The Chinese Ministry of Health instituted a policy to require all of the country’s healthcare facilities become smoke-free. Recognizing the enormity of this goal, a mid-term objective was to achieve success in half of the countries’ hospitals by 2010 [14
]. Hospitals were to implement smoke-free policies, stop selling cigarettes, and to have physicians acquire knowledge about tobacco control to support these initiatives. Guidelines were established [16
], and CATC helped develop the model program, wrote guidelines for enacting the policy, and implemented the program [15
]. They included pre-intervention and post–intervention surveys to assess change. However, there were expressed doubts in the media suggesting that hospitals were being designated as smoke-free when in fact they were not [17
]. In order to provide additional data to better assess the progress made by CATC’s initiative, the current study provided a more in-depth evaluation implemented with a sample of the hospitals in Beijing to provide an independent assessment of the intervention’s impact. We summarized the survey data CATC collected concerning the change in attitudes, behaviors and knowledge of physicians following smoke-free policy implementation and then provided some additional measures, including environmental nicotine levels and a systematic review and assessment of written hospital smoke-free policies.
The data demonstrate progress was made to establish smoke-free facilities in selected hospitals in Beijing, providing valuable information concerning the effectiveness of the model program. Changes in knowledge about smoking occurred, positive attitudes increased, and lower levels of SHS were found. We chose Beijing for this subsample since our previous monitoring indicated Beijing had the highest passive nicotine measurements in hospitals, and we felt this would be a good example of what might be achieved by this model smoke-free hospital project [16
]. For example, our previous study found levels with a range of values from 11.0 μg/m3
to .05 μg/m3
. During that study, nicotine was found in 100% of the passive monitors. While we still found that 96% of the passive monitors had measurable levels of nicotine in the current study, we did see lower amounts of nicotine in our selected sub-sample of hospitals. The current study found levels of SHS in Beijing hospitals ranged from below the level of detection <0.0056 μg/m3
to a high of 3.94 μg/m3
. This is a reduction of 65.1% compared to amounts found previously. The reduction is suggestive of progress since we only had our previous work in Beijing hospitals as a comparison to assess change.
Previous studies evaluating SHS exposure have also used self-reported surveys, qualitative studies, or assessment of airborne nicotine in worksites and hospitals [9
]. One such study in China found compliance with smoking restriction policies was poor, with more than 40% of smokers working under a smoke-free policy reporting smoking was still occurring “sometimes” in their workplaces [21
]. Evidence from focus groups conducted in 3 Chinese provinces found extensive misconceptions about SHS policies among physicians and educators [24
]. In addition, hospital personnel reported that regulations had been enacted without their input, and they did not understand their responsibilities or how to contribute to implementation of the policy [24
]. That study showed leadership was needed to help develop better SHS policies, improve implementation and compliance, and to provide more information to institutions to take tobacco control seriously [24
The current CATC study was an important step to improve implementation of SHS in hospitals, as well as to understand how to develop a model program that can be disseminated across the country. By determining, in a more conclusive manner, if a sample of the hospitals had achieved a smoke-free status or made substantial progress, this study augmented CATC’s implementation by including passive nicotine monitoring and conducting an assessment of the hospital policies in addition to the survey data already collected by the organization itself. This more extensive evaluation of a sub-set of the hospitals was to help confirm results and also to determine if any link between the intervention implementation and outcomes at the hospitals could be found.
We also were able to learn more about the policies that were developed by the hospitals. We found differences between hospitals, with some producing better (more comprehensive) written policies than others. The assessment of the policies was innovative in that we categorized the content of the actual SHS policies developed by each hospital in our sample. As mentioned, we did find a range in the strength of policies, with some hospitals seemingly incorporating more of what is considered best practices into their written policy statements. However, more work still needs to be done since none of the hospitals included all of these best practices in their policy statements [16
]. It was interesting to find a relationship between components incorporated in the policies and the level of nicotine found in the hospitals. It is known that more restrictive policies have the greatest impact on smoking behavior [22
]. However, we had few observations, and one hospital had much higher nicotine levels and was classified an outlier; thus, we did not have a large enough sample to truly assess this relationship. But rather we produced an example of what could be done on a larger scale during future investigations. We also cannot ascertain which components of the policy, such as staff education vs. enforcement or signage, were most important. However, the data are suggestive that staff education may have had a smaller impact on the higher monitor readings since little was done to change smoking by patients, family and other visitors who frequent the hospitals, possibly contributing to the higher nicotine measurements.
There were also other factors that could explain some of the changes noted. In this study, a guideline was developed and training and implementation strategies were applied across all the hospitals. A pre-/post-evaluation was conducted, and the additional assessment of nicotine in the environment, as well as the assessment of the policy, provided some additional information to determine the progress of the hospitals becoming smoke-free. The results reported here are a major step forward in improving evaluation strategies used to assess the implementation of smoke-free policies in hospitals in Beijing. The results were encouraging in that physicians did have more knowledge and positive attitudes post-policy implementation, there was an indication that hospitals were no longer selling cigarettes, and smoking was occurring more in the outdoor smoking areas (albeit self-reported). However, there is evidence smoking is still occurring indoors, especially in rest rooms (self-report) and in waiting rooms (nicotine monitoring). Smoking among patients and family members is still an issue, one that was not addressed in the implementation strategies, especially as the waiting area had the highest SHS level.
While this study indicates progress has been made in moving Chinese hospitals to become smoke-free, much still needs to be done. It is evident that continued implementation is necessary to improve compliance and move the hospitals closer to becoming completely smoke-free. A plan to provide resources, including materials and funding, would help to disseminate this model as well as to assure that all hospitals, not just the large, tertiary care facilities, can develop and implement such SHS policies. In addition, more in-depth evaluation of the policies’ impact, especially through environmental monitoring such as passive nicotine monitoring, provides a more accurate assessment of the locations.
This study does have limitations. The extended evaluation was only conducted in Beijing, and only large tertiary hospitals were included. These are considered the premier hospitals in China and attract patients from all over the country, and as a consequence they potentially do not provide a generalizable view of what is happening in smaller hospitals across the country. It is also important to realize that good policy development found in a few large Beijing hospitals may not easily be disseminated to the rest of the country due to more limited resources and greater problems faced by health care facilities in other regions or cities.
We did provide an assessment of the polices as well as the pre- and post surveys that were conducted, however, we could not take into account other factors that could have influenced the changes in knowledge and attitudes among physicians. Such factors could have included media influences, other government influences, as well as the 2008 Olympics, which included a focus on health care and SHS policies. Also, we are unable to make any causal statements concerning the relationship of CATC’s initiative and any changes found since our sub-sample was small and only conducted in Beijing. Also, the survey sample was a convenience sample of physicians only, and the manner used to select the sample as well as the sample itself, could have contributed to less accurate data being collected. However, the study did try to use best practices in implementation and evaluation, which could be used in future SHS studies in China [12
Due to increased education and knowledge among physicians, survey results may have social desirability bias. When health care professionals become more aware of what is expected in terms of smoking’s relationship to health, under reporting of smoking rates seems to be an issue. To address this, an additional evaluation component (nicotine monitoring) was useful since there was expressed concern that “many hospitals claim to be smoke-free, but in reality, they are anything but that”, and self-reported measures may not provide an accurate assessment of a smoke-free environment [17
]. Using additional evaluation techniques, including nicotine measurement or systematic observation, are strategies to improve assessment of SHS compliance [9