A “smoke-free” hospital in Israel—a possible mission

Abstract

Background. A revised antismoking law in Israel (August 2001) called for a complete ban of smoking in hospitals. An evaluation of a hospital process and short-term outcome of implementing such policy may guideline its sustainability.

Methods. Two cross-sectional, random-sample surveys of employees 3 months before policy implementation, and 6–9 months post-implementation. The pre-implementation survey included 368 employees (90.4% response rate) and the post-implementation survey, 364 (92.8% response rate).

Results. The ‘smoke-free’ policy significantly reduced smoking in the unauthorized areas. Before implementation, 63% of staff reported frequently observing smoking in the hospital, compared to 40% 6 months post-policy implementation (P < 0.001). Significantly more smokers reported leaving their workplace to smoke (17% pre- vs. 62% post-implementation, P < 0.0001). Sixty-five percent of smokers, in both surveys, agreed that “a smoke-free policy is unfair to smokers”. Fewer nonsmokers subscribed to this belief: 42% pre- and 34% post-implementation. Smoker prevalence remained unchanged (19%).

Conclusions. Implementation of a “smoke-free” policy is an effective way to reduce smoking in the hospital environment. More effort is required, however, to help staff quit smoking altogether.

Introduction

Introducing a ‘smoke-free environment’ policy is one of the key strategies proposed by the World Health Organization to reduce the harm from smoking [1].

A smoke-free work site policy has been shown to reduce the number of cigarettes smoked by workers [2], [3], [4], effect a reduction in environmental tobacco smoke [4], and increase smoking cessation rates among workers [3], [5]. Adolescents working indoors in a smoke-free workplace have a better chance of remaining nonsmokers [6].

A smoke-free policy was successfully implemented in the majority of U.S. hospitals within 1 year of being mandated by the Joint Commission on Accreditation of Healthcare Organizations [7], [8]. Israeli laws restrict smoking in public sites (1983) and in the workplace (1996). The laws generally forbid smoking in such buildings and permit, but do not require the establishment of designated areas for smokers. Based on the U.S. experience, and in accordance with these laws, the general director of Hadassah Hospital implemented a complete “smoke-free” policy in the hospital as of November 2000.

Up until this time, Hadassah had been active in its attempts to reduce smoking in the hospital: designated smoking areas with appropriate sign posting had been established (as requested by the above-mentioned laws), an inspector to enforce policy assigned, and educational and smoking cessation programs offered to all hospital employees. Despite all these efforts, smoking beyond the designated areas was still observed with employees, patients, and visitors alike largely disregarding the regulations and the inspector's admonishments.

After 10 years of such smoking prevention activities, a discussion group was initiated by the occupational health unit, for a new solution to the problem. The conclusion was that only by adopting a complete “smoke-free” policy could smoking behavior on the hospital campus be reduced.

After a period of canvassing and advocacy, hospital administration endorsed the policy and, coinciding with the “World No Tobacco Day 2000”, the hospital director publicly declared Hadassah Hospital a “smoke-free” hospital. In August 2001 (15 months later), antismoking law was revised in Israel. The revised law called for, among other things, a complete ban of smoking in all hospitals. The Hadassah hospital experience was cited as the test case to the viability of introducing such policy on a national basis. The revised law, which takes a harder line, expresses concern about the unchanged prevalence of smokers among the adult population since 1994 (32% among men and 18.4% among women), together with increasing rates of adolescent smoking. In the last decade, there was an 86% increase in the rates of smoking of youngsters (age 18) recruited to the military service. In 2002, 32.2% of male and 29.8% of females smoked at recruitment [9].

Process and outcome evaluation of policy implementation were an integral part of the policy implementation process. The findings of two successive random-sample surveys among hospital employees—before the policy's introduction and 6 months post-introduction—assessing attitudes toward the policy, short-term impact on smoking in unauthorized areas in the hospital, and changes in employee smoking behavior are the subject of this paper. It may be of value for planning and implementing a “smoke-free” environment in a workplace, educational institution, and other settings.