Clearing the air: Improving smoke-free policy compliance at the national oncology hospital in Armenia

Background: Smoke-free policies shown to reduce population exposure to secondhand smoke (SHS) are the norm in hospitals in many countries around the world. Armenia, a transition economy in the South Caucasus, has one of the highest male smoking rates in the European region. Although smoking in healthcare facilities has been banned since 2005, compliance with this ban has been poor due to lack of implementation and enforcement mechanisms and social acceptability of smoking. The study aimed to develop and test a model intervention to address the lack of compliance with the de jure smoking ban. The national oncology hospital was chosen as the intervention site. Methods: This study used employee surveys and objective measurements of respirable particles (PM_2.5) and air nicotine as markers of indoor air pollution before and after the intervention. The intervention developed in partnership with the hospital staff included an awareness campaign on SHS hazards, creation of no-smoking environment and building institutional capacity through training of nursing personnel on basics of tobacco control. The survey analysis included paired t-test and McNemar's test. The log-transformed air nicotine and PM_2.5 data were analyzed using paired t-test. Results: The survey showed significant improvement in the perceived quality of indoor air, reduced worksite exposure to SHS and increased employees' awareness of the smoke-free policy. The number of employees reporting compliance with the hospital smoke-free policy increased from 36.0% to 71.9% (p < 0.001). The overall indoor PM_2.5 concentration decreased from 222 μg/m³ GM (95% CI = 216-229) to 112 μg/m³ GM (95% CI = 99-127). The overall air nicotine level reduced from 0.59 μg/m³ GM (95%CI = 0.38-0.91) to 0.48 μg/m³ GM (95% CI = 0.25-0.93). Conclusions: The three-faceted intervention developed and implemented in partnership with the hospital administration and staff was effective in reducing worksite SHS exposure in the hospital. This model can facilitate a tangible improvement in compliance with smoke-free policies as the first step toward a smoke-free hospital and serve as a model for similar settings in transition countries such Armenia that have failed to implement the adopted smoke-free policies.