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Progress in Chronic Disease Prevention Evaluation of an Employee Smoking Policy -- Pueblo, Colorado, 1989-90

In December 1988, the Colorado Department of Health and CDC were asked to help evaluate a planned worksite policy banning employee smoking for the Colorado State Hospital, a psychiatric hospital in Pueblo, Colorado. Purposes of the evaluation were to

  1. determine whether implementation of the policy reduced the exposure of hos pital employees to environmental tobacco smoke (ETS) in the workplace; 2) assess the acceptance of the policy among employees; and 3) assess the effect of the policy on the smoking behavior of employees who smoked. This report presents findings from employee surveys at three time periods: before, and at 3 and 12 months after policy implementation.

Before February 1, 1989 (the day the policy was implemented), employees were allowed to smoke in designated areas within the hospital. After February 1, smoking by employees was prohibited indoors; hospitalized patients were permitted to continue smoking in designated areas on patient-care wards.

Self-administered questionnaires were distributed to all 1400 hospital employees in January (before the policy change) and May 1989 and in February 1990. The questionnaire asked employees to provide information about their exposure to ETS at work. Other questions elicited attitudes and opinions about the new hospital smoking policy.

The questionnaires were analyzed as cross-sectional samples of the hospital work force. A cohort analysis was done of 73 smokers who voluntarily identified themselves on the questionnaire and responded to the two follow-up surveys; this analysis permitted assessment of individual behavioral changes. All analyses were stratified by smoking status.

"Ever smokers" were defined as persons who had smoked greater than or equal to 100 cigarettes in their lifetimes, including both current smokers (who continued to smoke at the time of the surveys) and former smokers who did not smoke. "Never smokers" were defined as persons who had smoked less than 100 cigarettes in their lifetimes. Smokers were asked how many cigarettes they smoked during work hours and in a 24-hour day.

In January 1989, 1032 (74%) employees responded to the questionnaire; in May 1989, 762 (54%) employees responded, and in February 1990, 745 (53%) employees responded to the follow-up survey. Age, sex, and ethnicity of respondents to each survey were similar to the demographic distribution of the entire hospital workforce (Colorado State Personnel Office, unpublished data).

In January 1989, before the employee smoking ban took effect, 41.5% of employees reported working in a smoke-free work area. In May, 3 months after the ban, 72.1% reported their work area was smoke-free (p less than 0.01, chi-square test); in February 1990, 80.5% reported their work area was smoke-free. The percentage of employees reporting smoke-free worksites did not vary by smoking status.

From January 1989 to February 1990, overall employee support for the smoking ban increased from 59% to 68%, respectively (p less than 0.01, controlled for smoking status, Mantel-Haenszel chi-square test); the greatest change occurred among former smokers. Support for the ban was greatest among never smokers and least among current smokers (Table 1).

The reported prevalence of current smoking varied little during the evaluation. In January 1989, 29% of respondents were current smokers, compared with 24% in May and 25% in February 1990. Among the cohort of 73 smokers, the average daily number of cigarettes smoked at work declined from 7.7 in January 1989 to 4.2 in February 1990; during the same period, however, the number of cigarettes smoked after work increased from 8.6 to 10.3. The net average change in cigarettes smoked in a 24-hour day declined by 1.8 cigarettes, from 16.3 to 14.5. Reported by: GS Mayo, Colorado State Hospital, Pueblo; JA Pritzl, Colorado Dept of Admin istration; WF Young, RE Hoffman, MD, State Epidemiologist, Colorado Dept of Health. Program Svcs Activity, Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion; Div of Field Svcs, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Smoke-free worksite policies decrease the exposure of nonsmokers to ETS (1). The American Medical Association, the American Hospital Association, and other groups have advocated smoke-free hospitals (2,3). However, psychiatric hospitals present special challenges to administrators attempting to prevent the exposure of employees and patients to ETS through the creation of smoke-free hospital environments. The prevalence of smoking among psychiatric patients appears to be substantially higher than among the general population (4), and the concept of the smoke-free psychiatric facility has not yet been widely accepted by hospital administrators and staff (5). For these reasons, policies that restrict smoking in psychiatric facilities have been difficult to enact. However, smoke-free policies for psychiatric hospitals should benefit patients served by these facilities in ways other than reducing risk for smoking-related disease. For example, patients who are smokers may require higher doses of therapeutic drugs than do patients who are nonsmokers (6), and some psychiatric patients may be at increased risk for fatal and nonfatal injuries from fire caused by cigarettes (7).

This evaluation indicates that employee acceptance of smoking restrictions can be sustained in a psychiatric facility, even after being in place 12 months. These findings are similar to those reported in other worksites (8). Because inpatients were permitted to smoke indoors, approximately 20% of employees reported exposures to ETS at the worksite after policy implementation. Additional studies of smoke-free policies that benefit both patients and staff are under way at this facility. Through a combination of employee education and cooperation of all management levels, worksite policies can be implemented with minimal conflict and enforcement difficulty (9).

In Colorado, only modest short-term changes in smoking behavior (e.g., fewer cigarettes smoked at work) occurred among current smokers, but these were partially offset by an increase in smoking after working hours. Long-term changes in the smoking practices of employees may produce health and economic benefits for smoking and nonsmoking employees, as well as for employers.


  1. CDC. Passive smoking: beliefs, attitudes, and exposures--United States, 1986. MMWR 1988;37:239-41.

  2. Ernster VL, Wilner SI. Nonsmoking policies in hospitals. J Public Health Policy 1985;6: 197-203.

  3. Becker DM, Conner HF, Waranch R, et al. The impact of a total ban on smoking in the Johns Hopkins Children's Center. JAMA 1989;262:799-802.

  4. Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Prevalence of smoking among psychiatric outpatients. Am J Psychiatry 1986;143:993-7.

  5. Resnick M, Bosworth EE. A survey of smoking policies in Oregon psychiatric facilities. Hosp Community Psychiatry 1988;39:313-5.

  6. Vinarova E, Vinar O, Kalvach Z. Smokers need higher doses of neuroleptic drugs. Biol Psychiatry 1984;19:1265-8.

  7. Gaston EH. Solving the smoking problem on a chronic ward. J Psychiatr Treatment and Evaluation 1982;4:387-401.

  8. Borland R, Owen N, Hill D, Chapman S. Changes in acceptance of workplace smoking bans following their implementation: a prospective study. Prev Med 1990;19:314-22.

  9. Millar WJ. Smoke in the workplace and evaluation of smoking restrictions. Ottawa: Health and Welfare Canada, Minister of Supply and Services, 1988.

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