Implementing Smoke Free Policies in Psychiatric and Addiction

228 Pages·2007·4.14 MB·English

IMPLEMENTING
SMOKE FREE
POLICIES IN
PSYCHIATRIC
AND
ADDICTION
FACILITIES

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Centre for Addiction and Mental Health
Toronto, Ontario
February 27, 2006
The following individuals from the Centre for Addiction and Mental Health contributed to the
writing and editing of this manual:
Dr. Peter Selby
Kristen Cleary, MA
Janet McAllister, BSc. HK
Shelly Munro, RN

Special acknowledgement goes to all of the individuals who participated on the CAMH Smoke
Free Policy Committee:
Peter Selby, Joanne Campbell, Kristen Cleary, Rosa Dragonetti, Janet McAllister, Shelly Munro,
Andrew Arifuzzaman, Jeremy Albisser, Peter Basran, Rhoda Beecher, Wendy Fenomeno, Mark
Fernley, Roberta Ferrence, Manuel Gitterman, Paul Garfinkel, David Goldbloom, Christine Harris,
Larisa Hausmanis, Anja Kessler, Bernard King, Danielle Larmand, Ann Mahdy, Becky McEwan,
Betty Miller, Ruxandra Nedu, Larry Pilozo, Lysa Priolo, Billie Pryer, Anne Ptasznik, Billie Pryer,
Lisa Ramshaw, Peter Ritchie, Efrem Rone, Amer Shafei, Rani Srivastava, Marisa Tacconelli
Termine, Judith Tompkins, Trevor Young, Diane Whitney, Client and Family Advocates,
housekeeping and maintenance staff and security.

This manual will be made available on www.camh.net

Last revision: February 2006
TABLE OF CONTENTS

1. Rationale for Becoming a Smoke Free Facility
a. Background information on the smoking
population
b. Evidence for going smoke free

2. Policy Development
a. Understanding the steps needed to becoming
smoke free
b. How to create a smoke free policy working group

3. Implementation of a Smoke Free Policy
a. Training of staff on policy, Nicotine Replacements
Therapy
b. Different formats of trainings

4. Communication Plan
a. How to effectively create a marketing campaign for your smoke free
policy
b. Time lines for role out of communication plan

5. Evaluation Tools
a. Learn different types of evaluation tools
b. Understand the importance of evaluation pre and post
implementation

6. Frequently Asked Questions

7. Resources

8. Appendices
RATIONALE
BACKGROUND

According to the latest results from the Canadian Tobacco Use Monitoring
Survey (CTUMS, 2004), slightly more than 5 million people, representing 20% of
the population aged 15 years and older, were current smokers. Daily smokers
represented approximately 15% of the population smoking on average 15.2
cigarettes per day. The remaining 5% reported smoking occasionally.
Approximately 22% of the male population aged 15 years and older were current
smokers while the proportion of females was at 17%. Ontario smokers are
slightly under the national average at 19%, but smoke 15.4 cigarettes per day,
which is slightly more than Canada as a whole. If we examine the percentage of
workplace smoking restrictions it is quite high in comparison to many other
countries. Ninety one percent of employees reported some kind of smoking
restriction in their workplace while 71% reported a completely smoke free
environment at work.1 Therefore, much needs to be done to achieve 100%

smoke free work environments in Canada.
Health Care institutes, for the most part, are smoke free. However, due to the
high rates of smoking in mentally ill patients, psychiatric units and hospitals
introduced designated smoke rooms (DSR) as a means to accommodate
smoking behaviour. Smoking in psychiatric hospitals has been normalized over
the years. Cigarettes have been part of the client/staff relationship, smoking on
the psychiatric floor in the hospital is expected. While the rest of the province of
Ontario is going smoke-free, psychiatric hospitals have been exempted from our
new legislation. Looking at the research related to workplace, and client impact
of second hand smoke and smoking we have to ask ourselves if this is a norm
that needs to change. Recent evidence suggests these ventilation rooms fail to
achieve any significant improvements in air quality. Moreover, there is an ethical
debate on the provision of smoking cessation interventions to these patients.
The following highlights the relationship and association between smoking and
mental health problems.

Smoking and Mood Disorders: Anxiety and Depression
The rates of smoking in people with mood disorders ranges from 40-60 percent.
For those with an anxiety disorder, quitting smoking can have quite positive
effects on their level of anxiety and often reduces their needs for anxiolytic
medications. For those with depression the effects are mixed. People with a
history of depression are at higher risk of experiencing a depressive episode after
quitting and negative mood after quitting is one of the most significant indicators
of relapse. When people are depressed or experience a depressive episode
associated with quitting, the process becomes more challenging. One of the
ways to help people work through their depression without losing sight of their
quit process (which could compound the feelings of failure and hopelessness) is
to work with them on harm reduction techniques such as reducing their daily
intake of cigarettes. However, it is clear that people with depression are able
and willing to quit smoking.
Smoking and Schizophrenia

The rates of smoking in this population are almost quadruple those in the general
population and the mortality rates are also significantly higher. There are mixed
arguments around whether or not this population should and/or can quit smoking.
Research and our own experience has shown that in fact people with
schizophrenia can and do quit smoking. However, for some quitting is more
difficult or is not their immediate goal. Harm reduction is a non-threatening, often
effective way to help these clients work towards abstinence.
Smoking and Other Substance Dependence

Between 60-90% of those with alcohol dependence smoke. Smoking and
drinking are co-related. The more a person drinks, the more they are likely to
smoke. This is also true with other substances. There is also a very high
mortality rate in those with alcohol dependence who smoke. The traditional view
in this population has been to focus on the primary substance of concern and
ignore tobacco smoking behaviour. More recent evidence shows that it maybe
more effective for individuals to consider quitting all substances at once. It is not
uncommon when reducing or quitting one substance to increase another such as
tobacco. This is one of the reasons clients may want to consider addressing all
substances together. At the very minimum, clients entering substance use
treatment should be screened and advised to quit smoking. In our experience
many clients are interested in exploring their use of tobacco.
RATIONALE FOR GOING SMOKE FREE

Primary Reasons

Reducing exposure to Second Hand Smoke (SHS): Research shows that
second-hand smoke has many carcinogens and is a preventable cause of
many major diseases in smokers and non-smokers alike. The purpose of
going smoke free is to ensure that those who work, visit or receive services at
public facilities do not experience the many detrimental health consequences
associated with second-hand smoke such as chronic pulmonary obstructive
disease, asthma and cardiovascular disease. It is estimated that
approximately 1,000 Canadians will die each year from SHS exposure. About
1/3 of them die from lung cancer.2 In Ontario, it is estimated that SHS
exposure causes over 425 deaths per year, not including workplace
exposure.3
Second-hand smoke ranks third as a major preventable cause of death
behind only active smoking and alcohol. Second-hand smoke (or side stream
smoke) is the smoke that comes from the end of a lit cigarette as well as the
excess smoke that comes from the exhaled smoke that the smoker has
inhaled. Second-hand smoke contains 4,000 chemicals, of which more than
42 are known to cause cancer.4
(See Appendix 1 for CAMH data on air quality measures and Nursing
exposure to SHS)

Employee Satisfaction and Increased Productivity: In recent years, bans
on smoking in public places have become more and more restrictive.
According to stats Canada’s National Health Population Survey completed in
1996/7, 88% of smokers agreed that non-smokers should not be exposed to
SHS in their work environment. The number of non-smokers agreeing to this
statement was even higher at 95%. Currently the highest rate of workplace
smoking restrictions is in Ontario at 72%. 1 There is also a wealth of
information that points to smokers using more sick days, increased insurance
premiums as well as taking more breaks throughout the day. From a cost
perspective, it also costs business time and money to manage employees
smoking due to increased maintenance and housekeeping costs. According
to the Conference Board of Canada (1997) the estimated annual costs of
employing people who smoke is about $2565.00 per year. This accounts for
increased absenteeism, decreased productivity, higher life insurance rates
and maintaining smoking areas.7
You can calculate your costs based on the following formula.

Calculations:5

Annual Cost of Absenteeism = (Avg. # of days sick annually by ever smokers
– Avg. # of sick days annually by never smokers) X daily wage X (1 + benefits
paid: ratio estimated at 15% of wages)

minutes to smoke a cig
Cost of Productivity – Avg. # of cig/day X 60 X Avg.
hourly wage X (1 x benefits paid: ratio estimated at 15% of wages) X days
worked/year

Prevent Legal Action: As more people understand the harmful effects of
exposure to second hand smoke there is a higher likelihood that employees
may take legal action. Successful cases have been brought forward by
individuals who have been exposed to SHS and now have health
consequences due to that exposure.
“Heather Crowe was an Ottawa waitress for 40 years. During that time frame, Ms. Crowe was
regularly exposed to second-hand smoke in her workplaces - hotels, bars and restaurants -
until August 2001 when the City of Ottawa enacted smoke-free workplace and public place
legislation. In March 2002, Heather began to experience symptoms, and was subsequently
diagnosed with inoperable lung cancer.
Ms. Crowe made her claim to the WSIB shortly thereafter. In October 2002, the Board agreed
that Ms. Crowe contracted lung cancer due to second-hand smoke exposure in the
workplace, and ruled that she was entitled to health care expenses, personal care allowance,
independent living allowance (if applicable), loss of earnings benefits, permanent impairment
benefit, and other applicable benefits.
Ms. Crowe decided to go public with her case and campaign with various health agencies to
call upon provincial governments not only to declare second-hand smoke a workplace
hazard, but also to enact 100% smoke-free workplace and public place legislation.
Despite her continued chemotherapy treatments, Ms. Crowe has shown enormous strength
of spirit and dedication to tobacco control by traveling across Canada to meet with labour and
health ministers, as well as addressing many municipal councils considering implementation
of smoke-free bylaws.” 6
(See Appendix 2 for Canadian Court and Tribunal Findings that Second-hand
Tobacco Smoke is Harmful to Health)
Secondary Reasons

Change in staff attitudes, knowledge and behaviour: Attitudes towards
this addiction may be improved as there is increased awareness of the
repercussions of tobacco use and how to manage clients who would like to
reduce or quit. Often individuals will say that it is unfair to take smoking away
from clients who are dealing with other issues. However, teaching employees
that this policy is not about judging smoking but about protecting the health of
everyone, values can begin to change. This is the first step in the education
of health care professionals who work with their clients.

Change in utilization of Psychotropic Medications: Psychiatric patients
may present with nicotine withdrawal symptoms that mimic other psychiatric
behaviors. Unfortunately, during these times it is not unusual for clinicians to
prescribe psychotropic medications to manage symptoms when Nicotine
Replacement Therapy (NRT) could have been used instead. Utilization and
costs of other psychotropic medications especially the use of neuroleptics
such as clozapine should also be reviewed. Non-smoking patients often need
lower does of this drug.

Adverse effects on staff and patients: There is often concern that patients
will become physically aggressive if not allowed to smoke. By providing
extensive training and normalizing the routine use of prescription of NRT, we
would expect to observe no change in the number of premature discharges,
assaults, code whites (disruptive patient) before and after implementation of
the smoke free policy.

Increased cessation attempts by patients and potentially staff: By
bringing this issue to the forefront, clients and staff of your facility may
consider quitting or reducing their tobacco use. Offering cessation programs
and resources can be a valuable way to support your staff in complying with
the policy.

(See Appendix 3 for CAMH literature review)

1 http://www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/ctums-esutc-2004/summarya-sommairea_e.html
2 Makomaski-Illing, E.M. and M.J. Kaiserman. Mortality Attributable to Tobacco Use in Canada
and its Regions. Chronic Diseases in Canada. 1999;20(3):111-117

3 Ministry of Health and Long Term Care (2005). Health Effects of Second Hand Smoke.
Ontario. Retrieved from:
http://www.health.gov.on.ca/english/public/updates/archives/hu_04/tobacco/tobacco_2hand.html

4 OMA Committee on Population Health, November 1996
http://oma.org/Health/tobacco/2ndsmoke.asp
5 Towards a Healthier Workplace: A Guidebook on Tobacco Control. Health Canada. 2003

6 Ontario Campaign for Action on Tobacco. http://www.ocat.org/legalissues/tribunals.html

7 Smoking and the Bottom Line: The Costs of Smoking in the Workplace. The Conference Board
of Canada (January 1997). http://www.ocat.org/articles/body_c2a.html.