospital staff to deliver basic interventions. Training healthcare professionals to provide smoking cessation interventions to patients has been proven to change smoking behaviour. The many challenges faced in supporting smokers in hospitals, including acute medical illness and the potential for drug side effects, are some of the reasons training hospital staff is important. Studies in the past have shown that intervention training of health care professionals significantly increases their knowledge of registering patients’ smoking status and assesses their willingness to quit smoking. Many hospitals establish smoke-free policies on their campuses without training the health care providers. This should be addressed, and well-designed training packages should be set up for the staff and other healthcare professionals. These will lead to success in reducing overall smoking.

ii) Referring hospitalized patients to a community service on discharge. Many hospitals do not offer hospital-based smoking cessation services. Referring patients to community services on discharge will eventually decrease rates of smoking in and out of hospital premises.
iii) Counseling programs for all hospitalized smokers, regardless of their diagnosis. Counselling programs for this group boost smoking cessation rates after discharge from the hospital compared with usual care. However, stronger interventions are needed since cessation rates are substantially low for patients with cardiac diseases. These programs involve systematically identifying smokers on admission and bedside counselling sessions by specially trained nurses or counsellors.

How to deal with the challenges

Before the smoke-free policy should be enforced, planning ahead should be done. The smoke-free policy in the hospitals should be incorporated into the overall wellness planning, which includes the incentives offered to employees. The policy adoption and enforcement process should be approached as a chance to make a positive impact on the health of all those affected by the policy. The hospital should form a task force that is dedicated to enforcement, which includes smokers in the planning and implementation. In forming these committees, it is important to include both nonsmokers and smokers to ensure that the policy services meet the smokers’ needs.

When enforcing the policy, the hospital should collaborate with other organizations and local government entities in the community in which the hospital is based. This is because when the policy is similar to all healthcare organizations in the area, it will be easier for everyone to comply. Collaborating with other healthcare organizations will give the hospital facility heightened attention from the media, which is mostly positive. This also helps the hospital to reach out to public health and other prevention-oriented organizations and get their assistance and join in efforts to reduce the usage of tobacco.

Communication should be kept open with all the constituencies that are affected by the policy. Ongoing reminders of the policy should be given to all the affected parties by a variety of means. For positive feedback, share success stories of employees or other people who quit smoking due to the smoking ban policy. Communication n to the patients about the policy is very important. This should be done early enough or before their admissions to prepare them mentally. This will ensure that the policy is followed with little or no rejection. The policy should also be reviewed regularly and carefully monitored to ensure that momentum is maintained.

When enforcing the smoke-free policy in mental health facilities, the focus should primarily be on health issues and the interrelationships between mental health and smoking. All psychiatric facilities should involve all patients in the process of planning for the implementation of the smoke-free policy. Mental health patients will adhere to the policy better when they feel that their concerns have been heard. Tobacco cessation programs should be incorporated into patients’ treatment plans.
The hospital, in enforcing the ban, should strive to foster a non-confrontational approach. Successful facilities instruct their employees to approach all smokers with respect and a compassionate manner. The visitors should politely be informed of the policy to reduce any resistance. People should be made to feel that they have a say in enforcing the policy. The hospitals should be optimistic because, with time, the hospital's culture will change in response to the policy.

The top-down approach to the evaluation of the smoke-free policy implementation process is characterized by planning from the top, whereby the emphasis is on the managers directing the whole process of enforcement. Decision-making starts from the top, and the policy is then communicated to the staff after the top management has agreed upon the policy. The top-down implementation approach is a clear-cut system of command and control, mainly from the government to the policy implementation in specific organizations. The approach is important in evaluating the policy's success since it is a rational and comprehensive approach to planning. The following characteristics of the top-down approach are useful in evaluating smoke-free policy success:

Clarity and consistency of its goals: these goals are articulated at the top of the hierarchy. Policies made by the top management downwards are easy to evaluate because they tend to be consistent, with a touch of authority to them.

A Clear hierarchy of authority can be used to evaluate the effectiveness of the smoke-free policy. This is because there is a clear definition of where policies are made from. Most outdoor smoking bans in public arise from the government, which is a good example of a top-down approach. This consistency is important since it is difficult for people to follow the smoke-free policy ban if it arises from such an external source.

Resources and capacity to carry out commands from the top (Elder 2012); the top-down approach is a good evaluation kit since the government and other external sources provide the resources necessary to successfully implement the policy. These may be both financial and non-financial.

The International Agency for Research on Cancer is one major organization that has expressed an interest in the smoke-free policy within hospital campuses. Supported by the World Health Organization (WHO), the agency conducted a review of evidence on second-hand smoke and cancer, and the results were that it found sufficient evidence to conclude that involuntary smoking is a cause of some types of cancer (Adda, 2014). Exposure to other people’s smoke increases the risk of lung cancer in non-smokers by about 30 per cent and coronary heart disease by 35 per cent. The risk of contracting these diseases is especially higher in hospitals. The agency is a major supporter of smoke-free policy in hospitals due to the risks this may pose to hospitalized patients. The agency said that hospitals and other healthcare facilities must do more to help patients quit smoking by making their premises, including grounds, smoke-free.

Principles of community-based participatory research

One of the key principles of community-based participatory research is that it recognizes the community as a unit of identity and seeks to identify and work with existing communities. This approach acknowledges that communities have numerous individual and organizational skills, but they may also benefit from external skills and resources. The International Agency for Research on Cancer sends representatives to the hospitals to work on the smoke-free policy. This is an effort by the agency to work with the hospitals to reduce smoking-related diseases, especially cancer.

Another key principle is facilitating collaborative partnerships in all phases of the research (Nesnera, 2013). The agency should build on prior positive working relationships that exist between the hospital and the communities surrounding it. Facilitating these partnerships will benefit the organization and the hospital where the smoke-free policy has been enforced. All the stakeholders involved will feel at once, and positive relationships will be established. The agency should involve many of the original community partners within the hospital as well as new researchers and community organizations. Identifying and selecting partners can also be done by conducting community analysis to assess the values, needs and community resources required.

Building on strengths and resources within the community is another key principle of community-based participatory research. This involves identifying all the strengths, resources and capabilities within the community and using these strengths to the benefit of both the organizations involved and the community in general.

The main goal of the International Agency for Research on Cancer regarding the outdoor smoking ban in public areas is to reduce the diseases and deaths caused by smoking, especially cancer and other chronic illnesses (HSE, 2016). The smoke-free policy ban in hospitals is meant to reduce smoking in hospitals to reduce smoke-related diseases and deaths. The goal of the agency and the goal of the smoke-free policy in hospitals are interrelated, and due to these, the organization works hand in hand with the hospital to ensure that the smoke-free policy is successfully enforced.

Action steps to successful enforcement of the smoking ban

The first step to reaching this goal is to set a clear target date for implementing the smoking ban. This will prepare the employees, patients, and other people affected by the policy because there will be no smoking in the hospital facilities. The next step is to allow adequate time for the hospital staff and administration to develop strategies that will aid in implementing the smoke-free policy. In doing so, the hospital administration should be involved to ensure that it is supportive to prevent any resistance.

Another step is to address any concerns regarding patient and staff safety that may arise. Deal with questions regarding the policy implementation and ensure that there is an opinion from all those involved. Ensure that there are adequate nicotine replacement therapy options for the staff and patients. Set clear guidelines for the policy implementation to ensure that there is no confusion.

Bottom-up approach

The approach means that local actors participate in the decision-making about policy enforcement and in the selection of the priorities to be pursued. In the hospital setting, using a bottom-up approach means involving all the patients, staff, and management in implementing the policy. This approach is important as it is designed to adapt to the needs of all people.

Strengths of the approach

I) This approach involves raising awareness, training, participation, and mobilization of the local population to identify the policy's strengths and weaknesses.

ii) Different interest groups are involved in the decision-making process, which helps to draw up a local development strategy.

iii) It helps in the establishment of clear criteria for the selection of policies, strategies and appropriate course of action for the successful implementation of the policy.

Weaknesses

i) The strategy is mainly driven by existing infrastructure instead of business processes.

ii) The organizational structure established by this approach might have to be changed in later phases, especially by the top management.

iii) This approach does not have a clear line of authority.

Top-down approach

Strengths

i) There is a focused use of resources from the individual-managed application of the policy.

ii) This approach comes from the top or external sources, and it is, therefore, easier to comply with due to the rules and regulations involved.

iii) The operation and maintenance of resources are not initially impacted as severely as other approaches.

Weaknesses

i) Failure to involve all the affected people in the decision-making process.

ii) The cost of implementation of the policy is likely to be high.

When implementing the smoking ban policy within hospital premises, the top-down approach is the most effective to use. This is because the procedure is associated with an external source, especially the government. It will be easier to implement the policy in your hospital if other public places have enforced the smoking ban too.

References

Adda, J, Cornaglia, F. (2014) ‘The Effect of Bans and Taxes on Passive Smoking,' American Economic Journal: Applied Economics, p 32.

Alexander P. Nesnera. (2013). Implementing a smoking ban: tips for success. Retrieved from www.mdedge.com/currentpsychiatry/article.

Creswell, J.W. (2015). Qualitative Inquiry on Research and Design, 1st Ed. London: SAGE Publications.

Health Service Executive (2016). Tobacco Free Campus Policy, USA Journal.