Evaluating the application of a smoking ban regulation in a hospital

Evaluating the application of a smoking ban regulation in a hospital

emergencias 2007;19:255-259
Original Article
Evaluating the application of a smoking ban regulation
in a hospital emergency department
R. M. Sánchez del Castillo1, S. Navarro Ortega2, P. Tavera Mateos3, J. Del Pozo Sancho4
1
1 NEONATAL UNIT, HOSPITAL 12 DE OCTUBRE. 2EMERGENCY DEPARTMENT, HOSPITAL FUNDACIÓN ALCORCÓN.
ACUTE TREATMENT UNIT, HOSPITAL DE LA FUENFRÍA. 4EMERGENCY DEPARTMENT, HOSPITAL SEVERO OCHOA, MADRID.
3
ABSTRACT
RESUMEN
ackground: In May 2005 the Royal Decree prohibiting smoking
in public spaces and particularly in medical centres came into
force. Our study aims to analyse the consequences of implementing that rule on the nursing staff of the emergency service of Alcorcón Foundation Hospital, the changes in smoking habits, the awareness of effects of air polluted by cigarette smoke on health and the
arguments between smokers and non-smokers about cigarette use.
Methodology: A descriptive cross-sectional study based on a survey
of smokers and non-smokers of the nursing staff (nurses and nursing
assistants) of the emergency service of the Alcorcon Foundation
Hospital and a comparative analysis of responses and outcomes were done.
Results: The survey was answered by 71 staff members (44 nurses
and 27 nursing assistants), 19 of whom (26,8%) were current smokers.
After the implementation of the smoking prohibition, average cigarette
consumption during working hours was reduced by 4,7 cigarettes per
person and conflicts caused by cigarette smoke decreased.
Conclusions: The staff members surveyed were aware of the effects
of air polluted by cigarette smoke on the health of passive smokers.
Following implementation of the Royal Decree, both cigarette consumption in the workplace and arguments due to cigarette smoking
decreased.
Valoración de la aplicación de la normativa que prohibe
fumar en un servicio de urgencias hospitalario
B
bjetivo: En mayo de 2005 entró en vigor la prohibición de fumar en el servicio de urgencias del Hospital Fundación Alcorcón. El objetivo de nuestro estudio es analizar las consecuencias que ha tenido la aplicación de dicha norma entre los Diplomados
en Enfermería (DUE) y Auxiliares de Enfermería (AE) del Servicio de
Urgencias del Hospital Fundación Alcorcón, los cambios producidos en
el hábito tabáquico, sus conocimientos sobre la influencia del humo
ambiental de tabaco (HAT) en la salud, así como las discusiones ocasionadas por éste.
Material y método: Se ha realizado un estudio transversal descriptivo
entre los DUE y AE del Servicio de Urgencias mediante cuestionario dirigido al personal fumador y no fumador, con partes diferenciadas para
cada grupo, y un análisis comparativo de los resultados obtenidos.
Resultados: Se analizan 71 encuestas correspondientes a otros tantos
profesionales (44 DUE y 27 AE), entre los que 19 (26,8%) se reconocían
como fumadores. Tras la aplicación de la prohibición de fumar, el consumo
medio de tabaco durante la jornada laboral se redujo en 4,7 cigarros por
fumador, al tiempo que disminuyeron los conflictos ocasionados por el humo del tabaco (no discutía el 76,1% frente al 49,3% previo); p < 0,01.
Conclusiones: Tras la aplicación de la prohibición de fumar se ha reducido el consumo de tabaco en el lugar de trabajo y las discusiones
ocasionadas a causa de éste.
O
Key Words: Tobacco dependence. Smoking cessation. Tobacco
Palabras clave: Tabaquismo. Cesación tabáquica. Contaminación
smoke pollution. Occupational health services. Nursing. Passive
smoking.
por humo de tabaco. Salud laboral. Enfermería. Tabaquismo
pasivo.
INTRODUCTION
Besides the awareness campaign about the risks for people exposed to environmental tobacco smoke (ETS), there is
Correspondence: Rosa María Sánchez del Castillo
C/ Plaza del Sol, 12, 1º 4.
28922 Alcorcón (Madrid)
E-mail: [email protected]
scientific evidence that link passive smoking with diseases like lung cancer, ischaemic heart disease and chronic obstructive pulmonary disease1-3.
Passive smoking in the workplace constitutes a priority
Received: 9-3-2007
Accepted: 26-6-2007
255
emergencias 2007;19:255-259
health and safety problem2,4,5,11. Different government bodies
have issued statements, proposals of strategies and aims for
achieving smoke-free working environments6,7. The Spanish
national plan for prevention and control of tobacco dependence Plan Nacional de Prevención y Control del Tabaquismo8 6
aims to protect the population against ETS. The strategy defined by this plan aims to establish the workplace as a smokefree environment. The WHO’s Third action plan for a tobacco-free Europe (1997-2001) 9 points out that “By the year
2001, legislation should be enacted in all countries of the European Region to ensure that involuntary exposure to tobacco
smoke is eliminated in all workplaces, all public buildings and
all forms of public transport.”
The Spanish government has developed laws that are aimed to Project the population’s health against ETS. The act
on drug habits and dependencies and other addiction disorders
Ley 5/2002 de 27 junio sobre toxicomanías, drogodependencias y otros trastornos adictivos12 defines tobacco as a “drug”
and in its section artículo 33, it establishes a smoking ban in
all healthcare facilities. Later, they issued an act on healthcare
measures regarding tobacco dependence and regulation of sale, provision, consumption and advertisement of tobacco products Ley 28/2005, de 26 de diciembre, de medidas sanitarias
frente al tabaquismo y de regulación de la venta, el suministro, el consumo y la publicidad de los productos de tabaco
(BOE de 27 de diciembre de 2005) which came into force on
1 January 2006. In its section Artículo 7 it establishes a ban
on smoking in public and private working facilities and in all
healthcare facilities9.
The act Ley 5/2002 de 27 junio is applied in the Emergency Department in Hospital de Alcorcón since May 2005.
The present study aims to describe and analyse the consequences - decrease in tobacco consumption and in the problems originated by tobacco smoke in common areas - that
the application of this regulation has had among smokers and
non-smokers of nursing staff in the Emergency Department of
Hospital Fundación de Alcorcón, as well as the knowledge
that nursing staff had about the influence of ETS on the health of passive smokers14.
MATERIALS AND METHOD
We carried out a cross-sectional descriptive study using a
structured and close survey between 10/10/05 and 30/04/06.
The survey included all nursing staff in the Emergency Department of Hospital Fundación Alcorcón that met the following
criteria: to be working in the Emergency Department previously to the application of the regulation (May 2005) and to
256
continue working there at the time when the survey was carried out. We considered that a person was a smoker when
they acknowledge themselves to be on 1 May 2005 and if they
smoke at least 1 cigarette during the working shift even if they
did not smoke at the time when the survey was carried out.
The survey included a series of questions that were common to all the participants. These questions were aimed to assess the characteristics of the participants, the compliance
with the regulation that bans smoking in healthcare facilities,
their knowledge about the influence of ETS in the health of
passive smokers, the inconveniences caused by ETS to passive
smokers and the problems that arose among members of staff
that were caused by ETS. There was also another series of
questions that were specific for smokers about tobacco dependence, the changes that application of the smoking ban had
had on this dependence and the assessment of the activities
carried out for ensuring its correct application of the new regulation.
The questionnaire was developed by the research group
and it was validated by an experts group. Besides, we did a
pilot of the questionnaire in a group of six staff nurses (SN)
and nursing auxiliaries (NA) in Hospital de la Fuenfría, in a
department where the smoking ban regulation had also been
applied.
As the size of the population involved was manageable
and the participants were accessible, we did not carry out a
sample. Due to the characteristics of the study, we asked for
informed consent verbally.
We calculated the confidence intervals (CI) of 95% in the
percentages and we did comparisons using Chi-square and
McNemar tests (paired proportions). For quantitative variables
we used Student’s t test for paired samples if they were adjusted to a normal distribution. If they were not adjusted, we
used Mann-Whitney U test and the W of Wilcoxon test (nonparametric tests). Data were analysed with the computer programme SPSS 12.0. We used a 1 to 10 scale (1 was strongly
agree, 10 was strongly disagree) to assess the opinions of the
participants about different issues such as the influence of the
smoking ban to achieve smoking cessation, the actions carried
out to ensure correct application of the regulation, the knowledge the participants had about the influence of ETS on the
health of passive smokers and the inconveniences caused by
ETS in non-smokers.
RESULTS
The questionnaire was answered by 71 nursing professionals of which 62% were SN and 38% were NA. The average
R. M. Sánchez del Castillo, et al. EVALUATING THE APPLICATION OF A SMOKING BAN REGULATION IN A HOSPITAL EMERGENCY DEPARTMENT
age (standard deviation) was 34 (7) years and 88% of the participants were women.
73.2% of the participants were non-smokers of which
67.3% were SN and 32.7% were NA; 84.6% of them were
women. The average age was 34 (7) years. 26.8% of the
participants were smokers of which 100% were women. In
terms of profession, 47.4% were SN and 52.6% were NA (p
= ns in relation to smokers). The average age was 33 (7)
years, and they had been smoking an average of 14 (8) years.
The average consumption during a working shift was of
11 (7) cigarettes before the non-smoking regulation came into
force and this decreased to an average of 6 (8) cigarettes after
the application of the regulation. This decrease is significant
(p < 0.001).
In terms of tobacco cessation, 36.8% of smokers quit and
46.7% reported that they would quit although they still had
not set a date for this. When participants were asked on how
they assessed the application of the regulation to achieve smoking cessation, smokers that had quit gave it a score of 5.50
(median) and the rest of smokers gave it a score of 4 (median
p = ns).
In relation to compliance with the non-smoking regulation, smokers were asked if they acted in accordance with it
and most of them reported that they “always” complied with
it (84.2%). Non-smokers stated that the majority of smokers
complied with regulation “almost always” (67.3%).
The scores obtained when smokers were asked about the
possible influence of the actions carried out to ensure the application of the regulation are shown on Table 1. Among those actions, the preparation of areas to smoke outside the hospital premises and the creation of smoking cessation groups
got the highest scores.
In order to assess the knowledge about the influence of
ETS in the health of passive smokers, we asked participants to
assess the influence of ETS in the onset of different diseases.
The results are shown in Table 2. Among them, the one that
got the highest score was eye irritation and the one that got
the lowest score was cardiac effects. The conclusions from the
statistics study show that there are no significant differences
among the answers given by smokers and those given by nonsmokers.
Participants were asked to assess the inconveniences caused by ETS in non-smokers. The results are shown on Table
3. When comparing inconveniences caused by ETS among
smokers and non-smokers, we found no significant differences
between the answers given by smokers and those given by
non-smokers. The one that got the highest score was the fact
that it gets cold inside when windows are open to smoke and
TABLE 1. Opinion of smokers about the influence of the actions carried out to ensure
compliance with the regulation
Smokers
average SD
Information campaign
Distribution of handbooks
Preparation of smoking areas outside the hospital
premises
Smoking cessation groups
5.83 (2.78)
6.61 (2.93)
6.79 (2.85)
6.78 (3.30)
(1 to 10 score, where 1 is “Strongly disagree” and 10 “Strongly
agree”).
the one that got the lowest score was irritation of respiratory
tract.
When smokers were asked the question Do you think that
tobacco smoke bothers non-smokers working with you?, all
were aware of the inconveniences that tobacco smoke caused
to their colleagues. When we analysed the conflicts originated
by ETS –results are shown on Table 4– the arguments due to
tobacco smoke were not very frequent. We did not find significant differences between the groups (smokers and non-smokers) both before and after the application of the non-smoking
regulation.
We observed that, after the application of the regulation
the occasional arguments had decreased, virtually disappearing: only 2.8% of the participants have had arguments on a
regular basis. The percentage of participants that never argued
in relation to ETS before the application of the regulation was
of 49.3% and after the application was of 76.1% (p < 0.001,
Figure 1).
DISCUSSION
This study aims to assess the consequences of applying
the non-smoking regulation in the Emergency Department of
TABLE 2. Knowledge about the influence
of environmental tobacco smoke (ETS)
on the health of passive smokers
Smoker Non-smokers
average SD average SD
Eye irritation
Carcinogenic conditions
Cardiac conditions
Cardiac conditions
7.74 (2.60)
6.42 (2.69)
6.05 (2.57)
6.47 (2.69)
8.48 (1.67)
7.56 (1.89)
6.50 (2.14)
7.40 (1.80)
p
0.39 (NS)
0.10 (NS)
0.36 (NS)
0.27 (NS)
NS: No statistical significance.
(1 to 10 score, where 1 is “Strongly disagree” and 10 “Strongly agree”).
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emergencias 2007;19:255-259
TABLE 3. Assessment of inconveniences caused
by environmental tobacco smoke (ETS)
in smokers and non-smokers
Smokers
Non-smokers
average (SD) average (SD)
Eye irritation
Irritation of respiratory tract
Presence of smoke while
having meals
Rooms get colder due to
opening the windows
for smoking
Smell of smoke in hair
and clothes
p
7.42 (2.26)
6.68 (2.38)
7.12 (2.83) 0.92 (NS)
5.87 (2.77) 0.29 (NS)
7.89 (2.6)
7.55 (2.87) 0.71 (NS)
7.21 (2.27)
7.25 (2.14) 0.92 (NS)
8.25 (1.84)
7.92 (2.71) 0.86 (NS)
NS: No statistical significance.
(1 to 10 score, where 1 is “Strongly disagree” and 10 “Strongly
agree”).
Figure 1. Percentage of participants surveyed
that report to never argue in relation to tobacco
environmental smoke (ETS).
Hospital Fundación Alcorcón and to indicate how to establish
conditions for a better application of the regulation in other
workplaces.
If we compare it with other studies that describe nursing
professionals as a group among with a higher-than-average
prevalence of smokers5,16, prevalence is slightly lower in our
department to that established by data from the 2003 Spanish
national health survey17.
Smokers that took part in this study are familiar with the
negative repercussions of ETS on the health of passive smokers such as those originating respiratory, cardiovascular and
carcinogenic conditions. They are also aware of the inconveniences caused by smoking in common areas such as making
rooms colder when opening the windows to smoke, irritation
of the eyes and the respiratory tract, presence of smoke while
having meals and smell of smoke in hair and clothing. However, they smoked, mostly because tobacco dependence is a socially accepted addiction.
After the non-smoking regulation came into force, the
consumption of tobacco during the working shift has decreased and in some cases the consumption outside work has also
dropped. This reduction in consumption has been larger than
that documented by other authors11.
We confirmed that this type of policies change the environment and disfavour tobacco consumption18,19. In terms of
smoking cessation, smokers do not think that the coming into
force of the regulation has influenced them to quit, although
for a few participants it has constituted a significant motivation, which we think is important to point out. Before the application of the regulation, there were conflicts among members of staff caused by ETS. After the application of the
regulation, these conflicts have decreased4. This is confirmed
by other studies which show that there is a higher risk of conflict between smokers and non-smokers in companies where
there is no specific policy on smoking12.
TABLE 4. Frequency of conflicts caused by environmental tobacco smoke (ETS)
Before the application of the regulation
p = 0,47
I rarely argue with a colleague
Once a month I argue with a colleague
I have argued with a colleague in few occasions
I have never argued with a colleague
Total
258
After the application of the regulation
p = 0,62
Smokers
n (%)
Non-smokers
n (%)
Smokers
n (%)
Non-smokers
n (%)
0 (0%)
1 (5.3%)
10 (52.6%)
8 (42.1%)
19 (100%)
1 (1.9%)
1 (1.9%)
23 (44.2%)
27 (51.9%)
52 (100%)
1 (5.3%)
1 (5.3%)
3 (15.8%)
14 (73.7%)
19 (100%)
0 (0%)
0 (0%)
12 (23.1%)
40 (76.9%)
52 (100%)
R. M. Sánchez del Castillo, et al. EVALUATING THE APPLICATION OF A SMOKING BAN REGULATION IN A HOSPITAL EMERGENCY DEPARTMENT
We have found some limitations in our study that must be
considered. There can be a memory bias, as the participants were
asked about behaviours they had before the application of the regulation. On the other hand, as the design was descriptive and retrospective, we could not assess interesting issues such as motivation of the participants or conflicts originated between smokers
and non-smokers. In order to go more deeply into this matter, a
qualitative prospective study should be carried out. We could also
carry out studies that comprise a larger number of participants to
be able to compare the situations in different healthcare facilities.
In conclusion, from this study we can deduce that after
the regulation that bans smoking in healthcare facilities came
into force, and more specifically in the Emergency Department of Hospital de Alcorcón, tobacco consumption of smokers among staff (SN and NA) has decreased in the workplace and the exposition of passive smokers to ETS has been
reduced, becoming virtually extinguished. These results are
in concordance with those expected according to the policies
for prevention of tobacco dependence in European companies4.
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