Original Article Journal of Addictions Nursing & Volume 24 & Number 2, 82Y90 & Copyright B 2013 International Nurses Society on Addictions
Employee Attitudes About Moving Toward a Smoke-Free Campus at a Veterans Affairs Hospital Sonia A. Duffy, PhD, RN, FAAN m Lee A. Ewing, MPH m Deborah E. Welsh, MS, BA m Petra S. Flanagan, PharmD m Andrea H. Waltje, RN, MS m Stacey B. Breedveld, RN, MSN m Eric W. Young, MD
Background: Although Veterans Affairs (VA) hospitals have been smoke-free inside of buildings since 1991, smoke-free campuses have not been initiated. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters. Methods: In 2008, a cross-sectional, anonymous survey was conducted with a convenience sample of employees at a Midwestern VA (N = 397). Results: Descriptive statistics showed that the vast number of employees were in support of a smoke-free campus (76%), relocating the smoking shelters (62%), and offering employees assistance to quit smoking (71%). Multivariate analyses showed that those who were nonsmokers, older, women, and higher educated were the greatest supporters of policies to support a smoke-free environment (p G .05). Write-in comments were generally favorable but also revealed employee resistance related to freedom, personal choice, and potential loss in productivity as smokers go further away from the building to smoke. Conclusions: VA hospitals have unique challenges in implementing smoke-free campus policies. Keywords: smoke-free campus, tobacco, United States Department of Veterans Affairs
Sonia A. Duffy, PhD, RN, FAAN, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, and School of Nursing and Departments of Otolaryngology and Psychiatry, University of Michigan, Ann Arbor. Lee A. Ewing, MPH, and Deborah E. Welsh, MS, BA, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan. Petra S. Flanagan, PharmD, Stacey B. Breedveld, RN, MSN, and Eric W. Young, MD, VA Ann Arbor Healthcare System, Ann Arbor, Michigan. Andrea H. Waltje, RN, MS, School of Nursing, University of Michigan, Ann Arbor. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Sonia A. Duffy, PhD, RN, FAAN, VA Ann Arbor Healthcare System, 2215 Fuller Rd. Ann Arbor, MI 48105. E-mail: [email protected] DOI: 10.1097/JAN.0b013e318292947e 82
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BACKGROUND Tobacco use is the single most preventable cause of disease, disability, and death in the United States (Centers for Disease Control and Prevention, 2008). Moreover, more than 126 million nonsmoking Americans are regularly exposed to environmental tobacco smoke causing serious disease and death in nonsmoking adults and children. Each year, an estimated 3,000 nonsmoking Americans die from lung cancer and more than 46,000 die of heart disease (Centers for Disease Control and Prevention, 2010). In 1992, the Joint Commission (JC), which accredits most United States (U.S.) hospitals, enacted a standard that prohibited indoor smoking in hospitals. By 2000, 95.6% of hospitals met the first JC smoking ban standard. Moreover, the JC found that, by February 2008, more than 45% of U.S. hospitals had adopted a smoke-free campus policy and an additional 15% of hospitals were actively pursuing the adoption of a smoke-free campus policy, which prohibits smoking anywhere on the facility premises, including outdoor areas, such as entranceways, grounds, and parking areas (Williams et al., 2009). Although smoking rates among veterans have decreased from 33% to 22.2% in recent years (Department of Veterans Affairs, V H A Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, 2006; Office of Quality and Performance, 2001), the rates of smoking among returning Operation Iraqi Freedom and Operation Enduring Freedom are high (National Institute on Drug Abuse, 2009), particularly among those with posttraumatic stress disorder (Cook, Jakupcak, Rosenheck, Fontana, & McFall, 2009; Kirby et al., 2008). Moreover, many returning veterans have traumatic brain injuries (USA Today, 2009), which will make quitting smoking more challenging. In general, 25%Y40% of veterans serviced by the Veterans Affairs (VA) Healthcare System have a mental illness, and those veterans smoke at nearly twice the rate of people without mental health disorders, they smoke more heavily (Department of Veterans Affairs, 2006), and they have lower quit rates (Institute of Medicine, 2009). Similar to the general population, these elevated psychiatric comorbidities and smoking rates among veterans contribute to elevated mortality rates from cancer, cardiovascular disease, and hepatic disorders (Lambert, LePage, & Schmitt, 2003). April/June 2013
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Although all VAs have been smoke-free inside of buildings since 1991, the implementation of smoke-free campuses is challenging as Congress passed Public Law 102-585, Section 526 in 1992, which requires the VA to provide smoking shelters for veteran patients and employees. As a result, staff, patients, and visitors congregate in these shelters to smoke (Department of Veterans Affairs, 2008). Staff and patients often share these shelters, resulting in unhealthy role-modeling behaviors. Moreover, staff, patients, and visitors also smoke on the hospital grounds, particularly around entrances to the building forcing staff, patients, and visitors to walk through smoke clouds to enter the building. Hence, patients and employees at VA hospitals with smoking shelters do not benefit as much from the smoking bans as do patients and employees in non-VA hospitals with total smoking bans. This is unfortunate as smoking rates are particularly high among veterans (both veteran patients and veteran employees), many of whom were given cigarettes by the military. In 2007, a group of nurse champions suggested making their VA hospital a smoke-free campus. The nurse champions at the VA Ann Arbor Healthcare System (VAAAHS) met with administration, engineering, police, facilities management, pharmacy, and other groups to begin discussions on making the campus smoke-free. Because there was informal feedback that staff smokers were resistant to the idea and because the team wanted to make sure they were addressing all of the issues, a survey was conducted to obtain feedback from staff. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters.
METHODS Design A cross-sectional survey was conducted with a convenience sample of staff at the VAAAHS. The independent variables were staff demographics and tobacco use histories. The dependent variables were favorability of the facility becoming tobacco-free, importance of relocating the smoking shelters, and importance of offering employee assistance to quit using tobacco. Participants were also allowed to write in comments. Human studies approval was received from the VAAAHS. Sample, Setting, and Procedures The setting was a Midwestern VA hospital. All clinical and nonclinical staff (including, but not limited to, physicians, nurses, social workers, pharmacists and personnel from administration, research, information technology, police, and housekeeping) were invited to participate in the anonymous survey. Of the 1,740 possible staff, 397 staff completed the survey (response rate = 23%). Hospital staff survey response rates can range anywhere from 5.7% to 47% (Christini, Shutt, & Byers, 2007; Clarke & McComas, 2012; Haines, Stringer, Herring, Thoma, & Harris, 2011; Hinno, Partanen, & Vehvilainen-Julkunen, 2011; Stone et al., 2006). Journal of Addictions Nursing
The survey was made available on the Ann Arbor TobaccoFree SharePoint Web site. In addition, hardcopies were distributed to departments where employees may have limited access to computers (e.g., housekeeping, canteen services). A locked box was located in the atrium where surveys could be returned. Two reminder E-mails were sent to all employees directing them to the SharePoint Web site and where they could locate hardcopies of the survey. The survey was also publicized in the facility newsletter. Measures The independent variables were demographic (age, gender, race, education) and tobacco use status questions. To allow for sufficient power in the bivariate and multivariate analyses, race was categorized as White versus all other races, education as some college or less versus at least one college degree, and smoking status as current versus former versus never. Because there are no known valid and reliable instruments to assess employee attitudes on tobacco-free environments, three questions were developed based on administrators’ concerns. The first was ‘‘Are you in favor of the VA Ann Arbor Healthcare System becoming tobacco-free?’’ using a 5-point response scale ranging from ‘‘not at all favorable’’ to ‘‘very favorable.’’ The second asked staff members how important they thought it was to relocate smoking shelters farther away from hospital entrances, using a 5-point scale ranging from ‘‘not at all important’’ to ‘‘very important.’’ The third question asked how important they felt it was for the facility to offer employees assistance to quit smoking, using the same 5-point response scale as for the second question. In addition, respondents were encouraged to provide comments about the facility becoming tobacco-free. Data Analysis Descriptive statistics were generated for each independent variable. Chi-square tests and spearman correlation coefficients were used to examine relationships among the independent variables. After dichotomizing the responses (favorable/very favorable vs. neutral/not very favorable/not at all favorable and important/very important vs. neutral/ not very important/not at all important), multivariate logistic regression models were conducted to determine the predictors of favoring becoming a smoke-free campus, importance of relocating the shelters, and importance of offering employees assistance to quit smoking. All statistical tests were considered significant at a level of p G .05, and all analyses were run using SAS V9.2 statistical software. Write-in comments were categorized by two independent reviewers who then corroborated to determine the final categories.
RESULTS Univariate Analyses: Description of the Sample Means and frequency distributions for the independent and dependent variables are shown in Table 1. About 76% (n = 301) www.journalofaddictionsnursing.com
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TABLE 1
Description of the Sample (N = 397)
Characteristic
n
%
Not at all favorable
56
14.18
Not very favorable
16
4.05
Neutral
22
5.57
Favorable
26
6.58
275
69.62
Not at all important
43
10.91
Not very important
23
5.84
Neutral
85
21.57
Important
76
19.29
167
42.39
Not at all important
32
8.10
Not very important
17
4.30
Neutral
66
16.71
Important
80
20.25
200
50.63
59
15.01
In favor of Ann Arbor VA facility becoming tobacco-free (n = 395)
Very favorable Importance of relocating smoking shelters (n = 394)
Very important Importance of offering employee assistance to quit (n = 395)
Very important Smoking status (n = 393) Current user Former user
126
32.06
Never user
208
52.93
1Y10
19
38.78
11Y20
26
53.06
4
8.16
Number of cigarettes smoked per day (n = 49)
21 or more Thinking of quitting (n = 57) Yes, within 30 days
10
17.54
Yes, within 6 months
19
33.33
Not thinking of quitting
28
49.12
26
44.83
Medications (n = 21)
19
90.48
Take-home workbook and video (n = 21)
12
57
Interested in tobacco cessation services at VA (n = 58) Interest in type of tobacco cessation services at the VA
Individual counseling (n = 20)
8
40.00
Group counseling (n = 21)
7
33.33
Follow-up telephone calls (n = 21)
8
38.10
Less than 35 years
75
19.08
35Y44 years
81
20.61
Age (n = 393)
Continues 84
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April/June 2013
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TABLE 1
Description of the Sample (N = 397), Continued
Characteristic
n
%
45Y54 years
154
39.19
55Y64 years
76
19.34
7
1.78
Male
106
27.04
Female
286
72.96
306
79.27
80
20.73
16
4.07
140
35.62
Greater than 64 years Gender (n = 392)
Race/ethnicity (n = 386) White African American/American Indian/Eskimo/Asian/Pacific Islander/ Hispanic/Other Education (n = 393) High school diploma/GED Some college 4-year college degree
80
20.36
157
39.95
Nondirect care professional (e.g., administrator, research, information technology)
95
24.30
Nondirect care technical (e.g., administrative assistant, housekeeping, dietary, clerical, police, trades)
88
22.51
Direct care health professional (e.g., physician, nurse)
84
21.48
Other direct care health professional (e.g., social worker, respiratory therapist, pharmacist, dentist, optometrist, chaplain)
69
17.65
Direct care technical worker (e.g., patient care assistant)
18
4.60
All other
37
9.46
More than 4-year college degree Position (n = 391)
Abbreviations: GED = general educational development; VA = Veterans Affairs.
of the participants responded very favorable or favorable to the campus becoming tobacco-free. Almost two-thirds (62%) felt that it was important or very important to relocate the smoking shelters. About 71% felt it was important or very important to offer employees help with quitting. Over 50% were never smokers, 32% were former smokers, and 15% were current smokers. Sixty percent of the sample was over the age of 44 years and had at least one college degree. Most of the employees surveyed were women and White. Forty percent had a high school degree and/or some college, 20% had a 4-year degree, and 40% had more than a 4-year degree. Just under half were nondirect care professionals and nonprofessional, and just under half were direct care staff, mostly professionals. Of the current smokers (n = 59), just over one third smoked 1Y10 cigarettes per day, and over half smoked 10Y20 cigarettes per day. Almost half of the smokers (51%) were thinking of quitting smoking within the next 6 months. Of those, most (90%) were interested in cessation medications. Journal of Addictions Nursing
Multivariate Analyses of Independent Variables and Three Dependent Variables Regarding Issues Related to Becoming Smoke-Free Multivariate analyses comparing staff characteristics to the aforementioned outcome variables are shown in Table 2. Because educational level was highly correlated with position, position was omitted from the final analyses, which included tobacco use, age, gender, race, and educational level. Nonsmokers and former smokers were more likely to be in favor of the facility going smoke-free than current smokers (OR = 110.43, p G .0001 and OR = 60.414, p G .0001, respectively). Likewise, they were more likely to think that it is important to relocate smoking shelters (OR = 2.673, p = .0035 and OR = 3.293, p = .0008, respectively) or to offer employee assistance to quit (OR = 2.063, p = .0318 and OR = 2.169, p = .0300, respectively) than current smokers. The 45- to 54-year age group is more likely www.journalofaddictionsnursing.com
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TABLE 2
Multivariate Analyses Depicting Associations Between Selected Staff Characteristics and Staff Opinions About Moving Toward a Smoke-Free Campus at a Veterans Affairs Hospital In Favor of the VA Ann Arbor Healthcare System Becoming Tobacco-Free?
Feel That It Is Important to Feel That It Is Important to Relocate Smoking Offer Employee Assistance Shelters? to Quit?
OR (95% CI)
OR (95% CI)
OR (95% CI)
p
p
p
60.414 (19.43, 187.845)
3.293 (1.643, 6.597)
2.169 (1.078, 4.364)
G.0001
.0008
.0300
110.433 (35.038, 348.061)
2.673 (1.383, 5.168)
2.063 (1.065 ,3.995)
.0001
.0035
.0318
35Y44 vs. G35
1.600 (0.555 , 4.609)
0.955 (0.476, 1.916)
1.087 (0.527, 2.244)
.3840
.8962
.8208
45Y54 vs. G35
2.938 (1.137 , 7.587)
1.432 (0.776, 2.641)
1.495 (0.791, 2.827)
.0260
.2504
.215
2.880 (0.985 , 8.424)
1.300 (0.650, 2.600)
2.186 (1.020, 4.687)
.0534
.4584
.0444
3.529 (1.710 ,7.281)
2.236 (1.373, 3.643)
1.451 (0.863, 2.440)
.0006
.0012
.1606
1.408 (0.589 , 3.365)
1.240 (0.713, 2.156)
1.212 (0.673, 2.182)
.4415
.4462
.5222
4-year degree vs. high school/some college
0.967 (0.385 , 2.433)
1.311 (0.705, 2.438)
1.459 (0.772, 2.756)
.9439
.3924
.2445
94-year degree vs. high school/some college
2.310 (1.047 , 5.097)
1.172 (0.707, 1.943)
1.989 (1.152, 3.435)
.0381
.5377
.0136
Tobacco use status Former user vs. current user
Never user vs. current user
Age, years
55 or older vs. G35 Gender
Race
a
b
Education
Abbreviations: VA = Veterans Affairs; CI = confidence interval; OR = odds ratio. a Female versus male. bAll others versus White.
than the under 35-year age group to be in favor of the facility going smoke-free (OR = 2.938, p = .0260). Those 55 years and older are more likely than the youngest group to think that offering employee assistance to quit is important (OR = 2.186, p = .0444). Women are more likely than men to be in favor of the facility going smoke-free (OR = 3.529, p = .0006) and more likely to think that it is important to relocate smoking shelters (OR = 2.236, p = .0012). Those with a graduate degree are more likely than those with the least amount of education to be in favor of the facility going smokefree (OR = 2.310, p = .0381) and are also more likely to think that it is important to offer employee assistance to quit (OR = 1.989, p = .0136). No other significant results were found. 86
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Write-In Comments See Table 3 for a summary of qualitative staff comments about moving toward a smoke-free campus. For the most part, comments were in favor of the hospital moving toward a smoke-free campus. I believe it is HIGH TIME that VA went smoke free... we are desperately lagging behind the private sector....and VA should also not only relocate smoking shelters (which are mandated for veteran patients by Public Law 102-585, Section 526), but do away with them completelyVthat public law needs to catch up with the timesVCongress needs to end this detriment to April/June 2013
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TABLE 3
Summary of Qualitative Staff Comments About Moving Toward a Smoke-Free Campus
Comment
n
Ban smoking near entrances
27
Enforce current policies
18
Smoking is a personal choice
16
Move or improve shelter
10
Going smoke-free will decrease productivity (staff will leave grounds to smoke and take more time away)
7
Include patients in the ban
6
Why target smoking and not obesity
6
Change the law (for shelters)
5
All or none (unfair if ban is just for employees)
5
Offer employees support
4
Don’t help employees
3
Veteran employees should be able to smoke
3
Police smoke
3
Employees will smoke in their cars/Let employees smoke in cars
3
Patients should be allowed to smoke, but not staff
2
Employees smell like smoke
2
Offer incentives for nonsmokers
2
There are other more important priorities (e.g., parking)
2
Assist patients to quit smoking
2
Biased survey (decision has already been made)
2
Assist volunteers and visitors
1
VA going smoke-free is a role model for veterans
1
Increase signage
1
Costs too much to treat smokers
1
Include visitors in ban
1
Abbreviation: VA = Veterans Affairs.
public health, not enable it! We are a health care facility for heaven’s sake! The most common comment was related to smoking at entrances to the hospital, which also related to the fifth most common comment about moving the smoking shelter, which is currently located near an employee entrance. It would be nice if the smoking shelter was not located at an entrance so that all of us are not exposed to cigarette smoke when we walk into the hospital. The second most common comments were related to the need to enforce current policies. Regardless of the big no smoking sign in the front of the hospital, the patients seem to disregard that sign and continue to smoke in the area which causes me Journal of Addictions Nursing
to walk in the middle of the street in order to avoid the smoke. There is no consideration being shown. The third most common group of comments was related to ‘‘freedom’’ and smoking being a personal choice particularly by Veteran employees. If someone wants to smoke, it is THEIR business and not the organization’s. It smacks of big-brotherness to me. And I have never smoked. Americans should be free to make their own choices about legal things that are bad for their health. Freedom is not always about making the right decision but about making your own decisions. Ino amount of reason will slow the stampede of righteousness that is after all behind this rather silly undertaking. www.journalofaddictionsnursing.com
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It [smoking] is not an illegal activity. That is not fair for the employees, since the majority of the employees are veterans themselves. They were veterans before they were employees. That is a slap in their face to say they were employees first. As an employee and a Veteran, I feel there are more important issues than smoking. There were also several comments that made analogies between regulating smoking and regulating food choices. What is next? BMI’s of 30 or less or food is selected for us? Will a weight loss program be next, is there going to be cafeteria police telling junk food addicts where and when they can let their caged tiger loose? If you are going to discriminate against the minority group of addicted smokers for ‘health reasons’ you also need to get rid of all vending machines for the obese as well due to just as important health issue and give fines to them as well for their addiction. And since we want to promote good health, why not eliminate all the junk food, and pop machines. As well as that unhealthy food they serve in the canteen? The last time I looked, obesity kills more people than smoking. I am not against creating a healthy work environment, but let’s do it across the board. Comments were made about the loss of productivity as employees would now have to leave the grounds to smoke. I believe that they should smoke further away from entry ways, but do not make them go all the way across the street. A 20-minute break as opposed to a 5-minute break could add up to lost production hours. Forcing our smoking employees to walk out to city sidewalks or streets to smoke will only delay their return to their work stations. Will not allow extra time for going farther to smoke. Corrective action will become a frequent thing. Attendance issues become a very ‘grey’ areaVwith every abuser fighting the system. Although most of the comments were positive in regards to providing assistance to employees who smoke, there were some comments in disfavor of the policy. Don’t VA employees have health insurance to cover their own assistance? I used to smoke, but can we reward the people at the VA trying to stay healthy rather than cradle those who choose not to? 88
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DISCUSSION The write-in comments show the polarization among VA employees on this highly emotionally charged issue of taking the VA to a smoke-free campus. There is concern about maintaining personal rights to smoke, particularly among veteran employees who may feel that smoking is a personal freedom that they served and fought to preserve. On the other hand, there is also a fair amount of concern of the rights of nonsmokers to enjoy a smoke-free environment. In fact, the quantitative data as well as many of the qualitative comments reveal that most staff are in favor of a smoke-free campus. Studies have shown that anticipated resistance to smoke-free policies is much greater than actual resistance, and actual costs of implementation is 10%Y50% of the expected cost (El-Guebaly, Cathcart, Currie, Brown, & Gloster, 2002). Five years after implementation, Martinez, Garcia, Mendez, Peris, and Fernandez (2008) found a significant decrease in the staff perception of exposure to environmental tobacco smoke, and overall staff compliance with the policy increased over time. Many hospitals are adopting smoke-free campus policies out of concern for patient, employee, and visitor health and safety (Sheffer, Stitzer, & Wheeler, 2009). Hospitals can promote a healthy environment via smoking control policies such as removing smoking shelters from hospital premises and moving smoking shelters away from hospital entrances. There was substantial support by the participants of this study for relocating the smoking shelters and enforcing current policies related to smoking on hospital grounds. Moreover, there was substantial support by the participants to offer employees assistance to quit. Hospitals can promote a healthy environment by providing smoking cessation classes and nicotine replacement therapy to patients, employees, and visitors (Department of Veterans Affairs, 2010a). Although most VAs have offered behavioral counseling to employees who smoke, a recent 2010 VA directive now makes it possible to offer free, over-the-counter nicotine replacement therapy to employees who smoke (Department of Veterans Affairs, 2010b). Smoke-free policies can significantly reduce staff smoking (Lin, Stahl, Ikle, & Grannis, 2006; Longo, Johnson, Kruse, Brownson, & Hewett, 2001; Martinez et al., 2008; Wheeler et al., 2007), with the greatest impact on those individuals with the highest smoking rates (Farrelly, Evans, & Sfekas, 1999). Even outside of the hospital setting, smoking bans have helped employees quit smoking (Farrelly et al., 1999; Longo et al., 2001). Smoking bans appear to increase the efficacy of treatments aimed at smoking cessation or harm reduction (Grassi, Enea, Ferketich, Lu, & Nencini, 2009), which serves as additional support for the benefit of their implementation. However, the impact of the policy is lessened when employees are given designated smoking areas (Farrelly et al., 1999). Interestingly, it was the nonsmokers that were in favor of offering employees cessation services, whereas the smokers themselves were less interested in these services. This is consistent with the literature as it suggests that it is also the April/June 2013
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nonsmokers who strongly agreed that cigarette smoke represents a major risk to health (O’Donovan, 2009). Just under one half of the smokers said they were thinking of quitting in the next 30 or 60 days. Of those thinking of quitting, less than one third were interested in receiving cessation services from the VA. The most common treatment preferred was medications. Whereas the quantitative data supported offering smokers assistance with smoking, the write-in comments suggested that some thought that smokers should not be rewarded and perhaps nonsmokers ought to be rewarded. Moreover, nonsmokers were concerned that, if employees were no longer allowed to smoke on the premises, the productivity would decrease as smokers would leave the grounds to smoke. The analogies of restricting smoking to restricting food choices were interesting as they both supported and refuted this notion. Some suggested that, if smokers were restricted, it would only be fair to restrict those with food addictions as well. Others actually favored restricting food choice and the types of foods available at the VA. The age of this sample was somewhat older with over 60% greater than the age of 44 years. Although research suggests that younger age is related to greater support of smoking bans (Shahab & West, 2010), it is also related to higher smoking rates and less success with quitting (Bauld, Bell, McCullough, Richardson, & Greaves, 2010). In this study, it was in fact the older smokers that were in more support of smoking bans. Perhaps, because some of those employees in our study who were older were already experiencing consequences of smoking, they were more supportive of these policies. Most of the sample was woman, and of these women, many were likely to be nurses who may have been more in favor because they care for veterans with smoking-related comorbidities. These findings underline the notion that nonsmoking policies are generally accepted by nursing staff (Lin et al., 2006; Martinez et al., 2008; Sheffer et al., 2009; Wheeler et al., 2007; Wye et al., 2010) but are not effective in motivating smokers to stop unless additional support is given (Bloor, Meeson, & Crome, 2006). The sample was largely educated with most having at least some college or more. Consistent with the literature, those who were more educated were in favor of a smoke-free environment (Ferketich et al., 2010). Limitations This was a cross-sectional survey, which did not take into account changes in attitudes over time. The response rate was relatively low (23%), which may be because of the large number of surveys VA employees are asked to take in the face of competing work demands. Thus, the study may not be generalizable to employees who did not answer the survey, employees at other VA hospitals in different geographical regions, and employees in non-VA hospitals. On the other hand, the 23% of employees who did take the time to fill out the survey are likely to be those who have strong feelings on either side of this issue. Despite the low response rate, nondirect care personnel were well represented by Journal of Addictions Nursing
both professionals and nonprofessionals, whereas direct care personnel were overrepresented by professional staff. Nonetheless, position did not predict attitudes about the smoke-free policy. Conclusion Quantitative data suggest that most employees at this Midwestern VA who participated in this study supported enforcing a smoke-free campus, relocating VA smoking shelters, and offering employees assistance to quit. Yet, the write-in comments elucidate some of the unique challenges that VA hospitals face including the freedom and rights of veteran employees to smoke, productivity issues if staff have to leave the grounds to smoke, and equating smoking restrictions to restricting food choices. Keeping in mind these concerns, the VA needs to proceed with instituting policies that, within the confines of the law, reduce smoking on VA campuses because smoke-free campuses may reduce smoking rates among both patients and staff. Acknowledgments: This study was supported by the Department of Veterans Affairs (SDP 06-003).
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Department of Veterans Affairs, V H A Office of the Assistant Deputy Under Secretary for Health for Policy and Planning. (2006). 2005 survey of veteran enrollees’ health and reliance upon VA. Washington, DC: Veterans Health Administration. El-Guebaly, N., Cathcart, J., Currie, S., Brown, D., & Gloster, S. (2002). Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatric Services, 53(12), 1617Y1622. Farrelly, M. C., Evans, W. N., & Sfekas, A. E. S. (1999). The impact of workplace smoking bans: Results from a national survey. Tobacco Control, 8(3), 272Y277. Ferketich, A. K., Liber, A., Pennell, M., Nealy, D., Hammer, J., & Berman, M. (2010). Clean indoor air ordinance coverage in the Appalachian Region of the United States. American Journal of Public Health, 100(7), 1313Y1318. Grassi, M. C., Enea, D., Ferketich, A. K., Lu, B., & Nencini, P. (2009). A smoking ban in public places increases the efficacy of bupropion and counseling on cessation outcomes at 1 year. Nicotine & Tobacco Research, 11(9), 1114Y1121. Haines, T., Stringer, B., Herring, J., Thoma, A., & Harris, K. A. (2011). Surgeons’ and residents’ double-gloving practices at 2 teaching hospitals in Ontario. Canadian Journal of Surgery, 54(2), 95Y100. Hinno, S., Partanen, P., & Vehvilainen-Julkunen, K. (2011). Nursing activities, nurse staffing and adverse patient outcomes as perceived by hospital nurses. Journal of Clinical Nursing, 21(11Y12), 1584Y1593. Institute of Medicine. (2009). Combating tobacco in military and veteran populations. Retrieved from http://www.iom.edu/~/media/ Files/Repor t%20Files/2009/Militar ySmokingCessation/ Combating%20Tobacco%20Military%20for%20web.pdf Kirby, A. C., Hertzberg, B. P., Collie, C. F., Yeatts, B., Dennis, M. F., McDonald, S. D., I Beckham, J. C. (2008). Smoking in helpseeking veterans with PTSD returning from Afghanistan and Iraq. Addictive Behaviors, 33(11), 1448Y1453. Lambert, M. T., LePage, J. P., & Schmitt, A. L. (2003). Five-year outcomes following psychiatric consultation to a tertiary care emergency room. American Journal of Psychiatry, 160(7), 1350Y1353. Lin, D., Stahl, D. C., Ikle, D., & Grannis, F. W. (2006). Employee attitudes and smoking behavior at the City of Hope National Medical Center smoke-free campus. Journal of the National Comprehensive Cancer Network, 4(6), 535Y542.
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Longo, D. R., Johnson, J. C., Kruse, R. L., Brownson, R. C., & Hewett, J. E. (2001). A prospective investigation of the impact of smoking bans on tobacco cessation and relapse. Tobacco Control, 10(3), 267Y272. Martinez, C., Garcia, M., Mendez, E., Peris, M., & Fernandez, E. (2008). Barriers and challenges for tobacco control in a smoke-free hospital. Cancer Nursing, 31(2), 88Y94. National Institute on Drug Abuse. (2009). Substance abuse among the military, veterans, and their families. Retrieved from http://www .nida.nih.gov/tib/vet.html O’Donovan, G. (2009). Smoking prevalence among qualified nurses in the Republic of Ireland and their role in smoking cessation. International Nursing Review, 56(2), 230Y236. Office of Quality and Performance. (2001). Health behaviors of veterans in the VHA: Tobacco use. 1999 large health survey of enrollees. Washington, DC: Veterans Health Administration. Shahab, L., & West, R. (2010). Public support in England for a total ban on the sale of tobacco products. Tobacco Control, 19(2), 143Y147. Sheffer, C., Stitzer, M., & Wheeler, J. G. (2009). Smoke-free medical facility campus legislation: Support, Resistance, difficulties and cost. International Journal of Environmental Research and Public Health, 6(1), 246Y258. Stone, P. W., Du, Y., Cowell, R., Amsterdam, N., Helfrich, T. A., Linn, R. W., I Mojica, L. A. (2006). Comparison of nurse, system and quality patient care outcomes in 8-hour and 12-hour shifts. Medical Care, 44(12), 1099Y1106. USAToday. (2009). 360,000 veterans may have brain injuries. Retrieved from http://www.usatoday.com/news/military/2009-03-04-braininjuries_N.htm Wheeler, J. G., Pulley, L., Felix, H. C., Bursac, Z., Siddiqui, N. J., Stewart, M. K., I Gauss, C. H. (2007). Impact of a smoke-free hospital campus policy on employee and consumer behavior. Public Health Reports, 122, 744Y752. Williams, S. C., Hafner, J. M., Morton, D. J., Holm, A. L., Milberger, S. M., Koss, R. G., & Loeb, J. M. (2009). The adoption of smoke-free hospital campuses in the United States. Tobacco Control, 18(6), 451Y458. Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V., I Clancy, R. (2010). Total smoking bans in psychiatric inpatient services: A survey of perceived benefits, barriers and support among staff. BMC Public Health, 10, 372.
April/June 2013
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Employee Attitudes About Moving Toward a Smoke-Free Campus at a Veterans Affairs Hospital Sonia A. Duffy, PhD, RN, FAAN m Lee A. Ewing, MPH m Deborah E. Welsh, MS, BA m Petra S. Flanagan, PharmD m Andrea H. Waltje, RN, MS m Stacey B. Breedveld, RN, MSN m Eric W. Young, MD
Background: Although Veterans Affairs (VA) hospitals have been smoke-free inside of buildings since 1991, smoke-free campuses have not been initiated. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters. Methods: In 2008, a cross-sectional, anonymous survey was conducted with a convenience sample of employees at a Midwestern VA (N = 397). Results: Descriptive statistics showed that the vast number of employees were in support of a smoke-free campus (76%), relocating the smoking shelters (62%), and offering employees assistance to quit smoking (71%). Multivariate analyses showed that those who were nonsmokers, older, women, and higher educated were the greatest supporters of policies to support a smoke-free environment (p G .05). Write-in comments were generally favorable but also revealed employee resistance related to freedom, personal choice, and potential loss in productivity as smokers go further away from the building to smoke. Conclusions: VA hospitals have unique challenges in implementing smoke-free campus policies. Keywords: smoke-free campus, tobacco, United States Department of Veterans Affairs
Sonia A. Duffy, PhD, RN, FAAN, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, and School of Nursing and Departments of Otolaryngology and Psychiatry, University of Michigan, Ann Arbor. Lee A. Ewing, MPH, and Deborah E. Welsh, MS, BA, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan. Petra S. Flanagan, PharmD, Stacey B. Breedveld, RN, MSN, and Eric W. Young, MD, VA Ann Arbor Healthcare System, Ann Arbor, Michigan. Andrea H. Waltje, RN, MS, School of Nursing, University of Michigan, Ann Arbor. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Sonia A. Duffy, PhD, RN, FAAN, VA Ann Arbor Healthcare System, 2215 Fuller Rd. Ann Arbor, MI 48105. E-mail: [email protected] DOI: 10.1097/JAN.0b013e318292947e 82
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BACKGROUND Tobacco use is the single most preventable cause of disease, disability, and death in the United States (Centers for Disease Control and Prevention, 2008). Moreover, more than 126 million nonsmoking Americans are regularly exposed to environmental tobacco smoke causing serious disease and death in nonsmoking adults and children. Each year, an estimated 3,000 nonsmoking Americans die from lung cancer and more than 46,000 die of heart disease (Centers for Disease Control and Prevention, 2010). In 1992, the Joint Commission (JC), which accredits most United States (U.S.) hospitals, enacted a standard that prohibited indoor smoking in hospitals. By 2000, 95.6% of hospitals met the first JC smoking ban standard. Moreover, the JC found that, by February 2008, more than 45% of U.S. hospitals had adopted a smoke-free campus policy and an additional 15% of hospitals were actively pursuing the adoption of a smoke-free campus policy, which prohibits smoking anywhere on the facility premises, including outdoor areas, such as entranceways, grounds, and parking areas (Williams et al., 2009). Although smoking rates among veterans have decreased from 33% to 22.2% in recent years (Department of Veterans Affairs, V H A Office of the Assistant Deputy Under Secretary for Health for Policy and Planning, 2006; Office of Quality and Performance, 2001), the rates of smoking among returning Operation Iraqi Freedom and Operation Enduring Freedom are high (National Institute on Drug Abuse, 2009), particularly among those with posttraumatic stress disorder (Cook, Jakupcak, Rosenheck, Fontana, & McFall, 2009; Kirby et al., 2008). Moreover, many returning veterans have traumatic brain injuries (USA Today, 2009), which will make quitting smoking more challenging. In general, 25%Y40% of veterans serviced by the Veterans Affairs (VA) Healthcare System have a mental illness, and those veterans smoke at nearly twice the rate of people without mental health disorders, they smoke more heavily (Department of Veterans Affairs, 2006), and they have lower quit rates (Institute of Medicine, 2009). Similar to the general population, these elevated psychiatric comorbidities and smoking rates among veterans contribute to elevated mortality rates from cancer, cardiovascular disease, and hepatic disorders (Lambert, LePage, & Schmitt, 2003). April/June 2013
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Although all VAs have been smoke-free inside of buildings since 1991, the implementation of smoke-free campuses is challenging as Congress passed Public Law 102-585, Section 526 in 1992, which requires the VA to provide smoking shelters for veteran patients and employees. As a result, staff, patients, and visitors congregate in these shelters to smoke (Department of Veterans Affairs, 2008). Staff and patients often share these shelters, resulting in unhealthy role-modeling behaviors. Moreover, staff, patients, and visitors also smoke on the hospital grounds, particularly around entrances to the building forcing staff, patients, and visitors to walk through smoke clouds to enter the building. Hence, patients and employees at VA hospitals with smoking shelters do not benefit as much from the smoking bans as do patients and employees in non-VA hospitals with total smoking bans. This is unfortunate as smoking rates are particularly high among veterans (both veteran patients and veteran employees), many of whom were given cigarettes by the military. In 2007, a group of nurse champions suggested making their VA hospital a smoke-free campus. The nurse champions at the VA Ann Arbor Healthcare System (VAAAHS) met with administration, engineering, police, facilities management, pharmacy, and other groups to begin discussions on making the campus smoke-free. Because there was informal feedback that staff smokers were resistant to the idea and because the team wanted to make sure they were addressing all of the issues, a survey was conducted to obtain feedback from staff. The purpose of this article is to describe staff attitudes regarding making the VA hospital a smoke-free campus except for the mandated smoking shelters.
METHODS Design A cross-sectional survey was conducted with a convenience sample of staff at the VAAAHS. The independent variables were staff demographics and tobacco use histories. The dependent variables were favorability of the facility becoming tobacco-free, importance of relocating the smoking shelters, and importance of offering employee assistance to quit using tobacco. Participants were also allowed to write in comments. Human studies approval was received from the VAAAHS. Sample, Setting, and Procedures The setting was a Midwestern VA hospital. All clinical and nonclinical staff (including, but not limited to, physicians, nurses, social workers, pharmacists and personnel from administration, research, information technology, police, and housekeeping) were invited to participate in the anonymous survey. Of the 1,740 possible staff, 397 staff completed the survey (response rate = 23%). Hospital staff survey response rates can range anywhere from 5.7% to 47% (Christini, Shutt, & Byers, 2007; Clarke & McComas, 2012; Haines, Stringer, Herring, Thoma, & Harris, 2011; Hinno, Partanen, & Vehvilainen-Julkunen, 2011; Stone et al., 2006). Journal of Addictions Nursing
The survey was made available on the Ann Arbor TobaccoFree SharePoint Web site. In addition, hardcopies were distributed to departments where employees may have limited access to computers (e.g., housekeeping, canteen services). A locked box was located in the atrium where surveys could be returned. Two reminder E-mails were sent to all employees directing them to the SharePoint Web site and where they could locate hardcopies of the survey. The survey was also publicized in the facility newsletter. Measures The independent variables were demographic (age, gender, race, education) and tobacco use status questions. To allow for sufficient power in the bivariate and multivariate analyses, race was categorized as White versus all other races, education as some college or less versus at least one college degree, and smoking status as current versus former versus never. Because there are no known valid and reliable instruments to assess employee attitudes on tobacco-free environments, three questions were developed based on administrators’ concerns. The first was ‘‘Are you in favor of the VA Ann Arbor Healthcare System becoming tobacco-free?’’ using a 5-point response scale ranging from ‘‘not at all favorable’’ to ‘‘very favorable.’’ The second asked staff members how important they thought it was to relocate smoking shelters farther away from hospital entrances, using a 5-point scale ranging from ‘‘not at all important’’ to ‘‘very important.’’ The third question asked how important they felt it was for the facility to offer employees assistance to quit smoking, using the same 5-point response scale as for the second question. In addition, respondents were encouraged to provide comments about the facility becoming tobacco-free. Data Analysis Descriptive statistics were generated for each independent variable. Chi-square tests and spearman correlation coefficients were used to examine relationships among the independent variables. After dichotomizing the responses (favorable/very favorable vs. neutral/not very favorable/not at all favorable and important/very important vs. neutral/ not very important/not at all important), multivariate logistic regression models were conducted to determine the predictors of favoring becoming a smoke-free campus, importance of relocating the shelters, and importance of offering employees assistance to quit smoking. All statistical tests were considered significant at a level of p G .05, and all analyses were run using SAS V9.2 statistical software. Write-in comments were categorized by two independent reviewers who then corroborated to determine the final categories.
RESULTS Univariate Analyses: Description of the Sample Means and frequency distributions for the independent and dependent variables are shown in Table 1. About 76% (n = 301) www.journalofaddictionsnursing.com
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TABLE 1
Description of the Sample (N = 397)
Characteristic
n
%
Not at all favorable
56
14.18
Not very favorable
16
4.05
Neutral
22
5.57
Favorable
26
6.58
275
69.62
Not at all important
43
10.91
Not very important
23
5.84
Neutral
85
21.57
Important
76
19.29
167
42.39
Not at all important
32
8.10
Not very important
17
4.30
Neutral
66
16.71
Important
80
20.25
200
50.63
59
15.01
In favor of Ann Arbor VA facility becoming tobacco-free (n = 395)
Very favorable Importance of relocating smoking shelters (n = 394)
Very important Importance of offering employee assistance to quit (n = 395)
Very important Smoking status (n = 393) Current user Former user
126
32.06
Never user
208
52.93
1Y10
19
38.78
11Y20
26
53.06
4
8.16
Number of cigarettes smoked per day (n = 49)
21 or more Thinking of quitting (n = 57) Yes, within 30 days
10
17.54
Yes, within 6 months
19
33.33
Not thinking of quitting
28
49.12
26
44.83
Medications (n = 21)
19
90.48
Take-home workbook and video (n = 21)
12
57
Interested in tobacco cessation services at VA (n = 58) Interest in type of tobacco cessation services at the VA
Individual counseling (n = 20)
8
40.00
Group counseling (n = 21)
7
33.33
Follow-up telephone calls (n = 21)
8
38.10
Less than 35 years
75
19.08
35Y44 years
81
20.61
Age (n = 393)
Continues 84
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April/June 2013
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TABLE 1
Description of the Sample (N = 397), Continued
Characteristic
n
%
45Y54 years
154
39.19
55Y64 years
76
19.34
7
1.78
Male
106
27.04
Female
286
72.96
306
79.27
80
20.73
16
4.07
140
35.62
Greater than 64 years Gender (n = 392)
Race/ethnicity (n = 386) White African American/American Indian/Eskimo/Asian/Pacific Islander/ Hispanic/Other Education (n = 393) High school diploma/GED Some college 4-year college degree
80
20.36
157
39.95
Nondirect care professional (e.g., administrator, research, information technology)
95
24.30
Nondirect care technical (e.g., administrative assistant, housekeeping, dietary, clerical, police, trades)
88
22.51
Direct care health professional (e.g., physician, nurse)
84
21.48
Other direct care health professional (e.g., social worker, respiratory therapist, pharmacist, dentist, optometrist, chaplain)
69
17.65
Direct care technical worker (e.g., patient care assistant)
18
4.60
All other
37
9.46
More than 4-year college degree Position (n = 391)
Abbreviations: GED = general educational development; VA = Veterans Affairs.
of the participants responded very favorable or favorable to the campus becoming tobacco-free. Almost two-thirds (62%) felt that it was important or very important to relocate the smoking shelters. About 71% felt it was important or very important to offer employees help with quitting. Over 50% were never smokers, 32% were former smokers, and 15% were current smokers. Sixty percent of the sample was over the age of 44 years and had at least one college degree. Most of the employees surveyed were women and White. Forty percent had a high school degree and/or some college, 20% had a 4-year degree, and 40% had more than a 4-year degree. Just under half were nondirect care professionals and nonprofessional, and just under half were direct care staff, mostly professionals. Of the current smokers (n = 59), just over one third smoked 1Y10 cigarettes per day, and over half smoked 10Y20 cigarettes per day. Almost half of the smokers (51%) were thinking of quitting smoking within the next 6 months. Of those, most (90%) were interested in cessation medications. Journal of Addictions Nursing
Multivariate Analyses of Independent Variables and Three Dependent Variables Regarding Issues Related to Becoming Smoke-Free Multivariate analyses comparing staff characteristics to the aforementioned outcome variables are shown in Table 2. Because educational level was highly correlated with position, position was omitted from the final analyses, which included tobacco use, age, gender, race, and educational level. Nonsmokers and former smokers were more likely to be in favor of the facility going smoke-free than current smokers (OR = 110.43, p G .0001 and OR = 60.414, p G .0001, respectively). Likewise, they were more likely to think that it is important to relocate smoking shelters (OR = 2.673, p = .0035 and OR = 3.293, p = .0008, respectively) or to offer employee assistance to quit (OR = 2.063, p = .0318 and OR = 2.169, p = .0300, respectively) than current smokers. The 45- to 54-year age group is more likely www.journalofaddictionsnursing.com
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TABLE 2
Multivariate Analyses Depicting Associations Between Selected Staff Characteristics and Staff Opinions About Moving Toward a Smoke-Free Campus at a Veterans Affairs Hospital In Favor of the VA Ann Arbor Healthcare System Becoming Tobacco-Free?
Feel That It Is Important to Feel That It Is Important to Relocate Smoking Offer Employee Assistance Shelters? to Quit?
OR (95% CI)
OR (95% CI)
OR (95% CI)
p
p
p
60.414 (19.43, 187.845)
3.293 (1.643, 6.597)
2.169 (1.078, 4.364)
G.0001
.0008
.0300
110.433 (35.038, 348.061)
2.673 (1.383, 5.168)
2.063 (1.065 ,3.995)
.0001
.0035
.0318
35Y44 vs. G35
1.600 (0.555 , 4.609)
0.955 (0.476, 1.916)
1.087 (0.527, 2.244)
.3840
.8962
.8208
45Y54 vs. G35
2.938 (1.137 , 7.587)
1.432 (0.776, 2.641)
1.495 (0.791, 2.827)
.0260
.2504
.215
2.880 (0.985 , 8.424)
1.300 (0.650, 2.600)
2.186 (1.020, 4.687)
.0534
.4584
.0444
3.529 (1.710 ,7.281)
2.236 (1.373, 3.643)
1.451 (0.863, 2.440)
.0006
.0012
.1606
1.408 (0.589 , 3.365)
1.240 (0.713, 2.156)
1.212 (0.673, 2.182)
.4415
.4462
.5222
4-year degree vs. high school/some college
0.967 (0.385 , 2.433)
1.311 (0.705, 2.438)
1.459 (0.772, 2.756)
.9439
.3924
.2445
94-year degree vs. high school/some college
2.310 (1.047 , 5.097)
1.172 (0.707, 1.943)
1.989 (1.152, 3.435)
.0381
.5377
.0136
Tobacco use status Former user vs. current user
Never user vs. current user
Age, years
55 or older vs. G35 Gender
Race
a
b
Education
Abbreviations: VA = Veterans Affairs; CI = confidence interval; OR = odds ratio. a Female versus male. bAll others versus White.
than the under 35-year age group to be in favor of the facility going smoke-free (OR = 2.938, p = .0260). Those 55 years and older are more likely than the youngest group to think that offering employee assistance to quit is important (OR = 2.186, p = .0444). Women are more likely than men to be in favor of the facility going smoke-free (OR = 3.529, p = .0006) and more likely to think that it is important to relocate smoking shelters (OR = 2.236, p = .0012). Those with a graduate degree are more likely than those with the least amount of education to be in favor of the facility going smokefree (OR = 2.310, p = .0381) and are also more likely to think that it is important to offer employee assistance to quit (OR = 1.989, p = .0136). No other significant results were found. 86
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Write-In Comments See Table 3 for a summary of qualitative staff comments about moving toward a smoke-free campus. For the most part, comments were in favor of the hospital moving toward a smoke-free campus. I believe it is HIGH TIME that VA went smoke free... we are desperately lagging behind the private sector....and VA should also not only relocate smoking shelters (which are mandated for veteran patients by Public Law 102-585, Section 526), but do away with them completelyVthat public law needs to catch up with the timesVCongress needs to end this detriment to April/June 2013
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TABLE 3
Summary of Qualitative Staff Comments About Moving Toward a Smoke-Free Campus
Comment
n
Ban smoking near entrances
27
Enforce current policies
18
Smoking is a personal choice
16
Move or improve shelter
10
Going smoke-free will decrease productivity (staff will leave grounds to smoke and take more time away)
7
Include patients in the ban
6
Why target smoking and not obesity
6
Change the law (for shelters)
5
All or none (unfair if ban is just for employees)
5
Offer employees support
4
Don’t help employees
3
Veteran employees should be able to smoke
3
Police smoke
3
Employees will smoke in their cars/Let employees smoke in cars
3
Patients should be allowed to smoke, but not staff
2
Employees smell like smoke
2
Offer incentives for nonsmokers
2
There are other more important priorities (e.g., parking)
2
Assist patients to quit smoking
2
Biased survey (decision has already been made)
2
Assist volunteers and visitors
1
VA going smoke-free is a role model for veterans
1
Increase signage
1
Costs too much to treat smokers
1
Include visitors in ban
1
Abbreviation: VA = Veterans Affairs.
public health, not enable it! We are a health care facility for heaven’s sake! The most common comment was related to smoking at entrances to the hospital, which also related to the fifth most common comment about moving the smoking shelter, which is currently located near an employee entrance. It would be nice if the smoking shelter was not located at an entrance so that all of us are not exposed to cigarette smoke when we walk into the hospital. The second most common comments were related to the need to enforce current policies. Regardless of the big no smoking sign in the front of the hospital, the patients seem to disregard that sign and continue to smoke in the area which causes me Journal of Addictions Nursing
to walk in the middle of the street in order to avoid the smoke. There is no consideration being shown. The third most common group of comments was related to ‘‘freedom’’ and smoking being a personal choice particularly by Veteran employees. If someone wants to smoke, it is THEIR business and not the organization’s. It smacks of big-brotherness to me. And I have never smoked. Americans should be free to make their own choices about legal things that are bad for their health. Freedom is not always about making the right decision but about making your own decisions. Ino amount of reason will slow the stampede of righteousness that is after all behind this rather silly undertaking. www.journalofaddictionsnursing.com
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87
It [smoking] is not an illegal activity. That is not fair for the employees, since the majority of the employees are veterans themselves. They were veterans before they were employees. That is a slap in their face to say they were employees first. As an employee and a Veteran, I feel there are more important issues than smoking. There were also several comments that made analogies between regulating smoking and regulating food choices. What is next? BMI’s of 30 or less or food is selected for us? Will a weight loss program be next, is there going to be cafeteria police telling junk food addicts where and when they can let their caged tiger loose? If you are going to discriminate against the minority group of addicted smokers for ‘health reasons’ you also need to get rid of all vending machines for the obese as well due to just as important health issue and give fines to them as well for their addiction. And since we want to promote good health, why not eliminate all the junk food, and pop machines. As well as that unhealthy food they serve in the canteen? The last time I looked, obesity kills more people than smoking. I am not against creating a healthy work environment, but let’s do it across the board. Comments were made about the loss of productivity as employees would now have to leave the grounds to smoke. I believe that they should smoke further away from entry ways, but do not make them go all the way across the street. A 20-minute break as opposed to a 5-minute break could add up to lost production hours. Forcing our smoking employees to walk out to city sidewalks or streets to smoke will only delay their return to their work stations. Will not allow extra time for going farther to smoke. Corrective action will become a frequent thing. Attendance issues become a very ‘grey’ areaVwith every abuser fighting the system. Although most of the comments were positive in regards to providing assistance to employees who smoke, there were some comments in disfavor of the policy. Don’t VA employees have health insurance to cover their own assistance? I used to smoke, but can we reward the people at the VA trying to stay healthy rather than cradle those who choose not to? 88
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DISCUSSION The write-in comments show the polarization among VA employees on this highly emotionally charged issue of taking the VA to a smoke-free campus. There is concern about maintaining personal rights to smoke, particularly among veteran employees who may feel that smoking is a personal freedom that they served and fought to preserve. On the other hand, there is also a fair amount of concern of the rights of nonsmokers to enjoy a smoke-free environment. In fact, the quantitative data as well as many of the qualitative comments reveal that most staff are in favor of a smoke-free campus. Studies have shown that anticipated resistance to smoke-free policies is much greater than actual resistance, and actual costs of implementation is 10%Y50% of the expected cost (El-Guebaly, Cathcart, Currie, Brown, & Gloster, 2002). Five years after implementation, Martinez, Garcia, Mendez, Peris, and Fernandez (2008) found a significant decrease in the staff perception of exposure to environmental tobacco smoke, and overall staff compliance with the policy increased over time. Many hospitals are adopting smoke-free campus policies out of concern for patient, employee, and visitor health and safety (Sheffer, Stitzer, & Wheeler, 2009). Hospitals can promote a healthy environment via smoking control policies such as removing smoking shelters from hospital premises and moving smoking shelters away from hospital entrances. There was substantial support by the participants of this study for relocating the smoking shelters and enforcing current policies related to smoking on hospital grounds. Moreover, there was substantial support by the participants to offer employees assistance to quit. Hospitals can promote a healthy environment by providing smoking cessation classes and nicotine replacement therapy to patients, employees, and visitors (Department of Veterans Affairs, 2010a). Although most VAs have offered behavioral counseling to employees who smoke, a recent 2010 VA directive now makes it possible to offer free, over-the-counter nicotine replacement therapy to employees who smoke (Department of Veterans Affairs, 2010b). Smoke-free policies can significantly reduce staff smoking (Lin, Stahl, Ikle, & Grannis, 2006; Longo, Johnson, Kruse, Brownson, & Hewett, 2001; Martinez et al., 2008; Wheeler et al., 2007), with the greatest impact on those individuals with the highest smoking rates (Farrelly, Evans, & Sfekas, 1999). Even outside of the hospital setting, smoking bans have helped employees quit smoking (Farrelly et al., 1999; Longo et al., 2001). Smoking bans appear to increase the efficacy of treatments aimed at smoking cessation or harm reduction (Grassi, Enea, Ferketich, Lu, & Nencini, 2009), which serves as additional support for the benefit of their implementation. However, the impact of the policy is lessened when employees are given designated smoking areas (Farrelly et al., 1999). Interestingly, it was the nonsmokers that were in favor of offering employees cessation services, whereas the smokers themselves were less interested in these services. This is consistent with the literature as it suggests that it is also the April/June 2013
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nonsmokers who strongly agreed that cigarette smoke represents a major risk to health (O’Donovan, 2009). Just under one half of the smokers said they were thinking of quitting in the next 30 or 60 days. Of those thinking of quitting, less than one third were interested in receiving cessation services from the VA. The most common treatment preferred was medications. Whereas the quantitative data supported offering smokers assistance with smoking, the write-in comments suggested that some thought that smokers should not be rewarded and perhaps nonsmokers ought to be rewarded. Moreover, nonsmokers were concerned that, if employees were no longer allowed to smoke on the premises, the productivity would decrease as smokers would leave the grounds to smoke. The analogies of restricting smoking to restricting food choices were interesting as they both supported and refuted this notion. Some suggested that, if smokers were restricted, it would only be fair to restrict those with food addictions as well. Others actually favored restricting food choice and the types of foods available at the VA. The age of this sample was somewhat older with over 60% greater than the age of 44 years. Although research suggests that younger age is related to greater support of smoking bans (Shahab & West, 2010), it is also related to higher smoking rates and less success with quitting (Bauld, Bell, McCullough, Richardson, & Greaves, 2010). In this study, it was in fact the older smokers that were in more support of smoking bans. Perhaps, because some of those employees in our study who were older were already experiencing consequences of smoking, they were more supportive of these policies. Most of the sample was woman, and of these women, many were likely to be nurses who may have been more in favor because they care for veterans with smoking-related comorbidities. These findings underline the notion that nonsmoking policies are generally accepted by nursing staff (Lin et al., 2006; Martinez et al., 2008; Sheffer et al., 2009; Wheeler et al., 2007; Wye et al., 2010) but are not effective in motivating smokers to stop unless additional support is given (Bloor, Meeson, & Crome, 2006). The sample was largely educated with most having at least some college or more. Consistent with the literature, those who were more educated were in favor of a smoke-free environment (Ferketich et al., 2010). Limitations This was a cross-sectional survey, which did not take into account changes in attitudes over time. The response rate was relatively low (23%), which may be because of the large number of surveys VA employees are asked to take in the face of competing work demands. Thus, the study may not be generalizable to employees who did not answer the survey, employees at other VA hospitals in different geographical regions, and employees in non-VA hospitals. On the other hand, the 23% of employees who did take the time to fill out the survey are likely to be those who have strong feelings on either side of this issue. Despite the low response rate, nondirect care personnel were well represented by Journal of Addictions Nursing
both professionals and nonprofessionals, whereas direct care personnel were overrepresented by professional staff. Nonetheless, position did not predict attitudes about the smoke-free policy. Conclusion Quantitative data suggest that most employees at this Midwestern VA who participated in this study supported enforcing a smoke-free campus, relocating VA smoking shelters, and offering employees assistance to quit. Yet, the write-in comments elucidate some of the unique challenges that VA hospitals face including the freedom and rights of veteran employees to smoke, productivity issues if staff have to leave the grounds to smoke, and equating smoking restrictions to restricting food choices. Keeping in mind these concerns, the VA needs to proceed with instituting policies that, within the confines of the law, reduce smoking on VA campuses because smoke-free campuses may reduce smoking rates among both patients and staff. Acknowledgments: This study was supported by the Department of Veterans Affairs (SDP 06-003).
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