Capital Health, one of Canada’s largest integrated health authorities, recently closed the doors on the last of its smoking rooms. Its new policy protects all staff, patients, visitors and volunteers against exposure to secondhand smoke, and also prohibits smoking in homes while receiving care. However, it goes one step further by banning all smoking on outdoor property, including smoking within vehicles and parking areas. Perhaps the most striking achievement of all is that psychiatric and other sensitive units have been included, a sticking point still preventing full smoke-free policies in many other parts of the world.

The impetus for tobacco policy reform was multi-pronged and included compliance with civic bylaws and federal tobacco and customs acts, complaints of exposure to secondhand smoke, and fatigue in monitoring outdoor smoking areas. Legal opinions were obtained for the changed policy, and the process was carefully planned, communicated, and executed, with wide consultation and supervision by a consultant.

Concern was expressed regarding a perceived obligation requiring staff to “get patients to quit”. Health professionals recognise that permanent behaviour change requires willingness and readiness rather than policy declarations. This discord led to discussions centred on facilitating smokers to go off property rather than supporting them to abstain.

However, once the distinction between supporting involuntary abstinence (while receiving care) and cessation measures (for those wanting to quit) was clearly defined, capacity building and support requirements could be identified and implemented.

Capital Health, one of Canada’s largest health authorities, has banned all smoking on its outdoor property, as well as indoors, including psychiatric and geriatric units.

In situations of involuntary abstinence, prevention of withdrawal symptoms requires communication, respectful assessment and immediate support achievable through measures such as nicotine replacement products (NRT), and standing orders for nursing staff to initiate care in the absence of a physician.

In contrast, tobacco cessation is an ongoing process requiring interventions such as cognitive behavioural therapy, pharmacotherapy and group support. The objective of ongoing abstinence after discharge is supported by the establishment of community-based clinics and an open-label clinical trial funded by Health Canada (the health ministry), Pfizer Consumer Healthcare, and the Alberta Alcohol and Drug Abuse Commission. Management’s responsibility in the policy process was the abolition of tobacco sales on hospital property, reframing tobacco as a behavioural incentive, and supporting capacity building.

Two hundred staff members received training to enhance the capacity for treatment of tobacco dependence, and the development of tobacco reduction and cessation clinics. An additional opportunity for smoking cessation was created for staff members to quit smoking, and the interest and success have been significant.

Although the policy came into effect in October 2005, psychiatry, palliative care, geriatrics, brain injury, and tuberculosis units were granted a grace period until 1 April 2006. This extra time was considered necessary because of concerns that psychiatric patients would abscond to purchase cigarettes; tuberculosis patients could infect others by going off property to smoke; there could be an appearance of heartlessness by restricting smoking of palliative patients; cognitive impairment would make tobacco abstinence difficult; psychiatric patients would not access care because of smoking restrictions; and risk to the safety of staff members due to agitation and disorganised behaviour.

Argentina: PM ads and educational materials In Latin America, Philip Morris (PM) has sponsored a school programme “Yo tengo poder” (I have power) through a non-governmental organisation, giving information to teachers and students which it says is to prevent young people from starting to smoke. In some countries, the company is even allowed to work with the government. In Argentina, PM won an award for its work with the community. But in Bahia Blanca, on the coast to the north of Patagonia, there are few laws on tobacco control and many cigarette advertisements on the streets, with a special focus on teenagers and girls. The local government support the development of smoke-free places and it is forbidden to smoke in the hospital, but despite this, inside the hospital there are frequently huge tobacco ads from PM, and visitors arriving in the city via the main street are welcomed by a message on a large Marlboro billboard.

After the final closure, compliance appears to be optimal. There have been no reports of patients leaving against medical advice as a result of the policy, and no major disruptions experienced. Several other regions have expressed interest in duplicating the policy, and asked for input to benefit from some of the lessons learnt.