NC leads the way on tobacco-free policy

Cessation in tobacco-producing state

In the nation's biggest tobacco-producing state, no one can smoke or use tobacco on any campus of its 125 acute care hospitals or that of many of its psychiatric hospitals. North Carolina was the first state in the country to be 100% tobacco-free in its nonfederal hospitals. Employees at state hospitals who smoke also pay more for insurance premiums.

It is a sign of things to come as more and more hospitals remove smoking — and other tobacco use — from their campuses, not just their buildings.

"We are still the number one tobacco-producing state, and we have a tremendous number of health problems as a result of that," says Melva Fager Okun, DrPH, senior program manager for NC Prevention Partners in Chapel Hill, a nonprofit organization that seeks to reduce preventable illness and early death. "For us to have achieved this is remarkable. It's exceptional."

There's a message here for other hospitals, says Okun: "If we can do it in North Carolina, it can be done anywhere."

Already, it is estimated that one-third to one-half of U.S. hospitals have smoke-free campuses.1 "No matter which state you look at, you see this policy as a trend," says Anna McCullough, MSW, MSPH, research associate in the Department of Family Medicine Tobacco Prevention and Evaluation Program at the University of North Carolina School of Medicine in Chapel Hill. "There is a lot of energy around it."

No butts on campus

The Joint Commission enacted a standard in 1992 that prohibits smoking in hospitals, but not on hospital grounds. With the tobacco-free campus policy, employees cannot smoke outside on their breaks or at lunch.

If they can make it an entire shift without smoking, they may be convinced to quit entirely, says Carol E. Ripley-Moffitt, MDiv, CTTS, program manager of the UNC Nicotine Dependence Program. "I have had some employees who have come to our clinic and said, 'I want to quit smoking before this [tobacco-free] deadline,'" she says.

In North Carolina, the Duke Endowment provided a grant that supported the tobacco-free hospitals' effort, and the NC Prevention Partners worked with the North Carolina Hospital Association and assisted hospitals. As hospitals develop tobacco-free programs, they should consider these elements, says Okun, who works as a consultant with hospitals around the country:

• Make sure your policies address tobacco use, not just smoking.

When smoke-free policies go into effect, some smokers switch to chewing tobacco, Okun says. That means the users will be spitting the residue. "It's disgusting. No hospital wants that," she says. While chewing tobacco doesn't contaminate the air with smoke, it is associated with increased cancer risks of its own, she says.

• Provide assistance with smoking cessation.

"It is a very, very serious addiction," says Okun. "The first thing I would ask hospitals to do is to look at your benefit structure as to how you support employees in quitting. I would like all financial barriers to be removed." Offering free medications and ongoing cessation coaching can improve the quit rate, says Ripley-Moffitt.

• Create incentives for being tobacco-free.

As of July, state employees who use tobacco will not be eligible for the less expensive of two medical insurance options. However, the state has eliminated the copay for certain smoking cessation medications and provides free nicotine patches and free access to the NC Quitline telephone counseling service. Some private employers also give nontobacco users a discount on their insurance premiums, Okun says.

• Target subgroups of employees.

Smoking use varies considerably among the different occupations in a hospital. For example, a national survey by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that food service workers had the highest rate of smoking (44.7%) among 22 major occupations. The average rate for full-time workers was 28%. Younger workers had higher rates than older workers. Employers may want to target some of their interventions on high-risk groups, Okun says.


1. Goldstein AO, Steiner J, McCullough A, et al. State adoption of 100% smoke-free acute non-federal hospital campus policies. Int J Environ Res Public Health 2009; 6:2,793-2,799.