Another Tobacco Control Strategy for State Government: Enacting Smoking Policies in State Human Service Agencies

Paula M. Minihan, PhD, MPHTufts University School of Medicine

APHA Annual MeetingNovember 17, 2003

Rationale for Presentation State human service agencies find it difficult

to provide smokefree environments because many service recipients and staff smoke. Hundreds of thousands of employees and service

recipients are associated with state human service agencies nationwide.

e.g., State mental health, mental retardation agencies. State governments could protect these

individuals from ETS exposure, although few have done so.

Experience of state MR/DD (mental retardation) agencies may explain why this strategy is underutilized by state government.

Case Study: Smoking Policies in State MR/DD Agencies National survey provides information on:

Prevalence of smoking policies in agencies; Whether agency policies reduced involuntary

exposure to ETS for clients and employees; Influences on agency policies.

State MR/DD agencies share characteristics with other state human service agencies. Administer complex and largely privatized

service systems, including residential services; Medicaid is major funding source.

Lessons learned may be applicable to other state human services agencies.

National Survey Administrators in 49/51 state MR/DD

agencies completed questionnaires describing agencies’ smoking policies.

32 (65%) agencies had smoking policies; 17 (35%) did not. All 32 policies applied to programs operated

directly by state governments, albeit with variations in their restrictiveness and in the percentage of clients and employees that the policy covered.

Only 6 policies applied to programs operated by private vendors under state contracts.

Smoking Policies for State-Operated Programs (n=32) General policy banned smoking (21

agencies). Policy allowed medical exceptions for

individual clients (3). Policy exempted residences, allowing clients

and sometimes staff to smoke inside (8). General policy restricted smoking to

designated smoking areas (11 agencies). Policy allowed widespread exceptions for

clients (& sometimes staff), especially in residences (6).

Key Findings: State MR/DD Systems Nationwide Only one state agency policy (WY) nationwide

offered every client & employee associated with agency full protection from ETS. Policy banned smoking in state and vendor-

operated programs, including residences. Policies in remaining 48 agencies fell short of

this level of protection for various reasons: Agency had no policies. Policy banned smoking but exempted residences. Policy restricted smoking to designated areas

that weren’t enclosed or separately ventilated. Policy didn’t extend to vendors.

Major Influences on Agency Policies State Clean Indoor Air Statutes and

Executive Orders. Concerns about clients’ rights to

autonomy and self-determination in MR/DD agency policies and in federal Medicaid regulations.

Autonomy of private vendors operating services under state contracts.

I. State Clean Indoor Air Statutes and Executive Orders

Most state agencies with policies were simply complying with state clean indoor air statutes (28) or executive orders (8) that banned or restricted smoking in state government buildings or worksites.

By doing only what state law required, smoking policies in many agencies covered just: The minority (16%) of clients and employees who

lived or worked in residences operated directly by state government.

Minority of employees who worked in offices.

II. Concerns about Rights of Service Recipients Public is reluctant to impose intrusive public

policies, like smoking restrictions, in homes. State MR/DD agency policies and federal

Medicaid regulations protect clients’ rights to autonomy and self-determination. These forces have created a culture where

smoking is viewed as a client right that cannot be denied, particularly in residences.

Emerging evidence that smoking calms clients with major mental illness complicates this issue.

III. Vendor Autonomy Vast majority of agencies with smoking

policies (26/32) did not extend policies to private vendors operating programs under state contract. State clean indoor air statutes do not typically

apply to vendors. Smoking policies in these agencies did not cover

the majority of clients and employees who lived and worked in vendor-operated residences.

Six state agencies extended their smoking policies to vendors, so it’s possible to do so.

Conclusions Majority of clients and employees associated

with state MR/DD agency systems were vulnerable to chronic and involuntary exposure to ETS because: 17 agencies had no policies restricting where and

when clients and employees could smoke; Agency policies restricting smoking to designated

areas did not require areas to be enclosed and separately ventilated;

Agency policies banning smoking in state-operated programs and non-residential buildings were generally not extended to vendor-operated programs and residences.

Conclusions State clean indoor air laws, which were the

major determinants of agency policies, do not reflect how state government human service systems are organized at present. Statutory emphasis on “state government

buildings” or “worksites” fails to acknowledge that most state human services are currently delivered by private vendors under state contracts.

Statutory exemptions for residences ignore fact that clients’ residences also function as worksites for direct support staff.

Conclusions State MR/DD agencies could

potentially be liable for clients’ health problems or face workers’ compensation claims associated with exposure to ETS in state MR/DD systems.

Policy Recommendations State human service agencies

must do more than passively comply with state clean indoor air laws when establishing smoking policies and take steps to actively protect all clients and employees from involuntary exposure to ETS.

Policy Recommendations State clean indoor air statutes and

executive orders designed to protect state employees and recipients of state services from involuntary smoking should be modified to: take into account the privatization of many

state services, particularly human services; acknowledge the needs of direct support

staff who may be exposed to smoking within clients’ residences.

Policy Recommendations State governments have the power to enact

smoking policies in state human service agencies in the absence of statutory requirements. These should include: Bans on smoking in residential and non-residential

buildings operated by state government;

The extension of agency policies to vendors through contractual mechanisms;

The provision of smoking cessation programs and other assistance for clients, especially those with major mental illnesses for whom smoking may be calming, and employees.

Policy Recommendation In state human service agencies where

nonsmoking clients and employees face involuntary exposure to ETS, agencies should: Allow clients to select whether they live in

smoking or smokefree residences; Inform direct support staff that they could

be exposed to ETS on the job and allow them to select alternative smokefree worksites.