By Sheila Tucker

There’s no getting around it — hospitals can be stressful places, and stress can be a significant trigger for people who smoke. But smoking on hospital property creates issues for everyone. It exposes non-smokers to second-hand smoke; and the healthcare facility — which should represent health and healing to the broader community — is anything but that when the grounds are littered with cigarette butts and polluted air.

Smoke-free environments have been the norm in Canada for some time. All Canadian jurisdictions have legislation or by-laws concerning smoking and vaping in public spaces. The rationale for these laws and policies is to reduce exposure to second-hand smoke among patients, staff, and visitors; encourage smoking cessation; and allow health authorities to “lead by example” and project a healthy image in communities.

While there are many similarities in approaches to smoking cessation in health facilities, there is variation. Some jurisdictions have banned smoking entirely on facility property, while others allow smoking in designated areas on facility grounds. Despite these measures, smoking on hospital property continues to be a problem in many areas across Canada.

CADTH recently looked at the current evidence on best practices for implementing smoke-free policies on hospital grounds as well as enforcement frameworks used across Canada to reduce or eliminate smoking on hospital property. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures. The CADTH review identified a range of practices that support a smoke-free environment on hospital grounds. It found that the most effective policies are part of comprehensive smoking cessation programs that include cessation support for staff and patients; effective training, communications, and signage; and interventions such as public education campaigns aimed at “de-normalizing” smoking.

Many smoke-free grounds policies create an expectation that all staff will play a role in ensuring compliance with the policies. But evidence suggests that staff may require additional training or educational resources about smoking cessation to optimally counsel patients and visitors. Additionally, enforcement staff may require tools and training resources to help them feel adequately equipped to approach individuals who are smoking, advise them of the policy, and achieve the desired outcome while avoiding confrontations.

Jurisdictions under provincial legislation have robust enforcement mechanisms, with the option to levy fines to both individuals or corporations found to be not complying with or not adequately working to ensure compliance with existing legislation. There is limited evidence that this approach is effective at supporting behaviour change or reducing how often fines are issued. Compliance models that rely too heavily on enforcement and do not adequately recognize nicotine dependence may be seen as needlessly punitive. However, creating an accountability mechanism whereby facility or health authority leaders are held responsible for non-compliance may help ensure that these organizations remain focused on smoke-free grounds initiatives. Having provincial legislation in place also allows the responsibility of enforcement to be extended to public health inspectors and peace officers. However, ensuring there is adequate capacity to conduct inspections and enforce the legislation consistently seems to be a challenge in many jurisdictions.

At in-patient psychiatric facilities, there can be unique considerations associated with implementing smoke-free policies, given the relationship between mental health and substance use issues and tobacco use. Psychiatric facilities have often been considered exceptions in the context of no-smoking legislation and policy. Despite perceptions, evidence suggests that individuals living with mental illness are often interested in quitting smoking and capable of doing so with proper supports, and that smoke-free policies improve the overall health and safety of patients. The Centre for Addiction and Mental Health (CAMH) has implemented tobacco-free policies across all its grounds using a holistic approach to remove tobacco-related triggers that could inhibit attempts to quit. A 2017 study found that the CAMH policy is feasible, resulted in more positive attitudes toward no-tobacco policies, and led to a statistically significant decrease in patient agitation.

In many jurisdictions, tobacco legislation provides exemptions for cultural reasons, including Indigenous ceremonies during which smoke is produced. Some healthcare facilities across Canada have created indoor spaces equipped with ventilation for Indigenous ceremonies involving smoke. There is a distinction between ceremonial tobacco, which is made from plants and considered sacred by many Indigenous communities, and commercial tobacco, which contains harmful chemicals and is highly addictive.

There are no simple solutions to resolving the issue of smoking on hospital property. However, resources have been produced by organizations in Canada and internationally that are designed to address this complex issue.

CADTH’s report on best practices to facilitate smoke-free hospital grounds is freely available at cadth.ca/smoke-free-hospital-grounds. To learn more about CADTH, visit cadth.ca, follow us on Twitter @CADTH_ACMTS, or speak to a Liaison Officer in your region: cadth.ca/contact-us/liaison-officers.

Sheila Tucker, M.L.I.S., B.Ed., B.A.(Hon.), Dip. Ed., CPAD, is CADTH’s Liaison Officer for Newfoundland and Labrador.