BIOMEDICAL AND ENVIRONMENTAL SCIENCES 21, 257-263 (2008) www.besjournal.

com

Exploring Barriers to Implementation of Smoking Policies:

A Qualitative Study on Health Professionals from
1
Three County-Level Hospitals

JUN-FANG WANG*, SHAO-JUN MA*, CUI-ZHU MEI#, XUE-FANG XU#, CHUN-PING WANG*,
*,◊,2
AND GONG-HUAN YANG

*
Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, and School of Basic Medicine, Peking Union
#
Medical College, Beijing 100005, China; Union School of Public Health, Peking Union Medical College, Beijing 100005,
◊
China; Chinese Center for Disease Control & Prevention, Beijing 100050, China

Objective This study was to identify factors limiting the implementation of smoking policies in county-level hospitals.
Methods We conducted qualitative interviews (17 focus groups discussions and 6 one-to-one in depth interviews) involving 103
health professionals from three target county-level hospitals. A combination of purposive and convenience sampling was used to
recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation
occurred. The transcripts were analyzed for themes and key points. Results The main themes that emerged suggested that both
smokers and non-smokers viewed smoking very negatively. However, it was clear that, underlying this acceptance of the health
risks of smoking, there was a wide range of beliefs. Most of the health professionals pointed out that, as smoking was legal,
addictive, and influenced by social norms, currently it was almost unrealistic to expect all smokers to give up smoking or not to
smoke in the hospitals. Furthermore, they were concerned about the potentially detrimental effects of providing counseling
advice to all smokers on the interpersonal relationship among colleagues or between doctors and patients. In addition, low level
of employee participation influenced the sustainable implementation of smoking policies. Conclusions Simply being aware of
the health risks about smoking did not necessarily result in successful implementation of the smoking policies. Application of
comprehensive intervention strategies such as implementing smoking policies in public places at the county level, creating
supportive environments, promoting community participation, and conducting health education, may be more effective.

Key words: Qualitative study; Tobacco use; Smoking policy; HP attitudes

INTRODUCTION prevalence and higher quit rates among employees,

including doctors and nurses[3-5].
The morbidity and mortality caused by active Since HPs are influential role models for their
smoking and by exposure to secondhand smoke patients in health-related matters, smoking by HPs
(SHS)[1] make smoking in hospitals completely impedes their ability to assist patients to quit
inconsistent with the functions of hospitals where a smoking[6-9] and, therefore, interferes with efforts to
healthy environment should be established[2]. create and maintain smoke-free hospitals. Changing
Creating smoke-free hospitals is a necessary and smoking behavior and attitudes towards smoking
ethical extension of hospitals’ responsibility to policies in public places among HPs is a critical step
promote health, which is mandatory in some to facilitate then consequent changes in behavior and
countries. Smoking bans in hospitals not only protect perceptions among the general public.
patients from exposure to SHS, but also benefit the However, one unexpected problem that has arisen
health professionals (HPs) who are employed in the in China is that the smoking prevalence is quite high
hospitals. Like the smoking bans in other worksites, among HPs[10], which may be more common in the
smoke-free hospital policies have resulted in lower county-level hospitals. In contrast to this apparent
Abbreviations: SHS, secondhand smoke; HPs, health professionals; MCPH, Mianzhu County People’s Hospital; ACPH, Anyi County
People’s Hospital; XCPH, Xin’an County People’s Hospital.
1
This research was supported by the Fogarty International of the National Institute of Health in the United States.
2
Correspondence should be addressed to Gong-Huan YANG, 5 Dong Dan San Tiao, Beijing 100005, China. Tel: 86-10-65233870. Fax:
86-10-65233678. E-mail: yangghuan@vip.sina.com
Biographical note of the first author: Jun-Fang WANG, female, born in 1976, Ph. D. at Institute of Basic Medical Sciences, Chinese
Academy of Medical Sciences, majoring in epidemiology and biostatistics.
0895-3988/2008
CN 11-2816/Q
Copyright © 2008 by China CDC
257
258 WANG ET AL.
phenomenon among HPs population, there have been
very few studies addressing the issue of implementing
the policies to prevent smoking in these hospitals.
In order to make the relevant information
available, we chose three county-level hospitals as
experimental units to study the implementation of
smoking policies in these specific environments. The
aim of this study was to investigate the knowledge,
attitudes, beliefs, and practices of HPs in these three
hospitals with regard to implementing smoking
policies. The ultimate goal is to use this information
to develop a culturally relevant and effective
intervention to control smoking in the county-level
hospitals.
METHODS
Subjects and Settings
From November 2004 to April 2005, we conducted
one-to-one in depth interviews with the president, the
director of preventive health service and focus groups
discussions with representatives from the three target
hospitals. Characteristics of HPs thought to have an
influence over how they provide counseling advice
were identified from the literature[11] and discussed
with researchers. HPs were then purposively sampled
while considering some practical constraints at the
same time, such as accessing willing participants, and
time and resources available for the research, to
ensure that the final sample consisted of HPs with
these characteristics. Each group was homogenous in
terms of smoking status[12] and discussions with each
group were based on the principle of theme
saturation, i.e., the interviews stopped until no new
major themes arose from the final focus group.
Seventeen focus groups were undertaken with
representatives from the three hospitals, with four to
seven people per group. There were six groups with
HPs from Mianzhu County People’s Hospital
(MCPH) (3 groups of smokers, 3 groups of non-
smokers), five groups with Anyi County People’s
Hospital (ACPH) (2 groups of smokers, 3 groups of
non-smokers) and six groups with Xin’an County
People’s Hospital (XCPH) (3 groups of smokers, 3
groups of non-smokers). Six one-to-one in depth
interviews were conducted with hospitals’ presidents
and the director of preventive health service from the
three hospitals. In total, 103 individuals participated.
Every interview lasted about one hour.
Participants were recruited through the hospitals
liaisons that had been interviewed in an earlier phase.
They were provided verbal and written information
about the study (including an information sheet for
potential participants describing the study) and the
kind of people we were looking for.
Data Collection
A semi-structured interview schedule was
designed and piloted to guide the interviews, although
participants were free to raise other issues that they
believed to be important. Topics included: tobacco use
among HPs; knowledge, attitude, and practice of HPs
towards active smoking and exposure to SHS; the
existence, implementation and enforcement of
smoking policies; and views and suggestions on
creating smoke-free hospitals. Two investigators were
present at each interview. One was primarily
responsible for asking questions and facilitating
discussion, while the second recorded the session with
a digital voice recorder (with permission from the
participants) and took detailed field notes to record
observations and ideas.
Analysis
The investigators discussed and summarized the
content of each group discussion immediately after
each focus group session. There were several reasons
for immediate debriefing: to identify the most
important themes and ideas; to determine if these
differed from what was expected from the theoretical
and empirical perspectives; to determine if anything
should be done differently for subsequent groups; and
to discuss differences from previous sessions[13].
Recordings from the interviews were transcribed
verbatim and entered into a word processing package.
Three trained researchers read through the transcripts to
identify themes, and then coded and indexed the texts.
The process of coding involved identifying key themes
and marking these out on the transcripts. The process of
indexing involved bringing all data on a particular theme
together, starting with broad categories and narrowing
these into a larger number of subcategories. This was
done by copying the original transcripts and using the cut
and paste feature. Details of each theme were then
extracted, responses compared and contrasted, and the
key issues summarized.
Due to group dynamics in focus group
discussions, it can be difficult to gauge what each
individual thinks, therefore it is not always
appropriate to count the number of participants
giving a certain opinion[14]. Instead, we focus on key
themes emerging from the group discussions and the
range of opinions discussed. The frequency and
fervor with which particular views were expressed
were taken into account in the reporting.
RESULTS
Predisposing Factors: Knowledge and Attitudes
Both smokers and non-smokers usually mentioned
 BARRIERS TO IMPLEMENTING HOSPITAL SMOKING POLICIES
cancer, lung problems and heart diseases as being
possible dangers of smoking, with some also
discussing bad teeth, bad appetite, poor skin, and a
poor or unhealthy appearance. The smell of smoke
was in particular disliked, both in itself and trapped
in clothes and rooms.
However, beneath this superficial awareness of
the heath risks, there was considerable
underestimation and some skepticism as to how
serious they really were. A common reaction was to
refer to people (e.g. friends, families, or celebrities)
whose individual experience defied the statistics. For
instance, one smoker commented that he found the
low-level effects of smoking (cold, cough and so on)
easy to accept because he experienced them himself,
but he was more skeptical about the serious health
risks because of some people who smoked long but
lived a long and healthy life. In the same way, other
respondents sometimes wondered if the link between
lung cancer and smoking was certain because they
had known the fact that some non-smokers had lung
cancer while some smokers did not. Non-smokers
tended to mention that exposure to SHS was more
harmful than active smoking straightforwardly, but
even they thought that effective protection can be
achieved with simple measures, such as opening a
window, smoking in another room, or using an air
purifier, although none of these measures
substantially reduce exposure.
‘The link between smoking and diseases is uncertain
or is not supported by sufficient scientific evidence.
As we all know, Deng Xiao Ping (China’s paramount
leader) was addicted to cigarettes but lived to be
ninety years old’ (Smokers from XCPH)
‘I found it acceptable to smoke inside during summer
seasons, with doors and windows wide open.
However, during the winter period when all the
windows are closed and the air conditioners are
running, smoking inside is extremely harmful to the
non-smokers.’ (Non-smokers from XCPH)
Enabling Factors: Skills
The three hospitals implemented smoke-free
policies as part of efforts to build a nationally clean
city or to build up a Second Grade Class A Hospital.
The policies specifically required that HPs be
forbidden to smoke when they see patients, visit
inpatient wards or discuss-medical cases with
patients and their family members. Meanwhile, the
three hospitals used signs or posters to communicate
their smoking policy and penalties like fines for non-
compliance. At that time, top management attached
great importance to this and set up a working team to
vigorously implement the policy.
This method worked quite well, as far as
effectiveness was concerned, since exposure to
secondhand smoke was almost eliminated. However,
the enforcement only lasted for several months. After
that, all the ‘No -smoking’ signs and policies were
still present, but they had little restrictive effect on
smoking behavior due to lack of supervision and
management.
‘Some health professionals would not voluntarily
comply with the smoking policies, and they would go
along with rules only if they must pay a big fine when
they are caught.’ (Director of preventive health
service from ACPH)
Reinforcing Factors
A personal choice Smokers and non-smokers felt
that people should have personal choice as to whether
they smoke or not. Smokers further highlighted the
legality of smoking as a support for the argument in
favor of choice. Both the hospitals’ presidents and
staff felt that the right balance needed to be struck
between the rights of these two groups. They felt that,
ideally, it was fair for both smokers and non -smokers
to be entitled to provision in the form of smoking
rooms. However, due to space constraints, this was
not always feasible.
‘From the legal perspective, smoking does not violate
the law...smokers have their own freedom and rights
to smoke, and others have no right to intervene.’
(Smokers from ACPH)
‘It is an individual right for a person to decide
whether to smoke, so smokers should receive their
due respect.’ (Non-smokers from XCPH)
Addiction The issue of addiction was also
mentioned a great deal. Many smokers said that they
had attempted to stop but had failed on numerous
occasions. There was also a strong view among non-
smokers that smokers had a craving for
cigarette/nicotine, which had to be addressed. It was
generally accepted that people who needed to smoke
during work hours should be able to do so as lack of
nicotine could affect how well they carried out their
duties. Smokers also felt that a cigarette was a reward
for their hard work or aided them to relax when they
got stressed in the workplace.
‘I have tried to stop it several times, but I did not
succeed, I’m driven by something…I still feel a bit
controlled by the addiction.’ (Smokers from XCPH)
‘With the quickening pace of modern life, smoking
could help HPs with stressful jobs to deal with this
stress and it has pushed ahead with the health
260 WANG ET AL.
profession.’ (Non-smokers from MCPH)
‘I smoke from time to time. As a surgeon, after
several hours of operation, I'm often under great
pressure and so fatigued. Smoking a cigarette can
give me a lift during the busy schedule.’ (Smokers
from MCPH)
Doctor-patient relationship Maintaining a
good relationship with patients was of paramount
importance to HPs. A frequently cited barrier to
giving counseling on the health consequences of
smoking and on smoking cessation was a fear of
harming the doctor-patient relationship. This fear
seemed to explain the problem-based approach that
HPs employed towards raising the topic of smoking.
HPs reasoned that patients presenting with smoking-
related problems were more likely to listen to the
doctors’ advice. Many HPs cited previous
experiences of upsetting patients to support the view
that giving repeated advice without smoking-related
problems is counter-productive. A number of them
also held that this did not help patients to stop
smoking. Consequently, doctors avoided giving
repeated advice in consultations in which there was
direct evidence showing that smoking contributed to
the medical problems of patients. In addition, some
respondents mentioned mainly non-smokers gave
counseling, for smoking HPs did not play exemplary
roles for their patients.
‘Patients with smoking-related diseases are more
likely to follow the doctors’ advice ...and nonsmokers
practiced counseling more often than smokers.’
(Non-smokers from ACPH)
‘For patients suffering from tuberculosis and
hepatitis, after some education and persuasion made
by HPs, they have tried to smoke as few cigarettes as
they could.’ (Smokers from MCPH)
‘If you tell patients that smoking can lead to lung
cancer, some may argue with you that some smokers
have never got lung cancer while some non-smokers
have.’ (Non-smokers from MCPH)
‘Some patients believe that their illness is not serious
(such as hand injury, etc.), and therefore, they have
continued to smoke during the operation or when
their wounds have just been stitched up.’ (Smokers
from MCPH)
‘Doctors have clearer knowledge about the harm
caused by smoking than general non-professional
people do. And it's their responsibility to educate
others. But if the educator himself smokes, his efforts
will sound worthless.’(Smokers from MCPH)
Colleague relationships It is widely believed
that it is much more difficult to give counseling
advice to smoking doctors than to patients, since they
know very well the harm caused by smoking. Non-
smokers reportedly used a variety of approaches
when directly confronting the smoking doctors. Some
made explicit reference to (real or sometimes
fictitious) health problems that could be aggravated
by exposure to SHS. Non-smokers also used non-
verbal cues to ‘get the message across’ while
avoiding a direct confrontation with the smokers.
Non-verbal cues cited by (smoking and non-smoking)
respondents included intentionally loud cough,
fanning or blowing the smoke away, opening
windows, or facial expressions. Several smokers
admitted to having, on several occasions, heard and
understood the non-verbal cues, but chosen to pretend
not to have (i.e., they ignore it), particularly in cases
where such cues were perceived as ‘rude’. In cases
when non-smokers perceived raising the topic of
smoking might hurt the colleague relationship, then
non -smokers may have elected to do nothing (‘grin
and bear it’) or move away.
‘Due to the sensitivity of the issue, when confronting
the smoking colleagues or leaders at a higher level,
we have no choice but to tolerate the filthy smell or
simply to go away from the smoky environment.’
(Non-smokers from XCPH)
‘As health professionals know about the damages
caused by smoking, we usually tell them to stop smoking
in a friendly manner. Sometimes we directly asked them
to smoke outside.’ (Non-smokers from ACPH)
‘Sometimes they (non-smokers) would advise
smoking less, especially when catching cold, and not
bearing the smell of smoke.’ (Smokers from MCPH)
‘In the case that non-smokers are in the majority,
especially when all the windows are closed in the
wintertime and the smell of cigarette smoke is very
strong, we will intervene. However, such intervention
will not be to the extent that the smokers must
extinguish their cigarettes immediately.’ (Non-
smokers from MCPH)
‘They will use facial expression to show that they
dislike or are uncomfortable with the smell of smoke.
We can understand, but we pretend not to and
continue smoking.’ (Smokers from MCPH)
Not on the agenda of hospitals’ presidents
Participating hospitals’ presidents saw their role
primarily as handling the medical problems of
patients. They felt that the smoking problem in the
hospitals was very serious, but that there was little
incentive for them to take on the burden of this work,
since past experiences showed that implementation of
smoking policy did not improve hospital image or
 BARRIERS TO IMPLEMENTING HOSPITAL SMOKING POLICIES
bring more profits for the hospital.
‘The hospital president should attach great
importance to the quality of medical services,
construction of medical ethics and medical
style...while the issue of tobacco control is rather the
other department’s business.’ (Hospital president
from ACPH)
‘The head of the hospital, male doctors, patients, and
their family members all smoke, hence it makes it
difficult to implement smoking policies in the hospital
and it may require a large amount of human labor,
material, and financial support.’ (Hospital president
from XCPH)
‘Past experience indicated that the creation of a
“Tobacco free hospital” has neither significantly
improved the hospital’s image nor increased the
hospital’s profits, hence the work has not been
continued.’ (Hospital president from XCPH)
Social norms Smoking in the hospitals was
influenced by social norms. It was generally accepted in
the local culture that offering cigarettes to others in
some social activities is a courteous behavior, which
makes communication much easier, and that rejection of
the offer is a sign of lack of respect. Smokers and non-
smokers mentioned that it is quite common for patients
and their family members to offer cigarettes to the
doctors, and that the doctors usually accept the offer
even if they do not smoke the cigarette right away.
Smokers further highlighted that it was more difficult to
reject the offer from friends because your friends may
know you are a smoker. So when they offer cigarettes to
you, they also light up for you, and as a result, you
cannot help but to smoke straight away.
‘We also know the discomfort caused to non-smokers
by the smell of smoke and were keen not to smoke in
front of them. However, since the act of offering a
cigarette was as an important social exchange,
difficult to change.’ (Smokers from ACPH)
‘The act of offering cigarettes to doctors is seen as
courteous; it is meant to show respect to doctors.
Therefore, to accept the cigarettes from patients and
visitors are purely based on the social etiquette, and it
is believed that rejection of the offer of cigarettes means
disrespect to the others.’ (Smoker from XCPH)
‘Tobacco is made of air and grass; it often furthers
social interactions. When you need someone’s help,
offering cigarettes to him can interconnect people’s
feelings.’ (Smokers from MCPH)
DISCUSSION
In designing and implementing the needs
assessment research, it is useful to apply a conceptual
framework to help describe contextual influences on
behavior and assess optimal intervention entry points.
Failure to do so is analogous to proposing medical
treatment before understanding the pathophysiology
of the condition[15]. The Precede-Proceed model
conceptualizes the reciprocal relationship between
behavior and environment into three groups of
influencing factors[16]. Predisposing factors are those
that help make a health-conducive lifestyle change
possible, such as information or availability of
products necessary for the new behavior. Enabling
factors are those skills needed to implement the new
behavior and reinforcing factors are supporting values
and social norms that help individuals maintain the
new behavior.
Predisposing Factors
Based on KABP model (knowledge-attitude-
belief-practice), one possible facilitator or barrier to
implementing smoking policies was HPs’ attitude
towards smoking and passive smoking. If they did
not believe that there are any health risks associated
with smoking and passive smoking, then they were
unlikely to see the need for a smoking policy. The
fact that the majority of respondents mentioned, more
or less, the smoking-associated health risks indicated
that a lack of relevant knowledge should not be a
main barrier to the implementation of smoking
policies. However, it should be noted that this
widespread knowledge of the health risks might be
undermined by underestimation and skepticism
regarding the real level of danger for individuals.
Since HPs are health promoters, misconceptions
in this regard probably constitute a major
professional problem. The majority of studies-
including this present study-demonstrated that non-
smokers give counseling on the health consequences
of smoking and on smoking cessation more often
than do current smokers[17-20]. The difference
between the practices of current smokers and non-
smokers might be associated with the differences
between current smokers and non-smokers in
assessing smoking as a risk factor, as shown in the
present study. Clearly, effective interventions for HPs
would need to increase their knowledge on smoking-
related issues.
Enabling Factors
Ready-to-use implementation protocols for
smoking policies have existed for about 10 years [21-
22]
. Such implementation protocols roughly contain
the following steps: orientation (assessing the current
situation), deciding on the policy and developing a
plan of implementation, informing employees of a
plan for the policy change, and announcing
262 WANG ET AL.
consolidation of the policy. They recommend
obtaining support from top management, adjusting
the smoking policy to employee preferences by
means of a survey, and setting up a working team to
plan and implement the policy. Smoking policy
options are not put to a vote, but rather much effort is
taken to ensure that employees can express their
opinions about the policy and that there will be broad
employee support. In this study, top management of
the three hospitals directly enforced the smoking
policies without experiencing the orientation phase
and without consultation with all members of staff.
The working-groups spent a lot of time on
implementing it and achieved a certain success.
However, this implementation style conflicted with
the stress on participation and empowerment in
current health promotion and it seemed that this
result was at the cost of the satisfaction of a
substantial number of smokers and at the cost of
sustainable implementation.
Reinforcing Factors
The traditional approach for education in the
health professions involves disseminating
information through lectures, workshops, and printed
materials, to strengthen or broaden clinicians’
knowledge[23]. However, systematic reviews have
shown that many educational interventions that have
successfully increased clinicians’ knowledge have
failed to cause a significant impact on clinicians’
behavior[24]. The literature suggests that the ability to
affect clinical behavior through education
interventions is unlikely to increase until the factors
that affect clinicians’ decisions about whether or not
to implement knowledge are better understood [25].
The exploration of factors involved in the gap
between knowledge and behavior is a critical first
step in the design of interventions intended to
influence clinicians’ behavior. Reinforcing factors in
this study were based on the gap between knowledge
and behavior. These factors include choice, fairness,
legality, space constrains, addiction, doctor-patient
relations, colleague relationships, and social norms.
Summary and Recommendations
What have been described above are
predisposing, enabling, and reinforcing factors that
limit implementing smoking policies. Some factors
(e.g. social norms and space constrains) will require
long-term policy and corresponding changes in
systems. Other proximate determinants that might be
promising targets as immediate intervention
strategies are recommended: 1) Develop, implement,
and enforce smoking policies in public places at the
county level. A growing number of countries have
undertaken government action to restrict smoking in
public places. National, state, and local laws or
ordinances, which restrict smoking in public places,
are effective ways to reduce public exposure to
passive smoking. At the county level, it is likely to
advocate government to develop local smoking
policies. While a complete or comprehensive ban on
smoking in all public places should be an ultimate
goal, initial efforts may need to be less encompassing
so that success can be achieved. Thus, first efforts to
pass clean indoor air policies might target locations
that are crucial to social norms, e.g. hospitals, schools,
government buildings, and transportation. By focusing
on priority areas, key segments of the population will
be protected, attitudes among general populations will
begin to change, and the baseline of tolerance for
workplace and public smoking restrictions will grow.
2) Create supportive environments: the process
leading to the passage of clean indoor air polices
should be used to raise awareness and intolerance for
smoking in public places among community
members. Media attention focused around the harmful
effects of smoking and passive smoking often makes
community members themselves acknowledge the
necessity of implementing public smoking
restrictions. Without public support, enactment and
enforcement of clean indoor air ordinances are likely
to fail. 3) Promote community participation: active
community participation is key to building an
empowered community. Studies show that
communities with high rates of participation apply for
—and receive—more funding than those with low
participation rates. In addition, participating
communities achieve greater citizen satisfaction with
their communities. Communities seeking to empower
themselves can build active citizen participation by
welcoming it, creating valuable roles for each person
to play, actively reaching out to build inclusive
participation, and creating and supporting meaningful
volunteer opportunities. Of all the empowerment
principles, active citizen participation is perhaps the
most important. Not only does it lead to developing
true democratic processes, but also a higher rate of
resource acquisition and use, better results, higher
levels of volunteerism as well as a more friendly
community environment, as shown by previous
studies. In short, public participation is the backbone
of an empowered community. 4) Conduct health
education: health education interventions can increase
HPs’ knowledge on smoking-related issues, and dispel
misconceptions about smoking and passive smoking.
Accordingly, HPs with increasing knowledge on
smoking through education can take every opportunity
to advise their patients on smoking-related health
hazards, which definitely facilitates smoking cessation
among smokers.
 BARRIERS TO IMPLEMENTING HOSPITAL SMOKING POLICIES
ACKNOWLEDGEMNETS
We thank Fogarty International of the National
Institute of Health in the United States for their
continued support of our work through grant R01-
HL-73699.
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(Received September 28, 2007 Accepted January 24, 2008)