Moving Toward a100% Tobacco-Free Hospital Campus

Tobacco-Free Environment Resource GuideA Resource Guide for Northeastern Vermont Regional Hospital

August 2008

Supported by:Northeastern Vermont Regional Hospitals’

Environment of Care Committee & the Caledonia/southern Essex Tobacco Advisory

___________________________________________________________________________

August 2008

Dear Colleague:

Smoking is a health and safety hazard, both to the tobacco user and nonsmokers who are exposedto secondhand smoke, carrying very serious health risks. It is the leading cause of preventabledeath in the United States. Hospitals and health systems across the state and country are workingto encourage patients to adopt healthier tobacco-free lifestyles in order to decrease such statistics.Consequently, an increasing number of hospitals have begun to explore adopting tobacco-freecampus policies to protect their patients, employees and visitors. Such policies prohibit the use ofcigarettes and tobacco products both within the hospital’s buildings and anywhere on the hospitalcampus.

Implementing a tobacco-free campus policy is an ambitious goal requiring comprehensiveimplementation and communication strategies. However, as health care leaders, improving thehealth of patients, employees, and the community is central to our mission and well worthundertaking.

To that end, the NVRH Environment of Care Committee has partnered with theCaledonia/southern Essex Tobacco advisory to provide department managers and other staff aresource guide to assist in creating our tobacco-free hospital campus. Data from this report comesfrom reviews of the literature, relevant laws, hospital-specific smoking policies, tobaccotreatment programs, and other related guides and publications. Individual administrators fromhospitals that have adopted tobacco-free campus policies were interviewed to identify the bestpractices and issues to consider during tobacco-free policy development and implementation.

I hope that you will use this guide as a blueprint for action in promoting health and safety. Goodluck in your efforts to direct this important initiative.

Paul Bengston, NVRHPresident and CEO

Table of Contents____________________________________________________________________________

Introduction.................................................................................................................. 2

Why Implement a Tobacco-Free Campus Initiative?................................................... 3

Tobacco Effects on Health............................................................................................ 4

Benefits of a Tobacco-Free Workplace........................................................................ 6

Getting Started...............................................................................................................7

Implementation Timeline...............................................................................................8

Comprehensive Policy and Enforcement.......................................................................9

Communication Plan.......................................................................................................13

Key Talking Points..........................................................................................................14

Frequently Asked Questions............................................................................................15

Scripting/Role-Playing Exercises.....................................................................................18

Tobacco Cessation Best Practices....................................................................................20

Resources.........................................................................................................................22

References........................................................................................................................25

Introduction____________________________________________________________________________

Workplaces across Vermont and nationwide are going tobacco-free to provide clean air andprotect employees from the harmful effects of secondhand smoke. According to the AmericanCancer Society, lung cancer is the leading cause of cancer death for both men and women, withmore than 87 percent of these deaths being smoking-related. Consequently, removing smokingentirely from hospital campuses is becoming a fast-growing trend nationally, and hospital leadersare now emphasizing that tobacco use does not fit into their mission of promoting good health.

On January 1, 2009 Northeastern Vermont Regional Hospital which includes Corner Medical, St.Johnsbury Pediatrics, Physical Therapy and St. Johnsbury Family Medicine and any otherbuildings owned and operated by NVRH will become tobacco-free.

Input has been collected from around the state and organizations nationwide to create thisresource guide that provides managers and staff members with the information and resourcesnecessary to ensure the smooth implementation of this policy.

Your responsibilities include:1. Demonstrate leadership in education and implementation of this policy.2. Present this information to your staff no later than December, 2008.3. Demonstrate or practice the role-playing exercises.4. Ensure that your staff knows how to order/obtain information/resources.5. Ensure that your staff knows their responsibilities and are committed to making NVRHa tobacco-free environment.

By demonstrating your support of this initiative and using this resource guide to ensure all staffmembers feel comfortable and confident about their responsibilities, we can collectivelycommunicate NVRH commitment to provide an environment free of tobacco and second-handsmoke.

2.

WORKSITE GOALS# Provide a 100% tobacco-free hospital

campus environment.# Protect all employees from exposure

to environmental tobacco smoke.# Provide cessation support to tobacco

users who want to quit.

Why Implement a Tobacco-Free Campus Initiative?_________________________________________________________Health systems are in the business of providing health care, and as such, have a specialresponsibility to set an example for other organizations and the communities served. Themovement toward more progressive policies is beginning to gain momentum as a result ofheightened awareness surrounding tobacco issues. This effort communicates a consistent pro-health message and more importantly can improve community health and reduce tobacco-relatedhealth care costs.

COST OF SMOKING IN THE WORKPLACE_____________________________________________________________________________

While the adult smoking rate has gone down over the last 5 years, nearly 18% of Vermont adults stillsmoke. And for certain groups – like young adults and lower-income Vermonters – those figures areeven higher. Smoking puts people at risk for many diseases, can worsen chronic conditions likeasthma and heart disease, and exposes nonsmokers to secondhand smoke. The result is that nearly824 Vermonters die each year from tobacco-related diseases, which also affect the quality of theirlives, as well as their families and friends. Smoking also impacts Vermont’s businesses throughincreased costs. Based on national figures, the following estimates show some of the costs ofemployee tobacco use:

• Healthcare Costs – smokers’ healthcare costs are higher than those of nonsmokers: $2,284per year, per smoker1

• Smoking breaks – lost work time, compared to nonsmokers work time: $2,574 per year,per smoker2

• Absenteeism – smokers are absent more than nonsmokers and ex-smokers: $466 per year,per smoker3

There are other costs associated with smoking, such as secondhand smoke exposure andworkers’ compensation, but based only on the three issues above, the cost of employeetobacco use is approximately $5,324 per year, per smoker.

A pack-a-day smoker spends about $5 per day oncigarettes. That adds up to $150 per month and over$1,800 per year. For an employee making $30,000 peryear, quitting smoking is like getting a 6% pay increase.

-VT Quit Network, 2008

3.

Effects of Tobacco Use

________________________________________________________Tobacco use is the leading cause of preventable death, accounting for the deaths of more than400,000 adults in the United States each year. According to the American Cancer Society,cigarette smoking accounts for at least 30 percent of all cancer deaths. Secondhand smoke isresponsible for 3,000 lung cancer deaths each year in non-smoking adults and is the third leadingcause of preventable deaths after smoking and alcohol use. Smoking costs the United States morethan $167 billion each year in health care costs including $92 billion in mortality-relatedproductivity losses and $75.5 billion in excess medical expenditures.

TOBACCO FACTS_____________________________________________________________________________# Neonatal health care costs attributed to maternal smoking are estimated in excess of $366

million per year.# Tobacco smoke has been classified as a Group A carcinogen by the U.S. EPA, it contains

more the 4,000 chemicals, both gas and particulate matter.# Since 1999, nearly 70 percent of the U.S. workforce was covered by a smoke-free policy.

Workplace productivity was increased and absenteeism was decreased among formersmokers compared with current smokers.

# A study conducted in Helena, MT, found that the number of heart attacks fell by 40percent during a six-month period in 2002 when a comprehensive smoke-free air law wasin effect in the city.

# Secondhand smoke is responsible for 150,000 to 300,000 lower respiratory tractinfections in infants and children younger than 18 months of age.

# Each year there are an estimated 37,000 heart disease deaths in nonsmokers as a result ofsecondhand smoke.

# Secondhand smoke contributes to 7,500 to 15,000 hospital stays each year.

EFFECTS ON INPATIENTS WHO SMOKE_____________________________________________________________________________# Patients who smoked regularly before surgery had twice the rate of wound infections as

nonsmokers.# Smoking retards wound healing, whether the wound is surgical or the result of trauma or

burns.# The charges for a longer stay in the recovery room are at least 20 percent higher for

smokers than nonsmokers.# Smoking is the most common cause of pulmonary morbidity during surgery and

anesthesia.

-Nebraska Hospital Association (NHA), 2007

4.

SMOKELESS TOBACCO FACTS____________________________________________________________________________

# Smokeless tobacco includes chew tobacco and snuff. These products contain tobacco leafand a variety of additives.

# Chew tobacco is not a safe alternative to smoking. One can of snuff delivers as muchnicotine as 60 cigarettes.

# Chewing tobacco discolors teeth and promotes tooth decay that leads to tooth loss.# Studies show that 60 percent to 78 percent of spit-tobacco users have oral lesions.# Double dippers, who mix snuff and chewing tobacco, are more likely to develop

precancerous lesions than those who use only one type of spit tobacco. Long-term snuffusers have a 50 percent greater risk of developing oral cancer than non-users and spittobacco users are more likely to become cigarette smokers.

# About 8,000 people die each year as a result of chewing tobacco use.-Nebraska Hospital Association (NHA), 2007

VERMONT TOBACCO FACTS____________________________________________________________________________# In 2006, 18 percent of Vermont adults smoked.# Each year, 824 Vermonters die from smoking.# Each year, 70-130 Vermonters die from secondhand smoke & pregnancy smoking.# The annual smoking- attributable medical costs in Vermont are 233 million dollars.# 16 percent of Vermont youth, in grades 8-12 smoked in 2005.# 40% of clients with mental illness smoke.# 20% of pregnant women in Vermont smoke.

- VT Tobacco Evaluation and Review Board, 2008

100% Tobacco-Free Hospitals in Vermont

Fletcher Allen Health Care: January, 2007Brattleboro Memorial Hospital: June, 2008Rutland Regional Hospital: January, 2008North Country Hospital: January, 2007Central Vermont Medical Center: November, 2006Northwest Medical Center: May, 2007

- VT Quit Network, 2008

5.

Benefits of a Tobacco-Free Workplace_________________________________________________________

BENEFITS FOR EMPLOYEES

# A tobacco-free campus aids in the creation of a safe and healthy environment.# A carefully planned and implemented effort by administrators to address the effects of

tobacco use on employee health demonstrates that the hospital cares.# Employees who are bothered by smoke will not be exposed to it anywhere on the hospital

campus.# Employees who use tobacco appreciate a clear company policy about tobacco use at

work.

BENEFITS FOR ADMINISTRATORS

# A tobacco-free environment helps to create a safe, healthy workplace.# Direct maintenance costs are reduced when smoke, matches, and cigarette butts are

eliminated from facilities.# It may be possible to negotiate lower health, life and disability insurance coverage for

hospital employees as employee tobacco use is reduced.# The risk of fires across campus is reduced.# Administrators are relieved that a process for handling tobacco use on campus is clearly

defined.# The hospital fulfills its mission of improving the health of the community.

- Nebraska Hospital Association, 2007

6.

Getting Started__________________________________________________________________________

A tobacco-free campus policy inevitably affects hospital employees, patients, medical staff,volunteers and visitors. Even the neighboring households and businesses may be effected. To besuccessful the Environment of Care Committee in collaboration with the Caledonia/southernEssex Tobacco Advisory have developed a solid implementation plan that will make thetransition smoother for everyone involved.

Eighty-five percent of all tobacco users are addicted to the nicotine in tobacco products, such ascigarettes, snuff, chew, pipes and cigars. Many tobacco users make seven to eight attempts toquit the habit before they are successful in overcoming their addiction. Northeastern VermontRegional Hospital promises to be a place that supports this challenging process.

The Plan Takes into Consideration:# Advance notification of staff;# Policy development and enforcement;# Communication strategies; and# Ongoing cessation counseling and provision of pharmacotherapy.

The tobacco-free campus policy will take effect on January 1, 2009.

NVRH employees and family members who want to quit smoking, and participate in a smokingcessation program are eligible for FREE nicotine replacement aids through the hospital pharmacyand the VT Quit Network Tobacco Cessation Program, based on site.

Vermont’s Quit Smoking ServicesVermont offers phone, local and online support for smokers looking to quit or get moreinformation.Coaching and Support Options• Free Phone Coaching – 1-877-YES-QUIT (937-7848)• Local Quit Coaching – VT Quit Network program at your local hospital• Online Quit Smoking Service – www.VermontQuitNet.com

Nicotine Replacement Therapy Can Double the Chances ofSuccess!

7.

Implementation Time-line__________________________________________________________May

! Post announcements internally and externally of Tobacco Free Campus go live date.! Board notification. ! Plan changes in benefit coverage for tobacco cessation and support needs ! Plan series of community communication and education, monthly using various media. ! Layout brochures and handouts for availability in lobby and other public areas. ! Plan website changes ! HR begins education of potential new employees of upcoming change. ! Draft policy. Seek legal and Board input.

June-July! Seek Leadership Team input regarding policy ! Continue ongoing communication regarding Tobacco Free Campus at meeting settings,

Buzz meetings, staff meeting, leadership meetings.

August-September! Begin countdown using banners, signage, media campaigns, lawn signs. ! Provide brochures in lobby and other public places ! Prepare memo to all staff explaining hospital support to employees for smoking

cessation, including but not limited to, changes to benefit coverage for smoking cessationmedication, free nicotine replacement products, availability of cessation and supportservices, fitness room availability, dietary counseling, etc.

! Finalize policy ! Order/make all signage needed for campus

September-October! Post schedules for all support services and walk in support ! Provide managers and staff with scripting for non-compliance interactions and patients ! Presentations at community forums ! Review all benefit/support services and final policy with Board, Medical Staff, volunteers

and employees ! Provide “stress kits” which includes nicotine aids, rubber band, gum, etc.. to all

departments that can be given to employees, patients, and visitors to reduce the urge tosmoke

October-December! Organize celebration for a healthier workplace. ! Remove all smoking receptacles and put up signage. January 1, 2009! Enforcement of policy begins. -University of Michigan Health Services and

the Healthy Hospitals of NC Initiative, 2008 8.

Comprehensive Policy and Enforcement_____________________________________________________________________________Although various types of workplace smoking restrictions are possible, a tobacco-freecampus (TFC) policy is the most comprehensive option and provides the best health andsafety benefits for employees.

Policy Purpose:• Create a healthier environment for everyone who visits our campus by eliminating

second-hand smoke.• Demonstrate our commitment to improve the health of the community.• Increase hospital involvement in treating nicotine addiction.• Set an example we hope other organizations and businesses will follow.

Policy Goals & Objectives:• NVRH wishes to eliminate the use of tobacco products in the facilities occupied

by NVRH staff.• NVRH wishes to set an example as the leading healthcare delivery system in

Caledonia County that the health and well being of our patients and staff are ofutmost concern.

• NVRH wishes to continue fostering quality healthcare to all who seek medicalcare at NVRH by eliminating potential health threats, e.e., second-hand smoke,tobacco product use, etc.

• NVRH wishes to continue to educate all staff and members of the communityabout the adverse affects of nicotine addiction.

• NVRH wishes to reduce direct medical costs per smoking employee per year.Policy

1 0 0% TO B ACCO - F R E E C A M P U S P O L I C YSmoking and tobacco products are not allowed on any hospital property, grounds orin vehicles on campus. This policy applies to employees, visitors, patients, vendors andvolunteers. People who smoke will need to refrain from smoking throughout the workdayor leave company grounds to smoke or use other tobacco products.

9.

Enforcement____________________________________________________________The tobacco-free campus transition should be cast in a positive light based upon its healthpromoting merits. Enforcement should be supportive rather than punitive and conveyed assuch. TFC policies are most effective when they are accompanied by carefully plannededucation. Research demonstrates that the majority of staff accepts these policies bothbefore and after implementation, if they are well-informed and supported.

Legal IssuesHospitals have a duty to comply with federal, state and municipal law. Current accreditationguidelines provide for policy exceptions; however, accreditation guidelines are not law.Therefore, if hospital leadership does not support the exceptions, the hospital can eliminate theexceptions under the guidelines, thereby establishing a “tobacco-free campus” policy. Takingonly the Joint Commission standards into consideration, an institution that disallowed exceptioncriteria would be going “above and beyond” the minimum accreditation requirements. State lawcan add additional requirements and city ordinances may present another layer for consideration.When developing a policy that meets legal requirements, it is important to note that in specialcases, smokers have limited legal rights. For example, courts have recognized that smokers havesome contractual grounds to object to a nonsmoking policy, but only if they are members of alabor organization recognized under the National Labor Relations Act. Negotiations may benecessary prior to the implementation of a nonsmoking policy in order to avoid an unfair laborpractice charge.

Prior to ImplementationIn the weeks before the policy takes effect, management should clearly communicate tosupervisors, employees and security officials their roles in enforcing the policy. In orderfor employees to comply with policies, guidelines pertaining to disciplinary measuresmust be clearly understood and strictly enforced.

Disciplinary ProceduresSupervisors are responsible for ensuring that employees under their charge are awareof the policy and are in compliance. Supervisors are responsible for takingappropriate action to correct noncompliance.

Hospital VisitorsThe responsibility of informing visitors about the nonsmoking policy rests with all NVRHemployees and hospital volunteers. First, politely inform visitors about the policy. Then, if theproblem persists notify management and/or security regarding non-compliant visitors.

EvaluationMonitoring and evaluation is an essential part of the implementation plan and policyenforcement, as policies are not magic solutions. Monitoring assists in identifying any areasof confusion with the policy. Acceptance occurs slowly and often incrementally. To help in thetransition NVRH will continue to assess the environment to understand how the policy is beingperceived and its effectiveness. One way this will be done is by closely monitoring employee,

patient, and visitors comments.

Against Medical Advice In the event a patient threatens to leave the hospital to smoke, this should be considered anAgainst Medical Advice (AMA) event and your policy should be followed. NVRH will continueto be proactive at admission with standing nicotine replacement orders to ensure that the patientdoes not have problems with nicotine withdrawals.

Psychiatric PatientsResearch suggests that a higher rate of nicotine dependency exists among individuals withmental illnesses. Consequently, these patients are at a higher risk for smoking-relatedmortality and co-morbid diseases than the adult population as a whole. Because of thisincreased risk, hospitals providing psychiatric services including substance abuse andchemical dependency programs are encouraged to strongly consider uniform adoption ofthe policy among all services. Experience with existing tobacco-free facilities have shown thatthe fear of psychiatric patients “acting up” because of tobacco-free policies are unfounded or arenot substantive. Psychiatric units can and should implement tobacco-free policies along with therest of the facility. Staff on these units need intensive training and education in tobacco-freeenvironments, as they are sometimes on “locked units” and need to know how to address thepatient.

Family StressThe majority of smokers, no matter their level of dependence, recognize that smoking at ahospital is counterintuitive and will comply with your policy.To mitigate family stress NVRHwill provide “stress kits” that include nicotine replace products, such as gum or lozenges forvisitors who smoke.

Neighborhoods/Private PropertySeveral hospitals are on city-owned land or abut private property. In either situation,planning ahead will minimize challenges. Invite a representative from the city to participatein your planning. Including your neighbors in your communications will also help toeliminate concerns surrounding the change.

Personal VehiclesThe NVRH tobacco-free campus policy includes personal vehicles of employees and visitors.While it is not recommended to police the parking lot, if an employee is found smoking in theirvehicle the disciplinary procedure outlined in the policy should be followed. If visitors are foundsmoking in their vehicles, they should be given brochures or cards explaining the hospital policy.

PhysiciansThe involvement of physicians is critical for the success of the policy. NVRH staff will continueto seek input on pharmacotherapy standing orders and communicate the options available topatients, employees and visitors.

11.

Employees Leaving Campus on Work BreakReview human resource policies that address break time away from designated workareas and time clock procedures if staff travel off-campus during breaks.

Loss of Qualified EmployeesIn a time of workforce shortages, some hospitals worry that a tobacco-free campus policywill result in a loss of qualified employees. In most hospitals this did not occur afterthe policy was introduced. The majority of Vermont hospitals are currently smoke-free, reducingthe risk of employees leaving NVRH to work at another hospital.

- Nebraska Hospital Association, 2007

12.

Local Businesses and Organizations whohave adopted Smoke-free Policies:

EHVLyndon State CollegeNEK Human ServicesCVP

Communication Plan_____________________________________________________________________________The goal of the tobacco-free workplace policy is to provide a safe and healthful workplacefor all employees. Unfortunately, the simple message of “tobacco-free” or “smoke-free” cansometimes be misinterpreted to mean “smoker-free” or “anti-smoker.” Communicationis important to alleviate any misconceptions. Thoughtful planning and a sequencedintroduction of a new policy can help ensure the success of the policy.

The NVRH communication plan:� Clearly explains the rationale and provisions.� Reiterates the organization’s commitment to helping tobacco users who want to quit and

refer employees to additional sources of information on cessation services.� Includes distributing promotional materials and information through various channels. � Looks for opportunities to promote its pro-health message.� Promotes the new policy at least six months before it takes effect� Sends out periodic reminders in email and newsletters� Sends out a final announcement from management before the policy takes effect� Holds a news conference to announce the policy to the public� Creates a positive spin by emphasizing the policy’s benefits to employees’ health� Publicizes the expanded cessation services that are being made available� Assures all signage is in place by the start date

To ensure the greatest success with the implementation of the tobacco-free campus policy NVRHprovides a “supportive environment”. Some examples include:

Lunch-and-learn sessions Policy reference cardsScripts for approaching smokers “Frequently Asked Questions” guideTobacco treatment services “Care-Kits” for smokersWellness activities Pharmacotherapy productsSpecial kick-off events SignsStaff briefings Email to all employeesHospital web site Hospital newslettersMedia releases Flyers/brochuresNew employee orientation Payroll stuffers

Keys to a Successful Transition � Top leadership commitment � Employees are told why you are doing this� Employees have a chance to respond, vent and question� Everyone who uses tobacco products knows what cessation assistance will be� available� Tobacco users are reassured that this change does not mean that they have to quit

smoking or using other tobacco products� Managers and supervisors are educated so they can effectively communicate a consistent

message

Key Talking Points_____________________________________________________________________________The following is a list of talking points that are intended to provide a context for discussion withconstituents and stakeholders to provide a consistent message. These are typically for internaluse.

Some examples:Our mission calls us to improve the health of the individuals and communities we serve.Because of our mission, we believe that we have a responsibility to take a leadership role on thismajor health issue and promote a healthier environment by becoming tobacco-free.

As a health care organization, we are committed to the health and safety of our employees,patients, physicians, volunteers and visitors.The issue is not about whether an employee or visitorchooses to smoke; it is about WHEREthe employee or visitor smokes. This policy does not mandate individuals quit smoking or usingtobacco products; such use just needs to be off-property.

We are not taking away your choice to use tobacco products. We are asking you not to use themon the hospital campus.

This is a health issue, not a personal rights issue.

Our hospital will use coaching and support rather than strict discipline to address staff andvisitors using tobacco on hospital grounds.

Tobacco-free initiatives have the potential to improve the health of thousands, reduce health carecosts, and generally contribute to community health improvement.

In addition to improved health for everyone, other advantages of a tobacco-freeenvironment include a cleaner workplace, decreased fire risk, decreased maintenancecosts, lower medical costs and improved productivity.

“There is no safe level of exposure to secondhandsmoke. Tobacco smoke is deadly.”Dr. Richard H. Carmona,U.S. Surgeon General Report, July 2006

- Nebraska Hospital Association, 2007

14.

Frequently Asked Questions______________________________________________________________________________This information sheet of frequently asked questions is to assist managers, supervisors, and staffin providing consistent communication to all employees.

Q: What does tobacco-free campus mean?A: Effective (date), smoking and the use of tobacco products (includes but is not limited tocigarettes, cigars, chewing tobacco, snuff and pipe smoking) are not permitted by anyone on thecampus of NVRH Hospital, any NVRH Hospital owned/leased properties, or in hospitalowned/leased vehicles.

Q: Why is NVRH Hospital tobacco-free?A: As a major provider of health care in the community, we are committed to leading by exampleand creating a healthy environment for our patients, visitors, employees and volunteers who areon our campus. This initiative sets a positive example in the community.

Q: Are other hospitals becoming tobacco-free?A: Yes. This is a growing trend among hospitals nationwide to become completely tobacco-freeand eliminate designated smoking areas. In Nebraska alone, approximately 30 percent ofhospitals have already adopted smoke-free or tobacco-free campus policies. Additional hospitalsacross the state are also planning to adopt tobacco-free policies.

Q: To whom does the policy apply?A: All persons, including employees, volunteers, students, patients, visitors, vendors, contractorsand others who work in or visit hospital buildings, parking lots and grounds.

Q: Where on the campus does the tobacco-free policy apply? Is smoking allowed insidecars?A: Tobacco use is prohibited on all areas of the campus, inside and outside, including inside carsthat are parked on hospital property.

Q: Isn't smoking a personal legal right?A: We are not asking employees, visitors and patients to quit using tobacco products but torefrain from using tobacco products while visiting or working at NVRH Hospital.

Q: How will visitors and patients be notified?A: Extensive signage will be in place by December, 2008, and various other methods ofcommunication will be in place to ensure that visitors and patients are aware of the policy.

Q: Why can't we have smoking huts that are designated outdoor locations?A: Smoking and secondhand smoke are known health hazards. As a health care institution, weare committed not just to healing illness, but also to promoting wellness. Allowing smoking onour campus, even in designated areas, is not consistent with this commitment. We do not wantour patients, visitors and employees to be exposed to secondhand smoke while on our campus.

15.

Q: What kind of support is being offered to employees?A: Nicotine Replacement Therapy (NRT) and other pharmacological quit aids are being madeavailable to employees and may be obtained at no charge by registering with the NVRH TobaccoCessation Department. To assist employees who may elect to stop smoking, free smokingcessation classes are available as well. To register, call 748-7532 or 748-7304. Information on allresources for employees is contained in “Care Kits” available in each department.

Q: What kind of support is being offered to visitors while on the hospital campus?A: Visitors who wish to use tobacco must leave the hospital grounds in order to do so. “CareKits” are available for those who are experiencing stressful situations, such as a family memberundergoing surgery. Nicotine Replacement Therapy (NRT) in the form of gum or lozenge will beavailable to visitors and may be obtained for no charge at each department. (Note: “Care Kits”can have hard candy, gum, a coupon for a free soda, etc., and a card explaining the policy andavailable resources).

Q: What kind of support is provided to inpatients who smoke?A: The attending physician should assess and discuss the need for NRT or pharmacological quitaids with the patient, and if indicated, write an order for such an aid using the NicotineWithdrawal Order Form. Inpatients who smoke will receive at least one brief intervention by atrained tobacco cessation counselor to assess readiness to change their smoking behavior and begiven information about the cessation resources available to help them quit.

Q: What if the doctor writes an order for a “smoke break” for an inpatient?A: A physician’s order to allow a patient to smoke (“a smoke break”) will not be honored. TheNursing staff will follow NVRH Hospital’s Administrative Policy # xxx.

Q: How will the tobacco-free policy be enforced?A: All employees are accountable and responsible for using appropriate protocol for occasionswhen any person uses tobacco products on the hospital campus. (See script examples)

Q: What do I do if a visitor or patient becomes angry or disruptive because of the policy orbeing asked to stop using tobacco on the campus?A: Be polite and calm. Avoid confrontation. If talking to a visitor, calmly say, “I understand thatyou are upset. I am very sorry this is difficult. Please know that other staff members will likelyask you to stop using tobacco on our campus.”

Q: What is my responsibility as a manager related to the tobacco-free policy?A: Management responsibilities include:

Understand and follow the policy yourself.Discuss the policy with your employees and encourage their questions.Enforce the policy uniformly and fairly with all employees as well as medical staff,visitors, and patients.Support your employees’ efforts to inform patients, visitors, and other employees aboutthe policy, resources and options.Review suggested scripts with employees.

Be respectful of the employees who use tobacco, letting them know about the availableresources the hospital is providing (“Care Kits”, tobacco cessation programs, nicotinereplacement therapy).

Q: As a manager, what should I do if an employee leaves his or her work area for anextended period of time to smoke?A: Employees who exceed the allocated time for breaks and lunch for any reason must beaddressed by the manager or supervisor of that area. Managers are expected to enforce break- andlunch-time limits, as well as the off-unit and time clock policies. Excessive absence from theworkstation should result in the usual corrective action for the employee.

Q: What do I do if I see an employee who is violating the policy?A: Politely say, “This campus is now tobacco-free.” Be supportive and respectful. Let them knowthat you must report the violation to their manager. Any employee who refuses to comply withthe policy will face corrective action.

Q: Will our smoking policy be explained to job applicants?A: Recruiters will inform job applicants and new hires of the hospital tobacco-free campuspolicy. The policy and scripting will also be reviewed at New Employee Orientation.

- Nebraska Hospital Association, 2007- Rutland Regional Health Services, 2007

17.

Scripting/Role-Playing Exercises_____________________________________________________________________________These scripts are intended to help staff become more comfortable discussing the tobacco-freeenvironment policy with other staff, visitors, and patients in a respectful and supportivemanner. You should take time during a staff meeting to share this information with youremployees and conduct actual role-playing exercises.

Encourage employees to:• Be empathetic. The three to five minutes you spend with a person struggling with

their need for tobacco could help their craving dissipate.• Use common sense in every situation.• Remember that the encounter should be supportive, not punitive.• Share information about the hospital policy in a non-judgmental way.

“Care Kits” that provide support materials like gum, mints, a stress stick, rubber band, anda coupon for a small beverage will be available when the policy goes into effect and can beoffered to those visitors having a difficult time or undergoing a stressful situation.

OUTDOOR ENCOUNTERSIf you see a person using tobacco products on hospital property, introduce yourself and say,“Excuse me Sir/Ma’am, I just wanted to let you know that for the health and safety of ourpatients, visitors, and employees, all of our grounds and parking areas are tobacco-free. Ifyou wish to continue your tobacco use, you will have to leave the hospital grounds. Thankyou.”

Why are you making me leave hospital property?“For your health and the health of others, we are a tobacco-free campus. Many of ourpatients who come to this hospital have cancer or respiratory problems, and their health isaffected by secondhand smoke. We feel we should be providing them an environment freefrom the impact of secondhand smoke.”

Can I (staff) use tobacco in my vehicle?“The policy states no staff member is to use tobacco products in their vehicle on hospitalproperty or on company time.”

Can I (visitor) use tobacco in my vehicle?“We ask that you would respect our policy and not use tobacco products while on ourproperty.”

What are you going to do if I continue to smoke here?“Tobacco use is not permitted on the hospital property. Please extinguish your cigarette.”(Then walk away). If this behavior continues, notify Security.

18.

I have to have a cigarette! My loved one is very ill or just passed away.“I am sorry about your loved one. Is there something I can do to help? I can offer you a“Care Kit” to help you through this stressful time. Can I find someone who can assist you?”

If you are a smoker, you may choose to show more empathy because you trulyunderstand the impact of not being able to smoke.“I understand your frustration. Our tobacco-free policy has required me to make somechanges too. I'm sorry this is causing you additional stress. Although I must still ask you toextinguish and discard your cigarette, if you are interested I'd be happy to tell you about anoption that is available to support you while you are on our campus.”

SCHEDULERS & REGISTRATIONThese scripts can be used when patients call to schedule an appointment or when theyarrive at Patient Registration.“I'd like to let you know that as of January 1, 2009, NVRH Hospital is now a tobacco-freecampus. Tobacco products are not allowed on any property, grounds or parking areas. Ifduring your hospital stay you need support, a “Care Kit”and Nicotine Replacement Therapyand other quit aids are available to all patients with physician approval.”

UNIT SITUATIONSWhere am I (patient) allowed to smoke (use tobacco)?“Nowhere on our hospital grounds. We have implemented a tobacco-free campus policy asof January 1, 2009. If you feel that following this policy will be too difficult, we can discussthis with your doctor who can order a Nicotine Replacement Therapy or other quit aid tohelp you during your hospital stay. This may help the cravings.”

If appropriate, you can also add, “We also have information about smoking cessationclasses available for you if you are interested.”

Someone from the hospital took me out to use tobacco when I was here last time, whycan't I go outside now?“Since your last visit, we have become a tobacco-free environment. In an effort to promotethe health and safety of our patients, visitors and employees, we no longer permit the use oftobacco products on our property.”

Staff believes that patient is using tobacco in the bathroom.“For the health and safety of our patients and visitors, we are a tobacco-free environmentinside and outside. I can place your cigarettes in safe keeping until you are discharged. Ican also contact your physician for nicotine replacement therapy or other quit aids that mayhelp with cravings.”

The patient insists on using tobacco and wants to leave.“The use of tobacco is prohibited throughout our campus, and you will likely be approachedwhile using tobacco outside and asked to stop. Also, I will need to notify your physician thatyou left the unit to use tobacco against policy and medical advice.”

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I have heard that you can get really sick after quitting tobacco.“It sounds like you have heard different things about quitting tobacco. This is what I knowabout nicotine withdrawal: you can become irritable, become tired, begin to cough, have anincrease in your appetite, and crave tobacco. We have nicotine replacement products orother quit aids to help you control nicotine cravings.”

HOSPITAL STAFF/CO-WORKERSA co-worker tells you he or she cannot refrain from using tobacco products during the workday and is going to leave the campus to smoke.“When you choose to leave for an extended period of time to smoke, it impacts all of us,and has a negative effect on patient care. Why don't you try getting one of those “Care Kits”that are available for employees through your department manager. Nicotine ReplacementTherapy or other pharmacological aids may also work to control your cravings.”

SURGERY WAITING ROOMFamily member or visitor wants to go outside to use tobacco products while waiting for aperson in surgery.“I am sorry but our property, grounds, and parking areas are tobacco-free. If you choose toleave the campus, you may miss the opportunity to speak to the physician regarding yourloved one's condition. We can provide you with a “Care Kit” to make your visit morecomfortable. If you decide to leave the campus to smoke, we will notify you on your cellphone or pager when he/she is out of surgery.”

PHYSICIAN OFFICE“I'd like to let you know that as of January 1, 2009, NVRH Hospital and Physician Clinicsdoes not allow use of tobacco products on any properties, including buildings, grounds, orparking areas. We can provide you with a “Care Kit” to make you more comfortable whileyou are here.”

– Nebraska Hospital Association, 2007

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Tobacco Cessation Best Practices_____________________________________________________________________________According to the U.S. Surgeon General, comprehensive tobacco prevention programs aremost effective in addressing tobacco use. Comprehensive programs are those that combinecoverage for medication and counseling, as well as inclusion of workplace smoke-free airpolicies.

EMPLOYEE ASSISTANCENVRH combines smoking cessation initiatives with other on-site or off-site employee healthprograms. Other programs have been explored that will support a nonsmoking lifestyle (e.g., stressmanagement, weight management and exercise activities). On-site nursing staff and employee healthhave been involved and trained in assessing and referring smokers, using the model of the 5A’s.NVRH takes advantage of Employee Assistance Programs (EAP), health programs offered by healthplans and community-based organizations such as local health departments.

NVRH has developed a strategy based on an understanding of smoking as an addiction. We avoid anapproach that stigmatizes smokers. Many smokers require multiple quit attempts beforethey are successful in overcoming their addiction. NVRH is a workplace thatsupports this challenging process. NVRH carefully balances restrictions (e.g., higher benefitcontributions, restrictions where employees can smoke) with cessation incentives andsupport (e.g., opportunities for counseling, reimbursement for counseling and drug therapies).

NVRH’s health plan helps employees and their families quit using tobacco.Research shows that the most effective tobacco dependence treatment includes medications,coaching and counseling. This combination has been shown to double or triple the employee’schances of quitting successfully.

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Resources______________________________________________________________________________NVRH- Caledonia/southern Essex Tobacco Advisory is proud to announce, in conjunction with

the Vermont Department of Health, the formation of the Vermont Quit Network to continue to reduce the

statewide smoking prevalence. By rebranding the existing services as a single resource, the organizations

are making it even easier for smokers to choose the quit-smoking tools that best suit their needs.

The Vermont Quit Network brings together highly effective points of contact – the toll-free Vermont QuitLine, the hospital-based Ready, Set … Stop program as well as online and self-help resources – that foryears have helped thousands of Vermont smokers quit. The consolidated Vermont Quit Network makes iteven easier for smokers and their families to find the free resources they need to support their efforts.

“The NVRH-Caledonia/southern Essex Tobacco Advisory has found that offering a range of quitsmoking options, whether its online, on the phone or in person, increases the chances of success forpeople who smoke,” said Rose Sheehan, Coordinator of the NVRH-Caledonia/southern EssexTobacco Advisory. “The new Vermont Quit Network is a gateway to all the options.”

The creation of the Vermont Quit Network comes at a time when the decrease in smoking prevalence hasslowed. Roughly 22 percent of Vermont adults smoked in 1999, but strong educational and healthprograms have helped to bring that number down to just below 18 percent, where the figure has hoveredfor the past two years. The Vermont Department of Health’s 10-year goal for its “Healthy Vermonters2010” is to reduce the percentage of smokers to 11 percent.

There are an estimated 87,000 adult smokers in Vermont, and about half try to quit each year. TheVermont Quit Network’s new slogan – “Every Try Counts” – acknowledges that on average smokers make5-7 serious quit attempts and that each of these efforts brings them one step closer to smoke-free living. Most of the 18 percent of Vermonters who smoke started at a young age and have tried to quit in the past,but now need help to realize long-term success.

“W e chose the ‘Vermont Quit Network’ name because it really resonates for Vermonters, representingpeople working together as well as the range of choices we offer to support smokers trying to quit,” saidHealth Commissioner Sharon Moffatt, RN, MSN. “W e know just how difficult it is to quit smoking, so wewanted to empower people with a wide range of effective quit-smoking options.”

Bundled together in a single, easily accessible resource, the Vermont Quit Network is reaching out toVermont smokers and their families and friends with the following:· Direct mail. Every Vermont household is scheduled to receive a mailing in mid-April outlining the free

resources offered by the Vermont Department of Health with the three easy and convenient ways toaccess the services – Online, by Phone or in Person. Three follow-up mailings will go to a muchsmaller subset of lower-income households. W hile the smoking rate has been declining in Vermont,some groups still have disproportionately high rates of smoking, including lower-income Vermontersand young adults.

· Web site. The new site, VTQuitNetwork.org, introduces Vermonters to each of the three services,along with self-help options, so smokers have an idea what to expect before they call or log on. In thepast, some smokers have expressed hesitation about using the free services because they’re “notsure what they’re getting into.” The site also includes photos and bios of many of the coaches so thatsmokers can begin to meet some of the people behind the Network.

· Free Nicotine Replacement Therapy (NRT). The Vermont Quit Network coaches make it simple tohave free NRT shipped directly to a smoker’s home.

· Self-help podcasts. Self-help podcasts to support smokers in their quit attempts will also be availableat VTQuitNetwork.org.

For more information about the Vermont Quit Network, visit VTQuitNetwork.org, dial 1.800.QUIT.NOW(784-8669) or visit a quit coach at NVRH.

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ADDITIONAL RESOURCES_____________________________________________________________________________

American Lung Association of Vermont372 Hurricane Lane, Suite 101Williston, VT 054951-800-Lung-USA or 1-802-876-6500www.lungusa.org

Coalition for a Tobacco Free Vermont121 Connor Way, Suite 240PO Box 1460Williston, VT 05495802-872-6352www.tobaccofreevermont.org

Vermont Department of HealthVT Quit Network108 Cherry St.Burlington, VT 05402802-863-7359

American Cancer Society 1-800-ACS-2345www.cancer.org

American Heart AssociationPhone: 1-800-642-8400www.americanheart.org

American Medical Associationwww.ama-assn.orgNational Cancer InstituteBethesda, MD 208921-800-4-CANCER1-800-422-6237www.cancer.gov

National Center for Tobacco-Free Kidswww.tobaccofreekids.org

Centers for Disease Control & Preventionwww.cdc.gov/tobacco

National Women's HealthInformation Centerwww.4woman.gov

American Psychological Associationwww.apa.org

Addressing Tobacco in Managed Carewww.ahip.org

Agency for Healthcare Researchand Qualitywww.ahrq.gov

Society for Research on Nicotineand Tobaccowww.srnt.org

Tobacco Dependence TreatmentResearch and Informationwww.ctri.wisc.edu

For pregnant women:American College of Obstetricians andGynecologistswww.acog.org

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References______________________________________________________________________________

Coalition for a Tobacco-Free Vermont, 2007. It’s Time to Fully Fund Tobacco Control and

Prevention in Vermont.

Healthy Hospitals of NC Initiative, 2008. Healthy Hospital Timeline for Hospitals Going 100%

Tobacco-Free Campus Wide.

Nebraska Hospital Association (NHA), 2007. Moving Toward a Tobacco-Free Future.

Rutland Regional Medical Center, 2007. Rutland Regional Health Services Tobacco-Free

Environment Implementation Guide.

University of Michigan Health Services, 2008. Checklist to Implement a Smoke-Free

Environment.

Vermont Quit Network, 2008. Swiss Cheese Press Release.

Vermont Tobacco Evaluation & Review Board, 2008. Vermont 2008-2009 Tobacco Control

Workplan.

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