Impact of a long-term tobacco-free policy at a comprehensive cancer center: a series of cross-sectional surveys

Smoke-free policies are one of the most effective measures recommended by the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) to control the tobacco epidemic [1, 2]. Smoking bans can be implemented by private organizations, accrediting agencies or boards, and local, state, or federal governments through legislation [3, 4]. Both governments and health organizations play leading active roles in tobacco control, sharing responsibility in providing primary healthcare, educating the community about tobacco-related issues, and assuring that public environments are healthy [5, 6].

Since the approval of the WHO FCTC, more than 120 countries [7, 8] and numerous health organizations have strengthened their smoke-free policies [9–12]. By means of these smoking bans, workers at hospitals that have either governmental or non-governmental smoke-free policies in place may benefit more than the general population from such policies. The benefits of smoke-free policies in health care services include: (a) decreased exposure to second-hand smoke (SHS) [13, 14]; (b) increased number of quit attempts and slightly reduced smoking consumption prevalence [15, 16]; and (c) a greater involvement in conducting tobacco prevention and cessation activities [17–20].

In 2005, Spain passed its first comprehensive smoke-free law, which banned smoking in indoor public places, workplaces, and health care services, except in hospitality venues [21]. In 2010, that law was amended providing: (1) smoke-free indoors for the hospitality sector (bars and restaurants) without exceptions, and (2) Smoke-free outdoors in some public areas including hospital grounds, educational campuses, and playgrounds [22]. However, some hospitals had already implemented their own regulations to prohibit smoking indoors before the first national law was enacted [23, 24]. Since 2002, the Catalan Institute of Oncology (ICO), a comprehensive cancer center in Barcelona, has developed several tobacco control policies by following the guidelines from the ENSH-Global Network for Tobacco-Free Health care Services (http://www.ensh.eu) [15, 25]. Throughout the 12 years of the hospital tobacco control project, several policies recommended in the ENSH model have been implemented, including: awareness campaigns on the hazards of SHS, smoke-free policies to protect people from SHS exposure, tobacco cessation services (including psychological support and pharmacotherapy if needed), and training courses for professionals, promotion activities, and evaluation efforts. These policies have been regularly monitored through diverse methods including smoking prevalence surveys, self-audit questionnaires, and observational inspections [10, 15, 24, 26, 27].

Although previous studies have monitored the psychosocial and behavioral effects of tobacco control policies at the hospital level [15, 28–30], those studies have not evaluated the impact of long-term institutional tobacco-free policies combined with the national smoke-free bans.

Given this context, the aim of this paper is to describe the impact of a 12-year tobacco control project (2000–2012) implemented in a comprehensive cancer center in combination with two national smoking bans (passed in 2005 and 2010). We describe trends in smoking consumption, attitudes, and behaviors among hospital workers at baseline (before passage of the 2 laws), after the 1^st law (which banned smoking indoors), and after the 2^nd law (which banned smoking on hospital grounds).

The present study assesses, for the first time, the impact of a long-term tobacco control project in combination with two national smoke-free laws. Findings indicate a significant smoking reduction (mainly after passing the 2^nd law) and important changes in smoking patterns, including an increase in the proportion of occasional smokers, a rise in smoking abstinence during working hours, and an increase in support for the hospital tobacco control policies in the whole study population, particularly in non-smokers and health care providers. As previous studies indicate, the more restrictive the smoke-free policies, the greater the effects on smoking behavior [4, 34–36]. At baseline, smoking prevalence among hospital workers was similar to prevalence in the general population at that time (33.1% versus 32.1%, respectively) [37]. After the implementation of the 1^st law, prevalence remained similar to the general population (30.5% versus 29.4%, respectively) [31]; however, after implementation of the 2^nd law, smoking prevalence among hospital workers decreased sharply in comparison to the general population (22.2% versus 29.5%, respectively) [38]. This gradual decrease suggests an additive effect of the long-term organizational tobacco control policy in conjunction with national policies on hospital workers’ behavior.

Decreases in tobacco consumption were observed mainly in hospital workers ≥35 years old, doctors, and women. We hypothesize that the smoke-free legislation has had lower impact on the youngest group (<35 y) because young smokers tend to trivialize the harmful effects of smoking, and in our context there are insufficient initiatives addressed to motivate cessation among young smokers, even for health professionals”. It is also remarkable the decrease in smoking rates among women. Although, the hospital has not launched special campaigns addressed to them, we believe that the several cessation training programs addressed to nurses - who are 40% of our work force and from them 90% are women- may have had a stronger impact on quitting among this group. In addition, nurses smoking rates have had an appreciable decrease mainly after the passage of the 2^nd law.

Health workers are viewed as exemplary professionals by the rest of the society and thus they should be on the frontlines of tobacco control [39]. According to an international review that described smoking consumption among physicians, countries that implemented early tobacco control policies (e.g., the United States, Australia, and the United Kingdom) had a rapid decline in smoking prevalence among physicians, and currently those countries now have the lowest prevalence rates in the world [40]. A similar trend study conducted in Ireland showed also a striking decrease in smoking staff rates but with a stronger occupational gradient than in ours [41]. Our study reveals lower smoking rates among oncology nurses than among administrative and general population. However, oncology nurses at our institution still smoke more (by 10 percentage points) than oncology doctors, a finding that is consistent with the situation in other developed countries [42].

In the last decade, smoke-free policies in Europe have become more common in health care services due to the passage of both governmental [8] and non-governmental initiatives [43]. Nevertheless, despite the clear benefits of smoke-free policies [4], the WHO FCTC encourages organizations and governments to do more than just implement restrictions, advocating for the development of a broad tobacco control approach [1]. In this regard, our ‘Hospital Tobacco Control Project’ has developed a comprehensive tobacco-free model based on the ENSH-Global Network for Tobacco-free Health Care Services. The ENSH model integrates ten policies in agreement with Article 8, 12, 14, and 21 of the WHO FCTC (Article 8: “smoking bans in public places,” Article 12: “consumer information,” and Article 14: “access to treatment for quitting smoking,” Article 21: “research, surveillance and exchange of information”). The ENSH concept follows an organizational and cultural change model for implementing innovations [44] that has shown that a gradual implementation improves tobacco control policies [10, 45].

Many of the other policies recommended in the WHO FCTC have been poorly developed in health care services [46]. For instance, provision of tobacco cessation services (Article 14) is less than optimal [10, 47–49] and in many cases the programs offered form part of research studies, with a low likelihood of future sustainability [50, 51]. In our context, Catalan hospitals provide tobacco cessation services with the support of the regional government. Our comprehensive cancer center has offered tobacco cessation aid to workers since 2005, including behavioral support and free pharmacological treatment from 2005 to 2008. Afterwards, smoker workers should pay their own pharmacological treatment, and professional tobacco cessation consultation remains out of charge. A study assessing this intervention showed a high probability of abstinence at 6 months follow-up [26]. This result is in line with the substantial decrease in the prevalence of tobacco consumption among our hospital workers after the national bans, as well as the increase in the proportion of smokers who have consulted a health professional for help in quitting tobacco. In addition, the high dependence on cigarettes (i.e., the increase in subjects who have their first cigarette in ≤30 minutes of waking) and the low readiness to quit among our smoker workers is noteworthy, and seems to suggest that some “hardening” of smoking habits is occurring in this specific population [52]. Another remarkable point is the substantial increase in the number of occasional smokers in our hospital worker population. However, this finding is in line with other studies that have reported a similar increase in the number of the occasional smokers in countries where tobacco consumption in the overall population is decreasing [53] especially among some role model professions such as health careproviders [54].

Smoking cessation care in hospitals continues to present a challenge in many organizations [10, 47, 48]. Worldwide, the most commonly-identified barriers to smoking cessation efforts include: lack of resources, knowledge, time, and support [55–57]. The deficit in adequate tobacco cessation knowledge starts at the university level. According to a recent study, few health sciences degrees include tobacco cessation training in their curricula [58]. Also, constraints on financial and staffing resources may threaten the suitability of innovative projects [50, 51]. As a result neither health professionals nor hospital administrators see providing tobacco cessation services as part of their responsibilities [59]. In our study, hospital workers as a group increased their support for hospital tobacco control policies; however, agreement about the exemplary role of health professionals is still lower than desirable.

This study has limitations that must be considered when interpreting the results. First of all, our study was conducted at a comprehensive cancer center which has taken an active role in as a promoter of the tobacco control hospital model. Therefore, the remarkable decrease in tobacco consumption observed could be higher than in other hospitals. Nevertheless, in Catalonia, similar policies have been implemented at other public hospitals that are members of the Catalan Network for Smoke-free Hospitals (90% of public hospitals are members). This suggests that similar results can be expected at health care organizations/institutions that implement a long-term tobacco control policy that is supported by national smoke-free bans. Another potential limitation of our study is the possibility that cross-sectional surveys that use self-reported smoking status may suffer from information bias related to the increasing denormalization of tobacco consumption and associated attitudes to such consumption over time. However, data collected through cross-sectional surveys provide a real picture of the situation and this approach also prevents drop outs that typically occur during follow-up. It is well- known that hospitals have a high staff turnover rate, mainly among younger workers and the professional group “others”. The population in our sample was young and this was an important factor in determining the best design for our research aims. The inclusion of biological measures to confirm the accuracy of self-reported smoking would have improved the reliability of the data. However, previous studies have shown that self-reports are an adequate form of classifying smokers in observational studies [60].

In conclusion, a long-term tobacco control strategy—which included sensitization campaigns, tobacco cessation training, cessation programs, and periodic monitoring and evaluation—in conjunction with two national smoke-free bans, helped to reduce smoking prevalence rates among hospital workers. However, convincing health care providers to become more involved in tobacco control is still a challenge. In addition to the array of tobacco control initiatives that organizations could undertake (such as education, cessation programs, and awareness campaigns), future actions to effectively decrease tobacco consumption and increase providers’ involvement will depend on the commitment of public health departments, agencies, and governmental bodies. These should encourage and support health care providers, and especially to nurses, their engagement in tobacco control in order that they become part of the solution of the tobacco epidemic.